I load an acupuncture needle into a small tube and touch the plastic to her skin. I haven't even inserted the needle yet and she starts sobbing into the head cradle of the massage chair.

"I'm scared." The interpreter translates.

"I know," I say back. "Are you sure that you want to be needled? We can just do the moxa."

"Yes, I want the acupuncture. I want to get better." I tap the needle in and don't bother manipulating it. I know she can't handle anymore sensation than this without starting to scream.

I would like her to get better too. It's her first treatment and we have no idea what's wrong. This 22-year old woman showed up with a thick packet full of medical records. She requested a female translator and Urmila quickly volunteered. We helped her disrobe, cover her breasts with a sarong and sit into the massage chair. This was only possible because we were working through our lunch and so we had the privacy of an empty room.

She told me her story as I leafed through the medical records. About a year an a half ago, she got a high fever that turned into an excruciating headache with back pain, nausea, vomiting and photosensitivity. She went into the hospital, where they found an erosive lesion at her T12 vertebra. They put her on high doses of multiple antibiotics and referred her to a spinal surgeon for an exam and radiography. The surgeon wrote that the lesion was most likely infective, possibly an eosinophilic granuloma. He reported that his findings showed that the lesion was not infecting the soft tissue around the vertebra and that it was most likely not malignant (the spine is the third most common place for metastasis, behind the lung and the liver.)

For the last year and a half, she has been put on a myriad of antibiotics and drugs and she has been scanned, poked and prodded as doctors have tried to find the answer to her illness. She carries her medical records with her to these various places, but she does not have any of her radiographic scans for me to look at. She tells me that she has incredible pain in her neck and back, but as I examine her, she is able to turn her head from side to side, only reporting dizziness when she laterally extends. Her right side is subjectively numb and weak in comparison to the left. I find that the deep tendon reflex at her patella is hyper-reflexive, meaning that the signals at that tendon are not getting to her brain for some reason.

I can't get a needle anywhere near her spine or on her back. I tap two 36-gauge needles into the skin near her occiput and she screams at both of them, while asking me to put them there. The full treatment ends with a needle in each hand, each foot and two at the back of the neck. We spend forty minutes with moxa down her spine and at a point on her leg to help rejuvenate her immune system. I don't know if her nervous system is hyper-responsive because of her illness or from the trauma of being tested and examined over and over again, by strangers, over the last 18 months.

We get her off the table and she gives us her records to bring home while the rest of the team is finishing lunch. I quickly go over them with the team of doctors while I inhale the warm dal bhat that Auntie gives me.

"What do you think it is?" the team lead asks me.

"Spinal tuberculosis. It's the only thing I can think of, but it's just a feeling. It's impractical. And it wouldn't make sense that they didn't test her for it yet. What else can we add to the differential?" I am confused as I go through the mass of paperwork. She's been looked at by a dozen doctors and during this whole time, they haven't listed any real diagnostic options. In the last month, they've decided to test her for lupus and autoimmune disease. I don't understand why there is no clear direction of diagnostic possibilities listed early on in the disease. It seems like these doctors have been blindly running tests but none of the tests adds up to anything we can understand and they haven't charted their thought process or plan.

We decide to send her to the local Health Post for a Mantoux test (to check for tuberculosis). It's a simple test that costs 50 rupees. I'm not sure why this wasn't done in the first place. In addition, we check her rheumatoid factor and erythrocyte sedimentation rate. I am worried about auto-immune conditions, especially Ankylosing spondylitis, since an earlier Camp found an undiagnosed instance of AS here a few months ago. Regardless, I am hoping for something infectious that is treatable. If she can be treated, she can go on with a relatively normal life. If she has an auto-immune condition, it can be managed but her prognosis will not look so great.

______ Four treatments later and I am still putting together the differential. The patient and her family are on their way to India right now, just passing through Bhimphedi. They are searching for answers for her illness and are not sure where they will go once they get to India, but they think they can find better doctors there.

I have asked her to stay for 10 days while we go over her case and try to put together some clear goals for the doctors she finds. I am treating her symptoms and she is getting some relief, but the bigger job is to offer her some direction around the kind of care that she needs. I find that the greatest thing I can give her right now is compassion and empathy. Though we rarely have the privacy that she would like, we are often able to treat her in a room full of only women and with a female translator. Three times now, I have simply held onto her while she cries into my dusty lab coat about her situation.

I worry about her when I am not at the clinic and I know I have taken too much of her pain onto myself. For now, I am waiting until we can have the Mantoux test read and get some idea of the direction that she needs to go. I have a feeling that this is spinal TB but feelings don't mean much in this arena. I've got to be objective about her case and make sure that I am able to provide her with some directions when she gets to the hospital.

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