Andrew Schlabach left today. I thought he was coming back for one more visit before flying back to the States, but as I hugged him goodbye, he said that he's probably not.

I'm thinking about this as I needle my side-lying patient in the sun. Flies are landing on his exposed hip and I insert a seven inch needle into huantiao, "the jumping circle." I move the needle gently until he does jump and then move on to the next point. The flies are irritating me. For days, I have been trying to figure out how flies make the world a better place. I haven't come up with anything yet, but I'm sure they feed something I like. In a conversation last night, Debbie said she couldn't tell if she was annoyed or grateful about the wind as she meditated. I replied, "Not being able to decide if I'm annoyed or grateful describes so much of my experience here." We laughed. As I shoo the flies from this man's legs, I remember it and smile.

We had the conversation last night around the dinner table with Andrew. We were able to ask about our cases and get input from him. He knows this place so well, from years of researching his patients in Nepal. It's a blessing when he can quickly shine a light on a troubling presentation or help us navigate the politics around the local health post. It's changing the way I practice to have his instruction in the various classes that we've attended here: orthopedics, infectious disease, diagnostics, measurements of efficacy, case management and the progression of patients.

rest
rest

I turn back to this man and cover him with a light towel so that the flies won't bother him while he rests. I think about how far I've come in the past six weeks as I walk towards my next patient. While I was treating the other man's hip pain, Milan built a fire at the teahouse next door and boiled some water. He is just walking into the yard with it. We pour some into a bowl and I swirl a bar of soap around in it. I don some gloves and sit in front of the old man in front of me. I wash the wound between his fourth and fifth toe with the water. It's hurting him, so Ritesh and I use a cotton applicator to put some lidocaine into the deep, centimeter wide crevice. The wound is filled with some dried flower that a friend recommended for flesh generation. It's black and hard to remove from the two-month old hole.

tb
tb

I hear Andrew's voice in my head: If you've got a pus-filled wound that isn't healing but there's no inflammation around it, think about skin tuberculosis. Refer the patient for a Mantoux test.

Every time I see a case that has the potential for TB, I try to talk myself out of it. Especially this extra-pulmonary TB, which is something that isn't a big part of my reality back home. Yet, how could I be so surprised or doubtful? One in three people in the world have tuberculosis. Considering that the rates of TB in the US and other developed countries is so low, it's got to be pretty high in other places. India had the highest total number of TB cases in 2010 and we aren't far from there. In world medicine, it's considered a pandemic, with 1.5 million deaths per year, mostly in developing countries.

The diagnostic tests we've got aren't great, and I mean we as in The World And Those Of Us In It. The sputum test is definitive for pulmonary TB, but it's not always an accurate test for this extra-pulmonary stuff. When I suspected spinal TB in a patient last week, I sent her in for the Mantoux skin test and she had a positive reading, yet that test is highly inaccurate. She is unlikely to have a positive skin test, especially without a respiratory infection. I had to send her for a spinal biopsy in Kathmandu to get a more accurate result. The WHO and United States are currently subsidizing a new, fast-acting test, but it's yet to be released and who knows when it will be (no pun intended.)

Right now, the five of us on our healthcare team are looking at a handful of cases that look like extra-pulmonary TB and trying to navigate the governmental system and politics here that go with this. After the skin test, we've got to run a sputum culture before the local Health Post will write a government letter to enroll the patient in the WHO Directly Observed Treatment Short-Course (DOTS) program. We don't treat TB at our clinic. Patients must be quarantined and observed for the strong antibiotic regimen. However, getting them to that place is something we're finding hard to navigate....

I write a referral letter for my patient to take to the Health Post in the village where he lives. I pack the wound with clean gauge and tell him that he can't be walking around in flip flops anymore. I give him instructions on how to wash and care for the wound until Monday, when he can bring me the unreliable results of the test. Unfortunately, I've only got 3.5 weeks left in Nepal. If his skin test is positive, will I have time to go through the process with him? Who will manage his case when we're gone? Much of the problem with healthcare here has to do with a shortage of doctors - but so much of it also has to do with the inability of the doctors who are here to take responsibility for a case.

ARP can't use the community center in Bhimphedi from March until September so these people will go for six months without our clinic. Andrew and Tsering have bought land down the road but they are waiting for the Nepalese government to approve their proposal to build on that land. If they can get it, they can setup a year-round clinic here. A clinic staffed with health care providers who are being trained to take responsibility; to take charge of a patient's case and follow it through to the end. I am sad to see Andrew go today, but I am so proud that I got to be a small part of the beautiful work he is doing here.

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