Adventures on the Annapurna Circuit

For this blog entry, I want to share two issues I encountered while traveling in Nepal, just shy of my graduation from medical school: acute mountain sickness (AMS) and responding to a wilderness medicine incident as a medical trainee.

There is nothing more glorious

There is nothing more glorious than the period just after finishing medical school and before residency! For me, the highlight was being able to hike in Nepal. With the long travel time from Canada, and the multi-day itineraries most hikes necessitate, the post-grad period seemed like the ideal opportunity to make my dream of visiting the Himalayas come true.

Courtesy of Helene Morakis
Courtesy of Helene Morakis

I wrote my medical licensing exam, hopped on a flight and got ready to soak up the change of pace. While traveling, I found time to relax, (tried my best to) practice mindfulness and experienced the incredible kindness of Nepali people. Traveling was the perfect recharge that now has me geared up and excited for residency.

Annapurna Circuit

A few weeks before leaving for my travels, I began researching the Annapurna Circuit (APC). Having grown up at a staggering 240m above sea level in the Canadian prairies, I felt threatened by the Thorong La pass, which at 5416m is the highest part of the trek. My highest previous experience at altitude was 4200 meters, where I (unfortunately) developed Acute Mountain Sickness (AMS). My history of having AMS and following a typical itinerary for the APC put me at moderate risk for AMS(1). I decided to heed the Wilderness Medicine Society’s recommendation to take acetazolamide 125mg every 12 hours as prophylaxis(1).

Table reproduced from Luks, A. M. et. al 2019

While on the trek, I overheard many myths about AMS and sensed a general reluctance to take acetazolamide as prophylaxis(2). Himalayan Rescue Association does free daily teaching about AMS on the APC in Manang and on the Everest Base Camp trek as well(3). As we moved to higher altitudes, many guest houses and Annapurna Conservation Area Project outposts had accurate information about AMS and its consequences (High Altitude Pulmonary Edema and High Altitude Cerebral Edema). Surprisingly, despite this teaching and the availability of acetazolamide on the trail for purchase, there are still hikers that routinely require evacuation due to AMS, some by helicopter.

On the day before crossing the Thorong La Pass, I stopped for lunch with some trekking mates at Thorong Phedi (4538m). A few minutes passed before someone came into the guesthouse, visibly worried, requesting help from a doctor. It took me a few seconds (and my friends practically lifting me off my seat) to register that I could help! I was thankful to be hiking with an experienced nurse and we went to see the hiker together.

We were asked to see a fit hiker in his 60’s whose foot had been the victim of a rockslide. I clarified my training as a fourth-year medical student before asking details about the mechanism of injury and his past medical history. The hiker and his family were concerned and asked me to “rule out” a fracture. With positive Ottawa Ankle Rules findings, I wished for an X-Ray machine to rule out a clinically significant fracture(4). Keeping in mind there was no road access – the nearest road before the camp was in Manang (3500m, 15km away) or in Muktinath (3800m, 16km away) after the pass – the only ways out were by donkey or helicopter.

From a wilderness medicine standpoint, the injury was by all measures considered stable and the patient did not require an evacuation [reproduced from Isaac & Johnson 2013](5):

  • No deformity or instability on exam

  • No sense of instability reported by patient

  • Able to move and weight bear after accident

  • Distal circulation, sensation, movement (CSM) intact

  • Slow onset of swelling

  • Pain proportional to apparent injury

After a discussion with the patient, we decided that treating the injury as “stable” was reasonable and accepted the risk of delaying healing of a potential fracture. I recommended 24 hours of rest, ice (which kept the patient’s family busy fetching snow!), and elevation. I gave them ibuprofen to be administered on a regular schedule and instructed them to monitor CSM and plan an evacuation if there were any signs of impairment. I told the patient to continue the hike the following day if the pain did not increase with activity and to obtain medical follow up once they had returned to the city.

In hindsight, I recognized that I should have documented the encounter. I had written down the dosing of ibuprofen for the family, but I did not write a detailed SOAP (subjective, objective, assessment and plan) note. Properly documenting wilderness medicine encounters was a skill I learned in Advanced Wilderness Life Support. When we met the patient, he was generally well other than his foot injury. What if the patient’s condition worsened? What if the family forgot the plan in the stress of the situation?

I also found myself wondering about this patient long after I had left them. Reflecting upon this, I recognized that it is easier to “discharge” someone from an urban Canadian ED, where I have had most of my clinical experience because I know they can access good care if things change. The huge potential on the trail for loss to follow up made documentation much more vital in this case.

Later on, I pondered about the potential legal ramifications of helping this hiker. In Ontario, Good Samaritan laws protect health care professionals who provide first aid(6). From my understanding, there are no similar laws in Nepal, and there have been calls to define the rights and duties of those who witness or are requested to aid with an injury in the country(7).

In Nepal, I had a much-needed change of pace from medical school and plenty of time for reflection. I was inspired to see many organizations work together to educate guides, locals and hikers about AMS and hope to spend some time volunteering at the Himalayan Rescue Association in the future. Even after wilderness medicine training, being asked to provide first aid on the trail as a soon to be medical graduate caught me by surprise. I was happy to help and be able to have an approach to the patient in a low resource setting – and now recognize the importance of documentation.

I would like to hear your comments on this article: any experiences dealing with AMS, tips and tricks for musculoskeletal injuries in the wilderness setting, advice for navigating giving medical treatment outside of a hospital as a trainee or anything you would have done differently.

Courtesy of Helene Morakis

References

  1. Luks, A. M., Auerbach, P. S., Freer, L., Grissom, C. K., Keyes, L. E., McIntosh, S. E., … Hackett, P. H. (2019). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update. Wilderness & Environmental Medicine. https://doi.org/10.1016/j.wem.2019.04.006
  2. Kilner, T., & Mukerji, S. (2010). Acute mountain sickness prophylaxis: Knowledge, attitudes, & behaviours in the Everest region of Nepal. Travel Medicine and Infectious Disease, 8(6), 395–400. https://doi.org/https://doi.org/10.1016/j.tmaid.2010.09.004
  3. Himalayan Rescue Association. (2019). [online] Available at https://himalayanrescue.org.np/ [Accessed 30 Jun. 2019].
  4. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Worthington JR. A study to develop clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992; 21:384–90.
  5. Isaac, J. E., & Johnson, D. E. (2013). Chapter 13: Musculoskeletal Injury. In Wilderness and Rescue Medicine (pp. 84–85). Burlington, MA: Jones & Bartlett Learning.
  6. Good Samaritan Act, Government of Ontario (2001). Retrieved from the Ontario e-Laws website: https://www.ontario.ca/laws/statute/01g02
  7. Pandey, S. (2014). Good Samaritans. [online] The Kathmandu Post. Available at: https://kathmandupost.ekantipur.com/news/2014-07-13/good-samaritans.html [Accessed 30 Jun. 2019].

Further Reading

Cite this article as: Helene Morakis, Canada, "Adventures on the Annapurna Circuit," in International Emergency Medicine Education Project, July 12, 2019, https://iem-student.org/2019/07/12/adventures-on-the-annapurna-circuit/, date accessed: December 5, 2022

My Road to Emergency Medicine

Helene Morakis

MS4 at Queen’s School of Medicine

Incoming EM resident at the University of British Columbia

My first shadowing exposure to clinical medicine was in Pediatric Emergency Medicine (EM). Before starting medical school, I lifeguarded during my studies. Over six years, I had sent a handful of children to the Pediatric Emergency Department (ED) and always wondered what happened to them. I expected the shadowing experience to be chaotic and stressful.

The supervising physician shattered all my preconceived stereotypes about emergency medicine: she listened empathetically to patients and their parents, she took the time to teach her timid mob of medical learners and she managed to stay calm while juggling multiple cases of varying acuity. I left that shift – and all of my subsequent adult and peds EM shadowing shifts – in awe. I wanted to be part of this group of skilled physicians that made meaningful short connections with patients and was eager to tackle any case that came through the door.

I wanted to be part of this group of skilled physicians that made meaningful short connections with patients.

While in medical school I found I also loved the collaborative setting, the fast pace and the challenging contrast between cases in EM. My first two EM clerkship shifts entailed performing CPR, providing patient education in English, French and Spanish (and kicking myself for not learning at least three more languages!), ruling out a stroke in a non-verbal patient, and suturing a laceration after an assault. I was hooked. The opportunity to care for patients during their most difficult moments solidified my passion for Emergency Medicine. I love the “anyone, anything, anytime” mantra shared across ED’s that I visited on electives.

The opportunity to care for patients during their most difficult moments solidified my passion.

ANY

One
Thing
Time

EM is a broad and flexible field

Being fascinated by healthcare delivery in diverse settings and motivated by social justice I was interested particularly in Global Health and Wilderness Medicine in my pre-clinical years before dedicating myself to EM. Luckily, EM is a broad and flexible field and allows me to combine all of these interests.

I have been particularly interested in the online community that is working to advance EM and recruit medical students to the growing specialty on an international scale. Learning from and contributing to projects such as iEM is motivating and I am energized by like-minded medical learners around the world. My passion outside of school in the past two years has been working with the International Student Association of Emergency Medicine.

EM community is the best!

I may be biased, but I think the EM community is the best! There is an incredibly dynamic and well-established online presence that I have found very welcoming. Along with learning tips and tricks from FOAMed gurus, I had the opportunity to reflect on the EM mindset and social issues with the FemInEM community. Going to the FemInEM Idea Exchange 2018 (FIX18) conference last year in NYC as a student ambassador was an incredible experience and made me motivated to continue connecting with like-minded EM colleagues online.

Shana Zucker medical student, LGBTQIA+ advocate, at the FIX18 conference presenting her Queericulum

When I’m not in the hospital, I like to play outside. Participating in Wilderness Medicine allows me to do so even more and I like to think about how to deliver healthcare in non-hospital environments. I love that I can continue pursuing this passion through EM. The Wilderness Medical Society (WMS) has conferences, courses and research opportunities for medical students. I am working on my Fellowship of the Academy of Wilderness Medicine (FAWM) and hoping to gain more on the ground experience and contribute to research in this field as I move through my career!

When I’m not in the hospital, I like to play outside.

Hiking King’s Throne in Kluane National Park, YT, Canada, between EM shifts in Whitehorse, YT

The excitement and variety continue after shifts in EM. Between the online medical education community, on-shift teaching, research opportunities, the world of simulation and the interdisciplinary applications of EM, it is a specialty that academically has a lot of opportunities. Shift work is challenging, but offers flexibility to pursue my hobbies outside of work. There is a general culture of work-life integration and promotion of wellness shared among emergency physicians. At my home school program, Queen’s Department of Emergency Medicine, I saw this reflected in the resident and faculty mindsets and it contributed to my own prioritization of my wellness.

EM is a specialty that academically has a lot of opportunities.

The best advice I have received about choosing a specialty has been to follow my passions. The road to EM has been a fun adventure and has given me plenty of opportunities to do so. I am excited to start residency at the University of British Columbia. With teaching opportunities, unique pathology and a high volume of trauma, the residency at Vancouver General Hospital will be a busy but incredible ride.

Vancouver, BC, Canada

I look forward to pursuing my outdoor interests and enjoying urban amenities in Vancouver between shifts. With faculty and resident involvement in Wilderness Medicine and Global EM, I see many fun opportunities lying ahead!

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Cite this article as: Helene Morakis, Canada, "My Road to Emergency Medicine," in International Emergency Medicine Education Project, March 6, 2019, https://iem-student.org/2019/03/06/my-road-to-emergency-medicine/, date accessed: December 5, 2022