Headache and Vomiting at 3,400 Metres
Your 16-person group reaches the Huanglong scenic area in Songpan County, Sichuan, at 09:40 after a 2.5-hour drive from Chuanzhusi (3,000 m). The itinerary allows three hours on the boardwalk, and the upper platform stands above 3,500 m. At 10:20 a 67-year-old woman tells you she has a bad headache and feels sick. She is pale, her hands are cold, and she has vomited once. She takes medication for hypertension and swallowed a motion-sickness tablet an hour ago. Pulse 108, breathing 22 per minute, SpO₂ 84% on a wrist oximeter. She insists on continuing because "it is only a headache and I paid for this trip." The nearest oxygen station is 400 m uphill; the coach is a 15-minute walk back down the boardwalk; Songpan County People's Hospital is roughly 40 km away. The other 15 tourists are already walking toward the upper platform. It is 8 °C with light rain and wind.
1. What is your working assessment, and which findings would change it?
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Working assessment: acute mountain sickness with warning features, and I must actively exclude the dangerous alternatives before calling it benign.
Headache plus nausea plus vomiting within hours of ascending above 3,000 m fits AMS. But three things stop me treating it as routine: vomiting (AMS with vomiting is moderate, not mild), the low reading (84% is not automatically abnormal at 3,400 m, where 85–90% is common, but it must be interpreted against her baseline and her response to rest and oxygen), and her age with hypertension, which puts cardiac and cerebrovascular events on the list.
Findings that would push me toward HAPE: breathlessness at rest, a dry cough becoming wet or pink-frothy, crackles at the lung bases, cyanosis, or an SpO₂ that stays low after 10–15 minutes of rest and oxygen. HAPE can begin within hours of arrival and is the commonest fatal altitude illness.
Findings that would push me toward HACE: confusion, drowsiness, inability to walk heel-to-toe in a straight line, severe ataxia, or behaviour change. Ataxia and altered mental state are the decision points; do not wait for both.
Findings that would push me off altitude illness entirely: chest pain or pressure, pain radiating to jaw or arm, irregular pulse, one-sided weakness, facial droop, slurred speech, or a sudden severe headache unlike the others. Her cold clammy hands and pallor are nonspecific but consistent with either shock or simply cold and altitude.
Confounders to note: the motion-sickness tablet can cause drowsiness and dry mouth and may mask or mimic mild confusion; her antihypertensive may be contributing to dizziness. Record them, but do not let them explain away ataxia.
2. Set out your actions over the next 30 minutes, including what happens to the other 15 tourists.
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Minute 0–5: stop the ascent, do not send her up. No exertion, no walking uphill toward the oxygen station; the walk itself worsens both AMS and HAPE. Sit her down out of the wind, insulate her from the ground, loosen clothing, and have one named companion stay with her. Do not leave her alone while you chase the group.
Minute 5–10: oxygen and reassessment. Portable oxygen at 2–4 L/min if you carry it, or move her the short distance downhill to the coach and its supply. Warm her. Recheck pulse, respiration, SpO₂ and - critically - do a 10-metre heel-to-toe walk and three simple orientation questions after 10–15 minutes.
Minute 10–20: decide by trajectory, not by her opinion. Her desire to continue is not a clinical finding. If ataxia, confusion, breathlessness at rest, or a falling SpO₂ appear, that is descent now, not observation. Descent is the definitive treatment; oxygen and drugs buy time. If she improves clearly with rest and oxygen but remains symptomatic, she still goes down and does not re-ascend today.
The group problem. I cannot be in two places, and abandoning 15 tourists on a boardwalk is its own risk. Options, in order: (a) truncate the visit for everyone and take the whole group down - safest and often fastest; (b) if the group is compliant and the site is a single-boardwalk out-and-back, send them up with a firm 45-minute turnaround, a named buddy system, and a meeting point at the coach, while I go down with the patient and the driver; (c) call the agency to dispatch a local assistant or the scenic-area medical staff. I would choose (a) or (b) based on how quickly she deteriorates; I would not choose (b) if she shows any neurological sign.
Minute 20–30: transport and notification. Arrange vehicle transfer toward Songpan or the scenic-area clinic; call the agency operations desk and the insurance hotline; begin the incident record.
3. What do you document before leaving Songpan, and how do you handle the itinerary change, insurance and the tourist's own refusal?
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Documentation (same day, while it is fresh):
- A timed incident log: 10:20 onset and reported symptoms; each set of vitals with times and the device used; the oxygen flow and duration; the result of the ataxia and orientation checks; who was present.
- Photographs of the oximeter reading and of the scene conditions (temperature, weather), which are far more persuasive than a written claim.
- A short signed statement from the patient recording that she was advised to descend and that she initially objected, plus the names of two witnesses from the group.
- The hospital's diagnosis and discharge papers, the transfer receipts, and the name of the treating facility.
- A note that another tourist (or you) remained with her at all times - this is the evidence that your duty of care was met.
Itinerary change. Abandoning part of the visit is an emergency safety measure, not a favour. Notify the agency in writing immediately and give the group a clear, factual explanation. Under the Tourism Law's force-majeure/emergency provisions the agency must take appropriate safety measures, and any resulting change to contracted services must be discussed with the tourists and recorded; costs saved are refunded, extra costs are allocated as the contract and the statutory rules provide. Get the group's acknowledgement of the change in writing where possible, and never promise a refund you cannot authorise.
Insurance. Distinguish clearly: the agency's liability insurance covers the agency's fault, not her illness; her own travel accident/medical policy, if she bought one, is the relevant policy. You cannot complete her claim, but you must supply the incident report, the delay/medical certificates and the receipts, and give her the insurer's hotline. Failure to supply documents is the commonest reason claims fail.
Her refusal. Her consent does not authorise an unsafe plan. Record the advice you gave, why, and what she decided. If she still refuses and shows red flags, this becomes a medical emergency in which you act and notify the agency and, if necessary, local medical or police authorities - document that too.