This and That

Last night at 11:59 was the deadline for the completion of the new constitution. The government had requested another 6-month extension a few days before that, and the request was denied. A lot of people thought that they would pull something together at the last minute, but they announced last night that they had not been able to agree on the most contentious issues, and therefore the current government (known as the Constituent Assembly, or CA) is dissolved, though I think they may remain in quasi-power until the elections, which are set for November 22. What the next 6 months will look like nobody knows. And then it will be the job of the newly elected CA to write the constitution. Will it be a repeat of the last 4 years? Time will tell. For now things are reasonably quiet in the country. No protests have been reported yet. We'll see if things settle back to "normal" for awhile now, or what happens. If you're interested, here is one article that describes the situation somewhat, though I must say that news reporting in Nepal leaves something to be desired, and nobody really knows what's going on.

Life at the hospital seems to be more or less normal at the moment, with the usual volume of patients. I did have one man admitted when I was on call the other day who had been burned when he tried to drive his truck during a bandh and the protestors poured gasoline on his truck and set it on fire. Fortunately most of the burns are pretty superficial. But that's the sort of thing that happens when you break the protestors' rules. If you behave yourself they generally leave you alone. A few days ago we'd been told to be prepared for a curfew to be imposed at any time, in case things got out of hand around the constitution deadline. But that doesn't seem to have happened.

I was on call on Saturday, and had a busy day but a quiet night (which is a nice way to have it). The day started with an emergency C-section, and then we took a guy to the OR who'd had some kind of tractor accident and mashed up his hand. The resident and I worked away at it for awhile, cleaning the ends of his broken bones, cutting away dead/dirty tissue, and trying to find the ends of his tendons that had been severed. In the end I was feeling way over my head (hands are complicated!), and decided that, especially because of his high risk of infection, we should just wash, control the bleeding, splint it, keep him on antibiotics, and come back the next day with another (more experienced) surgeon to try to fix things. Which was just as well, because yesterday the other surgeon and I took him back to the OR, pinned his broken bones, and in the end decided that his tendons weren't fixable right now. So we put him back in the splint, and we'll probably send him to the leprosy hospital in Kathmandu later for a reconstruction. They are experts at tendon repairs and grafts there - they do it all the time for their leprosy patients.

Later on Saturday evening, a little 6-month-old baby came in. He had weighed 2.5 kg at birth, and weighs only 3 kg now. He'd had surgery at birth to form a colostomy because of a congenital problem that left him without an anus. Apparently he'd been doing okay (though not gaining so much weight) until 15 days ago, when he started getting sick and showing signs of bowel blockage. On further questioning, it turns out that his mother's breast milk supply hadn't been adequate, so he'd mostly been drinking buffalo milk for the last few months, which could explain his malnutrition. He was very sick when he came in - dehydrated, his belly really distended, and skin and bones. His bowel isn't completely blocked, and he certainly isn't in any condition for an operation right now - he wouldn't survive it. We are trying to get him some nutrition, but it's tough when he keeps vomiting. Things don't look too good for this little one. I pray for him every day when I go by. His young, hopeful mother, keeps looking at me and asking if it will be okay. I tell her we are trying, but that his condition is very serious, and that we need to keep praying. She nods every time I say that.

I must confess that most of the time I feel out of my comfort zone in one way or another. The language is a challenge, though thankfully there usually is someone around who can help me with translation when I get stuck. I share a lot of smiles with my patients and their families when I try to speak Nepali with them and fumble for one word or another. I'm thankful that most Nepalis are gracious and friendly, and most seem to appreciate that I try to communicate with them. Then, of course, there are more medical/surgical problems that I'm not familiar with than those that I am familiar with. It keeps me on my toes, for sure. The other day the resident and I were doing a tendon repair and pin fixation of a broken bone on another injured hand. We were both kind of fumbling our way through it. Thankfully our nurse that day has been a nurse in the OR for 23 years, and he has seen a lot of these sorts of surgeries. He basically walked us through it! It can be very unnerving to know that in a lot of the things I'm doing here, where I'm supposed to be the supervising and "in charge" physician, the nurses and the residents have more experience than I do! But if you can get over that, swallow your pride, offer the expertise and thoughts that you do have, but listen to their suggestions, it can be very rewarding. The other day I thanked the resident I'd been on call with for his help, and he said, "No, thank YOU for your teaching." I'm thinking, "Teaching? What teaching??" And I said, "Well, I teach you some things, you teach me a lot of things." To which he responded, "No, you teach like a senior doctor, the way I need to be taught. I just help you with the things I know because I've been here doing this for the last 1 1/2 years, but you have a lot to teach me." That's the kind of attitude that will make for a mutually rewarding working relationship!

I'm still taking Nepali lessons, but only once a week for a couple hours. Between studying Nepali, reading up on the many surgical things I need to read up on, building relationships here, and maintaining long-distance communication and wedding planning with my man in Mozambique, I'm being kept pretty busy. It's a bit of a roller coaster ride at times, but I'm thankful to be here, and thankful for all the prayers and support of people here and back home, without which I'm sure I wouldn't last long.

Off to the races

I'm happy to report that I had my first night on call last night, and not only did all the patients survive, but so did I! The last few weeks I've been hanging around the hospital and getting oriented, but they have had enough surgical coverage that they haven't needed me on the schedule yet, and for that I've been grateful. I've been starting to find my way around the hospital (challenge #1!), and become familiar with how things work around here. I still have plenty of questions and am figuring things out as I go, but there are enough people around who know what they're doing that I have lots of people to ask.

Photo courtesy of Paul Sherar

This week is the first week I've been slotted into the day/night schedule. I had an OR day on Monday. Did 2 laparoscopic gallbladders (known in the surgical world as lap choles), and helped another surgeon with a big burn debridement and skin graft. [By "help," I mean he taught me how to do it.] That patient is a 21-year-old girl with epilepsy who had a seizure and fell into the fire and burned her torso really badly. She'd already had one skin grafting procedure but because of very poor nutritional status and infection, the graft failed, so this was round 2. This is, unfortunately, not the first time she's been burned. Her face is badly scarred from the previous experience, which occurred when she was much younger. Sadly, burns in patients with epilepsy are not that uncommon around here.

The lap choles should have been a piece of cake. Back home, it's a favourite operation of mine. They can be challenging at times, but usually are nice and straightforward, and I can do them pretty quickly. Not here!! We do have a laparoscopic set-up, which is attached to a TV screen that always has that "popcorn" kind of appearance to it. Visualization is not great at the best of times. The equipment works...sometimes. If the electricity shuts off partway through then you really have fun! And even if it doesn't it always seems like something isn't working. It's been pretty warm lately (in the low 30's celcius) and humid, and I was sweating buckets in the OR, and I was also getting really frustrated because I couldn't see and I couldn't figure out why I couldn't see. Was it because I wasn't exposing it properly for myself? Was my assistant not retracting properly? Was my other assistant doing something wrong with the camera? Or was there something wrong with the camera itself? Or all of the above? I don't know, but it was not easy! And then just as I was finishing the second case, taking the gallbladder out of the abdomen, I spilled a whole pile of stones and had to make a bigger incision to get them out. Sigh! That evening I was exhausted, and the next day I was sore all over!

Photo courtesy of Paul Sherar

Then yesterday I was in the surgical outpatient clinic. Thankfully (for me), with the ongoing bandhs, the clinic was very quiet. That gave me time to figure things out as I went. With almost every patient there was some kind of issue that I needed to ask someone about. Either I had a question about how we do things around here, so had to make a phone call or run over to the minor OR where another surgeon was hanging out, or I was struggling to figure out what to do with the medical problem I was confronted with, or just how to interpret the X-Ray I was looking at. There was lots of orthopedics and urology, and very little "general surgery" as I know it. Add to that the fact that I was trying to do all this in Nepali, and we'll just say I wasn't moving very efficiently. The clinic aide was getting impatient with me - I could tell. And then at one point he said, "Doctor, you know it's okay today because of the bandh but usually there are a lot more patients than this and you have to go faster." Easy for him to say! I smiled and said I would try, and in my mind just told myself that it has to be okay for me to be slow for awhile, because it's just the way it is. I'll get faster, but there's a lot I'm figuring out as I go. I had decided when I woke up yesterday morning that I would choose an attitude of thankfulness yesterday, so I thanked God that because there was a bandh it gave me the time I needed to figure things out.

As mentioned, last night was my first night on call. I was nervous, but it was good to finally get started. The more you delay things the more nervous you get sometimes. Best to get on with it. Things went well, overall. I dealt with several things that I'd never dealt with before. Sometimes I'm not sure if I'm teaching the resident or if the resident (who has been working on this service for the past 1 1/2 years) is teaching me! A bit of both, I'd say. And that's just fine. The night started with an appendectomy for a guy with a ruptured appendix - something I know how to do!! Good start. Then we had a guy who'd fallen from a ladder and had injured his urethra. He was passing lots of blood but no urine, and his bladder was getting fuller and fuller. So I took him to the OR and put in a catheter into his bladder through his abdomen (not wanting to make the urethral injury worse). Not a hard procedure, but a new one for me. The resident, who had done it several times, taught me how!

Then we got called to the ER for a man who they said had dislocated his jaw. Great! I have NO idea how to handle that! I went to see the guy and looked at his X-Rays (which I couldn't make heads or tails of). But I looked at him, and thought to myself, "He looks awfully stiff!" I tried to get him to sit up, and he was rigid as a board all over. His jaw didn't really look dislocated (not that I really know what that looks like) - his teeth were just kind of clenched in this funny sort of way. I've never seen or dealt with a case of tetanus before, but I started wondering if that was what we were dealing with and not a jaw dislocation at all. On further questioning, sure enough, he'd cut his finger a few weeks ago, and while it didn't look terribly infected, it could certainly have been the source. We asked the medical (as opposed to surgical) docs to take a look, and they agreed...so he is now being treated for tetanus and we don't think his jaw is really dislocated.

We dealt with several orthopedic injuries, including a compound fracture (where the bone is exposed), but all of them we just temporized and did the initial assessment and care and left for our very capable orthopedic surgeon to deal with in the morning. Thank God we have one! And then there was a lady who'd had a baby a few weeks ago who had stopped breastfeeding on the one side because her baby didn't seem to like feeding from that breast. She showed up with that side about 4 times the side of the other, and when I stuck a needle into it today, I drained a lot of milk out. 

This morning there was a 6-year-old kid with a swollen calf, which my clever resident stuck a needle into and found pus. Pyomyositis, or pus in muscle (which I'd never heard of before), is apparently not that uncommon here. I took him to the OR and drained the pus. He should feel better soon.

The political situation remains tense here. Things are open here in Tansen now, after being closed for days, but there are still a lot of demonstrations going on all over the country, and in the southern part of the country there are still very strict strikes going on. Apparently the government has requested another 3-month extension on the constitution deadline, but the supreme court has said no. The problem is that because there is no constitution, nobody even really knows who is in charge, so we'll see who ends up winning the argument. And so it continues! I know a lot of people are praying for Nepal right now, and so we wait and see what happens. In the meantime, some supplies at the hospital are getting slim, and the number of patients who actually come to hospital is also significantly less than usual. Not a bad thing for me right now as I figure things out, perhaps, but not so good for the people of Nepal.

Life is crazy in Nepal

These days, there seems to be no such thing as "business as usual" in Nepal. Maybe that's always the case, but it's crazy right now! May 28 is the deadline for the government to finalize a new constitution for the country. They have been working on it since the middle of the last decade, when Nepal became a republic (democracy) instead of a monarchy. There have been numerous previous deadlines for its finalization, but they have never been met. There have been 6-month extensions, 1-year extensions, and it just seems to keep going. I was actually in Nepal for the previous deadline - Nov 28. At that time they extended it for another 6 months (which, as a side note, means that I have now been in Nepal for 6 months...to the day, today, actually), and said that if it was not completed by that time, a new government would have to be formed.

It was looking promising...sort of. One of the biggest issues had to do with getting former Maoist soldiers rehabilitated, and steps have been made in that direction. But there are SO many parties, with SO many demands, and it's getting more and more ugly as the deadline approaches. Nepal needs a miracle.

What do I mean by ugly? Well, as you've all probably gathered by now, the main method of protest in Nepal is to call a bandh, or strike. Pretty much anyone can call a bandh, and they decide how far-reaching it will be, and how strictly it will be enforced. These days there are bandhs happening everywhere, it seems. In the far west region of Nepal, the poorest, most remote part, they are currently on day 20, I believe, of a very strict one. Everything is shut down - the roads, the schools, the businesses. The situation out there is getting rather desperate for people...increasing food and fuel shortage, and just general misery, probably. Usually when a bandh is declared it is given a time frame. This one is indefinite, and there seems to be no sign of it letting up any time soon.

There have been a couple of nationwide bandhs where everything across the country is shut down, and they have been enforced quite strictly - more strictly than usual. Apparently starting tomorrow there is an indefinite nationwide bandh starting. Who knows what that means? In the Terai (the flat, southern part of Nepal that borders India), there has been one going on for quite some time. For people coming in and out of Tansen, travel through the Terai is usually necessary, though usually you can take a detour around it and go through Pokhara instead (adds an extra 4 hours to the drive). But now there's also a strict bandh in Pokhara. So we actually have some people who are sort of stranded here right now. One of our residents did manage to make it back from Pokhara to Tansen last night - but only because he travelled at night. You can imagine that nighttime travel has its own dangers, when you're driving along these narrow, winding mountain roads with no guardrail!

Our patients are affected. We have discharged some from hospital, but they can't leave because they can't get home. Or they have to stay in a "hotel" here in Tansen. Patients who are already in financial hardship because of their hospitalization...hospital bills, plus they are missing their income because they're not working...now are even more so, because they have to keep paying for lodging and food here, and still can't work.

I wasn't directly involved in any of these cases, but I'm told that yesterday 2 patients who came to the ER were dead on arrival, and another died shortly after arrival. That happens sometimes...but we all wonder if it has to do with the fact that people are waiting longer to come to the hospital because they don't know if they can safely get here. And we're concerned we may see more and more of this over the next few weeks. Yesterday in clinic we didn't know what to tell people about when to come back for follow up or test results. Usually pathology reports (which come from Kathmandu) are available within a month, but who knows when they will be available under these circumstances. Dr Doug, one of the other surgeons here, started telling people to come back for follow-up after the constitution was written. We all laughed at that one...will they EVER come back?

Usually ambulances and hospital vehicles can get through the bandhs okay, but I heard of an ambulance (carrying a patient in it) being vandalized somewhere down in the Terai the other day. Some friends who did manage to make it from Kathmandu to Tansen the other day (but are now stranded here for the time being - they were supposed to leave today) said that there are roadblocks (trees, rocks, stones, and lots of people) all along the way. They did let the hospital vehicle pass through them that day, but it sure took awhile to clear the block so they could even get through. I'm told the hospital vehicle didn't leave for Kathmandu today as it usually does on Wednesdays.

Here at the hospital we see the impact of all this on our patients and their families. And on people trying to get here or get out of here. But we don't (at least at this point) have any concern for our own safety, thankfully. But Nepal is suffering right now, for sure, and whether these demonstrations will accomplish anything or not remains to be seen. At this point they are accomplishing a lot of hardship and difficulty for the people of Nepal. Will they have an impact on the decision-making process? Time will tell. And what will things be like after May 28? If the constitution deadline is NOT met, what will happen? And even if it IS met, there is sure to be ongoing discontent. It may be a rocky ride for awhile.

Please pray for this nation, that God would move the mountains, and establish righteousness and justice as its foundation. Pray for protection and peace for all those who are affected by all that is going on. It all seems impossible, but we also know that God can do the impossible. So we look to Him.

First Day

Finally, I don't feel like I'm lying in my blog header anymore! Today I spent my first day in the hospital, and I now really am a General Surgeon serving in Nepal. Although this first week or so I'm mostly just hanging out with one of the other surgeons working here...they kindly haven't put me on my own QUITE yet.

I apologize in advance if this post is too "medical" for some of you. They won't all be like this!

It was a pretty straight-forward day. Started with team handover and morning report, which happens every morning at 7:45. The interns and residents give a summary of what's happened in the hospital over the last 24 hours, so that we all have an idea of what's going on. Then we made ward rounds. I'm not sure how many patients we saw, but there was certainly a range of problems. There was a baby with burns on the leg but who can't get a skin graft until her diarrhea settles down (risk of infecting the graft). There is a woman with a badly burned right side whose skin graft isn't taking very well. They are the only 2 burn patients in the hospital right now. Apparently there were several more last week, but all the others were getting so sick that their families just took them home to die. Such is life in Nepal.

There was someone recovering from surgery for an upper GI bleed, a man with a chest tube in each side for bilateral pneumothoraces (collapsed lungs) after a fall, another man in a halo because of a C-spine injury (who is actually recovering some of his extremity movement, and has been here for 4 weeks already and hasn't developed a bedsore, thanks to good nursing care and a fancy mattress with air pockets that inflate and deflate at different times to constantly redistribute his weight), a young boy recovering from surgery for a ruptured bladder and urethra after a fall, someone else with a hip fracture in traction, a man with some kind of immunodeficiency with multiple chest wall and back abscesses, a pancreatitis, someone else being monitored for a head injury after a fall, a couple postop patients who had ureteral stones (in the tube connecting the kidney and the bladder) removed, a kid with Henoch-Schonlein Purpura with a possible hydrocele, and a bunch of other things that I can't think of right now

Oh, and there was one post-op appendectomy patient. Fairly routine for a general surgeon, but the sweet part of this story is that the 2nd-year family practice house officer (kind of like a resident) who is hoping to get into a surgical residency, was telling us the story, and beaming from ear to ear because he had done the appendectomy skin-to-skin himself (with the staff orthopedic surgeon, who was the one on call that night, just standing closeby). He had done a great job, and he was thrilled. It was neat to see how visibly excited he was. Makes me excited about the teaching component of my job here.

Before the OR starts, we have our all-important chiya (tea) break in the hospital canteen. Today I had chiya and samosas. The OR started around 10:00 or so. I basically joined another surgeon for his OR day, but we split the cases. For my first day I got a couple of easy things...removing a small mass (looks benign) off the shoulder of a 9-year-old girl, and a straightforward inguinal (groin) hernia repair. For you surgically minded out there, yes, we have prolene mesh here, and I used it and did essentially a lichtenstein repair under spinal anesthesia. For the rest of you, you don't care...sorry! Prolene mesh is pretty cheap (less than $10 for a large piece...you cut a piece out of it to get the size you want, and then the rest gets resterilized and used on the next several patients, too). We also have a good variety of suture materials...all the ones I'm used to working with at home, so that's great. Gloves without holes in them get removed, sterilized, and reused. And, of course, we have cloth drapes. There is one doctor (Nepali) who has some anaesthesia training, and another one in training at the moment, and there are nurse anaesthetic technicians. We can do both general and local/regional anaesthesia here.

The last case of the day I did together with the other surgeon. It was a bit complicated. Looked like some kind of abscess (pocket of infection) inside the abdomen, but we couldn't tell from the ultrasound what it was or where it was coming from (Yes, we have ultrasound here. No CT, of course). Turns out, in the end, we're pretty sure it was his gallbladder. It was HUGE, and full of stones and really (sorry) foul-smelling pus. And it was stuck to everything...the colon, the duodenum, the liver, etc. We worked in there for quite awhile, and eventually opted to just remove a portion of the gallbladder (the part we'd managed to free from everything else), and then stick a few drains in and quit before we did something really bad (like perforate his duodenum) while trying to do something good (like take out his gallbladder). So that one was a bit of a challenge, but at least it was very much within the realm of what I'm used to...i.e. operating inside the abdomen!

I had an intern with me, and she assisted and closed the skin at the end and did a great job. As I mentioned, I am excited about teaching here, though I will still be learning a lot at the same time. I do believe that's what I've been brought up to believe a doctor should be...both a student and a teacher at the same time. So I guess that's okay.

I was happy to discover that I have not forgotten how to operate...nor have I lost my love of surgery and medicine. I had been starting to wonder after almost 6 months of not being in the hospital how I'd feel being back, but I feel very much at home...at the same time as this is all very new and will be for quite some time.

Tansen Home

As promised, here is a tour of my home here in Tansen.

The kitchen is the first room you come to when you walk in. I spent quite a bit of time after I first arrived trying to figure out the stove. I didn't realize that you need a lighter to light it, and I was wondering why I kept turning the knob and no flame came...and why the kitchen was smelling more and more like gas! I eventually figured it out.

Next is the bathroom - my least favourite room of the house. Water shortage is a big issue here, so you do everything you can to conserve water. Thus, there is a bucket under the sink, and the water in the sink drains into it. You also stand in a bucket to shower, so that you can collect the water you use. The final common pathway? The toilet. Yes, it's true that there is no back to the toilet, and that it appears to be smack in the middle of the floor. And there is no flushing mechanism, other than pouring water down it. 

As for the shower, it took me quite awhile to figure it out. There is an electric water heater, which works when there is proper electricity (and not just generator electricity). There hasn't been proper power the last couple days, so yesterday I skipped the shower, and today I opted for a cold one. The first day, there was electricity, so I turned on the heater about 30 minutes before shower time. Then it took me a good 10 minutes to figure out which knob you turn to get the hot water, which one gets you cold water, and which one makes it come out of the shower. And then getting the balance between hot and cold was quite a challenge, so I decided I might be best off just leaving the hot and cold knobs exactly as they were and just turning off the shower. Bad idea, as it turns out. A few minutes later I could hear the sound of running water, but assumed it was the guy next door showering. About 30 minutes later, someone knocked on my door and informed that that water was pouring off my roof. He came in and promptly closed the knobs that I had left open, and that solved the problem. I guess I'll be fighting with hot/cold issues every day.I think I would like the bathroom much more if there was a shower curtain. The problem is that Nepalis don't use them. Few even have indoor showers (most shower outside at a local public tap, or they do bucket baths), and those that do have showers don't seem to mind that the entire bathroom gets wet when they use it. So despite my best efforts to find a shower curtain in the Tansen bazaar yesterday, there was none to be found. Fortunately there is a couple I know coming for a visit next week from Kathmandu, and they have kindly agreed to buy one for me and bring it along.

 I really like the living room, but I really DON'T like the "couch" at the moment. It is a bench with a really old, ratty piece of foam on it, and a ratty piece of cloth covering it. I'll be replacing both the foam and the cover, which will make it more comfortable, and more colour-coordinated.

There are two bedrooms, both quite spacious and with good amounts of storage space. Feel free to come for a visit if you're in the area!

 This is the house from the outside

 If you turn 180 degrees from where I was standing to take the outside house photo, you can see the hospital.  It won't be too far for me to go if I get called in in the middle of the night!

Phul Kumari is my wonderful house helper. Daily life takes a lot more work in a place like Nepal than it does back home. Laundry is done by hand, cooking is always from scratch, groceries are purchased daily at the market or little shops, and there are other things too that make it pretty much impossible to both work full-time and keep house. Phul Kumari works for me two days a week, and is doing a great job so far. She cooks both Nepali and some western dishes, and is lovely to have around. She also is great for practicing Nepali with.

Goodbye Kathmandu - Hello Tansen!

Hi from Tansen! I have waited for several months to be able to say that, and now here I finally am. I arrived on May 1, and have been spending the last couple days unpacking, sorting, and working on getting settled into my new house here on the hospital compound. Once I am fully sorted, I will give a blog-tour of the new place and the compound. But I'm not quite there yet.

The drive from Kathmandu to Tansen is about 10 hours long, on a good day. "Good day" means that the roads are in good condition (no potholes from the monsoons), there is no landslide or road traffic accident blocking the road, and no political demonstrations going on to slow things down. Thankfully, the road was in reasonable condition, and there were no obstacles along the way, so we got here in good time. I'm told the roads get really bad in monsoon season, which will start in another month or so. Then we'll see.

Usually hospital staff take the hospital vehicle, known as "the Buck" because it is a cross between a bus and a truck (seating in the front, storage in the back) to and from Tansen. The Buck goes to Kathmandu from Tansen every Wednesday and comes back to Tansen every Thursday. We didn't take the Buck this time, because it was a Tuesday.

There are 3 stages to the drive. The first, which takes about 2 hours, is just getting out of the Kathmandu valley. It's not that the distance is all that great, but there is usually a lot of traffic and it's slow-going. The roads are quite windy at that stage, but because you're going so slowly you don't notice it too much. Once you finally get out of the valley, you suddenly realize you can breathe again (much less smog and pollution), and the road becomes quite flat and straight for the following several hours. This is because you are driving through the Terai, the flat land that is in the south of Nepal (as opposed to the foothills in the middle, and the mountains in the north). After about 6 hours of driving along that road, you pass under the "Welcome to Palpa" arch (Palpa is the district that Tansen is in), and then begins the uphill climb to Tansen.

That climb takes about 2 hours, and it is really the most hair-raising part of the trip, and the time you're most likely to get sick! Though I have to say that going down is worse than going up. The road is narrow and windy, and there really isn't enough room for 2 directions of traffic, but they sure try. There is a steep drop on one side of the road, and no guardrail. Once or twice a month, there is a major road traffic accident with multiple victims that end up needing treatment at the hospital here, and that can be quite a challenge! I will certainly blog about it when that happens. And ongoing prayer for safety would be much appreciated!

Thankfully our drive was uneventful, and we arrived in good time. Almost all my stuff was already here waiting for me in my house when I arrived, as I had sent it on the big hospital vehicle last week. As I said, stay tuned for more details about the place.

The last couple weeks in Kathmandu were good. I spent a final weekend at the Children's Home, where we had a party, complete with chocolate, cream donuts and Coke/Sprite/Fanta, and said our good-byes. I will still see them when I visit Kathmandu, and Paul and I are planning on having a wedding celebration there, Nepali-style, when we come back to Nepal in December. But I will certainly miss the times I had with them there...my big Nepali family!

I also enjoyed a final dinner with my landlady and her family. They have been hosting bideshis for over 25 years, and I enjoyed spending time with them and getting to know them a little bit during my time in Kathmandu. In case you're wondering, the Nepali custom is NOT to smile when having your photo taken. I don't think I plan to adopt that custom as my own!

I now have my wedding dress all designed and ordered, and it is being made for me in Kathmandu. Obviously I won't share any of the details about the dress, but I did think you might be interested in the name of the shop :)