Letter from Nepal.

I knew that my recent update in internal medicine abroad was not going to bail me out here. The young woman lying in front of me had presented to our hospital in the hills of Nepal, with fever of three weeks’ duration, headache, nausea and some change in mental status. Besides the history and physical examination, a complete blood count and perhaps a spinal tap would be all I would have available to make a diagnosis. A computerized tomography scan or a magnetic resonance imaging scan, although available, would be unaffordable. Elaborate laboratory tests and a neurological consultation tonight or in the coming days would not be available. The buck pretty much stopped with me. A recently donated edition of Adams and Victor’s Principles of Neurology in the library would be my best available resource. However, the common diseases in our setting which include tubercular meningitis, typhoid encephalopathy and Japanese encephalitis are usually not the forte of these standard textbooks. It would certainly be wise to find out what the book said. But knowledge of the local diseases would in all probability be more helpful and an important basis for the formulation of my plan of therapy, which would of necessity be empirical.
  This is emergency medical practice in infectious diseases for the vast majority of doctors in the Indian subcontinent. Like the tourist in Kathmandu gathering trinkets to take back home to decorate a Christmas tree, the physician has to try and find little kernels of information lurking in age-old tips such as the cobweb appearance of the cerebrospinal fluid suggesting the diagnosis of tubercular meningitis. The positive side is that the patients are usually so grateful for the little that we do for them.
  So rampant is tuberculosis that when I see a young person with fever, chills and a pleural effusion which is straw-coloured, empirical treatment with antitubercular medicine is started. To cut costs, many of us do not order other tests even if available. No pleural biopsies or special pleural fluid tests. I know Peter, my infectious disease consultant in Phoenix, would have turned pale with disbelief on finding out my basis for therapy. What! All that excellent residency training gone to waste? This is certainly not the methodical manner he taught me to work up a patient with coccidiodomycosis (the counterpart of a tuberculosis patient in Nepal) in the southwest United States. But Peter, ke garne (what to do?)! The choices are stark—tuberculosis v. malignancy. Do not miss the former. If it is the latter, there may not be much to offer the patient.
  It is indeed amazing how dependent we have become on the history and physical examination. If a patient has fever and chills for a week and just ‘suffers silently’ it is probably typhoid, but if the person is groaning with myalgias and arthralgias it is probably staphylococcal sepsis or typhus, both common causes of fever in our hospital. These unproven signs or ‘hunches’ come to the rescue when the initial basic blood tests are equivocal and the cultures are negative, which happens all too frequently; few modern textbooks, if any, will talk about these. In an ideal world, inflammatory markers, changes at the cellular level and treatment guidelines will be mentioned in great detail. These latter points, although certainly important, are unfortunately irrelevant for the vast majority of acutely ill patients in Nepal. In the old days, clever physicians would say they could distinguish a patient with typhoid from one with typhus from the smell. Although I would not go so far, this is an interesting observation.
  I am sure that having sophisticated, accurate tests will help immensely and provide a sense of closure for both the patient and the doctor even when the disease may not be curable. However, despite the limited tests and restricted treatment options, many cannot deny a sharp sense of being truly alive at being a doctor here in remote Nepal; perhaps for us this may be a chance to realize with wonder how astute physicians practised medicine in the old days, although this can be embarrassing, as it is so far behind the times!! Western volunteer doctors in the remote Himalaya Rescue Association high altitude aid posts (Pheriche and Manang) in the heart of the Himalayas almost always find their experience of helping acutely ill patients there without any laboratory tests very rewarding. Many return to serve again and again during future trekking seasons. No question, the excitement of honing your innate Sherlock Holmes’ skills that much more precisely because of a lack of investigative facilities in arriving at a diagnosis is obvious. Add to that a very grateful patient, and for many of us this is a combination worth settling for.


Nepal International Clinic and
Himalayan Rescue Association



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