After having met the “Third Man” on Putha Hiunchuli (in 2011)

I have experienced it myself. It happened in fall 2011 during my failed summit attempt on the 7,246-meter-high Putha Hiunchuli in western Nepal, somewhere above 7,000 meters. My teammates were out of reach, I was fighting my way up alone, physically and mentally at the limit. “Please!,” I suddenly heard Pemba Nuru, one of our two Climbing Sherpas, say behind me. “Please what?,” I asked and turned around. But nobody was there. Strange. Scientists call the phenomenon the “Third Man”. Descriptions of such hallucinations abound in expedition reports from the highest mountains in the world. Psychiatrists of the Medical University of Innsbruck and emergency physicians of the private research center “Eurac Research” in Bolzano have now examined about 80 such descriptions from alpine literature and discovered, according to their own information, a new disease: the “isolated high-altitude psychosis”.

Seven out of eight

So far, high altitude physicians have assumed that organic causes are responsible when altitude climbers suddenly see and hear people or perceive odors that are actually not there. The researchers from Austria and South Tyrol, however, found out that “there is a group of symptoms which are purely psychotic, that is, they are related to altitude but not to a high-altitude cerebral edema or other organic factors such as dehydration, infections or organic diseases”, explains Hermann Brugger, head of the Institute for Alpine Emergency Medicine in Bolzano. Brugger had found in an earlier study that seven out of eight world-class climbers who reached altitudes above 8,500 meters without bottled oxygen had hallucinatory experiences.

Almost jumped

Dhaulagiri

The good news of the new study: The pure psychoses in high altitude are only temporary and do not leave any consequential damage. The bad news: On the mountain, they can endanger the climbers. Thus the Slovene Iztok Tomazin, one of the authors of the study, describes a hallucination he himself had during a summit attempt on the eight-thousander Dhaulagiri in December 1987. Several (fancy) mountain guides had advised him to jump down the East Face telling him that in few seconds he would be on a flat, safe place 2,000 meters lower and this would solve all his problems. “I almost jumped and this would have meant death with a 100% chance,” writes Tomazin. But then he reflected and made a test: He jumped only two meters deep to a small ledge. The pain he suffered opened his eyes, that maybe it would not be such a good idea to jump down the whole wall.

Further research in Nepal

“There are probably unreported cases of accidents and deaths due to psychosis,” says emergency physician Brugger, adding that therefore it is important to inform extreme climbers about the possibility that hallucinations can occur. In addition, they should be given strategies on how to deal with the “Third Man” without being endangered, says Katharina Hüfner, psychiatrist at the Medical University of Innsbruck. Next spring, the scientists want to continue their research along with Nepalese doctors in the Himalayas. Among other things, they want to find out how often these psychoses occur at high altitude. “The highest mountains in the world are incredibly beautiful,” says Hermann Burger. “We just did not know that they can drive us mad.”

Oswald Oelz

“I will climb until I am dead,” says Oswald Oelz, sitting opposite me recently at the International Mountain Summit in Bressanone. The 73-year-old native of Austria lives as a retiree in an old farmhouse in the Zurich Oberland region in Switzerland. “I have a farm with sheep, parrots, ducks, geese, chickens. I write, read a lot, climb. And I travel around the world.” Oswald called “Bulle” Oelz scaled Mount Everest in 1978, on the same expedition, during which Reinhold Messner and Peter Habeler climbed the highest mountain on earth for the first time without bottled oxygen. Oelz succeeded first ascents in the Alps, in Alaska, Jordan and Oman. Until 2006 he worked as chief physician at the “Triemli hospital” in Zurich. The professor also researched in the field of high altitude medicine.

Oswald Oelz, you are a mountaineer and a doctor, you have got to know both worlds. Time and again, there are fatalities in the high mountains due to high altitude cerebral or pulmonary edema. Has the climbing community learned nothing over the past decades?

The climbing community has learned nothing insofar as they still climb up to altitudes where a human being doesn’t really belong. Above 5,300 meters, man is not able to survive in the long run. Nevertheless, he goes up there. This is a charm, a thrill. If he is sufficiently acclimatized, he can stay up there for a shorter or longer time. The problem is that, on the one hand, people are willing to ascent who are less fit for high altitude and, on the other hand, they climb too fast too high. The typical example is Kilimanjaro, where you climb up to almost 6,000 meters within five days or even less. There is a very high death rate. Per year about twenty so-called climbers die. That is kept strictly under lock by the government.

Oelz on the summit of Mount Everest

On Everest, reportedly two-thirds of the summit aspirants are prescribed performance enhancing drugs to increase their chances of summit success. Who is responsible for doping on the mountain, the climbers themselves or rather the doctors who hand over these drugs to them?

I have no idea to what extend climbers are doped on Everest. But I have no doubt that there are quite a lot using the “three D”: Diamox, Dexamethasone and Dexedrine. The mountaineers take Diamox for a long time, then Dexamethasone, a cortisone preparation, during the ascent and finally, to mobilize the last resources, Dextroamphetamine – a poison which was given to the Stuka pilots in the Second World War to make them more aggressive. In the history of alpinism, many climbers have died as a consequence of taking these amphetamines on Nanga Parbat and other mountains because they pushed themselves beyond their limits. Obviously this medication is prescribed by doctors. On the other hand, these drugs are also available illegally. Today you can get everything you want provided that you pay for it.

Actually, Diamox and Dexamethasone is emergency medicine.

This is certainly also a cause of the problem. I think Diamox is the most harmless of these. If someone makes this brutal ascent of Kilimanjaro within five days up and down, he is almost certainly a candidate for high altitude sickness. This can be avoided to a great extent by taking Diamox. It has few side effects. The beer tastes horrible, which is the worst side effect. You have to drink a little more water because it has a diuretic effect. But otherwise I personally recommend Diamox, if someone who wants to climb Kilimanjaro and has problems with high altitude asks me.

Climbing in Jordan

You were on top of Mount Everest in 1978, along with Reinhard Karl (Karl was the first German on Everest, he died in an ice avalanche on Cho Oyu in 1982). Four years later you suffered from a high altitude cerebral edema at Cho Oyu almost killing you. How can this be explained? You really had to assume that you can handle high altitude well.

I was not able to bear high altitude as good as, for example, Reinhold Messner but quite properly, when I had acclimatized. But I always had this time pressure. I was working in the hospital. I wanted to get as high as I could as quickly as I could in the few days I had left for mountaineering. In 1982, I had a severe high altitude cerebral edema. In 1985, on Makalu, we moved within nine days from Zurich up to 7,000 meters. There I had a life-threatening high altitude pulmonary edema. I would have died if I had not tried for the first time a therapy which then worked. I took the heart medication Nifedipine, which lowers the increased blood pressure in the pulmonary circulation, which is especially crucial in the case of a high altitude pulmonary edema. That saved my life. Afterwards I have made the appropriate studies, and we were able to prove that this drug can be used as a prophylaxis for people who are predisposed to high altitude pulmonary edema. In my opinion this isn’t doping. Furthermore we could show that in case someone is already suffering from a high altitude pulmonary edama, it can improve the situation significantly. Meanwhile, it has been found that the same effect can be achieved by Viagra. It widens the vessels also in the lungs, not just below. Thus the increased pressure in the pulmonary circulation decreases, and the people are doing better. This is, of course, more fun than taking a heart medication.

You referred to prophylaxis. Is it really practiced?

I know people who do it. In 1989, we published a work in the “New England Journal of Medicine”, the leading journal in the medical scene, in which we showed that people with a predisposition to high altitude pulmonary edema can be protected to a certain extent by prophylaxis with this cardiac medication. People who e.g. suffered from a high altitude pulmonary edema even in the Alps at an altitude of 3,000 to 3,500 meters should be recommended such a prophylaxis. Of course, it would be wiser to tell them: “Stop this stupid mountaineering, instead swim, run or whatever!” But these people are not teachable. They want some medicine.

“An embarrassing spectacle”

You had the privilege of traveling in the Himalayas at a time, when it was still a deserted mountain region without any tourism. How do you think about what is going on there today?

I follow what’s happening today in the Himalayas with fascination. It is unbelievable what the young really good climbers do in the difficult walls of the seven-thousanders. What I am following with great sadness is what takes place on Everest and on the other commercialized eight-thousanders. These endless queues of clients who are pulled up by their Sherpas – I think that’s an embarrassing spectacle.

Dr. Tobias Merz (l.) and his co-expedition leader Dr. Urs Hefti on top of Himlung Himal (© T. Merz)

20 doctors, nearly twice as many test persons. The Swiss research expedition to the seven-thousander Himlung Himal in fall 2013 had the objective to investigate the effects of high altitude on the human body. More than two years later, the first results are there to see. I have talked about it to Dr. Tobias Merz. The 46-year-old is a senior physician at the Department of Intensive Care Medicine at the University Hospital in Bern. Since his youth, Merz has been doing sports in the mountains. So it’s no coincidence that he has committed himself to high altitude medicine too. “In intensive care medicin a disease takes organ systems to the limits of the possible, in high-altitude medicine external conditions are responsible for this,” says Merz. Before going on expedition to Himlang Himal, he had already experienced high altitude as a climber in the Andes and the Himalayas. On the eight-thousander Shishapangma, Merz had reached a height of about 7,600 meters. He then had had to give up his own summit ambitions because he had been needed for a rescue. On Himlung Himal, he stood on the highest point.

Dr. Merz, in 2013 you reached the 7,126 meter-high summit of Himlung Himal. Do you feel somewhat queasy in hindsight if you look at your first research findings?

I already knew that high altitude climbing is a high-risk sport and that it takes you to limits of physiology and rationality. For me, the results were more a confirmation of what I had suspected and less a huge surprise.

But you have worked out something worrying for high altitude mountaineers.

We actually had two important results. One is very reassuring, one very worrying.

On ascent (© T. Merz)

Let’s start with the bad news.

There were 38 probands who were climbing this mountain. 15 of them reached an altitude of more than 7,000 meters. We have found evidence that three of these people suffered from cerebral edema while climbing, means that liquid had leaked from the blood vessels into the brain tissue. In that case the brain is swelling what can turn into a life threatening situation. It was worrying that neither we as doctors nor the test persons had noticed these cerebral edemas. Actually, the classical doctrine is that there a clinical symptoms occurring in parallel to the development of a cerebral edema such as headache, nausea or general sickness and that one has still time to take action, that is first and foremost descending quickly in order to avoid a life-threatening complication. But obviously it is not like that. We think that a cerebral edema can occur without warning. Of course, it makes the situation far more critical if a clinical disaster can happen like out of nowhere, within minutes.

But it was micro bleedings that were not even perceived by the mountaineers.

Correct. On top of the mountain these people felt like those who had no micro-hemorrhages. But these micro-bleedings that we could detect afterwards at the test persons are evidence of significant cerebral edema at high altitude. The good news is that these micro-bleedings can not be equated with brain damage. These climbers have returned and now have a completely normal brain. You can still see a few leaked blood cells, but the brain tissue is unharmed. So the climbers had a narrow escape. They were close to developing a severe cerebral edema. It then requires only a little increase in volume to fall from a normal level of consciousness into a coma.

Blood collection in Base Camp (© T. Merz)

So there are no warnings. But can we even say at which altitude the risk of cerebral edema increases dramatically?

We cannot prove it due to the design of our study. We did the MRIs (Magnetic resonance imaging)  before and after the expedition. The micro-bleedings occurred sometime in between. But we found it only at test persons who were higher than 7,000 meters. This is no proof, but at least an indication. And the affected climbers were those among all who had the lowest oxygen level. During the expedition, we checked the oxygen saturation in arterial blood twice a day.

Is there perhaps a predisposition to High Altitude Cerebral Edema (HACE)? And if yes, is it possible to test this vulnerability in advance?

No, such tests do not exist. We only can say very pragmatically: A person who had already a cerebral edema at 4,000 meters is more likely vulnerable in ever higher altitude than someone who has never had a cerebral edema. But there are no studies on that.

But younger people are probably more vulnerable than older ones. This has more mechanical reasons. The brain volume decreases with age, that is, a 65-year-old has significantly less brain matter in his skull than a young person. If the somewhat shrunken brain begins to swell, it simply has more space than the brain of a 20-year-old, whose skull is actually mostly filled with brain matter.

Would you say in the light of your study that high altitude climbing is irresponsible from a medical perspective?

I would rather say that every climber must consider by himself how much risk he wants to take. He has to be aware that a certain percentage of climbers get a cerebral edema. As in all high risk sports, it’s an individual decision whether one is willing to accept the danger.

You can book an expedition to the mountain we climbed from catalog, paying about 12,000 to 14,000 Euros. We as clients assume that the product which we buy is safe. And we also tend to delegate the responsibility for our well-being to the operator, expedition leader or guide. But it does not work. Actually, any high altitude mountaineer must be aware that he personally has to take this risk and nobody can take over that responsibility from him. This awareness is lacking a bit in commercial high-altitude mountaineering.

Camp 2 on Himlung Himal (© T. Merz)

Also an expedition doctor, if there is one, can do little.

The chance that he is getting sick is the same as for all others. And he can do little to treat the high altitude cerebral edema. It’s even difficult to bring down an ill climber from 7,000 meters. And it has to happen quickly. This brings an expedition very quickly to the verge of its logistical facilities.

Finally once again the good news: The statement that high altitude mountaineering makes stupid belongs to the category of popular misconceptions, doesn’t it?

Yes. For methodological reasons, we had doubts concerning the results of previous studies saying that climbing at higher altitudes, starting already at the height of Mont Blanc, cause brain damage. In these studies usually mountaineers were compared with non-climbers. But if I compare a 45-year-old mountaineer with a 20-year-old medical student, I will always find a relevant difference. That’s why we conducted this study, in which we examined every mountaineer with MRI before and after the expedition. We could neither prove that there is a loss of brain matter, nor that micro-infarctions occur as described in previous studies. Even the three climbers in our group who had micro-hemorrhages suffered no permanent brain damage. The cerebral edema is gone.

Shishapangma (8027 m)

The sad news from the Himalayas don’t stop. On the 8000er Shishapangma in Tibet a German climber died of a high altitude cerebral edema. The expedition agency Amical alpin informed that the climber from the Bavarian region Chiemgau had belonged to a group of six members who, together with expedition leader Thomas Laemmle and their Climbing Sherpa Pasang, had reached the 8013-meter-high central summit of Shishapangma on 10th May. While descending the climber at first had shown symptoms of a high altitude pulmonary edema.

Abseiled down to 7500 metres

„An immediate treatment with emergency medicine as well as the descent initially showed little effect,” Amical said. Thomas Laemmle, a sports scientist very experienced in high altitude medicine, decided to send the other members ahead to the lower camp. He wanted to lead down the altitude-sick climber slowly, on short rope. The following night the climber also showed symptoms of a cerebral edema. Laemmle administered an emergency medicine immediately. Until next morning he was able to abseil the climber to a height of 7500 metres. But the efforts to save the mountaineer’s life were unsuccessful. „A tent and bottled oxygen were already on the way up the mountain, but on 11th May at 11:23 he died in the arms of the expedition leader”, Amical announced.

Everest ascent cancelled

Due to the rescue Thomas Laemmle also got a high altitude pulmonary edema and frostbites at his toes. „Both are not so bad – now I’ve been in a hospital in Kathmandu – but an ascent of Everest without oxygen will not be possible”, Laemmle wrote in his blog. He had already reached the main summit of Shishapangma on 30th April. Initially Laemmle wanted to climb four 8000ers within four months: after Shishapangma he planned to scale Mount Everest and afterwards in the Karakoram Gasherbrum II and Gasherbrum I. Laemmle now wants to recover and set off for the two Gasherbrums on 8th June.