Mt. Whitney Portal Store & Hostel Forums General Mt. Whitney Portal Store Message Board Summited Whitney, and an AMS story...

First, thanks to some great advice on this forum! It was very helpful on our successful hike to the Summit!

Me and a group of 6 friends attempted Mt Whitney day hike thru the Main Whitney trail and 6 of us successfully completed the hike on Sunday. We were all first timers and hikers with intermediate skills.We had hiked Mt Baldy in LA (10,064 ft) a few times for practice.

Our hiking experience was great except for a severe case of AMS for one of our friends. We started at 3 AM and all of us took it very slow going up (12 hrs). We had spent the previous night at the portal, but wanted to be cautious and go slow to acclimatize well.

One of us decided (wisely, I might add) to go back at 13,500 ft. The rest of us split into two groups of 3 each. The first group was about an hour ahead. I was in the second group, and was feeling good, but the other 2 in my group were showing signs of fatigue and one of them complained about dizziness. We were discussing if he should go back, but after waiting for a while he was ok. We continued and summited at 4 PM and after taking few pictures, started back almost immediately. We were well dressed for cold weather and had headlamps. Almost immediately my friend's dizziness came back and he couldn't walk fast. I took over his backpack and carried it. We thought once we reach trail camp he might get better, but boy were we wrong! We reached trail camp at 9.30 PM, refilled our waters and filtered them, but his symptoms got much worse. He was not coherent and started blabbering, and his mobility decreased. Me and the other friend kept talking to him and helping him walking down, but it was very slow, we were moving about 0.5 miles an hour. Water, food didn't help. Since it was so late, there was no one else on the trail. We navigated thru the darkness with headlamps, carrying his backpack and refilling water whenever we crossed streams. We reached outpost camp at 1 AM, but his symptoms still remained the same. He couldn't talk at all and it didn't look like he understood what we were saying to him. A friendly group of hikers passed us at that time and stopped to talk to us. When we explained the situation they thought it could also be because of not having eaten enough salty food and drinking only water. They gave us some sodium tablets and offered a space blanket in case we wanted to sleep for some time and continue. In retrospect, we should have probably done that, but at that time we were not sure what our friend was suffering from and wanted to get him down as quickly as possible. We gave him the sodium tablets and continued down. He vomited after while. After a brief rest he was able to talk, but still not very coherent - something like 'I thank you both for not leaving me here', but not in a lucid way. We reached Lone Pine lake junction at 4.30 AM. My other friend was not having enough water and food - he was getting a bit stressful too. I was feeling sleepy, but OK otherwise. I asked my other friend to go down and get help from our other group of friends, but he came back after 30 minutes and said he was lost. After a while, my friend with AMS symptoms seemed a bit better, he could talk now, but still could not understand where we were and what we were doing. At 6 AM I decided to go for help, and asked the other friend to keep coming down. I reached our campground in an hour, completely drained and told the story to the other waiting friends. Two of them quickly left for the trail with a radio. About 45 minutes later we got a call from them asking us to bring our RV to the trailhead. We did so and met them at the trailhead. After a few hours of sleep, he regained his full mental abilities, but he still could not recollect all the events of the night - he vaguely remembers a few moments, but it was very fuzzy for him.

For a first timer on the mountain, it was a bit scary for me, but thankfully it ended well. I'm glad I was not too exhausted to help him. We thought it was AMS, but were baffled when the symptoms did not go away even after coming down to 9500 ft. I still don't know for sure, but it was probably a severe case of AMS. He is fine now, and we are all happy for that.

Have any of you heard about similar experiences? From the above account, can you say it was AMS for sure?

First of all, I'm glad your friend made it down OK, and has made a full recovery. And props to your group for staying with him all the way.

One of the first rules of mountain medicine is the if a person doesn't feel well at altitude, it is AMS until proven otherwise. I'm a bit surprised that you don't mention other symptoms of advanced AMS, such as loss of coordination (he was able to continue walking for 12+ hours), headache, vomiting (except for the salt tablet episode), and mood changes or uncooperativeness. That doesn't mean it wasn't AMS, it's just curious. It's also curious that your friend didn't begin to feel better after descending past Trail Camp. That should have made a difference, but perhaps his situation was advanced enough that it would take several hours for the symptoms to clear.

I'd wonder about your friends food intake, though, as those same symptoms can also be attributed to hypoglycemia (though as with AMS, your friend didn't exhibit all of the symptoms of hypoglycemia either). AMS usually doesn't get better once it starts, but lowering your blood sugar demand by resting will improve the availability of glucose to the brain. The fact that he felt better after resting makes me suspect low blood sugar. But if your friend ate well on the way up, and continued to eat and drink on the way down, then hypoglycemia doesn't seem likely, though it still might have been a contributing factor to his overall condition. I also wonder, is your friend diabetic?

All of that notwithstanding, it sounds like a mild case of HACE to me. If that is correct then you definitely did the right thing bringing him down ASAP. Another thing to think about in the future is having a better emergency plan. HACE can be fatal within hours of its first recognizable symptoms if not treated with descent, and possibly medication. Because you don't necessarily have a lot of time to get a HACE victim to definitive care (or at least low enough to make a difference), having a plan to get help could be useful. Helicopters won't fly in the dark, but your friend could have been evacuated by first light if authorities had known. Sending someone for help once it becomes obvious that you will still be on the mountain come daylight might be an option to consider if this ever happens again.

Wow. That was quite a story. Thank you for sharing it. It sounds like it was a combination of several things: Overhydration, sodium (salt) depletion, and AMS.

Most people remember to drink a lot of water during big hikes, but many of those same people forget that the body needs to also replenish the lost salt (due to sweating & working the body). People have even died during hikes and marathons due to overhydration and lack of salt to compensate. Salty foods/sodium intakes are a must during any major hike or climb.

My recommendation, for future hikes: Go to REI and pick-up the 'Margarita' flavor of "CLIF Shot Bloks". They have electrolytes, carbohydrates, and extra sodium. What's nice is that, because they are in a small gelatinous cube form, you can truly regulate your intake of them. I used these (and others of) "CLIF Shot Bloks" when I did a first-time summit of Mount Rainier about three weeks ago, and they made such an impression with me that I will never leave for any other major hike without them!

With that said, congratulations on your summit!!!

The sudden and dramatic onset strongly suggests AMS, at least in part.

However, it was very warm on Whitney this past weekend (I was on the MR), and dehydration/electrolyte imbalance was certainly a risk.

Your friend probably got sick as some combination of both. There are a few studies looking at the link between dehydration and AMS. The symptoms of both can be similar enough to make a definitive diagnosis difficult. Either can be life-threatening, as you saw firsthand.

Glad you all made it out safely!

Andy

I would respectfully disagree with this assessment (except for the AMS part). In my 30+ years of hiking and climbing I have never experienced, or known of someone else who experienced illness as a result of overhydration or sodium deficincy. Unless the OP tells me that his friend was drenched with sweat for hours on end, or drinking almost continuously, I would conclude that neither of these were issues for him. If his friend was eating anything other than candy on the way up, it is likely that he got plenty of replacement salt from his food.

Based on what you've written it is hard to say for sure that your friend had AMS (or, incidentally, something worse). I'm not a doctor. Someone else on this board probably is.

I have, however, done reading on AMS/HACE/HAPE for personal use. Most high altitude physicians will tell you that if your symptoms are anything other than mild don't "wait and see" what happens. Go lower.

AMS generally feels like a bad hangover, most notably a headache that is generally in the back of the head. Above 14,000 ft. a majority of people will experience at least some mild symptoms of AMS. AMS symptoms can range from mild in nature to pretty severe. Tolerance of this depends on the individual. Even experienced and very fit climbers can get AMS. Most know their tolerance zones and how to "acclimitize out" of AMS properly.

What concerns me about what you've written is your friend's inability to think. Based on what you've written -- and, again, I'm not a doctor -- your friend may have been borderline HACE (high altitude cerebral edema), which is a swelling of the brain. The tell-tale sign of HACE is usually a change in one's ability to think (what's called mentation). A staggering walk (like when you're drunk) is another tell-tale sign. HACE is serious and must be taken seriously.

I suspect malnourishment and exhaustion may have been present here too. But you were right to be scared. HACE can (emphasis on can, not will ... don't panic) be fatal in a matter of a few hours. If you have other symptoms and think you are developing HACE, test it. Draw a straight line on the ground with a stick, and walk it one foot in front of the other (just like the cops during a DUI stop). You should be able to do it no problem, even after several hours of climbing.

I saw several people with severe AMS/borderline HACE on the mountain this weekend. Multiple people were vomiting or dry heaving and staggering. As I mentioned in another post today, one guy was unable to stop from urinating all over himself.

I'm new to Whitney, but not mountains, and I really didn't like the "run and gun" attitude I saw many people taking on the mountain.

Steve,
You're way more experienced than I am, but I think it's tough to dismiss hyponatremia so easily. I just had a novice hiker acquaintance get airlifted out of the Grand Canyon on the brink of death from hyponatremia. The issue wasn't solely sweat but the balance between water and sodium in his body. He's fine now, thanks to the great IC unit in Flagstaff, but it's a good lesson to all who over-drink with good intentions that too much of anything, including water, can be hazardous.
Cheers.

thedejongs,

Acute hyponatremia has gotten a lot of attention in recent years. It is way, way better to "over-drink" in the backcountry than to worry about over-hydrating.

As a general rule, mix Gatorade powder into your water and you don't have to worry about acute hyponatremia.

If this had happened in the Grand Canyon I would put hyponatremia near the top of my list of suspected problems. But this case (as presented) doesn't fit.

BTW, I wouldn't say that your friend's problem was too much water, but not enough electrolyte. As Dryfly said, mix some Gatorade (actually, I would recommend Cytomax or Gookinaid) with your water and you will be fine.

Thanks to you all for sharing your thoughts. My first thought was HACE too, but I have read that HACE usually occurs after long periods on the mountains, such as a week or more. Is it possible that mild symptoms of HACE could occur even after 12-14 hours at higher altitudes? I am almost sure that he ate and drank well up to the top (he works out well and has done many hikes including grand canyon, half-dome, baldy), so it is unlikely that he had sodium deficiency.

My friend's symptoms included dizziness, sleepiness, disorientation, loss of memory (he didn't know where he was and where we had to go etc), irrational behavior, vomiting (after having the sodium tablets).

Those symptoms are entirely consistent with HACE. HACE is but one end of the AMS spectrum. The nausea and vomiting associated with mild AMS are in fact the result of mild swelling of the brain. It's only when this swelling gets to the point of causing more severe symptoms (drop in AVPU scale, lots of vomiting, loss of coordination, etc.) that it gets labelled as HACE. Contrary to what you may have heard, the bodily changes that may eventually become HACE start as soon as you reach altitude. How quickly and how far it progresses depends on the person, how rapidly they ascended, how high they went, etc. Each person is different, and past experience is no guarantee that future trips will be the same. Your friend may never again experience the symptoms he did on this trip, or he may experience them only occasionally. Pay attention, have a plan, and turn around if someone in the party is not doing well.

Ram,

No sources I know of say that extended time at high altitude is an absolute pre-condition for developing HACE. It can appear with alarming speed and worsen rapidly, particularly above 12,000 ft., and without any other symptoms of AMS.

The thing to remember next time is if you even suspect HACE, go down immediately. The Himalayan Rescue Association does not even allow backpackers with symptoms of HACE time to pack up their gear. They just give them oxygen and immediately take them lower, leaving all gear behind.

Also, remember that almost no one should get AMS in any form. Only a very small number of people have existing pre-conditions that make them more prone to the illness. Everyone else just fails to acclimate, which puts themselves and others at risk.

This story reminds me of one from last year:

    Three Errors and an Air evacuation July 14th

This hiker had been out for a number of nights, and was doing relatively ok. But then he developed severe HAPE symptoms suddenly while hiking from Guitar Lake to Trail Crest.

Steve is right, but it's my understanding that HACE may occur without any other symptoms of AMS being present.

Here's a quick guide that helps to distinguish between AMS, HACE, and HAPE, taken from "Medicine for Mountaineering," 5th edition:

AMS:
Headache or nausea with or without vomiting
Sleep disturbance
Undue fatigue or shortness of breath

HACE:
Increasing headache
Confusion
Ataxia (clumsiness when walking or using hands)
Progressively worsening disorientation
Coma and death

HAPE:
Increasing shortness of breath, particularly on exertion
Irritative cough later producing pink spectrum
Extreme fatigue progressing to unconsciousness

If you don't know, don't go any higher!

Dryfly,

I had read that in Wikipedia (http://en.wikipedia.org/wiki/HACE) - which could be wrong.

As far as acclimatization, we had hiked Baldy a few times (10,000 ft) and San Gorgonio once (11,000+ ft). We camped at the portal Friday & Saturday nights and started the hike early morning of Sunday (2:30 AM). One another observation is that he could not sleep Saturday night (due to noise from the neighboring campers and probably excitement)

Overhydration is an excess of water in the body.

Overhydration occurs when the body takes in more water than it loses. The result is too much water and not enough sodium. Thus, overhydration generally results in low sodium levels in the blood (hyponatremia (see Minerals and Electrolytes: Hyponatremia). Usually, drinking large amounts of water does not cause overhydration if the pituitary gland, kidneys, liver, and heart are functioning normally. To exceed the body's ability to excrete water, an adult with normal kidney function would have to drink more than 2 gallons of water a day on a regular basis.

Overhydration is much more common among people whose kidneys do not excrete urine normally—for example, among people with a disorder of the heart, kidneys, or liver. Overhydration may also result from syndrome of inappropriate secretion of antidiuretic hormone (SIADH). In this syndrome, the pituitary gland secretes too much antidiuretic hormone, stimulating the kidneys to conserve water (see When the Body Has Too Much Antidiuretic Hormone).

Brain cells are particularly susceptible to overhydration (as well as dehydration). When overhydration occurs slowly, brain cells have time to adapt, so few symptoms occur. When overhydration occurs quickly, confusion, seizures, or coma may develop.

Doctors try to distinguish between overhydration and excess blood volume. With overhydration and normal blood volume, the excess water usually moves into the cells, and tissue swelling (edema) does not occur. With overhydration and excess blood volume, an excess amount of sodium prevents the excess water from moving into the cells; instead, the excess water accumulates around the cells, resulting in edema in the chest, abdomen, and lower legs.

Treatment

Regardless of the cause of overhydration, fluid intake usually must be restricted (but only as advised by a doctor). Drinking less than a quart of fluids a day usually results in improvement over several days. If overhydration occurs because of heart, liver, or kidney disease, restricting the intake of sodium (sodium causes the body to retain water) is also helpful.

Sometimes, doctors prescribe a diuretic to increase urine excretion. In general, diuretics are more useful when overhydration is accompanied by excess blood volume.

Last full review/revision February 2003



Hard to tell as symtoms of AMS,low blood sugar,and overhydration overlap. As is common in illness there are frequently co-morbidities. So a combination of all the above may apply.

Actually,

AMS (a 'constellation' of altitude-related symptoms) is ubiquitous among high-altitude travelers. Everyone gets it, which makes it especially difficult to offer a one-size-fits all rule on what to do when (not if) you experience it.

Some people will indeed need to descend immediately at the first sign of a headache. Others will suffer little more than nausea and discomfort if they press on. And doing well or poorly on one trip is no guarantee you'll fare the same on your next climb.

Please note I do not include the two severe forms of AMS within the range of 'normal' symptoms: HAPE and HACE. If you suspect you or a fellow climber is suffering from either, the afflicted party must descend immediately.

combine two old clinical "saws"

1. Symptoms at altitude are due to AMS until proven otherwise
2. it is more common for a common disease to present in an
uncommon fashion, than it is for an uncommon disease to
present in its common fashion.

in this case,
common disease = AMS with HACE complication
unusual presentation = rapid onset and progression
of neurological symptoms without a typical preceding
and/or recognized AMS prodromal stage. Note that this
is not unheard of, it has been reported before.

uncommon disease = hyponatremia electrolyte imbalance
in this particular setting,mimicking the neurological
picture of AMS while at altitude, but without apparent
contributing factors such as salt-losing kidney or
other metabolic disorders, advanced age, diuretic or
other meds, prolonged vomiting,prolonged hypotonic
rehydration, or other usual factors.
usual presentation = neurological symptoms

So I vote for dx of rapid onset and progression of HACE. The failure to improve with descent does not rule it out, after all, many people with HACE do die on the way down or even once evacuated and treated. You saved his life. Harvey

Assuming from your signature that you're a professional guide, which I respect. But I have to disagree here. It is just not true that "everyone gets it." While everyone's body undergoes changes at high altitude, not everyone gets AMS, or mountain sickness. According to "Medicine for Moutaineering," 5th edition, the incidence of AMS in new arrivals to altitudes of 9,000 to 12,000 ft. is only between 25 and 40 percent. I formerly lived at 9,500 ft. and can attest to the fact that not "everyone" gets AMS. The changes your body undergoes at altitude are not the same as AMS, as I understand it.

Here I am quoting the text (MFM, 5th edition): "Almost no one should get altitude sickness. A few simple measures prevent altitude illness in most healthy individuals, and individuals who experience more than minor, temporary discomfort have only themselves to blame. Only persons with a few specific conditions are prone to altitude illness."

Is there a doctor in the house that could clear this up?

This is going to be a question of definitions. I'm going with a broad interpretation: AMS includes any symptom related to the body's reaction to a sudden gain in altitude.

That would be consistent with a casual reading of my copy of 'Mountaineering: TFOTH'.

If you restrict AMS to HAPE or HACE, then obviously that changes things.

People can acclimatize to various lower elevations, within limits, but they too will get altitude-related symptoms as they ascend higher, eventually including all the deadly ones.