Medical Problems

"As we made our way slowly, we were surprised to see figures ahead. We could make out two climbers sitting in the snow, with equipment strewn all around them...they were two lads of about twenty. One was wearing a black silk glove that had ripped apart to reveal yellowing fingers, frozen solid; the other was just sitting stupefied in the snow, his head bowed over his own useless, frozen hands. Yellow Fingers was quite chirpy; joking at the coincidence of our meeting at the summit like this. Dougal asked why his hands were exposed, and received a confident, flip reply. We told him that he had frostbite, and that he would probably lose his fingers, and maybe his entire hand. 'What do you mean, frostbite?' asked Yellow Fingers. We patiently explained, got his gloves and other clothes out of his sac, and did what we could to make them warmer...we heard later that the two lads had to face extensive amputation of fingers, toes, hands and feet, despite the finest treatment available at Anchorage Hospital."

Cold Injuries
Major hazards of a Denali climb are frostbite and hypothermia. Denali presents a combination of long exposure, severe weather, high altitude, low temperature and low humidity which make it one of the most severe climates on Earth. Cold resistance is impaired by high altitude hypoxia and dehydration. Mountaineering literature contains numerous vivid accounts of frostbite on Denali, such as found in Accidents in North America Mountaineering. Forty cases of frostbite (3-4%), is common for climbers on Denali each season. Several of these require extensive hospitalization, often with debilitating results. The basic essentials of adequate clothing, food and water are critical at all times. The following is excerpted, with permission, from Medicine for Mountaineering, Third Edition, by James A. Wilkerson, M.D.

"Frostbite is a cold injury produced by freezing of the tissues. The hands and feet,which are farthest from the heart and have a more tenuous blood supply, and the face and ears, which are usually exposed, are most commonly affected...As the circulation becomes severely impaired, the skin and superficial tissues exposed to severe cold begin to freeze. Ice crystals form within and between the cells and grow by extracting water from the cells. The cells are injured physically by the ice crystals, as well as by dehydration and the resulting disruption of osmotic and chemical balance..

Diagnosis and Prognosis

The typical early signs of frostbite are sensations of cold or pain [loss of sensation and numbness] and pallor of the affected skin. However, some victims may suffer little pain, and pain typically disappears as the tissues begin to freeze. As freezing progresses, the tissues usually become even whiter in appearance [pale, waxy] and all sensation is lost. With deep frostbite the tissues become quite hard.

The extent and severity of frostbite are notoriously difficult to judge accurately during the early stages, particularly while the tissues are frozen. After thawing some prognostic signs appear. With minor frostbite [frostnip], which only involves the tips of the fingers or toes, or a small area of the ears, nose or face, the tissues may only be red for a few days after thawing. With more severe injuries [frostbite], blisters commonly develop after rewarming and may cover entire fingers or toes. If the blisters contain clear fluid, the underlying tissues are usually still alive and can be expected to recover almost completely. When the blisters are filled with bloody fluid, portions of the underlying tissues are usually dead and cannot recover. The most severe frostbite injuries are not followed by blisters, probably because the circulation to the tissues is too poor. Such tissues commonly retain a deep purple color [after thawing].

Treatment

The preferred treatment for frostbite is rapid rewarming in a... water bath. Treatment in a wilderness environment should be attempted only when the following conditions can be met:

The victim can be kept warm during rewarming and afterwards... [so there is no danger of refreezing]. The greatest tissue damage occurs when frostbitten tissues are thawed and then refrozen. Far less damage is produced by walking on a frostbitten... [or thawed foot]. [Frostbite will spontaneously thaw by walking out or a night in the sleeping bag]. During rewarming, the water temperature should be maintained between 100 and... [105] degrees F (38 to... [40] degrees C). Higher temperatures further damage the tissues; the water must not be hot enough to feel uncomfortable to an uninjured person's hand. A large waterbath permits more accurate control of temperature and also warms the frozen extremity more rapidly, often resulting in less tissue loss, particularly when freezing has been deep and extensive.

During rewarming, hot water must be added to the bath periodically to keep the temperature at the desired level. (A frozen hand or foot is essentially a block of ice and does tend to cool the water.)... Warming usually requires thirty to sixty minutes, and should be continued until the tissues are soft and pliable. During rewarming, the frostbitten tissues usually become quite painful. Aspirin and codeine... may be given during rewarming or afterward for pain.

Following the rewarming, the patient must be kept warm and the injured tissues must be elevated and protected... Every effort should be made to avoid rupturing blisters, which invite infection... [At this point a determination must be made whether the patient can continue down]. Healing requires weeks to months, depending upon the extent of the injury. Subsequent care in the field should be directed primarily toward preventing infection. Cleanliness of the frostbitten area is extremely important. Soaking the extremity each day in disinfected, lukewarm water to which germicidal soap has been added may be helpful. A small amount of dry, sterile cotton may be placed between fingers or toes to avoid maceration. Antibiotics should not be given routinely, but if infection appears to be present, ampicillin or cloxacillin should be administered every six hours until a physician's care is obtained."

Body tissue which is frozen, thawed and refrozen will be damaged much more than tissue which is frozen only once. All precaution must be taken to insure that the thawed extremity is not refrozen. In many cases each season, individuals with minor frostbite are able to descend to base camp without further tissue damage. However, avoidance of refreezing is paramount and care must be given to prevent both infection and the breaking of blebs which occur with rewarming. Reaching the base camp airstrip will expedite your departure for medical treatment.

Acclimatization
It requires one to two weeks to become well acclimatized to a given altitude on Denali (depending on the individual). Individuals also lose this acclimatization in the course of a few weeks. Talkeetna is close to sea level which is a major disadvantage for someone who has established some acclimatization and is waiting to fly in. The longer they wait, the more acclimatization is lost. Several days spent high on peaks before your arrival will not be enough to transfer that acclimatization to your climb here. You will lose that acclimatization in transit.

Limit your ascent to 300 meters (1,000 feet) per day at elevations above 3000 meters (10,000 feet). The following schedule is the fastest recommended rate of ascent of the West Buttress given ideal weather. Expeditions should plan on 21 days.

Day 1: Base camp 7200 feet (2200 meters)
Day 2: Base of 'Ski Hill' 7900 feet (2400 meters)
Day 3: Upper Kahiltna 9600 feet (2900 meters)
Day 4: Camp 11,000 feet (3350 meters)
Day 5: Rest
Day 6: Bergschrund 13,000 feet (3960 meters)
or past Windy Corner 13,500 feet (4115 meters)
Day 7: Basin 14,200 feet (4330 meters)
Day 8 through Day 11: Rest in Basin, acclimatize and carry high sleep low.
Day 12: Move to 16,200 feet (4940 meters) Ridge Camp
or 17,200 feet (5240 meters) High Camp
Day 13: Rest
Day 14: Summit

Many other factors figure into this, including the weight carried, weather, and each member's health. The extra rest days at 14,200 feet (4330 meters) have proven to be critical before ascending higher. Allow 3 to 5 days food and fuel at high camp.

Physiological and Physical Impairment
Mountaineers preparing to climb Denali must be aware that everyone will be physically weaker at high altitude. Expeditions can expect to move more slowly and will not be able to carry very heavy loads. There are also other problems at high altitude less commonly known but potentially as dangerous, such as mental impairment, dehydration, fatigue, loss of cold resistance, and lack of recuperative powers. The major environmental variable responsible for these effects is lack of oxygen (hypoxia) associated with high altitude.

Mental Function
Bradford Washburn has estimated that above 18,000 feet (5500 meters) on Denali a person is reduced to roughly 50% of their mental capacity. During the winter climb of 1967, the tree members stranded at 18,200 foot Denali Pass for six days required approximately twice as much time to answer a series of subtraction problems as they did at 7000 feet on the Kahiltna Glacier.
In retrospect, most high altitude climbers can recall situations in which their thinking was impaired and their judgement poor. These effects are insidious, since climbers are not aware of the impairment at the time. A controlled exposure in a low pressure chamber is often necessary to convince a climber (or pilot) of the effects of hypoxia. Many high altitude climbing accidents may be attributed to such lack of judgement. Thus, it is important that climbers realize in advance that their mental functions will be impaired. Advance planning should be thorough and complete to avoid a critical situation which poor judgement and slow thinking will magnify. For example, sudden impulsive decisions to go on or return must be considered carefully.

Lassitude.
At high altitude motivation can diminish greatly. Thus, Joseph Wilcox, leader of a 1967 Denali party wrote in his diary:

"With five people crammed in the tent, morale decreased rapidly. There was no interest in cooking meals and by the next day no one was even interested in melting drinking water. We found ourselves very apathetic...not caring whether or not we got enough to drink or eat or if our gear was wet...we just lay there and waited with little or no sleep...by morning the cold had taken its toll...Jerry Lewis and I had numb feet and I had numb fingers."

Here the motivation to do even the simplest camp chores almost disappeared, yet these tasks of melting snow, cooking, or drying clothes in the wind will help determine the success and safety of the party. The will to survive and succeed must be maintained. Inactivity during tent bound stormy days can itself be devastating to morale, and as tiring and debilitating as climbing. Keep the body limber and mind alert on storm days with camp projects in and out of the tent.

Illness or Injury
It is difficult for the body to recover from illness and injury above 14,000 feet (4300 meters). Descending to a lower elevation is often the only solution for a complete recovery.

Diarrhea may be serious when climbing above 14,000 feet (4300 meters) because dehydration is further aggravated, and with impaired absorption the body receives little nourishment and is further weakened. A person suffering from severe diarrhea should descend or be assisted below 14,000 feet (4300 meters). This person should not go back up until gastrointestinal function returns to normal.

Dehydration
Dehydration is a major hazard of high altitude mountaineering. Dehydration may compound the problems of any illness or injury, making recovery more difficult. It contributes to frostbite directly, by causing constriction of blood vessels in hands and feet.

Climbers have difficulty drinking adequate amounts of water above14,000 feet (4300 meters). Fuel for melting snow is not difficult to carry, yet the tendency is to take only a minimum rather than an adequate amount. It is inviting tragedy not to have at least a week's supply of fuel if one plans to spend even one night above 17,000 feet (5000 meters). This fuel must be used to provide each climber with at least three liters of liquid per person each day. Water bottles should be filled as often as possible and kept in sleeping bags at night to prevent freezing.

Fatigue
To a considerable extent, Denali represents a problem in logistics and weather. Climbers feel that they must make the best use of good conditions, even though doing so may overextend the physical and emotional capabilities of some or all of the party. If violent weather overtakes them in this condition, tragedy can follow. Climbers must maintain a physiological margin of safety against fatigue and cold just as they do food and fuel. In this connection, it is worthwhile to put in the effort of preparing igloos or snow caves for shelter at high altitude rather than tents. They provide greater protection and rest.

Sleep
Standard sleeping mediations should be avoided above 10,000 feet (3000 meters). Sleep medications cause a decrease in the respiratory response, lowering blood oxygen levels, which can cause Acute Mountain Sickness (AMS). Diphenhydramine or Acetazolamide are the drugs often prescribed for sleep at high altitude.

Carbon Monoxide Poisoning
Cooking in poorly ventilated areas such as tents with all doors and vents closed, or old ice glazed igloos and snow caves, produced two serious cases of Carbon Monoxide (CO) poisoning in 1985, and two deaths in 1986. We suspect that many others also suffered lesser forms of CO poisoning. Furthermore, CO poisoning may be a contributor to AMS. This may have been the case in the 1993 rescue of a Czechoslovakian climber who developed severe HAPE (High Altitude Pulmonary Edema) and HACE (High Altitude Cerebral Edema). It is difficult to distinguish between Mountain Sickness and the early symptoms of CO poisoning. An inexpensive CO detector which has been found very beneficial can be acquired at most hardware stores. Avoid the temptation to heat shelters with cooking stoves. Allow for good ventilation. Extra caution is necessary if two stoves are being used at the same time. Cook in the open as much as possible.

"Carbon monoxide poisoning among mountaineers is probably much more common than realized. The effects of CO and altitude hypoxia appear to be additive, and thus CO exposure at altitude is much more dangerous than at sea level. Recent measurements by William Turner and Bill Summer, on Denali, found toxic levels (greater than 750 parts per million) of CO near the stove in tents, snow caves and igloos. A major factor in producing CO is the damping effect on the flame of having the pot too close to the flame from condensation on the pot. Keeping the pot warm and adding snow slowly to warm water thus produces much less CO than filling a pot with snow. Climbers cooking in shelters should try to minimize condensation on the pot.

Adequate ventilation is the key to removing CO from a shelter. The Swiss climbers' tent was made of an apparently unbreathable material, and closing the vents sealed the tent as well as their fate. The same could happen when cooking in a tent completely buried by snow, or in an igloo with glazed ice walls on the inside. In a tent, ventilation is a function of the wind and the area of the vent opening. When cooking in a snow cave or igloo, the vent must be at least of ski pole basket- sized diameter, should be placed directly above the stove, and can be sealed when not cooking in order to maintain warmth. Climbers with symptoms of Acute Mountain Sickness must be especially careful. CO poisoning should be considered in anyone unwell at altitude if using a combust able appliance in a closed shelter. Treatment is to stop the CO production, and have the victim if conscious, hyperventilate in fresh air. Descent to a lower altitude, administration of oxygen, and forced hyperventilation by mouth to mouth breathing may be required for comatose victims."