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Medex 2003 Hongu Expedition Report

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Introduction to Medical Expeditions and Medex By Simon Currin

High Altitude Medicine: a British Perspective By Jim Milledge

A Personal Overview of the Expedition By Simon Currin

Power Report By Denzil Broadhurst

Communications Report By Simon Currin

Logistics By Simon Currin

Personal Accounts

  1. Arun – Inuku Valley trek: and we thought we had it tough! By Jim Milledge
  2. “Up to the La” By Ian Manovel
  3. Horrific Valley By Chris Wolff
  4. Group 4 and Mera Peak By Denzil Broadhurst
  5. Don't mess with dodgy oxygen bottles By Denzil Broadhurst
  6. Mingbo La By Denzil Broadhurst
  7. Maoists and Penknives By Pete Smith
  8. The ascent of Mera Peak By Mireille Baart
  9. A Pointless Death By Simon Currin
  10. A Pointless Death, part 2 By Alex Horsley
  11. Maoist Encounter By Jim Milledge
  12. The Official Medex Group 1 Song 2003 Edited by Ali Mynett
  13. The End By Piotr Szawarski
  14. The North Face of Kala Pattar By Stephan Sanders
  15. Nepali Etiquette By Stephan Sanders
  16. The Three Pillars of Faith By Greg Harris

Science Report (written September 2003)

  1. Introduction By Jim Milledge
  2. Data Collection By David Collier
  3. Gastrointestinal perfusion at high altitude whilst resting and exercising By Stuart McCorkell, Daniel Martin, Mike Grocott
  4. Arterial oxygen saturation and heart rate at high altitude during the trek By Chris Wolff
  5. Oxygen delivery in sub maximal exercise at sea level and at altitude after slow acclimatization By Chris Wolff, Doug Thake, Dan Matisson, Lisa Handcock, Alex Truesdell, David Collier and Jim Milledge
  6. Non-invasive assessment of cardiac function during acclimatisation to high altitude By Gerald Dubowitz
  7. Heart rate variability at high altitude By Paul Richards, Mireille Baart, Mark Dayer, Annabel Nickol and Mary Morrell
  8. Glyeroltrinitrate headache as a predictor of acute altitude sickness, and its effect on brain blood flow By Neil Richardson, Oliver Kemp, Anja Kuttler, Roger McMorrow, Nigel Hart, Chris Imray
  9. Sleep disruption at high altitude and its influence on next day vigilance and cognition By Annabel Nickol, Paul Richards, Philippa Seal, Juliette Leverment, Tracey Hughes, Mike Skinner, Gerald Dubowitz, John Stradling, Jim Milledge and Mary Morrell
  10. Eden Trace recording at different altitudes during ascent to Chamlang base camp (5200m) By Michael Schupp
  11. Cognitive function at high altitude By Jennifer Leland and Greg Harris
  12. Effect of the parasympathetic nervous system on resting bronchial tone at altitude By Kate Wilson, Michelle White, Lisa Handcock and Martin Miller
  13. Changes in respiratory ion transport at altitude By Nick Mason, Ali Mynett, Emma Lam, James Anholm Katja Ruh and Alex Horsley,
  14. Beau Lines at High Altitude By Fionn Bellis and Craig Brooks
  15. The ACE gene and weight loss at altitude By Stephan Saunders, Matt Litchfield, Sarah Trippick, Sandra Green, Don Paterson, Hugh Montgomery and David Collier
  16. The effects of altitude and acclimatisation on retinal function By Dan Morris, Mike Donald, Jill Inglis, Ian Manovel and Rupert Bourne

Medical Report

  1. Snow Blindness

Pharmaceutical Report

Letter of thanks for the recipient of our donated drugs




Introduction to Medical Expeditions

By Simon Currin

There can be few institutions as curious as Medical Expeditions. A charitable organisation run by enthusiasts with a passion for combining science with adventure. In 1994 its members climbed Everest, Pumori, Lobuje East, Island Peak, Pokalde and returned with a wealth of scientific data. The membership worked hard to make it all happen and used their own cash to fund the research programme. In 1998 Medex was formed. Medex acts as a sister company to Medical Expeditions. Medex organises the mailing lists, runs frequent social events and executes the Expeditions. Funds raised by Medex are used to support the charitable works of Medical Expeditions.

The twin charitable objectives of Medical Expeditions are:

  1. Research into the mechanisms of all aspects of altitude related illness.
  2. Increasing, by education, awareness of altitude related illness.

In the eleven years since the charity was founded it has pursued its objectives with zeal. Medical Expeditions has run eight courses for doctors at Plas y Brenin in North Wales as well as two for members of the public. These courses, organised by Andrew Pollard and latterly by Peter Barry, have acquired an excellent reputation both amongst the international panel of speakers and amongst those that come to learn. Much of the work arising from the 1994 Everest Expedition and Kangchenjunga 1998 has now been published and presented in journals and at meetings throughout the world. The Medex Hongu Expedition 2003 is expected to yield a further crop of papers spanning the spectrum of altitude related illness and physiology.

Despite the many academic and educational successes the most important aspect of Medex is the unique human formula. Bringing together adventurers and academics from all backgrounds and giving them the opportunity, in their spare time, to work towards common and exciting goals. The excitement of participating in a major expedition is a powerful attraction and the prospect of doing some good science along the way has proved irresistible to many. Many friendships have been formed and have flourished and this is the greatest success of Medex.

I am very happy that the enthusiasm that flowed after '94 and '98 Expeditions remains undimmed today. Plans are already afoot for future projects and I am sure that the next decade will prove a very interesting time for both the charitable works of Medex and for its members.

This Report gives the details of its third major venture, Medex Hongu Expedition '03. Once again teams of trekkers, climbers and researchers ventured into a remote corner of the Nepalese Himalayas to study the debilitating effects of altitude on health.

I hope you enjoy reading the many varied personal accounts and I hope that some of the technical detail will be of use to those planning future, similar ventures. Many individuals have contributed to this report and inevitably there is some repetition but each account brings a new perspective. I have, therefore, left many of the contributions unchanged.

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High Altitude Medicine: a British Perspective

by Jim Milledge as published in the Journal of High Altitude Medicine and Biology and reproduced with the permission of Dr John West of the HAM&BJ

Although there are no mountains in the UK of physiologically significant altitude, the British were in the forefront of Alpine and Himalayan mountaineering development in the early days. So it is not surprising that British Physiologists were prominent in investigating the physiology of high altitude (HA) in the early years of the 20th century. The names of Haldane, Douglas, FitzGerald and Barcroft are well known in the history of our subject. However, the clinical effects of HA, by comparison, were neglected. Haldane, in his long paper on the Pike's Peak expedition of 1911 (Haldane et al.1913), does graphically describe the symptoms of acute mountain sickness suffered by tourists who came up to 4300m by train and he speculates that perhaps this is due to failure to their lungs to secrete oxygen into the blood. But of course, his main interest was in the physiology of HA, as was that of his contemporaries on that expedition. Similarly, expeditions to altitude by Barcroft in 1910 and 1921 were concerned primarily with the effect of hypoxia on the physiology of various systems of the body with only incidental mention of altitude illness, for instance chronic mountain sickness seen in Peru.

It is true that Ravenhill, a British doctor working in a HA mine in Chile, published excellent clinical descriptions of what we now call simple AMS, HACE and HAPE but his paper in the Journal of Tropical Medicine and Hygiene (Ravenhill 1913) was forgotten until re-discovered over 50 years later (West 1996). Otherwise, in the first half of the 20th century, we find very little published by British or indeed, by clinicians of any other nation, on the subject, with the exception of a few writings in Spanish from Andean countries (West 1998a). No doubt this neglect was partly due to the necessarily slow approach to the mountains dictated by the logistics of the time which allowed time for acclimatization so that very little altitude illness was seen, and perhaps partly by a notion that any symptoms one did have were trivial, self-limiting and due to lack of moral fibre! The subject was, therefore not worthy of serious study.

Post World War II

In the two decades following the War there was an explosion of mountaineering activity compared with before the war. Nepal became open to foreign Expeditions and in the '50s and early '60 all the peaks over 8000m were climbed for the first time. Aviation physiology advanced rapidly during and after the War and there was some spin-off from this for our subject, most notably exemplified by "Operation Everest" by Houston and Riley (1947). In Britain the School of Aviation Medicine at Farnbrough was a source of expertise on which the very few altitude scientists in the UK could draw. Thus when Tom Bourdillon and others was designing the climbing oxygen set for the 1953 British Everest Expedition they were able to get valuable help from John Cotes and others at the IAM Farnbrough. Of course, the data on ventilation when climbing at altitude and oxygen flow rates needed were provided by Griffith Pugh from his work in 1952 in the field on Cho Oyu. The performance of this open circuit system was one of the reasons for the success of the '53 Expedition. Another was Pugh's insistence on the importance of hydration at HA. However. in the '50s in all this mountaineering activity we hear very little of altitude illness, presumable for the same reasons as before the War. The leisurely pace of these expeditions was little faster than pre-war and great emphasis was placed on time for acclimatization. It must be astonishing for modern climbers to learn that in 1953, after a leisurely march out to Tangboche, John Hunt sent his team off on two acclimatization trips of a week or more! Not surprisingly we read nothing about AMS though some of the clinical problems high on Everest and other mountains may have been, in retrospect, due to HACE or HAPE neither of which conditions were recognised in the English speaking world or Europe at that time.

In 1960 Houston's paper in the New England Medical Journal (Houston 1960) alerted those few of us interested in mountain medicine to the condition he called high altitude pulmonary edema. Houston was not the first to describe this condition. For a discussion of this interesting controversy see West (1998b). However, his contribution to publicising HAPE cannot be denied. Having read his paper in 1960. I was able to make the diagnosis correctly in May 1961 in a Sherpa on Makalu. With John Dickinson, a British Physician working in the Mission Hospital in Kathmandu, Houston did the same service for HAPE in their 1975 paper (Houston and Dickinson 1975) although there had been previous papers on the subject (West 1998c).

The first major HA medical research expedition post-war in which British scientist were involved was the 1960-61 Himalayan Mountaineering and Scientific Expedition. It was commonly known as the Silver Hut Expedition after the prefabricated wooden hut we erected at 5800m on the Mingbo Glacier in the Everest region of Nepal. Again the science program was oriented almost exclusively towards the physiology of altitude acclimatization and altitude illness did not figure in the scientific aims.

The first studies of AMS by British altitude scientists were conducted by members of the Birmingham Medical Research Expeditionary Society (BMRES). This group, based on the Teaching Hospitals of Birmingham University, was formed in 1977 and went first to the Himalayas in the fall of that year. The leader was Joe Bradwell, an immunologist, whilst Ronald Fletcher, a General Physician was the most senior member and Medical Officer. Since then the group have been on many expeditions to the great ranges. Their main contribution has been in symptom scores and drug trials in AMS (BMRES 1981, Bradwell et al. 1986). More recently under the leadership of Chris Imray they have exploited the technique of near infra-red spectroscopy to measure brain oxygenation at altitude (Imray et al.2000).

In the last ten years a group now called Medical Expeditions has undertaken three major research expeditions to Nepal carrying out work in altitude illness and physiology. It all started with a few young doctors deciding they would like to mount an expedition to climb Everest and in 1992 they got permission for the post-monsoon season of 1994. Simon Currin was the leader and others included Andrew Pollard and David Collier. The latter two had been on an expedition to Chamlang (7270m) in 1991 on which some altitude research had been done and a research program was part of the planning for Everest ’94. However during the interval between the start of planning and setting off, a number of changes occurred. First the peak fee, demanded by the Nepalese authorities, increased by a factor of ten! Secondly various sponsorship possibilities evaporated when in 1993 the media seized on the scandal of the mess at Everest Base Camp and on the South Col. There were already plans to have some trekking groups in association with the Expedition. These now became much more important both in relation to a number of research projects for which the trekkers would provide subjects and also as a source of income for the Expedition. It was realised that if the Expedition organised the trek and dealt directly with the airlines and trekking agencies the cost could be kept below the price of a standard commercial trek. By charging the regular rate, the difference could help pay for the Expedition. The other activity, which brought in money, was organising weekend courses in Mountain Medicine at Plas-y-Brenin in North Wales. Andy Pollard had had a shattering experience on the Chamlang Expedition when he and his companions had come across a party, including some doctors, who had a member with obvious HACE. The party had not recognised the condition and the victim died soon after Andy arrived on the scene. This was the stimulus for him to organise these courses to disseminate information about mountain medicine but the spin off was that with speakers giving their time and keeping costs down, these course also produced an income for the Expedition.

The British Mount Everest Medical Expedition 1994 was very successful. Two members reached the summit, research was carried out on both the trekkers, the Everest climbers and on an associated group climbing Pumori. There were a number of events before the Expedition for team building and base line data gathering and afterwards for reunions, reporting back on results etc. Soon members were asking, “What next?” So, we renamed the charity, “Medical Expeditions” with the charitable aims of supporting research and education in altitude medicine and physiology. We began planning the same pattern of expedition, this time to Kangchenjunga Base Camp (North) where we went in the fall of 1998. We continued to run week-end courses for doctors and health care professionals as well as encouraging our members to present their research findings.

The expedition to Kangchenjunga Base Camp was successful in that we carried out a wide range of research projects and a small climbing team made a gallant unsupported attempt on the mountain itself though they failed due to the onset of bad weather. A number of members also climbed a trekking peak, Ramtang 6,600m). Our most recent expedition was to Chamlang Base Camp in the Everest region of Nepal in the spring of 2003. This too was very successful in terms of science carried out, trekking and climbing an easy trekking peak, Mera (6470m) and the Mingbo and Amphu Lapcha passes. These expeditions have all consisted of about 60 members trekking out in self contained groups of 8-12. Some observations such as AMS scoring and pulse oximetry are made twice daily on the trek and are available to all researchers so that their observations can be correlated with AMS scores, SaO2 etc. The main research is done on arrival at base camp at about 5000m with further observations in some subjects after a period of acclimatization. Projects have included work on altitude cough, oxygen free radicals and AMS, sleep, periodic breathing and cognitive function, pulmonary function, cardiac function, body composition and respiratory epithelium ion transport in relation to AMS.

Mention should also be made of a group of mostly medical students from Edinburgh University led by Kenneth Baillie, who made a successful research expedition to Bolivia in 2000. They made use of the facilities of Chacaltaya (5200m), a cosmic ray research station and small ski resort near La Paz. Their research also included projects on mechanisms underlying AMS.

In summary: In the early years, British scientists let the way in elucidating the basic facts of altitude acclimatization and interest in the mechanisms of the effects of altitude hypoxia continues to be a major interest. In the last 20-30 years the study of the mechanisms, treatment and prevention of mountain sickness has been added as a major concern of the increasing number of British scientists working in this field.

References

Birmingham Medical Research Expeditionary Society Mountain Sickness Study Group. (1981) Acetazolamide in control of acute mountain sickness. Lancet, 1, 180 3.

Bradwell, A.R., Dykes, P.W., Coote, J.H., et al. (1986) Effect of acetazolamide on exercise performance and muscle mass at high altitude. Lancet, 1, 1001 5.

Houston C.S. (1960) Acute pulmonary edema of high altitude. N. Engl. J. Med. 263 478-80

Houston C.S. and Riley R.L (1947) Respiratory and circulatory changes during acclimatization to high altitude. Amer. J. Physiol. 149 565-588

Houston C.S. and Dickinson J (1975) Cerebral form of high altitude illness. Lancet 2 758-61.

Imray, C.H., Brearey,S., Clarke, T. et al. (2000) Cerebral oxygenation at high altitude and the response to carbon dioxide, hyperventilation and oxygen. Clin Sci. 98 159-64.

Ravenhill T.H. (1913) Some experiences of mountain medicine in the Andes. J. Trop. Med. Hyg. 16:313-320.

West J.B. (1996) T.H.Ravenhill and his contributions to mountain sickness J. Appl. Physiol. 80:715-724.

West J.B. (1998) High Life: A history of high altitude physiology and medicine. Amer. Physiol. Soc. Oxford. (a) pp 146-154. (b) pp154-162. (c) p-162-163.

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A Personal Overview of the Expedition

By Simon Currin

After what seemed like years of political uncertainty we finally took the decision to go to Nepal late last year. Maoists had been causing turmoil in Nepal for 6 years and in the autumn of 2002 there seemed to be no sign of abatement. Coupled with that as 2002 drew to a close it seemed increasingly likely that the second Gulf War would be nicely timed to coincide with our Expedition. With so much uncertainty we abandoned our previous practice booking the international flights centrally and, instead asked individuals to make their own arrangements. We also drew up a voluntary bond system in order to arrange timely evacuation should the domestic Nepalese politics erupt whilst we were there.

The scientific component of the Expedition began in London in January 2003 with the data collection weekends. These were very well attended and ran extremely well. Many members took the time and trouble to journey in from their various corners of the world and were rewarded by seeing, for the first time, what the final shape of the Expedition would be. The base line data was collected with a minimum of fuss and the efficiency of our scientific team augured well for what would lie ahead at Base Camp.

At the end of January we were heartened to hear the unexpected news of a ceasefire in Kathmandu. I, for one, breathed a sigh of relief at this news though there was much speculation as to whether it would hold. Less welcome news was that the second Gulf War seemed to have been timetabled to start on the day that many members were due to fly out. Many had chosen the cheaper Gulf Air flights and transited through Abu Dhabi. As it transpired, however, only a few members had their flights cancelled as airlines scrambled to consolidate their bookings. All arrived safely, without incident and more or less on time in Kathmandu during late March.

The 57 members that took part were formed into 5 teams of between 10 and 13 each. Some of these groups were self selected others were put together by Medex organisers. Group 4 was the first team to head for Nepal and was responsible for much of the logistical work in both Kathmandu and Base camp. Their brief was to trek in first and set up the science projects at Base Camp in time for the arrival of the later teams. We were very fortunate in that George Wormald, who had worked tirelessly in the UK to freight the 1000kg of research equipment, was able to fly out to Kathmandu in mid March to oversee the Nepali end of the freight handling.

Groups 1 and 3 were to leave Kathmandu 4 days after group 4. Medex 2 left the next day and group 5 six days after group 2. We hoped that this staggering of departures would mean that the arrival of un-acclimatised subjects at Base Camp would be spread over seven or eight days and thus ensure that Base Camp data collection would be manageable. This seemed to work out OK although some anxiety was expressed when group 1 was, at one stage, only 1 day behind the advance party. The command, “Go back to Goa and stay there for 2 months!” was said to have echoed across the Mera La!

All members trekked in using the same route except Rajiv Joshi and John Milledge who took a short cut and flew to Lukla as they had limited time. For the rest of us we took the Twin Otter flight from Kathmandu to Tumlingtar in the Arun Valley and began trekking the next day from there. The airstrip is at just 400 metres and it is disconcerting, when bound for lofty Himalayan Peaks, to spend the first hour on trek going down. We bottomed out at 300 metres before crossing the Arun River and heading off up a tributary. Nepal is sub tropical and, at 300 metres it is very hot and humid. Accordingly we spent much of the early part of the trek drenched in either sweat or soaked by rain and hail. My drug company golf umbrella provided excellent shade and shelter.

Although the trail from Tumlingtar Base Camp is only 40 miles there is a stunning amount of up and down as it crosses valley after valley. We were to emerge at Base Camp considerably fitter having climbed 40,000 feet through steamy bamboo jungle and icy, glaciated passes. We were all much comforted when Jim Milledge conceded that it was, indeed, a “strenuous trek”. Despite the difficulties all but one member succeeded in the crossing the 5,400 metre pass that led down into the Hongu Valley and our Base Camp. Unfortunately one member had to retreat before the pass having become debilitated by a lengthy bout of diarrhoea. He was able to take the short exit to the airstrip at Lukla.

The first 14 days of the trek traversed the remote Nepalese foothills passing through many villages, valleys and passes to 3,400 metres. We came across no other trekkers during this time. Many of the villages displayed red flags and slogans pledging allegiance to the Maoist cause. All groups except Medex 2 had some kind of direct Maoist encounter. Groups 1 and 3 were stopped in the village of Bung and a polite request was made that they join the Maoists. They were initially asked for Rs30,000 but managed to negotiate a discount for expatriate membership. I think they ended paying around Rs250 each (about £2) except, of course, for Stephan who, in true student fashion, managed to evade a call for cash by running off. He was, I understand, hotly pursued by men with a curious array of firearms which included shotguns and flintlocks.

Group 5 faced down another request for Rs30,000 by using Jim’s finely honed negotiating skills. A former Medical Director of Northwick Park Hospital is used to negotiating with politicians and doctors and a Maoist armed with a hand grenade proved a poor match! I won’t spoil Jim’s story as I am sure it will appear in the full Report.

Later in the Expedition Group 3 had a second Maoist encounter but this ended on excellent terms when they were, en mass, able to produce their membership cards and swap comradely comments about George W and his antics in the Gulf.

Contrary to our fears the Maoist proved to be an entertaining diversion from the ups and downs of the approach trek. I am very pleased to say that all of the voluntary bonds have now been refunded.

Late snows blocked the planned high route via Panch Pokari and so we had to descend all the way back down to the Hinku River and then climb very steeply back up before following a new, and very strenuous trail along the western side of the Hinku Valley. Flowering rhododendron, magnolia and a campsite cut out of a bamboo jungle punctuated the impossibly steep ascents and descents before popping out into the excoriated valley floor at Kothe.

The village at Kothe had, 6 years earlier, been destroyed. A natural dam burst that sent a torrent of mud, water and rock surging down the valley. New bamboo huts have sprung up in the valley that has been freshly gouged by this terrifying force of nature.

All groups rested at Tagnag underneath jagged slopes of Kangtega and Kusum Kungru. At 4,200metres we were glad to take time to acclimatise especially as we had finally arrived amongst the mighty Himalayas. The foot hills were now all well behind us and were swathed in the obligatory afternoon mists. Ahead was the Mera La which, at 5,400 metres provides a formidable barrier to trekkers and porters alike as we were to find out.

At Tagnag we first met a Japanese commercial expedition bound for the Mera La. They had arrived at 4,000 meters 4 days after leaving Kathmandu and planned to take no time to acclimatise before their attempt to climb Mera – a 6,400 metre mountain south of the Mera La. The plan seemed foolish. More so when I met one of their members. I chatted with this elderly and oedematous lady and it was clear she was already struggling. We were to pass her the next day as she made painstaking progress towards their next camp at Khare. She did arrive there some hours after us but sadly she never left. Four days later, whilst her companions stood on the summit of Mera, she died. A needless and avoidable death about which there will be more in the full Report.

Khare at 5,000 metres proved the site of 2 further mishaps during our Expedition. Fortunately neither proved fatal but they both came very close. A lowland porter employed by a Russian expedition developed severe high altitude pulmonary oedema in the night and was resuscitated by group 2 with Certec bag, oxygen and nifedipine. By the morning he had improved very significantly and was able to descend escorted by one of our medical officers. Later on in the expedition one of our porters, whilst ascending from the Hongu Valley to the Mera La collapsed. He was carried over the pass and down to Khare and arrived in a very poor state. Several of our doctors worked on him and diagnosed a severe pneumonia which they were able to treat with sophisticated western drugs. However, it was Tracey, our specialist respiratory physiotherapist from the Brompton, who worked the magic and brought his saturations up from 40% to 80%. By chance, she was able to refer him on to another chest physiotherapist in Tagnag the next day.

The glaciated Mera La was magnificent and most of us had superb views. All groups, apart from Medex 2, then descended to the Hongu Valley before following the valley up to our Base Camp to the north of Chamlang. Group 2, anxious to delay its arrival at base camp, made an attempt on Mera Peak. High camp was established at 5,800 metres in one day and then occupied the next day. A violent thunderstorm broke in the afternoon and evening before our attempt and a few inches of snow were deposited. By 4 am the storm had passed and 6 people set off for the summit which they reached by 10am without event. Sally had been suffering from a respiratory infection and this, combined with a dose of acute mountain sickness thwarted our attempt but, nevertheless, we enjoyed the fantastic views from High Camp of Kangchenjunga, Makalu, Lhotse and Everest.

Base Camp was on a flat meadow near the upper Hongu River now little more than a stream. Surrounded by spectacular peaks it was denied a view of Everest by a twist in the valley. Chamlang, 7,100 metres, dominates the valley and Base Camp. When Group 4 had arrived they had to dig deeply into the snow in order to pitch the tents. Three helicopter loads of research kit were flown in from Kathmandu via Lukla. All had gone without a hitch and, by the time group 2 arrived Base Camp was a serene and orderly place. It felt a bit like the grid of an American town with everything laid out, toilet tents as well, in a planned and logical way. Not at all the medieval growth of our previous Base Camps! Undoubtedly Jim Duffy, our base camp manager on this expedition has a tidy mind!

Thanks to the efforts of Jim, Denzil and Gerald the place not only looked tidy but it was also functioning like a well oiled machine. No noisy petrol generator – the freighting company had refused to take it blaming, for some reason, the war in the Gulf! Instead electricity was efficiently and almost silently generated by wind and sun. The scientists were all quietly going about their business of data collection and most of their subjects were compliant and, even more surprisingly, uncomplaining. Drips and arterial lines were inserted, curious cannulae were being poked into all kinds of orifices and the usual bunch were pedaling the one wheeled cycle – now on its third Medex outing to the Himalaya. The whole scene was one of calm and orderly scientific endeavour. The only odd thing is that we were 5,000 metres up in the Himalaya and when the afternoon clouds rolled in the temperature plummeted like a stone bottoming out at -10 or so just before dawn.

The huge dome tent proved the social focus in the evenings and one night we counted 65 in there before the dancing began. Clapping to the ceaseless tune of Risamfiriri inside the big dome with the condensation dripping like rain as all 65 danced with those curious, squirming, sherpa hand movements. Smiling faces, burnt by the sun and unshaven for weeks. These are my happiest memories of Base Camp.

As the projects came to their end the groups began to drift away. Most headed back down the Hongu bound for Mera Peak. All but 1 in Group 1 summitted and all but 2 of group 5. Group 3 made an attempt but were thwarted by a storm as too, earlier in the Expedition, were group 4. After Mera Groups 1,3 and 5 were able to exit via the Zwatra La to Lukla in four or five days.

We in Group 2 chose to be different and press ganged a Michelle, Stephan, Matt, Piotr and Mireille to join us. We went up the Hongu to its source passing the moraine lakes of Panch Pokari as we went. We turned left and climbed up the moraines of the Hongu glacier and camped in a blizzard at 5,600 metres below the infamous Amphu Lapcha. It was on this pass 5 years earlier that 9 people on an Australian expedition had died in an avalanche.

We spent a bitterly cold night in camp and set off early for the pass. Fortunately our Sherpa staff knew exactly where they were going for the route was far from obvious. We climbed up under a steeply seraced glacier and then, in a rising, rocky traverse entered a loose gulley which we ascended on fixed ropes. This led out onto a rocky slope which we climbed for the final few metres to a precipitous rock ridge. There we waited for 3 hours as porters and their loads were lowered on separate ropes. It seemed take an age to get everyone over. Fourteen members, 22 porters, 8 kitchen staff, 2 local sherpa guides, 1 climbing sherpa and 1 Sirdar. Some 48 souls in all had to traverse under steep rock, abseil down a gentle snow ramp then queue for the “big” abseil over a rocky bluff and then down an icy gully. From there we traversed 45 degree snow slopes on north facing, unconsolidated snow. Thankfully the pack was stable and there was minimal risk of avalanche during our descent. The porters tobogganed on their loads down the final 300 metres snow ramp. We went on our backsides! However we arrived it was great to get into camp just before dark that night as all had had a long day. Much of our gear was retrieved by torch light that night as many of the loads - left the previous afternoon by porters lowered long before their loads – were thrown down the mountain!

Interestingly breakfast, the next morning was delayed, as some poor soul had to climb back up to the pass to retrieve the milk powder!

The walk from Amphu Camp down to Chukung was, for me, one of the best on the trip. The whole south face of Lhotse was before us and we had survived the Amphu Lapcha. Stephan and Matt broke off to attempt one of the other mountains in the Chukung Valley and I am pleased to say they succeeded in good style. For Sally and I we were now in familiar territory and spent the next few days retracing our steps of ’94 down the Khumbu. But how it has changed. Smoky huts daubed with yak dung have grown into substantial, stone built lodges with all – well nearly!- the comforts of a hotel. Shacks have grown into prosperous lodges and everywhere there is building and enterprise. The Khumbu has become a money making machine. No more so than in Namche Bazaar which now hosts dance bars and internet cafes.

Those that hadn’t sampled the delights of the Khumbu before scampered off to visit Kala Pattar and glimpse the magnificent splendour of Everest. Still a majestic sight even with a sprawling base camp at her foot accommodating 35 expeditions.

Whilst all this was going on Group 4 packed up Base Camp and dispatched the research gear by helicopter to Kathmandu. Once again all executed with military precision. Job completed they, with a few well chosen sherpas, set off to cross the other pass between Hongu and Khumbu - the Mingbo La. This they did in 2 very long days that involved several abseils both on the pass itself and on the Mingbo Glacier below. On the way they were able to inspect our other mountaineering objective Ombigaichen. This had first been climbed by Jim Milledge in the winter of 1960 and it had been our intention to climb it again. It seems however that it will remain a winter only mountain as the snow slopes that Jim had climbed were, in spring at least, denuded of snow and now consisted of hideously loose rock.

On the 28th April all groups, somewhat trek weary it has to be said, assembled in Lukla for a night of celebration before flying out to Kathmandu. Chang, sherpa dancing and more smiling, happy faces.

Back in Kathmandu the men lost 10 years as their beards came off and everyone counted the cost of the previous 5 weeks in lost weight. I think the record goes to Michael who shed 11kg though more on this in the Report. Attempts to regain the lost lard were largely thwarted by restaurants like Rum Doodle who manage to dish the dirt with the dinner and left many staring into the porcelain the following night. Fine food was however served up at the party given by our trekking agent who treated everyone to a fine Tibetan meal. Medex followed this up with dinner for 95 on the roof of the Marshyangdi Hotel with entertainment by a team of “cultural dancers and musicians”. Hmmm!

With Mera and the Amphu Lapcha in the bag the last remaining danger was a new threat to the world. A new disease, SARS, had taken a grip on the Far East and paranoia was running high. We boarded our flight to Bangkok and a few minutes later I had one of the paroxysms of coughing I had grown used to over the last few weeks. Instantly I was pounced on by the air hostess who gave both me and my neighbour a mask.

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Medex 2003 Expedition: Power Report

By Denzil Broadhurst
As each expedition takes place we are learning more about the best ways of providing power for the researchers. The rented solar power equipment had performed well on the '98 trip, hence solar power was to form the basis of the system for the 2003 trip. I was keen to try out wind power - knowing from Jon Pote's weather station in 1998 that there had been a light but consistent wind for a number of hours each day. The major problem with wind power is the altitude - just as we personally suffer from the effects of the rarefied atmosphere so does the wind charger, requiring significantly stronger winds to provide the same output power (at half atmospheric pressure you need 1.4 times the wind speed - since
the energy goes up as the square of the wind speed).

We had a few solar panels remaining from 1998, but also a number of new ones that Gerald was able to acquire at healthy discount in the USA. Lisa also borrowed a solar panel that had seen service in the Antarctic. I acquired a wind charger - of the type used by many yacht owners, which claims to have good low wind performance.

All of the new solar panels were of the flexible type - built on a stainless steel backing which allows them to be rolled and easily fitted in barrels for safe transportation. All of the power system was designed to fit into the 60litre blue barrels, the only exception being 4 rigid solar panels for which I made a wooden case.

We again planned to take a petrol generator for emergency use (one which we used in 1998), but because of the situation in the Gulf the airline refused to air freight it. At least that simplified the power system and saved weight on the helicopter to base camp.

The electrical power storage was provided by a set of 6 sealed lead-acid batteries bought from an electrical surplus outlet - unused but a couple of years old. The storage capacity we had in 1998 was excessive, so we reduced it significantly this time but even so these 6 batteries weighed a total of 120kg (>10% of the total research kit weight). We had some problems in getting the batteries air freighted from the UK - even though they are designed for aircraft and submarine use, and needed to provide copies of the manufacturer's "Material Safety Data Sheet" which identified them as a "non-spillable battery" and hence meeting the requirements for air transportation.

The USA is the main source of solar power equipment, so Gerald also acquired a couple of 20A solar charge controllers, and three large mains inverters. The inverters were of course designed for the USA 110 volts AC electrical system, but half the price of equivalent UK rated units. Virtually all modern medical electrical equipment and laptops are designed to run on a "universal" supply (saves changing the design for different parts of the world), so only a handful of older items needed additional small transformers to convert up to 240 volts. I had been round the various projects during the London baseline tests to check which equipment required these. Most people were, of course, using UK style plugs so the tents were wired up with a hybrid system of 110 volts AC but UK sockets. Since the cables were simply laid across the ground and open to the weather (which we had plenty of!) the use of 110 volts was probably a good safety feature.

The power system was designed with redundancy - 2 entirely separate systems were set up, with one (using a single battery) providing power for the base camp radio and research in one of the dome tents. The other system, using the remainder of the batteries, provided power to the rest of the research tents. In the event of any items failing the system was designed such that it could easily be re-wired.

The sun reached the base camp at around 7.30am, and research generally was not started until 9am or 10am, allowing some charge into the batteries before any power was used. Peak power from the solar panels was about 400watts, though this dropped rapidly when the afternoon clouds rolled in. We had to patch in an additional charge controller belonging to Gerald when we realised that we were over-rating one of the 20Amp controllers, having added in some of Gerald's solar panels to the main system. The wind charger typically provided about 10 to 15watts during the normal light winds, a small but worthwhile trickle charge that continued for most of the 24 hours. I did not build a wind charger controller into the system to prevent over-charging since a) the chance of ever getting the batteries fully charged was remote, and b) the typical charge provided was unlikely to exceed the trickle charge capability of the batteries installed (nominally 1% of their capacity).

Jim Duffy had designed an elegant lightweight tower system for the wind charger where most of the strength was in the guying system. To our delight (and a little surprise) once suitably tensioned it remained perfectly stable.

We had to restrict the use of some of the older (higher power) pieces of electrical kit at certain times. We also, on occasions, had to limit the number of laptop computers that were being charged, but overall we seemed to be able to keep the researchers happy with their power.

Medex/Medical Expeditions now owns sufficient equipment for future trips, though a few additional solar panels would be useful along with an extra solar charge controller. New batteries will have to be bought since the ones used on this expedition were donated to charities in Kathmandu through contacts at Lotus Energy. The cost of freighting them back to the UK was more than their value.

The equipment
Batteries 50AHr sealed lead-acid Hawker SBS-60 6
Solar panel 32W flexible Unisolar USF-32 7
Solar panel 20W semi-rigid Solarex MSX20L 4
Wind Charger 250W Rutland 913 1
Solar Regulator 20A BZ Products M20 2
Mains Inverter 110V, 1.3kW Whistler PP1250 2

In addition we also used a 10A regulator and some panels belonging to Gerald, and the panel borrowed by Lisa.

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Communications
By Simon Currin

Key to organising a smooth running expeditions is good communications during all phases.

In the months before departure Newsletters and information sheets were produced on a frequent basis. Meetings at Langdale, Hyssington and the Data Collection weekends also provided an opportunity for members to discuss and develop plans.

A new innovation for the Medex 2003 Expedition was the use of an internet Newsgroup. This was set up in the months prior to the expedition with the aim of cascading information as efficiently as possible. This proved very popular and a great number of families also subscribed to it. Dr Jane Morris kindly took on the role of moderating this Newsgroup for the duration of the Expedition. Whenever we managed to make phone contact with Jane she posted a message on our Newsgroup and was thus in an instant disseminated to friends and relatives around the world. We attempted to make contact with Jane by satellite phone on most days.

All members of the Expedition had email and this was in stark contrast to our earlier Expeditions. In addition we set up group forwarding aliases so that it was very easy for members to correspond within their groups and between groups.

Good and reliable VHF communications are essential. Nine VHF handsets and one 60-watt base station were deployed, with each trekking group having access to at least one set. Regular schedules were operated (co-ordinated by base camp) and there was a lot of traffic. Their use at low elevations was discouraged due to fears that they would become tempting attractions for terrorist but our fears prove groundless. As on our previous expeditions they proved an invaluable resource for logistics and rescue. They were used as a tool to glue this rather disparate expedition together and excelled in this role.

On BMEME '94 we had used HF Radio for long distance communications. This had proved unreliable and our most efficient communication had been via a bulky INMARSAT phone/fax at the Italian Pyramid. In '98 we hired our own INMARSAT and ran up huge phone and email bills. This time we were determined to keep the lid on costs and yet maintain good communications with the outside world for all sorts of social and safety reasons. Fortunately technology had moved on and all long distance communications were done with a smallish IRIDIUM telephone which I carried all the time. Though we did not use its data capacity to send messages we were able to receive texts free of charge. This web based text service, remarkably, is also free for the sender. We received a flood of texts which were transcribed and disseminated to their recipients. The IRIDIUM phone not only allowed us contact to the email Newsgroup via Jane Morris but also allowed individuals to phone families and friends. Despite the $5/minute price tag this proved a very popular pastime. The phone was kept powered up by a dedicated solar panel, charge controller and 4 amp hour 12 volt battery.

The only disadvantages of Iridium are its cost and unreliable reception in mountain valleys. All satellite phones in Nepal need a Government Permit and this, alone, cost over $2,000. The handset cost $1,500, the monthly subscription $25 and the calls $3.50. Nevertheless this must now be classed as an essential piece of kit for any large group venturing into a remote and dangerous wilderness. Regular contact was made with our trek agent the schedule the helicopter flights, arrange re-supply, arrange premature departures and helicopter rescue.

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Logistics

By Simon Currin

Our Expeditions have always been logistically complicated. Thankfully we have, over the years, learned from a lot of our mistakes and we managed to avoid a lot of our previous pitfalls. Several key decisions taken early by the planners meant that the logistics could be simplified. As a result very little equipment was lost or damaged and no projects were prejudiced by avoidable gear failures. These key decisions were:

  1. To use helicopters to transport the delicate medical research equipment to and from Base Camp.

  2. To appoint Jim Duffy and George Wormald as logisticians. Both proved to be thoughtful, energetic and able masters of their new found trade.

  3. To rely on wind and sun for power generation thus avoiding the need for generators and petrol.

  4. To freight baggage in advance of our departure rather than having to rely on excess baggage.

  5. To ask individuals to arrange their own flights rather than to book them all centrally.

  6. To delegate the provision of research tents to the Trekking Agent and to have one nominated member of his staff to ensure the safety of all our research gear from the moment it arrived in Nepal.

  7. To store the equipment in a room in the Hotel which meant that it could be accessed and sorted by members with ease rather than it being stuffed into a small store on the other side of town.

  8. To avoid taking research samples that required refrigerated storage. The transportation of liquid nitrogen has always been one of our biggest, and most expensive, headaches.

  9. Because of political uncertainties we, for the first time, instituted a bond system just in case we required uninsured helicopter assistance. Though the bonds went unspent the process was very useful as it made us all face up to the difficulties and uncertainties of travelling through Maoist areas. Having this financial buffer also meant that crucial decisions regarding safety could be taken, if necessary, according to merit rather than financial worries.

Since 1994 the Nepalese trekking agencies have become much more sophisticated organisations. We were very fortunate in choosing Sherpa Brothers to run our Expedition for us. Tenji shouldered a great deal of the responsibility that would hitherto have been taken by Medex organisers. The key factors that enabled his organisation to do such a good job were:

  1. A detailed contract which tried to foresee potential difficulties and define lines of responsibility.

  2. Sherpa Brothers sent an advanced land team into the Hongu to prepare the landing site.

  3. Appointment of a highly experienced team of Sirdars, sherpas and cooks.

  4. Early freighting of equipment to ensure time for it's passage through customs.

  5. Meticulous planning of supplies and supply lines as the Hongu Valley is far from the usual trek routes. The cooks and Sirdars were given each given budgets and provisioning list which proved remarkably accurate. No groups, as far as I am aware, suffered shortages though there were some allegations that some previsions had been sold off in the villages. We have no way of knowing whether or not this indeed was the case.

  6. Trekking Agencies in Nepal are in a precarious financial state due to the recent decline in business. In order to safeguard their cash flow 80% of their projected costs were paid ahead of the Expedition and the balance on our safe return to the UK.

  7. Porters and staff were equipped to a much higher level than on our previous expeditions. This occurred for a number of reasons: our insistence in the contract, increased awareness by agencies and staff alike and finally the excellent work of Porter's Progress which both raises awareness and provides an affordable bank of equipment for porters to hire.

As with our previous trips the 57 strong Expedition was broken down into 5 small, autonomous, units each supplied with their own compliment of staff. To avoid congestion these groups were kept separate in both time and space. The groups were formed as early as possible in the planning phase but this was delayed due to the political uncertainties that overshadowed the run up to our departure. This cohesive group structure is the single most important facet of our expeditions.

Things we got wrong:

  1. We made every effort to minimise our environmental impact but it was still distressing to see our porters combing the hillside for wood at base camp to cook on. I think that this is a mainly a cultural problem and is very difficult to address. I believe that our agent did everything in his powers to prevent it but maybe we should have been firmer with our sirdars.

  2. On much the same vein littering by our portering staff remained a problem though much less so than in the past. Most of our campsites were left spotless but there was a good deal of discarded rubbish along the way and I suspect at least some of that came from our porters. Again, only our sirdars could influence this and maybe we should have been firmer with them.

  3. We tried to hard to accommodate peoples mountaineering objectives and ended up with a fractured and dysfunctional Ombigaichen team. The mountain was never attempted and the royalty wasted. In future we must be more prescriptive about who climbs what and when rather than leaving to individuals to prepare themselves.

  4. Mountain training - or at least lack of it! A great deal of success and fulfilment was enjoyed on Mera. I am not, however, sure that all who attempted it should have been allowed to do so. We have always taken the view that members must select objectives that are within their grasp and must not expect to be guided either unofficially or officially by their companions. Mera has an undeserved reputation for being a stroll in the park. The fact is that it is a very high and remote Himalayan glaciated mountain which does require mountaineering skills to attempt safely. I think, in future we should be much more prescriptive about what people should and shouldn't attempt and maybe supply more in the way of preparatory training. It's a difficult one to get the balance right.

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Personal Accounts written by members of the Expedition

Arun – Inuku Valley trek: and we thought we had it tough!

By Jim Milledge

Apparently the first Westerner to make the trek north up the Arun Valley to the Dudh Kosi was Tilman in the autumn of 1950. He was followed by the members of the 1951 Reconnaissance Expedition to Everest. Michael Ward was the instigator of this expedition. Whilst he was a National Service Medical Officer with the Guards he had time to research the archives of the Royal Geographical Society and from evidence he found became convinced of a feasible route up Everest from the Nepal side. He had difficulty in convincing the Everest Committee of the RGS and Alpine Club but eventually succeeded. Eric Shipton was asked to lead the party and besides Mike, it included Bill Murray and Tom Bourdillon. In Nepal two New Zealanders, Edmund Hillary and Earl Riddiford, who were completing a successful expedition in the Indian Himalaya, joined them.

Mike Ward has just published a book, “Everest: A thousand years of exploration” (the Ernest Press, Glasgow). He describes it as a monograph and it is a serious historical study and well worth reading. In it he has a chapter on this 1951 expedition and a graphic account of their trek to Solu Khumbu. I thought members of our 2003 Expedition would like to read a bit of it. One must remember that the only maps available to them in 1951 were the ¼ inch to the mile survey of India. In Nepal, where normal survey was not permitted, these maps were not at all accurate. Although they had good Sherpas, from Darjeeling. They did not know the lowland part of the country. They left from Jogbani on the border with India on August 27th and the monsoon did not end until they descended into the Dudh Kosi 24 days later. They traveled to Dhankuta by lorry along an “appalling track across the flat terai”. Then up into the foothills to Dhankuta from where their trek started. This is some considerable distance south of Tumlingtar from where we stared our trek. They found that information about the route was “either lacking or unreliable” beyond the next major village of Dingla. Only later did Mike realise that they were following the lower valley of the Arun. They came to the river from the southeast and had to cross it.

I’ll let Mike tell the story.

“We crossed the Arun River, about 100 yards wide, at Legua Ghat. The ferry was a hollowed-out tree-trunk that took seven passengers and their loads. The two ferry men paddled into the current sweeping us downstream and with a few deft strokes of their paddles guided us towards the calm water by the opposite bank. After letting us disembark, they had to drag the ferry further up stream in order to repeat the process in the reverse direction. We followed the west bank of the Arun for eight miles and then took a path which climbed steeply across the grain of the country to the small village of Dingla. For a few exhilarating minutes we had our first view of the Himalaya. Makalu and Chamlang rose clearly above the clouds, and then suddenly we had a glimpse of Everest. But as quickly as they had lifted, the clouds returned, a black sullen mass of cumulus. It rained almost continuously for the next three weeks.

On 8 September the two New Zealanders, Hillary and Riddiford, came surging up the hill brandishing enormous Victorian-style ice axes. It was good to see them.
They were very fit, very hungry and exuded energy. Expecting to meet a group of well-dressed Englishmen, they were surprised and perhaps a little disconcerted to find that, if anything, we were scruffier than they were.

Our next objective was a 12,000ft pass, the Salpa Bhanyang, which crossed the ridge between the Arun River and the next valley west, the Hongu. As the monsoon took hold, leeches appeared on the end of every leaf. Black, pin-thin and about one or two inches long, they writhed around in clusters looking for blood. The faces of all domestic animals were covered with leeches and with the flies that clustered around their puncture wounds. Some leeches, gorged with blood, became as thick and as long as a thumb. They were to be found mainly on our ankles until brushed or burnt off with a cigarette stub, and the sores which they left behind did not heal until the monsoon ended and our legs became dry again.

On 15 September we crossed the 12,000ft Salpa Bhanyang pass in a thick, cold mist, and joined the route traditionally used by Sherpas when traveling from Darjeeling to Khumbu. Angtharkay was now on familiar ground. The previous year several Sherpas had died from hypothermia on this pass when caught in a blizzard.

We descended steeply to the Hongu River 7,000 feet below
[JSM interjection: via Gudel and Bung, as I well remember. We had the new high bridge over the gorge but they would have appreciated the full force of Tilman's verse

“For dreadfulness naught can excel
The prospect of Bung from Gudel,
And words die away on the tongue
When we look back on Gudel from Bung”

Except that with the monsoon clouds they probably could see neither from either! But worse was to follow!]

where we learned that the bridge over the next river, the lnukhu Khola, had been destroyed. When we reached the makeshift replacement, we found it to be so flimsy that a sudden surge of water destroyed it, leaving half our porters stranded on the eastern side of the river. The main party scrambled up the very steep western side of the gorge, only to find themselves walking straight into a hornets' nest. One porter was so badly stung that he flung his load down and jumped off the path, fortunately landing safely in the branches of a 15-foot tree below. Another porter developed a very high temperature, with a racing pulse at over 130 beats per minute. Most of us were stung and had swollen hands, legs and faces. As we crawled up the hill towards some abandoned sheds, the wind became a gale and the rain suddenly increased so much that it was as though buckets of water were being thrown over us. Rarely had we felt so miserable, half our baggage was probably lost and most of the porters were shivering violently with high temperatures and cold.

To add to our troubles we had somehow deviated from the main route; it seemed that we were lost and even the battle-hardened New Zealanders looked pretty glum.
Our morale, however, was strengthened by the sudden appearance of a wizened crone carrying part of a bamboo trunk. Angtharkay [their Sirdar] brightened immediately and money swiftly changed hands with, unusually, no pretence at bargaining. From the inside of the trunk there issued a fluid that looked like diluted vomit with the faint green tinge of bile and small solid particles. Angtharkay got some cups and poured out about half a pint for each of us. We drank it rapidly, trying not to see or smell it, because, if anything, it tasted even worse than it looked. But as the beneficent effects of the nearly-neat alcohol took hold, the disgusted expressions on our faces changed to a mixture of pleasure and stupefaction - and we all, porters included, pressed on up the hill with renewed vigor.

By about 2.0pm, however, we could go no further. We found some sheds covered in leaves and went to sleep in a quagmire of mud with rain still pouring down on us through the roof. Unaccountably we woke next day feeling better, yet still cold and wet. The rain was coming down in torrents as we made our way along a ridge, asking the way from one group of huts to another, until at last we found the traditional route again. Then, quite suddenly, on 20 September, the rain stopped. The monsoon had ended. We now descended to the Dudh Kosi River and followed it north to Namche Bazaar”

It was that expedition which gave us the much reproduced photo of three of them with umbrellas up and apparently up to their necks in a river. I am told they were actually sitting down in the water, cooling off. This photo was used in a caption competition in a climbing magazine and the winning entry was something like, “Are you sure, Caruthers, that the blue lines, on the map, are the foot paths?”

Jim Milledge, Rickmansworth, August 2003

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“Up to the La”
By Ian Manovel


From Khare Camp to the Mera La is not far to travel in the Himalayas but for me it was one of the most beautiful parts of the expedition. “La” means “col” or “saddle” the lowest point between Mera Peak and a cross-cut saw of rocky prominences heading toward Peak 41. At 5400m it is the most accessible entry point into the Hongu valley where the expedition base camp would be sited.

After so many days trekking through lowlands and forest, past villages, rivers, bamboo bridges and irascible yaks the La had become both a gateway and a mental challenge in the minds of the Group 4 team. Mind you, they were a pretty experienced bunch, a few trekkers in the group had not reached that height previously and there was a natural apprehension, not only at the sight of the massive, glaciated approach but at the thought of the altitude illness that might arise unexpected and unwelcome in our midst.

As usual our porters and Sherpas had shouldered their heavy loads and dashed off into the distance. There was a buzz of concern about safety and precautions. Only two days earlier at Tagnac we had difficulty convincing one of the youngest porters to swap his weary flip-flops (well worn coming up the valleys) for new trainers. Reluctantly, he had consented to reason in the snowy terrain but we all wondered how the locals would cope on the glacier.

Denzil led the short, steep climb up the spur behind Khare leaving us all breathless. The rising sun was glinting on the icy pinnacles all around and the La looked like a shimmering, white pavlova 600m above us. In spite of the snow and ice, we shed clothing layers rapidly as the sun beat down hotter and we slowly climbed higher. My face was daubed with sun-block but my skin still suffered in the intense radiation. My companions teased me about my ungainly, “duckfoot” ascent style but ever stubborn in the face of banter I toiled upward. Though breath was short our hearts were light as we left the mud and rock behind and paused to don crampons. Close in front, the porters seemed sure-footed in canvas frog boots and trainers.

As the sky drew nearer my overarching emotion was a sense of calm and peacefulness. The mountains were silent save for the occasional cracking of the glacier. The expansive silence combined with the cold air, hot sun, blue sky and the improbable beauty leaving me awe-struck yet at ease with the world around.

Nick stopped to test the deep snow for avalanche risk only to discover it gave way at the first kick, not a good sign as the morning grew warmer. Meanwhile, Kate and Lisa posed on a rock for snapshots with Mera Peak and its buttressed crags in the background. We all felt excited to have come so far and our spirits rallied against the obdurate elements. Ahead of us, a single file of porters could be seen inching diagonally up the side of the glacier’s nose. Silhouetted in stark contrast to the ageing, blue ice they were reminiscent of the expeditions of yore where helicopters were unheard of and all goods were carried in from the lowlands by long lines of natives. Fortunately a bamboo stake remained fixed in the snow at the top of the glacier ascent warning climbers of the nearby crevasse and the file turned sharply and disappeared behind a block of ice.

Overhead the sky was burning indigo, all around the dazzling ice and snow hurt the eyes, reflecting brightly in all directions. Just behind the glacier was an enormous overhanging rock wall that towered ominously over the end of the glacier. The shadow from the cliff was just beginning to form on the snow drifts banked up at its base as the sun approached its zenith.

Lungs straining and shoulders weary we toiled up the glacier. To our right hand side the ancient, ice wall shimmered pale blue and dusky ivory. Stalactites grew in profusion over the lip, hanging down in reckless shards. Pausing to catch a breath and enjoy the spectacular scenery, emotions ranged from caution to elation as we surveyed the summit of Mera on the horizon and the detritus of avalanches down the precipitous slopes…another “manovel moment.”

Once we gained the top of the glacier the surface was fairly level and the La could be seen a short distance away but in between lay a series of concealed crevasses. The heavy snow falls had covered the large fissures in the ice with snowy bridges. While the ground temperature remained freezing these bridges would support some weight and the unobservant trekker might pass over them unsuspecting of the cavernous space below. As the sun grew hotter the bridges could become less solid and we risked falling through… to make matters worse, thick clouds appeared, making the footprints in the snow difficult to follow. Gerald and Nick were careful to mark each danger zone with a few words of caution carved in the snow.

Looking back we could see all the way down into the valley below where we had trudged up days before. The peaks of Kusum Kunguru and Kantega zigzagged across the sky behind us marking the furthest borders of the Hinku valley. On the far side of the La was a gentle slope that rapidly inclined toward Mera Peak. Before us lay the Hongu valley. After two weeks of trekking we were finally peering over the edge toward our final destination! The end of the Chamlang ridge could barely be discerned on the far side before the clouds below us had risen obscuring the view. The wind grew stronger and we all donned hats and wind-proof jackets as we waited for the final members of the party to reach the La.

Visibility was very poor in the thick cloud and we worried someone might go astray. Harder still was the porter’s lot. The cook boys had gone ahead with the supplies and some chaps lacked food and water. We scrounged what we could and gave a share to each one as they emerged from the fog and onto the La. The delight on their faces at a few sips of water and dry biscuit was genuine and far more rewarding than the satisfaction of reaching the La. Without our happy team of locals we would never have made it. Fortunately our entire party crossed the area without incident arriving safely at the La and down the far side.

The days that followed were filled with extraordinary beauty and excitement but the day we reached the Mera La remains clearly in my mind as the highlight of the trip.

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Desolate Valley

By Chris Wolff

The valley was horrific; no soil, endless rocks and boulders and yet rushing streams of clear mountain melt water. At the edges of the valley; quite wide apart in much of it, were high banks of bare rock and earth with verdant overhanging earth and even fallen trees, often still alive though their trunks were sloping down towards the bottom of the valley. A lake high up in mountain had burst its banks one day in 1998, washing away the soil and the village of Kothe; most of the people were out above the rushing water and survived but saw their homes disappear in the raging torrent. No more did the yaks migrate up to their pastures, passing through that verdure.

When we saw it as trekkers, the village had been partially restored with very new log huts but the trek was through the nakedness of the rocky terrain, with the evidence of previous beauty present high on either side above the overhanging lips of turf along the sides, much of it densely wooded. Tagnag was almost as bad though it was up on a sloping side of the valley which had been spared. Looking down from the hills above Tagnag one saw a great boulder field with Tagnag just beyond the far side.

While walking through the rock strewn valley one could stop by the streams and occasionally find a pitiful tiny area of moss or other little plant, showing that if only there was soil there growth would be rapid and reconstitute the original habitat. To re-introduce soil by artificial means would require a vast international effort of great expense – not a very likely phenomenon in the depths of Nepal.

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Group 4 and Mera Peak

By Denzil Broadhurst

quote: "It's the highest Trekking Peak, but it's only a long snow plod to the top…."

With base camp up and running, and all of the other groups having arrived, we took the opportunity to make an attempt on Mera. The ascent back to the Mera La from base camp was a long and tiring day, especially as we spotted the Baruntse boys at a lower camp and thought that was where we were going to be camping. A reasonable spot for the tents, though Lisa awoke the next morning in a few inches of water - the frozen pond was no longer frozen. The ascent to high camp the next day at 5,800m was a more pleasant journey with glorious sunshine, avoiding a crevasse where a Sherpa had fallen down a few days earlier. High camp gave some superb views through the evening as clouds rolled along the valley below.

An early night, followed only too soon by the alarm call at 2am and a quick breakfast, allowed us to start climbing at 3am. Emma was not too well so had decided not to make the attempt, but was keen for Nick to make the attempt. Nick climbed with Ongchu, one of our climbing Sherpas, and having acclimatised exceptionally well soon disappeared from view in the clear, starlit night.

Jim, Lisa and I roped up to work our way steadily across the glacial slopes, while Gerald, Debby and our other Sherpa followed along some distance behind.

After a couple of hours we reached 6,000 metres, but rather than slowly getting lighter as dawn approached we realised a heavy bank of clouds had been building up above us, and spindrift was starting to blow across the faint track in front of us. Most of the time the track could be felt rather than seen - rather than sinking in a couple of inches you suddenly found you were sinking up to your calves when you drifted off the right line.

We reached a point where there was no obvious track in front, and nothing that could be spotted by the light of a head torch. Carefully I headed forward a short way - where a clear line of crevasses was obvious. Just the same to the left, and when I went to the right I found myself up to the thigh in a hidden crevasse. I called a halt until the light improved, and we got Lisa into a bivvi bag since her hands and feet were getting extremely cold.

The group behind caught up about 10 minutes later, and Gerald passed some down booties and a couple of still-warm water bottles to help thaw out Lisa's hands. Their Sherpa then continued past the point where I had stopped and disappeared completely - at least 3 metres down a crevasse. Debby held him without a problem, casually holding on to the rope with one hand, allowing Gerald to move forward and help him climb out. They eventually found a safe way across the crevasses and continued uphill, but once Lisa's hands had warmed up we looked again at the weather and decided there would be no sunshine for many hours - regrettably the safest thing was a descent for us.

The height gained over 2 hours of ascent was lost in what seemed minutes as we sped downhill, with visibility getting worse all the time - our previous footsteps were invisible as the spindrift increased. Sat in our tent at high camp I spoke to Gerald on the radio to see if they had also turned back yet - they were going to carry on a little further depending on the weather. A few minutes later there was a flash of lightening and the instant crash of thunder. "We've turned back now" was Gerald's brief message.

As Gerald and Debby reached the tent the snow started in earnest, putting down about 6 inches in the next hour. Nick had left without a radio - keeping weight to the minimum, and there was no sign of him as we waited for a further hour at high camp. As the snow eased off a little Gerald and two Sherpas headed back up the track with some bamboo sticks to attempt to mark the route, and eventually Nick and Ongchu could be seen through the snow making their way down.

Just 2 hours and 40 minutes after leaving high camp they had summitted, at which point Ongchu had exclaimed in delight that it was the fastest he had ever climbed it (and his 36th time on the summit). A few minutes later Nick had heard the buzzing from the hardware on his harness and realised the electrical storm was coming. They dug a snow hole and spent the next hour sheltering, then descended through the white-out conditions - unable to see any of the tracks. Both had fallen into crevasses on the way down, but thankfully only ever one of them at a time.

We all packed into one small tent having soup and hot drinks, thankful that we had all made it back down safely. Mera Peak - a gentle snow plod? maybe some of the time, but not for us…..

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Don't mess with dodgy oxygen bottles

By Denzil Broadhurst

Our oxygen bottles had failed to make it out of the UK, but a number of Indian ones had been rented from Kathmandu - and had been used on some of the people suffering from AMS. As backup we needed to check the large one that had been flown to base camp. Valves made of a mixture of metals can do odd things with temperature, so trying to force open a valve on a bottle down at freezing point is not a good idea. The result - Jim and I were presented with a bottle where the square lug on the top of the valve had been ripped off…. "can you do anything with this?".

Having heard horror stories of messing with high-pressure cylinders, our first action was to remove it over to the edge of camp, sit it on two stools and point it up towards Chamlang. Could this be the first rocket attack on Chamlang?

We were able to partially dismantle the valve, (after careful discussions with some of the anaesthetists who should know about the design of such things!), and get access to more of the steel shaft of the valve. We were then able to cut a screwdriver slot in the remaining stub of the shaft. Even after application of copious quantities of boiling water to warm the valve up, a simple screwdriver wouldn't do the job - as the blade snapped (apologies to whoever we borrowed it from!). Next we improvised an impact screwdriver using a small socket set and ice hammer, with the bell-like sound ringing round the camp on each strike of the hammer…. and finally it moved. Success - and no threat of invasion by the USA looking for weapons of mass destruction!

A few days later one of the other groups arrived carrying a smaller oxygen bottle, but we needed to fit a flow meter. A nice simple meter (Rotameter) relying on a slightly tapered inner tube inside a plastic container with a lightweight plastic bead - pushed higher up the taper as the flow increased. This is all on the low-pressure side of the valve, so no danger was expected. We were working in the dome tent with four of us crouched around the bottle, trying to figure out why the bead didn't rise up the tube, when BANG!!

I was on my back against the side of the tent, Gerald was looking stunned with fluid running from his nose - complaining about a possible burst eardrum, Ang Dorje had blood running down his cheek and Nick had blood on the bridge of his nose. Across the other side of the tent Jim was bent over clutching between his legs. A shout went up for a medic and Paul rushed across from his tent carrying various bags.

The base of the Rotameter was still fitted to the cylinder, but the rest of the plastic was shattered and scattered all around the tent. Paul treated the wounds - with Nick's major concern being to check that the plastic fragments hadn't damaged his (expensive) sunglasses. Jim refused an inspection of his injuries - which we later worked out had been caused by the tapered inner tube ricocheting off the roof of the tent (leaving a small tear) and impacting in a most sensitive area…. Gerald's hearing slowly returned to normal, and I went back to my breakfast, inspecting the new holes through the rim of my hat and bruise on the side of my head.

We had been extremely lucky to get away with just a few minor cuts - next time a few pairs of safety glasses will be in the toolkit, and we'll treat anything to do with oxygen bottles a great deal more seriously.

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Mingbo La

By Denzil Broadhurst

The failure of most of our group to climb Mera due to the foul weather had been very disappointing. This had been compounded by the decision not to even attempt Ombigaichen because of the loose rock on the ridge. We didn't fancy the climb up to the Mera La again, but were going to be rather short of time to do anything too major after we had packed up base camp and had it flown out.

Our climbing Sherpa had reconnoitered the Mingbo La route some time earlier whilst looking at Ombigaichen, and considered it passable with a small team provided the snow held off. A few of us had walked up the valley to attempt to get views of the area, and it certainly looked interesting. It would take us back into the Khumbu, allowing us to see some of the villages on the Everest trek route, returning to Lukla via Namche.

The day before the helicopter was due, Annabel and Paul headed out with a few of the kitchen crew, to set up a base camp below the La. Early the next morning we were delighted to hear the sounds of the helicopter resonating up the valley - and quickly loaded the first 400kg of research kit. The helicopter soon returned for the second load and we could finally pack up base camp completely. Gerald, Debby, Jim and myself then headed out up the valley with Ang Dorje and Rinji. Easy going to begin with, but then a laborious slog up and across the moraine to finally get to the base camp at 5,400m in the late afternoon.

The 6 of us squeezed into two small tents to eat and sleep, then we left at 5am for the start of what we expected would be a long day. We were back on to moraine initially, then as the sun rose we got out on to the broad glacier leading up to the La with superb views across to Everest. The views of the rocky lip of the La with Ama Dablam above, and to the right the ridge leading to the summit of Ombigaichen, were taunting us for hours as we slowly made our way up the glacier.

By late morning we were all on the La at 5,815m, watching as the last of the porters were lowered 150m down the 70degree ice and rock slopes on the Khumbu side by our climbing sherpa Ongchu, using 3 ropes tied together. It was soon our turn to abseil down, with the additional challenge of passing the knots. Rinji was waiting for us at the bottom, where a snow bridge spanned the bergschrund, to get us safely off the rope.

Our sherpas and porters started on the descent of the glacier while we re-grouped in sweltering conditions in the huge snow-bowl below the ridge. Eventually Ongchu made it to the bottom using 2 snow stakes as belays on the way down - allowing him to recover all of the ropes. Ongchu had crossed the La some years previously but was surprised to find the easy route he had used to descend the glacier was now a minefield of crevasses and ice pinnacles. We had to follow the footprints of the other sherpas, avoiding the dead-ends which they had tried and then crossed off in the snow.

A final descent of a short 50 degree slope of blue ice - for which some of us put our crampons back on and down-climbed, and the others waited for a rope to abseil down, led us on to huge steep rock slabs. We were now able to see the rest of our crew below us on the moraine - who helped by pointing out the safe descent route. Scrambling down some of the slabs, abseiling down others, then a final traverse on a narrow rock-strewn ledge got us down to where our cook boys were using the last of their paraffin to give us soup and hot drinks. We were not surprised that a group of French guides had failed to find a safe route up to the La from this side the previous year.

The walking now was much easier, and we were grateful that Simon was able to send some of his porters to meet us on the final descent and take our packs. Even with the increase in walking speed, and with the final hour in the dark, it was 7pm when we met up with Simon and Sally at their lodge in Pangboche. We hadn't been using our headtorches because we didn't want to upset the night vision of the porters, so the steep loose drop to the river and crossing the narrow wooden bridge with no handrails, in the dark, was an interesting experience!

A long, difficult, but thoroughly enjoyable day.

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Maoists and Penknives

By Pete Smith

As for myself, I had a fantastic trip from beginning to end. After leaving the group, the trip to Lukla was excellent and eventful. I started playing shove half penny with the Nepalese (Maoists) I thought if I proved myself the undisputed world champion at their national game I'd be the last one they would take money from or shoot! Well it didn’t quite work in the village of Paya. Sitting having lunch with my porter who happened to be looking through my binoculars, a group of Nepalese Maoists gathered and asked to use the binoculars. My nervous porter handed them over and a look of horror ascended his face as they told him they should be donated to their cause!

Caution being the better part of valor I offered to exchange the glasses for something more suitable. It worked! They were handed back in anticipation of the exchange. Bugger this I thought as I rummaged my bag and a red mist ascended me. I pulled my ice axe out of my bag and explained that if they could get it off me they could have it. Coupled with sentences like “please go away you naughty boys” or words to that effect! It worked, they did, but I spent a nervous two hours looking over my shoulder as we continued to Lukla.

On final thing. You may also recall that fantastic multi useful tool I so proudly displayed to Chris Wolf and the others. Well I know it didn’t get used much. Well not at all really! But on arrival at a lodge at Pangom this calf had a horn growing back into its head. The poor beast must have been in some discomfort, until following a request from the Lodge owner I was able to pull that magnificent tool from my pocket. I have attached photographic proof of the deed and trust you will rub this firmly up Chris’s nose!

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The ascent of Mera Peak

By Mireille Baart

It is 2.00 a.m. and I am laying in a tent in Mera high camp at 5800m. I wonder if we will go to the summit and climb Mera today. From yesterday afternoon until one hour ago there was a horrible snowstorm going on. However, the storm is over now. We hear some noise outside but after a while we hear that we are not going. Two hours later we surprisingly get bed tea and noodle soup. Oh, how disgusting! It is contaminated with kerosene and I can drink only a few sips of my tea. We are wondering what is happening. Why do we get tea and noodle soup in the middle of the night? Are we still going? It might be a bit late… However, after a while it seems that we will go to the summit though. It is nearly six o’clock when we are ready to go. I am on a rope with John, Piotr and our climbing sherpa Chomba. Ian, Michael, Damien and climbing sherpa Mingba go ahead. Unfortunately, Sally is not feeling well and therefore Sally and Simon stay behind.

We start walking slightly uphill over the Mera glacier. It is a nice walk, the weather has completely improved: the sky is clear and soon it becomes very warm. Later the slope becomes more steep. At the end of the steep part I am very tired and thirsty. Unfortunately, the drinking water is also contaminated with kerosene and I cannot drink it. After a short break we go further. It is not very steep any more, but a strong wind has risen now and it becomes colder. It is very tough as I am a little dehydrated and every few steps I need to rest for a while. Suddenly I see the last steep part to the summit, I take new courage and it all seems to go much easier. At 10.30 a.m. we are on the summit at ca. 6470m. Although, I must say we are on the highest point we can achieve: a big crevasse prevents us from climbing the last 5 meters to the summit. On the way my team mates had suggested to throw me over the crevasse with two ice axes and a robe, but I think they have seen too much of “The Vertical Limit”. The view is exciting: we can see several big Himalayan peaks, among others Everest, Makalu and Kangchenjunga. We take some pictures and then we start to descend. Mera high camp has been struck already and there is only one sherpa waiting for us with some kerosene contaminated hot lemon. After a short break we descend further to Mera base camp, looking forward to clean water and a nice sleeping bag. However, to our surprise base camp is also broken. There is nothing to do about it: we have to descend another two hours further to the Tryfan Rock and then, after a long day, we arrive exhausted, though satisfied, in Tryfan camp.

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A Pointless Death

By Simon Currin

On a cold and misty afternoon I went for a stroll above our camp at Tagnag. It was then that I first saw her. A swollen oriental face protruding, tortoise like, from the door flaps of her dome tent. She smiled and I nodded. Then the usual pleasantries. She was Japanese and four days into her trek. Her aim, with her companions, was to climb Mera but things were not going well. She had struggled over the high Zwatra La just two days after her arrival at Lukla. Things had eased a little with descent but she had then endured the climb to Tagnag arriving exhausted. We had taken a rest day here after a much lengthier and more gradual ascent but they were having none of it.

We chatted a while and then she sank back into her tent as the evening chill advanced. I went away with my thoughts. Why were they pushing on when clearly they should rest?

Next day, as we ambled towards the snout of the Mera Glacier, we quickly caught up with her. Beneath her comical linen helmet the same swollen face grimacing with effort as she heaved her way along the trail. One sherpa carried her bag and her empty water bottle and she begged us for water which we provided. Once her breath had returned we paused to chat, she even insisted, in true Japanese fashion, that she photograph our group. We moved on and she fell behind as the way steepened towards Khare Camp. That was the last we saw of her, a lone, ageing figure propped up with ski sticks staggering her way towards her mountain.

Four days later, on a broken radio call from Jim Milledge, we heard that she was dead. She had died as we had left her. Alone and in Khare where her companions had left her, three days before, to climb Mera. The porters had done their best but it seems she had refused all advice to descend. None of her fellow Japanese had elected to stay with her as her condition deteriorated. They had climbed their mountain but returned to find a corpse. A pyrrhic victory and a needless death.

We were asked to organise the evacuation helicopter using our satellite phone. This we willingly did but declined to pass on the Japanese leader's request for the rescue helicopter to deliver them a further 80kg of rice. It seemed a little too callous in circumstances!

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A Pointless Death, part 2

By Alex Horsley

We had spent two nights in Tagnag, blissfully enjoying the pleasures of a relaxation day, before setting off up the valley. The first we heard of any concern or distress in another group was on that trek to Khare. As a small group of us sat on a boulder, waiting for the rest of our group and joking with the sherpas, a pair of figures approached us from above.

They spoke no English but our sherpas translated for us. They were porters from the Japanese trekking group that Simon had encountered a few short days before. They had been sent to ask us (or anyone, it wasn’t clear) whether we could contact Kathmandu to arrange an evacuation of a sick trekker from Khare. That was it. How sick? How long have they been sick? We would have to wait until Khare to find out.

We pressed on up the mountain. The pace quickened slightly and we elected to press on without waiting for those behind. The heavy barrel of medical supplies, ably carried by a porter, was already far in front of us. There had been little urgency in the porters descending from Khare, and little in our ascent.

Khare is a bleak spot. The last patch of green: all above was snow and much below was rock. There were a smattering of low stone huts with the ubiquitous blue tarpaulin roofs and small huddles of porters taking shelter. The Japanese camp was just below all this, at the entrance to the small plateau of Khare. The camp now consisted of only a couple of dome tents and a toilet tent, the rest of the party having pushed on a couple of days previously.

We were approached by a sherpa as we entered the plateau. He was assigned to the Japanese trekker and it was he who had sent the porters down valley to Tagnag. She was unwell, and had been for some days. Now she was worse. He showed myself and Will Sargeant to her tent.

It was clear that she was dead. The pale waxy face was swollen and staring from her duvet sleeping bag, but she was still warm. Without any history or background we automatically started CPR and yelled for our sherpa to find out what had happened. But it was clearly pointless. The air bubbled into her lungs and gurgled out again with the chest compressions. She was dead and we stopped almost immediately.

The rest of the story we filled in slowly from different sources. She had apparently been unwell at Tagnag but had pushed on and refused to turn round. Unable to go further she would not turn back and waited for her companions as they continued up Mera. Their sherpa produced a list of the names and ages of those in her group. All Japanese, they were mostly in their sixties.

As we tried to contact base camp on our radio to arrange a helicopter, the rest of her group appeared over the snow and returned to their camp. We watched from a distance, their triumph now pointless. Not wanting to miss an opportunity, their sherpas informed us that the group was short of 80kg of rice, and could this be sent on the helicopter!

There is a bitter irony to this tragedy. We were over-equipped to deal with any but the most serious emergencies and carried not only a huge barrel of supplies and medicines but an oxygen cylinder too. The mountain was crawling with doctors that week as the Medex groups passed through, each one as well supplied as ourselves and surely containing more mountain medicine experience than any where else on the entire continent. While she lay dying and alone in her tent, with the casual support of her sherpa, we basked in the sun not three hours away. Even without us, there is a sherpa trained and equipped to deal with precisely this sort of situation, based at Tagnag. Any one of us could easily have averted this death.

The next day I had cause to dwell on it again. As we climbed over the Mera La the altitude started to take its toll on me. I became sluggish, nauseous and crippled by a throbbing headache. Fortunately it settled with descent, but the corpse in Khare acted both as a warning and an insight. She must have felt like this, and worse, for some days. And why? For the personal challenge, the fear of holding back her companions, the shame of failure? Whatever her reasons she made it to Khare, but her team should have sent her back or waited with her. A timely warning to us all that the mountains are not just a nice view.

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Maoist Encounter

By Jim Milledge

It was the third day of our trek from Tumlingtar to Chamlang Base Camp, April 4th. We left Gothe Bazaar and were trekking through paddy fields and villages. It was very hot by the time we stopped for lunch. We noticed that our Sirdar, Ang Dandi had been joined by a smartly dressed young man and the two were in earnest conversation sitting on a rock. The rumour went round that this was a Maoist asking for donations for his cause. He went off and Ang Dandi confirmed that this was indeed the case. He wanted donations from both us, trekkers and from the trekking agency via Ang Dandi.

We set off for the afternoon’s hike and later the Maoist caught me up and asked if I was the leader. I said I was the senior-most member and spokesman for the group. He told me that the good news was that the “Class struggle” had come to Nepal but that in order to continue working for the people, his movement needed money and he was sure we would like to make a donation to the cause. He suggested that three thousand rupees each would be appropriate, Rs 30,000 (£250) in total! I was non-committal and he said he would be round to our camp that evening to collect.

Following this I had a chat with Ang Dandi at our next rest stop and he told me that he had asked the man if he had a “pad” i.e. a receipt book since, he explained, if he were to give a donation on behalf of his company he would not be reimbursed without a receipt. Also previous groups who had been asked for donations had been given receipts. There was no receipt book. Ang Dandi also confirmed what I thought I had heard, that the Maoist leadership, now in Kathmandu for talks with the Government, had stated that tourists would no longer be asked for donations.

True to his word the Maoist showed up soon after we made camp at Phedi. I talked to him with Ang Dandi. First I asked him what exactly was his role in the Party and got him to enter this and his name in the back of my diary. I was suspicious that he might be just trying this on and would jib at committing his name to paper but he readily wrote it, “Roshan, Secretary of the Bhospor District Maoist Party Nepal”. He was normally stationed at Kotang, the District HQ which is why he had not encountered the previous 4 Medex groups. I then asked him for his party membership card. He did not have it with him. I asked, if I were to give him a donation had he got a receipt book. No.

I said that I thought it would be quite wrong for us to give him a donation for three reasons.

1. The leadership of his Party had given it out on more than one occasion that they would no longer be asking for donations from tourists. If we were to give him a donation the news would get back to Kathmandu and he, Roshan, might get into trouble and I would not like that to happen.

2. It would be quite irresponsible of me to give money to someone for the Party unless I could be sure he was a genuine Maoist and without some ID how could I be sure he was who he said he was?

I decided that the third reason was too much for his English which was better than my Nepali. However, it was not really up to appreciating this one; which was that I thought Nepal needed a class struggle about as much as a hole in the head! I was not willing to make a donation to that cause.

After a lot more discussion going around the same arguments he left but returned a second and a third time. By the third time he was suggesting that we might donate not Rs 3000 each but perhaps 250! I nearly weakened but then thought, no, if a large donation was wrong so was a small one. The other new point he made was to point to a small cotton pouch at his belt. “This is a bomb”, he said, rather diffidently. I felt it. It was heavy for its size and dimpled; clearly it was a hand grenade! However I couldn’t really take him seriously and after that he left.

The next day we learnt from a Sherpa who kept the Hotel in Phedi, that a couple of Dutch or German tourists who had stayed there had made a donation to this man of Rs 5,000 each! After returning to Kathmandu almost four weeks later I phoned the British Embassy and talked to one of the officers there. He thought it likely that our man was probably a Maoist now freelancing and that we had been right to call his bluff.

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The Official Medex Group 1 Song 2003

Edited by Ali Mynett

Sung to the tune of ‘She’ll be coming round the

mountain’

(Please excuse any foul language…shall try my best to

edit where possible!!)

Medex Base Camp do you copy? It’s Group 1,

Medex Base Camp do you copy? It’s Group 1,

We’ll be coming round the mountain

Eighteen days and counting

We’ll be coming round the mountain, we’re Group 1

(DIAMOX!!)

Michael Donald is our finest radio man,

Trying not to break the radio if he can,

In response to any utter

“Copy that” is all he’ll mutter

With his crotch rot all he needs is Canesten (HE’S A

FUN GUY!)

Giorgos Tsianos is our Greek god that’s his name,

He’s an international swimmer of some fame,

Washes himself three times daily

Next to Dan smells like a fairy

Like a Timotei advert with his flowing mane (BECAUSE

HE’S WORTH IT!!)

Jennifer Cleland is the oldest in the team,

Even so she keeps herself neat and pristine,

Eyebrow plucking and leg shaving

Facial scrubbing, she looks amazing

Pretending that she loves it in Nepal

(WHINGE, WHINGE!!)

Sarah Trippick has a quick one every morn,

Just to get a bit of heat before the dawn,

If her stomach wern’t so queasy

We all fear she’d be quite easy

In a tent alone she cannot get the horn

(W**K TENT!!)

Olly Kemp is such a farter it’s unreal,

Even when we’re trying to eat our evening meal,

Dead rat up the a**e we feel

Is the source of this ordeal

Only closely rivaled by his tent-mate Neil (GUFF,

GUFF!!)

Here’s a verse on our mate Dan we cannot miss,

He swears so much you know it really takes the piss,

The air is blue when he’s in camp,

F**K, S**T, B*S**RD, C**T, T*TS, W**K

So wash your mouth with soap and then we’ll give you

thanks (SMELLY C**T!!)

Group One Medical Officer is ‘Nasty Phil’

She’s got lotions, potions, every kind of pill,

Crossed the Mera La with Giardia

Ain’t a girl in camp who’s hardier

But has she been in the country long enough?

(“SHAME”!!)

Stephan Sanders and Matt Litchfield are a team,

“Which is which?” you ask – we know just what you

mean,

Charging up the hill before us

Brand new doctors soon to cure us

Now they’ve gone to Mera Peak 'cos they’re machines

(GOOD LUCK TONIGHT!!)

Jilly Ingles has a very infectious laugh,

Has an IOU on Dan for when he’s bathed,

Worried that she’d walk at snail pace

She’s been running up the rock face

Always smelling better than her other half (CHUCKLE,

CHUCKLE!!)

Neil Richardson’s our very own Basildon Bond,

Smeared in sun cream to make sure he doesn’t burn,

He’s an expert mountaineer

Although some would think he’s queer

With his ‘Borak’ impressions we love him dear

(“IN MY COUNTRY…”!!)

Brighton lent us Ali Mynett, what a chick,

Tends to set fire to her knickers for a kick,

With the right kit and the right tits

She’s got legs up to her armpits

She’s been tramping in her big boots the whole trip

(AND A G-STRING!!)

There’s a very naughty girl called Juliette,

Who has brought an incredibly large down jacket,

Her and Olly now an item

Snogging nightly we can’t find them

Squealing, screaming and play fighting, she’s the best

(EXCELLENT, CAMBRIDGE!!)

Group 4 Medex do you copy? It’s Group 1,

Building Base Camp must have been a lot of fun,

If we trip up in the Power tent

Or we don’t zip up the Dome tent

Then like naughty children they will smack our bums

(BREAKER BREAKER RECEIVING YOU 5 OUT OF 5!!)

Group 3 Medex, you’re behind us, it’s Group 1,

Snickers, Mars Bars, Beer and Whiskey…there are none,

Now you’ve got to Tumlingtar

HAPE and AMS so far

Romance blooming, rain is looming, now you’ve come

(ONE BY ONE!!)

Group 2 Medex, our great leader, it’s Group 1,

Without you the expedition wouldn’t run,

Even though you split for Mera

Day by day you’re getting nearer

Now you’re here, we’re all united, we are one

Group 5 Medex, do you copy? It’s Group 1?????????

(no response….where are they?)

THE END!!!!!!!!!!!!!!

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The End

By Piotr Szawarski

This is the end of the adventure. I am sitting in my room, listening to music, drinking tea. The mountains of paper, books and clothing make access to my bed a little tricky. There is a high avalanche risk and I am not sure about the weather. Perhaps I should use fixed ropes?

Allegedly I am back in the real world, the world of Starbucks coffee and Tesco supermarkets. No crevasses. It is comfortable here, but what is so real about it? I do wonder that, as I look at the photos taken on the white slopes of Mera. There, from the brilliance of the glacier rises ragged horizon with defiant, rocky towers of Mt Everest, Lhotse, Makalu and Kangchenjunga. Magnificent Chamlang claims the rule over Hongu. I remember feeling nearly dead up there. But after… so alive! I sip my tea and begin to surf the internet. Where next? Back to climb Pumori? That was Simon’s suggestion. It is certainly a beautiful peak. Khumbu was grand with Ama Dablam at one end and Nuptse and Mt Everest at the other. And the yak train on the way back made it even more original, if at all possible. Or perhaps I should explore Mexico’s volcanoes? It would be good to practice Spanish and they don’t serve dhal baht. How I miss this feeling of elation, when day after day I would wake up surrounded by amazing people in a fascinating country. I have climbed my first Himalayan peak; I have crossed Amphu Lapcha, an impressive and exposed high pass. I have played my role as a medical officer and gained valuable experience. I have spent my birthday in Chamlang Base Camp at 5000m and received my membership exam results over VHF radio. I have made many friends. What else one could want? The only thing missing from the journey through the middle of nowhere was Raiders March being played in the background. Looking at the photos of the real world I sip the tea… Every journey begins with a single step. It is a long journey to go back. It is time to begin again.

Post Script

It was drizzling when we were walking down to Lukla. It was last day of the trek. Soon we were to board the bird of freedom. Paul’s face was flushed and he brandished his walking sticks like an M16. There was strange light in his eyes as he shouted, his voice hoarse: “you had to be there man… you had to be there…” Mireille looked at her project supervisor with concern in her eyes. I looked at the green terraces emerging from the mists. We were going back to the real world.

Expedition Quotes

“Strange sensation having your feet sucked” – Annabel to a shop assistant in Field & Trek

“Testosterone is a hormone of darkness” – Mary Morrell

“Don’t use a knife you oaf! This is a non-stick pan” Dr David Collier to Dr David Hillebrandt (with the faculty of DipMM as an audience).

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The North Face of Kala Pattar (aka Island Peak, 6189m)

by Stephan Sanders and Matt Litchfield

It seemed like the perfect plan for Stephan and Matt: to get lost and climb the wrong mountain. With Mera in the bag from a lightweight Alpine style ascent requiring just three porters, one cook, one guide, three tents and half of Gerald’s chocolate stash they were psychologically and physically ready for their next challenge. Two machines ready for action…

Due to its mildly illicit nature, the true target of our preparations had been clouded in an ‘I could tell you, but I’d have to kill you’ cloak. As we sat with the Amphu Lapcha behind us, stranded through milk deprivation, it became clear that continuing this policy would soon result in group carnage. Even the Sidar was becoming openly suspicious. His questions regarding the need for a ground sheet and rope to ascend Kala Pattar had taken an uneasy tone. Stephan’s reassurance that these were “Just in case…” did little to appease him.

We set off towards Chukung, staggering under the weight of our oversized backpacks, accompanied by a curious ‘clinking metal’ sound. As we turned a corner the immense face of the Lhotse wall towered in front of us, though Simon had to point out that Island Peak was also there, just disguised against Lhotse.

A couple of hours later the group arrived at the junction between Chukung and Island Peak. The name of the game was subtlety – one of our greatest skills! We put our bags down, sat on the rocks and waited for everyone to pass. As various group members left with shouts of “Good luck! / See you in a few days! / Happy climbing!” the Sirdar looked distinctly unimpressed.

There were several climbing groups and a large rock collection at the base of Island Peak. We stood out from these groups in that they had both tents and water – we had neither. A few hours later, despite having constructed a luxury 5,000m bivvi, our water hunt had revealed only the creaking glacier 200m below or a patch of shit stained snow. We chose the snow.

Before dining we scouted out the first 500m of ascent then returned for ‘Smash a la tomato pasta con tuna surprise’ – the surprise being the bits of grit from the melted snow – and settled down for a quiet night. At 2:00am Matt insisted that we should try and climb the mountain, so off we went.

The climb became increasingly interesting as we ascended, progressing from grassy trudge to a rocky bit before a scramble with sections of ice. As the sun began to rise we reached the glacier that led to the summit ridge. Looking south we could see the peaks of Mera behind the Amphu Lapcha. We crunched our way up and then, using a snow bridge that looked as stable as Chernobyl’s reactor, crossed the bergschrund.

With just 100m of ascent to go, only a steep ice slope separated us from the summit. From the bottom this slope looked totally insurmountable and half way up Stephan realised that it actually was. We descended to the base where Stephan spent a pleasant couple of hours enjoying the sense of continuing life. Meanwhile in true Machine style Matt hopped up another team’s fixed rope and beat most of them to the top.

As we began the descent we came to the realisation that we had not had a decent pizza (sleep/drink/rest) for a long time. With this aim in mind we quickly grabbed our hidden kit from the bivi site and sped to Chukung. It was only here that someone told us that Island Peak and Kala Pattar were different mountains…

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10 Rules of Nepali Etiquette:

by Stephan Sanders

1) Contrary to popular belief it is actually considered rude to knock over the ashes of your host’s ancestor. Should this unfortunate incident occur it is best to scoop them up with your hands and depart with elegant haste.

2) In Nepal birthdays are celebrated by loading a backpack with rocks to prove that the passage of years have not affected the person’s strength or resolve. To demonstrate appreciation of this act the recipient should wave a raised middle finger in the air and sullenly carry the rocks all day.

3) Alcohol should only be consumed in moderation. Signs that you might have exceeded appropriate levels include:

· Being unable to find your room

· Lying on top of your mate and kissing him

· Merrily drinking contaminated water

4) Should you chance upon a bunch of marauding terrorists it is a mark of respect to leave your friends in peril whilst you calmly saunter ahead. This shows your friends what faith you have in their survival abilities.

5) It is acceptable to extort money at gun point only if a suitable receipt can be issued. Please note that the members of groups 1 and 3 will have free access to the Maoist website currently under construction where you can see free pictures of terrorist acts 24hrs a day.

6) When searching for a suitable toilet it is wise to avoid locations where entire trekking groups are watching. In the event of this occurrence the cheers should be accepted with a quiet dignity.

7) Out of respect for your leadership your cook may successfully follow you up the mountain assisted by only half a tent pole. He should be rewarded for his faith in your abilities with a place on your rope to aid his safe descent.

8) Should one trip whilst entering the ‘Power’ tent it is considered polite to accept the jeers and taunts with begrudging humour before raiding the tent’s chocolate supplies in the middle of the night.

9) Nepal may have a different attitude to flatus than that to which you are accustomed. It is non-acceptable to wake those in neighboring tents through episodes of explosive flatulence or to cause evacuations of the dining shelter repeatedly. These acts may be appeased by wearing a cheeky grin and practising unerring faithfulness to those back home.

10) Whilst trekking it is essential to maintain a high level of cleanliness to prevent perineal fungation. Trekkers will be expected to shower at least once in a six week period to ensure conjugal happiness at high camps.

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MEDEX 2003: THE THREE PILLARS OF FAITH

Or: How I learned to stop worrying and love Nepal.

By Greg Harris

My moment of prayer occured on the tarmac at Tribhuvan airport, as our chosen vehicle slowly dripped something volatile from its starboard engine while we tightened our seatbelts. Buddhism preaches that one should remain equanimical and smile in the face of adversity; Buddha must have flown with a different Cosmic Air to this one. We had but The Three Pillars of Trekking Faith to turn to and duly placed our lives in the hands of chef, Sirdar and Mount Everest whisky.

The next time I doubted my mind was while trying not to die from either smoke inhalation or hypothermia after an afternoon of walking up a big hill in a monsoon-like downpour, while all my warm, dry clothes were somewhere behind me in a big blue barrel. It was neither the weather nor the smoke that had me astounded – it was a demonstration of the miracles of Laxman. It can be only a miracle that produces pizza and chocolate cake at an altitude where normal mortals can barely think of how to get food to mouth.

The First Pillar of Faith

When you can think of no reason at all to be out in the middle of nowhere, in the rain, tired and grumpy, the only cure is a 5 course meal.

Group 3 continued on its occasionally merry way, punctuated by interesting illnesses, Maoist inaugurations and chocolate cake. Proving ourselves to be the most diverse of groups, we promptly divided in 4 directions. A lesser leader would have thrown up his hands and demanded that we all go home and leave him to his card games in peace. Not our Sirdar, who spent days in mental arithmetic working out how to split the staff into appropriate bite-size chunks, and how to pay them all. And it worked. We all got to where we were meant to go, intact.

The Second Pillar of Faith

Any Sirdar with an inexhaustible supply of clean, red tracksuits is worth trusting, even if the next town he suggests doesn’t seem to exist.

Mount Everest – powerful, intoxicating, it called us ever onwards. Its special blend of Scotch malt whisky with the finest Nepali alcohol kept us in good cheer and our porters in fine voice.

The Third Pillar of Faith

Lifting some spirits will lift your spirits.

Having faced our greatest fears (rain, cold, lack of showers, a leech, Chhewang’s socks) and overcome them, we had learned that nothing is achieved without hard work, but liberal doses of fried food and alcohol help!

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Medical Expeditions Science: 2003

Introduction

By Jim Milledge

This report gives some idea of the scope of the science attempted on the Expedition. In compiling it, from contribution from all the lead researchers, I was struck again by the incredible diversity of the projects undertaken. An enormous amount of hard work went into preparing and carrying through these projects by a large number of people. Apart from the names which appear in this report, there were many others without whose contribution the science would not have happened. It may be invidious to name some and not all but risking that I would like to pay tribute again to George Wormald who, though not able to come on the expedition, dealt with all the air freight, Denzil Broadhurst and Jim Duff who ran Base Camp so efficiently and much else. Annabel Nickol who, with help from Paul Richards, lead the science program and also the other members of Group 4 who set up Base Camp, especially the scientific infra-structure. Thanks are also due to Simon and Sally for organising the whole trip and getting us there and back. Ted Carter, Chief Technician at Queen Mary College who make his lab available and patiently helped us in innumerable ways during the data collection week-ends. Finally, of course, the science could not have been done without the active cooperation of all members who acted as (willing!) subjects.

As compared with the previous two Med Exp. Expeditions a much higher proportion of members were involved with research. This meant that the potential for tension between getting on with their own research and acting as subjects for others, was even greater than on previous expeditions. It is to everyone’s credit that in the event, both during the week-ends in London and during the time at Base Camp this potential threat did not become a problem.

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Daily Data Collection

By David Collier

Work on altitude headache with Eli Silber found that only half of reported headaches during the K98 expedition were accompanied by positive AMS scores. The visual analogue scale information taken at the same time as self-reported headaches suggested that such headaches were also associated with impairment of other capacities. This implies that the Lake Louise score may miss a substantial fraction of altitude illness. Whilst this might not matter for a scoring system for AMS to be used to diagnose and treat significant illness, this is not ideal for a research tool.

Tom Martin and I derived a Visual Analogue Scale (VAS) score from the K98 data, which we think may be a more sensitive measure of altitude illness than the Lake Louise Score. This requires validation in a number of other settings, one of which was the Medical Expeditions Makalu 2003 trek. Further data will also be collected on the APEX 2003 trip to Chacaltaya.

The 57 members of the Expedition each had a data diary which they filled in each morning and evening of the trek. The data recorded included; location, altitude, barometric pressure, air temperature, SaO2, pulse rate, symptoms of AMS both Lake Louise score and VAS, bowel movements and consistency and any medication taken. This vast amount of data has been entered into a large spreadsheet and the accuracy of entry is being checked. When this is complete the spreadsheet will be available to researchers who can then use it in the analysis of their own data.

I am very grateful to all members who diligently filled in their diaries and to the data collection officers in each group who ensured that this was done.

Hypoxic ventilatory response (HVR), acclimatisation to altitude and the ACE gene

Giorgos Tsianos, Jim Milledge, Annabel Nickol, Daniel Matisson, David Collier and Hugh Montgomery

Background There are two versions (or alleles) of the angiotensin converting enzyme, ACE, gene: an I form (insertion) and D form (deletion). Everyone has two alleles. Elite performance at high altitude and increased oxygen saturation levels in the blood during different ascent profiles is associated with the ACE I-allele.

Aims To see whether those people with the I gene have a greater increase in breathing when exposed to low oxygen levels. This might be apparent as a greater hypoxic ventilatory response (this is the amount by which breathing is increased as the oxygen level is lowered), or at altitude by higher oxygen saturations and lower carbon-dioxide levels.

Methods At sea level the hypoxic ventilatory response was measured. Gene studies were carried out to split the volunteers into two groups: those with two versions of the I gene (II) or one of each (ID), and those with two versions of the D gene (DD).

During the trek from 937m to 5000m resting oxygen saturations were measured twice daily. At Base Camp expiratory carbon dioxide levels and respiratory rate were measured each morning on the first 3 days.

Outcome Preliminary results show that there is no difference in hypoxic ventilatory response at sea level between the two groups, and no difference in expiratory carbon dioxide at Base Camp. The oxygen saturations will be examined soon. It seems that even though the I-allele of the ACE gene has been associated with an increased hypoxic ventilatory response during exercise in low oxygen levels, as well as increased blood oxygen saturation levels during rapid ascent profiles, this may not be the case during well planned, slow, and staged ascents to high altitude. The latter precautions could allow mountaineers to acclimatise better to the decreased oxygen pressures at altitude, protect them from the dangers of high altitude illnesses, and so contribute to an enhanced performance in such environmental conditions despite any genetic predisposition to the ACE I/D polymorphism.

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Gastrointestinal perfusion at high altitude whilst resting and exercising

Stuart McCorkell, Daniel Martin, Mike Grocott

This project was conducted by the Baruntse expedition group. We hypothesised that during hypoxia at high altitude, particularly when this was exacerbated by exercise, the blood flow to the gut would be impaired because blood supply would be directed elsewhere (heart, brain, muscles) to preserve oxygen delivery to "vital organs". To test the hypothesis we studied 6 healthy volunteers at Chamlang Base Camp (5000m) at rest and then using a stepped exercise protocol (stepping on and off large stone block) whilst measuring the carbon dioxide concentration in the stomach using a gastric tonometer. The gastric tonometer measures an increase in intra-gastric PCO2 when blood flow to the stomach is impaired. This is probably due to a combination of increased CO2 production related to anaerobic metabolism (resultant on decreased tissue perfusion) and decreased clearance of CO2 with reduced blood flow.

Preliminary analysis of the results showed significant hypoxia with exercise and suggest that some subjects had the predicted rise in intra-gastric CO2 during exercise but others did not. In some cases the intragastric CO2 was less than end-tidal CO2 which is physiologically improbable. Our experiment was limited by the lack of availability of blood gas measurements for technical reasons. These results may indicate technical problems with the use of the tonometer at high altitude (we had to conduct major repairs at base camp and were not able to recalibrate the instrument after this) or may be related to air swallowing occurring at the high levels of ventilation necessary to sustain the exercise protocol.

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Arterial oxygen saturation and heart rate at high altitude during the trek

Chris Wolff

Aims To study changes in Oxygen saturation (SaO2) and heart rate during ascent at altitude.

Methods I have plotted some data acquired during the trek that shows what happens to oxygen saturations (SaO2) on ascent and the reciprocal relationship found with heart rate. The group 2 values from morning and evening data collection sessions were averaged; immediately prior to and following ascent for rest day sessions at low and moderately high altitude. The low altitude ascent was from Salpha Phedi (1250 m; mean SaO2 95.4%) to Guraise (2800 m; height change 1550 m). Barometric pressures (PB), were 459 mm Hg and 385 mm Hg); acclimatization was for 36 hrs.

Outcome SaO2 rose from the initial mean value of 90.9% to 93% by the morning after arrival (around 12 hrs). There was no further rise in the remaining 24 hrs. This differed from the second group 2 acclimatization at Tagnag (at 4300 m; PB 456), illustrated in the left panel of the figure.

Fig 1. (left) Data from Group 2 members ascending from Kothe to Tagnag

Fig 2. (centre) Same data, (filled symbols only) plotted as heart rate V SaO2 to show reciprocal relationship of hear rate to SaO2.

Fig 3. (right) Heart rate and SaO2 in one subject climbing from Kothe to Tagnag showing the same relationship.

The ascent was from a higher level (Kothe at 3620 m; PB 498 mm Hg; mean SaO2 90.7%) and was around twice the recommended (300 m) increment (> 700 m). There was barely any improvement in SaO2 from the arrival value (84.9 %) for over 24 hours (85.2%). Eventually SaO2 reached 88.1% (at 60 hrs.) and may still have been rising.

The middle panel shows that there was a highly significant reciprocal relationship between acclimatization mean heart rate (HR) and SaO2. HR is known to correlate well with cardiac output (Q); so this is compatible with whole body oxygen delivery (DaO2 = Q x SaO2 x Hb x a constant) being kept constant (as seen with cerebral DaO2).

The right hand chart represents SaO2 and heart rate at a high metabolic rate, recorded on Piotr at 10-minute intervals by Mireille during a fast climb during the Kothe/Tagnag ascent. The two points with x in the middle were recorded during recovery. This HR v SaO2 relationship is highly significant and inverse, as in the acclimatization studies. Again this suggests an evening out of DaO2.

These anecdotal plots illustrate: 1. The initial maximum fall in SaO2 after each ascent. 2. The slow SaO2 rise for the higher altitude following a large ascent (delayed acclimatization). 3. The reciprocal relationship of heart rate and SaO2 for each of two very different metabolic rates. This is consistent with relative DaO2 constancy for a particular metabolic rate.

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Oxygen delivery in sub maximal exercise at sea level and at altitude after slow acclimatization

Chris Wolff, Doug Thake, Dan Matisson, Lisa Handcock, Alex Truesdell, David Collier and Jim Milledge

Aims To study the oxygen delivery system at rest and exercise at sea level and altitude and to determine if, at altitude, there is evidence of “steal” of blood flow. We hoped to study about 10 subjects.

The first two subjects analysed showed linear increases in cardiac output both at rest and at Chamlang base camp (5000 m approx.). In both there was a greater resting output at BC than at sea level with the altitude line, for cardiac output versus watts, above and parallel to the sea level line (see figure, left and middle graphs). The watts values are approximate so the result is a tentative one awaiting calculation of oxygen consumption. It seems likely that the increase in cardiac output (CO) above the resting value at sea level provides all the required oxygen delivery to the exercising muscle (DO2M; Wolff, 2002). The excess cardiac output per Watt is the same at altitude but with a lower oxygen concentration (CaO2 = SaO2 x Hb x 1.34). There would be enough oxygen delivery per Watt if Hb had increased enough to compensate for the lowering of SaO2, i.e. if SaO2 x Hb for altitude was the same as at sea level.

For these two subjects, oxygen delivery (DO2) can be seen to be the same at altitude as at sea level at these low work rates. However, for the third subject (right hand graphs) delivery is less at altitude than at sea level, a lower slope of the DO2 / work line. This suggests a degree of ”steal” of blood flow by the working muscles from other vascular beds in this subject. Partial analysis of a further five subjects indicate that they show similarly reduced DO2 at altitude.

REFERENCE: Wolff, C.B. (2003) Cardiac output, oxygen consumption and muscle oxygen delivery in sub maximal exercise - Normal and low O2 states. Oxygen Transport to Tissue XXIII, Ed. Wilson D. et al., Kluwer Academic/Plenum Publishers.

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Non-invasive assessment of cardiac function during acclimatisation to high altitude

Gerald Dubowitz

Background Echocardiography is a simple technique in which function of the heart and blood flow through it may be examined non-invasively. In utero there is a connection between the right and left chambers of the heart through the foramen ovale. This lets the blood by-pass the lungs, which serve no purpose for gas, exchange since this is occurring via the placenta. During birth the foramen ovale closes in most people so that blood flows through the lungs. In a minority it remains open, known as a ‘patent foramen ovale’ or PFO. It was speculated that ascent to high altitude might increase the prevalence of PFO by raising the pressure of arterial blood flowing to the lungs.

Aims The aim of this study was to evaluate whether in some people ascent to altitude leads to the presence of a PFO that was not apparent at sea level, and to determine whether people with a PFO do worse at altitude.

Methods Echocardiography was carried out at sea level and at Base Camp. A couple of mL of the volunteer’s blood was withdrawn from a cannula, mixed with bubbles and then reinjected. The bubbles show up on the echo, so revealing the presence of any abnormal connection between the right and left chambers of the heart such as a PFO.

Results and preliminary conclusions 32 studies were conducted at sea level and 50 at Base Camp. A number of people had a PFO at altitude that had not been apparent at sea level. It would seem that the presence of a PFO does not correlate with acute mountain sickness or cardiac function per se. Further studies would be helpful to see if there are other implications of a PFO at altitude on performance.

It was incidentally observed that a small subset of trekkers who took prophylactic acetazolamide had lower pulmonary arterial pressures.

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Heart rate variability at high altitude

Paul Richards, Mireille Baart, Mark Dayer, Annabel Nickol and Mary Morrell

Background Heart rate variability (HRV), which refers to the beat-to-beat alterations in heart rate, is a useful tool for studying autonomic function. HRV-analysis can provide information about the relative balance between the activities of the parasympathetic and sympathetic nervous systems.

Aims It is known that high altitude has an effect on the nervous system. The aim of this study is to investigate the effect of high altitude on parasympathetic and sympathetic balance using HRV-analysis.

At high altitude many people suffer from periodic breathing. It is known that at sea level HRV is related to periodic breathing during sleep in patients with congestive heart failure. The second aim of this experiment is to investigate if there is a relationship between HRV and periodic breathing at high altitude.

If we observe any difference in parasympathetic and sympathetic balance at high altitude the hypothesis is that this is due to sympathetic stimulation by the stress of hypoxia. Another aim of the study is then to investigate if this hypoxic stress is just general altitude hypoxia or if it is also influenced by the additional hypoxic insult of periodic breathing desaturations during sleep.

Preliminary results Six male subjects participated in the study. At sea level and at altitude (5000m) overnight ECG-recordings were taken. The ECG-recordings still need to be analysed for HRV after which we can draw our conclusions. We are developing methods to analysis the ECG-recordings for accurate HRV (it is not as simple as we first thought!) after which we can draw our conclusions.

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Glyeroltrinitrate headache as a predictor of acute altitude sickness, and its effect on brain blood flow

Neil Richardson, Oliver Kemp, Anja Kuttler, Roger McMorrow, Nigel Hart, Chris Imray

Background There is evidence that the brain swells at altitude, and it might be the case that people who cannot accommodate this swelling are more susceptible to getting acute mountain sickness (AMS). In other words, people more susceptible to AMS have a brain that fits tightly into the skull. Headache is a very important symptom of AMS and feels very similar to headaches caused by GTN, a drug that causes blood vessels to widen. We thought that GTN might be a good predictor of who was more likely to get AMS. We believed that GTN would do this by causing an increase in the volume of blood in the skull, that, when combined with brain swelling from altitude, cause greater stimulation of the nerves in the head leading to a more severe headache.

Aims (1) To see if there was a relationship between the severity of the headache caused by GTN and the symptoms of AMS as we ascended in altitude. If there was a relationship between headache with GTN and AMS, we needed to know whether the actions of GTN on blood flow were the same at sea level and altitude. If they were, we could assume that the difference in headache was due to the brain swelling at altitude, therefore our second aim was (2) To see if GTN had similar actions on changes in blood flow to the brain at altitude and sea level.

Methods We asked people who were on the Medex Makalu 2003 expedition to take GTN the evening before they ascended more than 300 m in height whilst trekking to base camp. We measured people’s headache by asking them to mark a cross on a line 10cm long between two statements, ‘No Headache’ at one end and ‘Worst Headache’ at the other end. We then compared this to how bad their AMS symptoms were the next day once they had ascended to a greater altitude. Once at base camp we gave the subjects GTN and measured changes in the amount of oxygenated and deoxygenated blood flowing to the head. We also measured blood pressure, heart rate and other factors. We compared these values to ones already attained at sea level.

Results and Conclusions There was no correlation between headache severity and AMS. This could be due to a number of reasons including the gradual ascent profile. This gradual ascent profile meant there were very few cases of AMS amongst the expedition.

There was little change in the effect of GTN on oxygenated and deoxygenated blood flowing to the brain at altitude compared to sea level. Other effects of GTN on blood pressure etc were all similar at altitude and sea level. This meant that the effects of GTN were conserved at altitude. However, as GTN was a poor predictor of who got AMS, it was of little consequence. However, one very interesting result was that the amount of oxygenated blood flowing to the head at base camp (just over 5000 m) suggested that the brain was lacking oxygen. It was previously believed that the blood flow to the head increased to compensate fully for the lack of oxygen in the blood at that altitude but our data disagrees with that. This data is in agreement with recent work by Chris Wolff and Chris Imray.

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Sleep disruption at high altitude and its influence on next day vigilance and cognition

Annabel Nickol, Paul Richards, Philippa Seal, Juliette Leverment, Tracey Hughes, Mike Skinner, Gerald Dubowitz, John Stradling, Jim Milledge and Mary Morrell

Background The low oxygen levels of high altitude can lead to periodic breathing and poor sleep quality at high altitude. Patients who have disturbed sleep due to breathing disorders (e.g. in obstructive sleep apnoea) have reduced ability to concentrate or vigilance, and impairments in some areas of cognition. Gerald Dubowitz has previously shown that a sleeping tablet, Temazepam, improves sleep quality at altitude. Some people have been concerned that if the sleeping tablet has not worn off by the next morning, it might impair mental performance.

Aims (1) To see whether people with marked sleep disruption at altitude had impaired vigilance and cognition the next day. (2) To see whether Temazepam led to an improvement in sleep disruption, vigilance and cognition compared to a Placebo tablet. (3) To see whether sleep disruption, vigilance and cognition improved following acclimatisation.

Methods Simple sleep studies were carried out which involved wearing a pulse oximeter on one finger to measure blood oxygen saturations and heart rate, and an actigraph to measure wrist movement on the other wrist. These measures help to indicate whether the volunteer is awake or asleep, and the character of their breathing. The day after each sleep study a test of vigilance was carried out. This was purposefully very boring, as volunteers were asked to lift their finger off a sensor every time a light came on at set intervals for 40 minutes. Tests of cognitive function were also carried out as is described later. The sleep study, vigilance and cognitive function tests were carried out on two consecutive nights just after arrival at Base Camp, and again after acclimatisation to altitude.

Preliminary results and conclusions We studied 32 people on arrival at Base Camp with Temazepam and Placebo, and 21 people after acclimatisation to altitude. Preliminary results show that vigilance is pretty good at altitude despite sleep disruption. This might be because we had the luxury of a good long sleep on most nights. Reassuringly, Temazepam does not seem to impair mental performance. Unexpectedly many people still had periodic breathing even after a week’s acclimatisation at Base Camp.

The actigraphic assessment of quality of sleep during ascent to high altitude

Michael Schupp

Aim: To assess the change in quality of sleep and sleep pattern during ascent from Tumlingtar (500m) to Chamlang base camp (5200m) over 3 weeks.

Methods: A total of 21 subjects were supplied with a wristwatch size accelerometer called Actiwatch which records movement of the dominant hand. It is an objective measure of quality of sleep and has been validated in shift workers, patients with chronic pain and people exposed to environmental noise such as residents near airports. This was accompanied by a sleep diary recording total bed time total sleep time and number of awakenings and 2 questions about the quality of sleep in the previous night in form of a visual analogue score.

Results: 19 out of 21 recordings were useful for analysis. 2 recordings had to be excluded due to equipment failure of the watch. Preliminary evaluation of the results show a significant rise in night activity above about 3000m with increasing numbers of awakenings during the night. Final analysis will be done once I get my hands on the sleep diaries, which are essential to define the sleep and bedtime periods prior to analysis of the actiwatch trace.

There seems to be a slight curse attached to the watch since a disproportionate number of subjects involved in the study developed serious complications such as HAPE and severe respiratory tract infections during the trip. I hope the subjects concerned won’t hold this against me!

Typical actiwatch trace at high altitude: double click to enlarge

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Eden Trace recording at different altitudes during ascent to Chamlang base camp (5200m)

Michael Schupp

Aim: To detect the night-time changes in breathing pattern, oxygen saturation and heart rate during a trek from Tumlingtar (500m) to Chamlang base camp (5200m).

Methods: 5 “volunteers” including myself were recruited to undergo 4 night-time recordings each at low altitude, intermediate altitude and at base camp. This not very popular project involved being wired up to 5 different detectors connected to a small recording unit prior to going to bed. These detectors consisted of 2 expansion belts around the chest and abdomen, a pulse oximeter on one finger, a snoring detector on the side of the neck and most popular of all a small cannula in the nose and mouth to detect airflow during expiration. The recording units needed recharging via solar power after each night which was the limiting factor to the number of recordings taken. Since the application of the detectors is slightly tricky and crucial to a good recording it had to be done by myself every time. This was not so bad at lower altitudes but rather unpleasant at higher altitudes and involved crawling into my victims tents, convincing them to get at least partially out of their sleeping bags and attach the monitors which took about 15min each. It usually involved the use of all my charm and elaborate persuasion to prevent the subjects from chickening out in the last minute. In the end I exploited the general craving for nice food by promising to invite everybody involved to a 4-course meal cooked by myself back in England.

Photo: Michael Schupp with Actiwatch and sleep monitor -double click to enlarge

Results: 3 subjects completed the entire series for which I am eternally grateful and 2 subjects failed to do the recording at base camp due to a severe chest infection (which subsequently spread to about everybody else in our group). The highest recording was taken on myself at high camp on Mera Peak, which was by far the worst night of the entire trip due to the altitude and a ferocious snow storm (see picture).

The equipment worked well in the low temperatures and the data is still awaiting analysis with the help of somebody experienced with the analysis software. However it is clear to see that episodes of periodic breathing and desaturation increased significantly at Tagnag (4300m) and above which certainly contributed to more frequent awakenings and a poorer quality of sleep.

The figure shows a typical record during sleep and shows periodic breathing. The top trace represents the nasal airflow. The next 2 traces show the chest and abdominal extension during inspiration and expiration. The 4th trace is the oxygen saturation, which drops to about 70% at the end of apnoea.

Double click thumbnail to enlarge

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Cognitive function at high altitude

Jennifer Leland and Greg Harris

Aims This study aimed to investigate decrements in cognitive performance at moderate and high altitude compared to sea level and to compare different methods of assessing cognitive functioning at altitude (paper and pencil tests vs. computerised assessment). The data will also be compared to that of the sleep team to evaluate if there is an association between cognitive performance and nocturnal periodicity of breathing.

Background Temporary impairments in cognitive functioning have been found at high altitude. Cognitive impairments have often led to accidents due to improper evaluation of danger or other poor judgement. Cognitive decrements appear to follow a specific time course after exposure to altitude with initial impairments in performance followed by a progressive return to baseline. This supports the hypothesis that there are different stages of adaptation to altitude, which, in turn, depend on factors associated with respiratory function. Unfortunately, however, many of the previous studies on human cognitive functioning at altitude can be criticised on methodological grounds, such as the absence of baseline data at sea level, small sample sizesor poorly normed tests.

Methods We hope we have overcome some of the problems discussed above by using previously well-validated tests. The (manual) neuropsychological tests used assessed cognitive functions which have previously been shown to be sensitive to the effects of altitude hypoxia and sleep apnoea; visual and verbal memory, planning and mental flexibility, motor speed and verbal expression. These were: Auditory-Verbal Learning Test (AVLT), Controlled Oral Word Association (COWA), Digit Symbol Substitution Test (DSST), Trail Making Test (TMT): Parts A and B, and the immediate and delayed Visual Memory task from the Wechsler Memory Scale. The computerised cognitive test battery (CogState) includes measures of sustained and divided attention, learning and memory, problem solving and decision-making. Alternative forms of each task were randomised across days and subjects.

Results Baseline and data at altitude on Day 1, Day 2 (pre-acclimatisation) and (Day 5-6 post-acclimatisation) for all tests (paper and pencil and computerised) on more than 20 subjects, baseline and pre-acclimatisation data collected for (approx.) 12 further subjects was collected.

Preliminary analysis of the computerised data indicates that there is a ‘failure to learn’ rather than a decrease in performance on arrival at altitude.

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Effect of the parasympathetic nervous system on resting bronchial tone at altitude

Kate Wilson, Michelle White, Lisa Handcock and Martin Miller

Background This is a follow-up study to the enormously successful (and hugely unpopular) ‘histamine study’ of the K98 expedition. There we showed that the airways are narrowed at altitude compared to sea level (an increased resting bronchial tone).

Aim This narrowing could be due to a number of factors. On the 2003 expedition we looked at one of these, the parasympathetic nervous system to see if its influence on the lungs is altered at altitude.

Methods 40 people volunteered to be studied and had their lung function measured before and after breathing ipatropium bromide (a drug which should enlarge the airways by blocking the parasympathetic nerves). We studied as many people as possible on arrival at base camp and some a week later.

Results Of the original subjects 35 were studied pre, and 28 post-acclimatisation. We had a lot of interest and cooperation from everyone (thank-you for that), and got some good spirometry flow loops. These are being analysed by Martin Miller in Birmingham and we hope to have some definite results to present at the ODG meeting in October.

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Changes in respiratory ion transport at altitude

Nick Mason, Ali Mynett, Emma Lam, James Anholm Katja Ruh and Alex Horsley,

Ascent to high altitude results in changes in the lungs, which suggest the presence of oedema, an abnormal accumulation of fluid, around the air spaces in the lung known as alveoli. Traditionally it was thought that the formation and clearance of this oedema fluid depended on the pressure in the blood vessels around the alveoli. However, over the last 10 years it has become apparent that active sodium and chloride transport, by a system of channels and pumps in the walls of the cells surrounding the alveoli, plays an important role as well in the control of the oedema fluid and that a lack of oxygen can effect how this transport system works. Because sodium and chloride ions are charged particles, their transport across a membrane generates a potential (voltage) difference and with sensitive equipment it is possible to measure the changes in ion transport by measuring the changes in potential difference. Although this is not possible in the alveoli, the nose conveniently contains tissue with similar transport properties and the potential difference can be measured by means of a very small tube inserted 4 to 5 cm into one nostril and connected by an electrode to a voltmeter. A second electrode connected to a small drip in the arm completes the measuring circuit. By perfusing the nose with very low concentrations of different substances it is possible to stimulate or block different parts of the transport system.

From earlier work at altitude, as well as studies in a low-pressure chamber, we knew that changes in the ion transport system occurred rapidly on ascent to altitude, but had little idea of how the system behaves at altitudes above 4500m or what happens with acclimatisation. Our long-suffering volunteers underwent baseline tests in London, which were repeated when they arrived at Chamlang Base Camp at 5000m, after up to 17 days trekking. None of our subjects were suffering from significant acute mountain sickness. Initial analysis of the results from Nepal shows that, unlike in our previous studies, the nasal potential difference measurements were unchanged at Chamlang Base Camp compared to sea level. This surprising result suggests that changes in ion transport normalise in acclimatised subjects and so cannot be responsible for the development or potentiation of lung oedema, nor does the ion transport system increase its activity in an attempt to clear the excess fluid. These findings are another important piece in the jigsaw of understanding how the ion transport system and the control of lung oedema works at altitude.

We have submitted our provisional results as an abstract to the British Thoracic Society Winter Meeting.

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Beau Lines at High Altitude

Fionn Bellis and Craig Brooks

Background Beau’s lines are transverse grooves across the nails. They occur when there has been interference with growth at nail matrix. Hypoxia, or lack of oxygen, can cause such growth deficits. There has been one published case report on the incidence of Beau’s lines at altitude, but many personal reports that their prevalence is high in those who have spent time at high altitude.

Aims To conduct a prospective study of the incidence of Beau’s lines in the members of Medical Expedition members travelling to Chamlang Base Camp 2003.

Methods 2-4 weeks after returning from Kathmandu volunteers were e-mailed to ask whether they had developed Beau’s lines. When information from the data books is available, relationships between the development of Beau’s lines and oxygen saturation and altitude will be examined.

Preliminary results Everyone on the trip consented to enrolment in the study (60 people). The prevalence of Beau’s lines so far is low, perhaps reflecting the gradual ascent profile of the trek groups.

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The ACE gene and weight loss at altitude

Stephan Saunders, Matt Litchfield, Sarah Trippick, Sandra Green, Don Paterson, Hugh Montgomery and David Collier

Background This project was investigating the ACE gene. This is a gene that has been associated with endurance athletes and high altitude mountaineers although no mechanism for this association has been discovered.

Aims We were investigating how ACE genotype was associated with weight loss during the expedition since maintaining your weight could give an advantage at high altitude. The project used skin-folds and other simple body measurements to work out how much fat and muscle our subjects had in London, at Base Camp and back in Kathmandu. We convinced 44 wonderful people to take part and are immensely grateful to them all.

Outcomes We are still busy analysing the data but hope to have some answers soon. In the mean time Matt and Stephan are thinking of another project that will persuade women to come and undress for us despite surrounding snow. Awards for the strongest arms will be presented in Old Dungeon Gyll.

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The effects of altitude and acclimatisation on retinal function

Dan Morris, Mike Donald, Jill Inglis, Ian Manovel and Rupert Bourne

Background High altitude retinopathy occurs when there are small bleeds at the back of the eye in response to the lack of oxygen in the air at altitude. Usually you are not aware of these bleeds and they clear up spontaneously.

Aims To see whether people with a high haematocrit (‘thicker’ blood) are more prone to bleeds at the back of the eye.

Preliminary results On this expedition we took pictures of everyone's eyes with a special digital camera and found that 18 out of 52 people (35%) had bleeds at base camp or back in Kathmandu after climbing Mera Peak. We also stabbed everyone's finger for blood (twice for those who were unwilling to donate!) and are currently analysing this and other data to find out who is most likely to suffer from this problem and why it happens. We also took up some sophisticated equipment to test colour vision and blood flow to the eye but this did not work, proving that in this harsh environment the simpler the test, the more likely it is to succeed! Many thanks to everyone who volunteered to be part of this study.

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Medical Report

Snow Blindness
Daniel Morris MRCOphth

Snow blindness is sunburn of the front of the eye. This occurs when too much UV radiation is absorbed by the cornea, the clear window which allows light into the eye. It is especially common at high altitude because there is less atmosphere to absorb the harmful UV radiation and there is often snow on the ground which reflects the sun’s rays.

The trekkers and climbers on this expedition were warned to wear sunglasses with sidepieces that fully absorb UV radiation and there were no reported cases of snow blindness. However amongst the porters and climbing sherpas snow blindness was the most common ailment treated by the expedition doctors, despite all being issued with appropriate sunglasses.

Snow blindness usually presents with intense pain, aversion to light and itchy red eyes. There is usually a temporary decrease in vision and the affected area can be seen when a special dye is put in the eye. At sea level healing occurs rapidly, usually within 12 hours. Antibiotic ointment is applied liberally to aid lubrication and prevent infection.

At high altitude snow blindness is potentially more serious because of a slower healing time, poor hygiene, continued exposure to UV radiation and poor compliance with treatment. These factors make infection more likely and in a remote environment, this can be sight threatening. Therefore more aggressive treatment and careful follow up is mandatory. Fortunately on this expedition all those affected with snow blindness were promptly diagnosed and treated so there were no cases of serious corneal infection.

It was observed that many porters were not wearing their sunglasses appropriately. They were seen hanging around their necks or sitting on top of their heads when they were most needed, such as glacier crossing during the middle of the day. It is worth remembering for the next Medex expedition that it is not enough just to issue sunglasses to porter and climbing staff but they also need to be instructed in their correct use, with suitable encouragement where necessary. Sunglasses prevent snow blindness, they are not just a fashion accessory to keep the hair out of your eyes !

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Pharmaceutical report

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Letter of thanks for the recipient of our donated drugs

Dear Friends
Thank you very much for such a good, practical and plentiful gift of medicines and sundries to Camps. Very much appreciated. We received them just before leaving for Rukum which is in the mid western region of Nepal, accessible by 'plane once a week - if you manage to get a seat on it!! Unfortunately, our two Nepali friends
had to walk 10 hours to the road end with porters carrying luggage. I know walking 10 hours is nothing to you folks!! We were able to use the Paracetamol and antibiotics without any trouble. Although we were there for cleft lips, palates and burn contractures, our surgeon had to operate on a patient with a bowel perforation. The patient had been operated on three times before so he now has a jejunostomy which we will close when we return in October. He benefited from the cephalosporins you left. The small packs of saline were excellent for the little children who had their lips and palates done. What more can I say? I don't remember receiving such a useful gift of medicines before. Again, with many thanks and please feel free to off-load any other
medicines you may not need in the future.
Yours sincerely
Ellen Findlay

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