This short post is partly speculative (as are a lot of things about the 2021 Everest season). It will raise more questions than it answers, but now is the time to ask.
First off, I have neither a medical nor an engineering background, so I would welcome thoughts from anyone who has.
First, some background. As you will know if you read my previous post, the 2021 Everest season has gone ahead despite the global pandemic. It has coincided with a major second wave of COVID-19 across India and Nepal. Nepal currently has one of the highest infection rates per capita in the world. There has also been an outbreak of COVID-19 at Everest Base Camp, the extent of which is not yet known.
There have been calls for operators to cancel their expeditions and donate their oxygen to hospitals. Despite the developing situation in both base camp and throughout Nepal, operators have decided to continue with their expeditions. To date, only one major operator, Furtenbach Adventures, has cancelled its expedition due to the COVID-19 outbreak.
The issue of oxygen is controversial, as I discovered when I wrote an opinion piece for UKClimbing (while the article covered wider issues, almost all the comments concerned oxygen).
Hospitals in Nepal are experiencing an acute shortage of oxygen, yet mountaineering operators have been busy stocking higher camps on Everest with oxygen cylinders in preparation for their summit pushes. Some operators have even been bragging about it on social media. With some 400 climbers plus Sherpas on Everest this year, it is estimated that 3000 to 4000 oxygen cylinders will be used.
Nepal’s government has requested that operators donate their used oxygen cylinders once their expeditions are over. Some reports have suggested that operators are responding.
But I’ve not yet seen any reports of 2021 Everest operators giving away either full or empty oxygen cylinders. If you have, then please post in the comments.
Operators will be reluctant to give away their oxygen cylinders because they reuse them from year to year. Unused cylinders are kept in storage to be used on subsequent expeditions. Used cylinders are refilled. A typical 4L oxygen cylinder, which can hold up to 960L of compressed oxygen, costs around $500, but much of that cost is the cylinder itself: refilling it is much cheaper.
There are additional complications, and I’ve seen a few posts on social media in the last few days describing these.
Expedition oxygen cylinders are much smaller than oxygen cylinders used in hospitals. They are typically designed to dispense oxygen at 2-4 litres/minute, although some operators are now advertising flow rates of up to 8 litres/minute. These rates are as much a function of the regulator attached to the bottle as the shape of the bottle. With a different regulator attached to the bottle, they can presumably dispense oxygen more quickly, the only limiting factor being the diameter of the opening on the bottle (engineers, please feel free to chip in).
As I understand it, COVID-19 patients need oxygen at much higher flow rates, 10-15 litres/minute. The problem seems to be either that the regulators needed for these flow rates do not fit the typical mountaineering cylinder, or the medical mask used does not fit the regulator. There is also, obviously, an additional logistical problem with getting oxygen cylinders off the mountain and down to hospitals in Kathmandu. These arguments are already being cited by at least one operator as reason enough for not giving their cylinders away.
There are obviously better ways of getting oxygen to hospitals in Kathmandu (and elsewhere) but are these just excuses? In any ordinary medical situation, using oxygen from mountaineering expeditions on Everest would be silly. But we’re not in an ordinary situation; this is a humanitarian crisis and every little helps.
It seems to me — and I’m happy to be told otherwise — that if you get those oxygen bottles to Kathmandu, it must be possible to swap the regulators for those with a larger flow rate and find masks that are suitable for medical use. There must be a way to get at that oxygen. Nepalis are nothing if not resourceful.
And in any case, we are talking about intensive care use in Kathmandu. There are patients who cannot find a hospital bed or who are being treated at home. Some of these may be patients at the medical facilities in Pheriche and Khunde. Surely even these smaller cylinders and slower regulators may benefit them while they wait for a hospital bed?
As for the logistical difficulties in getting the cylinders to Kathmandu: well, some operators this year have been using helicopters to ferry their clients from Camp 2 back down to base camp, and from base camp to the teahouses of Namche Bazaar. So they can’t seriously use logistics as an excuse.
I have been outspoken about Everest 2021. I felt the season was ill-advised from the start. The dangers were obvious: of taking our Kent variant into Asia, and bringing an Indian variant back again. It seems that both these things have come to pass.
I felt even more strongly when the second wave swept across Nepal and all the way to base camp. I could not believe that operators continued with their expeditions. They are now playing Russian Roulette with their clients’ lives and cannot guarantee their safety if anyone catches COVID-19 up the mountain.
Yet these operators still have a chance to redeem themselves. They still carry the means to help the people of Nepal. There is now a flight ban in place until the end of May. They have time on their hands to help find a solution to these problems.
IMO, if they refuse to help with oxygen, that will be their final sin.
Completely agree Mark. The season should not have gone ahead and when the latest wave of infection and deaths hit they should have cancelled immediately.
It does not reflect well on the climbing community and there is no justification for taking oxygen up a mountain while people just a few miles away are dying for the lack of it.
Mark,
1. I agree that holding an expedition during the peak of the pandemic for India and Nepal was a gross miscalculation,. I had Lukas Furtenbach text me yesterday telline me that he had done everything right, so don’t expect remorse from everybody. Morality is not part of the business model for most professional mountaineering outfits.
2. Regarding oxygen, I am an anaesthetist (anesthesiologist in America) so I know this subject well:
a) O2 is O2 in whatever cylinder it comes in – so any cylinders they have at Everest will be useful in KTM.
b) If you are on a ventilator, you will probably need a medical cylinder with the appropriate valves/regulators for ventilators. There are ways of easily moving O2 from mountaineering cylinders to medical cylinders. (Sailplane pilots do this on a regular basis for their high altitude flights.) Since people needing ventilators for COVID are a minority (roughly 20 percent of symptomatic covid-19 patients require hospitalization and about Â5 percent end up in the ICU. Most of those in intensive care require ventilators), most cylinders brought down from the mountain will be immediately useful. With a little elbow grease, all will be useful.
c) Regarding flow rates, you are thinking like a mountaineer and not like a physiologist. We are not into flow rates in critical care. We are into achieving a given SpO2 (oxygen saturation) that can maintain the patient alive, without O2 toxicity. We can achieve that SpO2 by 1) choosing the proper mask (nasal prongs vs face mask vs mask with a good seal) 2) PEEP or CPAP (we create a small pressure against which the patient has to breathe against, thus maintaining the alveoli open at the end of the respiratory cycle, or for its entiirety) 3) FiO2 (inspired O2 concentration) that we can vary since O2 is toxic and we don’t like to give 100%. We usually mix O2 with air to achieve concentrations that take us to a given SpO2 with less O2 in the mix. 4) Flow rate. (In an ICU I don’t expect the patient to consume more than 500 mls of O2/minute (1/2 liter/minute) In fact, it’s usually less (250mls/min), so flow rates greater than 1/2 liter/minute are just wasting precious O2. We use low flow rates in anesthesia often, and 1/2 liter/minute works fine when you have your belly open!
d) High flow rates offered by certain companies: From the above discussion, you can see this is a gimmick. Of course, when you are climbing a mountain your oxygen consumption will be much higher than the 1/2 liter/minute in the ICU. As an example, while climbing near the North Col, with 2 l/m flows, I was able to maintain my a continuous SpO2 above 92 consistently, a number which on the O2/Hgb dissociation curve is solidly on the flat part, which is close to normal and with little risk for developing HACE or HAPE.
In short, ALL the O2 cylinders at Everest could be used in KTM. If you are in a marginal situation with Covid, even 1l/min helps. By using all of the above tricks, you can make 1l/m work wonders!
But as you have already hinted at, most expeditions at Everest are not into the Buddhist mindset of giving. And therefore the fiasco that we have seen at EBC where the usual lack of cooperation has further enhanced the virus spread.
A final word. Like you, I have a great admiration for mountains, and therefore why I enjoy reading your posts. Next to me right now, I have a book by Gaston Rebuffat – Splendeur des Cimes. I think there are few left that can look at a mountain the way Gaston did. That splendor of the summits feeling is hard to find among the Everes crowd. I wonder what he would have said had he lived to see what we have done with the mountains he so loved.
Thanks for keeping Rebuffat alive with your writings.
Thanks, Dr Leo – I knew I could rely on you!
So, in a nutshell, if I understand you correctly:
1. The 10-15 litres/minute requirement is for the extreme cases of patients who need to be put on a ventilator. In these cases the oxygen can be easily transferred from mountaineering to medical cylinders.
2. For all other patients, mountaineering cylinders will still be useful, even just 1 litre/minute.
BTW, in Lukas’s defence, I believe he probably did do everything right once there. He seems to have been one of the few operators to have a doctor and testing kits. He says he kept his team isolated, and he is so far the only operator to cancel when he had to. His main mistake was to go in the first place.
This is a shameful story.
For many years Everest has nurtured excesses of selfishness.
Though never on such a scale as now, during this world-wide pandemic.
The AC’s Croucher Initiative, encouraging humanitarian comradeship on the mountain, never envisaged a situation like this, but it must apply just the same at the foot of the mountain – indeed to all Nepalese .
Mark,
1. In an ICU setting, I can’t see you needing high flows like that. If you have a tight mask, with no leaks, then think of the O2 consumption that I mentioned above – 250-500 mls/min (or 1/4 to 1/2 l/m). High flows are ONLY needed for counteracting big leaks. If you close the system with a tight mask, 1l/m flows are more than adequate. If you have open masks (face masks) then you would need high flows – but that is poor management and bad choice of masks because you are wasting most of the O2. In fact, this brings up a really good point – which is that in KTM they may not have many good tight fitting masks, like the ones we use above 7000m. And therefore they high O2 flows you are talking about. So the outfits should donate or loan their cylinders AND masks!
2. Yes, any O2 mountaineering cylinder will be useful and will save lives.
3. I think Lukas THOUGHT he was doing the right thing. And yet, I just saw a video and a pic on his FB site where they are testing people WITHOUT eye protection, and one in which he himself is administering tests without gloves or glasses. In the medical world, he and his testing team would be called SPREADERS, not testers with good intentions. If a Stanford nurse were spotted doing COVID tests like the ones in the pics, she’d be fired on the spot!
Sorry, but science is sometimes harsh and viruses could care less about good intentions – they are beaten with strict procedures, of which I see no evidence of at EBC, either from Lukas or any other team. If all had spent less money on the helicopters I see in their posts and more on properly trained personnel, the outcome MAY have been different.
But as I’ve said all along, I believe it was irresponsible to go there this year. Ballinger sat Everest out this year. Some big names in trekking did too (Kim Bannister).
As John Cleare just wrote – what a shameful story of both excesses and selfishness.
Thank you Mark, and thank you, Leo for the insights.
Phew, I was aghast at what I thought was my oxygen ignorance when flow rates of 1-15 litres a minute were mentioned.
So, low flow rates will assist the sick and therefore an “Everest” oxygen bottle could provide a real 12-24+ hours of oxygen. Then refilling becomes the issue.
I don’t know the ins and outs of this as we entrusted this to Russians “experts”, but I recall they screwed up one time as I weighed all the bottles prior to the expedition start and most were overweight by 200+ grams meaning they had been overfilled. Others suggested these had been filled with liquid oxygen for this to happen. We transported them very carefully. The bottles lasted very well though, attaching the regulator on a very cold bottle and still having 320 bar was a bonus!
Oops, a typo: flow rates of 10-15 litres a minute…
Jamie,
Your O2 saturation on the North Col is probably in the low to mid 70s without O2. With only 2l/m I was able to take it up to 92% with a tight fitting mask that also draws some air when I inhale. This is not a closed system like what we use in medicine where we can do your liver transplant with 1l/m. 🙂
8l/m is only needed on Everest if you have Covid and you are gasping for air all the time. On the summit, with 3l/m one can have 80% with a good mask. This is similar to what you show at BC once acclimated and without 02.
So the message again is that the mask is at least as important as the flow, but you need to use a pulse oximeter to confirm that all is well. That is, you need to close the loop.
The big problem in Nepal is ventilators. They are rare. Also, there are not too many doctors who are trained in crtical care medicine, and therefore the high flows they may say they need.
Thank you Mark.
I think it is the lack of co operation management and will power.
As i see the news today as below too.
Unknown owner’s 500 Mt oxygen cylinder found at Bhaisepati ,Lalitpur, Nepal https://ratopati.com/story/180842/2021/5/17/oxygen-cylinder-
All good technical information. Thanks Mark and to all for clarity. If outfitters are actually using helicopters to shuttle people off Everest from Camp 2 and from Base Camp to the villages, do you really expect expect them to give a proverbial rat’s ass about poor people in Kathmandu or the hill villages? This is simply more manifestations of the utter disregard of any kind of respect for the mountain or the culture that all too many of the suspect outfitters and climbers have.
It seems the road to Mt Bragging Rights is the easier road.