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Medical Report
By Dr Tim Baker

PREPARATION

The Everest Marathon is an extreme achievement in every sense; extreme environment, organisation, teamwork and personal achievement. From a medical cover point of view this began with a fantastic team who were fun, enthusiastic, professional and brought extensive expedition experience along with a skill mix spanning general practice, nursing, mountain & altitude medicine, sports medicine, and emergency medicine. In such an event as the Everest Marathon communication skills are as important, if not more so, than clinical skills. I was tremendously fortunate to be able to bring a team together with so many professional and personal skills.

The medical team were Dr Bill Morgan, Dr Judy Parsons, Dr John Tanner, Dr Sarah Wysling, Kate McEwan RN and myself. Protocols for medical management were taken from the most up-to-date sources I could find and I summarised them in laminated A5 for the medical team and group leaders. These flowed from a risk assessment (Bufo Ventures) and included authoritative guidelines in altitude medicine, AMS score sheets in English and Nepali, emergency evacuation procedures, diarrhoea, marathon medicine, fluid management, assessment of collapse and CIWEC clinic guidelines.

Each doctor and group leader kept a daily log-book to record notes to refer back to if required.

The chief medical officer (CMO) is tasked with sourcing equipment and medicinal supplies for the event. In previous years pharmaceutical companies had given sponsorship and/or supplies. This year, in the current economic climate, I was only able to attract minimal support, despite having had advice from previous CMOs, contacting upwards of sixty companies and using every opportunity I came across over twelve-months.

I was eventually able to source all the medicines at wholesale prices through the willingness of a pharmacist and wholesaler keen to support the Everest Marathon Fund any way they could. Unused medicines were either donated to Khunde Hospital or the Namche dental clinic, and those still in-date for 2011 are packed ready to go.

Equipment from 2007 was cached in Kathmandu and Namche and included an excellent backpack-stretcher, a variety of aircast braces and miscellaneous items. Oxygen was sourced locally in Kathmandu and the company Mountain Experience provided two hyperbaric bags which we tested before use. I sourced medical bags and some essential kit, and we also had emergency resuscitation equipment donated from various sources. On advice from earlier events each group (white, red and blue) had a medical backpack (carried by a medical porter) and a belt-pack (for the doctor on-call), as well as having a small blue barrel each (containing oxygen, more equipment and medicines) for re-supply each evening. In case of inspection in transit all kit was listed.

KATHMANDU

The hotel was excellent, with good facilities and reliable food. Here the medical kit was re-packed for the trek and we familiarised ourselves with equipment, oxygen and the hyperbaric chamber.

A morning was spent meeting the groups and everyone had a medical check-up. Each participant was given an A5 medical card where their details and medical history were checked and where entries were made for the duration of the trek. We learnt of several pre-existing conditions that hadn’t been recorded on participants’ medical forms, these were useful to know and included Achilles tears, bowel resection and blood pressure problems. These cards were collected in at the end for this report and medico-legal reasons.

Good medicine is about prevention. The group leaders put emphasis on participants having decent sleeping bags and clothing for the cold. Kit was inspected and good equipment was available for hire. The 12kg limit was strictly enforced to protect the porters and yaks.

The fun-run was a good chance to work together as a team. There was a variety of scrapes from falls on the uneven track, one sprained ankle and one person who felt faint but recovered well.

TREKKING

Hygiene was emphasized and everyone was advised to use alcohol gel from the outset. Each evening the group leaders would give a briefing about the following day and this was an opportunity for the medics to have a few minutes to cover relevant issues such as altitude symptoms and the ‘buddy system’ where each tent-mate looked out for the other. As the race got nearer, the group leaders and medical team met several times to discuss issues arising and anticipate potential problems.

Water that had been boiled and treated by kitchen staff was always available in the evenings for us to fill water bottles. These made good hot-water bottles for sleeping bags overnight. Food was ample and simple. It is amazing what can be served in such circumstances and temperatures. The chef and kitchen staff went to great lengths to assure safety and this was appreciated.

Accommodation was in hotels and lodges until we left Namche Bazar and thereafter in tents. These were of good quality and pitched near lodges where we could eat and find warmth, and where individuals could decide to pay and stay themselves if they chose. This was useful if someone was feeling unwell.

The unavoidable down-side of lodges and the buddy-system is that we are all in close contact with each other, and coughs and colds have always spread around each group. The best we can hope to do to prevent this and gastrointestinal upsets is to take care with coughing and with meticulous hand hygiene.

Each day as the groups set off from camp, the ‘on-call’ doctor for the day took the group’s red belt-pack and brought up the rear with the medical porter carrying the red medical backpack and blue barrel. We suggested that the best time to seek medical advice was upon getting into camp before dinner (usually 4-6pm). The CMO made a quick tour of all three groups daily once camped to ensure all was ok.

At Phakding the team practised using the stretcher, pelvic sling, traction splint, neck collar and fracture-cast, and even managed to convince a group leader that one doctor had fallen and broken her wrist.

Pre-race medical checks involved an interview with each runner to address any concerns, Lake Louise score to screen for altitude symptoms, resting pulse, oxygen saturation and co-ordination tests. Blood pressure, chest examination and further neurological examination were performed if there was any concern of pulmonary or cerebral oedema.

We used Sherpa translators and a Nepali version of the Lake Louise score for the Nepali runners, the oldest of whom was 65yrs.

RACE DAY

At the race meeting we established medical and marshalling points:

Helicopters can land at Lobuche, Pheriche, below Pangboche, Tengboche, Chorkhung and at Namche.

Doctors and marshals set off for their posts in good time. The doctor ascending to Gorak Shep had last-minute patients to review the evening before and the morning of the race. Anyone too unwell to run would have been escorted down to Lobuche.

Once the runners were off and past the Lobuche marshal point, the doctor there met with the descending Gorak Shep doctor before leaving with a medical bag and sweeping behind the last runner.

Marshals arranged food and drink at the stations, and they had six basic medical first-aid packs distributed along the course. There was exhaustion and dehydration amongst the runners but everyone who started finished, and there were no serious casualties.

Attempts to offer intravenous fluids from my bag into a runner’s arm were declined, so I had to carry it all to Namche.

COMMUNICATIONS

In previous years most communication has been by finding and talking to each other or by using runners. It was the intention that SIM cards would be bought in Kathmandu that the CMO, group leaders and Diana could use to communicate where there was signal in the Khumbu. In the event these did not all work even in Kathmandu because of network and SIM problems. In fact many of our own mobile phones on free roaming worked in the few places where there was signal, but I have yet to see my bill! Solar chargers worked well to keep devices working. It may be cheaper to purchase basic phones in KTM in the future.

The procedure in case of emergency was that the leader or medic would ensure that a sherpa knew that a helicopter was needed, where it needed to land, who is was for and what was wrong with the patient. They would then use their phone and local knowledge of landlines to ensure a helicopter pickup by contacting Mountain Experience in Kathmandu who could arrange transfer from the airport to the hospital or CIWEC clinic. The Gurkha team carried a sat-phone but this was not needed.

PARTICIPANTS

I think this is best captured by paraphrasing one of the runners’ recollections:

‘The competitors came from a variety of backgrounds but if asked would admit to a litany of distance running and mixed discipline events. Dan from Colorado had given up a M&A job under Bill Gates to commit to full time hill running. Dafydd & Sian had mountain biked at international level. Annie held the British marathon record for her age group. Russell was moving on from single Ironman’s to double and triples in ’10. Neil was looking for a fresh challenge after the Marathon de Sables. Very quickly, my three road marathons seemed like small beer in comparison. However, all shared a certain modesty in the face of a challenge which would test new limits on the body. One would fail to acclimatise and would end up in a Kathmandu hospital. Other competitors would labour under a variety of ailments from the common ‘Khumbu’ cough to sleeplessness, bouts of vomiting, mild hypothermia and even hallucinations. They warned that the hard part of the EM was getting to the start line. It appeared through slow ascent, excellent medical care and often bloody mindedness that most all of us would get to the beginning. The question remained, were we in any state to make it to the end?’

The event was a great success and there were no serious injuries. I’m glad to say that all but two people did make it all the way to the end, better than in previous years, and that these made good recoveries on our return to Kathmandu.

MEDICAL CASES

The event was a success and there were no serious injuries.

Fourteen of the group (19%) were prescribed acetazolamide for AMS during the course of the trek.

Medical Kit comments

• Medical reports from previous events were useful in compiling kit and estimating quantities. We didn’t use much this year and were able to donate quite a lot.
• CIWEC and HRA websites are great resources with local expertise
• ‘Plastic skin’ was very useful for cuts and grazes that needed simple closure and were not serious enough to warrant glue, steri-strips or sutures.
• We took four oxygen cylinders (and didn’t need any this year). I think this is the right amount, allowing one cylinder per group and a spare in case of loss or tampering. There were only two regulators supplied from Mountain Experience and one was taped together. It would be better to have three regulators brought to the hotel all in good condition.
• I bought equipment for airway, breathing and circulation support including OPAs, NPAs, pocket-masks, bag-valve-mask, O2 masks, surgical airway kits, portable chest drain kits, cannulae, iv saline and 10% dextrose. We carried the EZ-IO for emergency intra-osseous access and a CAT combat application tourniquet for haemorrhage control. This is ready for the 2011 EM.

Lessons learnt:

Diamox does not work for everyone. AMS is unpredictable at times. Individuals with mild to moderate Lake Louise Scores can get worse very suddenly. When a person is having difficulty acclimatising and has to descend he/she should be accompanied by a member of the medical team if there is any doubt about their safety. (Some individuals will under-report symptoms or may not test positive for signs of HACE even though it is incipient. If descending involves extra exertion, such as an initial climb to get out of a valley, this could precipitate HACE or HAPE). During the course of the trek fourteen (19%) of the group were prescribed Diamox, eleven in the first week.

It is important to ensure that a person who is suffering even from mild to moderate AMS is accompanied by a responsible adult with whom they can communicate at all times if they have to descend. It is also important that the group leader and/or medic responsible for that person realises that it may not be possible to maintain contact or give further advice once the ‘patient’ has descended, and therefore clear advice with contingency plans should be given to them in advance.

Throughout the trek the medic bringing up the rear of each group would on average have two people struggling each day, often with malaise, URTI or GI upset, needing some encouragement and TLC to get them to the next camp. This encouragement was important, as was discouraging extra rest days which would fragment the group and the medical team, and may lead to the possibility of not being able to rejoin the main group.

Finally, all runners and participants should be made aware of the potential dangers of AMS and that to ignore, conceal or underplay symptoms is putting themselves at risk.

Dr Tim Baker
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January 2010