Brenda in Nepal: A few ED Cases

The other day after a big rain storm, we got several snake bite cases. There are not too many venomous snakes here, but there is one called the Krait snake that causes similar coagulopathy issues as the Crotalus (pit vipers) in the USA.

Thank you google

Snake Bite to R medial foot.

Another interesting case was a man with chronic alcoholism (very common here) with an upper GI bleed. They were transfusing whole blood instead of packed RBCs. Apparently, they do transfuse PRBC and plts and plasma separately based in physician order, but they mostly transfuse whole blood. Needless to say, transfusion reactions are quite common.

Permission for pic given by pt and family. Under the towel is a unit or whole blood. The nurse said they cover the unit with a towel bc people might pass out if they saw the blood, lol.

Another interesting tib-bit is that there is no AA support groups here. There is a rehab facility that alcoholics or drug uses can go to, but families often cannot afford the high prices. The main drugs of abuse here are tramadol, phenergan, and diclofenac either by IV or oral according to Dr. Bishnu, who is the chief medical officer of the ED. He also states that the taxi cab drivers are the main population of drug abusers, but after seeing how they drive here, I'm almost not surprised.

Another picture of the department.

Strokes, both hemorrhagic and ischemic, are quite common here. Since it takes so long for the pt's family to get them to the ED, they pretty much never use TPA here, though it is available. A few of the strange things about comatose pts: if the pt has a normal resp rate and normal O2 sat, they will not intubate unless there is a threat to airway. Even if they do intubate, as in the case here bc he was vomiting and was an aspiration risk, they do not ventilate pts in the ED. The only ventilators are in the ICU. So as you see here, they just intubate and let the pt breath on their own with a small amt of supplemental oxygen.

Permission for pic given by family. This is an intubated ischemic CVA pt w a GCS of 3 and fixed dilated pupils.

Permission given by family. Intubated, not on vent.

As a tertiary center, Manipal gets several referrals for higher level of care or for admission. The infant below was born premature at 32w6d and had APGAR scores of 4/5/8 the outside hospital and was only 24 hours old. The family was referred for admission to the NICU so the family traveled all day to get here. On arrival, the infant was lethargic and found to be hypoglycemic. A bit of dextrose, and ta-da!, we finally got a cry.

Persmission given by family

In terms of average costs, below is a picture of one pt's bill for lab tests written in Rupees (US $1= R100). The registration cost to be seen in the ED is R 60 (US 60 cents). Other costs:

CT head= R 2100 (US $21),

CT abd/pel w PO and IV contrast= R 9600 (US $96),

admission to hospital deposit= R 500 (US $5).

Average monthly wages very greatly:

Average field worker or nurse assistant= R 8,000.

Starting nurse (new nurse)= R 15,000-18,000

Senior nurse= 25,000- 80,000

New MD= 35,000 base pay + 60,000 allowance for living expenses

When the pt comes in and the doctors order the tests, the family is required to go pay for the tests before they are preformed. If the family cannot afford or refuses the test, the pt does not get the test or treatment. Sometimes, the family will bring the order slip back to the doc and the doc will cancel some of the absolute non-essential tests to help lower the costs.

They also reuse their equipment. All BVMs and oxygen masks/tubing is washed and reused. Unused suture material is saved for later pts. Below is some tools in a cleaning solution... notice the sutures on the mix.

"Sterilize"

See the prolene sutures in there?

This is also interesting... They take dirty sharp needles and dip them into the white machine above, which melts the tips down supposedly making them not sharp anymore. Then needles are collected in the trash bin on the left/bottom there.

Another interesting difference is that for pts w virtually no hope or exceptionally poor prognosis, they allow the family to decide if they want to take the pt home to die or stay in the hospital.... most families take their loved one home. We had a case of a severe hemorrhagic R sides intraparenchymal, intraventricular, and pons stroke with midline shift who had a GCS3, and fixed dilated pupils and neg dolls eye reflex. After discussing the extremely poor prognosis with the family, they took him home to pass away. Honestly, I prefer this approach rather than the long ICU-trach-PEG-nursing home road we often use in the US. Granted, this pt's vitals were completely normal and he was breathing on his own.. but it's still interesting to see the difference between how these people view death vs how we do in the US. I was also told of a recent incident the week before I came here involving the death of a mother during child birth. The woman's entire village of at least 100 or more people showed up in the hospital and staged a protest by banging bamboo sticks, chanting, and yelling and nearly causing the hospital to close down bc they interrupted business. Since the people cannot afford lawyers and there are hardly any lawsuits, this is one of the only ways that locals can show their disapproval.