Over 800 participants from 25 countries joined the virtual conference this year which included Dr. Chris’ poster presentation on growth at altitude. Over the next several months we will extract the most relevant information to publish in our blog, starting with:
The Rule of 3’s
You can survive 3 minutes without oxygen
3 hours without shelter in a harsh environment
3 days without water
3 weeks without food
We will be sharing some of the science, experience and wisdom from these meetings addressing how to survive. For example, Dr. Peter Hackett of the Hypoxia Institute reviewed studies on how to acclimatize before travel or competition in a low oxygen environment.
Susanne Spano, an emergency room doctor and long distance backpacker discusses gear, how to build an emergency shelter in the wild, and when it is OK to drink from that refreshing mountain stream.
Michael Caudill, MD shares what NOT to eat when you are stranded in the wilderness in his lecture on toxic plants.
Presentations included studies of blood pressure in people traveling from sea level to high altitude, drones delivering water to stranded hikers, an astronaut describing life and work at 400,000 m, what is the best hydration for ultra athletes, how ticks can cause meat allergy, and, as always, the many uses for duct tape.
We will also update you on the treatment of frostbite as well as a discussion about “Climate change and human health.”
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How does living at high altitude affect the human body? It’s a complicated question that researchers have been trying to answer for years.
It takes two things to grow: adequate nutrition and the body’s ability to convert calories into energy. Observations over 20 years at the Ebert Family Clinic suggest that the decreased oxygen levels at altitude may interfere with optimal utilization of calories or decrease appetite and intake in small children.
After opening her pediatric clinic in Frisco, CO in 2000, Dr. Christine Ebert-Santos noticed that children living at high altitude are smaller than average. Dr. Chris and Meredith Caines Pollaro, an occupational therapist with expertise in feeding and growth in children, organized a group for parents of underweight children but did not find any consistent abnormalities. After this, Dr. Chris decided that smaller growth might be a normal pattern for little ones at altitude. The children were otherwise healthy, with nutritional analysis showing adequate intake, and no signs of endocrine or gastrointestinal problems.
Research on growth in children at altitude is sparse. So, in 2009, Dr. Chris recruited her daughter Anicia Santos to launch a detailed data analysis. Anicia worked with one of her math professors at the University of Colorado to convert the data into a unique growth chart for altitude which demonstrated the downward shift. Twice the number of infants and toddlers had weights below the 3rd percentile of the World Health Organization growth charts than at lower altitudes. Heights were also decreased. After years of gathering data, Dr. Chris and Anicia are getting ready to share their findings with the help of Logan Spector, PhD and graduate student Aaron Clark.
Spector, chairman of the department of epidemiology at the University of Minnesota, was concerned about his two nieces who lived in Summit County who were not fitting into the “normal” growth pattern. This sparked his interest in Dr. Chris’ research. He was able to recruit Clark to take on the project.
In the first study of its kind in North America, the growth charts of 970 kids living in Colorado’s high country are analyzed. With over 9,000 pieces of data, one thing is clear. From birth to 18 months of age, children living at altitude weigh much less than the average child. Length is also considerably decreased, though the weight discrepancies are more drastic. These findings were studied extensively and found to be statistically significant. Using the generalized estimating equation (GEE), Clark was able to analyze the data in a non-linear way. This compensates for correlated data. Clark created density graphs for both male and female children to depict these findings (see figures). When the graph line is fairly close to 1 on the y-axis, or a straight line across the top, this means there is little difference from the standard growth chart (age 2-18). The farther away from 1 on the y-axis, the more significant difference there is compared to standard growth charts (age 0-2).
There is no denying that something is causing these high-altitude children to fall off of the growth charts. The next logical question would be, what are the effects of this smaller growth rate? Initial research shows that children at altitude are catching up on the growth curve by age two. There does not appear to be any long-lasting deficits from the initial smaller growth.
After combing through research articles, a new study from Ladakh, India also displayed a correlation between children living at high altitude and smaller size. Specifically in Colorado, another study shows lower birth weights at high altitude, however, it does not follow the growth patterns of the children over time.
From what this research shows, a unique growth chart for children living at high altitude would be helpful. A new growth chart would account for the variations in size seen at altitude. This could save thousands of dollars in unnecessary testing looking for underlying disease or endocrine deficiencies as well as the anxiety for parents being told that their child has failure to thrive or is not being fed. Instead of being concerned when a child falls low on the growth chart, one might expect to see smaller children at altitude.
There is still much research to be done in this field. Hopefully, this study will serve as fuel for future studies.
Laura Van Steyn is a 3rd year Physician Assistant student studying at Midwestern University in Glendale, AZ. She graduated from the University of Colorado in Boulder with a degree in integrative physiology. After that, she worked as a CNA at Littleton Adventist Hospital prior to starting PA school. She hopes to work in women’s health or dermatology after graduating. During her six weeks at Ebert Family Clinic, she has joined Dr. Chris for numerous hikes and has truly enjoyed escaping the Arizona summer heat!
Yang, W.-C.; Fu, C.-M.; Su, B.-W.; Ouyang, C.-M.; Yang, K.-C. Child Growth Curves in High-Altitude Ladakh: Results from a Cohort Study. Int. J. Environ. Res. Public Health 2020, 17, 3652.
Bailey, B.; Donnelly, M.; Bol, K.; Moore, L.; Julian, C. High Altitude Continues to Reduce Birth Weights in Colorado. Matern Child Health J 2019, 23(11): 1573-1580
As the gateway to Machu Picchu, the city of Cusco, Peru attracts over 3 million tourists from all around the globe each year. With this many people passing through the city, you can imagine why local residents feared the worst when the COVID-19 outbreak began. However, out of a population of approximately 429,000 people, the city has only four COVID-19 related deaths – three tourists who traveled to the area and one native with previous risk factors.
Machu Picchu, a UNESCO World Heritage Site, brings 3 million tourists from around the world to the Cusco region of Peru every year.
One death out of 196 confirmed cases for the city makes for a remarkably low fatality rate of 0.5% for the native population. Peru as a whole has a fatality rate closer to 3% with over 6,000 deaths, making it one of Latin America’s most affected countries. Many believe the fatality rate to be even higher as testing has not become widely available in the country.
To understand why Cusco is such an outlier when compared to the rest of the country, there are several factors to take into consideration. One of those factors that researchers haven’t quite been able to figure out, but believe plays a role, is altitude. The Cusco region of Peru sits at 11,152 ft elevation compared to the capital city of Lima that sits at only 512 ft elevation.
Research comparing the high-altitude regions of Tibet, Bolivia, and Ecuador has revealed similar trends. A study completed April 22, 2020 and published in the June 2020 scientific journal “Respiratory Physiology & Neurobiology” indicates that populations living above 9,842 feet elevation reported significantly lower levels of COVID-19 cases than populations living at lower elevations. The research showed the infection rates in the Andes Mountains of Bolivia were one third the infection rates the rest of Bolivia, and the infection rates in the Andes Mountains of Ecuador were one fourth of the rest of Ecuador. In both Bolivia and Ecuador, the areas with the highest concentration of COVID-19 cases were located at an elevation close to sea level.
Why populations living at higher altitudes are experiencing lower infection rates is still not well understood, but there are a few theories at play. It is hypothesized that people living at altitude are able to live in a state of chronic hypoxia, or a state of chronically low oxygen in the blood. Hypoxia is one of the conditions caused by COVID-19, and if a person’s body is already used to low levels of oxygen, their symptoms may not be as severe. There are other environmental considerations at altitude that may shorten the life-span of the COVID-19 virus, including high levels of UV radiation that can kill the virus, low barometric pressure that does not support the weight of the aerosolized droplets that the virus lives in, and dry thin air that does not support the transmission of aerosolized droplets.
However, as intriguing as the effect of altitude on COVID-19 statistics is, it is important to note that there are several other proven factors that come into play when looking at these populations. First, most high-altitude towns and cities tend to be rural. When population density per square mile drops, the rate of transmission of infectious diseases also drops – rural settlements allow for natural social distancing. Second, populations living at higher altitudes have lower rates of obesity and generally have better overall health. Living at high altitude causes a reduction in the hormones that signal hunger, leading to consumption of fewer calories. Additionally, completely normal daily activities in a state of chronic hypoxia due to low levels of available oxygen in the air raises the body’s resting metabolic rate, leading to burning more calories. The healthier a person is prior to contracting an illness, the more likely their body is to be able to fight it off successfully.
Research regarding how altitude affects COVID-19 transmission, infection, and recovery rates is ongoing. It may be too soon to tell exactly why or how altitude comes in to play, but early findings are suggesting that now is a great time to be a resident of the great Rocky Mountains – but then again, when is it not?
Megan Schiers is a 3rd year Physician Assistant student studying at Midwestern University in Glendale, AZ. She graduated from Idaho State University in Pocatello, ID with a Bachelor of Science in Dental Hygiene and worked as a dental hygienist in Strasburg, CO for two years prior to starting PA school. She is passionate about increasing access to healthcare in rural areas and hopes to specialize in emergency medicine or cardiothoracic surgery following graduation this fall. During her six weeks in Frisco, CO, she has enjoyed hiking in the beautiful mountains, camping at Camp Hale Memorial, visiting Maroon Bells, and checking out Black Canyon of the Gunnison National Park.
Last week we were privileged to have a Zoom discussion with two high altitude experts from the Instituto Pulmonar Y Patologia de la Altura (IPPA) founded in La Paz, Bolivia in 1970. Dr Gustavo Zubieta-Calleja and Dr. Natalia Zubieta-DeUrioste answered our questions about their recently published article, Does the Pathogenesis of SAR-CoV-2 Virus Decrease at High Altitude?. They and the seven coauthors presented data comparing COVID cases in high altitude areas of China, Bolivia and Ecuador showing a marked reduction in numbers compared to low altitude areas in the same countries, with dramatic, colorful topographic maps.
Drs. Zubieta-Calleja and Zubieta-DeUrioste and their colleagues theorized four reasons why altitudes above 2500 m could reduce the severity of the corona virus. (Note: Frisco, CO is at 2800 m, Vail 2500 m). As described in their previous paper published in March, the intense UV radiation at altitude as well as the dry environment likely reduce the viability of the virus in the air and on surfaces.
The low barometric pressure causes air particles to be spaced more widely, which would also decrease the viral particles inspired with each breath, reducing the severity and frequency of infections.
Furthermore, residents accustomed to chronic hypoxia may express reduced levels of angiotensin converting enzyme 2 (ACE2) in their lungs and other tissues. This enzyme has been found to be the entry path for the corona virus into cells where it replicates. Finally, the normal adaptation and acclimatization of populations with prolonged residence above 2500 meters may reduce the severity of the disease in individuals, and reduce mortality. This includes increased ventilation, improved arterial oxygen transport, and higher tissue oxygenation mediated by increased red blood cells produced under the influence of erythropoietin, which could be explored as a possible therapy.
As we stated in our interview quoted in the Summit Daily News March 17th, none of these factors can be relied upon to protect every individual. Therefore it is important to continue frequent hand washing, wearing masks, social distancing, and avoid touching your face.
We are on the back slope of the epidemic, according to University of Massachusetts Dartmouth Professor of Biology Erin S. Bromage, Ph.D. He explains what to expect and where not to go in an article this week which was cited in the New York Times: The Risks-Know Them-Avoid Them. The bad news is that the back slope can have as many deaths as the upslope.
The good news is that you don’t get COVID outdoors, as long as you are not standing close to someone who might have the virus for a period of time, perhaps over ten minutes. Bromage reviews a series of epidemiologic studies tracing the spread of the disease in situations including standing outside talking to someone (one case), church choir practice (45 of 60 infected, 2 died), indoor sports, specifically a curling tournament in Canada where 24 of 72 attendees became ill, birthday parties and funerals (high rate of infection and many deaths related to hugging, kissing and sharing food), grocery stores (safe for shoppers but employees get infected), and restaurants (50% infection rate after sharing a meal with nine at the table). He also reported details about the spread of disease at meat packing plants, a call center and a medical conference.
The risk of infection increases with exposure to a larger number of virus particles over a longer period of time in a smaller space with poor air flow. This is why shopping and outdoor activities are not likely to be dangerous. Breathing releases a small number of virus, between 50-5000 droplets per breath. Talking expels more and singing is definitely a means of spreading virus. A single cough releases 3000 droplets traveling 50 miles per hour, mostly falling rapidly to the ground. In contrast a sneeze may release 30,000 droplets at 200 MPH, many of which are smaller and stay in the air longer.
Dr. Bromage writes that 44% of infections come from people who have no symptoms at the time. The virus can be shed up to five days before a person becomes ill. Most people contract COVID from a family member who brings it home. Children are three times less likely to become ill but three times more likely to spread the virus.
I wondered if the lower barometric pressure at altitude could cause viral particles to be less compact. I called Peter Hackett, MD of the Hypoxia Institute in Telluride and he agreed that theoretically the less dense air would not carry as many particles. We also discussed antibody tests, which are still experimental, not recommended and difficult to interpret. The population screened in Telluride showed a 0.5% positive rate, but when a disease has a low prevalence there are more false positives. They did blood tests on some 5,000 people early in the outbreak. They were not able to repeat the serology due to staffing problems at the lab where many technicians contracted the illness.
My advice is to wear masks anytime you are out of the house, except if you are biking, hiking, running where the viral particles will be dissipated rapidly. Wearing a mask during these activities is still a kind gesture to reduce the anxiety of others. Continue with frequent hand washing, avoid touching your face, practice social distancing, and when the churches reopen we should hum instead of sing.
Today, I am going to share news gleaned from meetings and publications that address the importance of preventive care, returning to daycare, pulse oximetry as a screening tool for COVID, and the Accordion Theory.
Every Thursday the Children’s Hospital of Colorado presents a panel of experts with updates and answers to questions.
“Your offices are the safest place in the country,” they proclaimed. With social distancing many parents and patients are delaying routine care which has led to the largest drop in vaccination rates in 50 years. This could result in outbreaks of measles, whooping cough, pneumococcal and other infections. With the loss of revenue, small clinics may go out of business, and large clinics and hospitals are laying off workers by the hundreds. If there is a large outbreak of preventable disease, on top of a resurgence of COVID, there could be a devastating shortage of providers to care for the victims. Now is the time to call your clinic and set up appointments for check ups and vaccines. If you don’t feel safe yet you can do a Telehealth visit initially and schedule the vaccines and hands-on portion of the exam in a month.
Another reason not to delay preventive care is the increase in stress, isolation, and anxiety which can cause serious depression. We had a tragic teen suicide in the county this month. Students from middle school through college should be seen annually for mental and physical health screening as well as vaccines. One mother told me that the depression screening done at our office “saved my daughter’s life.”
More daycares are opening soon. Parents are asking me whether to send their child back. These facilities follow strict public health guidelines to prevent infection. Children are not likely to be affected by COVID. Any child with symptoms should be tested. Enrollment should be diminished due to parents preferring to keep their child at home. However, if there is a high risk family member, I advise not to return to daycare yet.
School age children should be limited to playing with friends and family members who have been part of their social circle during the last two months. To borrow a slogan from the AIDS campaign, “KNOW YOUR NETWORK”. This is not the time to expand friendships. There will be no team sports this summer. Children should play outside and not share toys or balls.
An emergency physician in New York, Richard Levitan, published an editorial in the NY Times on April 20 advocating the use of pulse oximeters to screen for COVID. Citing the many patients with low oxygen levels and abnormal x-rays who did not complain of trouble breathing, the delay in obtaining results and inaccuracy of the COVID testing, he sees the simple pulse oximeter as a source of immediate information as to who needs medical attention. I’ve been speaking and writing about this for weeks.
Finally, one of the panelists at Children’s mentioned the accordion phenomenon. As we reduce social distancing restrictions and open commerce and travel, there will inevitably be more cases of COVID. It is likely that restrictions will be imposed again, and this may occur in cycles during the next year(s). We may be able to decrease future shutdowns by wearing masks and gloves when we go out, using hand sanitizer, soap and water, not touching our face, covering our coughs and sneezes, and limiting exposure to large groups of people. I hope all these will be permanent behavior changes except the masks and the large groups (I love the Lake Dillon Amphitheater and the BBQ challenge).
Take care, stay engaged, and have another safe week!
A panel of experts at the University of Colorado School of Medicine had some good news this morning: we may have passed our peak here in Colorado.
Of the 8,675 cases there are 374 deaths. Less than 2% of those with the illness are under age 18, compared to the population of 22% children. This week there are only 4 children admitted to Children’s hospital with COVID-19, two in the ICU. There is a leveling-off of patients presenting to the hospitals and less ICU admissions.
So social distancing has flattened the curve and no hospitals were overextended or lacked ventilators. The initial R naught (the number of people infected from one individual) of each infected person spreading to 4 is now down to 1.5. A study from Singapore showed that 7% of cases came from presymptomatic persons. The infection can be transmitted 2 to 3 days before symptoms show. Of 121 healthcare workers exposed 35% developed symptoms but only 2.5% tested positive.
Our own experience with testing has been equally frustrating. The virus can be present for weeks but usually rapidly declines after 7 days. The PCR test (polymerase chain reaction test – the standard nasal swab being conducted to test for Corona virus) is said to be 75% accurate in detecting viral RNA. Even patients we’ve tested during the first 4 days of typical symptoms have been negative. Other viruses identified at Children’s Hospital in the last month include rhinovirus, adenovirus, enterovirus and human metapneumovirus, which can all cause fevers and respiratory illnesses.
However, many people we are treating have the unusual symptoms and course that seems unique to COVID. Not all have fever. They experience chills, fatigue, sore throat, then improve. A day later they are having chest tightness, trouble breathing, making it difficult to talk or walk, and upper abdominal pain. They feel worse at night and better in the morning. Symptoms can last for weeks. Lung specialists describe several different effects the virus can have. ARDS (adult respiratory distress syndrome) is a diffuse loss of protective protein that causes the air sacs to collapse. The pulmonary disease in the second week is described as a cytokine storm, where the immune system overreacts and damages the lungs.
Testing is less accurate when the prevalence of a disease is low. In Colorado 1.4% have been affected, in comparison with Wuhan where 5-10% were. Experts and individuals are waiting for antibody testing to see if they are immune and if so for how long. Immunity in similar infections has been shown to last anywhere between 3 weeks and 3 months, as opposed to diseases like measles and chickenpox which confer lifelong immunity.
Pediatricians are seeing few patients in the office these days, which raises the concern for a future epidemic of preventable diseases from a delay in vaccinations. Most clinics, like Ebert Family Clinic, are only seeing healthy patients or those with noninfectious complaints such as eczema and lacerations. Anyone with respiratory symptoms or fever is seen by Telehealth. This is effective because COVID, like most illnesses in the community, is usually mild and self-limited. Antibiotics are rarely indicated. A recent study showed that of several hundred children diagnosed with community-acquired pneumonia, those given antibiotics had the same outcomes at those who were not treated, with 4% of each group needing hospitalization for worsening symptoms.
Telehealth does not allow for auscultation of the heart and lungs (listening with a stethoscope), but the vital signs including oxygen saturation, heart rate and temperature along with the patient’s history usually give the provider enough information to make treatment and testing decisions. A face-to-face video interaction is ideal, protecting the patient and provider from exposure to infection. The expanded use of Telehealth is one of the good outcomes of this pandemic, especially in states like Colorado with far flung rural populations.
The University of Colorado is doing 3000 telehealth visits daily. Specialists at Children’s are ramping up their services online while accepting the sickest patients in the state for inpatient care. They have the largest number of doctors in Colorado, many of whom are in research and can transfer to frontline and ICU duties. The University does 500 million dollars of sponsored research every year, with over 1000 studies. Many of these are on hold now, but with the capacity to initiate new trials within a week and laboratories adjacent to clinical care sites, CU has been tapped for many COVID-related studies. They are testing several antiviral drugs, including the new product from Gilead laboratories Remdesivir. There are also studies on disease modifying treatments such as steroids to prevent future problems caused by the infection. Other trials focus on sample collecting and processing. Some studies may show results within weeks but others take months or years to determine effect.
Vaccine development will proceed over the next 12 months. Until then, lifting of current social restrictions will depend upon having adequate and accurate testing to find cases early enough to quarantine patients and public health workers to trace contacts. Antibody testing must be done and repeated over months and years to determine susceptibility. Continued use of masks in public and the prohibition of large gatherings may continue for a year.
Another Spring season in Colorado. The ski resorts have closed early per the COVID-19 protocol, along with most other establishments. Even on the normal schedule, most ski resorts would have been closed for the season by now, bringing more people to the backcountry. But this year seems to have seen an upswing in backcountry activity, where many people are going to stay active while limiting exposure to others. Just over a week ago, a team of 20 search and rescue volunteers rescued a 26-year-old man who had fallen hiking on steep terrain around St. Mary’s Glacier, Colorado. Last year, a total of 10 snowmobilers were killed in the backcountry in avalanche slides. Only one was wearing a beacon.
Backcountry and Avalanche Safety resources, thankfully, are growing more plentiful and accessible, and last winter, we published an article on the basics. Earlier this winter, I spoke with backcountry athlete and web development colleague Dan Beerman, whose experience in the backcountry really broadened as a backpacking guide in New Mexico during the summers 12 years ago, followed by a position as a climbing instructor.
When I was a backpacking guide, I was on the search and rescue if I didn’t have a crew … We had a radio, so we were the point of contact for finding and doing extraction. That’s when I learned the most and was exposed to the most. I took my Wilderness First Responder course in 2014, and that was through the Wilderness Medical Institute.
Dan’s also a fellow hut tripper, and we’ve been talking about doing one together (when we’re on the other side of the current pandemic). He’s spent the last two New Year’s in huts, backcountry skiing or snowshoeing tours. This past year, he skied Buffalo Mountain’s Silver Couloir, in the Gore Range, and made an attempt at a couloir on Mt. Torrey’s. And there have got to be some good “couloir” puns out there.
I have aspirations to do the Colorado trail quickly, but I don’t know if I wanna do that in a competitive way or just recreationally backpack it. It’s hard to balance summer objectives, or climbing objectives vs. winter backcountry goals vs. alpine mountaineering objectives.
And he makes a great point:
In Colorado, your recreation is so close to becoming high-consequence all of the time! If the weather changes from the trailhead, that could be a really big problem.
I’m familiar. Nothing really teaches you as much or as quickly as getting caught in Colorado’s extreme weather patterns.
Dan took an Avalanche Awareness and Safety class through Colorado Mountain School, held up in Rocky Mountain National Park over two field days after two nights of class in Boulder. His main takeaway:
Check an avalanche conditions snow report daily. Observing the snowpack over the seasonis going to make your confidence on the day of your excursion a lot higher. I’d had no context for why avalanches were happening, where and why it’s dangerous. Having that lens through which to view weather events in terms of avalanche conditions is so valuable. It’s an intuitive thing about paying attention to the weather.
This is my first season getting out at Copper, for example, and they all have that double-black diamond terrain in the back bowls that are labeled ‘EX’ on it. There’s a sign that says, ‘Ski with a partner,’ and I just thought, ‘Oh, shit, that sign should probably be much bigger!’
Beacon, shovel, probe are the mandatory avalanche terrain items — you’re putting other people at risk if you don’t have [them], because even if you observe a slide, you can’t do anything about it. Additionally, if you don’t have a beacon in a slide, others can’t find you. You’re not contributing to a rescue, nor can you be rescued. In Colorado, there’s an increasing awareness for that. I typically will bring that with me all the time, it’s just always in my ski bag. Having some snacks, having some water, those are the kinds of things: you should never not have them.
I’ll take the goals of the expedition and plan accordingly. If I’m doing a ski trip, I’ll wanna get out and do hikes with weight or runs where I’m doing elevation several times. I like to do six weeks out, of four weeks of training and two weeks of tapering down.
I tend to be in a constant attempt to gain weight. On the Pacific Crest Trail I tried to gain weight prior, eating a lot of fatty foods, that kind of thing. Jonathan and I came up with this metric: calorie-per-dollar-per-ounce. Lightweight food that’s affordable, easy to ingest, easy to prepare, and you aren’t having to burn a lot to carry that with you to the backcountry.
[On the trail], peanut butter is always a winner. Olive oil is one of the highest calorie-per-ounce [food]. I have literally drank it before, but just add it to everything. I do eat a lot of standard trailmix, it’s easy and accessible. I’m a big fan of pumpkin seed mix or stuff with chocolate in it. I like CLIF bars. I do not like Luna bars because I’ve eaten so many of them. I can’t eat pop tarts anymore because they used to be in the meals that were issued when I was a guide. Snickers bars are a great calorie-per-dollar-per-ounce deal. I eat a Snickers bar or two before bed when I’m sleeping at altitude so my body has calories to stay warm.
I’ll make these mass-gainer complex food supplements. It’s like protein powder, but it also has carbs, like a workout and performance powder. And I would add that to water with coffee, and that would be a breakfast while hiking. There’s a lot of different kinds of powders and mixes you can add, but when you’re in calorie-burning mode, I do recommend this. If you’re hiking 20+ miles in a day or 4000+ feet of elevation in a day, you’re burning greater than 4000 calories, so you really have to eat more than you think you can.
I wouldn’t say that I had HAPE (high altitude pulmonary edema) or HACE(high altitude cerebral edema) … Definitely, especially when I was younger … I would travel from 4000′ to 10,000′ in a 24-hour period. I’ve actually had search and rescues where someone was having night-terrors or hallucinations [due to HAPE or HACE]. I was a backountry professional for the Boy Scouts at a camp at 10,800′ (one of the first backcountry camps, in New Mexico). I’ve experienced dizziness, nausea, insomnia, weakness of the knees, elevated heart rate … and I’m a runner, I’m in decent shape. But you should acclimatize before setting out on a trip.
One last piece of advice,
Learn the Leave No Trace principles. We live in a state where impact is so concentrated that the more that everybody knows, the more likely it will be there for the next generation.
Dan and his backpacking, backcountry cohorts keep a blog full of breathtaking landscapes and telling captions on CaptainsofUs.com.
There will be plenty of time to escape to the backcountry again after the risks of COVID-19 have subsided. The current time is a good time to start preparing mentally. Know before you go.
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.
An article published yesterday, April 13, 2020 in the Journal of High Altitude Medicine and Biology clarifies misconceptions in the media comparing high altitude pulmonary edema (HAPE)and COVID lung injury. The six authors include two critical care pulmonologists from the University of Washington: Andrew Luk MD and Eric Swenson MD, as well as Peter Hackett MD of the Hypoxia Institute in Telluride and the University of Colorado Altitude Research Center. Dr. Swenson is the editor of the journal and has given presentations in Summit County on altitude. Both Dr. Hackett and Dr. Swenson personally communicated with Dr. Chris yesterday.
Severe viral pneumonia, as seen in COVID-19, can cause Adult Respiratory Distress Syndrome (ARDS) leading to respiratory failure and the need for ventilator support. As with HAPE, this is a form of non-cardiogenic pulmonary edema, where the air sacs in the lung fill with fluid due to conditions not related to heart failure, the most common cause of pulmonary edema. Other causes include bacterial pneumonia, near-drowning, nervous system conditions, re-expansion, and negative pressure edema. Radiographic findings are similar in all these cases with diffuse bilateral densities in the lungs. All these patients have severe hypoxia.
At altitude, hypoxia can lead to uneven pulmonary vascular constriction, (hypoxic pulmonary vasoconstriction or HPV). In the areas with the highest pressure, fluid leaks from capillaries into the alveoli. With COVID, alveolar inflammation reduces the protein surfactant that maintains expansion of the alveoli. The alveolar collapse causes hypoxemia, low blood oxygen. Severe viral and bacterial infections also cause inflammation in other organs, such as the liver, kidneys, and brain, which is not seen with HAPE.
Medications used to treat HAPE are not likely to be useful in treating COVID pneumonia and may have harmful effects such as increasing perfusion to damaged areas of the lung that are not oxygenated.
Both these conditions likely have large numbers of patients with mild symptoms who recover without seeing a medical provider. However, both HAPE and COVID can cause a sudden, rapid deterioration with severe hypoxia and death.
ACCESS TO A PULSE OXIMETER TO TRACK OXYGEN SATURATION IS VITAL.
Oxygen levels below 90% merit medical attention. Pulse oximeters can be purchased online, at drug stores, or at Ebert Family Clinic.
A good friend in Hawaii recently sent me a YouTube video referencing Dr. Cameron Kyle-Sidell, a critical care and emergency room physician at Maimonides Medical Center in NYC. Dr. Kyle-Sidell was discussing his findings while working with COVID-19 patients in NYC and compared those findings to altitude sickness. I did a search and found he had posted several videos on social media comparing Acute Respiratory Distress Syndrome (ARDS) in COVID-19 patients to altitude sickness and reconsidering how these patients are treated. Altitude sickness is something I see and treat frequently here in Summit County. Based on the similarities between the two conditions, the same treatment for altitude sickness and high altitude pulmonary edema (HAPE) may be beneficial to COVID-19 patients.
In an interview with Dr. John Whyte, Dr. Kyle-Sidell described the acute ARDS he is seeing in COVID-19 patients as atypical and not responsive to standard treatment, specifically in regards to ventilator use and settings. He describes some of his patients as alert, talking in full sentences, and not complaining of shortness of breath but have oxygen saturation levels in the 70s (John Whyte & Cameron Kyle-Sidell, 2020). Normally, that is not the case when a person has an O2 saturation in the 70s and is in respiratory distress. However, this is not abnormal in patients with altitude sickness and HAPE. There are certain protocols in hospitals regarding when to intubate a person and to put them on a ventilator. According to Dr. Kyle-Sidell, these protocols apparently aren’t always helpful for COVID-19 patients with ARDS, and can at times be harmful.
The similarities between findings with COVID-19 and HAPE are remarkable. These similarities include: hypoxia (low oxygen levels), low CO2 (carbon dioxide) levels, tachypnea (rapid respiratory rate), patchy infiltrates seen on chest x-ray, bilateral ground glass appearing opacities on chest CT, fibrinogen levels/fibrin formation, aveolar compromise, decreased Pao2:FiO2 ratios, and ARDS in severe disease (Solaimanzadeh, 2020). Noting these similarities may be helpful when approaching treatments for COVID-19. Acetazolamide (Diamox), Nifedipine (Procardia) and Phosphodiesterase inhibitors (Viagra, Cialis etc.) have been used in treating HAPE and could possibly be beneficial in treating COVID-19. For example, Acetazolamide potently decreases the constriction of small vessels in the lungs that contribute to fluid build up (edema) seen in both HAPE and COVID-19 patients (Solaimanzadeh, 2020).
In our house call practice, we treat quite a bit of altitude sickness due to our elevation here in Summit County. During the ski season, we may see 3-4 patients per month that develop HAPE. The majority of the time, these patients can be safely treated and monitored in their residence or hotel room. Treatment for both altitude sickness and HAPE consists of oxygen, usually 2-5 L/min via nasal cannula continuously while sleeping or resting. We also treat our patients with an injection of a steroid, Dexamethasone. We closely monitor them and may repeat the dose of Dexamethasone or prescribe an oral steroid. These patients usually see some improvement by the next day and significant improvement when they descend in altitude. I have read recommendations for and against steroid use with COVID-19. More studies need to be done, which I will be following closely as future recommendations may change how I treat HAPE when there is also a suspicion of COVID-19.
The key to treatment is oxygen! We’ve seen patients with O2 saturation levels in the 40s and 50s and lungs that sound like a “washing machine”, as Dr. Gray, has described it (in a previous Doc Talk article). If we can get their oxygen saturation up into the mid 80s or 90s on 5L/min (of O2) or less via nasal cannula, typically, they can avoid an ambulance ride and emergency room visit. As Dr. Kyle-Sidell notes, many of the COVID-19 patients he sees are talking coherently and not in severe respiratory distress. A friend who is an EMT in New York described a man he recently transported to the hospital, in his 50’s, with presumed COVID-19. He had no respiratory distress, walking and talking coherently, no chronic medical problems but his oxygen saturation was in the 60s. He said they took him to the emergency room and he was intubated and placed on a ventilator. Apparently, this is a common occurrence from what he has seen. I am still amazed when a patient calls, gives me their address and directions to where they are staying and when I arrive, their oxygen levels are in the 40s. It is a very rare occurrence that I need to send a patient to the hospital, which they always appreciate. We monitor our patients very closely until their departure and have them call anytime, day or night, with any changes in condition.
Dr. David Gray, who started our business, has been treating these patients for over 18 years. He states that in a few of the HAPE patients that he has treated, including his own 13-year-old son, he has seen O2 saturations in the 30’s & 40’s. In these few patients, he was only able to get their O2 saturation up to high 60’s, low 70’s, on 5 liters. They were so much improved, clinically, that he accepted those levels. A large dose of Dexamethasone & 12 hours of rest, on nasal oxygen, resulted in marked improvement by the next day, every single time. His rule, as in patients with DKA, is “if the pathology didn’t happen rapidly, you don’t necessarily have to reverse it rapidly.”
Dr. Kyle-Sidell suggests not putting COVID-19 patients on ventilators based solely on numbers (John Whyte & Cameron Kyle-Sidell, 2020). Treating these patients with prone positioning, oxygen via nasal cannula, high flow on a non-rebreather mask or CPAP along with careful monitoring and a little patience may be preferable to a ventilator (John Whyte et al, 2020). If a ventilator is needed, using less pressure to reduce lung damage and higher oxygen levels may prove to increase the likelihood of a better outcome (John Whyte et al, 2020). There is so much to learn about COVID-19 and how to treat it. Treating it as you would with HAPE is certainly something to consider. I appreciate providers who are sharing their personal experiences in treating these patients. As healthcare providers gain more experience treating this virus and share their experiences, protocols will change and I suspect ventilator use as well as the death rate will decrease.
 A complication of altitude sickness in where the lungs fill with fluid and small amounts of blood
Danielle Shook MSN, NP-C is a board-certified Family Nurse Practitioner. She has been in nursing for over 27 years. She earned her Master’s Degree at University of Colorado, Colorado Springs through Beth El School of Nursing. Her nursing experience includes 10 years in Obstetrics and 7 years in Hospice home care. She has over 9 years experience as an NP which includes Family Practice at the Air Force Academy, Urgent Care, Acute and after hours care with the Army Premier Clinic as well as house calls.
John Whyte, Cameron Kyle-Sidell. Do COVID-19 Vent Protocols Need a Second Look? – Medscape – Apr 06, 2020.
Solaimanzadeh I (March 20, 2020) Acetazolamide, Nifedipine and Phosphodiesterase Inhibitors: Rationale for Their Utilization as Adjunctive Countermeasures in the Treatment of Coronavirus Disease 2019 (COVID-19). Cureus 12(3): e7343. doi:10.7759/cureus.7343