Machermo Rescue Post Report

Post Monsoon (Autumn) 2007

Rescue Post Doctors (first 5 weeks of the season) Julia Thornely and Kate Wilson:

On arrival in Kathmandu, we visited with Chhewang: HRA (informative), CIWEC (very useful discussion with director, Dr Pandey), Porters Progress (not open), Eco Tours and Treks (courtesy visit).

In Namche Bazaar: Namche Dental Clinic (very impressive and useful for dental referrals from Machermo), Sagarmatha National Park Chief Warden (interesting discussion about wildlife and environment. Would be useful to discuss dog policy further), Mingma at Panorama Hotel.

In Khumjung we visited Khunde hospital and had useful discussions with Dr Shonam Sherpa. Dr Khami Sherpa was away at a meeting.

We arrived at Machermo on Sunday 23rd September, where Kancha was waiting with lunch and refreshments.

On the way out, we made visits to Pheriche HRA post and Thyangboche Porter Shelter (very well built recently by the Monastery and charges 150Rs for night and hot meal).

During 23rd September to 29th October, we made the following trips:

Kate – Gokyo and Gokyo Ri

Julia – Gokyo and Gokyo Ri

Kate – Everest trek

Julia– Everest trek on way down

Educational Altitude Illness Talks

The talks were given daily at 3pm, with a visit beforehand to each lodge at 2pm to inform trekkers about the Rescue Post and to encourage attendance. We usually went round the lodges together, then took it in turns to do the talk.

The flip chart sheets were very useful and formed the basis of our talks, though we added a few topics and threw in some anecdotes for illustration.

Very good feedback was received about the educational value of the talks (especially concerning the understanding of AMS and the porters’ conditions). For example, a trekker with HACE descended because he had heard the AMS talk and recognised his symptoms. A trekker henceforth refused to stay at any lodge that could not accommodate her porter too.

Fundraising was overt, explaining that the post cannot run without donations. Increasing website awareness encouraged promises of financial support from home countries. Good sales of T-shirts, badges, books. Many trekkers were very generous. Chhewang kept meticulous financial records.

Each talk concluded with a conducted tour of the post, with an explanation both of the medical work and of the porters’ facilities.

Numbers attending the talks were 493 trekkers and 96 Nepalis, making a total of 589 in the first 5 weeks of the season. The maximum number at one talk was 50, with people sitting on the windowsills and floor, as well as some standing.

Porter Shelter

Number staying in the first five weeks of the season was 326.

Record number of porters staying in one night was 53.

700 porter nights stayed last autumn (2006), 250 last spring.

Good feedback was received from the porters themselves (eg. “Best place, this!”) They thought it was good because it only cost 30Rs per night and they can cook their own food, rather than the 150Rs charged elsewhere inclusive of a cooked meal.

The shelter is managed extremely well by Chhewang, who organised the bedding (airing it on the washing line), the structure (ensuring cleanliness and order) and the porters (good behaviour).

Porter Education

Chhewang shows the porters the BBC documentary DVDs “Carrying the Burden” and “The Porter’s Story” which are excellent. He also answers any questions they may have, but does not actually give them a talk, out of natural reticence. The TV broke and was taken to Namche for repairs and took a long time to come back. Chhewang will take it to Kathmandu or replace it if necessary in future.

Clinic Patients

Charges were introduced on 18/10/07 for porters – 20Rs for consultation plus treatment, because of possible misuse of free treatments.

Most trekkers were happy to pay for their consultations. There were some awkward moments for us, being used to the free NHS at home in the UK, when trekkers tried to get around the fee by asking about their personal symptoms at the lodges or during or after the talk. We endeavoured to steer them towards consultations if appropriate and advised them of the charges in advance.

Significant Cases

Porter 1 (16 years)

No previous altitude experience. Reasonable ascent profile.

Presented with headache, fever and cough with yellow sputum, all for 3 days.

Lake Louise score: headache 1, sleep 1

He appeared not unwell, chest clear, red throat.  HR 115, RR26, SaO2 67, temp 36.7

Diagnosis: mild AMS + Bronchitis

He was started on Co-Amoxiclav to be reviewed next morning.

That evening he suddenly collapsed, urgent call to shelter, carried to clinic by friends.

He was unconscious and unresponsive, breathing, with clear airway, Chest clear, HR>60/min strong.

He was given O2 concentrator, then SaO2 were recorded as 69%.

Changed to O2 via cylinder, became more responsive, SaO2 100%.

During the evening he started responding to voice, answering questions.

Temp 38.4, HR 96, BP 110/60, SaO2 82-86% on O2 concentrator.

Chest developed crackles RMZ, RLL.  Productive sounding cough.

Diagnosis: Chest infection + ?HAPE. 

Review during the night: Asleep but easily rouseable. Had been up, talking, drinking and went outside to PU. SaO2 decreased when asleep 69%, increased 89% awake, 56% off O2.

By morning he was chatting.  SaO2 84% in air for 20 mins.  Ran out of room and rapidly descended with a companion.

Given Co-Amoxiclav 500mg.  Letter to Dr Kami, Khunde Hospital.

Porter 2  (40 years)                               

Dog bite.  Stray dog not from the village, porter was dragging load when he was attacked by the dog.

He sustained superficial scratches 2” long on right calf, which looked clean.

Thorough and prolonged cleaning with soap/water and toothbrush. 

Dressed, antiseptic powder.

Porter 3 (52 years)   

Dog bites to both calves, through trousers, while sorting loads.

Superficial graze to left calf and very superficial skin marks x2 to right calf.

Thorough cleaning, opsite dressings.

Rabies protocol needed.

Trekker 1 (Female – 49 years)   

Previous altitude experience in French Alps.  No previous AMS. No high altitude experience before.  Reasonable ascent profile. Only medication HRT. 

Carried in complaining of chest pain radiating to left arm and neck.  Was well when walked from Dole to Machermo slowly that day and ate lunch on arrival.

Nauseated. Described palpitations but not confirmed on examination. Lake Louise Score 1.

Had similar chest pain 2 years ago, investigated for week NAD.

O/E: Conscious, talking, frightened, orientated. HR 110 regular, BP 140/90, RR 28. temp 36.2.  SaO2 86% on air, 100% on O2. Chest clear.  ECG appears normal.

Rx GTN spray, Aspirin 300mg, Buccastem 3mg.

Diamox 250mg stat because headache (started here)

Her SaO2 remained around 96% on O2, and around 70-80% in air, and her chest pain decreased but was still present. HR settled to 72. Vomited but no diarrhoea.

Plan to observe overnight at Machermo as no helicopter available due to weather.

Further episode chest pain that evening. Improved with reassurance. Able to walk to toilet, headache better.  Settled, looked much better with no pain. Declined food or drink other than water.  Husband slept beside her.

Slept little but rested. By morning little headache, no chest pain. central abdo discomfort (informed last night of intermittent abdo pain since KTM).

Slight epigastric tenderness, otherwise NAD. SaO2 74%, HR84, BP 140/85

Rx Aspirin 300mg (patient choice despite advice).

Must descend. Discussion with Embassy on sat phone recommending helicopter evacuation.  Insurance letter/ECG written. Patient left, with husband.

Porter 4 (19 years)

Previously >5400m, denies AMS. Good ascent profile.

Presented with headache, fever, ear pain, unwell since crossing Cho La.

Was treated with Diamox & PAC at Tagnag with no improvement. Continue descent.

He looked unwell, afebrile but felt hot. Left drum inflamed, coated tongue, cervical lymphadenopathy.  HS normal, chest clear, abdo NAD. No neck stiffness.

HR 78, BP 100/40, RR 28, SaO2 79%, temp 35.6.

Lake Louise Score: H2, GIT1, F1, D1, S0.  total = 5

No ataxia, mental state 1, no oedema, no dehydration.

Diagnosis: ?Otitis media, ?other infection. 

Unlikely AMS as previously high in this trip with no problems.

Rx Co-Amoxiclav, Paracetamol.  To go to Lukla hospital if not better.

Trekker 2  (Female – 57 years)   

Reasonable ascent, started at Jiri. No previous altitude experience or AMS.

Night visit to lodge: C/O diarrhoea, vomiting, shivering, headache, SOB, cough.

Diarrhoea 10/7 ago settled with Imodium. 

Lake Louise score: H0, GIT1, F1, D0, S1.  Total = 3.  Mild dehydration.

O/E Abdo soft, slight epigastric and marked lower abdo tenderness. 

HR96, BP 155/80, SaO2 87%, temp 34.6.

Diagnosis: Gastroenteritis

Rx Stemetil 12.5mg IM, Imodium stat.

Revisited in lodge next morning:  Diarrhoea x1.  Abdo pain settled, no fever, nausea or vomiting.  Drinking sips of water.

O/E Abdo soft, slight epigastric and lower abdo tenderness.  Afebrile, tongue dry but clean, alert, orientated, smiling.

Plan: Observe.  If no further diarrhoea no Ciprofloxacin. Imodium prn, fluids.

Baby     (Local from Khumjung -  5/12 old)           

No previous altitude, left Khumjung today.

C/O: Cough, diarrhoea for 1 week.  Seen at Khunde Hospital x3 in past week.

O/E: Did not look unwell. Tachypnoeic and coughing but able to breast feed.  Alert. Chest clear, no cyanosis, no recession, slight grunting, well hydrated. ?ESM. SaO2 reading 11% - functioning of machine? HR 148, RR 40, temp not reading.

Diagnosis: Probable viral cough/diarrhoea same as mum. Advice on fluids.

Mother of above    (33 years - Local from Khumjung)

On her way up to Gokyo to manage her lodge there.

C/O Cough for 1 week, productive of black sputum.  Diarrhoea for 12 days. 

Seen at Khunde Hospital x3 in past week, ?given Paracetamol.

O/E HR 128, RR28, SaO2 81%, temp 36.1.  No AMS symptoms.

Diagnosis: Probable viral cough, diarrhoea. 

Rx Azithromycin 500mg, Imodium, advice on fluids/hygiene.

NB later information.  Baby was taken on up towards Gokyo.  Died approx 2 hours after seen in clinic. Mother had 3 previous babies die under 1 year of age when taken to altitude. Accompanied by 1 older son alive and well (different father).

?HAPE, cardiac problem, anaemia, other?

Trekker 3              (Male 57 years)

Previous altitude experience <5000m in Peru.  No AMS

C/O 3 days mild symptoms AMS, becoming more severe in last 24 hours after ascent to Gokyo.  Previous night increasing headache, nausea, diarrhoea, abdo discomfort, not unduly SOB, unsteady on feet on path. Came down that morning.  Took Diamox. Lake Louise score: H2, GIT2, F2, D1, S3.  total = 10

O/E Poor co-ordination on heel-toe-test.  Normal cerebration, mild dehydration, chest clear.

Ataxia 1, mental state 1, oedema 0. HR 99, BP 140/80, RR14, SaO2 88%, afebrile.

Diagnosis: Early HACE, moderate/severe AMS.

Rx: Dexamethasone 8mg.  Diamox 250mg. Descend with assistance.

Trekker 4              (Male 55 years)

Reasonable ascent profile to Machermo, up to Gokyo then descent.

Previous altitude 4,600m max.

Carried from Gokyo by stretcher. Recent diarrhoea, pyrexia since KTM.  Trekked 6 days to Gokyo, unwell so had rest day at Gokyo.  Increasingly unwell today.

Productive cough, minimal headache.  Drinking, eating little, diarrhoea.

Rx: Co-Amoxiclav, Prednisolone 20mg, Paracetamol 1g.

SaO2 reported as 88% at Gokyo.

O/E Ataxic, crackles in chest bilaterally, cyanosed.  SaO2 20-44% in air, 60 with O2 concentrator. HR72, BP 155/90, RR24

Lake Louise score: H1, GIT2, F2, D2, S0.  Total = 7

Rx: Nifedipine SR 20mg, Diamox 250mg.

Later improved: Lying flat comfortably, easily roused from sleep and conversing rationally, occasional cough (productive/wet).

O/E Fine crackles throughout lung fields localising to right anterior/lateral chest, occasional wheeze.  Cold hands, toes.  Calves ok.  No longer ataxic.

HR66, SaO2 76% in air, BP 140/80, temp 36.0.

Rx Co-Amoxiclav. Prednisolone 20mg. To Lodge overnight.

Reviewed next morning at lodge.  Chest clear, purulent blood stained sputum.

BP 160/90, RR 20, HR 80. 

Diagnosis: Chest infection, AMS/early HACE/HAPE.

Plan: Descend.