Helicopter rescue from Sertung

Today is our first full day at Tipling Medical Clinic. When I awoke early and ventured out of my tent to watch the morning sun slide down the snow-capped mountains to the north, I noticed a tall white gentleman waiting at the clinic door, some 100 yards from our tents. He was with a lone Nepalese porter. I walked over to him and found out that he had been trekking for the last several days with a group of Christian Missionaries in a remote area north of Tipling. The prior evening he had developed a very sharp pain in his abdomen that was not relieved with antacids. His wife, a nurse by training, had urged him to come down to our clinic to be seen. He had departed his campsite at 4 AM and hiked down to our clinic with his loyal porter. Upon examination it was determined he had acute appendicitis.

The question now was what to do with him? He certainly could not walk the three days out of the mountains to receive the care he needed. He was also too heavy to carry, and even if we had found the four or five porters that would be needed to transport him to Kathmandu, his condition was too tenuous to have him away from immediate medical care during this three-day journey. We were left with no other option than to try to fly him out of the clinic.

Unfortunately, due to an ill-advised government regulation that only "major mountaineering expeditions" could carry two-way radios, we were left with no immediate way to communicate with a rescue team in Kathmandu. While we sorted out our dilemma we put him into a tent, started an IV drip for hydration, and gave him a dose of IV antibiotics in case his appendix ruptured.

Getting a helicopter into remote parts of the Himalayans is no easy task. First, you have to call the helicopter, which for us would mean sending our guide on a run to the closest phone; a VHF solar phone four hours away. Secondly, solar phones, needless to say, only work during the day, giving us a limited window when a rescue can be initiated. Thirdly, the cost of the helicopter rescue (roughly $1,500) has to be guaranteed by a third party before the helicopter will take off from Kathmandu. This can take several hours in itself. Finally, most pilots, due to the remoteness and poor maps of the area, have never flown into the Tipling Medical Clinic, and certainly would not fly in at night. The spring days are long in Nepal, but we were up against a time constraint. Nevertheless, we sent Nal, our fastest guide, running for the phone and we had the cooking staff draw an 8-foot "H" (for Hospital) with baking soda on the terraced field just below our clinic. We continued to see patients that morning, periodically checking in on our sickest one, and waited for the helicopter.

At about noon we heard the beat of the helicopter's blades against the sky and we all left the patients we were examining to watch the landing. The helicopter landed perfectly on the "H", kicking up a dust storm of dry dirt and baking soda. The pilot informed us that he had a difficult time finding us, initially not seeing our 8-foot "H". It was only after a second pass that he located us by spotting our bleached white laundry hung out to dry by our porters. After numerous photos of the pilot with all of the doctors and medical staff, the helicopter picked up and whisked the patient and his wife down the mountain to Kathmandu with two hundred wide-eyed villagers watching.

The rest of the day was uneventful except for a woman who was carried into my examining room by whom I thought was her son. She looked to be about seventy-years of age and was thin as a bone, weighting no more than sixty-pounds. Her face was drawn, she had a large mass under her left jaw, and she lay lifeless on the wood examining bed. After talking to her family through two translators (Tamang to Nepalese and Nepalese to English), I learned that she was not seventy, but thirty-years of age, and she had a three year old child. She had been losing weight for about two years and had withered away to her present emaciated state. We suspected tuberculosis (TB), which is quite prevalent here, or the worst case scenario, cancer. I consulted the pathologist who immediately took a biopsy of the mass under her jaw and then examined it under the microscope. Thankfully, the biopsy did not show the malignant cells we feared. At this point we assumed that she had disseminated TB, which is readily curable, if treated.

This case has interesting medical and ethical aspects. Earlier in the day, the pathologist had taken a biopsy of a sixty-three year old woman whose right breast had been hard and painful for over a year. This hardness and discomfort had spread around to her right underarm and back. Unfortunately, this patient's biopsy showed metastatic breast cancer. The question now was what to do. Should this woman, who has already lived five-years pass the life expectancy of a Nepalese woman, be encouraged to walk (or even be carried) the three-day journey to Kathmandu for cancer treatments that will at most be only palliative and not curative? These questions were answered for us by the fact that the HHC organization could not afford to fly her to Kathmandu. In addition, our patient was in no shape to walk or even be carried. Finally, as our sage leader Anil said several times during our trek, "…sometimes you have to play God." With this advice the decision was made to give her medication to ease her pain and to let her live out her remaining days in her home in Tipling. I am struck by how much different this decision would have been in the United States.

What to do with our thirty-year old woman with potentially curable TB and a three-year old child was not as difficult to decide; she needed to be seen by a specialist in one of the teaching hospitals in Kathmandu. Her family was handed some traveling money by Anil, they wrapped her in a blanket, sat her in a porter's basket with the back cut out allowing room for her legs, and then hoisted her onto her husband's sturdy back. They then left the clinic for the three-day trek out of the mountains.