Annapurna Base Camp Trek

As I depart this morning for my trek to the Annapurna Base Camp, I am both nervous and excited. There are too many unknowns not to be nervous. What will the weather be like? How cold will it be at night? Will the food agree with me? Am I bringing the right equipment? Will I be affected by altitude sickness? Simultaneously, however, it is all these fears that make the trek more adventurous and more exciting.

Originally, I had signed up for a group trek, but apparently it was only going to be me and another couple, and the other couple had to cancel last minute. I now am going to get a private porter/guide and luckily for the same price as before. Although usually a private trek is preferred and more expensive, I was looking forward to meeting the others in the group. But, after a little research, I realized that I will be hiking along a common trail and therefore will look forward to meeting the other trekkers. I can also have more say in setting our hiking pace. In addition, I have already met Subash, my guide, and although only 23, his English is great, he seems friendly though a little shy, and I feel like we are going to be great hiking partners.

Risks of Mountaineering

In preparation of my small, civilized hike in the Himalayas, I chose to get in the mood by watching a couple documentaries on Everest and reading Nick Heil’s “Dark Summit: The True Story of Everest’s Most Controversial Season”.

The first realization was that death is too much of a reality while climbing Everest. Over the last 15 years, Everest’s trek to the summit has claimed on average about 5 lives. And whether that death comes from falling and sliding down some of the highest snow and ice formations on Earth, or whether it is a slow death from hypoxic hypothermia, the risks of making this journey are very real. According to Heil, hypoxic hypothermia is a slow death where initially hands and feet begin to tingle and throb. Eventually, your limbs begin to ache as if being relentlessly squeezed. The brain will start to starve and swell causing slurred speech, poor balance, and finally persistent dementia. Humans are not meant to exist at 29,000 feet, where the summit of Everest resides.

In Nick Heil’s book, to describe the affects of hypoxic hypothermia, he writes:

“As the deep cold intrudes, nerve endings go numb and the pain recedes as circulation retreats toward the core. Often, ironically, it is around this point where freezing feels like being tossed into a furnace. Victims tear at their clothes, throw away gloves and hats, and frantically unzip their parkas, accelerating the slide. Flesh farthest from the heart—toes, fingers, nose, cheeks—freezes first, death advancing from the perimeter. Skin turns pales with frostnip, white during the full throes of frostbite, red and purple with blisters, and ultimately black with gangrene—cellular necrosis, doctors call it, the point at which living tissue is permanently destroyed.

“In the final stages, limbs become insensate and immobile, freezing into place as your body shunts blood toward the lungs and heart, trying to preserve the vital organs. Vision blurs and darkens. Involuntary shivering ensues, a last-ditch attempt to generate heat through movement. You mind swirls deeper into the subconscious, a deep dream state. A few who have returned from the brink of hypothermic oblivion have recounted their last conscious moments as almost pleasurable. ‘You really do start feeling warming,’ Weather wrote in his memoir Left for Dead. ‘I had a sense of floating. I wondered if someone was dragging me across the ice.’

“The ends arrives a few hours later, quietly, in the dark waters of unconsciousness. You blood runs chilled; most brain activity has ceased. The heartbeat slows, fluttering erratically, a wounded bird. This action might continue for a while, the vessel destroyed by the encroaching cold while the heart presses courageously on. At last the pump shuts down, and with that the limited circulation ceases. Internally, there is perfect stillness, equilibrium returning between a delicately calibrated but dissonant energy field in the form of a man and the larger energy field around him—the mountain, the air. The only movement now is wind, ice crystals skittering over rocks and snow, a jacket flap rustling, a clump of hair, stiff with rime, flicking across the forehead.”

Not to worry though, because in contrast, the Annapurna Base Camp Trek, which I am attempting will only take me to a maximum of 13,500 feet. Still a formidable height that will probably cause me to experience some altitude sickness, shortage of breath, and fatigue, but nothing that will threaten my life or necessitate me to bring my own oxygen.

For a little more of the science of altitude sickness, I did a little research. Higher altitudes come with a limited supply of oxygen, and oxygen levels in our blood are determined by the saturation of hemoglobin. After a certain elevation, this oxyhemoglobin begins to decline. Luckily, as amazing as the human body is, we can adapt in many ways, both short term and long term, to the effects of the decrease in oxyhemoglobin. That said, there are theories which show that above 26,000 feet, most humans can no longer acclimatize. This area has come to be known as the “death zone”.

The oxygen saturation of air at sea level is about 21%, and this concentration remains relatively constant until about 21 kilometers up. 21 kilometers is equal to about 70,000 feet, so I’m not planning on having to worry about anything except 21% concentration of oxygen. However, although the percentage stays constant, the atmospheric pressure decreases exponentially with altitude. This lack of oxygen pressure is believed to be the main cause of symptoms of altitude sickness.

I am aware of the symptoms that can arise at high altitudes and I will be careful as I ascend. If I am feeling really bad, I am prepared to stop and see if I start to feel better. A photograph of the final destination is less valuable if I am not around to enjoy it.

Spontaneity vs. Structure

I can attest to the excitement that came with preparing for this trip over the 6 months prior to leaving. From learning about the Balinese tooth filing ceremony and their complicated calendar system, to the USAT Liberty and how it sank, to how the US got so embroiled in the Vietnam War, to how to grow olives in Italy was a significant part of this adventure. Finding Lonely Planet travel guides, looking up other traveler’s blogs, searching for cheap airlines and figuring out how to get from A to B built up anticipation. I am someone who thoroughly loves the feeling of anticipation. It goes back to my birthday philosophy. I love the feeling knowing that my birthday is coming, that it’s one month away, then one week away, and finally days away. I love that anticipation for all that I can and then when my birthday comes, I bring my expectations down as low as I can. No easy task, but birthdays are one day of the year that too often have trouble living up to high expectations. I enjoy the lead-up, I enjoy planning an activity or two, and then I see what happens.

Leading up to five months of travel is slightly different from leading up to November 1st, but the excitement to be attained by the extended runway to what eventually was this trip was just as excitingly filled with thoughts of great potential. So although I sometimes wish I could be more like John Muir and do as he says–“throw some tea and bread into an old sack and jump over the back fence,” I’m not sure I will ever completely be able to do that. Luckily, planning every day’s activities and every night’s lodging for close to 150 days is almost impossibly daunting, which forced me to leave mostly wholes in my itinerary to be filled as I travel.

I also recognize that traveling without a plan requires great confidence and know-how. Having never traveled alone other than to summer camp or a host family in a very planned-environment, I cannot say that I possessed the know-how I would need to have the confidence to travel with minimal planning. Other than just nerding out on the planning, I also did it to assuage some of the fears that I had of this adventure.

Last note about this is that I did not try to eliminate unpredictability. Instead, I learned my options to pick and choose from as I made my way. I feel I chose a route and and some key activities, but have left the rest up to adventure.

Side note: I found a good discussion on spontaneity during travel in Rolf Pott’s book, “Vagabonding: An Uncommon Guide to the Art of Long-Term World Travel,” a quick read for any new traveler looking for some good advice.

The Dance of Travel Immunizations

In medicine, I’ve always heard that it never hurts to get a second opinion.  But in the case of travel immunizations, more opinions may mean a little more pain because they usually mean more pokes in the arm by long, sharp, shiny needles.  That said, when I didn’t cry, I sometimes received some celebratory lollypops.  (I’m calling that the silver lining.)  I do appreciate everyone who helped me figure out what I needed, but almost every time a new person, such as my friend’s girlfriend’s mother’s cousins’ next door neighbor suggested I have some XYZ vaccination against a deadly disease that wasn’t worth taking the risk on, I usually followed through.  When I finally leave on this trip, I will have so many fabulous antibodies floating around in my blood, that only kryptonite from my far-away home planet will be able to get me.  And lucky for me, there aren’t many mosquitoes that carry said kryptonite.

All kidding aside, the world and especially its jungles can be a scary place when you learn about all the diseases you can get.  Let’s take one disease, which I will talk more about when it comes to shots and dosages, as an example of nature’s lethality to be Japanese Encephalitis (JE).  Of those infected with JE, the CDC reports that 1 in 4 dies and of those who live, up to half may suffer permanent brain damage.  So with a little math, I learned that 63% of those infected with JE die or have permanent brain damage.  Like that good neighbor of my friend’s girlfriend’s mother’s cousin said, it’s not worth the risk.

Most vaccinations are easy.  One poke and I’m done, and a week or two afterwards, I’m ready to make out—vampire style—with a mosquito carrying that disease.  But not all immunizations are so easy.  One example is JE, which I just finished detailing the dangers of.  Don’t worry because I’m only going to go into detail on this one vaccination.  Currently, there are two vaccinations available against JE in the US, and those are JE-VAX and Ixiaro.  To serve as a quick bio, JE-VAX is the older, been-around-the-block vaccine that has been well tested and well documented, while Ixiaro made itself known in 2009 with a similar profile and slightly higher geometric mean titer. I didn’t know what those three words meant until I looked them up either.  Essentially, geometric mean titer just correlates to how much of the antibody is actually flowing through the blood.  JE-VAX is a 3-dose series at days 0, 7, and 30, and Ixiaro is a 2-dose series spaced 28 days apart.  Big pro for Ixiaro is its one less poke!

For the juicier part of this whole discussion, I was left with 25 days to receive either of these two vaccinations, and neither fit in the right time span.  It was time to put my nerd herd hat on and hit the journals.  First thing was looking at what the difference really was between the two.  I found Tauber et. al.’s article titled “Safety and immunogenicity of a Vero-cell-derived, inactivated Japanese encephalitis vaccine: a non-inferiority, phase III, randomized clinical trial” from 2007 in Lancet.  Basically, the article described the new Ixiaro vaccine and compared it to the old JE-VAX vaccine using a blinded study.  And not to worry, even the Ixiaro patients still had to receive the 3 shots, so they remained blind to what they were receiving, and the middle shot was just saline.  Conclusion of the study was that they both work, and the new one works slightly better.

Back to not having enough time to complete either course of injections, I found a study that compared JE-VAX when it was administered in two ways, one taking the usual 30 days, and one taking only 14 days.  The article, found in the American Journal of Tropical Medicine and Hygiene from 1999 by Defraites et. al. had results that gave me a sigh of relief.  The difference between the two dosing regimens was the geometric mean titers that I mentioned earlier.  Those who received the 30 day regimen had higher titers at follow up time points.  What does that mean for me?  It could mean that I have slightly less immunity; although, this is only very slight.  More than anything, it will mean that my immunity will probably wear off faster than average.  That same Journal of Tropical Medicine article said this; I’m not just making it up.  I’m not planning on being in Southeast Asia more than a couple months, and I’ll remember to boost my immunity next time Asian jungles call my name.  Importantly, I now have a good chance of avoiding that intimidating 63% statistic for the small number who acquire the infection.  Science, for the win.

T Minus One Month

My departure date both beckons and looms.  I leave the San Francisco Bay Area in less than a month, and before then, there is a lot to wrap up including job, apartment, and trip plans.  Since there’s little exciting to say about putting my room into boxes, one area of my trip planning that I love to think about is figuring out how to pack for a trip that will last almost 5 months.

When I begin to count out the days, if I wanted to bring a clean pair of socks for each day that I would be traveling, that will require 150 pairs.  I then add a couple extra for those days that necessitate changing half way through.  I realize that I am going to need a huge suitcase for each type of clothing leaving me with a socks suitcase, a shirts suitcase, a pants suitcase, etc.  That’s a lot of extra airline fees.

In all seriousness, there are two items that I thought most important when figuring out what to take.  Good shoes and a good backpack.  I have already purchased hiking boots that I wear several times a week breaking them in.  There’s no reason to use my moleskin for blisters if I don’t need to.  For a backpack, seeing as this was going to be my one piece of luggage, I wanted something big enough to hold the essentials but not so big that it wouldn’t help me cut back on what I was taking.  Given the length and character of my trip, and given that I would be both moving from hostel to hostel as well as hiking to the Annapurna Base Camp, I chose an internal frame pack by Gregory with 75 liters of space.  75 liters is on the big side, but I’m hoping to bring 4 to 5 changes of clothes, a sleeping bag, layers of jackets and fleeces, and a camera or two.  The pack had sufficient pockets to help me keep things organized, but not so many that it would be hard to utilize all its internal space.

Deciding what to put in the backpack will be difficult, but I need to remind myself that I can both clean the clothes I bring as well as find new clothes as I travel.  That knowledge, however, did not preclude me from getting the underwear with the tagline, “17 countries… 6 weeks… One pair of underwear.  (Ok, maybe two.)” by Exofficio.