There are Signs Everywhere Part 7 – And Then There Were Ten

From the 2013 Travel Journal – The WMS CME Trek to Everest Base Camp

Part 7 of There Are Signs Everywhere

Jim's morning yoga pose in the Khumbu

Jim’s morning yoga pose in the Khumbu

“And then there were ten” (almost nine)

Everything turned out all right in the end. But it had been an eventful 24 hours or so. Our down trekking days proved to be, in ways, more fatiguing than the up. We all enjoyed just-shy-of-scalding hot showers in Monjo, as well as the chocolatiest hot chocolate yet, and apple pie in doughnut form, making 11 Trekkers’ tummies happy. Glen interviewed us to make a list of the first foods we would eat when we got home, and from there, harnessing the group’s attention for more lecture after dinner at the Mount Kailash Lodge proved challenging. So I demanded focus the only way I knew how: “Folks, we can return to our talk of food orgasm (meant to say FOODGASM) after this lecture.” Of course the tea house room went silent just as the word orgasm left my lips. Fearless Leader’s face turned red, and then I broke right into Ophtho Emergencies in the Backcountry. We had another great discussion about the difference in practice around the world for the same illnesses. We covered Lateral Canthotomy (a procedure I’ve actually preformed twice in my six years as an attending) and other procedures that made some of our non-physician Trekkers queezy. Then, for the first time in a couple of weeks, many of us had a glass of red or a beer on the eve of our last trekking day.

One of Glen's awesome gadgets

One of Glen’s awesome gadgets

Another gorgeous day in the Khumbu

Another gorgeous day in the Khumbu - final trekking day

Another gorgeous day in the Khumbu – final trekking day

No joke: every day of this trek was a bluebird day. After sorting out meds for various URI (Upper Respiratory Infection) symptoms, we set out for Lukla. About two hours into the trek, I received word that one of our Trekkers fell and had back pain. Jim and I, along with Nima Dorji Sherpa, back-trekked in sixth gear about 20 minutes to find our friend in the excellent care of Deja, our soon-to-be 1st year med student at University of Chicago. Deja was holding c-spine immobilization, and proceeded to present the patient to me in an efficient and organized manner so that we were caught up in 60 seconds. Clearly, Deja took our scenario and lectures on trauma in the backcountry to heart. Our trekker had pain but luckily was completely neurologically intact, in spite of what was likely a 30-ft fall landing on her feet. We had a big debriefing on prevention and management after the fact, but in the heat of the moment, our team of physicians/Trekkers/Sherpas provided top notch care for our friend, facilitating a helicopter rescue in under an hour. The chopper landing and take-off were award-winning. Any photos posted here are with the patient’s permission. In the end, she had a serious injury – a fracture of her low back – but remained completely neurologically intact. The patient’s transfer out of Nepal was delayed about a week because of how long it took the physicians at the CIWEC Clinic in Kathmandu to convince the patient’s rescue insurance (obtained through her credit card) to arrange for a flight out to where she could be evaluated by a spine surgeon. Ultimately, she was transfered to Thailand, had an operation, and was walking 30 days after the initial fall. She has since returned to her job teaching and continues to travel extensively.

Take-home points:

1. Always go to the hillside (Uphill side) when passing yaks and donkeys on the trail.

Always pass yaks and donkeys on the hillside

Always pass yaks and donkeys on the hillside

2. Look before you step. When evaluating a patient for trauma, attempt to take a look at the site of the event to obtain details on the mechanism. This made a difference in this case in terms of her disposition and evacuation.

Site of Alena's fall

Site of the fall

3. Travel the Khumbu with expert Sherpas like Pasang, Dorji, Nim Dorji, Phula, and Dowa from Peak Promotions.

Peak Promtions Top Notch Sherpas

Peak Promtions Top Notch Sherpas, led by Pasang (second from left)

4. Practice stabilizing the c-spine ahead of time (like we did in our scenario).

Alena's c-spine immobilization

Our patient’s c-spine immobilization

5. Write a good history and keep a timed record of an event like this to pass on to the next provider. Consider pinning the written record to the patient to ensure it gets to the next provider.

6. Always get adequate travel and rescue insurance for a big trek, especially internationally. I personally use and recommend Global Rescue. These costs would be covered without question with proper insurance:

  • Cost of Helicopeter Rescue from the Trail to Lukla = $1000
  • Cost of Helicopter Rescue from Lukla to Kathmandu = $4000
  • Cost of transport for a patient that must be supine (like Alena with her L2 fracture) options: $60K for a private plane or $20-30K for removing the back two rows of a commercial airplane with a doctor and nurse accompanying the patient.
IMG_2146

Word from Pasang was no chopper had ever landed in that spot before

L2 Burst Fracture. The lateral cuts show retropulsion into the spinal canal. There was no spinal cord injury. The patient awlays had a normal nauerological exam.

L2 Burst Fracture. The lateral cuts showed retropulsion into the spinal canal. There was no spinal cord injury. The patient awlays had a normal nauerological exam.

Khumbu Moutain Puppy

After the event that day, the trek mojo was understandably a bit off until we saw Khumbu mountain puppies! Aren’t they the cure-all?

Khumbu Mountain Puppy. I'm not sure how he didn't wind up in my backpack trekking home.

Khumbu Mountain Puppy. I’m not sure how he didn’t wind up in my backpack trekking home.

We all finally made it to Lukla. Luke-warm-to-freezing cold showers obtained, but clean! Everest beers consumed, rehashing the drama of the day, the magic of the trek. At dinner, the group surprised me with a STARBUCKS LUKLA mug signed by all (a little choked up). I’m going to miss hearing those 11 voices everyday, now sing-songy like one of our Sherpas Phula.

First Lukla beers. Still at over 9,000 feet elevation

First Lukla beers. Still at over 9,000 feet elevation

Just when we thought the excitement for the day was over (9 pm), one of our Trekkers fainted at the dinner table (three times). He seemed to respond to some juice (glucose), but he made trip number two to the hospital in Lukla that day (which is a branch of the Kunde hospital -Sir Edmund Hillary Hospital), just to make sure everything was ok. Some low glucose, a bit of low potassium, and a normal ECG. The labs took less than 10 minutes to come back (ahem).

The physician at Lukla was from Switzerland, French part: Lucerne. He was very kind and showed us around a bit before we left (at 11pm). We saw how they keep pre-natal records (anything complicated goes to Kathmandu). He showed us the male and female wards, each with four beds. All patients are allowed one visitor overnight. Sometimes its required. For instance, if our friend had stayed overnight (as is the standard of care for many cases of syncope in the States) one of us would have stayed with him, and it would be our job to alert the staff if something alarmed on the monitor, or if the patient’s condition changed. The patients in Lukla had such ailments as new onset CHF (Congestive Heart Failure), dental abscess with significant facial swelling, treated with ceftriaxone, and mastitis, treated either with dicloxacillin or doxy (we weren’t quite sure, but we were hoping for the first). She was breast feeding from the unaffected breast, pumping from the diseased breast, happy as a clam. $300 (for tourists) for the visit – cash up front. You write to your insurance company for reimbursement.

The next morning, we woke up at 5 am to get one of the first flights out of Lukla. Glen, Laura, and I held hands tightly while the entire plane cheered on the pilots for an exhilarating take-off from that very short runway. The runway is so short, the plane actually dips down before the lift.

Inside the cabin, heading back to Kathmandu

Inside the cabin, heading back to Kathmandu

IMG_2166

Infamous Lukla Runway. Shot from the beginning of it, and you can see the end of it – the drop – at the end.

We all landed safe and sound, showered, fed, caffeinated, and began relaxing in our own ways: reading the paper, playing tennis, soaking up some sun, shopping, snoozing in Kathmandu. The final group meetings and dinner would take place over the next two days. We met back up with our trekker who’d been waiting at the Yak & Yeti after his heli rescue for HAPE and HACE in the setting of Traveler’s Diarrhea (Reminder, only definitive treatment is DESCENT).

Bottom line, like Luanne Freer talks about in her lecture “Finding Your Everest,” I think this trek was a life changer for many of the WMS Trekkers. Some will return to Nepal, others will not, but the Khumbu captured a permanent place in our hearts and minds.

Over the next month, the original 15 Trekkers would compile our pics and our thoughts, including the awesome long-exposure starry night photos Jim took from Everest Base Camp.

Namaste & hugs.

To read the trip summary including medical cases: WMS Everest Experience

Follow the 2014 WMS Everest Trek with Peak Promotions

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2 thoughts on “There are Signs Everywhere Part 7 – And Then There Were Ten

  1. Like I’m there without the exertion and the headaches. Though also without the live experience (like the Met in NY vs live in HD simulcast – great but not quite the same) and the cameraderie.
    But what is a canthotomy?

  2. Lesson No. 1, don’t hike at high altitude without eating, then, enjoy a celebratory serving or two of strong libations on an empty stomach. Lesson learned, but most of all the most memorable lesson of all, what friends I had to help me finish the journey; I will never forget that I had 7 or more physicians trekking me up hill to a small clinic in Lukla, and then once they figured out I was Okay, to start to take pictures for their scrapbooks, LOL. I really love these people, they are what medicine should always be about; brilliance, and compassion. Love to all. Glen

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