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. 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!