Saturday, June 26th

Alrighty, so, Saturday morning, I met up with a couple of other volunteers and we headed out to Boudhanath, Kathmandu, which is the site of one of the world's largest Buddhist Stupa, which according to Wikipedia is, 


" a mound-like structure containing Buddhist relics, typically the remains of a Buddha or saint, used by Buddhists as a place of worship."


It is quite and amazing feature of Nepal. It is a few levels more grand than the Swayambhunath Stupa (monkey temple), I believe. The whole area is one of the major areas of settlement for Tibetan refugees looking for a place where they can practice their religion freely, and as such, over fifty monasteries have grown in this area scattered around the back alleys or in the central area itself. For several hours, as a group, we explored the area. There were a couple of monasteries that we specifically wanted to visit, and then a couple that we stumbled upon. My favorite, however, was definitely Shechen Monastery. It was one of the largest ones that we visited, yet it was the quietest of them all. It was really nice. I will post pictures later. 

Shechen Monastery

We headed back to Thamel to get lunch and relax for a moment before a couple of us headed out to Shivapuri National Park on the outskirts of Kathmandu.
We proceeded to climb a road and staircase to nowhere up the mountain before giving up and coming back down, but I got some great shots of the valley from the mountain. Pictures to come. 

After that, I headed out to Kupondole to have dinner with Yuyutsu Sharma, and his son and daughter. For those of you who don't know, Yuyu is a Nepalese writer/poet, who has had many works translated into other languages and translates other works into Nepali. He came to UC Davis a couple of months ago to conduct a poetry reading and a workshop. I luckily saw his flyer one day going up the elevator at Sproul Hall, and jumped at the opportunity to meet the guy. He is an amazing friend and resource. 


Because of him, I have a lot of amazing things planned for my trip. Some of which include:


1. Staying an evening with a Swami, who lived at the top of one of the mountains in Shivapuri National Park for several years, and now teaches in the village at the bottom of the mountain.
2. Meeting with a Tamang Shaman who runs a shaman clinic in Boudhnath. 
3. A Walk through the slums along the Bagmati River in Kathmandu. 
4. Attending a book release this coming week, where I will also be reading one of Yuyu's poems in Nepali and English as part of the program, where the Israeli Ambassador will be attending. 


Well that's it for Saturday. New post for Sunday will be up soon. Took a day to trek to a couple of the most beautiful temples in the Kathmandu Valley.


Hermes

The Week

This post is going to be organized by days this week.

Monday, June 21st

A lot of new people came to the hospital today. We got 2 new volunteers from the organization that I'm here with. Both of them are living with me and Veronica at Damu's place. Julia, from France, and Mark, from Ireland. They are both very pleasant people and are great fun. 

Also, with the departure of the last two physiotherapy students from Kathmandu College, three new have arrived on their last rotations of Physical Therapy school! They are a bunch of great guys, and they all have a lot of teach and have such a strong will to learn. It's really good, and I'm enjoying the new energy a lot!

Wednesday, June 23rd

This was a great day at the hospital, perfect for my birthday, haha. I was bored at the hospital in the morning, so I played with the kids in the play/education room for a while and ended up making origami balls/balloons. You know, the kind that you would blow up after you do all the folding, yeah? and I came to think...

Dude, this origami stuff would be great for post-burn contraction patients who are affected in the hands and arms to regain fine motor movements of the fingers and hands. Not only that, but it'd be great for any of the kids to learn and fine tune their memory and get their fingers and brains moving. I'm going to test the origami therapy on a patient who recently got surgery to release a couple of his fingers from a post-burn contraction. I'm going to challenge him, once he's ready, to make an origami ball using only his thumb and his affected fingers.

And you guys, the "origami therapy" only gets better...stay tuned.

So today, Shyam, one of the most senior physiotherapists, will start letting me work with patients 1-on-1 with their in-bed exercises. More on that later. I have also started working with one of the student physiotherapists, Sudan, with his patients as well. We have been collaborating on his patients to refine and keep excellent progress notes on those patients. Which brings us to the second half of the "origami therapy" idea...

This specific patient that we are working with, let's call her sally, recently underwent major spinal surgery, and in addition to her physical exercises, must work on her breathing as well. As many of you may know, post-surgical patients are often given spirometers for this purpose. This patient, however, didn't want to do these exercises, so I came up with the idea to make a series of origami paper balls in a variety of volumes and used different paper thicknesses to create levels of increasing difficulty for the patient to blow up the ball. This idea is really only being used with this patient right now, and is super quantitative, so we are still using the spirometer every couple of days to qualitatively measure the lung capacity and strength, but I think I may have stumbled upon something interesting......

Today, my responsibility with Ponseti method assistance also increased, and some of the other physiotherapists have begun to trust me with assisting them with patients and allowing me to do more of the casting. Hopefully in the next two weeks they will begin to teach me specifically how to adjust the patients' feet.

Besides all that, it was my birthday, so everyone at the house skipped the usual Dal Bhaat dinner and went out for some food on the town. I ended up having some chili buff momo's, butter chicken, lassi, and naan. It was a quiet birthday, not bad, not bad.

Friday, June 25th

I arrived back in Kathmandu on Friday afternoon after a quiet half-day at the hospital. I was excited to be able to update my blog with lots of new pictures, but not too excited about the exorbitant amount of foreigners and smog, but whatever.

Friday night was chill, I just went clubbing with some of the other volunteers. Nepali clubbing is always an experience.

Saturday, June 26th

Saturday deserves a better post, but I am really tired right now, so I will leave it at that for now.

Satuday
Bouda
Shivapuri
Dinner

Last Resort

160 meter (465 feet) jump off a suspension bridge into a gorge? check.

Abseiling down 7 waterfalls, the largest of which was 50 meters (164 feet)? check.

Kids

This post is going to continue from Tuesday, but not in the form that I wrote it last.

The place that I'm staying is like a 6 story building. I don't quite remember how many stories, but I'm definitely on the top floor. From the building you can see all sides of Banepa, and if you look out back you see the outskirts of the town, some wonderful hills, and a school.

Adjacent to this school is like a vacant dirt lot. It is surrounded by little agricultural plots, and its kind of dusty and has random bricks all over the place. Everyday, however, you can see a large group of kids from the school playing soccer and cricket on this plot, and I thought, "dude, it's hella early in the evening, and we've got some time before dinner, let's go join some World Cup fever and play some football with these kids!"
So I got Veronica and Asim, and we figured out how to get back there and met the kids.

These kids are amazing at football. 'nuff said. They are like 6-10 years old and run through your legs. Yivraj is the pack leader, he's really good at English and Hindi, not to mention Nepali of course, he is kind of the main mediator between us and the kids. Saabin is the superstar team player, dude this kid is amazing, he dribbles like no other, but never takes a shot, he'll always end up assisting the goal even though he did all the work. Raajun is the scorer, always ready to make the shot. Sonam is the quiet girl with the pixie haircut who stands to the side, but will smile and wave at you timidly; she'll even bowl a ball in cricket once in a while.

The hospital is going well. I've been able to teach the physiotherapists here how to stretch a lot of different muscles in the body, and the educational exchange continues. I'm really glad, and I'm getting to know the kids really well, and I'm seeing a lot of crazy cases.

We were supposed to watch the Switzerland - Germany game last night, but the power went out just past dinner, but dude the Swiss won! Hella awesome.

Heading back to Kathmandu tomorrow after work. Will be doing some exciting fun stuff this weekend that you'll hear about on Sunday or Monday.

Ponseti

Today (Tuesday) was the start of an amazing educational experience. Today's post will be more like a recap of the day with some extra commentary on the side.

Note about pictures: I tried to upload some last night, but the computer here gave my memory card a virus, so I had to format my card and lose all the pictures that I had taken from Sunday afternoon onward, which is fine because I can retake most of them as they were of scenery in the area. I will upload them this weekend when I have WiFi in Kathmandu.

6:30am: Woke-Up, showered, got dressed, retook pictures from around the area from rooftop

7:30am: Ate breakfast, chatted with my roommates Veronica (from Australia) and Asim (from England)

8:30am: Left for HRDC

9:00am: Arrive at HRDC, and begin work

Tuesdays and Wednesdays are surgery days at the Hospital and Rehab Center for Disabled Children (HRDC), so really the only thing happening all day is surgery and PT for inpatients. No new patients are admitted or seen. To see surgeries, I have to choose a specific patient and write-up a patient history and summary of the diagnosis and evaluation in order to observe their surgery. I will probably begin that tomorrow.

So, for most of the morning I assisted with the casting of the children receiving Clubfoot treatment via the Ponseti Method.

The HRDC here in Banepa is the #2 hospital in the world for patients seen with Clubfoot with about approximately 400 cases a year. Clubfoot is a congenital condition that is characterized by 3 main aspects. Inversion of the subtalar joint, Adduction at the talonavicular joint, and Equinus of the ankle joint. If untreated, it becomes and amazingly gross deformity in older children and adults.

The Ponseti Method is a standard treatment for this malformation that was developed in the 50s that recently became popular again in early 2000. The treatment uses a series of plaster casts over several weeks to manually correct the position of the foot. It has a very high success rate (~90%) if done early (typically before age 2) and if done correctly. The method may be applied to children up to 10 years of age, although they may require more casts and possibly surgery, although it is quite common to do surgery in infants as well. The surgery is a minor heel release of the flexor digitorum longus and tibialis posterior to fix the equinus, which is an inability to dorsiflex the ankle.

Anyway, back to my experience. Since it was my first time, I assisted by helping to hold down the patients, so that the cast could be applied correctly on the affected leg. Often times, the patients have bilateral clubfoot, so they requite two full leg length casts. The casts remain on the children for about 6 days before the foot is further realigned and a new cast is reapplied. This continues for at least 5 weeks.

After a couple of times observing while helping to restrain, I switched places with Veronica, and directly assisted the physical therapist on the leg to casted. This involved holding the leg in the correct position while pulling on the first digit to help lengthen the tendons that run down the calf and into the foot that assists in dorsi flexion and some eversion.

After taking a quick break, Damu, the physical therapist that I am staying with, allowed me to apply the last layer of a quick cast to one of his patients. The material that we are using is a quick set plaster of Paris quick casting tape roll. Fellow student athletic trainers, if you have seen Hoagie apply a synthetic dynacast to an athlete this is basically the same stuff but 10x cheaper and doesn't stain your skin since it is just dried plaster of Paris (that is reactivated by warm water) on a cloth mesh (sort of like stretchy tape material without the adhesive). The wrapping of the last layer, smoothing, and molding it out, is similar to wrapping an ACE wrap around a sprained ankle, except that it goes around the entire leg.

After the pre-layer, cotton, and first layer of casting is applied, the foot is manually adjusted. This is when the crying starts because the the manual adjustment HURTS.

Damu said that by the end of my 6 weeks, I should be able to apply an entire cast from start to finish on my own.

12:30pm: Lunch

Today we didn't eat at the hospital. Instead, Veronica, Lydia (of Switzerland), and Prakash went to a stand outside of the hospital and ate stir fried noodles. It was pretty good. Cheaper than the hospital food too. Prakash explained to us a lot of information about the ethnic groups and castes of Nepal.

1:30pm: Retun to Work

The other physical therapist that I'm getting to know pretty well, Anu, was complaining of her neck being really tight, so I offered to stretch it for her (go Team ATR), and she had never learned how to stretch the neck before, and neither had Prakash. I did the whole "Talk to your armpit, Listen to your armpit" Spiel. I stretched some necks and helped the PTs to practice, and they loved it. I'm going to check if they remembered how to do it correctly tomorrow. We also talked about back mobilizations, and it was a great educational exchange between myself as a student athletic trainer, and the PTs who were students themselves, as they are finishing up their clinical rotations for their certification in physical therapy (a 3 year prerequisite to entering a 3 year BS degree).

2:00pm: Post-surgical patient physiotherapy department follow-up and evaluation

3:30pm: Depart HRDC

Banepa.

Sunday afternoon, with Shanika, one of the Projects Abroad staff, took me out on the Arniko Highway to Banepa. This dusty little town on the way to Tibet.

I'll have pictures of the trip from Kathmandu up later, but we went from 4000feet to 4800feet, and we're way in the hills. It is quite beautiful.

I'm staying at the place of a physical therapist who works at my placement. His name is Damu, and he is a wonderful guy, so pleasant and open. His wife is absolutely lovely as well, she works as a peace officer throughout the country. They are both such wonderful people and wonderful resources here in Nepal.

We stopped by the hospital that I'm working at as well, just to drop off some stuff, I didn't start working until the day after, but it was kind of a shock to see the patients. HRDC is the Hospital and Rehabilitation Center for Disabled Children. It is a mostly American and Swiss funded hospital that specializes in orthopedic pediatric ailments. The hospital itself is very well organized and actually has a department that does community based rehabilitation where they have divided the country into several districts and operate mobile camps and satellite campuses to conduct rehab where the patients can't make it to Banepa for treatment. It is quite the amazing hospital

It is the building on top of this hill.

The first day of work was great. I got to see so many different things. These were problems that you would never see in the United States, I didn't really even know what to make of them. Some of the most common things that are seen at HRDC are clubfoot, athrocryphosis multiplex congenital, osteomylelitis related problems, and polio, among many others. HRDC is also the only hospital in Nepal to conduct the Ponseti method of clubfoot treatment, which I will explain here if any of you want me to, but otherwise read it here.
http://en.wikipedia.org/wiki/Ponseti_method

Oh, by the way, this hospital, for orthopedic injuries, is on top of a freakin' hill. A huge hill. I'll have pictures of those later, and the 20 minute hike I have to climb up everyday along the rice paddies and terrace farms.

These patients are often seen quite late because of many reasons, some because of lack of money, others because lack of mobility. For a developing country whose major geographic element is the mountain, I can only leave you guys to imagine what that's like for healthcare access in this nation.

There is one patient who I have begun to really connect with, and she makes me want to learn the language more, so I can understand more of what the doctors and physical therapists are saying. She has the most beautiful smile and pleasant demeanor. She's from a super rural village in the northeastern part of the country and has been in this hospital in and out since she was 5 years old. She hasn't been back to her village since she was 5 and only sees her parents once a year. She has been in a boarding school in Kathmandu while simultaneously getting treatment at the hospital. When she was younger she had a chunk of her leg removed due to a bone infection (osteomyelitis), and now that she has finished growing, they put her through surgery to insert a leg lengthening device to spur osteogenesis over a course of 3 months in attempt to lengthen her leg by 10 centimeters. She is so amazing. She is also an amazing example of the diversity of people in Nepal, she is of Sherpa ethnicity, and has strikingly East Asian features, but is just part of a massive spectrum of East and South Asian features of the people here. It is quite beautiful to see such a melding of people, cultures, and religions in this country. In some ways it's almost a natural melting pot, unlike the United States, which has developed its heterogeneous population through immigration.
More on her later.

I spent today in the out patient department, the physiotherapy room, and the ward where the inpatients are. I really enjoyed my first day and I look forward to delving deeper into the workings of this hospital and its people.

If there's anyone you guys want me to write about here, and clarify, I would be more than willing to look up the information and have a separate post for it. It would give me more ability to tell you about cases, anonymously of course, where I see it happening here in real people.