It was a cold and snowy night when we got the call, and we were just finishing dinner. The aid-post's phone service was down, so the call from just over the ridge had been routed through Kathmandu to one of the teahouses in Pheriche; the owner of the teahouse came to the aid-post to inform us. There was a request for a housecall in Dingboche to see a patient with "severe AMS and gastroenteritis." Unsure of what exactly we would find, we loaded up our packs with an oxygen tank, iv fluids, dexamethasone (a steroid used in HACE), nifedipine (a blood pressure medicine also used in HAPE), and some other medications for vomiting and diarrhea.
Chris, Arjun, and I set out over the ridge in the dark. The path to Dingboche is steep, slippery, and hard to follow in the daylight. After dark, it was a real challenge. I led the wrong way up an even steeper yak path, and we had to traverse to get back on track. Luckily we have been walking the path every few days as part of a morning hike or on the way to our afternoon lectures in Dingboche. The falling snow looked like a meteor shower in our headlamps, and visibility became only a meter or so as we ascended into a cloud. On the other side of the ridge, we could barely make out the town lights but we eventually found the right tea house.
Rather than the expected patient with severe AMS, we found two patients with both HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema). One guy could not walk straight and was breathing heavily, but his companion could barely respond, fell when standing, and had oxygen saturation of 31% (normal for here is 85%). He is probably our sickest patient yet and might not have made it through the night without intervention. He also had vomiting and diarrhea (likely bacterial gastroenteritis) that had gone untreated for the last 4 days. They both needed oxygen, medications, and evacuation. But we had only brought one oxygen tank.
At this point we had a choice. We could get a large team to carry both men and all their gear over the treacherous path we had just came. Or we could get another oxygen tank, more meds, and camp out with the patients overnight in Dingboche. We chose the latter. Fortunately, the patients' trekking group and guides were supportive, and two porters agreed to hike to the aid-post to retrieve more supplies: more oxygen, dexamethasone, and some other supplies. Chris and Penny arranged the provisions and sent the porters back with what we needed. The "ICU" was setup in the common room of the teahouse, with the patients in their sleeping bags and Chris and I under blankets provided by the teahouse owner. We was awake for most of the night checking the patients' vitals every couple of hours, and the porters worked in shifts to keep the patients' oxygen masks in place and to help them get to the bathroom when the diarrhea recurred which was almost hourly.
Both patients exhibited rather disturbing "periodic" breathing which is similar to sleep apnea. This breathing is irregular where the time between breaths gets longer and longer until they have a "missed breath" or stop breathing for 20-30 seconds. Then they usually gasp - usually waking themselves up and frightening anyone sleeping nearby. This is a pretty typical breathing pattern at altitude, but the worse patient was doing so at 50-60 breaths per minute (about 3 times normal). At home, I would have intubated him hours ago and let he ventilator take over. One of the medications we use to treat patients with HAPE is sildenafil, aka Viagra, which I don't use often. Although it sounds funny, sildenafil is used in pulmonary hypertension although most people know it for it much more marketed and ...um... sexier indication. Whether it was just time on oxygen or the sildenafil, this patient seemed to respond pretty well and his breathing improved.
Finally, dawn broke, and with it news that the helicopter would arrive shortly. The patients had both remained relatively stable through the night, although the worse-off patient was still measuring a meager blood oxygen saturation of 50% and struggling to walk straight. Along with the porters, we helped the two men to the helipad and saw them off.
The beautiful landscape before us belied the tragedy that we learned about upon our return to the aid-post in Pheriche. Chris and Penny filled us in on the bombings in Boston and we immediately sought to connect with our family and friends in Boston. Chris's parents were on the sidelines near the finish line that morning and his brother-in-law, Jay, was running the marathon. We were relieved to learn that Jay's pace was such that he crossed the line and had moved out of harms way (along with his parents, Julie, and Garry and Sue) minutes before the bombs went off. Not even a distance of 7400 miles can provide the perspective to make sense of such events. Our hearts go out to those affected in Boston.
Hill and Arjun taking a breather atop the ridge on the way to Dingboche. Dark and snowy, moments later we were engulfed in a dense fog.
The two patients sharing a tank of oxygen while we wait for more supplies to arrive. The patient on the left has a mohawk hat...and a real mohawk underneath. The slightly bluish guy in the middle was in critical condition.
Hill, Arjun, and a porter helping the critical patient to the helicopter the next morning.
Chris, Arjun, and I set out over the ridge in the dark. The path to Dingboche is steep, slippery, and hard to follow in the daylight. After dark, it was a real challenge. I led the wrong way up an even steeper yak path, and we had to traverse to get back on track. Luckily we have been walking the path every few days as part of a morning hike or on the way to our afternoon lectures in Dingboche. The falling snow looked like a meteor shower in our headlamps, and visibility became only a meter or so as we ascended into a cloud. On the other side of the ridge, we could barely make out the town lights but we eventually found the right tea house.
Rather than the expected patient with severe AMS, we found two patients with both HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema). One guy could not walk straight and was breathing heavily, but his companion could barely respond, fell when standing, and had oxygen saturation of 31% (normal for here is 85%). He is probably our sickest patient yet and might not have made it through the night without intervention. He also had vomiting and diarrhea (likely bacterial gastroenteritis) that had gone untreated for the last 4 days. They both needed oxygen, medications, and evacuation. But we had only brought one oxygen tank.
At this point we had a choice. We could get a large team to carry both men and all their gear over the treacherous path we had just came. Or we could get another oxygen tank, more meds, and camp out with the patients overnight in Dingboche. We chose the latter. Fortunately, the patients' trekking group and guides were supportive, and two porters agreed to hike to the aid-post to retrieve more supplies: more oxygen, dexamethasone, and some other supplies. Chris and Penny arranged the provisions and sent the porters back with what we needed. The "ICU" was setup in the common room of the teahouse, with the patients in their sleeping bags and Chris and I under blankets provided by the teahouse owner. We was awake for most of the night checking the patients' vitals every couple of hours, and the porters worked in shifts to keep the patients' oxygen masks in place and to help them get to the bathroom when the diarrhea recurred which was almost hourly.
Both patients exhibited rather disturbing "periodic" breathing which is similar to sleep apnea. This breathing is irregular where the time between breaths gets longer and longer until they have a "missed breath" or stop breathing for 20-30 seconds. Then they usually gasp - usually waking themselves up and frightening anyone sleeping nearby. This is a pretty typical breathing pattern at altitude, but the worse patient was doing so at 50-60 breaths per minute (about 3 times normal). At home, I would have intubated him hours ago and let he ventilator take over. One of the medications we use to treat patients with HAPE is sildenafil, aka Viagra, which I don't use often. Although it sounds funny, sildenafil is used in pulmonary hypertension although most people know it for it much more marketed and ...um... sexier indication. Whether it was just time on oxygen or the sildenafil, this patient seemed to respond pretty well and his breathing improved.
Finally, dawn broke, and with it news that the helicopter would arrive shortly. The patients had both remained relatively stable through the night, although the worse-off patient was still measuring a meager blood oxygen saturation of 50% and struggling to walk straight. Along with the porters, we helped the two men to the helipad and saw them off.
The beautiful landscape before us belied the tragedy that we learned about upon our return to the aid-post in Pheriche. Chris and Penny filled us in on the bombings in Boston and we immediately sought to connect with our family and friends in Boston. Chris's parents were on the sidelines near the finish line that morning and his brother-in-law, Jay, was running the marathon. We were relieved to learn that Jay's pace was such that he crossed the line and had moved out of harms way (along with his parents, Julie, and Garry and Sue) minutes before the bombs went off. Not even a distance of 7400 miles can provide the perspective to make sense of such events. Our hearts go out to those affected in Boston.
Hill and Arjun taking a breather atop the ridge on the way to Dingboche. Dark and snowy, moments later we were engulfed in a dense fog.
A view from the valley floor in Dingboche shortly after the helicopter departed.
Ben loved his postcard! Thank you for the great posts and updates...it's fun to be part of your journey. We miss you! Michelle =)
ReplyDeleteCool! Glad the post add made it! It went into the post more than 5 weeks ago. We miss you too and are happy to get a bit of insight into your world through your blog too!!
ReplyDeleteChris & Hill
Wow, this is quite an account! Your words really depict some serious situations proving that your medical training has been remarkable! The photos are breathtaking! Love, Mom XO
DeleteSo glad your family and friends in Boston are all ok! I've been thinking about y'all....
ReplyDelete