Trekkers often get affected by High Altitude Pulmonary Edema (HAPE), a critical case of altitude sickness that affects the lungs. The consequence of HAPE can be fatal, often within hours. This can happen on any trek, even lower altitude ones. Trekkers heading to the mountains can learn from such experiences, so that they know how to take care of themselves and others. 

Today, we’re studying one such case that occurred on the night of June 29th, 2021, on the Hampta Pass trek. Through the case study, we’ll learn what went wrong and analyse what could have been done better.

The Hampta Pass trek is notorious for altitude sickness cases. It shoots up to an altitude of 14,000 ft in less than 3 days. Picture by Aditya Bodke

It was around 9.30 pm, when the Indiahikes team saw the blinking lights. Two red beams flashed into the night sky. It came from not more than 3 km above the Chhatru campsite. 

Flanked by towering peaks and mountainsides, Chhatru is the last camp on the Hampta Pass trek. Despite being the last camp, Chhatru is still at a daunting altitude of almost 11,000 ft. 

“Initially, when we saw the lights, we thought it was trekkers navigating down the section. To get confirmation, our Slope Manager, Ravi Ranjan, reciprocated with a return blinking call. He immediately got a response from them. It was confirmed. It was a distress call,” says Aditya Bodke, Senior Trek Leader at Indiahikes. 

“We knew they weren’t Indiahikes trekkers. They could have been solo trekkers, or trekking with another organisation or local guides,” says Ravi. 

Knowing someone was in trouble, a team of 6 experienced members from Indiahikes set out towards the SOS light. 

They carried a rope (which they could convert into a stretcher), an ice axe to cut through the snow patch on the way, a high altitude medical kit and one medium-sized oxygen cylinder. They also carried 2 radio communication devices, which could relay messages to the Indiahikes campsite.  

With rare road access at the camp, they took the team SUV as far as they could, and trekked for another 2.5 km. They rushed but it took them almost 25 minutes to reach the distressed group. 

10 PM: Upon reaching them, Aditya saw a trekker wrapped in a stretcher — it was a stretcher borrowed from the Indiahikes campsite at Shea Goru (the previous campsite). Four members from another organisation stood beside the trekker. A local staff member from Indiahikes Shea Goru camp was accompanying them too. 

Doing the first thing he’s been trained to do, Aditya bent down to check if the trekker was conscious. He asked the trekker’s name. “Divyanshu,” came a quick reply from the trekker. Aditya was relieved that the trekker was conscious and in his senses. 

His next step was to check the trekkers’ oxygen level. Aditya was stunned. It was at an alarming 37% saturation. At this level of saturation, organs begin to fail. The trekker could slip into multiple organ failure soon, which would eventually lead to death. Aditya acted fast. He immediately got down to supply oxygen to the trekker. Within 20 seconds, he had the oxygen on at 8 L/min.

Noticing that the trekker was coughing mildly, it didn’t take long for Aditya to recognise it as a case of high altitude pulmonary edema (HAPE). A cough along with such low oxygen saturation at altitude is a very big sign of HAPE. Divyanshu’s teammates mentioned that he had begun coughing after crossing the mountain pass earlier in the day. Aditya didn’t need to hear anything else. 

Wasting no time, he administered 500 mg of Diamox, 20 mg of Nifedipine and 6 mg of Dexamethasone, along with continuous oxygen supply. Diamox would help him to acclimatize quickly, by expelling bicarbonates from his body. A double dose of Diamox was the need of the hour (500 mg). 

Nifedipine would reduce the fluid pressure in the lungs, which was making it difficult to breathe for the trekker. The fluid prevented a smooth transfer of oxygen into the lungs as well. This is what caused the drop in his oxygen saturation levels. 

Dexamethasone would help reduce other forms of edema (swellings). In such cases of altitude sickness, other body organs swell as well, which hampers the smooth flow of oxygen to our cells. Dexamethasone reduces the swelling. A 6 mg dose is high, but was the need of the hour.  

The trekker’s Oxygen improved to the 60’s, but did not improve beyond that. Aditya knew there was tremendous pressure on his lungs. HAPE had taken a firm grip on the trekker. There was no time to lose. 

While Aditya checked on the trekker, the rest of the Indiahikes team planned out the evacuation. They would stretcher the trekker all the way to the road head, from where they would drive to Manali (64 km away). They would take the Atal Tunnel to Manali, which would buy them a precious 4 hours, as compared to the older route through Rohtang pass.

10.20 PM: In the heart of the desert-like Lahaul, the descent was steep and rocky. Their first challenge was an icy stream they had to cross. Then came the snow. The snow traverse was a 45-degree incline directly over the Chandra river. 

With one team member ahead, one at the back, and Aditya crouching below the stretcher holding onto the oxygen cylinder, they crossed the slippery section in the light of their headlamps.

From the Chhatru campsite, an alarmed set of trekkers watched on, as a series of headlamps and flashlights lit up the mountain side on a dark night. 

10.50 PM: Within 30 minutes, the evacuation team reached the vehicle. Meanwhile, Slope Manager, Ravi had radioed our base for the larger oxygen cylinder, which is kept at all Indiahikes camps for emergency purposes. 

Once the trekker was plugged into the large-sized cylinder, the vehicle rushed towards Manali. 

Throughout the journey, Aditya monitored the trekker, making conversation, keeping him in his senses and administering oxygen. 

The trekker stopped the vehicle to urinate twice (a good sign, showing that the Diamox was working). The first pee-stop was concerning. Divyanshu’s oxygen saturation dropped from 72 to 42 in a matter of two minutes. The trekker was surviving purely on supplemental oxygen. On the second pee-stop, Aditya didn’t take a chance. He went along with him, carrying the oxygen. 

1.30 AM: It took 3 agitated hours, but the vehicle made it to Manali. “Our biggest challenge was to make the big oxygen cylinder last throughout the journey,” shares Aditya. With careful estimation, they regulated the flow so accurately that the oxygen lasted just until the trekker reached the emergency ward. 

An X-ray of the lungs showed that one lung was heavily infected (a medical confirmation of HAPE).

The hospital tested him for COVID with a Rapid Antigen test, which came negative. 

They sent samples for an RT-PCR test, the results of which came back negative the next day

At the hospital, the trekker was put on supplemental oxygen, saline drips and administered a few regular medications. However, Aditya had already given him the life saving drugs on the slope, which helped the trekker recover quickly at Manali. The lower altitude of Manali, of course, helped the most.

As we document this on July 1st, the trekker is still in the hospital, on a steady supply of oxygen. He’s doing better, with oxygen saturation in the high 90’s. He may spend a few more days in the hospital before being discharged. Divyanshu’s full recovery from this may take a few months though.

The HAPE-affected trekker, Divyanshu, was kind enough to answer some questions for a case-study, to help us assess what went wrong, and what could have been done better to avoid a near-death experience. 

8 Lessons We Can Learn from the HAPE Case Evacuation

1. Have an acclimatization-friendly itinerary 

What could have averted the whole situation is a more well-thought-out itinerary keeping altitude gain in mind. Divyanshu’s team followed an itinerary that covered the Hampta Pass trek in 4 days, as opposed to the regular 6-day itinerary. 

Day 1: Manali (6,726) to Chika (11,500 ft) 

Day 3: Balu Ka Gera to Shea Goru (12,864 ft.), via Hampta Pass (14,065 ft) 

| Analysis: “Even with the 6-day itinerary that we follow, the Hampta Pass is notorious for AMS cases. The Hampta Pass trek starts too quickly, from above 9,000 feet. These are dangerous altitudes to start a trek. What the trek requires is an acclimatisation day in between. 

Which is why, even though the distance is short, an acclimatisation day at Jwara (11,200 feet) is excellent for the trek. It saves trekkers from getting into a messy situation later on. Divyanshu’s team needed a break between Chika and Balu Ka Gera.”  

| Learning 1: Always give your body time to acclimatise when you’re going on a trek that has a forced ascent. Include acclimatization days within the itinerary, if required stay at a camp for two days.

| Learning 2: Don’t make the mistake of acclimatizing at the wrong altitude. In case of Hampta Pass, many trekkers choose to stay at Manali (6,726 ft) considering it acclimatizing. It’s not acclimatization unless you’re within a range of around 2,000 ft to your next day’s altitude. Divyanshu should have spent an extra day between the 9,000 and 11,000 feet acclimatising.

The trekker spent a day at Manali and then started the trek. He has climbed up to 14,000 ft within 3 days, which could have brought on altitude sickness a lot quicker than usual.

2. When at high altitude, suspect and treat AMS first. Don’t attribute symptoms to anything else

“The night we camped at Balu Ka Gera (Day 2), I had very disturbed sleep. I woke up every few minutes,” says Divyanshu, recalling the night before he crossed the pass. “I didn’t eat much that night either,” he recalls. 

The next day too, he didn’t eat. Neither did he have much water to drink. 

| Analysis: “All these symptoms that Divyanshu felt — a lack of appetite, sleeplessness, are symptoms of AMS,” says Sandhya UC, co-founder of Indiahikes. 

“Most trekkers wait for a headache or to vomit to recognise AMS. But lack of appetite, sleeplessness, indigestion are also symptoms that indicate that your body is struggling to cope with the altitude. It is a clear sign of altitude sickness,” she adds.

| Learning: It’s not normal to feel sleepless or a lack of appetite at high altitudes. Don’t attribute it to anything else. The golden rule at high altitude is to suspect AMS first and treat it.

3. Catch symptoms early and nip it in the bud

“On the first day from Manali to Chika, I trekked very comfortably. I was fine at the Chika campsite as well. My oxygen was well in the late 80s (a normal reading for the altitude),” says Divyanshu. 

“The second day, when I was trekking from Chika to Balu ka Gera, I could sense my pace had reduced. I was lagging behind a bit,” he recollects. “When I was at rest, my oxygen reading was around 86 in the evening, so I still felt okay.” 

“The next day, when I started my climb to the pass, I was exhausted with every ten steps. I had to stop and rest. I even handed over my backpack to our Trek Leader,” he recalls. 

It was after they crossed the pass that Divyanshu felt full-blown symptoms of HAPE, with cough and difficulty breathing. “Just walking made him wheeze,” says his friend. So much so that their Trek Leader decided that camping at Shea Goru was a bad idea and started descending to Chhatru — a crucial good decision. 

| Analysis: “Most times, HAPE doesn’t occur as suddenly as trekkers think. But after it affects you, it can reach a deadly stage within hours,” says Arjun. 

“It is clear that Divyanshu’s HAPE did not happen after he crossed the pass. His fatigue at Balu Ka Gera, his sleeplessness, his lack of appetite are all clear indicators that he already had AMS at Balu Ka Gera, which grew in intensity as they climbed to the pass, and turned into a full blown case of HAPE,” he analyses. 

Aditya Bodke adds, “It’s not easy, but at times like this, when a trekker is extremely fatigued, it’s important for the Trek Leader to take the hard call of sending the trekker back. I would have probably returned Divyanshu at Balu Ka Gera. The sooner you turn around a trekker, the better it is. You may have averted a life threatening situation. Climbing a pass with symptoms is almost like signing a death warrant.” 

| Learning: Learn about all the symptoms of AMS, HAPE and HACE well if you’re going on a high altitude trek. We have always maintained that an informed trekker is a safe trekker. 

“On another note,” adds Aditya, “don’t always rely on oximeters. They are machines after all and can go wrong. Trust your instinct, trust what your body is telling you before you trust an oximeter.”

4. Always have Life Saving Drugs (LSDs) with you on high altitude treks. Know how to administer them. 

When Aditya met Divyanshu nearly 12 hours after he showed HAPE symptoms, he learnt that no medicines had been administered to him. He immediately whipped out Life Saving Drugs from our medical kit and gave him doses of Diamox, Nifedipine and Dexamethasone.

“I think it was a turning point when you gave me those medicines,” says Divyanshu. 

| Analysis: When Divyanshu told his Trek Leader that he was feeling a bit unwell at Balu Ka Gera, if he was given 250 mg of Diamox every 6-8 hours, he might have never gotten HAPE. In fact, his AMS may have disappeared altogether,” analyses Dr Lakshmi Selvakumaran, head of Learning and Development at Indiahikes. 

“From what I’ve observed, many Trek Leaders hesitate to administer medicines. Diamox is a diuretic. Nifedipine is a bronchodilator. Dex is steroid. Most Trek Leaders worry about side effects or allergies. Frankly, if it means saving a life, it’s better to risk a small allergy than risk a trekker’s life,” she adds. 

| Learning: On a high altitude trek, always carry Life Saving Drugs (LSDs) in your personal medical kit — Diamox, Nifedipine and Dexamethasone. These are medicines that are readily available. 

What’s more important is knowing how to administer them. 

Also, do not treat signs — like a loose stomach or a fever. Rather, get to the underlying reason behind the signs. It could be altitude sickness.

5. Go on a preventive course of Diamox if your trek involves forced ascents.

There are some treks that climb quickly (like the Hampta Pass or the Bhrigu Lake). On most such high altitude treks, AMS can be avoided with a simple preventive course of Diamox. Diamox is a medication that helps you to acclimate faster by making your body hyperventilate, thereby taking in more oxygen. To know more read this post on how Diamox deals with AMS.

| Analysis: Trekkers are often reluctant to take a preventive course of Diamox. Either ignorance or a false ego prevents them. Unfortunately, the Indian Himalayas are notorious for their swift climbs. It is generally not possible to camp at 1,000 ft intervals (as it is most prescribed by mountain climbers). We most often camp in gaps of 2 or 3 thousand feet. This very often results in situations where we develop altitude sickness. 

Added to this, a long day’s trek depletes oxygen in our blood very rapidly. While trekking we are breathing hard, losing oxygen. If we are unprepared, and carrying our backpack, the loss of oxygen is more rapid. 

| Learning: Being on a preventive course of Diamox can greatly help in acclimatisation. You need to take 125 mg of Diamox (half a tablet) at 12 hours intervals. I generally recommend an 8 am and 8 pm schedule. Be on a preventive course of Diamox on treks that (1) Have forced accents — camps separated by more than 1,500 feet (2) start treks at high altitude from road head, usually above 9.000 feet (3) treks that anyway reach altitudes above 14,000 feet.

6. Make yourself aware of trekking after recovering from COVID-19

It was only during Aditya’s interview with him that he learnt that Divyanshu had been infected by Covid-19 in February 2021. “Even though he wasn’t hospitalised, he did have symptoms of Covid,” says Aditya. 

| Analysis: This is a new topic that we’re all still learning about. But in an interview with Dr Sreelakshmi on trekking post-Covid recovery, she said, “If you’ve got a severe bout of Covid, I would advise waiting a minimum of 3 months before heading to the mountains. There’s a reason for this. For moderate to severe Covid, there can be scarring in the lungs and fibrosis as a sequela of the disease. You tend to feel body pain and tiredness long after the infection is gone. 

“Recovering from this takes some time. It takes 2-3 months to reach your Pre-Covid energy levels and get rid of the post-viral myalgia,” she adds. 

| Learning: If you have had Covid in the recent past, with symptoms (mild or severe), consult your doctor before going on a high altitude trek. 

It is also better to choose a high altitude trek that doesn’t climb above 13,000 ft, just to test the waters. Something like Dayara Bugyal, Phulara Ridge or Deoriatal-Chandrashila, where evacuation can also happen within 2-3 hours if you’re hit by AMS. I would also recommend doing a few local treks before getting on a Himalayan trek after Covid recovery.

How to go about Trekking Post-Covid Recovery: A Doctor’s Note

7. Always carry 2 personal 1L bottles of water with you

One of the things that could have exacerbated Divyanshu’s condition was that he did not have any water with him when he was descending from the pass. The team was scattered so he could not approach anyone else for water either. 

| Analysis: “This is a debatable point, because by the time he crossed the pass, he was already on the early symptoms of HAPE. Good amounts of water here would have helped him release bicarbonates from his body, allowing him to acclimatise,” mentions Arjun. 

“However, water is an elixir at high altitude. Just breathing and existing at high altitudes dehydrates you every minute. The moment your body doesn’t get it, it starts reacting adversely. Lack of water does not aid in acclimatisation” he adds. 

| Learning 1: Despite being a small point, there are big learnings here. It’s imperative that every trekker carries 2 1L bottles for themselves. These must be filled before the start of every day’s trek. A good way to assess whether you’re dehydrated is by checking the colour of your urine every time. If it is too yellow, you know you’re not drinking enough. What is more important is to ration your water on your trek. Some trekkers finish their water too quickly and then remain dangerously thirsty for the rest of the trek. It is asking for big trouble.

| Learning 2: When you’re on a trek, even if you have 15 team members, it’s important to stick together, or at least be within seeing-distance of each other. This helps the Trek Leader keep an eye on the whole team, not having to spend all his attention on just the first / last member of the team. Giving attention to one team member can put the others in grave danger.

It has taken us years of persistence, but at Indiahikes, we have managed to improve the overall fitness of trekkers to an extent that everyone is able to maintain an average pace. There isn’t much distance between the first and last trekker. That way, the Trek Leader and guides are able to flit between all team members to check on them and ensure their safety.

What we have seen in this HAPE case is not uncommon. In fact, the most dangerous aspect of HAPE is that it often goes unrecognised or ignored, until it reaches a stage where an emergency evacuation is required. 

The biggest change we can bring about in Indian trekking is to be more aware of the symptoms of AMS and HAPE and know how to treat them. Better yet, prevent them.

So if you’re signing up for a high altitude trek, take time to assess the organisation you’re trekking with, read about them, call them and talk to them, talk to other trekkers who have been with them. If you’re trekking at altitudes such as 10,000-11,000 ft, this doesn’t matter so much. But it becomes a matter of life and death when you’re trekking to 14,000 – 15,000 ft. 

If you have any questions or observations, drop in a comment below. We’ll be here to answer an doubts you have.

Note: We are very thankful to Divyanshu, who agreed to let us document his medical case and understood the importance of the learnings we got from it. 

Here's a real life case study that takes you through the evacuation of a HAPE-affected trekker on the Hampta Pass trek in the Himalayas.

Expert Analysis on a HAPE Case in the Himalayas: A Real Life Case Study

In this post, I’m talking about something you would surely want to know — how to prevent altitude sickness.

I’d like to first put a disclaimer — there’s no fool-proof way of preventing altitude sickness.

All these methods I’m putting down will reduce your chances of getting altitude sickness. And from our experience, they’re worth it.

I’m going to break this down into three parts.

As you already know, altitude sickness occurs when your body has not acclimatised well enough to the altitude.

Giving your body enough time to acclimatise is the most effective way to avoid altitude sickness.

That’s why you’ll see that we have “acclimatisation days” on our high altitude treks like Rupin Pass, Roopkund and Goechala. These are days where you simply rest at a particular campsite, without too much exertion.

So, splitting your itinerary as much as possible and taking it slow is most effective in preventing altitude sickness.

However, keep in mind that the amount of time required to acclimatise is different for every individual. Ideally, you should increase your sleeping altitude just by 1,000 ft every day.

But the Indian Himalayas climb very quickly. The difference in altitude between camps is high, usually between two and three thousand feet. This is because there is either no place to camp in between or there are no water sources etc. 

We call this a “forced accent”. You are forced to ascend more than required.

This makes you more susceptible to altitude sickness.

There are certain medicines that help you acclimatise faster.

Trekkers and mountaineers all over the world use a medicine called Acetazolamide (Diamox) to acclimatise faster.

This medicine is a diuretic. Our founder wrote a detailed article about how Diamox works. Give it a read.

In a nutshell, though, this medicine helps you acclimatise faster by increasing your breathing rate.

So for most treks that gain altitude too quickly, taking a preventive course of Diamox really helps. Especially if your trek climbs above 13,000 – 14,000 ft.

In fact, even for those who suddenly go up to high altitudes, like those who drive or fly to Leh, we recommend Diamox.

| Dosage: Start with a dosage of 125 mg (half a tablet) every 12 hours 2 days prior to your trek (usually when you arrive at Delhi). Increase it to 250 mg (full tablet) every 12 hours from the day you get to the base camp and continue until you complete the trek.

| Side effects: There aren’t too many side effects of taking Diamox. You feel a numbness/tingling sensation in your hands and feet. You pee more often (which means the medicine is doing its job). Some claim that they get a bit of loosies after Diamox. Generally, a Digene takes care of this. 

Keep in mind that Diamox is a sulfa-based drug. If you’re allergic to sulphides, avoid Diamox.

As an alternative to Diamox, you could keep a strip of Dexamethasone tablets with you. This is a steroid and reduces muscle inflammation in the body. It does not help speed up acclimatisation per se. So if you get hit by AMS, take Dex as an alternative. The dosage is 4 mg every six hours. Avoid taking Dex as preventive medicine though.

While Diamox reduces the chances of AMS hitting you, it isn’t a fool-proof medicine. Even those who are on a course of Diamox can get hit by AMS. 

So it’s important for your body to do its bit to acclimatise.

It’s imperative that you prepare your body to function well with lesser oxygen. You can do this by simply increasing your cardiovascular endurance.

Cardiovascular endurance is basically the ability of your lungs, heart and blood vessels to deliver oxygen to your body. Naturally, someone with higher cardiovascular endurance has a higher probability of acclimatising faster to high altitude.

Although there’s no proven correlation between altitude sickness and fitness, we can talk from experience. On our treks, we have found that it’s usually unfit people who are more prone to AMS. When I’m talking about unfit, I’m not talking about overweight or underweight. I’m talking about plain physical endurance.

Funnily though, we’ve also seen that super-fit trekkers climb too quickly, and then suffer from AMS at the next camp. If you are fit, keep the ego behind. Climb slowly.

Are hydration, good diet and warmth helpful in preventing altitude sickness?

By themselves, none of them are strong points to keep altitude sickness at bay. But together, they help in the general well-being of your body which could reduce chances of altitude sickness.

Hydration helps your body function smoothly. You need at least 4 litres of water every day on a high altitude trek. Every time you urinate, drink enough water, to keep the colour as close to colourless as possible. If it is deep coloured you know you are dehydrated.

Even diet plays an equally important role. It’s important to eat well at high altitude, but not eat too much. We don’t recommend a diet that’s very high on protein. High protein is harder for your body to break down. That’s why we don’t serve meat on our treks. A low-salt, wholesome meal is what we recommend.

Warmth is especially required when you expect temperatures below 5 degrees (which happens on most Himalayan treks). You must especially keep your head, your core, your hands and feet warm. So having enough layers, a woollen cap, gloves and woollen socks are mandatory on high altitude treks. We have seen far too many trekkers in just one or two layers of clothes telling us that they are OK with the cold, that they are not feeling cold. They are simply being heroic, but their core body temperature is dropping.

Alcohol is a big NO, especially if you are not acclimatised to the altitude. I made a video on why it is bad for you a while ago. Watch it here.

Smoking anything is not good either because it’s directly inhibiting the capacity of your lungs to send out oxygen to your body.

Both drinking and smoking, cause dehydration and that’s the last thing you need on your trek!

Overexertion is again something you must avoid at high altitude. Don’t try to cram too much into your itinerary. Take it slow and give your body the rest it needs.

With that, I’m ending my 4-part series on altitude and the body. I hope these articles have left you more informed and that you’ll be able to identify and tackle altitude sickness if you see it.

I’m putting down the links to the previous articles here. Make sure you bookmark them for future use.

> What happens to your body at high altitude

> What is altitude sickness and how do you identify it?

> How to treat altitude sickness – AMS, HAPE and HACE

Prevention of Altitude Sickness with Diamox | How Diamox Works | Dosage and other ways to prevent AMS, HAPE and HACE

How To Prevent Altitude Sickness (AMS), HAPE and HACE

Today’s article is an important one – it’s about how to treat altitude sickness such as AMS, HAPE & HACE.

Before I get into medications and technicalities, I want to share a golden rule with you. And it is not about descending, which most manuals will talk about. It is something you must always remember.

When it comes to altitude sickness, the golden rule is to stop it in its initial stages. The later it gets, the more dangerous it gets, and it could even turn fatal.

To stop it in its initial stages, recognising the symptoms is key. 

In my last post, I told you how to recognise the symptoms of altitude sickness. If you missed my previous post, read it here.

With that in mind, let’s get on to treating altitude sickness.

You need to carry three absolutely essential Life-Saving Drugs (LSDs) with you on a high altitude trek. It does not matter if you are trekking alone or with a group.

These are Diamox, Dexamethasone and Nifedipine. In India, you can buy them off the counter in most pharmacies even though these are prescription drugs. 

Diamox is a diuretic. To put it simply, it helps speed up acclimatisation. 

Dexamethasone (Dex) is a steroid. It prevents your body from releasing substances that cause inflammation. That’s how it helps temporarily treat edema. 

Nifedipine is a drug that reduces your blood pressure. You use it only if you have HAPE. 

Now let’s see how we can treat altitude sickness i.e. AMS, HAPE and HACE with these LSDs. 

1. Let’s start with the easier one, Acute Mountain Sickness (AMS)

AMS is the most common form of altitude sickness we see. It starts off with relatively mild symptoms. But if left untreated, it gets severe and could form into either HAPE or HACE. 

You’ve got to absolutely treat it when it’s mild (no rocket science there).

I’ll let you learn about AMS symptoms directly from someone who was hit by AMS. Read this story well because it is not exactly what you’ll expect. This happened last week.

It’s the story of my colleague Suhas, who was recently on exploration in Uttarakhand.  

He says, “We were at the first campsite, at around 8,500 ft. We had had a long day of trekking, mostly ascending and I was exhausted. Although I didn’t feel like eating much, I took two small rotis (which I couldn’t finish). After eating just one and a half roti and drinking some water, I went to sleep.

In my tent, I kept feeling very quesy and at around 10.30 pm, I finally stepped out of the tent and threw up. The uneasy feeling stayed with me all night and prevented me from sleeping. As I tossed and turned in my sleeping bag, I kept debating whether I should wake somoene up, but I didn’t. 

The next morning, after breakfast, I was again not feeling comfortable. I threw up everything I’d eaten. On the trek, when there was an ascent, I started to feel very tired. I was unable to carry my backpack. It was taking me almost double the time that I would normally take to cover the distance. Throughout all this, I never told anyone my symptoms. Finally, it was Arjun and Sandhya who noticed that all wasn’t well with me.” 

What Suhas has said here are classic symptoms of AMS – uneasiness, vomiting, lack of sleep, fatigue, lack of appetite. Notice how he never told anybody about his symptoms? This is also typical behaviour of someone who has been hit by AMS. Notice, also the rather low altitude.

He didn’t have a headache even for a minute! Most trekkers actually wait for a headache to confirm if it’s AMS. That’s not wise.

So here’s what you need to keep in mind. Drill it in. AMS can climb onto you in different ways. Not all the symptoms may show up (especially headache), but some of them will. Remember, the best way to treat altitude sickness is to recognize it early and take all steps to prevent it from getting worse.

Look out for feeling generally uneasy. Especially a bad feeling in the stomach and a pukey feeling. Look out when your pace reduces (and you’ll know it yourself, but don’t fool yourself thinking you’ll get over it). 

Do also keep an eye out for headache’s as they are an indicator of possible AMS.

You need an exceptionally sharp eye to spot these things in others. But if you have AMS yourself, you should be able to identify it. You just need to be aware of the symptoms.

Another way to tell if it’s AMS is if you have a pulse oximeter handy. You’ll find that oxygen levels have dropped. Anything below 85 is usually a low reading. And 83 is not 85. If it is below 85, take steps. 

Now, here’s the important thing. Don’t go trusting the pulse oximeter too much. It is, at the end of the day, just a device. Trust your symptoms more. That’s the only thing we go by in the mountains.

The first thing you must do if you have AMS is starting a curative course of Diamox.  

(I’m using “curative” here as this course is different from a “preventive” Diamox course. I’ll tell you more about that in my next post).

Take 250 mg of Diamox (one tablet). Drink 500 ml of water and rest for an hour. Even if you are mid-trail, try and rest for an hour. Resting is imperative because any kind of exertion depletes your body’s oxygen content.

After this medication, this is what could happen. In an hour’s time, your symptoms may reduce, but may not completely disappear. 

So move to your next camp. Take the rest immediately. After 4 hours (of the first tablet) take another dose of Diamox (250 mg). Keep yourself well hydrated. Avoid exerting yourself. Don’t go on sightseeing walks. 

In all probability, it is going to be evening by the time you have taken the second dose. 

The next few hours are critical. You want to take all the necessary steps before night-fall. If you feel better within two hours of your second Diamox dose, then your body has started to acclimatise. But continue to be on a course of Diamox (250 mg), ever 12 hours for the rest of your trek, starting that night. If you are not feeling better, do not panic. We go to the next level of medication. 

At around 9.00 pm take another dose of Diamox (again, 250 mg). Also, take 1 mg of Dexamethasone (we’ll call it Dex from now on). Dex is going to help reduce inflammation in your body that causes these altitude sicknesses. The Diamox and Dex combination will help you sleep better. 

The next morning, you have to make a decision. 

If you have slept well and feel better with none of the uneasiness, your body has acclimatised. 

Continue your trek but be on a course of Diamox (250 mg) every 12 hours starting that morning. End the course only after you complete the trek.

Remember, it is important, to be honest with yourself at this stage. Continuing on the trek while feeling uneasy can lead to further complications. Additionally, don’t worry about your money, given the circumstances you will be allowed to come back for the same trek for free. (Refer to our trekking policy).  

If you still have a lingering sense of uneasiness, then it is time to accept that your body is not acclimatising despite medication. 

Continue to descend until you have got yourself to an altitude of around 8,000 feet. This may take time. But the good thing is that with every 1000 feet that you descend you’ll feel better. 

A word of caution. Just because you start feeling better, do not stop your descent. An abrupt stop can make your AMS come back.  

Now, that’s how you treat altitude sickness such as AMS. It really isn’t difficult. Monitoring symptoms is everything! 

2. How to treat High Altitude Pulmonary Edema (HAPE)

The symptoms of HAPE are very distinct, but you could miss them if you’re not paying attention. 

There are two things you should be able to catch – cough and breathlessness.

If you have HAPE, you’ll cough a very dry cough every now and then. 

Next, notice how you walk around the campsite. If your movements are laborious or your breathing heavy, it is a big warning shoutout. You may even notice yourself breathing heavily while sitting. Anything will tire you. There is always a feeling of fatigue.   

These are the initial stages of HAPE. It is during these stages that you must recognise HAPE and start treatment immediately. 

I hate to say it but if there is any symptom beyond this – like the rattling sound from the chest, or blue-ing nails and lips, then HAPE has advanced. And HAPE escalates very quickly.

To treat altitude sickness such as HAPE, you need Diamox and Nifedipine. (I’m writing this assuming that you may not have canned oxygen with you as our Trek Leaders do. Supplementary oxygen can also work wonders while evacuating a HAPE patient.)

When you have identified HAPE, take 500 mg of Diamox immediately (even if you have taken Diamox a few hours earlier). We are talking about two tablets.  

Follow it up with 20 mg of Nifedipine. In India, we mostly get 10 mg tablets of Nifedipine. So take your first 10 mg, wait for 20 minutes and then take the next 10 mg. 

This will let the tablet settle in slowly. Within 30 minutes of the second 10 mg, you should be able to breathe easier. 

Nifedipine reduces the pressure in your heart and blood vessels. If you remember, I had told you that HAPE occurs because of high pressure around the lungs, when the air sacs start accumulating fluid from your blood. 

Nifedipine eases out the pressure around your lungs, giving it some space to breathe.

With these two tablets in your system, start descending. You should try to lose as much altitude as possible over the next three hours. 

If you cannot reach around 8,000 ft even after six hours, repeat the dose of 500 mg Diamox and 20 mg Nifedipine and continue descending.

You’ll be tired, but it’s a matter of life and death. You need to be at a lower altitude. 

Most trekkers recover upon reaching lower altitudes. You’ll recover too.

Again, it’s very important to remember that the best way to treat altitude sickness is by keeping an eye out for your symptoms and taking the necessary steps such as descending to a lower altitude. You do not want HAPE to escalate.

3) How to treat High Altitude Cerebral Edema (HACE)

The key for treatment of any altitude sickness is early detection. The earlier you catch the symptoms the faster you can take steps to ensure the altitude sickness is controlled. 

How to recognise symptoms and treat altitude sickness, Acute Mountain Sickness, High Altitude Pulmonary Edema & High Altitude Cerebral Edema

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