Pediatrician trained at University of Michigan Medical School, University of Hawaii and University of Chicago for residencies. Spent 20 years at the Commonwealth Health Center in Saipan, CNMI, before establishing Ebert Children's later Ebert Family Clinic in Frisco, CO in 2000. Published in the Journal of High Altitude Medicine and Biology
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.
The University was one of the first centers to use convalescent plasma to treat COVID. The hope is that antibodies from previously-infected and recovered individuals can be lifesaving for severe cases, although the best timing of such treatment, originally used one hundred years ago in the influenza epidemic, is not yet determined. Plasma donations can be arranged by visiting the UC Health website. Since most people will not need hospitalization, instructions for home care can be found on the CDC website.
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.
Dr. Chris with Dr. Eric Swenson from the University of Washington
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.
Dr. Chris with Dr. Peter Hackett of the Hypoxia Institute in Telluride, CO
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.
Dr. Peter Lemis is a cardiologist in Summit County, CO. He sat down with us in December to share his experience treating heart patients in the mountains.
Summit County cardiologist Dr. Pete Lemis
I graduated medical school in ‘77, practiced internal medicine in New Rochelle, New York, the first county just north of the Bronx. Then I went to New Hampshire for three years. I was reading the New England Journal and saw an unexpected cardiology opening at Henry Ford Hospital in Detroit. Next I was in Pittsburg for 26 years practicing cardiology. Decided I wanted to retire to Colorado, so I built a vacation home here only to discover I didn’t have to wait to retire to move here, so I came five years ago.
What is it about high altitude and the heart that makes it healthy for heart patients?
Summit is the fifth highest county in the US with the highest population of those counties. The 21 highest are all in Colorado. Lower air pressure means that although there is 21% oxygen in the atmosphere, there are fewer oxygen molecules. So every breath we take is giving us less oxygen, unless we breathe faster and deeper to make up for it, a natural tendency for people. They don’t even think about it. Some people have hypoxia without shortness of breath. Every once in a while, I’ll see a patient who moved to altitude for work or something, and they’re hypoxic. It is probably genetic that some people have a decreased central respiratory drive.
These patients with low oxygen often are ordered to have an echocardiogram. When they first come up here, they usually won’t have pulmonary hypertension. For some, the decreased central respiratory drive develops not when they first move here, but years after they move here. They become more and more hypoxic without having the feeling of shortness of breath. They have the same physiological response that people with hypoxia get. Their pulmonary vessels are still being constricted, which is reversible if diagnosed and treated with oxygen supplementation during the first few years of high altitude living. If not treated they are likely to get scarring of their pulmonary vessels. The length of time for this to develop is different for different people, and is unpredictable.
For example, I had somebody just this week who’s been here about 2 years who has a resting oxygen saturation of about 82% at 60 years old.
We can’t tell who is susceptible to this problem. There are likely some genetic factors involved. Dr. Johnson, who recruited me for my job in Summit County, has been here since 2008. He warned me about the issue of high altitude and hypoxia. Most doctors who are unfamiliar with life at high altitude think you adapt and that’s it. Dr. Johnson said to me, “wait three months and test yourself and your wife with an overnight oximetry to see if there’s hypoxia.” Based on that test I started using nocturnal oxygen and I sleep better when I use it. My wife doesn’t need it. Neither does her mother, who is 90 years old. Neither do my sons.
Awake, we’re able to maintain our oxygen levels, but at night when asleep most people who are here in Summit County have low oxygen. Hence my advice is to get a nocturnal pulse oximetry test. Low oxygen for several hours every night over the years can lead to pulmonary hypertension due to the narrowing of the pulmonary arteries. Then there is the question of what is normal: most high altitude studies were done in La Paz with indigenous, adapted populations as opposed to people living in the mountains of Colorado who have been here years or decades. (See what Dr. Chris has written on her collaboration with physicians and scientists in La Paz, Bolivia.)
We asked Dr. Lemis about arrhythmias at altitude. There are two categories-atrial (from the top chamber) and ventricular (from the bottom chamber).
Studies have shown that cardiac arrhythmias are increased initially, but people become acclimated after about 3 – 5 days and the risk returns to baseline. I don’t think these studies have been conducted over enough time. Hypoxia leads to an increase in arrhythmias. I see a lot of atrial fibrillation and atrial flutter up here; plus, I send three to four patients a month for an electrical procedure to ablate some of the cardiac conduction pathways to get rid of their arrhythmias. Many patients experience relief from atrial arrhythmias when put on nocturnal oxygen.
JB is a 70 year old who has lived at high altitude for 14 years. He experienced atrial fibrillation several times after returning to Summit County from a trip to sea level. He wore a heart monitor for over a month to see how his heart was beating. He felt the atrial fibrillation was related to dehydration and has prevented further episodes, never needing a pacemaker or other treatment. Jim uses a device that monitors his oxygen and heart rate continually while he sleeps, downloading a written report in the morning.
Why do so many people who live up here have bradycardia?
I think because many are athletes. Athletes often have an efficient heart; I see just as many people who have tachycardia because they have low oxygen. Low oxygen causes higher levels of epinephrine. This stimulates their adrenal gland, which can increase their blood pressure. Many people have high blood pressure at high altitude because they have low oxygen. One of my criteria for testing someone for low oxygen at night is if they have high blood pressure.
Many people have central apnea during sleep at altitude caused by the brain’s blunted response to high CO2 and low O2. Similar to obstructive sleep apnea, this central sleep apnea can increase the risk of heart problems. Many people with obstructive sleep apnea here at high altitude need to have oxygen put into their CPAP machine so they get oxygen, rather than just airwith continuous positive airway pressure.
There is less fatal ischemic heart disease up here. People tend to be healthier, more athletic. They’ve moved here for an active lifestyle. There’s less cigarette smoking, more exercise, generally better diet (not always), but people up here still have heart attacks. My impression is more of them survive their heart attacks because of their increased physical activity and healthy lifestyle. They have better collateral flow with more capillaries in the heart. They’re protected to some degree. The corollary to this is the fact that when visitors come here and have heart disease, I don’t think that their cardiologist back at low altitude understands high altitude risks and therefore are unable to provide appropriate medical advice. The same amount of exertion here is much harder on the heart, much more stressful to the heart, than it would be at low altitude. There’s something called a double product when you do an exercise test, related to blood pressure and heart rates. You get the same double product causing the same stress on the heart here as at low altitude, but it takes much less exertion to get to a specific double product.
People who are accustomed to a certain work load at home come up here and try to do the same amount of exertion. If they have coronary artery disease, suddenly there is a middle aged guy with coronary disease having a cardiac ischemic event, perhaps even sudden cardiac death.
Another important point is that people with known heart disease who live at low altitude, if they’re unstable at all, they shouldn’t be up here within three to six weeks of a heart attack. They should be able to pass a stress test at low altitude before coming to high altitude to visit.
Valvular heart disease patients who have not been treated with surgery, who don’t already live up here, shouldn’t come up here from lower altitude. People with heart failure can come up here if the failure is compensated.
For people who have trouble acclimating to high altitude in the short term, Diamox is quite useful. Using oxygen at night helps you acclimate as well. Diamox makes your blood a little acidotic which increases your respiratory drive.
Avoid alcohol when you first come to high altitude. Unfortunately people on vacation don’t do that. Alcohol is a respiratory suppressant. At high altitude the hypoxia and cold promotes diuresis, so people tend to get dehydrated. Anti-inflammatory drugs are useful in treating the acute altitude sickness for some people. During the first two or three days, try not to push your physical activity to the limits. Try to get a good amount of sleep.
I would say that I have way fewer heart failure patients [up here]. Because patients who develop advanced heart failure really do not do well here, so they tend to move away to lower altitude before that happens. I have younger patients as compared with my former Pittsburgh practice. I also have way fewer patients with COPD. Anything that causes chronic respiratory difficulties you will find a lot less of that up here. Plus, I’m working in an environment where there are less consultants.
Back in Pittsburg, two thirds of my practice was taking care of patients in the hospital, so I would deal with patients who would come in with a heart attack, with a heart failure exacerbation, or other acute cardiac problem. Here in Summit County, those severely ill patients get transferred down to Denver, so I provide more in-office preventive or post-illness follow-up than I do care in the hospital. My patients who need advanced procedures (e.g. heart catheters, ablation for arrhythmias), I generally send them down to our sister hospital (St. Anthony in Lakewood).
The cardiac surgeon who will do the bypass surgery usually knows that the patient returning to the mountains will have to be on oxygen for two weeks after surgery.
April 1 is traditionally celebrated in Colorado’s mountain resort communities as “Gaper Day.” Locals dress in their finest 70’s and 80’s outdoor fashions and commemorate the tourists who stop in the middle of the mountain to stare at the beauty that surrounds us. This year travel is discouraged, so the tourists are gone. Here are some local updates on the pandemic to reinforce these directives from Governor Jared Polis.
One day this week, several residents were intubated and transferred to intensive care in Denver. Physicians at St. Anthony Summit Medical Center have access to an ICU and ventilators, but patients with severe respiratory symptoms and hypoxia have a better chance at lower altitude. Let’s hope the day doesn’t come when the Denver hospitals are full, leaving us no choice but to provide this care locally in our low-oxygen environment.
As of April 3, 29 people in have been hospitalized with COVID illnesses, ranging in ages from 20’s to 60’s. There have been 43 confirmed cases in Summit County, according to the Summit Daily News. It’s here, it’s real, it’s dangerous to all.
Follow the footprints of the fox.
EVERYONE LIVING AT ALTITUDE SHOULD HAVE ACCESS TO A PULSE OXIMETER. You can buy this simple instrument at the pharmacies or call Ebert Family Clinic. You don’t need to go to the hospital if you are breathing normally and your oxygen is above 88%. You can call your doctor or the Ebert Family Clinic for a Telehealth assessment and advice. Our nurse practitioner Tara Taylor will be available 7 days a week between 9 am and 5 pm and Dr. Chris will answer calls and texts for parents and children 24/7. We all know to keep washing our hands: the Corona virus hates soap. Don’t touch your face.
And now I’m going to endorse recommendations from New York and other hard-hit locations: wear a mask and gloves when you go shopping. A bandana, ski mask, surgical mask, anything that reduces the spray of droplets from your mouth and the chance you will inhale these from others. We are all wearing gloves to keep our hands warm this time of year anyways.
For your mental and physical health, get outside every day. Walk around your neighborhood. Exercise stimulates the immune system. Sunlight helps prevent depression. Look up at the mountains. Gaze at the stars. Let us all be gapers.
During the winter of 2018, the Little Rock Climbing Center Alpine team ventured south to Ecuador for a mountaineering expedition. However, poor weather and high avalanche risk thwarted our summit attempts of Cayambe (18,996’, 5789 m) and Cotopaxi (19,347’, 5896 m). This winter (2019), we returned to Ecuador to attempt to summit Cotopaxi again, with a new and improved acclimatization plan and high hopes for better weather. Little Rock, AR sits at a mere 335 ft (102 m) above sea level … but we are lucky to have Pinnacle Mountain, with 750’ (228 m) of elevation gain to train on. A small mountain is better than no mountain! My training plan entailed hiking Pinnacle Mtn 2-3 times during the week, and then hiking or mountain biking on the weekend for approximately 3 months. I also rock climbed at the climbing gym 2 days a week, but Cotopaxi is not a technical climb, so that was mostly for fun. I took a week-long trip out to Colorado in September to reassess how my body reacts to high altitude. During this week we rock climbed in Boulder Canyon, Idaho Falls, and climbed the first and second Flat Irons, as well as hiked up to Sky Pond at Rocky Mountain National Park, hiked Mt. Bierstadt, and hiked out to Crystal Mill with Dr. Chris. I chose not to run too much this year for training because I have a meniscal tear in my left knee that gets aggravated on long runs.
We arrived in Quito, the capitol of Ecuador on December 30. Quito sits at 9,350’ (2849 m), so we took our first day pretty easy, and walked from our hotel to the older part of town with historic churches and cathedrals. Walking up the many flights of stairs in the Basilica del Voto Nacional got my heart pumping and legs and lungs burning! New Year’s Eve in the La Mariscal area of Quito was quite entertaining and a little rowdy, with fireworks, burning of effigies, and jumping over the fires. Our first day hike was up Rucu Pichincha (15,413’, 4697 m), a stratovolcano right in Quito! The TeleferiQo (a gondola) brings you up to 12,943’ (3945 m) where you begin the hike. The hike up Rucu Pichincha starts out mellow, on smooth trail with short steep, punchy climbs. Once you near the top, the steepness increases and the last few hundred feet involve very easy scrambling on sharp volcanic rock. The winter in Ecuador is typically the rainy season, so scattered showers and electrical storms are very common. However, we lucked out with perfect weather on Rucu Pichincha, and fantastic views of the big mountains – Cotopaxi, Antisana, and Chimborazo. The next day we drove to the base of the Ilinizas, and just missed the horse that was supposed to carry our packs up to the refugio. It was about a 3,000’ (914 m) climb up to Refugio Nuevos Horizontes, in relentless wind and dense fog. About half way up to the refugio, a lone figure emerged out of the fog. The horse that was supposed to carry out gear was carefully making his way down the mountain, such a surreal sight! We spent the night sharing bunk beds, packed like sardines in the tiny refugio (15, 696’, 4784 m). The next morning, the wind hadn’t let up, and the fog was still suffocatingly thick. A few groups had attempted an early morning ascent of Iliniza Norte, but said it was too icy and windy to summit. Our mountain guide, Alejo, suggested we traverse around the backside of Iliniza Norte to avoid the worst of the wind, and his advice was on point. The wind was whipping so hard at the summit (16,818’, 5126 m), we spent less than 5 minutes on top before beginning our decent back to the car. The wind was so strong on our descent (upwards of 60mph!), it knocked me off my feet several times. Next time I will use my hiking poles when it is so windy! We spent the next day resting and recuperating at Los Mortinos Hacienda, a cozy B&B at the edge of Cotopaxi National Park where we watched llamas graze, went horseback riding, and dined on fresh trout from a nearby river.
The next day we drove up to the Cotopaxi parking lot, and slogged up the soft, ashy trail for an hour or so before reaching Refugio Jose Rivas (15,744’, 4798 m) at the base of Cotopaxi. At the refugio we ate some dinner, hydrated, and then tried to rest as much as possible. Alejo woke us up at 10pm and by 11pm we were on our way up the volcano. The skies were finally clear and calm after days of clouds and windy weather, all of the stars were out and we watched an impressive lightning storm down in Quito. We began the trek in mountaineering boots as the glacier starts about two hours uphill. While I felt fine the day before hiking up to the refugio, I had a pretty decent headache when we woke up. My right foot kept falling asleep in my mountaineering boot, and I was starting to overheat because I had too many layers on. This was the first time on the trip that I felt bad, and doubts about a successful summit started to creep in my mind. Alejo asked if I wanted to turn around, but even though I didn’t feel good, I didn’t feel bad enough to turn around. After about two hours of hiking, we reached the glacier and donned our crampons. And then I started to finally feel GOOD! As long as I kept switching my stepping technique, alternating between duck-footing, side-stepping, and French technique, my right foot wouldn’t fall asleep. The higher we climbed, the better I felt! About an hour away from the summit is when it really began to get steep. Alejo said it would be really steep, then a little easier, and then really steep again. We trudged on. And it got steep — really, REALLY steep. Just keep moving. Step up, rest, step up again, rest. Repeat. The mountain seemed to keep going up and up and up. But then around 8am we were at the top of Cotopaxi! I had seen photos of the summit, but seeing smoke coming out of the crater with my own eyes was mind-blowing. We ACTUALLY made it! We waited for Ian and his guide to summit, and then spent the better part of an hour taking photos and enjoying what Alejo said was the nicest weather he’d ever experienced at the summit.
Ian brought along an Accumed Pulse Oximeter, so being the science nerd that I am, I measured my oxygen saturation percentage at various elevations over the course of the trip. While the percentage of oxygen in the air is the same, the fall in atmospheric pressure at high altitude decreases the driving pressure for gas exchange in the lungs, leading to lower oxygen saturation levels. I measured my oxygen saturation level on my right index finger after being seated for approximately 5 minutes. The Accumed Pulse Oximeter is a small battery-powered device that measures the ratio of red light and infra-red light that is absorbed through the finger to calculate oxygen saturation levels.
Here is a table of my oxygen saturation levels at various elevations throughout the trip:
Day
Location
Elevation
(ft/m)
O2 saturation (%)
1
Quito
9,350/2849
80
2
Summit of Rucu Pichincha
15,413/4697
75
3
Refugio Nuevos Horizontes
15, 696/4784
74
7
Summit of Cotopaxi
19,347/5896
57
Before reading too much into this very limited data set, there are a number of limitations with these observations I would like to point out. First, sample size is very limited, and I only took one reading at each elevation. Second, pocket pulse oximeters are not very accurate below oxygen saturation levels of 70%, and ambient light interference (as we experienced at the summits of Rucu Pichincha and Cotopaxi) can interfere with accuracy. Also, the literature suggests that pulse oximetry utility is limited in diagnosis of acute mountain sickness, and that measuring oxygen saturation after light exercise compared to rest may be more predictive of acute mountain sickness. I believe that I did not experience altitude sickness at any point during this trip. I had a mild headache after sleeping above 15,000’ (4572 m), but that resolved once we started hiking up the mountain. We stayed at the summit of Cotopaxi for approximately 1 hr, and while I had a slight headache and was day-dreaming (more than usual), I felt pretty good overall and had no problems on the descent. Pulse oximetry is painless and non-invasive, and can be a useful tool in evaluating respiratory and other complaints at high altitude, but care should be taken to minimize erroneous measurements to avoid misinterpreting the data.
Keshari Thakali, PhD is an Assistant Professor in the Department of Pediatrics at the University of Arkansas for Medical Sciences in Little Rock, AR. She is a cardiovascular pharmacologist by training and her research laboratory studies how maternal obesity during pregnancy programs cardiovascular disease in offspring. When not at work, you can find her mountain biking, rock climbing, hiking or paddling somewhere in The Natural State. She has a long-term career goal of merging her interests in mountaineering with studying cardiovascular adaptations at high altitude, and would appreciate any tips on how to accomplish this!
Dr Gustavo Zubieta-Calleja explains how lessons learned in La Paz can make space exploration easier
I just returned from the “Chronic Hypoxia” conference in La Paz, Bolivia at 12,000 feet elevation (3,640 m). The sponsor and organizers were Drs. Gustavo Zubieta-Calleja and his daughter Natalia Zubieta De Urioste who run the Institute of High Altitude Pulmonology and Pathology there. Presenters and attendees came from 16 countries covering topics ranging from molecular biology to genetics. Dr. Zubieta previously published a scientific analysis of centenarians living at various altitudes. He compared Santa Cruz, Bolivia, at sea level, with La Paz/El Alto, each with populations of over three million, and found there are eight times more people over 100 years old at high altitude. (BLDE University Journal of Health Sciences, see blog post 1/5/18) Since his father Gustavo Zubieto Castillo founded the institute in 1970, they have been advocates of the health promoting effects of a low oxygen environment. A presentation on “BioSpaceForming” even identifies chronic hypoxia as a “fundamental tool”, that “gives humans and other species an advantage on earth and beyond.” Dr Zubieta explained that the space station is engineered to have the barometric pressure (760 mmHg) and oxygen content of sea level. When the astronauts change into their space suits to work outside the ship they experience a pressure drop of over 200 mm Hg in a laborious process of donning the suit. Seeing that millions of inhabitants are healthy at 486 mm HG in Bolivia, he advocates that maintaining lower pressures and lower oxygen levels in the space station would be economical and promote the health of the astronauts. Several altitude scientists see this as a future that “uncouples biology and physics.
Anyone who travels to areas of high
altitude is at risk for high altitude pulmonary edema (HAPE). Classic HAPE
symptoms include a dry cough and shortness of breath with activity; leading
eventually to trouble breathing at rest. If left untreated, serious
complications can occur. Many other conditions can mimic HAPE, and it is
crucial for health care professionals to be able to distinguish between HAPE
and other disorders that may cause similar symptoms. Illnesses that may present
similarly to HAPE include pneumonia, a blood clot in the lung (pulmonary
embolism), and chronic obstructive pulmonary disease (COPD) or asthma. Your
health care provider will take a thorough history, but the following outlines the
differences between HAPE and other similarly presenting conditions.
Pneumonia: In both HAPE and pneumonia, shortness
of breath, fast breathing, and a fever occur. Normal oxygen saturations are
above 90%, and if you have HAPE or pneumonia, these could be as low as 60 %.
However, if you have pneumonia, you will feel a lot worse than if you have
HAPE. HAPE typically responds to high flow oxygen and you will get better over
a few hours. Whereas if you have pneumonia with low oxygen saturations, you
will need immediate hospitalization.
COPD/Asthma: High altitudes may exacerbate your
COPD or asthma. How providers tell the differences is through something called
pulmonary function tests. This tests how well your lungs work. Your provider
will have you breath into this device before and after being given albuterol.
If your lung tests improve after the albuterol, then COPD or asthma are the
more likely diagnosis. It is important to tell your provider if you have a
history of COPD or asthma, and if you are a current or former smoker.
Pulmonary Emboli (PE): Patients with a blood
clot in their lung typically have the same symptoms as HAPE but will sometimes also
have chest pain when taking deep breaths. You may also have blood in your sputum
and/or calf pain or swelling. You are more at risk for a PE if you have had a
recent orthopedic surgery (such as a hip or knee replacement), you have an
irregular heart rate, have a clotting disorder, smoke, or are on birth control.
If you have these risk factors and additional symptoms, your provider may order
a lab test called a d-dimer and a chest
CT scan to help distinguish between a blood clot or HAPE.
If you are experiencing any of
these symptoms, it is important to go see a health care provider immediately. A
thorough history and exam will help aid in the correct diagnosis and prevent
any potential complications. And most importantly, will help you get back on
track to enjoy your high-altitude vacation and living!
Miranda Bellantoni, FNP-Student
Luks AM, Swenson ER, Bärtsch P. Acute
high-altitude sickness. Eur Respir Rev 2017; 26.
UpToDate. Distinguishing HAPE from Pneumonia
2018.
Dr Christine Ebert-Santos presents to employees of the Town of Breckenridge. Contact Ebert Family Clinic if your organization or group is interested in learning more about living in our hypoxic environment admin@ebertfamilyclinic.com
