Dinner at Nine in the Terai


Dinner at Nine

A gentle tap on the door promptly at nine PM, and I was summoned to join the other Universal College of Medical Sciences (UCMS) Guest House residents around the formal dinner table for the meal. T-shirt and shorts was the order of the day. Quiet words, the Hindi equivalent of “pass the rice.” As always people watch to see that you use the sink in the corner before sitting down. The meat was mutton curry. The six of us ate quietly, served by the two boys who made the food, passing the dishes around family style. A set of stainless steel covered serving ware like a tiffin – one with rice, another with dal, of course. Sag, alu terkari and “pickle”. Water.

The meal was over in twenty minutes. Others returned to the Korean Soap Opera on the TV but I was a bit disoriented so I am writing this blog. The usual mealtimes here in the Terai are a bit different than my routine.

It’s not the heat, it’s the _________

There is no listing for Bhairawa, Nepal on the Weather Channel app on my BB. Nor for Bharatpur. Offhand, I would say it’s hot and humid. Sultry, if you must know.
The two people from UCMS hospital who met me at the airport noticed immediately that I was already sweating. In Maine in January I can recall hopping into a bathtub for a long soak that was not as hot or as wet.

It cleans out your pores.

On the way to town from the airport I could see flat rows of rice paddies stretching and disappearing into the haze. Flat as a pancake except for the paddy dikes and roads. Flat as a papadum. Right now it has rained just a little, and from the plane I noticed paddies within a hundred meters of the river were flooded but most were dry, except for bright green nursery beds. Every paved road is laid on enough gravel to make it a causeway, dropping off three or more feet on each shoulder.

A neat row of Ashok trees lining the road, and later again the periphery of the Guest House. We are not far from Lumbini, after all, and Ashok trees played a role in the birth of Buddha. Rickshaws, cows, goats, and ducks abound, a family of four goes by on a bicycle. One man is herding ducks, using a stick to ward off a marauding crow. An oxcart hauling furniture. Old rundown buildings, here mixed with the bamboo, thatch and wattle-and-daub of Tharu dwellings; look inside one to see a dirt floor and a color TV. From the car window, a startling vision in a field: a Frank Gehry-like Krsna temple, brand new and ultramodern expression of the classic Shikari architectural harmony. Wow.

To the Guest House where I drop my stuff. My room has A/C and a very large fan.

It’s Mango Time

The next stop was to the home of a surgeon, older white haired man who serves in an administrative role. I was offered mango and fruit juice and we discussed my trip. Quietly and systematically he laid out the things he viewed as issues. Care of ventilator patients. Whether some of the “P.D.s” – (post-degree MBBS personnel) could attend. The difficulty in retaining trained nurses. Which classroom to use. The culturally-influenced way in which crowds of family insist on being in ICU at all times, and the problems this causes when it interferes with patient care or at time of death.

One of my hosts is a young woman who turns out to be the Hospital Matron. B Sc from Hope International College, division of Purbanchal University in Kathmandu. First batch. She tells me about the staffing pattern and who will be in the class.

Busman’s Holiday

After a beep the chowkidar swings the gate open for our SUV. It’s Saturday, the place is open six days a week but not the clinics – not today. ER though, is hopping – first the male ward with sixteen full gurneys, everyone lying directly on the black plastic mattress, family gathered and a hum of activity. On the stone-tiled floor outside ER, an emaciated victim of (something) lies on a sheet, wearing homespun cotton dhoti and a turban.

Then the female ward, twin of the first. People here are obviously of Indian extraction, darker than in KTM or Tansen, but there are some hill people mixed in as well.

“Local population is about ten lakhs of people” I am told. One lakh is one hundred thousand.

The classroom space has A/C and it will be fine. A tour of the ICU, in which I got to open drawers and play with stuff. In the waiting area a whiteboard for status updates, written in Nepali. Change out of street shoes into slippers only my feet are too big, so I pad around ICU in stocking feet. One nurse in a Kurta and the other in a sari. ICU here has A/C, no windows to the outside, and 24-hour staffing by a doctor and two nurses for eight patients. Lots of MI but today we have a twelve year old victim of mushroom ingestion (he will die) and also OP poisoning (likewise). They use strepto but often the MI people show up too late.

Two nice ventilators, not in use today but on standby. No RT department. No ABG machine. Anesthesia writes the orders. Reminded to go check out their suction setup, and sure enough, a canister of saline holds the suction catheter they are re-using.

A quick huddle outside afterwards: eager to know whether I think the equipment is adequate. Yes.

The nursing school library. Ten copies of each textbook, students jointly study these but can not check them out.

Dropped off at Guest House, they tell me not to pay more than forty rupees for a rickshaw in the morning. DBT with the boys, all docs but one dentist. Mostly quiet except some discussion about foreigners visiting Solu Khumbu and not here.

Brown Sugar does not come from Sugar Cane

Monica phoned, then came over. She led me on a tour of the neighborhood, past a forlorn looking place used for drug rehab (“there is a problem with Brown Sugar”), and a small temple (built by the neighborhood so they did not have to walk far during Dasain). A brass band has their HQ in the neighborhood and Monica served as my negotiator since the members seemed to be there. 200 nrs for one song, and soon there was a crowd of kids too. We meandered to her family home a km away. Lovely afternoon, met her family, was plied with food every thirty minutes, and talked about TNS, career aspirations, mutual friends. Monica was happy to receive a long-promised copy of my book. Posed for a photo of course.

Then back here. Rinsed out my shirt and hung it up to dry.

And Sunday morning we begin three days of teaching critical care nursing skills in Bhairawa.

About Joe Niemczura, RN, MS

Experienced nursing educator and problem-solver. I have fifteen years of USA nursing faculty background. Add it with fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. I travel outside of Kathmandu Valley as well. When the recent violence happened, I knew the cities - I had trained people in those locations. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011. Global Health Nursing is not all sweetness and light; not solely milk & honey and happy moms and babies.
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4 Responses to Dinner at Nine in the Terai

  1. gaynor says:

    2 nurses to 8 patients would be a challenge, but I suppose a lot depends on the level of acuity. Is it the same ratio if any are ventilated? We don’t have RT departments in Australia, nor in UK. ICUs are run by ICU specialist doctors, and all decisions re management and ventilation strategies are made by them. Senior experienced nurses would tweak the ventilator settings but generally the bedside nurse (one on one for ventilated patients and sickies) would only alter FiO2 without medical say so. The bedside nurse would make ventilator changes though as directed as part of general protocol, eg: weaning. I’m not sure if any other country apart from US have RT departments? Maybe Canada? I’m a little vague as to what an RT does actually.
    I’m assuming they don’t use art lines or CVCs then in Bhairawa? Even taking VBGs would be useful in guiding ventilation management in the absence of an art line. You would still need a gas analysis machine but at least you wouldn’t have the risks associated with art lines in patients with such a high patient nurse ratio.

    • You hit all the key points. I have been asked to specifically cover mechanical ventilation, and now I see why. I did a version of this for the LNC BN class… Now, I am an old “Dial Twiddler” from way back…. But I will endeavor to teach what I can, sans ABGs.

      It’s all about phasing in…..

      follow my blog on Word Press

      http://www.joeniemczura.wordpress.com

      Or FaceBook The Hospital at the End of the World

      Mobile number while in Nepal:
      +9779802038060

      Ubi Caritas est vera, Deus Ibi est

  2. gaynor says:

    I know internet access may be a bit sketchy where you are but I’ve posted below a couple of great podcasts for basic ventilation strategies from a US doctor – excellent, with very logical, if fairly prescribed strategies. I like the way he is so logical, with step by step protocols and some good tables. It’s a kind of “can’t go wrong if you do this” approach and he explains things very well without going into too much detail for those starting out. Aussie ICUs would probably differ a bit – never seen AC used in our ICU – but the principles are great. There’s also a PDF handout
    http://emcrit.org/lectures/vent-part-1/
    http://emcrit.org/podcasts/vent-part-2/

  3. a YouTube link to a sort of rap/reggae tune about Bhairawa that shows you the town…

    enjoy!

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