Well, it’s finally happened, I am truly and genuinely homesick. I’m not just homesick, I’m a little sick of being here. I knew this feeling would eventually come and I’m glad it has happened now and didn’t happen sooner. The non stop hammering, and sawing, and drilling, and welding, and general construction that starts right outside my window at 7AM and continues until dark 7 days a week definitely is a big part of what is wearing on me. The clinic is also slowing down with patients so finding the utility of being here is becoming thin. Also, you know, I miss my wife. I haven’t seen her in close to like two and a half months. I miss her cooking and her smile and the way she fits right under my chin when we hug. I miss American food and being able to drive. I miss sleeping in my own bed with sheets and not in a sleeping bag. I miss being warm as I don’t wear less than 3 layers at any given time and am still cold. I miss not feeling short of breath and dizzy with any physical activity. I miss long hot showers as the ones here are brief and now much colder because the tanks have been periodically bursting and leaking leading Gobi to turn down the temperature setting. Also I miss being able to take a shower more than once every 2 or 3 days. I miss my friends. I miss being able to understand conversations around me. I miss sushi and cheeseburgers and take out with Deepali. I miss home.
This may all seem like doom and gloom but it’s not. I still am loving my time here but being homesick and enjoying the other parts of this experience aren’t mutually exclusive. Its just that I came to the mountains for peace ad quiet, which is what I’ve gotten since I’ve been here, but lately, over the last week, the non-stop toxic noise of metal on metal, sawing, banging, hammering is driving me insane. Reprieve comes from hikes away from the clinic and dinners with the team at night, especially when wine or beer accompanies the meal. Actually, over the weekend, I went on a hike to one of the gompas in the valley, Praken Gompa. (wikipedia page about gompas here: https://en.wikipedia.org/wiki/Gompa). While there, the Lama that lives at the gompa gave me a small blessing and some hot tea which was a wonderful surprise. The hike was a really needed escape and re-centered me to why I’m out here. The quiet, the warm breeze, the views. That inner peace quickly came back to me after even just a few hours being away from the hellish version of STOMP that is currently the clinic.
Also I've been listening to this song non-stop for the last week, I'm a little obsessed with it: https://www.youtube.com/watch?v=ql1-jjEPErw
We celebrated Gobi’s 43rd birthday on Saturday by going out to eat at the Tliicho Hotel across the road. He keeps saying this birthday is his sweet sixteen. We had some beer, ate some yak, and laughed about all the random things happening at the clinic. At the end of the meal the lodge owner said "no charge", what a great surprise.
Ok, case time!
The first case is a house call I went to last week. It was 6PM, an hour or so before dinner, but more importantly, an hour or so before dark, when Gobi gets a call from one of the hotel owners in Braga that there is a patient too sick to get to our clinic. Oy vey. Braga is about a 15-20 minute walk away and down about 100 meters from Manang. I’m on call so if someone is going to do a house call tonight, I’m it. Thing is, if I’m going to go all the way down to Braga and miss dinner, this guy better be sick and not just want room service. Gobi gives me the phone and on the other end is the patient’s girlfriend. She tells me her boyfriend felt well earlier but they hiked up to Ice Lake (about 1100 meters higher than Manang at 4600m) where he started to get really short of breath and fatigued on the way up. He thought it was normal because of them hiking so they tried to go higher but eventually he had to stop every 4-5 steps to catch his breath which prompted them to turn around short of Ice Lake. He was totally exhausted at that point, with worsening symptoms as he descended. Then she goes on to say “also he has no appetite and he’s been laying in bed doing nothing for 3 hours and is still short of breath”. Ok, I’ll bite, this guy sounds sick. I gather my gear including a stethoscope, blood pressure cuff, oxygen saturation machine, some altitude meds, cyanide capsule in case the situation goes south (just kidding) and head out to Braga with rain clouds looming overhead and the last bit of twilight to light my path. On the way there my Emergency Medicine brain comes out and I’m thinking of all the worst things it could be, namely HAPE. My god, is this really bad HAPE? The mind of the ER doctor is strange because I both wanted it and didn’t want it to be HAPE. Sick I know, just being honest. I didn’t get into Emergency Medicine to treat man flu. I get there to find a pretty sick looking guy in bed. I do my routine, ask the questions, take the vitals, listen to the heart and lungs. The lodge owner brought me a cup of what I thought was regular milk tea only to find it was more like a latte and one of the most delicious things I’ve had to drink since arriving in Nepal. Seriously, it was so good. Lucky for the guy everything checks out: lungs are clear, oxygen levels are low normal. He’s got moderate AMS and a touch of some bronchitis, no more, no less. Diamox and fluids are in order and after some discussion he decides against antibiotics and that he’s gonna catch a jeep first thing tomorrow morning. My job here is done. I charge the guy a king’s ransom for doing the house call after hours, finish my latte, switch on my headlamp, and start the 20 minute journey back up to Manang in the dark. Oh and those rain clouds from an hour ago? Its now raining full force, great. Whatever, I’ve got my rain gear, I’m prepared. I walk out of Braga and its raining, I’m alone in a foreign country, it’s dark with my only line of sight from my small headlamp, and I start thinking, “don’t sprain your ankle now ya bonehead”. Right at that moment, after being lost in thought and looking down at the ground I look up to see two glowing yellow eyes and a massive all white body. My god, a yeti, they’re real, I’m dead. My heart pounds out of my chest, my stomach falls to my feet, I get that squeeze of adrenaline only to quickly realize….it’s a horse, it’s just a white horse. The horse is more afraid of me than I am of it and it quickly runs off into the hills. Ok, get yourself together man. I walk a little further and a guardian angel in the form of a jeep comes by. I stick my thumb out, they pull over, I speak my broken Nepali: “mero naan Ben ho, HRA doctor”. The guys in the jeep repeat back “doctor?!”, they motion for me to get in, and I’ve got a first class ticket all the way back to Manang. I missed dinner but Indira warmed it up for me when I got back. Another life saved and another yeti avoided.
The next case was my first pediatric patient here. The cutest little 4 year old girl came in with her grandma for cough and cold symptoms with a fever. Pediatric patients still bring up that little bit of unfounded fear in me but upper respiratory symptoms with a fever, ok ya, I can do this. She looks great, drinking well and urinating well, proper hydration: check. Vitals show an oxygen saturation of 77% (now remember saturations here are lower than normal in the mid 80’s) with focal left lower lobe crackles and rales on lung auscultation. No respiratory distress. Pneumonia, clinically it looks and sounds like pneumonia. No chest X-ray here, no labs, just clinical evaluation. Some paracetamol liquid (Tylenol in America) and Amoxicillin should do the trick, come back if things are getting worse. Oh before you go….can I snap a picture?! Thanks!
Jenny had a patient this past weekend that really rang home how different medical care is here. A local 58 year old alcoholic male was eating breakfast with some co-workers when he had abrupt onset of speech change, complete left arm paralysis, and mild left leg paralysis. No headache, no seizure activity, no migraines, no symptoms when he woke up. It’s a stroke, most likely ischemic rather than hemorrhagic. Jenny and Gobi are summoned to his house 20 minutes after symptom onset. In America if this guy comes into the ER where I work: he gets rushed to the CT scanner, we inject contrast in his veins to look at the arteries of the brain, give a clot busting medication called tPA, and he goes straight to the ICU. You know what happened to him here? Nothing, absolutely nothing. He can’t afford the helicopter evacuation to go to Kathmandu even though he is well within an intervention window even with the 2 hour long transport time. He has massive psychosocial barriers to care including but not limited to his alcoholism and poverty. The good news is that his symptoms resolved significantly by the end of the day when Jenny and Gobi checked on him again. Not a stroke but rather a TIA, transient ischemic attack, or what many call a “mini-stroke”. Having a TIA puts one at more risk to have a complete stroke with permanent paralysis and possibly loss of speech or severe cognitive deficits. The compromised plan is to get him to take an aspirin a day and to have a regular check up with the local aid post worker. Not perfect, but something.
Update on Liz’s dog bite patient I mentioned last week. She went and saw him at his home and snapped a quick picture of his wound. Looks pretty good-ish. You can notice he has a few other scars on his chin so this is old hat for him. In the ER we never see the result of our suturing so it was kind of nice to see the end result.
Finally, a case from almost a month ago. I mention it now because I got an email update from the patient yesterday morning. The original case was a Polish male, about 30 years old, who came in for left eye pain worsening significantly over 24 hours. No trauma. He said he had a “really bad infection which left a scar” less than a month ago. He showed me the drops he was on, ciprofloxacin and tetracycline. Likely he had a bad corneal ulcer. He was wearing glasses but denied any contact lens use. Hs eye exam was impressive and I’m kicking myself for not snapping a picture. He had a completely injected/red eye with a very cloudy iris and pupil, pretty sure there was a hypopyon (pus in the eye). For all intensive purposes he couldn’t see out of that eye as he was experiencing severe blurriness, 20/20 in the unaffected eye, 20/200 in the affected eye. Also he had an APD (afferent pupillary defect) which is a bit complicated to explain but more or less means badness, deep structures of his eye are affected. I suspected uveitis or endophthalmitis, both very bad things to have at sea level, more so in the mountains. They both can lead to permanent vision loss. It was hard to really know for sure without a slit lamp or higher magnification exam though. I was worried enough that we got a helicopter for him to Kathmandu which I later had wondered might have been overkill. However, here is the email I got this morning from his girlfriend:
Coming back to Eye issue- [patient’s name] had consultation with eye doctor on the day when we landed in Kathmandu, who was not able to give the exact diagnosis so next day he had consultation in Eye Clinic with cornea specialist.
She gave the diagnosis that it was deep bacterial infection, but she saw also viral one.
Few antibiotics and viral pills were applied and after few days he starts to see better.
After back to Poland he did also consultation but all was already ok.
Thank You for Your help and advices.
Welcome to Poland (Cracow is very beautiful city ;) we owe You good coffee :)
hope You enjoy Himalaya
[patient and patient’s girlfriend names]
Nice when you do the right thing for someone and it works out well. Its moments like this that make you feel like a real doctor and that you’ve made a small difference in someones life.
Ok, that's all for now! Only 2 more weeks left until we close the clinic for the season and begin our hike around the western portion of the Annapurna Circuit. Stay tuned!