As I write this entry, I find myself sitting on the edge of a valley so deep that I cannot see the bottom, and above me the dramatic Himalayan peaks are slowly being obscured by afternoon clouds. I am in Nepal, which is one of the most mountainous regions on earth, and my role as a humanitarian health assistant has taken me further from the traditional role of paramedic than I ever considered.
Beneath the ridgeline that I have climbed in order to take in the view, sits a community clinic that is a hive of activity. Volunteer medical clinicians including nurses, doctors and paramedics from all over the world work alongside their Nepali counterparts to bring primary health care to remote communities. Although the medical tools are sometimes rudimentary, and the current clinic is a makeshift tin shack with a dirt floor, the team provide an invaluable and professional service where over 80 people are assessed daily.
Following is a snapshot of the last 24 hours operating as a paramedic with a humanitarian team.
0502 Unscheduled reveille and tea
I woke to the sound of footsteps crunching along the recently ploughed cornfields and opened an eye to see the dim glow of a head lamp on the skin of the tent. I heard the voice of our guide and lead interpreter Gokul inform us there was a walk-in. Although we were not scheduled to wake for another hour (or open the clinic for another three hours), a young girl had journeyed to the clinic at dawn for assistance. Gokul’s head popped into the tent with a big grin and a steaming pot of mountain blend masala tea. Next to me in the tent my colleague Mark grunted a thank you as he was handed the morning brew. Mark was one of my first clinical mentors when I was a student paramedic nearly a decade ago and we have been collaborating on humanitarian roles ever since.
We both dressed, which is no small feat given the tight space inside the tent, and moved to the clinic to greet the walk in. She was a young mother with a nine-month-old girl with a persistent cough. The clinics are partnerships of willing clinicians of varying backgrounds and our team included a Nepali doctor, Ramesh. He soon joined us to assess the young walk-in and after a consultation, the young mother was back on the track with a pocket full of medicine and advice. Thankfully our logistical support team had also woken, and we were called away to breakfast in the teahouse.
0633 An early opening
During breakfast another walk-in arrived at the clinic asking for assistance. The 78-year-old man had suffered some deep lacerations in a farming accident a few days before and had packed the wound with dirt to stop its bleeding. This is a common practice amongst the mountain communities and unfortunately, without adequate access to basic primary health care, the local wound packing technique can cause serious infections. By this time two other paramedics, Chloe and Alice, had joined us and whilst the patient was assessed and treated, the decision was made to open the clinic early.
0811 The people are coming
As 8 am passed, the clinic had already assessed and assisted 14 people and another 20 were lining up. In an area such as this, the opportunity to access free primary health care is very much appreciated. Clinical presentations ranged from minor skin infections, chronic issues (arthritis, COPD) and wound care. The team organized a rotating system that would allow small break to occur concurrently while the clinic continued.
0943 The tin clinic
Whilst the line continued to grow and our team worked collaboratively with the community, Mark walked into the clinic bleeding from his head. The clinic was essentially a tin shack with a dirt floor and low roof. Earlier the team had worked to create a clean and secure area to work in, however one aspect neglected was the roof. The corrugated iron roof had been bent near the entrance to allow water runoff, and while not a problem for many Nepali, Mark was over 6 foot. He had managed to catch the top of his head when entering the clinic. Needless to say, he was marginally amused that he had become a patient, but a quick patch up had him back outside working the triage line.
1214 Lunch interrupted
Team food was cooked daily by the guiding team inside their hut to keep the clinical staff operating. Our team cook was an unassuming 5-foot-tall Sherpa named Pemba who had recently summited Everest for the second time! While Mark and I were hanging out in the guides’ hut devouring the dal baht, I heard Bishnu calling my name. Sitting on the floor of the hut with our backs against the wall doesn’t allow for much room to move so as I stood up I inadvertently kicked Mark’s masala tea over, much to his displeasure.
Bishnu informed me that Chloe required some assistance in the clinic. As I entered, and even before Chole spoke, my heart sank, and I sent Bishnu to retrieve Mark as well. A young Nepali mother had carried her 8-month-old child into the camp who had over balanced when trying to sit. Located on the occiput of the baby’s skull was a 2-inch-long, 1-inch-wide “dent’. The realization that we were located hours up a single track in a remote mountain community with a baby with a fractured skull became very apparent. After some very gentle dressing and support, the baby and mother were placed into a 4×4 jeep for urgent transport to Kathmandu.
1513 A mobile medical team
A bit after lunch a message had travelled down the mountain to the clinic that a man required assessment, however, he was unable to walk to the clinic. The approximate distance and weather forecast were favourable to allow our team to send a mobile medical team up the mountain to locate him. Although I wanted to partake in the mobile team, I elected to remain in the clinic with the team to ensure the clinic functioned in half the team’s absence.
1633 The infected foot
Alice was attending to a 5-year-old boy who had walked into the clinic alone. He had been playing soccer a few days ago with his school friends when his foot had been severely scuffed. Although soccer is a big part of the regional activities, shoes are often lacking in regional areas. To further complicate this, many of the children utilize any means necessary to dress the wound. Recalling he old man from this morning who had packed his wound with dirt, so had this little lad. I assisted Alice cleaning the wound of debris before we bandaged and dressed the wound. He was discharged with some supplies and advice on re-dressing the wound in a few days.
1712 Closing for the day
Although the clinic was scheduled to close by 1700, there were several people waiting outside. The team came together to ensure that these people were supported, assessed and provided assistance. The ad hoc pharmacy had been utilized extensively and the resources depleted. The mobile medical team had arrived back just before close and our team debriefed on the day over a hot masala tea and sugar biscuits.
Under several headtorches the final drug audits were completed and the relevant clinical paperwork was filed. The team had assessed just over 100 people during the clinic’s operations this day and it was important to ensure that everything was ready for another day tomorrow.
2203 Rest and recreation
Finally, with all our formal responsibilities complete, Mark arrived at the shelters with a big grin. He had constructed a rudimentary shower out of an old bucket and was looking for somewhere to string up his contraption. Considering the ambient temperature was hovering around 11o Celsius I didn’t think I could be tempted, however a friend in need (is a friend indeed) and it had been days since we showered. After a bucket shower on the edge of eternity, we were soon soundly warm in our respective sleeping bags contemplating what the next day in the mountains would bring.
Humanitarian health issues are defined by elements that cause a serious threat to the health, safety, security or well-being of a community over a wide area. Usually a result of armed conflict or environmental origins these issues reduce the capacity of individuals and communities to appropriately thrive.
Although operating within a humanitarian operation requires specialized training for paramedics, the transition is relatively seamless for most who decide to participate in these operations. Treatment is often less focused on a referral pathway, and more focused on extended care, local education and prevention programs. Being specialist in prehospital care, paramedics are ideally suited to fill the void and support other allied health care professionals in these dedicated humanitarian teams.
Keen to get involved – check out www.thewildmedicproject.com or www.planetmedic.com.au