End of life — difficult discussions in disaster area.
An elderly female in her 80s was brought to the clinic after being carried on a straw-mat. They had hiked to the clinic for couple of hours after hearing that a medical team was providing care. She was barely able to sit up, and her husband, also in his 80s, wanted us to “fix” her. She only spoke the local Gurung language and some students were translating for us. She reported generalized pain all over her body. She had been buried in the debris for two days and was rescued by her husband after he himself finally crawled out of the debris first.
She was writhing and screaming in pain and we didn't have painkillers stronger than paracetamol and ibuprofen. When you have to decide on what to bring based on the chopper’s weight limit and its space, you are already making compromises. Access to stronger pain-relieving agents had always been an issue in Nepal since I remember my rotations in medical school at BPKIHS. However, at MGH, where I practice now, we have a highly specialized team of pain specialists who prescribe and recommend multiple formulations of very powerful and effective pain medications. Here in Singla, on top of a mountain in rural Nepal, I felt helpless and guilty that I was not able to help her. I gave her 1 gram of paracetamol. I heard her gurgling breathing as she pursed her lips to swallow the pill. I put my stethoscope on her chest and the gurgling was loud and everywhere. She was breathing 50 shallow breaths per minute, almost 4 times as fast as normal. I heard air passing through a lot of fluid. Her lungs were filled with fluid. Her heart was failing. At MGH, a rapid response team would have been activated and a team would bring high flow oxygen, IV lines and multiple medications to save her life. She would be quickly transferred to intensive care unit. Here in Singla, after surviving being crushed by her own home, she was lying on the floor on a straw mat, struggling to take these pills that you would take for an annoying headache. As we helped her to a sitting position, I was going over our inventory of medications, realizing that we lacked the medications to treat a patient with heart failure.
She was slightly more comfortable and I decided to give her acetazolamide, a medication I had brought with me in case I had altitude sickness. It increases urine output and can reduce fluid in the lungs. 2 pills went into her mouth without any questions from her. Did I adhere to the international guidelines of heart failure management? Did I even know what I was doing? What will I do once I leave the village the next day? I didn't know the right answers to any of these questions. All I wanted was for her to breath a little better so I could talk to her about our next steps. A couple of hours later, she was breathing normally and we moved her out to the waiting area. After seeing about 50 patients each, we took a short break and I went to talk to her family.
The couple had send their sons to the Middle East as manual laborers. The money they had sent was enough to build a small home that had now become a pile of rubble. Like many Nepalis, their sons had died in the Middle East. After pulling themselves out of the rubble,here they were, 10 days later, still without a roof over their head, water filling the woman’s lungs and a husband partially blind from an untreated cataract trying to help the best he could. Using an interpreter, I tried to explain to her about the poor prognosis given the lack of advanced and appropriate medical care. I was telling a woman who had survived so much that accepting death was perhaps her only option.
After a long conversation, she said she wanted to die peacefully at home, or whatever remained of it. However, the husband wanted to move to another village, hoping that there would be food and shelter there. He didn't know whether to stay with her, watching her die or try to find food and shelter for himself. There were other questions in my mind. how would I keep her comfortable for the last few days of her life? The chances that the trails would open in a week were slim to none so she wouldn't get any other medications to make her comfortable as she awaited death. Would she survive until the trails opened? Or perhaps she would change her mind and attempt to seek higher level of care, although both she and I knew that that’s not what she really wanted? I didn't know the answers and I didn't dare ask them out loud.
In these remote and treacherous mountains, they had spent 8 decades against all odds but the quake pushed them to the brink and now they had to decide whether to rebuild the house or to care for the sickly wife or just wait for the monsoon’s final blow while trying to live under a tarp.
Few hours later, the concoction of medications improved her breathing. She finally stood up with her husband’s help and they walked back through the mountains to their home to clear the rubble to spend the remaining days in what was left of her home before her time was up.
A personalized care plan which maximized comfort would have been setup in Boston. In Singla, she will be moving rocks as her heart eventually stops from the exhaustion.
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