Medical Student Electives


Matt Titterington:  IPPG elective report 2017

Matt1

Matt, a final year medical student from Oxford University spent his elective with IPPG. This is his report to inspire you…

I spent my elective with IPPG at Machermo and Gokyo in March 2017 and stayed for the majority of the pre-monsoon season 2017. I was there with Rich, Tom, Alice and Majel who were the other doctors as well as Nick, Rich’s partner, for the first few weeks. Of course we had Kancha and Pasanta to help us out. We were also joined later in the season by Utsav, a newly qualified doctor from Nepal.

First impressions

I arrived in Kathmandu a few days ahead of the rest of the team to a busy, bustling city. Despite the hectic and noisy streets, I managed to explore the city and find some beautiful and quieter spaces. Once the team arrived we got to work, making visits all over the city to KEEP, CAN and others as well as sorting medical supplies. We were soon thrown into the medicine proper however with our HRA induction, first with a lecture by Buddha Basnyat at the HRA HQ on altitude then a lecture by Prativa Pandey at CIWEC on infectious diseases. Despite our busy schedule we still managed a day of team building by going mountain biking.

Very soon it was time to fly! Kancha took us to the airport and guided us through the ‘check-in’ process (if you can call it that). The flight was interesting and landing was fun in such a small plane but we all arrived together safe and sound on the 7th March. The walk in was fantastic – I had never been trekking before but was pleased to find my boots were up to task! We had mixed conditions on the way up – some hot, sunny days but also days trekking through thigh-deep snow with very poor visibility. It certainly made for an interesting introduction to the Himalaya.

On the 12th March we arrived at Machermo! We were tired but we quickly set to cleaning up the place after a winter of being empty and taking an inventory. A few of us (myself included) were not feeling 100% but this seemed to pass within a day or two. Sleep disturbances were common at the beginning (lots of us were Cheyne-Stoking at night) but within a week we were feeling much stronger.

Day to day life at Machermo and Gokyo

Very quickly I settled into the routine of life at Machermo. It was a lot of fun living with the rest of the team and having Nick with us for the first few weeks was nice. Day to day life was built around a routine of tea, juice and food prepared for us by Kancha and Pasanta who do an amazing job.Matt3

Mornings were generally quiet so we managed several walks on the ridges surrounding Machermo for amazing views and a chance to expend some energy. In the afternoons we did the rounds of the lodges and gave the talk on a rotating basis, with two people talking each day. By the end I think we could all recite the talk from memory! The amount of people who attended varied from five or less right up to 35 people! Irrespective of how many came, it was a great opportunity to educate people and it was always fun hearing people’s stories and chatting afterwards.

Living at Gokyo was quite different. Because we didn’t regularly give the talk we had a less structured day. We ate at the lodges for all the meals and so got to know the lodge owners well and we met lots of interesting people. We took time out to go for walks and to explore the area too – I did one particularly long walk to a hill above the 5th lake. At 5600m altitude it was a tough walk, and added to the 2hrs it took to get there in the first place it was exhausting! I spent ten days at Gokyo in two stints – one with just Tom and the second with both Tom and Alice.

I also had my birthday whilst up in the Himalaya! The morning of my birthday I walked up to Gokyo with Alice for a day trip to see Rich and Majel. When I arrived they had bought me a cake from one of the bakeries and a lodge owner, Tashi, gave me a scarf and some chocolate. We took the cake back down to Machermo to share with everyone else. It was a lovely day and a great way to keep morale high!
Matt4Medicine at high altitude

Having never been to high altitude before (or a location so remote) there was a lot of learning to be done. We were dealing with an unfamiliar branch of medicine with unique constraints on the way we practice due to limited resources which was a novel challenge and was very interesting having come straight from a well-resourced first world hospital and a rotation on Intensive Care! I learnt an awful lot – both about altitude and wilderness medicine and was given freedom to lead consultations and form management plans – good preparation for becoming a FY1 next year.

We saw lots of interesting cases but I’ve summarised two below that I was particularly involved in.

Male presenting with headache, cough, shortness of breath and no appetite.

We were interrupted by this gentleman just before we were about to go for dinner. He walked in and looked grey and exhausted. He had come to us after sleeping for 18 hours straight in his room (but felt like he hadn’t slept at all). He was nauseous, sleeping poorly, feeling feverish and short of breath at rest, with oxygen sats of 51%!. We diagnosed Severe AMS ± HAPE ± chest infection. To cover all bases we gave treatment for all three given he was so unwell. He slept for 3hrs on oxygen and was feeling better. We got his SATS up to 82% but never beyond that. Due to it being dark he had to stay with us overnight and was evacuated the next morning.

 

Male presenting with SOB and chest pain.

We were woken up in the middle of the night by this gentleman who knocked on our door just after midnight. We opened the door and he immediately jumped into one of the patient beds which got us worried. He had a cough started this evening. Has pain in the centre of his chest at 6/10, burning, worse on coughing. His observations were normal.

We were initially slightly puzzled – he sounded very severe but looked fine after he had calmed down. After a few more questions we established that he had this pain before at home. We diagnosed heartburn with a strong component of anxiety, gave antacid and went back to bed!

Although I had to be supervised or discuss patients with one of the qualified doctors, I was treated as a proper member of the team and it was a great opportunity to get more responsibility and independence as a doctor.

After Machermo

One week before I was due to fly back to Kathmandu I left to go trekking on my way back.

After some concerns about the weather, I crossed the Cho-La pass solo on a glorious day! I headed up to Everest base camp and me the doctors working at the ER there. They gave me a tour and told me all about their clinic – they were much busier than we were!

I had an amazing time working with the IPPG. It was a fantastic experience to live and work in the Himalaya, especially having never been to such a remote or high-altitude location before. It was also a great chance to learn about a new and unfamiliar branch of medicine, and to learn about working in resource-limited environments. It has certainly inspired me towards more expeditions to mountain regions, and almost certainly convinced me to do the diploma in mountain medicine in the next few years! I’d like to thank IPPG for the opportunity, and also for the medical student bursary allowing me to do this in the first place.

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Kate Gazzard writes about her experience back in 2009

Interested in a remote experience for your medical elective? Away from the constraints of hospital medicine, whilst having the opportunity to integrate with the local population in a high altitude environment. Read the account below of (now) Dr Kate Gazzard from her time volunteering at the rescue post in September 09:

Day at the office

Just another day at the office

Wow – where to start!  In summary – I had the most amazing trip and would go back tomorrow if I could!!!

Teaching the masses

Teaching the masses

I absolutely loved my whole Nepal experience – the hiking, the mountains, the people and of course, the medicine!  Jenny and Paul were great, acknowledging how close I was to being a ‘real’ doctor and put me to work!  Jen and I hit it off straight away, and she was the most wonderful, enthusiastic teacher giving me every opportunity to see patients myself, present my findings to her and then nut out a solution. She also quizzed me in our down time and encouraged me to present the talks each day which I really enjoyed.

to hypoxic to learn?

to hypoxic to learn?

Kancha and Chewang were also wonderful!  So patient, so friendly and nothing was ever too much trouble!  They were also very patient with my complete lack of ping pong skill but still let me join in the games and even give me a point or 2 for my self esteem! Kencha also gave Jen and I a cooking lesson on my last day – Chapetti bread.  Mine didn’t look anywhere near as perfect as Kencha’s but we ate them none the less and had great fun in the process!

Cookery lessons

Cookery lessons

My only disappointment was that I couldn’t spend longer at Machermo!

In terms of the rescue post itself, I found it to be the coldest building I’d stayed in for my whole 8 weeks in the mountains!  (Not too mention burning a great big hole in my down jacket trying to get too close to the little fire in the lounge room!  Oops!!) I ended up moving to Namgyal’s lodge which was much warmer and gave Jen a bit of space.. nice to have our own rooms, especially as I was getting up at 5 to go walking before work and trying to study before bed.

As for the rescue post manual, it was excellent as a resource and we were all making notes for updates for next year.  As I was leaving, Namgyal and Gokyo were getting internet installed so I’m sure that will make a huge difference for next season. I organised my hike through Ecological Treks (Rakesh and Ramesh) and they were just fabulous with everything for my whole stay in Nepal! Highly recommended!!!  I also got the pleasure of meeting Elsie and having lunch with all of the above plus Jim Duff and his partner before I left K’du.  Great people and great fun!  Thank you for those contacts!

Machermo from the ridge

Machermo from the ridge

At the post we got into a great routine where every second or third morning one of us could start late to allow time for a good hike up the valley somewhere which was heaven! Great for the lungs and great for a bit of ‘me’ time. About 3 times a week I would walk up to Gokyo and have breakfast with the lodge owners of Namaste who have become like family to me, then walk back to work.  I ended up staying with them for 3 extra days after I had left the post en route back to K’du.  Speaking of Gokyo… I heard a whisper that you were looking at setting up another post there.  As I will be a doctor in less than 2 weeks times, I would LOVE to be kept in mind as someone who could help set up the post or do a season in Gokyo. It was my favourite spot out of all the places I visited and I would really cherish a chance to go back and give back to the people in the area that were so wonderful to me!

So, I think that about covers it!  I absolutely loved my time over there and am hoping to maintain contact with Nepal, IPPG and rescue medicine.  I’ve put my name down for the volunteer week long medical clinics run by Ecological each year and one day would even love to spend a season at Everest Base Camp!

I can’t thank you enough for my opportunity to work with the IPPG. I am so grateful for the experience and really hope to stay in touch.