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#5203 - 06/14/10 12:12 PM Re: Dexamethasone and HAPE [Re: Rod]
Steve C Offline


Registered: 09/22/09
Posts: 7718
Loc: Fresno, CA
Originally Posted By: Rod
We are talking Whitney Zone here correct? What are the chances in the WZ that you are going to come across someone in dire need about to die from HAPE or HACE and that you happen to have Dex in your pocket?
There is almost no place on the MMWT that if you start to feel bad you can't stop and rest or decide to turn around and descend.We aren't talking Camp 2,3 or 4 on Everest are we? I want to get this clear in my mind what we are talking about here.

Rod, yes we're talking about Mt. Whitney. In the last several weeks, there was a thread on WPSMB about a fellow in a party who was definitely suffering from HACE. The hiker was stumbling and possibly unable to descend due to the conditions in his state. Another hiker gave the party Dex, and it improved the striken's condition to where he was able to descend.

Last year in the Horseshoe Meadows area, there was a teenager who needed to be rescued due to HAPE.

Last year, a hiker died just over Paiute Pass due to altitude issues.

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#5205 - 06/14/10 12:44 PM Re: Dexamethasone and HAPE [Re: Rod]
Bulldog34 Offline


Registered: 11/12/09
Posts: 1254
Loc: Atlanta
Rod, I'm sure severe, deadly cases of HAPE or HACE don't happen nearly as often in the Sierra as they do in the Himalaya or other higher ranges, but I know from personal experience that it happens. Unfortunately it happened to someone I ran across at Cottonwood Lakes last August.

A teenage boy (16, I believe) hiking with a group. I stopped to chat with them for a while, and the boy was definitely suffering from a bad case of AMS (killer headache, nausea, lethargy, dizziness). His friends didn't seem that concerned about him, but I strongly suggested they get him back down to Horseshoe Meadow and then on to Lone Pine. They said they'd watch him and make a call about what to do a little later in the day. We chatted for a while about taking an easy pace, hydrating, eating, etc. All they had for headache was Tylenol, so I left some Advil with them and went on about my hike.

I was shocked to read in the Inyo Register the next day that the boy had to be medi-evaced out and was DOA at the hospital from "AMS", which I'm sure was probably HACE or HAPE. Hours after I left that group, the boy was dead from the altitude at "only" 11K'.

If I had had dex with me, would I have left some with them? I don't really know, in retrospect. The kid was suffering, but it looked like the same thing my wife expereinced her first trip up to 14K' (Pikes Peak). She was fine after getting back down to 7K' (quickly!), and the one personal experience I've felt with AMS went completely away once I descended about 2500 feet. I certainly didn't think this boy's life was in danger but, now that I have that experience in my rearview mirror, I may act differently in the future (assuming I ever have any dex with me, which is a big if).

That experience has definitely changed my perception about AMS - I always thought of the deadliness of AMS progression as being pretty much in the 20K' and above climbing world, but I see it a little differently now.

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#5207 - 06/14/10 12:51 PM Re: Dexamethasone and HAPE [Re: Steve C]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1019
Loc: Richmond, Virginia
This thread has morphed into something it did not start out as, and not what the original poster intended. I am repeating here much of what has already been said.

Are we talking here about simple AMS? - no

Was the original question specifically about HAPE only? yes

Is HACE or HAPE a life-threatening emergency - yes

How soon? - now

Is the death rate high? - 20-80% depending on circumstances.

Is it common at Whitney altitudes? - no

Does it happen at Whitney altitudes? - yes

Note: What is the official altitude threshold for altitude illness incl AMS, and complications HAPE, HACE and death -
8,000 feet and above. Yes, only 8,000 feet.

Was the original question about Dex for AMS or HAPE? - HAPE

Are there side effects of Dex? - yes

Are these short term or long term worries? - mostly long

Does a potentially dying HAPE or HACE victim need to worry about these side effects? no, the benefit far outweighs ANY risk.

What would you do if your climbing partner or family member was at altitude, and on the third day woke up with shortness of breath, coughed up pink-tinged fluid, had rattling in the chest, cyanotic blue lips, a heart rate of 140 and a respiratory rate of 40, and was delirious? See below.

If the patient has HAPE or HACE but because of weather, injury, darkness, or whatever, and there is no evacuation possible, and no Gamow bag, and no bottled O2, then please give the dex and conclude this thread here.

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#5208 - 06/14/10 12:56 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
CaT Offline


Registered: 09/24/09
Posts: 694
Loc: Blacklick, OH (formerly SoCal)
Great conclusion, Harvey.
Thanks.
_________________________
If future generations are to remember us with gratitude rather than contempt, we must leave them more than the miracle of technology. We must leave them a glimpse of the world as it was in the beginning, not just after we got through with it.
- Lyndon Johnson, on signing the Wilderness Act into law (1964)

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#5224 - 06/14/10 03:10 PM Re: Dexamethasone and HAPE [Re: Rod]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Rod, last year, a very fit climber on a guided trip to climb Langley, developed sypmtoms of HAPE, and in about an hour proceeded to die. This was under about 11k feet.

There is little that is as frustrating as encountering someone dying of something that is easily treated, but can't be, because you don't have the treatment.

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#5236 - 06/14/10 07:20 PM Re: Dexamethasone and HAPE [Re: Harvey Lankford]
Norris Offline


Registered: 06/14/10
Posts: 22
Loc: Del Mar, CA
A recent study found that Cialis (Tadalafil) was nearly as effective as Dexamethasone for prevention of HAPE in the HAPE-susceptible:

http://www.annals.org/content/145/7/497.full.pdf+html


And it would seem that the consensus opinion is still that Nifedipine is effective at both preventing and treating HAPE:

http://books.google.com/books?id=NG21K80G_04C&pg=PA811&lpg=PA811&dq=nifedipine+%2BHAPE
http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-2/altitude-illness.aspx

http://www.mpoullis.net/bsphysiol/altitu...tm#HAPE-therapy

I'd like to see a study comparing all 3 drugs, that would be worthwhile.

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#5238 - 06/14/10 08:15 PM Re: Dexamethasone and HAPE [Re: Norris]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
Harvey great consolidation of the questions with good answers.I am aware people suffer and have died from HAPE and or HACE on Whitney.It is not common. So what is the conclusion? Do we all to become instant SARs and carry dex to administer to cases of AMS that may or may not proceed to a deadly or dangerous level.So should we all start packing Dex in our basic 10 now basic 11? It is a tough call IMO.

Norris I have seen those studies. they also say that the increase vasodilation of Cialis and Viagra have been used as performance enhancers for distance events and may become banned in Olympic Sports in the near future.So not only will I tear up the mountain I can be "ready if the moment is right.


Edited by Rod (06/14/10 08:19 PM)

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#5246 - 06/15/10 05:04 AM Re: Dexamethasone and HAPE [Re: Rod]
Bulldog34 Offline


Registered: 11/12/09
Posts: 1254
Loc: Atlanta
Originally Posted By: Rod
. . . they also say that the increase vasodilation of Cialis and Viagra have been used as performance enhancers for distance events and may become banned in Olympic Sports in the near future.So not only will I tear up the mountain I can be "ready if the moment is right.


That could make for some tricky hiking . . .

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#5248 - 06/15/10 06:45 AM Re: Dexamethasone and HAPE [Re: Rod]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1019
Loc: Richmond, Virginia
Originally Posted By: Rod
Do we all to become instant SARs and carry dex to administer to cases of AMS that may or may not proceed to a deadly or dangerous level.

No, not to simple, uncomplicated AMS.

While Dex helps AMS symptoms quite well, it only covers up the symptoms. It does not help acclimatization. The patient is still at risk for developing complications, therefore Dex could be counterproductive when used for uncomplicated AMS.

Dex, as stated earlier, is for emergency RX of HACE, HACE/HAPE combo, and somewhat for HAPE alone. One of the fastest and best ways it helps is to perk up a patients mental function enough that they are again ambulatory to get themselves down, the preferred option.

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#5250 - 06/15/10 06:55 AM Re: Dexamethasone and HAPE [Re: Bulldog34]
wagga Offline


Registered: 10/07/09
Posts: 2248
Loc: Humbug Reach (Pop. 3)
Originally Posted By: Bulldog34
Originally Posted By: Rod
. . . they also say that the increase vasodilation of Cialis and Viagra have been used as performance enhancers for distance events and may become banned in Olympic Sports in the near future.So not only will I tear up the mountain I can be "ready if the moment is right.


That could make for some tricky hiking . . .


A lover with a hiking problem?
_________________________
Verum audaces non gerunt indusia alba. - Ipsi dixit MCMLXXII

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#5254 - 06/15/10 07:57 AM Re: Dexamethasone and HAPE [Re: wagga]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
Well the question is still out there. Do we all carry doses of Dex in case we come across cases of HAPE or HACE? Should they issue a wag bag and a dose of Dex?

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#5255 - 06/15/10 08:06 AM Re: Dexamethasone and HAPE [Re: Rod]
CaT Offline


Registered: 09/24/09
Posts: 694
Loc: Blacklick, OH (formerly SoCal)
Originally Posted By: Rod
Well the question is still out there. Do we all carry doses of Dex in case we come across cases of HAPE or HACE? Should they issue a wag bag and a dose of Dex?

Harvey or Ken -- Would the average doctor even Rx Dex at any dosage for their asymptomatic Pt so they can carry it on the trail with them "just in case", and esp. if they knew it might be used for someone else rather than for the Pt requesting it?
_________________________
If future generations are to remember us with gratitude rather than contempt, we must leave them more than the miracle of technology. We must leave them a glimpse of the world as it was in the beginning, not just after we got through with it.
- Lyndon Johnson, on signing the Wilderness Act into law (1964)

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#5257 - 06/15/10 08:37 AM Re: Dexamethasone and HAPE [Re: Rod]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
No. Hell, most don't go to the bother of taking a first aid course to be able to help other people.


Originally Posted By: Rod
Well the question is still out there. Do we all carry doses of Dex in case we come across cases of HAPE or HACE? Should they issue a wag bag and a dose of Dex?

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#5258 - 06/15/10 08:41 AM Re: Dexamethasone and HAPE [Re: CaT]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Originally Posted By: CaT
Originally Posted By: Rod
Well the question is still out there. Do we all carry doses of Dex in case we come across cases of HAPE or HACE? Should they issue a wag bag and a dose of Dex?

Harvey or Ken -- Would the average doctor even Rx Dex at any dosage for their asymptomatic Pt so they can carry it on the trail with them "just in case", and esp. if they knew it might be used for someone else rather than for the Pt requesting it?


Hard to speak about averages. Remember, in the office, they are ALL asymptomatic, even if near-death in the field.

You may find it interesting that something like 3% of the people we interviewed in our Whitney study a few years back DID carry dex or the equivalent. I was astonished by that.

The average person would not make such a request. The person who likely would, would be someone who had spent some time reading up on the subject. I've never had such a request. Diamox, yes.

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#5259 - 06/15/10 08:51 AM Re: Dexamethasone and HAPE [Re: Ken]
Harvey Lankford Offline


Registered: 11/10/09
Posts: 1019
Loc: Richmond, Virginia
Originally Posted By: Ken
The average person would not make such a request. The person who likely would, would be someone who had spent some time reading up on the subject. I've never had such a request. Diamox, yes.

Same here, Ken.
Harvey

PS:Original poster Akichow first brought up the question on this thread and is therefore, by his action, not the average person. I hope we have answered his questions.

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#5260 - 06/15/10 08:58 AM Re: Dexamethasone and HAPE [Re: Ken]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
I guess I should say my final word on the subject.It is unlikely any doctor would prescribe dex to an asymptomatic patient especially if it were for the possiblity to help a random stanger in the mountains.
I am all about personal resonsibility.There are way too many people who try to take short cuts in preparation and over estimate their ability.From climbing Mt. Hood with a hundred year storm on its way to taking a casual stroll up the Main Whitney Trail.Many don't train enough,acclimate enough or investigate enough their own ability at altitude. This age of a drug to fix everything makes us take chances we really shouldn't.It is really unfortunate that people get into trouble on our local 14ers.Dex,Diamox, Cialis/Viagra should not be thought of short cuts to preparation. No one should ever go expecting that some magical life saving drug is in the pocket of a random stranger passing by.

It would be an interesting study to find out the "story" behind everyone who has suffered Hape or HACE in our local 14ers. Did they train,were they experienced? I am sure there are some who did everything right and still got into trouble. I sure would like to know the reasons why people suffered AMS, HAPE or HACE and what they could have done to prevent it.


Edited by Rod (06/15/10 09:08 AM)

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#5264 - 06/15/10 09:29 AM Re: Dexamethasone and HAPE [Re: Rod]
Ken Offline


Registered: 10/29/09
Posts: 742
Loc: Los Angeles
Well, glad you are able to speak on behalf of the doctors of america. I certainly don't.
I wonder why you asked the question, if you had already made up your mind? In spite of the fact that I tried to *gently* suggest that the scenario you'd suggested is highly unlikely, and has not happened in, what, 50 years of combined experience between Harvey and I.

The more likely, although still not experienced scenario, would be a paramedic, another physician (you know that we generally cannot prescribe meds for ourselves), asked for a prescription for emergency use for themselves or someone they might encounter, I'd give it with no hesitation.

I can't quite fathom your reasoning for bringing up the issue of shortcuts in preparation, in the context of life-saving treatments? Would you come upon a person having a heart attack, and lecture them on inadequate preparation? It's just inappropriate to the situation under discussion, I think.

Your mileage may vary...



Originally Posted By: Rod
I guess I should say my final word on the subject.It is unlikely any doctor would prescribe dex to an asymptomatic patient especially if it were for the possiblity to help a random stanger in the mountains.
I am all about personal resonsibility.There are way too many people who try to take short cuts in preparation and over estimate their ability.From climbing Mt. Hood with a hundred year storm on its way to taking a casual stroll up the Main Whitney Trail.Many don't train enough,acclimate enough or investigate enough their own ability at altitude. This age of a drug to fix everything makes us take chances we really shouldn't.It is really unfortunate that people get into trouble on our local 14ers.Dex,Diamox, Cialis/Viagra should not be thought of short cuts to preparation. No one should ever go expecting that some magical life saving drug is in the pocket of a random stranger passing by.

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#5269 - 06/15/10 10:53 AM Re: Dexamethasone and HAPE [Re: Ken]
SoCal Jim Offline


Registered: 06/09/10
Posts: 27
Loc: Santee, CA
This thread seems to keep wandering between the indications for emergency uses of meds (injectable dex) and performance-enhancing/AMS-prevention pharmacology. While Diamox has been shown to be fairly safe in common use as a prophylaxis for AMS, the take home should be that there are "no shortcuts to the top" (as per Ed Viesturs). Fitness is key. All meds have risks and side effects and are no substitute for training. And if you're not familiar with emergency use of potent meds such as dex, then you shouldn't be concerning yourself with whether or not to carry and use them.

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#5270 - 06/15/10 11:12 AM Re: Dexamethasone and HAPE [Re: SoCal Jim]
Steve C Offline


Registered: 09/22/09
Posts: 7718
Loc: Fresno, CA
SoCal Jim wrote:
> Fitness is key.

Actually, Jim, in cases of HAPE and HACE, better fitness might be a negative factor. More fit hikers can ascend more quickly, getting them to the higher altitude danger zone faster. AMS and the more serious problems can hit even the most fit.

It might be better to say "Acclimatization is key."

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#5271 - 06/15/10 11:13 AM Re: Dexamethasone and HAPE [Re: Ken]
Rod Offline


Registered: 09/22/09
Posts: 660
Loc: Santa Clarita, Ca. USA
Ken I sense a real attitude against me in your response. That's OK if you think that is an appropiate way to discuss contraversial issues in this forum. I am working through this issue out loud through this thread and it brings up a lot of tough ethical issues.I am not lecturing anyone. I am trying to be open and honest about a real tough issue.
I don't undestand why you can't "fathom" my reasoning for bringing up the issue of short cuts in preparation.I see it as a real and dangerous problem that people think they can short cut their physical peparartion and acclimation knowing performance enhancing drugs might get them by without putting the actual study,and preparation necessary.That model is clearly followed in HS to Pro sports.Many people take the path of least resistance in preparation.

I really don't see the connection to having that opinion and lecturing people who have had a heart attack. That is my opinion and I am entitled to that.That may not have been the origional question asked in this thread but it has morphed into etical considerations of what is appropiate to do in a certain situation.Many discussions start out that way and evolve into peripheral topics.We are just having dialogue. No right or wrong absolutes are being laid out.


Edited by Rod (06/15/10 11:19 AM)

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