What was intended to be a short chat turned into a whole day affair with Mitch and I having to pause multiple times for food, coffee, laughter, ambient noise, coffee, passers by interrupting the recording…. did I mention coffee?
It was an absolute privilege and pleasure to be able to share my life changing experiences with Mitch and his audience and have a good laugh with someone I consider a genuine friend and colleague.
One of the challenges we faced in Nepal was the provision of Ethical Care.
This is a country where individuals can claim to be doctors and ‘prescribe’ Ayurvedic therapies in place of actual treatment, or even use fuzzy television screens as pretend ultrasounds to diagnose “bad blood on the uterus” or “cold water”.
In response to this, the need for maximal transparency and robust ethical standards in healthcare was and is vital.
Its for this reason that I can’t begin to communicate the enlivening experience of working at the Chisang Clinic: a Truly Ethical clinic.
I have never, and I say this with utmost confidence, Never, volunteered or been associated with an organisation whose moral stance on everything from operative costs and patient care was so completely humane and compassionate.
And Dr Karki is to thank for this.
Medicines are sold at almost cost price; the poor, elderly and “untouchable” castes are offered reduced costs – if not free care. And there is complete transparency; with a governing committee made up of local, district and national shareholders in Nepal.
Hajur Ama – Grandmother
One of many elderly women whose treatment is completely subsidized by the clinic.
But my favourite part; ultrasound is provided for free along with antenatal care and advice.
Its only because of the generosity of our incredible donors as well as the support of Sonosite Australia that the Chisang Clinic is now performing ultrasound scanning in Rural Nepal- adding a new dimension to the level of care already being provided.
Here’s a highlight of what we achieved with ultrasound in just the 3 weeks that I was at the Clinic:
More than 20 obstetric ultrasounds
2 women with possible life threatening placenta praevia’s referred to a district hospital for OBGYN review
2 kidney stones clearly diagnosed and referred
3 women confirmed and counselled about an unknown hysterectomy performed during C-Section.
2 patients cleared of pneumothorax
1 patient’s diuresis titrated based on IVC fluid status
2 men referred to district centres for suspected benign prostatic hyperplasia
1 Ultrasound guided diagnostic needle aspiration of an abscess
1 Ultrasound guided IM injection of NSAIDs
More than 14 Kidney ultrasounds screening for nephrolithiasis and 3 diagnosed and referred cases of hydronephrosis.
3 cardiac Ultrasounds to screen for gross abnormalities, 1 resulting in LVH diagnosis and referral.
1 US indicated referral for Polycystic ovary syndrome
But what further sets the clinic apart from the rest, are the efforts that are taken to be transparent and educate patients – slowly but surely improving the local health literacy.
We created diagrams and charts to SHOW patients exactly what we were examining and why.
And our efforts were rewarded with a surge in presentations from all over the district!
Watching on as a mother sees – with her own eyes- the flutterings of a tiny heart on a screen for the very first time is such a wonderful experience. Her eyes light up, a smile appears on her face, eyes wrinkling and a gasp of air escapes her lips in delight.
I only wish everyone who helped to make this possible could see it for themselves.
Yup! ultrasound Does save lives, and for me, the experience of being able to provide a new level of care and reassurance to my patients was pretty magical.
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.
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.
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.
“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.
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.
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.
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.
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-cosmicallybecause 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.