It seems appropriate to start writing this blog now not only because it helps build up the excitement (for me at least!) but also because the many friends and family who most of the time never hear from me deserve better!

So, at the moment I am in the fifth week of my nine-week 'Musculoskeletal and Dermatology' attachment, which involves orthopaedics, rheumatology and dermatology, which means bones, joints and skin! All great fun... hmmm. At the moment we have to share our week as equally as possible between the three specialities, which is naturally impossible, hence with us the orthopaedic surgeons are getting a leaner time of it. Which is probably a good thing for them, and a bad thing for us because they are the ones with a sense of humour.

Aside from that, I am trying to revise paediatrics, psychiatry and pathology, which involves immunology (white blood cells), microbiology (bugs), clinical chemistry (proteins and chemicals in blood and tissues), haematology (blood) and histopathology (which is basically the whole of medicine!).

Luckily, I have virtually finished planning my elective, and so don't have much to worry about from that point of view. I'm off in the middle of July, 6 days after my last exam, and come back on my birthday! I'll be doing a placement at Kanti Children's Hospital, which is in Kathmandu, for 6 weeks, and then spending a week following up my hygiene education programme again. This time I have bigger and better plans for it - I'm going to give the poor Nepalis lots of paperwork to fill in so I know exactly what's going on and am able to finally analyse some test results to find out if the programme is actually working or not!

Paediatrics in Kathmandu should be interesting - I'm hoping to see lots of cases of unusual infections, or diseases that have advanced much further than they ever would in this country. I expect I will see a few things that are quite harrowing. But I will go with my mind open and try to learn as much as I can when I'm there and think about the upsetting things afterwards when I get home.

Only time will tell how I'll cope with it - but in the mean time I can't wait!!

It's been a crazy couple of weeks since my last post, what with going to Spain (MUCH needed relaxation!!), getting signed off for two out of the three specialities I'm doing at the moment and dealing with my first emergency!

It's not quite as serious as it sounds - I was in a room with a nurse who was taking blood off a patient, and suddenly the patient went rigid and started to keel over, so I had to try and lay him down while the nurse fetched help. He woke up as soon as he was lying down, and was absolutely fine, but he really gave me a fright at the time. Everything I had been taught seemed to just slip out of my head as I panicked wondering what was the next thing I should do! I hope I will now be a bit more prepared next time something like that happens.

I have had my vaccinations for Nepal now - a grand total of one, since I am still covered by the boosters I had in 2007. A bit of money saved there - every little bit helps! Other than that, not much happening on the elective side of things; lots of potential plans for trekking/holidaying afterwards but nothing fixed yet.

It's now only 11 weeks till my first exam, and I feel I really need to get my head down now - get up early, stay up late, somehow get all that information into my head, and practise for the practicals! Fingers crossed.

I wish I had enough time and patience to write down everything I have seen and done over the past few days, but it has been so packed and busy I think there is no chance.

The flight was fine, I slept quite a lot and Jet Airways is a pretty decent airline! I am glad that my stop-over in Delhi was only three hours... I have met a few people since i came who stopped over in Delhi for a night and a guy at the airport in Delhi who had been there for a week and I really didn't hear good reports at all!

I was met at the airport by two old friends from Gorkha - two of the sisters of the faimly I stayed with last year and the year before. Lovely as they are, I don't look forward to staying over at their room again - they have the most stinky, wet, slimy, dirty bathroom possible, with a broken sink with no plumbing and a broken gutter... ugh! I don't understand how they stand it - their house back in Gorkha is at least clean and in good maintenance!

I met my family on Sunday - they are lovely. There is the mother, father, aunt, and two sons, - one older than me and one younger. They have a lovely top floor maisonette type thing with the three bedrooms and lounge on the lower floor and kitchen on the upper. The bathroom, fortuantely is clean with a functioning sink. Though once again the western-style toilet doesn't flush so you need a bucket of water to flush it and there is no toilet paper. But this is just something I have to get used to again!

The next day I had my introduction to the hospital - wow!!!! Wow, wow, wow, wow, wow. You can read as much as you like in textbooks, but it can never prepare you. For the medics among you, when we were just on our tour of the hospital, we saw two cases of hydrocephalus - the parents had abandoned them so they were receiving free indefinite care from the hospital fund. One was 2 and a half and one was 6, but they both looked nearly the same size with heads twice the size of a football, and the classic 'sun-setting' eye sign - better examples than the picture in my textbook!

We also had a four-hour long introductory lecture (!!!) from the very lovely, very enthusiastic and very talkative electives administrator, who also runs the Kanti Hospital Oncology Fund and is involved in other charitable work in the hospital.

Part way through our tour, we were introduced to one of the oncology doctors, who gave us some solid physiology grilling - I was horrified when I realised that I had covered most of the stuff in my pathology course yet still couldn't answer his questions when put on the spot! I am definitely missing my textbooks and revision notes!

After all that we went to a restaurant with the doctor who had just grilled us and the administrator - how random but very friendly!

I need to explain who 'we' is - I met three other UK med students when I arrived, from Southampton University, and they are also at Kanti for 6 weeks. Today I paired up with one of them, Matt, and we spent the morning on the oncology ward. The ward round was led by a different, more senior doctor from the day before, who was fantastic - he gave us a full briefing of each patient we went to see, what stage of treatment they were at, what particular problems they had and also some general information about the condition. I learnt so much!

I have found oncology at Kanti fascinating. As in the Uk they mostly have acute lymphoblastic leukaemia, but we also saw cases of acute myeloid leukaemia, Wilm's tumour, Ewing's sarcoma and clear cell sarcoma of the kidney. The was one very, very sick child with ALL who had severe depletion of all components of her blood - so low haemoglobin (anaemia), low platelets (the doctors thought she could have intracranial haemorrhages because of her clinical condition but of course access to radiology like MRI scans and CT scans is very difficult and costly) and low white cells (very likely to get a serious infection). She was unconscious, and the doctor explained that she needs ICU admission, but wasn't sure if there would be any beds available - there are only 4 beds in the ICU. She also needs a bone marrow transplant but would have to go to India for that and her family would seriously struggle to afford it. If she does get a BM transplant, the chance of cure is about 40-60%.

It is SO hot here at the moment, much hotter than I expected, and very humid. The temperature doesn't drop much even if it rains!Sleeping was a bit of a chore up until last night but I think I got to the point where I needed sleep so desperately I managed to fall asleep despite the barking dogs and heat!

I'm sure there was a better, more organised way of writing this blog but I have so much to do I have just written things as they came into my head! Hope it makes sense!

Please email me at chiara@yaksteak.co.uk - believe me, hearing what people have been up to at home, no matter how boring you think it is, is so nice when you're in a place like this.

Already I have come to the end of my stint on the oncology ward here - it has been a fantastic experience! We didn't have many new patients since the first day but saw many new things and learnt a lot! I watched an NG tube being inserted in less than sterile conditions, took a history and examined the patient and discussed the management with the doctor. I have been grilled several times and have learnt a lot about the problems specific to treating children with cancer in Nepal. The consultants there work by UK and US good practice protocols for treating each of the diseases, but not all of the treatments are easily available in Nepal. Moreover, if a child needs an investigation, for example a simple blood count or urine analysis, the parent has to take the sample to the pathology lab and order the report, then collect the results when they are ready and give them to the doctor on the next ward round. Or if a child needs a blood transfusion, again this has to be arranged by the parents. There simply isn't enough manpower, resources or staff to keep a unit running as efficiently as it would in the UK. I have been amazed though at how brilliant the parents are - no questions asked, they do what the doctor says and have full trust in him. The mother will usually stay with the child permanently, in the same bed, and will be taught what signs and symptoms to look out for and inform staff about.

I have some sad news - the child I mentioned in the previous post, who was unconscious and had suspected intracranial bleeds, had died by the time of the ward round the next day. The doctor explained to us how it was a perfect example of the girl not having adequate blood transfusions, whether from the doctors not realising due to the lack of regular intensive investigations, the parents having problems with getting hold of blood transfusions or the inability of the parents to pay for a bone marrow transplant in India. So sad - and it really rammed home how huge an effect these simple problems have. As our doctor said, the main issues preventing the cure rates for childhood cancers in Nepal being as high as those over here are the problems with supportive care.

My average day is relatively laid back. I usually get up at 6:30, drink tea and laze about for a bit, then wash and eat dal bhat before setting off on the half-hour walk to the hospital. Things usually start at about 10o'clock though we are usually there by about 9:30. The ward round takes about an hour and a half, and after that they have a follow-up clinic in a room to the side of the wards. Once this has finished - any time between 11 and 12:30, we can do what we like - take histories and examine, watch procedures if there are any, or even go home early if we feel really lazy!

The whole afternoon is free to do what I like - internet, exploring or sleeping and lounging around at home! I have to say I have done a fair amount of sleeping and lounging around - it's difficult to feel energetic in this heat and humidity! But I have a busy weekend planned - Italian food tonight, meeting a friend tomorrow morning, visiting Bhaktapur in the day, and eating out in Thamel again tomorrow night. I went to Bhaktapur last week but stupidly forgot my camera, so am going to take pictures. It's a beautiful 'city' (a town really) with old elaborate buildings, beautiful temples and (as all of Kathmandu) amazing views when the weather is clear and you can access a high rooftop!

Hopefully I should have a lot of photos for next time I write, and will remember the cable so I can attempt to upload them. In the mean time - keep the emails coming!

After our fantastic week on the oncology ward, with all the teaching and personal attention we got from the consultant there, it has been interesting getting used to not being spoon-fed! It has still been fantastic though - the range of diseases on general medicine - mostly infectious - is fascinating. I have felt lots of enlarged livers, heard some of the nastiest chest infections and seen some textbook neurological signs. General medicine, much like in the UK, covers patients in several different wards, and the ward rounds are extremely long and can sometimes be dull, depending on whether the doctors explain what is going on. What you don't see in the UK is such a mass of junior doctors on each ward round - there must be at least 15 milling around each bed, waiting their turn to write down a job to do at the end before they go home at lunch time. It is so laid back! It makes it slightly difficult to believe that they have a staffing problem in Kanti.

Our best way of dealing with the sometimes very boring ward rounds is to ask questions relentlessly, and try and get a quick examination in once the ward round has moved on and before the child has got too comfortable. We still have yet to perfect that strategy!

However, the best thing that has happened since my last blog is that I met up with Liz, a doctor from the UK who is doing a study on Japanese Encephalitis. JE is a very dangerous disease transmitted by mosquitos, which causes inflammation in the brain, killing roughly a thrid of patients and leaving another third with long term neurological consequences. There is no treatment, but this study is looking at whether artificial immunoglobulin therapy improves the outcome.

It has been fantastic because Liz has been teaching me and some of the others how to do the examinations and follow-up for the patients - each of them needs the same routine every day, and now we are able to do these follow-up examinations mostly alone, with her supervision. The children are very sick - mostly only semi-conscious, and have signs (for the medics among you) like clonus, severe neck stiffness, absent doll's eye reflex, upgoing plantars, posturing, etc - things I have only had described or very ocasionally shown to me. It has been very useful and also very enjoyable - I have become quite friendly with the family of one girl. Here I have also really benefitted from being able to speak Nepali - I am getting better at taking histories and talking to the parents about the patient's condition, and can also get to know their families better.

Aside from the hospital, I haven't been overly busy - it has been nice to relax and just read my book! I probably should be doing lots of reading up about medicine, but it is so hot and humid here I really don't feel like it, plus I think I'm still recovering from the horror of fifth year exams! I managed to get myself a nasty cold on Friday and recover from it the next day, leaving myself with a block left ear; I spent Wednesday of last week eating three lots of rice pudding with curry because of some confusing tradition for that day, and am looking forward to two more festival days tomorrow and Thursday!

It serves me right for not writing for so long, because now I have so much to tell you about it's going to take me ages to get through!

First in terms of the hospital: after two weeks of slogging it out on General medicine trying to get something useful out of the awful ward rounds, I decided to spend some time just helping out with the Japanese Encephalitis study. I found my Nepali skills coming into real use, and I was able to explain aspects of the study to the parents much better than I ever thought I would be able! There have been at least two holidays each week for the past three weeks so it seems like I have hardly been at the hospital in that time!

Two weeks ago I finally made it to Gorkha - so strange and exciting to be back! Everything and everyone was exactly the same, apart from the children of course, and it was great to relax into an atmosphere of welcome and homeliness. I spent my first day there walking around my old haunts, mainly the viewpoint at the end of the ridge where there is a gorgeous view of the surrounding hills and a little shelter to sit under. In the evening I went to the local radio station where one of my friends works, and watched what he did as a technician - which was quite fascinating and very complicated. I have no idea how radio stations work back in the UK, so had nothing to compare it to, but it was all pretty impressive to me.

That night we had the biggest rainstorm and thunderstorm I have ever heard - I thought my friend's house might fall down!! Certainly I found out the next morning that the water had come through the roof and soaked the rooms upstairs - fortunately my room was downstairs and wasn't affected!

The next day brought the meeting which I had arranged the whole trip for. We had lots of conversation about various aspects of the work we have going on in Gorkha - the most exciting being a potential toilet building project for schools - but since not all members were present, we weren't able to make any real progress. However, I feel that this is how work has to be done in Nepal - slowly chipping away until suddenly and unexpectedly something happens. I left looking forward to coming back and getting some real work done.

Another week of hospital work passed by, with nothing truly eventful happening other than a trip to see Nepal Medical College Teaching Hospital, which is a huge, private hospital with a 'free ward', almost on the scale of a British city hospital, but with hardly any patients - it was a bit of a ghost hospital, with vast whitewashed wards containing one or two patients, abotu 20 empty beds and a handful of relatives and nurses. It's quite a way out of the centre of Kathmandu so I wonder if that's why there are so few people there.

On Saturday, I set off with an 'auntie' who has been staying at our house in Kathmandu while her exams were on, to visit the whole family's village in Dhading, the district between Kathmandu and Gorkha. It was only a two hour drive to the district itself, and we stopped for morning dal bhat at another auntie's house close to the road. We ended up staying until late afternoon, as we had a two hour uphill climb to make to get to the village, and the sun was pretty hot!

The two hour climb was a pretty hard slog - very good for trekking practise! I was amazed how high we managed to climb within that time. The views were stunning - especially on the east side, the valley is even deeper and steeper that in velley in Gorkha, so after a while we couldn't see the bottom of the valley or the road we had climbed from. The latter part of the trek was mostly accross fields, climbing slowly up and around the hill. We managed to reach the house by 6o'clock - perfect time for making and eating dal bhat again and going to bed!

The house itself sits in several acres of terraced land owned by the family - it's a big family! My 'father' from the family I stay with here in Kathmandu is he eldest of six sons and one daughter! Currently only two of the sons still live at home in the village, each with a wife and a daughter, as well as their mother and father. There are actually three houses, all made of wood and mud, with tiled roofs. They have a concrete bathroom and toilet and a solar electricity system, so their electricity supply is more reliable than the supply here in Kathmandu. Hence, they are a pretty wealthy family. The whole atmosphere of staying in the village, however, was one of real tradition and old-fashioned Nepali lifestyle. They all work hard all day long to look after all that land and all their crops.

Part of the reason for my visit was to celebrate the festivl of 'Tij', which is a festival for women where traditionally they are allowed to leave their husband's home for a couple of nights and go to stay with their own parents. There they are pampered and don't have to do so much work, and traditionally sing songs about all the problems they have had with their mother-in-laws (whom of course they all have to go and live with and work for after marriage).

So one of the aspects of celebrating this is fasting all day on the day of the festival, and to help with this the women get up in the middle of the night before to eat dal bhat again. SO that night, I was promptly woken up at 1am to eat dal bhat! It actually tasted really nice at that time in the morning!

The next day was the day of the festival, and after a morning of relaxing and not doing much, I was dressed up in a sari and all the finery that goes with it, to go trekking to other villages further up the hill and watch their celebrations. I can now assert that it is definitely possible to do full on trekking in a sari and sandals - I managed a good four hours of walking up and down hills, through fields and along muddy tracks thus attired!

Perhaps inevitably, I became a big spectacle one we got to the more crowded places - there were probably a couple of hundred women all similarly dressed in red saris and jewellery, and a foreigner in a place like that is a bit of a spectacle anyway, let alone if she is dressed in a sari. Once the dancing started, I didn't have any choice but to make some attempt at turning the lightbulbs and waving my arms around in front of what seemed like hundreds of people... they seemed to enjoy it though which I suppose is the main thing!

I returned to the house thoroughly exhausted and slightly pleased with myself for having had the courage to do that, however awful it looked - it's not really my sort of thing usually! The next day, however, it was already time to leave, and I definitely could have spent a few more days soaking up village life and village food! We managed to do the trek back down to the road in an hour and a half, and reached the other auntie's house by 10am. Unfortunately, all went downhill from there: after about 3 horus of heavy rain, we went to search out a bus to Kathmandu: none came for over an hour and a half, and when one finally did come there weren't enough seats, so I had to sit next to the driver's gearstick and get poked in the back every so often. To top it off, we got stuck and a nice juicy 5 hour traffic jam, which really was not fun, and I didn't get home until 9:30pm, after having to phone my family and ask if someone could pick me up on the motorbike, since none of the taxi drivers would take me home because it was too close and they couldn't get enough money! Just to clarify, Kathmandu is deserted and dark by 9:30pm, except for drunkards, dodgy people and the od unlucky person like me who is trying to get home. Not great for walking home alone at night, even if it is only 15 minutes walk away.

So I'm not going to apologise for the terrible grammar in this post! Hope it has been interesting! The next plan is to head off to the awful heat and humidity of the Terai to see my old family who I stayed with from my Gap Year, and then to go back to Gorkha. I'll try to post during that time but internet connections are likely to not be so good so it might have to wait until I am back in Kathmandu.

Email me your news, it's so good to hear from you all!