The Everest ER Team

The team of doctors and staff for the Everest Base Camp tent arrived today. They brought with them a group of 15-20 Wilderness Medical Society (WMS) doctors and healthcare professionals who are getting CME credit for the trek to Everest Base Camp with wilderness medicine lectures and scenarios scattered in the trek. In addition, they had picked up a few stray misfits including one of the doctors brothers, a pre-med student, and a Russian girl who we are still not quite sure how she was connected. The other doctors (Chris and Penny) also returned from a few day trek off to Everest Base Camp and Kala Pattar. We had a celebration dinner at the Himalayan Hotel which included either yak or chicken steak, roasted potatoes, and sautéed vegetables. (Hillary opted for more vegetables and less yak, well really no yak.) Then they brought out apple pie, fresh apples, and several Everest beers or glasses of wine per person. Even Arjun had three beers and Jeet had a couple glasses of "red juice" (wine).One of the doctors stationed at the Everest Base Camp this season was in Pheriche two years ago (Suzi) and the other in Manang last year (Kristie). They talked about possibly switching locations with us for a day or two later in the season, so we might spend a few days in the Everest Base Camp tent in a few weeks. There was also a funny guy named Clay who is an American working in New Zealand and telling stories of the awesome working conditions there. We closed down the tea house at 9:30 pm and promised to see them all tomorrow.

H&C

March 31, 2013

In pic: Arjun (front) and Jeet (in back) kicking back with the EBC group at the Himalayan Hotel next to the aid-post.

The 65km Ultra Marathon

Today there was an ultra marathon which started at Gorak Shep (5200 meters / 17,000 feet) and ended in Lukla (2800 meters / 9,300 feet). This is the ultimate in off-road running and involves crossing suspension bridges, climbing steep stone steps, dodging yaks, and avoiding falling off cliffs. Not to mention the altitude, freezing temperatures, and glaciers. The record is just over 5 hours which not surprisingly is held by a local Sherpa.

We were in charge of providing a medical and water station around the mani stones in Pheriche. Luckily for the runners it was a clear, sunny morning, but it was cold. The water which was initially boiling, froze while we were waiting for runners.

In this race, we were initially told there were to be 50 Nepali and 3 western runners. One western runner had acute mountain sickness (AMS) symptoms and had to descend to Pheriche to start so she only ran 50km. Another western runner had vomiting and diarrhea which he was told was Giardia although it is more likely just bacterial travelers diarrhea, and he also descended part way and was just walking down. The third westerner was actually one of the organizers and the final sweep and he was also just walking. The 15 or so Nepali runners however were running and much more quickly than expected in just running shirts and t-shirts as if this was an average summer 5k. Amazing.

Luckily, no one needed our care, but we spent a few hours outside at the mani stones cheering them on and enjoying the clear morning.

While we were waiting, another guide with the same American trekking company came up to us asking to buy some antibiotics for his group which all had vomiting and diarrhea. He refused official consults and ignored my suggestion that they should not ascend with symptoms as every person we have had to evacuate so far had some type of other illness before ascending (either cough/URI or gastroenteritis). We will likely be seeing them again...

H&C
March 30, 2013

In pic: Hill and Arjun at the Mani stones trying to stay warm in the early morning, awaiting the ultra-marathoners.

Mystery IMG delivery

Tonight we received a very strange package of a bright yellow liquid in an Everest H2O bottle and a cryptic note.

The note reads:
IMG
Mike, Justin, Peter
2 capful of solution with 4 liter of hot water
Lisol cleaner for the tables
-Greg

The package had made the rounds to all the Pheriche tea houses without anyone claiming it or knowing what to do with it, so they brought it to us. Hopefully Mike, Justin, or Peter will think to stop by the aid-post when they arrive.

The obnoxious American trekkers

Not to hate on our countrymen too much, but our first encounter with American trekkers was rather infuriating. In particular the guide, an accomplished climber and trekker himself, found himself saddled with a diverse group of trekkers including several elderly folks and then a couple of hyper-wealthy young hot shots. When trekking it is commonly held that your progress on the route is dictated by the health and wishes of the team. In other words, you work it out as a group, and base the decision on the health and goals of everyone in the team. Problems arise when you've got a few members weakened by illness and a few members who don't care about anything other than making it to base camp. So the guide dealing with this group came to us hoping that we would both talk sense into the hotshots that wanted to proceed without the rest of the team and then to help evacuate the weak links. He was very indirect in his requests and talked a big game of making a robust donation to the HRA for our efforts. We agreed to help by educating his group through the daily altitude lecture. Naturally, the two hotshots showed up about 20 min late and were generally uninterested. The rest of the group was quite responsive and inquisitive about the symptoms of altitude illness and many of them sought consultations for GI issues that they picked up on the way. In a funny moment towards the end of the lecture one of the hotshots asked about appetite and how to improve it (lots of people encounter poor appetite up here; improvement usually comes only with time). The guy had returned from a hike and a looked white as a ghost. Penny called him out, asking whether he was sleeping well because his face was looking pretty sickly. The hotshot mumbled some non-response, but the rest of the group got a kick out of it. Out a team of nine, the guide had the two hotshots, 3 sick trekkers, and the rest were in between.

The next day the guide came to the aid post mid-morning with probably the oldest guy in the group who had been suffering with gastro stuff (vomiting, diarrhea...a common occurrence up here) and after much deliberation decided to evacuate him. The patient was uncomfortable, no doubt, but stable and really just need some fluids and rest. Two other members of the group decided that they wanted to leave too. The general feeling from us was that these people were just tired of trekking. So the guide asked the HRA to coordinate the evacuation, which we were happy to do, but he proceeded to reside in the aid-post or leave and return every 5-10 minutes for an update. Now in the US such behavior might be expected since evacuations (most things, really) happen fast...but this ain't the US. Coordinating a chopper takes hours and then communication is very hit and miss. The insurance company has to agree to the evacuation usually requiring talking to us about the medical necessity. There is much negotiation of what company will get the job, and when the chopper would arrive. On top of that the weather in the valley is super dynamic. Dense, blinding fog can roll in to Pheriche (or anywhere between KTM and Pheriche) in minutes and stop up air traffic.

Because of limited phone service here, it is usually faster to let the HRA home office in Kathmandu do much of the coordination. While we were waiting for all the coordination to happen, we were still seeing other patients, giving the daily lecture, and our usual daily merchandise sales. The guide would not leave us alone and even called the HRA home office in an attempt to speed the process. He also did not seem to understand that we could not guarantee that the other two not sick people may or may not be allowed to ride along depending on the pilot and the weather. While we are of course happy to coordinate the evacuation, it takes more time than if Nepali-based trekking companies do it since they usually call the helicopter first and the insurance company later. The trekking company or whoever calls the helicopter also gets a 20-40% kickback, so they are quick to volunteer to do so. However, the helicopter costs more to cover this kickback and service. This American-based company did not want to involve their Nepali-based company, but seemed to expect the same service from us even though we had explained that that was not how it worked. We found it unbelievable that a guide with 15 years of experience in Nepal would be so unfamiliar with the evacuation process and so naive about the communication available in the mountains.

By 4:30 pm or so, the weather had clouded as it usually does, and the prospects of a helicopter seemed lower by the minute. Usually the helicopters stop in Lukla for refueling or other tasks, and at that point they call us to alert us to their ETA. We had not heard from them, since they left Kathmandu, so we assumed they were still not yet to Lukla, but suddenly we heard the helicopter through the fog and clouds and ran to get the patient. We got him on board and after some negotiation, the pilot agreed to take the other two trekkers. After even more negotiation, he agreed to also take all their luggage (which was more per person than we have for 3 months!) It seemed a small miracle.

However, the helicopter had not even taken off before the guide turned to us and began bitching us out for not having more notice that it was arriving and not getting the helicopter sooner. The nerve of some people! And he didn't even give us even a small donation much less the large donation he kept promising in front of his trekkers.

All we really wanted after that was a beer, but the obnoxious guide and the rest of the irritating Americans we in our usual tea house so we had a cup of tea instead. We were very disappointed in the attitude and actions of these American tourists and apologized multiple times for they way they had treated Arjun and our Nepali hosts. Some days, I wish we had Canadian passports.

H&C

March 28, 2013

Just another Night in the Pheriche ED...

Just after we went to bed last night, there was knocking on the clinic door. Always open for emergencies, I opened the door to a local Nepali who was covered in blood and holding his right arm at an odd angle. Arjun and I tried to get the story of what happened but it kept changing. After cleaning up his head and face, he had a large linear scalp laceration down to the bone which didn't match his story of a blunt fall. We also recognized him as a patient we had seen only six hours earlier for gastritis and had sent away with instructions to avoid alcohol and spicy foods. He had alcohol on his breath and was barely upright. He then admitted to getting into a "discussion" with someone over yak dung who came after him with a kitchen knife. Huh? I thought I left the drunken knife-and-gun show in Boston.

He also likely had a broken arm but he wasn't very cooperative with us examining. So we decided to just splint it and send him to Khunde for an X-ray in the morning. I wish I had paid more attention in residency splint lab on working with plaster splints. I made a terrible mess. But we stapled his head, splinted his arm, and put him to bed in our "observation" ward because it was after midnight, his home was an hour walk, and home didn't sound safe anyway. When I awoke in the morning to arrange for him to go to Khunde, he was gone. Arjun tracked him down on his cell phone. Today his story is his wife eloped with another man and took all their money. He tried to stop her, and they got in a knife fight. He agreed to go to the Khunde clinic later after securing child care.

For those who don't know my reputation, I have a bit if a "crazy cloud" where if there is someone running naked in the emergency department halls who thinks they are Ra the Sun god, they are likely my patient. Psych patients find me somehow. They might say their chief complaint is "rash" but that's because he has scrubbed his body with bleach trying to rid himself of "the black bugs" or they have constipation because "the man in the shadows" won't let her near the toilet. So really this frequent flyer, alcoholic, vague story of trauma guy was pretty run-of-the-mill except he seemed out of place in Pheriche.

The full moon has been up most of the day and it seems to be affecting our patients and visitors. A group of Americans wanted a tour and to all buy t-shirts before 7am. They were quite nice, but I was still searching for my lost patient and still had my plaster splinting mess to clean up. Then we had two girls from Denmark with migraines and knee pain who were later seen taking a helicopter down after not wanting to pay our $50 consultation fee. (Helicopters cost $7500 minimum.) Then another drunken local with multiple long-standing complaints came by who was still drunk at 8am. And that was all before we even opened for the day. The stories have been strange all day and the complaints could have easily been on the ED board back in the US: migraine, back pain, epigastric pain, ear wax... Just another day stamping out death and disease - the international version.

Sherpas, Porters, and Prayer wheels

The people and towns along the trekking route are home to amazing people. Many of these are Sherpas which are thought to be an indigenous mountain people with roots in Tibet. They are frequently Buddhist although the religion blurs with Hindi in Nepal. Sherpas have been living in the mountains for many generations and are interesting to study because they do not seem to be as susceptible to altitude illness as low landers - either Westerners or other Nepalis. Some Sherpas are porters, but many are guides, tea house owners, farmers, or craftsmen.

Not to be confused, a porter is a job title. Porters carry loads sometimes more than their body weight (60+ kg!) up the mountain paths for about 800 rupees a day (~$9-10 USD). That seems like a terrible wage, but its one if the better paying jobs in Nepal. Fascinatingly, the porters usually prefer to carry the load from a strap on their head instead of backpack and waist belt straps like typical backpacking packs. They often strap multiple backpacks together and use their head straps. I wonder if they get neck pain from this, but they never seem to complain. Porters are frequently from the lowlands of Kathmandu and therefore often have altitude illness early in the season before they become acclimatized.

Prayer wheels and mani stones are scattered along the trekking route. They typically have the mantra "om mani padme hum" which literally translates to "praise to the jewel in the lotus" but has a much deeper meaning of the six Buddhist perfections: generosity, ethics, patience, diligence, renunciation, and wisdom. According to the Dali Lama, "Thus the six syllables, om mani padme hum, mean that in dependence on the practice of a path which is an indivisible union of method and wisdom, you can transform your impure body, speech, and mind into the pure exalted body, speech, and mind of a Buddha[...]"

Prayer wheels should be spun clockwise and always passed on the left. There are also many mani stones and stupas which also should always be passed clockwise or on the left. The people drive and walk on the left here as well. The only exception to "stay left" is when passing a yak on a cliff. Then, you should always stay on the mountain-side of the yak. And also mind the yak horns.Prayer wheels are scattered along the trekking route. Prayer wheels should be spun clockwise and always passed on the left. There are also many mani stones and stupas which also should always be passed clockwise or on the left.

The people drive and walk on the left here as well. The only exception to "stay left" is when passing a yak on a cliff. Then, you should always stay on the mountain-side of the yak. Also, mind the yak horns.

Island Peak & Chukhung Ri

We spent the last few days away from the Aid Clinic. The other volunteers kept watch over everything while we went off on a side trip. We went over the ridge between Pheriche and Dingboche and then up the valley towards Island Peak. We stayed in Chukhung which is a small town about halfway up the valley. We took a longer and higher route to get there than is typical, and just settled in for the night.

On our way to Chukhung we ran into two women from Cambridge (MA). It is a small world. We also met some people from Switzerland, and a large group of Germans who sang German folk songs for hours. In the tea house, we spent a long time talking to a Nepali guide who speaks 15+ languages fluently. He spent awhile talking to us about the diverse ethnic groups, religions, and customs of people in Nepal. He also told us of some good trekking routes and that we should visit Pokhara and the Chitawa National Forest before we leave Nepal. We have a few days on the end of out trip (assuming flights out of Lukla are on schedule). Perhaps it would be a good side trip. It's in the lower land area of Nepal and much warmer so that is appealing. Plus we could see Bengal tigers.

Sunday morning we hiked to Island Peak Base Camp which turned out to be a nine mile trek at 16,000+ feet which was pretty exhausting. The views were amazing however, and the trail varied between walking a high narrow ridgeline to crossing wide low glacial beds. It is quite likely that we were the only people around for miles in the middle of our trek. There were several tents at base camp though and a few people practicing their climbing skills on a nearby icefall, probably for a summit attempt in the next few days.

This morning we awoke early, ate toast and eggs, and hiked up Chukhung Ri. This very steep trail gained 2,500 feet in only 1.5 miles. It took us 2.5 hours to climb and only 45 minutes to descend. We attained the highest altitude so far this trip at 17,500 feet. We attempted to capture the beauty of 360 degrees of snow-capped peaks but it is still nothing to the first hand view.

Then it was back to Pheriche and the Aid Clinic. Despite intense sun for most of our excursion we arrived in Pheriche with snow blowing sideways at our backs. Fortunately there was enough sun early in the day to heat plenty of water for us to take steaming hot (million $) showers. Next we will man the Aid Clinic while the other two doctors (Chris & Penny) get away for a few days.

H&C

P.S. Has anyone received a postcard from us? We sent out a bunch but have no idea how long they take to travel back to the states (or anywhere else).

Even the darkest night will end

...the alarm never sounded. The power stayed on. The patients kept breathing.

The sun finally rose with crystal clear skies. The crackly satellite phone came to life at barely pre-dawn. A helicopter was arriving in 10 minutes. We packaged the first patient and walked him to the helicopter pad at first light. The sun was barely peaking over the mountains into the valley. Blades still spinning wildly, we placed him on board. It took off causing a stream of backwashed snow and dust, and we waved goodbye.

The second helicopter arrived 45 minutes later and we repeated the process. Hoping for the best for them both, we turn around and head back to the clinic for another day.

Hill

HAPE and the Titanic

Tonight we have two very sick patients who both have High Altitude Pulmonary Edema (HAPE). They each arrived by donkey late in the afternoon with low blood oxygen saturations and having trouble breathing. HAPE is a kind of altitude illness that involves swelling and water in the lungs which makes it hard to get what little oxygen is available here. It is a true emergency and the leading cause of altitude-related death.

If someone came in to the Emergency Department at home with an O2 saturation of 46%, they would be intubated, put on a ventilator, and headed for the ICU in about 90 seconds. Here there is no ventilator. No ICU. No intensivists or critical care team.

These two men needed oxygen and prompt evacuation, but poor weather and darkness precluded helicopters from reaching us. These men could not walk and were each larger than any of us. It takes 6-8 people to carry a stretcher for one mile on level ground in the best conditions. It was dark and below freezing. The route down is treacherous in the light. Evacuating them further would be extremely difficult without a helicopter or a full team of people and would place all of us in danger of hypothermia if nothing else. We had no choice but to start up the oxygen concentrator and try to get them through the night, hoping for clear skies in the morning.

Our solar and wind power has been charging the batteries daily, but the readout of the percentage of full power has been wildly fluctuating and difficult to determine the real amount of power left. Truly off-the-grid, there is no back-up. The oxygen concentrators are the biggest draw on the system. At 4pm, the battery read 85%. At midnight and it read "LO". At some point, an alarm will sound and then the power will stop. It feels like we are on the Titanic waiting for the boat to sink.

It is now 3:30 am. I am fully dressed except my boots in my sleeping bag next to my patients with oxygen saturations in the 70s, barely holding on for the helicopter that might arrive at dawn. For now, the oxygen concentrator continues to run. And I lie here listening to their scary periodic breathing and coughing fits, waiting for the battery alarm to sound...

Hill

March 19

The Sun Oven

Today the sun is out full strength, and we get a special treat. Not only does the sun fully charge our solar batteries and provide warm water (showers!), but Jeet has brought out the sun oven and is cooking a chocolate cake which will be ready in 2-3 hours.

Jeet has an amazing life story. He has been a cook all over the world including time in Qatar, Kuwait, and then more than two years in Bhaghdad. He was serving American, Romanian, and Nepali troops on a base there, and recounted the constant gunfire and explosions heard nearby. Jeet is also about 35 years old and his hometown is a five day trek from Pheriche. His father was a mountain climber and died during a climbing accident when Jeet was only 5.

H&C

March 18

Cold and quiet

Today is St. Patrick's day but we won't be having any Guinness or Irish whiskey. Pheriche is bitterly cold and remarkably quiet. It has been snowing intermittently all day with only a couple patients and no one showing up for the lecture.

It is so cold that Arjun started the yak dung fire in the afternoon (usually reserved for after dark) and Jeet made extra tea and popcorn. Since no one showed up for the lecture, we retreated to the nearby tea house for a beer and an attempt at internet access but the connection was poor. Maybe tomorrow.

H&C

Almost Christmas

The bad weather which delayed us only a few hours on our flight to Lukla also delayed all the other flights for 2-3 days afterwards. Therefore, the replacement medications, food stores for the next 2.5 months, and the rest of our gear including our warmest down jackets and snow boots was also delayed. We have been anxiously awaiting the arrival of these 600 kg which have been traveling by yak for 5 days. In the meantime, Jeet (our Nepali cook) has been amazingly inventive with the remaining supplies from last season.

The yaks arrived tonight and after dinner we opened 28 bags of goodies including a huge wheel of yak cheese, 100lbs of basmati rice, several jars of cocoa, antibiotics, and of course our gear bags. It was almost like Christmas.

H&C

Aid post power system

For those engineers out there, this is a schematic of the power system at the pheriche aid post. Pretty simple: 500w wind turbine + 16 x 80w solar array charge a large bank of batteries. We have power to run/charge laptops, light the post, and run medical equipment such as oxygen concentrators. There is lots of wind and sun here so it is really effective. We also have a solar array dedicated to heating water. We had our first hot shower in nearly 2 weeks a couple days ago. And it's HOT! Works surprisingly well.

The first patients

The HRA does not officially open until tomorrow (March 15), but we had a steady stream of patients today. Most people are in one of two large groups which have all come down with vomiting and diarrhea likely from improperly detoxified water or contaminated food. Most cases are caused by viruses in the US, but here it is frequently bacterial so we treat them with antibiotics which shortens the course. However, even with antibiotics, it is a miserable way to spend a few days.

We also had our first altitude illness case. A young man took a helicopter from Jiri toTengboche and then hiked to Lobuje in two days (usually takes four days for the unacclimatized). He came to us with a bad headache, vomiting, and shortness of breath. The main treatment for altitude illness is decent, but it was nearly dark, snowing, and he was alone as his trekking friend stayed in Lobuje. Luckily, he improved with Diamox and oxygen and will hopefully be able to walk down in the morning.

Tomorrow we officially open and will also begin our altitude lectures in Pheriche. In a couple weeks, we will also give lectures in the nearby town of Dingboche as well.

H&C

Pheriche

For those of you still tuning in, we arrived at the Himalayan Rescue Association aid post in pheriche a few days ago. Uploading photos and even basic text blog posts has proven too demanding for the modest Internet connection here. The owner of the Himalayan hotel, Nero, has welcomed us into town and grants us free access to his wireless network, so we have some connectivity.

The trek from Namche to Tengboche was quite challenging but rewarding. The first half of the day we made for Khunde, where there is a small hospital. A few inches of snow had fallen the night before so the trail, trees, and buildings were covered in white. From Khunde we headed towards our next stopping point, Tengboche. First we dropped down into a valley to cross a river. Next we began a long, steep ascent. it was slow going, and we were exhausted but thrilled to reach our destination. There is a monastery in Tengboche with beautiful buildings and grounds. Lots of prayer wheels and stupas all around. Plus, Tengboche is situated on a high saddle (3840m) between mountains that gives tremendous views north and south.

We took tea, mo mos, and then some Dahl bhat in the tea house there. A large group of Norwegian students were also at this tea house and Chris (the other doc) ended up evaluating and treating one for a nasty viral infection that had essentially immobilized the group in Tengboche for a few days. The next day the student was evacuated by helicopter to KTM because of his weakness and dehydration. The rest of the group seemed to have recovered. We took rest early and slept quite soundly after our toughest trekking day yet.

Finally, we began our last day of trekking towards Pheriche. This was perhaps the most pleasant day of trekking. We gained about 400m elevation but it was spread quite steadily over the day. We essentially followed a river through the khumbu valley. For lunch we ate chicken and veggie noodle soup and sipped lemon tea on a terrace. The weather was warm and sunny - pretty much ideal trekking weather!

Within just a few hours we reached pheriche pass, a high point overlooking pheriche, and then descended into town. Ah, to reach our new "home!" We dropped our packs at the aid post and without delay ordered a round of everest beers at the himalayan hotel!

Tengboche

On our route today we went through Khunde which is a small town that few tourists visit where we saw the Khunde clinic and the Hillary school both started by Edmund Hillary. The Khunde clinic is a small rural hospital with 15 inpatient beds, a birthing room, an ultrasound, and a small X-ray machine. They provide medical care mainly to locals and for minimal cost.

The trek today really begins to get into the mountains, and we spent most of the day staring at Ama Dablam (22,000 feet). We ascended to Tengboche which is a monastery town in between two mountains. The route there ascends to nearly the height of the town, descends to cross the river a few times, then ascends again about 500 meters over the last hour of the trek including several sets of stone steps. Definitely the most challenging day yet.

It is colder here in part due to the wind that whips between the mountains. We sat out in the sun eating momos (dumplings filled with vegetables, cheese, potatoes, etc and either steamed or fried) and hot tea.

H&C

Hill on the ascent to Tengboche. Breathtaking in every sense of the word.

Namche Bazzar

We are sitting at a coffee shop at 3440 meters (11,500 feet) on our acclimatization day. We were going to go for a day hike to the Kunde clinic and the Hillary school, but snow and blowing winds have kept us from wandering too far.

Namche is the largest of the towns we hike through and the last stop for any type of gear, ATMs, or real (not instant) coffee. In the past, it was the last Internet connection as well although that has apparently changed. On Saturdays, there is a large market in the center of town.

It is highly recommended that all unacclimatized people take an extra day in Namche. The human body can adapt slowly to the hypobaric hypoxia which occurs at altitude but it takes time. This alone reduces the incidence of altitude illness by 22% which is an easy preventative measure that unfortunately gets skipped too often.

Khunde clinic

On our route today we went through Khunde which is a small town that few tourists visit where we saw the Khunde clinic and the Hillary school both started by Edmund Hillary. The Khunde clinic is a small rural hospital with 15 inpatient beds, a birthing room, an ultrasound, and a small X-ray machine. They provide medical care mainly to locals and for minimal cost.

Outside of Khunde, we stopped to catch our breath at a stupa and had an amazing view of Ama Dablam.

Photo taken near a stupa just outside Khunde.

Lukla

Initially we were not sure we would be able to fly today as the Kathmandu airport was closed for take offs for small planes due to weather, but eventually we took off and flew into Lukla. The flight was surprisingly smooth, and we even found breakfast burritos at the Paradise teahouse behind the airport. From there we hiked first to Phakding for lunch and then to Munjo at 2850 meters where we stayed the night. Chris had his first taste of dhal baat (a Nepali typical meal of lentils & rice with veggies and potatoes which is very common on the trekking route) for dinner there. It's the only meal that is all-you-can-eat which is helpful for hungry trekkers.

It is quite a relief to be on the trail as it is much quieter here with out the cars and motorbikes and chaos of Khatmandu. Only yak bells and music being sung by porters while carrying loads more than their own weight and the roar of the river below can be heard.

H&C

Last day in KTM: adventures in photocopying, mailing, and repacking

Today is our last day in Kathmandu. The last 12 hours have been a little exhausting with final preparations, but we are finally ready to begin our trek. Among our to do list for yesterday was to make 250 double-sided copies of 4 forms for the research study (after getting final IRB approval), buy additional medications from the pharmacy, and mail about 100 postcards. Unfortunately the labor strike shut down the businesses until 6pm, and on top of that there was a power outage until 8pm. We were still awaiting final word from the IRB but had to go ahead with the copies or they would never have been done in time. Photocopies took over 3 hours on these older machines, but Chris and the store owner stayed until after midnight to finish the copies. While this was ongoing, we also acquired some more medications. The pharmacy was interesting as many medications have different names or formulations here than the US and no prescriptions are needed here. We tried several times to mail some postcards but no post offices were open. Then we had to repack all our things into bags going straight to Pheriche by yak, bags we will trek with, and bags that will stay in Kathmandu.

Finally we went to sleep at 2:30 am only to be awoken at 3am by some very loud tourists in the hallway and then again by jackhammers at 7:00am. We needed at get our bags to the HRA and with the strike, taxis were not common. We finally found one and sent him with all our bags and one person. As you can see, the cab was quite full. Then after more lectures and final housekeeping items, we left the HRA for final preparations. We found a "New Orleans Wine Bar" which had neither creole food or a wine list. We then met the other volunteers for a last supper of beer and pizza and celebrated Bex's birthday.

Tomorrow we fly out to the mountains for the main adventure. A taxi is coming at 4:30am to take us to the airport for the flight to Lukla.

H&C

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On the way to Himalayan Rescue Association office with our gear traveling directly to Pheriche. Cabs are "nano" here.

Homework

Nepali is quite a difficult language to learn even the basics in a week. Our instructor Prem is quite patient, but I'm not certain we are improving. The word hernu means "to care for" but harnu means "to kidnap" but once congugated the sound difference is subtle. More than once we said we kidnapped our patients instead of cared for them. Also confusingly, shaking your head side to side means yes here instead of no. We must have done poorly in class today because Prem gave us homework.

H&C

Completing homework before our Nepalese language lesson over a Ghorka beer. On the garden terrace of Helena's grill in Thamel.

Thamel

Street in Thamel, a tourist hub of Kathmandu...

Nepali Lessons

We have had a couple of Nepali language lessons which have been quite difficult but useful. The language is unlike any of the Latin-based languages and has a large number of "k" sounds in the words. Besides Nepali, we have also been learning how to care for the solar and wind power generators which power the clinic. We have had lectures on local antibiotic resistances and the local flora likely to cause diarrhea and fevers. There was also a demo on tooth extractions which I have never done before.

In the evenings, we are getting to know the other volunteers and their partners. Bex works in a ED in Christchurch, New Zealand while her partner Luke is a roofer. The HRA has already come up with a few construction projects for him in Manang. Luke towers above us all at 6'6" and with his red hair really stands out on the streets if Kathmandu. Jas and his girlfriend Heather are from Canada but both have been traveling for several months before coming here. Jas works as an emergency physician at an ED near Jasper, Canada. Heather is a nurse in the same department. The other two who will be in Pheriche with us are Chris and Penny. Chris is an emergency physician and Penny is a nephrologist. They are originally from the UK but have been working in New Zealand for several years.

Our poor Nepali language skills have lead to a few hilarious results. Momos are a Nepali fast food of sort. They are a dumpling-like dough filled with vegetables, yak, cheese, potatoes, or whatever they want and either steamed or fried. They are served with a spicy sauce which is usually tomato-based. Luke attempted to order a few momos for the group to go with our beers, but a miscommunication lead to getting 60 momos! Oops!

Today there is a Nepalese labor strike so all the businesses are closed. While it is nice to not be haggled by rickshaw drivers and tiger balm sellers, we still need to do a few errands before flying out on Friday morning including mailing postcards and making some copies for the research study. Hopefully they will be open tomorrow.

KTM

Kathmandu is the largest city in Nepal with a population of about 4 million if you count the surrounding "suburbs" but it is much more dense than similarly-populated Atlanta and takes up a smaller footprint. Most of the areas you would want to visit are within walking distance. The city is old and full of shrines, stupas, and artifacts which are incorporated into the many businesses and markets.

Thamel is the city's tourist area where most if the hotels and Western-type restaurants are located. It is also the home of merchants selling pashminas, mountaineering gear (remarkably good knock-offs of North Face and Mountain Hardwear), masks of Hindu gods, and tiger balm ("good for chest colds, distemper, and flatuance"). We are staying at Hotel Marshnangdi in the middle of Thamel.

We took a self-guided walking tour of Thamel to Durbar Square and wandered into a Grand Finale dance competition. People were crowded into the square and hanging off the shrines and monuments to see the stage. It was too crowded to see the shrines, so we will have to come back another day.

H&C

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Planning our next route over cappuccinos and a map of the city!