Remote Medical International Blog

Remote Medical offers MCA ENG 1 Exam and Certificate- Sole ENG 1 Provider on West Coast of USA

Tom Milne — Mon, 26 Oct 2009 12:32:17 PDT

Remote Medical now offers the MCA ENG 1 examination and certificate at our Seattle location. The ENG 1 is required for many mariners and yacht crew, particularly those operating on UK-flagged vessels. Until September, there were only two MCA approved examination locations in North America- one in Rhode Island and one in Florida. Now there is a resource for the Pacific region, as well as yachts traveling the West Coast, from Mexico to Alaska. List of MCA approved Medical Practitioners outside of the UK

The MCA ENG 1 complements the other services RMI already provides yachting and maritime including 24/7 telemedicine service, medical kit provisioning and medical kit restocking, medical training and certifications, and medical support staff for maritime and offshore. Those stopping in for an exam can also arrange for medical services for their ship or yacht, and pick up orders in person as an added convenience.

Exams are provided by Dr. Michael Cull at Remote Medical's Seattle offices, located at:

4259 23rd Ave W, Suite 200
Seattle, WA 98199 USA

Seafearer Medical examinations can be scheduled by calling the RMI office: 001 (800) 597-4011, or 001 (206)686-4878, or by emailing info@remotemedical.com

Tom Milne

Yachting and Luxury Travel Account Manager
tmilne@remotemedical.com

RMI Instructor Melissa Arnot Back in the Himalayas

Kevin Thompson — Tue, 20 Oct 2009 10:24:39 PDT

Remote Medical International Lead Instructor and First Ascent guide Melissa Arnot returns to the Himalayan Mountains after her successful summit of Mount Everest last May. During the next twenty-one days, Melissa and photographer Cory Richards will attempt to summit three mountains in the Khumbu region of Nepal, each rising above 20,000 feet. The expedition requires good weather, sound health and the motivation to cover an incredible distance over technical terrain. Follow Melissa’s Himalayan expedition on the First Acent Born Out There blog.

Open Ocean Sailing Medical Support: 2009 Mini TransAt, Chris Tutmark Interview

Tom Milne — Wed, 09 Sep 2009 15:43:05 PDT

"One Person in a Little Boat Against the Ocean""Self" photo from USA 724- Chris Tutmark

That's how Seattle-based sailor and yacht rigger Chris Tutmark sums up the Mini TransAt- a single-handed open ocean race starting September 13 that he's competing in following months of preparation, training, and qualifiers.

Spicy

The details of the race are a bit more spicy. Racers sail Mini's, 6.50 meter (21+ foot) high performance boats from France to Brazil. The races average 20+ days in length, and in an average day the competitors get only 4 hours of sleep while crossing the Atlantic, relying on skill and seamanship, with limited support.

I had the chance to check in with Chris in France a few days before the race and get a short interview before he headed out. His answers provide insight into the planning and psychology that goes into such a venture. As the medical sponsor for his bid, Seattle's Remote Medical International provided him with training and the Classe Mini spec'ed med kit, hence particular interest in that area.

Interview

Tom Milne/RMI: Describe the TransAt in a nutshell

Chris Tutmark: It's one person in a little boat against the ocean. The Classe has strict guidelines limiting outside assistance and gear so that the focus is on seamanship, endurance, and racing skill. Many sailors are attracted to this race for it's purity.

How do you manage the long days?

CT: Sleep psychologists advise the racers to stay out of serious sleep debt for the first 5-7-day section. Sailors will aim for four hours of sleep out of each twenty-four hour period, with one of those four hour periods unbroken if possible (otherwise short naps when possible). On leg two, most will aim for five hours of sleep every twenty four, with at least one of those hours being continuous sleep. The crux challenge for many racers will occur during the deprivation of the second stage, managing "how much is left", and finding out how to make that equation work.

Tell us a bit more about racing strategy on the TransAt...

A number of factors must be managed in addition to the physical. Each boat is equipped with a transponder, which shows a competitor the distance to the next port or finish, and each competitor can also see the other boats' distance to those points. That being said, the figure may be misleading- one boat may have a closer relative position, but due to weather patterns (prevailing and current), racers' sleep schedules, currents and other factors, a racer with a greater distance relative to another may actually have an advantage. For example, racers may have preferred strategies for crossing the doldrums, or may make up a new strategy on the spot.

In the end it's a blend of a race versus the other competitors, managing your own energy reserves, and maximizing individual performance. Days 12-20 are about endurance, pushing hard while your systems are already maxed, and knowing your own and everyone else's personal limits. To be successful you have to be able to maintain that edge without going into the red zone and crashing....

What support systems do race organizers have in place for contingencies/emergencies?

Although this is sailing and racing stripped down to a very pure form, the race organizers are very serious about safety. There are very specific required medical kits on each boat, specific training required of the racers (*TM note- these are the services Remote Medical is providing Chris), and seven support vessels spread throughout the fleet that are within VHF range at all times. Two MD's are on the race (one of them previously finished a TransAt), and a specific telemedicine support service is available to racers and support staff. Each boat carries an ePirb unit that allows them to signal race organizers to alert them of issues that either a) are manageable, b) require outside help or c) require an evacuation.

What are the most common medical incidents open-ocean sailors face?Sunset near Penmarc'h

The most common incidents include: sprains- wrist, knee and ankle; skin infections, due to the wet conditions, difficulty of proper hygeine, humidity and tropical conditions later in the race, and the fact that the racers' immune systems are compromised due to the extended physical demands of the TransAt. That being said, our required medical kits are capable of handling more serious issues as well.

What attracted you to the TransAt?

I like the simplicity. Much of my life as a sailor has been as part of a crew, which has been great. This race will present a different (although no lesser) type of satisfaction- all decisions, good and bad, will be my responsibility alone. For some people this race is part of a "bucket list", for others it can be a stepping stone to different solo open ocean races, such as the Vendee Globe. I see myself doing more of this type of racing, and helping establish and support these types of events in North America.

What will you do once the race is over?

I'll take a shower and get some sleep! After that, I'll be getting the boat packed up. I will be selling USA 724 after the race. This entire venture has been essentially self-financed, so plan be having the boat delivered to a prospective buyer either in France or North America after the race. I will have over a week in Brazil to wrap things up and decompress before flying back to Seattle.

Any final thoughts?

I have been struck throughout this process by the camaraderie the fleet and this group of sailors displays, it is phenomenal. There are eighty five boats, and everyone is helping each other. Yes, it is a competition, but it is also an amazing venture that we are sharing in. The bonds are very strong.

Chris and the other 84 competitors depart from La Charente France en route to Salvador Bahia Brazil Sunday, Sept. 13. Follow the updates, including current positioning, on the official race site-

More about Classe Mini: http://www.classemini.com/

Official 2009 Mini TransAt site: http://www.transat650.org/en/

Chris' Blog: http://usa724-mini.blogspot.com/

Tom Milne helps clients in yachting, expeditions, destination resorts and expatriate communities with medical support in his work at Remote Medical International. A WEMT and international mountain guide himself, Tom has managed expeditions from the Amazon to Antarctica. For more information or questions, contact Tom at +1 (206) 734-3427 or tmilne@remotemedical.com.

Remote Medical International ranked #147 on INC 500.

Andrew Cull — Fri, 28 Aug 2009 09:46:24 PDT

Remote Medical International was recently ranked #147 on the INC 500. With a growth rate of 1,206.6% between 2005 and 2008, the award is a real tribute to the hard work and dedication of the members of the RMI team. While we continue to grow at a similar pace, being listed among the fastest growing companies in the country provided a short break in which we took a deep breath to appreciate the dedication of our staff and strong relationships we enjoy with our clients.

RMI Legal Counsel Phong with Emily (Project Manager for the Medical Support Group) and Bryce (shareholder) at the INC 500 celebration.

Integrated Operations Director Christine Avakian recalls the days of RMI when Chris (to her right) and Andrew (CEO) shared a desk and phone in a small 100 square foot office.

While at the party last week, I was taken aback by the friendships, teamwork and focused execution that has become a cornerstone of the RMI culture and it is a privilege to work with such a competent and interesting group of people.

It was also an opportune time to recall our history and truly appreciate what we have become. During a toast, Christine Avakian, the third employee hired at RMI, recalled the time when I shared a desk and a phone with Chris Kenney (Director of the Equipment & Supply Group) in a small 100 square foot office. With operations in 6/7 continents and all of the major oceans, it is easy to forget where we started and that it wasn't all that long ago.

It has truly been an honor to work both with our staff and our clients. We will continue to move along with the mission of providing peace of mind for our clients operating in the worlds most austere and extreme places. We will also grow only as fast as we can effectively deliver our products and services at the level of quality that you can count on from us.

Thank you for helping us get there.

Kind Regards,

Andrew

Camels at Altitude

Kate Earle — Fri, 14 Aug 2009 09:41:30 PDT

RMI Instructor Kate Earle acclimitizing with the locals near Mt. Muztagh AtaWhen one thinks of two-humped Bactrian camels in Central Asia, one might imagine them as docile beasts of burden plodding along golden sand dunes. Well, not on this day. Somehow I found myself evacuating a 17 year-old male with altitude sickness in the shadow of Mt. Muztagh Ata's (24,758 ft.) glaciers on the back of a camel that was anything but docile. The camel bellowed, stomped, and actually broke free of its nose ring while crossing a treacherous glacial river (with my patient on his back) as if to announce that he would like to go back to the desert.

Before I sound ungrateful to the camel's aid, let me mention how necessary and grateful I actually was (and am). That morning, one of my students woke me up in my tent before dawn with projectile vomiting, ataxia, and a severe headache. By the time the sun rose and illuminated a landscape of white canvas nomadic tents, yaks, camels, and melting glacial streams, the male patient was lying heaped on the ground. It became evident that an evacuation would be necessary. Like all medical emergencies, I calmly inventoried my resources: five camels, two local guides, two cell phones with spotty coverage and nearly exhausted batteries, Diamox, a telemedicine subscription, and ten other bewildered and scared looking students. "It could be worse," I thought. It was no sooner that I said this when the hail began to fall. Suddenly the camp site looked less like a site for sleeping and more like an angry snow globe meets and even angrier pinball machine. I reminded myself that unexpected weather in the mountains can just as unexpectedly stop and after about 30 agonizing minutes, it did.

The complications didn't end there, regretfully. I was guiding a group of predominately North American students along the Silk Road and we had just begun our high altitude trek in the snowy Pamirs along the China / Pakistani border. Due to severe ethnic riots and conflict, China had shut down outgoing cell phone calls, text messaging, and Internet in Xinjiang province. Furthermore, border checkpoints and police checkpoints would slow any effort to get out of the mountains via the infamous Karakorum highway.

K2, the camelMeanwhile, the patient got sicker. The local Kirghiz nomads earnestly attempted to coax him to eat sour yak yogurt (a traditional remedy for AMS). The telemedicine doctor and I finally broke through on the telephone line and confirmed administration of 250mg of Diamox and immediate descent. It was deemed the strongest, most sure footed camel (affectionately named "K2" with his white color and icy "don't mess with me" attitude) would be the camel for the job.

But how does someone with poor balance and coordination manage to balance on a camel over steep and rocky terrain at a pretty good pace? We tied the patient loosely to the camel's front hump with a quick release knot and assigned two people to spot either leg of the patient and another two to spot the Camel on particularly steep parts of the descent. The local guides and I took turns leading K2 by the nose and enjoying the relief that K2 was acting patient and reliable and that every step to lower altitude was a step closer to stabilizing and improving our patients condition.

As a Wilderness Medicine Instructor, I constantly remind students there are unpredictable variables that can occur in a remote emergency. As the evacuation progressed, I smiled silently to myself thinking that somehow, this long and complicated morning was a mere test. Limited communication, challenging environmental factors, limited resources... remote medicine is about pulling out the stops and making it work. It is about adapting creatively to the situation at hand and giving up on the "ideal" situation. You have what you have. Critical moments can't be spent wishing you had taken another route, had a better phone battery, or were not trekking in a police state during severe political unrest. As I led K2 (the desert camel) through melted snow, we both breathed quickly to compensate for less barometric pressure and O2 per breath, I realized there is something to be learned from a misplaced camel at altitude. Be adaptable. Be steady. Patient, camels, and support work their way towards lower altitudesRemember that you carry much of what you need within yourself to deal with any environment and any emergency. Maybe you would rather be in the desert amidst rolling sand dunes instead of this oxygen deprived and cold hail storm, but guess what? You aren't! So you better make the best of it. Who would think that a camel at altitude could teach you such a simple but critical lesson about wilderness medicine? Especially one that spits and bellows.

These are lessons I will bring home to Seattle after six weeks of managing AMS, dehydration, heat illness, and orthopedic injuries while guiding students through some of the most dramatic landscapes on earth along North West China's Silk Road. Wilderness medicine skills go far beyond splinting and bandaging. They are the skills that help you manage the situation when four policemen armed with machine guns come into the yurt at midnight and are yelling in a language you don't understand. They are the skills that allow you to stay calm when a student is taken by ambulance to a Swine Flu Quarantine hospital for spiking a fever in Beijing at the time of a global pandemic scare. They are the skills when you suddenly find yourself in the middle of a lightning storm at the top of the highest sacred Tibetan peak where seconds count and the wrong decision could be disastrous. My experiences this summer have only reconfirmed my commitment to training people in these critical skills and I look forward to returning home to do it.

First, however, I am off to ride a horse across part of Mongolia's empty desserts, snow capped mountains, dramatic gorges, and grasslands to continue to live wilderness medicine as a philosophy as much as a practice.

RMI Instructor Receives Honorary Award from Marine Students

Kevin Thompson — Tue, 11 Aug 2009 14:17:55 PDT

Following a recent Wilderness EMT course in Leavenworth, Washington, Remote Medical International Instructor Steve Guthrie was awarded an honorary ice axe from the Special Operations Training Command, USMC. The ice axe award doesn't have an official name and it is rarely awarded, although there has been a 40-year tradition of Marine Recon units awarding paddles to honor exceptional performance. The ice axe is an adaptation from that award. It is presented to an instructor, or occasionally a student that shows "...exceptional expertise, dedication and commitment, and consistently performs above and beyond expectations."

RMI Instructor Steve Guthrie (center) poses with his new ice axe and two Marine Corp students.Every individual ice axe is customized primarily by the Marine that will present the award. There have only been 2 occasions where this award was presented to anyone outside of the Marine Corps. The first was to the U.S. Army 10th Special Forces Groups Mountaineering School. The second, and the only time it has every been awarded outside of the military, was to Steve.

Michael Truax, who presented the award, stated, "It is important to recognize the effort outside agencies make to facilitate our training. Steve, and RMI, definitely went out of it's way to make sure we were taken care of."

Steve tells us.. "I am deeply honored in receiving this award. It reflects not only individual achievement but also the excellence of the program and the hard work and dedication of everyone at Remote Medical International."

The Scarab™ Rescue Tool, The Next Level in Rope Rescue

Dave Svobodny — Thu, 16 Jul 2009 12:45:25 PDT

At the end of June I was given the opportunity to go to this years Mountain Rescue Association conference at Mt. Hood, Oregon. I was able to represent both Juneau Mountain rescue, a search and rescue group I have worked with for 3 1/2 years, and Remote Medical International whom I am an Instructor for.

The Scarab Rescue Tool in action during a lower.Sometime between learning the latest techniques of rope rescue, and talking to the former 10th Mountain Division founders of the MRA, I had some time for look at and use one of the newest pieces of rope rescue equipment called the Scarab Rescue Tool, which you can get in steel or titanium.

The Scarab Rescue Tool made by Conterra equipment, is one of the newest and I would argue most user friendly pieces of rescue equipment around. Having used both break-bars and Tuba extensively in Mountain rescues, I feel that the Scarab takes use and functionally to the next step. A few things I found I liked about the Scarab:

First thing I noticed was that it was much easier to use for a left-handed operator such as myself. Anyone who has been in the middle of a complex rescue system with break-bars will notice that all they are set up for right-handed use. This may not seem like such a big deal, but during a rescue anything that will make operations simpler, and easier will make them safer for your team.

The next thing I noticed was how easy and fast it is to add or take rope from the system. Anyone who has setup a break-bar just to realize that there is another 80 feet of rope that needs to be pulled through before the line is tight will know what I am talking about. With the Scarab it is simple and fast to pull all that line through.

I had the chance to talk to some of the folks at Conterra about the Scarab. Besides its speed and simplicity, they talked about the tests they ran the Scarab rescue Tool through. After running miles of rope through the Scarab they found two things. The Scarab has very little heat build up, and little to no signs of wear on the steel version.

The device is small, without any significant moving parts. It is simple and quick to set up.Also, for all of us that have had to hike rescue gear into the field the best part about the Scarab is its size. The titanium version weighs just 6.6 oz. and takes up less then half the room as a break-bar. The steel NFPA Scarab weights just 13.8 oz and has a strength rating of 26Kn, or about the same as knotted breaking strength of most 12.7 mm ropes.

The Scarab is much easier to brake with than a standard brake bar rack, especially if you are on uneven terrain.Having seen and practiced with both versions of the Scarab, I can’t wait for them to become part of my rope rescue kit. The Scarab represents the next level of rope rescue. You can find them on the Remote Medical equipment and supply page.

Reviews of the Scarab Rescue Tool from our Customers

NFPA Scarab Rescue Tool

NFPA Scarab Rescue Tool

Travel Smart, Travel Safe: Radio Interview with Andrew Cull

Tom Milne — Tue, 09 Jun 2009 14:47:47 PDT

RMI CEO Andrew Cull recently gave an interesting online radio interview, hosted and moderated by Larry Kaminer, President of the Personal Safety Group, which offers public and private training for a variety of groups including corporations and schools. The Personal Safety Group's online radio show brings experts in various elements of safety to his audience.

During this interview, Andrew outlines considerations for pre-trip planning and safe practices for international travel, and gives some interesting tips from his diverse experience.

Click here to listen to the interview on Travel Medicine online.

Wound Management in the Land of the Yeti

Kate Earle — Mon, 18 May 2009 18:45:21 PDT

Flying in a twin jet otter airplane (named after the abominable snowman "yeti") high above the Himalayas in the 12th poorest country in the world makes you question your mortality. "WOW! Look at that mountain!" is interrupted by sudden statements of sheer terror, "I think we are going to crash into it!!!" As the plane tumbled and pitched through the choppy Himalayan air, I furiously fumbled through my iPod to find appropriate music should the plane come any closer to scraping the peaks and mountain passes below. In just 40 minutes, we had flown from the hot, malarial, dusty, and flat Tarrai planes of Southern Nepal to one of the poorest and remote districts of Northwest Nepal perched high in the Himalayas along the Tibetan border.

It was no sooner than we hit the dirt runaway (that was incomprehensibly short) that we began to see signs of the recent Maoist insurgency. Dugout fox holes, sand bags, and rolls of barbed wire surrounded the airport and otherwise picturesque town of mud-walled and tin-roofed houses. Brian Smith (Founder and President of HAND- Helping Assist Nepal's Disabled and former RMI WEMT student) and I had come to conduct a Disability Needs Assessment in the Humla region. We quickly found that many of the disabilities would be war related and the others would be the result of lack of basic infrastructure such as roads, electricity, and a minimum 10 day trek to the closest staffed medical post.

In this small Himalayan town, there are no cars, no trucks, and no motorcycles, only the ringing of Tibetan bells around the necks and muzzles of yaks, burros, and horses making their way up the hillside. This was drowned out by by the piercing thud of the UN helicopter's rotors- slicing the mountain air and drowning the town in a cloud of dust. Several times a week, the United Nation brings in bags of rice since the Humla region suffers from food shortages year round. It is a critical lifeline for the 45,000 people of the Humla region where only 1 percent of the land is arable.

As an RMI Instructor, I am constantly defining "remote" medicine and "remote" environments. As the plane and chopper disappeared over the mountain range in a cloud of dust, I knew that definitive medical care was out of the question. The weather in Simikot (like most of the Himalaya) is known to spontaneously turn so the flight schedule was entirely contingent on conditions. Limited resources? Check. Lack of communication? Absolutely. Environmental challenges? Between the altitude, temperature, and UV exposure, this was also certainly the case. We set out with our medical kits, gear, a porter, and a translator into the definition of remote.

I am carrying a customized version of the Adventure Medical Kits Mountain Medic II and I am glad I have it as we immediately stumbled across an eight year-old who had sliced his finger open with a rock. Gangrene infection had set in. Not long after, another 12 year-old boy had hit the top of his foot with an ax while chopping wood. To control the bleeding, his family poured ground flower tikka powder (usually Hindus reserve this for covering the third eye to protect the wearer) to assist in clotting. Both patients needed considerable wound cleaning and management in a setting where soap and clean water is virtually nonexistent. We were not just treating them until they could get to definitive medical care, we were the medical care- a responsibility that runs through your head incessantly as you make decisions.

Irrigating a gangrenous axe injury with drinkable water while we figured out our next steps.

In the remote regions of Nepal, soft tissue wounds secondary to simple accidents such as these can lead to life long disability and even life threatening infections. The power of rudimentary skills and supplies,such as soaking, high pressure irrigation, tincture of benzoin, triple antibiotic cream, and sterile dressings cannot be underestimated.

We are now gearing up for phase three of our work here in Nepal which will involve identifying and guiding patients with treatable blindness through the Solokhumbu region to a remote eye surgery clinic in Phaplu. This is sure to be an unforgettable experience. The path is steep and narrow and the patients will be partially or completely blind. With that said, HAND (with Remote Medical International's donated medical gear and medications), will attempt to restore their eyesight if at all possible at a remote Cataract eye surgery clinic.

Despite the sometimes harrowing plane flights, food shortages, probable monsoon leeches, and political unrest that seems to shut down the roads everywhere we go, we are thrilled to put our knowledge and skills to the test. Our work in Nepal has and will continue to prove the critical nature of WEMT skills in places where medical care can be as elusive and virtually nonexistent as the infamous yeti.

Dispatch From Everest Basecamp - Part 3

Melissa Arnot — Wed, 13 May 2009 14:07:34 PDT

The weather at Everest Basecamp can be very unpredictable. Mostly, when it snows or the clouds move in it is just a little less comfortable, but at other times it can be the difference between life and death. The past few days at BC have seen really bad weather, cold with lots of snow and wind. In that same time there have been a few people who needed to be evacuated by helicopter, but have had to wait due to the poor conditions.

Remote Medical instructor Melissa Arnot assists HRA doctors in treating a poisoned climber.Unfortunately, in the midst of this bad weather a major medical emergency occurred. Some small bottles of whiskey came into basecamp that contained Methanol in them, which is a toxic poison if ingested. Two people drank this whiskey. Right away I heard the Himalayan Rescue Association needed help and went over to see if I could do anything. Watching the doctors move around and working was seeing remote medicine at it's finest. The patient that they were helping was very sick, and my Wilderness EMT skills were greatly appreciated. One of the first things to do as care providers was to think of all the things that could go wrong and how we would deal with them. The most important priority for this patient was airway, and with no suction device present, we immediately went to work on fashioning an improvised suction that could remove the fluid in the airway that we couldn't get to any other way. It was amazing to see everyone take inventory of what we had and start thinking outside of the box just like we teach in all of our wilderness medicine courses.

Once we were able to manage the airway, evacuation become our next priority. It was snowing outside and it didn't look good for a daytime evacuation, which meant preparing shifts to take care of the patient through the night. So much of taking care of this really sick patient was basic ABC care and watching for any changes that might tell us what was going on inside of this patient. In addition, we had to maintain IV fluid, foley catheter and simple cardiac monitoring. It truly made me realize the value of teaching these skills in the Remote Medical Wilderness EMT course to future WEMT graduates that could be in this situation.

A team of helpers carry the poisoned climber over difficult terrain to the helicopter landing zone.At first light we received word that a helicopter would be coming. We quickly secured the patient and prepared him for transport as a whole team of people prepared a litter for carrying. I was elected to stay at the patients head and manage the airway as we carried him to the helicopter pad, about 1/4 of a mile away from the clinic over rocky (and snow covered) terrain. We prepared a group of 7 to carry the litter and headed out. As we were walking, the helicopter landed and then took off again. I couldn't worry too much about what was happening, as I had to worry about the steps in front of me, but I did wonder where that helicopter went. Once we got close to the landing pad, we got word that the helicopter hadn't been able to idle and instead took another two patients out who were already at the pad when the helicopter landed. I, and all the other rescuers, felt disappointed but we were assured another helicopter was on the way, just as we watched more clouds move up. We waited for almost an hour, then decided we needed to get the patient back to the clinic and hope for a helicopter the next day.

The doctors at the HRA, and 3 other doctors from around base camp, did such an amazing job of stabilizing this patient. Everyone really came together, and much to everyones surprise his condition began to improve over the next day. It was such a great sign, especially knowing that we would have another full night ahead of us. Fortunately, a helicopter was able to land at first light the next day, and the patient was transported to a hospital in Kathmandu in stable condition, which was a big improvement from the critical condtion that we started with. No doubt the outcome would have been different if everyone hadn't been so dedicated to helping and also willing to really practice remote medicine and think outside of the box.