THE NYAYA HEALTH BLOG

Pediatrics Brief – Chaitra 2069

May 17, 2013 · Jackie Pierson

Summary

Chaitra 2069 saw an extremely high patient flow in both the Outpatient and Emergency departments.  There were a total of 75 pediatric patients (under 5 years) that came to the Emergency Room (ER).  The primary diagnosis, primary intervention, and outcome were recorded for all 75 patients.  Secondary diagnoses were entered when appropriate.

The most common diagnoses for pediatric ER patients during the month of Chaitra were Fracture, Pneumonia and Upper Respiratory Tract Infection (Figure 1).  Secondary diagnoses included Amoebic dysentery/Amoebiasis, Acute gastroenteritis and dehydration (Figure 2).  There was one misidentification of a patient who did not have age entered in the registry making it look like the patient was under 5 years and therefore grouped into the pediatrics data with a primary diagnosis of COPD.  Another, true pediatric patient showed a secondary diagnosis of COPD, a simple coding error.

The primary intervention used in the ER to treat pediatric patients was Oral Antibiotics/Oral Medications, followed by IV Antibiotics and Procedure Room (Figure 3).  The procedure room refers to the area where casting, splinting, suturing, bandaging and other minor procedures occur.  The intervention code Other, was used is less than 5 cases, and is continuing to decline.  Fifty three of the 75 pediatric ER patients were discharged Home, whilst 20 were transferred to Inpatient Service, and 2 were Referred out to another facility (Figure 4).  There were no pediatric ER deaths during the month of Chaitra.

Challenges

This month there was one coding error (a secondary diagnosis of COPD for a 1 year old) and a misidentification of a patient (no age entered therefore accidently grouped with the 5 and under data). Minor mistakes are expected in a fast paced ER environment where data entry happens by hand into a paper register.  All data was discussed at Bayalpata Hospital’s monthly data meeting.  Patient flow was also a challenge this month and will continue to be the case.

Next Steps

In order to have a proper pediatrics unit, the hospital must expand.  More buildings need to be built and more staff hired in order to efficiently triage the patients and provide quality care across all departments.  This however, will take time.

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Picture of the Week

May 14, 2013 · Sudan Thapa

Bayalpata Hospital physicians and nurses make rounds in the Inpatient Department (IPD) twice a day. The IPD has 18 beds which are occupied by patients with various symptoms. This 50 year old male was admitted to the IPD for treatment of severe pneumonia with sepsis. He came from the district of Bajura, which is a 3 day walk from Bayalpata Hospital. When he was admitted he had been ill for one month and had been treated at his local health post, but his symptoms continued to worsen. He was treated at Bayalpata Hospital for fifteen days, after which he was discharged to continue recovery at home. People from different districts of Far West Nepal come to Bayalpata with the hope of better treatment for their illnesses. The team at the hospital is always committed to relieving their suffering.

Walls and Flies

May 9, 2013 · Duncan Maru

There would be no whimper, only wailing and the banging of a mothers palm against non-reinforced concrete windowsills. Her daughter lay lifeless in the emergency room, surround by flies which had swooped in during her final hours like vultures on dying desert carrion. Stupid, stupid, stupid death [1]. It’s the system; preventable deaths are always about the system. How to fix systems?

But where do we begin? She was five years old, one of two children of a desperately poor family from a district to the north of ours. A little over a week ago, she had started swelling. Not being close to anything much by means of medical care, her parents kept her at home until she developed worsening fevers and breathing difficulties. Their hands forced, they made the several-hours-long trek south to our hospital, which by now had developed a regional reputation for its services. So, the system starts there: no health worker to identify her symptoms, no transportation to get her here quickly.

By the time she arrived, in the late evening, she was breathing heavily and was quite sick, though not in extremis. She received appropriate antibiotics. She continued to worsen however (antibiotics only start to work within about 24-48 hours). When I met her that morning, on rounds, she had vomited and likely aspirated, was in respiratory distress, and her level of consciousness was depressed. I was pessimistic about her prognosis; she needed an ICU which was over 14 hours away, a trip she would never survive. Another systems issue: lack of any sort of regional capacity for intensive care.

But let’s turn now to the systems that are more in our control. Firstly, we had to deduce what she was suffering from the resources we had. Though definitive diagnoses are rarely possible out here, let me suspend belief for a moment and describe what I think led to her demise. Our laboratory investigations showed hypoalbuminemia, or low protein in her blood. This is due to either malnutrition (Kwashiokor), protein losing enteropathy from an intestinal worm infection, or nephrotic syndrome. The latter, though epidemiologically less likely given the prevalence of both malnutrition and intestinal infections, is plausible since she otherwise didn’t appear malnourished and the parents did not give a history of diarrhea. In any case, all three are associated with overwhelming infection. In any case, we have treatments for all three of the leading possibilities. For Kwashiokor, we run a government program for the treatment of severe malnutrition; we have anti-helminthic medicine for worms; and we have steroids for nephrotic syndrome. We also have laboratory capacity to measure electrolytes, and intravenous fluids and medicines to correct imbalances. We have oxygen concentrators to help improve oxygenation when patients, such as she, develop respiratory complications. We have a team of doctors, nurses, midwives, health assistants, administrators to deliver these interventions.

That was where we started. What broke down was a systematic approach to her care. We ordered electrolytes, including a blood sugar, on rounds at 8:30am. We all acknowledged she was incredibly sick, but there wasn’t a rigorous system in place to continue to monitor her. I went to the outpatient department with one of our health assistants. The child’s mother, distraught and crying, somehow had the strength to get through the outpatient crowd and present to us about some chronic gynecologic issues that she had been having. It’s a matter of survival; even as her daughter was dying, this would be the only opportunity she would have to access care. She ultimately had both pelvic inflammatory disease and pelvic organ prolapse. When we came back to the emergency department during a break in the outpatient department, the girl was obtunded and seizing, though nobody seemed to have noticed. We checked her sugar and electrolytes from a hand-held i-Stat device. Her sugar was undetectable. She had been in hypoglycemic seizure for an unknown amount of time. She was also in worsening renal failure and her potassium had increased. She was still somehow breathing but with low oxygen, a fact that was exceedingly difficult to assess rigorously because we as of yet do not have a pediatric pulse oximeter (one of those items that littered with literally years’ worth of discussions and intermittently successful attempts). I called our staff physician, and we administered the usual interventions to treat hypoglycemia, seizures, hyperkalemia. She was already receiving the maximum amount of oxygen we could give her—we can’t do higher-level interventions like non-invasive or positive pressure ventilation or intubation. These are just some of the systems-issues; there are always so many that lead to that tragedy of errors of stupid deaths in resource-denied health systems like ours. We will be conducting a morbidity and mortality review on this case, during which we will dissect via a root cause analysis we have developed from more of these issues [2].

And so, engulfed by flies in our emergency department, the little girl died. A crowd was gathered outside, watching the mother pound her bare hand against our non-reinforced concrete walls of this government-owned, Nyaya health-run hospital, walls constructed 30 years before. Walls that housed little more than dust and graffiti and rodents until we came four years ago. Walls that now, on a daily basis, witness both the possibility and utter failure of rural health systems. Walls that represent some of the best healthcare this region has ever seen, and yet were constructed in such a way that would crumble at even the slightest quake of the earth.

I’m proud of our team.  There is a reason why 350 patients come to the outpatient department on many days. We do our best to provide dignified and effective care within the knowledge and resources that we have. Folks here are dedicated and work tremendously hard. And many patients really do get the right care at the right time and get better. Our staff physician on duty beautifully counseled the parents throughout the process and managed the crowd. Our doctor calmly and compassionately talked with the father, who literally seconds after his daughter had died, started to ask for medicines for a chronic leg ulcer he had. The father was gently told he would get the medicine; he then burst into tears. Everyone recovered quickly to get back to the dozens of patients still waiting to be seen, lab tests to be assessed, x-rays to be reviewed, procedures to be performed, medicines to be dispensed. We just lack some of the basic tools and systems to practice our craft—medicine—well.  From community triage and referral to advanced hospital management, we have such a long way to go.

The flies, they eat at your soul. It’s not the bites on the skin. It’s not that they are even close to the biggest problems we face as a healthcare team. It’s not even the frustrating fact that we’ve tried many different interventions and they continue to come back with a vengeance. It’s the sense that those flies are winning, that the forces of un-dignity and useless suffering are stronger than our own desires for dignity, justice, health. It’s the deep feeling of loss, that they survive and flourish even while yet another child has fallen. It’s the knowledge that we have the means to beat those flies—well-resourced health systems, that “resource-poor” is a lame term describing more of our collective impotence than any intrinsic reality. It’s the realization that its our collective moral failing that those systems remain an incomplete, imperfect, and fly-ridden work-in-progress.

1.              Farmer, P., Pathologies of Power: Health, Human Rights, and the New War on the Poor. 2003, Berkeley: University of California Press.

2.              Schwarz, D., et al., Implementing a systems-oriented morbidity and mortality conference in remote rural Nepal for quality improvement. BMJ Quality and Safety, 2011.

Picture of the Week

May 7, 2013 · Roshan Bista

Dr Roshan Bista, Medical Officer chatting with a 70 year old woman admitted to Bayalpata Hospital Inpatient Department (IPD) with diagnosis of Chronic Obstructive Pulmonary Disorder (COPD) and Left Ventricular Failure with Atrial Fibrillation. COPD was a major admitting diagnosis in the IPD last week.

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