Relationship between Cognitive Impairment and Acute Mountain Sickness, Nepal Experience

Isabel M. Algaze Gonzalez, MD

Program: Fellow in Wilderness Medicine at MGH

PGY: 5

 On top of Namche Bazaar.

As a born raised Puerto Rican, my comfort lies in the tropical setting, rainforest green and caribbean blue were part of my landscape before moving to Boston a year ago. I have seldom seen snow before and had only experienced cold weather once or twice in my lifetime. As part of Harvard's Wilderness Medicine fellowship program is my duty to venture and polish my wilderness physician skills in a remote location. So, I jumped at the opportunity to practice medicine with the Himalayan Rescue Association Pheriche Aid post, precisely because I  had never experienced cold or altitude personally and more importantly as a physician.

The first challenge was to prepare. Understanding that our stay in a third world country, in a remote area, would be three months long, with temperatures as low as -20^oC was intimidating but fascinating; adventure looks promising. I don’t own any cold weather gear or clothes, but the good thing is that I’m working under Harvard's Wilderness gurus who were very prompt to offer advice and reassurance. I kept reading about the diseases that I will encounter and frankly I may never see if it wasn’t for this volunteer opportunity. Since I would be staying for so long we decided that it will be very valuable to the community to engage in altitude research. We came up with a research that will evaluate the relationship between Acute Mountain Sickness and Mild Cognitive Impairment in trekkers ascending through the Khunde region in Nepal. A subject that has been poorly understood and studied given the difficulties to complete research in a remote location and harsh environment. The trekkers were tested in three different altitudes to finally compare the changes of cognitive behavior in altitude.

Friends for life. Indonesia and Puerto Rico.

Upon arrival to Kathmandu the cultural differences where absolute. The atmosphere is very hectic, loud and dusty. The mix of Hindu and Buddhist religions is very evident, from their building structures to their traditional clothing. I was eager to start the ascent from Lukla to Pheriche and apply all the reading that I’ve done. But before we got to trekked, we were given lectures on Nepali health problems and Nepali language. We got to meet and explore Katmandu with a very international group of doctors. The Pheriche group consisted of a Swiss Doctor with helicopter rescue background, whose partner is a mountain guide, an Indonesian Doctor with a Disaster medicine background and myself. The Manang group consisted of another USA Wilderness Fellow, and Irish Doctor who works in Australia and a Canadian from Montreal. We prepared the medications and were briefed on our responsibilities at the post.

The Trekking day has arrived and we are up at 4am given that the flight to Lukla is very dependent on the weather. We check all our excess food, medications bags, the aid post’s chimney and board the tiny airplane to arrive tightly in between two mountains at an air strip that was built at an angle to compensate for its short length at 9,383 ft. We already felt like we survived.

Porters carry all of our supplies. We each have a back pack with immediate necessities. There are no roads, the paths are rocky, steep and dusty terrain. The first day of trekking we hike from Lukla to Monjo. I thought I was in shape, but just going up 2 steps was enough to make me gasp for air. How do the porters carry more than twice their weight though this terrain? For me, they are proof of the amazing adaptability of the human species. Any movement caused significant fatigue and I thought to myself what have I gotten myself into? While catching my breath, I got the first glance of the beautiful imposing scenery of the Himalayas. I’m convinced that this is what heaven is supposed to look like.

 Research time. Giving and scoring the test.

There are many “Tea houses” along the way. The rooms have 2 twin beds and a light. Charging stations and sometimes internet are available for a fee in the public dining hall where every guest comes to share stories, the warmth of the stove, tea and food. Water is scarce, warm showers are expensive and very hard to find. People make due with baby wipes.

We stay 2 nights for acclimatization in Namche Bazaar, the biggest town in the mountains. We all had mild headaches that resolved with food and hydration. We hiked 4 hrs to the nearest “hospital” in Kunde to ask for tips and to see what services they offer there, cases we could refer there instead of a evacuating a patient by helicopter back to Kathmandu. We had our first shower and our last chance to use internet. The fifth day of hiking we ascend to Tengboche. Where we were able to see Lobuche peak,  also Ama Dablam and Everest along the way.  The sixth day of hiking was a particular cold and windy hike through the ridge of one of the many mountains in the Khunde region. We finally arrived to the Himalayan Rescue association Pheriche Aid post at 14,340 ft. My pulse was in the hundreds and my oxygenation in the eighties resting. Tachycardic and hypoxic by “normal” standards, were now a new “normal” at this altitude. We settle into our rooms and rest to organize and hopefully open the clinic in two days. We have no fuel for the night, little water and no heating. It will be a cold long night.

We wake up early and start to clean the Aid post that has been unused since last season. The clinic has solar power but the day has been cold and very foggy, not enough sun to fill the battery. We hope that no-one needs the oxygen concentrator today. We accommodate the medications and we have our first Nepali patient. We make a schedule and practice the Altitude talk that we are going to give every day at 3 pm.  

Trekkers receiving a Lecture on Altitude Sickness. Everyday at 3pm

On the other hand it has been years since I seat down as a family to eat, talk and play card games. I honestly felt a little uneasy and guilty that I was not living my hectic life. I guess I have nine more weeks to also “acclimatize” to another way of life. We start to introduce ourselves to the community and we have six more Nepali patients. The locals are very happy to have us here since is the only aid post 2 days at any direction. Foreigners are yet to come as climbing season is around the corner.