Lindsey Youngquist is a Rotary Ambassadorial Scholar studying Community Health in Nepal. She recently volunteered at Bayalpata Hospital in Achham.
Working towards Health Equity and Access in Rural Nepal
Posted by Brock Daniels
My hand shook ever so slightly. I doubt anyone else in the cramped, humid dressing room of Bayalpata Hospital noticed, which is good. I learned early on in residency that the appearance of supreme confidence is often more important than actual confidence in what you are doing. If anyone did notice, it was the person in the room who had the most reason to be nervous — after all, I was about to stick this seemingly enormous needle into her chest a few centimeters from her beating heart. Yet, this tiny girl with what was the largest pericardial effusion I have ever seen, looked up at me, unblinking, having shed only a few tears as I injected the lidocaine to numb the path the needle would take through her skin, fascia and muscle into the fibrous sac surrounding her heart. A sac abnormally filled with a few hundred milliliters of exudative fluid: imagine a Coke bottle’s worth of fluid in a space meant to hold little more than what a shot glass should. The look in her eyes seemed to say “don’t worry, you got this,” however one might say that in Nepali.
Why was I shaking, anyway? I’ve seen this done before, done it myself, and taught others how to do it. Moreover, this instance was in a remarkably controlled setting; pericardiocentesis typically epitomizes the emergent procedure – only seconds dividing life and death. We had decided to remove the fluid after much deliberation not to gain seconds, but to gain hours or days. What we believed to be a tuberculous effusion likely developed over the course of months. Had this much fluid accumulated rapidly, it would have been fatal. The effusion would have squeezed her beating heart, causing a condition called cardiac tamponade that prevents the ventricles from filling and the heart from pumping oxygen-containing blood to the rest of the body. Despite its chronicity, her symptoms, including progressively worsening shortness of breath, especially when walking and now, abdominal distention from an enlarging liver, suggested the fluid was getting to be too much. An ultrasound of the heart confirmed this, as pressure from the fluid could be seen denting the heart muscle as the ventricles filled. The anti-tuberculosis meds were not going to work fast enough. The fluffy clouds of exudate floating in the fluid would result in constrictive heart disease. She needed referral to Kathmandu for surgical intervention, but that was a 40-hour bus ride from here. Removing some fluid should temporize her condition long enough to make the journey.
Ultrasound-guided pericardiocentesis is very safe, and serious complications are rare. However, as it stood there, it occurred to me that, unlike at home, there is not a pediatric cardiothoracic surgeon with an operating room upstairs if, god-forbid, I punctured her ventricle; maybe not one in the country. It’s impossible not to imagine standing by helplessly watching this small girl exsanguinate into her chest. In these moments the tension between the consequences of doing nothing and the risk of doing something is visceral. The words “rural,” “remote,” and “isolated” suddenly seem inadequate. However, the distance between me and any rescue I might need is the same distance between her and anyone other than me who can do this procedure.
The privilege to work in places such as Achham lies not in the opportunity to see the obscure pathology such as cutaneous tuberculosis, rheumatic heart disease, or malaria that rarely presents in the U.S., nor in the “cowboy” procedures like reducing fractures or draining abscesses that we wouldn’t dare touch without a specialist consult at my hospital. The privilege lies in being able to bring developed world technology to the developing world, and more importantly, to leave it behind. I may have been the one to drain the fluid from around her heart, but the physicians and health assistants here have learned how to use ultrasound to identify effusions. They can now uncover previously hidden pathology, findings that change diagnoses and alter management. Yesterday they quickly referred a patient who was initially diagnosed with urinary retention, who in fact had a ruptured appendix, free fluid in the abdomen, and peritonitis. Today, we found a subcapsular splenic hematoma in a trauma patient originally thought to have only a pelvic rim fracture.
Work in such places is imperfect; the choices we are forced to make are neither clearly black and white nor ideal. At times it is incredibly frustrating like the cyanotic 2 year-old with a hole in the muscle that separates the right and left ventricle. As an emergency physician, I take certain joy in making diagnoses, however, such elation melts away quickly. Confirming the diagnosis means little if the father is in India and the mother cannot afford the money or time away from her children at home to take the child to a hospital in Kathmandu to have the defect repaired. Still, some solace may be found in knowing why the child is blue for the family and clinicians.
Much like the improvement in her symptoms from removing even a small amount of pericardial fluid, in resource-limited settings, small changes can often make a significant difference. I am honored to have the opportunity to teach here and share what I can. I hope the infamous resident motto of “see one, do one, teach one” holds true even in rural Nepal and that the physicians and health assistants here continue to use ultrasound to improve patient outcomes and pass this knowledge on to others. Moreso, I am humbled by the courage and strength of the medical staff and the patients they care for. I will not soon forget the unflinching eyes of that little girl as I drew what fluid I could from around her heart before the hemorrhagic fluid clotted off the needle. I also won’t forget how later that day she sat, not in an ICU, but eating rice at the teashop across from the hospital. The next morning she boarded a bus home; her parents had decided to make the trek to India instead of Kathmandu. I had to ask myself if there was such a thing as too much strength? More than once the physicians here have tried to follow up with her family, but their cell phone does not pick up. I like to think it’s because they are in India, getting her the treatment she needs.
Brock Daniels is an Emergency Medicine physician volunteering at Bayalpata Hospital to teach bedside ultrasound. He is currently a 3rd year resident in the Department of Emergency Medicine at the Yale University School of Medicine.
Posted by Nirajan Khadka
Nirajan Khadka is the Associate Program Coordinator for the Community Health Team at Nyaya Health. He is currently pursuing his M.A. in Sociology from Tribhuwan University.
I was just starting to doze off when I got a call from the emergency department (ED). We had some police men in the ED who were seriously ill. They had continuous vomiting, several episodes of diarrhea, and a high grade fever.
The police inspector who accompanied them told me further about the symptoms and duration of illness, and informed me that there are even more men who have been experiencing headache, vomiting, and diarrhea since lunch. I called the nurses from the inpatient department (IPD) for help, and asked them to prepare intravenous cannulas and medications to control the fever and vomiting of the patients who were making their ways toward Bayalpata Hospital. Our ED was packed until midnight with thirty sick policemen, and we had a strong suspicion that there was a food poisoning in the police camp. Thankfully, we had stabilized the patients within a few hours and felt that we were somewhat done.
The next morning I rushed to the ward to see how the patients had fared during the night. Surprisingly, I found around 100
more policemen in the ED with similar complaints. Apparently, the police chief had screened the rest of the men from the camp, and had brought them to the hospital early in the morning. We then had to triage them and kept those with the worst symptoms in the emergency room, while others were shifted to the lawn. Most of our staff members helped us deal with this disaster. Some were busy making oral rehydration solution, while others administered intravenous medications. This helped the patients a lot, and many of them were sent back to the barracks after 24 hours of treatment and observation in the hospital.
On the third day of admission, one of the patients developed seizures. His friends informed us that he had passed bloody stool
and had been vomiting continuously. He also had a high grade fever and associated stiffness of his hands. It was very frightening to see, and challenging for me, Dr. Duncan Maru (co-founder of Nyaya Health), and Dr. Payel Gupta (Director of Clinical Operations), along with three police men to try to help him through the seizures. The seizure was finally controlled after
half an hour of struggling with different injectable drugs, and he instantly began to calm down. We also began to administer broad spectrum antibiotics, to help him recover from his illness. Just the next morning, when I went to talk to him, he replied cheerfully with a thankful smile. I was relieved that he only had minor residual slurred speech and blurry vision.
Our patients eventually improved and all were discharged, but we didn’t know the real cause of the poisoning, which must have had an incubation period of around 6 hours. Some of the most common suspects include bacteria like Salmonella, E. coli, Shigella , and Clostridium perfringens. I wanted to send a sample to the Department of Food Technology & Quality Control (DFTQC) in Kathmandu, a city about 48 hours by bus from our hospital. This would have enabled us to analyze it for poisons and toxins, but was not possible due to the distance from Kathmandu. Nevertheless, we were relieved that we could help these policemen combat the food poisoning in their barracks. Every moment is a challenge when working in such resource-constrained settings, and it is always inspiring to see our staffs work in as a team, even in such circumstances. Ever since then, whenever I pass their barracks on my bike, I never forget to wave hello to my police friends.
Dr. Bibhusan Basnet , MBBS graduated from B.P Koirala Institute of Health Sciences,Nepal. He has a special interest in Emergency Medicine and Psychiatry and is the former Medical Director for Nyaya Health
Posted by Rashmi Sharma
“Ke garney? This is my son, and I am his father.”
This is what the father of Rakesh, the 11-year old boy, said to me when I met him. He had just been told that his son may have rabies, an infection that may be exotic in other parts of the world, but is all too real in rural Nepal.
Rakesh had been bitten by a dog about a month ago. The dog had also bitten his dad, and their buffalo, which had recently calved. At that time nobody thought much of it because the wound had healed by itself. That is, until about three days ago, when Rakesh lost his appetite, and developed a horrible spasmodic twitch every time he tried to drink water. He was then brought to the hospital; a classic textbook case of rabies.
We all knew it was fatal–this infection. And here was this boy, calmly sitting on his hospital bed, chatting, talking, laughing, and demonstrating his oral twitch to whoever wanted to see it again and again.
The doctors present in the hospital, Dr. Payel, Bhibhusan, Roshan, and I scrambled to find the best treatment modalities. He received eight intra-dermal 0.1 ml doses of the Rabies vaccine, as it was deemed the most effective treatment protocol according to the World Health Organization (WHO) in post-exposure cases. The father was given two intra-dermal injections. And then we started negative counseling, but tried not to be too negative. A physician never gives up on hoping. Hope is all you can offer when you can’t offer anything else. Hence, when I wrote his discharge papers, we referred him to a hospital in Nepalgunj which is about 15 hours away by road for “further observation and treatment,” hoping he would receive exactly that and more.
This was my first day. I had just arrived that morning, after a 12 hour jeep ride from Dhangadi, to work as a staff physician at Bayalpata Hospital. My first sight as I entered the hospital was a woman quietly wiping away her tears. I must have asked for an explanation, because someone very discreetly whispered into my ear that her five year old daughter just died this morning of severe pneumonia. I peeked inside and saw a tiny corpse shrouded in a blue shawl. It suddenly dawned on me: I am in Achham, one of the poorest regions in South Asia, and one that shoulders some of the world’s highest mortality rates.
It all felt very surreal. Where am I? Until about a week ago, I was living very comfortably in the United States, among friends, eating barbeques on the Jersey shore, driving to downtown Philadelphia for a night out. And within a week, I was off on a flight to Kathmandu, and in Achham. The journey itself was a lesson in contrasts. Nepal and the United States are worlds apart, literally and figuratively. The flight on my way to Achham offered a panoramic view of the mountains. It looked as if a child drawing a picture had set his imaginations on fire. The mountains are randomly stacked one after another as far as the eye can see into the horizon. The rice, paddy, and maize terraces bind them in varying shades of green, blue and yellow. The beauty of the place contrasts sharply with the hardness of life here. The view from the hospital premises looks like a dream. Picture perfect. My first afternoon, I saw the biggest, most perfect rainbow I had ever seen in my life. Achham is breathtakingly beautiful, but its very ruggedness and remoteness means that its people do not have access to the commodities that should be available in the 21st century world.
Towards the end of the day, Dr. Payel asked if I had further news about Rakesh, the 11 year old boy with rabies. So I called his uncle on his mobile. He told me Rakesh passed away within 10 minutes of being discharged from the hospital. He didn’t even make it back home. He didn’t even have time to take the bus to Dhanghadi, and reach the medical college in Nepalgunj. I was stunned. Actually, we were all pretty stunned even though we all know that Rabies is almost always fatal. It is so much harder to hope than to despair…and there have been a few cases of patients with rabies surviving after all…wasn’t there a survival story in Milwaukee several years ago? The staff in the hospital talked about how amicable and stable Rakesh had been. I kept remembering the comment his father made to me. “Ke garney? This is my son, and I am his father.” The literal translation of “Ke garney” in Nepali, “What to do,” is a phrase I had heard multiple times within a few hours of arriving in Bayalpata. Be it in the emergency room, outpatient department, inpatient department, or pharmacy. What to do when you are living and working in one of the most resource-deprived regions in the world, and everything gets 100 times more difficult to carry out as you are 15-20 hours away from the rest of the world.
Well, at least the advantage of having followed-up on Rakesh was that we talked his entire family into coming in to get rabies vaccinations the very next day. We counseled the family regarding the importance of immediate treatment for animal bites, and convinced them to stop drinking milk from the buffalo that had been bitten by the same dog. It suddenly dawned on me how precious and fragile human life is. Here was this boy, demonstrating his twitches just that afternoon, and then he was gone. We lost an 11 year old boy who had his entire life ahead of him due to something as preventable as a rabies infection. Is there any sense in this kind of fatality in this day and age?
What a waste of life. Ke garney? However, I quickly learned that, as a physician in Achham, there is no time to waste. There is always another patient who needs medical help. Later in the evening one of the nurses called for me, and we delivered a healthy 2.8 kg baby girl that night. The lady in labor did not make a single sound. Not even when a quick episiotomy was made without giving her any local anesthetic. She never complained about the stifling heat in the labor room. The power had gone off. The fan wasn’t working overhead. She gritted her teeth, and pushed. Not a sound from her. It was an example of the sheer strength of the Achhami people, of their ability to survive and thrive despite some of the biggest odds against them.
It humbles me, being here. I am more appreciative of the education and the opportunities I have received having grown up in Kathmandu. I know a lot needs to be done in Achham in terms of infrastructure development, education, facilitating healthcare etc., but I feel that by being here, and caring for patients, I am at least doing my tiny bit to help improve healthcare in Achham. One patient at a time, one day at a time.
Dr. Rashmi Sharma graduated with an MBBS from Kathmandu Medical College. She is currently a staff physician for Nyaya Health and the first female physician working at Bayalpata hospital.