Manali - Leh highway, how to avoid AMS?

Yogesh Sarkar

Alright people, there have been enough discussions regarding AMS in itinerary topics related to Ladakh. Lets have one here and spare those itinerary topics, maybe we can make this a sticky so any one going to Ladakh can find it easily and gain knowledge about the dos and don’ts?

To get the things rolling, here is an article on AMS.

High altitude-we all enjoy that tremendous view from a high summit, but there are risks in going to high altitude, and it’s important to understand these risks. Here is a classic scenario for developing a high altitude illness. You fly from New York City to a Denver at 5,000 feet (1,525 meters). That afternoon you rent a car and drive up to the trailhead at 8,000 feet (2,438 meters). You hike up to your first camp at 9,000 feet (2,745 meters). The next day you hike up to 10,500 feet (3,048 meters). You begin to have a severe headache and feel nauseous and weak. If your condition worsens, you may begin to have difficulty hiking. Scenarios like this are not uncommon, so it’s essential that you understand the physiological effects of high altitude.

What is high altitude?

Altitude is defined on the following scale High (8,000 - 12,000 feet [2,438 - 3,658 meters]), Very High (12,000 18,000 feet [3,658 - 5,487 meters]), and Extremely High (18,000+ feet [5,500+ meters]). Since few people have been to such altitudes, it is hard to know who may be affected. There are no specific factors such as age, sex, or physical condition that correlate with susceptibility to altitude sickness. Some people get it and some people don’t, and some people are more susceptible than others. Most people can go up to 8,000 feet (2,438 meters) with minimal effect. If you haven’t been to high altitude before, it’s important to be cautious. If you have been at that altitude before with no problem, you can probably return to that altitude without problems as long as you are properly acclimatized.

What Causes Altitude Illnesses

The concentration of oxygen at sea level is about 21% and the barometric pressure averages 760 mmHg. As altitude increases, the concentration remains the same but the number of oxygen molecules per breath is reduced. At 12,000 feet (3,658 meters) the barometric pressure is only 483 mmHg, so there are roughly 40% fewer oxygen molecules per breath. In order to properly oxygenate the body, your breathing rate (even while at rest) has to increase. This extra ventilation increases the oxygen content in the blood, but not to sea level concentrations. Since the amount of oxygen required for activity is the same, the body must adjust to having less oxygen. In addition, for reasons not entirely understood, high altitude and lower air pressure causes fluid to leak from the capillaries which can cause fluid build-up in both the lungs and the brain. Continuing to higher altitudes without proper acclimatization can lead to potentially serious, even life-threatening illnesses.


Acclimatization

The major cause of altitude illnesses is going too high too fast. Given time, your body can adapt to the decrease in oxygen molecules at a specific altitude. This process is known as acclimatization and generally takes 1-3 days at that altitude. For example, if you hike to 10,000 feet (3,048 meters), and spend several days at that altitude, your body acclimatizes to 10,000 feet (3,048 meters). If you climb to 12,000 feet (3,658 meters), your body has to acclimatize once again. A number of changes take place in the body to allow it to operate with decreased
oxygen.

The depth of respiration increases.

Pressure in pulmonary arteries is increased, “forcing” blood into portions of the lung which are normally not used during sea level breathing.

The body produces more red blood cells to carry oxygen,

The body produces more of a particular enzyme that facilitates the release of oxygen from hemoglobin to the body tissues.

Prevention of Altitude Illnesses

Prevention of altitude illnesses falls into two categories, proper acclimatization and preventive medications. Below are a few basic guidelines for proper acclimatization.

• If possible, don’t fly or drive to high altitude. Start below 10,000 feet (3,048 meters) and walk up.

• If you do fly or drive, do not over-exert yourself or move higher for the first 24 hours.

• If you go above 10,000 feet (3,048 meters), only increase your altitude by 1,000 feet (305 meters) per day and for every 3,000 feet (915 meters) of elevation gained, take a rest day.

• “Climb High and sleep low.” This is the maxim used by climbers. You can climb more than 1,000 feet (305 meters) in a day as long as you come back down and sleep at a lower altitude.

• If you begin to show symptoms of moderate altitude illness, don’t go higher until symptoms decrease (“Don’t go up until symptoms go down”).

• If symptoms increase, go down, down, down!

• Keep in mind that different people will acclimatize at different rates. Make sure all of your party is properly acclimatized before going higher.

• Stay properly hydrated. Acclimatization is often accompanied by fluid loss, so you need to drink lots of fluids to remain properly hydrated (at least 3-4 quarts per day). Urine output should be copious and clear.

• Take it easy; don’t over-exert yourself when you first get up to altitude. Light activity during the day is better than sleeping because respiration decreases during sleep, exacerbating the symptoms.

• Avoid tobacco and alcohol and other depressant drugs including, barbiturates, tranquilizers, and sleeping pills. These depressants further decrease the respiratory drive during sleep resulting in a worsening of the symptoms.

• Eat a high carbohydrate diet (more than 70% of your calories from carbohydrates) while at altitude.

• The acclimatization process is inhibited by dehydration, over-exertion, and alcohol and other depressant drugs.

Preventive Medications

Diamox (Acetazolamide) allows you to breathe faster so that you metabolize more oxygen, thereby minimizing the symptoms caused by poor oxygenation. This is especially helpful at night when respiratory drive is decreased. Since it takes a while for Diamox to have an effect, it is advisable to start taking it 24 hours before you go to altitude and continue for at least five days at higher altitude. The recommendation of the Himalayan Rescue Association Medical Clinic is 125 mg. twice a day (morning and night). (The standard dose was 250 mg., but their research showed no difference for most people with the lower dose, although some individuals may need 250 mg.) Possible side effects include tingling of the lips and finger tips, blur ring of vision, and alteration of taste. These side effects may be reduced with the 125 mg. dose. Side effects subside when the drug is stopped. Contact your physician for a prescription. Since Diamox is a sulfonamide drug, people who are allergic to sulfa drugs should not take Diamox. Diamox has also been known to cause severe allergic reactions to people with no previous history of Diamox or sulfa allergies. Frank Hubbell of SOLO recommends a trial course of the drug before going to a remote location where a severe allergic reaction could prove difficult to treat.

Dexamethasone (a steroid) is a prescription drug that decreases brain and other swelling reversing the effects of AMS. Dosage is typically 4 mg twice a day for a few days starting with the ascent. This prevents most symptoms of altitude illness. It should be used with caution and only on the advice of a physician because of possible serious side effects. It may be combined with Diamox. No other medications have been proven valuable for preventing AMS.

Acute Mountain Sickness (AMS)

AMS is common at high altitudes. At elevations over 10,000 feet (3,048 meters), 75% of people will have mild symptoms. The occurrence of AMS is dependent upon the elevation, the rate of ascent, and individual susceptibility. Many people will experience mild AMS during the acclimatization process. Symptoms usually start 12-24 hours after arrival at altitude and begin to decrease in severity about the third day. The symptoms of Mild AMS are headache, dizziness, fatigue, shortness of breath, loss of appetite, nausea, disturbed sleep, and a general feeling of malaise. Symptoms tend to be worse at night and when respiratory drive is decreased. Mild AMS does not interfere with normal activity and symptoms generally subside within 2-4 days as the body acclimatizes. As long as symptoms are mild, and only a nuisance, ascent can continue at a moderate rate. When hiking, it is essential that you communicate any symptoms of illness immediately to others on your trip. AMS is considered to be a neurological problem caused by changes in the central nervous system. It is basically a mild form of High Altitude Cerebral Edema (see below).

Basic Treatment of AMS

The only cure is either acclimatization or descent. Symptoms of Mild AMS can be treated with pain medications for headache and Diamox. Both help to reduce the severity of the symptoms, but remember, reducing the symptoms is not curing the problem.

Moderate AMS

Moderate AMS includes severe headache that is not relieved by medication, nausea and vomiting, increasing weakness and fatigue, shortness of breath, and decreased coordination (ataxia). Normal activity is difficult, although the person may still be able to walk on their own. At this stage, only advanced medications or descent can reverse the problem. Descending even a few hundred feet (70-100 meters) may help and definite improvement will be seen in descents of 1,000-2,000 feet (305-610 meters). Twenty-four hours at the lower altitude will result in significant improvements. The person should remain at lower altitude until symptoms have subsided (up to 3 days). At this point, the person has become acclimatized to that altitude and can begin ascending again. The best test for moderate AMS is to have the person “walk a straight line” heel to toe. Just like a sobriety test, a person with ataxia will be unable to walk a straight line. This is a clear indication that immediate descent is required. It is important to get the person to descend before the ataxia reaches the point where they cannot walk on their own (which would necessitate a litter evacuation).

Severe AMS

Severe AMS presents as an increase in the severity of the aforementioned symptoms, including shortness of breath at rest, inability to walk, decreasing mental status, and fluid buildup in the lungs. Severe AMS requires immediate descent to lower altitudes (2,000 - 4,000 feet [610-1,220 meters]).

There are two other severe forms of altitude illness, High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE). Both of these happen less frequently, especially to those who are properly acclimatized. When they do occur, it is usually with people going too high too fast or going very high and staying there. The lack of oxygen results in leakage of fluid through the capillary walls into either the lungs or the brain.

High Altitude Pulmonary Edema (HAPE)

HAPE results from fluid buildup in the lungs. The fluid in the lungs prevents effective oxygen exchange. As the condition becomes more severe, the level of oxygen in the bloodstream decreases, and this can lead to cyanosis, impaired cerebral function, and death. Symptoms include shortness of breath even at rest, “tightness in the chest,” marked fatigue, a feeling of impending suffocation at night, weakness, and a persistent productive cough bringing up white, watery, or frothy fluid. Confusion, and irrational behavior are signs that insufficient oxygen is reaching the brain. One of the methods for testing yourself for HAPE is to check your recovery time after exertion. If your heart and breathing rates normally slow down in X seconds after exercise, but at altitude your recovery time is much greater, it may mean fluid is building up in the lungs. In cases of HAPE, immediate descent is a necessary life-saving measure (2,000 - 4,000 feet [610-1,220 meters]). Anyone suffering from HAPE must be evacuated to a medical facility for proper follow-up treatment.

High Altitude Cerebral Edema (HACE)

HACE is the result of swelling of brain tissue from fluid leakage. Symptoms can include headache, loss of coordination (ataxia), weakness, and decreasing levels of consciousness including, disorientation, loss of memory, hallucinations, psychotic behavior, and coma. It generally occurs after a week or more at high altitude. Severe instances can lead to death if not treated quickly. Immediate descent is a necessary life-saving measure (2,000 - 4,000 feet [610-1,220 meters]). There are some medications that may be prescribed for treatment in the field, but these require that you have proper training in their use. Anyone suffering from HACE must be evacuated to a medical facility for proper follow-up treatment.

Other Medications for Altitude Illnesses

Ibuprofen is effective at relieving altitude headache.

Nifedipine rapidly decreases pulmonary artery pressure and relieves HAPE. Breathing oxygen reduces the effects of altitude illnesses.

Gamow Bag (pronounced ga´ mäf) This clever invention has revolutionized field treatment of high altitude illnesses. The bag is basically a sealed chamber with a pump. The person is placed inside the bag and it is inflated. Pumping the bag full of air effectively increases the concentration of oxygen molecules and therefore simulates a descent to lower altitude. In as little as 10 minutes the bag can create an “atmosphere” that corresponds to that at 3,000 - 5,000 feet (915 - 1,525 meters) lower. After a 1-2 hours in the bag, the person’s body chemistry will have “reset” to the lower altitude. This lasts for up to 12 hours outside of the bag which should be enough time to walk them down to a lower altitude and allow for further acclimatization. The bag and pump weigh about 14 pounds (6.3 kilos) and are now carried on most major high altitude expeditions. Bags can be rented for short term trips such as treks or expeditions.

Cheyne-Stokes Respirations

Above 10,000 feet (3,000 meters) most people experience a periodic breathing during sleep known as CheyneStokes Respirations. The pattern begins with a few shallow breaths and increases to deep sighing respirations then falls off rapidly. Respirations may cease entirely for a few seconds and then the shallow breaths begin again. During the period when breathing stops the person often becomes restless and may wake with a sudden feeling of suffocation. This can disturb sleeping patterns, exhausting the climber. Acetazolamide is helpful in relieving the periodic breathing. This type of breathing is not considered abnormal at high altitudes. However, if it occurs first during an illness (other than altitude illnesses) or after an injury (particularly a head injury) it may be a sign of a serious disorder.

There are inherent risks in traveling at high altitude. The information provided here is designed for educational use only and is not a substitute for specific training or experience. Princeton University and the author assume no liability for any individual’s use of or reliance upon any material contained or referenced herein. This paper is prepared to provide basic information about altitude illnesses for the lay person. Medical research on high altitude illnesses is always expanding our knowledge of the causes and treatment. When going to altitude it is your responsibility to learn the latest information. The material contained in this article may not be the most current. Copyright © 1995 Rick Curtis, Outdoor Action Program, Princeton University.

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puppydogben

This is all great information but doesn't it apply more to trekking than the manali-leh road journey. You can't exactly get out of the car/jeep and go down, down, down leaving yourself stranded by the side of the road with nothing to eat and nowhere to stay while everyone else carries on up the pass.
I remember doing the trip back in 2003 and feeling distinctly unwell when we reached the highest point, this was not aided by the driver insisting on driving right behind the next jeep with the windows down and exposing us to all the diesel fumes. When we arrived in Leh I had a splitting headache and was physically sick - the next day I was fine.
What I'm trying to say is you're right that no-one knows how they will react at such heights, there is no practice for it, and for sure, the manali - leh road trip(while stunning) goes too high too quick - you kind of have to put blind trust in the trip. All the advice from the OP is great but really deals more with trekking when you can go at your own pace.

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himadventures

Well that right but a stay of a day in manali and walking in city helps. Drinking water helps and avoid smoking.
A rest day at LEH is always required.

Yogesh Sarkar

Don’t get me wrong, I am not implying that you should follow the above advice. It’s just some thing to get the discussion started and also to ensure that people not only know about personal opinion and experience of other travelers, but also know some “scientific data”.

Both times I went to ladakh I went on my motorcycle so I know exactly what you are talking about and how difficult it is to follow such advice.

First time I went there in 2005 I took a night rest at Manali then at Keylong (got delayed due to Kokhsar bridge) and then at Sarchu before arriving at Leh the next day. On this trip I did suffer from apatite loss and severe headaches and only after spending a whole day in Leh I felt better.

What went wrong?

For starters we ran out of water during the initial accent to Baralacha La, even though my friend trekked down to a small lake to get some water it was too dirty to drink thus we could only use it to wet our mouth and face before we reached Bharatpur.

Second mistake we did was not taking Diamox while going to sleep in Sarchu even though it was becoming apparent we were suffering from AMS. We finally took Diamox at the start of More plains, which was already quite late. But some how managed to rough it out and reached Leh safely.

Second time I went to Leh was in September 2006 and this time I did the Delhi - Manali - Leh route with night stops at Manali and Sarchu. This time I did encounter a little breathlessness and little loss of apatite but nothing as serious as the last time.

What all did I do different this time?

For starters I was carrying 4 liters of water with me + topped up at various places, I also mixed glucose in a liter of water and drank that at regular intervals (every 20 minutes or so a sip of water or glucose) which kept me hydrated and gave me a little more energy than I would have had I been eating three meals a day.

When I stopped at Sarchu I took the Diamox pill before going to sleep and that some what reduce the symptoms in night and even next morning.

I am in no way implying that if you do what I did second time around you will not encounter AMS, however it did work for me and 6 of my friends and I for one plan to do the same when I go to Ladakh this year, no matter what scientific research and documents say.

shahronakm

Yogesh thanks for the info, really appreciated.

Ronak.

karnail

What about alcohol? Shall we totally abstain from alcohol? Will it react, if permissible the time difference etc.

vistet

the medical stuff would have a hard time being published in Princeton , starting with the references to Diamox : the regimen described :
is not used by the HRA, was not used when the document was written (1995) and is not what the guidelines from the International Society for Mountain Medicine.

At the risk of acting the parrot : 24 hours before , stop after three days at max altitude or descent, and talk to your doc before. There is a good physiological reason why there is no point in continuing longer , which leads me to my next point : filling in the blank spots here can give a understanding that leads some positive choices as well.

Starting with respiration : the underlying assumption is that it´s all about oxygen (true , as to symptoms) and that the body will gradually adjust to lowered oxygen content in the blood (it doesn´t) .

Extremely short altitude physiology :

Respiration has two main functions : to regulate acid balance by exhaling carbon dioxide , and oxygen delivery.

Breathing starts normally when carbon dioxide reaches a high enough level in the blood, and stops when it goes low
enough.

Note : yes , oxygen normally doesn´t come in to the equation.

With decreased available oxygen at altitude , oxygen levels in the blood will drop low enough to trigger the second line of defence , breathing will increase and blood oxygen levels will increase. With increased breathing comes also increased elimination of carbon dioxide , which gives a shift in acid balance (more alkaline blod) which ... acts as a brake on breathing. Taking Diamox leads to a new shift in acid balance (more acidic) which allows increased breathing again.This is why it works against periodic breathing (remember , breathing stops when carbon dioxide drops enough) , and speeds up acclimatisation. It is not as the Princetonian would have us believe , a treatment of symptoms , it attacks the underlying cause of the brake on the respiratory drive. After three days the body effects a third shift in acid balance by increasing the output of alkali substances via the urine , making it unnecessary to continue with the medication.

Practical perspective on the above : you need to ascend to a first level that is high enough to trigger oxygen drive instead of the normal carbon dioxide, yet is safe .. what is safe ?

Doh : there is something the large majority here can say right away : we know something of how we react to 8000 feet , because we we´ve flown a plane . Cabin pressure equals 8000 , in some cases 7000, feet.

This is 8000 feet sitting up , lung function will take a dive when you lie down as peripheral alveoli collapse , even more so with increasing weight (the abdomen pressing against the lungs) . Thus the the night time problems , and the stress on sleeping elevations .

Conclusion : if you have flown in to India , don´t dawdle in in Delhi, go for Manali , and take a trip up to the Rothang the second day. It would also be interesting to hear about how the accom situation is in Solang , sleeping 500 meters higher is obviously a good point. The single most important thing you can do to for comfort if not for safety is not to spend your second night on the road in Sarchu , at 4290 meters. You have three options at around 3300 meters , Keylong , Jispa and Darcha. Keylong has the widest range of accom, Darcha (basic dhabas) is closer to the midpoint of the road.

Too high , too fast ... hear , hear ! But expecting all of the changes involved taking place within three days is wildly optimistic. I did make a informal poll at my workplace about how long it takes to produce a red blood cell , with all the intervening steps , including a hematologist, and all agreed that it´s closer to a week. The red blood cell concentration does increase faster than that , though , the reason being the high urine output mentioned above and recognised by most with high altitude experience. If you pee a lot , you will concentrate your blood and have more tightly packed red blood cells delivered at your tissues. (Diamox is also a diuretic). Overdo the peeing thing and you get dehydration head ache - your basic hangover. This is where the water myth starts , I guess : since some headaches are caused by dehydration , the conclusion is drawn that AMS equals dehydration , and thus huge amounts of water will protect you against AMS. This is working against the body . Treat dehydration ( if you have a head ache that goes away after downing a liter of water , fine, but don´t expect anything good coming from adding extra liters after that) .

You´ll also find that no specialists in the field advocates large fluid intake , instead there are warnings against the concept :

(From the Himalayan Rescue Association website)

Useful links :
Prevention & treatment of AMS - guidelines from International Society for Mountain Medicine

AMS on Himalayan Rescue Association

"Altitude Illness" short extremy practical handbook, not just AMS but wilderness first aid as well.

vistet

Alcohol is a diuretic , enough of that going around in the body already. More importantly it also depresses breathing.

vistet

Actually , the one time it started to go horribly wrong I seriously considered it , and had the pack to pull it off. In the end I was incapable of leaving the guy next to me , who had progressed from violent vomiting and and massive ataxia to unconsciousness , behind , or the Tibetan baby in the next car who stopped crying.

So now you know why I can become a bit obsessive on the subject.

After that experience I made sure to acclimatise better : on the next trip I had one day extra in Keylong as well, and last time I The main had been trekking around the 3000 meter mark in Kinnaur before, and stopped in Darcha for the night.

Acclimatisation around 2000 meters gives some protection , but not much : the difference between me and the severe case was that I had spent two weeks in Dharamsala before .. and he a couple of days. All in the jeeps were affected , including the Tibetan family from Manali, with the exception of the driver who just had returned from Leh.

Summing up what I believe is important :

Simmer in Shimla , or bask at the Beas
You really need that extra day (or more to the point , that night)around 2000, either in Manali or elsewhere. One option from the Delhi end is to take the night train to Shimla via Kalka , and then take the bus to Manali.

Climb high , sleep low , Manali-style

The main advantage of a second day in Manali is that you can start the acclimatisation response by going high, and return to lower sleeping elevation. HPTDC buses leave for the Rothang La at 10 am. You might even fit in some snowball warfare at the top.

Secondary Sarchu sleeping sucks

Don´t make Sarchu your second sleeping elevation : at 4290 meters this is light years away from safe ascent rates. Keylong (wide range of accom) , Jispa and Darcha are all around 3300, few will have problems with this altitude after Manali.
I went on my own the second time , and using the local bus was a breeze.If you organise a jeep , the dhabas at Darcha makes the most convenient midway point. The buses in my experience are clunkers with drivers that inspire confidence. With the jeeps you get the opposite.

Drinking , driving & drugs

Don´t get dehydrated , which requires some attention with the lack of appetite that accompanies rapid ascents. Drink enough to keep up a large urine output, clearer than normal urine. If you get a headache , push a liter of fluid : headache gone = dehydration , cured . Headache that persists = AMS. There is no point in pushing fluids beyond this , it may slow down acclimatisation and present some risk.
Don´t use things that affect your fluid balance (alcohol works as a diuretic ), depresses breathing (sleeping pills, alcohol, ganja) or impairs lung function (tobacco). Garlic has a proven positive effect on respiration , but don´t expect miracles.

If you do the cannon ball run , the all nighter drive for Leh (around 20 hrs) you will zip past the problem of sleeping at 4200+ .. but you should be aware of the possibility of getting snagged even higher. This is what turned my first trip in to a horror tale , and it´s far from a unique experience.

Medicating with acetazolamide (Diamox)(something you obviously should talk thru with your doc ) in this context means either prophylaxis (start 24 hrs before , stop after descent ) or treating after it has become a fact , with double dosage. Prophylactic dosage removes the concern that you are not able to spot the symptoms because your judgment is affected - something which is a fact of life in some measure every time you go really high. See the earlier link for dosages and contra indications - but talk it over with a doc !

Lastly , don´t
pollute your environment : all food that produces gas , also means that these gases will expand as the air pressure drops . One of the non-glamorous aspects of Himalayan forays : HAFE , high altitude flatulent emission. Now you know why they drive with open windows..

vistet

Update , or rather a flash of realisation : the HPTDC buses apparently also stops in Keylong over the night , which means sleeping almost 1000 meters lower than in Sarchu.

lehlover

Hi Vistet,


I hope you remember that you had advised me for taking Coca 6x during my trip to leh.

Now the issues is I am unable to find coca 6x anywhere. The doc suggested me to take Coca 30 instead of 6x. Will it work? What should be the dosage?

AvidTrekker

vistet recommending homeopathic meds???

It was someone else, certainly not vistet...
.
.
.

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lehlover

You are right Avid. It was bhaswaran (I hope i got the spelling right, forgive me if its wrong) and not Vistet.

hitanshu

FWIW, here's my tuppence.

Did the Manali Leh route in three days: Manali, Keylong, Pang, Leh.
Took diamox as preventive at Keylong, Pang (before sleeping).
Took one disprin in morning at ZingZingBar, Pang.
Was drinking rasna water (basically sugar syrup) all through.

Zero AMS, no symptoms whatsoever. But yes, it helps to be paranoid and take the right precautions.

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four by four

I live in Shimla at an elevation of 7000 feet. I had gone to Leh by Jeep then by Bus in the year 2003. I had taken Homeopathic medicine called Giniko Biloba in liquid form and the doc had given me some tablets to eat namely (as written on the bottle) ARS/Bell/Aco/30. I felt quite fine even at khardungla(droveup on a Bajaj M/cycle ATX 4 stroke 100cc), though I did not try to walk too much once I reached the top, It was tiring. It was the same during the 6 days that I spent reaching, roaming and coming back from Ladakh.
Has anybody else tried this medicine? do send in your comments. I intend going this year with my brother who lives in the plains. Its mostly for him.
Thanks