March 2014 - Newsletter

This year-s NYSORA Asia was a smashing success! The first leg of the NYSORA Asia mission took place at the beautiful Yak and Yeti Hotel in Kathmandu, Nepal. Delegates from Nepal and surrounding regions flocked to the meeting seeking fresh knowledge from our international group of speakers, hailing from Australia, Belgium, Nepal, Singapore, Spain, Switzerland, and the USA. We are very thankful for Francis and Peggy Kwong of PING Healthcare for spearheading this highly beneficial endeavor.

Group photo from NYSORA Asia - Kathmandu, March 2014.

Currently in its 8th year, NYSORA Asia has held symposiums with unmatched educational value throughout Asia. To date NYSORA-Asia has provided didactic and hands-on training to over 2000 anesthetists in underserved areas in Asia. As with most NYSORA Asia symposium, we were able to sponsor many delegates with our ESOP (Educational Scholarship Outreach Program). We would like to acknowledge Pacira for their generous support to NYSORA's ESOP Scholarship Program. During our time in Kathmandu, many delegates were given an opportunity to have their first hands-on experience with Ultrasound guided techniques. Thanks to a generous support by EZono, NYSORA was able to donate an Ezono Ultrasound machine to the hospital of Dr. Bishwas Pradhan, our local host in Nepal. We received this note from Dr. Pradham in response to the donation:

"The donated USG machine is being used extensively. Our team is now more confident with nerve blocks and feel that the workshop has really changed the practice of regional anesthesia in our region."

This year's program included simultaneous sessions for delegates new to Ultrasound guided techniques, and smaller sessions for delegates who required advanced knowledge. The extensive planning and work put forth by PING Healthcare and Dr. Pradham helped shape Kathmandu to be one of the most successful NYSORA Asia endeavors to date. We look forward to the next NYSORA Asia symposium in Taipei, Taiwan next year.

Local Nepalese Delegates using a USG on a live model.	Q & A with the NYSORA Speakers
Dr Bishwas Pradham gives the opening speach at NYSORA K2 Mission in Katmandu.	NYSORA Asia in beauty of the Yak and Yeti hotel

Photography Credits: Mirza Ceho and Admir Hadzic

It was March 3rd 2014, 11pm when the wheels of Malaysia Airline flight 432 squealed and landed on the runway of Tribhuvan International Airport in Kathmandu. While all of the correspondance of the NYSORA international team, with the Nepalese Society of Anesthesiologists, were auspicious of a great educational outreach program, the chilled air laden with opulent smoke and frenzy at the immigration desk were not so foretelling of the an amazing journey ahead. It took about an hour to negotiate through immigration, discard grievances of baggage, lost in transit, and follow the taxi driver with the familiar NYSORA logo on his sign. Once in taxi, the mild mannered, kind smiles and demeanor of the driver started giving hints of what a beautiful country and people we were about to meet and befriend.

The drive through the unlit streets of Kathmandu from the airport to the Yak and Yeti hotel in the wee hours were filled with people preparing for the Shiva festival during upcoming weekend. Both sides of the streets were lit with fire, keepings residents warm while shining light on wares for the street vendors.

Early morning on the outskirts of Kathmandu

The unfortunate pollution of Katmandu is partly do to roadside fires, often involved burning plastic waste.

As we plowed into the hotel we were greeted by uniquely hospitable guards and hotel clerks. A message from the Vice President of the Society, Bishwas, warmed us up and we knew our educational mission was going to be a smashing success.

Bishwas Pradham, Francis Kwong, Admir Hadzic and PeggyKwong

Kathmandu and the Kathmandu Valley

During our first day in Kathmandu we made short excursions to the town to sightsee and enjoy local cuisine. For those who may be venturing to Kathmandu in the future, our team recommends China Room and Mount Everest Steakhouse as fantastic restaurants. While waiting for the NYSORA international collaborators to arrive from their respective homes in Australia, Belgium, Nepal, Singapore, Spain, Switzerland, and the United States, we met with the leadership of the Nepalese Society of Anesthesiologists and worked out the details of workshop strategy, organization and models and equipment. Once reassured that all details were in place, it was time to unwind over a couple of drinks at the lobby bar filled with the cacophony of diverse international languages. As the NYSORA Didactic program began, the shyness of local delegates, instructed by some of the very key international opinion leaders, gave way to spontaneity. The Nepalese delegates openly discussed case scenarios and solicited perioperative management strategies.

Opening ceremony by the Society of Anesthesiologists of Nepal.

The NYSORA trademark TNT lectures, followed by rapid-fire Q&A sessions with the speakers, proved to be an excellent choice of format, particularly since the command of the English language of our Nepalese colleagues was at an unexpectedly high level. We were particularly impressed by the level of knowledge of regional anesthesia of our Nepalese counterparts, given their lack of equipment. Nearly every delegate practiced regional anesthesia regularly, often without the aid of even a nerve stimulator, much less and ultrasound machine. Such equipment is extremely scarce in Nepal. Therefore the donation of the nerve stimulators by the NYSORA team (many thanks to Dr. Roman Zuercker for leading this effort) was greeted by cheers from the representatives of two top teaching institutions at the peripheral hospitals. However, the lack of modern equipment also mandated for the NYSORA team to adopt a different didactic approach during regional anesthesia workshops. The NYSORA international team met to discuss the best method to deploy the workshop to the Nepalese colleagues who are unlikely to acquire an ultrasound machine in the near future. Consequently, we developed a program that used ultrasound to demonstrate the anatomical principles and distribution of local anesthetics in the proper tissue planes rather than teach ultrasound-guidance as a sole method to accomplish nerve blockades.

Malikah Latmore and Admir Hadzic demonstrating principles of nerve blockade using ultrasound imaging.

This approach proved to be correct, as it engaged discussions about the anatomical principles behind administering safe and reliable anesthetics. The donation of an E-Zono 3000 Ultrasound System and trainers was most welcomed by the Nepalese Society of Anesthesiologists. They mutually agreed to have the E-Zono 3000 rotate amongst multiple hospitals, so the expertise of ultrasound guided regional anesthesia procedures could be shared amongst several institutions. We cannot thank E-Zono enough for their kind donation and contribution to this NYSORA ESOP (Education Scholarship Outreach Program).

Celebrations for the donated Ultrasound System!

Dr. Philippe Gautier giving Ultrasound advice using phantoms

As the most intense and gratifying workshop ended on Monday afternoon, the Nepalese society of Anesthesiologists invited the entire NYSORA team to an authentic Nepalese dining experience, filled with music, traditional dances and local food and drink.

If you are offered Raksi, NYSORA's non-wavering advice is don't be misled by translation of Raksi as "rice wine." It is best approached with the same caution one would exhibit with grain alcohol or petrol! It is quite potent and deceptively tasty. Needless to say, a few of us staggered through the dark streets of the city to the safety of our hotel beds. In keeping in tradition of NYSORA Asia ESOP programs, the team gathered nightly to discuss matters of academic interest; this year the theme being creation of the second edition of NYSORA Standard Peripheral Nerve Block Educational Posters.

The NYSORA Team in Katmandu, Nepal

The beautiful people of Kathmandu

The team building continued on several outings to sightsee the beauty of Nepal. Nepal is a beautiful country dominated by the gorgeous snowy peaks of the mighty Himalayas and rustic villages, where life goes on unaffected by modernization. The NYSORA team was particularly impressed by the views of the Himalayan Mountains from atop Nagarkot and through the windows the Nepal Air dual-propeller flight that huffed and puffed as it cut through the morning mist above Mount Everest.

Mt Everest seen from on-board of a Budha-Air propeller plane

Public cremation at Pashupatinath, Katmandu.

Dr. Alwin Chuen in his trademark pose taking a picture at the runway in Katmandu just before taking off on a propeller plane

For NYSORA team members with interest in photography, Nepal proved to be the eye candy. Armed with an array of Digital, Film and Video cameras, the team almost competed shot for shot, snapping photos of the incredible scenery. The photography subjects varied from children of Nepal, whose photo friendly eyes were filled with wonder and curiosity, to street scenes of locals staying warm by burning trash.

The overall impression from the street life is one of substantial economic hardship. Yet, the kindness and the smiles of the Nepalese people never lacked. We were all humbled by their simplicity of life, philosophy, friendliness and patience with which they carried out their tasks and conducted business on their street stands.

A visit to Pashupatinath proved to be one of the most memorable, if not heaviest, experiences in Nepal. A multitude of concrete slabs along the Bagmati River served for public cremation of the deceased, as the family, friends and relatives watched. Cremation is the most common burial method in Nepal, where the fire is started from the mouth, and spreads to the rest of the body. The philosophy behind this order is that both the first and last breath comes through the mouth. This holy site also has a government-sponsored hospice, on top of which there is a music conservatory, such an unlikely pairing of death and music. The heavy sight of burning bodies on concrete slabs, and pungent smell of firewood mixed with the odor of burning human flesh, commands thoughts of a the fleeting, efemoral nature of life and evoke meditation and introspection.

The site is frequented by holy Hindu men, the Sadu. The Sadu fall into 4 categories: the entertaining Sadus, hashish smoking Sadus, drink-milking Sadus, and naked Sadus. The naked Sadus spend most of their time naked while applying ashes from the cremation sites to their bodies.

They are also believed to possess extra ordinary sexual powers. The hashish smoking and drink-milking Sadus are believed to spend most of their lives doing as their designation implies. Although many tourists seem to leave Kathmandu quickly to pursue various trekking, rafting or rustic sightseeing, Kathmandu is a city that is historically, architecturally and culturally worth exploring.

Naked Sadhu at Pashupatinath.

Public cremation at Pashupatinath, Katmandu.

A particularly enlightening experience was a visit to the hospital of our local host. There we had an opportunity to see the organization of the hospital, patient flow, and operating room procedures. We were surprised and impressed by the patience of the Nepalese waiting for care.

Nepalese patients patiently waiting for their turn for examination in a local hospital in Katmandu

As an example, throughout the visit to the recovery room and perioperative areas, we did not encounter a single patient who showed signs of suffering or pain. Our local host explained this was due to stoicism and gratitude of surviving an operation. The operating rooms were reasonably well equipped, but most impressive were the few operating instruments prepared for complicated procedures such as open-heart surgery. The skill at which their cardiac surgeons operated, with the limited selection of tools, would put to shame some of the cardiac surgeons from affluent nations who operate surrounded by 360 degrees of lined up surgical instruments. Most certainly, Nepalese surgeons do not have spare instruments to throw against the wall or at operating room nurses in rage (laughs). Beyond the reasonably equipped operating rooms, the rest of the hospital visit was indicative of the lack of equipment and materials. For instance: we were amazed at the scene of mothers applying pressure on the femoral arteries of their children who just had catheterization for diagnosis of their congenital heart disease.

Patients in the recovery room

A mother holding pressure on the femoral artery after her son's cardiac catheterization for the diagnosis of congenital heart disease

As we lifted off the Kathmandu International Airport for our return home, our thoughts were filled with impressions of a beautiful country, hospitable people and the realization that there is so much more that can be done to improve lives in this part of the world. The prevailing feeling was the one of commitment to keep in touch with the Nepalese colleagues, their society of Anesthesiologists and their leadership, and return soon to deliver additional educational missions and equipment to leave behind. As we climbed to the cruising altitude, we intuitively pulled up Buddy Guy's song, Skin Deep. Its lyrics rang on in our heads with memories fresh from Nepal, "Skin deep, underneath, we are all the same."

I've been around a while, I know wrong from right, And since a long time ago, Things been always black and white, Just like you can't judge a book by the cover, We all gotta be careful, How we treat one another

A man in Louisiana, He never called me by my name, He said "boy do this and boy do that," But I never once complained, I knew he had a good heart, But he just didn't understand, That I needed to be treated, Just like any other man

I sat my little child down when he was old enough to know, I said I fell in this big wide world, You're gonna meet all kinds of folks, I said son it all comes down to just one simple rule, That you treat everybody just the way, You want them to treat you...

Skin Deep, Skin Deep, Underneath we're all the same, Skin Deep, Skin Deep, Underneath we're all the same, We're all of the same

Photography Credits: Mirza Ceho and Admir Hadzic

NYSORA Latin America was a hit! Many thanks to Dr. Pablo Helayel and Dr. Carlos Bollini for help in coordinating such a spectacular event. Here are some responses to the conference: