1 month in the mountains, 1 month to go. Hard to believe I’m at the halfway point of my time in Manang.
I’ve been away for much of the last week hiking up to the Thorung La pass which was an incredibly difficult but rewarding hike. The pass is at 5416 meters or 17,769 feet which is new record for me as far as the highest altitude I’ve been to. I was breathless and dizzy at the top but overall didn’t have much in the way of any altitude sickness. I climbed slowly over two days adhering to the recommended <500m elevation gain each day reaching the village of Yak Kharka (4035m) on day 1 and then the village of Thorung Phedi (4450m) on day 2. The last day, the day I went over the pass, was definitely the hardest hiking day I’ve ever had as I hiked a total of 22 miles with 3000 feet of elevation gain and 6000 feet of elevation loss. My feet, back, and hips were all so sore when I got back to Manang. Deepali and I completed a similar marathon hiking slog last August on our last day of the Rae Lakes loop in California hiking 19 miles with 2000 feet of elevation gain and 7000 feet of elevation loss. I told myself after that day I would never do that much in hiking ever again….guess I lied. The last few miles of the hike back to Manang especially seemed like they were never going to end. When I finally turned the corner of the trail and got my first glimpse of Manang I cheered, yelled, jumped for joy and started singing “MANANG, MANANG, YOU’RE A HELL OF A TOWN, THE SCHOOL YARD’S UP AND THE SHOPPING MALL’S DOWN….MANANG MANANGGGG!” I really couldn’t wait to get a hot shower, a comfy chair, and a big plate of dal bhat made by the best cook in Manang: Indira didi.
As bad as the last day was, the climb from Manang —> Yak Kharka —> Thorung Phedi —> Thorung La pass was really incredible and provided a wonderful slice of the Himalayas. I ate some really delicious food, took some great pics, and met some awesome people along the way. I got to chat with Kate and Kumar, a really wonderful couple who own the Thorong La Base Camp Lodge, which in my humble opinion, is the best place to eat and sleep at Thorung Phedi. Great food, great music, awesome atmosphere, and overall just a super warm and comfy place to stay at 4500 meters. Also, two different hiking groups more or less incorporated me into their crew for the 3 days while I was hiking. One group of guys (Alex, Felix [both from Canada] and I think Nathan? from Ireland) taught me a new card game called Queen of Spades which we played for hours at Thorung Phedi which I won by 1 point! Another group made up of some super cool people including George who is a free diver from the UK, Josh an Aussie who is applying to medical school, Sammy from the UK who gave me all kinds of advice on European travel, Dennis from Russia who taught me the card game of Durak (which means fool, also everyone kept calling the game Do-rag), as well as Annie and another girl (who I never got her name). Either way I hung out with them a bunch on my way up to the pass and hopefully our paths cross again sometime in the future.
I was pretty wiped after my hike so just kind of hung around town which was nice because it gave me a chance to take a few pictures of the Manang, a few of the pics I took are included below.
We did have our biggest turnout for the altitude lecture this past week with 75 people in attendance. There weren’t enough chairs and a lot of people had to stand but it was a really great lecture with lots of questions both good and bad. Yes, its true, there is such a thing as bad questions. One guy asked “ya, has anyone done any studies on the bottled water in Nepal? Is it safe to drink?” Like, I don’t know man, I guess someone could open the water and pour stuff into in and make it unsafe, the bottles are produced by a big company so we have no control over them. Its like asking, “ya are Oreos safe to eat? has anyone studied that?”. Also, don’t buy bottled water and add the the plastic waste in the valley which is super difficult to get rid of here, use the safe drinking water stations. Oh well, he meant well I’m sure.
\
Ok, final life update but totally worth mentioning. In the middle of the night on Friday night at like 1AM I woke up to someone making all kinds of noise outside in the courtyard. At first I thought it was a dog, then I thought maybe it was a patient looking for help, then I saw a headlamp, then finally I realized it was Jenny. "What the hell is she doing...?" Eventually I heard her yell out "Gobi...Gobi....GOBI!" Gobi didn't wake up but Indira did and when I heard Indira gasp I felt it was worth getting out of my warm sleeping bag to investigate what was happening. Well....what happened was.....one of the water pipes in Jenny's bathroom burst and flooded her whole bathroom! Jenny kept saying "THE ROOF HAS CAVED IN! THERE IS WATER ALL IN THE CEILING!" She had thought that because there was light snow and some rain overnight it had caved in the roof but really there is no way that amount of precipitation could have caused that much flooding. I woke Gobi up and he turned off the pipe from around the back of the building which solved the problem quickly. In the morning Gobi found the leaky pipe and replaced it, crisis adverted. It was a pretty funny situation though in the middle of the night and I couldn't help but to take a few pictures.
Not too many cases to report cause I was gone for a big part of the week. We of course had our usual diarrhea, upper respiratory infections, and blister care cases but here’s a few select special cases:
The first is a 39 year old German man who came in with 2 days of right lower quadrant (RLQ) abdominal pain. He had no medical problems, no previous abdominal surgeries, and overall felt well besides the pain. No urinary complaints, no change in appetite or stools. He had a temperature of 38C (100.4F) which he said was from “too much sun” with a HR of 100. He had tenderness in the RLQ without any other concerning signs like guarding or rebound, his abdomen definitely was not peritoneal or rigid for sure. So obviously my concern is for appendicitis. We talked about evac but he wasn’t too keen on ending his trip early. He wanted to give it one more day and return in the morning. Ok sure, I gave him some return precautions and fever control with instructions to come back in the morning but to be sure not to take any ibuprofen/acetaminophen beforehand. He returns. Vitals all normal, pain is persistent but not that impressive. I ask Liz to feel his belly too cause I’m definitely not too proud/stubborn to get another docs opinion when I’m a little unsure. Same exam but she thinks maybe it could be tenderness of the rectus muscle (the muscle that makes up the 6-pack on the abdomen). The patient and I talk at length, I still have concern for appendicitis, recommend evac, more talk, and eventually he decides he wants to just try ibuprofen and see how he does while staying in Manang for 2 days. He was a very reasonable guy to discuss care with. He never came back so I assumed he either ruptured his appendix, became septic, and rushed down to Kathmandu or Liz was right, and it was just abdominal muscle pain. I know that 10 times out of 10 I would scan that guy if I saw him in the ER but here, in a resource low area, compromises totally have to be made and CT’ing all belly pains definitely isn’t always the answer.
The next case was our very own Liz. She had just come back from the Thorung La pass a few days before I left and had asked me “Ben, can you look at this lump on my back?”. Umm sure Liz, I’ll look at that lipoma on your back. Well it turns out the “lump” on her back was…..duh duh duh….a tick! When I told her she just kept saying “EW! EW! Take it out!”. I recruited some help from Gobi and together we got some blunt tweezers and got the little bugger out, including a piece of Liz’s skin, haha. There is emerging Lyme disease here in Nepal but not many documented cases of it. Liz weighed the pros and cons and ultimately decided to start doxycycline at the treatment dose just to be safe instead of waiting for symptoms 3-4 weeks later. True wilderness medicine right there folks.
Liz had a case of a kid with a dog bite while I was away. There are a ton of street dogs in Manang (why they haven’t culled the heard I don’t know) and one of them got into a fight with one of the domestic dogs at a nearby hotel. The kid tried to break up the fight and sure enough, bite to the face. The laceration involved the vermillion border which Liz said came together really nicely with 5-0 nylon sutures. He got dog-mentin (Augmentin is the antibiotic given to every dog and cat bite) and was sent to Chame for tetanus and rabies post-exposure. Pretty standard stuff in the US but interesting how easily it was managed out here in the mountains.
Finally, for the grand finale case. Granted this isn’t my case but rather comes from our sister clinic in Pheriche. Carlo, the wilderness fellow from MGH sent me a message last week about a really sick patient who came in. Pheriche is on the way to Everest Base Camp and sits at 4371 meters or 14,340 feet so they end up seeing more advanced altitude sickness like HAPE/HACE. In Carlo’s words: “dude looked straight dead. Guy was just a floppy rag, no mental status”. Initial O2 saturations of 32% and heart rate of 133. Yikes. Spikes. He got close to 100% oxygen via a non-rebreather mask with an intramuscular injection of dexamethasone (strong steroid medication) and began to perk up and was able to walk the next day. Amazing how sick someone can be from altitude and then dramatically improve with descent, oxygen, and a little medication resuscitation. If a guy like that presented to the ER in the states, 100% sure he would have been intubated, placed on a ventilator, and brought up to the ICU immediately upon arrival.
Ok well, that's all for now. Tune in next week for more medicine in Manang!