Robert D. Glatter, MD: Hi. I'm Dr Robert Glatter, editorial member and advisor for Medscape
Emergency Medicine. With the recent spate of deaths of climbers on Mount
Everest filling the news, it seems like a good time to review the dangers
associated with mountain climbing in relation to managing altitude illness.
In order to do this, I want to turn to Medscape's own sports medicine
columnist, Bert Mandelbaum, an orthopedic surgeon and sports medicine
physician who just happens to be an avid mountain climber. Burt is co-director
of medical affairs at the Institute of Sports Sciences at Cedars-Sinai
and director of the fellowship and foundation-affiliated practice at Cedars-Sinai
Medical Center in Santa Monica, California.
Welcome, Bert. It's really a pleasure to have you join us for this
important topic.
You Are Only as Strong as Your Weakest Link
Glatter: Let's begin by talking about altitude and the evils of altitude and hypoxia.
Bert R. Mandelbaum, MD, DHL (Hon): As you mentioned, Robert, I love being a climber. I also love hiking and
diving. As a physician, I love the interplay between physical and physiologic
adaptation and some of the untoward things that can occur from a medical approach.
The first thing that comes to mind is all about the details. You're
only as strong as your weakest link when it comes to these sports. With
Everest or any climb—Everest is 29,000 feet—you encounter
the most amazing hypoxic environment. We go up there and there's a
low barometric pressure, oxygen is not available, and our hemoglobin is
not saturated. You have to prepare, and there are lots of details.
In the words of John Wooden, failure to prepare is really preparing to
fail. In these situations—and this is what we've seen at Everest
over the past few weeks—people are not focusing on those details.
Glatter: Right. Your point is to focus on details and preparation, which really
speaks to the heart of preparing for any sport or endeavor that you undertake.
In the setting of going up a mountain, the idea of acclimatization is
the key principle. Can you talk about what that means and how you go about
that when you start off on any type of climb?
Mandelbaum: Acclimatization is really like everything we talk about; it's about
concepts, technique, and technology. First, for the concepts of preparing
and acclimatization, you have to acclimatize physically, which is getting
in shape, and then also physiologically. It takes training.
We have a variety of approaches. We've learned over time that we prepare
using a high-high-low approach. You sleep high, you train high in a low-intensity
wave, and then you go to low altitude and train in a high-intensity wave.
The high-high-low approach is something we've learned over time in
preparing people for altitude.
As you get closer to the climb, you have to think about the issues of acclimatization
and how long it takes to go to a certain altitude. For every kilometer,
it takes 11.4 days to acclimatize to an altitude. When you go to 8800
meters, it takes 88 days to acclimatize. You never reach full acclimatization,
but that's the physiologic adaptation that you see. You have to consider
the training, nutrition, fluids, progression, and medicine you can take.
Hydration and the Five-Layer Rule to Avoiding Hypothermia
Glatter: That brings, in terms of going up the mountain, the issues of hydration
and fighting hypothermia. Can you speak to that a little bit? What are
those principles?
Mandelbaum: Again, you're only as strong as your weakest link. Let's talk
about hydration. When you're climbing, you have to drink 4 or 5 quarts
of fluid per day just to stay ahead of the game. You have to think nutritionally.
In terms of carbohydrates, the recommendation is about 70% overall.
You have to have the right clothes in terms of not sweating too much because
when you do, you have a tendency to become hypothermic. You have to think
about multiple layers. I like the five-layer rule. You have to think about
putting it on, taking it off, and having lightweight layers that are protective
of wind and the environment.
These details are incredibly important. If you have everything right and,
all of a sudden, you're sweating so much that you become hypothermic,
then you lose the game as well.
Everyone Is Prone to Altitude Sickness
Glatter: I think it's important for everyone to be aware that anyone who is
traveling to altitude is at risk, regardless of fitness level, age, prior
medical history, and prior travel to significant altitude. There are risk
factors that we see. Maybe you could talk about who is prone to get altitude
illness. Let's jump into discussing mountain sickness.
Mandelbaum: The first issue is that everybody is prone. I don't care what your
maximum oxygen capacity is. It has a lot to do with the rate of ascent.
The recommendations are to start under 10,000 feet when you start climbing.
Never go above that. If you fly somewhere, don't start at that level.
Start under 10,000 feet and then progress from there.
You should never progress more than 1000 feet per day for 3 days in succession.
On the fourth day, you should rest at that altitude. Those variables about
the rate of ascent are key to acclimatization overall. Where you sleep
is also key.
I've been around people who I thought were the best athletes—much
better than me—who couldn't acclimatize early on to some of
the climbs because of these variables. It has to do with the physiologic
makeup and things we don't fully understand within our bodies, such
as our hemoglobin type and so on.
Glatter: There are certain things we can do, such as avoiding alcohol, sedatives,
and being smart while we're climbing. Obviously, for nutrition, you
talked about eating more carbohydrates to gain more energy.
Moving on to mountain sickness, what are the first symptoms someone might
experience?
Mandelbaum: The first thing you feel is a
headache. You were telling me earlier about the first time you went up the Jungfrau
and you felt that headache. You feel your heart rate go up, maybe you
don't feel quite well, and your stomach is upset. Why is that happening?
Your heart rate is going up, you have vasoconstriction of your GI vasculature.
The pulmonary vasculature begins to vasoconstrict as you go there. You
get that headache and you begin to not feel well, including fatigability
and some shortness of breath. Those are the cardinal, early features of
acute mountain sickness.
Glatter: We talk about cerebral blood flow being one of the causes of the headache,
physiologically. We see increases in blood flow, which has been measured
through different ultrasound techniques and even by transcranial Doppler.
Medications to Help You Ascend
Glatter: Now, getting to the medications, there have been multiple studies published.[1-3] We often look to Diamox (acetazolamide) or
dexamethasone—and
ibuprofen—for people who've had a history of altitude illness.[1,2] It's something that is quite attractive and may have fewer side effects.
Can you speak on that?
Mandelbaum: I've tried either and both.
Diamox and ibuprofen work by different mechanisms.[1] Diamox is a carbonic anhydrase inhibitor and secretes more carbonate.
Trying to keep up with the respiratory alkalosis in a preventive way,
for me, has been successful. I would say that about 70%-80% of the time,
Diamox is successful as a preventive.
Ibuprofen is more for that headache you described.[3] It can be very helpful as an anti-inflammatory and make you feel more
comfortable. Sometimes it makes your stomach even more upset in the big
scheme of things, so you weigh the two overall.
Glatter: If you had to recommend one or two things that you're going to take
away from mountain sickness before you start climbing, would you tend
to go with dexamethasone or Diamox as your go-to?
Mandelbaum: I would probably start with the Diamox as the first step. It depends on
where we're going. Are we going to Mount Whitney at 14,500 feet, Kilimanjaro
at 19,300 feet, or Everest at 29,000 feet? Again, it depends on the details.
High-Altitude Cerebral and Pulmonary Edemas: Descend to 3000-4000 Feet
Glatter: Got it. Mountain sickness morphs into something called high-altitude cerebral
edema (HACE), and that's always a dangerous thing. Could you talk
about that and the dangers?
Mandelbaum: First, how do we identify that a patient, or you or one of your party,
has it? It's really about that headache. It gets more intense and
you begin to see more nausea and some vomiting. You see ataxia. The last
phase on the spectrum of severity is the coma. After the confusion and
bad headaches, that's what you begin to see.
In that setting, you have to think about dexamethasone immediately. The
most important thing is getting the climber down to 3000-4000 feet once
you identify symptoms of HACE.
Glatter: Absolutely. I think descent is the definitive treatment and we always
want to stress that. Certainly, the other measures and dexamethasone can help.
Moving on to the next syndrome,
high-altitude pulmonary edema (HAPE). That could start in a very subtle way, too, with a little shortness
of breath, but it can progress significantly. Can you comment on that?
Mandelbaum: Interestingly enough, Robert, in this spectrum, this claims more lives
than cerebral edema or acute mountain sickness. Pulmonary edema is from
vasoconstriction of the pulmonary circulation. That causes, first, shortness
of breath, exercise intolerance, and lastly, a dry cough. Those are the
cardinal features of HAPE.
When you have those symptoms, as you just said, you have to descend rapidly,
get below 3000 or 4000 feet, and then you'll begin to see some of
these symptoms abate.
Ginkgo Biloba, Hyperbaric Sleeping Tents—Are They Worth the Hype?
Glatter: There are some people who talk about natural remedies. I'm not sure
what your position is on
Ginkgo biloba or cocoa leaves. Some people are more homeopathic. Are there any data
to support the use of these?
Mandelbaum: I haven't seen any data, but I haven't seen any downsides. For
those who want to be homeopathic, I don't see the downside in those
situations, but I don't see the upside either. There haven't been
any great studies.
Glatter: There is also some thought about sleeping in tents before you ever go
on your trip, sort of at a normobaric hypoxia before departure to high
altitude. Do you have any thoughts about that? Have you ever heard of
anyone doing such a thing?
Mandelbaum: We've worked with athletes in terms of these hyperbaric tents. Considering
the concept of sleeping high, this affords you that opportunity. If you're
from New York City and want to do one of these climbs, that will help
with some of the acclimatization. It's not going to get you all the
way there, but it may help early on to build your red blood cell population.
Mount Everest—An Anarchic 'Deathtrap'
Glatter: Let's move on to
Everest now and some of the issues that we've seen in the news.[4] Thinking about that big picture that we discussed earlier, of people lined
up to summit and all the dangers of overcrowding—let's dive
into this. What is really the root cause of what we're seeing happen
on Everest?
Mandelbaum: It's really anarchy overall. For the government of Nepal to give 381
permits is a set-up for failure. We are back to the idea that not preparing
is preparing to fail. This situation of nearly 400 people at base camp
with no order, organization, permits, or screening of who's best,
who is or isn't experienced, who the guides are, or what their qualifications
are, is really set up for disaster, and that's what we've seen.
Glatter: In terms of developing a governing body that we talked about earlier off
camera, including the United States taking the lead and developing a federation
with bylaws that would behoove everyone to increase safety for the sport
and to have some law and order, so to speak...
Mandelbaum: I grew up with the International Olympic Committee, the United States
Olympic and Paralympic Committee, the Fédération Internationale
de Football Association, and other international organizations that do
just this. It's about prevention, maximizing performance, and taking
care of problems when they occur. There needs to be some type of international
organization.
This is a multinational group of climbers who are there. We have to think
about who is going to lead this type of federation, which develops criteria
for all of the climbers, the climbing organizations, how many permits,
what grade, watches the weather, and puts out various issues about things
that we just spoke about. I think that's key to do better for the sport.
Glatter: I think we're going to see a lot more deaths and suffering if we don't
act on your recommendations. There has to be something done very quickly,
because that scene that we saw this year was such a wakeup call to everyone.
It's really a deathtrap.
Mandelbaum: It's a tremendous deathtrap. Imagine hundreds of people sitting in
this death zone, at 28,000 feet with no oxygen or running out of oxygen,
and they can't move one way or the other. It's really an anarchic,
random environment with the most stressful conditions. We've got to
do better from a medical standpoint and from a sports organizational perspective.
Glatter: The Nepalese government needs to be aware of this. Their desire to take
permits and the economic benefits that they're reaping may be coming
at a significant cost.
Mandelbaum: Very much so. This is like many other issues we're dealing with in
our world. As physicians, we have a role in this. Obviously, these are
very medically related challenges that we have to think about. We have
to organize ourselves and be part of this.
Final Eloquent Words
Glatter: Bert, if you could give us five key takeaways from our discussion for
our audience, I'd really appreciate that.
Mandelbaum: I think the most important thing is that this is about details. We are
only as strong as our weakest link. I love the expression, which is from
the British military, of the eight Ps:
Proper prior planning and preparation prevents piss-poor performance.
Glatter: That's quite eloquent.
Mandelbaum: It's the takeaway message here because it really is about that. It's
a lot of those details of training, nutrition, fluids, progression, and
being studious and understanding. That's why it's such an interesting topic.
Glatter: Absolutely. I want to thank you for your time, Bert. This has been very
instructive and very enlightening. I think your thoughts on this subject
are incredible. Thank you again for joining us.
Follow Medscape on
Facebook,
Twitter,
Instagram, and
YouTube
References
-
Gertsch JH, Lipman GS, Holck PS, et al. Prospective, double-blind, randomized,
placebo-controlled comparison of acetazolamide versus ibuprofen for prophylaxis
against high altitude headache: the Headache Evaluation at Altitude Trial
(HEAT). Wilderness Environ Med. 2010;21:236-243.
Source
-
Sridharan K, Sivaramakrishnan G. Pharmacological interventions for preventing
acute mountain sickness: a network meta-analysis and trial sequential
analysis of randomized clinical trials. Ann Med. 2018;50:147-155.
Source
-
Lipman GS, Kanaan NC, Holck PS, Constance BB, Gertsch JH; PAINS Group.
Ibuprofen prevents altitude illness: a randomized controlled trial for
prevention of altitude illness with nonsteroidal anti-inflammatories.
Ann Emerg Med. 2012;59:484-490.
Source
-
Schultz K, Gettleman J, Mashal M, Sharma B. 'It was like a zoo':
death on an unruly, overcrowded Everest. The New York Times. May 26, 2019.
Source
Medscape Emergency Medicine © 2019 WebMD, LLC
Any views expressed above are the author's own and do not necessarily
reflect the views of WebMD or Medscape.