The glacier’s end melted into its terminal moraine fifty feet down the mountain and the middle person on the rope team in front of us was sitting down trying to glissade. They were not even sliding anywhere, making at best half-hearted efforts to push themselves forward with their hands. The slope did not seem steep enough to glissade anyway, not to mention the lack of regard for safety and style points this action implied. I did not complain, because our trip leader was standing next to the glissader, and he did not seem to be upset. It was abundantly clear that there were no crevasses between here and the edge of the glacier, and I had been hiking for the last eighteen hours, so this did not seem the time to promote a fanatic adherence to safety ideals.

I was a very tired MOFA leader, and resigned myself to wait until my rope team started moving again so that I could unrope, grab a quick energy bar and sip of water, and descend the last 2,600 ft to the car in the remaining two hours before dark. We were in Glacier Basin, 7,000 ft above sea level; we had summitted Rainier eight hours before. I was exhausted, but I figured I had just enough energy to drag my tired body and gear to the car. My alert system was turned off; we were seconds away from unroping and I knew the trail down was a highway for day hikers.

Accidents or medical emergencies can happen any time, and anywhere, and this includes the very last hour of a three-day trip, even as you near the trailhead. It can happen after you breathe your final sigh of relief after you descend your last steep slope, after you cross your last potential crevasse, and after you slip by the last serac. In this case, my mental fog lifted after a minute of stupor. The climber was not glissading; he was out of breath! The trip leader and I (both of us are medical doctors) made initial medical and MOFA assessments, and got the party unroped and off the snowfield.

We faced a difficult situation, both from the party management perspective of a trip leader, and from the first-aid perspective of a MOFA leader. We had a member of our party who, minutes before had been out of breath and unable to stand, but who now claimed to be okay. Our reserves of stamina and daylight time were limited. Four of our party were exhausted, and possibly more who were being stoic. We had redistributed some group gear to minimize loads of tired individuals. Even at our current pace, our party would be lucky to reach the trailhead before dark.

A similar situation could face any party, and you might be involved. The decisions that you would need to make would be similar. In our case, we did use some prescription medicines, an option not always available, but these actions were tangential to three critical questions: (1) walk out or rescue? (2) split the party? (3) how to get all gear and people to the trailhead safely?

Deciding whether or not to walk our distressed climber out was the most critical decision we faced. We were unsure whether or not we faced an asthma attack, a cardiac problem (such as a heart attack), high-altitude pulmonary edema (HAPE), or something else. The distressed climber became acutely short of breath each time he stood up and started to move; it was unclear if he could make it to the parking lot, and we certainly could not at a pace that would beat the setting sun. In principle, we would not want a person having a heart attack or an asthma attack, or even pulmonary edema to continue physical exertion. However, proper treatment for a heart attack requires an emergency room, and time is of the essence; waiting hours can be lethal. Furthermore, treatment of HAPE is descent, even if it requires mild exercise.

We chose to descend, even though we did not know exactly what medical condition we were facing. In most situations where self-rescue is possible, it should be undertaken. Delays in getting definitive medical care are more likely to be harmful than harm caused by moving the victim or exertion by the victim, although each situation will be unique and require the best judgment of the MOFA leader. Waiting for rescue will usually take longer than effecting a self rescue. In our case, we distributed all of the victim’s gear to other party members. Had there been more gear than we could manage, we would have had to cache gear or call upon other parties for help.

We also chose to split our party. Splitting a party reduces the resources of each group if a further emergency arises, so such a decision should not be made lightly. However, we faced the very real risk of compounding our problems as many party members had no energy reserves left. Our trip leader chose to guide this group down to the cars, leaving three of us to help walk the victim out at a slower pace, knowing we might still be faced with the possibility of a bivouac and rescue.

As we walked, I was able to gather more history that I did not have time to gather earlier. The victim had a history of asthma, but today’s difficulty was unlike any previous attack. The victim had no history of heart problems. The victim was taking some prescription medications, none of which seemed relevant; he had not taken acetazolamide. The victim had climbed Mt. Rainier several times before, always without incident. Today’s problems began shortly after leaving the summit, as mild intermittent shortness of breath, but had become increasingly severe, culminating in the episode at the terminal moraine. Initially, I discounted the possibility of HAPE, because I was clinging to the mistaken belief that HAPE always happens while ascending.

This was a classic case of HAPE, and illustrates a number of points climbers should remember. Altitude sickness is common - far more common than people recognize. Most people with altitude sickness, HAPE in particular, attribute their symptoms to other causes; in our case the victim initially discounted his symptoms as an asthma attack. HAPE can happen hours after a descent has started; it need not occur on the way up. HAPE can happen to people who have previously been to altitude without incident. The best treatment for HAPE is descent. All climbers should consider prophylactic use of acetazolamide both for their own protection, and for the sake of others in their party. Even if one cannot appreciate the bubbling lung sounds of HAPE, which may only be apparent in the later stages of HAPE or with a stethoscope, a hallmark of HAPE is orthopnea, or increased shortness of breath when standing up suddenly.

Note well: always keep your party or MOFA leader informed of your health, even minor shortness of breath or headaches. What may be minor symptoms now may form the basis of decisions later that impact the entire party. Stoicism is not only selfish, but also dangerous. If you are a victim, either by your own or your MOFA leader’s determination, the most unselfish thing you can do is to follow the guidance of your MOFA leader and party leader. You may not be thinking as clearly as other party members. Offering to carry gear when you need to minimize your exertion may endanger rather than help the party.

If you are a MOFA leader, be open-minded on MOFA issues and let your trip leader focus on party management while you focus on first aid. If you are a trip leader, shepherd your party’s energy reserves; you might need them to cope with an unexpected emergency even during the final steps towards your car. Keep the MOFA leader, the victim, and your medical supplies together. Ask other parties for help. Human life is more important than pride. Do not be afraid to dump gear. Even if the gear is never recovered, and even if it is made of titanium with gold trim, its cost will pale in comparison to the cost of a trip to the emergency room.