Handkerchief Parachutes

“I guess this is a horrible thing to say , but I felt better when I heard the guy in the next room also vomiting . I didn’t feel alone anymore.”

Wang is one of the now – being a weekend – two handfuls of Chinese who are visiting the Larung Gar institute hotel ,image in mid-December. She has spiky Laurie Anderson-y hair and her head rests on a wide triangle : chin down on the narrow breakfast table between us , fingers propped up against her temples.

” -I didn’t expect it to be this bad .. I got this headache right when we got here , and then I started to vomit ..

– Yes , I would expect that . ”

Cold is the known and working deterrent here . It is cold , every last inch of the water pipes are covered in arm thick insulation , and the electric blankets in the beds are a neccessity , not a luxury.

Altitude obviously isn’t . Had I heard or seen Wang the other night I wouldn’t have been calm or nice , now I find myself being curiously detached : yes , that could have ended badly. But now … well , she made it down to breakfast , and has actually eaten . And kept it down. On the mend.

” I thought there would be a small pharmacy or something…”

Not really . What is to be had is one of the never proven Chinese herbal remedies , and disposable oxygen cans. I usually refer to these as handkerchief parachutes ( right idea , totally wrong scale ) but these are the biggest ones I’ve seen so far . Not exactly table cloth parachutes – lets stretch it to shopping bags. The English specs say it contains fourteen liters – a few minutes worth for example for post op patients who aren’t fully awake yet.

“You slept where last night ?!”

I didn’t see this coming – Wang and all the others ( or at least the ones I could speak with , mostly indirectly ) all had made the same journey : from Chengdu ( 800-ish meters ) to Sertar …at 4000+ meters. Nonstop . One day. I continue my callous streak by mentioning my pet AMS trivia : two percent of soldiers flying in to Lhasa start to develop pulmonary edema. And that’s nearly four hundred meters lower than the Sertar hotel. There is the known option of sleeping down in the village – Wang mentions this – that would make it to a first night around Lhasa altitude instead. The other option , valid enough for a first night at Lhasas altitude would be to medicate preventively , and this is virtually unknown in China. After the great Yushu earthquake China sent in thousands of rescue workers higher than Lhasa , unmedicated and rushing straight to the front . This became a minor catastrophe in itself , as local rescuers had to shift focus to rescue their colleagues , and have them flown out after less than a day.

The others around me were not far off from Wang : the two other Chinese in my four bed dorm obviously would have benefited from going down. One said he spent the first four days in bed , the second still had splitting headaches after the second night.

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Working out at 4000+ meters : stair  excercise with yaks up to the top ridge with the institute hotel and the mandala , and photo op break during the kora around the mandala.

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Worlds Highest Airport

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Landing at 4411 meters … an instant aging experience. Well , I got younger again down in Daocheng at 3750 meters. But not fast . There is a better way of doing this : a long flight to Kunming , where the airport is at 2100-ish meter, and then a connecting flight to Daocheng/Yading . Doesn’t run in the winter though.

( There are now four airports at 4000+ meters : La Paz , widely believed to be the worlds highest is the lowest one at 4061 meters. )

Small Sip of Water on the Hemkund Sahib

Todays quick read : a small pilot study on altitude sickness in Sikh pilgrims . Pilgrims progress up the Himalayas in a manner that will make experienced docs shudder , in part from a mindset that invites suffering – to a point. It is the same reality described in Basnyats Disoriented and Ataxic Pilgrims , from Gosaikhund in Nepal , where a large majority of the yatras suffered from AMS.

This small study ( 28 subjects , interviewed at the Hemkund Sahib temple @ 4330 meters ) is fuelled by two concerns : the rapid ascent , and the minimal fluid intake. The authors have set up a info page for coming pilgrims echoing the same concern about the water intake , urging a high water intake not only during but also before trekking up the Hemkund Sahib. Their main source for this is an article by Peter Hackett , mentioning advice handed out by the Himalayan Rescue Association – in 1975 (!) . This advice coming up now will surprise anyone who

* has read what Hackett ( who after extensive work with the HRA summited on Mt Everest as part of a medical research expedition , and now is the head of the Institute for Altitude Medicine in Telluride ) written on the subject afterwards :

..In reality you only need an additional liter to a liter and a half of water at altitude. Too much water is harmful and can dilute your body’s sodium level (hyponatremia) causing weakness, confusion, seizures, and coma.

* has read the advisory from the Himalayan Rescue Association over the last decade :

Maintaining adequate hydration

Adequate amounts of fluid (about 3 liters a day) are necessary in the mountains:- dehydration mimics altitude sickness and may even predispose to it. On the other hand excessive water drinking should also be avoided as this may lead to electrolyte imbalances.

( Also note that right from the start in -75 HRA talks of total fluid intake , not about drinking water : all fluids count , and the only unique value of plain water is a stronger push towards hyponatremia . )

* has read the relevant part of Hacketts first study : the outcome was that all participants lost weight , and that those who had the highest weight loss were the the ones who did not develop AMS :

Weightloss occurred in both groups , but was less in the AMS group (P0.07) . Indeed , the worse or higher the symptom score , the less the weight loss.

The other strong predictor for avoiding AMS was higher urine output. The second source quoted by Sahota and Panwar manages to find support for that . And only that.

Sources mentioned here :

Current acclimatization advice from Himalayan Rescue Association

A Pilot Study on the incidence of Acute Mountain Sickness at the Sikh pilgrimage to Hemkund Sahib

The incidence, importance and prophylaxis of acute mountain sickness – Peter Hackett & Drummond Rennie in The Lancet , 1976

Altitude Myths @ the Institute for Altitude Medicine

Nerin et al : Acute Mountain Sickness : Influence of Fluid Intake

For a non-medicalese version of acclimatization and hydration advice , see this interview with David Shlim , another veteran of the HRA clinic in Pheriche , fifteeen years as head of the CIWEC clinic in Kathmandu, and co-author of the CDC altitude advisory with Hackett.

The Pope As A Coca User

The one news story on coca ( well played , Evo Morales ) that will be remembered this year : the Pope “combated altitude sickness” on his visit to Bolivia by drinking coca tea.

The missing story , and context is found in his itinerary : the Pope had a textbook preparation for flying in to El Alto/La Paz by first going to Quito @ 2800 meters , and staying overnight . He spent less than four hours in La Paz the next day before flying out to Santa Cruz … altitude 416 meters.

To be expected , the usual media mix up on the altitude of La Paz and El Alto airport : the airport , and only the airport , is at 4000+ meters . The low , and posh , end of La Paz is nearly a thousand meters lower. Town center is 3600-ish. The common claim of the worlds highest airport is also off the mark : there are now five commercial airports at at 4000+ meters , and El Alto is the lowest. Yading @ 4411 meters in China is the highest , nearly four hundred meters higher than El Alto . It will be the second highest after the completion of Nakchu airport.

To Lhasa – By Train or Plane

The short version : adapting to high altitude takes time. You can travel to Lhasa fast , and spend time in hangover country before coming closer to full capacity again. The other option is to spend some time enroute , and get more out of each day. This should be an easy choice for anyone who has more time than money , since the time  in Tibet will be the most expensive days  on any trip to China.

Train , as in the nonstop Beijing -Lhasa run , or flying in , also from Beijing , are the options most will chose between The benefits or risks are the source of intense speculations , but with the massive numbers of travellers to Lhasa  there is also some hard data now.

Reality check : one in three will get altitude sickness , coming in by train  from Beijing .
And this is good news : twice as many get it on flyins.

The high figure for AMS is a shocker for many , but is in the same order for Cusco travellers , and a 2011 study from Lhasa, which also found that AMS was more common on flyins. Early stages are of AMS are undramatic , and many won’t even think of the hangover like situation as sickness. On the other hand a few , depending on bad luck in the genetic lottery in combination with really fast ascent do get severe AMS. The rare and worst case scenario is pulmonary edema , which only appeared in the flyin group – see the notes and reading suggestions below.

There is a rich flora on speculations regarding the train vs plane issue , the main reasons given for not taking the train being that it a) runs too low for benefit , or b) it runs too high . A conservative plotting of altitude as the available amount of oxygen , factoring in the extra oxygen on the train , gives this elevation profile between Xining and Lhasa :

Xining-Lhasa

TO LHASA IN TWO OR THREE DAYS :

Fly in to Xining at 2283 meters , sleep minimum one night there . Every extra night at 2000+ is a major positive factor. Next leg of the trip to Lhasa by train or plane . The reason you probably haven’t heard of the flyin option from Xining is that you couldn’t , until this year. Train is still better than the plane , from two reasons : you get more time between Xinings and Lhasas altitude , and you spend your first day at 3000+ meters at rest. Think of it as being locked up in a Lhasa hotel room , with a oxygen tank by your bed . And with a lot better views.

TO LHASA IN ONE DAY :

Fly in from one of the international airports Beijing , Kunming or Chengdu . Obviously not my recommendation for firstcomers to high altitude – the chances of getting really sick are low , but the chances of the first day or two being spent in hangover country are excellent.

TO LHASA , THE INTERESTING WAY :

The really good news here is that there are a number of interesting options that are even better than the two day options , if you are willing to spend more time .

Take the train from Lanzhou , near the Beijing-Lhasa halfway point at Xining, and add acclimatization time at Labrang. Lanzhou is at 1600-ish meters , which is too low for effective acclimatization. Labrang monastery , an important pilgrimage site for Tibetans , is only a few hours away with bus , at 2945 meters.

Kunming ( altitude 1850 ) : International airport , and railway point.

Still too low for effective acclimatization , but a convenient gateway to the large Kham Tibetan region in Yunnan. Take the train to Lijiang @ 2400 meters ( and a day tour on the worlds highest cable car ) , onwards to Shangri La/Gyalthang .

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Shangri La old town was very interesting until a few months after my visit , when a massive fire destroyed most of it. Lots of other good reasons to visit the region – see  Losangs blog for a wealth of information on Kham and Amdo regions.

Chengdu : International airport (CTU) , and railway.

Chengdu is abysmally low , but gives  easy access to higher ground in the Kham Tibetan region. Kangding/Dartsedo is reached same day with bus. Despite it’s modest altitude at 2600-ish meters Kangding is serviced by the third highest airport in the world at 4280 meters , so you can boost your acclimatization by flying back to Chengdu and take a flight to Lhasa . A cheaper , more environmentally friendly day trip  to 4000+ is taking the cable car from near the town center.

ACCLIMATIZATION , AMS AND TRAVELLING TO LHASA :

The medical issues with travelling fast to 3000+ meters altitude are well known since decades back – see the guidelines from International Society for Mountain Medicine or CDC. With litterally millions coming in to Lhasa every year , two million by train , it’s now also  possible to make large scale comparisons between different travel modes , with comparable  groups.

Incidence of High Altitude Illness Among Unacclimatized Persons Who Acutely Ascended To Tibet ( Yeshung Ren et al in High Altitude Medicine & Biology )

This describes the results  of  monitoring flyins to Lhasa in a 3268 strong group of military personell. 57 % had various degrees of AMS , 12 %  vomited and received medical attention  , 2 % started to develop pulmonary edema.

A Survey of Acute Mountain Sickness And Vital Signs in Subjects Ascending To Lhasa Via The Qinghai-Tibet Train ( Younjun Luo et al in Scientific Research and Essays )

A similar group of military personell , forty nine persons , was closely monitored during the train ride and for a long period in Lhasa . AMS peaked in 14 % of subjects during the first three days in Lhasa. Worst outcome , in four out of fortynine , was a AMS score of 4 at the Tangu La pass high point and first and second day in Lhasa. One person vomited at the Tangu La. None developed pulmonary edema.

Altitude Illness in Qinghai-Tibet Railroad Passengers ( Tian Yu Wu et al in High Altitude Medicine & Biology )

Tian Yu Wu was a key figure in planning the health program for the workers constructing the railway to Lhasa , the worlds largest construction project at extreme , up to 5000+ meters , altitude. The key data here comes from 160 random Chinese lowlanders travelling straight to Lhasa , without any acclimatization stop at Xining. 31 % developed AMS , 4 % vomited at the Tangu La. Worst outcome : one person developed a balance disorder , which improved after receiving extra oxygen. He was given intermittent oxygen at Lhasa hospital , a clean bill of of health after a CT scan of the brain , and resumed his Lhasa tour after a single day of observation in the hospital.

Acute Mountain Sickness among Tourists in Lhasa, Tibet  – A prevalence study ( Labazangzhu , from Oslo University )

This is the result of survey among around two thousand tourists in Lhasa , nearly half Chinese , which gives a narrow advantage for the train and shows a AMS incidence of 51 %.  It has a number of problems making valid comparisons . It includes many different travel modes , persons normally living at 2000+ meters , and for example people travelling from Kathmandu in Nepal , which will include both unacclimatized persons coming directly from Kathmandu , and well acclimatized persons after  trekking at 3000+ meters.

MEDICATION ?

AMS is obviously common enough on both the nonstop train run and flyins to Lhasa to consider medicating with Diamox. Talk it over with a travel doc , not your GP. In China you will invariably be offered Rhodiola/Hong Jian Tin instead , which has no documented effect ( including the few who used it on the the train in Wu’s study ) . Rhodiola is often presented as a unique Tibetan herb and tradition : it’s not . The plant is found over large parts of Asia and Europe , including my home mountains near the Arctic Circle and the Pyrenees . It has  been known to western tradition from the first century greek physician Dioscorides , was renamed by Linnaeus in the 18th century , and became a part of the Stalin era medical research in the twentieth .

The adjusted elevation profile comes from recalculating the effective altitude from the inspired  amount of oxygen on the train , factoring in the higher oxygen concentration after Golmud . John B West , editor of High Altitude  Medicine & Biology , measured the O2 concentrations on one of the first runs of the train , and calculated the effect to a 900-1200 meter lowering of the effective altitude. I plotted it as one thousand meters lower  , with a build up factor during the first 100+ klicks after Golmud – which still are lower than Lhasa on the map.

Manali Standoff

Todays hindi expression : chakka jam . A sit down protest – with cars. Manali has come to a near stand still as the National Green Tribunal actually almost stod it’s ground on the issue of banning diesel traffic up to the Rohtang La pass. In the end the long forewarned decision was transformed in to a cap on the total number of vehicles , and a heavy tax on diesel vehicles. Little love was won by this compromise.

The stakeholders in the conflict , with or without active advocates :

* the Rohtang La biotope , crossed by the “Great White Snake ” : Thousands of  four wheel drive cars , leaving a trail ..less than white behind them . Pristine white snow in beginning of the season turns more and more in to something resembling the floor of a oil pit in a auto shop.

* the Manali taxi drivers , who rightly remarks that paying five thousand rupees won’t make the vehicle less of a burden for the environment.

* the day tourists , many of whom have the chance of ” touching the snow” at the Rohtang as a key driving factor for coming to Manali . And now , when even the weather gods have been conspiring against them , found out yesterday that they can’t even come up to the snow line : the road always closes on Tuesdays so that Border Roads can do some effective road work. Right now the road past Marhi at 3000 meters is basically a one lane tunnel in the snow – see the photo in the sticky above.

* the Lahaulis on the other side of the pass , waiting for the first fresh veggies and provisions in months since the road closed for the winter .

* the military , who hardly needs any advocates : the Manali-Leh road probably shouldn’t even exist without the backdrop of the Aksai Chin war and the tension between India and Pakistan. At least not as early as as in 80’s.

Short term there are only two winners at the moment : the Lahaulis have a chance of seeing the road not being one of the slowest roads in India ( often five hours or more for the fifty-ish klicks from Manali to Rohtang top) in peak season. The other winners are the tourists who choose to stay and take the tour buses … until the taxi drivers block them as well.

Long term the needs of the Army and locals will be solved by the Rohtang tunnel , but that’s years off still. The tunnel won’t make any real dent in the heavy traffic over the actual pass though , except in eliminating the heavy traffic nowadays the first week(s) after the spring opening.

The mid term solution is more people in less vehicles , i.e. ( clean , CNG ) buses. Like the HRTC buses plying the full Manali-Leh road these need to be custom made : bigger than the minibuses , but still with short enough wheelbase to navigate the hairpin curves.

The really bold move here would be going for a cable car ( rope way , as the Indians put it) . This would the litterally long term solution , since it would make Rohtang La a round the year safe attraction ,like the Jade Dragon.

And yes , there is a common denominator here : the taxi drivers will suffer horribly. Sometimes everyone can’t win . Maybe this conflict will be a preparation for Delhiites in what must come at home as well : Delhi has one of the best Metros in the world – and this isn’t enough. It also has some of the foulest air in India ( and Asia , worse than Beijing ) , and this won’t change until the traffic situation changes drastically there as well.