hmpg_feature_batwafamilyDear Friends,

If you are like me, you may find that reading through your Facebook feed has become very painful of late.  Right now there is so much frustration, anger, fear, and pain in our country.  These days, we see very few smiles, and feel precious little joy.  It’s easy to become discouraged; it feels like there is so little we can do.

But one thing you can do is support the Batwa people.

The Batwa are a wonderful tribe of pygmies in rural Uganda. Traditionally, they lived in the rainforest and were primitive hunters and gatherers.  All that changed when their government forced them out of the forest, as part of the creation of a world heritage site for silverback gorillas.

When the Batwa were evicted from the only life they have ever known, they were left to fend for themselves with no food, no land, no resources.  As a result, they began dying at an alarming rate, especially children under the age of five. That’s when Dr. Scott Kellermann and his wife Carol were called to Uganda to help save the Batwa.

When Scott and Carol first arrived, the Batwa were suffering and dying.  They held clinics under trees, hanging life-saving IV fluids from the tree branches.

Through the Kellermann Foundation, the organization started by Scott and Carol, the lives of the Batwa are beginning to look bright.  The Kellermann Foundation has created a Batwa Development Program, which has purchased land for the Batwa to live and farm, has built schools and sponsored the education of Batwa children, has built homes for Batwa families, has sponsored water and waste projects, and has set aside a small part of the rainforest where the Batwa can maintain their culture and pass on their traditions to future generations.

The Kellermann Foundation has also built a hospital, the Bwindi Community Hospital, which has been recognized as the top hospital of Uganda.  There, doctors from around the globe come to learn from, work with, and teach Ugandan doctors.  The hospital has had some astounding successes:

  • • In rural Uganda, many women attempt to deliver babies at home.  If their delivery fails, they are left struggling to find a hospital that can perform an emergency cesarean section.  The complications can be significant, such as death of the mother, death of the baby, or vesicovaginal fistula, a communication between the bladder and vagina, which causes continuous leaking of urine.
    • o The Bwindi Community Hospital has created a Women’s Dormatory, where pregnant women can come to stay at the end of their pregnancy to be near the care they require at the end of their pregnancy.
    • o They have created a voucher program where a woman can receive prenatal care and a delivery for the equivalent of 1 US dollar.
    • o The hospital now delivers 1,200 babies annually.
    • o They have built a pediatric ward that not only treats children, but has a demonstration garden where parents can learn how to grow nutritious foods and a test kitchen to teach mothers how to prepare foods to help their children thrive.
    • • The public health efforts of the hospital, and their HIV/AIDS clinic, have brought the HIV/AIDS rate in the community below 5%.
    • • They have built a nursing school—Uganda Nursing School Bwindi—that trains nurses to improve healthcare delivery throughout Uganda. This year, the first Batwa student is entering the nursing school!

But the Batwa, the Kellermann Foundation, and the Bwindi Community Hospital need your help to survive.  We would love for you to visit the hospital and see the work they do; however, if travelling to Uganda is not in your near future, please consider supporting the Kellermann Foundation financially.

    • • $225 can treat a malnourished child.
    • • $750 can provide primary education, materials, uniforms, and transportation for a Batwa child for a year.
    • • $1,250 per year can support a Batwa child through secondary school.
    • • $1,400 can build a house for a Batwa family.
    • • $1,500 per year can provide tuition, housing, and materials for a nursing student.

The Kellermann Foundation is a 501(c)(3) nonprofit charity.   It has received a Gold level from GuideStar, and is a “Top-rated” charity by Greatnonprofits.org.  You can support the Kellermann foundation by direct donation, or can support them through Amazon Smile.

I first met Scott Kellermann in 2015 when he visited Park City, Utah.  I have done medical work all over the world, but was so impressed by the work that they have been doing that I visited the hospital in 2016.  This year, I have decided to volunteer as an unpaid board member to help protect the Batwa, and to improve the state of healthcare in their region of Uganda.  I hope you will support us.

In these tumultuous times, you may not be able to change the results of an election, or correct the wrongs of our society, but you can help the Batwa. And that’s something worth smiling about!

Thank you,

Andrew Nyberg, MD MPH

Board Member

Kellermann Foundation

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Back in Kathmandu

May 19, 2015

Dear Friends,

Thank you for the well wishes, the prayers, the concerns. I am now back in Kathmandu with plans to leave Nepal in the next few days. It has been quite an adventure since the first earthquake hit Nepal on April 26. After assisting the evacuation of the wounded off Everest, we stayed open to be there for all the teams, guides, porters, etc. that were now leaving the region. In spite of this, we saw very few physically sick patients, but some very traumatized people. On May 5 we closed the Pheriche HRA post, as it had become clear to us that our mission for this season was largely concluded, and we were anxious to get on to other things.

After a beautiful walk down to Lukla, and a safe flight out of the Khumbu, I said goodbye to Katie and Reuben, who were headed back to the UK to work on their upcoming wedding.

Mama Bear and Papa Bear, parents to our favorite puppies, Black Bear, Brown Bear, and Grizzly Bear, waking up to say goodbye on the day we left Pheriche.

Mama Bear and Papa Bear, parents to our favorite puppies, Black Bear, Brown Bear, and Grizzly Bear, waking up to say goodbye on the day we left Pheriche.

Mama Bear and Papa Bear lead the way out of Pheriche.

Mama Bear and Papa Bear lead the way out of Pheriche.

Walking out of Pheriche for the last time.

Walking out of Pheriche for the last time.

Ama Dablam and the farm fields of Pangboche.

Ama Dablam and the farm fields of Pangboche.

The heavily damaged monastery at Tangboche.

The heavily damaged monastery at Tangboche.

Gobi and Tan relaxing at a Teahouse.

Gobi and Tan relaxing at a Teahouse.

A teahouse kitchen.

A teahouse kitchen.

The rhododendron in bloom.

The rhododendron in bloom.

Namche Bazaar.

Namche Bazaar.

The dental clinic in Namche suffered heavy damage

The dental clinic in Namche suffered heavy damage

Reuben and Katie at our favorite cafe in Namche.

Reuben and Katie at our favorite cafe in Namche.

The two bridges to Namche Bazaar.

The two bridges to Namche Bazaar.

The author, looking back on the two bridges to Namche Bazaar..

The author, looking back on the two bridges to Namche Bazaar..

The beauty of the Khumbu.

The beauty of the Khumbu.

A

A “Bob Ross” waterfall outside of Monjo.

Cherry blossoms in bloom

Cherry blossoms blooming in Phakding.

Renee and I integrated into an awesome group of medical professional from Scripps (San Diego) and Mass General (Boston), who were operating field clinics in the Gorka region on Nepal for International Medical Corps (IMC). I’ve spent the past 10 days working with them, visiting several different sites by helicopter, setting up a clinic and camp, and treating the local population. In my time with them, we have seen well over 600 patients, mostly for common complaints and chronic conditions, but all of these villages have been devastated, and their “healthcare” infrastructure has been devastated, either because the community health worker is no longer their, or the community health post was damaged, or the medical supply line has been severed due to landslides and impassable trails.

The author.

The author and a satisfied customer.

Bringing medical supplies to a village to set up a clinic.

Bringing medical supplies to a village to set up a clinic.

Children playing with a wheel and stick, their favorite activity.

Children playing with a wheel and stick, their favorite activity.

Three Nepali children at play.

Three Nepali children at play.

We were in the town of Ghyachchowk when the second earthquake hit. Thankfully everyone was safe, but the second earthquake has played a major toll on the mental health of the people we are seeing. Their world was devastated after the first quake, and they were just starting to get over the experience and rebuild when the second earthquake hit.

The town of Ghyachchowk.

The town of Ghyachchowk.

Looking into a destroyed house.

Looking into a destroyed house.

The middle school, the pride of the village, ruined by the earthquakes

The middle school, the pride of the village, ruined by the earthquakes

Villagers demolishing a house for rebuilding supplies

Villagers demolishing a house for rebuilding supplies

After the second earthquake many of the Nepalis we saw were suffering from Acute Stress Reactions; fearful that any aftershock could be the next large earthquake. The emotional ramifications of what they have experienced will affect them for the rest of their lives.

A girl and her chick watch the activity at the mobile clinic.

A girl and her chick watch the activity at the mobile clinic.

IMC Nepali volunteers Ocean and Iman singing with the locals.

Nepali volunteers Ocean and Iman singing with the locals.

Our team has finished their deployment, and are now cycling back to the U.S. Another team from Stanford arrived the day before yesterday, and will be going into the field today to continue our work. Other groups from IMC and other aid organizations are in the field, performing medical duties, but also rebuilding water supplies and toilets, helping rebuild structures, identifying areas nutritional deficiency, and working with villages to develop coping strategies and mental health first aid.

IMC Dietary staff member Suzanne and Nepali volunteer Kul assessing the nutritional status of villagers.

IMC Dietary staff member Suzanne and Nepali volunteer Kul assessing the nutritional status of villagers.

In the future, I hope to provide more stories of my experiences since the earthquake, but it has been difficult to wrap my mind around the repercussions of everything that I have bared witness to in this country. In the meantime, please accept this short account of my recent actions and movements.

Before starting this next blog, a few things have to be said….

  1. There are too many people who have been helpful over these past few days. What we’ve been through would have been impossible if Reuben, Katie, Renee, Tan, Gobi, Jeet, and I hadn’t formed such a tight bond over the past 7 weeks. We have become a kind of family, and were really able to perform exceptionally well together under extreme circumstances.
  2. So many people came out of the woodwork yesterday to volunteer their help yesterday. Several nurses, doctors, and EMTs stepped up and allowed us to treat and evacuate 73 patients. Countless other trekkers, climbers, and nepalis stepped up to help document, coordinate, carry, and care for those unfortunate victims from Everest. The circumstances under which they gave themselves were incredible. Our patients were bleeding, wounded, and dying, and yet no one flinched. They just kept giving.
  3. As trying as our ordeal was, it paled in comparison to what my colleagues at Everest Base Camp experienced. After the earthquake let loose a huge avalanche on Pumori that took out a large portion of Everest Base Camp, including burying the Everest ER facility and destroying the camps of several teams, the doctors of Everest ER, Himalayan Experience, the Norwegian Expedition, and others grouped together to become the first line of care for all those suffering on Everest. They had to pronounce the deaths of many people that they had come to call friends. Their incredible efforts made our work exceptionally easier. I am incredibly thankful for Meg Walmsley, from Everest ER, who, after spending the whole day and night treating patients in Everest Base Camp, flew in one of the helicopters down to Pheriche to help us as we continued the efforts to treat these patients.
  4. There were multiple helicopter pilots who have been working incredibly hard to transport patients and climbers, risking their lives to do what is right. In particular, a Swiss pilot from FishTail was the first helicopter in the air, and was instrumental in getting us the sickest patients first. For all the service that the HRA provided the victims on the Everest avalanche, we did not receive a single payment. As far as I know, this is also true for the helicopter companies, the expedition companies, and the lodges who all provided incredibly for those in need.
  5. Unfortunately, the country of Nepal is always overshadowed by Everest. What has happened on Everest this season is tragic. The story we can now tell is epic. But what is happening here pales in comparison to the suffering that is occurring elsewhere in this country. We have food, water, and a well-stocked clinic. We “suffered” because we didn’t have Internet for a few days. We were less informed than you, because we were only getting small pieces of the larger picture. The story I tell of the people of the Khumbu and the climbers on Everest should not take away from the stories of others in Nepal. Our hearts and prayers have been going out to this country that we have come to love. As we sent our patients away yesterday, we truly didn’t know what kind of world into which we were sending them.
  6. Looking suffering in the face is always hard. One of the hardest things in these experiences has been to see the suffering of my Nepali friends Gobi, Tan, and Jeet, whose families have been affected by this earthquake, and yet these men stay here and continue to work here when they so want to be with their families. Their courage has been astounding.
  7. I thank God for all my friends and family who have suffered worrying about me. I am also thankful for the training I have received through my medical career and training, and to all those who have had the opportunity to teach me. In the book of Esther, in the Old Testament, Esther is put into a position where she needs to risk her life to save her people. Esther is literally scared for her life, but her wise uncle Mordecai counsels her saying, “Who is to know that you were not meant for such a thing as this?” In the wisdom and faith of Mordecai, I trust that God has placed Katie, Reuben, Renee, Meg, Rachel and the rest of us in this place to do what we are able to save lives, and to stand witness to what has occurred.

25 April 2015

The season was continuing as planned. Renee had taken her medical student on a trip to Everest Base Camp, and had returned several days before. As per our schedule, Reuben and Katie had left on the 23rd for their own trip up to EBC, taking a detour to hike the Kongma La, a 5500m pass that connects Chhukhung to Lobuche, before continuing on to EBC. The weather had been poor, and it had been snowing. The Kongma La is a notoriously difficult trail, and in the back of our minds, we were all just a little worried for them.

With just Renee and I at the clinic, we had been taking turns on 24-hour shifts caring for patients. Over the past two days, Renee and I felt as if we had seen the entire population of Pheriche and Dingoche, as the locals kept coming in with “cough” that turned out to be nothing more than an Upper Respiratory Tract Infection. April 25th was my turn to be on for 24 hours. I was hoping that we’d seen all the cough patients, and would have a slightly less busy day. It seemed that my hopes were coming true. The morning had been light with only two patients, and as lunchtime loomed, I was sitting in our common room reading a book when I heard the front door bell and two people walked in. To our joy and surprise, it was Reuben and Katie, who had returned early from their trip. They had gotten up on the Kongma La, and had camped out, but a snowstorm had put over a foot of snow on their campsite, and they had decided that backtracking to Pheriche was safer than climbing down the steeper side of the Kongma La on a path they didn’t know. Their plan was to spend the night in Pheriche, then leave early the next morning to get up to Everest Base Camp by the traditional route.

I had to leave our little homecoming when an actual patient arrived, a young Nepali who had Khumbu Cough, a nasty, persistent bronchitis that is very common to this region. I was evaluating him with Tan’s assistance when the whole world started moving in a peculiar way.

I have only ever been in one earthquake in my life. When I was biking across America with Ride For World Heath, we experienced a small earthquake in Dateland, Arizona. Earthquakes are described as a shaking, however I think that is a wrong description. Shaking implies that things go back and forth in an almost rhythmic pattern. In the two earthquakes I’ve now experienced, it felt more like floating on turbulent water. It’s not rhythmic; it’s random. And for those not used to earthquakes, it takes a few moments to realize that you’re in the middle of one. Right as Tan and I were looking at each other, saying “we better get out of here”, Gobi was already outside pounding on the windows for us to get out. Renee, Katie, and Reuben were still sitting in our common room, trying to figure out what was going on when they saw Tan, my patient and I bolt for the door, and they soon followed.

The quake only lasted a few moments, and to my unaccustomed body it actually was pretty underwhelming, until I had the chance to see the changes to the world around me. Pheriche is a small town with approximately a dozen lodges that cater to trekkers and climbers, with a few private buildings. After the earthquake, only two of the lodges remained without any damage. The style of building common in the Kumbu region is to build with shaped stones, usually without mortar. Many of the walls of these buildings had weaknesses that caused them to fall after the earthquake. The HRA clinic lost the wall on the Southeast corner, where the bathroom, and the room where Jeet, our cook, slept.

In spite of the tremendous damage to the town, there was only one casualty, one of the Nepali women in town was hit in the head with a stone and had a small laceration to her scalp, which I stapled closed.

We then entered the period that was effectively the calm before the storm. It was lucky the earthquake occurred in the middle of the day, when most of the trekkers were out on the trails. Knowing the amount of damage that Pheriche sustained, we expected bad things from Dingoche, our neighbor town on, which was larger. For the next several hours we kept an eye on the hill, expecting to see casualties coming from next door, but none ever came.

Earlier in the season we had set up a new communication system that allowed us to talk with Everest ER. We kept sending out messages to our neighbors to the North but never heard a response. We were in the dark about their fate until Gobi was able to reach HRA’s headquarters in Kathmandu by satellite phone. That was when we first heard that there was massive damage to Kathmandu. We also learned that while the staff of Everest ER was safe, their tents were completely destroyed. At the time, they were estimating two deaths, ten critically wounded and twenty less critically wounded.

At 3pm, three hours after the initial quake we were rocked by a large aftershock that added more damage to many of the structures in town. With the threat of continuing earthquakes, we decided to sleep in the sunroom, which we supposed would be safer than sleeping in our rooms in the clinic. The trekkers in town mostly crowded into the Panorama Lodge, one of the few intact structures in town.

Although we were on continuous alert for the possibility of patients arriving, they never did. April 25 was not a good day for an earthquake in the Khumbu, as the day was overcast, cold, and snowy. Helicopters were not flying. We knew our friends were in a bad way, and we suspected that our lives would get busy in the near future, but were unable to predict when.

But with darkness falling, there was little to do but fall asleep. I was just about there when Tan woke me, saying, “Andy, Andy…” “What?” “We have a patient”.

And so at 9pm our first patient arrived from Everest. He was a young Nepali who had been thrown several feet by the blast of air the preceded the avalanche. The patient’s friend had gotten to him right away, put him on a horse, and then took the next 9 hours to get him from EBC to Pheriche.

It is important to know that when a large avalanche forms, it displaces all the air in front of it, so before being struck by the avalanche, EBC was struck by a huge gust of wind. Several people who were there told me that this wind did a tremendous amount of damage when it hit the camp.

The patient was complaining of right-sided pain in his ribs, his upper abdomen and his thigh. Hearing decreased breath sounds, I worried that this man’s rib fractures had caused a pneumothorax. An ultrasound of the lungs confirmed my suspicions. He also had rights sided flank pain, and a sample of urine contained blood and protein. I was concerned he may have damaged his kidney, or developed rhabdomyolysis, a dangerous breakdown of muscle tissue. Since his oxygen saturation was good, I started him on oxygen to help decrease the pneumothorax, and started IV fluids. A FAST ultrasound exam was negative, and I even ultrasounded his right femur with no sign of fracture. I tell you these medical details, not because I assume you are interested in the medical details, but to juxtapose the time and care I was able to give this patient compared with what was to come.

A second patient followed closely behind the first, with a hand injury. Renee treated him, and he was discharged. Although we were told that more patients were coming, we didn’t see anything more that night. We continued to monitor our one patient, and got a good, if cold, night’s sleep.

***********

April 26, 2015

I woke up at 5:45 when a FishTail Eurocopter flying by the Pheriche valley on its way to EBC. Aroused by this inordinately early flight, I got up to check on my patient. He was doing well, but a repeat FAST exam showed a full bladder, after he was unable to urinate, I became worried that he was obstructed for some reason, and all the IV fluids I was poring into him would eventually need to come out. As I was preparing to pass a Foley catheter through his urethra to drain his bladder, I got word that we were getting patients.

The FishTail pilot arrived with the two most critical patients, one with a head injury and the other with substantial orthopedic injuries. As the pilot unloaded the patients, he told Reuben, “I’ll be bringing you about 51 more patients.” For two hours, this one pilot was the only helicopter flying in the Khumbu. Clouds had socked in the Lukla airport, and none of the other helicopters could take off.

As more patients arrived, I took over the two clinic rooms, seeing four critical patients, including my patient from the night before. Katie was stationed at the room we use for research, and spent a large amount of time with one patient who was clearly our most critically injured. Renee transformed the sun room, which we had been sleeping in a short while before, into a third clinical space, and was able to get six patients on the floor in the room we normally use for our daily 3pm Altitude talks.

On one of the early helicopters, Meg Walmsley, an Australian anesthetist working at Everest ER, flew down to help us with the patients. She had been in the Everest ER tent treating a patient when it was blown down. The earthquake had set off an avalanche, which we all knew. What Meg told us, however was that the avalanche that took our EBC came from the nearby mountain Pumori, not from Everest, as we had all suspected. Meg lost all of her personal effects, and the Everest ER tent had been destroyed. She had spent all night treating patients at EBC, but then valiantly offered to come down to Pheriche to help us continue our care. Initially she helped Renee in the sunroom, but as more patients arrived with no concrete plans to evacuate them in site, we took over the dining room of the Panorama lodge, and Meg was tasked with caring for all the new cases that were being brought there.

The situation was quickly becoming a mass casualty incident, or what the American College of Emergency Medicine would call a medical disaster, which they describe as a situation “when the destructive effects of natural or manmade forces overwhelm the ability of a given area or community to meet the demand for health care.” In spite of the time and resources I could devote to my patient last night, we had gone from care with a scalpel to care with a saber: concentrating on vital signs, checking airway, breathing, and circulation, identifying injuries, and looking for obvious threats to life.

One of the large miracles of the day was how people kept showing up with offers to volunteer. We were in desperate need of doctors, nurses, and others with clinical knowledge that could triage and treat the patients that kept poring into our small town. But there were many people with no medical knowledge who also became incredibly important, working as scribes, taking records of patient names, and helping carry the injured. Early on we developed a system of using wide pieces of tape with markers to identify names, vital signs, and injuries on patients. This would help us quickly identify our sickest patients, and if we could evacuate the patients, this would help care providers down the road.

In spite of the bad weather over Lukla, Gobi had worked his considerable persuasive magic, and we were being told of a plan to get a Mi-17, an old Russian military helicopter, to fly to Pheriche, where it could take approximately 15 patients at a time. We now had the task of identifying which 15 patients were the most critically injured to assure they were on the first flight out. The weather patterns in the Khumbu are erratic, and you are never sure if a helicopter will make it, or if that helicopter was able to return, so it was important we get our worst patients out if an when we got the opportunity.

This is where one of our volunteers became a real hero. She and I went around, from the clinic, to the sunroom, to the Panorama, and talked with Renee, Katie, Meg, and the other clinicians to identify the patients that were in greatest need. We placed a sticker with a giant ‘E’ on each coat or sleeping bag, so it would be obvious to volunteers which patients needed to move. When helicopters land in Pheriche they don’t turn off their engines, this means things have to move quickly, and we could have no delays. Getting these patients down was the best way to save their lives.

The news concerning evacuation kept changing, and at first it sounded like the weather was too bad for any helicopter to lift. My biggest worry was that we would not be able to evacuate our patients, and would have to keep them over night. I was working with some wonderful volunteers, but at some point they would have to move on. How long could I expect Pemba to allow us take over his lodge and keep patients there? What if we had dozens of patients that needed to stay the night? How could we keep the critically injured alive when we didn’t have blood products?

At one point Reuben came around with a Chipati (think of a tortilla) with nutella inside, he said “Andy, you’ve gotta keep your strength up, I can’t have my doctors hitting a wall”. I thought to myself, is it lunchtime already? Only later did I realize that I hadn’t even had breakfast.

At some point in the morning, Ken Zafren arrived. Ken is an emergency physician at Stanford and Alaska Native. In the world of wilderness medicine he is a legend, and as the physician who recruits all the HRA volunteers, he is very heavily involved with the HRA. Although he had experienced the earthquake, and was aware that there had been an avalanche at Everest, he was completely unprepared for the amount of damage that had occurred in Pheriche (something we would hear frequently), and was surprised to walk into a mass casualty incident. His wisdom and experience were incredibly useful.

Reuben then came back and informed me, “We think the Mi-17 will be landing in an hour, get ready with your 15 sickest patients.” But then, before we knew it, two Eurocopters landed, and were headed back to Lukla. They had room to take four patients. We unloaded our four worst cases, Katie’s head injury patient, my orthopedic patient, and two other patients with head injuries that weren’t looking very good.

We had identified one other critical patient, so my list of 15 had dropped to 12. I started having volunteers transport them down to the “helicopter beach”, where they could wait in anticipation of the Mi-17.

The Mi-17 arrived as I was coordinating transportation of the critical patients. After I had gotten them all carried down to where the helicopter was, I headed there myself. To my utter chagrin, I saw the Mi-17 lifting off and five or six of our sickest patients were still on the ground. I then realized that several of the “walking wounded”, injured patients who were not critically ill, and could mostly still walk, had taken the opportunity to evacuate themselves by getting on the Mi-17.

Katie was caring for some of the patients, and Reuben, Gobi, and Tan were trying to coordinate helicopters and patients. I yelled at the crowd to “listen up”. I told them that ABSOLUTELY no one could get on a helicopter unless Katie had given them permission. The lack of leadership had lost us an opportunity to evacuate some of or sickest patients, and I needed to make sure that the HRA continued to keep stay in control of the situation, before someone else realized the power vacuum, and started trying to run the incident themselves.

With Katie in firm control of how patients were getting evacuated, I was able to return to the HRA and Panorama. It was clear that with our most critically injured patients being evacuated, we were shifting into a new phase. Now, with helicopters arriving to evacuate patients, the focus shifted from prioritizing acuity rather, and less stabilization. Also, the HRA staff began assuming leadership roles, whereas the direct triage and stabilization of patients fell to the nurses and physicians who had volunteered to help.

I returned to the Panorama lodge, where most of the remaining patients were, and announced we were changing things. Now any patients needing helicopter evacuation would go to one wall, while those who could potentially walk out or ride a horse on the other. We were lucky to have the Mi-17 and the Eurocopters available to evacuate patients, however I wanted to make sure all those who needed it got out, in case we lost those resources.

But in the end, that concern wasn’t warranted. All the patients from Everest had been brought to Pheriche. We were able to evacuate them to the airport in Lukla using three trips with the Mi-17, and about 10 trips with Eurocopters. When the last of the patients was loaded onto the Mi-17 and that beautifully large military helicopter took off over the Pheriche Valley, I looked down at my watch. We had a lot of people to thank.

Most of the volunteers, and almost everyone else in town was standing on the “beach”, which is really the main hiking trail through town. They were there to watch the helicopters take off. I called their attention. I told them, “In less than five hours, we treated and evacuated approximately 40 patients. Those of us at the Himalayan Rescue Association are volunteering our time to be out here. Today you are all volunteers of the HRA with us. Thank you for your help; there is no way we could have done this without you.”

Later Katie, Renee, Reuben, and I took a walk, and we figured out that I had grossly underestimated the miracle we pulled off. The first patient arrived at 6:40 am. The last patients were leaving just before noon. But we hadn’t seen 40 patients; we had seen 73.

***********

After the patients had gone, the HRA staff, along with Meg Walmsley and Ken Zafren, pulled chairs around our entrance room, and opened our last bottle of Coke. Like a bottle of Dom Perignon, we had been saving it for a special occasion, and this seemed the perfect time.

At approximately 1pm, 25 hours after the original quake, a second aftershock shook us out of our comfort. After the hectic events of the morning, it was hard to get back to life as normal. A group of people showed up for our 3pm daily altitude talk, and I only noticed it because I happened to walk by at 3:05.

***********

April 27, 2015

Tan, Jeet, and Gobi slept in the sunroom again last night. Reuben, Katie, Renee, and I elected to sleep inside, but every time there was a noise, we were wide-awake wondering if the walls were going to fall in on us. No one slept much.

Today became an odd contrast to yesterday. Yesterday we saw nearly 80 patients in a single day; today Pheriche was like a ghost town. Yesterday we were fighting for life; today we bore witness to the dead.

The helicopters were evacuating climbers from Camp 1 and Camp 2, and then were evacuating climbers to Pheriche, before heading down to Lukla. Today the body bags also came down. As a physician at the HRA, you become good friends with many of the Everest climbers, and today was our opportunity to see some of them again. It was a time to rejoice for the lives that made it, and a time to mourn for those who died.

It is also a time of uncertainty for Katie, Reuben, Renee, and myself. The trekkers are all leaving, and in a few days there won’t be any more trekkers or climbers. With most of the lodges closing, many of the Nepali workers are also leaving.

In a time when organizations all over the world are mobilizing to send aid to Nepal, we are uncertain of our continuing role in this disaster. On the one hand, with our proximity to all this suffering, it would make sense for us to try and dive in, and help wherever we can. On the other hand, after what we’ve been through, after what I’ve been through, I’m not sure how I will handle what awaits in Kathmandu.

Our thoughts are now more than ever directed towards home.

Time will tell where this story goes. Perhaps, as I stated in the beginning, God has more of a role for me to play in this disaster.

Earlier in the season, when all the big Everest expeditions were coming through Pheriche, the owner of an unnamed expedition company offered me the invitation to join his guides and clients climbing Lobuche East “anytime between April 12th and 20th.” Despite my efforts to secure a more specifics, I was merely assured, “show up at our base camp at Lobuche, and the guides will take care of the rest.

Not wanting to pass on this opportunity to get onto one of Nepal’s “trekking peaks”, I arranged with Katie and Renee to take off a few days during this time to try my hand at this peak. My hope was to be able to climb both Lobuche East, and Island Peak, two 6,000m peaks in the Khumbu region.  I have ascended to 5,500m twice in preparation for these bigger mountains.  Island is scheduled for May, so this was the perfect time to climb Lobuche East.  So I left on the morning of April 12, with plans to meet up with the group at their base camp that evening, hike to high camp the next day, and then summit the third. It was all going to be great!

Prayer Flags over Thokla pass

Prayer Flags over Thokla pass

I love taking pictures of these prayer flags....

I love taking pictures of these prayer flags….

Well I had good reason to be a bit worried about the specifics, or lack thereof.

I arrived at base camp in the mid-afternoon with cloudy weather closing in. I asked the Nepali’s around where the guides were, and they told me “they’re all up at high camp.”

Oh.

So I used their radio to speak with the expedition company owner, who was currently at Everest Base Camp. At first he didn’t remember me (great!), but then said, “Oh, well just go up to the high camp and you can meet up with them there.”

At this point I had already gained 700m in elevation. At the HRA we teach that in altitude, you shouldn’t gain more than 500m elevation per day, and here I was preparing to climb higher. Well at least I’ve been acclimatized to Pheriche’s elevation for several weeks.

There was one westerner, a Sherpa and a porter who were preparing to leave base camp for the trek to high camp. It was very clear to me that if I didn’t leave with them, there’d be no way for me to get to high camp that night. No way was I going to walk into a cloud to find a camp on the side of a mountain I’ve never seen before.

A call came in from the guides on Lobuche. They had no knowledge of me, and were not excited to have me joining their expedition. Further, they told me that the sleeping bag and mattress I’d been promised were not actually there. Thankfully I’d brought my own, not trusting the vague promises I’d heard. I’d hoped to dump some weight before starting up the mountain, but this means that I’d be carrying my full bag of equipment up to high camp.

The group heading up the mountain was equally as unhappy about me being there. This is a great way to start an expedition, feeling that you are totally unwanted!

The trail was tricky, intermixed among rock fields. At one point, a rope had been strung because the trail was rocky and icy. Exciting, but a bit unnerving.

A sketchy section of icy boulders that required a rope for safety.

A sketchy section of icy boulders that required a rope for safety.

As five o’clock rolls around, it begins to snow, and twilight sets in. I gain a ridge, and there are about a dozen tents marking. The camp is at 5,200m, a full 1,000m above Pheriche!

Arriving at high camp, 5,200m.

Arriving at high camp, 5,200m.

The group has been kind enough to let me stay in their gear tent. I set up my sleeping bag and mat, and share a stove with the team doctor, Tracy, who works at Vail Valley Medical Center. We spend some time discussing doctors we both know.

Night sets in early. The plan is to be ready by 7 to climb to the top of the mountain. I snuggle into my sleeping bag wearing all the clothes I own! Inside my Mountain Hardware 0-degree sleeping bag I wear a long underwear top, a Patagonia sun-shirt, a lightweight Patagonia Down sweater, and my heavy synthetic Rab jacket. On the bottom, I’m wearing midweight long underwear, trekking pants, and Gore-Tex pants.

Still I’m freezing!

After the obligate getting up three times to pee overnight (I forgot to pack a pee bottle), the dull light of dawn starts appearing. It is snowing. Hard. It snows at least 1-1.5 feet overnight.

The camp the next morning.  My tent was the green one.

The camp the next morning, buried in snow. My tent was the green one.

Me at the high camp.

Me at the Lobuche East high camp.

The call goes out: we’re going to hang tight and see what the weather does before deciding to go up the mountain. By 8 am, it is decided to down climb back to basecamp. No shot at Lobuche East this time.  A snowfall this big is too much a risk of avalanche.

Downclimbing in the snow.  Stuff avalanches were going off all around us.

Downclimbing in the snow. Stuff avalanches were going off all around us.

Last night’s rock scramble has become a snow route today. Stuff avalanches are falling all around us.  Difficult but fun down climbing leads us back to basecamp, where tea, ginger cookies, and a meal of French Fries with an egg (a new culinary favorite!) awaits.

Downclimbing in the snow.

Downclimbing in the snow.

The icy rope section the next morning.  This time going down.

The icy rope section the next morning. This time going down.

I didn’t make it up to Lobuche East, and at first I felt a bit like the redheaded stepchild no one wanted, but as I got to know the group, I still had fun in the end.

I made it back to the HRA clinic in time to celebrate the Nepali New Year. Nepal does its best to assert its uniqueness from the rest of the world (thus being 15 minutes off the rest of the world in time), and according to their calendars, April 12 is New Years Eve, and the year is 2072! To celebrate, we bought some beers, which tasted really good after two days of heavy hiking, and Jeet and Tan bought rakshi, the local moonshine, which was remarkably smooth and basically tasted like water.

While the trip wasn’t the one I wanted, it was fun to camp out in a snowstorm, and to celebrate New Years with friends. The next time I ring in the year 2072, I will be 91 years old….

Ama Dablam shrouded in clouds

Ama Dablam shrouded in clouds

As part of my continuous efforts to explore more of the Khumbu region, I took a day to do a sprint hike up to Chukung Ri, a 5550 m peak behind the town of Chukung, which is a town up the valley carved out of the Imja Khola river, which has its source on the mountains of Island Peak, Amphulapcha, Lhotse, and the North Face of Ama Dablam. Chukung is the stepping off point for expeditions up Island Peak (Imja Tse), 6189 m.

But I’ve been eyeing Chukung Ri on the map, at the same height as Kala Patthar, and close enough to turn it into a long day trip, it looked like a great peak to “bag” for an acclimatization hike to better prepare for mountains like Lobuche East (6119 m) and Island Peak. Reuben was supposed to join me for the day, but wasn’t feeling well, so off I go on another solo adventure in the Khumbu.

The trail from Pheriche to Dingboche

The trail from Pheriche to Dingboche

In spite of the long distance to be covered during the day, I took the hike out rather casually. After crossing the hill from Pheriche to Dingboche, I stopped in at the Snow Lion Lodge, where Renee’s research medical student is staying, to catch up with him and accept a cup of Sherpa Tea from the proprietress.

The Stupa in Dingboche

The Stupa in Dingboche

Decisions, Decisions.

Decisions, Decisions.

The trail from Dingboche to Chukung offers some great views of Imja Peak, which is also known as Island Peak. It is a relatively easy 6000 m peak, and for some reason seems very popular with Asian tourists. It has a distinct black diamond on its Southwest Face. Renee and I are planning on summiting this mountain in May.

The Southwest face of Island Peak with its distinctive black diamond.

The Southwest face of Island Peak with its distinctive black diamond.

Ama Dablam, apparently beautiful from any angle

Ama Dablam, apparently beautiful from any angle

Just before arriving at Chukung, I catch up with Scott Simper, an Emmy Award winning photographer and friend of my advisor, Scott McIntosh. He is out here working on some video projects, and will be climbing Everest later in the season. They’re headed to Island Peak as an acclimatization climb for Everest.

Memorial to a Polish Climber who died on the South Face of Lhotse (in the background)

Memorial to a Polish Climber who died on the South Face of Lhotse (in the background)

With Scott Simper on the trail to Chukung

With Scott Simper on the trail to Chukung

I enter Chukung, another hole-in-the-wall place that has a series of lodges and not much else, and look for the Sunrise lodge on the advice of Katie. The proprietor is kind enough to refill my water bottles and point me in the direction of the trail up Chukung Ri.

The town of Chukung with the South Face of Lhotse and Island Peak behind.

The town of Chukung with the South Face of Lhotse and Island Peak behind.

The trail is a dusty uphill battle, and almost immediately I catch up with a group of Chinese trekkers. Katie, Reuben, Renee, and I have discussed this on several occasions. It’s funny to feel so comfortable travelling these trails alone, only to constantly pass trains of trekkers clumped together with a guide in the front and another behind. The freedom of being able to explore these mountains and trails at your leisure, with all your needs on your back, free of guides, clients, and porters, is a freedom elusive to those who spend thousands of dollars for the chance to trek to Everest Base Camp.

Following the Chinese up the trail to Chukung Ri

Following the Chinese up the trail to Chukung Ri

But on this occasion, the group of Chinese trekkers worked to my advantage. I was able to get advice from their guides about the route, and at the summit, they were friendly enough. One of them was even a Pathologist in China. He was kind enough to take a couple of “summit shots” of me with my camera.

The trail up Chukung Ri

The trail up Chukung Ri

Island Peak from half way up Chukung Ri

Island Peak from half way up Chukung Ri

Getting to the top of Chukung Ri was a race against time, however. As I climbed higher, I was watching the clouds slowly gobble up Ama Dablam, Island Peak, Lhotse, and finally as I reached the summit of Chukung Ri, the clouds were threatening this small peak too. I wasted no time, and quickly descended. After all, getting to the top is just half the journey; I still had to get home.

Island Peak shrouded in cloud

Island Peak shrouded in cloud

Ridge line to Chukung Ri

Ridge line to Chukung Ri

Summit of Chukung Ri

Summit of Chukung Ri

Luckily, the return trip is an uneventful slog retracing my previous steps. I arrive back to Pheriche in time for dinner, tired but happy to have made one more assault in the Khumbu.

DSCN0837

DSCN0834

So after the Kala Patthar post, I thought I should write a more general post about what we do at the Himalayan Rescue Association clinic in Pheriche, because up until now, all I’ve shown you is my little adventures in the field. We actually do work too!

The author doing Nepalese Ebola Training.  Actually, I'm just wearing the bag from a new down comforter donated by the Australian Embassy, and using the EKG probes to harass people!

The author doing Nepalese Ebola Training. Actually, I’m just wearing the bag from a new down comforter donated by the Australian Embassy, and using the EKG probes to harass people!

There are three doctors at the Pheriche Clinic. Renee Salas is a Wilderness Medicine Fellowship at Mass General Hospital in Boston. We have known each other since we were both in a Wilderness Medicine Institute “Medicine in the Wild” course in 2009. Katie Williams is a general practice doctor from the UK, who is also a Diploma in Mountain Medicine graduate. She has been to the Himalayas multiple times, including working at a different clinic in Machermo last fall. Her fiancée is Reuben, who is a professional photographer who is starting to orient his career more towards wilderness and expedition photography. Katie and Reuben are planning on getting married 3 weeks after we leave Nepal.

We opened the clinic on March 15, although the patients couldn’t wait and we saw four patients on March 14th. To date, we have seen 124 patients in the past 23 days. We have evacuated evacuate 13 patients, or over 10%, mostly for High Altitude Pulmonary Edema, but have also seen High Altitude Cerebral Edema, an Upper GI bleed, and a pancreatitis patient.

Renee ultrasounding a patient

Renee ultrasounding a patient

Using our old-fashioned "suction cup" EKG machine on a patient.

Using our old-fashioned “suction cup” EKG machine on a patient.

Katie testing a patient's neurological functioning

Katie testing a patient’s neurological functioning

We do an altitude talk every day at 3pm, and thus far have given the talk to 229 trekkers and climbers. Renee is also running a research study looking at using Ibuprofen versus an anti-nausea medicine to help people with altitude symptoms. Since my research study has ground to a halt due to a malfunctioning ultrasound machine, and because the Nepal Health Research Council has not bothered to approve it yet, I have been helping her with her study. She also has a medical student who has been working over in Dingboche, the community next to Pheriche. So far we have enrolled 25 participants, with a goal of enrolling 200.

The author giving an Altitude Talk to trekkers and climbers on their way towards Everest.

The author giving an Altitude Talk to trekkers and climbers on their way towards Everest.

Evacuating patients by helicopter is often a big deal around here, and the helicopter services use it as a reason to send goods, food, or people up to Pheriche, as well as taking patients down.   The helicopters used here are used for general purposes, and are not specifically for medical usage, they have no medical crew or medical equipment.

Escorting a patient to the helipad.

Escorting a patient to the helipad.

Reuben and Gobi waiting for a helicopter.

Reuben and Gobi watching a helicopter to land.

Getting the patient secured in the back of the helicopter.

Getting the patient secured in the back of the helicopter.

A helicopter on approach with a box full of Easter goodies.

A helicopter on approach with a box full of Easter goodies.

Easter goodies landing at Pheriche.

Easter goodies landing at Pheriche, with Ama Dablam in the background.

A panorama of Pheriche and Ama Dablam from the helipad.

A panorama of Pheriche and Ama Dablam from the helipad.

Of course Easter here is business as usual, and the closest church is probably in Kathmandu, but we did find ways to enjoy the day. Reuben and Katie brought out Cadbury Eggs for each of us, and I broke out some Archer Farms (Target brand) Carmel flavored coffee, which was pretty good. We even had enough time to play a little Cricket with Jeet and Tan. It was my first time playing, so needless to say I was pretty awful.

A pretty great backdrop for a cricket match.  Katie pitches with Jeet at the bat.

A pretty great backdrop for a cricket match. Katie pitches with Jeet at the bat.

Our three puppies, Grizzly Bear, Black Bear, and Brown Bear, respectively.

Our three puppies, Grizzly Bear, Black Bear, and Brown Bear, respectively.

Katie playing with puppies.

Katie playing with puppies.

Luanne Freer, founder of the Everest ER, playing with puppies.

Luanne Freer, founder of the Everest ER, playing with puppies.

Puppies taking shelter from the snow.

Puppies taking shelter from the snow.

Kala Patthar

March 26, 2015

The fingers were finally saved, by another expedition of all things! This one was to a pile of rocks and scree known as Kala Patthar. Kala Patthar is probably the secondary objective on the minds of most trekkers to the Khumbu. It is a peak that is 5550 m (18,209 ft) high, but is dwarfed by everything around it. It’s claim to fame is the incredible views of Everest and Lhotse from its summit.

Right hand, looking more normal.

Right hand, looking more normal.

People trek to Everest Base Camp for the bragging rights, to say they’ve been there; they go to Kala Patthar to actually SEE Everest. Both of these locations are reached by continuing up the Pheriche valley until you reach the small community of Dugla, which is really just a couple of lodges next to a waterfall.   Above Dugla you come to the Thokla Pass, where many of the souls lost on Everest have been commemorated, including Scott Fisher, owner and lead guide of the Mountain Madness expedition, who lost his life on Everest in 1996, as described in Jon Krakauer’s Into Thin Air.

The small community of Dugla.

The small community of Dugla.

Thokla Pass.

Thokla Pass.

A memorial to Scott Fisher, one of the climbers who died on Everest in 1996.

A memorial to Scott Fisher, one of the climbers who died on Everest in 1996.

Thokla Pass.

Thokla Pass.

At the Thokla pass, you reach the Khumbu Glacier, and which is followed to Lobuche. Krakauer described Lobuche as a literal shit hole in his book. In the ensuing 20 years, things have slowly improved. Indoor toilets have replaced the outdoor pit toilets described by Krakauer, but there is no question, this is still the fringe of civilization.

Entering the Khumbu Glacier

Entering the Khumbu Glacier

Lobuche, where I stayed on my way up.

Lobuche, where I stayed on my way up.

I choose the nicest looking lodge, mostly because the walls are plastered instead of exposed rock, figuring that the plastered rock would be less drafty. After dropping my HRA credentials a bit, I have a conversation with the lodge owner, who is father-in-law to the lodge owner in Pheriche who sent Reuben and I on that wild goose chase. As it proves wise not to make enemies among the Sherpa, my friendship with his son-in-law nets me a free room for the night (saving me $5). The main room is cozy, and soon a group from Portugal befriend me and invite me to eat with them at their table. The leader of the group has had some incredible experiences, including biking from Kathmandu to the Holy city of Lhasa, Tibet. He has also solo sea kayaked for a week on the Antarctic Peninsula. We get along well. As is typical around here, it is an early night, as I plan on getting up around 4am to start the next leg of my journey.

I wake to a world in darkness. I had asked my lodge keepers to keep out a bowl of Muesli and powdered milk for me, and eat a creepy breakfast in a cold and dark dining room that last night had so much life. I sneak out in darkness, leaving most of my stuff in Lobuche. Too many miles, and I have to travel light. Travelling alone in the dark along the Khumbu Glacier is an exhilarating experience. Somewhere behind me I hear the occasional bell of a Yak train, like me making early time on this frozen highway towards Everest, but I’m as likely to meet a Yeti or a Snow Leopard, as meeting anyone else at this early hour of the morning.

The trail from Lobuche to Gorak Shep.

The trail from Lobuche to Gorak Shep.

The desolate landscape above Lobuche.

The desolate landscape above Lobuche.

People in the know say you want to be on Kala Patthar at sunrise, but these people also start their climb from Gorak Shep, 230m higher in elevation than where I spent the night. I’ll wake early, and just hope for the best. The road gets rockier and more desolate the closer I get to Everest. Finally Gorak Shep appears below me, a desolate little place for people making the pilgrimage to EBC. My goal is not base camp, but Kala Patthar, whose steep slopes start at Gorak Shep. The route is steep, and the altitude excruciating. We advise the people who come to our altitude talks not to ascend more than 500m per day. Climbing Kala Patthar, I will have gained 1300m in 24 hours.

Panorama view.

Panorama view.

Gorak Shep (in shadow at bottom of picture) with Kala Pattar in shadow and the morning sun on Pumori.

Gorak Shep (in shadow at bottom of picture) with the top of Kala Pattar just getting a bit of sun, and Pumori in full sun.

I feel relatively good. No headache, no nausea, just the fatigue of climbing at this altitude. I can do this because my plan is to summit Kala Patthar, and then descend back to Pheriche in one day.

DSCN0749

The sun rises directly behind Everest, a moment of panic. I didn’t climb all this way just to have the sun right behind the mountain I wanted to photograph! But still I climb. What I think is the summit is of course a false summit.

Still I climb.

Taking a break as the sun rises over Everest and Nuptse.

Taking a break as the sun rises over Everest and Nuptse.

Finally reaching the top, in true Nepali fashion the summit is covered with prayer flags. Literally buried in them. The summit turns out to be a slab of rock jutting out into nothing.

Approaching the summit.

Approaching the summit.

Reaching the summit, full of flags.

Reaching the summit, full of flags.

With all deference to Buddhists, I grab handfuls of prayer flags to pull myself up to the summit, and have to sit among them as I turn to look at the top of the world.

The route to the summit of Kala Patthar, with Pumori in the background.

The route to the summit of Kala Patthar, with Pumori in the background.

Sure I’m surrounded by giants, but the view sure is nice! Snap a few shots, enjoy the view, eat my favorite English candy bar made of chocolate covered sea-foam. Then it’s the long journey down.

View from the top, looking at Everest (left) and Nuptse (right).

View from the top, looking at Everest (left) and Nuptse (right).

Everest and Nuptse.

Everest and Nuptse.

Panorama of Everest.

Panorama of Everest.

Enjoying my favorite English candy bar.

Enjoying my favorite English candy bar.

Back in Gorak Shep and I can already feel that a bowl of cereal 8 hours ago is not enough to keep me going, however the idea of eating food from one of the lodges in this forsaken land is not at all appealing. Just keep moving!

I meet up with my friends from Portugal, who are headed to EBC today, then Kala Patthar tomorrow. Wish them well, I’ve got miles to go. I don’t have time for EBC on this trip, plus I will likely go back to visit the Everest ER crew after they have set up, and meet some of the Everest players vying for summit glory.

The hike back is like all return journeys, and not really worth mentioning. Exhaustion has set in by 4pm when I am back in Pheriche. The trip was approximately 25 kilometers, with 1300 m (4,300 ft) of elevation gain and loss in a day and a half. Needless to say my wander bug has been satisfied for the time being. But I have fulfilled one more of my Nepal objectives, and have gained a significant altitude, which should help me reach further high altitudes later in the season.

View of Pheriche from further up the valley.

View of Pheriche from further up the valley, Ama Dablam on the right.

The night before last I was feeling great. I had been reading articles about climbing mountains online at SummitPost.org, and simultaneously reading out of High Altitude Medicine and Physiology, 5th Edition, a great textbook about what happens to humans at high altitude. I had no sooner put the book down, when I had my own fist had experience of what happens to human bodies at high altitude.

No sooner had I turned out the lights than my feet started to really hurt, specifically the first and second toes of the right foot, and then the second toe of the left foot. Like excruciating pain. I’ve never had gout, but I imagine this is what gouty arthritis felt like. Except I had it in 3 toes! I also had mild pain in the 2nd MCP joint (that’s the first joint on the pointer finger) and the 3rd PIP joint (that’s the second joint on the middle finger). I tried taking ibuprofen, without any improvement in symptoms. I had to reach for the hydrocodone with acetaminophen, which was finally able to control my pain to the point where I could get some sleep.

I have never felt such pain before!

When I woke yesterday morning, my feet were not nearly as painful, but still quite swollen, but the middle finger on my right hand was so bad that I could not straighten it, and my fingers, especially on my right hand, were quite swollen. My knees ached, and I was generally not feeling well. It is as if I had aged decades overnight.

Yesterday I was on the day shift, and we were steady with 7 patients. I felt like my right hand was a withered, crippled, claw. Everytime I had to shake a customer’s hand it was excruciating.

After the day was through, I pulled down Auerbach’s Wilderness Medicine, 5th Edition (the copy at the HRA post has actually been signed by Paul Auerbach and Ken Zafren, who is one of the medical advisor’s for the HRA), not an easy task in itself! After flipping through Acute Mountain Sickness, High Altitude Pulmonary Edema, and High Altitude Cerebral Edema, I got to a small one-paragraph section on Peripheral Edema at High Altitude. According to this authoritative text, peripheral edema will occur in 18% of people over 4200 meters, and suggests the use of a diuretic medication for symptom relief. Ah, Acetazolamide (Diamox), you always seem to be near at hand in high altitude. I never needed it for Acute Mountain Sickness, it’s most common use at altitude, but here I am relying on its diuretic properties to let me pee away my peripheral edema.

My hands on the night of March 22.  The knuckle on my right pointer finger is obviously swollen, and I can't straighten my right middle finger much past where it is without significant pain.

My hands on the night of March 22. The knuckle on my right pointer finger is obviously swollen, and I can’t straighten my right middle finger much past where it is without significant pain.

My feet on March 22.  Look how swollen each of the toes look!

My feet on March 22. Look how swollen each of the toes look!

I took 125mg last night, and had two good pees overnight. In the morning, my left hand and toes had greatly improved. My right hand is still being a bit problematic, but acetazolamide and I keep waging our battle against excess fluid. 250mg during the day, and I’ll take another 125mg tonight. I am mostly back to normal, but still can’t quite straighten my right middle finger!

My hands on March 23.  The knuckle on the right 2nd finger is still somewhat swollen, and while I can straighten my right middle finger a lot more than yesterday, I still cannot straighten it completely.

My hands on March 23. The knuckle on the right 2nd finger is still somewhat swollen, and while I can straighten my right middle finger a lot more than yesterday, I still cannot straighten it completely.  My left hand looks pretty much normal.

While my toes look much more splotchy than they did yesterday, they are not swollen and feel much better.  I have a blister on the left 2nd toe from the trip to Ama Dablam, and my right 2nd toe has a bruise on it where a nearly blind guy stepped on my toe today (casualties of wearing flip flops in the HRA clinic!)

While my toes look much more splotchy than they did yesterday, they are not swollen and feel much better. I have a blister on the left 2nd toe from the trip to Ama Dablam, and my right 2nd toe has a bruise on it where a nearly blind guy stepped on my toe today (casualties of wearing flip flops in the HRA clinic!)

Adventure to Misadventure

There is a difference between adventures and misadventures. When Amundsen reached the South Pole, that was an adventure; when Shakelton got his ship ice bound in Antarctic waters, that was a misadventure.

Adventure: So Reuben and I set off yesterday to climb to Ama Dablam’s base camp. The plan was to backtrack down the same trail that we came up from Lukla. After approximately 2 hours, we would reach Pangboche, then cross the river and head up the trail to Ama.

Misadventure: At breakfast before setting off, I asked our head man from the HRA, Gobi, about the trek. He recommended that I talk with one of the lodge owners in Pheriche, who has a lot of knowledge of trekking in the region. So Reuben and I walked over to his lodge, and discussed our plans with him. He recommended that we travel over to Dingboche and cross the Imja Khola River to the east side. We would then find a trail and ascend. Following this trail, we would pass through a couple small Sherpa communities, and then end up half way up the trail to Ama Dablam’s with an easy final hike to the basecamp.

We were somewhat dubious; although this is the trail my friend Jenn had taken the previous season. We asked if there wasn’t too much snow, and if anyone had been on the trail, but we were assured that the trail was well used, and would be the best way for us to get to Ama Dablam.

So off we were, over the hill to Dingboche. We found the bridge and soon crossed. Things were well. It was a beautiful day, and we had a choice of two sets of tracks, which would surely lead us to the trail to Ama.

Reuben crossing the bridge at Dingboche.

Reuben crossing the bridge at Dingboche.

Wait…! Where did the trail go? We decided to break trail through the snow. Surely if we kept going, we’d find something that looked trail like.

Breaking trail with the town of Dingboche to our left.

Breaking trail with the town of Dingboche to our left.

This doesn’t seem to be working. Maybe we should drop down to the river, and we could cross to the other side, and then follow the trail out of Dingboche to Pangboche, like what we were going to do initially.

The Imja Khola

The Imja Khola

We are now hoping from rock to rock across and down the Imja Khola. There’s got to be a way across somewhere!?! We keep on. We know that if we keep following the river southwest of Dingboche, there is a place where the trail goes down by the river. Surely we can pick up the trail there.

Finding a trail of snow among the thorns and rocks by the riverside.

Finding a trail of snow among the thorns and rocks by the riverside.

Four hours, and we’re still just opposite of Dingboche. Doesn’t it only take two hours to hike from Pheriche to Pangboche?

 

Did you know that if we had gone the other way, we would probably be at the Ama Dablam basecamp by now?

We get to the spot. Look, there’s a trail going up the ridge! We decide to follow the trail. All seems good. Pace quickens. We are now following a trail. Someone has been here before. Who? Who was this person, and where were they going? It becomes clear that we are not just following one set of tracks, but someone has gone up, and then come back down in the same tracks. Fatigue is setting in, concentration lacking.

We follow the tracks to Rala Kharka, a small group of Sherpa huts with rock fences to differentiate small farm fields. The tracks stop in front of one of the shacks. All are locked. Nobody is home. No trail continues on from this village. We’ve been hiking for 6 hours.

The huts at Rala Kharka.

The huts at Rala Kharka.

It is still beautiful, but clouds are coming in from the south. A breeze picks up. We sit on the rock wall near the shack. A Snickers satisfies the hunger inside of me.

We keep punching on. There is a vague outline of a trail, and a monument of stone, more refined than a mere cairn. We head for it. According to the map, if we simply keep following this contour, we should end up on the trail from Pangboche to Ama Dablam.

Ama Dablam is no longer the objective. We are getting exhausted, dehydrated; the afternoon weather is kicking up. We are now seeking the warmth of a lodge in Pangboche. Just get there!

We keep post holing through snow. The first field is shallow with plenty of rocks protruding. Not likely to slide. We keep moving. We take turns. Reuben is wearing his mountaineering boots, with knee high gaiters. I am wearing a pair of light hikers. They aren’t Gore Tex (I don’t believe in that stuff in hiking boots, after all…). I’ve got a pair of permetherin coated ankle high gaiters made for keeping rocks and insects out of your shoes and pants. They would work great for Africa. Not made for Nepal. I will have to write a nice review of them online at Backcountry.com. My mountaineering boots are still in a bag on its way to Pheriche. My shoes feel like swimming pools. I can move my toes around, and see water slosh out of the canvas near the toes. I have already saturated 2 of my 3 pairs of sox.

The terrain gets sketchier. The snow is punchy, feeling like it might just support your weight, but then you break through a firm layer to the softer snow underneath. The lighter snow on previous slopes has given way to knee-deep snow that sometimes goes as high as your hip. There is no evidence of slides, but we kick off small snowballs with each step. I don’t have a slope meter, but estimate the slope to be approximately 45 degrees. It’s warm. It’s 2 in the afternoon.

Crossing snow fields that are looking ever more threatening on our way to Ama Dablam base camp.

Crossing snow fields that are looking ever more threatening on our way to Ama Dablam base camp.

Looking back from where when came.

Looking back from where when came.

We are walking above a forest of Rhododendron. These terrain traps are called “cheese graters” in the Avalanche community.

Knowledge is power. Knowledge is a dangerous thing. Nothing about this situation is good. This is where avalanches happen. This is where people disappear. The most common terrain to slide is 38-45 degrees. Slides are more likely to occur in the afternoon, when the sun has warmed the snow, in the spring. If the avalanche doesn’t seriously hurt us, being run through the forest below at 50 miles an hour won’t do anything good.

We come across a south-facing slope where all the snow has melted off. We can see a trail in the distance, but two more snow slopes, even scarier looking than the last separates us from this point.

We make a decision. We descend back to the river. We hike down the slope. When we enter the Rhododendron forest, the ground is again covered in snow. We slide from one tree to the next, slowly making our way back down.

Here we trade one bad situation for another. Post holing through a snowfield is hard work, but so is travelling among the boulders at the side of a quickly moving glacier fed river. The right bank of the river looks tempting, but there are no places to cross. There was a bridge at Dingboche. The next is at Pangboche.

At times large boulders completely block the left bank, forcing us to climb back up the slope to go around. This is not easy. In fact at one point, I find myself holding on to dried grass with my left hand, with bad footholds of soft snow. No tree trunks in reach. I am able to punch my right fist in the snow to make a questionable hold. This is the worst moment of the trip. I reached some more secure holding, but if I had started to slip, there’d be no stopping me, and I would have been in the river.

We were beaten down by the snow slopes; we are beaten down by the river. A few hundred yards away, we can see the hikers, yaks and porters travelling along the trail. The trail we were planning on taking that morning, until we listened to the worst bad advice I’ve ever listened to. They are on one side of the river; we are on the other. I curse the lodge owner. My anger does not stem from getting bad advice, but from bad advice that turned out to be incredibly dangerous.

We keep crawling along the boulders of the river. Dehydration is making me weak and mentally drained. I have only peed once today, and it was the color of Ale. This is when mistakes happen. Occasionally a porter sees us down in the river valley and calls out to us. This does not make anything better.

The tension eases in a subtle way: we come across yak dung. If there are yaks here, we must be close to a trail. Yaks have pretty free rain over the hills and pastures of this land, but they still need to get there. We walk along, following the pies of yak dung. Where a yak can go, we can go.

"Where a yak can go, we can go!"

“Where a yak can go, we can go!”

The next piece of evidence is trash. Candy bar wrappers and Coke bottles. Garbage has never looked so good. The going gets easier. Soon the bridge to Pangboche is in site.

Crossing the bridge is like the end of a nightmare. A trip that should take approximately 2 hours by the standard route has taken us 8 hours by our ridiculous alternative route.

Pangboche is on top of a hill, and we slowly make our way up the steps. Reuben knows of a good place that he has stayed in before. We enter and ask for lodging. After looking at us, they want to put us in one of their outdoor rooms. We insist to be inside. After some long consideration on their part, they reluctantly agree.

I quickly change out of my wet socks, and wring dirty water out of them. I am very grateful for the down booties I had been carrying all day. I change into a world of down: down jacket, down pants, down booties.

We head upstairs to the dining room. The custom in the Khumbu is that the lodges cost almost nothing (my stay cost me Rs 100, which is approximately 1 USD), with the understanding that you will eat there. We order a large pot of Honey Lemon Tea, and as we each drink cup after cup, my dehydration headache slowly dissipates. Since we get food free at the HRA post, I am eager to eat things that we don’t get there. I order chips with egg, which is French fries with an over easy egg on top. The egg yolk and fries are a great combination. I also order a freshly made apple pie, which was full of cinnamon-y goodness.

We sit around the stove talking with a firefighter from Melbourne, Australia, and a guy from Portsmouth, England, who have both left their trips early because of high altitude illness, before heading off to a much deserved rest.

Misadventure to adventure

Ama Dablam and Mount Everest, looking north toward Pheriche and Dingboche.

Ama Dablam and Mount Everest, looking north toward Pheriche and Dingboche.

We awake early in the morning to try a second attempt on Ama Dablam base camp. Just like yesterday, the view of Ama this morning is spectacular without a single cloud in the sky.

Breakfast is Tibetan toast with butter and jelly. Tibetan toast is a deep fried pastry that is somewhat like a doughnut. We pack our bags, and head off back down the trail to the same bridge that we were so thankful to cross the evening before.

Down the hill from Pangboche, cross the river, up the hill to Ama Dablam. We find a place to stash our excess gear under a shrub so we can travel light. Base camp is at about 4600 meters (15,100 feet), which is only about 300 meters higher than Pheriche, however we have to climb from the river, and so have a gain of over 600 meters from the river. Luckily for us, someone knowledgeable about the trail has recently been up to base camp, and we have a solid trail to follow. Plus, in the early morning, the snow is still firm enough that we don’t break through. Another day of breaking trail would not be an option.

Prayer flags on the route to Ama Dablam

Prayer flags on the route to Ama Dablam 

The approach to base camp

The approach to base camp

We get to basecamp around 10:30 am. There is nothing there but snow, cairns with prayer flags, and a few “long drop” toilets. But the views are spectacular! Ama Dablam continues to impress, but from this vantage point you can appreciate that it is on one side of a cirque of incredible peaks. In the background sits Everest, unassuming from this location, with its famous strand of cloud drifting off into space.

Prayer flags and Ama Dablam from basecamp

Prayer flags and Ama Dablam from basecamp

The author with Ama Dablam in the background.

The author with Ama Dablam in the background.

The other peaks that share the Cirque with Ama Dablam

The other peaks that share the Cirque with Ama Dablam

As we head down, we meet a guided group of Chileans and Spaniards heading up. By now the snow is softening, and the ground is turning to mud. They are already too late, as days quickly age in these altitudes. How funny to be just two people freely trekking around, among all these groups of guided tours.

The trip back to Pheriche is relatively uneventful. We passed several trains of yaks heading up to Everest with gear to support one of the Everest expeditions. One of the yak handlers told us that this expedition would use 60 yaks to get all their gear to basecamp. Multiply that by the number of various groups sending teams up the mountain, and it is clear why Everest is big business indeed!

Reuben and I shook hands as we crossed the bridge into Pheriche. The first hiking goal of the trip was accomplished. In the end, we bought more than we bargained for, but not more than we could handle.

A World Lit Only By Dung

March 17, 2015

The front of the HRA clinic in Pheriche, with the Everest Memorial monument out front.  It lists the names of all the known deaths on Everest, currently accurate through 2012.

The front of the HRA clinic in Pheriche, with the Everest Memorial monument out front. It lists the names of all the known deaths on Everest, currently accurate through 2012.

The plaque on the front door of the Pheriche HRA clinic

The plaque on the front door of the Pheriche HRA clinic

We have made it to the HRA post at Pheriche, and are slowly adjusting to our new routines. The valley that contains the small village of Pheriche is absolutely beautiful, with towering spires surrounding the houses, lodges, and farms. After arriving, we assigned ourselves rooms and got to work cleaning the residential side of the clinic. We then spent the next two days, March 13 and 14, cleaning the clinic, and arranging the medical stores.

View of the Pheriche Valley to the Northwest.

View of the Pheriche Valley to the South.

View of the Himalayas surrounding Pheriche.  Looking to the Northwest

View of the Himalayas surrounding Pheriche. Looking to the Northwest

The "business end" of the Pheriche HRA clinic, the reception area for patients, and the shop for selling t-shirts, etc.

The “business end” of the Pheriche HRA clinic, the reception area for patients, and the shop for selling t-shirts, etc.

The examination room, where we see most patients.

The examination room, where we see most patients, still in the process of being cleaned.

Our "Inpatient Ward" where patients staying overnight will sleep.

Our “Inpatient Ward” where patients staying overnight will sleep.

The kitchen, where Jeet keeps us well fed, and where there is an unlimited supply of hot water for drinks (my new favorite being a combination of Hot Chocolate and orange Tang, delicious!)  We sit around the small table for all meals.

The kitchen, where Jeet keeps us well fed, and where there is an unlimited supply of hot water for drinks (my new favorite being a combination of Hot Chocolate and orange Tang, which I call a Terry, after the British company that makes chocolate oranges.  It’s delicious!) We sit around the small table for all meals.

The common room at the HRA clinic in Pheriche.  My room is the door on the right.

The common room at the HRA clinic in Pheriche. My room is the door on the right.

A Panorama of the staff enjoying the heat of the Dung stove in the evening.

A Panorama of the staff enjoying the heat of the Dung stove in the evening.

My bedroom at the HRA clinic

My bedroom at the HRA clinic

When we arrived, we had the bags we carried, plus one bag carried by a porter. The rest of our supplies, including food, medications, and personal effects, were to arrive by Yak train. This hasn’t happened yet….

Supposedly they’ll be here by tomorrow. The clinic has now been open for the past 4 days, and we’ve seen several Nepali locals and guides, and have diagnosed two people with High Altitude Pulmonary Edema. One has been flown out, and the second is spending the night in the clinic tonight, and will be flown out tomorrow.

We have split up the schedule so every day there is a daytime doctor, a nighttime doctor, and a doctor who is off. The night doc is also responsible for our 3pm altitude lecture, which I gave for the first time today. Our schedule is such that you work each shift twice in a row, which ultimately gives each person 2 days off at a time.

So tonight is my first “night shift”. We’ve had good luck in the past not getting patients during the nighttime hours. We’ll see if it holds for tonight. Tomorrow I will also be on overnight, and then will have two days off. If I get good sleep tomorrow, then Reuben and I are planning on trekking down to the Ama Dablam basecamp, which is at approximately the same elevation as Pheriche, and is supposed to be quite spectacular.

It has been cold, and even snowed yesterday. Our building is powered by solar, with a solar water heater, so our ability to function is dependent upon how much sun we get, and how much we need to use the oxygen concentrators for our patients (our major source of energy expenditure).   It’s kind of interesting to have to be so conscious of our energy use. Many Americans and Westerners would probably be well of to have to live by solar for a period of time to have a better understanding of the implications of power use.

But today was sunny and warm, and we got enough of a charge that I could take a nice, hot, shower. This is the first shower I’ve been able to take since leaving Kathmandu on the morning of March 8, 10 days ago. The good news is that it is so cold here that you never really develop the bad smells that you would in more temperate climates, but I was still happy to wash all the days of travel off of me, and change into some fresh clothes.

Our daily routine is such: Jeet, our cook, has breakfast around 8am. We usually lounge, or work on projects until noon when we have lunch. If it is sunny, one or two people can take a shower after lunch, during the warm part of the day. Then at 3 we have our altitude talk. This usually brings with it a small flurry of business, as people realize that they are actually suffering from altitude illness. Dinner is at 6pm. Yesterday they bought a chicken, which was cooked with the Dal Bhat. I have decided that one determination of whether a country is civilized is how they cut up a chicken. Needless to say, I’ve been carefully picking around jagged pieces of bones here. But protein is still good! After dinner is the real treat of the day: Jeet loads the potbellied stove full of dried Yak dung, and we sit in warmth, the only external source of heat we have other than the kitchen’s gas burners, and the very occasional warm shower. For several hours in the evenings, we relax in the common room in comfort. We are only allowed one stove’s full of dung a day, so when it is done and the room starts to cool, people head towards bed. Renee and I have our bedrooms directly off the common room, so we have gotten in the habit of opening our bedroom doors after the others have left, and letting the remaining warmth of the dung stove heat our rooms before bed.

The following are pictures of the clinic, Pheriche, and nearby Dingboche, which Renee and I visited a few days ago.

The author in a PAC bag, which can effectively increase the ambient air pressure by 2 bar.  In Pheriche (4200m), this  simulates the much lower altitude of Lukla (2800m).

The author in a PAC bag, which can effectively increase the ambient air pressure by 2 bar. In Pheriche (4200m), this simulates the much lower altitude of Lukla (2800m).

Practicing with the PAC bag inside the sun room.  The author is currently inside.

Practicing with the PAC bag inside the sun room. The author is currently inside.

The village of Dingboche, a 30-45 minute walk from Pheriche. It is 200m higher than Pheriche, and quite a bit larger.

The village of Dingboche, a 30-45 minute walk from Pheriche. It is 200m higher than Pheriche, and quite a bit larger.

The village of Dingboche with Island Peak (Imja Tse) in the background (looks like a black diamond).  I am planning on climbing that mountain in May.

The village of Dingboche with Island Peak (Imja Tse) in the background (looks like a black diamond). I am planning on climbing that mountain in May.

Returning home to our small village of Pheriche.

Returning home to our small village of Pheriche.  Hard to see, but the HRA clinic is mid picture.

The Stupa in Dingboche.

The Stupa in Dingboche.

An old Stupa above Dingboche

An old Stupa that sits above Dingboche in need of repair.

The helicopter landing to pick up our HAPE patient.

The helicopter landing to pick up our HAPE patient.

The helicopter taking off with our HAPE patient.

The helicopter taking off with our HAPE patient.