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.