We’ve been in Manang for 2 weeks now and am definitely feeling a lot more settled. Mornings consist of sun bathing in the courtyard like little cold-blooded reptiles trying to shake off the previous nights cold temps while nights are marked with warm meals and card games with the barking of the town’s feral dogs as indication for bed around 9PM. Regular oxygen level checks reveal that my O2 saturations have more or less stayed steady at 88% to 92% depending on how much activity I’m doing around the clinic. Construction is really moving at a fast pace and hopefully by the end of this week I’ll be moved in to my palace suite with insulated walls, heated shower with western toilet, electricity, view of the mountains, and much less dust. Some of the more exciting moments of the past weeks construction include one of the welders having his morning chai while welding as well as one of the workers seeling himself in after ceiling repairs which required some impressive acrobatic work to escape through a small hole in the metal framework.
Liz, Jenny, and I have been taking turns giving the daily 3PM altitude lecture and by this point I’ve got my routine solidified. We get about 15-40 trekkers each day who show up to the talk and they are all super thankful afterwards so it does feel like we are getting safe altitude practices out to the masses.
The woman below is one of our more frequent visitors. A local woman who has lived in Manang her whole life. She never needs any medical consultation but rather is happy to just sit and watch everyone at work. If you talk to her too much she does eventually demand rent money for her “hotel” so she does have some dementia. Best to just say “Namaste” and move on.
Jenny left this past weekend to go up to the Throng La pass at 5400 meters. The pass is super snowy and the air is really thin but she made it back safely but exhausted. Liz will be going up next and then I’ll be making my trip up to the 5400 meter pass probably late next week.
I did a small hike up to 3800 feet onto the plateau above the unique rock structure you can see in the picture on the main page of this site. The area was really calm and peaceful and was a great way to spend the afternoon. I was also able to finish 2 more of my books since getting to Nepal. (1984 by George Orwell and Stranger in the Woods by Michael Finkle which was a gift from my grandma, Thanks Gradma!)
We had a special treat not too long ago where Gobi treated us to lunch at one of the nearby hotels Tilicho while construction was underway in the kitchen temporarily. I had some delicious MoMos and a local specialty drink of seabuckthorn juice. (wikipedia page here: https://en.wikipedia.org/wiki/Hippophae)
We’ve had our first evacuation this past week and no, it wasn’t for altitude sickness, but rather…..duh duh duh….terminal constipation. The patient was a young woman around 30 years old who hadn’t had a bowel movement in about 8 days. No history of gut issues, no history of constipation, no abdominal surgeries before. She said she had been eating dal bhat, high fiber foods, nothing out of the ordinary but still hadn’t been able to go #2. She came to us in the morning for advice on the 8th day. First up, lactulose to soften the stool. She had about 60mL of that but by the afternoon still nothing. Ok, lets try some bisacodyl which is a stimulant to maybe push things along. Hours later, no success. She’s back around dinner time. Jenny happened to have some glycerin suppositories in her personal med kit which she gave to the patient. Oddly enough suppositories are not available for sale in Nepal so we don’t have any in the clinic. Welp, come about 7PM the patient is now vomiting, feels awful, and is having severe peristaltic abdominal pain every 15-20 minutes. Her next questions “Can someone please disimpact me?” Ummmmm what? I guess HACE also stands for High Altitude Constipation Emergency. Well, I did swear by the Hippocratic oath sometime in 2010 so I guess duty calls. Jenny says “I’ve never done a disimpaction”, Liz says “I’ve done 2 in my 30 year career”, I go “I’ve done like 20”. They immediately look at me like I’m some expert in this field, thus, I draw the short straw. We send the patient back to her hotel room to release the dam far from our only clinic room. A little sweet smelling lotion on a surgical mask, some 7.5 sterile gloves, sterile lubricant, a large surgical bedsheet and we’re off. Liz comes to help. I feel the patient’s abdomen first of course and it’s really reassuring. The disimpaction goes well but the patient still isn’t feeling that great. Ok well the plan is to try and have a regular bowel movement and if you’re still feeling unwell I’ll come back. 9PM rolls around and sure enough the patient is still have peristaltic pain with some vomiting. I immediately think, “oh my god, am I missing something here”. I go through all my differential diagnoses like ectopic, torsion, appendicitis, volvulus, etc etc, and it all comes back to constiption based on the history and exam. Anyway, disimpaction round #2 happens (pun intended) and I’m able to get out significantly more. Vomiting stops, patient feels much better, I sleep easy. Next morning, patient is feeling unwell again and the peristaltic pain is starting to come back. She’s feeling weak, nauseous, and still no regular BM. Ok, time to throw in the towel. She has travel insurance and more or less has evidence of a large bowel obstruction from fecal impaction. We arrange the helicopter and have her and her friend pack up their gear. While we’re waiting at the helipad the patient goes “I wish I could $#!% all over this helipad.” The patient made it to Kathmandu and was kind enough to email me an update. She spent 2 days in a Kathmandu hospital, got IV fluids, antibiotics, no enema, no CT scan or colonoscopy. No word about any full BM or not. She was headed back to the States feeling very well with plans to see a GI doc and her regular doc once she returned. Another life saved.
Other interesting cases we’ve had include a Malaysian woman with a left lower lobe pneumonia with O2 sats at 58%, a young boy around 12 years old with mild HACE who we sent down to Besisahar by jeep, and another local man aged 65 who looked really sick but had a constellation of vague symptoms that could have been anything from an MI to gastritis. We sent him down by jeep as well with an update that he felt much better upon arriving to a lower elevation.
That's all for now, see you all next week.