On April 25, 2015, at 11:56 a.m. local time, a magnitude-7.8 earthquake shook Nepal, killing more than 9,000 people and injuring more than 23,000. Entire villages were flattened, leaving hundreds of thousands of people homeless. A major magnitude-7.3 aftershock on May 12 killed at least 200 more and injured another 2,500. The massive quake tested the country’s disaster preparedness on an unprecedented level.
“In any developing country, the infrastructure is suboptimal, and that challenge is made harder in a disaster,” said Randy Wax, MD, MEd, FCCM, section chief of critical care and resuscitation services at Lakeridge Health Foundation in Oshawa, Ontario, and former chair of the Society of Critical Care Medicine’s (SCCM) Fundamental Disaster Management Committee. “But we were fortunate that the critical care leadership in Nepal had already come up with concrete ways to help their people and our donated funds translated directly into providing critical care.” Subhash Acharya, MD, Nepal’s first intensivist, is chief among those leaders.
“As you could imagine, critical care in Nepal is very underdeveloped. Thus we want to develop critical care as a specialty in Nepal,” Acharya says. “We also support development of critical care nursing.” Toward that end, Acharya, his cousin, Nipesh Acharya, and several clinical colleagues founded the Nepal Critical Care Development Foundation (NCCDF) in 2012.
“When I was at the University of Toronto, during my fellowship in critical care medicine, I was very happy to have the immense resources we had [there],” Subhash explained in an e-mail. “People opened catheters or tracheostomy sets and just discarded [them]. Whereas in Nepal, when you need an item, you have to wait for the patient’s family to buy it, bring it to you, and then you [have to] check if it’s proper and then use it. You waste a lot of time and effort. I started thinking [about] how we could minimize this. The ICU Care Box was my idea, for which we [made] an emergency list of supplies that will save patients’ lives, so that they could be used without delay. When we established the foundation, we implemented the Care Boxes in our ICU at Tribhuvan University Teaching Hospital in Kathmandu. During the earthquake, we had no idea that supplies would be so deficient. So we converted the ICU Care Boxes to Disaster Relief Care Boxes and supplied them to ICUs inside Kathmandu that were functional, so that ICU patients did not have to wait for the hospital, government, or their family [to provide] supplies for their emergency management.”
To provide context, SCCM member Laura Hawryluck, MD, FRCPC, associate professor of critical care medicine at the University of Toronto, and an international member of the NCCDF, explains Nepal’s two-tier private/public medical system: “Those without the money to see private physicians must use the public system and pay for treatment, medications and related medical supplies before receiving care,” she says. “Families may have to sell their land, their animals, potentially their whole livelihood to pay for procedures or intensive care.”
ICU Care Box supplies are provided immediately to critically ill patients at no cost, but if the patient’s family can afford to do so, they can pay back the cost of care box supplies, thereby “paying it forward” for the box to be replenished for another patient who might not otherwise be able to afford critical care treatment, Hawryluck says. “There is a ‘golden hour’ to resuscitate critically ill patients and prevent multisystem organ failure, and the care boxes are designed to start that resuscitation.” One ICU Care Box typically lasts three months and contains such basics as IV supplies, central line kits, tracheostomy kits, chest tubes, catheter mounts, syringes, sterile gloves and dressings, along with a range of critical care drugs and antibiotics.
“The boxes are packed by the foundation; we purchase essential drugs and supplies from local medical suppliers,” Nipesh explains by e-mail. “We donate the care boxes to the ICU coordinator of the [medical] center. The nurse in charge is responsible for keeping track of the medical supplies and drugs used. If they run out of supplies, they inform the foundation and we refill them.”
Since the ICU Care Boxes had been distributed for a year and a half before the earthquake, “the foundation was already integrated with the hospitals, so we could get supplies in and help faster—it was a network advantage that others didn’t have,” Hawryluck says. “The Disaster Relief Care Boxes were tailored to people’s needs. There were a lot of crush injuries in the operating room, so we needed orthopedic trauma supplies. The conditions were really dirty, so maintaining sterility with gloves and gowns was a real challenge.”
From Ontario, Wax helped coordinate the SCCM’s donation efforts, which raised $8,000 for the ICU Disaster Relief Boxes, and helped direct the boxes’ construction. “SCCM always asks ‘What is the right way to help?’” Wax says. “Nepal didn’t need a lot of doctors showing up—supplies were the best way.”
Louisdon Pierre, MD, MBA, FCCM, SCCM member and chief of pediatric critical care at New York’s Brooklyn Hospital Center, can attest to that approach. “The amount of help in Kathmandu was overwhelming in a good way. There were three intensivists for every ICU patient—it had become a logistical problem to assign doctors who wanted to help,” says Pierre, who arrived a few days after the first quake. “By that point, the three needed specialties were anesthesiology, orthopedics and plastic surgery.” The most urgent basic need was shelter, both for patients and medical staff. He adds, “We knew the greatest need was in the villages, which were the hardest hit and had the fewest resources.”
Pierre was on his way to one of those smaller towns when the second earthquake hit. He went to the nearest local hospital, where he found the entire staff, patients and all hospital services outside on the grounds, because they feared for the hospital’s collapse. “It was quite chaotic—the buildings were still shaking and people were still screaming, but it was more about the fear than any extra damage,” he explains.
The local army had arrived with tents and awaited orders on where to pitch them. With his camping and wilderness survival background in the Scouts, Pierre found himself in charge of creating a field hospital and lining up patients for logistics. “I found satisfaction in just doing that,” he says. “Having been on several other missions in resource-limited areas, I know you have to be flexible with what you’re willing to do … I didn’t limit myself to being a doctor ... [in my organization] we try to be universal in providing usefulness—that’s fulfilling the ‘universal’ part of our mission.”
Pierre is the president of the Pediatric Universal Life-Saving Effort (PULSE), which he cofounded in 2010 immediately following—and motivated by—the earthquake in his native Haiti. Pierre is also a consultant to SCCM’s Fundamentals of Pediatric Critical Care Support course, which he has taught to more than 400 doctors in several countries, including Nepal, where he has been teaching annually for seven years.
Because Brooklyn Hospital Center medical staff were among the first to arrive after the Haiti earthquake, Pierre naturally compared the two. He estimates that 300,000 people died in the Haiti earthquake, and attributes the shocking difference in mortality to Haiti’s complete lack of healthcare infrastructure. “Critical care is not an unheard-of specialty in Nepal; they have intensivists and ICUs—that’s what made the difference,” Pierre says.
“We had to act quickly and efficiently, and I made sure that things went smoothly and effectively,” Nipesh says. “Purchasing supplies during the disaster, when most of the suppliers were closed or their employees had gone back to their families, was an issue. I had to make a few calls, go to their warehouses and collect the supplies to ensure we had enough to make donations.”
“Nipesh is a great logistician—he knows how to make things happen. He and Subhash are an amazing team,” Hawryluck says. “Subhash is a real leader. He has a way of seeing and responding to needs far beyond his training. He has a clear vision of what he wants to achieve in Nepal and a keen understanding of what is needed there. Why shouldn’t the Nepalese people have access to advanced specialized care to restore them to health? He knew it would take years, but that is what he wanted to do with his life.”
Wax says, “Developing local critical care leadership is an important way to help going forward. You can help one time with a donation, but more important is developing relations and ongoing links and support for helping the people in Nepal develop their own infrastructure.”
Hawryluck adds that any hospitals that can bring Nepalese doctors to Canadian or American ICUs for training will facilitate that advance of critical care medicine in the developing country as well. “The resilience that country has shown is just fantastic,” she says. “These kinds of stories aren’t told often enough.”
Donations to help support critical care medicine in Nepal may be sent to the NCCDF at www.nccdfnepal.org
NEPAL’S FIRST INTENSIVIST SHARES HIS STORY
Subhash Acharya, MD, works at the Institute of Medicine and Tribhuvan University Teaching Hospital, in Kathmandu, Nepal. He shares a harrowing first-hand account of the earthquake and the subsequent disaster response.
It was a weekend, and I had just enjoyed a football match with my colleagues and then gone to the [Grande International, Kathmandu] hospital for my ICU rounds. It’s a newly built private hospital with an intensive care unit (ICU) on the 14th floor where I do my work as a consultant and director of critical care. That building is probably the tallest building in the country, since we don’t have high-rise hospitals here. I had just finished taking a shower on that 14th floor when the earthquake started, and I initially thought it was a helicopter landing on the helipad. It was 11:55 a.m. It continued shaking terribly, and I realized it was an earthquake. I held the door handle, started praying and ran toward the ICU. The destruction I could see was unimaginable. I shouted to everyone to sit on the floor. We thought the building would fall down, but fortunately it did not. Being on the 14th floor, we could see surrounding houses and buildings collapsing all around and clouds of dust arising and covering the sky, as if bombs were being blasted.
Once it was a bit stable, I ordered one of our ICU doctors to take all the staff with him and leave, and ordered another ICU doctor to stay back. Then we checked all the patients. Ventilators, pumps and electricity were not working, and we had 10 patients. I felt like crying. But we connected all patients to oxygen flowmeters and Ambu bags. We started manually ventilating patients in every room, taking turns. We were fortunate that monitors and oxygen supply were still there. I noticed all the pumps that we had hooked to stands were functioning but others that were left on the tabletop were all over the floor and dysfunctional. Similarly, in each patient room, all the emergency drugs for the patient that were inside drawers were fine, whereas those kept on the table were all over the floor and not recognizable. This made me realize the importance of following basic principles and preparedness for disaster.
We were planning to evacuate and manage the patients, when suddenly the next earthquake tremor struck, which was as strong and even scarier because the building was already torn apart. At this time, I was in the central area with the elevators and kept holding the door. I could see the building separating and moving right and left, with a gap of two feet between blocks and a four- to five-feet shifting of two blocks. The water tank burst and water began to pour down just in front of the elevators. There were electric sparks coming from everywhere. In front of my eyes, I could picture the scene from the movie “Titanic” when water pours in as the ship is sinking. I then instructed other doctors and staff to run down, as I thought I would die anyway. I then started bagging patients by turn and once the swing settled, started texting for more people to come up. I saw that the Internet was working, so I texted an urgent message to all my residents and the faculties of my department to come to the hospital. Once I was able to shift all the patients down to the ground, I came down to the ground, both my calves were cramping. I remember I asked for water, drank and almost passed out. Then I lied down on the floor, and thanked God for saving my patients and my life. I wanted to cry loudly, but could not. Tears rolled down my eyes that I could not control.
I went home to see my family the same night around 1 a.m. and was terrified to see that everyone was sleeping outside on the open field, roads, ground—wherever there was an empty space. I stayed at home for a few hours and then went back to the hospital. Again, I started taking shifts, with a few hours of sleep in between. We divided our team into 12-hour and 24-hour shifts and started to run the operating rooms and ICUs. That went on for the next 10 days, operating day and night. I don't remember when I woke up or how many times I went home.