14-20 March 2014 #698

Killer climbs

Dhanvantari by Buddha Basnyat, MD

Imagine you are a mountain guide on an Everest expedition and are attacked by a client with an ice axe at 7,000m. If this were a dream you would wake up in cold sweat. Yet in almost every season, an encounter of this nature is not uncommon in the high Himalayas. 

As mountaineers ascend tall peaks, altitude sickness especially in its life-threatening forms like high altitude cerebral edema (HACE) and high altitude pulmonary edema (HAPE) can affect climbers.  Excessive brain swelling at altitude or HACE may lead to psychosis, violent behaviour, and eventual death due to cold exposure or accidental falls.

The Himalayan range, which includes 14 peaks above 8,000m, is unique in that it begins where the European Alps reach the highest point (about 4,000m). Clearly, hypoxia (lack of oxygen) stress that climbers feel in the Himalayas is much greater and therefore much more medically significant than in the Alps or perhaps even any other mountain range in the world. For example, the probability of suffering from HACE at Mount Rainier (4,392m) in Washington State, USA is much lower than in the 8,000m Himalayan peaks. 

Now that climbing season is almost here, it is relevant to discuss ways in which guides can help climbers at these very high altitudes. Nepali guides are well-trained in many aspects of mountain climbing, but knowledge about life-saving drugs is unfortunately amiss.  

Acetazolamide (Diamox) is a familiar drug which prevents and treats acute mountain sickness, the harbinger of the more dangerous forms (HACE and HAPE) of altitude sickness. But another lesser-known drug, dexamethasone, can be far more useful in life-threatening situations. 

Dexamethasone very effectively decreases swelling of the brain and treats symptoms like psychosis, which can potentially help the climber cooperate in his own rescue. Unlike drugs like penicillin, this corticosteroid (different from the kind that the infamous Tour de France cyclist Lance Armstrong consistently took to win), does not cause a deadly anaphylactic (allergic) reaction; in fact dexamethasone is used in the treatment of anaphylaxis. 

Although mountain guides are not trained medics, perhaps an exception needs to be made because finding a doctor at 7,000m to administer dexamethasone is extremely unlikely. Besides, the risk-benefit analysis tilts clearly in favour of giving the drug: the medicine works within hours, has very little side-effects, and usually one dose is enough. Having a properly trained guide could, therefore, mean the difference between life and death for the climber.

But administering dexamethasone orally to a patient who is trying to kill you with an axe due to temporary derangement caused by high altitude hypoxia, might not be possible. It will need to be injected into the muscle or vein. The hardest part for the guide will, therefore, be to administer the injection to the sick climber. 

Life-threatening illnesses at high altitude are best prevented. But in reality, our mountain guides will be faced with these problems and will need the skills and knowledge to deal with them. Hence proper, conscientious training in administering this drug will help guides save the lives of intrepid climbers and go a long way in projecting Nepal as a safe and attractive destination for mountain climbing.          

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