Abstract
A growing number of people are heading to high altitudes (>3,000 m) for work, recreation, and religious activities. According to official sources, between 1996 and 2019, visitors to Nepal rose from 393,413 to 1,197,191 per year—an increase of more than 300% (Pradshan and Koirala, 2024). Despite this, considerable physical challenges exist. The combination of low barometric pressure, weather extremes, and challenging terrain means that injuries and illnesses commonly occur (McIntosh et al., 2012). Given this, doctors and other health care providers often accompany groups to high altitude or work in medical facilities close to popular routes. We sought to interview a group of almost 50 doctors to find out more about working at high altitude and their experience of such a challenging environment.
The majority of those we interviewed had previously worked in the Himalayas—Nepal, India, and Pakistan—at altitudes of between 3,000 and 4,500 m. Typically, the duration of service was 3 months or less. Most were unpaid and responsible for organizing their own medical indemnity and health insurance. Accommodation, food, and “in-country” transport costs were usually paid for by other sources for the duration of their posting. Recruitment tended to occur following personal recommendation. Many doctors had more than 10 years of postgraduate medical experience, and the majority held the postgraduate diploma in mountain medicine.
Doctors often worked alongside a small group (<5) of knowledgeable local staff who were able to translate, provide nursing care, and organize evacuation. Access to clean water, electricity, and satellite communication was normally available. The latter ensured that support and expert opinion could often be accessed remotely. Up to 20 patients were typically seen each day. With other medical facilities often more than 12 hours away by foot, many patients were seen on more than one occasion. When available, helicopter evacuation was provided for the sickest patients. Although most patients were “walking wounded,” a small but significant proportion were transported by humans or animals to the medical facility. Most of the consultations were with visitors from developed countries; however, members of the indigenous population were also treated. In this latter group, medical fees were normally waived.
Doctors encountered a wide range of medical presentations at high altitude. As expected, acute mountain sickness, high-altitude pulmonary edema, and high-altitude cerebral edema were amongst the most commonly seen conditions. However, a wide range of primary care problems were also encountered. Gastrointestinal, respiratory, and soft tissue infections were amongst the most common presentations. In addition, ophthalmic, gynecological, and mental health issues were also seen by those that we interviewed. Cases of life-threatening trauma were rare. However, soft tissue injuries involving the hands, feet, and face were regularly seen.
An extensive range of drugs was normally available. These were “in date” and clearly labeled in English. The drugs chosen were familiar to doctors who had previously worked in developed countries. A form of oxygen delivery device was often provided. This consisted of either a concentrator, cylinder, or portable hyperbaric chamber. Adequate dressings and splints were available for those with soft tissue and bony injuries.
Only a limited amount of diagnostic equipment was available. This typically included a pulse oximeter, sphygmomanometer, and some form of urine analysis. A small number of those interviewed had access to ultrasound, electrocardiography, and point-of-care blood testing.
It was clear from those interviewed that the majority had a positive experience of working at high altitude. Many had undertaken long periods of medical practice in this environment, and in several cases, they had returned to high altitude repeatedly throughout their career. For experienced practitioners, such opportunities may offer enormous value—fulfilling an important medical role at high altitudes as well as providing a welcome change from the challenges encountered much closer to home.