[deky]

A lot of us petrol heads love to travel and Leh/Ladhak and beyond has been a favourite destination for us lately. One thing we really bother about is AMS and its affects.

What is AMS?
Why does it affect us?
Can we do something to prevent AMS?

Similar is my situation now, as I would be heading to Kailash Mansarovar in a few days. AMS has been on my mind and have been studying a lot about it on the net.

I asked a good friend who knows is a noted chemist about AMS and the following was his response to AMS

Hi Dhiraj..

You must have by now googled stuff about AMS and Diamox, and found a plethora of information, largely in jargon, and some things unrelated or contradictory to each other. Well that’s how medical science is, and more so on websites like wikipedia, which at times are not able to differentiate between proven scientific facts and sponsored research/ newspaper articles.

I’ll try to brief and simplify the most important issues here.

What is it?

‘Acute Mountain Sickness’ or ‘Altitude Sickness’ is a group of problems that may occur to somebody who ascends a very high altitude in a very short duration without giving their bodies sufficient time for acclimatization.

The starting symptoms include headache, swelling of feet (and may be hands) and breathlessness.

How do you know, whether it’s AMS, or simply fatigue and dehydration related to climbing?

Headaches may occur simply by fatigue and tiredness, and even dehydration. But headache of AMS has other typical associated symptoms, that may help in differentiation.

The two most dangerous (and potentially fatal/ life threatening) things that may happen in AMS are:

1. Pulmonary Oedema (Edema in US English): In normal language, it’ll mean swelling of lungs; in ‘desi’, it’s often called ‘lungs mein paani bharna’. The 3 most important indicating factors of this in AMS are:
(a) Dry cough
(b) Fever
(c) Shortness of breath even when the person is made to lie down or rest.
This is a potentially dangerous situation, which if gone out of hands, cannot be treated without hospitalization.

2. Cerebral (O)edema: or swelling of the brain cells. The 3 best indicators to this are:
(a) Vomiting
(b) Imbalance in walking (as if a person is drunk)
(c) The headache does not respond to painkillers
There’s very short time with the unfortunate person here, ‘cause if the symptoms are not reversed, the patient can slip into a coma very fast, or may have a paralytic attack and may even die.

Acetazolamide (Diamox) ?

Acetazolamide ‘DOES NOT’ treat AMS.

The best and only treatment for AMS is to get rid of the reason – ‘altitude’. Without wasting any time (for religious reasons or adventure), the patient should be made to descend from high altitude and made to rest.

Acetazolamide simply helps buy you some time while you are making efforts to shift the patient to a lower altitude. It is a diuretic (induces high rate of urine generation in the body) and tends to suck out liquid from the body cells. So it may help in reducing the edema from lungs and/ or brain. But the process is slow, with limited capability and with associated problems.

It is also, at times, recommended as a preventive medicine before you go to a place of higher altitude. It merely helps in the acclimatization process by manipulating the CO2 cycle and reducing the pH of the blood. However, since it is a diuretic (added to the fact that you are going to a cold place, and will be taking a lot of fluids), it will induce very frequent urination. This can become very uncomfortable in the outdoors, especially for ladies.

As a preventive medicine:

1. It should not be given:
(a) when the person is anaemic
(b) when the person is allergic to it, or to sulpha drugs. (How to know whether you are allergic to it – see notes at the end)
2. It should be given only when:
(a) the person has a history of AMS
(b) the person is expected to ascend the first 10,000 feet in a single day; or after ascending 8,000 feet, he is expected to ascend more than 2,000 feet per day.

So, how to prepare yourself? What to do now, and what do just before the trip, what to do during the trip?

1. Prepare yourself from now:
(a) Know your body water requirement from now (see notes at the end).
(b) Start reducing dehydrating culprits from your routine from now on. Cut down heavily on alcohol, tobacco and caffeine (tea, coffee, and cola); so that you can totally eliminate them from at least 3 days before you trip starts, without really missing them.
(c) Start walking longer durations from now on to prepare your body. If you use a treadmill, use the incline (or is it recline) function to good effect. Climb more and more stairs.
(d) Do some very simple breathing exercises (Pranayam) to improve the capacity of your lungs. You have a choice to follow any guidelines on this, Baba Ramdev, or Sri Ravishankar Ji or any other authentic trainer.
(e) Get an allergy test done for Acetazolamide with the help of a Doctor, or take a bigger risk by doing it in a very crude but basic manner (see notes at the end).
(f) If the traveler has a chronic problem like diabetes, or hypertension or thyroid etc., consult your physician to check whether you need to increase or decrease your daily dose of medicine.

2. Just before trip:
(a) No to alcohol, tobacco and aerated drinks from at least 3-4 days before the trip. Reduce tea and coffee intake.
(b) Rest completely for at least 24 hours before you start the major ascend.
(c) If at all you do decide to take Acetazolamide as a preventive medicine:
• Start at least 1-2 days before your trip begins.
• Take only half a tablet twice a day. You can double the dose if you find the above mentioned symptoms of AMS once you are at a high altitude.

3. During the trip:
(a) Give sufficient time to your body to acclimatize at progressively higher altitudes.
(b) Ascend slowly.
(c) Take moderate water intake (low intake may cause dehydration; excessive intake may lead to hyponatremia – sodium deficiency).
(d) In case of initial symptoms, try using common medicines like pain killers etc. If the symptoms point towards AMS, do the following 3 immediately:
• Administer Acetazolamide 250 mg tablet immediately, and repeat every 12 hours.
• Check whether oxygen can be administered nearby.
• Getting rid of all your emotions, just get back downstairs, and try your luck next time.
Notes:
1. Know your water intake: Having 8 glasses of water a day, or so many liters, or this, or that – these are all unscientific myths. Each individual has his/ her own requirement of water. The best indicator of whether your body is getting sufficient water, is the colour of your urine. Darker shades of urine indicate water deficiency. Transparent (water like) urine shows that body has sufficient water. The water requirement of each body also changes with the weather, season, surroundings and food. So, be your own judge.
2. Allergy test: Crush the damn tablet in a pestle-mortar in the kitchen and take the smallest grain from the tablet with a glass of water. Wait for a day to see any allergic signs. If nothing happens, repeat it with a bigger piece. Please note that this is not a safe method to try on just any medicine.
3. Other popular brand of Acetazolamide in India are: AVVA (by Intas: more economical but equally effective)

This was sent to me by mail and has been written by Mr. Raspreet Singh

I hope the above information is helpfull to others bothered about AMS.

Any other AMS related querries and suggestions can be placed here in this thread so that it can be helpfull to us members who are going to high altitudes.

[dushmish]

Very informative Deky. I have read stuff about AMS on the net and let me tell that this is the best write-up. Busts all myths and keeps it simple. Do convey my thanks to Raspreet Singh Saheb.

I have been contemplating a drive to the Himalayas and this info will come handy.

[ashthedivx]

Indeed a very informative mail. Thanks for sharing the same Dhiraj.

[hvkumar]

Great information, Deky.

I follow the advioce your doctor friend has suggested:

- Drink, drink and drink water, at least a few sips every 10-15 minutes during the drive
- Eat high-nutrition stuff like chocolates, biscuits, without bothering about diabetes and cholesterols
- Totally spurn liquor

This is the simple prescription - apart from Diamox - I have followed for Ladakh drives and I have been in the pink of health without suffering any problems.

[deky]

Originally Posted by hvkumar

Great information, Deky.

I follow the advioce your doctor friend has suggested:

- Drink, drink and drink water, at least a few sips every 10-15 minutes during the drive
- Eat high-nutrition stuff like chocolates, biscuits, without bothering about diabetes and cholesterols
- Totally spurn liquor

This is the simple prescription - apart from Diamox - I have followed for Ladakh drives and I have been in the pink of health without suffering any problems.

HV Sahib,

Chocolates would be protein, and I read somewhere 70% of your diet should constitue of carbohydrates. So you think eating chocolates would still be fine?

[hvkumar]

We also eat stuff like dry fruits and fresh fruits. Since the biscuits and chocolates have high levels of sugar, they are useful in combating fatigue. We also add electral to water.

[nitrous]

Chocolates would be protein

In which world?

[deky]

Since we on the topic of food in the mountains following is the suggestion that Raspreet made regarding food and hygene which I would like to share with you guys.

Also my apologies for calling chocolate proteins.

Basically (a) keep your tummy light and
(b)avoid potential sources of infection
For (a):
1. Avoid oily greasy fried and spicy stuff
2.Avoid anything that has caused stomach upsets or indigestion to you in the past
3. Since tea/ coffee has to be minimized, plan for things to keep you warm like soups (they are made by boiling, so are generally safe, but carry plenty of thermoform glasses with you and avoid utensils at dhaabaas) and boiled eggs and anything else that you can think of. Carry some Cup noodles with you.

For (b):
1. Avoid water from eateries and also from not so popular bottled brands
2. Avoid glasses and spoons at eateries, use bottles for drinking directly, or carry some disposable and some tupperware tumblers and plastic spoons/forks with you
3.Keep your hands clean. Since soap and water (and then a napkin) become too much of a hassle, carry a small dispenser of hand sanitizer (most popular and easily available is Himalaya, pick 2 small ones, in stead of 1 big one), you wont need water, napkin or soap.
4. Avoid fresh fruit juice: there is no way in this world to make hygienic fresh fruit juice.
5. Avoid anything with cabbage, minced meat, pork, beef and pre-cut fruits, vegetables and salad.
6. Carry a couple of bottles of 'not so expensive' cologne (like Premium or Park Avenue). You can use a couple of teaspoons in a glass/bowl of water to sponge your self clean, since there may be days when you would not like/ wont get a chance to take a bath.
7. Take a good supply of undergarments and keep changing them regularly even if you avoid a shower.


Apart from all this, make this home made remedy and carry with you:
One part of Almonds +
One part of Black Pepper +
Three parts of 'Mishri' (better if you find the good old big irregular crystals)

Crush all this in a pestle mortar into very small granules (can even use a mixie, but avoid making it into a fine powder) and store in a small tupperware container.

Take one spoonfull last thing before sleeping and swallow with a glassfull of very warm milk. This is a very simple but good remedy for cold and congestion (to be taken for at least 3 nights continuously). This can at times be taken as a precaution when you have the earlier or pre-symptoms of allergic rhinitis or cold (some people do have things like an itchy nose a night before you getting into a teriible cold.)

[tsk1979]

Diuretics make blood acidic, thats why they are recommended before starting the Ascent.
But if you are afflicted with AMS, only lowering altitude will have the beneficial effect.
Some climbers use some sort of pressurized bag with foot pump. Patient is put in the bag, and then air is pumped to simulate a pressure equivalent of 8000 feet.
A few hours in such a bag takes care of things.

So use diamox before ascending, and during ascend, and hope for the best. A good idea is not to linger too long at the high passes. Take a couple of pics and run

[hvkumar]

One advice for the Manali-Leh route is to avoid an overnight stopover at Sarchu, which at 4000 metres + is double the height of Manali where you would have started from just 10 hours ago. May be a better idea to stop at Jispa, but that will also mean a very long drive to Leh in one day.

[Rudra Sen]

Originally Posted by hvkumar

One advice for the Manali-Leh route is to avoid an overnight stopover at Sarchu, which at 4000 metres + is double the height of Manali where you would have started from just 10 hours ago. May be a better idea to stop at Jispa, but that will also mean a very long drive to Leh in one day.

To make it easy, I would suggest staying at Keylong for the first night. Sarchu next day stay wouldn't be a problem then. This again of course if you have time in hand. We did this.

[deky]

Would a smoker be more prone to AMS vis-a-vis a non-smoker? Any theories on this?

[topedgemonk]

Another important thing would be to not exert yourself too much in high places. (for eg:Sarchu).
Keep your movements to a minimum. You will feel ok at the moment you reach there, but exertion will cause you to get AMS very fast.
Try not to linger for too long at the passes, just a 'been there' snap and start your descent.

The single best treatment as said in the post below would be to come to a lower altitude asap if you are feeling the symptoms.

I guess Maggi noodles works because that is what most of the wayside eateries sell on the way to Leh

[svsantosh]

Trekking? - Get tested first

TIMES NEWS NETWORK

Bangalore: Our blood is thinner at higher altitudes and thickens as we come down to lower levels. This phenomenon can cause hypoxia, a condition characterized by lack of oxygen in the body as we go higher up to the mountains. It causes shortness of breath, headache, fatigue, etc. and may result in altitude sickness or chronic mountain sickness.
St Johns National Academy of Health Sciences in association with Quality Council of India organized a talk on this by Bolivian doctor and teacher Gustavo Zubieta-Calleja (Jr) on Wednesday. The college also felicitated his father , the 84-year-old veteran, Dr Gustavo Zubieta-Calleja (Sr.) for his contribution in the field of chronic mountain sickness. Mountain sickness is seen in one out of four people residing in or travelling to high-altitude areas, said Dr Gustavo (Jr). The first step in treating chronic mountain sickness is through methods like respiratory function test, ventilation test and breath-holding test, he added.

[akas_chauhan]

Originally Posted by hvkumar

One advice for the Manali-Leh route is to avoid an overnight stopover at Sarchu, which at 4000 metres + is double the height of Manali where you would have started from just 10 hours ago. May be a better idea to stop at Jispa, but that will also mean a very long drive to Leh in one day.

I think better is to start from Manali and stop at PATSIO. AT least that's what i did. Next day it'll be easier to cover PATSIO to Leh.

Originally Posted by deky

Would a smoker be more prone to AMS vis-a-vis a non-smoker? Any theories on this?

I'm a smoker and i did not have any sign of AMS, though i did not smoke while riding and sipped 3-4 lt of water a day.