Trust, submissiveness, and ingrained hierarchies: more adventures in feeling cervices

[Nb.  One last Nepal post, originally posted on our class blog]

The patient lay back, anxious, her feet in the stirrups as we crowded into the examination room. Looking at her, I told the doctor “no, it’s ok,” meaning, I didn’t need to do a pelvic exam on her. But the words “its ok,” whether spoken in English or Nepali “tik-tsa” are decidedly affirmative, as is shaking one’s head from side to side, and a pair of re-sterilized gloves were held out to me with tongs. No one asked the patient if this was okay with her, and the patients never argue with doctors. Not knowing what to say, I suited up and examined her. She had a nabothian cyst, a benign but tender lump on her cervix caused by blocked mucosal glands.
The doctor sends her home with ceftriaxone and azithromycin. Wait, what? Now we’re treating Gonorrhea/Chlamydia? The doctor, who is in fact a medical officer, which means he has completed medical school and internship but no residency, explains that the clinic lacks the ability to test for STDs, so when in doubt, he prefers to treat. Also, patients have a tendency not to come back for follow ups, especially if they believe that nothing was done the first time.
It’s an interesting combination: the abject submissiveness in the clinic, and the disinterest in following instructions such as “come back if you feel worse.” It’s not trust, I realize, that makes patients so passive, just ingrained hierarchies.
I take a moment to imagine what this clinic would be like if it were part of a more egalitarian society, and I have a bit more appreciation for the feisty Israeli patients who regularly have to be shooed out from behind the nurses stations and from inside the doctors’ workrooms, and even for the angriest American patients, screaming and screaming in the Harlem ED until police are called, aware of where they fall in the deeply unequal American hierarchies, and unwilling to tolerate it.


So, Nepal . . .

There are privileges I’ve always known I had, like white skin, english as a first language, education, a stable and financially comfortable family, and there are privileges where it never occurred to me to know that I had them. Like being warm in the winter. I wear my coat and hat and thick fleece-lined slippers indoors, and the tips of my fingers and toes are still icy cold. Only the most luxurious of luxurious buildings are heated in Nepal, and as the hospital librarian said today, laughing, “in the winter, we just suffer.” I’ve never spent a winter without heat before, or reliable hot water, and no, snarky-pants reader, Israel doesn’t count. Could I get a space heater? Not that easy in a city with scheduled rolling black-outs.
Like, we saw a patient who had had a stroke. I asked the Attending physician about tPA, one of the best treatments for stroke. He said it’s not used in Nepal; patients never get to the hospital within the time window (4 hours) for giving it. Anyway, the price is exorbitant. So there’s a technology challenge, of how to bring down the price of these medicines, and the transportation problem, of how to bring patients to the medicine. Alaska used airplanes, but, cost.
Like, I’ve seen my first tuberculosis patients here. The skin testing we use in the US is useless, everyone’s been exposed. A patient coughing blood is presumed to have TB, then double-checked by X-ray. I should ask tomorrow if there’s a national TB control program; I know there’s a national HIV treatment program not unlike the erstwhile pre-Obamacare Ryan White Fund, except using Indian drugs with busted patents. Technology problems, solved, sometimes. I’m supposed to buy a facemask, both for the TB and for the thick smog that erupts out of hundreds and thousands of tailpipes each morning and is hemmed in by the mountain ranges one can barely see through the smog.
And the mountains. Rising jagged and higher in the horizon than I’ve ever seen mountains before.

Tattoos I regret: my first patient with Nazi ink

The patient is here in the emergency room with headaches, yet another patient not having an emergency, but its after hours, and we’re the only show open, medically speaking, here in Nome, Alaska.
He asks where I go to school, and I tell him Ben Gurion University, in Israel.
“I’ve wanted to visit Israel,” he tells me, “but I don’t think I can. I got some tattoos when I was younger, that I regret.”
There’s only one sort of tattoo that would make someone afraid to visit a Jewish state. I’m guessing he’s got a swastika, but it could be SS, or maybe the HH.
He won’t specify what tattoo he has, and I have no need to ask him to undress, so I never find out.
He’s a big guy, and not that old, but seems shrunken in the hospital bed. He has a mild, almost gentle manner, and sounds sheepish when he talks about the tattoos. It’s hard to imagine him part of a neo-nazi gang, but I’m gonna assume the tattoos signify more than a casual interest. I wonder how he got from there to here.
I tell him I couldn’t recommend walking around Israel with that sort of tattoo visible, but if he kept covered up he’d probably be fine, and there are enough religious groups where the men wear long sleeves even in the summer that it wouldn’t stand out.
The nurse gives him a shot of toridol and the doctor writes a prescription to fill the next day, and we suggest he stay on top of his med refills so he doesn’t have to come back here to the ER at night.
I didn’t imagine I’d be treating former neo-Nazis in Alaska. I suspect my former neo-Nazi patient did not expect to be treated by a Jewish medical student in Alaska either.
I’ve heard of Jewish doctors refusing to treat patients with Nazi tattoos before. To be honest, it never occurred to me in that situation, but I wonder if I would have felt differently if he seemed less contrite and sheepish, if I had discovered the tattoos incidentally.
I hope not. Their rules are not my rules, and I play on my terms, not theirs, and tonight that means a shot and a prescription.

[Nb. old draft that I’m finally getting up]

I Count My Days

i count my days
weeks lose their meaning
the month is one third gone
then half, two thirds,
to much time to pass
and not enough at all
my days are read from checklists
my checklist reads
to check on her again
and so I do
so still and shrunken
i double check that she’s not dead
her pulse is there
but no response to pain
she barely gags.
the fabric of time shifts
slowing to accommodate
her fading days
good-bye mrs. T, i say,
leaving, then to the nurse apologize
for talking to the almost-dead.
oh she heard you, she smiled,
i almost imagine it’s true.


1. The backpack fits my body like a second skin. It feels good against the curve of my back. as it settles against my hips one hundred masks fall away. I won’t be a stylish new yorker, I may become a doctor but that won’t be all of me. But I can put on this backpack and walk for a long time.

2. The backpack fits my body like skin, like an exoskeleton, and home is where I lay my head, or where i have a friend, or nowhere. I met a woman who can’t return to her mother’s house unless she stops wearing dresses and calling herself Darlene. She just wants a place where she can live, with her cat. She has a friend upstairs in the hospital who’s in a bad way. She warned her friend “that is not working out for you.” “That” was cocaine. Her friend’s family drove up from Savannah to be with her, they aren’t allowing visitors, so her friends are worried. I know just how bad shape her friend is in from morning report; I say nothing. “I’m learning,” Darlene says, to take life one moment at a time.”

3. When the backpack is filled, I hoist it up and tighten the straps, but it still sags under its weight, pulling back against my hips, the buckle presses into my belly. My body sags under its weight.

4. It’s a stormy month to be here. The winds ground small aircraft and turn the Bering Sea into a milky green froth, like dishwater. The earth is gray with volcanic ash, coloring the mud that oozes and tracks everywhere when it rains, and coloring the dust storm whipped up by a cold wind blowing in from the interior. The wind grounds the commercial plane that was supposed to bring a sick baby in from one of the villages. The doctor orders the medevac. Wearing all of my clothes, I stagger forward into the wind like a drunk. The wind grinds dust and gravel against my skin.
On the way to the airfield, the paramedic tries to scare me. “They have polar bears where we’re going.”
From the Cessna Caravan configured with a stretcher, I watch the sun set over the Bering Sea and the snow-dusted bare hills of the Seward peninsula. Between the heavy bank of clouds and the low arctic horizon, the sunset is a long wedge-shaped streak of crimson shot against the surroundings.
When we descend, the pilot dances with the wind, dipping the plane from side to side until we hit the runway. I later learn that this is to prevent the plane from flipping over when it lands in such high winds. I want to snap a picture, but there’s no time- we’re picked up ATV to drive to the clinic.
The baby is fine. We medevac him anyway, stuffed down his mother’s jacket. The ride back to the plane is the coldest I’ve ever been. The paramedic is still trying to scare me about polar bears.

5. When it’s time to leave I find my skin has turned translucent in the subarctic light. Beneath it small blood vessels tangle like roots. My belly softened with winter’s lethargy. And my body has hardened to the backpack.


I learn slow

I learn slow. I learn
the same lessons
Fingers of my soul reach out
searching to break down
the same heart-walls
I thought I’d scaled
I’ll learn again, if You’d just
help me see Your face
in the face before me.

(still playing catch up, this is from a bit before rosh hashana and yom kippur, and also from   a pediatrics rotation)