Machermo post monsoon (autumn) 2009 report

Report Machermo Sept – Nov 2009 – Dr Paul Nickson
(edited by Dr Jim Duff)

Travel plans were largely tied in with the HRA induction course, the dates of which were uncertain. The need to book flights well in advance made this a little difficult. From previous reports it looks like most people have flown from Heathrow. Living in North Wales, Manchester was the most realistic option and the best deal was with Etihad Airways flying via Abu Dhabi. There were few flights that only made one stop (i.e. direct from AD to Kdu) and a Saturday flight costing around 605 GBP was the best deal. A simple phone call to their customer service desk ensured a luggage allowance of 30kg for myself and Ann, my partner, on both flights. In terms of booking return flights, Chhwang has closed the centre sometime in the first week in December, so a return trip booked for e.g. 10th December would be sensible, though I’d booked mine for 29 November.

As we arrived end of Sept at the very beginning of the tourist season it was very quick getting the visa organized at the airport, especially if you print off application form from the internet before hand and have 2 passport photos and the ready cash in dollars.

I met up with Dr Jenny Visser from NZ, Nick Cochand Med student and Chhwang in Kathmandu.

Chhwang was invaluable in sorting out our TIMS cards (for which passport photos needed), sorting out our tickets from Kdu to Lukla (and getting us onto the plane!) and getting credit for the mobile phone

The trip up to Machermo was largely uneventful but we experienced a late monsoon weather system which meant it was low cloud all the way up with only occasional glimpses of high mountains. The first couple of weeks were characterized by low cloud most of the day with mist drifting in by 3pm – generally cold and damp – rather like north Wales!

I had planned for freezing temperatures, not realizing that the stay in Kdu would be very hot and the journey as far as Namche was also quite warm – so pack some light weight cotton clothes as well as thermals!

In Machermo

A typical day –
Get up about 6.45 – although it’s light earlier, especially as the season progresses it’s just too cold to get up before then!
Kancha provides sweet Nepali tea then breakfast, after which the luxury of hot water for washing – it’s surprising how much of oneself one can wash with a small bowl of water!
Then it’s time for a round of highly competitive table tennis between Chhwang, Kancha and myself.
8am is usual time for planned follow up of patients seen the day before especially to review GIT problems or altitude symptoms before they depart up to Gokyo.

If it’s all quiet (and it usually is) one of us goes off for a walk leaving the other to “hold the fort” till lunchtime about 11.45. There are good walks up on the ridge north of the rescue post from which good views of Everest or the southerly ridge overlooking Luza, or up the valley, or as far as Pangka or first lake towards Gokyo. The fort holder can often read in the sunshine or catch up with domestic chores (by early November the water pipe doesn’t thaw out till about 9.30!)

After lunch there’s often more time for a walk and 1.30 one or both of us does the rounds of the lodges inviting people to the altitude talk at 3pm – it’s usually too cold and windy to sit outside after lunch and the sun goes off the centre by 2.30pm after which time the temperature plummets.

The daily talks are fun to give and we usually shared the talk, one of us doing the first bit (about IPPG and acclimatization and normal symptoms) and the other talking about AMS, HACE an HAPE. Most are keen for the pulse oximetry to be measured, tee shirts sell quite well and so do badges. Trekkers often book consultations on the basis of the talk.

After the talk the stove is lit (thank goodness – see below) and more tea, then evening meal at about 6.30 and we’re off to bed by about 8-8.30 as the heat goes out of the stove.

Social life in Machermo
Such as it is! Going round the lodges is probably the most sociable activity. We have had various visitors/friends etc drop by. It was good to see Dr Jim Duff and his party of UK and Australian doctors and we discussed plans for a rescue post/porter shelter in Gokyo which I think is much needed. We made a point of going out on Saturday nights to different lodges for a meal – it gave Kancha the night off and enabled Chhwang and Kancha to do some socializing – although we went out together they usually gravitated to their Nepali friends but we paid for their meals.

There is much time for reading – there is a wonderful and ever changing library as people donate or swap books. I too have failed to learn a significant amount of Nepali – to my shame. Amendments to the “library list” in the manual I believe will be made.

There is a DVD player with a selection of reasonable films – we understand it will play UK and Aussie DVDs, but some buy supplies in Kdu.

Sleep at altitude is often a problem – an iPod/MP3 player invaluable for those wakeful hours in the early morning when it’s too cold to put your hand out of your sleeping bag to hold a book!

Trips away
There is really no need for there to be two doctors there in terms of workload but it is very important in terms of moral support, companionship and having someone to bounce ideas off, particularly with difficulty cases of ?HAPE etc. Ann and I went to Gokyo, checked out the PAC bag at Gokyo Resort to make sure it was functioning (it was, but we were not convinced that the lodge owners knew how it worked) We also came across a sick porter about which Jenny will write in her report.

Jenny also had a trip to Gokyo and did Gokyo Ri and later had a separate trip to the 5th lake. She also spent a couple of nights at Phortse/Tengboche for the Mani Rimdu festival at the beginning of November. With Jenny’s agreement I left a little early (13th November) to meet up with Ann and do the Everest base camp trek – Jenny met up with her son and husband at the end of November to do the same via Cho La with Chhwang and Kancha when the post was closed.

Things to bring (or not)
No need for thermarest – plenty of mattresses at lodges
Alcohol gel just need for trekking – plenty at Machermo
Probably more money – easy to get though 1500nr/day (12GBP) just on food/drink while trekking especially the higher up you are. ATMs in Kdu will let you have 10,000nr at a time on debit cards.
It was great to have Jenny’s laptop for use as DVD player, downloading photos/transfer to memory sticks, recharging MP3 player and typing this report – not sure if there’ll be a IPPG one in future

I’ll leave Jenny to comment of the clinical side of things. In summary, a great experience – wouldn’t have missed it for anything!

Post Monsoon 2009 Season Report- Dr Jenny Visser
(edited by Dr Jim Duff)

First of all, many thanks to IPPG for this opportunity to practice a wide range of medicine in a beautiful and remote setting. It has been a challenge and immensely rewarding both professionally and personally. A huge thanks also to Chhewang and Kancha who supported and fed us and never tired of our requests for help. I would recommend the placement to any colleague who wants to experience something different, just don’t expect to see 30 patients a day!

The season started quite slowly and numbers of patients seen and trekkers at the lodges seemed to be down on previous seasons. Numbers picked up in late October and early November. Chhewang commented that the latter half of November was uncharacteristically busy; perhaps the recession had some effect on when people booked their trips?

On 16/10/09 a helicopter evacuated 2 sick trekkers from a trekking/camping group in Machermo. One had apparently been sick most of the night and in/out of their PAC. We were not called for assistance or advice. We had met the guide and members of the group in the preceding day, the guide was very experienced and discussed management of AMS/HACE and HAPE intelligently, however, we felt that we could have contributed to the assessment and management of the trekkers. I’m not sure if/how we can influence trekking companies and their guides so that they utilise all available resources (including us when we are only a few yak fields away!!).
There was the death of a porter in a freak rock fall accident on the Cho La pass early in the season. We saw a Swiss trekker the following day who had also been hit in the same rock fall, she was only meters away from the porter who died.

Internet facilities were connected at Gokyo in early November. They are up and running at Gokyo Resort (I sent one email successfully to NZ). On dial-up, so quite slow, but works! Cost 1000R/hour. Namaste Lodge also has an internet connection but it was not running when I tried it, lodge owners are waiting for their teenage sons to return to sort it out.

We saw a total of 176 patients (Nepali local=32, Nepali porter=33, Nepali guides=8, Nepali cooks=2 Total Nepali=75 and 101 trekkers).

The breakdown of diagnoses are given in table 1.

Of all diagnoses in all patients seen, gastrointestinal problems were the most common cause of presentation (just over 25% of all diagnoses). The second equal causes for presentation were URTI/LRTI/ENT closely followed by AMS. The fourth most common presentation was for trauma/musculoskeletal problems (including both acute and non-acute problems). Altitude related insomnia accounted for just over 5% of all presentations (this category was for insomnia alone, if the patient also had a headache, the insomnia was included in the AMS category). HAPE accounted for 4.2% of all diagnoses and HACE 1.6%. Dental and dermatological presentations accounted for 1.6% each. PUOs, genitourinary and psychiatric presentations accounted for smaller percentages. Thankfully there was only one death (see case write-ups for details).

“Other/Miscellaneous” included headaches of uncertain origin (4), palpitations (2), snowblindness (1), pterygium (1), postural hypotension (1), chicken pox (1), shingles (1), thrombosed haemorrhoid (1), contraception (1), nifedipine for HAPE prophylaxis (1), stye (1) and transient neurological event ?HACE (1).

In Nepali, the “top 3” presentations were for URTI/LRTI/ENT, then Gastrointestinal problems and then Trauma/musculoskeletal. In trekkers, Gastrointestinal problems and AMS presentations were almost first equal and URTI/LRTI/ENT third most common.

In Nepali, 1/3 of gastro presentations were for dyspepsia/reflux and 2/3 for diarrhoea/vomiting/nausea. In trekkers all (except one presentation for constipation) were for diarrhoea/vomiting/nausea. No trekker presented with dyspepsia/reflux.

In Nepali, we saw little AMS just one case of HAPE (in a Nepali guide).

There were 10 evacuations (5.8% of all patients seen). Eight were by helicopter, one porter carry and one by horse (see table 2 for details).

The daily talk was well attended. It often provided the social highlight of the day and we both enjoyed giving the talk, meeting people and answering questions. Chhewang says that this season we raised a record amount from pulse oximetry readings (the challenge is on!). The badges proved popular and we were sold out by 2/3rds of the way through the season. Tshirt sales were steady.

A total of 1317 people attended the talks. Trekkers formed the bulk of attendees (1159/1317) ,but many guides and some porters also attended (154 in total). See table 3

I’m not sure how this compares with other seasons, but the word amongst guides and trekkers was that this was a particularly bad season for gastrointestinal problems. Rumours circulated of the “Namche bug”, that the local mineral water was tainted, that 80% of a commercial trek needed to be evacuated off Renjo La because they came down with acute gastro symptoms etc. We did see a number of groups where many members were affected, often with symptoms coming on within hours of each other. There appeared to be three distinct patterns:
1 Severe nausea followed by vomiting and variable diarrhoea. Many members in one group (often tented camps) hit within hours of each other. Often lasting less than 24hrs and many settling without antibiotics. The presentation and clinical course would suggest a toxin induced food poisoning.
2 Severe nausea, stomach cramps, vomiting with/without diarrhoea. Members of a party affected sequentially (in 24hr periods). Acute symptoms often settled within 24hrs in both those on/not on antibiotics. Presentation tends to suggest an infectious viral gastroenteritis.
3 “Classic” traveller’s diarrhoea. Abdominal cramping followed by diarrhoea with minimal to moderate nausea/vomiting, usually responding to antibiotics within 12 hours.

Whether or not these were in fact distinct entities, I don’t know. Without faecal cultures difficult to know for sure (would make a great research project, if only we could arrange to culture samples). We still tended to treat all diarrhoea with antibiotics to cover the possibility of bacterial diarrhoea.
In all, 39 patients presented with diarrhoea/nausea/vomiting/cramping type symptoms. All those treated with antibiotics (except one) responded to ciprofloxacin. One trekker was placed on azithromycin as first line because of previous quinolone intolerance. One trekker had no response to ciprofloxacin after 24 hours and was switched to azithromycin. Of interest, one trekker with persistent diarrhoea, had been on 6 days of azithromycin and responded within hours with a change to a stat dose of 1g ciprofloxacin.

Studies at CIWEC and NIC that show that Campylobacter, not enterotoxogenic E.coli (ETEC), is the predominant organism isolated in travellers presenting to clinics in Kathmandu. However, thinking about it, is the predominant cause in trekkers on trekking routes still likely to be ETEC, given that this is faecal-oral and Campylobacter is more likely to be linked with poorly handled/cooked meat/chicken (not eaten by most trekkers)? And does this explain why we still get a good response to ciprofloxacin as first line therapy?

A switch to azithromycin (rather than a quinolone) as first line treatment for all diarrhoea in travellers to the Indian sub-continent and parts of SE Asia is an ongoing debate amongst travel medicine practitioners. There has been a drive towards this amongst some. Although none dispute that Campylobacter is now the predominant organism (and that a quinolone will have little, if any, effect in treating Campylobacter), debate remains as to the benefit of treating Campylobacter with antibiotics. I’m not sure what the normal practice is in the UK, but in NZ we have not treated acute Campylobacter with antibiotics for some years now. On the other hands, we have a lower threshold to treat travellers, especially when trekking at altitude, and I am generally supportive of this. For the moment, given our experience (and that of the last season) that most diarrhoea seen responded well to ciprofloxacin, I feel very comfortable retaining our current protocol.

Out of personal interest we recorded 677 of the talk attendees pulse oximetry results. These were all recordings taken at the end of the talk after they had been sitting listening to us for about an hour. The average 02 Sat reading was 87.3% (very much in keeping with what is expected at Machermo’s altitude). The range of readings (remembering that these were all asymptomatic patients) was 60-96%. The average pulse was 85.6/min (range 45-126/min).

Again, out of interest we recorded prophylactic diamox use in those trekkers having pulse oximetry done: 156/677 (23%) of were taking diamox. A handful of trekkers (5) were taking Gingko biloba prophylactically (all Americans) and a few trekkers said they were taking a Chinese herbal extract (not gingko), but we never found out what this was. There did not seem to be a clear association between country of residence and diamox use (I haven’t had time to do formal tests of association).

Note: 315 porters stayed in the shelter


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