Dr Elizabeth Chamberlain / Foundation Doctor / North Wales
When Elizabeth was a medical student, she could not wait for her final year elective to gain some experience in expedition medicine. This drive took her to join Exile Medics to help provide medical support for a series of mountain trail races in Nepal, run by Impact Marathon Series. The Nepal Impact project involves participants in local development tasks, such as helping to lay pipelines for running water, before they embark on a challenging mountain run.
I have long been interested in remote medicine, but it wasn’t until hearing Professor Chris Imray and Dr Sundeep Dhillon describe their adventures, that I realised it was something that I could get involved in whilst still at medical school. Both of them spoke of their time in the Himalayas, which had inspired me to visit some of the most captivating mountains on earth. You can therefore imagine my excitement when I was invited to join the 11-strong team of doctors and paramedics to support runners of a mountain marathon in Nepal.
Before going to Nepal, I was naively confident of the complexities of facilitating a mountain marathon. I am a keen mountain walker and have volunteered to provide medical care at several prominent UK marathons. What could be so difficult in combining the two? Regardless to say, my eyes were opened to the challenges involved in running an event on this scale.
Arrival
I landed in Kathmandu on Wednesday 8th November and was immediately enveloped into the chaotic bustle of the city. The unpainted roads teemed with taxis and buses, while swarms of motorbikes swerved round potholes which littered the surfaces. People crowded the roadsides and sat outside shop fronts, many wearing face masks against the dust that choked the city in a yellow haze. That evening I met up with the rest of the team in a bright and busy rooftop restaurant in the city centre. Fairy lights adorned the terrace and mingled with the prayer flags that appeared to stitch together the narrow streets of Thamel. The group had decided that it could not pass on this opportunity to go hiking in the Himalayas, so had planned to go trekking together in the days preceding the race. The activity was highly beneficial for getting to know everyone in the team, their experiences, strengths and expectations, and it vastly helped our professional cohesion during the race itself. It also allowed us to become familiar with the terrain and acclimatise to the environment. Although I had thought the trek was simply a bit of fun, I now appreciate the importance of being comfortable looking after yourself in order to effectively care for other people.
The race itself was being held at Kakani in the Shivapuri National Park. Despite its proximity to Kathmandu, it took us well over two hours by minibus to bounce our way round precarious hairpin bends to our destination. It was an eventful journey to say the least: facing down lorries on dark single-track roads, knocking over electricity wires in one of the villages, and getting out to push the minibus up one particularly steep stretch of track. We were relieved to pull up at last, at the gateway to our campsite.
We were greeted enthusiastically by Nick Kershaw, founder of the Impact Marathon Series. He described the organisation as a way ‘to harness the power of running marathons and to link it with sustainably building communities and bringing people together, leaving a lasting impact on the world.’ Runners from all over the world can sign up to the Impact Marathon, and choose to run a distance of 42km, 21km or 10km to raise money for local charities. Over the next few days I saw the passion and energy that Nick channelled into the event, and the determination it inspired in the runners.
The joy of arriving somewhere late at night strikes you the moment you leave your tent the following morning. At 5.30am I swathed myself in my warmest layers and emerged to join the sunrise yoga session. We trekked up to a small plateau, isolated from the camp by trees on one side and open to the valley on the other. The rising sun glittered on the grass and threw shadows to define the mountains across the valley. Low-lying cloud flowed like white water, obscuring the valley floor and snowy peaks blurred into the pale blue sky. It was truly a beautiful sight.
Preparation
As the medical team, the responsibility of the runners’ safety lies with you. For example, if a runner is ill or compromised, it is your job to educate them on the risks of proceeding. If the race course is unsafe, you must liaise with the race directors to alleviate those risks. And if the appropriate emergency equipment and procedures are not in place, then the event cannot continue.
During the days preceding the race the team mingled with the runners who were staying on site, digging alongside them to bring running water to a nearby village in ‘Project Pipeline’ and joining them for meals in the evenings. Besides adding to the sense of community, it also gave valuable insight into the runners’ lives and helped us to identify potential issues prior to race day. One afternoon, as we worked on the pipeline, a lady was explained that she was taking acetazolamide for the prevention of acute mountain sickness (AMS). This revelation prompted us to give a shout-out during dinner that anyone taking altitude prophylaxis medication should visit the medics in clinic. Acetazolamide is a diuretic which although helpful for the management of AMS could lead to severe dehydration when coupled with endurance running and traveller’s diarrhoea. In addition AMS rarely presents below 2500m and as we were based at 2000m the use of prophylaxis was unnecessary. Our interactions with the runners prior to the race also meant that they felt more comfortable approaching us with their problems. This was especially noticeable with runners who developed diarrhoea and might otherwise have been too embarrassed to discuss it.
Every evening we ran a clinic in a small room just behind the dining hall. Everyone took turns hosting it and I volunteered for each one, eager to learn. It was predominantly people with gastroenteritis or requesting blister care. I enjoyed giving hygiene advice and providing reassurance to worried runners, as well as observing my colleagues at work which I felt would shape my own future interactions with patients.
Besides the obvious care-giving role, our team was also tasked with ensuring the race itself was safe. The day preceding the race we set off to walk the route. The course was a 21km loop which the marathon participants would run twice. It would take the runners through dense forest and along narrow tracks around the mountain and involved over 1000m of ascent.
We met our first obstacle about 4km when the path came to an abrupt halt by a waterfall. A 10m high cascade of water tumbled into a small pool, with a few stepping stones around its edge, before pouring over the edge and down the mountain side. That in itself looked like a risky route to send scores of runners across, which images of slips, twisted ankles or fatal falls coming to mind. However, the worst was yet to come as we discovered that the path beyond had been obliterated by a small landslide. More ground crumbled away as the team carefully traversed the missing section, holding on to wire netting which was bolted to the cliff face. Scenic as it was, we could not allow the race to pass this way.
About half way round the route, we came to another place where the path had been destroyed by a landslide. This section was more easily passable so it was decided that with the assistance promised from the military, and appropriate warnings to the runners, it would be acceptable to allow the pass to pass this way. It was also located close to the evacuation point, the only place with vehicle access on that half of the route.
Upon our return to camp our team leader initiated a discussion with the race directors about the state of the route. Following this discussion a smaller group headed out, before dusk fall, to find an alternative route to cross the waterfall that would not compromise on the safety of the runners. The experience highlighted to me that a race director’s objectives do not necessarily correlate directly with the medical team’s objectives, so robust lines of communication are key when providing an exciting race which does not compromise on safety. It was unsettling to discover that we had the power to call a halt to the entire event, but by working effectively with the race organisers a suitable solution.
That evening was a whirl of activity as we prepared our kit bags and discussed the allocation of medical teams along the route. Both location and distribution of expertise was carefully considered in light of the terrain, potential injuries and distance to the evacuation points. We had a mix of skill sets within our team including paramedics, emergency medics and orthopaedic trainees. As the most junior member of the team it was decided that I should be paired with one of the more experienced doctors, Andrea, to be stationed at a point halfway along the 10km course, at the bottom of a steep descent. The rest of the group were split so that there was one paramedic and one doctor at each checkpoint, the remaining two medics forming a moveable team based at the start/finish line.
Race Day
A few of the teams had to be up before dawn to trek out to their designated locations round the course. Andrea and I were lucky that we didn’t need to be in position before 11am, so spent a more leisurely morning before hiking down to our checkpoint. I quickly understood the value of familiarising yourself with the route beforehand. The 10km stretch that now formed part of the route for all three races, owing to the change of course, was the only section we hadn’t explored the day before. Consequently, Andrea and I were unsure about where would be best to base ourselves. We had no map, only instructions to situate ourselves at the bottom of the descent, where we anticipated we would see the greatest number of ankle injuries, and a description of the route as ‘going 5km downhill and then 5km back up’. As we set off we soon realised that that description didn’t do the route justice. It was over very steep and exposed terrain which was rocky, loose and uneven. After descending to where we judged to be half way we discovered a flatter patch of ground, with some shade and running water, which seemed an ideal spot to pitch a checkpoint. However, we could see the track continuing downwards, so I stayed to look after our kit bags while Andrea jogged off to confirm where the lowest point of the descent was. After half an hour she reappeared, breathless from running and bearing the news that she still hadn’t found the bottom. In the end we set up our medical station and the next food and water checkpoint a further 1km along. It was situated at crossroads where runners would loop back to re-join the track to the start, giving us a convenient vantage point from where we would see all the runners twice.
Good communication is essential in any situation. Whilst working in the UK, I would frequently rely on having phone or radio signal with which to communicate with my colleagues. Prior to arriving at the race, our team had been informed that the army and local police would be assisting with the marathon, and that individuals with radios would be stationed at each checkpoint. However, it transpired that the police were not allowed in this area of the National Park due to its proximity to a military base. We were later informed that the army would only staff the section with the landslide. It was just as well several members of our team had had the forethought to purchase a local sim card while in Kathmandu. One of the factors making the mountain marathon an extreme event, was the fact that there were large sections of route where the runners were completely isolated, perhaps with several kilometres to the next checkpoint. Therefore, if a runner were to be injured or fall ill along these sections we would have to rely on passing runners to relay the news to us so that we could investigate. As simple as this method sounds, it was a lot more challenging in practice.
At about 1pm, Andrea and I started hearing reports about an injured runner on the section of route beyond our station. We were currently busy at our checkpoint, and the accounts we were receiving were vague. With confusion over the location of the patient and nature of the injury we decided it was best to wait until more solid information could be gathered, instead of rushing to assist an ambulant runner and leaving the medical station unmanned. For me this was a key learning point, as it emphasised our lack of resources and the risks of spreading ourselves too thin. However, we needed to investigate, and so directed a couple of the race facilitators on a motorbike to scout out and transport the patient back to us. A quick assessment suggested it was a fractured ankle. We arranged for the ambulance to come down from the finish line to collect and transport the patient to hospital in Kathmandu.
Putting aside the medical treatment of this patient, I found it fascinating to reflect upon the challenges of resource allocation when responding to medical incidents. While we had the time to consider our response to this injured runner, the multistage approach to her evacuation meant we could also assess and evaluate the use of our resources. The patient was fortunate that her fracture was undisplaced and with appropriate immobilisation, relatively pain free. Thankfully this was the worst injury to occur during the race but we had to ensure that we were always prepared for a time critical medical incident, such as a cardiac arrest or major trauma. Therefore, it made me think how we might have responded to another more serious emergency while all our resources were being used to evacuate this runner.
All races finish with the sweeper who runs the course at the end and ensures that there is no one left on the route. A highlight of the day for me was joining the sweeper who had caught up with the final runner. Andrea and I packed up our checkpoint and ran alongside them. We provided encouragement as they determinately climbed to the highest point at the Stupa overlooking the village, and then accompanied them under the rippling streams of prayer flags for the final descent to the finish line. It emphasised how we weren’t just there for the physical health of the participants but also to improve their general wellbeing and motivation on what was a tough race.
Farewell
The whole trip flashed by much too fast and at the end of the week I was sad to bid farewell to the team. It was an incredible experience which has opened my eyes to the challenges of working in extreme and remote conditions and inspired me to include expedition medicine in my future career.
I enjoyed working for Exile Medics, an organisation that seeks to provide expert medical care for expeditions and sporting events all over the world, who I have found to be extremely supportive of students looking for experience in these fields.
Top tips
- A good sleeping bag! There is nothing more important than being able to have a good sleep at the end of a long and busy day, and being able to stay warm throughout the night is key. Similarly, a pair of ear plugs can also be handy.
- Bring a large bag of Haribo, or other sugary snack of your choosing which doesn’t melt. These are great for making friends and helping morale.
- It is always worth staying awake for that meteor shower despite the early start the next morning. You may be tired but you won’t regret it
- Do a bit of research about your country of destination before going. I always make sure to know what to expect from the weather, have a plan of what I want to see and do and to learn a few basic phrases in the local language.
