Dr Tessa Coulson / GP / Manchester
In 2019 Tessa travelled to Nepal to work at the International Porters Protection Group (IPPG) rescue posts at Machhermo and Gokyo, in what turned out to be the final season for these clinics. Tessa describes two interesting cases she encountered there as well as her experience of witnessing the beginning of the end of these renowned establishments.
Setting the scene
Seeing your knickers frozen on a washing line is perhaps the best light relief to hard days
Since I was little, I have wanted to be two things; a doctor, and outdoors. By the time I got to university I gravitated towards the hiking club and chose optional study modules related to altitude. I undertook the Diploma in Mountain Medicine (DiMM) in 2014-15, during a couple of years out following foundation, before deciding on GP training. GP seemed a good “all-rounder” option, perhaps subconsciously allowing me to leave one adventurous foot in an open door.
I’d heard about the International Porter Protection Group (IPPG) whilst still a student and was really drawn to their work. Aside from the intrigue I had towards altitude medicine, the story of their work was fascinating.
Throughout the Everest region there are caves and boulders that hold a history that trekkers would not perhaps be so proud of. Whilst western visitors would sleep in their tent or local lodges, the porters carrying their luggage (or even the materials used to build said shelters), would have to use these caves and boulders as their best option for cooking and sleeping quarters.
This happened until alarmingly recently. Cue the founding of IPPG, in collaboration with Community Action Nepal.
For 17 years, IPPG – supported by donations – ran two rescue posts offering affordable food, accommodation and, if needed, very cheap medical care from volunteer doctors. These simple buildings made of stone and timber with corrugated roofing, served the villages of Machhermo (4,400m) and Gokyo (4,700m) and provided a significant upgrade in shelter and care for porters and trekkers alike.
Back to me at low-altitude university. I hoped I might be able to volunteer with IPPG for my elective and was gutted when the dates didn’t work out. I would have to wait several more years before everything would line up and I could finally apply. The wait was worth it, as having some experience under my belt gave me more to offer. When I was offered a place all I had to do was convince my wife and pet guinea pigs that it was a good idea. They agreed, and in September 2019 off I went.
A friend of mine (Hywel) is an audio producer and, over a coffee before I left, he began to hint that it might be exciting to record the adventure and turn it into a podcast. As I prepared to go, we did some trial runs of recording audio diaries and, convinced it would be unobtrusive and easy enough, I decided to record the journey. A year later we have a ten-part podcast documenting what happened. Hopefully it captures the wonder and magic of going to such a special place, but also the unexpected tragedy and drama that unfolded. It turned out to be ‘the last season in Nepal’ for IPPG, which seemed a fitting title for the podcast.
Kathmandu was the first leg of the journey, landing us in the monsoon season of a vibrant and hectic city. The transition from this, via one of the most dangerous airports in the world – Lukla – to mountain life is a swift and stark shock to the system. Upon landing you have several days of walking (and acclimatising) to the sound of yak bells and the gentle chatter of your companions, before you reach your home – the Machhermo post.
There is a simplicity to life at altitude. Especially after the busyness of one’s life and the endless preparations and re-organisation of socks and thermals pre-departure. The toilet is outside (I take you to it on one episode of the podcast), and the water comes to the rescue post via hose pipe from further upstream (another episode of the podcast focuses entirely on my obsession with water). You have a stove to keep you warm, and space in the “sun room” to hold the daily (free) altitude talk which trekkers, porters and guides attend. Education about prevention and appropriate management of altitude illness was a really important part of IPPG’s presence in the area. In terms of work-life, the surgery is a room with all the basics you need to treat anything from colds to head trauma. You live there with a handful of like-minded volunteer doctors and local staff.
Living at altitude brings pain in the form of cold and lack of everything you take for granted at home, but pleasure in its simplicity. It is an environment that lets you experience beautiful nature, from which your work emerges in the form of patients presenting with a full spectrum of conditions. We saw everything from altitude sickness to abscesses. Our caseload even included a local cow (true story). The environment can send you a patient at any time:
I’m tucked up in bed at 1am in Machhermo and am awoken by our post manager Kanchha to attend one of the lodges to see a trekker. I quickly put on extra layers to keep me warm for the walk under crystal-clear night skies to the lodge and, potentially, the long night ahead.
The trekker had ascended to Machhermo from Dole the day before, and felt reasonably well on arrival. A few hours later he thought he was coming down with a cold, and went to bed at around 8pm. At 11pm he awoke feeling breathless and coughing with a headache. Help was called for an hour or so later when things were worsening.
On my arrival the man, about 50 years old, is propped up in his bed. He is drowsy but rousable and looks worryingly grey and breathless. Next to him on the floor is a plastic bucket which he has been coughing into – a layer of rust-coloured sputum at the bottom. His breathing is noisy – crackles audible without a stethoscope, and he is centrally cyanotic. We get the oxygen concentrator going. The batteries on these amazing portable devices last about 1 hour when they’re going full tilt (delivering up to 6L/min). Luckily, we have a spare but he’s going to need more than that given the hours left until daylight, when you can plug into solar power. There will need to be a constant system of recharging them and shuttling to and from the rescue post. I also administer nifedipine, acetazolamide and dexamethasone.
The trekker’s improvement with treatment was dramatic over the next couple of hours, both symptomatically and in terms of his respiratory rate and oxygen saturations, and we were able to reduce the oxygen flow gradually. The trekking guide arranged for a helicopter evacuation, and when it arrived at around 7.30am he was able to walk, albeit slowly and with support whilst on the oxygen, to the landing spot – very satisfying.
What struck me about this case was how text-book it was: the fairly quick onset after arrival at new altitude, cyanosis, rust-coloured sputum (which we hadn’t seen in any of our other HAPE cases so far) alongside the incredible response to oxygen (simulating descent) and nifedipine. This was altitude medicine in action.
This time we are in Gokyo, it is evening and already dark, around 8pm. A guide arrives at the rescue post with two female trekkers. One has symptoms of moderate-severe acute mountain sickness. The other, 38 years old and usually well, has visual loss. They have come to Gokyo via the Renjo La (a pass at 5,350m), having started the day at Lungden at 4,380m, but had not had the usual additional rest day on the way up from Namche Bazaar. The trekker describes acute onset of blurred vision when nearing the top of the Renjo La which progressed until she could barely see a hand in front of her face. She had to be guided down to Gokyo, hence their late arrival time. She thinks the vision has improved a little since then but she is understandably very scared. There are no other symptoms of altitude illness. She is a contact lens wearer but has no other relevant medical history. On examination, her cornea is cloudy but there are no other abnormalities and her observations are as expected for the altitude. We treat her for suspected hypoxic corneal oedema, the risk of which is increased by wearing contact lenses. Luckily, the trekker had removed her contact lenses on the way down, thinking they might be part of the problem. By descending the 500m or so from Renjo La, her treatment has been started, so we continue aiming to improve the oxygenation to her cornea by placing her in the hyperbaric chamber (PAC). As the cornea gets most of its oxygen supply from the environment rather than a blood supply, we felt that enriching the environmental oxygen as much as possible would be more beneficial than administration via nasal specs, although we did need to alternate the two as she was only able to tolerate the PAC for short stints due to claustrophobia.
By the morning, the milky appearance of her cornea had improved to a certain extent, and her vision had vastly improved so that she was now able to read text and move around unaided. She was evacuated down to Kathmandu to expedite descent and recovery.
This case made us think on our feet, it was quite unusual and there is limited literature available on best management for altitude related hypoxic corneal injury. As with other altitude related conditions, descent or simulating descent with oxygen treatment until descent is possible is often the answer.
The last season in Nepal
The trip had two really upsetting moments for me. The saddest was the death of a trekker, which I’ll leave to the podcast to explain. The other was the quite sudden realisation that IPPG was facing a serious threat to its future. During our time there it would lead to the demise of their work in Nepal.
One afternoon in Gokyo, we noticed a neon sign had been put up on one of the local lodges, offering health care. There had been rumours but nothing concrete until this moment when a rival clinic arrived, seemingly out of nowhere. It was a private clinic owned by a private hospital in Kathmandu, with links to a helicopter company. Heli-vacs are fairly infrequent occurrences, which we only arranged for urgent cases. Not only is there great expense to the patient and their insurers, but they also pose a great risk to the helicopter pilots, and passengers, due to rapidly changing weather in the high-altitude mountain environment. The first time I advised helicopter evacuation for a patient, my heart was in my mouth as it hummed and bounced low to the ground so as to avoid a descending fog. It is also foreseeable that, as a result of the clinic’s links to both the helicopter company and the private hospital in Kathmandu, the medics working there might feel pressured to arrange more treatments or evacuations than are necessary. If helicopter evacuations become more common, insurance prices could sky-rocket, ultimately having a detrimental impact on the whole trekking industry. We will see what happens in the future.
The arrival of this clinic meant that there was a Nepali company and a western charity both offering the same service. The charity has provided stable employment to Nepali staff for many years, and the volunteer doctors have experience of working at altitude. The new private clinic has a relatively junior doctor working there, covering both day and night. The locals who IPPG employ have relied on them to put their children through education, and the porters who have used the service for years have received next to free health care. Whilst I am very aware that I’m a westerner commenting on a local issue in another country, it’s devastating that the upshot was that IPPG were no longer allowed to operate, and the private company is now the only medical support there. I really hope the new place can retain some of the IPPG ideals of porter rights and welfare, and continue to provide affordable yet good quality health care to those porters, guides, locals and visitors in the area.
It wasn’t until a couple of weeks after we got home that we received the official confirmation that the permission for the rescue posts to re-open had not been granted, spelling their forced closure and the end of an era for IPPG’s work in Nepal.
IPPG has faced several challenges over the years, from maintaining a steady stream of funds to keep the charity sustainable, to keeping abreast of an ever-changing political climate and dealing with the new medical council registration requirements for foreign doctors at short notice. However, through hard-work, support from CAN and good relationships with supportive locals, IPPG was able to continue with its valuable work, until this most recent insurmountable hurdle.
Since the forced closure of the rescue posts, the COVID-19 pandemic has pretty much wiped out two trekking seasons, and is likely to do the same to the upcoming seasons in 2021. The full impact of the absence of IPPG rescue posts in the area may only come to light once trekkers can return. The work of Community Action Nepal, however, continues and is more important than ever as these mountain communities cope with yet another disruption to their usual industries. You can support them (https://www.canepal.org.uk/howtohelp). Thank you if you do. Their website also contains details about volunteer opportunities.
Other options going forward to help support porters include KEEP (Kathmandu Environment Education Project), a non-profit organisation who run a porters clothing bank and regular education programs for porters about their rights and welfare, plus a lot more. See their website for more details on how you can help.
If you’re heading out to Nepal to trek or climb, use a reputable company and ensure they have a porter welfare “code of conduct” or similar. A reputable company should be able to answer any questions you have about what weight the porters are allowed to carry, their pay, where they will sleep and eat in the evenings and what insurance is provided for them.
The very point of adventure is that you don’t know what it will bring. For me it brought great peaks of mountains and happiness, and great troughs of cloudy valleys and changing times, all of it enriching. Seeing your knickers frozen on a washing line is perhaps the best light relief to hard days. That and the company of Kanchha, Samip and fellow volunteers Dan, Deb, Edi, Jen and Shankar, drinking steaming cups of sweet tea whilst watching as the sun rises over the mountains and glistens on the frosty turf. These are the things that I think of when I’m driving to the surgery on a dark and damp winter morning.
If you have the opportunity to take part in any similar trip, I couldn’t urge you more strongly. Despite the difficult and emotional moments, I would leap at the chance to go again.
The associated podcast is less than 1 hour combined – we edited it down considerably to keep it light and brief.
The Adventure Medic also has a news article about the closure of the Machhermo and Gokyo rescue posts.