Mountain Medicine, Critical Care Fellowships and ‘Surviving The Death Zone’
Staffing trainee rota’s can prove challenging. Dr Jeremy Windsor, a Consultant in Anaesthetics and Critical Care at Chesterfield Royal Hospital and Xtreme Everest investigator, has developed an innovative solution. This blog describes how it all started.
At Chesterfield Royal Hospital we have recently appointed our first Clinical Fellows in Anaesthesia, Critical Care and Mountain Medicine. Like other hospitals, there’s been a struggle in recent years to cover middle grade rotas. Whilst there are many reasons for this, we felt that the promise of study leave and funding to complete the Diploma in Mountain Medicine would see an increase in our numbers. And we were proved right!
The following case was the inspiration behind the programme and the blog that subsequently followed.
To celebrate their 30th wedding anniversary, Mike and Sylvie joined an organised trek to Mt Everest Base Camp. After more than a week on the trail the group finally reached the cold, windswept settlement of Gorak Shep. For trekkers there is only one reason to spend the night there - Kala Patthar. Situated a few hours above Gorak Shep, the rocky outcrop of Kala Patthar provides trekkers with some of the best views of Mt Everest.
Mt Everest from Kala Patthar
Early the next morning there was a real “buzz” as they all set off together, but after an hour Mike started to slow down and the pair were quickly separated from the group. Soon, the winds began to pick up. Snow started to fall and, as they reached the high point, Mike began to cough violently and collapsed to the ground. They were completely alone.
To understand what happened to Mike and Sylvie you have to turn the clock back to their arrival in Nepal. After a day spent sightseeing in Kathmandu, the couple flew to Lukla (2840m) and joined their trekking group. Over the course of five days the trekkers ascended more than 2000m to their lodge at Gorak Shep (5220m).
In such a short period of time the pair had to overcome an enormous physiological challenge. At Gorak Shep the PaO2 is just half of that found at sea level. To deal with this the human body has to undergo a complex and poorly understood process of acclimatisation. Many are unable to do this quickly and instead develop Acute Mountain Sickness (AMS). This condition can be innocent at first, with little more than symptoms of a mild “hangover”. However, left untreated, the headache, vomiting, fatigue and dizziness can be debilitating. In Mike’s case, AMS developed two days after leaving Lukla. Unfortunately the symptoms were all blamed on something else – a hangover, a poor nights sleep, unpalatable food, dehydration … the list went on! By the time the group left for Kala Patthar, Mike’s body had been struggling for days. But it wasn’t just the AMS that caused Mike to collapse.
At high altitude our network of pulmonary vessels respond to hypoxia in different ways. Whilst some remain open, others constrict. This forces large volumes of blood to pass through patent arteries. In some cases this damages the thin alveolar capillary membrane and leads to the leakage of fluid into the lungs. This condition, commonly known as High Altitude Pulmonary Edema (HAPE), had struck Mike. Left untreated, HAPE is fatal.
Gorak Shep from the trail
By now Mike was profoundly breathless, coughing violently and too exhausted to stand. Sylvie helped him put on his down jacket before sitting him on a rucksack and propping him against a large rock. Stumbling downhill she set off for Gorak Shep. Within minutes of arriving, a rescue team of local Sherpa guides and porters was dispatched to find Mike. Shortly after midnight the rescue team arrived back at the lodge. Mike was placed on a mattress beside the fire and supported with cushions. He was barely conscious and struggling to breathe. Mike’s face was badly swollen, there was evidence of vomit and crusting around his mouth and he was covered in cuts and bruises.
After initial management with oxygen and nifedipine his clothes were removed and wounds cleaned. Sylvie sat alongside him and did her best to offer reassurance. Using a satellite phone a helicopter evacuation was organised. But that would be several hours away and Mike was deteriorating. The bottled oxygen and nifedipine weren’t enough. Reversing the cause of Mike’s problems necessitated the use of a portable hyperbaric chamber or “Gamow (pronounced Gam-off) Bag”. Victims are placed inside the airtight chamber and air is pumped inside. The resulting increase in oxygen partial pressure has saved countless lives.
A Gamow Bag
The combination of bottled oxygen, nifedipine and the Gamow Bag slowly started to work. Over the next six hours Mike’s breathing improved and he slowly started to wake up. Shortly after dawn he was able to hug Sylvie and walk, albeit slowly, to the helicopter.
Memories of treating Mike have stayed with me throughout my medical career. Mike was able to survive a life threatening illness thanks to a combination of knowledge, experience and teamwork. These factors play an enormous part in anaesthetics and critical care. Through the posts created in Chesterfield, we hope that our fellows will have the opportunity to help others survive the “Death Zone”.
For further information about mountain medicine and the clinical fellow programme at Chesterfield Royal Hospital see the “Surviving The Death Zone” blog at:
Dr Jeremy Windsor MB ChB MD DCH FCARCSI
Consultant in Anaesthetics and Critical Care
Chesterfield Royal Hospital