Another Social Determinant of Health

Now that I’ve completed my second week at Patan Hopsital, I’ve settled into a routine. Each morning, I arrive at 8am for morning report, at which residents or medical students present an interesting case or two from the previous day. After the social history, the presentation includes two components which I have never encountered before: the patient’s concern and the patient’s expectation (almost invariably, the concern is something like “they are not well” and the expectation is “to go home soon”).

After the presentation and a multidisciplinary discussion, we begin rounds. Our team, consisting of three residents, an attending, and sometimes a fellow, cares for around twenty patients. The attendings stroll from room to room, as the residents scramble to retrieve and replace our patients’ paper charts. Presentations occur at bedside, in a mixture of English and Nepali. The patient’s family features prominently in the history and plan.

Whether visiting the clinic or admitted to the hospital, each patient carries a folder or, when the history is more substantial, a bag filled with folders. These contain everything from outpatient and discharge notes, to lab, echo and imaging reports, to the actual imaging films themselves, to medical bills and receipts. During rounds, we frequently ask the family for pieces of this record. If the patient needs rehabilitation, we ask the family to walk them around the hospital. If blood needs to be sent to the lab, we ask a relative to take it. If a patient needs to be transported, the family does it; if not enough relatives are available, the test or procedure may be delayed. If the patient eats something when they are supposed to be NPO (nothing by mouth), we may scold the family. If no one is at the patient’s bedside, we may ask another patient’s caregiver for assistance. For example, after drawing an arterial blood gas from an elderly man’s radial artery, the resident asked another man—a complete stranger to our patient—to hold pressure on the puncture site for five minutes. He did so, without question or even gloves, as the resident left the room to carry out his other duties.

I consider how some of these tasks may put patients or their relatives at risk. I also wonder what family members think about being assigned these tasks. Are they happy to assist in the care of their loved ones in whatever way possible? Do they consider it an additional burden? Do they accept it as a necessity of a system with limited resources? “Patients here have very low education levels,” several doctors have noted. “They will often do exactly as the doctor says, without questions.” In the words of another’s, “Many people view doctors like a god.”

I’ve only identified a few factors that limit physicians doing what they deem best. The first, and largest, is cost. Nepal provides certain medications (about 70) for free, and is in the early stages of rolling out a national healthcare system, but by and large patients pay their own way. Compared to the US, most medications, tests, and procedures are relatively cheap (e.g. ~$0.30 for a liter of fluids; ~$60 for a CT), but for Nepalis with meagre earnings, these small amounts can add up, even with the financial assistance that the hospital offers. Providers may present choice between a test or treatment that is first-line and one that is suboptimal but cheaper, such as a head CT instead of a MR angiogram for our young woman with refractory epilepsy, warfarin over a novel oral anticoagulant for our elderly stroke patient with atrial fibrillation. In both cases, the patients and their families chose the cheaper option.

Additionally, younger and female family members may cede decision-making to older and male relatives. For a 62-year-old man who fell after drinking two liters of alcohol (double his regular daily intake), we advised treatment of his alcohol use disorder and liver damage; his sons hesitated to agree to this because of his desire to leave the hospital—despite the fact that, in his delirium, he could not state their names, where he lived, where we were, or why he was there, and that he was actively visually hallucinating. When a 35-year-old man was admitted for acute pancreatitis, a potentially life-threatening illness, his wife seemed similarly torn by our recommendations and his demand to go home, and she remained silent when he decided to leave against medical advice (or, as it is written here, LAMA).

In addition to lack of education, poverty, and social hierarchy, among the other social determinants of health is patient communication (much like in the US). Take the case of a 47-year-old woman recently diagnosed with rheumatoid arthritis (based on heel pain, treated with methotrexate, leflunomide, hydroxychloroquine, and corticosteroids), who was admitted with severe mouth sores, a fever (T 101), low platelets (90), low hemoglobin (7.5), and low white blood cell count (less than 1000, with an absolute neutrophil count around 300). Along with oral mucositis and neutropenic fever, she was diagnosed with acute liver failure, oral candidiasis, staphylococcal skin infection, and, a few days later, alopecia. A medical student might recognize the cause of all these symptoms—methotrexate toxicity. Rather than taking it once a week (a dose appropriate for rheumatoid arthritis), she had taken methotrexate daily (a dose appropriate for cancer chemotherapy). “Completely iatrogenic,” the attending lamented. Moreover, her foot x-ray showed a calcaneal spur, and none of her labs were suggestive of rheumatoid arthritis. In other words, she was treated improperly for a disease she likely didn’t even have. After a week of withholding the medication and proper supportive care, everything besides her hair loss had resolved, and she was discharged. Since then, two more women have presented with almost the exact same story (although they likely do have rheumatoid arthritis).

We typically finish rounds between 11 and 1pm and then break for lunch for an hour or so. In the afternoon, I either assist the residents as they complete tasks for our team’s patients, or I shadow other team members at the outpatient department, which is somewhat like an urgent care, where patients are seen without appointments. My day concludes by 4pm, or a little later if there are remaining tasks. The duty resident stays overnight, admitting patients, seeing consults, and advancing care, until we all arrive the next day at 8am.

The internal medicine residents take 32-hour call every 3-4 days. There are no duty hour restrictions, no post-call days off, and, for many weeks during the first year of residency, no days off whatsoever. In a typical week, they work more than 90 hours. “Do you like this schedule?” I ask a group of residents. “This is the best place to train,” they reply. “It is better here than some other places.” Having just completed my residency interview tour, these attitudes are not foreign to me.

The internal medicine doctors display a deep and wide range of knowledge and skills, rarely needing to consult UpToDate or PubMed. I’ve observed first-year residents performing renal biopsies, bone marrow biopsies, lymph node biopsies, and joint fluid aspirations. On the floors, the generalists will independently manage strokes, seizures, pleural tuberculosis, dilated cardiomyopathy, and ulcerative colitis, without specialist consultations. Would patients benefit from specialist input? Most likely. Are such services available? Generally not.

In the coming week, the team has asked me to follow, write progress notes for, and present on one or two patients each day. While I’d readily accept this easy task at Columbia, I find myself hesitant to do so here, where I am still growing accustomed to the foreign environment. What if the language barrier leads me to misinterpret a patient’s complaint? What if I miss or misplace a report buried in the massive paper chart? What if I document something in the wrong place? I’m probably overthinking this, especially since the team is so laid-back and supportive. I just don’t want to become another social determinant of health, when patients already contend with so many. Then again, if I want to be impactful, now and in the long term, I will have to overcome this apprehension.

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.

When Will You Be Back?

I step off the airstair and pause, just for a second, before my foot touches down. It has been more than four years since I left Nepal, after completing two years as a Peace Corps volunteer. Four years. How strangely the time has moved. When I left, Barack Obama was president. My parents lived in a different house. I did not know if I would be accepted to medical school, and had no real medical knowledge. And, though I still feel inadequate, I think about how much I have learned in that time. I think about how the world has changed. I think about the countless phone conversations with my Nepali host family and friends—"when will you come back? this year? It has been very long.” Now, I think, as my foot touches down. I see the red-brick façade of the Kathmandu airport terminal, zigzag through customs and immigration, and heartily embrace my dear friend Ramesh, who rode a public bus for two hours to come greet me. “It has not been very long,” he says. And this feels true.

I am spending the month at Patan Hospital for a global health elective. I'm supposed to write weekly blog posts, which I'll repost here. Rereading some of my old Peace Corps blog posts in anticipation of this trip, I’ve felt that some of them were tainted with undertones of frustration, condescension, and even contempt. I will strive to avoid that this time, while still sharing my thoughts and feelings about this experience. In medicine, we use a format called SOAP—subjective, objective, assessment, and plan—to document and communicate patient (his)stories. I will organize my blog posts using this framework, but will lead with objective observations, so that you can develop your own impressions, independent of my own.

It’s 2am of my first full day and I cannot fall back asleep, jittery with jetlag and anticipation. At around 7:30, the other visiting students awaken and we have our breakfast of a croissant and boiled egg. They escort me through the winding streets of Patan to the hospital and show me to the library, where I am to meet our supervisor. There, I am told that he is on vacation and will not be back until four days from now. One of the students offers me to tag along in the medical intensive care unit (MICU), and gives me a tour and orientation.

Patan Hospital is the major teaching hospital for the Patan Academy of Health Sciences, a not-for-profit medical school in Nepal’s capital. The hospital has 320,000 outpatients and 20,000 inpatients per year, according to its website. The MICU has seven regular beds in one room and one isolation bed in another room. It is staffed by four nurses, around eight medical officers (doctors in training who rotate through various specialties), one resident, and one attending. In certain ways, it resembles an ICU in the United States—patients on ventilators, vitals machines beeping with the occasional alarm, fluids suspended from poles dripping into IVs. But the charts are all paper, the x-rays and CT films are held up to the light to read, and everything is older than in American facilities.

On my first day, I follow along on rounds, which are conducted in a mixture of English and Nepali, in a somewhat different format than in the states. When rounds conclude, the other student and I go next door to watch a coronary angiogram. These first two days, we have a lot of down time, which we spend practicing ultrasound, reading articles, and discussing the “cases,” as they are called here.

On the afternoon of the second day, the cardiologists invite us into the echocardiography lab. In a room with waiting room chairs and an echo machine, the patients are called one by one to the bed where the cardiologist places the ultrasound probe on their chest and takes pictures of the heart, while an assistant types up the echo report with numbers taken from picture printouts and the cardiologist’s verbal interpretations. The cardiologists seem more than willing to teach, quizzing us on the locations and appearance of heart structures, pointing out certain findings and explaining their clinical relevance and correspondence to the ECG.

At one point, one of the cardiologists turns to us and asks “So what learning objectives do you have for your time in Nepal?” It’s a fair question. For one, Nepal is a special to me, and the opportunity to return to a place that showed me such hospitality, and to reconnect with the people with whom I lived and worked, was too good to pass up. In addition to cultivating this connection, I’ve been thinking about how best to put my knowledge, skills, and experiences to good use, and I’d like to help support Nepal’s health care system in a sustainable way. I’m applying to residency in internal medicine, with an interest in hospitalist care and several subspecialties, including infectious disease, rheumatology, and cardiology, along with medical education and process improvement. I have not yet forged these intellectual passions into a unified vision of my potential role in Nepal, but I mean to. I know it will require many of the skills I learned in the Peace Corps, including identifying grassroots needs, building local networks, identifying motivated changemakers, mobilizing local and international resources, and working with diligence and humility. I am hoping that this monthlong rotation will begin to reveal these opportunities. So that’s my plan. Keep reading to monitor my progress.