Day 4: The Hubris of Himalayan Mountain Itineraries, #MM4MM

Today was the day we were going to the mountain.

The itinerary was clear: fly from Kathmandu to Lukla and then hike 3 miles downhill to Phakding.

It didn’t work out quite that way.

We woke up at 4:45 for a 5:00 AM breakfast followed by a group picture and a bus ride to the airport.

The Kathmandu International Airport is chaos personified. Noise. Cars. Monkeys.

We got in something that resembled a line and then we went through something that resembled security while people were pushing from all sides. Security was a decidedly informal affair. You did not need to take your shoes off. Liquids were fine. My metal detector flashed red from my phone in the pocket, I was waved though. After we got through security we moved to another room where we checked the luggage.

It was here that we saw that the flights to Lukla were delayed due to wind. We waited in that room for about 2 hours before the sign gets taken down and Lukla is open for business. We then go through another round of security. This one is much more fastidious with a few of our team having pocket knives confiscated and all of us getting an uncomfortably personal pat down. This put us in the gate area. More waiting.

While waiting, the first flight to Lukla, the one that had already taken off, returned with all of its passengers. The plane flew the 40 minutes to Lukla and couldn’t land. Lukla has one of the world’s shortest runways. It is so short that it pitches up 20 degrees to assist in slowing airplanes down for landing, and accelerating them for take off. To make things even more treacherous the end of the landing strip is a cliff so airplanes can’t easily abort a landing and try again. A landing a Lukla requires total commitment. So the plane made it to Lukla circled around a bit and didn’t attempt a landing due to visibility, or wind, or something, so they returned to Kathmandu.

https://youtu.be/jhvpwDuh3C4

Seeing those people return to the gate took the energy out of the team. We sat around the gate until noon. And they called our number, actually they called half of our numbers, our group is too big to fit on one airplane. Our group left the gate, boarded the bus and drove to the airplane, drunk with excitement.

We arrived at the airplane and the mood deflated. There was a crew of ten maintenance men & women wandering around the plane with the cowling off the left engine. We waited on the bus for about 15 minutes and then turned around and headed back to the terminal. Despite the maintenance crew it was a weather problem. The looks on the team that was waiting for the second airplane when we strolled back in was utter disappointment. It was mirror of our own emotions. The word was they would try to fly again at 2 PM. This was for a 9:00 AM flight.

2 PM approached it became clear that no one was flying to Lukla. But while we were eating moo moos and chow mein, Jim and Bishnu were burning the phones working alternatives. They gathered everybody and told us to leave the gate because we were going by helicopter!

Ooooh Exciting! The helicopter offered the opportunity of skipping past Lukla and landing in the lower, and hence less windy, Phakding. We divided into groups of 6 that weighed less than 540 kg. Nope change that to 520 kg because they wanted a full load of fuel. I tried not to be concerned that the helicopter company was called Fishtail Airlines.

Our group was Ellen, Anne Marie, JP, Stan, Ryan, and myself. We went back through security, including the overly handsy pat down, loaded into a van, and drove out to another part of the airport and…waited. But this time outside. Our helicopter landed, and was refueled. By gravity.

Then we were told it was too windy and if we couldn’t leave by three, we would be grounded until four because the whole airspace was being shut down so the prime minister of Pakistan could land (He coming for a two-day state visit). Right before the airspace shut down one helicopter with 6 of our group took off. We, on the other hand remained at our pleasant picnic table eating crackers. We could see another 6 of our group across the runway hanging by their equally grounded helicopter. Then we piled into the van and headed back to the terminal.

There, we figured we would head back to the hotel and take another run at this tomorrow, sans wind and Pakistani prime ministers. But no, Bishnu was not defeated yet. He bullied and cajoled another helicopter crew to take us. These guys were either less safety conscious or more desperate for the dough, but they agreed to take us. We weighed in, this time we were going with 5 people. Ryan was out. Then back through security. Back past the gentle molestation with a smile and out into, not a bus, not a van, but a luggage vehicle. Women in the cab, men with the cargo.

This time was different because we actually got into the aircraft! We took off and flew to Phakding. Except the helicopter wasn’t going to Phakding, it was going to Lukla, something we didn’t realize until we were on the ground bewildered that we were in the wrong place. The helicopter ride was pretty bumpy, pretty scary. We went through clouds with zero visibility. It was a white knuckler to the wrong place.

We texted upon landing we texted our leaders (thank god I bought that local SIM card, because I didn’t have the leaders numbers but Stan did, so he logged onto my hotspot and was able to establish communication) and it turns out another helicopter that landed a few moments ahead of us, also went to Lukla. They had secured rooms at a local tea house, the Namaste Inn. We humped it to the tea house had some masala tea and dinner (fried rice, chips, and vegetarian spring roll). There we learned the what had become of our group. The first helicopter group that left before three, indeed made it to Lukla and did the hike to Phakding. They had to use headlamps to make the final kilometer, as they were hiking in the dark. Two helicopters full of people were in Lukla for the night and would hike to Phakding at first light. Six people didn’t get out of Kathmandu and were back at our previous hotel. They were going to fly to Phakding at 7 and land by 8 the next day. Fingers crossed.

Travel in the Himalayas is not routine and does not follow your itinerary. To think you can schedule when and where you fly is just hubris.

Day 3 of the #MM4MM Trek to Everest Basecamp, a day in Kathmandu

Today was the last day before we begin trekking. As usual I woke up early, though it is getting later and later as my biological time zone catches up to my geographic time zone. I had a decent breakfast with most of the team. After breakfast I needed to replace the toiletries that I left on the bed in Huntington Woods on Thursday.

Ben used the wonders of google maps to find a drug store that turned out to be more of grocery store. I was able to get my deodorant and tooth brush (I had already replace the toothpaste), but Ellen needed a pharmacy so off we went. First north, then south. Past the crazy wedding car. Past the French embassy. And finally, after getting no closer to our goal, and realizing the futility of Google Maps in the twisted streets and back alleys of Kathmandu, we encountered a friendly Sherpa who guided us to a pharmacy. On the way back I bought a local SIM card with 10 gb of data for $22.

Then we had a morning meeting where we went over our equipment and weight limits. The guides and sherpas on our trip are surprisingly hostile to prophylactic acetazolamide while simultaneously extolling the ability of a positive attitude, a swallow of water, and mushroom soup to stave off altitude illness. A number of them support the use of symptomatic acetazolamide. At one point, one of the guides said acetazolamide only treats altitude illness and does not prevent it. I could hold my tongue no longer and blurted out the reference I covered on PBFluids months ago. In this study a randomized, blinded trial was done on the very route we were hiking. It showed that acetazolamide (Diamox) prevented the development of acute mountain sickness, both mild and severe.

The discussion on acetazolamide continued. The discussion on equipment continued. And then we broke up and did final packing. We had lunch and I had my first course of dahl bat. This delicacy of rice and lentils is a mountain staple and will be what fuels the team up to Everest Basecamp.

I loved it. I’m going to be just fine with Nepalese mountain food.

After lunch we gathered to board a bus to go visit the Monkey Temple and Boudhanath Stupa. We were all waiting in the lobby when I realized I had forgotten my sunglasses so I ran up to the room, borrowed the key from the cleaning staff, grabbed my sunglasses, ran back down to the lobby. Empty. Everyone was gone. I figured they must have just left so I walked out of the hotel grounds. Still no peeps. So Plan B: get a passport picture (I needed one for entry to the park and had used my last one getting the SIM card). I figured I’d get the picture then hail a cab and hook up with the group at the Monkey Temple. So I walked to the main drag (I had seen a photo place on our wanderings, looking for a pharmacy that morning) where I bumped into English Paul. Paul had to run out to do some last minute errands but he told me where to catch the crew. So I hustled back to the Radisson parking lot and hopped the bus.

Big mistake. I was at the back of the bus, on a bumpy road, with a belly full of dahl bat. It was hot stuffy and I could barely understand the tour guide. Traffic was terrible and it took an hour to reach Boudhanath Stupa.

The Boudhanath Stupa is a Buddhist religious site. It is a world heritage site. Surrounding the base are prayer wheels. You are supposed to circle the building clockwise and need to circle it only clockwise and an odd number of times. Thankfully 1 is an odd number. We then checked out a Thangka art school. A super knowledgeable proprietor gave an amazing lecture on symbology in the art and the various techniques that the artists use. He showed us how to differentiate a master from a novice. I was able to escape without buying one. (You’re welcome Cathy).

When we got back to the hotel I went for the passport photo. After that I went to the porch where a number of trekkers were hanging out. I brought out my scale, pulse oximeter, and blood pressure cuff and started gathering baseline data on almost everyone in the group for my science experiment. I’m totally going to win the science fair this year. People were really supportive and I got 15 out of 18 of our group to go through baseline data. Really excited for this.

Then we had dinner. And we were all given personalized headbands. I am Detroit Runner.

After dinner I went back to Bablo’s T-shirt emporium and bought a hat.

(That’s not the hat, this is)

I capped off the night by having a drink with an exiled Indian national that now makes his living as an arms dealer, though he preferred the title “defense contractor.” (My favorite part of the encounter was when he answered his phone “Yes General, thanks for calling me back”).

You meet all types at the hotel bar in Kathmandu.

Tomorrow Lukla!

Day 2 of #MM4MM, the trip to Kathmandu

All day I have been trying to think of a funny joke among the line of “What’s an interventional cardiologist’s favorite city? Kathmandu.”

Yeah, yeah, yeah, I know. Keep the day job.

I woke up at 1:00 AM

Went back to bed until 3:00 AM

Got up and started my day.

Figured out to use the origami coffee bags. Very cool.

Went down for breakfast. What a feast. The Korean breakfast at Paradise City was awesome. They had this noodle bar. I filled my cup with some noodles, lettuce, chicken meatballs, and some mushrooms. I took the bowl back toward my table when I was intercepted by the noodle chef who ran that station. Turned out it was a soup bar. Make you own soup. Once you have all the ingredients the chef boils it to cook the veggies and noodles. Total tourist move.

During breakfast we all agree that we have successfully made the leap to local Korean Time and congratulate ourselves on strategic withholding of sleep. (Important post script for this conversation: later That day, at around 2 PM, we all fell dead asleep on the plane. Total time zone hubris)

The Korean dad at the table next to us was wearing a Detroit Tigers hat. I asked him if he was a Tiger fan. Nope never heard of them. In fact there were lots of American sports logos everywhere you looked:  Tiger Woods, New York Yankees, Michael Jordan.

I started my acetazolamide.

We took the bus to the airport and it was amazing that nothing in Inchion looked older than a year. The airport was filled with American and Luxury brands. The Dunkin Donuts, Krispy Kreme and Jamba Juice surprised me.

We flew out on Korean Air Boing 777. John and I were in the middle section, each of us on the aisle without a middle passenger. Score! We flew all the way across China, seven-hours to Kathmandu. Seems like Jets are not allowed to fly over the Himalayas so you need to take a southern approach.

We landed. Snapped some photos. Bought a visa. Collected our luggage. Met Jim from Embark Tours. Took a 15 minute bus ride to the hotel. Met with a lot of the group. I am rooming with Stan. I had sesame chicken and some dumplings. Really good.

After dinner, Stan John and I walked into town and I got a t-shirt and some post cards.

Pretty tame day. Tomorrow we get to really see the city.

Day 1 on the #MM4MM: The flight of the endless sunset

So the trip to Everest Basecamp began yesterday. Cathy took Jeff, Silva and I to the airport Thursday morning.

I dropped my altimeter (gift from Rose and John) going through security. 😢 First casualty of the trip.

We then met John Raithel at the gate and boarded our A350. About this time it started snowing.

Turns out Jeff, Silva, and I were all assigned to row 32.

The the plane went to the pad for de-icing and then got in the cue to take off. We were the next one to depart when the captain decided we needed another round of de-icing and we would need to refuel since we were burning so much on the ground. The captain we needed to add 2 additional tons of jet fuel, which he then explained was not that much😳.

So the whole back to the gate to re-fuel, back to the pad to de-ice and get back in the cue to take off put us 3 hours behind schedule.

Jeff found it odd that we would need to refuel before taking off, but it turns out that Detroit to Seoul (DTW-ICN) is one of the longest non-stops that Delta flies.

Note the route we are taking because this the source of the post’s title. A few hours into the flight, I looked outside of the window and caught the last glimpse of the sun setting.

Then a few hours later I opened up the shade expecting to see darkness, but I got…

We had gone far enough north that we were able to keep up with the rotation of the earth so we were trapped in a perpetual moment after sunset. Eventually the sun must have set and night passed but I never saw it. A few hours later I looked out and it was getting lighter with Friday’s dawn.

We landed at 7 PM at Inchion International Airtport. We went through a shockingly relaxed customs and immigration and took a bus to Paradise City, a new, and very nice hotel.

We need to put markers on our bags since everyone on #MM4MM has the same bag. I’m going all #NephJC.

Today’s adventure: Kathmandu!

Everest. Myeloma. And the centrality of hope.

 

John Raithel and Jeffrey Zonder are on the Moving Mountains for Multiple Myeloma team going to Everest Base Camp. John’s story is incredible. Check out the video. (Despite the hosts claims, we are not climbing Everest next week. We are merely hiking up 18,000 to Everest Basecamp.)

Dig deep and give something. None of the money goes to buying my Ramen. All of it goes to the MMRF a 4-star charity that is delivering new treatments with amazing efficiency.

 

 

Moving Mountains for Multiple Myeloma fundraising goal increased

Last fall I crossed the $10,000 finish line that was established for every participant on the MM4MM trip to Everest Basecamp. To everyone who donated thank you! 🙏🏽

Now I want to squeeze the last bit of generosity 💵 from everyone in my network.

I’m raising the roof. The new goal is $14,000.

So once again I come to you with hat in hand.

I’m asking you.

I’m begging you.

If you have ever:

  • downloaded a lecture or
  • laughed at a tweet or
  • Looked smart from a nephrology factoid you learned here or
  • Played NephMadness or
  • Learned about a new article at NephJC

Then consider throwing a few bucks toward multiple myeloma research. I’d love $100 donations. But what I’m really asking for is a mountain of small donations. Can you spare 25 tax-deductible dollars? What about 10?

Part of me feels that if I can’t engage my network to raise money for something as good as the MMRF then what good is this whole social media thing?

If you are the suspicious type, take a look at what I wrote about the MMRF here. This charity is doing medical research right. They take steps to keep doctors in the drivers seat of study design and that strategy is paying off with new drugs and breakthroughs.

Lets make a great fund push in the last week before I ship out to Nepal!

Help me get to the bottom of Everest!

Thoughts as the Countdown to Everest ticks toward “go”

The trek to Everest base camp is a once in a lifetime experience. I should be bouncing with excitement but that is not what I feel. I feel unease. I feel unsettled. I read about the side effects of high altitude trekking: weakness, confusion, headaches, insomnia, nausea. This makes me nervous.

I look at the weather and see temperatures in the low teens. And that is at Lukla, elevation 9,300 feet, only half as high as Kalapatthar, our ultimate goal. I think of the previous times that I have been to high altitude. The top of Breckenridge at a hair under 13,000 feet, the top of Mount Democrat at 14,154. When you are on these peaks it is cold and windy and the plan is always to quick snap some pictures and get down. In a couple of weeks, we’ll be at those altitudes and the plan will be to go further up the mountain. We will go nearly a mile higher than anything in the continental United States. This is unsettling.

But this nervousness is in the name of something much greater. Something bigger than my personal discomfort. This trek is not an adrenaline fix. It is not about putting a dent in the bucket list. This is more important than my uneasiness and general anxiety. This trek is about rewriting the medical textbooks. It is about changing the narrative of a disease that just a few years ago had a dismal and short disease course. Multiple myeloma has a new narrative, one that is filled with words like remission, and hope, and dare we say…cure.

The Multiple Myeloma Research Foundation is a new type of disease charity. One that is focused on real advances. The MMRF is bringing treatments to patients and lighting lanterns of hope for patients everywhere, because if the story of multiple myeloma can be rewritten, so can any disease.

And so we climb. We trek. We hike to altitudes found few places in the world. We do it to call attention to this disease and the patients that are beating it. We are a symbol of a better future and for that I will suppress my anxiety and ignore some discomfort. This is big.

 

Help me get to the bottom of Everest. Please use this link to donate to the MMRF through Moving Mountains for Multiple Myeloma

Other posts on my trip to Everest Base Camp

#NoRestTilEverest

High-altitude renal syndrome

Everyone knows the famous George Mallory answer to the question about why he was climbing Mount Everest , “because it’s there.” But I just learned that he continued after that mic drop and spoke about doing science on these mountain climbing missions:

Sometimes science is the excuse for exploration. I think it is rarely the reason.

The three primary causes of high altitude sickness:

  1. Acute mountain sickness (AMS): headache, gastrointestinal symptoms (anorexia, nausea, vomiting), sleep disturbances, dizziness, fatigue
  2. High altitude pulmonary edema (HAPE)
  3. High altitude cerebral edema (HACE)

Lake Louise Acute Mountain Sickness severity score for acute mountain score:

Preventing AMS is usually dependent on limiting altitude gain, avoiding alcohol and drinking a lot of water.  Acetazolamide 125-250 bid is also effective.

The headache of acute mountain sickness can be decreased or avoided with medications:

Aspirin 320 mg po q4-hours x 3 doses, starting 1 to 2 hours prior to arrival

Ibuprofen 600 mg po q8-hours for at least 3 doses, starting 6 to 24 hours before ascent.

Ginko Biloba has been used with variable success as prophylaxis. 160-240 mg in divided doses

Dexamethasone 8 mg daily in divided doses can also be used for prophylaxis.

Nice review of AMS treatments and prophylaxis can be found here.

In studies looking at the etiology of AMS and HAPE, Vascular Endothelial Growth Factor and its soluble receptor sFlt-1 were thought to play a role. However in a study of 51 Denali mountaineers, blood levels were not associated with AMS.

The body has a number of strategies to adapt to high altitude trekking. Among the changes is the observation that the density of capillaries per unit of muscle rises. This sounds cool until you read that some scientists believe this is primarly due to a loss of muscle mass rather than growth in new capillaries.

Other strategies for adaptation include

  • Hyperpnea and tachypnea leading to hypocapnia
  • Hypoxia may trigger several receptors, including airway chemoreceptors
  • Tissue hypoxia also induces the production of hypoxia-inducible factor (HIF) transcription factors
  • Changes in metabolic pathways including oxidative metabolism, cell cycle and diminished myogenesis
  • Changes in hemoglobin oxygen affinity that alter arterial oxygen saturation and release to tissues
  • Increase in mitochondria and cytochrome oxidase occur but only after 7-9 days at altitude

Renal changes.

High-altitude renal syndrome is an asymptomatic chronic condition of high-altitude dwellers defined as:

  • High-altitude polycythemia
  • Systemic hypertension
  • Microalbuminuria
  • Hyperuricemia
  • Relatively preserved glomerular filtration rate

High altitude renal syndrome is part of the complex adaptive response to altitude.

Creatinine based GFR is unaffected by increases in altitude, however a study that used cystatin c based GFR assessment found a 3ml/min drop in GFR for every 1,000 meters the mountaineers ascended.

Interestingly, AMS was associated with higher eGFR.

Most electrolytes fall:

The decrease in serum bicarbonate comes from hypoxia induced respiratory alkalosis. Arterial pH at the top of Everest is estimated to be 7.7 to 7.8. PaO2 was 35 mmHg!

Trekkers in the mountains have hypovolemia due to increased insensible losses, increased anorexia, and decreased thirst. Additionally there is altitude induced diuresis. This diuresis seems to be an obligatory early phase of adaptation to altitude. The diuresis can cause a 1-3 liter loss of body water resulting in a 38% increase in blood viscosity at 5,800 meters.

The diuresis has variably been explained by suppression of ADH, increases in ANP and increases in BNP. Increases in BNP are associated with increased risk of AMS.

This paragraph is very interesting:

It remains unknown whether the altitude-induced decrease in plasma volume is adaptive or potentially harmful. If adaptive, then less effort should be made to correct ‘dehydration’, and fluid intake should be limited to simply following the thirst mechanism and to offsetting insensible losses (admittedly difficult to estimate, much less measure, on the mountain). Indeed, as discussed above, fluid retention rather than dehydration is associated with AMS. Perhaps diminished plasma volume is part of the body’s effort to supply oxygen to the most vital organs, overriding the not insubstantial risks of hyperviscosity and thrombosis associated with hemoconcentration.
There could be two beneficial effects of high-altitude diuresis:
  1. Early hemoconcentration elevates the blood concentration of hemoglobin prior to the slower onset of EPO-stimulated erythropoiesis
  2. Volume depletion reduces intravascular pressure and volume load on the lungs and brain, and may decrease renal oxygen consumption (90% of which reflects renal sodium reabsorption) due to diminished filtration

This article is excellent.

The Everest Itinerary

I am so excited to go to the Top of the World with MM4MM to help raise money and awareness for the multiple Myeloma Research Foundation. If you haven’t already, please take a look at my fundraising page.

The trip is being guided by Embark. They seem quite professional.

Here is the itinerary. From what I understand this is just provisional as all plans in the mountains must be.

 

Day 1. We meet in Kathmandu (4, 593 feet).

Day 2. We fly from Kathmandu to the world’s most dangerous airport in Lukla (9,383 feet).

Day 2. After landing in Lukla we hike to Phakding (8,563 feet).

Day 3. From Phakding we trek to Namche bazaar at 11,290 feet. Namche is in a bowl in the hill side, it is a commerce center. Will arrive in the afternoon and may need to climb up to our hotel.

Day 4. We have a rest day in Namche to help with acclimitization. We won’t go any higher to sleep but we will do day hikes. We should have the opportunity to go to Kumchong to see a Hillary School.

Day 5. The next day we will go to Tenboche (12,687 feet). This hike starts by going down and then up. We will be going to the Tanboche monastery, one of the largest in the area. Namche the crowd thins out and the villages are farther apart.

Day 6. The next day is at the Pheriche (14,340). We should get a view of Everest from here.

Day 7. Above Pheriche we encounter the glacier and go to Lobuche, 16,700 feet. We will be walking on the terminal moraine of the glacier.

Day 8. Biggest day is from Lobuche to Gorakshep. We will dump our gear and then climb up to the Everests Basecamp (17,598 feet). We will head back to Gorakshep to sleep (16,942 feet).

Day 9. The next morning we will get up early and head to the summit of Kalapathhar, the highest point of the trip (18,514 feet) and what should have a spectacular view of the glacier and Everest.

Day 10. We then go all the way to Pheriche (14,340 feet)  that night. Long day.

Day 11. The next day we go from from Pheriche to Namche where we will catch a helicopter to take us to Kathmandu.