Everest ER Base Camp Tent

From Gorak Shep, we hiked to the Everest Base Camp. Base Camp is actually not a particularly good campsite seeing as it is on a glacier covered with rock debris which is quite uneven and cracks and creeks at random. It also has ice pinnacles and underground springs from the melt as well as random pools within the glacier. In addition, you can't even see Mt. Everest from base camp.

The HRA also has a tent at Everest Base Camp (aka Everest ER) which we went to visit and spend the night. Three of our colleagues are stationed here, Suzi, Kirsty, and Pranav. In order to work at the EBC tent, you have to already have volunteered at either the Pheriche or Manang clinics for a season. The clinic tent was well-stocked for a tent and warmer than our clinic room.

They also have a mess tent which was well stocked with snacks and warm drinks. The Everest ER crew is supported by a commercial group which also supported a group of climbers, so they had a cooking tent and staff of at least four as well as more "exotic" foods than we had seen in weeks. When we arrived, they had just brought out a plateful of fresh watermelon.

We arrived in time for lunch which included freshly baked croissants, tuna, and potato salad which contained pieces of fresh apple. Amazing. After lunch, we wandered around base camp until it started to snow, when we retreated to the mess tent and spent more time hanging out with the crew. The commercial group supporting the HRA is also supporting the summit attempt of a Brazilian doctor and TV personality named Karina. She will be videoed and photographed by Scott, the shooter that interviewed Hillary and Chris earlier in the season. Karina and Scott were in the tent with us, discussing the possibility of a "weather window" in the upcoming days. Basically climbers in the base camp hang out for weeks on end for such a window: a break in the winds that is long enough for them to go from base camp to camps I, II, III, and finally to the summit and back. Last year, there was a single, 2 day weather window and there are photos of climbers literally waiting in line to make their summit attempt because there were so many of them. Scott was conferring with other groups and acquiring weather predictions from a variety of sources to verify the likelihood of the window. It was an exciting time to be at EBC!

Later we met for a dinner of dahl bhat...but dahl bhat unlike any other on us trip. It was served with a curried hard boiled egg (delicious) and a dollop of fresh salsa. Then, fruit for dessert! After dinner we enjoyed a hot tottie (whiskey + hot water + honey) courtesy of Lakpa and then went to see a movie at a large tent near the clinic tent. We had been invited by another expedition group to join them for the movie, and this was the real deal. They served wine and popcorn, and projected the movie on the back of the tent such that it was about 15 ft diagonal in size. Might as well have been at a movie theater!

After the movie we retired to a tent set up for us by the expedition company. Despite being located on a rather mobile and unstable pile of hard glacial rock, we slept soundly. Only the occasional shift in underlying rock or ice woke us up.

In the morning we enjoyed a breakfast of fried egg over spicy potato and some coco puffs on the side. We then packed up our stuff and started our descent back to Pheriche. We were sad to go! Such an incredible experience!

HRA's EverestER tent and 2013 Team: Kirstie (in blue), Suzi, and Pranav. Scott is at left getting advice on de-worming.

View of the Khumbu Icefall from Everest Base Camp. This is one of the most treacherous parts of the ascent as it involves traversing very unstable rock and ice as well as crevasses with ladders and ropes. Teams of Sherpas scout the route each year.

Ice pinnacles within the glacier. These were all over the place in base camp. So much ice and rock comingled and simultanesouly highly ordered and disheveled. The icefall looks remarkbly like a river or even the ocean with rises in falls in the ice that resemble waves. In many ways it is just a river that moves much more slowly than liquid rivers.

Happy Nepali Mothers Day!

Happy Nepali Mothers Day to all the mothers out there. (Nepal celebrates a few days early.)

The Italian Pyramid and Gorak Shep

We left Lobuche en route to Gorak Shep by way of the Italian Pyramid. The Italian pyramid is a landmark on the Everest base camp trek and has been around for over 20 years. We decided last-minute to check it out, and we were glad we did. We approached the pyramid around 7:30a and found the Nepali staff enjoying their morning tea and biscuits. We chatted and took tea with Kagi, the Nepali manager there for a while, basking in the sun outside the pyramid. The pyramid is composed of steel and glass, mostly, with numerous solar panels covering the south and west faces. It houses laboratory space, a modest medical suite, radio room, and office space. Quite remarkably, the entire pyramid and attached lodge can be operated remotely from Italy via a satellite Internet connection. Nepalis and Italians collaborate to staff and run the pyramid, and the focus of their efforts is monitoring the weather and geological changes in the Khumbu region. There is a piece of instrumentation called "Doris" that measures changes in the absolute position of the ground, and there are numerous weather instruments in the region that are connected wirelessly to data acquisition systems at the pyramid. Interestingly, the chinese forced the nepalis to remove seismic sensors from the grounds of the pyramid...presumably because of the close proximity to the Nepal/chinese border. The facility also has an impressive solar array beyond what is attached to the pyramid. Supposedly the rooms in the lodge for the staff are heated. Crazy!

Kagi advised us to take a "high trail" behind the pyramid back to the main trekking route towards Gorak Shep, the next stop on our way to Everest base camp. Though a bit slower going than the main route, we had incredible views of the glacier from our elevated trail. The trail to Gorak Shep then turns into a rough morrain with a rolling up and down approach- you really feel like your in glacier territory here. It was a tough stretch but the weather was ideal and we were in no rush so it was a pleasant trek. We arrived at Gorak Shep in early afternoon, ordered a bunch of pasta for a late lunch, and then wandered along the trail to EBC for a while before returning to the Himalayan hotel for dinner. We reconnected with Mike too (he had shot ahead for lunch at EBC) and killed a few hours playing No Peak and eating dinner. We marveled at the availability of 3G cell coverage here - our first since leaving the states! We retired early because we planned to wake up around 4am to ascend Kala Patthar ("black rock" in Nepali/Hindi), a high point in Gorak Shep that provides views of Mt. Everest which are particularly beautiful at dawn and dusk.

Waking that early was somewhat painful, but since we went to bed at 8pm it could've been worse...and in any case it was worth it! We started our ascent in the dark of course, but even halfway up to the 5550m peak (our highest point of the trip) we were capturing exceptional views of the Khumbu valley as dawn broke. Ama Dablam was one of the first peaks to be hit with light and Loboche peak was hit early too. Mike was burning up the hill and beat us to KP by about 30min. Nevertheless, we made it in time to see the sun shine first from behind Everest and then from over Everest. Breathtaking. Some of the best views were of Pumori, the mountain opposite Everest on the other side of the valley and just above KP. Randomly, we arrived at KP just as a Chinese trekker arrived, breathless and carrying an iPad. He intended to take a picture of the iPad, which had a picture of his friends, next to a Chinese inscription on the rock. But his camera battery was dead (probably from the cold) and so he asked us to take the picture for him. We obliged and he was so grateful he managed to insert himself into several of our photos up there!

We had the top of KP to ourselves for perhaps 20min before numerous other trekkers arrived. There is not much space up there so we decided to descend and get some breakfast. We hadn't realized how hungry we had gotten in ascending KP - upon finishing our breakfasts of egg sandwiches, we all immediately ordered second breakfasts of an additional sandwich! After recovering a bit, Hill and I packed our things and made for EBC, while a mike headed in the other direction towards the Cho La pass on his way back to Machermo.

Italian Research Pyramid:

First light hitting Ama Dablam, from near Kala Patthar.

View of dawn breaking over Mt. Everest (dark peak near the center of the pic) from Kala Patthar. ~5a

Ascent to Loboche

Today we left the clinic on a multi-day trek to Everest Base Camp. The first step of this was to ascend to Loboche which is at 4900 meters. To get there from Pheriche, you can either go up the valley to Dughla and then cross over the moraine to Lobuche or you can go around through Dingboche and over the Kongma La. The Kongma La is a challenging mountain pass which is where the Aussie and Mexican got lost weeks ago and where Chris and Penny made an epic one-day round trip (see past posts). One of the other doctors from the Machermo clinic, Mike, came to Pheriche last night and tried to talk us into going over the Kongma La, but we decided to make that a separate trip. We stopped above Dughla at a plateau where numerous chortens and prayer flags were placed as a memorial to lost/fallen Sherpa. We had incredible views of Taboche, Ama Dablam, and yak trains loaded with gear coming down from Everest base camp.

In the end, Mike would have been much faster than us as he did the pass in only six hours and was waiting for us when we arrived. However, we all stayed in the same lodge and played cards (new game: No Peak) after dinner. Then one of the locals began playing a wooden flute-like instrument and some women began singing Nepali folk songs. It was a wonderful impromptu concert.

At the Sherpa Memorial between Dughla and Loboche:

Yak Train, also near the Memorial:

Alpine Spring

Spring is emerging up here in the Khumbu and Imja valleys. We have taken a few day hikes to explore signs of green and growth. In both Dingboche and Pheriche the locals have planted fields with potatoes. In Dingboche the fields are watered via crude aquaducts (which run through the center of the village) and channels that are cut ad-hoc into the fields. The farmers then use large platters and manually "sprinkle" the fields from these channels.

The only flowers we have encountered are tiny purple ones that stem from aloe-looking leaves...just 5-10% of the size of aloe.  They are concentrated near springs and river banks, but often show up in the middle of trekking trails too. Remarkable. They are so small and unlikely to survive among the hugeness and harshness of the weather here, yet almost smile up you from the trailbed.

Juniper and cardamom (we think...) are the other plants that thrive up here and are in abundance. The cardamom has not woke up yet, but there are vast fields of dried green and red cardamom from last year throughout the region. We've found that the juniper overtakes north-facing aspects of the hills and mountains, whereas cardamom is restricted to more southerly faces.

Juniper (green, foreground) on the banks of a stream near Bibre in the Imja valley. Dried cardamom is in the background (kinda brown).

 Some of those tiny, ambitious purple flowers also in the Imja valley. Just outside a small settlement that abuts a stream.

 Main street Dingboche, with aquaduct. The pipes run to nearby teahouses for general water supply. At various points along the aquaduct farmers cut channels into fields for feeding their potato crops. Supposedly barley can also be grown up here, but we've haven't seen it yet.

 

 

Brawls, Belated returns, and Bloodletting

Normally we have a loud bell which people can ring at any time of the day or night for emergencies. However, last night we got a knock on the our window at 2 am which nearly scared us to death. We thought a yak was trying to break in or something. A guide had brought down a young man from Oklahoma on a stretcher with oxygen.

Ironically, we recognized him from the bakery in Dingboche from two days ago who was talking about his group's "aggressive" ascent schedule. He had gone too fast for his acclimatization and had succumbed to HAPE and HACE. Unfortunately for him, his guide had not recognized AMS symptoms in him in the several days beforehand, and although he had been warned not to ascend with symptoms, he did anyway. Also unfortunately, his guide has a drinking problem. Luckily for him, his guide and put him on oxygen and found a team to carry him down almost 1000 meters despite being intoxicated. He was actually doing quite well by the time he reached us although we continued him on oxygen overnight. The guide promised he had already arranged helicopter evacuation for the morning.

However, when morning arrived, the guide returned still reeking of alcohol and got into a shouting match with Arjun which nearly turned into punches. Much of the town of Pheriche turned up to watch. From what we understand, it was mostly about money. All the guys tried to intervene in the argument to avoid any injuries. In the end, the patient finally got a helicopter, the guide took off likely for more rocksi (the local rice-based fire water - kinda saki-like), and Arjun called the main office to report him and found out he is related to a famous politician. And this was all before 7am.

Chris & Penny had planned to hike to Kongma La (the same challenging pass which the Aussie and the Mexican had gotten lost on) in a single day. We had been told by multiple prior volunteers that it was possible in good weather. However, because of the altercation, they got a later start than planned.

The morning was busy with several patients and multiple tour groups including a WMS group with a BWH colleague, but we got some good donations and many t-shirt sales. The afternoon weather turned sour and even began snowing at one point, and we wondered how Chris and Penny were doing on the pass. Rachel and Nick who are volunteers in the Machermo aid post (a different but "friend" organization over Cho La near Gokyo) also came to Pheriche. (By the way, "La" means mountain pass in Nepali.) In addition, Sarah and Jim from Extreme Everest and Suzi from the Everest ER base camp tent also turned up. It was a little reunion. We had Rachel, Nick, Sarah, and Jim all over for a beer after a dinner of samosas. (Since Jeet learned they were a favorite, we have had them more often.)

Chris and Penny had still not arrived by dark. They had a sleeping bag and had borrowed our bivy sacs, so they would probably survive a night out although it would be uncomfortable. However, we were just discussing sending a search party when they turned up exhausted and starving. The gathering in the clinic was tame but enjoyable and after Chris and Penny arrived back safely, we had more to celebrate.

Always the researchers, we had asked everyone who had been at altitude for several weeks to donate a small amount of blood for the research study. Since most everyone present was medically trained, we had them draw each other's blood which resulted in the guys getting lightheaded and having to lie down. But in the end, no harm done, and we all went to bed around 10pm as it had been a long night for everyone.

02 May 2013

Challenges in research and the defective DNA tubes

We have a research project which is ongoing up here. There are two parts to the study. One is similar to the prior study I did in 2008 with ibuprofen as an alternative treatment for high altitude headache. This time we are also comparing it to another medication. The second part of the study involves DNA sequencing of people who do and don't have symptoms of altitude illness. Both of these have had some challenges.

First, the clinical trial (headache treatment part of the study) requires that our subjects have a headache at that moment which they are enrolled and that they are willing to track their headache for the next two hours. Initially, we had planned to keep the subjects in the clinic, but cold temperatures and space made this difficult. Also, we are having trouble recruiting subjects. Patients who come to the clinic have often already taken a variety of medications for their headache which makes interpretation difficult. We tried recruiting from the tea houses at dinner, breakfast, and even mid-afternoon with limited results. This technique had worked for the previous study I was involved in, but was not very productive this time.

Second the DNA blood collection has been difficult. First, many people do not want to give up their blood. Although we are not taking much, they prefer to retain all the red blood cells they can for transporting oxygen. I admit that I do understand their concern, but the blood is a very small amount and shouldn't matter in their performance. Second, the blood is difficult to collect. The clinic is near freezing most of the day which makes veins constrict and drawing blood a challenge. In addition, the DNA collection tubes are malfunctioning. These blood tubes are very special in that they do not have to be kept at a certain temperature and the DNA is still good. They are fairly new and although skeptical, it will be awesome if they work. I had called the company before leaving Boston to ask if their tubes would still function after flying around the globe on four flights, being transported to 14,000 feet on a yak, multiple freeze-thaw cycles over several months, and then the whole thing in reverse. The company assured me this would not affect the DNA stability and that they would still function at altitude. They were wrong. In order to collect blood, most blood tubes have a vacuum inside which helps them fill even though they are sealed. Initially, we tried several methods of venipuncture thinking the butterfly needles were the problem with the convicted veins which resulted in Chris and Penny getting covered in blood during one collection gone awry. However, it finally dawned on us that with the much lower atmospheric pressure here, the tubes did not have enough of a lower pressure to create a decent vacuum. By drawing 20mL of air out of the tubes before using, they then worked. Hopefully, this does not alter anything significantly upon descent or cause the tubes to break when repressurized.

There are also two things which are also out of our hands that have decreased our potential subjects. First, there are fewer people trekking in part from fewer flights from Lukla due to colder, snowy weather and new weight and passenger restrictions on flights. Second, the large Extreme Everest group is doing their own research and so none of their subjects are allowed to participate. They are taking up over half of the biggest tea house for over eight weeks and so many other trekkers are staying in Dingboche instead.

These challenges aside, we are hoping for more research subjects so that we do not have to continue the study next season.

Spring Cleaning

Today was a beautiful Spring day with bright sun and low winds. We decided it was time to do some Spring cleaning of the clinic. We had found several bottles of Lizol cleaner in the back room, some lemon and some rose-scented. We took the sheets off the beds and washed them, cleaned the plastic chairs and seat cushions, and wiped down all surfaces with the cleaner. Then we actually mopped the floor of the clinic. For a brief time, the clinic smelled like roses.

In our personal medical and survival kit, we have a roll of duct tape. Duct tape is universally useful in wilderness medicine. In fact, I've attended and given lectures on wilderness medicine uses for duct tape, zip ties, and safety pins. However, a whole roll of duct tape is heavy but the Ace Hardware store in Beacon Hill stocks smaller rolls in funky colors and patterns. Before leaving, we got a couple of these rolls one of which is wavy rainbow colored.

On the clinic floor is a line made from duct tape which we use to give patients the heel-toe ataxia test (like the old drunk driving test). The current duct tape is tired and worn, so we decided to replace it with some of the rainbow tape. I would have called it the "psychedelic hippie line" but Chris Hill has dubbed it the less politically-correct "gay pride line." Either way, we have left our mark on the clinic - literally.

Cloudy with a chance of Dahl Baat

Today was fairly cloudy and busy in the clinic which is a departure from the last couple days which have been quiet and sunny. Somehow several people decided to was safe to drink the water from the tap (which is a direct line from the spring which also waters the yaks and wildlife) so we had several cases of gastroenteritis. We also had an interesting smattering of other cases which were not altitude-related.

One rather unfortunate man presented with a flare of his external hemorrhoids. While I don't doubt that they were uncomfortable, I have never encountered life-threatening hemorrhoids requiring helicopter evacuation. However this man insisted he could not continue and requested a doctors note stating his condition was altitude-related. I refused, but he found a helicopter anyway.

Luckily, things slowed down after that and Jeet made a wonderful Dahl Baat with curry vegetables for dinner.

The HRA Clinic Tour

Here is a photo tour of the HRA Pheriche Aid-Post where we will be staying for the next 11 weeks.

Photo 1 & 2: The front reception - this is where we great people and have T-shirts for sale. It is also where most if the paperwork gets done and phone calls are made for evacuations.

Photo 3: Chris doing paperwork in the front room and playing music from his computer (or more likely trying to steal Internet from next door.)

Photo 4: The consultation and treatment area (aka the primary care clinic, the trauma bay, and resuscitation room). We have some basic diagnostic equipment such as an ultrasound, and EKG machine, and urine pregnancy tests, but most of the care is based on our history and physical exams. We can also do some basic wound care, suturing, and splinting.

Photo 5: The inpatient ward and ICU. When we have patients that need to stay overnight, we "admit" them to our two-bed inpatient care area. Here we have oxygen concentrators, oxygen tanks, a very basic vital signs monitor, and iv equipment. However, there is no auxiliary staff. No nurses, respiratory techs, phlebotomists, lab techs, transport staff - just us. A huge difference from the major academic tertiary care hospitals we have trained in.

Photo 6 & 7: Living quarters. We gather here by the yak dung stove after dinner for cards, movies, or just conversation. You can see Chris & Penny's room and Arjun's room off to the side.

Photo 8: The kitchen: this is where Jeet works his magic for our three square (although carb-heavy) meals per day.

Photo 9: Our room: Our -20 sleeping bags on top of the mattress and backpacks under the bed. Basic but all we need. Amazing that we found a living space smaller than our Beacon Hill apartment...