Today I spent most of the day in CT, and I learnt quite a lot about how they do things there. The scanner they have is a 4th Gen one slice GE model which is a fair few years old. It gets quite a lot of use because every patient who is involved in an RTA or a fall from heights will be sent for a head CT, this is because apparently cranial haematomas are quite common in these cases. On the surface this is quite good from a patient care POV but in practice it is hugely unnecessary as it’s not cheap and it’s a high dose to be giving someone who doesn’t really need it. In the UK the principles we apply to deciding whether to x-ray someone are based around the ALARP (As Low As Reasonably Possible/Practical) objective. There’s no such thing as a maximum dose for patients- this wouldn’t be practical at all as some patients undergo many entirely essential radiographic examinations, so setting limits would severely impact care for those patients. Instead we ensure that the examination is justified, and we do this by assessing whether the x-ray is going to provide the diagnostic information required for the healthcare team to provide relevant future care. A really obvious example would be if you went to your doctor with back pain and they referred you for a full spinal CT scan. This would be unnecessary because back pain is a common complaint and can be anything from a vertebral fracture to a pulled muscle or poor posture. Other examinations would be required and a better reason should be provided in order to justify the referral.
I’m not sure the ALARP principle has reached Nepal yet…
I really don’t want people reading this to think I’m condemning the hospital or the staff, I have to make this point clear. They are doing a fantastic job with very limited resources. They have minimal funding, even though this is the best hospital in the area, and therefore they can only afford the basics. One of the radiologists told me recently that handwashing is a simple process in theory but it’s expensive to implement and maintain, and I agree with him, but then the money they spend on improving their hygiene and infection control would perhaps be saved if they spent less on antibiotics and other infection-related costs? It’s an incredibly political issue and I have really limited knowledge on the subject so I probably shouldn’t be expressing my opinion!
Following on from yesterday’s saga of the unsedatable boy… well he was eventually quiet enough to be scanned and when I came into the hospital this morning I saw the results- a massive 7cm diameter Wilms’ tumour on his left kidney. It was huge and I have no idea how painful it must have been. Unfortunately in this country, when you get ill or injured you can’t just call an ambulance (there aren’t any, really) and even if you can get to the hospital you have to be able to pay for your treatment. This means that by the time you eventually get to see a doctor, your illness will be in the advanced stages. I also saw a girl the same age as me with a rectal tumour which was 2cm thick at its thinnest point. Things like this are heartbreaking but one really uplifting part of the day was the visit to the radiotherapy department. Apparently there are 4 RT centres in Nepal, and the one at this hospital is very modern looking (compared to the rest of the hospital) with a LinAc and a simulator for planning. I’m going to admit my ignorance to all things radiotherapeutic, but I can’t wait to compare notes with those who know about it when I get home. The oncologist told me that cervical cancer is the most common here with brain, breast and GI following closely behind. But with the RT department treating 12 patients a day and increasing to 20 a day by the end of the year, cancer isn’t necessarily the death sentence it used to be, if you are able to afford treatment, that is.
After a long day at the hospital, we all went out to a bar called Busy Bees in Lakeside, Pokhara. It’s a really touristy district with loads of bars and clubs and I was sort of dreading how naff it might be, but after trying one rubbish bar, Busy Bees was fantastic. They had live music, with the band playing all sorts of rock and metal from AC/DC to RATM which was totally up my street, so I danced pretty much all night. It was also quite cool because the radiologist who has sort of been “looking after” me was there too, enjoying himself by chatting up all the women but sensibly not trying that game with me! We stayed out beyond midnight which was reckless bearing in mind we were leaving for a rafting session at 6am the next morning! I’ll be going back soon next time the band is playing