In March 2005, I flew back to Nepal to volunteer at the Dr. Megh Bahadur Parajuli Clinic recently built by Himalayan HealthCare (HHC) in Ilam, a sizable village in the eastern part of Nepal, bordered by India to the east and Tibet to the north. This was my fourth trip to Nepal in four years; the previous visits had been three-week medical treks: the first is recounted in the Prologue, the second was into the mountainous region above Ilam, and the third was to Everest base camp. Each of these treks had allowed our medical team to offer primary care to hundreds of Nepalese patients. During one of my return trips I had the good fortune of reuniting with the patients whose stories are in the Prologue. The malnourished Tamang boy from the village of Sertung, whom our medical team had taken back to Kathmandu for treatment, is healthy and resides in a boarding school in Kathmandu, where he is at the top of his class academically. His father has returned to their village and still battles alcoholism. The young Tamang woman from the village of Sertung, who went into septic shock and had to be flown to Kathmandu, is also doing well. She is back in her village with her husband, and she recently gave birth to a healthy baby. Himalayan HealthCare has lost contact with the woman from Tipling who had abdominal tuberculosis and the English gentleman who had acute appendicitis.
Since my first visit to Nepal four years ago, the political situation remains unstable and, from a number of standpoints, has worsened. The Maoist insurgency, begun in 1996, has claimed the lives of more than 12,000 Nepalese, many of them innocent people caught in the crossfire of the Maoist-government fighting. Although some of the goals of the Maoists are praiseworthy (healthcare for all, increasing the standard of living of the Nepalese people, and the end to the monarchy as a governing body), their means to obtain these goals are abhorrent. The taking up of arms, mass slaughter of police and army personnel, extortion (by way of a "war tax"), and the kidnapping and induction of young men from the rural areas into their army are all repugnant and detrimental to the country and the Nepalese way of life. Many of the rural areas in Nepal now have few, if any, teenage through middle-age males. These boys and men have either been inducted into the Maoist army or have left their villages, with many having relocated to Kathmandu for work or India for study.
The consequences of this mass exodus are significant. In the rural communities, terraces are not being planted and harvested at the usual self-sustaining rates; Kathmandu has become a congested, and increasingly polluted city, and many rural health clinics and aid projects have either been shut down or drastically scaled back. Children are not receiving immunizations and supplementary nutrition, such as vitamins and iron pills; pregnant women are not receiving prenatal care; the population in general is not receiving adequate primary care. No one has yet empirically studied the changing healthcare statistics of these rural areas, but I am sure that there will be — as in many war-torn countries — a rise in the infant and maternal mortality rates and a worsening in the overall health.
How this war has affected HHC (an organization of which I am now a board member) is also significant. HHC has had to pull its staff members from the clinic in Tipling, as well as canceling regular medical treks to two remote regions in Nepal: the Dhading region, which lies north of Kathmandu on the border of Tibet, and the mountainous region north of Ilam on the borders of Tibet and India. Furthermore, an HHC staff member was recently abducted and then released by the Maoists. Dal, the young health assistant (who had run through the pre-dawn light during my first medical trek to get to the solar phone to call the helicopter for our critically ill Tamang patient), was abducted during his two-day walk out of the mountains from the Tipling clinic to Trisuli Bazaar, the trailhead that would have taken him back to Kathmandu. Dal recounted the experience for me when I was at the Ilam clinic, where he is now stationed due to the presence of the Maoists in Tipling.
Dal reported that he was taken by armed Maoists to a camp in the hills outside of Tipling village. As a form of intimidation, he was forced to wear a chain of hand-grenades around his neck while he stood guard at the camp the first night. He was then subjected to several days of interrogation, during which time he was questioned extensively about the HHC organization. The Maoists then tried to indoctrinate him into their philosophy and army, which he bravely rejected. Fortunately, he was not harmed. Upon his release, the Maoists levied a $400 "war tax" on him and gave him and HHC thirty-five days to register with them — a form of endorsement — or to stop our healthcare programs. Anil and the HHC board decided not to capitulate to this demand and were forced to remove the medical staff from the Tipling clinic in the Dhading region.
There is no doubt that the current government's response to the Maoists, as well as some of the government's army's tactics — which have been condemned by many human rights groups — have added to the tension and bloodshed. Furthermore, the massacre four years ago of the Nepalese Royal Family by a family member and the uneasy sharing of power between the democratically elected parliament and King Gyanendra (brother of the slain King Birendra) have left Nepal in a tenuous political situation. Additional fuel was injected into this political "tinder box" on February 1, when King Gyanendra, in an effort to deal effectively with the Maoists and the country's "corrupt" politicians, declared a state of emergency. During this "power grab," as many Nepalese people have called it, the King placed a number of the elected politicians under house arrest, closed the airports to all flights, turned off all phone lines and internet connections, and severely restricted the press. It was a frightening period for those who had friends and colleagues in Nepal, eased somewhat when the airport was reopened after one day, and the phone lines and internet connections were turned on a week later. However, the tight control on the press and the Monarch's complete control of the government continue.
Despite the uncertain political situation in Nepal — and much to the concern of my family and friends — I heeded a call from Anil, the director of HHC, and headed back to help in the new HHC clinic. I landed in Kathmandu, now under a visibly higher degree of security since my visit one year ago. The number of army and police officers at the airport, as well as around the city, had increased markedly. I had one day to spend in Kathmandu with Anil, who appraised me of his feelings about the King's implementation of emergency measures, which were similar to the thoughts or other Nepalese with whom I had contact during my visit. With an amazing blend of uncertainty, courage, resolve, and humor, Anil stated that he would give the King a chance at restoring peace and prosperity. An ardent believer in democracy, Anil, like many others in his country, has put the democratic ideal on hold. Similar to U.S. citizens after September 11, the Nepalese appear to be willing to forego some of their civil liberties for the hope of peace.
While talking to Anil, an educated, successful, and articulate man, who has a brother living in the United States, I wondered if he and his family would consider immigrating to America. He touched on this thought during our conversation, saying he has considered it more frequently as the political situation in Nepal has worsened. However, he is passionately committed to the welfare of the Nepalese people, and I imagine he realizes that Nepal — albeit not the safest place to raise a family — is the best place for him to be to serve his needy countrymen.
Before I boarded a plane from Kathmandu to Ilam, Anil and I headed over to the Nepal Medical Council to get my medical license, essential for a visiting doctor in the country. This medical council resides in a rundown, low-lying cement building on a dusty lot in the heart of the city. Next to it is the medical hospital where some of the HHC pediatric patients have received heart valve surgeries at no cost, thanks to the hospital and its doctors.
Upon entering the Council, we met several international medical volunteers who were also applying to work in Nepal. I sat down beside two registered nurses from Scotland who were with a humanitarian organization whose volunteers service the villagers in the hills outside of Pokhara, a sizable city in central Nepal, known as the starting point for the fifteen-thousand tourists each year who trek the popular Annapurna circuit. The nurses described the one week "full surgical camp" they run in the villages, recounting the abdominal surgeries their volunteer foreign medical doctors perform in a week of charitable healthcare. When Anil asked how they provide their surgical patients with the vital follow-up care after the surgeons have departed, they answered, "We have ophthalmology camps that follow the surgical camps and the ophthalmologists examine the patients." After we left the Medical Council, Anil and I questioned the appropriateness of having an eye doctor evaluate an abdominal surgical patient. However, one of the true motives of these medical camps became apparent after I learned that this organization is faith-based and given to proselytizing. The government of Nepal (a country that is 85% Hindu, 10% Buddhist, and 5% Muslim and Christian) has very clear and strict rules against humanitarian groups which proselytize. However, some religious organizations ignore this rule and offer the prospect of "health and the hope of heaven".
Healthcare providers who blur the line between their personal religious beliefs and their professional obligations do the profession and, more importantly, their patients, a disservice. There are very few professions similar to medicine in which one develops such intimate and privileged knowledge about another person. Moreover, the patient comes to the healthcare provider, often in a vulnerable state, and completely trusting that he will receive beneficial medical care. There is no place in medicine for healthcare providers who take advantage of patients' helplessness by recruiting them into a religious or moral belief system that is not their own. At present, it is a reality that the vast majority of charitable healthcare given throughout the world is by religious and faith-based organizations, but it is very troublesome that some of these organizations have another motive for the healthcare they administer. Additionally, medical professionals who proselytize denigrate the profession of medicine. We are trained to be objective, nonjudgmental, and fair. When a healthcare provider subjects patients to his or her own belief system, it lessens not only the sacred patient doctor trust and the profession of medicine, but also ourselves as human beings.
As I sat down for the Council's interview, the head medical doctor, one of a half-dozen Nepalese doctors sitting across the table from me, studied my file intently. He then looked up and asked me to tell the Council members about myself. As I started a long-winded sentence about my life's work to date, he hastily cut me off and said, "Thank you, you're approved, bye, bye." As I left this interview — the quickest of my medical career — I thought to myself that if it was this easy to get approved to work medically in Nepal, I could understand why these faith-based groups can so easily offer healthcare in this country.
The next day I headed to Ilam. After an hour's flight from Kathmandu and a three-hour winding, bumpy, and dusty car ride into the tea-covered hills of eastern Nepal, I arrived at the clinic. I had the pleasant surprise of seeing not only Dal but also Kamal. Both of these HHC medical assistants had been the real heroes of the first medical trek that I was on and the reason that the young Tamang woman survived. I felt an instant renewed kinship with these two from the bond that had formed during our earlier, intense and emotional experience. Kamal, true to the lives of many Nepalese, has to earn a living separated from his wife and three children. His family resides in Tipling near the health post which HHC is no longer staffing because of the Maoist activity. For Kamal to see his family, he must travel nineteen hours by bus and then hike two days to his village. Consequently, he sees them only once every several months. Kamal is not the only young Nepalese man in this situation; there are many more who have been separated from their families in the villages for extended periods as a result of the present guerrilla war. Despite the fact that these two had been living under the strains of a decade of violence, they, like Anil, still maintain a sense of optimism and have retained their good spirits.
Dal and Kamal showed me around the impressive new clinic. Built with international funds and the hard work of the Nepalese people, the clinic is a noteworthy accomplishment. The aesthetically designed three-story building contains two examining rooms, an ER, three inpatient beds, a pharmacy and laboratory, and even a small OR. Painted white and sitting on a hill that overlooks a scenic valley and poor village, this modest clinic — as I would quickly learn — is a beacon of hope for the people in this region of Nepal.
After the tour, I met the clinic's two young Nepalese medical doctors with whom I would become close friends during the week. Mahendra and Tirtha had both been at the top of their Kathmandu medical school class, and both had come to this rural clinic to embark on an adventure, as well as to fulfill a calling — their desire to help the less fortunate in their country. I had come to Ilam for two reasons: the first was my responsibility to HHC as a board member; the second was to fill, at least for a one-week period, the clinic's still-vacant senior medical doctor position. Because my medical school and residency training had been eighteen months longer than Mahendra's and Tirtha's training, I was designated their senior.
Prior to my arrival, the clinic had announced to the village that an American doctor was coming. This had generated a large amount of interest, so much so that there were several patients waiting for me the evening I arrived, a day before I was scheduled to start to see patients. It reminded me of my first trek four years before when we had arrived at the Tipling clinic to find a long line of patients waiting to be seen. That trek, because of the severity of illness of the Tamang woman, had been the most medically and emotionally trying. My second and third treks to Nepal had been less intense and had allowed me to offer the basics in primary care and the time needed to instruct our patients in preventive medicine. No patients on these two treks were critically ill. But this volunteer experience at the Ilam clinic would change all that, casting me back once again into the role of an emergency and critical-care physician — a role accompanied by intensity and emotion.
So, on the evening of my first day we started to see patients. A few of the first patients we examined had what I had learned from my prior treks to be common ailments in Nepal, namely, gastritis, worms, anemia, and arthritis. In addition, in what I came to see as a regular occurrence that week, many patients came to me for a second opinion. Prior to my visit, these patients had seen either Mahendra or Tirtha and now had returned to inquire if I agreed with the initial diagnosis. One patient was even so bold as to ask me to read one of the doctor's notes and tell her what it said. I politely declined her request and, after examining her, I told her that I agreed with the doctor's assessment. Mahendra and Tirtha said that this would be a common occurrence now that the villagers knew that there was an American doctor at the clinic.
Until I arrived, the clinic had seen an average of twenty patients a day and had admitted only one inpatient. All this changed after I arrived. The next morning, as Mahendra, Tirtha, and I went for our early morning meal at the canteen, we noticed that the patients had already begun to line up. After our meal, Mahendra and Tirtha informed me that all of the patients wanted to be seen by me. To manage this in the most efficient manner, we had each doctor present his patients' histories to me and then we performed the physical exam together, thereby allowing us to get through the fifty patients we would see each day.
One of the first patients reminded me of the critically ill Tamang patient mentioned earlier. Like that patient she had come to the Ilam clinic with a fever and was complaining of back and pelvic pain. She, too, had had a spontaneous miscarriage (her fifth of six pregnancies) three weeks prior to this visit. Over the last week her condition had worsened. Her medical history and physical exam, which elicited pelvic pain, suggested a diagnosis of endometritis. Unlike the Tamang woman's, this patient's vital signs, fortunately, were normal, and she had not started to show signs of septicemia. To avoid any further worsening of her condition, we admitted her, and she became our first inpatient. We started her on two broad spectrum antibiotics and began an IV for hydration. Her story became more interesting when we discovered that her hemoglobin was very low (5.1 g/dl instead of within the normal range 12-15), which meant that she was severely anemic; essentially, the oxygen carrying capacity of her blood was one-third that of a normal person. Her anemia was clearly chronic in nature; a person with a hemoglobin level this low who is not complaining of dizziness — and is able to stand — has developed the ability to compensate for low hemoglobin over at least a several-month period. Furthermore, since she had lost five pregnancies in as many years — most likely as a result of her anemia — we surmised that she had been anemic for some time.
Her condition started to improve with antibiotics and IV fluids, but she would also need four units of blood. Interestingly, the village's Red Cross blood service, for lack of refrigeration, has to rely on volunteers to donate blood at the time a patient needs the blood. So the blood bank developed a list of all the names and blood types of the villagers willing to donate. After a small sample of the patient's blood is drawn, it is "typed and crossed" against a small sample of blood that is drawn from each of several villagers who share the same blood type. Once the best matches are found, the chosen donors each give one pint of blood. It was from the generosity of these villagers that we were able to quickly start her on two of the four units she needed, thus helping us avoid any further deterioration in her medical condition.
That first day, as with each day of the coming week, we saw a number of patients who came to the clinic for a "second opinion." As before, most of these patients had already been evaluated earlier that week by Mahendra or Tirtha, and some had even been examined by specialists in a number of Kathmandu's teaching hospitals. It struck me as peculiar that these patients would assume that I, a general practitioner, would know more about their specific disease than a specialist. For all of these second opinion cases, I reviewed each doctor's assessment and medical plan for each patient and found all to be accurate and sound. In each case, I went out of my way to inform the patient that I agreed with his or her doctor's diagnosis, and told all of them to trust these accomplished medical professionals.
Our most seriously ill patient came into the clinic after we had completed our schedule for the day. She was a sixty-four-year-old woman brought in by her daughter and son-in-law. Her family had waited two days after her initial onset of worsening respiratory distress to bring her to the clinic because the patient had emphatically stated to her family, "I'll wait until the American doctor arrives." When she sat down in front of us, we knew right away that she would be admitted to our inpatient ward. Her respiration rate of thirty-five breaths per minute and her signs and symptoms of respiratory distress dramatically indicated her need for hospitalization. She had a history of hypertension and gout, and a cardiologist in Kathmandu had recently discontinued her digoxin, a medicine that helps regulate both the pace and strength of each heartbeat. On examination, her lungs were clear, her heart rate of ninety beats per minute was in the normal range, and her blood-oxygen saturation was normal. The increased rate of breathing at this point was unexplained; we surmised from her pale conjunctiva that she was anemic and would need a blood transfusion to correct her increased respiratory rate. We admitted her to one of our inpatient beds, drew her blood, ordered a chest X-ray, and did an EKG. We read the EKG before going to dinner and were alarmed to find that it showed an occasional premature ventricular contraction (PVC).
PVCs, as the name implies, are contractions that happen in the heart's ventricles at an irregular or premature time. These aberrant contractions are usually triggered by an area in the heart's ventricle that is irritable. (This is opposed to a normal ventricle contraction that is triggered by the atrioventricular node, one of the heart's steady pacemakers.) The irritability in the heart's ventricle can be due to a number of reasons, but hypokalemia (low potassium) and hypoxemia are two of the most common causes. If her PVCs were due to hypokalemia we could correct the condition fairly easily with potassium supplements. However, if this arrhythmia was triggered from an area in her heart that was now hypoxic or, worst yet, ischemic (in other words she was having a myocardial infarction or heart attack), the laboratory, unfortunately, did not have the capability to analyze her cardiac enzymes — the crucial blood test that would allow us to monitor and treat her heart attack. At present she was having approximately seven PVCs a minute. This frequency was enough for us to be concerned, but we felt we did not need to intervene — at least not yet. However, if the frequency of her PVCs increased, or if they began to occur in couplets or triplets, we would have to intercede, for at this point her heart could easily go into ventricular tachycardia, and she, most likely, would die.
Since this patient's admission, her labored breathing and respiration rate had increased slightly, and we began to hear wheezing. We gave her an aerosolized albuterol treatment to help dilate her airway, and we continued oxygen. Based on the patient's difficulty with breathing, I knew that if we could not find and correct the underlying cause of her respiratory distress, she would need to be intubated, but the clinic did not have a respirator. So, if she went into respiratory failure, our best chance of saving her would be to manually oxygenate her with a resuscitation bag. Manually oxygenating someone is physically taxing, and needs several people, continually taking turns, to effectively perform the procedure for extended periods of time. However, that part would be the least of our worries, for we would still have to transport her to the nearest major hospital, a four-hour drive out of the mountains on a steep, winding, and uneven road. If she did not die from the lack of adequate ventilation, then the ride would probably kill her.
The other doctors and I were hoping that the laboratory results would show that she was anemic, a condition we could easily correct with the goodwill and donation of a pint of blood from each of two or three villagers. But, when Mahendra informed me that the Red Cross lab technician was out of the village for the day, I began to worry. I wondered if there was anyone in town with type "O-negative" blood, the universal donor blood in an emergency situation. Much to my distress, the village's blood bank list was not available. At this time of the day it was still light, and the four-hour drive to the teaching hospital in the terai (the lowlands in southern Nepal) was still an option, although the drive out of the mountains would be extremely difficult.
After leaving my dinner untouched because I was so nervous about this patient's condition, I sat with the other doctors and reviewed a series of plans that we would take for each possible blood test result. At this point the blood work came back, and we were surprised to see that she was only mildly anemic (hemoglobin of 9.8 g/dl), not enough to explain her worsening respiratory state. But the blood work did show that she was hypokalemic with a potassium level of 2.5 mEg/l (normal is 3.5-5.1 mEg/l), a possible explanation for her cardiac arrhythmia, which now had ominously worsened with her PVCs having increased in frequency to twenty times per minute. What was more worrisome, however, was the fact that these PVCs were now coming in couplets. We quickly administered her potassium through the IV and went to review her X-ray.
The X-ray equipment at the clinic is rather rudimentary. Unlike the U.S. state-of-the-art digital X-ray equipment with images that can be transmitted over a phone line to any computer inside or outside the hospital, this X-ray machine, purchased in India for a few thousand U.S. dollars, still uses actual film. The technician develops each X-ray by hand and often gave us the films still wet, straight from the fixer and wash baths. Although the X-ray facility is antiquated, for this case it was more than adequate and it gave us some telling information about her — she had a massive heart. The silhouette of a normal heart on an X-ray film spans about one-third the distance between the patient's left and right chest walls. Her heart's silhouette filled more than three-quarters of this distance, which meant that she had massive dilated cardiomyopathy (DCM). In the majority of cases the etiology of DCM is unknown, but alcohol use and viral infections are fairly common causes. Her heart's ventricles had been enlarging for many years, and had finally reached the point where they could not adequately pump blood to her body — or even her own heart — thus putting her into heart failure.
Over the next several hours, even with the administration of a strong diuretic (Lasix), IV potassium, continual aerosolized albuterol treatments, and two broad spectrum IV antibiotics given for a possible pneumonia, her condition deteriorated. She became more hypoxic, her respiratory rate increased, and her cardiac arrhythmia worsened.
By now it was early evening and the sun was setting. With her condition declining and our only hope of getting her to a cardiac unit in a hospital all but dimmed, we decided to consult by phone a cardiologist in Kathmandu. He was a friend of Anil's and had been both Mahendra's and Tirtha's medical school professor. He informed us that even if we had wanted to take her to the closest hospital, it was not an option; the Maoists, in one of their more annoying anarchistic practices, had blocked the main road to the town where this hospital was located. He suggested that we continue managing her as we had done and to add another blood pressure lowering medicine (ace inhibitor), nitrates to dilate the coronary arteries, and heparin to help decrease the chance that her failing and inefficient heart would form and release a life threatening blood clot. We gave her the ace inhibitor, but did not have nitrates in the clinic. We could not give her the blood-thinning heparin because we did not have the ability in our laboratory to monitor her coagulation factors. Giving her heparin "blindly" would have been too risky. If we had thinned her blood too much she could have bled to death. Our conservative approach was the proper path to take. In the event that she developed a blood clot, we would manage it at that time.
In much the same way my critical care attending during my intern year had guided me toward the realization that Shari, my patient with AIDS, was going to die, I took Mahendra and Tirtha aside and gently let them know how grave our patient's condition was. But unlike my situation as an intern, Mahendra and Tirtha knew this patient's worsening medical condition and did not need my suggestion that they should alert the family for the possibility that she might not make it until the morning light. As I watched Mahendra, a young, caring, and sensitive doctor, rehearse what he was going to say to the family, I could see his eyes well up with tears. This moment took me back to my intern year and the deep and complex emotions that I, too, had felt so many times. His emotional investment in his patients was both inspiring to see and emotionally trying to watch. My heart went out to him.
One thought that had been going through my mind during this day, and was increasing as this woman's health grew more and more critical, was her words to her family two days prior, "I'll wait until the American doctor arrives." There is no doubt that in Nepal there is a mystique about foreign medical doctors, and perhaps even more about American doctors, but as I watched Mahendra and Tirtha carefully and skillfully handle every aspect of her care — with me only asking simple questions — I realized that these two doctors had done everything that I would have done for her, and perhaps even more. In addition, I realized that her decision to wait two days for care might have been the difference between life and death. If she pulled through, I would forget all about her decision to delay coming to the clinic. If she did not make it, it would have been one of the many indelible marks that this profession leaves on us caregivers.
The meeting between Mahendra, Tirtha, and the family went well, and Mahendra, with great sensitivity, explained the critical condition of the patient. The family's wishes at this point were not to try to transfer her to another hospital, but in the event that she went into cardiac arrest they wanted us to perform CPR. If this scenario ever transpired, we would then be obliged to transport her out of the mountains, encountering the Maoists' roadblock. The thought of managing her medically did not bother me, but negotiating with a Maoist guerilla at gun-point was disquieting.
With unease, we watched our patient closely throughout the evening. We administered serial aerosolized albuterol treatments, supported her with supplementary oxygen, and did frequent lung exams. In the early morning of the next day, remarkably, her lungs started to sound a little better; the Lasix, breathing treatments, and antibiotics had had time to improve her respiratory condition. During the next hours her condition decompensated several times, which necessitated our administering additional breathing treatments and keeping a close eye on her. Nevertheless, by the morning she had stabilized. Over the next day she showed slow but steady improvement, and with each passing day she sounded and looked better. Near the end of the week we weaned her off oxygen, and soon thereafter she began to sip homemade soup her family had brought. On my last day in Ilam, she took a short stroll around the courtyard of the clinic.
As with Shari, I was both relieved and surprised to see her survive. It reconfirmed in me the humble lesson that I have continually relearned: I, thankfully, am a terribly inaccurate predictor of death. Unlike Shari, this Nepalese woman did not have all of modern medicine available when we were treating her. We lacked some important basic medicines, were not able to follow certain laboratory results, and surely would have lost if we had been forced to perform CPR or manually ventilate her. However, she survived, and this fact reconfirms a lesson that I have known since intern year of residency: it is nature that heals people. Doctors and nurses can facilitate nature, but it is nature that does the healing.
This was the first of many difficult cases we managed during the week. The breadth of medical cases and diseases we saw in the clinic was impressive, including: diabetes, hypertension, anemia, pneumonia, prolapsed uteruses, infertility, gall stones, acute abdominal pain (which was diagnosed as an ovarian mass with the ultrasound by Tirtha), amenorrhea, depression, and congenital disorders, not to mention the common complaints of arthritis, gastritis, and worms — a far cry from my South Side of Chicago clinic where I normally see only diabetes and hypertension, and perform physicals on healthy children.
With this increased number of villagers coming to the clinic, inevitably there were a number who were sick enough to be admitted. Our inpatient ward, which had three beds, was filled the first night. By the second night we had six inpatients, which required use of the ER and ultrasound rooms to house them. The inpatients were also complex cases. We had a woman who presented to us with headaches, nausea and vomiting, increased blood pressure, and a low pulse rate. Mahendra quickly, and I think accurately, diagnosed her with increased intracranial pressure, a disease process that I had not seen since my medical school days. We also had one woman suffering from dehydration, a result of her nausea and vomiting from her chemotherapy for breast cancer, and two women with pneumonia. Our days were busy, and our nights were long and sleepless with the three of us taking turns checking on the patients.
As the week progressed, I continually witnessed the fine medical skills and knowledge that both Mahendra and Tirtha possessed. Both were accomplished medical doctors, with Mahendra excelling at the internal medicine cases and Tirtha adept on the ultrasound machine. I also quickly realized that we were functioning as equals; I was not their senior medical doctor. Their histories, examinations, diagnoses, and management of the patients were well done. And during this week, I found myself increasingly taking a back seat to their management of the patients, often relegating myself to my familiar role of informing the patient at the end of the visit that Mahendra's and Tirtha's plan for them was correct, and they should trust these fine Nepalese doctors — making my point as directly as possible.
Mahendra and Tirtha were quite aware of the patients' preference to see me during this week; nevertheless, it did not diminish their self-confidence or alter their interactions with the patients. In fact, they found it amusing at times. One case, which brought smiles, involved a patient who had come to the clinic with the complaint of pain in both knees. After a thorough lower extremity exam, Tirtha correctly diagnosed the patient with degenerative joint disease (arthritis) and gave him a prescription for a pain medication. Tirtha, with a twinkle in his eye, asked me, "Can you listen to the patient's heart and lungs before he leaves, or he will not be satisfied with his visit." I placed my stethoscope on the patient's chest wall and then back, hearing normal heart and lung sounds. "Sounds like arthritis to me," I said smiling at the patient. The patient then broke into a wide toothless smile, thanked me, and then left looking quite satisfied.
At the end of my last day at the clinic we had a farewell dinner with the whole medical staff. I commented how impressed I was with all of them, but especially how well trained I felt the Nepalese doctors were. I specifically mentioned that I was confident that this medical staff could handle almost any situation. This comment would eerily foreshadow an upcoming event.
I thought that, after dinner, the other doctors and I were going to have a relaxed evening and a chance to chat about our busy week, but as we were leaving the canteen the ambulance pulled up to the clinic. The attendant jumped out and, with the help of one of the nurses, quickly wheeled the patient into the clinic. As Mahendra, Tirtha, and I entered the ER and looked at the young, petite woman, we realized that she was one of the employees of the clinic. She lay on the gurney with her eyes rolled back and her teeth clenched — seizing. From the fact that her husband had found her at their home in this condition, we knew that she had been seizing nonstop for over thirty minutes. She was in status epilepticus, a true medical emergency. Most seizures last only a few minutes and then are followed by a postictal period when the patient is quite somnolent and sleepy. Status epilepticus can continue indefinitely, and therein lies the problem. Nonstop seizures can cause permanent brain damage or death. There is a real urgency to stopping a patient's seizure that is "status."
Our exam showed that her respiration rate was normal, her lungs were clear, and her blood-oxygen saturation level was within the normal range which gave us confidence that she had not swallowed her tongue. To ensure that this would not happen, we attempted to insert a tongue protector into her mouth, but her teeth were clenched too tightly. The next task, which we had to do as quickly as possible, was to stop her seizures. This meant inserting an IV into one of the veins in her arm and then administering her both a sedative (Ativan) and a loading dose of an antiepileptic medication (Phenytoin). Placing an IV into a small vein is tricky in any patient, but extremely difficult in a patient who is seizing. The nurse and Mahendra tried to get access into one arm, while I tried on the other; all were failures. Mahendra then tried to get access into a vein in her ankle, also without success.
By this time she had been seizing for at least forty minutes. It now became a dire need to get IV access. I offered to try to place a subclavian venous line, which entails inserting a large bore needle under the collar bone and into the large vein that runs just superior to the apex of the lung. When Mahendra heard this he looked up at me with surprise. "You can do that?" he asked. I had done many during residency training, but I had not attempted one in over three years. This procedure, if done inaccurately, can puncture the patient's pleura space, allowing air in between the lung and chest wall (pneumothorax) causing the lung to collapse, a major complication we wanted to avoid. Thankfully, Mahendra gained access to a vein in her ankle after we discussed the risks of the procedure. He then injected five milligrams of Ativan into her vein, but then, frustratingly, the vein ruptured, and we lost our IV access. We held pressure on the site and hoped that the Ativan was traveling up to her brain and would soon end her seizures.
We waited about ten minutes, all the while trying again to gain access into any vein in either arm. After it was apparent that the Ativan was not stopping her seizures, we knew that we needed to gain IV access again to repeat another five milligram dose of the same drug as well as load her with Phenytoin. While Tirtha frantically tried to insert a line into her hand, and all of us worrying that she might be suffering from anoxic encephalopathy, it crossed my mind that we might have to do a venous cut-down on her to get access. In this procedure you make a deep scalpel cut into the ankle and then isolate an accessible vein. In my medical school and residency training I had never seen this procedure done and had only read about it. The idea of attempting it made me pause with apprehension, but I was saved again when Tirtha announced that he had gained access into her hand. He then asked a nurse to tape the line securely in place. But, as misfortune would have it, at that instant the power went out in the hospital.
In Nepal, power outages are a regular occurrence, and in the mountains they are even more frequent. Sometimes the cause is a tree that has fallen on the line, but increasingly it has been the Maoists who have disrupted the flow of electricity. With luck, outages are short, but they can last for days.
As we stood in the darkness, there was complete silence momentarily. Then I heard Tirtha, a soft-spoken and mild-mannered Hindu exclaim, "God Bless it! This damn hospital!" Mahendra then yelled, "Get me a torch." I heard someone scrambling around me, and then a weak and fading neon flashlight was turned on and directed at the patient. Remarkably, Tirtha was able to hold the IV line in place throughout the darkness and while she was seizing. One of the nurses quickly secured the line to her hand, and we administered the additional dose of Ativan and the Phenytoin bolus to the patient, but this vein also ruptured while we were administering the final few milliliters of the second medication.
We had now given her all of the medications that we had available to us. Without IV access, we stood there exhausted and seemingly defeated. All we could do, once again, was wait and hope that these medicines were traveling up her arm and into her brain, and not sitting in the interstitial tissue around her ruptured vein. Perhaps the Hindu God Ganesh (good luck) was looking down on us at this moment, for in the faint, flickering light of the neon torch we saw her seizures start to wane slightly; then her arms, which had been tightly contracted against her chest, relaxed; finally, her jaw went slack. She had stopped seizing.
Soon the lights came back on. With the patient now motionless and in a deep sleep, the nurse was able to get an IV line into her cubitus allowing us to give her a bolus of glucose, on the chance that she had been seizing because of hypoglycemia. We then started her on a Phenytoin IV drip to maintain an adequate level of this antiepileptic medication in her blood. With her jaw now relaxed, we attempted to suction the secretions out of her mouth. This caused her to gag, a hopeful sign — neurologically at least — that her brainstem was intact. Later she aroused a bit from her groggy and postictal state and was able to follow the simple command of sticking out her tongue, also a hopeful sign that she had at least some higher cortical or cerebral brain functions intact. However, we would not know until the morning, after she had had time to sleep off the Ativan, whether she would have any enduring neurological deficits from the prolonged seizures. With her seizures now under control, we stepped out of the room to collect ourselves.
Working in emergency or critical care medicine often exposes the caregiver to an emotionally charged environment. When the patient whom you are trying to save is one of "your own," it, of course, increases the tensions. There were many moments during this frantic episode when everyone in the ER thought that we might lose her. Their frightened looks and adrenaline-dilated pupils gave away their innermost fears. I had not seen this emotional response in the staff at any other time. Despite the staff's fears, they were able to choke back the emotions which normally may have interfered with the execution of their duties. Indeed, they worked very well and effectively together. Now with the patient stable and her care in the able hands of Mahendra, Tirtha, and the medical staff — I took my tired body to my room and fell fast asleep.
I left Ilam early the next morning for the four-hour drive back to the terai and then to the series of flights that would take twenty hours and bring me back to my home in Chicago. I bid a warm goodbye to Mahendra and Tirtha. We had been through a lot in the last week, and we had grown to be good friends. I think that the ultimate compliment that one doctor can pay another doctor is to allow him to be his personal physician. If I had taken ill during my stay in Nepal, I would not have said, "I'll wait until the American doctor arrives," I would have placed my complete trust in both Mahendra's and Tirtha's ability to care for me.
As I traveled in the local minivan taxi down the steep, winding mountain road and watched the tea plantations glide by, I struck up a conversation with one of the locals in the cab. Having intimate knowledge of Ilam and the surrounding areas, he informed me that several people from villages outside of Ilam had told him yesterday that the government's army had begun a campaign in their villages to kill the Maoists and break their stronghold in this part of Nepal. (With a virtual clampdown on the Nepalese newspapers, news was carried by word of mouth.) Knowing this continual army-insurgent violence would inevitably, and regrettably, injure or kill innocent bystanders caught in the crossfire of this war, I wondered if some of the injured might be on their way to the clinic to be treated. If so, I knew the staff could handle the situation well. This thought of the clinic staff's competency provided a sense of comfort as I left this great country and wonderful people, who have had to endure so much pain and suffering.