There was only one medicine team on service at Lumbini Medical College. The team had one attending that rotated on a daily basis (sub-optimal, but commonplace in many low staffed systems), a first year medicine resident on call (24 hour calls), one senior resident (either second or third year), and a handful of interns (as an aside, the term ‘intern’ that we use to describe a year one resident is used differently in most places outside the US and Canada. Interns through Europe, Africa, and Asia are typically students just out of medical school but still not yet on a dedicated training program). The roles were defined as such: the plentiful interns pre-rounded on patients and wrote notes before doing tasks after rounds, the first year resident admitted patients and supported the interns to put out fires, and the senior resident was the first point of escalation for the first year resident if a question arose. Not all that different from most teaching hospitals I have worked in.

Despite the deficits in accessibility for patients I referenced in the previous entry, I was pleasantly surprised at the quality of the hospital on several levels. For one, the organization of patient information in the charts was great. Everything was neatly written and easy to find, with a binder at the foot of the bed that opened to a vitals chart and notes on the right with lab values printed and clipped down on the left. There was also a big manila folder at each bed with X-ray and CT films for easy review. Nursing was closely involved, participating in rounds with us, aware of the plan and making their own notes. Dr. Pandey himself oozed clinical excellence at the level of the highest level physicians I saw in Europe, emanating that aura of true mastery that made me wonder if he sat on some committee writing and conducting the specialist exams. Given our isolated setting, the attendings here managed cases many internal medicine doctors in the US wouldn’t touch, both on the wards and in the clinic: movement disorders, strokes, complicated rheumatologic crises, and a dozen things in between. They even read their own CT scans, only reaching out to radiology when unsure. The residents, when prodded by Dr. Pandey, were knowledgeable and on top of the cases, even with the growing pains of learning. Care also seemed to actually progress, with tasks getting done and patients being discharged in a timely manner, in direct contrast to my experience at so many other teaching centres outside of the west. If I got sick myself, I would have no objections to being admitted here, which is possibly the biggest compliment I could ever give a hospital.

Still, there was a reason why HVO had a partnership here to capacity build. Dr. Pandey explained some of this to me when we walked to a nearby café after rounds concluded sometime around 1PM.

‘Our problem here is lack of manpower,’ he explained to me. ‘We are four doctors in the department of medicine. We are responsible for all of the curriculum development for the college MBBS (undergrad medical school). We have to give lectures, grade exams, make teaching materials. Nobody else does this but us. We also have to round on all the patients, and then go to the outpatient department to see all the patients there. This makes it difficult for us. Even if we want to do more, we cannot.’

‘This is not unlike the challenges faced by all rural healthcare settings,’ I said. ‘Even in rich countries we have similar problems.’

‘This is true,’ he said.

We sat together chatting, sipping milk tea and snacking on pakodas, a quasi-quesadilla stuffed with potatoes. As our conversation evolved, I learned he was from a small village, making him one of very few from his upbringing who pursued a formal education. This anchored him here, working for shockingly low pay, giving back to the community through the teaching hospital. He also spent a year in California doing an unaccredited fellowship that exposed him to another level of academic medicine. I shared parts of my story as well. The 30 year old vagabond with big dreams to heal the world, backpacking from site to site with no attachments. I felt quite humble in his presence. It was pleasant.

‘You are not married?’ he asked.

‘Correct. Don’t think I would be here if I was,’ I answered with a laugh. ‘It’s not that I am not open to it. I am sure my time will come.’

‘You will need a wife,’ he said. ‘Someone to take care of you when you get sick.’

Sounds nice actually, maybe he was on to something.

Marriage does come with a lot of headaches though. Headaches that I don’t know would benefit me right now. Case and point, the first patient presented at conference the following morning.

‘Hello colleagues,’ the white-coated resident said while looking down at his hand-written notes. ‘This morning I would like to present the case of a 28 year old woman admitted to the ICU, who presented to the emergency department after an attempt of suicide secondary to a quarrel with her husband. She took some amount, possibly 10 to 20mls of liquid pesticide found in a shed before presenting to us and then progressively showing worsening symptoms of organophosphate poisoning.’

Organophosphate poisoning, I thought to myself. That’s one I haven’t come across since my time studying for licensing exams in Ireland. As the conversation between the residents turned Nepali I took the time to refresh my memory and look up some finer points on my phone.

Organophosphates are commonly the active component in pesticides and can be quite dangerous. They are an interesting toxin class, because they can be consumed inadvertently by agricultural workers, either through inhalation while spraying or even through the skin when clothing unintentionally gets wet. In humans its main action is the blockage of an enzyme that breaks down the neurotransmitter acetylcholine at the level of nerve cell communication. This means that acetylcholine receptors go into hyperdrive through constant stimulation. The effects are multifold, but as a general principle these receptors act both at the muscle tissue and also as part of what we call the parasympathetic nervous system that antagonises our ‘fight or flight’ sympathetic nervous system. As a result, the body winds up doing all the things opposite to fight or flight, which means the pupils get small, the digestive and urinary tract goes trigger happy, the heart rate goes very slow, the skin goes dry as sweating is shut down, and people can enter a coma from effects on the nervous system. The typical board exam question is of the farmer found unconscious with soaked clothing, usually with signs of having defecated or urinated, a fever without sweatingt, and small pupils. Our patient took things a step further and drank it directly from a storage container.

Given that I did my medical training in centre city Dublin, and then my specialist training in centre city Philadelpha, I didn’t have loads of exposure to unconscious farmers in my clinical practice. This was one where I got to be a student again.

As we sauntered up to the ICU, I put on my infection control gown and went to review the patient at the bedside with the residents. A new face stood among them, wearing a wool suit. He was somewhere in between young and seasoned, probably in his early forties, with a fit build and clean haircut atop a face with rounded Nepali features. His name was Dr. Udip.

‘It is nice to meet you doctor,’ he said. ‘We have been so looking forward to your arrival for the ultrasound training.’

I shook his hand.

‘I am happy to be here, thank you for having me,’ I said. Then I looked down at the patient in front of us.

She was on four limb restraints, wriggling around in the bed. Her eyes were clenched shut and a feeding tube inserted through her nose drained dark black fluid (gastric liquid stained by activated charcoal used to prevent absorption of poisons).

‘OP poisoning,’ Dr. Udip said with a nod.

‘I will have to admit that all I know about it comes from textbooks,’ I said. ‘I worked in a big city and didn’t see any cases at all during my clinical time.’

‘We see a lot of it here,’ he said, scanning the patient. ‘In theory its mortality should not be so high, but here it is commonly mixed with other compounds and the course can be long and complicated. In the last year we have had patients remaining in the ICU for weeks and weeks. We had one in the summer that was here for 81 days.’

‘My understanding is that management is typically supportive, is that right?’ I asked.        

‘In some way,’ he said. ‘We use atropine to counteract the effect of the drug, which depending on the patient can mean sometimes small doses and sometimes massive doses. Once the patient is effectively atropinized, we have to maintain that level of atropinization and taper slowly, which can take weeks. Then we control the other things as needed, like fevers with paracetamol and seizures with benzodiazepines. In the meantime though patients can get many complications of being in the ICU. I find the biggest risk of mortality comes from the elevated heart rate they maintain when on atropine. After weeks and weeks of this, patients can develop reduced cardiac output and die. I have seen this happen many times sadly.’

He was describing the process by which the drug atropine indirectly serves as an antidote for the poison. As the cells are driven to hyperstimulation, Atropine binds to some of the acetylcholine receptors and turns them off, essentially outcompeting the acetylcholine. While this does stop the harmful effects of excess parasympathetic stimulation, it has to be maintained constantly while the body generates new enzymes, which can take weeks, condemning the patient to the ICU with muscle paralysis and complications of being bed bound or intubated while you continue bombing them with atropine to counteract the toxin.

‘How do you know when the patient is atropinized? Pupil size?’ I asked.

‘Well, it’s a combination,’ he began, while directing me to a hand-drawn table in the chart. ‘We look at heart rate, pupil size, urine output, bowel sounds, and bronchorrea. The residents will examine to make sure there are no bowel sounds and no lung crackles and modify the dose as needed. It’s never really just one parameter. I would maybe say urine output is one I use most. The poison makes them produce a massive amount of urine so we target to get it down to 0.5 ml per kg per hour.’

This just means the poison makes you pee a lot so we give enough antidote so that patients pee a little. All new territory to me and I was stoked.

Despite how enthralled I was, the patient herself was in a lot of danger. She was requiring fairly high doses of infused atropine to maintain target parameters, which meant that she would probably stay in the ICU for a while. 

A few days later, we walked into rounds to find her very agitated. She was wigging out, and her vitals were all over the place. After some time she settled and we moved onto the wards when one of the residents, Ajay, got called down to evaluate her. She had a seizure and required to be put under with a breathing tube. Thankfully, that proved to be the zenith of her illness, likely the consequence of being under-atropinized. The team was able to modify the infusions and she was extubated the next day. After around 12 days she left the ICU and we saw her on the wards.

‘You must hug to show us that you’re all better!’ Dr. Pandey said to her and her husband at bedside.

They embraced in appreciation for the cheerful tone to what was clearly a terrifying ordeal for both of them.

Marriage, am I right?

I wish I could say this was my only experience with acute poisonings at LMC. In honest truth, poisonings were probably the single thing I remember most clearly about my time there. In the month I saw OP poisoning several times over, accidental and deliberate. I also saw countless patients with alcoholism, the most common legal poison worldwide. I also saw a case of one agent  more terrifying than both: Yellow Phosphorus.

It was a patient that was admitted the same day as our lady with OP poisoning. Dr. Udip stood next to me in the ICU. In the bed there was a kid, probably not older than 20, he sat up looking a little bummed but otherwise as healthy as anyone else in the room.

‘This is a patient who took rodenticide during an act of self-harm,’ the resident said presenting the case.

After the resident finished, he went over the labs and vitals, everything was stone cold normal.

Dr. Udip’s face didn’t match the relative well appearance of our patient. Focused eyes peered through his aviator glasses.

‘This has me very worried, we must watch him closely,’ he said. ‘These phosphorus based compounds in agricultural toxins have a very scary course. Patients come in after taking them and appear fine. Then the liver toxicity kicks in several days later.’

I nodded along

‘I have had patients die,’ he said. His face was somber. ‘We will have to hope that is not the case for him.’

We rounded on him for the next three days and he was just as normal every day that we saw him. On the fourth day of admission he was transferred up to the wards. 

The next morning I was rounding with Dr. Himal. Looking at the patient, I noticed the lighting made his skin look a little yellow…

‘Look at this,’ Dr Himal said pointing down at the chart.

His liver enzymes were in the two thousands.

‘We were going to plan for discharge today,’ he said.

‘Hold on,’ I said. ‘Surely it can’t be that sudden.’

I flipped a page back, 24 hours before, his enzymes were normal. I read them both back over twice. I couldn’t believe it.

My heart sank into my stomach.

‘What’s the likelihood we can get him evaluated for a liver transplant?’ I asked.

‘Not good,’ Dr. Himal said. ‘We can try to refer him to a centre, but it’s very costly.’

‘And livers are hard to come by,’ I said.

‘That’s right,’ he answered.

The thing about acute liver disease is that even when the liver totally shuts down, it takes time for the toxins it usually clears to start building up. It also takes time for all of the blood clotting factors to be depleted with the liver unable to make more. The onset is progressive, a slow march towards the breakdown of dozens of life-sustaining functions maintained by the liver.

I looked at our patient lying on his side in bed. I found his face hard to read. I couldn’t tell if he really understood. I want to say he was scared but I can’t say that he was. Maybe it’s because I was scared for him. My soul cried out as I looked at him.

He was going to die.

Sure enough, by end of day he was sent to another facility in a hail-mary attempt to get him expedited for a transplant that would never happen. He went into shock shortly after arriving and died in the next few days.

He was 20.

The many poisonings of LMC brought into focus one of the recurrent themes of rural poverty and its consequences: mental health. I think in medicine we commonly think of infections, or malnutrition, or maybe even interpersonal violence as the things that disproportionately impact the rural poor. However, substance abuse and mental health slots right near the top in my experience. The examples in our own communities are plentiful; I think of the opioid epidemic in the US that started in the American rust-belt of the Appalachians, or the Canadian and American indigenous communities that carry disproportionately high rates of substance abuse. The rural poor have suicide rates that double the urban poor when studied in North America, and although I don’t know the world-wide data, I can nearly guarantee that holds true globally. The reasons for this are multifold: more lack of opportunity, more isolation, increased menta health stigma, and access to lethal means (guns and poison) are just a few. I think much of that comes from the same generational traumas that underly poverty which breed people to self-medicate with substances of abuse or commit acts of self-harm.

I thought about our Yellow Phosphorus case for a while through that afternoon and into the following days. Could I imagine a more harrowing experience? Sitting in a hospital bed feeling fine, waiting for an inevitable wave to come over you with everyone watching? It makes me think of that song, ‘what would you do if today was your last day,’ or something along those lines. I don’t know what I would do.

That’s probably where I’ll wish I had a wife.