Mountain Medical Matters
We’ve hosted a number of Expedition Event over the years where we were joined by Dr Hannah Kittson, a Mountain Medicine specialist who was a wealth of information for customers heading off on adventures across the planet. There were some great questions from everything including ear infections, wearing contact lenses in extreme environments, what to do if you lose an inhaler, the best types of contraceptives to the physical realities for women in a high altitude environment. As you would expect from a medical professional, nothing was off limits for discussion!
We love sharing our knowledge with customers and thanks to Dr Hannah and our partnership with specialists Rapid Response Adventure Medicine and World Extreme Medicine we are able to share the professional advice with you so you can enjoy your adventures to the max……
Tip no:1
If you have any medical concerns prior to departure on expedition/to altitude, it is important to seek medical attention prior to the trip (in plenty of time for any medical problems to be adequately addressed). Having a good idea of family medical history, if possible can be helpful when considering risk of certain medical conditions, and may mean you need some further personal medical investigation prior to the trip.
UIAA medical guidelines are a useful source of further information on a wide range of topics - https://www.thebmc.co.uk/uiaa-mountain-medicine-advice-sheets. And the answer to some of the questions below has been based on the current UIAA guidelines.
Will altitude affect my asthma. What is a good back up for forgetting/losing inhalers?
Not necessarily - some people find their asthma actually improves at altitude. Even though potentially breathing in colder/drier may normally be a trigger, there are potentially fewer pollutants, therefore asthma may not be a problem. It is generally not a problem for those with well controlled asthma and few symptoms at sea level. Asthmatics who suffer symptoms on minimal exertion at sea level need full medical review before attempting altitude.
Unfortunately, there is no real substitute for lost/forgotten medications. Have PLENTY of inhalers. Put some in other team members kit so if personal kit is lost, you may still have a back up. Asthma medication should still work at altitude - extremes of heat are generally more of a problem. Though at high altitude/extreme cold, consider carrying them on your person. Consider a ‘rescue pack’ of medications including steroids and antibiotics - worth a discussion with your GP before travelling. If medication is lost or forgotten, you would need to consider getting medication replacements in country before embarking on periods without medical aid.
What height does thrombosis risk increase. What are the signs? Any precautions? Aspirin?
There is limited literature on the exact height at which you are at increased risk of thrombosis. An individuals risk will also depend on their own personal risk factors. But generally, increasing altitude increases risk, as does prolonged stay at altitude.
Most common sites of thrombosis - deep vein thrombosis (DVT) in limbs (most commonly leg, but can be arm) and pulmonary embolism (clot in the lungs). But clots can occur in other parts of body i.e the gut or the brain (though this is less common).
Signs of DVT - unilateral calf pain/cramping, swelling (can be just of calf/ankle region but can be of whole leg), redness of affected leg, affected leg feeling warm to the touch. Bilateral DVTs are very rare but can happen. Beware, can be passed off as muscle sprain etc, particularly on expedition.
Signs of pulmonary embolism - Shortness of breath (exertional and at rest), cough (can be productive of blood tinged sputum or sometimes fresh blood), chest pains, heart palpitations, lethargy, low grade fever.
Again, can be a difficult diagnosis at altitude, symptoms can be similar to altitude illness - treat for altitude illness (HAPE) but have in back of mind, particularly if someone also has the symptoms of a DVT.
Prophylactic medications are not normally recommended for healthy individuals with no significant risk factors or previous thrombosis. Aspirin can increase risk of gastrointestinal bleeding (and risk of GI bleeding is thought to independently increase at altitude). Individuals with risk factors/previous thrombosis should seek medical advice if travelling to altitude.
Dangers of contraceptive pills at altitude. Other options.
Combined oral contraceptive pills (COCP) theoretically increase risk of thrombosis during stays at altitude, in combination with dehydration, cold, normal adaptive changes that happen at altitude, any imposed immobility by weather/illness etc. There are few cases reports of this, however, and many women take the COCP at altitude without problem. Certain types of OCP are less associated with increased clotting risk.
Potentially should consider avoiding the COCP if spending >1 week above 4500m. Below 4500m, the COCP is thought to be safe in otherwise healthy, non-smoking women with no significant risk factors for blood clots or family history of blood clots.
There are many options for contraceptives/period control at altitude with potentially lower clotting risk, including the progesterone only pill, contraceptive injection, implant, coils.
The UIAA advice sheet on Contraception at Altitude (link via medical advice sheets on BMC website) is very useful. It is best to be well established on a method that works for the individual rather than trying something new just before going on expedition.
Some medications can be given to delay periods, but may not be appropriate for use in those with high clotting risk.
Best way to treat an ear infection at altitude.
Good pain relief is very important - combination of paracetamol and ibuprofen (if tolerated) regularly. A large proportion of ear infections are still viral and won’t respond to antibiotics. Antibiotics can be considered if bilateral infection, if the person feels unwell in themselves, if there discharge from the ear. Ear infections will usually last 3 days, but may last up to a week. A 5-7 day course of amoxicillin or clarithromycin are the most commonly prescribed antibiotics. If going on expedition, could consider discussing with your GP whether taking some antibiotics on the trip in case of infection might be appropriate, particularly if you are prone.
Do you recommend using the Lake Louise questionnaire when leading treks of >3000m. If so, what is the best way of doing it?
The Lake Louise score be useful as a guide for people to increase awareness of the symptoms that can be related to acute mountain sickness (AMS) i.e headache, nausea/vomiting, fatigue/weakness, dizziness/lightheadedness and functional ability. But you don’t necessarily need to score people formally. The score wasn’t designed to be used by guides for the treatment/diagnosis of AMS, it was designed as a research tool.
It would be important for people to be aware of the symptoms of AMS before the start of an expedition. A buddy system can be good - get people to discuss symptoms amongst each other, reporting to the guide/leader if concerned/symptoms deteriorating. Or discussing each day with the guide how they’re feeling with respect to the symptoms of AMS - having a daily ‘check in’. It is very important to know how a person’s symptoms are developing - particularly if they are worsening. It is important for guides to be able to create an atmosphere in which people feel comfortable to discuss the symptoms they are experiencing openly and honestly.
Health of local staff on expedition - how to ensure this.
Are they being hired independently by yourself in-country, or are they part of the expedition team booked through a company? If through a company, there may be measures etc in place - important to know what these are. They are a vital part of your team - include them in health discussions during the trip - find out how they’re feeling each day.
Do they have adequate kit to ensure their health and safety, even basic kit like sunglasses to protect against snow blindness.
Useful article on BMC website - https://www.thebmc.co.uk/porter-care-in-the-mountains
AMS, HAPE, HACE
Acute Mountain Sickness - Occurs at altitudes over 2500m typically, usual onset between 4 and 24 hours after ascent to new altitude.
Typical symptoms -
-Headaches - usually generalised.
- Loss of appetite
- Nausea/vomiting
- Dizziness/lightheadedness
- Lethargy
- Sleep disorders
- Some shortness of breath.
Headache is normally a feature, but you can have AMS without the headache.
High Altitude Pulmonary Oedema - This is an accumulation of fluid in the lungs. Usually occurs over altitudes of 3000m, normally after 24 hours of ascent to new altitude (but not always).
Typical symptoms -
- Shortness of breath - progressive from light workloads to at rest.
- Rapid decrease in exercise performance
- Cough - may or may not be productive
- Feeling of heart racing
- Chest discomfort/tightness
- Low grade fever
High Altitude Cerebral Oedema - ‘Swelling of the brain’
Usually occurs at altitudes >4000m, after 24 hours of ascent to new altitude (but again, not always). Can initially have similar symptoms to AMS, but deteriorate. But AMS doesn’t have neurological features (i.e altered mental status or ataxia (unsteadiness when walking)).
Typical symptoms -
- Severe headache not responding to normal pain relief
- Nausea/vomiting
- Dizziness or vertigo symptoms
- Ataxia - unsteadiness on feet, difficulty walking in straight line, particularly heel-to-toe walking (good to check for if people may try to mask their symptoms)
- Altered level of consciousness/confusion/hallucinations - irrational behaviour may be the first symptom.
There is a very useful UIAA information document on symptoms and management of these conditions.
Contact lenses and expeditions. Best way to treat eye infections.
Contact lenses can be used on expeditions - though this puts the individual at more risk of dry eyes and potentially serious corneal infections.
Minimizing risk -
- Recommended contact lens use for no more than 8 hours/day if able. Use of glasses other times/prescription sunglasses/goggles.
- Don’t sleep in them if you can avoid it.
- Strict (as possible) hand hygiene when handling lenses.
- Daily disposable lenses preferable to monthly lenses.
Any evidence of even minimal infection (even a simple conjunctivitis) should be taken very seriously. Contact lenses should be taken out. Start broad spectrum antibiotic eye drops. Should start to improve with antibiotics, but consideration of need for evacuation.
Contact lens wearers are also susceptible to corneal abrasions (which can be caused by trauma from the contact lens) - treated by stopping wearing lenses and antibiotic eye drops/ointment.
For further information on high altitude sickness we sell a number of specialist books:
Pocket First Aid and Wilderness Medicine
Medicine for Mountaineering
or you can find lots of helpful information at www.paramonte.org and of course, the link to the UIAA mountain medicine website at the beginning of this blog.
Dr Hannah Kitson joined us at our first Expedition event held in 2018. It was so successful that we have held two more since and look forward to announcing our next one at our Capel Curig shop in 2021. You can catch up on what you missed vis the links below: