The ambulance at the bottom of the cliff

A number of people have asked how life in the hospital is. That is a hard question to answer. The short answer is “it’s great!” If you are satisfied with that answer, feel free to stop reading. If you aren’t, the long answer is below. I do apologize, I have used a lot of medical jargon in this post. Go ahead and gloss over the medical sections if you don’t have a medical background. 

There are many feelings about working in the hospital that are hard to summarize. This has been my goal for so long. After 4 years of college, 4 years of medical school, 3 years of residency, and 4 months of language school, I’m finally where I want to be; working as a doctor in a hospital in the developing world. So here’s the whole scoop of where I am, what I’m doing, and what I think about it all.

Tansen Mission Hospital was built in the 1959. It was originally on the outskirts of town. The land was given by the town to United Mission to Nepal (who runs the hospital) because the land was thought to be haunted. However over the years the town has become less afraid of the ghosts and more interested in the hospital and the economic perks, and has gradually made it’s way towards the hospital. The hospital has a total of 165 beds, and is typically at 85% capacity, although can bloom to over 100% capacity in monsoon season. The medical ward, which will be my main responsibility, has a total of 32 beds, but there is always room for more on low beds on the floor, in the hallway, and on the surgical wards.


A severe case of tophacious gout

Most patients who come to the hospital present late and have advanced disease. There is a variety of illness, but most I am familiar with having treated in the United States.  One morning on rounds I kept track of the cases: 6 cases of COPD most of whom had symptoms of right heart failure due to long standing pulmonary hypertension, one of these cases was so advanced the patient was sent home to die as there was little more that could be done; 2 cases of alcohol withdrawal, one of whom had seizures; 1 person with cancer who had a blood clot in her lung; a stroke; a heart attack; a person with kidney failure from taking too many pain medications; a person with atrial fibrillation and a very fast heart rate; 2 cases of left sided heart failure, 1 with fluid in her lung and the other with unexplained fevers; a 24 year old man with a hole in his atrial septum who had developed eisenmenger syndrome; and pneumonia with a pleural effusion. That was a general days cases, but in my month in the hospital I have also seen a case of mumps with pancreatitis, typhus, malaria, meningitis, many GI bleeds, amoebic disentary, kala azaar (visceral leischmeniasis), a lot of tuberculosis, pneumothorax (spontaneous or related to TB/ COPD), and a host of psychiatric disease from depression to full blown schizophrenia.


A patient in the ED waiting to be seen.

Diagnosing and then caring for for this host of illnesses is a task. There are limited tests that can be done, and then the drugs available to treat them are few. Blood tests are essentially limited to CBC with diff, reticulocyte counts and blood smears, sodium, potassium, creatinine, BUN, ESR, and rheumatoid factor. Infectious tests include B24 (HIV), RK-39 (for leishmaniasis), thick smears for malaria, and ADA for TB. Cultures are also available, but rarely are positive in anything other than urine. Imaging mostly consists of plain films and ultrasound. There is a CT scanner 1/2 hour down the road, so if a patient is stable enough and has the money, this is a possibility. Echocardiograms are also available twice a week. This is not always convenient for sick patients, however, so I have been developing the skill of “quick scans”, which are very basic ultrasounds to roughly estimate cardiac function, look for pericardial effusions, and pleural effusions. This is quite helpful since a patient with shortness of breath and elevated neck veins may have COPD with cor pulmonale, left sided heart failure, pericardial effusion with tamponade, constrictive pericarditis from TB, or isolated right sided heart failure from a past MI. Endoscopy is also available twice a week, where they do EGD’s, however taking a look from “below” is limited to proctoscopy and sigmoidoscopy.

Medications are OK here, but antibiotics are limited. There is a lot of use of chloramphenecol, which I’m becoming a fan of. It is not used in the United States because it rarely causes severe myelo-suppression. Anti-coagulation for patients with DVT and PE is very hard, since we essentially only have coumadin, and the INR’s we get back from the lab are suspect at best. There is no low-molecular weight heparin, and PTT’s take 6+ hours to get back, so a heparin drip is not a possibility. As a consequence, the tradition here has been to give patients subcutanious unfractionated heparin, a practice for which there is no evidence to support. The nearest cath labs for patients with acute MI are in Kathmandu, a 10 hour drive away. Most patients could not afford a catheterization anyways. As a result they are often treated here in Tansen. A patient with STEMI who presents within the first 12 hours of chest discomfort can be given streptokinase, a “clot buster”. Of the 4 or so STEMI’s that I treated last month, none of the patients presented within that window. They are then simply put on aspirin and a statin, and we try to modify their risk factors.


The first EKG with clear ST elevations in V3 and V4

Second EKG, Still with ST elevations in V3 and V4, but now Q waves are present

I had a debate with one of our residents as to how long it took to develop “Q” waves in an EKG after an MI. I felt that it would take a week or so, and he argued it was much shorter. His case was proven a week later when we had a patient present with a STEMI, and the EKG over the next 2 days showed development of “Q” waves and “T” wave inversions. This is something rarely seen in the US since most every patient with a STEMI, especially in Rochester, will have cardiac catheterization and stent placement.


Third EKG, now ST elevations are gone, but Q waves and new T wave inversions are present

There are many people who do not do well, even with the best treatment we have to offer. If it looks like a patient is not going to survive, often the family will ask if they can take the patient home. This is for several reasons, including the comfort of the patient, the cost of hospital stay, and also that it is much easier to transport a live person than a dead one. When patients do die, rarely are tears shed. It is fairly matter of fact for family members who then automatically start the business of collecting personal items and arranging to move the body to home, where funeral rights are often performed. Autopsies are not acceptable to Hindus, so when there is a mysterious death, there often is no medical closure, only speculation as to what happened.

After a morning on the wards we will often head to the canteen to grab a chia (chai) and some samosas. From there it is time to see, usually 1-3 consults, if there are any at all, and then to the OPD (out patient department).

This has been the most problematic realm for me since I don’t speak Nepali very well. I generally can be understood, but I have a very difficult time understanding patients. They often mumble, and patients from more rural areas often will use different words than the ones I have been taught. So I often have a resident or intern with me to help interpret. I would like to think that I am also helping the interns learn, but I get most of the benefit of the arrangement. In an afternoon, up to 110 patients will be seen in the male clinic, and another 110 in the female clinic. There are “sorters” who function as nurse practitioners, who try to treat the simple cases, and then send the rest to see the doctors, which ends up being around 40 or so patients. Depending on the afternoon, there are between 2 and 4 doctors seeing patients, so it can be very slow or very busy.

I have seen some very interesting and puzzling cases in OPD. There was a case of pustular psoriasis that responded beautifully to coal tar. Lots of run of the mill hypertension. There is also a lot of depression with psychopsomatic manifestations, such as “whole body tingling” (always a red flag symptom). There is even some irritable bowel syndrome here, a diagnosis which I thought I wouldn’t see outside of the United States. This typically in young males who do not have any children. This is a big deal for the men, since in Hinduism a son is required to perform your funeral rights in order for you to move on to the next life. There is a tremendous amount of COPD and liver disease. There is a fair amount of smoking, however those who smoke will only have about 3 or 4 cigarettes a day due to the expense, and the cigarettes here are about half the size of those in the United States. I think that most of the COPD develops because 80% of the cooking is done indoors over an open fire. COPD tends to be worse in women than men, and quite often the women have never smoked. The liver disease is almost exclusively from alcohol abuse. The local drink here is “roxi,” which is a sort of rice wiskey. It is cheap, and usually consumed in large quantities.


I was puzzling over this left lung infiltrate in a patient without pulmonary symptoms until I lifted his shirt…


and found this massive lipoma (fatty tumor).

Tansen Mission Hospital is not the only hospital in the area, but it is the best. The the government hospital in the area rarely admits patients, and those who are admitted rarely will see a doctor. A plethora of medications are given treating 4 possible diagnosis, and if a patient is not able to pay the bill, they will be sent away regardless of how ill they are. In addition, Tansen Hospital has won several awards in the last year, including “best hospital in Nepal.” As a result, patients will travel for days sometimes just to be seen. This can make follow-up a little tricky.

Nepal is a country full of illness, some of it due to poverty, some self-abuse, and some seemingly really bad luck. Things have changed since Thomas Hale, the author of ‘Don’t Let the Goats Eat the Loquat Trees’, was here. But his perception of Nepal is still quite true. He felt that the hospitals here were like ambulances parked at the bottom of a cliff. When a person fell off, we could load them in and do our best to restore them to health. But the hospital does not keep people from falling off the cliff and it doesn’t fix the root problems of illness or prevent it.

There have been highs and lows in the hospital. There has been joy seeing patients I was sure were going to pass away do well, as well as sorrow from seeing patients who seemed fairly healthy die. The latter senario was of one of the most distirbing cases so far.  The patient was a 29 year old man who came in with abdominal pain and nausea. He was found to have pus in his stool and was placed on antibiotics and anti-emetics. The following morning he had a seizure which we all assumed was alcohol withdrawal. He responded well to benzodiazepines to stop the seizure, and we moved on to the next patient. The following morning, we found that the patient had another seizure. He never woke up, and was dead by the afternoon. This left my head spinning. Was he truly in alcohol withdrawal, or was he having seizures because some of the medications we gave him lowered seizure threshold? Did he have a bleed in his brain during one of the seizures, or was he still having subclinical seizures after the second seizure? I will never know why that young man under my care passed away and it freaked me out. What did I miss? What should I have done different?

The motto of Tansen Mission Hospital is “We treat, Jesus heals.” This is something I have to keep coming back to. We know that Jesus had the ability to completely restore otherwise incurable people with only a few words, or tincture of saliva and dirt. On the other hand I have seen people with incredible faith waste away from illnesses which were treatable, and that they should have recovered from. God has given us sharp minds, and incredible bodies that tend to function according to natural rules, this allows us doctors to diagnose illness and give medicines that generally help. However, the power of all of this ultimately rests with God. If He wants to restore a person despite my misdiagnosis and poor management, that is within his power and right. It is also equally within his power and right to thwart world class medical treatment. My role is only to show up, do my best, and then pray for my patients.


Sign from front of Tansen Mission Hospital