magazine_ Interview
Safeguarding those who save lives
A conversation about the transformation of high-altitude mountaineering, new risks for mountain rescue, and international guidelines for operations at extreme altitudes.
High-altitude mountaineering has changed dramatically – and with it, rescue at extreme altitudes: today, helicopters can fly up to 7,000 meters above sea level, and rescue teams work under conditions that were once unthinkable. But where technology creates new possibilities, the illusion of safety grows – and so does the risk for those who help in an emergency. Hermann Brugger, emergency physician and researcher, talks about dangerous developments in alpinism, overdue international guidelines for high-altitude mountain rescue – and those who are often overlooked at altitude: the Sherpas.
Mr. Brugger, together with your colleague Giacomo Strapazzon and an international team, you have developed new recommendations for rescue operations at extreme altitudes. Why now?
Hermann Brugger: The idea originated in the International Commission for Mountain Emergency Medicine, or “ICAR Medcom.” I have been a member since 1992. We realized that while there are many recommendations for high-altitude mountaineers, there are none for mountain rescue itself. Yet the field of operation has changed enormously. Modern helicopters can now reach altitudes of 7,000 meters in places like the Himalayas or the Karakorum. This not only opens up new possibilities, but also new risks for rescue operations.
Was there a specific event that triggered this?
Brugger: No, not a single accident. It was more the realization that there is a major shortcoming. It is astonishing that since the 1970s there have been guidelines for mountaineers who come from all over the world to climb the highest peaks in these mountains. But no one has thought about the rescue teams. Nor about the Sherpas in Nepal, who have always worked for the expeditions.
The Sherpas are often the first rescuers at the scene of an accident, sometimes literally carrying the injured down on their shoulders and putting themselves at great risk in the process.
Hermann Brugger, long-time emergency and mountain rescue doctor
What role do the Sherpas play?
Brugger: They are the true pillars of high-altitude mountaineering. Without them, there would be no high-altitude expeditions. Designated climbing routes are almost entirely secured by ropes; this is an enormous physical achievement that can be traced back to the Sherpas. They transport equipment, guide guests, and often carry out rescues, literally carrying injured people down on their shoulders. However, they are not trained mountain rescuers and are themselves at great risk – from altitude sickness, exhaustion, and avalanches. There have never been any recommendations on how they can protect themselves, and many of them have died in recent decades. The new guidelines were long overdue for them, too.
Are there problems with finding new recruits?
Brugger: Yes. Many Sherpa families have become wealthy by their standards, but the younger generation sees how dangerous this profession is and is now looking for other career paths – often abroad. This will have a long-term impact on the entire expedition business.
What do you consider to be the most important recommendation when it comes to the safety of rescue teams?
Brugger: Preventing altitude sickness with medication and guidelines on oxygen. Unlike here in the Alps, oxygen deprivation at these altitudes is a major problem. At an altitude of 5,000 or 6,000 meters, the oxygen content in the air drops by half. This has a massive impact on concentration and responsiveness – for pilots, doctors, and rescue workers alike. In a study conducted at terraXcube, (editor's note: Eurac Research's center for extreme climate simulation in Bolzano), we we simulated the effects of these conditions. The results clearly showed that reaction times increased noticeably at altitudes above 4,500 meters. However, this deficit can be almost completely compensated for with additional oxygen supply. This was important evidence for practical application.
At an altitude of 5,000 or 6,000 meters, the oxygen content in the air drops by half. This has a massive impact on concentration and reaction times.
Hermann Brugger
So could you say that oxygen is the most important “medicine” at high altitudes?
Brugger: That's definitely true for air rescue. Because oxygen works immediately. An additional supply compensates for the oxygen deficit almost 100% and reduces the perceived altitude by 2,000 to 3,000 meters – and that makes a huge difference, of course. That’s why we recommend taking oxygen with you for missions at altitudes above 4,000 meters. This is sufficient for short missions where the helicopter only remains at altitude for a short time. For longer missions or those carried out on foot, medication is required.
Which medications are effective against altitude sickness?
Brugger: Two are crucial: acetazolamide, better known as Diamox, and dexamethasone. Diamox helps improve acclimatization and is already very popular with experienced trekkers because it also has a positive effect on sleep quality at altitude. It should be taken especially for planned longer missions because it takes several hours to a day to take effect. Dexamethasone, on the other hand, is a cortisone preparation that works very quickly – ideal for spontaneous missions above 5,500 meters in altitude, where there is no time for preparation. Both drugs are available worldwide. So it’s not a question of resources, but of awareness and disseminating the right recommendations.
Are there also technical limits to air rescue?
Brugger: Yes. The official maximum altitude for helicopters is around 7,000 meters. Above that, flights are only possible with empty aircraft and a minimal crew. In exceptional cases, 8,000 meters has been reached – once, a helicopter even touched the summit of Everest with one of its skids. But such flights are not homologated, i.e., not officially approved.
The guidelines cover not only technology and medication, but also team structures and communication. Why is that important?
Brugger: Because at extreme altitudes, every detail counts. The strain is enormous, the risk is high, and decisions have to be made quickly. Good communication within the team, clear procedures, regular training, and mutual psychological support are crucial. All of this increases safety. These factors are actually standard in air rescue, but at high altitudes they take on a whole new significance.
In the past, it was clear that anyone who went above altitudes of 5,500 meters was on their own. Today, modern technology creates the illusion that you can be rescued anywhere.
Hermann Brugger
More and more people are drawn to high altitudes. What does that mean for rescue?
Brugger: It changes expectations. In the past, it was clear that anyone who went above altitudes of 5,500 meters was on their own. Today, modern technology creates the illusion that you can be rescued anywhere. Expeditions offer all-inclusive packages – with hypoxia training from the comfort of your own home, comfortable tents at base camp, and satellite connections. Many people believe they are safe. But at altitudes above 5,500 meters, there are no more guarantees.
You sound very critical...
Brugger: Yes, because the commercialization of high-altitude mountaineering conveys a false sense of security. Those who pay a lot of money expect to come home safely. In the past, it was clear to mountaineers: “If something happens, I'll stay up there.” Today, many expect to be rescued. This creates pressure, especially on the rescuers, who put themselves in mortal danger as a result.
How were the new guidelines developed?
Brugger: In a process lasting several years, together with colleagues from North and South America, Europe, and Nepal. We evaluated existing literature, analyzed studies, and contributed our own research results. The three studies we conducted in Eurac Research’s terraXcube – at simulated altitude – formed an important basis for this. For the points that were still open such as where there were no studies and therefore no evidence, we formulated questions – so-called PICO questions. These “expert opinions” were provided by the commission and the expertise of its participants. The results were finally approved by the ICAR General Assembly. This means that official international recommendations are now available for implementation worldwide.
The three studies by Eurac Research at simulated altitude
In the “Simulated Acute Hypobaric Hypoxia Effects on Cognition in Helicopter Emergency Medical Service Personnel” study pilots were exposed to a simulated altitude of 4,500 meters. This showed that their reaction times were significantly longer – a critical factor in rescue operations. Link to the scientific publication
In a second study, the pilots were given additional oxygen. The study proved that this completely compensated for the study participant’s cognitive impairments. Link to the scientific publication
The “Effect of Acute Exposure to Altitude on the Quality of Chest Compression-Only Cardiopulmonary Resuscitation in Helicopter Emergency Medical Services Personnel” study dealt with resuscitation at extreme altitudes. It showed that the quality of chest compressions decreases significantly with increasing altitude. Link to the scientific publication
What developments will have the greatest impact on high-altitude rescue in the coming years?
Brugger: Technical developments will undoubtedly continue. Helicopters will become even more powerful, the legal framework will adapt – and one day, rescues will probably even be possible in the summit region of Everest. But this development is also changing the spirit of high-altitude mountaineering. The classic ideal of alpinism is increasingly being abused – for prestige, ego, or career considerations. In the US in particular, it has become a matter of reputation: anyone who has stood on Everest is automatically considered to have the best professional skills – it is almost seen as proof of personal excellence. This has little to do with alpinism in its original sense.
Links to the newly published rescue guidelines: Helicopter Rescue at Very High Altitude: Recommendations of the International Commission for Mountain Emergency Medicine (ICAR MedCom) 2025
Hermann Brugger
Hermann Brugger was a long-time emergency and mountain rescue physician, founder and former director of the Institute for Mountain Emergency Medicine at Eurac Research. He has been a member of the International Commission for Mountain Emergency Medicine (ICAR Medcom) since 1992. Together with Giacomo Strapazzon and experts from Europe, North and South America, and Nepal, he has developed international recommendations for rescue operations at extreme altitudes.
My cookie preferences