Pre monsoon (spring) 2009

volunteers and Chhewang

volunteers and Chhewang

Report by Dr Shirley Gover, Dr David Gover and Tariq Qureshi (medical student)

We stayed at Machermo from mid-April until mid-May. We enjoyed our stay thoroughly. It was a particularly quiet season but 110 patients were seen and we did have a few cases of severe altitude-related illnesses.

Chhewang and Kancha were good and cheerful company. Chhewang managed the post and kept accounts meticulously and Kancha forever amazed us with his excellent cuisine and variety of dishes. Although there were posters in the Machermo lodges advertising our daily lectures, it was still very important to go round the lodges personally at about 1-2 pm to inform folk that they were taking place. The lectures were well attended and very well appreciated and a good amount in donations appeared for IPPG! More trekkers would have attended if we had managed to deliver the lecture in other languages (we struggled a little with French and German but didn’t do at all well!). It would be a good idea to make up some sheets on altitude illness in different languages to hand out. The excellent Medex booklet “High Altitude Illness” was available to hand out but we quickly ran out of copies. I think this is available in a few languages and I think it would be excellent to stock more of these. Knowledge of altitude illness varied widely amongst trekkers. A good number had very sketchy knowledge. We saw a lot of folk suffering because of too rapid ascent to Machermo. Many people have been given very conflicting advice about the taking of Diamox by their doctors at home.

Chhewang acted as interpreter for our Nepali patients. A PAC bag, pulse oximeter and stretcher are now kept at one of the lodges in Gokyo and Chhewang took Shirley and Tariq up there for a day to meet the lodge owner and check the equipment.

We had some very quiet spells and so it is essential to take lots of things to do. There is quite a good stock of books, including several on “Teach Yourself Nepali”, which I tried in earnest and failed miserably! Card games are very popular in Nepal. You would do well to revise a good few before you go!

In view of the fact we were quiet and that there were three of us, Shirley and Tariq took a trek for two days up to Gokyo 5th lake and ascent of Gokyo Ri, leaving David in charge. David did a three-day trek to Namche leaving Shirley and Tariq in charge.

In mid-May we had three days of blizzards and the number of trekkers fell dramatically. It was extremely cold living at the rescue post! Chhewang decided to close on the 15th May. In fact the HRA post at Pheriche closed the same day. The positive side of this was that Shirley and David had time to trek to Everest base camp with Kancha as porter and excellent guide.

Unfortunately bottled oxygen can no longer be delivered to Machermo post. Luckily the patients we had who needed oxygen therapy did all respond well to the oxygen concentrator. The commonest conditions seen were gastroenteritis, throat and chest infections as well as a large number of mild altitude-related illness. We had a good few folk with more severe illness and I will describe a few typical case histories:-

1) 53 yr old lady

Had trekked previously many times to 5000m without problems. Developed mild chest infection at Lukla. On reaching Machermo cough became worse. She developed temp, headache and nausea. She put herself on Amoxycillin and decided to rest at Machermo. Headache increased and she became increasingly weak and pyrexia persisted. On the third morning she called us down early to her lodge.

OE-

T 38.2

Not short of breath

Chest clear

P 100

Heel toe gait intact

LLS 13

Oxygen sats on air 62 at rest and 56 on exertion

Diagnosis: Severe AMS + chest infection

Rx: Put on oxygen concentrator, Diamox 250mg, Dexamethasone 8mg

Oxygen sats rose to 91% after 20 mins on oxygen. After 1 hour headache had improved enormously, weakness continued. Off oxygen, oxygen sats dropped again within 3 mins to 56%. Therefore helicopter evacuation arranged for that same morning.

2) 58 yr old lady

Sensible ascent to Gokyo, climbed Gokyo Ri (5357m) with no symptoms. On descent from Gokyo Ri onset of severe headache, nausea and fatigue. Daughter with her noticed unsteadiness. Stayed at Gokyo overnight but symptoms continued and started vomiting. Descended to Machermo next day, unsteadiness improved but intense fatigue, headache and vomiting continued. Daughter called us in afternoon to their Machermo lodge.

OE-

Tired

T 38

Vomiting

No neck stiffness

Oxygen sats on air 81%

Not short of breath

Chest clear

Heel toe walk intact

LLS 12

Diagnosis: Severe AMS (+ resolving HACE?)

Rx: Treatment given at centre and observed overnight, Diamox 250mg 8 hourly, Dexamethasone (8mg im stat, 4mg 6 hourly afterwards), Prochlorperasine 12.5mg im.

Oxygen sats remained 81-85% off oxygen. Next morning still very weak, nauseated and headache. Short of breath on exertion but chest clear. Helicopter evacuation arranged.

3) 24 yr old man

He and a friend had come over Cho La and descended to Dragnak. Developed severe headache, they ascended slightly to Gokyo and headache became much worse. Therefore decided to descend to Machermo at 10 pm. Slightly better on arrival.

LLS 7

Oxygen sats on air 83%

Rx: Diamox 250mg, Dexamethasone 8mg and observe overnight.

Next day he was much better. He and friend descended on foot to Phortse Tenga (3675m)

4) Nepali porter (aged 11!)

Brought to rescue post by American trekker at 7 pm who reported he was fine when last seen at 3 pm but had discovered him at 7 pm semi-comatose.

History from friends that he hadn’t drunk or eaten much all day, but no other history was given.

Previously fit.

OE-

Oxygen sats on air 85%

Temp, pulse and BP all normal

No neck stiffness

PERLA

GCS 11

BM 4

Moderate dehydration

Diagnosis: ? Post ictal, but no fit had been witnessed and no incontinence or tongue biting

? Toxicity

Rx: Given oxygen, Dexamethasone 4mg im stat, IV fluids 500ml normal saline. Monitored closely for the next hour and gradually GCS improved to 14. The history was eventually then obtained from his friends that he had drunk two large mugs of local brew (Chang).

We wanted to observe him overnight as his gait was still unsteady but whilst we were preparing some food for him he absconded. He was pursued to Namgyal’s lodge and found to be eating a large plate of Dahl Bhat and much better!

Interestingly, according to the American doc we met at Everest base camp, Methanol poisoning is quite a common problem amongst porters. We saw no evidence of this but this season at EBC they had had whiskey brought in laced with Methanol. One porter had died due to this at EBC and another had become extremely sick with renal failure. They had placed him on an alcohol drip and flown him out to Kathmandu; he had survived. So worth bearing in mind!

Report by Dr Matt Ladbrook

Preliminary

I first heard about the vacancy at the post through an advert posted on the pre-hospital/wilderness medicine forum on doctors.net.  The application procedure was straight forward.

I was able to gather a lot of useful information about the job from Dr Louise Cook over the telephone.  The IPPG website was fairly useful, but as a prospective volunteer I would have liked to have seen more about what to expect from life at the post.  A telephone conversation with a recent volunteer would have also been useful.

Transport and Accommodation in Kathmandu

Booking flights to Kathmandu was not a problem.  Visas can be obtained at Kathmandu airport.  Chhewang met us at the airport and took us to the Hotel Garuda.  Although this hotel has had a good reputation, it is currently undergoing repairs.  At present, better quality accommodation at the same price is easily obtainable elsewhere in Thamel.

Training in Kathmandu

We benefitted hugely from joining in with the Himalayan Rescue Association volunteers’ training.  I would recommend that arrangements are made for IPPG volunteers to join in again in the future.  Training included:  visiting the Nepal International Clinic and being briefed by Dr Bhudda Basnyet, visiting CIWIC clinic and attending Nepali language training lessons.

Travel from Kathmadu to Machermo

No issues.  Flights from Kathmandu to Lukla are often disrupted by poor visibility.  However, medical volunteers are given priority for travel.  The manager of Agni Air is also the manager of the Sherpa Tea House, a lodge right next to the airport.

The route up to Machermo is straight forward enough.  Chhewang is sensitive to the welfare of volunteers and manages progress well.

Activity at the Rescue Post

The post was generally quiet for the first few weeks, growing slowly busier as the season progressed.  The weather was unusually cold for the springtime.  This led to some quite severe disruption of flights into Lukla, which may in turn have contributed to trekkers ascending a little more quickly than they should have …  As the trails became busier, there was a pronounced increase in the amount of diarrhoea being reported (all but one case responded to ciprofloxacin).

We ran daily talks at 1500 hrs as soon as we had the post organised.  We missed just one talk when we went on a trek to Gokyo.  In all, we briefed approximately 400 trekkers, porters and locals.  Feedback received was excellent.  Generally, the sessions would run about an hour, depending upon the number of questions from the audience.  We relied heavily on the colourfully illustrated flipcharts provided by previous volunteers – thank you!  Sales of t-shirt and badges went well.

In total we formally consulted with 50 patients.  About 10% of these required evacuation (see Figure 1).  A number of patients were seen informally – these usually involved offering generic advice or looking at a cut, for example.  These patients were encouraged to make donations.

Figure 1

Figure 1: Bar chart showing numbers at daily talks, numbers of patients treated and numbers of porters staying in shelter, Machermo Rescue Post, between 8 Mar and 12 Apr 2009.

Sadly, a male Japanese trekker died whilst descending the valley in April.  Although I was not involved in his care, I heard that he had become unwell in Gokyo, refused to come to the post, had descended to Phortse and had died there, probably of HAPE.  This death certainly affected to trekkers who heard about it and I noticed far more concern and questions at the daily briefings.

Although it was usual for a few guides and porters to be present at the daily briefings, I do not think that formal briefings for porters staying the night in the post were run.  Perhaps this is something to be discussed with Chhewang.

On a number of occasions, there was helicopter activity noted up at Gokyo.  We were not contacted at the post to provide advice or treatment on any of these occasions.  There may be scope for improving the relationship with the lodge owners or advertising the post more effectively in Gokyo.  At the least, our sat phone number needs to available and the phone kept turned on all the time.  At the moment this does not happen routinely.

In general, we noticed very few posters on the way up to Machermo.  Those that there were, were small A5 sized with typed information – not very eye catching.

Inventory

In equipment terms the post was well stocked.  We felt that having a third oxygen concentrator would have been an asset, as one of the units is often away being serviced.  Additionally, the battery pack on the existing concentrator did not work.

Having 2 – 3 cylinders of oxygen would also be useful.  One of the patients I treated was in Luza, where there is no electrical supply to run the concentrator.

While we were there we had no fluorescein, although I understand that this is usually on the inventory.

It might also be a good idea to obtain a Kendrick traction splint – a light weight femur traction splint that packs into a pouch the size of a large pencil case.  They cost about £50.

The satellite telephone was reliable for making calls, but unreliable in sending and receiving text messages.  Frequently, messages would be delayed or just fail to arrive.  Reception is fine in the porch or from the courtyard.

Summary

I would recommend this posting, but potential volunteers need a crystal clear picture of the environment and of how busy they are likely to be.  Some laptops work at the post (4400 m), despite manufacturers warnings!

I would be happy to speak to people considering volunteering at the post in the future.

Improvements:

  • Put potential volunteers in touch with recent volunteers
  • Third oxygen concentrator
  • Oxygen cylinders
  • Fluorescein
  • KTD
  • More posters
  • Improved relationship with Gokyo

(Jim’s comments: We are in the process of organizing to have a doc at Gokyo village. Oxygen cylinders are subject to bans from aircraft flying into Lukla and we are negotiating with the helicopter companies to get round this. New posters are in the pipeline. Weekend information meets for new volunteers are now run).

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