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Posted by Duncan Maru

A five-year-old boy presented with five days of dark-colored urine, swelling around his eyelids, and a recent rash over his left lower leg that itself had started over three weeks ago.  He lived relatively closer than many patients, a one and a half hour walk from Bayalpata.  He was brought in by his father.  The swelling around his eyes had improved considerably over the two days prior to him coming to the hospital.  He had no blood in his stool.  Our Health Assistant, Udayji, evaluated the child, who was found to have red blood cells in his urine, high blood pressure for his age (128/84), and a rash over his left leg.  His abdomen was soft.  Udayji called Dr. Sizan Thapa, our Medical Director, to assist with the case.  Fortunately, his renal function, measured by our i-Stat device, was normal.  While there were other potential causes of the inflammatory changes likely taking place in his kidneys (such as various autoimmune diseases), our team felt that this was most likely post-streptococcal (from the rash) glomerulonephritis.   The team prescribed antibiotics for the skin lesions; no other treatments were indicated.  His blood pressure was not so high that it warranted anti-hypertensive treatment, and, since he lived relatively close, he could return later in the week for us to reassess his blood pressure and kidney function.  While we didn’t have additional specialized tests, this was one child for whom I felt we had fairly adequate diagnostics and treatments at our disposal.  Unfortunately, we do not yet have a Community Health Worker (CHW) program in his village to ensure that he follows up, though we hope to be expanding our CHW network there soon.

Rash over patient’s lower left leg.

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Duncan Maru, MD, PhD is a 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

Our patients often walk or are carried several hours to receive care, and in evaluating such patients, our providers often order an x-ray.  Our providers are highly skilled in x-ray diagnosis, but, unlike most doctors in the United States and other resource-rich areas, they do not have the benefit of having all of their x-rays reviewed and read by radiologists.  Our Health Assistants in particular have tremendous experience after years of seeing upwards of forty patients a day.  Yet much of the quality data over the last decade has shown that, in the absence of implementing systematic practices, even the most experienced providers will make mistakes.  Making morning rounds with the medical team, long-time Nyaya leader Dr. Bijay Acharya and our Medical Director Dr. Sizan Thapa expressed their frustration with trying to read patient x-rays at the bedside without a viewbox, and sometimes with the wrong x-ray in the patient’s bed space.  We also had no way of providing immediate feedback to our X-Ray Technician, Dhan Bahadur Bogati.  So, we had a trial day of radiology morning rounds, where we reviewed cases with Dhan Bahadur and the whole Health Assistant team.  Over the course of the initial session, Bijay outlined a systematic approach to reading chest x-rays, which are the most common form of x-ray used in evaluating heart failure, pneumonia, emphysema, pneumothorax, tuberculosis, and several other conditions.  After that teaching, he started asking the Health Assistants if they could read the x-rays on their own, using this approach.  It went so well that we decided to institutionalize morning x-ray rounds and his approach with the following very basic protocol:

The first days of trialing have been tremendously successful.  In a hospital where there are so many challenges and problems with delivering the excellent care that our patients deserve, it is a beautiful moment when we can identify a tangible way to improve the professionalism, quality, and safety of our services.  For us here at Bayalpata Hospital, this was one of those moments.

Health Assistant Taraman Kunwar (left) explaining the chest x-ray of a patient with emphysema to Dr. Sizan Thapa (right).

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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.

Dear members of the Nyaya Health family,

I am writing you today to tell you why we must forever change the way infectious diseases are diagnosed and treated in Far-Western Nepal through a new partnership with One Day’s Wages.


That “why” for me was found in Maya, a patient at Bayalpata Hospital last October. Maya was like many of the women I’ve met in Far-Western Nepal: she was young (only 17), had ended her studies too early due to marriage (after grade 7), and had a complicated first pregnancy.  Yet it was what transpired after her second pregnancy that moved me the most.

Nyaya Health has partnered with One Day’s Wages to build Far-Western Nepal’s first microbiology laboratory.

Maya’s pregnancy was complicated by high fevers in her final week that continued after delivery.  She was treated at the district hospital, but fever persisted. A week later, Maya arrived at Bayalpata Hospital thin, pale, and with a 106-degree fever and rigors.

Our clinicians did everything possible to identify the cause with the diagnostics available to them. But the greatest tragedy was that our staff could not perform the simplest of tests to work up a fever – a blood culture. Blood culture is so critical because it enables clinicians to identify and isolate the fever-causing bacteria. Without it, specific antibiotics cannot be selected to put an end to the bacteria’s assault on the body.

But in 2011, a laboratory that provided culture tests was a luxury not afforded to the people of Far-Western Nepal. As a result, Maya was treated with broad-spectrum antibiotics and hope. Her condition worsened as her father made journeys to 3 different hospitals seeking, but failing to find, the needed diagnostic capacity. When she eventually returned to our hospital, a transfer plan was prepared. Yet even after one of the most heroic and inspiring attempts at saving a life I’ve ever witnessed – one involving global collaboration and air transfer to a tertiary care center in Kathmandu — Maya succumbed to what we believe was visceral leishmaniasis or kala azar (black fever) in an intensive care unit with our physician and her father by her side.

It was a tragic, unfair and horrifying death for a young girl. Because the truth is thathope is not a strategy we would be comfortable with if Maya were our own daughter or sister. And a comprehensive laboratory capable of performing basic culture and diagnostic tests shouldn’t be an out-of-reach luxury, no matter where you live.

Since that loss, I’ve been determined to prevent such unnecessary deaths so that we can preserve the dignity, promise, and life of patients like Maya.

As this year comes to a close, please work in partnership with us to do just that.Make a donation through One Day’s Wages, and your contribution will be matched so that we can quickly build Far-Western Nepal’s first and most comprehensive culture and diagnostic laboratory that will provide early and accurate diagnoses to a population of over 260,000 people.

With more than hope,

Ruma Rajbhandari, MD, MPH
Nyaya Health

Posted by Jesse Brady

Bayalpata Hospital's delivery room. Many deliveries have occurred in this delivery room since it's opening. It is equipped with the the most basic medical equipment necessary to ensure safe and effective maternal and child care. Upon completion of the surgical theater and implementation of surgical services at Bayalpata, cesarean sections and emergency obstetrical procedures will also be available for mothers in Achham.

 

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 Jesse Brady is the Blog Editor of Nyaya Health and is currently pursuing her MS in International Medicine at Montana State University.

Posted by Duncan Maru

A baby boy died at 36 hours of life.  I had first heard about him back at the staff quarters at around midnight, when a seven month pregnant woman had just given birth in the bathroom.   He was small, 1.5 kg.  His heart rate was very slow, and we started bag-mask ventilation quickly. The mother had been having abdominal pain and vaginal discharge for a few weeks, had received no antenatal care, and was finally brought to Bayalpata Hospital (about twelve hours away from her house) because a health worker in her village had trained briefly with us.  Arriving in labor, she was initially evaluated and stabilized in our Emergency Department.  She then got up to go to the bathroom—outside, in the dark, unconnected to the Emergency Department—and the baby precipitously delivered there.  She and the baby, blood dripping down her legs, then came back into the Emergency Department.

Bijay Acharya (one of Nyaya’s founding physicians), Sizan Thapa (Medical Director), and I took turns providing breaths.  The bag itself was clearly not as sterilized as it should be.  One of our outstanding Health Assistants, Prakash Madai placed an intravenous catheter, and our Nurse Midwife Kamala Sharma gave ampicillin, gentamicin, and hydrocortisone, and started fluids.  While providing these breaths, the team provided stimulation and used warm water bags and a radiant heater to warm the baby, as we had no infant warmer.  Use of the radiant warmer itself was made possible by our recent solar installation.  Providing bag-mask ventilation—providing breaths for a patient when they have stopped breathing on their own— has a feeling of organized hyperactivity in the teaching hospitals that I am more accustomed to.  When you are trying to resuscitate someone at Brigham or Children’s Boston, you call a code and a team of highly-trained professionals come to the bedside.  The lights are on, numerous monitors are going, the stress is high, but you are not alone.  At Bayalpata Hospital, resuscitation is different.

Makeshift warmer consisting of a radiant heater and blankets.

There is an eerie calmness during resuscitation at Bayalpata, because there is so little for you to know, so few interventions, so few tests (in his case, none that were relevant), so few monitors (actually, none), so few specialists.  Yet beneath that simplicity lies the most complex of physiologies—the dying neonate—that is essentially a black box.  And so it was that we continued to resuscitate the baby for three hours.  At one point, we thought about intubation, as ridiculous as that sounds, to bag the baby through what could be—and it is impossible to say—a finite period of respiratory distress.  Not having smaller than a 4.0 size endotracheal tube, and perhaps not knowing what else to do with ourselves as we rotated bagging this child without any monitors, Bijay fashioned one out of nasogastric tubing and a syringe.  We talked through the various scenarios and ultimate plans for this child who we were keeping alive with our most bare of resources.  Thank goodness we didn’t ultimately use that makeshift tube; the baby started breathing spontaneously.  We observed the baby for some time, and then resolved to check his vitals every fifteen minutes and see where his young life would take him.  We had little other choice.  He did well through the night and the next morning.

Somewhat predictably, he started to crash midway through his second day.  Without a neonatal monitor, it is impossible to say when he first started to have issues.  The end result however was another extensive round of bag-mask ventilation until his heart rate dropped and dropped and dropped and then stopped.  Niroj Banepali, a visiting physician who is friends with Bijay, performed chest compressions for a few minutes, after which we acknowledged that the infant had died and that our resuscitation had failed.

We conducted a mortality and morbidity conference on this baby—the first one we’ve done for several months since the recent upheavals.  I was again impressed with the teamwork and collaborative spirit.  The meeting was concrete and productive, and I hope we can implement most of the recommendations, because we can do better.  This is 2011.  A child like this just should not die.  There is essentially 100% morbidity-free survival for a child like this in the United States.  With a few basic changes—a neonatal pulse oximeter, a neonatal pressure gauge, protocols for resuscitation, a cardiac monitor, a radiant warmer—this child could very well have survived.  All of these are simple things that don’t require huge investments in financial resources.

But for this child, and for his parents, such plans are meaningless.  Bijay and Sizan talked with the parents and explained what had happened.  The parents seemed to have a certain numbness, an acceptance of life’s harshness.  From the beginning they had expected the baby to die.  The next morning the baby’s mother, with blood still on her feet from the delivery, and without any footwear, started the long walk home.  Her husband carried the baby’s small body in a plastic bag.

My mind, trained in hospital systems, in hearing of this, first thought: how can we ensure better washing facilities and sandals for our mothers?  I am appalled at my own impotent thinking.  Is that all that I can come up with?   There must be a more bold response to such abhorrent injustice and indignity.  That image cuts deep, and yet I have little else to offer.

I do know that he will be the last child to die in the old delivery room.  A few days later, Sangita sister conducted the first delivery in our new delivery suite.  We were all proud of that achievement.  But that moment of progress was too little, too late, for that brave mother making the long walk home with her bare and bloody feet and her dead child in a plastic bag.

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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

There is a new HIV diagnosis in the outpatient department for a man whose wife is dead, an infant in respiratory distress in the emergency department, an inpatient unit whose patients seem to be bathing in flies.  Another child in the emergency department fell on her elbow from a few feet and probably needs an x-ray, but the x-ray has not been charged.  The grid has been out for too long and the solar power, despite all that it has done for this hospital, is not enough for all our electrical needs right now.  There are two patients with likely multi-drug resistant tuberculosis, without community health workers in their villages and no good way for following them up.  The delivery room, for some reason, has blood that has not been cleaned off the floors.  There are expired medicines, rat-eaten equipment, broken light fixtures, and busted windows.  The entire hospital needs to be tiled.  The head of the district just stopped in.  There is a question about an ultrasound for a post-partum woman with abdominal pain; patient toilets are overflowing with feces.  The month is December and if we don’t raise $200,000 this hospital will shut down.  Oh—and the man with the new HIV diagnosis?  He also has herpes zoster over the right side of his face and possibly herpesopthalmicus which can cause blindness.  This warrants treatment with IV antiviral medication and an ophthalmologist’s expertise.  But neither can be found for over twelve hours.

One of the core skills we learn as physicians during residency is how to effectively triage.  It is impossible to do just one thing at a time.  But the nature of the job also forces us to flip from one task to another.  This need for rapid task alternation is compounded when we try to be both physicians and implementers, leaders, and managers.  My role here in remote rural Nepal is as a leader, to work with our team to generate technical and financial resources to improve this hospital.  This largely consultant role is much easier than actually being a manager.  And yet at times I have felt paralyzed.  This is a moral paralysis.  There is no question about the need for action.  Our patients are suffering and dying needlessly.  What I can do is ponder and focus back on fundamental questions: where can we take small steps forward on our systems for the future?  How can we offer tangible acts of compassion and quality care in the present?   I can see this paralysis at times in our own staff and volunteers.  We often talk so much and yet weeks later nothing has been done.  We have no shortage of wonderful ideas, but we are lacking in their implementation.   I have become impatient with the round-and-round talk over cups of tea about what we can improve.  I crave concrete, small steps with implementable work plans.  But that is not always the necessary process.  Admittedly, I am finding my writing somewhat ironic in that it is reflective rather than action-oriented.

I do see progress.  There have been moments of compassion, care, and cure.  I am proud of what we have accomplished here; proud of the skill with which our team places intravenous catheters, performs simple interventions, revives children with pneumonia and sepsis, and fixes lacerations, abscesses, and broken bones.  Our staff work hard and operate as a really inspiring team, even when facing the harshest of circumstances.  But every fly I see hovering around our patients, every broken window, every patient who needs an EKG, an oximetry reading, or a lab test and who doesn’t get it, hurts.   Our patients walk hours to get care, wait in lines, suffer the greatest of indignities, and often die needlessly.  They deserve much, much more.  They deserve actions, not ideas.  They deserve for us to overcome our paralysis and act with moral certitude.

Being a clinician is a blessing because a particular patient can bring back your focus and awake you from your moral slumber.  When one child comes in with a correctable problem that we can treat or refer appropriately; when we can perform organic fixes for concrete diseases that don’t require our floors to be tiled, our medications to be dispensed via air-tight quality control mechanisms, or tests that we don’t have.  These patients inspire us and bring us back to the task at hand: identifying small, concrete steps to build better systems.  The diagnosis—moral paralysis—has a singular cure: the eyes, brows, hands, and hearts of those people who walk up this hill, hours from their villages, asking of us that we do better.

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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

“We’re just going for a walk down the hill.”  As he passed by me, I saw a sense of pride and almost playfulness in the father’s eyes.  He seemed to relish going for a walk with his daughter on a beautiful spring day in Achham.  I had met his daughter, sixteen years old, on the inpatient ward here a few days before.  They had travelled over 36 hours to reach Bayalpata Hospital.  She had suffered progressive weakness over the course of a year to the point where she could not walk and where the use of her hands was becoming increasingly difficult.  This was the first time she had sought medical attention.

On our examination, she had diffuse spastic paraparesis throughout both her arms and legs, tongue fasiculations, and otherwise normal sensory, cerebellar, and cognitive functions.  She had no lymphadenopathy or organomegaly.  She was severely wasted from malnutrition.  All of this seemed most consistent with an Upper Motor Neuron disease such as an early form of Lou Gehrig’s disease, though definitive diagnosis of that was far beyond the capabilities of our modest lab.  X-rays of the spine and lungs, sputum and skin tests for tuberculosis, complete blood counts from our QBC machine, chemistries from our i-Stat machine, liver function tests, ESR, HIV, Hepatitis B, were all unrevealing as to a source.  We thus planned to have her seen in Nepalgunj (about fifteen hours away), where she could receive additional testing.  The travel and medical costs would surely amount to over a year’s income for his family.  Most importantly, given it was quite likely that this was a progressive, relentless condition without specific treatment, she would see a specialist to help fit her for a walker and provide other exercises.  For the severely disabled in Far Western Nepal, living—and dying, which appears quite likely in the next few years for her—with dignity is a tragically unjust challenge.

So it was that going for a walk with his daughter meant hoisting her gaunt frame on his back.  Watching her father carry her joyfully down the hill, himself barely five feet tall, I thought of the challenges ahead.  The bed sores, the pneumonias, the contractures, the frustrations of a body whose muscles are failing—all for a family whose nearest hospital was a day and a half away and who could ultimately offer them so little.  I thought, selfishly perhaps, of my own sons, of that sense of wonderment I feel in Anand and Umed when they ride on my back.  As he disappeared over the ridge, I could only hope to have the strength of that girl’s father, a man who had given me the honor of being his daughter’s physician for a brief moment in their long walk together.

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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

We had engaging x-ray rounds today at Bayalpata Hospital.  On rounds the day before, we had been frustrated by the inefficiency and low quality of reading x-rays at the patient’s bedside without a viewbox.  Viewing x-rays at the bedside also did not afford us an opportunity to give meaningful feedback to our X-ray Technician.  With the leadership of Dr. Bijay Acharya, our long-time leader, and Dr. Sizan Thapa, our current Medical Director, we instituted radiology rounds.  I have included a slideshow of some of the cases from today.  Most of the images are of excellent quality, and we were able to discuss the few that were slightly overexposed or moderately mal-positioned with Dhan Bahadur Bogati, our excellent X-ray Technician.  We leave evaluation of quality and diagnosis to the reader:



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Duncan Maru, MD, PhD is a 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 Jesse Brady

 

Bayalpata Hospital's pharmacy. Medicine at BH is provided for free. The pharmacy dispenses medicine every day to all patients who bring a prescription. This free service is intended to provide safe access to medicine, and to thereby reduce the number of citizens paying exorbitant fees to private dispensaries which often provide unnecessary or inappropriate medicine.

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 Jesse Brady is the Blog Editor of Nyaya Health and is currently pursuing her MS in International Medicine at Montana State University.

Posted by Duncan Maru

This week, a 70-year-old woman with emphysema and heart failure was admitted to Bayalpata Hospital with shortness of breath and limited ability to walk, likely related to heart failure.  She had murmurs indicative of aortic and tricuspid valve insufficiency.  Based on an echocardiogram (ultrasound) performed by our Health Assistant Uday Kshatriya and interpreted with the assistance of Dr. Sizan Thapa and Dr. Bijay Acharya, she had dysfunction on the right ventricle of her heart, muscle thickening on the left

Snapshot of Echo taken by Udayji Kshatriya, Health Assistant

ventricle, enlarged filling chambers on both side, and a dilated aorta.  He used the curvilinear probe used for abdominal exams since a rat had sadly eaten away at part of the cardiac probe.  The image, shown below, had quality sufficient to our team’s current expertise.  Fortunately, her kidney function, which we measured in our laboratory, was normal.  She has improved symptomatically with administration of lasix.  The team discussed starting digoxin but felt that without the ability to monitor levels and her poor baseline function it was not going to provide more benefits than harms.  Even before she had this acute episode, she had limited mobility and walked with a cane.  She lives several hours away; to reach our humble hospital, she undertakes quite a journey.  Her son has to carry her for an hour to reach the road, then she has to take a tractor for 30 minutes to reach a cross-roads, then a bus for 30 minutes to the main transit area in Sanfe, then another bus for 30 minutes up the hill Bayalpata. She has to wait for her vehicle at each stop.  She does this all to come to a hospital that lacks a cardiologist, a heart monitor, an EKG, or any methods of monitoring digoxin levels.  To add indignity to injury, when she is in the inpatient unit she has a hard time keeping the flies away.  Her life expectancy is quite limited, yet with appropriate management of heart failure with existing technologies, we should be able to improve both the quantity and quality of her life.  She does not live in a village covered by our community health workers.  We spoke with our Director of Community Health Agya Poudel about monitoring her blood pressure, heart rate, symptoms, and kidney function through some mechanism via the local clinics.  Yet sadly it seems that her follow-up will be largely thrust upon herself and her family.  She is one of so many patients whose inspiring and tragic stories tell us every day that we are failing in so many ways and that we need to grow effectively and rapidly—to deepen and improve upon our existing clinical and outreach services, and to expand both in the clinic and in the community.

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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

As I wrote in a recent tumblr post, it was wonderful to walk again through the halls of Bayalpata and to witness its continued transformation into a dignified hospital.  Over the course of ten months since my last trip, nearly every part of the hospital has been better organized and cleaned, making a much more dignified environment for patients and their families.  The energy room has a new battery system that is well-maintained, the new inpatient facility has artfully decorated walls, the outpatient department has new partitions, the pharmacy and registration have been separated to decrease clutter, the emergency department has become much more organized, and cleanliness in general has massively improved.  In addition to our surgical expansion, we still need to improve the patient toilet facilities, the procedure and delivery rooms, and tile the entire facility.  That will be part of our long, hard, ongoing transformation.

Yet clinical and operational challenges remain, especially in the wake of the recent staff upheavals.  I will give several examples from a recent morning on the inpatient ward led by our current Medical Director Dr. Sizan Thapa.  On this particular morning, we rounded on eleven patients.  Dr. Thapa has a calm and gentle presence that I think patients, families, and staff all appreciate.

Most of the patients, from age one month to over sixty years old, had some problem that involved insufficient oxygen supply to their tissues, from heart failure or emphysema, to pneumonia or tuberculosis.  I will focus on the evaluation and management of hypoxia as a means of framing some of our current clinical challenges.  First, we do not currently have a working pulse oximeter.  These instruments are critical for triaging the severity of patients with lung and heart diseases.  We have had several oximeters that have broken, and have made multiple attempts to re-institute their use.  We remain without a clear protocol for the clinical use of oxygen.  One patient with emphysema had oxygen flowing, while another, who was breathing more rapidly and uncomfortably, did not.  The detection of heart failure also remains challenging.  We are not appropriately recording urine output or jugular venous distension, and we are not evolving lung exams, nor discussing these topics.  Some of the chest x-rays, which are important tests for measuring fluid in the lungs, were over-exposed, rendering evaluation more difficult.  Other chest x-rays could not be found at the patient’s bedside.  Management of acute exacerbations of emphysema, which is extremely common (due to smoking and indoor air pollution), remains unstandardized in terms of antibiotic prescription and steroid use.

These observations, about areas of improvement in how we think about and manage hypoxia and its causes, in no way detract from the work of our remarkable clinical and non-clinical staff.  The hospital has come a long way, and, we hope that through reflection and action we can continue to improve.  A small victory: we agreed to start doing x-ray rounds with our X-Ray Technician each morning before inpatient rounds.  This will streamline our reading of x-rays and will enable us to provide immediate feedback to our remarkable X-ray Technician Dhan Bahadur Bogati.  If changing hospital facilities is a long, hard process, then an even deeper, longer, and more challenging progression is the transformation of clinical practice.  It starts with the most simple of interventions.

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Duncan Maru, MD, PhD is a 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

In September of 2011, Bayalpata Hospital in rural Achham, Nepal almost collapsed under the weight of its own staff discontent.  The hospital, a government facility, had been largely abandoned until 2009 when our organization Nyaya Health endeavored to open it in partnership with local and national authorities.   Since then the hospital had already seen over 75,000 patients and seemed to have broad community support.  Yet over the course of that month, led primarily by our senior clinical staff members, a broad-based staff revolt happened, with threats of strikes, black armbands, verbal outbursts, some (not severe) forms of physical violence, blatant untruths published in national newspapers by our staff physician, aggressive, racist postings on Facebook, and angry, defiant letters to the Nyaya Health Board.  It was, in short, a mental, organizational, managerial, and spiritual disaster.  Ultimately, the crisis ended, though not without the departure of our three most senior clinicians—our medical director, our staff physician, and our nurse-in-charge—and not without significant loss of morale throughout Bayalpata staff and the Nyaya Health organization as a whole.  What happened?

The purpose of this piece is to discuss the managerial and pragmatic aspects of the case, and how we have endeavored to work through the crisis.  This type of crisis is all too common throughout the world, but all too little is discussed. We do not seek to get into the more broad spiritual/philosophical questions of the role and nature of international non-profits, non-local volunteers.  That discussion is important enough, but it was largely irrelevant to us as leaders and managers trying to work through the crisis; we had already committed ourselves to Achham and went into the work knowing that these sorts of episodes would be part of the work.  Our job has always been to stay put, stay reflective, stay committed, and stay pragmatic.

For some brief background, Bayalpata Hospital is supposed to operate as an independent entity via internal management structures, though staff are paid by the non-profit Nyaya Health Nepal (NHN, which itself is funded and technically supported by Nyaya Health International (NHI).  All current staff are Nepali citizens, except for the Country Director.  The Hospital has approximately 34 staff members, and provided comprehensive inpatient, outpatient, maternal, laboratory, and radiological services, though does not have an operating room.   The operating budget is expanding, though this fiscal year will be approximately 250,000 dollars.  NHI has been supporting direct clinical services in Achham since 2008, and Bayalpata Hospital is our only project.  NHN, at this young juncture and given a history of corruption among non-profits in Nepal, is largely a legal mechanism, and though we would like it to be an autonomous entity with real leaders and decision-makers, it is not that yet.

We cannot pretend that the following is an accurate synopsis. History, particularly in times of emotional strain, is always a reconstruction.  As we have written elsewhere, there is oftentimes a fog in resource-limited settings that makes management challenging.  To protect identities and career reputations, I am not naming names.  Briefly, the conflict arose, probably predictably, over staff salaries.  That the initial spark was over salaries is not wholly surprising: most of our staff live in dire poverty, struggle to survive, to put food on the table, to educate their children.  But at every weekly staff meeting salaries are discussed.  The deeper context of this affair was that it happened during a period of leadership transition.  The Country Director of Nyaya Health International had recently arrived in Nepal, and, while an experienced and effective manager, was neither Nepali, a speaker of the Nepali language, nor a physician.   We had been unable to arrange for an effective executive assistant for him to serve as a translator.  The Medical Director had recently transitioned to pursue additional graduate studies.  This left our previous staff physician, who had served Bayalpata as an excellent clinician for the last year to step into the role of medical director, overseeing all the clinical staff, including a new staff physician we had just brought on.  Both of them were extremely young and medical school does not prepare their future doctors for either the practical or leadership aspects of rural medicine.  Around this time, staff began to express concerns about our procurement team who made a series of purchases for our inpatient unit, leaving significant wastage of money on equipment that was both overpriced and of poor quality. Many staff felt that this was frank corruption, and that the Country Director did not take enough steps to remediate or discipline.

So, a power struggle ensued.  The new Staff Physician made several demands and made exceedingly unprofessional and at times racist comments in front of staff, directly to the country director, on Facebook, and to the NHI board.  The Medical Director and nurse in charge followed suit, and the staff in general universally supported threats of a strike.  Our Country Director attempted to mediate the situation, but was met with resistance.  Threats, counterthreats, in both written and verbal form, ensued.  The hospital was an extremely toxic and demoralized environment to work in.  To our staff’s credit, services largely continued unabated.  Throughout this process, the local government, most community members, and the police were all supportive of the Hospital and intervened in key moments to help keep it running.  The other details are not too relevant here; suffice it to say, that after over four weeks of negotiations and counter-negotiations, the only solution was to have the three senior clinical members leave.  This was a great loss organizationally and personally for all involved; the Medical Director and Nurse-in-Charge had served the Hospital with distinction for over a year, had given their hearts and souls to Achham, and now were forced to leave under the most unfortunate of circumstances.  Achham, with all its suffering and isolation and poverty, has so often broken the spirits and psyches of our staff and volunteers.  While they acted unprofessionally, they were broken by Achham, and Nyaya Health did not have the support or management structures to prevent that.

Subsequently, a community meeting was held, with local community members, government leadership, and Nyaya Health Nepal’s Kathmandu-based President.  This meeting, together with the departure of the three primary leaders of the strike, calmed the situation.  Now the challenge for NHI and Bayalpata Hospital was to identify what changes in our management structures could be put in place to prevent such occurrences in the future.   In Table 1, we present the management failures on our parts, and what we are endeavoring to do as a result.   Many of these failures were owing to our youth as an organization; it does take time to develop a community and leadership base.  We hope that this table can serve as a point of departure for others to discuss the issues of managing at the margins—of learning how to be an effective employer in impoverished areas.  We belief in working in communities that are marginalized, and who live at the margins of political power, the margins of health, the margins of the economy.  Managing at these margins presents unique challenges.  I should emphasize that when I say “management” it is not about me as a leader of an international non-profit managing a hospital from afar, but rather about us as as an organizationand a team developing effective management structures to deliver excellent healthcare.

Why does our somewhat rather parochial, he-said she-said drama matter to global health delivery?  Most global health practitioners can relate that this is an all-to-common type of occurrence.   The roots, or at least the correctable parts, of these problems, are poor management structures.   Yet those very poor management structures are oftentimes not what donors, grantmakers, or the public health and scientific communities want to hear.  The dirty secrets of management are not, on the face of them, particularly inspiring; rather they seem to confirm the “rat hole” of development aid.  As a result, many of us in global health delivery oftentimes have to lead double lives, where we internally are self critical but externally have to put on an inspiring face.   As advocates, we must identify what our supporters can relate to about our work, and “Saving lives” is a much more effective tagline than “Managing at the margins”.  The truth is that we do, in fact, do both: we save lives but we also fail so much of the time to enact the right management structures that can bring out people’s strengths rather than amplify their weaknesses.

Click image to view PDF.

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Duncan Maru, MD, PhD is a 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 Jesse Brady

 

Daal, Bhath, and Tarkari, the staple diet of Nepal. In every Nepali meal, there is a portion of daal (lentils) and bhath (rice). Vegetables which are not green, such as these, are called Tarkari.

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Jesse Brady is the Blog Editor of Nyaya Health and is currently pursuing her MS in International Medicine at Montana State University.

Posted by Duncan Maru

The patient with her mother.

She arrived walking, her sandals dusty.  Her small heart, failing her, literally bounding out of her chest, somehow carried her three hours from her village and up the mountain to our small hospital in remote Achham, Nepal.  I first saw her after being called by Chanakya Timilsina, our Health Assistant, who asked that I evaluate her since her heart was racing.  She peered around her mother’s legs anxiously.  I controlled my impulse to listen her heart right there as is often practiced here, and asked that she go to the emergency department.  There, I listened to her story.  She had presented initially quite ill with upper respiratory tract symptoms and a throat infection 6 weeks ago.  At that time, she described difficulty with breathing, exercise tolerance, and palpitations over the course of several years.  Her blood tests did not suggest acute rheumatic fever.  Our medical team determined she had chronic rheumatic heart disease and started her on a regimen of penicillin every three weeks as well as daily atenolol and furosemide (heart medications).  Since then, she has been symptomatically somewhat improved, had received her shot three weeks ago, and she presented again to follow-up for her penicillin shot.

I do want to provide some of the medical aspects of her evaluation for my medical colleagues, as I think it is instructive both about our resources and about the sheer injustice of her situation.  I also think it exposes some of my own weaknesses and limitations as a doctor, which I hope my more experienced colleagues will appreciate, and how underqualified I myself am to be caring for this child in the middle of Achham.  I do apologize to our lay readers for the jargon.  She was small, anxious appearing, and ambulating.  Her height was 121 cm and her weight 19 kg (approximately -1SD weight-for-height on the WHO standard).  Her pulse was initially recorded as 140 on admission after her long walk, though on my repeated exams she was 100s-110s and was regular.  Respirations 20.  Blood pressure was 100/70.  She had no rashes or nodules, and her hair appeared healthy.  Her oropharynx was clear and mucus membranes were moist.  She had shotty anterior and posterior cervical lymphadenopathy.  Her chest was clear to auscultation bilaterally, and her breathing non-labored.  On cardiac examination, she had a palpable thrill with visible right heart heave.  She had a loud P2 without splitting, a gallop rhythm (likely S4), a 1/4 diastolic murmur at the base, a harsh, 3/6 holosystolic murmur  at the LLSB (suggestive of tricuspid regurgitation) and a blowing systolic murmur at the apex radiating to axilla (suggestive of mitral regurgitation).  She had jugular vein pressure was  approximately 12 cm H20 though I was not confident in my assessment.  Her PMI was not displaced.  Her abdomen was soft without organomegaly.  She had no peripheral edema, she had 2+ distal pulses that were not bounding, and she had no clubbing or splinter hemorrhages.  She was quite thin but without noticeable muscle wasting.

With our QBC machine, we found a white count of 16 (80% neutrophils), Hgb of 14, and platelets of 380.  Her ESR was 5.0.  Her BUN was 8.0, Cr 0.6, and potassium 3.8 from our i-Stat machine.  ASO titers were again negative.   A previous chest X-ray had demonstrated left atrial enlargement and pulmonary vascular congestion.  We performed a repeat PA and lateral which was slightly overpenetrated but approximately the same.  There was no consolidation.  We elected to use our ultrasound’s cardiac

Echocardiogram images: subcostal view, showing left atrium, mitral valve, and aorta.

probe to try to generate some images for our cardiology colleagues.  I will admit that I was torn about this owing to the fact that I am neither a sonographer nor a cardiologist, but we felt it was worth doing in case it could provide some useful information.  Note also that the cardiac probe has been partially eaten by a mouse which further compromises image quality.  So this is clearly not the kind of evaluation that this child deserves, and I do think that there is a risk of this being a “toy” rather than of actual value, given our lack of qualifications to use it.  But we felt it was worth it and the risk of ultrasound is nil.  Our Health Assistant and Sonographer Uday Kshetriya performed the exam with me.  On subcostal views, we noted a large dilated left atrium, dilated right atrium and mitral regurgitation and triscupid regurgitation jets on Doppler.  The valves both appeared thickened.  The aorta seemed normal, and we could not get a Doppler jet on it.

As such, our assessment was a 10 year old girl with long-standing symptoms of heart failure likely from rheumatic heart disease, with right-sided heart failure, tricuspid and mitral valve regurgitation, and potentially mild aortic insufficiency, presenting for follow-up from her village three hours away from the hospital by foot, recently started 6 weeks ago on a regimen of atenolol 25 mg daily, furosemide 20 mg daily, and every three-weekly benzathine penicillin 0.6 million units.  She has symptomatically improved on this regimen, and today I felt she was at an appropriate fluid volume.  We considered other measures for her heart failure, including enalapril and digoxin and changing her diuretic/beta-blocker regimen, but felt that at this juncture, given our challenges in monitoring and follow-up (no EKG, no local kidney, heart rate, and blood pressure monitoring), we would leave her regimen as is.  We would discuss with our colleagues about arranging for surgery owing to the severity of her disease and felt that she would be a good surgical candidate since her functional status was quite good, as she was not malnourished and able to walk three hours to reach the clinic.

Chest x-ray, showing large left atrium and pulmonary vascular congestion.

I asked Agya Poudel, our Director of Community Health, to discuss with the mother her diagnosis and follow-up.  My poor Nepali language skills were particularly unhelpful in understanding the mother’s Achhami Nepali, but it was clear that the mother was quite appropriately emotional about her daughter’s state.  She had heard previously from us that she needed treatment in Kathmandu, but had not had the resources to get there.  Her concern was moving in an almost therapeutic sense for both Agya and myself, having seen the “ke garne” (what can one do?) resignation of so many parents here when facing the illness and death of their children.  We asked that she come back next week to travel back with us to Kathmandu, and in the meantime we have started emailing and calling our cardiology colleagues.  Within a few hours time, we were able to secure two free tickets via our partnership with Buddha Airlines.  Such will be the long process of trying to help her remarkable but ailing heart.

These are the cases that both inspire and expose us.  This little girl is surviving against the most abhorrently unjust physiologies, suffering a condition that should have been eradicated 60 years ago, walking three hours to a hospital that could offer her so little.   She certainly deserves far more than my clinical skills.  But we will get her to Kathmandu and we will get her a surgery.  And we will continue to build better systems within our hospital to better serve our patients.

In the meantime, this ten year old’s heart, holding her mother’s hand, started to carry her way back to her village.  It would be dark by the time she reached home.

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Duncan Maru, MD, PhD is one of the co-founder’s 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.

Living and Thriving

Posted by Tess Panizales

Within the bosom of Nepal’s southwestern mountains,

lies another life, challenged by its topography.

A culture of its own, surviving, and living life

the way it has existed and cherished,

the way it has evolved and learned.

 

Trodding through the rugged path,

coddling the sick over one’s arms, or

a makeshift cradle lugged by the community.

Reaching and hoping for help.

Bearing the burden of illness, carrying on the journey.

 

Seeking and longing for care,

that the refuge ahead provides compassion and love,

that the mission to be healed is within arms reach.

For the journey was and continues to be long,

and the burden needs solace.

 

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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.