Abstract
While visiting the Himalayan Rescue Association's (HRA) rescue post in Pheriche (4200 m), a Norwegian climber staggered in carrying a porter, more dead than alive, over his shoulder. The porter, from the lowlands of the Terai, had been working for an American trekking group that had ascended rapidly to Lobuche (4940 m). After leaving from Pheriche, the porter had developed high altitude pulmonary edema (HAPE), which was correctly diagnosed by group members. But instead of giving him appropriate treatment and arranging evacuation, they simply distributed his load to other porters and continued their ascent. The sick porter was left to fend for himself with life-threatening HAPE. Fortunately, the Norwegian who came across him several hours later was strong enough to carry him down the 400 m to Pheriche and in doing so saved the porter's life. The ADEMED students were less challenged by the practical medical management of a sick patient with HAPE than by the ethics of what had happened to the porter and their questions came thick and fast: “What are the ethics of care for employed staff? Is this normal within the trekking industry? Do they think they have no obligations to their hard working employees? They are treated like slaves.” These important questions had to be answered. Fortunately, the mood lifted as it gradually became obvious that the patient would survive.
Sadly, there were other opportunities to teach the students about the management of HAPE and high altitude cerebral edema (HACE). Some tour guides seem to ignore the needs of their clients, being controlled by the planned itinerary. At Gorak Shep (5170 m) a large commercial trekking group had three sick participants, two with severe acute mountain sickness (AMS) and one with a combination of HAPE and HACE. The latter had dyspnea at rest, an oxygen saturation of 57%, a pulse rate of 118/min, and was too ataxic to even attempt standing. He was in imminent danger of death. Three physicians from the Aachen group gave independent but identical advice. The trek leader followed the advice for the two AMS patients, but ignored advice on the recognized standard of care for HAPE and HACE or the practical offer of oxygen and a hyperbaric bag as the patient's descent was organized. He was eventually put on a horse to descend to Pheriche in a snowstorm: a severely ill man who had never ridden before, on a steep path without medical support. He was given no additional warm clothes. Again we had to counsel a worried group of students who witnessed a helpless person disappearing in the freezing mist. The guide defended her decision on the grounds of the group's published schedule. Most trekking companies state that their itinerary can be adapted if clients suffer from altitude illness (Eggert, 1998; Lechner, 2012). This flexibility is unrealistic during high season (Lechner, 2012). During October and November 2011, every lodge in the Everest region was fully booked in advance, and any group changing their itinerary is committed to complex logistics and potential bivouacs. It was this pressure that may have led to the potentially fatal decisions by the guide.
Growing numbers of unfit and inexperienced individuals, unaccustomed to adapting their goals to the terrain, weather, or needs of their team members, are participating in trekking and so-called adventure holidays and finding themselves in an unfamiliar and hostile environment for which they are ill prepared. With these changing demographics of visitors to high altitude and wilderness environments, combined with the pressure on accommodation in the most popular regions, it is of vital importance that trek leaders and the companies for whom they work are reminded of their duty of care to all of the people within their groups, whether they are paying clients or local portering staff.
Should the mountain medicine community be sanctioning the blanket use of medication such as acetazolamide or even dexamethasone for a trekking group without any specific personal assessment or indication, merely so that inexperienced clients can fulfill an often unrealistic dream and in so doing put their lives and the lives of their portering staff at risk? Should we be sanctioning the growing disregard of recognized rates of acclimatization? The argument is always the same: “Their holidays are limited and they should enjoy them!” but at what cost (Küpper, 2011; Luks, 2010)?
The problem of rapid ascents ignoring basic guidelines putting clients and local staff at risk is an international one. Shah et al. (2011) observed that most U.K. tour operators ignore the rules for acclimatization, which concurs with Lechner (2011) who investigated operators who offer tours to the Annapurna circuit. The preliminary results of the ADEMED Expedition 2011 support these data for the Everest region (Küpper et al., in preparation).
There is an urgent need to ensure that the traditional ethics and principles of mountaineering are not lost in the headlong rush towards a consumerist approach to commercial trekking and mountaineering. It should be possible to combine commercial ethics with the team concept accepting porters, clients, and climbing partners as having equal rights to care (http://ippg.net/trekking-ethics). It is only by reminding ourselves of these principles that lives not continue to be threatened and tragically lost in the Great Ranges.