58 years old male from Khung-1, Pyuthan came to our OPD with complains of fever for 2-3 weeks, pain in right side of chest with productive cough. He also had loss of appetite and loss of weight. On examination his temperature was 99° F, pulse rate 92/min and BP 110/70mmHg. On chest examination there were decreased breath sounds on right side of chest. Other examination was within normal limit.
Blood investigations, chest X-ray and Sputum for AFB (for PTB) were ordered. TLC 15,500/mm3 (N73L26E1), Platelet 3,70,000/mm3. Chest X-ray showed opacity in right lung with air-fluid level suggestive of hydropneumothorax/ pyopneumothorax.
To make sure what is inside I aspirated with a syringe and got thick pus, so the diagnosis was made Pyo-pneumothorax (collection of pus and air inside the lung). For definite treatment the pus should be drained with a pipe inside the chest, it’s called chest tube insertion and drainage and intravenous antibiotics. We all know that ideally money shouldn’t be the issue between the patient and the health worker. But he had only 1-2 thousand rupees with him. This is how most of our patient comes to the district hospital. It is the scenario of every government hospital in rural areas. He even didn’t have any family member to accompany. He had come to hospital thinking he will get some tablets and cough syrup and he will return back. We told him about his condition, what needs to be done and asked him to call his wife to come to hospital. He said, “She has to stay home to look after home and the cattle.”
After taking informed written consent, we gave him Inj. Cefuroxime, Inj. Metronidazole and under local anesthesia, we inserted a 32 no. chest tube in his right chest. A gush of thick pus came, about 550ml of pus was drained and it was attached with a bag with water seal. He was admitted under Inj. Cefuroxime, Inj. Metronidazole, Tab. Levofloxacin, Analgesics, Aciloc. Later his sputum report came which showed positive for pulmonary tuberculosis, so Anti-tubercular drugs were started.
He couldn’t afford the treatment so we did all for free. If we have had relied only on government free supply we wouldn’t be able to manage this case in a district hospital. Chest tubes aren’t available in most district hospitals. Many antibiotics don’t come under free supply. And if we had referred him outside the district either he would have returned back home or he had to sell his property to arrange money for his treatment. I had bought chest tubes, water seal bags from the NSI (Nick Simons Institute) GP fund, few medicines, tapes, sutures from my ‘Poor patient treatment fund’ (for which I collect donations from various kind-hearted donors) and got some medicines from NCCDF (Nepal Critical care development Foundation).
After 3 weeks of treatment, he improved a lot, most of the pus was drained but the entire lesion was not clear. CECT chest was the best option to see the extent and detail of the lesion and obviously a cardiothoracic consultation. But for that he had to go out from the district and he didn’t have money for that and he was not ready for that. So we discussed the situation, explained him and took out the tube and discharged him on Anti-tubercular drugs and other medicines. I know this isn’t the world’s best treatment what he got. People may say why you didn’t do pus culture, why you didn’t do CECT chest to see lesion, why didn’t you send him for the CTVS consultation, what if he develops some complications and many things. But what I am confident about is what I did is the best in this situation, what I did is the best any doctor can do in this settings. We knew that we had limited resources; we knew that we were less specialized. But everything was well explained to him and it was a joint decision to do the best in that situation. This is how we are giving our service; yes definitely compromised, may not be according to the international guidelines, may not be satisfactory to the super-specialized doctors but it is definitely stuffed with lot of warmth, devotion, dedication and right to the situation and settings.
Sometimes we have to act out of our profession and do something extra to provide health service in rural areas. I want to thank NSI, NCCDF and all the donors who believed in me and my work and helped me and my entire team.
Name of the author- Dr. Samir Lama
Brief Description about the author- MD General Practice, working at Pyuthan District Hospital, Nepal
Area of practice- MD General Practice, I see all general cases and do surgeries mostly LSCS, appendectomy, hernia, hydrocele.
epidemiology of your area in brief- Mid-western region of Nepal, hilly area, difficult in transport, nearest referral center is 4-6hrs long drive through the hilly roads.
Introduction of your rural health story
Suggestions for strengthening rural healthcare and Role of WoRSA