Famous!

The Winter 2015 JHU Engineering magazine just published an article about our summer experiences and the global component of the CBID program, with quotes and photos from our past blogs. Check it out here!

Of Mice and Misfortune

Yesterday, I returned to my room to find a mouse in my bed. 

It was still alive, and I wasn't in my bed, which are both good things, although at the time, I wasn't very comforted. You see, that same mouse had already caused me quite a bit of grief two hours earlier, when I awoke to a rustle in my curtains and saw two eyes staring back at me.

Like a sensible person fully aware of the size discrepancy between me and the mouse, I stayed in my room just long enough to take a photo before bolting down to the lobby until the rest of my team woke up. I really thought I had given the mouse enough time to get out of my room, but the long tail that I saw disappear under my sheets proved me wrong.

I told the front desk, who sent someone back with me, equipped with only his bare hands. When he spotted the mouse, he made the situation so much more comforting by exclaiming, "Oh! A rat!" He grabbed a thin metal pole, and I almost stopped watching out of fear that he was going to skewer the poor creature alive, but I think he meant to use it like a shepherd's crook to herd the mouse into the hallway so it could terrify someone else. I left to go to the hospital before he was successful, deciding that it wasn't worth the risk of re-entering my room to get my toothbrush or deodorant (sorry, team). 

When we returned, I asked the front desk if the issue had been resolved, and the response I got was, "I'm not sure- why don't you go check?", because that's what every person who's afraid of mice wants to hear. This time, I didn't go alone. My teammates soon discovered the poor little mouse, lying dead in the corner of my room. The front desk sent someone to wrap it up in a tissue and take it away, ending the mouse's reign in room 214. 

I've realized that even though I consider myself an adventurous traveler, I still continue to be bothered by things like not being able to find any toilet paper in Biratnagar, or having to take cold showers, or finding mice in my bed. While many of these are legitimate reasons to be uncomfortable, it frustrates me how little annoyances like this can affect my trip.

When I compare those annoyances to the problems people face here, it's almost embarrassing how easy it is to get caught up in the little things that differ between here and the States. It shouldn't bother me that ice cream tastes different, or that I have to bargain for taxi fares, or that the 1 on Nepalese rupees looks like a 9 and throws me off every time.

Instead, it should bother me that NICU's here are overcrowded, understaffed, and not able to save lives that could easily be saved in the US.

It should bother me that these hospitals have broken lifesaving equipment that no one knows how to repair.

It should bother me hospitals have to refuse treatment for sick babies because their parents cannot afford to pay.

It should bother me that  90% of babies born 12 weeks too early in countries like Nepal will not make it, while 90% of those babies born in the US will survive.

It's not just important that these things bother me more than my own inconveniences. What is especially important is letting that blatant injustice guide me to action, rather than despair.

To say that it's hard to show up to the NICU each morning is an understatement. I've joked before about wanting to take all the babies home with me, but in all seriousness, there are countless times each day where I wish that I could just whisk the sickest of babies off to Hopkins to receive the simple lifesaving interventions they need. I want to hold the babies that have been crying with no one in the ward to hear them. I want to be able to get these hospitals the equipment they need, without their funding being lost to bureaucratic inefficiencies. The worst part is that I can't do any of these things, because I'm an engineer, not a physician or a policymaker or a magician.

At the same time, I try to remind myself that I'm an engineer, and there's a lot of power in that. I have the unique ability to understand machines and the people who use them. I can design solutions that others haven't thought of. I can use technology in creative ways to help solve problems that seem larger, such as understaffing and detection of newborn danger signs, through a user-friendly vital signs monitor. As we learned from the Saving Lives at Birth conference, my team and I are working in a field with others who are just as passionate about saving babies in a way that is realistic and sustainable.

I'm still wrestling with how to process all the problems I've seen here; problems that are far worse than the silly little things I worry about when I travel. I'm working on fighting the two most natural responses, ignorance and despair, and instead turning what I've seen into fuel that will keep me going throughout the frustrations and uncertainties that will inevitably be a part of this project. Engineers have already done amazing things in this field, like creating low-cost respiratory support systems and figuring out how to keep babies warm during transport. Still, the problems that remain show that there is a lot of work left to be done. It's time to start doing my part. 

CBID goes trekking, and other touristy tales

One of the fun parts about these global trips is that we also get some time to see the sights outside the hospitals. We've had some time in the afternoons to explore Kathmandu and the surrounding areas, and had all day today for our own adventures. What follows is my completely arbitrary ranking of our tourist activities thus far.

5) Exploring Patan
A very long time ago, there were three kingdoms in the Kathmandu Valley, located in Kathmandu and the neighboring cities of Bhaktapur and Patan. I mention this because we got to check out the royal square in Patan after we finished up a morning of work in the Jhpiego office.

Here is our team hard at work synthesizing our observations and coming up with a strategy for next week....

Here are some of the temples we saw after.

4) Wandering around Kathmandu
We are staying in Thamel, which is an exciting, tourist-filled area of the city packed with shops and restaurants. Every time I leave the hotel, I notice something I haven't seen before.

The Kathmandu palace square is just a short walk from our hotel. It's amazing how a city that's become so modern can still have architecture like this tucked around the corners.

3) Eating
Our restaurant options are nearly endless. Within five minutes of our hotel, we have access to Indian, Nepali, Tibetan, Chinese, continental, Mexican, Italian, and "New Orleans" food, which Kimber says is nothing like what they actually serve in her native town. We've found new restaurants and returned to some of my favorites from last year, like the Momo Hut to introduce the group to the magic of Tibetan dumplings, and the Annapurna Cafe, which has the best and cheapest lunch food around. Our bill for all the food shown below was less than $10!

2) Monkey Temple
As the name would suggest, this is a temple that is surrounded by freely roaming monkeys. The view of Kathmandu is amazing, despite the smog. 

The monkeys certainly keep things interesting. Some might find them cool. I just find them creepy.

1) Hiking to Nagarkot
I've finally trekked in Nepal! One of my greatest regrets from my last trip has vanished, now that I've gotten to experience a small taste of the hiking here that attracts adventurers from all over the world. During our free day, a driver dropped us off just outside the city, with the plan to pick us up several hours later in a place called Nagarkot.

Although the hotel strongly encouraged us to get a guide, we turned them down- and I'm glad we did. We followed dirt or paved roads the whole time, and although we made a few wrong turns, the people we encountered were happy to give us directions. We must have said "namaste" to dozens of fellow hikers and people who lived near the trail, including lots of cute kids who would get so excited when we said hi to them. We also befriended some dogs who helped show us the way.

The view of the Himalayas became better and better as we climbed higher and higher. The view was our primary motivation, as we soon learned we had underestimated the length of the hike. After taking plenty of breaks for pictures and snacks, we eventually arrived at the Nagarkot tower, which offered the best view of the mountains for those who were tall enough to see over the hordes of people gathered there.

Our hike was more demanding than we expected, and most of the time, we weren't sure if we were going the right way. Still, the view throughout was rewarding, and the feeling of accomplishment at the end was wonderful. We realized it's a lot like what we're going through with our projects right now. Our direction can seem unclear, and we might feel unprepared for everything we have to face, but the important thing is that we keep going. It's absolutely worth it.

Motivations

Melody:

I’ve been in Kathmandu for almost a week now. I know your question will be, “How is Nepal?” so I’ll go ahead and answer.

It’s been a lot of things.

I could tell you about what I’ve learned from interviews at the hospital, the tourist sites I’ve visited, the food I’ve eaten, or the souvenirs I bargained for. I appreciate these experiences. But eventually the details will all blur together.

There’s something else that I will refuse to let myself forget. I saw a preterm baby in the neonatal intensive care unit that was severely ill and struggling to breathe. The doctor told me he probably wouldn’t survive the day. There were so many reasons—one critical piece of medical equipment was broken, there wasn’t enough manpower to perform another intervention, and the family was too poor to afford the last option available. It angers and upsets me that this life had a price on it that wasn’t/couldn’t be paid. A preventable death. So many failures along the way.

It was a horrible but powerful reminder of my motivations for working in global health. This is the story I won’t tell when I first see you again, but it’s one of the ones that will keep me going when I’m burned out by work, frustrated by global health politics, and am close to forgetting the real purpose behind the project. At those times (because I know they will happen), I’ll remember this and I’ll keep going.

Back Again

Hi loyal blog readers! Sorry for the lag in posting. We've moved back to Kathmandu and transitioned to a new government hospital, and we're still processing our experiences from our two days there. The reality of the constraints of our setting has become very clear over the past few days, and we've had more important things on our minds than writing witty blog posts. 

That said, we did want to share a few updates from last Sunday and Monday. During those two days, we visited Birat Medical College and Koshi Zonal Hospital, flew past Everest, and checked into Kathmandu Guest House. If all of that sounds strangely familiar, it's because we've done it all before on this trip. The big new news from those two days was the arrival of the rest of our team! We're very excited to have our whole team in-country, now that Melody and Jackie are in Kathmandu. 

On Sunday, we went back to Birat Medical College in the morning and Koshi Zonal Hospital in the afternoon. It was helpful for answering more of the "Oh, I can't believe we forgot to ask that!" questions we had from the previous visits. Each hospital gave us some key insights. Wes was able to talk to administrators at BMC who shed some light on how purchasing works for private hospitals, which will help us develop a plan for how this device would be marketed and sold to facilities. At Koshi Zonal, we saw how nurses responded to a pulse oximeter and oxygen regulator that stopped working, which is important for us as we consider how to design reliable technology that healthcare workers can maintain over time.

We departed from Biratnagar the following morning to fly back to Kathmandu. We were lucky to snag seats on the right side of the plane this time, so we once again had a lovely view of the Himalayas from the window. You know you're getting spoiled by global travel when seeing Everest isn't all that exciting because you just saw it a few days earlier...

We checked back into Kathmandu Guest House and decided to play some cards in the courtyard while waiting for the rest of our team to arrive. We expected them to arrive about an hour after us, but because this is Nepal, an hour turned into three hours, giving us time to take this very classy photo. 

Thankfully, the rest of our team, plus Mihika and Kimber from the Labor Trainer team, soon arrived to rescue Wes from losing too terribly. Their travel saga is quite the story, but in short, involved their first flight being delayed and then rescheduled with three hour's notice to get to the airport in DC, plus the entire Abu Dhabi airport shutting down, plus several hours waiting around at the Kathmandu airport. We're just glad to have everyone here now, and are excited to explore more of this exciting and colorful city together. 

Best of the East

There is an unmet need for tow trucks in Nepal. 

That was our conclusion yesterday after a crazy day that didn't include any babies, but did involve visits to temples, a surprise reunion with our New Year's Eve party crew, and our car breaking down on the middle of a mountain.  

The day started off with driving to Dharan, a city about an hour away (as we would learn that day, an hour here means anything from 60-180 minutes). We stopped by B.P. Koirala Institute of Health Sciences (BPKIHS) to see the outside. BPKIHS is a large referral hospital that receives the babies that are too sick for Koshi Zonal. Since Dr. Kusum was busy, we planned to visit the next day when she could join us. In the meantime, here are your two favorite bloggers posing in front:

We hopped back in the car with Binita and her family to visit two nearby temples. Nepal is predominantly Hindu, and it shows through the tikka-dotted foreheads and the temples scattered around the streets and mountaintops. 

Our next stop was the top of a mountain to get a view of the Eastern Region of Nepal. We drove up a steep mountain, with our little van straining next to the Jeeps passing it on either side of the single-lane road. When we stopped to let cars pass us, the van failed to restart, so we got out and walked the rest of the way to the top. Hooray for "trekking"!

After climbing a tall staircase, we reached the top and found this incredible view:

The fog had gotten so thick that everything we could have seen was obscured by the cloud that surrounded us. Disappointed, I jokingly put on the sunglasses I brought and professed hope that I still might need them. Amazingly, five minutes later, I did! The sun started to come back out as we walked back down the stairs, and just as we were about to leave, I asked if we could run back up again. This time, the view was amazing. 

We asked someone to take our photo at the top, and they decided to be artsy and tilt the camera, but it's still a nice photo if you tilt your head the right way. 

We returned to a wonderful traditional Nepali lunch made by Binita's family. It was the best food of the trip so far! 

As we were heading towards the car, a group of people called out to us and started waving. We thought we didn't know them, but it turns out, they were some of the people from our New Year's Eve party! We were surprised to see them 2 hours away from our hotel!

We got into the car to leave, only to discover that it still wouldn't start. Wes was there to give them a hand, and we were soon rolling down the hill again- for the time being. 

The van stalled a few minutes later, and after more unsuccessful pushing, it seemed to be that the car was out of gas, or petrol, as they call it here. We waited for another car to come by to drive up the mountain to bring back petrol for us. It arrived in a 2-liter soda bottle, which isn't traditional, but seemed to serve the purpose. 

The bottled gasoline worked for a very short while before the car rolled to a stop for good. A little before 5:30, we were told another car would come to rescue us in an hour. As the minutes ticked by, and the sky grew darker and foggier, we passed the time by learning Nepali. We can now count to ten (butchering the words for six and four because the sounds don't exist in English), and most importantly, can ask our favorite question for the caregivers we've interviewed- "Kina?" which means, "Why?"

The other car showed up nearly three long hours later, and we all piled in, only to realize that the biggest problem remained unsolved- what would happen to our original car? Turns out, the answer involved a single rope and something never covered in my driving exam. It was too dark and rainy to get a photo of our new car towing the other car, but it was a pretty funny sight. 

Unfortunately, we couldn't pull the car up a hill, and had to leave it there with our driver. Don't worry- he made it back later that night, pulled to safety by another van. We arrived at our hotel exhausted, with cramped legs from sharing the back of the car with four other people, but happy to be back. 

A tow truck would have rescued us much faster, but we also wouldn't have the story to tell. It's constantly an adventure here, and we're thankful to be a part of it. 

Getting in the Zonal

After a productive day at a well-equipped private hospital, we got to explore a completely different setting at Koshi Zonal Hospital. 

As a government facility, care is less expensive, but the tradeoff is that the hospital is "under-resourced and understaffed" according to the majority of the nurses we interviewed. 

Their NICU had five babies, limited by the number of available incubators. There were no ventilators or CPAP machines for respiratory support, and the only monitor in the unit was extremely old and not beig used. When we asked why, they said that it was only for the very sick babies- but considering that several of the babies had neonatal sepsis, it was unclear what very sick meant. 

The incubators were designed and built by the hospital's own security guard. We got to talk to him and learn that he has no engineering training, but was told during his days in the military that if he found an abandoned baby in the jungle, he should place it in a box to keep warm. He was inspired by seeing expensive incubators in other hospitals to create a low-cost alternative on his own. The result is a very cool (and very warm) example of local frugal innovation. 

We spent the morning interviewing nurses and nursing students and getting feedback on our design concepts. Everyone was helpful and excited about what we were doing. We observed a nurse taking vital signs on all the babies manually, and it took her over half an hour- a huge time burden for one nurse in charge of five babies, two of whom started crying while she was taking vitals on another baby. 

The visit was important in showing us how government hospitals cope with their limited resources. In places like this, which lack so many other interventions, it can be easy to be overwhelmed by the power outages, by the crowds outside the doors, even by the lizards on the walls! However, seeing these adorable babies continues to remind me that whatever we do, it is vitally important that we do something. There are plenty of gaps that need to be filled, but it's our job to fill this one the best that we can. 

Birat Medical College

On the second day of our trip we returned to the NICU of Birat Medical College here in Biratnagar, Nepal. This is a private tertiary level hospital with a well-equipped NICU with 5 infant warmers and 3 cribs. The room was bright and clean, and smelled of bleach with a hint of dirty diapers, as one may expect from a room with this many babies. The multiple  The infants were tightly wrapped in colorful blankets like hard candies from a jar. Take a look at the cool guy taking notes in the photo below.

However, this NICU was full of blaring noises, as multiple alarms sounded in unison occasionally drowned out by the piercing cries of babies.  The worst culprit was a temperature alarm that emitted a double chirp non-stop due to too low of a temperature because the temperature probe was not being used.  The nurses did not know how to disable the alarm so it just continued to sound in vein. We recorded a minute of sound as an example. Take a listen below.
<awesome audio clip pending...>

These auditory annoyances did not hinder the good quality of care that was being provided to the infants. Babies did not cry for long at all before being seen by the large number of nurses on duty. 

After our ovservations in the morning we got the chance to interview multiple nurses and get their feedback on our design concepts. Their responses did not agree at all, but that was actually more helpful for our engineering team as we attempt to design a better vital signs monitoring system. It was extremely helpful to get this feedback from our users who really are the experts of their domains. It is making me excited to design prototypes when we get back to the states in just over a week.

After a great day learning about the medical system here in Nepal we took a rickshaw to the local market to have a look around. It was slower and less terrifying than our usual taxi rides, but the pace allowed us to appreciate the surroundings much more. I was able to buy a small bag of popcorn off a street vendor for 20¢ and I really appreciated the small crunchy mid-day snack. Traveling on the roads sounded a lot like being in the NICU. Constant horns, sirens, and bells are going off as everybody tries to get where they're going as quickly and as cheaply as possible. All of the rickshaws have their bells mounted next to the spokes of the front tire so that the hammer hits the bell in rapid succession alerting (or not) all who walk in our way. 

Finally we discovered the roof of our hotel was a wonderful spot to collect our thoughts at the end of a long day, enjoy a beautiful sunset, and type up a (hopefully) good blog post.

Stay tuned for a future blog post about Koshi Zonal Hospital.

Happy New Year from Nepal!

The last day of 2014 started off with a stunning view of Everest and ended with us unexpectedly becoming the guests of honor at a New Year's Eve dance party. Oh, and we had our first hospital visit as well. Not a bad way to send off 2014!

We started the morning by flying to Biratnagar from Kathmandu. It's a half hour flight, but a 14-hour drive because the roads are poor and there is a mountain range in the way. We were lucky to snag seats on the left side of the plane, because once we ascended above the smog of the city, we had a clear view of the Himalayas. We asked the flight attendant which peak was Everest, and she pointed directly outside the window. Can you tell?

The crazy thing about Mt. Everest is that it's so tall (about 10,000 feet higher than our plane was flying), but compared to the mountains around it, it doesn't stand out. In this photo, it's the perfectly triangular peak in the middle, right in front of the clouds.

We were greeted by 75-degree weather and one of our Jhpiego hosts, Binita. She took us to meet Dr. Kusum (who guided us through our previous Nepal trip), and after the first of what will be many tea breaks on this trip, we headed to Birat Medical College. 

BMC is a medium-sized, tertiary-level facility, meaning it has high-level care, including a designated neonatal intensive care unit. This visit was introductory, so we didn't stay in the NICU very long, but we did get to observe for a little while. There were currently six babies in the NICU, which was fairly well-equipped. The facility has monitors, but not enough for every baby, and when we arrived, they weren't even using all the monitors they did have. We are returning today to spend the whole day in the facility, and we're hoping to observe how the nurses interact with the monitors and what might be the reasons why they don't always use them. 

After our visit, we returned to the hotel, and our hosts told us to rest for the remainder of the day. However, we were tired of sitting after all of our traveling and wanted to explore, so we walked around nearby Biratnagar. Despite being Nepal's second largest city ("Biratnagar" is Nepali for "huge city"), it's an entirely different feel from touristy Kathmandu. The streets are much less crowded, with bicycles and rickshaws being the primary mode of transportation. The biggest difference is that we seem to be the only Americans around- and the extra stares we get confirm that tourists are a rarity.

However, sometimes that extra attention can be an advantage. We wanted to celebrate New Year's Eve in some capacity, but had heard from multiple people that people in Biratnagar do not celebrate on the 31st because the Nepali calendar starts on a different day. This appeared to ruin Plan A, which was to celebrate at an awesome Nepali bar with a friendly mix of tourists and locals. We were seriously considering Plan B, which was to stay up until 9 pm, go to sleep, and celebrate the next morning (Baltimore time). Hey, the time change is rough. Thankfully, due to a stroke of luck, what actually ended up happening was far better than either of these. 

While we were in the hotel restaurant, someone invited us to a party happening in an adjoining room. We thought it was for the general public, so we went to check it out. Turns out, it was a dance party to ring in the new year. As soon as we entered, we became unquestionably the most popular people there. We had our photos taken with dozens of strangers, danced to techno music, and had so many people thank us for essentially crashing their private family party. After counting down to midnight, we joined them in celebrating the new year with cake, slightly creepy masks, and highly illegal fireworks. 

I'm pretty sure I will never again have a New Year's Eve quite like this one. It was a fitting end to what has been an incredible year, filled with unexpected surprises for all of us. Can't wait to start off the new year by working to save babies!