MAY-A-7
THE THIRD DAY IN LUKLA CLINIC FOR
143 PATIENTS,
AND A SURPRISE RECEPTION AFTER LUNCH BY A WOMAN NAMED DONBOCHE,
FROM THE VILLAGE OF NACHUA,
A POST-OP VISIT FROM A VERY GRATEFUL SNAKEBITE VICTIM,
WHO SHOWS US THE POST-TREATMENT RESULT,
AND HONORS US WITH KATIS AND COKE AND A CEREMONIAL
THANK YOU FOR SAVING HER LIFE AND LIMB
THEN A HIKE TO MAKE HOUSE CALLS ON ELDERLY INFIRM PATIENTS,
AND TO BE OVERWHELMED BY LOCAL HOSPITALITY,
IN “DEATH BY CHAI CEREMONIES”
BEFORE RETURNING FOR CASE PRESENTATIONS AFTER DINNER,
AND A MINI-MOUNTAINEERING, AND TROPICAL MEDICINE COURSE
May 8, 2002
This was the first day since arrival in which we awoke with the sun out on the distant peaks around us, and the weather stayed clear through about mid afternoon. Then, true to from, the air warmed up by the sun in the tropical valleys, pushed up by the rising expansion of this saturated airmass made into clouds as it condensed, then rained as it cooled further in passing the 10.000 foot level, right over our heads. But, for a brief time in the middle of our clinic, when we had a brief lull in the patient flow, we actually sat outside and tried to warm up and dry out in some rays. A few of us even tried to take in the good weather as far as washing, or at least drying out, some of the clothing that we tried to rotate amid the smaller volume of stuff we have carried, soon to get smaller when it is gong to be borne by backpack up the mountain trek.
I must be rather well acclimated and accommodating this altitude, since I took my pulse and saturation with the Nonin pulse oximeter I carry and check the patients with, and one of which will remain at the “Lukla Health Post” under the care of Nga Gyaljen Sherpa. Today, I was 92% O2 Sat and Pulse 56. I have done no running since the Boston and have not made any strenuous climbs yet. Sitting around has tightened up the left pyriformis, and I need to stretch it because of this relative inactivity, but I should get it to working when I am on trek.
I will record the interesting patients from those seen in clinics to the daily reporting of the case presentation after diner each evening, a mini-lecture course which further enhances the value of the course content for which I am certifying each of the participants: the three senior paramedic/firefighters will get CME credit for being with me, and the students get graded in a course. Although two of them, indene pendent spirits that they are, are graduating in absentia in order to take full advantage of this opportunity.
Most of us are quite healthy, and have even discovered how to run the water long enough for it to get not just warm, but scalding hot—too much of a good thing. The one unusual thing is that each of us seems to get drowsy and semi-naps for a little while after lunch each day. Since clinic goes to 1:00 PM and we have made it a habit of setting out on our graduated hikes of increasing length and difficulty each day, we have snoozed out after lunch, sometimes while still at table. Today, since we could be out at the picnic tables in the sun, we were there when a visitor came by.
Her name is Dumboche, and she comes from Nachua, a village down the valley, almost visible from the second day’s hike, although a long way by foot, which is how she came—both this time and last time. I did not recognize her, until she came and presented me with a bottle of Coca-Cola. She is the recovered patient who had almost died (as the local healer had confidently predicted she would, and left her to a self-fulfilling prophecy) after she had been bit several times by a very poisonous snake. She had been carried up the mountain by her husband, the only noble thing I believe he has been accused of in his inebriated life. We started working on her at once, and stripped off all the eschar in a wet to dry debridement and tried to get her back to good healing with nutrition and vitamins and antibiotics for the secondary infections that had turned very purulent. We had got her ready to go back with us, and a collection was taken up in the Lukla community for this fellow Buddhist, whom none of them knew, and we Europeans did not contribute as much as they did. We got her ready to travel with us, and then had to go find her husband who drank up most of the first days’ bounty, but Nimi threatened him, to say she would beat him if she found him this way again. He believed her, since this was no idle threat.
She had eventually stayed with Nimi herself, and is remarkably improved, such that she has only a few scars where the best she might have hoped for without this support is an amputations stump. This was definitely a life and limb saving treatment, and now one knows this better than t he patient herself.
That is why she walked up the mountain today to see me here and to carry with her silk Katis, the scarves of reverence and respect, which she layered upon me, and Nimi and Hati, as well as giving me the Coke, which must represents a lot more of her spending money than of mine.
I had told the group about the Buddhist cosmology, and the five elements and t he five centers of man, and that one should not desecrate anyone, even a child, by touching them on the head. Her mark of respect, just exactly as it was in the Mindanao culture I had worked in only a couple of months ago, is to claps both my hands and grasp them to pull them to her forehead. This is a gesture that is her call not mine.
We stayed with her and took pictures of those of us who had treated her then, and had a bit of tea, before she packed up to go down the mountain and we packed a few items to make some house calls down the mountain in a different direction to go with Nga Gyaljen toward his village. As we set off the weather changed, but we continued in a light drizzle. We past the oldest and longest of the “Mani Walls in all of the Kumbu” as we respectfully made sure we did not expose our left sides to it, a caution I am always using to signal to them to make sure they leave all sacred objects on their right—their clean hand side.
We went over a panoramic rock that gives a seeping view of the villages and of Nga’s project of planting 50,000 trees, American blue pines and a native Nepalese pine species, which are being brought out as seedlings from the nursery here supported by a grant from the WWF (once again—“Wildlife” not “Wrestling”). We stopped to see the older man that two of our group I had deputized to go down to visit on our first day. He had a strange set of recent symptoms, alleging that he could not get out of bed with his left leg weak and his abdomen distended. Each of these are true, but he did no t have any problem with his speech and his other neurological seemed POK. He did, however, have a CNS kind of response, a pathologic reflex of his left great toe called a Babinski, in which it withdraws, flares and goes up when the sole is stroked. So, he seems to have a spinal rather than a cerebral kind of stroke. He also had a large distended abdomen despite the MOM we had sent down which is getting some results in disimpacting him from his bedridden status. We will come back to see him after our trek, since there is no urgency that would require him to be evacuated right now.
We went along to two other hospitality houses, and found ourselves privileged to be inside genuine Nepalese Sherpa stone houses around the large fireplace where the inevitable “chai” is boiling, since we must stay for tea and biscuits. In fact we did at the first, which is the home of the mother of Dawa (=”Monday”) our host in the Himalaya Lodge. We had our tea and adjourned to Nga’s house, where we had not only tea but also the biscuits followed by a genuine Nepali standard---boiled potatoes which are peeled of their skins as they are hot, and then the white moist and hot peeled potato is ducked in a dish of salt—rather like the salted potatoes that were fed to us at the “full service” aid stations along the Big Horn Ultra Run. We sat through another round of Chai—I am calling the hospitality “Death by Chai” since they do not seem to drink water which I seem to need, but only about two dozen cups of tea per day.
We went on to a seventy-year-old matriarch who was alleged to be confined to her home, but I believe that was mostly by choice. She had a very large family in the house all aligned with their best Sherpani aprons on and eager to see what the doctors would be doing to add to their mother’s stock of medicines she had previously been given in Kathmandu. I had the students examine her and put on the pulse oximetry and take her BP, which had allegedly been high. Not now. We asked what medicines she was taking, and her husband produced a sack full. About fourteen drugs later, the only one she needed was the nifedapine for her BP and all the rest was about the sum of our pharmacy, so I carried back the thiazide diuretics we had carried in the event that she needed any medicine. IN fact, she needed about twenty fewer drugs, but she was pleased by the attention of her consultation.
This was the first house at which we were able to decline the already prepared tea, since we alleged that it would be dark by the time we had to get up the trail to Lukla, which was true by about ten minutes more.
As we climbed the steep path, with my suggestions to practice the
“rest step” and “PEEP breathing” the group was getting into it, ready for the
long trek. Then we passed an elderly porter, with a load of steel shelves and
awkward heavy objects in his backpack pulling on his tumpline. He was older
than I—not easy in these mountains—and he had come in one day from Namche to
which we will be trekking over the next tow days! I reminded my stalwart young
crew of this fact.
As I got to Lukla, I saw the military police fanning out for the
night patrol, with the day contingent coming in from their shift. Later I heard
that it was this outgoing guard for the night that got involved in a turkey
shoot against the Maoists down the valley.
A second sight was a Kodak moment. We heard some little kid voices in a singsong, and saw movement under a towel, anchored in place by rocks against the side of the trail as we were in town. I pulled up the towel to have four little faces peering back at me, their rosy red plethoric cheeks flushed with their excessive hemoglobin. “They are playing ‘marriage,’” explained Nimi.
Nimi has had very significant baby lust each time we had passed a child last trip, but she now has two adopted children of her own, each with a story. The one was found as a one-day old baby, which was crying in the forest where it had been abandoned. A policeman was told and came to pick up the child, and the next thing he knew it was hungry and needed feeding and changing. Nimi was known to have wanted a bay badly, but now she had a seven-year-old left to her permanently by her mother. But she came when the police called, and she adopted the little baby boy, now called “Dawa” (=”Monday”, the day he was bon and when he was found.) Lakpa and Nimi consulted the astrologers who had looked up in the Buddhist scriptures and the star charts and had found that the baby boy was an extremely propitious match for them
That brings me to the follow-up poignant part of the story of the snakebite woman. She had been very grateful for the care that I had started and Nimi had followed through in providing in 1999. As a sign of her gratitude, she wanted Nimi to take her daughter. The patient was very disconcerted that her own mother would not allow her to give her child to Nimi, even though all agreed it would have a much better life. So when she visited today, I told Nimi that she would have to take out the photos she is carrying of her new children so that the woman will know that now Nimi-Ji, too, has children. So, the mothers had a good time comparing kids.
Now comes the evening dinner, case presentations, and didactic lectures that the group seems to look forward to, since I am tailoring them for this environment.