Vo1.2. 0.2. Issue. I .Jul y. 2005

MMSN Newsletter

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Published ByMountain Medicine Society of Nepal

GPO Box. No. 1477, MaharajgunjKathmandu , Nepal

E-Mail: info@mmsn.org.npWeb : www .mmsn.org .np

'M:MS:N:Newsfe tter'From 'Ilie ([),sftof 'he 'l'resUfent

I cannot believe how time fl ies. But r used to say this asa kid even in 1970. It is true though about time flying,and what seems truer is that as we age, t ime seems tofly fastE! f . Yesterday you were in high school, and befo reyou know it you are now making plans to do yourpostgraduate work in medicine, for many of you this willmean going abroad. To USA or England, perhaps. Youwill be impressed by life there, the fast pace, therecognition that follows . hard work, better fortune,seemingly a brighter life for your offspring and spouse,and importantly a predictable life. Poor Nepal can hardlyoffer you any of these, especially not on the grand,western scale.

Yet for an increasing number of people from Sout h Asiathere seems to be a trend these days to want to comeback and contribute your " two cents" to your country.This is an energizing thought and transce nds t he usualwealth yardstick that is relentlessly used in the western,mate rialistic wor ld. The economy in our neighbouri ngcountr ies is certain ly improving by leaps and bound, andpeople from these countries find it more and moreattractive to return from the west after their t raining.

1 th ink there is also another slightly mystica l factor thatmakes people return and that is that too muchpredictability In the west makes life actua lly boring, thatyour chance of truly being alive are greate r here thanthere. Human beings sense this ananda that results f rombeing truly alive and there is also a natu ral attraction forthe unknown. I n the Kabala, Jewish, sacred, mystical

Vo1.2, No,2, Issue l, July-Dec 2004

zs, 'Prof !Dr. (]JzuUfIia (]Jasnya'text) it says thaJ when God created the world and wasabout to push t he last button, even he wasn't sure. Hesaid, " I hope it works." We puny humans need tointroduce th is amazing concept in our lives to enrich ourown existence here.

WhiCh brings me to my point. I think another way thatyou as young medical doctors can feel the desire to comeback to Nepal to enhance your life experiences will be ifyou do some research in the mountains of Nepal. Thisway you will " bond" with the mountains, have aninvigo rati ng experience, and clearly I think you will bemore motivated to come back. here and do your bit. Th iswill naturally have to be of your own voli t ion.

I know some doctors who live abroad but know moreabout the intricate, daily politics here than you and I . Ido not wish you to be like that. They live there but theheart is here. Wherever you live you have to be there,body and mind. If not this Is an effective prescription fora potential mental breakdow n. The doctors in the aboveexample are trying to have " chid pani, pa pa panl". Makeyour life simpler while you st ill have the chance. Join theMounta in Medicine Society of Nepal and get involvedwhole heartedly and factor the unknown, theunpredictab le in your own lives to make this life a tru lyworthwhile experience. Good luck.

Buddha Basnyat MD.President

(s. (/)r. Soni Snvastav

It came as a surprise when Prajan asked me to edit th isissue of t he MMSN newsletter. Afte r all, what do I knowabout mountain medicine? Which is a sad th ing, becausethis feeling is generally shared by many in my generationof young doctors. Here we are, enthusiastic youngdoctors determined to make a mark, dreaming about adifference -making career in the US and holidays in theAlps. When in fact, we can have both right here in thiskingdom nestli ng in the lap of the Himalayas. By nomeans am I saying we shouldn't go abroad•.What I amsaying is most of us haven't realized the vast untap ped

career fie ld we have right on our doorstep. And if wehave realized It, we're too lazy to take the Initiative to doanything about it.Fortunately this is changing, and MMSN is a major steptowards producing awareness among Nepali doctors thatwe don't need fore·ign doctors to come and treat in ourmountains. Did you know that when doctors are neededat high altitudes, foreign doctors are paid massivepaychecks in dollars or euros to attend thosecalls?Mountai n medicine in our country hasn't been establishedyet as a definite career opt ion, but wtl y not? Certainly

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not because it's not needed. wa6t' of awareness, oftraining opportunities, perhaps. But' surely"not for wantof interest? ' .MMSN strives to create this awareness and trainingopportunities for interested doctors. This doesn't meanthat we expect everyone to make a career in highaltitude medicine. In the near future we expect to have agroup of doctors who are well equipped to work at highaltitudes, when the need arises, or perhaps for a fewmonths a year, while the rest of the year they practice at'normal' lower altitudes.If you are,a young doctor (young at heart) who is lookingto widen your horizon, looking for new experiences,perhaps looking to experience and serve a bit of yourhome country before you set off to far off lands, you arethe doctor we are looking for.

t · Vo1.2, No.2, Issuer, July-Dec 2004

In this second issue of the MMSS newsletter, read aboutthe experiences of our MMSN members as they treatedpilgrims and conducted research at Gosaikunda, Dr.Puncho Gurung as he conducted a house call high. into.the mountains and Dr. Prajan Subedi who Madegorgeous new friends at Everest Base Camp, and manymore, with a bit of general knowledge on medicine athigh altitudes thrown in.I hope you will enjoy reading this newsletter , as I end,special thanks goes to Dr. Buddha Basnyat and Dr.Pritarn Neupane for inspiring leadership, and to Dr.Sanjai Yadav for helping in the formulation of thisnewsletter.Climb every mountain, bu~ slowly!

A memorable callA house call in Nepal's Himalayas

The young man came into the Himalayan RescueAssociation aid post in Manang at midday. He asked meto go and see a man in a nearby village who had beensick since the day before and was unable to move. Istuffed my medical gear into a backpack and followed theman to the horse that he had brought along, and, after atwo hour ride, we finally arrived at his village.

We walked through the narrow alleys to the patient'shouse, where a cow qreeted us on the ground floor, andclimbed the wooden staircase to the terrace to find amiddle aged man lying still on a mattress. Though inagony, he tried to smile on seeing me. The history of hisailment and subsequent physical examination made methink that he had either acute cholecystitis or liverabscess. He looked pretty sick, so I started treatmentwith intravenous fluids and antibiotics; followed bypethidine, which made him doze off for a while.

He needed an abdominal scan, and the nearest placewhere it was available was four days' walk away.Helicopter evacuation seemed unfeasible as this is tooexpensive for most Nepalese.The only viable option wasto fly him out from the local seasonal airfield, which wastwo hours' walk away. After telephone calls to the city,

zs, CDr. Punclio qU1U11{j

we found out there was a plane flying in tomorrow. Thiswas our best bet. By now it was apparent that my patientneeded medical supervision until he could be flown out tothe city hospital, and I sent the young man back to theaid post to get extra drug supplies.

Strong winds started in the evening, and it snowed lateinto the night. This had stopped by the morning, but thewhole valley was now covered with thick fog, and itseemed unlikely that the flight would come in. After a fewhours, however, the fog started to clear, so we put thepatient in a large basket, his legs dangling from two holesin its side, and started carrying him to the airport. Theflight came in when we were halfway along the trail. Twoof us rushed ahead to ask the , pilots to wait, and theparty finally made it just as the pilots, impatient to leave,were preparing to take off. To save a few preciousminutes, the sick man was lifted over the perimeter fenceof the airfield.

A few days later, I got the news that my patient had hadliver abscess and was recuperating in a hospital inKathmandu.

Puncho Gurung, volunteer physicianHimalayan Rescue Association, Nepal

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?rt?rtS:N'Newsletter Vol.2, No.2, Issuel, July-Dec 2004

APD and AMS at 3900m

~ :Matiram Pun, «». CBliupesli 1(fiat[~a

Nobody is immune to AMSabove 2000-2500m.

It is not related to physical fitness or gender.

Acute Mountain Sickness (AMS)

Acknowledgement

We are grateful to Himalayan Rescue Association ofNepal (HRAN) and Mountain Medicine Society of Nepal(MMSN) for supporting us. We would also like to thankMr. Govind Basyal, the senior medical staff of HRAN andMr. Surendra Khanal, a medical student and member ofMMSN attending the Health Camp, who helped in themanagement of the case. Professor Dr. Buddha Basnyat,the president of MMSN deserves our sincere gratitude.

accompanied with all the necessary medical kits. With theconsideration of severe AMS, we were about toadminister Dexamethasone (intramuscular) and Diamox

. oral if possible. In the meantime, Dr. Bhupesh joined usand took detailed history of the patient with othermembers. She was known case of Acid Peptic Disease(APD) and had been admitted at Dhunche Hospital withits aggravation on the way to Sacred Lake. She hadcontinued her mission despite all that and more than thatwithout taking food. So it was the case of, basically, APDwith hypoglycaemia further aggravated by mild AMS.The immaturity and haste in the case diagnosis andmanagement can sometimes be upside down. Foremostimportance, that everyone in medical science agrees, is

careful history takingand its analysis. Dr.Bhupesh was rightlythere like a consultantand carried out hisresponsibility smartly.She was given Dextroseintravenously andassessed. When sheregained theconsciousness, she wasgiven Antacid gel (thatshe was carrying)Ranitidine and Diamox.Since she was havingsevere pain, we gavel.rn Voveran as well.With the propercounselling, we alsostrongly advised themto take her down.

Almost all the members of the group complained ofheadache. She was carried down to the height of 3600m(Cholangpati) in a Hotel. She could not make it to theSacred Lake!

It is a syndrome complex of (a) headache (b) nausea (c) dizziness (d)sleeplessness and (e) fatigue. Of these, headache is the cardinal symptom.

Early AMS feels exactly like alcohol hangover. It is also heralded by thefeeling of deep inner chill or a sense of not being well.

Late or advanced AMS denotes increase in severity of the above mentionedsymptoms.

A typical picture will be: a porter arrives at a high altitude carrying a heavyload. Immediately, he goes in a corner of a dark room and rests therecovered with a blanket from head to toe. He doesn't want any tea or snacks.He starts to throw up once in a while. When asked, he says he has the worstheadache as if somebody is hammering a nail into his forehead and he feelst~rrible. He is still huddled in the corner at dinner time. When friends bringhim food, he does not even want to look at it. When asked, he says yes, Iwant to go down.

It was August 27, 2004; I was equipped with a 3S-80mm(zoom) Pentax camera. We were enjoying the sunset inthe far N6lth-West Tibetan Plateau from the hotelpremises at an altitude of 3900m of Nepal Himalayas.The trekkers and Locals say we can see the Great Wall ofChina from the Surya Peak (SOOOm) in fair weather.Dhunche, the headquarter of Rasuwa district, seemeddeep in the gorges of Langtang and Trishuli rivers whileLangtang Lirung Himal was standing with the majesticguardianship on the left. As the sun slowly slipped intothe leeway of sky and Tibetan plateau, in the Northhorizon, the pilgrims were coming in groups. The elderly'and children were being carried by the porters and somewere on horse back. One of the groups of women whocame on horse back,were residents ataltitude (1400m) ofNepal Valley-Bhaktapurproper.

Half an hour after thepilgrims' arrival, therewas much khailabailain the hotel. An HRAN(Himalayan RescueAssociation Nepal)official told mesomeone was having aserious problem. In themeantime, Surendratold me a lady hadacute mountainsickness (AMS). Hehad already told them:Descend! Descend !!Descend!! ! That is mainstay of management of mountainsickness which Prof. Buddha taught us. They hadcomplied. Actually one woman who was on horse backhad fallen unconscious within fifteen minutes or so aftershe had been there.

With the due consideration of the seriousness of thecase, I promptly consulted Dr. Ramesh and Dr. Bhupeshand went down to where she had been carried. She wasthe leader of their group and had not taken anything thatday. All of them were there from the height of 1900m(Dhunche) to the height of 3900m in a day for which wetook two days. Everyone was saying mountain sicknessand I was also equally convinced. Govind Basyal (SeniorMedical person of HRAN) and Surendra Khanal

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j'vt:A1S:N'Newsletter Vol.2, No.2, Issuel , July-Dec 2004

INTO TH IN AIR====~

It was dreams come true for me. I was full of mixedfeelings- a bit anxious, a bit worried, a bit nervous and a 'bit afraid when I was asked to accompany a team ofresearchers. going to Everest Base Camp (EBC) fo r astudy. To tell the truth, I was happy like anything to getthis opportunity. On top of everything, I was curiousregarding responsibilit ies in the study.

"Hello there!" It was Dr. Keith Burgess greeting me afterI reached the hotel where he was staying with the rest ofthe team. The team included Dr. Burgess, his daughterKatie, Dr. Phil Ainslie and Phil's girlfriend, Leanne. Ofcourse, I was supposed to jo in them.

Saturday morning it was, when we all met first. The nightbefore I had been on duty and it was quite a busy one.So I was feeling sleepy. After a short introduction andbrief discussion regarding the study I came to know myjob was to collect arterial blood sample for analysis atKathmandu and EBC. In total the re were three sets ofstudy- sleep study, ventilatory response and arterialblood gas analysis. All of these were supposed to bedone on the same subjects at Kathmandu and EBC. Thesubjects were none other than ourselves and some othertrekkers who were willing to help us. The analysis of thedata is supposed to give an idea regarding the predictionof period ic breath ing at high altitude.

Whatever might be the goal of the study, the only matterthat was worrying me WqS taking arterial blood samples.I had thought of going to ICU to see the procedurebefore the team arrived here in Kathmandu because Ihad got some clue when I read the proposal. But it never'happened. Now I was there; stranded. And to add to myworries I was expected to do the procedure outright!

Feeling sleepy, never done the procedure before; I pulledmy guts together and decided to give it a go. On the firstprick the blood rushed into the syringe. Thank God! I hadseen a senior doing the procedure some two years back.It helped a lot. "We!1 done!" I got the reward. Afterspending some t ime there, I came back home.

I just went straight to bed as I was ve:.ry tire d. It W2 S

only' few hours of sleep when my eves were open I couldIeei. "Wow!! } did it." I was over .vhelmed with j oy,

P. week pas;,Es I'V ! : ~. our b25 ~ li r ;:; d=; ::. cal ect ion atr\;;tn manc\ J. I t"'£A':i i.ecor -e (jul' :: c~rl f I G : -lt ir. cc li re: : ;ngtn e art erieI bleed.

It was the time to head for ESC. Dr. Burgess and hisdauchter had planned to go with an expedit ion team sothey left two days earlier. I, Phil and Leanne left twodays later. We were doing independent trekking andtaking tea-houses on our way up.

It was fun going with them. It took me quite a while toget adjusted with them . But I hope I did it well. I wasfeeling a bit lonely till I reached Namche Bazar. There Ifound a friend. She is gorgeous- regarded as one of thebest in the wor ld. Whenever I felt lonely walking alongthe trail , I would just look around at her and that's it ; Iwas ok. We were together till Dingboche. From there Ihad to go on and she had to stay. My fr iend there wasnone other than Mt. AmaDablam!

We took our time while going up there. We enjoyed thebeauty of nature. Sometimes running down the hill, attimes taking a nap in the yak farms and talking to eachother about past t rekking experiences; we had no ideahow those nine days passed. After walking nine daysfrom Lukla we were at the EBC.

The air was thin ; tents were colorful; people werefriendly and from various countries; mountains were allaround; the weather was chilly and windy-it was ESC.

We started work the day after we got there, we meantbusiness. Everyone was doing the ir part smoothly. It wasme who was struggling. High altitude; chilly weather;constricted arteri es; thick blood; too many peoplewatching and it was a 25G needle I was using. Takingarterial blood out left me sweating even at EBC. Nomatter, I used a hot water bottle to warm the artery fora few minutes. I had to do multiple pricks. But when Iwent for a larger needle it did the tric k. It was a loteasier.

We only had to work for a few hours each day. Afterthat, we dispersed. That's when I sta rted to feel lone ly. Iam the kind of person who can sit alone for hourswithout feeling lonely. sut it was not the ca. ~ there. Ihac to find a friend. And four.d plenry there-whiteg!i:.it -ening mountains, rocks standinq on t~· ::: iC-2 andKhurnbu icefall- all became my fr iends. V:hE.r;~' \'e : Istar ed tee!ir:'] k'r ~ e ly I had thelr cornp ".y th ;'C\u~J :'out-be

it G? ·;· or 'H;::t:. ~:-:~ re were :; ff:. ;: f'I2oaii f~xpe~ i:; 'j l l teamswt·,':. -e I t.. .:;ec L) 9 :1 ( :-: a : ~d off C' .- 1 talx fe" r-curs. OfCJur.;2 Sn~ r~ E:; were ai -. :'} 0; there ../;t~ , me.

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5WJvfSN NewsletterTime at EBC just flew. We were done with our datataking and it was time to head down. But I never felt likeI was spending my nights at -20 degrees Celsius. I wasstaring to enjoy it. I wanted never to leave the place. Itwas the first time I had made so many friends in such abrief tim e. I didn't want to break their hearts by leavinqthem alone there. But it wasn't meant to be that way . Ihad to come away . I did.

Heading downhill was also fun, in it's own way. The joyof returning home, meeting old friends and eagerness toshare experiences just kept me sparkling. I could notwalk because I was running all the time. It took only four

Vol.2, No.2, Issue1, July-Dec 2004

days to reach the place from where we could fly back toKathmandu (Lukla).

It had been a good learning period for me. I learnt - towork independently, to work as a team, to travel withoutfriends or family, to make new fr iends, to accommodatewith people who are different in many aspects (country,culture, thinking, attitude etc.). Most of all I got a greatchance to know myself, my capabilities and myboundaries. Thank you, MMSN, for this odyssey.

The 2061 G.oshain Kunda Trip

~ «». CRg.mesfi Su6edi

Going to the Goshain kunda has always been fun. I cantsay if it is the grave face of the lake or the magnanimouspresence of the mighty mountains that enthralls theexperience of each such trip, but it is for sure the colorfulpresence of the pilgrims that throng the holy lake at

Janai purnima that adds life to the whole experience.

High up there where the air is thin , playful mists veilwith tantalizing gait the holy lake which lies there withunearthly calm, spreading eternal peace with each ripplethat arises in it.

Do 5 and don't 5 at high altitude

Do Don't

1. Listen to your body Attribute headache, fatigue etc. to cold weather orexertion.

2. Drink plenty of safe warm water. (Around 3 liters . Be tempted to drink alcohol. (one can drink while comingper day). Dehydration predisposes to altitude back, that is, while descending)sickness.

3. Let the doctor know if you are taking any medicines. Take any sedatives.

-4. Let the doctor know of your previous illness/ Try to just push yourself. Courage displayed at

surgeries etc. (they might need to prepare the inappropriate occasions is foolishness, not bravery!medications accordingly)

5. Stay warm. Take classic baths. (cold predisposes one to AMS, HAPE)6. Accept your susceptibility to AMS. Assume that you would be struck the last.7. Be prepared to stay behind or return back earlier Be very religious and tough. 'Victory is not reaching the

than the orouo if vou have bad altitude sickness. top but camino back alive'.8. Understand that you are in an unprivileged situation Get frustrated.

and thinos can be less than expected.9. Report as soon as possible to somebody who knows. Present late

10. 10. Don't leave a trekker behind in your group withsomeone who does not speak the trekker'slanouaoe.

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. 9r1.?rfS:N:NewsfetterBut sadly not everything up there is picture perfect. Themountains are not hostile but ignorance about the properway to travel have left many pilgrims with a ratherunpleasant memory, some even close to losing theirlives.

And to be able to help these people is in itself agratifying opportunity.

In response to HRA's request to provide medical doctorsand medical students to run a temporary health camp inGoshain Kunda, MMSN appointed Dr Ramesh Subedi andDr Bhupesh Khadka as medical doctors and Mr MatiramPun and Mr Surendra Khanal as medical students to go toGoshain Kunda.

The Goshain Kunda Health Camp team comprised of thefollowing members: .

FromMMSN:

Dr Ramesh Subedi

Dr Bhupesh Khadka

Mr Matiram Pun

Mr Surendra Khanal

From HRA:

Mr Narahari Bhandari

Mr Bikram Neupane

Mr Govinda Basyal

Mr Khagendra

Mr Kiran Rai

Vo1.2, No.2, Issuel, July-Dec 2004

The team left Kathmandu for Dhunche on the wake ofthe upliftment of a week long Naka Bandah, on 8th ofBhadra. Three days of exhausting yet exciting trekbrought the team to the lap of the holy lake, where theywere surprised to find they were the only team this yearto set up a health camp, unlike yesteryears when theArmy and other organizations also used to set up theirrespective health camps. Now the whole responsibility ofattending the pilgrims lay on our shoulders.

During three days in the Goshain kunda, around 300patients attended the health camp, seeking health carefor various ailments. A primary data of different variablesof all those attending the camp was taken (the details ofwhich is available on the report booklet), which revealedaround 8-10 serious cases of HACE, who after receiving1M Dexona and Oxygen were taken lower to saferaltitudes.

More than 80% of patients attending the camp gave ahistory suggestive of AMS ( which ranged from mild tosevere cases).

. Besides this, service was also provided to cases of acutegastroenteritis, trauma and other general medicalproblems.

An important highlight of our trip was giving continuationto the previous year's research of children in the GK,wherein we collected data from more than 50 childrenattending the festival.

16th of Bhadra saw the team safely in Kathmandu.

Is there a genetic basis for the adaptation ofHumans to high altitude?

~ «». .ftmit.ftrjya{a. a». .ftni{q>andli

Our country Nepal is an amalgam of various races andethnic groups. But we must realize that apart from thebig cities and towns, our populations are not sohomogeneously scattered. Rather, if we look at thedistribution of our peoples before the significantmigrations that have occurred in the last fifty to seventyyears, we can recognize a specific pattern. This patterncan be correlated with the geographical attributes ofeach place. Take for example, ethnic communities likethe Tharus who have thrived in deadly malarious Terai(the low lying plains in the southern part of Nepal) wherehill-bound groups like Brahmins and Chhettris, dared notgo before the advent of DDT, deforestation and as a

result malaria control which began in the 1950's.Likewise, if one goes up north and reaches themountainous altitudes above 3000 m, scarcely will hefind a Khas or Newar village.

Of course, our country has not suffered humanhabitation since the beginning of time. Each of thevarious groups in our country must have set foot here atdifferent points in time: A fair question to raise herewould be- Why did each of these groups choose theirparticular niche? Did the Tharus go on living in the Teraibecause the genetic traits they carry support theirsurvival against fatal falciparum malaria? Do the Sherpaswho reside in the high altitude locales of the Himalayan

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:M~NNewsletterfoothills have genotypes geared towards adaptation tothe hypoxic environment therein? Trial and error overcenturies must have taught each of our various groupswhich location would be the best one for them. But,today with the advent of modern science, we are in aposition to define whether or not the geneticcharacteristics in an individual are the reason behind himbeing suited to a particular environment.

It has been hypothesized that Sherpas might bephysiologically different from the rest of us when itcomes to gehe products that enable survival at highaltitude. Some of these are erythropoietin (EPa),endothelial nitric oxide synthase (eNOS), angiotensinconverting enzyme (ACE) and vascular endothelialgrowth factor (VEGF).

Polycythemia is a compensatory mechanism to sustainoxygen delivery during life at high altitude. EPa, aglycoprotein growth factor regulates the rate of red bloodcell production by stimulating the proliferation anddifferentiation of erythroid precursor cells. Molecularstudies in vivo and in vitro have demonstrated that theaccelerated EPa gene expression is the first step in thepolycythemic response to hypoxia.

Nitric oxide, an essential endogenous vasodilatorregulates pulmonary vascular tone and maintainsphysiological low pulmonary vascular resistance. An

Vo1.2, No.2, Issuel, July-Dec 2004

enhancement of NO synthesis may contribute to greaterresistance to the hypoxic pulmonary vasoconstriction inhigh altitude pulmonary edema.

ACE plays an important role in regulating pulmonaryvascular homeostasis and maintaining electrolyte andvolume homeostasis that are supposed to be crucialpathogeneses of high altitude illnesses like HAPE andchronic mountain .sickness. Pulmonary vascularcompliance and permeability and other cardiovasculardisorders might be associated with changes in the humanACE genes.

VEGF is a disulfide bonded dirneric glycoprotein. It is apotent endothelial cell specific mitogen and permeabilityfactor known to be involved in vascular basementmembrane destruction and angiogenesis. VEGF mRNA ismarkedly upregulated in vitro and in vivo in hypoxicconditions. Several polymorphisms have been identifiedin the regulatory regions of VEGF gene, leading todifferences in VEGF expression in different individuals.

Perhaps Sherpas have sustained the beneficial mutationsin their genes when it comes to the production of thosesubstances, which has enabled them to survive at highaltitudes. The day is not far when having understood thegenes and their natural products necessary for high­altitude survival, we will be better able to cope with thedisease conditions of extreme hypoxia encountered in ahospital or out-patient setting.

MMSN Activities

1. One day Workshop on Mountain Medicine atMohego Building (17th June, 2004)

This was the first workshop MMSN organized andenjoyed massive success in it. We had participants fromNMC, KMC, Patan Hospital and Maharajgunj Campus.This was organized in consideration of impending SouthAsian Conference to be held in Kathmandu on 9th August,2004. The speakers were Dr. Bhupesh Khadka and Mr.Matiram Pun (AMS), Dr. Ramesh Subedi and Dr. BaroonRai (HACE), Dr. Nely Shrestha and Dr. Promish Shrestha

(HAPE) while Dr. Pritam Neupane highlighted on "Highaltitude and common medical conditions". Dr. Anil Panditand Amit Arjyal presented on the topic "Other problemsin altitude that mimic altitude sickness". Prof. Dr. BuddhaBasnyat quided and clarified the confusions throughoutthe interactive sessions. Mr. Govind Basyal, the seniormedical person from HRAN also presented about the lifeand activities at altitude. He along with another HRANstaff also demonstrated the Gamow bag and stressed onits importance as well as technical know-how to use it.The welcome speech was given by Vice-president ofMMSN Dr. Pritam Neupane and it was concluded with an

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9vt9rfS:N:Neuisletterexcellent piece of note on "How to Conduct a study" by

1'.. t4 ....~

MMSN president Prof. Dr. Buddha Basnyat.

2. The MMSNNewsletter (Vol. 1, Issue 1, 'July2004) ,--

The first issue of MMSN Newsletter was launched on 17th

June, 2004 in the MMSN Workshop at Mah~go Building,Maharajgunj. The issue was brought out under theeditorship of Dr. Anil Pandit. This was one step forwardfor our academic activities that MMSN is supposed to be.

3. "Mountain Medicine: Sharing the South AsianExperience" at Hotel Marsyangdi inKathmandu, Nepal ( 9th August, 2004)

The BP Koirala India-Nepal Foundation (BPKF), theMountain Medicine Society of Nepal (MMSN) and theHimalayan Rescue Association Nepal (HRAN) jointlyorganized a one day seminar on "Mountain Medicine:Sharing the South Asian Experience" at MarsyangdiHotetel in Kathmandu, Nepal. There were delegates fromInd ia, Pakistan and Nepal met in Kathmandu to share themedical problems in the mountains of the region. SouthAsia, no doubt, contains one of the biggest bulks of highallitudes-Hindukush, Karakoram and, of course, theHimalayas.

The seminar was inaugurated by His Excellency, Mr. V. P.Haran, Charge d' Affairs, Embassy of India and Co­Chairperson of BPKF. Prof. Dr. Buddha Basnyat, MedicalDirector of HRAN and president of MMSN, Dr. NelyShrestha, Dr. Kaushal K.Sribatava, Prof. Emeritus at theBR Ambedkar Center for Biomedical Research, DelhiUniversity, Delhi, Dr. Vidyasagar Casikar, the Head ofDepartment of Neurosurgery, St. Johns Medical College,Bangalore and currently a consultant neurosurgeon inAustralia, Dr. Thuppll ' Vankatesh, professor ofBiochemistry and Biophysics at St. Johns Academy ofHealth Sciences, Bangalore, Dr. Pritam Neupane, the vicepresident of MMSN, Dr. Sudhir K. Jha, a graduate fromArmed Force Medical College, Pune, and Dr. Abdul JabbarBhatti from Pakistan presented various papers.

The concluding session was facilitated by Prof. Dr.Buddha Basnyat and the topic was "How can we fosterHimalayan research in Nepal?" The Chairperson of HRAN,Mr.Ang Kaji Sherpa, expressed his commitment toorganize such seminars in the future as well. The MMSNis definitely going to play the leading role in suchactivities.

4. Goshainkund Health Camp - 2004 AD ( 30thAugust, 2004)

The Health Camp in Goshainkund is the regularprogramme of the Himalayan Rescue Association Nepal(1If{AN). The joint medical team of HRAN and MMSN was

Vo1.2, No.2, Issue!, July-Dec 2004

sent this year. The principal objective was to help thepilgrims in the Janel Purnima Festival at Sacred Lake ofGoshainkund. The team primarily targeted mountainsickness. Financial support was given by HRAN. MMSNmembers also assessed the prevalence of AcuteMountain Sickness (AMS) among the children (betweenthe age of five and fifteen) with the help of Lake LouisScoring System (LLSS) questionnaire.

S. Research on " Genetics and High Altitude" atNamche Bazaar (29th Bhadra, 2061)

Leading genetic research experts of High AltitudeDiseases, Prof. Dr. Masayuki Hanaoka and Dr. YundenDroma, from Department of Internal Medicine of Schoolof Medicine, Shinshu University, Matsumoto, Japan, werein Nepal for the study of possible involvement of geneticpolymorphism among lowlanders and high altituderesidents. MMSN members,Dr. Pritam Neupane, Dr. AnilPandit, Dr. Dipendra Sharma and Dr. Amit Arjyal alsotook part in the study. They collected serum from thehigh altitude residents of Namche bazaar and fromlowlanders of Kathmandu valley. The samples have beentaken to Japan for genetic analysis.

6. Prof Masayuki Hanaoka delivered talk onpossible genetic involvement in the HighAltitude Diseases especially High AltitudePulmonary Oedema (HAPE) ( 8th Mangsir,2061)

The MMSN organized a platform for all here and Prof. Dr.Hanaoka in the Postgraduate Hall of Mahego Building atMaharajgunj Campus. There Prof Masayuki Hanaokadelivered a talk on possible genetic involvement in theHigh Altitude Diseases especially High Altitude PulmonaryOedema (HAPE).

7. Journal Club of MMSN

The regular feature of MMSN is the journal club that isorganized on first Wednesday of every English month atBasic Science Building.The following people presentedthe papers given there in different dates during thisspan:

• Dr. Ramesh Subedi presented the paper "Efficacy ofLow-dose Acetazolamide (125mg BID) for theProphylaxis of Acute Mountain Sickness: AProspective, Double-bind, Randomized, Placebo­controlled Trial" by Buddha Basnyat et al publishedin High Altitude Medicine and Biology of VolA, No.1,2003

• Dr. Anu Shrestha presented a review on "Gingko bilobaTrials in the Clinical Medicine". The review was based onthe article of Mosby's Drug Consult-2002, CD ROM. Thiswas, basically, about the Gingko biloba vs Actazolamide

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5WMS7V7Vervs(ettertr ial on Alt itude diseases. She gave us a nice insight ofGingko. So this was educational rather than scientifi cjou rnal club.

• Mr. Matiram Pun discussed the artide "The

Va1.2, No.2, Issuer , July-Dec 2004

9. Guest lectures to Trekkers organized byHRAN on Altitude Illness and Hygiene (1stMay, 2005)

As their regular feature, HRAN was running training

www.mmsn.org.np(Site Info)

HomeAbout Us : Introduction I History I Executive Body J Members I Aims I otl}ectiveActivities: COntainsJournal Oub I Wor1lShOp I ConferenceMountain Medicine: High Altitude I Altrtude Sickness I AMS I HACE I HAPE I Acdimatisation I Assesment of Altitude Illness I Treatment d

Altitude Illness I Golden Rule for Ascent I SCoring System or AMS I AMSWo~eet

Mountain DestinationsVisiting NepalTravel Advice : Common Disease I Insect Bites I How to Keep Healthy I Immunization for Adult I High AltitudePhoto Gallery : Mountains I Health camp I Workshop & ConferenceNews & Events : Past I Present I FutureFeedbackSite MaplinksFAQsHelp UsContact UsVisit our website and get in touch with the world of mountain mencioe in Nepal. One of our recent additions is the discussionforum. It was created to make a place where all interested people could learn and share their experiences related to mountainmedicine.

PhysiologIC Basis of High-Altitude Diseases" bycurrent icon of Respiratory Physiology John B. Westpublished in Annals of Internal Medicine of "16November 2004 I Volume 141 I ssue 10 I Pages789·800". This is the review by the legend of thefield more than that it had three responses fromNepal- Prof Dr. Buddha Basnyat, Dr. Anil Pandit andMr. Matiram Pun. I nterestingly all three responsesappeared in the print version.

8. Sleep Apnea Study , at High Altitude (April,2005)

There was one research going on about Sleep Apnea atHigh Alt itude. Dr. Prajan Subedi from MMSN had j oinedit. He spent a week up to Everest Base Camp during thestudy.

program for porters and trekkers. They had asked twodoctors to deliver lecture on Altitude Illness and Hygiene.Dr. Ani! Pandit and Dr. Devlsh Pyakurel took class inHotel Marsyangdi for trekkers and porters on AltitudeIllness and Hygiene

10. MOUNTAIN MEDICINE: Nepali doctors'perspective (on 28th May,200S)

As the dynamics of our society changes, MMSN organizeda conference to share the experiences of our members,to bring to light the research being done, the work at ourhealth camps and the challenges faced by the workers,all Nepali health personnel working on home soil. A not­to-be-missed gathering!

Book Reviewzs, <Dr. Sanjay 'Yaaav

Doctor On Everest: Emergency Medicine At TheTop Of The World-A Personal Account of the 1996Di saster By Kenneth Kamler, MD. Paperback 320 pages,Publisher : Globe Pequot Press

Why climb Everest? Because its there. But what on earthwould a medic climb Everest for? Because medics likeanyone else find that its still there. Each adult 's childhood

aspiration of being on top of the world that is. Dangers inthe mounta ins are the reason not to climb it but it's alsothe reason to climb. In Kenneth's words 'You become akeen observer of nature's grand design and quie tnuances; meet ing through challenges that are sharply infocus is just energizing.' Working as an expedition doctoryou probably see this happening at close shaves.

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'M5IISWWe-rvsfelterDr Kamler is an orthopaedic surgeon in New York andspecialises in microscopic hand surgery. I magine th e nextmoment he is an expedition medic making the mostd iffi cult decisions of what takes human body and mind tofunction at soaring altitudes and saving lives at thegruelling conditions to aid survivors crippled to destiniesof AMS, HAPE and broken bones. Kenneth has nevermarie it to the summit although attempted on fouroccasions with the expedition teams. Each time as hisdream crashes he comes closer to 'His Everest' and...cores so personal and poignant triumph of ' there's morethan to summit',

Told through the eyes of climber himself with loyaldreams of climbing Everest and yet dedicating hisunlathornable compassion to attend the fallen warriors,this punishing recount is an egoless verbaHsation ofemouons ffilling apart that ruggedly looms large into hiswrit ings. Thoroughly entertaining and a real page turner,hi,; is an arduous effort to narrate everyday details likethe f<:let that he used sanitary napkins to keep hisunderwear clean, describes a dinner at teahouse where aSherpa girl with runny nose is able to carry five cups oftea to the table at the same time by placing one finger ineach cup and later the torme nting ironies of finding arn~ · ai"l 'l cboccbar in his pocket between the sighs oftumqer r~ngs and periodic breathings all amidst thed 1illing awareness of yourself messing in the heights ofphysio:ogical extremes. But he stands 'American Dr Sab'in the eves of all alike.

Do you fancy mountaineering a media to port ray anescapist on social crossroads? Where's the dividing linebetwoen first hand frailty of human body where nature isat Its cruel best and human body so unaware of it?

•

Vo1.2, No.2, Issuel, July-Dec 2004

Negotiating his dual role as medic and dimber, Kamlerport rays base camp at the social crossroads depicting theelaborate picture how unceremoniously it blends modernfabrics, commercial gears and hi-f intercom deviceswhile at the same time nourishes stingy yak dung,j uniper smells from the altar and the incessantlyfluttering prayer flags. And the line lies thin when yourun a veritable Emergency Room where all medicalsupplies came in by yaks and you are an observer to thetaxing trauma each passing moment left to the twists ofthe fate.

It's a real life drama, a grisly account of medical disasterin wilderness that graphically reads like a fict ion .DrKamler does not sound stylist in his literary capacity butonerously finds humour in the tell tale of one doctor andyou would wonder at times if he has pot-boiled apretent ious fictive of a God- player making all things rightuntil you close your eyes in refuge to empatt use thephysical pain and frustrations of high alt itude climbingfrom your cosy armchair read.

Although not specifically about the events of 1996, itilluminates new firsthand anecdotes beyond JonKrakauer's 'Into thin air' and should be a follow up if uhave already read one of the Everest disaster books .Kamler offe rs it with unique perspectives of humanemotions, exploratio n, adventure, the thrill of victory andagony all served in one menu. The cliff -hanger saga andglorious accounts of survival in amidst abandonment andstaggering recovery : this is every climber's mouthfulappetizer, but if you are also an avid mountain medic itshould be an id ng on the cake. An interesting read!

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