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

Patan Durbar Square and hot peppers

(2000 Saturday, April 10, 2010)

Saturday is the “weekend” here in Nepal. Don’t get me wrong; the shops are all open, the streets are just as bustling, the horns are still honking, but apparently no one goes to work. How the math works with that, I am not sure. Suffice it to say, we weren’t welcome at the hospital Saturday, we were told to take a rest day. Seeing as how we had gotten a day late start there in the first place, we were a bit disappointed, but that did not last long, as there was all of Kathmandu waiting for us, anxious to share its stories and secrets.

The original plan had been to rise at the crack of dawn (actually the pre-crack) to travel by bus 1 hour east to a small ridge-top village called Nagarkot, to stand atop a tower there and view the sunrise over the Himalayan range. Apparently the view is spectacular when clear, and many a visitor run out of film snapping photos of the experience. (I realize no one uses film anymore – the story sounded more romantic with film, than with running out of battery…)

Fortunately, Pete was in the recovery phase of whatever organism had been using his body as a vessel for its life-cycle, and was no longer vomiting, but the experience of the night before had left him exhausted and dehydrated, and he had a long way to go before he would be ready to traipse around the city sight-seeing. We took a bit of time debating our options, and finally decided to cancel/postpone the Nagarkot outing. Instead, Melissa, Ellen and myself traveled to Patan area with our friend/guide Bikki. We sadly left Pete back at the hotel, along with his dedicated and compassionate personal physician, Amanda. We certainly knew he was in good hands, so the rest of us decided it was ok to clear out. Jason wasn’t feeling all that great Saturday, more fatigue than illness, I think, and he stayed behind as well.

Patan is an older section of Kathmandu, and its draw is the many temples and stupas built so many years ago, yet still in tremendous shape. Some of them had to be restored after the earthquake of the 1930’s, and it seems they did an amazing job! We are able to go inside many temples, which reveals statues, offerings, and various symbolic items or structures of the religion. Hinduism uses a bell for luck and good feelings from the gods – a person entering a hindu pagoda would ring the bell at the entrance, or any of the bells throughout the temple as part of their prayer ritual. Buddhism, on the other hand, uses prayer wheels, and these are placed in similar fashion as the bells, at the entrance to the stupas, throughout the inside of the stupas, and often in a circle on the outside of the stupa, surrounding it, and allowing worshipers to walk clockwise around the temple turning the prayer wheels, and releasing the prayers into the breeze to be carried on the wind to the gods and to the people in need. Some of the temples were off-limits to Westerners, and we were not even allowed to photograph them from the outside. In the center of Patan is Durbar Square, a large cobblestone area, often bustling with people, where a large majority of the temples are located surrounding the main palace where the successive kings would live in those days. Each king apparently tried to outdo the previous by building a more impressive temple in the square in the image of his god of choice. Apparently each city in Kathmandu has a Durbar Square, (Patan, Kathamandu, Bhaktapur) meaning simply “Palace Square”, but Patan’s is supposed to be the best.

As beautiful as the temples were, the city proper of Patan was a bit of an assault on the senses, as it seemed more crowded and noisy even than Kathmandu itself and Thamel, the tourist district where we are all staying. By the time we had seen every temple Patan had to offer, we were shredded and on sensory overload, and decided to taxi it back to the hotel right quick.

Ellen was drained enough to hit the shower and the bed right away on our return to the hotel, and Jason was still in his bed, sleeping off whatever was bringing him down. When I checked on Pete, he had much more color than previously, and actually managed a smile (when he spoke of Amanda), and pointed me downstairs to the restaurant to find her, where she was dining solo and enjoying the night-time breeze out on the patio.

Melissa, Bikki and I ventured out into Thamel for dinner, settling on a garden restaurant whose name I of course forget, but it had much variety and was lovely. Melissa’s meal was apparently rather spicy, however she claims to have a rock solid set of taste buds, and she even accepted a bet I put forth to chew up and swallow a tiny green pepper that I had never seen before, but that Bikki said is the hottest pepper out there. 1000 Rupees she won from me as the tears spontaneously streamed down her cheeks, the clear liquid draining from her nostrils, and the drool collecting on her lower lip, hesitating there briefly until the drop was large enough to cascade with gravity down onto her plate as she leaned forward, smiling. “No problem” she says shakily, “Show me the money!” I learned my lesson, I suppose, don’t put any money (AGAIN) on Melissa’s iron stomach. She’s a machine.

This restaurant had no dessert. I don’t think it should be allowed to call itself a restaurant.

Off to bed! More manana. Namaste.

Sue/Team

Helping Hands Hospital

(0845 Sunday 4/11/10)

Namaste!

Sorry for the delay in updating you, we have been busy! I believe I left off after yoga on Friday morning, which btw, we are doing daily, and personally I think it is really helping with our focus. So lovely up there in the mornings. This morning was clear and blue and breezy, and altogether fabulous. Jason brought his TRX personal training system (as seen on TV, from personal training legend Todd Durkin…), and we had 2 sessions going today, me doing yoga on one side, and Jason doing strength training on the other. Where was everyone else, I wonder? Up late partying, I am sure. ☺

Before I get into what we’ve been doing for 2 days, I will inform you (ie Pete’s family and friends) that Pete was the first to fall. So if any of you others had money on Melissa, I’m sorry for your loss, and my lousy tip. That chick has an iron GI tract: she’s been eating grapes off the ground, raw meat from street-side vendors, drinking water from the tap, and no issues at all! Poor Pete had a Fanta from the local grocery store and just now emerged from his room after 30 hours of purging alien substances from multiple orifices. I wanted to make sure not to mention how sick he was until he was all better, so as not to worry the family too much. This morning he looks wonderful - great color, smiling, nibbling on saltines and daintily sipping Tang. Just another day in Nepal! We’ll see….who’s next?

Friday was spent at Helping Hands Hospital, where we had an extensive tour by Dr. Gupta, the hospital Director. I am so impressed by all the improvements since I was here six months ago. They are expanding the emergency room to double the size of the space and number of beds, which should be finished next week. The new ICU is almost finished, only needs to have the equipment and beds moved in. They have added a histopathology lab, which is something that almost no hospitals have here in Kathmandu; usually they have to send everything out, often to India. The pathologist here has a telemedicine set-up, and is able to sent photos of tissue to consult other pathologists on difficult cases. She was very interested to know if there would be any interest at Christiana Care in creating a relationship for consultations such as this. If there are any pathologists reading this, I’m going to be calling you when I get home. You can save some time by just emailing me now. ☺

There have been numerous additions to the lab equipment, and therefore the diagnostic capabilities have increased significantly. We spent some time with the interventional radiologist, who performs all echocardiography, stress echo, ultrasound, endoscopy and colonoscopy. He is very excited to work alongside the doctors from our team in the ultrasound department, to trade knowledge and skills. He inquired as to whether we are planning to come back any time soon and put on a multiple-day conference focusing only on ultrasound use for emergency medicine… I said that sounds like a great idea (I was already thinking that…). Anyone interested, you know where to reach me. (Paul and Jason, clear your schedules in the fall for a week or two…) I know that there are one or two other programs in the US that do periodic ultrasound teaching here in Kathmandu, however there apparently has never been a full conference on EMUS that is open to all comers. At Tribhuvan Teaching Hospital, there is an ultrasound in the ED, locked in a wooden cabinet, because no one knows how to use it. Just sitting there! There would be a patient sitting next to that cabinet on a gurney, a pregnant woman after a car accident who has abdominal pain and vaginal bleeding, and she waits hours to go to the radiology department to get a full US, all the while she could have been evaluated immediately if the physicians had the skills to use the US. Think about that…

After an exhausting day at the hospital, it was back to Thamel for some rest and regrouping. All of us needed to work on preparations for the upcoming conference, so there was a lot of key clicking and cursing at the wifi in the evening. I think the gals (sorry, the doctors…) are making great progress, and they are working hard on their presentations. I know I have already said this, but I am impressed with their dedication to making this conference, and their roles in it, successful. I hope they know how much good they are doing for so many people.

We all walked about 20 minutes through town to an outside garden-type restaurant for dinner, which was quite lovely, although the loud sound of the generator made it a little difficult to chat much. After 20 minutes or so, the power came back on and the generator turned off, ahhh! Many of the restaurants here that are considered “local” or “traditional cuisine” serve mostly Nepali food and Indian food, with an occasional smattering of Chinese food. Nepali food is really not that complicated; dahl (lentils), bhat (rice) and potatoes, usually with spinach and a meat choice if you want. There’s not much variation on that, it’s just vegetarian Nepali food or non-veg Nepali food. It’s awesome, btw. Indian food, however, has lots of options, and is quite delicious here. Be aware, though, as no one asks whether or not you want things spicy or mild, and if you don’t say so, they assume it’s spicy. Not great for wimpy little taste buds like mine, although not a problem for “iron stomach” Melissa. I think she can eat rocks.

This point in time, however, was the start of Pete’s downward spiral, so some of us left early to get him into his room near a bucket. It had been a long day, and I personally passed out at that point. There’s something wonderful about being in a place where there’s not that much to do after dark, and once the sun is coming up everything begins. I am the farthest thing from a morning person usually, but here I am up at 0500, ready to seize the day, and by 9pm, out like a light. No Project Runway, no Daily Show, no nothing. I heard a rumor that someone in our group has some DVD’s, specifically Star Wars, which may be tempting enough to have a late movie night one of these days. Maybe we’ll wait until we’re in the middle of nowhere in the rural village of Wana, as activities there will be even more scarce. The real show in Wana will be the stars, hundreds of thousands of them so bright at night, we’ll never be bored. I am so looking forward to it.

More soon!

Sue/Team

Radiologist performing liver ultrasound


EKG - see the suction cups!


Entrance to the Emergency Room (under construction)

Start the Day off Right!

(0900 Friday 4/9/10)

I just had to share this with you… Lest you think we don’t go all-in at Christiana Care, take a gander at our 6am activity today. Mind, body and soul, they say, so we plan to immerse ourselves in the culture here as much as possible. The plan is to be up here on the roof every morning at 0530. I wish you could have been there, truly! The noise of the Kathmandu street traffic had not yet started, the sun was just peeking up through the valley haze, the birds were chirping, (and trying to land on our outstretched fingertips), and the prayer flags were flying above, the breeze carrying the prayers away to bless those souls in need. I don’t know how anyone could not have a great day after a beginning like this. We hope yours was as wonderful. More later!

Sue/Team

Shopping, Monkeys and Meetings

(0800 Friday 4/9/10)

Namaste.

Finally the team is all together again! Poor Ellen and Jason spent 9 hours yesterday doing what should have taken two. Their Jet Airways flight was delayed leaving Delhi, as ours was, and they did not arrive here in Kathmandu until after 3pm! Accordingly, they were tired and grungy by the time they stepped out of the car at the hotel, but both of them were chipper and upbeat, much more so than I would have been. I have to hand it to them, they are graceful under fire.

The rest of us had spent the morning walking around the Thamel district of Kathmandu, window-shopping, people watching, and buying trinkets. This area can be a bit overwhelming to those who have not experienced it before – very narrow streets with cars, motorbikes, bicycles and pedestrians, all moving at a pace faster than what seems safe. It is unwise to walk to abreast on these streets, so we wound our way through single file, so as to avoid getting an arm or an elbow clipped off by a passing motor vehicle. We bought a few things here and there, and very much enjoyed people-watching and soaking up the culture and atmosphere.

We stopped by the shop of a friend of Jason’s and mine, Bishal Singhania, whose shop is called The Dreaming Room. It is an enchanting gallery tucked into a cubby off the streets of Thamel, full of Thangkas, Pashminas and statues. Jason and I got to know Bikki (Konal’s nickname) 6 months ago when we were here in Kathmandu and stopped in his shop to look at a large oil painting of Buddha, that had caught Jason’s eye while walking past. The painting captured both of our hearts, and we eventually purchased it, along with a Mandala Thangka painting. Bikki spent over an hour with us, explaining the history of the Thangkas, how they are made by Tibetan monks, and how the design, pattern and figures within them have special meaning. The precision with which these paintings are executed is really remarkable. Bikki was very knowledgeable about all of the art within his shop, and really made the experience of purchasing the beautiful pieces that much more meaningful to us. Later in our visit, while I was working in the hospital, Bikki took Jason to see the orphanage that he and his father run, and meet his 15 young girls of various ages, who, because of the generosity and hard work of Bikki and his father, have a comfortable home, clothes, and food, go to school, and learn skills. They were just the most precious family! We plan to all visit them at some point in the coming weeks.

So yesterday we all stopped by to see Bikki at his gallery, and he served us tea, and took Amanda, Pete and Melissa through the fascinating explanation of the Thangka paintings that he had told Jason and me last year. I think Amanda had here eye on a gorgeous red, black and gold Tibetan Prayer Circle painting. Bikki has some incredibly beautiful new pieces, and I know I will be spending some money in his shop this time around as well! We said our goodbyes to Bikki with the promise to call him later in the day, once Jason arrived, so that he could take us to one of the local temples, Swayambhunath, also called Monkey Temple. More about that in a sec. Here’s a link or two about Thangkas and Mandalas, and the info for Bikki's gallery, if you are ever in the area:

http://en.wikipedia.org/wiki/Thangka
http://en.wikipedia.org/wiki/Mandala

The Dreaming Room – Gallery of Pashminas, Thangkas and Statues
Bishal Singhania
M. 9851062245
J.P. Road, Thamel, Kathmandu, Nepal
Phone +977-1-4212274 (R), 4239056 (S)
konals@yahoo.com

When we returned to the hotel, we sat down for some lunch, and Ellen and Jason arrived, thankfully! It is a great feeling to have everyone back together. We filled the two of them in on events, and we all had a lovely lunch. The two of them still had some zest in them, so we decided to take Bikki up on his offer to be our personal guide to the Monkey Temple, and we all hopped in a cab and traveled about 15 minutes up a large hill above Kathmandu to the large Stupa, one of the most recognizable Stupas in all of Nepal. You will see it on many postcards and the front of Lonely Planet tour books. Its true name is Swayambhunath, but there are many monkeys that live up there in the heights, and they wander around the tourists and locals as though squirrels in Central Park, hence the nickname Monkey Temple. (Also because foreigners like me can never remember nor pronounce the true name. Shameful.) It was late in the afternoon, and as we toured the beautiful structure, the sun dipped and it became dusk, and a magical feeling came over the entire area, really enveloping us in the spirituality of the things that Bikki was teaching us. The Stupa itself is a large structure in the Buddhist religion, signifying the eyes of Buddha looking in all directions, and the 13 rings are the 13 steps to Nirvana. There are two additional obelisk-like structures on either side, representing Buddha’s two followers. Intermixed between the various Buddhist structures are Hindu temples, many of them, each for a different Hindu god or goddess. The lotus flower on the ground in front of the temples awaits the god to stand there when they arrive, and we stepped purposefully around them, careful not to tread on the place of the gods. People of both religions are praying here, intermingling and tolerant, as a shining example of the peaceful and accepting nature of both of these religions, and of the culture of Nepal.

As we left the impressive structure as darkness fell, we descended the 365 stone steps on the south side of the Stupa, one for each day of the year. I’m really glad we didn’t decide to enter that way…!

A quick taxi ride and we’re back to the Tibet Guest House. The evening was taken up by a meeting with Dr. Ramesh Maharjan, who is the Founder and Director of NADEM (see blog #1), and the General Secretary of the Conference we will be hosting next weekend. We discussed final details about conference logistics, the schedule, where we are on lectures, registration, certificates, journal layout, etc., the exhausting part of putting on a conference. I am happy at the progress we have all made, I think we are well on our way to making this very successful. Ramesh and I also discussed more thoughts about the future of Emergency Medicine here in Nepal, and I wish you could all see the excitement and passion on his face when he speaks of this conference, of the possibility of beginning training programs here for EM, and at the thought of the new Christiana Care International Emergency Medicine Fellowship starting next year and working with NADEM for this common goal. It is very inspiring.

Off to bed. I think there was food first, I don’t remember, way tired again. Like I said, good to be a complete clan at last.

Namaste!

Sue/Team

Good morning! (0600 Thursday, 4/8/10)

Just waking up with the birds singing, cars honking and dogs barking. Ah, Kathmandu! This morning will be the quest to retrieve the remainder of our team from the airport. I have just received word from them that, similar to our flight yesterday from Delhi to KTM, their flight will be delayed approximately 2 hours. Ellen and Jason have been trapped in what we call the “transit zone” at Delhi airport – this glassed-in area where people who have layovers are kept until about 1.5 hours prior to their flight departure. It has almost no food, few beverages, only a few comfortable chairs, and plenty of mosquitoes. And through the glass, one can see the “regular” people, shopping for Duty Free, eating Subway sandwiches, buying Cartier watches, and all sorts of fun stuff in the main terminal. Jason and Ellen have just learned their flight is delayed, so they get to enjoy 2 more hours in the “transit zone”. Fun stuff. I’m just glad they’ll be with us in a few hours.

Yesterday after arriving at the hotel and freshening up a bit, the team here met with Dr. Gupta Shrestha, President and CMO of Helping Hands Community Hospital here in Kathmandu. Dr. Shrestha is the personal physician to the Prime Minister of Nepal. Apparently our team is going to have tea with the Prime Minister later in the trip…glad I brought my good shoes! More on that when it happens. He also tells me that he has arranged for the Director of Logistics from the Ministry of Health to attend our EM Conference. I am very excited for the Director to see all of the hard work put forth, and all of the enthusiasm for the EM specialty among his physician constituents.

We discussed all details for the itinerary of the trip. The EM Conference on the 16/17th is shaping up nicely. Dr. Gupta gave me a large poster of the advertisement that has been circulating throughout Kathmandu for the Conference, and it is very impressive-looking! He tells me that over 100 participants have signed up, and they are closing the registration at 150 participants. How we are going to get 150 doctors through 4 simulations stations in 2 afternoons, I have no idea, but I am sure we will think of something. Maybe we’ll add a couple more simulations… Feel free to respond with ideas. ☺ I have brought all the equipment for the simulations, Dr. Gupta has arranged the venue and refreshments, and Dr. Ramesh Maharjan from NADEM has taken care of name tags, tote bags, agendas and schedules and the like. Dr. Ramesh and I will meet Thursday to go over the schedule of lectures, etc. He has invited 4 local specialists to lecture, and each physician on our team will be giving a lecture on a specific topic in Emergency Medicine. I know they’re all a little nervous about it. But no need to be! They are each incredibly smart, professional and dynamic physicians and individuals, and I am confident that they will each make a lasting and positive impression on everyone here. It is very exciting to me to see them be such a big part of this incredibly important movement toward the establishment of Emergency Medicine in this country.

We discussed the plans for our 5-day trek to the tiny village of Wana, Dr. Gupta’s birthplace, and the village that I visited on a similar trek in 2000 as a barely-3rd year medical student with Helping Hands. I am so excited to go back there, see the familiar green hills and beautiful landscape, and also to see how much it has changed. Dr. Gupta says there is electricity now, and that because of this health camp that we are doing, it will have the most advanced rural health post in the country! We will be bringing Xray, electrocardiogram, oxygen concentrator, nebulizers, glucometers, pulse-oximeters, etc, all to stay there permanently. Our team is bringing an ultrasound to use for the week, but unfortunately we must bring it back to Sonosite, at the end of the trip. We will be collecting all the medications needed for the camp over the next 2 weeks, and Dr. Gupta has already sent on quite a lot of supplies by porter and mule. It’ll be interesting to see how much of this we’ll all be shlepping up there on our own backs on the trek, or whether we can find some more porters for hire for the rest of the stuff. If we can’t, I’ll definitely get photos of that situation!

The plan for working here in Kathmandu in HH hospital was also finalized, and as we said danyabhat and goodbye to Dr. Gupta, we agreed to meet him tomorrow at the hospital to begin work, after we collect Jason and Ellen.

The rest of the evening was spent emailing our various families with word that we are alive, and crashing. Melissa and I went out for a quick adventure into the streets of Thamel to purchase some essential forgotten items, and some bottled water. If anyone is taking any action on who is going to be the first to get sick, I’ll give you the inside track… it’s gonna be Melissa. She already opened her mouth in the shower and brushed her teeth with the tap water, despite my advisement to use the bottled water. She’s a tough one, that Leming! If her family/BF is reading this, I’m sorry to break it to you. But she’s with a bunch of doctors, and we have enough medicine in our bags to treat an entire village, so I wouldn’t worry. She’ll just get it out of the way early. ☺

Then we were off to our respective rooms to bed. At 7:30pm. I have no clue what time it is in our internal clocks, but it must be either really late or really early, b/c even the rhythmic bass of the local “trekking-equipment-shop-during-the-day, kinky-nightclub-at-night” didn’t keep me from heading to dreamland.

More later!

Sue/Team

There's always a glitch....

Namaste from Nepal!

If you're reading this, you are likely a family member, friend or colleague of Sue Thompson, Jason Rita, Melissa Leming, Amanda Kijac, Pete Kijac or Ellen Finney. We are the team of doctors/support staff from Christiana Care Health System Emergency Medicine Residency in Delaware traveling to Nepal for the month of April, 2010. We have a packed agenda this month, including seeing patients in the Emergency Departments of 2 hospitals in Kathmandu, traveling to the remote village of Wana in the northeast for a 5-day healthcamp, performing research projects, and hosting a 2-day Emergency Medicine Symposium here in KTM in collaboration with Helping Hands Community Hospital and Nepal Disaster and Emergency Medicine Center. We are very excited about all of our plans.

Team A has just arrived in Kathmandu, and have checked in to the Tibet Guest House. We are now in the cafe, sipping banana smoothies. (Or coca cola, as in Pete's case....lactose intolerance. ick.) Team A? You wonder... Yes, Team A. Sit back for a cute little story, the story of the first (and hopefully only) glitch of the trip.

The best laid plans... We had to fly out of Newark, NJ instead of Philly, because it was cheaper. That's a good reason, yes? Newark is 2.5-3 hours drive from our places in DE, and we arranged a shuttle to pick all of us up at our homes one by one, and head up to the airport. We were running late, because the shuttle service (who is will not name here, kindly) realized after picking up the first stop, that the door of the bus was broken, and would not close properly. The driver felt this was unsafe, and may fly open on the freeway, and therefore we had to return to the shuttle depot to pick up a new one. The driver also had a bit of a lousy sense of direction, and even in this day and age, had no GPS. He was driving with one hand, and holding a map up to his face with the other. This put us about an hour behind schedule. We had, of course, prepared for this type of issue, so we weren't concerned, until, after the second pick up, we realized, we were one passport short! The passports were all at the team leader's house ever since we sent away for the VISA's, and we had planned to pass them out to their owners at the airport. We suddenly realized that Ellen's passport was not with the others.

Panic ensued and we pulled over and took the bus apart looking for it. Searched all bags, pockets, orifices, nooks and crannies, but no passport. We quickly realized it must be still at my house. We had not yet picked up Ellen, and were a bit hesitant to tell her of the developments. She took it rather well, actually. Jason, our logistical coordinator, took Melissa's car, and drove back to my house to look for it, while the rest of us kept going in the van toward the airport. We felt that Jason had enough time to make it back to Elkton to get the passport and then race up to the airport in time to catch the flight.

As luck would have it, the passport was nowhere to be found at the house! Jason searched high and low, but was unable to locate it. He then called the bus depot and traveled there to search the original van, but again, no luck. He went to the Kijac's house, looked through every blade of grass in the front yard, and found nothing but Parker's favorite bone. In defeat, he called us in the van to say he had no passport. But! he had a plan.

He and Ellen would stay behind in DE, and he had made her an appointment the next morning at 9am in Philly to get a replacement passport. Ellen would need her original birth certificate for the application. Ellen, however, revealed that her birth certificate resided in her parent's safety deposit box in North Carolina. Problem? Of course not! Ellen simply called her parents, her wonderfully not-panicked and understanding parents, who agreed to immediately go to the bankbox, retrieve the document, and head up to DE on a spontaneous road trip.

Jason was to begin driving south, and meet the Finney's in DC, to expedite the transfer of the birth certificate.

Before Jason left the house, however, he happened to see the corner of a blue item peeking out from between our living room couch cushions.... The passport was found!

It was too late, however, to get Jason and the passport to the airport in time. :( Ellen had to ride back to DE with the confused shuttle driver, and go back to her house. She and Jason had an extra night in their respective houses, pondering the events of the day, while the rest of us lifted off into the night to travel half the globe in 12 hours. Jason managed to change Ellen's and his tickets for the same flight the next day, and they are winging their way from Newark to Delhi even as I write these words. Melissa, Amanda, Pete and myself have completed our journey, and are anxiously awaiting the arrival of Team B, so that we can once again be a complete team.

No problem, I'm sure we'll have worse things happen before this is all over. :)

Everyone is safe, healthy, happy and hydrated, and they all say hello to you!

We will plan to blog daily or as often as possible while we are in areas that connect. Each of us will share some thoughts about this experience as the month progresses.

Thank you for your support and well-wishes!!