The feeling of putting the stethoscope around my neck was comforting. The nurse in this rural Himalayan hospital creaked her neck to the side as I asked her, in my foreign tongue, for its use so as to listen to and examine my newly found friend.
I had been unable to obtain his vital signs. His pulse had been faint and he looked horrible. This once vibrant young Indian man, who now had sunken eyes and the appearance of significant, life-threatening dehydration, was struggling. Too proud to admit that he was worsening, I told him straight out a few hours earlier (as we sat at roadside breakfast stand consuming coffee sweetened and spiced with chai) that it was time to get him to a hospital.
He was a driver, one of the pair that we’d hired through a close friend in Delhi to drive us to the Himalayan highlands. Ragu had accepted happily, as the quick, four-day journey would likely take care of a month’s worth of bills. As a truly dedicated professional, he was totally focused on us as his clients. The idea of giving in and potentially causing us to miss our flight out of Delhi was too much for him, but his worsening gastroenteritis, persistent nausea, and vomiting had left him in a greatly weakened state. Our return to the chaotic, noisy, and bustling streets of the Indian capitol would have to be put on hold.
He finally gave in and agreed to get to the nearest hospital. Our second driver, the young Jedi apprentice, raced forty kilometers through the winding, treacherous roads of the Himalayas in search of the nearest town large enough to house a proper hospital. We finally found one. An 800 rupee bribe in this corrupted Indian system was enough to have our newly found friend seen and evaluated in short order. His blood pressure low, his heart rate elevated, he was in desperate condition and required immediate fluid resuscitation.
I had spent the entire drive that early morning watching, calculating, and pondering his clinical course. He had looked bad the day before, but had been urinating, and was without diarrhea, likely due to the anti-diarrheal I had given him. Overnight, he had started vomiting and was not able to keep any fluids in his body. He was worsening by the minute and his condition deteriorated. I saw the desperation, observed his worsening state, and forced him to pull the trigger on promptly getting to the hospital.
Walking in, it was a vision I had never experienced before. The entrance to the emergency room was packed with people standing in line to be seen by the one physician present. The metal gurney appeared to be from a bygone era, both archaic and decrepit. Monu’s bribe prompted a quick evaluation and I was informed that Ragu was in hypovolemic shock. How had I let this happen? How could I have prevented it? The questions raced through my mind, but I was convinced in the end that I had succeeded in getting this stubborn man to give in to letting me find him proper help with intravenous fluids. The one-room emergency department festered with dirty and used IVs. The green laminated floor was covered in dirt, mud, and a layer of water. The end of the monsoon season was still evidenced in this hospital, and I was amazed at its condition.
Ragu received his initial fluids and was subsequently admitted to the inpatient medicine service. The man was very sick and, still, was asked to walk the three flights to the inpatient ward. An attendant boy of fourteen or fifteen followed him with two liters of fluid hanging overhead. I adjusted the IVs insuring the fluid continued to enter his system, and walked beside him, as I feared that he would fall over as a result of his weakened state. As we entered the male-only medical ward, I was (once again) amazed to see the conditions. I’m accustomed to patients requesting the remote control for their flat-screen televisions, bothered by the uncomfortable beds in their single occupant rooms. Here, families piled into the rooms, patients stacked onto one another. Ragu sat on a bed, careful to only take up one half, as the old man that was being transferred in at the same time required the other. Here was my new friend and driver in terrible shape, having to share one of eight beds in this packed room. The conditions were so far from what we see in America, so dirty and unsterile. Again, used IVs sat everywhere, medications yet to be given rested on tables, and one nurse cared for over thirty patients.
I was troubled, needed to do something, needed to employ my training. I was lost without my stethoscope, unable to evaluate properly, so I tracked down the nurse and asked her to find me a stethoscope. She was kind enough to find one, and as I listened to Ragu and obtained his blood pressure with a pre-1950′s sphinygometer, I felt the eyes of the local Himachal people staring, wondering what this big American was doing in their presence, giving so much attention to one man. He had stabilized with two liters of fluid and I was reassured; in fact, I was relieved.
With the fluid running in, we wondered where Monu had gone. He had disappeared, and had only occasionally been appearing with news from the local doctor. We wondered what he was doing. In fact, he was working the system, one dependent on the ability to pay out of pocket. He had raced to the pharmacy which was located a block away from the hospital. He had obtained the medication Ragu needed and delivered it to the nurse. There was no inpatient pharmacy that tubed the medications up to the rooms. Everything was done by hand, and the only way to get medications was to buy it yourself outside of the hospital. Sure, the nurse was happy to give it, but there was no way for her to get the medications unless they were given to her. Monu raced around and around, attempting to get the help Ragu needed, paying the appropriate people for prompt service. He had succeeded, and it was a wonder to see.
We had left Manali at approximately five that morning, piling into the all-wheel-drive Toyota minivan that had endured so much over the past several days. An unsuccessful attempt to reach the Rohtang Pass, stopped by mud slides and impassable roads, had followed one of the most fear-provoking drives I had ever endured. The winding roads, no safety barriers, death drops at every corner, the impeccable weaving through goods-carrying diesel trucks that traced the mountainside at a snails pace – it all added up to a terrifying experience, with nothing left to do but trust. There were trucks bent over the side of the roadway, folks on motorbikes, and auto rickshaws filling the narrow highway. The driving was insane — death-defying, in fact. Monu, as the young apprentice and healthy of the two drivers, did a wonderous job of navigating the madness of these roadways.
We felt that we’d left that morning with ample time to make our midnight departure out of Delhi. Though it had taken us fourteen hours to ascend to Manali, we were quite confident that leaving fifteen or so hours would give us some breathing time.
Oh, were we wrong.
Taking Ragu to the hospital, though necessary, cost us precious time. We had been caught in a struggle to balance the need to get him the proper care with the need to get to the airport in time. Monu was hellbent on getting Ragu back into the van with us, thinking that the treatment would be better in Delhi. I disagreed, feeling that our friend needed immediate care and that it was not safe for him to travel. Though I would have taken the responsibility of caring for him if I were forced to, I could not, in my best clinical judgement, take him with us. When the time came to depart, he stayed behind.
We did not take that decision lightly, but felt that we had no choice – the clock was ticking. Monu piled us back into the car and we set out, hoping that time would be on our side. Little did we know then that we would have to navigate through a severe rainstorm. The roads would be treacherous and every minute would feel like an eternity.
It wasn’t that we didn’t trust our young Jedi driver, but how could we (as the control freaks we were) just sit in the backseat watching events unfold? We couldn’t see fifty feet in front of us. The roads that, only days before, seemed impassable were now covered in mudslides. The rain poured down and left waterfalls on the side of the road. Rocks and debris littered the landscape of the road, and we sat in the backseat, doors unlocked, seatbelts off, and hands on the oh-shit bars. We were tense, ready to jump out of the vehicle at any time. Monu assured us,“No problem, sirs! Nine o’ clock we will arrive at the airport!” We believed him right up to the point that it appeared the road may close. He raced on, dodging and weaving between cars and trucks. We passed a head-on collision between a truck and a passenger bus and imagined what kind of shape we would be in if that were us. We raced through those mountains puckered and frightened.
We descended to the lowlands, passing through a lightening rain and dense fog. As we passed over the deteriorating roads, we looked at each other, all feeling a sense of relief. With a pound of the fist, we celebrated having endured a morning that felt like an infinite mind-suck of emotion and fate. Monu told us, “I think we can make it by nine o’ clock,” but had admitted that he thought that it may have taken us until 11:00 pm, as he had originally thought when we first left Ragu at the hospital.
Listening to music off my Ipod, amusing our young driver with selected songs from James Brown, the Grateful Dead, and Bob Marley, we sat in wonder. We were exhausted, the trip had been a whirlwind.
Kai had arrived after I’d been in Delhi for four or five days. I had originally set up this trip as a way to see a foreign land in the presence of a close friend who’d moved there a year prior. I mean, why not? I had worked hard over the past year, and it was time to get out of my shell and get back out into the world. I felt that the timing was perfect.
It had been, until bad news had reached us.
The friend I had visited informed me that his father was sick. He and his family had to make an emergency return to the States. My friend had to leave, but I had my old traveling companion arriving not two hours later. We had counted on our buddy as a tour guide, but now it would be two big ol’ Americans, solo in India for the first time. It was doable, and we felt pretty confident since we’d navigated many places around the world together before.
Over my first several days, I had become convinced that the next latest and greatest video game would be called Rickshaw. The madness of the fourteen-million plus population of Delhi caused me to revel in the wonder of chaos. I have spent the last several years in a predominately caucasian city in the middle of the mountain west. Black ties and white shirts were now replaced by saris and mustaches that would make Tom Selleck whimper. I had become a minority once again, and not knowing Hindi brought a hesitancy in my thought which sparked a definite discomfort. It took some time for the unease to pass, but that uncomfortable feeling became somehow familiar as I relied upon my previous travels.
Now that Kai and I were alone in the large chaotic city, I felt it was time to take on the Delhi traffic and diesel fumes. We boarded a rickshaw and headed to Hauz Khas Village, a hipster neighborhood in the middle of the city. The expats and young Indian crowd packed into TLR, a local restaurant with fantastic cuisine. The house music pumped, and though Kai had yet to sleep in the past thirty-some hours, we enjoyed bad beer and new sights.
The following day, Lonely Planet guided our tour. We had wanted to see the city as tourists. Though our friend had left for Atlanta, his fortunate family had provided us with their personal driver for the next two days. No doubt, we took full advantage. Sonu was formal and polite to a fault, but the man knew his way around the city. Supposedly, he had given my friend’s dad a ride from the airport upon his arrival, and his professionalism had gained him a coveted position as a result of that fate. He drove smoothly, and gave a simple nod when we asked him to take us to yet another tourist destination. Hauz Khas again for shopping, India Gate, and an afternoon gin and tonic at the Imperial Hotel later, and we felt that we had glimpsed from Delhi what we needed. We packed it in for the night, not knowing what adventure lay ahead in the coming days.
Even with an early morning, heading to Agra would be an all-day event. Sonu showed up in the stylish and comfortable Skoda. We knew that few travelers could be so lucky as to have a personal driver. The drive to the Taj Mahal was a long five hours through villages and towns that showed us a life that we had never seen. Trash littered highways, and the chaos of people moving about their days while cows lazed in the middle of the roads were all visually daunting. A stop at a local tourist restaurant was highlighted by a dancing monkey, dressed up with make-up and a costume. The cobra that accompanied this roadside show ended up costing us what felt like a fortune, but we were okay with spending unnecessary money, primarily because we could.
Hours and hours of roadside chaos finally subsided. We had picked up our Taj Mahal tour guide beside the road. My mantra of not trusting anyone wearing a visor or pink shirt was again correct. Our guide, though trusted by our driver, was a swindler, and we had entered an entrapment of tourism. The Taj Mahal was amazing, as had been previously slated by its inclusion as one of the great wonders of the world. We had desired a nice meal and a good beer afterward, but found ourselves in the Fishermans Wharf of Agra. The Taj Mahal restaurant was atrocious, and our trust of the guide was faltering.
Next up, we were pressed to do some shopping. We had agreed, as the thought of the Star of India blackstone motivated us to find gifts for our lovers at home. We were disappointed and, frankly, shocked at how we felt like pieces of meat amongst the madness of tourism. The experience was frustrating and we wanted out. The day would end abruptly out of this frustration, and the drive home was filled with as much amazement as it had that morning. Visions from Slumdog Millionaire appeared. Stopped at that the traffic lights along our way back to Delhi, we saw the young children stoned out of their minds on whatever they had been drugged with. Begging and pleading at our windows, the dirtiness and unfortunate reality that exists far outside of our previous experiences was pervasive. It was an eye-opening and appreciated experience, but Kai and I are mountain people, and the chaos of the cities were beginning to tire our traveling minds.
The next morning came early. It was four o’ clock, and as we cleared the sleep from our eyes, it was time to embark on the next stage of our journey. The dream of someday seeing the Himalayas was only kilometers and hours away. Our friend had arranged for one of his friends to drive us to Manali, and it was then that we first met Ragu and Monu. The Jedi master of driving and his young apprentice. It took us very little time to see their driving skills. Both had been born and raised in the Himalchal region, and both had honed their skills on the winding roads of the Himalayas. We were hesitant to accept the backseat, as we were unaccustomed to having drivers and giving up total control of our fates. A few minutes of mindless chatter and getting-to-know-yous later and we were off. The dark of the Delhi morning was filled with a torrential downpour, but there was excitement in our souls; we were ready to get to the mountains.
Someone had told us that a ten to twelve hour ride was to be expected. It took a number of day trips to understand that in Indian Standard Time, ten hours could be fifteen or sixteen. Easily. The trip up to Manali did not disappoint: it took about fourteen hours. We had considered flying, but Kingfisher Airline was not currently flying into Kull as it was low season. The drive was long and frightening. I could have sworn we died a dozen or so times, and there were countless moments that squeezing our eyes shut eased the tension. The weather had been clear, but the roads were far from it.
On reaching Manali, we found one of those gems that seem a wonder from days of the past. It is hard to imagine that there are areas of the world that have yet to become totally inhabited by the adventure tourist, but it seems that Manali is far enough away from a major port or airport that people just have not figured out how awesome it is. The expats are there, as would be expected, and the town definitely caters to the traveler, but it was very different from any other place I had yet been. The town was real, the locals filled the streets, and the markets were vibrant. We checked into a hotel that was quite nice, reasonably priced based on American standards, and we ordered beers and room service for the tune of about ten US dollars between the two of us. We were amazed at how far our dollars went, and were treated to a lifestyle of kings for what felt like pennies.
Day one was focused on seeing the tourist spots of Manali. We visited temples, waterfalls, and dined at about 10,000 feet in the middle of the forest. This was a restaurant like I have never seen. It was beside the road, open to air, and even had a goat present in the kitchen. There were flies, and it was dirty, but we were assured that this would be an incredible meal. We dove into the experience and were not disappointed. The desolate spot was situated at the bottom of a waterfall. A young local took us for a short hike to see the area for a tip of about fifty cents. We ate the food with vigor, all natural and taken from the forest, and enjoyed every flavorful bite. The local spices were exquisite, and the open-air ambience was unforgettable. Just a few minutes prior to sitting down for our meal, we had sat drinking a Pepsi-Cola, real sugar and all, out of the bottle while sitting at a dining table that resided in three inches of water beneath a waterfall. The cool water on our feet felt like heaven after our short hike, and the locals accepted the equivalent of a dollar for a couple of sodas, chips, and a package of cookies. We had entered bliss, and not a moment went by that we did not appreciate the opportunity to be amongst foreign sites, smells, and tastes.
Though the trip into the mountains was next to perfect, Ragu had become ill that morning. He started having diarrhea and felt that it was likely due to the local water he had consumed the night prior. The irony that a couple of Americas had yet to get sick, and a local Himachal had taken ill, did not go unrealized. He was miserable and his vigor to guide us began to dissipate. We asked him to take it easy and make sure that he got enough fluids, hoping that he would join us the following day as we ventured to the Rohtang Pass.
Monu reported that Ragu was feeling a bit better the following morning, and we embarked on our journey to the highlands. Ragu had stayed back, and though he had not admitted the severity of his ills to us, we were told later that Monu had prodded him to get to the hospital as we continued our travels. He would not, and this would later haunt us all.
Too few hours of sleep later, and we were once again traveling the perilous roads. It was not ideal to spend close to 24 of the previous 48 hours in the car, but we knew this trip was short, and we wanted to see as much as possible. It was seven am, and it was time to go higher. It had rained the night before, the river was raging, and the morning fog was thick. Up to the point that the lanes of the highway past Manali turned to one lane, we’d thought the previous day’s travels could not have been scarier. Switchback after switchback, passing trucks with only inches to spare on either side of the car left our eyes wide open to the possibility of tossing over the edge. Again, we were tense, but our trust of Monu was growing by the minute as he navigated the madness with perplexing ease.
We passed roadside stands with one-piece snowsuits from eras bygone and skinny skis that we had ridden in the late 1980s. We laughed giddily about the absurdity of being up here where the mountains were so fierce. Kai and I have both skied around the world, covering all but Africa and Antarctica in our quest to ride every continent, and we drooled at the thought of returning here to explore the mountains on skis. We imagined what it would like to be here or someplace like Kashmir, skiing by helicopter, exploring snows of an exotic land. The thought excited us and planted the seed for future travels.
To say the that the Rohtang Pass is daunting is an understatement. We thought the day would be rather short, a mere 40 kilometer drive to see the sights of the massive and awe-inspiring Himalayan peaks, but even this seemingly brief jaunt was cut short by time. Eight more hours in that all-wheel-drive Toyota minivan had convinced both Kai and me that soccer moms in the States must have known something that had previously evaded us. That Toyota killed it as we attempted to reach the top of the pass.
It was not that the roads were bad; they were awful. The rains of the previous days had wet the terrain to the point that they were barely passable. There was no asphalt, guardrails, or signs of organization. The roads were a cluster of trucks, 4x4s, brave motorbikers, and even a few brave adventurers on bicycles walking their bikes up the 14 kilometers to the summit. Areas of the road were somewhat clean, but as we drove higher and higher, the road turned into one to two foot tracks in mud, rock, and water. Trucks were stuck and buses were crashing into oncoming SUVs. It was exhausting and, unbelievably, even more terrifying than any our previous adventures. We were unable to make it to the top of the pass. Fate, time, and mud lay in our way. Tired of spending countless hours in this minivan, we decided to walk down that damn mountain, bent on enjoying every possible minute of this journey. It was mind-numbingly absurd and amazing. The images will forever rest in my mind, and were especially vivid after a few beers and a soak in a natural hot spring late that afternoon back in Manali.
Upon returning to the hotel that night, we again knew that sleep would be of utmost importance. It was time to return home to the grind of our workdays, and we had plans for a 40+ hour journey of more than 600 kilometers by car and 14,000 kilometers by air. Prior to packing it in, I checked in on Ragu. The diarrhea had stopped, but his condition looked to be worsening. He assured me, “No fevers, and feeling much better.” I tried to trust his word, but was becoming increasingly more skeptical.
We awoke early, showered and packed, and checked out of the hotel. I completed the annoying guest service questionnaire that was forced into my hand by the overeager staff as I hoped that Ragu’s condition had improved overnight.
As soon as I saw him, though, it became clear that it had not, and that it had, in fact, worsened. The vomiting had started, and he was unable to keep anything down. He was committed to getting us home in time and refused help. It was clear that he would need to be seen in short order, but thinking that he could make it to Delhi where health care was much better than up in the mountains, we headed out. Moment by moment, I watched as he became increasingly more uncomfortable. His cheeks and eyes were now sunken, he possessed very little energy, and needed multiple visits to the roadside to vomit the little amount of fluids he attempted to consume. The concern heightened as we stopped for breakfast along the roadside. It was clear that his condition had become severe. We raced to the next town, fighting the clock of illness and departure. The havoc fit the chaos of our adventure in a sublime manner. We took the stride given to us and did right in all facets.
Ragu made it without complication after being given a few liters of fluid. We were put into the position of having to leave him behind in that small-town, dingy, third-world hospital. I was stuck between my instincts and responsibility as a physician and those of a traveler needing to get home. He was stable and so we set out on the conclusion of our journey. The roads that once seemed treacherous now seemed like child’s play as the young Jedi Monu navigated us safely back to the airport, winning himself a bonus for arriving to the airport a full five minutes prior to our initial schedule.
I write now sitting on the airplane returning home, attempting to make sense of the dream that has been this last couple weeks. An 8:00 am Stella Artois at the Chicago O’Hare airport leaves me in a haze that allows for reflection. If it weren’t for times like these, I am unsure that I would be able to fully appreciate the times and everyday life that I live. The world is a wondrous place and I could not be happier about being able to experience things far outside of my daily ritual and reality. Life’s journey is unpredictable. Grasping the full experience of it all fills me with an invigorating consciousness.
Having just put in his dues as an Internal Medicine resident at the University of Utah, Dr. Douglas Sborov will soon embark upon his next adventure as an Oncology Fellow at Ohio State University. He is an avid skier who has traveled the world over in search of the perfect powder, and enjoys the practicality of telling it like it is.