To the Editor:
In an exchange of letters in the last edition of Wilderness and Environmental Medicine, Dr Litch and colleagues perhaps inadvertently misquoted and misinterpreted a valuable aphorism in regard to diagnosing altitude illness. The quotation was, “If you are not feeling well at altitude, it's altitude illness until proven otherwise.”
1.Dr Litch and colleagues have since changed this to “illness at altitude is altitude illness until proven otherwise.” They also pointed out the dangers of adhering too tightly to this diagnostic approach. I am afraid that Dr Litch's misquotation and his subsequent interpretation may lead to abandonment of a valid approach to the diagnosis of altitude illness.
- Litch J.A.
- Bishop R.A.
- Ripley R.
Medical emergencies at high altitude.
Wilderness Environ Med. 2000; 11: 297-298
The original statement, a quote I had made that first appeared in Stephen Bezruchka's A Guide to Trekking in Nepal in 1985,
2.was aimed at trekkers, not as a diagnosis guide for doctors. At that time, altitude illness was not as commonly appreciated among trekkers, and there was a tendency, that I had observed first hand, to want to attribute symptoms that occurred at altitude to anything but altitude illness (too much sun, dehydration, hitting one's head on a low doorway, etc). Also, I had discovered that acute mountain sickness (AMS) can present symptoms in many different ways, and it was difficult for trekkers to memorize a long list of them (headache, nausea, loss of appetite, lassitude, insomnia) to try to determine if they actually had AMS.
- Bezruchka S.
Trekking in Nepal: A Traveler's Guide.
5th edition. The Mountaineers, Seattle, WA1984
The aphorism has three benefits: 1) it suggests that one can use a global approach for diagnosing AMS. If one simply was performing badly at altitude compared to one's peers, it would be good to ask the question, “Could this be altitude illness?” 2) It puts altitude illness appropriately at the forefront of one's investigation of symptoms. It was not meant to suggest that all “illness at altitude is altitude illness,” as Dr Litch implies. However, it is important to remember that the vast majority of symptoms that resemble AMS at altitude is AMS. 3) The clause, “until proven otherwise” was there to make sure that people did consider other possibilities, and that not all illness at altitude is caused by altitude alone. During my 15 years at the Canadian International Water and Energy Consultants Clinic, I became interested in documenting the “proven otherwise,” aspect of altitude illness to establish a more realistic and tested differential diagnosis of illness at altitude. We documented and published case reports of suddenly symptomatic brain tumors at altitude,
3.pulmonary embolism presenting as high-altitude pulmonary edema,
- Shlim D.R.
- Nepal K.
- Meijer H.J.
Suddenly symptomatic brain tumors at altitude.
Ann Emerg Med. 1991; 20: 315-316
4.and Guillain-Barre syndrome misdiagnosed as high-altitude cerebral edema.
- Shlim D.R.
- Papenfus K.
Pulmonary embolism presenting as high altitude pulmonary edema.
J Wilderness Med. 1995; 6: 220-224
- Shlim D.R.
- Cohen M.T.
Guillain-Barre syndrome presenting as high-altitude cerebral edema.
N Engl J Med. 1989; 321: 545
There is a separate body of case reports that document other illnesses occurring at altitude, which, for the most part, were not originally considered to be AMS. These would include the heart attacks, seizures, and cerebral hemorrhages that have rarely been reported to occur at altitude.
Therefore, we should remember the original aphorism, and its intent. If someone becomes ill while trekking or climbing at high altitude, the first question should always be, “Could this be altitude illness?” The second question should be, “Could this not be altitude illness?” Dr Litch and colleagues appeared to be concerned that some people had focused too much on the first part of the phrase, and not enough on the phrase “until proven otherwise.” Although it is often possible to rule out altitude illness at altitude by experienced personnel, if there is any remaining doubt and the person is seriously ill, then descent is mandatory. In these cases, the “proven otherwise” part is something that happens after the person is evacuated to a lower altitude. I agree with Dr Litch and colleagues that altitude is usually associated with remoteness and lack of access to medical care, and evacuation is appropriate for any seriously ill person.
The case that prompted the exchanges in Wilderness and Environmental Medicine
6.was a classic example of medical abandonment while trekking, something that Dr Basnyat appropriately pointed out in his case report. Regardless of the final diagnosis, no one can claim that leaving this unfortunate man alone in a teahouse for four days with someone who did not speak his language constitutes appropriate care for a trekking client. Whether or not we understand why he ultimately died, we can use this case to reaffirm our commitment to getting sick people out of the mountains, or keep them continuously under the care of someone who can make adequate decisions regarding evacuation, until the situation is resolved.
- Goodman T.
- Basnyat B.
A tragic report of probable high-altitude pulmonary edema in the Himalayas: preventive implications.
Wilderness Environ Med. 2000; 11: 99-101
- Medical emergencies at high altitude.Wilderness Environ Med. 2000; 11: 297-298
- Trekking in Nepal: A Traveler's Guide.5th edition. The Mountaineers, Seattle, WA1984
- Suddenly symptomatic brain tumors at altitude.Ann Emerg Med. 1991; 20: 315-316
- Pulmonary embolism presenting as high altitude pulmonary edema.J Wilderness Med. 1995; 6: 220-224
- Guillain-Barre syndrome presenting as high-altitude cerebral edema.N Engl J Med. 1989; 321: 545
- A tragic report of probable high-altitude pulmonary edema in the Himalayas: preventive implications.Wilderness Environ Med. 2000; 11: 99-101
© 2001 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.