Dr Luanne Freer, leader of this years Nepal CME accredited Wilderness Mountain Medicine course in Nepal, has been written up in a brillant article on the illustrouis Smithsonian website in an article entitled ‘Inside the ER at Mt. Everest’ by Molly Loomis.
A middle-aged woman squats motionless on the side of the trail, sheltering her head from the falling snow with a tattered grain sack.
Luanne Freer, an emergency room doctor from Bozeman, Montana, whose athletic build and energetic demeanor belie her 53 years, sets down her backpack and places her hand on the woman’s shoulder. “Sanche cha?” she asks. Are you OK?
The woman motions to her head, then her belly and points up-valley. Ashish Lohani, a Nepali doctor studying high-altitude medicine, translates.
“She has a terrible headache and is feeling nauseous,” he says. The woman, from the Rai lowlands south of the Khumbu Valley, was herding her yaks on the popular Island Peak (20,305 feet), and had been running ragged for days. Her headache and nausea indicate the onset of Acute Mountain Sickness, a mild form of altitude illness that can progress to High Altitude Cerebral Edema (HACE), a swelling of the brain that can turn deadly if left untreated. After assessing her for HACE by having her walk in a straight line and testing her oxygen saturation levels, the doctors instruct her to continue descending to the nearest town, Namche Bazaar, less than two miles away.
Freer, Lohani and I are trekking through Nepal’s Khumbu Valley, home to several of the world’s highest peaks, including Mount Everest. We are still days from our destination of Mount Everest Base Camp and Everest ER, the medical clinic that Freer established nine years ago, but already Freer’s work has begun. More than once as she has hiked up to the base camp, Freer has encountered a lowland Nepali, such as the Rai woman, on the side of the trail ill from altitude. Thankfully, this yak herder is in better condition than most. A few weeks earlier, just before any of the clinics had opened for the spring season, two porters had succumbed to altitude-related illnesses.
Each year over 30,000 people visit the Khumbu to gaze upon the icy slopes of its famed peaks, traverse its magical rhododendron forests and experience Sherpa hospitality by the warmth of a yak dung stove. Some visitors trek between teahouses, traveling with just a light backpack while a porter carries their overnight belongings. Others are climbers, traveling with a support staff that will aid them as they attempt famous peaks such as Everest (29,029 feet), Lhotse (27,940 feet) and Nuptse (25,790 feet). Many of these climbers, trekkers and even their support staff will fall ill to altitude-induced ailments, such as the famed Khumbu cough, or gastro-intestinal bugs that are compounded by altitude.
A short trip with a group of fellow doctors to the Khumbu in 1999 left Freer desperate for the chance to return to the area and learn more from the local people she had met. So in 2002 Freer volunteered for the Himalayan Rescue Association’s Periche clinic—a remote stone outpost accessed by a five-day hike up to 14,600 feet. Established in 1973, Periche is located at an elevation where, historically, altitude-related problems begin to manifest in travelers who have come up too far too fast.
For three months, Freer worked in Periche treating foreigners, locals and even animals in cases ranging from the simple—blisters and warts—to the serious, instructing another doctor in Kunde, a remote village a day’s walk away, via radio how to perform spinal anesthesia on a woman in labor. Both the woman and the baby survived.
Dr Amy Hughes medical career has been far from ordinary and she talks about how she has ended up as medical lead at WEM.
Dr Hughes co-leads with Dr Luanne Freer our CME accredited Mountain Medicine course on the Everest Base Camp trail in Nepal.
Management of AMS
Prospective, Double-Blind, Randomized, Placebo-Controlled Comparison of Acetazolamide Versus Ibuprofen for Prophylaxis Against High Altitude Headache: The Headache Evaluation at Altitude Trial (HEAT)
High altitude headache (HAH) is the most common neurological complaint at altitude and the defining component of acute mountain sickness (AMS). However, there is a paucity of literature concerning its prevention. The researchers sought to compare the effectiveness of ibuprofen and acetazolamide for the prevention of HAH.
Three hundred forty-three healthy western trekkers were recruited at altitudes of 4280 m and 4358 m and assigned to receive ibuprofen 600 mg, acetazolamide 85 mg, or placebo 3 times daily before continued ascent to 4928 m. Outcome measures included headache incidence and severity, AMS incidence and severity on the Lake Louise AMS Questionnaire (LLQ), and visual analog scale (VAS).
Two hundred sixty-five of 343 subjects completed the trial. HAH incidence was similar when treated with acetazolamide (27.1%) or ibuprofen (27.5%; P = .95), and both agents were significantly more effective than placebo (45.3%; P = .01). AMS incidence was similar when treated with acetazolamide (18.8%) or ibuprofen (13.7%; P = .34), and both agents were significantly more effective than placebo (28.6%; P = .03). In fully compliant participants, moderate or severe headache incidence was similar when treated with acetazolamide (3.8%) or ibuprofen (4.7%; P = .79), and both agents were significantly more effective than placebo (13.5%; P = .03).
Fascinatingly the authors demonstrated that Ibuprofen and acetazolamide are similarly effective in preventing HAH. This adds another medication to the useful arsenal to use in the treatment of AMS and in particular is especially useful when you have a patient who can’t take acetazolamide (diabetics or sulphur allergies) .
Learn more about Altitude Medicine by joining Expedition and Wilderness Medicine’s CME accredited Mountain Medicine course in Nepal headed up by Everest ER founder Dr Luanne Freer
Nick Arding will be joining Expedition Medicines Mountain Medicine course on the Everest Base Camp Trail along with Dr’s Luanne Freer of Everest ER and Amy Hughes of Kent HEM’s service in October on what promises to be an amazing CME accredited course*.
Nick served as an officer in the Royal Marines for 22 years, travelling and climbing widely during that time. In ‘92 he took part in the British Annapurna 2 Expedition and in ‘93 led his own trip to climb the West Buttress of Mt McKinley in Alaska. He commanded the Commando Training Centre Royal Marines from 2003 to 2005.
In 2003 Nick led a Royal Navy expedition to climb Everest by its North Ridge; not only did they climb the mountain but his team were instrumental in rescuing two other climbers from above 8000m, the highest mountain rescue on record and for which he was awarded the Royal Humane Society Bronze Medal.
A keen rock climber and mountaineer since his teens, Nick holds the Mountaineering Instructor (MI) and International Mountain Leader (MIA) awards.He left the Royal Marines in 2005 to qualify as a teacher and now works as a leadership coach and management consultant. He has led civilian teams to Mongolia, Nepal and the Alps, and when not working can usually be found on a rock face or in a sea kayak! In 2009 Nick took a team of friends to the Rolwaling Valley in Nepal to attempt an unclimbed mountain called Cheki-go. He has close links with this region, having raised funds to sponsor local Sherpas, three of whom have been able to visit the UK to improve their climbing skills and English language.
*accredited by the Wilderness Medical Society
Next October sees the inaugural Expedition Medicine Mountain Medicine Course following the route of the Everest Base Camp Trail over period of 16 days based out of Kathmandu. The course will be CME certified for an estimated 20 points.
Expedition Medicine’s Mountain Medicine course in the Khumbu Valley in Nepal headed by Drs Luanne Freer MD FAWM and Dr Amy Hughes Medical Director of Expedition Medicine. Dr Freer many of you will know as the founder and director of Everest ER which is a seasonal tent-based medical clinic at the Everest base camp (17,600 ft/5350m) founded in 2003, a volunteer physician for the nonprofit Himalayan Rescue Association (HRA) in Nepal. Luanne, who is also a past president of the Wilderness Medical Society and medical director for the Yellowstone National Park aims to pass on through this mountain medicine course her years of experience of providing medical cover at this altitude as well as her passion for the Khumbu Valley and Nepal in general.
The Nepal Mountain Medicine course will also serve as a fundraiser for Everest ER
Expedition Medicine lecturer and wilderness medic par excellence Dr Luanne Freer organiser of 'Everest ER' writes about her plans for 2010
The Everest base camp medical clinic “Everest ER” will be on the mountain in April 2010 for our 8th season (!) As always, we offer services to base camp climbers, support staff and trekkers-through in support of our mission to prevent and treat illness at high altitude and to use proceeds for care from non-Nepalis to subsidize free or low cost health care for our Nepali friends. The 2010 staff will be comprised of myself, Lakpa Norbu Sherpa (our faithful logistics coordinator,) Dr Steve Halvorson, and Dr. Peter Hackett, longtime HRA volunteer and world renowned altitude expert (and Everest summitteer!) will join us for the month of May. We plan to carry out a research project aimed at answering a plaguing question a high altitudes everywhere – what’s the best treatment for high altitude “Khumbu” cough?
Mike Grocott Expedition and Wilderness Medicine lecturer speaks to the BBC about the Caudwell Extreme Everest Expedition
Everest trip helps critically ill
The lessons learned by medics from a trip to Everest could help the treatment of critically ill patients.
The team that braved the Himalayan summit to study the body’s responses to extreme adversity has recorded the lowest ever human blood oxygen level.
The results could see treatment plans for some patients with similarly low blood oxygen levels re-evaluated.
The “Caudwell Xtreme Everest” work has been published in the New England Journal of Medicine.
The blood readings established what has long been suspected – that high-altitude climbers have incredibly low levels of oxygen in their blood, which at sea-level would only be seen in patients close to death.
The average arterial oxygen level was 3.28 kilopascals or kPa – the lowest was 2.55 kPa.
The normal value in humans is 12-14 kPa and patients with a level below 8 kPa are considered critically ill.
Expedition leader Dr Mike Grocott said: “We rarely see below 6 kPa in our patients.
“Yet our readings were well below this and we were walking and talking and functioning normally.
“This gives us some perspective about what levels of oxygen deprivation people can tolerate.”
He said some critically ill patients may have adapted to the low oxygen levels and may not need the aggressive interventions, such as ventilation, that are currently given to get blood oxygen levels closer to normal ranges.
“All these interventions carry a risk of harm and you have to weigh up the benefits versus potential damage to organs like the lungs.
“Maybe we could be less aggressive in treating some of these patients.”
He said other intensive care researchers were planning to investigate it.
Acting as guinea pigs themselves, the London team of medics – five anaesthetists, two GPs and a vascular surgeon – took the first readings of human blood oxygen 8,400m above sea level.
The team climbed with oxygen tanks, then removed their masks 20 minutes prior to testing to give time for their lungs to get used to the low-oxygen atmosphere and to avoid any skewing of the readings.
The team were unable to make the measurement on the summit of Everest as conditions were too severe, with temperatures at -25C and winds above 20 knots.
Having descended a short distance from the summit, the doctors removed their gloves, unzipped their down suits and drew blood from the femoral artery in the groin.
The samples were then carried by Sherpas back down the mountain and analysed within two hours at a science lab set up at the team’s camp at 6,400m.
Based on calculations of the expected level of oxygen in the blood, the Caudwell Xtreme team speculate that accumulation of fluid in the lungs as a result of the high altitude might have contributed to the low oxygen levels.
They hope ongoing research will eventually lead to better treatments for patients with acute respiratory distress syndrome, cystic fibrosis, emphysema, septic shock, “blue baby” syndrome and other critical illnesses.
Dr Andy Tomlinson, an anaesthetist at the City General Hospital in Stoke-on-Trent and a keen climber, said: “The figures they have got are quite incredible. They are phenomenally low oxygen levels.
“There is obviously a difference between critically ill patients and fit and healthy climbers.
“Never the less, there are lessons to be learned for critical care.”
Dr Peter Nightingale of the Royal College of Anaesthetists said: “This may well make doctors re-evaluate their current provision of oxygen and the researchers may well be right that patients can run on lower oxygen levels.
“But we do not know and we need more research.”
Mike Grocott is a Expedition and Wilderness Medicine lecturer and presents on our UK training course – Expedition and Wilderness Medicine UK
Copyright Michelle Roberts
BBC News health reporter
Denny Levett is a Specialist Registrar in Critical Care and Anaesthesia at UCL. She is the deputy director of the Centre for Altitude, Space and Extreme Environment Medicine at UCL and has extensive experience in expedition medicine.
Denny has research interests in altitude medicine and diving and hyperbaric medicine and is a keen climber and diver.
She was the Expedition medical officer for the Caudwell Xtreme Everest research expedition in 2007 (www.xtreme-everest.co.uk) responsible for more than 250 climbers, investigators and volunteers in the field. She was also the expedition Deputy Research leader and is currently completing a phd in altitude physiology.
In 2005, Denny worked as a diving and hyperbaric medicine fellow at the Alfred Hospital, Melbourne, Australia treating divers with decompression sickness. She has spent nine months working as the expedition medical officer on three marine biology diving expeditions in Africa, Fiji and Oman.
Denny has also worked as a Medical Officer for ‘Across the Divide Expeditions’ since 1999. She has accompanied groups on hiking, white water rafting and mountain biking expeditions in remote locations including Guatemala, Nepal, Patagonia, Lapland and Peru.