Mountain and Alpine Medicine

Mountain sports of all kinds are very popular and the popularity continues to increase (3). Classical mountain climbing as an extensive endurance stress has a high health-promoting effect due to economization of cardiovascular work,
improved fat burning and improved peripheral perfusion. I want to intentionally state this at the start, since this editorial addresses especially possible risks and dangers of mountaineering activities. There are even diseases which are altitude-dependent and which are caused by hypobaric hypoxia with subacute action. The cover image on this special edition of the German Journal of Sports Medicine, showing a mountain climber at about 6700 m altitude trailblazing on Manslu (8163 m), illustrate the unforgettable impressions of mountaineering.

Above a threshold altitude of about 2500 m, the immediatereaction with deepening respiration andincreased heart rate is no longer adequate for thehuman organism to compensate altitude hypoxiaand a time-consuming acclimatization is necessary.Insufficient acclimatization leads to mountainsicknesses, of which the probability of occurrenceis usually underestimated. This is due especially tothe fact that the onset of mountain sicknesses has alatency between a few hours and several days (7, 11).This latency enables an asymptomatic stay at higheraltitudes despite insufficient acclimatization,when the stay is only brief and descent is made soonenough, that is before the mountain sickness becomesmanifest. Glacier skiing and the customaryascent of Mont Blanc (4810 m) in 1.5 days are everydayexamples that this tactic functions by makinguse of the latency time. The situation is basicallydifferent if one remains at a high altitude (whetherplanned or unplanned) and misunderstandingsare pre-programmed if only the target altitude istaken into account but the exposition time ignored (11). If risk factors like shallow breathing alsooccur, a life-threatening high altitude pulmonaryedema can occur at unspectacular altitudes, evenwell below 2500 m (4). Sports doctors must be awareof this problem, be familiar with the differentforms of mountain sickness, and be able to suggestprophylactic measures if they want to advise peopleplanning stays at high altitudes. In their article,Berger et al. give an excellent overview of thethree forms of mountain sickness: acute mountainsickness (AMS) and the life-threatening forms ofhigh altitude pulmonary edema (HAPE) and therare high altitude cerebral edema (HACE) (2). Inaddition to the pathophysiology, well-founded,practical recommendations for drug and non-drugprophylaxis and therapy are offered. This is especiallyimportant, since expedition mountaineering isbecoming more and more popular and even MountEverest is offered as a commercially-bookable guidedtour (5), sometimes even as a quick ascent usingnormobaric hypoxia at home for pre-acclimatization (10). Normobaric hypoxia, which can be usedfor acclimatization, enables exposition up to about7000 m at low altitudes with relatively little expenditure.Normobaric hypoxia has been very successfullyused for several years in fire protection, sincean open fire is practically impossible below 15%oxygen content and below 13% even explosive substanceslike benzene no long burn (6). Thus the topicof altitude hypoxia is not only important for sportsmedicine, it has also found entry into the areas ofgeneral and occupational medicine.

The geographic characteristics of mountains, withsteep ravines and flanks, along with the unevennessof paths and terrain mean that falls and accidentscan be considerably more serious than on levelground. Thus, an accident which is actually negligibleitself can lead to loss of balance and possiblyfatal falls. In dynamic types of sports, such as skiing,the high energy of movement can lead to high-speedtraumata. Faulhaber et al. analyze the accidentsamong mountaineers and alpine skiers. The dataanalysis show the noteworthy result that 75% of allfalls occur during descent and 70% of all fall victimswere visually impaired to some degree. This offers alot of potential for avoiding falls.

The mountains add considerably to the difficultiesof rescuing and retrieving accident victims.This was the subject in the Case Report by Tannheimer,in which the initial treatment and removalof a victim with cranio-cerebral trauma at 5700 mduring expedition mountaineering is described. Inan urban setting, a period of 28 hours before reachinga hospital is nearly inconceivable. This reportmakes clear that a group in the mountains mustoften rely on themselves and perform treatment ofinjured persons on their own. This means a greatresponsibility of mountaineers for one another importance of founded basic knowledgeof first aid and mountain rescue for all those who are in themountains.

The topic of first aid knowledge is one addressed by Küpperet al., who see clear potential for improvement (7). Since careand rescue of injured or ill persons in the mountains is almostalways more difficult and complicated than in urban areas,the requirements for the rescuers are also higher. The rule ofthumb indicates that the endurance performance capacity asexpressed by V˙O2max decreases starting at 1500 m altitudedecreases by 10% per meter altitude (1), that means it can bereduced up to a third even in the Alps. This must be takeninto account in undertaking rescue actions at high altitudesand implies that mountain rescuers must have a high basicendurance level.

This reduced endurance performance capacity, caused byoxygen partial pressure at high altitudes, necessarily raisesthe question of the tolerance of mountain sports in cases ofprior cardiopulmonary diseases. Anecdotal reports of suddencardiac death among mountain climbers make heart patientsand their physicians wary. Burtscher et al. address the topic ofsudden cardiac death for the individual mountain sports disciplinesand relativize the risk on the basis of founded numbersfrom nearly four decades in Austria. Their risk assessment andrecommendations for prophylaxis are a valuable treatmentguide for all doctors who deal in their everyday practice withcardiac-impaired patients who want to engage in mountainsports or who are exposed to high altitudes in their profession.

Lechner et al. address the suspension syndrome, a diseasewhich at first sight appears to be associated exclusively withsteep rock and ice walls (8). It is a generally rare disease pattern,which can occur during free suspension in a safety harness. Thegeneralized hypoperfusion with reduced brain perfusion andconsecutive loss of consciousness is, however, independent ofaltitude and can thus occur in industrial-medical settings, suchas among construction workers, window cleaners, etc., whichmakes knowledge of pathophysiology, prevention and emergencytreatment, including elucidation of misinformation concerningthe so-called rescue death, relevant for urban doctors.

With that, I wish all readers of this special alpine andmountain/medical issue of the German Journal of Sports Medicinea broad increment in knowledge and pleasure in thishighly-interesting border area of medicine, which is findingincreasing entry into our sports medical practice.