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Kumkum J Khadalia
 

Today any amount of information is available on the internet. However, does the Chardham Yatri or the Adventure Tourist visiting high altitude, know that High Altitude Illness (HAI) can affect anybody going to ‘High Altitude’? High altitude has been defined as 1500 – 3500 m (5000 – 11500 ft) and also as 2,438 - 3,658 m (8,000 - 12,000 feet). Does he/she also know that HAI is preventable, reversible and yet fatal, if not recognized and tackled appropriately!

He/ she cannot and should not depend on the tour organizers as relates to awareness about acclimatization and altitude illness, because if they were dependable there wouldn’t be the reports of deaths from HAI that we read about in the papers. The sorry state of affairs is evident in the May 2006 death of a camp leader on a Kullu Valley high altitude trek following three days of “illness” and the untimely death of a 14 year old boy from Mumbai on a trek near Manali [reported in the Maharashtra Times June 1st 2006].

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Acronyms used in the questionnaire
HAI High Altitude Illness HAPO High Altitude Pulmonary Oedema
AMS Acute Mountain Sickness HAB High Altitude Bronchitis
HACO High Altitude Cerebral Oedema HAH High Altitude Headache
Plastic Surgeon, Department of Plastic Surgery, Bombay Hospital Institute of Medical Sciences, Bombay Hospital, Mumbai 400 020.
Govindghat

Hopefully, most people embarking on trips to the high altitude do approach their Family Physician for advice. This is a questionnaire that could be given to them so they could assess their knowledge on the subject and if they do not seem to know the answers they should be encouraged to learn more about the subject.

  1. As one ascends, barometric pressure increases.
  2. Oxygen deprivation caused by the thin air encountered at high altitudes is the main cause of HAI.
  3. The following factors allow the body to acclimatize
    a. Gradual ascent
    b. Increased fluid intake c. Garlic intake
    d. High carbohydrate diet
    e. Work high, sleep low
  4. A good appetite at high altitude, suggests that you are not acclimatized.
  5. Above 3,000 m (10,000’) it is abnormal to experience a periodic breathing during sleep known as Cheyne-Stokes Respirations.
  6. The following factors contribute to AMS
    a. Ascending too quickly
    b. Overexertion
    c. Sleeping at high altitude
    d. Respiratory infection
    e. Dehydration
  7. Anyone can get AMS.
  8. It is not possible for a Sherpa to get AMS.
  9. Alcohol intake at high altitudes helps in acclimatization.
  10. Avoid drinking too much water at high altitudes.
  11. Dehydration is a common cause of HAH.
  12. It is advisable to sleep head-low on an incline.
  13. The diagnosis of AMS is made when a headache, with any one or more of the following symptoms is present after a recent ascent:
    a Loss of appetite, nausea, or vomiting
    b Fatigue or weakness
    c Dizziness or light-headedness
    d Difficulty sleeping
  14. Any illness at altitude is altitude illness until proven otherwise.
  15. Symptoms of mild AMS generally subside within two to four days.
  16. Having bizarre dreams is a symptom of AMS.
  17. Breathlessness at rest is a symptom of AMS.
  18. Moderate headache and difficulty sleeping are symptoms of Severe AMS.
  19. Severe headache and poor balance are symptoms of Moderate to Severe AMS.
  20. If you can’t walk straight, assume you have Moderate AMS.
  21. Never leave someone with AMS alone.
  22. The main principles of treating AMS are to stop further ascent, to descend if symptoms do not improve over 24 hours or deteriorate, and to descend urgently if signs of HAPO or HACO occur.
  23. Acetazolamide (Diamox) could be helpful in relieving Cheyne-Stokes Respiration if it causes sleep disturbance.
  24. The management of mild AMS is: stop ascent, rest, Paracetamol, Prochlor- perazine or Promethazine, Acetazolamide or Dexamethasone.
  25. Acetazolamide should not be given to people who are allergic to sulpha-containing drugs.
  26. Descent is not urgent in cases of Severe AMS, HACO and HAPO.
  27. Treatment of severe AMS with symptoms of HAPO is descent, Paracetamol, Acetazolamide, Nifedipine, Frusemide and Oxygen.
  28. After descending 300 m or 1,000 ft (or till symptoms improve) in case of moderate to severe AMS it is important to stay at the same altitude until the symptoms subside completely.
  29. Treatment of severe AMS with symptoms of HACO is descent, Paracetamol, Acetazolamide, Dexamethasone and Oxygen.
  30. The Gamow Bag is a rucksack.
  31. The Gamow Bag is a portable inflatable pressure bag which can simulate descent.
  32. Death due to AMS is not preventable.
  33. Specific medicines to be carried for treatment of HAI includea.
    a. Acetazolamide
    b. Dexamethasone
    c. Paracetamol
    d. Frusemide
    e. Nifedipine
    f. Prochlorperazine / Promethazine



Reason for writing this

Every trekking season a vast number of people of all ages visit the Himalaya. There are a number of deaths due to altitude illness among pilgrims and trekkers which go unreported. Two incidents that came to my knowledge in 2006 are mentioned in the write-up.

On a trek organized by a concern which has been organizing high-altitude treks ever since the 1970’s, I realized that the 'camp leaders' did not know what acetazolamide was and of course it was not available at any of the camps. One of our members developed symptoms of AMS which worsened to breathlessness at rest with a morning resting respiratory rate of 40/min and puffiness of the face. There were no medicines available to treat AMS and the camp leader had no knowledge about altitude illness. There were no standby arrangements for evacuation. We managed to get a local, and her daughter escorted her for the descent and she recovered.

The lack of awareness was appalling and unpardonable. Maybe the Family Physician could play a major role in eliminating death due to high altitude illness by stimulating people into learning how to prevent, diagnose

References

  1. Altitude Illness. http://www.ciwec-clinic.com/altitude/
  2. The High Altitude Medicine Guide. www.high-altitude-medicine.com
  3. Altitude Awareness. http://www.steponline.com/everest/Everest_lesson_9.pdf
  4. Shlim DR, Houston R. Helicopter rescues and deaths among trekkers in Nepal. JAMA 1989; 261 : 1017-9.
  5. Windsor J, Montgomery H, Letters, Greater awareness and education are needed to help prevent acute mountain sickness BMJ 2001; 323 : 514.
  6. James L Glazer, et al. Awareness of Altitude Sickness among a Sample of Trekkers in Nepal. Wilderness Environ Med 2005; 16 (3) : 132-8.
  7. A camp leaders demise at altitude is mentioned in the following blog http://peelamedu-bulls.blogspot.com/2006_05_01_archive.html
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