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 Posted by Brock Daniels

Our stoic, young patient.

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.

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