Category Archives: global surgery

part 19: breheimen

The Route: Sota Sæter-Sprongdalshytta-Arentzbu-Nørstedalseter-Fortundalen-Turtagrø. August 30-September 5, 2020. Day 136-42. 74 km.

Sota Sæter marks the start of the 350 km hiking route DNT MASSIV, a collection of already existing trails now promoted as a long-distance trail by the DNT. I followed the DNT MASSIV for the entire length from Sota Sæter down to Haukeliseter, starting out arriving at Sota Sæter in the middle of a wedding, where I was most kindly offered some wedding cake.

First of all, Breheimen is a very tough area to walk in, significantly tougher than Jotunheimen, one big valley away, and the toughest, but also arguably the most spectacular area since the Narvik mountains. Carved by retreating glaciers thousands of years ago and with Jostedalsbreen (biggest glacier on the European mainland) just on the other side of a deep valley. The ever undulating valleys are connected via snow-field covered passes, steep moraine slopes and plenty of stones, also of the boulder-sized, jumping kind slowing movement down to around 1 km per hour. For me, at least that is: At one point I was passed by three gentlemen, presumably in their 60s, moving with three times the speed of me. I met them twice, first while they overtook me on their way up a mountain a side and again when they came down that same side, me still on my way up..

Gravdalen

The terrain was sufficiently challenging that one night, despite being only 850 m from Sprongdalshytta with the cabin in clear view, I still decided to camp on the spot, due to the impending darkness in a very bouldery land shape too risky to walk in the dark, except in an emergency. The arguably hardest ascent of Norge på Langs was also to be found here: Short, but incredibly steep and muddy, right after Arentzbu on the way towards Nørdstedalseter. If more people walked here the trail would simply be eroded away. A bit further on, a quite nasty bridge had to be passed as well, the worst since Cunojávri. To exit the bridge, I had to throw down my backpack and jump down on it.

At this time of the year, I could have crossed the glacial river on foot. However, the staff at Nørdstedalseter cabin told of hikers having turned around at that bridge earlier in the summer, as waters were too high to cross the glacial river and they could not get onto the bridge. Apparently a stone was missing, they said. Anyway, upon their request I mailed them pictures of the bridge and they would then contact DNT about the issue.
The section Sota Sæter-Sprongdalshytta-Arentzbu-Nørdstedalseter was the toughest section since Knivskjellodden, where I furthermore managed to pick the wrong trail descending towards Nørdstedalseter: Trails made by sheep and trails made by humans look surprisingly alike. But more than 50 meters without a T-sign in this area should make you suspicious and often the sheep trail turn into vertical rock climbing.

In summary, Breheimen is a tough, tough, but also extremely spectacular and very underrated area. I had days of clear skies and optimal conditions in the beginning of September, and I was all alone on the trail, only crossing two people on this section. However entering Breheimen also means entering the area with easy resupply options via self-supplied DNT cabins, which will last until the mountains end, eliminating the need to carry more than food for 2-3 days at a time

Lesson learnt #9: In September with the beginning of sub-zero temperatures, the snowfields get incredibly icy and, at times, impossible to ascend. I met two guys carrying both crampons and ice axes and initially thought that a bit excessive. However, they were on the right track. Next time I´ll bring microspikes at least.

Dream trip #7: a) Exploring the area around Slæom, possibly with packraft. b) Walking the direct route between Nørdstedalseter and Sognefjellshytta passing the infamous stony area around Illvatnet. c) Walking on the edge of Breheimen including the area around the Fast DNT cabin.

The girl who stumbled while playing outside

Delayed access to surgery is one of the main reasons leading to complications and possibly death when working as a surgeon in conflict areas. The story below is from Yemen in 2012:

It was late afternoon and I was standing on the roof of the brand-new MSF hospital in the outskirts of Aden, the main city in the south of Yemen. It was the beginning of May and already around 30 °C while the muezzin called to prayer in a nearby mosque. Due to the tense security situation we were not allowed to leave the hospital at any time and the entire team was installed in rooms on the 2nd floor. If you needed a breath of fresh air you had to go to the roof. Only brief roof visits were allowed though, due to the risk of shelling.

The medical team leader came up and told me he had received a call from another hospital 4-5 hours away, a smaller facility where surgery was not available: They had received an 11-year old girl who had fallen down from a 1 meter high rock while playing outside. She was not doing well, they said, there was nothing to see on her body, but she had severe stomach pain and could not move. Could we receive her? Yes of course.

The MSF hospital in Aden

5 hours later the girl arrived and upon examining her it was immediately apparent  that she had peritonitis as she presented with a classic peritoneal reaction upon palpation of the abdomen. Blood tests, apart from hemoglobin, were not available, no imaging was possible, but none was really needed: She required immediate surgery. 15 minutes after she arrived, she was prepared and intubated and the surgery began. I had talked to her father via an interpreter and explained the situation, told him that I did not know what was wrong but adviced that she may need a stoma.
Immediately after opening the abdomen I noticed the 2*2 mm perforation on the surface of the small intestine approximately 40 cm from the ligament of Treitz. I remember telling the anesthetist that this was good news, the surgery would be completed in less than 30 minutes. I hope so, she said. Accordingly, I sutured the perforation and closed the abdomen. The anesthetist, trained in pediatric anesthesia and intensive care was responsible for the management in the recovery room. When I woke up the next morning I went downstairs to the recovery room, where the girl was sleeping. She was lucky, it went well, I remember saying. The anesthetist looked at me with an odd expression on her face: She is dying. She has acute renal failure. And there is no access to advance therapeutics such as dialysis, the only possibility to save her life.

The almost 24 hours it took for her to gain access a hospital with surgical facilities turned out to be too long. She died later that afternoon. Had she been operated earlier her life would almost certainly have been saved.

The young bleeding pregnant woman

Lack of access to prenatal care is one of the main reasons behind the high incidence of pregnancy complications in developing countries. But what does that mean in practical terms? The story below is from Cote d´Ivoire in 2012:

At around 10 am the midwife came to the operating theatre where we had just started todays list after completing the morning patient rounds: Mostly minor cases, incision of abscesses, dressing changes. Now, a 19-year old pregnant woman had presented with continuous heavy vaginal bleeding. According to the midwife there was no fetal heart activity and according to the woman, she was in week 33. We did not have access to ultrasound. She needed a Cesarean section. With no obstetrician employed, this is the job of the surgeon.

10 minutes later the woman was in the operating theatre and we prepared for the Cesarean section. Probably a placenta previa I thought.  I opened the uterus ,and I still remember the subsequent moments of  confusion and disbelief when I removed handful after handful of what looked like small white eggs. There was no child inside. Instead this was a molar pregnancy, which the woman had carried undetected into the 33rd week  due to the lack of access to pre-natal counseling in the remote are where she lived. I removed the mola and closed the uterus. She was 19. She would be able to have more children.

Duekoue, Ivory Coast

However, the postoperative course was complicated, she kept bleeding. Was this perhaps an invasive mola?  We will never know exactly. In the end we had to perform an emergency hysterectomy, but the vaginal bleeding persisted, however slowly diminishing. Was there perhaps also an element of coagulopathy? Possibly, but without adequate testing modalities, no way to know for certain and in any case no treatment would be available. After a few more days on the ward she was ready for discharge.

How does the future look, in this relatively remote part of the country, for a 19-year old woman, just married and  not able to have kids? Not necessarily bad, I was told. In many such cases a childless couple would raise the children of other family members, such as her sister, as their own.

Obviously with access to appropriate prenatal care, the condition would have been detected far earlier and she would most likely have been able to have biological children of her own.

Working as a doctor on Thule Air Base

Thule Air Base is a strange place: The northernmost US Air Force base, located on top of Greenland and close to the historical settlement Dundas, which served as base camp for several famous polar explorers such as Robert E Peary and Matthew Henson as well as Knud Rasmussen who founded a trade station here and named it Thule. The original Thule trade station was moved and now serves as the museum building in the modern settlement of Qaanaaq, on the other side of the fiord. Upon establishment of the Thule Air Base in the 1950s, the original inuit population were forcefully evacuated to the present day village of Qaanaaq, causing ongoing lawsuits for decades until the matter was finally settled by the Danish Supreme Court in 2003.

Thule Air Base
Thule Air Base

In brief, the main purpose of the Thule Air Base is to support the Thule Radar, a part of the BMEWS system to detect a missile attack against the United States.

Around 600 people live on the base, 150 from the US military, the remaining 450 being service personnel, mainly from Denmark and Greenland. The service contract with the Thule Air Base is with the company Greenland Contractors, who hires the doctors (in my case via an Agency). This service contract is currently (2016) the center of a major controversy.

Thule Air Base
Thule Air Base

Two doctors are permanently stationed on the base, one needs surgical skills. However, I did not have to use mine as the work is centered around general medicine including health certificates and administrative reports. There were no emergencies the month I was there. The closest was a call from a captain on a Lufthansa flight located right over the North Pole presenting a patient had abdominal pain. In the end it was decided that emergency landing at the base was not indicated. Though not part of the health care system in Greenland, Thule Air Base doctors and authorities will nevertheless assist with medical evacuations from nearby settlement Qaanaaq if needed.

My office

As a doctor you are provided with a car with a compulsory driving test at the base. I had a small apartment within the medical building/hospital ward, with no admissions during my time there. There is a small convenience store. The Top of the World Club (a bar/restaurant). And a fitness center. I was on Thule Air Base in August. The sun was never down and I covered the windows with plastic foil during the night.

Dundas

The scenery is spectacular with ~20 km road to drive on outside the base. One of these goes up to the Thule Radar. And despite many visits to Greenland, this is the only time I have actually been standing on the Inland Ice. I climbed the iconic Dundas mountain and visited the old Dundas inuit village. And lastly, I visited Alert, the Canadian base, located only 817 km from the North Pole.

Around Thule Air Base

Other posts on Greenland:
Working as a doctor in Greenland; Some basic facts.
Doctor in Qaanaaq: 24 hours on call.
Medical visit to Siorapaluk, the northernmost settlement in Greenland.
Nanortalik: 24 hours on call.

A photogallery of my time as a doctor on Thule Air Base is available on flickr.

Siorapaluk: Medical visit

At 77°47′ N , 47 km north of Qaanaaq, Siorapaluk is the northenmost settlement in Greenland as well as one of the northernmost permanently inhabited settlements in the world. 68 people live here permanently. There is a school, a church and a small library, all combined in one building. The doctor from Qaanaaq visits approximately every 3 months. Health services in these small settlements are provided by a health assistant, employed for a couple of hours a day, and with only a couple of weeks training. Thus all health issues are normally discussed either on phone or telemedicine with Qaanaaq. Siorapaluk is connected with Qaanaaq by twice-weekly helicopter flights.

It is February. Windy and around -30 °C. We travel with two snow-scooters over the frozen fiords and .bring rifles in case we encounter a polar bear. We wear special polar suits including protection glasses. In the middle of the polar winter, the sun is never up, but nevertheless there is a shimmer of light in the horizon. I have no idea about the direction we are taking and have to trust the local driver. In this hostile environment, all it takes is one wrong turn and we will never be seen again.

We leave Qaanaaq at 7am and arrive in Siorapaluk a couple of hours later. With me is an assistant nurse, who also doubles as interpreter, and the plan is to work as we possibly can in one very long day before returning. I see all the children and vaccinations are brought up to date. Dental status is checked. In fact I end up seeing most of the inhabitants and those not on the list, turn up queuing at the door once the rumor had spread of our arrival.

A tragedy struck this remote community in 2013: An old man died, presumably of food poisoning. What no one knew at the time of his death, he did indeed die from botulism, from the traditional meal kiviak. At his funeral, several of the guests ate from this sane meal, and subsequently his 46-year old daughter died and five additional guests were seriously ill. A case report on this event was later published in a forensic science journal.

On the way to Siorapaluk via the frozen Robertson fiord

A 25-year old Japanese man happened to pass by this place 40 years ago in search for extreme wilderness. He never left, and founded a family there. His reputation as a hunter is widespread and as I was looking to buy a polar fox fur, I went to see him at his storage facility in the basement of his house. He immediately apologized, he did have polar foxes, however they were brown and not white.  The white were sold out as confirmation season was approaching.

At 5 pm we wrap things up and travel back over the frozen Robertson Fiord to Qaanaaq.

Other posts on Greenland:
Doctor in Greenland – the basic facts.
Doctor 24/7 on call in Qaanaaq.
A typical day as a doctor in Nanortalik.
Life as a doctor on Thule Air Base.
A visit to Alert, northernmost settlement in the world.

A photogallery of my time as a doctor in Qaanaaq is available on flickr.

Photos from