Pa Nuru Sherpa, come up to the front of class and tell us why you are here,” I said smiling to a group of 24 high altitude Sherpa guides sitting at their make shift desks inside his tea lodge in Phortse, Nepal.
Susan teaches in Nepal
“Teacher Susan, 10 year ago,” he says in his broken English, “Before I take your class, I find stranger high on the mountain. He no walk, no talk. He just laid there like he was dead.” Pa Nuru with trembling hands takes a deep breath, “I scared. I didn’t know what to do. It first trip high on mountain for me.”
Pause. The room is silent. 48 eyes stare back at him, their breaths visible in the cold room.
He continues in a nervous and quiet voice. “We here because Susan will teach us what to do. I know what to do now. I have been to her class for four years. She taught me what to do.”
I swallow hard. I wasn’t expecting that. Pa Nuru had not told me that story before. His story made me feel proud to be standing there. I look around the room knowing half of the new students sitting before me have a similar story to tell. They have been to high altitudes carrying loads of gear on their backs and guiding clients. Some have climbed Mt. Everest more than once, Pa Nuru, more than 10 times, successfully. Sherpa’s have experienced pounding headaches and the Khumbu cough, been bitten by frostbite, rescued dying clients, and carried the dead off the mountain. Some of the dead have been strangers but some have been family and neighbors. They have no medical or leadership training, yet, somehow they have lived through it.
I am nervous now. Like Pa Nuru, I stand in front of class with hands trembling.
I have six days to teach 24 bright and skilled climbing and trekking guides in the Khumbu Valley how to prevent and evaluate altitude sickness. My goal—to teach confidence and competence–to stand up at the end of class, like Pa Nuru, and tell me what is wrong with their sick patient and have a rescue plan?
Pa Nuru interrupts my thoughts and continues.
“We all here because this class important. It will make us all better guides and leaders.” His silver tooth smile shined light upon the Sherpas.
I jump in with breathless excitement. “This is why we are here. You’re all here to learn how to take care of a medical emergency on the mountain,” I said loudly and slowly, slowly because of the English- Nepali-Sherpa language barrier. “Your new job is to recognize altitude sickness before it becomes a medical emergency. Look for small problems before they become big, bad life threatening problems. Listen for coughing. Start talking to your clients and porters. Check to see who acting drunk. That is what this class is all about. It’s a matter of life and death up here and it’s a big deal.”
I gesture with my hands over to the chalk board. The board reads:
2009 Khumbu Medical School
4th Annual-WELCOME
Are you ready to get started?
WE ALL START SOMEWHERE
Just like Pa Nuru, my first expedition to extreme altitude involved a rescue of a sick trekker. There she was, a fit 30- year-old female Chiropractor with projectile vomiting sitting near the crater rim of Mt. Kilimanjaro at 18,000 feet. Her severe headache and diarrhea crippled her. Exhaustion and dehydration plagued her. And that was the least of her problems. We were in near white out conditions and descending was not an option. Fortunately, we were able to stabilize her condition with oxygen and dexamethazone, the drug that reduces swelling in the brain, until the following morning. In my tent that night, I thought, how could this have happen? Where was her guide? Why was no one paying attention to her?
I had been told prior to my arrival that very few, if any African guides had first aid training, yet hundreds of guides march thousands of clients annually to the top of Mt. Kilimanjaro. All this could be avoided if someone new what to look for. Altitude sickness and death happens more than we think.
Something had to change and that is why I was there.
A few months prior, I was asked by a US based African trekking company to design a six day high altitude medical training course for their African guides. In order to comprehend my teaching challenges I decided to climb to extreme altitude with twenty African guides and thirteen of their clients. I wanted to understand the local Chagga Tribe culture, the Swahili-English language barrier, and the roles and responsibilities of the guides.
What I learned on the climb is that the African guides are culturally shy in the presence of western clients, especially the women. They had no confidence conversing with clients along the trail about general body functions and the status of their health. Maybe the guides felt they had no authority to ask such personal questions. But it is vital to recognizing the development of altitude sickness. I knew they would have to get close and personal with their clients. So I designed a custom course that would address altitude sickness prevention, evaluation, treatment and evacuation. I also came up with a plan to engage the guides to interact with clients. This involved one on one, guide to client conversations each morning and evening. The conversations began with a check list–like a check list one would use for going on a road trip; is my gas tank full? Do I have oil? Are the tires pressurized? Windows clean? The human check list for trekking to altitude is not much different. Are you eating? Are you drinking? Are you peeing? Are you pooping? Do you have any pain? A headache? A cough? I told them that if there is a problem with one of these questions then it might a clue that this is a beginning of a medical problem.
“Pay attention to everyone that is working for you. If you do this twice a day you will never have to carry a dead person off the mountain,” I told them.
After five courses and 100 students later, my EaMT course is making a difference. I receive e mails from students who have used their knowledge on the trail. I hear heroic stories from the Khumbu Valley. The guides are saving lives by recognizing the early signs and symptoms of altitude sickness.
On the final day of class, Pa Nuru, the once young potato and buckwheat farmer and inexperienced mountaineer now stands competent and confident in front of his graduating class. In perfect S.O.A.P. note fashion, I write Pa Nuru’s spoken words on chalk board.
Assessment: Brain Problem-He was acting drunk-crazy. No walk-no talk. High Altitude Cerebral Edema.
Plan: Descend. Give oxygen, hot Sherpa tea, keep body warm in Hypothermia wrap, Gamow bag if no descend.
“If only I knew then what I know now,” he says. “I could have saved his life. He died a day later after we carried him on our backs down the mountain.”
Written by Susan Purvis All rights reserved. December, 2009
Note from the author. Susan Purvis has embarked on a personal and passionate project that involves Philanthropy in Africa and the Mt. Everest region. Her goal is to continue to educate local guides working at high altitudes and in remote regions about wilderness and altitude medicine. Susan is a lead instructor for Wilderness Medical Associates and owns Crested Butte Outdoors www.cboutdoors.com. For more information about EaMT log onto www.susanpurvis.com. 2008 instructors included; Everest Base Camp doc, Luanne Freer, Kristin Peterson, PA-C and Birgen Knoff, RN.
