Living Safely in the Backcountry
KILLER ALTITUDE STRIKES AT 13,000 FEET
by Sheryl Olson
Ten days without a shower, 48 hours without diamox, and eight days without a beer; 2 days of hiking remained and the group was ready to party. Our team of 22 had trekked to Everest Base Camp (EBC), summited Kala Pathar, and was on the final leg of the journey down the mountain. Two of us had already celebrated birthdays on this trip and today was birthday
three. We arrived into camp early and the celebration began. We left our backpacks by our tents and gathered in the social room at the nearby guest house. It clearly was time to begin perfecting our bragging stories that we would soon share with our family and friends back home about our adventures of the last two weeks. The stories began to take on a life of their own as we commenced reminiscing the trials and triumphs of our trip. For many in the group, the mere accomplishment of surviving 10 days without a shower was deemed worthy of a trophy. One person was honored for his endurance while climbing Kala Pathar with a swollen, bruised, badly sprained ankle. Others shared how they first thought they would die from having acute mountain sickness and then how they wished they would die, and then how they were afraid they wouldn’t die as their misery of headache, nausea, and vomiting persisted. Everyone shared their favorite moments, favorite vistas, and favorite experiences. Digital cameras were out and the final few photos were taken to document this incredible experience. The icy cold beer cooled our dry parched mouths after a hot dusty day on the trail and the stories became flavored with tasteful morsels of embellishment.
We were camping at the small village of Deboche, elevation 12,326 ft (3757 m). The majority of the group was physicians and nurses participating in a continuing 
education adventure course focused on wilderness medicine. As instructors for the course, my husband, Larry, an emergency medicine physician, and I, a helicopter flight nurse, had been giving lectures and offering hands-on learning experiences throughout the days. The educational topics related to the mountainous environment and associated medical issues that can arise during a trek or expedition to high altitudes. The educational highlight towards the end of the trip is a simulated case scenario affording the participants an opportunity to assess, diagnose, and treat a volunteer “victim.” However, for this group, there was no need to create a scenario. Reality stared us in the face and challenged our team with decisions regarding our own trekking adventure and caring for a critically ill individual from another expedition.
This real time wilderness medical emergency began to unfold at 1830 hours when a Sherpa from another group walked into our camp and asked for our help. Most of our group had already settled into the dining tent for dinner. The Sherpa met our trip coordinator, Kyle, and told him he had brought to the village a sick person who he needed to get down the mountain. He reported that he had hired a horse to take the man to a lower altitude but that the man could no longer sit on the horse. They were forced to stop, and coincidentally, had ended up at a nearby guest house in the village where our group was camped. The Sherpa heard that “the doctors” were camped in the area. He walked to our camp, saw Kyle, and asked if someone in our group would check on the sick man. As Larry and I were walking towards our dinner tent, Kyle approached and apprised us of the situation, asking if we would be willing to see the sick person and if so, did we want to go now or wait until after dinner. There was only one question I needed to ask the Sherpa prior to deciding when to see this person. It was the one question that would quickly give me information about the severity of the problem. I turned to the Sherpa and asked if the man could walk to our camp to see us. When he replied, “No, too sick to walk”, the decision was made. We immediately knew the man must be quite ill if he was unable to even walk a short distance. It was a gut wrenching, adrenalin surging moment when you shift gears and mentally prepare for the worst, ready to deal with whatever is encountered.
Larry and I were already thinking in terms of severe altitude illness: high altitude cerebral edema (HACE) or high altitude pulmonary edema (HAPE), both life-threatening conditions. Larry went to get our medicine bag and a couple other folks in our group volunteered to bring the oxygen cylinder and Gamow bag (portable hyperbaric altitude chamber) while I headed toward the guest house to meet the patient. I mentally logged key points of information as the Sherpa continued telling me in his broken English the sequence of events. He told me his group began trekking at Lukla, 9186 ft (2899 m). The group spent an extra acclimatization day and night at Namche Bazaar. From there they trekked to Tengboche, 12,700 ft (3867 m), where they spent the night. Piecing together the parts of his story, it flowed something like this: They departed Tengboche the following morning intending to trek to Lobuche. Gaining higher and higher elevation, the man gradually became weaker and had increasingly difficult time breathing and walking. He finally became so short of breath and weak that he was unable to continue walking.
There was a doctor in the group and it was decided that the sick trekker and the doctor would stop early and spend the night in a small village, altitude 3900 m, in hopes that an extra night would help the trekker acclimatize to high altitude. The rest of their group continued on to Lobuche. The doctor gave the patient diamox and another unknown medication. The next morning the patient was not any better. The doctor left the patient in the village and met up with the group providing the trip leader with updated information on the patient’s condition. It was clear that the ill client would be unable to continue the trek to Everest Base Camp. The leader wisely knew that he needed to descend altitude. The decision was made to send a Sherpa from the group down to where the sick trekker awaited. The Sherpa would then assist the patient in getting down the mountain. The Sherpa arrived at the village where the sick client had waited alone throughout the day. They hired a horse to carry him and, with the Sherpa walking by his side, began the downhill trek in hopes of reaching Namche Bazaar where they would spend the night. As they began their journey, the patient’s condition began to significantly deteriorate. He became increasingly weak and extremely short of breath, unable to sit upright on the horse. Arriving at Deboche, 12,326 ft (3757 m), the Sherpa stopped and with help from the local guest house owners, got the man off the horse, into the house, up one flight of narrow stairs, and into a small room. Here the patient sat on a bed, unable to travel any further, breathing with great difficulty, feeling consumed with the apprehension of what was going to happen.
The Sherpa and I quickly arrived at the nearby house. Upon entering the small upstairs bedroom, I saw a young man, MR, sitting sideways on a twin bed with his back leaning against the wall, his legs crossed in front of him Indian style, and his torso bent slightly forward. His mouth was agape and his eyes were wide open as he struggled to suck in air with each rapid shallow breath. Having been a critical care nurse for 29 years and a helicopter flight nurse for 18 of those years, I was well experienced at making rapid assessments, developing a working diagnosis, and quickly initiating life-saving interventions. It was quite obvious from this presentation alone that he was in severe respiratory distress. Placing my hand on his wrist to palpate his pulse and count his respirations, I immediately became aware of his cool, clammy skin. Larry arrived with the medicine kit and we agreed we needed to give this patient dexamethasone, a steroid drug that can help with the treatment of high altitude diseases. Our patient, was breathing 50 times per minute and his heart was racing at 150 beats per minute. (Normal respiratory and heart rates range from 12 to 16 and 60 to 100, respectively.) One of the members of our trekking group had with him a Nonin fingertip pulse oximeter, which he graciously allowed us to use in the ongoing assessment of this patient. The oximeter, which measures the percentage of oxygen saturated hemoglobin, revealed a saturation of 48% to 49%. For comparison, my oxygen saturation in Deboche was 87%. This was truly a medical emergency as our patient’s body was being starved of oxygen.
Knowing that MR had slept at 12,700 feet the night before and that his difficulty breathing and weakness continued to get worse as he climbed higher, I had no doubt that high altitude pulmonary edema (HAPE) was the working diagnosis. Not having a stethoscope readily available, I placed my ear against his ribs and listened to the right side of his chest under his arm, the area of the right middle lobe of the lung, commonly the first lung field where fluid from HAPE accumulates. Then I listened to both the right and left sides of his back where I could hear air moving in and out of his lungs. His breath sounds were diminished and rales, the moist, wet, bubbling sounds distinctive with pulmonary edema, were audible throughout his lung fields. Compiling the history of his present illness with the subjective and objective data of his clinical presentation undoubtedly confirmed the diagnosis of high altitude pulmonary edema. The most important treatment for any severe high altitude illness is to get the patient to lower altitude. However, it seemed too difficult and impractical for us to attempt to descend by trail with our patient due to the severity of his symptoms and the time of day. It would have involved carrying him in the dark over rocky and unfamiliar terrain putting the care-givers at risk for personal injury. Neither was the option to summon a helicopter for evacuation viable. The sun had set and the night was moonless and black. No pilot would likely choose to attempt a landing onto such a small landing zone, surrounded by buildings and tall trees, in the darkness of the night. We therefore had but one option: to begin treatment for HAPE with the medical equipment and medication we had brought with us.
Others from our group brought the Gamow Bag and oxygen cylinder to the guest house. The room the patient was in was too small to pressurize and maintain the Gamow bag. There was a large room on the main level that we chose to be the central area for patient care. The next goal was to help MR down the flight of narrow stairs from his room to the largerroom where we could get him into the bag. We asked him if he wanted to be carried. He said he felt like he could walk. He stood up, took a couple of steps, and his pulse oximeter reading immediately dropped to 45%. He said he could hardly breathe and that he felt weak was light-headed. We encouraged him to let us give him as much assistance as possible to minimize his own energy expenditure. Once down the stairs, the oxygen bottle arrived and we had him breathe supplemental oxygen (O2) while the bag was prepared for inflation.
We were acutely aware that our precious O2 supply would be depleted after about 2 hours of continuous use, necessitating judicious titration. Details such as “Do you need to pee before you get in the bag?” and “Please drink some juice, tea, or water” were addressed. He had not eaten nor had he consumed much liquid since early that morning. He had not urinated all day indicating the presence of dehydration. He complied with our request to drink 16 ounces of a diluted oral rehydration solution and into the bag he went.
The Gamow Bag is cylindrical, 84 inches by 21 inches, and made of a coated nylon fabric. It has a lengthwise zipper to allow entry and 2 clear windows to allow visualization in and out of the bag. A hose and foot pump are used to maintain inflation pressure and movement of fresh air through the bag. To accomplish this, the pump needs to be compressed about 15 times per minute. The room we were in was not heated and nighttime temperatures dropped to the low forties and high thirties. The air pumped into the bag is the same temperature as the ambient air. Therefore, it was necessary to have our patient have a sleeping bag and wear his clothes, a jacket, and a knit hat while in the bag for warmth. After the bag was pressurized to 2 PSI, we were relieved to see MR’s oxygen saturation increase and his heart rate and rate of breathing decrease; all signs of improvement. He told us he was comfortable and wanted to sleep.
Communication between the patient inside the bag and those of us outside bag was easy. Though our voices were slightly muffled, he could hear and understand our questions and we could understand his answers. Together, we watched, pumped, waited. Several Sherpas from my group volunteered to rotate through the night, taking turns at the foot pump to maintain inflation. Over inflation of the bag is prevented by a pop-off valve. I also stayed in the room with the patient to be able to awaken him every 2 hours, allowing him to get out of the bag. At each break, the bag was easily deflated and unzipped. MR would sit or stand up for a few minutes, walk outside to urinate (initially with assistance), drink liquids, and have human contact sans the barrier of the bag. The first time he got out of the 
bag he initially felt relief to be able to sit up. He drank 2 glasses of diluted Gatorade and still denied the need to urinate. Within about 10 minutes, he was asking, rather begging, to get back in the bag. “I need to go back in the bag. Please put me back in the bag quickly.” His oxygen saturation quickly dropped when he was exposed to our actual altitude of 12,326 ft (3757 m) and he became very symptomatic with difficulty breathing and a rapid heart rate. He was given necessary medication, zipped up, and the bag was again pressurized.
This 2 hour rotation continued throughout the night. The second time out of the bag he was able to urinate, much to my relief as well as his! The night scenario went like this: I would wake him up, ask how he felt, note his O2 saturation percent, depressurize and unzip the bag. He would slowly stand up, walk outside with assistance to pee, drink 16 ounces, take the medicine we offered, sit down, start feeling short of breath, and ask to get back in the bag. We would zip and pressurize the bag and he would again fall asleep. The night was long for the “pumpers” but passed quickly for our patient as he comfortably slept at a simulated altitude of around 6500 ft. to 7000 ft. The most exciting observation was that by 8:00 in the morning, his oxygen saturation levels inside the bag were reaching the mid-eighties. The frustrating thing was that his oxygen saturation continued to drop15 to 20 percentage points when he got out of the bag and he still experienced shortness of breath which was aggravated by any activity. He did, however, say he was feeling better as compared to the day before; a sign that both the medicine and time in the Gamow Bag were doing their job in helping his body to heal. He was drinking adequate liquids but still had no appetite for food.
As morning dawned, my group was preparing for their own trek that day to Namche Bazaar. Departure time was planned for 8 a.m. The weather looked clear and our Nepali guide had made contact with a helicopter rescue operation. The helicopter was going to pick up the patient between 10:00 and 11:00 a.m. that morning. Our group decision was that I was the one that should stay with the patient, continue to provide care as needed, and facilitate his helicopter evacuation. If possible, I would fly with MR and if not, I would catch up with my group in Namche departing after he had been picked up.
My group, including Larry, gave me hugs and waved as they hit the trail. As the morning passed, hopes of a helicopter evacuation this day diminished. Clouds had formed down in the valley and gradually engulfed the mountains. I could hear a helicopter fly around now and then and knew the pilot was doing a reconnaissance of the area to see if there was any possibility of landing. But as I looked skyward and saw the enveloping clouds, I knew in my heart that a landing would not be possible. Fortunately, my patient was continuing to improve throughout the day and was finally asking to remain out of the portable altitude chamber after 17.5 hours of treatment. His oxygen saturation was now maintaining 68% to 70% in ambient air without supplemental O2.
The sun disappeared beyond the horizon somewhere amidst the already cloudy, grey, and darkened sky. Along with other porters, MR and I spent another night in the guest house at Deboche hoping for better weather the next day. Snow flurried outside giving little hope and no indication that the weather would be improved the next morning. The family living in the guest house brought 3 pieces of yak dung and 2 small pieces of wood for us to light in the wood-burning stove in the gathering room. Other porters had rented rooms upstairs and joined us around the stove. We exchanged greetings, briefly shared reasons for being there, and together enjoyed the precious gift of heat. MR and I talked and exchanged bits of information about our families. I learned that he was 30 years old, married, and a native of India. He had been to high altitude (4500m) in the Himalaya three years prior and during that visit had no illnesses or altitude related problems. He loved mountains and hoped he would be able to return to places of high altitude again.
The Sherpa who had accompanied MR to Deboche left early the second evening to rejoin his original group so they could continue their trek to EBC. I also was ready to rejoin to my group. There was really no reason for me to remain with my patient as there was nothing else I could do for him medically. I had exhausted my supply of altitude illness medications, the supplemental oxygen canister was nearly empty, and MR no longer needed the Gamow Bag. Ideally, the morning sky would be clear and the helicopter could come in and pick him up. If the helicopter was still unable to land at our location, the backup plan was for MR to continue his descent down the mountain, either on horseback or by foot. If the helicopter could land, and if the pilot so chose to allow it, I would fly with the patient to Kathmandu. If performance of the helicopter at that altitude precluded me from flying with the patient, I would begin my own trek down the mountain and rejoin my group in Lukla. Of course, I hoped to fly to Kathmandu with the man I had provided medical care to for the past day and a half. It seemed to be the final step in his treatment and the close of a chapter. But in my heart I knew he would be okay without my accompaniment so to me it didn’t really matter. I would hike the trail 10,000 times if I could save one life on each journey.
The yak dung fire gradually died and the night was cold. I hunkered deep into my down sleeping bag inside the large room where we had spent the last 30 hours together. MR was asleep and I listened to his soft, even, unlabored, rhythmic respirations. We awakened to a dusting of new snow and a bright, beautiful blue sky. About 9 a.m. I heard the familiar beat of blades only an A-Star helicopter makes. Down in the valley I saw a spec, a mechanical bird growing larger as the soft whirr of spinning blades grew louder. My heart began to pound and I thought about what an interesting twist it was for me to be the one standing on the ground waiting for a helicopter to land. For 18 years I had been the one in the helicopter and it was others waiting on the ground for me to fly in. And now the tables were turned. I needed the helicopter to transport a patient, a man that had nearly died of high altitude pulmonary edema. I watched every move of the aircraft and felt the pulsation of the blades as the pilot circled the small landing zone area, slowly moved into position for final approach, and skillfully maneuvered for a precision landing. My patient walked outside unassisted and I saw his eyes were filled with tears and I knew his heart was filled with thankfulness. Together we approached the pilot and exchanged introductions. Yes, he could take me too. My patient entered the helicopter with an oxygen saturation of 71%. Forty-five minutes later and 9,000 feet lower, we landed in Kathmandu.
MR had a glorious oxygen saturation reading of 92%. MR was no longer my patient. He was my friend. He could finally breathe again with ease, and so could I. A life was saved and a friendship had been created that will last forever.
Because of the Gamow Bag, MR is still alive today.
In 2008 I established a fund raiser with the goal of raising enough money to purchase portable altitude chambers for the high altitude villages along the Khumbu route to Everest Base Camp. I received enough money to purchase 5 Portable Altitude Chambers (PAC bags). In April of 2009, I guided and taught on 2 wilderness medicine adventure trips to Everest Base Camp with Wilderness and Travel Medicine. It was during these treks when we delivered 3 bags to the Villages. The other 2 bags will be delivered in the fall of 2009.
Sheryl, my patient, and our pilot
Porter carrying a portable hyperbaric chamber
Pressurized hyperbaric chamber
MR taking sips of water during a few minutes out of the bag