Nepal remains one of the poorest countries in the world and has been plagued with political unrest and military conflict for the past decade. In 2015, a pair of major earthquakes devastated this small and fragile country.
Since 2008, the Acupuncture Relief Project has provided over 300,000 treatments to patients living in rural villages outside of Kathmandu Nepal. Our efforts include the treatment of patients living without access to modern medical care as well as people suffering from extreme poverty, substance abuse and social disfranchisement.
Common conditions include musculoskeletal pain, digestive pain, hypertension, diabetes, stroke rehabilitation, uterine prolapse, asthma, and recovery from tuberculosis treatment, typhoid fever, and surgery.
In the aftermath of the 2015 Gorkha Earthquake, this episode explores the challenges of providing basic medical access for people living in rural areas.
Acupuncture Relief Project tackles complicated medical cases through accurate assessment and the cooperation of both governmental and non-governmental agencies.
Drug and alcohol abuse is a constant issue in both rural and urban areas of Nepal. Local customs and few treatment facilities prove difficult obstacles.
Interpreters help make a critical connection between patients and practitioners. This episode explores the people that make our medicine possible and what it takes to do the job.
In this 2011, documentary, Film-maker Tristan Stoch successfully illustrates many of the complexities of providing primary medical care in a third world environment.
I want to thank you all for your continued interest and generosity towards our ongoing work in rural Nepal.
March 16th, in response to the global COVID-19 pandemic, Acupuncture Relief Project suspended clinical operations in Makwanpur Nepal by closing our Bajrabarahi clinic along with its associated satellite clinics. Our foreign volunteers were transported back to Kathmandu where they were directed to immediately depart for their home countries by their respective embassies. Elissa Chapman, our Clinic Director, was on the last flight leaving Nepal on March 22nd before the airport was closed (and now remains closed).
Following the closure of the clinic, we paid to have a Nepali community health doctor travel to Bajrabarahi to spend several days training local health workers and staff in the prevention of Coronavirus infection. We also made our clinic facilities available to the local government to be used as an emergency hospital as needed.
At this point, with all of our volunteers safely returned to their home countries and our staff under a “stay at home” order, we are in the same holding pattern as the rest of the world. So far Nepal has few confirmed cases, however, the government has been slow to react and like many developing countries, Nepal lacks the fundamental resources and infrastructure to combat a severe outbreak. All we can do is wait and hope for the best.
We will reopen our clinic as soon as we receive clearance from the health authorities and hope to return foreign volunteer practitioners to the clinic to resume primary care services in early September. Your generous contributions help maintain our staff during this time of crisis and will also be used to restart our clinic operations in the aftermath.
Please consider a donation to help continue our work by visiting our website and donating at https://acupuncturereliefproject.org/donate. Acupuncture Relief Project is a volunteer-based, 501(c)3 non-profit organization (Tax ID: 26-3335265). Donations are tax deductible in the United States (and other countries) as allowed by law.
I sincerely hope that you, your family and your community are all well and safe as we all transcend this strange set of circumstances together. One world family.
Best regards, Andrew Schlabach EAMP LAc (USA) President, Acupuncture Relief Project
Our patients loved soaking up the rays with treatments on sunny days.
I cannot imagine having started my career as an acupuncturist in any way other than climbing on a plane and venturing to volunteer in Nepal. My time at the Bajrabarahi clinic was full of unexpected friends, learning a lot about myself, and deepening my relationship to my practice. It had been a difficult decision to leave my partner, pets, and friends, to put off my new job for 2 months, to do something so outside of my comfort zone. But I’d been dreaming of this for 4 years, it felt like something I had to experience, to do. I had traveled alone plenty, but never outside of North America. Now I was venturing into a culture so different from my own and practicing a medicine new to me, in a language I didn’t know. It was daunting. The responsibility of being a primary care physician felt heavy. When I left, I was giddy, unsure of myself, and just curious enough to do it anyways.
Arriving in Kathmandu was full of pure joy to explore a new place. I was driven to learn as much Nepali as possible so I could learn more about the people I met along the way! The trip to the clinic was gorgeous and full of anticipation. What was this clinic in rural Nepal going to be like? Was I going to be able to help in a meaningful way? Would I be able to keep up with the clinic flow? The short answer was yes. Everyone at ARP made this whole experience so smooth and comfortable. Sushila, Satya, Sanita, and Bex were so helpful and willing to discuss cases. They taught me a lot along the way, like how to take blood sugar. And they offered advice on things like where to refer out and what options were available for one of our patients who was at risk for DVT (deep vein thrombosis).
Our patient sits on a mat that is hand-woven with rice stalks, separating her from the cold stone floor. It’s early and our clinic hasn’t opened yet but this woman’s family called us to come have a look at her. It’s brisk and my fingertips sting and yet the morning sun is doing its best to cut through the frost. The house is made of concrete and clay bricks. It’s unpainted and is adorned with a simple corrugated metal roof. By the looks of it, 8-10 family members live here and they are all gathered around the small outdoor courtyard where the family does its daily chores. A couple of goats, staked in a pen, happily munching on some dried grasses are apparently oblivious to the small crowd of people. Chakkhu Maya Gopali, our patient, appears to be in her seventies. She is barefoot but dressed in a winter-weight kurta made of a bright red, black, and yellow fabric. Around her head and shoulders, she is wrapped in a thick wool shawl. Even before she says “jhumjhum”, meaning tingling, I can see by the way she is sitting that she is having a stroke. I’ve seen this same scene many times.
The morning sun glitters through the windows and my rhododendron plant stretches its leaves up to reach the light. I put on the kettle and sit down to eat my oatmeal with banana and soymilk, a breakfast poles apart compared to the roti with potato and chickpea curry I'd become accustomed to in Nepal. My city here in Victoria, Canada is famous for its rhododendrons, but the 100-year old plants look like babies in comparison to the rhododendron forests I have just witnessed while trekking through the Annapurna region; truth be told the plants are so bountiful that the local Nepalese verily use them for firewood to supply their wood-burning stoves.
I ended my volunteering experience in the village of Bajrabarahi, Nepal with the Acupuncture Relief Project only four weeks ago now, yet the atmosphere, pace and the patients' faces are still etched in my memory. I have been reflecting on my time in Bajra since returning to Canada and the difference in practitioner-patient dynamics compared to what I typically encounter here in the West. I was fortunate to travel to Nepal and volunteer alongside my husband Gavin, who is also a Registered Acupuncturist and Traditional Chinese Medicine Practitioner. It was his first visit to Nepal and sharing the work-day with him and the exceptional Nepali practitioners Satyamohan Dangol and Sushila Gurung, intern Sanita Gopali and interpreters and clinic staff Amrita Gopali and Sushila Waiba, was truly a dream-team manifest. Returning to Nepal, for me, after eleven years away from a country where I spent four years of my creative years from age twenty-four to twenty-seven immersed in a BA program in Tibetan Buddhism at Kathmandu University was strangely familiar, yet this time entirely new.
When I arrived in Nepal I was an anxious graduate student fresh out of acupuncture school during the Covid-19 pandemic. Having spent two years practicing medicine over zoom, I was nervous and doubtful about my skills as an acupuncturist. From the moment I arrived, everyone greeted and welcomed me with open arms. Satyamohan, Sushila, and the interpreters made me feel right at home and a part of every conversion. After just a few days with my new ARP family, all my worries melted away and I quickly found my new routine. The clinic is cleverly designed and well stocked, everything I could have needed to treat patients was provided and I was learning at a light years pace. The integration of the lifestyle clinic and neighboring health post is the perfect blend of Eastern and Western medicine. Together they are able to provide the patients with excellent primary care that would otherwise be difficult to obtain. One of the greatest advantages of working with the ARP was the ability to see a patient for 20-30+ visits. Seeing improvement with each treatment and trying different modalities was invaluable and rewarding. During my stay I’ve been able to regulate high blood pressure/sugars, reduce or eliminate complex pain syndromes, and support tremor/stroke rehab just with acupuncture. It blows my mind what few needles and Traditional Chinese Medicine can do.
Ramkrishna’s eyes brightened with recognition as we entered. His room… a small tin shed. A collage of colors and rust patinas cover every surface of the salvaged corrugated metal. Six feet wide and ten feet long, the self-standing structure features one small window which casts a blade of bright light across Ramkrishna’s face. He shares the space with dried corn, broken farming tools and a stack of dried rice sheaves which serves as feed for livestock. A rough pile of filthy blankets outline a sleeping area on the concrete floor. A small well-used tea kettle sits on a ring of partially charred sticks. The remnants of this morning’s cooking fire.
Ramkrishna December 2021, Thaha, Makwanpur, Nepal
Ramkrishna speaks breathlessly with an ominous gurgling in his chest.
“Finding our own definition of success means becoming aware of what we value. Often, this means rinsing years of conditioned thinking from our minds.” - Anonymous
I recently returned home to Portland Oregon after spending two months working as a volunteer at Acupuncture Relief Project (ARP) in rural Nepal. Within my first year of school at Oregon College of Oriental Medicine I knew that after I graduated from my MAOM program, I wanted to go work for ARP and Good Health Nepal. At that time, little did I know what it would actually mean for me professionally and personally. I can say without a doubt, working in an integrated clinic in rural Nepal these last few months was the most transformative journey I have ever undergone. To emphasize the enormity of such a statement I would like to share that my background includes extensive travel to 27 countries, 7-years as an Expat in Spain, two Master’s programs, 4 businesses (2 sole proprietorships, 2 LLC’s), a professional career in Business Admin, a significant history of personal health challenges and a recent separation from a six-year marriage.
Basanti is a 32 year old woman from the small village of Bajrabarahi, about three to four hours from Kathmandu (depending on your mode of transport). Ten years ago she fell in love with Dikpal; they married and had a child together. She presented at the clinic with stage four breast and brain cancer that had metastasized, possibly spreading to her bones.
Basanti was carried into the clinic by her husband in the early morning. Requesting a bucket be placed beside her bed, within minutes she was throwing up. It was Basanti's first visit to the clinic, her chief complaint being nausea and a one-sided temporal headache. For the past fifteen days she had been vomiting intermittently due to the severity of her pain. The constant sharpness in her left temple was so severe she had been bed ridden for weeks, struggling to keep food and water down. Basanti was initially hesitant to disclose her recent history, possibly because she was weary of further medical intervention. After some time she revealed she had had a mastectomy on her right breast eight months prior, followed by six courses of chemotherapy and twenty-five days of radiation therapy. Almost as an afterthought, she told me of a lump on the left breast that had been itchy for the past few months.
In my first week with Acupuncture Relief Project, a grandmother came to the clinic complaining of abdominal pain. She had eaten some bad buffalo meat and was now suffering from diarrhea and cramping. Despite her discomfort, she had a face that seemed made for smiling. As we discussed her pain, her face broke into a huge goofy grin, perhaps made goofier by the mere four teeth that comprised it. Her eyes twinkled and searched my face as she spoke. I took her vitals, felt her abdomen, gave her advice and treatment. The next time I saw her, she said her diarrhea had ceased and she had returned with a new complaint. As I evaluated her for this new pain, she looked at me and smiled her big goofy smile. She said “You really Love me. You Love me like my mother Loves me.” I was a little bit blown a way and admittedly, tears came to my eyes. My first thought: has no one loved you since your mother? Surely if someone had, you would have referenced that Love, being that you are so far in time from your mother’s Love. My second thought was no, “Love” is too strong a word; I “care” for you as any good practitioner would.
“Easy! Easy!” My motorbike’s rear tire spins out to the left as it loses traction on the rain soaked, stony... road? path?. It’s a cold wet Saturday morning and I’m wondering how good of an idea it was to come this way. Saturday is usually our day off, but today we are on a mission: three motorbikes slowly winding up through the misty hills near our clinic in Tistung. Mercifully the precarious drop-offs are obscured by low clouds meandering their way through the eerie landscape, giving us the illusion of navigating a precipice surrounded by an endless abyss.
The river is a lot deeper than I expected, soaking my boots. Now climbing the steep muddy bank, I grab a little too much throttle, finding myself slipping somewhat sideways with my bike bouncing ungracefully over the loose stones attempting to gain purchase.
Yesterday at our clinic, a volunteer practitioner, Emma Ellsworth and I managed a rather gory draining of a large skin abscess (carbuncle) on a thirteen year old boy. It was about a one inch, very painful lesion located between his left temple and the root of the ear. The procedure seemed easy enough as we numbed the area with lidocaine, sterilized his skin with povidone-iodine and prepared our tools. After making a small incision using a three-edged needle, copious amounts of turbid yellow puss were drained from the skin. (That was the easy part.) Then, using a sterile stick swab soaked in an antibiotic solution, I inserted the swab several centimeters into the pocket to clean its margins. Thankfully my assistant held steady as we worked quickly to finish the procedure. We dressed the wound, gave our brave young patient some medication for pain and infection, and sent him on his way.
Recently while working in the Bajrabarahi clinic I had the opportunity to help someone with an infected wound. A middle aged woman came into the clinic with a swollen, painful finger and a flesh wound that was clearly infected. Apparently she had placed her hand on the ground to help her stand up and she felt something prick her finger. After 6 days her finger began to hurt and after 10 days she was in our clinic asking for help. Her finger was swollen with parts of her skin that seemed to be shiny and lacked the texture of normal skin. The wound was open, roughly .5 inches in diameter, exposing pink flesh underneath with scabbed blood and dead skin covering half of the wound.
Having never dealt with something like this before, I wanted the clinic director, Andrew Schlabach, to come take a look. After giving a brief description I said, “I wonder if it is MRSA”, in which he responded with a good chuckle.
After coming to take a look, he told me I would have to clean it well with soap and water and get clean borders. So I brought her to the sink, scrubbed her finger for about 15 minutes with soapy water trying my best to clean out the blood and pus without hurting her. For a more deep clean, I used a long cotton swab to get under her dead skin and removed the pus that was hiding. Now that the finger was clean it was time to get clean borders. I was handed a sterile, surgical scissors and was told to find good light. So the patient and I sat on a bench in front of the clinic while I started to cut away her dead skin. Remember the skin that I said looked a little odd around her wound? Well, turns out it wasn’t attached to her flesh any longer. I couldn’t believe how much of her skin had been detached due to infection and would end up being removed.
After the removal of the dead skin, we made a poultice with Neosporin and some antibiotic herbs to put over the wound before wrapping it up and sending her home.
I look forward to seeing how she is doing when she comes in for a follow up. --Dean McNash
I don’t know about you, but I grew up eating rice for basically every meal. My job in the house was to make sure the rice was washed and cooked by the time my dad got home from work. Then he would make a vegetable stir fry or beans and the whole family would eat that every night. Any left over rice would be made into fried rice for breakfast the next morning. Only my asian friends understood why my family had two rubbish bins in the kitchen—one for rubbish, the other full of rice...and this was because they had the same thing in their kitchens too. Look under the sink cupboard and you’d find an industrial size of Aloha shoyu too!
I had never seen rice fields until I came to Nepal. When we first arrived at the beginning of October you could see all the tiers of rice that were carefully planted. The green stalks made the hillsides so lush and beautiful! Fast forward to today and this is the last week of camp. It’s the beginning of November and rice harvest has been in full force for the last week or so. This has caused our patient counts to be lower each day but it’s kind of nice that we get to spend more time with the patients who do come in.
One day after clinic I wandered through the fields to watch how rice is actually harvested. The people were all very friendly and didn’t mind that I was snooping around taking pictures. I’ve gone to Asian markets my whole life to buy my favorite brand of rice and have never once stopped to think about how labor intensive the process is. When the rice turns just the perfect shade of golden-brown, the whole community comes together to help one another harvest the fields. The rice stalks are cut into perfect bundles and then they are sent through a machine that pulls the grain from the stalk. How is this machine run? By man power. Someone is in charge of pumping the machine with their foot the whole time. Talk about strong quads! Once the grain is separated women put it in large flat baskets and sift out the smaller pieces. The stalks are then collected again and laid in the field in perfect symmetry to dry. These are later used to feed the cows, water buffalo and goats. -- Raina Chang
Before rice harvest (Taukhel)
After the rice has been harvested (Taukhel)
And this picture because no blog post is complete without a beloved water buffalo <3
I looked down to check that I had everything. I wore my white lab coat, new name tag, and had pens in my pocket. My supplies were all laid out for the day, so familiar, and yet the surroundings quite new; the clinic’s dark red curtains, the colorfully-woven stools, shelves of Chinese herbs, the sound of patients speaking Nepali, and simple beds with turquoise sheets. I reassured myself that there was nothing to be nervous about. I had been preparing for this for so long. Besides, I had done this before, hadn’t I? Some elements of my first day at the Bajrabarahi clinic in Nepal stand out in my memory. I keenly remember my apprehension as patients were funneled in to sit on the plastic lawn chairs and waited expectantly while taking in my appearance. I wondered if I would know what to do. Would I be able to help them? I had so many questions and I often still do.
Nothing could have prepared me for the transition into treating patients in Nepal. At first it felt like chaos. There were often people waiting to be seen both inside the small work space and outside, people talking loudly, coughing, spitting, laughing, and people looking through the windows watching me work. My interpreter and I sat on low stools in front of patients and tried to make sense of each case over noise, language and cultural barriers, and with no privacy whatsoever. I felt the weight of time constraints and the needs of many waiting patients. I sat all day in a riot of stimulation and found that my own expectations were surging. I began to realize that my mind was occupied with expectations of myself to make good assessments, catch red flags, establish rapport, and provide healing treatments. I even began to notice that I had expectations of how the stories should be told, how the body should respond to treatment, how the clinic atmosphere should be, how healing and health should be, and so on. Instead of letting each story unfold and really looking at what was in front of me, I was filled to the brim with my own ideas of what ‘should’ be happening. Each day in clinic I found that, much to my frustration, all of those expectations of how things ‘should’ go were being unmet and by having these expectations I was resisting life.
Cricket highlights are buzzing in my left ear, as I peel apart crinkling, plastic sleeves of a wedding album. My patient’s fourteen-year-old son splits his attention between the static screen and his sister’s wedding photos, dutifully providing me with descriptions of each face’s relation to the family.
“Mother’s big sister’s husband.”
“New husband’s mother’s big mother.”
Overhead, two occupied bird’s nests are harmoniously integrated into the wooden beams and cool clay of this traditional Newari home. An ornately carved shutter is open, shedding warm sunlight on my lap to compliment the sticky-sweet, masala tea in my hand. I am beginning to feel more healed than healer, the boundaries dissolving between myself, the soft, fleece couch cover beneath me, and the mother and son flanking my sides.
My patient’s charm is contagious. A muscular woman in pink who doesn’t rise past my breast, she pulled me in from the street, scythe in hand. She is beaming at her doctor’s compliments of her daughter’s beauty, which are completely sincere. The twenty-two year old bride’s smile outcompetes a heavy red tika, layers of bright cloth, and grass, glass, and metallic adornments. Her son tells me she lives in Baltimore, and I am excited to convey that I share a coast with his sister, as we three sit atop each other on the small couch.
I hear heavy footsteps below, and quite suddenly the television’s light is extinguished and the photo album stowed away. I greet my patient’s husband, “Namaste”, and receive a stoic acknowledgement. My patient is bringing her fingers to her mouth, offering me to join their morning meal. Feeling as though a storm has moved in, I enthusiastically thank them and take my leave. My thoughts wander to the metronome of my footsteps… is my patient seeking relief for more than her inflamed elbow?
Four years ago I fell in love with the most impoverished district of Nepal called Humla.Though I was there to research malnutrition, I quickly realized the desperate need of doctors in these vast Himalayan mountaintops…where ironically most doctors, even from Nepal, refuse to venture.But it seemed unpractical to be a conventional medical doctor where x-ray machines and pharmaceuticals were unaccessible.Enter naturopathic medicine.These past four years, I have dedicated to learning herbal therapy, water therapy, nutrition, spinal adjustments, counseling, homeopathy, acupuncture, and lifestyle modifications.And now, it is time to find out if all these skills I have accumulated can touch the medical aliments that Nepal faces.
This venture back to Nepal is through Acupuncture Relief Project - an amazing non-profit in Nepal that utilizes acupuncture in the delivery of primary medicine in the Makwanpur District.Though I’m not an “acupuncturist” the organization hosts many medical providers of other disciplines. I’m using this experience as a stepping stone to doctoring in Humla in the future (a longterm goal that I am quickly realizing is much more difficult to achieve than I anticipated).
Yesterday, I saw an 80 year old patient whose oxygen saturation read 75. In America, anyone under 90% gets an immediate oxygen cannula in their nose. When I first encountered this woman in her village, about 2 & ½ miles away over hills and valleys, I tried checking her vitals. During that encounter, I assumed the machine was malfunctioning due to sunlight or lack of proper circulation because it was reading 67. In my Western ignorance, I assumed anyone with a 67 percent oxygen saturation would clearly be dead – as opposed to squatting on the roadside chatting with me, discussing walking miles to the clinic, and leisurely watching the rolling clouds flow over the gorgeous valley. However, on the following day, she stayed true to her promise and hiked the giant hill 2 &½ miles to our clinic seeking help with her breathing. Her blood pressure had dropped to 85/60 at this point, her biceps so tiny they barely filled the cuff. She kept repeating that she wasn’t sure about being in the clinic because she’s just going to die soon anyway. I gave her my typical response, “I understand. Maybe we can make this time easier for you.” I was able to stall her for two hours. First I gave acupuncture. Then, I put the Albuterol inhaler to her lips and pushed it twice because she didn’t have the strength to do it herself. She had walked the distance uphill to the clinic alone, like any typical badass Tamang 80 year old with advanced COPD would, of course!
I told her to get her son to push the button at home and gave instructions for using the medication, unsure if it got through to her seemingly alert oxygen-deprived brain. Finally, the healthpost staff showed up, late, and gave her an Albuterol nebulizer. Considering her state, I assumed they would keep her there while I returned to my waiting tent full of a dozen patients and relatives. An hour later, I spotted her tiny figure out of the corner of my eye, making a run for it down the lane. I had my interpreter yell out, “Hey grandma!,” before we realized that she wasn’t suddenly pausing for a breath (why would she do that?), but was standing at the edge of the road urinating straight down onto the ground, clearly wearing nothing under her long colorful patterned skirt. “Hey grandma!,” we tried again. She turned around. I couldn’t bear to force the tough old mountain lady into anything she didn’t want. “You want to go home now, don’t you?” “Yes,” she replied, perhaps with a few comments about the importance of feeding the goats or playing with her grandchildren. “Okay I understand if you have to leave now but we might have some other medicine that will help. Do you feel better now?” “Yes, much better.” “Can you please come back on Friday?,” I ask, with a sigh as I sincerely respect her patient autonomy, as this relationship was built on the trust established by chatting her up on the roadside. “Yes,” she answers, as if the uphill hike with advanced COPD and oxygen saturation at 67 is a complete walk in the park. She gives me the little sideways headshake implying Nepali agreement, and takes off at a pace that would startle any 80 year old American.
Not long ago, I watched a man carefully walk into clinic, cane in hand, right arm and leg trapped in contracture from a stroke. He sat down silently and handed me his chart. I read the words hemiplegia…. aphasia… I turned page after page as other patients filed into the clinic to sit in the open chairs, waiting for me, the “new doctor”. I sat on my seat, my mudha, and continued to stare at the stroke victim’s chart as this new world faded around me.
As a practitioner in the United States the resources to work with stroke is limited to very rare opportunities in hospitals. My experience with stroke had only been in textbooks, lectures and TCM theory. This was new.
Taking a moment to compose myself, we greeted each other in the customary way of the Nepalese: I said namaste as I pressed my palms together and assumed direct eye contact. Bimdev returned the gesture with one hand raised, his right hand betraying his illness, and muttered an unintelligible reply. I began my work, taking vitals, touching his scalp, hands, arms, and feet. Looking into his eyes, I knew I was nowhere near instilling that patient doctor trust so crucial to healing and that I needed to gain it if I were to help this man.
She sat there like a queen, or a dictator, regally poised in a red plastic chair, her gold-tasseled nose ring eclipsed by her broad nose. Faded tattoos traced the corners of her chin in the shapes of upside down “E”s — symbols she later said have no meaning. Wisps of silver hair framed her face and pulled back into a small bun, displaying the sizable golden plates gouged through the centers of her ears. Their worth could be seen in their weight — thick, circular slabs resting uncomfortably on the cleft above her earlobes, a ruby shimmering at the center. The large beaded necklace she wore weighted by a heavy studded golden cylinder indicated she was a married woman. This necklace was the cleanest thing she was wearing, the neon green beads sparkling atop her dirt-laden choli (traditional top).
As I approached her, she sat stoic, still. Her vibrantly colored clothes countered the message of her icy demeanor — I felt unsettled by this contradiction, and the air of peculiarity around her. I sat down on my mudha (a brightly colored Nepalese bamboo stool), pretending to finish my previous patient’s chart, and finally looked up. Her eyes pierced mine — strong, sharp, intimidating. She stared at me as if she was sizing me up - all 4’11” of her. For a moment I sized up myself, too. “Namaste” (hello), I said in my best Nepali accent, holding my hands up in prayer at the center of my chest. Before she responded, the interpreter looked from me to her, mimicked my greeting and said, “Lasso” (“lah-so”). To my embarrassment, and subsequent confusion, I learned that this was the proper greeting in Tamang language. My patient, like many of the patients I saw in Tistung, was a Tamang woman.
I’m totally overdressed, now sweating in my puffy jacket that only a few hours ago seemed totally adequate to stave off the morning frost. The Nepali middle hills tower and surround my small team of companions as we examine a man whom we came to see. The small, thirty to forty square foot shed made of corrugated sheet metal that is cobbled together with wire, serves as a house for him and his wife. It becomes our backdrop as we sit on a blue plastic tarp spread over the dusty, hard-packed ground. The stench of gangrene burns my nostrils and I am thankful for the thin latex barrier provided by my examination gloves as I probe the bone deep wounds on his feet. His three goats and a small mangy black and white dog look on at the strange scene with indifference.
Just an hour earlier, I was witness to one of the loneliest human beings I have ever encountered. About a two hour hilly and steep walk from our Bajrabarahi Clinic -- basically two valleys over-- lays a small settlement of about a dozen stone and mud houses. Some have traditional thatch roofs, where others have a mixture of terracotta tiles and newer corrugated metal. A small creek supplies water to a population of about fifty Tamang people. The Tamang people may have been the original inhabitant of the Kathmandu valley originating from Mongolian tribes who migrated through northern Tibet into Nepal. Today they remain a very isolated ethnic group maintaining their own language and customs, rarely intermarrying with other ethnic groups. Typically they are very superstitious with a healthy skepticism of foreigners and have a higher than average poverty and illiteracy rates-- especially in these more isolated areas.
After living in Bajrabahari at the Acupuncture Relief Project headquarters for 3-1/2 months it has become my home. As I think about my “other home” in Portland Oregon it seems like a lifetime away. I never thought I would get use to living here but now I cannot imagine anything different. Elissa, Andrew, Tsering, Bibek, Didi, Chandra, Litle Bimala, Bimala, Gunaraj, Milan, Amrita, Sushila, Sunmaya, Anupa and everyone else all have become my Nepali family. The thought of leaving them in three weeks pulls deeply at my heart. But it is not only them that I will be saying goodbye too. After seeing many of my patients 2-3 times a week for this long has created a bond that I hope to never forget.
In the beginning of my clinic camp, the patients were wary of us as "the new doctors”. However, once the patient/practitioner relationship forms, they start to tell you more and more about why they are here, that story turns into more stories of their life, A bond starts to form. Everyday in clinic I look forward to our "Namaste" exchange and to hear the continued story. My favorite days are when they tell me about their families and how many animals they have. Two of my patients have continued to ask me to visit their homes on Saturdays. This is not an easy task, as I need to find an interpreter who will take me on their day off and also one who knows where they live.
This past Saturday, Gunaraj (a senior interpreter) agreed to take me on his motorcycle and visit two of my patients that live in the same village about 15 minutes drive from the clinic. Once we arrived at the first house I was instantly reminded that I should have not had lunch before we left. Immediately my patient was handing me two full plates of food and told me to eat. One plate of Dal Baht another place of rice pudding and fried doe, both piled high. Once Gunarj and I ate, she sat down and held my hand. We talked about her family and whom she lives with: husband, son, daughter in law and two grandsons. We talked about her pain and also me leaving. She asked me twice to take her back to America with me. She said she would love to go to America and take care of me. We both laughed and smiled at each other.
The second house was up the hill from where we were. I jumped on back of the motorcycle and held on tight, as it was a bumpy and steep road. As soon as we arrived, my patient came out and said she had been watching the road all day, as she was excited for my arrival. She invited us in and told us to sit. She instantly went to her stove and started warming up friend doe patties and a potato curry. Her mother, whom she lives with joined us as well. I began eating another big plate of food plus she gave us sweet tea with milk. We talked about her home and her animals. She asked questions about my family, if I had kids and if I was married. She was disappointed on my answers but said I am still beautiful and young and have time. She explained how it use to take her two hours to walk to the clinic and now she can get there in one hour because her knee’s are less painful. She told me how sad she was for me to go and disappointed that she cannot call me because we do not speak the same language. We took pictures, held hands and talked about her garden.
Reflecting on this day, I am overwhelmed with so much Love for my patients and my experience in Nepal. These four months have forever changed my life and I hope to come back again very soon. ---Warmest Namaste, Kallie Harrison RN, LAc, McAOM
Sitting in front a window at the Roadhouse in Thamel, realizing I’ll be leaving Nepal in less than 8 hours, feel like unreal. There is a strong voice inside me saying: I don’t want to go! These two months was like a dream, the kind of dream I wish I could encounter again and again. This is a country I ended up falling in love with regardless of its poor infrastructure and poverty. Before I came, I thought it would be just like any other trip I had, only with longer time and a bunch of volunteer work. I never thought this could be a trip that changed so much of me that my life will never be the same. This is a place I call it “home”, with many faces that I’ll miss in the future. This is a place I want to be a part of, not just as a tourist.
Here a cup of tea becomes much tastier because of the companionship. The meals are yummier with the cheerful spirit that our cook Bibek put into it. The stress is none as I’m always surrounded by those beautiful souls who made every moment delightful. The time here is just a rough guideline when you have nothing to do but enjoy the conversations while bathing under the sunshine. It was a great honor to be a medical provider for the people here, knowing that some of them walked hours to the clinic for me to carry out a treatment. Those moments that I was sitting on the stairways to have my hair braided by my lovely Ambrita will never fade. Sushila’s handcrafts, Bimala’s angel-like voice are the best things in the world. Those smiles, tears and hugs from our young interpreters touched me deeply every day. They say “Don’t go. Please don’t go.” If I have the choice, I’ll say “no, I won’t go” --- Yun Xiao
It has been a month now I have been living in Bajrabarahi, Nepal and I am in a nice groove. I am consistently seeing around 15-20 patients a day in the clinic and feel slightly less panicked every time I get a new one. Practicing Chinese Medicine here is very different than practicing in Portland. I consistently see elderly patients who have never been to a hospital or seen many doctors in their whole lives. It is an awesome responsibility to have their care in my hands, and I feel the weight of it each day.
Typically, the patients will walk into my station in the clinic, hands pressed together, with their headbowed and offer a “Namaste”. This greeting is always offered with a smile, no matter how much pain they are in. Then we sit and talk for a few minutes while I get a little history of their complaint. I will ask a few questions, and then do some exams. I have learned quickly (through the tutelage of my Team Leads), that physical exams are priceless and give you the best clues into figuring out a diagnosis, and later helping each patient. A month into clinic, I am beginning to feel more confident in my exam skills. The difference of practicing in the clinic here is that we aren’t just giving acupuncture treatments to our patients, we are often making referrals and coordinating with the health post to make sure each patient gets the care they need. And that is not always acupuncture. It’s exciting to widen the scope of my practice and build new skills each day. I have learned that I love cleaning wounds! I didn’t know that about myself before, but I do! When its rainy, patients will often come in with leech bites on their feet and legs, which I get to clean. And on a rare occasion, someone will come in with a laceration on their hand from their scythes, with which they use to work. I genuinely enjoy cleaning and bandaging each one. I may have never learned this about myself had I not come to Nepal. The other practitioners have learned that I enjoy this task and will often invite me over to look at their wound care, too. Self discovery comes in all forms here in Nepal!
Here I am with one of my patients, I wont post any pictures of wounds...Don’t worry
None of this would be possible without our amazing interpreters, who are rockstars. The interpreters are between the ages of 16-22ish and local to the area. They are the reason I get to sit with my patients and connect with them in a meaningful way. That is the difference between a translator and an interpreter. Our interpreters try to convey our tone, our affect, and really bridge the gap between myself and my patients. It can be an exhausting task, and the interpreters always handle it with such grace. Especially for being so young. If we have any down time in the clinic I love to learn about their lives, their culture and if they are up for it, give them a treatment.
I want to share a few photos a couple of my favorite patients. I love them all, but a few really stand out. Below is Abhi, who is two years old and was brought in by his mother. On our initial exam, he wouldn’t make eye contact with me or respond to me. As our treatments continued, I learned that he loved to have his belly needled and tickled. To see this kiddo smile and laugh while getting acupuncture was amazing!
Next is Samita, she is 30 years old and living with Rhuemathoid Arthritis. We have been working hard at keeping her pain down and keeping her joints as healthy and possible. She is very shy and very kind. After a month of working together three times a week, she is beginning to open up to me. Now her face lights up when she sees me and if I’m lucky, she will bring her 5 month old baby boy and let me hold him while she retains the needles.
Though the work can be heart wrenching at times, and exhausting at others, I find that I am happier and feel more restored than I think I ever have. When I am not in the clinic, I read books and rest, eat delicious Nepali food and share stories with my fellow team. We all laugh a lot, share, and support one another which is so wonderful. We all bond over our morning cup of coffee and what goodies we can find at the market. I am so grateful to get to be here in this beautiful valley, treating patients in such a supportive environment. --- Melissa Laws
As an American Acupuncture volunteer for Acupuncture Relief Project (ARP) in Nepal, I stepped into an eastern culture that is a distant shadow of my own, regarding the traditional farming lifestyles amongst a rich, agricultural setting.Our group of 3 American and 1 Australian Acupuncture volunteers inhabited a farming village named Bajra Barahi, during March and April 2018. An authentic way to experience Nepal is by walking through the farming villages and fields, as agriculture is one of the largest contributions to this country’s economy.ARP is in the middle hills region or Pahad, mainly populated in river and stream bottoms that are good for agriculture.This region is the best place to experience village life, as it is the most traditional.
The agricultural landscapes of Nepal are lush and breathtaking, especially in the spring and summer when crops are flourishing.All year round the farmers are rotating seasonal crops, such as, potatoes, cauliflower, wheat, mustard, rice, cabbage and chile.It is mostly terraced along mountainsides, making use of all space from this rugged terrain.Imagine amongst this idyllic setting, being back in time 100 years ago in traditional farmlands: there are no tractors, noMonsanto, no combines, no corporate farming, no John Deere.Just the land, the people, goats, water buffalo and simple farming tools:hoes, scythes, plows, sickles, etc.Welcome to Nepal.One of the trademarks of rural Nepal is the Doko, a carrying basket made from durable bamboo, hand-woven in a v-shape, allowing the average person to carry 20-50 kg on their back.It has shoulder straps and head straps called namlothat take part of the load off the shoulders.Dokos are used to carry grains, goods, vegetables, compost, etc.It is common to see men, women and children carrying doko’s on their back with the namlo straps on heads and shoulders, throughout the villages and fields in rural Nepal.
Now envision, a 73-year old woman with flip-flops, carrying 30 kg of potatoes in a doko on her back, climbing up steep terraces on rocks and dirt, or imagine a 60-year old man barefoot in the dirt, alone, hoeing a turf of land that is a part of a whole mountainside of terraced crops. When you spend time here, this western anomaly becomes a stereotypical reality in rural Nepal.Arriving in March during the planting season for potatoes and cauliflower, I witnessed many elderly women, looking to be in their 70’s, carrying dokos stuffed with compost taller than their own height, walking up and down steep hills. In awe, I even saw an elderlywomen walking with a Doko on her back full of BRICKS!(I have the photo to prove it!) In Nepal, everyone does the farming: elders, men, women and children. What I learned from my elder patients is that many of the young people have moved into Kathmandu to work, leaving the farming labor for their parents and grandparents, who do not know any differently than to keep farming. It came to my attention that more women than men work in the fields, because men leave the area (sometimes to foreign lands) to work for higher wages, leaving the women at home to manage the housework and farming.
Their trodden paths are just as remarkable as the loads they carry.I took many walks and even got lost at times, going up, down and around steep passages, wandering through narrow terraced edges, upon stone paths and bridges and irrigation walls through the labyrinthine, lush fields. Our first week, another ARP volunteer, Alisha, and I got lost in the fields and were trying to navigate ourselves through the obstacle course.It was a big enough challenge to keep from spraining an ankle, as we tramped through mud, rocks, trees and branches that we grabbed for support. We neither one knew Nepali language, meeting farmers along the way.They seemed amused, greeting us, “Namaste”, then using gestures and pointing for advice on directions with a mischievous grin.Another day, we explored the fields with a Hindu temple in the valley, surrounded by mountainsides of cauliflower and potato crops. The Hindu music blasted loudly from the temple throughout the terraced fields, providing an amphitheater to amplify this vibrant music for the workers to hear.It was a fun, upbeat walk with everyone being energized mutually by the same music.
It was very helpful for me to immerse myself in the community and surrounding terraced farmlands with walks to meet the people and see how hard they work:this way I could relate and understand better my patients and their orthopedic issues. It’s obvious why so many of them have back and knee problems, sprained ankles and falls.One of my female patients amusingly told me how she recently fell:while walking with her doko full of goat feces (compost), she toppled over face down.She still managed to walk a couple miles into town for her acupuncture treatments, and of course, she is still working.This I heard many times from my patients, that they continue to work, even with pain and injuries because they say no one else can do it.With the trend for the young people moving to the city or foreign countries, this generation may be some of the last to uphold this farming and cultural tradition
During my walks, I usually would cross paths with my patients working in the fields.One of my favorite patients, I would frequently see walking her water buffalos to graze.Sometimes, the buffalos were on narrow passages blocking my path, and she would graciously guide them off the trail so I could pass.She was always glad to see me and brought me ground apples and spinach to the clinic.One time I met one of my male patients hoeing in the field with 2 women, alongside another man plowing the old-fashioned way: guiding cows to pull the plow through the fertile dirt. They all were smiling and genuinely seemed happy to be working together, cultivating their precious land.While walking in the fields, patients invited me in for dinner a couple times, but I graciously declined as it was necessary for me to get back to the ARP site before dark. Almost every walkabout, someone would ask in English, Where you from?I would say America and that I worked at local Acupuncture Clinic.I always received a welcoming, positive response about working in their community clinic, realizing the strong local support and appreciation for the ARP Clinic in Bajra Barahi.
I soon realized that foreigners have aPied Piper Effecton the Nepali children and stray dogswhen walking about the fields and villages.Every walk I picked up either children or dogs to follow me and join me on my walkabouts. It is a wonder that I did not bring home one of these darling Nepali kids or puppies. The children would usually gather and giggle, shouting, “Namaste, where you going?”I discovered that most Nepalese people love having their photos taken, including the children.Often, I would linger with the children, attempting to communicate through the language barriers and take photos.If all we experienced were giggles, “Namaste” and a photo, that was enough for my heart to sing.These children are different from ones in western cultures, because they are not coddled and overprotected.I refer to them endearingly as “wild childs.”Their clothing almost always never matches and they’re usually sporting dirt, a snotty nose or wild hair. Once, I even saw a toddler playing with a sickle.Can you imagine any of this in the suburbs of the U.S.?These kids are tough and crying doesn’t get them anywhere.Often, the mother will carry the baby on her back while working in the fields.One time I found a silent little girl about 3 years old, alone, in the cauliflower field.She just curiously stared at me, while I attempted to evoke a response with ‘Namaste’.Moments later, I saw this 3-year old walking down the path, nonchalantly, leading her mother past 2 water buffaloes, just a hairbreadth away.I timidly followed her, thinking, if this child can walk next to these beasts, so can I.
In rural Nepal, there are a lot of stray dogs that are territorial and can behave more violently then the domesticated ones in western cultures.One time as I was walking the road out of town, a couple dogs approached me growling.It was scary enough for me to turn around and walk the other way.I noticed another golden, short-haired dog silently begin to follow me.At first, I was a bit scared, but began to realize his kind intentions.I started to feel like this dog was looking after me to keep me safe. (No, I did not have food in my pack.) He closely followed me for over an hour, down into the valley and even sat with me on a hilltop for some silent, contemplation.Then, he followed me all the way back to my door at the ARP site.I call this dog “Yoda” because he is wise; and in my photo, his ears are flattened on his sides like Yoda.Ironically, I had taken this photo a week before he followed me, while he sat on the edge of a steep bank overlooking the beautiful, lush valley with a large, delicious bone all to himself.I noticed right away this dog’s sweet energy and took his photo.Little did I know, Yoda would soon be my guardian angel during a walkabout.
My walks through the fields and villages in the Makawanpur district of Nepal became ritual journeys during my time living there. The harmony of the lush landscapes and vibrant culture,alongwith the Nepali people’s rooted connection to nature, created special memories for me that will liveon in my heart forever.I reflect back on the lifestyles and culture of Nepalese, “subsistence farmers”; and how in the west, these people would be considered impoverished and underprivileged.Hmmm, maybe the world has got it all backwards?These people live amongst cohesive communities and families (with minimal crime or divorces), panoramic views, clean air with deep connection to land and their food source, eating simple diets of rice, vegetables, chicken or buffalo meat and tea.Yes, they work hard, but they also have no need for the gym.How many people in the western cultures in their 60’s or 70’s can even walk up a very steep hill, let alone with a doko full of potatoes on their back? Who really is impoverished here?However, the one thing these people do lack is proper healthcare, and I am so grateful to have been a part of the solution through ARP to fill this void for these amazing people and culture.Namaste Nepal, I love you and promise to return! ---Trudy Wendelin
I’ve been moving around for awhile, but for most of my life I lived in one place. There is much to be said about having roots and feeling at home. Nonetheless when you change places it gets easier and easier to feel at home.
So for two months Bajrabarahi was home. It may sound odd, but perhaps it was easy for me to feel at home there because it reminded me so much of my old home. Walking through the hills around Bajrabarahi was a constant déjà vu.
In many ways Bajrabarahi was like my old home. Where I lived in the Apennine mountains in Central Italy, the houses are made of stone. Since the area is subject to earthquakes, the houses are often cracked, often abandoned. A wood stove and a fire cooks the food and keeps you warm. Water comes from the spring.
Just one generation before my time, the hills were terraced and ploughed by oxen, wheat was threshed the way rice is threshed in Bajra. Life is hard. The farmers say: “la terra è bassa!” The ground is low! You have to bend down to do whatever needs to be done.
If anything creates roots it is working the land. The land is measured in palm widths, my uncle would say. When you’ve been out there with the hoe, you know where it’s softer, where it’s deeper, where there are more stones. Working the land with your hands in the earth is, I believe, our greatest connection to the grand flow of humanity. It connects us to all our ancestors, from our mothers thousands of years ago collecting and sowing wild seeds to every farmer all over this earth who sows, harvests and feeds the world.
I’m relieved not to be a farmer any more. I don’t have to run down and milk the cow, split and stack wood. It’s not just all the hard work - I don’t have to worry when it will stop raining so I can plant the fields, or worry that the weather will change before I can harvest my crops. But there is nothing like that connection to the soil, to a place.
I have so much respect for the farmers in Bajrabarahi because not only do they work hard, they work beautifully. They arrange the cut stalks of rice and corn with attention and care. They plant hedges along the sides of the terraces, flowers in their gardens. Each terraced field with perfect rows demonstrates that these are people who do all their hard work with dignity and love.
Attention to the noble work of farming is important to us as acupuncturists and East Asian medicine practitioners. The roots of our medicine come from an agricultural society and much of the theory of East Asian medicine is not complicated or philosophical, it is simply farmer’s logic. For example, water puts out a fire, fire melts the metal to make an ax to cut wood, plant the same crop too long in the same field and the earth is exhausted, the earth is piled up or dug to make canals to control the water.
When you dig a ditch for water you know you’ll have to keep it cleared of debris for the water to flow smoothly. Our needles or hands are the shovels and hoes that clear the channels so everything can flow and pain can be relieved.
Attention to the weather, to wind, damp, heat, and cold are just as important to us as they are to a farmer. We must be watchful for changes and act with good timing.
It is both respectable and useful to be a good farmer or a good doctor. The farmers of Bajrabarahi make good patients, their sense of humor (or their shyness) and their dignity accompany their sore knees and backs. With them I’ve reflected on how the course of your life can change in a moment with an accident, a fever, or a stroke. I’ve been amazed at their resilience and determination in dealing with their maladies and hardships.
My patients were always pleased to know that I once had a cow and grew channa and dhal! I never worked as hard as they do, but I’m glad my life experience has given me an inkling of what their lives are like. --- Lynn Minervini
Patients come on a first come, first served basis, often arriving a little before 6am, slipping their appointment cards under a designated stone on the reception window sill. Many will have taken several hours to get to the clinic then may have to wait for some time to be seen, but time has a different value here and we get few complaints.
This different concept of time can manifest in many ways. A patient will often postpone their follow up appointments in order to celebrate a new moon or a festival. Between all the different ethnic groups that make up Nepal, there are more holidays celebrated here than there are days of the year, but neither intolerable pain nor life-threatening conditions are allowed to interfere with these occasions, or the intense periods of preparation and ritual often involved.
When I started fundraising for this volunteer trip, many friends asked me why I chose to come to Nepal with ARP, and my simple response was, “to step out of my comfort zone.” I have very limited international travel experience, and I knew that providing healthcare in a developing country for an extended period of time would challenge me on various levels, providing me with an opportunity for both personal and professional growth.
Fast-forward to my 8-hour layover in Istanbul, Turkey, en route to Nepal. As I roamed the airport, I realized that several conversations were happening around me in languages unfamiliar to my English-speaking tongue, and I suddenly felt a loss of connection within an airport full of people. My ears searched for words of my native language amongst the crowds of people in transit and waiting, but to no avail. Finally, after some time, I heard English words spoken from the mouth of someone sitting at a table adjacent to mine, and I initiated a conversation with the man who spoke those words that were familiar to me. Only a few hours had passed since I stepped off the plane, but I was already longing to connect with someone amongst the crowd of foreign travelers.
In the foothills of the Himalayas, Bhajra Barahi is made up of steep hills, the slopes of which have been terraced for farming. These plots of rice, cauliflower, mustard, squash, corn and radish cascade down toward the deep valleys with houses dotted all along the way. The main Bazaar of town has a busy road with busses and trucks rumbling through, but within a short distance the roads stops. Many homes and communities and their surrounding farmlands are accessible only by foot. Narrow foot-paths or rock walk-ways traverse through the forest and fields between the terraces. These paths are frequented by women carrying huge baskets resting on their backs and strapped over their foreheads that are full of vegetables, grass for animal feed, or wood from the forest that they will use for cooking fires.
When we open the clinic doors at 8:30, there are usually already a handful of patients waiting outside in the crisp morning air. Patients arrive throughout the day. There are no fixed appointment times. Locals are encouraged to come in the afternoon so that patients who have to travel further can come in the morning and have time to get home before dark. If its busy, they may wait up to a few hours. The Nepali interpreters call out the names of patients and show them in. You never know what story or problem is going to present itself that day. At this point in the camp, the majority of patients are returning and on a treatment plan, but new patients filter in each day. The following is just a brief peek of the people I have the pleasure of treating on any given day.
The day started like most days, a brisk late-autumn morning with a light frost on the ground and clear blue skies. A breakfast of churra (beaten dried rice), chickpeas and a boiled egg. Together the team is talking over a patient case regarding an eighty year old woman that we had visited the day before. She lives in a remote village within our catchment area and we heard from her brother (one of our patients) that she is blind and is having breathing difficulties. Collectively we agreed that we should have a look at her, so we dispatched one of our volunteer practitioners and an interpreter on a motorbike. They returned after several hours to report just how remote her house actually was and that she was in poor condition with weakening vital signs. Today we decide that we should dispatch an ambulance out to her and see if we can get her to a regional hospital. This is where the day started to go sideways.
Today's topic: Death! (the author does not pick blog topics; the blog topics choose him)
I began thinking about this after hearing that one of our ARP staff members, Tsering, had to step in to help a family who didn't know about Sherpa (an ethnic group here in Nepal) burial rights, help bury their father who had passed recently.The deceased was somewhat estranged from his family and living in Kathmandu, and when he passed, his daughters were at a loss at what to do for a proper burial.Luckily, Tsering and his wife were around and able to help the family, in the middle of the night, with proper burial rights.
The morning sunlight, through a gap in my curtain reaches onto my bed and teases my skin. I look outside the window to see beautiful blue sky above our mountain protected valley. Since last time, there is more yellow in the fields and the mustard flowers are coming into season. I am glad we are back in Bajarabarahi. The noisy bikes, trucks and polluted air of Kathmandu is left behind.
I hear a rooster crow in the distance. If you are quiet, you can also hear a buffalo – somewhere - munching his grass.
Fun fact, my body is 85% digestive tract with the rest being sensory and motor structures that assist me in attaining more food. My genetics are closely related to a fluke.
I love food. From fancy, high class meals (when they can be afforded/somebody else is paying), to simple home food, to in moments of weakness, blue box macaroni & cheese and/or packaged instant ramen. When traveling I have a deep respect for the food because I find that local food is the quickest way to get to know a culture. With globalization, and the increase of foreign travel, restaurants can always be found that have western food to appeal to picky foreigners or foreigners who are craving food from home. Initially, I try to soak up at much of the local cuisine as I can in a new place.
If you are an acupuncturist, herbalist, chiropractor, massage therapist, naturopath or other natural-health practitioner, Acupuncture Relief Project needs your help. We have two volunteer programs designed to provide opportunities to serve at our treatment facilities in Nepal.
Three months of lecture, review and physical practice and my three young students are looking at me with the blank stares of incomprehension. I’m temporarily at a loss for words. What went wrong?
As part of our long term goals in Nepal, it is our aspiration to train several Nepali born practitioners to serve in our clinics. We have partnered with a small school in Kathmandu, Rural Health Education and Service Center (RHESC) which has similar goals. This Japanese sponsored project began in the early 1980’s as a rural hospital but now finds that their facilities are landlocked within the crowded sprawl of the Kathmandu Valley. RHESC has been using acupuncture in conjunction with their rural hospital for over 30 years and now as part of their sustainability efforts, they have opened a small school. Their program has been accredited by the Council for Technical Education and Vocational Training (CTEVT) but they are hoping to expand to a full baccalaureate degree in the future. As an advisor to their Board of Directors, I have been been assisting with the development of RHESC’s curriculum, serving as a guest instructor, and we host many of their students at our clinics. This partnership with RHESC is a key that we have been looking for since we began in 2008… a pathway to legitimate licensure for our trainees.
After clinic one day I had the opportunity to experience a wonderful delve into the down country culture of the local folks I've befriended over the last couple weeks. Gunaraj, one of our interpreters, invited me to his house in the village just north of town, and so I joined him on his walk home, along with his cousin Sita who is also our receptionist, and our clinic manager Ritesh.
Today I fitted my elderly patient with her (hopefully) semi-permanent shoulder cast. This woman came into the clinic a few weeks ago. I remember treating her knee pain and when the visit was finished, she said, “What about my bone problem?” and pointed at her shoulder.
This is a classic pattern at our clinic. Right as patients are leaving, they add on a few extra problems and ask for medicine for it. I have to tell them to talk to me about it next time they come in. So, I told this patient to bring her x-rays and we would treat it next time. I assumed it was just arthritis in the shoulder. WRONG.
Having lived my whole life in a developed country, with most of my needs magically looked after for me, it was a cultural shock to see the many inadequacies the Nepalese people experience. From the pollution in the air to the chaotic traffic conditions everywhere; from toddlers roaming the roads unsupervised to stray dogs scouring the streets searching for food; it seems there is little regulation among the people yet somehow, they find a way.
In Bimphedi, a small remote village in the hills south of Katmandu where the Acupuncture Relief Project has a clinic. There is also an orphanage. The children that are there are coming from the streets in Nepal, from broken families, from families where the parents died, from village around the country that get sent to Katmandu to get allotted around the country to different orphanages.
It is a small community of children from the ages of 8-18, where they sleep in bunk rooms together, they eat together, they play together, they working the garden planting their vegetables and there is small school inside.
It’s been one week in Nepal and 3 days of clinic in Bajra Baraji. I’ve gone through so many emotions and learned so much about practicing primary care in a rural area. It’s been amazing but I have to admit that the first day of clinic was tough. That little voice in my head started saying stuff like, “You’re not a good enough practitioner, you don’t know enough, you can’t help anyone!” It’s hard enough to not let that voice rule over my thoughts in the best of times, let alone completely out of my element in a new country. I felt in over my head, seeing things like ear infections, gnarly wounds, ulcers and so many things I would refer out to a medical doctor back home. I was told the first week was going to be the hardest but I didn’t think that first day would end in tears. I barely made it to my room to wrap myself up in my zero degree bag to take some time to write in my journal.
At the beginning of my service with Camp B at Bajra Bahari, my first patient is a 70 year old male with right-side hemiplegia resulting from a stroke. I look at his chart and note he started daily acupuncture treatments two months earlier. I ask him what are his goals for treatment and he states "I want to use right hand to eat (Nepalis use their right hand to gather and mix and bring to their mouth dal bhaat - the mainstay of the Nepali diet) and to shave himself. I test his grip strength, simply asking to grab my two fingers and squeeze, comparing his right and left hand strength. His right grip is comparable to his left hand, however, when I test his dexterity, he is unable to pick up a pen with his right hand as his attempts result in his repeatedly dropping the pen.
I meet Buddhi for the first time at the end of the second last week of the camp. He had a stroke 5 years ago which affected the mobility of his left arm and hand. Although he can walk quite normally without limping, the stroke left constant burning sensation in his left hip and leg.
I think to myself, "OMG, I only have 6 days left in camp. What can I do for this man?"
Buddhi has almost no strength in his left arm, and poor grip in his hand. I ask him to hold a stone the size of his palm. He gingerly wraps his fingers around it, lifts up a few millimetres, then drops it.
I ask Buddhi what he expects me to do for him. He wants just for his hip pain to go away. He believes there isn't much hope for his hand to recover.
"OK, " I said. "We will concentrate on treating your hip but I still want you to work this hand." I make him come for treatment everyday even though he travels a few hours to get to the clinic. I also gave him homework to practice holding the "magic stone" for one hour at home.
Nepal for me was a practice in being comfortable with the feeling of groundlessness.
Have you ever been on a suspension bridge?
Nepal, I came to learn, is full of suspension bridges. My experience as a volunteer acupuncture physician was analogous to crossing a suspension bridge. After our first week arriving at camp we had our first Saturday off. It was decided that we would take hike into the local mountains to visit a village. The day was perfect, the sky clear and we were all excited to venture out and explore. We visited the villagers high in the mountains of Suping overlooking Bhimphedi. Our trusted guide Tsering informed us we would be crossing a suspension bridge on our decent back down. I immediately began to have anxiety as I have a fear of suspension bridges. That feeling of groundlessness gave me a pit in my stomach and sweaty palms as we started our decent and got nearer to the bridge.
There was definitely a special something in the air that Saturday night. We had just had a fantastic day off from clinic visiting the home of one of our rock star interpreters. As we wove through farm fields and villages, the other practitioners and I fell in and out of many conversations about what we have been observing of rural life in Nepal. Bottom line: It is hard work. We were constantly trying to figure out what kind of recommendations would be useful and realistic for these folks who farm the land of the Himalayan foothills. So much of what we see in clinic is basic wear and tear from years of walking these hills with heavy loads and the back breaking labor it is to subsistence farm without the mechanization we are used to in the west. We also see lots of COPD from cooking over open fires in the home with no chimney to ventilate, eyes becoming scarred and irritated from so much dust and sun exposure, and trickier issues of lots of GERD from an irregular eating regimen, unmanaged diabetes and hypertension all probably due to modernizing processed diet over the past few decades.
Has anyone ever seen the movie, or read the book The Hunger Games? I know it is a teen drama but I am not sorry to say I have done both, and rather liked them. The story of the Hunger Games itself is definitely fantasy, but one scene does tend to pop into my head from time to time while I am here in Nepal. The scene when the two poor kids from district 12, get taken to the capitol to have a feast. The kids are in awe that people have so much money, and spend their money on things like fashion, waxing, elaborate and ornate everything. While they are at the feast there is more food than they could possibly imagine, never before have they seen so much food, and people who can eat so much. Then a small vial of liquid comes around, and a citizen of the capital tells them that this liquid is to make them throw up, so that they can continue to eat more. That scene is basically the epitome of indulgence. The reason this scene tends to come to mind while I am in Nepal, is not because that movie poses any semblance of reality at all, but it serves as a stark juxtaposition of extreme poverty, and extreme overindulgence.
I come from a large Russian Orthodox family and an even larger community. I spent my childhood wondering what any limits might be. What would that look like, where would the red tape might be, and how I was to grow within them? But I knew from a very early age (8 to be exact), that I wanted to help others. It led me down the road to becoming an Acupuncturist and volunteering with the Acupuncture Relief Project.
Nepal and people who live in this country, the Nepalese; where do I begin? It was sensory overload the moment our flight landed in Kathmandu, the capital city of Nepal. The first thing that hit me was the humidity and not being able to read any of the signs nor comprehend what people were saying. At that moment, it finally kicked in that I was totally at a foreign country, far away from home. To a foreigner like myself, things seem chaotic. There are no traffic lights for vehicles, motorcycles, or pedestrians while everyone travels in all directions; however, to my amazement everyone is in harmony. There is order in a seemingly ocean of chaos.
Upon arrival to the ARP Clinic in Bajra Barahi, nestled amongst the peaceful tree covered hills in the countryside of Nepal, I sensed a note of an “uh-oh, what have I gotten myself into” sort of uncertainty. A freshly graduated, under-traveled, self-critical practitioner standing before the very place I would watch myself struggle and fall apart for the next six weeks. I’m supposed to say that I know what I’m doing and I can handle this, but let's not kid ourselves- I knew I was in for a wild ride.
It has been a pleasure to spend two months as part of the project living and working with the people of Sipadol and Bhaktapur.
In retrospect my role as a healthcare practitioner here has often been more one of a sports therapist and a personal trainer than I had envisaged. What constitutes the daily grind over here would be seen more as an athletic pursuit in the UK. All through the day you see the village women in their colourful saris and flimsy flip flops bobbing up and down along the near vertical paths through the valley with a giant pile of logs in a basket hanging from their heads.
In 2015, the Acupuncture Relief Project continued clinical projects in Bhimphedi and constructed an new clinic in the municipality of Bajra Barahi, Makawanpur. Operating in Bajra Barahi for the first time we provided over 12,000 visits to over 5,000 new patients from September 6th, 2015 to March 1st, 2016. This initial clinic camp helped us forge new relationships with the regional government and local healthcare establishment. We now have our much needed training and clinical platform that we have been working towards of many years.
Documentary filmmaker Tristan Stoch returns to Nepal in 2015 to follow up on his 2012 work Compassion Connects. This new series of seven short films focus on Acupuncture Relief Project’s current work in rural Makawanpur Nepal.
During our premiere screening in Portland Oregon, several guest speakers shared personal stories about their experience in Nepal. Some of these stories have been shared here. Please Enjoy.
Episode 1: Rural Primary Care
In the aftermath of the 2015 Gorkha Earthquake, Andrew Schlabach, Director of the Acupuncture Relief Project and Tsering Sherpa, Director of Good Health Nepal begin a new primary care clinic in the rural district of Makawanpur. This episode explores the challenges of providing basic medical access for people living in rural areas.
Sheri Barrows: Why Acupuncture?
Board of Directors, Secretary/Treasurer, Acupuncture Relief Project Participating on the Board of Directors since ARP's inception, Sheri was able to spend the 2015/16 season in Nepal with the clinic teams. Seeing first hand the complexity of practicing medicine in rural villages she came home with a better understanding of the challenges in accomplishing our mission.
This last year I was extremely fortunate to have taken a long hiatus from my paying work so that I could be in Nepal to help get the new clinic set up and to witness first hand how things were going in both Bajrabarahi and Bhimphedi. I had a hard time deciding what I was going to talk about tonight because there were so many stories to choose from but I kept coming back to one story that really moved me.
I was in the Bhimphedi clinic, standing near the door and I looked outside and watched a man being helped through the gate by about 4 people. He needed the support of all of them because he had had a stroke and the left side of his body was severely paralyzed. When it was his turn, he was brought into the clinic and Rachel Hemblade from the UK became his doctor. We learned through his wife that his name was Jagat and the stroked had happened about a year before. He was completely unable to speak and vocal testing showed that he could only achieve a barely audible sound for one vowel.
The thing that broke my heart with Jagat was how completely and utterly dejected he was. He had gone from being a 35 year old husband and father of three kids and a valuable community member to being totally dependent on others.
I have never in my life met someone as completely hopeless as Jagat was on that first visit.
Rachel told Jagat’s wife that for the best results he should come to the clinic every day for at least a few weeks and she asked if that would be possible. They live up in Bhimphedi 3, which is about a 4 hour walk from the clinic, but they were able to make arrangements to stay with family that lived just down the road. Rachel then enlisted the help of all of the family members that were at the clinic with him that day, including one of his young sons. She showed them some physical therapy exercises and she showed them how to help him form the sounds of the English vowels and told them they should practice all of it twice a day. When Jagat came to the clinic the next day I greeted him near the gate and though he wasn’t able to show hardly any facial expression I saw a faint sparkle in his eyes that hadn’t been there the previous day. By the end of that second treatment Jagat was able to make the sounds of all the vowels and he had regained a slight amount of movement in his left foot and hand so that when he left the clinic he was able to use a cane in his right hand and just one person supporting him on the left. As he passed me going toward the door I was so thrilled by his improvement that I gave him a little cheer and this time when he looked me in the eye there was a strong sparkle and a slight twitch at the corner of his mouth as he tried to smile.
Between the Acupuncture, Massage from Sarah and the homework he so diligently did, Jagat improved very quickly and by the end of the first week he no longer needed his wife to speak for him and was able to answer all of Rachel’s question himself, albeit slowly, and the muscles in his face were able to form a smile that lit up the clinic. Also by the end of that first week he was walking to the clinic by himself with just the aide of his cane and by the end of the third week he was able to stop using the cane all together.
After a month or so Jagat went back home to Bhimphedi 3 and would make the 4 hour walk to the clinic a few times a week for treatment. His doctor during Camp B told me that by the time she left in December, he had recovered about 70-80% of the abilities he lost to the stroke.
This story of Jagat is just one of so many examples of how the clinics make a difference and change peoples lives and I cannot begin to tell you how meaningful it has been for me to have been there and experience it for myself.
Episode 2: Integrated Medicine
Tackling complicated medical cases through accurate assessment and the cooperation of both governmental and non-governmental agencies, Acupuncture Relief Project extends the reach and effectiveness of it's medical model. This episode follows the stories of two patients who's care required a coordinated effort.
Sarah Richards: Heart
Acupuncture Relief Project Volunteer 2012, Team Leader 2015 Sarah has been a body worker since 2000 and has been to Nepal twice with ARP. She has recently stepped into the role of Volunteer Coordinator as a way to continue service to the project and to help support practitioners endeavoring to bring their healing arts to the people of Nepal.
I'd like you to bring your memory to the beginning of this last segment, To the story of the woman Hira Maya who had a life saving diagnosis that led her to heart surgery one year before this interview took place.
I had the honor and the extreme privilege to be there last year and treat her. I already knew of her interesting case based on the blog written about her the prior year and was eager to see her and hear how she was doing.
When she first came in, this is what I observed:
small, slight, tiny and yet heavy and weighted pale quiet withdrawn shy, timid under-nourished very shallow and labored breath hesitant
I say hesitant because she was not sure she wanted to receive any Tx, she thought we just wanted to do the interview and so she wasn't expecting, or maybe even wanting Tx. But with a little coaxing she agreed to let us take vitals and to get on the Tx table for a little body work.
I don't have enough time to go over all the details, but after 3-4 short Txs to address the major rib cage trauma and scar tissue from having heart surgery a third world country, here is what I observed:
bright talkative colorful smiling making eye contact willing and eager to receive treatment
and most importantly to me, she was breathing deeply and with ease
I know this change sounds dramatic, but it truly was....and it left a searing impression on me. Very little Tx resulted in dramatic change. Her presence, her essence was palpable from across the room, where before it was diminished.
Now, it is my belief, based on my experiences in Nepal, that it was not only the Tx but also the nature of the clinic itself that created this change in HM. The fact the Hira Maya had a place to go where health care workers were deeply concerned with her well being lifted a heavy weight off her chest.
The ARP clinics are a gathering place for community, a hive where healers and patients come together with curiosity and compassion, where deep listening occurs, where gentle touch is applied and where cultures collide to create a vortex of possibility.
My favorite part about the ARP experience is that the clinics in Nepal provide a testing ground for practitioners to to see what really matters in medicine. It affords a concentrated experience where your skills get stripped down and your fears highlighted to illuminate your greatest strengths and also your weaknesses. Maybe it's needles, herbs, touch, attitude, stamina, technical knowledge, intuition, presence, empathy or compassion, it all gets tested.
This sort of experience paves the way to build the foundation of understanding who we are as healers. Or like the phoenix, in some cases the experience burns and destroys only to then re-birth and re-build, this is where authentic healing and wisdom unfolds, for patients and practitioners alike.
Hira Maya gave a me a precious gift, thru her trust in me, she illustrated in a very vibrant way that when a clients case seems extreme, that when I'm not sure I have the skills to ease their suffering, when I ask myself how can a simple massage soothe something so complicated,
here comes the gift.....
presence, willingness, deeply listening and taking action from the heart, and rooted in compassionate loving kindness IS enough! I AM enough!
And it is with the strength of this knowledge I honor Hira Maya and bow to her in deep gratitude for this teaching and healing!
There is more to this story, yet my time with you is short, keep an eye on the ARP blog for updates and more stories like this.
Because I have valued my experience greatly with ARP I am developing the role of Volunteer Coordinator as way to continue my service to the project and support practitioners on their journey of growth, if you find yourself inspired by this event tonight, please reach out, volunteering is the biggest donation that we can receive!
Episode 3: Working with the Government
Cooperation with the local government yields unique opportunities to serve the rural population. Acupuncture Relief Project is invited to help establish a new integrated medicine outpost in Bajra Barahi, Makawanpur, Nepal. This exciting prospect enables ARP to forge a new clinic model applicable throughout Nepal.
Diane Wintzer: Primary Care
Project Coordinator, Acupuncture Relief Project Volunteer 2008, Team Leader 2010, 2012 A graduate of Oregon College of Oriental Medicine, Diane runs a very busy practice in Camas, Washington. Drawing upon her experience with Outward Bound she has helped Acupuncture Relief Project develop their training and mentorship programs.
About 9 months ago, I received a call from a senior patient whom I usually treat twice a month. She had a special request that day. She was wondering If I could rub some good smelling oils on her that would help her breath easier. According to my patient, her primary care doctor had just diagnosed her with bronchitis for the 3rd time this summer, and she was really having a hard time breathing. She was very difficult to hear over the phone, and I weighed out my desire to see what was going on against how much energy it would take her to get to the office. I knew it was a hot day, it was a 30 minute drive for her, and the passenger seat in her car didn’t recline which was hard on her back. I told her I’d like to see her, and that I had some things we could do to see if it would improve her breathing.
A few hours later my patient arrived. I noticed her ashen skin tone, her weakened voice, and her off-balance shuffle as we walked to the treatment room. But the check in was business as usual. I asked questions about her most recent visits to her PCP, her blood sugar numbers, and what she was getting done around the house. She reported a recent fall that left some bruising on her legs, but could not really say why it happened - she didn’t trip - she just sort of tumbled. She had been to a “fill-in” PCP (not her usually doctor) 2 days prior for her coughing and breathing difficulty, and after some assessment, he prescribed cough syrup with codeine and told her to get some better rest, and he provided antibiotics. In truth, my patient wasn’t sure if the doctor told her she had bronchitis or pneumonia.
She continued to share. She’d been sleeping in the recliner for a few nights because it made her feel better. She hadn't felt much like eating or getting outside. I noticed my patients short sentences, the time it took her to share, again the quiet voice, and her lack of clarity around things. She got onto the treatment table, and as I examined her bruising, I noted that it did not match up to the story all that well. She had fallen hard, and due to blood thinners, she was severely bruised from her ribs to her knees. I noticed my patient minimizing her injuries. I noticed her anxiety increasing rapidly while laying back on two pillows. I switched gears, sat her up in a chair, put some ear needles in to calm the anxiety, and began to compile the list of symptoms: Extreme shortness of breath; Leaning forward to naturally make breathing easier: Elevating her shoulders to use accessory muscles for breathing; Severe pitting edema in the lower legs that was not normal for her; The gray color to the skin; The confusion around details when she is usually sharp as a tack and full of story. I tried to take a blood pressure reading… it was barely readable.
I looked at my patient and without wanting to freak her out, simply stated that it was time to call an ambulance and go to the hospital because she was in cardiac distress. She had enough in her to argue me just a bit, just enough spirit to reach for the bronchitis diagnosis and being run down, just enough to tell me of the retirement party she was going to after this appointment of an old co-worker, and that the ambulance was too much money. I wrote out the base line symptoms quickly on paper and slid them in front of her so she could see them, and reminded her she was not going to be able to compensate for very long.
To make a long story short, my patient ended up with a diagnosis of acute Congestive Heart Failure, and had a week long stay in the hospital. A few weeks later the doctors managed a heart surgery where they repaired some failing valves. Just last week, after 9 months, she felt strong enough to come back in for acupuncture treatment. Recovery was hard as she, in the end, realized that she had been declining for a while, and just missed it. Today though, she was sharp as a tack, full of stories, and back to her household projects. And of course, she wanted some good smelling oils rubbed on her back.
Most days, this is not the case. Emergencies do not walk in the door frequently. People come in with sore backs, sore knees, insomnia, stress, digestive distress, fertility help, constipation… you name it, but some days the story someone tells has some anomaly in it, some aberration that stands out, or I just get some intuitive hit that something is not lining up. The more stories, the more patient touches, the more willingness to engage my patients, the more I find my idea of medicine being stretched. I am grateful to ARP for nurturing my ambitious heart and curious mind and expanding my ideas of what it means to be practicing acupuncture. I had no idea that being the best acupuncturist I knew how to be, would be a moving target, and would include days where my needles never came out of the package.
Episode 4: Case Management
Complicated medical cases require extraordinary effort on the part of Acupuncture Relief Project staff and volunteers. Illiteracy and the inaccessibility of medical facilities are major obstacles requiring innovative case management. This episode follows 4-year-old Sushmita in her battle with tuberculosis.
Terry Atchley: A long way from help
Acupuncturist, Acupuncture Relief Project Volunteer 2013, Team Leader 2015 A native of New Orleans and graduate of the Oregon College of Oriental Medicine, Terry traveled to Nepal to help open a new primary care clinic in Kogate. This experience allowed Terry to treat a multitude of illnesses and develop her connection to people through words, touch and understanding.
“Grief can be the garden of compassion. If you keep your heart open through everything, your pain can become your greatest ally in your life's search for love and wisdom.” Rumi
At 2am on my last night in Kogate I woke to someone pounding on the door. As the only medical team in this remote region we were sometimes called for emergencies. The patient was a young pregnant woman with pain and bleeding. I got dressed and hiked the steep trail to her house. As I entered her home, I saw the young woman was scared. She looked at me for reassurance and safety. I spoke with her and learned she was seven months pregnant and had a history of late term miscarriages, one which occurred when she was alone in a field.
I checked her vitals and listened for a fetal heartbeat, but heard silence. At this time I believed she was having a miscarriage and began to explore my options. I called for a rusty old land cruiser that functioned as an ambulance to take her to the nearest hospital which was two hours away down a very rugged terrain. I tried my best to comfort her as we waited. I felt helpless and incompetent. There was nothing I could do, but bear witness, hold her hand and offer comfort.
The dusty vehicle arrived with a single driver, it had a lengthwise seat in back with a spare tire on the floor and an ancient oxygen tank. I was not able to travel to the hospital with her and would not be able to follow-up with her after she got there.
The next day, as we were leaving Kogate, I received an update. She had given birth to a stillborn on the way to the hospital.
I think of this patient almost daily. When I returned to Nepal in 2014, I was eager to see her. I wanted to tell her all the things I couldn't say in the moment. Sadly, I learned she no longer lived in the village. She had divorced her husband and returned to her parents house in India.
This experience broke my heart. But this heartbreak helped me learn what it truly means to be a healer.
I had to look beyond objective findings, results or a cure. I believe being an excellent healer means sometimes we have to let go of the outcome. I had to let go of the notion that I needed to solve every problem to be validated as a practitioner. The answer to this case was not found in all the intellectual learning from school, but in my heart. I gave the only thing I could give in the moment- compassion. I had to release the expectation I had of myself as a practitioner and accept that my ability to care for a patient sometimes has nothing to do with medicine and everything to do with love.
Episode 5: Sober Recovery
Drug and alcohol abuse is a constant issue in both rural and urban areas of Nepal. Local customs and few treatment facilities prove difficult obstacles. Partnering with Sober Recovery, one of the few inpatient acute detox rehabilitation facilities in Nepal, Andrew Schlabach and Tsering Sherpa train volunteers in the use of acupuncture.
Episode 6: The Interpreters
Interpreters help make a critical connection between patients and practitioners. Recruiting local young men and women, Acupuncture Relief Project provides a unique training and employment opportunity. This episode explores the people that make our medicine possible and what it takes to learn job.
Bex Goebner: Death and Dying
Acupuncturist, Acupuncture Relief Project Volunteer 2015, Team Leader 2017 Bex lives in Northeast Portland with her partner and two young boys. In 2015, she visited Nepal and found some of the most meaningful teachers of her life in the patients she treated there. She is forever grateful for the mind-blowing, heart-opening experience that ARP has offered to her.
Lal Bahadur Lama had been an entertainer and artist for most of his life, though at the time I met him, he was a farmer. He grew up in Kathmandu, where he was trained as a painter and sculptor. In his early years, he would leap the steps of the Monkey Temple and position himself on a ledge. From there he would draw the snowy shadows of the Himal.
After he married Vagawoti Lama and took up residence in the village, he became part of an entertainment troupe. His beautiful wife would smile when she attended his stage shows for the King and Queen in their summer palace. On one of his favorite nights, Lal and his nephew wheeled out a life-sized elephant he had built and painted. As he stood in front of the king, Lal flipped a switch and the elephant’s spring-loaded trunk swung up in a posture of salute while the crowd cheered.
As a farmer, he missed his artwork, so he took up a side job with the Nepalese forestry department, where he could wander around taking photos. He decided to use some of this work to open up a photo shop in the village. He quickly put himself out of business by giving all his inventory away to his friends. He was bummed about this failure but proud of his generosity.
In 2015, I arrived in the village of Bhimphedi to find this 71-year old man. The clinic hadn’t opened yet but I got a call to his house for a respiratory emergency. I’m still not quite sure how it happened, but I was able to get him stabilized. ARP doesn’t typically do home visits, but I began going to see him most nights of the week.
Usually after dinner, I would visit his cold room to listen to his lungs and check his oxygen levels. I would hear his heart beat and notice that the second sound lingered too long. I would press into his right foot to make a deep pit and count the minutes until it refilled. I'd take a look at the rusted welding tank that fed him, making sure that his family hadn’t turned it down to save money. After I did this, I would sit next to him and hold his left hand, the one that wasn’t swollen. When he could catch his breath, he’d tell me who he had been.
Lal was dying from the end stages of emphysema, though he’d never smoked a day in his life. The honeycomb cysts in his lungs came from growing up in a Nepalese home with an indoor cooking fire. It was worsened by walking the polluted streets of Kathmandu, where the brick industry blackens the air.
Thirty times after I visited Lal, he died in the middle of the night. All of the funerals I had seen in Nepal were Hindi funerals. The dead were taken to the rivers, covered in marigold flowers and burned. Lal was put into a simple white coffin painted with a thick red cross. He was lowered into a deep hole in the dried riverbed and his flowered bedspread was folded on top.I kneeled there while the women wailed and people threw handfuls of dirt and roses into the hole.
In the end, we share the best memories we have and these memories go beyond where we live or the clothing we wear. It doesn’t matter whether we are the dying person or the witness in the room. At that moment, we cannot help but be united in our humanity.
Episode 7: Future Doctors of Nepal
Acupuncture Relief Project begins the process of training and licensing local practitioners. This critical step towards sustainability requires partnership with other organizations as well as the national government. This episode looks at the people and the process of creating a new generation of Nepali rural health providers.
For me, meeting the local interpreters, acupuncture students and our cook, and getting to know them on a personal level, has been the most amazing experience.
The high unemployment rate in Nepal means that many young people try to seek opportunities abroad and are likely to end up exploited as cheap labour. The average yearly wage of a Nepalese is $240USD and for many, going on a holiday is but a dream. I had a chance to listen to the stories of some of the youth I met and worked with. Prior to working for ARP, some were unemployed or had unstable low paying jobs, and pursuing higher education was something that they couldn’t all afford to do. Seeing their potential, ARP offered them a meaningful way to earn money and contribute back to their communities. Here are their stories:
Time is flying by and we have less than a week before this camp’s rotation is over and the clinic will close until September. The first week or so here was a mad scramble to work out how to treat two to three times more patients than I would normally see in a day; how to work through an interpreter; how to modify my intake for this population to get the information that I need; and how to screen patients for more serious health issues than I would come across at home. I became more comfortable with this dance, allowing me to really focus on assessing the effectiveness of the treatments and what could be done to get patients into the best possible shape before we leave.
When it's all said and done, leading a team in any capacity is not an easy job. Being a medical volunteer here also stretches each of us. I thank my team for working from day one in a new remote town, and also a new clinic! Yes, newness can bring challenges, but, like any spiritual growth, there is major relief that comes only pushing through the most climactic and painful time. It's like sitting down to meditate and you are faced with all the itches and discomforts in your body. You want to jump up and scream and run from it, but you know, only sitting a few moments longer will bring the most blissful freedom you can imagine.
3:38AM - can’t sleep. We have 6 days left of clinic. For those patients we see only once a week, today will be our final goodbye. A lump forms in my throat as I write these words…I’m not ready to say goodbye. How can I slow down the hands of time…Nepali time? The two months that I’ve been here have flown by. I don’t want these remaining days to go at the same pace. I want to savor every moment. I want to hear more stories. I feel I've only scratched the surface. I want to embrace this beautiful community that has enriched my life so much. The generosity. The kindness. The love. The thoughtfulness. The authenticity to which the Nepalese conduct their lives. I was not anticipating this…and I’m not ready to say goodbye.
Nepal is a materially poor but culturally rich country. They are the warmest hearted, most generous and toughest people I have met. Truly a humbling experience to be immersed into their culture and their community for this period and to build this relationship with them.
Actually getting to the clinic we have set up in the village is simple, although perhaps not easy, many have to walk, a long way. There has been a fuel crisis in Nepal for the last 5 months, making it extremely challenging for people to be mobile by way of cars, bikes and buses.
The acupuncture relief project is in the village of Bajra Barahi nestled in a valley within the Himalayas, about 36 (long and dusty) km’s south of Kathmandu.
The surrounding villages are scattered around the hills and to reach the clinic. We see patients every day in the clinic that have walked anything from 1-4 hrs to come and see us at the clinic. They have to walk up rough dirt paths, up mountains paths, and across bridges and through the fields, no exaggeration.
I know because I have taken some of these walks during my days off. The walks were a fulfilling experience for a Saturday challenge, dressed up in my hiking gear and ready for adventure, not necessarily something I would want to undertake if I wanted to go and see the doctor about my painful osteo-arthritis on my knees from overwork, or my bad back!
This has really opened my eyes to so many aspects of life out here.
Of course, for a start, most of us cannot really even imagine this a reality in our lives - that we would have no choice but to walk for up to 4 hours each way to visit the doctor! The fuel crisis has definitely added to this aspect of being here, however in my observation I feel that transportation is essentially still a huge luxury here regardless.
For me, it’s fascinating coming from a world where there are so many ‘cheap flights’ across the globe and for some people are as easy as getting a bus, yet these local villagers don't even have local transport set up for essential needs, what a paradox world we live in.
The majority of these patients are coming to see us for pain management of their knees and backs – and what with walking such distances to come for treatment seems a little counter productive sometimes. Unless of course this clinic is providing more then meets the eye, and they are coming for more reasons than the just pain in their knees, perhaps they are coming to simply be taken care of by someone, to be heard, to tell their story, which is undeniably a huge part of any healing process, and something of a revelation to most of the patients we see here. Most of these people have never spoken to anyone about their health complaints before, not even friends and family. Evidently complaining on any level is just not a part of their culture! I quote one of my patients - ‘Until I came here I thought I was the only one with knee pain, now I see almost everyone suffers from it!’
What a marvelous revelation to know she was not the only one who has this!!!
Cars are still a rarity here in the villages, its hard to fully grasp if its always like this or the fuel crisis for the past 5 months has transported life back in time100 years, when fossil fuels were just not a part of life. As we walk, we frequently come across men, women and children carrying the farm goods on their backs, in woven baskets with a strap around their head. It is no wonder that we see so many patients coming in for chronic pain management, degeneration of their knees and cervical compression giving widespread numbness and tingeing in their limbs.
Nepal seems to live in an almost timeless space as well…(we often joke about things happening n Nepali time - meaning when it happens it happens!)
I do see the magic of not living by such regimented time…and simply being, something that we are al in search of in the western cultures, the simple art of being.
Yet these people are living like this in their daily live. We have a busy clinic of approximately 100+ patients each day. All booked in to either come in the morning or the afternoon, no set times as this wouldn't make sense to them. So they turn up and wait outside gathering together in community for perhaps hours before they get into see us. Yet they are so content waiting, chatting, being in the sun, simply BEING, no iphones to play on, no kindles, no newspapers, no phone calls to distract themselves or keep themselves entertained, they simply are, simply let themselves be, what else to do, Perhaps they have the art of conversation that has been lost in the modernised and technology-led modern world. Wow such profound teachings to share with us all.
Another thing by which the Nepalese people have inspired me is their adaptability. Since there is limited fuel they don't have the gas for cooking, yet this is not an issue for the people here in the villages.
After the earthquake in April 2015 most of the people in Nepal continued to live in the tents they built as shelter afterwards for some months, as either their homes were crumpled, or unsafe to live in, or they didn't feel safe being in them anymore with the continuing aftershocks. They got used to preparing wood fires again outside in the ground to cook their food. Now that the fuel crisis has limited the amount of gas that is available they are all continuing to use this ancient method of food preparation with ease.
Our clinic is in the middle of a very rural farming town, where every house is like a little farm, with chickens, ducks, a couple of buffalo, some goats, drying corn hanging on the washing line next to the colourful clean laundry.
Inside the houses, the picture is very similar with the downstairs consisting of a room that is literally full of potatoes, winter vegetables and possibly their prized water buffalo.
Nepal is very cold in the winter, and it is felt here, as there is no heating, and no soothing hot water to thaw the bones out at the end of the day, conditions are very challenging to live in.
The local villagers essentially live in sheds, they wash in the streets using a community tap to wash their dishes, their babies, their clothes, and yet these people are the happiest people I have ever met. Always smiling, enjoying the simple pleasures of life of just taking such pleasure in greeting each other with such enthusiasm with putting their hands in prayer position and singing Namaste to each passer by.
Children run free in the fields, playing with each other, the goats and simply just being care-free children…. It’s evident that not having so much material possessions is also an incredible blessing to people. --- Zoe Nash
I have been filling the role of secretary/treasurer of Acupuncture Relief Project since 2008 when Andrew’s dream reached the point where it shifted from idea to action. When meetings with bankers and lawyers became necessary; when he needed my “type A” brain to figure out how to manage the mounds of information we were accumulating; and when the piles of legal documents needed to be filled out and filed – that’s where I came in. Since I am neither an acupuncturist nor a health care practitioner of any kind I have always felt a bit removed from the practice side of ARP. I handle the receipts for needles, otoscope’s, cotton balls, electro machines, foot stools, blankets, moxa and every other item used in the clinics and yet I have only heard second hand the stories about how the supplies have made a difference in the lives of the patients. Until now! This year I am extremely fortunate to have the opportunity to be here in Nepal for several months. To spend time in the clinics and to connect with the patients, practitioners and interpreters first hand.
Every day has been a learning experience and a gift but I am most affected and inspired every time one of our stroke patients comes to the clinic. Sure, I have watched the video on our web site of Birbahadur Thapa, showing his progress recovering from his stroke and I have heard the stories of other patients but it wasn’t until I actually witnessed the impact of acupuncture on a stroke patient for myself that I truly understood how important these clinics are.
Most of the stroke victims in Nepal are sent home from hospital with no physical therapy and no instructions on what they and their families can do to try to recover lost abilities, therefore they rarely experience any improvement after their stroke. Since a large number of our patients are illiterate, they also don’t really understand what happened to them and what “stroke” means so understandably this creates a lot of fear. When they come to our clinic they are often totally hopeless and demoralized because they have been in their condition for at least a year and often for many years. After just one or two treatments they experience noticeable changes and begin to feel hopeful. It is that shift to hopeful that moves me so deeply.
There is one man in particular that I have become very attached to. Jagat came to the Bhimphedi clinic for the first time with several family members because he needed their physical support to get to the clinic and, since he could not speak at all, he needed his wife to translate his facial expressions into words. I don’t believe I have ever seen a man as dejected as Jagat was on that first day. He is 35 years old with a wife and 3 kids and all of a sudden he cannot take care of his family nor support them financially. He no longer has a role in his community and people have stopped making eye contact with him – he has become invisible because he cannot participate in life and therefore he no longer matters.
His ARP doctor, Rachel Hemblade, went through multiple physical and vocal tests with him to determine what his abilities were, treated him with acupuncture and physical therapy, and then created a homework plan. Rachel recruited his family members to help him at least twice a day and taught them how to perform the physical therapy and voice coaching themselves. Jagat is very fortunate to have a caring family and everyone stepped up and said they would help.
The way Rachel fully and cheerfully engaged with Jagat and his family and her deeply compassionate manner had to have been reassuring for them on that first scary trip to the clinic.
On that initial visit, Jagat could not make any sound at all for two of the vowels and could barely sound the others. His entire right side was severely stroked. Hand in a claw like grip, shoulder barely mobile, unable to lift his arm up from his side, leg could move forward to walk at the hip only, foot had no motor control, face totally expressionless. Eyes immensely sad.
His home is a 4-hour walk from the clinic and thus would make daily treatment unreasonable so thankfully he was able to make arrangements to stay in Bhimphedi with friends.
When he came back to the clinic for his second treatment you could see an ever so slight sparkle in his eyes. For the first time since the stroke he had felt his body change and suddenly, he had hope!
When he arrived for his third visit he was excited to show us that he could now pronounce all of his vowels. I will always remember that visit because it was also the first time he was able to smile and his smile lit up the whole room.
By his fifth treatment he no longer needed a family member to interpret his facial expressions because he could answer Rachel’s questions himself, albeit slowly, and each treatment since has continued to bring improvement.
The crooked smile he directs at me when I exclaim with joy at his progress is a gift I will never get tired of receiving.
This is but one example from the hundreds and hundreds of patients ARP practitioners treat every year. And this is why I will never again be able to file a receipt for needles or pay for an order of cotton balls or any of my other secretarial duties without being deeply touched by my experience here. I am immensely proud and appreciative of everyone who makes this project function on a daily basis – Tsering, all the interpreters and practitioners, all of the advisors – and I cannot begin to express my admiration for the dedication, love and energy Andrew has given to make this project happen, year after year. When I signed on as a board member 8 years ago, I never could have imagined the significance it would have in my life. --- Sheri Barrows
It’s the dry season here in Nepal. It has rained a few times since we arrived in the beginning of January, but just a little bit. The village of Bajra Barahi, that houses the Acupuncture Relief Project clinic, is a rural farming village. Most of the people that live here are subsistence farmers. Almost every inch of open land is terraced fields. My previous career, before becoming an Acupuncturist, was an organic farmer. I love seeing how people farm here in Nepal. In the late winter/ early spring they grow a lot of potatoes, cauliflower and mustard greens. In the summer, after the potatoes are harvested, they grow a lot of corn, rice, peppers and tomatoes.
When we arrived here in January, the fields were flat and fallow. Then people started to work up the land, using oxen, rototiller-tractors and hand tools to form rows. They began to bring compost to the fields and dump them in piles spaced evenly around each field. Many people have livestock at their homes and are able to make their own compost mixed with pine needles and other foraged materials. People have their fields somewhat near their homes and transport the compost in baskets that are carried on their backs with a trump line across the top of their heads.
This is where the acupuncture clinic comes in. The life of a subsistence farmer is hard work. In the clinic we see a lot of aches and pains. We treat a lot of people whose neck is compressed, from carrying loads on their back and head, giving numbness and tingling down their arms and into their hands. We are able to treat the villagers for issues such as this. But the problem is that they have to continue to farm, carrying heavy loads to and from their fields. I think that they have a beautiful life. It’s better than sitting in front of a computer all day. Or at least that is my opinion. Our team of practitioners have had many conversations about what to do to help and we end up with no real answers. Farming is hard work, whether you carry a wheel barrel, shovel into a flatbed truck or carry loads on your back and head. But we can treat them with Acupuncture, discuss posture, exercises, help them manage their aches and pains and support their hard work.
So after the compost is delivered to the fields, it is spread out by hand into the rows that were already created. The potatoes are placed in the rows on top of the compost and the soil is hilled up over the potatoes in beautiful rows. The entire family seems to participate in the farming. There is a job for everyone. We have seen little kids carrying baskets on their backs with light loads. The older people are sitting on a tarp in the field, cutting the potatoes, preparing them for planting. It was unexpected gift to get to see the potato planting in what seems to be so early in the year. It appears now, that most of the valley is planted in potatoes and we are waiting for them to sprout, waiting for green. --- Stacey Kett
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One brisk morning in Makawanpur, as our team was finishing breakfast and preparing to head over to the clinic, a man stopped by to ask us if we could have a look as his mother. The man is a carpenter who has been helping us with our new clinic building and the weary expression on his face speaks volumes as to what might be going on with his mother. I grab one of our mobile kits and ask one of the other practitioners and an interpreter to come with me up to the carpenter’s village.
As part of my work in Nepal, I really enjoy visiting patients’ homes and doing house calls. Too often we don't have time or the resources to spend walking out to neighboring villages, but when we do, I always find the experience enriching and illuminating. For example, a couple of weeks ago I was returning from a house call when I was stopped in the street by another patient who asked if I could look at her mother. She told me that her mother had suffered a stroke more than a year ago. When I went to their home and saw her mother however, I quickly realized that her mom had not suffered a stroke, rather she was in the advanced stages of Huntington’s Disease. On my walks, I find many disabled, paralyzed and elderly people; I also get acquainted with the village drunks. Sometimes I discover a few cases of mental illness and birth defects lurking in the population. All of these conditions exist everywhere in the world, it’s just that we rarely get to see them all in one place. That is the beauty and nature of working in a village; our patients are everywhere. They vigorously greet us in the street, offering tea or food while giving us updates on their progress and interest in acupuncture. “Ma Dhukdhana! (I don’t have any pain)” an elderly Tamang man shouts while pointing to his knees and throwing his walking stick to the ground. “Deri Ramro! (Excellent!)” I reply while giving him a thumbs up sign. (I have no idea what that gesture might mean in Nepali but it usually makes people laugh.)
On this particular day, it takes us about 45 minutes to walk a few kilometers into the hills just to the west of our clinic. Small, two story, stone and mud houses are clustered tightly together along the hillside in this old Newari village. The Newar heritage can be seen in the intricate wood carvings around the windows and the sweeping uplifted corners of the rooflines. It looks like a 14th century movie set save for a few sad-looking satellite dishes and the modern water tanks. The road is so steep and rocky it’s only passable on foot, and yet, I see two decrepit motorbikes parked about midway up the hill. In most of these houses cows, water buffalo, goats and chickens are kept on the ground floor with the family living upstairs. The air is thick and stings my nostrils with the acrid wood smoke of cooking fires. Evidence of the recent earthquake can be seen everywhere with collapsed roofs, cracked walls and sometimes completely destroyed buildings. On the other hand, there are what appear to be centuries old buildings standing completely unaffected. Damage aside, there is no doubt that life goes on as the village is abuzz with everyday activities. A woman who looks to be at least 150 years old, offers for us to drink rakishi (local distilled alcohol) with her. We happily decline, as it is only 9:00 AM, and wish her a good day.
In the villages of Nepal, people do not live inside their houses. The house is really just for storage and sleeping with very small living spaces and low ceilings. Creosote coats the walls and roof beams from years of cooking fires and the smell of livestock, mold and dust permeates the air. Most daily life takes place in the small courtyard in front of the house. This is where meals are prepared, laundry is washed, crops are dried and where neighbors gather to socialize while they work. Thusly it was no surprise that when we arrived at the carpenter’s house, his extended family (about 12 people) were all gathered in this outdoor space enjoying the morning warmth from the sun and busy with their daily chores. On a hand woven grass mat in the middle of all of this activity, two younger women support and offer a cup of water to a woman who appears close to death.
I take a deep breath to calm my mind and offer a silent prayer. “Steady,” I think as I look to my assistants. Then we begin. Make contact, exam, vital signs- is the patient lucid? Barely. My interpreter and I listen to the family members tell their story and we ask many questions. Bit by bit we slowly begin to understand the situation.
The woman is nearly 80 years old (in Nepal, elderly people do not know their exact age as they do not celebrate birthdays and they do not have any government issued birth documents.) She is as thin and frail as you can image a person to be. Her daughter-in-law claims she weighs less than a sack of rice (40kg or 80-90 lbs). When we try to take her blood pressure, her upper arm is less than one inch in diameter and even our smallest cuff will not fit her. Her vital signs are so weak they are almost imperceptible. Her abdomen is distended and tender. Every bone in her body is visible through her thin and dehydrated skin. Cancer? Internal bleeding? She is in some discomfort but not in agony and periodically she speaks a few words, usually asking to be moved to a different position. “Sit me up,” she says, then after a few minutes “Lay me down.” She has been this way for 5 weeks, gradually declining. She has not eaten in three days and she is only drinking a few sips of water now and then.
I look around and take in the scene. “How many people are here?” I think. 10? 20? 30? Family? Neighbors? Every one fascinated by the activity; all looking to us for answers. I look at the carpenter, his weathered face with deep crows feet accenting his high cheekbones. In his eyes I see the question, “What do I do?”
Who is my patient? The woman who is dying or carpenter or the whole family… maybe the whole village?
Of course if I was in the U.S., I would just dial 911 and, like magic, a team of paramedics would materialize within a few minutes, whisking her away to the lifesaving miracles of modern medicine. I wouldn’t even give the slightest thought to how much that might cost. But here… the nearest hospital is 4-5 hours away by kidney-busting roads. Even if she survived the ambulance ride (I use the term ambulance loosely because it is just a four wheel drive truck with a flashing light and lacks any medical equipment or trained personnel) what hospital would we send her to? What can the family afford? If the patient is put on a respirator she could easily drain the family’s resources beyond their basic survivability.
What to do? How can I possibly answer this question for everyone.... Here is the reality. Like it or not, I am the senior trained medical provider in this village. This family is asking for my professional opinion, on which they will base their plan of action. “What is best?” I ponder. What advice will relieve the maximum suffering? What is ethical?
I begin by clearly stating what is happening. I look the carpenter in the eye, take a long pause, and say… “Your mother is dying.” I go on to explain that I do not believe there is any medicine that will prevent this from happening and that it will likely happen soon. I tell him that she is in some pain and that the hospital would be able to give her medicine to relieve that pain but it is unlikely they will prevent her from dying. It is my opinion that the ambulance transfer to the hospital will be very stressful and possibly fatal for her. It is my sincere feeling that she would be better off in the care and surroundings of her home and family. I empathize that it is a difficult but necessary choice he would have to make for himself, his mother and his family. Under the clear blue sky, surrounded by his extended family and neighbors, the carpenter received this news with stoic silence. He began to cry a little and then he said, “Thank you”.
What came next was an amazing sigh of relief. Everyone gathered there suddenly knew exactly what to do: make Ahma (grandmother) comfortable. They ask lots of questions. We show them how to keep her bedsores clean and advise them to change her clothing and bedding daily. We show them how to massage her dry skin with mustard oil and we explain that she needs to be out in the sunlight and with the family as much as possible. “Don’t leave her indoors, alone in the dark during the day. Hold her hand and speak with her even if she can not speak back to you.”
We left them saying that if her condition changes or if they felt her pain was becoming intolerable, “Just call us and we will come.”
The day after our visit the woman sat up on her own and asked to sit in the courtyard with the other women while they worked. She sat all day in the sun and sipped tea. This was the first time she had sat up under her own power for over a month. The women asked her what she was thinking about; sometimes she would reply and sometimes just sit quietly. That night she passed away in her sleep.
With every decision I have to make there is a consequence. I don’t alway get it right. Many of you might think that I made a poor decision in this case. You may be right. As much as I try to understand what is “best” for a patient, I never really know the answer. What I do understand is that every day our practitioners go to the clinic and try to palliate life. With simple acupuncture and herbal medicine we reduce pain and alleviate many conditions, helping people return to work and to the care of their families. With our assessment and diagnostic skills we help people access and understand the care they need, often guiding the treatment of other physicians. All the while we are working on those aches, pains and injuries that rural living delivers to the body, we’re getting to know our community. We are diligently surveilling for tuberculosis, cancer, hypertension, respiratory dysfunctions and infectious diseases- constantly scanning for signs of mental illness, depression, domestic violence and substance abuse. Maybe our treatment is just the context in which we relate to our patients and community. I can live with that.
Patients often tell me, “I’m afraid to ask my doctor a question.” In Nepal especially, questioning a doctor will likely earn you a prompt scolding. This fact really breaks my heart. Doctors rarely, if ever, offer a diagnosis or explain the drugs or procedures they are giving to the patient- even to us- and we ask. Illiterate patients (most of our villagers who’re over 50 years old) are totally at the mercy of the medical institutions and they are often frivolously over-treated and overcharged. When I end a patient visit with the query, “Do you have any questions for me?” my patients are stunned. How can such a simple concept go overlooked? Just like the carpenter and his mother, when we take the time to explain what is going on and what can be expected it make all the difference because it enables patients to make their own choices. If nothing else, hopefully through our example here in Makawanpur and through the students that we train, we can begin to get this idea into practice.
In the end, I’m not all that interested in what acupuncture (or any other medicine) can cure. For me it is enough to just struggle with the question, “What is best for this patient?” and to give my utmost effort to provide practical solutions and compassionate care.
Today I treated 17 patients. It is my first treatment day in the village of Bajrabarahi, in Nepal, working side by side with fellow acupuncturists from around the globe, brought together by the Acupuncture Relief Project.
I knew that the local villagers would be lovely and friendly people; I was told that they have a hard life and do not complain, but are grateful for the treatment and care. I also knew that I would treat a variety of health issues beyond the usual scope of an acupuncturist trained in New Zealand. But what I did not expect was to see an eleven year old boy come with his mum, and to feel helpless to do something for him.
He has, what appears to be a large lipoma on the inner thigh of one of his legs. It is hard and heavy, and it weighs down his leg and affects his walking. I am told that he has seen a doctor who advised surgery. I am also told that the family cannot afford to pay for the surgery.
Even worse, I do not think that the surgery would solve his problem. The growth appears to have taken over the muscles and is probably intertwined with veins and nerves. I have seen a similar case before in an elderly relative at home; a surgeon operated but it grew again, as not everything could be removed. Worse, it turned cancerous and the only further advice was amputation, as the growth increasingly cut off the blood supply to the lower leg.
But this is an eleven year old boy and he has walked to the clinic to see me, hoping that I can do something for him. And I feel so helpless. I do some acupuncture points for pain and one of my colleagues gives him some Chinese herbs to take.
I thank him for coming and tell him to come back in three days. As he leaves, he looks at me with a beaming smile on his face, happy with the care, and maybe relieved that the needles are out. And his shy smile makes me realise that the most important thing I did for him today was that I cared for him and that I showed him that I cared. But what he gave me in return was far more important; it was his trust in sharing his burden with me and in allowing me to treat him and to do the best I could for him. This little boy taught me not to feel sad for him, but to accept my own limitations, and to appreciate the connection that we all share as human beings. --- Andre Capiez
In Camas, Washington there is a very special woman named Kathryn Oftedahl who creates the most beautiful quilts. They are not just creations of beauty they are creations of love.
Recently, Kathryn graciously asked us to gift one of her quilts to a patient of our choice at our Bajrabarahi clinic and after much consideration we chose Laxmi Buddha Shrestha and her husband Ram Krishna Shrestha. Laxmi and Ram have lived in the village of Bajrabarahi their entire lives and they are farmers who grow rice, millet, potatoes, corn and more.
About 8 years ago, Laxmi began presenting symptoms of personality changes and uncontrollable muscle spasms. When Andrew was introduced to Laxmi a year ago, her family claimed that she had suffered a stroke, however, he immediately recognized it as Huntington’s Disease. Huntington’s is a progressive neurological and psychological disease that is due to a genetic defect. It typically appears in mid-life and starts with a slight tremor similar to Parkinson’s Disease. The tremors get progressively worse until every joint in a person’s body twitches violently in puppet-like movements. The tremors are relentless and even when Laxmi is sleeping her body doesn’t rest.
Laxmi is very fortunate to have a loving and compassionate husband whose humor brings a smile to her quivering face and extended family that help provide for her. She is especially appreciative of visitors as they bring a bit of joy and entertainment into her isolated world. A few of our ARP team visit and have tea with her at her home twice a week and Jamil, her doctor, treats her with acupuncture. While nothing can be done to cure or even slow the progression of Huntington’s, Laxmi says the acupuncture helps her feel “lighter” and sleep better.
In late October I had the opportunity to meet Laxmi and she had a ready smile as Tsering, Andrew and I walked into her room. Nothing that I had been told about her case had prepared me to see her twisted and constantly tremoring body on her sleeping pad. Amazingly to me, her eyes immediately went to the bright quilt Andrew was carrying and she was delighted when we covered her with all of the colorful flowers.
I cannot describe how very blessed I feel to have had the opportunity to be part of sharing Kathryn’s gift and seeing the joy it brought to Laxmi.
I would like to offer my heartfelt Thanks to Kathryn and everyone who makes this project possible. I wish you could all be here to witness the effect of your support. --Sheri Barrows, Secretary/Treasurer, Acupuncture Relief Project
Directors Note: A few weeks after Sheri's visit to Bajra Barahi, Laxmi quietly passed away in the arms of her husband. We were all honored to be able to work with Laxmi and her family and while we are deeply saddened by her passing we also recognize the relief in the end of her suffering. We continue to see Laxmi's husband, Ram Krishna, in our clinic and he is a cheerful reminder of the small role we play in this village in Nepal.
At our clinic in Bajra Barahi, Nepal each practitioner sees up to 20 patients a day. At the beginning of my stay there I was meeting all new patients. I knew some cases would be challenging and others would be a bit more familiar. I know right now, that some will need long term treatment and have slow progress, whereas some find relief in only a few treatments. I do hope however, to have as many successes as I can in the short amount of time that I am here. And it's the successes, little or big that keep me inspired to moving forward to help people.
The first time I met this patient he presented with low back pain, painful urination and red coloured urine. He complained that he experienced the back pain when bending over and had some frequency of urination. I thought he may have been experiencing a kidney infection but he did not have a fever nor was his pain severe.
I consulted with a colleague and he clarified that this was not a kidney infection but more likely kidney stones. After doing a kidney punch test confirming the presence of stones and taking his temperature (which was normal), my recommendations were to drink five to six liters of water, quit drinking alcohol, chewing tobacco, and come for acupuncture to move the stones. Expecting him to argue with me, he surprisingly agreed saying if that is what it took to pass the stones, that is what he would do.
Within a week he visited the clinic every day and every time I saw him he looked better and better. The pain kept decreasing as he held his side of the agreement to drink six liters of water! I enjoyed his energy a lot, he was a very positive man and grateful for the work I did on him. I especially appreciated that he wanted to get better as much as I wanted him to!
I predicted it would take about 6 appointments of checking in and doing acupuncture to resolve the stones. When appointment 6 approached, he came back saying he was having frequent urination but no red urine, urgency, or back pain. How could he be urinating ten times a day after all the work we had done? It was because he was still continuing to drink 6 liters of water per day because I had advised him to when he had the stones! Laughing at the very uncomplicated explanation, I told him he could now return to half that amount since the stones had finally passed. What else was there to do for him now? I could not think of anything to say but that he did not have to come to the clinic anymore unless something else came up. It does not seem like a big deal but for me, it was the first time I told a patient that our work here was done and I did not require him to come back again! It felt rewarding to know that this case was for now closed successfully. It enforced a reminder to me that it is great thing to give a patient the help they need with the intention of eventually seeing them less and less because they are improving. On the other hand, if we are constantly seeing a patient for several months/weeks without seeing any changes in their condition, what good are we doing?
I do believe that this patient did more than half of the work because he truly wanted to get better and was willing to put in the effort for that to happen. Patients and us practitioners have to work together as a team! I am hopeful for more experiences like this in the future. Specifically, I am looking forward to more successes as well as overcoming challenging cases. Even more so, having the right to say, "Great work! You don't have to come anymore unless something else happens!" and send them on their way. -- Alyssa Baser
A lady came through the clinic doors on our first week, assisted by her daughter in law, she crumpled in to a blue plastic clinic chair. She spent no time in presenting me with a huge bag full of scans and empty packets of pain killers explaining that she had terrible lower back pain, radiating down her legs. This would have been a typical sciatic nerve impingement presentation however the lady was fearful that the doctor might have to do surgery, and the pain was visible in every line on her face indicating this was much more severe.
On inspection of the scans, she had a severe bulging lumber disc which meant surgery would have been her only option in terms of long term pain management and reestablishing normality in her day to day life. I offered a simple distal treatment along with auricular acupuncture to help manage her acute pain and advised that she mustn't delay in seeking medical assistance from her doctor, to bring forward the date of surgery.
After 3 home visits trying to encourage her to take action, the lady was now bed bound and suffering with what appeared to be bed sores, using a bed pan with the assistance of two of her family members. Bound to a hard mattress in a small, partially ventilated room, she leans up on her right arm to sip tea with us, insisting she is now feeling much better and is opting out of surgery. On further questioning, it transpired she had been visited by the local shaman the night previously who had stayed up with her all night conducting a spiritual ceremony.
Shamanic healing is thought to be one of the oldest healing practices in Nepal, aiming to address the spiritual aspects of illness, to restore balance and harmony in the emotional and physical self. Jhar-Phuk (to cleanse, energise and blow in healing spirits) is initiated with singing, chanting, dancing, drumming, rice grain scattering and the burning of incense, aiming to dispel the root cause of pain, suffering and illness.
Intrigued by the sheer power that this one evening ritual had on my patients perception of pain and wellness posed a number of questions. Can belief and faith be transformative enough to instil a state of wellness in someone with debilitating pain?
It is not for me to question or judge but rather take a step back and admire these traditional forms of medicine deeply rooted in such communities, to grow and learn from these experiences. Be it placebo or not, I have now witnessed the power of belief that people place in shamanic culture generating positive change to people's lives, which leads me to question if this form of medicine is truly any different to our Eastern and western philosophies that we have come to live by? Are we all not working towards the same goal, to improve the lives of those who are sick or in pain? And if this is the case, why do we place so much emphasis on "cure"?
In this instance, the patient knew the consequences of opting out of medical intervention but found peace in the fact she was going to be in constant pain and would likely not be able to move again without the help of her family. Yet, her positivity was inspiring. She insisted that one day soon she would walk back down to our clinic for treatment. I wait for this day with optimistic anticipation and welcome the powerful benefits that this strength of faith offers to so many. -- Kim Shepherd
When I decided to go to Nepal to work on this project I knew that I would experience difficult situations that would challenge me in ways that I could never imagine. However, I wasn't quite so emotionally prepared as I had thought. It was our second day treating in the Bhimphedi clinic, and I was treating a young girl who looked no older than 3 or 4. She had been brought in earlier that morning with what looked to be an infected puncture wound behind her ear and she was distressed and crying. Perhaps frightened by the white coats and unfamiliar faces she would not let us near her to inspect the wound properly so she was dragged outside, which prompted all the patients outside to crowd around unnecessarily. This made the situation even more stressful. Despite the stress, noise and lack of communication, I could see that something was not right – her lymph nodes on her neck were visibly swollen and there was something unusual about the wound. I was feeling completely out of my depth but was expected to have this knowledge. I was relieved that the team leader was there who identified it as extra-pulmonary Tuberculosis (TB). Having experience in this environment and familiarity with such cases makes the difference in getting someone the right care.
I’m not sure what affected me more that day; the situation itself (that this child was clearly sick and had been for weeks, yet the parents didn't appear to be doing more to make sure she got better) or the fact that they had gone to see various healthcare professionals and still none of them had recognized this as TB. With each day that passes and as we get used to living in this culture, I realize that it is not that people don't love and care about their children – it’s that in some situations they don't know how to care for them or that there’s nothing else they can do. The lack of basic healthcare education means that a lot of children are really sick and nothing can be done about it.
What we have also come to realize and what makes me feel more disheartened is that even if and when they get to the hospitals or health posts, we cannot guarantee or expect that whoever sees them will be anymore qualified or knowledgeable than ourselves. This sense of frustration that I have found myself feeling over the past weeks occupies my thoughts most of the time and makes me wonder what can be done to help with the situation.
This is why I am so grateful to be here: To be working alongside such caring professionals who are collectively developing trust in this community so people can have the confidence to come to us with these concerns. The Acupuncture Relief Project clinic is perfectly placed to spot these serious health issues and drive positive change in the community through proper action, education and awareness. -- Rachel Hemblade
In 2014, the Acupuncture Relief Project continued clinical projects in Bhimphedi and Kogate, all villages in the District of Makawanpur. We hosted 22 volunteer practitioners and provided nearly 10,000 patients visits.
I would like to thank everyone who so kindly offered support and donations to help us respond to this terrible event.
One month after what is now known as the Gorkha Earthquake, our organizational attentions are returning to our primary mission. The 7.8 magnitude earthquake that occurred on April 25th, 2015 killed more than 8,800 people in Nepal and was followed by days of heavy aftershocks, some as strong as 7.3Mw.
In the first few days following the initial quake, we scrambled to make contact with our friends, staff and villages. Our foreign volunteers and volunteers of other associated organizations were escorted to their respective embassies who assisted in evacuating them to their countries of origin. We learned that no one associated with our project had been injured though several of our staff members homes had sustained damage. The villages of Bhimphedi, Kogate and Ipa, where we operate our clinic projects, sustained significant damage but only minor injuries.
After making an initial assessment, Acupuncture Relief Project and our local host organization, Good Health Nepal, started looking at emergency response plans. We made contact with USAID, Mercy Corps, Chokgyur Lingpa Foundation, several embassy officials and other organizations. We were strongly encouraged not to try to place a team in Nepal until receiving permission from governmental, military and police organizations. Instead we collected our Nepali staff and opened an office in Kathmandu. Lead by our ARP coordinator and Director of Good Health Nepal, Tsering Sherpa and his wife Sera Sherpa, this office staffed a 24-hour hotline where organizations could access our interpreting staff to support medical teams being sent to the field.
Interpreters were sent to Sindupalchowk and Nuwakot to support doctors and nurses in these remote villages. Other Good Health Nepal volunteers surveyed villages and distributed dust masks and tarpolines. More importantly, the office served to coordinate the efforts of several organizations in the distribution of medical and emergency supplies. They were able to provide government agencies critical data about the needs of the villages where we operate. We were even able to provide some funding and support to a group that was sheltering animals that had been traumatized and displaced during the earthquake.
I am so very proud of our staff for there efforts over the last few weeks. I think it is testament to the work we have done over the past several years that we had a trained group of young men and women ready and able to organize and provide practical, effective skills in the aid of their own communities. What we were able to accomplish with a few thousand dollars was truly amazing.
At this point, with the monsoon season starting, things are returning to some form of normal for Nepali’s. There are still many people living in temporary shelters and tent cities however schools and businesses are reopening and crops are being planted. Most people are turning their attentions to rebuilding their lives. We too are looking on to what happens next.
As of June 1st, we are closing our “emergency office” and sending our staff back to their home villages to help their families. Our first order of business is to assess the damage to our clinic building in Bajra Barahi and to prepare for a clinic team to resume our operations when the monsoon ends (early September). Tsering is traveling to Makawanpur to check on our clinic and also assure the District Health Office and our communities that we are eager to return to our work there. We know that the buildings and infrastructure may take many years to repair but we intend to address the trauma and emotional scars that fear and loss inflict as soon as possible. Our challenges will also include many health concerns due to damage of sanitation systems and healthcare facilities in our region. Currently the World Health Organization is projecting a major outbreak of Typhoid and other infectious diseases over the summer months.
Personally I am looking forward to being back in Nepal in September to reestablish our momentum in the training of healthcare providers in Makawanpur. The longer that we operate in Nepal, the more I see that the future depends upon inspiring and enabling Nepal’s young people to take responsibility for their community’s social welfare. Of course, this is always what we think in times of crisis. What we really need to think about is how rural areas of Nepal need access to compassionate, competent healthcare and social workers all of the time. -- Andrew
For as much as we glorify the medical profession it is actually a much simpler job than it seems. Don’t get me wrong, being a medical provider requires years of training and experience. In the developed world, medical providers are held to extraordinarily high standards. They should be as they are compensated very well for their responsibilities and we need their skills. My observation has less to do with expertise and more about attitude.
“How can I help you?”
This simple question should summarize our relationship with our patients by placing us in a role of service to our patients. Unfortunately, all too often, the question is presented more in the light of “What is the problem?”. This slight difference in language changes our role and places patients in our service rather than us being in theirs.
Nothing could be more clear in the developing world than the disparity between those who have money and those who don’t. People with money receive good access to medical care and are generally regarded with respect when visiting a clinic or hospital. Those who don’t have money, well… they are ignored. In Nepal, I have witnessed on many occasions, doctors who never made eye contact with their patients. I have seen them talk on their cell phone while they rifle though the patient’s records and summarily write prescriptions, sending their patient on their way without so much as two words exchanged. For the patient, this impersonal visit is often at the cost of their family’s land and livelihood. Again, there are many doctors who do very fine work and I’m not denying that hospitals, doctors, labs and technology do not cost real money —of course they do. As professionals, we need to make a living the same as everyone. The question is more one of, how do we serve our patients equally? How do we see each human being as a unique and valuable part of our community, equally entitled to our attention? For that, our profit driven system seems to fail us.
This year, I worked with one of our volunteer practitioners trying to manage a very persistent outer ear infection in a young Tamang girl. After several weeks of treatment with saline and vinegar flushes, topical herbs, oral and topical antibiotics, and topical anti-fungal agents, she still presented with a deep abscess just above the tympanic membrane. We referred her for a tuberculosis test to rule out a rare form of skin TB. It came back negative. Here is where it gets difficult for us, because we run up against the family’s ability to pay for other more extraordinary care. We appealed to the District Health Office for assistance and they requested that we obtain a referral from the local health post. After consulting with the doctor at the heath post, she agreed that the girl needed surgery to clean and close the abscess. However, she declined to write us the referral because “She [the patient] can’t afford the surgery, so what is the point.”
Now, dear reader, please don’t worry. These road blocks do not stop us and we generally find a way to help our patients. It is also not my intention to single out this one doctor because this is an attitude that pervades the entire health system. I would like to say it pervades the system “in Nepal” but I feel the problem is more far-reaching.
In my mind I ask, how can this be an acceptable response? How can it make sense to allow a persistent infection progress into permanent hearing loss or worse? How can that possibly serve the community?
In Nepal, the answer is that the doctor is not a part of the same community. He or she is separated by a gulf of education, opportunity and other socio-economic advantages. Doctors lose sight of the purpose of their service.
The other issue is that healthcare providers often don’t look beyond their own conclusions for treatment. When we have been trained to think an abscess equals surgery, it is hard to back away from that edge in order to think about other possible solutions or approaches. To remedy this, we need to take a more holistic approach to patient care. On an individual level, we talk about holism in the context of the patient, where we don’t just look at the disease process but rather we look at the whole person and how the disease is effecting their overall wellbeing. We need to extend this thinking to how we look at our overall system of delivering care. Instead of looking at medicine as individual modalities or treatment specialties, we need to go back to pondering how we can best alleviate a patient’s suffering. Often times it has more to do with providing information and education than it has to do with intervention, but it is impossible to arrive at this conclusion if we immediately jump to treatment.
Look at the fact that many research studies [1][2][3] show that the strength of the patient/practitioner relationship has a direct correlation to the patient’s medical outcome and it should be obvious that treating each and every individual with kindness and respect should go without saying. Yet, in my experience, this relationship seems to be lacking. This is especially true in the rural areas of Nepal where our patients are mostly illiterate and lack the education to ask even the most basic questions about their health. The doctor (I use this term loosely because usually the patient is seeing a health assistant and not a doctor) asks “what is wrong with you?” and then prescribes them a list of medications. Of course the patient has no idea what the medications do, they just believe that they will be cured. When they are not cured, they do not know what to do next. We have found that by just taking the time to clean an infected wound while explaining how to use simple soap, water and exposure to direct sunlight not only kills the infection and heals the wound but also prevents future infections. This simple practice injects new information into the community and effectively inoculates many would-be patients through dissemination. This is so much less-expensive and safer than the common practice of treating superficial infections with antibiotics.
At our clinics, we have the advantage of seeing our patients many times and we start to know them and their families. We laugh and joke with our patients (something unheard of in Nepal) and we start to understand their unique needs. We earn their trust and that trust allows us to help them in ways that transcend medical intervention. I am certain that our volunteers get tired of me telling them that a patient has the right to know their diagnosis. They should know the details of the prescribed plan (or medications) and what the expected outcome is. It is so simple. However, throughout Nepal’s medical system (and probably our own), patients lack this basic information. If they were armed with this information, they could make their own choices regarding their care. They could agree to be served by us, they could seek other advice, or they could do nothing. It would be in their hands.
This year we hosted our first ever formal community and press meeting. We invited our patients, community leaders, district health officials and members of the local and national press to hear what we have accomplished in Nepal and our ideas on transforming the rural care system. It was sort of a grandiose plan but it was very well attended and received. The District Health Chief spoke very highly of our service in Makawanpur and pledged his support in looking at a more holistic model of providing care. He introduced us to a new area in Makawanpur called Bajra Barahi which is regarded as a model health post in Nepal. Their development committee listened to our presentation with interest but also a heathy amount of skepticism. They had experienced several disappointments from other NGO’s who promised large benefits but delivered shoddy medicine with many poor outcomes. They were also very concerned about the sustainability of our efforts.
My response was simple. “We either earn the trust of your community and show you that we can be effective or else it doesn't matter if we are sustainable or not. We offer a simple, safe and effective addition to your health system in which we work side-by-side in partnership with your existing staff and facilities. If we show you that our system is effective, it is easy to adopt and sustain without us. We will show you how and you will have a model which you can share with every district of Nepal.”
They were satisfied with that answer and in the weeks that followed many doors opened for us. Baja Barahi’s development committee offered to give us a small clinic building and land within the existing health post compound. This new partnership with the district government has been the opportunity I have been looking for since beginning this project in 2008. It is our first opportunity to not only care for patients, but to start working on transforming the rural care system as a whole. In other words, now we have the opportunity to put-up or shut-up.
This is quite the mandate and to meet this challenge we truly have to address our sustainability. Since beginning in Nepal, we have recognized that it is not practical or cost-effective to sustain our project with foreign practitioners. Unfortunately the problem of training and properly certifying acupuncturists has been a major obstacle. A system of accreditation and licensure does not exist and we envision training a type of health-care worker that does not yet exist. Ideally this hybrid “Rural Care” provider would be trained in both basic allopathic medicine (same as the existing health assistant) as well as acupuncture, bodywork and medicinal herbs. They would support other doctors, heath assistants and health post staff but also provide holistic health advice, simple and effective treatment and be an advocate for integrated patient care. In order to be useful in strengthening Nepal’s rural health system, these new providers would need to be able to work independently in some very remote regions.
Our solution materialized in the form of a small acupuncture school in Kathmandu that was struggling to get started. Founded by a Japanese NGO and staffed by a few Nepali acupuncturists that were trained in China, the Rural Health and Education Service Center (RHESC) was able to acquire certification through Nepal’s vocational education system in 2013. That is a start but falls short of certifying the kind of provider we are looking for. This year we were able to form an alliance with the RHESC and I was honored to be given a position on their Board of Directors. My task is to write a curriculum that will be accepted by Nepal’s Health Professions Council, allowing them to offer a bachelors degree in Acupuncture and Rural Health Care.
I had the privilege of teaching a five-day seminar on the shoulder joint to the RHESC’s second year students and was impressed by their appetite for opportunity and education. Our challenge is to inspire them to work in rural areas where they are needed most. Starting in September 2015, we will be hosting 12 RHESC students as clinical interns. This mentorship program will allow students real-world field experience under our guidance and offer the district government the opportunity to see the potential of future employment of RHESC graduates. We have encouraged several of our current interpreters to compete for government scholarships available to students in rural areas for enrollment in the RHESC program. This will be the key to sustaining our clinics in areas like Kogate which is too small for us to sustain a permanent clinic.
These are all just the first few wobbly steps in the right direction and while all of these developments are exciting prospects, I try to root myself in my own experience. From there I see that when it comes to patient care, sometimes I can have a major impact on a person’s life. Other times I struggle to offer even the slightest relief no matter how hard I try. Either way I hope that I never fail at making my patients feel cared for. With this simple idea, I believe we can make a ripple in a much bigger pond.
“I believe that through open dialogue of not only my successes, but also my fears, challenges, and weaknesses, I will come to a greater understanding of myself and will help others do the same.” - ARP Volunteer Handbook
February 9, 2015
It’s our day off and we are traveling to a “palace” about 3 hours away for a team picnic. Our bus is full, and the trunk is packed with cooking supplies and food. We make one stop for more fruit and food, and another for this sugary milk fat condiment, kua. And then we just keep driving…
We arrive! But we have to walk about fifteen minutes up to the top. I carry a large stainless steel bowl of more bowls and utensils atop my head because that is the only way I’ll be able to manage. I get a glimpse of what the average day is a like for the average Nepali woman, and how life taxes their bodies. Life taxes our bodies in the States too…just in a bit of a different way.
Auntie, Jessica, Urmila, Suman, and Ritesh immediately get to work. They are all speaking Nepali and moving quickly. I’m not sure what is happening, but I want to help. I assist with washing and prepping the vegetables. That I can do without much communication.
We walk down to the “sink” about 100 meters away. The ergonomics are not the most ideal for our bodies, but there is so much beauty in the scene that it doesn’t matter. There are five of us squatting around this stone sink. We are washing a five liter bucket of tomatoes, julienning daikon, and slicing onions, all against a backdrop of mountains, trees, blue skies, and the clear horizon. Though Urmila and Jessica are chatting away in Nepali, we are all still there together, working together, creating a meal together. It’s just…great.
"DUDH CHIYA!" Ah, the milk tea is ready. We’ve had so much milk tea since arriving, and this is probably the best yet because it was made over a campfire and because it was made with all of us there!
Then we have our bacon egg sandwiches for breakfast! Whoa is right. We are all feeling protein deprived, and this is certainly a treat.
As we clear the plates, I see Auntie preparing a giant pot of beans. “She’s cooking more?” I ask Tiffany. “Yeah, lunch” I thought the sandwiches were lunch! Nope. There will be more, much more. So, while we digest before lunch, we go for a walk and tour of the palace.
I’m sitting atop a stone wall where cannons were once placed, looking out into the horizon.
I didn’t intend to, but the space was calling. I find myself in lotus position.
Tell me the secret.
My eyes softly close.
Nothing.
Wind brushes my skin. Do I go with the flow- with the wind, and let it carry me? Do I stand like bamboo and find flexibility? Do I stand like an old thick tree and stay as still and strong as can be? Tell me.
Then the wind stops. I feel the sun warm my neck and back; it envelops my heart. The sun nourishes me. It lets me grow and be loved.
My spine is straight, my shoulders are back, my eyes closed, and my heart is open. I hear footsteps and wanted to open my eyes and break away from this moment…but don’t. Its not like I feel danger, just don’t want to be seen like this. But if I open my eyes, will I be shaming myself? Won’t I be illustrating that I am not good enough – for this love I am receiving and worthy of?
Why am I here?
If I can’t receive, how will I give? How will I become the practitioner I want to be – my whole purpose for this trip? I want to be the practitioner who not only who treats with competence but more importantly with care and compassion.
Hmm maybe that is what I needed – to know that I am worthy of love and compassion, and to forget all that bullshit and questioning of the pathway – whether or not I am on the right one, or doing the right thing. It doesn’t matter in the end. In the end, it all boils down to love and compassion (how many times can I say those words?) Cliché? Maybe. But so true.
From slicing vegetable with friends to my own meditation, there are many ways for me to practice. I’ll grow as a practitioner. I’ll grow as a person. - Debbie Yu
He's sitting in an 8x10 concrete room with two beds in it. There is a small space heater and a post where the rusted, gigantic oxygen tank is tied with a bow made of hemp cord. There are three mudas, or woven stools, sitting on the floor. His family members usually sit on these stools but they offer them to Debbie, Ritesh, Bibeck, Pawan, Milan and I because we've come at this late hour for a house call.
He is cross-legged on the bed, propped up against four stacked pillows. There is a fleece blanket draped over his shoulders, like something you'd find in a young American girl's room; cream colored with orange and white flowers. He wears a maroon sweater over two shirts and a thick, knitted beanie with a pom pom on top. Despite this, he's still cold and it's an effort for him to stick his fingers out of the blanket so that we can put the pulse oximeter on it. He does it patiently and for as long as we ask and when we are done, he quickly puts his hands back under the blanket. I see that he is anxious, he's afraid to die. I take his right hand and massage it gently, while I check the pulse oximeter on the other hand to see if the number has gone up. He sticks his left arm further out of the blanket and motions to a large area above and below his elbow. I ask him, "What happened?" Ritesh translates: "He got these at the teaching hospital in Chitwan, they kept trying to take his blood." I look more closely, some of the bruises are the size of baseballs, two on his upper forearm, one at the medial elbow and three more below. He points to a small dot at the mid-forearm telling us, "They were finally able to get the blood when they tried down here."
I feel my face get hot as I look into his sweet eyes. More of his arm is bruised purple than not. First, Do No Harm. I am overcome for a moment as I imagine the nurses or doctors at the hospital sticking him over and over with needles as he's having breathing difficulties. He puts his arm back into the blanket with a small shake of his head about the bruises. I look at Ritesh and I see that he understands I am mad. He says, "There's nothing you can do." I know it's true and I swallow it down and move on.
Debbie gently rubs his back between his scapulas. We are both sitting on the bed and doing everything we can to calm him down. Terry, our team lead, is in Kogate and Andrew is in Kathmandu. We can get them on the phone if we need to but otherwise we are on our own. There are four interpreters with us, everyone is watching us.
The tank is bubbling in the background, but as Bibek checks it, the pressure meter slowly falls to zero. We look at the pulse oximeter and see that our patient's blood ox levels have dropped into the low 70's. Ritesh makes a phone call for more oxygen.
The tank arrives and it takes three people to carry it in the room. It's five feet tall and looks like something Jacques Cousteau pulled up from the depths of the ocean. I expect an old metal diving suit to be attached to it, but nothing is, which is part of the problem. The neighbor takes his time fussing with the hemp cord around the old tank. Debbie calls out, "Can you please hook up the oxygen before you tie the tank up?" Bibek translates. The neighbor ignores us all, like we are flies in the room where he is doing some serious negotiation with the ratty cord. Debbie repeats. Bibek repeats. We are ignored again.
Twelve minutes have passed since the oxygen ran out. Our patient's cells are starving. I am scared and I can tell Debbie is too. We have to get the oxygen levels up but all that's going up is his pulse rate: 103, 106, 108. Debbie's thumb sits gently under his clavicle bone. She is counting his breaths. "Forty." "Forty-four." "Forty-six." His respiration rate is grating in the background like nails down a chalkboard. His eyes are pleading. He is drowning. Everyone is quiet. None of us can breathe. I check my watch: Fifteen minutes at 70%.
I look to the neighbor; should I grab the damned tank and do it myself? He has finally tied the bow and inserted the valve piece. Now he is fumbling with a wrench to tighten the seal. His incompetence is maddening. I think I could do it faster, yet I don't budge. I don't want to stir the calm. I stay frozen like all the others, watching, waiting, hoping for that top number to start trickling up so that we know his cells are going to live. I am trusting that something higher, perhaps one of the thousands of gods or goddesses that live here, is in the room with us to help this guy get his wrench dialed into the right setting and set the oxygen to flowing. They say that the Nepalese have so many gods there are three for every human. That makes twenty-seven gods in the room with us. Eighteen minutes.
Finally, the pump is turned on. Debbie and I haven't helped hook a patient to an ancient oxygen tank before. We don't know anything about this old bubbling gauge, nor what the setting should be on. Regardless, the oxygen finally flows and the number on the pulse oximeter flashes up to 74. The heart beat goes down to 102. Debbie lets her breath out and whispers, "Forty four." We are moving in the right direction now.
It's been eleven days since that first home visit to "Uncle" Lal Lama's. Since that time, we've stopped by his house almost every day, sometimes three times a day, to monitor his vitals. This has to be done during our lunch break or after a full day of work. It requires that one of the translators gives up some of their downtime to come with us and we are so appreciative of their willingness to do this.
We have communicated to the family that our recommendation is for them to go to the hospital. They have refused, saying that the hospital in Chitwan said there is nothing more than can be done for Lal. They don't trust the hospital either, due to a series of negative experiences that have made them quite scared to go there. The hospitals here can be very scary places. Our team can't do much more than monitor Lal's vitals and provide some anxiety relief with acupuncture and we've let the family know this. They still refuse hospital care.
Our Uncle is not getting better. For the first week after our initial home visit, he was able to get off the oxygen tank for 10 or 15 minutes and venture into the concrete patio outside of his bedroom. Each gigantic oxygen tank would last for around 48 hours. This week, Uncle cannot get off the tank without plummeting into respiratory distress. Some tanks last for less than a day.
He is pinned in his small, dark room, like a undersea diver who is just visiting this life for as long as the oxygen will last. I have seen him moving through the stages of grief as he realizes that his time here is short. I have moved through these stages of grief with him. One afternoon, Ritesh and I arrived to find him in a splendid mood. He was telling us stories about his boyhood. He was living in Kathmandu and had gone to art school. He would travel up to the Monkey Temple and look over the Himal. He would draw or paint the Annapurna range in a series of mediums, ranging from charcoal to watercolor. He was also a sculptor and carved a number of animals at popular temples. He won an award from King Bhirendra for a gigantic elephant he created and painted, poised on springs so that as it was wheeled in front of the king, a spring popped and the large trunk swung up to salute the patriarch. He was an entertainer and dancer in a comedy troupe and it brought him great joy to give all of his gifts of creativity to his community and country.
The day that Uncle told us these stories about his life, I started crying as I was behind him, checking his lung sounds. Ritesh could see me as he translated and I wiped the tears away and tried to regain a professional demeanor. I took deep breaths and sat with Lal until he was finished telling his stories. On the walk back home, I tried to hold it all in, until I could get to my bed and bury myself in my sleeping bag to cry. I couldn't make it and burst into tears about 50 meters from the patient's house. I took off my white coat and held it over my face, as if it would stop Ritesh and the town of Bhimphedi from seeing me do this. Ritesh put his hand on my back and said, "It's okay. I can't cry so maybe you can cry for both of us."
It was awful to walk up to the house and find the whole team sitting outside. They saw me crying and there was no way to explain it. Lal was in a better mood than he'd been in for days but they all worried that something bad had happened. I told Andrew he was fine but listening to Uncle, I knew he was going over his life and that he was getting closer to his death. I was also starting to realize what an amazing person I had just been sitting with. I know we are mortal, but as I sat there I saw that no matter how amazing we are, we will all die. I will die. No matter how I love, how I live or where my hopes lay, I will die. As I sat on my bed crying, I saw that I was crying for myself, not Lal. I was crying for the mirror that Lal had just held up before my own life. I am just another diver in this ocean, a diver with a tank that is a little bit more full than his, but who is equally exploring this beautiful shipwreck and will have to go up to the mysterious surface again at some point.
I applied to ARP and I came to Nepal to find myself because I had started to question my identity this year. Each patient and every team member here is holding up a mirror for me to look into my own soul. I have spent so many years criticizing myself and never finding myself good enough, but some of these mirrors are shining back a spirit of generosity that I never acknowledged. Lal is showing me that I need to honor this amazing part of myself and I need to continue to live life as fully as I can. I need to spend my time in this adventure looking for the treasure that I know is there. I miss all of you back home and I send the greatest amount of love to you all. --- Rebecca "Bex" Groebner
I knew I wanted to volunteer with the ARP when I first heard of it four years ago, during my first year of acupuncture school. Now, sitting in my guest house in Kathmandu with dogs barking and gentle Nepali conversation drifting in through the window, it’s sinking in that I’ve fully realized that intention. I’ve spent more than six weeks treating patients in rural Nepal, doing my best to help however I could manage.
Earlier today I met a man named Rajesh playing guitar in front of his friend’s collectibles shop, and I ended up hanging out there for hours. Turns out he grew up near Kogate, the small village where Rachael and I ran our free clinic, and he told me how happy he was that I’d been volunteering to help people in his hometown. I told him I felt grateful to be there, far from the bustling noise and bad air of Kathmandu, where I could get a glimpse into the heart of Nepal. Most of Nepal is as rural as Kogate, and I feel lucky that I could live in such a small but beautiful community.
Most of the team stayed at a town called Bimphedi, which itself is hours away from Kathmandu. Kogate is about a three hour hike up the hill above that. Although Bimphedi seemed tiny when I first arrived there, its few dozen shops and paved main road made it feel like the city after my first week in Kogate. There no roads are paved, and the only traffic besides the occasional motorcycle is a rickety bus called the Himali Tiger that makes its slow, bumpy way up and down the mountain once a day most days of the week. Even this luxury is relatively new: there was no bus service about seven years ago. One patient shared the story of when his wife hurt her knee badly enough to require surgery. He and his neighbor had to carry her down the mountain to Bimphedi to catch a bus to the nearest hospital in a town called Hetauda. At that time, any supplies from Bimphedi also had to be carried.
Rachael and I stayed at the end of the bus line with the parents of one of our interpreters, Suman. They asked us to call them Ama and Buwa (mother and father), and they welcomed us into their home like family. We shared their same food, and our only extra luxuries besides what we brought were an electric kettle and a filter for the water from the outdoor faucet. Even electricity is relatively new to Kogate, set up within the last couple years, and Suman told me that the village didn’t change all that much as a result. Mamta, his sister in law and our other interpreter, also stayed with us, and our receptionist, Lanka, met us each morning after an hour’s walk from her home down the hill.
During our stay, Rachael and I slowly became recognized community members. We’d meet our patients and their relatives on our walks to and from the clinic and exchange enthusiastic Namaste’s with schoolchildren. I played soccer with the boys who hung out near the clinic, and kids often watched our treatments from the stone wall that surrounded our clinic. One of my most regular patients was also Suman’s good friend, and we hung out together outside of the clinic. I taught Suman a little tai chi and had a blast teaching them both to juggle. Rachael did a great job memorizing all of her patient’s names and began to recognize which of her patients were related. We’d see one patient herding his buffalo and another her goats near the clinic. Even our bus driver came in for one treatment. We were much less busy than the Bimphedi clinic, which served many patients that came from many hours away, but almost all of our patients knew one other as members of the same community.
On the second to last day of clinic I got a new patient who was visiting his daughter in Kogate from a more remote place. He has an enormous lemon-sized cyst under his right tricep compressing the nerves in his arm, causing pain down his hand and reduced motor function. He had gone in for surgery three years ago, but after draining fluid from the cyst, it swelled up again, becoming larger and more painful. He came back the next week, and he told me that at that point they wanted to amputate his entire right arm, which he refused. (I’m hoping this was a miscommunication, and that they meant to explain that completely removing the cyst would cause nerve damage in his arm that may then lead to such deterioration as would need amputation.) He also has knee pain, and when rolling his pant legs up for the acupuncture I saw severe psoriasis on his right foot, which he scratched to the point of creating sores that were open and bleeding.
This patient really drove home the issue of access to me. His hometown was a 2-3 day journey away, so it was impractical to refer him for treatment during the next camp in Bimphedi. The two treatments he would get from me would be all the care he was likely to get, and I knew there was only a little I could do. I explained that I couldn’t help decrease the size of the cyst, but we would try for some temporary pain relief for his arm and his knees, and I bandaged the open wounds on his psoriasis. He understood and wasn’t upset. He said he didn’t mind because could hide the cyst from sight under his jacket and the pain was managable if he was careful not to bump it, and the psoriasis he’d had since childhood. At his second treatment he at first reported “no change,” but went on to say that he’d had no arm pain at all the previous night and had noticed that his knee pain was less. I know this relief will be temporary, but it’s something.
On a larger level, I worry that our time in Kogate likewise provided only temporary relief for long term problems that we can’t fix, problems that boil down to a lack of adequate health care access. Over the next two months, the smaller number of volunteers for the colder season means that the ARP can only be there once a week instead of five days a week, and because of the lower patient numbers, I don’t know if the ARP can sustain a clinic there long term. The volunteers’ time could be better used in a busier clinic, and Kogate is already closer to the Bimphedi clinic than the hometowns of many of its current patients. But after being welcomed so warmly it was hard to leave not knowing how much continued care our patients would receive in the future.
Now that my time there is done, I have to take comfort in knowing that we did what we could, and for better or worse, all our actions there have created ripples. People came in for anything and everything, including cuts that needed bandaging, common colds, rashes, sore backs and knees, headaches, and gastritis, and we did what we could to help whether or not acupuncture and herbal medicine were indicated. We used whatever we had: pain patches, moxibustion, massage oil, eyewash, anti-itch cream, cough drops, and ibuprofen – anything appropriate. Rachael even used a few candles and layers of acu-tape to even out the handles on the crutches of one of her patients to help his structural imbalance. And although we’ve left already, for a time at least we were there and genuinely willing to listen and help, a sentiment often missing in local hospitals. (The woman who was carried down the hill for a knee surgery, for example, came back with her knee cap sewn back on too far up, in spite of her husband’s unheard attempts to object while watching the surgery.) One of our friendliest and most talkative patients, who enthused that our treatments gave him “a new life,” told us he thinks a big part of his improvement was due to our kindness and smiles. And on our last day, we were overwhelmed by the handmade necklaces and bouquets of the fragrant orange flowers our patients brought us to wish us a safe journey home.
I know my experience in Nepal will have ripples in me as well. In the face of different complaints and fewer resources, I found myself doing such doctor-like activities as dressing wounds, taking blood pressure, monitoring blood glucose, taking temperatures, looking down throats with a tongue depressor and penlight, and examining painful eyeballs for irritants. This experience, in addition to the practice with acupuncture and herbs, will help me give better and more complete care to my future patients. I’ve also come away with the realization that people aren’t so different all around the world, and that I didn’t necessarily need to travel halfway across it to find folks who need more or better medical care, particularly in rural areas. Regardless, I will miss my Nepali patients and friends, and if whatever community I find in the US can spare me for long enough, I hope to return to Nepal to come see them. - Eliot Sitt
Project Director's note: Don't worry about Kogate. It is a village very near to our hearts and we will continue to support it as we develop our sustainability plans in Makawanpur. In fact, I hope to retire there one day.... I have my hilltop all picked out. -Andrew Schlabach
Here in Nepal, very little is convenient. Nothing is handed to you on a platter ( except our dinner, thanks Auntie). The modern world of convenience has not yet arrived to Bimphedi. Their is no internal plumbing in the houses, nor heating, nor appliances. There is wifi though? Bizarre.
Everything takes 10 times longer because of this; cleaning clothes, having a shower, making coffee, making food etc. And we live in luxury compared to most locals. We enjoy hot water, electricity, and wifi!
It is much more apparent and more emotional at clinic. At home when someone presents to my clinic, they have probably already seen a doctor, and had some scans or tests (depending on their condition). They may already be under the care of a specialist. They usually know what they have and have a pretty good idea of how they got it. For the most part, patients arrive with a clear cut medical diagnosis. (NB. I'm talking about the Australian system here, our national medical system is, thankfully, very good). If they don't already have a diagnosis, it's free/cheap to obtain one. I can simply say, 'Go consult your Doctor, then come back to see me' and I can be confident that it will be taken care of on the other end. After this has been done, it is my job to apply Chinese Medical thinking and methods to their health problem.
At home, lumps are scanned, biopsied, and removed. At home, digestive ulcers are viewed by endoscopic cameras, medicine is given, and dietary advice is understood. Alcoholics have access to the help they need. STIs are tested for and managed. Lower backs are x-rayed and orthopaedically tested. The list goes on.
In Nepal, this is not the reality. Patients will come to our clinic with the problem, and no information beyond that.
Like the lady with the grapefruit-sized lump on her inner right thigh. It hurts. It's been there for 5 years. Can you help?
Like the woman with sore breasts for 6 months. They hurt. There are lumps. What's wrong?
Like the man with the chronic leg infection. Sometimes is weeps pus, sometimes it doesn't.
The children with paralysis from high fevers that weren't treated.
The out of control diabetes and high blood pressure.
The huge number of alcoholics.
We are triage; It is our job to ask all the right questions. Get an accurate symptom picture. Know which diseases are indicated. Know which tests will confirm or rule out these diseases. Hope that when we send them to the local hospital, they will actually perform the tests, prescribe the right medication, and if we're really lucky, explain what's wrong to the patient. This is all only if the patient can even pay for it at all.
We are also medical counsellors; We explain what is wrong to the patients as the doctors never seem to. And give good advice, a crucial part of health care in my opinion. How can people care for themselves and their families when they are given no information and their illiteracy prevents them from accessing it themselves.
And, then of course, we are doctors ourselves, performing treatments and providing ongoing care.
So this is what was meant when we were told that we are now 'Primary Care Physicians'? Ouch
In this setting I am finding the need to step up in a huge way. My clinical knowledge, especially western medicine diagnoses and disease management has had to be expanded in a big way. Not a bad thing, certainly. Thank God for the team of practitioners around me and the Merck Manual app! I've learnt that the important thing is not to know everything, that is impossible. The important thing is to care, and be willing to try and figure it out.
I've never learned so much, in such a hands-on way, in such a short space of time. Thank you ARP, my team mates, and, everyone back home who helped get me here.
Most of all, thank you to my Nepali patients for being the sweetest and the absolute toughest teachers I have ever known.
In my fourth week of volunteering at the Kogate Clinic, I hiked over an hour away to a town in the next valley called Ipa. Suman (my awesome translator) and I were on a mission to see an old patient of the project that has ALS (a degenerative neurological disease) and can no way make it to our clinic.
Bim is in his 80's. He can't walk and can only really manage to go from sitting to to lying by just falling backwards onto a well placed cushion. If he wants to sit back up he needs someone to lift him. He lives with his wife on the top of a hill overlooking Ipa valley. From the other side of the ridge you can see white capped Himalayan peaks across on the horizon. It is really quite picturesque, but because it's so remote walking to and from here can be quite difficult. The road there is very uneven and rocky; even a motorbike would have trouble with the steep climb.
We arrive at Bim's, passing the neighbouring house where a couple of grazing buffalo peeking up at us and a dog barking protecting his territory greet us. Bim is sitting on the porch of his little mud house looking a little blank and weary. His wife gets up to welcome us and asks if we'll be staying for lunch, which we politely decline. She herself is in her 70's, a tiny lady that has obviously worked hard her whole life. She stands so stooped over I can only imagine that having her husband immobile has given her more than her fair share of work each day.
This is my first experience visiting someone to do a remote treatment. I'm not even sure where to start. I ask how he's doing and we go straight to checking out his worrisome bed sores. After attending to these and educating his wife to keep them clean and dry, I proceed to cut his finger nails and gather more information about his general well being.
While he was still up for it, I gave him some electro-acupuncture to stimulate the muscles in his legs but he didn't last long before getting uncomfortable. Staying in one position for too long was Bim's biggest problem and his wife can barely manage to help lift him from sitting. I'm guessing without any extra help she must drag him across the mud house floor to his bed.
I chatted and demonstrated to Bim the importance of regularly moving the muscles in his feet and legs to preserve the limited movement and strength while helping his circulation. While I gave his wife an acupuncture treatment I kept checking to see if he was doing his exercises, which he found quite amusing.
Luckily, I had packed some herbal antibiotics which I prescribed partly for his bed sores and also more concerning was his burning and occasionally bloody urination. I was concerned he had a possible infection, prostate issues, or something more sinister, so I planned to further discuss with the team the logistics of getting him more care.
This really felt like a hopeless situation I was walking into, however, he has no other support; while his wife is doing everything she can. All I could do was the best on the spot healthcare I could provide while trying to make him smile and feel cared for. After spending just over an hour with the couple Suman and I made the trek back to Kogate in time for lunch. On the way Suman said 'I'm so happy today!' I asked him why and he replied 'we got to go for a nice walk and did you see the look on Bim's face when you said we'd be back next week?' I thought, yeah he's right, I feel happy too.
That moment really resonated with me as to why I'm really here.
I went back and visited Bim and his wife two more times before the camp ended. My last visit was bittersweet. I'd had a feeling this would be the case, so when Suman and I were walking to his house that day, I told Suman that I wanted to focus our visit on making Bim smile.
When we arrived Bim was lying on his porch with a tiny little black kitten by his side. The results from his urine test I had his son get while he was in Kathmandu were not great, but his discomfort when urinating had improved. The hardest part was seeing Bim's decline over the past two weeks. His feet were swelling more and now he couldn't wiggle his toes. We checked his sores, cut his finger nails and I decided only one acupuncture point was necessary as I gave him leg massage instead. We talked about the kitten in which his wife wasn't too keen on, but I could see he liked this cat. The cat had no name so I suggested Bim pick a name for the little kitten. He named her Kali (which means black in Nepali) and took much delight in me asking about Kali and bringing her over to say hello to him.
Once we'd finished his treatment and discussed getting another urine sample tested, Suman and Bim's son lifted him onto a straw mat in the sun. He laid on his side while I gave his wife an arm and shoulder massage in the sun. She looked so relaxed by the end of it. It was as if I'd lifted a weight from her shoulders. I was chatting with her and their son, until Suman pointed across to Bim where I saw him sleeping peacefully in the sun. He had only been sleeping one to two hours a night and in the past week had not been able to sleep during the day. This was a blessing. This was also the last time I saw Bim. And this is how I would hope he passes on when his time comes. Even though I knew I couldn't drastically change his situation I felt I gave him, his wife, and their son a little relief. --Rachael Haley
“Are you a shaman, is there medicine in the needles?” is a question I hear a lot; which is not really that different than a steady stream of Americans asking if acupuncture really works, but here I don’t have to defend my profession using science terminology that people may remember from high school. I always decline being a shaman, but the question has me wondering if I should step out of the western mindset for a moment, since I am, after all, in Nepal.
The Acupuncture Relief Project is supposed to be a set schedule, you show up for six weeks, do the work, and conclude said scheduled events with empowering stories to tell your friends and family about life in the third world, but four weeks in I’m convinced that this short trip to a land I knew nothing about has become one of the greatest markers on my journey through life and as a practitioner. It has become a doorway that has opened me up to a flowing path of knowledge that has been cascading through time for millennia.
Being here is like stepping back in time. There’s our personal comforts of electricity and internet that keeps us connected with the other side of the planet thousands of miles away, but when we step past the front door a different reality comes into perspective. Not just one of rural Nepal, but of all rural places in which man inhabited across the globe up until the building of great city centers and the industrial revolution. The people can go as far as they can walk in a day, they must carry everything at once on their back (or heads), roads are traveled paths full of treacherous rocks, and their joints are put to the test on an hourly basis. Farm, family, and prayer is life. There isn’t much else, because when it takes you an entire morning to make breakfast or feed the animals that will eventually become dinner, there isn’t much time for anything else. Your neighbors will always be your neighbors. Your neighbors are probably distant cousins, and the town drunks are drunk because there’s no such thing as an –ism that explains an escape from the harshness of the world.
Then there’s me. Standing in the unique position of strolling down the street, settling down into clinic for the morning fighting my usual personal habits; which even on the other side of the world hold true to who I am: NOT A MORNING PERSON. Then slowly, but surely, magic happens. People tell me their stories of everyday life, their major issue that’s ailing them, and no more than the shamans of the past I pick my tools to either poke, burn, or send down their throat to subdue their suffering. At the end of the day my fellow practitioners and interpreters have become a clan. Like a family we speak our own language and do our respected duties to provide a service to the village. It’s in the moments after I’m done consuming the home grown and prepared dinner that I reflect on what happened on the day that passed. It all seems like a blur, because it seems like it can’t be described. I pull myself back to the moment when I touch my fingers to a patient’s wrist. Being in the moment while the spirits of past Chinese medicine scholars’ knowledge flow through me to try and explain what imbalance of the universe sits before me, speaking to me through a radial pulse. What is going on inside of them?
We’re spoiled with not having to grind and boil herbs for every person or prick them with animal bone needles, but for the most part I am living in the spirit of the greatest Chinese practitioners of the past. I am looking at people that live in the elements and are truly affected by the world around them. They are the microcosm that is showing me the macrocosm. The cold of winter after a damp rainy season is inside them. It’s in their joints, stagnating at the bottom of their pulse, and weighing on their mind. It’s up to me to see them as something more than tendonitis or gastritis. I have to see them in the world they live in, which is one where wood like tendons will break down easily if not nourished by smoothly flowing water, or that a spicy food diet is like scorching the earth over and over until the soil becomes dry and can no longer nourish the village. No electronic imaging means that lump is a big ball of damp requiring heat to unblock stasis. I have to look at them through the wisdom that is Chinese medicine and the realities it was born out of. Perhaps I am not a shaman, but I do wield a medicine that makes sense for their lives, because it was the medicine that was born out of the lives of generations of laboring villagers.
I get to escape the world that is studied in books and the perceived notion of modern scholars on what they think the classics mean. Formula and dosage dogma goes out the window when you have a limited amount of supplies. You use what you can get. You use what you have to the best of your ability and the presentation that is before you. Studying wind cold invasion in a text book or what the pulse should look like is nothing compared to meeting a woman who has been out in the cold all day working with a sparse amount of covering and didn’t have lunch heated in a slow cooker. It’s hard not to think cinnamon and ginger with hot porridge isn’t the best remedy no matter what the ratios are.
Like I said, it’s just a reminder of the journey. Here I am in a country that is culturally Hindu, I’m of European ancestry, and I’m learning about the true nature of Chinese medicine. I am uncovering the mystery of where this medicine came from and how it is so successful at treating the human condition. Being able to come here and have one epiphany after another certainly seems like magic to me. So the next time I get asked, “are you a shaman?” I may just have to respond, “with how all of this has worked out, I might just as well be.”
“The modest disposition begins with the recognition that there is no one method for solving problems. It’s important to rely on the quantitative and rational analysis. But that gives you part of the truth, not the whole….This is a different sort of knowledge [folk wisdom]. It comes from integrating and synthesizing diverse dynamics. It is produced over time, by an intelligence that is associational – observing closely, imagining loosely, comparing like to unlike and like to like to find harmonies and rhythms in the unfolding events. The modest person uses both methods and more besides. The modest person learns not to trust one paradigm. Most of what he knows accumulates through long & arduous process of wondering.” – David Brooks, The Social Animal
Well, I said that Nepal was going to be a life changing experience and it has been in so many ways.
Lazy Cogitation
I came to Nepal as a newly graduated Practitioner from a Chinese Oriental Medical School in Portland, OR, with all sorts of images and cogitations of what life would be like in Nepal. I thought about the many people that I would have the opportunity to treat and all of the new treatments I would learn about as they arose. The only thing that has come out of what I now call Lazy cogitation (trying to foretell what will happen), is that Iʼm in Nepal. Iʼve been confronted with many medical situations in which I had no idea what to do, and I use the Nepali term “K Garne” (What to do?) often. With no internet, it is very difficult at times to figure out what possible syndrome(s) some of my patients have. I return to the basics of the eight principles in Oriental medicine and work from there. I see many orthopedic cases, lower back pain, knee pain and different dermatological cases I previously had no experience with.
From Practitioner to A Kinder Spirit
Kogate is a rural, agricultural community that I have had the pleasure of living and serving in while here in Nepal and many of the villageʼs people have reached out and touched my life. Being immersed into this community, changes have begun to occur within me. They have invited me into their homes to share their meals, celebrate holidays, dance to their local music, sing some of their songs, drink the local home brew and just enjoy life with them. I have begun to realize that a transformation is beginning to occur; I am smiling now more often then not. Laughter is becoming something that occurs even more often now. I am still the white medical person, but they welcome me into their community with open arms and laugh with me as I try to speak the Nepali language. As they come into the clinic we now have another connection between us besides the treatment time; we have celebrated other times amongst one another.
Namaste, a greeting, has become even more meaningful as smiles are exchanged between us as we pass one another along the road or as we greet one another in the clinic before I begin their treatment. The little children of the area are so wonderful. Always coming up to the window in my treatment room and watching what is going on. As I walk up to the house that I live at, four or five of the children that live at the bottom of the hill will clasp their hands together and say Namaste with a smile and a laugh.
A very precious moment occurred one day as I was walking back up the mountain from the lower camp clinic to the clinic in Kogate. A group of school age children were walking in front of us. They were mostly girls ranging in age from 9-13 years, and one little boy maybe 8 or 9 years old. He started to walk next to me for a time. As we traveled up the hill together we played a little game. I would start to run a bit and he would chase/race along side of me. We played like this as we traveled further up the mountain. I thought to myself, does he need to turn around and head to his house? Itʼs not uncommon to see the children playing or walking along the mountain roads or trails. Reason being many of them have a long walk to school. Alman and I just continued up the mountain and I figured he knew what he was doing. I had my headphones on listening to music ( a 3 1/2 hour hike goes easier with tunes) so I took them off and put them on him to see what he would do. He smiled, moved his head back-and-forth and we continued up the mountain. All of a sudden a group of little guys joined us and began to ask me all sorts of question in Nepali. All of a sudden, Alman grasped my hand with his hand. He wasnʼt going to let anyone else in between him and I. We walked this way for the rest of the time, then a trail branched off and he went his way and I went mine. The following week as I traveled back up to Kogate ( we had to go down to the lower main camp every weekend), I saw a group of little guys sitting on a big rock. Almon was one of the boys and as soon as we recognized one another, he jumped down from the rock and ran up to me, grabbed my hand and walked with me up the road again for awhile. This time I had to branch off to take one of the short cuts so we waved good bye. Our third meeting occurred as I was walking down from Kogate. An older man and young boy were walking up and soon I realized that it was Almon. As we passed each other he reached out and grasped my hand. I have three more times to travel that route between camps. I hope I will be able to meet up with Almon again.
Brothers
The two young gentlemen, Suman and Bibek, are our translators. I could go on for hours talking about these two outstanding men. They are always looking for ways to help me in every aspect of life. They have taught me what true selflessness really looks like. We spend a lot of time together. We walk to clinic 4 times a day. We walk on mountain goat trails in the day and night. We eat meals together, sit and look up at the stars and laugh until tears come to our eyes. I tell them they are good friends. Their reply is always, “No! We are brothers!” As time has passed, friends of Suman and Bibek have joined us. Powan, another Suman and Bibek would spend the evening talking and laughing with us. I couldnʼt understand what they were talking about many times, but it didnʼt matter. We were enjoying life. Often, either Suman or Bibek would translate what was being said either by the young men to me in English or what I was saying to the young men in Nepali. The range of these two menʼs capabilities continuously amazes me. Their use of English is outstanding, having to translate the many questions we ask our patients during a treatment as well as in everyday conversation. They carry with them a small notebook that if a word comes up in our conversation that they didnʼt know they write it down.
As my departure date draws nearer and we sit in the night air at the top of the hill, I comment on how leaving is bitter/sweet. Bitter because I was leaving all of Kogate, the view over the village houses and fields and the people. But sweet in that I would be reunited with my dearest friend and love, Susan, my wife, and my two sons, Bryce and Forrest, and Hava, my new daughter-in-law. Suman looked at me and said “We will be your shadows.” Bibek said, “You are in our hearts. You will never be far from us.” Bibek explained that there are two kinds of shadows, good and bad. The good shadows live within the heart of the person. The bad shadows live within the head of the person.
Becoming part of the family
Not only had I become Sumanʼs and Bibekʼs Di (older brother), but I have been accepted into Sumanʼs family. Durning one of the five days of the Tihar holiday celebrations, one of the sisters in the family honors their brother by making a wreath of different flowers which they place around the brothers neck. They then place a red tika and seven different colored dots upon the red tika. Then they bring out a huge plate, which is made out of leaves, filled with many different types of foods and treats and place it in front of their brother. On that day the lower camp came up to Kogate for the weekend so they could see the village. We had had a class and were standing around when Suman came out of his house, having already gone through the honoring celebration by his oldest sister, and asked me to come into the house. The family was sitting around the room and there was a mat on the floor at one side. It was covered with flower pedals. They instructed me to go and sit on the mat. Then his oldest sister came and did the brother-honoring observance; placing a flower wreath around my neck, applying the red tika on my forehead and the seven colored dots on top of the red tika. Then I was instructed to place a red tika dot over the ones that Suman had placed on her forehead. Suman, his oldest sisterʼs son and myself sat in another area of the big room and the specially prepared plate of food was placed in front of each of us. It was a joy and honor to have been invited to be apart of this familyʼs observance.
Sumanʼs father andmother are my gracious host and hostess and now friends/family. They prepare all of our meals for us, make us hot tea each morning and share their lives with us. At times, we are invited into their home for dinner. The food is delicious. All the cooking is done on a mud-form cook stove, branches are fed into an opening at the bottom to the fire. This gives the food a smoky delightful flavoring. The food is generally the same for each meal: one hard- boiled egg for breakfast with beans, which I would put my egg into. Lunch and dinner consist of rice, with either greens or a chopped up potato in a curry sauce and a pickled salsa or radish mixture. I thought I would get tried of eating the same thing each day but I havenʼt. In fact, between walking down to the clinic and then back up the hill to the house for meals, I have lost close to 20 lbs. Nepali meals are spicy, at least for me they are. I have had to get used to my mouth and lips being hot which really hasnʼt been too difficult to do!
They ask me questions about America and my life there. Sumanʼs mother wants to come back to America with me, saying that she would cook all of Susanʼs and my meals. I told her that I feel America is not the place for her; that life here in Kogate is better. Life here is very hard but it is simpler. Not the rushing around, all the different ways in which one is pulled. When I ask my patients if they have a lot of stress in their life, they just look at me with an uncertainty. They donʼt know what stress is. They live each day and moment as it comes, taking whatever is before them as it is. At least this is how it seems to me. They donʼt understand the word stress. Sorry...a little rabbit trail.
Life in Kogate is hard but it has so many other things that make it a wonderful place to live. Here, you live each day as it arrives and do what needs to be done at a nice slow steady pace. Nobody telling you what to do, to hurry up. You do the job and if you need to stop, you stop. I tell her that life in Kogate is good.
Life in Kogote is like stepping back into American history, in that it is basic. Its simpler life is what has been a part of the transformation that has and will continue to change me.
Life in Kogate is GOOD!
If you would like to sit with me and have a cup of tea I will talk with you about the fullness that is now a part of who I am because of this life-changing experience.
To all of you who made it possible for me to come to Nepal and the people of Kogate, I THANK YOU from my heart. --- John Timm Jr.
It's 4 AM and I can't sleep. I'm thinking about how much I still need to get done before wrapping up my volunteer stint here in Bhimphedi, Nepal in 10 days. I have to write this blog post and a publishable case study, which I still haven't picked out yet. All this while treating a ton of patients 6 days per week and trying to spend time with the beautiful friends that I've made here. I'm mad for letting myself get back to this state of unease and sad for the heavy loss I'm about to experience.
Coming to Nepal, I assumed I would have a somewhat stressful and uncomfortable "third world" experience. And when I first arrived, it took a while to adjust to the time change and environment. I had terrible insomnia, bowel issues, breathing problems and I was anxious about starting my work in the clinic. The first week in clinic was slightly overwhelming. Although I only treated 7 people my very first day, I still felt frazzled. I did not realize how serious the conditions would be that I would be expected to diagnose and treat. I am definitely way more than an acupuncturist here. I am a primary care doctor. Im finally getting used to saying that and believing in my ability to be just that. It is now not nearly as daunting to treat someone with a massive oozing non-healing sore, tonsillitis, uncontrolled hypertension, paralysis or diabetic neuropathies. The possibility of someone coming in with tuberculosis, fungal infections and typhoid fever does not freak me out nearly as much anymore. Just another day in the clinic.
Even out of the clinic, I no longer feel like I have a chronic case of the cooties. When I get bit by a mosquito, I no longer think "I hope I dont get malaria." And when I see a piece of chicken poop, I dont necessarily think, "Is that a leech?" I stopped using hand sanitizer every 5 seconds. I dont guzzle grapeseed extract everyday either. Maybe I won't actually contract a major disease here. Just maybe.
It was the 7th day of clinic when I finally started to feel my rhythm. I had a bunch of return patients that day, so the interpreters labeled it "Susana Day." I was in awe of how these people were trusting me with their health and actually getting better. That helped build my confidence and ease my anxiety. I was cleaning wounds, checking glucose levels, using an otoscope to check for ear infections, working with infants and kids with disabilities. I'm not saying my treatments have been perfect, but I can say that I am providing attentive and thoughtful healthcare and truly connecting with my patients.
After the first week or so, and settling into a simple routine here, I realized that I was the happiest and most peaceful that I had been in years. I wake up early, go for my walk to the look-out point above the river, do some qi gong and yoga. I get back home to eat a simple breakfast that Auntie makes in her outdoor kitchen, and head off to clinic. I work from 8:30 am to 4:30 pm, with a quick lunch of Dahl Baht. When I get off work, I take a quick rinse off in the outdoor shower/ spicket and finish my charting while waiting for Auntie to provide us with another plate of spicy Dahl Bhat for dinner. I go to bed super early and wake up in the middle of the night to go pee in the outdoor squat toilet. Six door latches later and I usually have a hard time getting back to bed. Thats when I ruminate over my patients. Then I get up and start all over again.
I am certain now that I am happiest with a simple life and a regular schedule. Back home in Brooklyn NY, things have not been so simple. The last 4 years were dedicated to intensely studying Chinese medicine while working, barely socializing and commuting around a hectic city. I did not realize just how much my irregular busy schedule was wearing me down.
Aside from my clinic experience, I have also had other pretty epic adventures. I've visited many holy sites for both Hindus and Buddhists. But that is not limited to the myriad of temples and stuppas that are everywhere. The land here is thick with spiritual history and energetic density. While trekking in Langtang National Park, I climbed the highest I've ever climbed (almost 16,000 feet) and visited lakes and rivers that were created by Shiva himself. I hitched a ride on the crowded rooftop of the local bus up to Kogate to celebrate Tihar, the Hindu Festival of Lights. I was blown away by the density of spirit in this remote mystical shire that has the most spectacular views I have ever seen. (Kogate has since become my happy place.) Between all the gods and goddesses, witches and shamans, you feel a spiritual energy here like nowhere else I've felt.
There's been a lot of clarity for me here in Nepal. Following a simple routine in this special place has helped reconnect me with my true self again, a calm and content being. I chose to come to Nepal without knowing hardly anything about where I was actually going. Somehow I just felt it was where I needed to be. And I was right. What was supposed to be a stressful "third world" experience turned out to be one of the most peaceful and happiest moments in my life.
In the last 3 days I have treated 64 patients, 55 of those are my regular patients. Even though Im pretty exhausted by the end of the day, providing healthcare does not stress me out. It's having deadlines and taking on too many tasks and responsibilities that disrupts my spirit. Although I have seen the light again here, I need to take that light into everyday life, especially going back to NYC, the land of complexity and excess. My intention is to set up a simple life, slowly build a community-inspired acupuncture practice, and be creative and healthy. All I really need is healing, music and creativity. I'm making a promise to myself to keep it simple, stick to a regular schedule and get into nature as often as possible to feel its peaceful energy and let it always remind me of who I really am. ---Susana Correia
In that instant, when you’re sandwiched between a motor bike on your right, its passengers shirt tail grazing your arm, a gutter filled with unidentifiable sludge on your left, and an oncoming taxi crammed with 12 Nepalese wildly speeding toward you, you start to re-evaluate the meaning of chaos.
How do these millions of people survive in the streets of Kathmandu with no road lines, lights, stop signs or any apparent rules of the road?Cars, vans, bicycles, pedestrians, tuk-tuks and animals all playing a calculated game of frogger. It’s fastinating to watch – unnerving at times- but strangely beautiful.
I’ve learned to enjoy the thrill of going on a harrowing taxi ride, like a child enjoying rollercoasters….or a fight against incontinence!
It occurs to me that perhaps why there are not many accidents (that I’ve seen) is because people are in the flow of the moment here. Not generally distracted by phones, eating in the car, putting on make-up – all the things I see far too frequently in the USA. Biking around Portland I get to watch many drivers – and a shocking number are not actually looking at the road. It’s insanity! Maybe the comfort of road lines, lights, signs has put us on auto-pilot. Our ability to take in our surroundings, to be sharp and reactive, declines. We kill people because we can’t wait to send a text?! WHAT!?
Maybe it’s love that saves lives and prevents accidents in Nepal. I have been reading the book Shantaram, a story about an Australian fugitive who escapes from prison to the slums of India. In the story, a character explains why millions of people can manage to live in relative peace together in India is because no one loves like Indians. It’s this collective love for each other that keeps people from freaking out over the claustrophobic conditions, lack of resources and general chaos. I believe this law of love, if you will, applies in Nepal.
Nothing is done alone here, potentially using the toilet is your one moment of precious privacy…potentially. People live with multiple generations of family. They walk, shop, eat, laugh, yell, cry, smoke, drink, sit on stoops together. Contrast this to the typical American, for whom it can be a struggle to car pool with another person. There’s an ingrained sense of independence in Americans. I can do this, not we can do this. Perhaps the Nepalese culture of sharing, of interdependence, plants the seeds for love to grow. I have come to know the warm love of community in Kogate, being immediately embraced as a sister and daughter into my host family. My walk to the clinic each morning is enriched by a “Namaste!”, a smile, a familiar nod. I feel as cared for by them as, I hope, they feel cared for through my work.
There are millions of people and animals, moving as an amoeba, depending upon each other for survival. Horns blaring here and there, not out of anger, but seemingly (again this is not my culture, so I’m speculating) to alert another of your presence. “Hey! My taxi is 1 inch from your foot, excuse me, I don’t want to crush you!”. A courtesy. When horns blare in the U.S. they’re usually followed by a violent gesture, yelling, or at least some dramatic facial gestures from the driver. I am thankful horn on horn violence is a rarity in Portland :)
So next time I’m feeling late for work, stressed about the pace of traffic, ruffled by the inevitable obstacles set before me, I’ll try to be part of the ameoba. Give thanks for the protective bubble of my car, the safety of the sidewalk, the rules of the road that, theorically, allow me to put on make-up while driving. But of course I won’t! ---Amanda Johnson
My experience with the Acupuncture Relief Project began after reading an article in an Acupuncture newsletter. The information on the website described it as a cultural immersion and it truly lived up to that description. As a participant we lived with a local resident and learned what is like to be part of the local culture and live the lifestyle of the residents in Bhemphedi, Nepal.
I found the people of Nepl to be a very gracious culture. At one point I had commented to an interpreter that I was so impressed with how kindly we were being treated and he responded that we are guests of Nepal and that is how guests should be treated. There was never a time we felt unwelcome - whether we were working, trekking, or walking through the village, everyone was kind and respectful. I found particular delight in the young children I encountered on my daily walks or coming home from the clinic. The would shyly say Nameste, then say hello. They would giggle with delight when I said Hello back to them. They were so excited to know their English had been understood and would say hello and goodbye repeatedly just to have me answer them.
Our team stayed with a delightful lady we called Auntie. We stayed at her house which consisted of four bedrooms. The remainder of the house consisted of an outdoor kitchen, outside bathrooom and outside shower. Aunti was a gracious host who worked hard serving three substantial meals a day for six to twelve people. All cooking was done on two propane burners as there are no ovens or electric/gas ranges. There are no luxuries in Nepal - appliances that we consider normal and essential such as microwaves, washing machines, clothes dryers, and dishwashers are not available in the rural villages. Electricity would go out with no warning and there was never rhyme or reason when it would go out or how long it would stay out. The Nepalis, used to it happening, would go about their business as they were accustomed to such interruptions.
The work at the clinic was busy and intense. We saw many different conditions usually related to lifestyle. Farming is mostly done by manual labor, women and children carry extremely heavy loads on their backs and necks. The country is steep and everyone walks on narrow and rocky paths often carrying large loads of vegetables, firewood and staples such as rice and lentils. The lifestyle contributes to back, neck and knee problems which were common ailments treated at the clinic. Numerous other condtions such as stomach pain, menstrual disorders, stress and skin conditions were seen and it was gratifying to see so many respond to acupuncture treatment. Seeing the reults of the treatments has inspired me to return home and work with patients in my private practice.
When it rained the electricity would go out and the rain would come through the roof at the clinic. Patients would get wet yet they never complained. They were all appreciative that we came to volunteer and they would sit in the cold, rain, or whatever to take advantage of health care services. Heath care in Nepal is limited to non-existant. There is no such thing as health insurance and any services are always out of pocket expense. Employment opportunities are very limited and most people cannot afford to pay for care. The ARP project is staffed by volunteers and patients pay nothing for the services. Patients repeatedly thanked the team for what we provided and would bring in vegetables , freshly made mustard oil or other gifts out of appreciation. They would walk or ride the bus one, two or three hours to come to the clinic and it was not uncommon for them to have to wait an hour or two before being seen. They were always gracious and never complained about the wait -they were just grateful for a chance to get some help.
As part of the experience I learned a lot about life in Nepal and In general it is a very hard life. Women and children carry heavy loads on their backs to provide feed for animals or wood for a fire. Central heat or air is not an option. We trekked in the area where it is very cold and the only way to get supplies there is by humans, horses or yaks. Food is limited in supply and in variety. We stayed in small tea houses along the way and the owners were always gracious hosts and willing to share a warm fire in the very cold evenings. The rooms were unheated, the bathroom were outside and unheated and I thought about how much colder it would get in the coming months. I knew I would be home with my central heat and they would still be there with nothing but a clay cooking stove to provide heat and cook their meals. Yet the guest houses were always warm and welcoming in attitude and in service.
Educational opportunites are also limited in Nepal and I met many young people who valued the opportunity to attend school. Any chance for an education is appreciated. School is held six days a week and students often walk great distances to attend. There are no school buses - any season, any weather, and they walk to class as they know the more they learn the better the possibility of having a better life than their parents.
The interpreters at the clinic were young {18-25} and absorbed all they could from the doctors. The clinic where I volunteered was located in Bhemphedi although two nights I stayed in the village of Kogate as ARP has a satellite clinic there. One of the family members was a beautiful and enthusiastic young lady, Riesta, who wanted to read to me. I had a book on my computer tablet and she jumped at the chance to practice her reading and verbal English skills. At one point there was a statement in the book about life is not Disneyland. What is Disney land she asked? The conversation that followed found me searching for words to describe cartoons, amusement parks, Disney movies and many other subjects. It is challenging to explain those things to someone who has no concept of those experiences are like. She wanted to know all about America - politics, college, entertainment. the list was endless and she was a captiated listener as I attempted to explain and answer questions. She told me she was headed to college soon - she would take her backpack, take the bus, and go to a different town where her sister lived. College with only a backpack? I was amazed - not quite the experience for students in the States.
The second night Riesta came to read to me, she brought a small container of chocolate, dried coconut pieces and other treats. They were in a small container with a ribbon and she carefully unwrapped the ribbon and wanted to share. I looked at the container which held small candies and I knew they must have been a special gift for her. They were unlike anything I had seen in our local village - definitely something out of the ordinary. For Americans sweets like that are common, but for her it was something unusual and special. I initially declined saying I didn't want to ruin my dinner and she seemed so disappointed and hurt. I agreed to take her offer and she seemed so happy that I did. Her kindness and generosity was so very touching as here was someone willing to give when she obviouly had so little. This experience exemplified the Nepali culture in general. They are generous, gracious and caring and would share whatever they had even if it means they go without.
I listened to young people talk about their dreams and aspirations of traveling or having careers as fashion designers or journalists. It is an eye opening experience to relieze how much is available to the average American. If we want to travel, go to college or pursue a specific career it is always an open door. We do not have the limitations and obstacles that exist in Nepal. It was hard watching their glowing eyes as they spoke - yet wondering if any of them will ever achieve their goals. It was inspiring listening to their hopes and dreams but at the same time it was emotionally wretching knowing the reality of the situation. Many expressed to me their desire to visit the Staes as they view it as a place of great opportunity. Their views made me appreciate so much what we have and expect and how much we take for granted. Employment in Nepal is extremely narrow and many leave the country to pursue employment wherever they can, often in low paying jobs but they feel so fortunate to be working they take any job available.
Everywhere I went in Nepal I was asked how I liked their country, how was my stay, what do I think? Everyone takes great pride in their country and so much wanted the "guests" to enjoy their stay. They wanted our group to feel at home and welcome and appreciate what the country has to offer. In the end, my life in in Nepal has been challenging, educational and enlightening, and will always stand out as a memorable rewarding experience. ---Marian Klaes
Long after I realized the man's injuries were too extensive to survive but not until his wife said "arret" and gently reached out with her bloodied hands to stop my chest compressions. Coming to Nepal I knew clinic would challenge me in ways I couldn't even comprehend, yet I looked forward to those challenges and the personal and professional growth that would hopefully follow. I knew I would help many people, and anticipated it would be the ones I couldn't help that would stay more present in my mind. And it's true, they do, but not in a way I ever expected.
There appeared to be confusion ahead, someone mentioned rockfall and an injury. I asked if there was a doctor present, said we were a medical team and offered to help. People cleared the trail and we were ushered ahead. My heart raced, do we have the skills needed to help? A man was unconscious in the middle of the trail with an obvious head injury and a woman kneeling at his head. No one seemed to be taking charge, I was so grateful to have Jacq and Susana with me. We later realized our porter, Peking, had been there for quite some time before us. The woman started speaking rapidly in French, I said I spoke a little French and asked her to slow down. It appeared the man had been hit in the head by rockfall 15 minutes prior. He was just below the rockfall and looked to be in pretty bad shape. We quickly moved him slightly down trail to a safer area. I felt little to no pulse and Jacq started started chest compressions as we tried to gather more information. We checked his pupils with my headlamp and they were fixed, we were told he had been unconscious the entire time. I took over chest compressions and quickly realized how extensive his injuries were. The woman at his head was covered in blood and his wife, she told me they live in the mountains near Toulouse. She asked if I thought he would be ok. I expressed my concern with his injuries and difficulty for rescue. We then realized the man had been hit by a rock and fallen off the trail and it had taken an hour and half to get him back up to the trail, where he had been for 15 minutes. It quickly became clear he not only had a significant head injury, but likely a spinal injury from the fall and it had been too long, he would not survive. There was nothing more I could do for him. At this point all my attention shifted to his wife. The rest of their party and the other guides and porters stood back, they had also been there much longer than us and I can only imagine what this first hour was like. We were told a helicopter had been called, a teahouse was ten minutes down the trail and a landing site further below. I said we need a stretcher, trekking poles or branches I suggested. I continued chest compressions as his wife was asking me what I thought. I gently said it was a bad injury to his head, I was worried about what further damage had been caused by his fall and pulling him back up to the trail and feared it had been too long. She nodded. I said I couldn't feel a pulse and he wasn't breathing on his own, but I would continue chest compression as long as she wanted me to. It would be a long trip down the trail, waiting for a helicopter and then a half hour flight to Kathmandu as well. She had amazing composure and seemed to be slowly putting everything together. I continued compressions and allowed her time. "We live in the mountains, the Pyrennes, I can't believe he will die in these mountains." She started to cry. It was truly heartbreaking. Here is a woman whose name I do not know yet and we are in the most intimate moment. She reached out and gently pressed my hands to his chest "arret" and she looked up at me "Merci, thank you for trying." People arrived with two big pipes, ropes and big plastic rice bags to form a stretcher. Bistare (slowly, which is my most used word in clinic) I said and then asked for 5 minutes and waved people away to clear the trail as I had no idea how long it would take to get this man down and what shape he would be in. Jacq and Susana cleared the trail and we stood back and gave her time. My thoughts raced to my family, his family and my years of guiding. She knelt there for a few minutes and then stood up. We rolled him onto the stretcher and I kept saying gentle and bistare. I picked up his bloodied backpack in one hand and his wife tightly grasped my other as we slowly followed them down the steep and winding mountain trail past the tea house to the a wide spot on the river. Just days before we stood happily gazing up the valley and to the adventure that was waiting for us. I lead her to the river and helped her wash the blood off her arms and face. The three of us sat with her next to the stretcher waiting for the helicopter, watching monkeys cross the river and swing in the trees as other groups looked on. I gently rubbed her back, uncertain what else to do. Susana brought out her space blanket to more fully cover him and we held it down with river rocks. There were three others in their party but they had mostly stood back, I expect in shock. One came down to sit with her and I started to gathered blue yellow and white flowers into a bouquet for her to place on his chest. I expressed how sorry I was for her loss and hugged her, she was grateful for our efforts. I think it was over when the rock hit him she said, he never put his arms out as he fell down the cliff. Loading the helicopter was less than graceful and a very difficult sight, but as it took off she waved and blew kisses. We stood in quiet shock and it started to sink in more fully. I no longer could keep my composure and felt a heaviness settle over me with tears in my eyes.
We still had three long hours hiking uphill, I was lost in my thoughts. Personally, the mountains are my playground and it shook me to the core to see such a tragedy in a place that gives me so much happiness. We are in such a rough country, yet I do not think the outcome would have been any different on any trail anywhere else. My heart goes out to the guides and porters, obviously shaken and overhelmed. I spent ten years guiding and gratefully never had to deal with more than minor injuries. And to the couple, they remind me of my parents who traveled extensively and loved to walk and hike all over the world. It could easily have been my family. Someone lost a husband, perhaps a brother and a likely a dad. Shortly oceans away they would be getting a terrible phone call.
That evening from our little hilltop village we could look way down the valley to the river. They has been out of electricity for 9 days which seemed appropriate. Our group, the four of us, two guides and two porters ate Dahl baht together by candle light. Later we climbed up to the roof and sat under the nearly full moon to talk. Shaken and sad with graphic images flashing through our mind we talked about what happened, could we have done more and what our roles had been. We will never know what occurred before we arrived, but I truly believe we were meant to be there. Medically there was nothing that could be done and I came to that conclusion quite quickly and clearly, allowing me to focus my attention to his wife. I spent two hours in one of the most intimate moments in ones life with a woman whose name I would only later learn. It was my hope that I could offer some calmness, comfort and compassion. Allow her some time and space to process before being whisked from deep in the mountains to the chaos of Kathmandu and the reality that awaited her.
I sat under the moon for hours before finally going to bed, and was then bolted awake with an image at 3am. I returned to the roof flooded with moonlight and prayer flags gently blowing in the wind. What was it going to take for me to process? I bought prayer flags the next morning and the following two days my heart and body felt heavy. I wasn't sure if the flags were more for myself or for the couple. We got up at 4:30am to hike high up to Gosandkunda Lake, a sacred Hindu lake. At first glance I saw the place across the lake where the flags were meant to go. Everyone in our group had a moment with the flags and then Peking, our porter, and I hiked up. We tied the flags togther, one for each if them. Peking tied one end to the trident at the base and I climbed up to secure the top. It felt peaceful and calm, and as if a large weight was lifted off my shoulders. I was suppose to be there for some reason. Her friend had asked for my email and I looked forward to one day hearing from her. In time, I hope she finds comfort in the care I we tried to provide and I will share photos from our sacred lake.
At the end of our trek I returned to Kathmandu to a short but wonderful email from her friend. They were back in France, grateful for the help and compassion and sent details on the funeral in hopes we might light a candle or hang flags. We are back in Bhimphedi and clinic has reopened after the holiday. Tomorrow morning we will be up early to walk out to my peaceful morning viewpoint for a quiet moment and to hang flags at the same time as they will be remembering in France. Exactly one week after his passing. Those flags will be hung with a much lighter heart.
Before I left for Nepal I was told, "You do the best you can and it's usually enough." And it's true. - Beth Fitzgerald
Well, I survived my first week of clinic. Luckily for us it started off slower than expected which gave us a chance to get our feet wet. I'm finally feeling some rythym in the treatment room. I am impressed with everyone's ability to work together and lean on each other. The interpreters are doing an amazing job as well. I am so impressed by their eagerness to learn. Being a practitioner in Nepal is challenging and humbling at times. There are times when you do not have the anwsers, the skills, or the resources you need to help a patient. We must be okay with asking for help from others because working here in this environment is hard enough. And sometimes It's okay to just admit defeat. This leads me to vulnerability. Not something many of us like to experience. When I decided to come here I thought it was because I wanted to help people and I wanted to become a better practitioner. And both of those things are true. Although I think my patients are probably gonna help me become a better practitioner more so than me helping them with their problems. I am learning so much from them which will be valuable for me in my practice. Their health is so poor and they have so little here, yet their smiles remain and their lives continue. Not to say I am not getting good results; I am definatly seeing some improvement in my patients, but it seems only natural when they are coming to see you three times a week. But some situations we just cannot change. At times It gets so busy I feel like I am doing the same treatment on everyone or I am using too many needles just to cover my bases. You never have a moment to think about your treatment plan, you just listen to their story and act. I promise in time I will be more thoughtful about my treatment plans and use less needles.
But today I realized I came for another reason; to explore myself and what is means to be a practitioner. I initially went into healthcare because honestly, I just didn't feel really good at anything else. Coming from a long line of nurses, I strived to be different, but helping others always called to me and that's what I'm good at. I wanted to connect with people, understand compassion and humanity. I feel so detatched from myself at times at home working in the intensive care unit. We just go about our days, going through the motions, thinking we are doing good and helping people, but are we? In the hospital I practice my skills, take orders and give medications. If there is something that goes wrong I call the doctor and they handle it. Here, we don't have that luxury. In my clinic I hear patients problems and I treat them with acupuncture or herbs and I can rest assured in the fact that they are also probably seeing multiple other practitioners. But I wanted to put myself in an environment where I would need to use all my skills without relying on all the resources or luxuries we have at home. I wanted to tap back into why I went into medicine in the first place. To understand compassion, humanity and altruism. I feel like those things are rare in life, and here in Nepal I see it everywhere. I have a wonderful family, lots of friends and a great man at home, but something has always felt lacking in my life and today I felt it. We are so closed off as westerners and here I've realized I'm guilty of that myself. Nepali people's hearts are so open and there is a sense of community no matter where you are. It is so easy to connect with people here, like family. And today we came together as a community to help this patient. And I better understood compassion and humanity.
Today I was challenged in every way I could imagine. I was forced to be a primary care practitioner; a role I have not had to play. And I was scared. A young women came into the clinic, first visit. She was only 24 years old and was four months pregnant. She complained of a mass in her abdomen that was getting larger and becoming painful. I felt it and it was pulsating. I then noticed the young woman was breathing rather fast and also noticed the pulsation going up to her neck. After chebking her vital signs and listening to her heart (which she had a very clear murmur) I decided she needed to be transported to the hospital for a further cardiac evaluation. I decided not to treat this patient with acupuncture but use my efforts to locate family and call an ambulance in addition to discussing the case with my team leader. I knew what I would do at home, but this is Nepal. We could not get a hold of the one ambulance in town and the health post was closed for another hour. So we decided to wait. Not something I would do at home. We had a choice of sending this frightened woman on one of our interpreters motorcycle to get to the hospital an hour away or waiting on the ambulance to take her which would be a few hours. I had to make a choice. I don't usually have to make these choices! I just wanted her out of our clinic to a place where she could be stabilized if need be, but what where would that be? From my experience I suspected an dissecting aortic aneurysm, left untreated could be fatal. My 24 year old pregnant patient and her husband are now looking at me for answers on what to do and how much this will cost because they have no financial resources. I felt helpless. There was so much I wanted to do for her, but couldn't. I couldn't fix her problems, afford to pay all the bills or promise she would make it. The ride alone to Kathmandu would be four hours. All I could do was get her in an ambulance and hope I was wrong. She is now in a hospital in Kathmandu getting care. They will run a series of test that they probably cannot afford, and may find out she needs surgery she cannot have because she is pregnant. I guess I could have treated her, hoped I was wrong and sent her home with her family to celebrate the upcoming festival like she wanted to do, but I couldn't. I'm not sure what the right decision should have been. I don't know if we will know the outcome of this situation. So many of our patients have situations that would be considered life threatening to us, but here it's just part of life. I feel defeated no matter the outcome. If you think you have helped someone by sending them to a higher level of care, you have probably helped them rack up a bill they will never be able to afford. And when you see how hard these people work just for sixty bucks a month or less you don't want to waste their resources. But if you do nothing, they could die in your care. Being responsible for that decision is nothing to take lightly. Working in the clinic and staring into your patients eyes and seeing so much pain is heartbreaking. The conditions here are rough and sad, and it wears on you. Even if you make a positive change in their condition they still have to work and that usually involves carrying 85 lbs of wood on their heads or backs and walking hours a day in the fields or to the next town. So We can only do so much, and that has to be okay for now.
I received word today from the patient's husband. She has been transferred from the heart hospital to another hospital for urgent surgery, but it will cost 200,000 rupees (about $2000 USD). The family must pay it before they will do the surgery, and of course they want our help. The practitioners donated money to pay for the ambulance, but now we have to make the decision. I'm sure we would all pay for the surgery if we could, but that's not the point. Everyone here is under the poverty line. How do you decide who you help and who you don't? It's the hardships here that is life. Its breaks your heart, and toughens your skin at the same time. Even with all the good we do here, sometimes it feels like you are not doing enough. - Jacqueline (Jacq) Bailey
Director's Note: Jacqueline probably saved this young woman's life (and possibly the life of her unborn baby) by quickly identifying her life threatening condition and taking proper action. The practitioners took a collection amongst themselves to pay for the ambulance transport to the hospital in Kathmandu. Our organization appealed to the Manawanpur District Health office for financial support for the patient and they paid for half of her surgical expenses. The young woman underwent open heart surgery to repair a dissected aorta and is now stable and recovering though not completely in the clear. All of this illustrates the roll of our project in providing access to medical care and appropriate assessment. No single intervention is complete without the support of an entire medical system and we strive to play our part in applying the RIGHT MEDICINE at the RIGHT MOMENT. I humbly congratulate Jacqueline for a job done to perfection. -Andrew Schlabach, Director, Acupuncture Relief Project.
In 2013, the Acupuncture Relief Project undertook a courageous challenge of opening three experimental clinics in the remote regions of Bhimphedi, Kogate and Ipa, all villages in the District of Makawanpur. For the first time since we began working in Nepal (2008), we achieved a full partnership with the local government. Operating under the Nepal Social Welfare Council in cooperation with the Makawanpur District Health Office, we are now subject to the necessary oversight, inspection and reporting requirements of other governmental and private healthcare institutions. While this adds some level of expense, bureaucracy and complexity to our operation, it also allows us a new level of authority and access to government assets such as facilities and medications.
In our first three months here, we provided over 7000 primary care visits. Our volunteer practitioners work 6 days per week and they tackle some of the most difficult medical cases found in any modern hospital. Tuberculosis, diabetes, stroke, domestic violence, alcohol abuse, and seizures are common to our treatment rooms. Many times the “best care available” is the “only care available”... and that would be us.
My trip to Nepal was an amazing life experience with many shared gifts. I feel like I have been challenged and grown enormously in my skills as a teacher and community facilitator. I went to Nepal for 3 weeks to teach the beginnings of a much larger acupuncture course. My students were the translators who work for ARP. To make the training more practical, I combined mindful body awareness practices with acupuncture theory and point location. The community also asked me to inform them on high blood pressure. To address this request, I worked with our students to put together a play called 'Blood Pressure, the Stranger in our Village'. We went with this title because strangers are regarded as mysterious and untrustworthy in the village. They may hide in the jungle and disguise their footprints. Blood pressure is a little like this as it creeps up on you, and often we don't know why it's there. This play uncovers some of the issues that affect blood pressure in the community, and how the community can take responsibility for it. The play got amazing feedback with people wanting a longer and bigger outdoor production. Over 100 people came with families walking for 1 hour or more to see our play. All the students worked really hard and after hours to pull this play together in a short period of time. I saw each one of them meet challenges and grow. It was very rewarding for all of us.
I was able to benefit the community through teaching the translation team the beginnings of a longer acupuncture course. Many of them indicated an enthusiasm to continue with their studies. I and they believe it is possible for them to become acupuncturists for their community. The team as a whole took on a greater responsibility to gain experience in community health education. Their roles as translators has grown into acupuncture student and health educators. The community also received a play about themselves and witnessed a better health potential for their lives. This is a great material resource for the Acupuncture Relief Project.
I too feel that I have grown enormously as a person. Throughout my time away, I had a sense of feeling at home in myself. For the first time in my life I had a sense of feeling settled and kind of 'natural'. I'm a little shy to even talk about it, but I'm relishing the feeling. I felt so welcomed in Nepal, with people open to what I have to offer. It really brought out the best in me. I've always felt like I have such a mixed bag of skills that don't quite join up. An acupuncturist, a painter with playback theatre skills, a light footed bush walker, and a Process Work student. Strangely, all these things came together with ease in Nepal. The most exhilarating thing was when I would suggest things to people and they would say 'why not!' I'm adopting the 'why not!' attitude for myself. I realise that knowing people from other walks of life allows me to see some of my self imposed limitations and engaging with this community has opened up potentials I was barely aware of. I glimpsed what is possible when all of my skills work together. It was surprising to me and I know there is more to come.
I have put together a 15 minute video of our play. It will give you a feeling of the atmosphere on the day. I also worked closely with Tsering Sangpo Sherpa on a translation of the play. It's included below and well worth a read. Thank you dear reader for sharing this journey with me. --Lynn Lobo
In 2013, Acupuncture Relief Project undertook its most challenging clinic project to date operating three new clinic sites. After braving the leeches and torrential rains we were able to establish and provide over 10,000 primary care visits.
20-year-old male patient presents with decreased mental capacity, which his mother states has been present since birth. He lacks verbal communication skills and his mother states he is prone to angry outbursts. Within 5 acupuncture treatments, he is less agitated, his violent outbursts have decreased, and he is helping around the house, which he has not previously been doing.
Subjective
20-year-old male patient presents with obvious communication problems, and decreased ability to understand and follow verbal communication. His mother answers questions for him. She states he has been this way since birth, and then points to his chest and states “it was not properly formed.” He is prone to angry outbursts, and his mother advises caution when touching him. She does not think he will allow any needles to be inserted. Due to his tendency to physically strike people in an angry reaction, his mother is concerned about his being touched too much during the treatment. The outbursts are random. He is capable of taking himself to the bathroom, has a daily bowel movement, and occasionally has undigested food in the stool. His urine is clear to yellow, depending on how much water he consumes. His appetite is poor. He has been taken to other doctors who have prescribed medication, but the mother reports difficulty in getting him to comply. When he has taken it, the medication does not seem to help, so has been discontinued.
Objective
On the initial visit, the patient appears to be very agitated, and his eyes dart around the room as he walks through. His mother holds his arm to physically lead him in and direct him around the clinic. After he is seated, he continuously turns around to look out the window so his chair is turned to allow him to focus on the activity outside, which calms him slightly. Due to his mother’s concern about touching him too much, pulses are palpated lightly. They are fast and full. He is warm to the touch. He is partially uncooperative with tongue diagnosis, but he does open his mouth and curls his tongue upwards. Sublingual veins are engorged and purple. He is agitated, and swats at anyone who is standing too close. At times, the interpreter stands outside the window to distract him and keep him visually occupied.
His mother accompanies him on each visit to answer questions, and to provide assistance with bus travel. They travel 1.5 hours each way to get to the clinic, so regular treatments are somewhat of a challenge.
He is frail in appearance. Blood pressure is not taken as he does not want the compression on the arm. His mother points to his chest, makes motions with her hand and tries to describe the appearance of the chest. The shirt is not removed, however from the description it is possible he may have pectus ecavatum, which is the most common congenital deformity of the anterior chest wall. Several ribs and the sternum grow abnormally, producing a caved-in or sunken appearance of the chest, which is consistent with how she is describing him. Gentle palpation of the chest and sternum do not confirm a deformity.
Assessment
DX: Autism spectrum disorder (ASD)
Autism is characterized by lack of eye-to-eye contact, impairment of facial expression, delay in or total lack of speech, repetitive mannerisms, and lack of social development with aggression, irritability, hyperactivity, volatile emotions, temper tantrums, short attention span and obsessive-compulsive behavior.
TCM DX: Kidney essence deficiency, Spleen qi deficiency with fire harassing the heart
In Asia, autism is typically classified as a delayment disorder. In Traditional Chinese Medicine, it is known as one of the 5 delays, which are observed in the areas of standing, walking, hair growth, teeth eruption and speech. This type of brain disorder is viewed in TCM as an energetic dysfunction, an imbalance of yin/yang, and an imbalance of mind and body functions.
Reason and awareness, which are strongly affected by autism, are primarily ruled by the Heart, Spleen and Kidney. The Heart holds the mind or spirit and rules the mental functions including the emotional state. The Spleen is linked to the mind’s ability to study, memorize and concentrate. Kidney qi controls long-term memory. Autism treatment includes eliminating the phlegm as phlegm misting the mind leads to dull wit, incoherent speech, mental confusion, lethargy and decreased attention span. The condition of phlegm fire harassing the Heart presents as disturbed sleep, talking to oneself, uncontrolled laughing or crying, short temper and tending towards aggression.
PROGNOSIS: It is not anticipated the patient will recover and be fully functioning. The purpose of treatment is to calm the patient, reduce agitation, reduce the number and intensity of angry outbursts, improve sleep and hopefully improve cooperation.
Plan
It is recommended he be treated 2 times per week for 5 weeks before reevaluating. The focus of treatment is to tonify the Heart blood, qi and yin, clear Heart heat and tonify Spleen qi and Kidney essence.
Scalp acupuncture is initially utilized, as autistic patients often have a difficult time following directions and being cooperative, so body acupuncture is not always an ideal method. Scalp acupuncture is effective because so many key nerve points can be found on the scalp, and it is less painful and less visible, making it easier to avoid panic. With scalp acupuncture, patients do not need to lie down and stay motionless. This is ideal for autistic patients.
Typical Treatment: Start with scalp points. As patient becomes calmer, add press needles and ear seeds to protocol. Scalp work is performed with the central line, verbal communication, frontal lines and GV 16.
Alternate Treatment: Press needles added at PC6, HT7, HT3 and ST40. Ear seeds are placed on the Heart, Point Zero and Shen Men. Mild massage is added to the Shaoyang channels of the arms and legs.
Outcome
Following the initial treatment, the patient’s mother noted he seemed calmer, and appeared to be sleeping better. By the third treatment, it was noted he was much calmer in the treatment room, and did not seem disturbed when his arms and legs were touched. After one point, he actually laid down on the floor in a very calm and relaxed state.
Each treatment seemed to be making a difference. By the fifth treatment, he was helping to sweep the floor, feed the chickens and cut the grass, which he had previously not been doing. “Cutting grass” in Nepal means using a hand scythe, manually cutting the grass in small areas at a time while on your hands and knees. Due to the distance and difficulty of travel, after 2 weeks of care, visits were reduced to once a week.
By the fifth treatment, the patient appeared to be doing much better. His mother stated he was much calmer. She also said he had been speaking a few words, which he used to do but had stopped trying. From a practitioner standpoint, relative to the initial visit and after 3 weeks of care, he was much less agitated, more cooperative, and agreed to stick out part of his tongue for the first time in clinic for tongue diagnosis.
Conclusion
The patient experienced a notable reduction in agitation and was calmer with each session. This was noticed by the practitioners and interpreters as well.
It is recommended he continue with 1 treatment per week for 4-6 weeks before transitioning to 1 treatment every 2-3 weeks. If improvement continues, moxa and possibly body needles could be added to the treatment strategy. Although a full recovery is not expected, it is anticipated that with continued care he will have a significant reduction in behavioral problems, be more helpful with home duties, and possibly learn to speak a few words. It is very apparent that acupuncture treatments are having a positive influence on this patient, which is helpful to both him and his mother.
Severely malnourished and non-ambulatory 11-year-old female presents with increased tone and spasticity in all extremities, frequent seizures, and currently requiring assist for all mobility. Patient was seen for a total of 10 physical therapy treatments with significant improvement in passive range-of-motion, moderate improvement in posture and spasticity, slight improvement in active range-of-movement, and a 50% decrease in seizures.
Subjective
11-year-old female patient is carried into clinic with significant tightness in all extremities. Per caregiver report, she has minimal social interaction, an inability to feed or dress herself, toilet or ambulate, and currently requires assist for all activities of daily living and all mobility. Caregiver reports a seemingly normal development until the age of 2 when “all of her muscles got tighter” and began to alter her mobility. She was able to crawl, ambulate and communicate. However, between the ages of 2 and 5, she had a pronounced increase in muscle tone, paralysis, and began having difficulty with all mobility. At 5 years old, she started using a cane to ambulate and progressively stopped walking and speaking. A vague history, slowly gathered over the course of multiple treatments, includes a difficult birth, which required forceps, 21 days in a paralysis ward around 6 years old with no reported improvement, and a subsequent lack of social interaction. On the 6th visit, it was revealed that she was neglected by her parents and confined to her bed for extended periods of time. The current caregiver is a distant relative as the parents do not want to care for her unless she is able to feed and toilet herself. The caregiver’s goal is for the patient to move better and walk more.
Objective
On the initial visit, the patient appears to be very agitated, and his eyes dart around the room as he walks through. His mother holds his arm to physically lead him in and direct him around the clinic. After he is seated, he continuously turns around to look out the window so his chair is turned to allow him to focus on the activity outside, which calms him slightly. Due to his mother’s concern about touching him too much, pulses are palpated lightly. They are fast and full. He is warm to the touch. He is partially uncooperative with tongue diagnosis, but he does open his mouth and curls his tongue upwards. Sublingual veins are engorged and purple. He is agitated, and swats at anyone who is standing too close. At times, the interpreter stands outside the window to distract him and keep him visually occupied.
His mother accompanies him on each visit to answer questions, and to provide assistance with bus travel. They travel 1.5 hours each way to get to the clinic, so regular treatments are somewhat of a challenge.
He is frail in appearance. Blood pressure is not taken as he does not want the compression on the arm. His mother points to his chest, makes motions with her hand and tries to describe the appearance of the chest. The shirt is not removed, however from the description it is possible he may have pectus ecavatum, which is the most common congenital deformity of the anterior chest wall. Several ribs and the sternum grow abnormally, producing a caved-in or sunken appearance of the chest, which is consistent with how she is describing him. Gentle palpation of the chest and sternum do not confirm a deformity.
Assessment
DX: Spastic quadriplegic cerebral palsy
Spastic quadriplegia is defined by spasticity of the limbs, rather than strict paralysis. It is distinguishable from other forms of cerebral palsy in that those afflicted with the condition display stiff, jerky movements stemming from hypertonia of the muscles. The primary effects of cerebral palsy are impairment of muscle tone, gross and fine motor functions, balance, control, coordination, reflexes and posture. Swallowing and feeding difficulties, speech impairment, and poor facial muscle tone can also indicate cerebral palsy. Associative conditions, such as sensory impairment, seizures and learning disabilities can also occur. When present, these associative conditions may assist with a clinical diagnosis of cerebral palsy.
DDX: Diagnosis is complicated by lack of past medical history, parents not currently being involved in care to clarify development, and by exacerbation of symptoms secondary to lack of care and stunted growth. Differential diagnoses consist of muscular dystrophy, acquired brain injury and Rett syndrome.
Muscular dystrophy is a group of diseases that weaken the musculoskeletal system. Although more common in males, it can occur in females and is characterized by progressive muscle weakness and wasting, poor balance, atrophy, scoliosis, frequent falls, joint contractures, inability to ambulate and wasting of the muscular system. Patient’s history and initial disease presentation per caregiver report has many of these characteristics. However, muscular dystrophy does not typically involve spasticity. This diagnosis is further ruled out as details of the birth are learned.
Rett syndrome is characterized by a period of normal motor development followed by developmental stagnation and then regression of motor and language abilities. Onset typically occurs between 6 and 18 months of age with subtle developmental delays, developmental progress and then stagnation, followed by developmental regression. Hand wringing is a classic symptom and is often confused with autism. Rett’s can also be confused with cerebral palsy. Regression is actually rarely seen with cerebral palsy and spasticity is uncommon with Rett’s. Initial history gathered exposes a period of normal development followed by regression. This diagnosis is considered due to the reports of regression around 2 years of age. It becomes clear, however, that the regression seen with this patient is most likely due to neglect. Rett Syndrome is further ruled out secondary to spasticity.
Acquired brain injury (ABI) is brain damage caused by events after birth such as stroke, brain tumor, infection, hypoxia or ischemia, and can result in an upper motor neuron lesion possibly resulting in spasticity. Without a detailed and accurate history, it is not possible to rule out an ABI. The patient’s caregiver reports a difficult birth, which is likely the cause of the initial injury. However, with the history of abuse, it is possible that the symptoms were exacerbated by events after birth.
Initial Treatment
The movement patterns of proprioceptive neuromuscular facilitation (PNF) to bilateral UE’s and LE’s are utilized to decrease tone and spasticity. The goal is to facilitate more functional movement patterns, thereby increasing the patient’s ability to participate in activities of daily living, such as self-feeding, mobility and toileting, thus decreasing the caregiver burden. The patterns of movement associated with PNF are composed of multi-joint, multi-planar, diagonal and rotational movements of the extremities with the emphasis on decreasing spasticity and increasing range-of-motion. Movements are initiated passively, progressed to active-assisted, and eventually active if patient is able to assist in a controlled movement. Passive range-of-motion (PROM) to right wrist and hand is performed to prevent further contracture development. All exercises are performed bilaterally and slowly, with a constant smooth motion for 5 minutes to each extremity, allowing the muscles to relax and to decrease tone. Seated and standing balance training is performed with emphasis on trunk control, posture, alignment and weight shifting to the right LE. Weight bearing can be very effective at decreasing tone. Progress is made towards prone over a bolster and quadruped (weight bearing through elbows and knees) to facilitate different body positions, in addition to weight bearing though UE’s, primarily the elbows. Weight bearing exercises are also used to increase bone density, improve circulation, increase strength, promote Lung health and reduce tone and spasticity. Neurological reeducation exercises, such as PNF, are performed to decrease spasticity and facilitate motor control to enhance patient’s ability to move independently and increase functional mobility. Patient is being seen 2-3 times per week to decrease spasticity, promote increased range-of-motion, decrease risk for further contractures, increase mobility, and for continued family training and education. She is also receiving acupuncture after each physical therapy session. Reassessment is to be completed after 6 visits, and appropriate family training and education is initiated. Initial treatment is selected based on severity of presentation, knowledge of limited resources, and family’s education level.
Outcome
Patient was treated 10 times and had significant improvement in passive range-of-motion, moderate improvement in posture and spasticity, slight improvement in active range-of-movement, and a 50% decrease in seizures. Patient had a moderate reduction in spasticity during each session, significant increase in passive ROM, and slight improvement in active ROM (most noted in UE’s) between treatments. She experienced an overall improved affect and social interaction throughout the course of the treatments. She was able to reach out towards people with her left UE, and often able to touch someone’s nose with verbal cues. She could sit with a narrower base of support for up to 30 minutes with supervision only, and stand with contact guard assist (previously requiring physical assist). Additionally, she had some use of her left UE for balance. Patient tolerated prone over bolster with weight bearing and engagement of UE’s for 15 minutes for facilitation of back extensors and head control, also allowing gentle percussion to the back to support respiratory health, and decrease risk of current cough progressing to pneumonia. Family was encouraged to vary patient’s position frequently to increase strength, mobility, Lung health, and opportunity to interact with different environments.
Nutritionally, the patient was encouraged to increase fluids throughout the day and include softer, higher caloric foods for overall increased intake. Extensive caregiver education about cerebral palsy was initiated to increase understanding of the disease and how to best work with, and help, the patient for both patient and caregiver benefit as well as long-term prognosis. The caregiver was highly encouraged to seek acupuncture treatments herself due to the heavy caregiver burden. Training was completed with the caregiver to continue PNF and standing exercises to maintain newly-gained range-of-motion, facilitate weight bearing, reduce spasticity and minimize pain.
This case was complicated simply by the complexity of the diagnosis and high level of care required. Information gathered on the sixth visit revealed significant neglect, further reinforcing the focus of treatments to be caregiver education, a simple home exercise program, and to initiate a search for possible support groups. A referral was made to Cerebral Palsy Nepal, an outreach program offering therapeutic and practical support to 15 of the 75 districts in Nepal. Possible support includes home visits and a mobile team who assist with therapy, acquiring equipment, practical guidance and emotional support to patients and their families. During the initial visit, we discussed methods to increase patient’s food intake, particularly healthy fats, setting up an appointment with a doctor to address possible medications, specifically to manage seizures, a more appropriate and supportive chair for her home to increase interaction with the environment, and perhaps most importantly, supporting and educating the caregiver.
Conclusion
This case was challenging for me at many levels. From the initial evaluation it was apparent that the medical history was extensive, but vague. Though confident with the diagnosis, it took multiple visits to unravel a more complete history. It was important to focus on treating the patient, but also ensure the caregiver could see the benefit so she would continue to bring the patient into the clinic. I tried to provide an environment where she felt supported and open with the patient’s history, as the caregiver was initially guarded and defensive.
Though the patient’s prognosis was poor, I was surprised how much improvement I saw despite the severity and duration of her disease. With minimal prior intervention, I was able to clearly see the effects of my treatment. I was able to make moderate to significant progress with the patient’s active and passive range-of-motion, seated and standing balance, and overall reduction in tone and spasticity. The patient appeared more comfortable, was engaging with the practitioners and actually smiled during the last treatment. Despite this progress, life in rural Nepal is challenging even for a healthy and able-bodied individual, and it is difficult to predict how much carry-over into daily life will occur, as the patient must fully rely on her caregiver.
As the case progressed, it became clearer to me that the most important components were not the actual interventions during treatment, but developing a relationship and providing an environment where the caregiver was open to education, assisting in establishing appropriate connections, and helping to establish relationships for continued support. The burden lies on the caregiver to continue to bring the patient in for treatments, to be open to further education and training, and follow through with a home exercise program.
19-year-old male presents with trauma-related chronic hip and low back pain with limits in range-of-motion that interferes with daily life. After 24 acupuncture treatments over the course of 6 weeks, the patient has increased range-of-motion and significant pain reduction.
Subjective
19-year-old male patient presents with complaints of hip and low back pain. He describes the back pain as a dull ache that worsens while bending either forward or backward. He is able to walk fairly comfortably, but it is worse when carrying heavy loads. He experiences occasional tingling down the legs. The back pain began 8 or 9 years ago with a fall from a tree. He landed flat on his back onto a branch on the ground. He lost consciousness for about 5 minutes. After regaining consciousness, he found it too painful to walk. He did not receive treatment at that time. The back pain gets worse while working in a position of forward flexion for extended periods of time.
For the past 5 or 6 years, he has also experienced a gradual onset of hip pain, which prevents him from being able to squat at the toilet or separate his knees enough to straddle a motorcycle. The pain radiates down the anterior and lateral aspects of his thighs. He feels some hip pain while seated in a chair, and resting one ankle on the opposite knee is too painful of a position to maintain. He is also physically unable to place either knee above the other in a seated position. He reports tightness along his anterior thighs, as well as occasional neck and upper back pain along the spine.
Objective
The patient appears in good health and overall good spirits. He is alert with a small build and friendly demeanor. The patient has normal range-of-motion at the waist in flexion, extension, lateral flexion and rotation. The erector spinae are tight with tenderness along the lower borders of the spinous processes of L1 to L5.
Passive hip abduction is restricted to 40 to 45 degrees bilaterally (50 degrees considered normal), with a feeling of intense tightness in the inner thighs. There is tenderness upon palpation at the gluteus medius muscle, particularly on the right, at a point halfway between the greater trochanter and the top of the iliac crest.
The patient is unable to maintain a squatting position for more than a few seconds due to hip pain. The Faber test is positive for pain bilaterally in the initial position of one ankle placed on the opposite knee without downward pressure applied by the practitioner. The pain is felt deep in the hip bilaterally, with additional back pain on the right side near the SI joint. The right leg appears shorter than the left by about an inch, and the right PSIS appears slightly higher. There is tenderness at the SI joints bilaterally.
In the supine position, the right leg appears slightly shorter than the left. Leg length measurements show 29 inches from the prominence of the greater trochanter to the lateral malleolus bilaterally, but 34 and 35 inches from the umbilicus to the medial malleolus on the right side and left side, respectively.
Braggard’s test (aka the reinforcing straight leg raise) is positive bilaterally with tingling appearing at about 70 to 75 degrees and reappearing with passive dorsiflexion at a slightly lower angle. The tingling is felt down the posterior thigh and popliteal fossa. Strong dorsiflexion with the leg fully extended, but not raised, also results in tingling in the popliteal fossa bilaterally.
The Valsalva maneuver results in a tingling sensation in his toes. The piriformis test is negative for tingling sensations, although the position causes discomfort in the hip. DTR’s at the patellar and Achilles tendons are normal bilaterally.
He has a wiry pulse, and pink tongue with a thin white coat.
Assessment
DX: Upon interpretation of the objective testing performed, this patient has multiple structural problems involving the low back and pelvis, including hip joint pathology, sciatica, possible sacroiliac joint subluxation and compensatory muscle tightness of the low back and thighs.
The positive results of the Braggard’s test and Valsalva maneuver suggest sciatica caused by a space-occupying lesion in the lumbar spine. Possibilities include intervertebral disc herniation, osteophytes or spinal stenosis. Disc herniation is the most common of these causes and also consistent with this patient’s history of trauma. The trauma conceivably could have caused a subluxation of a vertebrae in such a way that it could compress a nerve root. However, no obvious misalignments of the spinous processes are observed upon palpation. Spinal stenosis and the presence of osteophytes are less consistent with the history of trauma and is unlikely in this case due to the patient’s young age.
The sciatic symptoms, in this case, may also be caused by muscle tightness in the pelvic area compressing the sciatic nerve. However, the negative result of the piriformis test suggests that the sciatic nerve is not being compressed by the piriformis muscle, which is commonly involved in sciatic compression due to muscle tightness.
An imaging study of the low back such as an MRI or x-ray would be needed to determine the nature and location of any space-occupying lesion and to make a definitive diagnosis. There isn’t severe enough evidence of nerve root compression at L3, L4, L5 or S1 to affect DTR’s, as bilateral patellar and Achilles’ DTR’s respond normally.
Due to the number of years that have passed since the original accident, it is difficult to ascertain the exact nature of the original injury that caused the back pain and radiculopathy. Given that this injury was untreated, it is likely that compensatory muscle tightness, serving to guard the initial injury, has resulted in slow-onset hip pain and subsequent structural imbalance.
TCM DX: Qi and blood stagnation in the Du Mai, Bladder and Gallbladder channels
PROGNOSIS: This patient has responded well, experiencing significant improvement, to previous acupuncture treatment for back pain. He is willing to come in frequently for treatment. The patient is likely to experience pain reduction and increased range-of-motion over the course of treatment. However, because his condition is complex and chronic in nature, he is unlikely to see a full resolution of all of his symptoms.
Plan
Treat with acupuncture and/or electro-stimulation 5 times per week for 2 weeks, before reassessing. Focus primarily on hip pain, which has not received previous, direct treatment, and continue to reduce back pain.
Typical treatment for hip pain: GB40, GB34, ST34, SP10, LI4, TB5, GB28, Ah Shi x2 superior to the greater trochanter, deep insertion towards the joint. Electro-stimulation 100/2 from GB40 and GB34 to the Ah Shi points superior to the greater trochanter bilaterally
Typical treatment focused on back and/or neck pain: SI3, BL62, BL60, BL23, LI4, DU20 and Hua Tuo Jia Ji points at tender vertebral levels (often L2-L5)
Outcome
After 24 treatments within 6 weeks, the patient had only occasional, mild back pain, sometimes brought on by carrying heavy loads. He came for many treatments reporting no back pain at all with the majority of the treatments focused on addressing the pain in his hip.
The patient was able to sit in a chair without pain. He could place one ankle on the opposite knee with only minimal pain, which he still felt deep in the hip. He was able to place one knee on top of another, while seated in an even more crossed position, whereas before treatment this position was impossible. The left knee over right knee position was more comfortable than right over left, but he still felt some deep, hip pain on both sides while seated in this position. The patient could now tolerate downward pressure during the Faber test, with significantly reduced pain in comparison to the initial treatment.
The patient was able to maintain a full squat position without pain with both heels flat on the ground, but it was difficult to maintain his balance if his heels were farther apart. He reported feeling much looser in the thighs and pelvic girdle, with passive abduction showing normal range-of-motion at about 50 degrees.
His apparent leg length on the right from the umbilicus to the medial malleolus measured a half inch shorter than the left side at 34.5 inches instead of a full inch shorter at 34 inches, as was measured in treatment 12. A leveling of the PSIS’s was observed.
Braggard’s test remained positive bilaterally, but the tingling sensation was reduced by about 70%. He no longer felt tingling during the Valsalva maneuver.
Although the patient’s condition was not fully resolved, he experienced an increase in range-of-motion and a significant reduction in pain and overall tingling sensations.
Discussion
This case was challenging because there were multiple structural abnormalities coexisting without a clear diagnosis. It was initially difficult to decipher where to focus treatment. Because the back pain had already been improving from previous acupuncture treatment, the back pain resolved to a manageable level early in the course of treatment, resulting in an overall treatment focus on the hip pain.
The patient found the hip pain difficult to describe, but the functional limitations were clear. While many people in the west find it difficult to squat because of how often we use chairs and seated toilets, the inability to squat is unusual and inconvenient in a rural Nepali environment, particularly because squatting is the normal position during bowel movements. It was also a detriment to this patient’s quality of life that he couldn’t sit normally without discomfort prior to treatment.
Continued treatment of this patient with acupuncture would focus on continuing the pain relief of the hip joint with distal Gallbladder points and deep local needling, as well as a continued loosening of the local musculature of the pelvis, low back and thighs. Additional assessment is needed to determine the cause of the leg length imbalance. The nerve root compression causing sciatica should also be more precisely assessed, ideally with an imaging study.
This case study suggests that acupuncture with electro-stimulation can have a significant therapeutic effect on complex, long-standing musculoskeletal conditions, and has the potential to be a valuable therapy in an environment with limited access to diagnostic imaging and allopathic medical care.
28-year-old male presents with chronic sinusitis, nasal blockage, throat pain and ulcerations for 18 months. The patient also presents with gastric pain. After 9 acupuncture treatments over the course of 1 month, the sinus blockage is 100% resolved, with a complete resolution of subjective throat pain and ulcerations upon inspection. The gastric pain is significantly improved.
Subjective
The patient presents to the clinic reporting symptoms of throat pain beginning 18 months prior to the first consultation at this clinic, and becoming progressively worse. The pain is constant, and worse at night. Consumption of hot, salty or spicy food or drink aggravates the pain. Cool drinks are relieving.
The patient also presents with complete sinus blockage, with an inability to breathe through the nose. He daily expectorates a small amount of yellow, watery phlegm from the nose. He finds smoky environments irritating. He experiences temporary relief with the use of saline solution and a neti pot.
He reports epigastric pain that is worse with cold foods, and bloating every day that is relieved by belching. He experiences occasional acid reflux and diarrhea, and night sweats, anxiety, lower back pain, poor energy, weakness and the occasional headache. All symptoms flare up simultaneously.
He has never smoked, although he chews tobacco daily. He occasionally drinks alcohol. The patient uses Rynex (cough suppressant, decongestant and antihistamine), as needed, to relieve his symptoms.
Objective
The patient is noticeably congested, with a constant sniff and breathing through the mouth. He has no fever or sweating, and a normal facial complexion without flushing. An endoscopy performed 18 months before presentation to the clinic was negative for any gastrointestinal ulcers. Upon visual inspection, there are multiple ulcers at the back of the throat (on the oropharynx and posterior soft palate). The ulcers are small in size, approximately 1-3mm in diameter, red and swollen at the edges, with a white interior. There are no ulcers visible within the oral cavity, and the tonsils appear only slightly swollen, but without ulcers or exudate. The uvula itself is swollen and deviated to the right. The lymph nodes of the neck show no swelling or pain on palpation. Visual inspection of the nose reveals small polyps bilaterally. The polyps are approximately 0.3cm across, but not large enough to block the nasal passage. They are pink in appearance with no exudate.
Pulse: Rapid and thready
Tongue: Big, sticky, deep yellow coat
Assessment
DX: Chronic sinusitis and upper respiratory tract inflammation; Possible chronic bacterial or viral infection, such as streptococcus or mononucleosis
TCM DX: Kidney yin deficiency with deficient heat rising and scorching the Lung
PROGNOSIS: With regular acupuncture treatments, reduction of throat pain and congestion is expected within 10 treatments. The nasal polyps are only treatable with surgery. Because there is no pathological findings within the gastrointestinal system, it is expected that positive functional improvement can be gained with acupuncture and dietary changes.
Initial Plan
Treat with acupuncture 2-3 times per week for 10 treatments before reassessing.
Focus on reducing the heat in the throat and tonifying the Kidney yin.
Base Rx: KD7, KD6, LV3, ST44, LI4, KD3, PC6, LU7, LI20, Bitong, as well as threading the REN and Stomach channel
Advice: Stop chewing tobacco, avoid smoky environments, keep using neti pot as needed, ensuring the water is boiled clean first.
Outcome
After 9 treatments, the patient reported major changes in his throat pain, ease of breathing, and gastric pain. He experienced no throat pain at all, eating and drinking was no longer painful, and he could breathe freely through his nose. His gastric pain was relieved by a reported 75%. He no longer experienced coughing or sniffling, but still had some bloating. He discontinued his treatment at this point because he was happy with his level of improvement. The patient generally felt he had more energy. His anxiety had reduced to the point he rarely noticed it, and he no longer experienced night sweats. The throat ulcers had resolved and the oropharynx and tonsils appeared a healthy pink colour, without swelling. The nasal polyps were unchanged.
Conclusion
Acute or chronic infection was not considered as thoroughly as it should have been, as the patient had already experienced the symptoms for 18 months upon presentation to the clinic, and did not display signs of fever or swollen lymph nodes. The treatment may have been improved by further defining the cause of his throat pain and ulcerations. Antibiotics may have been helpful in this case. However, acupuncture treatment still achieved a satisfactory reduction in his subjective and objective symptoms.
A TCM diagnosis of Lung yin deficiency could have been explored for a more targeted treatment.
The patient’s outcome was improved by his compliance with lifestyle and diet advice, and his commitment to regular treatments (2-3 times per week). This case clearly illustrates the effectiveness of acupuncture for chronic sinus congestion and sore throat.
A 58-year-old man, of rural Nepal, presents with left hip pain, reduced strength and mobility in his left hip and significant muscle wasting in his left leg. After 30 electro-acupuncture treatments over 6 weeks and Traditional Chinese Medicine, the patient reports a significant decrease in his pain and inflammation levels and improved strength and muscle tone in his left leg.
Subjective
A 58-year-old male presents with chronic, left hip pain with intermittent referred pain into his lateral left leg; either down the iliotibial band (ITB) region or into the lateral lower leg. The hip pain is a throbbing, deep ache, worse in cold/damp weather and at night when he is trying to sleep. He is unable to straighten his left leg in bed due to pain and stiffness. The patient uses handmade wooden crutches to walk without fully weight-bearing on his left leg. He has been relying on these to walk for 6 years. The pain started over 6 years ago with a gradual onset without any history of trauma. The patient reported having an x-ray taken at this time, and repeated hospital visits for tests and prescriptions of western drugs over a 7 month period. After taking these medications (unknown) with minimal improvement, he threw out his medical reports and ceased treatment. After a prolonged period of rest, he was unable to weight-bear through his left leg without significant pain. He reports the x-ray described the joint as having a ‘jagged edge.’ Prior to the onset of his hip pain, the patient was an active farmer in rural Nepal.
Objective
The patient presents with a slightly depressed demeanor. He is slight in build and stands with either all or most of his weight through his right leg. On observation, the patient’s left leg appears shorter, contracted at the hip and knee and has obvious muscle wasting in both the upper and lower leg. When walking to the clinic, he places minimal weight through his left leg, using the crutches as support. Due to postural imbalances, he cannot stand on both legs with equal weight distribution without left hip pain and his right knee having to flex about 30 degrees to get his left leg on the ground. The left iliac crest is visually higher than the right. The right ilium appears to be positioned more anteriorly. On his left hip, around his greater trochanter, there are 5 deep, large scars that are a result of abscesses that erupted after his initial onset of hip pain and hospital visits. The following orthopedic tests are conducted:
FABER’s test: Positive on left side
Straight leg raise: Negative on both sides
Thigh circumference is measured 15cm above the superior border of the patella to assess the extent of muscle wasting in his left thigh.
Right thigh measures 40cm.
Left thigh measures 35.5cm.
Palpation: A tight muscle band is palpated in the left erector spinae from T11 to L5, plus tightness in the left quadratus lumborum.
L1-S1 myotomes/muscle strength testing:L1-L3 (hip flexion/psoas) – unable to resist on the left side due to painL4-S2 (knee flexion/hamstrings) – 2 (Oxford scale)
Range-of-movement (ROM)
Right
Left
Hip Passive Flexion (0-125°)
125°
80° with pain (a joint end feel cannot be felt)
Hip Passive Internal Rotation (0-40° )
30°
Minimal movement without pain
Hip Passive External Rotation (0-45° )
30°
Minimal movement without pain
Knee active extension (0-15°)
5°
0° (shaky due to quadriceps weakness)
Reflexes: Patellar and Achilles: Normal on both sides
Dermatomes: Lower limb sharp/dull test is normal apart from a small area on the left upper thigh (L1-L2 nerve distribution), which has reduced sharp sensation. Several deep, large abscess scars found around his left greater trochanter, possibly contributing to a slight sensory loss.
True leg length from ASIS to medial malleolus: Right 75cm, left 75cm
Apparent leg length from umbilicus to medial malleolus: Right 84cm, left 82cm
Postural imbalance may be causing apparent leg length discrepancy of 2cm, which is exaggerated by the contraction of his left knee and hip in a flexed position.
Extra note: On assessment of his crutches, 1 crutch is over an inch taller than the other and the handles are about 2 inches different in height. The patient is advised to trim down the taller crutch to make them the same height, and then the handle height can be adjusted if necessary.
Tongue: Swollen with a thick coat centrally
Pulse: Thin and tight
Assessment
DX: Osteoarthritis of the left hip (sequelae of osteoarticular tuberculosis)
The patient’s reduced range-of-movement and the flexed position of the hip at rest, pain on weight-bearing and the description of a ‘jagged edge’ in his initial x-ray all indicate probable arthritic changes in the left hip. Initially, there was suspicion of infectious arthritis. However, considering the eruption of the abscesses several months after the initial onset of pain, it is unlikely that infectious arthritis was the initial cause of his pain. It is quite feasible to suspect that the patient may have had osteoarticular tuberculosis of the left hip. Osteoarticular tuberculosis is very rare in western countries. It is, however, still common in developing countries like Nepal. The hip joint is the second most common joint affected by the disease. Treatment of osteoarticular tuberculosis typically includes anti-microbial drug therapy of at least 9 months duration. This appears consistent with the patient reporting having taken a lot of western drugs and having several hospital appointments over the course of 7 months. This would also coincide with the abscess scars (they are a common complication of the disease). Other than anti-microbial therapy, an arthroplasty of the affected joint is often the solution if there is severe joint deformity. This currently is not accessible to the patient due to location, cost and health facilities in the region.
TCM DX: Wind-cold-damp bi syndrome
PROGNOSIS: Due to the fact that the condition has been left untreated for several years, it will take extensive treatment and continued care to maintain patient mobility and comfort levels. A complete cure is not expected.
Initial Plan
Acupuncture/electro-acupuncture treatment 5 days per week for 6 weeks
The focus is on local and distal points on the left hip and with electro-acupuncture to stimulate qi and blood flow, activate the muscles and reduce inflammation in the joint. As pain levels decrease, encouragement to place more weight through the left leg will be advised. Adjunct modalities when time permits include myofascial release/cupping to address muscle imbalances and increase circulation. Exercises will be prescribed to help build muscles in the left quadriceps, which will help support the hip joint. Chinese herbal medicine will be prescribed to improve patient energy levels and decrease pain and inflammation. Patient education regarding his expectations of improvement and self-care at home will be prescribed.
Typical treatment:
Supine/right lateral recumbent: ST36, SP10, GB34, LV3, LI4, SP6, SI3, BL62, 5 local Ah Shi points of the left hip and local needling around the scar tissue near the left greater trochanter
Electro-stimulation (2 pairs) - left gluteus medius, vastus medialis origin (SP10) and left tibialis anterior (ST36), peroneal muscle (GB34); 2/100 hertz
Alternate treatment:
Seated forward: Hwa Tou Jia Ji points, particularly on the left lumbar spine (deep paraspinals), to release the taught band of muscle
Additions to treatment (time permitting):
Cupping: Left lumbar spine and right thoracic; Left hip and ITB
Exercises: Isometric contraction of the left quadriceps muscles to activate and assess muscle tone
Herbal formula: Du Huo Ji Shang Wan
Outcome
After 6 weeks of treatment, the patient reported occasional dull pain in the left calf and thigh. Some nights, he was able to sleep pain-free. He experienced aching only in cold weather or after sitting for long periods of time. Sharp/dull dermatome testing became equal on left and right in L1-L2 nerve distribution. Range-of-movement testing showed a great improvement in passive, left hip flexion to 90 degrees without pain. The joint had a solid end feel at this range with application of overpressure. Knee flexion and extension strength became equal on both sides without pain (Oxford scale - 5). He attained 10° of internal rotation and 15° of external rotation in his left hip without pain. Apparent leg length remained the same and left thigh circumference, measuring muscle tone, increased by ½cm.
Continued Plan
It is recommended the patient continue with treatment for as long as it is available to him.
Even though these modalities appear to decrease pain and inflammation, it is possible the patient would see further improvement with a modality that specializes in postural rebalancing, exercise and reeducation. Without further imaging, it is hard to give an accurate prognosis. It is likely, in a western culture, with more resources and affordability, this case would have been treated with a left hip arthroplasty and follow up rehabilitation care.
Discussion
Due to the severity and chronic nature of the patient’s condition, a full resolution of his pain was not expected. The history of onset and initial diagnosis are still unclear. The environment in rural Nepal creates the challenge of walking up and down rocky paths, which makes walking for the patient more difficult. Doing this on crutches that were uneven in height likely contributed to the patient’s postural imbalance, particularly the taught band of muscle in his left lumbar region. Because of the chronic nature of the patient’s condition, it was imperative to discuss with him the need for continued care and management of his pain and mobility. The Chinese herbal formula, Du Huo Ji Sheng Wan, has been shown to inhibit inflammatory responses and pain in some biomedical studies on animals. It may also increase blood circulation and enhance the function of macrophages to clear inflammatory tissues. It is likely this contributed to the patient’s progress by decreasing inflammation and increasing circulation in the joint.
40-year-old male presents with chronic, burning gastrointestinal pain with accompanied acid reflux, belching, fullness, diarrhea, weight loss and occasional rectal bleeding. The patient also experiences fatigue and insomnia. Receiving only acupuncture and Chinese medicine therapy for this condition, the patient has shown an almost complete remission of symptoms after 8 treatments.
Subjective
Patient is a 40-year-old male presenting with gastrointestinal pain and diarrhea with initial onset 2-3 years prior to his initial consultation at this clinic. Patient reports pain is worse after eating and feels like a burning sensation in the epigastrium, with concurrent pain in the lower left and right quadrants of the abdomen. Spicy and oily foods exacerbate the problem and are generally avoided by the patient. Bowel movements are frequent with burning pain and diarrhea. The stools are yellow, loose and have a history of occult blood. Other gastric complaints include acid reflux that improves with belching, bloating and foul flatulence.
The patient experiences fatigue during the day and insomnia at night that manifests as difficulty falling asleep. Urination is frequent, yellow in color, but without discomfort.
The patient has not been able to seek medical attention for this condition before, nor taken any medications.
Objective
The patient’s appearance is thin, with visible ribs and gaunt face. Speech is soft, but he’s mentally alert. The sclera of his eyes are red, with a slight jaundice.
Upon palpation of the abdomen, exquisite rebound tenderness is felt halfway between the xiphisternal junction and the navel, as well as at bilateral points in the right and left lower quadrants, slightly lateral to mid-line between the navel and pubis (ST27 & KI14).
Tongue is red, with thick coat that is densest at the root and yellow in color.
Pulses are large, expanding and rapid with particular excess in the guan positions.
Assessment
DX: Chronic gastritis with inflammatory bowel syndrome, potentially Crohn’s disease
TCM DX: Damp-heat in the lower jiao; ST yin deficiency with fire
The level of transmural inflammation throughout the digestive tract gives high potential to chronic inflammatory bowel syndrome, which includes Crohn’s disease and ulcerative colitis, characterized by chronic inflammation at various sites in the GI tract, resulting in diarrhea and abdominal pain. Tenderness upon palpation reveals inflammation focused around the ileum and colon, which is present in 45% of Crohn’s patients. Lack of chronic bloody stools differentiates from ulcerative colitis. The relapsing and remitting of symptoms over the course of 2 years is also a likely marker of Crohn’s disease.
Prognosis
Regular acupuncture and herbal medicine treatment to mediate the more serious symptoms of the disease, and allow for remission. The patient already avoids foods that exacerbate the condition. Follow-up treatment will be required to manage symptoms, considering the reoccurring nature of inflammatory bowel conditions.
If there is little to no response to therapy within 8 treatments, a colonoscopy or ultrasound would be indicated to rule out further obstruction or ulceration of the Large Intestine. A stool sample would also be ordered to check for inflammatory markers and/or if parasitic infection is responsible for the inflammation.
Plan
Treat with acupuncture 2 times per week with daily Chinese herbal medicine intake. Upon the eighth treatment, the patient will be reevaluated.
Treatment principle: Drain damp-heat, clear Stomach and Large Intestine fire, nourish yin and unblock stagnant flow of qi & blood in Yangming channels.
Alternative points: PC6, KI14, ST40, LV8, DU20, Ling Gu
Herbal Formulas: Formulas are based on presentation of pulse at each treatment, and are adjusted according to symptoms and herbal availability.
Huang Lian Su: 8 pills TID for first week to clear inflammatory heat of Stomach
Shu Gan Wan: In conjunction with Ma Zi Ren Wan, 2 pills TID to clear Stomach heat and course the Liver to prevent overacting on Stomach and insulting Large Intestine qi flow
Ma Zi Ren Wan: 2 pills TID to drain damp-heat from Large Intestine and moisten dryness from yin deficiency
Zhi Bai Di Huang Wan: At treatment 7, in conjunction with Tao Ren Cheng Qi Tang, 2 pills BID to clear deficiency heat and tonify yin
Tao Ren Cheng Qi Tang: 2 pills BID to unblock bowels, stop bleeding, clear damp-heat
Outcome
After 8 treatments, the patient reported a complete resolution in burning pain and majority of problematic GI signs and symptoms. After 2 treatments, the burning pain in the epigastrium had decreased and sleep improved. At this time, due to an increasingly wiry pulse, the formula was changed from Huang Lian Su to Shu Gan Wan to address Liver overacting while concurrently clearing Stomach heat. After 4 treatments, the pain and symptoms in the epigastric area had almost resolved, while the burning pain in the lower abdomen remained with burning diarrhea and painful bowel movements. The chief complaint being diarrhea, the formula Ma Zi Ren Wan was added in concurrence with Shu Gan Wan. After 6 treatments, blood was noted after bowel movements, with moderate pain during movement. Slight anal prolapse was noted giving suspicion of hemorrhoids. The patient reported a descending nature of the pain from the whole abdomen to below the navel. The decrease in overall GI complaints and an unrooted pulse allowed for the formula Zhi Bai Di Huang Wan to be used in place of Shu Gan Wan to tonify yin while clearing empty heat. Tao Ren Cheng Qi Wan replaced Ma Zi Ren Wan to address the signs of bleeding. After 8 treatments, the bleeding had ceased, lower abdominal pain had been resolved, stools no longer had undigested food and were, overall, soft and formed. Palpation of the abdomen was negative for tenderness. The chief complaint became pain from hemorrhoids.
Future Plan
The nature of inflammatory bowel disease to flare-up requires the patient to comply with follow-up treatment when a relapse period occurs. Since the condition is primarily inflammatory, it is still classified as pattern 1 according to the Montreal classification of Crohn’s disease. If constant relapse patterns occur, it is possible the disease will advance to pattern 2 or 3, requiring more substantial treatment. Pattern 2 involves primarily stenotic or obstruction, and pattern 3 is primarily penetrating or fistulizing, both requiring different therapeutic approaches and possible surgical intervention.
Outcome
The patient responded well to the treatment plan. Considering the limited resources available to the patient, using acupuncture and herbs alone were effective in remitting a pattern of chronic inflammation that has been ongoing for 2 years without any form of intervention. With continued support and treatment, if relapse occurs, it is likely the patient will be able to live a comfortable life with a lower chance of complications from chronic Crohn’s flare-ups. Acupuncture and herbal medicine alone have proven greatly effective for signs and symptoms of GI inflammation, and should be considered as a first line treatment for pattern 1 classifications of Crohn’s disease. In conjunction with allopathic care, it could be hypothesized that Chinese medicine would also be effective complementary care for pattern 2 and 3. Due to the limitations of the accessible health care services available to the patient in Nepal, it is difficult to obtain objective GI imaging that is generally necessary for diagnosis of the progression and severity of Crohn’s disease. If such measures were more readily available, it would better define the improvement of interior structures in the absence of allopathic treatments.
60-year-old female presents with spinal trauma sequelae consisting of constant mid- to high grade pain and restricted flexion of the spine. In conjunction with the treatment for the spinal pain, the patient is treated for pain of the right knee with mid-grade pain and global swelling of the area causing functional impairments. With the completion of the prescribed treatment plan, greater than 75% improvement in symptoms of the spine, and greater than 90% improvement in symptoms with respect to the right knee are achieved.
Subjective
The patient presents upon first consult with a complaint of thoracic and lumbar spinal pain greater than 1 year with respect to onset of symptoms. The patient admits to having fallen from a ladder and landing on her spine over a year prior. The duration of the spinal pain is constant with no respite, even while resting. The quality of pain is a mixed pattern of sharp and dull pain as described by the patient. The main aggravators of the pain are forward bending, sitting and household chores. The patient finds but minor respite with warmer weather.
The patient’s concurrent complaint is right knee pain. The onset of the complaint is greater than 1 year. The area of pain is described as the entire knee. The duration of the patient’s pain is intermittent with a dull, achy characteristic with occasional episodes of sharp pain. The occasional episodes of sharp pain have no distinct pattern the patient can recall. The patient’s main aggravators for the right knee pain are standing, sitting, cold weather, flexion greater than 45 degrees and household chores.
Social history:
No reported history of smoking or drinking
Medical history:
Stage 2 hypertension [unmanaged]
Reports previous diagnosis of degenerative joint disease in knee
Medications & Supplements:
No reported medications
Review of systems:
Cardiac: No palpitations or chest pain
Respiratory: No shortness of breath
Digestion: No reported gas, bloating, nausea or abdominal pain
Sleep habits: Easy to fall asleep, but wakes frequently at night
Bowel movements: Patient reports WNL
Urination: Patient reports WNL
Integumentary: No spontaneous sweats or night sweats
Heat signs: Hot flashes
Objective
Vitals: BP: 175/99 mmHg, PR: 59 bpm
Pulse: Thready with transient changes of slippery and tight
Tongue: Large, red/purple coloration, dry and flattened tip; Peeled coating in the upper jiao of the tongue, yellow, light coat in middle jiao and thick white coat in the lower jiao. Engorged sublingual veins with distention greater than 75%
Palpation: L3 vertebra is enlarged on palpation as compared to other L vertebrae; T7, T12 are tender to the touch.
Visual inspection: L3 is visibly enlarged and protruding posteriorly as compared to other lumbar vertebrae.
AROM of spine: <30 degrees flexion, 25% lateral flexion with grimace, 25% extension with grimace
AROM of knee: <60 degrees flexion
PROM of knee: <60 degrees flexion; Crepitus felt and clicking heard with movement
Reports: MRI of the lumbosacral region taken 09/18/2014
Impression: Compression fracture of T7 and T12 vertebral bodies with marked anterior wedging. Compression fracture of L3 vertebral body. Probably osteoporotic fracture
Degenerative changes in lumbar spine with mild L5-S1 neural foraminal stenosis
Assessment
Before ascertaining medical records from the patient, differential diagnosis was the following:
Diagnosis (spine): Degenerative joint disease/osteoarthritis, herniated disc, spinal lesion, Osteoporatic fractures of T7, T12 and L3 (knee): Degenerative joint disease/osteoarthritis
TCM Diagnosis (spine): Bony bi due to underlying KD yin deficiency, bi syndrome due to wind-cold-damp invasion, qi stagnation and blood stasis causing pain (knee): Bony bi due to underlying KD yin deficiency with wind-cold-damp invasion
Initial Plan
Treat with acupuncture and Chinese herbal medicine with the 10th treatment designated as the reevaluation point for determination of progress. The length of time for the 10 treatment protocol is over a period of 6 weeks. The beginning treatment is focused on local stimulation of qi, blood and neural system around the right knee, while distally treating the spinal pain. This treatment approach is based upon the assumption of degenerative joint disease/osteoarthritis of the spine and osteoarthritis of the knee. Both of these western diagnoses are concurrent with findings of bi zheng – bony bi syndrome with underlying Kidney yin deficiency as the root. The herbal formula used in conjunction with the acupuncture is Du Huo Ji Sheng Tang with a dosage of 8 pills TID.
Typical acupuncture point selection for initial plan is: He Ding, Xi Yan, ST34, ST36, SP10, SP9, KD3, SI3, UB62, Zhu style scalp acupuncture for spinal pain, Yao Teng Xue.
The patient’s hypertension is an ongoing discussion, as the patient has been dealing with misinformation from local health authorities in the form of only suggesting dietary changes, or improper explanation of the importance of controlling hypertension. A secondary issue is the local rumors about drug therapy, especially hypertension medications. The rumors surround the side effects, some true, some not, which lead to out-weighing the need to control hypertension in the patient’s perspective.
Treatment Progression
The patient was steadily receiving benefit from acupuncture for the right knee pain, but having limited results with the spinal pain after the 3rd acupuncture visit, which was the visit on which the patient brought the previously taken MRI report and film. Upon review of the report of findings affiliated with the MRI, a change of acupuncture treatment was taken for the 4th visit.
Acupuncture procedure: Hua Tuo Jia Ji at levels of T7, T12, L3; The needles were placed at the depth of the periosteum of each vertebral body and then electro was applied at a continuous frequency of 80Hz. Additional points would be prescribed depending on changes in pain level of the right knee: UB40, Ah Shi 2 cun above UB40, Ah Shi 1.5 cun lateral UB40, UB39.
A change in Chinese herbal medicine was made as more yin deficient symptoms were being seen. Along with Du Huo Ji Sheng Tang 8TID, Zuo Gui Yin was added with a dosage of 3 pills BID.
Continued discussion was had regarding hypertension, but no progress had been made by this point in time.
Outcome
Final outcome for the patient after the 10th visit are as follows:
Subjective
Greater than 75 % decrease in spinal pain with or without activity
Greater than 90% decrease in knee pain with or without activity
No night sweats
Waking no more than 1 time per night
Objective
AROM of spine: WNL in all directions with no grimace present
AROM of knee: WNL in flexion with no grimace present
PROM of knee: WNL in flexion with no grimace and less crepitus felt, but clicking still present
Health management goal: Agreement was made with the patient to be assessed in Kathmandu and receive counsel with drug therapy to care for her stage 2 hypertension. In this agreement, the patient acknowledged the need for continuous monitoring to make sure hypertension is properly managed, even after medication is prescribed.
Conclusion
Maintenance care will be needed due to the patient’s age, history of trauma, bone degeneration and lifestyle that leads to excess exposure to inclement weather. The overall prognosis with maintenance care is good considering the results seen in regular care with respect to quality of life and pain management.
Injury prevention discussions and testing are deemed continually necessary considering the patient has been diagnosed as osteoporotic by physicians in Kathmandu. These discussions and tests could be a major step towards prevention of accidents and further degeneration that could lead to bone damage. Proper evaluation for high risk osteoporotic regions of the body needs fracture risk assessment (FRAX), which includes DEXA scans, and if deemed necessary, use of proper drug therapy. Monitoring of ongoing bone loss, or response to treatment with regard to osteoporosis, should be repeated approximately every 2 years per standard of care for patients with known osteoporosis.
A major goal to achieve, outside of maintaining a relatively pain-free state of health for the patient, is continued monitoring of the patient’s hypertension. This concern was agreed upon by the patient at the last visit. The patient agreed to see a physician in Kathmandu hospital system and receive drug therapy counseling with intervention for her hypertension. This health concern, in my point-of-view, outweighed the concerns held by the patient in regard to pain management. Poor understanding of hypertension is linked to inadequate public education and understanding of the causes of hypertension, and pathologies created by persistent
58-year-old male patient presents with ataxia, severe dizziness, vertigo and slurred speech. Symptoms started after a severe febrile illness in November 2012, and appear to be getting worse since that time. After 8 acupuncture treatments, patient reports a minimal decrease in overall dizziness and vertigo, and his walking appears slightly smoother immediately after receiving acupuncture.
Subjective
In November 2012, patient had a febrile illness for 6 or 7 days with severe vomiting, diarrhea and dark colored stools. Immediately following this illness, patient reports difficulty speaking and walking. He was admitted to the hospital for several days and received a CT scan, a routine blood panel, urine and stool testing, and was put on medication, which he discontinued on his own.
Patient presents with difficulty walking independently and slurred speech, which he reports has gotten worse since the febrile illness in 2012. Whenever he stands up and starts to walk, he has severe dizziness and vertigo and feels like he and his environment are spinning. No change in dizziness when he stands and looks upward. He is unable to stand up or walk without support. He reports occasional mild back pain, more chronic than the current illness and not coinciding with the difficulty walking. He has no pain in his legs.
He reports being diagnosed with high blood pressure, but stopped taking the medication as it “was not helping” him. He has headaches at least a few nights per week. The location and severity of the headaches is hard for him to determine. He is unaware of a history of ear pain or chronic ear infections. There is no hearing loss or ringing in the ears present. He has had blurry vision in the right eye for the past 20 years, after a foreign body hit him in the eye while he was riding the bus. Glasses have been recommended, but he prefers not to wear them.
Objective
Patient presents with ataxia with inability to walk or stand from a seated position without support. He has mild muscle spasticity on both legs while walking with support. Patient is able to stand on his own briefly, reports feeling very dizzy and unstable, and visibly has a hard time maintaining equilibrium. Balance is equally unstable when standing on just his right or left leg with support. The patient is able to walk on his toes and heels, while supported, with no pain.
The deep tendon reflexes of both patellas, Achilles’ tendons and hamstrings are all responsive and normal. Seated muscle testing of knee flexion, extension, ankle dorsiflexion and plantar flexion, and hip abduction and adduction bilaterally all have normal strength and range-of-motion. All cranial nerve tests are normal. Patient is able to move both arms smoothly overhead and no intention tremor is apparent. Tympanic membranes are both intact, though may have minimal scarring. No pain present around the ears with palpation. Nystagmus is not present.
Blood pressure is measured at 165/105. He is missing several front teeth, which he reports fell out on their own several years ago.
Directly after the febrile episode, on 11/19/12, he had a MDCT scan of his head. The report concluded there were no abnormalities present at that time. All routine blood and urine testing was normal. EKG and ultrasound of the pelvis and abdomen were also normal.
The pulse on the left hand is thin overall, and deep and weak in the chi position. The pulse on the right hand is slippery and forceful in the cun and guan positions, and deep and weak in the chi position.
The tongue has a dry, pink body with a thick, yellow coat at the root.
Assessment
DX: Cerebellar ataxia due to febrile illness
The patient does not have recent medical records or thorough diagnostic imaging. Several neurological conditions are also possible diagnoses in this case. Multiple sclerosis, Ménière’s disease and other causes of damage to the cerebellum must also be considered for this patient.
Multiple sclerosis (MS) can often present with ataxia and slurred speech, although these are not typically the primary symptoms associated with this disease. The most common symptoms of cerebellar dysfunction that are seen in MS can include dysarthria, instability of the head and trunk, intention tremor and incoordination of voluntary movements and gait. Along with ataxia, nystagmus can also appear early in the disease. MS is an autoimmune disease, typically starting between the ages of 20 and 40, more common in women than men. Most forms of MS usually start gradually, with an attack of symptoms, followed by a period of remission. Primary progressive MS does not have any periods of remission. It gets progressively worse, and typically presents with other primary symptoms that are not seen in this case, such as extreme fatigue, pain, numbness and tingling. Primary progressive MS can be ruled out definitively with an MRI of the brain and spinal cord with absence of scarring of the myelin, and a lumbar puncture of fluid surrounding brain and spinal cord, showing an absence of antibodies.
Ménière’s disease is a disease of the inner ear. This diagnosis is initially considered before his symptom of slurring of the speech is known. The primary symptom of Ménière’s disease is recurrent episodes of vertigo, which can last 20 minutes to 24 hours at a time. When severe, it can lead to falling and difficulty walking. Ménière’s disease typically presents with hearing loss, ringing in the ears, and a feeling of fullness or pressure in the ear, with which this patient does not present. His balance is not improving and vertigo is constant when he is standing and attempting to walk, neither of which are present in Ménière’s disease.
Cerebellar ataxia, due to stroke, is also possible, but not likely for this patient. Cerebellar stroke accounts for only 1% of all strokes and has 1 of the highest mortality rates. This type of stroke typically comes on suddenly with symptoms of headache, nausea, repeated vomiting, dizziness, vertigo and inability to walk or stand, but does not typically include fever or diarrhea. Coma occurs in about 50% of these cases and edema formation is also common, often leading to sudden respiratory arrest. Other causes of cerebellar damage are more genetic in nature and occur earlier in life, or are a result of nutritional deficiencies primarily related to alcoholism, which are not factors for this patient.
The diagnosis for this patient is likely to be cerebellar ataxia due to physical trauma, which in this case was a prolonged fever. Based on the history of his present illness, his symptoms started directly after having a prolonged fever for 6 to 7 days. The cerebellum is particularly sensitive to thermal injury, and prolonged fever can cause irreversible damage to the tissue and permanent cerebellar dysfunction. The damage is expected to be along the midline of the cerebellum, as the movement of the trunk and legs are affected in this patient. The damage would more likely be along the lateral hemispheres if the arms were affected. The damage is also suspected to be bilateral, as speech disturbance occurs only when damage is along both sides of the cerebellum. The most primitive areas of the cerebellum are connected with the vestibular nuclei and apparatus. Damage to this part of the cerebellum results in disequilibrium that is obvious with rapid changes of body position, and the presence of dizziness and vertigo, both of which this patient displays. These signs and symptoms can make the damage look like it is in the vestibular system itself, although coming from damage to the cerebellum.
TCM DX: External wind in the channels with underlying Kidney qi deficiency
The initial febrile illness resulted in an external invasion in the channels from which the patient has not recovered. He had no obvious preexisting signs of wind due to organ pathology before the febrile illness, making the source of wind most likely external in nature. Kidney qi deficiency is evident in this case due to age of the patient, history of hard physical labor before his present illness, intermittent lower back pain, missing teeth and the weakness of bilateral chi pulse positions.
Prognosis
Prognosis is poor due to the likely source of injury from November 2012. The main goal of treatment is to support the overall health and well-being of the patient, and potentially slow the progression of the neurological disease. Although unlikely, based on other clinical results involving brain trauma, it is also possible that with intense treatment, the patient may regain the ability to walk independently, and improve the quality of his speech. Acupuncture, electro-acupuncture and Chinese herbal medicine will all be used to work towards these goals.
Initial Plan
Acupuncture treatments are recommended 2 to 3 times per week for 16 sessions before reevaluation. Acupuncture would have been recommended more often, due to the severity of the patient’s condition, however he lives over 2 hours from the clinic and has to rely on family support to bring him by bus.
The focus of treatment is to expel wind from the body to reduce spasticity and erratic movement of the legs while walking, and to support the Kidney organ system. Typical acupuncture treatments involve combinations of the following points: GB12, 20, 34, 39, 41, SI3, BL62, TW5, LU7, LI4, LR3, 8, SP6, KD3, 6 and Ba Feng.
Scalp acupuncture with electro-stimulation is used along the motor line, including the speech, dizziness and vertigo area, and 3 lines for voluntary movement. Scalp needles are manipulated for 10-15 minutes while patient walks with assistance or moves legs while seated. Electro-stimulation is used passively for approximately 25 minutes.
The Chinese herbal formula, Qu Ji Di Huang Wan, is selected to help nourish the Kidneys with added support for the eyes.
The Epley maneuver is performed at the first several treatments before Ménière’s disease is ruled out as a diagnosis.
Patient is referred for glasses to reduce the effect the blurry vision in his right eye is having on his dizziness and walking. It is recommended that he continues to have his blood pressure monitored and resume medication if needed to reduce the long-term risk of stroke. Updated and more thorough imaging, and a routine blood panel are recommended to help confirm the diagnosis. However, this information is not likely to change the direction of treatment or prognosis based on the history of the illness and objective information, and will likely put a greater financial strain on the family.
The patient is informed of the prognosis of his illness, including the unlikelihood of regaining the ability to walk independently or improve his speech. He agreed that using acupuncture and Chinese medicine to try to regain some level of normal function, reduce the severity of his symptoms, and support his body as a whole, is worth the investment of his time.
Outcome
After receiving the Epley maneuver, patient reported an initial decrease in dizziness and vertigo, but stopped improving after a few repetitions. The maneuver became unnecessary as the patient no longer felt dizzy with the various changes in head position.
Patient showed little response to the 8 acupuncture treatments. Before-and-after videos showed the patient’s gait to be slightly smoother with less muscle spasticity after treatment. The patient reported feeling less dizziness and vertigo immediately following treatment and at night. His symptoms while walking, however, remained unchanged. No change in quality of his speech had been detected. After the first several weeks of treatment, the patient became less compliant with the frequency of his treatments, as the travel distance and subsequent hardship made treatment frequency too difficult for the patient and his family.
Revised Plan and Prognosis
Since the patient showed minimal improvement, it was recommended that he continue treatments later this year when a team will be present for 6 continuous months. If he is able to have 2 to 4 treatments per week for 12-15 weeks straight, it will be more evident if his symptoms will continue to show improvement, or if the minimal improvement already seen is the maximum benefit expected. His prognosis remains poor due to the nature of brain damage, the progression of his symptoms over time, and his advancing age. Considering how severely this affects his life, it is worth an intensive series of treatments on a frequent basis to see if his brain can be retrained to coordinate walking. The patient and his family are unsure of their ability to be compliant with the frequency of treatment based on the hardship they are experiencing, and the amount of effort it takes for him to come to a session.
Conclusion
The patient was only able to make it to the clinic for 8 treatments out of the recommended 16. Patient compliance with acupuncture treatment is even more important for patients who have severe pathology, such as brain trauma. It is not uncommon for results to be very slow for patients with severe conditions, and although minimal, he was making some progress in the quality and intention of his gait, and reduction in dizziness and vertigo. Based on several factors surrounding this case, it is unlikely that his walking will ever be what it once was, but it is in the realm of possibility to help him regain some of the coordination he would need to be able to walk on his own with the support of a walking stick. For him to regain even that level of independence would greatly improve the quality of his life, since he places a great burden on his family because of his lack of function. This is obviously difficult for him to accept. With acupuncture and Chinese medicine, it is possible that giving his body some much-needed support, and clearing some of the remaining external pathogens, his symptoms may start to improve. He has made little progress in just 8 visits, but there is still a chance for him to improve with an intensive series of treatments.
71-year-old male presents with cough and severe shortness-of-breath, caused by emphysema. Initially, patient was stabilized during an emergency home visit. At patient’s request, palliative home care was provided. This type of care is necessary for anyone suffering from chronic illness, yet as doctors, we often don’t follow cases through to this point. How do we manage end-of-life care in rural Nepal?
Subjective
Patient presents with a chronic cough of 3 years duration and shortness-of-breath. Acute symptoms began 10 months ago when he presented with severe pain in the solar plexus area and inability to breath. He was diagnosed with allergies at the local health post, but allergy medications were not helpful. He was transported to a hospital and diagnosed with emphysema and a pneumothorax. 1 month ago, patient was hospitalized for a second time and sent home with an oxygen tank, which he requires for respiratory stability.
He is only able to breathe if he sits up straight or leans forward. Cold weather and fatigue make these symptoms worse. Warmth, warm water, sunshine, his nebulizer and black coffee make it easier for him to breathe. His cough is productive with white mucus that is sometimes tinged with blood.
In addition to this, the patient suffers from worsening anxiety, insomnia, sharp left-sided chest pain, weight loss, daily nosebleeds, constipation, loss of appetite and 1-sided edema in his right limbs causing leg pain when walking. His leg pain and sleeping are better when sitting in a cross-legged, seated position with pillows stacked behind him. All of these symptoms are made better by listening to the radio and visiting with friends and family, taking his mind off his pain.
Objective
Patient presents with a thin body. Clothes that once fit him are now baggy. His ribs, scapula and clavicle bones are easily visible. He becomes breathless with small movements. His facial color is blanched. Patient breathes out through pursed lips.
Patient has a score of 40 on the Palliative Performance Scale (PPS). Ambulation is low. He requires assistance from a caregiver for moving and elimination. He is unable to do any work. He can drink from a cup, but requires assistance to eat. Food intake is reduced, but water intake seems normal. He is often fully conscious or drowsy. He is rarely confused, unless his blood oxygen levels drop below 70%.
Patient has +1 pitting edema in the right hand and +4 pitting edema in the right foot. The leg feels room temperature on palpation. Dorsiflexion of the right foot causes pain and increases shortness of breath. Blood oxygen levels rise and fall, becoming more extreme over the course of our visits, with the lowest reading being at 63%. The pulse and respiration rates rise as the blood oxygen levels fall.
Lung exam shows increased expiration time with decreased lung sounds in the lower lobes. Lungs are clear to auscultation in the lower lobes. Soft to medium crackles and high-pitched wheezing on both inhalation and exhalation are present. An occasional pleural friction rub can be heard in the right middle lobe. Cardiac auscultation shows an irregular heart beat with an extended diastolic conclusion (S2). Both lung and heart sounds decrease over time.
The right radial pulse is weak and deep. The left is thin and deep. His tongue body is dusky with multiple cracks. The tongue coat is thick, dry, yellow and stringy. There is a +3 sublingual stasis.
Assessment
DX: Hospital records show that the patient was diagnosed with emphysema 10 months ago. X-rays show honeycomb cysts, and radiological conclusions communicate that a cyst in the “left middle lobe” burst, causing a pneumothorax.
This patient is a non-smoker and hasn’t had the occupational hazards that are usually associated with emphysema. It is likely that the lifelong use of a traditional Nepalese indoor cooking stove, with combustible biomass fuels, contributed to his disease state. In addition, x-rays show lower lobe thickening and concentration of bullae, which is a typical indicator of a genetic, alpha-1 antitripsin deficiency. This deficiency reduces the likelihood of cellular repair to lung tissue predisposing to emphysema, even with reduced exposure to inhalants.
TCM DX: Lung qi deficiency with obstruction by damp-phlegm and Kidney yang deficiency
PROGNOSIS: Patient’s condition worsens daily. It is evident that he is moving through the stages of grief, and acceptance of his death. Due to a PPS scale of 40, it is likely that he will die sometime in the next couple of months. An accurate BMI and FEV1 reading could help with a more accurate prediction of his lifespan, but the tools to measure this are not available to us at this time.
Initial Plan
Patient is recommended to go to the hospital, but he refused.
Plan for this patient focuses on improvement in his quality of life, palliation of symptoms associated with end-stage COPD, and support for patient and his caregivers around any other physical, mental-emotional or spiritual issues that may surface concerning his death process.
Typical treatment:
Monitoring of physical vital signs
Codeine, at a dose of 30g per evening, to provide minimal pain relief and reduction of cough so that the patient can sleep (This is purchased from the local pharmacy, where it is available to anyone.)
Cranial sacral therapy (CST) to release the occiput and tentorium cerebelli, to reduce anxiety and calm wheezing
Mild massage of the neck, shoulders and area between the shoulder blades
Education for patient and his family, including information about his disease, the cleanliness of his living area, danger of too much bed rest, etc.; Providing accountability for family members around his care
Emotional support around and witnessing the grief and death process; Discussion of the patient’s goals and desires for his final days
Drawing supplies and encouragement to engage in activities he finds enjoyable, including a small walk to the porch in the sunlight
Outcome
During first contact, the respiratory emergency was stabilized and patient’s oxygen levels returned to normal ranges for his disease state. After that time, the patient showed relatively stable oxygen levels, less anxiety and was able to sleep through the night. He began sharing his life story, but was not yet able to discuss his death.
After 3 weeks, the patient presented with +4 pitting edema in his legs that prevented him from putting weight on his feet. He reported sharp chest pains. He became vocal about his death and stopped smiling and laughing as much.
At 4 weeks, the patient reported lowered anxiety and a feeling of increased relaxation. He asked for more practitioner visits, reporting feeling best on days when we came.
After nearly 30 patient contacts, the patient’s family reported a respiratory emergency with sharp chest pains. Upon arrival, pulse oximeter readings showed a blood oxygen level of 63% with a pulse of 34 bpm and respiration rate of 28. The patient could not maintain consciousness and at some point, could not recognize family members. Cultural traditions around death were already being performed by the family. He died during the night.
Discussion
In developed nations, the progression of COPD is delayed and the quality of life increased by using long-term oxygen therapy (small, portable tanks), and morphine to reduce the feelings of shortness of breath. Patients are recommended to follow a regular exercise and pulmonary rehabilitation program to maintain aerobic capacity and hence, maximum oxygen uptake.
A portable oxygen tank was not an option for this patient. His oxygen tank required 3 strong men to lift it into his room. The tubing to the tank allowed him 8 feet of movement from his bed. The costs of the tank were so high that the family often turned the tank off even though the patient would respond with blood oxygen levels in the low 70%. By the time of response to his respiratory emergency, he had been non-ambulatory, due to the tank, for over 15 days. With complete bed rest, elderly patients can lose up to 5-6% of their muscle mass each day and aerobic capacity decreases markedly1. Though it was recommended that the patient move each day, he reported that he was too weak to get out of bed.
This patient faced substantial impediments to obtaining morphine for pain control and relief of his shortness of breath. Had pain control been available for this patient, his quality of life would have been increased, and based on emerging studies, his lifespan may have been increased as well(2).
Conclusion
This patient and his family tried to get help from the local health post, a hospital in Kathmandu and a teaching hospital in Chitwan. They experienced an unfortunate misdiagnosis and multiple, failed attempts at a blood draw that left the patient’s arm completely bruised. During their final hospital visit, they were told not to come back, and were given medications for asthma and allergies. No healthcare provider explained the diagnosis to the patient, nor walked the patient and his family through the reality of his upcoming death. The doctor who prescribed the oxygen tank never spoke with the patient or his family about the risks associated with geriatric bed rest.
Though ARP is not an organization that commonly provides home care, and specifically, palliative home care, our team opted to continue providing such care in this patient’s case. The patient had no other options and our volunteers and interpreters were willing to spend the extra time, after a full day of clinical work, to perform vitals checks, and help educate the patient. Our organization is not often asked to provide end-of-life care and as such, we have not developed protocols for the management of these cases. This situation presented us with an opportunity to determine the resources that ARP can commit to such cases.
Our management of end-of-life care is dependent on the circumstances taking place outside of regular clinical hours. Are our volunteers and interpreters drained of energy from seeing a surplus of patients most days? In this case, we had numerous bus strikes that lowered our daily case loads, and I felt that I had enough energy to spend with the patient. The patient went through many stages of grief and as such, the nightly visits were emotionally charged requiring me to commit to a great deal of self-care, including morning and evening meditation, Taiji practice, writing and a lot of support from my team members. It was often hard to find an interpreter to volunteer to sit with a dying man when they faced the alternate choice of watching a movie or simply going to bed after dinner. This presented the possibility of resentment from the interpreters, which was something that I didn’t want to risk. I tried to rotate through the interpreters and to go either right before dinner, or shortly thereafter. This kept the task associated to a time that already held a social commitment, and it seemed to be less jarring for everyone.
As healthcare providers, it is hard to accept that no matter what knowledge we bring to the bed of a dying person, we will not find a way to “save” the patient and somehow magically restore their body. I encountered this difficulty in the first couple of weeks with Lal Lama. I worked all day to problem solve health issues that could be cured or managed. At night, I had to shift my intention so that I could listen to a patient’s story about his life and receive information about what his best death looked like, so that I could advocate for that if necessary. I had to tell the patient that there was nothing I could do to cure him, and that we were limited in the management of his pain. I felt myself unworthy of sitting with Lal and told myself that there must be a doctor nearby who could do this job better than I could. I finally came to realize that I was the best that Lal had, and in the end, I am so grateful that I embraced that and became the listener and friend that he needed. He taught me how to sit with the dying and how to die when the time comes for me.
1 Merck Manual
2 Lamas, Daniela and Rosenbaum, Lisa. Painful Inequities - Palliative Care in Developing Countries. New England Journal of Medicine. 366: 199-201. January 19, 2012.
57-year-old female presents with hand tingling and severe wrist pain that began 9 months prior to visiting the clinic. Both wrists are affected. Patient reports pain began first in right wrist, but currently feels more pain in her left wrist. The western diagnosis for this patient is De Quervain’s syndrome, caused by repetitive stress injury. After 7 treatments with NSAIDs, acupuncture, moxibustion, topical pain ointment and electro-stimulation, patient reports 75% reduction in pain.
Subjective
Patient is a 57-year-old female presenting with bilateral wrist pain. Pain began with the right wrist, and now her left wrist is more painful. Patient points to bony prominences on both wrists, near radial styloid, and reports chronic pain for the last 9 months. Patient reports that pain is worse with cold and damp weather. She comes to the clinic with no prior intervention or treatment for this wrist pain.
Objective
Patient appears in good health with weight proportional to height, and luster in facial complexion, hair and skin. Blood pressure is 120/80 and blood glucose is 101 mg/dL. Tongue is pale with white coat. Pulses are thin and weak. When palpating both right and left wrists at the location of the radial styloid, near acupuncture point Lung 7, patient reports sharp pain. She tests positive when performing Phalen’s test, reporting numbness and pain after holding hands in prayer position for several seconds. Noticeable prominence on both wrists at the radial styloid is evident. Patient tests positive with Finkelstein test, reporting severe pain with thumb flexed across the palm, enclosing fingers around thumb in a fist and deviating and rotating the fist toward the ulna. DTRs (deep tendon reflex) for brachioradialis, biceps and triceps are normal.
Assessment
DX: De Quervain’s tenosynovitis
De Quervain’s syndrome is stenosing tenosynovitis of the short extensor (extensor pollicis brevis) and the long abductor tendon (abductor pollicis longus) of the thumb with the first extensor compartment. Inflammation of the tendons, and subsequent fibrosis over the radial styloid of the first digit dorsal compartment causes this area to become thickened and bone-hard, raising the skin and creating a prominence that is tender and painful. De Quervain’s tenosynovitis is most commonly due to the repetitive stress injury involving repetitive hyperextension of thumb. Diagnosis is based on the major symptom of aching pain at the wrist and thumb, aggravated by motion. Physical testing is the Finkelstein test as described above.
Considerations for differentiating include:
• Dorsal ganglion of wrist – Cysts are fluid filled with clear high viscosity fluid. This patient’s swellings are bony and hard, more consistent with De Quervain’s tenosynovitis.
• Carpal tunnel syndrome (median nerve compression within wrist) – This is diagnosed with a positive Phalen’s test of elicited numbness and tingling along median nerve pathway, which includes the second finger. Further testing with patient shows no numbness in second or third finger, ruling out CTS.
• RA (rheumatoid arthritis) – A blood test for RA factor is useful for this diagnosis. Usually, there is symmetric involvement of multiple joints that are inflamed, with redness and warmth. RA symptoms often include symptoms of malaise and fatigue. Patient does not show any characteristic redness or warmth in swelling, or signs of fatigue.
• Cervical radiculopathy of C5 or C6 nerve root – Sensory abnormalities in a distribution involving the dermatome; Patient tests normal for deep tendon reflexes, ruling out cervical radiculopathy.
• Scaphoid fracture in wrist – Can test using tuning fork on scaphoid bone; If fractured, patient will report pain. Patient does not report any accident occurring with onset of pain. Pain first occurred in right wrist and then left wrist. This is more consistent with repetitive stress injury from hyperextension of thumb.
TCM DX: Cold-damp bi syndrome with local channel blockage of Lung and Large Intestine channel. Pain in wrist is less when stick moxa is applied to area. Condition is worse with cold and damp weather. Bi syndrome is characterized by the obstruction of qi and blood in the channels due to the invasion of pathogens of wind, cold or damp, as well as heat or blood stasis. Cold bi is characterized by severe stabbing arthralgia with fixed location, alleviated by warmth and aggravated by cold with white fur on the tongue and tight pulse. Damp bi is characterized by soreness and fixed pain in the joints with local swelling and numbness, aggravated on cloudy and rainy days, with white and greasy tongue coat, and soft or slow pulse.
PROGNOSIS: Fair; Inflammation of tendons can take several months to heal completely. Reduction of pain is expected through the use of NSAIDS and acupuncture. Plan is to reduce pain by 50% over 7 treatments.
Plan
Treatment Principle: Move qi, remove meridian blockages with warmth and resolve dampness.
Treatment: Patient travels over 4 hours to clinic. Traditionally, any type of tendonitis treatment involves rest, ice, NSAIDS, stretches, modification of activity, possible corticosteroid injection and possibly surgery. Thumb spica splint that immobilizes thumb, preventing hyperextension, may help.
Rest, or modification of activity, is not likely to be viable components of treatment with this patient, who uses her hands for daily chores.
Ice is not available in rural Nepal. Both corticosteroid injection and surgery are outside the patient’s parameters for availability and affordability.
Initial plan includes acupuncture treatment 1 time per week. Placement of the needles are along the Lung and Large Intestine channel that align with the tendons and muscles of extensor pollicis brevis and abductor pollicis longus. The needle direction is toward the bony prominence. Alternating treatments each week with moxa 1 week and electro-stimulation for 20 minutes the following week. Experimenting with a topical NSAID ointment preparation by crushing 2 x 100mg sodium diclofenade tablets and mixing into 83ml container of petroleum jelly. Patient is being treated with oral NSAID of ibuprofen, 400mg TID for 10 days. Patient is instructed to use topical ointment at night after completing chores of the day. Patient is also instructed to wrap thumb with an Ace bandage to prevent hyperextension during the night while sleeping.
Outcome
During first contact, the respiratory emergency was stabilized and patient’s oxygen levels returned to normal ranges for his disease state. After that time, the patient showed relatively stable oxygen levels, less anxiety and was able to sleep through the night. He began sharing his life story, but was not yet able to discuss his death.
After 3 weeks, the patient presented with +4 pitting edema in his legs that prevented him from putting weight on his feet. He reported sharp chest pains. He became vocal about his death and stopped smiling and laughing as much.
At 4 weeks, the patient reported lowered anxiety and a feeling of increased relaxation. He asked for more practitioner visits, reporting feeling best on days when we came.
After nearly 30 patient contacts, the patient’s family reported a respiratory emergency with sharp chest pains. Upon arrival, pulse oximeter readings showed a blood oxygen level of 63% with a pulse of 34 bpm and respiration rate of 28. The patient could not maintain consciousness and at some point, could not recognize family members. Cultural traditions around death were already being performed by the family. He died during the night.
Outcome
Patient was tested at sixth treatment with Finkelstein test and reported no pain on right wrist and only slight pain on left wrist. At the seventh and final treatment, she reported an overall 75% reduction in pain.
Conclusion
The use of NSAIDs to reduce and limit the pain, and reduce inflammation with acupuncture and moxa, proved very helpful for this patient. The swellings in both wrists were quite small in area, superficial and seemed to respond well to topical NSAID preparation. However, for larger areas or deeper inflammation, the topical application would not be useful.
Dietary changes, such as using or increasing the dosage of turmeric, may aid in the reduction of inflammation. Initial diagnosis was carpal tunnel syndrome. However, with further testing and interaction with the patient, De Quervain’s syndrome became more likely. Both these syndromes are due to repetitive stress injury. Treatment over time changed to focus more on the hyperextension of thumb and associated tendons and ligaments, and less on the wrist compartment.
15-year-old female presents with purulent, non-healing ulcers in the right ear canal. After 20 treatments, using an integrative approach that included Chinese herbal medicine, acupuncture and antibiotics, the patient experienced a reduction of pus, reduced pain and itchiness. However, the condition did not resolve. The treatment and investigation became directed towards possible skin staphylococcus, otomycosis (a skin fungal infection), skin tuberculosis and acquired cholesteatoma. A referral for further investigation is necessary for a definitive diagnosis.
Subjective
15-year-old patient presents with non-healing, suppurative ulcers of the right, external ear canal. The patient reports she has an 8-year history of upper respiratory tract infections (URTI) and ear infections with the ear ulcers. With the use of an unknown quantity of antibiotics and eardrops, there has been no resolution of the ulcers. The ulcers developed to this severe stage 1 year ago and have gotten continually worse. She reports intermittent pain and itchiness with constant, copious amounts of thick, sticky pus. The hearing in the right ear is diminished. The submandibular glands are occasionally swollen bilaterally. She suffers from intermittent headaches. The patient does not show any symptoms of an acute infection, as there is no fever, intense pain, painful swollen glands or an acute sore throat.
Objective
On first inspection of the ear canal, an accumulation of chronic, inflammatory cells are evident with a copious amount of pus being produced. Initially, the tympanic membrane is not visible.
The location of the ulcers are a third of the way down the ear canal at 5 o’clock with a bigger ulcer half way down at 12 o’clock. They are inflamed, suppurative and crater-like with a definite circumference.
With consistent treatment, the less deep ulcers clear to expose a larger ulcer at the end of the ear canal at 1 o’clock. It appears to be partially covering the tympanic membrane. It is unclear if the tympanic membrane is affected. Upon asking if the patient can taste the vinegar being used to alter the environment of the ear, she claims she cannot, indicating tympanic membrane is intact.
Upon inspection of the left ear, no redness is observed, nor associated pain or itchiness noted. The tympanic membrane is intact.
TB mantoux test and TB sputum test – both negative; For a definitive result, a skin biopsy and pus culture is necessary. The pus culture determines which bacteria is present in order to find the antibiogram, which can determine a bacteria’s sensitivity to an antibiotic.
Initially, when cleaning the debris in the ear, up to 10 cotton swabs were necessary. After 15 treatments, only 2-4 cotton swabs were used, indicating a significant reduction in pus secretion.
Assessment
DX: Non-healing, suppurative ulcers of the right external ear canal
The body’s ability to heal the ulcers is compromised due to the location at the deep end of the external ear canal, poor visibility and difficult access, and the chronic nature of the disease. The ulcers respond to the antibiotics and antifungals, but do not heal completely. Possibly, the wound has become antibiotic-resistant over the years. An infection of the middle ear cannot be ruled out, as it is impossible to investigate under the circumstances.
Possible cutaneous staphylococcus infection: A culture is required to identify.
Otomycosis: Fungal infection of the external ear canal; Malodorous discharge, inflammation, scaling, severe discomfort and itchiness with minimal pain characterize fungal infections. A culture is required to identify for exact diagnosis and appropriate treatment.
Skin TB: Non-healing wound is the main symptom of skin TB. Characteristic histopathological features on skin biopsy and pus culture confirm the diagnosis.
The patient experiences a combination of all of the above symptoms at differing times. Further testing is required for complete and accurate diagnosis.
Acquired cholesteatoma: Cholesteamtoma can give rise to a number of appearances. If there is substantial inflammation, the tympanic membrane may be partially obscured by an aural polyp. The presentation of this disease penetrates into the middle ear and should be considered. Further analysis is recommended to rule out potential for this condition
TCM DX: Chronic, turbid, damp-heat in the external ear canal
It is most likely that the ulcers began with a channel pathology of an external invasion. Over time, the chronic and damp nature of the condition has become more systemic.
Lung qi and wei qi are affected due to the history of URTI. The Lung system is the most exterior organ and is the first internal organ typically affected by external pathogens. The Lung system includes the skin and is associated with wei qi. As the wei qi becomes weakened, the body’s ability to have a strong defense becomes negatively affected.
Spleen and Stomach qi deficiency due to the chronic nature of the condition. One of the Spleen’s functions is to identify the turbid and to transform and transport this pathogen. The Spleen also produces and stores white blood cells that clean bacteria from the blood. This function is important in tissue regeneration and in stimulating an immune response in the body. The cold nature of antibiotics damages the Spleen and thus the ability to be effective in healing the chronic nature of the ulcers.
Prognosis
Poor prognosis without the skin biopsy and pus culture to identify the pathogen as bacterial, fungal, skin TB or drug-resistant skin TB. Infection is the single most likely cause for the delay in healing. The inflammatory phase has become prolonged because of the chronic nature of the condition. With ineffective, yet consistent treatment, both internally and externally, surgery is recommended because of the excessive granulation of the tissue that is hindering the re-epithelialization of the local area. Alternatively, with the confirmation of skin TB, the healing will occur with the use of appropriate medication. The potential for a good prognosis is possible if the above recommendations are followed.
Treatment
Due to the chronic nature of the ear ulcers, therapy is adjusted throughout the process. Treatment is according to the nature of what the patient is reporting and how they present over the course of 1 month. Below is an outline of the sequential treatments.
The following is done at every treatment from the beginning.
- Acupuncture: Ear tacks applied every 2- 3 days to San Jiao 17 and 21, Gallbladder 2 and Small Intestine 19. These points are used locally to activate circulation and decrease inflammation.
The following occurred at the same time. The pus decreased before plateauing and never fully resolved.
- Internal antibiotic Chinese herbal medicine (CHM) Huang Liang Jie Du Tang 7 days
- External antibiotic CHM Huang Liang Jie Du Tang mixed with Neosporin 10 days alternating days
- Aural saline flush on alternate days for 7 days
After the above stopped working, the following was prescribed.
– Azithromycin, 500mg PO for 5 days
– Aural vinegar flush on alternate days for 8 days
– Cloxacillin, 1gm TID for 7 days
Once the antibiotics stopped working, a fungal approach was taken.
– Antifungal ear drops 4 drops TID for I month
– Fluconazole 150 mg PO once per day for 3 days, then once per week for 3 weeks
The following was prescribed to support the digestive system.
– Internal CHM Si Jun Zi Tang taken over the 4 weeks of treatment
The following was prescribed at the end of the treatment plan to help boost the immune support and aid the ear.
– 50% colloidal silver/50% rubbing alcohol ear flush, 4 times per week for 2 weeks
– Multi vitamin and 500mg vitamin C taken daily – long term
Outcome
After the initial 5 treatments, it became obvious that the ulcers were difficult to heal and would require different approaches in the attempt. Through the observation of changes over a series of 20 treatments, the plan was adjusted 3 times. The patient reported decreased itchiness, pain and discharge. As soon as the medicines were completed, however, the itchiness reappeared, but to a lesser degree. The discharge also increased, but to a lesser degree than when she initially started treatment. All of this was indicative that the ulcers were still present.
Ongoing Treatment
The patient and her family were informed that further investigation was necessary. With the consistent treatment that she had been receiving, to act on the referral that had been given would ensure the resolution of the non-healing ulcers. To continue using the antifungal eardrops, taking a multi-vitamin and extra vitamin C would be beneficial in the support of her immune system.
Conclusion
This has been an interesting and important case, as it not only demonstrates the efficacy of using an integrative approach, but it also highlights the ability of acupuncture to serve as an initial access point of care in which the patient received regular treatments and the opportunity to closely follow her progress and therefore prognosis. Significant improvement has been achieved, clearing the way for the definitive understanding that a referral to the appropriate hospital is necessary. A referral for investigation and/or surgery has been written bringing attention to the patient’s lower income status. This is imperative for the family so they are not subjected to unnecessary financial burden. This can, otherwise, have a significant effect on the family not following through with the investigation necessary for the ulcers to resolve.
58-year-old male presents with persistent contraction of 3rd, 4th and 5th fingers of right hand. He reports it began insidiously 3 years ago, and that it might be due to a leech bite from 25 years ago. After just 3 treatments using electro-acupuncture and manual therapy, passive and active range-of-motion have improved by 35%. To be limited in hand dexterity in this rural country is traumatic and debilitating. Acupuncture is a quick-acting and cost-effective alternative to surgery. This is especially important for this case where health care access and financial resources are limited.
38-year-old female presents with a 4-year history of involuntary spasming throughout her entire body. The patient does not have any available medical records and the cause of spasming is unknown. Over the course of treatments, the patient experienced a feeling of ‘lightness’ in her body, especially immediately after treatments, and an overall improvement in her well-being. Due to the severity of her condition, permanent change in her spasming is unlikely, however a 20% reduction in spasms was observed during the course of treatments.
63-year-old female presents with chronic purulent vaginal discharge, pruritus vulva and tingling in the extremities. Test results show hyperglycemia of RBS 540 mg/dl as well as vaginal candidiasis. Patient received 9 treatments of acupuncture, referral for insulin therapy, advice on diet and exercise, as well as Chinese herbs. With education, continued treatment and case management, she will be able to control her diabetes and prevent further candida overgrowth and complications.
SUBJECTIVE
63-year-old female presents with white, foul-smelling vaginal discharge, for the past 3 years. Patient reports vaginal itching, which has increased in severity over the last month. She describes the area as ‘burning’ with small red and purple raised sores and no pus. Secondary complaints include blurry vision, red eyes, weakness in her limbs, some achy pain and tingling in both her legs and feet.
Patient feels thirsty, craves sweet foods, and reports an increased appetite for the last 2 years. She eats irregular meals, which usually consist of rice, green leafy vegetables, potatoes and dal bhat. She drinks milk tea with sugar a few times a day and drinks approximately 1.5 L water per day. After eating, the patient feels bloated with occasional nausea. Her energy levels fluctuate and she describes a feeling of a dry scratchy throat, especially in the afternoon. The patient experiences burning and dribbling urination at a frequency of 8-9 times per day and 3 times per night. The urine is described as cloudy in appearance. Her stools are daily, loose and often have a foul smell. She tends towards rumination and says she often wakes at night with difficulty falling back asleep.
52-year-old female presents with chronic, burning epigastric pain accompanied by acid reflux, nausea, belching and decreased appetite. The patient also experiences daily headaches and dizziness. With conjunctive therapy of acupuncture, Chinese herbal medicine and antacid treatment, the patient reported an 80% improvement in her condition over 10 treatments, experiencing a decrease in severity, frequency and the absence of many symptoms.
Subjective
Patient is a 52-year-old female who presents with moderate epigastric pain, a complaint that the patient has had for 6 to 7 years. The pain manifests as a burning sensation in the epigastric region, at times exacerbated when the patient eats, while at other times is relieved with food. Occasionally, the patient wakes in the night due to her gastric pain. She experiences acid reflux after eating, a decrease in appetite, belching and nausea both on empty stomach and after eating. The epigastric pain is aggravated by the consumption of spicy and greasy foods. Bowel movements are daily, formed and easily passed without pain. The patient denies diarrhea or loose stools, blood or mucus in the stools, and vomiting.
The patient also experiences both headache and dizziness daily, which she has had for 1 year. The headache manifests as a throbbing pain, located primarily in the temporal region and occasionally in the frontal region. Dizziness occurs mostly when the patient moves from a seated to standing position, though occasionally she will experience dizziness when attempting to focus on a point in the distance. The dizziness can be accompanied by blurry vision.
The patient experiences sleep disturbances with both difficulty falling asleep and difficulty staying asleep, often waking several times throughout the night. She reports a feverish sensation in the afternoon, and night sweats.
The patient’s diet consists primarily of rice, lentils, vegetables, chickpeas and dado (corn meal and buckwheat).
The patient has not received any medical treatments for her gastric pain, headaches or dizziness.
Objective
Despite the patient’s complaints of gastric pain, headache and dizziness, she appears to be in good health for her age and environment.
She experiences a moderate level of epigastric pain and acid reflux after every meal. Nausea and belching is experienced daily. Headaches and bouts of dizziness are also a daily occurrence. Abdominal palpation reveals no masses or objective tenderness in any of the 4 quadrants or on the midline, and no indication of an enlarged Liver or Spleen. Both Murphy's sign and McBurney's point are negative. The patient’s blood pressure is 120/70 mm/Hg. Tongue is pale with fissures throughout body. The pulse is thready.
TCM DX: Stomach yin deficiency, Liver and Kidney yin deficiency It is suspected that the patient has non-erosive gastritis accompanied by a gastric ulcer, and potentially a duodenal ulcer. Though nonerosive gastritis is generally asymptomatic, it manifests as mild dyspepsia and other vague symptoms, which are part of the patient’s presentation. Additionally, non-erosive gastritis is commonly caused by Helicobacter pylori (H.pylori), a bacteria that is speculated to be in the local water supply in considerable quantity.
Accompanying the gastritis, a gastric ulcer is suspected. Gastric ulcers manifest as a variable pain picture in which the epigastric pain does not follow a regular pattern. A common manifestation of a gastric ulcer, in which eating sometimes exacerbates rather than relieves the pain, is consistent with the patient’s pain presentation. On occasion, the patient wakes at night due to her epigastric pain, a common manifestation, and suggestive of a duodenal ulcer. However, the patient does not possess any of the other defining characteristics typical of a duodenal ulcer. Such symptoms include a consistent pain pattern of absence of pain when waking, pain that appears midmorning, is relieved by food, but recurs 2 to 3 hours after a meal.
Similar to that of non-erosive gastritis, gastric ulcers are commonly caused by H.pylori or overuse of NSAIDs. The patient lacks a history of NSAID use, further suggesting that the suspected ulcer is a result of an H.pylori infection.
Stomach cancer is not likely with this patient’s presentation as there is no occult blood in the stool or concurrent symptoms that often accompany cancer, such as weight loss or extreme fatigue, etc. Stomach cancer may become a concern in the future if the gastritis is due to a H.pylori infection, as it has been shown that the occurrence of stomach cancer is 3 to 6 times more common in persons with H.pylori infection.
Prognosis
With regular acupuncture, in conjunction with herbal and antacid treatment, the patient is expected to experience a minimum of 50% improvement in her epigastric pain and associated symptoms. Progress is contingent upon patient’s compliance to the treatment plan, and taking herbal and antacid supplementation as prescribed, as well as the avoidance of trigger foods.
If the patient experiences little to no response to the conjunctive therapy within 10 treatments, an endoscopy and stool analysis would be indicated to rule out microscopic blood in the stool. If endoscopy proves H.pylori infection, triple antibiotic therapy is indicated. Proton Pump Inhibitor (PPI) therapy would also be indicated at this time to help further mitigate stomach acid.
Both interventions would be supplemented with concurrent acupuncture.
Plan
Treat with acupuncture 3 - 4 times per week with daily intake of Chinese herbal medicine and antacids. The patient receives 10 treatments, after which there will be a reassessment of the patient’s condition.
Acupuncture: Acupuncture treatments generally focus on clearing empty heat from the Stomach and nourishing yin of the Kidneys and Liver.
Typical acupuncture points utilized in treatment consist of ST44, REN12, REN6, ST25, P6, REN17, ST36, KI3, SP6, KI10, LV8, LV3 and LI4.
Chinese herbal medicine: Internally, formulas to tonify Kidney, Liver and Stomach yin, and clear Stomach heat
Liu Wei Di Huang Wan: 3 pills BID for the first 2 weeks of gastritis treatment to simultaneously address the headaches and dizziness
Stomach Formula (Mayway): 3 pills TID for the following week of treatment with focus on nourishing Stomach yin and clearing Stomach heat
Antacid Treatment: Mitigation of Stomach acid to reduce pain; 2 tablets 5-10 minutes before meals and 2 tablets before bed
Lifestyle Advice: Counsel patient to avoid foods that trigger gastric pain, namely spicy and greasy foods.
Outcome
After 10 treatments, the patient reported an 80% decrease in her gastric pain and associated symptoms, as well as her headache and dizziness. She no longer experienced burning epigastric pain upon waking in the morning, and the epigastric pain that remained had decreased from a moderate level of pain to a low level of pain. Additionally, she no longer experienced any acid regurgitation after meals, or belching before or after eating. Her nausea became sporadic, rather than daily, and decreased in severity. She reported an improvement in her appetite. She still woke several times in the night, though gastric pain was no longer the cause. The patient could not note if there was more improvement in her epigastric pain and associated symptoms on either Liu Wei Di Huang Wan or Stomach Formula.
Her headaches decreased in severity and frequency. Before treatment, she experienced headaches daily. After treatment, she could last several to many days without a headache. Her dizziness was still consistent, though it decreased in severity. Additionally, she no longer experienced night sweats, and the heat sensation in the afternoon decreased in severity and frequency. The patient reported more significant improvement in her headaches and dizziness, night sweats and heat sensation while taking Liu Wei Di Huang Wan.
The patient would experience a recurrence of her epigastric pain when she would overindulge in spicy and/or greasy foods.
Discussion
According to the District Health Office of Makawanpur, 80% of cases reported to the Hetauda Hospital are for epigastric pain or gastritis. Therefore, it is pertinent to address the nature of gastric pain and what effect acupuncture, Chinese herbs and other forms of supplementation can have on the condition.
The patient responded well to the treatment plan, with combination therapy of acupuncture, herbs and antacids, with varying degrees of efficacy at mitigating the patient’s symptoms outlined above. The combination therapy is important for the management of the patient’s epigastric pain, and I think that decreased efficacy would result if treatments were to be used out of combination. With continued treatment, it is expected that the patient will continue to improve.
3 patients present with stage 2 essential hypertension (HTN), 1 of which is a female (76 yo) and 2 of which are male (61, 50 yo). In addition, each patient presents with knee pain and various other tertiary complaints. All 3 patient’s conditions are pharmaceutically unmanaged. However, through herbal supplementation, acupuncture treatment and lifestyle education, each patient’s blood pressure was reduced to normal, prehypertensive or stage 1 range.
Subjective, Objective, and Diagnosis
Patient 1: 76-year-old female patient presents with constant headaches that alternate between both the temporal region as well as the vertex. The patient’s headaches are often accompanied by dizziness, and exacerbated by the ingestion of spicy foods. The patient has floaters and experiences regular bouts of blurred vision. She has a history of bilateral eye pain and right-sided cataracts. Both eyes are frequently bloodshot. The patient appears dehydrated as measured by skin pinch test, which demonstrates tenting. The patient’s feet, however, are moderately edematous, but not pitted. Rebound is not timed. Although she does not currently smoke tobacco, the patient purportedly did so for 47 years prior to 2013.
The patient complains of frequent bloody noses, swollen ankles and a tingling sensation in her feet. Secondarily, she reports lower extremity heaviness and aching, primarily felt in the knees. Lastly, the patient complains of low back pain that is sore in nature. Flexion and extension of the back are limited and elicit mild to moderate pain, though the patient has maintained full range-of-motion. The patient is slight, possessing a small frame, and mildly hyperkyphotic stature. Her symptomology has reportedly spanned the last 6-7 months. Blood pressure is measured at 160/110.
The patient’s answers to questions are short and of an irritable tone. She is reluctant to engage, and often rolls her eyes when given lifestyle advice.
The patient’s tongue is peeled and heavily fissured, while the pulses are strong, forceful and wiry.
TCM DX: Liver yang rising Constitutional Kidney yin deficiency
Patient 2: 61-year-old male presents with high blood pressure, measured at 180/110. The patient’s secondary and tertiary complaints are bilateral knee and low back pain. The patient experiences occasional, infrequent and random dizziness and blurred vision. Both symptoms are exacerbated by the ingestion of hypertensive medication, and are intensified by bright light. He sites this limited experience with his medication as further deterrence for long-term allopathic treatment. The patient reports regular epistaxis. The most recent of epistatic events purportedly lasted 10 hours. He admittedly consumes moderate amounts of alcohol on a nightly basis. Despite his efforts to increase water intake, he tries, but struggles to decrease salt consumption.
The patient is of medium stature and average build. At times, he is highly engaged in treatment, making good eye contact and easily communicating symptoms. His enthusiasm is erratic however, and his commitment to regular therapy is inconsistent. His attendance ranges from daily visits to random weekly appearances. Similarly, his tolerance for questioning is unpredictable.
The patient’s tongue is bright red, and the coat is fury and yellow. The patient’s pulse is wiry.
DX: Stage 2 essential hypertension
TCM DX: Liver yang rising Kidney yin deficiency; Qi and blood stagnation
Patient 3: 50-year-old male presents with high blood pressure, measured at 184/108. The patient reports red, itchy eyes and blurred vision. Upon further questioning, the patient confirms occasional epistaxis. His sleep is restless and disturbed with frequent night sweats. All symptomology is intensified by the ingestion of spicy foods. The patient denies headaches and dizziness.
The patient appears physically fit. His movements are quick and erratic. His focus is on his knee pain and trigger finger, but he is attentive and receptive to lifestyle coaching. The patient is reliable and highly compliant with the treatment plan and recommendations.
Tongue is red, and the coat is both thin and white. The pulse is wiry.
DX: Stage 2 essential hypertension
TCM DX: Liver yang rising Kidney yin deficiency; Qi and blood stagnation
Assessment & Treatment
Allopathic perspective: Hypertension refers to elevated systolic and/or diastolic blood pressure. Ideally, blood pressure is measured at 120/80 while 120-139/80-89 qualifies as prehypertension. Stage 1 hypertension is diagnosed at 140-159/90-99 and Stage 2 is >160/>100.
Hypertension is often times asymptomatic. When signs and symptoms do appear however, dizziness, facial flushing, headache, fatigue, epistaxis and nervousness are common. Such symptomology is not unique to high blood pressure, and is likely the manifestation of a complication involving an affected organ.
The etiology of the disease is difficult to define, as many factors may contribute to the development of hypertension throughout one’s life. There are 2 overarching categories based on the origin of the diagnosis: essential and secondary. Essential hypertension, or primary hypertension, implies an unknown etiology and accounts for the majority of hypertensive patients. The small population suffering from secondary hypertension likely have kidney damage, or endocrine dysfunction, that in turn causes the blood pressure to rise.
A blood pressure cuff, or aneroid sphygmomanometer, is utilized in the measuring and diagnosing of blood pressure. It is important to evaluate the patient’s blood pressure on at least 2 separate occasions to ensure an accurate diagnosis, as blood pressure may fluctuate.
For a newly diagnosed patient, further examination may include routine testing to detect target-organ damage and cardiovascular risk. Urinalysis, spot urine albumin, creatine ratio testing, blood tests (creatinine, K, Na, fasting plasma glucose, lipid profile), thyroid-stimulating hormone measurements and an ECG may also be conducted.
1 of the primary factors associated with essential hypertension is high animal fat or sodium chloride consumption. Other lifestyle choices that play a large role in the development of hypertension include smoking tobacco, and drinking alcohol and coffee. Although chronic alcohol intake is one of the strongest indicators of high blood pressure, even moderate intake can lead to the development of hypertension in a percentage of individuals. Similarly, smoking is a strong contributing factor. This is exacerbated by the tendency for coexisting sugar, alcohol and caffeine ingestion.
The high correlation between lifestyle choices and hypertension implies the opportunity for resolution through lifestyle modification. Mild hypertension can often be resolved through weight loss, restricted sodium consumption, exercise and relaxation. For those with more severe hypertension, drug therapy is often considered necessary. Prescription treatment typically includes diuretics (thiazides, loop diuretics, potassium-sparing agents), ACE inhibitors (captoril, enalapil, lisinopril), calcium channel blockers (diltiazem, amlodipine, verapami, nisoldipine), vasodilators (hydralazine, prazosin, clonidine, minoxidil) and/or beta-blockers (propranol, acebutolol, betaxolol, cartedolol). The initial pharmaceutical intervention in Nepal involves a beta-blocker called Atenolol. Atenolol is available at most health posts countrywide.
Despite the variety of antihypertensive medications, a percentage of blood pressure patients go untreated. Such patients are at great risk for debilitating, or potentially fatal, heart conditions, cerebral hemorrhage or infarction, renal failure or stroke.
TCM perspective: All 3 patient’s range dramatically from a constitutional perspective. The group of individuals varies in gender, age and lifestyle and demonstrate diverse signs, symptoms and peripheral complaints. Nonetheless, they all share the same disease and corresponding diagnosis: Hypertension due to Liver yang rising.
Liver yang rising is characterized by symptoms of facial flushing, headache, dizziness, disturbed sleep and irritability. Various eye complaints, epistaxis and soreness of the low back and knees are also symptoms associated with this diagnosis and are common amongst all 3 patients. The upward movement of yang is the result of an underlying yin deficiency. Without adequate yin, the Liver fails to be nourished and anchored, which in turn leads to yang rising.
Patient 1 and Patient 2 are approximately 10 and 15 years older than Patient 3. Consequentially, their lists of symptoms are more extensive as a result of the more progressive nature of their conditions. This is likely the result of further depleted yin reserves.
Treatment: Throughout the course of treatment, each patient’s blood pressure and related symptoms are heavily monitored. Each patient receives acupuncture, herbal supplements and dietary recommendations. Various local points are utilized for secondary and tertiary complaints, while the overlapping acupuncture points included LV2, LV3, KD7, SP6, LI4, LI11 and DU20 (needled against the channel). The apex of the ears bled upon each visit. All 3 patients are prescribed Wu Ling San, 3 tablets BID. In addition, each patient is advised to greatly reduce his or her sodium intake, and increase water consumption. The adverse effects of smoking tobacco and drinking alcohol are discussed, and decreasing usage suggested.
Prognosis & Safety Measures
The prognosis is fair. Response is expected within 6 treatments. Given the advanced nature of each patient’s condition however, reducing systolic and diastolic measurements to within normal limits is less likely. A steady reduction in either or both numbers requires continued treatment. Strict adherence to the treatment plan is required, as daily acupuncture, herbal and dietary compliance creates greater opportunity for recovery.
Prior to treatment, the severity of the cardiac condition, and the potential complications, are discussed. Both eastern and western treatment options are communicated. If progress is not documented within the first 6 preliminary sessions, the patient is to be referred to an allopath or prescribed hypertensive medication.
Outcome
Over the course of 6 treatments, all 3 patients began to see significant results.
Patient 1: Upon conclusion of the sixth treatment, the patient’s blood pressure was measured at 116/80. The patient reported less severe headaches, experienced at a lesser frequency. The patient no longer experienced floaters or had painful eyes. The patient’s skin no longer tented upon pinching, and she no longer suffered from lower extremity edema. She still complained of the occasional episode of tingling in her feet. Her low back pain had decreased by half with treatment 3-5 times a week. The patient’s attitude had improved as her conditioned improved. She explained that as her body healed, she was less uncomfortable, more productive and less agitated.
Patient 2: While under my care, the patient’s blood pressure was measured at 150/90 by his sixth visit. Within 2 more treatments, both acupuncture and herbal, the patient’s blood pressure was reduced to 140/90. His dizziness and blurred vision subsided entirely, despite exposure to bright light. The patient had not had a bloody nose since treatment commenced. Both the patient’s back and knee pain were decreased significantly. Purportedly, the back pain had ceased while the knee pain improved 90%. The patient’s unreliability was ultimately short-lived. He soon returned for daily treatment, and his tolerance for lengthy intakes became less volatile.
Patient 3: The patient’s blood pressure was reduced to 150/94 within 6 treatments. The patient’s eyes were no longer itchy or red. Only occasional blurring of his vision persisted. While under our care, the patient had not had another bloody nose. His knee pain improved 50% and his trigger finger improved 75%. Although highly compliant, the patient’s wife fell ill, and he was unable to continue further treatment.
Discussion
Hypertension is extremely prevalent in Nepal. However, due to limited access to healthcare, high blood pressure often goes undiagnosed. Many patients do not receive adequate education regarding their hypertensive condition, and are unaware of it’s associated risks and complications. In addition, many prefer native forms of treatment over that of conventional medicine. For these various reasons, the condition commonly goes unmonitored, or remains unstable and potentially life threatening.
For those patients who pursue a formal diagnosis and the appropriate medications, compliance is highly variable. This is also true for those who pursue acupuncture and herbal treatment. Regular attendance is required, daily herbal dosing is a necessity, and consistent efforts to make healthier lifestyle choice’s are obligatory. Conveying the importance of these measures can be very difficult.
Successfully treating a cooperative patient can prove similarly difficult, as the appropriate herbal formula selection is highly important. Initially, Tian Ma Gou Teng Yin was utilized for Patient 1. Given the patient’s LV yang rising diagnosis, the formula was indicated. Patient 1 reported a reduction in some of her symptoms (eye complaints, headaches), but there was no documented change in her blood pressure. As a result, Tian Ma Gou Teng Yin was replaced with Wu Ling San. Wu Ling San’s diuretic function acquired great results within a short period of use. These results were later replicated in both Patient 2 and Patient 3.
This information is of significance as it may help in the treating of this highly common condition. In addition, it may help avoid heart attack and stroke.
40-year-old woman presents with depression, emotional stress and dream-disturbed sleep. She presents with a secondary complaint of chronic ringing in her ears. 2 months ago her daughter committed suicide, and she is emotionally distraught from the incident. The clinic provides a safe place for her to express her sadness, and renders her with coping mechanisms otherwise unavailable to her.
Subjective
40-year-old woman presents with stress, unstable emotions and dream-disturbed sleep. Originally, patient complaints were of bilateral knee pain and chronic ringing in the ears, but she has not been to the the clinic in over a month. When asked about her previous symptoms, the patient becomes visibly upset and begins to tear up. She explains that her quality of sleep is poor, and she wakes many times during the night. The patient's 14-year-old daughter committed suicide a month prior, and she has not been able to sleep through the night since. The patient reports having dream-disturbed sleep, including nightmares, about the incident. She also reports constant ruminating thoughts about her daughter without any relief. She is distracted from work and has a hard time getting daily tasks at home completed. She has a lack of appetite, is not cooking, and is not eating full servings. She complains of being weak from the emotional pain in her heart and suffers palpitations. She suffers from blurry vision and headaches, which are worse after a crying episode. She also discloses that she has a son and husband at home who are also suffering, and another daughter in Kathmandu.
The patient is unaware that acupuncture and herbs will benefit her stress, depression and dream-disturbed sleep. The patient would like to work on this, and would also like to continue addressing the ringing in her ears. She reports that the ringing in her ears began 1 year ago, and describes it as high-pitched, coming and going throughout the day. The patient reports that she has had diminished hearing since birth. She agrees to a treatment plan of coming to the clinic regularly, but only when her neighbour also comes.
Objective
The patient is visibly upset. She conceals herself under a scarf, which covers her head and lower face. She is not able to look the practitioner in the eyes while explaining how she feels, and tears up when talking about her stress levels and sleep. The patient quickly wipes tears from her face and eyes, and looks frustrated as she does. She has a lack of lustre in her eyes and a dull complexion. Occasionally, there is a scent of alcohol on her breath in the mornings. She is distracted by the ringing in her ears, and needs to have questions repeated. Her voice is muffled, and she speaks with a slight speech impediment (confirmed by my interpreter due to the language barrier).
Her pulse is deep and choppy on the left, and slippery on the right. Examination of the patient’s ears shows a bright red irritation along the lower border of the tympanic membrane in the right ear. In the left ear, there is visible scarring on an opaque white coloured tympanic membrane.
Assessment
DX: Post-Traumatic Stress Disorder (PTSD) with a secondary complaint of a right-sided chronic outer ear infection.
In order to differentiate PTSD from Acute Stress Disorder, it is important to consider that PTSD is identified by recurrent, intrusive recollections of an overwhelming traumatic event. Symptoms of PTSD include avoidance of stimuli associated with the traumatic event, nightmares and flashbacks. Depression, other anxiety disorders and substance abuse are common among patients with PTSD. Symptoms last for over a month. With Acute Stress Disorder, people have been through a traumatic event, have recurring recollections of the trauma and avoid stimuli that remind them of the trauma. Unlike PTSD, Acute Stress Disorder symptoms begin within 4 weeks of the initial incident, last a minimum of 2 days, but do not surpass 4 weeks. As this case spans a timeline of almost 10 weeks following the traumatic event, PTSD is the more probable diagnosis.
TCM DX: Liver qi stagnation with phlegm fire harassing the Heart
Liver qi stagnation as seen in the symptoms of depression, irritability, poor appetite, ringing in the ears and a choppy left pulse. Prolonged Liver stagnation leads to phlegm fire harassing the Heart. This is identified in the symptoms of mental restlessness, insomnia, dreamdisturbed sleep, palpitations, lethargy and a slippery right pulse.
Secondary Complaint TCM DX: Outer ear infection - damp-heat in the Sanjiao channel
Treatment plan
Acupuncture: Treat with acupuncture 3 times per week for 10 treatments before reassessing.
Focus on calming the mind and promoting sleep (soothing Liver qi and dispersing Heart phlegm). Resolve outer ear infection by clearing heat in the Sanjiao channel with acupuncture and the use of antibiotic ear drops.
To assist with clearing the ear infection: SJ17, SI3
Allopathic: Administer Ciprofloxacin antibiotic ear drops, 2 drops TID for 10 days to the right ear to resolve the infection.
Herbal: Internally use formulas to harmonize and soothe the Liver qi: Chai Hu Shu Gan Wan, 8 pills TID for 3 weeks
Counsel the patient about the purpose of the clinic, reaffirming that it is a place of healing and non-judgement. Assure her that the clinic is a safe place for her to reveal her emotions in order to heal, and convey the importance of healing. Ensure that the patient is provided with a secure environment for her to properly grieve.
Prognosis
Primary: Using regular acupuncture and herbal treatment, 75% improvement in sleep is expected within 10 treatments. A 50% decrease in stress levels is also expected. This being said, grief is a process that differs from individual-to-individual, and it is not certain how much time this will take. The acupuncture, herbs, environment of the clinic and the support of the community will aid in this healing process.
Secondary: Using antibiotic ear drops and acupuncture, a complete recovery from the ear infection is expected. Ringing in the ears is also expected to dissipate, although the scarring in the left ear, and the speech impediment, indicate that full recovery of hearing is unlikely.
Outcome
The patient continued to have good and bad emotional days. 3 out of 7 days were good. On the good days, she was cheery, talkative and animated in her story-telling of daily events. She spoke with her hands and her expressions were large and without constraint. She came to the clinic on her own, without the support of her neighbour. Her eyes were bright, and she was able to smile while she spoke. On the bad days, she reported crying spells followed by blurry vision and headaches. These, however, were not everyday, as they were before. When asked if the clinic was helping her cope with the stress that she feels, her face brightened, she smiled and said yes, while looking the practitioner in the eye. She was still having a difficult time sleeping through the night due to the difficulty with falling back asleep after dreams. However, she reported that the dreams were not always disturbing anymore, and that sometimes they were good memories of her late daughter. She stated that she misses her daughter, and this was in part the reason why she was unable to fall back asleep. She still felt that, at times, she gets stuck in her thoughts, and is unable to escape them. She was now able to express her sadness through conversation with the practitioner. Her appetite was fully recovered, and she was cooking regularly for herself and her family. She stated that she felt stronger, and able to get through the day. The weakness that she felt before was becoming less and less with each treatment.
After 6 treatments, the patient reported less ringing in the ears. She had an easier time hearing conversations and was less frustrated when trying to listen while in settings where several conversations were occurring simultaneously. The ear infection had cleared and the patient communicated that her hearing had not been further compromised.
Conclusion/Discussion
This case demonstrates that the use of acupuncture and herbs effectively provides support to the healing process of psychological conditions such as PTSD. The environment of the community style clinic also plays a role in benefiting the patient, by providing a place of healing where there are no other options.
The limitations of this case include the lack of objective evidence, as this is more of a psychological case, and measures are often subjective in nature. Background information about the mental state of the patient, as well as if alcoholic behaviours were present before the incident, would be interesting to note. Unfortunately, this information is not available. Despite these limitations, this case demonstrates the effectiveness of acupuncture and herbs in terms of benefitting psychological health, as the patient shows continuing improvement.
It is concluded that further treatment with acupuncture and herbs will be beneficial to this patient. It is both the physical treatment, as well as the environment in which it is administered, that will continue to heal the depression symptoms and the patient's spirit. It is important to have this space available as a safe place for emotions and grieving, as well as a place to break free from everyday routines. Having alternative options available in order to avoid substance abuse is valuable in a rural setting.
Upon further research and speaking with the Acupuncture Relief Project interpreting staff about suicide and village culture, it is found that, just as in the western world, it is a sensitive subject. There is apparently much gossip and talk of the patient and the event amongst people in the community. This gossip is behind the backs of the family involved, and is often about the increased alcohol consumption of the patient. Culturally, the village takes pity on the family. Suicide is not socially accepted, and is viewed as a failure on the parent's account, especially when it involves a young person. Suicide creates an air of bad luck surrounding the community. It is said that the spirit of the deceased is stuck in-between heaven and earth and is in a space of unrest. Spirits are taken very seriously in Nepal, as it is believed that they can harm people. Without knowing the conditions of the home environment, it is hard to speculate if the patient will experience a full recovery. Is there support at home? Do the husband and son respect the grieving process and allow it to occur? This makes the support of the clinic in the community that much more important. The clinic provides not only physical care with acupuncture and herbs, but also a safe place for emotions to be expressed without judgement.
Continued treatment
Educate the patient about possible coping strategies, such as taking 10 diaphragmatic breaths when the world seems too much, or when she is having trouble stopping the thoughts in her head. As treatment continues, work towards teaching the patient about meditation techniques, and how space for the spirit can be created anywhere.
70-year-old female presents with acute abdominal, chest and scapular pain, vomiting and diarrhea. At the local hospital, she was diagnosed with acute cholecystitis via labs and ultrasound. She received anti-nausea medication and was turned away for further treatment. After 7 treatments using acupuncture and Chinese herbal medicine, the patient’s pain improved 90%, and she had complete resolution of vomiting, nausea and diarrhea.
Subjective
Patient presents with severe abdominal chest and scapular pain. Onset occurred 2 weeks prior with an increase in severity 4 days ago. The pain in the abdomen is achy, and at times sharp in the upper right quadrant, and radiates across the abdomen. The chest pain presents behind the sternum, and radiates to the scapular region. Pain is worse with deep inhalation, and affects her daily activities. Patient reports whole body pain and feeling feverish. Her body feels heavy and she lacks appetite. She experienced nausea and 6 bouts of vomiting in the last 2 days. Her stools have been loose, and darker in color for the last 2 days. 10 days prior to her visit to the clinic, she had been evaluated and treated at the local hospital for the same severe pain, nausea and vomiting. She reports being diagnosed with gallstones, and treated with anti-nausea and asthma medication. The patient reports being told she was too old for surgery. Prior to the acute symptoms, she had been eating a diet of rice, lentils, vegetables and meat, a diet high in oils and fats.
Objective
The patient appears physically uncomfortable and distressed. She has a dull gray pallor, orbital edema, red eyes, and a flat affect. Sitting slouched in the chair, her responses are short and eye contact is minimal. Her breathing is labored and slightly rapid. Patient displayed involuntary guarding of the upper abdomen. There is severe pain upon mild palpation of the upper right and left quadrants of the abdomen. Murphy's sign is positive upon first visit (deep inspiration exacerbating pain during palpation of the upper right quadrant halting inspiration). The back pain is moderate upon moderate palpation around the scapula region. Vital signs at first visit were slightly elevated. Blood pressure is 150/95 mmHg, pulse rate 115 beats per minute, respiratory rate of 27 breaths per minute, temperature 99.5 degrees Fahrenheit and 93 spO2.
Patient's tongue is very pale, and puffy with grey scalloped edges, especially on the right side with a thick greasy yellow coat. Her pulse was rapid, and slippery.
The patient brought in medical records from her prior visit to the local Hospital. Labs revealed elevated serum bilirubin total and direct, and serum amylase levels. An ultrasound (USG) of the abdomen revealed a calculus of 13mm in the gallbladder lumen.
Assessment
DX: Acute cholecystitis
TCM DX: Damp-heat in the Liver and Gallbladder; Underlying SP qi deficiency with damp accumulation; LU qi deficiency
Prognosis
Acute cholecystitis usually subsides within 2 to 3 days, and resolves within 1 week in 85% of patients. Due to the patient’s age and lack of resources and history of asthma, a routine choleosystecomy was not performed during her hospital visit. Complications of acute cholecystitis include an infected gallbladder progressing to gangrene, or perforation of the gallbladder if left untreated. The patient is from a small village that lacks healthcare. She travels 2 hours each way to the clinic. With proper monitoring of the patient’s condition, acupuncture and Chinese herbal medicine treatments, the patient’s severe pain and acute symptoms will likely resolve within 6 treatments.
Initial plan
Patient is to be treated at clinic 3 times per week for 3 weeks. Monitoring of patient’s vital signs and symptoms to be assessed at each visit. Focus on reducing pain, inflammation of gallbladder, and preventing further complications. Acupuncture and Chinese herbal medicine, with focus on draining damp-heat from foot Shaoyang channel, and moving qi and blood. If symptoms do not reduce at each treatment, or vital signs worsen, patient will be referred to the hospital for complications of acute cholecystitis. Nutritional education to be incorporated into treatment.
Typical Treatment
Acupuncture: Dannagxue, right GB34 and right GB40 with electroacupuncture 5Hz continuous; LV2, UB19, UB18, UB20, ST40, LV14, GB44, GB40, GB21, REN10, REN12, Ling Gu, Da Bai and left auricular LV/GB point.
Cupping: Stationary cupping along Bladder channel from cervical to mid-thoracic region x 8 bilateral.
Chinese herbs: The patient is treated with Chinese Herbal Medicine. At the first visit, she is given Da Chai Hu Tang, 8 tea pills TID for 14 days. Ban Xia Xie Xin Tang is added at the fourth visit, 3 capsules TID for 12 days.
Lifestyle advice: Nutritional recommendations of a low fat, high fiber diet are discussed. Patient is advised to incorporate more turmeric and mint tea into diet. In Chinese herbal medicine, turmeric rhizomeis known as Jiang Huang. It invigorates the blood, reduces blood stasis, reduces pain, and drives qi downward. Pharmacologically, turmeric acts as an anti-inflammatory, anti-hyperlipidemia, antibacterial and hepatoprotectant agent. It is easily accessible in the region of Nepal in which the patient lives. Mint is to help reduce pain with its natural anti-spasmodic effects, and grows abundantly in the region.
Outcome
The patient showed progressive improvement throughout all 7 treatments. At treatment 7, the patient experienced a total of 90% reduction in abdominal and scapula pain, with complete resolution of chest pain. Patient reported her digestion as good, with no gas or bloating, and a complete resolution of nausea, vomiting and diarrhea. Patient’s affect was brighter, she was talkative, smiling and made full eye contact. Her tongue appeared less puffy and greasy, and her pulse less rapid. All vital signs were improved, blood pressure 140/95 mmHg, pulse rate 95bpm, respiratory rate 22 bpm, and 95 spO2.
Conclusion
This case was significant because of the severe pain with which the patient presented, and her lack of options. The patient received 7 acupuncture and Chinese herbal medicine treatments in 2 and a half weeks. She experienced 90% reduction in pain with complete resolution of diarrhea, nausea and vomiting. Due to the patient’s age, economic standing and past medical history, she was unable to have a cholecystectomy. She received anti-nausea and asthma medication, and was turned away for further treatment at the hospital. Acupuncture and Chinese herbal medicine helped to reduce her pain, systemic symptoms, and improve her overall quality of life.
Chronic cholecystitis, long standing gallbladder inflammation commonly due to gallstones, is a potential future complication. To help prevent future complications, management of the gallstones themselves is necessary. A modified diet of less fats and oils and more vegetables is recommended. Continued treatments with acupuncture and Chinese herbal medicine is also recommended. The gallstone, and gallbladder function, should be reevaluated by ultrasound and labs to monitor progress.
45-year-old male presents with psoriasis for 5 years, possible psoriatic arthritis for 2 years, and idiopathic neck pain and stiffness for 2 months. After 17 treatments of acupuncture and herbs, he has regained full range-of-motion, has less pain in his neck, his rashes are less painful and itchy, and he has more movement in his fingers and toes due to a decrease in swelling.
Subjective
45-year-old male presents with lesions on his scalp, back and limbs that began about 5 years ago. When his condition began, the patient was in Qatar working with construction and plaster. The lesions subsided upon his return to Nepal, and completely resolved within a year of being back. He continued to work in Kathmandu with plaster and construction. 2 years ago, he noticed the lesions returning. When the lesions erupted again, they began on his scalp, and continued to spread down his back. From there, the lesions spread to his abdomen and legs. Patient reports moderately achy and sometimes burning pain, with moderate itchiness that can be a nuisance at night. He finds them to be most bothersome during the day, and especially when he first wakes up, because it is the first thing that he notices. The patient reports that when he scratches the lesions, they are "weepy with water," and bleed. He has seen 1 other doctor in Kathmandu who gave him some creams and medication, but the patient does not recall what they were. They were not helpful. The rash does not subside with soap, or cold or hot water, and is actually irritated by most of the soaps that are available. As a result, the patient has stopped using soap entirely. Other than soap, the patient does not know if there are triggers that aggravate his condition, and he denies being emotionally or physically stressed.
The patient reports swelling with stiffness in the joints that began about 2 years ago, and has gotten progressively worse. Swelling occurs in the small metatarsals of his right foot, and his thumb, index and middle metacarpals on his left hand. He experiences moderate pain in his wrists and shoulders. He reports that his fingers are hard to move and bend, are usually moderately painful, and occasionally feel hot and burning. They are sometimes aggravated by cold. His brother also suffers from the same type of lesions, and swelling.
The patient presents with neck and shoulder pain that began about 2 months ago. The onset was idiopathic, sudden, and he cannot recall any possible causes. He reports the pain to be very severe and achy, with no sharpness. He says he can feel an electric sensation running downwards to his fingers when he coughs. Occasionally, the pain radiates up to his temporal area, or down to his wrists and hands. However, he denies numbness and tingling, or loss of strength in his arms and hands. Patient has severe pain and stiffness when resting, and he currently takes Paracetemol (acetaminophen- dosage unknown) to provide about 12-13 hours of pain relief.
Currently, the patient is not working due to his conditions, and he is supported and cared for by his son and daughter.
Objective
The lesions on the patient's body range from a large diamond-shaped patch on his lower back, that is about 5" wide and 8" long (his largest lesion), to multiple smaller ones ranging from .5" to 2" in diameter that stagger throughout his upper back, abdomen, elbows and legs. The lesions are discrete plaques that have a pink and tender appearance, as well as shiny, silvery white "scales." There are multiple breaks in the skin with some blood and weeping, possibly due to scratching. There is flaking and dryness on his scalp.
He has some obvious swellings on his toes and fingers. Most noticeably, his right second metatarsal, left thumb and third metacarpal are swollen to double the size of the same joints on the opposite hand and foot. He has limited range-of-motion in his right hand and can only clench his left hand 50% of normal, making a "C" shape.
The range-of-motion in his neck is 15 degrees flexion (normal 50 degrees), 30 degrees extension (normal 60 degrees), and lateral flexion of only 20-25 degrees bilaterally (normal 45 degrees). Most limited ROM is the lateral rotation of 10-15 degrees bilaterally (normal 80 degrees), and the patient has to move his entire torso to compensate for the lack of rotation. He reports moderate to severe pain in all movements past these ranges, and his face indicates that he is uncomfortable.
His labs are positive for elevated rheumatoid factor. This can be indicative of rheumatoid arthritis, but can also indicate other kinds of autoimmune disorders, such as psoriasis and psoriatic arthritis.
The patient seems in good spirits and looks healthy for his age and environment. He smiles during the whole interview, even when he is doing something that is uncomfortable. He makes eye contact during conversation. When rising from the chair to go to the massage table to undress, he rises very slowly, deliberately and is gentle with his motions.
His pulse is soft, thin, slippery and empty in the deep Lung position. His tongue is pale pink, slightly puffy, with teethmarks and a white coat that is thin in the front, but thicker in the back with small, bilateral prickles.
Assessment:
TCM DX: Lung qi deficiency leading to wind-damp-heat, and qi and blood stagnation in the foot Shaoyang channel; Possible underlying blood deficiency
Lesions on the skin indicate involvement of the Lung organ system according to Chinese medicine, and the nature of resolving and recurring are indicative of a wind pathology with an underlying blood deficiency.
Western DX: Psoriasis with psoriatic arthritis
While rheumatoid arthritis is still a possibility, the history of a prolonged, severe psoriatic condition makes it more probable that it is psoriatic arthritis. However, both psoriatic and rheumatoid arthritis are treated similarly. His neck pain and stiffness are likely due to acute muscle strain and/or tendon sprain of the neck as a result of unidentified causes. It is a possibility that the arthritis is affecting the patient's neck, but physical examinations and presentation indicate a muscular source of his problem, rather than vertebral.
The pattern of lesions on the patient's skin most resembles a condition of psoriasis. Psoriasis is a dermatological inflammatory condition due to immune stimulation of epidermal cells (kerotinocytes). Although its exact cause is largely not understood, the result is erythematous lesions on the body. The presentation of lesions can be pustular, but the most prevalent and classic presentation is the discrete papules, or plaques, with thick, shiny, silvery scales. A family history is common, and there is a genetic susceptibility that can be triggered. Therefore, the condition can have episodes of spontaneous remission and recurrence, or triggered eruptions followed by remission when the trigger is removed.
Prognosis:
With regular use of both acupuncture and herbal treatments twice weekly, at least a 50% improvement in his severe neck pain and stiffness is expected within 13 treatments. The psoriasis is much more difficult to predict. Psoriasis is a difficult condition to completely understand and manage, even with good access to resources, unlike the situation the patient faces in Nepal, where resources are less accessible. Psoriasis is considered mild if less than 10% of the body is covered in lesions. Since the lesions cover about 20% of the patient’s body, his case is moderate. There are many important factors to consider, such as genetics, environment, lifestyle and psychoemotional triggers. Using acupuncture and herbs alone, a 25-50% improvement in the moderate pain, itching and size of the psoriatic plaque, and arthritis, is expected within 13 treatments.
Initial Plan:
Treat with acupuncture twice weekly for 13 treatments, in conjunction with Chinese herbal medicine, before reassessing. For the rash, focus on reducing moderate itch, and possibly the size of the psoriasis. In the joints, focus on reducing moderate pain and swelling. Reduce severe pain and increase range-of-motion in the neck. Use herbal medicine to reduce inflammation of the lesions and joints, then begin to tonify blood and strengthen Lung.
Typical points include wide Hua Tou Jia Ji points, inserted laterally towards the transverse processes, from C2 downwards, with SI14, GB20, SJ3 and SI3 to open the DU. Trigger points in the areas of the neck and shoulders are also indicated. To clear damp and heat, use LU5, ST40 and surround the largest lesion. To tonify and circulate, use ST36, UB13, UB17, LI4 and LV3.
Formulas to take internally are Xiao Feng San for clearing wind and itch. Add Dang Gui Yin Zi or Si Wu Tang to tonify blood once itching is reduced. Have patient take home moxa stick and 7 star needle, to try for 1 week, to see if it helps with the itchiness or size of the lesions.
Counsel patient to spend time in sunlight. UV therapy has been shown to be effective for psoriasis. Continue to guide patient on being emotionally aware, and to release negative emotions if possible. Psoriasis can be triggered or aggravated by emotions and stress. Educate patient on what psoriasis is, and what is going on in his body at a very basic level, and that the condition may come-and-go on its own. Try to identify possible environmental or lifestyle triggers so that he can take steps towards avoiding them, if possible.
Outcome:
After 13 treatments, the patient reported a significant decrease in the itchiness of his psoriatic lesions from moderate to mild, but no noticeable decrease in the size nor the amount of lesions. He wasn’t noticing the itchiness as much when he woke in the morning, nor during the day. He reported that the moderate pain in his fingers and toes had decreased to mild pain, and that it was easier for him to bend them. His left hand could close to about 75% of a completely closed fist. The most significant improvement was in the patient's neck. He reported that it was easier to move his neck, and the pain had decreased from severe to moderate pain. For the past few weeks, he needed his son or daughter to help him get up out of bed, but now he was able to rise from bed on his own. Range-of-motion tests showed that the patient could laterally rotate his neck, up to 55 degrees, without having to move his torso. His flexion improved slightly to about 25 degrees, or just half of full flexion. Extension was still around 30 degrees with minor pain in the front of his chest, and lateral flexion improved to almost full 45 degrees, but with moderate pain and stiffness.
Continued Plan:
Beginning at treatment 14, more emphasis was placed on recovering range-of-motion in his neck, rather than on surrounding the psoriasis lesions.
Continued Outcome:
On treatment 17, the patient had full lateral rotation to 80 degrees, and only with mild pain and stiffness. He could also manage full flexion, with only slight (very mild) pain in the back of his neck. Extension was much better, at 40 degrees, with very slight pain in his pectoral region. Lateral flexion had almost returned to a full 45 degrees, but he had to perform the motion slowly. He was able to lift his shoulders to 90 degrees more easily, which is not something he was able to do previous to the treatments, though it was not measured at the initial visit. Overall, there was about 80% improvement in the presentation of his acute neck pain.
The patient's movements became quicker and he no longer moved as gingerly as he had at the initial visit. He could also look up more comfortably during conversation. He enjoyed moving his neck to show the increased range-of-motion he was experiencing.
The patient's psoriasis condition improved slightly. There was a reduction in itching and pain. He said that the combination of acupuncture, herbs and the home moxa treatments had been incredibly helpful in decreasing the constant and moderate pain and itching from his lesions. He reported that the itching was no longer constant and the pain was more mild. Inspection of his lesions showed that many of the smaller ones had decreased scaling and appeared tender, but according to psoriatic progression, this was a small improvement. The largest lesion had less weeping and bleeding, possibly indicating that he had been scratching less. There was at least a 50% improvement in the moderate pain and itching of the lesions, though only a 10% (at most) improvement in the appearance and size of the lesions.
He reported that the swelling in his fingers and toes continued to improve. The moderate pain was mild and intermittent. The swelling had decreased to where the patient was able to close his left hand 90%, in comparison to the 50% from the first visit.
Discussion:
Psoriasis is an interesting condition because there are so many factors involved, therefore many therapies with which to try to manage. Western therapies include UV light therapy, vitamin D, immunosuppressants, corticosteroids and other anti-inflammatory drugs, along with education about possible environmental and emotional triggers that can be identified and possibly removed. Unfortunately, in Nepal, many drug therapies like Coal tar, Anthralin, and Calcineurin Inhibitors (anti-inflammatories) are not available. Also, it is difficult to educate the patient on how to use the drugs properly, and to monitor patients once they begin using potent drugs for a prolonged period of time. Therefore, drugs that tax the Liver and Kidneys such as Methotrexate or immunosuppressants like systemic corticosteroids are not viable options. More research needs to be done for viable therapies that are readily available to the patient, such as emollients (especially with salicylic acid), that can help to soften the lesions. Hydrocortisone is available in Nepal, but the large surface area of lesions makes it both contraindicated and expensive. Vitamin D3 analogs have been shown to be effective, and he can absorb it by UV (sun) therapy. The process of questioning, communicating and educating the patient about environmental, emotional and lifestyle triggers is also difficult, due to cultural and language barriers. The acute neck pain and stiffness has been resolving nicely. Even though acute situations can resolve on their own, I believe that the treatments quickened healing, and helped him regain his range-of-motion. The patient has also begun mentioning pain "deep inside" his neck, so it may be worth considering if there is an arthritic cause to his neck pain, and if he may begin to develop chronic neck pain.
The most important part about this case, however, is that from the initial visit with the patient, I was focused on trying to help him with his psoriasis, due to my own interest and curiosity from a practitioner's standpoint. My perspective and perception about the case shifted at the reevaluation, when I realized how much the neck pain and stiffness was affecting his quality of life. At that point, I was able to focus more on making tangible gains in his mobility, and he was very responsive to the treatments. This shift in emphasis was vitally important to his daily well-being and a good outcome to this case.
80-year-old male presents with vomiting 20 minutes after each meal for 2 years. At the time of initial visit, patient was vomiting undigested food and water several times per day. Other symptoms include burning esophageal pain, the feeling of constant hunger, and a sensation of “something stopping the food in his chest.” Gastroesophageal Reflux Disease (GERD) and hiatal hernia are suspected causes of vomiting. Vomiting decreased after acupuncture treatments, herbal medicine, dietary changes and the addition of antacid therapy.
Patient presents with right-sided paralysis of his upper and lower limbs due to an ischemic stroke 9 months ago. Additional sequela includes speech impairment with the inability to say anything, but the phrase “la”. On presentation, this patient had not received any other post-stroke treatment. After 25 acupuncture treatments over 7 weeks, the patient was able to walk up to a ¼ mile without assistance, and showed partial control of his middle and index finger. He recovered the ability to say “tho” and “kho” in addition to “la.”
Jacqueline Bailey LAc MAcOM Dipl OM RN November 2014
OVERVIEW
57-year-old post-menopausal female presents with constant burning uterine and bladder pain for 3 years. Allopathic care has been unsuccessful in diagnosing and providing relief of symptoms. In using combination therapy of acupuncture, Chinese herbs and western antibiotics, the patient has had a marked decrease in burning sensation and uterine pain, and almost complete cessation of accompanying symptoms in 10 treatments.
Subjective
The patient presents to the clinic with a chief complaint of “burning uterine pain.” The pain has been constant for 3 years and is accompanied by back pain, dysuria and dyspareunia (painful intercourse). Other comorbidities include gastritis, burning urination with a history of urinary tract infections (UTI’s), and previous kidney stones. She was hospitalized in 2011 for nephrolithiasis (kidney stone) and hydronephrosis (water in the kidney) of the right kidney. The patient is 4 years post-menopausal and has 8 children, all vaginal births, with no complications reported. Prior to menopause, the patient took Depo-Provera to regulate her menses. Prior to taking Depo-Provera, the patient experienced bleeding for weeks at a time. There is no evidence of abnormal bleeding or vaginal discharge at present. Urination is frequent and volume is adequate. Patient voids 3-4 times at night. Burning pain is increased just before voiding. Additionally, she suffers from burning on the soles of her feet and night sweats. Otherwise, patient feels cold. Digestion is complicated by gas, bloating and frequent loose stools. Lack of thirst is reported. Skin and eyes are dry and itchy, and vision is sometimes blurry. Temporal headaches and dizziness are also reported. The patient is frustrated with her symptoms, as allopathic care has not provided her with answers or pain relief. In a fit of frustration, the patient destroyed previous medical records containing ultra-sound imaging. Patient was also given vaginal estrogen cream by unknown physician, but stopped using it because it did not help her symptoms.
Objective
The patient is an overweight (estimated BMI is 27.4) and age appropriate 57-year-old female. Her demeanor is pleasant, but tearful regarding her current state. She is oriented and appears to be in relatively good health for her environment. Patient points to her vaginal/bladder region when talking about her uterine pain. Abdominal palpation reveals a cooler lower abdomen, and guarding with tenderness on deep palpation of the left lower quadrant, periumbilical and suprapubic regions. No masses are felt. The upper abdomen is warm to touch. Pelvic exam reveals erythema and dryness externally and inside vaginal canal, with poor skin turgor. Neither discharge nor lesions are observed. A dense pressure can be palpated anteriorly, and patient is reporting tenderness. Cannot rule out prolapse, but no protrusions seen or palpated. Costovertebral angle tenderness present indicating possible renal calculi. Initial pulse is thin, fast and weakest in the left chi and guan positions. Tongue is pale and swollen, with a yellow, dry coat and peeled in the front.
Urine test reveals slight abnormalities: Clear yellow acidic urine with epithelial cells (15-20) and pus cells (10-12); Trace levels of albumin Intra-vaginal ultra-sound (IVU): There is radio-dense shadow in right pelvic region indicating potential abnormality.
Bilateral nephrogram: Shows prompt and symmetrical excretion from both kidneys, which are of normal shape and size. No significant post-micturition residual urine
Impression: Calculus present in right ureter
Medications on discharge: Omnatax (Cefotaxine) 3rd generation cephalosporin 20 mg PO x 5 days (antibiotic), Dolopar (anti-cholinergic) tab x 5 days, Urimax (Tamsulosin) 0.4 mg x 15 days (alpha-antagonist), AZO (urinary analgesic) 20 mg every day for 15 days
Updated: 11/6/2014
pelvic ultra-sound results: Kidneys are normal shape and size, no calculi noted. Bladder is normal, uterus is free of lesions and no endometrial abnormalities or masses visualized. Pancreas and gallbladder normal. Liver is 12.5 cm in length and fatty tissue present. Impression is fatty Liver stage 1.
Assessment
DX: Atrophic vaginitis with recurrent urinary tract infections
The patient meets high risk requirements for Uterine or Bladder prolapse due to her age, weight and multiple pregnancies. As a result of physical exam, prolapse is not detected, though safety parameters have been established for future prevention. Pelvic inflammatory disease is ruled out because although the patient has a few signs and symptoms, she has no vaginal discharge or fever, and the ultrasound is negative. Endometrial tissue is healthy, and there is no history of sexually transmitted diseases. Talking about such topics in the clinic is sensitive, and pap smears are not readily available to completely dismiss this as a causative factor. Same argument can also be made for bacterial vaginitis. Fibroids are ruled out. Patient has not had abnormal bleeding, and there are no palpable masses. This is further confirmed by ultrasound. Interstitial cystitis is probable, although the cause is unknown. Many believe that there is a defect in the protective lining (epithelium) of the Bladder, resulting in the leakage of toxic substances into the Bladder, causing irritation. Usually, if interstitial cystitis is suspected, there will be an absence of bacteria on the urine culture. In this case, pus is present (bacteria is untestable). Cases exist where interstitial cystitis can exist in the presence of a UTI. In these cases, pain is usually much more severe as in this patient’s case. The diagnosis of atrophic vaginitis makes sense because the patient is post-menopausal, which decreases the body’s supply of estrogen. This then causes a decrease in vaginal secretions, thinning of the endothelium and predisposes women to mechanical weaknesses. The earliest signs are usually burning or dyspareunia. It can be exacerbated by a superimposed infection, such as a UTI.
TCM DX: Liver/Kidney yin deficiency with heat consuming the fluids, complicated by an underlying Spleen yang deficiency leading to damp
PROGNOSIS: Patient has seen many allopathic doctors over the years with no relief. Due to the fact that the patient has limited funds, and cannot afford further testing to rule out other pathologies or treatment, prognosis could be poor. Patient is very eager, however, to seek acupuncture treatment for as long as is necessary.
Initial plan
Treat with acupuncture and Chinese herbs 3 times per week for 10 treatments before reevaluating. Focus on nourishing Liver and Kidney yin and clearing heat. Increase moisture and decrease pain. Internally use Dang Gui Liu Huang Tang (4 pills TID) to nourish blood and Kidney yin and clear heat.
Typical treatment: A combination of LV8, KD6, P6, P7, SP6, REN2, REN3, KD2, ST28 and ear Uterus, Bladder and Liver points
Alternative treatment points include GB41 (Dai vessel), SJ5, SP9 and GB 34.
Obtain urine analysis and culture to rule out UTI. Encourage patient to consider a pelvic ultrasound to rule out calculi.
Outcome
The urine analysis and culture revealed acidic, cloudy urine with pus. Bacteria not testable. Herbal formula was switched to Si Miao San (8 pills TID) for 5 days, and ibuprofen 200- 400 mg every 6 hours was given for inflammation and pain.
Ciprofloxacin 500 mg PO BID was given for 5 days to eliminate suspected UTI. Due to the patient’s risk factors for Uterine and Bladder prolapse, a referral was made to physical therapy for pelvic floor strengthening and bladder training.
Pelvic ultrasound was ordered. Calculi was ruled out and image was grossly normal, with the exception of a fatty Liver.
On the final visit, the patient reported burning pain only at the vaginal opening and little pain with urination.
Conclusion
Patient should continue coming to the clinic for treatments 2 times per week for maintenance therapy to achieve optimal goal of minimal pain, and continue nourishing yin and blood. Continue pelvic floor work to prevent prolapse, and consider the use of vaginal moisturizer during intercourse. Patient is encouraged to use trans-vaginal estrogen cream to increase lubrication and tone, and to empty bladder completely with increased water intake to prevent recurrent UTI’s.
Over the course of 10 treatments patient slowly had resolution of symptoms. Constant reminders were given to patient to continue with her pelvic floor exercises despite discomfort. Due to the sensitivity of the case, patient needed a lot of emotional support and privacy in the treatment room. It is important as healthcare practitioners that we provide our patients with the proper environment they need to heal, which in Nepal in a community treatment room, can be challenging. In the United States, 40% of women suffer from this syndrome, and only 25% seek medical attention out of fear of embarrassment (www.aafp.org). In rural Nepal, education and access to healthcare is very limited, and women are encouraged to keep such topics suppressed. This case demonstrates the difficulty of working with the female population of Nepal on a sensitive topic, as well as challenges with language, interpretation and lack of resources.
53-year-old male presents with right-sided hemiplegia following a hemorrhagic stroke 1 year ago. Patient complaints include decreased range-of-motion, pain, numbness and weakness of his right side including the shoulder and arm. Concluding 10 treatments, comprising of acupuncture with electrical stimulation and Chinese herbs, the patient reports decreased pain, improved range-of-motion (ROM), increased sensation in limbs, and greater muscle strength.
SUBJECTIVE
53-year-old patient presents with right-sided hemiplegia after suffering a hemorrhagic stroke 11 months ago. On the day of the stroke, patient experienced muscle weakness along with headache and seeing red. Patient entered shower to pour cold water over his head when he began to feel sensations of insects crawling up the left side of his body. The feelings began at his toes, ascending up his lateral and anterior legs, left hypochondriac region, lower and upper arms, side of his neck and then to his head, where he felt pressure in the parietal region, and lost consciousness. When he regained consciousness, he experienced paralysis on his right side. Patient was sent to Chitwan Medical Teaching Hospital in Bharatpur where he was hospitalized for 2 weeks. After the hospitalization, he attended physical therapy sessions including electrical current therapy for 2 weeks. Patient reports having received several medications unknown to him, and he did not undergo any surgical procedure. 12 months prior to the stroke, he was prescribed blood pressure medication, though was not consistently compliant. While hospitalized during the first 3 days after incident, his blood pressure (BP) was 240/120.
On initial visit to the clinic, patient complaints include a heavy feeling and numbness on the right side of his body, pain in the right shoulder near deltoid attachment, especially with grasping or rotating of arm, pain in upper right side of the neck with movement of his arm, pain in right thumb and wrist especially when grasping, an inability to move shoulder, and accompanying pain with active and passive rangeof-motion. He also complains of overall body stiffness, inability to move toes 2, 3 or 4, feeling of coldness in the toes and limping while walking.
Secondary complaints include problems with concentration and with speech when speaking fast, trembling of right hand with certain activities, as well as the inability to dress himself without assistance.
The patient reports that he is currently taking Amlod, a calcium channel blocker, and Losartan/Hydrochlorothiazide, a diuretic, for maintenance of hypertension.
Bowel movements are normal with no complications regarding digestion. The patient reports frequent and urgent urination, nocturia at a frequency of 3-4 times per night, and water intake of 3-4 glasses per day.
OBJECTIVE
Patient seems solemn and reserved.
Pulse is wiry and thin on the right side, and wiry, thin and slippery on the left.
Tongue presents as thin and pink with a thin, white coat and stagnation of sublingual veins. Initial blood pressure is 160/100.
ROM in the right arm and shoulder exhibits an inability to actively adduct without causing severe pain to upper shoulder and neck. Lateral flexion of the neck 35 degrees to the right induces pain to the right shoulder proximal to the AC joint. Supination of forearm, beyond 90 degrees, creates moderate to severe pain in anterior shoulder near AC joint. Patient is able to extend leg to full range with no difficulty or pain. Patient is able to move each individual finger, but demonstrates an inability to contract toes completely. The second, third and fourth toes on the right foot are permanently contracted in dorsiflexion. Strength/grasp test of the right hand indicates 30% less strength than left hand.
Sharp/dull sensory testing indicates deficits in the following dermatomes: C5, C6 and S1. They show no sensitivity to stimulation, while the dorsal aspect of foot and toes 2, 3 and 4 experience dull sensation, regardless of sharp stimulation.
Patient exhibits no difficulty in reciting the vowel sounds a, e, i, o, u, cha and la. His face appears symmetrical with no drooping of eyes and lips, or deviation of the tongue. No slurring is noticed upon speaking. His signature is precarious with significant trembling.
ASSESSEMENT
DX: Cerebrovascular accident d/t cerebral bleed; CVA indicates a hemorrhagic stroke leading to post-stroke sequelae with right-sided hemiplegia
TCM DX: Blood and qi deficiency with blood stasis causing blockage of channels and collaterals with internal wind
PROGNOSIS: Good; Although a complete recovery of motor and sensory skills is unlikely, prompt action following incident, including physical therapy, coupled with his overall constitutional health, significantly improves this prognosis. It is expected that acupuncture will continue to improve this patient’s condition.
PLAN
Treatment principles: Move blood, tonify qi, open channels, extinguish wind.
Acupuncture: 3 times per week for 5 weeks with a reevaluation at the 10th treatment; Focus on stimulating Yangming channels (Stomach and Large Intestine), as well as Gallbladder and Triple Burner channels on affected side. The unaffected side should have a constitutional focus of tonifying qi and blood while clearing any residual wind and phlegm.
Standard treatment comprised of electrical stimulation with leads connecting LI15 to TB5, LI11 to LI4, ST34 to ST41 and GB34 to LV3 at a continuous frequency of 5/100 for 20 minutes; Additionally, left-sided motor scalp line and leg motor and sensory lines are needled to stimulate the right side. Alternating pi ci treatments are performed with needles inserted 1 cun (1”) apart down entire Large Intestine channel from LI16 to LI2 and Stomach channel from ST34 to ST44.
Herbal formula, Bu Yang Huan Wu Tang, is prescribed at a dosage of 8 tablets BID, along with increased water intake of at least 8 glasses a day.
Patient is instructed to sign his name before each treatment to analyze trembling
OUTCOME
Patient was compliant with treatment plan, attending every appointment, and becoming increasingly more energetic and outgoing with each visit.
Patient reported a 50% overall improvement including complete resolution of the thumb, neck and shoulder pain. He reported the ability to straighten toes, as well as increased sensation and feeling of warmth in the toes and upper and lower legs where he had initially experienced numbness. Patient also described increased strength and less shaking in upper and lower leg.
Patient reports that he was now able to remove his shirt by himself. His blood pressure dropped to 130/90.
His signature was more developed, even and distinguishable with a 30% decrease in trembling.
CONCLUSION
Currently, the patient has had 11 treatments and is responding very well. His mental and physical states have greatly improved. He reports that before treatments, he had a feeling of numbness and heaviness all over his body. Now, on the day following a treatment, he feels a sensation of lightness in his body and spirit. He often mentions, “I feel great” and has become more cheerful since his first treatment.
The patient continues to maintain a treatment plan of acupuncture 3 times per week. Patient needs to continue this plan for 2 or more months. Following this time, a healthy and active lifestyle is important for maintenance of hypertension, as well as continued improvement.
It has been communicated to the patient that, with many post-stroke cases, the odds of a full recovery are not good. However, due to his diligence and compliance with treatments and care, both at the clinic and initially following incident, his chances for recovery are greater than most. He is reminded to maintain his motivation to recover, surround himself with encouragement, and believe in the mind’s ability to help the body heal.
Being a part of Acupuncture Relief Project (ARP) for seven weeks becomes your life so much that the day to day moments take a while to digest. As life is, when you are in it, it’s hard to see.
But, I have left there. Now, I am home, and everyone is asking me, “How was Nepal!? Tell me about your work and your time there?”. I think I am just now able to express a slice of all that has happened, all that I experienced there. There are quite a few things I have come to see now, and would like to share.
It is easy to hit everyone “right off the bat” with the most important part of why we join ARP, that is, the patients, the clinic work. In seven weeks I saw over 700 patient visits myself in the town of Bimphedi! This is huge, because as a new graduate of a Masters of Science degree in Acupuncture, this is more patient contacts than I treated in my entire program and it is more patients than most successful East Asian Medicine practitioners see in a year in the US. But really it’s not the number of patients as much as the experience itself, the health concerns we saw and treated, day in and day out. As you can imagine, it was good hard work. The work that is not just to keep you busy, but to make a real difference, and is truly productive. The work gave me back a sense of purpose, a sense of what is important, not just in my life but in the world. It’s that part — the sense of feeling alive and living so deeply in the present state — that I miss the most about Nepal.
I remember one night around 10:30 pm (which meant it was around 9 am back home in Seattle) I woke suddenly and couldn’t get back to sleep. This had never happened before, as every night we are all so dead tired post dinner, we crash so that we can meet another day. I remember realizing there in my bed, that this was the quietest it had been in my world at the time. I was actually able to be alone with my own thoughts and breath. I remember thinking about how holy the night was for those who did night vigils, and understood why. These times were very limited, especially in Nepal, as it is a place of community where you are always surrounded by people. Even then, in my bed, I wasn’t alone, for the other two practitioners, friends that were now my sisters, quietly slept there next to me. Ask anyone who has lived out in the land how beautifully quiet and still the night is, especially those times when you wake to use the outhouse, and look up into the dark night lit by stars. In Nepal, the only other sounds you hear at that time of the night, are insects and far-off howling jackals (which is quiet different from my life in Seattle.
We were living in the house of Auntie Krishna, our true house-mom, who hosts visitors like us, out of her three extra bedrooms in the town of Bimphedi. This district of Nepal, approximately a four hour drive south of Kathmandu, is a land of vast farms consisting mostly of corn and mustard fields, set among forested hills, valleys, and gorges. The word ‘phedi’ itself means a base of a hill.
Bhimphedi is mainly a one dirt-road bajaar (marketplace) that consists of small shops, an elementary school, a little post office, orphanage, jail, religious buildings, and (our favorite) the “internet/butcher’s shack”. Our clinic is also here on the main road, which runs full fledge with non stop action from Sunday morning to Friday noon. Bimphedi (being more of a town than a rural village like Kogate) is very populated and busy. All three practitioners at this clinic treated over twenty patients per day. This is why the middle of the night is literally the only time to be alone.
The clinic in Bimphedi is a two room concrete walled building with low ceilings and a thin mat covering the Earth floor. In the early morning you can hear music blasting from this same building, letting everyone in the town know that the daily yoga session has commenced. Our team of three practitioners and three interpreters used the largest room to treat patients. This way we were all close to each other. Every day upon arrival we set up 12 chairs in a big circle, each of us rotating around 4 chairs. On one end of the room near the front door (which is so low you have to bend down to enter), is our dispensary station. It consists of a table and shelves lined with Chinese herbs, some basic medication, medical supplies, needles, moxa and the like. Most of these supplies and herbs dwindle away as time goes on, which means we had to get creative. In this place, we measured out herbs into a scale, and placed them into brown bags with instructions. On that side of the room we also had a space where we piled cushions to make a makeshift bed for patients to lie down, as well as a massage chair for back treatments. On the other side of the room is a huge window where cold air flows in. This November and December time, the room tends to be colder than outside due to the lack of direct sunlight. It is actually quite amazing that in this mountainous region it is still sunny out. We try our best to keep our patients covered and to keep a balance between the warmth of the moxa, and the fresh air that is needed to clear the smoke that fills the room. The adjacent smaller room is where our much needed receptionist organized the patients files, and prepares the patients for treatment in an orderly fashion.
Our team quickly found the rhythm of the space and to the flow of treatment within the first week — even though the first couple days was extremely chaotic! In time, everyone supported each other, and was then able to give the best care to the patient sitting in front of them. Some of the patients needed more time and work than others, but over all, every patient is treated the same. It doesn’t matter what their background, wealth, caste, age, or status is. As such this is an exact image of true community acupuncture.
One by one the patients enter and take their seat, more often than not, knowing where to sit as they are regulars. Sometimes we say “Aunus” and “Basnus” “please come in” and “please sit”. We have come to learn little sayings like this, as it brings a smile to our patients faces and helps us connect. The most common ones are, “Tapailai kasto chha?” “how are you?”, “ke bhaiyo?” “what happened?”, “dhuksani” “painful”, “maaph ganuhos” “excuse me/sorry”, and of course a good old shivering of “dherai jaado!” “very cold!”. The Nepali people are very expressive, polite, and love to smile, laugh, and sing. Their clothes, their streets, their food, their homes are all filled with bright colors, traditional prints, jewels, and the smell of spices.
When we walk around this town, down the street to and from clinic, we hear many loud and direct “namaste!” (or “lhaso!”) greetings by fellow patients and neighbors as they sit with each other in front of stores or their homes. Sometimes they stop us to talk about their health, but more often, to invite us in for tea or to visit for a special occasion.
We also see the children as they wander to and from their way to school, dressed in their baby blue uniforms. It is such a delight to see many of the younger children following us down the roads when we are hiking, or in Bimphedi and Kogate. Some are shy but curious, peering from rooftops, hilltops, from behind trees, or into our rooms especially in Kogate. They make loud animal like sounds, howling to draw attention, and laugh hysterically with any little reply they get from us. Some of the more brave ones call out to us in the little English that they know, asking our name or where we are from. I think about my own childhood, riding bikes on the street and playing in the forest and creeks behind my grandparents house. This is something that all children in the world deserve.
Before the construction of highways, goods from India have been taken to Kathmandu from Bimphedi, and every day a bus runs through it, on to neighboring towns like Hetauda or Kogate. This is the same bus we have climbed onto the top of many Fridays, taking the trip to be with the rest of our team. It is a three hour curvy bumpy nauseating drive — unless you ride on the top. Come Sunday morning we travel back down to Bimphedi to do it all over again.
Even though the distance may be short, the journey is longer. The road is a perilous dirt track consisting of bends, twists, multiple switch-backs, that often cling to cliffs, sometimes with landslides and falling rocks. I honestly don’t know how the drivers round the corners, as they make their way up and down the mountains with confidence and precession. On the “himali tiger” bus that we take to and from Bimphedi on the weekends, I watch the bus driver as he pays more attention to the music dial above his head. Thankfully he has two other young teen boys who are working with him. They hang off the bus, banging on it as it rounds corners with distinct cues as if to say, “turn turn turn!” or “you are all good on this side!”. They signal for other cars, often getting off to check the scene (i.e., how close it is to the edge), or to help other vehicles maneuver around it. In each stop they throw passengers luggage and goods up to the top and collect the bus fee. The bumps, the stop and go, the back and forth, for me, was the worst part about Nepal. It is nauseating. Many people get so sick they throw up out the windows. Which of course, makes it all worse.
The best place to sit in any vehicle, is up front, if at all possible. On the bus, the front seat is a three person seat that faces sideways toward the driver with the clutch in between. No seat belts, music blasting, sometimes the bus literally turning into a dance hall. This seat is often taken by the elderly or new mothers with their babies. 6 am, early Sunday mornings, this is where I sit for the journey back to Bimphedi. Since we are the first stop, we have first pick. But come half-way down the mountain, the seat, like the rest of the bus, is so overfilled, so cramped, that I am only half way sitting. On the next stop, when I can, I crawl over what seems like twenty people to the door, jump out and make my way climbing up the side of the bus to the top. The top of the bus, with the rest of the boxes, luggage, rice filled bags, my friends, young men and kids, is indeed the second best seat. Up on the roof of the bus is not nauseating at all, but your bum gets sore, it is 10 times more cold, and as people remove their luggage and goods, you tend to slide around with nothing to stop you. We find this all the more fun and can’t help but laugh and scream every time we hit a big bump, duck under branches or wires, and make our way over narrow cliffs. Safety aside, the freedom that is felt in this part of the world is so appreciated.
You can imagine seeing over 20 patients a day how much you would change and grow personally and as a practitioner. I am reflecting about when I was applying to ARP and how I talked about three words that summed up my interest in being a part of it: self- exploration, commitment, and learning. It is interesting to reflect back on those words, and to see how much I was able to accomplish there.
I joined ARP post-graduation, so as you can imagine, after years of studying with focus on memorizing, test taking, clinical application, pulling out any bit of information from the depths of my brain (ok, or books), and an over-all disconnect from the world outside of the classrooms, self-exploration was essential. It helped me connect back to why I am in this field to begin with. That is, my calling to help heal and make a difference in people’s health.
In my blog, right before I flew out to Nepal, I wrote a passage about healing. I had been contemplating the word, the verb Heal which is defined as, “to make whole or to restore to health”, and it’s relationship to being whole, “free of defect or impairment, having all of it’s parts in entirety”. I was wondering if all of my passion, my intent, my calling, even going to Nepal itself was to help heal, how was I going to be able to do this? I mean, I wondered if healing completely and being whole is even attainable as a human? Is it attainable while we are alive?
I know that then, and still now, that I don't have the answer to these questions, but I think that the process of reaching wholeness, of becoming healthy, healing, and of being human itself on Earth, is almost one thing. It is as if healing and reaching wholeness is what we are living for. Being out here in Nepal I saw first hand how the human is holistically comprised of mind, body and spirit, and that the healing process needs the mental, physical, and spiritual work and can’t be separated.
In my intent to come to Nepal and be part of ARP I had also asked for a sign, possibly an answer to my questions and thoughts on healing and my role as a practitioner. Was I really capable of doing much? Could I really help with TCM? What if I don’t know what to do for my patients? What if someone dies in my care, and I am not able to help them!?
I was reading from Lao Tzu’s Tao Te Ching at the time and turned to a poem titled, Water and Stone: “What’s softest in the world rushes and runs over what’s hardest in the world. The immaterial enters the impenetrable. So I know the good in not doing. The wordless teaching, the profit in not doing — not many people understand it.”
To me this poem was a reminder when I was working in Nepal that I didn’t have to do anything, to do much. It was a lesson to learn and to practice of just being. It is not really about saving anyone, changing anyone, putting in needles correctly, dosing correctly or teaching through my mind as much as it was about being myself, transmitting love, and really taking time to connect from the heart, smile, and be present. This is always a hard lesson for me — balancing the mental and the heart. Even now I am not sure if I was able to do this as much as I wanted, but I hope I was able to; I think I was. I remember the last day when the ladies, a few of my patients, showed up at Auntie’s home to say goodbye. They showered us with gifts and flower necklaces called Malla. I think about patients, like the young girl nearly my age, that was crying on our last day at clinic, and I think of how much I was touched by their love too. I often think about all the friends I made, the interpreters, Auntie, our neighbor friend and how much I miss them and know that they miss me.
I think that there is healing in that knowing, but I also know that the next time I return to Nepal (if am blessed with that opportunity) there is more to give from my heart. More stretching to do. More connecting to do. I want to hear more of their stories. I want to spend more time with them in their homes and in the fields. I want to hold more babies hands. I want to touch more women through massage and craniosacral therapy that I am now studying, just because. I want to laugh more.
This is really the spirit part of being human; from here I think the most healing can take place.
At the same time I know and experienced how important knowledge of the mind is. Nepal is a country where education is passed vial oral transmission and the power of talking with our patients is something that will last for future generations. Preventative healthcare is one of the most important parts of what we do in this field. As Thomas Edison said, “The doctor of the future will give no medicine, but will interest his or her patients in the care of the human frame, in a proper diet, and in the cause and prevention of disease.”
Educating our patients about their medical conditions, be it diabetes, osteoarthritis, high blood pressure etc. changes their life. We teach them to make informed decisions about what they can do to help themselves, change lifestyle factors, and/or understanding the medications their on etc., even if we are no longer there. All three of these conditions were actually very common in Nepal. I can’t tell you how many patients we saw with a blood pressure reading of 130/90, so common that it wasn’t even a major concern anymore when we were seeing other patients with a BP reading of 180/100! I also had a patient whose blood glucose was so high that the machine actually read ‘HI’ and gave no number! I spent a lot of time educating this patient and his family about diabetes, and the need to go back to Hetauda to see an endocrinologist to get a correct insulin dosage, since it had been over 10 years. In this community clinic setting it was interesting to hear the other patients over time advising each other from what we had told them, specifically to drink more “pani” (water) which was a major issue. Now that they have this information, naturally they will continue to advise their family and children to do the same.
The commitment to this community was not only through educating the patients, but serving a roll, participating in building a clinic that can be sustainable for time to come, and helping other practitioners like myself do the best we can as health care providers. This means we had to step up to provide the primary care role that would normally be provided by physicians in developed nations. We had to do this to provide treatments that the patient’s needed. The patients recognized and trusted us as primary care medical practitioners as they would any “doctors in white coats”. They saw us as people who were there to help them with their health. They put themselves in our hands, literally, and this was definitely scary to start with. One of our main purposes there was to help treat the community through Traditional Chinese Medicine specifically Acupuncture, but was actually far more than that. We were the only medical practitioners (esp. in the remote village of Kogate) they had around, or had ever seen. Some of the conditions we were treating were so chronic and serious that if we didn’t help, the patient would quickly be in a critical condition. Many individuals needed to be referred, but out in Kogate which is at least a 6 hour trip to any other medical facility, any hope for an ambulance to take them to the hospital is limited. The patients often did not have money to travel, or get the care they needed, so we were their best hope. In other cases when we wanted to refer, the best care available would be from trained health workers that were more pharmacist than doctors. The patients would hardly receive the care they actually needed. It was up to us to make diagnosis, prescribe not only herbs but common pharmaceuticals, and monitor the patients. This is beyond our scope of practice in the US despite our study of pharmacology. Sometimes we actually needed to do minor surgery such as stitching up wounds or lancing an infected boil. More than anything though, being a health care provider meant really listening to our patients, spending the needed time with them, and connecting, which like most places in the world, is very rare especially in our Western health care model where physicians don’t have time to actually listen to their patients until they are expected to move on to the next patient. Taking care of their body, is just another (major) piece of the human experience toward healing.
In Bimphedi, I had a patient that I was seeing every day that came from a neighboring village with her son and daughter-in-law. They rented a room across from the clinic. She was an elderly women who had an ischemic stroke 10 days prior, and had almost complete left-sided paralysis of her arm and leg. Her facial/cranial nerves, hearing, and mental faculty were all fine, but she had been blind in both eyes since 2010. She had sensory ability in all dermatomes (of her leg and arm) but the motor function of her left arm and legs were affected. She was also bedridden. This was an amazing experience to have a patient that came in so soon after her stroke, and that I was able to see and treat her so frequently.
It definitely took commitment however to show up every day, especially after long days at the clinic or going over early mornings. There were days where her inability to feel or literally see the progress she was making, made it hard to continue. Of course, the progress was slow and subtle. In addition, both her and her son were depressed, and had a hard time being away from their home. There were days where both of them questioned if I was really helping, which was hard for me, and I had to remind her (and myself) how much she was improving, from being unable to grab my hand, to sitting up on her own within two weeks. There were days I had to remind the son how important it was to help her to get up and move, even if I wasn’t there to help. Still almost daily (besides Saturday), I would go and needle, do electroacupuncture, keep her company and teach the son and daughter-in-law how to massage her, do moxa on her, and help them exercise her arms and legs. In one month, she was able to move her left arm with 80% full range of motion, and she was able to stand and walk with us holding her under her arms! This was amazing to witness.
Another patient I was seeing at least twice a week was a 26 year old male who had right sided paralysis of his face. He had facial twitching, facial nerve damage, loss of hearing to the right ear, and his right eye was crossed as a result of an occipital craniotomy surgery in 2010. He had fallen and fractured his occipital fossa and needed surgery to prevent hematoma or a hemorrhagic stroke. He came in for treatment of severe dizziness and vertigo, balance issues, and a heavy sensation to his head, all of which affected his ability to work. His right eye was also unable to close, and he had burning and itchiness that bothered him.
I met him on his fifth treatment. By that time the weakness in his right arm and leg were 80% improved with electroacupuncture. I worked with him doing facial electroacupuncture, and other body points, as well as put him on herbs. By the 10th treatment he was able to move his right eye lid up and down and feel it, there was no longer burning or itchiness, and his eyelid could close 60%. He also no longer had nausea, dizziness or feeling off balance, or heaviness in his occiput. His right arm and leg were 100% better and he was back at work. By the 15th treatment he was able to puff out his cheek, wrinkle his forehead, and close his eye 80%. Since his injury was over 3 years ago, this was also amazing results, beyond what we had discussed for prognosis, and it was an important lesson in keeping the patients chief complaint in mind as you treat, which was all 100% resolved.
Other cases I dealt with were a lot of ear and lung infections. I seemed to get all the ear infection patients, I mean, at least five a day! Those were some of the hardest cases I dealt with because some of the patients were children or elderly, which always increases concern. Some of the patients did fine with Pu Ji Xiao Du Yin, or Chuan Xin Lian Pian which are internal Chinese herb formulas, but some would get better and then get worse again, or it would be a week with no improvement and so I would have to start them on one of the antibiotics we had access to: amoxicillin. In these cases you hope that you are making the right choice. It is always based on doing your best with the knowledge you have, but there were definitely times I was looking into ears thinking, “I don’t know what I am looking at” or “this isn’t getting better, I don’t why, what should I do?”. The thing with antibiotics is that you have to educate the patients on taking the full dose, because the infection needs to be fully gone before they stop taking it. This was the worst part because there were patients that were not compliant, or come to find out, had been on amoxicillin for long periods of time, taking it when they didn’t need it. This means that the amoxicillin was not strong enough for them any more. Sadly, we have this overuse in developed nations as well. There were many patients I saw with blown out tympanic membranes, and yet were given ear drops by local pharmacies or the health-post. Many other patients were given amoxicillin when they didn’t even have any infection to begin with! So these patient’s would be susceptible to further infection since their healthy gut flora was decimated. Luckily in Bimphedi we had access to Probiotics.
Besides the plenty of back and knee pain, other common cases included multiple fungal and dermatitis infections, some harder to treat than others. In these cases I also had to educate the patients to continue taking meds or applying topical creams/ointment until it was all gone, enforcing that it often takes a lot of time before it clears. Again, there were times when I had to give fungal creams, topical antibiotics, internal herbs and acupuncture just to “hit them with everything I had”. And there were times when I personally had to buy these medicines for them knowing that they, or their parents, grandparents etc., didn’t have the money to get it themselves. When it starts to visibly clear up, it was such a relief and such a feeling of success.
I joined ARP with the commitment to serve these patients, with the medical training and wisdom I have, but it went far beyond the clinic walls.
One of the most important parts of this program is that ARP hires locals to help with all the other ground work. One of the most important local workers is Tsering, officially the “Nepali liaison”, the best bridge APR has, that is continuously working on establishing long term clinic projects. Unofficially we called him “our Nepali Santa” because he always made sure we were comfortable in our home away from home, bringing us honey, peanut butter, holiday cakes and all the supplies we needed for the clinic that could be found from Hetauda to Kathmandu. He is also a musician, has been working with APR from the beginning, and is an amazing interpreter who also knows Chinese Medicine because of his passion and self-studies. Other team members include all the wonderful youth interpreters (and neighbors) who quickly became our friends and siblings here, who made us feel at home, shared stories, meals, hikes, bus rides, songs, camp fires, tree planting, holidays and birthdays, laughter, and worked so hard in the clinic with us every day. We truly couldn’t do any of it without them! I miss you all!! Training them in various subject of this medicine, and learning from them about Nepal, was one of the best part of ARP for me. All the drivers, cooks, house mom, secretaries are all Nepali. Helping to offer these various jobs and educating these brilliant interpreters, establishes sustainability in the time to come. I hope each one of them will continue to study this medicine and in time be able to run the clinics on their own. This is important for me because I truly believe all people everywhere have the potential to solve their problems, increase availability, create long-term solutions, develop skills within their own communities, and know that every one of us already have within us amazing skills, ideas, and gifts. We share by helping each other, rather than this notion of, “we are here to save you”. Honestly, I have never seen such an intelligent group of individuals, who are so proud of their country as our Nepali ARP team. It is for this exact reason I find that we need to do relief work in our own backyards as well. Due to my experience with ARP, I find myself wanting to study even more, especially in Western medicine now that I am home. “Ours is not the task of fixing the entire world at once, but of stretching out to mend the part of the world that is within our reach.” (Clarissa Pinkola Estés)
With all of these experiences that I have mentioned, accelerated learning that takes place here for the practitioner, is the aspect of volunteering that I would highlight for anyone who is considering ARP. Again, seeing over 700 patient visits in 7 weeks quickly teaches you what works and what doesn’t as far as TCM is concerned. More importantly, I also learned about myself in this intensive setting. With all my comforts set to the back burner, I learned how much I can be challenged and how much I can grow. Traveling is uncomfortable because it opens up your mind, it creates situations that push you to meet new people, sometimes it means you have to get around where no one speaks your native language, eat different foods, live without hot water! It teaches you clearly how much you take for granted.
I learned to trust myself more in Nepal, to follow my intuition. Now I have more confidence and commitment to bring back all that I learned to my home, in hopes of building and working in many more communities, and in my own practice. I honestly see that it is possible to change the world, by offering health care to those in need, building sustainable clinics here in Nepal is do-able, and therefore it is do-able everywhere else in the world.
I know that there are neighborhoods in my own city that call for involvement, be it in education, medicine, feeding and housing those in need, or any volunteering we can do. There are Native American reservations next door to us, asking for our participation especially in the cold months. There are beautiful landscapes in this country maybe you have never visited, beaches that need to be cleaned up, farms that need work, and forests that are calling you to come and discover life.
The first stop I had coming home was Dubai. As you can imagine, it was worlds away from where I had been the last 7 weeks. Besides the differences in culture, gaudiness, over the top buildings and highways, it was the first place I was truly all alone. No roommates, no loud speaking neighbors, no singing or laughing heard between the thin walls, no animals, not even the crazy beeping horns and noise of Kathmandu. Just quiet.
I realized then that this was the first of many days I now would be alone, and it was overwhelmingly sad. I know I’m not really alone though, I have so many friends and family and lovely people surrounding me like my beautiful husband. But the day to day existence in most of America, even being surrounded by so many, is just isolating; I had forgotten that. Here in Seattle, I see so many people rushing to somewhere, separated, on their phones, standing in lines, hardly engaging, hardly making time for each other. It is a consumer-driven culture that focuses on material possessions (or the illusion of it), and we all know it, but may not be aware of it. It was honestly culture shock coming back. I must say here that I had been traveling in Asia for almost 5 months.
I remember laying there in the three star hotel room of Dubai (which is like a 10 star), thinking about all the Nepali men on the plane with me, also traveling to Dubai. All the men who are now there for work, probably some sort of labor construction. I think about if they are being cheated, if they are happy there, if they are finding whatever it is they are looking for. Because being in Nepal, I had never been somewhere that has such a sense of peace, with people so welcoming, so happy despite their conditions. When you slow down enough to see what matters, to embrace nature and the immaterial, you feel alive. I want that feeling to last forever. I want everyone to know it, I want my children to experience it — to feel so blessed.
I know that all over the world, even in our neighborhoods, there are people who are struggling and having hardships, family problems, money problems, or major health issues. When you look at this culture so put together by community — where everyone knows each other and looks out for each other — I really struggle being without it, and I really know that out of everything I learned the most, is that community is essential now. I know that there is work to do; we all have to move towards Unity. It is the only way to become sustainable, to make a difference, to raise our children up, to learn from our failures and what is not working any longer for the masses. It is all attainable, I witnessed that in Nepal. Slowly but surely. I know that I am fortunate to be able to have knowledge of this medicine, and to use it to be a conductor, to do my part in the world. I know that I am fortunate to have been able to travel, learn, and work in Nepal, and I hope that I can continue to be part of many more projects around the world. I don’t know when or where. All I know is that my whole being, from deep in my core, is yelling out, “WE ARE MEANT TO BE TOGETHER!!” –Asiya Mahdiyah Shoot MSA, LAc
After a few days exploring Kathmandu, just the day before heading to Bhimphedi, we had our first serious meeting. I think this is where the reality of everything really hit home for me. The next day we would be heading to our home base to start the camp and I knew that it was “business time” and that things would get really interesting.
The first week I felt like a deer in the headlights. The culture, meeting our new family of interpreters/hosts, training, and getting to know the procedures and practical aspects of working in the clinic, combined with the volume of patients, was totally overwhelming! But the ability to deal with it and push forward with a positive attitude grew stronger and stronger. Now, going into the 4th week and looking back, I can say this has been one of the best experiences of my life. The experience keeps challenging me and changing me, and in turn the experience becomes even more amazing.
The speed needed to treat the amount of patients that arrive each day without compromising efficacy has been a steep learning curve for me. And the label of “Dr” comes with the perception that we can bring a magical cure to all diseases. Although the acupuncture and the primary health care we are providing here is extremely beneficial, I am beginning to witness firsthand what does and does not work for many different conditions.
One example is the many presentations of ear infections that walk through the door - acute, chronic, perforated ear drums, young children, seniors, etc. Given the danger of complications and progression of an ear infection - risking permanent hearing loss or encephalitis - when western medicine is somewhat available, seems risky. Here we are personally faced with the responsibility of caring for these patients. I become aware that an ego-centric belief of my skills should not override my medical judgement. Working with ARP is teaching me to refer out if we don’t have the correct medicine, knowledge or skill, but to still practice good patient care. This awareness of a broader medical picture, in practice with acupuncture, moxibustion, Chinese herbs and primary health care, provides a complimentary system that benefits the community here in so many ways.
Lacking the linguistic skills to communicative effectively has been another barrier. For me a huge part of this project is the interpreters. The relationships between each and every one of the practitioners and the local interpreters are vital. All the interpreters carry with them a very proactive and positive attitude and this project would simply be ineffective without them. At times it feels as though we - interpreter and practitioner- are one person treating the patient, where our communication and action come together so instinctively.
The experience here with ARP has been extremely rewarding. The challenges I face here have served to provide answers to ways in which I can better myself and increase my knowledge. My acupuncture amigos, ARP, and the interpreters are all such a dedicated bunch of people to share the journey with and I feel like we are all gaining invaluable knowledge in medicine and primary health care. I’m appreciating every bit of time I’ve had so far in Bhimphedi, Nepal.
I don't really know what to write about as far as my experience in Bhimphedi, Nepal goes. There are no dramatic events that stick out in my mind. All I know is that it is one of the most wonderful experiences of my life, composed of small, subtle and beautiful moments.
First of all, I've always dreamed of working in a small rural community. Our clinic is small and simple with three practitioners, three interpreters and always twelve patients rotating in and out. The room always seems small and dark when we first enter but we set out the blue plastic chairs and the bright quilted cushions and once the room fills with its first round of patients, there is a vibrancy in there that I love. Days are long and we work hard but we always have moments of laughter with the interpreters and the patients and these interactions and relationships are as much part of our medicine as the needles and the herbs. On days when patients bring us some of the many vegetables and fruit that they grow in their fields at home to thank us, I would walk home with the goods in hand and think about how I've always dreamed about being this exact kind of practitioner.
Secondly, Nepali people are amazing! They are all so kind and welcoming and every Nepali person I have ever met here has an amazing voice and know the words to every Nepali folk song. Dinner time and bus rides can break into spontaneous songs at any moment and you never know when it's going to happen- it's incredibly lovely. Our interpreters are all amazing and bright people and they work very hard with us, but they also know how to party hard. Christmas and New Years here have been the best that I can remember because both times we ended up with some spontaneous cake fights followed by some serious dancing. Both times, more cake ended up on us than in us ---in fact, I can only recall getting one bite in before someone smeared frosting on my face and by the end of it all the entire cake was gone.
Finally, because the community and the people are so amazing, I have really enjoyed the experience of growing with them as people and as a community and also helping them grow by educating them about health and healthcare. The interpreters have regular training sessions with us and learn from us everyday in and out of clinic (as we learn from them too). And as much as possible we try to educate our patients about their conditions, about their health, and about health in general while simultaneously learning from them in the treatment process. I think that the education and connection are the most important legacies we are leaving behind even if there is no clinic tomorrow.
These are only drops in a bucket of moments that I can talk about. The connection and relationships formed with the community IS healthcare, and it is what I have been lucky enough to experience through Nepal. --- Phonexay Simon
One brisk afternoon in a remote village in the Southern district of Makawanpur, Nepal several men and women, bundled in many layers of brightly colored wool clothing, sat in the sun waiting for their turn to see the “Doctor”. Many of them had never been to see a medical provider their entire life. Now, in their small village of Kogate, our team of practitioners moved their chairs out into the small courtyard in front of the rustic clinic building, as it was too cold to treat indoors. Some of the villagers waited many hours for their turn to tell the doctor about their pain, injury, or other health concern. Around the low stone wall that surrounds the courtyard, a dozen children and adults watched their friends and neighbors being treated. How strange this must have looked as our practitioners inserted several small needles into their patient’s bodies. A constant chatter filled the air as the villagers discussed the scene and asked their friends if the needles hurt. “Dhukdaina” they replied. “It doesn’t hurt”.
Sometime in the mid-afternoon a small boy of about 8 years was ushered into the clinic with a gaping head wound. Blood poured from a two-inch gash and his skull was clearly visible in the opening. The practitioners quickly assessed the boy for a concussion and interviewed the clearly shaken mother about the cause of the injury. It was determined that the family did not have the resources to transport the boy to the regional hospital, which was nearly 3 hours by way of a very expensive, four-wheel drive, ambulance ride. The team advised the mother about what they could do and what care would be required in the following days. They then proceeded to carefully clean the wound. A topical anesthetic (Lydocaine) was applied to help numb the area as damaged skin was clipped away with a scalpel and scissors. Finally the wound was closed with a medical-grade super glue and suturing tape. The boy was given a mild dose of Tylenol to help with the pain and some herbal antibiotic (clear toxic heat) tablets to help reduce the chance of infection. The mother was given a cup of tea while the practitioners did their work. After the procedure was finished the team educated the mother on how to look for signs of a concussion or infection. She agreed to bring the boy back the following day (even though it was a several hour walk to the clinic) or sooner if the boy took a turn for the worse. They agreed upon a contingency plan to administer Dicloxacillin (an antibiotic drug) if the boy exhibited a fever or other signs of an infection.
This kind of visit to our clinic is not at all unusual but may seem atypical to an “Acupuncture Clinic”. In fact, much of our clinic practice does not involve acupuncture at all. Our teams have assisted with child birth, responded to mid-night emergencies, diagnosed cases of cancer, parasitic infection and diabetes, and reported suspected cases of polio to the World Healthcare Organization. We see our clinic as new model in the delivery of primary healthcare in rural and developing regions. In this model we utilize what we call the “best care available” rule in our treatment planning. We pride ourselves on our expert diagnostic and evaluation skills which help us determine our plan. We start by asking ourselves “What is the best care for this condition?”, “Is that care available to this patient?” and “How do we help our patient’s access that care?”. Many times we conclude that acupuncture is the “best care” available because it is effective in treating many conditions, especially pain and other inflammatory pathologies. Acupuncture is also very inexpensive, safe with very few side effects, and easy to teach to other healthcare workers. Chinese herbal medicine, local Ayurvedic herbs, and naturopathic supplementation are also employed wherever they are deemed effective--and they are very effective when used properly. In addition, we are authorized and provided 40 listed allopathic drugs by the District Health Office. We use this pharmacology sparingly and wisely. For some of our patients, who have the means to travel to a regional heath post, we order labs and imaging (x-rays, ultrasounds, MRIs and CT scans). Many times we refer patients to specialists (surgeons, neurologists, gynecologist, etc). We partner with the local government and attempt to guide patient care though accurate reporting, good referral procedures and followup. Educating patients and healthcare workers is sometimes more important than all of our treatment modalities combined. Soap, water, and general hygiene become one of the most effective antibiotics. In Nepal, pharmaceutical antibiotics are commonly over-prescribed. This results in resistant strains of bacteria, allergic reactions and a general weakening of the patient’s digestive system. There is no counting the number of patients we have seen with damaged hearing due to uncontrolled chronic ear infections. Many of these patients have been given Amoxicillin irregularly for 10 or more years. The result is very hard to kill infections and irreparable damage to the tympanic membrane and middle ear structures. This affects many young people in Nepal and is completely preventable with better training and patient management.
This year, the Acupuncture Relief Project undertook a courageous challenge of opening three experimental clinics in the remote regions of Bhimphedi, Kogate and Ipa, all villages in the District of Makawanpur. For the first time since we began working in Nepal (2008), we achieved a full partnership with the local government. Operating under the Nepal Social Welfare Council in cooperation with the Makawanpur District Health Office, we are now subject to the necessary oversight, inspection and reporting requirements of other governmental and private healthcare institutions. While this adds some level of expense, bureaucracy and complexity to our operation, it also allows us a new level of authority and access to government assets such as facilities and medications.
In our first three months here, we provided over 7000 primary care visits. Our volunteer practitioners work 6 days per week and they tackle some of the most difficult medical cases found in any modern hospital. Tuberculosis, diabetes, stroke, domestic violence, alcohol abuse, and seizures are common to our treatment rooms. Many times the “best care available” is the “only care available”... and that would be us.
Since we were attempting to operate in a new region, it was necessary to select and train several new language interpreters. We began by advertising for English speaking locals three months before opening our new clinic. We interviewed many and finally invited 15 students for training. There is so much more to being an effective medical interpreter than just speaking English and we looked for students who not only possessed good language skill but also demonstrated empathy, sensitivity and a profound interest in their communities. At the end of our initial three-week training session, we offered employment to eight. Our new crew of interpreters, aged 18 to 24, had never met a foreigner or spoken to a native English speaker. What they lacked in confidence, they made up with in determination. Each week on their day off they attended classes taught by our volunteers. Classes included medical terminology, anatomy and physiology, safe clinical procedures, Chinese medical theory, concepts of therapeutic relationships, diet, and exercise. They also learned some basic auricular acupuncture protocols and massage techniques. All of this helped them become better at advocating for the information that practitioners needed to make a proper assessment.
Our interpreters are crucial to our success in the clinic. When starting in a new village, it is imperative that we gain the trust of the community and the skill our our interpreters enables us to make that critical personal connection to each of our patients. This is no easy task. Our practitioners and interpreters work side-by-side all day, everyday, slowly perfecting each others rhythm, emotion and syntax until they seamlessly work as one. Once this happens, it is a magical experience for the both patient and practitioner. People start to get better.
One of the things I find the most interesting in working with the interpreters is that they experience a truly unique perspective on what it is that we do here. They are not familiar with our medicine... or any medicine for that matter. They are interested in what we do but they are more interested in what they are doing for the people of their communities. At a recent training meeting, I tasked our interpreters to list 10 ways they thought our clinic was helping the people of their village. I think every healthcare professional should take note, only one of their answers had anything to do with acupuncture or medicine at all. Their number one answer was... “laughter is good medicine”. When I asked them to explain this, they elaborated that no one in Nepal had ever experienced a doctor that laughed with them, or took the time to know anything about their life outside of their health complaint let alone explain a diagnosis, treatment plan or medication. The fact that everyone was treated exactly the same, with kindness and patience, regardless of their ethnic group, caste or socioeconomic status, was what our interpreters saw as our greatest contribution. They also commented that self-care, proper use of medication and dietary advice we offer empowers people to take better care of their own health. Can it really be that simple?
As this project strives to integrate so many modalities and medical concepts into a model of accessible, effective and ethical care, I am struck by the notion that there is really no such thing as alternative medicine. When people work together because they truly care about the wellbeing of others... this is medicine.
The inevitable gastrointestinal irritation happens when traveling and especially when living in rural Nepal, and I was the target this week. As I laid there staring at the ceiling between the bouts of bodily functionings, I was trying to recount all of the possible causes for it. Was it something I ate? Or the water when I washed my toothbrush off under the spigot? Was it that yogurt that the lovely couple offered to me and then poured for me on that house call the other day? Or was it all those school children at the satellite clinic in Ipa who were holding my hands and playing with my hair? Did I remember to wash my hands? Regardless of the reason, it was happening. And although being sick is never fun, this time it allowed me to see a different side to health care. A type of care that is apart from the allopathic anti-diarrheal, anti-nausea pills, and is unlike the rebellious stomach qi (the medicine we have been practicing here each day). I went to a witch doctor.
Three days of the sickness nonsense is just not pleasant, so I was willing to give anything a go. When our native Nepali ARP officer Tsering suggested that I go to the local Shaman I leaped (slowly) at the opportunity. He explained that in the culture here it was important to heal the spirit because sickness is the result of something attacking the person's spirit. The translation of the attacker is a witch. A witch bite is a bruise or unexplained mark on the skin. For me, it was a little more than a bite, I was attacked. A witch had attacked me from in the jungle surrounding our village, or from in the river water, or from a spirit of someone who had passed, and as a result, I had fallen ill.
The Shaman (who happens to be the father of one of our interpreters) conveniently lives just up the hill. He is not like the Disney'fied' witch doctors that one might imagine, with wild hair and a wild outfit, he is a down to earth father, husband, and worker of the land who is also a talented Shaman. He took my pulses, asked a few questions, just as we as acupuncturists practice, then went into the house to get his supplies. The supplies included a bowl of dry rice and red powder, another small bowl of ash, two cigarette-like sticks of herbs burning, a knife, and a cup of hot water mixed with salt and turmeric. As daunting as these sound the process was quite calm. He performed what I can only describe as a cleansing type ritual with the burning herbs, and tossing of the rice and red powder. I drank the salty water, and the knife was only used to stir it. At the end, I was told to rest and sleep for about an hour before returning back to the clinic house. And that was that. I returned feeling a little dazed and curious about what had just happened. It seemed a little surreal at the time, but as I sit here three days later feeling a whole lot better, I smile to myself, and think there must have been something to it.
Remembering the spirit is an important lesson. The medicine that is found in pills, or from acupuncture needles is effective, and does heal, but these medicines are not everything. Watching the ebb and flow of the three medicines - allopathic, traditional Chinese, and traditional Nepali intertwine and crisscross over one another here in Kogate is such an amazing dance. They support one another. It's a shame that we try so hard to keep them separate. -Liz Kerr
70-year-old female patient presents with urgent, frequent diarrhea. No enteropathogenic organisms are present, however blood is found in the stool. Allopathic care has been unable to resolve her symptoms. After 17 acupuncture treatments and the use of Chinese herbal medicine, the patient has experienced 75% reduction in symptoms since the initial onset 14 weeks ago.
Subjective
70-year-old female patient presents with urgent diarrhea with initial onset 2 months prior to 1st visit. She suffers from frequent, watery diarrhea 12 times per day that occurs upon waking in the morning, after eating, and throughout the night. Mucus and undigested food are present in the stool. The stool is reported to be red, black, yellow and white in color with a strong odor. Patient was admitted twice to the Chitwan Medical College Teaching Hospital in Chitwan, Nepal and reports no change in symptoms with allopathic medicine, nor does the patient understand the cause. Patient's appetite is poor with little water intake (2-3 glasses per day), and a subjective sinking sensation. She does not have a fever, nor does she experience abdominal pain, but does report feeling cold. Previous to the onset of diarrhea, she reports having a history of normal bowel movements.
OBJECTIVE
Patient is very soft-spoken, but alert with full mental capacity. She has a gentle, optimistic spirit and appears to be in relatively good health for her age and environment.
Hospital lab tests run at Chitwan Medical College Teaching Hospital 15 days after initial onset of symptoms show an initial diagnosis of dysentery. Complete Blood Count (CBC) shows Eosiniphil Sedementation Rate (ESR) value of 46 Mm/Hr (normal range 0-20). Urinalysis indicates urine pH 5.0 (slightly acidic), potassium level of 2.58 Mmol/l (normal range 3.5-5.5) and urea 14 mg/dl (normal range 20-40). Stool culture shows a RBC (Red Blood Cell) count of 2-4, indicating blood is present in the stool, a pus count of 6-8 with mucus present on physical examination, and no enteropathogenic organisms after 48 hours of incubation. No pain on abdominal palpation, nor abdominal masses, are found. Slight gurgling is detected in the lower left quadrant of the abdomen on palpation. Hands and feet are cold to the touch.
While at the hospital, the patient was given the following medications at an unknown dosage and duration:
Cifran: Ciproflaxacin - broad-specturm antimicrobial Metron: Metronidazole - antibacterial and antiprotozoal Ondem: Serotonin type 3 receptor antagonist, typically used for nausea/vomiting associated with cancer and post-operative treatment Pantop: Proton-pump inhibitor for gastroesophageal reflux disease (GERD) Bifilac: Probiotic Dometic: Domperidone - antiemetic Codophos: It is not clear which medication was administered; either Odophos, which is an iron mineral supplement, or Colophos, which is a laxative. Potclor: Potassium electrolyte supplement Enterogermina: Probiotic/anti-diarrheal Doxobid: Doxofylline - anti-asthmatic
Upon discharge from hospital, the patient was administered the following meds: Dometic 10mg PO TID (3 days) Pantocid 40mg PO BID (10 days) Codophos 15mg PO TID (2 days) Enterogermina 1 Tab PO QD (7 days) Potclor 15ml PO TID (5 days) Doxobid 400mg PO BID (10 days) Cifran 500mg PO BID (5 days) Metron 400mg PO TID (5 days) Seroflo 250mcg PO BID (continuous); Fluticasone Propionate is a corticosteroid used for asthma. The patient has a history of asthma.
Pulse is slippery, and the tongue is red and moist with a thin, white coat.
Due to the presence of pus and blood in the stool, another diagnosis could be colorectal cancer. This diagnosis seems less likely because the abdominal scan is negative for masses, nor is occult blood present in the stool. Another possibility is diverticular bleeding.
This is more likely than colorectal cancer as diverticular bleeding becomes more common with age. However, it often causes major bleeding, which is not present in this case. Ulcerative colitis is the most likely culprit, with frequent bloody diarrhea being the primary symptom. Systemic symptoms are often absent or mild. It can also be aggravated by NSAID's.
TCM DX: Primary - Spleen and Kidney yang deficiency with sinking Spleen qi; Damp-heat present in the Stomach and Large Intestine
PROGNOSIS: Good recovery is expected due to her overall good health and relatively short duration of symptoms.
INITIAL PLAN
Electrolyte salt pack is administered on first visit for rehydration.
Acupuncture and moxibustion 3 times per week for 3 weeks before reevaluation. Focus on lifting Spleen qi, nourishing the Spleen and the Kidney and clearing damp-heat from the intestines. Use of moxa is intended to replenish pure yang energy in the Kidneys. Herbal treatment of Bu Zhong Yi Qi Tang 2 pills TID to nourish and lift Spleen qi. Diet recommendations include the elimination of dairy and the inclusion of more high fiber foods such as fruits and vegetables, meat and warming (aromatic) foods to address nutritional deficiency. Increase liquids to at least 1 liter water per day. If symptoms do not continue to improve over the 1st course of treatment, further lab tests will be ordered.
Typical treatment: ST36, ST25, CV12, CV6 and LI 0 with 1" deep needle insertion
Alternate treatment: SP3, SP4, DU20, LI4, SP15 and ST37
Treatments include abdominal indirect moxa at the periumbilical region near ST25, SP15, CV12 and CV6. Particular emphasis is placed on the herbal formula as patient needs to receive daily care and nourishment to fully recover.
OUTCOM
After the 3rd treatment, little change was seen with Bu Zhong Yi Qi Tang, so the formula was changed to Fu Zi Li Zhong Wan (8-10 pills, TID) alternating with Li Zhong Wan (3 pills, BID). More emphasis was placed on tonification of the Kidney yang energy. At the 6th treatment, the patient reported that the stools were more soft than watery. Mucus and undigested food in the stool were still present.
At the reevaluation (9th visit), the patient was having 7-9 bowel movements per 24-hour period, approximately a 40% improvement from the initial visit. Her appetite was better and she was eating a wider variety of foods 3 times per day. Though mucus was no longer seen in the stools, there was still a strong odor and the patient continued to experience urgency to use the toilet. A high fiber, low fat diet was recommended. At this treatment, the patient reported feeling dizzy since the initial onset of symptoms 3 months ago.
The patient took a minor fall sometime in the days after the 9th treatment, injuring her left medial knee joint. As a result, ibuprofen was administered to decrease inflammation. An increase in bowel movements to 10-11 per day coincided with the administration of ibuprofen, suggesting that the NSAIDs were irritating the mucosal membranes.
After cessation of the ibuprofen (13th visit) the patient reported only 3-4 bowel movements per 24-hour period for the previous 4 days. However, she still experienced days with as many as 8 bowel movements. Stools still alternated between soft and watery with strong odor and yellow in color, but were not always urgent.
Ten weeks (15th visit) after initial acupuncture treatment began, an herbal formula was added to further help clear heat from the intestines: Qing Wei San 6 pills TID. Fu Zi Li Zhong Wan was reduced to 6 pills TID. After the addition of Qing Wei San, the patient's stools reduced to 3-4 per day with a formed consistency. At this time, a follow-up stool analysis and CBC was ordered. Pus cells were no longer found in the stool with the RBC count in the stool reduced to 0-1 HPF.
Treatment plan was modified to continue with 1 acupuncture and herbal treatment once per week for 2 additional weeks before requesting another stool analysis and CBC. If blood is still present in the stool or if symptoms return, a colonoscopy will be ordered to determine further course of action.
CONCLUSION
Over the course of treatment, the patient experienced significant improvement in symptoms and arrived for each appointment optimistic about her progress. Due to her age, recognizing the role and good health of the Kidneys in her treatment prognosis is critical to her well-being. 2 critical points in the treatment plan were the switch from focusing on the Spleen to focusing on the health of the Kidney yang energy and the addition of the heat clearing formula to stop bleeding in the intestines. When little results had been achieved from the formula, Bu Zhong Yi Qi Tang, the treatment approach was changed to more strongly nourish the Kidneys. The formula was switched to a Kidney-based formula in the Li Zhong Wan family. When the stool analysis showed that there was still blood present in the stool, Qing Wei San was added to help cool the gastrointestinal tract and stop bleeding. Diarrhea can be an especially dangerous symptom for the elderly. With acupuncture, Chinese herbs, supportive care and allopathic testing, I am optimistic that the patient’s health will continue to improve. A colonoscopy would confirm the diagnosis of ulcerative colitis at which point a more accurate management plan and prognosis could be made. At this point in her progression, I expect that the patient will need to continue care at the clinic for an additional month, focusing on herbal and dietary therapy to resolve her condition. As a member of the elderly community in a small, rural village in Nepal, the improvement in my patient's health is a significant contributing factor to the health, well-being and sustainability of her community.
30-year-old female presents with lower abdominal pain, burning urination and shortness of breath for the last 5 months. With the discovery and treatment of a parasitic infection, and with concurrent treatment of a urinary tract infection, the patient found significant relief.
SUBJECTIVE
Patient presents with achy, burning lower abdominal pain with burning urination for 5 months. The burning is daily and constant at a moderate level intensity. It is worse during the night and during her menses, which is regular at 28 days. Menstrual flow is heavy, lasting 6 to 7 days. It is dark in color with some clots. She reports dysmenorrhea with burning pain and cramping in the lower abdomen and back, persisting all 7 days of her cycle. The patient also reports 5 months of burning urination that is scanty, dark yellow and cloudy with a sense of burning and achiness in her urethra. She experiences a sense of urgency and urinates 10 to 15 times a day. Furthermore, she reports loose, yellow-colored stools containing mucus starting 3 months ago. She has a bowel movement 3 times a day. She denies visible blood in the stool and reports no burning sensation of the anus.
Patient reports shortness of breath (SOB) for 1 year, which occurs when walking, and is worse at night while lying down. Symptoms have been worsening for the last 4 months with occasional tightness in her throat, wheezing, sore throat and cough, all of which are worse at night.
She reports feeling tired, having poor memory, night sweats and being irritable and anxious, with difficulty falling asleep.
5 years ago, she had a dilation and curettage (D&C) procedure due to a miscarriage. She has 2 children and is not currently pregnant. She denies any vaginal discharge or rash.
OBJECTIVE
The patient appears to be in average constitutional health for her age and environment, but appears fatigued and weak as though she is fighting off a pathogen. She is somewhat thin, and often slouched in the chair under a draped shall. Although her face is somewhat pale, she has flushed, red cheeks and mild, red-tinged eyes. Her palms are damp to the touch. She speaks with a weak voice, and is mentally sluggish, though has many complaints and concerns about her health. She also has a dry cough heard during her treatment visits.
On palpation, the patient is tender and timid. She reports moderate pain that is achy in nature when applying deep pressure to the low abdomen. There is also moderate pain with moderate depth pressure to the mid-abdomen. No tenderness in upper quadrants. Moderate pain on strong percussion of her low back.
No significant findings on auscultation of bowels. Minor wheezing in both upper lobes of the lungs upon auscultation. Vital signs include: Temperature of 98.8°F, oxygen saturation of 98% as measured by fingertip oximeter, and a resting pulse rate of 78bpm.
Her tongue is pale, with red sides and tip. It is fissured, with a thin white coat. Pulses are thin, wiry, a little rapid and slippery
LAB RESULTS
Urinalysis Panel: Pus cells (2-4 HPF) and “plenty” of epithelial cells; Dark yellow color; Slightly turbid appearance and acidic pH; Trace albumin; Blood, ketone, bile and glucose are not seen.
Blood Panel: Hemoglobin 12.0 gm/dL = low range (normal female range is 12.1 - 15.1 gm/dL) Total leucocyte count: 11,800 cu.mm (normal is 4,00-11,00 cu.mm) = little high Neutrophils 75% (normal 40-70%) = little high Monocytes 00% (normal 002-10) = little low Lymphocytes and eosinophils are in normal range.
Stool Panel: Most significant finding is presence of ascaris lumbricoide ova (roundworms) along with red blood cells (2-5 HPF).
ASSESSMENT
DX: Urinary tract infection (cystitis); Roundworm infection; Possibility of Kidney infection due to duration, as well as possible infection or inflammation in the uterus. However, low temperature and medium pain upon palpation of low abdomen and back rule out significant infections.
Secondary complaint of dyspnea (SOB)
Explanation: Pus cells (pyuria) in urine indicate some type of infection in the urinary tract. More accurate diagnosis of a UTI requires nitrites to be found in the urine sample. 95% of UTI’s occur when bacteria ascend the urethra to the bladder. The most common bacteria is gram-negative strains of e.coli. In addition, increased white blood cells in the blood lab, specifically high neutrophils and low monocytes, indicate a mild bacterial infection. Hemoglobin levels, being on the low end, is probably due to anemia and malnutrition based on patient’s environment and parasitic infection.
Roundworms are a nematode (non-segmented cylindric worm that ranges from 1mm to 1m in length). They are a helminth parasite (compromising hosts nutritional status) that are transmitted fecalorally when contaminated plants (or soil) with the eggs on them are consumed.
TCM DX: Damp-heat in lower jiao (body): Lower abdominal burning, and burning urination, that is dark yellow and cloudy
LV/KD yin deficiency: Chronic sore and dry throat, knee and low back pain, night sweats, five center heat, feverish, thirsty, dizzy, irritable, insomnia, burning, itchy eyes, blurry vision, burning worse at night
Cure of burning urination and burning low abdomen is highly probable within 2 months, with proper conjunctive care, including acupuncture, internal Chinese herbs and Western medications (antibiotics). Typically, acute bladder infections and parasitic infections are resolved within 48 hours after the onset of medication.
Chronic UTI’s may take up to 1 month to resolve. The SOB is expected to improve 80% within 3 months.
INITIAL PLAN
Treat with acupuncture 2 times per week for 2 weeks. Reassess in 1 week to assess patient’s progress after taking parasite medication. If burning urination is not resolved, administer antibiotic medication. In addition, sanitation and hygiene is discussed with the patient, along with recommendation to increase water intake, consume cucumber juice and accessible antibiotics in diet such as raw garlic, to decrease the burning urine.
Acupuncture: Focus on points to clear heat and remove toxins, especially from the lower jiao, nourish yin and blood, Lungs, Spleen and Stomach.
Chinese herbs: Huang Lian Jie Du Tang 3TID for 2 weeks to clear internal heat, then Dang Gui Liu Huang Tang 3 TID to clear yin deficiency heat
Allopathic medicine: Albendazole (400mg PO once) is administered for roundworms. Ibuprofen (400mg TID) is given for 5 days upon first visit.
Subjective: 9 days after initial visit, the patient reports her stools being less yellow and more formed. She is still experiencing burning urination with burning pain into her urethra, but reports a 20% reduction in symptoms with treatment. She urinates 8 times per day and 3 times per night.
UPDATED PLAN
Acupuncture treatment 2 times per week for 2 weeks to clear UTI and decrease lower abdominal pain.
Trimethoprim/sulfamethoxazole (160/800 mg PO BID) for 10 days is given for UTI. This medication is later extended an additional 4 days due to unresolved symptoms.
Stool and urine to be retested in 1 week.
OUTCOME
19 days after initial visit, the patient reported her stools being formed, 2 times a day, and no longer yellow. The burning in the low abdomen was still daily, but less at night and had decreased in intensity by 70%. She was able to tolerate deep-level palpation to her low abdomen with mild tenderness. The burning urine was 50% less, but still bothersome, with burning pain into the urethra. She was urinating 5 times per day and 3 times at night. Her temperature was 98.5°F. She visibly looked more energized with less redness in her eyes.
The patient reported it being easier to breath and coughing less. She still experienced minor wheezing, heard upon auscultation, but it was less oppressive.
There was also less gastric pain in the mid-abdomen, and only mild tenderness upon deep palpation. Her night sweats and sore throat were also less frequent.
A follow-up stool panel indicated that the helminthic (roundworm parasite) ova and microscopic blood was no longer present.
Urine lab showed pus cells at 3-5 HPF and epithelial cells at 4-8 HPF. Color was light yellow, appearance still slightly turbid, pH acidic and with trace levels of albumin.
CONCLUSION AND FUTURE PLAN
This is a case where the patient was reporting a multitude of health complaints that seemed unrelated, and complex. This was compounded by her reluctance to report significant details about her health history. On previous visits to this clinic, practitioners focused on her knee pain and burning itchy eyes, which was mostly resolved by the time I saw her. Her burning lower abdomen and urination was listed among her secondary complaints, but was not found to be significant. This case shows the importance of discerning between signs and symptoms, providing integrative care, and trusting one’s instinct to direct proper care and plan-of-action, including the ordering of proper lab panels. This treatment approach exposed and properly treated the roundworm infection.
Thus far, this patient successfully experienced reduction in burning urination, burning low abdomen pain, and a host of other conditions, including SOB. The SOB was likely due to roundworm infection since the larvae move via the bloodstream to the lungs where they are coughed up, swallowed, and travel back to the small intestines where they mature into adult roundworms. Common symptoms of roundworm infection include coughing, shortness of breath and wheezing. If not resolved in the next month, a proper assessment of asthma needs to be done, and possible administration of asthma medications (bronchodilators beta 2-agonists, anti-cholinergics or corticosteroid etc.) may be needed.
The increased number of pus cells in her second urine test indicated that a urinary tract infection was persisting. Trimethoprim/ sulfamethoxazole (160/800 mg PO BID) was extended to 14 days.
If the burning abdominal pain and urination is not resolved within 2 weeks, a stronger antibiotic may be needed. Other causes of pus cells in the urine should be considered, including sexually transmitted diseases, kidney stones, other infectious pathogens such as candida, or even tuberculosis in the urinary tract. Though not likely, cancer must also be considered. Her temperature should be monitored. It may also be necessary to order a gynecological examination to rule out infection, inflammation or scarring caused by the D&C.
Acupuncture and herbal treatments should be continued into the future, 2 times a week for 10 weeks, with focus on tonification and to move qi/blood in the lower jiao. Probiotics, iron supplement and a multivitamin with B-complex should be considered. In 3 months, the patient should be checked again for roundworm eggs. If the case is not resolved within this 10 week period, she should be referred for an ultrasound or CT scan to examine her kidneys and ovaries.
I’ll always hold space for Nepal in my heart, my soul and my hands. My hands because my hands are my tools, they are the hammers that deliver the nails (or the needles in my case) and they got a lot of action let me tell you. All of my experiences, including and probably especially the hard ones, have changed me in many ways. Some ways that I can see now and some ways that I think will continue to unravel as my life goes on. I didn't just improve my acupuncture skills, I became a primary care provider. Mostly, the experience taught me about myself.
It taught me about different ways of living or being that make it easier to understand what happiness is. I learned that I just need to relax and breathe it in. Be open and let it flow me. To cherish what I have and the people around me. It taught me a lot about cultivating true relationships and friendship.
In Nepal, there is no hiding who you really are when you live with the only other five people for miles around who can speak the same language as you and you are totally cut off from the outside world. There's no getting all made up and putting in a cute outfit to look your best. There is no going home when you're tired, grumpy or uncomfortable. You show up everyday with grease in your hair and dirt on your face and you bear it all, good or bad. And you know what? People will still love and accept you for who you really are. I got closer to my clinic team than I have to many of the people who have come in and out of my life throughout the years.
Thank you Nepal for bringing these people into my life. Not only did this experience teach me about making true connections with the people I lived with; it taught me about connecting with people that don't speak the same language as I do, my patients and all the other people who live in Kogate.
Nepal has some of the sweetest kindest people I have ever met. I felt so loved in Nepal. I was welcomed with open arms and opens hearts wherever I went. Something that I will never forget are the smiles of those people. They smile with their eyes, which offers you a glimpse into who they really are. A vulnerability, most people in the United States are unwilling or unable share. But its something that means so much and helps me to see how truly connected we all are.
We don't always need words to express compassion and love and kindness as long as we are willing and able to be open enough to connect with one another. The people of Kogate take care of one another they share and barter and feed each other. They drum and dance and sing together. They live off the land and appreciate what they have even if its not a lot and they make the best of it. Patients would come in so happy and excited that we where there to help them they would bring flowers, pumpkins, mustard greens spiny cucumbers whatever they could afford to give away. Most of all they gave us their love and kindness.
Although many of my memories of Nepal are silver lined, it wasn't always rainbows and sunshine. Literally it rained for most of the first month we were there. Some days where a real struggle for me. Living without all of the comforts of home took some getting used to I won't lie... I had to let go a lot of fear. Especially my fear of of bugs because they were everywhere including my hair. They existed in all shapes and sizes but I especially remember the giant ones. I had to sacrifice my ankles to leeches and bed bugs as a peace offering to the insect community. I had to let go of some of my control issues as nothing in Nepal seems to work right or on any sort of time schedule. Plans are just an outline for what you'd like to have happen but Nepal defies any sort of structure you may lay out.
This lesson made itself apparent even into my last days there as Nepal is having its first elections since the end of a long civil war that only ended a few years ago. There was a mass transportation strike around the country and I wasn't sure if I would make it to the airport in time to catch my flight home. And as much as I rant and rave about the people and my patients and their kindness, there’s always an exception to the rule.
This was made apparently clear to me by one of the patients that I treated the most. He came into the clinic everyday. He was suffering from the effects of a stroke that he had last February. He lost his ability to say anything but the phase la in Nepali, which means ok. He had also lost most of the mobility of the right side of his body. He was a very angry man and rightly so. I can only image how frustrating it would be to lose so much of who you are. He got frustrated easily with my treatments because they were often painful and his anger and pain was palpable in my heart. I found it so difficult to treat him as I absorbed his frustration and I quickly became physically and emotionally drained. I found myself dreading the thought of treating him everyday. I discovered that I have a habit of looking to my patients for acceptance and I wasn't getting that from him. I began to close myself off from him, but of course this only made my treatments with him more uncomfortable.
I spoke to Andrew (our project director and team lead) and he talked to me about the importance of just holding good space for people and keeping an open heart. That sometimes the largest role we can play in our patient’s lives is just showing them that we care and are there for them. This really resonated with me. Suddenly, it all made sense. All I really had to do was show him that I cared about him, that I wasn't trying to hurt him. I was really trying to help and that I was invested in him getting better. Once my attitude changed toward him, he changed his attitude about his treatment and me. He was no longer so angry. He was actually pretty happy when he came in which the whole team noticed because previous to my change in heart, he would often yell out in anger. He was also making great progress in his recovery. He regained the ability to walk on his own, he had started saying more words and he had an increase in active and passive movement of his right arm.
This was an incredibly important lesson for me to learn about patient-practitioner relationships and it was also one of the hardest and most uncomfortable experiences I had in Nepal. It just goes to show that from suffering comes growth.
Nepal has taught me countless lessons. First and foremost, I want to remember that humanity is beautiful, don't ever give up on it. There is an incredible amount of people in the world ready and willing to freely share their kindness and love with you if you’re willing to share yours with them. Nepal has also taught me to "Harden the Fuck Up!" (a phrase we would commonly tease each other with when someone was whining a little too much). I don't need every luxury in the world to survive or to even be happy and often what I think I need is what ends up impeding my happiness. I am a lot stronger than I ever thought I was and that is truly empowering and liberating thought. As reflected on all that my Nepal experience has taught me, I can’t wait to bring these lessons home and apply them to my new life as an acupuncturist... and most of all as a human being. - Haley Merritt
For the record, this is my second time writing this blog post. I wrote one a couple of weeks ago and Andrew had politely given me some feedback on it, called it fluffy, and asked me to consider rewriting it. Something about me not realizing how much I had grown here in Nepal, and sort of missing the boat on that in my first attempt. Needless to say, I was disheartened by his comments and stewed for a few days over them. I had already been through so many challenging experiences at that point and I wasn't really up for delving deeper anymore. But as I have learned (a few times over) there really is no where to run and nothing to distract you here in Kogate, Nepal. It's like acupuncture bootcamp, complete with mental, emotional and physical components.
So what do I write about then? I still had about a week and a half here, and to be honest I wasn't feeling particularly inspired by anything. Don't get me wrong, I have had many many amazing experiences while in Nepal that I will cherish forever. But sometime in this past year I stopped connecting with my heart. I felt exhausted, and therefore I would remain emotionally detached from pretty well everything to avoid the exhaustion. Unfortunately this detachment showed up in clinic, and I was having a hard time connecting with patients. I didn't recognize this disconnect until it was brought up via my initial blog post. So a few good cries and emotional talks later, I had arrived. Now this still is no big, ah ah, blow my mind, breakthrough moment. It did however spark a little something that I only expect will grow with time. But maybe those are the best kinds of insights.
I have written about Bim before in my personal blog, I've treated him a few more times since then and gotten to know him a little more. He is a man that we see on our way to the village of Ipa, where our outreach clinic is. Bim is actually the reason that ARP is here in Kogate. He initially started travelling seven hours to the Chapagoaon clinic for treatments when ARP was practicing there. His family told ARP that they should come to Kogate to practice, and 9 months later here we all are. Thanks to Bim, he is the reason so many people have received medical attention.
One of the last days that I was to go to Ipa, Andrew gave me one of his insightful speeches. He told me that this man is surely dying, he will not live much longer, and he really hasn't had the best quality of life these past four years. So today, your charting and point selection really doesn't matter. What matters is that you make connection with him. I'm thinking to myself...is this about me? Or is everyone getting this inspirational speech? No, I was right, it was specifically for me.
The treatment went as usual. How are you feeling today? Any noticeable changes? How's your sleep, breathing, bowel movements? Bim began telling me about how tighten and painful his legs were, and when I touched them I could feel the bow strings that were his tendons. I learned that he has been in a contracted sitting position pretty well ever since his disease became debilitating. Bim is always seated outside when we come so I started asking his wife how she gets him in and out of the house. He has a large family, but they are not always around to help them, so it is up to her to care for her husband of 42 years. She looks to weigh about ninety pounds, and is not in optimal health herself. She says that she has to drag him in and out of the house when she has no help, so he spends his days on the front porch. I was sitting there beside Bim listening to this, wishing that his family would be of more help to them, but who am I to judge this family. They are as supportive as they can be.
Then an idea struck me as I was listening to Suman, my interpreter, change my English words into Nepali. Suman looks pretty strong, and I've got some muscle on me to, what if we took Bim on a walk? Right now? Why expect the family to do this if were fully capable? So that's what we did. With one of Bim's arms over each of our shoulders we picked him up and walked him around their small courtyard. Because he was only able to use his tip toes we were pretty well carrying dead weight. It was substantially more challenging than I would have thought. It was only a short walk, but here's the best part; when we sat Bim back down in his spot, his face was beaming. I have truly never seen such gratitude on someone's face. In that moment I was more than humbled.
This story isn't about this cool thing that I did to make a sick man smile, and it sure isn't a pat on the back for myself either. Actually anytime that someone has told me how proud they are of me for what I am doing for the people of Nepal I want to say, thank you, but it's quite the opposite of what you think. It's more like this: I've been changed by the people and experiences here in Nepal. So be proud of Nepal and people like Bim for giving me the opportunity to come back to my home and be able to share with you all how to become more heart connected to oneself and others. - Allissa Keane
I know many people that travel often and tell stories about their 'breakthrough moment' or an 'epiphany'. Friends and family told me, when I was leaving for Nepal, that I would have amazing experiences and it would change my life. I have no doubt that this will be a life changing experience, or that my time here will be amazing. However, in my head, as I was boarding the airplane and imagining all the things that would come. I daydreamed of sitting on top of a hill and having the meaning of life showered upon me. I would break down from some hardship and then see the light through the darkness of my despair.
So far, none of that has happened. Instead, I've been learning lessons little by little. They sneak up on me, so much so that I don't realize I'm learning them until I look back and realize I've changed. It reminds me of how my mom presents an idea to my dad. If she gives the idea outright, with all its facts and all its information, he shuts it down right away. However, if she gives him little tidbits, subliminal messages, and offhand comments, in time he comes to the exact same idea or conclusion on his own.
This happened to me in Ipa (or Epa, even Nepali's can't come to a consensus on the spelling).
Ipa is our outreach clinic. Every Monday and Thursday we trek an hour and a half along the dusty, rocky, uneven road. The walk there is "Nepali flat", meaning there is very little elevation gain in the end, but you will rise and fall hundreds of feet along the way. Our walk to Ipa on October 24th was sunny and hot. We had butterflies flitting around us and grasshoppers jumping around underfoot. Leeches, thank goodness, had abandoned the hot dry grasses. Four of us walked to Ipa that day. Andrew, Allissa, Ritesh, and I. Two practitioners, an interpreter, and a pre-medical student/assistant/odd jobber.
Our first stop, as with every time we travel to Ipa, was about an hour into the walk. We made a house call to a man who has a neurodegenerative disease. We suspected, with our limited technologies, either Parkinson's or Multiple Sclerosis (MS). Allissa did an acupuncture treatment on him, and his son brought out fresh honey that they'd harvested from the wall of their house. It tasted wonderful. We broke off a piece of the fragile honeycomb and stuffed the whole thing on our mouths. Occasionally a larva got thrown in the mix, but it's just a dash of protein, right? The honey at the house in Ipa was particularly delicious after a long, sweaty walk. The sunlight glinted off both the metal plate and the golden honey, making the entire presentation seem all the more appetizing. We sucked out all the sweetness possible until we were left with only wax, which actually makes for a pretty good chewing gum substitute.
After we treated the man, we continued on to the school house where we held the main outreach clinic. We took one room of the two room school building and used it as a treatment room. Chairs were set up outside and inside a platform with two mats. About half of the patients we treated outside, sitting in the plastic chairs.
The community likes to hang around and watch our clinic work and we encourage it. Patient confidentiality and privacy here takes a backseat. It's more important for us to be open, honest, and visible to the community. They take comfort in their friends and family being with them. In some cases, privacy is preferred, and we always accommodate for that. In Ipa, The school itself is set on a ridge with the "road" traveling right in front of it. Some of the community members or patients sat on the edge of a cliff, squatting or sitting, oblivious to the extremes of their environment, content with watching us work, gossiping, and looking after the babies of those getting treated. A pleasant breeze washed over us from over the cliff, it was especially welcomed on the hot day.
Our first patient at the clinic was a small girl with diabetes. The first time we tested her glucose it was 525. The second time it was 320. The third, it was back up to 500s. Her glucose was dangerously high and we had been trying to write to some doctors in the US about what type of medicine she needs. That day in Ipa we didn't have any glucose strips left in order to test her blood sugar levels. We performed an acupuncture treatment and said that we were working with some doctors in America to help her. She had the most amazing attitude. She hung around our clinic the whole day and our little inside joke was “yes dukchaa” which combines English “yes” and Nepali “pain” or we said “no dukchaa”. Often she would point to objects and say their name in English, showing her intelligence and eagerness to learn English. Her and I developed a great friendship that day. She started holding my hand and tugging at my hair, running away and giggling after. At the end of the day, she walked us part of the way back and then handed me a note. It was pretty long, and written in Nepali. I had Ritesh, one of our interpreters, transcribe it for me.
Here is what it said:
I am Babita Basnet. For the good health of Nepal, namaste to the well wisher [this is a respectful greeting]
Hello (Namaste) Doctor
I am 13 year old kid born in a poor typical Nepali family. I have been having sugar disease or blood sugar disease since I was 11 years old. I am always worried (scared because she had this problem). I am very interested in studying and I love all sorts of extracurricular activities but I am very worried and scared because I have been attacked by this sugar disease since I am very young. What should I do? Our economy is no good. I can’t go to many places to have my medical tests and till now I have been managed with medicines. Sometimes I feel “what will I do?” when I can’t afford for my medicines. I am just scared. Will my problem (disease) ever be solved (cured)? I don’t think so if I can’t get a good medicine that will help me with my disease. I always use insulin but it burns me and it hurts very much. How long will I have to live with this pain? I am not able to concentrate on my studies because of my family’s condition and stress of my disease.
Love Babita Basnet Epa, Pachkanya-6 Makwanpur
This little girl, who had been so chipper and playful all day, described her fears and anxiety over her life-changing disease in under 200 words. I didn't know what to do. I felt pretty helpless when I was reading her letter.
One of the hardest things to do here in clinic is to tell someone we are unable to help their problem. It's one of the most important things a doctor can do: honesty. On Thursday we met a lady who had a fever four years ago. During the course of her fever, she was hospitalized and lost hearing in her left ear and partially in her right ear. She came to us with a couple other complaints: headache, body pain. I looked in her ears and the ear canal and tympanic membrane looked normal, if a bit opaque. There was some redness in one and a small amount of moist earwax. None of this should have caused partial or complete hearing loss. We used a tuning fork to do a basic hearing test and it confirmed her partial and complete deafness. Andrew looked at her and said “We will not be able to fix your hearing. The fever likely caused permanent damage to the auditory nerve, something that is deep inside your brain”. As Ritesh translated you could physically see her face fall.
Often times our patients view us as magic workers- able to fix anything. We bring our foreign clothes, foreign faces, and foreign medicine. They come to us, sure that we can fix anything. They have so much hope when they come to the doctor. She had hope that we could fix her hearing through treatment. The same treatment that is fixing her husband's body pain, her mother's headaches, or her friend's menstrual irregularities. But we can’t do everything. And we had to tell her that. You could see on her face when she realized the permanence of her situation. She had to reroute her future plans. Everything that she had hoped would return vanished with our words and she had to imagine her future with only partial hearing in one ear. For the rest of her life.
We’ve told people this before, and I've always known the value of honesty in the clinic. But this was one of those "snuck up on me" moments. When I look back at all the previous times we've been honest with our patients, regardless of the news, I see the value of doctor-patient honesty with a new clarity. We bring hope, compassion and our expertise. But sometimes we also bring bad news, disappointment, and heartbreak. -Tessa Concepcion
I have a clairvoyant friend who told me I would have a profound, potentially life-changing experience while I was in Nepal. I'm in a distant land helping a very rural, select group of people heal, naturally this will be profound, duh. Even so, I can't help but wonder about her prediction and it's implications. Will this experience be so changing I will be cognizant at the time it occurs or more subtle- something I'll reflect back on years from now, hindsight offering clarity I cannot comprehend in the moment? I don't know. What I do know is my anticipation waits unabashedly for the answer.
I have not spent much time with groups of females. So much feminine energy often overwhelms me and leaves me feeling shy and self-conscious. Did I fit in? Was I being judged on my abilities to act as a "normal girl" should act? These insecurities carried into adulthood and I've spend many hours working through what "normal" and femininity mean to me.
All the volunteers in this group are females ranging from 22 to 37 years old. We come from different backgrounds and share different stories. Since I've arrived I kept the ominous prediction in my head, always thinking the profound experience would be clinically related and maybe it will, but it could also be a more interpersonal one.
We have all been requested to write a blog expressing our authentic experience here, but I've struggled with this. My ability to process the goings-on veiled by overstimulation and fatigue. The days can be long and I am often riddled with self-doubt and insecurity about my capabilities to heal and help. Sometimes the only saving grace is the people I am sharing this experience with.
I have created a bond with the volunteers that even now, in it's very early stages, I can recognize as lifelong. I'm learning that my insecurities about everything aren't just something I alone have to suffer with; each of us are overwhelmed, unsure, emotional and confident all at the same time. In this adventure, completely out of my comfort zone, I am surrounded by a group of people that will support, help, comfort and hug me. The walls I keep up to protect my vulnerability haven't come crashing down, but I am letting these women see a part of me generally reserved only for those very close. We joke, cajole, offer tough love and make fun of each other daily. I laugh often and wholeheartedly. The relationships I am building with my colleagues is challenging to express in words, it is a feeling I have of knowing this is a moment to be cherished in it's fleetingness. This is a small window of my life that will be closed sooner than I am prepared for, it casts a melancholy air but reminds me to stay in the moment and be grateful.
Tomorrow is the last day of our second week of clinic. My experience living and working in Nepal has seemed slow to evolve, but I realize is actually evolving very quickly. Last week was extremely difficult. The weather here in Bhimphedi was hot and sticky, the clinic was brand new, I was seeing more patients in one day than I've seen in a week and on top of all of that, I ended the week feeling sick and exhausted. I know from past experiences with travel that this is normally the point when I have a breakthrough. I had to remind myself of that, since it has been 12 years since I have lived abroad for a period of time. I've always been the type of person who when the going gets tough and I become stressed, I find a way to absorb that stress and "toughen up" in order to get through it. Unfortunately, this is usually when I get sick. This is exactly where I found myself last weekend...sick, tired and uninspired. When I was asked to be the team leader of the Bhimphedi satellite clinic, I knew in my heart that I was up for the challenge. I didn't know at the time that that challenge would have very little to do with the logistics of leading 2 other practitioners and keeping an organized clinic. It's turning out to have everything to do with learning how to thrive and follow my heart in an otherwise stressful situation.
We all have coping mechanisms. Over the years I've become quite good at learning to exist in difficult environments and adjusting my body and mind so that each one was filed away into its predesignated spot in an attempt to keep my surrounding environment running smoothly. My heart didn't usually have much of a say. My surrounding environment was probably never as calm as I thought it was and I was certainly not in a state of inner calm. In recent years, as I've tried to incorporate my heart's desire into my coping mechanism, I often ended up appearing very vulnerable....a scary feeling for the girl from the east coast! But as I started to include my heart's needs into how I reacted, I started to feel a sense of freedom from this vulnerability. I feel as if the opportunity I'm being given as the team lead for the Bhimphedi clinic will expand my heart in a way that until now, I didn't truly realize needed to be expanded. Perhaps there is a way for me to exist, calmly and peacefully from the heart, within a stressful environment. Perhaps order and direction can co-exist, within myself, with a sense of vulnerability and an open heart. This is still a bit of a scary prospect for me and one that I will probably continue to stumble over many more times, but as I've begun to discover in recent years, it's also a freeing prospect. As I learn through Vipassana meditation, perhaps this is the key to responding rather than reacting. We respond with our hearts. We react with our minds.
When viewed from the mind, everything we do here on a daily basis seems to be a lot of work...from showering to using the toilet to communicating. But when I start to relax and look at what or who is right in front of me, I realize it's not so much work...it's life. And when it's smiling back at me, I can't help but soften and smile back. I think I'm starting to see the magic of Nepal. ---Patty McDuffey
I feel my time in Nepal (only 12 days so far... crazy, feels like a year) has already greatly stretched, opened and expanded my view of culture, community, self and life in general. A perspective and growth I think and hope will stay with me forever. I feel like every moment is packed with SO much stimulus, it can feel like an overwhelming sense of raw emotions... bursting and bubbling... trying to make sense of, integrate and digest everything at once, before the next moment, equally as intense and stimulating arrives. There is just so much to take in and process... (A little alone time each day for me is highly needed).
Being immersed in some Nepalese city life and culture in Kathmandu for a few days after arrival and introduction to our Acupuncture Relief Project team was a whirlwind of exciting events while we adjusted to our different time zones (America, Canada and Australia). On reflection some highlights include a trip on the back of Andrew’s (our team lead) motorbike from the airport to the earth house hotel. Goodbye Australia and hello Nepal... a complete cultural change!!! As the thick smog filters through my respiratory system, my eyes water from the smoke and speed of the bike, animals, pedestrians, bikes, motor vehicles and fuel trucks weave a path with many honks and near clashes, and I think back to my friend saying to me before I left that Nepal/India can often feel like you have landed in a completely different universe... yet the chaos to me feels so fluid and free and somehow I felt a sense of adrenaline, excitement and a great sense of LIFE!!!
We had a very warm welcome and I felt extremely safe and at home. I was already beginning to sense that Nepal was a place of unpredictability and really keeps you on your toes... literally... those first couple of days we did a lot of walking... exploring and discovering the city and some of its treasures... lead partly by Andrew along with some of his Nepalese friends/connections... who are very interesting and inspiring people who generously shared their stories, art and knowledge of the city, temples and hot spots. (And by hot spots I don’t mean wi-fi... a concept, which has become foreign to us in Kogate and at its mention our ears prick up with anticipated attention).
Some “hot spots” for me included the monkey temple ‘Swayambhunath’ where we had some great laughs watching many monkeys jumping and playing in a small water pool (remind me to show you a video of this) and a sacred site Pashupatinath where on one side of the river bodies are burned in funeral celebrations and on the other side there are temples for fertility. The way life and death are so connected here is very beautiful... A sense of impermanence and flow... Everything seems more out in the open... the rubbish being another example... instead of feeling disgusted by it I also see it gives another understanding that we use SO much unnecessary packaging and garbage in our society and here its just more ‘out there’. In Kogate all the rubbish we use we burn so it really gives you a more immediate idea of what and how much you bring/use/dispose of.
Our journey to Kogate was an adventurous funny, somewhat scary ride with all 7 of us packed into a jeep bobbing up and down with all the bumps, lots of screams of near close encounters with oncoming traffic around bends and the often sketch (Patty’s sketch scale rating) roads and lots of girly giggling (our poor driver ...a young Nepalese man who found enjoyment from telling us cars had just tumbled down the cliff the other day... totally NOT funny information while squeezed in the back of a jeep on that road!!!!).
We arrived somewhat relived, very hungry and tired.... Only the next day could I fully appreciate the beauty of our new home and its mountainous surrounds. There is a little running creek which today we bathed in on our one day off ... it felt lovely and was refreshingly cool. We have explored some of the little trails around after our clinic days and the beauty is very overwhelming and breathtaking... as is the altitude and the steepness!!!
Setting up the clinic was exciting and the first week has been both challenging and rewarding. The Nepalese people are very sweet and welcoming, funny and grateful. I think I have treated and seen more people/conditions in the first week than a whole semester at college! From pregnant women, young children to people in their 80’s and all different social classes they arrive at our clinic late morning and just keep rolling in ... often I have around 10 family members in the room all having their input into a particular case and getting involved (at first can be very overwhelming, along with the children piling around the windows all watching, sniggering and giving you shy smiles).
Being a “primary health worker” aka “famous white doctor” has been a big adjustment in my thinking and practicing mind and I have found working with new assessment tools and exams rather challenging yet I feel privileged to learn these new skills in practice and be able to help the people where is needed. Sometimes they don’t need acupuncture or herbs, they need a medical diagnosis or a referral or simply to be heard and listened to.
One of my patients I have seen everyday this week is an older man who suffered an ischemic stroke in late February and now is unable to speak. He comes in with his wife (a very caring beautiful lady) and is only able to sound “la la la” and is partially paralyzed on his right side. I have been treating him with acupuncture, using both electro and scalp acupuncture and also doing speech training with him. I sit in front of him (or Tessa, another volunteer who is helping out does) and we sound out the vowels getting him to watch us and try his best at copying our sounds. He finds this frustrating I think yet with the right encouragement he develops a big smile! This warms my heart and I feel so humbled by these people I have met who seem to have many health concerns yet are so open, happy and grateful. Many great qualities I will continue to aspire towards as my time here with Acupuncture Relief Project continues. - Anna Helms
Acupuncture Relief Project takes on its most challenging clinic project in the remote region of Kogate Nepal. Project Director Andrew Schlabach outlines the clinic's vision and obstacles.
In 2012, our Third World Medicine Immersion Program continued to attract passionate and qualified volunteer practitioners who provided over 10,000 patient visits at our clinic facilites in Nepal. These volunteers worked six days a week and participated in over 60 hours of continuing education focused on improving their skills in case evaluation, treatment planning and patient progression. At the completion of thier stay, each practitioner presented a case study for peer review. These case studies help us analyze the efficacy of our clinic efforts. For their participation in this course, our volunteer practitioners received 54 Professional Development Activity (PDA) credits from the National Certification Commission of Acupuncture and Oriental Medicine (NCCAOM).
Acupuncture Relief Project also completed the analysis of our Patient Reported Outcome Measures (PROM) data. This small research study provided demographic data and some key insights into the efficacy of our clinic and serves as a definitive piece of evidence supporting our clinical model. Read more... Download our Annual Report and Financial Statements click here.
Compendium of Clinical Case Studies: Volume One
Case studies provide a way for us to capture and share a small piece of our overall clinical experience. These case studies help us analyze the efficacy of our clinic efforts and contribute to a body of evidence that supports our overall project model. We share them here to provide our community some insight into our work in advancing our medicine both at home and abroad.
If you have any questions about our financial report, case studies or would like to find out how you can help, please contact me at This email address is being protected from spambots. You need JavaScript enabled to view it.
Acupuncture Relief Project takes on its most challenging clinic project in the remote region of Kogate Nepal. Project Director Andrew Schlabach outlines the clinic's vision and obstacles.
In 2012, our Third World Medicine Immersion Program continued to attract passionate and qualified volunteer practitioners who provided over 10,000 patient visits at our clinic facilites in Nepal. These volunteers worked six days a week and participated in over 60 hours of continuing education focused on improving their skills in case evaluation, treatment planning and patient progression. At the completion of thier stay, each practitioner presented a case study for peer review. These case studies help us analyze the efficacy of our clinic efforts. For their participation in this course, our volunteer practitioners received 54 Professional Development Activity (PDA) credits from the National Certification Commission of Acupuncture and Oriental Medicine (NCCAOM).
Acupuncture Relief Project also completed the analysis of our Patient Reported Outcome Measures (PROM) data. This small research study provided demographic data and some key insights into the efficacy of our clinic and serves as a definitive piece of evidence supporting our clinical model.
In 2013, when Acupuncture Relief Project relocated its facilities to the Makawanpur region south of Kathmandu, it became evident that having an affiliated Nepali organization would be an essential component to the effective implementation of an integrative primary healthcare model in Nepal. Good Health Nepal, or Suswasthya Nepal, was created as a non-governmental organization to serve in partnership with Acupuncture Relief Project.
Good Health Nepal is lead by Mr. Tsering Tsangpo Sherpa. Mr. Sherpa has been working for ARP since 2010, first as a medical interpreter and then as an advisor to the board of directors for ARP and director of Good Health Nepal.
The NGO works to improve local village economies by training and employing a team of medical interpreters who serve alongside the clinical practitioners. Additionally, Good Health Nepal works closely with the Nepali government, District Health Office and Village Development Committees to secure clinic locations, promote cooperative relations and locate potential opportunities for the growth and evolution of healthcare in Nepal.
In 2013, Acupuncture Relief Project established a partnership with the Rural Health and Education Service Center (RHESC). This mutually beneficial partnership is providing the school with experienced guidance. ARP’s director, Andrew Schlabach, serves on the board of directors for RHESC. He is working to strengthen the curriculum with the hope of eventually creating a fully accredited Bachelor’s degree program. This partnership will provide ARP with the Nepali-educated workforce to staff the integrative health clinics on a year-round basis.
There are three pillars that are critical to the establishment of a health profession in Nepal: cooperation from the Health Professionals Council, a school to offer adequate training and a Bachelor’s program to offer the corresponding degree. ARP successfully petitioned the Health Professionals Council in an initial attempt to pave the way to professional licensure for acupuncture in Nepal. In 2013, RHESC, located in Kathmandu, became Nepal’s first acupuncture university. The current program offered is at a certificate-level and is accredited by the Vocational Education Department.
The clinics in Bhimphedi and Bajra Barahi host student interns from RHESC who are in their final year of school. During the upcoming year, ARP plans to host four graduates who will begin their three-year residency, the completion of which will qualify them to work at one of ARP’s clinics.
It is our hope that RHESC graduates will choose to work in ARP’s clinics year-round, as well as in other remote villages in need of properly trained, integrative healthcare practitioners.
Acupuncture Relief Project takes on its most challenging clinic project in the remote region of Kogate, Nepal. Project Director Andrew Schlabach outlines the clinic's vision and obstacles.
In 2013, Acupuncture Relief Project undertook a new clinic pilot project in the Kogate (Ko•Got•Tay) region of Nepal. This clinic was located about four hours south of Nepal’s capital of Kathmandu in a region of unknown population (approximately 40,000). The Kogate clinic provided an inexpensive basic healthcare solution to the people of the region.
This clinic provided the only healthcare available in the region. Our volunteers transformed these few basic buildings into a primary care clinic and trained a handful of local people to be language interpreters and medical assistants.
This two-year pilot taught us much about what it takes to live and work in remote areas. It also served to solidify our relationship with the District Health Authorities in Makawanpur, the district in which lies Kogate. In 2015, the District Health Office asked us to relocate our clinic operations to the municipality of Bajra Barahi. While we are happy to be working in this new region, we will miss our friends in this quiet mountain village.
The town of Bajrabarahi is located about three hours southwest of Kathmandu. In early 2015, Acupuncture Relief Project was offered a small abandoned building (above) and was asked by the District Health Office in Makawanpur to join them in a joint clinic venture to create Nepal's first integrated health model for rural areas.
The Gorkha earthquake in March of 2015 severely damaged this building, requiring us to spend much of the summer renovating and rebuilding, as well as adding a second floor. The first floor of the building serves as the clinic, while the second floor offers dormitory-style housing to our practitioners. We were able to open the clinic to patients in November 2015 (below). This clinic serves a catchment area of over 100,000 people and stands beside the government health post.
We have begun our journey to reform the delivery of primary care in this region through cooperation and education of local people and healthcare workers. This facility also serves as a training facility for students studying acupuncture and rural health at the Rural Health Education and Service Center (RHESC) in Kathmandu. Our goal is to have year-round operation at this facility by Nepali-born practitioners by the year 2020.
In 2013, at the same time as the Kogate pilot project began, ARP opened a satellite clinic in Bhimphedi, a small village located three hours south of Kathmandu between Kathmandu and the city of Hetauda. The Village Development Committee offered us the use of a small community building in the center of town to be used as our clinic.
This clinic, still in operation today, is located in the same district as the Kogate clinic. Located about 3,000 feet lower in elevation than Kogate, the slightly drier, warmer climate allows us to provide treatments outside in the warming sunlight during the winter months. Many patients access our services from distant villages via local buses that arrive each morning. News of our ability to affectively treat post-stroke sequela has traveled throughout the region attracting patients from as far away as the Nepal-India border.
The clinic’s strategic location along a main road facilitates access from many rural areas, allowing us the opportunity to continue to serve the Makawanpur population of approximately 40,000. Since inception, Acupuncture Relief Project volunteers have provided over 25,000 primary care visits at this clinic.
Serving small remote villages by utilizing motorbikes and on foot, our volunteers are able to reach many patients who would be unable to come to our main clinic.
Acupuncture Relief Project focuses on on training local interpreters and medical practitioners. Our hope is to provide sustainable resources for the communities we serve.
No team is complete without our behind the scenes support. Here is a tribute to the Didi's (sisters) who take care of us everyday. We couldn't do what we do with out them.
Acupuncture Relief Project, Inc. is a volunteer-based, 501(c)3 non-profit organization (Tax ID: 26-3335265). Our mission is to provide free medical support to those effected by poverty, conflict or disaster as-well-as to provide meaningful experience to influence the development and personal growth of compassionate acupuncture practitioners. Thank you for your support.
Acupuncture as primary care in rural Nepal: a practice-based clinic overview survey study
Andrew Schlabach, Christa Caputa, John Gunnar Ramstedt, Kelli Jo Scott, Andrew Vu
Abstract: Acupuncture Relief Project (ARP) conducted a practitioner/patient survey of its operations at the Vajra Varahi Health Care Clinic in Chapagaon, Nepal and associated outreach health clinics between September 15, 2011 and March 1, 2012. The survey included the collection of demographic information and provides a clinic-wide overview of patient assessment, prognosis, and treatment outcomes.
Background: Acupuncture Relief Project (ARP) operates a primary care health care clinic in rural Nepal which was founded in 2008. Over the past four years, practitioners from ARP have conducted over 100,000 patient visits in the course of providing cost-effective health care and treatment in undeserved and impoverished communities. The goal of this project is to document clinic operations in order to help guide future research in Nepal as well as contribute to a growing body of evidence that uses acupuncture to deliver primary care in developing countries and rural environments.
Findings: Demographic and chief complaint data was consistent with care provided in Complementary Alternative Medicine (CAM) clinics as well as allopathic Primary Care clinics in the United States. Clinical outcomes were comparable with those reported by other CAM clinics.
Conclusions: The overview survey completed by the Acupuncture Relief Project in Nepal was successfully implemented. Not only was the demographic data gathered to better treat and address the most prevalent concerns of patients, but the implementing of the survey became a teaching tool for practitioners to shed their subjective data gathering and rely more on their objective data-gathering skills.
Nepal remains one of the poorest countries in the world and has been plagued with political unrest and economic instability for the past two decades. Acupuncture Relief Project (ARP) practices in Chapagaon, Nepal and villages in the surrounding area. Over the last four years ARP has provided over 100,000 treatments to patients living in rural villages outside of Kathmandu, Nepal. Their efforts include the treatment of patients living with HIV and AIDS as well as people suffering from extreme poverty and social disfranchisement. Common conditions include musculoskeletal pain, digestive pain, hypertension, diabetes, stroke rehabilitation, uterine prolapse, asthma, and recovery from tuberculosis treatment, typhoid fever, and surgery.
ARP conducted a survey in an effort to gain a “big picture” perspective of the clinic operations and assess who and what they are treating in order to guide further research and improve efficacy of treatments. This survey was conducted from September 15, 2011 through March 1, 2012. A Patient Reported Outcome Measure (PROM) enabled the clinic team to use a standard survey to collect their data created particularly for their population. Patient Reported Outcome Measures utilize patients’ perspectives on the progress of their wellness. The clinic researchers had three goals for the survey; to collect demographic data on the patients, to collect data regarding efficacy of treatments, and to create a common platform where practitioners and patients can communicate.
Out of 519 patients who answered the language question, only one spoke English and most patients are illiterate in their native language. Because of these specific limitations unique to the population that frequents the ARP clinics, it was determined that an oral survey utilizing a medical language interpreter would be the appropriate tool.
Appropriate assessment is also difficult in these clinics. When practitioners volunteer to serve in Nepal, they are operating in a foreign environment. They need an interpreter to communicate with their patients, and the cultural differences can create an enormous disconnect between practitioner and patient. ARP needed a tool to bridge those gaps in communication. Utilizing the survey actually encouraged practitioners to utilize more objective measures in their assessments and provide better prognosis information to their patients.
In addition, ARP hoped to show patterns in the length of time in which symptoms began to resolve.
There is no other research published regarding the chief complaints most often seen in rural Nepal clinics. Our findings may allow some generalization about the needs of these particular populations.
Methods
The overall purpose of this survey was to determine the types of cases that are being treated at the Acupuncture Relief Project’s clinic in Chapagaon, Nepal, as well as the efficacy of those treatments, and the local community’s perception of the treatments being received. Basic demographic information (age, sex, primary language, and how far the patients traveled to get to the clinic) was also gathered. The questions in this survey were written specifically for this investigation. ARP runs for five months each year. The survey was taken for that duration to give a snapshot of one annual cycle.
There were four similarly designed sections to the survey, one to be filled out at each the first, fifth, tenth, and twentieth treatments in the clinic. Their purpose was to rate the progression or decline of the initial chief complaint that brought them into the clinic. For each of the treatments after the first, there was a subjective section to be filled in with the patient’s assessment of their progress and an objective section to be filled out by the clinician based on their observation and assessment of the patient’s progress. A five point scale was used and the answer choices were as follows: has gotten worse despite the treatment, has not responded to the treatment, has responded somewhat to the treatment, has responded greatly to the treatment, and has been resolved. Clinicians were also asked to use a combination of subjective information collected from the patient and their objective observations to assess the percentage that the chief complaint had resolved since the survey initiation. Answer choices were: less than 10%, 10%, 25%, 50%, 75%, 90%, or 100%.
The second purpose of this survey was to train volunteers how to better evaluate and assess patient cases and see how it is different in this clinical environment (given language barriers, cultural perceptions, etc.) than it is in a typical Western setting. There were questions specifically designed to direct and teach the clinicians to estimate how long it may take for the patients to get better, or to see a change in the condition of the chief complaint. This part of the survey included two sections; 1) Assessment, with five possible answer choices being: significant improvement expected within five treatments, ten treatments, beyond ten treatments, significant improvement expected with allopathic care, or significant improvement not expected. 2) Plan, with response options being: patient to be treated at this clinic, patient to be treated at this clinic in support of allopathic care, patient to be examined and referred to allopathic care, patient examined but not treated.
During the fifth and tenth treatments the patient charts were reviewed to see if any Chinese herbs were prescribed or if any referrals to other practitioners were given. The surveyors were also asked to record any secondary complaints that had arisen for the patients and if there were any, they were also evaluated, as above, at subsequent appointments.
The survey was administered orally during the initial intake to the clinic by the practitioners who each received two hours of training to standardize the responses. Periodic reviews of the surveys were done to insure proper documentation. The clinicians were assisted by Nepali interpreters, who are integral to the running of this clinical setting. Each interpreter has received a minimum of forty hours of training in medical concepts and terminology. They each have one to four years of experience working in this clinic. The practitioners were volunteers and all held master’s degrees or the equivalent, depending on their country of origin, in acupuncture and Oriental Medicine. Their experience ranged from recent graduates to five years in clinical practice.
Five hundred thirty-four surveys were completed and the data was compiled and input by a research group of master’s students in their final year at Oregon College of Oriental Medicine. The quantifying software used was Fluid Surveys and Microsoft Excel. Fluid Surveys was the primary software used to input data and to gather information. Microsoft Excel was used to calculate the average number of days between the first treatment and their fifth, tenth, and twentieth treatments. Scatter graphs were also made using Excel to give a clear visualization of the data due to the extensive sample size. This survey was funded by Acupuncture Relief Project.
Demographic Findings
Approximately 542 surveys were completed during this five month period of time. Seventy percent, (378/542) of respondents were women and 30% (164/542) were men [Table 1]. Patient age was tallied and there was a wide range with all age groups represented. The most common age group was 46-55 years old at 22% (119/528) of those polled. Age 0-16 year olds made up 3% (16/528), 17-25 were 6% (36/528), 26-35 year olds represented 13% (73/528), 36-45 year olds were 19% (36/528), 56-65 year olds 17% (94/528), 66-75, 12% (67/528) and the oldest group, those 76 and older, were also 3% (21/528) [Table 2].
Sixty-eight percent, (354/517) of the patients surveyed were new to this group of practitioners in the clinic and 32% (163/517) had been seen in the clinic at some point in the past [Table 3]. Of those returning, 64% (83/129) were seen less than 10 times, 20% (26/129) 11-20 times and 16% (20/129) were seen more than 20 times [Table 3a]. These final 16% are the more chronic disease cases probably requiring long term frequent care to maintain their current level of health. As a gauge of public opinion, the returning patients were also asked, “Has the treatment at this clinic been helpful?” Responses of those 157 patients polled who had been seen before in the clinic were as follows: the majority, 46%(73) found it helpful, 25% (40) found it very helpful, 20% (32) somewhat helpful, 4% (7) not helpful, and 3% (5) found it curative [Table 4].
In addition to the primary clinic in Chapagaon, there are several outreach clinics in outlying communities. The mountainous terrain of this region and its lack of roads present special transportation challenges for the more severe cases and the most debilitated patients. Traveling to the clinic in such conditions and back again can potentially negate the benefits of the treatment received. In these instances, team members will set up clinics out in the village schools or other public spaces or even on rare occasions, serve patients in their homes, typically traveling with an interpreter thirty to sixty minutes on a motor bike to the more remote areas of the region. Thirty-four percent, (183/536) of the surveyed patients surveyed were seen in these outreach clinics and 66% (353/536) were seen at the primary clinic in Chapagaon [Table 5]. Forty-nine percent, (249/506) of the patients arrived at the clinic on foot and 51% (257/506) used a vehicle, which in almost every case is public transportation [Table 6]. This public transportation includes overcrowded busses and small vans carrying 25+ people. It is not uncommon to see elderly people in need of care, outside on the top of a van or bus, having traveled long distances over rugged terrain to get to the clinic. This survey also included demographics for how long the patients traveled to get to each clinic. Thirty-nine percent, (200/518) took 0-15 minutes, 32%(168/518) took 15-60 minutes, 23% (120/518) took greater than one hour and 6% (30/518) took greater than 4 hours to travel one-way to this clinic [Table 7].
Most patients in Nepal speak more than one language, including in some cases English. But generally, they are most comfortable communicating in their local dialect whenever possible. The survey question was asked to patients as, “What language do you speak best?” [Table 8]. Findings were that out of the 519 responses to this question 75% (387) spoke Nepali, the national language, 12% (60) spoke Newari, the common local language of Chapagaon, 11% (58) used Tamang, a common language in villages outlying Chapagaon. There were 3% (13) who spoke other languages, including Gurung, Magar, Sherpa, Kirati, Tibetan, and 0% (1) spoke English.
Clinical Findings
Initial Exam Sixty-six percent (347) of the 524 patients that were surveyed at their initial visit presented with a musculoskeletal chief complaint [Table 9]. This included acute and chronic pain pathologies, joint dysfunction, deformities, and weakness. In this category, lumbar pain and knee pain made up 22% (112) of the total. Other categories included 6% (30) of patients reporting “other pain” pathologies including migraine headache, abdominal pain and eye pain. Five percent, (25) reported neurological disorders including peripheral neuropathy, tremors, and paralysis. Respiratory complaints made up 5% (25), usually presenting as asthma or COPD. Digestive disorders making of also made up 5% (25) included gastritis, diarrhea, GERD, and constipation. Patients also presented with infectious diseases 1% (7), reproductive complaints 2% (9) and other pathologies including scar adhesions, eczema, depression, carbuncles, hypertension, and diabetes.
Five Visits At the fifth visit, 97% (219/225) of patients had received 4 or more acupuncture treatments. Thirty-seven percent, (82/221) received Chinese herbal treatment and 22% (48/221) received other treatment modalities offered at the Vajra Varahi clinic including massage, Tibetan herbal medicine, homeopathy, moxibustion, tuina, or guasha. Seven percent, (16/223) of patients were referred to other clinics for adjunctive or primary allopathic care [Table 10].
Practitioners were trained to use a combination of patient-reported information obtained through their interview and objective measures in the patient chart to assess the patients’ progress. This information was reported in two ways. First, practitioners assessed how much of the overall chief complaint had been resolved [Table 11]. This assessment showed that of 218 respondents, 51% (112) showed 25-50% improvement of their chief complaint, 24% (52) showed greater than 75% improvement, and 25% (54) showed 10% or less response. Second, practitioners assessed how the patient’s response compared with the treatment plan [Table 12]. For example, a stroke patient showing 10% improvement at 5 treatments would indicate a good response whereas a patient with a minor muscular strain showing 10% improvement at 5 treatments would indicate a poor response. This assessment showed that of 218 respondents, 60% (131) showed some response and 30% (66) showed a better than expected response to treatment.
Also at the fifth visit, secondary complaints were recorded [Table 13]. Fifty-three percent, (78) of the 146 patients that reported were now concerned with a secondary musculoskeletal complaint. Ten percent, (15) reported other pain pathologies, 10% (14) respiratory complaints, 10% (15) digestive complaint (all of which were diagnosed as chronic gastritis) and 12% (17) had other complaints including hives, insomnia, fatigue and emotional imbalances.
Ten Visits At the tenth visit, 96% (76/79) of patients had received 8 or more acupuncture treatments. Fifty-eight percent, (45) received Chinese herbal treatment and 29% (21) received other treatment modalities offered at the clinic as listed previously. Sixteen percent, (12) of patients were referred to other clinics for adjunctive or primary allopathic care [Table 14].
Utilizing the same combination of subjective and objective measures as used in the 5th visit assessment, practitioners evaluated patient progress. The majority of patients saw dramatic improvement of their original chief complaint over the course of their treatment [Table 15]. This assessment showed that of 76 respondents, 55% (43) showed 50-75% improvement of their chief complaint, 16% (12) showed greater than 90% improvement and 28% (21) showed 25% or less improvement. Assessment of patient response compared with the expected response recorded in the treatment plan [Table 16] showed that of 77 respondents, 45% (35) showed some response and 52% (40) showed a better than expected response to treatment.
Number and Frequency of Patient Visits
Acupuncture Relief Project teams at the Vajra Varahi clinic serve approximately 70-90 patients per day and offer frequent follow-up treatments. During the survey period, 534 new patient visits were surveyed. Of these patients, 42% (226) continued care to fifth visits with the average number of days between initial intake and fifth visit being 26.3 days (treatment every 5.26 days). Fifteen percent, (79) of patients continued care to 10 visits with the average number of days between initial intake and 10th visit being 48.9 days (treatment every 4.89 days). Two percent, (11) of patients continued care to 20 visits with the average number of days between initial intake and 20th visit being 91.4 days (treatment every 4.57 days).
Discussion
The overarching goal of the research team was to gather baseline clinical data, inspire further questioning, and inform future research. As a starting point, the primary aim of our overview survey was to collect demographic data regarding patients, and to assess the efficacy of treatment. We were interested in answering a number of questions. One, how do the ARP clinical demographics compare to other primary care clinics? Two, what primary complaints being treated in ARP clinics are similar to other primary care clinics?
We found patient demographics in the ARP clinics to be consistent with acupuncture clinics in other settings. 70% of ARP’s patients are women vs. 30% men, and 66% of patients’ chief complaints were musculoskeletal. This is comparable to numerous studies conducted in the United States. For example, the data collection program at the Oregon College of Oriental Medicine (OCOM)1 surveyed 2,485 patients and reported that 70% of patients were women, and 57.6% of patients presented with musculoskeletal issues as their chief complaint. OCOM utilized both the Measuring Your Medical Outcomes Profile (MYMOP)2 and Patient Reported Outcome Measurement Information System (PROMIS)3 as data collection instruments in a Practice Based Research (PBR) style setting, which is similar to the design utilized by the ARP.
Chief complaints reported in the ARP clinics were also similar to those reported in US primary care clinics. In 2010, data were collected on 27,157 adults in a questionnaire done by the CDC utilizing the census bureau of the United States. Data showed that within three months of the survey, 17% of adults experienced a migraine or severe headache, 15% had experienced neck pain, 29% experienced low back pain, and 5% experienced face or jaw pain.4 According to the CDC, however, there was no conclusion as to treatments being sought, frequency of treatments, nor outcomes of treatments. “Overall, 20% of adults aged 18 years and over had not made an office visit to a doctor or other health professional in the past 12 months, 16% had 1 office visit, 26% had 2–3 visits, 25% had 4–9 visits, and 14% had 10 or more visits. Twenty-seven percent of men and 14% of women had no office visits to a doctor or other health professional in the past 12 months.” 4
In addition the CDC study reported musculoskeletal disorders, COPD, and digestive disorders as most prevalent. According to the CDC survey, of 229,505 adults, 118,972 had arthritic conditions or chronic joint issues. 20,974 had diabetes, and the third most prevalent disease was ulcers.4 This is not representative of treatments received or pursued, only prevalence of disease presentation.
New Data
An unexpected outcome of the research was how the implementation of the survey helped practitioners hone their diagnostic skills. Analog pain scales, or any pain scales, do not work in the environment in Nepal. Pain scales are culturally limited. ARP’s patients have no context for scales of pain. They either have pain or they have no pain. Because we cannot utilize a pain scale that is key to interpreting patients’ pain, practitioners in Nepal have to change the way they gather their intake data and assess a patient’s condition. Practitioners are taught to utilize mostly information the patients provide to assess pain and prognosis. Because of the language barriers and context differences, patients in Nepal can only tell practitioners what their pain feels like in general terms (mild, moderate, or severe). Practitioners have to, based on their own objective data, determine extents of pain and to what extent that pain is interfering with a patient’s life, independence, and well-being. The actual implementation of the survey made practitioners take that step. Because practitioners had to translate their patients’ experiences onto paper and in English, it forced practitioners to be more decisive with what they were seeing. It pushed them to do more orthopedic testing and be more specific when recording their palpation findings. Overall, it helped them diagnose with less reliance on subjective reporting.
With the survey in use, practitioners were able to more finitely assess where a patient was at the beginning and then assess progress throughout treatments. Often patients expect to regain fully what was lost and so the smaller steps of progress get lost. But when there are tangible, palpable changes, patients can see that they are making progress toward a goal. This keeps patients engaged in their own recovery as well as trusting in the medicine’s ability to help them achieve optimal health.
Bias
Does the fact that this survey was conducted verbally by the treating practitioners create a greater capacity for bias? Most certainly this must be considered for a couple of reasons: the patients may feel pressured to give a positive response in order to continue receiving care or to receive optimum care, and the practitioners may lean toward the most positive outcomes when interpretation of a vague answer is needed. However, given the conditions and Nepal setting (predominant illiteracy, multiple languages, etc.), it was determined that this was the only responsible and logistical way to conduct this survey. Several factors that potentially reduce any bias must also be considered. For example, the large sample size and the fact that multiple practitioners and interpreters conducted the surveys. With a stronger emphasis on objective clinical findings, standardizing orthopedic testing was required when determining percentage of improvement or lack thereof.
Further Research
In the future, the information gleaned from this survey may be used several ways. First of all, the practitioners, through the course of conducting this survey were enabled to successfully extract more specific data from the patient, both subjective and objective. This helped to better identify and quantify treatment progress and also lead clinicians through the process of formulating a treatment plan for each patient. This procedural part helped to facilitate discussions on how to evaluate pain and determine prognosis in this specific clinical setting. Because this was such a useful tool in the overall flow of the clinic, administrators are considering permanently implementing a similar process into the existing patient intake and follow-up protocol. Secondly, data from this survey will help the clinic plan for its supplies by identifying trends in patient care.
Information that may have been useful to obtain, after evaluating this study, are the details about the 16% of patients that were referred to other practitioners for further evaluation and/or care. It would be helpful to track these patients and if possible to find out A) whether or not they went to where they were referred, and B) whether or not they returned to the ARP clinic for treatment. This is a potential area of future investigation. Knowing these details would further aid in serving this population in ways that would maximize resources. Based on the findings of this study ARP plans a future investigation into the use of mineral supplements and Chinese herbs in the treatment of the common complaint of persistent abdominal pain (gastritis).
Table 1. Patient Gender
Table 2. Patient Age*
Table 3. Treatment History
Have you been seen at this clinic before?
Table 3a. Treatment History
How many times has the patient been seen at this clinic?
Table 4. Returning Patient Subjective Benefit of Treatment*
Has the treatment at this clinic been helpful?
Table 5. Clinic Facility
Table 6. Patient Transportation
How far did the patient travel to this clinic?
Table 7. Distance Traveled
How long did it take the patient to travel to the clinic?
Table 8. Spoken Languages*
What language does the patient speak best?
Table 9. Chief Complaint
As assessed on the 1st visit.
Table 10. Patient Care at 5 Visits
What care has the patient received at five visits?
Table 11. Subjective/Objective Improvement of Chief Compliant After 5 Visits
Table 12. Subjective/Objective Response of Chief Compliant After 5 Visits
Table 13. Secondary Complaint
As assessed at the 5th visit
Table 14. Patient Care at 10 Visits
What care has the patient received at five visits?
Table 15. Subjective/Objective Improvement of Chief Compliant After 10 Visits
Table 16. Subjective/Objective Response of Chief Compliant After 10 Visits
Table 17. Frequency of Treatment
Average number of days from initial intake to:
Conclusion The overview survey completed by the Acupuncture Relief Project was successfully implemented. Not only was the demographic data gathered to better treat and address the most prevalent concerns of patients; but the implementing of the survey became a teaching tool for practitioners to shed their subjective data gathering and rely more on their objective data gathering skills. This was perhaps a greater outcome than general demographic data. Since ARP began its visiting practitioner programs, there was a need to shift practitioners’ perspectives on information gathering for prognosis. Utilizing this survey gave practitioners the opportunity to determine patient baseline health and then progress achieved with ongoing treatments.
The data analysis will help ARP in documenting and legitimizing their clinic model. Low-cost, small-footprint facilities employing acupuncture as the primary treatment modality can deliver effective primary care in developing nations, rural environments, and underserved communities.
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2 Paterson C. Patient-centred outcome measurement. In Macpherson H. Hammerschlag R, Lewith G, Schnyer R. (eds) Acupuncture Research: Strategies for Establishing an Evidence Base. London. Churchill Livingstone, 2007.
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Staniszewska, S., Haywood, K. L., Brett, J., & Tutton, L. (2012). Patient and public involvement in patient reported outcome measures: Evolution not revolution. Adis Online, 5(2), 79-87. doi: 1178-1653/12/0002-0079.
It's pouring down rain outside. The other practitioners and I have just returned from what should have been a 30 minute taxi ride but which turned into a 90 minute escapade through the streets of Kathmandu. I myself am relieved to be back at the clinic and thankful that it is Saturday night, which means tomorrow is a half day. I definitely will be sleeping in! My roommate, Lindsey, and I have just completed a 3 week course with a local Tibetan healer on how to perform treatments with singing bowls. This has left me partially elated, and partially exhausted. It's been 3 weeks since I had a full day to myself.
Eagerly I change from my soaking wet jeans and layer on two pairs of fleece pants, a wool shirt, hat, gloves, and socks in preparation for bed, even though it's only 7pm. Do I really want to go to bed? I ask myself. It's hard to believe there are less than two weeks left of clinic which means I will be saying goodbye to all the clients I have grown to know, as well as all of the people whom I now consider a part of my team; the four other practitioners, six interpreters, the two housekeepers, Umila and Uma, and of course, Nicky the clinic director. I am definitely having one of those moments which can spark tears. I remind myself "I am strong, I won't cry. Not when I still have almost two weeks left to enjoy it all."
In the distance I can hear the other practitioners upstairs, decompressing from the day. Their voices are gently echoing through the halls, laughter interspersed between chatter. I smile. I know just what they are talking about...the taxi ride. As I inch on a second pair of socks to ensure my warmth I hear a loud drumming noise which perks me up, followed by a few trumpets, then more horns. "What is that?" I wonder. I get up and walk to my window. Low and behold there is a parade coming down the narrow street below. I open the window and poke my head out to see about 25 people dressed to the nines in bright colors...red, orange, blue and green...marching down the muddy road with instruments. At the tail end of this little party there is a grey car with marigold flowers streamed down the sides. Five people are crammed inside the vehicle and since it's dark outside I can't make out any faces of the people inside it. One thing I am sure of-it's a wedding party! "I wish I had better lighting!" I slide my body further out the window in hopes of gaining a better view of the details which doesn't improve my vision in the least. Flashing my head lamp down below like a spot light is one thought which passes through my mind but thankfully my common sense stops me and I continue to hang out the window in awe, muttering under my breath, "Woooow".
Heading upstairs to join the others suddenly sounds like a perfect idea so I add on one more layer, my black fleece jacket, and walk upstairs with a little bounce in my step. I head towards the door to the group room and see everyone sitting around the table with a tin cup in their hands. There is no electricity at this point in time so there are about five candles lit. I choose the kitchen door first and see a two liter Mountain Dew bottle which I immediately know is filled with Rakshi, a local made rice wine. I grab a tin coffee cup and pour myself a glass, well actually half a glass, this beverage is much stronger than it tastes I suddenly recall. I then walk into the main room and sit to join the conversation which has now changed to musicals. In the back of my mind all the events of the day are coming to the surface as well as this welling up of appreciation. I find myself randomly calling out, "I love you guys!” Everyone laughs. "Are you buzzed already?" They ask. "No I just am having one of those moments and I have to tell you all love you and I am going to miss you when I leave." Finally one of the other practitioners, Joey, smiles back and says, "I love you too Jazz. Cheers to us!" --- Jasmin Jones
35-year-old female presents with left-sided facial twitching and paralysis. After 7 acupuncture treatments, the patient regained over 50% of her facial functioning with 80% of the facial twitching resolved.
SUBJECTIVE
Patient presents with left-sided facial twitching and paralysis. There is painful twitching with frequent tearing of the left eye. The cheek and mouth also twitch, and feel as if “the face is twisted.” She has moderate pain (5/10) with smiling that interferes with sleep, concentration and in social situations, causing her not to want to interact with others. Nothing makes the pain worse. The quality of the pain is sharp. She reports that the twitching is activated when eating or performing other motions with the mouth. The throat is sore and the patient is having difficulty shouting. Patient reports waking with the condition 15 days prior. She has not received any other treatment or medication for this condition. She walks for about an hour to get to the clinic. There is no prior history of the condition. The patient states that on her side of the bed there is a window with a draft.
OBJECTIVE
Patient appears to be in good health for her age, cultural background and environment. She has a suppressed demeanor and it is difficult to maintain eye contact with her. She speaks very low and says few words when questioned.
There is no visible facial twitching. Upon cranial nerve exam, cranial nerve v, the trigeminal nerve, shows laxity in the masseter muscle. Cranial nerve vii, the facial nerve, shows difficulty in closing and keeping the left eye closed, pursing lips, baring teeth, flaring the nostril and expanding the cheeks with air while keeping the mouth closed. All sharp/dull sensory tests are negative. All tests are negative for any involvement of the right side of the face.
Pulses are thin and wiry. No visible deviation of the tongue or thick coat.
ASSESSMENT
DX: Facial paralysis (Bell’s palsy) Restricted or impaired control and functioning found in the cranial nerve exam shows motor impairment of the following muscles: orbicular oculi (closes eyelids), levator labii superioris alaeque nasir + alar part of nasalis (flair nostrils), buccinator + orbicularis oris (puff out cheeks with air while pursing lips), risorius plus levator labii superioris + depressor labii inferioris (bare teeth). Based on the cranial nerve exam, the facial nerve is predominantly affected, leading to the diagnosis of Bell’s palsy.
TCM DX: LR wind rising due to LR blood deficiency
PROGNOSIS: Because the patient is starting treatment in the acute stage, a full recovery is expected.
INITIAL PLAN
Treat with acupuncture 3-5 times per week for 10 treatments before reassessing. Focus on nourishing and building LR blood and eliminating LR wind. Use needles on the face to stimulate the multiple affected muscles. Internally, use Dang Gui San 1tsp TID to tonify blood.
Typical treatment: Bilateral: ST36, LI4, LI10, LR3, LR8, Yin Tong, GB20; Left: 1 needle threaded from the midline just below the lower lip up to the left corner of the mouth, TW17, SI19, LI19, LI20, GB1, ST3, ST4, ST5, ST6, ST7, CV24, Jia Cheng Jiang; All needles with strong stimulation
OUTCOME
After 6 treatments, the patient reported 1/3rd improvement in the condition. The facial twitching was reduced and no longer visible after needles were inserted. The left eye closed without any difficulty and there was no longer any tearing of the eye during treatment. The patient reported no longer having a sore throat or difficulty shouting. There was no longer any laxity in the masseter muscle. Cranial nerve testing still showed some difficulty smiling, baring teeth and puffing out cheeks with lips pursed. Visually, the patient could perform these tasks at least 50% better than during the first treatment. The patient was able to make eye contact and be much more engaged during treatment.
CONCLUSION
With continued care, it is possible that this patient can expect to see a complete recovery. Her condition has already responded favorably to acupuncture and herbal treatment. During the last visit, the patient was asked to start coming in for treatment every other day for 2 weeks to determine how much progress can be made during this time. She was also counseled to move her bed to an area of the house where there are fewer windows and no draft. In addition, her herbs will be increased to 2tsp of Dang Gui San TID.
31-year-old male presents with chronic abdominal pain. The patient has suffered from abdominal pain for the past 11 years, but has had a worsening of symptoms in the past year. Case analysis after 11 visits over 2 months.
SUBJECTIVE
Patient presents with pain in the epigastric, umbilical, hypogastric, lumbar and iliac regions. The patient describes the pain as burning and sharp in nature, worse after eating, and migratory in nature. Symptoms have occurred gradually over time (starting 11 years ago), but have increased in severity over the past year. The patient had an endoscopy 5 months ago. The results were negative. The patient states that he has trouble maintaining his weight (most likely due to malabsorption), and in the past has had diarrhea stools as often as 6-7 times per day. Currently, this patient is having 1-2 stools per day, which at times are small in amount and often feel as if they are incomplete (and also described as “goat- like stools”). He denies blood or a tarry appearance to the stool, but states that at times there is some visible mucous. He has abdominal cramping and sensations of nausea without vomiting, prior to bowel movements, that are relieved after defecation. The patient also states that he gets frontal and temporal headaches prior to bowel movements with relief after defecation. The patient describes a bitter taste in the mouth after meals. In the morning, the patient awakes to belching, foul breath, liquid in the mouth and a bitter taste. The patient describes the liquid as watery, slippery and light green to black in color. The patient has also described intermittent low-pitched ear ringing, as well as intermittent itching to the skin with a mild redness and rash. The patient states that all of his symptoms are worse with spicy and greasy foods. The patient feels warm overall. His primary emotion is frustration and anger. He has difficulty resolving conflicts with others and avoids challenging situations. The patient denies any significantly stressful life events during the time that his symptoms progressed over the past year. He has high-pitched tinnitus in both ears. The patient has a family history of an aunt who also had a similar condition with similar symptoms who died at the age of 40.
Typical diet: Dhal and rice, potato’s, minimal spicy foods, no alcohol
OBJECTIVE
The patient appears thin and somewhat malnourished and deficient. His cognition appears to be intact and his speech is age appropriate. He is visibly disturbed by his illness and there is a sense of desperation in his search for a solution. The sclera of his eyes have a red tint and he occasionally has watery and itchy eyes. He has a stye on the superior, left eyelid.
He is extremely reactive and tender to palpation particularly in the left upper and lower quadrants, as well as within the hypochondriac region on the right side just inferior to the 10th rib. The patient winces with pain upon palpation and needle insertion. Upon auscultation, hyperactive bowel tones can be heard in all 4 quadrants. The Liver and Gallbladder appear to be inflamed and exceptionally tender upon examination. The patient is referred to the health post for lab testing to rule out possible cholelithiasis and hepatitis. Labs drawn include bilirubin total and direct, AST, ALT and amylase. All results within normal range.
Pulse: Wiry/slippery and bounding superficially, deficient at the base
Tongue: Red, no coat (peeling particularly on the left side of the tongue), with red prickles to sides and tip.
ASSESSMENT
DX: Possible chronic parasitic infection, IBS, malabsorption syndrome, H. Pylori-Gastric Ulcer or Crohn’s disease
TCM DX: Acute: Damp-heat in the LR/GB overacting on deficient SP/ ST (with possible deficiency heat) Constitution: Spleen Qi deficiency leading to the accumulation of damp.
PROGNOSIS: Due to the length of time that this patient has had this condition, it is likely that this will take a significant amount of time for the gastrointestinal tract to heal.
INITIAL PLAN
Treat with acupuncture 2 times per week for 10 treatments and then reassess. Focus on points to tonify the Spleen, move stagnation, and eliminate dampness in the middle jiao. Internal herbal treatments include: Huang Lian Jie Du Tang, Gui Zhi Gan Jiang Tang, Stomach Formula, Er Chen Wan, Zi Sheng Wan and Intestinal Fungus Formula. Warm needle moxa on ST36. Dietary considerations, such as avoiding overly spicy foods, greasy foods and uncooked meat are discussed.
Typical treatment: ST36 (tonify qi and blood), SP6 (tonify qi and blood), ST25 (tonify intestinal function), SP15 (tonify intestinal function), CV6 (tonify SP/ST), CV3 (reduce damp-heat), CV12 (tonify yin organs and ST), LI 10 (tonify), PC6 (tonify SP/ST and reduce nausea), LR13 (reduce and harmonize the SP and LR), LR5 (reduce dampness and heat in the lower jiao), LR3->(angled towards)LR2 (reduce excess fire in the LR), LR14 (reduce excess in the Liver), GB24 (reduce excess in the Liver).
OUTCOME
After 11 treatments, the patient failed to experience significant improvement. Further diagnostic testing (including eosinophils, Hgb, Hct, stool evaluation) to evaluate for a possible chronic parasitic infection or gastrointestinal bleeding was ordered. All test results were negative. The patient was asked to bring in a sample of the black/greenish liquid that he has in his mouth in the morning in a sealed container for examination and objective data.
The patient progressed from 6-7 bowel movements per day to 1-2 per day. He became much less needle sensitive as the treatments progressed.
CONCLUSION AND REVISED PLAN
Further testing, consistency and continuity of care is necessary to properly evaluate this patient, create an appropriate treatment plan and a healing and trusting relationship. Test with herbs for at least 2-3 weeks, in addition to acupuncture 2-3 times per week for another 10 treatments before reassessing. Continue to provide encouragement and consider possible underlying emotions that may exacerbate the patient’s symptoms (when diagnostic testing has ruled out other possible causes).
Discontinue Intestinal Fungus Formula.
Initiate Gallbladder inflammation test: ¼ cup of olive oil by mouth; Monitor for changes in symptoms for the next 24 hours. If the test is positive, refer for ultrasound of Gallbladder.
Consider Jia Wei Xiao Yao Wan 10 pills BID for 2-3 weeks for both excess and deficiency symptomology. Emphasize importance of consistent herbal plan to measure herbal efficacy.
43-year-old female presents with a severe headache. 9 months ago, the patient contracted Typhoid fever. During the illness, she had a headache that covered her entire head and a mild fever for 5 days. She has had severe headaches ever since. Acupuncture is providing some relief from the headache, but she needs more consistent treatment. Case analysis after 7 visits over two months.
SUBJECTIVE
The patient presents with a headache located primarily in the temporal and vertex regions. Light and sound do not trigger the headache. She has sinus pressure that contributes to the pain. Her sense of smell is inhibited by the sinus congestion. She presents with occipital neck pain further aggravating the headache. Her hands and feet are cold and sweaty during the day. She sweats profusely when the pain is severe and at night. Her digestion is normal. Menstruation is regular with 4 days of bleeding, 2 of which are heavy.
Medications: PRAN 10 (Propanolol HCL) - a beta blocker used for hypertension, anxiety and panic; Depthyline 25 (Amitriptyline Hydrochloride) - a tri-cyclic antidepressant; Paracetamol 500 mg (Acetaminophen/Tylenol); Anims - pain reliever
OBJECTIVE
Patient appears to be in good health for age and environment.
Tongue is dusky and red. Pulse is deep, thin and rapid.
Blood pressure: 135/109;Heart rate: 110; Follow-up BP measurements: 128/82 and 128/98
The occipital and frontal sinuses are tender upon palpation.
An imaging study CT/MRI was done within the last 6 months and showed no abnormalities in her brain.
Assessment
DX: Headache from the sequela of Typhoid fever, sinus blockage, occipital neck pain
TCM DX: Blood stagnation in GB/LV channels, blood deficiency due to the febrile disease, phlegm in the LI and BL channels, qi and blood stagnation in the BL channels
PROGNOSIS: This is difficult to treat due to the fact that the patient lives 2 hours away and is not able to come for consistent treatments. If she is able to come for more regular treatments, the prognosis will be better.
Initial Plan
Treat 3 times per week for 10 treatments before reassessing. Focus on building and moving the blood in the channels, clearing the blockage in the sinuses and moving blood and qi in the occipital region. Five day course of Xue Fu Zhu Yu Tang to help move the blood and stop the pain.
The patient came to the clinic 7 times. She came in 2 sets of treatments. 1 was 3 treatments every other day and the next set was 4 treatments in a row. The treatment sets were 3 weeks apart. She noticed after the first set of treatments that her hands warmed-up and she stopped sweating at night. Her headache was better and she had less sinus congestion and pain. The second set of treatments yielded a reduction in pain and an increased sensation in her hands and wrist.
The severity of her headache decreased by 50% during the treatment plan, showing that she responds well to acupuncture. She was advised to increase the frequency of treatments. However, because she lives far away, she is not able to come as often as would be necessary to significantly affect the pain level.
Conclusion
This case is incomplete and more information is needed on several topics. The frequency of the headaches is not understood or charted. Which medications are being used is not clearly understood and were charted on 2 separate days indicating that I may not have all the information. The treatment that she received for the Typhoid fever is not known, nor do we know what her other symptoms were from the Typhoid fever. The course of Typhoid fever can include a dormant period of the pathogen. Therefore, if treatment was not given, she may be a carrier, and the bacteria may present itself at a later date. More information is also needed for a clear TCM diagnosis. Are there other LV/GB signs? Are there true heat signs?
After analysis, it is clear that acupuncture treatment had good results, despite the lack of a full diagnostic work-up. However, a more comprehensive exam is necessary to further progress this case further. The herbal treatments may have been too short-term to properly evaluate its therapeutic benefit.
65-year-old female presents with dyspnea and continuous cough. The patient also presents with chronic, severe pain and inflammation of all joints of the hands and feet. With 9 acupuncture treatments and the use of Chinese herbs, the patient experienced a 6% O2 increase, more than a 50% reduction of pain and a 90% improvement in range-of-motion in her hands.
SUBJECTIVE
65-year-old female patient presents with chronic dyspnea and continuous cough. The difficult breathing started 4-5 years ago and has become progressively worse. The patient does not live in a high traffic area, but has used an indoor fire to cook for most of her life. She now uses gas. The difficulty she experiences breathing is continuously present with no history of asthma attacks and no history of fever and chills. The patient does not report chest tightness or coughing at night. The dyspnea lessens with rest. Occasionally, cough is accompanied by small amounts of white or red phlegm. The dyspnea is the same with inhalation as with expiration. She reports not being able to walk from the microbus to the clinic (about 150 feet) without severe wheezing. It is hard to take a deep breath and she sometimes feels like she is unable to take in enough air. She also reports waking from difficulty breathing. The condition worsens in the winter, in the afternoon, and when walking or lifting. The patient has a family history of breathing difficulty including both her mother and sister who have had medical intervention concerning their conditions. The patient feels cold and gets common colds easily. She has spontaneous sweating.
The patient reports bilateral pain, inflammation and stiffness of all of the joints of the fingers and the feet including the ankles. The pain started 4 years ago while she was still working in the fields and has since gotten worse. Warmth helps the pain and movement makes it worse. The pain is burning, tingling and “unbearable.” There is no accompanying fever. The patient reports good energy and appetite. The pain is severe, worse in the afternoon, and interferes with walking and sitting. She has no family history of pain and inflammation in the joints.
The patient experiences pain in the shoulders and knees and a heavy, dull ache in the low back. The patient no longer does field work and does very little activity. No other medical treatment has been administered for these conditions.
Objective
The patient has difficulty talking due to breathlessness and audible wheezing. When she moves, the wheezing increases. She has a weak and raspy voice with the occasional weak cough. She appears to be in average health for her age and environment. A strong wheeze can be heard through auscultation of her lungs. The first measurement on the oximeter is recorded at 91% O2. The patient is in moderate pain, indicated by her ability to smile, laugh and respond to questions. However, walking and sitting are difficult. All joints of the patient’s hands are swollen to 40% larger than normal and her feet and ankles are swollen to 30% larger. Both the hands and feet are hot to touch. No bone deformities are present. The patient has an 80% reduction in the active range-of-motion of all her finger joints and is unable to make a fist. She has a 30% reduction in the active range-of-motion of all the joints of her feet. The passive rangeof-motion of her joints was not tested.
Pulses are deep, weak and soggy. Her tongue is pale and swollen.
Assessment
DX: COPD and osteoarthritis (pronounced in the joints of the hands, feet, knees and shoulder)
TCM DX: Lung and Kidney qi deficiency with wind-cold-damp bi syndrome in the joints
PROGNOSIS: Using acupuncture and herbal treatment, improvement is expected within 10 treatments. However, due to the severity of the pain, inflammation and breathing difficulty, more significant outcomes are expected over a longer course of treatment.
Initial Plan
Treat with acupuncture 3 times per week for 10 treatments before reassessing.
Focus on reducing swelling and inflammation (cold-damp bi) first. As swelling is reduced, add treatments to tonify the Lung (wei qi) and Kidney qi.
Typical points: LU1, REN17, LU9, KD3, SP6, LU5, ST36, LI4, UB 3, UB23, as well as local points at sites of swelling and pain
Du Huo Jie Xie Wan (8 TID) for first 2 weeks to reduce swelling and inflammation of the joints; Then switch to Ding Chuan Wan (8 TID) to tonify the Lung and Kidney qi
B complex vitamin with 100mg B1, 100mg B5 and 100mg B6 to assist with wound healing and as anti-inflammatory agent
Counsel the patient about proper ventilation of home if ever cooking with a wood fire and wearing a mask when in polluted or high traffic areas.
Outcome
After 9 treatments the patient reported major changes in her breathing, pain and inflammation. The patient’s voice was stronger with less audible wheezing and she could take a deep breath. She no longer had times when she felt like she couldn’t take in enough air. She wasn’t waking wheezing and she could walk from the microbus to the clinic with a very small amount of wheezing. The patient continued to have a regular cough, however it decreased from being continuous to 2-3 times per day. When phlegm was present it was only white. The pulse oximeter generally read between 95-97% O2 and only occasionally read 92- 93% O2.
The swelling in the patient’s hands completely resolved with only minor swelling of the lateral ankles. The hands were no longer hot to touch and the patient reported no feelings of heat in the joints. The pain decreased over 50%. The patient had full active and passive range-of-motion in her feet and had a 90% increase in the active range-of-motion in her hands. She was able to walk and sit without severe pain and make a complete fist.
Continued Treatment
This patient needs continuous, intensive acupuncture and herbal treatment for her lungs and arthritis. Continued monitoring of oxygens saturation rates, lung auscultation and a chest x-ray are objective measures of her progress that would be beneficial. The patient has responded positively to treatment thus far and further improvement is expected.
Conclusion
The effectiveness of acupuncture and herbal medicine for both COPD and arthritic pathologies is clearly outlined here. The importance of regular treatment and the use of objective measures to quantify progress is essential.
70-year-old male referred for massage treatments for pain associated with spondylosis of the spine and neuropathy. The patient is simultaneously receiving ongoing acupuncture treatments. At the time of the referral, he had completed 18 acupuncture treatments. The main objective, through the combination of massage and acupuncture, is to manage pain, increasing the patient’s quality of life.
SUBJECTIVE
Patient’s chief complaint is of severe pain in the low back and right shoulder. The patient defines severe pain as discomfort that inhibits or prohibits his daily activities, such as walking without help from others. He experiences “tingling” sensations in both hands that radiate posteriorly down both legs to the feet, originating at the lumbar region of the back. The frequency of the overall pain is constant and increases with activity (walking and getting up from bed), but the radiating sensation is intermittent and unpredictable. The onset of the radiating sensation may correlate to the severe levels of pain in the lumbar region of the spine. The intensity of the pain fluctuates daily between severe and mild depending on the amount of activity in which he engages and the treatments he receives. He defines mild pain as a discomfort he recognizes on a daily basis, but doesn’t interfere with or prohibit his daily activities. Direct sun exposure alleviates the pain. He reports that the pain interferes with sleep when at a moderate level. The patient defines moderate pain as a discomfort that is constant, distracting and interferes with his daily activities (ie. walking), but doesn’t require help from others. The onset of the pain is unknown, but increased after being hit by a car 1 year ago. Pain increases with cold temperatures and with coughing episodes. Patient states that surgery has been recommended, but he is unable to afford it. He expresses his fear of becoming paralyzed from spinal surgery. He experiences depression and at times wishes he were dead because he feels like he can no longer provide for his wife and be useful to his family. He feels stressed and emotional most of the time, especially when his pain levels increase and his ability to be useful to his family decreases. Although he has never received a professional massage treatment before, he uses self-massage with Tiger Balm daily for temporary relief of shoulder and low back pain.
Objective
Visual observations while at the clinic, indicating pain and stress, include the following: Walking slowly with assistance from his wife and a walking stick Facial expressions associated with pain when walking; Attempting to sit or stand by himself or removing clothing in preparation for a treatment Tone and speed of voice increases with movements that cause pain Tears when answering questions about his pain and his perception of how his condition affects his wife and family Muscle spasms on the bilateral wrist flexors, including flexor carpi radialis, flexor carpi ulnaris, palmaris longus, flexor digitorum superficialis and flexor digitorum profundus as well as triceps brachii when lying in the prone position on the table
Postural analysis findings: Bilateral medial rotation of the shoulders; Mild Right shoulder elevated; Mild Posterior tilt of the pelvis; Mild Genu Varum; Mod
Palpation: Hypertonicity of the erector spinae group, gluteal region and hamstrings Palpatory tenderness on the right supraspinatus, infraspinatus, rhomboid major, minor, biceps tendon, teres minor and major and the anterior, middle and posterior fibers of the deltoid Palpatory tenderness with increased pain on origins of bilateral quadratus lumborum, gluteus maximus, gluteus medius and gluteus minimus
AROM: Lateral flexion, rotation, flexion and extension of the head and neck ( cervical spine) are all within normal limits with minimal discomfort. Extension and flexion of the cervical, thoracic and lumbar spine are within normal limits. Moderate pain occurs with flexion of the spine beginning with contraction of the action. Rotation and lateral flexion of the spine are all within normal limits with no pain indicated. Abduction, adduction, flexion and extension of the arms are below normal limits with pain increasing with extension and abduction. Increased pain at the biceps tendon on right shoulder with flexion of the right elbow.
Plan
Continue Traditional Chinese Medicine treatments 2-3 times per week as recommended by acupuncturist. Massage treatments ( approx. 30-40 min. each) at least 2 times per week for 5 weeks to increase relaxation, stress reduction, and decrease overall tension and pressure of the muscles of the posterior spine, shoulders, pelvis and legs. These muscles include, bilaterally, the erector spinae group, supraspinatus, infraspinatus, rhomboid major, rhomboid minor, biceps tendon, biceps brachii, teres minor, teres major, deltoid, quadratus lumborum, gluteus maximus, gluteus medius, gluteus minumis, piriformis, biceps femoris, semitendinosus, semimembranosus, gastrocnemius, peroneus longus and peroneus brevis. Massage treatments include the following techniques and purposes for the muscle groups affiliated, bilaterally, with the posterior spine, posterior shoulders, posterior pelvis, posterior thigh and lower leg:
Effleurage: To relax the muscles, stimulate the peripheral nerves, increase lymph and blood flow, remove waste products and begin to stretch the muscle tissues
Pettrisage: To increase mobility between tissues, stretch the muscle fibers, increase venous and lymphatic return, relax the muscles and aid in waste product removal
Compression: Hypertonic muscles soften and lengthen. Muscles are flushed and interstitial stasis is reduced. Released histamines dilate capillaries, increasing cellular nutrition. Muscles fire faster with increased amounts of acetylcholine. Muscle lesions heal faster with increased collagen production. Stretching muscle fibers increases capillerization. Fascia is rejuvenated and enlivened. Range-of-motion and freedom of movement increase. Myofascial pain and secondary autonomic phenomena caused by trigger points are usually eliminated.
Hot/warm hydro therapy: Use of the warm singing bowl technique, warm compress with vapor wrap and prossage soft tissue lotion
Heat therapy dilates the blood vessels of the muscles surrounding the lumbar spine. This process increases the flow of oxygen and nutrients to the muscles, helping to heal the damaged tissue.
Heat stimulates the sensory receptors in the skin, which means that by applying heat to the lower back, pain signals transmitted to the brain will decrease, partially relieving discomfort.
Heat application facilitates stretching the soft tissues around the spine, including muscles, connective tissue and adhesions. Consequently, with heat therapy, there will be a decrease in stiffness while improving flexibility and creating an overall feeling of increased comfort.
Vibration: Used to help sedate the patient’s nervous system and aid in general, overall relaxation. Singing bowl vibration on the quadratus lumborum and plantar surfaces of the feet and sacrum
Homework for patient: Stretches for flexion of the spine twice daily, morning and bedtime Hot water bag each night before sleep Continue to use Tiger Balm oil and self-massage, as needed, for pain relief. Increase water intake by 1 liter. Rest as much as possible
Outcome:
After a total of 10 massage treatments, the patient reported a 15% decrease in overall pain. Patient stated that he consistently experienced a 50-75% reduction of pain symptoms during the first 48 hours after a massage treatment before symptoms gradually returned. Pain increased to severe levels with activity upon the onset of its return after the initial 48 hours. The patient appeared more relaxed when receiving treatment and when in the treatment room. His range-of-motion was the same, but with less pain. He was able to walk by himself without his wife’s help. He could sit, stand, remove his clothing and upright himself from a prone position on the massage table without assistance. Tenderness and pain with palpation and touch decreased. He presented with less physiological mannerisms associated with pain. He smiled for the first time during treatment 9. Muscle spasms occurring during the treatments decreased moderately. Hypertonicty of the erector spinae group decreased minimally.
Conclusion
This patient completed a total of 40 acupuncture and massage therapy treatments over a 3 month period. During this time, he received pain relief, even if only for brief periods after the treatments. Consistently, within 48 hours of each treatment, the patient’s pain would return to severe levels, interfering with his daily activities, thereby decreasing his quality of life. Based on the patients age, severity of the physical condition, emotional health and socio-economic status, it is my opinion that the short-term focus of care should consist of encouragement for improved emotional health to promote a better quality of life. Long-term care for pain with acupuncture and massage is appropriate to provide pain relief, provide hope and contribute to his overall quality of life. With continued treatment, I believe that the patient would benefit from care focused on education of his condition, including the objective and subjective observations, providing pain relief and recommending resources that can support a better quality of life.
70-year-old male presents with severe cervical and lumbar pain, neuropathy of the arms, hands, legs and feet, incontinence of bowels and anal rash. His doctor has advised surgery. After 8 treatments he is able to sustain 40 -50% relief of pain for 4 days.
SUBJECTIVE
Patient presents with severe lumbar and cervical pain, reporting bilateral heaviness, weakness and tingling sensations in his arms and legs. He reports that the neuropathy is worse in his left arm, but is present in all 10 of his fingers, and brought on by cold water and cold temperatures. The tingling in his right leg is worse than in his left leg. Patient also has incontinence of bowels, occuring 4 to 5 times per day. Bowel movements are urgent, formed and easy to pass, but there is pain due to a rash around his anus. He reports feeling hot inside his body, especially at night. His doctor has advised surgery, but he is hopeful that acupuncture might reduce his pain enough to avoid surgery.
The onset of neck pain was 4 to 5 years ago, and the onset of back pain was 8 to 9 years ago. Patient relates his pain to a history of heavy labor, working as a field digger and brick carrier. For years he carried more than 60 kg on his back, but now he is unable to lift 200 g of weight. The pain came on gradually, but has become severe in the last year.
The limb neuropathy began 14 months ago after being hit from behind by a bus. He landed on his right medial knee, upper thigh, chin, nose, forehead and right anterior shoulder. There were no broken bones, but an MRI which was ordered on 4/13/11 revealed nerve damage. After the accident, he was unable to grasp food properly, count money or hold a glass.
The neuropathy radiates from the neck, down the right arm and into both hands. Patient reports heaviness, weakness and tingling in all fingers, but denies pain in the limbs. He can feel warm and cold, but he reports subjective numbness in both hands.
Patient reports no change in pain or neuropathy with time of day, but cold weather makes it worse and heat makes it better.
The neck and back pain are severe, and the symptoms are constant.
In the right leg, patient reports a cold, tingling sensation from sole to knee, which is most intense between the lateral ankle at GB40 and the lateral leg at GB34.
OBJECTIVE
Patient appears to be in relatively good health, but severely challenged by the pain in his neck and low back. He is unable to perform AROM and orthopedic tests due to the severity of his pain. He is unable to walk without support from his wife, and exhibits severe pain when standing up or beginning to walk. He also has difficulty balancing when standing up, almost falling over.
Sharp/dull test on the fingertips, arms and toes show no objective numbness. DTRs on bicep, triceps, brachioradialis, patella, hamstring and Achilles are normal. Grip strength is 50% weaker in left hand than right. Nail bed blanching shows normal circulation in both hands and feet.
Cervical AROM shows full range-of-motion with flexion and lateral flexion, extension and rotation, but with report of severe pain with motion. Cervical compression test increases neck pain and heaviness in arms. Cervical distraction test brings relief to neck pain and heaviness in arms. Upon palpation, there is severe pain and tenderness at left C2-C4 and right and left C6 and C7.
Lumbar flexion AROM is 80 degrees (normal 90) with pain on motion. Extension is 15 degrees (normal 30) with pain on motion. Lateral flexion is 20 degrees (normal 30) with pain. Rotation shows 25 degrees (normal 30) with pain on motion.
There is no radiation of pain with exams.
The muscles along the neck and back present with severe rigidity upon palpation. It is difficult to insert a needle without bending due to tenseness of erector spinae musculature.
Tongue: purple-red body, thin bright pink tip, slightly deviated to the right, transverse cracks and purple sublingual veins.
Patient records include:
April 13, 2011: CERVICAL MRI:
Cervical spondylosis of C4–C7 Bulge of disk posterocentral at C3–C4 C4–C5 (posterocentral protrusion of disk); narrowing of bilateral neural foramina with possible impingement of bilateral existing nerve roots Diffuse bulge of disk with left posterocentral protrusion at C6–C7 with indentation of thecal sac and cord – possible impingement of existing nerve roots Slight increased signal intensity in the cord at C5-C6 level with myelopathy
LUMBAR MRI:
Lumbar spondylosis Right-sided spondylosis at L4 – minimal anterolisthesis of L4 over L5 Mild bilateral posterolateral bulge of the disk at L1–2, L2-3, L3-4 with mild narrowing of bilateral lateral canals L4–L5 disk bulge/posterocentral protrusion – stenosis of bilateral lateral canal and neural foramina Bulge of disk with annular tear and posterocentral protrusion at L5–S1 with mild compromise to central and lateral canal – no nerve root impingement T2 sagittal image of dorsal spine shows minimal posterocentral bulge of the disk at T8–9, denting the thecal sac
ASSESSMENT
DX: Cervical spondylosis of C4-7, with nerve impingement at C5-7 and disk bulges at C4-7; Lumbar spondylosis, with right-sided spondylosis at L4, and disk bulges at L1–5
TCM DX: Bone bi syndrome; qi and blood stagnation of Bladder channel and Governing Vessel at cervical and lumbar regions due to and compounded by history of overwork and trauma; Underlying Kidney yin deficiency creating a malnourishment and deformity of bone, leading to qi and blood stagnation transforming into qi and blood deficiency; Qi deficiency and stagnation in the channels leading to neuropathy in the hands and feet
PROGNOSIS: Due to the physical deformity of the cervical and lumbar spine, complete recovery is unlikely. With continued acupuncture treatment in conjunction with stretching, traction, massage, electrostimulation and cupping, a decrease in pain and neuropathy is likely. The aim is to avoid or delay surgery for as long as possible with consistent acupuncture and conjunctive therapies.
INITIAL PLAN
Patient is treated at the clinic 3 to 4 times per week for 1 month, after which treatment progress will be assessed. Focus on Hua Tou Jia Ji (HTJJ) points in the cervical and lumbar regions to stimulate qi and blood circulation in local areas of degradation, disk bulging and pain. Teach patient stretching and exercises to reduce pain. Nourish Kidney yin, tonify qi and blood, move qi and blood.
Typical treatment: Acupuncture: HTJJ points needled deep at C4-7; HTJJ points at L1-5 needled wide and deep and angled medially, with bilateral electro-stimulation at 5 continuous frequency for 30 minutes; Electro-stimulation from S2 to DU2 bilaterally at 5 continuous frequency for 30 minutes; BL40, KI7, LR3
Cupping: Bilaterally along Bladder channel from cervical to lumbar region x 10
Massage: Tiger Balm or Bai Jie Balm applied with massage and pressure point therapy to neck, shoulders and low back
Traction: Neck and arms with a focus on neck for 10 - 15 minutes and arms for 2 minutes
OUTCOME
After 8 treatments, the patient reported 40 – 50 % improvement that lasted for 4 days after treatment. He also reported less pain with bowel movements due to the disappearance of the anal rash, as well as a 50% increase in his bowel control. He reported being able to walk for an hour and a half without trouble, and appeared to be able to sit, stand and walk without the distress that he exhibited in his first several visits to the clinic. Upon palpation, his musculature was also much less rigid than before.
CONCLUSION
This patient presented with a difficult case due to severe pain, the pressure of impending surgery and no significant change until treatment 7. This case teaches the importance of having the patience to adhere to the treatment plan. The strategy is now revised to a longterm plan of 3 visits per week for 6 months, after which the need for surgery will be reassessed.
With continued treatment over the next 6 months, the intention is to manage pain, regain balance and agility, reduce the neuropathy and regain bowel continence. Future treatment should be focused on acupuncture with conjunctive therapies: electro-stimulation, cupping, traction, stretching and massage.
10-year-old female presents with active phase of Juvenile Rheumatoid Arthritis (JRA) as demonstrated by multiple articular bony joint deformities, severely limited range-of-motion in all affected joints, and a history of recurrent episodes of alternating fever, chills and profuse sweating, immediately preceding joint inflammation and swelling. Within the course of 9 acupuncture and moxibustion treatments plus Chinese herbal and vitamin supplementation, the patient noted cessation of recurrent episodes of fever, chills and sweating, decreased heat sensation in joints with active inflammation, and temporary decreases in pain while walking.
SUBJECTIVE (as reported by patient’s father)
The patient was evaluated by allopathic medical physicians at a Kathmandu hospital at least 2 years prior to her first visit to VVHC. Blood tests and x-rays (not available for review) indicated rheumatoid arthritis. She was prescribed multiple medications, which she took for 2 weeks. Medications included injections she was advised to receive weekly for 4 weeks. She had 2 injections, which “had no effect.” All medications were too expensive to continue. The patient’s father refuses to involve allopathic medicine in the current management of the patient’s disease, but agreed to update blood tests (CBC, ESR).
Patient presents with hot, swollen ankles and knees, making it too difficult for her to attend school.
O – 6 years ago with 3-4 days of tidal fever, cough and “cold”
F – Fevers come every week to 3-4 months and last about 4 days. They are preceded by a sensation of inflamed tonsils and are followed by joint swelling and a sensation of heat in the affected joints, which are warm to touch, but with or without redness and pain.
Q – Affected joints vary with each episode, but are typically bilateral. Without fever, most joints feel cold and stiff inside.
P – Cold weather and prolonged immobility, such as bus rides, seem to worsen her overall joint stiffness. Swelling increases with mobile activities, such as walking. Wearing warm stockings helps reduce stiffness.
S – Patient reports significant difficulty with ambulation due to both restricted ROM and occasionally severe pain.
T – The duration of active, inflammatory phases is unclear, but seems variable.
Objective
Patient’s affect is flat and timid, with infrequent eye contact. She does not speak and looks to her father for answers to physician questions. She nods occasionally. She ambulates slowly with rigid, erect posture, arms extended and inanimate at side, with somewhat of a shuffle and notably reduced knee and foot flexion.
Her tongue is purple red with a crimson tip and thin white coat at back. She has erythematous sublingual sores (ulcers). Her pulses are thin and rapid.
She displays no observable expressions of pain during palpation of affected joints, but quietly gasps and retracts (i.e. guards) her limbs with attempts to move a joint beyond its passive ROM.
Elbows: Lateral epicondyles are enlarged, rounded (2X normal), bony-hard, cool, without erythema or edema and non-tender; Limited extension to ~145 degrees
Wrists: Mildly enlarged (<2X), bony landmarks obscured to palpation, non-tender; No active or passive extension; Active/passive flexion ~ 20 degrees; Inversion/eversion <10 degrees with mild crepitus of right wrist
Hands/Fingers: Mild bony enlargement of proximal and medial interphalangeal joints bilaterally, cool; Patient unable to flex fingers into fist
Ankles: Swollen, red, hot
Knees: Soft swelling over medial and lateral femoral and tibial condyles (3X normal)
Weight: 22kgOral temperatures (in sequence of visits): 94.4, 97.1, 95.5 (variable, low)
Assessment
DX: Polyarticular arthritis, systemic juvenile arthritis with osteopenia (Still’s disease)
TCM DX: Shaoyang or blood level heat/heat bi syndrome; bony bi/ wind-cold-damp with latent damp-heat toxin
PLAN
Treatment principles: Warm and open the channels and collaterals, move qi and blood, dispel cold, damp, wind, nourish blood, tonify qi, blood and 5 zang organs (constitution). Induce prolonged remission phase of JRA, prevent recurrence of active phase of disease by strengthening constitution and promoting optimal immune function. Treatments consist of combinations of in/out and sustained needle acupuncture, indirect moxibustion and refilling herbal prescriptions and dietary supplements.
Dietary advice: Avoid night shade vegetable family, animal fats, greasy/fried foods, sugar and spicy foods. Increase oral hydration of warm fluids and incorporate cinnamon and turmeric into meals.
Dietary supplements: Calcium 500mg, vitamin D3 500 IU per day, B-complex 1 tab once daily, ibuprofen 20-40mg/kg/day in 3-4 divided doses (not to exceed 880 mg in any 24-hour period) for no more than 5-7 days without clinic evaluation (Liver and renal function labs need to be updated)
Herbs: Feng Shi Ding 2-3 pills BID
Acupuncture: 3 times per week
The following acu-points are used: SP9, LI11, LI10 TB5, GB34, BL11, LR3, LI4, TB3, LI5, SI7; In/out needling: DU14, ST34, SP9, ST36, BAXIE, ST36, KD3
Limit to 8-9 points per treatment.
Auricular acupressure seeds (1 visit): Shenmen, Kidney, Liver, Knee applied bilaterally to leave in place for 3-4 days
Patient noted reduction in both pain and difficulty with ambulation immediately following treatments. The father reported cessation of alternating fever, chills and profuse sweating episodes as well as an improvement in her energy. The duration of pain reduction benefit was limited to 2-3 days. Patient’s shen appeared brighter and showed increased interest and attentiveness during her treatments. She was able to actively extend her legs to 180 degrees and dorsiflex her ankles to ~5 degrees. The first and second MCP joints had 30 degrees flexion. After treatment 5, ankles no longer felt hot and her knees were warm without erythema.
At her 6th visit, the formula was changed to Xuan Bi Tang Wan 3 tablets TID. A stronger blood/qi/KD nourishing herb was being considered for her 9th visit, given that the joint swelling and inflammation was waning. Liu Wei Di Huang Wan was chosen and dispensed to patient at 9th visit, 8 TID.
Because it took 6 hours of public transportation to get to and from the clinic (>18 hours of missed work per week for patient’s father), this schedule was not feasible. Patient received treatments every 3-7 days for 8 treatments.
Conclusion
This young patient has a severely disabling, progressive disease and lacks resources required for allopathic management regimens known to induce and prolong remission phase and reduce joint destruction associated with Juvenile Rheumatoid Arthritis (JRA).
Each day that severe, active-phase joint inflammation continues, indicates potentially permanent joint damage, reduced mobility and reduced quality of life for patients with JRA. The patient’s father accompanied her to most clinic appointments and provided a limited and inconsistent history of her disease condition, possibly indicating cultural-conceptual and/or practitioner-patient communication challenges. This definitely represented a barrier to optimal assessment of her condition. It was clear from his account of her history that he did not understand the disease process of JRA, its management, or the implications of ineffective management.
The long distance between home and clinic resulted in excessive time away from work for her father, which severely limited treatment frequency and potential efficacy. This patient was unable to maintain the optimal 3-4 times weekly treatment schedule, yet still noted both subjective and objective improvements during the course of her 9 visits over 6 weeks: increased joint range-of-motion, reduced joint inflammation, cessation of systemic inflammatory symptoms, improved constitutional energy and spirit.
It is expected this patient would benefit from incorporating massage and physical therapy into her treatment regimen. Some of her reduced joint mobility seems to be from muscular contraction due to the combination of prolonged guarding of joints and limbs and reduced mobility. A more aggressive treatment plan using a greater number of acupoints with longer needle retention, plum blossom, jing-well acupoint bleeding, scalp acupuncture and/or electroacupuncture may enhance treatment efficacy and may be employed as patient comfort permits.
11-year-old female presents with large lump over left radial artery at radial styloid process, causing pain to the local area. She had minor surgery to remove a gelatinous substance from within the cyst and was informed by the doctor that it will keep growing back. After 9 acupuncture treatments, including internal and external herbal medicines, the cysts presented with 70% reduction in size.
SUBJECTIVE
Patient presents with large lump over radial side of left wrist. She reports (with the help of her mother) that it started to grow a year and a half ago and refers to it as a “bone growth.” She saw a doctor to inquire about removing the lump and was informed that it was not possible due to the innervation of the cyst.
There is no change to the pain or growth with temperature. Some stimulation via massage has been helpful to reduce pain and swelling. Patient states she visited a doctor to have it surgically removed and was prepped for the procedure when the doctor opted not to do a complete removal due to innervation of the cyst by the radial artery. The doctor did remove a gelatinous substance from the top layer of the cyst, but the mass grew back. The size of the cyst at first visit to this clinic on January 17, 2012 has been the same for 1 year.
At age 2, she contracted pneumonia. Since then, she catches colds easily, 3-4 times per year, each lasting up to 2 weeks. These present with a runny nose with clear mucus, cough with some phlegm, body aches, headaches, loss of appetite and slightly looser stools with frequent urination. Since beginning treatment, she has had no common colds.
OBJECTIVE
Patient has a thin body, but appears energetic, smiling, talkative and open to conversation with full eye contact. She knows some English and answers the questions directly when she is able. Upon palpation, the skin is warm, tougher than the surrounding skin, and exhibits a hard central mass that is moveable. The cyst sits half an inch off the skin and about half an inch wide, on the crease of the left wrist, with localized sharp pain when palpated deeply, which she expresses through guarded behavior. There is also some additional swelling and redness at the height of the mass, but no lack of range-of-movement in the joint.
Tongue: Pink body with a red tip, white tongue coat, thicker at root
Pulse: Thin, slippery overall with deficiency in the right cun position, and deep in both chi positions
Patient records include: X-ray of left wrist, July 20, 2010 (1 ½ years prior to current treatments): No abnormal bone growth is shown Ultrasound of left wrist, July 4, 2010 (1 ½ years prior to current treatment): Reveals cysts growing on either side of radial artery, with possible nerve innervation
Approximately 1.7 x 0.9 cm of cystic legion is noted in the volarradial aspect of the wrist, with a smaller cyst measuring 0.6 x 0.3 cm rooted deeper. The left radial artery is intimately related to area of the posterior wall of the superficial cyst. It shows normal color and doppler flow in the radial artery.
Hospital visit, February 20, 2011 – check-up (1 year prior to current treatment): Swelling in left wrist for past 10 months, gradually increasing in size. Positive for pain, but no trauma indicated. At time of check-up, 4 x 3 cm2 in the wrist at the ventral surface and lateral margin
ASSESSMENT
DX: 2 ganglion cysts growing around the left radial artery, with some innervation by the surrounding nerves of the local area
TCM DX: Mass due to phlegm accumulation in the channels and collaterals of the Lung with some qi and blood stagnation present as indicated by the fluid filled node over TaiYuan (LU9) and slight compression of the artery. Condition is due to constitutional wei qi and Lung qi vacuity, with Spleen qi vacuity, allowing for retained pathogens to harbor within.
PROGNOSIS: Due to placement of the cyst, it may not be possible to completely resolve the node. It is likely that herbal treatments, acupuncture and self-massage will reduce the size of the cyst, but it may not resolve completely.
PLAN
Patient to be treated at the satellite clinic 2 times per week for 10 weeks and reassess progress after a second ultrasound. The focus will be on constitutional points, surrounding the area with needles, herbal treatments internally and externally, along with self-massage and qi gong. Aim is to reduce pain and size of the cyst to avoid surgery.
TYPICAL TREATMENT
Acupuncture: Surround the dragon technique with 5-7 needles includes LU7 (Lie Que), LU9 (Tau Yuan) and LI5 (Yang Xi) all threaded towards the center of the cyst; ST36 (Zu San Li), SP6 (San Yin Jiao), SP9 (Yin Ling Quan) and KD3 (Tai Xi) to boost constitutional deficiencies.
Moxa: Indirect pole moxa for short duration to reduce pain and swelling in the area. In the future, try small rice grain moxa directly on the swelling.
Massage: Light yin tuina massage mixed with qi gong to the area to increase qi and blood flow.
Herbal Medicine: San Zhong Kui Jian Tang (Hai Zao, Kun Bu, Jie Geng, San Leng, E Zhu, Bai Shao, Gang Gui Wei, Hunag Qin, Huang Lian, Long Dan, Lian Qiao, Zhi Mu, Huang Bo, Tian Huan Fen, Chai Hu, Shang Ma, Ge Gen, Gan Cao) drains pus, reduces swelling, abcesses and hard nodes; 1 capsule TID internally and 1 capsule mixed with oil to make paste to apply externally over area morning and night. Once the cyst has shrunk by 80%, Yu Ping Feng San (Huang Qi, Bai Zhu, Fang Feng) will replace San Zhong Kui Jian Tang internally for the constitutional deficiencies.
Lancet: At the 3rd treatment, the cyst was punctured with a lancet. A small amount of gelatinous fluid and blood was extracted.
OUTCOME
After 9 treatments, the cyst reduced in height and redness by 70% from initial inspection. The swelling spread in width, but reduced in height. There was no longer a hard mass underneath and no redness to area. Palpation revealed little to no pain, and no guarding to area.
CONCLUSION
Continue care for 4-6 more treatments. Follow up with ultrasound for further assessment. Prognosis is good, revealing no current need for surgery. However, it is unlikely the node will stay dormant without continued care, and attention to underlying constitutional deficiencies.
35-year-old female presents with multiple bilateral joint pain beginning 18 months previously and had received a diagnosis of rheumatoid arthritis at the Arthritis & Rheumatic Diseases Treatment Centre in Nepal. After 10 treatments of acupuncture, in conjunction with herbal medicine, she experienced a significant reduction in joint pain and inflammation.
SUBJECTIVE
Patient is a 35-year-old woman presenting with bilateral multiple joint pain which began approximately 18 months ago. She describes bilateral knee and shoulder pain, pain in her wrists, hands and ankles. Her symptoms originally began with pain in the right shoulder, which after 1 to 2 months was followed by pain in her left shoulder. Within 2 to 3 months, the pain spread to her wrists, then hands. The most recent development has been the pain in her knees and ankles, which began approximately 6 months prior to her first consultation at this clinic. She reports that the severity of the pain in each affected joint is intermittent and unpredictable, and has a tendency to move around. She describes the pain as aching and stiffness, which is worse at night, and for which she takes non-steroidal anti-inflammatory medication (aceclofonac 200mg). This allows her to sleep an average of 6 to 7 hours straight per night, whereas without it she only manages to achieve 5 to 6 hours per night of broken sleep.
Prior to the onset of joint pain, the patient reports she had intermittent cold and flu symptoms over a period of 12 months, including nasal congestion, sore throat and generalized body aches. She did not consult any health practitioners regarding these symptoms. She was prescribed medication approximately 12 months ago, which she had been taking up until 2 months prior to this consultation. She reports that the medication has provided no relief, therefore she has ceased taking it. Her symptoms have not noticeably worsened since ceasing the medication. She has been having Ayurveda oil massage and steam baths every other day for the past 12 days. This has not provided any relief.
The patient reports that the most severe pain is in her right hand, in particular the fifth metacarpal joint, and in her left shoulder.
Bowel movements are 1 to 2 times daily and fully formed, and urination is 3 to 4 times daily and is pale to medium yellow in colour. Menstruation is regular with mild pain with medium to heavy bleeding for 2 days and light flow for 3 days. Her sleep is disturbed by pain, for which she takes anti-inflammatory medication, daily, to manage.
Stiffness and pain is worse in the morning and for the first 1 to 2 hours upon waking, is less in the afternoon and then worse again late at night.
Objective
Patient’s overall health appears to be above average for age and environment. Her demeanour is generally relaxed and cheerful, but with a tendency to carry herself with a slight unease. She occasionally winces due to pain. There is distinct rebound tenderness when palpating the joints of the right hand compared to the left, especially the metacarpal joints. There is also strong palpable tenderness when applying mild to medium pressure to the medial and superior borders of the scapula on both shoulders, and when applying medium pressure to the posterior and anterior borders of the glenorohumeral joint of the left shoulder. There is distinct tenderness when applying moderate pressure to the lower borders of the patella and medial epicondyle of the tibia on both knees. Ankles do not produce distinct tenderness when palpated.
The knees, ankles and fingers can be passively and actively moved through all range-of-movement without restriction, with the exception of the left shoulder, which triggers pain on passive and active lateral abduction above 90 degrees. There is no apparent swelling of the joints in the knees, shoulders and wrists and none appear misshapen.
There is mild palpable swelling in the fifth metacarpal joint of the right hand. The joints of the hands and knees feel slightly warmer to touch than others.
Tongue is light red with normal body, thick yellow root and red tip. Pulse is rapid and slightly slippery.
Assessment
DX: Initial blood analysis taken at the Arthritis & Rheumatic Diseases Treatment Centre in Lalitpur, 12 months ago, shows elevated serum rheumatoid factor and raised white blood cell count. This result, combined with symptoms of multiple bilateral joint tenderness, mild joint swelling (in greater than 3 joints including in the hands and wrists), and morning stiffness for greater than 1 hour, resulted in the patient meeting the criteria for a diagnosis of rheumatoid arthritis which was given at the above clinic where her initial assessment was carried out.
TCM DX: Wind-damp bi syndrome due to damp-heat, and wind-heat toxin due to latent heat invading the joints causing qi and blood stagnation and damp retention. Over time, if left unabated, this typically would lead to swelling and deformity due to phlegm stagnation and blood stasis.
PROGNOSIS: Besides mildly visible signs of synovial thickening in several small joints, the patient is otherwise free from any severe pathological tissue changes. Therefore, successful management of systemic joint inflammation may help to preserve the mobility and dexterity of the joints. Depending on the outcome of acupuncture and herbal treatment, this may include conventional drug therapy.
PLAN
Treatment principles: Dispel wind, resolve damp and clear toxic heat. Open channels and collaterals. Invigorate qi and blood.
Treat with acupuncture 2 to 3 times weekly for 10 treatments before reassessing. Treatment approach is to use Shaoyang channels to dispel wind and damp and Yangming channels to purge heat toxin and move qi and blood. Points are also used to nourish blood and qi to anchor wind and prevent pathogenic factors from attacking the channels.
Typical treatment: TB5 and GB41, needled contra laterally, with Shaoyang points such as TB2, GB39, GB35, GB36 and GB34 to dispel wind-damp from the channels. LI11 and ST3 are used to expel heat. SP6 is used along with LI4 and LIV3 to anchor wind and circulate blood and qi throughout the body.
At the third consultation, Shu Jin Huo Xue Tang was given as a powder with a dosage of 4g twice per day to dispel wind and damp, invigorate blood and remove blood stasis. The prescription is to be followed for 10 days and then reassessed.
OUTCOME
As early as the third consultation, she found it easier to walk for longer periods, as she had less pain in both knees and no pain in her ankles. She could take a shower without pain, whereas before, this used to cause pain in her shoulders and hands. The palpable pain in the first and second metacarpal joints of both feet increased significantly since the fourth treatment, with distinct visible and palpable swelling. Initially, she had reported mild pain in these joints and no noticeable swelling.
After 10 acupuncture treatments over 5 weeks, the patient reported having not taken painkillers for 2 weeks and was sleeping 6-7 hours per night without them. She reported only mild pain in her left shoulder (the initial site of most pain) with some mild to moderate tenderness upon palpation around the medial and posterior borders of the scapula. She could laterally abduct her left shoulder to 120 degrees and passive abduction was to 160 degrees without pain. Palpation of the medial epicondyle of the tibia of both legs produced mild to moderate pain.
From treatment to treatment, the patient reported fluctuating levels of pain and inflammation in her left elbow and both hands. In particular, the pain in her left hand would move from joint to joint, sometimes over a period of 24-48 hours.
After the fourth acupuncture treatment, the patient had been recommended by a friend, to consult a Tibetan medicine doctor specializing in the treatment of arthritis. It was agreed that she would cease the Chinese herbal medicine and proceed with the Tibetan herbal medicine prescribed to her alongside acupuncture. Tibetan herbal medicine would be more consistently available to the patient over a longer period.
Conclusion
This patient experienced a significant reduction in pain and inflammation within 10 treatments. She is advised to continue treatment 1 to 2 times weekly for another 4 to 6 weeks with the hope of continuing to improve her symptoms. Whether or not acupuncture treatment and herbal medicine alone, without conventional drug treatment, will result in a full remission from symptoms, is unknown. However, it appears that acupuncture may be a useful therapy for managing pain, inflammation and preserving joint mobility and delaying long-term site and enzymatic damage, which usually results from persistent and chronic inflammation and swelling of the synovium in the joints. It is also possible that her progress over the last 6 treatments was aided by the prescription of Tibetan herbal medicine. However, as she experienced significant relief after the initial 4 acupuncture treatments, it is presumed that acupuncture has and may continue to play a significant role in managing her symptoms.
72-year-old female presents with left hand tremors that extend up the arm and into her neck and jaw. Tremors have been present for 2 to 3 years. Hospital and doctor records report Parkinson’s disease. Over the course of treatments, the patient experienced periodic relief, with regression and return of tremors. Overall, her posture, mood, outlook and sense of independence improved, leading to a significant improvement in personal affect over time.
SUBJECTIVE
Patient presents with tremors in her left hand and arm, extending up through her neck and into her face and jaw. Hospital charting from 6 months prior shows a diagnosis of Parkinson’s disease. The patient reports having previously taken tri-hexyphenidyl hydrochloride, propanolol hydrochloride, levadopa and carbidopa tabs, but states that she is not on them now and is seeking a cure from Chinese medicine and acupuncture. She also reports having been diagnosed as a diabetic and declares that she has blood sugar levels tested regularly. The most recent reading was 145 mg/dL.
O-Tremor symptoms have been present for 2-3 years.
P-Patient reports that warm weather alleviates her symptoms and cold weather exacerbates.
Q-In addition to tremors, she experiences numbness in her tongue and has trouble speaking clearly, a symptom that fluctuates on a weekly basis. She reports mouth dryness, dizziness and blurry vision when walking.
R-Tremors begin in her left hand, move up into her arm, and eventually spread to her neck and jaw. During the course of treatment, the patient reported experiencing tremors in her right hand and arm as well.
T-The patient reports constant tremor while in a waking state throughout the day and evening.
Objective
The patient presents with stooped posture while walking, arms held closely in front of her. While she sits in the treatment chair, her hand and fingers tremor with an inch of movement back-and-forth. Her lower jaw shakes when she is not speaking. The tremors disappear with movement, and her movements are bradykinetic. She exhibits signs of depression from day-to-day—diminished affect, low voice, frequent sighing and responds to questions about her condition with frustration.
From treatment-to-treatment, her tongue changes from pale and dusky to more red, and sometimes purple-tinged. Her pulse is thin and easy to push through, but at times will have a wiry/tight quality or will show a superficial flooding or slippery quality.
Assessment
DX: Parkinson’s Disease
In order to differentiate the patient’s diagnosis of Parkinson’s disease from benign essential tremor, it is important to clarify the differences. Benign essential tremor—Typically hereditary, benign essential tremor is characterized by tremor present with movement and absent at rest. It is normally bilateral and increases with age (Merck, Mayo Clinic). Essential tremors are not associated with stooped posture or shuffling gait, although they may cause other neurological symptoms. Benign essential tremors typically start in the hands, and can eventually affect the voice and head.
Parkinson’s disease—Characterized by voluntary and involuntary movement affected by tremors, the symptoms typically begin unilaterally, but can progress to affect the body bilaterally. Symptoms are mild at first, and the severity of the disease is quite variable from person-to-person. Cardinal symptoms are: tremors, rigidity, bradykinesia, postural instability and Parkinsonian gait (characterized by short, shuffling steps and diminished arm swinging). Secondary symptoms include: anxiety, confusion, memory loss, dementia, constipation, depression, difficulty swallowing, slow, quiet speech and monotone voice.
To note, occurrences of misdiagnosis can happen. There are no medical tests for this disease and a definitive diagnosis of Parkinson’s is not possible while a patient is still alive. The most accurate diagnosis would be made by a neurologist who specializes in movement disorders. Therefore, the true diagnosis in this case study is speculative and impossible to confirm.
The patient exhibits stooped posture, impaired gait (she requires help walking to clinic on certain days), and holds her hands stiffly in front of her, while walking in a shuffling manner. She also experiences tremors while seated with hands in her lap (at rest). It appears likely that her condition is, in fact, Parkinson’s disease. During the course of treatments, she displays intermittent confusion and memory loss, both in repetitive questions, the need for counseling on her condition, and interpreters stating that she is incoherent. These are indications of possible mental degeneration accompanying the Parkinsonian condition.
TCM DX: The patient shows a mixed excess/deficiency pattern consisting of underlying deficiencies leading to uprising of excess, Kidney yin deficiency and Liver blood deficiency, with an uprising of wind in the channels, Liver qi stagnation and uprising of Liver yang.
KI yin deficiency is apparent with thin pulse, red tongue tip (empty heat) and low back pain, and can partially be assumed with age (72) of the patient. Liver blood deficiency is apparent in the thin pulse that is easy to push through, the dizziness and blurry vision with activity, and dryness of the tongue. Wind in the channels (due to blood deficiency) and uprising of yang, is exhibited by the tremors, and can be detected in the pulse. Liver qi stagnation is exhibited by frequent sighing and mood swings from day-to-day. Blood stagnation and empty heat alternate in her pattern. Tremors are observed by the practitioner as more pronounced when stagnation is present, indicated by the dusky and/or purple tongue alternating with a redder tongue tip concurrent with less pronounced tremor of the hands and mouth.
INITIAL PLAN
Treat 3 times per week for 3 weeks. Diminish wind in the body while tonifying underlying deficiencies.
Typical treatment: Scalp tremor line, later with electro-acupuncture. ST36, LR8, SP6 to nourish blood, KI3, LI4 and LI11 to diminish stagnation and clear heat, as well as locally to treat tremors in the arms. GB20 is used to expel wind. Tiger warmer therapy is applied to the left arm, and often both arms and the sides of the face and neck. Electro-acupuncture typically connecting points LI11 and Hegu (LI4), or LI5.
Additional treatments: ST3, ST4, ST41 and LR3. Parkinson’s may be a condition of reversal of Stomach channel qi, which enters the GB channel through ST8(Janice Walton-Hadlock). An intention of descending Stomach channel energy has come to be a focus in treatment.
Herbal formulas prescribed include Gastrodia 9 (Seven Forests formula) to diminish tremors and Tao Hong Si Wu Tang to move and nourish blood.
Patient is encouraged to engage in light movement of the body, and to receive massage from family members. She is referred to the physiotherapist, though exhibits significant resistance to exercise..
OUTCOME
The patient arrived for treatment daily for a total of 6 weeks.
Tian Ma Gou Teng Yin (for wind) and Liu Wei Di Huang Wan (for Kidney yin and blood tonification) were later added to her treatment plan.
She only had 1 visit to physiotherpaist.
Given the advanced state of the patient’s condition, it was clear that acupuncture may not decrease symptoms of tremor over the longterm, but may help on a short-term, symptomatic basis. The patient experienced relief the night after each treatment, less numbness in her tongue, and an increased ability to speak clearly. However, her condition would subsequently relapse after each period of relief, so it cannot be known whether the acupuncture and herbs were helping, or if it was a natural regression of symptoms typical of the disease. Significant time was committed to answering the patient’s (sometimes repetitive) questioning of her condition, educating her about the severity and irreversibility of the disease, and encouraging her to think positively and actively engage in her own process of healing.
What was striking over time was the improvement in the patient’s mood and affect. She began to walk to clinic on her own on a regular basis and was visibly happier over the course of treatments. Her posture improved, and she became more engaging, which despite her shifting moods, remained at a higher level than when she originally came into the clinic (although this can be due to trust and relationship that grows over time between patient and practitioner). As seen within the first 5 treatments, her mood changed significantly and her speech clarified. She was more likely to engage in conversation, both with her healthcare provider, as well as with family, and began to open up.
In subsequent treatments, she exhibited moods that showed a decline in outlook, including frustration over not experiencing the amount of relief desired, and seemingly, over a lack of control over her body and her life. During the fourth week of treatment, the patient reported a remarkable improvement. On 1 visit, she stated that she experienced the feeling of being “completely cured” following her treatment the day before. This type of relief, although short-lived, also added to the hope and positive outlook that overrode her frustration throughout the course of treatments. After 7 weeks in treatment, she went home to her village in a warmer climate, returned to the clinic during the ninth week, and reported a complete disappearance of symptoms while she was home. This brings to question both the power and possibility of acupuncture, as well as what the role of stress-reduction can play in Parkinson’s disease and other neurological disorders. Acupuncture and Chinese medicine has been shown to reduce stress, and if relief of symptoms from disease is a secondary outcome, then the importance of this therapy is of paramount significance.
In the Vajra Varahi clinic, this patient experienced periodic relief of symptoms, with relapse and gradual decline. Parkinson’s is a degenerative disorder, and slowing the progression became the main focus in direct treatment of the disease. In addition, the role of the acupuncture practitioner for this case has been one of guiding healthcare and outlook, counseling her towards a full understanding of her condition so that eventual acceptance is possible, and helping to facilitate a state of contentment and happiness that can be applied to her life as a whole.
36-year-old female with lumbar spinal stenosis presents with severe low back pain with referred pain down the posterior left leg and anterior right thigh. The patient lives several hours from the clinic, but was able to stay in Kathmandu temporarily in order to get daily treatment for 2 weeks. After 12 treatments, the patient reported 80% of her pain relieved for a sustained period of 4 days, after which the pain started to slowly return.
SUBJECTIVE
The patient presents with severe low back pain with referred pain down the posterior left leg and anterior right thigh. The pain interferes with her ability to walk without limping. The issue had a gradual onset beginning 3 years ago, continually getting worse, and within the last year it has increased to severe pain. Nothing helps the pain and the patient reports that it is made worse by bending, straightening, twisting, standing, walking and sitting too long. The patient describes her pain as severe, with a sharp burning quality running from the left PSIS area down the posterior portion of the thigh to the middle of the posterior calf and down both the anteromedial and anterolateral portion of the thigh just above the patella. The patient rates her pain as intolerable and constant. No muscle weakness or stiffness are reported. Due to the cost of recommended surgery, the patient hopes acupuncture can help her avoid surgery and perhaps slow the long-term progression of the arthritis.
OBJECTIVE
The patient received an MRI, which showed compressed nerves due to the narrowing of disc space between lumbar vertebras 4 and 5. She was informed that the disc space is narrowing due to arthritis of the spine and surgery is necessary to scrape the bone away from her nerve.
The patient reports no use of any prescription medications or OTC pain relievers.
Patient appears to be in good health, besides dealing with severe pain. Because of pain, the patient appears to be severely distracted, however can answer questions competently. The patient walks with a limp in her left leg. She is unable to sit up without assistance after laying down for the treatment due to the severity of her pain, rather than weakness. All transitions between positions - sitting, lying, standing - are strained and painful.
The Valsava test is positive with severe pain referring down the posterior left leg and anterior right thigh.
Palpation shows no significant findings on her lumbar spine, but shows her pain starting at L3 to under L5 and surrounding the posterior superior iliac spine (PSIS) and down into the sacral foramen, especially S2. Her right PSIS is more proximal than the left and tension is found in the right piriformis. Palpation down the left posterior thigh shows pain directly down the Bladder meridian to BL57 and palpation at the right anterior thigh shows the pain running along both Spleen and Stomach meridians to SP10 and ST34 region.
Patient shows no signs of muscular atrophy. Difficulty in walking is due to pain, rather than weakness.
Her blood pressure and heart rate are within normal limits at 113/84 and pulse 72 b/m.
ASSESSMENT
DX: Lumbar spinal stenosis with narrowed disc space between L4 and L5. Possible subluxation of the sacral iliac joint. Due to her age, it is hypothesized that she has the congenital form of lumbar spinal stenosis.
Medical recommendations from hospital: It is likely that the doctor at the hospital is recommending a laminectomy, foraminotomy or a nerve block.
TCM DX: Bone bi syndrome with qi and blood stagnation in the Bladder, Governing Vessel, Stomach and Spleen meridians with underlying Kidney essence deficiency and Liver blood deficiency.
PROGNOSIS: Due to the severity of the condition and the nature of lumbar spinal stenosis, the prognosis is fair with regular treatments. The patient is young. In the long-run, treating with just acupuncture and herbs leads to a likely poor prognosis. These modalities may delay surgery, but chances are, will not eliminate the need for it.
INITIAL PLAN
Treat with acupuncture daily for 7 treatments and then reassess. The treatments focus on breaking up qi and blood stagnation in the Governing Vessel, Bladder, Stomach and Spleen Meridians with electro-acupuncture as the main modality. Internal herbal treatment includes Huo Luo Xiao Ling Wan and Xiao Huo Luo Dan Wan. These formulas are used to break up blood stasis, open the collaterals and move qi and blood to stop pain.
Typical treatment: Left: SI3, ashi BL57; Right: BL62, LI4, GB21; Bilateral: HTJJ L3 – L5, Shi Qi Zhui Xia, ashi PSIS area, BL32 – 34, GB30, Huan Zhong , BL40, BL60. Electro from left HTJJ L5 to left BL60, right ashi PSIS to right BL60 and bilateral BL32 to BL40, 5/100 Htz milliamp with mixed frequency. Pain patches and ear seeds are utilized to increase the effects of treatment outside the treatment room. Salonpas pain patches with camphor and menthol to provide a cooling analgesic effect and ear seeds on lumbar spine and sciatic points are also given at the end of each treatment.
Alternate treatments: Right: ST34 and ST41 for right thigh pain, superficial transverse needling with manual stimulation of ashi points surrounding the PSIS for sacral realignment.
OUTCOME
Due to the circumstance of the patient living several hours from the clinic, daily treatments were given for the first 12 visits. On the 12th treatment, the patient reported 80% of her pain was relieved and tolerable. Bending, straightening, twisting and walking no longer caused her pain. Furthermore, she no longer needed assistance in getting up from the prone position. The patient could walk without a limp. The 13th treatment was spread out to 5 days later to observe if the pain relief could be sustained. On the 13th treatment, the Valsava test indicated considerable treatment results with moderate pain only at BL32, rather than severe sharp, burning pain radiating down the posterior left leg and anterior right thigh as seen on the first visit. It was reported at this visit that 80% pain relief was sustained for 4 days after the 12th treatment, at which time the pain began to return slightly. However, she felt enough pain relief to return home to spend the Dosain holiday with her family and start work for the harvest season. The outcome was better than I, the practitioner, initially expected. Perhaps the MD’s assessment for surgery was premature and the original prognosis was understated. With continued acupuncture and herbal treatment, the inflammation and pain could be reduced long-term and the degenerative nature of the disease might be slowed.
CONCLUSION
Due to the inflammatory process and degenerative nature of lumbar spinal stenosis, regular acupuncture and herbal treatment might be the best option for long-term pain relief and slowing the progression of her arthritis. The patient was informed that regular acupuncture and massage treatment might be the only alternative to surgery. Due to the logistics of living so far from the clinic, if her pain returned or worsened, surgery might be her only option for sustainable pain relief.
50-year-old male presents with post-stroke sequelae symptoms manifesting as severe right-sided paralysis. After 10 treatments starting in September 2012, the patient exhibited improvement in his condition and fair measurable progress.
Subjective
The patient had a stroke in November 2011. He received medical attention 24 hours later at the hospital and was treated with western medical pharmaceuticals unknown to the patient. He stayed in the hospital for 9 days. While at the hospital, he learned of an acupuncture program in Kathmandu. He began getting treatments there 14 days after he left the hospital. He doesn’t remember exactly how many sessions he had. Perhaps about 7. He came to the Vajra Varahi Clinic in March 2012. Prior to my attending him, he had 15 treatments at the clinic. Current symptoms are paralysis of the right side of body, numbness in the hand and foot, inability to move fingers or toes, numbness of his lips (right side) and tongue, difficulty walking, an unsteady gait, the sensation of weakness in the right knee and ankle, stiffness in the shoulder, elbow, wrist, hip and knee joints, general fatigue and heavy sensation in the body. The patient is worse in cold weather, fatigue and when hungry. The quality of sensation that the patient experiences in his body is heavy, achy, tingling and weakness. The severity of the condition and the impact on his life is immense due to his inability to work, care for his animals or farm his fields.
The patient reports difficulty in walking due to his toes having no ability to move. This requires the patient to lift his leg straight up and land the foot on the whole sole as opposed to heel-to-toe walking. This gives the patient an unsteady gait that he reports also makes his knee feel like it could give out. The distance the patient walks to the clinic from his home would have taken him 20 minutes prior to the stroke. Currently, it takes him close to an hour.
While in the hospital, the patient received 1 physical therapy session. The patient maintains an exercise routine based on what he learned in PT while at the hospital. He reports that he massages his foot and hand daily. He doesn’t take any western medication or supplements, though he does take Tibetan herbs.
Despite the extent of his symptoms, the patient identifies that he would like to focus on improving his speech, reducing the swelling around his lips on the right side, regaining some use of his right hand and improving his ability to walk and feel more balanced.
Objective
Patient appears to be in good health with a strong spirit and determination to improve. He has spent his life working the land and raising animals. This has taught him patience and endurance.
The patient’s left arm is used to lean on a walking stick as he raises his right leg directly up from his hip and places his foot down on the whole flat of his foot, as if it were one solid block. He is unable to walk in a normal heel-to-toe stride. His right hand is contracted and he holds his entire arm tight against his belly. His face appears symmetrical and bright except for about 10% swelling in the right upper and lower lips.
When seated, the patient uses his left hand to move his right hand into position. The right hand is contracted, however passive stretching of the digits and opening of the palm happens easily and reveals tremendous flexibility. The patient has a medium-strength grip in his right hand, about 50%, compared to the left. He has no ability to extend the fingers or even wiggle or twitch them. After opening the hand, it slowly folds back into a soft contraction within a few seconds.
Sensory testing using light, medium and heavy stroking of the patients affected areas, while the patient has his eyes closed, shows complete response. Hip flexion and extension has normal ROM, however the strength of the hip is reduced by 30%. Hip flexion and extension are occasionally affected by stiffness in the hip joint from the action of lifting the leg to place the foot. Most of the stiffness remains in extension position. Although I do not speak the patient’s language, I can hear that there is very minimal slurring in his words. When the patient leaves the treatment, he lifts his leg off the ground about 2 inches higher than when he came in.
Tongue – swollen, pink, light white coat
Pulse – slightly rapid, superficial and wiry
Assessment
DX: Post-stroke sequelae with paralysis of the right hand, fingers, foot and toes; Overall stiffness, weakness and heaviness
TCM DX: Qi & blood deficiency; KI yang deficiency; Wind & phlegm obstructing the channels and collaterals
PROGNOSIS: The prognosis for a full recovery is poor, however we expect some hand mobility to return and sensation to continue returning to the foot and toe’s. As these functions return, we expect to see less weakness and stiffness in the joints affected by the stress caused by the impairment. The treatment plan will need to be long-term and the patient must remain hopeful and committed.
Initial Plan
Treat with acupuncture 4 times per week for 3 months before reassessing. Focus on strong stimulation with electro-acupuncture crossing affected joints. Use scalp points associated with motor function of upper and lower limbs using hand stimulation of needles.
Typical treatment: Left: Dr. Zhu motor points for upper and lower limbs with deep insertion and heavy stimulation. Dr Zhu speech points on scalp.
Right lower: Ba Feng, KI1, LV3, GB41, KI3, SP3, SP6, ST41, GB39, ST36, GB34, KI10, He Ding, Xiyan/Xiyuan, ST34; Right upper: Baxie, HT8, PC8, PC6, Xu Duan – 10 drains on the right hand and right toes, TB5, LI10 X 3, LU5, biceps ashi
Electro: 2/100 mixed – Dr. Zhu scalp points, biceps ashi – PC6, LI4 – LI10, ST 34 – ST 36; Alternative treatment consists of similar points crossing joints such as KI10 – KI3, SP6 - SP3 and/or GB34 - ST34.
The patient is given a bottle of Po Sum On (aromatic oil) and instructed to use it with his home routine that includes daily massage and physical therapy. Included in home therapy are visual exercises to stimulate the brain and motor connection. The patient is instructed to first perform the physical therapy routine with the unaffected side of the body while creating a strong eye connection with the movements. Then, the patient performs the same movement therapy with the affected side, again keeping a strong visual connection.
The patient uses Tibetan medicine as his herbal treatment and expresses positive feelings about this. Keeping detailed track of all changes and astute observations with each treatment is imperative. The smallest details are critical to observe and note, both for the clinician and patient. Constant encouragement through the likely long process of healing must not be overlooked. Reminding the patient of all the changes at each session will help in the process of staying positive.
Outcome
Patient reported that over the course of the 9 treatments, he has, for the first time, noticed significant improvement. After each treatment, he reported more nerve sensation in his hands and feet, with greater ROM in his knee and ankle. The swelling in his lips responded immediately to the treatment and the patient reported clear speech. The patient had a 10-day lapse in treatment, which brought back 30% of the lip swelling and 5% of the speech problem. After 1 treatment, clear speech returned, even though the lip swelling returned quickly after treatment. The quality of the stiffness and pain is reported by the patient as deep, dull and achy. ROM in the shoulder joint and elbow progressed from about a loss of 40% in extension to 10% with complete disappearance of shoulder pain. There was still achy pain in the bone in the elbow joint. The contracture in the right hand remained, rendering the hand useless still, but the hand had a softness progressively allowing the hand to stay open longer. The patient reported a tingling sensation in his 3rd & 4th fingers which may be a forerunner to the return of nerve function. The patient was able to place his heel on the ground and land on his toes though there was a slight supination of the foot upon landing on the toes.
Conclusion
In the past, this patient received acupuncture treatments of a more constitutional nature without any change to his symptoms. His current response to treatment has been exciting. He has had fair outcomes with measurable changes in symptoms. At this time, the patient mostly hopes to regain sensation and functioning in his toes so that he may improve his gait, as walking is the only option he has in his village. It is imperative for the patient to continue with regular treatment in order to maintain the progress that has been achieved. In stroke cases, it appears that focused, aggressive and frequent treatments are critical. Using visual exercise where the patient first does the physical therapy with the healthy hand or foot, while keeping focused on the movement to imprint on the brain, and then repeats the same exercise with the affected hand or foot is important as are home massage and physical therapy in conjunction with acupuncture treatment. It is also important in working with post-stroke sequelae that the practitioner employ careful documentation and critical observation so to better track changes, however big or small, in the patient’s condition. Constant encouragement and reminders of change help to show the patient their progress throughout the frequently slow healing process.
32-year-old woman presents with constant low back pain and burning urination. She has been diagnosed with severe hydronephrosis in the right kidney and, due to pain, recommended to have a nephrectomy. After 10 treatments with various Chinese medicine modalities, her pain was reduced by 50% and the frequency of her pain was only every 2-3 days. The burning urination resolved.
Subjective
A 32-year-old woman presents to the clinic with a chief complaint of low back pain on the right side in the kidney area, which radiates up the thoracic region of the erector spinae muscles and over to the left kidney area and left thoracic region erector spinae muscles. The pain is described as constant and achy, with sharpness that comes and goes. The onset of this pain was about 1 year ago and nothing seems to change it. Her second complaint is continuous burning urination. She reports no urinary hesitancy, urgency or frequency. The urine is clear to light yellow and output is equal to input. The patient reports some dizziness when standing up and occasional night sweats (2-3 times per week). All of these symptoms have been present for a little over 1 year. Previous to the onset of these symptoms, the patient reports no prior history of trauma to the area or kidney problems, nor has any significant family history of disease.
OBJECTIVE
Patient appears to be in good physical, mental and emotional health for her age and environment. She is soft spoken, but seems educated, engaged and alert. She is the mother of 2 children, ages 2 and 6, and comes from a higher caste, which increases her access to healthcare. Her pulse is slightly rapid and slippery, her tongue red and quivering. Upon palpation of the area of chief complaint, bilateral moderate muscle tension along the thoracic region of the erector spinae muscles, more tightness on the right, is noted. On the ninth visit, the patient brought in lab tests and imaging that had been taken 13 months previous to initially being seen in the clinic. They reveal that her right Kidney is smaller in size and significantly compromised in function. The left Kidney measures 11.5 cm in length, while the right Kidney measures only 7cm. A diuretic renogram taken 1 year ago, reports 94.1% differential function in the left Kidney and 5.9% in the right. The glomerular filtration rate (GFR) of the left Kidney was 88.8; the right Kidney GFR was 3.5. The most recent imaging and urinalysis, 5 months ago, reveals that her right Kidney has become even more compromised and surgery to remove the diseased Kidney was recommended.
ASSESSMENT
DX: Atrophied, poorly-excreting right Kidney with severe hydronephrosis and a thin renal cortex; Hypoplastic right renal artery
TCM DX: Kidney qi and yin deficiency with deficiency heat; Qi and blood stagnation in Bladder meridian
PROGNOSIS: Originally, the prognosis for resolving the complaints of low back pain and burning urination, in an otherwise healthy young woman, was quite good. All of that changed on her ninth visit to the clinic, when upon our request, she presented her full history of medical reports and imaging studies to us for the first time. Due to the severity of her condition, the long-term prognosis for the health of the right Kidney is poor. But due to her response to the treatment thus far, the prognosis for alleviating her symptoms with acupuncture and herbs is good.
INITIAL PLAN
Acupuncture treatments twice per week for 5 weeks and then reassess. Focus on tonifying Kidney qi, nourishing yin and reestablishing the free flow of qi and blood to the local area. Herbs are given to tonify Kidney qi and yin and promote urination.
A typical acupuncture treatment includes the following points: DU20, BL23, BL24, BL26, BL28, BL40, KI7, KI3 and SP6. On several treatments, thread the inner Bladder line all along the thoracic vertebral region due to tightness along the erector spinae muscles and referred pain, especially on the right side. Electro-acupuncture (continuous @ 5 Hz and mixed 2/100 Hz) is used in the low back area bilaterally, as well as localized massage.
Ba Zheng San to clear heat and Dao Chi Wan to promote urination.
OUTCOME
After 10 treatments, the patient reported significantly less intensity (50% less) and frequency of the low back pain. Burning urination resolved. She also reported no more dizziness or night sweats. The low back pain was no longer constant or even daily in occurrence, sometimes only noticeable every 2-3 days. The best herbal formula results were seen with Dao Chi Wan, given at appointments 9 and 10. During her re-evaluation at treatment 10, the patient volunteered that she had good energy and felt strong.
CONCLUSION
As far as the medical reports for this patient conclude, the nephrectomy was recommended primarily due to the fact that she was experiencing pain. With 10 treatments of acupuncture and herbs, we were able to reduce the pain significantly in both frequency and intensity (50%). She was also no longer experiencing any burning during urination. If at some point, she no longer experiences pain or other symptoms, and her bi-annual scans and tests reveal continued normal function in the left Kidney, I feel it is reasonable to assume that she could potentially avoid the surgery altogether.
CONTINUED TREATMENT
The patient was aware that there is a high likelihood that she will eventually need to have the Kidney removed. She planned to continue to be monitored by her medical doctor and have imaging done approximately every 6 months or more frequently, if symptoms increase, to assess the progression of the hydronephrosis. Acupuncture and herbs, at this time, are useful palliative care and should be continued at the current course, as long as the symptoms are present. When the symptoms are completely alleviated, a maintenance course of treatment (once per week) should be implemented to maintain the strength of the system and to potentially improve Kidney function bilaterally.
40-year-old male presents with right-sided neck pain, without nerve radiculopathy, down the arms bilaterally. He has seen his physician who diagnosed him with nerve impingement and wants to do injections of Xylocane and Tricant local to the area of pain, inferior and slightly lateral to his occiput. After 6 acupuncture treatments, including electro-stimulation, massage and topical pain patches, the patient reports improvement in pain frequency and quality.
Subjective
Patient presents with right-sided neck pain that has been present on and off for the last 5-6 years, but has become constant over the last month. The pain can be worse with cold. Heat packs alleviate the discomfort. There is no radiculopathy, but he does notice that his left arm can feel weak when he’s walking uphill. When it is most severe, he can feel pulling over his head to the frontal and parietal bones. He has had physical therapy in the past for right shoulder muscle spasms and they have resolved. He has no history of heart palpitations or hypertension. He is not currently taking allopathic medications.
Objective
The patient appears to be healthy and is comfortable answering questions about his discomfort. Upon palpation of his neck, tenderness is noted suboccipitally at the origin of the trapezius muscle and the insertion of the splenius capitus and cervicus muscles. The scalenes are also tight and tender. Palpation reveals a slight anterior rotation on the right of the first cervical vertebrae. Cervical compression, distraction and maximum compression tests are negative. His pulse is moderate, but thin and his tongue is red with a greasy, yellow coat. An x-ray report shows no clear indication of a problem. In comparison to the left, his ROM on the right is decreased with lateral flexion and rotation. The pain also increases with lateral flexion and rotation to the right. Grip strength in the left arm showed some weakness by comparison to the right and felt cooler to the touch.
Assessment
DX: Possible cervical rotation of C1
TCM DX: Bi syndrome due to qi and blood stag in the DU and BL channels
PROGNOSIS: Acute phase- good; Underlying chronic phase will take time to unwind the fascia and muscle spasms that tend to sublux the vertebrae.
Initial Plan
Treat with acupuncture twice weekly for 4 weeks before reassessing. Focus treatment on loosening the muscles and fascia that are pulling the vertebrae out of alignment and impinging the nerve with use of acupuncture needles, electro-acupuncture and massage with traction and joint mobilization.
Typical treatment: GB20, 21, BL10, An Mian, ashi in cervical area and above occiput at the origin of the trapezius muscle, TB14, LI15, SI12- 13, LI4, LV3; Electro-acupuncture from GB20 to ashi in cervical region; Massage suboccipitally and into vertebrae with myofascial release techniques and traction; Local application of Salonpas topical patches with menthol and camphor to move qi and blood, thereby clearing stagnation and decreasing pain.
Outcome
After 6 visits, the patient reported 80% less pain in the right suboccipital area and noted that the pain shifted to a broader area with less intensity. His ROM in lateral flexion and rotation to the right became equal to that of the left. He still felt a slight pulling in the muscles upon rotation to the right. He was encouraged by the treatments, noticing that his left arm felt better and strength had returned.
Conclusion
This patient agreed to let us treat him in lieu of injections even after his doctor told him there was no other care available to him for his condition. This case shows some of the strengths of acupuncture and massage in making changes in musculo-tendinous conditions that are both acute and chronic in nature. He will continue to be seen twice per week until the pain is resolved, the ROM becomes equal and the vertebral subluxation shifts.
81-year-old female presents with complete left-sided hemiplegia following ischemic stroke 2 months ago. Over the course of 7 weeks of acupuncture treatment, the patient regained limited voluntary dorsi and plantar flexion of her left foot, flexion and extension of her knee and elbow, and increased sensation in her left arm. The patient also developed a cough due to fluid in the lower left lobe of her lungs 5 weeks after the stroke, a common concern for patients with limited mobility living in the cold and damp houses of Nepal. The cough was successfully treated with Chinese herbs.
SUBJECTIVE
81-year-old female presents with hemiplegia of the left side as sequela of ischemic stroke. 1 week prior to initial assessment, the patient awoke from resting and was unable to move, her left arm and leg were numb, she could not talk nor open her left eye, and could not sit up by herself. Her family immediately transported her to the hospital where she was admitted for 4 days. At the time of discharge from the hospital, she had regained some limited speech and could open her left eyelid.
Initial exam is 7 days after the stroke. She reports inability to move either left limb and has limited movement of the left side of her face. She describes her entire left side as feeling heavy and numb. The patient tends to feel hot, particularly in the evening, and experiences night sweats. She has no appetite, a slight thirst for cold drinks, blurry vision, dizziness and complains of a dry throat.
Medications upon initial evaluation include Atorvastatin (Lipolow-10) 10mg QD, Aspirin 75mg QD and Ranitidine (R-Loc) 150mg QD.
OBJECTIVE
Patient appears thin, weak and is bed-ridden at time of initial assessment. She is unable to sit upright without assistance. There is no atrophy of muscles on the left side. Her skin is dry to touch, and she exhibits some degree of hearing loss normal for her age.
The patient demonstrates no voluntary motor control of her left limbs. Her left forearm and hand is mostly contracted and cannot be extended with gentle force. She can slightly raise her left shoulder and can easily move her left arm with her right. Her left hip joint is slightly mobile, and there is no apparent contracture of her left thigh and leg. There is no notable temperature difference side-to-side on palpation. Both sides are warm when covered by blankets.
DTR’s all measure +2 on the right and +3 on the left. Dull sensation is intact and equal on both arms and legs. Sharp touch is equal side-to-side on dermatomes C6, C8 and L5, but slightly decreased on dermatomes C7 and S1 on the left side at the distal tips.
The lateral corner of the patient’s left eyelid droops slightly compared to the right, but she can raise and close both eyelids. The patient’s left side of the mouth droops, and she cannot smile equally on both sides. She can puff out both cheecks. She exhibits slight aphasia and hardly responds to questions when asked. There is some moisture gathering at the lateral corners of her mouth and left eye.
Pulse is thin and taught across all positions, floating and rapid.
Tongue is thin and red with a thick, dry, yellow-grey coat.
ASSESSMENT
DX: Left-sided paralysis as sequela of an ischemic stroke
TCM DX: Sequela of wind-stroke with wind-phlegm obstructing the channels and collaterals and underlying yin deficiency with empty heat
PROGNOSIS: Guarded as the patient is 81 years old and suffered an ischemic stroke. Factors in her favor include daily acupuncture treatments, continued progress in voluntary movement of her left foot over the first 30 treatments, and dedication from her family in assisting her recovery with constant care and physical therapy exercises at home
INITIAL PLAN
Acupuncture treatments 6 days per week with regular reassessments at 3-week intervals.
Focus acupuncture on clearing wind-phlegm from the channels and collaterals with continuous monitoring of vital signs for evidence of hypertension or pneumonia, both of which pose a greater risk to the patient’s life than post-stroke sequela.
Typical points include: Jiao’s motor region right side upper limb ~ lower limb, left LR3 ~ ST36, GB41 ~ GB34, Ba Feng, GB39, SP6, LI4~LI11, Ba Xie, DU26, CV24, ST4, ST3, SJ23, Yu Yao (~ indicates e-stim between points at 5Hz continuous for 5-8min). Total treatment time is limited to 10-15 minutes, as the patient is easily fatigued by acupuncture.
Counsel patient about twice-daily exercises to flex and extend left toes, foot, leg, fingers, hand and arm. Encourage routine exercises in spite of lack of joint movement. Encourage patient to go outside daily to sit upright in the sunshine and take short walks with the assitance of her family. Teach the patient’s family to massage the patient’s left limbs with mustard oil, gently moving the arm and forearm to full extension to reduce contracture
CONTINUING TREATMENT PLAN
Subjective
4 weeks into treatment, the patient develops a cough with inability to expectorate. She denies fever or chills, sore throat, headache, or tension in her neck and upper back. The little sputum she expectorates is thick, sticky and yellow-grey. She is living on the ground level of a brick and mortar house with hard pack dirt floors. She spends most of her time on a makeshift bed, consisting of a pallet of 3 blankets over top of a plastic tarp to protect her from the cold-damp weather of early winter in Nepal. The patient’s family takes her outside daily in the sun to do exercises and rest in the warmth for a few hours each day. Otherwise the patient spends most of her time lying on her back in this room without electricity or heat.
Objective
Chest auscultation finds high-pitched crackles in the upper lobes, and percussion produces increased resonance in the lower left lobe of the lung. Blood pressure is 160/70mmHg, pulse rate is 68bpm, and pulse oxygen measures 92%. Oral temperature is 98.3 deg F.
Assessment
DX: Possible consolidation of the lower left lobe of the lungs, likely due to immobility and secondary pulmonary hypertension. The exact cause and severity of the fluid in the lower left lobe of the lungs cannot be determined without additional testing.
TCM DX: Cough due to phlegm-heat in the lung PROGNOSIS: Good as the condition is caught early and is monitored with auscultation of breath sounds at every acupuncture treatment. The patient’s living environment will not change, however, and will be a continuous challenge throughout her recovery.
Updated Plan
Points added to the initial acupuncture prescription include LU5 and ST40.
Internal formula administered is Qing Qi Hua Tan Wan 8 pills TID for 3 weeks. The patient is also immediately referred to her allopathic physician for uncontrolled hypertension and is prescribed Amlodipine 5mg QD.
Counsel the patient and her family on adequate water intake and proper diet to reduce phlegm and hypertension.
OUTCOME
After 36 treatments, the patient exhibited major changes in the motion of her left foot, and marked improvement in auscultation and percussion of her lungs. She described her limbs as feeling “lighter.” At this time, she was able to walk slowly with the assistance of a walking stick and 2 other people, and she could stand with a walking stick and the support of 1 other person. Her shen/mood became much brighter as indicated by her laughter and smiling during treatments. She began to look forward to walking with her goats in the fields again.
The patient’s left knee could actively flex and extend through 90 degrees range-of-motion. She could plantar and dorsiflex her ankle 5 degrees and dorsiflex her great toe voluntarily. The other toes could dorsiflex with needle stimulation. She could flex her left elbow 10 degrees and extend 5 degrees, but she continued to be unable to move her left fingers and wrist. Contracture of the left forearm significantly reduced with regular home massages, and the patient reported pain and tingling in her left arm after massage and acupuncture. Sharp/dull touch became equal side-to-side, while DTR’s on the left were still at +3. The patient was also able to sit upright on her own for long periods of time without assistance, and her speech became much clearer and easier to understand.
The patient described her lungs as feeling less congested, and she found it easy to expectorate phlegm. Her lungs sounded markedly clearer on auscultation. High-pitched crackles remained, but there was no longer resonance on percussion of the lower left lobe. However, the lower right lobe exhibited some slight resonance with percussion. Her blood pressure reduced to 130/72mmHg, pulse rate was 72bpm and pulse oxygen increased to 96%.
Her tongue was thin and slightly red with a clear dry coat. Her pulse was slightly rapid, thin and taught across all positions.
CONTINUED TREATMENT
The patient will need continued daily acupuncture treatments with emphasis on clearing wind-phlegm from the channels and collaterals. The patient’s blood pressure and lungs should be routinely monitored. Her physical abilities should be objectively measured every 3 weeks with emphasis on active range-of-motion, DTR’s, sharp/dull touch and facial muscle testing.
With further resolution of the consolidation in her lungs, herbal treatment focus may shift from clearing phlegm-heat from the lungs to nourishing the patient’s yin and clearing empty heat. The patient should be referred to allopathic care for more testing, diagnosis and stronger medications if the consolidation in her lungs becomes more significant, spreads to more than one lobe, if she develops a fever or if her blood pressure increases above 140/90mmHg.
The patient has responded well thus far to regular acupuncture and herbal treatments, and continued improvement is expected.
CONCLUSION
Routine acupuncture treatments are an effective method for regaining mobility post-stroke, particularly when used in conjunction with supportive home care and regular physical exercises.
In providing daily treatments, the acupuncture physician is in a unique position to serve as a primary care provider, monitoring for other physical ailments which may develop quickly and pose a significant threat to the patient’s recovery. As demonstrated in this case study, routine auscultation of the lungs led to early diagnosis and treatment of fluid consolidation in this patient’s lungs.
62-year-old male was diagnosed with Parkinson’s disease 8 years ago and has been receiving treatment in this clinic since 2009. This case explores the positive role that Chinese medicine can play in providing palliative care to patients living with a chronic degenerative disease.
Subjective
62-year-old male presents with a burning sensation in the body and bilateral trembling of the legs and arms. The burning sensation is felt in the head, knees and soles of the feet. It begins when he wakes in the morning, increases in severity during the day and subsides when he goes to bed. Patient reports that during flare-ups, his trembling and other symptoms decrease.
He experiences bilateral trembling of the legs and arms and trembling of the mouth and tongue. Symptoms began 8 years ago with trembling in the 5th finger on the right hand. It progressed up the arm and eventually lead to bilateral trembling of the arms and legs. Patient’s family reports a lack of tremors during sleep, which resume upon waking. He notices a feeling of stiffness in the whole body, especially pronounced while walking. Patient expresses difficulty in remembering words and completing sentences, and that other people have difficulty hearing him when he speaks. Symptoms get worse with stress, sadness, fatigue, hunger and goat meat.
Associated symptoms include: day and night sweats, vertex headache, positional dizziness, vertigo, excessive salivation, constipation, thirst, pain and hesitancy with urination, mouth sores and difficulty with sleep. Patient expresses an understanding of the chronic nature of his condition and is sometimes overcome by sadness, worry and fear.
Objective
The patient presents with visible bilateral trembling of the arms and legs, and trembling of the mouth. Trembling is more severe in the patient’s arms in comparison to his legs. His voice is noticeably diminished in both strength and volume, demonstrating signs of hypophonia. Patient exhibits bradykinesia of the upper and lower limbs while walking, a slightly unsteady gait and rigidity in movement.
Patient’s tongue is purple with horizontal central cracks and a greasy yellow coat. His pulse is slightly rapid and wiry
Assessment
DX: Parkinson’s disease
The patient presents with the 4 cardinal signs of Parkinson’s disease: resting tremors, rigidity, bradykinesia and postural instability. Associated autonomic dysfunction is also present as seen in the patient’s propensity to suffer from constipation and urinary difficulties. Laryngeal dysfunction and dysphasia, commonly seen in Parkinson’s patients, are observed with softness of voice, vocal tremors and excessive salivation. Relief from symptoms with the use of Levodopa is often used as confirmation of a Parkinson’s diagnosis, and the patient has experienced relief with this medication.
TCM DX: LR and KD yin deficiency leading to fire and internal wind
Prognosis
The prognosis for this patient must bear in mind the chronic and degenerative nature of his disease. The goal of treatment is to provide palliative care to help relieve the symptoms of the disease and the side effects of his medication. Treatment is also aimed at prolonging the effectivenes of his medication and to slow the progression of his disease. Additionally, the goal of treatment is to help the patient psychologically cope with his condition, and will at some point transition into providing a form of hospice care. Given these conditions, there is a good prognosis as Chinese medicine is effective at meeting these goals
Plan
Treat 3 times per week to help moderate symptoms and slow the progression of the disease. Focus on reducing the burning sensation in the body by clearing heat and nourishing KD and LR yin. Internally, use the formula Zhi Bai Di Huang Wan in a dosage of 8 pills TID. Acupuncture point selection includes KD2, KD6, LU7, SP6, LI11, LR2, GB20 and Jiao’s scalp tremor line.
As treatments progress and the burning sensation disappears, expand treatments to focus more on settling wind and helping with speech. The patient is switched to the formula Tian Ma Gou Teng Yin in a dosage of 8-12 pills TID. Acupuncture points are expanded to include TW5, DU15, DU16, CV24 and Jiao’s scalp speech zone.
Treatments can last indefinitely so long as the patient continues to experience positive symptomatic relief. Reevaluate every 12 visits to assess progression of his condition.
Outcome
After 3 treatments, the patient reported a 2/3 reduction in the burning sensation in the head and a complete absence of burning sensation in the knees and soles of the feet. He also exhibited a visible reduction in bilateral trembling during and after treatment. The patient reported that the effects of treatment last for about 2 hours, and extend the effectiveness of his medication. His demeanor and affect became visibly lightened after treatment
Conclusion
The difficulty of and question brought up by this case is understanding the role that Chinese medicine can play for patients suffering from chronic progressive diseases. This case demonstrates that the use of acupuncture and herbs can provide palliative care and help to increase the quality of life for patients by mitigating the symptoms associate with Parkinson’s disease.
Additional questions arise due to the nature of side effects caused by Levodopa, which can help to control trembling associated with Parkinson’s, but also causes trembling and other symptoms normally experienced by Parkinson’s patients. It is difficult to assess how much the treatments address the symptoms associated with Parkinson’s diseases versus the side effects of the patient’s medications.
Ultimately, the effects of treatment are beneficial, as they provide symptomatic relief for the patient, and may help keep the patient on the lowest dose of medication possible for the longest period of time. Furthermore, the effect of acupuncture and tri-weekly treatments to help patients cope psychologically with the reality of their condition, cannot be understated, as many patients with Parkinson’s disease are susceptible to depression. The patient expresses that while he has an understanding of the progressive nature of his condition, coming in for treatment not only provides him with relief from physical symptoms, but also provides him with a sense of hope.
52-year-old male presents with right-sided, burning head and ear pain, right-sided hearing loss and anosmia. It is determined, after an initial ear examination with an otoscope, that the patient has a severe right-sided ear infection. After 12 treatments, which includes the use of acupuncture, internal and external Chinese herbs and antibiotics, the patient reports a significant reduction in the burning sensation. Objectively, the right side tympanic membrane shows a 90% improvement. There is no change in the anosmia and hearing loss.
Subjective
The patient presents with right-sided, burning head and ear pain that started 6-7 months ago. His symptoms also include right-sided temporal headache, an itchy sensation deep in the right ear, tinnitus that comes and goes and right-sided hearing loss. He reports he can hear people talking, but can not clearly understand what they are saying. Anosmia started 2-3 months after the burning head/ear pain started. The patient reports that it feels like he has a ‘fire’ inside his right ear, and prior to the pain starting, he heard a bug-like sound. He has moderate pain (4/10), which doesn’t interfere with work when he is concentrating on a task. When he is not distracted, the pain is constantly present. Nothing makes the pain better or worse. Although he has loss of smell, he can taste his food.
Objective
The patient appears to be in good health for his age and environment. He’s always in good spirits and maintains eye contact during the interview. He is often joking with the other patients in the room while waiting his turn for treatment.
An initial right ear examination with an otoscope shows a purulent and inflamed tympanic membrane. The entire membrane is ringed with redness with bright red streaks throughout it. There is pus along the superior border and the entire tympanic membrane is severely scarred and cloudy. The left membrane appears normal and healthy.
A strong smelling substance, called Tiger Balm, is held under the nose while the patients eyes are closed. He reports that he is unable to smell it. Both sides of the nose are checked by holding the balm under one nostril while the other is plugged. Anosmia appears to be bilateral.
Hearing loss is checked by using a 128 hz tuning fork. Patient reports that he is able to hear the sound until it is 6 inches away from the right ear. The left ear is also checked. He can hear it until it is 1 foot from his ear.
Pulses are wiry, slippery and rapid, especially in the Liver position. Tongue shows a pale center with red sides and a greasy yellow coat.
Assessment
DX: Severe, right-sided ear infection with anosmia and auditory deficit
TCM DX: Damp-heat in the Triple Burner and Gallbladder channels
PROGNOSIS: Using oral antibiotics, herbs, antibiotic ear drops and acupuncture, a complete recovery from the ear infection is expected. With the treatment of the ear infection, there is a possibility the patient may recover
Ramkrishna December 2021, Thaha, Makwanpur, Nepal
On the initial visit, the patient appears to be very agitated, and his eyes dart around the room as he walks through. His mother holds his arm to physically lead him in and direct him around the clinic. After he is seated, he continuously turns around to look out the window so his chair is turned to allow him to focus on the activity outside, which calms him slightly. Due to his mother’s concern about touching him too much, pulses are palpated lightly. They are fast and full. He is warm to the touch. He is partially uncooperative with tongue diagnosis, but he does open his mouth and curls his tongue upwards. Sublingual veins are engorged and purple. He is agitated, and swats at anyone who is standing too close. At times, the interpreter stands outside the window to distract him and keep him visually occupied.
Outcome
Outcome
Conclusion
As healthcare providers, it is hard to accept that no matter what knowledge we bring to the bed of a dying person, we will not find a way to “save” the patient and somehow magically restore their body. I encountered this difficulty in the first couple of weeks with Lal Lama. I worked all day to problem solve health issues that could be cured or managed. At night, I had to shift my intention so that I could listen to a patient’s story about his life and receive information about what his best death looked like, so that I could advocate for that if necessary. I had to tell the patient that there was nothing I could do to cure him, and that we were limited in the management of his pain. I felt myself unworthy of sitting with Lal and told myself that there must be a doctor nearby who could do this job better than I could. I finally came to realize that I was the best that Lal had, and in the end, I am so grateful that I embraced that and became the listener and friend that he needed. He taught me how to sit with the dying and how to die when the time comes for me.
Outcome
Conclusion
With regular acupuncture, in conjunction with herbal and antacid treatment, the patient is expected to experience a minimum of 50% improvement in her epigastric pain and associated symptoms. Progress is contingent upon patient’s compliance to the treatment plan, and taking herbal and antacid supplementation as prescribed, as well as the avoidance of trigger foods.
57-year-old post-menopausal female presents with constant burning uterine and bladder pain for 3 years. Allopathic care has been unsuccessful in diagnosing and providing relief of symptoms. In using combination therapy of acupuncture, Chinese herbs and western antibiotics, the patient has had a marked decrease in burning sensation and uterine pain, and almost complete cessation of accompanying symptoms in 10 treatments.
Patient appears to be in good health for her age, cultural background and environment. She has a suppressed demeanor and it is difficult to maintain eye contact with her. She speaks very low and says few words when questioned.
The patient appears thin and somewhat malnourished and deficient. His cognition appears to be intact and his speech is age appropriate. He is visibly disturbed by his illness and there is a sense of desperation in his search for a solution. The sclera of his eyes have a red tint and he occasionally has watery and itchy eyes. He has a stye on the superior, left eyelid.
DX: Headache from the sequela of Typhoid fever, sinus blockage, occipital neck pain
The patient has difficulty talking due to breathlessness and audible wheezing. When she moves, the wheezing increases. She has a weak and raspy voice with the occasional weak cough. She appears to be in average health for her age and environment. A strong wheeze can be heard through auscultation of her lungs. The first measurement on the oximeter is recorded at 91% O2. The patient is in moderate pain, indicated by her ability to smile, laugh and respond to questions. However, walking and sitting are difficult. All joints of the patient’s hands are swollen to 40% larger than normal and her feet and ankles are swollen to 30% larger. Both the hands and feet are hot to touch. No bone deformities are present. The patient has an 80% reduction in the active range-of-motion of all her finger joints and is unable to make a fist. She has a 30% reduction in the active range-of-motion of all the joints of her feet. The passive rangeof-motion of her joints was not tested.
Patient has a thin body, but appears energetic, smiling, talkative and open to conversation with full eye contact. She knows some English and answers the questions directly when she is able. Upon palpation, the skin is warm, tougher than the surrounding skin, and exhibits a hard central mass that is moveable. The cyst sits half an inch off the skin and about half an inch wide, on the crease of the left wrist, with localized sharp pain when palpated deeply, which she expresses through guarded behavior. There is also some additional swelling and redness at the height of the mass, but no lack of range-of-movement in the joint.
Patient to be treated at the satellite clinic 2 times per week for 10 weeks and reassess progress after a second ultrasound. The focus will be on constitutional points, surrounding the area with needles, herbal treatments internally and externally, along with self-massage and qi gong. Aim is to reduce pain and size of the cyst to avoid surgery.
Patient’s overall health appears to be above average for age and environment. Her demeanour is generally relaxed and cheerful, but with a tendency to carry herself with a slight unease. She occasionally winces due to pain. There is distinct rebound tenderness when palpating the joints of the right hand compared to the left, especially the metacarpal joints. There is also strong palpable tenderness when applying mild to medium pressure to the medial and superior borders of the scapula on both shoulders, and when applying medium pressure to the posterior and anterior borders of the glenorohumeral joint of the left shoulder. There is distinct tenderness when applying moderate pressure to the lower borders of the patella and medial epicondyle of the tibia on both knees. Ankles do not produce distinct tenderness when palpated.
To note, occurrences of misdiagnosis can happen. There are no medical tests for this disease and a definitive diagnosis of Parkinson’s is not possible while a patient is still alive. The most accurate diagnosis would be made by a neurologist who specializes in movement disorders. Therefore, the true diagnosis in this case study is speculative and impossible to confirm.
DX: Atrophied, poorly-excreting right Kidney with severe hydronephrosis and a thin renal cortex; Hypoplastic right renal artery
