Relationship between Cognitive Impairment and Acute Mountain Sickness, Nepal Experience

Isabel M. Algaze Gonzalez, MD

Program: Fellow in Wilderness Medicine at MGH

PGY: 5

Nepali baby with gastroenteritis the most common infection in Nepal

My first case of High Altitude Cerebral Edema (HACE) was a mild one and I hesitated to make the diagnosis. I was expecting someone completely disoriented, incoherent and ill looking.  It was a middle aged man that was complaining of "my feet are not going where they are supposed to"  He was coherent, oriented times 4, looked good in general, however had a headache and marked ataxia. The nepali interpreter and aid post manager, who had vast experience assisting doctors before me, saw me performing all sorts of neurological exams and when I was about to go through the mini mental, he put his hand on my shoulder and told me "yes this is HACE". The patient was appropriately treated and, also to my surprise, there was great improvement after 6 hrs into treatment.

  

Everest climber with HAPE. Checking for B lines.

At the end of the season we saw 500 patients 65% Nepali and the rest were foreign trekkers and climbers. We saw about 15 High Altitude Pulmonary edema (HAPE) cases, 9 HACE and 5 combined HAPE and HACE. Acute Mountain Sickness (AMS) was one of the predominant diagnosis along with gastroenteritis, Khumbu cough (type of bronchitis) and pneumonia.
There was a surprising amount of Nepali suffering from AMS. Foreigners developed altitude related illness mostly from coming up too fast. In contrast Nepali patients developed symptoms mostly because of carrying heavy loads, poor hydration or lack of altitude     experience. 

          Gastroenteritis seemed inevitable given general hygiene practices, boiling water was not enough. If the gastro didn't get you the dryness, cold and dust in the air could trigger the dreaded Khumbu cough, where patient's cough, and cough and cough until your chest hurt.
Pneumonia was quite predominant in locals because heating was based on sitting next to a burning fire stove every day. 

Kata from our porter and guide to Everest Base Camp. Here with the Indonesian Dr. Chandra Sembiring and friends

As for my study, the researchers arrived and trekked to their respective altitudes. We recruited our target number of subjects. We noticed many changes in cognition amongst ascending trekkers. Data is very exciting and we aim to publish sometime this year.
I had the great opportunity to absorb cultures very different from mine. l got to see and treat illnesses that I would have not encountered under other circumstances. I learned to survive under extreme conditions. I gained knowledge about climbers, trekkers and their medical needs. I learned about cognitive impairment. This was an incredibly amazing, challenging, beautiful journey and I'm very grateful to have this opportunity and hope that my findings benefit and advance the care of the increasing number of people that engage in wilderness experiences.

On top of Kala Pattar. Behind me Mt. Everest