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