Dr. Besser's Notebook is a regular column that examines public health issues across the nation.
The trails in the foothills of the Himalayas are serpentine and in places quite treacherous. Lose your footing and you can drop hundreds of feet. Budh Ram was a 15-year-old shepherd from one of the little villages around Manali, an idyllic town high up in the Indian state of Himachal Pradesh.
In 1986, at the end of my last year of medical school, I worked for five months at Lady Willingdon Church of England Hospital under the guidance of Laji, the facility's (and the region's) only physician and surgeon. What an incredible experience for me.
Together we delivered babies, removed appendices, debrided wounds and cared for a diverse population of Tibetans, Nepalis, Kashmiris and others. Tuberculosis, a sometimes fatal lung infection, was rampant, spread by both infected people and contaminated milk.
I met Budh Ram on one of the dimly lit hospital wards in the mission compound. He was quite small for his age, a likely result of chronic malnutrition. His mother and several other relatives shared his small space in the wooden room, providing for all his in-patient needs. He had fallen on one of the trails near Manali and had sustained a bad break of his left femur. The bone had poked through the skin and the wound it created had been quite dirty. By the light of a kerosene lamp, we examined his leg as he lay in traction.
Each morning, Laji would clean the wound and assess progress, not wanting to operate and place pins in the bone until the wound had been properly managed. Laji moved through the ward with business-like efficiency.
"How are you doing?"
"Wiggle your toes."
He reviewed Budh Ram's vital signs, looking for any sign of infection.
One morning when we entered Budh Ram's room, Laji's whole manner changed. Budh Ram was sweating profusely and his fists were tightly clenched. "Open your mouth," Laji commanded. Budh Ram cautiously opened his mouth a fraction of an inch. "Tetanus", Laji said.
Like many children around the world, Budh Ram had not been immunized. The open wound on his leg had allowed the bacteria that cause tetanus to enter his body and multiply.
Laji summoned one of the watchmen and gave him a note to take to a hospital five hours away by motorcycle. Budh Ram's slim hopes lay in getting tetanus antitoxin into his body before all of the toxin had bound to his nerve endings, doing permanent damage. It wouldn't be long before each of his muscles went into constant spasm. For a boy with a broken leg, the pain would be excruciating. Even with rapid treatment, it was likely that his respiratory muscles would seize up and he might die.
All day we waited to see if the drug would arrive. By evening, we'd received word that the first hospital had not had any medicine. The search would continue through the night. Budh Ram was given medicine for pain and we began to help him breathe with a respiratory bag and mask. Every few minutes his back would arch, his face would grimace and his eyes would open wide with fear. His mother sat by his bed comforting him, putting a cloth on his brow.
Budh Ram died the next night. I'd spent four hours by his bed squeezing breaths into his lungs 10 times per minute. We had no modern intensive-care unit, no ventilator and no monitors. Eventually, the lack of oxygen stopped his heart.