Thursday, May 19, 2011

My last day in Bhairahawa

Today was my last day at LEI.  And, as excited as I am to meet up with Rene' tomorrow in Kathmandu, there was some sadness today.  Sadness because I had to say goodbye, or, until next time, to a group of people I now consider colleagues that have shown me SO much kindness and gratitude during my stay.  Following surgery and seeing patients in clinic today the staff held for me a going away gathering, which was held in Dr. Byanju's office.  Dr. Byanju, as well as the director of LEI, thanked me for the time I had volunteered at LEI, and welcomed me to return.  I was given gifts of a Buddhist scarf, a statue of Lord Buddha, and a lei (I suspect they have a different word for it, but not sure what it is).  The director also placed a red Tilak on my forehead.  A number of pictures were taken, some of which are below.
On the left is the director of LEI, who also started the original hospital 25+ years ago.  On the right is Dr. Byanju, my gracious host for the past 2 weeks.

I was also graced with a Nepali cap, making me feel like a true local.
In the center of the picture and to the left are the ophthalmology residents, numbering nine in total.  Most of them will go on to fellowhip training after completion of residency.  I am confident that each of them will become successful ophthalmologists in part due to the excellent instructors/attending physicans under whom they are training, as well as the wide variety of pathologic conditions to which they have exposure to be able to hone their clinical and surgical skills.

I am blessed to have been able to spend time here.  It is my hope that I have given as much as I will be taking away from my experience.  I hope to be able to return some day, and to continue to help advance LEI's provision of vitreoretinal care.

Thanks to all that have followed this blog, and, namaste'.

Free day, continued

This temple was our destination and turn around point on Tuesday.  Lots of birds, lots of incense, and a number of people meditating in the lotus position.  Even though the walking surface wasn't what you'd call clean, no shoes were allowed.
Above pic shows me and our driver for the day, who is in the middle.  The guy on the right?  A local guy who wanted to be in the picture :).

Me and the ophthalmology resident who joined me for the excursion, and, since he also spoke English, graciously answered all of my questions for the trip.

Having trouble posting more pics with descriptions.  The two pics above without captions show some of the surrounding mountains.  I was intrigued by the layers of rock, and their angle, as shown in one of those pics, since it reminded me of some of the rock formations in Colorado.

Free day

I was surprised to find out that only was Tuesday, May 17, celebrated as Buddha's birthday, but it's also celebrated as a holiday and all businesses are closed.  After seeing postoperative patients in clinic, Dr. Byanju offered to have a driver and one of the ophthalmology residents act as a guide for me and drive me to some areas of interest to the north.  During my entire stay so far, I have yet to see the sun.  The skies are constantly overcast, and little did I know that there are actually mountains not far to the north.  As an aside (since I know some of you reading this would be interested), the vehicle that has been my transport vehicle most of my stay is a diesel powered Toyota LandCruiser, which also has a 5-speed manual tranny.  When that vehicle wasn't available I got to ride passenger on a motorcycle, which helped abate to some degree the mid-day heat.

Prior to our travel north, Dr. Byanju requested we make the several kilometer drive to the India border (to the west) so he could buy some bread.  This is an open border to residents of Nepal and India and as such, the border is a flurry of activity.

One of many tour buses getting ready to cross the border into India.

Looking back at Nepal from the border with India.


The top picture is not great, but lets you know where I am.  Palpa, like every other place I've been in Nepal so far, feels VERY heavily populated.  While in Palpa I visited the hospital, which is sponsored by Lions Club, and is affiliated with LEI.  The middle pic is the operating room inside the Palpa hospital.  Notice there are two tables and only one operating microscope.  It seems typical in this region for there to be two patients in the operating room for each surgeon.  As one patient is being operated on, other staff are readying a patient on the nearby table for their surgery.  This setup is primarily with cataract surgery, since retina surgeries require much more time.  The bottom pic was taken as we were driving through Palpa.  The cow is privileged.  While I've heard lots of horns blaring at cattle, I've never seen anyone lay a hand on one.

The software I'm using for this blog is not being user friendly right now, so I will continue it with another post.

Tuesday, May 17, 2011

More pictures of LEI (Lumbini Eye Institute)

Over that past few days I've had the opportunity to grab some more pics of LEI that I'd like to share.

Below is another pic from the ward, an area (which is in the original hospital) where patients spend overnight following surgery.  Sometimes patients will remain here for several days following retina surgery.
Looking out from the room in the previous picture.

Below is an exam room where ophthalmology residents will see some of the 500 patients per day currently coming through the Eye Institute.  This, being Summer, happens to be their slow season since one of the primary industries is agriculture, and farmers are busy with their crops.  The busy season for the Institute is Winter when up to 1200 patients will come through the Institute daily.  Their conditions may range any where from needing an eyeglass prescription to needing emergency surgery

Above is a picture of the registration area.  Patients currently have both an electronic record as well as a paper chart.  While the electronic record is kept indefinitely, the paper record is discarded after three years of inactivity.  After registering, the patient will have a series of rooms to pass through as different parts of the eye exam are conducted.
This is a view to the west from a 2d story window of the Institute.  Economic times are very trying for the country in general at this time.

I have two more days before my departure from LEI.  I will try and post once more before I head to Kathmandu to meet Rene' and begin the relaxation portion of my trip.

Sunday, May 15, 2011

My 1st week

Today, Sunday, is not taken as a religious day here (although it is in India).  Saturday is taken as a religious day in Nepal.  That being the case, I will be at the hospital today starting my 2d, and last, week.  Today will begin with an ophthalmology resident's presentation and discussion at 7:30 am, followed by seeing patients in clinic.  I don't believe there will be surgery today, but am not certain.  This evening I will give my presentation to the staff and local doctors on use of tPA (tissue plasminogen activator) in the treatment of submacular hemorrhage.

Work here as a retinologist is difficult.  Not only are the pathologies difficult to manage, but the volume of surgery is high.  Nepal has a population of roughly 30 million, with only three retina specialists.  Consider that in the US, there is one retinologist for approximately every hundred thousand people and you can see how the volume of need here is high.  This, on top of performing surgery with equipment that could benefit from being updated.

Most of the patients being seen and treated are from India and this is due to several factors.  One factor is that 100 Indian rupees are worth 160 Nepali rupees, so patients coming across the open border from India get a significant discount vs having the same surgery in their home country.  Other factors that come into play are that the population in nearby India is significantly higher, and also, there is no where closer in India for patients to travel to for their eye care.  I've seen patients that have travelled as long as 9 hours by bus.  For reference/comparison, New Delhi is an 18 hour train ride away (to the west).

Yesterday, Saturday, I was treated with a trip to Lumbini and the birthplace of the Buddha.  I was informed a few days ago that this coming Tuesday is the celebrated birthday of the Buddha, an event that many make a pilgrimage to attend.  The temple which houses the marker stone of Buddha's birth is surrounded in an expansive landscape of Buddhist temples and shrines from various nations.

The Buddha's birthplace.

Below are a few pictures of the various temples we visited.  It is required that all visitors remove their shoes before stepping onto the grounds of the temple, so be sure to wear your sandles if you visit.  Not shown in these pictures, or visible from these sites, is the backdrop to these temples which is highlighted by a highly undeveloped countryside.

This is a picture showing the circle of life (specific to the Buddha), shown as an elaborate painting on the wall of a temple.  History has it that immediately after birth he walked and took seven steps.  Under each of his steps grew a lotus petal.

Tuesday, May 10, 2011

1st days in Nepal

Have come to find out that my hotel, and Lumbini Eye Institute, are actually in Bhairahawa (I may have misspelled this in an earlier post), not Lumbini.  Lumbini is 22 Km away.  Dr. Byanju has graciously offered to take me to Lumbini this Saturday.  I'm looking forward to visiting the birthplace of Siddhartha (the Buddha).

Monday, my 1st day here, was VERY taxing, throwing myself into an environment with little in common with back home, other that the conditions I would see, and operate on, in people's eyes.  The volume of surgery patients is high, with many people with complete retinal detachment, others with vascular issues resulting in vitreous hemorrhage.
This is a picture of Lumbini Eye Hospital/Institute.  It was built ~5 yrs ago, and is where patients are seen in multiple subspecialty clinics and also have surgery.  It is bustling with activity, with patients showing up around 7 am for clinics not beginning until 8-9 am.

The picture to the left is one of the original buildings of Lumbini Eye Hospital, which was funded by Seva Foundation.  This building currently serves as a ward (their term) where patients stay overnight following eye surgery.  Patients are given a cot to sleep on, with up to 8 cots per room.  No food or drink is offered.  No air conditioning.  No amenities.  Just a cot.  And daytime temperatures around 100 F.  I will be there this morning to attend a resident's lecture at 7:30.

The above three pictures show where I spend most of my time - in the operating room (they refer to it as OT, or operating theatre).  The only anesthesia patients receive is a retrobulbar block prior to walking themselves into the OR.  There is no intravenous anesthesia, and no IV.  When the surgery is finished, the patient gets up from the table and, with assistance, walks to recovery.  What we refer to as operating room turnover in the US consists of the surgeon replacing gloves with new ones, while the next patient is escorted in.  While I don't have the stats on their postoperative infection rate, it is very low.

Time for me to get ready for the day ahead.  Stay tuned!

Monday, May 9, 2011

Getting here

Let me just say up front that the trip here is loooooooooooonnnnnnnnnnnnngggggggggggggg!!!!!!!.  Left LAX around midnight Friday night for the 17h 20m flight to Bangkok (BKK).  Thanks to traveling west, the flight gave everyone aboard about 15 hrs of darkness.  Felt like I was hibernating.  First flight I've been on that served 3 meals.  Accommodations with Thai Air were very good and I would highly recommend them.  Arriving in BKK, I was amazed at the modernity and no-expense-spared feeling of the airport.
This is a pic inside BKK airport on the way to my gate.

The flight from BKK to Kathmandu (KTM) at only 3 hours wasn't nearly as tiring, plus it was in daylight.  The service again was very good, this time accented by availability of beer and wine ad lib with lunch, and after lunch, the offering of cognac.  All served up with a pleasant smile.

Upon arrival at KTM the culture shock hit.  Absent were the signs directing to my next gate (although I didn't have those at LAX or BKK, either).  Present were signs in Hindi, narry a word of English being heard, and lots of people trying to make a rupee off of tourists.

This is a pic of the check in area at KTM for domestic flights.  Yes, those round things you see are scales, and anything and everything being checked is weighed.

While sitting in this waiting area to depart to Bhairawana (only a 30m flight), I met Pete and Lynn.  Pete is a internist, and Lynnn is a med tech, and they were on there way to a mission hospital not far from Lumbini, where they would be spending 4 weeks.  Had the feeling of how small a world it is when I discovered Pete and Lynn live in Grand Rapids, MI, which is where I did my ophthalmology residency.  The pic to the left shows, from left to right, Lynn, Pete, me, and my driver during my stay in Lumbini (he has a long name that I still haven't learned how to spell).
Above is a pic of Hotel NANSC, where I will be staying until my departure May 20.  And below is a pic of the view of things across the street from the hotel.

More to come later!