Mismanagement of Patients with High Altitude Illness Evacuated from the Mount Everest Region in Nepal

The availability of helicopters in the Everest region is both a boon and a curse. Many lives are being saved with this facility, but trends of fake rescues and helicopter evacuations, even for minor ailments, without consultation from physicians of Everest ER (Everest ER is an emergency clinic based at the Everest Base Camp aid post at 5,300 m and run by the Himalaya Rescue Association) is increasing (Dawadi et al., 2020; Leshem et al., 2008). The authors (S.P. was one of the volunteer doctors at the Everest ER in the spring of 2022) also witnessed many helicopter evacuations from higher camps (especially camp 2 at 6,400 m)—mostly flying directly to the capital city Kathmandu.

Besides very sick patients, even patients with mild to moderate AMS (acute mountain sickness) and early HAPE (high altitude pulmonary edema), which could have been effectively managed at the Everest ER with descent and basic medications like oxygen, were also evacuated directly to Kathmandu from Camp 2 (Leshem et al., 2008).

The worrisome aspect is that most hospitals in Kathmandu do not have knowledgeable doctors in high altitude medicine. There is a huge gap and lack of knowledge of altitude case management in most of the tertiary care centers in Kathmandu resulting in instances of patients with high altitude or cold-related illnesses being over or undertreated.

Here are a few representative cases.

A young Sherpa lady on her 10th day of arrival from 5,000 m to Kathmandu started suffering from severe headaches, vomiting, and seizures. She actually had sinus venous thrombosis but was wrongly diagnosed with HACE (high altitude cerebral edema), given her recent history of descent from high altitude. Ten days after descent, she could not be suffering from HACE.

Another trekker suffering from severe AMS at 5,550 m improved significantly just with the descent to Kathmandu. However, in Kathmandu, he was admitted to an ICU setting and treated with acetazolamide and dexamethasone for 5 days. Just descent very often cures.

Another mountaineer with severe shortness of breath [a patient with HAPE] received a strong diuretic [furosemide] and his dehydration was aggravated, leading to renal injury. HAPE is noncardiogenic pulmonary edema triggered by hypoxic pulmonary hypertension.[Basnyat and Murdoch, 2003] [The mainstay of therapy is descent and oxygen, not diuretics which can often be counterproductive as in this situation].

Finally, a patient was evacuated with severe epigastric pain and vomiting was diagnosed with AMS and was discharged on ibuprofen. Multiple large duodenal ulcers were seen on endoscopy the next day when the patient felt worse. Many providers assume any patient brought from a high altitude has altitude illness.

Besides gross misuse of insurance and risky helicopter transfers from very high altitudes, (Skinner R, 2018; Safi M, 2018) what we present here clearly illustrates the fact that doctors in hospitals in Kathmandu, including private hospitals, need to enhance their knowledge base about high altitude diseases because of this changing trend of direct helicopter evacuation, given the topography of Nepal.(Dawadi et al., 2020).

Failure to do so might lead to incorrect diagnoses and may potentially cost lives. Input in helping to rectify this situation from stakeholders like the Nepali government, diplomatic institutions, insurance bodies, and authorities like the Nepal Medical Council may be essential.