When people talk about my work, they like to use the term global health. I am going to let you in on a secret. I don’t like the term global health. I think this misrepresents the central tenet of what I am trying to do. You don’t need to travel to Nepal to find marginalized people who need help.

Hell, look at Philadelphia. How many of my black patients lost family members to gun violence? How many of my opioid use patients died in the streets of overdoses in their twenties? I think of the lack of support for uninsured patients that I cared for on a monthly basis: calling the specialized congenital heart disease clinic for my patient who was an uninsured refugee and getting denied, or when I admitted a patient with ovarian cancer who had a lapse in insurance when diagnosed with treatable cancer who had to wait until it progressed to untreatable before coming to hospital. In downtown Philly, you can be born in Washington Square with a life expectancy in the late-eighties, or be born 7km north in Strawberry Mansion to a life expectancy *twenty* years lower. My objectives are not in global health per se, they are in health for the marginalized.

I wish I could tell you that I have a better term but I don’t. I like to say I am in humanitarian medicine, although that always leads to more questions. Alas, the search for a better term continues.

I am open to suggestions.

When it comes to health for the marginalized however, the mac-daddy of all infectious pathologies still remains tuberculosis, or TB. A hardy bacteria that comes from a special cell-line, it is notoriously difficult to eradicate and typically presents with long winded histories of worsening shortness of breath with a cough, weight loss, and night sweats. I have seen my share of TB both in the field and in the US when I worked in a clinic for refugees.

Before arriving in Nepal I had been told to expect lots of TB, as it remained steadily endemic in the area. It was to no surprise then, that every day on the wards we covered three or four patients with TB ranging from sick to not-so-sick. There was one that I remember from my first day rounding in the high dependency unit with Dr. Udip.

‘This is an elderly lady who came in with shortness of breath for several months, acutely worsening in the last three days. X-ray shows a unilateral effusion (fluid on one side) and multifocal infiltrates (lots of shmutz in the lungs),’ the resident said.

We went over all of the relevant data and examined the patient, a tired old lady. You could see her temples prominently shaped against her wrinkled skin.

‘We tapped the effusion and are waiting on some preliminary data,’ Dr. Udip said.

‘Any TB exposures?’ I asked.

‘This is Nepal,’ he said with a smirk. ‘We are all exposed to TB.’

’Fair,’ I nodded.

The team moved on and we began walking together.

‘Let me tell you a story,’ he started. ‘Before I worked here, for some years I worked at the mission hospital in Palpa. It has been there for some time, run by a charity group staffed with many foreign doctors. I was young at the time, and I remember there was an American doctor; he was old. We had a patient once and I remember him saying “this is Nepal, everyone has TB,” and you know this really annoyed me at first. He was this foreign guy, coming here and telling us Nepalis that we all have TB. In the end it turns out he was right.’

‘That’s unfortunate in its truth,’ I said. ‘Do you wind up seeing many drug resistant strains here?’

‘Not so much. If we do, we are actually not allowed to treat them. All of the medicines for TB in Nepal are covered through the global TB fund. Part of this arrangement is that drug resistant strains are sent away for modified regimens,’ he said.

‘Interesting.’

Thank goodness for the global TB fund. Without it, the disease would be out of control.

Even though Nepal had a two-tiered health system with public and private arms, the public sector was still billed directly to the patient, not the state. This meant that even with insurance, if patients’ care exceeded their insurance plan and they could not pay, they wouldn’t get services. 

It was kind of fucked up, actually.

I saw patients that came in with heart attacks and couldn’t afford to pay for the stents to open up their blocked arteries, meaning they would have to just settle for drug therapy. I saw patients with sepsis whose families ran out of money so they elected to remove them from the hospital to die in peace at home. I even saw one patient who came in with symptomatic low blood sugar, went into cardiac arrest, got successful CPR and was intubated in the emergency room, only for their family to find out they couldn’t afford the deposit required for admission to the ICU, it went like this:

I was walking with the team through the emergency department, as we would after rounds to review patients who were flagged for admission to medicine. The ED resident came and started presenting a patient who looked mildly distressed on some nasal oxygen. In the next bed over, I saw an intubated patient with a family member in plain clothes squeezing the oxygen bag into their breathing tube. I couldn’t help but interrupt the resident.

‘Sorry, is that patient coming to medicine?’ I asked, pointing to the next bed.

Some conversation was had in Nepali. This was actually fairly commonplace, where I would ask a question in English and get no direct answer while some discussion ensued.

‘We should probably start with them right?’ I said.

More Nepali discussion went back and forth between the teams. One of our medicine residents then translated for me.

‘This patient is going to leave against medical advice as they cannot pay for the admission,’ he said.

I was flabbergasted. It seemed like the attending with me that morning, Dr. Yadav, also had some thoughts and engaged in a heated conversation with the ED staff. The language differences meant I had no idea what was happening. In the end I didn’t press the issue further, choosing to just observe. I brought it up a few days later while having dinner with Dr. Pandey.

‘Yes, yes. I heard about this,’ he told me ‘Both Dr. Yadav and Dr. Himal placed a formal complaint to the college about this. The problem is that if we admit such a patient and they cannot pay, then the college comes after the doctors and takes it out of our pay.’

Imagine. 

I am not here to criticize. If there is no money there is no money, period. It’s another reminder of the obstacles of healthcare structures in poorer countries.

I also remember rounding on several patients a day with acute strokes. The management of stroke is completely dependent on how quickly you can detect the problem and give medicines to treat it before brain tissue starts to die.

‘What capacity do we have for treating strokes here?’ I asked Dr. Udip one day on rounds.

‘Sadly, none,’ he said. ‘Even if patients come in right away, we don’t have thrombolytics (stroke busting medicines) or the right nursing capacity to handle treatment. We had one patient last year that we managed to treat. We got them airlifted to Khatmandu to a specialty stroke centre for a thrombectomy (a surgical procedure that sucks out a brain clot, typically reserved for strokes that come in slightly after the window where we can give the medicine has passed). The patient arrived sometime around 11AM, and got the thrombectomy that night around 7.’

‘So our quickest turnaround time for strokes is eight hours at best, involving an airlift to the capital?’ I said. ‘Sounds expensive.’

‘Very,’ he answered. ‘We also don’t have access to rehabilitation. I had actually tried to get one built here with the help of some friends from Australia who were going to fund it. We established a non-profit, got approval, even hired staff. Everything was ready. Then unfortunately the funding situation failed to materialize.’

‘That’s tough doc, I am sorry to hear that,’ I responded.

What else could I say?

It was becoming clear to me that the deficits here at LMC were not in clinician quality, or even in healthcare frameworks. The doctors were great, cared a lot, and things got done efficiently. Patients just didn’t have access to care because they couldn’t afford it and doctors didn’t have access to necessary services because it was too costly to the system. As a tertiary referral centre, one of the presumed centres of excellence in the region, the hospital had no dialysis, no capacity to ligate esophageal bleeds, no laparoscopic surgery, no ability to stent coronary arteries in heart attacks. The individuals in the system were doing their best with what they had. Even if they did have these things, how many patients would actually have access as opposed to being locked out due to the high cost? For the first time, I was working in a place where the barriers to excellence truly were resource driven.

This meant that when it came to my contribution for medical education, in truth they didn’t need me. Dr Pandey and Udip alone had ten times the clinical teaching acumen I ever will. This is where I have the handy dandy ultrasound, though.

The ultrasound training program went well, starting in the evenings of my second day. I ran a five day introductory course with lecture material and hands on training to level the playing field with all the trainees. Since they had already been given the online learning platform in the lead up to my visit, some of them already had some knowledge in interpreting scans. I would then round with the team daily, and if there were cases that benefitted from a scan I would be able to train the residents and interpret images in real time. In short order they were using the probes on their own without me during call at night, and it was leading to useful changes in management.

As typically happens when I bring the ultrasound training and portable probes to a site, other departments caught wind. First, it was surgeon that sat across from me in the canteen. We start chatting about nothing in particular and he asked me what brought me to Nepal.

‘You can use these ultrasounds for surgical patients?’ he asked.

‘Definitely,’ I said. ‘It depends mainly on how much you would be interested in learning but there are lots of diagnostics in surgery it could help with.’

‘Interesting…’ he said. ‘Would it be possible for the surgical department to get some of this training as well?’

‘I don’t see why not.’ I answered.

‘I will speak to the head of my department.’.

The same happened for anesthesia, and pediatrics. So when I finished the formal coursework for medicine, I moved to the next department, and then the next. By my third week, I was finishing the training program for the fourth department in the hospital and just about everyone had heard about the sexy bearded man from America* doing ultrasound training.

*Their words not mine. Cannot confirm the use of the word sexy.. Can confirm for American.

Regardless of whether the sexy label was verbalized, my studliness probably reached its apex when I walked into the ICU one afternoon to conduct ultrasound training around 5PM. We had been setting aside the window from 5 to 7 for the anaesthesia residents, and on this particular day I walked in to find one of them standing stiff at the foot of a patient’s bed while the other was knees-up on the bed doing CPR.

My interest was piqued.

As nonchalantly as I could to prevent adding further anxiety to the code, I grabbed a pair of gloves and stood within the peripheral vision of the second-year anaesthesia resident at the foot of the bed. There were two nurses involved as well, one on the left and one on the right, engrossed in some task.

I walked up to the intern doing compressions and placed a light hand on his back.

‘As soon as you need a break I am ready to assist with CPR,’ I said.

He nodded in acknowledgement.

So for a moment I did nothing, and only observed. The patient was old, probably in his seventies. He was intubated, with defined ribs rising from his chest. The anaesthesia resident at the foot of the bed, a second year that I had worked with during our training, was standing firm, not saying much. She was in the right position, yes, but it didn’t really feel like she was in charge. Nobody was saying anything. I gave it more time.

The intern on the chest signaled for me to take over, and so I did. I got on the chest and did my thing, counting. By the time I got up to sixty, still no words or action were taking place around me. I could feel time slipping.

‘How long have we been coding for?’ I asked the resident.

‘About five minutes before you arrived,’ she said.

‘Have we given epinephrine? I asked, huffing as I bounced on the chest.

One of the nurses nodded. Good.

‘Have we established the rhythm?’ I asked.

No response.

‘Are we able to get pads on, or a machine to establish rhythm?’ I said.

Again no response. I saw eyes darting at each other.

‘Have we got a machine?’ I huffed again.

The nurse in front of me scurried and I felt a few of them mobilize behind me to get the defibrillator.

It was around this time one of the medicine residents was arriving in the ICU. He came up to the head of the bed next to the anesthesia resident. Venomous words were exchanged in Nepali. I continued compressions.

I told the intern behind me to get back on the chest as the extra curriculars between medicine and anaesthesia worked themselves out, and I grabbed a strip of paper on the table at the foot of the bed, it was a blood gas analysis.

‘When is this from?’ I asked the two residents, interrupting their spat.

‘Recently but before the arrest,’ the medicine resident said. ‘This is one of our patients from upstairs, he was found to be in severe obstructive pulmonary disease (high carbon dioxide in blood) on the wards requiring intubation with transfer here. He arrived here less than twenty minutes ago.’

Looking at the numbers on the slip, yes, he showed the classic pattern of carbon dioxide excess from his lung disease, but he also had a potassium level that was undetectable.

‘His K is less than 2,’ I said.

He made a face. Blood gases weren’t the most reliable. He didn’t want to commit.

‘I know, but we have to treat this as real and the cause of his arrest,’ I said.

He nodded and turned to the nearest nurse with a Nepali request for a bag of potassium. The defibrillator machine was also arriving now. 

‘Are we ready for a pulse check?’ I asked out loud. ‘Can one of you please grab the pads from the machine?’

‘Yes, we are ready,’ the anesthesia resident said.

We stopped compressions, and as the pads went on, nothing came up on the machine. It wasn’t turned on.

I had a feeling this would happen.

Looking up at the heart rhythm on the bedside monitor, I saw a squiggly line spazzing up and down.

‘This looks like Vfib,’ I said to the residents. ‘This is a shockable rhythm, are we ready with the machine?’

Again, they got the pads on the patient, and now a matching squiggle came up on the small screen attached to the pads.

‘Let’s get ready to shock,’ I told them.

Again, there was a significant lack of familiarity with the machine and it wasn’t set on the right mode, nor was it charged. After a delay of nearly thirty seconds, we successfully delivered a shock.

The rhythm on the machine changed from wild squiggles to formed complexes.

‘I have a pulse,’ one of the docs feeling the neck said.

‘Excellent,’ I said. ‘Nice work everyone. Let’s get a blood pressure to start and a 12 lead ECG. I think the potassium likely helped here. I would re-check the labs once the first bag is done.’

I was lying. The code was not excellent. As a matter of fact it was terrible. No rhythm check until close to ten minutes in. No shock delivered until around 13 or 14. No addressing of the underlying potassium issue. These were all basics of cardiac resuscitation and only really happened when I started making demands. This was a gap in our capacity.

So, for all the things I have said about the quality of the residents here at Lumbini Medical College, I discovered one part of their curriculum that could use some help. This was nobody’s fault as much as it was a reality of the obstacles faced by the system. For me, this was good, as it gave me a lead to chase.

In the coming weeks I met with several people: nurses, residents, attendings, and leadership. They all seemed to echo the same need for advanced cardiac life support (ACLS as we call it). Getting formal cross-department ACLS training and certification for nurses and doctors was costly and difficult, which is why it was still not yet prioritized. Patients were suffering as a result.

This is a personal area of interest for me as well, with my adrenaline-lined passion for critical care. It begs the question: how about using my role as a capacity-augmenter to bring such type of training here? It’s something I am working on. It’s too big a task to organize alone, and what I need is more people, in particular critical care nurses to facilitate training staff to work together in code situations.

Maybe, just maybe, I could form my own group of like-minded individuals to deliver this type of training in areas of need. I wouldn’t even really need a group, just one person would probably suffice. 

A partner in crime to travel the world with, helping patients and training medics? Sounds like the dream.

Still, the arc of this story for LMC and their patients remained clear. They had all the right ingredients to be a great hospital, they were just missing some higher level services, and the patients themselves didn’t have enough money to pay for care.

Oh, and as for our patient? His potassium was corrected and this stabilized his heart function. However, the long cardiac arrest likely left him with a brain injury from poor oxygenation of the brain, and he remained machine dependent for several days until his family decided to take him home to pass away in peace.

Whether that decision was guided by compassion or by finances I don’t know.