Short Story: The Truth About medical mission to Nepal

I was volunteering at Aloha Medical Mission’s free health clinic in Honolulu with their intake process when I learned about medical missions broad in third world countries.  The pictures and stories made me think “one day, I’m going to do that!”  I was enthralled and made it a life goal to serve in a medical mission.

After graduating from nursing school, I was taken by a whirlwind of milestones. I passed boards, started a new job, got married and bought a home in Mililani Mauka.  Life was great.  I actually forgot about my medical mission dream.  Despite having met those milestones, I still felt something was missing.

Fast -forward thirteen years later, I had transitioned from the Medical-Surgical floor to the Intensive Care Unit.   Soon after that transition,  I endured a painful separation and eventual divorce.  It was there in the ICU that my dream of going on a medical mission was lost and found.  My friend Christy told me that Dr. Bradley Wong was recruiting nurses for a medical mission to Nepal.  She was not able to go but thought I would be interested.  I was elated!  I didn’t know exactly where Nepal was on a map but I figured I could check Google.  In a short amount of time after that conversation, I was seated across a salt and pepper haired man dressed casually in a t-shirt, shorts and flip flops asking me questions about my experience as a nurse.  My answers satisfied him enough to offer me a position on Aloha Medical Mission’s first surgical mission to Nepal for 2010.  To be exact, we were travelling to Dhankuta, Nepal. It’s a ridge top village in the eastern region of Nepal.  Thank you Google!

I had no idea what to expect.  Who will I be working with? What equipment do I need?  What is the charting like? How much will this cost?  Do I need shots? Am I going to experience altitude sickness? What do I bring? Endless questions zipped through my head.  When I shared the news of my trip with my friends and family they asked even more pertinent questions: is it safe?  What is the political climate?  The unknown was calling me and it made me nervous and excited at the same time.  I last time I felt this uneasiness was when I moved from Med-Surg to the ICU.  Since then, I’ve learned to embrace change.

Thankfully, Dr. Wong had a pre-mission meeting to help answer questions.  Eager doctors (surgeons, anesthesiologists, dentists), nurses, and lay people gathered in the living room of his home in Aina Haina.  He told us how the mission came to be.  Dr. Bikash Gupta approached Dr. Wong about bringing a medical mission to Nepal roughly two years from the actual mission.  Dr. Wong had spent some time in Tansen, Nepal working and teaching the local doctors and medical students.  Through a series of fortunate events Dr. Gupta and Dr. Wong along with Hitesh Karki (Dr Gupta’s childhood friend and an engineer based in Kathmandu) met and planted the seed for our mission.  So there we all were, at best we were acquaintances. Dr. Wong covered the logistics of our travel: what, when, where, how much it would cost.  I was told lodging would cost $300.  I couldn’t help but think “per night?”. Nope, it’s $300 for the duration of our stay for three weeks.  What a deal!  When the general meeting was done, I still had more questions regarding my nursing role.  I wanted to know what was expected of me.  Being an ICU nurse I was accustomed to the routine and  some control of my environment.  This was the most uncomfortable I would make myself on purpose.  Almost like getting a Brazilian wax but longer.  My self pep talk ensued: “Deep breaths Julie. You can do this. You’ve been waiting your entire nursing career to do this. You’ll figure it out.  Don’t mess it up.” Yeah, no pressure.

The day finally came when we all met at the Honolulu International airport with one carry-on and one check in luggage.  Our other check in would be an LBC box full of supplies for the mission.

Essentially we were all mules of the mission. Korean Airlines and their model like flight attendants flew us nine hours into Incheon, Korea for a 20-hour stop over where we  each had a nice hotel room.  The hotel provided first world fully functional cold and hot water knobs.  If I had known what was to come in Nepal, I would have savored every sedentary second on that western style toilet. I would have (in slow motion) caressed the fluffy hypoallergenic pillows with sheets and comforter to match whilst mouthing the words “kamsahamnida comforter, kamsahamnida” (thank you in Korean).

Korean Airlines bused us from the hotel back to the airport the next morning to take the next leg of the trip to Kathmandu, Nepal.  The eight hours in the sky sequestered us from the truth that awaited us outside the International Airport in Kathmandu: abject poverty like I’ve never known.

As we landed, I noted the densely packed pastel colored buildings in the basin of Kathmandu, Nepal.  I debated if the buildings were pastel or faded by time from a previous glory.  I saw string with what I thought was clothing strung between buildings.  Later I learned it was not laundry but prayer flags.  The airport was diminutive compared to other International Airports I’ve seen.  We deplaned onto the tarmac, no jet way. We walked a short distance from the airplane to the glass door entrance framed by the red bricks of the airport.   We made our way into the small airport and stood in a congested line for our visas.  Then went downstairs to fetch our luggage with the assigned box of supplies.  The routine task took hours. Then we waited some more with our many carts of boxes and luggage in a haphazard exit line.  Animated negotiations in a loud foreign tongue took place in the front of the line.  I saw Dr. Gupta talking to an airport customs official.  My naïve mind did not fathom that the airport official was casually obstructing our exit for the international lubricant: cash money; rupees.  After the negotiation settled, we eventually left the travel purgatory.  The flurry of luggage, boxes and people herded into mini buses was a chaotic but concise movement. About 15 minutes into riding to our hotel for the night, it was obvious our Nepali drivers possessed uncanny spatial abilities.  Cars, buses and mopeds come within inches/millimeters of each other and the bird’s nests of electrical wires that dangled precariously above our bus.  In traffic, cars and buses were so close to each other one could easily reach out the window and pick a stranger’s nose in the car next to you.  Needless to say, the American personal bubble of 2 feet was definitely nonexistent here.

Our travel took days to get to Dhankuta.  We flew from Honolulu to Incheon, Korea. Incheon, Korean to Kathmandu, Nepal.  In Kathmandu we took a domestic airline called Buddha Air (it felt blasphemous to say out loud. I likened it to saying “Jesus Air”, just didn’t seem right) for a one hour flight to Biratnagar.  In that short domestic flight, we flew along side the Himalayan range with a great view of Mount Everest.  From Biratnagar we took a six-hour bus ride up to the mountains.  Switch back roads made the climb easier for the bus.  Local buses were stuffed to the max and apparently the roof is considered seating.  When our bus and the oncoming bus came to a hairpin turn and turned simultaneously,  two years was shaved off of my life span for each turn.

Six hours with a couple of pit stops later, we arrived to Dhankuta, Nepal.  Blurry eyed and exhausted, 36 of us stumble out of the mini buses.  Our reception was spectacular.  It seemed the whole village and neighboring villages came to greet us.  We were told it is similar to the greeting they reserve for royalty.  Horns and drums playing a meandering beat while we walk through single file to receive a tikka on our forehead (red wet chunk of what looked like small grain rice), a pale yellow silk scarf over our shoulders and a garland of marigolds.  It was a parade for us. We walk approximately a mile to the district hospital through most of the main street. People were standing on their balconies and others lined the street to greet us with their smiles and camera phones.

The women and girls of different sects wore their bright colored saris with gold jewelry in their ears, nose and neck.  The slow parade pace made it possible for us to take pictures of them as well as selfies with them.  The pomp and circumstance took us to the doors of the Dhankuta Hospital. The pink-peach building that stands three stories tall had people peering out of windows and the rooftop to catch a glimpse of us.  The official greeting was given in Nepalese while we all nodded and smiled.

We had one day of rest before touring the hospital and unpacking.  The task of unpacking our 20 plus boxes and making a fully functional mission would take approximately three hours.  My station was just outside the OT (Operating Theatre- British influence) in the recovery room.  My cohort from our Aloha Medical Mission team was a familiar face.  I worked with Diana on the Med-Surg floor at Queen’s years ago.  Our job was to keep our patients safe immediately after surgery in the recovery room. Bear in mind, I have not worked in recovery room at home but have received patients directly from the operating room into the safety of the surgical ICU with all the fancy accouterments of western medicine, monitors and seemingly unlimited supplies.  That is not the reality I faced in Dhankuta. Hello sub-culture shock.  A picture forever burned into my memory was that of latex gloves carefully hung over jalousies to dry for the purpose of re-use.  Taking the reduce, reuse, recycle practice to another level.

At home, I was use to throwing away a pair of latex gloves after one use from any interaction with each patient.  The mission supplies were limited to donations and what our staff bought.  The practice change was eye opening.  That first mission I learned gloves, tape and alcohol pads were luxuries.  My equipment for the mission consisted of an automatic BP cuff, a pulse oximeter, thermometer and my five senses, the latter was the most essential of my tools.  My dependence on our monitors at home had me undervalue common sense and my senses.  Now I promote using and trusting instinct more than any equipment requiring an electrical outlet or batteries because technology is man made and will, at one point or another, fail you.

Aside from stable vital signs, vigilant assessment on airway patency, signs of bleeding and intolerable nausea/vomiting and pain was our priority.  We had Dhankuta Hospital nurses in the recovery room with us that understood some English and translated for our patients.  Nepali nurse Sita quickly picked up our assessment and discharge from recovery room practice.  Although Sita’s English was limited and my Nepalese was nonexistent, we were able to communicate save a few inconsequential misunderstandings due to use of different terms.

The system we created worked well. Each unit (pre-op, OT and recovery room) an essential cog in the wheel of the mission. We would receive the patients from the OT and the anesthesiologist would give us report while the surgeon wrote recovery and post-op orders.  When the patient met criteria to leave the recovery room, we transferred the patient on a gurney to the post op ward I gave report in English to a Nepali nurse.   They would smile and nod.  I worried if anything was lost in translation.  A volunteer medical doctor from Kathmandu, Dr Rajat Pradhan, spoke fluent English and was the resource for the Nepali nurses in the post-op ward.  He was present for each transfer from the recovery room and translated for me using terms familiar to the Nepali nurses.  For example our “PRN” is their “SOS”.  With the repeated interaction we built a rapport.  I had tendency to explain in pantomime, which I can only hope made it fun for them.  The post op orders were very similar.  We started to have a predictable pattern and flow.

In the recovery room, we asked patients the same questions over and over so I paid attention, asked how to pronounce words and picked up some Nepalese.  I’d ask them to open their eyes, take a deep breath and if they had any pain.  I also noted that for most adults when greeted “Namaste” their immediate response is to bring their hands together (as though if to pray) and verbally respond with “Namaste”.  So with each patient that came into the recovery room, I greeted them with “Namaste!”  I also learned the respectful terms for males and females in relation their age and my age.   Learning the culture and language of the country/region on each mission is a priority for me.

After a few days, we deciphered our role in the recovery room and held a standard.  Whatever gaps regarding to patient care, we quickly found a workable safe solution.   The paper work was scant and inconsistent.  We needed something consistent that the Nepali nurses could read.  Thank goodness the Nepali nurses can read and write English!  We made a standard postop order set that addressed pain, n/v, activity, diet and dressings etc.  The days were long and the work was challenging.  Each challenge engaged the team to think critically and presented an opportunity to be creative.  And as each day passed, I let go a little bit more of my western practice that did not serve our patients in Nepal.  Letting go was not easy but it was necessary.

When I returned to work at Queens my perspective could not help but change in so many ways.  I was eager to share my experience with my family and friends; hundreds of pictures of what I saw, did and ate.  I developed a disdain for our western culture of waste and felt impotent with any meaningful change in my hospital.  On a mission, there was an instant gratification of finding and fixing a systems problem without having to form a committee and meet month after month until a watered down version of the intent is even considered.  It was because our actions were limited to our time frame of the mission.  The feeling of being effective and making a difference is definitely one of the addictive qualities of a surgical mission.

Two-year-old Naresh and I in 2011

Again in 2013 with his Dad and Dr Rajat Pradhan. A burn contracture release on his right arm gave him full range of motion.  Full range of motion means later in life he can provide for his family.

It’s been seven years since my first mission.  But I remember people asking me if the experience was profound and life changing.  My initial reaction was “no, not really” but felt obligated to say yes.  Only years after my first mission I can answer that question not with words, but my actions:  I’ve been going on 2-3 surgical missions a year since then.  I changed my work status from full time employee to call-in.  I now directly help the mission leader, pick up donations and have countless boxes of medical supplies in my home.  I also carefully vet and recruit nurses that join the missions.  I’ve had the honor to serve the people of Nepal, Philippines, Honduras, Cambodia, Ecuador, The Marshall Islands and Kenya.  I’ve been on every Aloha Medical Mission mission to Nepal.  Nepal holds a special place in my heart because it was in Nepal that I found my heart.  This is my passion, my life’s work. That feeling of missing something in my life has not returned since I discovered my passion.  I plan to do it until I physically cannot do the work.

Written by Julie Gamboa, RN

2017-38809  Exp. 10/17