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Stitching Up the Nepalese

I do not like to write.  I never have.  I write because I have to.  Not for a grade or even for a check, but out of an obligation to myself to preserve the memories that I hold most dear, least they are lost to the deepest recesses of my memory.  This is my story of Nepal. 

I spent one month in Kathmandu working in a medical clinic for the poor, hiked for two weeks to the base camp of Mount Everest and spent Christmas and New Years in a small village east of Kathamndu that is engaged in civil war.  I am a thrill seeker, on a mission to experience as many of life’s great adventures as I can.  Nepal has been my greatest so far, but I am hopeful that it marks the beginning rather than the end.  

I found a medical internship on the internet that was offered through an organization called Helping Hands in late October 2003. Two weeks later, I was on a jet crossing the Pacific bound for Kathmandu.  I had no idea what to expect, but I knew that it would be exciting.  I had only read a few accounts from previous volunteers and had not seen any pictures of the clinic or the accommodations.  I figured that any opportunity to practice medicine without a license is a good one and, that if the internship did not turn out to be what I hoped I would spend the two months traveling around South East Asia.  I would never have guessed that two weeks after leaving I would be standing at the base camp of Mount Everest or that I would spend Christmas dinner with a Major in the Nepalese army, the most important doctor in a small village in the eastern part of Nepal, the Deputy Chief of Police, and an X Colonel in the Gurkha army.        

Twenty five hours after leaving Washington my plane touched down in Kathmandu.  I felt like Alice, tumbling down the rabbit whole.  I was still groggy from the sleeping pills that I had taken to help the hours pass.  Everything was moving as though I were in a dream.  I had spent ten hours sleeping on the floor of the Bangkok airport the night before, and was filthy.  My plane had traveled from Washington to Atlanta and then on to LA for an unscheduled nights stop, and then onto Tokyo, Bangkok, and finally Kathmandu. 

The plane rolled to a halt on the tarmac in Kathmandu somewhere near the terminal.  A flight attendant was standing at the bottom of the stairs pointing in the direction of a large brown building that I gathered to be the main terminal.  I have never been so excited!  These were my first moments in the country that was to be my home for the next two months.  I was quickly swept by a flood of emotions that I had not expected.  For all of the traveling that I have done, it was not until I set foot in Kathmandu that I ever felt that I was a long way from home!  When traveling in Europe I see myself.  Our customs, laws, and for many of us even our color comes from Europe.  But everything in Nepal was foreign.  It is in fact, much farther than on the opposite side of the globe, it is a world away. Nepal is the most amazing country on earth!  In an area the size of North Carolina, there is jungle and the world’s highest mountain.  The country is at the junction of two continental plates which accounts for its strange topography.  The Indian sub-continent has been slowly migrating north for several million years and is crashing into the Asian continental plate.  As the two plates collide, the Indian plate is diving under the Asian plate, giving birth to the Himalayas.  These mountains are still growing at the rate of a couple of centimeters a year.  That is a tremendously fast rate for a mountain range, making the Himalayas not only the world’s highest mountains but also one of the world’s fastest growing.  The Himalayas rise until you reach Tibet and then the landmass drops down onto the continent of Asia.     

Westerners think that all of Nepal is as cold as Mount Everest, but its temperatures are actually quite divers.  Kathmandu is warm because it is in a valley, but the surrounding hills can drop well below zero.  The Kathmandu clinic only sees about fifty to seventy patients in the winter.  It is to cold for villages to make the journey into Kathmandu.  In summer however, their patient load jumps up to as many as two hundred people a day.  The coldest time was in the morning.  Even then it did not drop much below the upper thirties.  In mid-day it warmed up to fifty or sixty degrees.  That being said, it was still very cold.  No one in Kathmandu has heat.  We piled on layer upon layer of clothes in the mornings and evenings but it was inescapable.     

I saw a man with a clef pallet my first day in the clinic.  Neither his pallet nor his upper lip had formed, making it difficult for him to eat and to otherwise live a normal life.  I had read about clef pallets, but had never actually seen one.  When he opened his mouth you could look right past where the roof of his mouth should have been right into the frontal sinuses.  That day was the first time in sixty years that he was able to come to Kathmandu to have surgery.  He had walked for two weeks from his village and expected quality service!  Just think about that the next time that you complain that your doctor is not able to see you for a week.

The facilities in the Kathmandu clinic were basic at best.  That being said, I was amazed at what the doctors and nurses could do with their limited supplies.  The secret to their success was their commitment.  There were three full time doctors and several other doctors who had private practices and offered their time a few days a week to include; an orthopedic surgeon, two OBGYN’s, a radiologist, an anesthesiologist and a pediatrician.  The doctors were excellent.  They had made the decision to do something about poverty in Kathmandu, and their decision showed in their work.  They gave each case equal attention, and cared enough about their patients that when someone came back for a follow up they could not only remember their cases but also their names.

The clinic is located in a neighborhood called Chabahil on the Eastern side of Kathmandu, not more than a few minutes walk from one of the most important temples in all of Hindu and the world’s largest Buddhist Stupa.  The clinic’s orange walls are barely visible behind two or three anonymously gray buildings.  The filthy alleyways that separate the buildings are dirt, and so narrow that you could easily touch either wall with your arms outstretched.

The pharmacy, two small exam rooms, and the operating room were on the first floor.  On a crowded day, fifty people were packed as tightly as sardines into these tiny rooms.  Privacy as we know it in America is unheard of in Kathmandu.  The best they had was an old dirty curtain that hung around the exam table to save the patient laying there at least a little embarrassment.  The doctor sat in the corner of the exam room and another volunteer and I sat on stools beside the exam table.  There were days when we would be busy taking patient histories, a patient would be lying on the table waiting to be examined, and ten other patients would be standing over our shoulders waiting patiently for their turn.  Once I had finished taking one patient’s history with the help of an interpreter and my own broken Nepalese, I would hand off the exam card to the doctor to review.  Then, push through some people to the exam table and examine another patient.  When I finished giving the exam, I would present what I found to the doctor, and he would take a look at them and prescribe what they needed.  The days were crazy!  I did not know even half of what I needed to know about anatomy or diagnosis.  I learned everything I needed on the spot.  At first I was overwhelmed, but within three weeks it was second nature.  Difficult…yes, but I have never done anything that I loved more!  The clinic’s staff tried their best to keep their equipment sterile, but there were too many people working in the exam room who did not understand sterile procedure for it to be maintained.  Somehow though, patients were not coming back with infections.  The exam table sheets were not changed between patients and gloves were frequently reused.  That day’s gloves were thrown into an autoclave to be sterilized, and could always be seen drying on a clothes line on the roof the next morning.  Most of the nurses felt that gloves were only necessary if they were going to dip their fingers directly in blood.  I could not believe this at first, but I was surprised at how quickly I got use to it.  I was, however, careful to always keep a set in my back pocket.  

The x-ray room, dental clinic, and main operating room were equally chaotic.  The lab only had one microscope, an autoclave, a centrifuge, an oven, and some rudimentary supplies.   In spite of their limited supply, however, they were able to do hematological test, urine, and stool test accurately.  The x-ray room was a little bit homemade, but was very functional.   

My first experience suturing was a nightmare!  I had seen it done several times but no one had ever actually shown me how to do it.  A three year old girl came into the clinic on a busy afternoon with a deep laceration above her left eye.  She had been playing on the roof of her house and fell, hitting her head on a metal bar that was protruding from the concrete.  The surgeon on call that day was Dr. Uday.  He was busy with another patient and looked at me and told me to go do it.  When I walked into the room, I was faced with a dilemma.  I did not want to look as nervous as I was in front of the girl’s mother and several of the nurses in training, but at the same time I did not want to charge into something that I did not know how to do.  I calmly ask the nurse in charge if she would help me and she kindly nodded yes.  I took a deep breath, grit my teeth, and picked up the needle to begin.   

I have not been that nervous or excited since my last week in Airborne School when my company made our first jump.  Trying to deal with a screaming child, a worried mother, and ten pairs of eyes on you your first time suturing is very intense.  The last thing I wanted to do was hurt her, but even more importantly I did not want to cause any farther scaring to her forehead.  I was both nervous and excited because at that moment I was responsible for her.  I could not let my uneasiness interfere with the responsibility that I had been given.  I was very focused, but in a different way that I would have been mountain biking or testing the limits of a new car.  It was more memorable, more pure.  Although I first experienced this kind of feeling while in Airborne School, I have not been able to express exactly what it is or why it is important until now.  

Allow me to provide a little bit of background.  I had girlfriend once who was amazingly successful at everything she did.  For a long time, I was jealous of her until I recognized the magnificence of her talents and decided to learn exactly what it was that made her so successful.  After much thought, I realized that the spark in her eyes was raw courage.  It was not an absence of fear, but rather a mastery of it.  When you are afraid, that fear is a tremendous amount of energy that you can do one of two things with.  Either you can let it cloud your mind and distract you from your goal, or it can be harnessed, conquered if you will, turned around, and used to help you achieve your goal.  This is extremely difficult to do, but if achieved, it is beautiful.

This feeling of nervousness, excitement, and extreme focus exist only for a moment, when you master your fear and use its energy to help you reach your goal.  Some may call it adrenaline, but adrenaline is a chemical and what I am talking about is a moment in which the true character of a man is revealed.  To push past whatever inhibitions are holding you back is exhilarating.  I have come to cherish this moment, to look for it, to need it.  No matter how short the moment maybe, it gives me an unparalleled high and peace of mind to know that what we are capable of is limited only by our own inhibitions.  Just a few days after coming to Kathmandu, I began a trek to Mount Everest base camp with two other volunteers from Helping Hands.  Our plane ground to a halt in Lukula.  We had left Kathmandu hundreds of miles behind us and entered a world that had barely changed for a thousand years.  The temperature had dropped down into the low fifties and the nip in the air told us that winter was fast approaching. We grabbed our luggage and walked past the armed guards with old soviet style weapons to the nearest hotel to acquire a Sherpa for the trip.

The early day of trekking in the foot hills bled together as one long continuous day.  In truth, there is nothing foothilish about them!  The “foothills” are steeper and higher than the Colorado Rockies!  We all suffered from altitude sickness to some degree during the trek.  I got it first.  It hit me hard on the second day… I remember it well.  That day we hiked to a high village called Namche Bizar.  I have no idea how far it was as the crow flies, but I do know that I hiked for six hours up the steepest and longest hill I have ever seen!  I cannot imagine that there is a more physically grueling day in all sixty two days of Ranger School.  Nemche Bizar was so high that the trail we were on disappeared into the clouds before the village was visible.  To turn around at any point was to see deep valleys carved by emerald green water rushing off the jagged peaks.  As we climbed higher we could see rows of mountains slowly rolling back in the direction of Kathmandu.  I enjoyed this view a lot because I was so exhausted that about every ten minutes I had to sit down so that my lungs and my head did not explode!  That was the most difficult part of our trek, but in retrospect it did enrich the experience.

We had hiked over one hundred and twenty kilometers uphill before finally reaching base camp on the morning of the eighth day.  We were swept by a feeling of accomplishment and success as we gazed up another eleven thousand feet to the summit of Everest and then past it into the deepest blue sky that I have ever seen.  We were standing on the Everest ice fall which is a large glacier that winds its way down the mountain.  The glacier originates somewhere high on the mountain, but breaks apart at the base camp forming huge towers and canvasses of ice.  Every so often we would hear a deep crack echo off the peaks.  It was the sound of the ice breaking apart as it flowing down the mountain at the pace of about three to five feet a day!  That is extremely fast for a glacier which is one of the things that makes summating Mount Everest so dangerous.  As climbers ascend the ice fall they have to worry about the possibility of a tower of ice breaking at the wrong moment and crushing them beneath twenty tons of ice. 

The outline of the base camp is abruptly interrupted by a crashed helicopter.  Last spring a large Soviet modal helicopter was flying around the base camp when it crashed leaving wreckage thrown about the area.  As you can imagine, the wind at that elevation can be very unpredictable.  The helicopter was grabbed by an unexpected gust of wind and hurled to the ground.  Our guide told us that nobody was killed in the crash which is amazing because the helicopter itself is torn to shreds.

Near by the helicopter I found a very peculiar artifact.  A large human bone, probably a femur, was sticking half way out of the ice.  How long had it been there?  How did it get there?  I reached to dig it out of the ice but stopped.  That is someone’s grave.  No animals live that high on the mountain.  Scores of expeditions have attempted Everest over the years, some have succeeded but most have failed.  I just happened to come across the bones of someone who had died higher up on the mountain.  There is no way of actually telling at what elevation the man died, or how long ago because the glacier would have carried his remains down from higher up on the mountain.     

Everest base camp

To be completely honest, I did not find climbing to Everest base camp very difficult.  I am in pretty good shape, and most things physical come fairly naturally to me.  There are, however, plenty of things that I find extremely difficult, starting with school.  During our trek we learned a great deal about each other’s strengths and weaknesses.  One of the other volunteers is in his second year of medical school and is on the national dean’s list.  As soon as we arrived at base camp I was blown away to hear him say that our trek had been the most difficult thing he had ever done!  What!! if I had not had my backpack I could have run half of it!  The most difficult thing that I have ever done was my first two years of pre-med.  Every night was like war, I hated it, and would not do it again for anything less than the Eiffel Tower! 

I was sad to leave base camp.  In the few short minutes that we were there something changed inside of me.  I realized that I was no longer burnt out.  I graduated from college last May and was sick of school.  At the end of last year I could not focus on anything.  I even dreaded going to medical school which has been my lifelong dream.  Standing on the Everest ice fall, I turned to my friend and without even thinking about it said “now I am healthy.”  Since I have come back from Everest I have felt differently.  I cannot wait to go back to school, I can concentrate to on anything for as long as I need to, and whatever bitterness I may have felt has been replaced by a profound enthusiasm and an insatiable desire to learn.  Now, I know that many people get burnt out.  Everybody has his own way of dealing with it, but I had to climb the world’s highest mountain.  What does that say about me; I don’t know maybe I’m just dramatic!

It took us four days to descend.  It was certainly easier, except for on the knees.  Before we knew it we were back in Lukula awaiting our plane to Kathmandu.  We happened to meet a small band of Tibetan refugee children on their way to India our last night.  Their guide had smuggled a group of about ten children between eight and fourteen across the border of Tibet and into Nepal in search of a better life.  He explained to us in nearly flawless English that China rules Tibet with an Iron fist.  The Tibetans are a devoutly Buddhist people, but under Chinese rule they are not allowed to practice their religion.  Anyone caught trying to escape is, regardless of his age, thrown in prison and killed.  These children’s parents had given them up, fully understanding what would happen to them if they were caught.  They were chasing what is perhaps the most durable desire of mankind, freedom.  Their hope was to reach India, and with it the freedom to practice their religion and rise to their fullest potential as human beings.The children and their guide were forced to travel at night for fear of detection.  Can you imagine traveling with ten young children in temperatures well below zero across miles of deserted rough landscape…I can’t.  Their leader lived in Kathmandu and had made several journeys across the border.  His motivation for taking such a risk was that he had escaped as a child and had been raised and educated in India.  He spoke four languages and described for me the dismal situation of Tibet.  The movie “Seven Years in Tibet” actually describes their situation well.  The real reason for China invading Tibet has nothing to do with nationalism.  It is because from that elevation it is possible to maintain air superiority over all of south Asia. 

We bought dinner for the children that night, which cost us all of about four dollars.  They had Dahl Baht which is rice, lentils, and curry vegetables.  I went to bed that night thinking about my life.  We were in the same lodge and I was on a trek having the time of my life, and they were running for theirs!  The world is an interesting place my friends.  You meet the most interesting people in the most unlikely places.   

I spent two weeks in Kathmandu before leaving for my second excursion, this time to the second permanent Helping Hands Clinic in a small village about five hundred kilometers east of Kathmandu. Khandbari was much warmer than in Kathmandu.  It is located a few thousand feet lower on a face of one of the steep foothills of the Himalayas.  We were told that Khandbari is real Nepal.  It has not been touched by the effects of tourism that have certainly impacted Kathmandu and the villages along the Everest trek. 

I had never flown onto a grass air strip before.  Just like in the movies, someone had to go out and drive off stray chickens and other vermin so the plane could land.  Another volunteer and I were with a team of three doctors who were going to Khandbari to hold a five days health camp for women.  They had brought with them at least one hundred pounds of supplies for the week.  We were warned repeatedly by Dr. Gupta, the director of Helping Hands, not to bring more than fifteen pounds of luggage each for fear that the plane would be too heavy to take off. 

As we came in for landing Dr. Dangal, the OBGYN, leaned across the seat and with a hint of pride in his voice told me that this was the best grass landing strip in the country.  What are you suppose to say to that?  The plane ground to a halt and we were greeted by bright sun, warm air, and about twenty curious children.  Security as we know it in America is a joke.  They are guarding against an entirely different kind of threat.  Surrounding the airport was a system of trenches that the army had dug to protect itself against a possible Maoist attack.  Razor wire with beer bottles tied around it surrounded the perimeter and soldiers were standing guard in the bunkers that fortified the trench system.  The bottles were a simple but clever idea.  The though is that if someone tries to climb or cut the wire the bottles clink together alerting the soldiers. 

Elephant trekking in Chitwan

Before we could leave the air strip we had to present our papers to the officer on duty.  In my infinite wisdom, I forgot my passport.  I was terrified that I would have to go back to Kathmandu because I did not have the proper ID, but thankfully, my military ID worked like a charm.  The mood of the officer at the gate changed completely when Dr. Gupta handed off my ID.  His look changed from suspicion to respect, and he stepped aside so we could pass.  Dr. Gupta quietly leaned over to me as we were walking away and said that my military ID was much better than a passport!     

While in Khandbari, I had the great honor of training with some X-Gurkha soldiers.  The Gurkhas are among the best soldiers in the world.  They are recruited by British army and are known for their bravery, endurance, and loyalty.  I became friends with an officer who introduced himself as Captain Hari.  He invited me for an early morning run on our first meeting and it became a daily event.  Even at fifty Captain Hari could smoke me!  There was no way that I could compete.  He could charge up hills that were so steep that you could almost lean against them to rest.  All huffing and puffing aside, we had a great time!  There was nothing quite like running along a nearly deserted trail as the sun broke over the peaks as Captain Hari explained to me the history of the Gurkhas and his many adventures around the world!

Christmas and New Years would have gone completely unobserved had it not been for our very good friend at the clinic Dr. Anil, and the three most important men in town.  It was wonderful having someone to pass the holidays with.  We had Christmas dinner around a camp fire and served duck stir fry, fried vegetables, chicken (that we had killed that afternoon), and of course gallons of tea.  One of our guests was the village mayor who had been a Colonel in the Gurkhas, a major in the Nepal army whose name was Prem and was in charge of the compound in Khandbari, and the Deputy Chief of Police.  Prem had studied at Sand Hurst in England, and Davinia was the chief of police.  Both he and the Major had the very difficult job of protecting the village from any possible Maoist attacks. 

Perhaps what made the evening so memorable were the four men with machine guns standing guard around us the entire night!  Nepal is in political crisis.  The Maoist are a radical group that is trying to overthrow the monarchy.  We never hear about this at home but the country is in nothing less than civil war.  There had not been any fighting in Khandbari when we were there, but there had been several fire fights in the surrounding villages.  These men had become friends of ours through Dr. Anil.  Since the best doctor and the three most important men in town were together in the same place; they were not taking any chances.  We returned to Kathmandu a week late because our plane had been delayed for six days.  That’s the third world for you!  By then, my time in Nepal was drawing to a close and I was sad to be going home. 

Traveling abroad is a bit like being in love; the experiences that you share with that person last a lifetime, and the emotions that you feel are the feelings by which you will judge all other relationships in your life. Likewise, my experiences in Nepal will last me a lifetime, and they have provided me with the tools by which I may better judge my own society. 

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