On the morning of day three at the clinic, Dr Karki received word from one of the villagers that “an elderly man was sick and dying, could we please visit them?” Over 15 years ago, when living in the village, conducting his doctoral thesis on fertility and public health, Dr Karki had formed a close relationship with one of the village seniors. Over our Nepali tea that night, Dr Karki relayed to me the story of how he met ‘Grandfather’ ‘Hajur Bua’ – as I would come to call the old man. Walking through the main road of the village, opposite where the clinic stands today, a voice would call and a friendly face would wave a younger Debendrah Karki over to sit and have a glass of fresh milk in the shade of a beetlenut tree. “We would talk in the afternoons” reminisced Dr Karki “about life in the village, the crops that season, politics…”.
It was clear this man was a special sort, a genuinely humble and likeable individual, and I hadn’t even met him yet. Packing a backpack with my stethoscope, my little black leather book, and BP cuffs, a thermometer and a pulse oximeter, we made our way down the road to the old man’s house.
Sunset by the Side of the road
Hajur Bua. I called him by the Honorific for grandfather in Nepali.
I still don’t know his name.
We reached the house after a fifteen minute walk; A lovely brick structure, and made our way to the roof where the family were sitting enjoying afternoon tea, Grandfather lying on the thin mattress of an outdoor bed. We sat down on traditional weaved stools and began.
Grandfather lay there, my two fingers on his pulse as an excuse to hold his frail, feverish hands in mine. I spoke, Dr Karki and his son Chitij translated. Hajur Bau’s son, whose house we were in, would answer, and I would wait for the translation. No matter how skilled the translator, there is always something lost in the process, so rephrasing questions to pick apart every detail became commonplace, not just here but in general over the three weeks I was in the clinic.
Grandfather appeared poorly and sickly. An old, emaciated face that was paradoxically shiny and reddened from fluid retention.
His weak, airy voice was more of a whisper as he struggled to maintain the breath to finish his words.
I could see why Dr Karki was hurting.
When we see warm, independent, “Big” people reduced to dependency, weakness and suffering through old age; it shatters our illusions of our own permanency and strength. It was unnervingly personal for me, I can only imagine now how the village was feeling; a local figure now bed-bound.
I listened to his heart.
I have never heard a heartbeat that sick before.
It throbbed and crescendo-decrescendo’d every few beats. With turbulent flow, S3 and S4 gallops, and an Austin-Flint murmur (background rumbling). His lungs crackled audibly.
I’m not au fait with the ‘death rattle’ as it is commonly described, though grandfather appeared close to the end. His breathing laboured, rattling loudly enough to hear without my stethoscope, his head bobbing up and down, trying to get in every last ‘sip’ of air that he possibly could before coughing uncontrollably, trying futilely to expel the build-up of fluid and mucous in his lungs.
His feet; from toes to above the ankle were “wet”. Their fluid filled tissues retained every fingerprint in a concave imprint; pitting edema it’s called for a reason.
He complained of fevers at night, coughing, wheezing, bad chest pain which had been present for at least a month or two now, constant shortness of breath….. His signs and symptoms read like the Oxford handbook list under ‘Heart Failure’ and when we actually started the history… I basically went through the Framlingham criteria ticking off every one!
His BP was 114/65 on the right and 104/54 on the left with a heart rate of 88 and respiratory rate of 19.
We were meticulous.
Every vital sign was taken, checked, re-taken and re-checked.
Grandfather was sick and dying.Grandfather had COPD, Digital clubbing, noticeable JVD, a visibly pulsatile carotid artery, productive cough, and most of all; he was in pain, grimacing at every cough.
I spent (in what would become a routine) a full six or seven minutes just listening to his heart. The subtle clicks, only a few in every minute. The expiratory crackles as they occurred in every lung lobe. Appreciating every respiratory sinus arrhythmia, the deep rumbling between each ejection, the slight whooshing-gurgling-clap of his regurgitant valves.
We knew he was in heart failure; that much was obvious. But what was causing it and why? Was it a cardiomyopathy? Hypertrophied ventricles? Aortic stenosis or insufficiency?
We returned the next day, with the portable ultrasound I had brought for the clinic. It was time to put my barely formed critical care skills to the test to assist Alka in the diagnosis.
Transthoracic Intercostal echo examining LVH
Lungs, Heart IVC.
I scanned between every rib that I could, searching for fluid, for air, for a consolidation. And I was rewarded with B-Lines in the lower lungs – an empiric sign of fluid. It confirmed our suspicions of pulmonary edema (fluid in the lungs). Scanning the heart was harder. I was wary of causing Grandfather any more pain than he was already in, or compromising his ability to breathe by pressing too hard on his diaphragm to get the perfect subxiphoid view. I slowly learned just how much pressure I needed, along with the right angle to get that picture perfect ultrasound. Thanks to grandfather’s skinny frame and lean build, I could get a great transthoracic view between his ribs as well.
His ventricles were dilated and hypertrophied.
They collapsed and billowed out where they shouldn’t have, but at least they were pumping and everything was beating regularly.
Before starting any kind of therapy, we needed a better picture of his fluid status. The Inferior vena cava became a good friend of mine those next few days. Using ultrasound I could see as each breath compressed its walls and each heartbeat pulsed them open again. It was the perfect tool to add to our arsenal of signs to measure hydration levels.
After speaking with the family who had given up hope, along with the village, we realised that grandfather was in no shape to travel, and to get a doctor to come all the way to the house was simply impractical and unaffordable.
It was up to us.
Between myself, ‘R’ the UK Emergency nurse, and Alka, the local Health Assistant (equivalent of a Nurse practitioner or Physician Assistant) we came up with a plan. First off Alka ordered a battery of tests that were available at the clinic: Typhoid, platelets, clotting time, bleeding time, RBC, WBCs, differential White count, albumin, bilirubin, creatinine, haemoglobin, blood typing…
Yamuna the clinic pathologist was a master. She was so efficient that by hand, with only a few pipettes, test tubes and the necessary chemicals and reagents, she finished the entire report within an hour – whilst also doing testing for another five patients, re-dressing a wound, cleaning the clinic beds, taking each blood sample herself AND listening to me yammer on!
The tests were normal. As we thought- his heart was the problem.
With pump failure, fluid wasn’t moving around the body properly and instead was getting stuck in all the wrong places.
Thanks to Alka’s years of experience as a local provider and prescriber, the process was fast-tracked and Grandfather got his medicines faster than if the family would have had to journey to the pharmacy in the next town. Already the value of the clinic as a rural and local entity was clear.
Until that day (or rather the next few days) I had never witnessed the awesome power of Furosemide as I did then.
Day 1 on Diuretics:
I had gained a new-found respect for the “magic” of lasix and the potency of positioning.
The difference that elevating his feet and sitting him up in bed made was astounding!
Concurrently, with every improvement in the edema of his feet, grandfather was breathing more easily. And there was an added benefit; with the diuretics on board- to put it plainly, water has to go somewhere!
7 urinations a day become the new norm, and with the toilet about 200 meters from the bed, grandfather was up, walking and enjoying the exercise!
At about day 7 he walked 2.6 kilometres and noted he hadn’t even become short of breath, only tired!
So continued our efforts.
Every late afternoon Dr Karki, Chitij, Alka and I would make our way to Grandfather’s house. We would enter and he and I would bow deeply to each other.
I formed an immensely special relationship with this man.
We had established a ritual. He would raise his hands in ‘namaste’ all the way to his head and I would follow, our fingers touching each other’s, after which I would pat his shoulder and sit next to him on the bed, Dr Karki translating between his lovely son (and carer) and myself; how the day had been. How many little toilets, big toilets, how far had he walked, how many times did he wake up that night, how was his eating, was he coughing more or less, how was the pain in his chest? All these became markers far more reliable than any vital sign I could have taken. Based on the answers his son provided, I could have told you grandfather’s blood pressure, how ‘wet’ his lungs were…
And with each day, Grandfather was becoming slightly stronger.
Though his pain, especially in his chest still ailed him, and he was still fluid overloaded, his heart still failing him.
This is what rural medicine is supposed to be like! This was the epitome of teamwork, all of us using our strengths to benefit the patient; and This was a real relationship with a patient!
I knew each of his daughters and sons, and even some of their daughters and sons. I knew how many cows were in his field, how many years his son had spent in Dubai so he could build the house we were sitting in…
But more so, this was a man who had been left for dead; given up on.
The few days before we arrived, people from the village had been coming to say their last goodbyes to grandfather and spend time with the family.
The family themselves had begun to expect his death.
We were very- and I mean VERY careful not to give the family false hope.
Grandfather was going to die.
Just not as soon and not in as much pain.
With his improvement we began seeing an increase in patients presenting at the clinic. Word spreads fast in the village and seeing grandfather doing better, more and more elderly men and women; and their families began coming to the clinic. It was a success on so many fronts.
The Clinic waiting area Full! with patients waiting to be seen!
“I just wish I knew more” I remember thinking again and again. I only wished there could have been a cardiologist there to see him, or really anybody more experienced than me!
So I did what any Gen Y would do; I turned to the interwebs!
My only access to the internet was at 1am most nights when the bandwidth was strong enough for me to use facebook, twitter and google.
And so that’s where I began, lying under my mosquito net, staring into the pale light of my Iphone screen as crickets chirped outside my window. I turned to the #FOAMed world; asking for advice from leading clinicians there.
And as always, @RFDSDoc A/Prof Minh Le Cong came to the rescue, pointing me in the right direction with a few articles, guidelines and some pearls of wisdom.
Our objectives for grandfather became threefold:
- Do no harm (don’t allow the disease to progress and don’t initiate any treatment that would make him worse)
- Try to relieve his pain and palliate as best as possible in this resource and finance limited environment
- Do what I can to improve his cardiac function and minimise the strain on his heart and lungs.
With Furosemide we removed his excess fluid and his lungs began to clear up- thus reducing the strain on his heart.
With Nitrates (Isosobide DiNitrate) we further reduced his fluid overload and allowed better blood flow to his heart which reduced some of his chest pain from exertion.
And then came the tricky bit: Pain Management.
In rural under-resourced areas, Codeine Kills.
Harsh, I know. And not always true.
However in this environment that’s exactly what it CAN do.
Children will not force their parents to eat if they refuse. The constipation from codeine causes malaise and a lack of appetite, which in turn means less eating, which reduces energy and nutrition, which reduces the ability to move, which spirals down in an ugly self-perpetuating cycle of bedbound reliance and eventually death.
Naloxone isn’t available for PO administration here and playing with laxatives was far from ideal.
So Alka ordered some Tramadol (a synthetic opioid) from the district supplier and this became our first attempt at analgesia.
It was magical.
On the fourth night we explained to the son how to dose the tramadol, when to give it and what to look out for; especially its psychological side effects in the elderly. I returned the next morning an hour after Grandfather’s first dose to make sure he wasn’t experiencing any adverse effects. Nope, he was fine.
We returned later that night to grandfather sitting himself up in bed, conversing non-stop with Dr Karki and his son. His eyes were more alive than I had ever seen, and between the reduced fluid in his lungs and the reduced pain, he was chatting away like there was no tomorrow.
The next day, he looked into my eyes, Dr Karki translating, and told us he hadn’t slept that well for as long as he could remember.
I still maintain that one of my most valuable experiences in Nepal was this:
that we could remove someone’s pain. That we could take away suffering.
One of the paths we would walk to Hajur Bua’s House
Yes, grandfather was still dying, and no, he probably wouldn’t survive beyond the winter. But he said his pain was now very bearable, more an irritation.
A few days passed and I left grandfather’s house every night feeling enlivened and inspired.
Then he spiked a fever. A Chest infection ; just what we didn’t need.
Between starting antibiotics and having to re-adjust and titrate his doses of all the medicines he was on, we spent longer and longer every night at the old man’s house. Though each night, I listened, and I think we both took comfort in each other’s presence. I would gently hold his hand in mine, and he would squeeze a ‘thank you’ and hold on far beyond when I would have normally let go; having measured his pulse. Days passed and he improved.
Finally! Grandfather was stable enough to make the one and a half hour, bumpy car drive into Biratnagar city to see a cardiologist.
The drive was not the most pleasant. We were too tightly squeezed together for any kind of monitoring and the car was too bumpy for me to keep my finger on his pulse; instead I made do by holding his hand. I became sensitive to every twitch in his muscles, every shiver. I knew when he was unconformable and we would stop and rest by the roadside.
Almost at Biratnagar and I sensed Grandfather’s hand tighten and squeeze mine. I had the car stop. His face became contorted in pain. An ugly grimace that I had naively become used to not seeing. Stuck by the roadside with a pulse oximeter, a stethoscope, a box of emergency medications and his own personal meds; I knew I was ill prepared for anything more than an asthma attack.
I looked down and recognised the finger curling and wrist flexing of a carpo-pedal spasm.
I inwardly sighed in relief and began coaching Grandfather through a series of slow breathing exercises in my broken Nepali.
“arahm”, “Pistarih” “relax”, “slowly”…
Back on the road until we arrived at the Cardiologist.
Fields of mustard flowers by the roadside of Bhuanne Village
Dr Lakhe, a Japanese cardiologist was an amazing, though not very talkative clinician. It was a somewhat funny experience, walking through a shambles of a converted apartment to a dingy room with a state of the art Cardiac Ultrasound machine. I was relieved to hear from him that I had been somewhat on the right track.
Grandfather had tricuspid regurgitation, Left ventricular hypertrophy, pulmonary hypertension and heart failure.
Dr Lakhe kept him on the Furosemide and Nitrates at the doses we had initiated and also started some other agents, I still have yet to hear from the clinic staff what they are though I would guess at ACE inhibitors and anticoagulants.
But most importantly, I had sat down with Dr Karki and Alka one evening before, all of us previously having had an in depth conversation with the family; and we discussed how grandfather should be cared for long-term and especially once he became too ill to leave the house.
Palliative care isn’t a familiar concept in rural Nepal and frankly, my only understanding of it was the bare principles; but that was all the mattered here.
Nobody should die in pain and without dignity.
My last moments with Grandfather, before leaving him to drive to the airport, were spent in our usual ritual; We bowed and brought our hands together in Namaste, the tips of our fingers touching.
“thank you” his son said tearfully.
“My pleasure” I replied
I bowed to Hajur Bua and his son; turning away, Chitij and I made our way to the airport.
Lung Scan for Pulmonary Edema on a rooftop with family in the background husking corns to be roasted.
Thus ended 19 days with my most special patient in Nepal.
Dhanyabad and Namaste,
-Aidan, ‘The Little Medic’
Please note: full permissions for all photographs and disclosure of personal information pertaining to medical treatments were granted by the patient and family on multiple occasions. NO legal nor ethical contravention of privacy, confidentiality or privied information standards has been committed.