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OB/GYN "Camps" in Ilam

Volunteering opportunities December 3rd through 19th of 2010 and the future

Volunteering OB/GYN Providers for HIMALAYAN HEALTHCARE of Nepal

Contact Himalayan Healthcare at www.himalayan-healthcare.org regarding medical/dental treks, and ninacarrollmd@aol.com regarding OB/GYN camps starting in December 2010.

Whether you are an obstetrician/ gynecologist, certified nurse midwife or anesthetist, volunteering with Himalayan Healthcare (HHC) will be a life changing experience for both you and your Nepali patients. Family practitioners and internists welcome, too. HHC is an extraordinary nonprofit organization founded in 1992 by Anil Parajuli of Kathmandu, Nepal to serve people living in the remotest villages of Nepal. Accessible only by long treks over 3-5 days’ duration over Himalayan mountain passes and verdant valleys, the people of Tipling and Dhading are mostly Tamang origin and blacksmiths living above the clouds and out of sight of health care provided by the Nepali government. To date there have been 70 medical/ dental teams which have trekked to these villages where basic health services and training were provided by physicians, nurses, midwives, and dentists. People who need hospitalization and surgery, walk or are carried for several days down to Kathmandu where HHC continues to provide financial and social support until they return home healthy. Making health care accessible, available, affordable, and high quality is key to HHC’s mission.

OB/GYN CAMPS: medical volunteering with HHC

During the five years of civil war which ended in 2006, HHC expanded their work to Ilam 300 miles east of Kathmandu. There the Dr. Megh Bahadur Parajuli Community Hospital (MBPCH) opened by in 2004. Since then more than 25,000 patients have been served by the local doctors and more than 25 international medical/dental teams of different specialties. Before or after the journey to Ilam, you will be able to visit Kathmandu, Lalitpur (Patan), and Bhaktipur to explore the exquisite Buddhist and Hindu temples. When you arrive HHC will help you obtain a DMC license from the Nepal Medical Council in Kathmandu to be authorized to practice medicine in Ilam. We will fly Buddhair to Bhadrapur, then drive 2 ½ hours to the town of Ilam which has a semitropical climate in mountainous eastern Nepal near Darjeeling, India.

The MBPCH in Ilam will be the center of this ob/gyn camp’s activities. Depending on the number of health care providers participating, activities will include: 24 hour coverage of ob and/or gyn emergencies, cesarian sections, hysterectomies, D+C, abortions, tubal sterilization by minilaparotomy, clinic screenings for STDS, contraceptive implants, IUD, insertion, pessary fitting and insertions, etc. Short treks to the outlying villages to provide screening, education and training of patients and skilled birth attendants (SBA) might be possible to arrange. Regular training sessions of midwives, nurses and technical assistants will be provided by the international staff.
This is a critical project for Nepal since both maternal and neonatal morbidity and mortality are among the highest in the world in part attributed to the fact that trained health personnel are only present in about 12 – 15% of births and 90% of births occur at home or in the fields with 10 % of women delivering alone. There is a neonatal mortality rate of 56 per 1,000 live births and maternal mortality is 540 per 100,000 live births. It will be crucial to create culturally and religiously appropriate models so that women will understand and increasingly seek the obstetric services provided.

Since 2006 it has been possible to perform cesarian sections and treat pregnancy-related complications in Ilam when staffing levels of skilled doctors are optimal. In 2006, more than 300 women received prenatal care and there were 101 vaginal births and 92 cesarian sections. Currently there are 6 midwives on staff, but no doctor to provide cesarian section since turnover rates are high. Modern equipment and supplies are needed to consistently improve the hospital care and develop clinic sites. Remote villages need to have birthing centers staffed by SBA and when possible, midwives. Proper use of clean home delivery kits (CHDK), knowledge of sterile technique, and appropriate neonatal management at birth needs to be disseminated to remote villages. Knowledge and screening for obstetric complications and emergencies, including obstructed labor, infection, postpartum hemorrhage, and eclampsia, with availability of basic medications, tools, and when possible access to transportation to the hospital for more skilled care, need to be taught and reviewed to insure quality.

Patient education to help women identify problems, decide to seek care, be able to reach an appropriate medical facility then receive adequate care there is key. Prevention of unplanned, unwanted pregnancies helps reduce maternal morbidity and mortality, so family planning services are available. Abortion has been legalized in Nepal since 2002 as follows: electively, through 12 weeks’ gestation; for rape or incest up to 18 weeks; at any gestational age if the fetus or mother’s life is endangered. Comprehensive Abortion Care services are provided by government, nongovernment organizations (NGO), and are affordable and performed by skilled providers who are trained and certified through IPAS.

Data is lacking on the prevalence of HPV in Nepal. www.who.int/hpvcentre Depending on the results of the 2009 pilot study funded by Quest Diagnostics, it would be useful and interesting to seek and obtain grant funding for a prevalence study while simultaneously obtaining cytology (Surepath or ThinPrep) and HPV DNA testing with Hybrid Capture 2 (HC2 probe B, Digene) and gonorrhea and Chlamydia testing, and possibly providing visual inspection (VIA) or colposcopy with “look, see, treat” (LLETZ or cryocautery) in high risk populations. Donations or funds will be necessary to secure equipment and pay for cytology and pathology laboratory costs. Eventually vaccination with Gardasil could be offered if HPV prevalence rates match those in developed countries. Merck, the pharmaceutical company who developed the Gardasil vaccine, offers free vaccine to grantees. www.GARDASILaccess@AccessToTreatment.org

Uterine prolapse is a major health problem. Pessaries can be purchased and/ or donated from suppliers of medical instruments/devices. Vaginal and abdominal hysterectomy can be offered to appropriate patients, as there is an operating room and anesthetist for spinal anesthesis. Laparoscopy is not available at this time.
General screening for STI, vaginitis, and a range of gyn problems, such as pelvic inflammatory disease, dysmenorrhea, abnormal uterine bleeding, dyspareunia, polycystic ovarian syndrome, premenstrual syndrome can be performed. With life expectancy at birth being 63 years for females (although the probability of not reaching 40 is 22.5% for women) menopausal issues may become a concern, such as vulvovaginal atrophy and vasomotor flushes.

Your presence and/or presents in the form of time or donation of medical supplies will be an invaluable contribution to the healthcare of women in Nepal.

Contact: Nina Carroll MD 55 Pond Avenue Brookline, MA 02445 617 232-0202 office 617 733-5213 cell and email: ninacarrollmd@aol.com regarding the OB/GYN camps and visit www.Himalayan-healthcare.org

Posted by ncarrollmd 13:59 Archived in Nepal Tagged health_and_medicine Comments (0)

Himalayan Healthcare in Ilam

Scout mission for Himalayan Healthcare (HHC) 2009 ) Scout mission for Himalayan Healthcare (HHC) 2009 for Megh Bhadur Parajuli Community Hospital (MBPCH) in Ilam, Nepal

semi-overcast

11 Nov Kathmandu, Nepal in the streets without traffic signals
Tatas, Terrios, Marutis, Mahindras and Hero Hondas have replaced the rickshaws and thousands of pedestrians that made up street traffic of 1997 when I last visited. Poinsettia trees, bougainvillea, red bottlebrush, soot-coated banana trees, dirty dogs, black and tan goats, sewing machines and tailors on street corners, rubble, roosters and dust--- unchanged.
Soni and I walk from the Himalayan Healthcare office to Patan’s Durbar Square, stopping to shop and stand admiring the exquisite carvings of the Newari people on the temples.

12 Nov 2009 Maoist demonstrations
Their politicial activities preclude going anywhere efficiently so we don’t. A day to read, relax, plan. Grey, almost cold out, drizzling. Dal bhat, a watery lentil soup/sauce with curried vegetables served with white rice: lunch and dinner.

13 Nov 2009 Travelling east past the Himalayan range
Breakfast of hardboiled egg, crustless bread, butter, sweetened creamy tea then taxied with Suk to Tribhuvan airport where we waited for Sudarshan who came on his motorcycle (Bazaz 135 ct). Suk came to Kathmandu from Tipling with the help of HHC 14 years ago receiving his education here and living at the office. His transportation back to the office was on the Bazaz. His job includes looking after the patients and their families who come into Kathmandu for hospital care, managing their appointments, hospitalizations, family’s lodgings, food, transportation—all supported financially through HHC.
Tribhuvan airport. Bags were X-rayed for security. No passport or ID necessary. Then a walk through a cubicle “Ladies” separate from “Gents” where we were frisked by a same-sex security officer partially obscured behind an ancient floral curtain. Our combined bags weighed less than 70 kilograms. Flight delayed because of Maoist demonstrations or weather. It’s dry and hot.
Airport sights: women all shapes and sizes in wild colors of saris and khurtas with pants, sandals, and painted toes, and bindis on their foreheads. WiFi down, actually unavailable for all but about twenty minutes in the past four days.
Box lunches from The Bakery Café in Bhadrapur where we wait for the driver to take us the 2 ½ hour of hairpin turns up the mountains of bamboo, brush plant, tea plants, and lush semi-tropical vegetation to the town of Ilam perched on a mountain top.

14th Nov Meeting the hospital staff at MBPCH
We met Dipesh, the administrative and financial officer, in the morning who translated my slideshow into Nepali. The slideshow outlined the goal of a long term OB/GYN project, Safe Motherhood Project, for the women living in Ilam and surrounding districts. It was initially targeted for the community hospital management committee members and local stakeholders and representatives of women-run organizations as well as maternal and child health service providers in these area. Supplies of instruments, pessaries, OCPS and hormone therapy for menopause, and Bakri balloons (devices to arrest hemorrhage in childbirth) were listed.
With the help of Dr. Sunil MBBS (British system of medical education equivalent to an MD but before residency training, like a flexible internship), Binod, anesthesia assistant and owner of a local pharmacy in Ilam, and the hospital team of ANMs, (assistant nurse midwives roughly equivalent to a LPN, which is licensed practice nurse) we examined 19 gynecology and obstetric patients.

15th November Planning meetings for the April Camp (team of docs/ nurses)
Several potential meetings from the agenda could not be accomplished:
1. District Health Officer Dr. Tara was away at a medical camp for 1 month
2. Gynecologist in Phidim Hospital was not available (resignation? health?)
Patients arrived early from the morning to get tickets which allow them to be seen by the doctor.
The same team saw 25 patients providing history, pelvic exams, diagnoses, and treatment plans as possible given the limitation of not having trained staff to perform pelvic ultrasound and hormonal lab screening (TSH, FSH, LH, Prolactin) is not available except through mailing specimens at considerable cost.
Board Meeting 3:30 – 4:30 PM The objective of the meeting was to discuss The Safe Motherhood Project about how to reduce maternal and child morbidity and mortality as well as provide HPV/ STI screening with family planning services to the women of Ilam and the surrounding districts. The goal was to engage board members to disseminate ideas about the project to their villages and surrounding areas and encourage them to organize meetings with the other groups, stakeholders and service providers of the district.
At 6 PM Dharma Gautam, Sudarshan, and Dr. Nina went to the Nepalbani FM office in Ilam to tape a radio interview about the Safe Motherhood Project and the screening for HPV prevalence during her GYN OPD session at MBPCH November 14 – 18, 2009, as well as the plan to bring a multidisciplinary, but largely ob/gyn team in April 2010, then twice a year if needed. The 35 minute interview in English and Nepali broadcast at 8 PM.

16th Nov Tea gardens and Women’s Groups
Walk to the tea garden as morning walk at 7:15 a.m., we spent about 1 hour 15 minutes there and came back to hospital, had breakfast and tea! Patient check up lasted until 3:30 p.m. 22 patients were checked by Dr. Nina with the regular help of Dr. Sunil, Binod Ji and ANMs who were being trained to screen patients for pelvic organ prolapse. In the afternoon, there was a scheduled meeting at the Mahila Jagaran Shangh office with the women groups, representatives of family planning. Participants introduced themselves, then Dr. Nina presented her project's slide show The Safe Motherhood Project and elaborated on specific issues in HPV, HIV, STD, family planning and abortion, midwife-training issues, and April 2010 Camp issues. Women participants were interested in learning more about HPV and there was a lively exchange of questions and answers with the help of Dharma Gautam. As a HHC representative, Sudarshan talked about the upcoming “hysterectomy camp” (a program of international health care providers scheduled to visit a specific region or health center to provide a specialty service) in April, Dr. Nina's project and her long-term commitment for Ilam. We expressed gratitude for their attendance and hoped they would communicate the goals of HHC project as well as dialogue with us about ways that HHC can support women's health issues. We appealed for help from the women groups and organizations, particularly about the financing and staff which will be needed for the screening camps to keep a record of women with pelvic organ prolapse who might need surgery or pessary fitting and insertion during the April 2010 OB/GYN camp.

17th November More patients……they kept coming
Patients from 9:00 a.m. Because of the Meeting in Ilam, patients had been turned away yesterday, but many returned. 25 patients were examined. Preparation of the introductory training slideshow: POP (pelvic organ prolapse) and HPV (human papilloma virus).

18 November 2009 Communication
At 7:50 AM I arrive in the Spiral Room to find all of the female staff waiting for the talk about the Safe Motherhood project, HPV and the Surepath project , and Pelvic Organ Prolapse: identification, screening and treatment. They are eager to learn.
Breakfast of hard boiled egg, toast, and sweet creamy tea on the balcony with sunshine and staff. Goal of maximum 15 patients, saw 24. One ANM named Sita Tamang from Ilam came to observe and was very helpful and eager to learn.
At 3 PM with Dr. Sunil, Dipendra (MMLT masters in medical lab technology), and Sudarshan we left by taxi for the observation tour to the four sites in Ilam where we were joined by Dharma.
MBPCH delegation escorts me into Ilam for various meetings:
Mary Stopes (International) Center 027-520857 greeted by Upendra, clinic coordinator, and Bhagawati , staff nurse. (marystopes.org.uk). This site which is all in clean royal blue started in 2004 and is a full service outpatient ob/gyn provider from antenatal care, abortions and family planning, including mini-laparotomies which are performed under local and take about 20-25 minutes. Their patient volume is about 6-7 patients per day, open 6 days per week. Charges: abortion 1495r, copperT free, but removal 100 r, Norplant insertion free, but removal 250 r, OCP are free and minilap is free and transportation is provided. Their maximum capacity is about 9 patients/ day for abortions.
Family Planning Association of Nepal (FPAN) Ilam branch. Senior branch manager is Kumar. Dr. Asha is a general medical doc and there are two staff. They perform 1 CAC/ day, and see 3-4 other patients. They do outreach clinics seeing about 10/ day in those settings

District Hospital is deplorable District Hospital of Ilam 25 bed hospital
Hysterectomy camp 2009 details provided by Binod who provided spinal anesthesia. His verbal summary from his recollection is as follows: 1 OR with 2 operating tables. 12 operations/ day. Spinal anesthesia provided with bupivicaine and morphine. 73 surgeries were performed including: vaginal hysterectomy, anterior and posterior colporrhaphy, laparotomy. no abdominal hysterectomy. no pathology. no recovery room. 5 bed ward. hospitalized for 3 days. 35 patients were turned away for lack of time.

Unitylife is a 15 bed private hospital just opened in September 2009 and using a networking membership-based model charging 15,000r for lifetime healthcare and currently with 3000+ patients who have joined.

Farewell gathering sweet speeches and presentation of a beautiful handloomed scarf from Ilam. One I have been coveting, yet never told a soul…. and some black tea. Lingering over goodbye dinners exchanging emails, photos, hopes, and expectations. Two of the key staff people are expecting their first baby and wives live 12 hours away by bus.
7:30 – 8:30 PM Investigative Tour of the hospital to assess supplies, equipment, instruments, and resources for future OB/GYN camps, especially planning for April 2010. In attendance with Dr. Nina were: Dr. Sunil, Dipendra, Binod, and Dipesh. Details below: Surgery/ Inpatient resources for OBGYN CAMP 2010

19th November
Tea planting ceremony on the hospital grounds at 7:00 AM, then taxi for the 2 ½ hour drive through lush bamboo stands and tea garden and small village with morning markets to the airport at Bhadrapur for the late morning flight back to Kathmandu. Sudarshan showed our tickets and checked our bags. No identification was required Then we had tea and momos since our flight was delayed by fog. The security checkpoint had a sign: “You are not allowed to have explosives in the airport.” There was a door and a closed cotton curtain behind which my bags were opened and I was patted down by a female Nepali security guard, then she opened the bolted door on the other side of the cubicle and I was in a small waiting room. There was a large group of Bhutanese refugees who were leaving Nepal for various countries.
The journey past those Himalayan peaks and back to Kathmandu and planning for the next project to bring improved obstetrical and gynecology services by enlisting US health care providers who are looking to learn, about while contributing to the health of women in Nepal. An April “camp” is being. Interested nurses, midwives, doctors can view: www.Himalayan-healthcare.org and/or email: ninacarrollmd@aol.com to learn about how you can contribute.

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Posted by ncarrollmd 20:20 Archived in Nepal Tagged health_and_medicine Comments (1)

Himalayan Healthcare in Ilam

Himalayan Healthcare (HHC)
scout ob/gyn mission to Ilam 2009

13.11.2009

Specially prepared Ilam program in hand, I board Buddha Air with Sudarshan of HHC and we fly with the Himalayan range snowcapped above the clouds to Bhadrapur to lunch under a shade trade at a small hotel while waiting for our driver.
The road to Ilam at sunset is lined with great sights: a goat walking a boy, a girl walking a cow, mustard fields, poinsettia trees, trucks with colored headlights, bamboo stands, roadside fires, haystacks the size of houses, marigolds with no leaves, dust-coated palm fronds, hairy pigs, dirty dogs, no cats, men smoking and staring, women working, wild saris strewn on clotheslines, the fat orange sun obscured by brown mist, the hairpin turns, higher and higher we climb out of the hot dusty plain.
The Megh Baradur Parajuli Community Hospital (MBPCH) staff greeted me with marigold and a very long white scarf and a gave me a grand tour of the hospital which is amazingly well equipped. The courtyard in the middle is serene and beautiful. At dinner in the canteen there is lively conversation about patients seen in the last 24 hours. Tomorrow Saturday patients start at 9 am.

by Nina Carroll (originally posted on davidmd.travellerspoint.com by accident)

Posted by ncarrollmd 07:41 Archived in Nepal Tagged health_and_medicine Comments (2)

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