Nepali Times
How much is too much?


Inaruwa, Sunsari - It is common knowledge that there aren't enough doctors in Nepal, especially in rural areas. Kathmandu Valley itself is full of doctors and so are maybe a few other towns. But there simply aren't enough doctors in most district hospitals, and some are even running in the absence of a single doctor. The status of health services in most parts of Nepal is pathetic, and that is why the government is opening so many new medical colleges.

But I was surprised to find out that the Sunsari District Hospital in Inaruwa has quite a few doctors. In fact, for the people of Inaruwa, there seem to be too many. If you are from Inaruwa and feel otherwise, I apologise. The hospital there has never been short of trained medical professionals. Besides the doctors posted there by the Ministry of Health, the hospital has been adopted as a teaching centre by the BP Koirala Institute of Health Sciences (BPKIHS) in Dharan. And for the last seven years, many have been provided here, to improve the quality of health care and also expose the doctors of tomorrow to the conditions in a not-too well-equipped hospital. Now, consultants (specialist doctors) from various departments at the BP Koirala institute go with students three times a week to provide specialist care in Inaruwa's out patient department (OPD). And for the past three years, about half-a-dozen newly graduated interns have been posted there 24 hours a day, seven days a week and 365 days a year in rotation, along with consultants from two departments. They help run the hospital and provide emergency services at any time of day or night under the supervision of the consultants and the doctors in government service posted there.

Well, by Nepali standards, this is a lot of doctors. So I guess some people think a few can be spared. Those of you who read Kantipur may have noticed a small item tucked away in the inside pages in the edition of 17 October. The report said that the people of Inaruwa had beaten up the doctor in charge of the district hospital (the District Health Officer, or DHO), a few other members of the hospital staff, and two \'sikaru doctors, referring, I guess, to us interns. Not a totally new concept for the people of Inaruwa, who have beaten up DHOs on several occasions before, and even a nurse just a few months ago. I was present at the scene and after reading the article in Kantipur, felt the need to set the record straight.

The article mentioned two \'sikaru doctors' trying to treat a woman who had been bitten by a snake. According to the report, these doctors released the tourniquet from her leg and reapplied it incorrectly, letting the poison through her body. They then are said to have called the DHO, who immediately referred the patient to the BP Koirala institute in Dharan. And, since the patient died on the way, an angry mob beat up all these people at the hospital. The gist of the article seemed to be that the interns were responsible for the death of the woman and that the beating administered by the mob was somehow justified.

Well, the snake had bitten the patient on the hand and not on the leg, and there was a physician from our institute who supervised the whole treatment from start to finish. And he, after discussing it with the DHO, referred the patient to Dharan because the Sunsari District Hospital did not have equipment for artificial respiration, which she would probably require soon. The DHO and an intern telephoned the emergency department in Dharan to inform them that this patient was on the way.

While I'm at it, I would also like to take the air out of the widespread belief that tying a very tight tourniquet to treat snake bite is helpful. A torniquet should be tied leaving one finger-width worth of extra room, so that the blood supply is not hampered, but lymphatic drainage is blocked. This is because 90 percent-if not more-of the snakes most of us encounter are not poisonous. If you tie a very tight tourniquet, you stop the venom from entering the bloodstream, but with the blood supply cut off, the part below the tourniquet is sure to develop gangrene. Whether the snake was poisonous or not, this part of the body will turn black and be completely useless soon. Meanwhile, even a not-too-tight tourniquet will retard the absorption of the poison. This is why doctors remove tourniquets and tie them again themselves, loosely, as they should be. I see no error on the part of any of the doctors in Inaruwa in this case.

But thanks to the \'brave' young men from Inaruwa, there won't be too many doctors there, at least for the time being. One of the doctors was officially transferred to a different hospital a few days before the incident, leaving only one doctor there on government service. Since he was beaten up, my guess is the remaining doctor will get himself transferred out or simply quit. And for now, us interns have been posted back to Dharan, while the institute decides what to do with the internship program. But the fact is, that none of us is terribly enthusiastic about going back and risking another beating. It sounds harsh, but I can't help thinking that the services given to Inaruwa\'s hospital by the BP Koirala institute should be suspended, at least temporarily, so the people there realise that they have as much to gain from the internship program as we do, if not more. And they need to understand that we are not experimenting on them or playing with their lives, but merely working under the guidance of our seniors while gaining experience. After all, similar internship programs are running smoothly in the Dhankuta and Morang District Hospitals without problems.
It is hard to understand the antagonism to sikaru doctors all over, especially in Inaruwa. After all, no one is a great cardiologist or ace neurosurgeon from the womb. I suppose some of this has to do with the local quacks and unlicensed pharmacists who abound in rural areas. As for me, I intend to remain a trainee all my life, and keep myself open to all there is to know. It is interesting, though, how people tend to forget that doctors are also human. And that all people, whether one's near and dear or doctors themselves, eventually die. Doctors aren't god.

It disappointed me that people we were treating and serving had no clue what we were doing there after seven years. It wasn't the physical beating-I was only hit by two badminton rackets, which I blocked off and broke-but the attitude of the people that got me all riled up. In any case, I am thankful that when the mob rushed towards our hostel, at the doorway they ran into me-6 ft tall and 75 kg-and not a woman doctor. She would have met the same fate as the nurse who was badly beaten up and kicked by Inaruwa's bravest a few months ago. I feel bad for the next doctor on government service who will be posted here.
This Dasain I prayed for the people of Inaruwa. May the lord give them good health-and the good sense to realise that there aren't that many doctors in Nepal.

(Dr Milan Piya is an intern with the BP Koirala Institute of Health Sciences.)

(11 JAN 2013 - 17 JAN 2013)