A report on

2010 Healthcare training

Rosemary Knight, September-October 2010
rosie.knight@xtra.co.nz

The purpose of this report is to record the work of the 2010 KSP team, so that the next team can plan programmes and supplies to build on what we achieved. Any planning should also consider the recommendations in the report on the women’s healthcare survey conducted by Rachael Gentile and Bishu Tamang in April 2009 (here).

This report records:

• conditions treated by village healthcare workers
• surveys of the healthposts at Ghunsa, Tellok, Mamankhe, and Lelep
• tuition provided to Ghunsa healthcare worker Tenzing Wangmo Sherpa.

Conditions treated by village healthcare workers

According to the healthpost registers, the healthcare workers treat the following conditions:

More common: headache, wound, skin infection, toothache, gum bleeding, mouth ulcers, common cold, chest infection, tonsillitis, pneumonia, cough, conjunctivitis.

Less common (but recorded in most healthpost registers): breathlessness, worms, gastritis, heart disease, burn (hot water), vomiting, diarrhoea, hypotension, hypertension, joint pain, scabies, allergy, fever, mumps, fungal infection, urinary tract infection, breast lumps, chicken pox, dermatitis.

Four conditions that account for most antibiotic usage:
• skin infections
• dental abscesses
• respiratory infections
• eye infections.

In Ghunsa, the arrival of the medicine order from Lelep is unpredictable, and Tenzing often runs out of amoxycillin in particular. Future KSP teams could assist healthcare workers to reduce antibiotic use for these four conditions through village education. Simple strategies, such as using salt and boiling water in the early stages, are within the scope of practice of all village healthcare workers. Most households also have salt and can boil water.

Ghunsa

Tuition: Tenzing received 25 hours tuition in how to:

• assess wounds and suture skin with nylon (intermittent and continuous)
• clamp and tie a bleeding blood vessel
• remove sutures and dispose of sharps (suture and injection needles)
• give local anaesthetic injections (xylocaine 1% only) and intramuscular
• clean and decontaminate instruments used for suturing
• have confidence in prescribing appropriate antibiotics (ciprofloxacin,
   amoxycillin, amoxycillin & clavulanic acid, IMI penicillin, metronidazole,
   tetracycline, cotrimoxazole)
• diagnose, triage and plaster fractures with wool roll, backslabs
   and crepe bandages.

Tenzing and I began work by reviewing the patients she had seen in the last week. We discussed her role in health education, particularly in managing health and injuries before infection requires the use of antibiotics. She also had some questions about medicines.

Discussion: Topics arising from the review of patients included:

• use of lasix and amlodipine (both in her formulary)
• values for hypertension in older people
• management of migraine (one woman has them often)
• cold water as current first aid for burns (salt or butter is still being used)
• signs and treatment of first, second, and third degree burns
• specific signs of pneumonia
• signs and management of viral versus bacterial infections
• take home message about antibiotics
• tepid sponging technique (mondato pani in Nepalese) to reduce fever
• possible causes of headaches (a common problem): effects of heavy
   physical work and dehydration

Skills revision: Tenzing revised the following skills:

• handwash for a suturing procedure
• prevent and manage a needlestick injury
• give an intramuscular injection (penicillin ‐ in the formulary) and
   ergometrine (in the future)
• dispose of sharps (she uses a plastic bottle – to be burned and
   buried when full)
• make and apply a sling
• handle and care for instruments
• clean and decontaminate instruments, using metal containers and water
   boiled in the school staffroom or in the thermette (lesson given by Rob).

Medical books donated: The trekking group donated the following medical books:
• Where women have no doctor: A health guide for women, by A. August
   Burns, Ronnie Lovich, Jane Maxwell, and Katharine Shapiro.
• Where there is no doctor: A village health care handbook, by David Werner
   with Carol Thuman and Jane Maxwell.
• The NZ Pharmacy Reference – MIMS New Ethicals Medicines Manual 2010,
   (CMPMedica (NZ) Ltd, Auckland).

While this last book has information beyond Tenzing’s scope of practice, it has a good index. She knows how to use the index to increase her knowledge of the medicines she uses and to make safe decisions.

Information and any treatment we discussed was marked in these books, so that Tenzing could find it again, and I could double-check it for appropriateness. By this process she got to know the books and how to use them. The three together are a useful cover for her.

Vaccinations: A man from Lelep attends every 2 months with a cooler box of vaccines. Tenzing says there is usually a good attendance of patients. Lamu, the midwife, keeps a vaccination record.

Management of post-partum haemorrhage: The use of ergometrine for post-partum haemorrhage was one of the recommendations that Rachael Gentile made in her April 2009 report and one of the objectives of the 2010 visit. Tenzing says that ergometrine costs 700Rs per vial and has a short expiry period. She cannot get authority for this medicine from the doctor at Lelep. The Ghunsa healthpost is not funded by the government, so she would have to buy ergometrine from a private hospital in Taplejung. The team was unable to discuss this with the doctor in Lelep, as he was away.

Another reason for not stocking ergometrine is that Tenzing is unwilling to spend so much on a medicine she says no woman has needed. I asked Lamu (midwife) about the incidence of post-partum haemorrhage. She said she uses “home methods” in childbirth and that there have been no complications. Rachel reported the same response in April 2009, that the government does not authorise the use of ergometrine, and it has never been needed. However, Tenzing is required to cover the midwife’s territory in her absence, so for her own education we spent a day discussing the post-partum stage of childbirth, including:

• demonstration of what 500mls of blood loss looks like, using coloured
   water on a sheet, so that she can recognize risk
• the role of breastfeeding in promoting uterine tone
• the role of examination of the placenta in decision-making
• examination for a tear or visible cause of bleeding
• massage of the uterus and bi-manual compression
• how and when to use ergometrine
• suturing a vaginal tear ‐ this is beyond her scope at the moment,
   but since she is developing suturing skills, and we were discussing
   post-partum haemorrhage, so I felt I could not omit it. For the future
   she has:
   – one box of polysorb (absorbable) sutures, expiring 2015
   – notes on post-partum haemorrhage and detailed illustrations
      of suturing a tear
   – skills in intermittent and continuous suturing techniques.

Capacity of the Ghunsa healthpost: The healthpost in Ghunsa is clean and well-kept, and stock is well-managed. Tenzing already had a process for cleaning instruments, but needed access to the school staffroom for boiling water. Now she can boil water in the (New Zealand donated) Thermette when necessary.

Patients expect to get medicines when they come to the healthpost, but Tenzing is firm when medicines are not necessary. She observes expiry dates of medicines.

Patients, including trekkers, pay for medicines, but not for consultations. While I was there, a trekker received a course of ampicillin and cloxacillin (the post had run out of amoxycillin) and paid 138Rs, which is the replacement cost of the medicine.

As discussed at the village meeting later, the healthpost could increase the money available for supplies by charging trekkers for consultations and for medicines. Purchase of a receipt book for this purpose was discussed. Tenzing uses the money from medicines to replace stock.

Tenzing uses instruments confidently and competently, and learns quickly. She is compassionate and makes good decisions. She runs the post from 10-4 with a lunchbreak, and goes down on Saturday mornings to see if anyone is waiting before taking her day off. When the post is quiet, she sometimes helps in the junior school. She has a folder of notes on the skills learned this trip and a practice board for suturing. She plans to study from the books and is committed to the village and to doing a good job.

Medicines currently in use at Ghunsa health post

• vitamins
• dentek
• antacid

• ear/eye drops & ointment
• cetamol (paracetamol 500mg)
• penicillin injection
• folic acid
• move fast ointment
• salbutamol inhaler
• dettol soap
• glosen iron capsule

• albendazol
• ranitidine
• niclosamide
• brufen
• lasix
• aspirin

• antibiotics
   – metronidazole
   – ciprofloxacin
   – tetracycline
   – amoxycillin
   – amoxycillin & clavulanic acid
   – ampicillin & cloxacillin cotrimoxazole
   – IMI penicillin
   – neosporin ointment
   – ciprofloxacin eye and ear drops

Resources left at the Ghunsa health post
A stethoscope and blood pressure cuff were left for Lamu. Tenzing will teach her to take blood pressure.

For wound care
• several sets of suture instruments and some artery forceps
• 4 boxes 3/0 nylon sutures x 36 packets ea. (exp. 2015) will last ~2 years
• 1 box of 4/0 nylon for finer work – face, hands, and children
• Omnistrips – steristrips for small wounds or to support suturing
   – 2 boxes of 50 each
• enough xylocaine 1% local anaesthetic for 15 patients
• a good supply of Betadine
• 2 sets of small drapes to create a clean field for suturing
• 40 non-toothed forceps – one for each family to remove stings
• lifting forceps to remove sterilised instruments safely

For plastering fractures
• bandage scissors for cutting bandages used to hold plaster backslabs
   in place
• plaster of paris, wool roll and crepe/gauze bandages for about eight
   fracture treatments
• a reuseable plastic sheet and apron, one sling, enough plaster gloves
   for 2 years.

Midwifery in the wider Ghunsa area
Tenzing and Lamu the midwife are happy with the way they share healthcare in Ghunsa. Neither of them would change anything about their work. Lamu is responsible for delivering and managing contraceptive care, pre and post-natal education, and childbirth. She also keeps the vaccination record. Their answers about ergometrine were the same – that the doctor in Lelep does not authorise it and there has been no need for it in the past.

Lamu says there was one girl born in Ghunsa in 2009, and two boys born, one in Folay and one in Ghunsa in 2010, and that all were “easy born”. Her register recorded these three. However, when women brought their children for the preschool sessions and the distribution of shoes, Doreen and Sheryl felt there were more babies and toddlers in Ghunsa than the three above.

I visited Lamu’s house again with Rob to pay her salary. Rob thanked her for her work and asked her if there was anything she wanted. She said that she would like to take blood pressures, so we bought a blood pressure cuff and stethoscope in Kathmandu and packed it with the pharmacy supplies to go up to Ghunsa. Tenzing will teach Lamu how to take BP.

Lamu’s travel costs for 2009-2010 were 1500Rs to Taplejung, 900 to Lelep and 800 to Lelep, total 3200Rs. This was paid with her salary. The depo-provera register records the following: Ghunsa 18, Phole 10, Gebla 4, Amjalissa 2, Yangma 6. Total = 38 on depo-provera + 4 pill-takers. Sometimes the women from distant villages come to Ghunsa and sometimes Lamu goes to them.

Women's health session

Recommendations for future work in Ghunsa To extend Tenzing’s practice and improve the health of the village, a future team could assist her to provide more proactive health education e.g.

• I saw several skin infections/cellulitis needing aggressive treatment.
   In each case the wound and limb were dirty and the injury was many
   days old. Teaching people to clean a wound with salt and hot water
   and to present early to the healthpost for advice is achievable and may
   reduce antibiotic use.

• In December 2010 Tenzing attended a two month dental course at the
   Himal Dental Hospital and Institute of Dental Science in Chabahil,
   Kathmandu. There is now a good opportunity for village education to
   prevent abscesses and dental caries. Trekking shops at the teahouses
   on the Kangchenjunga route all stock sweets and sweet biscuits, so
   dental health is a concern.

Tellok

There are three health care workers in Tellok. (There were four when Rachael visited). The one who was present was Kalimara Tebi (not one of Rachel’s list of four), one was on sick leave, and one on Dashain holiday.

Kalimara Tebi said that 25 babies were born in Tellok this year. She said they manage post-partum haemorrhage with “home methods”, and it is not a problem. With demonstration, I took this to be breast-feeding, massage and bi-manual compression. They do not have ergometrine.

Tellok healthcare workers are competent to suture skin, using reels of suture material and resterilising mayo needles. From the register, the health post is still providing decent healthcare (as in Rachel’s report) and the post is busy. Tellok serves a large area.

Health session held during our visit to Tellok
Morning: About a dozen women, several girls and boys, and some of our porters came for the flipchart and video session. Sheryl, Doreen and Philippa dropped in to help. The women liked the flipchart with drawings and nepalese language. I was grateful to our Sirdar, GB, for his professionalism and his willingness to translate the subject matter of ‘women’s business’. One woman, Hima Bhatta Rai, who was confident and outspoken, offered to have meetings at her house to teach other women about the topics we discussed, using the information GB wrote in Nepalese from my notes. Hima Batta would like a copy of the flipchart.

Hima Batta said that the 3 main problems for the women in Tellok are headaches, heavy bleeding and menstrual pain. After discussing these problems with them through GB translating, I wrote some suggestions for management, confirming the advice in ‘Where women have no doctor’. GB wrote parallel nepalese translations of my answers, which Hima Batta took with her. They offered local solutions e.g. water with garlic and special spices for menstrual pain. We discussed anaemia, and iron rich foods, particularly vegetables and meat. In 2009 Rachael noted that anaemia was one of the common problems in Tellok, and that iron supplements are readily available and given to all pregnant women. For headaches we discussed the link between physical work, heat and dehydration. The nearest doctor is two day's walk away in Lelep or Taplejung.

Afternoon: 10 women, 2 men and several boys and girls came in the afternoon. We showed the video again, using a timeline to show the developmental stages. GB had written a translation of these stages in simple nepalese, so that I could use them next time. There was much debate during the video and I felt that knowing women were interpreting for others. Hima Batta Rai gave a lecture on the dangers of smoking in pregnancy. They enjoyed the DVD of ‘Babies’ to finish the afternoon.

Mamankhe

The health care workers (all women) in Mamankhe are (according to the teacher):
• Prikash Shresta, the midwife, who lives in Morong
• Ganga Kumari Gautam, who does the vaccinations and lives in Khewbang
• Narad Manibardewa, peon, who carries medicines from Taplejung, lives
   in Mamankhe.

Before we left Mamankhe, we were shown the new healthpost, a beautiful building under construction in a hollow below the museum. As at November 2010, it is about 8 months from completion. The new post may be more convenient for patients and produce a better working environment for and a new accountability from the healthcare workers.

New healthpost, Mamankhe

The current health post is in a state of disuse, dirty and untidy. The medicines cupboard was in disarray: used needles and syringes, a kidney dish containing skin tissue, and a used instrument. The post has a good supply of instruments – forceps, artery forceps, blade handles, a hook and scissors, but they are used or dirty and not stored in a way that protects them. Medicine boxes were empty, or contained the wrong medicines. However, Rob and David found a good supply of medicines in a locked cupboard in the vaccine fridge room.

A cooler box contained 15 old vaccines. Vaccines will still be delivered in a cooler box in the near future as we were unable to repair the vaccine fridge on this trip. The register suggests a reasonable number of patients are seen when the HCW is in attendance. The entries were intermittent, with gaps of one to a few weeks. In this respect, the provision of healthcare in Mamankhe seems to be unchanged from April 2009 (Rachael Gentile’s report). Without an interpreter, I was unable to talk to the peon and cannot make further observations.

The post has several good locally-produced manuals with diagrams for patient education. There is potential for good management of area and village health, and data collection, given the range of government documentation stacked unused on the shelves, for example:

• Child health register, defaulter followup slips, multipurpose contact card,
   specimen collection register, micronutrient distribution register,
   immunisation register – some entries.
• A register that records information according to caste or ethnic grouping,
   level of disadvantage, and religious minority. Ethnicity is also noted in
   the main register.
• Logistics Management Information System – family planning programme,
   malaria programme, ARI programme (respiratory infections), nutrition
   programme, injections, tablets and capsules, liquide solution and
   powder, surgical and miscellaneous.

Lelep

Healthpost consulting room, Lelep

Pasang Sherpa is the healthcare worker who holds the key to the health post. He received his training in Dangutar and his dental training in Taplejung (he says they do dental extractions in Lelep). All entries in the register were in nepalese, so my information on the table of conditions treated there is piecemeal, gathered from GB’s translation when he was free, and difficult conversation with Pasang Sherpa, who did not want to talk to me about his work. Rachael noted that there is an abundance of education materials. They are still there, but while the consulting room was tidy, the state of the other two rooms and the condition of the education materials did not suggest that they had been used recently.

The doctor, Kunjilal Masi was due in Lelep in 7 days.

Pasang Sherpa said he was leaving that day for Ghunsa to administer the oral Vitamin A programme for babies from 6 months to 5 years, but did not leave while we were there. He walked to Tapethok in the evening to suture a Khukuri knife wound.

I was asked to enter the instruments we left there – a suture set, toothed forceps for exploring wounds and 6 non-toothed forceps to give to families to remove stings – in a log book. These were hastily tied up in a plastic bag and locked in a cupboard, which was full of unsorted instruments – he had had to return home to get the key for the cupboard, kept separately from the health post key, and so I felt they might never be used.

Discussing the vaccine fridge at the healthpost, Lelep

Chering Sherpa is the health post assistant. He is a young family man who lives in Lelep. He is trained to check and look after the fridge and did TB training in Biratnagar. He cleans the post, takes sputum specimens from patients and escorts the patients who’ve tested positive for TB to Taplejung for treatment. He brings medicines back for the post. He says he earns 50Rs a day and wants to improve his situation.

Contraception is managed by the healthcare worker. The register appeared well-maintained. Depo provera: 35-40 women; pills: 25-30 women; condoms: 2.

Acknowledgements

The Kangchenjunga School Project wishes to thank those who donated health equipment, expertise, time, and money for the October-November 2010 trek:

• Covidien provided nylon skin sutures for use during teaching sessions.
• Aaron Morgan of Covidien provided his expertise at a suture workshop
   and ongoing support during preparation for the trip.
• USL Medical provided Omnistrips (skin closure strips) to give Tenzing
   an extra product for wound management.
• Wellington Hospital Sterile Services department donated several
   instruments, including two sets of instruments for suturing, so that the
   clinic always has a clean set available and some small surgical drapes.
• Pharmacist friends and neighbours in support of the project donated
   US$200. With this money we bought clinic supplies in Kathmandu to take
   up to Ghunsa.
• Bernie de Ruiter from Wellington Hospital Fracture Clinic gave up one of
   her days off to share her knowledge of managing fractures in remote
   areas.


Rosemary Knight
rosie.knight@xtra.co.nz
10 January 2011