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Posted by Duncan Maru

Surgery Facility Renovations Workplan (click image to view PDF)

Owing to uncertain travel times, it is typically wise to anticipate spending about 36 hours in Kathmandu after leaving Achham.  I am thus left trying to squeeze as many meetings and tasks as possible out of my trip.  During my previous “exit trip,” four weeks before with Agya Poudyal, we had seven meetings in the span of a day, ranging from corporate partnerships to procurement to activism to doctors.  This last time was no exception.  Accompanied by Pradip Bagale, our new Kathmandu Administrator, I had the good fortune of spending the day, from eight in the morning to nine at night, meeting with distributors for the renovations of our surgical and laboratory facilities.  Pradip was making up for an approximately 3 month gap, during which we had had no Kathmandu personnel, and this was his first week on the job.  This day also represented the shifting of organizational emphasis to Kathmandu-based procurement for Bayalpata Hospital, a critical process for the organization occurring in the wake of the recent staff upheavals.  We had elected to bypass a general contractor for our renovations, in favor of procuring all the items and working with the craftsmen directly, rather than through a middle man.

Over the course of the day, we worked out the pricing, specifications, and work plans for the windows and partitions

Procurement and Pricing of Renovation Materials (click image to view PDF)

manufacturer, the solar water heater supplier, the door and woodwork carpenter, the AC/heater unit distributor, and the tile company.  We also made agreements with the medical supplies company for such core items as infant warmers, EKGs, and pulse oximetry probes.  Throughout the day, it was clear that Nyaya Health Nepal President, Mr. Acharya, commanded a strong and respected influence among the suppliers, which was quite helpful in ensuring quality at an appropriate cost.  It was ultimately a satisfying day, knowing that by the end, Nyaya had finally committed organizationally to buying all materials for the renovations.  After several months’ delays, we were finally following through on our long-standing promise to build surgical capacity.  During the subsequent days we did scramble with our Country Director, Gregory Karelas, to identify the best mechanism for payment, but ultimately the deals were sealed.  We provide here the final procurement and pricing list for these items; some minor tweaking has occurred with the distributors and/or pricings but the figures provided are largely accurate.

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Duncan Maru, MD, PhD is the co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.

Posted by Richa Pokhrel 

Various staff members working together to make Momos (Nepali dumplings) for everyone. This evening helped bring many of the staff together to work and eat as a community. That night, we made around 300-350 momos.

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Richa was born in Nepal but grew up in Iowa.  She is currently the Director of Evaluation and Research at Nyaya Health.  Richa has a Master’s in International Development from the University of Pittsburgh.

Posted by Aarti Bhatt

[The following is an example of Nyaya’s teamwork approach to providing the best care to patients.  These case studies were discussed via our international listserv, to provide a spectrum of professional input.]

Case 1 X-Ray

 Case 1: A 38 year old female with four days of fever, cough, and epigastric discomfort.  Hemoglobin on admission 6.7.  Chest x-ray showing diffuse patchy infiltration.  Clinical picture concerning for tuberculosis (TB), malignancy, or severe pneumonia (PNA).  Condition improved following administration of Levofloxacin and Clotrimazole.

Case 2 X-Ray

Case 2-65 yr female presenting with dyspnea on exertion, facial swelling, and bilateral pitting edema. Lung exam shows bilateral lower lobe crepitations. Past history of Hypertension, Chronic Obstructive Pulmonary Disorder, and APD (Acid Peptic Disease). Chest X-Ray (CXR) shows diffuse enlargement of heart concerning for severe Chronic Heart Failure(CHF) and bilateral pleural effusions. Improved on Lasix, Ceftriaxone, and nebulization treatments.

Case 3 X-Ray

Case 3: 50 year old female presenting with several month history of cough, hemoptysis, weight-loss, and anxiety.  Upon examination, patient is tachycardic to the 180s with an irregular heartbeat.  Past history of pulmonary tuberculosis and COPD.  CXR taken 3 days Prior To Admission showing hyperexpansion of lung fields and tubular heart, typical in a COPD patient.  Pulmonary nodules consistent with past TB infection are also visible.  Clinical picture is concerning for relapse of TB as well as superimposed supraventricular tachycardia vs. atrial fibrillation with rapid ventricular rate (RVR).  Unfortunately there is currently no ECG available at Bayalpata Hospital, so the best course of action is to continue close heart rate monitoring, IV fluid resuscitation, and administration of broad spectrum antibiotics (Levofloxacin or Ceftriaxone/Azithromycin) to treat lung disease.  She is currently stable but if the heart symptoms worsen we will start her on Diltiazem for rate control.  We are awaiting AFB results (to test for TB) from 3 days prior.  This patient is severely ill and still managed to walk an entire day to seek medical care at Bayalpata Hospital.

 

Health Assistants Kriti Bista, Prakash Madai, and Khadak Jung discussing an x-ray.

These cases are heartbreaking.  In America we pride ourselves on practicing evidence-based medicine, but we also rely heavily on the ease of ordering any diagnostic test whenever we please.  We never question the availability of something as basic as an ECG!  The patients I have met in Achham are resilient and brave beyond my wildest imagination, and what this experience has taught me is that sometimes all you can do is the best you can.  Sometimes you have to make choices within your constraints and hope that your patients can hold on for one more day.

Health Assistant Prakash Madai interpreting an x-ray.

Above are also some pictures from x-ray rounds, which Dr. Thapa has been conducting each morning.  The Health Assistants systematically go through x-rays from the previous night.  They describe the presentation of the patient and read each x-ray in English.  The x-ray machine is a valuable piece of equipment and a fantastic diagnostic tool which we try hard to utilize to the best of its ability.  X-ray rounds are just one example of this.

[The following illustrates some of the feedback provided by our medical consultant listserv.]

 Jason Andrews, MD: Thank you for sharing these interesting cases and your very thoughtful management.  One suggestion I would make is not to use Levofloxacin in patients suspected of tuberculosis.  The reason is twofold: one, you risk developing further resistance to quinolones (already 30% of multi-drug resistant TB cases in Nepal have quinolone resistance, likely due to their indiscriminate use); two, you may delay the diagnosis, as quinolones have potent antituberculous activity and can lead to temporary improvement in the patient’s condition.  There is quite a bit of literature on this issue.

I would suggest that Levofloxacin not be the initial antibiotic of choice in cases in which TB is being considered, and would consider not using it for initial therapy for pneumonia at all for this reason.  Doxycycline or Azithromycin can be used for atypical bacterial coverage if needed, and used with Ceftriaxone for severe/hospitalized cases.

In the first case, for example, the 38 year old woman with a Hemoglobin count of 6.7, I doubt very much that pneumonia was the only diagnosis leading to that degree of anemia, and would evaluate other medical comorbidities (and nutrition).

Just some things to think about to add to your excellent care.

Michael Polifka, MD: Case 1: For a 38 year old female with these x-ray findings, TB is certainly highest on the differential list.  Her Hemoglobin of 6.7 goes along with a chronic process.  She very well may have a superimposed secondary bacterial infection, which would respond to standard antibiotic Rx, though with underlying TB I would have try to avoid a quinolone to minimize resistance if she turns out to have MDR-TB.  Has her HIV status been checked?  Are there any other findings on physical exam to suggest a primary source of malignancy (much less likely inherent age group)?

Case 2: Has an ultrasound been done for pericardial effusion?

Case 3: The chest x-ray does have diffuse calcifications, suggesting old TB, but there is also a right apical infiltrate that with her hemoptysis very likely indicates recurrent TB.  Again, I probably wouldn’t use Levofloxacin, as in Case 1.  With her irregular tachycardia and COPD she very likely has either rapid atrial fibrillation or multifocal atrial tachycardia; with rates of 180, she would absolutely benefit from a slower rate.  A calcium channel blocker is a good choice if her blood pressure can stand it.  If not, Digoxin would work, though slower, as long as her potassium levels are okay.

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Aarti Bhatt is currently a 4th year medical student at the Medical College of Wisconsin, and will soon start her residency in Internal Medicine/Pediatrics.  She is also a Community Health Volunteer at Bayalpata Hospital. 

Posted by Gregory Karelas

The patient was of a young woman who presented to the Emergency Department (ED) with rectal bleeding for the third time this month. I watched our doctors go through preliminary check-ups and interventions with her at the end of the work day, and then left for my office, confident that all was under control. When I emerged for dinner that evening, our clinicians quickly pulled me into the ED. Given limited technology, they were unable to perform a colonoscopy and concerned that the patient would need a blood transfusion before the end of the night. Moreover, they had spent the last three hours defending themselves against a barrage of criticism from the patient’s family, accusing them of ineffectiveness and spitting advance blame for any devolution of her condition while in our care. Worst of all, and paradoxically, the family refused to allow referral for potentially life-saving transfusion services that our hospital could not provide.

In the interests of saving time and with hopes of convincing the family otherwise, I got on the phone with colleagues across the region: hospital directors, surgeons and lab specialists at four different medical centers between Mangalsen and Dadeldhura. Due to lack of transfusion services or lack of responses to my then “late night” call, we found no outside technical support. We did, however, reach a senior Nepali physician whom I had once interviewed for a position at Bayalpata and called that night in a moment of resource-seeking amidst withering options. He was a voice of support and reassurance when we needed one, informing us of transfusion options that we could access before morning. We thanked him. And then returned to the waltz of harassment and hurt that awaited us with the patient’s family.

My two hours of subsequent intervention did little. I could hear the shouting before I entered the ED and took the patient’s mother-in-law to my office, away from the commotion around us. She had been the primary perpetrator of abuse against our clinicians and the driving force behind her son’s decisions for his sick wife. We spoke. And she cried. But she never wavered. I then spoke with her son privately in the ED call room. But after thirty minutes of progress by inches, the furthest we got was “I need to talk to my mother.”  Our staffs were tired and frustrated, and the hope of winning this debate had begun to feel beyond reach.

Ultimately the patient spent the night. Our staffs had fought hard and wanted to keep going. But we decided to stop.  It was after 10p.m. And the best we could do was to make sure that the family didn’t return home. As our parties parted ways, I brought the family a jug of water and asked the night guard to send immediate word if the patient tried to leave the hospital.

Two days later, the young woman with rectal bleeding returned home alive. She left with no real diagnosis and no visible fear that she would likely return to our ED soon.

So, yes, the patient was healed enough to go home. And yes, the night was a remarkable example of teamwork, resource identification and die-hard perseverance. But it was hard. It was hard to watch people refuse care for a woman who needed it. It was hard to see her suffer throughout the mayhem around her, completely powerless and subject to the rhetoric of her husband’s family. It was hard to watch our staffs, whom I admire and care for in endless ways, take such a beating as reward for their altruism. And it was hard to fight and lose…

People have said that life is cheap in Achham. And maybe that’s true. Maybe that’s why we do the work we do. To honor the lives that others don’t. Or to set a model of compassion and grit that defies the skeptics of free healthcare and the challenges of survival in this forgotten fold of the Earth. So we keep trying, fueled and impassioned by the toils that brought us to Achham in the first place. Perhaps hoping that the bruises we invite bring us closer to our vision.

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Gregory Karelas is the Country Director of Nyaya Health.  He graduated with an MSc in Medical Anthropology.

Posted by Tess Panizales

Bayalpata staff members are provided living quarters and share meals within the hospital compound. This fosters a family relationship among the staff that nurtures teamwork to help deliver care to the community.

 

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Tess Panizales is the Quality Program Manager of the Department of Surgery at the Brigham and Women’s Hospital Center for Surgery and Public Health.

Posted by Aarti Bhatt

The patient's knees. According to the patient's father, the rash began with this vesicular appearance and progressed to the more severe form that is seen in the other pictures following the addition of herbal paste.

A 9-year-old girl presented with an 8 month history of rash on the extensor surface of her legs, chest, arms and face.  As per her father’s report, the rash began as small papules (see picture of knee) and worsened over time.  In the last 5 months the family has tried various medications, including unspecified antibiotic injections, pills, Vaseline, and an herbal paste which was applied over the face.  Since using the paste, the rash became more severe and prompted the patient to come to Bayalpata Hospital, which is almost a 2 day walk from her home.  At the time of admission, the patient’s face was covered in brown herbal paste, was diffusely erythematous, and was draining fluid.  The presumptive diagnosis was uncontrolled eczema with superimposed contact dermatitis, secondary to use of herbal paste.  There was also some concern of superinfection of the skin.  The patient was placed on Megapen (combination Ampicillin/Cloxacillin), oral Prednisone, and topical Vaseline treatment.  The pictures below were taken on day 9 of oral Prednisone.  Unfortunately, we do not have pictures from admission, but the rash does seem to be improving.  Upon examination, the patient showed no signs of joint involvement, lymphadenopathy, or any other symptoms that would cause concern about a rheumatologic condition.  Currently, the skin does not look

Rash on day 9 of oral steroid treatment. The patient's skin was also dry and flaking which added to her discomfort.

superinfected, but with chronic uncontrolled eczema there is certainly concern for this.  The question here is one of outpatient management. Considering the long distance the family has traveled for medical care, what would be the best course of action?  Some considerations include a high dose topical steroid followed by a low dose steroid. Vaseline could be used at home to keep the skin moist.  Ideally we would like close follow-up for this patient, but the distance of travel precludes this.  Perhaps the patient could return every 6 months for outpatient follow-up?

The rash had also spread to the patient's chest.

Once again we ask ourselves similar questions.  Are we providing good counsel?  Are we missing something?  The family is frustrated, as this has gone on for so long; we are unsure if they trust us more than their own herbal remedies.  What must it be like for this young girl who for 8 months hasn’t been playing with her friends, has been missing school, and has been feeling isolated because she can’t be like other kids her age?  Despite many doubts, they have placed trust in us by traveling here, and we will do whatever we can to help her regain a better quality of life and deliver some answers.

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Aarti Bhatt is currently a 4th year medical student at the Medical College of Wisconsin, and will soon start her residency in Internal Medicine/Pediatrics.  She is also a Community Health Volunteer at Bayalpata Hospital. 

Posted by Ruma Rajbhandari

The team investigates the problem.

When Dhan Bahadur, our X-ray Technician, called us over and told us that our X-ray machine was broken, I was shocked.  This was the WHIS-RAD, the extremely durable and safe machine promoted by the World Health Organization, for being perfect for resource-poor settings.  It was supposed to last for many years, not break down after merely 15 months of operation.

However, here we were, Gregory (our Country Director), Bharat Rawal (our Maintenance Assistant), Deepak Bista (our Database Manager), and Dhan Bahadur staring at the machine, wondering why none of the lights that signified that the battery was charging were lighting up.  The machine would start up but when we tried to shoot a film, it would automatically shut down and a light would flicker—“Error 11”.

“You know, the last time the x-ray broke, we opened up the machine and found a wire that had been eaten by a mouse,” offered Dhan Bahadur.

Deepak Bahadur Bista, Database Manager, goes in for a closer look.

So, we proceeded to unscrew the large metal case of the machine and take a peek inside.  The first things that caught my attention were tiny, black mouse droppings, littering the inside of the machine.  My heart sank—a $30,000 machine potentially ruined by these nasty, tiny creatures!  Although the whole machine was encased in a metal cover, there was a small hole in the back for wires that the mice could get in through.  Dhan Bahadur, to his credit, had duct-taped the hole after the last mouse incident, but it was still possible for a persistent mouse with good teeth to get through.  We combed through every part of the machine but found no wires that had been chewed through this time around.

Dr. Ruma Rajbhandari, Volunteer Physician, reports voltage readings to Sergio in Spain.

The WHIS-RAD is produced by a Spanish company called Sedecal.  We emailed their customer support department with our problem and received an immediate response.  However, the response was quite technical, requiring us to measure voltages across various internal parts of the machine.  I think that they must have assumed the hospital would have some sort of a Maintennance or Engineering Department that would be involved with fixing the machine.  Little did they know that our X-ray technician and Maintennance Assistant simply had a 10th grade education.  We wrote back to Sedecal explaining the situation and asked them to come on Skype and lead us step by step through the process of figuring out what was wrong with the machine.  Sergio Rios, the Support Engineer for Sedecal, promptly downloaded Skype (or Skypeeeee as he likes to call it) at 3:30p.m. Achham time, or 10:30a.m. Madrid time.

For the next eight grueling hours, a Spanish engineer in Madrid (Sergio Rios) and three Achhami staff at Bayalpata Hospital were linked together via a laptop computer and an amazing video chat program, transfixed by a single goal—how to fix the x-ray machine so that we wouldn’t have to turn away any more patients who had walked for hours (some over 2 days) to obtain an x-ray.

Dhan Bahadur Bogati, X-Ray Aide; Deepak Bahadur Bista, Database Manager; and Bharat Rawal, Maintenance Assistant (left to right) think through new angles to the problem.

Despite their limited formal education, our Achhami staff came together as a team and each brought with them a skill without which the x-ray could not have been fixed.  Dhan Bahadur, having been the x-ray technician since the very beginning, knew all the nuances of the machine—when certain sounds would emanate from the machine and which lights should light up at what time.  Bharat was our hospital’s “Mr. Fix It.”  He was particularly good with electrical repairs and owned a small handheld voltmeter, without which we could never have figured out what was wrong with the machine.  Deepak, with his Bachelor’s in Computer Science, had put together the circuit boards of computers and was instrumental in replacing the defective line monitor board, the ultimate culprit behind the broken machine.  Voltage fluctuations are very common in Achham where triple-phase electricity still does not exist.  According to our Spanish support engineer, despite the use of a voltage stabilizer, erratic voltages had damaged the line monitor board.

Sergio Rios, Support Engineer from Sedecal, leads the charge from Spain.

At 11:30p.m. Achham time (6:30p.m. Madrid time), we all broke out into huge smiles and yelps of joy as we saw all the battery lights on, the machine lighting up, and Dhan Bahadur finally able to shoot an x-ray!  We cannot thank Sergio and the Customer Support Department at Sedecal enough for their dedication in leading us step-by-step through the process and essentially giving us a whole day of their time.  When our internet connection was too weak for video, Sergio would even take pictures of various parts of his prototype machine and send them to us over email.

Finally, an enormous thank you to Skype for being not only amazing (what other program can claim credit for bringing people in the unlikeliest corners of the world together to fix a machine?) but also free!

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Ruma Rajbhandari is a physician at Boston’s Brigham and Women’s Hospital.  She volunteers with the Nick Simons Institute and Nyaya Health.

Posted by Tess Panizales

The Bayalpata Hospital Cooks, Deepa Bam and Laxmi BK; prepare three meals a day for the staff. This picture illustrates how much rice is prepared to keep the staff nourished and ready for the work ahead. Rice is a staple food for the people in Achham, and despite the mountainous terrain, rice terraces have been creatively built to provide the necessary supply of grain.

Posted by Dan Schwarz

Recently, thanks to the efforts of volunteers from around the world, donors, and our dedicated staff, several substantial technological improvements have been made at Bayalpata Hospital.

In the past, we’ve struggled with the lack of consistent electricity, and consequently, have had to carefully ration our energy utilization.  This has, of course, further limited our options for implementing new technologies within our daily work.  Recently though, with the help of the Nepali Government, SunEdison, and Gham Power, we were able to install the first phase of a solar energy project.  This has proved to be an extraordinary addition to our patient care, allowing our staff to provide energy-dependent clinical services (everything from simple CFL bulbs to operating our laboratory equipment) 24 hours a day, regardless of the status of the public electric grid (which is frequently shut off or running at very low voltages). 

Solar panels now provide Bayalpata Hospital with much improved energy, allowing for more utilization of energy-dependent technology.

As our energy situation has improved, we have been able to start thinking more creatively about integrating more energy-dependent technology into our daily clinical and administrative operations.  Databases for our store manager and pharmacist have been implemented, documenting all consumable stocks, projecting needs for coming months, and (very importantly) helping our pharmacist to be aware of pharmaceuticals that will expire soon.  Thanks to a recent donation of laptops from our supporters at the University of Pennsylvania and the Brigham and Women’s Hospital in Boston, MA, we are now able to have a laptop in each clinical department to ensure that any point-of-care pharmaceutical administration can be appropriately logged into the pharmacy database.  In the past, these kinds of drug administrations were frequently not logged, causing substantial inaccuracy in the database’s stock versus the stock on the shelves.

New laptops that have recently been donated have been networked to utilize the hospital pharmacy and consumable database, ensuring that hospital stocks can be accurately monitored.

In tandem with distributing computers throughout our clinical and administrative departments, we are extremely excited to welcome the introduction of ADSL internet to our hospital, now available on wifi in all buildings on campus.  This initiative, which dates back over two years, is a massive credit to the Nepali government, which has worked for years to slowly expand infrastructure into the Far West, recently reaching Achham.  Phone landlines were first installed in early 2011, followed by the introduction of ADSL capability in late 2011.  We now have 4 phone lines at Bayalpata Hospital, and have wireless internet in all of our clinical, administrative, and staff quarters buildings. The degree to which this has changed our pace of work and our ability to connect to the outer world—both professionally and personally—cannot be understated.

One other major step forward has been the decision to move to an all-digital general patient registration process.  Starting in December 2011, all patients coming for outpatient visits at Bayalpata Hospital are registered directly into our patient database, rather than into the former paper-registration system (which then had to be back-entered into our patient database).  The decision to take this step was based on the huge burden of work that dual paper and digital registration caused, while also taking into account the profound importance of maintaining proper patient records.  To date, we are not yet at a point where our clinicians are using a full electronic medical record, nor will we be for quite some time, but we aspire to take small steps in that direction over the next year.  Eventually, we envision a digitally-run hospital, with online (protected) storage of patient records, obviating concerns of termite or water damage, or of the patient losing the records that we currently ask them to keep and bring back when they return.

Kalpana Bhandari, Bayalpata Hospital’s new Patient Registration Assistant, registers outpatients using the hospital’s new digital registration system.

Slowly but surely, along with our partners in the Nepali government and other local organizations, we are working to improve not only the health standards of the people of Achham, but the actual manner of healthcare (and other service) delivery.  We have made enormous strides for the people of Achham over the past three years since first opening the Sanfe Bagar Medical Clinic, but there is still an immense amount of work in front of us.  These small improvements in technology and service delivery do not solve the problems of the Achhami people, but they do help us along our way in that journey.

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Dan Schwarz is the member of the Board of Directors and a medical student at Brown University School of Medicine. He completed his MPH at the Harvard School of Public Health.

Progress with Time

Posted by Dan Schwarz

After being absent from Bayalpata for nearly six months, I returned in late December with great excitement to see the many changes and steps forward that have transpired since I’ve been gone.  And indeed, I have not been met with disappointment.  While our staff had continued to work diligently, serving the people of Achham, I had returned to my academic obligations in the US, finishing med school and preparing to begin my residency training next year.  Prior to leaving, as the former Director, I was heavily involved in planning and designing our programs, both new and old, so returning to see their progress has been a truly rewarding and inspiring experience.

Please see below a slide show of some of the most recent developments at Bayalpata Hospital – accomplishments that have, in some cases, been years in development – all of which make me deeply proud to be a member of such a wonderful team.



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Dan Schwarz is the member of the Board of Directors and a medical student at Brown University School of Medicine. He completed his MPH at the Harvard School of Public Health. 

Posted by Tess Panizales

Bayalpata serves patients of all ages. This child is one of our youngest patients (other than newborns), who came in with asthma exacerbation. By educating the parents about this condition, and providing support via Community Health Workers, we hope to be able to control and manage this condition at home.

 

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Tess Panizales is the Quality Program Manager of the Department of Surgery at the Brigham and Women’s Hospital Center for Surgery and Public Health.

Helping a Dead Man

Posted by Duncan Maru

Here is a man we can help.  He’s a forty-two year old farmer and migrant worker to India who is extremely sick, but fixable.  I first heard about him a few minutes ago from one of our superb Health Assistant, Chanakya, who found me while I was going through expired medicines in the surgical building with our Country Director, Greg.  He wanted to ask me about this patient in the emergency department on whom they had run several tests.  Even our modest laboratory showed severe illness.  Our i-stat demonstrated acute renal failure (creatinine of 3.4) and acidosis (bicarbonate of 12), and our QBC machine showed severe anemia (hgb 5.7) and an elevated white count of 25,000 (though his lymphocytes were only 500).   Seeing him confirmed this.  He was breathing extremely rapidly, with cool extremities, in acute renal failure from severe dehydration, unable to phonate likely from a stroke, impaired gag reflex, with a large right-sided pneumonia and perhaps a pleural effusion.  Given significant inguinal and cervical lymphadenopathy on exam, and the aforementioned lymphocyte count, he almost certainly has HIV.  But we have oxygen, intravenous fluids, and antibiotics.  We can get him through this sepsis and pneumonia and get him on antiretroviral treatment.  He has had fifteen days of cough, fever, and shortness of breath and was only now carried to Bayalpata Hospital from his village, which is two and a half hours away.  Over the last few days he has developed difficulty speaking, possibly from a stroke, though he is not neurologically devastated.   Despite the very late presentation to care, we can do this.  We start some more fluids.  He looks extremely sick and is breathing rapidly, but we need to get an x-ray.   Here is a man we can help.

We get him on the x-ray stretcher, which is an aspect of the system that I have not appreciated before—one of so many systems issues that you don’t see until you’re going through them.  I’m glad, however, that it’s not monsoon season.  We walk him the 20 meters to the x-ray.  Our X-Ray Technician, Dhan Bahadur, gets him ready.  I step out.  Outside, one of our Health Assistants (HAs), Chanakya, approaches me saying that the patient’s HIV test was positive.  Sizan (Medical Director) and I talk about broadening his antibiotic coverage.  The team had already given him ceftriaxone upon admission.  My mind stupidly floats to imipenem (a very broad spectrum and expensive antibiotic that we don’t have).  Gentamicin can’t be given due to his renal failure.  Levofloxacin would be a good choice, but we don’t have it.  We settle on ciprofloxacin and discuss renal failure dosing.  Here is a man we can help.

Someone (I forget who) comes out saying the man has passed out.   I rush in.  Unresponsive, without a pulse, I start chest compressions and ask for a bag-mask ventilator.  Our code team training in residency doesn’t prepare us for this.  There is no anesthesiologist, no STAT nurse, no EKG, no monitor.  Just you and your palms.  Hard, fast, deep.   Our training is about systematization, about ordering chaos, or at least attempting to.  There is nothing ordered or systematic about running a code today in Achham.  We will fix that, we will—but right now, we are not there yet.  Still, we can do chest compressions well.  Hard, fast, deep.  We don’t have a defibrillator; all we have are our hands and some epinephrine.   The other HAs and nurses are all there, helping.  The room does have an element of quietness that is eerie compared to the loudness of codes in the US.  Sizan asks that I switch out.  I’m impressed by the chest compression technique of the staff, and especially the readiness to quickly rotate out to avoid fatigue.

It is odd waiting for the x-ray to dry while doing CPR.   When it has dried, the x-ray shows complete opacification (“white out”) of his right lung.  Sizan correctly points out that he likely had a significant aspiration event.  Compressions are ongoing.  After some time, I remember that we do have that Welch-Allyn vitals monitor in storage that has a pulse oximeter.  We had not started using it, because without a protocol it would soon be broken or misused.  I ask for it.  It proves largely unhelpful, though I do note that it helps us to assess the quality of our CPR, based on the heart rate and oxygenation.

We give epinephrine and calcium, and then some more epinephrine.  We set up a dopamine drip after it seems his heart has re-started, after about ten minutes of CPR.  At that point we also ask for a laryngoscope to consider intubation to protect his airway, as insane as that sounds given that the nearest ventilator is about 15 hours away.  All we can find, however, is a pediatric set.  That I think is for the best, though it still feels awful not being able to make those tough decisions.

Ultimately we call the code and stop the resuscitation efforts.  His pupils are fixed and dilated.  I do my duty, listen to the heart for a minute, and assess for complete cessation of respirations.  Sizan gently informs all the men, who had come with him from his village and had gathered outside the x-ray room, of what happened.   They seem appreciative.  We chat for some time.  In the United States, one of my deepest privileges is to console patients’ families in the intensive care unit when their loved ones are dying.   In fact, it is one of the few unambiguously right things I feel that I do as a physician; most of our treatments lack evidence, but compassion-giving needs no evidence.  Here, I do not deserve such an honor.  In the emergency room, I mutely shake the hands of all his village members and touch them each on the shoulder.  They seem to understand that we tried our best.  The acceptance of death here continues to unnerve me.  A forty-two year old father of four.  We did not help this father, husband, brother.

I stupidly go back to grab the vitals machine.  The dead man is still there, without a sheet on.  Sizan comes back around and asks Urmila sister to bring a sheet in.  I bring the vitals machine to the emergency room and put it in our “respiratory” area.  We’ll have it there for now and try to protocolize it soon; it no longer belongs in storage.  I leave the emergency room.   The river looks so still below in the valley.  The setting sun is painting the hills purple, red, orange, and yellow.  Some women are gathered on the hill singing, their voices slicing through this rainbow.  I think about the mother.  What will she do now, with four children, in her dead husband’s village?

The body has been removed, and the family leaves.  I think back to the tragedy, how we could have done better.  I hesitate writing the above in such graphic detail because I do think the team performed admirably with such limited resources and experience.  We did not deliver the high quality care that this man deserved.  But tha is a systems issue and not a personal one.  We can think back on a series of “ifs:” if he came in a day earlier, if this was detected in the community, if the team had started fluids earlier, if we did better CPR.  He was so sick—acute renal failure, advanced AIDS, sepsis, pneumonia, stroke—but the bottom line is that “ifs” are not what Bayalpata Hospital needs; we need “whens.”  We need to improve our systems.  We are helping people, but we have so much to improve upon.  That, I hope, is what we can do through reflecting on these tragedies.

Usually, in the medical world, reports such as this one end with the time of death.  I don’t know what the time was.  We did not record it.

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Duncan Maru, MD, PhD is the co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.

Posted by Duncan Maru

It was a straightforward task: to measure malnutrition in the areas served by our community health workers (CHWs).  In August, we mobilized our CHWs, who went out into their communities and recorded heights and measurements for over 1500 children.  Subsequently, however, all the surveys were left in a filing cabinet and were not analyzed until I asked about it.  When I started to go through the data with our Director of Community Health, Agya Poudel, we found that 17 of 90 of the first children were malnourished, with Z-Scores of -2 or -3.  These children should have been followed-up with nutrition counseling, supplementation, and regular assessments.  Yet their data had been sitting in a filing cabinet.  Furthermore, it was demoralizing for our CHWs, who had done a tremendous amount of work without any follow-up.

There were miscommunications about using the heights and weights instead of the mid-upper-arm circumference, about what a Z-score was, and about how to follow-up identified cases.  The disaster that was our community assessment of malnutrition demonstrates a basic moral challenge of Nyaya Health: can we follow up on the health of our patients with determination and rigor?  Can we make that moral commitment to our patients?  I’ll admit that finding out about this malnutrition assessment was one of the lowest and most demoralizing moments I have ever faced in Achham.  It suggested an organization whose morality and commitment only runs skin deep.  I as a long-time leader of the organization, bear direct responsibility for enabling or even fostering such a culture.  But to emphasize: this was a management failure on the part of Nyaya, not a personal one on any individual’s part.  We failed as a team to treat the children in our survey as our own.  We acted unethically.  It is not that we as individuals failed to care, it is that we did not have the appropriate management and communication structures.  Yet from every crisis comes an opportunity.  Better management is, after all, a moral imperative.  I spoke with folks on site about this, and I do think we identified some concrete ways to avoid this tragedy in the future.  Agya and her CHW Aarti will go through all the data and will follow-up with the children who had low Z-scores.

Beyond the basic task of finalizing those data and tracking the malnourished children down, we will be taking strides to prevent such lapses in ethics from happening in the future.  We have added the following insights to our wiki.

As a team, we’ve had some tough conversations about this, and I think we are ready to do better. Mistakes are inevitable in this type of work; the question is whether we can reflect and build better systems.  I have full confidence that we can.  We will.

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Duncan Maru, MD, PhD is the co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.

Posted by Tess Panizales

During Diwali, the Festival of Lights, children gather in groups to visit households and establishments, where they dance and sing religious folk songs to celebrate and worship.

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Tess Panizales is the Quality Program Manager of the Department of Surgery at the Brigham and Women’s Hospital Center for Surgery and Public Health.

Posted by Duncan Maru

I interact with our patients briefly, in the context of a consultation by one of our clinical team members. For most of the patients with whom I consult, I will never know whether we had the right diagnosis or the right treatment.  Without a clear mechanism for following up with our patients, I cannot know if they come back alive, if we helped or harmed them.  These are such dedicated and courageous patients, and they deserve better.  They travel for up to two days, some carried by their relatives, others by their own feet, by tractor, by bus, and by jeep.  They are brothers, sisters, husbands, wives, sons, and daughters; the fabric of a society at the margins of economic and political power, trying to build a better community.  And so it is that we owe them better mechanisms to ensuring adequate follow-up.

Indeed, the very moral heart of our work here in the remote Far West is following through.  There are two distinct cultural forces that make following through so difficult for us: that of biomedicine and of international development.  The biomedical culture is fairly universal throughout the world, especially within the Nepali medical system, which places much of the onus on presentation, diagnosis, treatment, and follow-up of patients.  Within the international development community, promises are so often made without adequate moral commitment to do whatever it takes to follow through on those promises.  As I’ve written elsewhere, ideas, criticisms, promises, and plans are epidemic; what is lacking is tangible follow-through and implementation.  I am proud that our hospital does attempt to reach out, through provision of free services and through our community health worker program.  But the norm is to dispense medicine without a clear plan for following up or following through.

Our healthcare team is morally committed.  Yet translating that moral commitment into moral action requires better systems.  In discussing these problems with our Director of Community Health Agya Poudel (who has started spending more time with patients at the hospital to better understand their needs), our current Medical Director Dr. Sizan Thapa, and others, we are pursuing three avenues to make Bayalpata a more accountable hospital, and improving our capacity for following-up with patients:

1.        Patient follow-up program.  We have started a modest program to follow-up selected patients with diseases in need of rigorous follow-up.  These patients may come from the inpatient, outpatient, or emergency departments.  Please see the protocol, register, and database at the following link.

2.       Community Health Worker Referral system.  We have formally started a card system for referring patients.  This is a project that we had discussed several months ago and purchased cards for, and that we have now started to implement.  The data for this will be tallied via our current CHW database.

3.       Health post linkages.  Over the summer, members of our team conducted initial surveys of five surrounding health posts (government clinics staffed by mid-level providers).  We are formalizing this through monthly phone calls.  This is primarily for maintaining good relationships with the health posts, and to engage them in helping to follow up patients through our patient follow-up program.

Now it is time for us to demonstrate that we can truly make that moral commitment, to following through on our promise of following up.

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Duncan Maru, MD, PhD is the co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.