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  • Ben Church

Manang!

Arriving in Manang was a bit, ummm, anticlimactic. We arrived to basically an active construction zone. I knew this going into it but didn’t really comprehend how much building materials and dust and junk would be strewn about the place.


(Our courtyard for the time being until all the construction is done)

(the massive junk pile where all the construction scrap ends up but with pretty mountain views)


My room isn’t flagged to be a bedroom, it’s actually going to eventually be an office, but it will have to do for now until our bedrooms are finished. Jenny and Liz are also housed in future office rooms as well. Indira and Gobi are in bedrooms but I’m the only one who has electricity in their room at this point which is kind of nice. We have a random little water tap outside for washing dishes, washing clothes, brushing teeth, and for drinking water after boiling of course.

(my temporary room, little messy at the moment)


As a small aside there is a friendly dog named Bhalu who frequently sleeps outside the main entrance to our clinic and occasionally steps into the courtyard for a quick visit.



Bathrooms. Ah the bathrooms. I had heard we would have regular/western toilets here but alas, these are not ready either. Squat toilet it is. See below. I have gotten used to using them, not to say I enjoy it, more that I’ve got no other choice. I talked to Deepali on the phone and told her about it and she says “See! They aren’t so bad are they?!” Errmmmm ya I guess? Squat toilets are old hat for her as she’s been to India tons of times growing up. Anyway, it’s temporary as the bathrooms and toilets are all ready, it’s just that the plumbing needs to be set up. This will likely happen in the next week or two, fingers crossed. But really, having western toilets is kind of a luxury around these parts as all the previous teams from the last 37 years have been using squat toilets so I really can’t complain.



(The squat toliet)


Indira is the Queen of the kitchen and has been spending her time organizing all the food stuffs in between serving up some really yummy and filling meals. Breakfast so far has been muesli, chapati pancakes with honey, porridge with golden raisons, and more muesli. All served with milk tea or hot chocolate. Mmmmmmmm. Lunch is dal bhat almost without fail. Indira’s slogan is “DAL BHAT POWER, 24 HOUR” so I doubt dal bhat lunch will change too much. I don’t mind as it’s a super hearty and delicious meal after a solid morning of work but it is giving me a little bit of HAFE. Dinner is a little lighter than lunch with dishes like tuna pizza, soups, chapatis with veggie curries, and aloo roasti (shredded potatoes with yak cheese).


I’ve spent much of this past week indulging in my OCD organization tendencies by labeling and organizing our entire pharmacy. Guess I have part of the pharmacy gene in me after all (making my Dad proud!). It took the better part of 3 days but I’m happy with the result. There was just bags and boxes of mixed up meds and bandages and gauze and equipment and needles that were all totally useless if you needed any of it. The antibiotics and some of the other meds were already organized but really 75% of the pharmacy was a total mess. NOW if you need anything at all you just look at the shelf and it’s all labeled clearly. Ahhhh, so much relief. Believe it or not there is a whole airway kit up here replete with endotracheal tubes, cricothyroidotomy kits, BVMs, and rocuronium. Hopefully I will never, ever, ever, EVER have to use any of that equipment but if I do I know I’ll have a little Cien voice in my head whispering sweet airway mnemonics in my ear.


(view of the pharmacy)

(antibiotics, altitude meds, anti worm, you name it we got it...expect maybe tPA)

(one shelf after days of organization, ortho supplies/gauze with suture and wound materials to the right)


(the clinic room where we see patients)


We’ve seen about 35 patients this past week which has been a really great change of pace from the endless tidal waves of patients at the Baystate ER miracle center. Complaints have ranged from lacerations and blisters to diarrhea and stomach aches to pneumonias and of course some altitude illness mixed in. We had our first HACE case a few days ago which was exciting. A young girl who came up to Manang too fast with her family. The road to Manang is both a blessing and a curse in that it lets people ascend too fast but at the same time when it’s time to evac someone the road facilitates this really well. She had a severe but gradual 10/10 headache starting the night before with lots of vomiting, anorexia, and just an overall super crummy feeling. No confusion at all but on physical exam she had a wobbly heel-to-toe walking and some end dysmetria with finger to nose. We sent her down by Jeep to Chame, about 1000 meters lower. Dexamethasone was obviously recommended. Not a slam dunk case of HACE but she was in the grey zone of severe AMS vs mild HACE, best not to be cavalier with management here.


Another interesting case was of a Nepali guy with what appears to be chronic mountain sickness. I really didn’t know too much about this condition until encountering this fellow (being around a UK doc and NZ doc I’ve naturally been picking up some of their terms like jolly good and wee bit). He’s in his mid 40s to early 50s and normally lives much lower down near Kathmandu. He goes up to work at a tea shop just below the Thorong La pass at bout 5200 meters (about 17,000 feet) during the hiking seasons of Spring and Fall. Gobi has seen this guy a lot. He usually presents with moderate to severe lower extremity edema/swelling as well as facial and sometimes arm swelling. Prescription for Lasix has usually fixed him up but not lately. Descent also improves his symptoms. On exam he has obvious hypoxia induced clubbing of his fingers (see pic below) and has resting O2 saturations of about 70% without respiratory distress. We suggested Diamox with the Lasix this time around to see if that would help. He plans to come back in a week or two with a bunch of medical paperwork that his wife has including labs and chest X-rays from Kathmandu so I’ll keep you posted with any new ideas.




Anyway, the Wifi is obviously up and running at this point so hopefully updates will be a little more regular on a weekly basis. Let me know in the comments if there are any other pics or things you wanna see around the clinic!

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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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