Waiting….

(Please remember not to share this on social media. Thank you!)

I (Les) have not been allowed to work this past week. My work permit and registration at the Nepal Medical Council both expired on Sunday, November 22, and have not been renewed.  In fact, the same thing happened to all the foreign missionaries in Tansen.  At least for me, as a US citizen, I have a 3 year visa in my passport. Those on our team who are not Americans had to go on a tourist visa to stay in Nepal legally. But none of us are working until we get the work permits. Since we arrived here 30 years ago, this is the first time we have had to stop working. This is the result of several unfortunate things converging at the same time:

1. When the last 5 year agreement was expiring in January, a new agreement still needed to be written, so we were all given 6 month extensions. But the government decided that the UMN hospitals should no longer be managed by a foreign mission, but by a trust set up in Nepal.  This is probably the result of increasing nationalism and Hindu lobbyists gaining more influence. This was announced in May, and we were given another 6-month extension to allow time for the legal work of forming the trust. UMN now has the trust established, but there was not enough time for the hospital agreement to be made before time ran out on November 22.

2. Nepal’s new federal system, written into the constitution that is being implemented now, means that the provinces have more self-governance rather than everything being managed from Kathmandu, the capital. Unfortunately, it is still not clear which powers are being given to the province. It seems that everything now requires approval from both the province and the federal government, doubling the bureaucratic red tape and administrative hurdles. The hospital is getting registered as a new community hospital in the province. But the provincial office staff are learning how to do this themselves, apparently without much guidance on what this process should involve. For example, they requested that the personal information and professional qualifications of all 400 staff be photocopied and submitted. Now that all details have been submitted, they are waiting for a committee with a radiologist, pathologist, physician, and managers to meet so they can review our application. The work in Kathmandu to get our visas cannot go forward until the hospital is registered in the province, and UMN and the government have a working agreement signed.

3. Dashain and Tihar, the 2 main holidays of the Nepali calendar, fell late this year, so most government work was shut down or running with minimum staff from mid-October for a month. And usually when the person with power to authorize something is on holidays, their duty is not delegated to anyone else, but left until that person returns. So right when the crunch was on to figure out an extension or some other deal, nothing was happening until right up to the last few days before time ran out.

4. Lock down and work from home during the Covid-19 pandemic affected all work by both the government office staff as well as the UMN staff working in Kathmandu. Even the hard working ones were struggling to get things done that had been previously managed efficiently.  

So while we are forbidden to work, we are taking a break, and have come to Pokhara for 3 days to celebrate my birthday. (We returned safely to Tansen last night) We are also praying about how long we should wait in Nepal for our work permits, before we take a longer break, returning to the USA to see family and friends. On the one hand, we don’t want to leave if God wants us to stay, and if the work permit will be approved soon. But on the other hand, it is even harder to be away from family when our reason for being here, working in the hospital and ministering to patients and visitors, has been taken away for an indeterminate amount of time.

The hospital has been struggling along with only the Nepali national staff working, at least the ones who have not been quarantined for testing positive for Covid-19. Thankfully no staff are critically ill. Hospital work is now running at under 50% of our normal capacity. It is hard to see patients waiting for tickets to be seen, or giving up and going home without care, when we are right here and willing to help. It is also sad to think of the new junior doctors, who still need a lot of supervision and support from the senior doctors, losing half of their mentors. We are certainly thankful that we have at least a few good senior Nepali doctors working hard to keep things running.

So pray, pray, pray! God knows what He is doing, even when we don’t. We are trying hard to see where God is going with all of this, and to join in with Him rather than to fight against Him. Thank you to everyone who supports us in prayer, especially in these coming days.

Les turns 60 in Pokhara. Cookies and coffee for breakfast!

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Families in hard times

(Please remember not to share this on social media. Thank you!)

Little Khari was just six months old. She lived in a mud/brick house in the village with her older sister, her mom and her grandma. Her father was away in India, trying to earn a cash income to support his family. Until the lockdown (Covid) he was working a good job at a hotel, but that ended in March. He decided to remain in India in hopes of finding some other work, as he knew there was nothing he would be able to do in Nepal. Other than a small senior citizen stipend that the grandmother receives, this family had no money coming in on which to live.

Village home
Cooking in a village kitchen

The family did have a little land, and they could grow enough to feed themselves for about 4 months of the year. However – there was only the mom and grandma to work the land and plant the crops. They also had to care for the one oxen they owned.

Look closely – there are oxen and people in those fields. Usually they are located far from the owners’ homes.

One day, Mom and grandma had to both be out working in the fields. Khari was left with her older sister – who was just a 2 year old toddler. At some point, Khari rolled into the fire used for cooking and began to scream and cry. Her mother was too far to hear, but a neighbor heard the cries and went to investigate. She pulled Khari out of the fire and took her outside and called the mother.

Khari was still conscious when her mother got to her, but her legs were badly burned. Due to the lockdown, getting any transport was difficult. They managed to get her to a nearby hospital, who referred them to another, bigger hospital in Butwal. That hospital also said they couldn’t help Khari and suggested they go another hour up the hill to the Mission hospital in Tansen.

When they arrived in our Emergency room, the doctors immediately admitted little Khari. She had 12% burns on both legs below the knees, and 2% were deep burns. She received various treatments here – and the mother was provided with a high protein, nutritious diet so that she could breast feed Khari and help her to heal.

Mom holding burned baby at Tansen Mission Hospital

This family had to borrow money to get to the hospital – and if it weren’t for the gifts sent by people like you to help give free care for poor patients, little Khari wouldn’t have been able to obtain medical care. Her mother wouldn’t have been able to get good meals in order to gain strength to be able to feed and care for her baby.

Lockdown and Covid have affected us all – but these people who had so little to start with are struggling so much. We are so thankful that – because of you – the hospital can be here….still open and serving the most needy among us.

Khari did fully recover and was able to return to the village with her mom. Thanks for your prayers – and for your support!

Mom and happy baby at discharge time

 If you are interested in hearing more stories, and about the joy that Les finds in serving here each day, please sign up to hear the Virtual Itineration on Thursday, November 12 at 11 AM Eastern time. You need to register in advance: https://gbgm.zoom.us/meeting/register/tJ0sdeyqrz4jE9Iv_j4EZe78ZHEJEcS9C_N3

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Tested!

After almost 3 days in isolation, the staff who had been in contact with the covid positive patient (5 days previously) were called to the tennis court on the hospital compound to get their swab tests. The process took about 2 hours to get everyone done.

Lining up for testing

In between each test, the area was disinfected.

As the time went on, and more were tested, eventually the guys in their hot, plastic PPE had to walk away, and take off their head gear to cool off a bit! Then they suited up again and returned for more tests….

Les was one of the final ones done.

We were so thankful to get the results in 24 hours – and to learn that Les and all the others tested that day were negative! I don’t think an hour passed before Les was dressed and back at work at the hospital. Hmmm – maybe he wasn’t enjoying all that time alone with me?? 🙂

Unfortunately in other testing, it was found that 4 staff had turned positive. They are not sick, but are currently quarantining.

The medical ward was emptied of patients, and has been completely cleaned and disinfected. Tomorrow out patient clinics will resume again. Although – patients never stopped coming – and our maternity ward is filled and overflowing into the surgical area!

Thanks for your continued prayers for the hospital. We are so thankful that in spite of difficulties, the Mission hospital can continue to serve the people of Nepal.

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Quarantined!

I (Les) saw her on Tuesday morning rounds. She had been admitted on Monday by the surgical doctors with a breast abscess (collection of pus in the breast tissue). But the surgical ward was full of patients, and since the medical ward still had empty beds that day, she was put in the medical ward. She was started on antibiotics, and the pus was drained on Tuesday morning by the surgeons. After she returned from the procedure, the medical ward nurses asked me to write the order for her to be moved to the surgical ward, since there were now empty beds there. But I noticed the surgeon had written that during the procedure her oxygen level had been unexpectedly low, and she was now on oxygen. I went to examine her, to see what was happening.

She was in a regular bed, in a ward with other medical patients. Everyone was wearing masks, which is now our routine, both for staff and patients. She said she had no breathing difficulty or coughing, but I could see she was breathing fast, and her lungs had crepitations, a crackling sound caused by infections such as pneumonia. I added an antibiotic to treat pneumonia, and asked for a chest X ray. I also asked that she be kept on oxygen in the medical ward, rather than moved to the surgical ward. When the X ray came back, she indeed did have signs of an infection in her lungs. By evening she was breathing a little harder, so she was moved to the room for critical patients.

Wednesday morning on rounds she was about the same. When the team discussed the case, we considered the possibility that this could be Covid-19. There were now increased numbers of cases in parts of Nepal, including transmissions within those communities. Although we had not seen many cases yet, we were expecting more to come. We asked for her to be tested for Covid-19, which we are still unable to do on site, but must send the sample to the regional government testing center. While the test result was awaited, it was decided to send her on to the government Covid-19 hospital in Butwal, over an hour away, which was done on Thursday morning.

Her result came back Thursday evening as positive. It was decided that all staff who had contacted her directly would be put in isolation until tested for Covid-19, but all would have to wait until 5 days post exposure. 18 of our doctors, including me, were identified as having had contact with her, as well as quite a few nurses and other staff. On Friday, the remaining doctors mostly spent the day discharging anyone from the hospital who could be, and seeing emergency patients who came.

In my second day of isolation, which feels a bit like solitary confinement, I have had some time to think things over. We are quite a pair here in our house: one of us not allowed to leave the house (me), and the other unable to do so (Debbie), due to her broken leg. We sent Sarda, our household helper, home, so that we wouldn’t be exposing her and putting her whole family at risk. We are also trying to keep safe distancing between the 2 of us, wearing masks even in the house and washing hands a lot. We are trying to stay thankful and to keep trusting God, by doing spiritually uplifting reading and watching some shows (thankful for internet!!), praying, and keeping in touch with family and friends. What is God’s plan for us during this time when we feel like we have absolutely nothing to contribute? I hope to use some of the time to think of our hospital procedures again, to avoid this kind of shut down, and to prepare presentations I need to give in the future. Perhaps we just needed to stop doing our “busy work” and to “be still”. And – I am now the chief carer for Debbie – she says I’m getting good at making chiya and getting her the things she needs!

Debbie is still not able to bear weight on her leg and uses crutches just to get around in the house. Most of the day she has to keep her leg elevated, and she continues to do her physio exercises. In 2 more weeks she will get another x-ray to see how the healing is progressing. Thank you to so many of you who have emailed and been praying for her. And now – thanks for your prayers for us! I should get a swab test done on Monday, and we are praying for negative results.

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A little singing and dancing….

There are days when I feel as if things will never change… every day is the same, every week, every month.  I stopped counting lockdown days at 100… and I have to say how thankful we are that just yesterday restaurants and hotels in our town opened again so we could enjoy a meal “out” – the first in months.  We were excited! (We do still wear our masks out in public and in the hospital!)

No one knows what the future holds – but we are hopeful that things will continue to open here to make people’s lives easier.  We are thankful that bus service within our district has opened so that more patients can make it to the hospital.  So many were waiting until too late to come or arriving much sicker than normal.  The maternal-mortality rate had skyrocketed due to the lockdown.  Now our outpatient clinics are almost at capacity again, and the wards continue to be full.  The doctors and staff are working hard!

As for covid patients – we have had very few.  For awhile, there were dozens of positive cases housed in isolation areas near us.  Virtually all were young men who had been working overseas or in India and had tested positive upon returning to Nepal.  They were housed and fed – and entertained themselves by singing and dancing.  All have now been sent home to their villages after their 2 weeks of isolation.

The schools remain closed in Nepal.  On our hospital compound, there is the small “tutorial group” which has been the school for missionary kids for many years.  In March, there were only 2 students in the school – a brother and sister from Korea whose dad is a surgeon here.  Also living on the compound were 4 other young school aged children who were home with nothing to do (their school was closed).  We decided to make a change and to invite those children to join the school for several hours 4 days a week.  We got a couple of volunteers (including myself) and the school has been very lively these past weeks.  We are thankful we can help these children to have a bit of “normality” during these strange days.  I tutor the oldest Korean boy 3 days a week in English – he is doing great!  We just finished reading “The Magician’s Nephew” which brought back so many memories of me reading to my own children here during our homeschooling days.  I also have been doing music once a week again – now that there are enough children to make it more fun!

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Flights into Nepal are scheduled to start again on Aug 17.  We wait to see what will happen.  We continue to pray for Nepal, for the U.S., and for the world – for an end to the virus, and for an end to the hatred and division which seems to loom so large in these times.  Let us love each other as best we can!  And take time to sing and dance a little – it can brighten your day.

 

 

 

 

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Our (dirty?) laundry…Not anymore!

Many years ago (30 now!) when we first came to Nepal, we were told by the Methodist church (our sending agency) that they would pay for certain appliances and necessary items for our home in Tansen.  This list included things like beds, table and chairs, gas cooker/oven, and refrigerator.  However – one item was not included – a washing machine.  At that time, I will admit that no one had a washing machine in Tansen.  That is one of the reasons we had a house helper – to wash all our laundry by hand.  I remember getting blisters on my hands from wringing out diapers during the occasional absence of our house helper, so when my parents came to visit us soon after Hannah’s birth, they brought a “mangle” purchased at an Amish store!  (For those too young to know what this is:  https://en.wikipedia.org/wiki/Mangle_(machine) That was amazingly helpful for our remaining 10 years in Nepal with kids.

During our almost 10 years in the U.S., I once again enjoyed a washer – but I still clung to the habit of hanging our laundry out on lines to dry as much as possible.

In 2012, we returned to Tansen and found that our househelper (same one as before) had aged right along with us, and doing our laundry by hand was harder for her!

So, when a family left Tansen soon after our arrival, we purchased their machine – a simple twin tub washer which you filled with water, washed, moved the clothes to the other tub which was a spinner, then refilled the other side with water to rinse, and then another spin.  It was a good system, but still could use quite a bit of water – even though we drained it into buckets and used it on the garden. It was also a bit time consuming.

twin tub washer.2

This machine was kindly paid for by good friend of ours in the U.S.  Because, our sending church still did not consider a washing machine as a necessary piece of equipment. Now – I do want to say that Global Ministries and the United Methodist Church are a great supporting agency.  They pay us a salary, give us insurance and support us in many other ways. We are so thankful for them and for many people who support us!  I just find this particular rule a hard one to understand sometimes.

We used to think that washing machines used more water than by hand – but that isn’t always the case.  People here run water from the tap the whole time they are washing – filling bucket after bucket of water.  Frustrating in a place where water can run short.

We moved to another house 4 ½ years ago, and got to use the machine left here – a front loader which was amazing!  It used so little water and was very efficient.  But – it was old, and leaked, and then – right after the lockdown started here – it quit.  So – we had no househelper (due to the lockdown), no washing machine, and no shop open in order to purchase a new one!  I “borrowed” other people’s machines who lived near us to get through this time.  No – I didn’t go back to doing our laundry in buckets.  (Even though we were remembering that way back when I used to wash our laundry by hand even on family vacations in Nepal!  I was younger then…)

So – imagine my delight this past week when shops opened up, and I found just the type of frontloading washing machine that I wanted!  We got our old machine taken out of our house (and had to remove the bathroom door in order to get it out!) and I scrubbed the long-neglected floor under that old machine to prepare to get our new one!  The next day, a “bokne manche” (a person who makes a living carrying things on their backs) was dispatched from the store in the bazaar to bring our machine to our house.  (That walk takes us about 30 minutes only carrying ourselves!)

They brought the machine to the house, and our workshop guys helped us install it.  (They also rehung the door!)  Now – I am so happy to be able to put the laundry in our new machine, and not have to run up and down the hill to where I had been using another machine (which was one of the twin tub types so it meant multiple trips per load).  Sometimes I go and watch our new washer work – just for entertainment! (Les has threatened to put a bow and ribbon on the machine and say that it is my anniversary/birthday present.  Actually – I am okay with that!) 😊

new washer

Life in Tansen goes on – and we are thankful for small mercies, like washing machines!  If you have the time, watch the “magic washing machine” TED talk.  I found it quite fascinating! https://www.youtube.com/watch?v=6sqnptxlCcw

Thanks for your prayers. Thanks for reading this more light-hearted look at our life.  During these days of so many difficulties, we hope it brings a smile to your face.  We think of you and pray for you. Stay well!

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Needed: God’s Mercy and Grace

I have written this blog post at least 3 times – and it just hasn’t been right.  I find it very difficult to put my thoughts into words.  Please accept my rather rambling jottings as I try to share.

This is day 72 of our lockdown in Nepal.  For many, many days, the numbers of patients in the country stayed very low.  Then, a couple of weeks ago, the numbers started rising quickly, and now the positive count is over 2000, with 8 deaths.  On top of that, we actually got our first positive cases here in Palpa on Sunday evening.  Right now, we have 5 positive (but not sick) men in isolation in a small building just outside the hospital.  Our staff is helping keep an eye on things there.  In our isolation room at the hospital, we had one man die yesterday (but his test results haven’t come back yet) and another man waiting also for test results.

The government decided to once again extend the lockdown until June 14, and the airport is closed until June 30.

When the first news came through here about the terrible death of George Floyd, we also learned of 2 young dalit (untouchable caste) men who were killed in a nearby district.  One of these young men had fallen in love with a high caste woman, and he and his friends were on their way (according to Nepali custom) to meet her at her home and then they were going to get married.  The hopeful groom and one of his friends’ bodies were found later by the side of a river.  The other friends had run for their lives. These young men had apparently been beaten to death by high caste villagers who were against an inter-caste marriage.

My heart breaks for those who have no voice.  The poor, the oppressed, the children. I pray for God’s mercy on us all and long for the time when we can care for and love each other better.

I know that many of you are also praying for this world.  I am thankful to so many of you who have loved and supported us and the people of Nepal for so many years.

I am attaching a link to a short video recently put together by our surgical team here.  Thank you, in the midst of all the chaos and need, for taking time to read my words, and to listen to this video. #stillinmission

https://www.umn.org.np/news/844

God Bless You!

 

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One who believed…One who was healed

It was 8 years ago today that we returned to Nepal to serve again at the United Mission Hospital, Tansen.  When we were applying to come again, we had to put down how many years we were willing to be here.  Les said, “10 years?”  I was quite emphatic in my response, “No way!”  And here we are – 8 years gone by already!  I am reminded again that it is good (for me) that God doesn’t tell me in advance His plans!

Last month I was privileged to visit the New Life Psychiatric Rehab Center for a Prayer service for the new building.  It wasn’t quite finished, but people were visiting and it seemed a good chance to gather and thank God for the work done, and pray for the future needs.IMG_3103

The building looks great – it will be wonderful to be able to house more people who are in need of care – those with mental illness or other problems who have no family to care for them, and no other place to get help.  Currently there are 9 clients in the facility, but this will more than double the amount who can stay there.

It was encouraging to see the animals being cared for, and fields and crops being raised and used to help create some financial support for the clients and staff.  It isn’t much, so there is still a big need for gifts from outside to fund the running of the NLPRC, but it was good to see the residents themselves able to do their part.

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I met a man there named Karka.  He had been kept chained up by his family, and was brought into the hospital with deep wounds on his wrists from being kept in bonds.  The bones were visible, and there was so much infection that one of the orthopedic doctors was sure that the hands would need to be amputated.

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Pun Narayan, who is the force behind this center, and also the head of the Pastoral Care/social services department at the hospital, didn’t want to see this amputation happen.  He prayed – and he believed that God could do anything – including the full healing of Karka.

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And it happened!  Yes, he has some scars to remind him of what he went through – but he has full use of his hands and is able to remember that God was the one who healed him.

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I am sure I do not have the faith of Pun Narayan.  I continue to be humbled by our Nepali Christian colleagues.  Even though they always ask us to speak at gatherings, lead bible studies, or teach them, I am constantly thinking that it should be the other way around.  I have so much to learn from them.

Please do continue to pray for the NLPRC – that the new building would be completed soon, and that the staff would remain strong and faithful in their service.  And pray for us to be humble servants willing to be used as God asks.

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Breathless

I’ve been thinking of writing the story of a man who came in struggling so much for breath, that Les and the other doctors didn’t think he would make it.  But as I typed the title, I thought it also described the start of 2020 for us…waiting for our visas!  Many of you know that the hospital agreement with the govt expired on Jan 15.  We did get a 6 month extension, however, that didn’t automatically translate into new visas for the expats.  As we prayed, sent documents to Kathmandu, and waited for word, it really was a rather breathless time!  Would we get to stay?  Have to go to a tourist visa and stop working?  It was unsettling!  But – thanks be to God, we all got visas stamped into our passports on Jan 15 – the day the old visas expired.  Last minute answer to prayer – but we are sure in God’s eyes it was just at the right time.  Please continue to pray for the hospital agreement which needs to be completed soon!

Our good friend, Steve, from Australia, wrote up his version of what happened the night the breathless man came into the hospital.  He is an anesthesiologist who spends a year in Australia working to earn money to support himself here for the next year.  He and his wife have been doing this for probably 10 years now (or more) and we are so thankful for them.  And we miss them when they are not here.  I hope you enjoy his version of events. (This does have medical terms and explanations, but I think the story is still interested to non-medics, too!)  After reading his, I didn’t feel I could say it any better. (Les thought he was spoken of too highly in this version – but I thought it was right on target!)

“My phone buzzed at 4.30am. My anesthetic staff asked could I come to the  High Dependency Unit (HDU) to help intubate at patient with Acute Respiratory Distress Syndrome (ARDS). ‘Dr Les had asked.’

 I had been deeply asleep and couldn’t put two thoughts together. Dr Les, however, is a walking legend who never asks for anything from anyone, and who can be trusted in that way where you just start assuming whatever he’s asked for is a good thing. The default position is trust and you can discuss it later. I was not in the position to discuss anything – I could barely remember my own name.

The temperature was about 42 outside and probably all of 50 in my bedroom. I fumbled about trying to dress in the dark and not wake Ana. I couldn’t find clothes, I couldn’t make my rapidly cooling body work, I nearly left without glasses without which not a single thing, near or far is in focus. I eventually left the flat and managed to negotiate the 2 padlocked gates, and 50m of downhill cobblestone that separate me from the HDU.

Every day for the previous week, we had had a one hour ‘class’ on HDU. There are only 3 of us in the hospital prepared to care for a ventilated patient, and we are trying to increase that pool, just as I am about to depart it for another 12 months. We have an old ‘home ventilator’, a Puritan Bennett LP6, from the 1980s maybe. While fancy touch screen Evitas have been donated and another old German machine has been donated, it is the LP6 that has outlasted them all. I have lost count of the number of successful snake-bitten patients we have seen through their paralysis with it. We jerry rigged a way to enhance the oxygen intake by attaching a reservoir to the air inlet. It did 5.5 weeks non-stop for Govinda the Guillain-Barré Syndrome patient. It’s proved to be a good choice for our setting – running on electricity not compressed gases, with dials, not electronic controls, with a simplicity and durability that suits our ABG (Arterial Blood Gas) free hospital.

The classes focused on the ventilated patient in our hospital: our protocols, our habits, our successes and failures, our budget and indeed, our LP6 specifically and how to get a healthy but paralyzed patient through the 2 to 6 days that they are ventilator dependent due to their snake bite. The first minutes of the first class were about ‘Who to ventilate’ and I had been pretty blunt in saying we didn’t have the equipment or staff for people who had bad lungs. In fact I admitted that we ended up giving most of our snake bite patients pneumonia anyway, despite them starting off with good lungs. Sure, there was room to change the rules, and the new mother I had ventilated just before the Dashain holidays for 3 days, was a good example. In her case she was badly hypoxic, but all other organs and functions were working well. She was previously well with no diseases – and she was a brand new mom. But the general rule was: Good lungs, single organ or system disease, and for learners: snake bites only.

Dr Les had been in those classes all week. The cold air woke my brain enough to wonder, as I skipped from torchlit stone to torchlit stone, why Les thought it OK to intubate and ventilate a patient with ARDs, and how he had become involved since he wasn’t on call anyway.

My phone rang again – ‘Are you coming?’ – and a few minutes later I arrived to see an older man, breathing like a train, hypoxic, cyanotic, with a good spO2 trace on the monitor behind him, a reliable trace reading 60%. He did not appear to be conscious, did not respond to my voice and had small pupils that were asymmetrical and sluggish. Surrounding him were the medical and surgical juniors on call, the senior medical on call, who was also an HDU class attender, and Les, and the junior anesthetist on call…plus a bunch of family members. He was not only breathing, but he was being bagged – somewhat synchronously by 2 of the junior doctors.

The history was that he was normally healthy and had suddenly become short of breath at 12.30am. It seemed to come out of nowhere – he had been fine the evening leading up to it. In a time-unconscious society, it was interesting that the family could name the exact moment it all started. He had been transported quickly to the hospital, en route, completely inconsolable and tearing his clothes off in the freezing cold air, desperate to breathe. He’d already failed CPAP, and now was failing being bagged in time with his breathing.

I felt a bit of a failure as a teacher. He didn’t look remotely like a patient I said was suitable for ventilation in our little hospital. His brain was not working, his lungs were not working, he was older and as for ‘should have a good chance of recovery’ – he appeared to have no chance. He didn’t look like someone who was going to last the night, or even the next hour. Add on to that a chest Xray that looked like a big heart with some early failure, his ECG a resting tachycardia to 130 with widespread ST and T wave changes – and current BP of 170/70 … I assumed he was dying before us. I suspected a big PE or an AMI. I suspected that an attempt to intubate him would see him die from his profound hypoxia turning into complete anoxia, while the tube was finding its way to the right place. I said: “No. He is not going to survive, and he might not even survive the intubation.”

I don’t like saying no, but we have been down these roads and the implications for the patient, the family, the next patient to land in the HDU, the hospital in general, the morale of the nurses and the 3 of us willing to look after a ventilator and the patient attached to it … no one gains anything except practice in grief. The medical on call had done the right thing I had taught in the ‘class’ – “the decision to intubate and ventilate is a big one and should be shared between a minimum of 2 senior doctors – this is especially helpful when the decision is not to ventilate – you don’t want to make that decision alone – share that grief.” So he was the one that had called the ever helpful Dr Les out of bed. I had also taught: “the anesthesia service is excellent and can intubate your patient for you in the HDU – they are on call 24/7” … which is why the junior partner of the anesthesia on call team was present  … it was her, that had called me. I guess at least some of the things I had taught were learned and being put into practice.

I trialed CPAP again and made the patient worse. I drove the O2 sats down to 40% with a good trace and a color that matched the numbers. I sat him up, put on an oxygen mask, the non-rebreathing  type with reservoir bag, and he returned to 60% with huge breaths, a very long expiratory phase, wheeze and he remained deeply unconscious. The sats didn’t fall and the medical on call told the family yet again he was not likely to live and we couldn’t ventilate him. I left and returned to my day off, as the sun was threatenSteve anesthetisting the horizon.

The next day I asked Dr Les how fast the man died – Did he make it to ward round a few hours after I left? Les said, he did not die, he in fact was about to have a trial off oxygen altogether! I went to the HDU, about 28 hours after I had condemned him to fade away without what I assumed would be a cruel and fruitless intervention, if he was to in fact survive its commencement; – and here he was sitting up in bed, smiling, with a healthy look, easy breathing on room air with saturations in the mid 90s.

If I was a failure as an HDU teacher, then I was an abject failure as a prognostician.”

Just a note to say that Steve is not only a great teacher, but also a great doctor.  He (along with Les) is but one of the doctors here who serve with a humility that never fails to touch my heart.  And – these doctors give thanks many, many times for God intervening to save those patients who we feel are beyond the help we can offer here.  To Him be the glory!!

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Snake Tale

It was a rainy night in early August in a village a couple hours north of Tansen.  Something woke the mom in her typical Nepali mud house – and when she looked over to where her 12 year old daughter, B, was sleeping, something didn’t seem right.  As she lit a lamp in order to see better, she was shocked to see a large snake wrapped around her daughter’s neck!  It was a Krait – and it had bitten her!.  The mom yelled for her husband, and they managed to get the snake off of her and killed it.  They realized they needed to get help as soon as possible.  Calling for an ambulance from where they lived wasn’t possible – so the father hurried out into the night and managed to find a vehicle willing to drive them to Tansen.  They started off towards the hospital.  Unfortunately, the car broke down after some way.  They got out and found another vehicle and continued on in the dark and the rain.  This next car ran out of gas…but the third vehicle finally made it to the Emergency Room at Tansen Hospital.  By now, this young girl was struggling.  The Krait is the type of snake which causes paralysis of the nerves – and it was getting hard for this girl to continue to breathe.  Within minutes of her arrival in the ER, she had to be put on a ventilator as she was no longer able to breathe on her own.  She was moved to the HDU (High Dependency Unit), where she was given multiple doses of anti-venom, and the prayers for her healing began.

Les was doing rounds the next morning with the medical team, and saw B on the ventilator.  Her face, neck, and breathing muscles were completely paralyzed from the snake venom.  This made her look unconscious, except that she was able to weakly squeeze a hand when asked to do so, and to wiggle her toes a little. Her mother, who had stayed at the bedside all night, was convinced that her daughter was as good as dead, and was quite despondent despite assurances that she would now likely recover.  As they were checking her, they realized that perhaps she shouldn’t be a medical (adult) patient – Her mother said she wasn’t 14 as her chart said, but only 12.  So – she was taken over by the pediatrician and his team of doctors.  She has had a long journey back to health – she will hopefully be discharged in the next few days from the hospital.  She took a long time to get off the ventilator, and then developed a pneumonia which required intravenous antibiotics.  However, we are so pleased that B has survived and is now thriving and almost ready to go home.  Her smile lights up the Pediatric ward and warms our hearts.  Her family will be able to return to life in the village – and won’t go with a huge debt over their heads thanks to the generous giving of so many friends from around the world who support the Medical Assistance Fund.  Thanks for your continued prayers for Tansen hospital – and for B and her family.b-snake-bite.jpg

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