Survival

Case History

When my ordeal began, I was 22 years old. I had come to Nepal from Australia 5 weeks before to do my senior year elective for medical school and to hike in the Himalaya. Several months before leaving home, I had become engaged. At home, in addition to studying, I trained as many as 10 hours per week in various sports, especially karate (in which I had competed at an international level).

At the suggestion of local physicians, I spent the first 2 weeks hiking and climbed to an elevation of 3000 meters. After working for about a month at the main government hospital. I headed north from the Kathmandu Valley on another short trek. Trekking on these popular routes means hiking from one rustic lodge to the next: Therefore, one need only carry the bare minimum of food and equipment.

On 22 December 1991, I was hiking with a man whom I had met 2 days before. We were attempting to cross a 4400-meter pass when a blizzard swept in and caused us to lose our trail. We discussed but could not agree on the safest course of action: I chose to turn back, whereas the other man continued climbing.

With the mountain trail covered in snow, I followed a creek in the hope that it would lead down to the village that was on my map. The snow deepened, and the creek only led me to a precipitous waterfall. I slept under an overhang, then spent the next day slogging through snow; at one point, I fell into water. That night, sheltered by a narrow rock ledge, I consumed the last of my food: two chocolate bars. I wrote to my fiancee and to my family, apologizing for my carelessness and explaining the circumstances that had led to my situation. It was so cold that I expected to die.

On the third day, I continued to descend slowly. I eventually decided to make camp under another overhang. Hemmed in by snow and difficult terrain, I was becoming apathetic, and my feet had lost sensation. A huge boulder provided adequate shelter, and nearby was a clearing from which I might signal a search helicopter. Without a tent and without the means to start a fire, I cleared a place for my sleeping bag and climbed into it. It was Christmas Eve.

While under the rock, I starved. Each day I made snowballs, laid them out to melt, and slowly sucked out the water. I tried to pace my consumption by reading two pages of a book for each snowball. I sampled all of the nearby vegetation but nothing was edible. A caterpillar happened by and I ate it. My desire for food increased during the first 20 days, then leveled off; however, intrusive thoughts and dreams of eating never left me. I knew that I was losing weight. Bones protruded where muscle had been. Walking became an arduous task. I recalled news of an Irish hunger striker who had lived for 60 days without eating; I thought that I could last that long.

The cold was intense. Most nights, I could not stop shivering; sleeping was somewhat better during the day. When I arrived at the rock, the sleeping bag and one moderately warm set of clothing were all that was dry. On sunny days, I laid out my wet, frozen clothes, and after 2 weeks I was able to wear them. This improved my situation immensely. Because I knew that much body heat is lost through the head, I kept my head wrapped up in towels and clothes. My feet were swollen and numb; I feared that I would lose them. When wrapped in socks and clothes, they eventually warmed, but became terribly painful. I tried to keep them just cold enough to impair sensation but not cause further injury.

As the weeks wore on, I grew bored and anticipated dying. I made several attempts to climb down the mountain, but each time the deep snow and my lack of endurance forced me to return to the rock. The loneliness and sensory deprivation were hard. I imagined being back home with my fiancee, family, and friends. To share my thoughts and express my love, I continued to write to them. I was acutely aware of the anguish that those at home would feel because of my actions. When my pen ran out of ink, I despaired.

It gave me pleasure to look at the snowflakes falling or birds flying over the beautiful, rugged hills. I watched in awe as avalanches crashed down cliffs. I dreamed of rescue and of being reunited with those I loved. I imagined the impossible: mountains erupting like volcanoes, or lost airplanes colliding with hillsides, bringing people into the area to save me. For many hours each day, I prayed for my loved ones at home and for my erstwhile trekking companion.

I monitored time by the cycle of the moon. The sixth week was the hardest. It became more difficult to stay warm. I had persistent nausea and urinary urgency but was often unable to void. After one final attempt to walk out failed, I became suicidal and intentionally ceased intake of fluid. On the third stuporous day, I had a vivid dream that I was home in Australia with my fiancee and family. I awoke, very upset that I had given up, and again began to take snow water.

On 2 February 1992, 42 days after losing my trail in the blizzard, I was spotted by a search helicopter after I staggered into the nearby clearing. The following day, the helicopter lifted me off of the mountain, and I was taken to Patan Hospital.

The following section was written by Mark D. Zimmerman, Kana Appadurai, Leon B. Jellett, and Frank H. Garlick.

Commentary

Management and Course

On presentation, James was gaunt and seemed extremely fatigued. Though emotionally labile, he was lucid and had an excellent memory. His blood pressure was 114/70 mm Hg supine and 60/52 mm Hg sitting; his heart rate was 108 beats/min supine and 120 beats/min sitting; and his body temperature, taken rectally, was 98.2 °F. On day 2 of hospitalization, he weighed 61 kg (his prestarvation weight had been 80 kg). He had prominent tenting and some flaking of skin. Both feet were swollen, calloused, and warm and had normal pulses; light touch sensation was slightly reduced. James had bilateral right conjugate gaze palsy and vertical and horizontal nystagmus. Power was normal in all muscle groups except hip flexors, which were 4/5 (slightly diminished), and he had deep tendon reflexes. Heart and lungs were normal, and one finger-breadth of nontender liver was palpable.

On day 1 after the rescue, laboratory results showed a total leukocyte count of 6400 cells/mm³ (70% neutrophils, 30% lymphocytes), a hematocrit of 0.44, and a prothrombin time of 17 seconds (14 seconds for control). Other laboratory values were as follows: blood sugar level, 5.11 mmol/L; creatinine level, 0.1 mmol/L; albumin level, 44 g/L; sodium level, 128 mmol/L; and potassium level, 3.0 mmol/L. A urine sample was trace-positive for ketone. The results of chest roentgenography and electrocardiography were normal.

James was initially rehydrated with normal saline, 2000 mL/d given intravenously, and liquids, 1500 mL/d given orally. Dextrose was added after the first dose of parenteral thiamine, and use of intravenous saline was discontinued after day 2. Urinary output averaged 80 mL/h from the first night. Food was given in small aliquots every 2 hours, increasing from 2000 to 4000 kcal/d; protein was added gradually during the first week. James received intramuscular thiamine and vitamin K as well as oral multivitamins supplemented with trace elements.

Within 12 hours of admission, the gaze palsy resolved. Because of emotional lability, James was seen by a psychiatrist, who noted some paranoia and thought that he had a mild organic brain syndrome. She recommended that his contact with strangers be limited and that mild tranquilizers be given.

On day 3, James's feet became extremely painful, and he required parenteral meperidine. By day 4, the creatinine level was 0.06 mmol/L and the hematocrit was 0.39. On day 6, he was found to have a third heart sound and tachycardia; although the results of chest roentgenography were normal, he was given furosemide. By day 10, he was eating well and seemed to have normal fluid balance. He was flown home to Australia, accompanied by a medical rescue team.

On admission to Royal Brisbane Hospital on day 11, James weighed 64 kg. A slight drop in orthostatic blood pressure, nystagmus, diminished ankle reflexes, and a positive result on a Romberg test were noted. The serum magnesium level was 0.77 mmol/L. Magnesium aspartate, oral morphine, and valproate were added to the treatment regimen.

The erythrocyte transketolase level was 0.76, a normal value. Levels of plasma vitamin A, serum ascorbate, 25-hydroxyvitamin D, and iron; total iron binding capacity; and levels of calcium, phosphate, copper, zinc, and selenium were all normal on day 11. Syncortin stimulation produced a normal cortisol response. Results of electroencephalography done on day 16 showed decreased α activity and bisynchronous slow-wave formation. An electroencephalogram obtained on day 23 was normal.

James was discharged from the hospital 5 weeks after his rescue. He eventually resumed his studies and graduated from medical school 1 year later than he had planned. Fine vertical nystagmus, which still persists 5 years later, prevented him from pursuing a career in surgery. He is now working as a medical house officer. He married his fiancee, and they have a daughter.

Discussion

A physically fit young man became lost in the Himalaya in winter and survived for 41 days at an elevation of 3000 meters by eating only snow. He lost approximately one quarter of his total body weight and sustained neurologic damage from thiamine deficiency. We discuss the physiologic mechanisms of starvation and factors that may make a person more likely to be a survivor.

Starvation

Total caloric deprivation for periods of 2 to 8 weeks has been reported [1-6]. In monitored hunger strikers, weekly weight loss averaged 2 kg, although more weight was lost during the first week [1, 2]. Infection, burns, exertion, or fever may increase this rate by threefold or more [7]. James's average loss of 3.3 kg/wk was probably lower than expected, considering the energy that he expended trying to keep warm and to escape.

During starvation, sodium- and potassium-activated adenosine triphosphatase pump activity, protein synthesis, and immune response decrease; anabolic and catabolic steroid activity are also altered [8-10]. James's physical conditioning may have enhanced these adaptations, but we know of no other reports that corroborate this idea. These same physiologic adaptations may be a source of danger when feeding is recommenced because the heart is ill-prepared for the stress of fluid, calories, and protein [11-13]. Our overaggressive rehydration attempts may have caused mild heart failure. A low phosphate level is a key factor in refeeding syndromes, but in 1992 we were unable to measure serum phosphate levels in Nepal. Health and Williams [14] found that altitude and cold had no protective effect against weight loss among mountain climbers.

In addition to conserving calories, a starved body attempts to save protein: It preferentially uses ketones and fatty acids and recycles sugar fragments derived from gluconeogenesis [15]. A side benefit of reduced protein catabolism is that the resultant decrease in urea excretion markedly decreases the requirement for urinary output. James's need for snow intake was thereby lowered. Nevertheless, his accounts of withering musculature and weakness show that his body was not able to utilize fat stores exclusively, even though these were adequate. At the time of rescue, his hemoglobin and serum albumin levels were normal; subsequent tests showed that this was not explained by hemoconcentration alone. The body saves its more essential proteins, such as hemoglobin, albumin, cardiac muscle, and certain enzymes, by feeding off of fat first, then skeletal muscle [15, 16]. In none of the accounts of intentional starvation cited above were albumin or hemoglobin levels reported to be low. It may be that albumin levels only decrease if starvation is accompanied by tissue injury [17].

After 6 to 8 weeks, a fast often takes a turn for the worse [2-5]. Of interest, three intentional fasts described in the Bible were each broken at 40 days [18]. In week 6, even before ceasing intake of snow, James had nausea, marked weakness, and visual disturbances. For a well-nourished person, however, 40 days does not mark the point of total caloric depletion, and in fat alone James should have had 2 months' worth of calories [15]. On arrival at Patan Hospital, he still had a modest residual layer of fat.

James presented with overt signs of Wernicke disease; this condition may have been aggravated by food that was given shortly after he was found on the mountain. The gaze palsy responded promptly to parenteral thiamine. The foot pain may have been caused in part by the axonal peripheral neuropathy of thiamine deficiency [19, 20], but thermal damage probably played a large role. Aside from brief, transient paranoia, signs of the Korsakoff syndrome never appeared.

In a study by Victor and coworkers [19] that included mostly alcoholic persons, the mortality rate from the Wernicke-Korsakoff syndrome was 17% in the first 3 weeks; of patients who had long-term follow-up, 60% had horizontal nystagmus on last examination. Reports of nonalcoholic persons have emphasized the various presentations of thiamine deficiency [4-621, 22]. Administration of glucose infusion without thiamine resulted in coma in one patient after a 60-day hunger strike [23] and in death in another patient after a 45-day hunger strike [3]. Thiamine depletion is one of the landmarks in a fast, a point of trouble even before fat calories are entirely spent.

After James received thiamine for 10 days, the serum transketolase activity (the best laboratory indicator of thiamine deficiency) was normal. Although thiamine administration exceeded that given in published recommendations [19, 24], James sustained long-term neurologic damage.

Survival

Publicity surrounding James's case generated disbelief in both lay and medical circles. Many wondered how a person could survive for 6 weeks in the Himalaya eating only snow. As noted above, some persons on hunger strikes and other fasts have survived on water alone for this length of time. In James's case, the profound stresses of environment, isolation, and uncertainty were added to starvation. Personal qualities that were evident in his story resemble traits of survivors of other instances of extreme human struggle, such as war, physical disasters, or treatment of cancer.

From the start, James took measures to save himself. Recalling a medical school lecture on hypothermia, he reduced heat loss by drying his extra clothes, toweling off whenever he became wet, covering his head, and consuming melted snow rather than snow. By establishing a home base, he took what he thought was the best course of action. It later proved to be crucial to his rescue that this base was near a clearing in the dense pine and bamboo forest.

Roud [25] found a willingness to fight in long-term survivors of cancer. Survivors of concentration camps reported that survival was associated with focusing energies on the present, preserving high self-respect, and overcoming emotional hostility and depression [26]. Patients with cancer in nursing homes who, on psychologic testing, showed higher self-esteem and a lower sense of helplessness and hopelessness lived longer than a matched group of patients with cancer [27]. Siegel's experience with patients with cancer [28] is that exceptional survivors are more likely to be independent, inquisitive, and active on their own behalf.

Pearlin and Schooler [29] have emphasized that in dealing with extreme stress, the use of a variety of coping mechanisms may be advantageous. Imagination and a cognitive restructuring of the meaning of the stress may help a person endure it [29]. James occupied his mind with lengthy, detailed recollections of pleasant times and mentally drilled himself on the minutiae of karate maneuvers. He read Dickens's Great Expectations cover-to-cover six times. He repeatedly envisioned possible rescue scenarios even while acknowledging that the likelihood of some of them happening was remote.

Glassman's interviews with survivors of cancer [30] revealed that many grasped a deep sense of the wonder of life at a time when their own short-term survival was threatened. James's account tells of unremitting hunger, severely painful feet, fatigue, loneliness, guilt, and doubt. At the same time, his thoughts were often caught up in admiration of the valley of deep snow, the birds who visited nearby trees, and the stars and the moon. He laughed at the remarkable ironic similarities between himself and the character Pip in Dickens's novel. He prayed for long periods, mostly for others.

Connections to that which is good-to surrounding beauty, one's Creator, or one's family-seem to be some of the keys to survival. Several authors have noted close family ties in people who survive extreme hardship [25, 27, 28, 30, 31]. Herman [31] presented an account by a stabbing victim who, by visualizing his relationship with his father, held onto life just long enough to be saved. James wrote to his loved ones until his pen ran out of ink, a loss that he felt deeply. Once despair finally took hold and he decided to let himself die, a dream about his family shook him to resume the fight.

Here we have tried to tell the story of one man who survived an extreme threat to his life. He began with a strong body, then limited his heat loss, stayed active, used his imagination in positive ways, stayed connected with his loved ones, and prayed faithfully. But even after hearing and reflecting on this story many times, comparing it to the accounts of others and searching for the science in it, much lay beyond explanation.

In January 1992, while James was starving under the rock, his sister Joanne came to Nepal to organize a search. She sent Sherpa rescue parties into the district 15 times. Nepalese Army helicopters took 10 search trips over those mountains. At the end of the month, after local experts had long been saying that her brother must be dead, Joanne purchased her plane ticket back to Australia. On 2 February, she requested one last helicopter flight to view the area in preparation for a body search in the spring. James was spotted during this last fly-over.

Mark D. Zimmerman, MD

Patan Hospital; Katmandu, Nepal

Kana Appadurai, MBBS, MRCP(UK)

Westlake, Australia

James G. Scott, MBBS

Royal Brisbane Hospital; Brisbane, Australia

Leon B. Jellett, MBBS, FRACP, FRACMA

Ipswich, Australia

Frank H. Garlick, MS, FRCS, FRACS

Aspley, Australia

Dr. Appadurai: 274 Horizon Drive, Westlake QLD 4074, Australia.

Dr. Scott: Royal Brisbane Hospital, Herston Road, Brisbane QLD 4029, Australia.

Dr. Jellett: First Floor, Office Tower, Westway Centre, Gordon Street, Ipswich QLD 4305, Australia.

Dr. Garlick: 27 Chartwell Street, Aspley QLD 4034, Australia.