The Last Free Summer 2
Mark Clapp, Neal Viradia, Emily Gifford, Poonam Patel, and Suzanne Weaver, medical students from the University of North Carolina (Class of 2011), share some Stories from their expedition to the ancient Tibetan kingdom of ‘Guge’ in India
During our medical trip to the Spiti Valley of India, we had the chance to be exposed to all types of medicine in an amazing environment. The majestic snow capped mountains served as the walls to our clinic with dense snow filled clouds overhead providing a patchy roof. The monastery and His Holiness the Dalai Lama’s, guesthouse served as beautiful artwork mounted upon the walls, and, lastly our temporarily pitched clinic tents served as the perfect finishing to what would be our ‘home’ and work space. Breathtaking was a word that was used in common conversation. In the midst of this beautiful scenery, we held clinics at local villages. Clinics consisted of eight tents; there were two internal medicine tents, one ophthalmology tent, one pediatrics tent, one ob/gyn tent, one dental tent, one triage tent, and one pharmacy tent. We were assigned to one of the tents each day with our team members. The diverse team consisted of medical students, dental students, doctors, and nurses with 37 of us in total from all across the globe. The clinics were really enjoyable experiences, but busy, and we saw roughly 200 to 500 patients each day. Below are some of our most memorable moments from the days which we held clinic.
From Poonam
The Donkey Kick
I have very fond memories of Nako. It was the location of our first clinic site after many days of acclimatizing to the altitude and after endless travels along death curved roads (which confronted my fear of heights on many occasions). About a kilometer down the road from our clinic site was our tent community - most people stayed in this luxury tents set upon a hill overlooking terraced farmlands and looking up to a majestic range of mountains - lucky us!
Trust me, I hate waking up early. I am a very grumpy morning person, but the beauty of the place, maybe the fresh mountain air and the gentle persuasion of Mark, Matt, Tom and Brandon (BB), I was usually up at the crack of dawn to the sounds of cranky cow moo’s and to the indescribable ruckus of the frisky donkeys, yes the frisky donkeys (more about these underestimated creatures later). We usually hiked up the hill with me trailing at the back and Tom (the coolest dentist ever) staring back at me encouragingly. What a fabulous way to start my day.
Ophthalmology was my first clinic assignment (other possible assignments included medicine, ob/gyn, pharmacy - dreaded and triage - dreaded). On that first day of clinic I was so excited. The idea of being on Himalayan Health Exchange was my driving force at the end of last semester when I was so “over it.” This was my first attempt at the use of limited resources and a translator. I got pretty good at using the ophthalmoscope and slit lamp. That first day, I never ceased to be amazed by how grateful and happy these mountain people were. They may have thought I was crazy because given some free time I stared at their sun induced leathered skin faced and their small toothed smiles. Their happiness, considering their limited resources and the harsh conditions in which they live made the ” I need to wear cute earrings” material girl in me melt. I want this pure happiness. I want the happiness of the man that hugged me for ten minutes (seriously) when I gave him sunglasses and a pair of reading glasses. I asked him (in my reaaallly bad Hindi) what made him so happy and he said it was the love in the way I treated and talked to him. I was stunned, me Poonam Patel, was pouring out love. Alas I was already growing from this experience.
Okay, so I drifted into sentimental land for a bit. For sure during our clinic day we saw many people (and sometimes not so many), saw interesting cases, but, there was always some time for some fun. So as promised, I will talk a little more about the frisky donkeys. Ophthalmology (and dental) people were spoilt at Nako. We set up station on the verandah of the monastery and had perfect view of all the happenings at the tiny pitch tents that were sprawled in front of us. Around midday, when the sun was thumping down on us, our stomachs yearning for the naan, beans and rice - the frisky donkeys decided to get us out of our hunger comas. Two particularly ‘happy’ donkeys were chasing each other and then decided to go prancing by one of the medicine tents nearly taking out some of my colleagues. The finale of their impromptu performance was the classic donkey kick - the like that you see in cartoons.
From Emily
Life in the Paeds Tent
One of my favorite days in clinic was when I rotated through the Pediatrics clinic. Our pediatrician warned us that the most common complaint from parents is that their children do not eat enough. I did not really believe her, but I was convinced by the end of the day when almost half of the patients that we saw were visiting us for this reason. We learned that many of the patients were drinking even 8 cups of chai (a very sugary tea) a day. Our pediatrician was able to communicate to the parents that perhaps their children were not eating much because they were so full of tea!
On that same day we diagnosed a one-year old with cerebral palsy. She had a clenched left hand and had a positive Babinski sign. The pediatrician grabbed our best interpreter and carefully explained to the family what this would mean for the girl. The family was very stoic and calm, as is expected in the culture; public displays of emotion are generally taboo. It left me feeling unsettled, to not be able to really communicate with this family and to find out how they felt about this diagnosis. I also wish that I could follow that little girl, to see how she progresses and receives care in the future.
From Neal
“Good Morning Doctor Sab”
One of my favorite memories of the trip was in the village of Tabo. Tabo lies at the base of high barren mountains and has an amazing night view, which was great for roof top star gazing. The village is pretty small and quaint. I will always remember this one old lady that we saw every morning on our walk to the clinic site. She would sit outside her wood and mud house knitting socks and scarves to sell. She had the biggest smile on her face, but you could tell she had lived a hard life. She waived hello each morning and say, “good morning doctor sab” to me (sab is the Hindi equivalent of sir). I guess she picked up that I was of north Indian decent and understood Hindi, which I had managed to master on my trip. I could understand the language before, but being forced to use it when talking to drivers and airport personnel will really help you learn fast. Anyways on our last day, after we had packed up and most of us were hanging around the monastery guest house, she came up to me and introduced me to her friend, another old woman. She said that her friend was sick and that they didn’t realize that we were leaving the next day, all in Hindi of course. Her friend had been having bouts of gas and diarrhea for a few days and also had a fever. I was in a dilemma at this point; all of the meds were packed up and off to the next clinic site and additionally there weren’t any attendings around. This lady had come specifically looking for me, thinking that I would be able to help her friend. I felt I had a special connection and an obligation to try to do something. Luckily, I had my bag of personal medicines in my book bag, so I grabbed a 4th year medical student that was sitting in the lobby where we were originally talking. We were fortunate to find some meds that would be able to help her symptoms for a few days and hope that she could fight it off. I explained to the woman that these were my sample medicines and that they will be able to treat her symptoms, but that was all that we could do for her. I felt bittersweet at this point; I was glad that I was able to give her something, but also that I wished we could have done more. However, the grateful look in both their eyes really touched me. These women really showed me how rewarding the medical field can be and it was nice to be able to put the skills I had learned from the trip and the first year of medical school to use and actually be able to help someone.
I Guess Its Not In My Fortune
The internal medicine was an interesting place and busy place. I can recall one day that I must have seen 30 patients before lunch. It was also a place that had many bizarre chief complaints such as burning urination in the sun, and sweaty palms when working outside. However there is one patient that I particularly recall from one of my days in the internal medicine tent. She was my first patient of the day, a 30 year old woman who looked a lot older from a hard life in the harsh climate and working the orchards and fields. She complained of an earache in her left ear and some muffling of sounds. It turned out she had a piece of ear wax that had impacted in the canal. The attending and I tried to pull it out with some tweezers that we had, but could not get it out; what we really needed was a q-tip or other blunt tip object. The attending thought she was certain that she had saw some “wax loosener” in the med bags in the pharmacy, so I told the patient to wait and went to look. The pharmacy tent was a disaster zone, they were swamped by a horde of school kids who had shown up during their break and had been seen by the peds tent trying to get their meds. I was told by the team members working the pharmacy that day to search the bags since they hadn’t seen it. As I rummaged though the bags, I didn’t see anything either. I went back to the attending and told her and the patient. The patient offered to go back home, since she lived close and come back with some wire she had. We though it couldn’t hurt so we sent her off. She returned later with a small piece of wire and we attempted to remove the wax, after cleaning the wire with alcohol of course. Once again it wouldn’t come out. The lady looked at us and told us in Hindi that I guess it’s not in my fortune. She was appreciative of the effort we had put in and left with a smile. It was amazing to see how these people truly live in such a remote place and how limited access to medicine can be.
From Mark
Sorry Sir, I am not Qualified
There seemed to always be an adventure in the internal medicine tent. On my second rotation through internal medicine, I recommended a rectal exam to the attending based on the history I had taken. The attending agreed and we walked with our teenage-girl translator to a private room in the nearby health clinic. On our walk, we were explaining, through our young translator what we were going to do and why we needed to do a rectal exam. He looked hesitant and uneasy about the upcoming procedure, as most people do when they find out they need a rectal exam. Once we entered the exam room, the patient asked for all the women to leave the room, which meant that he wanted me to do the procedure. I looked at him with this blank stare and thought, “I am sorry sir, I am not qualified to do that.” The attending read my mind and informed him that she was the doctor. However, I was reminded of the element of surprise associated with the medical field.
Listen to Your Heart
If I were a child and my parents brought me into a crowded tent to see a doctor who didn’t speak my language and who looked very different from myself, I probably would be scared out of my mind. But then again, there aren’t too many young children who see doctors as friendly people; they somehow can’t get that image of the needle out of their mind. The children we saw in the Himalayas were no different. Some placed an unknowing trust in you, while others wouldn’t have anything to do with you. The language barrier and short supply of instruments sometimes made the history and physical challenging, but there never was a case we could not handle. Like all children, they were curious in what you were doing. For one group of boys, I showed them how a stethoscope worked. They were unsure at first about what to do with the ear pieces, but they caught on quickly. I held the diaphragm above the apex of my heart and did the universal sign for quiet. I could see their ears tuning in until they final heard the soft “lub-dub” of my heart. At that moment, their faces showed pure elation and I will never forget those smiles.
Just Breath
The internal medicine tents were constantly buzzing. You never knew what the next chief complaint would be and you couldn’t dare guess. One morning, a man came to me presenting with chest pain. He had recently fallen on his left side and noted signs of point tenderness. On physical exam, those points were easy to locate by the instantaneous guarding on mild palpation. I asked the attending how you could diagnose a broken rib without any available diagnostic tools. She instructed me to place my hands on the patients back and ask him to just breath. Upon his inhalation, I heard and felt the bones grind beneath the skin and that moment, I flinched in pain for him. With no other therapy other than wrapping, pain killers, and a order to rest, the man’s gratitude was overwhelming, despite the pain we put him through during diagnosis.
From Suzanne
The Hammer and Chisel
I got to rotate through the dental tent today, which I had been looking forward to since we started having clinics. I think it is fascinating how much problems in the mouth relate to problems with the body as a whole, so I was excited to get a dentist’s perspective about that…plus I really wanted to pull a tooth. And I did; two, in fact! Other than that, my roll was limited to handing the dental students lots and lots of gauze and watching over the sterilization of the instruments. The sterilization process consisted of trying to boil all of the instruments for at least 30 minutes, but because of the altitude and some strong wind, we were never really sure if the water boiled vigorously for the whole 30 minutes. But, we did the best we could given the circumstances. One case in particular stuck out to me today. The dentist working with our group literally spent an hour on this one man. His tooth had eroded nearly to the gum line, and from what I understand, he was trying to get the root out. He said if he were at home, he had a simple instrument that he could use to do it without any problem. Because it was electric, however, he did not have access to it here. We had the local dentist come visit us today, and so he inspected this patient’s mouth. He asked if he could have a try, so our dentist gladly handed him the hammer and chisel. He proceeded to go to work on this man, using so much force that I (and our dentist) winced just watching it. Sure enough, he succeeded in getting a piece of the root out, but I wondered at what cost (I can’t imagine the amount of pain this man will be in after the anesthetic wears off). After the local dentist walked off, our dentist had a combination of respect and discomfort written all over his face, and I knew he must be thinking the same thing I was: that there is truly a different standard here, and that these people are not just toughened by the physical environment.
The Cutest Grandmother Ever
So, I finally made it to a primary care tent today after doing triage, ophthalmology, dentistry, and OB/GYN. Even though I had memorable experiences in each tent (witnessing the joy of the old man who could finally read clearly again after a simple, inexpensive pair of +1.50 reading glasses, doing my first and therefore extremely awkward pelvic exam, reassuring a terrified woman that she would not die from her hemorrhoids), I was extremely ready to practice the skills I had learned throughout the year in the internal medicine tent. It was in some ways a very frustrating day, however. There were so many ailments that were directly related to the patients’ lifestyles that we felt rather powerless to alleviate. Just as doctors in the U.S. are probably overwhelmed by diseases related to our sedentary lifestyle and fat-laden diet, we were bombarded with sun-related dizziness and headache, backaches, and GERD. It was hard to tell the woman who drinks 10 cups of chai (tea) a day that the best way to stop her “stomachaches” is to stop drinking it when obviously she was expecting us western doctors to have the miracle medicine to stop them. Similarly, it was frustrating to only be able to offer the man who lifts heavy rocks for a living a month’s supply of ibuprofen. The most memorable patient though was a woman who we all immediately deemed “the cutest grandmother ever.” She kept giggling every time we tried to put a stethoscope under her shirt, and every time I tried to examine her, she would grab my hand and shake it. She kept saying “doctor,” (the only English word she knew, apparently) with a huge grin on her face and bowing to me. I wanted to somehow convey that I wasn’t a doctor yet, only a student, and that it was I who should be in awe of her for displaying such optimism, humor, and grace in the face of such adversity, but because the only Hindi words I know are “vomit,” “fever,” “pain,” “diarrhea,” and “eyes,” I could only bow in return.
Final word
These stories are just the tip of the iceberg! For all of us the three weeks on the trip resulted in more memories and great friends that we could have ever imagined. We recommend the Himalayan Health Exchange trip to everyone. Our last summer was truly an outstanding and meaningful experience with lots of new things to learn, beautiful sights, and always in India - the unexpected.
Corresponding author, Neal Viradia, second year medical student, University of North Carolina nviradia@email.unc.edu
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