External Affairs

Standing Firm on Shaky Ground

Nepal’s doctors and medical workers are compensating for poor infrastructure with fierce commitment

After the second big earthquake on May 12, even big hospitals moved both serious and non-serious cases to temporary shelters outside the hospital buildings. Credit: Vivek Singh

After the second big earthquake on May 12, even big hospitals moved both serious and non-serious cases to temporary shelters outside the hospital buildings. Credit: Vivek Singh

Kathmandu: On April 25, 2015, the day of the earthquake, Dr. Pawan Kumar Sharma cycled the full three kilometres from his home to the Patan Hospital where he is the medical director. “I made sure my children and wife were alright and then took off,” said Sharma, when we met him on the day after the second big quake, and he was dealing with the ‘new’ crisis. “I stopped cycling whenever I felt a tremor, and continued when it abated. This way, I made it in less than 30 minutes. I didn’t have a choice – I was needed at the hospital.”

Once at the hospital, Sharma stayed there for three days straight. “I had to presume my family was safe through the tremors,” he said.

In the nearly one hundred hospitals across Kathmandu, as well as in countless smaller healthcare outfits dotted around the city, the earthquakes and the ensuing medical crisis brought out the best among the country’s health professionals.

The Patan Hospital seemed best-prepared of all of Kathmandu’s hospitals to respond to large-scale disasters. We were told that the hospital conducts mock drills every six months. “The timing, staff response, everyone was so well tuned. Everyone knew what to do, whom to look to for help, what to say and what not to,” said Dr Ashish Shrestha, a senior doctor with 12 years of experience. Shrestha was on the frontlines of Patan’s response. He handled many of the more than 1,000 patients who came to the hospital in the days following the disaster. There were 57 deaths at the facility.

A disaster triage area was set up immediately, and patients taken to different areas marked green, yellow and red, based on the severity of their injuries. The hospital was able to handle the tremendous inflow better. “We have nearly 900 staff here. Most of them knew what to do and therefore reacted well,” said Sharma. “Looking at how my staff reacted, it gives me great hope.”

The safest bet

Rajan Prasad Dhakare, 41, senior pharmacy assistant, was stepping out for lunch when the earth shook. “I saw the traffic signal post falling down just as I stepped out of the hospital. We all immediately crouched down and when the shaking stopped a little I returned to my pharmacy inside the hospital,” said Dhakare. He rushed to his home, which is 15 minutes from the hospital by bike, and made sure his family was safe. “I have two kids. So I was really scared, but once I went home, made sure they were fine, I returned to the hospital and was here till 11pm.”

Dhakare, who had missed the drills, quickly carried essential medicines like tetanus, midazolam, plaster of paris, out to the disaster triage area, and made sure they were re-stocked periodically. “Even though we saw through these quakes better than most other hospitals, we do need more training. Also, the health professionals, they need an escape and safety plan. Without a guarantee to our safety, how can we work well?” asks Dhakare.

At the Bir Hospital and Trauma Centre, Kathmandu’s equivalent to AIIMS in New Delhi, the inflow of patients was among the highest. “For the first three days, we were just cleaning blood all day, from 10am to 7pm,” said Sarita Denda, 45, a sanitary worker. Her daughter works as a cleaner at the same hospital. “Our house is quite far away in the Kalanki area. It cracked during the quake, so we’ve been living in tents only the last few weeks. After yesterday’s second quake, we’re really scared.”

Bir hospital consists of an older building and a recently built trauma centre, which was completed only last year, with  aid from India. The older building, already in a dilapidated condition, cracked at various points and all the patients were either evacuated into open tents or into the trauma centre. Dr Badri Rizal, 38, a consultant orthopaedic surgeon handled many of the emergency cases, along with the rest of the ortho team. “Before the first earthquake we were in the nearby centre, but then we came here,” he said. “For one week we ran the OT (operation theatre) continuously, 24 hours a day. Patients kept coming.”

Even under normal circumstances, the waiting lists at the Bir Hospital OT and the Out Patient Department (OPD) can stretch for weeks or even months. “In disaster management, we can definitely use more preparation. Most of the staff here was doing 24-36 hour duties, it was all instinctive. I’m happy about the commitment shown, but I hope we are better prepared the next time. I won’t want to do it like this again.”

On the frontlines

Kathmandu had the benefit of hospitals with superior infrastructure. The majority of the country, in the days after the quakes, relied on smaller setups, including sub-health posts, health posts, primary health care centres and in some cases temporary health camps, for emergency care.

“What happened was that on the second day we had these aftershocks,” said Samghana Kanwar, 41, an Auxiliary Nurse Midwife (ANM) at the Budanilkantha health post on the fringes of Kathmandu. “We had just done a delivery and since it was a caesarean we were doing the sutures when this happened. We all rushed out, the baby had already been taken outside and only the patient remained inside. When the shaking stopped we returned and finished up.”

Apart from deliveries, in the health posts we visited in Budanilkantha and Panga, both of them located on the fringes of Kathmandu, the handful of personnel handled as many cases as they could before referring the patients to bigger hospitals.

Suresh Khadke, 36, a public health inspector was completing a year on the job at the Panga Health Post when the first earthquake struck. “On a regular day, we get a maximum of 25 to 30 patients,” Khadke told us. “On the day of the first quake it was a holiday and the health post was closed. But once patients started coming in, we opened a temporary health camp outside and began receiving hundreds every day.” Khadke and his team of five at Panga could offer little more than basic first aid. The poor condition of their health post only made their job harder.

“We have not been given any training in handling disaster situations,” said Durga Asure, one of the ANMs at Panga. The sub-health posts and health posts are meant to provide only for preventive, promotive and basic curative care, so they were completely unprepared for a natural disaster. “We know what to do in case of allergies or if someone is pregnant, but for the kind of injuries we saw after the quake, we just didn’t have the medicines or tools required.” Still, Khadke and Asure bandaged up whom they could and referred the others to the larger public and private hospitals within the city.

Unlike Panga and many other health posts across the country, the Budhanilakantha health post, having been recently renovated, survived the quakes without much damage. “We received a lot of head injuries as well as a lot of trauma cases. There was one person who couldn’t stop vomiting,” said Dattaram Adhikari, 30, health assistant, who had his quarters above the health post itself. All eleven of the staff here were on duty continuously for the first few days after the quake.

“Some disaster preparation would have definitely helped,” said Adhikari. “Even though I’m happy with how we reacted, we felt very inadequate and had to react by instinct. Thankfully none of our families was affected too badly, but some of us also have psychological trauma and the terror that the quakes caused will take some time to go away.”

It’s all rubble at Ramkot

Doctor’s coats hang on a door in Pattan hospital, Kathmandu, Nepal. The hospital was best equipped to handle a large scale disater as Doctors, Nurses and other hospital staff worked dedicatedly over days non-stop after the first big earthquake hit Nepal on April 25, 2015. Credit: Vivek Singh

Doctors’ coats hang on a door in Pattan Hospital, Kathmandu, Nepal. The hospital was best equipped to handle a large scale disaster as doctors, nurses and other hospital staff worked dedicatedly over days non-stop after the first big earthquake hit Nepal on April 25, 2015. Credit: Vivek Singh

Right from where our taxi turned off Kathmandu’s ring road towards the Ramkot primary health care centre, there was little visible but rubble. The day after the second big earthquake, there were many blocks to traffic because of broken buildings fallen across the roads. Whatever the first earthquake had left standing in Ramkot, as well as Sitapaila, seemed to have completely broken down.

These were some of the worst-affected areas, in terms of lives lost as well as property damaged, and for anyone injured the Ramkot PHC was the closest source of aid. “There was only so much we could do,” said Dr Ayaz Luita, 27, who’s been serving in Ramkot PHC for the last seven months. “We don’t even have an X-ray machine. For the first two days it was difficult to manage. My father also ended up suffering from post-traumatic stress disorder, so I had to attend to him as well.” They managed with the supplies they had; when those ran out, new supplies only arrived two days later.

“This earthquake has taught a good lesson on the importance of being prepared, not only for us, but for our country’s entire health apparatus,” Luita said – a thought echoed by other health care professionals, who saw a great personal initiative from doctors, but little coordination between centres or up the chain of medical relief. “The first three days were spontaneous, very independent and sporadic, even though we were prepared theoretically, it didn’t work at the time of crisis,” said Dr. Sharad Onta, assistant dean at the institute of medicine, Katmandu. He is also a senior member of the People’s Health Movement, Nepal. “Now the task at hand is not just rescue and relief. Everything that was broken before the earthquake also, in terms of the system and structures, we should try to fix.”

Those systems need to extend to the psychological care of medical workers themselves. “There were at least 70 cases here every day,” said Sangeetha Yogi, a nurse at the Ramkot PHC for the last 17 years. Yogi worked exhausting hours at the clinic while her mother-in-law watched her children. “To be honest, I’m a bit shaken myself and it would be really helpful if some psychological care and counselling can be provided for us staff as well.”

In Kathmandu as in the outskirts, the lack of preparation, both mentally and procedurally, have taken their toll on medical workers, leaving them with high levels of stress. As Dr Sharma of Patan Hospitalsaid, “I’m really happy with how my people responded. But we also have to keep in mind that one day, the doctors will also break.”

Sibi Arasu is a journalist living in Chennai. Vivek Singh is an independent Delhi-based photojournalist. Their reporting was supported by Public Services International.