APR-C-12
THE LAST CLINIC DAY IN BORAT,
FOR A TOTAL OF 771 PATIENTS HERE ADDED TO
298 FROM SHERBALING, SUMMING TO 1,069 PATIENTS
FOR THIS SERIES OF MEDICAL CAMPS:
WITH AN AFTERNOON EXCURSION TO THE UHAL RIVER
TROUT AQUACULTURE AND THE NETTING OF THREE BIG RAINBOWS
FOR DINNER, CELEBRATED WITH THE HEALTH
CARE STAFF OF THE BORAT PHC CENTER.
April 27, 2002
The last clinic day, we knew, would be a gully-washer. The number of patients who knew about the clinic and the free medicines would have increased by word of mouth, and the people from such places as Lahori to which we walked yesterday, and the surrounding hills will have heard about us, and they will know that their last chance at us will be in this full clinic day.
It began inauspiciously enough. I tried to give myself a cold-water bucket bath, but had no laundry or other cloth that could serve as a towel, so I tried to drip dry outside in the cold sun as it started up the day. There would be no rain today, but there would be not much of the day to see the sun if it were out there to be seen. We went in to the clinic and the mobs surged toward the door. We had Anuj police the area so that we had only two patients and their attending families enter at a time to each station. The one senior and one junior student were at each of two stations and since Sabrina had some from of GI distress and stayed back in bed (“I started her on Cipro” opined Laurie) I covered Kathryn, who, although a junior, really took to the mounting pressures of the clinical push for a large volume of patients. She was at first very reluctant to shorten her exams and focus on the chief complaint for fear she might miss something, but the issues brought before us were rather straight forward, even if the circumstances of the patient living in this environment were not.
One of the early patients was a young boy with a sinus in his leg with a long draining unhealing sore, continuing now in the tibia for a year. The students did not recognize this as a classic osteomyelitis with a sequestrum, with bone “spitting” from the dead bone in the middle of a tough “involucrum.” He needed a sequestrectomy and drainage, and I told them that giving antibiotics would not cure a problem of a dead infected bone fragment in the tibia.
One patient also had a bulge between the eyes over the bridge of the nose, and the young man was having increasingly frequent seizures. Everyone focused on the lump, which they thought might be an abscess that needed drainage—which, of course, would be lethal. They were looking unwittingly at an anterior myelomeningocoele, with a bulging rhinencephalon. This is a difficult problem and needs specialized attention, which it is unlikely the boy will receive, even though we recommended strongly that he get it. Within a few minutes, we also saw a child with flail lower extremities and a fixed lumbar myelomeningocele, and a shunt placed to arrest hydrocephalus. This had been done at IGMC, (Indira Ghandi Medical Center) in Simla. Since the child had been under good care doing the right things, it was appropriate that they continue such follow-up there without our interference in this setting. But, he also needed some specialized services which were unlikely to be achieved here or even in Simla—special PT and walkers and braces to get him trained to be able to walk, even if he had very little recovery expected in the flail lower extremities.
We had several skin rashes, among the much more frequent scabies (another question about the futility of treating scabies when the kids will go back to getting there mite re-infecting them?) and these were uniquely fungal. But there were a number of foamy “Loquia” that could have been candida or Trichomonas which we hoped the local “Doctora Bish” would treat. She was originally from Goa and had her mother visiting for a month. WE met them at the dinner tonight in which all the local health care personnel were to join with us and we would talk. But since our Hindi, and their reticence were inhibitory, a lot of time was spent staring at each other through a jet lag haze in my instance at least, and an exhaustion from having completed a clinic of over 1,000+ patients in five full working days.
Doctora Bish knows that there are several types of “PID” (pelvic inflammatory disease). Since she cannot differentiate them with any tests she has at her disposal, she treats each with everything, hopping thereby not to miss much. I believe that the fungal infections we saw might have been a result of such shotgun therapy.
One man was seen with prostatism. He had dribbling urination. We suggested he get himself followed in a clinic that could do something about this, since I was not about to try to undertake a prostatectomy here in Borat, after having done several in the hospital in Embangweni Malawi.
THE AFTERNOON “LIST” DOUBLES OVER THE MORNING
The queue that was awaiting us in the morning was doubled for the afternoon, and I knew we would have to pick up the pace and also shorten our prescription time frame since we would run out of drugs from our stock, already low on some analgesics and antacids and down to nothing for some drugs. We had left for lunch amid a large and colorful crowd standing at the door, which looked dolefully at us as we got into the Tatas to wheel away for a forty-minute lunch break. “Why, indeed, were we leaving?”
When we returned, they were still there squatting in the shade of the bushes, and made a rush toward the door. The first through the door was a son assisting his father, who was staggering in with a sheaf of papers and X-Rays under the son’s arm that included a CT scan of the brain---in Borat! Right! We are going to take on the advice and further management of a man with a recurrent brain tumor in a medical camp screening clinic manned by non-graduate medical students! He had a skull plate in the right frontal area, which had been replaced in the burr hole circumferential craniotomy. The CT scan showed me the recurrent right frontal meningioma, and the history of the patient relayed by his son, was that he had been operated on in Simla, but now had become blind and his left side paralyzed after the treatment that had been given there, so he had brought him to us to get some medicine to cure his paralysis and blindness. We tried to explain that there was no medicine that would do that, here, or in Simla, or in Washington, DC. The faith that these people have in the Western medicine to rescue them from some of the residua after their own Ayurvedics have failed is touching from my perspective, knowing the nostrums we are packing, which have a high placebo value if nothing else, but a number of the students seem to share the patients faith and gullibility. For every problem, there is a readily available cure, and all that is needed is to match the cure and the prescription. I explained to the patient through his son, and no less to the students, that there were certain things we could fix, some we could mange, and these were at the margin of the human condition; but immortality was out of the reach of the wealthiest among us, and no amount of “fixing” would solve certain inexorable conditions, including the one he had and a number of others with which the US citizenry has also not yet come to terms, and that a certain equanimity in the face of these facts was better learned than a shopping list of cures for each disease. The important thing about medical school is learning the distinction of many of those with marginal benefit to management and which are accepted as beyond our skills at present. The students are only slightly further along that learning curve than were the patients here.
“What, no medicines? He surely must have some medicines!” said the son. He was given a few multivitamins, with a reinforcement of the previous advice to the son—“These are NOT treatment for his disease, but are really given to make you feel better about our interaction with him.” It is for that reason that the skull plate is put back in place tightly for a patient with a malignant and spreading brain tumor. The swelling caused by the increasing tumor size, leads to a comatose condition, and a quiet painless death is preferred over the presumably longer life and consciousness of someone whose skull plate is removed so that the brain can herniate out of the skull with a fungating tumor mass which may leak, and drain and become a complicated nursing problem, to say nothing of the intracranial sepsis that may result. The students could not appreciate why a skull plate is replaced, when, for sure, it will lead to a shorter life with increasing intracranial pressure. I am suddenly impressed with the difference in age and experience between me and them, since I have been in medicine for longer than any of them have been alive, and they area all eager to correct my misapprehensions.
One of the more fascinating patients to show up was limping slightly and used a cane (actually, a forked stick.) He had an externally rotated and foreshortened left leg with the toes pointing pout, but that did not keep him from farming and regularly working rigorously in his fields. To my surprise, he had an X-Ray in a sleeve, rolled up and ragged around the envelope. I pulled it out, and there were two bits of information. He had a fall off the mountain on November 3, 2000. He was seen some weeks later and carried in for an X-Ray, which was enclosed. He was treated with a bandage, and now here he was.
I was looking at something I have not seen before, and showed it to the students as something, which they would likely never see again. I am looking at the natural history of the standard intertrochanteric hip fracture! This man had fractured through the femoral neck of the hip and impacted the fracture site, with the trochanters tugged in opposite directions by the muscles that insert on them. He was untreated (I do not suspect that the “bandage” helped very much!) Sir William Osler had said that the treatment of a hip fracture in an elderly person in winter was to open the window. Pneumonia would solve the pain and immobility problem
This man had no such immobility problem in the winter of 2000. He was necessarily up and about, and the impacted fracture healed, albeit not without a lot of pain at the time. Now he was stumping around with the leg in the classic emergency room stretcher position that is diagnostic of intertrochanteric hip fracture—hip X-Ray redundant. He would have had a hip nailing in minutes to hours anywhere in the first world, and we would never have seen what the natural history of a survivor of an untreated hip fracture looked like.
For me, the maximum yield from these repeated trips into the heart of the world’s hinterlands, beyond the medical pedagogy yield, is a direct view of the untrammeled human condition among populations not led to believe that life is a pain free experience and that any untoward outcome is obviously someone’s fault from a bad fix.
We pushed hard and saw them all---every last one of them. We even had a small fraction of some medicines left over, some of which I will pack with me to Nepal, and the others will be carried back to Simla to make the trip with me next month to the Spiti Valley.
I had seen a sign in English—as well as a subscript in Hindi, although I did not know, of course, what the subscript said, and I do not think that it is a coincidence that the English notice was the dominant one---“Trout for sale!” I have been salivating since arrival at the view of the rapids and pools of this Uhal River and its mountain habitat that made it look like “Trout Unlimited’s” poster child. But, on the banks of the river, with concrete tanks flooded with the fast aerated waters of the Uhal River were aquaculture tanks of trout. I believe their principle product in this largely vegetarian community is the sale of live trout fry since most of them go out of here too small for Europeans to eat (although the curse of the third world’s seafood cuisine is to cleaver up all fish into bony little chunks as a condiment rather than a fillet main course—here and especially in the Far East, I had noted) but there was a brood pond with large rainbows and a few large brown trout in it. These two to three foot trout were swimming around in the swirls of the pools, and would rise in frenzy when I walked by, since they are conditioned to see a human shadow and associate it with the fellow who throws the feed pellets into the water. We did that, and the big trout lunged at the feed and each other. After bargaining a bit, a large net was brought out when it was understood that we wanted some of the large trout and not the usual small fry, and a price was set for six to eight kilos of trout—three large fish. With a toss of the pellets and a lunge of the net, three big trout were scooped, and we watched as they were stunned and gutted with a razor blade. The guts and gonads of these big fish were tossed back into the pool and the trout within the pool went into their mad frenzy to slash and swallow what had recently been the still quivering remains of their schoolmates.
We brought these three newspaper wrapped fish back to the Guest House for our special farewell dinner, hosting our local health care team—the “doctors” and the daughter of one of them, a sharp and interested young girl named Monica whom we had impressed into service as a translator—at age 11,doing the most critical part of our health care interviews—and the mother of Doctora Bish from Goa. To get ahead of the story of an otherwise uneventful evening, the magnificent trout were served up to us—no surprise—cleavered into bony bits fried in peppery oil, garnished with special Chutney made by the mint that Anuj found by the roadside. They would have made spectacular grilled boneless fillets—but then that seems more like a dinner than a condiment, and even a condiment is more meat than most of our vegetarian guests might allow to pass their lips.
After this long grueling day with five of the students on the line (Sabrina still being bed-ridden) it was time to present cases and make up the student evaluations. Each student had a chance to present one or more cases and then make comments or questions on anything they wished on this experience. Of course, they all reported that it was an eye-opening, if not life-changing, experience. But, two of the students, and both of them juniors, hung behind. Kathryn was intrigued and wanted to know more about how she could integrate Eastern and Western medicine, wanted to know more about my opinion about alternative healing, and was generally “into” this clinical experience that might otherwise have b en overwhelming to her without guidance. She will do well as a clinician.
Lena also held back and wanted to talk to me when we were alone. This is because she was quite unsure of what she wanted to do, and now was even more so. Clinical medicine does not seem to be for her. She was put upon by the urgency and preemptory nature of the patient demands, particularly when they were sick or there was any frustration, as with faulty translation. She had taken off on the fugue from her start in medical school from which she had been absent for the year and a half getting the MPH with which she was also uncertain and dissatisfied as a career with which to make a living or get excited about as a career. She has been wandering the world and was eager to hear about the further places I have been, not necessarily working—Africa Antarctica—perhaps to escape any coming to terms with the fact that she does not really want to go back in to return to medical school, which is hard, and medical practice, which is harder. Many students have taken these trips with me to see if medicine might be for them, and it has helped nearly every one of the premedical students in their applications to medical school. In fact, of the students I have taken, such as Amy Hayes, Elizabeth Yellen, and now even marginal candidate Signi Paige has now been accepted into the University of Miami medical school for admission next year, only Hadley Abernathy, who applied last year after several years as a teacher, and was not sure she would be a good candidate was conditionally accepted as an “alternate” at GWU, and by the most recently posted emails, she had just chosen to go to Harvard graduate school for a PhD in education overt the move up on GWUMC’s acceptance list which I had arranged. If nothing else, this trip has now proved valuable to one already accepted medical student by defining clearly what she does not want to be doing the rest of her life, and it is better now than later to make that decision.
It might have been a social “downer”, since several of the students were sick, all of us were exhausted, and each of us were here as hosts to the local medical community who had been invited to our farewell dinner. We stared at each other in weary jet lagged hazy grogginess. If it were not for one thing that I could resurrect from my background of paying attention to detail in the tours of Kinnaur, and the Sutlej and the big construction project at Sangla in watching the underground hydroelectric systems being developed, it might have been a bummer of a conversational evening. The “Head Man” of the “Works”—the Hydel—hydroelectric, the only game in town—and I discussed hydroelectric plumbing, power and efficiency.
I had seen the construction of the big Sutlej Power project called NAFTA JAFRI in 1998, and seen the construction of Asia’s first totally underground power project, using the huge vertical distance drops of the raging waters of this roaring river for power generation. This NAFTA was a big power project, which fed the national grid. The other projects are called “mini-hydro power projects” with the one being built at Sangla generating 300 megawatts, for example. The power plant here—the first in all India, built by the British Raj in 1932, generated 36 mW when it was opened, and it has undergone three subsequent updatings to 40, 52 and now 60 mW output, so it is still in the “mini-power” category, despite it’s revered grandfather status. By contrast, the Sutlej NAFTA-JAFRI will generate 15,000 mW, which is a major contributor to the power needs of all India, such that the use of hydro power is probably more than twenty percent of the India electrical generation with the reliance also on nuclear power.
There are three penstocks, four meters across for each, that drop this column of water from the elevation of Borat at 6,300 feet to the five turbines at elevation 4,300 feet. This drop in altitude as well as the coining down of the penstocks at the turbine entry gives a huge power head from two reservoirs of 11. 5 and 5 million gallons each alongside the Uhal River which could keep the power generation going for about a month in the absence of new inflow. The reservoirs silt up and the siltation tanks must be cleaned out every other year. I had noted that the power plant in the Indus River below Thicksay had been out of commission because of the siltation that had affected it on my last visit, but that they were busy cleaning it out to put its power generation back on line.
Because I knew a little about India’s hydroelectric power potential and could remember the different installations I had visited before, I made the Head Man proud in detailing the accomplishments of this, the oldest “hydel” project in India, which he supervises. His status is about that which the “head railway engineer” at the Hauptbahn in Germany or the Gar in France would have in his local community, and he was flattered that the talk of the evening was not all about doctoring, but could use his expertise as well.
When we finally staggered off to make the long trip the next morning by cluttered roadway back to MacleodGanj in Dharamsala, the head Man came to the Guest hose to see us off, as well as the waves from the many patients along the way who now knew us.
There were 289 patients seen in two days in the Sherbaling Monastery, and 771 patients seen here in Borat in three full days for a total of 1,069 patients seen and treated. And six medical students taught, three local health care workers in Borat enhanced, and one international professor further worn down!