Getting to Wana...a different way than expected

Sunday 4/18

We sent the Kijacs off with a small amount of fanfare – we were relatively late leaving for the airport for our flight to Tumlingtar, and the Kijacs weren’t flying until after 3 in the afternoon. Quick hugs and goodbyes were said, and we left them at the Tibet Guest House and set off for our flight.

Melissa, Ellen, Jason, and I are traveling with Dr. Gupta from Helping Hands, as well as a cook/porter named Purna. Purna is small and wiry and fit as can be – he has been a trekking guide in the Himalaya for >15 years, is of the Khumbu region, and has summited almost all of the big ones. He has consented to being our cook for the Wana health camp, and accompany us on the trekking sections. We hear he is very talented! (both cooking and trekking, that is.) We tried very hard to travel lightly, as a portion of the trip today will be on foot, and there is only 1 porter available. There is quite a bit of medical equipment that we are bringing, as well as the heavy ultrasound, then our personal gear and the food and cookware. This doesn’t sound like much, but it is more than we are able to carry ourselves! Luckily, over the last few years and many of these types of trips, Jason and I have perfected the art of managing on next to nothing.

Unfortunately, as we were waiting inside the terminal for our flight to be called for boarding, we were informed that a significant rain the night before had soaked the Tumlingtar runway. It appears that the Tumlingtar runway is dirt, but usually very functional. When it rains, however, the runway turns to a 3-foot deep mud alley, and planes are not able to land or take off. Awesome. The airport staff felt confident that because it was only 10:30am, that the runway would dry out enough during the hottest hours of the day, and be usable by 4 or 5 pm. So we settled back in the restaurant to have a snack and a beverage. And wait.

To make a long story short, (although there is enough evidence to show I may not be capable of doing so) everything eventually snowballed into a flight cancellation, and we were left with 5 hours wasted in Kathmandu. After much finagling, we managed to change all of our tickets to Kathmandu to Biratnagar, in the southeast region on Nepal. Conveniently, Biratnagar is just south of Dharan, which is where BP Koirala Hospital is located, at which I was planning to visit the Emergency Department and the physicians there that run it. I have been in contact with an Australian physician who works there, and there is potential for collaboration there for our proposed fellowship and their proposed international EM fellowship training program. I had originally planned to see them after Wana, but first is good as well, however they unfortunately were not available as late as we were to arrive, and we needed to leave very early the next am in a jeep to drive the 8 hours it takes to get to Wana.

We spent the night in Dharan on the BPK Hospital grounds, at the house of Dr. Gupta’s sister. Her son is a general practice physician at the hospital. They were all very kind and hospitable and we had a brief night’s sleep before getting up at 4:30 to depart for the long jeep ride. Melissa, unfortunately, began to have an illness overnight, and didn’t get much sleep. GI issues, that’s all I’ll say. She managed the jeep ride pretty well, given the circumstances.

The long ride to Wana was scenic, for sure, and once we left the tarmac road for the rocky dirt trail that covered the last 3 hours, it became a game of who could hold on the best and not fly around the back of the jeep, where the four of us – Melissa, Ellen, Jason and myself – were crammed. At Chainpur, Jason Ellen and I decided to leave the jeep and trek into Wana via the trail, down the gorge, and up the other side. Melissa was still too ill at this point to join us – she did put up a bit of a fight at being left in the jeep, but luckily was too weak to overcome our insistence that she drive in, for her own safety. The jeep made it to Wana in little under 2 hours, and the three of us (four, really, as Purna trekked with us), took about 3 hours to reach the village. It was absolutely worth the effort, as the scenery and people along the trail afforded us gorgeous views, fascinating encounters and many photo opportunities. We actually saw 2 patients along the way, and referred them to come to Wana for a full evaluation over the next few days. There’s nothing quite like drumming up business for yourself at any opportunity!

We were welcomed at the outskirts of town by what seemed like every inhabitant of the village wishing us “Namaste”, good luck, long life, and placing flowers around our necks, in our hands, and beautifully deep, rich red-colored powder on our foreheads. What an amazing welcome! We kept saying “danyabat” (thank-you) over and over, which for some reason made them all laugh…? I guess being amusing is better than accidentally offending… We felt so invigorated, and I just felt a magical and spiritual blanket enveloping us for the rest of our walk to the health post in Wana.

We met the “mayor” of the town, Dambar Bahadur Shrestha, who certainly commanded respect with his manner and voice, and were welcomed warmly by both him and the Director of the Wana Health Post, Posharaj Shrestha. It was about 6pm at this point, and too late to see any patients (although the were lined up on the hill) and we got settled into our small guest house (vacated and donated by some employee of the health post, I am sure), had a lovely dinner, and were off to bed to rest for the next day, which would prove to be a busy one. But that’s the next story, which you'll get in 4 days. I'll make sure to cram a week's worth of stories into the 2 days before we arrive home!

Namaste and good night!

Sue/Team

We're ba--ack!

Hello all and Namaste!

We are finished with the trip to Wana for the health camp, and it was very successful. Many adventures to say the least. Currently Ellen and Melissa are trekking in the Annapurna region, hoping to reach Annapurna Base Camp on Tuesday, then returning to Kathmandu by Thursday morning. We all have to be at the Kathmandu airport on Friday noon for the flight home. The two of them left Wana this past Thursday to begin their journey to the western region where Annapurna I stands as the tallest peak. They have an ambitious trek planned, trying desperately to make it to BC in the short week they have to trek. Any injuries or illnesses aside, they should make it no problem.

I stayed in Wana an extra day to continue the health camp and finish seeing all the patients that weren't seen yet, since we arrived in Wana a day late (that story to be explained later). Jason and I returned from Wana via Dharan, where I met and worked with Dr. Malla, who is the Director of the BP Koirala Hospital Emergency Department, which is the largest and most up-to-western-standards ED in Nepal. More on that later as well. The two of us then flew back to Kathmandu last night. Tonight we leave for the west, also to the Annapurna region, but we are trekking up to Manang, where the Himalyan Rescue Association has a medical clinic, in order to meet and collaborate with the physicians there (one of which I went to medical school with!). I think the grammar in that last sentence is likely making my mother groan.

So, I will upload a few blogs detailing what's happened up to this point, with a few photos. I will update you with a day-to-day as I type it up. I have a 7-hour jeep ride to the trekking starting point overnight tonight, so I believe I'll have some time. Although that may depend on how uneven the road is.... I apologize that we will be offline again for 4 days, but that's the breaks out there in the wilderness. Rest assured, families, that your loved ones are safe and functioning, that they did a great job at the health camp, and that they are likely tired, sweaty and filthy on the trekking trails, but also likely experiencing breathtaking views of the Himalaya, peaks like Daulaghiri, Macchapuchare, and Annapurna, as well as meeting amazing people and wildlife, and pushing their endurance to the limits, all the while enriching themselves with the experience. I know you will enjoy the stories they will tell on their return!

Sue/Team

Technical difficulties, and the 1st NEM Conference

(0945 Sunday April 18, 2010)

Hello followers!

If you haven't logged on in a few days, this may be news to you, but to those of you who have, you may have been wondering what happened to us. The blog was removed for a few days, and was suddenly reinstated this morning. After some investigation, it seems that people use blog sites for phishing scams, and Blogger has a computerized scanning program that goes through all the blogs and flags anything that seems suspicious. Since there are so many blogs, when one gets flagged, it automatically gets removed until the team can review the blog in detail. There is an appeal process that the blog owner can go through to have the blog re-posted, which apparently is 5 steps and a lot of effort, and a 5-7 day wait for results, which I was fully preparing to go through, and then when I checked the blog this morning, it was miraculously back up! The team must have reviewed the blog already and decided it was safe. As if anything we said could have been interpreted as offensive or scammy! I was actually concerned that I might have made a statement about the government or something along those lines, yikes! But no such worries.

So back to business.

Today the Kijacs are leaving to return to the US. We are all sad to see them go, as we are a little family now, and we have had a good time together here. I am hopeful that Amanda and Pete have enjoyed their trip and their experience here in Nepal. They certainly have both made a wonderful impression on all those that they came in contact with. Pete's smiling face and wonderful attitude was so refreshing, and even though he spent a few days feeling awful, he managed to smile through the entire illness. His technical knowledge and adventurous spirit truly contributed to the success of the team. Amanda's lecture on ATLS (advanced trauma life support) was very well-received, and her calm and professional demeanor was impressive. She trained over 100 physicians on ACLS and adult intubation, and never complained. It was wonderful watching her wander through the streets of Thamel, shopping for things, thinking of her family and friends and what gifts they would like. Her openness to the culture and to learning the way of life of Nepalis was contagious. Seeing her and Pete together in this experience was inspiring. I am happy to have gotten to know them both well during this trip, and I look forward to continuing the friendship.

Ellen, Melissa, Jason and I are leaving Kathmandu in a few minutes for a 5-day trip to the rural village of Wana, where we will be conducting a health camp. I must run, and there is no time to upload any photos, I apologize. We have hundreds of photos from the Conference the last 2 days, and I am excited to share them with you. The next post will be in 5 days!

We hope all of you are well.

Sue/Team

For your viewing pleasure

(1930 Thursday April 15, 2010)

This will be a short one, as tomorrow at the crack of dawn we all will be piling in a taxi or two (the taxis here are SO SMALL...) bound for Kantipur Dental College to our Conference, 1st Nepal Emergency Medicine Conference. We are very excited! It seems that it has grown quite a bit as we are getting closer to the date. Originally we were going to cap the registration at 100 participants, but there has been a surge of new inquiries in the last week as people have been working with the team at the hospital, and word of mouth has spread not only throughout Kathmandu, apparently, but to Pokhara and Dharan, etc. Dr. Gupta has invited the local news station to cover the event, and a few pharamaceutical companies have decided to sponsor a portion of the cost and display their literature at the venue. It seems Dr. Ramesh doesn't know how to say no to people, so we have about 140 people registered for the entire conference, lectures and simulation labs, and another 30 registered for just the lectures. No pressure! The gals and I went through our lectures and our lab simulations today, and I think we are more than ready.

I am really proud of each of these physicians, this team. They have worked very hard to prepare for their contribution to this conference, especially those that have complicated topics, and I am very pleased with the results. I hope they are taking this as seriously as I know the medical professionals of Nepal are, for to them this is a once in a lifetime experience to gain knowledge and skills from specialty-trained physicians who have spent years studying and practicing the topics that they themselves want so badly to learn. I think that the experience of the conference will be incredibly fulfilling for the team, and they are going to be very happy that they worked so hard to make it successful. Wish us luck tomorrow!

I don't have much time to write more, since I want to go over my slides a few more times before hitting the hay, but I wanted to put up some additional photos for you to enjoy in the meantime. These are not working pics, those are on my camera, and I still need to download them from the card, so those will come tomorrow. Enjoy these shots! We miss you all!

Sue/Team

(btw, I'm sorry Mrs. Kijac, that there were a few days gap between blogs... Pete says you were anxiously awaiting the next installment, and I hate to disappoint! Trust me that Pete and all of us are working and playing hard, being safe, and taking care. Thanks for following along!)

Mountain Flight - the top of the world!

NOTE: this photo is not, I repeat not a postcard, or an Ansel Adams that I scanned into this blog for your benefit. It is a real-time photo taken by Peter Kijac out the cockpit windshield of our mountain flight this morning, looking at the top of the world, Mt. Everest (or Sagarmatha, the Sherpa name), flanked by her two mates, Lhotse on the right and Nuptse on the left. Pete has mad photography skills, as you can see, and we enjoyed a gorgeous view of the entire Himalaya range this morning, which Pete captured on his camera masterfully. I know you will all enjoy seeing the photos when he returns. I will try to put as many of them up here on the blog as I can, stay tuned!

(also, I know I skipped a day, I forgot to write about Tuesday. I will do that tonight and post it tomorrow. sorry!)

(2100 Wednesday April 14, 2010) – this is Melissa’s blog!!!!!

It’s the Nepal New Year today! The group was told that today would be like every other day here and nothing special would be taking place. However, we awoke bright and early, minus the bright, at 4AM and took a taxi to the airport over the bumps and potholes that litter the “streets” here. I can’t speak for the rest of the group but after waking up yesterday at about the same time it was challenging to emerge from my slumber. However, I knew my fortitude would be rewarded. We arrived at the airport fully awake, and waited anxiously at the entrance to be allowed in for the rather swift security check. Once inside it was less than 1 hour before we were boarding our flight. Having only 18 passengers it was not long before we were in the airplane with our seatbelts fastened in anticipation of take-off. It was a simple mountain flight operated by Angi Airline which occurs multiple times a day, but to us it was the flight of a lifetime. We ascended into the clouds over Kathmandu and promptly banked to the right, headed towards the Himalayas. It had stormed the night before and we reaped the benefits by a perfectly clear day over the mountains. All the snow-covered peaks were beautiful, but Mt. Everest was by far the highlight. It was truly majestic and an unforgettable site to be so close to the top of the world.

After the journey we returned to our humble hotel rooms and each of us took a well-deserved siesta. Except Sue and Jason, who took a rikshaw to Mike’s Breakfast for “a delicious, fabulous, awesome and mouth-wateringly good” meal. (That’s a direct quote – Mike’s is apparently the best place for breakfast in Kathmandu, it’s mentioned in all the guidebooks, likely because of the sign out front, claiming “our water and ice are SAFE, we wash all vegetables, fruits, and flatware in iodonized water, and our dairy is PASTEURIZED”) That’s what I’m talkin’ about! Ellen, Amanda and Pete were up and walking around town before 10AM and had pizza at Fire and Ice for lunch, it was much talked about the rest of the day. I awoke slightly before lunch, after a quick meal, the females headed over to Helping Hands. While we were at the hospital Jason graciously helped with logistical planning for the conference by uploading Sue’s lecture, making copies of forms that are needed, searching for fabric and a mattress that will be needed for the ultrasound portion of the conference. He has been such a enormous help during this whole trip I know that it could not have been done without him. Pete also assisted with making ECG photocopies for the breakout sessions of the conference. Pete is an invaluable member of the team as well, we are very lucky to have such support from the two of them.

Some exciting events occurred at the hospital today. We were able to give an Ultrasound tutorial to the ED physician there covering E-FAST, gallbladder and aorta. He was very excited about learning how to use this technology daily to help diagnose the treat patients. I was the “patient” for him to learn on. As it turns out my aorta is of normal caliber, my gallbladder has no stones and I have no free fluid in my abdomen (phew, that’s a relief). Once the patients started showing up, they came in droves! My first patient of the day was eventually transferred to the Heart Center, because she was likely having a heart attack. My second patient was a toddler that was hit and pulled by a motorcycle, but thank goodness was okay. Amanda was able to tap an inflammatory knee effusion like a pro. Ellen saw a relatively young gentlemen with dizziness and a headache and saved him from having to get a head CT and/or lumbar puncture by doing a very thorough history and physical examination, and she in tandem treated a gentlemen with COPD expertly. Sue was quite busy during this time supervising all of us and guiding us as to what to do. It is very different here than back home. I usually present to the attending and have them say that either my plan acceptable or it’s in need of slight improvement and discussion occurs. Here the physicians that are running the ED are asking me what to do. I am to them more knowledgeable and the expert on the matter. This both scares and excites me. I know what I know, but I also know that there are things I don’t know yet. That is why I am so thankful Sue is here to lend a helping hand when needed. I don’t think that any of us could have traveled here and participated in as fully and practiced medicine as we are without her being here with us and guiding us.

After we retired from the hospital for the night were driven back to the edge of Thamel for dinner and bed. However, for the New Year there was a concert with stage set up in the middle of the road. We had just reached the edge of the pit section when 50 or so teenagers decided to storm the stage area. We were able to wait off to the side of the street and thankful were not trampled on. We snaked out way through the crowd of people, slowly and were able to emerge close to a pizza place. We were famished by this time and all six of us sat down to a delectable meal. Sue ate a whole 30 cm pizza and I ate all but 2 slices of one. What can I say, work hard/play hard/eat hard. I am saving the two extra slices for breakfast in the morning, that’s how good it was. Now were are in the lobby after going over our conference practical scenarios for the meeting Friday/Saturday and it is 1AM. Time to go bed! Hope everyone back home is doing as wonderfully as we are here.

Namaste!

Melissa Leming
(more medical photos coming later today)

The Strike

(2100 Monday April 12) - this is Ellen's blog today!!

We took our time this morning, considering the Maoists were on strike and all. Well, Melissa and I did. I’m pretty sure Amanda and Pete were up at 5, Sue was visiting every hospital in Kathmandu setting up international opportunities, and Jason was on a half century plus ride around the Kathmandu valley. We were originally supposed to be picked up in an ambulance because no taxis would be running due to the strike. But, then we were told not to come because the Maoists would most likely not let us pass, not being sick in the ambulance and all. Oddly enough the strike only lasted an hour; however, we did not know this for approximately 4 hours, making the strike last about 5 hours for us...

Sue had visited Helping Hands in the morning and determined we could come in the afternoon, since patients might show up. So, after spending the morning working on the lectures and adding photos to the internet we set off for Helping Hands. Melissa stuck to the ultrasound, Sue was in the ED, Amanda and I rounded on the floors while Pete was our national geographic photographer. It was pretty interesting as our day consisted of (in Nepali terms) TB, Enteric Fever, Parotiditis, COPD, a bezoar, pneumonia, broken bones, wounds, dehydration, Alcoholic liver disease, encephalopathy, cardiac valve lesions, obstetrics, etc. Sue broke out the new EKG machine we are taking to Wana only to find it missing a few pieces. Thankfully she set it up here so we could get parts before we got out to Wana. Amanda set up to work with Dr. Gupta in his private clinic one day this week and we are both trying to figure out how to get into the hospital where we can catch 40 babies in one day…

After finishing work at the hospital we headed out to meet up with Jason at Boudhanath and catch the classic sunset view of the Stupa. A few of us checked out the Tibetan Medical Center in the area only to find an office with herbal medicines in huge jars. It is apparently big in Pulse diagnosis, but we must have just missed the doctors because it was closing and we didn’t get that much information.

The Stupa was beautiful, especially with the sunset and people in traditional Buddhist garb. We however did not see the candles Amanda really wanted to see as for some reason they were not lit, and we did not fit in as we were dressed in traditional hospital garb (scrubs). As we were taking pictures of others and their dress, I’m pretty sure we were being photographed just the same. Pete hung out on photographer’s row, getting the “money shots” of the stupa. Buddha Stupa was by far my favorite, as the top was completely golden with the sunset. In the surrounding plaza, filled with shops and roof top restaurants, everyone walks clockwise. We thought it wouldn’t be that big of a deal if we just walked quickly to a restaurant counterclockwise, but you definitely feel like you are doing something wrong… At different areas in the central plaza, behind the prayer wheels, people were doing rites towards the stupa. In fact, I’m pretty sure one couple did the rites the entire time we were touring and eating, which must put them in fantastic shape since this consists of a version of sun salutation with each one.

Sue and Jason went to a lecture on Everest this evening resulting in us calling the rest of the trip off and heading to Everest base camp ASAP. Umm, I wish. Meanwhile, we went and ate some food overlooking the Stupa. However, we were underwhelmed and had to grab some desert at a bakery in Thamel. We went to the one where most of the staff is hearing/speech impaired and they encourage sign language. This was before we knew that Pete spoke sign language… which he does…as so does Melissa. Who knew? I’m pretty sure the staff enjoyed chatting it up though, and we will probably have to go back as the cakes were pretty delicious.

But now, I should probably finish my lecture…since there is no pressure in doing an international conference for 100 physicians in 3 days…

Ellen

Tribhuvan University Teaching Hospital, and an orphanage house-call

(2200 Sunday, April 11, 2010)

I just want to put it out there that attendance at morning yoga is dwindling…for the last 2 mornings it has been only Jason and myself… Write your favorite team member an email or a text and call them out – get them to come to yoga! Or at least find out for me if it’s the instruction that is the problem…Jason and I have no formal training.

Today was a full day!! After breakfast (Pete back on track at this point, btw) we headed to Tribhuvan University Teaching Hospital to meet Dr. Ramesh and have a tour of the ED and the rest of the hospital for the team. The University is very large and impressive, and it certainly seems as though there is ample space for all the departments and educational areas. The main hospital entrance is packed with people, coming in to register to be seen in the outpatient department. Their chief complaint will determine which specialty OPD office they are assigned to, and then they move to that area and stand around until their number is called. At any time in the morning or afternoon, there are about 300 people milling about in the hospital’s main floor lobby and hallways. Often they are sitting on the floor, eating, or sitting on benches, or chasing their child around the area. Always they are talking and crowding to be the closest to the door of their designated opd office. Often they push into the office and stand in a line directly behind the patient being seen. No such thing as HIPAA here in Kathmandu!

The emergency room is exactly that – a room. Not the largest room I’ve seen, but not the smallest, either. It seems smaller, because there are literally patients and family members everywhere, on the gurneys, in chairs, on the floor. There is no triage system, so the patients, after being let in the locked iron gate by an armed guard with absolutely no medical or triage training whatsoever. But he looks intimidating; anyway, it gets the job done. J After being let in the department, the patient or whoever brought them in will come right up to the small rounded desk in the corner, behind which the physicians and nurses stand and do their paperwork, call consultants, and generally escape the chaos of the room. There is not much escape, however, as the patient will stand directly in front of them and wave their intake form, stating their complaint over and over and asking every doctor to see them immediately. The physicians and nurses go through the patients one at a time, and often it is the loudest and most vocal patient that is seen first, rather than the sickest. This is the main difference I noticed between TUTH and our system in the US – our triage system allows us to identify the sickest patients immediately, and target them to go back to a room right away and be evaluated. The staff at the triage area also learns the chief complaint and a brief history of the illness, and is able to begin some investigation or treatment, even prior to the patient seeing the doctor. The triage area is separate from the treatment area, really separating the doctors from the chaos of the waiting area, and keeping a feeling of calm in the department, leading to improved physician performance and patient experience. The nurses at triage, of course, are subjected to the stressful environment for long periods at a time, and because of this they change assignments every 4 hours.

Unfortunately, we are unable to work in the ED at Tribhuvan, as Ramesh has made inquiries of the Department chair and he has not yet received permission to make an invitation to us. Politics, politics. We plan to make those arrangements for the future fellow and next team. Dr. Ramesh took us on rounds, however, and explained each patient’s complaint, exam, work-up and treatment plan, consulting us frequently on complicated cases. They have “boarding” in their ER the same as we do – it seems that their inpatient departments often operate at >100% as CCHS does, illustrating again that there are many similarities in global medicine, despite all the differences.

We spent a little time with Dr. Ramesh in his office, where he sees patients in a study having to do with tropical fever, in collaboration with a group from Thailand. We then had a lovely meeting with the Director of the Tribhuvan Nursing School, who was asking whether or not we have a nursing school in DE that would be interested in an elective exchange program for nursing students. They have RN students from the UK, Sweden, Netherlands, Norway, and Germany who come for 4-6 weeks for a clinical elective here at TUTH, as well as in various rural community health centers. I think this will warrant a conversation with the U of D nursing school director. Oh, the conversations I will have when I get home! I certainly think that this would be a great place for a nursing student to broaden their scope of practice and sharpen their physical exam skills, given the lack of resources.

We had a brief lunch, and then the residents went with Dr. Ramesh for his bedside teaching session with the senior medical students. This is a great way to observe the teaching process here, really see the knowledge level of the medical students, and hone their own teaching skills in the process. The case was a middle-aged female with no urine output for seven hours, likely urinary outlet obstruction. The students presented the case and discussed the differential diagnosis. The woman who was the presenter seemed to struggle a bit, but in general they seemed bright and enthusiastic, eager to learn and discuss the medicine.

Once we were all back “home”, we regrouped and decided to go with Bikki to his orphanage to meet the girls. Bikki and his father run an “orphanage” for 10 girls from the ages of 4-11, which is partially funded by a national organization for homeless girls, and the rest by Bikki and his father themselves. I put the word orphanage in quotations, because unlike what I think of as an orphanage, where parent-less children live and are taken care of while waiting to be adopted, a facility of the same designation here or in India appears to be almost a family, where the children are not adopted by the family, per se, but they are not at all up for adoption by anyone else. The understanding is that they will live at the home until the age of 18, when they finish secondary school. They will be prepared to enter university at that time if they choose to do so. Some of them are orphans in the truest sense of the word, but many of them are daughters of single mothers, who could not afford to raise them on their own, and decided to give them up to the orphanage. The parents have relinquished all legal rights to the children in those cases, although they sometimes get to see their girls for a day or two surrounding some holidays, if they choose to.

Bikki’s girls are ADORABLE, simply a breath of fresh air. All of their little dark heads of shining hair bobbing around the playroom, as they trade dolls, play games, and hop over one another in games of leapfrog. They all gathered around a game on the floor, which looked like a combination of checkers, backgammon and air hockey – apparently you have to flick the various checker-like pieces into the corner pockets. One of the girls was incredibly gifted at this game, and could probably have won enough rupees from the audience to buy an entrance fee to secondary school!

We went outside to the rooftop with the girls, where they often play Frisbee, ball, hackey-sack (they’re WAY good at hacking, as well!), and dancing. I just MUST share some photos of these adorable little cherubs! They sang in unison while each one came forward individually and danced a traditional Nepali dance, with arms and hands curling in front of them, feet carefully stepping left and right to the beat, and spins that would make anyone dizzy. They seemed to be having a ball performing for us, and it was easy to tell which ones were the next ballerinas or Bollywood dancers. (Or whatever dancers they have in Nepal besides the ones on the signs in the streets of Thamel that come out at around 10pm as the boom-boom-boom-boom music starts.
We had brought our medical bags, and so we gave each of the girls, as well as their housemothers, a full check up. Most of the girls were perfectly healthy, as Bikkis had assured they would be, but the housemothers had a few issues, so we make some recommendations. One little girl appeared to be recovering from a viral illness with enlarged lymph nodes, a fever, and a headache. We removed the makeshift bandage that someone had placed there 5 days prior. She apparently was improving greatly – no further fever, pain almost gone, eating and drinking well. We planned to return on Thursday for a re-evaluation, to ensure that she is continuing to improve.

We were reluctant to part with the lovely angels, but it was quite late. We handed out some gifts we had brought them – just some puzzles and learning games – which they seemed to like very much. It’s always a great day as a parent when one of your so-called friends introduced your child to blue Play-Dough… Blue carpet, here we come!

Bedtime was early tonight, as the girls wiped us out. Looking forward to tomorrow, when apparently there is going to be a Maoist Strike about the price of passports and needing passports to go to India from Nepal. All of the city of Kathmandu inside Ring Road is apparently going to be shut down, and therefore there will not be any card on the road, no taxis no nothing. Work at the hospital will be impossible, unfortunately. But I am sure we can find something fabulous to do.

Thank you all for your wonderful email replies and support. We are having a wonderful time, but obviously we miss you and or homes. I apologize that this blog is about 3-4 days behind schedule, but we are just so busy, I have to schedule time just to sit down and write!

More soon, Namaste!

Sue/Team