SOME RECENT TRENDS IN MOUNTAINEERING MEDICINE
DR. ARNOLD PINES
Generalised Cold Injury (Hypothermia)
MAN is a tropical animal. Adaptation to cold climates is not particularly efficient and depends mainly on man's manipulation of the environment by clothing, external heat production and other deliberate measures. The body dissipates heat very quickly at the cost of evaporating body water. Regulation of body temperature is by sweating, adjustment of the deep and peripheral vessels in the body and shivering. The central part of the body keeps a uniform temperature of 37° C. but the periphery is maintained at about 33° C. When the central core temperature becomes as low as 33° C. danger begins, consciousness dims and decreases rapidly below this. The lowest temperatures horn which recovery has been recorded are 16 to 18° C. At great heights diminished oxygen decreases working capacity and there- lore heat production; the high ventilation rate may cause much heat loss by evaporation. Heat loss when the body and clothes are dry is mainly by convection, increased by wind chill. Conduction of heat is greatly increased by wetness of clothes and soon become very dangerous. Heat failure seems to be the cause of death, either by standstill or by fatal disorderly rhythm (ventricular fibrillation).
Warning signs of hypothermia are changes in mood, withdrawal, much bad language(!) and irritability; stumbling and falling are followed by apathy and then coma. Exhaustion predisposes.
Treatment: An axiom is that death is often erroneously diagnosed when the body core temperature is below 27° C, taken by fee rectal thermometer. Resuscitation should be continued for some hours at least before abandoning. Rewarming is best done rapidly. Patients should be placed into the most protected environment available, inside a sleeping or polythene bag preferably with another climber. Hot liquids and foods are important and especially at great heights oxygen, preferably warmed. When in shelter only, alcohol is useful. The patient should be moved as little as possible because this may precipitate fatal fibrillation of the heart. Clothes should not be removed till the patient is better. Hot baths at 34° C. help rapid rewarming. During the rewarming period the body temperature may drop by about 3° C. at first because of circulation of cool blood from body reservoirs, and treatment must continue.
Local Injury (Frostbite)
Frost nip is reversible. The exposed part blanches and remains white and should be treated immediately by rewarming with the hand or glove. Rubbing should never be done.
In Frostbite the tissues freeze and ice crystals form between the cells. It occurs especially at high altitudes for various reasons. The blood thickens and becomes sluggish especially if dehydration is allowed to occur. Lack of oxygen impairs compensation by exercise and shivering, while mental clouding may lead to inadequate precautions being taken. Poor appetite diminishes the fat insulation of the body and decreases energy production. However wind chill may be less.
Prevention: Equipment and clothing must be first class. In deep snow the feet can be at many degrees below freezing point though the ambient temperature is much higher. Fluid intake must be as recommended by Pugh i.e. at least 6 pints of liquid daily at great heights: oxygen must be available if required.
Treatment: Affected tissues must never be rubbed: this only destroys the damaged tissues. It is best to evacuate frostbite patients to a base camp or hospital quickly if possible. It is safe to walk on frost-bitten feet, the tendons often being intact but very damaging and dangerous if they have been partially or completely thawed. The general measures detailed above are important. The affected part should be warmed, preferably using a container with water at 44° C. Water that is too hot is damaging. Hot towels, a cloth wrapped round the part or use of armpit or abdomen are substitutes. After rewarming the part should be cleansed and wrapped in clean soft dressing. Off the mountain the part can be exposed as long as it remains warm. Reassurance and analgesics are important. The part is easily infected and antibiotics by mouth should be given.
Though large areas of skin and other tissues may look dead and black in colour, surgery should be avoided as long as possible. Most cases gradually heal over in six to twelve months and conservative treatment for as long as possible is important. Drugs of operations to dilate the blood vessels are probably useless. It is surprising how even with deep frostbite a limb may return to almost normal over some months.
High Altitude Illness (Pulmonary and Cerebral Oedema)
Adaptation to altitude is complex. A chief purpose is to facilitate oxygen from the mouth to the cells despite relative lack in the atmosphere. Most people adapt very well given time. Others adapt very poorly and develop illness which is often acute, dramatic and life threatening. The illness used to show itself particularly in young, fit and impatient climbers, but with recent tourist development the middle-aged and elderly may be exposed far too quickly to heights of 12,000 feet or more and, with ill- advised exertion, may develop the syndrome. The lungs, brain and eyes are chiefly affected.
Mild forms are very common. Headache, irritability, weakness, nausea and vomiting, palpitations and rapid breathing are often noticed on the third day of exposure to great heights. With rest, restricted effort, perhaps the use of diuretics and reassurance the symptoms usually abate. I found metaclopramide 10 mg. relieves nausea very quickly. If neglected, severe illness may develop very quickly. The brain swells and bleeds, the eyes become inflamed and bleed and similar changes occur in the lungs. The mechanism of these changes is much disputed. The right side of the heart which drains the veins developes high pressure at high altitudes, related both to anoxia and to low atmospheric pressure. During exertion vessels which normally protect the lungs from this pressure may open, particularly under the influence of lack of oxygen .ind carbon dioxide and the pressure may be transmitted directly to the lungs with profuse leaking of fluid. Some blood vessels may be closed by blood clots and pressure on the remaining ones may be too great. Reflexes from the swollen brain may also cause water logging of the lungs. The effect of cold on the skin may cause reflex shutting down of arteries in the lungs. The kidney probably plays an important role. It shows signs of damage and, perhaps because of deficient hormone control, may not excrete the excess of fluid found in the body, especially in the lungs and brain.
Symptoms develop from the mild ones described above. Confusion, hallucinations, fits, stupor and coma rapidly develop. They may occur in women, especially at pre-mentrual times or when on the "pill". The illness is found in any high mountain range, especially in the Andes and possibly less in the Himalaya and Alaska. A chronic form (Monge) has been best described in the Andes. Inhabitants of high places are often at risk if they descend to sea level for a time and then return to the previous heights.
Prevention: Time to adapt remains essential. As a rough rule when camping above 10,000 feet each extra 2 - 3,000 feet requires two or three days adaptation; though climbing can be much higher during the day. Alleviating factors include fitness, and exposure to heights previously but individual variation and morale all play a part. An increase in the blood carrying capacity for oxygen is part of adaptation and may be helped by a month or two of iron taken daily beforehand. A tenet often held by experienced mountaineers and which is probably correct, is that a water diuresis of pale and profuse urine - shows good adaptation to height. A poor output of dark yellow urine is a bad sign. Some use diuretic tablets such as frusemide 40-60 mg. or the more powerful bumetanide 1-3 mg. to get rid of the dangerous excess of water, though others' experience has been disappointing.
Treatment: At the first signs of severe illness, the climber must be made to rest and should be returned, preferably by a stretcher, to lower altitude as soon as possible. Enough oxygen should be available to give a generous supply for 24 to 48 hours. 40-80 mg. frusemide or preferably 1-3 mg. of bumetanide should be given at once and repeated. Morphia in small doses is useful. Acetazolamide does not help in prevention or treatment. When the patient recovers, all manifestations of illness disappear, leaving no permanent damage except when there has been bleeding in the eyes. However when a climber next goes high he must allow very slow adaptation. If any warning symptoms recur, it is probably best never to go to such heights again.
"It is not likely that instances of severe acute mountain sickness will diminish in frequently, for high altitude climbing is ever more popular. Experienced mountaineers, although aware perhaps of the syndromes of mountain sickness, will probably foolishly trust their physical conditioning and past achievements rather than pack enough bulky, expensive oxygen to be life saving, should illness occur. Inexperienced adventurers are not likely to even know the hazards.
"If one were thinking primarily of safety, one should not climb big peaks at all. But challenge and objective danger are necessary for certain individuals whose lives ordinarily hold no elemental risk or chance to prove the physical capacity to endure. Sporting activities can satisfy a primitive need to test oneself. Although injury is not sought, the possibility of personal harm is variously accepted, minimised or denied as a part of the psy- chologic preparation for hazardous recreational endeavour. Some mountainers even openly announce a preference to die in activity at a height of prowess rather to succumb a bed in valetudinarian desuetude. It is not likely that persons such as these can be induced to protect themselves fully on mountains" (Wilson, 1973).
Muscle performance depends on the presence in the muscle of sufficient glycogen, a carbohydrate derivative. It has been shown that "stuffing" with carbohydrate before strenuous athletic activity greatly increases muscle glycogen, especially if carbohydrate has been restricted for a few days beforehand. Thus in mountaineering, carbohydrate intake takes preference to protein and fat. "Stuffing" oneself with carbohydrates such as rice, bread, porridge and other cereals, spaghetti, potatoes etc. is advisable. Sugar is much less helpful.
Sleeping drugs are often dangerous because of after affects on alertness, motor ability and agility, sometimes for days after a single dose. At great heights, warm coverings and hot food and drink are essential. Alcohol is probably the safest sedative. Hali- peridol may have less hangover. Practitioners of deep relaxation or Yoga are at an advantage! Restlessness and insomnia at great heights may be very wearying so that an individual hypnotic may have to be resorted to despits its dangers. Chloral, nitrazepam, diazepam or hexobarbitone are perhaps less noxious.
These are dilated veins at the end of the gut which eventually protrude through the anus. They are very common in climbers and may cause much disability especially if they thrombose, bleed or get infected. Uniquely there are no valves in these vessels so that intra-abdominal pressure, especially in the upright posture is transmitted directly to these vessels. Pressure may increase by carrying heavy loads or straining with a dry and meagre stool. Piles are very common in the West but much less in the East: this has been attributed to absence of residual fibre in Western diets. Spasm of the muscles forming the anal sphincter may be important.
Prevention in climbers: Bulk in food is important. Bran, wholemeal porridge, and bulk adders such as those derived from seaweed (e.g. Isogel or Normacol) are important. The lattter are very light and can be carried in high mountain packs. A high water intake helps, as does avoidance of straining and obsession with daily habit.
Before expeditions, any piles must be treated. The mildest cases may respond to changes of diet and habit and the use of suppositories. All other cases must be treated more actively. Injections cause shrinking of piles which may be sufficient for a few weeks but they usually recur afterwards. An operation is usually required. The old radical one was often unpleasant. There have been several recent, conservative and much easier operations, several of which can be performed as an out-patient. A medical opinion should certainly be sought.
Imflammation, prolapse and thrombosis of neglected piles, both internal and external, may occur. Treatment includes suppositories, bathing with warm water and dilation of the anus by the insertion of several lubricated fingers together with pulling of one buttock sideway to relax the sphincter.
Prevention of infection
Gastro-enteritis is common and disabling, infection is conveyed from "carriers" through poor hygeine especially in food handling. Prophylaxis by regular anti-bacterial drugs helps greatly. The most convenient drug is sulphadoxine (Fanasil); 2 g. given once weekly gives prolonged and adequate blood levels. On 3 expeditions I have used it weekly for members and the porters - often carriers of infection - and have almost completely eliminated gut troubles due to infection. Sulphadoxine also protects against malaria, typhoid, cholera, and most infections of the lungs, kidneys, skin and eyes. Sulfameto-pyrazine is a rather similar compound, perhaps more easily available, but I have no experience of its use.
Psychological problems are often very important in mountaineering expeditions. Peter Steele discusses these in his book 'Doc- tor on Everest'. He also discusses female problems in mountaineering in a recent article in the Nursing Times (Dec. 1973).
- "Pulmonary Oedema of Mountains," Editorial, British Medical Journal, 1972, 3.65.
- "Acute High Altitude Illness in Mountaineers and Problems of Rescue," Rodman Wilson, Annals of Internal Medicine, 1973, 78 : 421.
- "The Renal Element in Pulmonary Oedema," Pines, A., British Medical Journal, 1972, 3, 642.
- "Hypothermia," Hervey, G. R. Proceedings of the Pvoyal Society of Medicine, 1973, 66, 1053.
- "Frostbite," Ward, M., British Medical Journal, 1974, 1.67.
"Mountain Rescue" (hypothermia), Snook, R., Upadate, 1973, 1279.