[sidebar]Village destruction in remote Pheriche. Photo courtesy of R. Salas.[/sidebar]
On April 25, 2015, a 7.8-magnitude earthquake struck Nepal, killing almost 9,000 people and causing an avalanche on Mount Everest that killed at least 19 people. Renee N. Salas, MD, MS, a fellow in wilderness medicine in the Massachusetts General Hospital department of emergency medicine in Boston, was stationed at a medical clinic for climbers near the Everest Base Camp when the earthquake hit. As one of a handful of physicians in the area, she was on the frontlines of treating the injured in the aftermath of the quake.
Dr. Salas recently sat down with ACEP Now Medical Editor-in-Chief Kevin Klauer, DO, EJD, FACEP, to talk about the challenges she faced caring for those wounded in the quake using the limited resources available at the small clinic where she was working.
Dr. Kevin Klauer: Tell me about yourself.
Dr. Renee Salas: I went to medical school at the Cleveland Clinic Lerner College of Medicine, trained at the University of Cincinnati, and then came to Massachusetts General Hospital [MGH], where I’m completing a two-year wilderness medicine fellowship.
KK: You were in Nepal for three months?
RS: Yes, I was. I got in country on March 1.
KK: Was this part of your wilderness training experience, or was this a really long vacation?
RS: Luckily, the best part is when your job feels like it could be a vacation. All of the fellows at MGH spend three months working for the Himalayan Rescue Association. It’s an organization based in Nepal, with one clinic in Manang and one in Pheriche. Pheriche is approximately a two-day hike away from Everest Base Camp, and I was stationed there when the first earthquake happened.
KK: So the clinics weren’t established for relief efforts. What was the clinics’ purpose?
RS: The Himalayan Rescue Association started in 1973. Its foremost purpose is to see the trekkers because there were a lot of life-threatening altitude illnesses, like high-altitude cerebral edema and pulmonary edema, but there wasn’t any medical care up in these regions.
KK: You go up there planning on seeing the local people, and then what happens?
RS: On April 25, everything changed. We were having a conversation in our living room in the clinic. All of a sudden, everything started shaking. To be honest, an earthquake didn’t cross my mind for the first five to 10 seconds because we were supposed to start construction on the clinic. Once we realized what was happening, we ran outside. Inevitably, every building except for two within the village of Pheriche was affected. When we ran outside, people were screaming; you could hear buildings collapsing and see dust clouds. We did quick surveys to see if anyone was injured. Thankfully, this happened during the day because the casualty rate would have been much higher if it happened at night. Unfortunately, there was a lot of uncertainty because we had limited communication. Even the satellite phone wasn’t working.
Nepal’s last major earthquake was about 80 years ago, and every 80 years or so, Nepal tends to have a large earthquake. It was due.
KK: If you’re planning on taking a trip internationally to hike or mountain climb, probably one of the safest places for the next 80 years is going to be Nepal. It finally hits you that this is an earthquake. What was your first emotion?
RS: My first feeling was concern about whether there was anyone who needed medical care because that’s part of my expertise.
KK: The uncertainty—tell me about that.
RS: Our concern immediately went to the Himalayan Rescue Association team up at Everest Base Camp. We had a radio system between our two medical posts, but we found out later that the radio had been blown by the avalanche wave into the Khumbu ice field. One of the physicians at the Everest emergency department, Rachel Tullet, an emergency physician in New Zealand, estimated it was probably about 200 miles per hour.
KK: When did you have the realization of, “Wait a minute, we are going to be receiving all kinds of patients with varying degrees of injury and trauma”?
RS: The earthquake occurred around noon, and at 8:30 or 9 p.m. we saw three headlights coming down the valley from the Everest Base Camp region. We got the first two patients. One was evacuated out on a horse and the second one by foot, and then there was a third one who was uninjured, who was leading the other two. One of them we were concerned probably had potential internal solid organ injuries as well as a pneumothorax and some fractured ribs. He was admitted overnight in our clinic. The other one we were able to treat and discharge. We were woken up at 5:30 in the morning hearing helicopter traffic heading up the valley. The first helicopter pilot said, “Here’s four patients. I have about 60 more that I’m bringing you.” There were three physicians at the post, two clinic managers who were Nepali, and a cook. We ended up getting 73 patients in total.
KK: What happened to the guy who came in by horseback?
RS: He was stable overnight. He was a bit hypoxic. One interesting point is that people’s oxygen saturation is routinely between 80 percent and 90 percent, but that’s normal. He was hypoxic relative to what I would expect for that altitude, so he was on oxygen overnight. There are no cars because there are pretty steep trails that go through this whole region. Transportation is either by foot, horse, or helicopter; a lot of goods are transported via yaks.
KK: Certainly some unique trans-portation challenges. If I had to choose between the yak and the horse, I think I’d have to go with the yak. It’s a smoother ride, from what I hear.
RS: I never did get the chance to ride on a yak. I’ll have to save that for my next trip to Nepal.
KK: How did you plan to care for all these people, and did you have enough resources to do it?
RS: We had a three-bed hospital: one bed where we would see active patients and complete evaluations and two beds that were considered inpatient beds, which essentially were two stretchers in a small room. An ancient ultrasound machine was the only imaging modality that we had. We had the ability to do IVs. Even then, we only had 20 bags of normal saline.
KK: Your imaging modality was only an old dinosaur ultrasound machine. Did you also do lung scans to looking for pneumothoraces?
RS: We did the EFAST [Extended Focused Assessment with Sonography for Trauma] on the first patients who came in that night. During the mass casualty itself, we used ultrasound to make sure it wasn’t a pneumothorax as long as I didn’t think a patient was having a tension pneumothorax and getting hypotensive from that or tamponade. Because there was such a high volume of patients, we really had to limit our time with each one.
KK: Tell me about the sickest or most challenging patient you took care of.
RS: The first one that comes to mind was a climbing Sherpa, I guess a Nepali, who had what appeared to be isolated head trauma. He was about a Glasgow Coma Scale of nine, and he was protecting his airway, but he was very combative. He actually came down from Everest Base Camp. I think the only reason we were very successful at what we did was because of the amazing work that they did at the Everest Base Camp. They were the first responders, pronouncing the deceased in their tents.
KK: How do you manage airways without equipment?
RS: You don’t. While we had a GlideScope that someone had donated and we had endotracheal tubes, there was no vent, we didn’t have the resources to bag anyone we intubated, and there were no medical personnel on the helicopters. The patients are all lying in the back of this giant cargo bay.
The Sherpa with head trauma was protecting his airway. The only alternative I considered was putting in a nasopharyngeal airway, but I didn’t feel he warranted that. It came down to easy interventions you can do that don’t require any further monitoring because that wasn’t going to happen.
We ended up having to manage his combativeness; if you stimulated him, he tended to get a bit more combative. He came down with his hands tied together for safety reasons for a helicopter transport. We untied his hands while he was on the floor in our sunroom, a staging area for patients, but then we ended up having to apply the physical restraints again when we evacuated him. Unfortunately, he later died.
KK: How long after all this was done did you come home?
RS: We ended up closing the clinic on May 5. We were supposed to close on May 22, so we closed a couple of weeks early. After we closed, it took about two days for us to hike out.
KK: I can’t thank you enough for taking the time to do this. I wasn’t sure how sensitive you were at this point because it has to be incredibly difficult.
RS: It was probably one of the most powerful experiences I’ve had: watching both the local and international trekking community come together and rally, caring for these 73 patients and giving them the best care that we could.