We Give Them Love.

I'd like to share the story of my last night in Kogate. The events that transpired left a very lasting impression on me and I find writing therapeutic.

I treated a young 6 month pregnant woman during my time at the clinic. She presented with a history of miscarriages, only one I knew of at the time. The previous year she was 7 months pregnant when she went into labor- in a field, alone. She gave birth to a breeched baby by herself, so the translator told me. Unknown to me at the time, she'd had two previous miscarriages prior to the field birth. She seemed anxious about her current pregnancy and I did my best, with my limited means and knowledge, to comfort her in the final months of her pregnancy. As my time ended at the clinic, I informed her a new well-qualified practitioner would be replacing me. She did not like this information and stated she would not come to the clinic if I was not going to treat her, then she offered her house for me to stay so I could remain in Kogate. I very strongly considered this heartwarming gesture. I treated her on my last day in clinic and told her to remain calm and take it easy during the last two months before the baby.

Our last day in clinic ended with a spontaneous Nepali dance party. Many of the women from around the area gathered, played drums and demanded we dance. A good time was had by all. We were woken at 2 AM with a knock on the door. My pregnant patient was experiencing bleeding and pain. Haley, Allissa and I, quickly got dressed and hiked the 20-minutes over to her house. Allissa is in training to help with births back in Canada, but overall, none of us were prepared and the presentation didn't sound good. When we arrived at the house we saw a small puddle of bright red blood at the doorway and entered to see the patient on the floor wincing in pain.

To set the scenario, the house was a single room building with a thatch roof. Inside to the left of the doorway was a cow and calf eating grass. To the right against the wall was a small bed-frame with out a mattress and a fire pit with a window on the wall above it. No chairs, no mudas, no tables.

We walked over and began asking questions. When did the bleeding start? A few hours ago. Are you in pain now? Yes. She was visibly pale and in pain. Her blood pressure was quite low, but her other vitals were normal. This is when we learned she had a history of 3 previous miscarriages, late in term. We decided it was time to take a look below. She said she felt like "something was coming out" and I thought she meant the baby.

Thank god Allissa was there because I can honestly say I know nothing of childbirth, from the amniotic sack to the placenta. I don't know what's going on in there. I can remember learning that acupuncture can induce labor, help with pain, turn a breech presentation (over time, not when in labor) and that a few points should be avoided during pregnancy. The last bit mentioned is what kept me from learning more. Let a pregnant woman's body do it's thing with the baby. I can help you get pregnant- someone else can deal with the rest. That was my mentality until this patient and after this experience I vow to learn everything there is to know about pregnancy.

Anyway, we took a look and there was definitely something coming out. I though, "is that the head?!" but Allissa informed me it was actually the amniotic sack. It's what pops when women say their water broke. The sack hadn't popped yet, but was protruding from her and about the size of a softball.

At this point we stepped outside to regroup and call Andrew (who was in Kathmandu) for advice. We were able to make one very short call relaying the situation and to ask for help. Andrew just said call an ambulance, then the prepaid minutes ran out and we were alone with this situation.

Fist of all, the nearest hospital is over 2 hours away down a very bumpy, dangerous mountain road. Secondly, the ambulance has only a driver, no paramedic or EMT was inside to help the patient. In fact, the ambulance is just a land cruiser without space for a gurney. There is a lengthwise seat for the patient to attempt to lay on, a spare tire on the floor and an ancient oxygen machine.

The patient and her husband didn't want us to call the ambulance because they didn't have money. It would cost 2500 rupees (25 USD) to get her to Hetouda, the nearest hospital. We told her we would pay for it and she agreed to let us call. We used a phone from one of the many bystanders now lingering in and around the house. Most were family members.

I guess she moved because the protruding sack burst. A bloody watery mix covered the dusty floor around her, but she seemed to be in less pain. We sat with her for an hour and a half rechecking vitals and listening for the baby's heart beat. I did not hear it.

The patient didn't cry or display any emotion. She reacted to the pain, but was able to participate in the Nepali conversation going on around her. Mostly just local gossip.

We were unsure what to do when the vehicle arrived. Do we ride to the hospital with her? What if she goes into labor on the way down the mountain? Do all three of us go or just me since she's my patient? These would not have been questions if it was not our last night in the clinic and if there were not Maoist strikes going on preventing any transportation due to danger. If it was a regular day, I would have gotten in the car with her and held her hand the whole way, but I didn't.

I made sure she was comfortable and told her one last time that everything was going to be ok, then I shut the door and watched the ambulance drive away. I couldn't go with her for several reasons. Logistically, I would have been stuck in Hetouda without ID, cash or even a bra on. Also, if she had gone into labor, I would have been of no help. She is more experienced than I am when it comes to birthing, I've never even watched a Youtube video or The Miracle of Birth.

Afterward, it was about 5AM at this point, we all walked quietly back to the house, the magnitude of what happened lingering in the air. I suggested we look for shooting starts so we could make a wish for her and the baby's safety. We did.

As the lights from the ambulance became less visible in the distance my mind immediately went to what I could have done differently. Could I have prevented this? Were there signs? I can  declare gross negligence on so many levels given my limited scope of practice. The rational side of my brain comforts me and says I did all I could. The emotional side questions, debates, doubts and worries. The worst part of it all is I left. I left her at the ambulance. I left her in Kogate. I left her alone when she needed me the most. I should have held her hand longer. I should not have told her not to worry. I should have sent her to Hetouda earlier in the day when I treated her, just because. I had an intuitive hit about her a few weeks before when we were returning from one of the trips to town. An ambulance passed our vehicle up to Kogate and I thought, "I hope that's not my pregnant patient." I just felt uneasy about her and kept telling her to come into the clinic every other day, just so I could make sure she was ok.

We found out the next day that she did give birth on the way down to the hospital- a still born baby. I was never able to tell her goodbye or that I wished I could have done more. I don't know if she was ever able to show the emotions that go along with such an event, but I have. I've cried for her many times since leaving the clinic. I think of her all the time. I send her healing energy as often as I can. I lack the words to fully describe what it's like to witness the loss of a life in this manner. I am plagued by what-ifs; my memory haunted by her face, the blood, the smells and the fading ambulance lights.

I miss the clinic. I miss the patients and the community. I miss the quiet. And I miss her.




Addendum: Some time has passed since I left Kogate and this young patient, but in my many hours of reflection I remembered this story.

During our last few days at the clinic the entire volunteer group was together eating dinner when Andrew posed this question to us- did we make a difference to the people of Kogate?

Each offered a subjective opinion relaying stories and breakthrough moments with patients. I found this question a challenge to answer, of course I think I made a difference to the people of Kogate, but equally important- they made a difference to me. I've changed in so many ways, many of which are not yet apparent. The experience seeps out slowly, as I expect it will over time.

But how much of a difference did we make? We can't help everyone and the program is only 5 months. Unlike many volunteer groups that come to Nepal, we offer follow through with patients based on the length of time we are here. This is beneficial for continued care and gathering statistical information, but makes it very challenging to leave. Many healthcare-based groups come to remote areas, treat thousands of patients in a week, then leave and claim they helped and treated many. But did they? How do they know if the practitioner only saw the patient once and never followed-up? This is where ARP is different, but the question how did we make a difference is still present.

Tessa, a pre-med student and odd-job-doer of the group offered this analogy:

While walking along a beach, an elderly gentleman saw someone in the distance leaning down, picking something up and throwing it into the ocean.

As he got closer, he noticed that the figure was that of a young man, picking up starfish one by one and tossing each one gently back into the water.

He came closer still and called out, “Good morning! May I ask what it is that you are doing?”

The young man paused, looked up, and replied “Throwing starfish into the ocean.”

The old man smiled, and said, “I must ask, then, why are you throwing starfish into the ocean?”

To this, the young man replied, “The sun is up and the tide is going out. If I don’t throw them in, they’ll die.”

Upon hearing this, the elderly observer commented, “But, young man, do you not realise that there are miles and miles of beach and there are starfish all along every mile? You can’t possibly make a difference!”

The young man listened politely. Then he bent down, picked up another starfish, threw it into the back into the ocean past the breaking waves and said, “It made a difference for that one.”

We continued our conversation discussing how we helped our patients differently than an allopathic practitioner would. MDs in Nepal vary greatly in competence levels and I've learned most patients leave hospitals without more understanding of what is wrong than when they entered.

During my stay at the clinic I spent a bit of time educating patients. I can read medical records, x-rays and MRIs and explain the results to the patients. I can assess an ear infection and prescribe the appropriate medications needed. I can flush compacted earwax and clean an infected wounds. Many times patients refused to see allopathic doctors, even when we suggested they should. Sometimes patients would come in with an ailment they'd had for years. For example, hearing loss from a typhoid infection as a child. These patients would carry with them all their hopes and dreams of returning to normalcy and we would inform them we could not help. I learned this in the clinic- sometimes all we can do is be there, hold their hand and say, "I cannot change your situation, but I care about you and I am here."

That is not an easy lesson to learn, which makes incidents like the aforementioned one painful. Ritesh, a translator, chimed in on our conversations by saying, "We are different because we give them love."

And sometimes that is all you can do. Give them love.