Posted by Micheal Polifka
This post was written by Dr. Michael Polifka, Nyaya team volunteer, as a personal journal entry during a recent trip to Bayalpata Hospital in Achham, Nepal.
The varying amounts of moisture in the air (from a lot to more) coupled with the winds that circulate around the hilltops makes for constantly changing mood of the view of the river valley and surrounding hills in both the early morning and setting sunlight that is ever beautiful. Today, the fog extends up the hill from the river bed so that little of the mountains across are visible. The swallows are still seemingly happy as they chirp and do their sharp aerial acrobats right outside my room while several sitting on a wire just outside my open shutter wonder what my tooth brushing is all about. This morning while having my usual breakfast of roti that I fill with a aromatic chick pea stew, Amir, one of my Nepali colleagues, brings an xray for me to look at while I am waiting for my chiya to cool down enough to take a sip. A six year old girl was brought by her father into the ER this morning after walking for five hours having fallen and landed with her body weight on her flexed left elbow a day and a half ago. Looking up at us from a bench the father is obviously stressed from his daughter’s pain and a long walk through the night. The xray unfortunately shows that the child has shattered her elbow and is at real risk to a life long disability from a non-functional joint without operative management, available only a 15 hours bus ride away. Amir explains the needed referral to the father, who responds that he doesn’t have the funds for such care. And so Amir and I discuss the best way to cast her elbow knowing that likely it will be frozen in that position for life. ‘Fortunately’ it is her left, unclean arm (people eat only with their right hand here) . As the father mulls over and over the long term dilemma he will face when his daughter is at an age for marriage and she is less than fully functional and the guilt he must feel of not being able to provide even basics for his young daughter. The emotional stress is so clear in his right eye; you see quite awhile ago he was traumatically blinded in his left one. He has been through a similar circumstance before.
Rounds start with Bikash, the other Nepali physician, thereafter first in the four bed ER then to the six bed inpatient ward. First is an elderly woman with chronic lung disease, from a life long combination of exposure to cooking fire and cigarette smoke, who has acute pneumonia. In the next bed is a small one month old infant also in respiratory distress but more severe. The mother, legs crossed, sits on the bed holds the swaddled infant in her arms. Obviously malnourished, the tiny child’s chest retracts with each rapid breath, it’s face completely covered by the oxygen mask. As Bikash is talking with the parents, I notice the handle of a small sickle sticking out of the back of her sari. Taraman, the PA explains that she keeps it there to ward off evil spirits from the child. Seeing how terribly sick the infant is, I think quietly he’ll need all the help he can get. I am surprised that the next bed is empty. Yesterday a drunk young man fell from a thirty to fifty foot height and was brought in by a friend. His left leg was both numb and weak; and his xray showed a spine fracture. Desperately his family had taken him from the hospital in the night and were planning on taking him to a hospital in India, at least 30 jarring hours away by bus, where they hoped they could find him advanced care.
Next is a middle aged woman with pneumonia and dilated heart failure who is improving; she has classic deformity of leprosy of her right hand, fortunately the only permanent defect before being treated; that her current problem would be so straight forward to treat. Then a 14 year boy with abdominal pain, a 20 year woman who delivering a healthy child in the hospital several hours ago will be observed and discharged in a few more hours, and last a 40 year woman gored by her bull in her genital area two days ago that she was attempting to feed grass. She had more stitches than one could count by Bikash two days ago and is now on large doses of antibiotics to try to prevent a secondary infection.
We all go then to the outpatient area, where there are 150 patients to be seen. Here I move from provider table to table, to discuss the wide variety of cases that present to them. A woman with malaria she caught in India was only partially treated now recurring, we discuss why; an 18 year boy with clinically apparent mononucleosis, we discuss the physical exam findings; a 35 year man with a lemon size benign tumor on inner thigh, that I lead Amir through surgical removal tomorrow afternoon. And then an elderly woman with a large abdominal mass, almost certainly a cancer, whose almost cheerful response to a clear but simple explanation radiates a long and simple life kept in balance. Most cases are straight forward though some are frustrating because of the limitation of resources here in this remarkable outpost that attempts to bring up to date medicine to the rural poor. Just before lunch Bikash asks me to see an 18 month old girl who 3 days ago drank from a stream and now has a leach deep in her nose (this is a new one for me). So I brain storm a bit and figure out a non traumatic way to get it out. There are big smiles all around when it actually works.
As I am leaving for brief lunch, I return and see Amir and Megha doing CPR on the little one month old that we saw earlier on rounds. After ten minutes we stop, efforts were that futile even from the start. The parents response is universal when told; tragically this is the second child that has died, the first was at 3 months of age. Their agony is expressed in a sing song wailing chant that is joined in by a dozen family relatives who were waiting just outside. Under the metal roof of the hospital the noise is deafening, perhaps it drowns out the agony of the parents momentarily. I stay on the far side of the room silent and tearful trying to absorb some of this aspect of their culture. After ½ hour they proceed out, the child’s uncle holding him, of the back door and down the hill. The room now suddenly quiet, I notice the mother’s small curved knife on the now otherwise empty hospital bed; I guess the evil spirit wasn’t deterred.
As I am waiting for the food to be served, I look out of the kitchen window. There are 6 bare foot boys who had been playing cricket; their game came to a grinding halt when 10 or so cows obviously weren’t able to tell the difference between a grazing area and a make shift cricket pitch. The cattle responded very slowly to their yelling and pushing, apparently the grass was greener on this side. Smiling to myself at the scene, I couldn’t also help but be aware of the contrast to the tragedy just minutes before.
The afternoon was as busy as the morning and went by in a flash. First, we review a chest xray with finding of TB. Then we review the thankfully negative HIV test of the 9 month old who had been breast fed by an HIV positive mother. (Virtually all HIV positive women here contract their illness from their spouse who have been to India to work for extended periods. Typically they learn of his illness only when he dies of AIDS). I am delighted to see a patient with rheumatoid arthritis that I had seen six months ago. She was the first patient that was started on a protocol for disease remitting therapy and is doing really well. Later is a 14 year boy who is two months into treatment for leprosy, he too is doing well, without any more clinically apparent disease. There are many others with less complex problems, but I always try to find some relevant clinical point to review. The last of the day is a 12 year boy who at 1 ½ years had head trauma and was left with a seizure disorder, untreated since then. Three years ago during one of his daily three to five seizures he severely burned his dominant right hand. Untreated and now with severe contractured scarring, Amir and I are impressed by his positive spirit. He proudly writes his name with both hands in both English and Nepali. We discuss his seizure treatment, Amir will arrange for the boy to see a plastic surgeon.
In the early evening I stand outside my room and watch across the valley as a storm moves in. Lightening above the clouds, moonlight behind me, the wind picks up as clouds darken the sky. As I go inside the wind suddenly increases, and seems to be blowing inward from the two windows and door, each being on a different wall of the room. I close the shutters and climb into bed as the rain begins to pound, but in spite of the storm outside, I am peacefully content about today’s work and am soon asleep. Some work days stand out more than others; this was one of them.
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Dr. Polifka is a physician volunteer who recently worked at Bayalpata Hospital, Accham.
Tags: Achham, Bayalpata Hospital, Far West, Fracture, global development, global health delivery, global mortality assessment, Health equity, healthcare, HIV, Michael Polifka, Nepal, NGO, Nyaya Health, rural health, rural life
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