By Larry Rigsby M.D.
Dr. Larry Rigsby, practices as
an Internal Medicine physician in Montgomery, AL. He is a regional medical
director for Eagle Hospital, a medical consultant for Himalaya Inc. and has a
great interest in high altitude medicine and physiology. He is a mountaineer
and have been on several expeditions to Alaska including Denali and Moose's
tooth. He recently climbed Ama Dablam in the Himalaya and will be on the
north or Tibetan side of Everest this spring.
He plans to do a series on
mountain medicine to help promote safety in the mountains and keep climbers
and trekkers up to speed on the latest medical info available. The first in
the series is on Travel Medicine with subsequent articles on Altitude illness,
hypothermia , frostbite etc. These will be updated periodically. He is willing
to do a short Q&A, submit questions to
Medicine for Trekkers and Climbers in the Himalayan Region
Just getting to base camp healthy is half the battle.
Unfortunately, every year a number of climbers or trekkers will have to abort
their plans due to illness. Whereas gastroenteritis or bronchitis might not be
considered such a major illness at sea level, it can be devastating at
altitude. This article will focus on preparation and preventive measures which
can be taken to help insure you will arrive at base camp healthy and ready to
tackle the climb.
It is important to get a physical examination at least 4-6 weeks, or longer,
in advance of your trip. This is important so you may identify and correct any
problems which may be uncovered. This will also allow adequate time for your
immunizations (see below).
physical should be done by a physician who has knowledge of altitude illness
and travel medicine. The physical should evaluate your general health and
screen for illnesses such as hypertension, diabetes mellitus, anemia, ulcer
disease, cardiovascular disease and lung problems such as asthma. A
cardiovascular risk assessment should be made, especially for anyone with a
strong family history or over the age of 40. 8000 meters is not the place you
want to discover you have an illness such as asthma or a bleeding ulcer.
Get a good
dental check up and correct any problems. Again, an abscessed tooth can put an
end to a climb. Prepare your medical kit (see below) in advance and make sure
you are not allergic to the medications or that they do not interfere with any
current medication you are taking. For example, you cannot use Diamox or
Acetazolamide if you are allergic to sulfa. It might be wise to take Diamox
and see how you react prior to taking this for the first time at altitude.
Altitude is not a place to experiment with anything.
Pretend as if you are leaving two weeks prior to the scheduled date. Have your
gear ready and bags packed two weeks prior to departure. Don’t over train and
don’t overwork. Just as a marathoner would do, try to peak in your training
2-3 weeks before and then begin a taper. At this point in time, just maintain
your level of fitness. A last minute effort may well lead to injury or over
training. If this happens, a level of fatigue will set in that will take a
while to resolve. This can also affect the immune system and lead to an
increased susceptibility to viral illness such as colds and influenza.
Keep up your
nutrition and hydration during this time.
As the saying
goes “The hay is in the barn.” Enjoy your family and the excitement of the
Travelers should update their routine immunizations and have adequate immunity
to measles, mumps, rubella, tetanus, diphtheria, pertussis, varicella and
infection. Climbers going to Asia or Africa should have adequate poliovirus
vaccination. Influenza vaccine should be considered, and pneumococcal vaccine
considered if indicated.
Hepatitis A is
the most frequent, vaccine preventable, travel related infection. The
hepatitis A vaccine is indicated for most non-immune travelers in the
developing world. Typhoid vaccine should be considered as well. Vaccination
against hepatitis B, rabies, yellow fever, cholera, meningococcal disease and
encephalitis might be considered depending on the area of travel and level of
exposure. These vaccines are not indicated for travelers to the Himalayan
The Center for
Disease Control and Prevention (CDC) has a web site: www.cdc.gov/travel/. This
site provides information on immunization requirements and updates on travel
related infections. The World Health Organization (WHO) has a similar site:
The risk of
malaria is considered low for trekkers or climbers going to the Himalayan
region. If your travels take you elsewhere, you need to consult with your
physician or the CDC web site to see whether malaria prophylaxis is indicated.
Your medical kit should be developed with the consultation of your physician.
As pointed out earlier, high altitude is not the place you want to have a drug
or allergic reaction. You should have an ample supply of your regular
prescription medicines such as blood pressure or diabetic medications. It is
not a bad idea to have a dual supply, one in your carry on and the other in
your checked luggage.
taking the following items in your medical kit:
Insect repellent containing DEET
Topical antibiotic cream
Iodine tablets and/or water filter
Diamox or Acetazolamide
Acetaminophen or Tylenol for analgesia
Ibuprofen or Advil for analgesia and as an anti-inflammatory
Immodium or Lomotil for diarrhea
A nasal decongestant such as Afrin
Pepcid or Zantac for heartburn
An antibiotic, especially a Quinolone such as Ciprofloxacin
A prescription pain medication such as Tylenol with codeine
An asthma inhaler if you are prone to exercise induced asthma
or asthma associated with bronchitis or upper respiratory infections
Associated Illness: During air flight, barotrauma can occur to the ears and
sinuses due to the pressure differential. This can cause pain in the ears and
sinuses and diminished hearing. This is especially the case if one has an
upper respiratory infection. It is important to chew or swallow during ascent
and descent. Use a nasal decongestant spray if you have a head cold or upper
infections. Be careful of handshaking and wash your hands frequently.
clots. Extended air travel may increase the risk for venous thrombosis or
blood clots. This is controversial. However, it is reasonable for all
travelers to do the following:
Avoid dehydration by consuming a lot of fluids
Avoid constrictive clothing
Move about the cabin every one to two hours
Change positions in your seat frequently and flex and unflex
the knees and ankles
Aspirin may be helpful, but it is not formally recommended
crossing several time zones may experience jet lag. Melatonin is a popular
treatment for this. This is of unproved benefit. The body clock normally
resets at one hour per day. Engaging in an activity in sunlight shortly after
your arrival at your destination may help.
The cabins are
not fully pressurized in commercial jets flying at high altitude. The
atmospheric pressure is equivalent to approximately 2500 meters above sea
level. For the fit mountaineer or trekker, this is inconsequential. However,
for someone with existing cardiopulmonary condition, this can pose a problem.
Heads up here. Don’t blow it in Katmandu. There is a lot of excitement here
and there is a lot of disease waiting to happen. Chill out. Stay relaxed and
focus. Continue to rest, hydrate, and avoid alcohol. Limit your time out in
the city. You can buy your souvenirs and celebrate on your way home. Now is
the time to be diligent with handwashing and prevention of traveler’s
diarrhea, upper respiratory infections and bronchitis (see below).
Travel Related Illness: As noted, hepatitis A is the most frequent vaccine
preventable, travel related illness. The risk for hepatitis A is 300 per
100,000 travelers per month in developing countries. The incidence is much
higher in backpackers and those traveling in remote regions. Hepatitis A
vaccine is recommended. Four weeks after the first dose of the vaccine,
immunity develops in approximately 95% of individuals. Two doses provides long
term immunity. Intramuscular immune globulin can be given to those requiring
Diarrhea is the most
common illness of travelers. This is termed travelers diarrhea or “turista”.
It can occur in up to 60% of travelers. The incidence is high in Katmandu. The
highest risk months are from April to July. This risk does not diminish with
the length of stay and the attack rate in one study was 49% per month during
the first two years of residence. Approximately 20% of people affected will be
bedridden for several days and up to 40% have to change their trip itinerary.
This can be devastating to a climber or trekker.
organisms are enterotoxigenic E. coli, Campylobacter, Shigella, and
Salmonella. Viral causes and parasites such as Giardia and Cryptospiridium are
occur between 4 and 14days after arrival. The illness generally lasts 1-5
days. The classic symptoms of “turista” are malaise, weakness, loss of
appetite, and abdominal cramps followed by watery diarrhea. Low grade fever
may occur. More severe forms may have symptoms of colitis with blood and pus
in the stool. Belching and indigestion are typical of giardiasis. Most cases
are self limited. However, antibiotic therapy has been shown to reduce the
duration from 3-4 days to 1-2 days with as little as one dose of antibiotic.
Most of the organisms responsible are sensitive to the Quinolone antibiotics
such as Ciprofloxacin, Levaquin, or Norfloxacin. The current treatment
recommendation is 1-5 days of treatment with either: Ciprofloxacin 500 mg.
twice daily, Norfloxacin 400 mg twice daily, or Levaquin 500 mg daily. Pepto
Bismol tablets or liquid can be given in large doses. Azithromycin or
Zithromax may be helpful. Some species of Campylobacter have become resistant
to the Quinolone antibiotics and should be sensitive to Zithromax or
drugs such as Loperamide (Immodium) or Diphenoxylate (Lomotil) can be used to
control the diarrhea. Caution should be exercised using these drugs when
bloody diarrhea is present.
replacement is the most important aspect of treatment. This should be done
with an oral rehydrating solution which contains sodium and glucose. The
intestine is able to absorb water if sodium and glucose are present. Packets
of oral rehydration solution are available. You can make your own solution
using one teaspoon of salt and eight teaspoons of sugar in one liter of water.
One cup of orange juice and two bananas can be added for potassium.
persist with intractable vomiting, diarrhea, increasing abdominal, pain,
fever, and bloody diarrhea; medical attention should be sought.
the key. The following measures can be taken to help prevent “turista”.
be purified. This can be done either by boiling for 5-10 minutes, using
iodine tablets or solution and waiting approximately 30 minutes, use of a
compact water filter, or adding two drops of 5% sodium hypochlorite (bleach)
to 1 quart of water and waiting 30 minutes.
Wash hands with soap and water frequently and especially
Avoid uncooked food (other than peeled fruits or vegetables).
Avoid unbottled beverages and unpasteurized dairy products.
Eat well-cooked hot foods.
Use bottled water for drinking and brushing teeth.
Avoid ice cubes.
Remember alcohol does not sterilize water or ice.
Beware of Chang!
Condiments on the table can be contaminated.
diarrhea, respiratory infections are the most common illnesses affecting
travelers. If indicated, pneumococcal pneumonia and influenza vaccines are
excessive outdoor exposure in areas of heavy air pollution, especially during
hot or humid times of the day. Avoid prolonged exposure to fumes from indoor
cooking and stoves, especially in tea houses.
Most cases of
bronchitis are self limited and do not require specific antibiotic treatment.
For symptoms that persist, especially if the cough is productive, an
antibiotic such as Zithromax or Levaquen would be a reasonable choice. If the
cough is accompanied by fever, pleuritic or sharp chest pain, or shortness of
breath, you may be dealing with something more serious such as pneumonia.
Immediate medical attention would be advisable in this circumstance.
Dr Larry Rigsby is
willing to do a short Q&A, submit questions to
We ask you to
consider giving or helping with:
The dream is to build a series of
clinics across Nepal.
1. Ryan, E., Kin, K. Health Advice and Immunizations for
Travelers. N Eng J Med, 2000, Vol. 342:1716.
2. Thielman, N, Guerrant, R. Acute Infectious Diarrhea. N Eng J
Med, 2004, 350:38.
3. Hoge, C, Shlim, D, et al. Epidemiology of Diarrhea Among
Expatriate Residents Living in a Highly Endemic Environment. JAMA, 1996,
4. Center for
Disease Control and Prevention (CDC). www.cdc.gov/travel/
Health Organization (WHO). www.who.int/ith/.
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