Nepal: Kanti Childrens Hospital
RMF Nurses Triage 787 Patients: Q2 2018
August 01, 2018
Ganesh Shrestha, Pragya Gautam, Dr. Purushottam Adhikari, and Dr. Shreeram Shah
Summary of Activities
Shortly after the April 2015 earthquake, Real Medicine Foundation (RMF) started its support of Kanti Children’s Hospital by donating more than $400,000 worth of medicines, medical supplies, and laboratory supplies. RMF continues to support a blood bank, lodging, food, transportation, medicines, laboratory services, and other necessities for needy patients and their families. In March 2017, RMF also began supporting human resources at Kanti Children’s Hospital and is now providing the hospital with medical officers who serve in the Surgical ICU and Neonatal ICU, as well as registered nurses who serve in the triage area and Medical ward.
- 7 medical staff members supported by RMF Nepal have continued to serve at Kanti Children’s Hospital.
- 73 patients were treated in the Surgical ICU
- 183 patients were treated in the PICU
- 656 patients were admitted to the Medical ward
Pediatric and Surgical
RMF’s medical officers served a total of 183 patients at the PICU and 73 patients in the Surgical ICU of Kanti Children’s Hospital from April to June of 2018.
The ICU beds provided by RMF in previous quarters are now fully functioning and being utilized in the ICU.
RMF nurses use a triage system while serving in the Emergency Unit of Kanti Children’s Hospital. Through this system, they classify and provide tags to the patients: code red requires immediate medical action for survival, code yellow indicates a serious but not life-threatening condition, code green indicates a less severe condition that can wait, and code black means dead on arrival. In the triage section of the Emergency Unit, patients are sent to the respective color zone for treatment, generally either the red or the yellow zone. From April to June 2018, RMF nurses classified a total of 787 patients with 99 code reds and 688 code yellows.
From April to June of 2018, a total of 656 patients were admitted to and treated in the Medical ward. Among them, 241 patients were female, and 415 were male. The most common systemic disease in the Medical ward was respiratory disease, followed by cardiovascular disease.
Kanti Children’s Hospital is the only government referral level Children’s Hospital of Nepal. The hospital was established in 1963 as a general hospital with 50 beds, which today have a capacity of 320 beds. The hospital treats children up to the age of 14 from all over the country, a total target population of 13-14 million children. Following the earthquake, where parts of hospital building were damaged, there is in general a need for equipment and capacity building for better health service delivery.
- Provide necessary medical supplies, blood, and nutritional support for patients. Also providing access and transportation to testing and procedures
- Give instruction of patients needs, education, amenities during hospital stay, and financial support to family of the patient
- Management to various hospital programs such as a blood drive program, a free-of-cost kitchen for patients and families, playroom and library for patients and siblings, and clothes bank for needy patients and family
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At Dhulikhel Hosptial, a 17-year-old mother had a premature baby with a complex anterior abdominal wall deformity, and the baby was referred to Kanti Children’s Hospital for further management. The baby’s intestine was exposed, and the deformity also caused the splitting of its genitalia. The baby was admitted to the Surgical ICU of Kanti Children’s Hospital, and on the third day of admission it underwent surgery. The baby’s condition was further managed with intravenous antibiotics and nutritional support for 10 days in the SICU. After about 15 days in the hospital, the baby was discharged and called for a follow-up after 3 months. The father and mother were happy to get the treatment done.
Rupa Paswan, a 1-month-old girl from Jhapa, was admitted to Kanti Children’s Hospital with abdominal distention and rectal bleeding for 5 days. Her intestine prolapsed rectally 2 days before admission, and she had not passed a stool since then. She was admitted to the Surgical ICU for about 8 days. On the day of admission, she underwent an emergency exploratory laparotomy (an investigative surgical procedure), which revealed an intestinal condition called ileocolic intussusception. That same day, she also underwent several other surgical procedures to treat the prolapse and intussusception. The postoperative course was uneventful, and she was discharged after 10 days.
Baby of Sushila Pariyar
The 4-day-old baby of Sushila Pariyar, a resident of a remote village in the Dang District, was referred from Nepalgunj Medical College to Kanti Children’s Hospital. The baby was admitted to the Surgical ICU of Kanti Children’s Hospital on June 27, 2018 with massive abdominal distension and multiple vomiting episodes since birth.
After admission, his condition was managed in the SICU with intravenous antibiotics, intravenous fluids, and gastric decompression. The abdominal distension gradually decreased after few days of treatment, and the child passed stool normally. He was transferred to Surgical Ward after a week in the SICU. On suspicion of Hirschsprung’s Disease, a rectal biopsy was done. The patient was discharged 13 days after admission. The mother was happy that the distension had been relieved and the child was feeding normally.
Areshma Rawal, a 2-year-old girl from Humla District, was admitted to the Emergency Unit with a recurring fever for 2 weeks and rapid breathing and wheezing for 1 week. According to her father, she was well until 2 weeks ago when she gradually developed a fever that worsened progressively. Areshma was born at home via vaginal delivery and was fully immunized as per Nepal national guidelines.
At the time of admission, Areshma’s mid-upper arm circumference (MUAC) was 9cm and her height was 71cm which revealed severe acute malnutrition (SAM). A systemic examination revealed crepitations, crackling noises, in both lungs. Her cardiac results were normal. While her abdomen was soft, it was distended, and her liver was palpable. Her costal margin, the cartilage between the 7th and 10th ribs, was also normal.
After completing initial examinations, the patient underwent all necessary laboratory testing and began treatment. On the 3rd day of admission, the child showed no signs of improvement and was transferred to the PICU. 3 days later, she was transferred to another ward where she began PEM treatment, which was well tolerated. Her condition was improving, but her respiration rate was still high at 55-60 breaths per minute, and she still had complaints of abdominal pain. She was checked for tuberculosis with a Mantoux test and a GeneXpert machine, but the test results were negative.
The doctor had planned an abdominal CT scan for the child, but the father wanted to take Areshma back home due to financial challenges. Fortunately, Kanti Children’s Hospital was able to provide the CT examination free of charge. Finally, the CT results revealed Koch’s Abdomen, a form of abdominal tuberculosis. As per national guidelines, anti-tubercular treatment (ATT) was started and the patient was kept for a week to ensure that her condition improved, as her home is in a remote part of the country. Areshma was discharged under ATT and the family was asked to follow up in OPD after 2 months.
Von Gierke Disease
Apsara Lopchan, a 3-year-old girl from Makwanpur District, was admitted to the Medical ward with a provisional diagnosis of chronic diarrhea. According to the patient’s party, Apsara was passing loose watery stools 4-5 times per day for 4 months. She also had a history of abdominal distension and a recurring fever for 1 year. Upon admission, her temperature was 98°F, her pulse was 88bpm, and her respiration 24 breaths per minute. As patient was suffering from diarrhea, dextrose normal saline (DNS) and oral rehydration salts (ORS) were administered.
Lab testing revealed that Apsara’s fasting blood sugar was low at 30 mg/dL, her iron level was high at 165 mcg/dL, and her ferritin level was normal at 25 ng/mL. Her Mantoux test results were negative for tuberculosis, and her routine urine culture results were normal. An ultrasonography (USG) revealed an enlarged liver.
The patient was closely observed for possible seizure and hypoglycemia. During hospitalization, she received a Xone injection to treat her urinary conditions, and Fortiplex syrup, a compound of B vitamins, was prescribed at the time of discharge. The patient’s party was also provided with nutritional counseling upon discharge and advised to feed her every 3-4 hours. As her diarrhea had stopped, the patient was discharged and followed up with a liver biopsy report 15 days later. Apsara’s final diagnosis was Von Gierke Disease, otherwise known as glycogen storage disease type I (GSD I).