You have been told that getting altitude experience is quick and easy in the Andes of Ecuador, and being from flatland Ohio, that sounds good, prior to your planned climb of Denali (Mt. McKinley).   However, between you and your 2 climbing buddies, you can only get a 5 day window to get down there and climb.  You fly into Quito (~9000 feet) and spend the night there.  Next morning your driver shows up bright and early to get you to the base of your climb of Soroche, a gorgeous 15,000 foot glaciated peak.  You are definitely sucking air as you hike up to the hut, positioned in a stunning setting at about 12,000 feet.  That night after a light dinner (no one is particularly hungry) and despite mild headaches, everyone is psyched about the climb the next morning.  You awaken pre-dawn the next morning to clear and calm skies and a beautiful show of the stars.  You excitedly awaken your buddies only to find that Liz isn’t doing too well.

Scene and Primary Assessment: It’s 12,000 feet and cold but you have the right clothes, a hut, and plenty of food and water.  ABCs are okay.  No trauma, no D.

Secondary Physical: Liz complains of a splitting headache and nausea.  She said she hardly slept at all.  Nothing else of note.

SAMPLE: Complaining of nausea, lack of appetite, poor sleep the night before, and severe headache.  Allergic to peanuts.  Birth control.  Liz says she has some codeine and wants to take it for her splitting headache.  Never felt this way before.  Ate a light dinner the night before, regular bathroom the night before.   No events of note.

Vitals: Patient HR 88, RR 20, AOx4

Setting: 12,000 feet.  It’s 4:30 am, mid-January, 25 degrees F., clear, calm, and dark.  It’s 4 miles downhill on a trail/road that an ATV or high clearance 4WD rig might make.  From there you think it is about 10 miles down to the nearest town, which may or may not have a clinic.  You have cell phone coverage but don’t speak Spanish and no idea who to call if you need help.   Your friend is convinced that Liz has altitude sickness and that she must descend, ASAP.

What do you think is going on?
What questions would you want to ask Liz?
What do you do?
What do you wish you had in your first aid kit?


What do you think is going on?  

When you hear hoof beats, think horses, not zebras.  At altitude the first thing to consider with an ill patient is altitude.

Liz likely has some kind of altitude illness.  The question is which one?  Given the nasty headache most likely Acute Mountain Sickness (AMS) but it could also be High Altitude Cerebral Edema (HACE).  Due to the relatively limited time at significantly high altitude (12,000 feet), and no respiratory issues, unlikely to be High Altitude Pulmonary Edema (HAPE).

What questions would you want to ask Liz?  The most important issue is to differentiate between AMS and HACE.  To do so you want o check out whether there is any altered mental status.  The most important question to ask is “Can she walk a straight line?”  And rather than just ask her, have Liz try it in front of you.  If she can’t walk a straight line, or shows any other signs of altered mental status, then the worry is definitely HACE (and the treatment is to descend ASAP).  You might also double check with Liz to see if she had ever been to altitude before and if so what happened.

What do you do?  Go back to bed!  Assuming no altered mental status it is most likely Liz has AMS.  Treatment is to go no higher and wait 24 hours, it should self-resolve.  You don’t need to descend (at least at this point).  Basically, you get a free rest day.  Stay hydrated (not that it’s going to help altitude illness, but you are breathing hard in the thin air and the air is cold and dry so you are drying out more quickly) and try to eat.  Keep an eye on yourself and your other buddy to make sure you aren’t coming down with AMS.  Keep an eye on Liz to make sure her AMS doesn’t get worse and potentially morph into HACE.

What do you wish you had in your first aid kit?  Diamox might help Liz’s AMS and it might help you and your other buddy prophylactically avoid AMS.  Dexamethasone would be good to have just in case Liz’s AMS started to morph into HACE.  Liz should be discouraged from taking the codeine for her massive headache as it could depress respiratory drive.