I worked in the Emergency Department of a a non profit International Non-Governmental Organisation teaching hospital. It was an imposing building overlooking the city of Pokhara and looks expensive (i.e beyond reach for many of the locals). The reality of the fact is that it isn’t, but not many people know that. As a result between the hours of 08:00 and 15:00 - when the regional ‘cheap’ hospitals are open - the teaching hospital ED is remarkably quiet.
In ED we saw the many similar conditions to those we see in the UK. However there was an awful lot more trauma (resulting from RTCs and falls from trees!) and an alarming number of cases of meningitis.
In Nepal, if you injure someone resulting in a disability that stops them working, you have to support them for the rest of their life. There are horror stories of people reversing to kill people that they have run over. I heard stories that it is cheaper to bribe the police when there is a dead body!
In the lulls we visited the wards and saw some interesting paediatric cases including:
- Organophosphate poisoning
- Viral meningitis
- Tetralogy of Fallot
- Pulmonary TB
- G6P deficiency
Patients admitted with Trauma had to have either the money for their treatment on them, or a relative who could pay with them. If neither were the case then the intern treating them could decide whether to treat them assuming that they could pay. If the intern got it wrong then the sum would be subtracted from his wages. In special circumstances there was something called the poor patient fund, essentially a pot of money raise from charity events by the student and interns to pay for treatment for the poorest of patients.
There were a couple of key initiatives in place that I found interesting - there were signs to wash your hands all over the ED, yet no one actually did it. In fact there was no soap anywhere, even in the toilets. On top of that there were public toilets in the middle of the ED with urine leaking out onto the floor. That was hard to understand.
Another government initiative aims to reduce maternal mortality resulting from childbirth. With this in mind they prove a simple birthing kit for every birth free of charge. Included are soap, a razorblade for cutting the cord, something to tie the cord, a sterile plastic sheet and instructions! In addition to this the government has also pays for the first 4 antenatal clinics that the mother attends (whether she can get to them is another matter) and gives every mother 1000 RPs when she gives birth to each of her first two children. This money covers hospital costs.
I have noted a few patient cases below that I found interesting, partly due to how the repercussions of living in a poor country miles from the hospital affects the outcome of the medical case, but also because of the different standards in patient awareness:
Patient case 1 – Wolf Parkinson White Syndrome
30 year old man brought in with shortness of breath HR of 232 and palpitations.
Known WPW and left ventricular failure. Accessory pathway ablation would have been carried out in the UK due to his frequent admissions, AF and LV failure. In Nepal this procedure is only available in Kathmandu and costs more than a month’s salary.
He was cardioverted medically and discharged from ED
Patient case 2 – Trauma
A 52 year old lady with massive wounds on her hands, soles and left hand side.
She had been hanging washing from an electricity line with a metal pole. Her hands and feet were the result of entry and exit points of the electricity and her side was where the pole had been touching her.
She had travelled 3 hours on public transport to get to hospital She died in the ED
Patient case 3 – Type II diabetic
53 year old female with poor glycaemic control requiring insulin. She lives rurally and is poorly educated. Consultants worry she would not understand the use of insulin and its disastrous effects in accidental overdose. They decided to induce hypoglycaemia while in hospital as a means of demonstrating to her what they meant!
They did not feel she understood so she was not given insulin to administer at home. The risk of insulin induced hypoglycaemia outweighs the requirement to lower blood glucose
Patient case 4 – Heart failure
63 year old female with end stage heart failure.
The consultant told the family that she had months to live. He told the patient that she was going to be fine and would live for years. He rationalised this by saying that he did it for the good of the patient, as she would have a happy remaining few months!
Good intentions, but doesn’t she have a right to know?
The above blog was taken from an elective report written by Craig Hicksman