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[nicolefoxmtns2mtns]

Final Reflections

Just as it was a whirlwind in Nepal, returning back to the States has been just as chaotic! I landed at 12:30 AM last Sunday, and had to re-pack everything from my bags to my car by Tuesday morning to drive down to Monument Valley and start my next clinical rotation! For the next month, I have the privilege of continuing to work with rural healthcare – this time in rural Utah on the Navajo reservation. Health statistics on the reservation (life expectancy, rates of certain diseases, etc.) are often compared to similar rates of mortality and morbidity in developing countries, so there are a lot of medical parallels with my last rotation in Nepal.

Much like Nepal, the scenery coming down here is spectacular (though red rock monoliths and endless blue sky have replaced the lush green and white mountains of the Annapurna). Also much like Nepal, my accommodations are humble – I am living out of my tent at the Monument Valley Tipi Village, which is adorable! There is a central kitchen (with a fridge!), and a HOT shower anytime I want it (so, actually, even more glamorous than Nepal!). Another similarity to last month is the diversity of the community around me. From Navajo to French to German to Swiss to Hindi, the myriad languages I hear each evening at the campground is a lot like travelling internationally.

Transiting back to clinic was a bit difficult on the first day. Though I learned a lot about what to do with little to no resources in Nepal, it took me a few patients to remember all that we have available in the States! Even in a place as comparatively remote as Monument Valley, we still have the luxury of a lot of point-of-care lab testing (or the ability to send it out for a patient, without sending the patient themselves to the nearest city). I had to re-learn to change my default thinking from, “that’s not available here,” to “that’s something we can do!”

The biggest lesson from Nepal, however, is still true here: these patients have given up hours of their days to travel long distances to come to this clinic. In the US, where we put such a high priority on getting patients in and out quickly, I’m grateful to my time in Nepal to remember to put myself in the patient’s shoes. I still need to be efficient, but not at the expense of giving the patient enough time to be heard and honored for the effort that they put into coming to see me for care.

We’ll see where the next few months take me as I start applying for jobs – with an eye on practicing rural medicine in the States. And, of course, accruing some vacation time to get back to those mountains outside Kathmandu…. 😊

[nicolefoxmtns2mtns]

The end (to this chapter)

My flight took off from Kathmandu just after a thunderstorm, creating gorgeous, fast-moving clouds in its wake. I was fortunate to have a window seat, and absent-mindedly took pictures and videos of the clouds to pass the time. My dad is a pilot, and I thought of how many incredible displays like this he must have seen over his 40-plus year career. A bank of clouds lifted, and a range of enormous peaks suddenly appeared just under the wing of the plane. My heart soared as I recognized an unmistakable, sheer face with twin peaks – Maccupucchare! The sacred mountain that we had seen from Ghandruk had emerged from the clouds one last time. Flanked by Annapurna South to the right and outlined in gold by the setting sun, it was breathtaking. Just as quickly, the clouds drifted over the Annapurna range, obscuring them in a thin blanket of white.

I am writing these words in the same airline seat, and I honestly am so overcome by gratitude to have gotten that one last, chance view of those peaks that I have tears in my eyes. My immediate, unfiltered, gut feeling when I saw those peaks was, “I’m home!” I take this to mean that I’ll be back again.

[nicolefoxmtns2mtns]

Final Days in Kathmandu

Our last week culminated in Kathmandu, and was spent both touring hospitals and cultural sites around the city. Highlights included:

-          Visiting Pashupati, a holy site on the banks of a river where Hindus bring their deceased to be cremated on an open pyre. We were able to witness the end of one funeral celebration, complete with dancers holding golden, flaming lamps and hundreds of bystanders singing along to bhajans (holy songs)

-          A tour of the HRDC hospital for disabled children, in the hills outside Kathmandu. Entirely supported by private donors and grants, the open, sunny hospital is doing incredible work for handicapped kids in Nepal, The organization does everything from surgery to public awareness campaigns about treating people with disabilities equitably. I was incredibly impressed by the scope of the work they are able to do, especially with almost no funding available from the government.

-          An incredible vegetarian meal outside the largest stupa (Buddhist temple) in Nepal

-          Wandering around the ancient brick city-within-a-city of Darbur Square, dating back to the 16th century

One of my favorite moments of the whole trip was actually my last day. My friend Megan and I had the latest flights out of the group, and decided to spend the morning wandering through town to the Chhauni National Museum. We wandered through side streets, stopping for chai (and Hindi practice) with a local tea seller. When we reached the museum, arrived a little earlier than opening, so we wandered toward some loud music and chants coming from an alley in back. What we found was a puran, a week-long Hindu ceremony. Held in a large tent adorned with brilliant pink and orange sashes, the lead priest laughed and sang and generally carried on, unbroken, for what we were told were 14-hour celebrations each day for seven days straight. We were invited in to the tent, and soon found ourselves being invited to dance with the older ladies seated next to us. The musician leading the bhajans started to sing the songs in English so that we could understand as we danced. It was so organic and welcoming; characteristic of everything in Nepal, we were invited into the community with open arms and absolutely no expectation other than to simply be. We left adorned with tikkas (painted marks on our foreheads), garlands of marigolds, and full hearts.

[nicolefoxmtns2mtns]

The Trek to Poon Hill

No trip to Nepal would be complete without a trek to see the Himalayas. After finishing out our clinical time in Ghandruk, we were fortunate enough to be able to trek over to Poon Hill, a popular destination point along the Annapurna circuit. We backpacked through misty rhododendron forests and up countless flights of beautiful stone stairs to the town of Ghorepani, at the base of Poon Hill. A pre-dawn hike up the hill rewarded us with an absolutely beautiful panorama of the whole range. Coupled with a warm cup of milk tea, you couldn’t ask for anything warmer, body and soul.

Pictures often speak louder than words: I’ll let them do the talking for this portion of the trip 😊

[nicolefoxmtns2mtns]

Lessons in rural health

The second day in clinic ended up being a day in bed for me after a serious case of what the group has come to call Shiva’s Revenge (read: making the toilet your best friend). Despite doing our best to eat cooked food and drink only filtered water, quite a few of us have been taken down a day or two. Luckily, immodium and anti-nausea drugs are cheap; after a few extended naps and some liters of oral rehydration salts, we’ve all been able to bounce back (minus a pound or three).

The remainder of the week in Ghandruk clinic had a lot more room and more translators available than our first day, which really helped to establish a better rhythm. We saw patients from a few months old to 87 (the oldest that I saw, who walked up not only the steep steps to the clinic but who knows how many countless stone steps to reach this part of the district). The care that we could provide was a series of both small triumphs and frustrations. For many routine complaints – a child with an ear infection, a woman with anemia, the same 87-year-old gentleman with likely pneumonia – we had the basic medications or interventions necessary to treat. What was hard for all of us was seeing chronic complaints, such as chronic lung disease or heart failure. Even with the highest standard of treatment in the U.S., these conditions are difficult to manage. Here, the best we can offer is a suggestion to seek medical care in the nearest city, Pokhara. Whether the patients can make the 5-hour trek down the hill and the hour and a half bus ride to seek out that care is never something we will know – but the likelihood seems small.

The group debriefed a lot about feeling like we couldn’t do enough for many of the patients we saw. Coming from a U.S. medical model, we are much better at throwing the kitchen sink at patients than we are at acknowledging when we are not able to help. The greatest lessons that I am trying to take away from the experience are gratitude and resourcefulness. Gratitude, both for where I am typically able to practice medicine as well as the patience of the health workers that have facilitated our trip. If the tables were turned, there is no way that I could have translated patient visits into a second language as effectively, especially while trying to withhold my clinical judgement so that some random foreigner could try his/her hand at rural medicine. Even if we thought that what we could do was limited, we were stretching the capabilities of these clinics to maximum capacity, and given the latitude to do so. I have always been interested in rural medicine and learning to work with what’s available, and this trip has helped reiterate the need to learn those clinical tools. I know that some of the skills I have learned on this trip will be useful in rural Utah, and hope I can continue to build on that skill set during my next rotation in Monument Valley.

[nicolefoxmtns2mtns]

The Top of the World

I woke up this morning to the most beautiful mountains that I have ever seen. Rising out of residual clouds from yesterday’s storm, the peaks of Annapurna and Macchupicchali (“Fishtail” peak) dominated the skyline. Words nor pictures can truly describe the magnitude of those mountains when you see them in front of you. Our elevation is just over 6,000 feet, and the summit of Annapurna (one of the tallest in the world) is over 24,000 feet – over three vertical miles above us. The peaks look sheer and insurmountable, even to someone who loves chasing summits and arduous climbs. Everyone naturally congregated to the patio and the roof as they exited their rooms, quietly taking pictures and soaking in the sun and the peaks.

Our first stop of the day was the main health outpost in Ghandruk, which serves most of the surrounding villages. After a welcoming ceremony (with beautiful leis made of orange flowers), we loaded stacks of medications into our packs and carried them to Kimchee.

The health assistants (Nepali health workers with a similar training and mission to physician assistants) in the area had spread that word that we could offer clinics in dermatology, pediatrics, orthopedics, and women’s health; we soon had a line of patients for those as well as any other systemic issues spreading down the block. It felt like barely controlled chaos. We had a steady patient flow at the Dunche clinic, but we had enough translators to manage. Here, we were short a few that we were expecting, and what we could do bottlenecked quickly. One of the most famous adages in medicine is a quote from a doctor named William Osler: “Listen to the patient; he is telling you the diagnosis.” Being about to carefully listen to and ask questions of your patients is the most critical element of medicine. Without this part of our craft, I often felt powerless and in the way as the Health Assistants did their best to translate 120 patient cases for us.

For us students, the cases were fascinating: different skin lesions, a classic case of hyperthyroid, acute exacerbations of chronic lung conditions. The hyperthyroid patient in particular is one that I will never forget. A young woman in her mid-twenties, she came over to our table wrapped in a pashmina shawl. When she took the shawl off her neck, she had an obvious goiter (swelling around her thyroid). She had every symptom of a hyperactive thyroid, straight from a textbook: a tremor, fast heart rate, hair loss, bulging eyes, elevated temperature. As we learned more of her story, we found out that a group of students had seen her two years ago. Our trip leader, Scott, even spent two whole days taking her around Pokhara (the nearest city), getting every test run that she needed to start the correct treatment. Two years later, those medications had run out; as the caretaker for a deaf and mute mother and an alcoholic father, she wasn’t able to go back to the city to continue getting the ongoing tests and treatment that she needed. In the U.S., almost every medical center would be able to run the test she needs, and every pharmacy would carry the medication to treat her. Despite the fact that we almost never see cases as advanced as hers, many of the social issues she faces are the same. Just like we see at home, every patient has a story, and every story influences each person’s ability to seek out and complete care. We again referred her to Pokhara, knowing how difficult it is for her to get there.

I hope that we gave back at least a portion of what we benefitted from the patients. The health assistants have some different approaches to treatment regimens than we do; even if our direct patient care may not have been as streamlined as we had wanted, I hope some of the dialogue with the health assistants can broaden both of our approaches to treatment.

[nicolefoxmtns2mtns]

Mind the Gap

When traveling in Nepal, there are a few key points you need to know before you travel on the road:

1.       You have probably driven few times in your life without a seatbelt. Ironically, you will want one more than any other time here, but there are none to be found in any vehicle.

2.       You won’t need to wait at any stoplights (there are none), but you might have a traffic jam caused by a cow sleeping in the middle of the road.

3.       Your driver knows the dimensions of his vehicle to the exact inch. You will pass huge lorries (cargo trucks) on tight turns with LITERALLY only an inch to spare (as in, the driver will stop to pull in the side mirrors to leave enough room). This happens on turns, in the middle of a four-wheel-drive road, in a manual vehicle, with your driver not even breaking a sweat.

4.       Guardrails, though needed, are nonexistent – despite thousands of feet of vertical drop on high mountain passes. Those “low shoulder” signs from the States seem laughable…..

5.       Look for the bling. If your driver doesn’t have at least one figurine on the dash, a few flashing lights, and/or a Buddha quote on the back – you should probably find another taxi.

[nicolefoxmtns2mtns]

Departure

After I graduated with my undergraduate degree, it was equally likely that I would be travelling or living abroad than not. I was incredibly fortunate to have a series of public health-related fellowships, scholarships, and jobs that took me all over Asia. From my start researching measles and neglected tropical diseases in the Philippines to Singapore, Cambodia, Viet Nam, and nearly a collective year and a half in India, preparing to set off to travel or live abroad was more the rule than the exception.

Every time a trip was set, a familiar surrealism would set in. Despite having everything in place, the nature of planning an endeavor abroad months in advance almost makes it feel like the actual time to leave will never come. You can’t sit on pins and needles of excitement every day, so you simmer your emotions on low, going about your routine with a vague trust that this dream will truly come to fruition.

Now, as I get ready to depart in just one day, the reality of taking off is starting to set in – but it almost comes more in small reminders than a grand realization. I don’t need to buy yogurt for my breakfasts next week (or for many weeks to come!); the blank spaces on my Google calendar after Thursday mean that paper, not electronics, are going to be more reliable than internet for a while. These little proofs almost cause a cognitive dissonance to the routine that my brain still expects – the trip is truly real, and it’s truly about to happen!

The biggest difference that I feel embarking on this journey is leaving my husband Tim and dog Blondie behind. Those two have been a fixture on nearly every adventure since Tim and I met six years ago, and it feels like I’m leaving without a portion of myself. As I write this, Blondie is right by my feet, knowing that the bags I’m filling mean that a big trip is coming. My greatest hope is that this trip will be the first of many to do similar health outreach projects in the future, and that Timmy can be by my side on the next one.

Off to finish packing! Will write more from Nepal.