High Altitude Medicine: A Medical Student’s Experience at Gosaikunda Health Clinic(4380m)

Author: Sachet Subedhi

MMC, IOM

Email: subedisachet@gmail.com 

Introduction:

I am an outdoor enthusiast and an active member of the Mountain Medicine Society of Nepal, based in Nepal. Currently in my fourth year as a medical student at Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, I combine my passion for the outdoors with my medical studies, fostering a deep interest in understanding high-altitude medicine and its applications.

My Experience:

Thousands of Hindu and Buddhist pilgrims visit the holy site of Gosaikunda at an altitude of 4380m in the Janai Purnima festival. Most of them take a rapid ascent in 1-2 days from Dhunche which is at an altitude of 1960m and stay for one night to take a holy dip in the lake on the occasion of the festival.  Previous studies have reported cases of Acute Mountain Sickness (AMS), High Altitude Headache (HAH), High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE) among pilgrims. The Himalayan Rescue Association(HRA), a non-profit non-governmental organization has been running a temporary clinic near the Gosaikunda Lake through medical doctors every year for over 25 years during the festival to provide care to the pilgrims and manage many high-altitude cases. This year a team of five medical doctors with a medical student were stationed in the HRA clinic in August 2023.

Figure 1: This is me standing in front of our clinic. The temporary medical clinic is situated inside this structure (Sachet Subedi)

Our journey started in Kathmandu. We went to Dhunche in a jeep and stayed at Dhunche(1960m). We spent the following nights in Chandanbari (3,300m), Lauribina (4,610m), and finally on the fourth day, we reached Gosaikunda (4380). Our team worked to spread essential awareness about AMS to ascending pilgrims. We advised the trekkers whom we met on our way to ascend slowly and take prophylactic acetazolamide to reduce the risk of AMS.

Then in the main day, we set up the clinic and I was assigned to measure patients’ vitals and keep proper records of the patients including their age, sex, residence, date of ascent, and diagnosis. Our leader and other members of the team managed the cases. As the resources were very limited, there was a judicious distribution of medicine to the pilgrims.

Figure 2: View of Holy Gosaikunda Lake from HRA  clinic (Sachet Subedi)

More than 5000 pilgrims visited the holy site on Janai Purnima. During record keeping, I found the ascent profile of pilgrims hasn’t changed much. Most pilgrims ascent quickly in 1-2 days to the holy site like in the past. We found the majority of our patients in the clinic were suffering from mild to moderate AMS. During my stay, I got a close look into the management of two High Altitude Cerebral Edema cases, four probable High Altitude Pulmonary Edema cases, fall injury in an alcohol hangover and tinea corporis in a five-year child of a local family. The severe AMS cases were descended by porters carrying them on their backs as Helicopter rescue wasn’t feasible due to bad weather conditions for evacuation. In the clinic, I also encountered several pilgrims who had taken acetazolamide as prophylactic complaining about a tingling sensation in limbs and frequent urination.

In the clinic, I saw a firsthand example of the effect of religious dynamics on patients on compliance with our medical advice. There was a middle-aged man with moderate AMS. He was in no state of comfort and our medical team advised him to descend as soon as possible. But he resisted and took one extra hour to take the dip and then started to descend.  This made me realize that we should always consider religious values when thinking about patients’ compliance with our medical advice and deciding what is good for patients.

This immersive experience has deepened my understanding of high-altitude medicine and ignited my passion for mountain medicine. I think opportunities to work in a team in high-altitude settings are invaluable in nurturing the next generation of wilderness medicine practitioners and enthusiasts worldwide. Diving into the divine water at Gosaikunda and experiencing a real scenario of wilderness was a major takeaway from this trip.

I would like to thank Himalayan Rescue Association and Mountain Medicine Society of Nepal for the opportunity to work in such setting. I am grateful to the medical team for their constant guidance during my stay in the clinic.

Reference if necessary:

1. Basnyat B. Acute mountain sickness in local pilgrims to a high altitude lake (4154 m) in Nepal. J Wilderness Med. 1993;4(3):286-292. doi:10.1580/0953-9859-4.3.286
2. Zafren K, Pun M, Regmi N, et al. High altitude illness in pilgrims after rapid ascent to 4380 M. Travel Med Infect Dis. 2017;16:31-34. doi:10.1016/j.tmaid.2017.03.002
3. Basnyat B, Subedi D, Sleggs J, et al. Disoriented and ataxic pilgrims: an epidemiological study of acute mountain sickness and high-altitude cerebral edema at a sacred lake at 4300 m in the Nepal Himalayas. Wilderness Environ Med. 2000;11(2):89-93. doi:10.1580/1080-6032(2000)011[0089:DAAPAE]2.3.CO;2
4. Schmickl CN, Owens RL, Orr JE, Edwards BA, Malhotra A. Side effects of acetazolamide: a systematic review and meta-analysis assessing overall risk and dose dependence. BMJ Open Respir Res. 2020;7(1):e000557. doi:10.1136/bmjresp-2020-000557
5. Koenig HG. Religion, spirituality, and medicine: research findings and implications for clinical practice. South Med J. 2004;97(12):1194-1200. doi:10.1097/01.SMJ.0000146489.21837.CE