Hello Everyone! First off, Happy Mother’s Day to me mum and me mum-in-law. I love you both. Also Happy Mother’s Day to my sister, my grandma, and to all those other mums out there in the mumiverse.
This post will be my next to last post before the end of the season. We leave this Saturday to hike the rest of the Annapurna Circuit so our last clinic day will be this Friday. I’ll try to post something this Saturday before we leave (as long as the WiFi cooperates).
There is much to be done this next week including taking inventory of the pharmacy (what meds expire, what meds we used most, etc) as well as recording our clothing inventory (we sell fleeces, t-shirts, hats etc with the HRA logo on them). We also need to fill out an end of year report including our most interesting cases and what recommendations we have to make the clinic better. Also we’ll need to pack for the trek out of here!
This past week I got out for two hikes. One great, one not so great. The first was to this plateau at about 3800m near the town of Julu. It was perfect. I didn’t see a single soul on the hike, the weather was outstanding with that warm mountain breeze & sunny skies, and the views of the mountains were incredible. Short and sweet but one of my favorites thus far.
The 2nd hike was to Tilicho Lake at 5000m, supposedly the highest lake in the world. Jenny and Liz went to Tilicho Lake earlier in the week so I ran the clinic by myself (gasp!) for 3 days including the lecture. Once they got back it was my turn to go to Tilicho Lake. I hadn’t been drinking that much water leading up to the day I left and the morning of my departure I felt a little…off. I thought no big deal, I’ll be fine. Well the hike to the Tilicho Basecamp is 9.5 miles from Manang and about 600m elevation gain, slightly outside of our <500m altitude gain recommendations to help prevent altitude illness. The trail out there was really beautiful but by the time I got to the basecamp I was utterly exhausted. I checked in and laid on my bed for an hour just trying to catch my breath which really is pretty abnormal for me up here. I didn’t eat much that night and finally when I did pee, oh boy, I knew I was super dehydrated. I drank another 2 liters of water but still got a headache throughout the night and had very little appetite with some nausea in the morning. Believe it or not, I had moderate dehydration that precipitated AMS (Acute Mountain Sickness). The lake is another 3 or 4 miles and another 900 meters higher from basecamp. Ultimately I didn’t think it was worth it to push on, I would have made myself more exhausted and put myself at risk for even worse altitude sickness. It was a tough decision and I was pretty disappointed to have to turn around without going to the lake. It’s my first real defeat while hiking but I am glad I had the right mindset to turn around because even after getting back to Manang, I was completely wiped out. Well, I’ll just have to hike out to the lake next time I’m in neighborhood.
While Liz and Jenny were away hiking to Tilicho Lake, Indira had bought some local fish caught from the Marshyangdi river as a special treat. It was this meal that I had my first real moment of “I really don’t want to eat that” since arriving here in Manang. Every meal Indira has made this season has been so good, really I mean it. I always look forward to what she had made for lunch and dinner. That is, except for this one meal. We had the head construction worker Muluk, his wife, as well as Rosen (one of the constructions workers) over for the meal so it really was kind of a special occasion. Now don’t get me wrong, I love fish, really any type of seafood for that matter. My favorite food is lobster. My email is sushiben@gmail. However, this fish…wellll it was basically a bag of bones with a tiny bit of fish meat. I didn’t want to be rude so I ate my fish but the whole time I was thinking “please God let me survive this meal and not choke on a fish bone”. I also couldn’t eat the fish without using my left hand (which in Nepal and India is considered the “dirty” hand) so I was super self conscious that everyone thought I was gross for using it. Even Gobi, who barely speaks at dinner turned to me and said “Hey, are you ok?!”. Oh ya, just great, just over here eatin’ my bones. The curry sauce the fish was cooked in was SUPER delicious but the fish was just….erhhmmm…..not so much. There were leftovers the next day and Indira asked if I wanted some of the limited supply. I said, no thank you, I want you and Gobi to enjoy.
Another big snow storm came through Manang over the weekend dropping about 5 inches of snow. It quickly melted in the mid day sun but the morning was made really beautiful with blue skies and a layer of white snow covering all the buildings and mountains. Who doesn’t love a snow storm in May?! (Probably everyone of my family and friends in New England reading this after the endless winter they just had)
Ok, What time is it? Case Time.
First up is a local Nepali minor trauma patient. He’s in his mid 40s and lives a few towns away. He was riding his motorcycle when he hit a rock and flipped over the handle bars. Luckily he was wearing a helmet which I can’t say is true for everyone in the valley, especially the younger guys. He came in with left flank pain, made worse with breathing. No other pain, no distracting injuries, no belly or chest pain, and no shortness of breath. He had some mild external abrasions over the left flank but nothing too severe and had a lot of pain to palpation without any crepitus. My worry was for a splenic or renal injury as well as for a possible rib fracture or small pneumothorax. Worries aside, he most likely had a rib or muscular contusion. His vitals were all normal, abdomen was soft, lungs were clear, so I gave him the a-ok. He left with some Tylenol + Codeine as well as Ibuprofen for pain control. A check up 24 hours later showed he felt better with the medications. Thumbs up.
I had another pediatric patient again with a viral URI and fever. The kid was just fine but I mainly included the patient because of how cute him and mom were. Nepali women carry their children on their backs. The moms will bend over, place the child on the upper shoulders at which time the kid instinctively wraps their arms around mom’s neck, and then mom wraps a large scarf around both mom and baby making a little baby burrito. So cute.
Our tiny portable ultrasound came in handy for two cases this past week. I may have mentioned before but there is only a curvilinear probe attached to the ultrasound. Anyway, one case was a local Nepali 50-ish male with RUQ pain with eating fatty foods associated with belching. No fevers, no previous surgeries, no jaundice, abdominal exam was benign. Sounds like gallstones. Sure enough, the ultrasound shows gallstones. Easy peasy, lemon squeezy. Recommendations were to go to Pokhara or Kathmandu non-urgently for a consultation with a surgeon regarding an elective cholecystectomy (gallbladder removal). The 2nd case was a 20-ish Danish female with a past history of well controlled hypothyroidism who presented with left unilateral pre-tibial swelling and a sore calf. No chest pain, no shortness of breath, no birth control pill use, and no history of bleeding/clotting disorders in the family. The linear probe is really the most accurate tool for diagnosing a DVT (deep vein thrombosis aka blood clot) but the curvilinear will have to do. I felt confident I was looking at the common femoral vein and it’s bifurcation with the deep femoral vein as well as the popliteal/gastrocnemius veins which were all compressible and without any signs of a blood clot. Not sure why she had the swelling, maybe from a clot in a superficial vein (which is not a life threatening condition) or maybe from her thyroid disease or maybe from something else, who knows. She looked well and the exam and ultrasound checked out. Kind of neat to use such advanced technology here in the backcountry to make accurate and immediate diagnoses and treatment plans.
Lastly I’m really excited about a possible case report write up from this season. Upon reviewing our cases from the season we had two cases of pediatric HACE, one was a 12 year old and one was a 16 year old. I ran the cases by our medical director and another American doctor in charge of recruiting for the HRA and both said that there isn’t much literature on pediatric altitude illness, let alone pediatric HACE, and that I should write up the cases, do a literature review, and submit the paper to the WEMJ (Wilderness and Environmental Medicine Journal). I’m excited to continue a little project after I leave here. Also, just to toot my own horn, I had a case report published recently in the WEMJ in March of this year that I forgot to mention earlier in my blog. You can find the article here: https://www.wemjournal.org/article/S1080-6032(17)30257-0/pdf. If you don’t have access just shoot me an email and I’ll be happy to send it over. It’s a really incredible story of a man who had a cardiac arrest on Mt. Monadnock in New Hampshire and was saved by the park ranger there after she shocked his heart back into rhythm. He made a full recovery after coming to our hospital which is definitely not the norm considering how advanced his disease was. I interviewed the patient and the park ranger so the paper is more of a Q&A story type publication. Worth the read if you’re interested.
Ok, that's all folks. Stay tuned for my last post from Manang before we leave for the western half of the Annapurna Circuit!