APR-C-8
THE THIRD DAY OF CLINIC IN THE SCHOOL
IS PRECEDED BY A RUN THROUGH THE BIRDSONG AND A
CONTEMPLATIVE MOMENT OF WAITING IN ROSE GARDENS BEFORE AND AFTER THE
FULL MEDICAL CAMP
APRIL 26, 2001
NONPARTICIPANTS ARE BORED, ABSORBING
HUGE AMOUNTS
OF SPECIAL ATTENTION AND RESOURCES, WHILE STUDENTS
ARE FASCINATED WITH THE PANOPLY OF ORDINARY THINGS
IN DIFFERENTIAL DIAGNOSES: HERNIAS, PILONIDAL CYSTS, CONGNITAL DEFECTS,
ABSCESSES, TB, ARTHRITIS,
AND THE EXOTIC: A RACHITIC ROSARY, POTTS DISEASE, MULTIPLE CHONDROMA
SYNDROME, BAKER’S CYST,
AND I ADMIRE A HOLY MAN’S SACRED TROUT, THE “TCV”
(“TIBETAN CHILDREN’S VILLAGE”) AND “DHAMVANTRI”, LORD OF PHYSICIANS
I tried to tape, once again, the sound of the morning birdsong, and realized two things about the new Walkman I had just bought in Manila. It had screeched in protest one cool morning in Derwood when I had taped the forest birds of the temperate zone to contrast with the tropical birdsong of the subcontinent. I thought it was because it was cold that the tape was not pulling correctly, but there is no such excuse that could account for the repeat performance here in the warm moist tropical dawn. The second thing I found out was that I could not play back the sounds I had just taped. So a brand new top of the line tape recorder with new batteries and tape means that the recorder is faulty—and the bane of my audio existence is the fighting with the balky tape machines while trying to capture some live action on the run.
After the same process as the preceding days, the uphill run and the stop at the horses in their morning exercise, I went to breakfast and got ready to work. One of the exercise boys came up to me in the galloping “Figure Eight” exercise circuit in the ring, and reined up sharply in front of me and said beaming proudly as I admired his mount “An Indian Horse.” We got to clinic and went through the long queue of waiting patients who had arrived several hours before we did. The first for me was a chubby little boy described as a “mud muncher.” “A what?”
“Well, he never eats, and goes around eating mud instead.” Somehow, he must have taken in some high calorie mud, since he was about the only chubby Indian kid I had seen, with a rather doting set of well to do parents who were bringing him in for their concerns, not any of his. This can be treated by a rather simple dose of deworming medicine, and moving on to the next patient.
I learned the name of the Speaker of the Himachal Parliament who had been the glad-handing politician on our opening ceremony. His name is Gulab Singh Thakur. There is any number of people around with the last two names, so I hope that the first makes him somewhat distinctive!
When I had come over the steep hill and down the incline toward the river that gushes out of the Dhaulidhar into the Kangra Valley, I noticed two this on the way to the morning clinic. One was a “trout pool” under the bridge that carries us over to climb the far side roadway, with several people looking down into the water. I would have expected a “No Fishing from Bridge” sign elsewhere in the world, where the effort is mainly to keep people safe from being struck on the bridge while concentrating on the excitement of the fishing. But, here, the people were already milling around on the bridge looking into the water and no one was fishing anyway, as they would be unlikely to as a part of their vegetarian practices. I heard there was a holy man who lived on the riverbank and he was the protector of the fish in the river, and I resolved to take a look later to see what holy creatures there were that would be swimming under the bridge.
A second thing I noted was a sign that I could only read in the quick flash as we passed by, announcing a temple to Dhanvantri, “Lord of Physicians.” I had not heard of this minor deity, and was told there are quite a few professional deities, with another being Vishrakarma, “Lord of Architects.” I will have to learn about a few of these specialized deities in the tens of millions of the Hindu pantheon. We had come to a brief halt along the “Gandy” at the roadside crossing of a narrow gauge railroad, and saw the Gandy Dancer come out to throw the Gandy to switch the train from one narrow gauge track to another. This is like the turn of the century when the trains were the principle arms of economic expansion of the heartland—and here in India they remain so. On any given day, the biggest city in all India is the train system, with a higher population aboard than in any other city. From the conditions in the majority of the cars (as opposed to the “A/S Chair Car” (First Class) we had been in, the cars are always overflowing with bodies hanging on to every railing no matter ho loosely connected to the carriage. If one has been inside any of these crowded cars, even is one is so lucky as to have got a small spot on a hard bench, it is apparent that the “best seat in the house” is most probably on the roof, where the air may be filled with cinders and clinkers, but definitely breezier and less putrid than the human and vermin associated smells inside the car.
In my first experience on an Asian passenger train along the klongs in Thailand in 1977 and my most recent excursion from Delhi to Chandigarh, I had remarked that even in the first class cars, the bathroom facilities are a surprise, since they are equipped with an “Asian toilet.” That means there is a hole in the floor through which you see the miles and miles of retreating track and the sleepers on which the narrow gauge rails are spiked. It is a good thing the trains are as busy as they are, since the tracks would be overgrown from this excess fertilization of the interrail track from the continuous lengths of human manure spreaders laced across India. This mobile septic system is a rather good epidemiologic vector for communication of fecal pathogens, such as vibrio cholera, typhoid, hookworm, and hepatitis, not to mention the possibly unaesthetic depositories in train stations where the cars might be stationary for a while. But, the Indians are proud of their trains, and the elaborate network of tracks that are built across rivers that flood during the monsoon and trestles as the foothills of the Himalayas are approached have been an engineering challenge that the Brits had triumphed and the Indians maintain. The trains largely run on time, too, but for a few forgivable exigencies, such as one of the numerous sacred cattle which might choose to walk along the easier pathway of that fertilized interrail line, and might stop in some occasions and deliver a calf, during which they are not to be disturbed. There are written laws that govern the right of way of sacred cattle in roads or railroad ways, especially if they are additionally burdened by the process of giving birth in the throughway, under which circumstance they are NOT to be disturbed.
COMPLAINTS IN CLINIC
BEGINNING WITH A CLASSIC MODERN SYMPTOM
Back to the clinic business at hand despite these reveries, I had a written complaint from one patient that stirred up further images of a whole new set of reveries. This woman’s complaint? “I am having too many thoughts!”
I believe that must be the title of a whole essay coming up on that subject!
In essence she was overwhelmed, probably by what she thought was the pressure of life rushing on around her in all what she considered the modern busyness of her everyday life. I might have said, “Come along to the Big Apple, the City That Never Sleeps, or get shoved onto overloaded moving subway cars by white-gloved station subway packers in Tokyo, or try to navigate through Cairo traffic. Odd that this bucolic countryside setting would be the context for this rather urban modern “the world is too much with us” complaint! But, this just shows the obvious, that mental health may be modified by the external circumstances, but is largely a matter of how we react to them.
As I would move around to the other students, and oversee some of their patient management or show them the findings from some of the interesting ones we had found, I would go through a gauntlet of chorused “Hellos” and “OKs” from whole groups of school children who would vie with each other for my attention. I also had visitors, such as the leopard hunters from last evening who would come to see me and interrupt the patient flow, which I had tried to keep efficiently moving.
I saw a student with a serious deep abscess in the arm extending up the forearm, who needed IV antibiotics to treat this intensively for a day or so before an I and D to drain this very significant life-and-limb threatening condition. She was admitted to the TCV, and we would make rounds on her later.
I saw a woman with submandibular salivary gland stones and an abscess, who needed antibiotics and a careful I and D with an expected salivary fistula as a complication if there was any significant stricture of the ducts in which the stones had been obstructing.
While some of these illnesses are classic late presentations of untreated disease—as might have been seen in the earlier half of the last century in the US, not every patient is so neglected here. In fact, one older man came to us with a large bag of medicines, and a list of complaints of every system. Not only had he seen a doctor and been treated before, he even had a pacemaker! He opened the bag of medicines he was carrying, not so much to show us what he was already taking, but with the hope of getting some more. That’s entertainment! So, medical care serves the function of social attention in this part of the world, too, and we met a few over-serviced patients, who had less a barrier to their excessive doctoring than most Americans do, since their medical care was not just perceived of as free (as an insured American might) but it really WAS free. All that he had to invest was the time in seeking out these resources, and since that was a principle source of some of their entertainment, the pursuit was self-fulfilling.
Now, in distinct contrast to this atypical patient who had actually found these resources he was seeking, I also saw many more who had serious disease never yet encountered by any physicians or health are workers. One untreated young woman came in with florid hyperthyroidism, with palpitations and tremor, weight loss, and sleeplessness, without a clue why she could not shut her eyes. We next saw a weak and anemic man with undiagnosed lymphoma. We heard a roaring murmur of a ventricular septal defect in a young child with failure to thrive. I had seen several children with Carrie, who said they looked like normal three year olds—the problem was that they were seven. So, she had to recalibrate what “failure to thrive” might mean in the Indian context.
At the time we were stretched thin in personnel, particularly translators, we even had Ravi serving as a translator, but then he got taken over by our special “problem”—Maria. Allegedly a retired nurse, she could not stand the sick and the poor folk we had as our staple patient population, and demanded that she have he trip reticketed to leave early. Ravi had to work on that and send a vehicle and driver to get the new ticket. Later, she needed the car and driver to take her back to the hotel on a special trip since she had wilted in the heat, and had made plans to go visit Dharamsala, for some purpose she could not come up with except that it would mean she would not be tied down here in a clinic she had nothing to do with. The best reason she could bring up for her going off to Dharamsala was “to goof off, and get me out of sulking in this insufferable heat.” We must screen such non-participants from any future interference from those who are trying to do the work, since they are enormous drains on the attention and enthusiasm of those who are really trying to help
I was called to see what was alleged to be a big non-reducible, but non-tender inguinal hernia. If that allegation is true, it is almost by definition a sliding hernia, a concept that was foreign to each of the students who were present, including those who would be going into surgery. I examined the patient, and explained what made a hernia a sliding hernia, then promptly reduced it—so it was an ordinary, though large, indirect inguinal hernia—the kind I would have helped our next month’s surgical intern Kim do if we had the minimum of equipment and local anesthesia. But we sent this one on to the local hospital for elective repair.
Next was a garden-variety pilonidal cyst, but no one knew nor had seen one before. I found a young girl with a large Baker’s Cyst, and carried her around for each of them to find and name it. Half of them got the answer tentatively right, but none had ever seen one before. I helped Kim drain a large “blue-domed cyst of Bloodgood” from a young girl’s breast. There were some cerumen impactions that could be cleaned out. Only minor procedures and some simple treatments are available, but many of these are quite helpful.
Some patients are quite frustrating, like the Ayurvedic “doctor” from yesterday, who has had 25 years of irritable bowel disease, without a single test or prior work-up of any diagnostic kind, who is waiting for me to “give him something to fix it.” It took me longer to explain to him than to most of the patients, that we had no cures for a disease we could not define or even have the first questions about, and that he would need a diagnosis before treatment. “OK; Then, what will you be giving me to fix it?”
After we had gone through most of the patients and a lot of our medicines, we went over to the Tibetan Children’s’ Village, and made rounds on their inpatient service with the male nurse who was in attendance there. This was just like the formal professorial ward rounds in other more structured parts of the world including the acute discomfort it gave to a few of the participants. I had the students examine and make comments on the patients and the others ask questions of them or disagree with their findings. We saw the serious arm abscess we had sent over earlier. We saw a significant rash, etiology not determined. We saw one inpatient with Erysipelas. We had one classic presentation of a young man who had once ha pulmonary TB and now had a tender collapsed kyphotic lumbar vertebra. None of my students had ever seen Pott’s Disease—TB of the spine—as I had such a rich course of this disorder in my experience in Nigeria 35 years ago.
We then had a patient who would be a fascinating problem in any ward on earth. He had a strange disfiguring of his nails, and bony masses in his knees and upper arms that were chondromas. This is a very rare syndrome I might not have known either if I had not had such a patient when I was at NIH at NCI when the chondromas had become chondrosarcomas—the name of this unusual situation is called Mafucci’s Syndrome. Our brief set of bedside teaching rounds—although more like medicine than surgery rounds—was enough all by itself to make this a creditable medical school rotation.
We saw that a TCV intervarsity basketball game was in progress, and watched it, with the imposing backdrop of the Dhaulidhar Range. I then got my hands on one device that is as good as an instant translator anywhere on earth==a Frisbee. After tossing this around for a while among kids, you know them relatively well—a language that I am glad that I had already developed.
I could not believe what I was seeing when we looked down from the bridge on he brief stop we made on the way back to the hotel in our Taragarh Palace. Christi and Elizabeth had wanted to make a phone call home to assure everyone the, again, that they were all right. We stopped at the sign which I always say reminds me of “One Stop Shopping” (This is an inside joke for which you have to understand both medicalese and Briticisms.) The sign says “STD—Chemist.” Elizabeth made he brief phone call while I ran down to the bridge and looked down in the pool under the bridge. They were huge!
Two dozen very large trout were rolling in the pool, picking off whatever washed into the riffle at the head of the pool around a little cascade near the bridge footings. We were joined by a number of locals who also came not look, each aware that these special creatures were the protectorates of a Hindu saint who lived on the river bank. I could not see what kind of trout the were, but here was a natural history of mountain trout in a tropical environment from the streams coursing off the Dhaulidhar—like the big rainbow trout I had once seen caught in the Aberdares in Kenya, as we stepped over the deep tracks of the forest elephants and swatted insects in the tropical heat, while a 2 kilo rainbow took a Mrs. Simpson wet fly.
We retired to the rose garden of the Taragarh Palace, for the mandatory “chai” break. Some of the group wanted to swim in the pool, and did. As they adjourned for that purpose, the others among us sat around after chai and drank Godfather beer.
We dined in the Taragarh for the evening, preparing to pack out of our last clinic in the school tomorrow, while Maria and Habeeb are carried out by special arrangement to Dharamsala tomorrow to return early as the rest of us take on the clinics at the school for the last day and the monastery the following day. This may have been our most medically interesting day, which, for that reason, was a bit of a bore to others who were not “into this illness thing.” But that is the banner under which this ship had set sail, and we are not yet done with that part to be converted into the more cloying steady diet of narcissistic tourism. We will have our share of that, but some of our numbers are getting a jump on that steady diet already.