High Altitude Medical Research in the Khumbu: Work and Play at Lobuche

Happening Issue 94 Jul, 2010
Text by Dr. Ravi Shankar / Photo: ECS Media

The glass panes were glistening in the morning sun. Outside the wind was beginning to pick up speed; inside it was warm and cozy! State of the art equipment glinted on the worktables before us. The rows and rows of solar panels harvesting the sun could have energized a small community. Power was plentiful and the luxuries of life in the Khumbu like central heating and running hot water were commonplace in ‘The Pyramid’. My good friend, Dr Soni Srivastava had stayed here before and described the place as a five star hotel. Computers, televisions, DVD players, plush furnishings and a high speed satellite link made life ‘king size’. ‘The pyramid’ is a geological research station where research is conducted on weather patterns, glaciers, rocks, snow, ice and sediments, among others. I and my friend, Dr Anip Joshi, were standing in the deck of the pyramid while one of the local employees talked about a science (geology) far removed from our own, in his precise, well modulated voice. We were at around 5000 m. altitude at the outskirts of Lobuche in the Khumbu region of Nepal. The day was warm but would turn chilly the moment the sun slipped behind the clouds.  

Lobuche is rumored to have a pretty bad reputation. It has been termed the ‘bad and the ugly’, the ‘armpit’ of the Khumbu. Many mountaineers and trekkers have made Lobuche infamous with such graphic descriptions as “the lodges are dreary hovels, and sanitation is non-existent.” But, the location is magnificent. The lodges are on the lateral moraine of the Khumbu glacier with spectacular views of Nuptse and Tawachee and a whole range of other peaks to the south. And, on climbing the moraine there’s a spectacular view of Pumori (‘Daughter’ peak, in the Sherpa language).

The SPACE Trial
I was a bit apprehensive knowing that I would have to spend over a month in Lobuche doing clinical research. The ‘reputation’ of a place plays an important role in how it is perceived. Your mental picture is colored by your prior reading and descriptions by compatriots and friends. We were involved in the SPACE trial. ‘SPACE’ stands for SPirinolactone and ACEtazolamide, and we and other doctors were investigating whether a ‘water pill’, spirinolactone, could be used as an alternative to the more common acetazolamide (Diamox) for the prevention of acute mountain sickness. Acetazolamide is a good drug but has a number of side effects. The study was to be carried out on healthy trekkers traveling above 17,000 ft towards Gorak Shep (5180 m), Everest Base Camp (5365 m) and Kala Pathar (5545 m), a popular high viewpoint above base camp. The study was being conducted by the Nepal International Clinic and the Himalayan Rescue Association and was approved by the Nepal Health Research Council.

Subjects were enrolled along the trail at either Pheriche (4240 m) or Dingboche (4380 m) by the first part of our team who were staying in Pheriche. They were given a blister pack of eight pills and were instructed to take one pill twice a day (morning and evening) till they reach Lobuche (4910 m). The volunteers were given either spirinolactone, acetazolamide or a sugar pill in the blind study, and neither we nor the subjects knew who received which pill. On reaching Lobuche they checked in with us (the second part of the team). The subjects were administered the Lake Louise self-report questionnaire (for altitude sickness) and underwent a thorough physical examination. We checked their oxygen saturation using a pulse oximeter and carefully listened to their lungs to check for any evidence of fluid. For the volunteers the study finished at Lobuche. There was no blood work involved and the study did not markedly interfere with the trekkers’ routine. They had the benefit of receiving comprehensive and free medical checkups in the high Himalayas and received two cups of tea or other hot drinks of their choice in Pheriche/Dingboche and in Lobuche.

Acute Mountain Sickness
Acute mountain sickness (AMS) used to extract a heavy toll from trekkers before we understood its causation, its effects on the body and how to counteract the effects. Trekkers going to the Khumbu (Everest) region are especially at risk as they have to spend a prolonged amount of time at high altitude. Many trekkers fly in to Lukla at 2800 m and immediately go higher without spending time acclimatizing at low elevations, which increases the risk of AMS. Most people start trekking from the day of arrival and overnight at Phakding, a pleasant riverside village. The next day they reach Namche Bazaar, at 3400 m, the major town, often described as the capital of the Khumbu. To trek to either Everest Base Camp (EBC) or the Gokyo lakes from Namche and return requires more than a week with all the acclimatization halts. This period is usually spent at an altitude greater than 3500 m (11,500 ft). Given the problems encountered by trekkers who came down with AMS, the trekkers’ aid post at Pheriche was started in a yak herders hut to provide much needed medical care in this remote corner of the Himalaya. It has been successful in spreading awareness about AMS, staying healthy at altitude and reducing the death rate and sickness associated with altitude.

The Mountain Medicine Society of Nepal
The Mountain Medicine Society of Nepal (MMSN) is an organization of medical students, faculty members and doctors of the Institute of Medicine (IoM) and other Nepalese medical schools. MMSN members conduct a journal club every month, publish a newsletter and are involved in various research projects about mountain medicine. They also provide medical cover for the famous Everest marathon. A number of studies have been conducted in the Khumbu region by MMSN members, some in collaboration with foreign visitors investigating problems of altitude.

The Eco Lodge
We stayed at the up-market Eco Lodge, reputed to be the ‘best’ lodge in Lobuche. The Eco Lodge is tastefully decorated and designed; the rooms have plate glass windows and the doors are decorated and well insulated against the cold. Our room was on the ‘sunny’ side and this was a big relief, for even during the day time Lobuche is freezing cold in the shade and life on the ‘dark’ side of the lodge can be unbearable. In the high Himalayas, the Sun is often the difference between life and death! The place is less windy than Pheriche, but a wind does come up and gains force by afternoon.

The days were, to our great relief, sunny and warm. With less of the atmosphere above us (thinner by 5 km compared to sea level) the ultraviolet rays were strong and powerful. I used to sterilize my drinking water using the sun. The rays were. however, only mildly successful with the sludge of soap, sewage and organic matter which flowed through the center of the settlement. The nights were bitter cold and we each spent them huddled under a blanket, quilt and sleeping bag, combined! The evenings were pleasant in the heated dining room, though it was small and soon became crowded with trekkers, lodge staff, porters and guides. It was torture to touch the water. While washing or cleaning I used to lose sensation in my hands for over five minutes. Someone once said, Nirvana in a cold place is a heated room and warm water and I wholeheartedly agree! Even inside our room, the drinking water inside our bottles routinely froze by the early morning and had to be thawed out during the day.

The food at Lobuche was fresh and good, but a bit too westernized for my taste. This unfortunately is a common feature throughout the Khumbu. Pizza, spaghetti, macaroni, fried beans on toast, chicken a la Kiev, chicken cordon bleu! The Nepalese staple, dal bhat at 370 rupees a plate was far too expensive. Our group of doctors was staying for over two months and the lodge gave us a subsidized rate for the rooms. They had a lovely hot shower but at 400 rupees per shower it was a heavy strain on the pocketbook.

Everest and the Annapurnas
The region becomes barren as you walk towards Pheriche from Pangboche (4000 m), reputed to be the oldest human settlement in the Khumbu. The flora is limited to a few hardy shrubs, and as you climb towards Lobuche along the Khumbu glacier even these start disappearing. The cold is constant and bathing becomes an uncomfortable chore. I have also trekked a lot in the Annapurna region north of Pokhara where there are distinct differences with the Khumbu. A main attraction of guesthouses in the Annapurnas are the solar showers. Plentiful warm water running over your body at the end of a tough long sweaty day is pure bliss. I have wondered why the Khumbu lodges do not go in for solar showers. Sunshine is plentiful throughout the day and our star, the sun, could be easily harnessed to do such mundane chores as heating water and cooking food, among others. The Everest region has good yak burning stoves in the dining rooms and these tend to be the center of activity during the long cold evenings. Compared to the Annapurnas, the Khumbu mountains (Himals) rise straight up from the surrounding landscape without any intervening ranges, making for some truly  spectacular Khumbu views.

Study Volunteers
Our study volunteers started arriving in Lobuche by around 10 o’clock each morning. Our official hours were from 4 to 6 in the evening when we had the maximum number of subjects. Then, around 7 o’clock in the evening we went on ‘rounds’ to various lodges and the tent camps where we encountered an eclectic mix of subjects. The volunteers came from the US, UK, France, Ireland, other countries of Europe, Australia, New Zealand and others. We became friends with a truly multinational group. Many volunteers came from Canada, especially from Vancouver in British Columbia. One group showed up with a lady suffering from multiple sclerosis, paralyzed from the waist down and was confined to a wheel chair. Her companions had designed a special wheel chair for her and they were on their way to Gorak Shep and Kala Pathar.

Other Patients
We attended to many patients during our stay in Lobuche. In fact, we the only medical help available beyond the Pheriche health post. One night we were awakened by the guide of a Frenchman who was suffering from chest discomfort. His guide suspected pulmonary edema (fluid in the lungs) and had begun to inflate a Gamow bag (a kind of pressure bag used to treat this affliction). We examined the Frenchman and his lungs were clear, but his blood pressure was way above normal (180/120 mm Hg). He was a hypertensive and on treatment, but had stopped taking his pills after starting the trek, something that many hypertensives seem to do. Another of our patients was an American Gastroenterologist who developed severe diarrhea on the trek and was having stomach cramps. She had some dehydration, which we treated using oral rehydration solution (Jeevan Jal). Our most serious case was an Italian lady whom we suspected was suffering from high altitude cerebral edema (HACE) or fluid in the brain. Her oxygen saturation was in the low 50s. Lack of a common language was a significant barrier to communication, but we gave her a life saving shot of ‘dex’ (dexamethasone) and put her in a Gamow bag. She was later evacuated by helicopter to Kathmandu.

Illnesses were also common among the Nepalese. There is a misconception (though it is decreasing) that Nepalese do not suffer from altitude sickness. This often leads them to disregard basic precautions. The fact is that most Nepalese trekking staff and porters are from the lowlands and are just as susceptible to altitude sickness as foreign trekkers. It is imperative for responsible trekkers to look after their Nepali staff , watch for signs of AMS and seek treatment for them when necessary.  

Day Trips
Life at Lobuche was not all work and no play, however. Within 10 days we went on a day trip to Kala Pathar and Everest Base Camp. For most of us the top of Kala Pathar (5545 m ) is the highest point we’ll ever reach. Just 365 meters below it, Gorak Shep is a delightful settlement across the Khumbu glacier from the foot of Nuptse peak (7804 m). We found the food there, at the Himalayan Lodge, to be spicy and delightful. But Kala Pathar, on the ridge top above, is a long climb and we found the going difficult even after having stayed almost two weeks in Lobuche. The climb got progressively steeper as we went up and the last 20 m. were a veritable scramble on all fours up a steep pile of black rock (kala pathar) which threatened to topple down at any moment. The oxygen pressure was low and breathing a bit difficult, but the view was stupendous. Ama Dablam, the most photogenic of mountains from lower down the Khumbu valley, looked quite insignificant from up here, but nearby Pumori (7161 m) was majestic. From the top of Kala Pathar it seems that we could reach out and touch it. The black pyramid of Everest dominated the view, at its full 8850 m.  (29,035 ft). The eternal snow plume was blowing from the summit—Sagarmatha to the Nepalese, Chomolungma to the Tibetans. As we climbed higher, more of the great massif appeared to our east, but the wind was up and threatened to blow us off the top into the depths of the Khumbu glacier.

Going to Everest Base Camp, along the Khumbu glacier, is a long tough walk. The mountain views were tremendous, though Everest itself is not visible from EBC. A Thai mountaineering team was in residence when we were there, preparing to descend after an unsuccessful attempt on the peak. Everest Base Camp in the midst of all those high peaks must surely rank among the most desolate places on Earth. On the way back we stopped at the Himalayan Lodge in Gorak Shep, again, for ‘refueling’. A German national had died in the lodge toilet and a police team was coming up to investigate. It was a very long day from Lobuche to Gorak Shep, Kala Pathar and EBC, over nine hours walking. By the time we arrived back at Eco Lodge the sun had set behind the mountains and another cold dark night was upon us.

Does Lobuche warrant its ‘infamous’ reputation?
A s noted earlier, when we opted to stay at Lobuche, we were concerned about the its reputation, but thankfully, conditions are steadily improving in this high cold place. The Eco Lodge is expensive but offers good accommodation. The neighboring Alpine Lodge also offers good accommodations and is a potential competitor. The other lodges continue to be comparatively dismal, however, but have made efforts towards improving their facilities. A tank to wash clothes has been constructed at the center of the settlement. Compared to other settlements in the Khumbu region, Lobuche lags behind, though things are definitely looking up and a remixed and reloaded version of Lobuche can be expected in the near future!

I spent around a month there, at 5000 m. It was cold and difficult but thoroughly enjoyable. It was a ‘different’ sort of experience and I enjoyed the difference. In the words of the international educator, Shiv Khera, “Winners don’t do different things. They do things Differently.”

The author is a medical doctor at KIST Medical College and a member of the Mountain Medicine Society of Nepal (mmsn.org.np). He may be contacted at ravi.dr.shankar@gmail.com. He thanks Dr Buddha Basnyat, the driving force behind MMSN and the SPACE trial study; also Dr Anip Joshi co-investigator and Dr Matiram Pun, for their support, as well as other co-investigators, the staff of the Himalayan Rescue Association post in Pheriche, the staff of the Eco Lodge in Lobuche, and Mr Nuru Sherpa of the Himalayan Hotel at Pheriche for all their help. There are many other individuals who assisted, too numerous to be named and thanked personally (including trekkers who volunteered to participate in the study).