Students — 17 June 2013 at 1:49 pm

Altitude Elective in Nepal

Mike Freeman / 5th Year Medical Student / University of Glasgow

If you are interested in this article, you may be interested in these others relating to altitude:

Drugs in the Mountains

Medication Use Among Mount Everest Climbers

An Unusual Case of HACE?

This summer I heard the tragic news that fourteen climbers were killed in an avalanche on July 12th on Mont Blanc. Roger Payne, amongst them, was a widely respected mountain guide and accomplished climber whose death shook the mountaineering community. Whilst working in Switzerland in the summer of 2009, I was lucky enough to learn from Roger first hand on a climbing trip that he guided. Of his many stories and anecdotes, his sagacious advice to ‘live life like a thrown knife,’ remains my favourite. His thirst for life and adventure was truly contagious.

Mountain Medicine Society of Nepal

Returning to the UK feeling inspired by Roger’s stories, I made contact with the Mountain Medicine Society of Nepal (MMSN) and had my first experience of Nepali friendliness. It came as a warm reply to my e-mail, from the secretary, offering assistance with my research project. Instead of politely explaining to them that I hadn’t really intended to do any research, the seed had been sown and idea for a project soon began to develop into a reality.

Following a series of emails and internet searches, I discovered that the burden of altitude-illness in the Himalayas is substantial, despite recent improvements in safety and knowledge in ‘Western trekkers.’ Every year around half a million religious pilgrims from Nepal, India and China also ascend to altitude sites scattered throughout the Himalayas. Unlike trekkers, awareness of altitude sickness is low, adversity is often favoured and turning back is not even considered! Pilgrims, seeking enlightenment, forgiveness or cure, are at great risk of suffering the progressive and life threatening forms of altitude illness.  In August, during the annual Hindu festival of Janaipurnima, around 20,000 determined pilgrims ascend to a high altitude ‘holy’ lake in the Langtang region of the Nepalese Himalaya.  This pilgrimage and its pilgrims would form the basis for my research. I set out to study the unique risk factors for altitude-illness in this highly susceptible population.


After months of planning I arrived in Kathmandu, Nepal’s capital city. The taxi ride from the airport was a wholly disorientating experience. The smells and choking fumes, the deafening Suzuki’s car horns and the cows lying in the middle of the frantic, potholed road took me by surprise. For some reason, despite all my planning, I hadn’t prepared myself for any of this.

With ten weeks before the festival began, I had some time to explore. I got my first glimpse of the mountains on a trek in the Annapurna mountain-range. With eight out of the ten largest mountains in the world tucked within its borders, Nepal has some of the most beautiful and dramatic scenery imaginable.  Unwilling to leave the hills, I spent a fortnight in a community hospital, where I got my first experience of obstetrics and surgery . Soon after, on a kayaking trip on the monsoon flooded Trisuli  river, I found myself hitching back over the mountain pass to Kathmandu with my guide, sat in our kayaks on the roof a lorry. It wasn’t your average journey! Once back in the capital I began work in the Kathmandu Model hospital. The department I worked with travelled to remote areas in Nepal to run fortnightly surgical camps, setting up temporary operating theatres.

Village Life

After a month, I escaped from the city to a small village north of the Kathmandu valley. I stayed with a very hospitable Nepali family and I helped out at the local Health Point having a more authentic Nepali experience.  Without any trained medical staff present there I tried my best to help, but often struggled with my limited knowledge of the Nepali language.  In the afternoons, I visited the local secondary school where amongst other topics I was asked by an embarrassed head-teacher to teach sex education. One of the classes ended in a disaster, when a student drew the male sex-organs on the white-board unwittingly with a permanent marker pen. As amusing as his drawing was, it was a little awkward explaining this to the head-teacher.  After a few weeks I was incredibly reluctant to leave this village where I had been so welcomed, but departed with two Nepali medical-students  to the north of Nepal to begin my research.

The Research

The dirt road that winds its way along precarious cliff edges towards the start of the trail was a little unnerving. The abundance of abandoned, dilapidated buses at the valley bottom served as a reminder of the hazards of this journey. Sat on the roof of the overcrowded bus as it rocked from side to side, I managed to convince myself I was in the ideal position to jump off should I need to. The relentless monsoon rain that falls on Nepal during the summer months means a number of landslides annually dissect this road and require a crossing by foot.

After just ten days at altitude we were able to complete the study successfully and collated data obtained from 170 of the pilgrims. This data nearly perished as a co-investigator accidently knocked his rucksack off the edge of the path- which then tumbled down the hillside. Covered nearly head to toe in leeches, we eventually recovered the rucksack with the kind help of the locals. The subsequent bus journey back towards the capital city continued late into the night. The road had disintegrated under the tracks of the countless buses during the festival period, but fortunately the darkness concealed the exposure and helped ease the sense of impending doom.

The return flight to the UK was a memorable one; not least because of the awesome views of the Himalayan peaks finally offered as we climbed above the monsoon clouds. For the past few months, I had become totally absorbed in the life I had in Nepal; I was returning to what seemed like a strangely ‘foreign’ home. I found myself reluctant to be leaving behind all the negotiating, the laughter and the daily adventures Nepal had provided.

There and back again

As I settled back into my medical rotations it didn’t take long before I began to feel restless and start to think what I could do next. I knew a team based at University of British Columbia, Vancouver, who had also worked at this festival previously. After making contact, we began working to develop a protocol for a large-scale longitudinal study. We sought to collect enough genetic data for a Genome Wide Association Scan for altitude sickness. I also considered the use of ultrasound to detect cerebral oedema and so liaised with an Emergency Ultrasound Department in Boston, Massachusetts to include an ultrasound study as part of the project.

Before I knew it I was leaving the UK again for my senior elective. First in Boston, I collected the ultrasound probe and received training on its use from the A&E department at Massachusetts  General Hospital. To my dismay the device began malfunctioning. With little time before the festival I eventually managed to fix the problem with a tenuous DIY ultrasound repair.

Arriving in Kathmandu, we discovered that ethical approval had somehow still not been processed. To complicate matters the entire team were, for some reason, unable to withdraw money and the local Health Board was now refusing permission for us to continue with the research plans. After three days of countless taxi-rides, official meetings and cups of dubious sugary-tea, we were fortunately given the official stamp-of-approval. We met with the two Nepali doctors and two medical students from the Mountain Medicine Society of Nepal (MMSN) who would be helping us with the study and we were finally ready to begin our research.

We had organised jeep transport this time, but still found ourselves crossing a worrying  landslide by foot. After a series of near misses with the constant rock fall, we were relieved to make it across in one piece.  Four members of the team were based at the start of the trail and five of us based at the lake at 4380m. We provided roti and other snacks to entice volunteers and a large poster made by locals drew more attention to our base. The poster needed some prompt alteration as it initially read “free poison”! The days were long, starting at 04:30 and busy usually until 23:00. We collected demographic information, buccal genetic samples, baseline balance information, heart-rate, blood haemoglobin and oxygen saturation and finally exhaled carbon monoxide and nitrous oxide.  At high camp we worked along-side the Himalayan-Rescue-Association who run a temporary health camp during the festival. We collected altitude illness information, saliva genetic samples, ultrasound scans, balance (ataxia data), heart-rate and oxygen saturations.

A further translation error nearly landed me in bother when I was advised by an amused porter that my pronunciation of the Nepali word for bracelet was in actual fact the word for vagina! My attempts to find our identifying red bracelets for follow ups were soon halted and he kindly offered to take over from there on.

Additional members of our research team joined us at the lake for the busiest night of the festival to provide extra help in all the chaos. Amongst the pandemonium of sick pilgrims who arrive in their masses, there are very scant toilet facilities, limited accommodation, monsoon rain and of course a festival of music, alcohol and dance. Eight of us shared a double-bed sized room and on the busiest day I spent the night in the health camp hoping to examine sick pilgrims with the ultrasound. Once again the research was a great success. In all, we managed to collect longitudinal data on 567 pilgrims (95% of those recruited by the low altitude team!) and a further 96 sick pilgrims at the lake.

During the festival period I also gained great experience of wilderness medicine, where resources were minimal. I remember my alarm as a lady sat conscious with an oxygen saturation of 29%; the lady lying next to her with severe pneumonia was in greater need of the oxygen at that time! Patients sometimes required urgent evacuation down the mountain; which would involve being carried on the back of a porter, along with an oxygen cylinder, often in the middle of the night. It was a horrible reminder that unlike trekkers, these pilgrims could not afford the insurance needed for helicopter rescue and as such death was a distinct possibility.

Final words

Shortly after returning home to the UK I was admitted to hospital and treated for Typhoid fever. Nepal has made its mark on me; I have also had Giardia, food poisoning and a lot of diarrhoea; but aside from all that, I have experienced some of challenges of field research, I’ve been awed by the mountains and humbled by the generosity and kindness of the people. In many ways this has been pilgrimage of my own during my medical school years. In the niche world of altitude illness research and expedition medicine, I have experienced a sense of responsibility, purpose and adventure that has shaped my future ambitions. It is strange now, to think, how much resulted from the kindness and slight misunderstanding of that first email. There is a famous Nepali saying ‘khe garne?’ which translates as ‘what is there to do?’ Well in my opinion Roger saying covered it pretty well in his words ‘live life like a thrown knife’.


Destination / Nepal
Time of Year / June- August
Weather / Monsoon season, plenty of rain and clouds, but mountain tops can still be seen early in the mornings!
Religion / Hinduism and Buddhism
Money Spent / Flights roughly £500. Daily living costs will vary (approx. £5-10)
Vaccinations / Hep A, Hep B, TB, Rabies, Typhoid, Japanese Encephalitis (optional)
First Aid Kit / Alcohol gel, Rehydration Sachets, Antibiotics, Paracetamol

Positives / Diversity of scenery and landscape; Potential for adventure with outdoor pursuits; Cheap living costs

Negatives / Things often don’t go to plan- be prepared to be flexible; The clouds, leeches and landslides might worry some, but remember the monsoon scares away most tourists and makes for a more authentic experience of Nepal


Placements can be arranged very easily once you have arrived in Nepal if things don’t work out as originally planned. Bear in mind that as you move to a smaller and more rural setting less English is spoken, but there is often more scope to get hands on experience. It is a great experience to spend some time living with a Nepali family but it can feel a little restrictive if for a long time. A water filter is a great alternative to chemical treatment. Finally make sure to google ‘Himalayan Hash Harriers’ before you leave- this is a must do for anyone – runner or not!

I am hugely grateful for the support and help I have received during these projects both in Glasgow, Boston, Vancouver and Nepal and to the organisations that provided me with essential funding and research equipment.