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Going Global

The Going Global blog is an opportunity for emergency physicians to share their experiences practicing and teaching outside the United States. Submit an article about your experience to EMN at emn@lww.com. Be sure to include a brief biography and photographs of the authors. Photos taken during time spent abroad are also welcome, and should be 300 dpi and in jpg, tif, or gif format.

This blog was started by the emergency medicine residents of Palmetto Health Richland in Columbia, SC, who travel the globe on medical missions. The program is under the direction of Thomas Cook, MD, who oversees one of more than 40 academic departments of emergency medicine that sponsors Global International Emergency Medicine Fellowships.

Tuesday, February 27, 2018

Providing Care at 10,000 Feet

BY ZACH HARDY, MD, & DANIEL BAKER, MD

Going on a medical mission with the Himalayan Health Exchange to the Himachal Pradesh region of India allowed me to see a part of the world that I had never experienced before. The patient population that we were seeing had very little access, if any, to medical care throughout the year. We had to travel on foot to their villages to provide care because of their remote location. But the trip was quite unforgettable—we spent all our off days hiking through the Himalayas, had night-time views of the Milky Way, and ate more Indian food than we could have ever imagined.

The flight from Delhi to Leh was incredible. We could see the mountains peeking through the clouds, giving us our first view of the Himalayas. We landed in Leh, a small town in Himachal Pradesh, after more than 24 hours of flying from Atlanta, and met with our companions while we recovered from our flights and attempted to adjust to the altitude.

We left Leh the next morning to drive to our first clinic site, Sarchu. The road there consisted of nine hours of cringe-inducing single-lane roads bordered by treacherous drops. We crossed the Taglang La pass (17,582 feet), the second highest pass in the world, according to the sign at the top. This rapid elevation gain made a number of members on our team feel the effects of altitude sickness, so we were happy to make it down to the relatively low elevation of Sarchu, where we would be camping (13,500 feet). Sarchu itself consisted only of about 50 yards of shacks set on either side of the highway. Each one had a big sign repeating the same offer: "Breakfast Lunch Dinner. Bed available!"



Our first clinic day was an eye-opening exposure to the challenges of providing health care in remote settings. We were limited significantly in our ability to diagnose and treat, given the minimal stock of tools and medicine we had. The majority of the patients presented for gastroesophageal reflux disease, eye complaints, and chronic musculoskeletal issues. Many patients we saw in Sarchu were road workers who had only come to the area for work. The uncertainty of follow-up care weighed heavily on our decision process. We had to decide what limited supplies to pack and bring on our trek for the next three weeks.

The next day, we packed up for the first time and headed out on foot with a local monk, «Lama G,« as our guide. We hiked for the next five days, working our way toward the Phriste La pass (18,250 feet). It was quite a momentous achievement when we crossed; this was the highest elevation most of us had ever reached. Sadly, we were only allowed 10 minutes at the top to take pictures before descending so we didn't develop altitude sickness. On the other side of the pass, we dropped down into the valley where we would spend the next two weeks.

The Toll of Everyday Life

Going into the valley felt like being transported back in time. Each village we came to consisted of fewer than 100 people. The lifestyle they lead is incredibly physically demanding. They would work from sunup to sundown performing physical labor such as carrying bushels of grain or making mud bricks by hand. They worked with only minimal tools, and relied entirely on the glacial snow melt for irrigation and drinking water.

It was apparent how much this lifestyle took a toll on their health in the clinic. Nearly every older woman we saw had diffuse chronic pain from carrying these heavy loads on their backs for so many years. We saw a man who presented with dry eyes and hoped to obtain sunglasses. We noticed, however, he was walking with a limp, so we asked to take a look at his leg. When he pulled up his pant leg, we were shocked to see what looked clearly like a complete knee dislocation. Apparently, he had injured it in a fall 30 years prior, and had walked with that limp his whole life.



We would gather around for didactics after each clinic day. Each of us had to prepare a 15- to 20-minute lecture for the group. These helped us place the issues we were seeing into context. We discussed various topics, including altitude-related disease, rheumatic fever, sexually transmitted diseases, peptic ulcer disease, acute hepatitis A, and more. We also had enlightening conversations about the ethics of medical missions as well as the social issues and dynamics of India.

We had nine clinic days and saw more than 300 patients. We were able to help with a variety of acute issues, including eye irritation, GERD, musculoskeletal pain, and viral and bacterial infections. We also found several worrisome findings, including a man with possible tuberculosis, a young man with what seemed to be heart failure, and a woman with signs of liver cancer. We were not able to do much for them in the field, but we were able to help somewhat by having them follow up in the city. Overall, it was an amazing experience that showed the positives and negatives of global health and allowed us to work with a great group of people.​

Dr. Hardy is a graduate of the Texas Tech School of Medicine, and Dr. Baker is a graduate of the Medical University of South Carolina. Both are members of the Palmetto Health EM Class of 2019.