All posts by Roberto Santos

Roberto Santos is an avid outdoorsman, prolific reader, writer and web developer currently stationed in the Colorado high country. Originally from the Northern Mariana Islands, his work, study and adventures have taken him from surfing across the Pacific, to climbing the highest peaks in Japan and Colorado.
Acclimation, Altitude Science, Doc Talk, Health, High Altitude

Ileus at Altitude: When Your Gut Blows Up Like a Potato Chip Bag

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Myasthenia Gravis (MG) is a condition caused by the production of antibodies that block acetylcholine receptors. This blockade of neuromuscular signaling results in rapid muscular fatigue and weakness. Increased activity tends to worsen muscular issues which usually resolve with rest. Prominent symptoms of MG include drooping eyelids, double vision — OMG (ocular myasthenia gravis)– difficulty swallowing, slurred speech, and shortness of breath. Generally, muscles in the face and throat are considered to be the most commonly impacted by Myasthenia Gravis. However, this condition can affect any muscle group throughout the body (1). Gastrointestinal (GI) manifestations such as abdominal pain, recurrent vomiting, and constipation have been reported by individuals with MG. A case presenting to the Summit Medical Center located at 9,100 feet illustrates an unusually severe manifestation:

A road covered in tire tracks through white snow passes by a blue and red sign for St. Anthony Summit Medical Center and its emergency room, in front of dark green conifer trees that stand out against a snowy mist that settles over a pine-forested mountain background.
St. Anthony Summit Medical Center on Peak One Drive in Frisco, Summit County, Colorado, at the foot of Peak One of the Ten Mile Range, enshrouded in snowy mist.

A 70 year old woman was brought to the emergency department (ED) with severe abdominal and chest pain, concerned that she had a dissecting aortic aneurysm. She reported three previous episodes of severe  pain in the 2 weeks leading up to the ED visit, all starting in the afternoon, increasing to prostration by 5 pm and resolving with bed rest. Past medical history was significant for myasthenia gravis for which she took azathioprine 100 mg BID (twice daily). Two months previously she had a flare with ptosis and double vision, treated with prednisone 40 mg daily. 

Laboratory tests were normal. Imaging showed distended loops of bowel consistent with ileus. She was treated with pain medication and symptoms resolved.

The patient continued to have episodes once or twice a month, including another ED visit, precipitated by treatment with duoneb, which has  anticholinergic activity, a tonic water drink, and guaifenesin, both antimuscarinic substances that interact with the cholinergic receptors in the viscera.. Taking pyridostigmine, a cholinesterase inhibitor, led to resolution within 2 hours, marked by “sparkly” sensations in her arms and legs and reactivation of bowel sounds with flatus. 

An x-ray of a torso showing marked intestinal distention.
CT scan of patient with intestines diffusely distended with bowel gas.

Until recently, GI symptoms were considered rare in myasthenia gravis. Then a case study in 2001 demonstrated that gastric dysmotility was a common feature among individuals with Myasthenia Gravis (2). Among all the motility dysfunction reported, gastroparesis was found to be a common autonomic feature in MG patients (2). Gastroparesis is the slowing or stopping of movement in the GI tract resulting in delayed gastric emptying. Further research demonstrated that intestinal pseudo-obstruction was considered to be one of the most common GI manifestations of individuals with MG(3,4,5).

In 2007 it was demonstrated that receptors in gut muscles were structurally similar to skeletal muscle receptors, indicating that GI motility could be highly impacted by the presence or lack of acetylcholine (6). Considering that antibody production in Myasthenia Gravis Individuals can decrease acetylcholine binding to receptors, the presence of GI symptoms among other autonomic dysfunction symptoms suggests inadequate treatment which can result in a poor prognosis for these individuals (7). 

What was previously considered a rare symptom within a rare condition, is now being proposed as an early identification tool. Taking into account receptor similarity,  GI symptoms can be used as early indicators of myasthenia gravis, specifically gastrointestinal dysmotility (8). The case study showed that MG developed less than a decade after the initial onset of gastrointestinal dysmotility symptoms (8). There is a clear need to identify GI symptoms earlier in MG individuals. This will allow for better treatment and improved long-term health outcomes for these individuals. 

At altitude, the low barometric pressure causes gaseous distension in normal individuals producing increased flatus (see blog on HAFE). Combined with MG, GI manifestations can be even more severe. Medical providers treating residents of  high altitude communities should consider MG in the differential of patients with abdominal complaints and treat recognized MG patients with anticholinesterase medications to control symptoms. None of this patient’s providers were aware of this manifestation of MG, including the neurologist who specializes in MG, the gastroenterologist who performed an  upper endoscopy and colonoscopy, the ED staff, the radiologist and the primary care provider. Patients with MG and their providers need to be aware of medications that interact with the cholinergic receptors in all parts of the body and screen for these as possible precipitators of symptoms outside the classic description of the disease.

Submitted by Ana Campos, PA-S.

References 

1. (NHS) https://www.nhs.uk/conditions/myasthenia-gravis/ 

2. Vernino S, et al. Myasthenia gravis with autoimmune autonomic neuropathy. Auton Neurosci. 2001;88(3):187–192.

3. Pande R, Leis AA. Myasthenia gravis, thymoma, intestinal pseudo-obstruction, and neuronal nicotinic acetylcholine receptor antibody. Muscle Nerve 1999;22:1600-1602

4. Musthafa CP, Moosa A, Chandrashekharan PA, Nandakumar R, Narayanan AV, Balakrishnan V. Intestinal pseudo-obstruction as initial presentation of thymoma. Indian J Gastroenterol 2006;25:264-265. 

5. Seretis C, Seretis F, Gemenetzis G, Gourgiotis S, Lagoudianakis E, Pappas A, Keramidaris D, Salemis N. Adhesive ileus complicating recurrent intestinal pseudo-obstruction in a patient with myasthenia gravis. Case Rep Gastroenterol. 2012 

6. Mandl, P, Kiss, JP. Role of presynaptic nicotinic acetylcholine receptors in the regulation of gastrointestinal motility. Brain Res Bull. 2007;72:194–200 

7. Putri Aaliyah. Autonomic Dysfunciton. Gastroparesis as autonomic manifestation of myasthenia Gravis: A rare case report. Clinical Neurophysiology. 132: 94-95, 2021 8. Alnajjar, S., Idiaquez Rios, J., Fathi, D., Liu, G., & Bril, V. (2022). Gastrointestinal Dysmotility as the First Manifestation of Myasthenia Gravis. Canadian Journal of Neurological Sciences, 1-2.

8. Alnajjar, S., Idiaquez Rios, J., Fathi, D., Liu, G., & Bril, V. (2022). Gastrointestinal Dysmotility as the First Manifestation of Myasthenia Gravis. Canadian Journal of Neurological Sciences, 1-2.

Acclimation, Altitude Science, Athletic Training, Backpacking, Exposure, Health, High Altitude, High Altitude Training & Fitness, Mountaineering

Mountain People Can Still Get Mountain Sickness: HL-HAPE, a Fourth Type of High Altitude Pulmonary Edema

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There are three types of High Altitude Pulmonary Edema (HAPE) recognized in visitors and people living at high altitudes. These include classic HAPE (C-HAPE), which involves an individual that lives at low altitude traveling to high altitude. Re-entry HAPE (RE-HAPE)  is seen in an individual that lives at high altitude who travels to low altitude and then returns to high altitude. And high-altitude resident pulmonary edema (HARPE) which occurs in an individual that lives at high altitude and does not change altitude (Ebert-Santos, Wiley). While these have been extensively studied and are subtypes that people are warned of, a fourth unexpected type of HAPE has been recently described by pediatric pulmonologist Santiago Ucros in Bogota, Columbia at the Universidad de los Andes. (Ucros)

Highlanders HAPE (HL-HAPE) occurs in people that live at high altitude who then travel to higher altitudes. Though most people who live at high altitudes for long periods of time assume they are immune to HAPE, the recognition of HL-HAPE shows this is not the case. One man had a run-in with HL-HAPE during his long-awaited trip to Mt. Kilimanjaro. 

A man wearing a neck gator under a grey baseball cap and dressed in cold-weather jacket and pants sits on a rock next to a tall giant groundsel plant with cushions of dead leaves puffing up heads of light-green leaves before the sloping of the mountain down into a valley with a white cloud floating above it.

A resident of Summit County, Colorado, Jonathan Huffman set out to climb Mt. Kilimanjaro with his wife Katie when he was 37 years old. He is originally from Texas, but has been living in Breckenridge, Colorado, elevation 9,600 ft, for 15 years. In preparation for the climb, he spent the summer hiking multiple fourteen thousand foot peaks in Colorado, trail running at 9,000-12,000 ft, and mountain biking. 

Two people stand smiling toward the camera with an arm around each other, dressed warmly in long pants, thick jackets and hats, one holding a water bottle, standing on an open field of high alpine shrubs with Mt. Kilimanjaro illuminated in the pink light of the sun, streaked with long, narrow clouds in the background

The elevation of Mt. Kilimanjaro is 19,341 feet and the summit generally takes each group anywhere from 5 to 9 days, depending on the route taken. In September, Jonathan and Katie traveled to Tanzania where they spent two days adjusting to jet lag and preparing for their climb. They had chosen to follow the Lemosho Route which is 42 miles long with an elevation gain of 16,000 to 17,000 feet. 

On the first day, Jonathan and his party started at the Lemosho trailhead (7,742 feet) and hiked up 9,498 feet to the first camp. He noticed that his throat felt dry and he found himself having to clear it often. He attributed this symptom to the dusty environment. 

On the second day, he felt as though his body was fighting the dust, which had found its way into his eyes, sinuses, and throat. He also felt extremely fatigued and stated that every action felt more difficult. Though he could tell his body was struggling to adapt, Jonathan continued to push forward with full force. He made it to the second camp at 11,500 feet. 

A group of orange and white panelled tents sit in the shade of a rocky mountain peak streaked with snow, illuminated in sun above the camp against a cloudless blue sky.

“Day three, we went from 11,500 feet to 13,800 feet,” Jonathan recounts. “After we arrived to this camp, our guides offered to allow us to take a break then hike even higher. This was [an] optional acclimatization test … but I actually skipped it. I was so tired when I got to camp on this day, I decided to just nap in the tent until dinner time.”

On the fourth day, Jonathan’s group hiked up an overpass to Lava Tower located at 15,190 feet. This was also an altitude test, and he passed. He stated that this was the highest he had ever climbed, but that he was beginning to feel more like his normal self. The group stopped for lunch at the tower, but he did not have much of an appetite. He ate the food anyways at the insistence of the guides. 

A sea of clouds illuminated in blues and soft pinks stretches out behind several tents pitched over a shaded, rocky mountain slope in the foreground.

“Then after lunch, we descended down to Barranco Camp [from 15,190 feet to 13,044 feet] and this is where I realized I had HAPE.”

As they were nearing the camp, he felt fluid building in his lungs that was easy to cough up. By the evening, however, he felt as though he was drowning and was unable to lay down. While the guides encouraged him to immediately hike down, he did not want to hike in the dark. He spent the night propped up on duffle bags or sitting in a kitchen chair, with his oxygen reaching as low as 67% at one point. 

Two people sit in the dark of a tent, one with an oxygen mask on and a red head lamp illuminating tin food containers and medical supplies in the foreground as he is administered oxygen.

In the morning, he received 30 minutes of oxygen treatment before beginning his 8-hour descent. His symptoms improved when he reached 6,500 feet. He was picked up in a rescue vehicle and received further treatment at a hospital in Moshi. While he made a full recovery, he stated that he still felt the effects of HAPE while exercising in Colorado at times, up to months after the experience. While Jonathan was only about 2 days away from the summit, he knew that turning back was the best choice. He plans to re-attempt the climb in a few years. 

Jonathan’s story serves as an important reminder to those living at altitude that HAPE can affect anyone. Jonathan’s wife Katie along with everyone else in the group also experienced mild symptoms of altitude sickness including headaches. Research still needs to be conducted on the cause and prevention of this condition in all types. While this shouldn’t stop hikers and climbers from climbing mountains, they should be aware of the signs and symptoms of HAPE, when to seek treatment, and the best ways to prevent it from occurring. 

A map of the Lemosho route as listed on the Ultimate Kilimanjaro guide site can be found here.

A group of people in bright colored pants, jackets and backpacks make their way down a red dirt trail surrounded by tall green grasses and trees extending over a white SUV with a red cross symbol on it in the background down the road.
A man in a beige baseball cap takes a selfie with three men in hats and jackets behind him smiling toward the camera with a white jeep labelled with a red cross in the background behind them.
Acclimation, Altitude Science, Exposure, Genetics, Health, High Altitude, Sleep at Altitude

Are Epigenetics the Bridge to Permanent Physiologic Adaptations in Organisms Living at High Altitude?

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Epigenetics slide from speaker at Hypoxia conference in La Paz Bolivia, 2022

The CDC defines epigenetics as “the study of how your behaviors and environment can cause changes that affect the way your genes work… epigenetic changes are reversible and do not change your DNA sequence, but they can change how your body reads a sequence.”1 Examples of epigenetic changes include methylation, histone modifications, and non-coding RNAs. Researchers have postulated the involvement of epigenetics in an organism’s adaptations to hypoxic high-altitude environments. After looking into this topic, I questioned if epigenetics may be the bridge to the permanent physiologic alterations in organisms living at high altitudes. 

Hypoxia Inducible Factor-1 (HIF-1) is a nuclear transcription factor activated in hypoxia states, and regulates several oxygen-related genes. The role of epigenetics, specifically methylation of HIF-1 in the expression of the erythropoietin gene, in states of hypoxia was researched. Erythropoietin was chosen due to it being a widely known protein that stimulates erythropoiesis in states of hypoxia. It was confirmed that HIF-1 binds to a HIF-1 binding site (HBS) on the erythropoietin enhancer and will induce transcription of erythropoietin.2 CpG methylation in the HBS interferes with HIF-1 binding, thus inhibiting the activation of transcription of erythropoietin.2  They also found that there were several other oxygen-related genes that were susceptible to similar epigenetic changes.2 Another study investigating HIF-1 and its binding to HIF-1 response element (HRE) upstream to a target gene confirmed the potential for epigenetic changes, specifically methylation. They found that this HIF-1 binding site has a CpG dinucleotide, making it inherently susceptible to methylation.3 To clarify, the most notable epigenetic change is the methylation of cytosine located 5’ to guanine, known as CpG dinucleotides.3 Again, they reported that methylation of the CpG island in the HIF-1 binding site upstream of the target gene, erythropoietin, was negatively correlated with its expression.3 

Furthermore, research on epigenetic changes in rats exposed to long and short-term intermittent hypoxic environments and their room air recovery treatments suggests there is a long-term effect in rats exposed to long-term intermittent hypoxia.4  Rats were exposed to short-term (10 days) and long-term (30 days) intermittent hypoxia resembling obstructive sleep apnea oxygen profiles.4 The short-term hypoxic rats treated for 10 days at room air reversed their altered carotid body reflexes including hypertension, irregular breathing, and increased sympathetic tone. While the long-term hypoxia rats treated for 30 days at room air did not have a reversal of altered carotid body reflexes.4 There were similar results in reactive oxygen species (ROS) and antioxidant enzyme (AOE) levels. The long-term hypoxia rats had increased levels of ROS and decreased AOEs in their recovery periods compared to the short-term hypoxia rats.4 

Erythropoietin is not the only oxygen-related gene that is affected. For example, a study looked at the methylation profiles of Tibetan and Yorkshire pigs under high-altitude hypoxia. IGF1R and AKT3 were two notable differentially methylated genes found to have high expression and low methylation levels in Tibetan pigs that suggest a role in adaptation to hypoxic environments.5 Both genes are responsible for cell proliferation and survival.5 Tibetan pigs are known to have become physiologically adapted to their high-altitude hypoxic environment over generations and epigenetic changes were verified in the genome-wide sequence ran in this study.5 This study alludes that epigenetics is not only a bridge but may be a part of the permanent physiologically selected adaptations to ensure survival at high altitudes.

In conclusion, research demonstrates a variety of epigenetic changes that are taking place in these high-altitude hypoxic environments. The research suggests that they may likely be tissue-specific as well. There are definite knowledge gaps in the exact roles that epigenetics may play in hypoxic environments and gene expression. There is room for more research and identifying alterations to epigenetics to improve human physiologic adaptations to hypoxia. 

References 

1. Centers for Disease Control and Prevention. What is Epigenetics. https://www.cdc.gov/genomics/disease/epigenetics.htm. Accessed December 30th, 2022.

2. Wenger, R.H., Kvietikova, I., Rolfs, A., Camenisch, G. and Gassmann, M. (1998), Oxygen-regulated erythropoietin gene expression is dependent on a CpG methylation-free hypoxia-inducible factor-1 DNA-binding site. European Journal of Biochemistry, 253: 771-777. https://doi.org/10.1046/j.1432-1327.1998.2530771.x

3. Yin H, Blanchard KL. DNA methylation represses the expression of the human erythropoietin gene by two different mechanisms [published correction appears in Blood 2000 Feb 15;95(4):1137]. Blood. 2000;95(1):111-119.

4. Nanduri J, Semenza GL, Prabhakar NR. Epigenetic changes by DNA methylation in chronic and intermittent hypoxia. Am J Physiol Lung Cell Mol Physiol. 2017;313(6):L1096-L1100. doi:10.1152/ajplung.00325.2017

5. Zhang B, Ban D, Gou X, et al. Genome-wide DNA methylation profiles in Tibetan and Yorkshire pigs under high-altitude hypoxia. J Anim Sci Biotechnol. 2019;10:25. Published 2019 Feb 5. doi:10.1186/s40104-019-0316-y

A woman in a white coat with long, dark, straight hair below her shoulders smiles.

Emily Paz is a third-year medical student at Rocky Vista University College of Osteopathic Medicine and is looking forward to pursuing a career in orthopedics. She is from the central coast of California and earned her Bachelor of Science degree in General Biology from the University of California San Diego. She worked in an emergency department as an EMT after her undergraduate education which reaffirmed her passion and curiosity for medicine. In her free time, she enjoys snowboarding, practicing Muay Thai, cooking, and spending time with family and friends.

Acclimation, Altitude Science, Athletic Training, Backpacking, Exposure, Health, High Altitude, High Altitude Training & Fitness, Mountaineering

When Altitude gets High, does Stroke get higher?

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Does altitude increase or decrease risk of strokes? As one review put it, “Due to limited literature, lack of large series, and controlled studies, the understanding of stroke at high altitude is still sketchy and incomplete”. What is clear is that stroke at high altitude can often be misdiagnosed (or underdiagnosed), due to the similarity of initial presentation with high altitude cerebral edema (HACE). Both conditions present with imbalance or ataxia, and both can present with focal neurological deficits.  There are few large urban populations at high altitude (Addis Ababa in Ethiopia is 7,726 ft), so medical providers have fewer resources.  Without the ability to perform neuroimaging with a CT scan or MRI in a timely manner a diagnosis of HACE vs. stroke could be uncertain. HACE often causes global cerebral dysfunction, differentiating it from an early stroke before the onset of focal symptoms can and often does prove challenging. 

While the prevalence of strictly hemorrhagic and ischemic strokes at high altitude remains murky, it is known that exposure to high altitude can result in conditions such as TIA, cerebral venous thrombosis (CVT), seizures, and cranial nerve palsies. Most of the research that has been done on strokes is focused on “moderate” and “high” altitudes, as opposed to “very high” or “extremely high” altitudes. As such, there is very little research on populations living at 3500m or higher. There was at least one tangible piece of evidence indicating that the higher the elevation, the earlier the mean onset of stroke – Dhiman et al. (2018) found that at an elevation of 2,000m, the mean age of onset of stroke was 62 years. The age decreased to a mean of 57.9 years at 2,200m in another study (Mahajan et al. (2004)). Yet another study (Razdan et al. (1989)) found 10.9% of the patients in their sample suffered strokes aged < 40, though this was at an altitude of only 1,530m. Some reports suggest higher stroke prevalence at higher altitudes, and at a strikingly young age – between age 20 and age 45.

Student presentation on stroke at altitude at Colorado Medical Society meeting 2022

There have been mixed results on the effect that altitude has on strokes. One systematic review study found 10 studies displaying an increase in stroke prevalence with higher altitude, 5 other studies showing that altitude was actually protective against stroke, and 2 studies in which the results were ambiguous. This study and other sources alluded to the fact that poorer stroke outcomes at higher altitude may be due to polycythemia and increased viscosity of blood. Specifically, Ortiz-Prado et. al noted that “living in high-altitude regions (>2500m) increases the risk of developing thrombosis through hypoxia-driven polycythaemia which leads to a hypercoagulation unbalance”, which was associated with increased risk for stroke. Ortiz-Prado et. al noted that most of their info came from “very few cross-sectional analyses”. These analyses did find “a significant association between living in high-altitude regions and having a greater risk of developing stroke, especially among younger populations”. When the effects of altitude on stroke were broken down by race (Gerken, Huber, Barron, & Zapata, 2022) it was found to be protective in some populations (Whites, African Americans), but detrimental in other populations (Hispanics, Asian-Pacific, and American-Indian). Going back to the work of Ortiz-Prado et. al, altitude increased the risk of stroke at elevations above 3500m, when the time spent at this elevation was at least 28 days, and more so in younger persons (below the age of 45). At lower elevations, between 1500m and 3500m, increased / easier acclimatization and adaptation to hypoxia seemed to offer protective effects against the risk of stroke. Chronic exposure to hypoxia at high altitude triggers adaptive / compensatory mechanisms, such as higher pulmonary arterial flow and improved oxygen diffusing capacity. Ortiz-Prado et. al concluded that a window of ideal elevation seems to exist – below an altitude of 2000m the adaptive mechanisms do not seem to be sufficient to yield a protective effect – however, above 3500m, adaptive mechanisms may actually become maladaptive (excessive polycythemia & blood stasis), yielding a higher risk for stroke. A lack of any adaptation (i.e. in altitude naïve persons) was even more detrimental at such high altitudes, with the authors concluding that “above 3500–4000m, the risk of developing stroke increases, especially if the exposure is acute among non-adapted populations” (Ortiz-Prado et. al, 2022).

Strokes are more common in males compared to females, and this held true at altitudes of 3380m, 4000m, and 4572m. In addition to the standard vascular risk factors such as hypertension, smoking, and diabetes, the higher incidence of polycythemia in persons living at high altitude is thought to play a role. One study (Jha et al. (2002)) found that 75% of the patients in their sample who had suffered strokes had some form of polycythemia – this was at an altitude of 4270m. (Dr. Christine Ebert-Santos of Ebert Family Clinic in Frisco, Colorado at 2743m suspects everyone who lives at altitude has polyerythrocythemia as more accurately described by Dr. Gustavo Zubieta-Calleja of La Paz, Bolivia at 3625m.)

Only about 2% of the world’s population resides at what is considered “high altitude”. Given the current world population (over 8 billion, 5 million), that is still over 160,100,000 people. The sheer number of people that may be at increased risk of stroke is all the more reason for us to act, and act soon, to get more research done. This is further exemplified by the fact that “cerebrovascular events or stroke is the second leading cause of death worldwide, affecting more than 16 million people each year” (Ortiz-Prado et. al). Guidelines need to be implemented to assist in the diagnosis and treatment of stroke at high altitude, to help differentiate it from related conditions such as HACE, giving patients the standard of care that they need and deserve. While a fascinating topic, stroke seems to be delegated to the sidelines in the mountains, cast aside by culprits such as HAPE, HACE, altitude sickness, and hypoxia. More research, more resources, and more funding need to be funneled into understanding stroke at higher altitudes. Overall, it is clear living at or even exposure to higher altitudes can result in a multitude of neurological symptoms, and that a higher incidence of stroke may yet be one of them.

References

Maryam J. Syed, Ismail A. Khatri, Wasim Alamgir, and Mohammad Wasay. Stroke at Moderate and High Altitude. High Altitude Medicine & Biology.Mar 2022.1-7. http://doi.org.mwu.idm.oclc.org/10.1089/ham.2021.0043

Current World Population – https://www.worldometers.info/world-population/ 

Ortiz-Prado E, Cordovez SP, Vasconez E, Viscor G, Roderick P. Chronic high-altitude exposure and the epidemiology of ischaemic stroke: a systematic review. BMJ Open. 2022;12(4):e051777. Published 2022 Apr 29. doi:10.1136/bmjopen-2021-051777

Gerken, Jacob (MS), Huber, Nathan (MS), Barron, Ileana (MD, MPH-S), Zapata, Isain (PhD). “Influence of Elevation of Stroke and Cardiovascular Outcomes”. Poster presented at a conference in Colorado, in 2022.

Links

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9058702/ https://www-liebertpub-com.mwu.idm.oclc.org/doi/full/10.1089/ham.2021.0043

Born in Salt Lake City, Utah, Piotr Poczwardowski has also lived in Upstate New York, Florida, and Colorado (where he spent the 13 years prior to moving to Glendale for PA school). While attending the University of Denver, he volunteered at a nearby hospital Emergency Department, and also participated in a study abroad program in Italy. After earning a degree in Psychology, he worked as both a Primary Care Medical Scribe and Neurology MA. His main hobbies include skiing, watching movies, hiking, swimming, playing video games, reading, and playing ping pong. Piotr has also volunteered at the Sky Ridge Medical Center Emergency Department and secured a job as a Primary Care Medical Scribe after graduating from the University of Denver in 2018. Piotr is now attending Midwestern University’s PA program in Glendale, AZ.

Exposure, Health, High Altitude

Exostosis of the External Auditory Canal – Surfer’s Ear

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You do not have to be a surfer to have surfer’s ear, but what is it exactly?

Not to be confused with swimmer’s ear surfer’s ear or exostosis of the ear auditory canal is when there is the presence of multiple benign boney outgrowths. It is quite common in individuals who have repeated exposure to cold water or wind, which typically ends up being those who surf waves in the pacific.

So now that we know what surfer’s ear is, how can we tell if we have it?

The diagnosis of Surfer’s ear is made by visual exam with an otoscope by a medical provider. Generally, there are no symptoms of Surfer’s ear unless there are multiple bony outgrowths, or the ones present are occluding your ear canal. In those cases, you may experience ear infections as these outgrowths can narrow the ear canal causing water and debris to become trapped and cause an infection. When there is significant occlusion of the ear canal typically 90% or more conductive hearing loss may occur.

What is the treatment for surfer’s ear?

A great preventative tool, to decrease the occurrence of these bony outgrowths is to wear ear protection like ear plugs when you have exposure to cold water or earmuffs when exposed to cold winds. As mentioned above, when there is only a few and/or small boney outgrowths there tends to be no associated symptoms and in those cases no need for treatment. In those, however, that continue to have exposure to cold water/winds, have several boney outgrowths and/or significant occlusion the only definitive treatment is to have those bony outgrowths removed surgically, this is typically done by an Ear, Nose, and Throat specialist.

References

  1. Surfer’s ear. UCI Health Otolaryngology. https://www.ucihealth.org/medical-services/ear-nose-throat-ent/hearing-ear-disorders/surfers-ear. Accessed October 11, 2022.
  2. Weber PC. Etiology of Hearing Loss in Adults. UpToDate. https://www.uptodate.com/contents/etiology-of-hearing-loss-in-adults?search=surfers+ear§ionRank=1&usage_type=default&anchor=H9&source=machineLearning&selectedTitle=1~150&display_rank=1#H9. Published March 15, 2022. Accessed October 11, 2022.
A young woman with chest-length, curly, dark brown hair smiles showing bright white teeth, dressed in a white coat over a black top.

Gabriela Rodriguez Ortega is a second year Physician Assistant student at Red Rocks Community College in Arvada, CO. She grew up in South Florida and received a Bachelor of Science in Biomedical Sciences and Bachelor of Arts in Psychology from the University of South Florida (Go Bulls!). Prior to PA school, she held many positions in the medical field including ENT medical assistant/scribe, pharmacy technician and ER medical scribe. In her free time, she enjoys spending time with family and friends, running, hiking, roller skating and playing guitar.   

Altitude Science, COVID-19, Health, High Altitude, Pandemic

Altitude Promotes Better Survival Rates in Critically Ill Obese Patients with COVID-19: A Presentation from the Chronic Hypoxia Symposium

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The 8th Chronic Hypoxia Symposium is recently took place in La Paz, Boliva, and I had to pleasure of hearing Dr. Jorge Luis Velez’ presentation on altitude, obesity, and COVID-19 survival rates. Dr. Velez is an intensive care doctor and the head of critical medicine at Pablo Arturo Suarez Hospital in Quito, Ecuador, as well as being a professor at the Central University of Ecuador. With Quito being the second highest in elevation capital in the world at 9,350 feet, Dr. Velez understands the effects of altitude on the human body.

https://cdn.boundtree.com/assets/btm/University/Articles/ArticleHeroMobile-To-intubate-or.jpg

Dr. Velez conducted a study among 340 unvaccinated adult patients with severe COVID-19 infections requiring intubation. Of the 340 patients, 45% were obese, 43% were overweight, and 12% were of normal weight. The results of the study showed that obese patients had significantly reduced mortality rates and higher rates of successful extubation when compared to the overweight and normal weight groups. Successful extubation is commonly described as extubation without the need for re-intubation within 72 hours. Obese patients were found to have a 31.17% mortality rate and an 81.03% rate of successful extubation. Overweight patients were found to have a 40.14% mortality rate and a 73.00% rate of successful extubation. Patients of normal weight were found to have a 48.72% mortality rate and a 53.85% rate of successful extubation.

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These results are surprising given that obesity is a widely accepted risk factor for high severity COVID-19 infections and increased mortality. Other factors that may have contributed to the increased survival rates of obese patients with severe COVID-19 infections is that in their study, the obese patients happened to be on average younger and a higher proportion of males. Despite variables in age and sex, Dr. Velez still concludes with statistical significance that “patients with obesity had a 52% less probability of dying in relation to those of normal weight.”

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Despite this emerging research, we still recommend maintenance of a healthy weight and lifestyle, as the effects of a healthy weight have been extensively researched and proven to be beneficial for a heart health, joint health, mental health, sleep, the digestive system, and more.

Family Nurse Practitioner Ana Sofia Bedoya administering the new bivalent COVID-19 vaccine to Dr. Chris in her office at Ebert Family Clinic in Frisco, CO.

Looking for other ways to protect yourself from COVID-19?

The new bivalent vaccine uses the same technology with upgraded protection against the omicron variant. The vaccine is the best way to reduce risk for you and your family during the holiday season, as well as protecting from reinfection if you’ve already had COVID-19.

References

Luis Velez, J., 2022. Altitude Promotes Better Survival Rates in Critically Ill Obese Patients with COVID-19.

Artime, C. A. A., & Hagberg, C. A. H. (2014, June). Tracheal Extubation. Respiratory Care, 59(6), 991–1005. https://rc.rcjournal.com/content/respcare/59/6/991.full.pdf#:~:text=Successful%20extubation%20is%20dependent%20on%20two%20factors%3A%20the,a%20planned%20extubation8%3B%20however%2C%20this%20definition%20does%20not

Cameron Santiago is a second-year Physician Assistant Student at Red Rocks Community College in Arvada, CO. He grew up in Colorado Springs and received his undergraduate degree in Biology from Colorado State University. Prior to PA school, he was an inpatient phlebotomist and urgent care technician. In his free time, he enjoys fishing, hiking, and spending time with his dogs and family.

Acclimation, Altitude Science, Backpacking, Exposure, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering, Technology

High-Altitude Pulmonary Edema is not just for tourists

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HAPE can affect long term locals too. There is no specific test to diagnosis HAPE leading to delayed treatment or improper treatment, including death.

HAPE is defined as fluid accumulation in the lungs when an individual spends about 48 hours at elevations of 8,200 feet or higher. This can occur when 1) tourists who are not accumulated to high altitudes appropriately 2) locals who re-enter high altitude after being at lower elevation for a period of time or 3) long term residents who develop an illness.

What are the signs and symptoms you ask? Exhaustion, dyspnea on exertion, productive cough, tachypnea, tachycardia, low oxygen saturation levels, and crackles upon lung assessments are the most common to be seen. These are very generic symptoms and resemble many other diseases, such as pneumonia and asthma, leading to misdiagnosis and improper treatment.

How is HAPE treated?

The answer is simple, oxygen. The body is being deprived of oxygen and is unable to feed our cells. By giving oxygen (either through an artificial source or returning to lower elevation) and allowing the body to rest, the body is able to meet its demand for oxygen and symptoms resolve. If one receives oxygen and symptoms do not improve, there is most likely an underlying cause that is contributing to the symptoms unrelated to HAPE.

A pulse oximeter is the easiest way that one can monitor their oxygen levels at home. This device can be purchased over the counter, relatively inexpensive, and easy to use. By placing the pulse oximeter on one’s finger, the device will read the individual’s oxygen level which should be greater than 90% (when at altitude). The heart rate will also be recorded which tends to be between 60-100 beats per minute when at rest for adults.

References

A new mechanism to prevent pulmonary edema in severe infections. Lung Disease News. (n.d.). Retrieved September 2, 2022, from https://lungdiseasenews.com/2015/01/14/researchers-discover-a-new-mechanism-to-prevent-pulmonary-edema-in-severe-infections/

Bhattarai, A., Acharya, S., Yadav, J. K., & Wilkes, M. (2019). Delayed-onset high altitude pulmonary edema: A case report. Wilderness & Environmental Medicine, 30(1), 90–92. https://doi.org/10.1016/j.wem.2018.11.002

Fixler, K. (2017, October 12). Colorado doctor: Health effects of living in mountains unknown to medical establishment. SummitDaily.com. Retrieved September 2, 2022, from https://www.summitdaily.com/news/summit-county-doctor-makes-a-case-for-high-altitude-disorder-that-affects-even-the-acclimated/

Acclimation, Altitude Science, Athletic Training, High Altitude, High Altitude Training & Fitness, Hyperbaric Therapy, Technology

Interview with Retired Fighter Pilot Andrew Breithaupt: Altitude Earth and Sky

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I had the honor of interviewing Andrew Breithaupt who recently retired from US Customs and Border Protection in the Department of Homeland Security where he served as an Air Interdiction Agent piloting multiple types of aircraft.  He currently serves as a Lieutenant Colonel on active duty for the US Army, stationed in Minneapolis, MN.  He began Army flight school in 1992 to become a helicopter pilot, ultimately qualifying in 4 different types of Army helicopters including the UH-1H, OH-58, AH-1, and the AH-64 Apache for which he became an Instructor Pilot training new Army aviators at Fort Rucker, Alabama.  Later he began his transition to fixed-wing aircraft in the civilian community. After nearly 10 years of Army active duty and multiple overseas tours, he was selected to enter service for US Customs and Border Protection where he served as a federal law enforcement agent for over 20 years, retired in December of 2021.  He holds his commercial pilot license for single engine & multi-engine fixed wing as well as rotorcraft with instrument privileges and aircraft type ratings. He has over 30 years of aviation experience and more than 2,500 hours of flight time over his career. I sat down to chat with him about his accomplished career and learn more about his aviation and altitude expertise.

In army flight school, specifically aeromedical training, he was taught the effects of aviation on the body. One of the first lessons they learned in their training was how to recognize the early warning signs of hypoxia. These include shortness of breath, dysphoria, nausea, vomiting and lightheadedness. This type of training is often done in altitude chambers, so trainees can experience these effects before they are in the air, including how aviation can affect your vestibular senses. A position change as simple as looking down to change a radio or instrument can completely disorient a pilot due to the change in direction of the fluid within the inner ear against the cilia. This can lead to the sensation that the plane has rotated and flying sideways. They are taught to trust their instruments because an overcorrection can lead to what they teach in flight school as a “death spiral.” The training is often done in a Barany Chair and simulates vestibular senses experienced during flight.

Elevation in Summit County, Colorado ranges from 7,947 feet to 14,270 feet, the highest peak being Gray’s Peak. With people living as high as 11,200 feet, as Andrew does at his home in Blue River located south of of Breckenridge, CO.  Andrew shared some very interesting aviation altitude requirements which might surprise some. He spent much of his career operating non-pressurized helicopters and Federal Aviation Regulations prohibited him from going between 10,000 feet to 12,000 feet for more than 30 minutes without oxygen. When flying above 12,000 feet, pilots are required to have supplemental oxygen regardless of the amount of time spent at that elevation depending on the category of aviation being conducted such as commercial operations. This is according to the CFR (Code of Federal Regulations) Part 135 which governs commercial aircraft operations. How interesting is it that pilots have these regulations, yet many people who live in Summit County or those summiting 14ers (peaks at 14,000 ft. or above) are at or above these elevations with no supplemental oxygen on a daily basis. When flying private aircraft, CFR part 91.211 specifies flight crew can fly without pressurization or supplemental O2 below 14,000 feet and passengers below 15,000 feet.

While in the Army, Andrew would rarely operate aircraft above 8,000 feet and would typically not have supplemental oxygen on board. They were trained to begin descent immediately if they were to notice the early signs of hypoxia. Keeping a pilot’s license requires strict annual or even semi-annual FAA physicals and continued training to ensure their bodies can withstand the effects of aviation.  As you can imagine those holding these licenses are some of the most fit men and women in the country.  Andrew rarely felt the effects of altitude even with altitude changes as great as 8,000 feet coming from sea level. He would typically remain at these elevations for two hours or less piloting non-pressurized aircraft.

To give some perspective, when you hop on a commercial flight for your next adventure these planes typically fly around 28,000 to 36,000 feet of elevation. When beginning the ascent, the aircraft pressure stabilizes at 6,000 to 8,000 feet, approximately when the dreaded “popping of the ears” is felt. Supplemental oxygen and quick donning masks are required on all these aircraft in case depressurization were to occur due to the rapid hypoxia which would occur at such high altitudes.

Andrew moved to Summit County in November of 2021 from Stafford, VA with his wife and five sons ages 24, 22, 19, 14, and 11.  Andrew and his family spent a significant amount of time in Summit County for snowboarding and skiing competitions and quickly fell in love with the area prior to spending the last 5 years living in Stuttgart, Germany. This is when they decided one day, they would become full-time residents of the county. They moved here for the “people, climate and lifestyle,” a combination I am learning is hard to beat outside of Summit County. With ski and snowboard season right around the corner, he and his family are excited to get back out on the slopes.   Andrew currently travels between his home in Blue River and Minneapolis for his position in the Army. With each trip back he feels his body more quickly adjust to the altitude changes. Thank you for your service Andrew, and welcome to the community!

Ellie Martini grew up in Richmond, VA and is currently a second-year Physician Assistant student at Drexel University in Philadelphia, PA. She completed her undergraduate degree at The College of William and Mary in Williamsburg, VA where she received her BS in Biology. Before PA school she worked as a rehab tech and medical scribe at an addiction clinic. In her free time she enjoys hiking, biking, group fitness, traveling and spending time with friends and family. 

Backcountry, Backpacking, Exposure, Health, High Altitude, High Altitude Training & Fitness, Huts, Medicine, Mountaineering, Naturopathic Medicine, Wildlife

Lost, Stranded, and Hungry in the Mountains of Western Colorado? A Mini Guide to Edible Plants

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From backpacking and camping to skiing and snowboarding, there are plenty of activities outdoors in the Colorado high country. If you find yourself wandering around and lost without food in the mountains, there are several wild plants that you can eat. 

However, before you consume the delectable greens, there are a few precautions to take.

Moose shopping
  • Do not eat any wild plants unless you can positively identify them. There are iOS and Android apps that you can download prior to your hike to help distinguish plants, such as PictureThis and NatureID. 
  • Be aware of environmental factors such as pollution or animal waste. Avoid popular wild animal gathering areas.
  • Make sure you’re not allergic to the plant by rubbing it against your skin and observing for a reaction. If so, do not eat the plant. Before ingesting a large quantity, eat a small amount and check for a reaction. 

It may be difficult to cook if you did not come prepared with a portable stove, pots, and water, which could limit ways to enjoy vegetation. Here is a list of edible plants, how to identify them, where can they be found, and which part you can eat.

Wild plants

Dandelions (Taraxacum officinale): yellow ray florets that spread outward from center with toothy, deep-notched, hairless basal leaves and hollow stems. They can be found everywhere and anywhere. Every part of the dandelion plant is edible including the leaves and roots.

Yellow-green hemispheres bud in a bunch from green stems with pine needle-like leaves.

Pineapple Weed/ Wild Chamomile (Matricaria discoidea): the flower heads are cone-shaped and yellowish-green and do not have petals. Often found near walking paths and roadsides, harvest away from disturbed, polluted areas. If you’re feeling anxious about being lost, pineapple weed promotes  relaxation and sleep and serves as a  digestive aid.

Fireweed (Epilobium angustifolium): vibrant fuchsia flowers. Grows in disturbed areas and near recent burn zones. Eat the leaves when they are young as  adult leaves can stupefy you. Young shoot tips and roots are also edible. 

Wild onions (Allium cernuum): look for pink, lavender to white flowers with a strong scent of onion. They grow in the subalpine terrain and are found on moist hillsides and meadows. Caution: do not confuse with death camas. If it doesn’t smell like an onion and has pink flowers, it is not likely an onion.

Cattails (Typha latifolia or Typha angustifolia): typically 5-10 feet tall. Mature flower stalks resemble the tail of a cat. Grow by creek, river, ponds, and lakes. This whole plant is edible, from the top to the roots. Select from pollution-free areas as it is known to absorb toxins in the surrounding water.

Wild berries:

Wild strawberries (Fragaria virginiana): they are tiny compared to  store-bought. Can be identified by their blue-green leaves; small cluster of white flowers with a yellow center; and slightly hairy, long and slender red stems.

Huckleberries (Vaccinium spp): They grow in the high mountain acidic soil and flourish in the forest grounds underneath small, oval-shaped, pointed leaves. They resemble blueberries and have a distinguishable “crown” structure at the bottom of the berry. They can be red, maroon, dark blue, powder-blue, or purple-blue to almost black, and they range from translucent to opaque.

Deep blue berries stand out against bright red and green, waxy leaves.

Oregon grapes (Mahonia aquifolium): powder-blue berries, resembling juniper berries or blueberries, with spiny leaves similar to hollies that may have reddish tints.

Fun fact: The roots and bark of the plant contain a compound called berberine. Berberine has antimicrobial, antiviral, antifungal, and antibiotic properties.

Mushrooms

Brown whole and halved mushrooms lie on a green table with ridged, sponge-looking caps.

True morels (Morchella spp.): cone-shaped top with lots of deep crevices resembling a sponge. They will be hollow inside. A false morel will have a similar appearance on the outside but will not be hollow on the inside and are toxic. Morels are commonly found at the edge of forested areas where ash, aspen, elm, and oak trees live. Dead trees (forest wildfires) and old apple orchards are prime spots for morels.

Short, stubby mushrooms with white stems and brown camps stand in a row growing over grass.

Porcini (Boletus edulis): brown-capped mushrooms with thick, white stalks. Found at  high elevations of 10,500 and 11,200 ft in  areas with monsoon rains and sustained summer heat.

There are many more edible plants, flowers, berries, and mushrooms in the mountains. These are just 10 that can be easily identifiable and common in the Western Colorado landscapes. I recommend trying out the apps listed above and reading “Wild Edible Plants of Colorado” by Charles W. Kane, which includes 58 plants from various regions, each with details of use and preparation. Hopefully this post made you feel more prepared for your next adventure. 

Resources:

Davis, E., 2022. Fall plant tour: Frisco, CO | Wild Food Girl. [online] Wildfoodgirl.com. Available at: <https://wildfoodgirl.com/2012/eleven-edible-wild-plants-from-frisco-trailhead/> [Accessed 10 July 2022].

McGuire, P., 2022. 8 Delicious Foods to Forage in Colorado | Wild Berries…. [online] Uncovercolorado.com. Available at: <https://www.uncovercolorado.com/foraging-for-food-in-colorado/> [Accessed 10 July2022].

Rmhp.org. 2022. Edible Plants On The Western Slope | RMHP Blog. [online] Available at: <https://www.rmhp.org/blog/2020/march/foraging-for-edible-plants> [Accessed 10 July 2022].

Lifescapecolorado.com. 2022. [online] Available at: <https://lifescapecolorado.com/2014/01/edible-plants-of-colorado/> [Accessed 10 July 2022].

Pfaf.org. 2022. Plant Search Result. [online] Available at: <https://pfaf.org/user/DatabaseSearhResult.aspx> [Accessed 10 July 2022].

Cindy Hinh is a second-year Physician Assistant student at Red Rocks Community College in Arvada, CO. She grew up in southern Louisiana and received her undergraduate degree in Biology from Louisiana State University. Prior to PA school, she was a medical scribe in the emergency department and an urgent care tech. In her free time, she enjoys baking, cooking, going on food adventures, hiking, and spending time with family and friends.

Acclimation, Exposure, Health, High Altitude, High Altitude Training & Fitness

Non-Freezing Cold Injury

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Eighteen-year-old, NorAm skier, NCAA Division I Rugby player, and lover of the outdoors, presents to the clinic complaining of cold, painful hands. She states hands always feel cold, and in cold weather they are extremely painful. Blood tests to rule out vascular disease were normal. What could be the cause of this?

Normally, in cold weather our bodies work to keep essential organs functioning. Skin is not considered essential. When exposed to cold, blood vessels constrict, decreasing blood flow to the skin. Because the metabolic demand of our skin is low, more important organs like our heart and brain need the blood flow. Paradoxically, exposure to cooler temperatures like those below 15 degrees Celsius or 59 degrees Fahrenheit can cause cold-induced vasodilation. This allows blood to flow to the skin to help prevent more serious injury or frostbite. The vasodilation cycles in 5- to 10-minute intervals.

Nonfreezing cold injury (NFCI) occurs when tissues are damaged due to prolonged cooling exposure, but not freezing temperatures. NFCI is due to exposure of the extremities to temperatures around 0 to 15°C or 32 to 59°F, commonly the hands and feet. Current theory is that NFCI is due to a combination of vascular and neural dysfunction. With prolonged vasoconstriction, the skin experiences reduced blood flow with a neurological component influencing the damage as well.

Some patients living in cold environments like the Inuit, Sami people, and Nordic fisherman have a larger cold-induced vasodilation response and more rapid cycling. This is thought to decrease their risk of NFCI. Is it possible that patients who develop NFCI have a smaller and slower cycling of their cold-induced vasodilation? Could this be the issue with our patient with NFCI?  Further research is needed to learn more about NFCI and find better ways to treat it.

What we do know is there are 4 Stages of NFCI:

Stage 1: During the cold exposure – Loss of sensation, numbness, clumsiness. Usually painless unless rewarming is attempted.

Stage 2: Following cold exposure – occurs during and after rewarming. Skin can develop a mottled pale blue-like color, area continues to feel cold and numb, possible swelling. Usually lasts a few hours to several days.

Stage 3: Hyperemia – affected area becomes red and painful. Begins suddenly and lasts for several days to weeks.

Stage 4: Following hyperemia – affected areas appear normal but are hypersensitive to the cold. Areas may remain cold even after short exposure to the cold. This stage can last for weeks to years.

Mountains covered in pine forests reach up past tree line toward a deep blue sky spotted with fluffy white cumulous clouds over two people in bikinis standing on paddle boards reflected with the clouds in the dark water below them.

Outdoor paddle sports like kayaking and canoeing put patients at greatest risk due to the continual exposure to the cold, wet environment. It was thought that in order to have NFCI, one had to be exposed to both cold and wet environments. However, it has been shown that this is not always the case. Like in our patient, exposure to just cold environment can trigger the syndrome. Our 18-year-old patient is an avid skier and spends most of the winter on the mountain. It was also noted that she enjoys paddleboarding and kayaking, which were recognized as triggers for the hand pain. We are unable to determine exactly what caused our patient to develop this syndrome. But we do know it affects their life significantly.

 We choose to live in the mountains because of the things we love. Whether it is hiking, biking, skiing, kayaking, paddleboarding, or the hundreds of other activities offered in this area, we are at risk of NFCI. Currently, there is no good treatment for this syndrome. Prevention is  best. The purpose of this blog is to share information about staying healthy at high altitude. Sharing this information on the stages of NFCI with friends and family will help prevent this painful, debilitating syndrome.

Resources

Nonfreezing cold water (trench foot) and warm water immersion injuries. UpToDate. https://www.uptodate.com/contents/nonfreezing-cold-water-trench-foot-and-warm-water-immersion-injuries/print#:~:text=Nonfreezing%20cold%20injury%20%E2%80%94%20NFCI%20is,to%2059%C2%B0F)%20conditions. Accessed July 14, 2022.

Oakley B, Brown HL, Johnson N, Bainbridge C. Nonfreezing cold injury and cold intolerance in Paddlesport. Wilderness & Environmental Medicine. 2022;33(2):187-196. doi:10.1016/j.wem.2022.03.003

Rachel Cole is a Physician Assistant Student at Red Rocks Community College in Denver, Colorado. She originally grew up in Salt Lake City, Utah, where she learned to love the outdoors. She studied Biology at Western Colorado University in Gunnison, Colorado prior to PA school. She played soccer for the college and fell in love with Colorado and small mountain towns. When she is not studying for school, she enjoys skiing, hiking, backpacking, fishing, waterskiing, canyoneering, and any other activities that get her outside. After graduation she hopes to practice family medicine in a rural community in the mountains.