Insourced
[This post concerns primarily the nerdly arts, so feel free to skip it if that's not something you're interested in.]
So it's taken a little while to figure out how best to put me to use, and that is going to be in two areas: first, teaching some introductory computer courses for hospital staff: very basic stuff for those who have used computers very little or not at all, and a bit more advanced for those with some experience or who use them day to day but want to learn a bit more about particular applications, etc. Second, being a jack-of-all-computer-trades, assisting with various issues around the hospital. At the moment, the latter means banging away at an existing MS Access database. You database weenies will recognize the symptoms: Access used as a big Excel spreadsheet, without any validation of entered data, and Excel reports for outside organizations generated by running Access queries/filters by hand and copy/pasting the results into Excel. So I'm creating forms to make data entry easier, faster, and more accurate, and reports that make it possible to skip at least one monkey of the current report generation solution.
[In case anyone who's read this far this wasn't at some point in time connected to WGBH Interactive, the monkey scale refers to the number of humans involved in some sort of technical process that really should be completely automated, but for some reason isn't. A three-monkey solution requires three people where ideally there would be none involved, etc.]
Last year at this time: my own air-conditioned office with stable electricity, a honkin' big Macintosh multiprocessor computer running OS X, dual LCD monitors, finely chilled Diet Mountain Dew in the refrigerator a few paces away, and only occasional use of MS Office software. This year: an un-airconditioned closet (with lizards!), power that goes out several times a day (and at least one lightning strike since I've been here), a CPU of uncertain vintage running XP, a small out-of-focus CRT monitor, the nearest Diet Mountain Dew probably several hundred miles distant, and up to my ears in MS Access all day. Karma-wise you'd think I'd spent the last 12 months loading kittens into catapults or something.
Which doesn't mean I've been able to avoid breaking things. A few minutes after sitting down at and powering up that PC of uncertain vintage for the first time, I got one of those "You're making a huge security mistake" popup messages - apparently the firewall wasn't turned on. So, being both security-conscious and Windows-ignorant, I turned it on. I didn't realize until later that the PC of uncertain vintage was the official mail server, and I'd clobbered mail traffic by activating the firewall. Yeah, the firewall can probably be configured to be active and allow necessary mail connections, but for the moment at least, I'm leaving it alone, rather than wreaking further havoc.
But, as Molly would put it, it's all good. Suman, who's overseeing my work, may still consider it up in the air as to whether I'm making any kind of net contribution around here (he was the one who asked, "Hey, you didn't by any chance change the security settings on that computer, did you?"), but I've got a couple of weeks to convince him. Meanwhile, I seem to get a person or two a day who comes to my door thinking I'm the person to talk to regarding employment at the hospital. I've considered reviewing CVs and looking a little gruff while hiring everyone on the spot, but figure that's going to be a pain to sort out in the long run, so I redirect them to Suman's office.
Actual teaching began this week, with staff figuring out when and if they can come to classes. I'm supposed to have a different group each day of the week except Saturday, for an hour or so in the early evening. I'm starting to hit my stride with the beginners, but I'm still figuring out what to teach the more advanced folks, some of whom have certainly spent more time with MS Word, Excel, etc. than I have.
Connectivity, continued, or things we already knew about internet communication but forgot until recently:
Weather can affect satellite connectivity: I'm guessing that whatever satellite is used for providing the internet connection here is a geosynchronous satellite, and thus isn't wandering around the sky relative to the fixed satellite dish on the roof of the admin building, but from my vantage point in the telephone closet, I can watch the connection lights on the satellite modem blink on and off (they should remain lit when the connection is strong), and they looked like the starting lights at a drag racing event yesterday morning as heavy cloud cover (followed by a thunderstorm) rolled in. And here I was blaming the chicken. This contributes to...
The simpler the web page, the faster and more reliably it loads for users with slow connections. And the converse: the more stylesheet, javascript, AJAX, etc. heavy the page, the less accessible the site. Yeah, I know you're sitting there with your DSL line or your cable modem or what have you, and you don't care, but after you've had gmail time out 12 or 15 times just while trying to refresh the inbox (and yes, I'm using the HTML version for slow connections), these things become important. At the moment, gmail is the most twitchy, with Facebook a close second ("Damn you, static.ak.fbcdn.net! Deliver my packets unto me!"), and the New York Times site coming in third. A couple of days ago I was trying to view some random NYT article that was taking its sweet time loading (that's you, graphics8.nytimes.com), and while waiting I took a peek at what had already arrived: 27 external CSS and JS files requested by the page. I'm too lazy to have done straight page-weight comparison, but so far, between a JS- and AJAX-heavy page and a simple page twice or three times the filesize, give me the latter every time. Low-overhead sites load pages every time. And don't get me started on multimedia ad banners.
You don't have to boil your laptop battery to use it. I hear our ancestors used to have to do that to get them to work, but I haven't seen it done myself.
My school's not the only institution blocking YouTube. Laid hands on my first local iPhone today, and no, not one of the just-announced ones with the engraving of Steve Jobs' new liver on the back, either. The owner was asking why the video (YouTube) button didn't work, I was giving it a try, and the search button was "Suchen" instead. Further examination revealed that the phone was language-localized for German. Wondering by what path it made its way here...
SPAM is indeed everywhere. More of a housekeeping note than anything else: I've got commenting here on the blog set such that I have to review comments before they show up on the public site. That's cause the ratio of SPAM comments to actual user comments is currently running about 20:1. I try to check in, review new comments, and post them at least once every 24 hours. Just in case you were wondering whether comments disappeared into a black hole.
Sukhumbasi, June 14
Above: children of Sukumbasi, Nepal. More photos @ flickr
Sunday is usually hectic, but what with the strikes late last week, this Sunday was even busier than usual: 400 patients seen in the outpatient clinic, instead of the 300 or so of an average Sunday. But I wasn't involved, much; they've figured out what to do with me, to make the most of my skills while I'm here, and that's going to involve teaching computer classes for hospital staff - very general introductions for those who have had little exposure or experience with computers, basic Microsoft Office skills for those with some background. Plus, it appears, a smattering of "we've had this problem, can you take a look at it?" type issues. And yes, laugh all you want, but most of the computers here are running Windows XP of some service pack or other, so this 23-year Macintosh veteran is going to have to bone up on his dark-side skills.
So I spent most of Sunday working on course outlines, as I hadn't arrived packing a complete syllabus, but I did manage to tag along as Dr. Grahame, his wife, son, daughter-in-law, the three Swiss students, Suman, and a driver made their way to the small town of Sukumbasi, a few km away from the hospital. The town is composed of about 40 families, has only been in place five or six years, and is sited on a former riverbed - recently-placed dikes redirect the water during the rainy season and make the area possible for habitation.
But "possible" does not necessarily mean "easy." While they're eking out a few small plots of crops on the land, the primary means of income for the town is river rocks, collected for use in construction elsewhere. And that means of support is important enough that as we approached the town in our Land Rover, the turnoff from the main road was blocked by three town residents, as it appears outside construction companies and other contractors have been coming to the area and driving off with river rock without paying the town residents for the use of their resources. The hospital "H" on the Land Rover and the fact that we were squeezed into the vehicle tightly enough that we weren't going to be leaving the area with more than a pebble or two in our pockets meant the gentlemen blocking the turnoff gave us permission to pass.
The income derived from river rock works out to about $0.50/day/person, and just in case that wasn't tough enough, a heavy thunderstorm on May 13 destroyed several houses. There's already some reconstruction and/or construction of new stronger houses with concrete supports, etc. under way, thanks to some particular donations from overseas. The donations go toward materials and any specialty skilled labor needed, and go through what is basically a town council; the general labor required is provided by the residents.
Also pictured is the new well, dug (by hand) in the last few months. 90 meters deep, it will eventually have a pump, but at the moment, to get water, you lower a bucket by rope and haul that bucket back up by hand. Or you talk the kids into grabbing the rope and running for 90 meters. And as much of a pain as either of those are, they're much easier than the long walk retrieving water previously required.
We also poked our head into the one-room schoolhouse, and just in case there was any doubt as to how much learning is going on there, Dr. Grahame's wife brought a new sari for an elderly blind (and leprous) woman living just outside the village. The newspaper wrapping the new sari was immediately grabbed and pored over by several of the children. And they didn't seem all that interested in the "New Miss Deutschland chosen" article, either.
The Swiss students finished their stay and left early this morning; I've had a flatmate for a couple of days in the form of Kat, a student from the UK who finished her university degree late last week (she'll be taking over the Swiss students' former digs later today). While her freshly-minted degree is in embryology (and yes, I've already tried talking her into teaching at a certain Norfolk institution), she's applied to graduate programs in public health, and is going to be working with the community outreach programs here.
Two days, seven sites
(Above, Dr. Paudel, orthopedic surgeon (L), and pants surgeon (R))
Today has been a slow day at the hospital, most likely due to the strikes (bandh) taking place in Janakpur and other smaller towns that closed the roads to traffic, keeping patients from getting here (the physician in charge of the hospital, returning from Kathmandu today with family, had to talk his way past several roadblocks). So far my attempts to figure out what the strikes are about are met with vague talk of "politics," as it seems no one wants to delve deep into a discussion of Nepali politics, at least with this foreigner.
The previous two days, however, have been full ones, as I've spent both with Dr. Paudel, the orthopedic surgeon. Tuesday is his scheduled day in the operating room, and I was able to join his team as they were getting started on the day's surgeries. First up was not really surgery, technically speaking - for the gentleman who had forearm fractures set with open reduction and internal fixation last week, Dr. Paudel checked the range of motion and whether the fracture remained properly set, which testing would have been extremely painful for the patient had he not been sedated. A 14-year-old boy had a separated shoulder set with an open reduction, two gentlemen had foot ulcers cleaned (and in one case, skin-flapped and skin-grafted), and the last gentleman had a small piece of glass under the skin of his forehead he wanted removed. He had been warned that it was so small we might not be able to find it, and that turned out to be the case.
I'll admit this was my first time viewing actual surgery, so I don't have much "here's how it works in the average American operating room" experience with which to compare, but I'm guessing that most American operating teams don't take tea between operations, period, never mind as a complete team, and as far as I'm concerned, that lack falls squarely into the category of Things Wrong With American Medicine.
Wednesday was a completely different experience. Instead of spending an eight-hour day entirely in one room (except for a few minutes in a small side room for the aforementioned teas and lunch), I accompanied Dr. Paudel as he left the hospital grounds at 5:30 a.m. to visit small medical clinics/pharmacies between here and the town of Sindhuli, 30KM or so away.
I am a complete wuss (and no, that's not a medical term) when it comes to motorcycles, so while Dr. Paudel is an excellent driver, it did take me an hour or two to unclench my knees and hands after riding on the back of the motorcycle most of the day. The first half of the route to Sindhuli is paved, but the second half is narrow and unpaved, covered with a mix of gravel of various sizes and the occasional patch of sand. The route winds through beautiful hill and river valley country, and given the width of the road and the lack of a center line, standard procedure is to lean on the horn when approaching any kind of blind curve or hilltop, just in case there's a huge Tata truck or bus coming around the corner from the other direction. The motorcyclist is also keeping his eyes peeled for pedestrians, livestock, and recently-felled trees in the roadway. So I'm hanging onto the back of the bike, with the bicyclist part of my brain that never did like gravel roads or sandpits trying to ignore the fishtailing sensation that occurs every hundred yards or so, trying not to lose my grip every time we hit a good-sized bump in the road, all the while thinking, "If I get bounced off of here at 50KM/Hr, I'd better do it in such a way that the driver and the motorbike are left otherwise undisturbed, because the driver's the best person within a couple hundred kilometers to reassemble me after I land."
My wussitude aside, Dr. Paudel's goal for the day was to drop in at several small combination clinic/pharmacy establishments and at the hospital in Sindhuli to network, press the flesh, and generally direct some orthopedic surgery business his direction. At every stop that involved some impromptu examining and consulting, whether orthopedics-related or not, regarding patients who turned up at the establishment we were visiting at the time.
(The first stop also involved some impromptu zipper-replacement surgery, pictured above, on the surgeon's pants.)
Shortly after we wrapped up the visits in Sindhuli proper, Dr. Paudel's cell phone started ringing every couple of minutes, as new cases requiring his attention had arrived back at his clinics near the hospital. That urgency increased the KM/hr of the bike and with it, the terror on the back of the bike, on the return trip. Four children had broken arms in unrelated falls; three of those were treated with casts and slings, but the fourth, a girl of about 4, had a fracture and displacement that needed surgery to fix. The usual rate for that surgery was 15,000 rupees (about $215), but because it was clear the family couldn't afford the fee, and because the girl had been brought to the cooperative clinic (where Dr. Paudel could set his own fees), he offered to perform the surgery for half the usual rate, and possibly would have reduced the fee significantly beyond that. But the family apparently misunderstood the offer of the reduced rate, and left without making arrangements for the surgery. It's possible that they'll make arrangements elsewhere, but the most likely result will be that the little girl doesn't get surgery at all and is left permanently disfigured.
14 hours after we started out for Sindhuli, Dr. Paudel had seen patients at six different sites. A reader asks, "Have they figured out what you are going to do yet?" and the short answer is "sort of," but the best idea yet came from a member of the staff at the last stop of the day, who suggested that I park myself out in front of the clinic, as an advertisement to the effect of, "foreign doctors practice here." My advanced age probably makes pulling that off easier for me than for most first-year students, and frankly, work as signage is less hazardous to patients than most other uses for first-year students.
No-see-um questions, part 1
Is that "zzzzzzzzz" I hear (meaning it's inside the netting and circling) or is it "zzzt, zzzt, zzzt" (meaning it's outside the netting and repeatedly banging its head against the insecticide-treated netting trying to get in)?
If I spin around quickly in the shower, will I soak the entire surface of my body with sufficient water volume frequently enough to keep the little bastards I know are in the room from landing and getting a toe/proboscis hold?
Is that mote floating in the beam of sunlight across the room innocent household dust or does it have venipuncturous intent?
What day of the week is it again?
How many ways can I misspell
mefiquinonemelfiquonemefliquininemy malaria prophylaxis medication?If tomorrow is the day of the week to take my weekly dose of mefloquine, and I get thoroughly bitten today, am I more screwed than at any other time of the week?
Can I break my personal record (25) for number of bites received on a single 4cm x 8cm patch of appendage skin while said appendage was next to (inside, but next to) the netting for a brief period while sleeping?
To be continued, I'm sure...
In the general clinic
The physicians here have to be some of the most patient people I've ever met. Yesterday (Sunday) was my first full working day at the clinic, and I was shadowing a different physician (Dr. L) as he saw general patients. He and a second physician were each working at a desk in a single room about the size of the exam rooms I'm used to, and at one point during the Sunday rush I counted 12 people in the room not counting the two physicians and myself. That most likely included the two patients actually being seen at the time, an accompanying family member or two apiece, and then several additional patients (and family members) waiting to be seen by one or the other of the physicians. Patients sit on a stool next to the doctor's desk and present him with their paperwork, or at least that's how it's supposed to work, but at any given minute several waiting patients are also trying to present the doctor with their paperwork. And that's not counting patients seen earlier in the day who have their completed lab work in hand and who jump in as well to have their visit finished off. But it's all very polite and orderly - maybe every once in a while someone pushes their paperwork in front of someone else, but that's about it. An American HIPAA enforcement administrator, however, would probably succumb to a case of the vapors almost immediately.
Most of the actual examining is done with the patient sitting right by the desk, but there's also a small curtained-off area with an examination table for use when the patient needs to be examined lying down, or if the examination is going to involve disrobing more significant than the pulling-up of a pants-leg or the baring of a shoulder or midriff.
A quick tallying from my notes for the day shows 33 patients, ranging in age from a couple of months to 80s or so, seen between about 9:30 AM and 4 PM by the physician I was shadowing, but I know I missed several, so that's an undercount. My conversational and history-taking Nepali is nonexistent, so Dr. L tried to slip a few words of history/condition to me in English during examinations and as he took the paperwork for the next patient; cases I did manage to note included several possible cases of leprosy (referred to the official leprosy part of the hospital for further testing and treatment), postherpetic neuralgia, fungal skin infections, vitiligo, gynocomastia, acne vulgaris, impetigo with staph infection, scabies, orchitis, giardia, tinea corporis, tinea versicolor, dizziness with vomiting, cough with fever, possible rheumatic fever, and a huge ankle abscess immediately referred to the wound care clinic. Oh, and one case of hypertension.
A couple of things brought up by readers/emailers ("Hi, Mom."). Altitude: I'm not sure what the exact altitude is here at the hospital, but it ain't Everest Base Camp (5360 meters/17600 ft). Janakpur, the last airport flown into en route, averages about 70 meters (about 69 meters higher than Norfolk) and I'm guesstimating the hospital grounds at another 10-20 meters above that. So (a) it's not high enough to be cool in any temperature sense, and (b) it's not high enough to be above mosquito range. I don't have a thermometer at hand, but so far it strikes me as similar to summer Norfolk: hot and humid. It's just within bearable for this AC-spoiled westerner when the fans are working or there's a light breeze. When the power cycles off (and it's done so a couple of times while writing this), the fans die, the wireless signal indicator goes to zero, and I start to melt. And yes, all three of those make FB/gmail chatting on-again, off-again.
Close calls in traffic: a couple of current patients here, originally seen/operated on before I arrived, are two gentlemen who had their arms hanging out right-side bus windows when another vehicle got a little too close (traffic is on the left here a la the UK), so while my vehicle travel has been minimal so far, my arms are gonna be inside the vehicle at all times when such travel does happen.
Church service Saturday morning: involved a great deal of singing and the introduction of an out-of-towner who apparently said more in the way of brief self-introduction than the speaker was interested in translating; was not an SDA congregation so far as I could tell (but I'm still working on getting some of the church history/theology/etc); and I am pleased to report that some things are indeed universal: small boys the world over while away the service drawing and coloring, lying on their bellies on the sanctuary floor.
Statler & Waldorf? Beavis & Butthead? Stan & Ollie?
Friday is a half-day at the hospital, with regular business winding up at about noon. As I don't have an official schedule yet, I spent the morning shadowing Dr. Paudel, an orthopedic surgeon who was seeing general patients, 20 or so in the space of a couple of hours, with one patient or family group coming into the room before the previous one left. You future dermatologists, this is the place to be: about half the patients were here for some sort of skin condition. Three Swiss third-year medical students are, at the moment, the only other folks here in a capacity similar to mine, and as this is an official rotation for them, as I'm writing this, they're spending the afternoon working on a report on their time here.
Yesterday was the last couple of legs of the travel to get here (and "here" is Lalgadh Leprosy Hospital, in Lalgadh, Nepal). Rattling around in my head for a while has been a brief comparison of Boston and Norfolk drivers, or more directly, the different shortcomings of each, and after a trip from and to the Kathmandu airport, I'm not sure I have much to complain about anymore. I nearly had to use my right hand to unclench my left hand upon arrival - some combination of driving on the left hand side of the road, the center line as an extremely abstract concept, and an almost non-existent seatbelt encouraged a fairly firm grip on the handle above the passenger-side door. A 25-minute smoother-than-expected flight on a Buddha Air 18-seater delivered me from Kathmandu to Janakpur (and ended what seemed to some merely a tour of airports), where a gentleman from the hospital picked me up. We made a couple of stops in Janakpur to pick up plane tickets for other folks and a couple of boxes of medications, and headed to Lalgadh and the hospital.
I'll admit that the last flight and the first portion of the drive to the hospital had me thinking, "I've come to a country best known for its mountains and I've managed to find the absolute flattest part in which to spend the next eight weeks," but low hills appeared as we approached the hospital, and the grounds themselves are at the top of a small hill. Rumor has it that on a clear day, I'll be able to see Everest from the top of the water tower, but I haven't yet made the ascent.
I'm still learning my way around the grounds, and I'm just getting started on learning everyone's names and the etiquette for various interactions, but I've been assigned residence in the Annapurna cabin, where, at the moment, my housemates are two lizards, a smaller one who seems to patrol from the roofline down, and a larger one who patrols the ceiling. I was supposed to be joined in a couple of days by another medical student, but he's a no-show, and apparently that's not all that uncommon - folks make arrangements months in advance to come, then drop out of contact and never show up. The cabin has everything I need: running water, filtered (drinkable) water, electricity (as much as anywhere on the grounds - apparently a good share of Nepal's electricity generation is hydroelectric, so the supply is dependent on the meltwater runoff and the rainy season, so we're headed into the 16-20 hrs/day of power part of the year), and I'll be damned, wireless internet. I've got a good strong connection to the hub from my front room, but the available bandwidth seems to be in the 36-56k ballpark, so videoconferencing is probably out. And I'm learning the finer points of mosquito netting use ("Mosquitoes: outside netting. Mosquito-eating lizards: also outside netting. Self: inside netting."). It's hot and humid, and it's going to take a few days to adapt to that, but frankly, so far it's about as hot and humid as Norfolk in July or August, so I don't have anything to complain about.
Saturday is the day off here, with most folks attending a church service mid-morning, and Sunday is apparently the busiest day of the week, with the staff seeing 300 or so patients on average. I'm not sure whether that's because most other folk have Sunday off, or for some other reason, but I'll report back when I find out.
Other wildlife of note, mostly not inside the cabin or the netting: 1 semi-feral white cat who patrols the grounds with a yowl that sounds Siamese in origin. Semi-feral as in one of the physicians pointing to bite marks on the ankle of another member of the staff and demonstrating the water-toss employed as a deterrent towards any future bites. 1 monkey being chased off the domestic terminal building at Kathmandu airport. (I don't know why, but the latter made my day.)
June 4, 2009: Kathmandu
Kathmandu, at least this corner of it (Jawalakhel) is very quiet at night, particularly compared to my corner of Ghent with its roaring impressing-someone mufflers and backing-up beeping of the midnight Starbucks delivery truck. Doing exactly what you're not supposed to do to adapt to a new time zone and sitting down for a brief nap in the early evening, I got several hours of sleep, with the result that I'm up most of the night. Around 3:30 or 4 a.m. the first bird sounds begin, not all that distinguishable from Norfolk bird sounds to this nonbirder, gradually growing with an occasional dog bark until 6:30 or so, when the first human sounds start: growl of a truck or two, voices elsewhere in the hotel, the first taxi honks. Bursts of music: someone's alarm clock, or is that a ring tone?
I arrived in Kathmandu midday yesterday (June 3) on a flight from Singapore, with a planned overnight here before continuing on a domestic flight to Janakpur and ground transportation to Lalgadh. The same gentleman from NLT who picked me up at Tribhuvan Airport and delivered me to the hotel is supposed to pick me up today to return me to the airport, and when he left yesterday neither of us knew when that was supposed to happen. Yesterday's attempts to figure that out failed, and that's now the first task today.
In the interest of keeping things confusing, time-zone wise, Kathmandu is 9 hours and 45 minutes ahead of the East coast of the U.S., and 12 hours 45 minutes ahead of the West coast. So at noon in Norfolk (and 9 a.m. in California), it's 9:45 p.m. in Kathmandu. Why the fractional hour, I'm not sure...
Off to Kathmandu, accompanied by travel-sized canine
"We have voted, and decided that Parker is going to travel with you in your backpack for the summer. Sorry, you have been outvoted, 2 to 1."
I've spent the last two days with my brother and sister-in-law in northern California, and I fly to Kathmandu this afternoon to volunteer with Nepal Leprosy Trust in Lalgadh in the Central Region of Nepal through June and July. I'm going to attempt to keep the blog updated; drop me a line at the usual suspect email addresses, look me up on Facebook, or jump into the comments below.