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When do you stop CPR?

Beth Fitzgerald | Acupuncture Volunteer Nepal

Long after I realized the man's injuries were too extensive to survive but not until his wife said "arret" and gently reached out with her bloodied hands to stop my chest compressions. Coming to Nepal I knew clinic would challenge me in ways I couldn't even comprehend, yet I looked forward to those challenges and the personal and professional growth that would hopefully follow. I knew I would help many people, and anticipated it would be the ones I couldn't help that would stay more present in my mind. And it's true, they do, but not in a way I ever expected. 

Beth Fitzgerald | Acupuncture Volunteer Nepal

There appeared to be confusion ahead, someone mentioned rockfall and an injury. I asked if there was a doctor present, said we were a medical team and offered to help. People cleared the trail and we were ushered ahead. My heart raced, do we have the skills needed to help? A man was unconscious in the middle of the trail with an obvious head injury and a woman kneeling at his head. No one seemed to be taking charge, I was so grateful to have Jacq and Susana with me. We later realized our porter, Peking, had been there for quite some time before us. The woman started speaking rapidly in French, I said I spoke a little French and asked her to slow down. It appeared the man had been hit in the head by rockfall 15 minutes prior. He was just below the rockfall and looked to be in pretty bad shape. We quickly moved him slightly down trail to a safer area. I felt little to no pulse and Jacq started started chest compressions as we tried to gather more information. We checked his pupils with my headlamp and they were fixed, we were told he had been unconscious the entire time. I took over chest compressions and quickly realized how extensive his injuries were. The woman at his head was covered in blood and his wife, she told me they live in the mountains near Toulouse. She asked if I thought he would be ok. I expressed my concern with his injuries and difficulty for rescue. We then realized the man had been hit by a rock and fallen off the trail and it had taken an hour and half to get him back up to the trail, where he had been for 15 minutes. It quickly became clear he not only had a significant head injury, but likely a spinal injury from the fall and it had been too long, he would not survive. There was nothing more I could do for him.  At this point all my attention shifted to his wife. The rest of their party and the other guides and porters stood back, they had also been there much longer than us and I can only imagine what this first hour was like. We were told a helicopter had been called, a teahouse was ten minutes down the trail and a landing site further below. I said we need a stretcher, trekking poles or branches I suggested. I continued chest compressions as his wife was asking me what I thought. I gently said it was a bad injury to his head, I was worried about what further damage had been caused by his fall and pulling him back up to the trail and feared it had been too long. She nodded. I said I couldn't feel a pulse and he wasn't breathing on his own, but I would continue chest compression as long as she wanted me to. It would be a long trip down the trail, waiting for a helicopter and then a half hour flight to Kathmandu as well. She had amazing composure and seemed to be slowly putting everything together. I continued compressions and allowed her time. "We live in the mountains, the Pyrennes, I can't believe he will die in these mountains." She started to cry. It was truly heartbreaking. Here is a woman whose name I do not know yet and we are in the most intimate moment. She reached out and gently pressed my hands to his chest "arret" and she looked up at me "Merci, thank you for trying." People arrived with two big pipes, ropes and big plastic rice bags to form a stretcher. Bistare (slowly, which is my most used word in clinic) I said and then asked for 5 minutes and waved people away to clear the trail as I had no idea how long it would take to get this man down and what shape he would be in. Jacq and Susana cleared the trail and we stood back and gave her time. My thoughts raced to my family, his family and my years of guiding. She knelt there for a few minutes and then stood up. We rolled him onto the stretcher and I kept saying gentle and bistare. I picked up his bloodied backpack in one hand and his wife tightly grasped my other as we slowly followed them down the steep and winding mountain trail past the tea house to the a wide spot on the river. Just days before we stood happily gazing up the valley and to the adventure that was waiting for us. I lead her to the river and helped her wash the blood off her arms and face. The three of us sat with her next to the stretcher waiting for the helicopter, watching monkeys cross the river and swing in the trees as other groups looked on. I gently rubbed her back, uncertain what else to do. Susana brought out her space blanket to more fully cover him and we held it down with river rocks. There were three others in their party but they had mostly stood back, I expect in shock. One came down to sit with her and I started to gathered blue yellow and white flowers into a bouquet for her to place on his chest. I expressed how sorry I was for her loss and hugged her, she was grateful for our efforts. I think it was over when the rock hit him she said, he never put his arms out as he fell down the cliff. Loading the helicopter was less than graceful and a very difficult sight, but as it took off she waved and blew kisses. We stood in quiet shock and it started to sink in more fully. I no longer could keep my composure and felt a heaviness settle over me with tears in my eyes.

Beth Fitzgerald | Acupuncture Volunteer Nepal

We still had three long hours hiking uphill, I was lost in my thoughts. Personally, the mountains are my playground and it shook me to the core to see such a tragedy in a place that gives me so much happiness. We are in such a rough country, yet I do not think the outcome would have been any different on any trail anywhere else. My heart goes out to the guides and porters, obviously shaken and overhelmed. I spent ten years guiding and gratefully never had to deal with more than minor injuries. And to the couple, they remind me of my parents who traveled extensively and loved to walk and hike all over the world. It could easily have been my family. Someone lost a husband, perhaps a brother and a likely a dad. Shortly oceans away they would be getting a terrible phone call. 

That evening from our little hilltop village we could look way down the valley to the river. They has been out of electricity for 9 days which seemed appropriate. Our group, the four of us, two guides and two porters ate Dahl baht together by candle light. Later we climbed up to the roof and sat under the nearly full moon to talk. Shaken and sad with graphic images flashing through our mind we talked about what happened, could we have done more and what our roles had been. We will never know what occurred before we arrived, but I truly believe we were meant to be there. Medically there was nothing that could be done and I came to that conclusion quite quickly and clearly, allowing me to focus my attention to his wife. I spent two hours in one of the most intimate moments in ones life with a woman whose name I would only later learn. It was my hope that I could offer some calmness, comfort and compassion. Allow her some time and space to process before being whisked from deep in the mountains to the chaos of Kathmandu and the reality that awaited her.

Beth Fitzgerald | Acupuncture Volunteer Nepal

I sat under the moon for hours before finally going to bed, and was then bolted awake with an image at 3am. I returned to the roof flooded with moonlight and prayer flags gently blowing in the wind. What was it going to take for me to process? I bought prayer flags the next morning and the following two days my heart and body felt heavy. I wasn't sure if the flags were more for myself or for the couple. We got up at 4:30am to hike high up to Gosandkunda Lake, a sacred Hindu lake. At first glance I saw the place across the lake where the flags were meant to go. Everyone in our group had a moment with the flags and then Peking, our porter, and I hiked up. We tied the flags togther, one for each if them. Peking tied one end to the trident at the base and I climbed up to secure the top. It felt peaceful and calm, and as if a large weight was lifted off my shoulders. I was suppose to be there for some reason. Her friend had asked for my email and I looked forward to one day hearing from her. In time, I hope she finds comfort in the care I we tried to provide and I will share photos from our sacred lake.

Beth Fitzgerald | Acupuncture Volunteer Nepal

At the end of our trek I returned to Kathmandu to a short but wonderful email from her friend. They were back in France, grateful for the help and compassion and sent details on the funeral in hopes we might light a candle or hang flags. We are back in Bhimphedi and clinic has reopened after the holiday. Tomorrow morning we will be up early to walk out to my peaceful morning viewpoint for a quiet moment and to hang flags at the same time as they will be remembering in France. Exactly one week after his passing. Those flags will be hung with a much lighter heart. 

Before I left for Nepal I was told, "You do the best you can and it's usually enough." And it's true.  - Beth Fitzgerald

Challenged in Every Way

Jacqueline (Jacq) Bailey | Acupuncture Volunteer Nepal

Well, I survived my first week of clinic. Luckily for us it started off slower than expected which gave us a chance to get our feet wet. I'm finally feeling some rythym in the treatment room. I am impressed with everyone's ability to work together and lean on each other. The interpreters are doing an amazing job as well. I am so impressed by their eagerness to learn. Being a practitioner in Nepal is challenging and humbling at times. There are times when you do not have the anwsers, the skills, or the resources you need to help a patient. We must be okay with asking for help from others because working here in this environment is hard enough. And sometimes It's okay to just admit defeat. This leads me to vulnerability. Not something many of us like to experience. When I decided to come here I thought it was because I wanted to help people and I wanted to become a better practitioner. And both of those things are true. Although I think my patients are probably gonna help me become a better practitioner more so than me helping them with their problems. I am learning so much from them which will be valuable for me in my practice. Their health is so poor and they have so little here, yet their smiles remain and their lives continue. Not to say I am not getting good results; I am definatly seeing some improvement in my patients, but it seems only natural when they are coming to see you three times a week. But some situations we just cannot change. At times It gets so busy I feel like I am doing the same treatment on everyone or I am using too many needles just to cover my bases. You never have a moment to think about your treatment plan, you just listen to their story and act. I promise in time I will be more thoughtful about my treatment plans and use less needles.

Jacqueline (Jacq) Bailey | Acupuncture Volunteer Nepal

But today I realized I came for another reason; to explore myself and what is means to be a practitioner. I initially went into healthcare because honestly, I just didn't feel really good at anything else.  Coming from a long line of nurses, I strived to be different, but helping others always called to me and that's what I'm good at. I wanted to connect with people, understand compassion and humanity. I feel so detatched from myself at times at home working in the intensive care unit. We just go about our days, going through the motions, thinking we are doing good and helping people, but are we? In the hospital I practice my skills, take orders and give medications. If there is something that goes wrong I call the doctor and they handle it. Here, we don't have that luxury. In my clinic I hear patients problems and I treat them with acupuncture or herbs and I can rest assured in the fact that they are also probably seeing multiple other practitioners.  But I wanted to put myself in an environment where I would need to use all my skills without relying on all the resources or luxuries we have at home. I wanted to tap back into why I went into medicine in the first place. To understand compassion, humanity and altruism. I feel like those things are rare in life, and here in Nepal I see it everywhere. I have a wonderful family, lots of friends and a great man at home, but something has always felt lacking in my life and today I felt it.  We are so closed off as westerners and here I've realized I'm guilty of that myself. Nepali people's hearts are so open and there is a sense of community no matter where you are. It is so easy to connect with people here, like family. And today we came together as a community to help this patient. And I better understood compassion and humanity.

Jacqueline (Jacq) Bailey | Acupuncture Volunteer Nepal

Today I was challenged in every way I could imagine. I was forced to be a primary care practitioner; a role I have not had to play. And I was scared. A young women came into the clinic, first visit. She was only 24 years old and was four months pregnant. She complained of a mass in her abdomen that was getting larger and becoming painful. I felt it and it was pulsating. I then noticed the young woman was breathing rather fast and also noticed the pulsation going up to her neck. After chebking her vital signs and listening to her heart (which she had a very clear murmur) I decided she needed to be transported to the hospital for a further cardiac evaluation. I decided not to treat this patient with acupuncture but use my efforts to locate family and call an ambulance in addition to discussing the case with my team leader. I knew what I would do at home, but this is Nepal. We could not get a hold of the one ambulance in town and the health post was closed for another hour. So we decided to wait. Not something I would do at home. We had a choice of sending this frightened woman on one of our interpreters motorcycle to get to the hospital an hour away or waiting on the ambulance to take her which would be a few hours. I had to make a choice. I don't usually have to make these choices! I just wanted her out of our clinic to a place where she could be stabilized if need be, but what where would that be? From my experience I suspected an dissecting aortic aneurysm, left untreated could be fatal. My 24 year old pregnant patient and her husband are now looking at me for answers on what to do and how much this will cost because they have no financial resources. I felt helpless. There was so much I wanted to do for her, but couldn't. I couldn't fix her problems, afford to pay all the bills or promise she would make it. The ride alone to Kathmandu would be four hours. All I could do was get her in an ambulance and hope I was wrong. She is now in a hospital in Kathmandu getting care. They will run a series of test that they probably cannot afford, and may find out she needs surgery she cannot have because she is pregnant. I guess I could have treated her, hoped I was wrong and sent her home with her family to celebrate the upcoming festival like she wanted to do, but I couldn't. I'm not sure what the right decision should have been. I don't know if we will know the outcome of this situation. So many of our patients have situations that would be considered life threatening to us, but here it's just part of life. I feel defeated no matter the outcome. If you think you have helped someone by sending them to a higher level of care, you have probably helped them rack up a bill they will never be able to afford. And when you see how hard these people work just for sixty bucks a month or less you don't want to waste their resources. But if you do nothing, they could die in your care. Being responsible for that decision is nothing to take lightly. Working in the clinic and staring into your patients eyes and seeing so much pain is heartbreaking. The conditions here are rough and sad, and it wears on you. Even if you make a positive change in their condition they still have to work and that usually involves carrying 85 lbs of wood on their heads or backs and walking hours a day in the fields or to the next town. So We can only do so much, and that has to be okay for now.

I received word today from the patient's husband. She has been transferred from the heart hospital to another hospital for urgent surgery, but it will cost 200,000 rupees (about $2000 USD). The family must pay it before they will do the surgery, and of course they want our help. The practitioners donated money to pay for the ambulance, but now we have to make the decision. I'm sure we would all pay for the surgery if we could, but that's not the point. Everyone here is under the poverty line. How do you decide who you help and who you don't? It's the hardships here that is life. Its breaks your heart, and toughens your skin at the same time. Even with all the good we do here, sometimes it feels like you are not doing enough. - Jacqueline (Jacq) Bailey

Director's Note: Jacqueline probably saved this young woman's life (and possibly the life of her unborn baby) by quickly identifying her life threatening condition and taking proper action. The practitioners took a collection amongst themselves to pay for the ambulance transport to the hospital in Kathmandu. Our organization appealed to the Manawanpur District Health office for financial support for the patient and they paid for half of her surgical expenses. The young woman underwent open heart surgery to repair a dissected aorta and is now stable and recovering though not completely in the clear. All of this illustrates the roll of our project in providing access to medical care and appropriate assessment. No single intervention is complete without the support of an entire medical system and we strive to play our part in applying the RIGHT MEDICINE at the RIGHT MOMENT. I humbly congratulate Jacqueline for a job done to perfection. -Andrew Schlabach, Director, Acupuncture Relief Project.

The Stranger in our Village

Lynn Lobo | Acupuncture Volunteer Nepal

My trip to Nepal was an amazing life experience with many shared gifts. I feel like I have been challenged and grown enormously in my skills as a teacher and community facilitator. I went to Nepal for 3 weeks to teach the beginnings of a much larger acupuncture course. My students were the translators who work for ARP. To make the training more practical, I combined mindful body awareness practices with acupuncture theory and point location. The community also asked me to inform them on high blood pressure. To address this request, I worked with our students to put together a play called 'Blood Pressure, the Stranger in our Village'. We went with this title because strangers are regarded as mysterious and untrustworthy in the village. They may hide in the jungle and disguise their footprints. Blood pressure is a little like this as it creeps up on you, and often we don't know why it's there. This play uncovers some of the issues that affect blood pressure in the community, and how the community can take responsibility for it. The play got amazing feedback with people wanting a longer and bigger outdoor production. Over 100 people came with families walking for 1 hour or more to see our play. All the students worked really hard and after hours to pull this play together in a short period of time. I saw each one of them meet challenges and grow. It was very rewarding for all of us.

Lynn Lobo | Acupuncture Volunteer Nepal

I was able to benefit the community through teaching the translation team the beginnings of a longer acupuncture course. Many of them indicated an enthusiasm to continue with their studies. I and they believe it is possible for them to become acupuncturists for their community. The team as a whole took on a greater responsibility to gain experience in community health education. Their roles as translators has grown into acupuncture student and health educators. The community also received a play about themselves and witnessed a better health potential for their lives. This is a great material resource for the Acupuncture Relief Project.

Lynn Lobo | Acupuncture Volunteer Nepal

I too feel that I have grown enormously as a person. Throughout my time away, I had a sense of feeling at home in myself. For the first time in my life I had a sense of feeling settled and kind of 'natural'. I'm a little shy to even talk about it, but I'm relishing the feeling. I felt so welcomed in Nepal, with people open to what I have to offer. It really brought out the best in me. I've always felt like I have such a mixed bag of skills that don't quite join up. An acupuncturist, a painter with playback theatre skills, a light footed bush walker, and a Process Work student. Strangely, all these things came together with ease in Nepal. The most exhilarating thing was when I would suggest things to people and they would say 'why not!' I'm adopting the 'why not!' attitude for myself. I realise that knowing people from other walks of life allows me to see some of my self imposed limitations and engaging with this community has opened up potentials I was barely aware of. I glimpsed what is possible when all of my skills work together. It was surprising to me and I know there is more to come.

Lynn Lobo | Acupuncture Volunteer Nepal

I have put together a 15 minute video of our play. It will give you a feeling of the atmosphere on the day. I also worked closely with Tsering Sangpo Sherpa on a translation of the play. It's included below and well worth a read. Thank you dear reader for sharing this journey with me. --Lynn Lobo

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