Hold the phone!

It's our last night in Dhulikhel--tomorrow we head to Kathmandu before traveling to Pokhara for a four day hike to Poon Hill! In light of the lack of Internet that is about to take place and the then imminent return to the States, I'm warning you now not to expect more pictures or posts til after March 4th, when we fly in to Chicago!
I was a little disappointed that I was unable to change my flight to add a 10 day layover in Berlin to see the twin, but these things happen. Love you Thrynny and will see you in September :)
Wishing everyone all the best and hope to see you soon,
Elisabeth

Bhaktapur and Shiva-ratri

In Bhaktapur--one of many Mandir (Hindu temple)

Two days ago we visited Bhaktapur, a nearby city with a well preserved center (it's a world heritage site and they charge admission...a bit touristed but very worth seeing). It was also a holiday for Shiva's birthday, and everyone seemed pretty festive! We saw lots of people lighting bonfires in the street in the evening, dancing in masks, and lots of people getting their foreheads dotted red. Katherine and I got seats in the front of the bus on the way back to Dhulikhel, and that was quite the experience. I felt sure we were going to hit a person, but amazingly, that was avoided! Driving requires new levels of skill in some countries...

Yesterday we saw Anandaban, the Leprosy Hospital. It was started by Australians about 70 years ago, and is a Christian hospital. We got to see a lot of patients with leprosy, though the hospital serves patients with any disease as a normal hospital would. I had no idea how complicated the care could be. Many patients were getting orthopedic surgeries, plastic surgeries, and creative solutions to problems like ptosis--taking some tensor fascia lata (in the leg) and attaching it to the temporalis muscle (in the face), so that with chewing motions the eye could blink. It was very interesting--and we also were able to see the mycobacterium under the microscope! Aarti has previously interviewed several patients, and shared some of the stories that people had told her about the social stigmas that exist toward people with leprosy. I am so thankful we got to see this place. They have been collaborating with the University of Washington on research for some time, and I'm looking forward to checking out some of their papers when I return to the States. It has also been revealing to see different hospitals here. Bir hospital, the only public hospital we saw, is quite different than Dhulikhel or Anandaban.

Anandaban, the Leprosy Hospital

Today we had our last day of formal lectures and had a wonderful talk from the community health department about the Nepali healthcare system. I saved the powerpoint, but it was really interesting to hear statistics about how much Nepal spends on healthcare (about $3/person annually), how many doctors they have, what the challenges are...really a great talk. We've had lots of conversations about this in general, but it was awesome to have something formalized.

Discussions here with other international students or Nepali people or just among ourselves often touch on the dangers of international "aid" and non-governmental organizations. It's so difficult to responsibly do good. I want to make sure I'm very thoughtful about how I travel and work as a doctor in the future, and it's really interesting to hear different perspectives on this. As a medical student and really just a student in general, I am learning so much here, and it's hard to imagine being here and being in a position where I wouldn't be a student (even many years into a medical career). Many things are just SO different. If anyone has any suggestions on further reading, please let me know. Things I already have on a list are "Dead Aid" and "The Blue Sweater".

Hope life is grand for everyone...

The best 24 hours ever!

In the common room of the guest house before the trek to Nagarkot! Aarti, Katherine, and Joanna, our friend from Switzerland!

This weekend we hiked to Nagerkot! 10 miles up MOUNTAINS! The trek was everything I expected a trek to be, through farmland and small villages. It was a beautiful day with unreal views of the Himalayas the entire way. We are a group of CHAMPS! I felt like we were on some epic mission to get to Nagarkot, over the neverending staircase, up to the misty mountains. Thank you, 21 years of fantasy book reading! Haha! :) We stayed at "The Hotel at the End of the Universe" and woke up to a sunrise over the Himalayas, with a view of Everest and the Anapurnas as well. I'm just going to try and load some photos,because every word I type seems to detract from the experience :)

At the End of the Universe. That's not a backdrop! :)

Tomorrow, we visit the leprosy hospital! On the curriculum front, the experience continues to amaze me. We had a fantastic experience last week from the derm faculty and general surgery. We learned about typhoid fever and the dreaded complication of bowel perforation. I saw my first x-ray with air under the diaphragm! (secondary to bowel perf, please see Aarti's blog). There were three patients in the hospital with perfed guts from typhoid--a completely preventable disease. Most cases advance here due to mistreatment with antibiotics, which are available over the counter. Super interesting. Dermatology seems to translate into "money maker" no matter which culture you're in! The department was beautiful. They told us they take from the rich (with cosmetic procedures) and give to the poor. Noble cause! And they were excellent teachers. We saw what was likely a presentation of lupus (malar rash, joint aches, difficulty breathing) so the rheumatology nerd in me was going nuts. The leprosy lecture was fantastic--far more in depth than the 15 minutes dedicated second year of med school! Aarti and Niki took pictures--and will hopefully post on their blog!

The staircase to inifinity! The upward going parts were slightly more difficult, but how beautiful is this??!!!

I also spent time in the procedure room, and I seem to attract vasectomies, so I got to see another one of those! Interesting to have seen several different techniques at this point. This was still no scalpel (so no actual incision), but using suture (rather than clips or nothing) to tie of the vas and while the surgeon claimed he was using fascial interposition (hiding one end of one tube under a separate fascial layer), I just saw a little hand waving...benefit of the doubt? :) Hopefully no reversal needed because I'm pretty sure that's not an option! Interestingly, most people wait here until they have a son prior to permanent sterilization, and they also wait until their youngest child is over 4 years old due to the high infant mortality. Those issues did not arise in my vasectomy counseling in the States!

The sunrise over the Himalayas! Those are mountains, not clouds!! Also, a very nice moon.

Another topic that we brought up was pain control. This is a really controversial discussion even in the States, and we had some really interesting conversations about it. There is what I consider to be very limited pain control here. Patients seem to get opiates only if they are terminally ill from cancer. We have collectively seen things like wound debridements, post op pain, vasectomies, and suprapubic catheter placements without the use of what we would consider adequate analgesics (post op patients get ketorolac--a strong form of ibuprofen). I have mixed feelings about this. I don't think it's dangerous to give a patient some morphine prior to a wound debridement and would be infinitely more comfortable with the procedures. I also think that with the over the counter pharmacies that exist, oral opiates would present major issues. We obviously are dealing with serious consequences of opiate over-use/abuse in our country. It's tough to weigh the pros of pain control and cons of the abuse, tolerance, hyperalgesia, and criminal activity of opiates. Sometimes I think they're the worst drugs we've discovered/invented--but then seeing the patients in pain here makes me think otherwise. By no means straightforward!!!

Vasectomy in the procedure room--a fun place to learn, and the language barrier is slightly less detrimental!

Excursions!

We visited a TB hospital last week as well as the oldest hospital in Kathmandu (120 years old!). We had an extensive tour of the waste management system in the hospital (a bit random, but it gave us exposure to the wards and I think the WM people were the only ones not on lunch break at the time we visited. Hehe).

There were lots of creative ways to manage the waste and an extensive recycling system--very refreshing and much more thoughtful than our own hospitals. It was also good to see that needles weren't just getting dumped somewhere!

My favorite thing we've done so far was the visits to the health outposts! Aarti, John, Katie and I went to Bolde, a 2.5 hour jeep ride and a 45 minute hike into the beautiful Nepali hills! The road was a bit treacherous, hugging the hills and one time we left the jeep to move rocks off the road! We stopped on the hiking part to visit with some of the locals and got to meet two women and a local medical shaman, who shared his expertise in prenatal care--using a method consisting of forming nine boxes that included numbers that added to fifteen no matter which direction you worked your math magic! If he did that and created an amulet for a woman, she would deliver, he said. He also said he has been referring deliveries to the hospital for the last 15 years, so perhaps that's for the best :)

The women were also very interesting to speak with. They gave us a run down of their days, told us the men usually drink tea while they wake up, make food for the livestock, feed the family, work in the fields, and re paint their house (a daily process apparently!). This reminded me a lot of womens' roles in Mali, while the men make tea. Some things are hard to change...

We got to the health outpost after a beautiful hike. My favorite part aside from the people were the people trees! I have no idea what the actual taxonomy is, but these are huge old trees that come in pairs of male and female and they are somewhat revered. They look completely amazing. And, did I mention they are called people trees? Fantastic.

We also passed a very nice little Buddhist stupa as people in this area are Tamang, who are Buddhist. Cultural reminders!

I already wrote a bit about the health outpost visit--with the patient education session on cervical cancer and screening. It was so remarkable and I have a very high level of respect for the doctor we worked with. It is so rare for someone from this country to stay as a physician, and particularly rare for someone to want to work in rural areas with and for a remote community like this. She trained in Austria, returning to Nepal every few months, always ensuring that what she learned would continue to have relevance to her work in Nepal. There are two Norweigian medical students working at the outpost as well, Havar and Kari (spelling?), doing research on iodine deficiency and cervical cancer, respectively. Aarti thought people were referring to Harvard research, not Havar's research, so now I like to think of Havar as Harvard. :) Fun times with foreign languages!

Niki and Katherine had a different experience at their health outpost and saw a lot of patients over their day. They also said they had a great experience!

Over the weekend, we visited a stupa (hindu shrine) called Namo Buddha, where a man sacrificed himself to a mother tiger and her cubs and afterward got sucked up to heaven/nirvana. It was such a beautiful hike! There were beautiful prayer flags everywhere and you could hear the drums and chants from the monks. We walked to another town afterward and it was an amazing look at the countryside. There were tons of orange orchards that smelled completely magically orangey and I definitely romanticized the somewhat idyllic scenes of women working in their terraced fields (didn't see any men working though! A lot of men leave the country to outsource their work to India due to tough exonomic circumstances in Nepal, and send money home. This is pretty complicated but seems like a tough deal. They are absent a lot and oftentimes gamble or pick up STIs in India that come back to Nepal with them).

Sundays are work days in Nepal, so we had a day of orthopedics yesterday (focus on extrapulmonary TB--TB bone infections!) and today picked up some pediatric lectures. I've been super impressed with the curriculum they're piloting with our group. I must admit I had low expectations of things working out, and have been pleasantly surprised! I expected to be fighting for myself a lot to get good learning experiences, but it feels as though things are just being dropped into our laps! It's really making me happy and excited to learn more on my own. We've been doing additional reading in some of the tropical medicine books here and it's pretty amazing to be seeing what you're learning about so consistently.

We also just got Internet working in our guest house?!!!! So that's pretty awesome! Takes one challenge out of emailing and blogging, leaving us more or less only dependent on the electricity, which comes and goes.

I have many more photos that I'll try and add to this post as time allows--hospital learning, hiking, the beautiful countryside, more from the health outpost visit! And fun times at the KUIC (our guest house).

Til then, love and missing!
--Elisabeth

A woman we spoke with on the hike up to Bolde, with a baby goat! Born last night :) BABY ANIMALS!! 

Catch Up

The river valley we followed to find our health outreach (REMOTE!) 

So internet is very iffy so far in Dhulikhel due to a variety of complicating factors--electricity outages due to load shedding of electricity as much of it is sold to India (interesting. probably more on this if I ever feel like writing about challenges in Nepal), time in clinic, and slow/inaccessible computers.
The most recent posts were written about a week ago, but I wanted to write them up anyhow.
Other things that have been going on:
Two days ago we saw a TB hospital and the oldest hospital in Kathmandu! We learned about waste management at one of the hospitals--super interesting the creative methods.
Yesterday was my favorite day so far--a visit to a health outpost in a remote village: 2.5 hours driving and 45 minutes hiking to reach! I have some photos (and bruises from the bumpy jeep ride!) but it was FANTASTIC!!! We were with an OB doc who is doing research on HPV/cervical cancer, and got to see her give an education session to the health volunteers. Super interesting, and pretty complicated research: convincing remote, shy, conservative Nepali women to have Pap smears for a very abstract concept like cervical cancer.  Interesting stuff.
Today was also wonderful. We saw a patient with rheumatic heart disease and had a lecture from her cardiologist. He had us all listen to the murmurs, look at the echo, and I don't think I'll ever forget that clinical picture.
The day terminated with a discussion about challenges to healthcare in Nepal, often similar to challenges in the States but on a different scale. I feel as excited as I was at times at Carleton--constantly thinking about so many new things: medicine, culture, societal issues--my brain is buzzing! PUMP THE BRAKES! :)
Tomorrow we'll hopefully hike to a nearby town and maybe we'll get internet and I can put up more pictures from the outpost, the clinic, and the hikes we've been doing.
Sorry for the journalistic, flight of ideas post. I promise things will get more thought out and I'll spend more time fabricating posts later on--once the excitement fades a bit perhaps haha!
Love you all and miss you! 

From the TB hospital! There were posters explaining the TB treatment program (this is a worldwide effort to control TB, particularly drug resistant strains). 

a Stupa! (Buddhist shrine) 

Bolde health outpost--with Havar (or as Aarti says, Harvard, the Norweigian medical student researcher!) 

Medicine in Nepal

Dhulikhel hospital from the library. Quite a climb to the wards!

We've already seen some really interesting things--even in two days in Dhulikhel. Things that wouldn't even enter my differential diagnosis are commonplace here: tuberculosis, typhoid, brucellosis! We saw a patient who had come in with adrenal insufficiency secondary to disseminated tuberculosis, which is completely crazy (it's speculated that this is what killed Jane Austen! Of course I know something like that...)

We have started the past couple mornings with morning report hearing from all the doctors in the hospital about who was admitted overnight. Then we have tea break :) Then we meet for rounds to see some patients and have a lecture on a topic of global health (so far, TB and typhoid). Then we have lunch (usually with chia!). Afternoons involve (so far) more lectures, before, yes, another chia break!

Tomorrow the tentative plans are to go to a TB hospital and later in the week we are hoping to do a "community outreach" experience, which I'm psyched for because I love community health!!!

There are kinks to work out as far as our clinical experience, but overall this is completely fascinating and really inspirational. I am really looking forward to the rest of this month.

Cool factoid!!  You can get chronic typhoid infections if you are coinfected with schisotsomiasis because the typhoid can live inside the schistosomes and avoid being killed with antibiotics!! What??!! 

View in a room in our guest house where we actually aren't staying but you get the idea.

Morning Report at Dhulikhel Hospital

Studying in the library!

Dhulikhel

View from the brief hike to a view point. Himalayas!

Dhulikhel Hospital aka Dhulikhel Spa. This place is huge and beautiful. Wow.

We arrived in Dhulikhel! We met up with Katie, John, and Ben who have been scoping out the scene for the past week. This is a great respite from the noise and dirt of Kathmandu--beautiful! Mountains! The hospital is also fantastic--high quality medicine and doctors in a beautiful setting. I think the hospital looks like a spa.

Other favorites so far:

HIMALAYAS! You might think you've seen mountains, but PUMP YOUR BRAKES. You have not seen these mountains. They are BEAUTIFUL! Yesterday we hiked to a lookout near our hostel along the most perfect hilly trail. Words will in no way do this justice. Find me in March and I'll show you pictures, which will also not do it justice. I felt like I was in a fantasy novel and tried as hard as I could to burn the images in my brain, so hopefully that sticks. :)

Dal baat: This is Nepali Thali (Nepali food! yum!) I literally could eat this every day for a month and probably still love it. It's scrumptious.

Chia: Nepali tea! There are chia breaks intermittently throughout the day and I could drink this stuff a LOT. Much better than the coffee breaks in the States. Why is it that just about every other country in the world has a lovely tea tradition of relaxing and sipping a hot beverage, and Americans have coffee-to-go?

Patan Durbar Square: Area near our guest house in Kathmandu where there were lots of Hindu temples with really really amazing carvings and buildings. Truly just a beautiful place! Leading to...

Hindu Gods: Shiva, Vishnu,Brahma--a Hindu trinity! I want to read stories about these gods. It is so cool to see all these carvings and temples and know that such a huge portion of the world's population finds so much significance in this tradition. I want to know more!

We met some Norweigian engineers today, and one quoted a statistic that 70% of tourists to Nepal will return. This place gets into your bones! It's so beautiful, the people so friendly, and really just something intangibly amazing. I think I'll be part of the 70%. Who wants to come with??! :) 

Nepali Thali! (Dal Baat-delicious dish that we eat at lunch/dinner

Patan Durbar Square: I have a bajillion pictures of this beautiful place. This is just to give you an idea!

Mountains! This is on the five minute walk to our guest house from the hospital.

Medicine in Nepal: X ray from a patient with disseminated TB. We have been getting some amazing medical experiences.

Aarti's Tour!

Prayer flags on the Buddhist Stupa

Favorite things in Nepal:

1) New words. We had a two hour language lesson with Dil yesterday right after arriving. I love these words; I love how great people are about helping us practice, and the way faces light up when you try Nepali phrases. When you think you hear Aarti saying "sub-I", she is not referring to a medical subinternship, however. Nepali people, like the general American populace, do not know that English word. "Sibai" means "all" as in we are alllll going to Dhulikhel, not as in we are all doing sub-i's in Dhulikhel. :)

2) Cold/Hot. The temperature during the day gets really steamy and nice! As soon as you are in the shade or the sun goes down, it's really cold! I love it! It's perfect! Nice and warm for walking around, nice and cool when you want to snuggle under covers and sleep.

3) The feeling you get inside Stupas and Mandir (temples of the Buddhist and Hindu varieties). I like that feeling that there are such big things in the world. Similar to how you feel inside churches, or listening to symphonies, or being in the mountains or on the shore of Lake Superior. It's beautiful.

4) Food. This is self explanatory, but dal baat is delicious. Fruit is delicious. New tastes are fun and I love trying it :)

5) Beautiful people. Such a wide variety of faces and skin tones and eye shapes and colors and styles. I love people watching here and chatting with people in stores or on the bus.

6) Tuk-tuks: One form of public transportation: like a small gutted out van where you pay a small sum and sit on a bench and go from place to place, stopping when you say you need to stop. Reallly reminded me of sotramas in Mali, and I think they're so much fun!

7) Baby animals! Mainly baby monkeys and puppies :) These were found in abundance today and gosh it's amazing how cute baby animals are.

8) Friends. Old and new. I am so incredibly lucky to be here sharing this experience with some of my favorite people in the world. I learn so much from them and the thoughts they share as we explore new places and learn new things. I can't wait to learn medicine here with them and see more of this beautiful country.

Sending so much love! Namaste from Nepal!!

Stupa--behind me are the prayer wheels and you turn them as you walk clockwise around the Stupa praying.

Another Stupa--we got to go inside and there were huge beautiful gold Buddha statues and wonderful paintings.

Cremations near the Hindu temples, by the river. The orange coverings are covers on bodies being cremated.

Cheers to a wonderful first day in Kathmandu!

Kathmandu

Aarti, sitting for tea in Newa Chen

Niki peering out her window at Newa Chen

Courtyard in Newa Chen

Newa Chen

Bedroom at the guest house Newa Chen

We ARRIVED!! Flight 5 hours delayed for a 10 hour layover in Bahrain, but it's cool cause I got to try a McArabia at the McDonalds, which was really delicious, and teach Arran and Niki to play Bohnanza, which is the best card game ever!! Aarti met us at the airport and took us to Newa Chen, the guest house where we spent last night and will spend tonight. It is a beautiful house from the 17th century in Kathmandu. I am blown away by the BEAUTIFUL wood carvings, friendly staff, and delicious breakfast served :) Just after arriving we left for our first language lesson from Dil, this amazing Nepali gentleman. Now we can greet and count in Nepali! The MacKinneys let us invade their home and shower and fed us dinner before the 35+ hours with 5 hours of sleep kicked in and we left to go crash in beds with hot water bottles warming our feet!

Today, 3/4/12, we woke up and had a wonderful meal of fresh fruit, eggs, and dal baat with fried flatbread, as well as Nepali Chia (tea!!). We practiced saying greetings and learned how to say we thought the breakfast was delicious. :)

Aarti Katherine and I took off for the airport to search for our bags which didn't arrive yesterday then met up for a day on the town. Aarti was an absolutely wonderful tour guide and we saw some beautiful places in the city today. We visited several stupas (Bhuddist temples) and Bhagmati (sp?), the holiest river in Kathmandu where the Hindu dead are cremated and have a very old temple. Afterward we visted Thamel, a shopping district, and shopped and had some Nepali beer (named Everest!) while meeting up with Aarti's friends from Accham where she worked last month.

The day has been so so so wonderful, and I am absolutely ecstatically happy! This is such an exciting place, with fantastic people, and it's so much fun to learn a new language and try all these new things! I really want to learn more about the religions we're experiencing all the "melting pot" of cultures in Nepal. I don't think I've ever been in a place with such ancient things interposed so much with modernity. I'm rambling a bit, and really don't want this to be a travel journal though that's what it was on this post, but I'm still swimming a bit in the newness of it all.

Miss you all and cannot wait to share the boatloads more of photos!

Departure!

At the airport with Niki, Katherine, and Arran!
&!7gj*!!%#€!!!!
So exciting!!!
First off to London, Bahrain, and then Kathmandu!