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Pericardial TB in the Last Mile

We were down in Sanfebagar, a large settlement about 45 minutes by foot from Bayalpata Hospital. It was a Saturday, the one day off in Nepal’s six-day work week. Several of our staff had taken the opportunity of the day off to organize a blood donation camp to stock our new blood bank, the only one of its kind for several hours. I stood outside with our community health workers and staff, looking on at the line of blood donors and chatting about our patients. We discussed one patient in particular, Nirajan, who lived only a few minutes from the donation camp. Nirajan is a nine-year-old boy who had been seen by our clinicians two weeks prior and diagnosed via ultrasound with a massive pericardial effusion. The diagnosis was not hard to make, and the etiology was almost certainly to be tuberculosis. Over 12 hours away from an intensive care unit or a cardiologist, our clinicians at that time made the decision that most rural doctors would make; they prescribed Nirajan anti-tuberculosis therapy and steroids.

What happened following the diagnosis hits at the heart of our healthcare delivery challenge and our own failures to move fast enough to meet it. Under the government system, our hospital can only dispense medication to patients who live within the boundary of our immediate village development committee. Nirajan happened to live in the neighboring village. His village is under the jurisdiction of the government-run Female Community Health Volunteer program. The community health worker who covers Nirajan’s ward—who we supervise and train as part of our public-private partnership—had for unknown reasons not been notified by our staff to follow up with Nirajan’s family concerning his treatment. Nirajan’s mother went to the local government dispensary for assistance, but found it unattended. Everyone had failed him.

This was two weeks ago. Now, Nirajan Khadka (our Associate Community Health Director), Roshan Bista (our Medical Director), and I made our way through one of Sanfe’s narrow alleys to come to his cramped mud house. There we found Nirajan with his mother, father, and two younger siblings. They greeted us and stepped outside.

His mother explained the situation that had led to his not receiving his medications. Nirajan looked on with a bright and inquisitive look, reminding me of my own twins. As is almost a cultural custom for citizens interfacing with doctors, she pulled out Nirajan’s plastic bag of records that contained his chest x-ray. I quickly confirmed his diagnosis. He indeed had massive cardiomegaly on that x-ray consistent with a large pleural effusion.

We requested that he visit the hospital the following afternoon for a repeat echocardiogram. We were aware of the strong possibility of Nirajan needing to visit our partner hospital located 12-14 hours away via jeep, possibly even to travel all the way to Kathmandu. Nirajan Khadka informed the family of this; the father stated that they had about 3000 Rupees ($35) for his care.

The next afternoon, his mother brought Nirajan to the Hospital. We performed his echocardiogram and physical examination — confirming a truly massive pericardial effusion though no evidence as of yet of tamponade physiology. We decided it was best that he go to Kathmandu where he could get a tap and have ICU access immediately available. I quickly shot off an email to our long-time friend and CEO of Nepal’s largest airline, Buddha Air, who within 30 minutes had secured two free plane tickets for Nirajan and his attendant taking off the next day. We informed Nirajan’s mother; they would travel with us that night.

We left around 8:00 pm to catch his 9:30 am flight the next morning. We traveled in a caravan of four vehicles; three ambulances in addition to our private jeep. The jeep I traveled in carried Nirajan as well as an infant who had fallen and had sustained a skull fracture and quite possibly intracranial bleed. He needed urgent head imaging and neurosurgical consultation. In Boston “urgency” means within minutes; in our case, we would hope to get a head computed tomography within 24 hours.

In the ambulances, we had six fracture cases that had been stabilized but required orthopedic surgery at Nepalgunj Medical Center, our partner hospital. Our two most sick were femur fractures. The first was a gentleman with bilateral femur fractures who incidentally had uncorrected club feet (something easily corrected with surgery early in life). The second was an adolescent who had sustained a left femur fracture and head trauma. He had lost a significant amount of blood, and would soon be the first recipient of our banked blood from the day prior.

A little over twelve hours later, with some stops for boluses to manage pain and agitation for the femur fracture cases, we dropped off the seven patients, and sped to the airport to arrive less than 10 minutes before take-off. Nirajan made it.

After a day and a half worth of meetings in Kathmandu with business, non-profit and government partners, we met up with Nirajan who was staying at our partner Saathi Seva. For our patients for whom Kathmandu is truly a foreign land, Saathi Seva is truly a critical component of our accompaniment program. There, Nirajan met Nepal’s only pediatric cardiologist, who safely drained the excess fluid. Nirajan started his anti-tuberculosis therapy and will stay at Saathi Seva for another week to make sure he is clinically stable to travel back to Achham, where we will follow him through his treatment.

Nirajan’s treatment was made possible because of our partnership with an organization named Watsi, a website that crowdfunds medical interventions and with whom we were the first to partner. Within a few days of posting, we had raised over one thousand dollars to pay for both short- and long-term costs, for both medical and accompaniment expenses. For distant referral patients and, through a similar organization called Kangu, our pregnant patients locally, we can fund much of our individual patient costs by small donors around the world.

Nirajan’s story shows the value of partnerships and relationships like those Possible has with Saathi Seva, the Nepali Ministry of Health, Buddha Air, GE (from whom we had received our Logiq E portable ultrasound), the Indian Embassy (from whom we obtained our ambulance), medical centers across the country, and crowdfunding partners like Watsi—and how building these relationships over time within business, government, philanthropy, and community organizations is essential to growing and expanding and deepening the work.

Download an infographic that visualizes Nirajan’s journey.

 

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