APR-C-7
FIRST CLINIC DAY IN SHERBALING MONASTERY
WITH A VIRGIN CREW OF CLINICIANS
AND THE BOXED PHARMACY I HAVE CARRIED ALONG
April 22, 2002
As we had driven along the road yesterday, the “equal opportunity” for the 2001 “Year of Women’s Opportunity” in India, announced in a poster I saw in the Delhi airport on arrival is apparent in the hot and heavy road construction. It seems that women, dressed in colorful saris and flowing headdresses, are the heavy hod carriers of this society, and they would gracefully carry a headload of rubble from a construction site and dump it over the side of the mountain, that they are whittling away in the eternal process of erosion of the uplands. I had remembered many of the places I had passed along the road side, like the tea plantations and the army cantonment and the Taragarh Palace—a place we had stayed last year. Many of these I knew quite well from running, and asked Santosh our driver to stop at least once, since I was babbling about huge trout in the river beneath a stone bridge at a mountain side site where a holy man lived, who was custodian of these large fish. “Right!” said Santosh. He does not understand English that well, but does know that there is a lot of weed along the roadside at this elevation that gives people a rather distorted view of the world, so he was wondering if I had inhaled a bit too deeply as we passed the burning refuse at the roadside brush fires. At that time the two medical students in my jeep were Lena, who has body decoration of her own, I noted in a pierced tongue with a stud she can compare to the Indian women with a pierced nose, and Marita, who is still trying to find CD’s or music as a belly dancer at each stop we make along the way.
Finally I persuaded Santosh to stop. He figured I was just trying to get out for a roadside Pee Stop, which I would also have worked into the occasion if it were possible in a less populated area, but I crossed over the large stone bridge and pointed down. There, in the pool at the foot of a little falls are huge fish, finning around in circles. There must be about two hundred of them visible, with some showing the colorful flash of their sides as they roll as big rainbows, as long as your leg. Some are large scaled carp-like fish further downstream, but, sure enough, here is a very dense population of fish in a fishing hole that would be like shooting them in a barrel, but for a few factors. This is a largely vegetarian population. Second, these are living creatures under the care and feeding of a holy man recluse on the hillside who is guarding them presumably, and they are also a bit of roadside entertainment—as they had been to me the first time I had seen them on the run. The lavender jacaranda blossoms were bloomed out on the roadside trees over arching us. I had also seen the Tices’ riding of the Maharini’s “Queen Mother” whose palace the Taragarh Palace was in the morning exercise of the polo ponies while I had run up the road through he tea plantations, but by this point the fellow riders in the jeeps were interested in little else except getting the ride over with and arriving wherever we were going to be.
SHER is at 32* 03.10 N, and 076* 41.18 E, which presumably puts it about 8* north of the tropics and about a mile and a half up in altitude. Nonetheless, the very hot and dry April temperatures made everyone impressed with the fact that this must be a tropical exotic environment, which must have tropical diseases. There are a few mosquitoes, but no Anopheles that live this high, so malaria is not part of that mix of illnesses, and the largely vegetarian diet changes the disease pattern also. For orientation, that GPS mark puts Sherbaling Monastery only 24.6 miles, at bearing 300*, from the Hotel Bhagsu which we left in the afternoon of a long day’s drive to get here. This spot is 7,235 miles from HOME at 338* (meaning that the shortest great circle route is up and over the north polar approach.) It is 6,898 miles from the BOSM (Boston Marathon earlier this same week) at bearing 335*, only 92.8 miles from CHAN at 177*--i. e. the last two grueling days’ drive from the train station we left forty-eight hours before and 242 miles from DELI at bearing 173*
Since people were both wiped out and also curious to see pictures and hear what to expect, I gave them the hard copy of the description of last year’s mission here, and showed them a few pictures I had carried from last year, and also showed a few on CD on my laptop. I had unpacked the Action packer, which is largely stuffed with the heavy clothes for the overnights on the Everest Trek Route and the latter half of my trip here in the subcontinent with a second team in Nepal.
Probably everyone woke up around 3:00 AM this morning, but it is for sure that everyone overslept at the eight o’clock breakfast that would start our day of the first clinic. We walked down a steep ridge in a woodsy “shortcut” to the main monastery hall where we had set up four stations, as I unpacked the MAP boxes and catalogued the medicines, which I had made Xerox copies of the bills of lasing for each station. As soon as the monks and students knew we were here, the deluge arrived, and the teams of paired senior/junior students at each table with a translator, a medicine list, a functioning pen, and about sixty shoving curious patients each leaning over the one who was being examined trying to get to be next by shuffling the pages of the waiting queue to make sure they came up next overwhelmed each team. They started off, as does every medical student group despite the instructions in orientation. They try to cover their uncertainty by being very thorough, or flippant, and asking for lots of information or tests, and then coming to a screeching halt or panic when they do not have whatever they just thought of to do—a BP cuff, or otoscope, or set off on a search through eh pharmacy—doing anything in a fugue to abandon their station and inspire further panic in the waiting patients who are sure they have been abandoned. There first patients seen took over thirty minutes each, and they were healthy students with very little wrong, just trying to get some kind of free medicines.
I ran around to each station trying to support them, but they knew that if I was standing by they could turn over the problem to me to solve and make themselves less uncomfortable. The registration tem would figure this out also and make a note that this was a VIP patient and should see only Dr. Glenn, which made everybody instantly into another VIP. Anuj came over to say we should set up another station where just I would see patients, which would instantly gut the credibility of all the other stations and make them even more panicky than before wince they would get stuck on their first unanswered question and simply shut down, shunting all the patients over to me. As a good triage officer knows, the leader of a triage team should never get involved in the care of an individual patient since that would tie him down so that he could not circulate and keep the whole system going. The long and restless queues of patients figured out rather quickly that they would never be seen, not in the pre-lunch break, and probably not today at the pace and hesitancy that the lists were moving, and the senior students seemed to be the ones most in need of efficiency lessons. By noon, Kathryn had said how much fun it was but most of the others were already overwhelmed. I said that there was no such thing as instant experience, and they would grow comfortable with the sustained ambiguity over time, but that they had to identify which were fixable problems and focus on these and move on quickly with clinical information and judgment. I also warned that as they succeeded in solving a couple of problems, they would get rather cocky about the ease with which that happened and get further slipshod as gunslingers when the next patient came along and miss things in mistakes BY NOT LOOKING. That happened by afternoon. I was groggy from jet lag, as I heard the most junior of the medical students summarize a young boy’s problem as “just a kidney infection.” No way. That would be a very serious problem in a young boy who would have no reason for having a urinary tract infection to begin with, but even cystitis would require work-up in a male, with a pyelonephritis probably being lethal. So, we went the whole spectrum from being afraid and wanting to fugue from the hotseat, to being cocksure at a distance and bring on the next patient since I have already diagnosed this one as having a brain tumor. At lunch, I explained that this “sine wave curve” of despair at ignorance, to exhilaration at false wisdom, would keep cycling, but it is hoped to be continuing upward at a slope that would be dampened in the swings.
More because the patients gave up waiting than because efficiency improved, we stopped early around four o’clock, and Mirdoc, a fellow born in Ladakh who was a manual road laborer there had come to teach English to the youngest monastery students, and he was the one who took us around the monastery on a tour of the shrine and the icons, including the fifteen meter statue of the gilded Buddha. AT he time we entered the shrine the monks were at prayers in full monotony of their mantra and chanting with the blare of the horns and the crashing of the cymbals. We took our shoes off and presented a “kati” the silk scarf that indicates respect, to the Buddha, as we circled around the curious monks who continued in their sonorous prayers with sideways glances by the young boys at the western strangers walking around in the temple—and to them the perhaps stranger appearance of one of us—the bubbly blonde from MCP-Hahnemann now enroute to a surgical residency in South Florida, getting into it, prostrating herself before the e Buddha, and exercising all she had learned in the past several weeks of her meditation courses and study of the Chakra points of the body meridians, and the herbs and crystals and aromas, and massage and healing mantras.
We came back to the Guest House, and they had about an hour to rest before we would go off to the Government Guest Hose over Bir monastery where I had been last year; they were aware that they would each be presenting a patient from their day’s experience to me, and that they would be taking a drive over to another place to eat. Two of them never reemerged saying they needed to sleep more than eat, so Sabrina and Lena stayed back as the rest of us got into the jeeps and drove the long and dusty back roads over the ripened rice paddies where colorfully dressed men and women were sitting in the terraced rice fields as the sun was setting behind them. We saw a flock of sheep being herded by two walking haystacks of greenery, and an older man in front carrying a bundle of twigs for firewood. We went on to the Guesthouse on the mountain we had once gone up through the rhododendron forest to get to the top of Felding last year. WE sat in the garden as the bats came out and the stars came out to outshine the earlier planets. Four of the students then presented their patients, each of them quite simple stories, and we had dinner, before making the sleepy drive back. As we returned, I remembered the stories I had swapped when I had returned last year from my unexpected encounter with the Bir Monastery, and had come up to meet the delegation of men who had been sent to see me during the time I was going to join with Hem in his second meditation session instruction. They and I talked about leopards and the other big cats which are still present here, before they took over the conversation by grilling me about what was this stuff called health insurance and how could you insure health, and how was it possible to collect on it, as some of their Indian physician colleagues had done by moving to the US and getting very wealth in practicing medicine?
So, this closes a rather low-key day in the opening of the least of our acuity of care—the relatively healthy monks of the Sherboling Monastery where we will repeat another clinic day. The students are trying to get a handle on this routine and also figure what is expected of them, since many of them are taking this as a course, and they are going to have to be evaluated and graded on their performance, so they cannot blow it off. I am reading about the next series of missions I may be taking to Sikkim in a colorful book and Bhutan. I learned that the mountain of Sikkim, the 8,000 meter peak Kanchenchunga, means “Five Jewels of Snow.” The ancient Hindu symbol of the “Swastika” (“Swas”= “Breath”of life) was studied by Hitler as a scholar of the Hinduism since he aspired to be a pure Aryan—but got the orientation of the limbs of the Swastika wrong. There is also a new book by a South African military surgeon called the “Dressing Station”, which I will try to read if I can stay awake to do so. My day time nadir is effecting my ability to make observations and record them, but I do not want to give in to my impulse to get up at the 1:00 AM jet lag wakefulness and delay the whole process of orientation (meaning getting centered in the East) all over again. On the other hand, one of the medial students may already have gone a bit far in “orientation” having picked up at least the trappings of the whole religion, mysticism and healing parts beyond the useful in “participant observation.”
So, as always, we are off to a stagger start, with a slow clinical effectiveness at the outset until the team gains experience and a routine in taking care of large volumes of problems with minimal resources, and among a group of very varied acumen and prior life experience. By the time we get into the more rural village of Barot, which even has a small hospital we will be working in, we may get up to some speed, by which time the team will have gone from clueless through cocky to possible eventually competent, and it will be time to continue on our way through the tourist destinations such as the Taj Mahal—for me, again.