AUG-B-5
THE LINGSHED-02 TREK
THROUGH THE REMOTE
ARID MOUNTAIN VILLAGES OF
ROADLESS ZANSKAR,
THROUGH SERIES OF
HIGH DRY PASSES,
AND WITH RAIN,
HAIL, AND ARDUOUS CLIMBS AMID
SPECTACULAR
SCENERY, SOME SAW FROM HORSEBACK,
AND I HIKED EVERY
INTREPID METER OF THE LONG AND DUSTY WAY
AUGUST 4—20, 2002
The entire experience of this exhilarating, rewarding, and exhausting trek is recorded in an extensive and detailed handwritten log of the whole exotic experience. There will be the usual photojournalist’s record in a huge series of what will be a spectacular cascade of stunning photos, as well as the customary audiotapes and on-line photos coming your way.
But the handwritten manuscript says it all best and on the scene, as often I was writing without believing my eyes as to the scene before me. This trip was unique, and now that we have returned, not simply to pavement, but to a road of any kind at all, with the promise of electricity, even if it is as intermittent as the dreamed of hot water shower that has been absent from my life for now three weeks running, I will try to get this message off to let you know that I am back, safe, and presumably sound
Just wait until this “Show and Tell” from this unique experience!
I had introduced the freshman clinicians, none of whom had either practiced medicine in any way nor been involved in such an exotic and demanding setting for this, their first experience. Not only am I the only veteran, I am also the only one with a professional license of any kind, so we had several careful sessions in setting up the ground rules with this diverse group, which I would have to supervise closely for every interaction—and that is for over 750 patients in very remote settings, some of well over weeks to months walk from a road. Their only access to a town or supplies such as tea and kerosene has been by “chardering”—that is, the very arduous trek out on the frozen solid Zanskar River—now a roaring white water stream during the summer snowmelt and glacier meltwaters swelling it, but in the long months of winter (ten of them, in fact, at this altitude despite the 33 degrees of latitude) the temperature dips to – 41*. That is both F and C, since that degree of supreme cold is where those two scales cross. Compared to “chardering” we have had it easy---but not quite so.
OUR FIRST
EMERGENCY:
EVACUATING
DESATURATED SHAFKAT
FROM HANAUPATA
BACK TO LEH
On the very first night, after hiking through the very spectacular canyons of red (jasper) and green (copper) rocks from the dusty road head at Fangila, we arrived in the village of Hanaupata—probably 35 inhabitants. There, my own GWUJ medical student freshman Shaka, a Bangladeshi who had worked tirelessly on fund-raising for this trip as his reward for finishing the first year at GWUMC and as a way to get his trip back to Bangladesh for the first time in eight years when he left as a boy, came tottering in, ataxic and confused. He was insistent that he was going on, but we were only at 12,000 feet altitude and he was hypoxic, and we would be climbing much more than a vertical mile more in the next two days through passes that would be lethal to anyone in his conditions. I pulled out the Pulse Oximeter and could not believe what I saw. His O2 saturation was 52%--a level at which I have never seen anyone conscious. My own at this same time measured 96% saturation, with my pulse up to 77 while his was 122. This 44% “point spread” I had also not seen before. I checked the others who were feeling ill, and they never got below 80% saturation.
I repeated it before and after I started him on Diamox, and repeated the dose. He measured the same on another occasion and up to 60% at his best. He was loaded on a horse at 4:00 AM led by our best guide, Abdul, and was still confused about where he was so he did not express fright at never having been on a horse before, especially led through the spectacular canyons we had entered in twilight with a string of donkeys carrying our medical kits and the camping gear. I had written a note referring him to Leh Hospital and Dr. Dawa, and listed the record of his pulse oximetry for inclusion in his chart when evacuated at Leh Hospital where I had just given the Grand Rounds last week. They could hardly believe it either, that he was still talking at such severe desaturation, and they gave him Lasix, O2 treatments, and a chest X-Ray, as I was packing up after seeing the patients of Hanaupata.
It was a good decision to evacuate Shafkat, but their was no room for discussion or options of this decision—he would not have survived moving on and up—as he had said “But, I heard that if we got sick we could ride a horse!” That would mean he could get into deeper trouble quicker, since he would be gaining altitude rapidly which was the last thing he needed in such hypoxia.
ON AN OFFICIALLY
BILLED “TREK”
This was not a lesson learned on the two young women medical students, each of whom had headaches at Hanaupata, and were ill in the morning. We had to trade in donkeys for horses to put them on horses in order for them to go on, an animal reserved only for emergency evacuation, but then they did not have pulse oximetry desaturations any worse than 80%. Once they got on a horse, they never got off, at least not while going uphill, so they converted this advertised “trek,” into a horseback climb. When the dentist, local “Doctor Sid” saw them riding, there was no way he was going to walk uphill, so he chose to ride, and then Hem’s leg went bad and he too had to mount up. Cullen later had diarrhea so he was put on what would have been a packhorse, and soon I found even the staff, from cook to Norbu to the horse handlers riding on the uphills on what was supposed to be a trek. Only four of us walked and climbed every step of the way—farmboy Buffalo medical student Shawn, a wrestler, the Boulder backpackers, and the oldest man on the expedition---three times the age of the youngest rider and two and a half times older than the oldest habitual rider. I walked and climbed every step of the way, and went through all the high passes, attended every clinic and saw every patient and village.
The “easy ride” became a contagion that spread through those who were gasping hard on the uphills. At one point, Cullen and I were climbing hard, panting at full ventilatory capacity, when we heard the girls Anita and Sheila well behind us on the steep switchbacks going uphill, laughing and singing. “It sounds like they need to walk,” Cullen panted.
CHRNIC IN OUR
REMOTE PATIENT POPULATION
Everyone got sick at one time or another, and mine was severe laryngitis nasopharyngitis from the desiccation of high altitude hyperventilation at which rate the palate dries out like cardboard, and a purulent exudates appears which plugs up the nose and makes it hard to breathe even without the swirling desert dusts and the smoky dung fires in the cooking huts. I learned only later that I had placed a pack of "Eclipse” gum, like Chiclets, stored in my pack, and chewing this mentholated gum is a method of keeping the palate just moist enough to avoid the severity of the problem that set in on me within a couple of days of puffing up the high passes.
With all the dust and heavy contamination of the sinuses, I “should have been taking antibiotics all along” advised one of my very junior companions, who was of the belief that she should be on antibiotics at the outset, burdened by two beliefs—“It certainly can’t hurt” and “It will prevent the pressure I feel will b e uncomfortable in my sinuses.” I gave several lectures on the treatment of viral of other self-limited inflammations and the rigors of antibiotic careful usage, but since they insisted on starting antibiotics even before we were under way, there was no way they could go through the trip without them. I told all the participants that these were prescription drugs under the use and direction of a licensed practitioner, and since there was only one licensed physician on the trip, though they were surrounded by boxes of these potent agents, no one was to self-medicate without my prescription. This fell on deaf ears, and some shared the bounties of the drugs that others were taking, and then fell victim to the nearly inevitable consequence of diarrhea.
The couple who came from Boulder had the habit of drinking six liters of water on trek each day—a real hassle in just getting that much water into their Nalgene bottles each day, especially when it had to be bottled designer water before they could run the enormous quantities through my new Pur filter; (“But we always drink this much at altitude”—presumably the latitude of Boulder since they had never been anywhere near as high as this or out of the country. I remembered the crazy Californian aerobics instructor who “Loved to ‘pound water’” and she was evacuated off the Everest trek route in seizures with a sodium of 106 after just four liters of water on trek.
WITH CHANGING
DEMANDS FOR PORTERAGE OF PACKAGES,
THEN PEOPLE
We had 32 donkeys at the start, but we kept having to get more and more horses, ending the trek with 26 of the latter and very few of the former, since the donkeys could not carry more than 40 kg, while the horses could carry twice as much and were frequently then called upon further to carry the team members and even some of the staff. So much for trekking. If I will be leading this trek again, I will have to personally check out every participant and make sure that each is not coming on the “trek” to resort as soon as possible to the easy way, and never give up the advantage of being carried up hill on the “emergency evacuation vehicles.”
Our clinics went well, even those to which we had to trek to deliver the medicines such as the village of Narok across the Zanskar River. And the people everywhere entertained us, now where as enthusiastically as the children of Lingshed, who were hilarious in their song and dance performances. I will have to have you read about little “Pigpen” and “Miss Tubbers” at Lingshed singing a choreographed song they had learned in school for our benefit.
THE FORMAL
ACADEMIC PROGRAM:
DIDACTIC LECTURES
AND PATIENT PRESENTATIONS
There were regular series of didactic lectures and formal case presentations that each student had to do from each site we had attended with clinics. There was an amazing natural history of the diseases seen, with the “Clinic Under the Trees.” In a Virgin Population, we could see the untreated natural history of the most basic illness processes, yet recognize that these people were also not in an American-style “Exercise Deficiency State.” So, if they got pat the childhood, when almost every kid had purulent upper respiratory infections and worms, with diarrhea, the adults were much healthier than those seen in an American, with no vascular or metabolic disease. Of course, if you are constantly walking up and over mountains, the inevitable complaint will be osteoarthritis of the knees, which is far easier to treat than coronary vascular disease, diabetes and obesity.
The treks involved the high climbs of several very high passes, sometimes several in a single day. The sequence of the first few days climaxed when I climbed through Sangeyla Pass, at 17,960 feet. But the trip to Narok entailed going back and forth over three passes, one of which was Chochokurila—no small achievement either. But, it was leaving Lingshed in the rain that almost did me in. The horses were slipping on the mud, and Shafkat, who had rejoined us after our last day in Lingshed through the arrangements of Abdul in running our itinerary backwards and intercepting us after he was discharged from Leh as OK to travel, was on one horse as it slipped off the muddy mountain and off an embankment.
For reason unclear to me, we had to climb up and over a big mountain to reach the valley on the far side, which could have been reached by going up the valley around the mountain directly from Lingshed. Perhaps it was the extra Chang that Tsering drank as a “stirrup cup” to see us off from Lingshed, his home village. But, we had to give up all the hard won thousand meters uphill to go down the far side in what was an unnecessary warm-up to the really heavy climb ahead.
I was at the head of the troops, and set out against the steep switchbacks of the bigger mountain on the far side of the valley. My lunch and water bottles had gone with the pack string up the valley circumventing the mountain so I did not see them all day. But I was carrying the rain jacket and extra warm clothes with a liter of water when I came down the valley and found the riding horses. Basu, our cook, insisted I leave my raincoat and the water bottle on the riding horse, since he would be walking along behind. But with the young women on them as riders, the horses would take two strides forward and wait as they gasped. By that time I was several miles ahead struggling up the steep hillside switchbacks heading toward an ever-receding pass called Parfila Pass. It began to rain. I was wearing a cotton tee shirt and was now separated from both water bottle, and raincoat with pockets stuffed with warm dry gear.
I climbed harder and faster to generate more heat since I was sliding away into hypothermia, especially since as I approached the top, the winds picked up. I barely made it over the top of the pass, and then ran down the far side to try to generate heart as a marathon runner. I was too exhausted to eat when we pulled in over a snow bridge into camp much later, and I simply crashed to recover my strength for the morning, checking first on two people who were also beat up by the same mountain despite having ridden the uphill part of it.
CHANGES IN ROUTES AND
PLANS,
AS NEEDED WITH THE
CIRCUMSTANCES
We changed routes because of the rain and rising waters in a few side streams we would have to ford, and the horses’ heads would be under for a few of these if we kept on the way we were going. This would mean that we would skip a few villages that were expecting us, and we would drop in at a couple that did not know we were coming. Further, we had a roadside pickup awaiting us at least 100 km from where we would emerge from the roadless wilderness, so we would have to send a runner or rider ahead to divert the bus to pick us up between Pidmo and Padum, both new stops on our clinic tours, and the last of our medical camps. This we did, as in the case of Shafkat’s evacuation, simply because we had no choice. This made for long treks over very imposing mountains and along the Zanskar River canyon through deserts, but we made it to the trail head and actually intercepted the bus at the Padum site we had hoped to find when Norbu sent a message ahead on a motorbike. The Pidmo Village was delighted with our “drop in clinic”. This also made for long drives, but the drives were around and alongside the glaciated spectacular Great Himalaya Range through very high road passes. We also went through the troubled spots of the Kashmir border, along the Suru River Valley, the only area in India of Shiite Moslem dominance, whereas most of our travels and all of our treatment were in nearly pure Buddhist cultures
SUMMARY OF THIS
EXOTIC AND STRENUOUS EXPERIENCE:
SUPERB!
BUT, NOT FOR
EVERYBODY!
You may gather from my notes on the travel log that this was a very rewarding and interesting exotic adventure trek, and one that was certainly rewarding for the investment of energy put into it. It was a first time experience—the first time we had conducted an old-fashioned “trek mission” on foot; the first time Hem had taken on the logistics of such a trip alone; the first time many of the remote villagers along the isolated Zanskar Range had ever had exposure to Western medicine; and the first time we had taken a group of unscreened trekkers, none of whom with any previous clinical or trekking experience, and none of whom had a license to practice any form of professional art, out into the unknown. Despite this “leap of faith” and with a few modifications and reservations, not least of which came in the nature of the advertised “trek” itself, it was an amazing success. This was in large part due to the resilience and expertise of a few folk, and I name a couple of them now: Basu, our Nepali cook and his assistant Rinji could pull off gourmet dinners in camps equipped with little more than dung fires; Abdul, our very special and competent “Man Friday” rescued Shafkat and got him back after treatment to intercept us purely on intuition of the route we must be taking and backing up on it; and Hem—now only a month away from his September 24 arranged marriage in Simla and rolling with each punch, even when he himself had a bad leg and needed to ride the upslopes of the mountain passes.
So, “Lingshed-02” came off as a success, and an enjoyable one! I expect it will be an experience worth repeating, with more careful screening of participants and preparation that will include a few detailed items I had included in my more comprehensive record of this event. But, it was a stunning visual experience, with the arduous exertion required to carry it off never interfering with my interest in recording it for others to share in this remote and exotic adventure travel for a purpose—and the people of the remote Ladakhi regions of this isolated part of troubled Kashmir made it very worth the experience and exertion. Just wait until you see the pictorial displays!