Doctor Without Borders

I am here in Kathmandu on an elective rotation at Patan Hospital through the Mayo International Health Program. Mayo has a collective trust from which a committee provides scholarships to visit under-served areas internationally and work alongside foreign physicians to experience care in a resource-limited environment and incite interest in future work abroad. I was very fortunate to receive a scholarship to go to Patan, and now we find ourselves here in Kathmandu.

Each day I walk about 15 min down the road to the hospital. Patan is a 450 bed hospital that was originally founded by Christian missionaries, and only recently in about 2008 was it turned over to the Nepali Government. They have a 60-bed pediatric wing, which includes a children’s ward, PICU, and NICU, as well as a two nurseries, an outpatient clinic, a high-risk patient clinic, and a pediatric research unit. The hospital itself offers lab services, blood banking, x-ray, and ultrasound, while CT/MRI can be obtained at another hospital in the city.

After arriving at the hospital, I head over to the library in the pediatric wing for the morning conference. My first day, the conference was a comprehensive audit of the PICU and NICU, where they reviewed patient cases and discussed their management. Multi-drug resistant klebsiella sepsis in newborn infants caused quite a bit of discussion, as klebsiella is a bacteria that can acquire antibiotic resistance fairly rapidly and cause something of an outbreak within a hospital. After conference, we head to the ward to review the patients prior to rounds. I joke that, in being excited about the different patient cases, I sound like a jerk since I’m enthusiastic about, well, sick children, but it’s really quite fascinating. While Nepal hasn’t escaped the omnipresence of bronchiolitis – it’s so common in the US, we call the winter ‘Bronchiolitis Season’ – their most common disease seems to be bacterial pneumonia. It seems the smog in the city, along with the high density of people here, causes a perfect storm of lung infections, and we have several babies on the service right now recovering from pneumonia. One delightfully precocious ~3-year old girl has been in the hospital for several weeks now after a chest tube was needed when her pneumonia turned into a lung abscess.

Beyond the common cases, though, you have the weird/cool cases. There’s a classic phrase in medicine, “when you’re in Texas and you hear hoof beats, think horses not zebras.” It means, basically, that common things are common, so don’t go chasing House-MD style after the strange diagnosis. Well, I specifically flew halfway around the world to see the strange diagnoses, and they’ve been happy to oblige! For example, Diphtheria is the D in the DTaP vaccine that you’ve had and given your children (unless, well, you’re an idiot. Sorry, that’s a little hostile. I mean, unless you’re exercising your parental freedom… to be an idiot). Back in the 1920's, there’d be more than 120,000 cases annually in the US and 10,000 deaths. But after we introduced the diphtheria toxoid vaccine, there’s now about five cases annually. I’ve never seen a case, until now that is. Another disease we rarely see in the States is Epiglottitis, where you have a very serious infection of your upper airway. Even though we rarely see it, everyone learns about it in detail and remembers it because of what can happen if you don’t. In Epiglottitis, children present leaning forward, drooling, and having difficulty breathing while speaking with a muffled ‘hot potato voice.’ If you go to look in the back of their throat with your tongue blade, though, the child may die (the irritation from the tongue blade can cause their airway to lock down). So you don’t mess around with the Epiglottitis, but it’s most commonly caused by a vaccine preventable bacteria, Haemophilus. Well, turns out they get 2-4 cases here a month!

It’s not only vaccine-related diseases, though. A 10 year old boy presented from a rural village with facial swelling and difficulty breathing, as well as a swollen belly. An x-ray showed a pericardial effusion (fluid in the sac around the heart), which began to squeeze his heart and compress it from beating. They had to insert a needle under his rib cage into the space just around his heart to pull the fluid out. He had fluid in his face, his lungs, his heart, his belly… what could’ve caused this? Well, turns out, he comes from the same rural area where children often catch and eat under cooked freshwater crabs, and they get a parasite that causes this massive inflammatory reaction leading to all of the fluid buildup (it’s called Paragonamiasis). Crazy!

I’ve been able to joke around with the interns and medical students here, and we’ve had lunch together in the cafeteria, grabbed milk tea before rounds, and just hung out in the afternoon. Just yesterday they asked me what my thoughts were, about how different our two hospitals are, and I actually had to say my main impression was how similar everything is. It’s really quite striking to be in such a different environment, but rounding with a team where they go to the bedside, have the intern present the patient, then have a teaching session in almost the exact same way we do Stateside. What are we worried about regarding fluid management in the setting of pulmonary disease? SIADH. How many grams per day should an infant gain in the first two months of life? 20 to 30. What’s the differential diagnosis for diffuse swelling? Think liver, kidneys, and the heart… the list goes on. It’s great.

Plus the milk tea is like ten cents. Which is awesome.

                 55 cents total for lunch

At the end of the workday then I walk back home to hang out with The Hotness. We go to our local gym, which I’ll more diplomatically describe as ‘rustic,’ get food for $1 at a local vendor’s shop, and then watch TV shows or wander around. Well, I’ll hang out with The Hotness for now, that is, until her big adventure…