Posted by Tanya Shah
The decision to refer a patient to a hospital for surgical care is not easy for Nyaya Health providers to make. The cost of transportation alone can be prohibitive and surgical services at the referral centers also require significant cash. For the average family in Achham, this can mean more than a month of wages and, for more expensive procedures, even a family’s life savings.
Yet we frequently face these difficult referral decisions. A recent example involved a 10-year-old boy who came to our clinic after suffering from abdominal pain for three days and having little to no appetite. During registration, he was immediately triaged to see the doctor by our auxiliary nurse midwives because of his symptoms and degree of discomfort. His skin was hot to touch and he had a fever. His heart rate was fast for his age but his blood pressure was normal. Upon examination, we discovered that he had significant tenderness in the right lower part of his abdomen. However, his pain was widespread, especially with rotation of his hip.
His diagnosis was clear – he was suffering from appendicitis. However, the treatment decision was less obvious. The primary question was whether his family could afford to take him to the nearest surgical center, over ten hours away by harsh mountain roads. Otherwise, he would be forced to hope for resolution of his condition through conservative treatment using fluid and antibiotics.
The poor road conditions in some areas can make travel to a referral center a difficult journey for patients.
We gave him intravenous antibiotics, fluids, and pain medication. After several hours he was more comfortable and his vital signs had improved. However, his fever remained high and he was able to make very little urine. Because he was showing signs of systemic infection in addition to his appendicitis, the Nyaya staff encouraged his father to take him to the distant referral center for surgery. Although the evening bus was full, his father flagged it down outside our clinic and he was able to get a seat for himself and his son.
With the expansion of our services at Bayalpata Hospital, which we will move to this summer, we will be able to perform surgery in the future. This case is one of many that illustrate the need for such services in this district. By reducing the need for patients to travel such large distances for referrals, we can help save both patients’ lives and their family’s much-needed cash in this poverty-stricken region. We are also implementing a program to conduct extensive follow-up on patients who we refer to distant hospitals, in order to monitor their condition and provide additional care if necessary once they return to Achham.
