Musings from Manang
Hey everyone! Happy New Year! (Saturday April 14 was the Nepali New Year so it's now the year 2075 in Nepal) Lots of updates to report on!
First off: I have finally moved into my permanent room! I can’t even tell you how happy I am to have my own space. For the last 3 weeks my door was always open, dust was always blowing in all over my clothes, construction workers were coming in and out of the room, it was cold, and I never truly felt “home”. Now that I have my own space I feel so much more settled which is nice. Now that I’ve set my room all up and I’ve been able to take more regular showers/wear clean clothes Indira is calling me “fancy boy”. I guess that's better because up until 2 days ago Indira thought my name was "Ban".
In other news, there has been a theft in the kitchen. On the early morning hours of April 10 Indira heard a strange noise coming from just inside the kitchen. She investigated just in time to get a small glimpse of the culprit caught read handed before he made a daring escape. His name: cheese dog. His crime: eating a quarter wedge of yak cheese including the wrapper covering the cheese. Indira found the dirty thief later on in town, scoping out his next target no doubt. She was able to snap a quick picture.
Also big news: Gobi’s 10 year old son Grishm arrived early last week and it’s been really fun having him around. Grishm came up to Manang in a jeep (which we totally don’t recommend) and he pretty soon got sick which we all assumed was acute mountain sickness. Soon though he was spewing liquids from both ends and quickly came to find out he had some questionable fried noodles in one of the lower villages that gave him gastroenteritis. In 24hrs he felt great….his dad on the other hand got sick with the same symptoms right around the time Grishm got better. Oh well, all is good now and luckily that GI bug didn’t spread to the rest of us.
The electricians have left after rigging up the whole clinic and bedrooms with lights and power. They even installed a set of solar panels on our old lecture hall for back up power. We celebrated them and the end of the electrical work by having a big meal together where Indira cooked up some delicious dal bhat (of course!), chicken curry and vegetable curry, tomato chutney, and some raw onions and chilis on the side. Wicked good. The only thing missing was a little raksi (local wine, wikipedia page here: https://en.wikipedia.org/wiki/Raksi).
I took a small trip to the neighboring town of Braga and walked around the monastery there which was a really nice break. It’s perfect moments like sitting and watching the clouds roll by while feeling the warm wind blow across my face that keep bringing me back out to the mountains.
Over the weekend we had a big snow storm come in. At first I was like, “please no more snow, I escaped the New England winter to get away from the snow” but that attitude softened when I learned this was the first time Grishm had ever seen snow. We had some snowball fights, built a snowman, and played target practice until the midday sun evaporated all the snow away.
Ok, enough with life updates. On to the cases!
Two broken bones this past week. We don’t have X-rays but the exam was pretty consistent with fracture in both cases. One was a Chinese trekker who rolled his ankle coming off a ledge. His entrance to the clinic was a little dramatic as a jeep brought him to the edge of town and four locals grabbed a stretcher and brought him in on it, basically dropping him in the middle of our dirt courtyard. He likely had distal fibular fracture, possibly a really bad ankle sprain, but the guy had severe point tenderness over the posterior lateral malleolus and could not weight bear or even walk one step. Either way both diagnoses would be treated the exact same as far as our management is concerned. When we told him his trip was over he was so upset and eventually started crying. Poor guy. Liz and I splinted him, loaded him with some ibuprofen and acetaminophen with codeine and got him some crutches. Plan was for jeep evac the following morning. The guy spoke little English and when I asked him if he had used crutches before he didn’t even know what I was talking about. We got him on the crutches and tried to give him some instructions on how to use them. At first it all seemed ok but the guy had to walk about 2000 feet to his hotel room for the night. Gobi and I escorted him over there and the guy was like swinging his whole body weight from one step to the next. I kept pushing him back while Gobi kept pulling on his clothes from behind. “Dude! Slow down! You’re going to fall!” It was almost comical how reckless this guy was on crutches. He was swinging over rocks and ledges like there would be no consequence if he fell. It took probably 15 minutes to get him from the clinic to the hotel and while we waited outside for the hotel owner to get the keys to his room he says “I walk now, I think I walk, it ok, I can still go over pass”. The ibuprofen and tylenol with codeine had kicked in at this point. He had said this so many times previously and I kept telling him “no way” but this time I just said “ok fine, if you can walk go for it”. He took one tenuous step, little pain, then another step and he screamed in pain. “Ya dude, your ankle is broken, you’re not going up the pass”. Anyway, he left in the morning for X-rays and possible casting. The hotel owner returned the crutches which was great cause that is our only pair. Oh and the other fracture was a local who had a large rock fall onto his arm with a radius fracture. That case was much more straight forward.
Also in the mix of cases this week was a Ukrainian who decided to do the Annapurna circuit clockwise which meant at the Thorung La pass he went from Muktinath (elevation 3700 meters or about 12,200 feet) to the Thorung La base camp (elevation 4900, or about 16,000 feet) which is a difference of 1200 meters in one night, an almost guarantee for altitude sickness that high up. He made it over but by the time he got to use he was SUPER sun burnt, felt really short of breath and sick, and had oxygen saturations in the low 70s with crackles at the bases. Guy was a hot mess. Jenny gave him O2, nifedipine, some aloe for the burns, some mild pain killers for the headache, as well as the treatment dose of Diamox for his AMS. Heli evac was a pretty obvious choice for moderate HAPE, he agreed, and Gobi arranged everything. Well…after the helicopter took off and was half way to Manang the patient called and cancelled the helicopter on his own accord without saying anything to anyone. Gobi got the call from the helicopter company that they were turning around. The guy had decided that he now didn’t want to pay the fee for arranging the helicopter. Ugh, frustrating. He improved over the next 2-3 days but quickly became a pain in the @$$ coming and going from the clinic. Eventually him and his girlfriend decided to walk down after 3 days here in Manang. Good luck and godspeed buddy.
Lastly we had a young local who had a large right axillary mass, aka a lump in his armpit. It was presumed to be an abscess. Jenny saw him initially and after telling me about the case I said “oh we can ultrasound that”. We have a sonosite ultrasound with a curvilinear probe up here. The guy had already left but came back after 3 days when the lump increased in size with more pain despite antibiotics. (I know I know, any medical people reading this, the treatment for abscess is I&D [incision and drainage], he wasn’t my case). On his second visit I was around and quickly got out the ultrasound. The results were, ummm, not super straightforward. The pictures showed a heterogeneous complex cystic structure, not a big black fluid filled sphere that would be typical of an abscess. Likely what I was seeing was a located abscess. The patient’s mom was here this time. I gave her the option of having us cut it open or going to Pokhara to have a better ultrasound done and having the I&D done there. She opted to go to Pokhara because she said the same thing happened to his son last year and last year’s team tried to cut it open but it didn’t work and he needed a second I&D in Pokhara. Ok, down he went. Not the most exciting case but it was the first time using the ultrasound here so I thought it was worth mentioning.
Well that’s it for now. Stay tuned for next weeks post where I may be sharing my experience at the Throng La pass at 5400 meters, the highest I will have ever hiked in my life!