Matt Knox / Emergency Medicine Doctor, Australia
Denali, or Mount McKinley for the uninitiated, is the tallest mountain in North America and one of the Seven Summits. Though in the same country as some of the most expensive health care in the world, it is an austere environment. Matt Knox climbed Denali this year, but like all of us tend to find at some stage, no matter where you are, you are still a doctor.
The gamble had paid off: sharp blue and clear skies with just a hint of wind. For the last week a Buddha-like high pressure system had sat on the mountain so we pushed the limit with altitude gain. Every step was an effort, but pretty soon the up bit was going to run out and we would be standing at the summit of Denali, the 6194m highest mountain in North America and one of the Seven Summits. It’s at times like those that you start pondering what twists of fate might have led you to that point.
I could trace it back to a sunny afternoon in London about two years prior. Sitting at my computer practicing procrastination, I came across the Diploma of Mountain Medicine run by the University of Leicester, a part of the UK suspiciously devoid of mountains. As a locum A&E middle grade doctor (known as a CMO to those in my home country of Australia) I could get all the time off I needed, and combining my favourite pastime of climbing with medicine seemed like a pretty sweet idea. My style of climbing was on rock, but I still thought of ice axes as one of the coolest things ever made by man. The course was expensive but offered incredible training and travel opportunities, and it was there that I met Jon – a paramedic and keen winter climber. I moved to Glasgow to play in the Scottish highlands and develop my winter climbing, and during a drunken evening Jon apparently asked if I wanted to climb Denali with him, and I apparently said yes.
So the training started in earnest, which consisted mostly of walking up the steepest things I could find, carrying the heaviest thing I could find. In the meantime another opportunity arose to work as an expedition doctor on a record-breaking ascent of Kilimanjaro known as the Wings of Kilimanjaro. I was surprised to find out that I was chosen more for my phone banter than qualifications, and it was a great way to improve my fitness further and get some more high-altitude experience before Denali. It was on this Kili trip that I met Matt and Luke – two of the editors of this prestigious publication (ahem! ed.) – indeed a write up of the Kili trip will be gracing your edition of Adventure Medic soon.
Jon’s good mate Oly made up the third member of our trio, and we got to know each other well during the organisation of the trip. In the meantime I had moved back to Australia so we kept up the training, sometimes two or three heavy sessions a day, and kept in contact by skype. Then on the auspicious day of 22nd of May (the same day the HMS Beagle departed on her first trip in 1826, and the day the Wright brothers received their patent for their ‘flying machine’ in 1906) we met in Anchorage for our attempt on the mountain. More importantly, that date is historically the start of the time that the Denali National Park enjoys its most stable weather, and we were hoping to prove the rule.
We used a company called Exposure Alaska to arrange our food and help us with transfers, then we found ourselves in Talkeetna – the town at the Southern edge of the Denali National Park – getting ready for our flight onto the glacier. Oh, one thing we did forget and I definitely recommend you have with you on a trip like this – a simple bit of plywood to put your stove on so that it doesn’t melt into the snow. We made-do with snow shovels and the avalanche probe, but only with constant attention to stop the pot from tipping over. It was rather annoying.
If this was a movie, I would make a bit of a montage here. Just imagine it: flying in a single prop plane with ever-growing snowy mountains on either side, sketchy ski-landing on the glacier dwarfed by cliffs, strapping our gear to sleds and ourselves to the sleds, setting off roped together with determined but apprehensive faces, looking back with anger as the bloody sled slides off track again and tries to pull you over, stopping for a drink while gazing with awe at pink skies receding over jagged peaks, working hard with the shovel to level off the campsite, sitting on the poo-can with arse cheeks exposed to the cold mountain air, three grown men snuggling into the tent for a sleep. Days passed this way and life became simple. Eat, walk, pull sleds, get blown away with the view at every turn, make camp, repeat.
A Doctor in a Foreign Land
It was not until we arrived at 14,000 foot camp that we came across our first significant medical event. I had heard a rumour about a 20-something year old guy with chest pain and shortness of breath, so I offered my help at the medical tent. He had woken up with the pain though he was completely well the day before and had been following a sensible ascent profile. The pain was sharp, right sided and pleuritic (changed when he took a breath). Pneumothorax, or ‘popped lung’, is more common at altitude, and my clinical examination was consistent with this suspicion. Thankfully it was not (yet) a tension pneumothorax, so I suggested he be evacuated to a lower altitude sooner rather than later.
The nurse who was stationed there as medic agreed with my diagnosis, but said that after discussion with the doctor at the closest hospital by satphone, they were treating him as HAPE (high-altitude pulmonary oedema) with nebulisers and oxygen, with a plan for him to walk down in the morning. They weren’t even giving nifedipine, which is standard treatment for HAPE in the literature. The nurse declined my offer to talk to the doctor myself. Obviously the climber was a bit concerned that my opinion was so different to the official advice he was getting, which got me in trouble with the ranger for contradicting them. There was nothing else I could do so I wished him luck and left. I found out a few days later that this climber did not improve, and he was in fact evacuated, chest x-ray confirming a pneumothorax which needed drainage. But he lived. (Insert smirk from myself.)
There are a few learning points from this: Denali is not like the UK or French Alps where they are quite likely to send a helicopter for you. You have to be as independent as possible and expect to rescue yourself if you find yourself in trouble. Also, it’s bloody difficult to diagnose over the phone, and I would hope that doctor would have changed his or her mind if the patient was in front of them. Lastly, if you are medically trained, make sure you bring some big cannulae with you to relieve a tension pneumothorax should this ever happen to you or someone near you.
Back to the Montage
After this our climb continued, and so does the montage. Ice and snow slopes getting steeper, sleds left behind, carrying massive packs up fixed ropes, puffing harder and harder, suffering from the surprisingly intense heat, bitterly cold at night, incredible ridge walking with panoramic alpine vistas, icicles hanging from the inside of the tent, building walls out of cubes of ice.
And then it was summit day. We got to this point in 8 days, and in a perfect world we would have liked to stay at 17,000 foot camp for a day to acclimatise, but the weather was rumoured to be turning bad soon, and we were feeling pretty good, so we decided to push on. The day was spectacular with clear skies and not too much wind. We packed light in an attempt to go fast, but the fast bit was beyond us considering our relative lack of acclimatisation. The last steep push is aptly named ‘Pig Hill’, but after struggling up it we popped onto the summit ridge. Then something concerning happened.
I saw a guy ahead being led down an extremely exposed ridge on a very short rope. A fall to either side would have been deadly and he was very unsteady on his feet. It was obvious that he had HACE (high-altitude cerebral oedema) and I asked if they needed help, once we met on a (slightly) wider part of the ridge. He was an inexperienced climber on a guided group who had gotten to this point in seven days. At that altitude it took me a while to work out that their average altitude gain was about 570m per day, well above the maximum recommended gain on 300-500m per day. And they were doing it without acetazolamide, a diuretic that helps you to acclimatise. The next bit of good news was that the guides, who were looking pretty altitude-beaten themselves, had left the medical kit down at camp! So we cracked out or kit and gave him 250mg acetazolamide and 8mg dexamethasone, and our best wishes as there was nothing else we could do for them at that point.
So we moved on and each step was like walking through treacle. But we got there and bagged the summit. Such a feeling cannot be described. From the base, Denali has a greater altitude gain than Everest, and we got to the top purely due to our own aching muscles and grit. At that moment I felt light and given to fly. But the top is only half way, so we reminded each other to maintain focus and made our way down again. We saw the unsteady guy stumble back into 17,000 foot camp a few hours after us, but he was looking much better. We would all do well to remember that Denali is a very severe environment, and even though you may have ‘professionals’ with you, they cannot always be relied upon to look after you. And don’t forget your med kit.
What took us nine days to climb took us a day and half to descend. We ran out of water three quarters of the way down, but instead of stopping to melt some snow for water, thoughts of a flight home and warm shower kept us moving, which in retrospect was a mistake. By the time we got to base camp I was feeling very unwell and my pee had turned a murky shade of brown. I had probably given myself a touch of kidney failure from dehydration and rhabdomyolysis where the products of muscle breakdown become toxic for the kidneys, so I spent the next few hours drinking as much water and electrolyte as I could stomach, before finally collapsing into bed.
We had to wait a couple of days stranded on the glacier before the weather was clear enough to get the flight back, but that gave us plenty of time to reflect on what had been an eventful, but ultimately successful, climb of the tallest mountain in North America. It’s was an experience that seemed taxing and pointless at times, and I admit there were a few ‘why the fuck am I doing this’ moments, but it was all worth it for that summit feeling, and the memories of camaraderie that will be with me forever. And my pee cleared up, so that was good.
Doing Denali yourself
Best time to go / Late April to mid-July, with the most popular time being mid-May to late June
Cost (Aussie dollars) / $1400 return flights, $1500 for Exposure Alaska ’Deluxe Package’ which includes airport pickup, Anchorage hostel, transfer to Talkeetna, flight to the glacier, and 15 days of food (3 person team), $350 (USD) for climbing permit, $450ish for climbing insurance, cost of gear variable depending on what you already have, lots of money for celebratory / commiseratory beers.
My medical kit included drugs (acetazolamide, nifedipine, dexamethasone, lots or paracetamol and ibuprofen with some stronger analgesics like codeine or tramadol, antiemetic, antihistamine, aspirin, loperamide, buscopan), oral rehydration salts (lots – it’s good to have one of these daily), SAM splint, bandages and dressings, duct tape (on your feet for blister prevention) and compeed (blister treatment), cannulas for pneumothorax, pulse oximeter (this was mostly for fun, we got down to 82% at 17,000ft camp), medical tape, scissors, cable ties. It would be smart to take chloramphenicol ointment for small wounds and to prevent conjunctivitis in the event of snow blindness, but we learned this on the mountain unfortunately. One of us carried this complete kit, others had a small easy access pack each with analgesics.