Leaving our comfort zone

With the increasing availability of specialists in Kathmandu who provide a reasonable quality of care, we try not to do things here in Tansen that are too far out of our realm of expertise and comfort when we can help it. These days, it seems that more and more patients are able to afford to go to Kathmandu when needed and pay for the care there, and so we often refer more complex cases there. However, Nepal is still a very poor nation, and there are many patients who could never afford to go to Kathmandu for care. In fact, their hospital fees here get paid for with charitable funds. In those cases we do the best we can, even when we are pushed beyond our usual scope of practice.

We have a visiting pediatric surgeon here right now who has been here many times before. He was asked to help with a little 6-month-old girl who was born with an encephalocele. For those of you non-medical types, that is where a portion of the spinal canal doesn't properly form, so there is a connection between the spinal canal and the surrounding tissues, and causes a leak of the fluid around the spinal cord and brain (CSF, or cerebrospinal fluid) into a fluid-filled sac outside the spine. This little peanut had a big mass, about 30-40 cm in size, coming out from the back of her neck, filled with CSF and connected to her spine and brain. Normally this would be operated on by a neurosurgeon, but this family was dirt-poor, and couldn't even afford care in Tansen, let alone go to Kathmandu. So we sent the MRI (which we sent her elsewhere for and paid for out of charity funds) to this surgeon over e-mail to get his opinion. Not being a neurosurgeon himself, and never having done a case like this, he consulted a neurosurgery colleague back home, who thought that this was probably doable, and told him how to do it.

We did the operation on Monday. Aside from some nervous anesthetists (and surgeons!), everything went well. The mass came off easily, and the hole in the spinal canal was closed off. Baby did well. We were pretty pleased. The next morning we heard that she was doing "Dherai ramro" (very well), and we were excited to hear that. But on rounds we noticed that her fontanelle (baby's soft spot on their head) was a bit full and bulging (a sign of increased pressure in the brain). She looked okay otherwise, though, so we just watched her closely. By later in the day her level of consciousness had deteriorated, and her breathing pattern was abnormal. We knew there was a potential for this to happen. We decided to remove some of the excess fluid with a needle and hope for the best. (We understood from the neurosurgeon that sometimes it takes time for the CSF balance to sort itself out after an operation like this). But the next morning she seemed worse. Now her right eye was not focusing, and she was even less alert. A quick SMS/e-mail consultation with the neurosurgeon and we decided the best thing was to send her to Kathmandu ASAP for something called a VP-shunt (where they insert a drain that drains the CSF into the abdominal cavity). If she deteriorated in the meantime, we could insert a temporary drain here in Tansen before sending her to Kathmandu. He told us how to do this.

Enter the next set of problems. In Kathmandu at the moment, all the doctors are on strike. In fact, this is nearly nationwide, though it hasn't affected us yet. I don't really understand all the reasons for it, but only true emergencies are being cared for. Everything else is on hold. Thankfully, one of our Nepali doctors here has a brother who is a pediatrician in Kathmandu. He contacted him, and arrangements were made that we could transfer this little one today (Thursday) and someone would care for her there. I think they even agreed to do the surgery for free. Social services agreed that we would cover the cost of her getting there and for any medicines she would need.  All well and good, provided she was still alive by today. (Did I mention that we have been praying up a storm over these past few days?)

As the day progressed yesterday, she grew worse and worse and we knew we needed to put this drain in or she was going to die. Unfortunately our anaesthetist doctor is away, so we only have nurse anaesthetists right now. They are very good and very experienced, but they were understandably nervous. Fortunately (??) for them, by the time we got her to the OR, she was so deeply unconscious that we didn't need to give her anaesthesia other than a bit of local anaesthetic. We then used a central line (special kind of IV) kit...expired, by the way...as a drain. When she got to the OR she was only breathing (gasping, really) maybe 3 times a minute, and I really thought she was going to die in front of us. (Insert more fervent and desperate prayer!) We got the drain in, and a LOT of fluid came out, obviously under high pressure. We waited....

After a few minutes, she started breathing on her own. Her heart rate normalized. She started making a few...just a few...movements. We all realized we'd been holding our breath and all started breathing a little easier. She was coming back to us in front of our eyes. It was amazing...truly miraculous! Over the next several hours she started moving more, opening her eyes a bit, and her pupils, which hadn't been reacting at all, started reacting. She wasn't totally awake, but she was getting there. This morning at 5 am she was put in the ambulance and they left for Kathmandu. We pray she made it there safely and that she is able to get the care she needs. We pray for a full recovery for her. We pray for her parents to enjoy many years with her. And most of all, we pray for her and her family to come to know the One who really has saved her life. We serve, Jesus heals.

Why it's hard to get things done in Nepal

Paul has been diligently working away at a couple different building projects here in Tansen. One of them is coming along swimmingly...the one that involves a dedicated team of skilled workers from Kathmandu who have a deadline after which they will lose money on the contract. He is more of a consultant for that job. The other project, the building of a new nursing station for the medical ward, is being done by the hospital workshop staff, and it isn't coming along quite so quickly. Paul gets asked regularly how much longer it will be before it's done. If he could keep workers there for more than an hour or two at one time, it would really help!

That isn't to say there isn't progress being made. A few months ago they were working at chiseling away (by hand!) the extensive rock that needed to be removed before the building could even start. Eventually someone figured out that if they held a blowtorch to the rock for a few minutes and then poured cold water on it the rock would break faster. It was a little frightening to see the fragments of rock start flying everywhere, but thankfully there were no injuries!

 Now the foundations have been laid, the walls built (the gaps are where large windows will go), and the roof trusses built, welded, and secured in place. The bathrooms have been tiled, and the tiles for the rest of the nursing station have been ordered. There remains the installation of windows, tiling the whole place, designing, building, and installing the cabinets, countertops, and shelves, as well as some other things. Theoretically this is doable by the end of April (when we come home for a few months...more on that later), but given the challenges along the way, we're not sure what will happen.

A typical day for Paul:
-9:30 am go down to the job site, where 2 or 3 workers are ready for the day's work. Instructions given, as best as he can give in Nepali, and work started.
-10:00 am - one or more of the workers gets called away for one reason or another. Perhaps they need to haul some oxygen cylinders somewhere, or repair a leaking pipe, or paint the house of someone who will be moving in the next week, or any number of other things. Paul is left with one worker (if he's lucky!)
-10:30 am - Paul gets called to a surprise meeting that could have been planned in advance, but advance planning doesn't seem to be a familiar concept here in Nepal. The meeting takes the rest of the morning.
-12:45 pm - Paul goes back to the building site to check in before lunch. The workers have left for lunch 15 minutes early, and Paul sees that the tiles, which had been going in straight while he was directly overseeing the tiling, are now uneven and crooked and need to be re-done.
-1-1:30 pm - Lunchtime, during which we often pray desperately for some kind of progress to be made for the rest of the afternoon
-1:45 pm - the workers come back from lunch (10-15 minutes late). Thankfully there are now 2 of them. The other one is busy with something else for the rest of the day. Paul explains to them that they need to redo a lot of the work they had done in the morning. The funny thing is, they KNEW the tiles weren't level...but maybe they thought it didn't matter.
-1:45 pm to 5 pm - Amazingly, they are able to focus on work for the afternoon (okay, so perhaps not so typical a day!), and so after removing the crooked tiles and replacing them, they are able to make some progress with the tiles.
-5 pm - Paul is explaining what the plan will be for tomorrow, when one of the workers tells him, "Oh by the way, I'm taking leave tomorrow." Again...advanced planning is a non-concept here. No wait...that IS advanced planning - they told him the evening before!

It is no wonder Paul's hair is greyer than it was when we arrived! Ideally, this project needs to be done before we leave in late April. Without his direct supervision, it may never get done. Pray that they are able to meet the deadline.

Why the deadline? Well, our exciting news is that we're expecting a baby in July, so we will be returning home for a few months to have the baby and adjust to being a family of 3 before coming back to Nepal, Lord-willing, in late October. Jessica is now into her second trimester and is doing well. We do appreciate prayers for this time of transition, and for a safe and healthy pregnancy and delivery.