In this unit, students explore the link between altitude and potentially dangerous Acute Mountain Sickness (AMS). Students learn about the variations of AMS, its symptoms and treatments. The unit is brought to life by using historical information, a personal account of a hiker experiencing AMS and "Everest adventurers" worksheets. The culmination of the unit and the research project, allows students to explore the effects drugs have on the brain and the body (analogous to how AMS affects the brain and the body).

Start by asking students whether they’ve ever been climbing before. How high? What do you think happens to your body when you climb up really high?

Testing the Altitude provides a personal account of a female climber trying to get altitude sickness! The students “snowball”, is the section Testing the Altitude – Snowballing used as a comprehension exercise. Take up the students’ answers with the whole class. Make sure the students understand WHY the woman would want to get sick. Was it a good idea? Not something to try!!

Normal Acclimatization, AMS, Severe Forms of AMS all provide accessible background material about AMS. It is a lot of information to absorb all in one class. AMS Quiz 1 and AMS Quiz 2 test for knowledge and understanding. Students can answer the questions in class using their four worksheets. Or, the quizzes could be given in future lessons and graded.

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QUIZ 2 ANSWERS:

1. F - acute
2. T
3. T
4. T – golden rule #1
5. T
6. F – never ascend if you have any symptoms of AMS
7. T
8. T
9. T
10. T
11. T
12. F - decreases
13. T
14. F – Sherpas are also susceptible
15. T
16. F- drink lots of water
17. F- carbon dioxide
18. T – golden rule #4
19. T
20. F – NOT directly linked

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Altitude Sickness: A History delves into the past of the condition. Discuss climbing with regard to AMS in the FUTURE. First without Oxygen on Everest details Messner & Habeler’s successful first ascent without O2. AMS in the Himalayas is a supplementary sheet that you may choose to give to your class as a review of AMS. Sherpas and Altitude is another interesting supplementary sheet detailing the history of Sherpas and their remarkable ability to function at high altitudes.

The Research Project is the culmination of this unit. Read the assignment over carefully with the pupils; most students will try to do TOO MUCH. Set a length you feel appropriate. Research and Note-Taking is designed to help the students prepare for their project.

Do you want the students to present their findings? If so, then Oral Presentation Hints and Peer Evaluation of a Class Presentation 1 OR Peer Evaluation of a Class Presentation 2 will also be helpful.

If you decide against presentations, at least allow for 15 minutes of class time for pupils to read each other’s projects.

I'm standing at the dusty, isolated Weatherford Trail, just outside Flagstaff, Arizona. With me are Annette McGivney, her husband, Mike, and their toddler, Austin. I just finished strapping a heart-rate monitor around my ribs. Its watch-like display encircles my left wrist. A digital watch adorns my right. An altimeter dangles from my pack. Add a pocket protector and I'd be the epitome of backpacking geekdom.

All this electronic paraphernalia--Annette, too, for that matter- will help monitor my general well being during a typical three-day trip up and into the San Francisco mountains. There is nothing wrong with me physically. I am a healthy, 36-year-old experienced backpacker who lifts weights and runs 25 miles a week. Yet there's a very good chance I'll get sick this weekend. At least, that's the plan.

My first (and only other) brush with altitude sickness came some 12 years ago, the day after driving from Los Angeles to 8,000 feet in the Sierra Nevada. The next day, we hiked to 10,000 feet, where a nasty headache forced me to go to bed early. I recovered overnight, though, and reached the 12,000-foot summit the next morning.

This time, I've hurtled my body from my nearly sea-level home to the trailhead in less than 12 hours. In a couple more hours, I will have hiked another thousand feet or so. Tomorrow, we hope to summit 12, 633-foot Humphreys Peak. It's a typical vacation scenario for time-pressed backpackers.

Apart from reaching the top of Humphreys, my goals are: A) to show that going too high too fast is a prescription for acute mountain sickness (AMS, also known as altitude illness); and B) to make it clear that you can keep AMS from ruining your time in the mountains.

So far, simply shouldering my 40-plus-pound pack at this elevation has me panting like a poodle on hot pavement. Four-thirty is late to be hitting the trail, but the summer sun will be hanging around for several more hours, and we plan on hiking just a couple of miles before making camp. Besides, it's Friday, and I'm anxious for sweet mountain air to empty my head of office worries.

Mike inquires about my next of kin. I tighten my hipbelt, adjust my trekking poles, and follow Annette into Coconino National Forest. The path weaves among immense ponderosa and Scotch pines squatting like escapees from a Christmas tree farm. Solitary aspen, as big as I can reach around, soon appear.

We hike for a while in silence, immersed in the sights, sounds, and aromas. But it doesn't take long before I call to Annette, "Wait up! ...We've got...to...switch...places." With every wheezing step, I'm falling farther behind her long legs and effortless, acclimatized pace (her Flagstaff home is at 6,500 feet), and my head feels slightly detached, like I've guzzled a beer on an empty stomach.

"Sure," shrugs Annette, backtracking. "You feeling the altitude already?" She's oblivious to my dagger looks, idly shifting her pack as she waits for me to stop making Darth Vader noises.

After another 90 minutes and a 1,000-foot elevation gain, we drop our packs for a few tests designed to catch the early signs of AMS (more on this later). First comes the tandem gait test, a less humiliating version of the roadside heel-to-toe walk along a straight line. Rock juggling comes next, which I abruptly abandon while several day hikers pass I smile and wave, feigning nonchalance while sucking on a smashed finger. They wave nervously, and hustle on by.

Finally, I rip off 10 jumping jacks. I'm winded, but still feel pretty good. I may survive after all.

All joking aside, AMS can be serious business, and no one is immune. About a quarter of all those who go to even moderate altitudes of 6,000 to 9,500 feet will feel some degree of its symptoms. Up the ante to even higher elevations and the symptoms become more severe - those who continue anyway may die.

As for me, my scenario is "typical for some of the high performance, stressed individuals who try to do too much too fast," according to Charles Houston, M.D., of Burlington, Vermont, world-renowned for his 50-plus years of research in high altitude medicine. By climbing so quickly, I starved my body of the essence of life: oxygen. In response, a chain of automatic reactions began in an attempt to compensate.

First, the lack of oxygen in my blood sent a message to my brain: Breathe faster, stupid. My heart also began to pump faster and with more force to move blood, and the oxygen it carries, through my system more quickly.

"Acclimatization helps the cells get along on a smaller oxygen budget," Dr. Houston says. Given more time and a slower gain in altitude, my body would gradually adjust and allow me to enjoy high-altitude backpacking with few, if any, symptoms of AMS.

But I wasn't here to take my time.

Almost 1,400 feet higher up the mountain and I'm decidedly more light-headed, stumbling a bit, and giggling a lot. It's important to note that on a list of phrases ordinarily used to describe me, "giggles a lot" would fall near the bottom, just after "likes to wear pink lacy things." I turn on my tape recorder and state that Annette may have to start "tarrying the cape recorder." More giggles. I perform the required tests without too much bungling, though I can't figure out how long we'll need to reach the top of Humphreys tomorrow at our current rate of ascent. It takes me 3 full minutes to do the math.

We haul the packs down to a protected, much-used campsite in a narrow little valley just off the trail and begin the familiar routines. I manage to set up the tent without impaling myself while Annette, choosing to keep me away from open flames, starts dinner. My appetite is unaffected, at least, and I devour a big bowl of curried lentil stew with garlic Melba toasts, washing it down with lots of water. (Dehydration, though a good way to promote AMS, is not a hardship I'm willing to risk.) While hanging our bear bags, I spot two faint and fast shooting stars in the slice of blackness above us--a good omen for tomorrow, I decide.

I wear the heart monitor to bed and record my lowest rate of the day just before nodding off: 76 beats per minute, as opposed to my sea-level resting rate of 55. Annette's is an unremarkable 59.

I wasn't showing clear symptoms of AMS yet, but my mental stumbling was typical of getting high. "It is well-known that mental tasks can be performed accurately at high altitudes," says Ken Zafren, M.D., medical director of the Denali National Park Mountaineering Rangers in Alaska and associate medical director of the Himalayan Rescue Association, "but often take longer than at sea level." An accompanying headache or lack of appetite, though, would have been a clear sign to stay put until all symptoms improved.

Some of my slow-wittedness also could have been chalked up to general fatigue. By the time we stopped for the night, I'd gained 9,000 feet of elevation in about 15 hours. Annette's lower heart rate indicated that her body was struggling much less than mine, testimony to the wisdom of climbing just 3,000 feet in elevation for one day. As a rule of thumb, experts recommend that at elevations above 5,000 feet, travelers should climb no more than 2,000 feet per day. You can climb higher as long as you descend to sleep at or below that 2,000-foot mark.

Midway up what seems an endless switchback, I'm doubled over, gulping the thinning air like a goldfish on carpet. The day started well enough, even though I awoke four or five times during the night. We were on the trail by 8:30 after a decent breakfast, and lunch was a restful repast in a sun-dappled grove of spruce and pine.

But just after lunch, a nagging ache took hold behind my eyes and it has translated to a permanent squint. We're above treeline now and hiking into a buffeting wind so strong that at times we stand in place, unable to make headway against the force. Tall, skinny Annette catches the wind like a sail and there are moments when I fear she'll be lifted off the narrow ledge of trail and into the canyon nearly 1,000 feet below. This is starting to be not so fun.

I'm sitting with my head in my hands, trying not to move or talk. The slightest motion makes my head throb. I don't need the heart-rate monitor because I can hear my pulse; it's that bass drum pounding between my temples. We're a few hundred vertical feet from the top, our packs stashed behind some boulders at a saddle where the summit trail branched off. I thought that without the extra weight I could make it, but I've been kicking and tripping over rocks like a drunk after an all-nighter.

"I stumble all the time, but usually you don't," Annette points out above the roar of the wind, now pummeling us with 50 mph gusts. She stands over me, her brow furrowed with concern, snapping pictures to document my shades of green as the nausea sets in.

"I have to turn around," I mumble, finally. Normally it would kill me to stop this close to the top. But today, at this particular moment, the top of Humphreys seems as distant as the summit of Everest. I don't even look back as we pick our way down through the boulders. I just want to get down, to feel better.

While not fully realizing it--or much of anything at the time--I was in the throes of AMS, according to Dr. Houston. The nausea, headache, fatigue, and mental confusion all pointed to the obvious: I should have gone more slowly. If I'd spent a night in Flagstaff, I might have been slightly better off, though Dr. Houston says that "a full day and night would have been best."

Both Doctors Houston and Zafren stress that ascending at a reasonable pace is always the best insurance against AMS, but they also recommend the prescription drug acetazolamide (Diamox) as a preventive and treatment for AMS when you don't have time or opportunity to acclimatize. They recommend 125 milligrams twice daily, starting the day before you begin to ascend and continuing for 24 hours after you arrive at the highest point. Since many doctors are ill-informed about altitude illness and Diamox, help yours get up to speed by doing some research ahead of time on the topic.

Dr. Houston also notes that ibuprofen "is a little more effective than aspirin at relieving the headache, but doesn't change other symptoms."

We make good time going down, and the wind subsides once we're in the protection of big trees. For all I care, though, we could be walking through a stump-filled wasteland; my senses are numb. The headache and nausea haven't abated, and I try not to snarl as we pass some cheery dayhikers. Sips of water don't help.

Finally, we stop to check, the distance to the Arizona Snow Bowl, a local ski area where we'll call Mike to pick us up. It was to be our water stop for tonight's camp, but I see no point in continuing this misery. I've accomplished my mission and am ready to bail.

We take off our packs, and I sulk while Annette pulls out the map. "Do you feel like eating anything?" she asks.

A moaning "Oh God, no" is all I manage before throwing myself across a trailside log and retching violently, keeping a white-knuckle grip on my water bottle. I am suddenly struck by the thought that our lunch--cheese-peanut butter crackers and baby carrots--was much too orange. Between heaves, I hear a soft "click, click" and realize Annette, dedicated journalist to the end, is capturing my indignity on film.

I flop back down by the log and drag a sleeve across my mouth. "That doesn't seem very low-impact," Annette drawls in her driest West Texas tones.

The trip down is a blur. I feel better immediately after throwing up, but my respite is short-lived. By the time we reach the Snow Bowl, I'm again flat on my back fighting nausea. I lose that battle, as well as another skirmish on the way down the serpentine road after Mike picks us up. After two days of dry, dust-caked hiking, the only thing I manage to take off is my boots before collapsing grimy and exhausted on a bed at Annette and Mike's house. Five hours later, I'm able to take a shower, then pass out again until 8 the next morning. I awake weak and still queasy, but on the mend.

It took me two full days to feel strong and steady again after that trip, and thinking back on it still makes me queasy. Next time, I'll take that extra day or so to give my body the time it needs to adjust. Still, I can't help but wonder if altitude will always be a challenge for me.

While various theories explain why some people react so badly to altitude, none have held up under scrutiny. "The cause of AMS and the reason Diamox works are both subjects of active debate among the experts," says Dr. Zafren. "The answers are not in." The latest research indicates that both High Altitude Pulmonary Edema (HAPE) and High Altitude Cerebral Edema (HACE), more serious conditions that may follow AMS, are due to leaking blood vessels in the lungs and brain that cause life-threatening fluid buildup, or edema, in those critical organs.

Researchers are seeking answers to these and a slew of other altitude-related questions on mountains and in labs all over the world. And who knows? Maybe some day you'll be able to rush from sea-level desktop to mountain-top in a weekend. Until then, use AMS to your advantage; there's no better excuse for adding an extra day or two to your vacation.

This “snowballing” is a comprehension exercise. How much did you understand? You start with the basic ideas (or nuggets), and then roll on the more complex ones!

1. As you are reading the story Testing the Altitude, write down five questions that occur to you. The questions should be ones you have about the meaning of the text or way the author has expressed ideas. Select questions that, if they were answered, would increase your understanding of the passage.

2. Now join a partner. Try to answer your ten questions together. Select five that both of you:

• feel have not adequately answered
• have refined or rephrased
           OR
  Choose five new (more compelling) questions that your discussion has raised.

3. Join with another pair to form a group of four. Discuss and try to answer all of your questions; you may have some that are the same. At the end of the discussion, select one question to present to the class for discussion. This final question might sum up several questions in an attempt to get at the “nugget” of the story. You might record an alternative question as a backup in case another group presents you first-choice question before you get a chance!

4. Read your question to the class! Record the discussion notes.

DISCUSSION NOTES You will notice during your discussions questions fall into different categories:

• Some can be easily answered; for example, “What is AMS?”
• Some allow for more than one answer, but you can make educated attempts at answering them; for example, “Why did the writer use a particular example to develop a point?”
• Some are excellent questions raised by the text, but ultimately do not allow for very satisfactory answers; for example, “When is science going to find out more about AMS?”

A good discussion involves a variety of questions. It is important that you respect the questions of your classmates. Sometimes it is necessary to begin with fairly obvious ones about the meaning of certain words before it is possible to ask more challenging questions about the ideas those words are conveying.

What is meant by high altitude? Some "formal" medical definitions:

• High Altitude: 1500 – 3500 m (5000 - 11500 ft)
• Very High Altitude: 3500 - 5500 m (11500 - 18000 ft)
• Extreme Altitude: above 5500 m (18000 ft)

Practically speaking, however, we generally don't worry much about elevations below about 2500 m (8000 ft) since altitude illness rarely occurs lower than this. Acclimatization is the process of the body adjusting to the decreasing availability of oxygen. It is a slow process, taking place over a period of days.

• Hyperventilation (breathing fast)
• Shortness of breath during exertion
• Increased urination
• Changed breathing pattern at night
• Awakening frequently at night
• Weird dreams

As one ascends through the atmosphere, barometric pressure decreases (though the air still contains 21% oxygen) and every breath contains fewer and fewer molecules of oxygen. One must work harder to obtain oxygen, primarily by breathing faster. This is particularly noticeable with exertion, such as walking uphill. Being out of breath with exertion is normal, as long as the sensation of shortness of breath resolves rapidly with rest.

As the amount of oxygen in the lungs decreases, the blood becomes less and less efficient at acquiring and transporting oxygen . This means that no matter how fast one breathes, attaining normal blood levels of oxygen is not possible at high altitude.

Dramatic changes take place in the body's chemistry and fluid balance during acclimatization. The osmotic center, which detects the "concentration" of the blood, gets reset to a more concentrated level. This results in an altitude diuresis as the kidneys dump fluid. The reason for this reset is not understood, though it has the effect of increasing the hematocrit (concentration of red blood cells) and perhaps improving the blood's oxygen-carrying ability somewhat. It is normal at altitude to be urinating several times per night. If you are not, you may be dehydrated, or you may not be acclimatizing well.

Persistent hyperventilation (to glean oxygen from the thin air) results in an over-reduction in the level of carbon dioxide (a normal metabolic waste product) in the blood. It turns out that the presence of carbon dioxide is the key signal to the brain that it is time to breathe (the lack of oxygen is a much weaker signal, kind of an ultimate safety valve). As long as you are awake it isn't much trouble to remember to breathe, but at night, an odd breathing pattern develops due to a prolonged argument between these two "respiratory centers" in the brain. Periodic breathing consists of cycles of normal breathing, breath-holding, and accelerated breathing. The breath-holding may last up to 10-15 seconds. This is not correlated with altitude sickness. It may improve slightly with acclimatization, but does not usually resolve until descent.

When acclimatization lags significantly behind ascent, various symptoms occur. Acute Mountain Sickness (AMS) represents the body's intolerance of the hypoxic (low oxygen) environment at one's current elevation.

Who can get AMS? Anyone who goes to altitude! It is primarily related to rate of ascent. No way has been found to predict who is likely to get sick at altitude. There is no prevalence based on age, gender, physical fitness, or previous altitude experience. It’s OK to get AMS, but you must be able to avoid the severe, life-threatening forms.

RECOGNIZE AMS. In the context of a recent ascent, a headache, with any one or more of the following symptoms above 2500 meters (8000 feet) qualifies you for the diagnosis of AMS:

• Loss of appetite, nausea, or vomiting
• Fatigue or weakness
• Dizziness or light-headedness
• Difficulty sleeping
• Confusion
• Staggering gait

The key to avoiding AMS is a rational ascent that gives your body time to acclimatize. People acclimatize at different rates, so no absolute statements are possible, but in general, the following recommendations will keep most people from getting AMS:
At altitudes above 3000 meters (10,000 feet), your sleeping elevation should not increase more than 300 meters (1000 feet) per night, and every 1000 meters (3000 feet) you should spend a second night at the same elevation.

You will get worse, and you might die. This is extremely important - even a day hike to a higher elevation is a great risk. Stay at the same altitude until your symptoms completely go away. Once your symptoms are completely gone, you have acclimatized and it is OK to continue ascending. It is always OK to descend; you will get better faster.

AMS is a spectrum of illness, from mild to life-threatening. At the "severely ill" end of this spectrum is High Altitude Cerebral Edema; this is when the brain swells and ceases to function properly. HACE, once present, can progress rapidly, and can be fatal in a matter of a few hours. Persons with this illness are often confused, and may not recognize that they are ill.

The hallmark of HACE is a change in the ability to think. There may be confusion, changes in behavior, or lethargy. However, it is probably easier to recognize a characteristic loss of coordination that is called ataxia. This is a staggering walk that is identical to the way a person walks when very intoxicated on alcohol. To test for this abnormal walk, have the sick person do a straight line walk (in medical speak this is called the "tandem gait test"). Be fair: do this on level ground, take off their backpack, and don't have them try it in big heavy boots. Draw a straight line on the ground, or have them follow a crack in the teahouse floor. Have them walk along the line, placing one foot immediately in front of the other, so that the heel of the forward foot is right in front of the toes behind. Try this yourself. You should be able to do it without difficulty. If they struggle to stay on the line (the high-wire balancing act), can't stay on it, or fall down, they fail the test and should be presumed to have HACE.

The treatment is immediate descent. This is of the utmost urgency, and cannot wait until morning (unfortunately, HACE often strikes at night). Delay may be fatal. The moment this is recognized is the moment to start organizing flashlights, helpers, porters, whatever is necessary to get this person down. How far down? At least to the last elevation at which they woke up in the morning with no symptoms of AMS. Bearing in mind that the vast majority of cases of HACE occur in persons who ascend with symptoms of AMS, this is likely to be the elevation the person slept at two nights previous. If you are uncertain, 500-1000 meters descent is a good starting point.

People with HACE usually survive if they descend soon enough and far enough, and usually recover completely. The staggering gait may persist for days after descent. If recovery has been complete, and there are no symptoms, cautious re-ascent is acceptable.

Another form of severe altitude illness is High Altitude Pulmonary Edema, or fluid in the lungs. Though it often occurs with AMS, it is not felt to be related and the classic signs of AMS may be absent. Signs and symptoms of HAPE include any of the following:

• Extreme fatigue; breathlessness at rest
• Blue or gray lips or fingertips
• Cough, possibly productive of frothy or pink sputum
• Gurgling or rattling breaths
• Chest tightness, fullness, or congestion

Whereas HACE descent is complicated by confusion and staggering on the part of the victim, HAPE descent is complicated by extreme fatigue and possibly also due to confusion (due to inability to get enough oxygen to the brain). HAPE frequently occurs at night, and may worsen with exertion.

HAPE resolves rapidly with descent, and one or two days of rest at a lower elevation may be adequate for complete recovery. As with AMS, once the symptoms have fully resolved, cautious re-ascent is acceptable.

It is common for persons with severe HAPE to then also develop HACE due to the extremely low levels of oxygen in their blood (equivalent to a continued rapid ascent).

Respiratory depression (the slowing down of breathing) can be caused by various medications, and may be a problem at altitude. The following medications can do this, and should never be used by someone who has symptoms of altitude illness (these may be safe in non-ill persons, although this remains controversial):

• Alcohol
• Sleeping pills (acetazolamide is the sleeping tablet of choice at altitude)
• Narcotic pain medications in more than modest doses

Porters, called Sherpas in Nepal, are just as susceptible to the ravages of AMS as westerners. Porters may be at increased risk of severe forms of altitude illness as they are unlikely to know anything about AMS, are more likely to have a communication barrier to telling their clients how they feel and may even actively hide their symptoms as they fear losing their job due to illness.

The mainstay of treatment of AMS is rest, fluids, and mild analgesics: acetaminophen (paracetamol), aspirin, or ibuprofen. These medications will not cover up worsening symptoms. Descent is always an option, and recovery will be quite rapid.

Trekkers always wonder about how to tell if a headache is due to altitude. Altitude headaches are usually nasty, persistent, and frequently there are other symptoms of AMS; they tend to be frontal (but may be anywhere), and may worsen with bending over. However, there are other causes of headaches, and you can try a simple diagnostic/therapeutic test. Dehydration is a common cause of headache at altitude. Drink one liter of fluid, and take some acetaminophen or one of the other analgesics listed above. If the headache TOTALLY resolves (and you have no other symptoms of AMS) it is very unlikely to have been due to AMS.

Acetazolamide (Diamox) is a medication that forces the kidneys to excrete bicarbonate, the base form of carbon dioxide; this re-acidifies the blood, balancing the effects of the hyperventilation that occurs at altitude in an attempt to get oxygen. This re-acidification acts as a respiratory stimulant, particularly at night, reducing or eliminating the periodic breathing pattern common at altitude. Its net effect is to accelerate acclimatization. Acetazolamide isn't a magic bullet, cure of AMS is not immediate. It makes a process that would normally take about 24-48 hours speed up to about 12-24 hours.

Acetazolamide is not recommended as a prophylactic (preventative) medication, except under specific limited conditions outlined below. Most people who have a reasonable ascent schedule will not need it, and in addition to some common minor but unpleasant side effects it carries the risk of any of the severe side effects that may occur with sulfonamides. Acetazolamide is indicated under the following conditions:

• Treatment of persons with AMS
• Treatment of persons bothered by periodic breathing at night
• Prophylactically for persons on rapid forced ascents (such as flying into Lhasa, Tibet)
• Prophylactically for those persons who have repeatedly had AMS in the past

Acetazolamide Dosage:

For AMS: A dosage of 125 mg every 12 hours. This is 1/2 of a standard 250 mg tablet. This has been shown to be adequate for accelerating acclimatization and minimizes side effects. The medicine can be discontinued once symptoms resolve.

For periodic breathing: 125 mg about an hour before bedtime. The medicine should be continued until you are below the altitude where symptoms became bothersome.

Among trekkers there is a lot of mythology about acetazolamide. Let's clear the air a bit:

MYTH: acetazolamide hides symptoms - Acetazolamide accelerates acclimatization. As acclimatization occurs, symptoms resolve, directly reflecting improving health. Acetazolamide does not cover up anything - if you are still sick, you will still have symptoms. If you feel well, you are well.

MYTH: acetazolamide will prevent AMS from worsening during ascent - Acetazolamide DOES NOT PROTECT AGAINST WORSENING AMS WITH CONTINUED ASCENT.

MYTH: acetazolamide will prevent AMS during rapid ascent - This is actually not a myth, but rather a misused partial truth. Acetazolamide does lessen the risk of AMS, that's why it is recommended for people on forced ascents. This protection is not absolute, however, and it is foolish to believe that a rapid ascent on acetazolamide is without serious risk. It is still possible to ascend so rapidly that when illness strikes, it is likely to be sudden and severe, and fatal.

MYTH: If acetazolamide is stopped, symptoms will worsen - There is no rebound effect. If acetazolamide is stopped, acclimatization slows down to your own intrinsic rate. If AMS is still present, it will take somewhat longer to resolve; if not - well, you don't need to accelerate acclimatization if you ARE acclimatized. You won't become ill simply by stopping acetazolamide.

A Review of the AMS treatment options:

1. What does the acronym AMS stand for?
_______________________________________________________________________

2. Define AMS in your own words:
_______________________________________________________________________
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3. What are some symptoms of AMS?
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4. What are the two types of severe AMS?
_______________________________________________________________________
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5. Describe the best way to acclimatize while trekking:
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6. What is the drug-free treatment for AMS?
_______________________________________________________________________
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7. Name ONE medication a person suffering from severe AMS can be given:
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8. Describe “periodic breathing” and explain how it relates to AMS:
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9. Who is susceptible to AMS?
_______________________________________________________________________

Climbing High: The Early Pioneers

The earliest written accounts of mountain sickness date back nearly two millennia, but even more ancient evidence of the human urge to venture into thin air exists; the Iceman, for example, was found in the Alps at 10,000 feet on the border of Austria and Italy, and appears to have died in a fierce storm some 5,000 years ago. Scientists are still debating precisely what the Iceman was doing high in the mountains, but written accounts clearly reveal the story of the human quest to go higher, and the gradual discovery of our physiological limitations in extreme altitudes.

Over the centuries, we have learned through trial and error, and even through the untimely deaths of those who ventured too high. With the popularity of ballooning in the eighteenth century and, in the middle of the nineteenth century, alpine climbing, many theories about the cause of altitude sickness were advanced. But this century's leap into aviation and space travel has brought with it a much deeper understanding of the human ability to function at altitude.

First century A.D.

The earliest known account of mountain sickness can be traced back to the first few decades of the first century A.D. The account was written by a general to Emperor Wudi of the Han Dynasty: "South of Mount Pishan (in the Karakoram range) the travellers have to climb over Mount Greater Headache, Mount Lesser Headache, and the Fever Hill, where they will develop a fever, turn pallid, feel a headache, and vomit, which also occurs in asses and other animals without exception." In those days, military campaigns, as well as hunting and trading, lured people high into the mountains. Today, scientists are able to attribute such descriptive names of locations to the effects of mountain sickness.

602-664 A.D.

In his research, author Dr. Houston uncovered an early account written by perhaps the world's first mountaineer: "An outstanding early mountaineer was Xuan Zang (A.D. 602-664), a Buddhist missionary, whose Travels to the Western Regions describes crossing passes and climbing mountains in the Tien Shan, Kun Lun, and Karakoram ranges. He really loved mountaineering; his highest climb was Lingshan (6,000 meters), making him the first high altitude climber and probably the earliest true mountaineer. Zuan Zang wrote of this high climb: ‘The journey is arduous and dangerous and the wind dreary and cold. Travellers are often attacked by fierce dragons so that they should neither wear red garments nor carry gourds with them, nor shout loudly. Even the slightest violation of these rules will invite disaster.’”

1590

In Peru, a Spanish Jesuit priest by the name of Jose de Acosta wrote of the ill effects of altitude that he observed in himself and his companions while crossing a high mountain pass in the Andes: "When I came to mount the degrees, as they call them, which is the top of this mountain I was suddenly surprised with so mortal and strange a pang, that I was ready to fall from top to the ground....I was surprised with such pangs of straining and casting as I thought to cast up my heart too; for having cast up meat phlegm, and cholera, both yellow and green; in the end I cast up blood with the straining of my stomach. To conclude, if this had continued, I should undoubtedly have died...I therefore persuade myself that the element of the air is there so subtle and delicate, as it is not proportional with the breathing of man, which requires a more gross and temperate air, and I believe it is the cause that death so much alter the stomach, and trouble all the disposition."

October 15, 1783

The dream of flying was first realized on October 15, 1783 when the balloon "Aerostat Reveillon," carrying Pilatre de Rozier, rose to the end of its 250-foot tether, stayed aloft for 15 minutes, and landed safely. A few weeks later, free flights were made. With the success of lighter-than-air manned ballooning in the years to come (due to the efforts of the French Montgolfier brothers) humans had access to higher elevations than ever before, but no one knew exactly how high humans could ultimately go.

1850

By the middle of the 19th century, ballooning was in full swing and aeronauts were testing their wings in long distance and high altitude flights to explore the dynamics of lighter-than-air flight. Even by this date, little was known about altitude's effect on human physiology. Nonetheless, one author felt free to expound on the therapeutic effects of high altitude on the body. In his book History and Practice of Aeronautics published in 1850, John Wise suggested, perhaps unwisely, "sending chronically diseased persons through the healthy fields of life-inspiring air above the earth."

Wise concluded his book with a chapter subheading that posits "Aerial Voyages are Life Conservative." He wrote: "Now as we rise up in the atmosphere there are two causes acting in beautiful harmony upon the invalid calculated to produce the most happy results. While the most sublime grandeur is gradually opening to the eye and the mind of the invalid -- the atmospheric pressure is also gradually diminishing upon the muscular system, allowing it to expand -- the lungs becoming more voluminous, taking in larger portions of air at each inhalation, and these portions containing larger quantities of caloric, or electricity, than those taken in on the Earth, and the invalid feels at once the new life pervading his system, physically and mentally. The blood begins to course more freely when up a mile or two with a balloon -- the excretory vessels are more freely opened -- the gastric juice pours into the stomach more rapidly -- the liver, kidneys, and heart, work under expanded action in a highly calorified atmosphere -- the brain receives and gives more exalted inspirations -- the whole animal and mental system becomes intensely quickened, and more of the chronic morbid matter is exhaled and thrown off in an hour or two while two miles up of a fine summer's day, than the invalid can get rid of in a voyage from New York to Madiera, by sea."

1862

In 1862 a balloon manned by Sir James Glaisher and a companion by the name of Coxwell flew about as high as the summit of Everest. Glacier's written account of that flight describes in detail the rapid deterioration he experienced the higher they ascended, until the point at which he became unconscious. Glaisher lived to recount the experience (as did Coxwell) which appears in the book Ascent from Wolverhampton:

"I... looked at the barometer, and found its reading to be 9 3/4 inches, still decreasing fast, implying a height exceeding 29,000 feet. Shortly after I laid my arm upon the table, possessed of its full vigor, but on being desirous of using it I found it powerless -- it must have lost its power momentarily; trying to move the other arm, I found it powerless also. Then I tried to shake myself, and succeeded, but I seemed to have no limbs. In looking at the barometer my head fell over my left shoulder; I struggled and shook my body again, but could not move my arms. Getting my head upright for an instant only, it fell on my right shoulder; then I fell backwards, my back resting against the side of the car and my head on its edge. In this position my eyes were directed to Mr. Coxwell in the ring. When I shook my body I seemed to have full power over the muscles of the back, and considerably so over those of the neck, but none over either my arms or my legs. As in the case of the arms, so all muscular power was lost in an instant from my back and neck. I dimly saw Mr. Coxwell, and endeavored to speak, but could not. In an instant intense darkness overcame me, so that the optic nerve lost power suddenly, but I was still conscious, with as active a brain as at the present moment whilst writing this.”

1875

The early pioneers who ventured into thin air flew higher and higher, testing man's adaptability to a rapid ascent to altitude. Unlike mountaineering, where climbers mostly took time to acclimatize, the early balloonists experienced acute exposure to altitude, and some of these attempts proved fatal. The flight of the Zenith from Paris in 1875 resulted in the deaths of two balloonists, Sivel and Croce-Spinelli.

September 2, 1891

Around this time, Dr. Houston wrote: "a young French physician lay desperately ill high on Mont Blanc. He had hurried up from the village of Chamonix to help build a new observatory. The next day he climbed to the summit (4,800 meters; 15,771 feet), and within 24 hours wrote to his brother that, due to mountain sickness, he had never passed so terrible a night. He died three days after arrival, a victim of altitude, and was called 'a martyr to science.' His is the first well-documented case of high altitude pulmonary edema."

Climbing Mount Everest, the tallest mountain in the world, was a challenge that eluded scores of great mountaineers until 1953, when Sir Edmund Hillary and Sherpa Tenzing Norgay first reached its summit. Over the next three decades, more "firsts" followed, including the first ascent by a woman, the first solo ascent, the first traverse (up one side of the mountain and down the other) and the first descent on skis. But all of these climbers had relied on bottled oxygen to achieve their high-altitude feats. Could Mt. Everest be conquered without it?

As early as the 1920s, mountain climbers debated the pros and cons of artificial aids. George Leigh Mallory, who died on Everest, argued "that the climber does best to rely on his natural abilities, which warn him whether he is overstepping the bounds of his strength. With artificial aids, he exposes himself to the possibility of sudden collapse if the apparatus fails." The philosophy that nothing should come between a climber and his mountain continued to have supporters fifty years later.

In the 1970s, two of its strongest proponents were Austrians Reinhold Messner and Peter Habeler. Messner had achieved considerable notoriety by completing a series of spectacular alpine rock climbs without the use of metal protection pegs. In 1974, Messner teamed up with Habeler, a quiet Mayrhofen guide who shared his philosophy, and the pair proceeded to take the climbing world by storm. Agile and slight of build, they scaled the Matterhorn and Eigerwand faces in record time. In 1975, they made a remarkable ascent of the 11th highest mountain in the world, Gasherbrum, without using supplemental oxygen. By 1978, they had set their sights on climbing Mt. Everest -- without bottled oxygen.

Messner and Habeler quickly found themselves the subject of criticism by members of both the climbing and medical communities. They were labeled "lunatics," who were placing themselves at risk for severe brain damage. The physiological demands of climbing Everest had been studied on previous expeditions, and found to be extreme; in 1960-61, tests conducted on members of an expedition led by Sir Edmund Hillary concluded that oxygen levels at the summit of Mt. Everest were only enough to support a body at rest -- and that the oxygen demands of a climber in motion would certainly be too great.

Despite the controversy, Messner and Habeler continued with their plan. They would climb together with the members of the Austrian Everest Expedition and then make their own separate attempt for the summit. The teams arrived at Base Camp in March of 1978 and spent the next few weeks establishing a secure route through the Icefall, erecting camps I-V and preparing for their ascent.

Messner and Habeler's first attempt began on April 21. They reached Camp III on the Lhotse Face on April 23. That night, Habeler became violently ill with food poisoning from a can of sardines. Messner decided to continue his ascent, without his debilitated partner, and set off with two Sherpas the next morning. Upon reaching the South Col, the three climbers were suddenly trapped in a violent storm. They battled temperatures of -40 degrees Fahrenheit and winds of 125 m.p.h. for two full days. Exhausted from struggling with a torn tent and severe hunger, even Messner later admitted to believing his venture was "impossible and senseless." Finally, a break in the weather enabled the shaken party to descend to Base Camp and recuperate.

Messner and Habeler discussed making one more bid for the summit. Habeler had begun to reconsider the use of oxygen, but Messner remained steadfast, declaring that he would not use oxygen -- nor climb with anyone who was using it. He believed that climbing as high as possible, without oxygen, was more important than reaching the summit. Habeler, unable to recruit a new partner, relented, and the two became a team once more.

On May 6, Messner and Habeler set out again. They reached Camp III (7200 meters) easily and, despite a new blanket of heavy snow, felt ready to move on to the South Col the next day. They were now reaching altitudes where they could expect to feel the effects of oxygen deprivation. Messner and Habeler had agreed on carrying two oxygen cylinders to Camp IV, in case of an emergency, and had also made a pact to turn back if either person lost his coordination or speech.

The next day, it took them only three and a half hours to reach the South Col (7986 meters), where they camped for the afternoon and evening. Habeler complained of a headache and double vision on the climb up, but felt better after resting, even though both men frequently woke up from their naps gasping for air. They forced themselves to drink tea, hoping re-hydration would lessen the effect of the thin air.

At 3 am on May 8, the two woke and began preparing for the day's attempt on the summit. Simply getting dressed took them two hours. The weather was questionable, but they decided to break camp. Since every breath was now precious, the pair began using hand signals to communicate. Progress was slow. Trekking through the deep snow was exhausting, so they were forced to climb the more challenging rock ridges. It took them four hours to reach Camp V (8500 meters), where they rested for thirty minutes. Even though the weather was still threatening, they decided to continue -- at least to the South Summit, which was 260 vertical meters away.

Messner and Habeler now faced exhaustion unlike any they'd encountered before. Every few steps, they leaned on their ice axes and gasped for breath. Messner described feeling as though he were going to "burst apart." As they climbed higher, they fell to their knees and even lay down in an effort to recover their breath.

Upon reaching the South Summit, the pair roped themselves together and pressed on. The wind battered them about, but they saw a break in the sky and were hopeful that the weather would improve. They had 88.12 vertical meters to go. Messner described a feeling of apathy mingled with defiance. They reached the Hillary step and continued, alternating leads and resting three or four times. At 8800 meters they were no longer roped together, but were so affected by the lack of oxygen that they collapsed every 10 to 15 feet and lay in the snow. Messner testified into his tape recorder that, "breathing becomes such a serious business we scarcely have strength to go on." He described feeling like his mind was dead -- and that it was only his soul that compelled him to crawl forward.

Sometime between 1 and 2 in the afternoon on May 8, 1978, Messner and Habeler achieved what was believed to be impossible -- the first ascent of Mt. Everest without oxygen. Messner described his feeling: "In my state of spiritual abstraction, I no longer belong to myself and to my eyesight. I am nothing more than a single narrow gasping lung, floating over the mists and summits."

It took Habeler an hour to get down to the South Col, and Messner an hour and three quarters -- for a distance that had taken them eight hours that very morning. They reached Base Camp, jubilant, two days later.

Messner and Habeler's success puzzled the medical community, and caused a re-evaluation of high-altitude physiology.

Messner would return to Mt. Everest in 1980 to successfully complete a solo ascent -- again without supplemental oxygen.

The Himalayan begins where other mountain ranges leave off. Everest Base Camp is at the foot of the huge mountains, yet it is 1000 meters higher than the highest point in Europe. Your body can adjust to these altitudes, but only if given enough time. Being in a hurry in the mountains of Nepal can be deadly!

The most important change of environment that all human beings are exposed to in high mountain areas is the drop in atmospheric pressure. At the top of Everest, pressure is only 320 hPa, while at sea level it is 1013 hPa (one hectoPascal = one millibar). It is not the breakdown of the gases that make up the air (oxygen, 21%, nitrogen, 78%, rare gases, 1%) that is reduced (because in fact, this remains the same at any altitude), but the partial pressure of each component. This is why the quantity of oxygen that our lungs can absorb falls significantly the higher we go above sea level (nearly 70% less at the top of Everest).

To simplify things, it can be said that at 8 000 m, for example, the gases in the air “penetrate” to the inside of the lungs with less force. It is this lack of fuel to the body that gives mountaineers problems with getting their muscles and brain to function properly. Other elements also play a role in variations in pressure. As the atmosphere is thicker at the equator than it is at the poles, the air pressure there is therefore higher. This explains why at the top of Everest (whose latitude is close to the equator), it is higher than had always been supposed.

This theory had long been the subject of fierce debate until Messner and Habeler* succeeded in climbing the giant without oxygen. The season, variations in zones of high and low pressure, as well as sudden changes of temperature, are all other factors that are of great importance in the phenomenon of pressure variations.

The greatest danger on an expedition, apart from an accident, is acute altitude sickness, usually caused by inadequate acclimatization (the adjustments your body makes as it ascends) to high altitudes. This clinical symptoms of altitude sickness include the following: headaches (96% of cases), insomnia (70%), anorexia (38%), nausea (35%). They may also be associated with breathing difficulties, a dry cough and, sometimes, dizziness or very localized swellings. In 99% of cases, these symptoms can be overcome spontaneously by taking aspirin. Failing this, the best treatment is to go back down a few hundred metres. In 1% of cases, the symptoms may become worse.

You should adjust your schedule so that after 3000 meters your sleeping altitude is no more than 300 meters to 400 meters higher than the previous day's sleeping altitude.

All that is required to ensure a safe trek is a basic awareness of AMS and a willingness to rest or descend if symptoms worsen.

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*Two Austrian climbers first summitted Everest without oxygen in 1978; see First without Oxygen on Everest

Nepalese Sherpas employed by Himalayan expeditions as porters and guides, have an unmatched spirit and positive outlook that has been written about around the world. From the early days of mountaineering, their prowess at high altitude has not gone unnoticed.
It is generally believed that the first person to recognize the value of employing Sherpas for expeditionary work was the Aberdeen physiologist, Dr. A.M. Kellas. In the early 1900’s he spent several months every year exploring the more remote passes and valleys of the Himalayas with trusted bands of Sherpas assisting him.

General Bruce, too, appreciated the hardiness of Sherpas. For the pioneer Everest expeditions of 1922 and 1924 he engaged his porter force from among the considerable expatriate Sherpa community in Darjeeling, India. These men performed so well, climbing and carrying to the highest camps, that it very soon became the custom for all Himalayan climbing expeditions to hire Sherpa help in Darjeeling. A system of registration came into force that contributed to the recognition of Sherpa "Tigers" and the creation of an elite force. Word filtered back to the Sherpa homeland in Nepal, which was out of bounds to Westerners, and every year more Sherpas would make their way to Darjeeling to take on this kind of work.

Sherpa Tenzing Norgay, hearing of the continuing British climbing expeditions to Mount Everest, came to India in 1933. In 1935, at the age of 19, he was picked by Eric Shipton to take part in the exciting reconnaissance he was leading to the Everest area. Tenzing stayed on in Darjeeling and took part in no fewer than seven Everest expeditions, culminating in his successful first ascent of the mountain with Edmund Hillary in 1953. By that time, Nepal was opening up to outsiders, and Sherpas were hired locally and brought down to Kathmandu.

The first ascent of Everest, far from marking an end to interest in the accessibility of the highest point on Earth, opened the floodgates to hordes of other climbers, trekkers, and tourists into the Solu Khumbu region, noticeably changing the local economy and lifestyle of the Sherpa people. With the arrival of modern climbing and the desire to conquer the world's highest peaks, theirs became the gateway culture to Everest and other peaks for visitors in search of mountaineering glory.

Are the Sherpas and other highland peoples physiologically different from the rest of us? Dr. Cynthia Beall, Case Western Reserve University and Physical Anthropology, postulates that there may be a genetic factor involved in Sherpa strength at altitude: "The Everest climbers must not only exert great physical effort to climb the mountain, but do so while under tremendous hypoxic stress. This stress is not something that can be mitigated in the way, for instance, that we would put on extra clothes when we are cold. We must adapt physiologically. How the Sherpas do this more effectively than others has been a puzzle to anthropologists and physiologists, and we don't really have the answer. There is evidence of a gene that allows their blood to carry more oxygen, but there are other factors that affect this, as well."

Consequences: breaking rules results in consequences … some are societal rules and some are natural. It’s all about personal choices. Break curfew - get grounded; climb too high, too fast – get AMS.

You’ve learned what happens to your body when you climb at high altitudes. AMS can kill you. Now you will be researching what happens to your body when you experiment with drugs. Can drugs also kill you?

You can divide your project into sections however you wish. Here are a few ideas:

2. Within the types of drugs, there are also different kinds of the drug. For example, for alcohol you can have beer, wine or hard liquor. You might want to explore the different “brands” as well.

3. What exactly do the drugs do to your body? Be specific!

4. Explore the addictive qualities of drugs. What is addiction? How do you get addicted? What makes you “need” the drugs? How is an “addicted” person’s brain different from someone who is not addicted to drugs?

5. Study someone famous who is/was involved with drugs. What do River Phoenix, John Belushi, Janis Joplin, Chris Farley all have in common? Why has Robert Downey Jr. been in the news so much lately?

6. What is the connection between athletes and drugs? Why do athletes take performance-enhancing drugs?

7. What treatments are available for drugs?

Begin by deciding where you might find information on your topic. You might consider:

• The Internet
• Books
• Magazines, newspaperss
• Computer databases
• Audio and videotapes
• TV and radio programs
• Interviews

As you track down your sources, ensure you make note of:

• where you found or saw the source
• the title of the source
• the author or director
• the page numbers or length of program
• the publisher or producer
• the publication or release date
• the city of publication or release

As you are researching material, you need to be confident of your sources. Ask yourself the following questions:

• Who is the author? Is the author an authority on the topic?
• Does the information seem believable?
• What sources of information has the author used? Do these sources seem reliable?
• What is the author’s point of view about the topic? Is a particular bias shown?
• When was the material published? Is it important that the material be up-to-date?

Although these questions are directed at printed matter, you could use the same criteria to examine non-printed matter such as videotapes or radio programs.

1. To take effective notes of your sources as you research your topic, first decide what is important for your purposes.
2. Your notes are for your own use, so you can devise any kind of individual shorthand that will help you speed up the note-taking process; don’t hand in your rough notes.
3. Although you will likely gather much of your research by making summary notes, remember to copy any material you want to include as direct quotations so that it is identical to the original.
4. Try not to just print stuff off the Internet – you retain/understand information better if you write it out yourself. If you don’t have time to write out your material, then at least use a highlighter to emphasize the important points as you read.
5. As you continue note-taking, you may need to set limits for your topic. Keep your deadline in mind and don’t get overwhelmed!

Be prepared.
As you gather material for your presentation, ensure that you have enough to address the topic, but not so much that you will overwhelm your audience. Keep focused; don’t go off on too many tangents.

Be confident.
Practice delivering your presentation in front of a mirror, on tape or in front of family and friends until you feel comfortable. Practice won’t necessarily make perfect, but it will help prepare you for all of your classmates watching and listening to you.

Prepare a strong, creative opening.
Begin your presentation in a way that interests your classmates. Hook your audience immediately and it will be easier to keep their attention.

Project your voice.
Speak loudly enough for those at the back of the room to hear you. Ask at the beginning of your presentation if everyone can hear you.

Maintain eye contact.
Look at your audience as much as possible and glance down at your notes only long enough to remind you of what you plan to say next. Avoid looking at friends and giggling fits.

Don’t rush.
Speak clearly and slowly so that your audience has the time to consider what you are saying. Don’t think about “getting it over with” – think about “getting it done well.”

Be enthusiastic!
If you sound interested in your topic, your audience is sure to be interested as well.

Involve your audience.
Ask them questions, request their help where necessary (don’t just choose friends), or present them with a mini-survey on your topic. The survey shouldn’t take more than a few minutes to fill out.

Don’t get distracted.
Field questions, but don’t get distracted from your topic at hand.

Use audio or visual materials where appropriate.
A poster, chart, map, taped interview, recorded music and other such materials can help make your presentation more effective. If you feel comfortable with the “traditional” presentation method, then try something new! How about presenting your information as:

• An interview with a famous person or character
• A show-and-tell event
• A local TV personality’s report

Presenters:
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Notes:
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Two things I liked:
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Suggestions for Improvement:
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Overall Impression:
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This checklist will help you to evaluate the members of your group once a group task has been completed. Read each question carefully and circle the number that best describes your answer.

6 = excellent              - more than was expected
5 = very good             - everything that was expected
4 = good                     - most of what was expected
3 = satisfactory           - the minimum of what was expected
2 = unsatisfactory       - needed some improvement
1 = v. unsatisfactory   - needed a lot of improvement

How would you describe your group’s ability to:

COMMENTS:
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