Accidental Hypothermic coma at Adam's Peak:

Advice to pilgrims

THE Sri Pada pilgrimage season starts in December and ends in May each year. Pilgrims, mostly Buddhists from all over the island, climb this mountain annually.

Medical and surgical casualties are quite common especially at the Sri Pada Maluwa, situated 7,000 feet above sea level.

Thanks to Voluntary Medical Aid Camps managed by the Sri Lanka Saukyadana Movement, whose present secretary is my namesake Dr. D. N. Atukorale, the medical and surgical problems of the pilgrims are efficiently treated by experienced doctors, medical students, nurses, first aid workers and other volunteers trained by the Movement.

I started helping the movement from my medical student days and later when I was attached to General Hospital Colombo (now called National Hospital, Sri Lanka or NHSL) during 1964 to 1970. During this period, we treated a large number of pilgrims with medical and surgical problems.

The common problems we came across at the Maluwa camp were asthma, heart problems such as angina and heart failure, hypertension hypoglycaemic attacks, fever and psychiatric problems such as hysteria.

But the most dangerous and life-threatening medical emergency encountered by me at the top of the mountain was hypothermia coma which commonly occurs at the Maluwa due to extreme cold, insufficient shelter, severe fatigue due to 10 to 12 hours of climbing and due to strong cold winds prevailing at the peak of the mountain.

Lowering of human body temperature below 95 F is termed hypothermia and accidental hypothermia is said to occur when the reduction of body temperature is not deliberately planned (as in open heart surgery).

Six patients with hypothermia coma were brought to the Maluwa camp during 1962 to 1968 and all the patients had very low body temperature and were in a collapsed state.

In addition to these unconscious patients there were a large number of other patients with hypothermia (body temperature below 95 F) who were quite conscious and these patients were not "admitted" to the camp and were given outdoor treatment.

Out of six patients with hypothermia coma brought to the Maluwa Saukyadana camp, five were young females and all of them had inadequate warm clothing and all responded to our treatment and walked out of the camp in three to five hours.

All our cases were deeply unconscious due to acute exposure to cold and had been healthy previously except for one pregnant woman who was very anaemic.

According to medical literature, females are less prone to hypothermia probably due to the fact that females have more subcutaneous fat than males.

All our patients were below the age of 25 although according to medical literature, hypothermia coma commonly affects those over the age of 60. All our patients were Kodukarayas (those who climbed Adam's Peak for the first time).

Precipitating factors

Environmental temperature at the Maluwa is very low (50 to 60 F)

Wet-cold conditions are present at the Peak.The winds at the top are very strong.

There is insufficient shelter for the thousands of pilgrims who climb the mountain during Poya (full-moon) days.

The severe exhaustion resulting from the eight to 12 hours climbing of about five miles without proper nutrition probably makes them more susceptible to hypothermia.

The clinical features

The clinical features of mild and moderate cases of hypothermia are not discussed here. In severe hypothermia, the patients appear pale and puffy mimicking myxoedema (hypothyroidism).

The pulse is usually slow and sometimes irregular. The blood pressure (B.P.) is usually low and respiration is depressed and respiratory rate is usually slow.

Low reading thermometers borrowed from cardiac operating theatre of National Hospital, Colombo were used as the common thermometers available in our hospitals cannot record temperature below 94F.

All our patients had temperature readings below 92 F and in two of our cases the axillary temperature was below 90 F and the actual (core) temperature of these two patients are sure to be about 88F.

Management

All our patients were treated in our Saukyadana camp at the Maluwa. If the clothes were wet, they were replaced with warm clothing and all patients were wrapped up in warm blankets. They were gradually warmed with the help of an electric heater until they regained consciousness.

Rapid warming should be avoided as rapid warming can cause sudden death especially in the elderly. Any dehydration present should be corrected with intravenous (I.V.) glucose solutions. None of our patients needed I.V. fluids.

Some authorities use routine oxygen in patients with hypothermia and we did not have facilities to give oxygen at the Maluwa camp.

Although some doctors give routine IV Hydrocortisone in hypothermia coma patients, to combat stress, our patients recovered dramatically without any such drugs.

It is very important that other illnesses such as head injury, lung infections and brain attacks (strokes) should be excluded in patients with hypothermia coma. It is unwise to carry hypothermia patients in the head up position as this posture may precipitate convulsions.

According to Committee on Accidental Hypothermia of the Royal College of Physicians, London, mortality in accidental hypothermia is 37.5 per cent and if the core temperature is below 85 F, the mortality is 73.3 per cent.

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How to prevent hypothermia

* Sri Pada pilgrims should carry adequate clothing especially waterproof over garments. Reserve clothing should be carried in a plastic bag.

* They should have adequate rest and adequate refreshments such as biscuits, sugar candy (sookiri), aggala, aluwa, toffees and glucose packets. The pilgrims should refrain from climbing to the point of exhaustion.

* As the facilities for shelter at the Maluwa (top of Adam's Peak) are not sufficient for thousands of pilgrims who reach the Peak from various parts of the country especially on full-moon days (Poya days) pilgrims should be advised to refrain from climbing on "Poya" days.

* Elderly people (those over 70 years) especially those with chronic illnesses such as bronchitis, asthma and heart disease should be advised not to climb mountains like Adam's Peak.

- D. P. Atukorale