Local children greet us at entrance to village of Sertung

We awoke each morning at the Sertung medical camp to the beautiful view of the snowcapped Ganesh Himals to the north and our proverbial cup of hot chai brought to our tents by our Nepali cooks. Each morning after a hot breakfast we would leave our tent area, ascend the twenty feet to the adjacent terrace, find our two translators (one who would translate from Tamang to Nepalese and another who would translate from Nepalese to English), and start to see patients.

Over the next three days at the clinic we would see over five hundred patients, but only one of them will forever stand out in my mind. She was an 18-year-old Tamang woman who was carried into the clinic by her husband and mother on our second day. She arrived wrapped in a blanket and was laid on the wood-examining table in my room. She was pale, her hands were trembling, and between bouts of vomiting she moaned something unrecognizable even to her family. The history we received was vague and incomplete, largely due to the language difficulty of a double translation. What little we initially learned was that three weeks ago she had suffered a spontaneous miscarriage, and since then had not gotten out of bed, taking only a little food and moderate liquids during this time. It was only in the last few days that her condition had deteriorated to her present state. What further complicated the story was that the person who witnessed the miscarriage was not present, so we did not know if our patient had delivered both the fetus and the complete placenta.

Proceeding with only this information, we took her vitals - normal except for an elevated heart rate of 120. Her physical exam was also relatively normal for someone who looked as sick as she did. The only part that was suspicious was her pelvic exam. It showed that she had cervical tenderness, but no discharge. At first glance we suspected endometritis, pelvic inflammatory disease, a more serious infection of the uterus and ovaries, or pyelonephritis, an infection of the bladder and kidneys. All three of these could have been caused by bacteria that had entered her genital or urinary system after her miscarriage.

We started her on the only two IV medications we had, neither of which would completely cover all of the possible pathogens that she may have had. We also started an IV to re-hydrate her. We checked on her periodically, and after the last patient of the day, I went to see her and she communicated through her mother that she felt better. She indeed looked better and her tremors, which we attributed to nervousness, had resolved. In addition, her blood pressure was normal. However, she still had vague abdominal pain and a repeat pelvic exam still elicited cervical tenderness. In addition, she had developed a fever. I made the choice at this point to send her back to her hut with antibiotics that she could take orally. In hindsight, I should have kept her at the clinic overnight to be watched.

Our dinner that evening was interrupted by one of our Nepalese cooks who urgently informed us that one of the young women that we had treated earlier that day was now being prepared for death by a shaman medicine man. As we grabbed our stethoscopes and ran to the hut I could not recall any Tamang woman we had sent home to die.

After a breathless run up the trail we pushed our way into a crowded, dark, smoke-filled hut. Our gas-lantern cast a swath of light that fell on a young woman lying on the dirt floor in her mother's arms. She was in a tremulous state and barely arousable. We instantly recognized her as the young Tamang woman we had seen earlier in day who had suffered a miscarriage. She had a high temperature by touch, her blood pressure was 80/60 and her pulse was weak and very high. She was in septic shock. The story relayed to us was that she had thrown up her medication shortly after returning home. She had then tried to walk across the room and collapsed. Her tremors came soon after that. The family, convinced that she was going to die, summoned the shaman.

We bundled her in a blanket and raced her back to our makeshift clinic. We placed two large caliper IV's, ran two 500 cc's bags of fluid into her wide open, and placed a Foley to collect and monitor her urine output. Her condition worsened soon after this when she started to throw up large amounts of green and yellow bile. We did not have any way to prevent her from aspirating her own vomit into her lungs, so we did our best and manually wiped her mouth out after each emesis. After she received 1 ½ liters of fluid, her systolic blood pressure came up to 90, enough to keep her perfused. However, we quickly learned her blood pressure would drop if we decreased the rate of her IV fluids. The IV fluid was keeping her alive. With her IV fluids wide open and her blood pressure at a minimum level to keep her alive, we took a quick break and scoured our few available IV drugs, our collective brains, and two books for help.

Needless to say, we were not in a good situation. We did not have the proper antibiotics to completely cover all of the different bacteria that may have been causing her septic shock. We also did not have any way to protect her airway and no way to suction her mouth. In addition, we also did not have any cardiac medications in the event she went into cardiac arrest. Finally, the only thing keeping her pressure up was the IV fluid, which at the present rate would run out before the first light of morning, the earliest time that we could have a helicopter land. With little to be optimistic about we did our best at making an ICU at 7,000 feet and hoped for the best.

I informed Anil that we would not have enough IV fluids to make it till the morning. Anil, without hesitation, made the decision that two of his guides would return to the Tipling Medical Clinic for more fluids. This trip from Tipling to Sertung, two days prior, had taken us four hours. What Anil was now asking the guides to do was to leave Sertung, descend 2,000 feet into a steep treacherous ravine, climb up the other side, and then ascend another 1,000 feet to the Tipling Clinic. These guides would then have to return the same route back to us. They were going to try to do this total round trip in four hours and with only a flashlight to see the trail. I paused when I heard this plan remembering the difficulty in cresting this ravine two days prior in the dim light of dusk.

The Nepalese people are a tough, proud and strong lot. Their lives have been lived in a country with numerous social and geographical barriers, many of which they continuously overcome. The Nepalese people are also some of the most genuine, gentle, and humble people I have met. These two guides were no exception. With nary a hint of apprehension or reservation, Kamal, a medical assistant, and Tulu, a literacy teacher, knowing the potential danger of the trip, quickly and quietly grabbed their packs, said goodbye, and headed out the door.

As the two guides ran through the darkness of night, John, the other family practice doctor, Som, a medical assistant, and I stayed with the patient. We took her vitals every 15 minutes and read, under the dim glow of a propane lamp, our two medical books for any information that would be useful. Our task, to keep her hemodynamically stable for the next twelve hours, in many ways was the most straightforward and least fraught with danger: straightforward in that we had to keep pushing IV fluids into her as fast as possible, or she would die; and least fraught with danger in that we were in a safe place. The guide's task, on the other hand, was the least straightforward and most fraught with danger: least straightforward, both physically and mentally, as any climber who has had to run at altitude through darkness would attest; and most fraught with danger, as any wrong step on the trail could be disastrous.

The IV fluid we were administering was helping, but the lack of the proper IV antibiotics was a cause for concern. We had given her a series of IV antibiotics that covered a broad range of potential pathogens, but we were missing an antibiotic that would cover anaerobes, an important group of pathogens that very well could have been causing her present septic shock.

Earlier in the day, when our patient first arrived at our clinic and again when we first rushed her back to our makeshift ICU, I had asked the staff what IV antibiotics we had with us. Both times the staff had diligently reviewed with me all the available antibiotics, none of them being broad spectrum enough to cover all of the potential pathogens she may have had. As we sat there taking her vitals and worrying if we were going to lose her, I said jokingly to break the tension, "I would give $1,000 for Imipenem," a drug with a very wide spectrum of coverage. Som, taking one last look through the box of haphazardly arranged medications, suddenly stopped, smiled, and then held aloft a vile. It read, "Imipenem." My mouth went slack as I carefully re-read each letter. Why we had twice overlooked this medication is anybody's guess. As we drew up the chalky-white medication into the syringe and administered it into her thigh, a feeling of hope entered me for the first time since finding her comatose on the dirt floor of her hut. All we had to do now was to protect her airway, and keep her blood pressure up with our dwindling supply of IV fluids.

At 2:30 AM, three hours after Kamal and Tulu left, they returned with two backpacks full of the much-needed IV fluid. These two guides had run the equivalent of fifteen minute miles non-stop for three hours, at 7,000 feet elevation, in near complete darkness, through some of the most hazardous terrain I have seen, to get us this fluid.

At 5:00 AM, one hour before dawn, we sent Nal, a medical assistant, running down the valley to the closest solar phone.

At 8:00 Nal returned with news that he had made phone contact with the medical helicopter. We had our cooking staff again make a large "H" with baking soda on the terrace below our clinic.

At 10:00, with our patient hemodyamically stable and afebrile for the first time in sixteen hours, we heard for the second time in this trek the welcome beat of the helicopter blades against the sky. We all ran out of the clinic and saw the pilot set down perfectly on our "H", raising a cloud of dust and baking soda that momentarily engulfed the helicopter. The patient, being carried in a blanket by six guides, was halfway to the helicopter before they opened the door. The guides laid her on the floor of the helicopter and fastened her IV to a strap on the roof. Her husband and Som jumped in and straddled her with their feet. Her distraught mom shoved a handful of soiled money into her son-in-law's coat pocket as we closed the door. The helicopter picked up, hovered momentarily as if deciding where to go, then turned to the north and headed down the valley to Kathmandu. When the dry dust of the field kicked up by the helicopter settled, one of the Nepalese guides, in typical humble Nepalese fashion, thanked me for saving her life. In all honesty, I didn't save anyone's life. I did what anyone in my situation would have done. I gave her all the medication and IV fluid we had. The real heroes were Kamal and Tulu, the two Nepalese guides who risked their lives and ran through the darkness of night to save a young woman's life.

The remaining two days of clinic in Sertung were routine with most of the patient's complaints being the typical gastritis, headache, worms, and diarrhea. There was, though, one other case that was of interest. He was an eight-year-old boy with severe malnutrition. His mother had died in childbirth with him, leaving him to be raised by his father. A combination of his father's alcoholism and lack of money attributed to the young boy not being properly cared for. At eight years of age he weighed only 40 pounds, and he had the classic moon face, swollen belly, and emaciated appendages that is typical of protein malnutrition We referred him to The Kathmandu Nutrition Rehabilitation Center. His medical condition, being of a chronic nature, did not necessitate a helicopter evacuation. Rather, he and his father would hike the four-day trek out of the mountains with us after we finished our medical camp.

Our second medical camp ended after dusk on April 6th under the glow of florescent lamps powered by the generator the porters had carried over two mountain passes. The line of patients waiting to see us this day had formed early and stretched a good way down the path leading up to the clinic. The patients today, as in all the clinic days, waited patiently for hours to be seen. To not disappoint them we held clinic well into the evening, until the last patient was seen.

After dinner we were invited back to the clinic where we were greeted by close to one-hundred villagers all standing in a circle. They had assembled to give us a thank you celebration. The women formed one-half of the circle and the men formed the second half. The children of the village made up the inner circle. Several of the adults had brought the traditional Nepalese drums, which produce a melodic sound more reminiscent of a sharp moan than a tympanic drum beat. The entertainment for the evening was the village women singing a traditional Nepalese song to the rhythm of their drums, and then slowly fading their voices as the men would start their song to the same beat. This serenading between the men and women continued for some time, and being the honored guests we were all encouraged to dance. After some embarrassing and fun dance steps, the singing ended and Anil made some heart-felt remarks. We in turn had an opportunity to thank the Sertung villager's for allowing us the opportunity to serve them. The evening was perfectly delightful.