Wednesday, March 3, 2010

Cancer Hospital Part II: Dr Robin (from the US) Lecture

Click here to see a blog about our first visit to a hospital in Nepal.

Or click here to see a blog entry about our first visit to the cancer center.  

Or try this for the entry about driving to the cancer center.

Or, if you'd rather read about Nepalese art instead of Nepalese hospitals, click here

Or, if you're more in the mood for a story about trekking, accidental and otherwise, go here.

But if what you really want to read is the last chapter in Our Visits to Nepal's Cancer Center, bless you, and read on:

Nine o'clock on a Sunday morning.  I've been frozen solid in the back of a taxi on what is optimistically called the Indo-Nepali Highway for over five hours.  Stiff-legged and starving, we arrive at the hospital and park in their otherwise empty parking lot.  Practically falling over ourselves, we crawl out of the car at the hospital and eventually meet up with our escort who leads us to the only lecture hall at Nepal's only cancer center.

Inside the auditorium the crowd collected, exactly as in the US:  first the young students and eager-looking residents (who sit in the back), then the department heads and administrators (who mostly sit in the front), then the bedraggled looking on-call doctors with attendings filing in throughout.  I learned later some of the senior doctors had come in from around the countryside on their day off, but for the rest of the physicians it was just another work day: everyone in Nepal works a six-day workweek with Saturday being the only day of rest.

I was introduced to the head of the hospital, a radiologist (who I believe had driven in all the way from Kathmandu) and was seated at his side at the head table.  He had each attending in the audience introduce themselves and their specialty -- the hospital has about 15 radiation oncologists (who give both radiation and chemo), a small handful of hematologist-oncologists (who mostly manage leukemia), a few surgeons, and then a group of radiologists and pathologists, who, as the head doctor said, "are here only and strictly to serve the radiation oncologists.  We are all the moons that rotate around the sun of our radiation oncology brethern." An interesting model!

Then, as takes place at all morning meetings, the younger on-call doctors were asked to stand up and outline the events of the evening before (how many admissions, how many emergency patients etc), and then I began my talk.

But just like at lectures in the US, there was trouble setting up the computer – and just like in the US a procession of short-haired guys came forward trying to get the dang thing to work.  I started the talk out (sans computer) joking about how computer glitches seem to be something all nations shared and then I ad libbed a bit – about how we were on our first trip to Nepal and how much we liked the country and what an honor it was to be there – at which point the computer mercifully became functional.  During much of the drive from Pokhara I had wondered whether my flashdrive's Powerpoint presentation would be compatible with whatever they had on their computer, and it was with great relief that I watched that baby flash up on the screen in full-color and perfect Powerpoint 07.  God bless compatibility!

As I started the talk I asked what percentage of their patients were women with breast cancer.  They initially replied that they had no way of giving an accurate number as Nepal has a) no tumor boards and b) cancer registries.  I asked if they could just kind of ballpark it (“Ten percent?” I asked, “Fifty percent?”), and one young doctor stood up and said “Less than five percent and most cases are advanced.”  I asked for the most common tumors they saw in their hospital and they replied “Head and neck tumors from smoking and cervical cancers in the ladies.”

I said I wished I could talk about those cancers but that I was a breast cancer doctor and that in fact as much as 50% of radiation patients in the US had breast cancer, and I explained about the fact that today's talk was one I had given to US surgeons a few months earlier and that I would try to adapt it for their use.
I am glad I didn't have time to think but simply launched into the talk.  In retrospect, the information I gave – which was mostly about intricacies in management decisions in early breast cancer – must have seemed largely esoteric, inapplicable, or simply a  luxury they can't afford.  While I was talking about women with tiny early lymph node breast cancers, every patient I heard about or saw there had horrendous, high-risk, probably fatal locally advanced disease.

Nonetheless I pressed on, and the talk seemed to be enthusiastically (or perhaps politely) received.    I skipped a couple of subsections after asking if they applicable (no, they don't see any pre-cancers or dcis; no, none of their patients undergo reconstruction or get implants) and talked a fair amount about NCCN (National Comprehensive Cancer Network) guidelines, with which it turned out they were quite familiar.

The hospital head, a radiologist, asked for “queries” after I finished, and the questions were quite good (several about treatment of locally advanced disease, two about re-treatments, two about concurrent treatment with chemo, two about internal mammary lymph nodes which led to a discussion of CT treatment planning, and one surprising question about the role of Oncotype Dx testing after which I also discussed the timing of BRCA testing adding “when it gets here, which it will.”)  I thought that overall the QandA period was – as is often true at US lectures – the part where the most learning took place. 

A posse of young doctors then led me back to the radiation department where they wanted to show me their breast treatment plans.  They were very apologetic about how basic the plans were and I found myself wanting to reassure them that they weren't much different than those we used to use in the US.  But then, to my astonishment, they brought the actual patient into the room, drew her field on her skin, and asked me to come critique.  A pack of doctors and I went in to see the patient who lay there with her head turned away.  I immediately noticed a couple of suboptimal parts to the treatment fields, and pointed them out.  These were small things that any second year resident would notice so they shocked me by asking how they could fix it.

They looked absolutely abjectly guilty and it was only at that moment that it dawned on me that just because they had reasonable machines didn't mean they were giving optimal treatment.  One of the young doctors said at one point, “We are all indigenous, we are all products of the training here in Nepal and we are uncertain.”  So I straightened up my shoulders and set to work.  In the end we reviewed breast, lung and pelvis films and I made significant suggestions for each.

They also showed me their record-keeping and charts which were striking for their minimal documentation.  Histories and physicals were relevant and usually adequate; physics documentation was basic and all hand-written, but the real paucity of charting was in the radiation prescriptions.  The physician would write a tiny note giving his plan and then the very basics of a prescription.  I saw one hopefully atypical chart that didn't even give a site for treatment:  the entire prescription read only “15 fractions/30 Gy.”

I looked all through that particular chart and literally couldn't figure out which body part was supposed to be treated over 15 fractions, and then was further confused when the treatment part of the chart showed that the patient had in fact been treated 15 times, had a break of about a month, and then returned for 15 more treatments to the mysterious body part. Upon further inquiry I learned that the prescription had been written for a women with lung cancer.  The reason for the break in treatment was financial:  patients have to pay in advance of their treatments.  Although she had paid at the start for 15 treatments she could not return for the last half of her treatment until she had gathered enough money to pay for them. 

And this is the famous "consent form" I saw.  I talk about it on this blog entry but for the new arrival, this is a consent form where the husband of a presumably illiterate woman with cervical cancer has given his consent (via two fingerprints, since he is also illiterate) for her to get radiation treatments.  Since cervical cancer is a sexually transmitted disease, there is tragic irony that the husband is the one who has to give permission for this poor woman to get treatment for a disease that he probably gave her.

After reviewing some current patients I was escorted to a small conference room.  Three young residents then presented their most recent cases, with history, brief physical, and plans.  Each case was a "horrendoma" – advanced and generally neglected disease – and each came under short discussion.  The interesting thing to me was that the plan that the residents proposed was changed at least twice, including once where the whole goal and prescription was changed.  It appeared that they let the residents enough rope to almost but not quite hang themselves.

We were just about to leave when one young doctor came running up and said “Oh no please please just a few more minutes” and we guided into another planning area where he presented a patient with T3N2 lung cancer.  He asked me to review the volumes he had drawn for tumor, which were all fine; but he hadn't included any lymph nodes in his tumor volume, again something a US second year resident would automatically do.  We talked about NCCN guidelines and tumor patterns of spread and I suggested he change his tumor volume accordingly.

The remarkable thing about all the physician requests was how naked they were in their pleas for guidance.  There was no bravado, no false confidence, only a strong and unashamed desire to improve their practice.  They looked slightly embarrassed but absolutely willing to do whatever it took to improve the outcomes for their patients. It was utterly inspiring.

On the way out the main doctor talked about how much they wanted contact with the outside world, how he wondered what else they could possibly do to improve themselves.  We talked about the idea of a visiting professorship; the advantage of perhaps an organization like ASTRO occasionally providing a doctor for a few days – even one day – and talked about how one guy going to the US and trying to come back and incorporate what he's learned doesn't work as well; how it needs to be somebody coming to their facility, seeing their resources, and making recommendations based on what's there, not elsewhere.

The frustration in his voice again came to the surface as we walked out to the (still empty) parking lot.

(Even six weeks later, the image of the empty parking lot still affects me: the idea of all those cancer patients coming to their cancer treatments on bikes and by foot)

So this is what I will remember the most:  the empty parking lot, the patients who looked us right in the eyes and said "Thank you, thank you, thank you," the breast cancer patient with her head turned away as I amended her treatment plan, the frustration in the doctors' voices, and the unabashed thirst for more knowledge in their eyes.

Saturday, February 27, 2010

Getting to the Cancer Hospital With a Sidebar about Driving in Nepal

When last we left off, lo these many non-blogging days ago, Jeny and I had made the decision that we would try to return to Nepal's Cancer Hospital so I could give a lecture and perhaps a hand.

Going back to the Cancer Hospital in Bharatpur from Pokhara was actually a fairly ambitious undertaking.   I wasn't particularly worried about the “content;” I had brought along a thumb drive for use in blogging that miraculously contained a Powerpoint presentation I had given  a few months before.  It was called  “Breast Cancer Update for the General Surgeon” and I hoped that with a little tweaking I could make the talk applicable to oncologists in Nepal.  So content wasn't an issue, but the logistics were a bit daunting. 

In the best of all possible worlds getting to Bharatpur would mean at least a four-hour drive each way, several hours at the hospital, and buy-in from the kids that it would be okay to leave them alone with Jeny's parents for a long day.  Fortunately the kids readily agreed (very readily!) and Jeny's family  kindly made arrangements for us to be driven to Bharaptur by a young man from Pokhara.  Our driver's name was Manipush,.  He was only 22 but had been driving his own personal teeney Suzuki taxi ever since he managed to buy it three years previously.  A very hard-working and heroic driver was our Manipush.

This is how I figured it:  we'd drive in pre-dawn cozy-taxi warmth for an hour or two, and then at dawn we'd see a gorgeous Himalayan sunrise, grab a quick warm-up with a tea-and-toast breakfast at the side of the road, and then set off on the last couple of hours of straight, mostly paved roads, where I would be able to sit in the back seat, review my talk, and maybe even start up on my latest vacation novel.

As was nearly always true in our travels, my American vision differed from considerably from Nepalese reality.  The taxi was unheated and the windows leaked and in a singularly stupid move I hadn't brought a coat (in my defense it was the only time I was unprepared for cold weather).  I was wearing a sweater and fleece but the cold was piercing.  The Pokhara Valley was socked in a dense, above-ground wet “tule fog,” and visibility was often less than twenty feet.

I sat in the back of the taxi for hours, shivering and unable to see a thing except for the occasional terrifying looming-out-of-the-fog-speed-demon-Indian lorie bearing down straight for us.  Or, if that wasn't scary enough, sometimes we had a guaranteed-to-be-maximally-combustible oil truck bearing down on us.

I can't begin to describe how scary it can be to drive in Nepal.  This link may give the tiniest of ideas.  Or for a longer, even more vertiginous view, try this link.  (Do not, however, watch this if you ever have any intention of going anywhere in Nepal on a bus.)  Or, if you'd like to see even more, try this not-vetted-by-the-nepali-tourism-board Lonely Planet video

The list of terror-inducing road realities is endless: First off, you drive on the left, so everything is turned around for a long while.  But on top of that, road engineering is primitive at best.  The very best roads are barely two lanes.  There are no breakdown lanes.  There is no room to pass, but everybody passes anyways, giving small toots of the horn to remind everybody a) I'm passing and b) we all, every one of us,  want to pass you and have both of us come out of this alive.

The army was everywhere during our trip.  Often only feet away from us. Often they're friendly.  Not always.


And then there are the pedestrians.  The vast majority of people in Nepal have no car, no motorbike, no bicycle; they walk.  And a lot of the times they're walking right by the side of the road.  Or the highway.  Or in the middle of the lane of the highway.

And the vast majority of farm animals in Nepal are a) not penned in and b) sooner or later are walking to market so they live out their kharma and become lunch.  So you have people in the street.  You have yaks in the street.  You have sheep, cows, goats in the middle of the lanes. 

 And most terrifyingly of all, you have four year old girls darting out into the street (in our first heart-stopping encounter with a four-year-old in the street we missed her by less than a foot).

And there is no infrastructure on the roads.  There's no speed limits.  There's no street signs, no warning signs, no "curve ahead" or "steep incline ahead" signs.  You just go around the corner and look down at a thousand feet of free fall.  And maybe an oncoming bus.  Surprise!

And we drove it in the fog.  Well,  Manipush drove it in the fog.  I was curled up in the back in a fetal position knowing that all along the side of the road there were children playing mothers cooking, and detritus from previous accidents. 

Needless to say, I didn't sleep.  And I was so cold, so unbelievably cold.  I took everything I happened to have in the previous day's backpack to lay on my shivering little self.  I found two “yak wool” scarves I had bought as presents; instead of going to their intended recipients I ended up wearing them on  my legs.  I had brought a Size Very Small “Harvard Med School” hoodie to give to the department director; it was too small to wear but perfect for laying on my back.  I had a tiny hat which covered my neck if not head. 

It was gray, cold, bleak; every once in a while we could see kitchen stove fires in roadside shacks or peasants out gathering firewood or carrying produce on their backs en route to market.  Animals ambled by;  cows, goats, sheep.  We hit checkpoints and passed microbuses laboring up the hills.  We lost so much time in the fog we felt we couldn't stop  for breakfast, so I chewed on the butt of a granola bar I found at the very bottom of the backpack and lay there in misery while the kilometers slowly ticked by. 

We finally arrived in Bharatpur,  home to a small medical college and the Cancer Center, but still, not exactly the center of civilization.

When we finally arrived at the Cancer Hospital, we were again the only car in the parking lot, and I did jumping jacks and yoga moves waiting for our escort.  Fuzzy-headed and frozen we made our way to a small auditorium where I became instantly awake upon seeing the now famous sign and a room full of shiny expectant faces:

More to come......

Thursday, January 28, 2010


Sometimes in crowds in Nepal I just lifted the camera up and panned around the crowd and and took pictures. 

Sometimes I was too far away, sometimes too close.  Most of the time people couldn't tell, sometimes I think they suspected but tolerated the intrusive.curious.techno-laden American.

I only wish I'd lifted the darn camera more often.

And pretty soon there were faces everywhere......