Stalling

I guess I have been putting off composing this, my last blog post for “teachingcardioinkathmandu”. 

I arrived back in Canada last week (4 hours to Bangkok, 17 hours to LA, 2 HOURS in the immigration lineup to get into USA, 6 hours sleep in a hotel in LA and then 2 hours back to Vancouver: 31 hours total). It took about three days to get over jet lag but that is just physiology.  It takes much longer to shake off the feeling that I have left behind more than just a few kg of weight. 

On my last day in Kathmandu, on the drive to the airport Anil (hospital car driver) asked me what music I wanted to listen to and I said “you choose your favorite music”.  He selected a CD of piano music.  I love listening to someone play piano but for some reason it brings out more emotion for me then listening to other instruments.  I have always thought (illogically) that it was because there is more space left open between the notes that are available to fill with feeling…  So as the notes played out, and as we drove the back streets of Patan to the airport, I watched the scenes unfold in front of us and I felt what I always feel as I leave Nepal: reluctance to leave. 

I consistently get so much more than I give when I am there, and that was true in spades for this trip.  I learned more about who I was as a teacher, what my preconceived notions were about pedagogy, and I learned that the more you know about a culture the more you realize the vast amount you don’t. 

That’s the beauty of a long term relationship, however,  I have a lifetime to keep learning about it.

Namaste

Thanks for reading!

Pheri betaula (see you again)

Batch two!

 Vice Chancellor Karki meets the 2nd batch after the orientation lecture.

Second batch during orientation lecture.

Second Batch during orientation lecture.

Shiny and New

Today we met the second batch of PAHS medical students, 60 bright, shining (mostly female) faces.  This the is the result of all the hard work by Dean Rajesh Gongal and his admissions-selection team that was being carried out on the day of my arrival to PAHS 6 weeks ago.  Since then interview scores were tallied, total points for rural status and other minority markers were accrued, and the list of names of the successful candidates was published in the National newspaper.

Then began an extraordinary process.  Each potential student was invited to visit PAHS (along with their parents), and personally meet the Dean.  The point of this meeting was to make sure that the students (and their parents) understood fully the unique mission of this medical school.  It was explained carefully that their medical training will be centered around social accountability, and that they will engage in bi-yearly rural postings throughout their 6 year program.  Further, they were told that they will spend 6 months at a rural district health post in their 5^th year of study, and depending on their level of scholarship support, they will spend anywhere from 2 to 4 years of service as doctors in a rural setting after completion of their MBBS degree.  In the end 100% of those that were offered positions,  accepted.

As I saw them in the lecture theatre, all shiny and new to the program I saw a mixture of emotions reflected in their faces.  I saw eagerness and enthusiasm, quiet reflection and in some faces there was uncertainty, not for the path they have chosen, rather the uncertainty that comes from being thrust into a new and unfamiliar environment.  Kathmandu remember, may well be the largest city some of the rural students have been exposed to.  Some have spent most of their lives in remote villages where the only access is by path (not Pathfinder). For these students there will be many adjustments ahead, being away from family, living in a student hostel, and making new friends.  The class however, also includes students that have grown up in Kathmandu and they will have their own adjustments to make.  I couldn’t help but imagine how the urban students will look a week into their first 2-week rural posting, where they are allowed to bring only the clothes they are wearing, a tooth brush, a pen and a journal.  All the students lodge with individual host families in a remote village where distractions, beyond your thoughts, are few.  For the urban students these postings may be their first trip outside of the Kathmandu City ring road and their first glimpse of the rural poverty crippling their country.

One year from now I will return to teach this new class and while the first blush of excitement may be gone from their faces, I hope the burning desire to learn, coupled with the growing commitment to serve the poor of their country will have taken it’s place.

 At the gallery in Patan with Kunda Dixit (left) and David (right).  The pictures on the top row are the originals with stories below of where the people are now.

A People War

Last week David and I had the incredibly fortunate opportunity to spend two hours with Kunda Dixit (Publisher of Nepali Times and author of three books describing the ten years of Nepalese civil war). The initial book was titled A People War and was a collection of photographs that chronicled the indelible imprint left by armed conflict on the people of Nepal.  The book highlights 72 haunting photographs taken by amateurs and professional photographers and painstakingly selected by Dixit and two colleagues (Shahidul Alam and Shyam Tekwani), from the over 3000 submissions. Following the publication of the first book Dixit took the framed prints from the book on a tour across Nepal and gathered written comments from Nepalese people who came to see the “in situ” exhibits in their villages.  These written reflections and reactions formed the basis of the second book “Never Again”.  During the cross- Nepal photo exhibit stories of the people captured in the original images began to emerge, particularly what they had done since their images were captured during the time of conflict. Their stories were complied for the third book “People After War”.

A museum of the framed prints from the original exhibit has been established in Patan and we had the extraordinary opportunity to have Kunda Dixit describe each print and to tell the story of the people in the image.   There are also books on a central table in the museum that continue to capture the written responses of people who have the good fortune to visit this museum.  Plans are in the works to fully open the museum to the public including the follow up stories of the people in the original photos.

What struck me about this exhibit was that it took me on a journey starting with despair, through anger, to the emergence of optimism for lasting peace in this country.  I ran the gamut of emotions but was left mostly with hope.

While a visit to this museum is not noted in any of the popular “travel guides” of Kathmandu, for the people traveling here who want to engage with Nepal at a level beyond being a tourist, here is your chance.

To see the exhibit contact Kunda Dixit at the Nepali Times:  kunda@nepalitimes.com

Angela's Afternoon

One year ago my family lost my 33 year old niece, our wonderful Angela.  She was a bright star in our world.   Her profession and her passion was taking care of children and as a result, David and I have honored her memory by dedicating one afternoon each visit to Nepal to having fun with the children of Sonrisa Orphanage (www.sonrisanepal.org).  These days are called “Angela’s Afternoons”.

This past Wednesday was our third Angela’s Afternoon.   We hired a big van and 15 of the children plus two Aunties, two uncles (including Bishnu- Sonria’s director), plus David, myself,  Bibiana,  Jason and Sibita all piled in and drove to the cinema. 

Who knew that traveling in a big comfortable new van “guaranteed smooth ride” would have made so many children so car sick???  Turns out the children have no problem in the normal taxi’s of Kathmandu- the one’s with no suspension and bumps and jolts galore; but put them in a smooth riding vehicle, go over 50 km per hour and take cover.  Faces turned pale, then green.  In my head I could hear my niece Angela say “Oh Mylanta!”    Luckily Bishnu had a supply of plastic bags and after a kind of squishy 30 minutes we made it to the theatre (tipping the van driver extra for his –ahem- clean up).

Kids are resilient though and once in the door of the giant new shopping mall restless tummies were immediately forgotten.  All the adults were assigned two children who clasped our hands tightly.  We rounded a corner and Bishnu directed us to go up in the elevator to the fourth floor.  As I went to go in I was met with fierce resistance and looked down to see two sets of eyes as large as dinner plates.  Elevators with glass walls are pretty scary things when you have never been in an elevator before!     With a little coaxing however Anita and Ramita trustingly followed me in.  As luck would have it the doors opened at floor three and we were swept out with the crowd.  No problem.. David saw AN ESCALATOR going up to the fourth floor…. Another completely new experience!  This one was trickier because you have to time things getting on and off.   Despite sweaty palms and a few missteps, however, we all arrived on the fourth floor intact.

All in all 24 tickets were purchased and despite being 20 minutes late in arriving we managed to find our assigned seats in the dark..  This cinema is one of the new deluxe movies theatres in Kathmandu and the film was a Hindi “boy bonding” flic where three guys go on a road trip to Spain in advance of one of them getting married.  This is the new generation of Bollywood movies with the requisite gorgeous Indian actors, love stories, and musical numbers, but set outside India and everyone wears western clothing. The screen was enormous and the Sonrisa kids were soon completely captivated.

Intermission arrived and 15 bags of popcorn and pepsi’s were passed around.   The movie built to it’s happy ending with the boys having bonded by addressing each of their deepest fears: scuba diving, paragliding and running with the bulls.  Not sure what the children actually took away from the plot but they seemed to be enthralled with the images and music.

While it was a kind of rough start, the fourth Angela’s Afternoon ended happily with 15 children sent home (IN TAXI’S!!) with chocolate cookies (bought by Jason) and instructions not to eat them until AFTER getting home. 

Myself, I couldn’t help but think that Angela, realizing that kids get car-sick and are afraid of things they haven’t done before, would have had all the bases covered and three contingency plans ready to deploy.  Angela would have known.

After the show, serious poses for the camera.

 at the cinema (through the security check- apparently film piracy is rampant so they check for movie cameras).

 after the movie, at the inflatable climbing wall (Dinesh already at the top!).

arriving at the mall!

In the still of the night

Disclaimer: Descriptions of bodily functions below

Around noon yesterday I started to feel significant lassitude and light nausea.  It persisted over dinnertime (all I could choke down was a "Mango Slice" drink) and by the middle of the night I was vomiting...  Sadly I will never be able to drink a Mango Slice ever again...

I woke up to significant diarrhea AND was scheduled to give Grand Rounds at 8am!!!  Somehow I managed to give my presentation without bolting off the stage in disgrace..

In the depths of the night, while barfing into a bucket, I was consumed with dire thoughts... I kept picturing a young girl we saw in the ICU at PAHS who had been admitted to hospital with "belly pain" that progressed to respiratory failure and ended in her death.  Surrounded by darkness, I imagined myself in that bed, intubated and attached to a ventilator looking up at the faces of the concerned but perplexed doctors as they tried to figure out what was wrong with me.

I had this feeling 10 years before in Nepal, high in the mountains, suffering from altitude sickness, knowing that the line between illness and health here is razor thin. This feeling compounded by being kilometers by rough trails away from the nearest road.  Back then, however, it was for me a choice to come to Nepal and explore the mountains.  For the Nepalese people this is their day to day reality.  In the remote parts of the country, you get sick and you suffer.  You get really sick and you may die. 

But after the darkness, comes the more rational light of dawn.  Antibiotics are procured, rehydration salts are consumed and in time the bug I contracted will be beaten into submission.  Not so however for the young girl in the ICU.

OK one last try to show you the winning poem...

And finally a poem by Kishor Adhakari title: "My Heart"

My small heart,

The natural electricity powerhouse of my own

Beats like a fist

Against my rib case

Thumping desperation

To burst out and roam

Further than my chest

Far beyond my rib case

Throbbing,

Pulsing,

And beating forever and ever  

 My mom used to say, serve the poor

 Lord Buddha says, love the poor,

 I do have the heart that makes me kind;

The heart that rules my mind.

 The miracle is the way you boom,

 Unprompted since i was 5 mm

 Inside the mother’s womb,

 Sometimes let me feel your presence,

 And bump inside the four rooms

From dawn to dusk,

And round the clock,

You are there for me,

Vigil all the time,

Supporting life even when

It is all alone.

Why does it feel this way?

The exact same thing

every day

I have no more to say,

I have no word to say,

How divinely and supremely

I am proud of you

Simply because, you are the

reason i am,

You are all my reason.

My Heart Poem by Kishor Adahkari

And finally a poem by Kishor Adhakari title: "My Heart"

My small heart,

The natural electricity powerhouse of my own

Beats like a fist

Against my rib case

Thumping desperation

To burst out and roam

Further than my chest

Far beyond my rib case

Throbbing,

Pulsing,

And beating forever and ever  

 My mom used to say, serve the poor

 Lord Buddha says, love the poor,

 I do have the heart that makes me kind;

The heart that rules my mind.

 The miracle is the way you boom,

 Unprompted since i was 5 mm

 Inside the mother’s womb,

 Sometimes let me feel your presence,

 And bump inside the four rooms

From dawn to dusk,

And round the clock,

You are there for me,

Vigil all the time,

Supporting life even when

It is all alone.

Why does it feel this way?

The exact same thing

every day

I have no more to say,

I have no word to say,

How divinely and supremely

I am proud of you

Simply because, you are the

reason i am,

You are all my reason.

It is Friday, the last day of the Cardio Block here at PAHS.   

Two significant events marked this auspicious date.

During our case wrap up the students marked us with tikka’s and gave us lovely gifts (pashmina for Bibiana and I and a Nepali hat (Tupi) for Jason!  They gave us each a Buddha statue to remember our time here.  It was quite humbling.

We also had the prize presentation of Mero Mutu Mero Kala 2011 

(My Heart, My Art).  There were almost 30 submissions consisting of paintings, photographs, sketches, poems and two music videos!.  Considering there are only 58 students in the class that is an amazing response!  Such a strong response in the form of poetry was a surprise to me, since there are rarely poems in the Heartfelt Images contest in Canada.  On the other hand Nepal is a country that has national holidays to celebrate it’s famous poets…

The judges had difficult decisions to make but we awarded prizes in three categories: Photography, Poems and “Other Media”.    Here are the winners of the competition:

A painting incorporating the Nepali flag and national symbols with the heart and circulation (by Pravakar Parajuli)

 and a photograph illustrating the role of the heart to pump blood by Prakriti Bhattarai.

And finally a poem by Kishor Adhakari title: "My Heart"

My small heart,

The natural electricity powerhouse of my own

Beats like a fist

Against my rib case

Thumping desperation

To burst out and roam

Further than my chest

Far beyond my rib case

Throbbing,

Pulsing,

And beating forever and ever  

 My mom used to say, serve the poor

 Lord Buddha says, love the poor,

 I do have the heart that makes me kind;

The heart that rules my mind.

 The miracle is the way you boom,

 Unprompted since i was 5 mm

 Inside the mother’s womb,

 Sometimes let me feel your presence,

 And bump inside the four rooms

From dawn to dusk,

And round the clock,

You are there for me,

Vigil all the time,

Supporting life even when

It is all alone.

Why does it feel this way?

The exact same thing

every day

I have no more to say,

I have no word to say,

How divinely and supremely

I am proud of you

Simply because, you are the

reason i am,

You are all my reason.

Thank you to David for the two Buddha pictures in last post!

road less taken

Each morning at 5:30 the morning sun coupled with the local rooster wake us up.  Rain or shine we head out for a dawn walk around our neighbourhood.  The route varies each day and is dictated by how much time we have and whether it rained over night; flooded muddy paths are hard to negotiate!

This morning David and Bibiana and I walked over to Patan Durbur Square (the oldest part of Patan) and while striding along a pretty busy main road, a red brick pathway going off to the left caught my eye.  I turned in and we started to follow the very narrow twisting laneway flanked by tall old brick buildings.

The laneway broadened out slightly and there were two choices, continue to follow the path, or go off the right through a  small wooden doorway into an inner courtyard,  For no  particular reason I walked through into the courtyard.  It was about 100 square feet, the buildings were original dark brick with old carved wooden window frames.  Against one wall was a single 30 foot tall Golden Buddha statue.  There were no plastic chairs, motor bikes or electrical wires.  There was a small brick gathering spot for morning washing and I suspect little has changed in the courtyard in the past 100 years.  To the right of the Buddha there was an old didi leaning on a window frame looking into the square.  She was dressed in the traditional white sari of a widow and she had a kind smile. We exchanged a Namaste as I walked back toward the door to leave the courtyard.

From time to time it’s good to not have a plan, and let chance be your guide.

hard labour

There was an initial flicker of mild curiosity in her eyes.  She may have wondered what the woman with curly yellow hair was doing at the end of the bed, but that was quickly replaced by a distracted, more primal look, her eyes simply registered pain.  She was in active labour, having regular contractions but not quite dilated enough to begin pushing.  Pain for pain's sake, no pay off for the effort.  Her sweat-stained bright orange cotton tunic top was draped over her distended belly, her hand gripped the metal rungs of her hospital bed and beads of sweat stood out on her forehead. She didn’t make a sound, all her effort instead was focused on enduring the closely spaced contractions.  

In Nepal when women give birth in maternity wards at the hospital they don’t go seeking a painless delivery with epidurals and analgesics.  We were told that pain medications are reserved only for unspecified “special circumstances”.   I could hear my Canadian colleague ask “Isn’t a painful labour enough reason”?

In place of intravenous drips and analgesic gas there were the soothing hands of mothers and didis. Backs were being massaged, thighs and feet were being rubbed, and water was being offered to parched mouths.  In fact, aside from some of the doctors and interns, there was a complete absence of men in the ward.  The men, banned from the labour wards, were all squatting on the floor or in the stairwell outside the labour ward.  They had a distinctly different look in their eyes, a continuum from boredom, the ones who had been through this before, to rank fear, clearly the first-timers.

Birthing in Nepal, it seems, remains firmly behind a gender curtain where women circle the wagons and silently, painfully usher in the next generation.

a twinkle in her eye

I was accompanying two colleagues on rounds in the hospital and we were at the bedside of a critically ill patient who was in the intensive care unit with a very serious infection.  Often patients in the ICU are so sick they have a breathing tube that is allowing a machine to breathe for them and this was the case for her.   Up until that point I had only seen her as a very sick young patient.  As part of a routine examination my colleague leaned over and raised her eyelids one at a time.  As he did the light over-head reflected in her eyes as it would have if she had been awake and alert. Under other conditions you would have said she had a twinkle in her eye.   And just as quickly her eyes were closed again as if a curtain fell to end a brief play.  But in that split second I saw her not as a very sick patient but as a vibrant young woman.   I imagined her smiling and laughing.  It made me think of how much importance we place in what we see in someone’s eyes; the joys and the sorrows. 

If as they say, the eyes are the windows to the soul, then I hope she knows that for an instant I saw her fully, despite the drugs, the sedation and the breathing tube. 

I felt her spirit.

Nourishment

It was 12:15pm, the end of a long morning that started early (presenting Grand Rounds) and was concluding with a two-hour tutor prep meeting before our last PBL case next week.  It was hot and ceiling fans were making a whirring sound above my head.  The noise from the fans was competing with the gurgling sounds my stomach was making in anticipation of lunch.  Just about that point, Mili (CV Block Director at PAHS), told us that we (the faculty) were requested to attend a meeting in the PAHS classroom.    I put aside my thoughts of duita roti ani tarkari (my usual lunch) and joined the faculty as they filed into the classroom.  A set of chairs were arranged at the front of the crowded classroom and we were invited to sit down facing the 58 students.  It was explained to us  by one student that it was Guru Purnima, the full moon day, and they were there to give us (their teachers) a special honour by applying abir (red powder) as a tikka to our foreheads.   Thoughts of food instantly vanished and were replaced by the kind of nourishment that comes from an exchange of the heart.

Grand Rounds PAHS

Today Bibiana and I gave a Grand Rounds Talk for the Patan Hospital and PAHS faculty and medical students.  Our topic was "developing a culture of scholarship" in an academic medical institution.  My role was to talk about how basic scientist faculty could look at Scholarship.  I used the expanded Boyer definition (Scholarship Reconsidered):  Discovery, Integration, Application and Teaching.  Bibiana talked about how Clinicians can embrace a triple career of Research, Clinical Work and Teaching.

Shahid Gangalal Heart Centre, Kathmandu Nepal

 Dr. KC, Director of Centre (3rd from left) plus Cardiology Staff, CA, Jason and Bibiana on our visit to Heart Centre

Very modern Catheterization Lab  (Angiography,  Stenting, Coronary Artery Bypass Grafting, among other procedures).  This government-run centre takes off the street patients (no referral necessary) and only charges them ~15 rupees for a consult with a cardiologist. Private patients pay a fee to be seen and that offsets the cost for poor patients (this is a relatively common practice in some Hospitals.

But what did they learn????

So here we are in week 4 (of 5) weeks of PBL teaching at PAHS.  Soon we will assess what the students have learned during this block.  The method of assessment at PAHS is conducted in two ways.  One involves an end-of-block written exam using Multiple Choice Questions (MCQ).   MCQ involve a short “stem” followed by a specific question and four options from which students select the single correct answer.  The other written exam consists of Problem Based Questions  (PBQ).  PBQ reflect the kind of learning done in the PBL tutorials.  In these exams students receive a patient scenario and they have to generate short written answers to some relatively open ended questions.

At UBC we use MCQ in our written exams so the format of questions is similar.  There are two differences however; one is that the MCQ at PAHS are generated to be discipline specific (e.g. physiology questions, anatomy questions, pharmacology etc….).   MCQ at UBC are purposely created to integrate the disciplines.  Another difference is that our MCQ exams are held at the end of year, whereas here the exams are held immediately after the block concludes.   The obvious advantage for the PAHS students is that at the time they are tested the information is fresh in their minds.   At UBC the students may have participated in any where from one to three additional blocks before being tested on the material.  The challenge here however is that PBQ test a different type of learning.  For one thing the PBQ are not specific to any particular disciple but instead integrate subjects.  In addition the questions are open ended and don’t rely on a student’s ability to “recognize” a correct answer.

Is one method better than another? I suspect the answer lies somewhere in between.   The true test of course is when the students begin to apply the basic science learning when interacting with patients.  Will what they learned now be accessible and relevant?  Time will tell.

the light bulb

I am quite sure Thomas Edison did not have this image in his mind when discovered electricity…nonetheless

It was well after 6pm and I was in a small, hot seminar room with three Nepali medical students who were having some trouble understanding the cause of an electrical disturbance in the heart.  The single fan was rotating the stuffy air around and I was up at the white board explaining the tricky mechanism behind the arrhythmia when it happened.  I could actually see the light bulb go on for one of the students.  Literally, his eyes lit up fueling a 1000-watt smile, and he almost levitated above the chair in excitement.  It was one of those palpable experiences in education that convince you that all the mediocre moments, all the frustrations with teaching bureaucracy, all the hours of preparation have come down to this single moment in time.

a few more pics from Bhaktapur

A walk in Bhaktapur

Jason, Bibiana and I spent the morning in the town of Bhaktapur (City of Devotees), a medieval city that neighbours Kathmandu.

Paying attention

Here in a world that seems quite removed from the internet connectivity of the classrooms where I teach in Canada, I came across an interesting article about the role of social media in promoting attention while attending conferences.  It's worth a read I think.  Even better.. tweet about it.

http://www.alistapart.com/articles/conversation-is-the-new-attention/

Educational Crack Cocaine

Yesterday I gave two back-to-back lectures on my favorite topic, cardiac electrical activity and the genesis of the electrocardiogram.  During the lecture the students are extremely attentive and I face a sea of bright receptive faces.  Partly because I was teaching for two hours and partly because English is not the student’s first language, I built in frequent breaks where I invited the students to discuss in Nepali what I had just taught.  I often given students in Canada time to reflect on a difficult topics during my lectures, but here the second I make the offer “Nepali bolnus” the students virtually thrown themselves into discussion.  Drawings are pored over, rapid-fire gestures are made, differences in understanding are vigorously debated and the energy level is palpable.  It’s like a fire hose of clarification for the students.   For me, it’s educational crack cocaine.