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Out of the Tunnel

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It has already been two weeks since the operation to remove a NET from my mesentery.  My ordeal began on Monday, March 2 at 5 pm when I checked into Cedars-Sinai Medical Center for an unusual early-evening combined colonoscopy and endoscopy.  I remember nothing of these procedures other than waking up about 30 minutes later with a blurry doctor telling me he found of nothing. My innards were perfectly clean as far as he could see, which is pretty amazing considering the abuse I have subjected them to over the years.   Since my surgery was scheduled for the next morning at 7 am, they kept me right there in the hospital.

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Five tiny incisions, and one slightly larger one.  I’m pretty sure I no longer have a belly button.

The next several hours were a blur.  I think they must have slipped me something.  The last thing I remember was looking at the red digital clock across the room and seeing 7:00 a.m.  I awoke amid a misty commotion all around me of doctors and nurses.  I squinted through the chaos and saw another red LED clock that read 10:00 PM……Holy shit!  10 PM???  I remember doing the math and thinking I was out 13 hours!!!! Later I figured out it was really 15 hours!  I was expecting 2-3 hours.  Early the next morning I was told the operation actually took 9 hours, but it took me another 6 hours to come out of the anesthesia.

According to my surgeon, who stopped by the morning after , the surgery took much longer than anticipated due to the positioning of my mesenteric tumor amidst a jungle of critical blood vessels.  If he were to nip one of them, I could lose half my bowels.  He made the decision to go 100% robotic knowing that this would triple or quadruple the time for the operation, but allow for very precise cuts.  As a bonus, they found the primary (e.g. “original”) tumor in my small intestine, which they resected. I have been assured that I won’t miss the 9 cm of removed bowel.  The primary tumor was not visible on any of the previous scans, and that they found it is of great significance.  There was no longer any mystery about the source of my mesenteric tumor, and by removing the primary tumor, my chances of a quick recurrence should be reduced.

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Day 3 in the hospital.  I look way better than I feel.

My doctor asked how I was feeling, and I told him I felt like someone punched 6 small to big holes in my belly, rummaged through my entire digestive tract, then yanked out a sizable section out through my belly button.  And then Mike Tyson used my belly for a punching bag for 5 minutes.  Actually, except for Mike, that is pretty much just what happened.

The next 6 days were a roller coaster of progress and setbacks, including an infection of unknown origin that left me feverish for 2 nights, getting dropped by a rushing X-ray tech (set me back at least 1 day), spasming at my first attempt to drink a clear liquid, and pained shuffles up and down the corridors.  But progress finally won out over the setbacks, and they released me almost exactly 1 week after I was admitted.

I made my final visit today to Cedars-Sinai for a last follow up with my surgeon.  He gave me the good news that I am officially NED (no evidence of disease)!  But Neuroendocrine tumors, even when you’ve had them removed, have a propensity to recur.  So I will be on a surveillance program, with scans every 3 months for at least the first year.  They are recommending that I can stop the monthly injections that I have been getting to slow down the cancers growth (a big relief to my digestive system).  This is all the best news I could have hoped for!

The care I received at Cedars-Sinai was amazing, from the orderlies, nurses, technicians (well, except for that one harried X-ray tech) and the dozen or more doctors that were involved in my care.  My main team consisted of my surgeon, a NET oncologist, gastroenterologist, and urologist.  All of them have been caring, funny, and exuding professional competence.  In spite of this being the most difficult medical journey of my life, I feel like I made the best choice!

I’ve now been staying with close friends just waiting to heal up sufficiently to fly back home to Thailand.  In the meantime, the world has imploded with the Covid-19 pandemic and it’s now a race against time through a dark tunnel to get back home before Thailand closes its gates.  If I can’t get back in time, I will be officially homeless…

Operation California

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My surgeon!

I am currently sitting at Black Canyon Coffee at the Chiang Mai airport waiting for my flight back to California.  In a few days, I hope to be getting surgery to remove an alien growing on my mesentery.  This is a good thing.

It took me 4 scans, 2 biopsies, 8 shots in the ass, and more trips to Bangkok Hospital than I can remember, to get to this point.  Finally after ruling out prostate cancer, and getting a diagnostic confirmation from the Cleveland Clinic, it all comes down to this one 2.5×1.5 cm tumor.  The consensus is get it out if at all possible.

I talked with two surgeons affiliated with Bangkok Hospital.  One was willing to do the traditional slice and dice procedure, and the other one was an expert in laparoscopic (minimally invasive aka. key-hole) surgery.  Neither had any experience excising neuroendocrine tumors.  I had to wonder if they would even know what one looked like. So I went on the internet.  It turns out there are only a handful of facilities in the USA that have a specialization in Neuroendocrine Tumors (NETs).  It boiled down to choosing between Dana-Farber Cancer Institute in Boston, The James Cancer Center in Columbus Ohio, City of Hope in Duarte, California, and Cedars-Sinai Medical Center in Los Angeles.  One didn’t take my insurance, and one didn’t follow-up after 3-4 emails.  In the end, I chose the Carcinoid and Neuroendocrine Tumor Program at Cedars-Sinai.  In about 48 hours, I have an appointment with a surgeon who specializes in NET tumors.  Not to disparage my doctors in Chiang Mai, all of whom gave me excellent care, but this feels like moving up to the big leagues.

My prospective surgeon, Dr. Kosari, has reviewed my scans and believes the tumor is resectable (Doc speak for “yea, we can cut it out”) and likely can be done minimally invasively using a robotic assist.  As the picture shows, the robot looks a little scary.  Sean Connery would agree.

I want to emphasize that my disease has not worsened or progressed.  Surgery, if possible, is a good thing (my new mantra).  My disease will still be there, will still be incurable (BUT NOT TERMINAL).  If successful this will be a step towards my ultimate goal – high life-quality while waiting for something else to kill me.  Stay tuned.

Medical Care in Thailand: Observations from a Reluctant Patient.

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imagesI am now 7 months into my battle with Nueroenocrine cancer.   I have had way more contact with the medical community here in Chiang Mai than I ever wished for.  I always figured that most people died in a hospital bed, so better to stay away.  However, I now feel somewhat qualified to make some observations about health care in Thailand that might prove useful to anyone thinking about retiring or traveling here for medical care.

An Update

But first, a very brief update of my current status.  I have now been on monthly injections of Sandostatin LAR for 5 months.  These injections are not a cure, but intended to stop or slow the tumor growth, and stop or limit the proliferation of tumors.  They do come with some unpleasant, but mostly bearable, digestive side-effects. Suffice it to say that if I had one of the more common side effects then, I would have been a cult hero in my fifth grade class.  Last month, I traveled to Bangkok for another Gallium 68 PET scan.  The scan showed no growth of my one known tumor, but continued to “light up” my prostate, suggesting something might be there too.  Last week, I had a biopsy done on my prostate where my urologist turned it into a pin cushion by removing 24 small cores.  Fortunately, I was in Lala Land at the time.  Early this week I got the results: nothing at all going on there (except BPH which I have known about for years).  Good news!

I will be meeting with my oncologists next week to discuss our next move (surgery or more Sandostatin injections are the two most likely).  Unfortunately, the one known tumor is in my mesentery, and is very unlikely to be the primary.  Where the hell is my primary?  Most likely it is 1. too small to see, 2. gone already due to immune response, or 3.  hidden away somewhere, most likely in the curlicues of my small intestine.  Neuroendocrine tumors (NETs in the lingo) are sneaky nefarious bastards.  Once they have metastasized they are nearly impossible to 100% expunge from your system via surgery or medicine.  This will make the decision to cut or not to cut a difficult one….So that’s where I stand at the moment.  In the meantime, digestive issues not-with-standing, I feel great and life goes on mostly as normal.

Medicine in Thailand

According to the World Health Organization, Thailand ranks #47 amongst 190 countries in terms of the quality of their healthcare system.  For perspective, the U.S. ranks #37.  Thailand, except for the tiny states of Brunei and Singapore, ranks number one in south-east Asia.  Thailand ranks 65 spots above India that magnet for medical tourism.  So by WHO standards, health care is pretty good here.  My own experience corroborates this conclusion.  But it is only good if you have money (or good insurance).

I receive most of my healthcare at Bangkok Hospital, Chiang Mai (BHCM).  Bangkok hospital is a country-wide system of hospitals that was started by a Thai doctor in 1972 as the first private hospital in Thailand. Prasert Prasarttong-Osoth parlayed his medical degree into a $3.2 billion fortune that includes Bangkok Airways and 3 regional airports.  BHCM is in my view the best hospital in Chiang Mai.  From its welcoming lobby that exudes the ambiance of a 5 star hotel, replete with live music from grand piano, to its immaculately attired english speaking staff,  to its state-of-the art equipment and spotlessly clean ORs and examining rooms, anyone will feel confidence in the care they are about to receive.  But the quality of that care comes with some significant caveats.

Caveats

In the course of my diagnosis and treatment, I have seen more than a dozen doctors.  They all impressed me with their caring attitudes, and general intelligence.  However they collectively are the product of an insular system of in-breading.  Virtually every doctor in Chiang Mai obtained their medical degree from Chiang Mai University Medical School.  Many are listed as faculty members there in addition to their hospital posts.  Thai culture’s pronounced stratification, makes questioning one’s supervisors/seniors/elders difficulty at best.  This just has to stifle innovation and the adaptation of new or alternative treatments.

I normally meet with two oncologists, one is an elderly woman listed as a professor emeritus at Chiang Mai medical school, the other is a youngish male with an MD degree from there.  When I meet with them, she does 95% of the talking, while he mostly stares at his computer.  She will suggest something, and he will do his best imitation of a MLB bobblehead doll.  On the rare occasion when I meet with him alone, he becomes talkative, and full of ideas and intelligence.  I would consider asking to be seen by just him, but I am afraid that it would make an irreparable rent in their cultural universe.

Another caveat is the lack of accountability.  Malpractice lawsuits are nearly unheard of in Thailand outside of a few high-profile nose-jobs-gone-wrong that splash across the headlines.  When a doctor makes even an egregious mistake, about the strongest reaction is “oops”.  Doctor’s are looked up to in Thailand to a much greater extent than are western doctors.  Thai patients seldom question their care, and confidently swallow unmarked pills given to them in completely unlabelled baggies with instructions of when and how many to take.   There is a clear advantage for patients if doctors have a paranoid fear of being sued.  I cannot say how much this accountability issue effects health care, but it will weigh heavily on me if I have to decide on invasive surgery.

The bottom line for now is that my health care has, in my view, been very good.  My doctors’ decisions have been verified to the extent possible by Dr. Google and his myriad colleagues.  I also received a “virtual” second opinion from an oncologist at the Cleveland Clinic, who, after reviewing all my records, scans, and even my original tissue biopsy samples, concluded that the care I have been receiving is spot on.  But my disease is uncommon, complicated, and varies from case to case.  Experience here is lacking so I may have to consider returning at some point in the future for evaluation at one of the handful of “NET Centers” in the USA.

Aches and Pains

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Note: I am writing this in the evening of March 8, but have no internet connection, so I will post it when I do.

True to form, what looked like a relatively easy day on the map, turned out to be grueling. We began at Junbesi at about 2600 meters and climbed up and around one of the north-south ridges. Net gain was only about 300-400 m, but all the little ups and downs probably doubled that. Then it was down down down to another river-crossing via a long steel suspension bridge, then up for 1 hour to a small village for lunch, then up up up to Taksindu La (la = pass), a low spot in the next north-south ridge. Then came the grueling part. A 900 m plunge. While easing my way down the steep trail, I found out that the smallest appendage on my body can cause the greatest pain. No not that one…..my right pinky toe. That little bugger started jamming on the morning downhill section. A boot lace readjustment seemed to help my toe a little, but then my left achilles heal started to get stabbing pains – not fun, a snapped tendon would end the trek on the spot and require evacuation. The pain seemed to lessen on the way down, so hopefully a couple of NSAIDs will solve it.

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In spite of the gray weather, portions of the hike were through very pleasant forests.

To make a miserable day even worse, the afternoon clouds came again and the rain began. By the time we reached the hillside village of Nuntala, it was a steady downpour. I stood in the rain while Bhakda ran from lodge to lodge looking for rooms. The one he finally chose was distinctly NOT luxurious. The room had a 2 inch-thick mattress about half the size of a standard twin, and room enough beside it to turn around. The down-the-hall toilet was standard squat. No sink, no trash can, no shower, no warm wood stove. I think the night before must have put him over budget and this is a make-up.

The highlight of the day cake just before sunset, when the clouds parted and gave us a glimpse of snow covered 6000 m peaks.

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A sunset treat.

After a baby-wipe bath, and donning some warm, dry clothes, I felt much better. Down in the cold dining room, along with my usual pre-dinner hot tea, I was also offered a tasty plate of spicy buffalo meat.

Tomorrow, we finish the downhill plunge to the low point in the trek at 1500 m, so I have a 700 m downhill to negotiate with my bum feet in the morning. But my guide promises that tomorrow is any easy day; I would like to believe him….

Some scenes from the day’s hike.  Flowers were every where, terraced hillsides, and cute Sherpa kids.

Unexpected Luxury

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Note: This post was written on March 7 but will be posted on a future day when I have a stable internet connection.

Today was a long day, so this will likely be a short post. We climbed over a high pass, Lamjura La, which is the highest we will be for several days. At 3500 m elevation (about 11,500 ft) the climate there is decidedly cooler. Small patches of what looked like relatively fresh snow flanked the trail. We arrived at a small tea house for lunch just below the pass at 11:00 am and with the sun, the temperature was quite comfortable. As we ate our lunch, clouds began building and the wind blowing. By the time we crossed the pass, the clouds had obscured the sun, and a stiff wind made it feel quite cold.

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11,500 feet high but in the foothills. Lamjura Pass is in the distance.

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Your hero at Lamjura La.

The descent down to the village of Junbesi was an endless slog down a deep valley. The start of our descent passed through a mossy, magical forest of pine and rhododendron. Farther down as we approached the Junbesi river, I was surprised to see road-building activity once again. This road came up the river from the south. Our trek is essentially a eastward march directly across the topographic grain defined by the southward flowing rivers draining the high Himalayas. Hence our route is 90 degrees to the topography and therefore intensely up and down. However, in the aftermath of the 2015 earthquake, the road-building frenzy utilized the north-south valleys to access these rural areas hardest-hit by the earthquake.

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It was a long slog down from the pass, but through some nice forest. Gokul, my porter, is for scale.

As we approached Junbesi from above, we could see the new road, passable but still under construction. Junbesi also had power from a generator downstream. The town is much more prosperous than the small villages along the ridge lines. Our accommodation for the evening, the Ang Chokpa lodge, was a very pleasant surprise. I got a large room with an attached bath AND hot water in the shower. I was even able to access a reasonable town-wide WiFi for about $5, although it went down before I could post this. I’m writing this sitting around the wood burning stove in the toasty common room while digesting my spaghetti dinner (a nice change from dal bhat). Tomorrow looks like a relatively easy flat day on the map, but I have learned that Nepali flat means up down up down up down….

 

Climb to Sete

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Note: I am writing this on March 7, but I am now well off the grid, so I will be posting this at some future date).

I awoke this morning at 3:20 am, partly because I went to sleep at 9 pm the night before. I was quite knackered from the long previous day going over two passes. Of course, I had to pee. Which brings me to the subject of tea houses.

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The tea house at Sete

Many are also known as lodges. They are generally stone building, one to two stories, that double as a family’s (or two or three) home. This section of trail is sparsely populated by trekkers, therefore the lodge business is distinctly secondary to other means of income and subsistence, mainly farming. They provide the most basic of accommodations, generally a very small room with 1-3 beds crammed in. The floor is bare wood, the mattresses are an inch or two thick, and if they have the luxury of electricity, there will be a dim light hanging from the ceiling. Toilet facilities (basic Asian squat) are down the hall, or in the present case, down the steep wooden stairs.

So back to peeing, by the time I was done getting out of my warm sleeping bag, finding my shoes in the dark, clambering down the stairs and back up, I was wide awake. After all I had already had 6+ hours of sleep, in most cases sufficient for me. So I spent the rest of the wee hours reading the news (at the time I still had a cell connection), trying to sleep again, and completing yesterday’s blog post.

Today we climbed a mountain, in reverse. We started by following a small stream downhill to the east, eventually emerging high on the north canyon wall of the Likhu Khola. Just across the side valley from us was a flurry of road building, with tight switchbacks being built on a nearly vertical wall. It turns out that this will be the service road for a Chinese-financed dam and hydroelectric power plant on the Likhu Khola. Given the narrow canyon at this point, it seems like an ideal site. Before you yell environmental foul, think about what life would be without power. This power plant will be a godsend for the people of this area that lived without power or roads when the earthquake hit.

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The new road across the valley wind Ying it’s way down to the Power Plant site

The trail gradually descended to the east finally getting down to the river at the village of Kinja. This was the final destination of the road. After a brief rest and a check-in at the Khumbu district office, the trail southeast and straight up. We were now in Sherpa territory. We regained all the elevation we lost in the morning, and then some, finally arriving at Sete, perched high above the valley, at 3:00 pm. Sete, as far as I could see, consists of a couple of tea houses, nothing more. Our station for the night is the Sherpa Guide Lodge, owned by a school teacher. The school is apparently located a 20 minute walk away, so we had to await his arrival at 4 pm to check-in.

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Enter a captionNew bridge being constructed across the Likhu Khola

Now, I am sitting in the owner’s kitchen, together with my crew, and various undefined members of the extended family, mostly because it’s warm in here, if a bit smokey. They are all speaking animatedly in Nepali, which always sounds to me like they are fighting. I mentioned this to my guide, and he said it’s because they are all drinking their home-made brew. Oh yea, I had to try it! They poured me a small milky looking glass out of what looked like a tea kettle. The taste wasn’t unpleasant. Of course they drink it warm and uncarbonated. Apparently they make it from wheat, although it didn’t taste anything like a wizen. It also had small round floaters in it that looked like small bugs, apparently some kind of spice they add to it. I would gladly drink more, but I didn’t given that I am trying to acclimate to the altitude – which here is 2500 m, or roughly 8200 ft.

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Dinner with the fam.

Tomorrow we climb over the highest point this side of Namche Bazar, a high pass of 3500 m (11000+ ft). I’ll likely be in bed by 9 again tonight, hopefully for a longer sleep than last night.

Up and Down Up and Down

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There is literally no place flat in the Himalayas, and today’s march from the jJiri to Bhandar proved the point. I climbed over two passes, through three villages, crossed one large river, and passed countless homes destroyed by the 2015 earthquake. My guide said it would take 6 hours, now I know to add 25% to his estimate as the old man factor. We left at 7:30 am, and arrived at Bhandar at 4:30. That included a 45 minute lunch stop at a small, dark lodge perched next to the trail.

Our lunch stop for the day.

The hike passed through pleasant pine forests, interspersed with small family plots growing wheat, rice and potatoes. All of the plots we terraced on the steep slopes. Most of the plots were only a 2-3 meters wide, with a drop of a meter or more down to the next terrace. My mind boggled at the though of how much labor this took, not to mention the DIY irrigation engineering.

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Shivalaya.  The climb out of this village was brutally steep.

This region felt the brunt of the 2015 earthquake. Many (most) of the homes are made of stone and became piles of rubble. Now construction is rampant. In the aftermath of the earthquake, the government, inundated with foreign aid, went on a road building spree. Only a few years ago, getting to Bhandar involved exactly what I did today. Now two new roads service this town. These are only roads in the sense that one can navigate them by truck or 4×4.  They have been scraped into the hillsides, switch-backing up and over passes and down steep drops. My foot trail crossed one of these roads multiple times on the way up and over the day’s second pass. Ankle-deep dust on these roads meant I wore a silky tan coat by the time I arrived at Bhandar.

Many of the lodges have not yet been repaired in Bhandar, the one Is am staying in, Shoba Lodge, was built recently – out of wood instead of stone. I had a nice proud moment when I arrived at the lodge when the other trekkers staying here said they took 2 days to get here to my 1. I did a few imaginary fist pumps. Fortunately, the lodge had a gas hot water heater hooked up to a shower head, so I got the dust off me. Now I’m awaiting for my ration of dal bhat to arrive. I’m thinking I will sleep well tonight.

Highway of Death

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I feel lucky to be alive tonight. I have survived the most dangerous part of my trek, the 200 km drive to Jiri. But let’s start at the beginning…

My guide, Bahkta and my porter, Gokul (who is a slightly darker version of the Marlboro man), met me at my hotel at 8:00. We also had a driver who I am pretty sure is in training for the Indianapolis 500.

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From the left, me, Mario Andretti, the Marlboro man, and Bhakti

Our car was a small Toyota sedan, and we all clambered in and headed out into Kathmandu’s traffic. I asked to sit shotgun, and man, was that a good choice! Bahkta and Gokul stuffed themselves in the back. The first hour was spent getting out of Kathmandu. On the outskirts of town we passed mile after mile of brick factories; the Nepalese were busily creating the tools for their own demise during the next big earthquake. The traffic was stop and go, mostly stop. Finally we emerged onto the the Aranko Highway, a route built by the Chinese in the 1960s that connects Kathmandu to the Tibetan border. After a couple of hours we branched off onto the B.P. highway, a new road built by the Japanese that connect Kathmandu to the southern lowlands.

Let me describe these roads: hair raising (if I had any), vomit inducing, ass-puckering and pee loosening doesn’t begin to do this route justice. Nominally 2 lanes, in reality it would be a generous bike lane in the US. Often, when a truck and a bus pass, both vehicles would slow to a crawl, and inch past each other with mm to spare, horns a-honking the entire time. The road climbed and fell, often with shear drop-offs. Guardrails? Who needs ’em! My driver drove like he was late for his wedding (more likely his funeral). With incredible skill he passed all manner of slower vehicles with inches to spare between us and oblivion. And all this describes the first half of our route.

About halfway, we made a quick stop for lunch – delicious dal bhat and curry.

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A delicious lunch, Dal baht, the 24 hour fuel

Fear makes the best spice. After lunch, the route crossed a bridge and followed the Tampa Koshi River to the north. The road was now an ancient, nominally paved, single lane trail, pot-holed and washed out by floods over long sections. The road demanded 20-30 km per hour, my driver insisted on 50+ km per hour. Any on coming traffic was negotiated via a game of chicken; we won more than lost. The road then left the river and climbed, and climbed and climbed. Finally, we reached Jiri at 3:30 pm, for a 7 hour 30 minute time – probably my driver broke his own world-record. Jiri turns out to be a rather dismal village at the end of the road. Main Street is a wide but rough dirt road. We checked into a small Sherpa guest house. I bought my crew a beer, and we had another meal of dal bhat. I feeling at once excited and apprehensive about the coming trek. Tomorrow it begins.

Kathmandu

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When I last visited in 1986, Kathmandu had a population of 400,000, today this exploding city is now an order of magnitude larger with over 4 million inhabitants. Today I toured some of the famous landmarks of the city with a driver and guide. Dubar square, a couple of famous temples, and a cremation site along the river.

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View of Kathmandu from Swayambhunath Temple

None of this impressed me much, but what did was the incredibly lasting impact from the earthquake that struck Nepal nearly 3 years ago. Over 9,000 people perished in that temblor, but it could have been far, far worse. The earthquake struck at noon on a Saturday which is Nepal’s Sunday. Schools were closed, children were out playing in the streets and parks, and businesses were shuttered. But the property lose was unbelievable. My driver said that in his village only a single house was left standing and that house became a field trip stop for building engineers. Bricks are everywhere. Piles of recycled brick, neat stack of new bricks, and many piles of broken bricks that no one has yet bothered to haul away. Construction is everywhere, yet still has so so far to go. Dust. Oh the dust. A perpetual yellow haze hangs over the city and coats everything left outside. In spite of all this, the tourist district is bustling again; Nepal is open for business.

Scenes from a shaken city

The drive today also reminded me how aching poor Nepalis are. The homeless are everywhere and by comparison the cardboard shacks inhabited by SoCal’s homeless seem like palaces. My tour guide said that over the last 10-20 years, there has been a mass migration from rural Nepal to the city where hopes for a brighter future collided with the harsh reality. Yet in the face of hardship, the Nepalis remain upbeat. My tour guide talked proudly of how Nepal is now a democracy after years of incompetent governance in a country run by kings.

I spent the late afternoon completing my supply shopping, and having a last beer and pizza in relative civilization. Tomorrow morning I will be drive about 185 km (8 hours!) on the Araniko Highway, arguably the most dangerous section of road in the world. I checked it out on Google maps and all I can say is that I hope I can ride shotgun.

The Adventure Begins: Bangkok to Kathmandu

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After 32 years, I have finally returned to Kathmandu. I left Bangkok about 11 am after stuffing myself with 3 Krispy Kreme donuts and a cup of Starbucks (my waistline hopes they never open a KK franchise in Chiang Mai, the rest of me does). My flight was delayed by about an hour as we entered a holding pattern south of the city, then waited another 30 minutes on a taxiway while waiting for a parking spot. Although my memory has faded, it seems that not much has changed at Tribhuvan International Airport, it is still tiny and rather chaotically ad hoc. The trekking company I booked with had a driver dutifully awaiting my late arrival, and we drove slowly through the dusty, dusty streets, lined by piles of debris and bricks seemingly still leftover from the Earthquake 3 years ago. I arrived at the small botiqueish Dom Himalaya hotel in about 30 minutes. I was warned to tell the front desk 5 minutes before I showered so that the could turn on the hot water. Yes, I’m back in the third world.

With the remainder of the day free, my first step was to find an ATM. Here’s where my adventure began. My transaction went normally until the screen said “take your cash”, then it flashed “transaction cancelled”. My card reappeared, but before I could grab it, the machine slurped it right back inside. Then the screen reset to “please insert your card”. I could almost see that damn machine smile at me for offering such a tasty morsel. To make matters worse, I got an email from my bank in the US notifying me that I had just withdrawn 35,000 rupees or about $340. So now I am standing there with no rupees, no ATM card, and the bank had just closed 15 minutes prior. I was forced to dip into my emergency dollar cash reserve, which I was able to change into rupees at a nearby money changer. I guess I’ll be waiting at the bank door at 10 am tomorrow morning.

I spent the rest of the afternoon and evening getting a local SIM card, and picking up some odds and ends for my trek. Kathmandu is very different than I remember it. Back in 1986, the streets of the city had more sacred cows than cars. Now the cows have apparently been banished to be replaced by a cacophony of sacred cars and motorcycles. One nice thing though, the main part of the Thames area is a maze of walking streets, no cars. That made for a very pleasant shopping stroll amongst the myriad of small shops selling trekking gear. I finished the evening with a fine meal of Indian food at the Third Eye Restaurant.

A romantic candlelight dinner for one in Kathmandu.