Diploma in Mountain Medicine: A Perspective of a Female Doctor from Nepal

Introduction

Mountain activities such as climbing, marathon running, ice climbing, biking, and trekking are gaining popularity (Nepal Climbing and Mountain, 2020). As they do, there is an accompanying increased risk of a mishap, making trained medical personnel in mountainous regions of paramount importance. With this aim, the International Climbing and Mountaineering Federation (UIAA), the International Commission for Alpine Rescue (ICAR), and the International Society of Mountain Medicine (ISMM) formulated the diploma in mountain medicine (DiMM) as a specialized training course in mountain medicine (Peters, 2000). This course is available in several mountainous countries, including Nepal.

Why DiMM?

Nepal is a country of Himalayas with 1,310 mountains >6,000 m and 8 “8,000ers” including the world's tallest mountain, Mt Everest (Actual adventure, 2020). Thus, the DiMM course in a Himalayan country such as Nepal provides mountain doctors an opportunity to get real altitude environment exposure. Most DiMM courses throughout the world have durations of several months or years of separate sessions, whereas the Nepalese DiMM is a bundled course lasting up to 1 year. The course included 1-month face-to-face course in Nepal at 5,400 m and several months of preparatory assignments before and afterward. This makes it easier to plan a leave of absence and saves time and money for candidates.

The DiMM course together with good knowledge and the broad range of skills of a general practitioner, knowledge of travel medicine, infectious diseases, and emergency medicine produces a good mountain doctor (Hofmeyr et al., 2017). DiMM graduates can clarify misheld beliefs, educate many groups, treat illnesses, and maximize the chances of clients to safely reaching their desired summits. Furthermore, they can, themselves, enjoy the beauty of the mountains, experience the rigors of expedition life, and importantly practice medicine in a challenging and truly unique environment. This course benefits all doctors who are practicing at high altitudes or wishing to join expedition or trekking groups in remote areas (Peters, 2000).

Despite the benefits, it is not seen as a mainstream path to follow as a career choice by many medical graduates. Medical personnel especially from developing countries and those countries with no DiMM course are unaware of it. Furthermore, in developing countries such as Nepal, cultural beliefs and social values discourage females from participation in such courses. However, I was benefitted on having a philanthropic parent, my father has a trekking company, so aiming to work in mountains was never a problem but a pride. I was familiar about mountaineering from childhood, as I grew; insight on altitude-related problems, death, lack of health facilities, and lack of medical personnel in mountain encouraged me to break the mold and pursue my career as a mountain doctor. Five Nepali females have completed the course so far and I am the fourth participant. Nepal DiMM also provides a bursary to encourage female doctors from developing countries to participate in this course. MMSN (Mountain Medicine Society of Nepal, 2017) has always supported and encouraged me including other females in this field. Reading articles and attending programs from MMSN, WMS (Wilderness Medical Society, 2020), and ISMM (International Society of Mountain Medicine, 2020) have been my guidance and an inspiration.

As a Participant

I had many doubts and fears of the unknown before starting the course. I was eased into the course starting with friendly lectures, scenarios with artificial models where I could practice resuscitation skills, and use noninvasive medical equipment and improvised items on fellow course candidates before we traveled to altitude. Free time was utilized in socializing and sharing experiences. Trainings on wall climbing, aerobic exercises, and running before the course helped me stay physically strong, other females were no less. Wearing full climbing gear, placing anchors, and utilizing different rope knots helped develop my rock climbing and rescue skills. Many candidates were able to climb the most difficult rock pitches to reach the top while other candidates belayed. Rappelling down the rock with a fellow participant as a victim was scary until I practiced it multiple times. After helicopter training, I was able to select safe landing sites ensuring the area was cleared, signaling the pilot to land, and finally load and rescue patients. In many remote regions, the best method to rescue a critically ill or injured victim is helicopter (Tomazin and Kovacs, 2003).

To reach our final training destination, the journey to Kangla Glacier (5,320 m) started early morning from Lamjung (760 m). Frequently checking on 21 participants and the wider support team, carrying a large medical kit while trekking at altitude was a challenging job. The group was divided up and exposed to simulated cases on the way to Manang (3,519 m), taking on a variety of roles including leaders, treating doctors, assistants, communicators, and rescuers. I did not witness or feel any forms of discrimination throughout the course, everyone worked in harmony. As a team, we were responsible to make a quick review of area safety, then assess the patient, provide primary care, generate rescue plans, and evacuate as per available local resources and medical kits might permit. Following these, discussion among candidates and feedback from instructors broadened the knowledge of mountain illness and related topics. “Practicing good leadership and teamwork develops team spirit to coordinate and collaborate synergistically” (Rudolph et al., 2020). It is an effective method of learning.

Searching for a victim using an avalanche transceiver, a map, and a compass felt a bit like playing hide and seek, but in a real-life emergency this training and familiarity can save lives. Time management was crucial as schedules were hectic with morning lectures, wilderness skill training sessions later in the day, evening hikes to simulated cases, and presentations at night. A surprise objective structured practical examination before heading to base camp (5,200 m) pointed out areas for development and provided a chance to revise skills. Slow ascent, acclimatization, rest, and use of prophylactic acetazolamide (125 mg twice a day) are the preferred guidelines to prevent acute mountain sickness (Imray et al., 2010). Following these guidelines, most participants had no altitude sickness as they climbed to base camp. Mild breathlessness on exertion and disturbed sleep are the normal physiological changes (Imray et al., 2010) I experienced. Deep snow, slippery ice, bad weather, and physiological changes made training at high camp (5,400 m) more exhausting, but it is realistic training for working in harsh environments.

Setting anchors with ice screws, using ice-screw thread, practicing rope halting, spacing, and special rescuing technique with a blistered foot and cracked fingers were distracting. However, using sunglasses, sunscreen, proper gloves, boots, and warm clothes saved us from snow blindness, sunburn, frostbite, and hypothermia. So personal care and precautions to prevent avoidable injury are very important (Brants and Metcalfe, 2017). Finally, being able to combine all the knowledge and skills to rescue a fellow student as a mock victim developed confidence in me to serve as a mountain doctor in future.

As a female, urinating in the toilet tent was a luxury but searching for a safe outdoor site was exhausting for me. So, relieving oneself before the hike or early in a safe site will be best. Furthermore, dysmenorrhea or menorrhagia during the trip can add to the fatigue of high-altitude work. Thus, taking analgesics, or postponing menstruation using the oral contraceptive pills (OCP) before the trip will be helpful. However, using OCP especially in the extreme environment and in women with risk factors has a potential risk of thromboembolic-related events (Keyes, 2015).

All in all, working in extreme environments is equally challenging for everyone. Finding one's passion and becoming physically and mentally strong are crucial.

Challenges as a Mountain Doctor

The duty starts before the trip and includes risk assessment, screening, ensuring appropriate immunizations, and preparing a medical kit as per participants. (Hofmeyr et al., 2017). A medical kit should be prepared wisely as it will be the only diagnostic equipment and treatment options available (Wordsworth, 2011). Despite good knowledge and skills, treatment of victims may still be inadequate due to lack of resources, evacuation difficulty, and environmental uncertainties. Therefore, mountain doctors should always be prepared for worst-case scenarios. Doctors must be extra cautious and physically fit; they are equally susceptible to altitude illness, injuries, and sometimes need to wake on a midnight emergency call. Hence, a good doctor–patient relationship should always be maintained (Hofmeyr et al., 2017).

There can be financial implications due to loss of income from regular work especially when volunteering. However, preparing oneself economically beforehand prevents us from the financial implications, there are paid mountain programs for doctors as well (Brants and Metcalfe, 2017).

Furthermore, most organizations provide free accommodation, food, travel costs, medical registration, and work permits, and some will even provide a daily living allowance (Imray et al., 2010).

A Career in Mountain Medicine

As activities at high altitudes are growing in popularity, so is the opportunity for interested doctors to work in the wilderness (Wordsworth, 2011). Many physicians work at altitude as a hobby, whereas other doctors make it a career. Mountain medicine is growing progressively as a specialty in developed countries. (Wordsworth, 2011). Furthermore, many doctors are not aware of the DiMM course and many have not explored their interest in the wilderness. The Himalayan Rescue Association (HRA), several Nepali owned trekking and mountaineering agencies, as well as other organizations provide interested doctors a great opportunity to work at altitude in Nepal.

Still, there are not enough trained mountain doctors throughout the world. Furthermore, 28% of female participation in the Nepal DiMM course of 2019 demonstrates an opportunity and a need for more women engaging in this medical specialty. Females who are bound by cultures, social norms, and discrimination should break the bond, organizations such as ISMM, WMS, MMSN, and other mountain medicine societies are always supporting and encouraging us.