"Mero kaam doctor-guru ho" (my work is doctor-teacher)

Nearly 60 years ago, coincidentally, almost the same time that Snohomish Family Medical Center had it’s start with the arrival of Dr. Aller in Snohomish, the United Mission to Nepal Hospital Tansen (UMNHT) was begun under the inspiration and persistence of Drs. Bethel (MD) and Bob (PHD) Fleming and Dr. Carl Friederick.  The hospital foundations were literally carved out of the steep south side of Shrinigar Hill, a then denuded area about two kilometers from the market in Tansen,  donated without much hesitation considering the property was believed to be haunted. 

Tansen bazaar on left...UMN Hospital below white
building on right.

                                                            

                                                                                                       
                                                                                                                   And now it is a complicated maze of buildings, 7 in all, connected by a series of stairs and ramps to provide access to all the various services on some 15 different levels.  Even after nearly 3 months here, I sometimes go in the wrong direction!

Although Joe Niemczura’s description as “The Hospital at the End of the World”  is a bit of a stretch,  the main road in this part of the Palpa district does seem to end here.  Travel can continue on dirt roads and uneven paths into the rhododendron forests just a ridge away to the north, eventually finding the Kali Gandaki River in the deepest gorge in the world as it winds its way from Tibet around the Annapurna Mountains flowing east to join the Ganges. 

With the addition of the latest building providing space for  a new lab ,  maternity ward,  library and 6 conference rooms, the hospital now has about 180 beds, the census running usually about 140  during the dry season we have been here, increasing to overcapacity  soon as the Summer monsoons hit and the meningitis, encephalitis and typhoid cases increase.  We will miss that by just a week or two.

The foreign staff come from Britain, Australia, Norway, Sweden, Korea as well as the US.  Nepali staff include several senior physicians, a dentist, the residents and interns in training as well as  most of the other services to include physical and occupational therapy, pastoral care, lab, Xray, ultrasound techs, surgical assistants, pharmacists, nurses and medical assistants.

Docs are assigned to different sections of the hospital, usually on a rotating basis, but I have been on the medical inpatient ward  and the male outpatient department for my duration.  Others work in maternity, surgery, orthopedics, pediatrics,
 burn unit or the emergency room.  My focus has
 been on teaching:  not doing the medical evaluations and treatments myself; rather supervising the work of the residents and interns  with  the goal that as they become more independent they will multiply any work I might do alone.

Although, teaching is part of the mission of this hospital, the demands of the urgent often interfere with that process;  most of the expats here, but for me, do a lot of the primary care.  It would be good if we had more interns and residents, but the geographic isolation we have along with puzzling lack of support from the government for medical education, there is some difficulty in getting doctors to train here even if we do offer the enticing salary of $1.25 daily for interns and three times that for residents (in most training programs the docs actually have to pay for being allowed to train).

  

My day begins at 7:40 AM walking down the stone pathway  from the guest house , down the steps, beyond the family members of patients enjoying the morning sun at the end of the orthopedic ward, 




up the stairs  past the always busy laundry  

and the hoist  to the clothes lines on the roof , 

  

up the cement

ramp  at which end 
are families quietly conversing or sleeping on the bench outside the maternity ward waiting for word of an expected birth, and, finally, up the stairs to the conference room  for morning report that includes a brief Bible reading and prayer before the on-call interns tell about the patients admitted during the night  and give the day’s total census in the hospital.  We admit about 30 new patients every day to all wards, deliver about 150 babies a month and see over 12,000 people in our emergency room annually.

Up and down is the way of life here, but actually, on average, Nepal is quite level: 50% up and 50% down.

Docs conferring before Rounds

I

I spend most of the morning with Dr. Theo Beels, an internist from Grand Rapids, returning for 3 years to finish his career here as he started it in Kathmandu in the early 70"s.

We, with 2 or 3 doctors in training, visit all the men and women over 14 years of age that are in the medical ward, reviewing their problems, treatments.   The census usually is about 35.  With antibiotics easily available and some local docs giving patients 8-10 pills of all types to “cover what ails you”  (with good fortune, one of these might possibly be a helpful med) we see many infections - meningitis, kidney infections, pneumonia -  that are partially treated and thus requiring longer treatments with more sophisticated drugs for full recovery.  Psychiatric illness is common; suicide attempts are usually with insecticides, helpful resources are lacking, our pastoral care team is trained in assisting mental health concerns.  Chronic lung disease is nearly universal, TB ubiquitous.  HIV:  usually 3 or 4 cases always on the ward.  We have special outpatient clinics for TB, HIV, leprosy and diabetes.

Morning Tea Conference

We finish in time for “conference” under the umbrella at the canteen  before going to the surgical and orthopedic wards to assist in any medical problems they have.  There are 3 surgery rooms allowing about 600 procedures a month, including minor procedures.  

A baby delivered by C-section

Two broken legs

 I am amazed at the number of bone injuries here,  often 4-6 a day including  upper and lower extremities and spine, many of which are days old, some with secondary infections as people travel long distances to get help here.  Folks fall out of trees, down hills, off roofs,  as well suffer motor bike, bus and car accidents on these narrow winding roads.  Seizures also contribute to injuries, both fractures and burns.  We have a special room for burn care with 5 beds; sometimes they are all full. 

Borken arm

The burn unit

Child getting bones reset

Persons needing to be seen in the outpatient department get their tickets first thing in the morning, first come, first served.  100-110 tickets each for each clinic: pediatrics, women, men.  I spend my afternoons in the outpatient men’s clinic with an intern or two as they see evaluate patients and develop a treatment plan.  I review that with them, teach examination skills, trying to improve both their knowledge base and critical thinking.  It is a joy to see their abilities and confidence improve, but as you teachers know, some days, one wonders if anything has been retained.  I worry that, given the inefficient nature of taking time to teach, I have overburdened others with the job of seeing all the rest of the patients, but hang on to the hope that by empowering these young docs, in the end, the care will be given more efficiently and, more importantly, accurately, long after I am gone. 

It is a joy to work with these affable young Nepali doctors who have received their basic training in Nepal, China, or India; we work and laugh together with mutual respect.  I tell them being a doctor is a sacred position, a holy trust.  The hospital motto,  “We serve, Jesus heals,” is evidence that we are privileged to partner with the God of the universe in bringing healing, hope and love to those for whom we care. 

Mural in the entranceway to the hospital.

Thank you for being a partner with us on this journey.

Khasiram, the Tailor

Khasi Ram is a bright spot on our trips to Tansen bazaar.  His shop is on Steep Street.  When we walk to town, we have a choice of either walking the high road or the low road.  Jon prefers the low road and he thinks it's easier.  Well, it has a bit more paving, but you end up arriving in town at the bottom of steep street, which means you then walk quite a sharp incline for quite a stretch!  I don't prefer starting out my trip that way.  I prefer the high road, which is rougher, more ups and downs, but you arrive at the top of Steep Street.  Beth and I always take the high road.


Khasi Ram's shop is closer to the bottom of Steep St. and it is quite picturesque.  This was his grandfather's shop and he lives in his grandfather's house.  His father was also a tailor.

Food is laid out on the cloth on the floor....electricity was out,
as it often is in the evening, so we had candlelight!

 Khasi Ram, and his family, are Christians as of six years ago.  His wife had developed a large cyst on her side over some months and the doctors said there was nothing to do about the condition.  She was bedridden and one day Kasi Ram could find no pulse.  All indications were that she had passed.  Their uncle was a Christian and had the pastor of the Tansen church come to pray for her
immediately.  Miraculously, she sat up and was able to interact with them. ..about 40 minutes had gone by. The pastor also prayed with oil for her physical condition and the tumor shrank and she has had no more problems.  This

Kasi Ram is studying the cover he made for Jon.  The doors
in the house are a little over 4 ft. tall.....and ladders are the
stairs from floor to floor.  The main room is their bedroom.
I got to sit on the bed to eat while everyone else was on the
floor.  They added some roast chicken to our meal, and
finished up with mango in yogurt.....yummmm.

Nepali's eat Dal- Bhaat every day.
Rice is served with a small dish of
lentil soup which ir poured over the rice
and eaten with the fingers of the
 right hand.  Spicy potatoes and
vegetables were added.

got Kasi Ram's attention!  They heard about Jesus and accepted him into their hearts and lives.  The son has been in Bible School two years and helps lead the worship at the church, as well as other ministries.  The daughter also leads worship with the praise band.  She also works at the hospital in the dental department.  

KasiRam as been a favorite tailor of the missionaries and has had many into his home.  Their smiles are the most prominent feature about all of them. 

I am wearing the  Kurtha Surwal that they sewed up for me.  He even helped me find the fabric in the shop across the street when I was really frustrated about the kits of beautiful
outfits being too small for me.  They fashion them for the small Indian and Nepali frame....not enough fabric for some of us!  I appreciated his compassion.

Dhaka tour

Tansen is known for it's dhaka cloth, a distinctive weave with many patterns.  We have bought some from the many vendors in town.  But, we finally got to visit the 'factory' down the hill from the hospital.  Thankfully, we hired a driver, as Beth's knee is waiting for surgery and I'd just as soon not walk uphill straight for a kilometer, at least.  We had visited the silk factory in Chiang Mai and I had visions of something like that.....well, it's not like that.

We were led behind the owners home to a long, low building of mud bricks and entered through a window-like door....which took some doing for me.

Before us was a long row of rough-hewn looms straddling a trench in which the weavers sat. The threads were fed to them from an elaborate set-up over each loom.   Having seen the large display of patterns in the shop, I understood the 'ticker-tape' above each loom was what guided the weaver.  Beyond that, I don't know how to describe it.  Obviously, this is not silk, but            wool or cotton.  So, the rough surroundings suit the sturdier cloth.

We saw this cloth primarily in the topis that men wear on their heads. Unlike Afghanistan, they do not have a particular significance as to religion, status, or age.  Jon is having our tailor make covers for the laptop computer and the i-pad.  I have fabric to make sofa pillows of when I get home.

Looking to our right, we saw there was another set of looms in as large a room as we were in....here we see a mother with her child.

This solar panel doubles as a stove, it seems.  Maybe that's it's purpose....



In the picture at the right, two of the many visitors from a Kalamazoo, MI
church are with Beth and I.  The church has sent a team of electricians, among others, to rewire the hospital in 7 weeks....no small feat!

A Morning Walk

The ridge behind which are the Annapurnas

With my hip finally feeling strong, and my feet's consent, Jon and I took a morning walk on his day off yesterday.  After an initial uphill effort, it was easy going (until we came back).  Tansen Hospital is perched on a hillside, almost to the top, but not quite.  Our living quarters are on the 'edge' of a knoll that gives us a great view......this walk was to see what was on the other side of that ridge I've been looking at.

There is  currently a 'bhandh' in place ...meaning a work and travel stoppage, usually politically inspired.  The Nepal gov't has not had a constitution written up to satisfy the diversity of the constituents, so various factions, not just the Maoists but certainly including them, have the authority to call these bhandhs.  This is said to pressure the gov't into action.  What it does is prohibit any vehicles on the road, thus businesses are closed.  Neighbors report anyone doing business.  So, food, medicines, supplies are in short supply.  The hospital is running out of oxygen.  Patients have to walk to the hospital, some arrive too late.  As the Nepali's say "Ke garne?" Or "what is there that can be done?"  Anyway, all this to say, we met a lot of people walking yesterday.

Well, on with our walk......
 Outside the emergency room entrance, across the street is a busy waterhole.  Most homes do not have running water, so jugs must be filled every day, maybe more than once.   It's probably the best place to catch up on gossip !

 We turn right and a long hill takes us up past homes on the left and the hospital wall on the right.  Here we pass a couple.  He's wearing the
topi, the cap worn my men and made of dakha cloth,  hand-woven here in Tansen.  She has a 'mixed' apparel look, but the distinctive feature is the Patuka.....a 5 meter length of cloth wrapped around the abdomen.   It can be seen on men as well as women.  Jon says it is the hardest thing to get throught to examine a patient.  All kinds of things can be found in it...a pack of cigarettes, food, money, whatever a pocket usually holds.
Behind them is a young girl bringing her water jugs to fill.

 


At the top of the hill we met a rooster who posed grandly!
Far below him is a community soccer field which is also used by our nursing students.  Just getting to it and back would be enough exercise for me!  Oh, to be young again!




As Jon was taking a photo of a cactus blossom, two proud-to-be-Hindu men walked by, then stopped and one started talking.  I told Jon I thought he wanted a picture taken of his hair.  He had taken his topi off and was unwinding his long string of hair!

Jon engaged with him then and took these photos.  The man called it his Hindu hair.  We didn't ask how long it had been growing.
                                                                           As you can see, he has the tika sign on his forehead which is a religious symbol of the Hindu faith.

And then he wrapped up the hair and tucked it back under his topi.
Below is the beautiful cactus bud and flower.  The large cactus was filled with these....and a bit of garbage.














      As we meandered up the road (paved even), we passed this family who I think were going to a wedding or event because of what they are carrying.....The young woman is dressed in the Kurtha Suwal,  a 3/4 length top with matching pants and scarf around the neck, flowing backwards.  The older woman is wearing a Sari which is 6 meters of cloth wrapped masterfully around the body.  A short sleeved and bodiced top always accompanies this.  I wonder at what age a woman switches to the Sari?  We  Videshis (foreigners) wear the Kurtha Suwal, by and large.  I think they are carrying a gift and some food....who knows?

 WE soon reached the village at the 'gap'...
And what did we see when we looked over the ridge?  More farm-clad hills and deep valleys!
                                                                         But, if the haze had been gone, the Himalayas would have been RIGHT THERE.  You could tell beyond the next ridge, it was jungle.  If we were younger, we might  do a trek there.....it's a great trip, staying in villages and walking thru
rhodedendron  forests....The trees are the rhodies!
 I think there are a view bugs and things, too.

This picture was taken by Jon over a month ago when a storm had cleared the
haze and he captured the Annapurnas.  The haze often conceals the
foothills, also,

So, it's time to walk back home. We're facing the hospital hill and trying to find our place. Looking at the picture below,  find the larger building in the middle... we are the tiny one to the right of it.  They almost look like one building...between trees.

 The nursing school is in that clump of trees below, and Beth's house is behind that tall tree above it. The children's school house is up at the small shiny spot and the large building on the right is housing built by the Lions many years ago. for hospital personnel....lots of people living there, and room for more.

Would this hen and chicks be part of the family of the proud rooster?

Remember the 'bhundh' is on....no vehicles.  And there are no storefronts open in this village.  They spent their time sweeping the street, I think, as it was spotless.  Gorkhekot is the name of the

town and the Wisdom English Boarding School had two buildings....the one above with the bell, and the one a bit farther out of town....all closed down for the bhundh.

Now we have to go up the down.....and this lady, with her Patuka is going our direction.  She has the strap of her satchel around her forehead, as many do.

Notice the Dokaa on the girl's back?  The bamboo pack basket uses a trumpline to hold it by the forehead.  She adds the support of her hand and arm to prevent injury to her neck I'm sure. She is hauling these rocks for the wall-building project of these young men.  Who has the harder job?  We see women doing the physically demanding jobs a lot!  Filling sacks full of gravel, to sell, hauling bricks, etc.

Now we are back where we started....the hospital emergency entrance is on the left where the men are standing.  I don't know if the cow came to the emergency room, or decided to watch the action.  This looks like the cow that lives up that little street to the right, along with a goat and a few chickens.



 Below is the entrance to the rest of the hospital and a seating area for folks who prefer the out-of-doors.  There is a large waiting room inside that holds a pack of people on benches, but it looks to be a way to catch whatever diseases walked thru the door and are waiting to be seen.
The lady in front is returning with dishes, having fed her relative who is a patent in the hospital.  Families are responsible for feeding the patients, and someone also sleeps under the patient's bed to take care of their needs....call for a nurse, if need be.  The little hotels around the hospital also house the rest of the family and sell meals.    The newer building in the background is the lab, conference rooms and maternity.

The many flowers brighten our days.

Jon has been counting....and thinks there are 7 buildings on 15 different levels.  So goes the add-ons over the 50+ years of existence.