by Britta Das
“Pasang, do you understand the madam’s exercises?”
“Yes, sir.”
“Could you show them to me?” Dr. Bikul points to his examination bed.
“Yes, sir. Of course, sir.”
Carefully, Pasang climbs onto the bed and demonstrates his homework. Not totally correct, but acceptable, and I say nothing.
Dr. Bikul seems satisfied. “Hmm. Good. You do the exercises like the madam has told you. Come back if you still have pain in ten days.” He turns to me.
“Are you finished with Pasang?”
“Yes,” I answer.
Dr. Bikul nods at Pasang. “Okay, Pasang. You can go home.”
My nerves are settling, and with a new confidence, I eye Dr. Bikul. He is definitely handsome. Young, maybe my age, he has an athletic posture and wide, strong shoulders. His hair is thick and black, and his dark and smooth features are beautifully underlined by his white lab coat. His eyes are big and expressive, and now they sparkle with a shy smile.
“I would like to talk to you more about physiotherapy. It is very interesting.”
“That would be fine,” I reply. “Any time.”
Our discussion seems to be finished. Pema and I rise to leave. Throughout the entire visit Pema has been quiet, but now she teases him. “Doctor, you still have many girls out here waiting for an examination.” Suddenly, I feel embarrassed and rush to leave the room. Outside, Pema smiles from ear to ear. “You really told him about physiotherapy. Isn’t it?” We both laugh. I have to agree with Pema. We earned our first small victory.
Back in our physio room, I do not feel quite as victorious looking at a neat pile of referrals that are stacked on my desk.
“Where did these come from?” I ask.
“Inpatients, sister. They are referrals from the wards.”
With a sigh, I look at the diagnoses: an old woman with chronic low back pain; a leprosy patient with an ulcerated foot; more back pain patients.
A young woman, perhaps thirty, enters the physiotherapy room. She comes from a village two days’ walk from Mongar where she heard that a new foreign doctor has arrived. She insists that I have to treat her. At first, I am confused by her lack of a referral, and when I ask her if she has already seen another doctor, she nods. She saw the gynaecologist before, but now she wants to see me. After more prodding, her concern finally becomes obvious. She has come because she wants me to check the intrauterine device (IUD) that is part of her family planning. I am not sure if I should laugh or cry.
Helplessly, Pema explains to her that although I am a “doctor,” I am not that kind of doctor. Obviously disappointed, the woman asks repeatedly if I might not look at her. Guiltily, I think about her long journey through the rain to the hospital. How quick the news of my arrival has spread to the villages, and how happy she was at first, thinking that finally a woman would look after her private concerns. Although this misunderstanding came about through no fault of my own, I cannot help but feel overwhelmed and wonder if I will be able to meet the high expectations for a foreign “doctor.”
At the end of the day, we finally arrive at the bottom of the pile of referrals. Tshering Dema, sixty-eight-year-old female from Mongar district. Stomach ulcer. Scoliosis. Low back pain.
Pema tells me that I can call any older woman Abi instead of addressing her by her given name. We agree that I will try to do as much of the talking as possible to practise my Sharchhopkha.
The old abi from Ward B is a delight. The intense sun of high altitudes has wrinkled her face like a prune. A single stained tooth sticks at an odd angle in her mouth and accentuates her glowing smile. While Pema takes a history, Abi mumbles a continuous flow of words, not once ceasing to grin.
My turn arrives to start the physical assessment. Immediately, Abi peels herself out of her kira, and before I have a chance to protest, she is lying on the bed, stretching a pair of incredibly large (and even more notable, incredibly dirty) feet towards me. Awkwardly, I clarify to her that she needs to be upright. Abi gives me a toothless smile, points at her back—and continues to lie on the bed. When I finally convince her to stand, she busies herself putting her kira back on. With much difficulty I get her to stay undressed long enough for me to throw a glance at her back.
Her trunk is deeply rutted just above the hips, perhaps from continuously wearing a kira belt much too tightly. That, combined with extremely heavy fieldwork and years of carrying her children and later her grandchildren on her back, is enough to cause pain in even the strongest of spines. Abi’s vertebrae are oddly twisted and turned, making the diagnosis of scoliosis almost an understatement. I ask her to do a few movements. Abi just smiles.
While I am contemplating my helplessness in resolving her pain, the lights come on, indicating a functioning electricity supply. Like a flash, Abi is back on the bed, looking at me with great expectations. I switch on the infrared lamp, which has become an object of great desire, and Abi mumbles happily. Within a minute or two, she is fast asleep. Unfortunately (but not surprisingly) only ten minutes later the lights go off again. I tell Abi, “No lights, no machine!” so again she smiles, dons her kira, and, in leaving, insists on squeezing a bunch of walnuts into my hand.
“Kadinche la,” she thanks me. Slowly, bent over, diminished to maybe three-quarters of her real size, she limps out of the room and waves goodbye. I noticed on her referral that she was discharged from the hospital today, and I am sure that I will not see her again. She is probably already on the way home to her village, back to the fields and a myriad of chores.
8
om mani padme hum
“Don’t move.” Pema rushes towards me and quickly pinches the front of my lab coat between her fingers. “I got him!” She inspects her catch, focusing on her fingertips. “They really like you.”
Throwing my hands in the air, I have to grin. Yes, the fleas seem to thrive on me. Since my arrival two weeks ago, every day in the hospital is flea-collection day, and I am the designated collector. No one else seems to have a problem with those awful, tiny, bloodsucking beasts. I have asked several doctors what I can do, but they just give me a puzzled look and tell me to change my clothes after I get home. Of course I change my clothes, I think, but what good does it do when I simply refresh my flea supply the next day as soon as I touch a patient. Sometimes I can see them jumping over, other times I just feel that annoying itch somewhere inside my shirt. And they always head for my underwear! Like a rash caused by cheap laundry detergent, I have semi-permanent red dots all along the elastic of my panties and the outline of my bra. Hats off to mosquitoes and blackflies, but they are nothing compared to fleas. I have spent a few sleepless nights already, trying not to scratch, trying to ignore the unbelievable itch. No chance. By now, my skin is overly sensitive and bleeding in some areas.
Pema is full of sympathy. “They are terrible. Nima gets many bites all the time. I don’t know, they never bother me or Chimmi. Maybe it’s because we have darker skin.” Her concern for me is genuine, but she has no solutions either.
We return to our previous discussion. Pema is studying the anatomy of the shoulder and possible causes of pain in that joint. Mongar is turning out to be typical of any physiotherapy referral pattern: syndromes come and go in spurts. You might not see a single shoulder patient for months, and then within a day there are four patients with similar symptoms. Yesterday we were flooded with chronic shoulder pains.
Pema wrinkles her forehead in concentration. “What are rotator cuffs?”
“They are the supporting muscles of the shoulder, the little ones inside. These ones,” I point to the picture in the book.
“How we can treat them?” Pema is eager to get to the interesting stuff.
I try to be as unspecific as possible, to encourage her to think on her own.
“Well, how do you treat other inflammations of tendons?” I ask instead of replying.
A “Jang oma exercise pincha mo?” interrupts our studies. “Should I do my exercises now?�
� An old, leathery face twinkles its remaining teeth at us. I laugh. This meme (a Sharchhop title for old men) is another one of my favourite characters.
“Nan odo, Meme!” I reply. “Come in, come in.”
Meme shuffles through the door, pulls his gho off his shoulders, and heads straight for the stool beside the heat lamp.
“Mangi, Meme.” No, not now! I try to explain that there is no electricity and therefore no heat lamp. Pema doubles over in laughter at my attempt at speaking and signing Sharchhopkha and then translates in a few short words. Meme looks disappointed that his idea of exercising is not available today. I point towards the pulley system in the door frame.
“Nan exercise pi. Nado?” You exercise now, okay?
A reluctant “Dikpe, dikpe” is the answer. Okay, okay.
I watch Meme as he gets ready. His legs are bowed from years of hard work in the mountains. His trunk is thin and fallen in, every rib is showing, and his collarbones stick out like two thin shelves. He wears a farmer’s tan on his lower arms, and the rest of his body, except for his feet, is rather pale. His hair is grey but still thick. A wispy moustache and an equally thin goatee underline his marked cheek bones, and permanent laughter lines are etched deeply into his face.
Meme scrunches up his already squinting eyes. Skeptically, he inspects the pulley and draws the string tentatively. It moves. Surprised, he pulls some more. Look at that, it works. Meme turns to me triumphantly. His face smiles with a thousand wrinkles, a thousand proofs of a long and happy life. He starts joking with us and clowns around with the rope. His efforts cannot exactly be described as exercise, but they serve their purpose. At that moment, the light bulb springs to life again. In an instant, Meme drops his preoccupation with the rope and sprints towards the heat lamp. Lights mean electricity, electricity means taking a rest under the comforting heat of the infrared rays. Meme’s life is indeed blessed.
Soon, another old man pulls up a stool beside the heat lamp. He brings with him his tattered physiotherapy referral, a prayer wheel, and his rosary. While he patiently waits his turn for treatment, the two pearl-sized globules hanging from the handheld prayer wheel make round after round, swishing and pulling the cylindrical drum on the top, as he slowly rotates his wrist in a clockwise direction. The other hand is busy with the rosary, his thumb steadily counting and moving the beads. He mumbles something under his breath, but I cannot understand the words, so I ask Pema.
“He is saying Om mani padme hum,” she explains.
Minakpa Meme never loses his unshakable smile.
Om mani padme hum? Is that a prayer, or is he hypnotizing his pain away by repeating the same words over and over? I ask what it means.
In response, the old man murmurs his words loud enough for me to hear. “O manee peme hu, O manee peme hu, O manee peme hu, O manee peme hu . . .” The same syllables are repeated over and over, slightly slurred, and each time a rosary is moved and the prayer wheel completes a few turns. I ask for the meaning and find myself pleasantly surprised that this praying meme has an answer for me. Generally, I have noticed that the Bhutanese are extremely religious and follow their rituals diligently; however, few are able or willing to explain the deeper meaning. This meme is obviously well learned and well spoken because he seems to have many things to say. With much difficulty and many long pieces of explanation, Pema translates for me.
From what I understand, Om mani padme hum is a mantra, a prayer that, through its devout repetition, brings one closer to a desired outcome. There are many mantras in existence, but in Bhutan Om mani padme hum is the most common one. Literally translated it means “Hail oh jewel in a lotus.” Mani means “jewel,” padma means “lotus,” om is the sound of the beginning of all things, and hum is the end; om together with hum represents the universe.
It is believed that with each turn of the wheel, merit is accumulated. Each time the mantra is murmured, it is added to the many prayers out there, thereby increasing the likelihood of the enlightenment of all beings. The act of reciting the mantra gains merit for a spiritual path that will lead closer to enlightenment.
Having exhausted Pema’s translation vocabulary, the old man turns, closes his eyes, and presumably continues murmuring for the enlightenment of all beings.
The news of the heat lamp has caught on, and soon we have a queue of eager patients waiting for a blissful holiday at physiotherapy. Unfortunately, the power surge is short-lived, and a little later we again sit in the semi-darkness of the room. Our patients disappear.
When at noon the power still has not returned, Pema rushes home to bring Nima back to the hospital. The little boy’s cough has worsened, and Dr. Pradhan, the medical specialist, has promised to have a look at him. Pema seems relieved but nervous when she returns to the physio room with Nima on her arm.
“He thinks it’s only a cough. I get cough medicine for Nima.”
I have noticed that Pema puts great trust in Dr. Pradhan.
“What does Dr. Pradhan think of Nima not crawling?” I ask carefully.
Pema twirls one of Nima’s fine black curls around her finger and the little boy begins to giggle. She then gently picks him up and supports him in a standing position on the floor. Nima wobbles and sways but keeps his shining eyes fixed on his mother.
“Perhaps he got injury to the head. Or maybe it happened during birth.” Nima continues to giggle until a bout of coughing rattles his little body and Pema hugs him tightly. “But I think he was fine in the beginning.”
Determined, Nima frees one of his hands from Pema’s embrace and raises his fingers to his lips. His expression becomes distant, almost thoughtful, while in slow, steady circles, his index finger caresses his lips.
“Don’t!” Pema gently scolds her son, then turns to me. “I am not sure that he can hear me, you know. Sometimes he smiles when we talk to him, but we just don’t know if he hears us. I want to take him to Vellore. Dr. Pradhan also thinks that only in Vellore they can give good diagnosis.” For the first time since we met, I can see a tear rolling down Pema’s cheek. It leaves a little dark mark on the front of Nima’s sleeve.
I nod and turn to the papers on my desk to give Pema some privacy. From Dr. Pradhan I have learned that Vellore in Tamil Nadu is one of India’s foremost diagnostic and research hospitals. Due to lack of equipment and resources, many conditions simply cannot be diagnosed properly in Bhutan, and for complicated diagnoses or treatments, patients are sent to India. However, the costs for the Bhutanese government for each referred patient are huge, and the waiting list for outside referrals is long. And yet for Pema, Vellore signifies her only real hope. So far, no one in Bhutan has been able to make a diagnosis for her baby. Myself, I am confused by the little boy’s signs and symptoms, which, if nothing else, point towards cerebral palsy.
“We only live for him now,” Pema says with a sigh. In a sudden impulse, I reach out and put my hand lightly on her shoulder. The young mother looks at me and tries to smile, but her dark, sad eyes betray her. I stroke the soft curls on Nima’s small head, and the boy rewards me with a little gurgle. Unnoticed by Pema, he has managed to again free his hand, which is promptly on the way to his lips.
Then he turns his head and I think I see happy recognition on his face. I follow his glance to the door.
“Good afternoon, ladies.” Pema’s husband enters with a box of sweets from the bakery. He offers me a tired smile, then reaches down to cuddle his son, who squeaks in delight. “I thought you might be hungry.” Turning to Pema he asks, “What did Dr. Pradhan say?” For a while the two parents discuss quietly.
“You’re not working today?” I ask Karma.
“I took the afternoon holiday so I can take Nima home.” His answer is slow and drawn out with the slur of fatigue. “Nima didn’t sleep well last night,” he apologizes, and I can guess that none of them did.
“Why don’t you go home, too?” I say to Pema and point at the powerless bulbs. “I am sure we won’t get many more patients.” For a moment I wonde
r if I am overstepping the boundaries of my authority but then reassure myself that no one will notice anyway.
“You will be okay by yourself?” Pema asks, then gets up quickly, perhaps afraid I might change my mind.
“Of course,” I lie with fake confidence, searching for one more rationalization for Pema’s early departure. “We always advise our patients to take some rest, don’t we? And I think that is what Nima and you need most right now, too.”
And it is true, after all. Perhaps there is not much we can offer here in our little physiotherapy department, but at least I can put a small part of my western training to use.
9
Choden
I noticed choden a few days ago during rounds when Dr. Shetri explained that she was a case of transverse myelitis, admitted to the hospital for a urinary tract infection caused by her catheter. A little unclear about this diagnosis, I had asked further, and the doctor explained that transverse myelitis is a viral disease, attacking the spinal cord and leading to neurological deficits. The disease left Choden partially paralyzed from the waist down, and for about four years she has not walked or stood. When I watched Choden that day, I noticed that the muscles of both of her legs seemed to violently contract in frequent spasms, leaving her curled up on the bed, helplessly writhing in pain. When I asked whether she was receiving any treatment for her legs, the answer was no. She was here only to fix the urinary tract infection.
No one seemed to think that Choden was a candidate for physiotherapy treatments—except for me. I wanted to give it a try. I asked permission to work with Choden, and reluctantly the doctors wrote out a physiotherapy referral.
The apparent hesitancy with which I am granted a trial period of treatment irks me a little. I am puzzled by the doctors’ attitude towards my role at the hospital. Although I am seemingly welcomed as part of the staff, there is an unspoken underlying resentment whenever I suggest something different from what has already been prescribed. At times, I wonder if it is all in my imagination; perhaps I am a little paranoid and hear criticism where none is meant. Yet I cannot shake the miserable impression that I am treading on somebody’s toes.
