I know many people that travel often and tell stories about their 'breakthrough moment' or an 'epiphany'. Friends and family told me, when I was leaving for Nepal, that I would have amazing experiences and it would change my life. I have no doubt that this will be a life changing experience, or that my time here will be amazing. However, in my head, as I was boarding the airplane and imagining all the things that would come. I daydreamed of sitting on top of a hill and having the meaning of life showered upon me. I would break down from some hardship and then see the light through the darkness of my despair.

So far, none of that has happened. Instead, I've been learning lessons little by little. They sneak up on me, so much so that I don't realize I'm learning them until I look back and realize I've changed. It reminds me of how my mom presents an idea to my dad. If she gives the idea outright, with all its facts and all its information, he shuts it down right away. However, if she gives him little tidbits, subliminal messages, and offhand comments, in time he comes to the exact same idea or conclusion on his own.

This happened to me in Ipa (or Epa, even Nepali's can't come to a consensus on the spelling).

Ipa is our outreach clinic. Every Monday and Thursday we trek an hour and a half along the dusty, rocky, uneven road. The walk there is "Nepali flat", meaning there is very little elevation gain in the end, but you will rise and fall hundreds of feet along the way. Our walk to Ipa on October 24th was sunny and hot. We had butterflies flitting around us and grasshoppers jumping around underfoot. Leeches, thank goodness, had abandoned the hot dry grasses. Four of us walked to Ipa that day. Andrew, Allissa, Ritesh, and I. Two practitioners, an interpreter, and a pre-medical student/assistant/odd jobber.

Our first stop, as with every time we travel to Ipa, was about an hour into the walk. We made a house call to a man who has a neurodegenerative disease. We suspected, with our limited technologies, either Parkinson's or Multiple Sclerosis (MS). Allissa did an acupuncture treatment on him, and his son brought out fresh honey that they'd harvested from the wall of their house. It tasted wonderful. We broke off a piece of the fragile honeycomb and stuffed the whole thing on our mouths. Occasionally a larva got thrown in the mix, but it's just a dash of protein, right? The honey at the house in Ipa was particularly delicious after a long, sweaty walk. The sunlight glinted off both the metal plate and the golden honey, making the entire presentation seem all the more appetizing. We sucked out all the sweetness possible until we were left with only wax, which actually makes for a pretty good chewing gum substitute. 

After we treated the man, we continued on to the school house where we held the main outreach clinic. We took one room of the two room school building and used it as a treatment room. Chairs were set up outside and inside a platform with two mats. About half of the patients we treated outside, sitting in the plastic chairs.

The community likes to hang around and watch our clinic work and we encourage it. Patient confidentiality and privacy here takes a backseat. It's more important for us to be open, honest, and visible to the community. They take comfort in their friends and family being with them. In some cases, privacy is preferred, and we always accommodate for that. In Ipa, The school itself is set on a ridge with the "road" traveling right in front of it. Some of the community members or patients sat on the edge of a cliff, squatting or sitting, oblivious to the extremes of their environment, content with watching us work, gossiping, and looking after the babies of those getting treated. A pleasant breeze washed over us from over the cliff, it was especially welcomed on the hot day.

Our first patient at the clinic was a small girl with diabetes. The first time we tested her glucose it was 525. The second time it was 320. The third, it was back up to 500s. Her glucose was dangerously high and we had been trying to write to some doctors in the US about what type of medicine she needs. That day in Ipa we didn't have any glucose strips left in order to test her blood sugar levels. We performed an acupuncture treatment and said that we were working with some doctors in America to help her. She had the most amazing attitude. She hung around our clinic the whole day and our little inside joke was “yes dukchaa” which combines English “yes” and Nepali “pain” or we said “no dukchaa”. Often she would point to objects and say their name in English, showing her intelligence and eagerness to learn English. Her and I developed a great friendship that day. She started holding my hand and tugging at my hair, running away and giggling after. At the end of the day, she walked us part of the way back and then handed me a note. It was pretty long, and written in Nepali. I had Ritesh, one of our interpreters, transcribe it for me.

Here is what it said:

I am Babita Basnet. For the good health of Nepal, namaste to the well wisher [this is a respectful greeting]

Hello (Namaste) Doctor

I am 13 year old kid born in a poor typical Nepali family. I have been having sugar disease or blood sugar disease since I was 11 years old. I am always worried (scared because she had this problem). I am very interested in studying and I love all sorts of extracurricular activities but I am very worried and scared because I have been attacked by this sugar disease since I am very young. What should I do? Our economy is no good. I can’t go to many places to have my medical tests and till now I have been managed with medicines. Sometimes I feel “what will I do?” when I can’t afford for my medicines. I am just scared. Will my problem (disease) ever be solved (cured)? I don’t think so if I can’t get a good medicine that will help me with my disease. I always use insulin but it burns me and it hurts very much. How long will I have to live with this pain? I am not able to concentrate on my studies because of my family’s condition and stress of my disease.

Love
Babita Basnet
Epa, Pachkanya-6
Makwanpur

This little girl, who had been so chipper and playful all day, described her fears and anxiety over her life-changing disease in under 200 words. I didn't know what to do. I felt pretty helpless when I was reading her letter.

One of the hardest things to do here in clinic is to tell someone we are unable to help their problem. It's one of the most important things a doctor can do: honesty. On Thursday we met a lady who had a fever four years ago. During the course of her fever, she was hospitalized and lost hearing in her left ear and partially in her right ear. She came to us with a couple other complaints: headache, body pain. I looked in her ears and the ear canal and tympanic membrane looked normal, if a bit opaque. There was some redness in one and a small amount of moist earwax. None of this should have caused partial or complete hearing loss. We used a tuning fork to do a basic hearing test and it confirmed her partial and complete deafness. Andrew looked at her and said “We will not be able to fix your hearing. The fever likely caused permanent damage to the auditory nerve, something that is deep inside your brain”. As Ritesh translated you could physically see her face fall.

Often times our patients view us as magic workers- able to fix anything. We bring our foreign clothes, foreign faces, and foreign medicine. They come to us, sure that we can fix anything. They have so much hope when they come to the doctor. She had hope that we could fix her hearing through treatment. The same treatment that is fixing her husband's body pain, her mother's headaches, or her friend's menstrual irregularities. But we can’t do everything. And we had to tell her that. You could see on her face when she realized the permanence of her situation. She had to reroute her future plans. Everything that she had hoped would return vanished with our words and she had to imagine her future with only partial hearing in one ear. For the rest of her life.

 

We’ve told people this before, and I've always known the value of honesty in the clinic. But this was one of those "snuck up on me" moments. When I look back at all the previous times we've been honest with our patients, regardless of the news, I see the value of doctor-patient honesty with a new clarity. We bring hope, compassion and our expertise. But sometimes we also bring bad news, disappointment, and heartbreak. -Tessa Concepcion

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