[Ann Emerg Med. 2008;52:457.]
I woke to the sound of a fist on wood, metacarpal muffled by a thin cushion of skin, urgently hammering away in the darkness. I delivered myself from the fetal warmth of my sleeping bag, donned a headlamp, and went to investigate. Pushing open the creaky wooden door of the Himalayan Rescue Association clinic, I stood facing 6 or 7 dark, tired faces. I recognized the foremost young man as the grandson of the 91-year-old Manangi man I had seen earlier that day on a house call with Gobi, our Nepali translator and de facto chief medical officer. Laboring with pneumonia and delirious from sepsis and hypoxia, the desiccated and leathery village elder was moribund, and we had communicated such to his family. Nonetheless, we had gone heroic, developing-world style, infusing fluids and ceftriaxone intravenously, hoping to give him a fighting chance. I roused Gobi who, after 4 to 5 minutes of animated conversation and gesticulation with the men, turned to me and said, simply, “He's worse.”
Manang was bathed in the high Himalayan moonlight and we walked without torches. Gangapurna and the Annapurnas glowed blue, their unfathomably massive icy faces—which in the light of day taunted and raged like angry gods—now were like benevolent ancient fathers ameliorating the loneliness of the night. We strode by teahouses packed with snoring Israelis and Europeans, and passed rakshi (the local bathtub spirit) houses still brimming with the drunken exuberance of teenaged porters. Clockwise we rounded the town's stupa and dutifully spun the prayer wheels, urging good karma for our patient and ourselves. A few stray dogs joined our troop transiently, hoping for a handout, and then drifted off into the muddy alleys of old Manang as silently as they had arrived.
We ascended the moist, mushy wooden ladder from the stable to the upper living quarters of the family's house. The air was thick and sweet from incense and the wood-burning stove. Old women wept and chanted mantras. Young men in jeans and leather jackets milled about with hands in pockets, smoking cigarettes. Yam, the local health worker, came from the old man's room and greeted us: “Namaste, my friends. He has passed.”
The man lay in the corner of the back room, swaddled in musty wool quilts and yak hair blankets. His visage, illuminated only by the flickering of candlelight, was calm and lacked the washed-out, veiny pallor of the deceased in the fluorescent houses of healing in the West. Gobi chatted with the man's son and grandsons. We learned that, in his youth, the man had trained briefly in a Buddhist monastery to become a monk but had abandoned it to become a trader. Like many Manangi men, he had become a man of the world, travelling to Hong Kong, Singapore, Indonesia, and Malaysia. Gobi shook hands with the man's son and, with a gentle shrug, said quietly, “Ke garne?” (in Nepali, roughly, “What can you do?”). I offered my Western-style condolences with a handshake and a brief, firm grip on the son's shoulder. As I turned to leave, I felt the son's hand on the back of my neck, protectively guiding my head below the low-lying top beam of the wooden entryway.
Walking back to the clinic, Gobi explained that already the man's family and the local villagers were beginning to gather at the man's house to pay respects. In the morning, the local Lama would come to the house and begin the days-long mourning ritual as prescribed by the Tibetan Book of the Dead. This would culminate with the man's being cremated on the banks of the Marsyangdi River, just west of the village. As we passed the rakshi house, ebullient laughter lifted from the small wooden shed, echoing off of the soaring, snow-packed flanks of the stony old men who loomed silently above us, casting their moon shadows, knowing things but not telling.
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