The Girl Who Could Not Remember Crossing Rupin Pass: A HACE Case Study

This is one of the oddest cases of Acute Mountain Sickness (AMS) we have had on the Rupin Pass trek. We say this because AMS is not uncommon on treks like Rupin Pass that rise above 15,000 ft. But this case was one of a kind. 

Please note that what follows is a factual documentation of what occurred on the trek and the remedial actions that were taken. This information has been published with the trekker’s consent.

Here are the facts of the case as we know them.

What we knew of Sunaina’s fitness before the trek: Sunaina Narayanan (name changed) did not submit her fitness screenshots to her Ground Coordinator, Vishnu. Her experience of trekking to Markha Valley in Ladakh, she claimed, was sufficient proof of her fitness.

What we observed during the trek: Her pace was slow. She was always among the last five people. She was struggling with her backpack and even told our Trek Leader that she had a swelling on her tailbone. Seeing her struggle with a backpack that was over 10 kg, our Trek Leader advised her to offload her backpack. She refused.  

Diamox course: She was not on a preventive Diamox course.

Bottomline of the case: Mild case of High Altitude Cerebral Edema (HACE) on the seventh day of the trek.

Details of the Case, as told by our Trek Leader Geet

Day 1: Arrival at Base camp, Dhaula. Normal vitals.

Sunaina came to Dhaula sprightly and determined. She had the confidence of an experienced trekker. She had done Markha Valley before, which climbs to 17,000 ft at its Pass of Kongmaru La and 15,000 ft  at Ganda La.

What concerned me was that her backpack was heavy. We weighed it at the base camp and it was over 10 kg. Ideally, a backpack should be just around 7 – 8 kg. She refused to offload her backpack when I suggested it.

Her vitals were normal. Her Blood Pressure (BP) was slightly low at 100/67. It wasn’t below the lower limit, but was still worth noting. Her oxygen readings were above 90, which is good. When the oxygen saturation readings are below 85, that is when we step in.  

Nevertheless, I decided to keep an eye on her because of the low blood pressure.

Day 2: Trek to Dhaula to Sewa for 9.5 km. Gastrointestinal issues show, nullified after food and medication.

The initial climb from Dhaula is usually hard on trekkers. This is when their legs are just getting used to the terrain and the ascent. It is a stiff climb until you cross the village of Dhaula, after which the trail becomes gentle with short climbs. It drops to a descent on the way to Sewa. Throughout, I could see Sunaina among the last set of trekkers.

Once we reached Sewa and trekkers set out to explore the village, I found Sunaina inside her room. She had headache and nausea.

She hadn’t eaten anything since lunch. That was 12.30 pm. It was now 5 pm. I knew she would feel better after eating. But she refused to eat when I asked. She wanted to sleep it off.

On a trek, it is important that you eat on time. Hunger is a sign of a healthy body. If there is loss of appetite, especially on a high altitude trek, it is a symptom. At Sewa’s altitude of 6,300 ft, I didn’t want to take it as a symptom of altitude sickness. (Anything above 7,000 ft is considered ‘high altitude.’)

In around half an hour, she started throwing up. The fourth time she threw up, I lost a bit of my patience and insisted that she eat something. She finally agreed to have one thepla (flat bread made of wheat flour), after which I gave her Eno. I also gave her half a paracetamol for her headache.

The food had made a difference – her headache had vanished. Half an hour after this, I saw her go outside and click pictures with her camera.

Her oxymeter reading was above 90 – a good reading.

Day 3: Trek from Sewa to Jiskun of 11.5 km. Normal vitals. No symptoms.

Day 4: Trek from Jiskun to Udaknal of 11 km. Normal vitals but with signs of struggle.

She was clearly struggling with her backpack. She told me that she had a swelling on her tailbone. I asked her to offload her backpack. If a trekker is struggling too much with his/her backpack, offloading is the wisest thing to do.

But she refused to offload her backpack. She wanted to tough it out.

Her oxygen reading on arrival at Udaknal was 88/90, but it was still well within the danger cut off. Her reading went comfortably above 90 in the evening.

Day 5 ,6 and 7: Trek from Udaknal to Lower and then Upper Waterfall. Rest day in between. Normal vitals. No symptoms.

Day 8: Upper Waterfall campsite to Rontigad via Rupin Pass (15,380 ft). Sunaina’s condition deteriorates rapidly

Sunaina had not had a good breakfast before starting the climb to the Pass. But I seemed to have missed an indicator that all was not well with her. My attention was largely on two other struggling trekkers. I was about 30 minutes away from the rest of the group as I was with these two trekkers.

When I caught up with the rest of the group at the Pass, I saw that Sunaina was panting hard. She had trekked up the gully with the Assistant Trek Leader, Abhishek.  

Usually, at the Pass, I sit on the rock outcrop and observe trekkers to ensure they are all okay.

That’s when Sunaina caught my attention. She was sitting on a rock, camera in one hand and water bottle in the other. She was neither taking photos nor drinking water.

She wore a blank, dazed expression.

I approached her and asked her thrice how she was doing. She did not respond. I shook her lightly.

The fourth time, she said that she was blacking out. Abhishek told me that she had been saying she was blacking out while climbing the gully as well.

I took out my oxymeter and checked her oxygen — it had fallen down to 72/140!

That was alarming!

And then, if her oxygen readings weren’t alarming enough, she started trying to remove her warm layers. She said she was feeling suffocated and hot. This was at 15,380 ft, where we were surrounded by snow and the temperature was in single digits.

This was a clear sign of HACE, an advanced form of Acute Mountain Sickness. Her blacking out, her irrational behaviour and weakness clearly pointed to High Altitude Cerebral Edema (HACE).  From being completely normal the night before, her condition had rapidly deteriorated.

HACE climbs quickly and can turn fatal in few hours. Descent is the only cure.

We didn’t have time.

We had to descend her quickly. I asked other trekkers to pack her bag and take it with them. I gave her 250 mg Diamox and started readying the oxygen cylinder. Meanwhile, Abhishek started rushing her down the slope.

On the way down, she gave up. She reached past the second slide and sat down. She told me she wanted to go to sleep right there.

This was when I started administering the oxygen. I started at 4L/min. She wasn’t responsive. I took it a notch higher to 6L/min. She started responding. At this point, she mentioned that she had a very bad headache.  

HACE is essentially an accumulation of fluid in your brain. Your brain swells up against your skull, causing a very, very bad headache. Now, it was time for a bigger boost to buy us time.

We gave her 4mg Dexamethasone. Dexmethasone is a steroid. It would reduce the fluid accumulation in her brain, thereby reducing the swelling. It would give us time for descent.

We started descending again. However, she was too weak to walk. I continued administering oxygen to her at 6L/min for another 40 minutes till we reached the end of the snowline.

We finished an entire oxygen cylinder.

I readied the next oxygen cylinder that our technical guide had been carrying. I had a feeling we may have to descend her all the way down to the safe altitude of Sangla (8,600 ft).

But with loss of altitude,  she was starting to walk better. Her headache had slightly reduced. I made sure she had something to eat.  

On reaching Rontigad, she was looking much better. She lay down but could not sleep. The adrenaline of Dexmethasone was still in her system. She still had a mild headache. I gave her half a paracetamol for headache and the welcome drink we usually give our trekkers. I asked our cook to make dal rice for her. While she was improving rapidly, I could not afford to relax.

She was not yet out of danger.

Working backwards, if she was affected by HACE at Rupin Pass, then its onset had happened much earlier – most likely at Upper Waterfall. This meant, to be safe, she had to be descended to an altitude lower than Upper Waterfall. Her body was not acclimatised to that altitude. But Rontigad is at the same altitude as Upper Waterfall – 13,100 ft. 

On the flip-side, her oxygen saturation was 88/90, well within the cut off. Her BP was normal at 114/ 80.

Before going to sleep, she mentioned that she could not remember anything from pass until lunch. While that is common for a HACE victim, it is still an astonishing thing to hear!

I checked her oxygen again late in the night at 1.45 am. It had risen to a nice 92/88. It was safe for me to go to sleep.

Day 9: Trek from Ronti Gad to Sangla

With the rapid loss of altitude, she was back to normal.

What do we take away from this Case study?

Sandhya Uc, Cofounder

There a few things I noticed in this case: over-exertion being the primary one. You must be able to understand your body’s limitations and work with them. Over-exerting yourself on a high altitude trek is just going to deplete your oxygen count.

The second is: pay attention to your appetite. Loss of appetite on a trek is not normal. It is a symptom that all is not well and must be treated as such.

Sunaina’s symptoms, which we missed, must have started showing up at Upper Waterfall campsite. By the time she reached the top of Rupin Pass, her condition had escalated from AMS to HACE.

From here, our Trek Leader took necessary actions really quickly. With HACE, which turns fatal in few hours, quick, rapid action is what saves lives.

Ideally, Dexmethasone should have been administered at the Pass itself along with Diamox. However, by administering oxygen quickly, and a boost of Dexmethaosne later, she was able to recover by the time they reached Rontigad. I would call that lucky, since Rontigad is almost the same altitude as Upper Waterfall, where she must have been affected.” — Sandhya Uc, Co-founder

So that’s the story of the girl who was affected by HACE. This is the second case study we have documented on our website. You can find the first case study here.

Feel free to drop in a comment below with your thoughts. We invite AMS-related comments and discussions. Please refrain from criticising any trekker or trek leader in the above case study. This is a factual account and is only meant for knowledge sharing purposes.

If you would like to contribute your personal experience of altitude sickness to our database, then please fill the following form. We’ll get in touch with you.

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Aswati Anand

Aswati Anand is a journalist in love with the Himalayas. She is interested in stories of resilience from difficult terrains and sustainable living. When not mooning over the mountains, she can be seen doodling in her sketchbook.

10 thoughts on “The Girl Who Could Not Remember Crossing Rupin Pass: A HACE Case Study

  1. This is a big learning for me as an amateur trekker and will definitely help me prepare better for my upcoming treks. I appreciate the spirit of India Hikes to share the detailed case study. Thanks a lot!

    Quick question: How can I procure Dexamethasone and Diamox ? Are they available across all local pharmacies and do I need a prescription to get these drugs ? Any specifics on the dose/ quantity/ strength to keep handy during a high altitude trek ?

    1. Hi, yes these can be bought without any prescription. Start on a dosage of 125 mg every 12 hours 2 days prior to your trek. Increase it to 250 mg every 12 hours from the day you get to the base camp and continue until you complete the trek. Hope this helps.

  2. Very nice learning from the incident. Good that you guys are sharing it.

    It is always my concern. Now a days most of the people take things for granted. They think that fitness remains same in a years time without doing anything to improve it or even to maintain it.

    In June 2017, I went to Pangarchulla (not with IH)and was surprised to see people who just showed up because they have to tick off something from the bucket list without any preparation/knowledge of dangers or anything for that matter.
    Leave alone love and respect of the mountains!!
    That resulted only me and one more guy (whom I literally dragged) being at the summit. (we were 13 to start with!!)
    God save these people.. I hope people become more respectful about the mountains..

  3. Appreciate the commitment of IH to safe trekking! This was very, very informative. I would hope that all trekking / adventure organization and guides are as informed about Altitude Sickness and take as much precaution as you guys do. Thanks for sharing.

  4. I am curious to know how you administer oxygen to someone who is walking and not in a position to carry the cylinder. Is this a portable cylinder? Who was carrying it while she was walking? Just curious.

    1. Hi,
      HACE is a very rare occurrence. It is a very advanced form of Acute Mountain Sickness (AMS). The most effective way to avoid it is to be aware of its symptoms. You must also watch out for AMS symptoms at all times that you are at high altitudes. Being able to treat AMS at an early stage will go a long way to prevent HACE and HAPE. You can read more about AMS here.

    1. Hi Mayur,
      You can carry one, but it will add to the weight of your bag. If you are trekking with Indiahikes, all our Trek Leaders carry portable oxygen cylinders and our campsites are equipped with bigger oxygen cylinders. So, it is not required that you carry one of your own.
      We do not have oxygen cylinders for renting or on sale.

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