I have been practicing medicine with an interest in wilderness medicine for some time now and this is one of the best articles I have read! I certainly took some new tips away from it that will change some of my practices in the mountains. Hope you don't mind I've downloaded it and added it to my library to share. Thanks for posting.
Thanks very much for your kind words. I have enjoyed putting this together and much of it is things I have personally found very useful over the years - delighted if it is of use to others - and it really is the icing on the cake to get such positive feedback from another medic - thanks a lot!
best wishes, Mark
Hey Mark, I think you should make an epub and/or PDF version and sell it online. I would buy it and keep it on my iPad for a quick reference for expeditions.
Many thanks Brad - and thanks for the tips - if they didn't work me so hard in my 'day job' maybe I'd explore that option. But as I said to Pablo above - it really is just great if people find the article useful... thanks to Eric V there is a French version of it coming out soon!
Best wishes
Mark
About 9 years ago, I attended a lecture by an MD who talked about the serious dangers of using benzodiazepines. I thought nothing of it, till I was approached by a fellow who almost always slept poorly and used Temazepam. He asked me to check up about current opinions, since he had cancelled a few trips because of his failure to sleep, after he swore off the drug after the lecture
It took 5 minutes of searching google to come up with the above-cited study, the results of which seem to contradict many opinions on the web.
Thanks for your comment. An interesting little study on low dose temazepam - but number of subjects in study way too small, to really draw any conclusions.
Many people take sleeping tablets at altitude - I used to back in the 1980's. But there is no escaping from the fact that the benzodiazepine class do suppress respiration - and even temazepam has a hang-over effect.
Up at altitude respiratory drive is (believe it not) compromised by overbreathing, which lowers CO2 levels.. not a problem awake and active but is the cause of the 'periodic breathing' when trying to sleep - and you 'forget to breathe'. Current advice is bad idea to take a drug which works by sedating you and further suppressing respiratory drive - although as I say, many get away with it.
In my article I am suggesting an alternative and safer way to get a better nights sleep - which is to target the annoyances which keep you awake, ie the periodic breathing, heartburn etc. Periodic breathing responds to a small dose of Diamox (large dose makes you pee more), use antacids etc - and I personally found this better than slugging myself with benzo drugs, the way I did back in the 1980's - when I used to take double the dose of temazepam used in the study - and at altitudes of up to 6500m. I suspect if you did a study on a few 100 individuals taking these kind of doses at the kinds of altitudes I am talking about then some individuals would be demonstrably more hypoxic as a result - and would have more impaired cognitive function - which are a recognised 'hang-over' effect of taking most drugs in the 'benzo' class.
Anyway, current medical consensus suggests caution round sleepers at altitude - I go along with that.
But it is a peer-reviewed, placebo-controlled study; most of the other stuff is anecdotal. If you have a peer-reviewed reference to "there is no escaping from the fact that the benzodiazepine class do suppress respiration" that should be in this article as well (especially if it can be quantitatively placed in the mountaineering context) -- let people read both.
This is not my field, but a search of the medical literature might prove very informative... e.g. temazepam and respiration .. that was the first scholarly article that came up on a google search of temazepam and respiration. An unbiased search of PubMed could probably yield a lot more, on both sides.
I bookmarked this page for future reference. What a great compilation of mountain specific medical advice. Having suffered frostbite, I was immediately drawn to the frostbite section and read it all. Having nothing to do but sit on my butt recovering for over a month, I too took progressive photos of my feet healing. If I had not been familiar with Dr Bangs work with frostbite in Alaska, I might have lost more of my toes. The general consensus back then was early amputation to avoid infection and gangrene. I waited a couple of months before surgery and luckily only lost part of two toes. When I went to the medical center I had 7 doctors come and look because none of them had seen frostbite quite as bad as I had it.
Thanks very much for the kind words - and I had a look at the photo of your foot on your SP page - nasty - but easily done... actually I am now nursing a very mild frostbite to my R big toe at this moment, from Mont Blanc last week. It was just minus 15 C on top, so nowhere near as cold conditions as you experienced. But what did it was that despite multiple applications of water repellent, my old alpine boots absorb water now, so after a night bivvying on top of Mont Blanc were frozen solid - which in turn froze my feet next day.
best wishes, Mark
I wore an older pair of leather boots and the crease that developed from wear is what pressed against my toes when I strapped my crampons a bit too tight. The crease matched the "freeze" line on my left foot to a tee. Inspired by this article, I posted a page with my pictures and comments.
Thanks again - I've linked your piece to the main Expedition Medicine page - compliments the frostbite section nicely.
Yes - we not only made the summit of Mont Blanc (from Italy), but spent 23 hours up there, part in a rather 'open plan' snow cave - in a thunderstorm! In the morning despite a very uncomfortable night we traversed to the Italian summit before descending the '3 Monts' route - all in frozen boots, in my case.
BW Mark
I think this is an outstanding article, well-researched, well-referenced, and also states the limitations clearly. Better than most commercially published stuff! I will certainly carry a hard copy of this next time I head to the Himalayas.
Thanks!
As a fellow general practitioner and mountain climber, I have to say your article manages to organize loads of useful information in a concise and organized fashion. Thank you very much for this. It's definitely going into my bookmarks.
Thanks for your kind words - I had a lot of fun writing it. Having read it, you will know I did the initial work on it to update myself on high altitude, in preparation for a trip to your country, back in 2011.
Yay Fatty I finally worked it out! Brilliant article am very impressed! Am now off to bed after reading it for the 2nd time and realising why you thought I hadn't - as hadn't posted anything.....well I nearly didn't this time as NOT user friendly to techno phobes!! Anyway will probably text you tomorrow en route to heathrow....WHaaaaaaaa tomorrow has become today time for bed!! xxxxxxxxx
Less of the Fatty - this is in the public domain! Have a great trip and hope you don't need the information! xxx
Jonkandonkan - Jun 10, 2015 1:09 pm - Hasn't voted
What about ROS
Hi and thank you for a great article!
I am going to an 7000m expedition soon and thinking about maybe bring some anti-oxidative supplements. Considering the high altitude (3800 - 7134) and physical activity (will be walking and carrying all our gear up the mountain) the oxidative stress will be pretty high.
Too reduce this stress, what is your opinion on supplements like Vitamin C and/or (or maybe some carotenoid like astaxantin)? Just "prophylactic" for health and performance.
There are some studies suggesting supplementation to diminish high altitude exposure associated oxidative stress.
Hi - I am not an expert on high altitude, just an enthusiastic amateur with a little bit of experience and a medical degree. I haven't seen the studies you refer to yet.
I haven't yet seen the UIAA (see link above) recommend the supplements you describe - and they would represent the medical experts in the field of high altitude.
My personal opinion is that performance at altitude is more about following an appropriate acclimatisation program (UIAA guidelines have always served me well - again, as above), keeping hydrated, keeping the calories coming in - and being in tune with how you are doing, so you can take the right action if you become unwell.
In 2011 at the age of 50 I climbed Aconcagua 6962m so nearly as high as you are going. I didn't take any supplements - but followed UIAA guidelines to the letter - and I didn't suffer from so much as a headache due to the altitude - I had no health problems. But I was pretty short of breath from above 6400m and all the way up to the top!
Good luck with your 7000er!
Best wishes, Mark
Pablohoney - Jan 21, 2013 8:02 am - Hasn't voted
GreatI have been practicing medicine with an interest in wilderness medicine for some time now and this is one of the best articles I have read! I certainly took some new tips away from it that will change some of my practices in the mountains. Hope you don't mind I've downloaded it and added it to my library to share. Thanks for posting.
markhallam - Feb 9, 2013 4:14 am - Hasn't voted
Re: GreatThanks very much for your kind words. I have enjoyed putting this together and much of it is things I have personally found very useful over the years - delighted if it is of use to others - and it really is the icing on the cake to get such positive feedback from another medic - thanks a lot!
best wishes, Mark
radson - Feb 9, 2013 1:19 am - Voted 10/10
PDFHey Mark, I think you should make an epub and/or PDF version and sell it online. I would buy it and keep it on my iPad for a quick reference for expeditions.
Brad
markhallam - Feb 9, 2013 4:17 am - Hasn't voted
Re: PDFMany thanks Brad - and thanks for the tips - if they didn't work me so hard in my 'day job' maybe I'd explore that option. But as I said to Pablo above - it really is just great if people find the article useful... thanks to Eric V there is a French version of it coming out soon!
Best wishes
Mark
MoapaPk - Jun 26, 2013 11:49 am - Hasn't voted
Maybe consider some of the newer literautureYou might want to read this:
Everest Base Camp Study
About 9 years ago, I attended a lecture by an MD who talked about the serious dangers of using benzodiazepines. I thought nothing of it, till I was approached by a fellow who almost always slept poorly and used Temazepam. He asked me to check up about current opinions, since he had cancelled a few trips because of his failure to sleep, after he swore off the drug after the lecture
It took 5 minutes of searching google to come up with the above-cited study, the results of which seem to contradict many opinions on the web.
markhallam - Jun 27, 2013 12:08 am - Hasn't voted
Re: Maybe consider some of the newer literautureThanks for your comment. An interesting little study on low dose temazepam - but number of subjects in study way too small, to really draw any conclusions.
Many people take sleeping tablets at altitude - I used to back in the 1980's. But there is no escaping from the fact that the benzodiazepine class do suppress respiration - and even temazepam has a hang-over effect.
Up at altitude respiratory drive is (believe it not) compromised by overbreathing, which lowers CO2 levels.. not a problem awake and active but is the cause of the 'periodic breathing' when trying to sleep - and you 'forget to breathe'. Current advice is bad idea to take a drug which works by sedating you and further suppressing respiratory drive - although as I say, many get away with it.
In my article I am suggesting an alternative and safer way to get a better nights sleep - which is to target the annoyances which keep you awake, ie the periodic breathing, heartburn etc. Periodic breathing responds to a small dose of Diamox (large dose makes you pee more), use antacids etc - and I personally found this better than slugging myself with benzo drugs, the way I did back in the 1980's - when I used to take double the dose of temazepam used in the study - and at altitudes of up to 6500m. I suspect if you did a study on a few 100 individuals taking these kind of doses at the kinds of altitudes I am talking about then some individuals would be demonstrably more hypoxic as a result - and would have more impaired cognitive function - which are a recognised 'hang-over' effect of taking most drugs in the 'benzo' class.
Anyway, current medical consensus suggests caution round sleepers at altitude - I go along with that.
MoapaPk - Jun 27, 2013 12:18 am - Hasn't voted
Re: Maybe consider some of the newer literautureBut it is a peer-reviewed, placebo-controlled study; most of the other stuff is anecdotal. If you have a peer-reviewed reference to "there is no escaping from the fact that the benzodiazepine class do suppress respiration" that should be in this article as well (especially if it can be quantitatively placed in the mountaineering context) -- let people read both.
This is not my field, but a search of the medical literature might prove very informative... e.g. temazepam and respiration .. that was the first scholarly article that came up on a google search of temazepam and respiration. An unbiased search of PubMed could probably yield a lot more, on both sides.
markhallam - Jun 28, 2013 9:25 am - Hasn't voted
Re: Maybe consider some of the newer literautureThanks for your message - am just off to the Alps for 2 weeks and will reply properlty on my return
bw
Mark
reboyles - Jul 2, 2013 4:22 pm - Voted 10/10
Bookmarked!I bookmarked this page for future reference. What a great compilation of mountain specific medical advice. Having suffered frostbite, I was immediately drawn to the frostbite section and read it all. Having nothing to do but sit on my butt recovering for over a month, I too took progressive photos of my feet healing. If I had not been familiar with Dr Bangs work with frostbite in Alaska, I might have lost more of my toes. The general consensus back then was early amputation to avoid infection and gangrene. I waited a couple of months before surgery and luckily only lost part of two toes. When I went to the medical center I had 7 doctors come and look because none of them had seen frostbite quite as bad as I had it.
Bob
markhallam - Jul 14, 2013 2:38 pm - Hasn't voted
Re: Bookmarked!Thanks very much for the kind words - and I had a look at the photo of your foot on your SP page - nasty - but easily done... actually I am now nursing a very mild frostbite to my R big toe at this moment, from Mont Blanc last week. It was just minus 15 C on top, so nowhere near as cold conditions as you experienced. But what did it was that despite multiple applications of water repellent, my old alpine boots absorb water now, so after a night bivvying on top of Mont Blanc were frozen solid - which in turn froze my feet next day.
best wishes, Mark
reboyles - Jul 14, 2013 5:13 pm - Voted 10/10
BootsI wore an older pair of leather boots and the crease that developed from wear is what pressed against my toes when I strapped my crampons a bit too tight. The crease matched the "freeze" line on my left foot to a tee. Inspired by this article, I posted a page with my pictures and comments.
http://www.summitpost.org/climbing-injuries-frostbite/856321
Thanks and congratulations on getting up Mt Blanc. You mentioned "on top" so I presume you made the summit.
Bob
markhallam - Jul 14, 2013 5:36 pm - Hasn't voted
Re: BootsThanks again - I've linked your piece to the main Expedition Medicine page - compliments the frostbite section nicely.
Yes - we not only made the summit of Mont Blanc (from Italy), but spent 23 hours up there, part in a rather 'open plan' snow cave - in a thunderstorm! In the morning despite a very uncomfortable night we traversed to the Italian summit before descending the '3 Monts' route - all in frozen boots, in my case.
BW Mark
LoneRanger - Jul 19, 2013 12:45 pm - Voted 10/10
Excellent articleI think this is an outstanding article, well-researched, well-referenced, and also states the limitations clearly. Better than most commercially published stuff! I will certainly carry a hard copy of this next time I head to the Himalayas.
Thanks!
markhallam - Jul 21, 2013 9:54 am - Hasn't voted
Re: Excellent articleThanks the positive feedback - really pleased if it is useful.
Good luck on your next Himalayan venture and stay well!
best wishes, Mark
flightsimmer668 - Aug 24, 2013 5:48 pm - Hasn't voted
Concise and packed with useful informationAs a fellow general practitioner and mountain climber, I have to say your article manages to organize loads of useful information in a concise and organized fashion. Thank you very much for this. It's definitely going into my bookmarks.
markhallam - Aug 25, 2013 1:56 am - Hasn't voted
Re: Concise and packed with useful informationHola Doctor!
Thanks for your kind words - I had a lot of fun writing it. Having read it, you will know I did the initial work on it to update myself on high altitude, in preparation for a trip to your country, back in 2011.
best wishes, Mark
pipmos - Oct 31, 2014 8:37 pm - Hasn't voted
FlipYay Fatty I finally worked it out! Brilliant article am very impressed! Am now off to bed after reading it for the 2nd time and realising why you thought I hadn't - as hadn't posted anything.....well I nearly didn't this time as NOT user friendly to techno phobes!! Anyway will probably text you tomorrow en route to heathrow....WHaaaaaaaa tomorrow has become today time for bed!! xxxxxxxxx
markhallam - Nov 1, 2014 8:55 am - Hasn't voted
Re: FlipLess of the Fatty - this is in the public domain! Have a great trip and hope you don't need the information! xxx
Jonkandonkan - Jun 10, 2015 1:09 pm - Hasn't voted
What about ROSHi and thank you for a great article!
I am going to an 7000m expedition soon and thinking about maybe bring some anti-oxidative supplements. Considering the high altitude (3800 - 7134) and physical activity (will be walking and carrying all our gear up the mountain) the oxidative stress will be pretty high.
Too reduce this stress, what is your opinion on supplements like Vitamin C and/or (or maybe some carotenoid like astaxantin)? Just "prophylactic" for health and performance.
There are some studies suggesting supplementation to diminish high altitude exposure associated oxidative stress.
markhallam - Jun 12, 2015 2:35 am - Hasn't voted
Re: What about ROSHi - I am not an expert on high altitude, just an enthusiastic amateur with a little bit of experience and a medical degree. I haven't seen the studies you refer to yet.
I haven't yet seen the UIAA (see link above) recommend the supplements you describe - and they would represent the medical experts in the field of high altitude.
My personal opinion is that performance at altitude is more about following an appropriate acclimatisation program (UIAA guidelines have always served me well - again, as above), keeping hydrated, keeping the calories coming in - and being in tune with how you are doing, so you can take the right action if you become unwell.
In 2011 at the age of 50 I climbed Aconcagua 6962m so nearly as high as you are going. I didn't take any supplements - but followed UIAA guidelines to the letter - and I didn't suffer from so much as a headache due to the altitude - I had no health problems. But I was pretty short of breath from above 6400m and all the way up to the top!
Good luck with your 7000er!
Best wishes, Mark