A Confused Teammate on the Mountain: Assess, and Get Down
Treat altered consciousness as an emergency first, and only then as altitude illness. Waiting for morning, sleeping it off, or giving oxygen and watching are the dangerous options.
If a teammate becomes confused at altitude, run the emergency checks first: airway, breathing, warmth, blood sugar and temperature, gait and focal neurological signs — while preparing to descend or call for help. Recent ascent plus altered consciousness or unsteady walking means HACE until proven otherwise. Do not wait for daylight, do not leave them alone, and do not give anything by mouth to someone who cannot swallow.
Confusion at altitude has one dangerous interpretation and many correct ones. The dangerous one is "it's just the altitude, let's see how they are in the morning". The correct response is to treat it as an emergency and work out the cause while you act.
Four things, in order
- Scene safety. Ventilate the tent and get away from any stove or flame. Move away from avalanche runout, cliffs or traffic.
- Are they responsive? AVPU — alert, voice, pain, unresponsive. Unresponsive but breathing: recovery position. Not breathing: CPR and call for help.
- Breathing and circulation. Respiratory rate, lip colour, pulse, breathlessness at rest. Control major bleeding first.
- Warm and measure. Dry layers, insulation from the ground, sleeping bag. Measure temperature, SpO2, blood glucose and heart rate if you can.
High altitude plus altered consciousness
Suspect HACE first.
- Recent ascent or poor acclimatisation, plus altered consciousness (drowsiness, incoherence, not waking normally, odd behaviour) and/or unsteady walking.
- Ask them to walk a straight heel-to-toe line. Unsteady, or needing support, is a red flag.
- HACE is a clinical decision, and you must exclude hypoglycaemia, hypothermia, stroke, head injury, infection, drugs, alcohol and carbon monoxide. Do not wait for certainty — descend.
Check for HAPE at the same time.
- Breathless at rest, cough, blue lips, cannot lie flat. HACE and HAPE can occur together.
- Oxygen, warmth, descend or call for help. Do not simply give oxygen and observe.
The mimics you must exclude
| Clue | Possibility | Field action |
|---|---|---|
| Cold sweat, palpitations, missed meals, diabetes | Hypoglycaemia | Sugar only if alert and able to swallow |
| Cold hands, shivering that stops, confusion | Hypothermia | Dry layers, insulation, gentle rewarming |
| Stove or charcoal in the tent, headache, nausea | Carbon monoxide | Ventilate, move, call, oxygen |
| Facial droop, one-sided weakness, slurred speech | Stroke | Note onset time, call for help, descend |
| Head impact, vomiting, unequal pupils | Head injury | Do not move, call for help |
| Seizure, post-ictal drowsiness | Epilepsy | Protect the head, nothing in the mouth, note the time |
| Fever, stiff neck, cough | Infection | Evacuate and get medical care |
| Alcohol or sedatives | Intoxication | Do not induce vomiting, keep warm, watch breathing |
Do not
- Leave them alone to "sleep it off".
- Give food, drink or medication to someone unresponsive or unable to swallow.
- Use alcohol or sleeping tablets to get them to sleep.
- Continue ascending because "the SpO2 is okay".
- Improvise with prescription drugs or steroids. If you are WFA/WFR trained and carrying a doctor-prescribed kit, follow your training and the prescription — descent still comes first.
Evacuation
- Record: time, altitude, rate of ascent, changes in consciousness, gait, breathing, temperature, glucose, medication, allergies.
- Send: coordinates, number of people, injuries, weather, a possible landing zone, what you need.
- Descend if it is safe. If not, insulate, oxygen, and wait for rescue. Do not send the whole team away.
- Night descent only when it is safe and necessary; otherwise keep them warm, keep oxygen going, monitor continuously, and move at first light.
Prevention
- Ask each other morning and evening about headache, nausea, sleep, gait and consciousness. "Are you okay?" is not a check.
- Nobody sleeps alone in a separate tent, nobody gets left behind on an ascent day.
- When one person's consciousness changes, the whole team's objective drops immediately.