Clinical Work in Tansen

Now on day three of my pediatrics rotation at Tansen Hospital, I am getting the hang of how things work on the wards and in clinics. Each morning at 7:45 AM the medical staff meets for devotional time - Bible reading and prayer - followed by presentation of the cases admitted overnight on the different services. Then we round on the inpatients. At any given time, there are around 30-40 patients on the pediatric ward, not including the newborns on the maternity unit or the orthopedic and surgery cases. We see each patient every day, which usually takes until 10:30 or 11:00. Then we have tea (chiyaa) before heading to outpatient clinic, where there are some 70-80 patients to be seen each day. "We" consists of two interns, a general practice resident and the attending. Since I don't speak Nepali, I don't get to do much on my own, mainly observe. But I do ask lots of questions, and I get to examine each patient, so I am learning a lot.

On the inpatient service (kids in the hospital), we have many cases of typhoid fever and meningitis, as well as pneumonia and neonatal sepsis (newborns, especially preemies, with widespread infection). But we also have some unusual cases, such as this little 5-year-old boy, who was admitted with heart failure due to severe anemia. His hemoglobin was about 3 (normal is over 12!!). With such a low hemoglobin, his poor heart had to pump overtime to get enough oxygen to his body, and it just couldn't keep up. He is doing much better now after three transfusions, but he probably has some kind of congenital problem that will require blood transfusions for the rest of his life. We suspect thalassemia (a genetic defect in the production of hemoglobin molecules), but he will have to go to Kathmandu for the special tests to diagnose the problem. The mission hospital here in Tansen has agreed to help with the family's travel costs to Kathmandu, as well as the costs of long-term follow-up in clinic, lab tests, and ongoing blood transfusions.

Another interesting case is this 6-year-old girl with rheumatic heart disease, who also came in with heart failure and a huge murmur caused by diseased heart valves. Rheumatic fever is a complication of strep throat infections. It is relatively uncommon now in the U.S. because most strep throat infections are easily treated with penicillin. But here in Nepal, many families don't have easy access to health services (i.e., they have to walk for hours or days to the nearest hospital), so there is a much higher incidence of rheumatic fever. One of the most serious complications of rheumatic fever is damage to the valves of the heart, causing leaking of blood back across the valves when the heart pumps, instead of forward to the body. This can lead to back up of the whole circulatory system, with fluid in the lungs, congestion of the liver, and swelling of the extremities and abdomen - which is how this patient presented. She is doing better with treatment of her heart failure. An ultrasound of the heart will help us to see how much damage there is to her heart valves. She may eventually be able to get heart surgery in Kathmandu.

Unfortunately, not every story has a happy ending. Last night, one of our newborns died from overwhelming infection. He was delivered at home and developed an infection in the first few weeks of life. By the time he reached the hospital, he had to be intubated and placed on a breathing machine. Despite antibiotics and all the right care, he didn't make it. Yesterday, I attended a c-section of a woman with twins at 33 weeks of gestation. One of the twins was discovered to have died in utero due to a complication known as twin-twin transfusion (where one twin "steals" the blood supply from the other), so the poor mother had to undergo surgery to deliver one deceased baby and one premature baby. The living twin, weighing 1.5 kg (about 3.5 lbs) is doing well as of the time of posting this blog.

Please pray for these patients and their families. It is devastating to lose a child or to be told your child may never be normal and healthy. Most of the families are very poor, so the burden of caring for a sick child is enormous - not just hospital costs and medications, but travel costs and time lost from work to bring the child to town. I wish I could pray for these families in their own language. But at least I want to offer to pray for them in English if I can find someone to translate my request. So please pray that I will be able to demonstrate the love of God to them before they are discharged.