Respiratory Therapy in Nepal

            It’s only been a week and three days since our return from our ventures overseas but it feels like much longer because for every moment we’ve been away, I’ve had a desire to be back in Nepal.  You see Nepal wasn’t like any ordinary trip for me.  I went there with intentions to volunteer but came home with a greater appreciation for another culture and understanding of myself.  Before and after the trip, I’ve had numerous people ask me, “why Nepal?”  Aside from the fact that Eric had already spearheaded the project in this country, I can now respond with, “well, why not Nepal?”  From the views of the landscapes seen from above on a mountain, to being in the middle of crowded streets hearing the friendly locals speak, “Namaste!” (translation: hi) as you walk by, it’s every traveler’s dream to feel so welcomed in a place that is so foreign. 

            I’m not much of a risk taker.  In fact, I was one of the last members to become officially on board with the trip before the fundraising commenced.  There were a lot of considerations I had to make and personal questioning as to whether I could handle being away from home for so long.  Despite the planning, the trip was like a risk in itself for me!  I came to the realization that living in fear will hold me back from the world’s greatest experiences that I would never want to miss out on.  I was lucky to be traveling with my classmates and some of my dearest friends. 

            It has truly been an experience of a lifetime.  I am very fortunate and grateful to have been able to see all that I have and make friendships out of the people I met in Nepal.   From collaborating with the extremely knowledgeable doctors, students and nurses at Bir Hospital to us singing while sitting on a mountain in Pokhara, Nepal has opened the gates to wonders that I could’ve only imagined until now.   Oddly enough, my whole perspective has changed because three weeks was definitely not long enough. 

            I remain inspired to help others and hope to be a part of something as special as this in the future.  A very warm thank you to our supporters in both Canada and Nepal and to our readers from around the world!  To Team Nepal: You are an incredible group of focused, driven, and hard-working individuals to work with.   Thank you for the everlasting memories.

To be continued…

Jenny

As I sit at home back in Canada, my experiences in Nepal already seem so far away and it has only been a week.  This opportunity has given me a much broader understanding of who I am right now and who I want to be in the future.

Volunteering at BIR Hospital encouraged me to strive for alternatives and to constantly ask questions.  With their busy personal and professional lives, I’m so grateful to ICU staff for taking the time to create such wonderful and lasting learning experiences for us.  During my clinical orientation this week, I constantly found myself referring back to my time at BIR.

I’m even grateful for the crazy, rickety taxi rides up the mountain to Dhapasi as they brought us to the Imagine and Possibilities Houses of Nepal Orphans Home.   It was a privilege to meet Michael “Papa” Hess who created this amazing organization that creates homes for orphaned children where they could finally just be kids.

Outside of volunteering, we tried to experience as much of Nepal as possible.  One of our goals was to go bungy jumping at The Last Resort (160m drop) which overlooks the Bhote Kosi River.  As someone who does not like heights, the thought of jumping made my stomach churn and my head spin.  Later, I realized my 3 minute negotiation process with staff at the suspension bridge was a lot like my journey to Nepal.  In October, when we first began to discuss going to Nepal, I was apprehensive.  I wasn’t sure if I could do it.  There was a lot we didn’t know and couldn’t have known before getting there.  While we researched a lot beforehand, we knew there’d be aspects of Nepalese life we could only understand once we got there.  At some point along the way, though I’m not sure where, I decided to just jump into the experience.  Now, I look back and think with a smile, “I can’t believe I just did that.”

In conclusion, I am still an individual who likes to overly research and plan before I go anywhere or do anything.  However, I realized that sometimes you can’t plan everything and you just have to take a risk.  While you have to make the decision yourself on whether or not to jump into the unknown, you need to remember that there are people – friends, family, even strangers – that can help make the fall a little easier.  So thank you again to everyone who supported us!

I’m so excited for what the future has in store for me the next time I go to Nepal as an experienced and registered respiratory therapist!

Cheers to new adventures!

-Marry

Our last day at BIR hospital was celebrated with a ‘hand off’ ceremony for all the donations we made and a fond farewell from the staff in the ICU. In attendance was the acting director of BIR hospital, Dr. Ravi, Dr. Pradip, Dr. BB Singh, and the sisters/nurses.

Nepal, we miss you already!

A special thank you from Dr. Pradip on behalf of the ICU department and BIR hospital.

All good things must come to an end and this certainly holds true for my time in Nepal. I want to thank you all for following our blog and I apologize for not being more diligent with my posts. Truth is I got really sick during my last week here. I’m talking about a persistent fever and a dramatic loss in weight (sorry mom, didn’t want to worry you, but surprise). It was during this time that I truly felt at home in Nepal. I had people caring and nursing me back to health, new friends concerned over my well being, and local doctors giving me the special attention I probably didn’t deserve (helps to know people in high places). Dhanyabad. Thank you all!

So in an attempt to fill in the gaps, here are some highlights of my trip

Volunteer at BIR hospital

This has been an invaluable experience and has inspired me to always strive to be a better health care practitioner. Special thanks to Dr. Pradip, Dr. Navindra, Dr. Kiran, Dr. BB Singh, and all the ICU staff. You have all welcomed us in with open arms and treated us like one of your own and I am forever grateful. Never had I imagined how much of an impact several RT students could have, so never sell yourself short.

First Aid training with Next Generation Nepal

I have been a reluctant leader my whole life, but if this trip has taught me anything, it is that I am capable of anything. This trip has forced me to handle logistics, lead a team, and get out of my comfort zone to teach in front of an entire class (not once, but twice).

Ride out with Nepal Ambulance Service

This has been a humbling experience and has given me a new appreciation as a paramedic. Seeing how limited the equipment was here has made me realize just how lucky and spoiled we are back at home (spoiled as both emergency care providers and patients). Respiratory therapy is truly universal and holds true in the emergency setting as well, and I can’t wait to apply my new skills everywhere I go.

All the other little things

I’m talking about volunteering at Nepal Orphanage (Papa’s House), teaching pulmonary ventilation to the nurses at Annapurna Hospital, all the new friends I’ve made, and all the random acts of kindness from helping out street kids to fixing a blind man’s guitar (who also coincidently beat me in a one sided game of backgammon).

Thanks to all the people who made this trip possible: all the doctors and staff at BIR hospital, family and friends back at home for the support, all my new friends in Nepal for the hospitality and memories, everyone at Michener from the staff to my classmates, my RTWB team (Annette and special thanks to Eric for paving the way), and finally to my Nepal team (you guys are truly amazing).

Conclusion. It would be naïve of me to go home and think that I changed the world or that my work is done. Far from it, I would be considered lucky if I even made a dent in the grand scheme of things. Let this be the beginning of many things to come. My initial goal prior to coming to Nepal was to have an impact on the lives we come across. My goal has certainly been met and exceeded. I for one, have been impacted by this trip significantly, and have gained a new perspective and outlook on life. So to continue this streak of respiratory therapy around the world, I propose a new destination each year to educate those that want to learn. Email me if you want to join (clement@rtwb.ca) or visit rtwb.ca to learn more about us. To all the followers of our blog, thank you once again. To be continued…

“What I’ve experienced is that I can’t know the future. I can’t know if anything that I do will change what happens tomorrow. I can’t know with certainty, but what I do know is if I do nothing, nothing will change.” ~Dr. James Orbinski

Until next time,
clem

Outro song
Wallflowers- heroes

This week at Bir Hospital has been filled with presentations by Michener students. On Tuesday August 14th, Marry, Mandy and I presented the topic of Spontaneous Breathing Trials. For those of you who aren’t familiar with the term, it is a procedure used to assess whether or not a patient who is being mechanically ventilated is ready to have their breathing tube removed. Our audience, composed of doctors and students, were very intrigued by the presentation and mentioned that past RT students volunteering in Nepal were always so passionate about it. We tried to create discussion throughout the presentation to compare and contrast techniques and considerations between our practices. What I thought would take 30 minutes at maximum, turned out to be roughly an hour and a half of discussion. I was so impressed by their interest and willingness to learn from us. I felt very comfortable speaking to the group because they made me feel part of the team. The environment at Bir Hospital is very team-oriented as the departments are small in size and the number of health care workers are also minimal compared to our health care system back at home. Collaboration is key and I was able to sense this from our conversations with the health care professionals.

My experiences in Nepal thus far has taught me a lot about myself - that I am capable of doing anything I put my mind to. This is the frame of mind I want to be in prior to starting our clinical rotations this September. The phrase, “mind over matter” has never been more relevant to me since coming here. Whether I’m using it to expand my knowledge and further advance in my studies or overcoming my fear of heights (which I didn’t know existed until I was 160 meters in the air bungy jumping or 600 feet high heading down a zip line), I’ve realized that I can talk myself into doing whatever it is I want or am meant to do. Of course I can’t forget about the supporting cast behind me. Each day the “Nepal Team” amazes me more and more.

“Dream big, live large,” as Tiff likes to quote.

- Jenny

My Last night in Nepal was bitter sweet. Im leaving earlier than the group to head to Hong Kong to visit my father. Im going to Try and reconnect with him as I only see him once every couple of years. Nepal has shown me a lot about myself and my character. Something’s I know I need to work on and something’s I need to keep being next level, haha.
As I said my goodbyes to not only the doctors at Bir hospital and to the locals that we’ve developed great relationships with, I couldn’t help but tear up. You would think I would be happy to go home but at the same time I’m saddened by the thought that I really dont know when I’ll be back. Good laughs and good eats have been the centre of most of our encounters with locals and tourists and Frankly I’m going to miss it. Not to worry I shall be back.

Thanks goes out to Bir hospital for accommodating the bunch of us and showing us what the health care system is like here. I’m sure I speak for the lot of us when i say, we are great full and thankful for the opportunity to learn along side the icu doctors and the anesthetists. The educational experience has been priceless. Special thanks to Dr. Pradip, Dr. Ravi, Dr. Bibi Singh, Dr. Kiran and Dr. Navindra. Hopefully when I return home I’ll see differences during clinically and also share my experience with those who are interested.

To my family of SRTs and RRTs at home. This was a great learning experience not only on a personal level but also a social level. Learning about the culture and the way people live here is a great eye opener and has allowed me to become more culturally sensitive. I’ve been taking pictures on this trip and have called it the ” the anything is possible” shot. And it’s true, anything is possible. Never give up. “perfect practice makes perfect and practice makes progress”, 2 quotes I will always remember from 2 amazing teachers of mine. Thank you. If you ever get an Oppportunity to do something like this, take a second and think about what you say next. Seize the day and to quote our Canadian born rapper and my friends in Nepal “YOLO” (you only live once) I said yes, will you? I thought The experience was extremely rewarding and so much better than just going to site see. The purpose of this trip was to help and volunteer, the rest was truly secondary but it made the experience that much better. I felt like there was purpose. This is my second time doing something like this and I enjoy it more and more each time. If u can, Take the chance and go hard or go home!

This trip has been more than gratifying. We’ve spent 6-8 months planning and raising awareness for our cause. Through pub events, silent auctions, raffle draws, bake sales and donations we were able to reach our goal in money raised. This is a true testament to committing to something and getting exactly what you want out of it. Its holds true to, if you believe in something it’ll happen. It’s incredible that it’s been 6 months and now the trip over, but you know what, it was all worth it. We didn’t know it would become so big. Our blog and our stories are shared with the world and to have people email us personally and respond to our posts about our experience is a feeling i can’t put Into words. There is no way I thought it would be what it is. Go big or go home, right? I want to say thank you to all of our supporters at home and The Michener, our RT family back at home and all those around the world following us. Without all of you this experience would not have been the same. And im really happy that i can share this experience with you all. Blogging is not easy and I think i could only do it part-time, aka part-time blogger. Thanks for all of your support and for keeping up to date with us. Through the wonderful world of the world wide web I hope you had a great time with me and had a similar experience as i did, thank you.

#Nigel

This photo is in no way promoting the use of marijuana, but goes on to show how readily drugs are available here in Nepal. It was taken during one of our hikes up to a monastery.

In an effort to be a better humanitarian (self proclaimed), I feel an obligation to share with you social issues I’ve noticed simply walking down the streets of Thamel. Among all of them, I’ve decided to focus on one, drugs.

On one of our first nights here, we came across a local girl on the streets who had overdosed on some concoction of drugs and opted to help her out. As the days went by, the problem of drugs became more noticeable. In my short time here, I have already been offered hashish and cocaine, especially from rickshaw drivers after you turn down their offer for a ride. After doing some research, I found out that heroin and opium are also readily available. What ultimately led me to this post was seeing the vast majority of drugs among the street kids. It is no longer a surprise for me seeing kids huff on paper bags in broad daylight, whether it be glue, boot polish, petrol, or burning plastic.
Anyways, I guess the purpose of this entire post was to simply bring about social awareness.

And yes, this post is totally respiratory therapy related. As advocates of healthy lungs, smoking or huffing of any substances is bad. Smoking increases the number of goblet cells in your mucosal (goblet cells increases the amount of secretions, reason why smokers cough up so much junk). Lastly, the overdose girl had an increase risk of aspirating (foreign substance into the airway) on her own vomit, so we had to keep her on her side even though she was flailing around.

The problem here isn’t just the drugs, or it’s immediate availability, it is about awareness. So although this isn’t much, let this be the first step against social ignorance and negligence.

clem

For the first time since we started at the hospital, the ICU wasn’t full. There were 4 patients, 2 of whom were on ventilators, one on a mask and bubbler, and last one breathing room air looking like he was doing quite well. The patient in bed 3 was the one who caught my attention the most. Admitted for acute pancreatitis, he was intubated after his sats dropped significantly. The pancreatitis was concluded to be a result of excess alcohol consumption. He had persistent tachycardia, which doctors thought could be due to his fever but when his fever passed he continued to have severe tachycardia. On auscultation, there was bilateral consolidation with laboured breathing noted. There was a decision to go from a VC-CMV mode to CPAP today for some reason, which no one could explain. As the patient still had tachycardia and very dark urine with a PF ratio of 151 we had concluded this patient was in MODS (multiple organ dysfunction). We define this when there are more than 2 systems in a patient’s body that are failing. There were also signs of sepsis present.

We were discussing the idea that the patient had developed ARDS, which Dr. Pradip said was common in these patients. With the ARDS, we suggested to change the mode back to a more controlled and less spontaneous mode, as he looked quite agitated from the ventilator and was starting to bite on the tube. Before switching to the VC-SIMV mode, we mentioned it may be a good idea to sedate the patient more, which was then done. With ARDS we target a low tidal volume (lung protective strategies), high PEEP and change the FiO2 according to your PEEP (ARDSnet protocol). We adjusted the PEEP from 5 cmH2O to 7 cmH2O when Dr. Pradip inquired about how we think the PEEP could potentially negatively affect this patient. We worked together to decide with a higher PEEP, decreased venous return is possible and thus CO may decrease. With a decreased CO may result in decreased perfusion to the kidneys and lead to kidney failure. This could explain why we saw very dark urine. So the first organ to fail was the pancreas, which lead to the respiratory system, kidneys and circulatory (sepsis). The possibility of an added liver abnormalities or failure is quite high due to this patient’s history of alcohol consumption. We discussed obtaining another new ABG result, even though they are extremely expensive to do at Bir. For this patient it is one of the most optimal ways of guiding treatment especially with his ARDS.

The main reason I was interested in this case was mostly for the MODS and ARDS. I thought it was a good collaboration to decide how to guide this patient’s ventilation in anticipation of a positive outcome. 

- Mandy

This photo was taken this morning which also happened to be Nigel’s last day. Here we are with the amazing team at Bir Hospital.

Jenny

Last Thursday, we were given a wonderful opportunity by Dr. Pradip to interact with prospective critical care nurses at the Annapurna Neurological Institute and teach them what we’ve learned about ventilator modes.   Trying to cram what we learned in a semester into a 1 hour session with language barriers was certainly a great learning experience!   I learned the importance of being concise, talking slowly, enunciating words clearly, and most of all – simplifying a significant amount of knowledge into smaller components.  I also learned a lot about body language.  At first, I didn’t think I was relaying information very well.  When I asked my group if they understood what I just said, they would tilt (not shake) their heads left and right.  In Canada, I would interpret this as no.  However, in Kathmandu, it’s common for people to tilt their head like this to signify understanding.  And when I quizzed them later, they exemplified a great comprehension of the material.

In Dhapasi, Mandy and I went to a girl’s orphanage – the Imagine House.  Again, I experienced the same lesson on being concise when helping the girls with their English and Math homework.   After a few miscommunication issues with other girls, I was very pleased to see that Gita, a little girl I was helping earlier who had to re-do a significant amount of work, was able to complete the rest of her math homework on her own!

While they were very different experiences, the lessons I took away from them were very similar.

I’m very excited for what the next week has in store!

-Marry

(Below are pictures of the group at Annapurna Neurological Institute where we taught nurses in small groups about ventilator modes)

Prior to my departure from Toronto, I had plans to blog and photograph every moment that I could during my time here in Nepal. Once I started my observership at Bir hospital and began volunteering at a nearby orphanage called Papa’s House, I quickly discovered how busy our daily schedules would be. I find that I am often caught in the moment with whatever it is I’m doing to even be thinking about taking photos. My experience at Bir Hospital and the educational opportunities provided by Dr. Pradip have been utterly surreal. We’ve been listening in on bedside rounds and have been asked to contribute any thoughts or ideas surrounding patients with respiratory-related conditions/disorders. Working with the healthcare practitioners here inspire me to become a more innovative thinker seeing as how they are able to make due with the limited resources available to them. They encourage questions and always find the time to ensure that we understand the concepts and values discussed.

Dr. Pradip arranged a teaching opportunity for us at Annapurna Neuro Hospital this past Wednesday. At first I was hesitant because it was something I had never done before. We were asked to teach the basics of mechanical ventilation to 32 student nurses. Since there were 7 of us teaching, I looked at it more as a presentation - something I’m familiar with. When we arrived at the hospital, we were taken by Dr. Pradip to the teaching room where in filed the 32 student nurses. After each person introduced themselves, we split into small groups of 6 to begin our mini seminar. Mandy and I were paired and I felt we were very well organized with what we wanted the student nurses to learn and the order for delivery of information. We began by discussing the 3 waveforms of pressure, flow, and volume, proceeded with phase variables, followed by modes and lastly settings on the ventilator screen. The student nurses seemed very eager to learn by the questions they were asking. I think this has to be one of my favorite moments since arriving in Nepal.

Each afternoon this week, we’ve been dedicating our spare afternoons to volunteering at an orphanage as previously mentioned. Just seeing the kids so happy and selfless despite the reason why they’re living at an orphanage make all my problems at home seem small. But I almost want to say that it’s something I’ve noticed with everyone here. Forget the dangers of living in a 3rd world country; the people here are absolutely wonderful. Thursday was our last day at Papa’s House and it was terribly difficult saying our goodbyes. We’ve technically known these children for 3 days but grew attached to them instantly. I admire how the children and people of this culture in general, interact with one another. Regardless of their age, they are all very well-mannered, respectful and share a strong sense of community.

It’s my 7th day in Nepal and I’m already realizing the worth of this trip. My appreciation for other cultures has surely expanded from my point of arrival and I look forward to learning more about Nepal.

Before I end off, I just want to say thank you to everyone who supported us from day one and along the way. A special thank you goes out to Clem, Caroline, Marry, Tiffany, Mandy and Nigel for being such an amazing group to work with. Although we have another 2 weeks to go through, I just wanted to acknowledge them and let them know how much I appreciate their efforts in making this all possible. No one’s hard work goes unnoticed.

- Jenny

As my classmates were spending the afternoon sharing their knowledge about ventilation with nursing students at Annapurna Neuro Hospital, I got a chance to spend some time in the ICU with Dr. Pradip. He was very eager to talk to me about one of the patients who still had his ETT (breathing tube) in and was currently hooked up to a T-piece and bubbler. Immediately this struck me as strange, thinking about how this patient has to use so much effort to suck in a breath through that tube without any support. So it was no wonder that he was using accessory muscles, and sometimes forcefully exhaling, But his saturation was good and stable.
The debate was about the next step for this patient. Dr. Pradip considered a tracheostomy because the patient could not clear his own secretions (couldn’t cough on demand). But we talked it through and realized that he was not receiving the humidity that he required, and his tube was likely full of thick and dry mucus. In fact, the same patient had a mucus plug the day before when Nigel had visited. Because of increased resistance, it was likely harder for him to take a bigger breath in needed for coughing, and trying to force those secretions through a tube seemed impossible.
I mentioned extubating because he was not receiving any ventilatory support at all, and before I knew it, Dr. Pradip was reaching for the suction getting ready for pulling the tube out.
The extubation was very different than what we’re used to at school. Whereas we follow a specific set of guidelines and procedures, here it was a bit more unorganized. I guess you can say they are more easy-going with the process. I also trust Dr. Pradip’s expertise and experience in anesthesia, so I took the differences (no auscultation, not having a high-flow system ready, less PPE etc) to be differences in protocol and personal preference perhaps.
The tube came out full of discoloured mucus and the patient’s cough immediately improved. His respiration rate slowed down and his breathing pattern became more normal. He was given nebulized epinephrine as per protocol to prevent swelling of the vocal cords. Overall, it was a successful extubation, even if it did not follow the specifics that we’ve been taught. I was very glad that Dr. Pradip asked me to be present for this, and valued whatever little input I had to give. It reminded me of how excited I am to begin my clinical placement, and gain the experience to act as confidently as Dr. Pradip did today.
-Caroline

Wednesday was really busy, we were all in the hospital and expecting rounds to happen but I think they opted to do bedside rounds instead. We had a teaching plan to give to some nursing students at Annapurna neuro hospital. Dr. Pradip asked us to explain venilation to them and it worked out pretty nicely. Actually it wasnt so much a lesson as it was a discussion within groups . We mainly talked about mechanical ventilation first principles and modes. There were 32 nursing students and 6 of us who want to help, so we divided up into 5 groups. It wasn’t a difficult lesson but I questioned myself sometimes, only because I wasn’t being asked any questions. I took it as either, I was pretty clear with my discussion topics or they were too shy to ask. I think its the first one. I just hope they understood. Drawing diagrams really helped and drove key ideas. I could here the sisters ooo and ahh. To be honest I was nervous to start the discussion, but as the time went on I got more comfortable. It’s not easy to teach, that’s for sure. This was an awesome experience, I had Dr. Navindra sit in on my group and help me translate and drive home key messages. It was very helpful for them and me. If we had a ventilator on hand, it would have been much more interactive for the nurses. I also found that there were certain words that would explain things much clearer than words that we commonly use to describe waveforms. For example. When we talk about a volume control mode we say it controls volume and it’s constant, but changing one word like constant to fixed got the nurses to understand much quicker. Amazing how language not only can act as a barrier but also a means to break that barrier to establish a common learning ground.

Overall I think the discussion went well, everyone seemed to finish at the same time. And the sisters were very happy we came to help.

Thursday is a public holiday so there weren’t any scheduled rounds, so it’s going to be a day of catching up on blogs and school work for me. I was talking to one of the other team members and we both mentioned how we wake up everyday at 730 and finish our days at 2 and 5. And yet it seems like there isn’t enough time to do everything we want.

We’re headed to Pokhara this weekend, it’s like a vacation spot for locals and a hit with tourists. I’m excited, it’ll be a mini vacation for all of us.

See you after Pokhara!

#Nigel

Intubation equipment, tubes and meds are checked and ready to go!

#Nigel