Blog Post 1 From my Nepali Adventure now that I am reconnected to the interwebs.
-A series of Blog posts about my experiences volunteering at the Chisang Clinic in Bhuanne, Morang, Nepal.
Burn thy tongue child
and you shan’t taste the bitterness.
Im not even sure how to describe it, so instead I’ll start with my journey so far.
I should disclaim at this point that this blog post will be very long (over-written) and slightly graphic.
Its been three days and 18 hours since I last showered – an enamouring thought.
Getting off the plane and stepping into dusty heat, I found myself in Nepal, in the lovely company of Bhutwa, a professional… well, a professional at a lot of things, among them driving. In his three words of English he showed me to the car, helped me load my luggage (of which I was about 16 kilos overweight thanks to an ultrasound and bag of medical supplies), he handed me a note from Dr Karki’s son Pratik, explaining that I would be taken from the airport to Dr Karki’s house where I would meet him and his grandparents later that day and to make myself at home.
Needless to say The Karki family and household were beautiful, warm, welcoming and just all round helpful. Although I had to wait a few hours till Pratik arrived home from school, in this time I communicated using hand gestures with Bhutwa and the Karki grandparents.
The next day I met ‘R’, an emergency nurse from the UK, we immediately celebrated at the fact that we would not be alone as the only foreigners in a city of Nepalis.
With a bit of help from Dr Karki over the phone, we made our way to the airport and caught a domestic 45 minute flight to the city of Biratnagar – Nepal’s second largest city, home to about half a million people.
I have to admit that I was awestruck by the beauty of the Himalayas – there’s something magical about their glistening peaks that calls to you – admittedly through the dirty window of a 45 seat aeroplane- but nonetheless a subtle majesty (if I may borrow from Shelley).
We met with Dr Karki and his son Chitij, a soon to be med student and now good friend of mine, and stayed with them that night, rising at 7 to begin what will be for me an unforgettable day.
Dr Karki is truly an incredible person. Its been almost a month that I have spent in his company now and I still hold a deep respect for his ethical fortitude and dedication. A Nepali born in a very rural village, he began his studies overseas with a scholarship to study engineering from his Jesuit school. Fast forwards a bit and he has a masters, PhD and two post-doctoral fellowships in public health and ethics from Harvard School of public health and UC Berkeley, just to name a few.
Yet he still appears most at home sipping tea and speaking with the villagers about life and the happenings of the local community. After working with the US embassy and for the WHO, setting up Nepal’s first Public Health school, and being instrumental in the recovery efforts of the Sri Lankan Tsunami with WHO, he retired from his academic life to bring public health to rural Nepal. And that is exactly what he does today.
Our day began with Nepali coffee, Chinese pears, guava and biscuits, before setting out to visit one of the District hospitals of Biratnagar – Noble Medical Centre. A for-profit, private hospital just outside the heart of the city.
The hospital is a sprawling complex amidst the compact houses of Biratnagar.
Dr Karki explained that to truly appreciate exactly what the health system faced from a rural medicine perspective, we had to understand the resources, capability and attitudes of the centres we would be referring patients to who couldn’t be cared for at the clinic.
He wasn’t wrong.
“R” was unsurprised by the state of things, remarking that it was comparatively clean to those she had worked with in India.
I on the other hand was astounded by the dark, dingy atmosphere and lack of natural light.
“It’s daunting for a rural villager, they just get lost here” Dr Karki explained, and I understood why. Coming from a rural setting with open fields and compact housing, the complex of dingy hallways and corridors – all painted in off-white, was a maze that confused even me.
We began at the outpatient departments where some 70-90 patients might be seen in any one day – per speciality- by an assortment of doctors and healthcare assistants – the Nepali version of physician assistants. Unfortunately, anyone who takes a temperature or blood pressure, or even applies Band-Aids is revered as a doctor by simple villagers which leads to much confusion and mistreatment by those who would abuse the trust of the public – only those in the know would differentiate between a health technician with a few months on the job experience, a health care assistant with a few years of technical college education, a nurse with a university education, or an MD with postgrad training in a speciality. Nepal abounds with quacks selling all sorts of magical cures, performing abortions in backyards with little more than coat hangers and rags…. The horror stories abound across this beautiful country.
‘R’ and I, led by Dr Karki went from the ODPs to the operating theatres.
I was impressed by the enthusiasm, commitment and general attitude of the surgeons and anaesthetists. They were making do with what they had and really trying to achieve the best results with the medicine and resources at their hand. I saw caesarean sections where boiling hot water was used to soak towels as a method of stimulating uterine contraction and controlling small bleeds; in laparoscopic surgery gloves were tied with sutures and cut in half to be used to collect the removed contents of a cholecystectomy, vecuronium was used with Propofol in anaesthesia along with blind regional nerve blocks.
All in all it was probably what western medicine looked like some ten to twenty odd years back.
From the OT’s we visited the ICU.
“We are planning to build a 100 bed ICU, the biggest in Nepal” is what I was proudly told by a paediatrician.
It seems our friends in Nepal do not realise the purpose of an ICU is to care selectively for the most critically ill of patients – the ones on ventilators, numerous infusions and whom are unstable or thereabouts – it is NOT so that your hospital can boast about its facilities – especially not when there is open sewerage running outside the window of the wards and recovery rooms.
“R” and I visited the ICU – 5 patients.
In an ICU of 4 rooms, each with at least 6 beds; there were five patients.
One; a child was on a pressure assistive ventilator. The rest were occupied by sick looking, but not critical patients, some sitting upright sipping on rehydration solutions.
After some explanation from Dr Karki, I came to understand that the ICU is a money making machine. Why charge a patient 1,200 rupees a night for a stay on the wards when you can charge them 13,000 rupees to stay in an ICU where they will supposedly get ‘the best’ medical attention. Of course this price excludes all nursing care, all clinical consumables, every visit by the doctor costs an extra amount, every medicine as well is charged to the bill.
It would seem that Nepali medicine seems not to understand the “Intensive” nor the “care” part of the ICU concept. There was not a doctor in sight, there were a few nurses in the corner chatting about something or other, on their phones, holding a magazine, I will admit that one was actually seeing a patient. Break time wasn’t for two hours.
Eight ventilators sitting alone in an empty ICU room, with empty beds. Properly folded sheets and a fully stocked drug cart – (I use the term fully stocked very broadly}
Oh and in case I forgot to mention, there was one old defibrillator sitting beneath a dust cloth in the corner of one of the rooms.
For the whole ICU.
I don’t want to mention that there weren’t any resus trolleys or carts between the 7 operating theatres, And only one in the whole ICU.
But even though I was frustrated at the clearly self-serving nature of the ICU, and even though I was surprised at the lack of resuscitation equipment in what is traditionally meant to be a resuscitative unit, nothing prepared me for the emergency department.
We walked in together.
One large, crowded room, there must have been at least forty beds. All within view of each other, every patient accompanied by a family member or three.
We ambled towards the nurses’ station at the heart of the department and there met the 3 doctors running the completely full department that day.
They seemed genuinely nice people. Warm, softly spoken.
At this point my attention was caught by a young baby. Lying there swaddled in blankets was this tiny human, a boy. His grandfather sat cross legged on the bed, squeezing a resuscitator bag hooked up to oxygen.
The “family ventilator” as its known.
I had heard stories of this from other people who had volunteered in countries like sub-Saharan Africa, or the slums of India; But it never occurred to me that here in Nepal a grandfather would be breathing for his grandchild.
In Blue blankets and a white and pink patterned one piece lay a 6 week old child. Intubated, clearly agitated, whilst his grandfather vigorously bagged him, every now and then forgetting his task, letting go of the bag to talk to a passer-by or one of the nurses.
“na ramro” I said. “bad”, pointing to his lax hand.
He took up his job once again, bagging at one hundred miles an hour, squeezing the bag without enough time to refill it properly.
At the foot of the bed lay an old pulse oximeter with an adult finger probe – there were no paediatric probes in the hospital. Its batteries had died after reading a saturation of 48, and so it hit me.
Here is a baby. Intubated, being artificially ventilated by an untrained family member and there is NO monitoring. Incredulous.
Yet very Simply; no one seemed to care.
No oxygen sensors, no ECG, no blood pressure. I won’t even begin a tirade on the absence of end tidal capnography.
I watched this babies’ chest rise and fall – barely a half millimetre or so, I couldn’t feel a heartbeat beneath my fingers. I borrowed a stethoscope from one of the doctors.
There were barely any breath sounds on the left hand side, and the heartbeat was weak.
I’d gotten involved now.
It’s a right main-stem intubation I thought.
I kindly suggested to the supervising doctor that it may be wise to put the patient on a monitor and re-evaluate the tube position.
‘oh, I can’t do that, they have to pay for monitoring, for the leads.”
Yes. Patients must pay for the ecg dots needed for monitoring,
This was insanity. Nobody, none of the nurses, or doctors or assistants seemed to even look in the direction of the baby or family as they bustled past to see other patients, not even whilst we were talking about the child.
I would normally be ashamed of the fact that I used my “privileged” position as a white westerner in a foreign country to curry authority and respect. I have no such qualms in this instance.
I do not apologise.
“I don’t care what it costs, I’ll pay, I want monitoring now please”
The doctor nodded an ‘ok’ but nobody budged. The nurses kept going on their merry way.
I turned on the monitor myself and put on the finger probe, gently inserting a tiny toe into the misshaped rubber grip. Finally, a nurse came and applied the ecg dots to the baby’s chest.
I wasn’t sure what to make of it.
The oxygen saturation was 46% .
Suffering from pneumonia, this baby had been rushed to another hospital which, being full, referred him on to this ED.
And here, ‘sating’ in the forties on 100% oxygen via endotracheal tube lay a sickly baby.
The plethysmograph was working fine, the ecg was reading a pulse in the 110’s, there was no blood pressure cuff.
I asked for a pediatric BP cuff and finally a doctor and nurse, seeing the screen came over to examine the child.
Another nurse appeared, and another doctor; an intern I believe.
A doctor took over from the grandfather, her hands ripping the bag out of his and finally, slowing down the ventilations so this child could catch its breath – literally, whilst adjusting the tube.
Already the faint sound of gurgling was growing stronger.
“Suction?” I suggested. A minute later a soft tip catheter was produced and the baby’s mouth successfully rid of gunk. A good few minutes passed and then the pulse began to slow.
I called over the head of department who I had met earlier.
The female doctor began concernedly bagging and her intern auscultated for heart sounds
She started compressions just as a syringe of 1:10,000 adrenaline was brought to the beside from one of the nurses – she’d had to dilute a 1:1000 ampoule down with a previously opened 1L bottle of saline.
No patent IV access. The one cannula in the baby’s wrist was either clogged or tissued, there was no flow.
There was nobody at the bedside besides the two doctors. All the nurses were conveniently seeing other patients in the cluttered and chaotic mess of a ‘room’.
I was in deep now. I had gotten involved where I shouldn’t have.
I hate the way people’s stomachs distend when you compress their chest. There’s something utterly wrong about it. It’s like a seesaw where the diaphragm is like the hinge.
At this point I will skip forwards and cover the details in their barest form. Maybe in another post I will include the way events unfolded but its neither necessary nor pleasant.
With a blocked IV, a half formed, half trained team of local doctors and nurses and myself watching on I saw the neonate slowly slipping away.
There was no IV access for too long a time. I guided their compressions to achieve adequate depths and allow for re-expansion.
It was a chaotic and frankly unpleasant experience.
After about 15 or so minutes we achieved a return of spontaneous circulation only to lose it again and regain it at about 45 minutes. I decided to remove myself after a confident and experienced paediatrician arrived to take over the resuscitation and post resus care.
Even during the resuscitation I was cognisant of the fact that if this child survives neurologically intact it will be a miracle. That profound a hypoxia for that long never ends well.
Afterwards I douse my hands with the alcohol gel I carry in my pocket. Sitting down on the opposite bed, Dr Karki joins me.
“are you ok?” he asks concernedly
I nod an affirmative.
The father approaches me and in broken English asks
‘what are my baby’s odds, what is the ratio?”
“I don’t know” I reply “ask the doctor in charge” I point to the paediatrician
It was then that the reality of the situation hit home. I had just done exactly what I had promised myself, my family and my mentors I wouldn’t do.
I had gotten involved and gone way out of my depth.
The experience revealed to me my own recklessness and immaturity.
The question I kept asking myself was how illness of this gravity could have occurred.
Micro-cosmically because a ventilator was refused to be brought to the emergency department time and time again.
A ventilator, one of more than 8 in only one room which are lying unused upstairs.
Because of money. And bureaucracy. And apathy.
Macro-cosmically because the child wasn’t taken to hospital until it was profoundly ill, after that it was referred from hospital to hospital because they were “full”.
I’ve realised that this system is supremely apathetic.
Doctors who aren’t allowed to care. Are discouraged from it in fact. Who are trained to shout at and verbally abuse patients, to refuse care if there is no money, to order tests based on cookbook recipes to ensure the maximal amount of money can be charged for each consult.
They didn’t even think to suggest the family pay for a monitor.
They were happy to wait the hour before the baby was transferred to ICU rather than giving the child analgesia, even watching to ensure the family ventilates their child properly.
This system is sick
Here the price of human life is cheap and the price of healthcare infinitesimally more expensive.
It is irrelevant that the child’s father came and met me outside the hospital afterwards and thanked me. Apparently that is rare here as well.
What I hate most? That I feel regret about what I did; I regret getting involved.
That’s what I am saddened by.
That I saved a baby today and I have to feel regret because I acted when nobody else cared enough to look in the direction of this child. I insisted on starting monitoring.
I cannot and choose not to imagine how the situation could have played out otherwise; likely the doctor who gently removes a grandfathers hands from the resuscitator after he had unknowingly bagged a lifeless body for an hour or more.
Through my actions I resuscitated a person today– a rare occurrence and I don’t feel proud.
What pride or ego I could have had is tainted by fear and the knowledge that today I learned a lifelong lesson.
Its been a long day. I’m feeling fine, normal, but I have a lot to think about.
I’m in the village of Bhuanne now, and just saw the clinic for the first time and its fantastic!
I guess what will happen as a result of today remains to be seen, though Dr Karki assures me that the likelihood of any negative sequelae is extremely low here in Nepal.
You did the right thing but the wrong thing.
But if this baby survives then maybe it was worth it.
Funnily enough I have no desire to know the outcome. I guess you could say I’m at peace with my actions.
I wished the father goodluck and gave him some money to cover the cost of the monitor as well as the first night in in the pediatric ICU.
And that was the end of the day.
I should mention that throughout my entire stay at the clinic Dr Karki urged me to write about my experiences exactly as I felt and witnessed them. “Be honest” he implored. no sugar-coating. A believer in evidence and the unbiased truth, he even asked me to include every negative thing along with the positive when I wrote of the clinic.
Well, this piece is certainly not complementary of Nepali medicine.
I’ve realised that I’m an idealist;
a child with my first taste of the real world.
And its bitter, but I’m still an idealist.
Im getting used to Nepali curry though; at first it’s hot but you get accustomed to the feeling of a numb mouth and prickled lips.
Burn thy tongue child
and you shan’t taste the bitterness
We received a call from the father 3 days later.
A decision was made to turn off the ventilator in the ICU and the baby in blue knits passed away peacefully with his family only allowed to see him a few hours afterwards.
I can only vaguely recall the pained face of his mother in the ED.
The father thanked us for our assistance and compassion, he promised to bring any other children of his to our clinic if they ever became ill, rather than waiting for the illness to progress before seeing local quacks and then finally going to hospital – the local way of doing things.
This was by far my most sobering experience in Nepal. My frustrations have been tempered in the light and beauty of the countryside and its people; their warm faces and the giggles of healthy babies coming in for check ups.
Since then I have had the most wonderful time at the clinic. Honestly it has been 3 weeks of absolute magic!
But that can wait till the next blog post.
All turned out well for me, a lesson with relatively little pain- I guess that in itself is a gift.
Namaste and Dhanyabad,
Aidan – The Little Medic.