Travel health

Altitude sickness prevention

 

grey Altitude sickness preventionIt is really hard to put into words how extreme altitude affects you but I shall try: Imagine waking at 3am inside a refrigerator with the worst hangover of your life. Inside the fridge is a treadmill. Run on this for 12 hours straight…with a plastic bag over your head.

Some of my most vivid memories were formed inside a high altitude torture chamber; climbing Island Peak (my first Himalayan mountain), trekking the Inca Trail with my parents, trekking parts of the Andes with a donkey and finally returning to Nepal to climb Manaslu, all involved various degrees of altitudinal discomfort. Don’t be put off though, I am going back this October for some more high altitude suffering with some good friends so it can’t all be bad news…right? Dealing with altitude can be seen as just a regular part of adventuring at the really good places.

So why does altitude affect the normal functions of your body?

As altitude increases, atmospheric pressure drops, this means that less oxygen is delivered to your body with every gasped breath. After some time the body responds by producing more red blood cells (to transport the limited oxygen) in a process called acclimatisation. There are also some changes in how the body manages its fluid.

grey Altitude sickness preventionGeneral rules for altitude sickness prevention are as follows:

  1. Go up slowly. When above 3000 meters try not to sleep more than 300 meters higher than the previous night and take a rest day every 3 days, or for every vertical kilometre gained.
  2. Take planned acclimatisation walks. On a rest day climb about four to five hundred metres then descend and sleep at your original altitude. This shocks your body into making more red blood cells. It is a proven method and is how climbers can survive at extreme altitudes.
  3. Remember the old adage “climb high, sleep low” Don’t sleep on top of a high pass if there is a chance to sleep lower in a valley. It is the altitude you sleep at which tends to dictate your risk of altitude issues.
  4. Drink lots of fluids. One thing that many people don’t realise is that you will pee a lot at altitude, this combined with exertion and dry air sucking moisture out of your system can lead to dehydration. Maintaining good hydration levels helps the body to acclimatise.
  5. Be honest with yourself and your trekking partners. A niggling headache or slight nausea can be your body’s warning that AMS (Acute Mountain Sickness) is just around the corner. Rest and take it easy if you are feeling poorly.
  6. Have an altitude profile to plan your trek or climb (see image below). This will help you to plan your altitude gains and to factor in rest days at clever intervals.
  7. Drugs. Some people use them, some prefer not to. Diamox (Acetazolamide) is a diuretic drug which is commonly used to treat and prevent AMS. It is generally only used if a person is going straight from sea level to around 3000 meters or if someone is planning to climb (and sleep) at more than 600 meter altitude gains per day. This drug speeds up acclimatisation but takes a day or two for the full effect so is not super helpful in cases of acute AMS. A dose of 125mg once or twice daily is commonly used to aid acclimatisation, starting 3 days before going high. Higher doses are commonly used in cases of acute AMS. More detail can be found in the footnote*.

AMS has stages, almost everyone who visits areas at high altitude will suffer some or many symptoms, I sure haveplenty of times.    The most common symptoms include: Headache, breathlessness, insomnia, nausea and loss of appetite. Keeping a close, honest track of these is very important in monitoring and managing your acclimatisation. There is a great worksheet here which helps in tracking and monitoring progress of symptoms.

If in doubt, descend and don’t push yourself too hard.

Below is the altitude profile of a climb to extreme altitude. It shows a lot of up and down done to shock the system into acclimatising as well as possible. Most treks to high altitude have available altitude profiles where you can plan rest days, acclimatisation walks and see which days to watch closely with regards AMS risk.

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(Reproduced with permission from Mal Haskins @ Speedfly8000)

 

HAPE and HACE

Many of the serious health issues that occur at altitude stem from water’s nasty habit of shifting location as we go up in the world. At sea level much of the body’s fluid spends its time helping out in our circulatory system, moving red blood cells and nutrients about and flushing away toxins. This arrangement is rather agreeable for survival. At high altitude the water can go where it’s not wanted or needed. The fluid not being where it is meant to gives rise to the symptoms many trekkers suffer at altitude. If too much moves to the brain or lung cavity it can cause serious, often fatal, conditions such as HAPE (High Altitude Pulmonary (lung) Oedema), and HACE (High Altitude Cerebral (brain) Oedema). Yes, Australians spell Oedema differently to the rest of the world, deal with it! The mechanism is similar to how ankles can swell on long haul flights but much more serious.

Don’t cancel your adventure just yet though guys, HACE and HAPE rarely occur below 8000 metres and only ever kicks in after you body has given plenty of warning signs. It can occur much lower at altitudes as low as 3000 metres but usually this is due to a rushed or non-existant acclimatisation plan.

I will not go into details here on treatment of HAPE and HACE, treatment involves rapid descent if possible, Adrenaline, Dexmethasone and oxygen given by qualified physicians.

HAFE 

HAFE is another uncomfortable part of trekking at altitude. Gasses expand at decreasing pressure, this also happens in the bowels. This expansion, combined with a trekking diet commonly high in carbohydrates can lead to High Altitude Flatulent Extravaganzas. There is no cure for HAFE. It can be managed by walking separately from the group from time to time and by leaving the tent open a bit at night.

Sun Smart 

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Recent research has confirmed a long held belief that people get sunburn more readily at high altitudes. UV-B levels, the most damaging UV band, have been proven to be around 60% higher at 2500 meters than at sea level. Higher UV-B levels combined with snow reflecting the sun’s rays can lead to sunburn in some interesting places, like under the earlobes! I once ended up with a seriously sunburnt and swollen tongue after an extended climb at altitude. It happened after gasping with my mouth open for too long. I could hardly talk let alone eat properly and it was absolute agony. This is one experience I certainly do not want to repeat. It is crucial to cover up and regularly apply a high SPF (Sun Protection Factor) sunscreen while up high.

The dry air and harsh sun can lead to cracked lips so buy, and regularly use, a high SPF lip balm as well. I have a special top with a little pocket in the sleeve near my wrist which just fits a lip balm. Remember guys, it is not seen as dorky to use lip balm above altitudes of 2500 meters.

 

 

 

Above: The author being very sun smart after suffering a sun burnt tongue.

Altitude affects everyone differently. Some unfit people will spring along without an issue while some super-athletes can struggle at the slightest elevation. One person’s response to altitude can differ from trip to trip as well. Once I was in the Andes trekking at around 4500 meters and had to spend an excruciating 24 hours in my tent, curled in a foetal position with a pounding headache, nausea and no chance of descent; yet the next time I went high I got to 7000 meters before even getting a slight headache. The main rule is to be gentle with yourself and to descend if in doubt.

So, if you are smart, plan your height day by day and don’t push yourself too hard, you can have a healthy and most importantly fun time playing in the world’s high places.

Much more detailed information on this topic can be found here: Medex Book English Version and Guide to High altitude medicine

Thanks to Mal Haskins for his input into this post. Mal does loads of cool stuff in extremely high places. Check him out here: Vertical Resources 

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*Acetazolamide.

Action: This drug works by forcing the kidneys to excrete bicarbonate which leads to a slightly more acidic blood. Our bodies monitor levels of (the slightly acidic) Carbon Dioxide (CO2) by detecting the blood’s acidity. Making the blood more acidic fools the body into thinking that CO2 levels are higher than they actually are. This triggers an unconscious deeper and faster baseline breathing rate. By breathing deeper and faster more oxygen is taken in.

Acclimatisation: I eluded in the text above that a low dose of Acetazolamide can be used to aid acclimatisation. The normal dose is 125mg twice daily. This only speeds up normal acclimatisation processes, hence if acclimatising to a certain height normally takes 24-48 hours, Acetazolamide can reduce the time by 50%. Stopping the drug will not reverse acclimatisation, the rate will just return to pre-dose speeds. Being a diuretic or fluid pill Acetazolamide also ‘concentrates’ the blood, that is, less fluid in circulation means there are more oxygen carrying red blood cells in every millilitre of blood.

AMS While the mainstay of AMS treatment is rest and descent if possible, Acetazolamide can be used in higher doses to treat the condition. The dose is much higher than for prevention at 250mg every 4-6 hours. The diuretic effect reduces over the course of a few days (by which time you should be feeling comfortable again)

Cheyne Stokes Breathing: Gasping rapidly at altitude means the lungs are clearing CO2 faster than Oxygen is being taken in. As mentioned above, the body ‘listens’ to CO2 levels more closely than to oxygen levels when setting baseline respiration rate. Having the body clear CO2 so efficiently can lead to a drop in respiration rate to nil in some climbers during sleep (as the body reads a low CO2 level and assumes a relative high oxygen level). When the breathing stops during sleep a climber will wake up desperately gasping for air and rather upset about the while situation, not to mention tent-buddies waking to find a friend lying there peacefully not breathing! By artificially increasing respiration rate, a low (125mg) dose of Acetazolamide before sleep can counter this whole scenario.

Random fact: When you drink a carbonated soft drink whilst on Acetazolamide you can feel but not taste the bubbles (which are CO2 and acidic). I have no idea exactly why this is but guess it is due to the blood being more acidic, closer to the pH of the bubbles of CO2 and harder for the taste buds to pick up. It is a really, really weird sensation, try it if you get the chance!

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What is heat stroke ?

It seems a bit weird to be writing about what is heat stroke , the first aid for it and related illness in the middle of a dreary Melbourne winter, however, in Saudi Arabia, where my sister is soon to relocate, it is always hot…damn, hot.

This one’s for you sis.

Heat related illnesses are caused by heat exposure above the bodies inbuilt ability to thermoregulate or get your body temperature back to normal. Heat stroke is distinct from the fever you experience when fighting infection. A fever is caused by excess heat coming from those brilliantly intricate chemical reactions that your immune system uses to fight a bug.

Heat Stroke Risk Factors:

The main risk factor is prolonged exposure to the sun, with activity. Things that increase risk of Heat Stroke include:

  • Pre-existing health conditions such as obesity, alcoholism and being under weight.
  • Medications including anti-histamines, diuretics, stimulants and some anti-depressants and antipsychotics.
  • Some illicit drugs including cocaine and amphetamines.

What is heat stroke?

Classical heat stroke passes through a variety of stages on its way to being fatal. Some of the first signs are thirst, profuse sweating, muscle cramps and dizziness. At these first warning signs you should get out of the heat and rehydrate. If you don’t, a relatively minor ailment can progress to dry skin, respiratory problems, numbness, rapid, strong pulse and loss of consciousness. A temperature higher than 40.6 degrees will confirm heat stroke in a patient but normally diagnosis is made from clinical history alone, i.e. he was jogging in the sun then fainted.

Heat stroke Prevention:

grey What is heat stroke ?Like many conditions, the best treatment for Heat Stroke is prevention:

  • Wear light loose fitting clothes that block the sun but allow you to sweat (evaporative cooling).
  • Avoid strenuous training during the hottest time of day – 11am to 3pm.
  • Avoid dehydrating substances like alcohol, caffeine and stimulant medicines, they can make heat stroke come on much faster.
  • In humid climates remember that cooling by evaporation of sweat is limited, cotton in light colours are the best clothes and just hang in the shade by a pool sipping a (non-alcoholic) martini.
  • Vents in hats not only look fashionable but they allow the sweat to evaporate from the head.
  • Drink plenty of water or isotonic drinks.
  • Umbrella hats look ridiculous but are the best hats ever invented to prevent heat stroke.

 

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Heat stroke Treatment

If prevention is unsuccessful the body temperature must be lowered immediately. The mainstay of treatment is cooling and rehydration (with salty drinks exactly like those used in diarrhoea) The patient should be moved to a cool area (indoors, or at least in the shade) and clothing removed to promote heat loss. This is called passive cooling.

Should passive cooling fail to resolve symptoms or if the patient is really sick, active cooling methods may be used: Basically this means bathing person either totally or in part in cool water.

Wrapping the patient in wet towels or clothes can be counter-productive as towels etc can act as insulation and increase the body temperature. Cold compresses to the head, neck, groin and torso will help to rapidly cool the victim. A fan or anything else suitable may be used to aid evaporative cooling. Evaporation is really helpful as the water in contact with skin literally sucks heat out of a patient as it evaporates.

Immersing a seriously ill patient into a bathtub of cool (but not cold) water is the most recognised method of cooling. This requires the effort of 4-5 people and the patient should be monitored carefully during treatment. If it gets to this stage you need to seek urgent medical advice. Immersion should be avoided for an unconscious patient, but if there is no alternative the patient’s head must be held above water.

Heat stroke prognosis

Let’s face it, most people know to get out of the sun when they start getting headachy and slow. But even if you miss the early warning signs the prognosis is good. Most people recover fully from a bout of Heat Stroke with only a decent head ache to show for their troubles. Drinking isotonic rehydration fluids (used in diarrhoea) and over the counter headache tablets will fix this in time.

After you’ve recovered from heat stroke, you’ll probably be more sensitive to high temperatures during the following week. So it’s best to avoid hot weather and  heavy activity until your doctor tells you that it’s safe to resume your normal activities.

There are wildly varying reports on the prognosis after serious Heat Stroke requiring hospitalisation, the best bet is to avoid this situation!

 

grey What is heat stroke ?

Travel first aid kits

My last pharmacy job was working in Melbourne’s CBD. As such, my main demographic consisted of relatively fit and healthy 30 year old go-getters. One of the main reasons for them to visit a pharmacy (disregarding the inevitable Monday morning Emergency Contraceptive pill rush) was for travel health advice, specifically what travel first aid kit to take.

Now clearly a holiday to the beach would have different travel first aid requirements to a remote trek at altitude so I’ll start with the basic kit I take everywhere with me, apologies for people living in countries with different brands, I have attached links to most things so you can get something equivalent. A first aid kit doesn’t have to be big to be good, you won’t be performing open heart surgery. Mine is smaller than two beer cans.

So here is what’s inside:

Oral rehydration salts Hydralyte Blackcurrant is the best tasting, the fizzy tablets are easiest to use.
Adhesive tapes & sterile bandages I usually take a thin Leukoplast and a few wound pads, that way you can get creative. Don’t spend big bucks on buying every type of bandaid known to man, be creative.
Betadine liquid  Iodine is the best antiseptic, messy but it kills the bacteria. (hint, you can apply then wipe off after 3-4 minutes to avoid mess as it will continue working in the wound after this time).
Lubricant eye drops No particular brand, I take the single ‘serve’ vials as the 30ml bottles need throwing out 30 days after opening.
Eye wash cup Good link here. If you get something in your eye you can rinse it out by filling it with boiled, cooled tap water (okay) or your lubricant eye drops (best). Hold the cup over your open eye and tilt back you head.
Insect repellant DEET is your friend the more the better, unless you have sensitive skin. If going to Asia I buy over there as the repellant is cheaper and stronger.
Antihistamines  This is personal. Different people react differently to each one. I take Polaramine (Dexchlorpheniramine 2mg) as it is a good trade off between drowsiness and anti-itch property. *Check with your pharmacist if you are taking any other meds or have prostate issues*.
Nasal Decongestant     Again this is personal. I take tablets containing pseudoephedrine but again seek advice.
Scissors/tweezers/splinter-lance A splinter lance is basically a solid needle with a big handle, I love these things, soo handy. When buying tweezers it is how neatly the ends come together, not how pointy they are which defines how good they are.
Pain relief Again, personal but I take Paracetamol as I tend to share a lot of my kit and this is safe with most medications and conditions.
Triangular bandage You can make an arm splint, put pressure on major wounds and do heaps of handy stuff with these (non-sterile).
Sunscreen  Mine has a carabiner so I can clip it to the outside of my pack which helps me remember to REAPPLY!
Tampons and sanitary pads Not only useful for women.
Tubular finger gauze  Hopefully the most major injury you get abroad is a cut finger, it is, I reckon, the most likely. Tubular gauze is the only way to neatly dress a fingertip wound. Note the applicator that comes with the gauze is far smaller than the one in the link.
Rubber gloves  For your safety when helping others.
Fingerdoms  This is my name for them. Handy little condom shaped finger stalls which keep a bandaged finger clean and dry.
Lip balm  Remember gentlemen there is no shame in having kissable lips!
Heavy crepe bandages x2  For sprains and strains
Blister dressings Those thick rubber ones which stop the friction.
Cotton buds …which my wife usually steals, but they are good for cleaning muck out of wounds.
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Finger-doms

grey Travel first aid kits

Tubular gauze for fingertips with applicator.

 

Now that is about it for my first aid kit. Remember this is a basic first aid kit and should be enough to get you back to civilisation in one piece. I’ll write about extras for high altitude trekking and special places in another post. In my next instalment I’ll discuss specific medicines which are handy to carry while exploring.

What have I forgotten? Feel free to comment below.

Mosquito bites

grey Mosquito bitesAlmost everyone in the world can recognise that high pitched phantom in the night. At best, a mosquito bite will cause local irritation, maybe some swelling over a few days. At worst, a bite can transmit serious illness and land you in hospital fighting for your life. Illnesses such as Yellow Fever, Malaria, Dengue Fever and Ross River Virus are all spread by this humble insect. Thankfully studies have shown that the transmission of HIV via mosquito bites is extremely unlikely.

With the exception of Antarctica, mosquitos live in every part of the world. They even survive in the Arctic where they are active for a few weeks a year when water melts to form pools on the permafrost.

Even the most determined nature lover will curse these annoying demons whose only reason for living is to feed fish whilst in their laval stages. So how do you avoid getting bitten?

“Know thine enemy”

Move

  • Mosquitos can only fly at around 2kms an hour so a gentle breeze (or a quick run around) will waft them away.
  • If walking with friends, go first. The cumulative attraction of a group is noticed more at the back.
  • Go gently. Mosquitos are strongly attracted by carbon dioxide on your breath and lactic acid on your skin. The less you exert yourself the less attractive you’ll be (The same rule applies in gyms!)
  • Try to go in sunny areas and avoid damp, shady spots as Mosquitos dehydrate easily.
  • Mosquitos take a few seconds to bite after landing. Developing a twitch when sitting still will keep them from biting.

Cover yourself

  • Originally developed as a pesticide in 1946, DEET oil is the active ingredient in many insect repellents. Mosquitos find the smell of DEET repulsive even if we are sweating copiously and smelling like a banquet. *Warning* DEET can be irritant in high concentrations and it melts certain plastics. DEET also stings like hell on cuts. It is safest to only spray onto clothes and vulnerable areas such as areas with high blood flow and less fat like the neck, wrists and ankles.
  • Loose fitting, long sleeved shirts and trousers may mask your tasty odour and confound mosquitos’ feeding efforts as you move.
  • Earthy colours attract less attention than bright reds and blues which look like the flowering plants that mosquitos also feed on.
  • Some companies make Permethrin impregnating kits to turn your mosquito nets and clothing into serious bug killing gear. You can check them out here.
  • If you can handle the smell, dry your clothes over a fire as mosquitos hate smoke.
  • Mosquitos are paranoid about getting their wings oily so lube up your skin with natural oils such as crushed orange peel, onion or garlic.
  • Avoid smelling like a flower. Scented laundry powder and personal hygiene products will attract mosquitos.
  • If all else fails you can do a Bear Grylls and roll in mud, this will mask your attractive odour.

Camping

  • As mentioned previously mosquitos hate smoke so build a fire with green wood and ferns then bathe in the smoke (if fires are allowed where you are camping).
  • If there are only a few mosquitos around hide in your tent for half an hour and leave your friends outside. The mosquito population will soon be full. *Warning, best not to tell your mates why you are hiding in your tent*
  • Mosquitos are most active at dawn and dusk so chill out in your tent until it is totally dark before coming out to roast your marshmallows.

Diet

  • Dehydration may magnify our reaction to bites so drink plenty of water to stay hydrated.
  • Eat raw garlic, the essence laces your breath and will repel the mosquitos…it also repels the opposite sex so weigh up the risk versus benefit of this option.
  • While there is no solid scientific evidence to prove efficacy, many people believe that large doses of Vitamin B1 works to repel mosquitos.
  • Stimulants and sugar rev up the metabolism which sends out a loud invitation to mosquitos, best avoided.

If bitten

The anticoagulant in mosquito saliva sets off an allergic reaction that causes swelling and itching. Once bitten, the sooner you gulp down an antihistamine tablet the better they can work to block this allergy.

  • Older fashioned sedating antihistamines (such as Polaramine and Phenergan) are best for mosquito bites as they have a separate anti-itch property on top of their allergy blocking abilities.
  • I find that pushing my fingernail firmly into a bite stops itching longer than just scratching does, this also stops the risk of opening up a bite to infection.
  • Scratch around the bite but not directly on it.
  • Cold compresses reduce the swelling and relieve itching.
  • Antihistamine creams work really well to give relief from bites. Promethazine cream works wonders but has been taken off the Australian market…if anyone wants to smuggle me some in that would be awesome!
  • If desperate, applying cortisone cream will reduce the swelling of all but the worst bites.
There you are my best hints on avoiding these nasty little buggers. Next time you see me sitting in the sun next to a smoky fire twitching and eating raw garlic you know that I have not gone completely loco…

*Random Fact* Despite mosquitos being much lighter than water droplets they can fly in the rain. Mosquitos are too small to break the surface tension of water so if they get hit in flight they are just slightly diverted before continuing, awesome video here

 

Jet Lag – Its cause and tricks to beat it

Jet lag is a real pain in the sleeping pattern. You have saved up for the trip of a lifetime and flown to an exotic destination just to land as an irritable, insomniac with eyeballs hanging out on stalks. You may suffer poor sleep upon arrival, trouble falling asleep (if going east), waking really early (if going west), concentration difficulties and even changes in bowel routine. Jet lag is only caused by flights going East-West or West-East. North-South flights don’t cross any time zones and will not cause Jet lag. However extended North-South flights can cause travel fatigue. Travel fatigue is different to Jet lag in that it is just your body protesting being trapped inside a dehydrating tin can for many hours. The length that jet lag symptoms last varies between individuals. Some people bounce into their new time zone without breaking stride whereas others can suffer for many days and nights.

What causes Jet lag?

Your circadian rhythm dictates your sleep/wake cycle by regulating levels of ‘wake up’ and ‘get-to-sleep’ hormones. As you have suddenly landed in a new time zone your body clock is out of sync with your surrounds, your circadian rhythm is busily pumping out go to sleep messages as you eat brunch. Adjustment to your new zone is easier if you have travelled in a westerly direction than if you have travelled in an easterly direction. Usually you need to cross three time zones to suffer jet lag proper but some people can suffer symptoms after crossing only one or two time zones.

How can I fix it?

Preflight

One good trick to minimise jet lag is to train your sleep patterns a bit before going. For example, say you are traveling to Denmark (as I will be soon for Christmas! Woop). Denmark is ten hours earlier than my home so 10pm here is midday there. A few days before flying, stay up later than usual so that your body clock begins shifting a little. This can minimise the shock. Clearly you want to check your maths so you are not pre-shifting in the wrong direction!

During flight

As soon as you board your flight change all watches to destination time and sleep accordingly. From what I can tell cabin crew dim the lights according to the time zone you have left so sleeping can be a pain. However, I find that even if you cannot sleep having your mind on destination time helps enormously.

Upon arrival

Basically push through the pain barrier and don’t sleep until it is night time. Napping is the worst thing you can do when jet lagged. You will likely be walking around drooling and staring blankly at monuments but push through. Some people take short acting hypnotics to help getting to sleep, even though this is not strictly recommended everyone does it *wink*.

Light sends a strong signal to help adjust your circadian rhythm so get out in the sunlight during the day and close the blinds at night. Melatonin is regularly used to aid adjustment but there is much debate as to its effectiveness and the dosage needed, not to mention legality in some countries.

So there you have it, all of my best tricks to beat jet lag, wait, one more…COFFEE!

 

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