the first several days...

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Well hello and sorry for a long overdue entry! It's been difficult to find time and inexpensive internet until now...in Pokhara, a major tourist haven and gateway to the Annapurna's.
So let me rewind and go from the start...I will get better at writing more frequently so I don't have to write about 20-some very interesting days each time!

I arrived in Kathmandu on Nov 3rd after an 18 hour flight from LA to Bangkok, and then another 4 hours or so from Bangkok to Kathmandu. The views of the Himalayas from the airplane were stunning, I couldn't believe I was actually going to be hiking amongst them soon. I arrived on the same flight as one of the internists in the group, so after passing through customs (not much security here) we walked out into the chaos of taxi drivers desperately trying to give you a hand and whisk you off somewhere. We didn't see anyone there for us initially, then after a bit of confusion found someone from our hotel and were helped into the van and away from the airport we went into the continuing chaos of Kathmandu. Its the epitome of the third world city, with dirty streets, cows wandering around everywhere, incessant horns being blown by the drivers of motorbikes, trucks, and buses and suffocating exhaust fumes. We drove by row after row of unfinished concrete block buildings, across the Bagmati river shantytowns, and finally to the "tourist" area of town to the Yak and Yeti hotel in which we were all staying before the trek.
That evening I met the rest of the team. All together we were comprised of me, Jackie (internist from LA), Bud (OBGYN from Philadelphia), Dawn (OBGYN from Boston), Gery (internist from Boston), David (president of Himalayan Healthcare and family practice in Buffalo), George (ophthalmologist from Buffalo), Donna (nurse from Maine), Bonnie (nurse from Connecticut), Anna (nurse from Switzerland), and finally Louis, the photographer (also from Buffalo) who came along for documentation of the trip.
Anil is the main guy and head of Himalayan Healthcare here in Nepal, and I was to find out in the coming days what an amazing person he is, and how much he is trying to do for the people of his country.
We met him that evening, had a brief meeting at the office about logistics, then all went out for dinner at a traditional Nepali restaurant.
The next day we had a guided tour of Kathmandu, taking in the sights such as Pashupatinath which is the largest Shiva (hindu) temple. It is along the Bagmati river and we saw the ghats along the river as well, which are places where people are cremated, and their remains go into the river. There were a few actively burning bodies in small mounds of sticks/wood and families nearby. I saw a small foot sticking out of one, which looked like a small child. Many children die here from disease and lack of healthcare and proper sanitation.
Next we went to the Boudha Stupa, which is a large Buddhist temple, with many monasteries surrounding it. It purportedly has the fingernail of Buddha inside, and is the most powerful Buddhist temple in Nepal.
We went to another Buddhist temple called Swayambhu, and then to the Durbar Squares (main squares) of Kathmandu, and its close neighbor to the south Patan. Patan used to be a separate kingdom before the area was consolidated into the Kathmandu Valley and into Nepal. I couldn't write all of the sites and holy places we saw, the whole area is full of them, religion is so much a daily part of life here and so many hindu shrines are around every corner for one of the countless different gods. We did see the Kumari though, who is the "living goddess" a living incarnation of the hindu goddess Taleju. She is a young girl from a low caste that is selected from a process similar to the discovery of the reincarnations of the lamas in buddhism. However, when she reaches puberty the goddess leaves her and they have to find another, and she goes back to regular life. They just named a new Kumari recently, a 3 1/2 year old girl, she lives a secluded life and comes to the window of her ornate temple a couple of times a day for the people who gather below to see her. She's all dressed up in her goddess "costume" more or less. Its a strange tradition.
After the full day of sight-seeing and still with jet-lag we called it an early night and prepared for leaving early the next morning for the trek.

Nov 5th:
We left the hotel in a caravan of 3 landrovers, our porters/staff had already gone ahead to get things ready for our arrival. This was a long driving day up and out of the Kathmandu Valley, and for about 12 hours on a very steep/winding/bumpy road. Halfway along we were still able to get phone service and we found out that Obama was president! So we all had a little celebration alongside the road of the valley we were through and shared some celebration beers at lunchtime. We were apparently all Obama supporters. After a long day along some rather precarious ridges we were relieved to make it to our camp around 7pm. Our tents were set up, dinner was almost ready and we all huddled in the dinner tent trying to keep warm. The best part was when dinner was over, hot water bottles were distributed to everyone for our sleeping bags. It was freezing so we were all so happy and it was the first taste of how "luxurious" this trek was going to be.

Nov 6th:
We awoke to a basin of hot water and a call of "tea? milk tea? coffee?" outside our tents. While we were poured the hot beverage of our choice (yes, luxury) we packed our things up and readied ourselves for the first day of hiking. The morning was cool and crisp with a light frost on the ground, and we saw our first views of the Langtang mountains. In the light we saw the small village of Syabrubesi below our camp. Our breakfast was delicious, the trend of the meals on this trek. We set off on the trail, all of us in small groups at our varying paces. We were joined by the rest of the team which included Nepali volunteers, many university students from Kathmandu who were from the villages and acting as translators, a lab tech from the hospital in Ilam, and an aspiring young journalist who came to write an article for the "Nepali Times". We got to know everyone well in the next two weeks and I was amazed at the great attitudes and cohesiveness of the group as a whole. The first day was a lot of uphill climbing, and it tested my legs and lungs. We stopped halfway for a hot lunch prepared by the kitchen staff that ran ahead. After cresting the first ridge, we descended down into another valley where our camp was set for the night. We learned this night that all Nepali dogs are quiet during the day and bark all night long. A trend that I've continued to find to be true.

Nov 7th:
Again a cold morning and climbing back up out of the valley. Once we ascended the first section we walked along a ridge for most of the morning and the sun quickly warmed us up. The mountain views were again gorgeous, and after lunch we ascended again to the pass which was about 14.000 feet or so. The panarama was amazing, and I was reluctant to start descending on the other side. We again camped low in a valley, and were treated to singing and rum punch this night. By this time we were quickly getting to know one another's personalities. We had quite the crew, and were well represented by several distinct personality types, which all melded together terrifically. Bedtime comes early when the sun sets at 6pm so everyone mostly made their way to their tent by 8 or 9, ready to hike into Tipling, our first village the next day.

Nov 8th:
We hiked into Tipling in the afternoon, our first village that we were to set up a health camp in. The people are mainly of the Tamang ethnic tribe, who are a minority and largely discriminated against and live in poverty in the hills. We were welcomed with garlands of marigolds and a white scarf placed around our necks as we entered the area where the health post is. They have two long buildings with 3 or 4 exam rooms and a dispensary which was now better stocked with the medicines we brought along with us. Normally there is a health worker here who has been trained for 18 months by Himalayan Healthcare, then they live and work up in the village (usually their native village) being the sole health provider for the whole area. They are overwhelmed with the vast amount of work to be one and the lack of resources available. Generally if its anything serious they have to send the patient down to Kathmandu which is a 3-4 day walk, or be carried in a basket on someone's back if they can't walk themselves. We got settled in this day and talked a bit about what to expect the next day of seeing patients over dinner. As dinner ended our first patient showed up who was an "emergency" that had just come in knowing that we were there. I saw her with one of our internists, Jackie. She was a 30-something year old woman in rapid atrial fibrillation, short of breath, and a marginal blood pressure. She had moderate crackles on lung exam and had a loud holosystolic and a low diastolic murmur, which we concluded after a lot of discussion with the other doctors that were probably MR and AR (Mitral and Aortic Regurgitation). She hadn't had any children for several years and the likelihood of her having had rheumatic fever as a child are pretty high. So here we were without much we could do without monitoring. We gave a low dose of IM Lasix, hoping it would help her dyspnea without lowering her blood pressure too much, then had a group discussion of whether to give her digoxin, or a beta blocker, or nothing. With her blood pressure marginal we decided to wait and see how the Lasix affected her and take it from there. A few hours later she was breathing slightly more comfortably, but her rapid afib had slowed to a more controlled rate in the low 100's. At this point it was decided that the best thing to do would be to just refer her to Kathmandu. She more than likely needed one if not two valve replacements. During this time a women with a huge elbow abscess also came in, involving the joint and likely the bone. She was given broad spectrum antibiotics and again sent down to Kathmandu the next day. The majority of the money we paid for the trek goes to the hospital care of these patients. Himalayan Healthcare (HHC) covers the transport, lodging, and medical bills for whatever the family can't afford for all of the patients they refer down to Kathmandu during these treks, which is amazingly generous, most of these patients can't afford much.
And this was before the first day of the camp even started....

Nov 9th:
The first day of Tipling health camp. With quite a few doctors and a large number of patients to be seen, three of us were assigned to do triage (me and two other nurses), and the additional nurse did wound care. Basically for triage I would see the patient first, take vitals, do a brief history, and then either finish the physical exam and treat them myself if it was quite straightforward, or send them on to the appropriate physician in the group. Sounds easy enough, but with complaints that I'm not used to treating in cardiac surgery and translation that was culturally and linguistically different, this was quite difficult! There was a trend of a lot of gastritis and arthritis (for some reason H. Pylori is rampant up here and EVERYONE has gastritis it seems). The arthritis was a given, with all of the hard labor they do farming and being porters. The other easy thing to treat was worms, mostly ascaris, which manifested as bloating, diarrhea and worms either in the stool or vomit. It became second nature to ask "and do you see worms in your diarrhea?" and the answer more than not was "yes". The most difficult thing to see was young children and babies with worms, bad impetigo (staph/strep infections on the skin) and some really bad cases of tinea capitis. They just don't have good hygiene and the mothers don't wash their children regularly. I also saw a lot of chronic ear infections, and the usual upper respiratory problems. COPD was surprisingly very common, then as we discovered in the coming days they all have their kitchen fires in their homes without proper ventilation, and many smoke cigarettes as well. I didn't see any "emergencies" on this day, but a couple of children with pneumonia and a rule out acute abdomen were "admitted" and we kept overnight for IV fluids and antibiotics. There were also many cases of glaucoma and vision problems that kept George our opthlamologist busy (he was the rockstar of the health camp because he brought dozens of pairs of glasses that he handed out) and the women's issues that were sent to Dawn and Bud, our OBGYN's. They have access to Depo shots here, and are trying to educate the women about family planning choices and birth spacing. They have many children, but then again they have to because inevitably one or two of them die. It was an overwhelming day mentally and physically, we saw around 165 patients between 10am and 7pm or so. We had to turn people away to come back the next day.

Nov 10th:
Second day of camp. A few of us took a morning hike down into and around the village. It's a very simple life there. They have little electricity, basically enough for each home to have one or two lightbulbs at night. Farming millet and mustard is the main way of life there, and the village as a whole is very poor. A couple of the translators that came from Kathmandu introduced us to their extended family that was still living there, and we got a lot of curious looks and "Namaste!" from the small children running around. The buffalo and goats are generally either tied up next to the home or wandering around, and the chickens also run wild through the paths. Because of the civil war it had been 6 years since the health camp had come to the village, and it is not a touristed area, so we were the first group of foreigners to be coming through in quite some time. In retrospect, it was so different than the villages I have visited since that are on heavily touristed paths. Very untouched and pure, the people were very welcoming and sincerely thankful. There was an anthropologist there, which was a strange sight all of a sudden seeing a tall white man come out from the village. He had been studying the village and the people since the 80's and was back on a short vacation from the University of Michigan for a visit. He was as surprised as well to see us!
Late morning we began seeing patients again as they lined up at the registration desk. They didn't get seen for free, as Anil believes that they won't value the care or put the effort into maintaining it (they have to pay their own village healthworker with help from Himalayan Healthcare), they they pay a very small, affordable amount to be seen. The second day was similar to the first, except for the worst patient we saw, a man who had fell 500 feet while gathering plants on a cliff. He had lost consciousness for 3 days according to his family, they stitched up his face with needles and thread, and carried him to us when they found out we were there from where they lived a few hours away. Anna did an amazing job of cleaning his facial lacerations, which were astounding. He likely had multiple facial fractures, as well as other body fractures. As a testament to the strength and hardiness of these people, he had regained consciousness the day before and was completely lucid. His wounds were starting to smell awful, we gave him broad-spectrum IV antibiotics and fluids, and he was actually able to eat somehow that night. We weren't sure if he could make the trip to Kathmandu and survive but he was able to take food and liquids and stayed conscious the night and the next day so he was packed up and again sent out on his brother's backs. I again saw many dirty kids (who were so cute), headaches, COPD, arthritis, gastritis, etc. Only a couple of hypertensives in the whole group. We again saw around 160 patients this day.
That night after dinner the local adolescents and young adults in the village put on a show of dancing and singing for us around our campfire. We were introduced to the folk songs we would hear again and again throughout the trek, and the maadel, a two sided drum that accompanies the singers. Some beers were rustled up from an adjacent village and we celebrated our first two days and 320 or so patients having been treated.

Nov 11th:
We packed up and left Tipling, and were again were adorned with garlands of marigolds as we left the village. Shortly after we left the village proper we came to the small settlement of the Kami's, or the blacksmith caste. They are the lowest caste, and make the tools that the other caste's use. The primary difference in the villages is that they can't enter the homes of the other castes'. Their settlement also appeared to be poorer and the children also less kempt. Another reminder of the oppressive caste systems that are still in place here.
It was a beautiful day of hiking in the hills, the terracing in the steep hills of the valley for farming were impressive. We reached the village of Shertung mid-day, where there is another healthpost sponsored by HHC, but we didn't do a health camp on for this trip. They raise Angora rabbits there as part of the SPIRAL foundation, a foundation in partnership with HHC that helps the women of the village to create handicrafts that they sell. The goal is to create self-sustaining incomes, rather than relying on help from the NGO's. I started to understand on this trip the problem of "helping" from outside sources. The only reason I felt good about us being here was that HHC is also sustaining some form of healthcare continuously, and they are also helping train teachers for the schools, empower the women, etc. I realized that me and the other providers here really aren't helping....but the money we gave for the trek is helping in smart ways that Anil is working on to create self-sustaining improvements in the communities. Its so much more complex than I imagined, and I still can't fully grasp the complexities of "development" and its subtle and not so subtle positive and negative impacts. I only saw the tip of the iceburg.
The rest of the day was more hiking up into the valley toward our next destination, Lapa village, which sits at the end of the valley surrounded by mountains, basically a "dead end". When we walked through the village of Borang a school full of small children in their blue uniforms caught sight of us and we disrupted school as we walked by and they yelled "Hello! Hello!" over and over. I can't reiterate enough how adorable the Nepali children are. Runny noses and all.
We would reach Lapa the next day, and spent another warmer night camping in the valley under a clear sky and the Ganesh Himals to the north.

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