Rural agony to smile

 

 Dr. Pawan KB Agrawal

       

We all are bound to experience pain at least once in our lifetime in one form or the other. The severity of pain is subjected to individual experience and determination to tolerate. At times the pain bound us to kneel in front of someone whom we expect to be powerful enough in a hope that we will be relieved. 

Being a doctor, determined to face the rural challenges to bloom a light of happiness in those desperate faces with excruciating pain coming across such helpless yet hopeful patients is a routine.We do grade pain but often we are not able to address the individual experiences adequately.Nevertheless we always thrive amidst our limited resources and destitution of our fellow patients to help them sustain through their difficult times and at times these turmoil carve a beautiful story to inspire courage and hope in a doctor patient relationship. 

A week back I had this patient 32 years in one of the emergency beds during morning rounds.Two hours earlier I was informed by my colleague medical officer about receiving him in agonising pain in his abdomen which started from his scrotum the previous day.The pain had started the earlier morning.Since there were no vehicles to carry him and he could not walk for three hours with the pain, helpless he prevailed throughout the afternoon alongside his ignorant wife and three small children not knowing what was awaiting him. 

Rather than taking him to a religious healer, they preferred him receiving care in a hospital. A wise and often rare scenario in most of our deprived areas where these religious healers are the only prospects.

With the dusk, some of his relatives finally fetched a jeep and a ride of two hours along the bumpy gravelled roads and finally landed him in our emergency ward. Whatever be the reason pain must not happen. This is what we often emphasize to our fellow medical service providers. 

He received some pain killers while he was being examined and investigated. We established the diagnosis of right obstructed inguinal hernia and explained the patient & his relatives that he needs to be operated as soon as possible in order to save the part of his intestine that had come out as hernia and had been stubborn not to go back.

We could not be sure though if the part of his intestine needed to be cut and repaired. As a general practitioner, a generalist, we are regularly operating hernia that goes in spontaneously but a situation like this where a part of the intestine might need to be cut put us in dilemma given limited instruments, anaesthetic expertise and post operative care. 

Another challenge poking us was his referral, a journey of 10 hours by jeep depending on a driver to the nearest higher hospital in Dhangadi,far western Nepal in case the patient party agreed. 

We explained and discussed the scenario with the patient party, scrutinised every option in details. It would have been best if we could refer him in an ambulance with a paramedic to Dhangadi. But it was yet far from happening. 

The turmoil of helplessness,poverty and health care resources in each of us endured the entire night and settled in the afternoon as we, doctors and patient party eventually concluded to put the situation on faith and proceed with surgery in our hospital. 

The patient party agreed that if surgery goes wrong or he dies,they would not raise any claim.A life was on our hands then.How could we not do our best and help him survive was a challenge. 

He was rushed into the operation room almost forty hours later.Together with another generalist Dr. Bikash who is also my mentor since I started working with Possible in Accham two months back.

We put him under spinal anaesthesia and took every precaution available at our disposal. As we explored, the faith or whatever we name it served us with a hope that the part of intestine might survive.It was almost on the verge to die, had we opened him few hours later or had referred him.The anxiety diminished with a sigh of relief. 

After he was shifted to the ward, we prohibited him to eat and had him keep on intravenous fluids.After two days we started with liquids and had him have usual diet on fourth day. He was then walking happily without pain and discharged on seventh day after we are pretty sure that the complication would not happen. 

Sometimes we do end up with a climax where a family turns upside down with an unexpected helpless death of the beloved on a hospital bed.But to our faith & the conviction of his fellow relatives,this time a life in despair was restored with balance and smile for his new journey back home with his small family.

Struggle for health

 

Samir Lopchan

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.

 

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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
Conclusion
Suggestions for strengthening rural healthcare and Role of WoRSA

Ruptured Ectopic Pregnancy with Shock with Severe Anemia in Rural Nepal, Managed By GP

Dr. Bikash Gauchan

This is a real story from the rural The Far Western Region of Nepal in Achham District which is often considered the remotest and poorest region in whole South Asia.

20 years old female presented with Abdominal Pain for the last 7 days at Bayalpata Hospital in Achham District of Nepal. The Clinical Team of Bayalpata Hospital is lead by General Practitioner. The female described her abdominal pain to be diffuse, constant, and severe. She also developed multiple episodes of vomiting. She just married two months ago and she was having regular menstruation cycles two months ago after which she started to have irregular flow and the amount of flow was reduced. When I evaluated her she was in severe pain. Her abdomen was severely tender. She was pale. We performed ultrasound and found there is fluid collection intra-abdominally suggestive of blood and her urine for pregnancy test came to be positive. We finally came to the conclusion that she had Ruptured Ectopic Pregnancy. The next level of hospital from Bayalpata Hospital is 10 hours jeep ride and the lady did not have that many hours is she was referred to higher center.

There was dilemma what to do and what not to do. Dr. Santosh Kumar Dhungana and I decided to proceed for Exploratory Laparotomy at our own facility, Bayalpaya Hospital. We arranged blood donors for her as she is O positive. Luckily we were able to find some donors from our own staffs and from the armed police force. People in this part of hilly region do not want to give blood and our blood bank lacks necessary blood all the time and we always have hard time explaining people why blood donation is important to save lives.

Dr. Santosh gave general anesthesia and worked very closely with one of our staff nurses. Another staff nurse scrubbed with me. I proceeded with the surgery. When I opened the peritoneum, gush of blood came out of her abdomen and nearly 40 % of scrub nurse and my body were wet by the blood. We calculated the intra – abdominal collection to be more than 2 litre. We drained all the blood. The ectopic pregnancy was located on the right fallopian tube at Ampulla and there was small site of perforation from where blood was continuously oozing. We performed right tubectomy. And inserted Right Abdominal Drain. We started blood transfusion for her. After 2 hours of surgery and one hour of close monitoring she was transferred to ward to close monitoring.

One the 4th Post operative day, we were able to remove her abdominal drain and she was discharged home on 8th day of operation. Bayalapata Hospital has two GPs and they feel very proud to save this lady.

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Dr. Bikash Gauchan  MBBS, MD  Medical Director Bayalpata Hospital - Nepal