High Altitude Medicine - Caring for locals and trekkers at 14,000 feet in Pheriche, Nepal

Bryan Jarrett, M.D. 

Wilderness Medicine Fellow, 

Massachusetts General Hospital Department of Emergency Medicine

PGY4

06/29/2019

The Himalayan Rescue Association Clinic in
Pheriche with Anna Dablam in the background

Three months above 14,000ft at a high altitude clinic 10 km away from Everest Base camp taking care of trekkers and the local Nepali population, armed only with my stethoscope, an ultrasound, and my clinical training… sign me up. My name is Bryan Jarrett, and I am a Wilderness Medicine Fellow at Massachusetts General Hospital. Our specialty focuses on providing care in resource-limited and remote environments, and this certainly qualified.

The Himalayan Rescue Association has been providing care in the Khumbu region since the 1970s. Their first and longest operating clinic is in the town of Pheriche, a stop on the trek to Everest Base camp and multiple other locations, done by approximately 25-30,000 international visitors each season (the trekking seasons are in the Fall and Spring). In order to support these trekkers, a large number of Nepali lodge workers and porters migrate seasonally to these high altitude communities during these times. By the end of almost two and a half months of clinical work, our team of three physicians and a Nepali medic named Thaneshwar had taken care of almost 700 patients and evacuated 27 people by helicopter for severe illnesses.

The majority of our patients were Nepali (70%), and the most common diagnoses we saw were upper respiratory tract infections (33.6%), followed closely by acute mountain sickness (8.6%), gastroenteritis (8.3%), and musculoskeletal complaints (6.2%),

Helicopter evacuation of a critical patient after a large snowstorm 

making this experience just as much international primary care as it was high altitude medicine. Our interesting cases were a good mix of typical emergency medicine cases presenting in this austere environment as well as a large number of the two severe forms of altitude illness, high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).

High altitude pulmonary edema is the more common of these two, resulting in interstitial fluid in the lungs causing shortness of breath at rest, and in its most severe form, significant hypoxia and possibly death. We had 22 cases of HAPE, of which the majority were Nepali, and we evacuated 13 of these by helicopter down to Lukla approximately 5000 ft below Pheriche, or usually all the way down to Kathmandu. A normal oxygen saturation at 14,000 ft is approximately 80-90%, but most of our patients with HAPE presented with saturations in the 50’s with significant shortness of breath. The mainstay of our treatment was supplemental oxygen via oxygen concentrators which we ran off of power supplied from solar panels, and most patients improved on oxygen and nifedipine, a medicine to decrease the blood pressure in the lungs. Thankfully, all patients we saw were able to either ride a horse or helicopter down to lower altitudes for a safe recovery.

Fewer patients presented with high altitude cerebral edema, a condition in which the brain swells at high altitude causing confusion and difficulty walking. All but one of these six patients were evacuated by helicopter after treatment with oxygen and dexamethasone, a steroid shown to be helpful in improving this swelling. Many of these patients came in being carried by friends, horses, or porters; confused, and unable to walk on their own.

 A patient with HAPE, with a normal saturation 

on supplemental oxygen, with ultrasound images 

of B-Lines representing the Interstitial edema in 

his lungs

There are very few places where one can treat young, otherwise healthy patients with acute, potentially deadly conditions and watch them improve over 12 to 24 hours with treatment. This was a truly special aspect of this experience. While providing care for these unique pathologies only found with this prevalence in a few locations around the globe was invaluable, the true joy was providing medical care to the local population. This was less glamorous, and provided less excitement, but ultimately greater satisfaction. We were able to repair significant lacerations, give antibiotics to respiratory and skin infections, and treat basic aches and pains. I will never forget the beautiful mountains, the young patients who are still alive because we were there to provide them with much-needed care, and the friends I made in the process.