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  • Ben Church

Goodbye Manang

Well, that’s all folks. We leave the clinic and Manang behind, the place that has been home for the last 2 months, and start our trek over the western half of the Annapurna Circuit. Every step I take is one step closer to home. It’s a bittersweet feeling. I’m definitely ready to start heading back to America but also a bit melancholy that the experience is coming to a close.


This week went by really fast. The medication inventory is done, the clothing inventory is done, and our bags are all packed and ready for the Jeep trip back to Kathmandu. I gave the last of the altitude lectures to a standing ovation (just kidding, a few people clapped and one person sneezed). Now I’ve just got to get over the pass at 17,000+ feet for a second time and it’ll be all new mountains, rivers, and scenery on the other side.


I had one of the best experiences/moments this past week that probably will be one of my favorite and most memorable of the trip. Indira brought Liz and I to one of the local gompas to take part in a small ceremony. The name of the ceremony is in the local language so Indira doesn’t really know how to spell it but basically it is a time when those who are feeling lonely come to the buddhist temples/gompas to pray/chant together so that their loneliness is diminished by all those around them joining together. We made a small offering, I lit two butter candles (one for Deepali and one for my family which obviously includes my new family on Deepali’s side), and said a small prayer for myself and for those I love. There were about 2 dozen men and women chanting. The whole experience was so calming and I truly felt this inner peace sitting and just emptying my brain of all the useless noise. The lama there gave us a small blessing with flower infused water. I asked Indira about the water after the ceremony as I watched her drink it so I did the same. She told me it was the water the lamas bath in. She let the joke go for a while before finally telling me she was joking. Ha. Ha. For a minute I thought I drank holy bath water. Later, as I walked out of the temple I was feeling so at peace and then I noticed a dead chicken hanging from the doorway. Indira said it was good luck. I might incorporate this into my apartment back home, what do you think Deepali? We walked out of the temple and Indira saw some women she knew who then invited us over for tea. We sat in the sun, drank some peach tea, Indira chatted with the ladies, and eventually I seized the opportunity and took a selfie. The hike back to the clinic turned into an impromptu Nepali nature walk with Indira pointing out local plants all the while exclaiming “oh you can eat this!” quickly followed by her picking what looked like grass and quickly chomping it down. We were only gone for 2 hours but it was absolutely perfect.

hiking up to the gompa

baby yak

inside the gompa

butter candles





Really beautiful Buddhist art that is found on the outside of many Buddhist temples. Lots of symbolism within this. This particular art is called Bhavacakra. On a very basic level, the upper 3 quadrants represent the levels of heaven while the lower 3 quadrants represent the levels of hell with the outer ring representing daily life. The entire image is the universe with the circle representing the wheel/circle of life and re-incarnation depending on your good or bad deeds in life, Karma. If you're interested definitely read more by following the links below

Bhavacakra wiki page here: https://en.wikipedia.org/wiki/Bhavacakra

Levels of samsara: https://en.wikipedia.org/wiki/Sa%E1%B9%83s%C4%81ra_(Buddhism)


the good luck rotting chicken

Liz and Indira

me and Liz

me and Indira

the gompa gate

chatting

tea time selfie!

The construction is coming to a close. The workers here really have made this place really comfortable, especially so for all the generations of doctors coming in after us. Hot showers, western toilets, large beds, stone courtyard…it’s basically a 5 star hotel at 12,000 feet now.


One interesting thing that is ramping up around these parts is the caterpillar hunt. You heard that right, the caterpillar hunt. Technically the hunters are after a fungus called Ophiocordyceps sinensis that kills the caterpillars and then grows out of their head (wikipedia here: https://en.wikipedia.org/wiki/Ophiocordyceps_sinensis). It goes for big, big money and is used as an aphrodisiac in eastern medicine. Price is something like $10,000/kilo. So the lodges are all full of people coming to get their slice of the pie. As the trekking season ends, the caterpillar season begins.


Lastly, I wanted to include a snapshot of our lecture for everyone who has been following my blog. Below are all the slides from start to finish we use to give our 30 minute lecture. My favorite is the 2nd to last slide.

Intro slide

Acclimatization slide

AMS slide

AMS risk factors

schematic of the trek over the pass

AMS treatment

all things Diamox

HACE

HAPE

HAFE. Result of low atmospheric pressure combined with copious amounts of dal bhat

Closing slide

Case time? Case time. Last Case time ever!


A young local teenager came in with oil burns to his left foot. The burns occurred about 5 days ago, blistered, and then the blisters rubbed off when he put his sandals on. No loss of sensation to the burns which would have been consistent with 3rd degree burns. They were 2nd degree burns covering about 1-3% of his total body surface area. Back home, these go to the burn center. 2nd degree on the hands, feet, face, genitals, etc, basically any sensitive/important area get referred. Really large burns like 2nd degree covering >20% body surface area or 3rd degree covering >10% body surface area get referred as well. What happened here? We put some silver infused cream on ‘em and wrapped them up. Keep the wounds clean, keep them dry, and god speed.

ouch, 2nd degree on the forefoot, black spots are likely 1st degree burns

small area of 2nd degree burn

We had 2 helicopter evacuations this week!


First was a middle aged Thai trekker who came in late at night with vomiting, fatigue, and headaches. Long story short, he had evidence of food poisoning as his symptoms occurred acutely after eating. He also had some mild acute mountain sickness. Vitals were notable for O2 saturations of 85%. I gave hime Zofran, encouraged fluids, and started Diamox. He came back the next day now with diarrhea, more fatigue (laid in bed all day), and worse headache. His O2 levels were still in the 84-85% range. He really wasn’t improving after 24 hours so evacuation was recommended. Antibiotics were started for the diarrhea. Unlike in America, diarrhea here is almost always bacterial so the recommendation is start antibiotics at the first sign of diarrhea. Since he was having a bowel movement every 1-2 hours, a Jeep evacuation involving 10-12 hours of driving seemed cruel. A helicopter evac was coordinated and while we were talking to the insurance doctor he heard oxygen saturations of 85% and panicked. “Give him oxygen right now!!” Ok, whatever you say boss. I got a great video of the evac and I thought some really great pictures as well. Thing is, when I got back to the clinic, I realized I left my SD memory card for the camera in my room. Rats! Oh well, I got some good photos of the next day’s evacuation. I did get an update from the patient’s wife that he was admitted to the hospital in Kathmandu and was given IV fluids and antibiotics. They collected a stool sample that came back positive for an invasive bacterial illness in his gut. He was better after 48 hours and was then discharged. A+


The second patient was a young, healthy female who had about 24 hours of right lower quadrant (RLQ) abdominal pain. Her pain started after lunch at which time she felt like she needed to have a bowel movement which she did x3, all soft stools and no diarrhea. This symptom is medically known as tenesmus. She then had vomiting later with more RLQ pain. She had anorexia to dinner that night as well as breakfast the next morning with more pain and then presented to our clinic at 9AM. No urinary symptoms or gynecologic symptoms. Her vitals revealed a fever of 38C and tachycardia to 122. Hmmmmmm. The exam had obvious RLQ pain with severe guarding and rebound tenderness with a negative psoas sign but a positive obturator sign and Rovsign’s sign. This all very suspicious for appendicitis. I did do an ultrasound to look for a super large ovarian cyst which showed a normal ovary. Her urine pregnancy test was negative. She did have a diarrheal illness 1 month before which is important because a diagnosis called mesenteric adenitis is on the differential diagnosis. Mesenteric adenitits is more of less reactive enlarged lymph nodes that occurs after a diarrheal or upper respiratory illness. She got some pain control and I held off on antibiotics as she was leaving on a helicopter within hours. She left on the helicopter on Thursday and emailed me Friday. Guess what? Big whopping appendicitis. Had the surgery very soon after arriving in Kathmandu. Really happy everything turned out well and I made the right decision to evacuate her. At the time of this posting she was recovering well in a Kathmandu hospital post-operatively.


the helipad looking north

the helipad looking south

chopper arriving

chopper landing

Gobi springing into action after directing the helicopter to land

the patient and friends waiting to board

Gobi, man of mystery, man of action

the heli leaving


Finally, not my case but one from Pheriche that I got from Carlo (the other wilderness medicine doc working at our other clinic). A man was walking down the Lhotse face after summiting Everest (with something like 90+ people summiting that day) when a fridge sized piece of snow/ice came barreling down and basically snapped the guy’s tibia and ankle in half. Her got splinted at camp 3 and then helicoptered off to Pheriche from there! That’s amazing since most helicopter pilots won’t fly that high because of the low atmospheric pressure. I told Gobi the story and showed him the picture below where he recognized the pilot and said “oh that guy?! he’s a total cowboy. Italian guy who will fly wherever, whenever, in the worst weather. I’ve flown with him before and I would never do it again”. High stakes at Everest for sure.


pretty solid splint job

I won’t be updating the blog again until Monday the 28th/Tuesday the 29th once I’m back in dusty Kathmandu. If you’ve been following along this long stayed tuned for my trip report from the western half of the Annapurna circuit as well as a last post reflecting on my time here before I head back home! Namaste!

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I'm Ben! I'm an Emergency Room doctor in Massachusetts who loves backpacking. I'm spending 3 months in Manang, Nepal at 11,500ft above sea level from March to June 2018 volunteering with the Himalayan Rescue Association. This is my blog about the experience.

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