It was an old, dirty, plastic bottle filled with water that sat on the patio table in front of me. Next to it, the stem of an umbrella rose up through a hole in the glass tabletop. I sat with three Nepalis, two of whom ate buffalo momo dumplings. I had a plate of chowmein (which here means egg noodles fried in mustard or soil oil with green onions and dried chilis.) Ritesh, our clinic manager, had this as well, though he got his with fried buffalo stomach and I taught him the English word tripe.

This was my third time at this Newari restaurant, and as such, the third plate of chowmein that I've had since coming here. This one was far saltier than the other two had been, and I was struggling to finish it. I coated it in hot achar sauce to try and take some of the salt out, but I was feeling parched. I usually have my water bottle with me, but I had been grieving about the interns and not thinking straight. I watched my companions drink repeatedly from the water bottle on the table and thought to myself, many times, not to do this. I did it anyway; two small sips were all I needed to feel a million times better.

Since this lovely dinner, I had three days worth of abdominal cramping and diarrhea. I have learned something in coming to Nepal, and it's something I like very much about myself. First, I don't throw up when I have food poisoning. On one hand, this might be problematic in that I don't get the bacteria out fast and limit the duration of my illness. However, it means that I don't have to vomit, and that's definitely worth being sick longer. I don't think anyone likes to vomit, so I think it's just super cool that I usually don't. Secondly, I don't let it get me down. I manage to stay in a relatively good mood and with lots of energy to work, regardless of the cramping and diarrhea. I decided to give this bout three days before hitting my bottle of ciproflaxin and it appears that was all I needed. Whew!

Today I spent the morning cleaning, organizing and documenting our remaining herbal dispensary. I listened and watched the practitioners with their patients and interjected when asked (and a couple times, when not asked.) One woman this morning has been especially tough for two of our practitioners. She has liver function tests that show the beginning stages of liver disease. She has non-pitting edema. Her nails are starting to come off her fingers, but they aren't spooning and they aren't technically clubbing. What could it be? We talked about this case for thirty minutes the other night at dinner and once this woman was in front of me, the symptoms were all over the place. Finally, we asked about pesticide use and sure enough, she uses these on her crops everyday.

Three of our farmers this morning are suffering from the beginning stages of liver disease with shortness of breath and a number of organ problems that seem to be traced back to pesticide use. This is a tricky area, since it's hard to prove. An article in Environmental Health Perspectives talks about an analysis on farmers in developing countries who are suffering chronic pesticide poisoning with symptoms that include headache, dizziness, depression, limb weakness, poor balance, difficulty concentrating, and vision difficulties.

We're seeing far too much of this here. They often don't wear gloves or masks, don't wash their hands and then eat food. Of the three we talked to today, two wore gloves and one wore a surgical mask while applying the chemicals. None of them seemed to understand the detrimental effects these substances are having on them. In a country as beautiful as this, I have been quite surprised to find that the vast majority of the farmers here are using pesticides in high amount.

Strewn through this mix are a number of patients suffering from post-stroke hemiplegias, auto-immune conditions affecting the nervous system, the occasional lumbar disc lesion, cervical radiculopathy and a handful of other conditions that can mimic some of these symptoms. Our practitioners have twenty minutes with each patient to gather information, do objective testing, make an assessment and then treat with acupuncture or chiropractic. We see most patients 1-3 times per week, to continue gathering information and determining a diagnosis. We work with the pharmacist who runs the Healthpost here and the doctor at the Primary Healthcare Center in Palung to get blood tests and imaging to progress our cases. It can be hard to differentiate these things in the first few visits.

With chronic pesticide poisoning, I am still trying to determine our course of action. The results on the last few patients I have seen show the liver to be distressed, the lungs are severely affected (in a country where, after infectious disease, COPD is already taking the lives of over 40% of the folks left), and kidney function has been undermined. The testing and imaging add up for these farmers, who often carry many years worth of records through our doors when they come.

The organophosphates seem to cause irreversible toxicity to the nerve cells and deficits in cognitive function. I am still researching the possibilities and trying to figure out how we can educate people, with simple language, about avoiding these chemicals.

During lunch, Dr. Jessi and I took a patient up to the Healthpost to speak with the manager there about an orthopedic referral. The patient is  an 80-year old woman who is so osteoarthritic that it looks like she completely detached the head of her humerus. The humeral head appears, from x-rays, to have split into two pieces. The shaft of the humerus rises up into the shoulder girdle as this lady moves her arm.

From the paperwork, it looks like the government hospital recommended surgery, but the patient reported that they told her she was too old. After an hour of back and forth with three Nepali interpreters, the manager, the head midwife and two other staff members, we found out that it was the patient's children who had refused. They were worried about costs (which could be as little as $1500 US with the right connections or as high as $7000 US without) and the long-term recovery time for an older, osteoarthritic patient.

In the end, the manager of the healthpost has decided to call her children to come in so that he can talk with them, as he has been to their home before and thinks he can make some headway. The patient agreed to revisit the hospital in Kathmandu with her family so that she could get more details to make an educated choice. And, Dr. Jessi and I decided to create a non-surgical, Plan B solution, in case the family still decided not to do the surgery. At the very least, Jessi can create a molded cast/sling from Plaster of Paris, fitted to this woman, so at least if she stumbles a bit, she will have a minor degree of protection.

Lunch was delicious, as always. The afternoon was so stacked with patients that I ended up treating a few in the end to get everybody home. We are still working with reception to try and even the patient load between providers, though it was highly uneven today, with one of my practitioners treating 27 people in 7 hours. It was a good day, with a lot of great work done, but I'm hoping we can streamline the process a bit more this week.

Humeral head detachment