CV PBL Tutorial Group

 CV PBL Tutorial Group:  Batch II

Ritu, CA maam, Monisma, Koomal, Shweta, Napoleon, Raveena, Rabin, Tassi and Ashok.

Donning the "white coat"

On Friday the new batch of students were inducted into the PAHS family in a ceremony where, for the first time, they don their short white coats and recite an oath that symbolizes their commitment as medical students to the underserved of Nepal.

First Dean Rajesh Gongal addressed the students with heartfelt words:

"Now that you are committed to pursue this way of life, we will help you , guide you and walk with you in this journey, for you are not alone in this journey as our destination is a common one, our aim the same , the relief of human suffering. Let the ceremony today be the mark of your entry into PAHS family. We will work together, laugh together, sometimes  maybe cry together but all the  time grow together.

My fellow students, let not the white coat that you don from today be a  symbol of status, nor let it elevate you away from the patients; let it instead be a symbol of kindness, a symbol of respect and a symbol of love. Let it also be a reminder for you to always be humble, a reminder that all that you will study in six years is only a fraction of what is there to know which is only  a fraction of what is already known which is only a fraction of the whole truth. Medicine is not  only about curing, for there are only a so many diseases that you can cure ; it is about caring and comforting.

Let this ceremony also be a symbol of your commitment to PAHS mission, vision and goals, to serve the people of Nepal ,especially those who live in remote and underprivileged part of the country; your commitment to be the leader in field of health, your commitment to make this country and its people healthy."

And if you are so committed then read after me the oath of PAHS Student…..

I pledge that as scholar in the field of Medicine, I will at all times act with compassion and respect towards patients and their families, regardless of their caste, religion, socio-economic status, age or handicap.

I pledge to respect the confidentiality of patients and their medical records.

I am committed to the Mission , Vision and Goals of Patan Academy of Health Sciences  in serving the disadvantaged, particularly those in remote rural areas of Nepal.

I will work together with the local community to help them address the health issues important to them.

I will study to the best of my ability and commit to continue learning and keep up to date for my entire medical career.

I pledge that I will at all times act with integrity, honesty and professionalism, dedicating my life to the service of others.

Oath  Part I

Oath Part II

Chocolit Schmoclit

My niece Angela died unexpectedly from a medical condition in 2010.  I was traveling here in Nepal at the time and was unable to make it home in time for her funeral.   Angela ran her own child care business in Canada and so while David and I were still in Nepal we decided a fitting way to honour her memory would be to provide the children at Sonrisa Orphanage with a day dedicated entirely to fun and play called Angela’s Afternoon.    We have been able to host one per year since then and we celebrated our fourth Angela’s Afternoon this past Monday.

Bishnu rented a van and piled the 15 children, two Aunties (Ganga and Januka), one Uncle (Bill), as well as Bibiana and myself and we drove for 45 minutes up to a hillside village called Godavari.   We spilled out and Bishnu distributed bags of bananas, two huge pots of cooked food (yes pots!!), roti’s, utensils, paper plates and plastic containers of water.  

Loaded down we started to climb..

and climb

It was hot sweaty work and after 2 short breaks and nearly 3 hours we arrived at an idyllic hilltop covered in pine trees whose shade was a welcome relief from the hot sun.   Lunch was sumptuous and healthy: a huge pot of cooked “masala” potatoes and another large pot of flavourful fried rice.  This came along with hard-boiled eggs directly from Sonrisa’s 47 chickens.   Bananas were our dessert!  I was astonished how much food a tiny, hungry well exercised Nepali child can consume in one sitting.

From our lunch spot we continued on and spent the next two hours hiking along a gorgeous ridge high above Kathmandu and the surrounding city sprawl.  The breeze was glorious and it was really comfortable walking in and out of trees and fern grottos.

So when I say hiking ….   I should qualify that hiking with boys and girls’ ranging in ages from 8 to 15 is an entirely different experience then the hiking I am used to.  This was more like a cross between hide and seek, volley ball and the 100 meter dash, with a little Bollywood dancing thrown in for good measure.  Every mound of dirt was climbed, every tree stump was stood upon, streams were jumped, leeches were discovered and flicked off ankles, flowers were gathered, bugs and worms were examined and all manner of wild fruit was picked and eaten.  The smallest children had only two speeds, full on running and stopping.  At one point I came around the bend to see the smallest boy Wonchu holding Bibiana’s hand while they both ran down the trail with joyous abandon calling out “kukur” the Nepali name for dog.

(photo credit: Bibiana Cujec)

Eventually however we descended the ridge and made our way, in the dying light of the afternoon, back to where the Van was picking us up.  

We all squeezed into the van and within 5 minutes ... .  

Life teaches you so much, should be open to learn.  My lesson on this Angela’s Afternoon involved chocolate.  As an extra treat I asked Bishnu to buy each of the children a chocolate bar to be distributed at the top of the long hard climb up.  We gathered together and Bishnu gave the bars of chocolate out.  While they were appreciated by the children, and I got a chorus of “thank you sister”,  I noticed that it wasn’t with the kind of excitement North American children might exhibit.  Bibiana and I talked later about it and concluded that for these children chocolate was nice but not necessary.  Time spent together with each other, with Bishnu, the Aunties and occasionally the visiting didis and dais are what is really valued.  Repeatedly throughout the day as I was walking on the trail or sitting on the grass a tiny hand would entwine with mine or one of the children would cuddle into my lap.   There was no requirement for conversation; it was simply sharing space and contact. 

(photo credit Bibana Cujec)

It made me think back to the times I saw my niece Angela cuddled with children.  Somehow children know what is important... so did Angela.

(wedding photo credit:  Miranda Clark)

The New Batch

A little over one and a half years ago David and I gave a welcoming address during orientation to the 2^nd batch of Medical Students at PAHS.  These are the same students that I am now back to teach.  In between they have completed their “pre medical” course, been out to the community slums in Kathmandu, and traveled to remote villages to take part in their first rural visits.  They have been accumulating some introductory clinical skills under the careful tutelage of their clinical preceptors.

I got to accompany a small group into the hospital as they learned how to use their stethoscopes and perform a cardiac exam. 

These stethoscopes were generously donated by Littman and brought to Nepal by the UBC medical students “Health Trek Nepal” who came here as volunteers this past summer.  Eight lovely cardiology stethoscopes were donated to the clinical skills program to be used by students that don’t own their own.

Earlier this week I gave a welcoming address to batch III PAHS students as they begin their own medical education journey.  

and the circle continues...

Teaching to give back

Children in the Sonrisa Orphanage in Nepal have all found a loving home and shelter under the care of Bishnu Rai and the Sonrisa didis and bhais.  While the orphanage has been the welcome recipient of generous donations from many friends in Nepal and abroad, Bishnu wants the children to understand the importance of giving to others less fortunate then themselves.  It was to this end that all 15 children arrived at the Social Welfare Centre Briddhashram, an Elders Hostel adjacent to Pashpatinath, the Hindu Cremation Site. 

For older Nepali’s without family support, this is where they spend their last years, supported by the charity of others.  While we were there a supply of curd and Biten Rice was delivered as a donation by Indian businessmen.  

The hostel was arranged as a single story of rooms that framed an inner courtyard, the centre of which was a stone platform graced by a centuries old Hindu shrine.   Residents of the hostel were clustered around the stone stairs of the shrine or in corners of the courtyard under whatever shade the trees had to offer.

Many of the didis’ were absorbed with the task of spinning bits of cotton into wicks that would be lit for morning pujas.  Old wrinkled hands crafting each wick with the efficiency that can only come with a lifetime of practice.

Most of the people we saw could get around on their own steam or with wooden canes. The reality was that many of these men and women were only 10 years older then me but the harshness of their existence led to deep lines in their faces and stiffness in their bodies, some bent at the waist from a lifetime of carrying heavy loads.

The Sonrisa children arranged themselves and their instruments (violins, drums, flutes) in front of the assembled gathering of elders.  

The music started and almost immediately the crowd was rapt with attention.  Bodies started swaying and hands clapping.  

Music has incredible power to evoke memories of earlier days when bodies were limber and graceful.  Soon the didis and dais were dancing with abandon, ignoring the piercing mid-day heat. 

In those fleeting moments you could see their younger flirtatious spirits.   With age comes a release from inhibitions and permission to express unbridled joy.    

There is so much to be learned from our elders.  

After the blood comes the tears

“After the blood comes the tears”

This was a quote by a Nepali villager who was attending a unique photographic exhibit of images that chronicled the 10 years of war in Nepal.  This quote was selected to be on the cover of one of a trilogy of books* edited by Kunda Dixit (Editor of Nepali Times) and now displayed in a unique gallery in a corner of Patan Doka.  Kunda was kind enough to invite myself, Jason, Bibiana, Darren and Shona for a guided tour of the gallery.

*

p://www.nepa-laya.com/eventdetail.php?id=60

The images below are a sample of how the gallery is set up.  The framed prints were published in the first book [A People’s War].  These images were toured around the country where scores of Nepali people wrote comments as they viewed the images.  The second book [Never Again] was a compilation of the written comments (including the quote above).  While touring the images people identified people in the original pictures.  The third book [People After War] pairs the original images with updated photos and stories of the people ten years later.  The story of Gita Giri is one poignant example.  In the original image she is photographed grieving over the body of her husband.  Ten years later she recounts the vividness of the memory of that day.

To fully understand Nepal it is necessary to understand the reality of the legacy of a decade of violence and to believe that the path leads to sustained peace.  A trip to the Dixit Gallery in Patan is a good start.

Mero Mutu Mero Kala

I announced the  “Mero Mutu Mero Kala” (My Heart, My Art) contest at the lecture this week.   This is an opportunity for the students to conceptualize artistically what they are learning about the cardiovascular system.   Last year we had 35 entries from the class of 60 students.   They submitted amazing paintings, sketches, poetry and a spectacular music video that summarized one of our PBL Cases (www.youtube.com/watch?v=HlZ0aDS2TfE).   

I’m excited to see what this year will bring in terms of artistic creativity.  I have also asked the students to submit a logo for the contest and we will select the best one to adopt for this contest.   I’ll keep you posted.

Kakani National Park

We have Wednesdays and Saturdays off.   Last year when we were here Bibiana, Jason and I got in the habit of going into the surrounding hills for a few hours to clear our heads of the smog and noise. 

Our close friend Bishnu Rai (Himalayan Sunrise Trekking) organizes our day walks.  On Wednesday he picked up myself, Jason, Bibiana, and Sushila Rai (our colleague from PAHS) and we drove about an hour outside of the city.  The road, like most outside of the city, becomes quickly steep, narrow and windy.  It is still raining as the monsoon tails off and so from time to time we were slipping in and out of ruts of mud.  I was thankful Bishnu had organized a four-wheel drive jeep as there are no guard rails and these roads are barely perched on the steep hillsides.   

We arrived at a National park called Kokani (yes it is pronounced like the beer in BC).  Our first stop was a monument to the hundreds of people who lost their lives in the crash of a Thai Airlines jet in the 80’s.  It was both chilling (to see how many died) and a stark reminder of the fact that air travel into and out of such a mountainous country retains a certain amount of risk.

The first half of the trek was literally slashing our way along a tiny jungle-like path that was completely overgrown with vines and undergrowth.  As expected we all had a few stray leeches in our socks and on any exposed skin.   The cicadas were deafening and the temperature ricocheted from steamy and hot to cool and pleasant when we got out on the ridge in the breeze.

We walked for about 5 hours along a ridge.  Mostly thick clouds that drifted around us like thick smoke embraced us.  Occasionally we caught glimpses of Kathmandu city.  From that high up the city looks beautiful if you ignore the yellow haze of chronic air pollution.   It is easy to see why early visitors to Nepal called this valley Shangri-La.

Chics and other diversions on our day off.

Chics!

A pond on the royal grounds, filled with squirming eels!

Street scene in Thamel (tourist district in KTM)

Street sign for copies of the Toronto Medical School Notes!!!!

On our day off Bibiana, Jason and I decided to take advantage of a Banda (a strike that bans local motorized traffic) and walk  from Patan to Thamel, the tourist region of KTM.  We left at 8am and it is about a 60 minute walk.  When there is no traffic and the air is clean and rain-washed it harkens back to the KTM of about 30 years ago.

We were spellbound by the Royal Ponds filled with squirming, splashing eels.  On the far right on the "cute scale" from eels we also saw boxes of fluffy chics for sale.

Like Cindarella at midnight however the spell was broken and at 10am the Banda was lifted and the  traffic and pollution returned.

Lights Out

When you have limited electricity you make the most of daylight. 

Here people are asleep early and awake at first light. 

Really first light. 

The rooster wakes us up at 4:45am and we roll out of our beds and by 5:30am we go out for a morning walk through Patan.  The light is that grainy pre-dawn monochrome and it is clear we are already late comers to the street party.  Students in their school uniforms and back packs are already on their way to schools, shop keepers are open for business,  if you walk through the street markets pungent meat is already slaughtered and colourful vegetables and flowers are artfully displayed for sale.

Daylight is a precious commodity when rolling brownouts limit electricity every day.   During monsoon, with lots of hydro-electricity available, the times without electricity are limited to two 4-hour periods a day.  A schedule on the wall tells you on any given day which hours it’s on and off.  Once the monsoon rains stop however and Nepal needs to rely on India to import power, the cuts can be up to an astounding 16 hours per day.  Rumours are swirling that this winter it may be up to 20 hours per day without power.

If you are a student that leaves little time for studying outside of daylight hours.  Access to Internet and searching for resources online are similarly restricted.  If you are lucky you live in a residence or your parents home, that has an inverter and you are supplied with auxiliary power during the cuts.   If you aren’t, you study before the sun goes down or in the few hours that power flows into your house.

Try it sometime.  Limit yourself to 16 hours of electricity and to make it more realistic make at least 8 of them in the middle of the night. 

Now I know why I get emails from my Nepali colleagues in the middle of the night.

Day One

Day one

Nine expectant faces in a decidedly hot tutorial room.  We introduced ourselves: what will we each bring as a strength to the discussion and what will we each need help with.  Strengths were varied: love of physiology or pharmacology, drawing diagrams on the board, creating summaries or flow charts, good listening skills, asking good questions.   On the flip side they would need help from each other with physiology, pharmacology, drawing on the board, speaking English.  Commonalities were established and the beginnings of rapport were established.

They established ground rules for our group (pretty standard PBL behaviors) and we were into our first case.  Their enthusiasm was wonderful.  No shortage of discussion and definitely no lapses into silence.

An hour later I gave my first lecture.  The classroom is hot and small and three students share small tables lined up in three tight rows.  Fans are running constantly to move the hot air around but that means that we need to use a hand held microphone that is awkward for teaching and the acoutistics are marginal at best.  Despite that the students seemed remarkably attentive and we took frequent “speaking Nepali” breaks where they could discuss in their own language what I had just taught them in English.  Those islands of comprehension were vital as it gave them some time to test their understanding and to be more active in the learning process. 

Meeting a new class for the first time is always a bit daunting; until you take each other’s pulse (figuratively) and get the temperature of the room; warm reception or cool, serious or relaxed.   I feel that we are off to a good start.  I’m grateful to be here.

That's the funny thing about "shuffle" in iTunes; you never know what will come up.  Here I sit in my apartment in Patan bathed in sweat listening to Bing Crosby sing I'm dreaming of a white Christmas...

Christmas and snow couldn't be further from my mind.  Heading into another round of 5 weeks of teaching is occupying most of my frontal cortex and a fair chunk of my limbic system if I'm being honest.  Last year I approached this with the unbridled enthusiasm of someone doing something brand new.  This time around I am in no way less excited, just a little more daunted by the task ahead.  I know where we fell down last time around and I'm (frankly) scared about making similar mistakes again.  

As if to allay my anxieties I promptly ran into two of my favorite, now second year "Batch 1 students", that I taught last year.  They virtually exploded in delight when I walked down the hall towards them.  "CA mam you're back!!!"  They explained that they were getting ready for their comprehensive exam including cardio and could they sit in on my lectures this year and possibly have some one on one tutorials to cement their cardio???   

Yep this is why I do this. 

Well tomorrow I will head back to Kathmandu for my second year of teaching Cardio at PAHS.  If you are getting this post it is either because you were on the list last year or you asked to be updated on my work in Nepal.

If you are getting this and would prefer not to be updated with each post, no worries just let me know and I will remove your email from the list and you can check in on the blog when and if you have time.

I will update either in transit or once I arrive in Kathmandu

Namaste
CA didi