Saturday, August 4, 2007

Sequoia/King's Canyon Backpacking-with Emergency

Part of the challenge and the appeal of backpacking is being ready for the unexpected. As backpackers, we chose equipment for the conditions we’re likely to encounter, build in a safety margin, and accept the responsibility remote terrain demands. As skill levels increase the safety margin can be provided more by knowledge and less by weighty gear. Planning a trip requires an honest evaluation of your own skill level and that of your group. What is your fitness? Who isn’t comfortable with class III cross country? Does someone have a medical condition that may influence their abilities? Can you pick a safe route through rough terrain and will you backtrack to avoid scrambling that is over your head? A leader needs to continually reassess his group on a trip. Who didn’t sleep well and can’t hike 20 miles today? Whose “bum knee” is acting up? You need to know your route, have contingencies to cut a trip short, and know what emergency services are available at any trailhead to which you might evacuate. You should consider your route in relationship to weather, seasonal snow pack, and elevation. Can you expect to go cross country at 7500’ when you know man eating manzanita grows on south slopes at this elevation? Will you be able to cross a river in the afternoon on the third week of July when the watershed is still full of snow? The longer and more remote the trip, the more detailed the planning should be.

This is the story of a serious illness in a remote part of the Sierra Nevada. It has a happy ending largely because of advanced planning, the group’s level of fitness, experience, and lightweight ethic. In retrospect, there may have been other steps that could have improved the outcome further. It gives an example of a commitment to self rescue and the decisions that led to this possibility.

It started out well enough. Four excited people out for an 80 mile, four day trip in King’s Canyon. All of us had prior backpacking experience and were in good shape from running ultramarathons. Lee, who sells medical equipment, was in peak shape for a 100 mile race a few weeks later and had been on several backpack trips earlier in the season. Jeff, busy putting together computer network deals, hadn’t been running as much and was on his first backpack trip in several years. Jackie, Jeff’s wife, also hadn’t backpacked in years, but had been running and hiking with a pack to get ready. They had arranged grandparent babysitting so they could enjoy the trip together. As the leader, I’ve spent more than 1000 nights on backpack trips. One month earlier I had run the 223 mile John Muir Trail in just under four days and was looking for a tough trip but one where I’d actually get to enjoy the mountains. I’m comfortable with long trail days, unroped class IV cross country, solo backpacking, and navigation. As a physician I’m familiar with the medical conditions unique to high elevation travel. I carry a 6oz “prescription strength” first aid kit to match.

Our loop was to include dramatic high mountain cross country on the first northerly miles of the unofficial “Timberline Route”. It would join and head south on the John Muir Trail with a final night’s camp at Rae Lakes. On the final day we would cross Glen Pass and return to King’s Canyon down Bubb’s Creek. I was especially looking forward to the Rae Lakes camp. When I ran through Rae Lakes a month earlier I enjoyed brief glimpses of evening colors on the steep headwall called the “Painted Lady” and could sense the tranquil, moist, still, and cool evening air. But I had to run on into the darkness of Wood’s Creek and missed being part of that stillness and beauty. On this trip I promised to fully surrender to the evening I had missed at Rae Lakes. It was a promise which I would not be able to keep.

We began a little later than planned at Cedar Grove and began the 11 mile, 6000’ climb to Kennedy Pass. A slightly slower than expected pace and late start had us arrive at Kennedy Pass two hours later than planned. Because of the delay and reports that Pine ridge trail was blocked with multiple fire downed trees we elected to go cross country to Granite Pass via Volcanic Lakes. The class II/III scrambling slowed us again and it was just before dusk when we crossed the trail at Granite Pass and camped at Lake 10,785. Everyone was tired but in good spirits.

The second day started by breaking camp quickly and hiking 1 ½ hours. We had breakfast and coffee at the view-rich tarn atop Glacier Pass. By late morning crossing the State Lakes valley, Jeff was feeling more worn out than he should and his fingers were swelling. He didn’t feel especially short of breath or have a headache and his appetite was good. He told me of a prior elevation problem, and he declined using Diamox. We continued a good pace despite a long lunch and swim at Horseshoe Lakes. Our crossing of White Pass was slowed when we crossed the ridge 600’ too high and descend a steep talus/scree gully. We carefully descended two by two (on opposite sides of the gully) to a small fork of Cartridge Creek. As we ascended toward Grey Pass Jeff really began to lag. Despite our intention to cross Grey and Red Passes and camp at Marion Lake (10,300’) we stopped short at 11,200’ in a lovely meadowed bowl complete with trickling stream, glacial polished granite kitchen, and sandy tent sites.

By the third morning it was clear that Jeff was really sick. He hadn’t slept the night before due to feeling he had the flu and an upset stomach. He felt dizzy, was unable to concentrate, and had a haggard look. He was lagging well behind the group and reported feeling short of breath. His lungs sounded clear when I pressed my ear against his back on top of Grey Pass and he answered coherently. His feet and fingers were swollen. We forced coffee and oatmeal on him at Marion Lake, but even a long rest didn’t restore him. He took a small dose of Diamox at Marion Lake but continued to feel miserable. It was on the way up Cartridge Creek, that his pace dropped and he had to stop and rest to catch his breath every 2-3 minutes. I made a diagnosis of acute mountain sickness with possible early pulmonary edema. We were now about as far away from a trailhead as we could be. It was time to carefully consider our options and try to get out on our own.

High altitude illness is better avoided than treated. Slow elevation gain—typically less than 2000’ per day once over 8000’—can help prevent the problem. Once an altitude illness develops, the best treatment is descent to lower elevation. Even as little as 2000’ of descent can improve symptoms significantly. Medications can help prevent and treat these illnesses, but generally aren’t available as a prescription is required. Although I did have Diamox available, Jeff hadn’t wanted it the second day when he first became sick. He was now vomiting and so couldn’t absorb any we gave him. This made descent our only realistic option. The most immediate way to lose elevation would be to descend Cartridge Creek to the Middle Fork of the King’s River and exit at Wishon Reservoir. This would get us low quickly, but make us dependant on getting a ride back to our cars and to the hospital if Jeff’s condition didn’t improve. It was also a 40 mile trip. A shorter option was to cross Cartridge Pass, descend into the South Fork of the King’s River, cross Taboose Pass and drop to Highway 395 on the east side of the Sierras. For this option we would need to climb two 12,000’ passes and would again be dependant on getting a 250 mile ride back to our cars from a no telephone trailhead. Pre-trip planning had a Wood’s Creek exit as an option to shorten the trip, but this again would involve crossing two 12,000’ passes and significant mileage. The final option was to cross Cartridge Pass (12,000’ but now only 2 miles away) and continue down the South Fork of the King’s. This would give us one high pass but would let us drop quickly and permanently below 9000’ and get us back to our own cars. The main disadvantage was the lack of a trail down the canyon. Looking at the topographic map I could envision the giant talus and overgrowth likely to be present in a narrow 3000’ deep canyon. There was a risk taking a sick person down this route but it was the shortest option, would get us permanently to low elevation and back to our cars. We decided it was our best option.

As the three of us divided up the contents of Jeff’s pack we were glad we were traveling light!! With heavier packs, it would have been much harder to help him as much. I assigned Lee to “pace” Jeff as I noticed that Jackie was more sympathetic towards Jeff and was less likely to encourage forward progress and regular intake of food and fluid. Jeff vomited several times while crossing Cartridge Pass, but remained coherent and able to hike slowly. He did not report a headache but just wanted to sleep. Once over Cartridge Pass we reassigned Jackie to take care of Jeff’s while Lee and I descended to Lake 10,860 to have soup ready for Jeff to eat when he arrived.

Jeff ate little at our lunch stop and slept for two hours. He felt little better as we continued to descend to the South Fork of the King’s. When we arrived we left the trail and initially followed easy cross country through the pine forest duff. Then the canyon narrowed and we began to climb over car to cabin size talus and wade through dense Aspen and Willow saplings. We scheduled a 5 minute rest for every 20 minutes of hiking and encouraged Jeff to eat. However jelly-beans were all he could keep down. When Jeff reported feeling dizzy and unable to concentrate and began stumbling in the dense undergrowth, I became concerned that it might not be safe for him to continue. In full view of the narrowing canyon we came to a wide granite shelf I felt might be the last place that would allow a helicopter landing. I laid out the options to Jeff in certain terms: keep hiking or stop here and let Lee and me hike out and call in a helicopter. Jeff was unwilling to surrender and drew on his experience pushing through misery as an ultrarunner. He rallied for an additional two miles for a late camp at 8800’ and dinner in the dark. He was able to help set up camp and even kept down a small part of dinner.

Overnight the low camp elevation effected its treatment. Jeff, while not back to normal, showed his bravado by yelling us out of bed at 6am. He was able to eat a decent breakfast and keep up the jocular banter characteristic of our trips first days. With less worry about Jeff, the amazing beauty of the canyon became apparent. It was a snaking granite causeway never more than ¼ mile wide with 4000’ vertical to the peaks high on both sides. The walls were sculpted in turrets and spires with talus fields littering the bottom as an afterthought. The riverbed usually allowed for the fastest progress and was replete with small falls and pools. This would have been a much more difficult trip if it hadn’t been September in a low snow year. A dipper served as our guide down nearly ½ mile of the canyon and several small falls cascaded from the cliffs above. It more than made up for the missed night at Glen Lakes.

As the day progressed and our elevation continued to decline, Jeff returned fully to normal. We arrived at the cars, bathed quickly, and began the long drive home. As memories bubbled up in the introspective time after a long trip, many questions surfaced. Had we ascended too quickly? We camped at 6400’ the night before the trip then at 10,800’ the first night out and 11,200’ the second night. I’ve certainly followed this pattern before without any problems. Planning for a slower ascent or lower campsites may have been safer. Should I have screened the group better? I screen my Sierra Club group members before accepting them on trips, but didn’t do this for someone I knew well. Jeff had actually had bad headaches at elevation before which I didn’t know about. Was there anything else I could have done once Jeff got sick? Here I feel that I should have advised Jeff to start Diamox earlier and continue it even when he got really sick. It might have kept the problem from getting worse or helped it resolve sooner. Should I have chosen a different way out? Certainly if Jeff had been sicker, descending Cartridge Creek would have been a better option. Here the best immediate medical response for an individual would have made the group overdue at least a day and necessitated begging for a 100 mile ride. It was more risky to go cross country, away from other hikers that could have helped and into a rough trail-less area but it was the only option that preserved a self rescue.

Mountains are unconcerned with the processes of man. Every step and every storm gives us immediate and impartial feedback on the consequences of our actions. The simple and pure experience can not but result in faith that the actions of our everyday life also make sense and have meaning. Time spent in the mountains represents a smaller portion of life but the clarity an attentive visit can provide casts a reassuring light on the larger but fragmented life we otherwise live. We must approach the mountains fully responsible for ourselves and fully accepting of the consequences of our actions. If we succeed we grow and become part of their slow and permanent glory. If we fail we retreat into a smaller portion of a more diffuse life.

First Aid: Ultralight Style

The rule “if you don’t use it take it out of your pack” just doesn’t apply to first aid kits. How do you design a light first aid kit without compromising safety? Start by sizing your kit for your group and trip length. No need to take eight days of a medication if you’re only going to be out for a weekend. Make sure only one person takes the “industrial strength” kit so the weight isn’t duplicated. However everyone should have the basics or they’re less likely to use them early when they can do the most good. An individual should also bring any specific medications they need such as an Epi-pen if they’ve experienced severe sting/food allergies. Don’t forget personal prescriptions. Next consider the specifics of your trip. If you’re not going above 8000’ you probably won’t need altitude sickness medications. Plan your kit for the common problems you’ll encounter. Blisters rank among the most common and can become dangerous if infected. It’s important to take a good variety of dressings and tapes to treat them. Sprains and cuts are also common. A small array of bandages (including steri-strips) are important. Finally know how you can improvise and what “non-medical” treatments work (like descent for the altitude illnesses) so you don’t have to carry everything you might remotely need. Splints can be made with sticks, rope, and torn clothing. Ripped cloth can be used as gauze for large wounds if first sterilized by boiling or soaking in a dilute iodine, bleach, or Aqua Mira solution. Large volumes of water rinse wounds and a dilute water purification solution can replace a specific disinfectant.

Altitude Illnesses:

Acute Mountain Sickness—Headache, nausea, vomiting, weakness, malaise, poor sleep. Usually occurs 24-48 hours after a too rapid ascent. Worsened by exertion, best treated by dropping 2000’ and ascending more slowly. Can use Diamox 125mg twice daily for 5 days prior if prone, 250mg twice daily once it develops.

High Altitude Pulmonary Edema—Shortness of breath often with audible rales (crackling sound like crumpling paper), blue color (in severe cases) best treated by RAPID descent. This is an emergency!! Can use Nifedipine if available.

High Altitude Cerebral Edema—Headache, confusion, hallucinations, incoordination best treated by !RAPID! descent. This is an even more severe emergency. Can also use Decadron if available.

High Altitude Flatus—The tendency for passing increased bowel gas at high elevation is generally not a serious medical problem except in markedly anal retentive ultralighters. Tentmates may become short of breath and turn blue in more severe cases. Tarps minimize this effect and are recommended as a preventative.

First Aid Kit: My 6.2 oz of protection

Wound closure

4 circular/4 standard cloth type “Band-Aids”

2 small/2medium Compeed patches

2 packages of Steri-strips

Blister Tape—Leukotape P sports tape or Kinesio waterproof (Sticks better than Duct tape and breathes)

Small roll of sports tape

2 safety pins

small bottle of benzoin

Medications (Rx=need prescription*)

10 Aleve (12 hour duration anti-inflammatory)

10 Benedryl—sleep aid, allergic reaction

6 Tums—indigestion, reflux

6 Imodium—diarrhea

4 Vicodin (Rx)—severe pain

6 Diamox 250mg (Rx)—altitude illness

6 Doxycycline 500mg (Rx)—broad spectrum antibiotic

4 Hydroxyzine (Rx)—sedative/pain

4 Decadron (Rx)—allergic reaction, altitude sickness

2 small foil pouch topical antibiotic

*Your personal physicians may be willing to prescribe small quantities of many of these medications for trip use. Make sure you know how to use them before you go. Write down directions and seal them in a waterproof bag. Keep track of expiration dates. If you’re not sure of what you are treating, DON’T.


25 Iodine pills—antiseptic, emergency water purification

Water/windproof matches, firestarter

2 needles in small insulate piece, wrapped with 10 years heavy thread

mini-photon light with locking on switch on elastic wrist strap

Other—stored elsewhere

Tweezers/scissors/knife on smallest Swiss army knife

Everything is stored in a waterproof ziplock bag(s) for easy visualization/access. Keep iodine away from anything metal—best to store with bandages.

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