Week 2. Embodying being a Primary Care Physician

We are PCPs…I am a Primary Care Physician…keep feeling this block of embodying being a PCP

In the States, we are very aware of our scope of practice, and careful of what we can and cannot do…not to mention I work with NDs, so it is very easy to just refer my patients to them when the need arises.

We are also very aware of differentiating modalities in the States – Western medicine, Chinese medicine, chiropractic, physical therapy, massage therapy, etc…

Even within Chinese medicine, acupuncturists can be very bias – with styles like TCM, 5 element, Dr. Tan balance method, essential oils, herbs..

Here in Nepal, there is only medicine. People don’t care what it is, they just want care and medicine; they just want what works.

We, as the practitioners, also must not be bias, and not differentiate, but rather just always think what is best for the patient.

There is a health post nearby that can do basic lab work, and prescribe some basic medications. We work closely with them, refer when needed – but we must tell them exactly what we want done, or what we want prescribed and dosage.

Unfortunately, we also cannot trust those practitioners at the health post, or even the local doctors – we must embed into our minds that they know very little, that we know more than them
(and its true, I just came across a patient with fractured ribs, who was prescribed not only pain meds, but meds for chronic bronchitis...)

“I am a primary care provider. I am a primary care provider…”

It’s week 2. I must stop doubting myself.

I also must not be afraid to be wrong... It is how I will learn.
Ex. diagnosis suprispinatus tendonitits - but I am only moderately confident - so I go back home and study my orthopedics to ensure adequate diagnosis for next visit.

Boy, is this hard.

Clinic Prep Day!

January 9, 2015

Clinic Prep Day!

Today is clinic prep day! Sterilized, cleaned, inventoried the supplies – ah yes, reminded of why we came here! Contrary to what FB pictures have been posted, this trip isn’t meant to be fun and games, tour, trek, or whatnot – we came here to provide medicine and work. 

cleaning the chairs

Bex organizing and stocking the first aid kit

outside the clinic

Had a class with the interpreters – made sure we are all on the same page and communicated what we want to see in each other – repetitive themes that came up were

-Comfortable with communications – correct [grammar] or ask for clarification, or rephrase to ensure accurate translation

-Respectful of roles – as practitioners, know the interpreters job is merely to interpret, not to rely on them to read between the lines, or to pick up your slack and for ex. Explain how acupuncture works, etc. As interpreters, know not to offer your own advice to the patients, and remember that that is what the practitioners are for.

Then we had a class on Primary Care – what it means to take on the primary care practitioner role, and letting go of the limiting title, of “acupuncturist.”

Andrew really likes to push our boundaries on our comfort levels…

In clinic, we always focus heavily on our subjective findings – asking question after question. He urges us to shift the focus to objective findings – palpating, testing, objectifying the pain scale, looking…even in uncomfortable situation. Terry, our team leader, says last year she had to do a vaginal exam. (I’m thinking – uhh…we never even learned in school how to do that!)

We also discussed heavily on the idea of care vs. treatment. As providers, we are always thinking, “what to do, what to do?” We get paid for what we do – the CPT codes. Care, however, is everything else.

Sometimes care does requires intervention, sometimes simple monitoring or patient education is all that is necessary. Ex., for a boil, you could prescribe antibiotics, or just educate the patient to clean the area with soap and water, and expose to some sunlight. Nepalese people don’t know this…they don’t shower often, but [at least in this village] do have access to running water and soap – just need someone to hear them and guide them!

Though my breath stops a few times and I feel I have no idea how I am going to manage all these cases, I keep hearing its normal to feel panicky, and to “trust the process.” Reminds me of the acupuncture boards.

Regardless – all in all, I feel super excited and privileged to have the opportunity to offer phenomenal medicine, to be a PCP, something I can’t title in the U.S, to wear my white coat with confidence, to expand my boundaries, to get to know my patients well. True medicine is slow and I am so grateful have the time here to witness the ability of slow medicine.

Self-care and arriving in Bhimphedi!

January 7, 2015
Morning qigong self care

Bex and I started off our day with morning qigong and taichi on the rooftop in Kathmandu

Reminded me of going to the parks in Chengdu with the gang :D!
The neighbors across the street found it highly entertaining. A nice substitute for TV I’m sure.

Self care will be crucial during our time here- we hope to continue this 6am ritual – once we start seeing 20pts/day 3pts/hr, 6 days/week

(we continue our ritual on a beautiful field 2min from our new home :D)

January 8, 2015
Arriving to Bhimphedi

Left for Bhimphedi via “sumo” car. 3.5hrs of bumpy, narrow roads and relentless honking …but the yin to the yang is that the scenery was just gorgeous!

And alas, we arrive to our home for the next 2 months!

Andrew took us for a walk – quiet, peaceful, no need for a face mask – finally feel like I can relax a bit, finally feel more in my element – ready to start what I came here for!

 All the locals greet us “Namaste” and a smile, and make us feel welcomed already.

Reality Check #1

January 6, 2015

Just had dinner followed by what seemed like our groups first official team meeting – and reality check.

Here we read the “three elements of service." Andrew (ARP’s director) had us all read them to ourselves and note what stood out the most. He also recommended we journal while here, stay present and notice how we will change come 4, 6, 8 weeks (because we will). We should constantly remind ourselves, and reflect why we are here – this will remind us to stay present. It sounds very cliché, but cliché things are usually true. Staying present is extremely difficult – esp. after a long day of work, esp. when the patients present overwhelming cases, esp. when its about time to head back home, esp. when we will actually have pretty good access to internet, and thus access to home.

I took a few moments to reflect on my intention of service to my community. Community comes in many shapes and forms - family, work/clinic/colleagues, neighborhood and of course this current group of 6 volunteers I just met! From what I see thus far, the Nepalise community seems strong. Back at home, sometimes I feel community is crumbling as people are more submersed in their own world, or to technology. I hope the experience and sense of community I am exposed to here in Nepal will change me, and help me bring that sense back home.

I always envisioned my self leaving home, needing to “get away” so I could “grow up.” I no longer feel this way… I just started working at Alpine Integrated Medicine, a clinic just 5 minutes away from where I grew up, and I love it. It’s been only about 3 months, but I love collaborating with the other practitioners – together we can create the best plan for the patients. I feel this Relief Project will only double that capacity.

The goal is to simply provide great medicine – to help the patient get better. Modality is not as important.


Next: Reality Check #2: Infectious diseases, and safety

Arriving to Kathmandu, Nepal

A mixture of awe, excitement, apprehension, and jetlag overcome me as I gaze at the snowy landscape through the airplane window– and I know it has come time to embark on this long-waited-for adventure

About to land!

30 plus hours later, 2 layovers, a time warp, 1 dinner, and 3 breakfasts later, I and my two travel companions find ourselves in Kathmandu, Nepal! Its 1030am, and we’re ready for breakfast #4.

Of our 60days in Nepal, we will be in Kathmandu (KTM) for just 4 days. Our 4 days here are the only days to be “tourists”, but more importantly to adequately acclimate to the new time zone, altitude, and air quality difference – so that we have energy to work!

Pollution in KTM is rough – worse than China I think, yet the skies maintain blue!

Having just been to Asia a bit over a year ago, I feel immune, or easily able to adapt to the chaos of traffic – as a pedestrian and as a passenger in a taxi… Nepali taxis drive the sketchy small Suzuki’s and as I endure the bumpy ride, I gaze apprehensively at the door that looks as if it may break off any second. At least there are no motorcycles swerving onto and driving along the sidewalk (Chengdu – I’m thinking of you)!

Baan Chang Elephant Park

Asiya came to visit! She found us an amazing elephant park to visit. The Baan chang elephant park teaches you about the behaviors and lifestyle of elephants and how to wash and care for them.

Fed them full bunches  of bananas and sugar cane. "They never say no to food." We wanted  to feed the  ones  in the back, but it was a challenge to pass the  front ones without them asking for more  food!

We took them on a walk...or did  they take us  on a walk? Either way it was scenic with luscious greenery all around, a bit nerve wracking at first tryin  to relax without being too relaxed that we might fall off because sometimes the  elephants can be "naughty," our guide tells us...

We washed them in a  pretty gross lake. Our trainer guide took our elephant,  Baan Wat, to the center, deep! Asiya and I are  like " come here (to the perimeter)." He's just smilling, chillin  on top of Baan Wat motioning us to go there...grossss the water  comes to past our abdomens. Did I mention there are chunks of stools floating around...its ok,  we pretended it was just Greenlake and had fun! ..even though out  of no where the guides start throwin  buckets of the water on us..I used every piece of Asiya's dry shirt I could find  to wipe  my face on.

A few things I learned;

-Sleep only for about 4 hrs/day. Can eat the remaining 20hrs/day!

-lifespan similar to humans. 80yrs is common, but could live to 100 if healthy

-skin starts to pigment when ages, starting around 30yrs.

-skin is a few inches thick, so to tell them good job, or 'deet!' you must forcefully pat their truck. They won't feel it if you only pet them.

-Vision is poor. Color blind too. Smell and hearing senses are sharp

-Amazing creatures! Wonderful inspiration for 'elephant walking' in Thai yoga massage!

Thai yoga massage course in Thailand!

Baan Hom Samunphrai, 'the house of sweet smelling herbs,' and my home for 2 weeks. A humble family business with Homprang passing on the oral tradition of Traditional Thai medicine she learned from her grandmother. A comfortable and welcoming ambiance with every house, every chair, and every curtain handmade by the family. I, along with only 7 other students, were delighted and beyond thankful to be invited directly into their home.

Side note - There were 3 French students ..and  I ended up learning  more French phrases than Thai!

Each day consists of one hour of Radisaton (ancient Thai yoga) and 6 hours of Thai massage demo and practice. Tends to be challeging for those who are new to such practice...as for me, after Bastyr and  China externship with an average of 10hours/day, this is vacation and how learning should be .

Can't forget the herbs! Herbal compress day! We thought it would be a nice break from 'work.' Little did we know...
We foraged, we chopped and smashed, we wrapped, and finally we massaged them into all the meridians!