58 years old male from Khung-1, Pyuthan
came to our OPD with complains of fever for 2-3 weeks, pain in right side of
chest with productive cough. He also had loss of appetite and loss of weight.
On examination his temperature was 99° F, pulse rate 92/min and BP
110/70mmHg. On chest examination there were decreased breath sounds on right
side of chest. Other examination was within normal limit.
Blood investigations, chest X-ray
and Sputum for AFB (for PTB) were ordered. TLC 15,500/mm3 (N73L26E1), Platelet
3,70,000/mm3. Chest X-ray showed opacity in right lung with air-fluid level
suggestive of hydropneumothorax/ pyopneumothorax.
To make sure what is inside I
aspirated with a syringe and got thick pus, so the diagnosis was made Pyo-pneumothorax
(collection of pus and air inside the lung). For definite treatment the pus
should be drained with a pipe inside the chest, it’s called chest tube
insertion and drainage and intravenous antibiotics. We all know that ideally money
shouldn’t be the issue between the patient and the health worker. But he had
only 1-2 thousand rupees with him. This is how most of our patient comes to the
district hospital. It is the scenario of every government hospital in rural
areas. He even didn’t have any family member to accompany. He had come to
hospital thinking he will get some tablets and cough syrup and he will return
back. We told him about his condition, what needs to be done and asked him to
call his wife to come to hospital. He said, “She has to stay home to look after
home and the cattle.”
After taking informed written
consent, we gave him Inj. Cefuroxime, Inj. Metronidazole and under local
anesthesia, we inserted a 32 no. chest tube in his right chest. A gush of thick
pus came, about 550ml of pus was drained and it was attached with a bag with
water seal. He was admitted under Inj. Cefuroxime, Inj. Metronidazole, Tab.
Levofloxacin, Analgesics, Aciloc. Later his sputum report came which showed
positive for pulmonary tuberculosis, so Anti-tubercular drugs were started.
He couldn’t afford the treatment
so we did all for free. If we have had relied only on government free supply we
wouldn’t be able to manage this case in a district hospital. Chest tubes aren’t
available in most district hospitals. Many antibiotics don’t come under free
supply. And if we had referred him outside the district either he would have
returned back home or he had to sell his property to arrange money for his
treatment. I had bought chest tubes, water seal bags from the NSI (Nick Simons
Institute) GP fund, few medicines, tapes, sutures from my ‘Poor patient
treatment fund’ (for which I collect donations from various kind-hearted donors)
and got some medicines from NCCDF (Nepal Critical care development Foundation).
After 3 weeks of treatment, he
improved a lot, most of the pus was drained but the entire lesion was not
clear. CECT chest was the best option to see the extent and detail of the
lesion and obviously a cardiothoracic consultation. But for that he had to go
out from the district and he didn’t have money for that and he was not ready
for that. So we discussed the situation, explained him and took out the tube
and discharged him on Anti-tubercular drugs and other medicines. I know this
isn’t the world’s best treatment what he got. People may say why you didn’t do pus
culture, why you didn’t do CECT chest to see lesion, why didn’t you send him
for the CTVS consultation, what if he develops some complications and many
things. But what we did is the best in this
situation and in these settings. We knew
that we had limited resources; we knew that we were less specialized. But
everything was well explained to him and it was a joint decision to do the best
in that situation. This is how we are giving our service; yes definitely
compromised, may not be according to the international guidelines, may not be
satisfactory to the super-specialized doctors but it is definitely stuffed with
lot of warmth, devotion, dedication and right to the situation and settings.
Sometimes we have to move ahead and act out of our profession and do something extra to provide health service in the rural areas. I want to thank NSI, NCCDF and
all the donors who believed in me and my work and helped me and also my whole team for supporting me.
