Altitude Illness while Trekking/Climbing in Nepal

Just like cruising at 10,000 meters requires cabin pressurization, walking to 5,000 meters requires a spacesuit, or more realistically acclimatization, your body’s very own cabin pressurization system. So, unless you have the genes of the extinct Denisovans, which give Sherpa their unmatched capacity at high altitudes, you are better off taking it slowly along with the use of preventive medication.

Acclimatization:

What to do for Acclimatization?

  1. Above 2,500 meters limit your daily ascent to 1000 meters between night stops.
  2. Have a rest day every 3 days or 1,500 meters ascent, whichever comes first.
  3. Drink 4 liters of fluid every day. ORS is highly recommended. Yes, you will be urinating much more frequently, but remember you would be peeing almost as much even without the 4 liters.
  4. For the Everest trek starting at Lukla. Some might require the preventive use of acetazolamide (Diamox) in addition to the aforementioned points. Dosage: 125 mg twice daily initiated a day before the climb and continued until descent starts or after 3 days at target altitude for an extended stay. For children below 16, the suggested dose is 2.5mg/kg twice daily.
  5. In the case of allergic reaction to acetazolamide, dexamethasone can be used. Dosage: 4 mg every 12 hours starting with the day of ascent and continued until descent begins. Dexamethasone should not be used for more than 10 days and should not be used for children.
  6. If the prior history of High Altitude Pulmonary Edema is present, nifedipine must be used preventively. Dosage: 60 mg daily, divided into smaller doses for sustained release, starting the day before ascent and continued until descent begins or 5 nights at target elevation.
  7. Make sure you are warmly clothed at all times. Carry a fleece in your day pack and make use of your Windstopper.

What NOT to do for Acclimatization?

  1. Do not continue ascent with a headache or any other sign of altitude illness.
  2. Avoid alcohol at all costs.
  3. Do not take sleeping pills.
  4. Do not sleep during the day and generally stay active.
  5. Avoid heavy exertion.

The fact that there is about half the amount of oxygen at 5,000 meters above sea level, gives your body a long to-do list, so you can continue to enjoy your vacation. And simply put, the things that your body does for you are called acclimatization. Help it by doing your part, you know it is your body after all.

  1. Your body will increase the pulse rate and breathing rate/depth. Given that your heart is already working harder, do not push it by exerting yourself.
  2. Your body will let go of non-vital fluids by increasing urination. Do your part by replenishing the fluids.
  3. Your body will thicken blood through fluid loss and increased red cells production. This increases the danger of internal blood clots. Do your part by drinking enough and remaining active during the day.
  4. Your body might go through a phase of periodic breathing which will disturb sleep. This is normal. Do your part by not suppressing this response through sleeping pills.
  5. However, nothing will acclimate you above 6,000 meters.  Do your part by limiting the length of stay and/or using supplemental oxygen.

Above everything else, remember that acclimatization is a process that takes time and depends on a wide variety of factors. And the single most important factor that causes sickness has got to be cockiness. The fact that you are an ultra-athlete or in the SAS is irrelevant to the mountains. Be kind to your body by giving it time and listening carefully to what your body is telling you. And we cannot stress this more but DO NOT ever think of ascent with any symptoms of altitude sickness.

Acute Mountain Sickness (AMS) and High Altitude Cerebral Edema (HACE)

AMS is a bloody ‘hangover’ that can quickly progress to HACE, a fancy term for a lot of water in your brain.

AMS presents itself as a headache along with one or more of the following: nausea/vomiting, fatigue, dizziness, or sleeplessness. These will show after you ascend to an altitude your body isn’t comfortable with. That is the reason why you have to take it slow and listen to your body. Now look at the symptoms, various factors might be causing them other than the altitude. A ‘hangover’ may be an actual hangover or dehydration or possibly a lack of essential salts. That is why drinking enough water/ORS and avoiding alcohol is important. Fatigue and dizziness can be the result of exhaustion or exposure. Hence the need to avoid exerting oneself and proper clothing. AMS is that much easier to come to terms with once you have ruled out confounding causes through proper prevention.

 

Mild AMS                                                                       

AMS usually develops slowly, almost imperceptibly. If all you have is a mild headache along with one or the other symptoms also of mild intensity, this is just a warning shot. Heed it. Stop ascent, rest, drink water/ORS, and maybe some snacks. Also, take a mild analgesic (paracetamol or ibuprofen) or antiemetic (ondansetron) if needed and see how it goes for the night. Do not climb until all symptoms have resolved.

Moderate-Severe AMS

If however, you have a severe headache along with one or more of the accompanying symptoms of moderate-severe intensity, it is time to get into treatment mode. And the most effective treatment is immediate descent. Even a 500-meter drop can be helpful, but sometimes 1,000 meters might be necessary. Ascent can be initiated after symptoms resolve completely.

HACE

In extreme cases, severe AMS can give way to HACE which is characterized by ataxia, confusion, and altered consciousness. It is now time to say goodbye to the mountains and go into rescue mode. Descend immediately at least 1,000 meters.  Supplemental oxygen must be used until the evacuation helicopter arrives.

High Altitude Pulmonary Edema (HAPE)

HAPE means water in your lungs and while uncommon, it is fatal, much more so than AMS and HACE. It is characterized by difficulty breathing at rest, cough, rapid heart rate, rapid shallow breathing, and possibly blue skin color. Immediate evacuation is necessary and the patient needs to descend at least 1,000 meters. Supplemental oxygen must be used if available.

Environmental Hazards while Trekking in Nepal

Khumbu Cough

As you go higher, you will cough that much more and at times the coughing can get so violent that it hurts like hell. Surprising as it might sound, there is no consensus on the cause or treatment of this problem. Bronchial irritation due to the cold dry air perhaps has something to do with it. Breathing through the mouth is also thought to exacerbate the situation. The best way to avoid the Khumbu cough is to breathe humidified air by using a mask of some sort. A buff is great for this purpose and a handkerchief will do just fine. Just make sure it isn’t too tight. Also, make sure to dress warmly and remember to protect your neck and head from the cold. Candies or cough drops will help.

Diarrhea

Diarrhea is a common problem among travelers. Make sure you eat freshly cooked proper food according to your dietary requirement and drink clean water to avoid the problem.

Knee problems

Use trekking poles. You will walk much better. Another very important thing is to descend slowly. After the labors of an uphill climb, even a small stretch of downhill seems like a godsend sign to walk faster and reclaim some of the lost egos. But do not fall for it (pun intended). Please go downhill only a little bit faster than your uphill pace. Your knees will love you for it.

Sunburn

Serious sunburn not only looks but must be treated as a second-degree burn. And that was what the buffs were covering. But as we all know it is easily preventable. There is, however, a susceptible group that should be cautious: redheads, blue-eyed blondes, individuals of northern European descent, and children. Another susceptible group seems to be those that are used to seeing snow and mountains in their home country and usually get by without much prevention there.

The main difference in the Himalayas is the altitude which results in that much more UV rays and your usual regimen might not cut it here. Let us suggest one:

Choose an SPF 30 sunscreen that is effective against UVA. 30 might sound like a small number given that there are sunscreens with SPF ratings of 100, but believe it will be more than adequate. If you feel like it, push it to 50 but beyond that, it is just a waste of money. The UVA bit, however, is very important, not to avoid sunburns but to avoid long-term skin damage. Your money is better spent on UVA protection than high SPF ratings.

Make sure you are done applying your sunscreen by the time you sit for breakfast as it is very important to do so at least half an hour before exposure. And don’t forget your ears and neck. However, the skin above your eyes is better off without sunscreen because sweat will wash the cream into your eyes irritating. Leave it to your sunglasses to protect that bit of skin.

Later on, before you sit for lunch wash your face and apply the sunscreen again. Since sweat will wash off sunscreen anyways reapplication is very important while SPF rating isn’t. If you have been sweating too much consider a more frequent application.

Other ways to protect against sunburn are creams based on titanium dioxide and zinc oxide. Also, a sun hat is great.

Snow Blindness

The term snow blindness is misleading. While snow is important, it is the amount of UV that is the deciding factor. This is perhaps one of the reasons why some people who come from lowland areas that see a lot of snow, usually make light of this. And the high amount of UV in the Himalayas takes its toll. Hence, sunglasses with good UV protection is necessary and you should put them on even on overcast days. Also, make sure the glasses offer sung and complete protection for the eyes. Straps that hold the glasses are highly recommended as it makes the job of losing the glasses very hard if not impossible. If you have a penchant for misplacing things, consider getting an extra pair.

In case you are blinded, know that it will pass on its own in a few days. Meanwhile, avoid exposure to light and do not rub your eyes. Painkillers and eye drops will give some relief. Localized anesthetics, however, must be avoided.

Blisters

Make sure your boots are a good fit and break them back home. A thin inner sock is also very helpful for preventing blisters. Check your feet at the earliest sign of a hotspot, and cover the area with tape or moleskin.

If you are judicious, you will never have to go through the hassle of breaking, sterilizing, and bandaging a blister.

Chafing is another problem that is encountered by many. The most suspect parts are the inner thighs and collarbone area. Moleskin will work great if you are susceptible to inner thighs chafing and a pair of socks tucked under the strap of your bag will take care of your collarbone. Calamine lotion works wonders in healing the skin once chafing has developed.

Avalanches

The Annapurna Base Camp Trek is one of the few treks in Nepal in which avalanche is an issue. While relatively rare, there have been incidents. Precautionary measures are perhaps the most important reason why the casualty rate is so low. Unlike media depictions which might have given the impression that avalanches can occur anywhere anytime, certain avalanche gullies funnel avalanches and most of them usually occurs after 10 am. The most active area for avalanches in the Annapurna Base Camp Trek is the section between Dobhan and Machhapuchhre Base Camp. And even within this section, certain gullies are most dangerous. The easiest rule of thumb is that when you see an awesome waterfall or a stream on your side of the trail, do not loiter around that area. Snow gets funneled in the same way as water and hence streams and avalanches generally follow the same route. It is also a good idea to cross avalanche-prone areas before 11:00 am. This is especially important if there has been fresh snow or rain recently. In case you face an avalanche there are certain things you can do to increase your chances of surviving:

  1. Create an air pocket around your face by holding your arms in front of your face. No matter what the situation is going to be, you will need air.
  2. If you are near the surface, swim, or at least try to. You will stay near the surface that way.
  3. When the whole action stops, take a deep breath and try to raise your arms, before the snow hardens. Once the snow hardens, it will be as hard as concrete, restricting all movement.
  4. Stay as calm as possible. Don't yell. No one will hear you. Also, unless, you are very near the surface, it will be impossible to dig yourself out. So keep your fingers crossed until help arrives.

Frostbite

Frostbite is irreparable and mountain weather is unpredictable. Get a good pair of boots. Running shoes will not cut it. Make sure to put on warm clothing and ensure that they are dry. Be sure to update yourself on the weather from lodges and other trekkers. If the terrain is heavily snowed over it might make sense to wait for other groups to pass through. Once the trail is broken, it will make both walking and navigation easier.

Frostbite is the body’s response to protect vital organs in the face of rapid heat loss, by limiting the amount of blood circulation to the peripheries. As such, the signs of frostbite will first appear in the parts furthest from the heart: toes, fingers, nose, cheeks, and ears. If you feel numbness in fingers and toes you can increase blood circulation to these parts by moving them. Also adding a layer of clothing might help. Cover your ears, nose, and cheeks. But your primary objective should be to find the warm shelter of a lodge as fast as possible. Immersing the extremity in lukewarm water (about 40 degrees C or 105 degrees F) will be very helpful. This treatment is especially important if the numb parts have started to turn whitish and waxy. Do not rub such parts. Continue with the treatment until the whitish parts start to turn red. It can be very painful though.

In severe cases, evacuation must be considered.

Carbon Monoxide Poisoning

While it doesn’t happen often, there have been cases of carbon monoxide poisoning. Ensure proper ventilation before using a heater in your hotel room. Ditto with heaters used inside tents. Dining halls in lodges are rather porous and usually safe.

Hypothermia

It is colder in the mountains than your body’s capacity to cope. Hypothermia results when your body cannot compensate for heat loss and results in shivering and mental confusion in mild cases to a silent heart in more severe ones. Hypothermia also exacerbates many other altitude and cold-related illnesses.

Follow the dress code for mountains and you can leave all dangers behind. And the dress code is layers. Synthetic thermal underwear works great as a base layer. Avoid cotton like the plague for once wet from sweat, it makes things uncomfortable by losing its insulating properties and increasing heat loss through evaporation.

A light fleece works great as the next layer and tops it off with a wind and waterproof jacket. Have a down for evenings and mornings at night stops. The great thing about layering, in addition to insulation, is the ease with which you can shed and add clothes. This is very important as it gets hot while walking and the moment you rest you will feel cold. Add to this the drastic fluctuations in temperatures that are the hallmark of the mountains.

As such the dress code is not just suggestive but necessary.

Pre-existing Conditions to consider before Trekking in Nepal

The following list is not exhaustive and it is certainly no replacement for a thorough consultation with a trained professional. It is simply presented as a reminder to formulate a personalized plan in consultation with a specialist.

When you plan for the mountains with a pre-existing medical condition hope for the best, but be ready for the worst. Have enough medications and some more. Make a kit with clear labels and keep it in your hand-carry during flights. Have an official letter from your doctor about your condition, medication, and emergency contact. Also, if you intend to travel in a group through a travel agency, consider the fact that there is very limited scope for changes in the original itinerary. You might be better off traveling with your close circle who understand your condition and are open to itinerary revisions. Also, make sure you are frank about your condition with your travel agency and insurance provider.

Avoid High Altitude if you have these pre-existing conditions

  1. Sickle cell disease- Increased risk of sickle cell crisis.
  2. Pregnancy- First three months put the fetus at high risk.
  3. Pulmonary hypertension- High risk of High Altitude Pulmonary Edema (HAPE)
  4. Obesity Hypoventilation Syndrome- High risk of Acute Mountain Sickness, High Altitude Pulmonary Edema (HAPE), and heart failure.
  5. Carotid Surgery- Difficulty/Disability to increase airflow in response to low oxygen content. It might be possible to undertake a trek depending upon the kind of surgery. A thorough consultation is required.
  6. Congenital Heart Problems- High risk of High Altitude Pulmonary Edema (HAPE).

Take Extreme Precautions if you have these pre-existing conditions

  1. Obstructive Sleep Apnea- Travel with a CPAP machine. Supplemental Oxygen required.
  2. Diabetes- Take readings more often and manage blood sugar levels religiously. Make sure your glucose meter will work in extreme cold and high altitudes. Dosage changes might be necessary. Make sure you know the guidelines.
  3. Chronic Obstructive Pulmonary Disease- Supplemental oxygen might be required. Severe cases should not travel to high altitudes. Bronchodilators are helpful.
  4. Neuromuscular Diseases- Depends upon the exact nature of the disease.
  5. Chronic Kidney Disease- Makes it hard to maintain fluid, electrolyte content. Hard to acclimate to low oxygen content. Increased susceptibility to HAPE.
  6. Cystic fibrosis- Supplemental oxygen, antibiotics, and physiotherapy will help. Depends upon the severity.

Take Precautions if you have these pre-existing conditions

  1. Radial Keratotomy- Carry corrective glasses. While laser surgery doesn’t cause problems, avoid high altitudes for 6 months after the surgery. Carry corrective glasses.
  2. Heart Diseases- Depends upon the type and severity of the problem. Ascend slow and acclimatize well. Take extra days if required. Use Diamox preventively.
  3. Arrhythmia- Supplemental Oxygen might be required. Avoid exertion.
  4. High Blood Pressure- Regularly check blood pressure. Take regular medication and do not change the dosage without consultation.
  5. Anemia- Reduction of physical fitness. Iron supplements might help in certain cases. High altitude performance is highly dependent on the type and severity of anemia.
  6. Obesity- Slightly higher risk of AMS.
  7. Epilepsy- Make sure members of your group know what to do in case of a fit.
  8. Peptic Ulcer- Increase in gastrointestinal bleeding. Avoid alcohol, smoking, caffeine at high altitudes. People with peptic ulcers should avoid dexamethasone unless for treatment of HACE/HAPE.

Don’t worry about these pre-existing conditions

  1. Asthma- Continue with usual treatment. You might do better at high altitudes.
  2. Migraine- frequency, and severity can go up. Continue with regular medication.

Immunizations to consider before coming to Nepal

Being a very welcoming country, nobody will bother with your immunizations before issuing a visa to Nepal. But the good gesture might not always work out for your benefit.

Important immunizations to get before trekking in Nepal

  1. COVID 19
  2. Hepatitis A
  3. Typhoid Fever
  4. Chickenpox
  5. Influenza
  6. Tetanus

An Immunization List for hypochondriacs ;)

  1. Hepatitis B- Get 3 shots for this if your itinerary involves lots of blood work and casual sex.
  2. Japanese Encephalitis- Only if you intend to stay more than a month in Nepal during Aug-Oct.
  3. Meningococcal meningitis.
  4. Cholera- Unless you intend to drink the filthiest water you can find, you can pass on this one.
  5. Polio.

Immunizations to consider before coming to Nepal

Being a very welcoming country, nobody will bother with your immunizations before issuing a visa to Nepal. But the good gesture might not always work out for your benefit. Nobody in their right mind imagines that they will get bit by a rabies-infected dog while planning a trip to Nepal. But a clinic in Nepal took care of 118 such cases among travelers over seven years. And that is just 1 clinic. The bottom line- shit happens and it is better to think, ‘That could be me’ rather than ‘Oh Lord, Why me?’.

Important immunizations to get before trekking in Nepal

  1. COVID 19
  2. Hepatitis A
  3. Chickenpox
  4. Typhoid Fever

 

Recommended Immunizations to get before trekking in Nepal

  1. Measles-Mumps-Rubella
  2. Influenza- This vaccine is updated annually and is highly recommended. Nepal has had its share of Swine Flu and Bird Flu in the past.
  3. Tetanus- If you can’t remember the last time you had a booster dose, get one just in case. It is good for a decade.

An Immunization List for hypochondriacs :

  1. Hepatitis B- Get 3 shots for this if your itinerary involves lots of blood work and casual sex.
  2. Japanese Encephalitis- Only if you intend to stay more than a month in Nepal during Aug-Oct.
  3. Meningococcal meningitis.
  4. Cholera
  5. Polio.

 

Insurance for Trekking in Nepal

The most important thing with travel insurance is the fine print. Pore over the finer things no matter who you approach. It has to cover the highest altitude in your itinerary and for the Himalayas, it is advisable to make sure that the insurance covers up to 6,000 meters. But most importantly it has to cover helicopter evacuations. Air Ambulance coverage out of Kathmandu is not necessary as hospitals here have all the facilities you will need. Before you go shopping for one, a check-up with insurance companies you are already connected with. It might be your bank or your health insurance provider. If not, you will find many options online. Remember the bit about the fine print though.

Let us hope you will never get to claim your insurance. But if you have to evacuate, make sure you keep all your receipts and signed medical reports. Also remember, helicopter companies in Nepal will not send in a chopper unless they are completely assured of payment and they will not deal with your insurance company. You will have to provide the cash guarantee and later file a claim with your insurer. The guarantee can be provided through a credit card, your trekking agency, or your embassy.

It is also important that not only you but the porters and guides you use are insured too. And you might be in for big trouble if something happens and there is no insurance. One of the perks of going through a travel agency is that they will take care of the porter/guide insurance for you.