It was five in the morning and the room shook again…..I jumped up ready to dash outside but it was just a brief aftershock. Some seventeen hours after the initial earthquake, we had experienced several brief reminders of mother nature’s powers. I couldn’t sleep anymore – it had been a difficult night, waiting for patients to arrive from Everest Base Camp. We had treated two the evening before – one was an inpatient overnight hopefully awaiting evacuation this morning.
Our only update up until this morning was that in the aftermath of the earthquake, an avalanche had swept into Everest Base Camp, taking out many tents in its wake, including the Everest ER tent and severely injuring ten climbers, wounding twenty more and sadly resulting in two deaths. Thankfully our fellow HRA volunteers, Everest ER Doctors Rachel Tullet and Megan Walmsley together with their manager Lakpha were alive and well. It was just one year and one week since the deadly avalanche that had torn through the Khumbu Ice Fall – tragedy on Everest had struck again.
Rewinding back to that moment the ground shook, we had been reunited back at the HRA Clinic in Pheriche as Reuben and I had returned from a few days trekking. We had in fact been due to visit Rachel and Meg – our chosen route being to trek via the Kongma La pass, one of the three passes that encompasses the so-called “Everest the Hard Way”. The day before, we had trekked up from our first camp to 5400m, just below the pass when heavy, dark clouds rolled in fast and snow started falling just after one in the afternoon. We had to pitch a tent and were grounded for sixteen hours in a snow storm, myself struggling with mountain sickness before waking at five the next morning to nearly two foot of snow and clouds glooming over us. The pass would have to wait, the route was now obscured – trails less obvious, visibility minimal. As we packed away a frozen, snow covered tent hurriedly, we set off with ice axe and crampons and descended back to Pheriche. We arrived just thirty minutes before the earthquake struck. Had we taken the usual route to EBC, we’d have just arrived as the avalanche struck.
At first the room started to move. Renee, Reuben and I looked at each other in bewilderment; time seemed to stop momentarily. I recall thinking whether or not we should dive under the table. We then heard movement to our left – Andy, Thanasur and the clinic patient were exiting the building. As we left the threshold into the open space outside the clinic, we stood with a scattering of locals and trekkers who had just done the same. The ground was swaying – it was so surreal, the senses completely dumbfounded as we were simultaneously trying to comprehend and anticipate what might happen next. The noise…….a kind of unsettling creaking and moaning will stick with me forever…it was like being trapped in a zone – your senses on edge, trying to compute. What was happening? And then reality……the screams as surrounding lodges started to collapse. Not in total, but rocks collapsed out of the weaker structures. The puppies fleed for safety. We looked at each other for answers. And then it was over. We had been hit by an earthquake.
In the moments that followed we turned to each other for support. It was humbling to be part of such a close team after such a short period of time together volunteering at the Himalayan Rescue Post at Pheriche. Reuben and I had already volunteered for a season in the Gokyo valley at the Machermo Porter Shelter and Rescue Post and had been excited to spend time with the HRA volunteers that we now proudly call friends. Drs Andrew Nyberg and Renee Salas are both Emergency Physicans from the U.S. specialising like myself in Expedition and Wilderness Medicine. We were joined by our post manager Gobi Bashyal, Thaneshwar Bhandari and our cook Jeet Magar. What followed was a mix of trepidation and a rush of adrenaline. Most of us had never experienced an earthquake – Gobi, trained in post-earthquake management told us to keep away from damaged structures in the event we might experience after shocks. And so we set off slowly to explore the village and couldn’t quite believe the destruction that lay before us. The whole village had been affected – save for two lodges, all had structural damage that essentially had rendered the village closed to trekkers within a matter of minutes. Little did we know the devastation that had simultaneously hit Kathmandu and though insignificant in comparison to the thousands injured and those that perished, the tragedy that had followed up at Everest Base Camp.
Unsure of what to expect the morning after the tragedy and with only brief communication with our base office in Kathmandu, we remained alert though emotions were at an all time high and sleep deprivation was already taking effect. As the flow of adrenaline ceased and the nerves settled, I closed my eyes again to try and get some rest – it was difficult – was it normal to be still experiencing after-shocks so many hours later? Just as I’d dropped off, I woke with a start as a helicopter thundered overhead……a quick glance at my watch revealed it was 0542…..the day had started and the weather was good – it was time to prepare for the rescue and help in any way that we could. I strolled lazily over to the main thoroughfare just after six a.m. to look on ahead at the helipad and find out what was happening. It took off again and appeared to head down the valley – the rescue operation was in progress and we were on standby. Minutes later however, the same Fishtail Air eurocopter returned to the helipad. Reuben was ahead of me as I walked over and as I approached, I overheard the pilot saying we needed lots of hands to help carry. As I looked into the back door of the heli, I was a little taken aback to see two climbers crammed onto the floor. I then turned to the pilot who said Everest Base Camp was destroyed and from the air, in utter chaos with tents and equipment littering the glacier. Still processing, he then explained he would be bringing 51 critically injured climbers to Pheriche as quickly as possible whilst the weather window held. This was way beyond any of our expectations and though we had anticipated being busy, we had no idea we would be staging a mass casualty evacuation and receiving every injured climber from EBC. It had already been an incredibly busy season, seeing over 300 trekkers, porters and locals for a multitude of conditions including those symptoms associated with trekking to high altitude – acute mountain sickness, high altitude pulmonary oedema and high altitude cerebral oedema with over 30 helicopter evacuations. Now as I approached the first of the injured climbers, I spoke with a very calm male explaining I was one of the Doctors working in Pheriche and that we would carry him over to the HRA clinic. He had multiple broken bones and though one can only imagine the thoughts racing through his mind in the aftermath of the earthquake and avalanche, he was alive and we needed to act fast to continue stabilising his condition. As I walked round to the other side of the helicopter and glanced upon the other injured climber, I felt disheartened. A quick look beneath the down sleeping bags, revealed the extent of his injuries – that combined with the notes from the doctors treating overnight and laboured breathing painted a dismal picture. And yet he had also survived and we had to be thankful for this small miracle and do our best to keep him alive.
The HRA post at Pheriche was established in 1973 by the Tokyo Medical College and operates twice a year during the spring and autumn, serving both the local and trekking communities for a period of ten weeks. The facilities encompass a small reception, one clinic room and two additional rooms that can accommodate inpatients whilst behind the scenes, the volunteer doctors and staff have a lounge, bedrooms, kitchen and bathroom. Though we can treat many conditions and have a vast medicines cupboard, facilities are basic – it’s a remote mountain post.
Within thirty minutes of the first two climbers arriving into the post, more started to arrive on stretchers. The clinic started to fill as scores of trekkers approached volunteering their services, medicines and medical / first aid experience where able. Having stepped out of my clinic room to retrieve some morphine for my first patient, I found another – this time on the floor. It was quickly apparent that we needed to triage and move the more stable patients to a nearby lodge, thankfully Panorama, owned by Pemba was the nearest and still structurally intact to enable this. I found Renee in our sun room, usually a place of relaxation where we educate trekkers on altitude illness, now transformed into a makeshift ward with six climbers taking up the floor space as they lay bloodied, clothes torn in places with donated sleeping bags keeping them warm, with injuries varying from broken bones to head injuries and reduced conscious levels. As more and more climbers were brought into the adjacent lodge and with the weather appearing to close in, it crossed all of our minds just how we were going to cope overnight.
During all of this, I felt focussed however the commotion outside was distracting and it was difficult to try and stay calm. More and more climbers were being stretchered into our triage area – many straight into the Panorama lodge so from across the way, it was difficult to understand whether they needed to be seen and treated in the clinic. There was no room however and by now, many volunteers were involved in triaging in the lodge – coming across for bandages, oral pain medicines and materials to close minor head wounds. In a mass casualty situation like this, it is very difficult to see the bigger picture and admittedly, I got drawn into the care of my injured climbers who all appeared to be from the same team. At one point, I became quite emotional; a Japanese medical student had wandered into the post very early and was helping me communicate with my patients but then he had to leave with his family. My critically injured patient was starting to pull off his oxygen mask and I could barely record a blood pressure; I knew he was starting to get confused in addition to having sustained head injuries and the prognosis became worse. I pushed some fluids through but there was still so much to do elsewhere.
In the meantime, Reuben was busy trying to coordinate the scene outside the clinical areas with still more trekkers approaching to volunteer their services. He asked Jeet to make some food for all of us and I remember walking into the kitchen at one point, amidst the frenzy outside and in the clinic, and found him carefully shaping and slicing chapatti circles. If only I had been able to capture that moment on camera…. Reuben brought us hot juice and chocolate chapattis though I couldn’t initially face food; he had to tell others to stop what they were doing and remember to focus on themselves first. It was crazy. Next came a wave of locals from the lodges with milk tea for the injured climbers; they were intent to ensure their job was fulfilled. I felt awful when I snapped at them for lifting one of my patients to 60 degrees – they had sustained a dislocated and possibly fractured hip; the movement was agony for them. Though I am sure given the circumstances, the warm liquid was soothing I felt guilty that I had not supervised this more closely. That sort of encompassed the problem I was facing: there was no control, we were the middle-ground between the point of injury and initial treatment and were not really equipped or prepared to deal with this sort of tragedy. The best we could do was act fast and as a team to facilitate getting these injured climbers to safety and more finite medical care. We still had no idea how bad things were in Kathmandu.
At one point, I went for a walk to the mani stones that are a waymark in the village for the HRA Clinic as well as to pass good tidings for those on their journey into the mountains. Gobi was here with Reuben and both were talking whilst awaiting news on whether we would be able to evacuate any of the climbers to Lukla. At that time, a few of the Eurocopters were still ferrying the injured down from EBC but clouds had rolled in and there were no flights down the valley. Conditions were looking ominous. I also needed a hug and got one from both of them – another example of teamwork. I had left my three patients with the Japanese medical student and they were communicating – it had given me some space to try and clear my head and get perspective. When our first two critically injured patients had arrived, I had started with the usual ABCDE assessment and started to try and gain IV access (it proved difficult but we got the original IV line working again) and then I glanced into the other clinic room watching one of my colleagues using ultrasound. At home, I can ultrasound a neck vein before placing a large neck line for powerful medication use in intensive care or theatres but I am not trained to evaluate the abdomen and I got a little hung up on this. I had questioned my clinical skills when in fact, as patients continued to arrive, we barely had the chance to triage them as by now there were so many others doing this job for us! Back at the clinic, feeling more positive, I went to help Renee give some of her patients i.m. injections of dexamethasone and tramadol. She was busy making labels for each of the injured climbers; we had decided early that this would be a quick way of triaging those in need of early evacuation and so attached tape to their chests detailing names and injuries. This became a very useful and important tool later that morning.
Whilst Gobi remained at the helipad coordinating with the locals who have authority in Pheriche and neighbouring Dingboche, Thanasur continued to help us treat our patients. At one point I caught him looking a little tearful; the Nepali patient we had on the floor in the middle clinic room looked very unwell and all of us were praying he would make it. Whilst scanning the three rooms to see how each of the clinic inpatients were fairing, I heard a commotion outside and Reuben came flying into the clinic saying “get the two sickest patients ready for evac now….” and so the moments of doubt surpassed in an instant and one of the greatest achievements I have witnessed of a community and its volunteers working together was about to start. Though it needed some authority amongst the chaos and finally, I found my place in all of this…..
As we moved my climber out towards the helicopter, the adrenaline flowing in every volunteer was evident. People were rushing, stumbling and IV fluids dropped to the floor which jeopardised the IV access. “Bistari, bistari….” I shouted – “slowly, slowly…” as the stretcher was carried out for all to see. Another moment to remind us of the gravity of the situation was seeing the helicopter so close to the footpath – rather than in its usual place some 250m away at the helipad. It’s strange how thoughts like these sink in when you are so busy and have hundreds of other more important things to be concentrating on. Again I called for the team to move slowly down the bank towards the helicopter – it’s blades were still spinning however working for two seasons in the Himalayas, I know it is safe to approach from the front. Our stretcher team was a mix of Nepalis and trekkers – I couldn’t see Gobi or Thanasur initially as their presence is so reassuring; they can tell the Nepalis to take things one step at at time. There were two Spanish volunteers who I later found out were firefighters – they were very good although still the adrenaline was charging. I rounded one side of the helicopter and climbed in to help guide the stretcher in; before I could stop the other team however, they were loading a second climber in whilst my patient with bilateral leg fractures still had their legs outside one of the helicopter doors. It was less than smooth but we got them on and the helicopter took off down the valley.
In the excitement that followed this first evacuation, two more of the four sickest patients arrived out towards the evacuation point. I was talking with Reuben when one of these, a Nepali with significant head injuries and facial swelling, started to sit up and become quite combative. He had been secured overnight with hand ties and we had to do the same, trying to keep him calm as a combative patient in a helicopter is a flight safety risk. It was difficult. A few of us stepped in to keep him still and in the stretcher – I got chatting to the lady firefighter and we formed a friendship in that instant. After a rescue of this proportion, there are always people who stick in your mind more than others – people you can look to in a sea of faces, people who are reliable and know how to get the job done. A helicopter landed once again and in an instant people were lifting this patient and he nearly fell off the makeshift stretcher; “not yet….” I said – this was not our ride but people didn’t understand this. Just as we were preparing for the next helicopter, an almighty roar came up the valley and a Russian MI-17, operated by Shree Airlines came thundering into view, landing on the helipad in the distance. This was the first of what was to become three big lifts down the valley – we loaded 16 injured onto the craft in a matter of minutes but it was not pretty. And sadly, walking wounded were trying to jump on board before those on stretchers; Reuben caught someone with a finger injury trying to queue hop. People were frightened; they wanted out and who can blame them? But what was certain was we needed more order otherwise people were going to get injured; Gobi had to motion for one stretcher party to follow the crowd – they were trying to cut upstream of the unsteady bridge crossing which put them at risk of the rear rotors. This MI-17 was a beast and watching it take off, fully loaded, was impressive. I felt so proud that we were a part of this.
I stayed put for the remainder of the evacuation and made a quick decision how we were going to make order out of the chaos. Though the rescue mission was flowing smoothly, there were hundreds of people, each in teams with stretchers trying to get their patient rescued. More and more stretchers started to arrive on the footpath outside Snowland Lodge. And so I started to open jackets and look at the labels; I numbered them in priority of injury for evacuation on the next helicopters. We had eight lined up and ready but more injured climbers started to be lowered out of order onto the footpath. Andy shouted out at one point to follow my orders – nobody was going to get on a helicopter without my say so. With that, people obeyed and watched – waiting for the go ahead to lift and carry their stretcher and its injured climber to the inbound helicopter. It made such a difference; yes, we had to jiggle the order once or twice according to injury and also explain to some trekkers who had become fixed on their one patient that they would eventually get evacuated but it was a smooth and effective operation. When the MI-17 returned, I asked everyone to wait as the default was for all to launch down the bank as had happened previously and with authority we had “number 1….go….number 2….go….number 3…and so on”. It worked like clockwork. A few people tried to get their group members down but I managed to intervene – there was no time to be lenient nor to change tactics. During the time we were waiting for the helicopters or MI-17, there were volunteers approaching saying they had someone who needed to go down urgently. Despite the fact climbers lay before us with varying degrees of injury, they had come from the lodges with a message and we had to take this seriously. A quick check of oxygen saturations and respiratory rate reassured myself and the volunteer that these individuals could wait a while longer. I also saw trekkers arriving into the village who had no idea what was going on. Communications had been shut off since the earthquake so people were none the wiser; it must have been quite a shock to see casualties lying everywhere with helicopters flying fiercely up and down the valley. Looking up to the ridge, trekkers were also visible in their throngs looking out onto the events in the village below – it must have been a sight to behold especially given the devastation that had hit Pheriche the day before. Reuben tapped me on the shoulder at one point and introduced me to Dr Ken Zafren, HRA Director with whom I had been in email contact intermittently over the preceding four years regarding the posting. What a time to make introductions! We were able to chat and talk through the mornings events – he seemed pretty impressed with how the evacuation was progressing.
As we evacuated all those injured on stretchers, we were then left with walking wounded – many still significantly so with possible limb fractures and also others with chest and head injuries. Still requiring order, I grabbed chairs from the nearby lodge and asked people to do the same. We sat everyone down and started to triage once again. One Sherpa didn’t have a label and looked upset – he’d picked up on the fact that we were evacuating those with labels. So I made him one and added his number – that seemed to rectify his situation. As I filed up and down in front of them, each Nepali climber grabbed their jackets and made their number visible. They did seem to make up the majority of the walking wounded simply as they outnumber the Western climbers 3:1. Luckily, the MI-17 came back for it’s final sweep and somehow, I managed to maintain order even though I was gradually being pushed down the bank as swarms of injured and their volunteer helpers motioned towards the helicopter. I hadn’t seen much of Reuben during this time but his job was loading people onto the MI-17 in addition to much of the groundwork between volunteers at the clinic and the HRA Staff. As the final climber was boarded onto the MI-17 and the doors closed, he headed back towards the crowds now gathered on the path that had been the site of the casualty evacuation. Andy shouted up to all to say a massive thanks to all involved and that they were, as of this morning, also Himalayan Rescue Association Volunteers. A rapturous round of applause filled the air and then the crowds departed; just like that. It was an amazing feat; in just 5 hours we had received, triaged, treated and re-evacuated over 70 injured climbers from Everest.
Back at the clinic, we took a moment to sit down in the reception and debrief. Ken sat with us as did Meg – during all of the commotion she had flown down to assist and now told us of the horrors that had occurred the previous day. She had been treating a climber in the Everest ER clinic when the earthquake hit – minutes later the avalanche had swooped down off Pumori and flattened everything in its wake, destroying the middle of EBC and taking with it tents and throwing climbers frightening distances. Luckily, she had been fully dressed in warm layers on what was a cold morning for after that instant, all her belongings had been buried. In the hours that followed, they worked together with the other camp doctors and hundreds of team members to treat the injured – I cannot imagine the scenes nor the sights they witnessed; it must have been horrific. In brighter spirits now as we revelled in the success of evacuating all of the climbers, we drank some Coca Cola and ate digestives. But then there was a thud and with that we launched for the door; we were being hit by another giant aftershock. The ground swaying again was just awful. And then it stopped.In the hours that followed, we each turned to our inner selves to try and seek comfort and solice. Jokes were less prevalent, worries more rife. Our staff were concerned about their families back in Kathmandu – still we didn’t have internet. I rang home on the satellite phone and heard Nepal was all over the news but we were still locked in our bubble up here. The ground was still moving and the building popping from time to time; I was suffering with vertigo. Sleep didn’t come lightly that evening as we wound down from the day’s events. We had finished our job and now had to wait to find out what would unfold next. The following morning Meg flew back to EBC and so we spent the day trying to get back some normality. For things to be the way they had been 72 hours ago…..we watched The Lego Movie singing “Everything is awesome…”. Light humour seemed to be the way forward. And then at 6pm on the evening of the 27th April, we reconnected with the world. Having craved this since the moment of the earthquake, the reality was more difficult to deal with. The influx of messages though incredibly moving was so overwhelming. I couldn’t bring myself to read the news nor face the true devastation that was occurring in Kathmandu. It is my seventh visit to this beautiful country and I have friends whose families live less than an hour from the epicentre. It hurt too much to know the numbers, the crisis unfolding and whether we would get out and to safety. That, and the continued aftershocks has been hard to deal with and four days later, I am still experiencing unease as the building vibrates with the wind or helicopters flying overhead. Hopefully this will settle in time. One thing I am grateful for is to have Reuben here with me; I am not sure I could have coped without him.