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Elective Title:
Reaching new Heights – Surgery in Nepal
Elective Dates:
7th January 2013 to 28th February 2013 (8 weeks)
Institution:
1. Gandaki Hospital / Western Regional Hospital (WRH) – 5 weeks
2. Annapurna Neurological Institute (ANIAS) – 3 weeks
City/Region/State/Country:
1. Pokhara / Kaski district / Western development region / Nepal
2. Kathmandu / Kathmandu district / Central development region / Nepal
Students Name:
Harley
Benjamin
(surname)
(first name)
Preceptor/s:
Dr Pranaya Shrestha – WRH
Dr Basanta Pant - ANAIS
Associates:
N/A
Keywords
File Name
Nepal, Pokhara, Kathmandu, Surgery
Neurosurgery
Elective report: Ben Harley ID 3891398
Research Report
No
ABSTRACT:
Nepal is poor economically but rich geographically and culturally. New Zealand has
strong historical links with Nepal and this combined with the warm and friendly people
make it a great country to go on elective.
Gandaki/Western Regional Hospital is a 350 bed government run facility covering all
modern specialities and is located in the picturesque adventure town of Pokhara.
Patients are mostly poor and rural. While the neurosurgical experience was limited to
ward rounds and outpatient clinics I was able to learn a great deal about the
neurosurgical issues faced in rural Nepal, their investigation and non-operative
management. Trekking and paragliding were amazing experiences while staying in
Pokhara.
Annapurna Neurological Institute (ANAIS) is one of the best neurological units in
Nepal and serves an urban, richer patient population, with beds for 55 patients. The
surgical experience here is excellent with daily ward rounds, outpatient clinics and
operative theatres. The staff were warm and welcoming and I was quickly integrated
into the team and was able to attend and assist in interesting procedures such as split
brain surgery.
Non-medical experiences including visiting important historical sites and seeing
breathtaking views of the Himalayas. I would recommend Nepal to anyone wanting an
adventurous elective.
Figure 1: View from Poon Hill at dawn looking back at the
Annapurna mountain range from a height of 3210m.
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Neurosurgical Elective in Nepal
Nepal – the basics
Nepal is desperately poor nation, with a population of over 30 million crammed into an area
little larger than New Zealand. What’s more the country is bordered by two of the worlds
emerging superpowers – China and India and as such is described as being like a “fruit
between two stones” due to the political difficulties this causes. Economically, Nepal is very
poor, ranked 157/187 countries on the UNDP Human Development Index. Life expectancy is
68 years, the mean years of education for adults is just 3.2 years and most Nepalese live on
less than $2 per day, or 240NZD per year.
Why Nepal?
My decision to choose Nepal was a collective one with my good friend and fellow medical
student Duncan Shannon. Duncan is a student of Prof. Ian Bissett, who is the head of the
department of surgery at the University of Auckland and travels to work at Gandaki Hospital
in Pokhara, a town in Nepal, (Figure 2) on a regular basis. He spoke very highly of the
experience we would get and this combined with the childhood stories about the exploits of
Edmund Hillary Duncan and I had heard made it an easy decision for Duncan and I to
choose to go here on elective. All set to go, Duncan and I were to meet in Kuala Lumpur,
Malaysia before flying to Kathmandu (the capital of Nepal) to start our elective. However on
arriving in Kuala Lumpur I was dismayed to find that Duncan had contracted an unknown
disease that was giving him high fevers, diarrhoea and severe fatigue, meaning he was unfit
to travel. In hospital his chart was a medical education in itself – Chikungunya, an unfamiliar
viral disease was the first diagnosis, later changed to a diagnosis of Typhoid. Too sick to
travel the question for me was weather to carry on or not? Nepal was an unknown 3 rd world
country to me with numerous dangers. I was prepared with vaccinations and all the
necessary medications and clothing but if anything went wrong there would be no
companion to assist me. In the end after discussions with Duncan and promises of regular
calls to my girlfriend it was decided that this trip was just too good an opportunity to miss and
I am glad to say (now that my elective is over) it was a decision I did not regret.
Figure 2: Gandaki / Western Regional Hospital, with the Annapurna mountain
range situated in the background.
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Pokhara
The first part of my elective was set in the picturesque location of Pokhara, situated 200km
northwest of the capital Kathmandu in a valley beside the Phewa Tal (Nepali for Lake). The
only word to describe Pokhara is breathing. The shear scale of the Himlayas is beyond
anything that can be imagined in New Zealand and despite us claiming to be the adventure
capital of the world, Pokhara in my opinion well and truly takes that crown due to the
spectacular views, paragliding, zip-lining and other activities on offer.
Travel to Pokhara
Getting to Pokhara is fraught with danger no matter which method of travel you choose. The
plane ride from Kathmandu is short – less than half an hour but plane crashes have been
recently reported along this route so I was weary of this travel option. The alternative is little
better, with bus cashes a regular occurrence. Sheer 1000ft+ drops on single lane roads
leave little room for driver error. I elected to take the bus and discovered a number of ways
to reduce the risk. Firstly by travelling with well established companies I found I got more
experienced and well-rested drivers. Bigger is better and gets you right of way at all times so
travelling in large tourist bus is also essential. The best way to reduce the risk was to travel
during the day when visibility for the drivers is optimal.
Accommodation:
As a tourist hotspot, Pokhara has a huge number of guesthouses that provide a basic room
with a bed and shower. Electricity is heavily rationed because despite being rich in natural
power resources including gas and hydroelectric power, India owns the power companies
that make these resources useable. All electricity is sent to India to supply their needs and
whatever is left over is sent back to Nepal. This typically means that the power supply only
lasts for a maximum of 8-12 hours per day, restricting many basic aspects of daily life
including cooking and showering. Guesthouses are very cheap by western standards and I
paid a daily rate of around 450 Rupees or 6 NZD.
Despite not having my friend Duncan with me I was hearted that the guesthouse I was
staying at contained a number of friendly types including a group of three Australian medical
students and a volunteer orphanage worker and we became fast friends. I was grateful that
the medical students were starting working at Gandaki hospital the same day that I was so
we could share travel expenses and also spend time viewing the local sights after work as
well (Figure 3).
Figure 3: My adoptive friends from across the ditch – Jared,
myself, Jackie, Jane and Duane
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Western Regional Hospital
Known locally as Gandaki Hospital (Figure 2), this is a government run hospital with 350
beds. The hospital was established in 1965 and despite showing clear signs of neglect
externally with fading paint, crumbling walls and plants growing from between cracks, it
provides a professional service to its patients. In contrast to private hospitals, patients do not
have to pay for staying within the hospital and for the cost of their medical treatment but they
are required to pay for any materials used during their treatment and stay. In practical terms
however I found that many are too poor to pay even this and thankfully these costs can be
covered by donations and government funding. I paid a nominal elective fee of 50 USD per
week and part of this money goes to helping poor patients as well.
General surgery experience:
For the first week of my attachment I was with the general surgical team. Ward rounds
started at the very reasonable time of 10am and were normally completed within an hour.
Rounds were similar to in New Zealand and consisted of a consultant leading the team
around each of the patient beds, reviewing each patient with the registrar then asking the
junior doctors and students about relevant aspects of the case. Despite being conducted in
Nepali I found the team very helpful and generous with their time, regularly checking my
understanding of what was going on. Thankfully all medical terms were written and spoken
in English. The most valuable time for me was the outpatient clinic time on Wednesday
afternoons. Here 5-6 consultants and senior registrar sit in a small 16x8 foot office on the
lower level of the hospital and have patients streaming in one after another. Patient privacy
and building patient rapport were foreign concepts as the team easily saw over 100 patients
in less than 2 hours. I am slightly ashamed to say that this system did have one great
advantage in that it was a fantastic teaching exercise with quick fire examinations, diagnoses
and treatment plans.
Theatre was a very interesting exercise, with large pots of boiling water serving as the
primary method of sterilization and all gloves are washed and reused, significantly reducing
costs. The term “general” truly applies to these surgeons with a scope of practice that
encompasses general surgical, urological and plastics procedures. During my time I
witnessed the team perform inguinal hernia repairs, renal and ureteric stone removals, a
radical prostatectomy and a dermoid cyst excision. It was sobering to see that an inguinal
hernia repair ran to 1,485 Nepali Rupees – less than 20 NZ dollars and significantly less
than our group had spent at dinner the night before.
Apart from patient concerns I found it important to consider my own safety in theatre. This
was highlighted to me by a story I was told by a recent medical graduate from Auckland
University who had previously worked at Gandaki. She suffered a blood splash in her eye
from what turned out to be an HIV positive patient. After months of nervous waiting,
thankfully she was ok but this served as an important reminder to take special care. Before
approaching any patient in theatre I was sure to check the patient chart as most patients
were tested for HIV, Hepatitis C and Hepatitis B. I also took full face splash proof masks but
was chided for this by the surgical registrar as being unnecessary due to the fact that it
would “obscure my vision.” In the end I chose to use them anyway. My final line of protection
was anti-retroviral tablets. There were kindly supplied by Dr Mark Thomas at Auckland
Hospital who advised me to start taking the course of drugs immediately after receiving any
blood splash or needle prick, thankfully I did not have to take them but they were important
for peace of mind in theatre.
The days at Gandaki were not taxing and the team was usually finished by 2-3pm in the
afternoon (no lunch breaks), leaving time to read about the conditions and procedures I had
seen that day and enjoy Pokhara. After my exciting week in general surgery it was a short
shift down the hall to the department of Neurosurgery, my real area of interest.
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Neurosurgical department experience:
In contrast to other hospitals, at Gandaki the first 6-beds of the department of surgery serve
as the Neurosurgical department. The neurosurgical team (Figure 4) was small but
experienced and consisted of one consultant (Dr. Shrestha), one senior medical officer (Dr
Ganga) and one junior medical officer (Dr Santosh).
Figure 4: The neurosurgical team: Myself, Dr Santosh, Dr Ganga
and Dr Shrestha.
My first week did not start well when I learned on my first day that Dr Shrestha was
considering de-establishing the department within the next 1-2 months and only minor
procedures were being performed. Dr Shrestha was very helpful however and together we
devised a plan – I would stay for 5 weeks and get experience of the types of neurosurgical
problems experienced in rural Nepal and then shift to the Annapurna Neurological Institute in
Kathmandu.
The advantage of being on such a small team was that they really took me under their wing,
Explain each patients’ condition and management clearly and concisely. Each day consisted
of a ward round of the 6 beds in the neurosurgical unit as well as rounding on patients in
intensive care, the post-surgical ward and any other department requiring a neurosurgical
opinion. After this it was off to clinic to see patients for the next few hours except for
Thursdays which were reserved for operations (none of which occurred).
I quickly found that head trauma was the most common presentation, usually due to road
traffic accidents. As mentioned, bigger cars get right of way in Nepal and the majority of
accident patients I saw were from motorbike riders presenting with extra-dural or subdural
haematomas. These patients were managed with diuretics (mannitol) and dexamethasone to
decrease intracranial pressure and sent home or referred to Kathmandu for frther
management. Road traffic accidents are made all the more difficult in Nepal by poor lawmaking. The law states that in a crash the larger car always pays for the medical care and
working compensation of the smaller vehicle, due to the fact that it is assumed that the larger
vehicle will always contain the richer individual. The person who is at fault in the crash is
irrelevant. The law also says that if a driver kills another in a road accident there will be no
jail time but a one-time charge of 500,000 rupees, appropriately 6,500 NZD. The problem
with this situation was that when a car hit a pedestrian, the financial incentive may work
cheaper for the driver to back up and kill the pedestrian rather than pay for their medical care
and work compensation. It has only been with the introduction of car insurance in recent
years that this practice has reduced. This is just one example of how poor governance
adversely affects the peoples of Nepal on a daily basis.
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A lack of clear legal guidelines and established indemnity cover also mean that doctors must
practice medicine very defensively for fear of legal prosecution. I witnessed this while with
the neurosurgical team at Gandaki. Almost every patient wanted a head CT and it was
always provided. The team explained that even in cases where the chance of intracranial
injury was small, they could not convince patients of the risk of radiation and if by some
small chance there was a neurological issue present and the patient deteriorated, they were
openly liable for all subsequent costs. Despite its frequency of use, getting a CT scan could
be challenging - patients often could not read so sometimes would end up in the ultrasound
department – the busy pace at which the technicians worked meant that often we would
send a patient for a CT and get them coming back with an abdominal ultrasound!
Nepalese in general appear happy and welcoming but this does not mean that they are any
less vulnerable to the same sorts of psychological disorders that we find in western
countries. One such example is what is called “Saudi Arabia Syndrome.” When I first heard
this I was expecting some exotic parasite or tumour but discovered that it refers to
psychogenic seizures in women due to their husbands being overseas working in the Middle
East to earn money for their families, a common occurrence in Nepal. Wives are expected to
maintain the household as well as perform the traditional jobs of the husband including
running any businesses they may have at home and performing tasks requiring physical
labour. This puts them at extreme stress and leads to anxiety and depression. In some
cases psychogenic seizures can also present in patients who had previously had seizures in
the past e.g. caused by neurocysticercosis (see below). This was suggested to be because
of the extra sympathy and support these seizures resulted in them receiving, leading to a
kind of learned helplessness. To me these conditions also highlighted the high level of
gender in-equality in Nepal and the important role of social workers in helping women deal
with social issues.
Neurocysticercosis is a relatively unknown condition in the west but is common in third world
countries with poor sanitation and food preparation. It involves tape worms ingested from
poorly prepared pork or vegetables which take up residence in the intestine and send larvae
to tissues such as muscle and brain. Here the body reacts by creating a cyst around the
larvae and attacking them with the immune system. Patients commonly present with
seizures and head CT usually shows multiple calcified lesions in the brain, old abscesses
that are triggering off abnormal electrical activity. Removal is usually not necessary and
normal treatment is antiepileptic drug therapy with review after 3 months. When the patient
has had 1 year of being seizure free the antiepileptic is removed and the patient is usually
cured from then on, though re-infection is relatively common.
Activities in and around Pokhara:
Pokhara is full of excellent restaurants and fun activities. Paragliding was a real highlight.
This is performed in tandem with an experienced guide. It was simply amazing to launch off
into the crisp morning air, following the eagles up on the thermals into the atmosphere and
look back over the snow topped Himalayas. Trekking is another essential activity while you
are in Pokhara – I participated in a five day trek with other students (Figure 2) up to an
elevation of 3210m at a site called Poon hill. The stunning view of the Himalayas at dawn
was an experience I will not soon forget and the highest point we reached along the trek was
3,300m. To put this in context Mt. Cook, the tallest “mountain” in New Zealand has a total
height of only 3724m, just 300 metres higher than this “hill.” Nepal is on a grander scale than
any other country in the world and I would also recommend having a look at the zipline and
mountain biking while you are staying in Pokhara.
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Kathmandu
My next stop after Pokhara was the bustling capital of Nepal. I had only seen the tourist
district of Thamel on my way through to Pokhara and it was good to get to see more of the
city. There are a number of historical sites such as Durbar Square which contains temples
from the Hindu and Buddhist religions. The massive temple Swayambhunath is another
highlight and a trip out to Nagarkot takes you above the pollution of Kathmandu valley to
give a panoramic view of the Himalayan range.
Accommodation and meals:
Thamel district is situated near to most of the major sites and institutions. Accommodation in
general is a little pricier than Pokhara but I found a very reasonable place called Pilgrims
guest house for $10 per night that offered a queen bed and shower which was more than
sufficient for my needs. Travel to the hospital was 20 rupees (around 30 cents) by the local
bus but if I was late I could easily get a taxi for the equivalent of 5-6 NZD. As in Pokhara
there are restaurants to suit you regardless of your gastronomic proclivities and you won’t
pay more than 8 NZD for a very good meal. The Northfield Cafe is a highlight not to be
missed.
Annapurna Neurological institute
Annapurna neurological Institute (ANAIS) is situated in the busy metropolitan centre of
Kathmandu. It was established in 2009 and as the name states, is a dedicated neurological
institute with a total of 55 beds. As a private hospital patients are visibly more well off but still
poor by western standards. While the typical neurosurgical cases such as intra-cerebral
haematoma and cerebral tumours are present, in general patients present much later than
they would do in New Zealand. As I was also to find, other lifestyle factors such as the
increased presence of guns and the heavy manual labour also made for some uniquely
tragic presentations.
Days start with a conference at 8:15am during which patients in each ward are read out with
overnight changes highlighted. Any new cases admitted overnight are presented by the
medical officer with a subsequent questioning by the resident senior doctor – a good
learning experience. On my third day I was asked to make a PowerPoint presentation about
history, examination and management of a 6.5 year old girl who had been suffering from
drop attacks caused by absence seizures. I was a bit intimidated but thankfully the rest of
the surgical team were very understanding and gave me a lot of help.
After this morning meeting wards rounds start. 55 beds are reviewed starting with the
neurological ward and followed by intensive care. Ward rounds finish by around 10 to
10:30am and then it is off to outpatient clinic for rapid fire history, assessment and diagnosis
of – 5 minutes per patient. Outpatient clinic winds up by 12pm in time for the most important
task of the day – theatre.
The first case that struck me was of a young girl of 7 years. While walking up a second floor
stairwell at school to go to class, a man outside who had arrived back from a day of hunting
without success fired off his gun in anger. This was a musket type gun and one of the pellets
hit her beside her right nostril, coming to a stop ear her basal ganglia (Figure 5, left – next
page). Thankfully this bullet missed life-critical regions such as the hypothalamus and
amazingly there was no obvious neurological deficit. Retrieving the bullet was a difficult
prospect but after a long discussion it was eventually decided to go ahead with surgery. The
operation was challenging from the start - the stereotactic frame had to be repositioned in
the CT scanner because the interference from the frame was obscuring the view of the
bullet. The stereotactic frame was placed and the bullet located so that the stereotactic
probe was touching it (Figure 5, right). Despite the best efforts of the entire team the bullet
refused to budge. A decision had to be made about the risk of using more invasive and
traumatic surgical tools and the decision was eventually made to leave the bullet where it
was, the risk was just too great. It was disappointing to have to stop when we were so close
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to success but it was the correct decision for the patient. As the consultant surgeon said
after the surgery – one of the cardinal rules of surgery is not to let your ego get in the way of
ensuring the best outcome for the patient – so in this regard I considered the surgery a
success.
Figure 5: Brain Imaging of in 7 year old girl. Stereotactic CT scan (left) and
fluoroscopy guided retrieval (right).
The day after this operation was the surgery of the 6.5 year old girl whom I presented earlier
with drop attacks who required a corpus callosotomy to palliate her seizures. I was allowed
to scrub and help with the initial opening of the scull cap – my first true operative experience
in Nepal! The surgery was very difficult as the dissection plane travels just laterally to the falx
cerebri which contains the superior saggital sinus – a structure every neurosurgeon fears as
it has the potential to bleed prodigiously. Using micro-dissection under the surgical
microscope my supervisor Dr Pant carefully dissected down the plane of the intrahemispheric fissure, between the peri-callosal arteries to the level of the corpus callosum.
The dissection itself took many hours as the surgeon had to keep checking and rechecking
his position and needed to dissect each and every axonal fibre to ensure that there would
not be transmission of seizure activity from one hemisphere to another once the patient
awoke. This was exacting work but it was both exhilarating and a relief when the final fibre
was cut and the closure could begin. It was also amazing to see this procedure done without
the advanced imaging guidance (MRI Stealth) we have in New Zealand and also pleasing to
see how quickly she recovered from surgery into a happy young girl again. While seizures
are common in the west, other deficits are more unique to Nepal.
The Nepalese are expert climbers – they have to be in such a mountainous country and this
also means that they have to be expert at carrying large loads up and down steep hills. The
traditional way of carrying objects is for them to place a basket on your their backs and tie a
piece of rope so that it sits around the forehead. This enables the carrying of much heavier
loads than shoulder straps would allow but also puts the neck at high risk of hyperextension
injury. One tragic case demonstrating I saw while on a ward round. The patient was a young
man in his 20’s who had been carrying a heavy load of rocks and slipped, forcing his neck
back into hyperextension, causing a complete trans-section of the spinal cord at the C6-7
junction (Figure 6, next page). There was partial paralysis of the diaphragm and loss of all
sensation and motor power below this level. I asked what the likely outcome for this patient
would be and was told that despite being moved to intensive care he would likely develop
severe pneumonia, a horrible death for a patient who despite his physical deficit was
mentally fully capable. In the end he was taken home by his family to live his final days in
their company. After this I felt like telling every person I saw carrying objects like this to stop
but obviously didn’t as this is just part of their culture and essential for the heavy loads they
need to stay employed and provide for their families.
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Figure 6: T2 weighted MRI scan showing
trans-section of spinal cord at C6/C7 vertebral
junction.
Lumbar disc herniation was the most common presentation to the neurosurgical department
and was almost always treated with micro-discectomy – the removal of the bulging area of
dsc behind the affected nerve root. I was able to see at least 6 of these operations during my
time and learned a lot about the surgical planes of dissection and the overall process of this
operation. Overall the patients I saw achieved good results, regaining their ability to walk and
function in their daily life.
Culture:
Overall the Nepalese are a wonderfully friendly people – always ready with a friendly
“Namaste” (Hello). Nepal truly is a melting pot of cultures – there are the traditional Nepali
peoples in addition to Tibetan Refugees displaced from China and Indian people from the
south. I was particularly impressed to see the high level of religious tolerance between
Buddhists and Hindus who despite worshiping different deities manage to coexist well, even
worshiping in the same temples in some cases. Having a smile is essential in Nepal, it is an
important face saving gesture and a head shake for no is almost never appropriate, instead
a head bob from side to side is common, another face saving gesture that can mean no, yes
or maybe depending on the circumstance – very confusing! A tip for success would be to
ensure that you barter carefully. Bartering is a core part of everyday culture – the sticker
price is almost never the final price and to get a fair deal you need to take this into account.
At the same time I found it important to consider that the vendor would likely have paid and
whether I was ripping a poor 3rd world individual off for the sake of 50 cents New Zealand. If
you offer a price, you must be willing to pay for it, lowering your price again if the vendor
meets you is a big no-no. One area of caution – there were strikes when I was in Nepal and I
was strongly warned against travelling by car on these days as people would pelt the car
with rocks and I would potentially be attacked. I was fine in the end however and overall I
found the Nepalese culture a fun and enriching experience.
Summary:
In summary despite a difficult start I had a fantastic elective. I was thankful for the friends I
made along the way and more than anything else this was what made the experience for
me. The contrasting experiences of a government hospital and a private dedicated institute
showed me the wide scope of practice of neurosurgeons working in the third world and I
would love to come back and work in Nepal in the future. From what I have seen, working in
the third world enriches your practice as a surgeon by giving back to those who are most in
need of your services.
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Thank you:
Professor Ian Bissett for his advice prior to coming to Nepal
Dr Shrestha and the rest of the Neurosurgical team at Gandaki Hospital
Dr Pant and the rest of the team at ANIS
Jane, Duane, Jackie, Jared and Jo, my adoptive friends from across the ditch
Duncan Shannon and Maddie Moore my friends in New Zealand
To my family in New Zealand for their support, particularly my girlfriend Pushpa.
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Post-Elective Student Evaluation and Recommendation Form
Please complete the following by ticking the appropriate box and include any specific comments.
Aspect of Elective
No
Yes
Would you recommend your choice of
country / city for your elective?
Yes
Would you recommend your choice of
hospital for your chosen elective?
Yes
N/A
Comment / Recommendation
Be aware that Gandaki does not
have
neurosurgical
theatres
operating but ANAIS offers an
excellent experience
Was hospital/ institution
accommodation available?
N/A
Was the standard of hospital
accommodation acceptable?
N/A
Not sure, guesthouses are easy to
find and great value
Was alternative acceptable and
affordable accommodation available?
Yes
Was the general cost of living
acceptable?
Yes
10 NZD/day max
Was there adequate transport between
accommodation and hospital ie safe
and affordable?
Yes
Taxis are 5-6 NZD max
Was access to the nearest city / town
acceptable?
Yes
It was less than 15 minutes drive
from accommodation to hospital or a
35 minute walk
Did you encounter any threat to your
personal safety?
No
Did you encounter any problems with
theft?
No
Did you travel with a fellow medical
student?
No
Be careful around dogs and monkeys
and make sure to get Rabies
vaccinations before you go.
Any barriers in regards to cultural
issues
Any barriers in regards to language
issues
Sadly the fellow medical student I
was meant to be travelling with got
sick right before we left. I would
recommend
travelling
with
a
companion.
Small philosophical disagreement
with regards to sponsorship but
nothing major
Yes
No
The staff were very accommodating
and explained things in English very
well
Would you recommend traveling with
another student?
Yes
I was lucky and met other great
students along the way but this is not
guaranteed
Was access to personal medical care
available / acceptable?
Yes
Luckily I did not have to see a doctor
but pharmacy was readily accessible
Poor
Satisfactory
Do you feel your supervision
adequate?
Excellent
Excellent
Did you consider your elective to be a
worthwhile experience from a medical
perspective?
Satisfact
ory
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Both supervisors were excellent
It was a shame that the neurosurgical
department at Gandaki was underresourced but ANAIS was an
excellent experience.
Did you consider your elective to be a
worthwhile experience from a personal
development perspective?
Excellent
Did you consider your elective to be a
worthwhile experience, overall?
Excellent
Pokhara and Kathmandu give a great
spectrum of what life in Nepal is like,
both the rich and the poor. Amazing
friends, trekking and paragliding.
Met fantastic people and had great
fun learning about the culture of
Nepal
and
how
to
practice
Neurosurgery. .
Any further comments / recommendations:
Essential items for hospital each day: White coat, Name badge, Face shield/glasses, Stethoscope.
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