Posted by Ruma Rajbhandari
Note: The following post has graphic content
It seemed like it would be a quiet day at Bayalpata Hospital—the Outpatient Department queue was much shorter than the 200 patients that we had been averaging almost every day over the last week. The government had declared a national day of mourning for a past prime minister who had recently died so many patients probably thought the hospital was closed for the day. We had finished up morning rounds and were headed to the OPD when Dr. Bikash, our Medical Director, received a call that the Bayalpata Hospital ambulance was needed. A jeep had overturned in Jayagad–there were a few injured who needed to be transported to the hospital. Unfortunately, our ambulance driver was on personal leave at the time. Fortunately, our Medical Director was familiar with the ambulance and with the roads. He, another volunteer physician and I immediately headed to the site of the accident. On the way to the scene, we came across a few army personnel who were also headed to the site. They told us that there were about 8-10 injured—significantly more than the “few” we had been told earlier.
There were about 40-50 people at the scene of the accident. A swarm of people surrounded our jeep as soon as we pulled up. Groups of people shouted for us to come see this patient or that. We asked to be led to the severely injured and examined these people as quickly as we could and got them into the ambulance.
The first man I saw was sitting on the ground, holding his left chest, clearly in severe pain. He was taking very short, shallow breaths and crying out in pain. He had a good pulse and could answer some of my questions. He had very severe pain over his chest wall on the left—likely rib fractures. Fearing a pneumothorax, I listened for breath sounds on both sides and thankfully they were equal bilaterally. We quickly loaded him into the jeep.
By this time, the swarm around the jeep had intensified—everyone wanted to get on the ambulance to get to the hospital—at least a two hour walk away. The army personnel literally had to fight off people trying to get on. We shouted, “We can only take the severely injured right now. We will come back for the rest of you.” We filled up the ambulance with the 6 adults and 2 children who we thought were most acutely in need of care.
The drive back to the hospital was as harrowing as the drive there. Although the road has vastly improved since my last visit to Bayalpata over a year ago, parts of it are still not completely tarred. There are areas with mounds of mud and rocks that need to be carefully avoided along with the narrow edge of the road and the precipice below. A woman moaned and cried in the back with every bump and eventually vomited. All we could offer her in the cramped ambulance was a piece of cloth to vomit into. A small child with a four centimeter laceration over his forehead amazed me with his bravery—he did not drop a tear.
When we pulled up to the hospital, staff were ready to receive the injured. They had put additional mattresses on the floor of the Emergency Room and in the halls of the hospital. Each mattress had equipment on it for starting an intravenous line as quickly as possible. We separated the injured patients by severity and dealt with each as fast as we could, trying to assess for injuries, treat for pain and decide who needed X-rays.
The man with chest pain turned out to have four fractured ribs. Another man had cervical tenderness—a cervical collar was quickly constructed for him out of cardboard, gauze and duct tape, before he received cervical spine X-rays. We packed another nose which was profusely bleeding. Many lacerations, mostly of the scalp and forehead (likely from the passengers hitting the metal roof of the jeep) were sewn. In about two hours, Bayalpata staff on that day (consisting of two full-time doctors, 2 health assistants, 3 ANMs, an X-ray technician, a lab assistant, two health aides, administrative and management staff) along with three volunteer physicians were able to successfully manage 17 injured patients. The teamwork among the staff in dealing with a disaster such as this was absolutely remarkable. I smiled as our Hospital Administrator went around making sure that everyone had gotten their Tetanus booster shots.
That’s not to say there weren’t problems. There were many things that could have gone better. Infection control in our procedure room needs to be improved. Many of our suture kits do not have the proper instruments. We lack certain supplies like face shields, booties and sufficient gowns to protect our doctors and nurses from coming into contact with bodily fluids. We also did not have sufficient staffing to deal with a disaster such as this and attend to the one-hundred or so OPD patients that had walked many hours to see a doctor that day. .
Nevertheless, that night at dinner we congratulated ourselves on a job well done on a historical day for Nyaya—the largest traffic accident that we had handled to date. Unfortunately, we were too quick to celebrate. The following day, at 11AM, as we were nearing the end of our staff meeting, another ominous call came in—there had been another jeep accident—this time more severe than yesterday’s. Answering our query of how many were injured, Dr. Bikash only knew “dherai” (many people).
The second day’s events were similar to the first—only more severe. We treated twenty-one injured patients. The sickest patient was a young twenty-one year old with a possible abdominal bleed and a left humeral fracture. He was transferred to a tertiary center in Nepalgunj for surgery as we do not have an operating room. (According to some family members who arrived to collect some of this patient’s belongings at the hospital today, he is in stable condition.) In addition to this patient, we dealt with multiple fractured limbs, including a four-year-old with a fractured tibia and fibula, a twenty-one year old with a clavicular fracture, and a fifty-three year old with multiple rib fractures. Scalp lacerations were one of the most common injuries—our health assistants and doctors sutured about seven of them in total. After initial stabilization, we transferred a few patients to higher centers for further diagnostic imaging like CT scans or specialty services like dental and abdominal surgery not available at Bayalpata.
Two jeep accidents in two days—coincidence I thought. According to the Director of the Hospital, Dan Schwarz—definitely not coincidence. There was a large festival in Sanfebagar to commemorate Nepal Tourism Year 2011 that was drawing in hundreds of people from throughout Achham and surrounding districts. Many of the jeep operators from the Terai had come to Sanfe to take advantage of the business opportunities. Not only where these drivers not familiar with the roads but people were being packed into these jeeps, on top of the jeeps and anywhere else they could fit. A typical patient load for these jeeps might be fifteen people—they were packing in at least twenty-five. With drunk driving being a fairly common occurrence and the poor condition of the roads, it was a perfect mix of factors to bring about two major accidents in two days.
Despite the severity of the accidents, it was very satisfying knowing that were it not for Bayalpata Hospital, thirty-eight injured patients would not have received timely care.
The WHO report on global mortality and morbidity, projects, by 2030 motor vehicle accidents will be the third cause of mortality and morbidity worldwide. With a lack of infrastructure in Achham, Bayalpata Hospital will likely see a continued number of cases due to motor vehicle accidents in the future.
Dr. Ruma Rajbhandari, MD, MPH, is currently a volunteer at Bayalpata Hospital. She is a resident physician in Internal Medicine at Brigham and Women’s Hospital.