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MEDICAL PROBLEMS & TREATMENT

Altitude Sickness

Three trekkers on average die each year of altitude sickness in Nepal despite the fact that we now know as much as we need to know to prevent every trekker from dying of altitude sickness. Why is this? People who choose to trek in Nepal are not always hikers and mountaineers; they range from travellers who find themselves in Nepal and hear that trekking might be fun, to busy business people looking for a more adven­turous holiday. These people may not think of the potential hazards of their chosen holi­day. and may not ask the right questions or read the right sources before heading out. This section will review the problem of alti­tude sickness as it relates specifically to trekking in Nepal. The concepts are not dif­ficult. and we look forward to a time when trekkers will no longer die needlessly from altitude sickness.

Some people are more susceptible to alti­tude sickness than others. If you know you get altitude sickness easily, you just have to adjust your acclimatization schedule accord­ingly. if you get a severe case of altitude sickness, it doesn’t mean you can never go to high altitude again, but it means you will have to be more cautious in the future.

Awareness of altitude sickness has caused some trekkers to be unnecessarily anxious as they trek. The progression of symptoms is usually gradual, and you have plenty of time to react appropriately. As long as you don’t ascend with acute mountain sickness (AMS) symptoms, and you descend promptly if your symptoms appear to be worsening, you have almost no chance of becoming an altitude-sickness statistic in Nepal.

Acclimatization & Altitude Sickness Our bodies have the ability to adjust to higher altitudes if given enough time. This process of adaptation is called acclimatization. If you were flown to the summit of Mt Everest, you would have a few minutes of conscious­ness before you passed out and died. How­ever, acclimatized climbers have made it to the summit safely without using supple­mental oxygen by allowing their bodies to adjust gradually to the increasing height.

If a person travels up to altitude more rapidly than his or her body can adjust, AMS symptoms develop. If ignored, the symptoms can occasionally progress to the more severe forms of altitude mountain sickness, such as those described in the following paragraphs.

Your body adjusts to altitude initially by increasing the rate and depth of breathing Studies have shown that people who adapt well to altitude automatically increase their breathing more than individuals who get al­titude sickness easily. This sensitivity to a change in altitude appears to be genetic. Other adaptations include an increase in heart rate and a gradual increase in red blood cells. Once you are acclimatised to a given height for a few days, you are very unlikely to get mountain sickness at that height, but you can still get ill when you travel higher.

Altitude sickness occurs as the result of failure to adapt to a higher altitude. Fluid accumulates in between the cells in the body and eventually collects where, unfortu­nately, it can do the most harm: in the lungs and brain. As fluid collects in the lungs, you become breathless more easily while walk­ing, and eventually more breathless at rest A cough begins, initially dry and irritative, but progressing to the production of pink, frothy sputum in its most severe form. The person ultimately drowns in this fluid if he or she doesn’t descend. This syndrome is referred to as high-altitude pulmonary oe­dema (HAPE). When fluid collects in the brain, you develop a headache, loss of ap­petite, nausea and sometimes vomiting. You become increasingly tired and want to lie down and do nothing; As you progress, you develop a problem with your balance and coordination (ataxia). Eventually you lie down and slip’ into coma, and death is in­evitable if you don’t descend. This syndrome is called high-altitude cerebral oedema I (HACE). HAPE and HACE can occur singly I or in combination.

AMS Prevention: The Acclimatization Line

As you prepare for your trek in Kathmandu, you are at an altitude of 1300m. You  can probably move safely and rapidly up to a height of around 2800m without getting I ill. This height will be slightly different for I each individual. The altitude between where  you are fine and where you will develop  AMS is called the ‘acclimatization line’. Awareness of this line as you travel up in altitude can help you prevent illness and react  appropriately if you do develop symptoms.

Although itineraries are designed to try to  prevent AMS on treks, some people will be more susceptible than others, and unless  trekkers choose very conservative schedules, some are likely to get AMS. The purpose of advice on altitude sickness is not to prevent all people from getting AMS. The purpose is to prevent anyone from dying of AMS. In other words: it’s OK to get altitude sickness; it’s not OK to die of altitude sickness.

Try to spend your first night on a trek at, or below, 2800m. If you do fly in to a higher altitude, be sure to rest there for two days before trying to go higher. If you start to get symptoms of AMS, you have crossed your acclimatization line. If you have been as­cending relatively slowly (less than 300m per day), it is likely you are only a short dis­tance above the line, and resting at the same altitude will allow you to get over your symptoms. However, if you are ascending rapidly, it is more difficult to determine at which point you crossed your acclimatization line, and you may be far above it. In that case, it will be necessary to descend below the line at which your symptoms began in order to get better.

For example, trekker A has slept at 2800m, then ascends to 3300m. She spends an extra day at that height to help acclimatize, then ascends to 3700m. She feels fine when she gets there, but the following morning she awakens with a headache, loss of appetite, and fatigue. Since AMS symptoms generally take several hours to develop after arriving at a new height, her symptoms most likely began close to 3700m. By resting for a day at the same height, she will likely acclimatize and be able to continue her ascent.

On the other hand, trekker B has slept at 2800m and then ascended to 3300m the next day. The following day he climbs to 3700m and the next day to 4200m, arriving at that camp site with a headache and nausea. He spends the night at 4200m, but is worse in the morning, with a severe headache, vomit­ing and lack of coordination. Since he has been ascending so rapidly, it is difficult to determine exactly where his symptoms began. However, a clue is the fact that the symptoms began as he was ascending to 4200m. Therefore, he crossed his acclimatization line at least six to 12 hours earlier. Since his symptoms are now so severe, he must descend immediately and not try to wait for his body to adjust. He is too far above his acclimatization line for further acclimatization to take place. Most likely he will have to descend to 3700m or lower in order to improve. These examples show how the acclimatization line concept can be useful in determining what course to take in regard to AMS symptoms.

Treatment of AMS

The treatment of AMS is firstly to not ascend with symptoms and, if symptoms are severe, to descend. Des­cent will always bring improvement and should not be delayed in order to try some other form of therapy in serious cases. In rare cases where descent is difficult or impossible, a portable pressure chamber is effective.

The first portable pressure chamber was invented by Igor Gamow (pronounced ‘gam- off’), and dubbed ‘the Gamow bag’. Since then, an French-manufactured bag (Certec), and an Australian bag (Bartlett’s) have been released. Although they have minor differ­ences, they function equally well. Treatment with a portable pressure chamber mimics the most effective treatment for altitude sickness, which is descent. The patient is placed in what looks like a large sleeping bag, and zipped inside. An air pump increases the pressure in the bag by two pounds per square inch, mimicking a descent of between 1220m and 1830m (depending on the alti­tude at which the person enters the bag).

Bags have been in use at the Himalayan Rescue Association (HRA) aid posts in Pheriche and Manang since 1988. One hour of treatment in the bag is very effective at improving the mild to moderate symptoms of AMS, and this improvement may persist even after coming out of the bag. Severe cases of mountain sickness (HACE and HAPE) are improved in the bag, but this improvement tends to deteriorate after coming out of the bag, requiring repeat or prolonged (four to six hours) treatment in the bag.

Three medications have also been proven useful in treating and preventing AMS:

Acetazolamide (Diamox)

Useful in pre­venting mild symptoms of AMS if taken prior to ascent. You should not routinely take Diamox for a trek in Nepal, as most people will not need it for the gradual ascents usu­ally associated with trekking. However, if you know from past experience that you do not acclimatise well, and the itinerary you are going on has an unavoidable sudden in­crease in altitude, Diamox may prevent AMS symptoms.

Diamox does not prevent the progression to severe symptoms of HAPE or HACE, so you must still watch closely for AMS symp­toms and respond appropriately. Diamox prevents or improves AMS by increasing the respiratory rate and depth, mimicking the breathing of a good acclimatiser. Thus, if you feel better on Diamox, you truly are better. Diamox doesn’t mask the symptoms of AMS.

Diamox is useful in treating the headache and nausea associated with mild AMS, and it also can improve your sleep at altitude if you are being disturbed by the irregular breathing and breathlessness that can occur My recommendation regarding Diamox is to carry it with you, use it to treat mild symptoms, and use it prophylactically only if you have had experience before with AMS on a certain schedule, or face an unavoid­able abrupt increase in altitude. The usual dose is 125mg (half a tablet) every 12 hours as needed. Mild tingling of hands and feet is common after taking Diamox and is not an indication to stop its use.

Diamox is a diuretic and increased urine output can be expected when taking the drug. People with a known allergy to sul­phur drugs should not take Diamox, al­though allergic reactions to Diamox itself are extremely rare.

Dexamethasone (Decadron)

This potent steroid drug improves the symptoms of HACE through an unknown mechanism, apparently without improving acclimatisa­tion. It is an important drug to carry for emergency use, but it should never be taken prophylactically to prevent AMS. People with severe headache and loss of balance can be improved enough with this drug to allow them to avoid a night-time descent, or to convert them from a stretcher case to being able to walk. The improvement with dexamethasone is occasionally so dramatic that people might be tempted to continue upward while still taking the drug. How­ever, since adaptation to altitude has not been improved, this could be dangerous. Once the drug is started, the person should refrain from going to a higher altitude while still taking it. If you are able to go off the drug for 24 hours without further symptoms, you may continue your ascent.

Nifedipine

A drug ordinarily used to treat heart problems and high blood pressure. However, it has been shown to reduce pres­sure in the main artery in the lungs, which improves severe cases of HAPE. For this reason, nifedipine should be included in trekking first-aid kits. The initial dose is 10mg every eight hours. Treatment with nifedipine should be accompanied by an immediate descent.

Diarrhoea

Diarrhoea is the most common illness ac­quired by travellers in Nepal. Travellers’ diarrhoea is simply infectious diarrhoea, ac­quired while travelling, usually because standards of public health and hygiene in developing countries are minimal to non­existent. The organisms that cause diar­rhoea are passed in stool, and are acquired from eating or drinking contaminated food or water.

Antibiotic treatment for travellers’ diar­rhoea has been shown to be highly effective i at shortening the illness, sometimes ending it in several hours. Since travellers’ diar­rhoea can vary in intensity from a few loose bowel motions to severe fever, cramps, vomiting and watery diarrhoea, the decision to treat it should be based on the severity of the illness and the need to carry on with your travel plans.

Causes of Diarrhoea

Most cases of diarrhoea in Nepal – more than 80% – are caused by bacteria. This fact makes it easier to guess what might be causing your particular case of diarrhoea. Bacteria are all susceptible to antibiotics, and thus a bacterial diarrhoea can easily be shortened by antibiotic treat­ment. Giardiasis accounts for 12% of the diarrhoea among travellers in Nepal, and Entamoeba histolytica (amoebas) causes just 1% of diarrhoea in Nepal. Gastrointest­inal viruses account for about 5% of the diarrhoea. Cyclospora is a protozoan organ­ism that causes diarrhoea mainly in the late spring and during the monsoon (roughly May through October).

Bacterial Diarrhoea

The sudden onset of relatively uncomfortable diarrhoea is the minimum description of bacterial diarrhoea. Additional specific symptoms can only add to the certainty of the diagnosis. Fever, vomiting or blood in the stool can all be present, and are much more often associ­ated with bacterial diarrhoea than with pro­tozoal diarrhoea. Sulphurous-smelling farts and burps, thought by many to be an indi­cation of a Giardia infection, are also com­mon with bacterial infections. Thus these should not be taken as a reason to treat yourself for giardiasis.

Food poisoning (caused by toxins that can be produced by bacteria growing on contaminated food) can present exactly like bacterial diarrhoea. However, the difference is that by the time the person who has food poisoning is able to seek help (that is, strong enough to leave their rooms or the immediate vicinity of a toilet), they are usually on the way to recovering rapidly. People with bac­terial diarrhoea may have vomiting and fever in the first 12 hours of their illness, but these symptoms usually subside spon­taneously, leaving diarrhoea and cramps as the only persistent symptoms. The distinction between food poisoning with vomiting and bacterial diarrhoea with vomiting is not crit­ical to make in the first 12 hours, since the patient can’t take an antibiotic until the vomiting has stopped anyway. If all symp­toms go away rapidly, no further treatment is needed; if diarrhoea persists, it is likely to be a form of bacterial diarrhoea.

Viral gastroenteritis has essentially the same symptoms as bacterial diarrhoea, but does not respond to antibiotics. However, the symptoms will go away by themselves within a few days.

Bacterial diarrhoea will always go away by itself, but the length of time can vary from a few hours to more than two weeks, with an average duration of three to five days. However, now that effective treatment exists, it doesn’t make sense to wait from two to 10 days to see if you are going to get better on your own. Currently all patho­genic bacteria that can cause diarrhoea in Nepal are susceptible to a group of anti­biotics known as fluoroquinolones. The two most commonly used are norfloxacin or ciprofloxacin. Therefore, it is not necessary to know exactly which bacteria you have in order to recommend treatment. Antibiotic treatment with a quinolone antibiotic can shorten the illness to less than one day, and side effects are extremely rare.

The treatment for all bacterial diarrhoea is either norfloxacin (400mg) or cipro­floxacin (SOOmg), both taken twice a day for one to two days. Some studies have shown that a single dose of ciprofloxacin or norfloxacin can cure a bacterial diarrhoea, but for now it seems safer to take at least two doses. If the diarrhoea goes away quickly, there is no need to take further treatment. If the diarrhoea has not signifi­cantly improved after taking four doses of the antibiotic, there is probably some other cause of diarrhoea present. For those people who cannot take quinolone antibiotics for any reason, the drug azithromycin appears to be the best choice. The dose would be 500mg once a day for two days.

Ciprofloxacin and norfloxacin should not be routinely used by children. A good choice for children in Nepal is an antibiotic called nalidixic acid, which is available as a liquid preparation. The dose would be 50mg per kilogram per day in three divided doses for two days. An alternative for children is azithromycin in a dose of 10mg per kilo­gram of body weight per day as a single dose each day for two days.

Giardiasis

An infection with the Giardia lamblia parasite is characterised by the gradual onset of churning intestines, in­creased gas, and two to five loose stools per day. Stools are often urgent and sometimes crampy. Upper abdominal pain can occur, but vomiting is rare. There is often a daily pattern of several loose stools in the morning, followed by a relatively normal day.

Once Giardia protozoa have been in­gested, they begin causing symptoms after one or two weeks (not the next day after a suspect meal). Often people have symptoms for a week to a month or more before decid­ing to seek treatment because it is not very severe each day, and they hope it will go away. Sulphurous-smelling burps and farts can be associated with giardiasis, but are equally common in bacterial diarrhoea, and thus are not useful in helping to make the diagnosis.

The best treatment for giardiasis is tinida- zole, which is available in Nepal without prescription. The dose is 2g as a single dose each day for two consecutive days. Tinida- zole has the potential for side effects, which consist of mild nausea, fatigue and a metal­lic taste in one’s mouth. Tinidazole cannot be taken with alcohol. An alternative is albenazole (400mg) once a day for seven days. This drug has very few side effects.

Amoebiasis

The term amoebiasis refers to an infection with a specific type of amoeba, [ E. histolytica, and accounts for only 1% of diarrhoea in our patient population in Nepal. This is an important figure to remember, since the local laboratories diagnose amoeb­iasis in almost everyone who submits a sample. If you have had diarrhoea for only a few days, be very sceptical of a local labora­tory that reports you have amoebas. A person presenting with amoebiasis will commonly have several weeks of low-grade diarrhoea, alternating every few days with either normal stool or constipation. Very rarely, a person with E. histolytica will present with classic amoebic dysentery: frequent passage of small amounts of bloody, mucoid stool, as­sociated with cramps and painful bowel movements. This classic form of amoeb­iasis is so rare in travellers in Nepal that we see less than one case per year.

E.h istolytica infection is treated easily in Nepal with 2g of tinidazole per day for three consecutive days, followed by 500mg of diloxanide furoate (furamide) three times a day for 10 days. However, diloxanide furoate is no longer available in Nepal ex­cept through the CIWEC Clinic Travel Medicine Center. This regimen is highly effective and well tolerated.

In the USA, tinidazole is not routinely available (although it can now be specially ordered through compounding pharmacies), and metronidazole is used at a dose of 750mg three times a day for 10 days.

Cydospora

This organism infects the upper intestine, causing diarrhoea, fatigue and loss of appetite. The illness lasts from two to 12 weeks, averaging six weeks. Fortu­nately, the illness is a risk in Nepal mainly from May to September, which is outside the main trekking seasons. It has been shown to be waterborne, and iodine is not sufficient to kill it. The organism is rela­tively large, and can be filtered by almost all trekking filters. It is easily killed by boil­ing. The treatment for Cyclospora diarrhoea is an antibiotic called trimethoprim and sul­famethoxazole (sold commonly as Bactrim) twice a day for seven days. This is a sulphur drug, and cannot be taken by those people allergic to sulphur.

Cryptosporidium

This is another parasite of die upper intestine which causes a pro­longed, low-grade diarrhoea. It is rare in Nepal, accounting for only a handful of cases per year. It can cause symptoms for one to three weeks, but eventually it will go away by itself. The antibiotic paromomycin is effective in treating this parasite.

Dientamoeba fragilis

Because this para­site resembles an amoeba, and has no cyst form, diagnosis is difficult. It can cause low-grade symptoms for a number of weeks. When diagnosed, it can be treated with tetracycline (250mg) four times a day for 10 days, with excellent results.

Tropical Sprue

Tropical sprue is a syndrome of fatigue, weight loss and chronic diar­rhoea. Sometimes patients can date the onset of this illness to an acute bout of diar­rhoea that never quite cleared up. The cause of tropical sprue is thought to be an infection with some type of intestinal organism, but the exact cause has not been discovered. The diarrhoea is often not prominent after a while, and people present to the doctor with fa­tigue and weight loss. We usually look at the stools a few times to try to find a protozoan parasite, and often treat people for suspected Giardia or E. histolytica infections. If we fail to find a cause for their diarrhoea, or the treatment fails to improve their symptoms, we perform a d-xylose absorption test. This test can determine whether the upper intes­tine is able to absorb food normally. This test is always abnormal in the presence of tropical sprue. If the d-xylose test shows poor absorption, we treat for tropical sprue, with tetracycline (500mg) twice a day for six weeks, along with folic acid, 5mg per day. Improvement is dramatic within a few days of the start of treatment.

Symptomatic Treatment

For many years travellers have relied on antimotility drugs, such as diphenoxylate hydrochloride (Lom­otil) or loperamide (Imodium), to control the symptoms of diarrhoea until the self­limited infection has run its course. These days, loperamide seems to be favoured over diphenoxylate. The antimotility agents paralyse the bowel, preventing bowel move­ments, but they do nothing to shorten the length of the illness. Effective antibiotic treatment of bacterial diarrhoea can make people asymptomatic within a day, whereas untreated bacterial infections can last from several days to two weeks. Diarrhoea that is severe enough to make you think about an antimotility agent should be treated with an antibiotic.

Loperamide should be used if travel or sightseeing is necessary before you have re­gained control over your bowel movements. What else can you do when you wake up at Sam with severe diarrhoea and have to ride a bus for the next 12 hours? Studies have shown that loperamide is safe to take along with an antibiotic even in the presence of severe diarrhoea.

Supportive Care

Diarrhoea can result in the loss of a great deal of fluid from the body, and much of the ill-feeling associated with diarrhoea (weakness, dizziness) is just from dehydration. People with diarrhoea are often reluctant to drink fluids because they feel nauseated, or the fluids cause cramping when they reach the stomach. The best approach to rehydration is to take fre­quent small sips of fluid (a friend can often encourage the sick person to drink). Oral rehydration solution (ORS), a mixture of sugars and salt easily absorbed by the intes­tines, was invented as a public health strategy to prevent deaths among children in de­veloping countries. These solutions have the advantage of being easier for the intes­tines to absorb, resulting in a greater level of rehydration for the amount of liquid con­sumed. ORS is important in the care of diar­rhoea in infants, who can lose proportionally more water in a shorter period of time than adults. However, ORS solutions taste salty and may actually limit the amount of fluid taken in if this is the only liquid allowed. In adults ORS can be an advantage when vomiting is present, limiting the amount of fluid intake, or when diarrhoea is unusually severe. Urine is the best guide to the ad­equacy of replacement: if you have small amounts of concentrated urine, you need to drink more.

Much has been written about specific diet­ary approaches to diarrhoea, but there is no scientific evidence to support any one view. Some people believe not eating for a while will improve diarrhoea, while others suggest specific foods such as bananas, dry toast or yogurt. However, none of these ideas have been tested. I would suggest that if you are not hungry, you should not force yourself to eat, but should continue to drink fluids. If you’re hungry, it is OK to eat foods that ap­peal to you as long as you initially avoid greasy or spicy foods.

When you have diarrhoea there is an ex­aggeration of the gastrocolic reflex, which means that when you put food in your stomach, it immediately causes your intes­tines to contract, resulting in cramps and more diarrhoea. This reflex is not harmful, nor will it make whatever caused your diar­rhoea worse. Once the initial cramps or diarrhoeal episode pass, it is often possible to finish eating your meal.

Vomiting

Vomiting associated with bacterial diarrhoea is a potentially serious problem, since it adds to dehydration and hinders efforts at rehydration. We have never seen severe de­hydration in adults who had diarrhoea but not vomiting. Vomiting almost always occurs at the beginning of bacterial diarrhoea, and usually lasts six to 12 hours. Rarely, vomiting and diarrhoea persist together for four or five days, resulting in individuals who are quite dehydrated and miserable. They often have to be helicoptered out of the Himalaya in this condition.

Vomiting also prevents the use of an oral antibiotic to shorten the infection. There are currently no injectable drugs known to shorten the course of bacterial diarrhoea. The only option is to try treatment with an anti-vomiting drug until the person can retain the oral antibiotic, such as norfloxacin. In our experience, however, it is almost im­possible to stop the vomiting associated with bacterial diarrhoea by injecting an anti-vomiting agent. Anti-vomiting therapy appears to work most effectively if given just as the repeated, spontaneous vomiting is stopping. An injection or pill of prometha­zine, or prochlorperazine, or a suppository of either drug, can eliminate the threat of further vomiting, allowing norfloxacin to be taken, which will then shorten the diarrhoeal illness dramatically.

Intestinal Worms

Travellers are more concerned about intes­tinal worms than they need to be. Worms are never the cause of diarrhoea in travellers, and rarely cause any symptoms at all. The most common worms have no ability to multiply within the intestines, so even if you accidentally ingest a worm egg, you will only have one worm present for its life span (one to two years). It takes at least seven weeks for a worm egg to grow into a worm, so there is no use having a stool exam to check for worms until you have been home at least two months. Although approximately 95% of Nepalis have worms in their intes­tines, worm infestation in foreigners is rela­tively rare. Even among US Peace Corps volunteers living for two years in remote villages, the rate of worm infestation was less than 5%.

Respiratory Infection

Colds

Respiratory infection is second only to diarrhoea as a health concern among travellers. Many trips are ruined by severe respiratory infections. Virtually all respira­tory infections begin as a common cold, caused by a virus. The symptoms consist of some combination of runny nose, congestion, sore throat and cough. The viruses can be picked up on aeroplanes, crowded buses and trains, in restaurants or any place where you might encounter people with colds. Travel, with its various stresses such as jet lag and uncertainty, will render you more susceptible to colds. Under normal circum­stances the cold should last three to seven days and go away by itself. However, colds can lead to bacterial infections of the sinus, lungs or ears. This can result in sinusitis, bronchitis or ear infections. Twenty per cent of patient visits at the CIWEC Clinic Travel Medicine Center are for complications of colds. Severe colds can result in missed treks or missed goals on a trek. Knowing how to recognise and treat the complica­tions of a cold appropriately can save you many days of misery, and help preserve your long-established trekking plans.

Influenza is a severe form of respiratory infection that can be prevented by having an annual influenza vaccine. Studies have shown that the same strains of‘flu’ circulate worldwide, and the flu vaccine from your home country will be effective in Nepal.

Sinus Infection (Sinusitis)

Sinus infec­tion is the most common complication of a cold. The sinuses are hollow spaces in the bones of the face that connect to little holes in the back of the nose. Viruses can travel from the nose to the sinuses, causing in­flammation which can allow bacteria to in­vade. Once the bacteria invade you might feel pressure or pain in a particular portion of your face, and the mucus running from your nose might turn thick and yellow or green in colour. Finding small amounts of blood when you blow your nose is also common. As the infection goes on you may lose your appetite and feel much more tired than usual.

There may be no clear-cut division be­tween your initial cold symptoms and the sinus infection. Many people come to us with a cold that simply hasn’t gone away after two or three weeks. This is how sinus infections most commonly present. Any cold that is not getting better, or is getting worse, after seven days should be considered a possible sinus infection, and you should think about taking an appropriate antibiotic. Some of these prolonged infections will eventually clear up on their own, but an anti­biotic will make them better within days. A convenient antibiotic to take while trekking is azithromycin 250mg. The dose is two pills the first day, followed by one each morning for four more days. Thus, six pills is all you need to take to have the equivalent effect of 10 days of another antibiotic.

Bronchitis & Pneumonia

Bronchitis is the second-most common complication of a cold. Bronchitis is an infection of the breath­ing tubes in the lungs. The symptoms are a progressively worse cough, accompanied by the production of greenish or yellowish mucus when you cough. Bronchitis is similar to sinusitis in that there may not be a clear point in time at which your viral cold be­comes a bacterial bronchitis. Seven days is long enough to wait before thinking of treating a cough that is not getting any bet­ter on its own. The same drugs recommended for sinusitis are good treatment for bron­chitis as well, and the two infections are often present at the same time.

A deep cough accompanied by high fever may represent a deeper infection called pneu­monia (an infection of the lung tissue itself). The same antibiotics can be used, but you may be quite sick with pneumonia and should seek professional medical attention.

Inner Ear Infection

The third common complication of a cold is an inner ear in­fection (otitis media). This type of infection is very common in small children because their Eustachian tubes (which allow the inner ear to equalise air pressure with the outside) are small and can get blocked easily. The infection is uncommon in adults, but seems to be more common in adult travel­lers. A cold is almost always present for several days, and then one gets the sudden onset of severe ear pain, usually in only one ear. A doctor can make the diagnosis by look­ing at the ear drum through an otoscope, but if this is not available, you can treat your­self with any of the antibiotics used to treat sinusitis or bronchitis.

Fever

Trekking occurs, by definition, in remote areas where access to medical care is rare. Thus, the traveller needs to be able to make some decisions about the cause of a fever if it occurs while trekking. Fever almost al­ways means you have acquired some kind of infectious disease. By evaluating the as­sociated symptoms and the travel history, you can often make a good guess as to the cause of the fever, even while trekking in a remote area. Some fever-related illnesses go away without treatment, eg, the flu, while others will require treatment, eg, typhoid fever. The purpose of trying to guess the cause of a fever is to determine whether specific treatment will be of benefit, and whether the trek should be abandoned.

Fever often has distinct symptoms, such as burning on urination, severe diarrhoea, or cough and chest pain. These symptoms make it more clear as to what may be the source of infection. However, fever sometimes occurs with only a vague feeling of being unwell, such as headache, fatigue, nausea, or loss of appetite. In the first days of such an illness it is difficult to determine the cause of the fever. We have found, however, that there are five main diseases which ac­count for almost all fevers, headache and malaise in Nepal. By taking a careful history and noticing key aspects of the fever and headache, a presumptive diagnosis can often be made.

Frostbite

Frostbite is the injury resulting from frozen skin tissue. The circulation of warm blood to the extremities can ordinarily prevent them from freezing in cold weather pro­vided the extremities are protected from the environment. When hands or feet get cold they first feel cold, then numb, and then they begin to freeze. In extreme cold, touch­ing a piece of metal or spilling petrol on your hands can induce instant freezing of skin, but in the Himalaya one almost always goes through the progression from cold to numb to frozen.

Frostbite is not a major concern on most trekking trails on most days. However, from October to April, storms can occur that dump a metre or more of snow on the high passes. The two most popular treks, Everest Base Camp and Around Annapurna, take people above an altitude of 5000m. The combination of high altitude and snow can produce frostbite very easily in unwary or unprepared trekkers.

On the Annapurna circuit, most of the trekking is at low to moderate altitudes on easy trails. Therefore, the temptation is to wear either running shoes or lightweight cloth-and-leather hiking boots. The heavy boots necessary to cross Thorung La in snow seem like too great a burden to carry for the one or two days they might be needed. If snow catches trekkers at the pass, they try to push on in their light shoes, and frostbite can result. High altitude plays a deceptive role in inducing frostbite, making tissue more susceptible to cold injury due to lack of oxygen to protect the skin cells. Several frostbitten people have told me they were very surprised to see they were frostbitten because they had felt colder in other settings without getting any injury.

Prevention of Frostbite

The key to pre­vention is to notice when your feet or hands have gone numb and to stop immediately to warm them up. Once they have gone numb, you have no control over whether they are starting to freeze, since you can’t feel it. To warm up numb feet you must stop walking, get out of the wind, avoid sitting directly on the snow if possible, take off your boots, and place your feet against someone’s abdo­men or under their arms. The return of feel­ing is often painful for a short time. Put on dry socks if your socks are wet. Be prepared to stop and warm your feet every time they go numb. If your whole body is cold, it’s im­portant to increase your clothing layers, add a hat, get out of the wind and drink hot drinks where possible.

Response to Frostbite

If you are not vigilant enough, you may notice that the skin on your toes or fingers has frozen. The digits will be numb and feel hard and waxy, with a whitish appearance. The one accept­able way to warm up frozen extremities is by a process of rapid re warming, which may be hard to perform if you are not carrying stoves and large pots. The technique is to heat enough water to submerge the frozen extremity. The water should be at a tempera­ture of around 34° to 37°C (91° to 97°F). The extremity is placed in the water until it rewarms and a red flush of circulation returns. This process can be very painful. Blisters may form, and the foot will then have to be protected from further trauma.

Most of the time the frostbite is not no­ticed until the person reaches their next des­tination, and the foot has already rewarmed during the descent. People take off their shoes and notice that blisters have formed. If a disaster has occurred, such as getting lost on a pass and spending one or two nights out, the toes may appear blackened and shrivelled, without the formation of blisters. This is a sign of freezing, thawing and refreezing, and means deeper damage has taken place.

There is no way to undo the damage that has been done once frostbite has occurred. Further treatment is aimed at preventing the situation from getting worse by avoiding trauma to the affected areas and preventing infection. It is not necessary to start taking antibiotics. If there are blisters or open skin, the affected area should be washed in a ster­ile fashion, and a sterile dressing applied. If there are only deep blisters, with hard skin over them, or blackened skin, dressings may not be necessary. Walking should be aban­doned or kept to a minimum. Evacuation by horse, yak or helicopter may be necessary depending on the degree of injury.

Only a handful of people get frostbite in­juries in Nepal each year but, like altitude sickness, these injuries are all preventable. Even relatively minor frostbite ends the trip and forces a return home, since healing can take several months. If you are going above 4000m, be prepared for walking in snow.

Traumatic Injuries

Trauma is the most common cause of death among trekkers in Nepal, and a major cause of evacuation. Trauma results most often from falling off a trail, or having something fall on you while trekking. Nepal features a wide variety of trails, ranging from smooth valley bottoms to exposed rock traverses that make even hardened mountaineers queasy. Many accidents take place during a mo­mentary lapse in judgement: scrambling up or down for a photo, not paying attention to your feet, or trying to climb between trails on steep terrain after taking a wrong turn.

Trekking accidents do not just happen to the inexperienced. Experienced trekkers often travel into more difficult terrain on less-travelled routes, with a higher risk of falling from steep terrain or being hit by a rock fall. It is important to concentrate when you are trekking, particularly towards the end of the day when your legs and mind are both tired. It is also important to look up and try to assess the risk of rock or ice fall from above. Some gullies are obvious chutes for rock fall or avalanche. Look for signs of  recent rock fall or falling ice, and don’t linger in these areas. If you are crossing an obvious landslide or large rock-fall area, rest before you start across, and then don’t stop in the middle. If it looks particularly unstable, have the party move across one person at a time, so that only one person will be injured if something slides. Remem­bering not to stop and rest in an unstable area saved my life once in the Everest region. I was walking across a lot of loose rocks near a river bed below an area that had obvi­ously slid before. I forced myself to move on, even though I was out of breath from carrying a heavy backpack at 4200m. Twenty seconds after I passed, the area where I had originally wanted to rest was swept by a huge rock fall!

Initial Assessment

Trauma usually oc­curs in a very sudden and unexpected man­ner, leaving bystanders momentarily stunned. Scrambling to reach someone who has fallen, you may forget some basic rules of safety. Make sure that other members of the group are out of danger, and then be careful to take a route to the victim that doesn’t expose that person to further rock fall. If the situ­ation is still very unstable, with continued rock or ice fall, you may have to move the person away from the danger before making a complete assessment.

When you and the victim are in a safe spot, you have to make an initial assessment of his or her condition. This can be done quite quickly, and the process of doing this helps you to organise your thoughts and begin to come up with a plan. It is import­ant to approach the person with a set of prior­ities in mind, rather than be forced to react emotionally as each injury is uncovered. The rule of‘ABC’ has proved very useful to help a rescuer move from an overall emo­tional reaction to a plan of action. ABC stands for ‘Airway, Breathing and Circula­tion’. If the person is conscious and talking, then obviously the airway and breathing are all right. If the person is unconscious, how­ever, it is necessary to check immediately to see if their breathing is obstructed, and if not, whether they are breathing at all. You can then check for signs of circulation by feeling for a pulse. If the victim has no res­piration or pulse after a traumatic fall they are dead. Cardiopulmonary resuscitation (CPR) is futile in this situation, because the cause of death will have been due to mas­sive, irreversible head trauma or massive loss of blood.

If the person is still alive but not con­scious, or is confused and combative, then they have a head injury. Make note of that, but keep on with your initial assessment. In­spect the head, look for signs of scalp lacer­ation (feel the back of the head), and then feel all the rest of the bones in the body briefly, looking for swelling or deformity that might indicate a fracture. If the person is awake, they can generally tell you where they hurt, but do a complete assessment anyway; the person may be unaware of a large cut on their back, for example. Once you have done an initial assessment, you will be aware of their level of consciousness, any large bleeding cuts or bruises, and any signs of broken bones. The next step is to begin to stabilise all these injuries.

Spinal Injuries

Most people feel there would be nothing more emotionally trau­matic than becoming paralysed. The spinal cord is the bundle of nerves running along the backbone from the skull to the pelvis. Major trauma can break the vertebrae, or tear ligaments in the spine, leading to a tear in the fragile spinal cord itself. If the spinal cord has already been injured in a fall, the person will be unable to move their limbs (depending on the level of the injury), and may not be able to feel any sensation in their body in the area below the injury. Neck injuries can lead to paralysis of all four limbs, while injuries below the neck can lead to paralysis of the legs. If the person is already paralysed, you still need to be very protective of the spinal cord, so further injury will not take place.

The danger feared by first-aid givers is in taking care of someone who is not yet paralysed, but who has an unstable injury to the spine. As one starts to move the patient, the unstable bones slip, and suddenly the patient is paralysed. This scenario, while etched into the minds of all people trained in first aid, is fortunately exceedingly rare. You must be particularly careful of the spine in someone who is unconscious, and can’t tell you if their limbs feel numb or paralysed, or whether their neck or back hurts. However, common sense should pre­vail. If someone is conscious, does not com­plain of pain in their neck or back, and is not sore to the touch in these areas, you can safely assume that a spinal injury is not pre­sent, and it then becomes easier to move them to safety.

Bleeding & Lacerations

Most small cuts will stop bleeding on their own, but rela­tively large arteries may keep pumping blood for a long time, particularly from scalp wounds. Put direct pressure with a cloth or dressing over the area that is bleeding, and press relatively hard. Don’t keep pulling off the dressing and looking to see if the bleeding has stopped. Apply pressure for five full minutes (use your watch) before you look to see if the bleeding has stopped. You can then tie a dressing over the wound and hopefully move on to assessing other injuries. If you move the patient around, you may restart the bleeding, so make sure you check the dressing as needed. Large wounds may benefit from cleaning and su­turing, even in the field, but this can wait until all other aspects of the situation have been stabilised. It is not necessary to elevate a limb to stop bleeding, and it is almost never necessary to use a tourniquet on a limb to stop bleeding. Large lacerations can be cleaned and sutured even several days later, so don’t feel a great urgency to do a repair unless you are trained to do so and have the appropriate equipment. If you know how to repair lacerations, I recommend doing so, since the infection rate in my experience has been very low, and the comfort and ease of caring for a wound that has been closed makes it worth taking the risk of closing a wound in a field situation.

Fractures

Broken bones hurt. A conscious person can usually direct your attention to an area of concern. If a limb appears de­formed, a fracture is likely. If the bone is broken, but not bent out of place, the person may just have pain in that specific area. There is relatively little urgency to trying to fix a broken bone, since healing will take many weeks at best. However, if the broken bone ends are separated, they can injure nearby blood vessels and nerves, which is why the limb needs to be carefully splinted. If there is a deformity, you should try to straighten the limb with gentle traction before splinting. It is safe to exert gentle traction to straighten out a fracture, and it protects the nerves and blood vessels, as well as making the patient much more comfortable. Have someone else hold the limb above the frac­ture so you have something to pull against. This will work well on the arm and lower leg, but it will be impossible to hold a bro­ken thigh bone (femur) straight without a special splint. In the case of a broken femur, try to straighten the leg gently, and then tie the injured leg to the good leg to try to hold it in place. A good splint will keep the bro­ken bone ends from moving around inside, will decrease internal bleeding, and will make the patient much more comfortable. Pad the inside of the splint to protect the skin, and check frequently to make sure that the splint is not cutting off circulation to the hand or foot.

If the broken bone is associated with a laceration of the skin, the fracture is said to be ‘compound’, which means the normal problems of the fracture have been ‘com­pounded’ by the risk of infection due to its exposure to the outside environment. Com­pound fractures require much more urgency than non compound (‘simple’) fractures. Most compound fractures will need to be taken to a operating room and thoroughly cleansed as soon as possible. Until then, put a sterile dressing soaked in povidone iodine (Betadine) or other disinfectant over the wound, and splint as usual. If you have anti­biotics, you should start them immediately. The best choice would be to take cephalexin (500mg) four times per day. This drug should not be taken by people who may be allergic to penicillin.

Head Injury

The terms ‘unconscious’ and ‘coma’ are vague generalisations. These two terms can describe a wide range of reactions, ranging from temporary amnesia following a blow to the head to complete unresponsiveness to deep pain. An altered mental state following a blow to the head is due to direct trauma to the brain. Most often this is just a bruise, and the person will improve steadily. However, if a blood vessel is actually tom, blood may accumulate in the closed space of the skull, gradually squishing the brain. Thus, it is important to note whether a head-injured person is getting better or worse with time.

Most cases of brief unconsciousness lasting less than a minute are not associated with any serious internal injury to the brain. The person may be confused, combative, or have trouble remembering what is happening to them, but they improve steadily over a number of hours. The medical term for this condition is ‘concussion’, which simply means a blow to the brain severe enough to cause a brief change in consciousness. A more seriously injured person may not respond to spoken commands, but might be making spontaneous movements, or push your hand away when you touch them. The most seriously injured person will not respond in any way to your touching them or talking to them. Try to note just how an unconscious person is responding when you first see them, and then keep track of whether they appear to be getting worse or better. If they are slowly getting better, you usually can be reassured they will recover. If they are getting worse, there is very little you can do except to try to get them to advanced medical care, and to be sure they are in a position that allows them to breathe freely.

Other Medical Problems

Animal Bites (Rabies)

All mammals are capable of carrying and passing on rabies. Dogs are the most common transmitter of rabies virus to humans, but the virus has been passed by cats, monkeys, cows, horses, raccoons, foxes, bats and skunks, among others. Nepal is considered to be highly endemic for rabies, mainly in the street dog population. There are numerous monkeys around certain temples in Kathmandu, and since they have constant contact with the dogs, they are thought to be capable of transmitting rabies as well.

Dogs infected with rabies may not show any signs of illness at the time they bite you. People usually think of rabies as producing an aggressive, drooling animal, but it can just as often present as simply a slow staggering gait, irritability, or paralysis of the hind legs. It is impossible to determine by looking at an animal whether it has rabies. The bottom line is that if you receive a bite or a scratch from an animal in Nepal, and the animal is not a closely observable pet, you will need to seek post-exposure rabies immunoprophylaxis. You should try to obtain these shots as soon as possible after the inci­dent, but it is not necessary to try to find a doctor in the middle of the night. In prac­tice. tourists in Nepal have been able to get to a doctor within three days, and people who were trekking have reached medical care within five days. This figure compares favourably to the average delay in treatment in the USA, which is five days.

Since post-exposure rabies treatment can be expensive, and sometimes difficult to ob­tain. prevention of bites is the best approach. It is sensible to be aware of animals around you in the street. Don’t step around blind comers, or step into courtyards without looking first to see if you will surprise a sleeping dog, or a dog with puppies. If you are charged by an aggressive-looking dog, bend down and try to pick up a stone. The dogs in Nepal are used to having stones thrown at them, and often will turn tail and run if you appear to be picking up a stone. Be aware that the monkeys around temples are extremely aggressive, and are used to humans having food in their hands or in their backpacks. Don’t wander around eating, and don’t try to feed the monkeys. A little awareness can save you hundreds of dollars in treatment, many hours of worry, and weeks of having to arrange your schedule around a series of rabies shots.

If you are bitten by a rabid animal, the rabies virus will initially stay at the site of the wound. This means it is possible to wash out a lot or all of the virus. Wash with soap and water, then a disinfectant, such as povi­done-iodine (Betadine). You will still need to receive rabies immunisations, but you will have greatly decreased the chance that you’re infected with rabies.

Psychological Issues

Even at the best of times, travel involves a level of stress higher than we usually deal with at home. Trekking in Nepal may involve jet lag, loss of contact with familiar support systems, bombardment of sights and sounds, beggars, and uncertainty as to whether you are strong enough to complete your itinerary. Even try­ing to absorb a particularly beautiful or mov­ing event can be a form of stress. Trying to accomplish simple tasks, such as finding i decent room, buying a bus ticket or obtain­ing a visa can lead to hours of frustration and uncertainty. If you are headed to re­mote areas, you can have a sense of being too far removed from familiar surround­ings. You may suddenly realise you are two weeks’ walk from a strange and terrifying capital city, which is still a two-day flight from your home.

Most of us try to avoid the unexpected, and to exert control over our surroundings, to try to make sure things happen the way we would like them to. When things don’t go as we think they should, we expect someone to be able to account for it, to take responsibility. When one shifts to an environ­ment and culture halfway around the world, these rules can change as well. Michael Palin, while trying to travel around the world in 80 days without flying, summed it up nicely: ‘What in Europe had been prob­lems to solve, in Asia became limitations to accept’. One of the most difficult things for travellers to adjust to is the loss of their sense of control. They may fall quite ill des­pite all their efforts to avoid it. Their trip of a lifetime might be scrubbed by three days of bad weather that grounds the flight. Since we are used to being in control, and rarely face situations that are beyond our control, our stress levels can reach astro­nomic proportions. However, in adventure travel, events may truly be beyond anyone’s control. The successful travellers are the ones who can learn to accept the limitations and work within the new systems as they are encountered.

Personal Physical Coals

Adventure travel­lers often add an artificial stress to their journeys: the question of whether they will ‘make it’ or not. Trekking is often very goal-oriented: the viewpoint of Kala Pattar near Mt Everest, or crossing Thorung La Setting out to do something you are not sure you can do is part of the adventure. But linking the attainment of this goal with a psychological sense of worth can be danger­ous. I have seen many neurotically anxious people heading out for routine adventures, heedless of the needs of their travelling companions, oblivious of the local culture, compulsively monitoring their own health, all with the goal of standing on some patch of ground they have read about.

People who are planning adventurous journeys should think about the psycho­logical aspects of their plans – finding a bal­ance. They should train physically to gain confidence in themselves and have more fun. They should realise it is truly the journey, not the goal, that will be their adventure.

Decompensation

Sometimes travellers are simply overwhelmed by the sights and sounds and lack of coherence of their environment. The exposure to what appears to be abject poverty is taken personally, as if they must do something themselves to fix it. The food is perceived as different, unappealing and unsafe. The rooms are dirty and noisy. Usu­ally, people gradually adapt, but occasionally they go home within a few days, feeling personally defeated. If you encounter some­one in this condition, a gentle approach can be helpful. You can point out that they don’t have to feel responsible for the unpleasant things they are seeing. You can try to get them to question whether the people they are seeing, who are quite poor, are actually suffering or unhappy. You can point out that they chose to travel to see and experience new things, including unfamiliar food and accommodation. If they can’t recover their composure within a few days, they should go home, or – less defeating – travel to a less formidable part of Asia, eg, Thailand.

Panic Attacks

‘Panic attack’ is the term used to describe a terrifying sense of being unable to breathe and about to die. Such at­tacks can be associated with chest pain, weakness, dizziness and hyperventilation. A panic attack usually leads to abandoning a trek, occasionally a helicopter rescue, and then a series of unsatisfying encounters with doctors who may not recognise the true diagnosis. The point to remember is that an overwhelming sense of dread is part of this syndrome, and the patients are often certain they are dying. The combination of symptoms present at the same time in an otherwise healthy person is the key to the diagnosis. In people who have never experi­enced panic attacks before, reassurance and an explanation of the diagnosis works well.

The cause of panic attacks is not known, but it seems that people who experience a panic attack suddenly have a racing pulse, pounding chest, and a feeling that they can’t breathe. The sense of panic and dread occur after experiencing the physical symptoms. In this way, panic attacks are not thought to be a purely psychological condition.

Sexually Transmitted Diseases

Most of the sexually transmitted diseases (STDs) we used to worry about have become minor concerns in the face of acquiring HIV infections (AIDS) from casual sexual contact.

Travellers often behave as if the time they spend travelling is not part of their ‘real’ life. Those looking for adventure may be looser with their sexual behaviour than when they are at home. They may be lonely after prolonged travel, or just in search of new thrills. The new sexual partner might be another traveller, a local man or woman, or a prostitute. Any of these people could be a source of an STD. I have seen several cases of women who contracted genital herpes from one or two nights spent with a casual partner (another traveller) who failed to warn them he had the disease. Male trav­ellers may recently have been with prosti­tutes (especially in Thailand), and could also be harbouring gonorrhoea, syphilis or HIV. Apart from abstinence, the only sure way of minimising the chances of contracting STDs is to use condoms.

Sores, blisters or rashes around the geni­tals, discharges or pain when urinating are common symptoms of gonorrhoea, herpes and syphilis. In some STDs, such as wart virus or chlamydia, symptoms may be less marked or not observed at all in women. Syphilis symptoms eventually disappear completely but the disease continues and can cause severe problems in later years.

HIV/AIDS can also be spread by infected needles and blood transfusion. Insist on 148 Health & Safety – Women’s health brand-new disposable needles and syringes for injections. These can be purchased from local pharmacies. Blood screening for HIV/ AIDS has been introduced in most Asian countries, but can’t always be done in an emergency. Try to avoid a blood transfusion unless it seems certain you will die without it.

 

WOMEN’S HEALTH

Vaginitis

It is not clear whether the risk of acquiring yeast vaginitis, a painful, itchy irritation of the vagina associated with a whitish dis­charge, is increased while trekking. Antibi­otics can sometimes initiate a yeast infection. If a woman has a history of yeast vaginitis, she should carry treatment, which can either be topical (in the vagina), or oral (pills).

Amenorrhoea

Some women travellers note that their periods stop for a while, or become irregular. This may be associated somehow with the stress of travel. Your periods will return to normal after a while. Pregnancy is the other main reason travellers might stop having periods, so be sure to check for this possibility if you have been sexually active.

Urinary Tract Infection

The urinary tract is usually free from bac­teria. In women, the short tube from the bladder to the outside (the urethra) can allow bacteria to invade from the vagina. An infection called ‘cystitis’ (inflammation of the bladder) can result. The symptoms are burning on urination and having to urin­ate frequently and urgently. Blood can sometimes be seen in the urine. Fever is usually not present unless the infection has spread to the kidneys. Sexual activity with a new partner, or with an old partner who has been away for a while, can trigger an in­fection, probably from the trauma of sexual intercourse. Symptoms of cystitis should be treated with an antibiotic because a simple infection can spread up the urethras to the kidneys, causing a more severe illness. The best choice of antibiotic is either norfloxacin (400mg) or ciprofloxacin (500mg), taken twice a day for three days.

Oral Contraceptives

Women who are already taking oral contra­ceptives (‘the Pill’) could prevent bleeding during their trek by taking their pills with­out a gap between monthly cycles. There appears to be no significant side effects of doing this, although some doctors feel birth- control pills have a slight risk of increasing the chance of forming blood clots in the veins that could break off and go to the lungs. There are no examples of this occur­ring in women while trekking, and it seems safe to continue taking the Pill while trekking to altitudes below 5500m. However, start­ing the Pill shortly before a trek simply to prevent menstrual periods is not a good idea. Many women experience side effects when beginning oral contraceptives, and it is bet­ter to be stabilised on a particular brand of medication and dose before you head to a remote area.

Pregnancy

Although little is known about the possible adverse effects of altitude on a developing fetus, almost all authorities recommend not travelling above 3650m while pregnant. In addition to the risk of altitude in Nepal, there is the constant risk of getting ill, and not being free to take most medications to relieve ei­ther the symptoms or the disease. There is no evidence that travel increases the risk of miscarriage, but one in five pregnancies ends in miscarriage in any case, sometimes ac­companied by profound bleeding which might require an emergency dilatation and curettage, or put you at risk of requiring a potentially unsafe blood transfusion.

Even normal pregnancies can make a woman feel nauseated and tired for the first three months, and have food repulsions or cravings that can’t be satisfied by the diet available on a trek. During the second tri­mester, the general feelings improve, but fatigue can still be a constant factor. In the third trimester, the size of the baby can make walking difficult or uncomfortable.

Most vaccinations can be given safely during pregnancy, but the actual effects of all immunisations during pregnancy are not known.

One can certainly find examples of suc­cessful travel while pregnant. But since the outcome of pregnancy is always in doubt, you should be careful about exposure to alti­tude, infectious diseases or trauma while pregnant. Travelling to Nepal while pregnant should not be undertaken lightly, and if you are uncertain about how you will feel, it might be better to wait and come trekking with your child.

RESCUE

If you trek into the mountains for two weeks from Kathmandu, you are two weeks’ walk from Kathmandu. This fact often does not impress itself on trekkers until they become sick or injured on the trail and need to return to Kathmandu. In recent years, communi­cation from the mountains to Kathmandu has improved dramatically with the pres­ence of both microwaved linked phones and satellite phones. The police and the army posts throughout the country also have radio capability. There are a few reliable medical posts in the hills (the HRA aid posts at Pheriche and Manang and the Khunde Hospital are all staffed by Western doctors), but most accidents or illnesses will occur in the absence of reliable medical care. If you find yourself ill or injured in the mountains, here are the steps to take to get rescued.

First of all, don’t panic. If someone falls, take time to assess the situation: suspected broken bones may only be bruises; a dazed person may rapidly become more oriented, and be quite all right in an hour. If it is severe AMS, descend with the victim; do not wait for help. In most areas of Nepal, some kind of animal will be available to help transport a sick or injured trekker. In western Nepal, ponies are common; in the mountains, yaks are usually available. As extraordinary as it may seem, many Nepalis are both will­ing and capable of carrying Westerners on their backs for long distances. Even if heli­copter evacuation is considered, it may be necessary to transport the patient to a place where it is possible to land the helicopter.

If you happen to be near one of the air­fields in the hills, you may be able to arrange a seat on a scheduled flight. By negotiation, space can usually be found for a seriously injured or ill trekker, or a charter flight might be arranged, but airport officials, are quite unsympathetic to trekkers who are merely demoralised by the unexpected hard­ships of trail life and hope to jump the queue in order to get out sooner. If there is no nearby airfield, or you have missed the available flights, then the only alternative is to request a helicopter rescue flight.