I always feel like a bit of an ass when people toot my horn about my marvelous career. Yes, I am blessed to have worked in a handful of very different places, but I still feel very much like a spring chicken. I am 30, only 7 months out from residency and still finding out what real adult-life is meant to look like for me, gestating in that cocoon I so fatefully built after my torrid fall from grace in the summer of 2024.

This project marks a good reflection point as I look back on this year in a brave new world. My first 100 day voyage came to an end over Christmas as I returned to the frosty north, if only for a little while. I have cemented some key truths during these months:

1. Every health system has its own problems; the ‘resource limited setting’ label doesn’t account for this and is misleading
2. The humanitarian sector is full of disillusioned romantics
3. Ethical partnerships and political stability are the key to fruitful development
4. Money and press moves everything, even when it comes to aid
5. Getting paid to do this is really hard
6. You need far more pairs of underwear when backpacking in hot climates

There are definitely more out there, but these are the ones that come to mind.

Regardless, during this phase of my career, my objective remains to see as much as I can: different organizations, different models, and different settings. In the process, I am planting seeds for recurrent visits or longitudinal projects where there is interest. As of now, I am involved in some longitudinal curriculum building projects in two countries, one, Afghanistan, and two, Nepal.

So how exactly did I end up in Nepal? Well, it started when I was still in my early goo days.

The connection came from a friend of mine who did an away rotation in Zambia through the Mayo Clinic where he is a resident. He told me about how his attachment was facilitated by a non-profit group called Health Volunteers Overseas. I looked up their website, and clicked myself into a series of sub-menus describing their projects abroad. It didn’t take long for me to stumble upon an appealing looking ‘apply now’ button.

So I sent my CV and a few other bits, and waited. This process was one I have repeated with dozens and dozens of NGOs in the last year. In the vast majority of cases you never really hear back. Sometimes you do though, and this time I heard back fairly quickly, in a matter of days for that matter. A man by the name of Peter Rice sent me an email, to the tune of something like this:

Hi Dr. Tiboni,

I am a semi-retired internal medicine doctor and the HVO liaison for the two teaching hospitals in Nepal, Lumbini Medical College (LMC) and Devdaha Medical College. I am very excited to review your CV, especially as we are just getting an ultrasound project off the ground at LMC. Would love to set up a time to chat. 

Thanks very much, and I look forward to our conversation.

Best,

Peter

To which I responded:

Hi Peter,

Free to chat tomorrow anytime except for 9-10am EST. Currently on leave before traveling to the Middle East on Saturday.

Would love to connect! Let me know a time that suits.

Regards,

Juan

And just like that, we were off to the races.

Peter was, as advertised, an extremely affable and genuine community doctor in Alaska who was now on the back-end of his career and looking for ways to give back. He was new to the humanitarian sector, only just having started with a trip to Nepal in 2024 and being offered to liaison Health Volunteers Overseas (HVO)’s existing partnership with Lumbini Medical College, a private rural hospital and medical university in the southern flatlands of Nepal. Our first conversation lasted longer than anticipated, encompassing not just prospects for the work, but also discourse on our place in this world through the lens of humanitarian work. I was very flattered by Peter when I found that he was the one asking me for advice on how to make a meaningful impact.

‘It seems like you’ve done so much already,’ he said.

Tooting my horn, needlessly.

Needless to say, I’ve noticed in this career (and in life for that matter), that sometimes you meet people who just seem to get it. And when I say it I don’t really know that I can define what it is, but it’s a feeling, a vocational entanglement to this life of service that can’t be explained. I was really surprised when I went into medicine to realize it’s just as full of self-serving egoists as any other line of work. It seems paradoxical, but it’s true: doctors are human. Some are lovely, some are selfish, some are patient while others are petty, some don’t seem to care, and some maybe cared once but found it all so deflating that the light has left their lantern. I like to think I maintain a spiritual connection to my work as a care-giver and when I find others that vibrate on the same wavelength, the connection is immediate. Peter Rice is one of them.

Already, he had some ideas about how to bring an ultrasound curriculum to Nepal. In the week we connected, HVO was able to fund the purchase of two cart-based ultrasound machines for the hospital. He then introduced me virtually to Tanping, an internal medicine specialist and coordinator of the ultrasound fellowship at Cornell in New York. The three of us started laying groundwork remotely for an online platform to bring ultrasound training material remotely for a few months before my in-person arrival in January of 25. In parallel to my other projects over the last few months, we had been meeting online with the trainees in Nepal to get them warmed up to the basics. This was met with medium-level success—it’s a hard skillt to learn from videos without a hands-on instructor. Still, the work began as early as September 24, and here I was finally arriving to Bhairawaha airport after a two-legged layover in Qatar and Khatmandu in January.

Nepal’s challenges, like any low-middle income country, are rooted in its past. For much of its history, Nepal thrived as a trade hub between Tibet and the Indian subcontinent. Despite this, its geographic makeup of awkward mountain terrain and lack of abundant natural resources meant that its industry remained agrarian even with the high amount of trade. Notably, they were never colonized, despite attempts from the British during the Anglo-Nepalese war of 1814. In the years following this war, Nepal was unified under a single kingdom in the mid-1800s. However, the resultant Rana monarchy governed with self-serving isolationist policies, keeping Nepal stagnant while consolidating wealth amongst the elite. When India gained independence shortly after World War II, Nepalis entered an armed struggle leading to the fall of the Rana regime in 1951 and a transition into a new constitutional monarchy, with power shared between the crown and a democratic parliament. Despite this, Nepal still remained largely dependent on agriculture, with only small-scale industries emerging. Then came the Maoist insurgency (1996–2006), a decade-long civil war between the Maoist communist party and the acting government which destroyed infrastructure and further hampered progress. When the war ended, the monarchy and the country transformed into a democratic republic in 2008. However, true prosperity has remained elusive due to several factors of governance, and 20% of the country remains below the poverty line. The lack of economic opportunities has created a seismic brain-drain, with dozens of thousands of Nepalese seeking work abroad—a trend that continues today, with economic returns from expats forming a significant portion of the country’s GDP in conjunction with tourism and hydro power.

Nepal’s healthcare system has followed a similar trajectory. For much of its history, medical care was limited to traditional healing practices, with Ayurvedic medicine and local shamans serving as the primary sources of treatment. Modern healthcare began to take shape after the 1950s, largely driven by foreign aid and NGOs. Furthermore, Nepal’s current two tiered health system (public and private), only further perpetuates healthcare inequality. Even in the public sector, patients must pay for (heavily subsidized) healthcare. State health insurance is available, but is neither cost free nor comprehensive; the government’s National Health Insurance Programme costs families an annual premium and provides up to 100,000 Nepali Rupees in coverage per year (around 750 USD) with limitations—some advanced treatments or specialty care might not be covered. Even today, healthcare access remains starkly divided, with Kathmandu and other major cities boasting well-equipped hospitals while rural areas struggle with a lack of doctors, facilities, and supplies.

Despite being a low-middle income country by definition, the road infrastructure I saw all throughout Lumbini province from Bharawaha to the hospital some 60 kilometres away—a drive that took two and a half hours—was reminiscent of some of the poorest places I have ever been. I would read later that Nepal has the worst road infrastructure in all of Asia per the World Economic Forum. Evidence of everything mentioned above.

Outside of the bumps, my driver was friendly, relatively short in stature (as I would learn many around these parts were), and did his best to chat despite severely limited English. I was struck by the colourful gas transport trucks on the road, covered with personalized insignias of everything from Manchester United to TikTok logos. Unfortunately I fell asleep towards the end, and woke up once we were already arriving at Lumbini Medical College (LMC).

LMC is a private medical college located in the Palpa district of Lumbini province some 300 kilometers from Kathmandu. Opened in 2005, it is a teaching hospital funded by med student admission and patient services. Despite being tucked away in a small village on the outskirts Tansen, a town of 50,000 people, it was a large medical facility that serves as the tertiary referral centre for several districts. It had 500-700 beds, complete with inpatient medicine, pediatrics, general surgery, neurosurgery, ENT surgery, orthopedics, anaesthesia, and dermatology departments. The medicine department, the hosts for my four week stay, consisted of four attendings, nine residents (three in each year), and a steady stream of interns and medical students from the college.

The objective of my visit was fairly simple: establish the point of care ultrasound curriculum and join the department as visiting faculty for clinical teaching. HVO would send more volunteers from our POCUS training staff for small intervals throughout the year to expand and sustain our partnership in education.

I can manage that, I thought.

On the first morning after my arrival I met one of the attendings in the canteen for breakfast, Dr. Himal. He was a first year attending just after finishing his training at LMC, and was the one to show me the ropes. The canteen was fairly humble, but packed a punch. No listed menu meant every day I was at the mercy of Nares, the canteen owner, who very quickly realized he was not dealing with a typical gringo and pivoted from serving me plain rice with vegetables to all manner of local fare.

‘Namaste,’ he said. ‘My name is Nares. Welcome to LMC. Where you are from? And what food you like?’

‘From Argentina,’ I said. ‘But I lived for many years in Canada, then Europe, then the US. What you eat, I eat.’

‘Argentina, yes! Messi, Messi… Okay sir,’ he said with a smile and a head bob.

We became friends.

After breakfast, I joined the residents for their morning conference. The first-year residents rotated 24 hour calls every three days, which started and ended at morning report where they would present admissions from the previous day. In Nepal, medical education is taught in English, which means that everyone had functionally competent English, making my life a hell of a lot easier. However, I realized quickly that as soon as clinical discussions picked up steam, the conversations would turn to Nepali on a dime and leave me out to lunch.

Noted, I thought.

After morning conference, some of the resdients branched off to the clinic while a few continued to the ICU to start rounds. At LMC, despite the ICU being formally under the Department of Anaesthesia, the medical teams and surgical inpatient teams still managed their own ICU patients, and anaesthesia only got involved for ventilators and sedation. This meant that on top of rounding on 30 patients in the ward and high dependency unit upstairs, the medical team also rounded on their ICU cases.

Walking in, the conditions of the ICU were pleasant. It was spacious, with a lot of capacity and appeared clean. My arrival corresponded with the dead of winter, which also correlates with the lowest ICU volume, as Dengue, scrub typhus, and viral encephalitis happened in the summertime and were the bigger source of volume. Still, there were a small handful of patients under our team.

After a few minutes, one of the attendings showed up in a neat looking tweed jacket. He was seasoned and very professorial in his demeanor. He wore articulate glasses, and despite appearing to be in his mid-forties, carried a boyish smile. His accent was thick but clearly intelligible. His name was Dr. Pandey.

‘Doctor, we are so happy you are here,’ he said gently tugging at my arm. ‘I have been very insistent with our residents to use the ultrasound machines you have purchased for us, but we are lacking in skills.’

‘I am so happy to be here,’ I said in return. ‘I will do my best and hopefully we will get the chance to do good scans and learn from each other. I also have much to learn from you!’

‘Ah,’ he said with a smile and head bob. ‘In medicine… The learning never stops!’

We also became friends.

As rounds began, Dr. Pandey insisted that the residents speak in English to facilitate my understanding of the cases. So we started on the first one, which turned out to be the first of many with this diagnosis I’d see over the next month.

‘This is the case of a 44 year old male, with a known history of alcohol use and chronic liver disease,’ the resident started. ‘He presented in the evening with dark black vomitus and low red cells with concern for a gastric bleed, likely secondary to esophageal varices. His red blood cells dropped during the course of the night but his vomiting stopped, and he is currently stable on octreotide therapy.’

In patients with later stage liver disease, the liver becomes stiff and less effective, which through a complicated series of mechanisms leads the blood flow behind the liver to become congested. Over time, this stretches the walls of veins in multiple places, like on the surface of the abdomen or in the esophagus. These veins in the esophagus become engorged and start to stick out into the throat. If they rupture, this can lead to large-volume variceal bleeds into the stomach, which are dangerous and life threatening.

Taking a look at the patient he looked relatively unbothered by his predicament, laying in bed and looking up at us with a blank stare.

Dr. Pandey then immediately stepped into professor mode, grilling the residents with high-level questions on the management of variceal bleeds.

‘What percentage of variceal bleeds recur within the first month after endoscopic ligation?’

The residents stood strong for a moment, and then looked at each other admitting defeat. I was hoping he wouldn’t turn to me because I didn’t know the answer myself.

Dr. Pandey then gently provided the answer, around 11%, complete with a citation. He then continued to ask questions, some of which the residents got right and others where they needed nudging.

‘I know the answer because I still remember in my Harrison’s textbook from when I was a resident,’ he began after one line of questioning. ‘I was traumatized by this page. It was the 179^th page in the 17^th edition and 279^th page in the 18^th edition. On the top, to the left, there was a diagram with all of the pathophysiology of this disease. I can never forget it.’

I couldn’t help but laugh under my mask. Pandey is cooking!

Then he turned to me.

‘In your centres, you probably have access to the TIPS procedure, am I right?’ he asked. This is a procedure that places a tube connecting the pre-liver veins to the post liver veins to reduce the enlargement of varices and prevent future bleeds.

‘Yes that’s right.’ I answered. ‘However, I’ll be honest, we really try to avoid it. It can worsen the liver disease, especially hepatic encephalopathy. I have seen it once or twice only, but yes, we do have it.’

‘That is excellent,’ he said.

‘So in these patients, we can do endoscopy here or they have to go somewhere else?’ I asked. This was in reference to placing a camera down the throat to visualize the hemorrhage and then tying it off to stop the bleed.

‘Unfortunately we cannot perform definitive management here,’ he said. ‘We do have access to endoscopy, I am actually the one person trained here who can do it, but we don’t have the tools for ligation. So, if we do the endoscopy, we cannot fix the bleed. This means that these patients have to stabilize here in the ICU first, and then we have to speak with them about the cost of endoscopy in another centre. Even if we wanted to do the endoscopy alone, we try not perform the procedure unless the patient can consent, especially because it is expensive. If we go in there, we can disturb the bleed, or maybe even the patient wakes up and is upset because they now have to pay a lot of money.’

‘So even if the patient is actively bleeding, we just give blood, correct any underlying clotting disorders, and treat medically before they can be awake and stable to consent for transfer to definitive management?’ I asked.

‘That’s right.  Of course this is not ideal,’ he said before continuing with an emerging smile. ‘Here in Nepal, we must worry about two things. First the patient’s pulse. And second, the patient’s purse.’