Semi-Blind

The woman, 25 years old, lies on her back as the resident turns a hand crank to lower the head of her metal cot. One year ago, she was diagnosed with systemic lupus erythematosus, and recently has been spilling abnormally large amounts of protein into her urine; we have just consented her for kidney biopsy to determine the extent of the damage and the appropriate treatment. There are four other cots in the room occupied with their own patients; in the one adjacent, a woman recovering from a stroke is sopping up lentil curry with a piece of roti. The resident places gel on the ultrasound probe and scans the patient’s back in search of the kidney’s lower end. He measures its depth and, placing an empty syringe on her back, draws air into it to create a suction mark indicating the site. Then he sets the ultrasound probe aside, unwraps the sterile kit, and dons a pair of sterile gloves. With tongs, he picks up cotton doused with iodine and makes expanding concentric circles on her back. As he cleans, some of the iodine solution seeps onto her kurta surwal. Then, across her back he drapes a sterile cloth, placing the hole in the center over the suction mark. He draws lidocaine into a syringe and injects it under the skin to numb the area. He takes a handleless scalpel blade and makes a stab incision at the site. He takes the biopsy device from a chlorohexidine-filled metal basin and carries it to the sink, where another resident rinses it with sterile water. “They are supposed to be single use, but we reuse them because we have limited resources,” he tells us. Then he places the biopsy needle in the incision. “Sister, breathe long,” he says, “now stop!” and he plunges the needle into her back, his fingers stopping the needle when it reaches the pre-measured depth. He withdraws the needle and taps it on the inside of a saline-filled tube to shake free the thin column of kidney tissue, which we inspect together. He repeats this. Then he wipes her back with some clean cotton and places a dressing. “You should stay like this for three hours,” he tells her, and pushes the cart out of the room to the nurse’s station, where the kit will be sent off for resterilization.

Hardly a minute goes by that I do not think of how drastically different health care is in Nepal compared to the US. Consider how a kidney biopsy might be performed in the United States. The biopsy itself would be performed by a nephrologist, not a general medical resident. The woman would be in a hospital gown, in a room to herself. The bed would move electronically. We would be wearing a sterile gown, a mask, and face shield. We would wash our hands before putting on the gloves. We would do a timeout for patient safety. We would use the ultrasound to visualize the needle the entire time. We would only use each biopsy needle just once. We would throw away the kit at the end of the procedure.

Aside from being a sideline critic, I’ve struggled to carve out an active role for myself. Even though I speak decent Nepali, the differences in names of medications, structure of presentations, keeping of records, and organization of the hospital make it difficult to fluidly and fully function as a patient caregiver. Everyone has been incredibly supportive—taking time to explain things that I don’t understand, or that may differ from my experience in the US. So far, I have had just one experience in which I felt useful.

The man is in his fifties, with a urinary tract infection complicated by acute kidney injury, along with an underlying pleural based mass suspicious for TB (I’ve seen more TB in a week here than in all my time in the US: pleural TB, cutaneous TB, TB meningitis—you name it). The team was also concerned he might have a PE, for which he was on enoxaparin empirically, as his kidneys would not be able to handle the contrast needed to see this on CT. On Sunday, the nurse alerted us that she could not get an IV or draw labs, which would be important for treating and monitoring his kidney failure. The team proposed trying a central venous line in the afternoon; I suggested we try an ultrasound-guided peripheral IV but was told “we don’t do that here,” although one of the interns, Sanjeev seemed to think it would be a good idea. The team attempted the central line, but it was complicated by bleeding and had to be aborted. The heparin was held with a plan to try again the following the afternoon. On Monday rounds, I again suggested the ultrasound-guided IV and was generally shrugged off, although Sanjeev suggested we try in the afternoon. The nurse was then able to place an IV, so we held off. On Tuesday afternoon, the IV stopped working so, on Wednesday morning we found ourselves again without access, and with no labs for the past three days. “We could try an ultrasound-guided IV,” I said once more. Sanjeev, ever supportive, nodded and proposed we give it a shot. “Have you done it before? Are you trained?” I said that I was. “Ok,” the resident said, “you can try this afternoon, and if you can’t do it, we’ll try a femoral line.”

That afternoon, Sanjeev and I rolled the ultrasound machine into the room, along with the other materials for placing an IV. We scanned both arms for veins, identifying a few potential candidates. I tried first, watching the ultrasound screen as I eased the needle into the patient’s arm. Suddenly, a flash of blood. Sanjeev assisted me by easing the catheter off the needle and into the vein. We attached a syringe and began drawing off blood for the crucial labs; however, the flow of blood stopped after just enough to fill the first test tube. We tried again in the other arm, extracting enough blood to fill the second and third test tube, but again the IV did not take. Sanjeev proposed a different approach: I would use the ultrasound to find the location and course of the veins, which he would mark and then attempt to cannulate without the ultrasound. “So, we’ll do it blindly?” I asked. “Semi-blind,” he said, smiling. With this approach, he succeeded almost immediately. All the while, the patient lay in bed patiently, tolerating the repeated sticks without a word of complaint.

By this time, a few other interns had gathered round to watch us. As we cleaned up, one mentioned that his patient had poor venous access as well. With HIV, hepatitis B, and hepatitis C, this would be a different sort of challenge. Wearing only gloves, we again performed our semi-blind technique, with success on the first attempt. The other interns seemed impressed. “Sanjeev, you should create a protocol for this,” said one. “Be careful,” I cautioned Sanjeev, “Once you become the intern who can always place an IV, that will be all you do all day!”

As medical students who spend most of our time shadowing and thinking, it always feels good to do something to contribute to the care of patients. Here, this is all the more challenging, but not impossible. I will continue to look for opportunities to offer something to the team and our patients without coming off as an ignorant western savior—whether that means pulling up MDCalc to calculate a CHA2DS2-VASc score, congratulating a diabetic on her blood sugar control, or finding a compromise to a standard approach that, in Nepal, gets the job done.