Kidney Function at Altitude: An Interview with Nephrologist Dr. Andrew Brookens

How much do you know about the role your kidneys play? Does elevation affect their function? How do your kidneys help you adjust to high altitude environments?

The remote mountain communities have a new hero. Altitude Kidney Health just opened their practice at Ebert Family Clinic in Frisco, Summit County, Colorado this week. Dr. Andrew Brookens, a native Coloradan, grew up in the Denver suburb of Englewood, and spent years living at twice the altitude in Bolivia with the Peace Corps before dedicating his career to bringing his current legacy of accessible kidney health care back to Colorado. His passion for providing service to the Colorado high country and beyond and his appreciation for his cross-cultural heritage is powerful in a recent talk between patients and publicizing.

What do you want people to know about you and your background?

I was born in Englewood, Colorado, and I knew pretty early on that I wanted to be helping people, in health care. But the first job I took was as a waiter. I thought that was just great.

God bless you! I know just how valuable that is.

But it’s funny, because I don’t consider serving patients too much different than waiting tables and serving clients there. So, what I did was I had to sort out whether I truly wanted it. And I went to college out East, and I decided to do the coursework for medicine and medical school. But I decided at the end of medical school, I think there’s more to life than just going straight through and being a science junkie. So I got a degree in Public Policy and Spanish, and I lived in South America and did the Peace Corps for two and a half year.

I went to Cherry Creek High School in Englewood. I went to Duke University in North Carolina. I went to Bolivia [for the Peace Corps], which was great, because a second goal was to learn Spanish fluently. My grandfather is from Puerto Rico, my grandmother’s from Dominican Republic, and a lot of family speaks Spanish only, and I decided, you know what, I could just go straight on through and be a science junkie, or I can learn a little bit about the world, you know, some of this cross-cultural reality that is in my family. And I decided I just need to figure some stuff out for myself first.

And I’ve heard Bolivia is another undiscovered gem in South America.

Yeah, exactly. Bolivia is one of two landlocked countries in South America. And it has three main areas from the high plains — they call it the altiplano — but it’s up at about 12,000 – 14,000 ft. It’s intense. And it’s totally flat land, as you look out across the landscape. It’s like the Great Plains of the States, but flatter. And then there’s the mountain valleys and then there’s the Lowlands, which are tropical. And so I lived in the mountain valleys at 10,000 ft. And it’s beautiful, and I of course went there to learn Spanish, and I got placed in a village where Spanish was the second language. The first language was Quechua, so I had to learn Quechua to survive!

I did two and half years there doing youth education and local economic development. I worked with women weavers to help them sell their weavings, and market it in the cities. And I worked with the tourism committee to help bring more tourists to their lands, because agriculture was a declining economy, and we wanted to help them develop ways to generate income in their own villages.

I was going to take a new job back there, but I sorta decided to follow a lady back to Colorado, and I landed back in Boulder, where I was waiting tables again! So the relationship ended, and I had a chat with my brother, who’s one of my inspirations, and Peter said to me one day — I called him up and I asked him, “What are you doing?”– and he said, “I just took the MCAT,” and I had this visceral reaction, I remember getting sort of warm in the face, and thinking, “What are you taking the MCAT for? I’m supposed to be taking the MCAT!” And I had no idea I’d felt like that. But it was such a strong reaction, I hung up the phone with him, and I signed up for basically what was med school and the career for the rest of my life that night.

And so I did medical school at CU in Denver, and we were the first class to transfer out from the Denver campus to Aurora. It was a wonderful experience: the peer group, as well as experiencing the new campus and all of the things they had to offer afforded a variety of learning opportunities.

During that experience, I got to travel to the mountains of Colorado and do a clinical rotation in Steamboat [Springs], which was fascinating for me. Because it was about seeing the community and not just seeing the next test and my studies. And as a guy who’s from CO, going out there and seeing what the mountains were like and what the needs were like … one of the docs who I worked with, who’s still in practice there, is this fascinating doctor who trained himself to do some specialty procedures because otherwise he had to send patients down for these procedures who couldn’t afford to spend the night in the city, and it was just complex. And he has pioneered the offering of some specialty services in addition to his general medical practice in that part of the state. It just opened my mind to this reality of what the need is in parts of Colorado and in many states, frankly, that don’t have access or aren’t right next door to a major medical center.

Was he a nephrologist as well?

No, he was a general internist, and he was doing gastrointestinal procedures: colonoscopies and things like that. So that kinda sparked a flame, and I decided to follow my soon-to-be-wife to Seattle where I finished my training. I did Internal Medicine residency, and then kidney, or nephrology, fellowship in Seattle, Washington. And at the end of five years there, my wife, who’s also from Colorado, and I had made a decision … we decided to go back to Colorado. And so we moved back to Colorado in 2016, I took a job with a large Nephrology practice in West Denver [Western Nephrology]. I loved my job, it was a great group of colleagues, and yet I still felt like there was more to pursue, going back to that same experience that I mentioned, which is we could be doing more for our patients who live in the far flung areas of the state.

To ask a patient to come in, driving six hours or five hours from Craig, for a 15 minute visit with me, it felt like the greatest disservice. Why would a patient conceivably wanna lose a day or two, trek all the way down here, pay me to see me, and then maybe return home, maybe not necessarily better off. I just didn’t feel like that was making sense. I don’t wanna be naive about it, but it was my deep-seated belief that we could do more to bring health care to Coloradans everywhere, no matter where they are. And that’s why I decided this is the time. So in late 2018, I decided to resign my position and set out to make this company, which is Altitude Kidney Health. This is the dream that I’ve had all the way back to the days when I thought I wanted to just help people and started waiting tables. I felt like creating a practice that delivers health care to Coloradans like I can no matter where the Coloradans are is … I feel like the luckiest guy in the world.

So as I go through the community evangelizing our new Nephrologist, a lot of people don’t know the term “Nephrology”. What are some things about Nephrology that affect more people than they realize?

I love that. It’s a great question because a lot of providers don’t know some of the things that are most intimately related to Nephrology, too. The kidneys have their hands in tons of pots in the body. Not only do the kidneys clean your blood — so when you pee, that is a fluid that’s made by your kidneys and stored in your bladder until you pee it out. And what it does is it gets rid of waste products and toxins, everything from the breakfast burrito you had to the glass of wine you’ll have tonight.

But in the same way that it cleans toxins out of your body, it’s finely tuning electrolytes. If you watch the Gatorade commercials about electrolytes and things, the kidney has the job of balancing those electrolytes so finely that they really shouldn’t vary more than a couple iotas off normal, and that’s thanks to the kidney. Everything from potassium to acid levels in your blood, sodium levels and the amount of water that’s in your body.

When you feel thirsty, because you haven’t drunk, or because you just had this delicious, massive pizza, or you’re working out, that is your kidney in that signaling process. Kidneys help you understand that you’re thirsty and it’s time to drink.

In addition, kidneys control many functions. Up here at altitude, we know that patients make more blood cells. The kidneys are one of the first steps in the creation of blood cells, which are made inside your bone marrow. The kidneys signal that. We see patients with kidney disease not only suffer from imbalances of electrolytes and a build up of toxins as kidney disease progresses, along the lines of those two main functions I mentioned, when your kidney disease progresses, I see patients start to lose blood cells. They make less and less, and that’s because signals weaken coming from the kidney in patients who have kidney disease. I also see patients develop weaker bone structure or musculoskeletal disease from kidney disease, and that’s something that’s intimately regulated by the kidney because it helps to balance minerals like magnesium and phosphorus and calcium in your body.

And in addition, I think the kidney has its hand in a really key element that most providers are aware of but maybe patients not: blood pressure. Your blood pressure’s regulated in a tight range, and the kidney allows that; it’s the one that determines how long that leash is. How long can it go, how high can it go? Outside of that range, there may be other factors. If you’re truly dehydrated, maybe your blood pressure drops. Or there are other things that can cause your blood pressure to elevate, including aging, and this stiffening of your arteries. But even so, despite all these other processes, the kidney is the main determinant of your body’s blood pressure.

One of the key features I ask all of my patients is about blood pressure. It’s also one of the things we discovered we can do better for patients with because many times we’d ask patients to check their blood pressure, but they either didn’t know how to, didn’t have the system, or didn’t have the time to send the data back to us in the clinic. So that’s one of the things that we’re also [doing], in addition to trying to reach more patients: using a clinic in the mountains and Telehealth, so that we can see any patient any day. We also have a blood pressure recording system, so that way, patients who get one of these kits from us can simply step on a scale or record their blood pressure, and instantaneously, that data point is sent by bluetooth to our clinic.

I think that’s something, because what I’ll find is patients who don’t necessarily have known kidney disease, but they’ve maybe dealt with blood pressure for years, and they’ve found it harder and harder to deal with or control over the years. Those are patients who would greatly benefit from a kidney analysis or kidney care and blood pressure management. That’s what we can do.

Good segue: I wanted to ask you more about the tools that you use as a Nephrologist that might be distinct to your practice. Up in the mountains, we’re obsessed with pulse oximeters, because we’re constantly watching blood oxygen saturation. Is there anything else that you use specific to your practice?

The pulse oximeter is something we use also, especially because it relates to the oxygen-carrying capacity of the blood or how much blood you have. And it also relates to how the kidneys are balancing and helping manage what your respiratory status is. So we look at that.

The blood pressure is the most important vital sign for me. Weight is the second most important vital sign for me. The reason that’s second most important is because many patients who get blood pressure or have heart disease, and patients who have certain types of kidney disease, will get swelling. I’ll sometimes see my patients gain 5 lbs. in a day or two, and that’s all from salt in the diet and swelling. So weight and measuring your weight, especially if you’re a person who’s swelling, is a big deal because these are patients who — we especially see it after a big barbecue or holiday meals, where food is delicious and salty — those are the patients who are most vulnerable. We’ll see those patients have a much higher risk of having blood pressure changes and even becoming sicker to where they are hospitalized. With close monitoring of their blood pressures at home, we can often take patients who’ve been in and out of the hospital once, twice, or even ten times in a year, and we can help them stay out of the hospital, just through close monitoring and prevention.

So what we do is our nurse at the clinic will often be in touch with the patients, monitoring their blood pressures and weights, and if the patients don’t notice it, she may notice and … reach out to [them] and tell them, “I’m concerned about the 5 lb. weight gain you’ve had in the past few days,” and then talk through it. If a medicine change is needed, we can make it there on the spot, or whatever else.

In addition, communication and close contact to patients. The Telehealth system we use allows patients to take a kidney appointment from the comfort of their living room couch or office. Or they could go to their local doctor where they live and get on the computer screen with them and have what is a video visit, kinda like FaceTime, and they can dial right into our clinic and access us. And that tool isn’t a clinical tool, but it is an access tool. Access is maybe half the battle. Using that and the remote vitals monitoring collapses the distances between us and our patients to minimal or no barrier.

Is there anything distinctive about how high altitude changes the physiology when the kidneys are concerned?

Love it. So, the kidneys balance acid in the blood. Many patients up at high altitude not only have lower oxygen levels, they may have higher blood counts in order to improve their oxygen-carrying capacity. Especially your typical person who comes up for a ski trip and they’re not used to the altitude. It takes a few weeks for your body to make the blood cells to compensate for that. So those people especially may struggle to survive or breathe up here at altitude. And so the pulse oximeter is helpful.

What happens is when the body breathes faster to get more oxygen, the kidneys compensate. So what you end up doing is … breathing more quickly to get more oxygen, and it also lowers the carbon dioxide and the acid levels in your body, so we end up often seeing that the kidneys … adjust the level of bicarbonate. And bicarbonate is simply baking soda, dissolved in your blood. That’s a kidney response. As you breathe more quickly, you get rid of acid, and then the kidneys will adjust by peeing out some of the bicarbonate or the baking soda.

When you breathe out acid, which is carbon dioxide in your breath, your body becomes more basic. Your body becomes more full of baking soda.

In addition, we also see the kidneys responding through blood pressure changes. I think blood pressure will often fluctuate. It’s probably varying by individual, but we see many patients’ blood pressure increase at altitude. And the kidneys are constantly adjusting and titrating that, too.

So, that being said, what do you advise in general to maintain kidney health?

A lot of patients who don’t have advanced kidney disease are advised, appropriately so, to hydrate well. Many patients might be told to drink more water, and I think, in general, that’s a great recommendation. Many patients who are constantly light-headed or dizzy or dehydrated or don’t drink enough water, they could know it because they’re feeling [that way], or even had an episode where they blacked out or passed out and fell down. These are patients where a little bit more water — I’d even add that saltwater, so broth or a soup — is a great way to treat that, by giving yourself more salt and water, which helps to elevate your blood pressure.

Now, the caveat is patients who have swelling and heart problems would be well-served to avoid extra salt. If it gets more tricky, and patients are thinking, “… this is really too confusing,” that’s where we often recommend having a chat with your regular doctor, and if need be, with a kidney doctor to sort out a personalized recommendation.

The converse recommendation is also true. In patients with advancing kidney disease, hydration is good, but minimizing salt is the most important thing you can do. For patients who have known kidney disease that’s moderate to severe, minimizing salt intake is the number one recommendation.

The number two recommendation for patients with known kidney disease, as well as for patients generally, is “less is more”. I have a number of patients that come into the office who take two Advil or two Aleve, … and maybe they take it two times a day or four times a day. And unbeknownst to them, they’re scarring their kidneys down. Just from taking regular over-the-counter pain relievers. Tylenol has its own risks, but it is far safer as a pain reliever than Advil, Ibuprofen, Neproxin, Aleve, and Motrin and things like that.

Along those lines, many patients will come into my office and I ask them all to bring pills that they take. They may come in with a grocery bag full of twenty supplements, because they go to a naturopath … not to knock on naturopaths. I’m a person who deeply believes in the value of some of these alternative therapies and non-Western therapies. But at the same time, I often see patients in my clinic who, by the time they’re taking more than a couple supplements, are putting themselves at big risk of the two supplements or multiple supplements interacting with each other, or interacting with their life-saving vital medicines that they take, prescribed by a provider. The more pills you take, the more chance there is for a bad reaction. So in general, I find that [with] patients who come to me with kidney disease, I often find myself recommending that they reduce or eliminate supplements. Because some of these supplements are known toxins to the body or kidneys, even though they may help you with cholesterol or libido or something like that. But most supplements are not proven, not tested, and they’re definitely not signed off by the FDA. And that is risky to patients.

Speaking of medications, we often advocate for people who are prone to altitude sickness to be on Diamox pretty regularly. As far as we know, it’s very low-risk as far as side effects go. Does it pose any particular risk when it’s taken often?

The two things Diamox does, that I understand, to help you with altitude sickness is it gets rid of fluid — it’s a diarrhetic — and it also gets rid of bicarbonate, the baking soda in the body. It actually helps that process of adjusting the body in response to going up to altitude. For patients who hydrate well and don’t have that risk of falling down from low volume or depletion, commonly known as dehydration, Diamox should be fairly safely tolerated There are not a lot of known allergies.

Recently, I’ve come to know a couple people who have lost or donated a kidney. Have you ever encountered patients with “phantom pains” where a kidney used to be?

That’s a great questions for a couple reasons. Phantom pains occur. There are some rare cases where patients who get phantom pains from surgical removal of an organ would be well-served to return to the surgeon, or a provider that they trust, and discuss about whether they would benefit from repeat imaging.

It’s possible that a fluid bubble, what’s called a seroma, or a complication, like an infection … could arise in that space. Most of the time, phantom pains are things we don’t have a good response for. Again, I think a “less is more” approach is good. And that’s actually why I recommend complementary therapy. In addition to taking the Tylenol, I have many patients that find their pains relieved by acupuncture or massage or other things that don’t put yet another pill in their body.

But it brings up another important topic: patients who progress along the spectrum of kidney disease to more severe kidney disease, where their kidneys start to shut down and are no longer working enough to support them, need some sort of advance therapy known as dialysis to treat them. And not everybody wants or needs dialysis, but for those who do, transplant is a great option. So we often refer patients promptly for transplant evaluation, because the waiting list for transplant is often many years. Standard around the country would be in the order of 3 – 6 years, and in some states, it’s going to be closer to 10 years.

But live donation of an organ, a kidney, is one of the future visions I see for patients with kidney disease. Dialysis is a therapy that is truly invasive: timewise, personally, personal space, blood … it’s really hard on patients, but it’s something that like any skill you learn, like riding a bike, can be learned. I can imagine a world … [where] most of us will be able to donate a kidney and will never know we lost a kidney. We won’t feel it. We won’t suffer the medical consequences of it. And the national transplant registries have changed the order of prioritization of organs such that if you are a person who donates a kidney, in the future, if you suffer a kidney failure yourself, you have a higher priority level for receiving a transplant, because of the gift you gave earlier in life. And that’s really important because a patient who’s facing years of dialysis on that wait list for a transplant, if they ask their friends and family members whether they’d consider being tested to see if they’re a candidate to donate their kidney, I imagine a future world in which few or no patients are on dialysis. The moment a patient is seen to be heading toward needing dialysis, they are prepared for a live kidney transplant, and then they get paired up with somebody across the country or even somebody in their own backyard … who can donate. Once you get a transplanted kidney, you have to be on medicines that control the immune system, but you never have to spend a day thereafter in a kidney dialysis center. And that’s a really useful thing, because many patients don’t have the time, or they risk losing jobs or spending time with their loved ones because of the amount of time they spend on dialysis.

So, the kidney phantom pains are an issue, but truly patients who donate organs are patients who have given the gift of life, and most of the time don’t suffer a single side effect or consequence of that donation. And they should feel like they have the right to follow up with the surgeon or the team that helped them facilitate that to get their needs met or their questions answered, including phantom pains. Because often, that’s something worth looking at.

What do you enjoy doing in your freetime?

I am father of a four-and-a-half year old, so there’s nothing better than spending time with my wife and my son, who I’m now trying to teach to play tennis and ski, because those are my two favorite activities.

Last question: do you have a favorite ski hill?

I don’t. I used to. I grew up skiing Vail and Beaver Creek, but these days, we do everything we can to avoid the I-70 ski traffic on ski weekends. And if that means going to a Front Range ski area, or a ski area off the beaten path, we love exploring the deep reaches of the state. Any day I’m not on my skis or with a tennis racket, you can find me on a road cycle if I’m not at work.

We’re excited to be here. We’re a growing company and have hired another Nephrologist in our practice (Dr. Eileen Fish), so we are always looking to see how we can help communities solve their needs for kidney health.

Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.

Alcohol at Altitude

What causes alcohol to have more influence on you at altitude? Is it the lack of oxygen, the inability of your body to adapt quickly, or is it just a perceived feeling? 

I received my undergraduate degree at the University of Wyoming, found at an elevation of 7,200 ft. Our school always said any opponent who chooses to take us on at 7,200 ft. would surely lose because of the altitude. The same was said for drinking. We would challenge our “sea level friends” to drinking games where they repeatedly lost because of our alcohol tolerance at altitude. 

After several years of living at sea level, I am back at an elevation of 9,000 ft, studying pediatric medicine in Frisco, CO. On the weekends I enjoy having a drink with new friends and coworkers to wash away the weekly stress. As the drinks start flowing, I find myself thrust back into my undergraduate days, but this time I feel like the opponent where a single beer gets me tipsy and I am unable to keep up. 

Beer and Backcountry: Best Friends Forever?

This got me thinking. 

In a study done by Harold S. Ballard, MD, he states “Alcohol has numerous adverse effects on the various types of blood cells and their functions. For example, heavy alcohol consumption can cause generalized suppression of blood cell production and the production of structurally abnormal blood cell precursors that cannot mature into functional cells. Alcoholics frequently have defective red blood cells that are destroyed prematurely, possibly resulting in anemia” (Harold S. Ballard).

Red blood cells (RBC) are responsible for carrying oxygen throughout your body. Anemia is a decrease in RBCs, and this condition can have several symptoms like fatigue, lightheadedness, pallor, and headaches. At high altitudes there is less oxygen, so your body goes into overdrive to produce more red blood cells to compensate. Alcohol interferes with RBC production and thus your body’s ability to carry oxygen to the brain. Is it possible that because of this process you are more affected by alcohol at high altitude? Possibly, but the effects of alcohol on RBCs usually occur with heavy alcohol consumption or chronic alcoholism; rarely does this occur with the occasional beer. 

It has been argued that the effect of alcohol at altitude is more of a perceived feeling of drunkenness rather than a true physiologic affect. Ray Isle, Food & Wine Executive Editor, says that you are not actually getting drunker, but “what does happen is because you’re at altitude – even if you don’t get altitude sickness – you’re still not getting as much oxygen, so you often feel a little lightheaded and dizzy. Combine that with alcohol and you start to feel more messed up than you normally would” (Speigel, 2018). To reduce this combined effect and the feeling of being drunker at altitude, alcohol.org recommends waiting 48 hours after you ascend to start drinking (Staff, 2019).

To further substantiate these findings, a highly acclaimed study completed in 1987 measured the blood alcohol level of individuals at 12,500 feet and those at sea level. When consuming the same amount of alcohol the study found that there was no difference in blood alcohol levels between the two groups (Collins, Mertens, & Higgins, 1987). This suggests that despite the perceived feeling, physiologically, there is no difference when drinking at altitude versus sea level. 

Snacking on the deck of one of Colorado’s backcountry cabins after a mild hike in at over 10,000 ft.

As I sit here completing my single beer that feels like three, I am surprised to know that this feeling has relatively little physiological merit to it. However, I still don’t think I would challenge a high altitude native to a drinking game!

Katherine Peter is currently a Physician Assistant student at Des Moines University. She hopes to work in Orthopedics in Houston, TX following graduation. Throughout her clinical year, she has traveled around the U.S. to several states including Florida, Iowa, Colorado, and Nebraska. She enjoys meeting new people and is always up for a new adventure. 

References

  1. Collins, W., Mertens, H., & Higgins, E. (1987). Some effects of alcohol and simulated altitude on complex performance scores and breathalyzer readings. Aviation, Space, and Environmental Medicine, 328-332.
  2. Harold S. Ballard, M. (n.d.). The Hematologic Complications of Alcohol. National Institute of Health .
  3. Speigel, A. (2018, June 13). How to Drink at Altitude . Retrieved from Food & Wine: https://www.foodandwine.com/news/how-to-drink-high-altitude
  4. Staff, E. (2019, January). Is Altitude Sickness Worse When Consuming Alcohol? Retrieved from Alcohol.org: https://www.alcohol.org/effects/altitude-sickness/

Athletes vs. Amateurs: Observations of an Altitude Expert

Ski America is a company that has organized accommodations and itinerary for international athletes and vacationers at ski areas around Colorado since 1988. The Omori family, Ski America’s founders, lead their clients on tours of Colorado’s most renowned mountains, including Aspen (8,040 ft.), Vail (8,120 ft.), Beaver Creek (8,100 ft.), Copper (9,712 ft.), Keystone (9,280 ft.), Breckenridge (9,600 ft.) and Arapahoe Basin (10,780 ft.).

Ryoko and Jimi Omori

Jimi Omori started Ski America as a tour operator for Japanese skiers and snowboarders. Ryoko joined in 2005, and now Ski America’s service is more than tour operating, assisting from first-time skiers of age 3 to professional racers. With over 30 years of experience guiding amateur skiers and international athletes alike, the Omori’s have made some fascinating observations of how people adjust to the high altitude environment of the Rocky Mountains.

The other day, Ryoko shared some of their valuable insight and experience with me over a cup of tea:

How long do your clients typically stay at altitude?

So we have two different kinds of customers. In November until early December, we have a lot of Japanese racers from Japan. They are high school kids, college students. They stay two to four weeks here, in Frisco or Copper Mountain. Then, from December to April, we have clients from Japan who stay in Vail or Aspen. Most of them are senior skiers, over 60 years old. They stay about a week in Vail or Aspen. Six nights is very average.

How often do you get repeat customers?

Quite a lot. Not all of them come back every year, but more than once. I would say, 70%.

Do you see new customers every year?

Yes.

How do you advertise in Japan?

Word of mouth.

How do you prepare your customers for the altitude?

When I set up the reservation for them, I send them the lodging confirmation and shuttle confirmation, how to get to the Colorado Mountain Express counter at Denver International Airport. With that information, I also send how to get ready for this altitude by e-mail to every customer: Don’t stay up all night before coming over here, don’t overwork before coming here, most importantly, don’t catch a cold before coming over here. That’s the most important thing. And keep yourself hydrated on the flight and on the shuttle. You can always stop at a restroom on the way from the airport to get here. Do not drink a lot [of alcohol] on the flight, and especially on the first night staying here. I encourage them to drink two liters of water a day.

They are so excited to be here, so they tend to forget about the altitude, because there are all the trees, it’s not above the tree line here. In Japan, [this elevation] is way over the tree line. So I always remind them, “You are going to be almost [at the elevation of] Mt. Fuji. So, move slow the first and second day of staying here.”

What about conditioning, physical exercise to prepare? Are they athletic?

They’re pretty much athletic. They’re avid skiers. They ski in Japan regularly. So I do not give them any athletic advice in Japan.

Do they come straight from Denver up to elevation, or do they stay in Denver a certain amount of time?

No. The flight arrives at 12:30 or 1 pm, so it’s very convenient for them to get on the shuttle in the afternoon, and they will be here before 5 or 6.

Do they ski the next day?

Most of them, yes.

What about oxygen or medication? Do you ever tell them to bring ibuprofen or anti-nausea medication?

No. But if anything happens here, I recommend taking [something] for a headache, like Advil.

What is the earliest sign that something might be wrong or that they need medical attention?

Headache. Or sometimes nausea. We had 150 racers last November, and out of 150, I took 5 kids to the clinic for altitude sickness symptoms.

Is it at the beginning of their stay?

Very beginning. [Typically] the second day of skiing. They are okay on the first day. They do not notice anything on the first morning, so they feel, “It’s okay, let’s go skiing!” and spend the day on the mountain, and they have jet-lag, and they can’t sleep well on the second night. And on the second morning most of them notice the symptoms. Those are the Copper clients. And I have 350 guests from Japan staying in Vail and Aspen. Last year, I didn’t see anyone get sick. So it’s only in Summit County, because it’s much higher.

Do you think there are any other correlating factors, like their age or where they’re from?

Age. The racers are from middle school to college, so they’re young. Their hormone level is not stable. And they are staying with their other teammates, apart from their parents, so it could have some emotional factors affecting them, too. But at the same time, the racers have a lot of muscle that needs a lot of oxygen. The higher metabolism that younger kids have [make them] more prone to high altitude sickness. The clients who stay in Vail or Aspen, they are much older, like, 40s, 50s, 60s. And they’re not as athletic as the racers. They do not do any training. So their basic metabolism is low, so I believe they do not need as much oxygen.

Does anyone come from a high elevation in Japan, or is it mostly sea level?

Mostly sea level. Only some of them are from Nozawa, it’s about 1000 m (3,280 ft.), so it’s much lower than Denver.

Nozawa, Japan

Is there a difference between the guests that come from Nozawa and the guests that come from sea level?

No. Whenever I see the doctor in the ER, or the Copper clinic, they always say it’s dehydration. No matter how much we tell them to keep hydrated, it’s not enough.

So what does the ER or clinic often give them besides fluids?

Oxygen. And they say it’s okay to take over-the-counter headache medication.

How long is their visit to the hospital? Is it just a couple hours, or do they stay overnight?

Just a couple of hours, or less than that.

Do they ski the next day?

Most of the time, the doctors say not to ski the next day. We carry a pulse oximeter in our office. We have 20 of them. We do not do this for the Vail clients, because they don’t get altitude sickness. So we only do this for the guests staying in Summit County. When we [check them in], we distribute pulse oximeters, one per room. We encourage them to measure [their oxygen level] every morning. Then, after the doctor’s visit, the doctors say it’s okay if your oxygen level is over 90%, 20 minutes after getting off oxygen.

What’s the lowest you’ve seen the oxygen level on any of your skiers?

38. [He was] 15. He was at the ER. He was transferred to Denver by ambulance. He was there about three nights, and he went back to Japan.

Was that the only time somebody had to go back to sea level?

Yes. But it sounds like he had a heart issue, which we didn’t know [about].

Have you witnessed any other factors that help them acclimate more effectively?

I encourage them to eat carbohydrates instead of getting a lot of oily foods. If you have a lot of french fries, it’s very oily, it will take more time and blood to get to the stomach. So the blood flow doesn’t go through the brain [well].

What about caffeine or other holistic remedies?

No. We have some repeating guests who had … symptoms in past years, and we encourage them to visit a doctor in Japan [who] can prescribe … Diamox. One of the ski coaches [from Japan] … has to be here with his team. He has no choice. And he’s [had] a lot of altitude sickness in the past. So we told him, “You should see a doctor and get Diamox prescribed, and start taking it before leaving Japan,” and it’s been working great.

A young skier shreds her way down a snowy back bowl on a powder day.

Is there a routine that your clients do to prevent feeling this sickness?

Just check blood oxygen level every morning.

Of the clients that come here regularly, do they acclimate quicker each time?

They learn. We always see lower numbers of altitude sickness patients, because they learn what they need to do, like drinking a lot of water and checking their blood oxygen level. And only the numbers can tell. Even if they feel good, if the numbers are bad, if they go skiing, they will have a problem. Especially for the young kids. They [don’t] trust what you say. As the years go by, the coaches will learn, and the kids will learn what they can and what they cannot do.

Is there anything different about the philosophy of treatment in Japan vs. the US?

You know what, we do not have altitude sickness in Japan. Only if you climb up Mt. Fuji, in one day, it could happen, but not everyone does that. The highest elevation of one ski area in Japan is about 2000 m (6,561 ft.). No one has experienced high altitude sickness in Japan.

When I climbed Mt. Fuji, I saw a lot of people with cans of oxygen that you can spray. Do you ever use or recommend that?

No. I don’t think it works. If you breathe it for five minutes, it will work for five minutes. So I guess it’s very effective if a ski racer uses it right before the start [of a race]. I believe some of our Vail clients [have seen] the bottle and have purchased it, but I’ve never heard anything about it, good or bad.

Smiles and high spirits all around

In closing, I asked Ryoko if she’d noticed a change in her own physiology since living at high altitude, to which she replied that she is always impressed by her increased stamina and speed when she steps on a treadmill back at sea level. I asked her if she ever experiences symptoms upon coming back to a high altitude from sea level. “No,” she says, laughing. She doesn’t typically engage in any strenuous activity the first day or two after travelling, “because I’m lazy,” she says.  

Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.

Parkinson’s Disease at Altitude: an Interview with the Locals

In a previous blog post, “Increasing the Altitude to Decrease the Symptoms of Parkinson’s Disease” a PA student described the relief of Parkinson’s Disease (PD) symptoms experienced by arguably the most influential person with PD in the United States, Michael J. Fox. This got the rest of us thinking, could people living in Summit County who may be faced with this debilitating disease have a decrease in symptoms? I was fortunate enough to interview Nancy and Tom, full time residents of Summit county for the past 11 years, who offered insight to this question. When I started this interview, I was seeking only the facts related to PD symptoms at altitude. But within the first couple minutes I knew it was going to be something much different. 

I met Nancy and Tom in a local coffee shop one morning. First, Nancy came in. She was full of energy, articulate, and eager to answer my questions.  She began the story. Nancy is no novice to PD; she has cared for people with the disease twice in her life. First, with her father and now with her lifelong partner. She has experienced similarities and differences over the course of both of their illnesses. 

Nancy’s father lived on the Front Range of Colorado at the time of his diagnosis. He was 75 years old and had some prior health issues including open-heart surgery. He experienced cognitive changes and within 5 years he was living in a nursing home. These cognitive changes were an indication that the disease was severe and would progress more quickly. He became incontinent and quickly found that he could not care for himself. After fighting PD for 10 years, he passed. Nancy’s mother passed just 3 short months after her father.

During this time Nancy was at the height of her career in education, working long hours, in a world that she describes as “publish or perish”. For her, the decline and eventual death of her father seemed like part of the normal aging process. She cannot recall any clear difference in her father’s symptoms when at altitude versus closer to sea level. She says that his decline was much quicker than her husband’s has been.

For many years Nancy and Tom lived in Denver, but also had a home in Silverthorne. In 2008, prior to his diagnosis they moved full time to Frisco, CO. Nancy describes Tom as always being “fidgety”, but even she admits that fidgety is an understatement.  She was really tipped off that something was wrong when Tom would wake up in the middle of the night and “throw himself off the bed” in a fit of a nightmare. This occurred for several years and was so bad that she couldn’t sleep. Sleep disorders are one of the most common non-motor symptoms of PD and usually increase over the course of disease. It was these symptoms that eventually led them to see a neurologist. He was diagnosed with PD approximately 8 years ago. 

As Nancy and I were speaking Tom strolled in to the coffee shop. Tom is 73 years old and the first thing I noticed was that he was a handsome man with an athletic build, but walked with a slight stooped posture. His gait was smooth, but perhaps not as quick as a man his age without PD. This slow gait is a common symptom of PD and medically referred to as bradykinesia. 

As Tom begins to speak his voice is soft and raspy. He says that his brother and nephew speak the same way and he has attributed this to years of yelling during sporting events and coaching. He has even undergone procedures on his vocal cords. However, it’s hard to know why his speech is so soft, as difficulty with speaking is also a secondary symptom of PD.

Tom grew up in Pueblo, CO, which sits at about 4600 ft.  He was always extremely athletic and went to college on a football scholarship. But he’ll tell you he wanted it to be basketball. He was a long time ski instructor, enjoyed golf, and taught middle school physical education. He was always coaching and motivating his students. Nancy describes Tom as well coordinated and unable to sit still. However, in 1993 he was in an accident where he fell while rollerblading without a helmet. He hit his head, which left him with a subdural hematoma. Tom was admitted to the hospital and underwent surgery. He spent weeks in the hospital and endured intense therapy to regain strength for everyday activities including learning how to drive and shower. 

So, the question becomes has altitude ever played a role in Tom’s symptoms? They have traveled and been on planes since his diagnosis. But the short answer seems to be no, he hasn’t noticed a difference. In one account from the previous blog post on PD, a patient noticed a reduction of symptoms when a plane went above 10,000ft. Tom has been on plane several times, with the most recent being last fall where they flew to Maine to visit their granddaughter. He stated that he did not notice any reduction of symptoms at that time. In fact, Nancy reports that both his cognition and mood were exceptional in Maine. When I asked Tom to recall a time when he has noticed a change in symptoms he said only when he misses a dose of medication or when he is not active for long periods of time. Tom takes Sinemet, which is levodopa, a chemical compound that is converted to dopamine when it crosses the blood brain barrier. It’s one of the only medications that quickly and effectively decreases the symptoms of PD, but it does not stop the progression of PD. 

This led us to wonder, has he potentially become acclimated to living at altitude his entire life? He has been at 9000ft for many years; may he not be reaping the full benefits that could come with intermittent hypoxia? Even when he skis at 11,500 ft., which is only a 2500 ft. increase from his baseline, is that not a large enough increase? 

There are still many questions that are unanswered. And there remain reasonable theories about the effects that altitude can have on a patient with PD. For future families like Nancy and Tom I believe it could be a worthwhile avenue of exploration. But for now, Tom’s symptoms will be controlled with medication and exercise. He still skis, golfs and dances. When I asked about dancing, Nancy laughed as Tom reached over to touch her shoulder. Nancy explained that they don’t go out dancing but “We always dance in the kitchen, even when we had a small kitchen and now we have a big one.” 

This blog post was intended to be scientific and related to research, and while we raised several interesting questions during our conversation, it ended up being much more than that. I am grateful to Dr. Chris for introducing me to Nancy and Tom, which sparked the conversation. I will forever be touched by their story. It’s moments like this in medicine that reminds us as students that even as we’re drowning in studying, clinic hours, and trying to pass exams, that humans are behind every patient. Thank you for sharing your story and I hope you keep dancing in the kitchen for many, many years to come. 

Summit County has a Parkinson’s Disease support group that meet on the 3rd Friday of every month at 10am. For more information visit: https://parkinsonrockies.org/get-involved/support-groups/support-group-summit-county/

For another article on Parkinson’s Disease in Summit County check out this story from the Summit Daily: https://www.summitdaily.com/news/summit-county-local-shares-her-experience-living-with-parkinsons-disease/

Karisha Schall is a PA student at Midwestern University in Glendale, Arizona.  During the past year of clinical rotations, she has traveled many places and moved a total of 7 times in Arizona, Colorado, and Washington. After graduation she will be working with the VA hospital caring for Veterans. When not working or studying you can find Karisha listening to music, enjoying the company of family and friends, or finding a way to be active through fitness.  

References:

Loddo G, Calandra-Buonaura G, Sambati L, et al. The Treatment of Sleep Disorders in Parkinson’s Disease: From Research to Clinical Practice. Front Neurol. 2017;8:42. Published 2017 Feb 16. doi:10.3389/fneur.2017.00042

Kumar. “Parkinson’s Disease.” Rocky Mountain Movement Disorders Center, www.movementdisorderscenter.org/parkinsons-disease/. May 1, 2019

Jones, D. “Parkinson’s and Alzheimer’s” Department of Pharmacology AZCOM. Midwestern University Lecture. March 14, 2018. 

Driver-Dunckley, E. “Movement Disorders: What you need to know”. Department of Neurology. Mayo Clinic Arizona. Midwestern University Lecture. May 3, 2018. 

The Benedict Excursion: Testing Your Limits at Altitude

In a previous blog, I described preparing for a trip to the Benedict huts above Aspen, Colorado. After over eight hours of skinning uphill in the snow and two hours snowboarding back down, we are all back home, and I’ve finally cleaned all the pistachios and cookie crumbs out of my car. And yes, it took me eight hours to reach the hut.

I’ve been on numerous hut trips in the Colorado Rockies year after year, and it’s safe to say the trek to the Benedict huts (there are two: Fritz and Fabi) is the most challenging, mentally, physically and emotionally. The winter trail descriptions on the 10th Mountain Division Huts Association website did provide some insight into navigating the route. However, we found the descriptions of elevation gains and mileage to be quite different from the route we took: a winter trail marked by blue diamonds and arrows (a pretty standard trail marking practice).

Even following the appropriate trail markers, there is a crossroads where, looking at a map, we could see that the recommended Smugglers Mountain Road trail was significantly longer than the 10th Mountain trail we decided to take. And even after having taken the shorter route, we hiked about two miles farther than the trail directions had described. Having started at Upper Hunter Creek trailhead, we’d expected to arrive in 4.8 miles, but had long passed 6.

The trail description listed an elevation gain of 2130′, but by the time we reached the hut, we’d gained over 2300′. This isn’t a gradual incline, either. It is important for anyone setting out on this trail to know that you will be climbing the grade of a ski hill the entire way.

Our team came from the Colorado high country and San Francisco. We are all fit, athletic and experienced in various kinds of outdoor recreation. After collecting the San Francisco constituency from the Denver airport, we made a point of allowing a full day to acclimate in Frisco, Colorado, at 9000 ft. Blood oxygen levels were quite normal for people coming from sea level, averaging around 90%. Those concerned about nausea and headaches started taking Diamox, and we all made sure to drink plenty of water and prioritize sleep before setting out on the trail the following day.

By the time we arrived at the hut, it was 8 pm, and the sun had just dipped below the mountains. Sore and sunburned in spite of multiple reapplications of sunscreen, the rest of our evening was devoted to self-care, recovery, and refueling. All the food we had painstakingly carried up was certainly worth it. Our epic journey up the mountain had been fueled by nuts, energy bars, stroop waffles, chocolate chip cookies, and a lot of water. So we immediately got to work lighting up fires to melt snow for our water filtering systems and cooking a hearty sausage and tomato pasta.

Classic hut breakfast on a propane stovetop.

We were sure to feed every craving for calories, because we weren’t about to pack it all back down after what we’d just been through to get it up there. Although I’d planned to do some snowboarding, the following day was mostly dedicated to resting, eating, reading, and games. Frittata with bacon, shiitake mushrooms, manchego and peppers (and of course, pancakes) for breakfast; the aforementioned epic sandwiches for lunch, and loco moco’s for dinner. Plenty of chocolate, cookies, coffee, beer and bourbon to close the calorie gap. And constant water intake. I refused nothing.

Epic hut sandwich.

Hut trips require considerable effort, not only for the traverse and recreation outdoors while you’re in residence, but also for basic necessities. With no running water, snow must be collected in the winter to be melted over a fire you have to build, then boiled and/or poured through a filtering system. There is typically a large supply of wood for these fires on hand, but for less-maintained structures, gathering and chopping wood will also claim a lot of calories.

Recovery on a hut trip must be efficient in order for you to enjoy your time there while also preparing for the trek back out. Stretching, hydrating, feeding your cells nutrients, and sleep are what it’s all about. While the rest seem simple enough, choosing foods to replenish your supply of nutrients and treat any ailments or injuries you may have may take some more thought. As I mentioned in the previous blog on Packing for a Spring Hut Trip, the intense physical challenge of these trips requires energy your body can quickly convert from sugars and caffeine, which make chocolate and coffee easy options. For the time I can give my body to rest and recuperate, I want to feed it denser meals with better nutrient-to-calorie ratios, and this is where I look for proteins and carbohydrates that will take my body a longer time to process.

Stuffing our faces with Dr. Chris. See above for sandwich.

My body will use all these nutrients (including fats) even as I sleep as it repairs and replenishes itself. The extremity of long exposure to the elements stresses your brain as well as the rest of your body, and well-hydrated sleep is one of the best things you can do for it.

Alcohol, as you know, dehydrates the body. But a hut trip without beer and whiskey is not something I’ve ever heard of, so I make sure I continue to hydrate with plenty of water as well. The sugar from alcohol, however, may contribute to your store of energy the following day, but there is definitely a threshold where the amount of consumption contributes more to a disabling hangover. I continue to do more research on the matter.

Being so sore the first night, I was a little concerned about being able to move the rest of the trip. As much as I wanted to just lie down, I know stretching is just as vital to healing muscle mass after strenuous activity, and the combination of ample hydration, nutrient intake and stretching gave our bodies the resources to maximize the time we did spend napping and sleeping the next day. I did manage to get out on my split-board for a mini-tour around the site in the afternoon before dinner the second night, but it hadn’t snowed in the area in a while, and the snowpack was very hard after so many days of warm Spring weather.

The hut sits at the top of the mountain we ascended, so the terrain immediately around it doesn’t get much higher. The area is also pretty heavily wooded in all directions, so building a kicker to snowboard off of was out of the question. The party in the Fabi hut next door invited us to some skiing just a 3-mile hike along a ridge away, but none of us felt like adding 6 more miles to what we’d already trekked.

#activerecovery

I am glad I made a point of skiing around the hut, though. It was a great way to get my blood and breath moving around my body with fresh nutrients. One of the best parts about going on a hut trip is how efficiently it makes you spend your time. Even time lying down doing nothing is just as valuable as time exercising.

Mountain Kate

We set back out to the trailhead early Easter morning. Two nights and two unforgettable days later. We didn’t get any new snow, so those of us who weren’t on snowshoes were skiing/snowboarding down hard-pack. Con – crete. A two hour ski run sounds amazing. This was like two hours of squats. With a backpack on. So that happened.

But it sure beat the hike up! In retrospect, I’d say we packed appropriately. We might have had some extra food for the way down, but we were fortunate that the weather was sunny and warm, and that no sort of emergency required extra rations. I was almost too warm between the daytime sun, and the wood stove at night. But again, the weather could have been worse, and I would have needed every single layer I’d brought. Not mad about that. In a word, “harrowing” was mentioned more than once while on the trip. But no one had to carry any beer or bourbon back.

The high altitude research team from San Francisco.

Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.

Genetics at Altitude: Should pregnant mothers or women who are hoping to conceive sleep on oxygen?

A child in my clinic had a small appendage in front of her ear, called a preauricular tag. I told the mother that I had just returned from a conference where I learned these are more common at high altitude. She replied, “But his father has one also.”

“Yes,” I explained, “There is an interaction between the genes and low oxygen.”     

Birth defects can be increased or decreased by the chronic hypoxia at high altitude. Geneticist Igor Salvatierra from the Hospital Materno-infantil discussed the interaction between oxygen levels and chromosomes at the Chronic Hypoxia conference in La Paz, Bolivia. He focused on a deformity we also see more commonly in Summit County, Colorado at 2800 meters: outer ear deformities – microtia.     Birth defects can be structural, like the outer ear, or functional, such as deafness, and occur in 1 out of 33 infants worldwide. Only 50% of abnormalities can be linked to a specific cause. Club foot is an example of a birth defect that is less common at higher elevations. In contrast, microtia is three times more common, with preauricular tags twice as common as at sea level. This is due to the interaction between genes and the environment.

Research has identified an enzyme called Jarid1B that is affected by hypoxia, including sleep apnea, copy number variation (CNV) and epigenetic factors such as stress and diet. These act on chromosome 1q32.1 to change the coding of proteins involved in the development of ear cartilage very early in fetal development.

At lower altitudes, the hypoxic environment can be caused by sleep apnea. In early pregnancy this could be one of many factors that, if added to the genetic predispostion, could cause a deformity in the fetus. Luckily the fetus is fully formed before the sleep difficulties in late pregnancy.

Should pregnant mothers or women who are hoping to conceive sleep on oxygen?

From what I learned in La Paz, not necessarily. There are factors in our low-oxygen environment that decrease our risk of other diseases.

Acclimatization Vs. Adaptation: Interview with Dr. Alison Brent on “Charting Pediatrics” Podcast

Dr. Christine Ebert-Santos recently sat down with Colorado Children’s Hospital’s Pediatric Emergency Medicine physician, Dr. Alison Brent, to share her experience and expertise in high altitude medicine.

After having practiced for decades in the Commonwealth of the Northern Mariana Islands, Dr. Chris opened her own practice in the high mountain community of Frisco, Colorado, where she has spent 20 years servicing natives, transplants and visitors alike. The mountain communities in Colorado are found at elevations higher than any others in North America, and are among the highest in the world. It has become her legacy to contribute to the research and improvement of medical practice in high altitude environments across the globe.

The full podcast episode from Charting Pediatrics can be found on Spotify, Google Play, and the Apple Podcast app.

Dr. Brent: “I know that sometimes in these South American countries, the high altitude illness impact for children can be even greater than what we see in the US.

Dr. Chris: Well, that’s where you get into ‘acclimatization vs. adaptation’. And what doctors in the United States need to know is that, just because a person lives at high altitude in the United States, we may be acclimatized, but we are not adapted, like the natives of La Paz and Nepal. So therefore we don’t have hundreds of generations changing their genetic adaptation to high altitude. We may have 20 years or 40 years. So the risks are still there.

Dr. Brent: Wow, it’s an amazing process. I know that when I moved to Colorado from flat-lander country, I found that there were just huge textbooks on high altitude illness. And it’s fascinating that you’ve taken this over as a very important part of your career.

Dr. Chris: Yes, well we have 5 million tourists every year coming just to Breckenridge, so it’s probably 10 million to Summit County. Plus, we take care of all the children in the surrounding communities, Park county and Lake county, which are higher: over 10,000 ft. So it’s very important to be aware of anything that can come up in both our visitors and our residents.

Dr. Brent: So this very important topic doesn’t just apply to practitioners who might live in Colorado or other mountainous areas. It really applies to practitioners all over the world who have patients who may travel to these areas. And with that in mind, when you have a practitioner and a family who live near sea level and they’re planning a trip to the mountains, how do they start to advise that family on how to get ready for a trip to a high altitude area?

Dr. Chris: I occasionally do get calls from physicians and families who are planning to bring their children, especially if they have a very young infant or a child with special needs. And so, things that I like to tell them are, Number One: If you could travel by wagon, train or mule, you would be best adapted to high altitude, because arriving to high altitude gradually helps your body adapt.

Second best to that is to stop over an intermediate altitude area. Fly into Denver and spend the night there before you come up to the very high altitude areas, especially Summit County. You start to get altitude symptoms around 8,200 ft. or 2500 m, which is the altitude of Vail. If you’re at a lower resort, most of the other resorts in the United States are below 8000 ft., and the risks of altitude illness are not as great. But the rewards of coming to the Colorado Rockies are also greater, because we have seven world-class ski resorts within an hour of where my office is, so it’s definitely worth it. Just arrive, take your time getting up there, relax, try not to do anything too strenuous the first day.

Consider taking Diamox or acetazolamide; the pediatric dose is 5 mg per kg per day, maximum of 125 BID. This has an effect of increasing your ventilatory drive, and definitely decreases the risk of acute mountain sickness when people come to visit the mountains. It’s best to start the day before, but even starting when you get up there works. And if you go to the Hypocrites app, you will find that it is listed for altitude sickness prevention.

Thirty to fifty percent of people visiting the mountains, especially when you fly right in and drive straight up, will experience some symptoms of acute mountain sickness, whether it’s a little nausea or vomiting or headache. So be prepared with some ibuprofen with dose appropriate to the age of the child, and Zofran would be a good thing to have in your pocket, too. It could save you a trip to the ER or doctor’s office. Because we’re just talking about the first 24 to 48 hours. If you could keep everybody in your travel team comfortable, you will have a great vacation.

Now, once you get there, or if you can before you arrive, we tell everybody, “You should have a pulse oximeter.” It’s just a little finger clip. At our office, they cost $17. Walgreens might sell them for $30 or $36. Knowing that oxygen level tells us everything.

You can call me anytime. I give my cell phone to all my patients, because … we need to know when someone’s oxygen is outside the normal range. If it’s below 90, we may want to see that child or even adult, because we do have family nurse practitioners, more urgently. And that is the key piece of information for knowing how sick someone is, and whether they need to be seen within a few hours or can wait until the next day.

Dr. Brent: Do you just prescribe oxygen if their oxygen saturation is low, or do you like to see them as well?

Dr. Chris: We can send oxygen anytime, day or night. We have three oxygen companies, and I can call them up and give them your number and location. I do, of course, want to see anybody that I’m prescribing oxygen for, but I may not have to see them in the middle of the night. Especially if everything sounds classic. My own patients that I’ve already identified as having a risk for Re-entry High Altitude Pulmonary Edema (R-HAPE), we can just set that up, even ahead of time.

Dr. Brent: You know, one of the things that I’ve noticed popping up in the mountains are oxygen bars, where, essentially, people can use an oxygen concentrator at a bar to relieve some of their symptoms. Should we think about preventative maintenance and getting people coming up here set up with oxygen before they come, or do you like to measure the oxygen saturation before you give oxygen? Because people say they just feel better having a little oxygen in the mountains.

Dr. Chris: Definitely the non-prescribed sources of oxygen, such as the canisters that you can buy in every store and the oxygen bars can help you with your headache and nausea. Use that for 10 or 20 minutes, feel better, that may be all you need.

Dr. Brent: And then what about the kids who you might see who have an oxygen saturation less than 90%, you see them in your office. How does the treatment plan roll out from there?

Dr. Chris: So the biggest concern we have is High Altitude Pulmonaryt Edema (HAPE). Now, don’t be scared, this is less than one percent of visitors, and probably between one and two percent of residents. The risk of developing HAPE is increased in anybody who has an inflammatory process going on, such as a cold or influenza. It definitely can occur in the first 24 to 48 hours in visitors, or even up to five days in our resident children who have a cold or some other underlying illness. So we do want them to have a pulse oximeter. This can develop fulminantly so that they’re doing fine for the first 24 hours or the first 4 days of their cold, and then all of a sudden, they kind of gas out, and they’re just lying on the couch and not eating well. Or it can develop very slowly.

So what we like to do if we know their oxygen is low, and whenever we see them in our office the first thing we do after the history and physical is to try an albuterol treatment and inhalation in case there’s some underlying broncho-constriction or asthma component. That would basically be most helpful in families with a history of asthma, or families that tell me they’ve used albuterol … before with that child or personally. It doesn’t usually change their need for oxygen. But it might help their cough.

However, once we do start somebody on oxygen in the office and call the oxygen company to set up a home concentrator, we see them back the next day and parents will tell me their cough was much better using oxygen. So oxygen is the main treatment. We are always thinking, “Could this person have pneumonia? Could this person have asthma?” Because of my experience at sea-level and taking care of very sick kids, if you have somebody with an oxygen level of 79 or 85, and they had asthma, you would certainly know that. You would hear some wheezing, there would be retractions, rails. They’d be in distress. If they had pneumonia, they’re sick, they’re not eating, they have a fever, you hear vocal changes in their respiratory findings. Most of these kids that we see, both the residents and the tourists with HAPE, we often won’t hear anything in their lungs, because children, how often can you get them to take a deep breath. And we often won’t see anything on the x-ray, so I don’t typically do an x-ray until the following day. If they’re not better and the parents are still concerned, we will do an x-ray. Often the x-ray won’t show anything. And this is where I’m hitting my head against the wall, and why it took me nine years to get my first publication. Because high altitude experts and all the pulmonologists are just freaking out that what I’m calling HAPE, or HARP, High Altitude Resident Pulmonary Edema, often does not show changes in the x-ray, and that I don’t do x-rays on all these hypoxic kids I see, because I know they’ll do fine if they just get some oxygen.

Dr. Brent: I love that approach of less is more, so we totally support that at Children’s Colorado. If you think a child has more than acute mountain illness and they actually have some degree of HAPE or HARP, how do you treat them differently?

Dr. Chris: Basically, oxygen. Now when a family arrives for their vacaction, and they’ve got, you know, ten family members in a condo, and one of the kids is sick, you know, we want to have a low threshold treatment. Influenza: we’re gonna put everyone on Tamiflu so that it doesn’t spread. You know, possible strep throat or is there any possible role for anti-biotics, we’ll have a low threshold.

And then we really sell them on the oxygen. You guys don’t have to leave. Your kid will adjust to the oxygen. We have things on our blog on how to keep your two-year-old from taking off their oxygen canula. That can save your whole vacation if you just understand that oxygen is the treatment, that you don’t have to go downhill.

Every once in a while we do have someone sick enough that we will send them down to Denver, directly to the hospital. But a lot of parents will ask me, “Well, what if I just take my kid instead of putting on oxygen, we’ll go down and check into a hotel in Denver?”

I’m not too happy with that, because I [say] you have to be under medical supervision, you have to know that your child’s oxygen is good once you get to Denver. As long as you’re here in the mountains, I’m your physician, you can call me anytime day or night, we can change our plan if it’s not working. If you’re in the condo and you don’t think your child is doing well, we can put your child in the hospital or send them down to a lower altitude if things are not going well.

Dr. Brent: So Chris, a lot of the literature does say that … one of the treatment plans would be to go to lower altitude, but you’re saying they can just stay in the mountains with oxygen and salvage their vacation.

Dr. Chris: Absolutely. We do it many times, every week at our clinic and in the emergency room. They do it every day, I’m sure.

Dr. Brent: Absolutely. Well, often times, when they do get down to see me in the ED, it’s a pretty easy diagnosis of, usually, some variant of acute mountain illness, and often times they’re better when they get to Denver from when they were up in the mountains. They may no longer have an oxygen need. And those kids who are then going to go back up, I hate to change anything that you or another pediatrician may have done, so we usually just keep them on their oxygen, and if the family wants to try going back to salvage their ski vacation, we let them do that.

Dr. Chris: As long as they have a home pulse oximeter, that little finger clip, they will know when they need to call someone.

Dr. Brent: That is wonderful. You mentioned a few of the co-morbidities that you worry about in children who may have an underlying influenza or some reactive airway disease. Are there other conditions, like kids with Down Syndrome or any other special groups that you worry about?

Dr. Chris: Definitely Down Syndrome children are a concern. Of course, I have many Down Syndrome children in my practice, and they do fine. But Down Syndrome children do have airway problems because of their hypotonia. So they’re more likely to need CPAP or have poor oxygenation during sleep. They’re more likely to have pulmonary hypertension or cardiac defects in general. And they also have increased pulmonary vascular reactivity. So … if you’re going to take a vacation and bring your child to altitude, make sure you have a pulse oximeter and that you are watching them very carefully for signs of decreased energy, poor feeding, color, anything that … is concerning that you as a parent are wondering, “This is not normal for them.”

All children, and even adults, when they come to altitude, they do have a decreased appetite. So that can last for months. Also sleep issues. There’s central apnea that is universal when anyone comes to altitude. Sleep is not going to be the same, and it takes a couple weeks for, actually, your sleep to adjust. But if it’s really interfering, and things are just not going well, we should take a look or consider whether that child is doing okay at altitude.

The other children who should not come to altitude are children who have a cardiac shunt with increased blood circulation in the lungs. That could really put them at risk for HAPE, and children with sickle cell disease. That can be really a crisis, even at altitudes as low as Denver, can cause a problem. So you need to be in touch with someone experienced with your condition if you want to travel with those conditions.

I have read in … articles by Peter Hacket and the other altitude experts not to bring children who are less than six weeks old up to altitude. Here’s the issue: you have a family wedding, everyone’s going there, you want to bring your new baby, they’re probably going to do fine. So I would say, just know where your local pediatrician that you can call anytime day or night is, and that baby will probably be fine.

Dr. Brent: Would you say the same for premature infants?

Dr. Chris: Premature infants, they are probably going to be okay. Once again, we have babies who are born in Denver and come home a few days or a few weeks into their early life experience, and we just check their oxygen in the office, or we can send a respiratory therapist from the oxygen company to their house to check their oxygen. And that is the best way to really keep track of what’s going on. Because babies are used to being in a low-oxygen environment. Remember, the uterus, the womb is like Mt. Everest. The oxygen saturation is 40 – 60%. So they don’t tell us that they’re having oxygen problems. They’re not breathing hard, they’re not retracting, they’re not coughing. They’re just mellow, but they may not be feeding well, so we want to check their oxygen by measuring it.

Right now we don’t have inexpensive ways of measuring oxygen in infants less than one year, but I’m sure that’s coming through very soon. The Owlet is out there, we haven’t found that really reliable at high altitude. But we will be able to measure babies’ oxygen in our office, and sometimes, we will send families home with one of our infant pulse oximeters if we have concerns, and it’s night-time or weekend, and we can spare that piece of equipment.

Dr. Brent: I know we’ve talked about HAPE. Let’s talk a little bit about HACE, or High Altitude Cerebral Edema, which my understanding is just a part of the spectrum of acute mountain illness where you get some vaso-dilation going on in your brain and this can be even worse. How do you evaluate and then treat patients, especially kids you think may have some HACE?

Dr. Chris: So, diagnosing HACE in children, I don’t even know of a case. Because it mostly occurs above 15,000 to 17,000 ft. That is the flurid adult onset where they have trouble walking, talking, thinking, and you’ve got to get them down the mountain as soon as possible. However, the acute mountain sickness HAPE and HACE spectrum, it’s probably a continuum.

So there’s recently an article in the Journal of High Altitude Medicine and Biology or on the Cerebral Volume. And some people have more or less space around their brain. So does their brain expand under the influence of high carbon dioxide from increased ventilation or low oxygen, and that causes the headache and the nause and the vomiting, and is that an early spectrum of HACE that you can treat with oxygen? Babies who are very fussy, just can’t calm them down, just not eating: are they having a form of Cerebral Edema, that they would feel better with oxygen? We really don’t know, but those are things that there are a lot of research going on and providers should think about when somebody gives us a call or comes through the door with their child.

Dr. Brent: That’s good to know. And I know that you have your own practice here and specialize in taking care of kids, so let’s switch gears a little bit to kids who actually live at altitude. There’s so many problems I know at altitude. I think some of the smallest babies in the country are born in Leadville, CO. So how do you handle some of these kids? What are the problems you see? Is it worth the tradeoff to have a small baby who may not grow so well, but to live in the splendor of Colorado?

Dr. Chris: Well I just came back from the Chronic Hypoxia Conference in La Paz, Bolivia, where there were researchers from sixteen different countries, and one of the things that I learned there is that one reason that newborns can tolerate hypoxia during a difficult birth or resuscitation is because they’re coming from a chronic hypoxia environment. And their metabolism and their chromosomes and mitochondria are all switched on to a low-oxygen environment. And that helps them during the first couple weeks of life. So we actually say that probably the detrimental part of living at high altitude is more than counter-balanced by the increased health that we have, decreased myocardial infarctions, decreased strokes, longer active lives. But specifically in our newborns, they have decreased birth weights of about one ounce per every thousand feet of elevation. So our newborns are more likely to be 5.5 to 6.5 lbs. rather than 7.5 to 8 lbs. And about one third to a half of our newborns go home on oxygen based on pulse oximetry studies in the nursery that are less than 90. The Heart Association or the cardiac screening is not even done in our nursery. We are … the exception of the world, because we would have to do an echo- on every baby that we see. So most of these babies go home on oxygen, but I see them in the office when they’re three or four days old, another half of them their oxygen is fine and we tell the parents, “Okay, you can have them off oxygen, but we’ll check them one more time at two weeks before we have the oxygen company pick up the tanks.” So I very rarely have children, newborns, that are on oxygen for more than two weeks. That being said, nobody really knows what’s normal. If I have a child living at 11,000 ft., should that baby be held to the same standard as the kids in Kremmling at 8,000 ft.? Or in Frisco at 9,000 ft.?

We are planning a newborn oximetry study, and we’re in contact with some of the medical device manufacturers to try and get some equipment loaned, so that we can send this home with parents and find out what is normal, and establish our own normal. My normals are based on 19 years of clinical experience. If a baby meets 89 to 90 in my office during a clinical exam while they’re quiet or sleeping or breast feeding, I will tell the parents they don’t need oxygen.

The concerns we have is if the baby is at home for long period of time with low oxygen, the changes that are supposed to take place in the heart and lungs, such as the closing of the PDA and the decreased muscular lining of the pulmonary arteries may not proceed the way they are supposed to. And that process can take up to four months. So that’s why we don’t want to leave our infants with oxygen below 89 for long periods of time. We’re not worried about a few days or a few hours, the oxygen tank runs dry or the canula falls off. We’re not worried about brain damage.

We certainly know … — I’ve been a pediatrician for 40 years — my first 20 years as a pediatrician where we would have parents who refuse surgery for their cyanotic children, and they’d be going to second grade and you wouldn’t know there was anything wrong with their brain, they’d be blue as could be. So those are the concerns that I must address with all parents, because they are going to be terrified about this.

The next thing that is going to cause an issue with these newborns is the grandma in Florida is going to absolutely freak out that her little grand-baby is on oxygen because nobody else in the world understands our situation. We have 30,000 people living in Summit County with 5,000 in each of the surrounding counties, and another 60,000 in Eagle county. Outside of that, there aren’t any communities in North America at this high elevation. So we are the only ones who really have to deal with this. The rest of the doctors and family members are totally mystified by what we’re doing.

The second thing is, not only are they born a little smaller, but we have twice the number of children who are below the normal percentiles on the WHO and CDC growth charts during the first two years of life. So instaed of three percent, we have seven percent. What that tells me is that the whole growth percentile thing is probably shifted downward. We have just analyzed 30,000 data pieces from growth charts from our clinic and the Community Care Clinic in Summit, with the help of the Minnesota Department of Epidemiology, and we are hoping to publish our own unique high altitude growth charts.

The reason this is important is because when our children come down to see a specialist at Children’s Hospital, they get told that they are not feeding their children, and that their children need to see an endocrinologist and have $2000 worth of tests done. Whereas, after my first five years as an experienced pediatrician working with feeding specialists and OT’s watching these kids grow, I decided these were normal, healthy mountain kids. Very important information.

Dr. Brent: And so, Chris, do these kids eventually catch up by the time they’re 8, 10, 12, 16, adults?

Dr. Chris: They catch up by the time they’re 2.

Dr. Brent: By the time they’re 2, perfect. So they’re not shorter than the rest of the kids in the country.

Dr. Chris: Not at all.

Dr. Brent: Just wanted to make sure. Otherwise you might not have such a huge influx of people coming in to Colorado. Anything else you’re concerned about or have to do anticipatory guidance for for kids born in Colorado?

Dr. Chris: In our population, we also see children who have Re-entry HAPE. So during spring break, they go down to visit grandma in Florida, and when they come back they have a cold, and that night, the mom calls me and says, “Oh, he’s coughing and he sounds really congested.” Well, that’s my clue that probably lungs are filling with fluid and that child needs oxygen. So we want people to be aware of that who do live at altitude.

The other thing that I’m just starting to explore is we had a case of a post-traumatic HAPE, where a student from the mountains was going to school in Denver and was hit by a car and had three broken ribs. He was hospitalized in Lakewood overnight, he had a scalp laceration, he had x-rays and CAT scans that did not show anything in the lungs. So he left the hospital at noon the next day with an O2 sat of 94. By 10 ‘o clock that night, his oxygen was 49. He had rails in both lungs, however the x-ray did not show fluid. The emergency room doctor in Summit diagnosed Re-entry HAPE, he was sent back down to Lakewood. He was on 20 liters of oxygen. He was in the ICU, he had a CT scan, which also read as normal, and by the morning, he was on 4 liters of oxygen.

Now, to me and to that ER doctor, the only thing that this could be is HAPE. However, once again, I can’t get this past the high altitude experts and pulmonologists with normal imaging. So I’m throwing a question out there. We need to be sensitive to and start to discover whether there are cases of post-surgical, post-traumatice HAPE. I hear the stories, and that brings us to the blog.

The blog at highaltitudehealth.com. So as I said, it took me nine years to get my first paper published. However, in the blog, you can publish anecdotal and personal stories of your experience with altitude. And it’s out there for people to read and say, “Oh! Maybe that’s what’s happening to me or to my child. Or maybe I should know about that before I make my trip to altitude. Or maybe I should know about that with these children who are coming down to see me from altitude.”

So I highly recommend that anyone who’s interested or visiting or living at altitude read our blog, highaltitudehealth.com. And you can get some ideas and you can make some comments and give us your ideas. And that can lead to further study and research and help us understand these situations.

Dr. Brent: That is a wonderful resource for everyone, and I would hope that our listeners and our Charting Pediatrics family all over the world listen to this. There are so many children that I see in the ER, and when I mention that I think that they have some kind of acute mountain illness, they look at me like I’ve got a fork coming out of my head. They’ve never heard the concept, and … like, “How can my kid be fussy and not eating and not sleeping, and why …?” And they don’t know that. So I think the more we can get the information out there, that would just be wonderful. So glad you’re doing this. I do think that, personally, I get a little bit of re-entry illness everytime I drive from Denver to Vail. I come down Vail pass, I get a little queasy, I get a little headache, and it takes me … a day or two to get back on track, then I’m right back down to Denver and all my symptoms are gone. So, crazy that after 15 years, I still have my little own issues with altitude in this …

Dr. Chris: Well, I have an interesting anecdote that I haven’t put on the blog yet. I made a presentation to our first line, first-responders, and someone came up to me and said that he works in Denver, so he reverse-commutes. And every time he came home on weekends, he would be sick. His primary care physician in the mountains put him on acetazolamide. And that took care of his symptoms. So he’s kind of on chronic acetazolamide, which we’re seeing more and more that this is a very safe medication that you can take when you need it. It doesn’t have to be before you arrive, it can be after you arrive, it can be five days after you arrive. If you’re not sleeping well, you can try this. The only side effects are tingling in the hands and feet, and a very bad change of taste for carbonated beverages.

Dr. Brent: That could be a good thing. I think, I know when my physician talked to me about Diamox, she had mentioned that some of the side effects are headache and GI distress, which is what I had anyway, and I thought, well, why would I want to take a medicine that the side effects are the same as the disease. But you’re saying you don’t see that very often.

Dr. Chris: I have not seen that at all.

Dr. Brent: Excellent. And no issues with kids either. Do you think that, when I see kids in the ER who have some acute mountain illness that I should be starting Diamox at that low dose? The 5 mg per kg on those kids as well?

Dr. Chris: Yes, it doesn’t hurt. And it’s definitely empowering to parents. Just like, for parents to know that they can call me on my cell phone. For parents to know that there is a medication they can give. They may not need to give it, like we give anti-biotics and say, “Okay, if their ear pain gets worse, start the anti-biotic.” More than half of them will never give that anti-biotic. But having the ability to treat your child, you feel so helpless when people are uncomfortable or sick or suffering around you, but having the ability to give them a very safe medication or call somebody for information can really give them a lot of peace of mind.

Dr. Brent: And so my overall message I’m getting from you is really one of empowerment for families taking care of their kids, that there are so many solutions. They can keep their vacation. But the mainstay is oxygen, and in your back pocket you have a little Diamox, and maybe a little Zofran.

Dr. Chris: Yep. And ibuprofen.

Dr. Brent: And ibuprofen. Excellent. One quick question: Is there ever a role for inhaled steroids if there’s some inflammation going on ? You talked about a trial of albuterol.

Dr. Chris: My families whose children have had recurrent HARPE have told me that they do not feel that adding steroids has helped. Now, that being said, all the kids — and I see 30 – 40 cases per year of mountain resident children who have a hypoxic episode during an illness and have to use home oxygen — if they have more than one episode, we do refer them to the cardiologist that comes quarterly to our office to have an echo- at high altitude to rule out any hidden cardiac shunt that could predispose them. But many of these parents will self-refer to one of the many fine pediatric pulmonologists at National Jewish or Children’s Hospital. And when they go there they will inevitably be told that their child has asthma and needs to be on inhaled steroids. They will be on inhaled steroids for a year, and they will not have any more episodes, which they were not going to have anyways. So, there you go.

Dr. Chris at Children’s Hospital in Denver

Dr. Brent: I love that answer.

This has been such a wonderful talk. In closing, I love to ask this of each of our guests here: What is the most rewarding aspect of your practice?

Dr. Chris: My relationship in the community and with the families is so special, because of the small size of our community. I am able to give my cell phone to the families, and I only get a few calls a week. I might be in my office, suturing up a three-year-old and save them the cost of going to the ER, you know, once a month or every second month. But because of this low-oxygen issue, I just feel that it’s important that we touch bases and have access to understanding what’s going on with both children and adults in our community. And I also have appreciated texting, because it’s less invasive, so it’s something that’s not urgent, like a rash or an eye discharge, my patients will text me or sent me pictures. and we are having a Telehealth app coming into our practice too, so that will make it more HIPA-compliant, and more comprehensive care for the Ebert Family Clinic.

Dr. Brent: Well, hopefully we can get all of you at the Ebert Family Clinic on Tiger Connect, and solve all your problems at once. But, Dr. Ebert-Santos, it has been such a pleasure to have you on the podcast today. Your passion is palpable, what you do has such a wonderful impact on kids and their families, not only in Colorado, but those visitors who can salvage their vacation to our beautiful state because of the the things you do. So on behalf of ChartingPediatrics, thank you, and hopefully we can have you on for a follow-up episode sometime in the near future.

Dr. Chris: Yes, when we finish these research studies on newborn hypoxia and normal oxygen values in adults, we’ll have more to tell you.

Dr. Brent: Well, you are on, and we can’t wait. And until next time, keep on keeping kids safe out there!

Packing for a Spring Hut Trip

Another winter has come and gone, and now Spring is in Colorado. Which means Winter will be back a couple more times before the snow all melts.

We’ve organized a team of friends from San Francisco, Denver, and Colorado high country for a backcountry excursion to one of Colorado’s 10th Mountain Division huts. The Benedict huts, our dwelling for two nights tucked into the wilderness outside of Aspen, are almost 6 miles from the trailhead, with an elevation gain of over 2000 ft. : a formidable trek, even for the experienced. And experience in wilderness trekking is one thing, but altitude is a game-changer. We will be well over 8000 ft. long before we reach the huts, so preparation for such an undertaking requires as much attention to mental, physical and physiological condition as much as clothing, gear and rations.

Weather & Conditions

This has everything to do with the weather, so it’s important to be on top of tracking all the resources available to you. At the top of my list in this region is the Colorado Avalanche Information Center. They provide up-to-date reports for high-risk areas around the state according to a comprehensive and easy-to-understand rating system. When considering this information, I always remember that our trek will take us through several types of terrain, and thus, several types of conditions: in and out of trees, varying steepness and exposure (to sun, wind, precipitation, etc.), all kinds of microclimates and environments (wetlands, scree fields).

The Colorado Avalanche Information Center provides no shortage of visuals to aid your risk assessment.

As far as incoming weather patterns are concerned, one of the most popular and reliable forecasts endorsed by people who play outside in Colorado is Open Snow. Founding meteorologist Joel Gratz updates local forecasts regularly, and provides information on what to expect with the outdoor adventurers in mind.

For our upcoming hut trip, it looks like the storm we’re expecting will be warmer and milder than recent systems, with most of it heading toward the northern mountain region. That being said, however, I’m keeping in mind that any projected weather system can be just a few degrees colder, a few inches wetter, and a few miles closer and change conditions dramatically. So let’s talk about how we can anticipate this with …

Gear & Clothing

The Commute

In any season in Colorado, there are essential comforts I always pack to get me to and from any hut that requires a hike, and to keep me happy while I’m enjoying the site. Dead of Winter, Height of Summer alike, the sun and glare is liable to be more intense than anything you’ve ever experienced at sea-level, while at the same time, the temperature and lack of humidity can cool your body significantly, night or day. Depending on how strenuous the commute is or how active you intend to be even after arriving at your destination, you may be constantly shedding, then adding, then shedding, then adding layers, so keep it all very accessible.

For this particular trek, I’ll be in snow gear. Basically anything I’d wear snowboarding: snow pants, outer shell on top, hat, gloves. I want it to be warm and waterproof on the outside. Underneath this shell, I want layers that I can strip down to as soon as I start moving and sweating with a 40 -60 lb. pack on. Unless the storm turns out to be much more intense (in which case, I’ll keep the outer layers on), I expect my skin to be steaming, so I won’t want to be in much more than warm compression tights, a t-shirt, and a light pullover. Your outer shell is for blizzards and water-proofing, so whatever you are stripping down to should be significantly lighter. Also, sunglasses or goggles. The glare from snow is significant. I bring both, because goggles get way too hot while I’m trekking uphill.

Here’s the tricky part: What are you going to wear on your feet? This is where the weather forecast comes in. This time of year, after such a snowy winter, I’m expecting most of the trail to be covered in snow, and the storm moving in is likely to bring more. I will be scoping out the trail pre-storm, which will give me a much better idea of what to expect, but I’m preparing to have snowshoes or a split-board and skins strapped to my snowboard boots. Of course, skis with skins are another alternative. There is a very slim chance most of the snow on the trail will be melted down, in which case I would probably opt for waterproof boots instead, which I would expect to get pretty muddy.

Avalanche Gear

Whether it’s on the commute or while you explore terrain around the hut during your stay, there are some essentials you can pack for the worst-case scenario. I’ve gone into more detail in a previous blog, but standards that I will be keeping on me are a shovel, probe and beacon. But these tools are only a small part of avalanche preparedness. More important than the endless supply of technology you can invest in is knowing what conditions and natural phenomena to be aware of during your trek, and the Colorado Avalanche Information Center is a great place to start familiarizing yourself with these.

Cabin Comforts

There is only one limiting factor to this list, but it is considerable: how much you can carry. For six miles. Uphill. In snow.

Most of the huts in the 10th Mountain Division hut system are equipped with soft mattresses, small pillows, and blankets. The kitchens are stocked with utensils and dishes, there is toilet paper, paper towels, hand sanitizer and dish soap, as well as ample supplies of wood for burning in the wood stoves. So most of your weight will be food and drinks.

I always pack a sleeping bag and extra pillow, because the guaranteed warmth and comfort are worth it when you’ve spent your day being intensely active outdoors. And keep in mind you’ll want warm, dry layers to change into that you haven’t been hiking and sweating in all day. What do you want to be wearing when you’re lounging around the cabin reading, cooking, eating, playing cards, etc.? For me, this looks like socks, long underwear, a pullover and slippers that I can crush into my pack. And then what are you going to throw on when you have to go back outside into the dark cold of night to use the outhouse? Your Colorado uniform: a hoodie.

There won’t be running water, so you can’t expect to shower. When you’re in the wilderness for a long time and need to be discerning about how much weight you carry that isn’t food and water, bathing is of low priority. But for a short trip like this, I don’t mind bringing some form of wet wipes; they’re light-weight and take up very little space. Toothbrush and toothpaste should be obvious, though.

Medication & Acclimation

From climbing Mt. Fuji to Colorado’s 14er’s, I’ve noticed a lot of people bringing pressurized cans of oxygen. High altitude research has taught me just how temporary and unnecessary this trend is. Often, the most effective remedy for altitude sickness is 5 – 10 minutes on oxygen. I’m pretty sure you’ll blow through a whole can of gas-station aerosol oxygen before it does you any lasting good.

Avoid this by giving yourself time to acclimate before you get to extreme elevation. Ebert Family Clinic in Frisco, Colorado, specialists in high altitude research, always recommend keeping track of blood oxygen saturation with a pulse oximeter, and this is something small, inexpensive and very portable. Our team will be spending at least 24 hours at altitude before we embark on the trek to the hut. This way, members from lower elevations will have access to an oxygen concentrator to facilitate acclimation.

Physician and high altitude expert Dr. Christine Ebert-Santos recommends packing the following mediations for hut trips: Acetazolamide, Benadryl, Ibuprofen, an EpiPen, Acetaminophen, and topical antibiotic oinment. Of course, be aware of any allergies to medication in your party. It is also helpful to be aware of what symptoms you may expect to experience, should you start having trouble acclimating, including dizziness, nausea, hyperventilation, and fatigue.

Food & Water

This is where most of the weight you pack in will be. Again, no running water at the hut, so expect to boil all the water you need for drinking if you run out of what you bring. There are lots of compact water purification systems you can easily pack as well. For our six mile trek to the cabin, I will have a Camel Bak and a couple Nalgene-sized thermoses full of water tucked into my pack.

You don’t want to have to cook everything you bring, so snacks you can easily access and eat are essential, especially for the trail. For this particular hike, I expect to burn more calories more quickly than any other average day, so I want lots of nutrients per gram: pistachios, energy bars, jerky … And don’t underestimate the power of sugar and caffeine, this is precisely the kind of work your body acts quickly to convert these nutrients to energy for. And yes, I mean chocolate. (Fruit also contain a lot of valuable sugar, I’m told.)

While we’re at the cabin, we’ll have access to a propane stove, so we’ll be able to cook some hearty meals. Bacon, fruit, yogurt, bagels and cream cheese are all easy breakfast foods to pack. If you are fortunate enough to be on a hut trip with Dr. Chris herself, you will have pancakes at least once. It’s also easy enough to bring fixings for the most epic sandwich you’ve ever had: guacamole, sprouts, turkey, ham, greens, tomatoes, bread; and remember, it’s a good chance to justify all the calories you get from mayonnaise and mustard.

And speaking of calories and sugar, I feel like whiskey and beer were invented to accompany the warmth of a fire in a remote, mountain cabin. The good news is that you are sure to be carrying less out than you did in. The bad news is that hangovers are exacerbated by high altitude, so pay more attention to your consumption than you would at any lower elevation, and be sure to have plenty of drinkable water at hand.

Am I Ready?

Hut trips in Colorado are mentally and physically challenging, even in the best conditions. The more time you give yourself, the better. Know before you go and don’t go alone. And don’t be intimidated. I’ve successfully guided friends from sea-level who don’t consider themselves athletic to destinations well above the tree line without incident.

Always be checking in with your body, your team, and your environment.

Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.

Increasing the Altitude to Decrease the Symptoms of Parkinson’s Disease

By Jessica Thomas PA-S

 In May of 2009 Michael J Fox’s “Adventures of an Incurable Optimist” aired on ABC. This special chronicled his decision to battle the effects of his Parkinson’s disease with optimism and hope. During the production of this special he journeyed to the Kingdom of Bhutan. While in Bhutan, Michael J. Fox noted that his symptoms of Parkinson’s disease had almost completely vanished. 

 Bhutan lies between China and India, on top of the Himalayan Mountains. Bhutan is an extremely unique country since it is cut off from the rest of the world and has a desire to keep its culture unaffected by today’s modernization and globalization. Altitudes in Bhutan average 8-9,000 ft above sea level. When Fox’s parkinsonian symptoms decreased, he couldn’t help but wonder about the connection between the increased altitudes and the decrease of his symptoms. 

With more research into the topic it becomes apparent that Michael J. Fox was not the first person with Parkinson’s disease to notice a difference when in the high altitudes. According to Fred Ransdell, author of Shaky Man Walking, he has had two individual experiences where his tremors almost completely vanished. The first takes place whenever he is flying. Mr. Ransdell states that as the plane gains altitude he will remain completely asymptomatic until the plane lands. The second was when he was driving over a mountain pass at 9,000 feet elevation and he states that at that moment he noticed that his tremors were gone. How can this be? 

The first theory for why the increased altitude (>6,000 ft above sea level) decreases symptoms of Parkinson’s disease stems from the pH of our blood. When at higher altitudes we breathe faster and deeper in order to get enough oxygen into our lungs. When we breathe, our body discards carbon dioxide in proportion to oxygen we take in. Knowing this, it is understood that the increase in breathing also causes our body to get rid of more carbon dioxide from our blood which in turn will raise the blood pH making it more alkaline in nature. Naturally our blood is alkaline (approximately a pH of 7.3-7.4), otherwise death would ensue. Acids in our body are generally cell by-products, meaning that when our body is making energy or other necessities to life, they will give off acids. These acids are processed through the lymphatic system. When we have increased acids in our body the lymphatic system can get backed up. The back-up of acids in the body can cause stiffness, pain, and swelling. As the back-up worsens, deeper problems occur that affect the function of the cells and the tissues which can turn off hormone, steroid, and neurotransmitter production. Although this is an oversimplification of the process, it is easy to see that the more acidic the blood is, the more we may see increased symptoms of Parkinson’s disease. Correction of this acidosis is thought to preserve muscle mass in conditions like Parkinson’s and help with coordination. 

The second theory revolves around hypoxia and the main neurotransmitter that Parkinson’s disease effects. A study published in Springer titled Intermittent Hypoxia and Experimental Parkinson’s Disease found a link between hypoxia and the increase of dopamine synthesis. We know that atmospheric pressure reduces with altitude and with that so does the amount of oxygen. The reduction in the partial pressure of inspired oxygen at higher altitudes lowers the oxygen saturation of the blood which leads to hypoxia. But what does this have to do with parkinsonian symptoms? The results of this study revealed that a two-week course of intermittent hypoxia training in patients with Parkinson’s disease increased dopamine synthesis in old and experimental PD animals which restored the asymmetry of DA distribution in the brain. Parkinson’s disease is a progressive disorder that affects dopamine-producing neurons in the brain. When these neurons are destroyed, the production of dopamine severely decreases and we see symptoms such as tremors, slowness, stiffness, and balance problems

The Michael J. Fox Foundation for Parkinson’s Research received a research grant in 2018 to study the effects of altitude on Parkinson’s Disease. The study consists of two individual parts. The first part is a focused survey that asks individuals with Parkinson’s about their best and worst experiences with their symptoms during their travels in the last 2 years. The second part of the study will be an in-depth survey that with capture the travel experiences prospectively. 

Maybe we see the decrease in symptoms because of the hypoxia or maybe it is due to the increased pH of our blood, or maybe it is because of something we have yet to discover. With the new study from the Michael J. Fox Foundation on the horizon, answers to this question may be within our grasps. 

Jessica Thomas is a Physician Assistant student at Des Moines University in Iowa. Following graduation Jessica will be practicing family medicine in small town Iowa with an emphasis on preventative care and pediatrics. Over  the course of the last year she has had the joy of living and working in 6 different states around the country and has experienced many different climates and learned how to care for the ailments that occur in the different regions of the United States. When not at work or studying, you can find her reading on her porch swing, watching Hallmark movies in bed on Sunday afternoons, or spending time with her family and friends. 

References

F. R. (n.d.). Altitude and Parkinson’s disease. Retrieved from https://www.shakymanwalking.com/altitude-and-parkinson-s.html

Altitude in Bhutan. (n.d.). Retrieved April 12, 2019, from https://www.bhutantravelbureau.com/about-bhutan/township-altitudes/

Belikova, M. V., Kolesnikova, E. E., & Serebrovskaya, T. V. (1970, January 01). Intermittent Hypoxia and Experimental Parkinson’s Disease. Retrieved from https://link.springer.com/chapter/10.1007/978-1-4471-2906-6_12

Bloem, B. R., & Faber, M. J. (n.d.). Exploring the Effect of Altitude on Parkinson’s Disease. Retrieved April 12, 2019, from https://staging.michaeljfox.org/foundation/grant-detail.php?grant_id=1813

Ma, H., Wang, Y., Wu, J., Luo, P., & Han, B. (2015, September 01). Long-Term Exposure to High Altitude Affects Response Inhibition in the Conflict-monitoring Stage. Retrieved April 12, 2019, from https://www.nature.com/articles/srep13701

Parkinson’s and Nutrition. (n.d.). Retrieved from http://parkinsonplace.org/programs-services/parkinsons-and-nutrition/

Schwalfenberg, G. K. (2012). The alkaline diet: Is there evidence that an alkaline pH diet benefits health? Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195546/)

Expected Variations in Nocturnal Oxygen Saturation in Infants: Comparing Needs at Sea Level to High Altitude

What is a normal overnight oxygen saturation for a child? This question is asked frequently by parents who have a child that may be requiring oxygen after evaluation. As healthcare providers working at various altitudes and caring for children, knowing the change in baseline oxygen saturations when at different altitudes is key to educating patients.  There are physiologic changes that result in transient changes in respiratory rate and volume while sleeping which will be discussed before exploring nocturnal oxygen needs at sea level versus needs at high altitude in healthy children. 

To begin, I will define a few terms that may not be familiar, but may be used when discussing oxygen needs. Oxygen saturation is defined as the amount of oxygen bound to hemoglobin in the blood, expressed as a percentage of maximal binding capacity.1 The simplest and most non-invasive way to obtain this information is through a pulse oximeter, which is placed on the patient’s finger, toe, or ear when vital signs are being taken. Oxygen saturation is known as the “5th vital sign” and tells medical providers whether or not a patient is delivering enough oxygen to their body. Hypoxemia is defined as insufficient oxygenation of the blood.2 There are multiple causes of hypoxemia, however we categorize hypoxemia as an oxygen saturation of less than 90 percent on a pulse oximeter. Finally, we use the term desaturation to describe a patient whose oxygen saturation continues to go below expected values.

In healthy, full-term infants, sleeping approximately 16 to 18 out of 24 hours is expected. A majority of their sleep cycle is REM and occurs when they fall asleep, with shorter duration of NREM sleep. As the child’s nervous system matures, there will be predictable changes in their sleep cycle, which will be more similar to a child or an adolescent. In children and adolescents, NREM is entered when they initially fall asleep, and accounts for approximately 75 percent of total sleep time, with alterations every 90 to 100 minutes of REM and NREM. In addition, there is a progressive increase in REM in the final third of the night.3 Understanding these cycles, what occurs during these cycles, and how they change over time are important in understanding the physiological changes (Table 1) that occur while you are sleeping.

  The physiological changes that we are focused on are decreased respiratory rate and decreased respiratory volume, which are seen in NREM and in the phasic stage of REM. In infants, periodic breathing is also an observed pattern of breathing that is expected after the first 48 hours of life until about 6 months of age. Periodic breathing is recurrent central apnea interrupted by breathing efforts. This topic will further be discussed in the high-altitude study, as these episodes are more common at high altitude.4

Table 1: Normal physiologic changes during non-rapid eye movement (NREM) and rapid eye movement (REM) sleep.5

In a study conducted at sea level in Brisbane, Queensland, Australia, 34 healthy term infants were studied at 2 weeks, 3, 6, 12, and 24 months in a prospective longitudinal cohort study. The study mentioned that there was limited data on reference ranges for normal nocturnal oxygen in infants, but that they aimed to develop a cumulative frequency (CF) reference-curve. This curve may be used as a tool to compare a child’s nocturnal oxygen saturation to see if the infant falls within the range for infants that are similar in age (Figure 1). Overall, the median nocturnal saturation was between 98 and 99 percent, for infants living at sea level.6 

In an additional study, conducted at high altitude in Bogotá, Colombia, 122 healthy full-term infants were studied in 4 various groups. These groups were coupled differently and were only monitored until 18 months of age. The groups were <45 days, 3 to 4 months, 6 to 7 months, and 10 to 18 months. In addition to these groups, 50 infants completed three overnight PSG studies and were analyzed as a longitudinal sub-cohort.

In this study, their overall data was presented differently and they also looked at SpO2 during wakefulness and respiratory events, which are more likely to occur at higher altitudes. An interesting finding, that was not present in the study at sea level in patients of similar size, age, and weight, was the increase in total, central, and obstructive apneas. In addition, there were also very high frequency oxygen desaturation events that again are not seen when living at lower altitudes. These events were reported as normal in infants living at high altitude. Overall, the median SpO2 was between 92 and 94 percent at high altitude.7 

To conclude, the median oxygen saturations at sea level were between 98 and 99 percent and between 92 and 94 percent at high-altitude. This said periodic breathing, which is normal until six months of age at any altitude, causes transient desaturations and are more common at high altitude. Apneic events are more commonly seen in infants at altitude, but are considered normal.  These studies have offered reference ranges and tools to better aid clinical judgement when caring for a patient that may require oxygen.

Felicia S.

References:

1. Oxygen saturation. Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. (2003). Retrieved March 23, 2019, from https://medical-dictionary.thefreedictionary.com/oxygen+saturation.

2. Hypoxemia. The American Heritage® Medical Dictionary. (2007). Retrieved March 23, 2019, from https://medical-dictionary.thefreedictionary.com/hypoxemia.

3. Wise, M., and Glaze, D. (2018). Sleep physiology in children. UpToDate. Retrieved March 23, 2019, from https://www-uptodate-com.ezproxy.stfrancis.edu/contents/sleep-physiology-in-children?search=sleep%20physiology%20in%20children&source=search_result&selectedTitle=1~134&usage_type=default&display_rank=1#H4. 

4. MacLean, J.E., Fitzgerald, D., & Waters, K. (2015). Developmental changes in sleep and breathing across infancy and childhood. Pediatric Respiratory Reviews, 16(4), 276-284.

5. Hanyang Medical Reviews. 2013 Nov;33(4):190-196. https://doi.org/10.7599/hmr.2013.33.4.190.

6. Terrill, P., Dakin, C., Hughes, I., Yuill, M., & Parsley, C. (2015). Nocturnal oxygen saturation profiles of healthy term infants. Archives of Disease in Childhood, 100(1), 18-23. 

7. Duenas-Meza, E., Bazurto-Zapata, M., Gozal, D., Gonzalez-Garcia, M., Duran-Cantolla, J., Torres-Duque, C. (2015) Overnight Polysomnographic Characteristics and Oxygen Saturation of Healthy Infants, 1 to 18 Months of Age, Born and Residing at High Altitude (2,640 Meters). Chest, 148(1), 120-127.