Everest Marathon medical report 2013

by Dr Wendy Dodds

I had followed details of the Everest Marathon, ever since its inception in 1987 and had often thought about running it, but never quite got round to it.   In January 2013, Diana used her persuasive powers to get me to be Chief Medical Officer, though my initial thoughts were to be one of the 5 ‘jobbing’ doctors, enjoying the experience without too much advance effort.  Having cleared the indemnity hurdle with the Medical Defence Union, I was very pleased that Kam Mom, the chief Pharmacist at the University Hospitals of Morecambe Bay NHS Trust and Liz Holdstock, Dispensary Manager agreed to supply the required pharmaceuticals.

The initial preparatory work was not onerous, clearing those over 65 (who I was confident would be far less trouble than some of the ‘youngsters’) and getting in touch with a few potential participants with minor medical problems.  Dave Buckler, previous and future CMO, was a great help in providing advice in the initial months of preparation and answering my final queries in the days before departure.

The most important medical element was the mix of the team and we arrived in Kathmandu with a combination of medical skills which complemented each other perfectly.  Based on previous trekking experience and work with sporting groups, it is general practice skills which are paramount and the four doctors with this experience brought additional expertise in sports medicine and trauma.  The two hospital based doctors brought additional skills, including altitude experience, providing an excellent combination to cover most eventualities.  Added to medical skills were the essential common sense and good fitness levels, ensuring that there were always 6 functioning doctors, apparently not always the case in previous years.   Our first medical meeting took place in Abu Dhabi airport during the long wait in transit on the way out.  This gave us the chance to introduce ourselves and go through the theoretical working arrangements in Nepal.  The plan was always to be flexible and adapt according to circumstances.

The first morning in Kathmandu was initially spent initially with everyone, going over important hygiene matters with Helen emphasising important aspects of altitude and acclimatisation.  Then, in our 3 groups, each pair of doctors went through the medical details that had been provided by all participants, checking accuracy and omissions.  Despite doing this rigorously, it was surprising to learn over the ensuing days and weeks that there were still a number of non-disclosures and failure to inform when self-medicating, despite emphasising the importance of this ( 2 used Diamox without notifying us).   The fact that two of the participants bore an uncanny resemblance to Richard Branson and Daniel Craig was not recorded on their medical cards but their activities were closely monitored!

The cancellation of the fun run, due to demonstrations linked to the forthcoming general election, allowed us an afternoon to familiarise ourselves with the stretcher pack, hyperbaric bag and go through the medical packs.  We all experienced the hyperbaric bag;  at a previous marathon an ‘accompanying person’ had had to go in with the patient to keep them calm, though it would have been a tight fit with two!   Both the stretcher pack and the hyperbaric bag were impressive pieces of kit which we were grateful to be taking with us. In the middle of this we had our first medical ‘call-out’ when a competitor in Adrian’s ‘special Olympics’ ‘cracked’ his head as he and his 3 legged partner dived for the line.  Fortunately steristrips sorted this, though those hearing the head hit concrete were almost as traumatised as the injured party.

Hyperbaric bag with one brave doctor inside
Hyperbaric bag with one brave doctor inside

After our two nights of luxury at Hotel Shanker, we had a ridiculously early start to the airport to ensure being ready for the first flights to Lukla.  Rather than the potentially frightening experience of one of the ‘scariest journeys in the world’, this turned out to be an exhilarating flight.  We had our first experience of lemon tea and more lemon tea, while the troops re-assembled and our bags loaded onto the yaks for the journey to our first resting place in lodges at Phakding.  The second day of trekking covered 800m of ascent and brought us to Namche Bazar where we were to enjoy our final 2 nights in lodges, before the camping began.

A medical barrel had been left here 2 years earlier so we checked the contents and decided what we would carry on with us, decanting this into a somewhat smaller barrel.  We decided against taking the interosseous infusion set as rather than the expected quick firing access with which some of us were familiar with, it required slow steady drilling which none of us felt confident to use for the first time.  We were provided with a mixed collection of oxygen cylinders, with an even greater mix of regulators and hoped that we would not be called upon to use these often.  Apart from retail therapy there were visits to the Sherpa museum and the Everest View Hotel.  There was a leisurely outing on the Thamo loop to experience the final 6 miles of the race route, cruelly beginning when in sight of Namche but turning away for 3 miles before heading for ‘home’.  We made contact with the medical station run by a solo doctor, who kindly showed us round and was a potentially useful contact should we have need of assistance on race day, though the climb to the aid post was enough to prevent all but the fittest of patients from visiting.

Leaving Namche the pattern of the days were set with yaks being loaded with kit bags before breakfast and then the groups setting off behind.  Each day one doctor acted as ‘sweeper’, taking up the rear with a medical pack being carried by the medical Sherpa, with the stretcher pack, hyperbaric bag and an oxygen cylinder to hand to deal with anyone in difficulty.  We met the cook teams for lunch and, after fantasising about chips, they were provided at our first idyllic riverside venue.

Khumjung was our first camp and it was good to be eating in the nearby lodges so we only had to retreat to our tents once we had filled our Sigg hot water bottles and were ready to sleep, after reading and talking in the lodge.  At 6.30 am we were greeted with a warm towel and bed tea, which revived us enough to pack our bags and have them ready to go before breakfast.  Unfortunately one of our marshals was unwell at our second camp in Dole, so descended with his wife to Namche.

A relatively easy day brought us to Machermo where, due to a slight change in plan and threat of severe cold at Gokyo, we were to spend 4 nights, with a day trip to Gokyo.  Unfortunately one of the group had a recurrence of an existing condition that had been in abeyance for over a year and, for safety reason,s we had to arrange a helicopter evacuation for the next morning.  This was also the occasion of the only ‘night’call when a tummy upset resulted in a tent call;  fortunately this could be dealt with from the tent and it settled promptly.  Because of difficulties with phone reception we were very grateful that ‘Captain’ Chris of the Ghurkha regiment was able to lend us his satellite phone to contact Mountain Experience in Kathmandu who provided an exemplary service in organising the evacuation.

The first helicopter evacuation
The first helicopter evacuation

The trip to Gokyo was very rewarding with many completing the ascent of Gokyo Ri, after which the marathon was going to appear easy!  Most visited the medical post at Machermo and listened again to the advice on acclimatisation, which re-enforced the message that we had been giving since leaving Kathmandu.  The following day one of the group, who had been having difficulty acclimatising, began to experience symptoms of HAPE and so another helicopter evacuation was arranged through Mountain experience via Chris’s sat phone.  Because of the difficulties with standard phones it is recommended that a satellite phone is leased for the next Everest Marathon, to facilitate communication.

Machermo medical post
Machermo medical post

From Machermo we retraced our route down the valley returning to our lunch spot by the river before climbing to Kangjuma, where the attraction of the bakery was too tempting to overlook.   From here it was to be a reversal of the marathon route for 17 miles at a leisurely pace.   The first serious stop was Tengboche, with another compulsory bakery stop and the opportunity of visiting the famous Gompa.  We descended to Deboche with views of Everest and our campsite faced eastwards ready for the morning sun over Everest.   Another leisurely day passed the checkpoint at Pangboche before reaching our camp at Pheriche where we arrived early enough for a cold water wash and where visited the medical post.

There followed a tough day with over 600m of ascent to Lobuche, passing the Everest memorials en route.  Most took the advice of a rest day, though a few non-runners made the trip to Kala Pattar, from where there were superb views of Everest and Nuptse.  Two stayed half way at Duglha overnight before coming on to Lobuche, a wise move to break the journey into two 300m ascents and allowing recovery.   Another two returned to Pheriche, one with on-going acclimatisation problems and one with injury.   Lobuche was where the medical team divided to allow Helen and Alistair to reach their race day posts, followed by Ruth early the next morning.  Simon kindly stayed until lunchtime so that, with 3 of us doing the pre-race medicals, we finished ahead of kit checking.  Paul and I accompanied the runners to Gorak Shep, though two had opted to start at Pheriche and one was sadly not well enough to start but was able to walk back to Namche after overnighting in Pheriche.

A few struggled to get up to Gorak Shep and there were two new cases of GI upset en route, not ideal within 24 hours of an arduous marathon.  There were interesting challenges in the lodges, threatening to do more harm than any of the rough bits of the course.  One of the latrines was so icy that life and limb were threatened, whilst another lodge was a ‘work in progress’ such that there were regular gaps between the floorboards, not wide enough to fall through but enough to cause damage on night time excursions.

On race day Doctor Paul stormed down the first three miles ahead of the runners to help man the first control post at Lobuche.  Meanwhile a helicopter was almost called to evacuate a runner who ‘failed to get out of bed’, only to learn that he was lying-in to avoid the sight of breakfast.   To the sound of ‘When the saints…’ from Doug’s bugle, the runners were off at 6.30 sharp.  After packing away the bugle in Doug’s down jacket, I found that the sweep team had left me behind so it was a sprint to catch them up, followed by a SLOW descent to control post 1 at Lobuche.  Noeline had done a marvellous job assisted by Dr Paul and there were no medical events so far.  I accompanied Noeline to control post 2 at Duglha where all the runners had safely passed safely through, so left Noeline to breakfast with Ginny whilst I ran on to Pheriche, only to arrive 1 minute after Dr Simon had left with the sweep team.   I caught up as they began the long haul through the linear village of Pangboche, where Yael was ably running the control post.  Leaving the 2 tail-enders and our one walking wounded with Dr Simon, the sweep team proceeded, catching the next ‘tail-ender’ after we had crossed the river but before the climb to Tengboche.  There was a marvellous welcome by Dr Ruth and Adrian with rice pudding and chocolate.

On the descent an awkward fall by the ‘tail-ender’, though not serious, did cause a delay but the biggest delay was before the next river crossing when our yakateers lost control of their charges:  the medical Sherpa stopped us and rushed to help with one lively yak last seen hurtling towards the river with 6 purple bags strapped to it.  After a 10 minute delay it was safe to cross before the long haul to Kangjuma where Dr Alistair and Geoff were manning the control post.  We had to push on if our ‘tail-ender’ was to be in with a chance of getting through the final cut-off above Namche.  Despite a valiant effort he was timed out by Bruce at Chorkhung and I was left to chase Pete on the final stretch.  The loop proved a pleasant surprise, meeting and greeting those on the homeward stretch, and it was lovely to see Pat beaming from ear to ear, saying what a marvellous day she had had.  They were coming through thick and fast, young and not so young.  I thought that I had seen the last but arriving at the last control post at Thamo, where Hilary was doing the feeding and watering, there was a weary man lying on the ground summoning up energy for the final stretch.  He did valiantly walking quickly but not able to run those final miles.  The Namche gompa came into view through the low cloud;  a hop, skip and a jump and the finish was in sight, with Dr Helen there to see in the final runner after a long day on the finish line.  No major medical events on the day, though a few bumps and bruises and a few sore knees.  Two nights in comfortable beds in Namche was the medical treatment of choice before the final haul back to Lukla.

Nit picking, fortunately runners not affected!
Nit picking, fortunately runners not affected!

All drugs that would have expired by the time of the next event in 2015 and all parenteral medications were donated to the medical clinic at Namche.  Despite having acclimatised it was still an effort carrying two bags of supplies up the hill. ‘No sweeping required’ was declared by our leader, though there were a few aches and pains en route and one of the helicopter ‘joy riders’ who had preferred a 10 minute jaunt to a day of walking was not too well on arrival in Lukla.  All survived the early morning flight to Kathmandu and soon we were relaxing by the pool where it did not take long to learn that swimming at altitude is almost as hard as running.   Whether it was the spread of the Khumbu cough or the pollution in Kathmandu there was a lot of coughing and spluttering on the flight back to Heathrow, but all survived the journey, though at least two of the doctors coughed and spluttered for several weeks.

Interestingly, shortly after our return there was a report in the popular press about the findings of a team in Pisa, Italy, who claim it is possible to predict those likely to experience AMS when progressing to higher altitudes based on O2 sats and heart rate at 11,000 feet.

A huge thank you to Helen, Ruth, Simon, Alistair and Paul who made the experience so enjoyable and helped to make the work go easily (?) and smoothly.

 

The medical team at Kangjuma
The medical team at Kangjuma

What about the stats?

24 episodes of diarrhoea +/- vomiting

17 with symptoms of AMS, 12 mild responding to symptomatic treatment (paracetamol, fluid) and in 2 cases given a single dose of Diamox), 4 moderate treated with Diamox and one case of HAPE requiring helicopter evacuation from Machermo.   [I think the itinerary was planned well, to allow acclimatisation to occur as one commercial trip to Everest base camp in October required 25% of a group to be evacuated by helicopter.]

14 cases of upper respiratory tract infections, a few requiring antibiotics though most responding to symptomatic treatment (thanks to Helen for advising that a supply of Lemsip should be taken).

4 episodes of minor trauma (2 sprained ankles, blisters, laceration and a few non-documented sore knees treated symptomatically)

7 ‘other’ conditions (2 cases of painful haemorrhoids – so the homeopathic Pilex cream purchased in Kathmandu came into its own, 2 cases of low back pain, an allergic reaction, dental abscess, skin rash)

I looked at the diarrhoea cases to see if they linked with how water was treated, but information from only 2 groups was available.  Of those who DID NOT report diarrhoea, the majority were using more than 1 method of ‘sterilising’ water, mainly boiling AND filtering /treating with the chlorine dioxide drops provided, though a few were boiling, filtering and treating with the drops provided.  BUT those with diarrhoea had a similar mix of treatments so the jury is still out for the ‘best’ method of treating drinking water.  It is possible/probable that the diarrhoea, at least in some cases was ‘food borne’ rather than ‘water borne’, definitely the case for some lodge soup in Lobuche.  Despite daily reminders to ‘gel’ before eating, it is easy to slip back into ‘home’ routines.