posted by Aditya Sharma
An 18- year old male from the district of Bajura was injured while hunting with family members. He was accidentally shot from behind at an oblique angle, which created a bullet tract from the lower right abdomen, through part of the abdomen, transecting the genitalia, and exiting through the left thigh. We found no exit wound for the second bullet, and it is likely that this bullet is lodged inside the patient’s abdomen.
The patient’s family carried him for 10 hours to the Bajura hospital, where no doctor was available. They were told that he should be transferred to another center for care. The army was stationed nearby and arranged for a military helicopter to transfer the patient from Bajura to Sanfe, which was the furthest distance they could manage. The patient was transported along with two relatives. The group then waited two hours at the airport while others tried to find a stretcher to bring him to the Nyaya Health clinic. Unfortunately, they could not find a stretcher so he was carried from the airport to our clinic.
On arrival, the patient was pale and shivering. His systolic blood pressure was around a low 60 mm Hg. He also had two small-gauge intravenous (IV) catheters in his wrists which had been inserted during his earlier journey. We quickly replaced these with two larger ones for more rapid infusion. Upon examination, we found that the patient had frank peritonitis, or inflammation of the membrane lining the abdominal cavity. We treated this with a combination of two antibiotics (ceftriaxone and metronidazole). With these steps, the patient slowly became more comfortable.
Initial treatment by Nyaya Health staff of patient with bullet wounds
He began to slowly ooze bodily fluids, followed by stool, through the entrance wounds. At this point, we decided he needed an urgent transfer from the clinic to a proper hospital setting. We decided that his best option would be to first go to the TEAM hospital in Dadeldura for re-stabilization and re-evaluation and then be transferred to the Nepalgunj Medical College Hospital, which is approximately 10 hours away from our clinic by auto. There, he would be able to receive appropriate care based on need, including intensive care management and an exploratory laparotomy, which is a surgical procedure to examine the abdominal organs.
Unfortunately, no member of the patient’s immediate family was available to agree to our transfer plan. Given the lack of policy for medical decision making within the larger framework of medical ethics in Nepal, we were forced to keep the patient at the clinic until his older brother could arrive and agree to our plan. We were informed that the brother was coming by jeep and would arrive within hours to take the patient to a center that provides more extensive services.
However, the entire night passed and the brother did not arrive, nor did we receive further news about his whereabouts. In the morning, we decided we needed to urgently mobilize the community and government to support an immediate transfer given the lack of family consent. We called the District Health Office (DHO) and were given permission for the transfer. The head of the DHO called the district police headquarters on our behalf to support the transport. In the meantime, we used our local connections in Sanfe to arrange for a jeep to transport the patient to the Nepalgunj Medical College. By 2pm, over 36 hours since the injury, the local police, community members, and our staff helped the patient into the jeep.
Community members help transfer the patient from our clinic to the jeep.
We left the two large-gauge IVs with lactated Ringer’s solution, which is used after blood loss due to trauma, in his arms and arranged for the jeep to stop at every hospital along the way to Nepalgunj to have the fluids replaced.
Despite the significant length of time since the injury, we were relieved that the patient responded quickly to our management and seemed stable before transport. He is expected to do well if he receives surgical care soon. For us, this situation helped demonstrate the ability of a mobilized community to assist with urgent access to health services. We will write an update once we receive news about the patient’s condition.