The risk of severe frostbite leading to the loss of fingers and toes is rare for trekkers on Kilimanjaro. However, it’s still essential to be prepared, especially if you find yourself stuck or lost in harsh weather conditions. Make sure everyone in your group is properly equipped with thick socks, sturdy boots, gloves, and warm hats.
The initial stage of frostbite is called ‘frostnip’. During this stage, fingers or toes may feel cold and painful, followed by numbness and a whitish coloration. If you experience frostnip, it’s crucial to warm the affected areas gently on a warm part of the body, such as under the armpits, until the normal color returns. However, in cases of severe frostbite where the affected body part becomes frozen, it’s important not to attempt to warm it until reaching a lodge or camp.
The recommended treatment for severe frostbite is immersion in warm water at around 40ºC or 100ºF. Seek medical assistance promptly after warming the affected area. Proper preparation, awareness of symptoms, and prompt treatment are key to minimizing the risk of frostbite while trekking on Kilimanjaro.
All climbers must assess the risk of frostbite to determine the type of clothing and protective gear to bring. We have been unable to find previous specific reports discussing the incidence or risk of frostbite on Kilimanjaro despite a daily present threat with hundreds of annual occurrences. At extreme altitudes, the ambient air temperature provides little warmth to the body. The sun can provide a warm environment, perhaps 80-100°F (26.7-37.8°C) in the skin of a person wearing a light shirt and sun hat, but the air temperature is below freezing. The advent of wind or storm can create unexpectedly severe and dangerous situations. Few people realize this, and it is not unusual for climbers to end up with sunburn and frostbite simultaneously. Settings presenting these conditions include high-altitude mountaineering worldwide, high-altitude ski trips, polar expeditions and expeditions to the seven summits. The well-known cold and UV dual injury problem has received recent attention in determining the best protection for high-altitude climbers. UV radiation increases 4-5% per 1000m in elevation, reflecting off snow to increase exposure further. UV burning and eye damage can occur even when temperatures are very low. This is especially a problem in the spring and summer, where the sun’s angle at high altitudes is nearly perpendicular to the strong UV rays. UV radiation is weaker in the winter, however it can still cause frostbite because it takes only a few degrees increase in skin temperature above the freezing point for snow or cold water to cause freezing injury. UV radiation also penetrates and weakens nylon material commonly used in outdoor gear. This lessens both its insulation by creating holes and tears and its water resistance, which is an important factor in cold precipitation settings. High-altitude precipitation can create a life-threatening situation with the body’s energy reserves being used to maintain core temperature. This is the reason frostbite is a constant threat on any type II or III climb on used to the climb classification scale. In our recent correspondence with MDs accustomed to working at high altitudes, minimum protective clothing is considered a sun hat, long-sleeved shirt, light gloves and wind pants. On the seven summit quests, this generally does not prevent freezing injury. Success has been found with sun-protective clothing, the best being wet skin clothing as this provides the highest protection. Although Gore-tex is traditionally considered poor insulation, it is the best low-volume clothing for protection against wind-driven snow or rain. For feet, it’s been suggested to utilize VBL socks and boots with insulation rated for 5000m above sea level. UV protection for the eyes requires quality sunglasses with side guards and dark lenses. UV burning of the cornea can be treated at any altitude provided the right medications are available. This article focuses explicitly on frostbite of the hand as this has been the most common site of injury for ourselves and other climbers who have given us reports.
Climatic Conditions on Kilimanjaro
WIND CHILL FACTOR
The wind chill factor is the felt air temperature on exposed skin due to the wind. Wind often lowers the temperature and can be 5 degrees Celsius less at 5000 meters. With the actual air temperature at minus 5 degrees, a wind of 16 km an hour would feel like minus 15 degrees. Cold wind increases the rate of heat loss and reduces the body temperature more quickly than it would in calm conditions.
LOW TEMPERATURES
Temperatures on Kilimanjaro can be quite low, so there is a risk of hypothermia. Hypothermia occurs when the body loses heat faster than it can produce heat, causing a dangerously low body temperature. This is more likely at higher altitudes because of the lower air temperature and slower and less vigorous body movements.
And within hours, George noticed that his toes were frozen and white. They had lost all sensation, and he was finding walking difficult. Austin was also suffering. Every time he took his gloves off to take a photograph, he found that his fingers would quickly become numb and painful. They were both experiencing the signs of frostbite and realized that it would be unwise to continue to the summit far from help. They made the difficult decision to turn around at 5700 meters. Frostbite is an injury to the body caused by freezing body tissue. It is most common on the extremities, such as fingers, toes, nose, ears, cheeks, and chin. Because of the cold temperatures and high wind chill on Kilimanjaro, the risk of frostbite is high.
High Altitude
High altitude is the main problem when considering the cold conditions on top of Mt. Kilimanjaro, though it is the wind on the last two days that normally causes the bulk of problems in attempting the ascent. Acute mountain sickness (AMS) concerns any high-altitude trekking or climbing trip. AMS covers various symptoms but the principal indicator is a headache. If any other symptoms are experienced, then a descent is indicated. The proper acclimatization of altitudes over 3000m is very important. This should be at a rate of not more than 300-500m daily, with an extra night for every 1000m. This is why Kilimanjaro can be trekked in such long periods, and as a result, the chances of reaching the summit are greatly increased. High altitude pulmonary oedema (HAPE) and High altitude cerebral oedema (HACE) are the most dangerous forms of altitude sickness; the buildup of fluid on the brain (HACE) or on the lungs (HAPE) has a fast onset and if not treated with immediacy, descent and medical assistance, can be fatal. Symptoms are recognizable with HAPE from a dry cough and difficulty in the early stages, which, if developed it to being brought up pink frothy sputum and a blue tinge to the lips. HACE symptoms are similar to that of being drunk and it is advised that an affected person should attempt to walk in a straight line, if they are unable to do so then immediate descent is necessary. These two forms of AMS are caused by a lack of acclimatization and climbing too high too fast. Although there is no foolproof prevention of AMS, medication (acetazolamide) has been proven to aid in prevention and faster acclimatization.
Low Temperatures
The daily temperatures on Kilimanjaro change very dramatically. Observations have shown that when sky conditions are constant, the air temperature decreases almost linearly with an average lapse rate of 6.5 degrees Celsius for every 1000m increase in altitude. This means that it is coldest just before the new sun arrives at dawn because the night has the longest duration. (…) Since the freezing level is around 18,000 feet, it is obvious that the cloud level during the night is usually around 16,000 feet because it is here that precipitation is spread in the form of snow. These nightly clouds trap the heat from the earth below, resulting in warmer temperatures at the summit during the day than at night when it is clear. This is shown by the fact that the rate of sublimation is great during the day due to fierce solar radiation, but at night it is less as the snow refreezes.
It appears that temperatures on the mountain have been shown to follow a consistent pattern regardless of the altitude. Studies have shown that the freezing level at the equator is around 18,000 feet, and this is also the average height of the summit of Kilimanjaro. At this elevation, the temperatures fluctuate around the freezing point both on a daily and a yearly cycle. The higher up one goes, the colder it gets. The mountain has lost 80% of its glacier ice since 1912. This is generally due to the fact that the winter snows just do not compensate for the summer heat, and also that there has been a general trend of warmer and drier weather in East Africa.
Wind Chill Factor
This phenomenon relates to the cooling effect of wind. At altitude, wind speed is rarely constant and gusts of 40-50 mph are common. Around the summit, the average wind speed is 12 mph. Using the formula, Wind Chill Index = 13.12 + 0.6215T – 11.37V^0.16 + 0.3965TV^0.16 where T = Air Temperature and V = Windspeed in mph, it is possible to calculate wind chill at different locations on the mountain. Wind increases the rate of heat loss from a warm object to its surroundings so that it cools to the steady-state temperature more quickly. In the case of the human body, the heat the body loses is replaced by internal metabolic heat, so that the body continues to cool unless it increases the rate of heat production or reduces heat loss. Should the ambient temperature drop below 0°C, a situation common on Kilimanjaro, wind chill will become detrimental to climbers, where frostbite injuries can occur in less than 30 minutes. Case studies have shown wind chill to have a large effect on temperatures actually experienced by climbers. At an altitude of 5895m, expedition doctors on the ‘Save the Children’ climb recorded the temperature in Barafu camp to be -15°C, however with winds of 10 mph, this was equivalent to -40°C with respect to the wind chill factor. It was here that 6 of the climbers suffered from varying degrees of frostbite, an indicator of the severity of wind chill on Kilimanjaro.
Understanding Frostbite
When the body is exposed to cold for long periods, the blood vessels constrict, decreasing blood flow to the extremities to save body heat. This can cause the tissues to freeze. This occurs most quickly (within minutes) in extremely cold temperatures, high wind chill, and/or when wet. When skin is exposed to cold and wind, the temperature decreases even if the ambient temperature is above freezing. However, frostbite can also happen in non-freezing temperatures. Those at high altitude can get frostbite because the oxygen-starved tissues are more prone to freezing. Elevation causes an increase in breathing and heart rate, using up more calories and fluid. If fluid intake and calories are not sufficient, a mountaineer can become relatively hypoglycemic and dehydrated, increasing the risk of frostbite from low energy stores in cold, hypoxic conditions. Elevation can also cause a condition called high altitude peripheral edema, where there is an excessive amount of blood in the hands and feet. This causes redness, swelling and pain similar to frostbite. If this occurs, it is important to differentiate between frostbite and edema. Lastly, isolated very high altitude areas have an increased risk of solar frostbite. UV radiation is more powerful at altitude, and snow fields act as a perfect reflector. UV damage to the skin can cause a necrosis similar to frostbite (MIMMS).
Definition of Frostbite
Frostbite occurs in 3 stages of severity. First-degree frostbite is when ice crystals form on the skin. This is identified by hard, pale, and cold skin with a mild burning or tingling sensation. Second-degree frostbite is when the skin freezes and the ice crystals spread to deeper tissues. Fluid-filled blisters develop 36-48 hours after rewarming the skin. If a medical professional is not seen, this can be identified by swelling and a burning sensation. Third-degree frostbite is more severe and occurs if frostbitten skin is re-exposed to the cold. This results in blackened skin that is numb and painless. Large blisters form, and it may lead to amputation of the affected area. This occurs as the new ice crystals remaining in the skin and the underlying tissue act as splinters in the body.
Frostbite is an injury of the skin and deeper tissues that is caused by prolonged exposure to freezing or near freezing temperatures. Frostbite is most likely to happen in body parts that are furthest from the heart: hands, feet, arms, and ears. Lesser severity cold injuries can occur in the form of chilblain or trench foot. Chilblain is where there is inflammation in the skin as a result of repeated exposure to cold, but the effects are not long-lasting. Trench foot is a result of the feet being cold and wet for prolonged periods and can cause damage to the skin and underlying tissue and nerve damage. In severe cases, amputation of the feet may be required. Frostbite is of more significance than these other cold injuries and affects 1,300 people who take part in outdoor activities annually in the United States.
Causes of Frostbite
Frostbite results from exposure to cold, low humidity, and the body drawing blood away from the extremities to the vital organs in the body core. The reduced blood flow to the hands and feet will increase the chance of frostbite. Reduced blood flow will decrease the amount of oxygen in the area. Frostbite occurs when the skin and body tissue are exposed to the cold for prolonged periods. When the temperature is below -15°C, blood vessels will start to constrict to maintain body temperature. This is a way to prevent heat loss from the body and to maintain core temperature. If the body is losing heat, the body will reduce blood flow to hands and feet resulting in a higher chance of freezing. High altitude increases the risk of frostbite, and it is not essential to have cold weather. At high altitude, the partial pressure of oxygen is significantly lower than at sea level. This means that the oxygen concentration in the air is reduced. Low oxygen saturation in blood is known as hypoxia. Hypoxia causes vasoconstriction (the constriction of blood vessels) also to increase the oxygen concentration to the heart and lungs. This will make the affected area more prone to frostbite due to the reduced blood flow. High altitude also results in the low humidity of the atmosphere due to quick saturation of air with increasing elevation. This would increase sublimation of ice, causing further cooling of the skin and an increased risk of frostbite.
Symptoms of Frostbite
Numbness is the first symptom of frostbite. It is followed by clumsiness of the affected part. That is when you notice that your hands are not working properly or your feet are flopping around more than they should be. But even this mild degree of frostbite is hard to recognize in oneself. Near the end of a NOLS course in the Yukon, one of our students developed severe frostbite in his feet, despite the fact that everyone, including him, thought that he was taking good care of them. It is essential to be on the lookout for any symptom of frostbite, as its progress can be halted if it is recognized early enough because the body can resupply the affected areas with warm blood, but if it is not treated promptly and properly the tissue will die. Dead tissue turns black. White or yellowish patches on the skin are another bad sign. These are caused by blood and other fluids that are leaking from damaged tiny vessels. A black blister is a sure indication that the tissue beneath it is dead. The redness and swelling that accompany the final stages of frostbite are inflammation caused by the body’s attempts to clean up the dead tissue and fight off infection. This is somewhat of a mixed blessing, very inflammation will cause further damage to the tissue, but it is a sign that the body is returning the frostbitten part back to normal, provided that it is given the chance. Any of the above symptoms warrants prompt medical treatment. If frostbite has gone so far as to cause the freezing of deeper body tissues or, God forbid, the entire body, the situation is more serious. The very young, the very old and the chronically ill are particularly susceptible to this sort of thing. Alcoholics, the mentally ill and anyone who has spent a prolonged period in a high altitude without proper acclimatization, are also at high risk. People have died from hypothermia in temperatures well above freezing, because they were not properly protected against the cold. A NOLS group working with troubled youths once brought a homeless man on a day hike to an alpine meadow, where he died of hypothermia twenty feet from safety in a stone hut. High altitude hypothermia is comparable to hypothermia at very low temperature.
Risks of Frostbite on Kilimanjaro
High altitude climbing is associated with certain risks, and frostbite is one of the more common medical problems that can be encountered. The risk is definitely present on Kilimanjaro, even though it is often perceived as a “walk up” mountain. Injuries related to cold exposure are non-freezing and freezing. The non-freezing injuries known as chilblains and trench foot can occur but are relatively rare on Kilimanjaro. Chilblains occur on the toes and fingers and are painful, itchy swellings that occur in response to cold and moisture. Trench foot is painless at the onset and is a result of prolonged exposure to wet conditions above the freezing point. The exact pathophysiology is not known, but it is thought to be the body’s response to rewarming ischemic extremities. Damage can be permanent and result in the need for amputation. Frostbite can occur on any body part exposed to extreme cold. Damage to the skin is superficial in mild frostbite but can extend to a deep injury involving the tendons, muscles, and bones. The extent and severity of a frostbite injury may not be immediately obvious and can take many months to determine. Healing is often associated with scarring and disfigurement. Simulation studies have shown that despite Kilimanjaro being close to the equator, temperatures can drop low enough for altitude to be a significant risk factor for cold injury, and frostbite has been documented in mountaineers on the mountain.
Altitude-Related Risks
Altitude exposure is, perhaps, the most significant influence on an individual’s chances of developing AMS. A large majority of trekkers on Kilimanjaro will experience at least some mild form of AMS due solely to the high altitude to which they ascend. Kilimanjaro is a tall mountain. The most feasible routes for trekkers top out at Uhuru Point on the crater rim. This point is over 5,980 meters (19,500 feet) high. This is considerably higher than the high altitude trekkers and climbers start to feel the effects of altitude on mountains in Colorado, for example. Even the seasoned Colorado climber who can spend weeks acclimatizing at 3,960 meters (13,000 feet) is not immune to AMS on Kilimanjaro. His chances of developing AMS on Kilimanjaro are quite high unless he has previously acclimatized at a high altitude for a prolonged period. As a general rule, the incidence and severity of AMS are directly related to the elevation attained, and the speed with which it is attained. On Kilimanjaro, this means that the shorter your climb, and the higher your sleeping elevations, the greater your chances of developing AMS. High sleeping elevations are a common cause of AMS among trekkers who use the popular “48-hour assault” on the summit. This method, in which climbers hop from 2,800 meters (9,200 feet) to over 5,400 meters (17,700 feet) in less than two days, is a virtual guarantee of severe AMS.
Temperature-Related Risks
Though less dangerous than altitude effects, the weather on Mount Kilimanjaro can present a considerable challenge and risk of hypothermia and frostbite. The defining factor in the climate of Kilimanjaro is the altitude and the temperature decreases as the altitude increases and there is a drop in temperature of about 6.5°C for every 1000m climbed. The freezing point of water or 0°C is reached just around the top of the mountain and during the coldest parts of the nights, the temperature at the summit can drop to between -18 to -30°C. Wind chill can make it much colder. It is clear then, that the climate at the summit can be an extreme hazard to health and life. Frostbite and hypothermia can have severe effects at any time of the year, but in the rainy season when a number of cold fronts move across the plains, it is even more dangerous. During these periods not only is there more rain and snow, the temperatures are even colder. Cold conditions occur at all levels on Kilimanjaro, even in the rainforest. This is due to the high altitude and the time it takes to climb up the mountain. The climbers climbing too slowly are also more likely to suffer from the cold. They are exposed to cold for a longer period, especially at night, than faster climbers. This increases the risk of hypothermia.
Personal Factors
Individuals vary in their physiology and susceptibilities to cold or frostbite. While population-based studies have demonstrated that susceptibility to frostbite appears to be influenced by genetic factors, there is relatively little data on individual risk factors. Factors such as being a smoker, a history of frostbite, pre-existing medical conditions such as Raynaud’s disease, diabetes, peripheral neuropathy, and cardiovascular disease all increase individual risk of cold injury. Previous cold injury damage to the skin or deeper tissues can increase the risk of cold injury occurring again in the same location. Medications that cause vasoconstriction can reduce peripheral blood flow and increase the risk of frostbite, an example of this being ergotamine or beta-blockers. Sleep deprivation, exhaustion, and malnutrition all impair shivering and increase the risk of hypothermia or cold injury. Finally, alcohol consumption and frostbite have a long association, possibly related to the peripheral vasodilatation and a false sense of warmth leading to inadequate protection and subsequent cold injury. Individuals who plan to climb Kilimanjaro need to consider their own susceptibility to cold-related illnesses carefully based on the previously described risks and their own personal risk factors. A careful consideration of these factors, in particular, should deter those who are at higher risk from attempting to climb Kilimanjaro, as preventative measures may not always be successful and treatment is by no means straightforward on the mountain.
Prevention of Frostbite
Proper clothing is paramount when preparing to attempt Kilimanjaro. A common denominator in equatorial mountain climbing is that the days are warm and the nights are sub-freezing. The 30-40 degree (F) difference between the summit and the base can create a recipe for disaster when someone is ill-equipped with clothing. It is said that at least $1000 should be spent on proper clothing and gear to ensure a safe and comfortable trip. Cotton is a poor insulator and should be avoided. It absorbs moisture and dries very slowly. Synthetics and wool are much better insulators. Good wicking is also important. With the cold conditions on Kilimanjaro, moisture may freeze if not wicked from your skin. Boots should be insulated and large enough to accommodate heavy socks. Plastic mountaineering boots or overboots are recommended for the summit attempt. Down jackets and pants are a nice addition for the summit attempt because of the excellent warmth to weight ratio. Windproof and waterproof outer layers are essential. Goggles and glacier glasses will help to protect your face from the sun and wind. 2-3 Nalgene wide-mouth water bottles are recommended for the summit attempt. These can be placed upside down in your pack and kept from freezing by your body heat. Water bladders have a tendency to freeze because the hose will often become covered in ice. Bring a wide-mouth bottle to sleep with in your sleeping bag. Wrapping it in a sock will keep it from freezing during the night. Also bring at least 2 litres of liquid for the night in a water bottle or hydration system, and a pee bottle to avoid having to get out of your tent at night. Dehydration can increase your chances of getting frostbite. Drink plenty of water. An assortment of high caloric snacks will ensure that you are eating enough during the climb. Weight loss is common at high altitude where your metabolic rate can increase by 30-40%. It is critical to replace the fuel that your body is burning. Try to be well fed and well rested for the summit attempt. Overexerting yourself can burn too much fuel and increase the chances of altitude related illnesses and frostbite.
Proper Clothing and Gear
The potential for frostbite is quite high on Kilimanjaro. Climbers may suffer frostbite on any of the routes, even during the hottest season of the year. At the summit, severe low temperatures and wind chills may cause frostbite. According to one study, certain climbers truncated their climb due to cold temperature more than any other cause. It was also shown that climbers who reached the summit experienced nearly 3 times as many episodes of frostbite than those who did not reach the summit. The most important factor in preventing frostbite is to remain warm and dry. Climbers should have warm protective clothing and gloves or mittens. Layers of clothing can be added or removed to maintain proper body temperature, and moisture must be wicked away from the skin. Boots and socks are vital; the most common cause of frostbite is frozen feet. A pair of properly fitting plastic boots are essential for climbing Kilimanjaro, as they help prevent both frostbite and snow blindness. Sunglasses and goggles are the other main defense against snow blindness. With decreased visibility and an impaired sense of direction, climbers are at a much higher risk for frostbite and other cold injuries.
Acclimatization
If all of these methods of acclimatization are utilized, the chances of a safe and successful climb are greatly increased. It is important not to cut corners with this step as the risks of not acclimatizing can be severe and have lifelong effects. Success in this phase of preparation often means the difference between achieving the summit and an early and disappointing descent.”
There are also artificial means of acclimatization that are becoming popular; one is the altitude tent which simulates sleeping at altitude, this is often used by athletes. The second is acclimatization through the use of a drug called acetazolamide (Diamox). This works by increasing the amount of alkali in the blood, which causes an increase in ventilation, which then increases the amount of oxygen in the red blood cells. This, in turn, builds up a resistance to altitude illness. A newer technique, still under review to assess its safety and efficacy, involves using dexamethasone. This is a steroid that can be used to treat the symptoms of altitude illness. A preventive course of treatment may be started in the event of an early descent due to illness with the hopes of continuing the climb if symptoms subside.
“In order to avoid frostbite and other cold weather injuries, proper acclimatization is essential. This is the main idea behind properly preparing your body for the changing conditions. The best and safest way to acclimatize is to hike slowly, allowing your body to increase the amount of red blood cells it has and thus absorb more oxygen. The slower the rate of ascent, the higher the probability of successful acclimatization. For this reason, it is important to spend at least 3 nights at or above 3500 feet (10668m). If you begin to show symptoms of altitude illness, it is important to not go higher until symptoms have decreased.
Hydration and Nutrition
Surprisingly no vitamin or mineral supplementation is necessary, provided you are able to eat a mixed diet. Altitude does not increase vitamin or mineral requirements; only in cases of deficiency diseases or malabsorption disorders is supplementation necessary.
High altitude does not substantially increase your daily calorie requirements. While you may find that you are not as hungry, it is important to try to eat at least the same amount as you would ordinarily eat at home. This should consist largely of carbohydrates, which are easily digestible and an effective fuel. A high carbohydrate, low fat, low protein diet is suggested at very high altitudes of 6000m and above. Despite a contrary popular belief, scientific evidence shows that this kind of extreme altitude is associated with a reduced rate of fat metabolism, so it is more difficult to use fats as a source of energy and the consumption of fats does not improve acclimatization. High carbohydrate consumption has been proven to be beneficial for altitude climbers.
One of the most successful ways of achieving higher fluid intake is by drinking plenty of hot drinks; in this way you obtain fluid and warmth, although it is important to also drink plain water. Fruits such as oranges are good at high altitude because they contain both water and simple sugars, which enhance fluid retention and provide energy. Bite-sized, dry, salty foods like pretzels are easy to eat without taking a rest and stimulate thirst.
Dehydration can be a serious problem at high altitudes. It is often difficult to drink enough at altitude because the usual thirst signals are so blunted. Furthermore, the higher rate of breathing results in increased urine output and consequent fluid loss. It is important to make a conscious effort to drink more, even when not thirsty and especially on arrival at a higher altitude.
Avoiding Overexertion
In order to avoid overexertion, a climber should travel slowly and steadily, resting frequently, especially at the end of the day. A heavy pack, poor physical condition, and a too rapid ascent are frequent contributing factors in overexertion. A climber should strive to reach a higher elevation during the day and then return to a lower elevation to sleep. High altitude hikes and climbs are usually more strenuous than the same activity at lower elevations and extra days may be necessary for the body to acclimatize to the higher altitude. This additional time should not be considered overexertion if the climber is progressing at a slow and steady rate. For frostbite prone areas, climbers should not wear tight fitting boots or clothing. Overexertion can be a technical issue in climbing. As an action, it involves many variables of gradient, load, and fatigue and as a predisposing factor, each variable can be manipulated to greatly minimize the risk of overexertion. When considering speed of ascent or load carried, there is no defined quantitative guideline which separates safe from unsafe practices, however, climbers should remember the mountaineering proverb ‘speed is the enemy of altitude’. As the rate of ascent increases, so do the likelihoods and severities of AMS, HAPE and HACE. RMI’s altitude guidelines (which are aimed at minimizing risk) suggest that for every 300m gain in elevation, an extra day should be taken to acclimatize and any further climbing beyond this should be done at the same, or a lower, elevation.
Treatment of Frostbite
Deep frostbite and superficial frostbite of the hands and feet require evacuation to a medical facility. This is because frostbite leads to fragile, painless tissue that is easily damaged. In the mountain setting, this can be a particular problem as trip evacuation may involve the need to use a rescue litter over rough terrain, which is likely to cause tissue damage to frostbitten areas. A further problem is that in frostbitten limbs, there is often coexisting immersion Trench Foot (affecting skin and muscle tissue, this is painless, has a mottled appearance, and can take days to become evident). Trench foot will be made worse by frostbite damage rendering the limb useless with lingering neuropathy. Frostbitten hands and feet provide a sensible high level of medical care as soon as possible. This will help to prevent complications and potentially allow rapid rewarming and treatment by methods such as hydrotherapy.
Call for medical advice as soon as possible, describing the extent of the injury. It might not be obvious to you if tissue has died, so a doctor should make an assessment. Except in extreme conditions, it is generally safe to use first aid measures to rewarm the frozen tissues. In extreme conditions where there is a risk of refreezing, you should not thaw out the tissue until a proper medical facility is reached. This is because refreezing causes further damage. For example, in the mountain setting, you should not rewarm tissue until you are sure you can protect it from refreezing as would be the case in a trip evacuation from the mountain. The decision as to whether evacuation to a medical facility is necessary will depend on the judgment of the doctor, but as a general rule, superficial frostbite does not require evacuation if you can provide safe conditions to thaw and protect from refreezing. Folk remedies are not recommended and, in particular, the use of stoves to thaw out frozen tissues can cause burns to numb skin.
Recognizing Frostbite
Signs of frostbite can be divided into mild, moderate and severe degrees of injury. After the skin is exposed to cold, it becomes very cold and red, and a warm stinging sensation may develop. A white or yellowish grey colour in the skin, combined with loss of feeling and a hard waxy appearance, indicate freezing of the skin. Skin being warm and still pliable indicates mild frostbite. If the skin is hard and has lost feeling, then ice has likely formed in the tissues beneath. Blisters may develop after re-warming, and blister fluid may appear clear or bloody. Peeling of the skin can occur as the injury heals, and the frostbitten part is often more susceptible to frostbite in the future.
Frostbite can be a tricky condition to self-diagnose for laymen and experts alike. This is because frostbite involves the freezing of skin, and most mountaineers at high altitude will get some form of frostnip which is a warning of early frostbite. No clear line exists between frostnip and mild frostbite, and the variety of skin reactions to cold and wind makes diagnosis and classification of frostbite quite complex. Diagnosis is especially difficult at high altitude because the early stages of frostbite can resemble chilblains and non-freezing cold injuries. Signs and symptoms of frostbite can also be masked by the use of aspirin and other medications, and a general anaesthetic state. As a worker at high altitude in the cold, it is important to be vigilant for early signs of frostbite at all times.
First Aid Measures
You should only attempt to warm the affected area if there is no chance that the affected part or parts could refreeze before reaching a warm environment. It is better to leave the frozen area alone than to warm it and then refreeze it later. With this in mind, the best ‘first aid’ for frostbite is to place the patient in a protected environment, avoiding further cold exposure. Pain from the warming process can be lessened by immersing the affected areas in water at 37-39°C. The affected part should be padded to prevent contact against other surfaces. Elevation and light movement of the part may also help in reducing pain. Rubbing and massaging the frostbitten area must be strictly avoided. A loose sterile dressing should protect any blisters on the affected area. Considerable fluid intake and a high-calorie nutritious diet are advisable during recovery. Alcohol and tobacco should be avoided as they have a detrimental effect on blood flow. Prompt transport to a medical facility is suggested. Although all mild to severe frostbite should be evaluated by a health professional, certain injuries (third or fourth-degree frostbite, or any injury associated with hypothermia) require the expertise of experienced cold injury specialists.
Seeking Medical Attention
Seeking medical attention is important when experiencing severe symptoms of frostbite. However, most cases of frostbite (especially stages 1 and 2) can be treated by the methods described above and do not require amputation. The doctor will check for signs of infection and will determine the extent of tissue damage by various methods such as X-rays, bone scans, and angiography. The doctor may need to trim away the dead tissue in order to prevent infection and promote healing. This should only be done several weeks after the frostbite incident, as the line of demarcation between dead and viable tissue is sometimes hard to determine, and it’s best to let the body heal itself if there is no risk of infection. If the doctor determines that the damage is severe, he may refer the patient to a specialist in burn treatment or orthopedic surgery. Physical therapy can also be useful in rehabilitation from frostbite, especially in cases involving severe damage or possible amputation of digits or limbs.
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