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| From ladakh 2009 |
Anticipation, realization, reflection. Another adventure has come and gone, and I'm left with woefully inadequate photographs and rapidly fading memories as a full month has now passed since I returned to the routine and realities of residency in Rochester. The summer of 2009 took me once again to my homeland of India, but to an area I'd never been. Ladakh, high in the Himalayas, lies within the rugged, contentious, and astoundingly beautiful region of Jammu & Kashmir. For two days we traversed the Line of Control (LOC) between India and Pakistan en route to Kargil, the site of their last military conflict 10 years ago in 1999, before heading southeast into the Zanskar Valley. For the next month, I worked as an assistant lead physician, helping lead a group of 29 medical students and 7 other resident physicians and a dentist, trekking and setting up medical camps in remote villages in an effort to provide some level of medical care to this otherwise isolated group.
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| From ladakh 2009 |
My usual habit, when I travel, is to post periodic updates from cybercafes, as a means of documenting my impressions and (mis)adventures in as close to real time as possible. This serves both as an effective foil to my notoriously poor short term memory, and as a way for my friends and family to follow along. In Ladakh, however, this proved impossible. For 24 straight days and nights we trekked with packs on our shoulders and supplies on our mules and horses, sleeping in tents, without toilets, running water, or electricity. No showers, no shaves. No phones, no internet. No connection to the outside world whatsoever. There's a song by Weezer that I often would hum when I found myself trekking alone: "The World Has Turned and Left Me Here."
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| From ladakh 2009 |
Ladakh is a spectacular place, one I've always wanted to see, and it did not disappoint. High above the tree line, we were surrounded not by any vegetation but by soaring, snow-capped peaks nourishing, via descending tributaries, the mighty Indus River below. We trekked through glacier-carved valleys; the sun high overhead darkening our faces and arms; the dust from the trails matting into our scalps, layering on our skin, settling into our ears, onto our necks, and under our fingernails. We climbed, packs on our shoulders, negotiating hairpin turns, countless switchbacks, and gingerly crossing -- one-by-one -- wobbly, gap-toothed rope bridges spanning high above raging rivers below.
As we moved from the Buddhist heavy areas near Leh towards the more Muslim dominated Kargil, the transition was evident around us. Prayer flags gave way to prayer calls, as monasteries were replaced by minarets, bald monks by bearded mullahs. As we moved south from Kargil into the Zanskar Valley, Buddhist prayer wheels again emerged along the roadsides, as the onion domes of local mosques disappeared.
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| From ladakh 2009 |
The Himalayas, spanning 2,900 kilometers, represent one of the most spectacular manifestations of plate tectonics. Most geologists will tell you that the world's most immense mountain range began forming about 50 million years ago, when the landmasses of India and Eurasia, driven by plate movement, collided. About 225 million years ago, the Indian subcontinent was a large island situated well below the equator off the coast of Australia. About 200 million years ago, India began to forge northward, at a rate of around 9 meters per century. As both of these landmasses have roughly the same rock density, when they slowly but violently converged, neither could be subducted below the other. As a consequence, the only way to relieve the pressure between the colliding plates was via skyward displacement, forming the jagged, soaring Himalayan peaks that continue to this day to grow in height by about 3 cm per year.
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| From ladakh 2009 |
Every morning, I'd stand in awe of the sunrise over these mountains, warming us and illuminating the valley against the backdrop of a cloudless, blue sky. Every night, I'd gaze up at a celestial masterpiece, unmatched by any place I've ever been, however remote. I've never seen so many stars and meteors; so much of the Milky Way; or any of Jupiter's moons, let alone three of them with nothing more than a pair of binoculars. My neck sore from being craned skyward so long, I couldn't help but to consider my relative insignificance in the universe's unfathomably grand scheme each night as I lay in my sleeping bag.
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| From ladakh 2009 |
I'd wake up most mornings around 6am, my bowels reliably reminding me that it was time to emerge from my tent, and start my day with a shivering squat in the poop tent. I'd follow this with a modified bucket bath, stripped down shirtless in the cold morning air, washing my face, hair, and upper body, before brushing my teeth and warming up with a cup of tea. By then the sun would usually be just peeking over the mountains. Soon the shivers would be replaced by beads of perspiration, and the layers of outerwear would give way to coats of sunblock. This usually took minutes.
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| From ladakh 2009 |
The clinics we ran were mostly out of our tents. We'd send word to the villages of our plans in advance, if possible, but news of our arrival usually spread fast regardless. There is not any form of consistent medical care aside from some traditional healers, known as umchees. We would usually set up multiple tents, including one for triage, pharmacy, and the dentists. Our largest tent, which served as our dining tent at night, we'd divide into three separate parts and use to see adults and children. Usually we'd have one or two medical students, with a translator, get the initial presenting complaint, do a focused physical exam, and come up with a plan. They'd then present it to one of us residents, and we'd decide on the appropriate management from there. We saw a lot of infectious diseases, like skin and soft tissue infections, intestinal parasites, pneumonia, and tuberculosis. We saw countless cases of scabies, lice, and ringworm; chronic perforated otitides media; malnutrition; and visual complaints. Long winters stuck indoors made alcoholism a major problem, as well, and with it alcoholic gastritis and peptic ulcer disease.
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| From ladakh 2009 |
Our pharmacy was reasonably well stocked. We spent a lot of time in Leh before embarking on the trek taking stock of what medications we had available and what we would be necessary and sufficient to carry with us. Every patient, child or adult, symptomatic or not, was given a dose of the antiparasite medication Albendazole for deworming, and a 15 day supply of multivitamins for some nutritional support. Chronic disease management, as in most of the developing world, remains problematic. We could only offer temporary, stopgap measures for complaints such as chronic arthritic pain, heart failure, hypertension, and diabetes, for instance. Access and affordability remain major barriers in such remote, poor places. The regions where we worked and trekked through are accessible only by foot and for only about 3.5 months out of the year. The mountain passes that need to be crossed to get into and out of the region are snowed out the rest of the year, and there are no roads. The organization I worked with comes to Ladakh every August to run these medical camps, but for most of the rest of the year, access to care is unreliable at best, nonexistent at worst. And even when groups like ours come, they can only bring what they can carry on their person or on mules and horses.
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| From ladakh 2009 |
The pace of the clinics varied from place to place. There were frantic days when we saw as many as 200 patients in several short hours, others when we saw no more than 30 or 40 the whole day and spent much of our time playing cards and quizzing each other on our medical knowledge, waiting for more patients to show up. On the busy days, the rate limiting step was often the number of translators available to speak Hindi and Ladakhi. A few of us could speak enough Hindi to get by without translators, but nobody knew Ladakhi, so without local translators, the degree of difficulty increased rather markedly. On the whole, however, we worked hard and were able to help most of our patients, at least to some extent.
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| From ladakh 2009 |
In our down time, we enjoyed our gorgeous surroundings and each others' company. We played a lot of cards and threw the disc around almost daily. We told stories, riddles, and jokes. With the cook staff and guides, who had brought a bat, ball, and wickets, we played regular, rather competitive cricket matches that would leave us winded given the altitude. At night, we'd stargaze, play more cards, and even had a pair of bhangra nights, dancing around a bonfire once we had descended back below the tree line at the very end of our trek.
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| From ladakh 2009 |
The Dalai Lama, in exile from Tibet, has resided in Dharamshala since 1959, which is about 700 kilometers away across rugged Himalayan terrain in the adjacent Indian state of Himachal Pradesh. He visited one of the first towns we passed through, Padum, about a week after we had been there. Though we didn't get to see him, his visit still had a profound effect on our trip. In the days leading up to his visit, we'd routinely pass scores of Buddhist villagers headed in the opposite direction as us, in hopes of seeing the Dalai Lama in what was likely his final trip to to the region. The number of patients we saw at the medical camps we set up during that 5-day period was undoubtedly lessened by the hordes that traveled to Padum.
In addition to the medical care we provided to the inhabitants of Ladakh, there was plenty to do within our own group. The altitude, the unforgiving sun, the dust, and the demands of the trekking took their toll. We struggled with dehydration, bronchospasms, and respiratory infections. Many in the group battled diarrhea and vomiting at different points, and one night in particular, over the course of six hours, no fewer than thirteen members of our group came down with gastroenteritis that threatened to cause severe dehydration. A fellow resident, Paul, and I stayed up the whole night, admitting members of our group into our 'sick ward,' which was just our large dining tent, where we could keep an eye on them and help them through the night with IV fluids, IM antiemetics, extra toilet paper, and buckets.
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| From ladakh 2009 |
We had to alter our schedule and stay back at that campsite for an extra day due to the severity and scope of the illness. Throughout the trek, as strong and fit as we considered ourselves, nature would continually humble us. The mountains -- formidable, aloof -- would overpower our naive ambitions. Foolish pride and false pretenses of invincibility were shattered by falling rock, melted by the scorching sun, suffocated by the thin mountain air. We would often be left lying weakly in our hazy tents, on dusty sleeping pads, begging for just one more cool breeze to relieve the heat. Then in the evening, as soon as the sun would disappear beyond the mountaintops, the chill of the night -- sharp, unforgiving -- abruptly set in. We would curl, fetal-positioned, into our expensive sleeping bags, on the same dusty sleeping pads, and shiver the night away in a fitful sleep, craving the sunlight that so recently had tortured us so. The hikes up the steep inclines would leave our hearts pounding, our lungs gasping for breath, our heads throbbing. The water we gulped from our filtered bottles evaporated off our sweaty skin no sooner than we'd gulped it down our parched throats. The mountains, at 14,000 to 19,000 feet, clearly had the upper hand. No amount of pricey equipment from The North Face could alter that.
At one point early on in the trek, while attending to an ill colleague with respiratory distress from bronchospasms, I pulled out a portable, fingertip pulse oximeter, which measures the oxygen content in your blood. We normally should have oxygen saturations between 96-100% in the ambient air we breathe, and I was reassured that my wheezy companion was saturating between 94-96% -- not bad for being at 15,000 feet elevation. At sea level, the oxygen content in the air is 21%. As we move to higher altitude and are thereby subjected to less atmospheric presure, the oxygen content drops. This is why we experience difficulty breathing at higher altitudes, and what is commonly referred to as 'thin air.' By my estimate, the oxygen content of ambient air at 15,000 feet should be about 13.5%, a significant difference from sea level. Out of curiosity, I stuck the probe on my finger before putting it back in the pharmacy tent, and was startled to see it read 83% and then 84% on two subsequent checks on different fingers. The pulse it measured correlated to the one I palpated on myself, and I rechecked my colleague's to find the same, normal reading. Since I was asymptomatic, I did nothing aside from giving my hemoglobin a pep talk. Apparently it worked, since 5 days later when I rechecked my oxygen saturation, it was 96-97%. My body got the message and likely produced more red blood cells (which carry hemoglobin, which binds oxygen) in the interim, making the adjustment to compensate for the changed environment (a process called secondary polycythemia). Physiology in action.
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| From ladakh 2009 |
Later in the trip, after crossing the Shingo La Pass, the highest point in our monthlong trek, I developed, for the first time in my life, a throbbing toothache. I tried taking Tylenol and then Ibuprofen, but it became increasingly painful, to the point of nausea. It didn't improve even after we descended 3000 feet over the next day and a half, and it became some of the worst pain I'd ever felt. After 48 hours, when my face started swelling, and my left nasolabial fold disappeared, I decided to start antibiotics for a likely abscess. At that point, though, the pain was almost unbearable, and I resorted to raiding the Pharmacy boxes, where I discovered an intermediate acting anesthetic similar to novocaine. Using a steel syringe from the dental box, I gave myself a series of dental nerve blocks, which despite giving me some left facial droop, finally alleviated the pain (albeit for only 3 hours at a time). It allowed me to sleep, though, and recover some strength. And fortunately, by the next morning, the antibiotic had worked well enough to relieve a significant amount of pressure, which got me through the last 9 days of the trek before I reached Mumbai. I'd never been so excited to see a dentist, even though I knew I'd need a root canal. After four dentist visits in Mumbai and two more back in Rochester, my root canal is finally complete. My dentists in both Mumbai and Rochester were astounded by the size of the abscess they saw on the x-ray and both theorized that it must've been tremendously painful. I confirmed their hypotheses.
All told, I gained a fair amount of stamina over the month, but lost some weight in exchange. Between the physical demands of trekking at high altitude and a few days of toothache-induced anorexia, I dropped 10 pounds. But fear not, I got a good start putting it back on with the help of my grandmother's cooking in Mumbai.
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| From ladakh 2009 |
full album of pictures: ladakh 2009
