Leaving Nepal

30 days have come and gone and I sit here in Kathmandu airport writing blog posts, sipping English Breakfast Tea (lemon tea no longer available), and wondering if the past month was just a dream.

I had a great time here, made many friends and even more memories. I look forward to returning for a trek in the future :)

I spend tonight in an airport hotel in Delhi, then it's onto Surat tomorrow morning for the wedding.

Pokhara and Chitwan blog posts to come. I want to include photos from 3 different cameras and can't do so from my phone.

Merry Christmas! Hope everyone has a fantastic holiday and stays safe despite the weather!

For my Nepal friends: I'm sad to leave you but look forward to saying namaste in Canada :)

India here I come!

Looking forward

Many updates tonight! I hope the touristy ones have given a better idea of my time here, and the hospital posts some insight into the similarities and differences in healthcare. I'm actually now done my clinical rotations here (and for medical school!) and am off travelling with Nipesh and Sahadev to Pokhara and Chitwan. Not sure if updates will happen while I'm away but certainly after. Bhaktapor is written but meeds photos. I will also add an update on NCCDF, and a post reflecting on my experiences at TUTH, the broader themes in it, and how best we in Canada could help Nepali healthcare going forward.

Christmas Eve I leave Nepal and head to India for Abhishek's wedding. After the wedding I'm in Istanbul for 5 days before returning to Toronto.

Weekend 3: Bhaktapur

Weekend 3 (and final) started with an impromptu trip with Nipesh and Sahadev to Thamel square the Friday night for some drinks and live music. It was quite cold so we sat outside by the fire (there being no heat inside, as is standard for buildings here). I was grateful for this because smoking was quite common there and my lungs were happier outside. Drink wise it was a bit of dilemma because I didn't want beer, but travel advice was to avoid ice. I ended up starting with Glen Fiddich scotch straight. The music was a band doing covers of primarily Western songs but there were some Nepali ones as well. We also ran into two Australian army men on leave who had just arrived in Nepal. All in all a good evening.

Saturday I met up with Yeshey and we took the bus to Bhaktapor. This time it was a 90min bus ride sitting facing backwards. I had felt mildly nauseous before boarding, and was very nauseous by the end. Fortunately no vomiting! Total cost was 60NPR for both of us. Home was by taxi for 800 NPR - a lot more, but my stomach appreciated it!

Bhaktapor is the third of the three city states formed during the Malla dynasty (the others being Kathmandu and Patan). All three are traditional Newari settlements (the native ethnic group for the Valley). The people of Bhaktapor are historically known for their wood carving skills and it showed: there were streets upon streets of historic building with amazing detail. There were also many squares, including a Durbar (palace) square, and Peacock Square named for a detailed carving of a Peacock in a window.

Peacock square

The eponymous Peacock

We spent a lot of time in Peacock Square, including lunch at the Peacock Cafe. There we also toured the Paper Factory where they make paper using traditional methods. It was quite impressive as the processes for making pulp, dry into sheets, rolling to flatten were all there. There was also a printing press and the tools for carving the dies. This was all contained in connected historic Newari homes that they were slowly restoring.

Dhal Bhaat in Peacock Square

Making paper

And drying in the sun

Me on the roof

Overall Bhaktapor was my favourite of the three former city states: it was quiet, still very historic, and not too touristy. Apparently here I rated as a tourist attraction - a young Indian woman (early 20s?) touring enthusiastically asked to have her photo taken with me! Unfortunately I forgot to have a photo with her on my camera!

Weekend 2: Lonely Planet Walking Tour

My second weekend here started with Nipesh, Sahadev, and two of their friends coming over the Friday night for drinks and food sharing. I attempted to make pancakes for maple syrup (a challenge when I was trying to substitute eggs and milk as well!), and they made BBQ: mutton and chicken. For the BBQ portion, we actually set up a small campfire on the back porch and sat around it. It was a lot of fun sitting outside, drinking beer, eating meat, and chatting. Unfortunately I still have very little Nepali so I didn't follow a lot of the conversation.

BBQ!

The next morning I slept in and caught up on things (like blog posts...) before heading out on the Lonely Planet's walking tour. The tour starts in Thamel square, but I started by walking there (4km). I then followed the tour, seeing all sorts of bustling streets and squares, as well as countless historical monuments. At one isolated Buddhist temple (a mini Swayambunath), an artist called to me and for whatever reason I listened and followed him into his shop - normally I just ignore the countless hawkers. In the shop I discovered he was a student and was thus stuck working the Saturday. He showed me his work and his masters work, explaining stories. The works were impressively detailed and relatively affordable. After some negotiation (go me!) I ended up purchasing two paintings for souvenirs.

The rest of the walking tour brought me to historic Kathmandu with the main shopping street - Asan Tole. I also discovered my student card gets me into Durbar Square for free. Eventually I returned home via a different residential street where a child approached me saying "hello, where are you from?". I said hi and was friendly but kept walking, having read about street children looking for sweets or money (who remain street children because they receive both!). He eventually asked me where I was going, to which I replied: "home". He became quite confused at this and stopped following me. Guess I don't look like I belong here :).  I was exhausted after the walk - I estimate it was 10-12km total. Of course that's the only exercise available so take it while I can!

Clear enough day to see the hills around the Valley! And the wonderful state of the road TUTH is on...

A better road and more typical of the useful roads used to get around

A rare area where one can sit peacefully.

The former palace. There's now apparently a poor quality museum in it. The Kingsway road runs immediately south of here. Many familiar brands have shops there.

A common sight. Dogs are everywhere!

One of the sites highlighted in the guidebook. If anyone is really curious have have photos of most of them :P

Another common site. Park anywhere, even by old shrines.

Poetry festival in Durbar square

Food and Shopping

I know some of you would have had at least 5 posts with pictures of food by this point. With all my allergies food has never been a prominent travel item. I've done quite well eating with the locals though and though I better include one post for memories. By paying a bit extra here for food and a cook, I've been able to enjoy custom Nepali food everyday! I've also done well out at restaurants. Usually the only items I am unable to have are milk tea (VERY common), and the chicken. Milk tea is easily substituted with lemon tea. I rarely have meat, though buffalo and mutton are fairly accessible.

Nepali food is often dal bhat - rice and steamed lentil soup. To this assorted varieties of veggies and meat can be added. Veggies will include cauliflower, potatoes, egg plant, peppers, beans (note, that's what they look like, no idea if actually the same plants). Chicken is often added as well.

Meal after an OT with "shaved" rice. It's not really shaved but I forget the proper term.

Dal bhat out at Baktapor

Shopping is most commonly roadside stalls or shops by the side of the road. The roadside stalls at first shocked me, but it was explained to me that there is no rent to set up shop there. Makes sense to me! Both types of shops are independently owned and bargaining is expected (though tourists can expect to pay the tourist rate everywhere, even after bargaining).

I'm a lousy bargainer and I've tended to default to Salesway, a local "department" store that has a grocery building, hardware / kitchenware building, and alcohol / refrigerated food building. It also has fixed prices and computerized checkouts. Some curious things I've noticed wandering around Salesways: there is no brand protection and there are 5 different brands of corn flakes, Kelloggs Corn Flakes come in many flavours such as mango and strawberry. The houseware section was interesting: the water heater for a shower was priced at 6000 NPR - around 1 month's income for a lot of Nepalis. Hot water is definitely a luxury in this country! (there is one at Canada House).

Corn flakes galore!

There's even soy milk!

Outside of Salesway, even with Christmas lights. Very atypical storefront. And I don't know why the lights are there but they remind me of Christmas :)

More typical shops

Boudhanath Stupa

One evening in my second week here, Yeshey, the intern from Bhutan, offered to take me to see Boudhanath. We travelled in a small, crowded bus for ~20minutes to get there. Buses in Kathmandu are essentially large vans and safety is questionable, but they are quite cheap (as low as 10NPR for students!). Unfortunately they refused to accept my TUTH student card. Oh well!

Upon arriving at the square, they DID accept the card and I was able to enter for free. Boudhanath is much like Swayambunath in appearance. It was built in 500-600AD. Legend has it that the land was given to a woman based on the size of an elephant hide. The woman was ambitious and stretched it to circle the whole square! The Stupa is the most significant religious building for Tibetan Buddhists and there is a significant expat community and monasteries in the area. It was very peaceful joining the pilgrims and walking clockwise around the Stupa several times.

Me at Boudhanath

Normally Buddha is depicted cross legged. This is a rare example of one seated upright, about to stand up. In a temple at Boudhanath square

Looking out at smaller monuments and the surrounding buildings behind.

Pashupatinath Temple
After leaving the Stupa we walked past an abandoned temple complex, through a park (only park I've seen in Kathmandu!), and to Pashupatinath, a major Hindu temple complex and World Heritage Site. The temple was initially built in ~400AD on the banks of the Bagmati river and is the seat of the diety Pashupatinath. Today it continues as a large, functioning temple and many cremations occur here along hte banks of the river. I won't even try to comment on the role it plays in Hinduism here - I simply have too little knowledge of Hinduism for context. Perhaps another post.

Throughout overpopulated Kathmandu there are still patches where people attempt to farm.

Abandoned temple complex on the way. I don't know it's name or history. The main building (back left) looked like it was being used as a house

Parkland with random shrines

Main temple complex. The smoke in the upper left is from cremations by the river.

Tourism!

On my first day off here, at the suggestion of my host, I hired a tour guide (actually a friend at NCCDF) plus driver to see the sites. Total cost was $70, which included guide, driver, and car for the day plus admission to the sites and lunch. Overall not a bad deal, especially as I was by myself in a city a knew nothing about.

First, some historical context from Wikipedia, Lonely Planet Guidebook, tourist brochures, and word of mouth. Kathmandu was founded at a strategic location where two rivers join and was originally a trading post on the India-Tibet trade route. The Malla dynasty ruled from ~1200 until their conquest by the Shah dynasty in 1768. The founder of the Shah dynasty actually united all of Nepal as we know it today. The dynasty lasted until 2008 when Nepal converted to a constitutional democracy following 10 years of civil war.

During the Malla reign, in 1482, the kingdom was split into three: Kathmandu, Patan, and Bhaktapur. Today Patan is essentially part of Kathmandu, while Bhaktapur somewhat maintains its identity.

Kathmandu Durbar Square

First up in travelling was Durbar Square in old Kathmandu. Durbar = palace and this was the original seat of government during the Malla reign, later adopted by the Shah dynasty as the palace location for all of Nepal. The square is full of temples, shrines and statues, as welthe original 18th century, and subsequent early 20th century palaces. There is also the temple of Kumari, the living goddess. The goddess is chosen from the Newari (natives of Kathmandu valley) people, and must meet something like 200 attributes. Typically she is around 4 years old when chosen, and her tenure as goddess is over when she has her first period.

While in Durbar Square I went into the old palace (included with admission to the square for tourists). The palace was impressive and it was great to see the former coronation square and equipment. There was also a strange museum that was founded decades ago to promote recent members of the royal family, and hasn't changed since. Very different from Western museums.

Overall Durbar square is bustling, noisy, and very touristy. Even with my own guide I was approached by people asking if I needed a guide! This was also true when I returned on the Lonely Planet walking tour (another post to come :)

Kumari's temple. The detailed woodwork is classic for most of the historic temples and buildings in Nepal

Palaces. The white neo-classical one was inspired by the architecture in London and built in the early 1900s.

Temples in Durbar Square

Durbar Square proper

The original building which gave it's name to Kathmandu. Apparently built with one tree.

View from up the palace. In the distance on the hill is Swayambunath

 Patan Square (Lalitpur)

One of the other former capitals, Patan square is not quite as large. I thought it was overall prettier and a nicer atmosphere than Durbar square. We enjoyed the square from a handy lookout, wandered around it, and then had lunch at a cute cafe overlooking the square.

Me at Patan Square! Significant Hindu temple is on the left of the photo. The palace is on the right.

View from the cafe

Random political rally we ran into. This is for the Congress Party, which recently won the election over the Communist Party.

Water source. These historic wells are quite common and apparently fill right up during monsoon season. During winter there are taps running in the bottom. Any water sitting the bottom is not very clean.

Swayambhu Nath (aka The Monkey Temple)
The highlight of the day was Swayambhu Nath. It's a Buddhist Stupa originally built in ~450AD, but most recently renovated in 2008. It is one of the holiest sites in Buddhism, but is also revered by Hindus and there is a Hindu temple at the site. It is also known as the monkey temple due to the large numbers of monkeys running around the complex.

Monkeys at the Monkey Temple

Me at Swayambhu Nath!

Swayambhu Nath

Surgery

It's been a while since my last post.  My apologies. I've been rotating through neurosurgery, cardiac surgery, and ICU and staying later to maximize exposure to each one. I've also been trying to maximize tourism in Kathmandu :)

This post is primarily on the surgeries here (Operating Theatres or OTs as they are called here). I've split it by specialty because each was very different experience.

GI
The GI surgery team is made up of a Professor, Jr. Attending, 1x MCh (PGY4-6 Canada), 2x 3rd year MS (PGY3), and 1x 1st year MS (PGY1). Rounds with the team usually consisted of all the above, but sometimes the Professor or Jr. attending would not be present. English was only used by the Professor and the Junior attending, the residents were not comfortable enough in English and defaulted to Nepali during rounds.

Elective surgeries are typically done with the Jr. Attending or MCh as the principal surgeon, with the MS3s assisting. I never saw the MS1 scrub.

Emergency surgeries for GI are entirely different: the MS3 is the senior surgeon and the senior resident is called in only exceptional cases. Furthermore  common presentations such as appendectomies will be left to the MS2. This graded responsibility matches a Canadian surgical training. What astounds me is that unlike in Canada, the residents operate completely unsupervised - the Jr. attending will be home, and the MCh (senior resident) will only come for the very challenging cases. While I didn't stay to observe GI emergency surgeries, quality of the incisions (not midline etc.) makes me think that overall quality of care is sacrificed by using this system.

With respect to the surgeries themselves, surgeries are far more often done with an open approach. This reflect a combination of limited expertise for minimally invasive techniques as well as later presentation of cases such as cancers. Access to interventional radiology is also limited, necessitating more surgical approaches.

Open surgeries are generally similar to Canada with the same equipment. Drapes, gowns, and wraps for sterile equipment are all reusable. Curiously the OR lights use one large overhead fixture that is adjusted by unsterile assistants. Sponges are rinsed many times over and reused during the procedure.

Cases I saw included open splenectomy with splenic vein hepatic shunt, laparoscopic cholecystectomy, and elective appendectomy. Hernia repairs are actually done done under local anaesthesia in the minor OT, the same area that sebaceous cysts, lipomas, etc are done.

Equipment storage

Scrub sinks - the water is specially filtered

Equipment setup. The bowl with red is the basin for rinsing and reusing the sponges.

Empty OT. Giant light is visible in upper left.

Anaesthesia equipment

Sterile prep area. Individual  instruments that become required would be carried with a half sterile grasper.

 Formaldehyde. Doctors add it to pathology specimens before handing to patients' family for delivery to pathology.

Minor OT for hernia repairs under local anaesthesia.

Neuro Surgery
I spent 2.5 days with neurosurgery at the suggestion of Dr. Subhash Acharya, my contact here. I'm glad I did! The neurosurgeons are excellent teachers and their English is much better. I participated in 2 clinics plus a day of surgery. The clinics were much like te GI clinic (see other post), and was a great environment for practising neuro exams. There was one lady who presented with Pott's disease (TB of the spine) after 7months of being unable to walk. She had impressive upper motor neuron lesions!

Neurosurgery OTs were much as with the GI ones for equipment. Significant limitations were using a scalpel blade to shave the head (only tool available), using manual drill and saw to open the skull (they have a power saw but it's broken), and closing with sutures instead of plates (unable to access a plate distributor in Nepal). I can't really comment much more on the surgery itself because I haven't seen neurosurgery in Canada.

Neurosurgery was much more organized for emergency and the MCh (PGY4-6) was the principal surgeon.

Neurosurgery OT. Note the windows up high making it truly a theatre.

Hand saws

Saline warmer. In GI hot sterile saline would be poured from kettles into the field. In Canada the bottles are stored in a warm environment and so come hot.

Cardio, Thoracic, and Vascular
Cardiac, thoracic, and vascular surgery all takes place in a different building, the Monmahon Centre for Cardiothoracic Surgery and Transplantation. Apparently it is a separate hospital with different management from the TUTH but is still affiliated with Tribhuvan University. The building is newer than TUTH and feels much more organized.

OTs rooms in Monmahon are new (last. 10 years) and cardiac cases were almost identical experiences to home including disposable drapes. Largest equipment change was creating disposable pieces such as aortic and venous cannulas are sterilized and reused. Apparently the head and founder of CTVS completed fellowship at Sick Kids and Boston Children's so that would explain many of the similarities.

By far the largest different were the cases: mitral valve replacements were common, as were congenital repairs, including ASDs or Tetralogy of Fallots presenting at 20+years of age. Rheumatic fever is very common and I saw at least three cases of mitral stenosis on my clinic day.

With respect to responsibility, the professor was present for all the cardiac cases, but would only scrub in for theoat complex procedures (e.g. Tetralogy of Fallot, triscuspid repair). The junior faculty and senior staff did most of each case. There would also be 2-3 rooms going at one time, allowing up to 5 cases per day to be done (as supposed to a max of 2 at home). The senior resident (~PGY5) would operate autonomously with the junior resident (~PGY4) on common cases such as ASD closure and mitral valve replacement. In Canada mitral valve pathology is rare (thanks to antibiotics and low rheumatic fever incidence), and it wouldn't be until the final year of residency (PGY6) that a resident would attempt this under staff guidance.

Cardiac OT room. The bypass pump (heart lung machine) is under the red drape.

CVICU. The beds "look" empty but each actually has an infant on it. Monmahon does paediatric surgeries but does not have cribs.

I also did spend a day with thoracic and vascular. Vascular was a day of AV fistulas for dialysis and was much as in Canada. Thoracics seemed similar but having not done Canadian thoracics it's hard to say. There was one interesting case of a foreign body swallowed by a 1 month old. I'm not sure how and there is no child protection services here for further investigation. It was treated with scope to pick into the stomach and then surgery to remove from the stomach.