Today is Wednesday, the day I juggle two outreach clinics in one day. The clinics sit about twenty minutes apart by motorcycle. The morning clinic is in the village of Sipodol, nestled between green mountains and terraced fields. The afternoon clinic is in the bustling urban metropolis of Bhaktapur. It takes Sachyamohan and me forty-five minutes to an hour on the busy Ring Road of the Kathmandu Valley to reach the clinics. In the early morning, the fog hangs thick, damp, and cold across the Ring Road, and we often arrive at the clinic stretching out our knees and bouncing the cold out of our limbs. To reach Sipodol, we leave the Ring Road and ascend into a bamboo grove, then follow a winding road that snakes down into another valley. The last five minutes bounce and jostle the bike with unpaved dirt roads, rocks and potholes.

Across from the Sipodol clinic is a small shrine to Ganesh. The shrine was build around a rock that eroded into an abstract form of the deity. It has been painted into Ganesh’s likeness with scarlet and ochre minerals. The clinic director and Sachyamohan look down onto the brightly painted elephant, touch pious fingers to forehead and then enter the clinic. The clinic director is a wiry elderly woman that grins deeply from ear to ear whenever she sees us. Our clinic space is a simple eight by ten foot room with two twin beds, a long wooden bench and five chairs. My first week at Sipodol we treated two patients. This week we open the door to nine smiling faces. I take a deep breath and calculate that the Acupuncture Relief Project expects me to treat ten to twelve patients before lunch, and I reckon we can still meet our goal to be at Bhaktapur by 1:30pm.

We start treating the first returning patient, a man recovering from a surgery to remove a benign tumor from behind his ear. He has a thick scar from the removal, balance issues and hearing loss from the surgery. He adamantly believes that acupuncture is helping him, but he wants reassurance that his balance will return. I counsel him that I cannot guarantee that his balance will improve. I try to get more information about his tumor, about the surgery, hoping that it may provide insights for a more accurate prediction about his progress with acupuncture. The information comes back in scattered stories of Nepali festivals, and contradictory statements about whether the tumor was in his brain or his scalp. His symptoms before the surgery are just as elusive. This reflects the challenge of treating patients in Nepal. I made the typical American mistake of neglecting to make time to immerse myself in Nepali culture, festivals, and folklore before I left the States. In return, I find myself daily searching for the right colloquial phrase to elicit the pertinent clinical information that I need from my patients. Sachyamohan and all of the interpreters do an exceptional job of helping us find the answers, but some days it all gets lost in translation. His wife chimes in that his appetite has improved since getting acupuncture with the Acupuncture Relief Project (ARP), but he still has some short term memory loss. I begin to needle and continue gathering information from husband and wife as I palpate sutures in the skull looking for the correct acupuncture points.

While we talk, the room is humming with side conversations between waiting patients. Voices rise and fall in a crescendo of good natured teasing. Laughter erupts. Sachyamohan puts on some Hindi dance music from his phone. The frenetic rhythm of the music matches the cadence of voices in the small space. I like the joy in the voices. I like the organic swell of sound. I can barely piece together my thoughts. I begin to describe acupuncture to a new patient, letting them know the difference between a therapeutic and non-therapeutic sensation at the needle. I begin to needle. I see my patient pull a face and ask if the needle feels okay. Just as she answers, a wave of raucous laughter erupts throughout the room and a fresh cackle of teasing ensues. I cannot hear my patient’s answer. I take a deep breath. I repeat my question, leaning in to listen for the word “Tiksa” meaning, okay. I hear the sweet sounds of Tiksa pass her lips, and continue. I’m not sure how to politely ask the room to lower their voices and make a note to ask Sachyamohan’s advice over lunch.

I hear an odd shuffling sound coming from the door to the clinic. Curiosity causes me to glance over my shoulder. A young woman in her mid-twenties is carrying a woman on her back into the room. She holds the woman’s legs to her waist, supporting most of the woman’s weight with a silk scarf tied around her forehead and slung underneath the woman’s derrière. This is how women carry heavy loads in Nepal. They carry firewood, baskets of brick, stones, cement, or basically anything heavy by creating a sling from their forehead for the load. It is the first time I have seen a person carried this way and it catches me off guard.

The woman’s name is Sanu Kanchi (full name is omitted), and her daughter-in-law is the one carrying her. Her daughter also accompanies them and together the younger women, pull and push Sanu Kanchi into a seated position on one of the beds in the room. Sanu Kanchi cannot walk or control her legs in anyway. They occasionally twitch and flex on their own. She tells me that I will fix her in just five treatments, because this has happened before. About one to two years ago she went to the main clinic in Chapagaon for the same thing and she was ‘cured.’ I ask her if at that time she also had lost complete control of both legs. She assures me that, yes, it was exactly the same, and the previous acupuncturist had her walking again within five treatments. She continues without pause sharing that she is upset with herself because she ate yoghurt at the last festival and the yoghurt caused her legs to stop working again. I ask if she had had diagnostic tests done at one of the hospitals, and she tells me that they did four x-rays and none of them showed any issue in the spine. I ask about blood work or if anyone had discussed the possibility of an autoimmune disorder with her. She says no and emphasizes that it was the yoghurt. She did this to herself and now she is counting on me to fix her again.

No pressure. No pressure. I try my best to tread the murky waters of proper patient care. There is a narrow channel of safe passage between riptides where informing the patient of possibly negative health outcomes meets hope. My goal is to educate, inform, and maintain hope without giving false promises. My role here is further complicated by the nature of practicing medicine in Nepal. My colleagues and I often find ourselves doing the initial diagnostics, and referring patients for specific lab work or imaging. If we do not specify the lab work we want, there is no guarantee that the appropriate tests will occur. A perfect example is Sanu Kanchi’s case: she has had multiple normal x-rays, but has not been sent on for blood work, an MRI, CT Scan, or neurologic testing to suss out why she is loosing function in her legs. She also could easily not be able to afford an MRI or CT scan, but blood work costs the equivalent of three dollars.

Sanu Kanchi’s insistence that I will fix her in just five treatments churns my stomach with concern. I work to discuss the possibility that her condition may not improve like before, she may have a progressive disease or she may have an autoimmune disorder that cycles through remissions and regressions, amongst other possibilities

I state as clearly as possible that I do not know what kind of condition she has at this point in time. I would like her to consider doing more diagnostic testing with the hospital. I also need to find her chart from Chapagaon to get a clear picture of the previous acupuncturist’s assessment of her condition. She grins and reassures me that I will fix her. I decide to resume this discussion the following week, after doing some research.

The phone rings as her daughters shift her onto her stomach for treatment. The process of moving her around takes both family members. All three women smile, laugh, and joke as they get Sanu Kanchi ready for treatment.

On the phone the Bhaktapur clinic is asking when we will arrive. We are currently running thirty minutes past lunch. Today feels overwhelming, both with patient volume, the complexity of the cases, the commute, and my time constraints. I remind myself to breath and hum a comforting tune while I needle the final patients at Sipodol.

After a quick lunch, we hop on the bike to the Bhaktapur clinic where the morning seems to repeat itself. We end up treating until six pm, and ride home in the dark along the Ring Road. People walk slowly and steadily across the Road at unpredictable intervals, while cars and bikes weave around them. This is how one crosses the streets in Nepal, and it holds true for even the busiest street. The street crossings strike me as brave in the darkness of night, but I soon realize this is normal life in Nepal. It is only striking to me, the foreign visitor. I breath in deeply again, and wonder what do I really know about treating patients here in Nepal. My mind hovers on the case of Sanu Kanchi, and all that I don’t know about her daily life. Can she afford further testing? I flip through the possible causes of her leg dysfunction, the prognosis for each, and her unwavering faith in me to fix her. I feel stuck between a rock and a hard place. I hope, no matter the outcome, that we find a way to communicate effectively about her health.