11 October 2014

Ill on the road: Mr Peter the patient patient (Part 2)

Sometimes, when a desperately desired goal draws near, the effort required to reach it increases exponentially. That's how I feel after the taxi drops me outside the hospital and I shuffle into reception, the last of my physical and mental energy draining out of me into the Delhi heat. No one's attending the desk. I try a nearby counter but they have little English and just direct me back to the vacant reception desk. I can do without this. But a young man appears; I must go to the Emergency Department in the next building, he says, pointing. I creep out the door and across to Emergency, lean on the desk and say I need to see a doctor.

A few questions, then I'm taken to a gurney where a gentle, smiling orderly helps me lie down. A doctor and nurse arrive quickly; I'm questioned, prodded, and assessed; tests are arranged. A nurse inserts a cannula into a vein in the back of my right hand. Most of the rest of the day consists of visits from various doctors, all of whom ask similar questions to which I try my best to give consistent, accurate answers; of being connected to drips; of having blood samples taken; of being prodded -- one doctor palpates my abdomen with such vigour I wonder if he's trying to take a biopsy with his bare hands. I keep my yelp moderately dignified.

The smiling orderly comes with hospital pajamas and helps me change, then eases me back down onto the gurney. He puts his hand on my shoulder in solidarity and says something in Hindi; I have no idea what he's saying but understand him perfectly, and his kindness threatens to undo me. I hold it together and thank him.

On a gurney opposite me lies an ancient, yellowed woman, her eyes closed and sunken into the dark hollows of their sockets, her breathing shallow and strained. She looks to be barely alive, and compared to whatever affects her, my own illness seems trivial. On the gurney next to her, a man groans and, somewhere down the corridor, someone screams. A monitor bleeps regularly and monotonously -- the kind of sound that could be used to torture a prisoner. When a nurse checks to see I'm still O.K, I ask to sit up; she adjusts the bed and at my request places my bag next to me. I retrieve my pen and notebook and write a little. I don't like labels -- I prefer to say 'I write' rather than 'I'm a writer' -- but these roughly scribbled notes fulfil a commitment I made years ago to write every day, and in maintaining this perfect record even under these circumstances I consider I'm justified in calling myself a writer. Of course, what I see as dedication, others might see as obsession -- harmless enough, but ridiculous. Maybe they're right.

The gentle orderly comes and wheels me to the ultrasound unit. This involves a short trip between buildings, into the pleasant heat of the evening -- I've been continuously cold in triage, even after my kind orderly has tucked a blanket around me -- and I look up at the darkening sky with its tinge of orange. Crows fly overhead, black silhouettes, free to fly where they will. The sight fills me with joy and longing and hope; I'll get through this, I'll once again share the world with crows and kites and rose-ringed parakeets and the ubiquitous pigeons; I'll see babblers and palm squirrels again in the Deer Park, and maybe barbets or even the grey hornbill in the Lodi Gardens. Then the door swings shut behind us and we carry on to Ultrasound.

I'm given a thorough going-over. The doctor spends a long time going back and forth over the painful area, then calls someone else to confer. Part of the lower bowel has thickened, she says, most likely because of inflammation. This means a CT scan will be ordered, and the preparation for this is one of the most unpleasant experiences I've endured for many years.

A nurse wearing a mask appears at my bedside, clutching two one-litre bottles of pale pink, frothy fluid.
   'You must drink two litres in two hours,' she says, waving the bottles at me. She repeats her instructions, holding up two fingers for emphasis: 'Two litres in two hours.'
She puts the bottles on my tray. I look at the soapy froth and just know this won't be pleasant. I don't know the half of it.

It tastes like disinfectant mixed with dish-washing liquid, and for all I know, that's what it might be. I time my gulps, sometimes managing three in quick succession, sometimes just two. I want this over and done with, so I force the vile fluid down, finishing the first bottle ahead of schedule. The pace slows for the second bottle, though, because it's so nauseating each gulp makes me feel like vomiting. Surely there must be a better way? Once again, sheer will-power keeps me carrying on, but I wonder about people who simply can't manage this awful requirement -- how much is really necessary for a good CT scan? With about a third of the second bottle to go, I gulp another mouthful and somehow suppress the gag reflex so I can swallow the foul fluid. Involuntarily I shudder and grimace, and look up to see an orderly watching me as she waits by a wheelchair. She smiles, and I grimace and shudder again, deliberately this time, and say, 'It's horrible!' and she shakes with laughter -- not unkind, but understanding, and I feel a little better. I finish it all well within the two hours and the nurse with the mask comes and gives me the thumbs up; beneath her mask, she's smiling, as if proud of me.

After that, I couldn't care less what they do to me, which is just as well, considering the indignities I'm put through for the scan itself. This is when I start thinking about dignity and wondering why what would have horrified me before my illness now seems trivial. All I want is to know the scan's successful, and the more thoroughly they prepare me, the better.

The operator tells me the machine will ask me to hold my breath and I must do as it says. What he doesn't tell me is that if the machine does indeed issue the instruction, it must be in Hindi, because all I hear from time to time is something incomprehensible. Fortunately, it doesn't matter, and when I finally collect the report over a week later, I'm astonished at the clarity and resolution of the images.

Back on my gurney in triage, I'm visited by a doctor who breaks the good news to me.
   'It looks like appendicitis,' he says, 'so we'll start getting you ready for a laparoscopic appendectomy.'
   'That's great news,' I reply, aware of the irony of joy at having my appendix whipped out.
The doctor smiles and agrees this would be a simple and straightforward solution, but he points out they still want to do further testing to be sure they've correctly diagnosed the problem. This is when I'm so grateful I'm in one of India's best hospitals. Who knows what would have happened if I'd been diagnosed and treated in some place less thorough, with rudimentary facilities? I'd probably have lost my appendix and continued to deteriorate. The outcome doesn't bear thinking about. Here, though, in the hospital that can list as patients some of India's most important people, the doctors take no chances.

However, while appendicitis still seems likely, the preparations for surgery continue, and I'm taken for an echocardiogram. Usually, I imagine, this would be comfortable enough, but I've lost so much weight I'm nothing more than skin over skeleton, and at times the pressure of whatever it is he's rolling over my ribs feels like being massaged with a knuckle-duster. I keep quiet and put up with it. Something seems to worry him, though, and he calls someone else in; they keep pointing to blue and red flashes on the monitor. I learn later that I have a small amount of fluid around the heart, almost certainly related to the infection; fortunately, this isn't serious and I'm cleared for surgery.

That surgery doesn't go ahead, however. Late in the afternoon an administrator arrives, saying I'm to be admitted but I must pay 20,000 rupees deposit. I tell him my insurance company will pay; he asks for the name but isn't interested in contact details or policy number. I still have to pay myself, he says. Fortunately, my credit card works and I spend my first night in a room with three other patients, up to a dozen visitors, and no privacy whatsoever. In the morning I'm visited by a doctor who updates me on the test results -- my total leucocyte count (TLC; the concentration of white blood cells, which fight infections), is about double the normal figure, he says. The gastroenterologist also arrives, and this is when I learn of the change of plan. After a closer review of the CT scan, he says, they've decided the inflammation of the appendix is secondary, and the likely problem is an infection around the junction of the small and large intestine. They want to do a colonoscopy.

This, he says, means they'll give me a laxative in the evening, and when I'm 'crystal clear' (his phrase), they'll do the colonoscopy in the morning. Fine, I think, do whatever's necessary. If I have to make 7 or 8 trips to the toilet in the night, I'll manage that.

What I don't realise is that the laxative isn't a simple dose of something I can swallow in one go -- it's another two one-litre bottles of some other fluid within two hours. This vile stuff is even worse than that for the CT scan; it tastes like salty, lemon-scented floor polish. Don't ask me how I know what floor polish tastes like; I just know that with every mouthful my brain shrieks, 'Floor polish! Floor polish!' I try replacing the thought with 'Peach schnapps!' which I've never tried but had heard was revolting, but it doesn't work. The weird association with floor polish is too strong.

I force down the first bottle but fall behind schedule. Given I've eaten almost nothing for about four days, surely I don't need to swallow the lot? By the fourth trip to the toilet, I can guarantee I contain nothing solid whatsoever, but, doing my best, I keep attempting to swallow what tastes like distilled evil. Halfway through the second bottle, however, I realise another mouthful will turn it from a laxative to an emetic. I stop drinking it. The report I see later lists the quality of the preparation as 'Good'.

Once again, what I'd have thought of as mortifyingly undignified leaves me completely unmoved. It's all necessary, all irrelevant as far as my dignity's concerned. The sedative helps, too, and I remember almost nothing of the procedure, which I later find slightly disappointing because I'm interested to know what they're finding. Perhaps if I hadn't been sedated, though, I might have felt differently.

All this time, I've been on various drips, mostly broad spectrum antibiotics and saline with dextrose. My TLC returns to normal. My gentle orderly has been replaced with one who marches around like a bantam rooster, erect and bossy -- 'Change!' he says, handing me clean pajamas -- but he's efficient and well-meaning. Most of the staff call me 'Mr Peter', and I don't correct them -- I like the sound of it. The cannula comes partly loose; I point this out to a nurse, who adds extra tape that doesn't work and eventually the cannula comes out completely. She puts a new one into a vein in my left arm. That's one advantage of being so emaciated -- all the veins beneath the skin are clearly visible. The call button doesn't work, so to call a nurse if I need a drip disconnected, I have to get out of bed and push the button on the wall. I then have to repeat the procedure to remind them to reconnect the drip. The phone by my bed has been blocked, and when my friend Sally visits she arranges to have it unblocked so she and my brother and perhaps others can call me. A technician comes, checks the phone and indicates it's now fixed. It isn't, and still no one can get through. All these I can deal with, however, and I use these inconveniences to practise being patient.

On the second day, as I lie patiently waiting for whatever will be done to me next, an elegant middle-aged woman enters the room and introduces herself.
   'I'm from the New Zealand High Commission,' she says, and is on my case after receiving a phone call from my brother in New Zealand. Ramita asks how she might help, so I point out the problems the hospital's having getting in touch with the insurance company. After repeated attempts, I'd finally managed to get someone to record my policy number and the contact phone number, but the problem seems to lie with identifying the local, Indian insurance provider that should act on behalf of the New Zealand company. Besides, an administrator tells me, she's rung the New Zealand number several times and has yet to receive a response from my case manager. Needless to say, this has added stress I don't need. Ramita promises to phone the insurance company and get the problems sorted out, and I discover later she's as good as her word: with her intervention, communication between the insurance company and the hospital is finally established, just in time for me to be discharged.

I give her Sally's number, too. This proves to be crucial at the end of my stay when the hospital won't allow me to phone Sally directly; instead, I phone Ramita and ask her to relay the message that I'm ready to be picked up. Again, she's as good as her word.

On the third day, the supervising surgeon visits. He explains the diagnosis and prognosis, says encouraging things and seems generally satisfied with my progress. I can be discharged today or tomorrow, he says; it's up to me. Today, please. He smiles, shakes my hand, and, like most of the doctors, puts a reassuring hand on my shoulder. This small gesture always moves me, and I wonder whether I'd have been so affected by it had I not been in such dire circumstances. I do know that when Ramita walked in and identified herself as being from the New Zealand High Commission, I struggled very hard to retain my composure. Sally was still returning from a visit to the UK, so apart from my friends at the Smyle, I'd seen no one I knew. The sight of Ramita, and Sally later that day, reassured me in ways words simply can't describe.

All I'd had to sustain me was the knowledge I was in good hands, and the thought of my family and friends. Very few knew I was seriously ill, although some of my closest friends had some inchoate intuition something was wrong. Perhaps this can be explained logically -- for example,  by the slightly longer than usual spacings between blog posts -- but I'm not completely convinced. I thought constantly of those great friends and how, if they knew my condition, they would be providing every kind of support and aroha they could, and maybe that constant thought, in extremis, might have a way of making itself known.

Late in the afternoon I change back into my filthy clothes in readiness to be discharged. Sally's on her way to carry my bag and facilitate the administrative details. But the supervisor at the nurse station on my ward won't let me leave; wait in your room, she instructs me. Restless, I end up sitting in the corridor outside my room with several people who've been regular visitors to the other patients. I attempt to strike up a conversation with one man, but his English is almost as bad as my Hindi. He persists, though, and we manage to communicate a little about ourselves. Raj is a farmer from Haryana; his father-in-law, the man in the bed beside mine, has just had bypass surgery. Raj has no children yet, and has been married just six months. Eventually he holds up his phone and asks 'Photo?' We sit together and smile at the camera, and once more I'm moved by the fact that this man whom I've known for little more than a few minutes has felt interested enough to want a record of our fleeting interaction. When I finally leave, I shake his hand and try as best I can to indicate I wish him and his father-in-law all the best.

What will become of the photograph?
What will become of us?

The evening darkens. Outside, three stories up, a kite swoops past, close and beautiful in its command of the dusk. Birds of various types cross the sky: pigeons, crows, parakeets. I watch and can almost feel what it's like to soar through that warm, darkening air, watching the pitiful chaos of human life anchored so inescapably to the ground. Finally, night turns the plate glass window to a black mirror, and I turn away and look down the corridor. My life seems to comprise patient waiting.

Sally arrives and the nurse arranges a security man to escort us to the Billing counter. With her usual astonishing efficiency, Sally's already phoned the hospital's International Relations Manager to sort out the protocols, and she now leads me to the International Payments desk. Here we hit a snag; the man says we have to go back upstairs and wait. Sally knows this is not correct and asks to speak to the IRM. Some checking, and the man says the approval from my insurance company for payment has just arrived a minute ago. I go back upstairs while Sally lights a fire under the bureacracy.

Upstairs, the nurse now insists I must go back downstairs to Billing, so the security guard and the bantam rooster orderly take me down to Billing. The man from International Payments stands there; he looks in horror at me then starts gesticulating wildly at the orderly, asking him why I've been brought down here. I'm taken back upstairs to wait.

Finally, Sally arrives, having managed to convey to the IRM that my treatment during discharge is far from satisfactory. The IRM sets things in motion, even arranging a taxi to replace the one Sally had ordered but which had long gone because of the delays. We go downstairs again and I'm refunded most of my admission fee. While waiting, Sally explains the fiasco to one of the nurses, who has a good sense of humour and laughs with us.

Then we have to go back upstairs to collect the reports. The nurse and security guard accompany us, and at the nurse station the supervisor looks at me as if wondering why I'm back here.
   'You have not paid your bill?' she says.
I drop my head on the counter and start laughing; everyone else laughs, too. The reports haven't been collated, and we lose more time while the supervisor photocopies, files, arranges, and finally hands me my file. She shows me the prescription for my medication and gives a hopelessly inadequate description of how I'm to take my pills. I don't care; I'll get the information from the pharmacist or a reputable online site.

Sally picks up my bag and we go downstairs for the last time, out in the hot Delhi night, and into the air-conditioned taxi. The fiasco has ended.

Sally has arranged a discounted rate at a wonderful guest house in Green Park, and while I settle in there, she collects my medicines from a pharmacy and picks up a takeaway pasta for me -- no spices, as my doctor has instructed. What would I have done without her help? Somehow I'd have muddled through; eventually -- probably the next day -- I'd finally have escaped; I'd have ended up somewhere marginally liveable, relying on food that might or might not repoison me. I almost certainly wouldn't have ended up in Delhi's best hospital, getting the best treatment possible; and I'd have been under the immense stress of trying to negotiate Delhi's transport system while barely able to walk and mostly unable to think. To have someone attending to all those things and more, so all I have to do is sit back and appreciate how lucky I am is, again, beyond words.

Similarly, I think of all the obvious help I've received from other people: Ramita from the NZ High Commission in particular; my brother, who contacted her and activated my insurance policy; the staff at the Smyle, who arranged a taxi to the hospital and made sure I paid only the true fare; the Bardia people who organised my transport to Nepalgunj and flights to Delhi; my aunt, who took such great care of me in the UK when I came down with that other illness that may or may not have been related; others whom, to my shame, I might have overlooked. But the appreciation and gratitude that finally squeezed that small tear from my eye as I lay in the emergency department extends further, including all those who simply showed some compassion for someone having a tough time, like the man at Nepalgunj airport and the orderly who didn't need to grip my shoulder in a gesture of reassurance but did so nevertheless. It includes, too, and in a peculiar way I don't fully understand, particularly those who were unaware of my troubles but would have gone to endless lengths to support me if they had known, simply because they're my greatest friends.

The world is full of violence, suspicion, intolerance, hatred, and innumerable other evils, and we hear about those every day. But the world is also full of kindness, acceptance, joy, concern for others, and the recognition that we all share similar needs, and those things are mostly ignored by the media or trivialised by being turned into sentimental feel-good stories. Nonetheless, these characteristics of human nature comprise the essence of what's good about us; we all have the capacity to feel these things and most of us do. The last weeks have taken a huge toll on me, but the lessons have been priceless. Maybe I did, after all, find what I was not looking for.

1. Here's Part 1.
2. Recovery's going well. I'm still tired, weak, and thin (some would say emaciated, and they'd probably be right), but I'm improving steadily. I leave India in the wee hours of 17 October and touch down in New Zealand shortly before midnight on the 18th. It's been quite a journey.

1. Butterflies at Dachigam National Park, near Srinagar. Sometimes things that look fragile are more resilient than they seem.
2. A very pale, perhaps leucistic, palm squirrel in Delhi's beautiful and fascinating Lodi Gardens.
3. Babbler in the Lodi Gardens. Love these crazy birds.
4. Himalayan bulbul at Manali. Another beautiful bird that evokes strong, good memories.
5. Indian grey hornbill in the Lodi Gardens. Judging from the very small casque (the protuberance on top of the bill), this is probably a young bird.
6. Mosquito at Manali, in healthier times. A medical cannula's one thing; this kind of intrusion into a vein's quite another, particularly where malaria's endemic. My illness in the UK would probably have been a suspected case of malaria, but I had good grounds for believing it wasn't. I was right.
7 & 8. Proof of two things: I'm recovering, and I have plenty of time on my hands. The last photograph's from the second day after being discharged; the penultimate one's from this morning. 

Photos and original text © 2014 Pete McGregor

08 October 2014

Ill on the road: The limits of control (Part 1)

When, lying on my back on a gurney in triage at the Max hospital in Saket, New Delhi, I felt something very unbloke-ish slip from the corner of my right eye and trickle down my cheek, the cause wasn't sorrow or regret or that odious emotion, self-pity, but immense gratitude. Gratitude for two things in particular: my family and friends, whose aroha sustains me; and the kindness, compassion, and assistance of people who at least initially were complete strangers. That thought continued to sustain me, and often choke me up, over the next several days while I underwent exhaustive testing leading to an eventual diagnosis of and treatment for a nasty case of amoebic colitis.

Who knows where I picked up Entamoeba histolytica? I'd been persistently unwell since late August, but the parasite might have been biding its time for much longer; conversely, the other, mostly mild, illnesses might have been unrelated. Travelling in India during the hottest, most humid time of year puts great stress on the body, and a stressed body resists infections less effectively than a more resilient one. I'd had a mild cold during late August and that, too, can't have helped. Later, in the UK, something suddenly flattened me: fit and well one day, I ended up shaking, feverish, and asleep the next. My luck held, though, and my aunt looked after me superbly despite being clearly frustrated by my refusal to abandon my onward travel plans. That illness, however, was almost certainly unrelated and probably viral, and I recovered well and in time to travel onwards to Kazakhstan (briefly) and then to Kathmandu.

That's the dilemma of dealing with illness while travelling: do you tough it out and carry on with the plans, trusting the illness will pass (as most do), or disrupt the travel, stay put, seek treatment, and waste precious time? In my case, I suspect an early diagnosis would probably have been inaccurate because the symptoms were mostly nebulous, and the treatment would have been similarly ineffective.


The acute phase begins after the first day of a trek into the Annapurna Sanctuary. After the earlier illnesses, and considering I've lost a frightening amount of weight, I've been apprehensive about my ability to handle the walking, but the fear proves unfounded. I pace myself well, my legs and lungs handle the sometimes steep ups and downs easily, and I find my spirits lifted by the environment through which we walk. This, I think, will be what I need.

What I don't need, though, is the evening's vile meal: bitter, indeterminate vegetables fried with stodgy, greasy noodles. I wake in the night with a stomach ache, a headache, and feeling unwell, and by morning I realise continuing further towards the Sanctuary is out of the question. If my condition worsens, I'll be in serious trouble, two or more days' walk from the nearest road. I pull the plug. We walk out via the river trail and catch a bus which, for the first hour, creeps along a jeep track at about walking pace. I don't mind; shattered and unwell, I simply sit back in my seat and gaze out the window. Somehow I still manage to find joy in the sight of small, golden-brown dragonflies thronging over brilliant green paddy fields; at the diverse and abundant butterflies flitting and bobbling everywhere; at waterfalls plummeting from the mountainside into wild little streams that surge across the track; and at shacks of all descriptions -- fowl houses, storage sheds, simple shelters, and homes, sometimes with little to distinguish one from the other. The journey back to Pokhara takes about four hours.

Medical treatment in Pokhara is unreliable -- misdiagnoses of pathology samples are reputedly common -- so I take it easy for a few days. At times I find myself literally running with sweat but have no way to tell whether this is the result of fever or simply the heat and humidity -- power, and therefore a cooling fan, is unavailable much of the day in Pokhara because of Nepal's load shedding programme. Well-spaced doses of paracetamol + codeine, interspersed with ibuprofen, keep the headache, and perhaps the fever if that's what it is, under partial control while I try to decide what to do. Eventually I book a seat on a bus to Bardia National Park in the far west of Nepal, thinking I'll stop there for a couple of days then cross back into India and head for Delhi to seek treatment if I'm still unwell.

A well-regarded travel agency sells me a ticket on a bus and says it will take about eight and half hours to get to Ambassa, the transfer point for Bardia.

It takes thirteen hours.

Thirteen hours of hard travelling.
Thirteen hours of having the two different passengers in the seat next to me squeezing up against me, using my shoulder as a rest for their greasy-haired heads.
Thirteen hours of loud, monotonous, mostly similar-sounding Nepalese pop music that relies heavily on excessive use of violins and male-female duets.
Thirteen hours of humidity and sweating.
Thirteen hours of trying to find a position not uncomfortable enough to prevent sleep.
Thirteen hours of trying not to think about the time.
Thirteen hours of resignation and patience when the bus stops yet again.

At a stop in the dead of night, I get off to stretch my legs and stumble towards the rear of the bus. A woman dangles her baby through the window into the cool of the night, and it looks at me, astonished by this thin, pale apparition. I smile and wave. No response. I try again, and from the dark in the back of the bus I hear the mother laughing; she picks up the baby's hand and waves it back. She laughs and says something to her child and we wave at each other, and eventually a wide smile transforms the baby's face.

It transforms my heart, too.

At Ambassa I transfer to a jeep, which bumps slowly along a track and crosses a river bed. An enormous and beautiful owl sits on a rock in the shallows; it turns its head to regard us then lifts into the air and flies into the night. Despite the noise of the diesel engine, the owl's soft, silent flight is almost palpable.

Further along, we see two wild boar by the side of the road, and my excitement mounts -- already we're seeing wild animals. What else might be next?

Nothing. Dogs, a few people, buffalo, cattle. At the lodge, I'm so tired I go straight to my room and sleep for three hours, which in retrospect is nothing like enough to recover enough energy for a guided walk in the afternoon, a walk which turns into a nightmare.

Just an hour into the walk I realise this is a mistake. I must turn back, I tell the guide, but he insists that just a short way further on is the best place in the park to see tigers. Persuaded, I agree to continue, and a few minutes later I'm rewarded -- not with a tiger sighting, but with a close view of three giant hornbills. The guide gasps, and clasps my shoulder.
  'You are a lucky man,' he says, explaining that to see a giant hornbill is far rarer than seeing a tiger -- he hasn't seen a hornbill for six or seven months.
Later, the lodge manager confirms this. I try to feel lucky, but by now I'm having difficulty concentrating on anything other than staying upright and mobile.

The best place in the park for seeing tigers is occupied by people working with elephants. Much shouting and noise; no tigers. We walk downriver to a quieter spot and wait for tigers to come and drink and bathe. They don't. I feel a pinprick on my ankle, reach down and instinctively pick off the agent -- a leech, which hadn't yet fastened itself to my leg. When the elephants leave, we return to the lookout tower, which sways alarmingly. I step backwards and just manage to skip sideways to avoid falling down the unprotected stairwell. Things aren't going well.

We do see an adolescent rhinoceros come to the river to drink, but it's a long way off and dull in the hazy afternoon light. Nothing else noteworthy appears.

How I manage to walk back to the lodge remains a mystery -- sheer force of will, probably; a determination to keep putting one foot in front of the other. The guide slows to explain how the tower we're passing is called the Deer Tower; others are called the Tiger Tower, the Elephant Tower, the Rhinoceros Tower, and so on. I think to myself, 'I don't give a rat's arse what you call them, just keep walking,' but of course I politely say, 'O.K.,' unable to expend the energy to think of something more intelligent.

At the hattisar, the elephant stables, I now know I'll make it, and I allow myself the luxury of stopping and leaning on my bamboo staff to rest. The half blind rhino eats his evening meal at the fence of his enclosure, so close I could reach through and touch the monstrous beast, but because I know he's already killed someone, I don't.

I spend the next day trying to recover, and failing. The tiny amount I manage to eat runs straight through me and I know I'm weakening rapidly. By evening I know I'm in serious trouble, with no Internet access, at least three hours from the nearest airport, and with only enough cash to buy bus tickets but not flights -- and I wouldn't survive the necessary bus journeys.

I talk to the lodge manager and arrange a jeep trip to the closest airport, at Nepalgunj. He has a travel agent friend who will try to arrange a flight to Kathmandu, he says; be ready to leave at 7 a.m. I pack almost everything, manage to survive the night, and shortly after 5 a.m. comes a knock on the door. The lodge manager's ready to go, and within minutes, so am I.

The jeep crawls towards Nepalgunj at 40 km/h, even on the black top, but eventually we arrive at the airport. The travel agent has not only booked a flight to Kathmandu, but an onward flight to Delhi;the catch is that I have to endure a gut-battering ride on the back of his motor bike over a rough road through clouds of dust and filth into the city to find an ATM that will accept one of my cards. The first accepts neither, but fortunately the second allows me to draw out just enough to pay for the flights. Then it's back on the motorbike for another gut pounding and filth drenching.

We get back to the airport as the plane takes off.

The young travel agent works wonders, though, and gets me on the next flight, less than an hour later. At the gate, a young man who looks distinctly Tibetan chats with me. He and his companions have just completed a trek in Lower Dolpo, to Phoksumdo Lake. The route Schaller and Matthiessen took on their journey to Shey! I feel a twinge of envy but know I could never have managed such a journey with this illness so the envy's minor -- instead, the overriding feeling's one of delight at talking to this kind and interesting man who's just been where I'd have loved to go. He asks about me and I explain my situation; he expresses concern and reassures me we'll get to Kathmandu in plenty of time to catch the flight to Delhi. Kindness like this brings a lump to my throat and at times I struggle to retain my composure. Emotions are very close to the surface, but I manage to avoid embarrassing myself; more importantly, I avoid embarrassing him and others nearby who would no doubt feel hugely uncomfortable at the sight of a haggard, filthy foreigner wiping tears from his grimy face in the middle of the airport. 'Get a grip, mate,' I tell myself, 'harden up,' and that blunt, down-to-earth, antipodean stoicism saves me on more than one occasion.

Later, in the hospital, I think hard about all the apparent indignities I've been put through, which have turned out to be nothing like as undignified as I would have expected. On the other hand, bursting into tears in public would have been as undignified as anything I could imagine. I find myself wondering about dignity, and while convalescing, I discuss this via email with  my aunt, and in person with the friend who's provided such wonderful, tangible support here in Delhi -- recommending the hospital, collecting and storing my luggage, arranging transport and this marvellous place to recover, extracting me from the clutches of the hospital's administration system after I'm supposed to have been discharged (more about that later), running errands for me, and much more. Dignity -- the concept seems hard to pin down, perhaps because I'm unsure what questions to ask, but my initial feeling, and one I still think comes close to capturing its essence, is that it's the gracious acceptance of what's necessary. That certainly describes what I feel was my reasonably dignified response to some of the diagnostic procedures I was subjected to -- but how does it explain why I'd have felt such a loss of dignity, such mortification, if I had, after all, broken down in the airport? Necessity and acceptance would have had nothing to do with that situation, if it had happened.

Perhaps dignity depends on understanding one's limits and capabilities. In an early email my aunt suggested it might depend on self-knowledge and 'the ability to be true to yourself in changing, sometimes diminishing circumstances'. Often this manifests as the appearance of reticence, or a distancing of oneself from the situation; sometimes it can cross the line into the kind of aloofness that can appear haughty, which may or may not be deliberate. Usually, I imagine, it's simply that one doesn't know any more appropriate way to react other than to do nothing, and this kind of unresponsiveness can be seen either as dignified or haughty.

But, perhaps a well developed understanding of oneself is not always necessary in order to act with dignity. For a start, how well do any of us really know ourselves? Someone who agonises much less over these things might have only a vague idea of their capabilities and limits yet still have an entirely healthy sense of self-worth that allows them to act in a dignified manner. Put simply, 'I might not know much about myself, but I know I'm just as worthwhile a person as anyone else.'

My friend suggests a distinction: one kind of dignity relies on a justified (and not inflated) appreciation of one's own worth; another relies on knowledge of appropriate behaviour in particular circumstances, especially in cultures that differ substantially from one's own. For all I know, if I'd broken down at the airport, I might immediately have been surrounded by people wanting to comfort me, by people who saw no loss of dignity in what I'd have perceived as mortifying weakness but who instead welcomed the opportunity to support a fellow human being.

At Delhi I'm so weak I can hardly carry my bags, and although my main pack weighs a mere 9 kg I resort to a trolley to wheel it to the Metro. Crossing from New Delhi Metro station to Pahar Ganj requires battling the crowds fighting to get through the security check, and without shame I jump the queue and elbow my way through. I take the quieter, back way to the Smyle, where the recognition and obvious delight on the faces of the staff lifts my spirits after this punishing, twelve-hour journey. They have no room for me, but the manager arranges one -- quiet, dark, clean, with a fan and a/c, and reasonably priced -- at a hotel just around the corner, and gets one of the staff to carry my bag there. Here might not be home, but I'm close to friends, and treatment is no more than a night's sleep away. For the first time in days, I begin to feel safe.

1. Part 2, about my time in the hospital, is on its way, but I can't promise how long you'll have to wait.
2. '...whose aroha sustains me..': The concept of aroha's a little tricky to pin down, but it's better than the word 'love', which is almost useless unless qualified.
3. '...The route Schaller and Matthiessen took ...': Described in Matthiessen's remarkable book, The Snow Leopard.

1. The guest house where the acute stage first manifested.
2. Annapurna South the following morning.
3. Pokhara night life.
4. The yearling rhinoceros at Bardia National Park.
5. This lizard in the garden at the Bardia Jungle Cottage had just gulped down a small ant.
6. The first day after being discharged from hospital. Nothing left in the tank. (Actually happier than I look; just worn out.)

Photos and original text © 2014 Pete McGregor