The NEW ENGLAND JOURNAL of MEDICINE

Renee N. Salas, M.D.

April 25, 2015, began like any other day at the remote Himalayan Rescue Association (HRA) clinic in Pheriche, Nepal, where I’d been working as a volunteer physician for the past 6 weeks.

Days had passed quickly while our team cared for international trekkers and climbers, as well as local Nepalis, treating routine illnesses and addressing high altitude emergencies. But on this day around noon, the ground began quaking beneath my feet as I sat in our living space. My bewilderment quickly dissipated as I darted outdoors to join the rest of the village in the open spaces. Time seemed to slow as I watched buildings crumble through a haze of dust and snow. Screams filled the air.

As the earth quieted, we dis- covered that despite widespread structural destruction in the village, there was only one minor injury. Disruptions in phone and radio communications made contact with loved ones and our HRA colleagues, including Everest Base Camp (EBC) farther up valley, difficult to impossible. Rumors of the extent of the damage in other regions began to circulate. With limited contact with the world outside the village, anxiety grew.

Given the continued after shocks, many people remained outdoors. As an emergency physician, I began preparing myself for patients who could arrive at any time. A light snow covered the ground as we waited.

Nine hours later, our clinic received the first two casualties from EBC and only then learned that the camp had been hit by a horrific avalanche off Pumori moun- tain. Early the next morning, we were notified that all the wounded from EBC would be transported to our small clinic by helicopter.

Rescue from HelicopterPhase two of this mass casualty incident occurred at 4200 m in a remote wilderness region called Pheriche. Our clinic was a three bed facility with limited resources, and the nearest hospital was approximately 15 hours by foot down a narrow, uneven trail. The situation was further complicated by stormy weather, so a timeline for evacuation to urban hospitals remained uncertain at best. About 150 people came to assist us, some spontaneously and some recruited. They seemed to step seamlessly into the necessary roles as our community joined together for a common purpose. Our clinic filled instantly, so overflow patients were placed in our sunroom and the dining room of the neighboring lodge.

Most patients’ wounds were consistent with blast injuries from the high velocity avalanche. Clinicians at EBC had provided marvelous care, and our team furthered treatment with our available resources. We placed a large piece of white tape on each patient’s chest and marked it with his or her name, presumed injuries, vital signs, and drugs administered. Although my training had prepared me to deal with such crises, we lacked subspecialty care, access to blood products, and imaging diagnostics other than ultrasound.

Yet we were lucky. The weather cleared, permitting same-day evacuation of all patients down to the nearest hospital in Lukla. As the last helicopter departed, our team determined that we had evacuated 73 patients, ranging from a hypotensive patient with multiple extremity injuries to the “walking wounded.” The crowd celebrated our united achievement and then respectfully dissipated into the cloudy afternoon.

Wilderness medicine, a sub specialty of emergency medicine, is practiced in austere environments with limited resources and therefore naturally intersects with disaster medicine and global health. It draws on skills that any medical professional might one day require to ease suffering and pain, whether in a hospital or clinic or on a remote vacation, airplane, or isolated country road. In part because of the scarcity of resources, wilderness medicine is as much an art as a science. A first responder at EBC, for instance, had ingeniously fashioned a femur traction splint out of a tent pole, padded preformed splints, and duct tape. By necessity, creativity flows. When required, simple materials can be sculpted into lifesaving devices.

With no laboratory and limited imaging capabilities, wilderness medicine physicians focus on the history and physical exam, spending far more time in contact with patients than an emergency physician in a high income country generally can. In Pheriche, I carefully palpated the length of each patient’s bones to determine the pretest probability of a fracture so that I could appropriately allocate scarce resources. With no surgeons and a minimal drug supply, analgesic medications became first line treatments. As I protected my patients from the bitter temperatures, I attempted to provide whatever comfort I could in this harsh environment.

As a team of three physicians, two clinic managers, a photographer, and a cook, we could never have given the massive influx of patients the quality of care they deserved. So, upholding our Hippocratic Oath, we did not “fail to call in [our] colleagues”  medical and non medical volunteers alike. Members of our suddenly expansive team ranged from a physician from EBC and trekkers and villagers with first aid training or medical backgrounds to people carrying stretchers, lodge workers distributing tea, and volunteer administrators recording names. Everyone gave their time without hesitation and overcame enormous stressors, time pressures, language barriers, and difficult working conditions. Though emergency medicine anywhere thrives on a team effort, the smooth collaboration of such a diverse international team in this small remote village was unlike anything I’d ever seen. The avalanche was a small event in the breadth of devastation, suffering, and death affecting the region. I became one minor player in a disaster response that extended from the moment the blast wave struck EBC to patients’ release from the urban hospitals that received our evacuees.

Far from my home institution’s seemingly infinite resources, I was severely limited in the ways that I could heal my patients. I thus returned to the foundations of medicine outlined by Hippocrates, “warmth, sympathy, and under standing,” dispensing a lingering touch on a shoulder, a hand squeeze, a tissue for wiping tears, or assistance in drinking tea. I realized that the technology that so often invades our clinical in- teractions at home may obscure the humanity that is fundamental to our practice the power of the human touch or the listening ear. Even in Boston, it’s these human moments that I remember most after a clinical shift, and such experiences are what will remain with me after the tragedy in Nepal, reminding me of the art, humanity, and teamwork inherent in the medicine I am privileged to practice.


 

Himalayan Rescue Association Nepal

Dhobichaur, Lazimpat (North Gate of the Royal Palace)
P.O. Box No. 4944,
Kathmandu, Nepal
Phone: +977-1-4440292 / 4440293
Fax: +977-1-4411956
E-mail : hra@mail.com.np

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