APR-C-9

THE FOURTH AND FINAL CLINIC DAY AT SCHOOL SETTING,

AS WE HAVE TO SEND A FEW AWAY FOR SPECIAL ENTERTAINMENT

April 27, 2001

BATHE IN BIRDSONG OF DAWN AT TARAGARH ROSE GARDEN,

 THEN SEE ADVANCED PATHOLOGY IN LAST SCHOOL CLINIC,

WITH CEREMONIAL DISTRIBUTION OF TOOTHBRUSHES AND PASTE;

SWITCHBACK DRIVE TO SUMMIT OF BILLING,

THROUGH RHODODENDRON FORESTS, AND HIKE ON HILLSIDE,

BEFORE BONFIRE DINER AT GOVERNMENT GUEST HOUSE

            The wind and a bit of rain picked up later last night and through the dawn, so I hesitated for a while before deciding to go out anyway on the run, as rewarding as the prior runs had been.  The recently jury-rigged Norelco shaver has suffered yet another near-meltdown despite a new capacitor and step down transformers and adapters in the series I use to power electronic things in the excursions into foreign electrical systems.  I would far prefer that the shaver be the meltdown target than that the computer would suffer the same fate, although all I am doing with the laptop at present is entering the heading for a later filling out of the narrative in transit.  As you might guess from the transit by Tata over the mountain roads of Himalayan India and by train along the Gangetic Plain, there will not be any good typing time until the long layovers in the air and in Frankfurt.

            At breakfast, it seems that our numbers are thinning out for the last clinic at the school, since Maria, of course, is having one of the vehicles drive her to Dharamsala for no known purpose, and Habeeb is going along so as to make a trek on a different time and route than he would have if he had stayed with us.  The subtraction of some of the non-participants actually speeded us up rather than retarding us, since we had fewer ancillary folk subtracted from the service to look after them.

            As we drove in to the town, we saw musicians in uniform, acting like a hired Mariachi band, preceding a bride and groom—the latter decked out in a gold laced turbine, looking like the greater finery was invested in the groom than the bride.  When we slowed down to take a picture, both bride and groom turned around and we congratulated them—I believe I have served as their official wedding photographer, since the only other officials I could see in the wedding party were the musicians, who were making the kind of blaring noises that I had associated with Middle Eastern weddings I had seen at close range in Egypt and Bahrain.  The “garden” to which they were escaping from the duty and diesely fumes of the road in the middle of the kiosks and peddlers and the small shops was hardly a paradise view of a heavenly garden—probably not the first nor last time that the happy couple would have to disillusion themselves from the imaginary to the reality of India.  It was a jungle of overgrowth in a thick green tangle designated the “tennis court” for Shib Thakur.  In terms of nurture versus nature, both the roadway in which I had encountered them, and the “tennis court” to which they were going were rather ratty and disheveled, but they were smiling as we wished them a bon voyage into whatever marital bliss there would await them in the facilities of the brown dirty road or the green tangled court yard.

            I had a reality check of my own as the unsorted humanity poured in as I sat between Christa and Kim, checking on the numbers of patients in our room and running around the others a few times each our.  Included in the school of patients who flowed into our nets were a patient with hemi atrophy of the face, as a congenital defect, coughs, night sweats, weight loss, the litany of Tb, and lots of it; there were those who complained of the allover aches and pains, almost always beginning with the primary complaint in the knees, for reasons of the need they have of those knees in flexed squatting posture on a regular basis; one patient described a migraine, or at least a hemicranial headache with an aura and nausea.  There were abdominal pains, but nothing surgical, rather a pain that had been present for the last several years.  Some had acute abdominal disease, but in later stages, such as later amebiasis.

            One woman came in with a story so classic it should be described.  She was kicked by a cow in the side of the head during the milking of the cow several years before.  She had been somewhat forgetful, beginning a few months later, and had a few things slipping out of her hand on the same side as the kick, with weakness in the opposite side.  I could almost see the “old engine oil” of the liquefied subdural hematoma she must have had in the parietal area where she had been kicked all that long time ago, from the tearing of the bridging veins that allowed the blood to slowly collect under venous pressure.  A good neurologic exam might be able to show the great signs such as the ones called “astereotopognosis”—the failure to recognize things by their shape on the side of the lesion.  But, we did a rudimentary exam since the instructions and answers for the testing went thorugh a very poor and literal minded translator, who thought all the fine pints we were asking were more ludicrous than annoying, and would translate a four sentence question into a one word query.

            W saw a young boy with a known and already (inadequately) treated Stage III B Hodgkin’s Disease, who had huge lymph nodes and anergy.  We saw only one rheumatoid arthritis and one man who had what sounded like coronary artery disease—a refreshing change from the monotony of these diagnoses in a more developed part of the world.

            We broke in mid-morning, and all the uniformed school children were lined up in rows, squatting on their haunches, under the bright sun and in front of the snow-capped Dhaulidhar Range, as they attentively watched us talk to them through translators as we unpacked big boxes in front of them.  We talked to them about washing their hands and about cleaning their food, and about brushing their teeth. They squatted in perfect order with patient waiting and no lunging for the goodies we brought out as each received a wrapped toothbrush and full tube of toothpaste. I had tried to instruct them on keeping the items in their wrappings, but that apparently missed translations, since the entire area was shortly swirling in the discarded wrappers as dust and scrap paper were whirled up in small tornados.

            Now, it was our turn.  We stood as three of the boys took out a small drum and a few blocks of wood, which they used to tap out a rhythm.  Two young girls got up out of the ranks, and stood in front of their schoolmates and us.  The younger looked up at the older of the two, and took her cues from what she was doing.  Both were barefoot in the dust and stones and roots of the courtyard, which they then stirred into a foot stomping cloud with very practiced moves in time to the primitive drum.  The elder girl was very graceful, and wiggled through very intricate maneuvers as her hands were stylistically pointed in one direction or another, the red sari of her school uniform flying in directions opposite to her next move in response to her last one.  She was very good.  When she returned to the ranks and they filed off in military precision, I caught her in passing and congratulated her on her skill.  How hard she was working was apparent by the fact that she was wringing wet, but she never sacrificed one aesthetic turn for the inconvenience of dancing in the dust under the mid-morning sun.  And she had done this for the same reward of the same single toothbrush and tube of paste they had each received.  As they went back to their slates, they wheeled in a military rank, even the toddlers, and shouted their well-rehearsed American salute---“OK!” 

            As I returned to seeing more patients, I saw classic untreated problems of the kind I had not considered since medical school: like Tic Dolereux—trigeminal neuritis and inflammation of the Gasserian ganglion for which surgical treatment was still in vogue when I was on neurosurgery, now with several new medicines to control it.  There was the urethral stricture of old gonococcal urethritis, certainly a problem that is no stranger to anyone who has worked in Africa for a while.  There was silicosis from the dusty environment, and multiple eye problems from the same reason, the pterygia and other irritation responses, which are understandable, and hardly preventable given the environment.  There were only a few classic psychotic patients, one a woman who was led around by her relatives, and no one I saw was nude, or acting out, or shouting to spirits such as are often found in African big cities.  Chronic problems seem to be taken care of by the families; it is the acute ones that cause them to be brought in for some treatment.

In later afternoon, I had seen some unusual conditions that were still instantly recognizable---fibrous dysplasia of the mandible being one of these.

Two of our senior students, each going into medicine, and each of whose lives are considerably modified by their juvenile diabetes (as Michael said: “You may have arthritis, but I am a diabetic—there is a little more sense of ownership”), are packing insulin pumps and electronic blood sugar monitoring devices which they use about eight to ten times per day.  Their finger pads are all scarred.  Michael non-chalantly uses his cuff to stop the bleeding.  Both he and Jenna “talk the talk” and discuss the changes in their requirements given the change in diet and activity.

And it is not just the medical devices that are increasing the net worth of the student packing a five to ten thousand dollar pump and monitoring system on his or her person.  Three of the students had PDA’s, the Palm Pilots loaded with a Merck manual equivalent, particularly of the drugs they were not used to using and an instant dosing resource.

            I talked with each of them at our gazebo tent lunch, particularly interested in both Michael and Jenna.  She had graduated last year, and had matched in medicine at UCSF—a premier residency.  She had a boyfriend who had come up with an Internet based idea for a diabetic care program, and she had the background in the MBA degree from Wharton to go to Venture Capital and start up a company.  Both the company and the start up boyfriend faded later in the year, but it was a worthwhile experience for her and she was ready when she met a colleague of her father’s (and, coincidentally, the husband of Kathy Anderson, pediatric surgeon friend of mine who was formerly here at Children’s in Washington and is now in Southern California, where her husband, French Anderson, is working up a gene therapy business to prevent polyposis) who was trying to do a preventive GI disease company, which is still going.   Jenna and I have a lot of connections through Mayo Clinic one generation apart, since I was her father’s contemporary.  Then when she went to Southern California, she ran into Tom De Meester and the South African Surgeons who had moved with him.  But now she has to get a residency seriously started—and it would be unlikely after breaking a contract at UCSF that she would be welcome back there.  She was open and up front when she applied at the Brigham, and she was accepted there—so she is on her way to an even more premier residency post.  My medical student colleagues are not ordinary people.  Quite apart from denying their diabetes to be allowed to be a disability, the compulsions developed in managing it have made them into overachievers in other areas---and now, here they are with me in Dharamsala.  There will be little else that stands in their way.

OUR EARLY AFTERNOON PACKING IT UP,
AND THEN AN EXCURSION BY TATA
UP THROUGH THE RHODOENDRON FORESTS TO BILLING

            This was our fourth and final clinic in the school setting here near the TCV, with one more tomorrow at the Monastery, for which we had sequestered some drugs and supplies that would not be used here, but would be needed for the monks and the dependents and school children there.  But, it was time to reward the faithful for the work they had been doing.  We all climbed into the Tatas and Mahindas with a sense that we were on a brief vacation.  To take advantage of the sightseeing part, Michael Eiffling climbed on top of the roof rack of the Mahindra that Ravi was driving and he was joined by Raj and a couple of the others periodically as they took off, using the “best seat in the house” position on and Indian bus or train—a posture that would get one pulled over and ticketed in the USA as unsafe at any speed.  We drove back toward the Guest House, but then kept going above the Guest House, behind the garden and up the hill, that until then had just been a steep backdrop to our dinner quarters.  The small “SUV’s” (if there were such a name for them in India, and if the were 4 WD or other than diesel powered compact trucks) started the climb up the switchbacks of the winding road up the mountain.  I pointed out the area where we might see down the valley into the terraced rice paddies where I had walked up on the Tibetan style monastery at Bir.  From up on the mountain, this gilded small edifice in the middle of the green became smaller and “cuter” the higher we went, and it seemed to be a jewel in a garden as we got still further up toward the 12 kilometers toward Billing.

            Santosh was our driver, and he responded to the flattering things we said about his driving expertise.  Despite his limited English, he tried to join in our jokes and later—as proven on our return down the mountain, made much more challenging in the dark—he even tried to join in our songs.  As we climbed, I recognized that the majority of the trees I was seeing were rhododendrons.  As we got higher, we were cooler, and the fully leafed out trees became earlier in their process of flowering to budding.  At first there were scattered crimson rhododendron flowers, then we encountered clusters of the trees in bloom.  Still higher there were lighter trees with whiter blossoms.  It is like the huge rhododendron forests I had seen in Nepal at Lukla and on trek up the Everest approach alongside Meru Peak—where the colors of May must be an overwhelming spectacle.

            I felt very much at home, sine I will be returning to Derwood at the time the azaleas are in blossom about to give way to the scarlet rhododendrons I saw everywhere around me here.  At one stop, I could shuffle through rhododendron petals like piles of discarded Tournament of Rose Parade float covering.  I got to walking up the steep mountain and I was OK when moving, but on stopping, I had severe pyriformis muscle spasm.  I was standing like some Indian fakir in the “Going to the Sun” pose, balanced on one leg while the opposite hip was in flexion over adduction—the only pose that could get my sciatic circulation again so it would not make for a cold numb foot on the left. I was eager to do some serous climbing, and tried to do just that when we stopped at a shepherd’s hut at the top of Billing, as high as the road goes in this foothill of the Dhaulidhar Range.  

            I got out and started climbing up the steep slopes over sheep trails with an occasional sheep finding its way back down to join the flock around the hut.  As I climbed, I could see more and more of the Dhaulidhar Range and the snowcapped mountains that rim the Kangra Valley.  I had left the GPS in the Tata, but carried the cameras for a panoramic view of the slanting sun on the massif before a tinge of Alpenglow made it all pastel.  “Purple mountain’s m majesty” I believe is what they call it in another nation’s folklore.

            I stood atop the peak and looked at the sod and scree beneath my feet.  I could see the fossils and the evidence that is the first and last line of the John McFee book “Assembling California”—“Do not forget: the summit of Mount Everest is marine limestone!”   Christa and a couple of the others were coming up after I had been up top for a while stretching, and they thought I was in some from of Buddhist trance, stretching a rather irreligious left pyriformis that picked this day to object to not running and insufficient climbing.  When we went back down, we stopped behind a rock, where our gang had started a small fire and we had the obligatory “Chai”.  A special treat brought from Atlanta, was a bag of shelled pecans and another of walnuts—my kind of snack.

A ROUSING CHORUS IN A ROUND OF PERFECT HARMONY

            We had tried to sing a Hindu song and also a Buddhist song, and after a few Negro Spirituals, without getting into Christmas songs, there were few others we could identify as special American songs.  I decided to pick one that no on else knew and then teach it until we could all do it well—after all we had about two and a half hours in the dark going down a treacherous bumpy set of switchbacks fording streams and jouncing about in the Tata which Santosh was driving so expertly.  So, I began, one of three stanzas at a time, of “Dona Nobis Pacem”.   There were five of us, Jenna, Carrie, Elizabeth, I—and most enthusiastic of us all, clapping his hands when he could take them both off the steering wheel as we careened down hill, Santosh.  That means we had enough for two each on each stanza with me taking the odd man out third part of the round.  After we had done it often enough to perform it for our fellow travelers as a round, they asked “Did we get it about right?”  I said: “I don’t know; let’s see!” and then I played back the tape I had recorded of the prior tries, while the tape recorder had been in my pocket.  They all thought we sounded even better than they had thought we were after mastering the three parts and harmonizing with all the overtones ringing in the Tata.

The new song, made to order for this purpose, was better than any other common part of a culture that was too diverse to have everyone “singing from the same page.”  We had tried a few of the Rock and Roll era, and had run through Beetles songs, the Carpenters, and a select couple of favorites of each, but it was more dependent on the era we grew up than where that had happened.  When we got back to the Guest House for our very much later dinner, we had carried some firewood to a cement apron in the middle of the garden, and soaked the wood with the fire-starting magic fluid out of the camp stoves, and made a bonfire.  We actually needed it, since the mountain air by night was quite cold.  But, of course, the bonfire inspired the group to do their dancing around the fire—some of it looking aboriginal, and probably the most memorable being Jenna’s imitation of the young girl at school today who had made the moves after our toothbrush ceremony.  Tall angular blonde Kim looked like either a yoga while dancing and posturing, or probably more accurately, she looked like me, balanced on one foot going through contortions to stretch a stubborn left pyriformis!

We were drowsy and tired after our late exertions of this day, and piled into the jeep-equivalents to ride back to the Taragarh Palace for our last night in such luxury before moving down market a few notches—into tents, sleeping bags and monasteries for the next few nights.  Stick around—as the new advertisement for the newly re-named Anderson Consulting Accentrix now has it  “Now it gets interesting!”

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