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Rapid Responses: Rapid Responses published:
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High Altitude Sickness
- Richard V Heatley (28 August 2006)
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Wobbles on the slopes
- Alistair Sutcliffe (30 August 2006)
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Avoiding Deaths on Everest
- Stephen P Cobley, Jim McKenna & John Allan (5 September 2006)
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Damned if you treat, damned if you don’t.
- Sean T Hudson (3 October 2007)
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Richard V Heatley, Consultant Gastroenterologist St James's University Hospital, Leeds, LS9 7TF
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Sir, Dr Sutherland (26th August) is to be congratulated on his ascent to the summit of Everest and his interesting observations on the deaths of those who were not so successful. Very recently I was in the Andes at a relatively modest 4000 metres and yet despite being a very regular distance walker and having a few days of acclimatisation I found my exercise tolerance significantly reduced from normal. Those around me who were also visitors vehemently denied any altitude effects despite almost universally being obviously dyspnoeic even on mild exertion. Earlier this week there was a television programme on the geology of the Andes. The reporter at similar altitude also denied altitude effects despite clearly having a respiratory rate over 30/min after apparently only taking a few steps on the flat. Dr Sutherland’s suggestion that denial may be due to confusion or euphoria as an early manifestation of cerebral oedema may well be correct. In the Andes, an area of increasing tourism, this may well be exaggerated by the regular consumption of coca tea encouraged by the locals as a preventative for altitude effects! Perhaps there is a need for some form of external monitoring to give early warning of altitude sickness for those obviously at risk, that does not rely solely on the individual’s own interpretation of the situation. Competing interests: None declared |
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Alistair Sutcliffe, GP Whitby Group Practice, YO21 1SD
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Sir, in response to Dr Sutherland's article about high altitude climbing, I have several points to raise. As an Everest summiteer from May 20th 2006, I also witnessed several high-altitude disasters, and agreee that the majority of problems occurred in people with 8000m experience. Frankly I was appalled at the lack of "self-conservation" that one sees on these big climbs. People forget that water and food are often the key to the self-determined factors allowing a summit attempt. We are all, as individuals, able to alter the equipment we use, the physical shape we are in, and the mental strength prior to departure on the expedition. Of course, the major determinant is weather, which we just have to wait for. One has to put fuel in the furnace to maintain the strength to climb, and whilst other team members are supportive, it is no-one else's job to tell you to eat or drink. People know the risks of climbing mountains such as Everest, and should be able to look after themselves as much as possible. Good luck and keep climbing. Dr Alistair Sutcliffe. Competing interests: None declared |
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Stephen P Cobley, Lecturer Fairfax Hall, Headingley Campus, Leeds Met University, LS3 6QS, Jim McKenna & John Allan
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Andrew Sutherland rightly draws attention to fatalities on Everest, attributing prolonged exposure to high altitude through protracted rates of ascent as a fundamental cause. While we agree that a 1 in 10 death ratio is unacceptable, we also feel that learning from the successes of the other 90% is warranted. These successes emphasise that death at high altitude is avoidable. The Everest West Ridge expedition (www.armyoneverest.mod.uk) highlights the importance of a collective, inclusive approach in extreme conditions, incorporating detailed planning, dynamic leadership and a holistic maintenance of the overall aim. After 60 days of climbing on Everest’s most demanding and treacherous route, there were no deaths, severe injuries or significant evacuations (in a season where over 40 were reported on other routes). The expedition began with a clear mission and careful selection of personnel, with social ‘fit’ of utmost priority. Across almost 3 years of preparation, the climbers prepared through prescribed training, simulation and education within a framework of kinship and loyalty. They were physically fit, well fuelled, properly equipped and psychologically adaptable to meet conditions that many had not previously experienced. This attention to detail also resulted from the combined efforts and inputs of University sport physiologists, psychologists, dieticians, biochemists, Army medical specialists and Everest veterans. This prolonged, co-ordinated approach was central to minimising the worst effects of extreme environmental conditions, including altitude. Prior to arriving at Everest, small ascent teams were created, each with specific, time-phased plans and clear contingencies to cover foreseeable events. These teams, each with designated leaders, regulated hydration, nutrition, energy expenditure and rest. They guarded against the onset of acute mountain sickness and generated ‘banter’ to reinforce collective standards. But for impossible snow conditions above 8000metres, any of 13 climbers were positioned to complete the final 800m to the summit, where only 13 humans had ever previously reached the summit via this route. Astonishingly, 20 of 21 climbers attained a height 7500 metres without oxygen. Crucially, when the key decision to withdraw was made, leaders were all cognitively capable, predicting realistically and with emotional maturity. The careful choice of participants and repetition of core values through the preparation period meant that climbers accepted their role as ‘followers’. This helped them to set aside personal aspirations for glory and ‘once-in-a-lifetime’ achievement in favour of survival. While the pace of ascent may be a useful diagnostic yardstick, we maintain that this comprehensive, integrated approach is central to managing the sporadic, unpredictable nature of altitude susceptibility. Furthermore, the success of this approach reaches into the fabric of the climbing community over and above quick-fix, commercial ventures that sanction individual ambition above collective safety and camaraderie. Competing interests: None declared |
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Sean T Hudson, GP and medical director expedition medicine St Pauls Medical Centre, St Pauls Sq, Carlisle, Cumbria
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Damned if you treat, damned if you don’t. The problem with treating Americans The adventure travel market is undergoing an exponential growth, and UK companies are at the forefront of providing safe and well organized overseas ventures for people of all nationalities and in all environments. The government recently recognized the need for standardization in this field and in 2007 released the BS8848 document which set the gold standard for providing support and care on organized trips outside of the UK. Part of this document covered the need to provide some level of medical support by a recognized medical practitioner, preferably in the field with the organization, especially in remote regions with limited access to medical facilities. UK companies were some of the first to provide medical cover on their expeditions, with doctors, nurses and paramedics often offering their skills in lieu of the opportunity to travel to exciting destinations, or going out of purely altruistic motives, to allow a population with disabilities and pre-existing conditions to participate in activities they would otherwise not be capable of. The situation seemed to be harmonious until the possible implication of providing medical cover to Americans, among others, was highlighted. The Defence Unions advise doctors, that although they are covered to treat Americans, they are not covered for any court case that arises in North America. (Americans obviously being at liberty to sue a doctor in America if they choose, independent of where the transgression occurred). The GMC advise all doctors not to participate in any activity without the appropriate cover. The doctor is therefore left to decide if they are willing to take the risk, which is against the advice of the GMC. If however a doctor makes the decision not to provide medical cover for an American on an expedition, the American participant seems to be perfectly within their rights to sue for racial discrimination, bringing an action against the company organizing the trip and reporting the doctor to the GMC for improper conduct. The Defence Unions seem to escape any culpability in the eyes of the racial discrimination board as they are not discriminating against Americans but rather against any legal action taken in the US, whether it be by an American or a UK citizen. What about the American citizens that reside permanently in the UK? Or the dual nationals that retain their American status but are also UK citizens? At the moment they still fall into the same bracket so the advice to the doctor is the same. How can this ludicrous, untenable situation be rectified? Does the solution lie in something as simple as a signed legal waiver, or will it be necessary for the defence unions to accept the risk? Whatever the solution it can not be allowed to continue as it is, with doctors risking being sued for treating or being sued for refusing to treat. Competing interests: None declared |
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