MAY-A-6
SECOND CLINIC DAY IN LUKLA,
WITH MORE AND MORE INTERESTING CASES,
FOLLOWED BY A SECOND AND LONGER HIKE
TOWARD THE VILLAGE OF TUKE’,
THROUGH THE CLOUDFOREST OF RHODODENDRONS
AND THE OLD MOSSY SNAGS OF DEAD TREES SURMOUNTED
WITH AEROPHAGIC PLANTS, BROMELIADS AND CROWNED WITH WHITE ORCHIDS
May 7, 2002
The second day of our clinic in Lukla worked more smoothly with the predictable larger number of patients (now that they have heard that we are here and have started their walk yesterday from distant villages) and a larger number of interesting cases. At around ten o’clock as the team was in a rather smooth forward pattern of patient interviews, with my seeing each patient from as much a distance as the team members felt comfortable with, and a few of these included mumps (our pediatric Intensivist had never seen a case in the USA) and a florid impetigo, also worse than he had ever seen. But this also included a young soldier stationed here from South Nepal near Chitwan Royal Park (home of the one-horned Asian Rhino, and also the Anopheles mosquito) who came in with a shaking chill, yellow eyes, dark urine and a periodic fever. This led to a discussion of malaria, which even he knew he had, yet no one other than I had ever seen before. I treated him with the same S/P that I had for scores of patients in Malawi last month (Cotrimoxazale).
At the only point of a small lull in the action today, the commander of the 156-man military police unit patrolling Lukla came by. I had been introduced to him last night by Nimi as I had returned from my “hotel call” on the Malaysian patient who had been seen at Pherche by—of all people, Luanne Freer, whom I had first brought to Nepal in 1999, who was somewhat under the spell of Mark Head as a tent mate of his. I had seen the patient among his 26 member-climbing group that had set out from Kuala Lumpur with the uniforms embroidered with “Everest Base Camp and Kala Patthar”. Only three did not summit the Kala Patthar, two for diarrhea and one for this respiratory ailment, which he was carried from Gorap Shep on a litter, with a stop at HRA, where a doctor said he had acute mountain sickness and gave him Diamox, saying he might have pneumonia, but they would not have the medicines for that. I guessed her name, and they had said, “That’s it!” Then all the members of the team wanted to pose with us and said they would send me a note for the return and follow-up. The leader had made it to within 400 meters of the Everest Summit once before and was advertising and soliciting support for another Malaysian attempt at the 2004 excursion.
On leaving the Sunder Hotel, I met Nimi and Pati and the Captain of the military police unit here to guard Lukla from the Maoists who could bring the tourist trade on which Nepal depends down to even less than the trickle it is now. Ngaylin had met an American returning from Mera Peak and the whol expedition had foundered in snow over the knees, and had to turn back, so the only real climbing expedition that I know about up there now has already turned back.
I invited the commander in chief to come by to visit, and he came at around ten o’clock, armed with his camera and sent a soldier to fetch his wallet when I produced my card. He formally presented me with his, and all the troops snapped to attention and a formal “Present Arms” posture as we walked out into the brief moment of sun that we had during our long cloudy day today. The commander wanted his picture taken with me, and repeatedly said how grateful he was to have our team here and this volunteer effort with free medicines. About one third of the patients have been from his troops, and they have been very well behaved, even carrying in their twenty five year old BAR automatic weapons and stacking them up against the wall as I examine them, with a cautionary hand up to guard the kids and dogs from knocking over their unsteady weapons.
Then, this “photo op” became generalized, and soon we had the impressive picture of a dozen uniformed soldiers cradling their rifles and the digital cameras from everyone in the group—photos taken by someone who had never taken a photo, now using a great leap forward to the higher tech end of the photography trade. After a bit more of the bonhomie, with a series of soldiers and their commanders and I and the rest of the team under crossed BAR rifles, we returned to the somewhat startled patients who had been left waiting. But we made up for their inconvenience, in making a series of difficult diagnoses and treating them, at a rate of 108 patients today to add to the 82 patients yesterday.
Our post-prandial big events have seemed to include a nap for most of the team, unaccustomed, as they have been to the altitude at which they arrived fresh in the bounce from Kathmandu. I may have had an advantage since I have been in the Himalayas a few weeks already, but I, too, feel hollow and drowsy after lunch, when we generally sit around and stare at each other, with most of them asking only a few questions about what comes next. The next, was a drill which will increase each day until our trek: a hike in a different direction that will be twice as long and twice as hard each day until we are re3ady for the long haul up toward Everest and the Kala Patthar attempt, which I believe each of them capable of doing with the two techniques of PEEP breathing and the Rest Step. At first it seemed strange to be taught how to breathe and walk, since these are two things most of us have been doing all our lives, but it makes a tremendous difference in energy conservation along the way to “Use bone, not muscle” in getting up the mountain slowly but surely, “Flowing up the Rock” rather than trying to muscle up and getting exhausted, cold and wet, then freezing in a necessary long rest stop.
Despite a gloomy weather in the cloud layer in which we were hiking, I could appreciate the variety of tropical alpine speices spread out on the forest slopes around us. There were multiple varieties of rhododendron, many times with multiple species in the same place—red, small white and yellow all side by side. There were some large dead snags, still standing, and covered with a moss and a series of aerophagic plants, and a few recognizable bromeliads. Atop all these various forms of cloudforest life, perched as saprophytes on an old standing snag, there was a crowing layer of white orchids. This was the foreground against a spectacular mist-shrouded mountain valley in steep hill sides, surmounted, when a gap could be found in the upper cloud layer, by snow capped Kunde Peak, a 6,000 meter peak over the route we will be taking and on the sloes of which is Kunde Hospital.
The weather again was the usual afternoon drizzle and cloudiness, but we were going along the trail that has the hikers coming up from Giri, six to ten days down depending on the load they carry. We met several of the up climbing porters, who were wet and straining under seventy kg or more in their tumpline baskets, to get the goods delivered to Lukla for the Thursday market and ton to Namche Bazar for its Saturday market. There was also traffic in firewood, and fuel, which is cheaper on a porter than it is to be flown in. WE saw a cave where the porters lay down to sleep at night, with a fire at the entrance and a few leaves swept together for a mattress. As the sign says: THE SHERPA PORTER: Tough, Reliable and Vulnerable. They are often carrying little except their payload, since they can save money by not buying food. At 70 R’s per kg for the portering from Giri (the road head) to Namche over ten days (less than $1.00/kg for a seventy kg+ load,) they will try to climb straight through without the need to stop to rest or eat. If you think that big muscle men can climb mountains, there are two contradictory examples I can give: watch an accomplished female climber, and watch any scrawny Sherpa. They have to have the technique, that is, waddling along, with the down-mountain leg locked at the knee, for two thirds of the stride at rest, with minimum time in dynamic muscular exertion. Without these techniques to finesse high altitudes, no one could make it. Event he jocks who decry the need for special techniques wear out within the first day and have to adapt a method that seems to them to have been invented by themselves rather than taught. I can even watch yaks coming down mountain who always come down on a switchback course, using the diagonal to lock the downhill leg to hold them on a bone strut, rather than a muscle under tension. We will see how well this message last night and the practice run we did to day will sink in when the going gets steeper and the air thinner. “It just makes so much sense!” said Jennifer. She will make it.
We are now going to go through the cloudy mist and gloom of our usual evening get together, and after dinner I will go through their didactic experience and also their case presentations and a lecture on parasitism for those who did not need to know it in medical school beyond the test, and for the firefighters who never in their wildest imaginations would have believed they would be asking questions about biliary versus peptic abdominal pain.
Remind me to tell you about the relief of a warm shower on return from the hike. First, you have to wait until a critical point in the day when the cooking generates enough heat under a water heater somewhere, and then turn on the tap for a long time until it makes it out to my room. But since there is no drain in the floor, or the small drain is plugged, the cold three inches of water on the bathroom floor is quite a thrill stepping into it. I think of it as the test all Hindu bodies are put through at the river at the ghats. The wrapped body is brought down to the inclined ramp and the feet of the shrouded body are immersed in the river; if that does not “quicken the soul back into lively movement” then the next stop for this body is atop the funeral pyre. So, at present, my excursion into the cold shadow of the valley of the bathroom has not directed me toward the ghat.