Monday, June 8, 2009

Such a Good Boy by Mark Zimmerman, MD, former Medical Director of Patan Hospital and currently, CEO, Nick Simon Institute, Nepal

That night in the Emergency Room, the area around the doctors’ desk was hot and crowded. Some people were trying to slide the charts of their own patients to the top of the pile. Others made yet another inquiry about the status of their relative’s treatment, or tried to gain an advantage by mentioning the name of some acquaintance who worked in our hospital. In Nepal, who you know is everything.

Paban the medical resident and I edged our way through the throng. It was time to divvy up the internal medicine patients. We sorted through the charts you take emphysema and this typhoid fever one, I’ll take this stroke and that pleural effusion. I went to search for a 16-year-old boy named Tej Bdr Tamang, whose left side of the chest was completely white on the X-ray (a sign that something other than normal lung was there). I found him in the wide, deserted outpatient hall, taking refuge from the bedlam of the ER. He sat on a wooden bench, erect, with his back to the wall. His brother beside him had jumped up to signal me when I’d called out Tej’s name.

I brought the boys in to an examination room, where the many stretchers left just enough space for a doctor to slide between. Patients’ clothing, bottles of water, half-eaten snacks, sputum containers, and urinals cluttered the tabletops and floor. Because Tej was too short of breath to speak easily, his brother told me about the illness. Three weeks of dry cough, fever, and now shortness of breath. I examined Tej and his reports, and decided that he probably had a tubercular pleural effusion a collection of fluid around the lung. He was sick and could not just be sent home on medicines, so I made arrangements to drain off some of the effusion.

It was quiet in the procedure room. Tej climbed up onto one of the exam tables. I helped him take off his shirt, a girl’s shirt embroidered on the front with three pink birds singing on a holly branch. After explaining the procedure to him, I put on sterile gloves, began to sort through my tray, and just then the hospital lights went out. That part of the Emergency Room was under construction, and the wall in front of us, as well as one in the room beyond, had been partially knocked down, leaving an opening out to the hospital courtyard. It was wide enough for the soft light of early evening to light the room, and for the pale purple of a jacaranda tree to accompany us Tej in his breathless anxiety, and I sorting, clinking the various instruments for pleural drainage.

The night was busy, with not enough nurses on duty, so I planned to have Tej’s brother assist me by pouring the antiseptics into bowls and handing me some xylocaine. Still, I was glad when Sushila turned up to help; better to have a nurse, especially with this boy being fairly sick. “This will sting a bit.”

A stoic lad though reed thin, he didn’t flinch at thee cold alcohol swab or at the jab of local anesthesia in his back. The fluid was easy to find. I fixed the position of the fat needle, about 2 inches into his chest, by clamping it near the skin, hooked up a valve and tubing, and began to drain him. Sushila held the outflow tube and a measuring jug. I pulled on the plunger. The big glass syringe became hot in my left hand as it filled with his fluid. I turned the valve and pushed. Foamy yellow liquid splashed into the jug.

The three of us formed a triangle, each brushing against the other two. Sushila spoke softly, intently to Tej.

Such a good boy.
You don’t even whimper, do you?
You are a brave young man.
So helpful to us, you are.
Such a good boy.

Thirteen, fourteen, fifteen syringes-full of fluid. I asked Tej how he was doing. “OK, but not much better.” I asked Sushila if she was getting weary. “Of course not.” The lights came back on.
Sushila repeated her litany once more and then I recognized the cooing words. I knew that she was speaking not just to Tej, but also to her own son.

I took care of Pujan two years before. He’d come to Patan Hospital with a sudden onset of severe headache and fever. It wasn’t meningitis, but that was about as far as we could go with a diagnosis. Our hospital’s equipment is limited and a nationwide strike that day prevented us from using the CAT scan across town. Pujan who never let his Mom walk to the hospital at night alone, who was tops in the local karate club, who gave portions of his food to kids who had none he died two years ago this month. The jacaranda was also in bloom then.

Sushila’s husband is one of Nepal’s better-known artists. The Christmas after her son died, Sushila brought me one of his paintings, framed. It hung in my apartment, reminding me of them. She was better that second year after he died than she was during the first, but that glow that she once had seemed to have disappeared. We spoke from time to time, in the hallway or between patients. She drew some small solace from mentioning again the virtues of her lost son.

Tej began to cough at the same time as the fluid came more slowly. The chest was near dry in that area. I pulled the needle out.
“Ah, isn’t he such a good boy? Doesn’t even whimper, does he, doctor?”

Sushila went off to measure and empty the jug’s contents. I taped some gauze over the puncture site. His brother helped Tej to get his shirt on. I walked back into the swirl of the main ER, to write up his papers for medicines and a return visit.

This was written by Dr. Zimmerman a decade ago, but is relevant just as much today, indicating how little Nepal has changed.
This piece literally brought tears to my eyes, blinding what I was reading. What I thought was going to be a fairly 'clinical' story bloomed into something far beyond. "... the pale purple of a jacaranda tree to accompany u..." - fantastic imagery! This may be a "non-political" story but the political/social overtones are there for all to see: poverty - Tej wearing a girl's shirt; the electricity going off; the crowded hospital; the name dropping; and, of course, the lost potential of youth, as signified by Sushila's loss.

Tej Bdr. Tamang survived and is alive and well today.


Anonymous said...

Hi, I saw just same picture at Tansen mission hospital when I was there in March,09. There is so much need to do for Nepali people, hopefully things will improve by committed people of the nation and also by help and assistance others as well. Unless there is no war and hunger. Bring peace in your country that people will just live for good of family and children. Best of luck!

Anonymous said...

Thanks for putting this story in your blog.The story encapsulates the socio-economic conditions of Nepal and the grinding poverty.At least this boy lived...
But what about the mother in a remote village who dies due to obstructed delivery and the menstruating girl who, forced to sleep in cowshed, dies of snake bite in W.Nepal-cases I have witnessed ...