HOW TO STAY HEALTHY
Tibet is the highest plateau, requiring a long journey to the nearest help or to the lowest altitude from many of its remote destinations. There are no reliable emergency helicopter rescue services; the sick or injured must be carried or ride a pack animal or motorbike to the nearest road for evacuation. Traffic accidents are the main cause of several injuries, while the most common sickness are altitude sickness, respiratory ailments, and diarrhea. You will need a first-aid kit plus the skills to use it and, unless traveling with a suitably experienced guide, some knowledge of wilderness medicine, especially regarding high-altitude illness.
By Dr, Jim Duff
Get fit, have your teeth checked, and if you are ever sixty-five or have a medicine
condition (high blood pressure, heart disease, asthma, diabetes, etc.), consult a doctor who understand what your trip entails for a thorough physical examination and advice. For additional information, go to www.treksafe.com.au
Tibet and China don’t require specific inoculation for entry. Start on your
immunization at least a month before your departure: update diphtheria, tetanus, measles, rubella, and polio vaccinations, and have hepatitis A and typhoid immunization. Obtain expert medical advice on the need for the following optional immunizations: rabies, hepatitis B, meningococcal meningitis, and malaria. The Center for Disease Control (CDC). (Go to www.cdc.gov/travel/destinations.china.aspx) provides up-to date information on immunizations.
The kit described below is a suggestion only. Quantities are for person during a
three-week remote-area trip in Tibet. The kit contains some prescription-only medication, so ask your doctor or pharmacist about inactions, doses, and side effects. A useful, compact medication resource for your kit is Pocket First Aid and Wilderness Medicine,
Splinter tweezers (pointed ends)
Protective latex gloves (two pairs)
Dressing and Wound Care
10 adhesive strips
1 moleskin packet
5 gauze pads (2-inch x 2-inch)
2 sterile nonstick dressings (4-inche)
2 sanitary pads (for absorbent padding)
1 roll plastics food wrap
1 elastic bandage (4-inch)
2 crepe bandage (4-inch)
1 roll duct tape
5 wound closure / butterfly closure (1/4-inch)
5 alcohol swabs
1 bottle povi-iodine / betadine with dropper
Allergy, Inflammation, and Itch
Antihistamine tables: 10 tablets chlorpheniramine maleate 4 mg or diphenhydramine 25 mg
30 tablets acetazolamide (Diamox™) 250 mg
10 tablets nifedipine modified release (MR) or long acting (LA) 20-30 mg
20 tablets dexamethasone 4 mg
10 tablets / capsules ciprofloxacin 500 m or norfloxacin 400 mg
20 capsules co-amoxiclav or amoxicillin 250 mg or cefalexin 250 mg
20 tablets tinidazole 400 / 500 mg or metronidazole 400 mg
1 tube antibiotic ointment (mupirocin or Fucidin) (0,5 oz)
10 capsules Loperamide
4 sachets oral rehydration solution (ORS)
Eye and Ear Infections
1 tube antibiotic ointment for eye and ear: chloramphenicol or soframycin
10 tablets ranitidine 150 mg
Nausea and Vomiting
10 prochlorperazine suppositories 5 mg (preferred) or 5 mg tablets
10 tablets paracetamol/acetaminophen 500 mg
20 tablets ibuprofen 400 mg
20 tablets codeine phosphate 30 mg (a doctor’s letter should be carried with this opiate)
HEALTH AND MEDICAL PROBLEMS
Many of the health issue trekkers might encounter in Tibet are quite similar to those
experienced in mountainous areas anywhere in the world. In most cases simple preventative measure such as boiling or treating your weather conditions will help you avoid most of the following health-related situation.
All water in Tibet is suspect and must be treated before drinking whether in the mountains or towns. The simplest ways to achieve disinfection are by bringing water to a rolling boil; by adding six drops of povi-iodine/betadine to a quart (liter) of water and waiting sixty minutes; or by adding two iodine tables (tetra glycine hydro periodide) to a quart (liter) of water and waiting thirty minutes.
THE HIGH ALTITUDE QUARTED
When about 2500 meters in a wilderness setting, the following conditions are common and often occur together: altitude sickness, hypothermia, dehydration, and low blood sugar due to lack of food. These conditions share some similar symptoms, if one condition is found, check for the others (and check the rest of your group).
HIGH ALTITUDE SICKNESS
As you ascend to high altitude, your body has to acclimatize to the decreasing amount of oxygen available and this takes time. If the ascent is too fast and /or the height gain too much, symptoms and sign of high-altitude sickness (also called high altitude illness) appears. Note that some people are acclimatize much more slowly than others. Altitude sickness consists of:
AMS (Acute Mountain Sickness): common but not life-threatening if dealt with
HACE (High Altitude Cerebral Edema): less common but life-threatening.
HAPE (High Altitude Pulmonary Edema): less common but life-threatening.
These three forms of altitude sickness can vary from mild to severe and may develop rapidly (hours) or slowly (days). People often refuse to admit they have altitude sickness and blame their symptoms on jet lag, cold heat, infection, alcohol, insomnia, exercise, lack of fitness, or migraine, and risk death by continuing to ascend. The chances of getting altitude sickness in Tibet are high and there comes a point when it is vital that the leader/doctor/ companion starts making decisions for the patient; for example, ordering immediate descent even if the patient disagree. What follows is a very brief description of AMS, HACE, and HAPE. It is strongly recommended that you get more in-depth information before travelling.
Go to www.treksafe.com.au/medical/notes_for_doctors_and_leaders.htm.
Warming: Do not ascend you can with symptoms or signs of altitude sickness
as this has led to many deaths.
AMS (Acute Mountain sickness)
Typically, symptoms appear appear within 12 hours of an ascent if the patient rests
at the same altitude, mild moderate symptoms gradually disappear as the person
acclimatizes to this altitude. AMS may reappears if the patients ascend higher as
acclimatization to the new altitude must take place all over again. If AMS worsen, it eventually become HACE.
Symptoms and Signs:
Headache, plus on or more of the following:
Loss of appetite or nausea or vomiting
Poor sleep, disturbed sleep, frequent waking, periodic breathing (while asleep breathing stops briefly followed by gasping breaths)
Rest, mild painkillers, oxygen. If not improving or if getting worse, descend!
HACE (High Altitude Cerebral Edema)
HACE is the accumulation of fluid in and around the brain. Typically, symptoms
and signs of AMS become worse and HACE develops (but HACE may come on so quickly that the AMS stage is not noticed). Also, HACE may develop in the later stages of HAPE.
Symptoms and Signs:
A diagnosis of HACE is made when there has been an attitude gain in the last few days, and the patient has a severe headache (not relieved by ibuprofen, paracetamol, or aspirin). The important symptoms and signs are severe headache, loss of physical coordination, and a declining level of consciousness.
There is a loss of physical coordination (ataxia), and the patient become clumsy, with difficulty doing simple tasks much as tying shoelaces or packing a bag. (A simple test for ataxia is the heel-to-toe walking test: ask the patient to take ten steps placing heel to toe; this needs level ground and no assistance. Excessive wobbling or inability to do this means HACE)
HACE victims will experience declining levels of consciousness with loss of mental abilities much as memory or mental arithmetic, eventually leading to confusion, drowsiness, and unconsciousness, Changes in behaviors, and nausea and / or vomiting also may occur.
HACE (High Altitude Pulmonary Edema)
HAPE is the accumulation of fluid in the lungs. HAPE may appear on its own
Without any preceding symptoms of AMS (this happens in about 50 precent of cases) or it may develop at the same time as AMS or HACE. HAPE may develop very rapidly (in one to two hours) or very gradually over days. It often develops during or after the second night at a new altitude and is the most common cause of death due to altitude illness. HAPE is more likely to occur in people with colds or chest infections. It is easily mistaken for chest infection or pneumonia. If you have the slightest doubt, treat for both.
Symptoms and sighs:
Reduced physical performance (tiredness, fatigue) and a dry cough are the earliest signs of HAPE. The important sign is breathlessness: increasing breathlessness that progresses to breathlessness even while at rest. Breathing ate at rest increases as HAPE progresses (At sea level, resting breathlessness rate to twelve breaths a m minute. At 19,700(6,000m),
Normal acclimatized resting breathing rate is approximately twenty breathes a minutes).
As HAPE gets worse, the cough may start to bring up while frothy sputum that may be bloodstained.
General treatment of Altitude Illness
Prompt, timely decent will begin to reverse all symptoms, Descent 1700 to 3300
feet (500 to 1000m) or more. Resting at the same altitude is only acceptable if the patient has mild AMS and is improving with treatment. Give oxygen either as bottled oxygen or by using a hyperbaric bag, such as PAC, Gamow, or Cretic. With HAPE or HAPE, avoid exertion as much as possible; carry the patient or at least assist them to walk and have someone else carry their pack. Keep the patient warm and hydrated and give occasional sugary drinks. If lying flat makes the patient feel worse, prop the patient up in a semi-reclining position. Give ibuprofen for headache and prochlorperazine for persistent vomiting. Acetazolamide (Diamox) is useful; give it to speed acclimatization to reverse AMS symptoms and for the periodic breathing (120 or 250 mg every twelve hours) and for HACE or HAPE (250 mg every eight hours). Note that his drug causes tingling extremities and sensitivity to sunburn.
Specific Treatment for Altitude Illnesses
HAPC: Give dexamethasone 8 mg at once, then 4 mg every six hours.
HAPE: Give nifedipine MR or LA tablets, 20 to 30 mg, every twelve hours. Note:
Nifedipine can drop the patient’s blood pressure. To reduce this risk, lay the patient down and keep him or her warm and hydrated.
If the patient has to re-ascend once symptom-free (e.g., driving out of Tibet over
high passes), give oxygen and continue giving acetazolamide (Diamox) 250mg every twelve hours. For HAPE, also give dexamethasone 4 mg every twelve hours; for HAPE also give nifedipine MR 20 mg every twelve hours.