Category Archives: Backpacking

Acclimation, Backpacking, Exposure, Health, High Altitude, Mountaineering

The Ups and Downs of Life in the High Country 

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By Renée Thakali

Life has plenty of dips and ascents but when living and working at altitudes over 9,000 feet above sea level the ups and downs can have a significant impact on your body. For the past 50 years I’ve had the pleasures and pains of living and working at high altitudes in Nepal and Colorado and at more ordinary altitudes (300 to 600 feet) in the midwestern USA and even at sea level on a tropical island in the Pacific Ocean. It’s no surprise to me that it was much easier to acclimate, live, climb and work in the higher altitudes when I was in my 20’s and and 30’s, than at later ages in my 60’s and early 70’s. 

I have never been and never will be a mountain climber. Yet my work in conservation and forestry and my recreational pursuits in Nepal and Colorado have led me to some precariously high mountainous spots. By the time I reached my post in Marpha village in the lower part of Mustang District in Nepal, I had already completed two years of Peace Corps service in the lower hills of central Nepal (3,000 to 8,000 feet in elevation). Every day of travel in Nepal meant trekking (hiking) on hand built stair steps made of rock, some which felt like the endless stairway up to heaven. In Nepal the hills and mountains are endless and it seems like you never reach the top. And what goes down usually has to go back up if not even higher! A daily 8 hour trek can rise up more than 4,000 to 6,000 feet and then go back down all in the same day. Fortunately, where I worked and lived there were plenty of small rustic tea shops, which served hot sweet milky tea and biscuits or a fried rice flour donut for snacks, and morning rice and beans or dal bhaat to fuel travelers. From the nearest city with motorable roads, it generally took me 5 days of trekking up and down the hills (in the USA these “hills” would be considered mountains by most people) to reach Marpha, a tight cluster of flat roofed, white houses below a towering cliff along the Kali Gandaki River at about 8,000 feet in elevation.  

I occasionally climbed on steep narrow trails to reach the nearest forests that were at least 2,000 feet above Marpha, closer to the high Himalayan mountains of Tukuche Peak and Dhauligire towering nearby.  I marvelled at my local Nepali companions who hiked up these high trails almost daily to gather firewood or graze their sheep and yaks and yet they seemed to never get out of breath or have any difficulty carrying heavy loads of firewood with a simple tumpline or (naamlo) strapped across their forehead, while I stopped to rest frequently and to catch my breath once I got to about 10,000 feet. (All elevations mentioned here are approximate as I did not have an altimeter.  I recently checked on Google Maps for elevations of most places mentioned in this article.) 

Several times I trekked up to Muktinath, which took a whole day to reach by foot and lies at about 13,000 feet.  Even then in my early 20’s once I reached over 10,000 feet in altitude, my hiking pace slowed down considerably and it was definitely harder to breathe and to continue taking steps up and up. The local girls I was with held onto the tails of their horses to get assistance up the trail. At Muktinath I had a slight headache and even walking up one flight of stairs was difficult. I stayed for a few days and had no other symptoms that I can recall. 

A few years later I moved to Gunnison, Colorado and worked daily in the high country of the Gunnison National Forest as a forester. Gunnison lies at about 8,000 feet and almost every day I drove to reach the forested lands from 10,000 to 12,000 feet in elevation. I was usually at the higher elevations for about 6 hours a day, walking in the wild forest lands and even traveling by cross country skis and snowshoes in the winter to complete my forestry work. I usually experienced mild headaches in the higher country and it was always a relief to drive my jeep back down the forest roads to the lower country in the late afternoons. 

Wouldn’t you know that my next forestry assignment was on the tiny tropical island of Saipan at sea level in the middle of the Pacific Ocean!  No problem with elevation there, but I did have to acclimate to a tropical humid climate 24/7 and 365 days a year. 

We took a vacation to Nepal to visit family after we had spent almost two years on Saipan. It was the warm wet monsoon season and no airplanes were able to fly up to Jomsom. There were no roads to Jomsom back then. Our only option was to hike or trek the 5 days to Marpha and then another 2 hours beyond to the village of Thini which lies at about 9,000 feet. We arrived wet and tired. After a week of resting we next trekked up to Tilicho Lake, one of the world’s highest lakes at about 16,000 feet. It isn’t that far by distance from the village of Thini to Tilicho Lake, but we first had to climb over the high Meso Kanto La (pass) at about 18,000 feet, (the highest elevation that I have reached). 

On Day 1, we camped a few thousand feet below the pass at approximately 14,000 feet. My head was pounding hard and I don’t think I was able to sleep much that night. The trail ended at the camp site and the next morning we forged up and onward over the steep rocky mountainside. To make it a bit easier I made frequent switchbacks or turns, zig zagging back and forth, up and up to the 18,000 foot pass. It was very difficult for me and maybe took a few hours to climb up 4,000 feet in elevation. My head ached, it was hard to breathe, and I took short frequent breaks until I finally reached the pass, where the rest of my family were waiting for me. My 9 year old daughter had no problem easily following her 50 year old Nepali uncle and 21 year old cousin who seemed to trek straight up from the camp to the pass. She was even smiling as she greeted me. I could barely talk and I am pretty sure I was not smiling then. It was much easier to go down the steep slopes to Tilicho Lake where we camped one night at about 16,000 feet. I had a pounding headache the whole time and looked forward to day 3 when we retraced our steps back up to the Meso Kanto La pass and then followed the trail all the way back to Thini village. I was exhausted and my legs felt like jelly, but it felt wonderful to be back at a lower elevation of 9,000 feet and in a warm house with hot soup for dinner and a comfortable dry bed to sleep in. 

Fast forward a few decades, I’ve retired and we are back in Nepal, this time trekking into some high country in Kanchenjunga National Park in eastern Nepal, not to climb the peaks but to view the mountains and the blooming rhododendron trees in the high forests. No longer in my 20’s or 30’s, I am 60 years old. I now trek at a much slower pace and find it harder to climb higher than about 10,000 feet, feeling breathless and often experience an aching sharp pain from muscle spasms in the middle of my back as I try to climb the endless rock lined steps up the trails. There were two times during the 6 day trek that I had to turn back and go down after reaching at least 10,000 feet. The trails were wet, snowy, slippery, among thick forests of pine, fir, rhododendron and oak. One day I reached a rustic yak herder shelter and could go no further.  It snowed that night, and melted snow dripped through the wooden shakes of the roof of the shelter onto my sleeping bag. The morning was bright and clear and the yak herder convinced me to climb up another 1,000 feet to view Kanchenjunga mountain peak. He carefully took my hand and pulled me up the steep, slippery rocky slope to a viewing site and then carefully held my hand as I slipped back down to the shelter. I am no agile mountain goat!

A family of two adults and two youth in warm mountaineering clothing pose in front of a large rock at a high alpine lake with snow covered mountains in the background.
Renee Thakali, Hem Bahadur Thakali, Asa Thakali and Keshari Thakali. Tilicho Lake at about 16,000 feet altitude, in the Annapurna Range of Mountains, near Thinigaon, Nepal. August, 1990.

A month later we rode on mountain bikes up from Jomsom at 8,000 feet to Kagbeni at about 10,000 feet on Day 1 of a mountain bike tour. On Day 2 we continued to pedal up the gravel road to Muktinath at about 13,000 feet in elevation.  There were a few steeper road sections above 11,000 feet near Jarkot where I had to dismount and push my bike up the road. I had no energy or breath left to pedal uphill and I was using the easiest gear possible. I took an Ibuprofen before bed to lessen my headache and I certainly enjoyed the fast downhill ride back to Jomsom. 

Fast forward another 9 years. I am now 70 years old, live at 300 feet in elevation in central Arkansas and we are visiting Nepal again. This time we reached Jomsom and Thini village at 9,000 feet by bus from Pokhara, a day-long journey over treacherous roads alongside steep cliffs and numerous landslides. At this age I know to pace myself and to take plenty of time to acclimate. I did not get headaches but I did have a scratchy sore throat for three weeks, which promptly disappeared after I returned to the low and warm valley in Pokhara. While in Thini I  was able to take longer walks and hikes to higher locations each week. By the third week I was hiking for 4 to 6 hours and made it to sites up to about 10,000 feet before turning back and going down to Thini village. On only one occasion did I experience exhaustion and those painful back spasms during the last few hours of a long day trek where we reached almost 11,000 feet. The next time I did a long day trek I took one capsule of Ibuprofen early in the day to prevent the back pain and that seemed to work. 

At this age, I no longer want to climb up to the forests above Thini and Marpha like I used to 30 or 40 years ago. I am content to look at them from far below. These days travelers can zip to upper Mustang villages at elevations from 12,000 to 14,000 feet and higher in only one day from Jomsom via 4 -Wheel Drive jeep or even by motorcycle, which is no problem for the local people who have lived at these extremely high elevations for centuries, but it can be an issue for lowlanders from India or other foreign countries which lie at much lower altitudes. Prior to the road construction it used to take trekkers and locals on foot or horseback at least 4 to 5 days to reach Upper Mustang villages from Jomsom giving them time to slow acclimate to the higher altitude. I’ll stay safe at home and look at the pictures of the wild places in upper Mustang in the colorful coffee table books in my living room. 

A woman with short hair and glasses smiles wearing a bright yellow scarf and blue shirt.

Renée Thakali has lived, worked and recreated at high elevations for many years. She first went to Nepal as a Peace Corps Volunteer in 1977 where she began a lifelong adventure of travel and working in community conservation projects. While in Nepal she met her future husband Aita Thakali and his family in Thini village, Mustang District, located in the high Himalayan mountains near Annapurna and Dhaulagiri peaks. Renée worked for more than 35 years as a forester for the United States Forest Service in four states including Colorado in the high Rocky Mountains in and around Gunnison. Her other international forestry assignments took her to Afghanistan; the Philippines; and to the tropical Pacific island of Saipan to restore forests and train the local forestry workers. She fills her spare time with photography, cycling, trout fishing, swimming, traveling, and visiting family. She has a B.Sc. in Natural Resources and a M.S. in Forest Management from Michigan State University. Renée is a member of the Pit River tribe, an indigenous tribe in northeastern California. Renée has two grown daughters and lives in Conway, Arkansas with her husband and two cats.

Altitude Science, Athletic Training, Backcountry, Backpacking, Child Growth & Development, Doc Talk, Exposure, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering, Resources, Uncategorized

UPDATE FROM ENGLAND: INTERNATIONAL SOCIETY OF MOUNTAIN MEDICINE CONFERENCE

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Dr Chris was invited to present a poster : “Chest X-ray Findings on 139 Hypoxic Children at High Altitude” in the Peaks District three hours north of London. She also gave a presentation with slides to the assembly of over 200 doctors from around the world-Japan to Kyrgyzstan. She introduced our book “Surviving and Thriving at Altitude” in the section on mountain literature and addressed a small group with an overview of conditions she sees in children at altitude. The meeting was held in a tent with the participants in their puffy jackets carrying their backpacks.

Speakers covered topics relevant to mountain living including “Women at Altitude”, “Children at Altitude”, hypoxic training for athletes, REDs: relative energy deficiency syndrome, climate change, hypothermia, frostbite, and more.

A concern here in Colorado with so many world class athletes, especially adolescents, is the balance between calories burned and calories needed for maximum muscle development and performance. REDs affects every system in the body, from sleep to mental and physical well-being. German orthopedic and trauma surgeon Volker Schoffl works with Olympic athletes using a questionnaire for initial screening, blood tests and physical exam to establish the diagnosis. A team of psychologists, nutritionists and physicians determine and implement treatment.

Experts from The Altitude Centre in London, James Barber and Dr. Patrycja Jonetzko, a cardiothoracic anesthesiologist, described programs to prepare athletes competing in low oxygen environments. Using equipment to create a hypoxic environment such as face masks and tents, they expose subjects for various lengths of time from minutes to hours during the weeks leading to the event. They described progress towards individualized targeted programs to increase mitochondrial efficiency.

Physiology of altitude adjustment

Dr Deborah Miller spoke during the section on “Children at Altitude” . She had just spent three months working as a pediatrician in Saipan in Micronesia where we first met. Her altitude expertise comes not only from several rotations in remote mountain clinics but personal experience with altitude illness in her children in Nepal and Colorado. She described her experience at the HRA Clinic in Nepal, at 14,300 ft. Her talk included environmental exposures with descriptions of sun toxicity. Ultraviolet radiation exposure is increased by 90% due to reflection of light from snow compared to 15-30% from sand or 5-20% from water. Treatment is similar to that for hives with antihistamines and topical steroids.

Dr Miller shared guidelines for estimated walking distances with children from momgoescamping.com. Start with ½ mile per year of age, reduce by 50% for steep elevation, increase by 10% if the destination is of interest to the child and by 25-50% if they have friends along.  Now for the pack: decrease distance by 10% while assuming you will end up carrying it, and another 10% if you have a heavy pack.

The final and most important points from both her and Dr. Chris’ experience about children visiting altitude are:

  1. Previous excellent altitude performance does not always predict future performance
  2. Recent illness can play a role (and make them more susceptible to altitude illness)
  3. Emergency plans are important
  4. HAPE can take a long time to fully resolve

The day devoted to frostbite and hypothermia highlighted the importance of international registries and cooperation for progress in these devastating conditions. Although Canada, Alaska and Scandinavia have many cases the group leading investigations is based in Minnesota, where extremely cold winters and homelessness create conditions that make frostbite and hypothermia common. Rachel Nygaard, PhD discussed her work in this field.

There were fascinating and complex discussions about how and when to combine the various drugs used for resuscitation from cardiac arrest in hypothermia and the vasodilators for frostbite.  Of course, there was emphasis on the universal adage that “no one is dead until they are warm and dead”, citing cases of cardiac arrest for over 2 hours with full recovery.

There were many more interesting sessions and much informal learning and networking. Dr. Chris was reacquainted with physicians who remembered her presentations at conferences in Telluride in 2016, Snowbird in 2024 and Lake Louise in 2025.

Support sharing information and promoting research through the nonprofit Summit High Altitude Information & Research.

Dr. Christine Ebert-Santos stands at a podium against a dark background.
Dr. Christine Ebert-Santos stands in front of a poster with graphics and text describing high altitude research.
Avalanche Safety, Backcountry, Backpacking, Exposure, High Altitude, Huts, Mountaineering, Resources

THE WAY OUT

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A TRUE STORY OF SURVIVAL IN THE HEART OF THE ROCKIES

This book by long time Colorado high country resident, writer and hut master Devon O’Neil is essential reading (or listening) for everyone who loves nature, mountains, rivers, adventure, or snow. Skillfully written to weave in  stories of tragedies and near-misses, he includes details about avalanches, frostbite, hypothermia, river raft catastrophes, mountain bike crashes and moose attacks- something for everyone!

We are including a review of this book on highaltitudehealth.com because the true story it describes is a scenario not unlike many others that have occurred (and always has the potential to play out) at so many backcountry high altitude excursions. At a recent author event with Devon at Next Page Books in Frisco, CO, the author even noted that part of the appeal and thrill of these experiences are the risks inherent in the activity, which includes, not least of all, changeability of weather and conditions in high altitude environments.

Two bright headlamps shine in darkness over snowy trail.
Headlamps of hut trip members searching for late arrivals

The main story involves a group of families from Salida, Colorado who embark on a trip to Uncle Bud’s Hut at 11,000 ft. Fathers and their teens come from a variety of backgrounds but all with some expertise in medicine, rescue, and extreme sports. When a snowstorm comes in and two of them are separated and missing the rescue team is also broad, experienced, and personally committed to finding their friends. All the family members affected by this event are skillfully and sympathetically portrayed.  Colorado readers will relate to the locations, relationships and situations.  O’Neil includes a thoughtful discussion of the risks we take in our sports and recreation and how it can affect us and our families in the years to come.

This narrative contains crucial information for staying safe as described in our blog posts about climbing fourteeners and hut trips, such as wearing layers of wear clothing that wick moisture, carrying adequate nutrition and water, using communication devices with backup power sources, strategizing fire starting materials, and avoiding dangerous wildlife.

In spite of the dangerous events described in this particular account, Devon also noted personally that his aim was not to diminish the importance of embracing the adventure of being in the outdoors in the face of risk. It is in the risks, after all, that we find so much of the thrill of every outdoor adventure.

I expect someday this book will be a movie, bringing Into Thin Air (the book by Jon Krakauer that was a hit movie) to our backyards..

Windows shine light on late sleepers in their sleeping bags at hut

Backcountry, Backpacking, Exposure, Health, High Altitude, Huts, Mountaineering, Summit Huts

Lightning Strikes in Colorado

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My love for hiking developed during my childhood explorations of the breathtaking landscapes of the Sierra Nevada. As I ventured into the rugged mountains and hiked along scenic trails, I couldn’t help but feel a deep connection with nature. However, my passion for hiking was not without its moments of caution. On several occasions, I witnessed the awe-inspiring yet intimidating power of lightning storms dancing across the vast mountain skies. These encounters instilled in me a profound curiosity about the risks associated with lightning strikes in high-altitude regions.

When I moved to Colorado for PA school, my awareness of the dangers posed by lightning strikes grew even stronger. The dramatic topography and frequent thunderstorms in Colorado amplify the risk for individuals exploring high-altitude areas. It was during my last clinical rotation at a burn unit that I had the opportunity to care for several patients who had been struck by lightning. Witnessing the effects firsthand fueled my determination to educate the public about the actionable steps they can take to stay safe during lightning storms.

Lightning strikes

​Lightning possesses an immense amount of energy, with a voltage of over 10 million volts (in comparison, most car batteries measure 12.6 V).1 Additionally, a lightning bolt reaches incredibly high temperatures, reportedly up to 30,000 Kelvin (53540.33 F).1 Lightning injuries occur in different ways, including as direct strikes, side splash, contact injuries, or ground current. 

Direct strikes are uncommon, accounting for only 5% of cases, and happen when a person is directly struck by lightning.2

Contact injuries occur when a person touches an object that is struck by lightning. 2

Side splash injuries occur when the current jumps or “splashes” from a nearby object and then follows the path of least resistance to reach the individual. These injuries make up about 1/3 of all lightning related injuries. 2

Ground current is the most prevalent cause of injury, accounting for half of all cases, and occurs when lightning strikes an object or the ground near a person and subsequently travels through the ground to reach the individual. 2

In Colorado, an average of 500,000 lightning flashes hit the ground each year. Based on data since 1980, lightning causes 2 fatalities and 12 injuries per year throughout the state.3According to data since 1980, lightning causes an average of 2 fatalities and 12 injuries annually throughout the state. 3 Colorado ranked third in the United States for the number of lightning fatalities between 2005 and 2014, as depicted in Figure 1.

Fig. 1. Lightning fatalities by state. 3

The high number of injuries attributed to lightning in Colorado can be influenced by several factors. One of these factors is the easy access to high elevation terrain, such as 14ers (mountains with a peak elevation of at least 14,000 feet). This accessibility allows inexperienced outdoor enthusiasts to venture into potentially dangerous situations due to their lack of knowledge and preparation.

For instance, individuals who are not familiar with summer weather patterns may embark on a hike above the tree line late in the day, underestimating the risk of a storm forming. This lack of understanding puts them in an exposed and perilous position should adverse weather conditions arise.

Even with thorough preparation and extensive knowledge of weather patterns, it is still possible to find oneself in a situation where you have to weather a storm. Given that a significant proportion of Colorado’s hiking trails are located above the tree line, where appropriate shelter is sparse, hikers are more susceptible to lightning strikes in these exposed areas. 

Pathophysiology of Lightning Strike Injuries

The overall ratio of lightning injuries to deaths is 10:1 and there is a 90% chance of sequelae in survivors.4 The primary mechanism of injury in lightning strikes is the passage of electrical current through the body. The high voltage and current can cause tissue damage through several mechanisms, including thermal injury, electrical burns, and mechanical disruption of tissues. The severity of the injury depends on factors such as the voltage and current of the lightning bolt, the duration of contact, and the pathway the current takes through the body.

Lightning strikes can cause various types of injuries, with cardiac and respiratory arrest being the most common fatal complications.5 The path of least resistance determines the flow of electricity through different organs in the body, with nerves being the most conductive, followed by blood, muscles, skin, fat, and bone. 5 When lightning strikes, the electrical surge can induce cardiac arrest and cessation of breathing by affecting the medullary respiratory center. As a result, most patients initially present with asystole and may progress to different types of arrhythmias, commonly ventricular fibrillation. 5

Interestingly, there have been case reports documenting successful resuscitation of lightning strike victims who were initially apneic and pulseless for as long as 15 to 30 minutes. 5This has led to the recommendation that in the immediate aftermath of a lightning strike, individuals who appear to be dead should be prioritized for treatment.

Superficial skin burns are experienced by around 90% of lightning strike victims, but deep burns are less common, occurring in less than 5% of cases. A characteristic skin manifestation of a lightning strike is the Lichtenberg figure, which is considered pathognomonic. Neurological symptoms can also occur, including keraunoparalysis, which is a transient paralysis affecting the lower limbs more than the upper limbs. This paralysis is often accompanied by sensory loss, paleness, vasoconstriction, and hypertension, and is thought to result from overstimulation of the autonomic nervous system, leading to vascular spasm. In most cases, this paralysis resolves within several hours, but in some instances, it may last up to 24 hours or cause permanent neurological damage. 5

Additionally, it is common for lightning strike victims to have a perforated tympanic membrane (eardrum) or develop cataracts immediately following the incident. These injuries to the ear and eyes are associated with the intense energy of the lightning discharge. 6

What can hikers do to stay safe?

Preparation

Monitor weather forecasts: Stay updated on weather conditions before engaging in outdoor activities, especially in areas prone to thunderstorms. Pay attention to thunderstorm warnings or watches issued by local authorities. Having a mobile or handheld NOAA Weather Radio All-Hazards (NWR) can also be helpful as it can transmit life-saving weather information at a moment’s notice. 

In Colorado most thunderstorms develop after 11 am, so it is best to plan your trip so that you are descending by late morning.7 Fig. 2 shows number of lightning fatalities by time of day in Colorado between 1980 and 2020. The vast majority take place after the 11 am threshold.

Fig. 2  Lightning fatalities in Colorado by time of day3

What to Do If Caught in a Storm

If you can hear thunder, you are close enough to be struck by lightning. Lightning can strike up to 25 miles away from the storm. 7 Once you hear thunder, if possible quickly move to a sturdy shelter (substantial building with electricity or plumbing or an enclosed, metal-topped vehicle with windows up). Avoid small shelters, such as picnic pavilions, tents, or sheds. Stay sheltered until at least 30 minutes after you hear the last clap of thunder.

Fig 3. Areas to avoid when sheltering from lightning.

If you are outdoors and cannot reach a suitable shelter, avoid open areas, hilltops, and high places that are more exposed to lightning strikes. Seek lower ground and stay away from tall objects, such as trees, poles, or metal structures. Bodies of water, including lakes, rivers, pools, and even wet ground, are conductive and increase the risk of a lightning strike. Move away from these areas during thunderstorms. Separate group members by at least 20 ft as lightning can jump up to 15 feet between objects.

​If a strike is eminent (static electricity causes hair or skin to stand on end, a smell of ozone is detected, a crackling sound is heard nearby), the current recommendation is to assume “lightning position”, pictured in Fig. 4.

Fig. 4. Lightning position8

To potentially reduce the risk of ground current injury from an imminent lightning strike, another strategy is to insulate oneself from the ground. This can be done by sitting on a pack or a rolled foam sleeping pad. However, it’s important to note that this and the lightning position should be considered a strategy of last resort and not relied upon as the primary means of prevention. Maintaining this position for an extended period can be challenging, and it’s crucial to prioritize seeking proper shelter and following established lightning safety guidelines to minimize the overall risk of injury. 5

Case Study

25 YO F presents to the Burn Unit as a transfer from Cheyenne Regional Medical Center s/p lighting strike. Patient (pt) was caught in a thunderstorm on a hike and sheltered under a tall tree. Suddenly, she felt like she was being lifted up into the air and then dropped. Pt had a brief (<5 sec) loss of consciousness (LOC). When she woke up, she was completely numb and couldn’t move any of her extremities. Witness (friend) states the lightning splashed from the tree to the pt. Pt denies hitting her head with the fall. She denies taking blood thinners. She has no past medical history (PMHx) or past surgical history (PSHx).

Physical exam 

Neuro: AOX4, No CN deficit on exam, LE paralysis resolved, LE paresthesia improving but still present

HEENT: L ruptured tympanic membrane, hearing loss on L side

CV: RRR

MSK: Soft compartments diffusely

Skin: Lichtenberg figures on bilateral LE 

Fig. 6. Lichtenberg figure on LLE

V/S: BP: 128/92, HR: 96, RR:18, SPO2: 98%, Temp 98.1F. 

CBC, CMP, troponin were all WNL. Serum hCG negative. CK mildly elevated (222) 

EKG showed NSR.

CXR, CT brain, and c-spine neg for acute injury

She was admitted to the UC Health burn center for observation with tele. Her lab work and vitals remained stable throughout her hospitalization. She was evaluated by the trauma team with a negative trauma work up. The day of discharge, she was tolerating a regular diet, ambulating and sating well on room air. She was deemed appropriate for discharge home without patient audiology and ophthalmology follow up. 

References

1. US Department of Commerce N. Understanding lightning science. National Weather Service. April 16, 2018. Accessed July 8, 2023. https://www.weather.gov/safety/lightning-science-overview. 

2. Cooper MA, Holle RL. Mechanisms of lightning injury should affect lightning safety messages. 21st International Lightning Detection Conference. April 19-20, 2010; Orlando, FL. 

3. US Department of Commerce N. Colorado Lightning statistics as compared to other states. National Weather Service. March 4, 2020. Accessed July 7, 2023.https://www.weather.gov/pub/Colorado_ltg_ranking. 

4. US Department of Commerce N. How dangerous is lightning? National Weather Service. March 12, 2019. Accessed July 8, 2023. https://www.weather.gov/safety/lightning-odds. 

5. Chris Davis, MD; Anna Engeln, MD; Eric L. Johnson, MD; Scott E. McIntosh, MD, MPH; Ken Zafren, MD; Arthur A. Islas, MD, MPH; Christopher McStay, MD; William R. Smith, MD; Tracy Cushing, MD, MPH. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Lightning Injuries: 2014 Update. WILDERNESS & ENVIRONMENTAL MEDICINE. 2014; 25, S86–S95 

6. Flaherty G, Daly J. When lightning strikes: reducing the risk of injury to high-altitude trekkers during thunderstorms. Academic.oup.com. Accessed July 8, 2023. https://academic.oup.com/jtm/article/23/1/tav007/2635599. 

7. NWS Colorado Offices – Boulder G. Colorado Lightning Awareness Week june 19-25, 2022. ArcGIS StoryMaps. June 25, 2022. Accessed July 8, 2023. https://storymaps.arcgis.com/stories/11d021f1b800429a869ead2dc32c0f96. 

8. McKay B and K. How to survive A lightning strike: An illustrated guide. The Art of Manliness. April 25, 2022. Accessed July 8, 2023. https://www.artofmanliness.com/skills/outdoor-survival/how-to-survive-a-lightning-strike-an-illustrated-guide/. 

A woman with long, light brown hair over her shoulders wearing a blue, sleeveless shirt with red details smiles with blue eyes.

Sophia Ruef is a Physician Assistant student at Red Rocks Community College in Arvada, CO. She grew up on the central coast of California and earned her Bachelor of Science degree inBiology with a concentration in anatomy and physiology from Cal Poly San Luis Obispo. She worked as an EMT and a tech in the Bay Area after her undergraduate education. In her free time, she enjoys hiking, backpacking, canyoneering, and spending time with family and friends.

Acclimation, Altitude Science, Backcountry, Backpacking, Health, High Altitude, Huts, Medicine, Mountaineering, Technology

New Use for Existing Technology and HAPE/HACE

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by Kaity Barker-Grasser, FNP

Ultrasound itself is not an unfamiliar technology to most, having been used in obstetrics and gynecology (OB/GYN) for many years. Newer research is now showing that ultrasound imaging may have good applicability in both high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema (HACE). Pulmonary edema (or fluid in the lungs) is identified as “B-lines” or “comet tails” and is easily distinguishable on ultrasound (Gargani, 2019).

Illustration of the rib cage and clavicle bones indicating different probe positions to scan the lung using Ultrasound, accompanied by two images of lung Ultrasounds where asterisks indicate shadows of the ribs and white arrows indicating the pleural line.
Gargani, 2019

Using ultrasound to measure the diameter of the optic nerve can also assist with a diagnosis of HACE, as an increased diameter indicates increased intercranial pressure from HACE (Shookahi et al., 2020). The advantages of ultrasound over traditional imaging include being highly portable and usable in austere environments (such as back country), no radiation like many other imaging techniques, accurate for diagnosing pulmonary edema and other conditions, and takes little time for providers to master. Ultrasound also has a significant cost savings as the machine itself is relatively inexpensive, does not require special construction like adding lead to an Xray room, and is applicable in many other diagnoses (including kidney disorders, gallbladder disease, pneumonia, trauma, muscular disorders, and gynecological complaints). Ultrasound also has the capability to differentiate types of pulmonary edema, as well as other lung disorders, and generally much faster than a traditional Xray as there is no radiographic lag between clinical onset and ultrasound changes.

Three x-ray images displaying different etiologies of B-lines: cardiogenic pulmonary edema, noncardiogenic pulmonary edema, and pulmonary fibrosis.
Pulmonary Edema on Xray, Mayo Clinic, 2024

Pulmonary Edema on Xray Mayo Clinic, 2024

In HAPE, an increase in the number of B-lines indicates an accumulation of fluid in the lungs. Healthy individuals acclimating to the altitude have been shown to have a physiologic increase in B-lines during the first 4 days of high-altitude exposure as well as pregnant individuals having an increase in their baseline b-line count. Keeping these differences in mind, an increase of B-lines of more than 3 in a lung field, in more than 2 lung fields indicates an increase in extravascular lung water (EVLW) and could support a diagnosis of HAPE. Correlating this with clinical signs and symptoms of altitude sickness (HA, dizziness, fatigue, shortness of breath, nausea/vomiting), as well as HAPE (hypoxia, cough, exercise intolerance) can support a more rapid diagnosis of HAPE as well as assist with deciding need for oxygen and/or altitude descent (Yang et al., 2018; Heldeweg et al., 2022). The provider can also use the ultrasound to monitor resolution of the pulmonary edema to help support decisions to discontinue oxygen or to encourage altitude descent. Those with comorbidities such as heart failure can also be monitored for early signs that their treatment plan is not adequately addressing their EVLW and can receive correction prior to needing hospitalization (Chiu et al., 2022).

Two x-ray images of the chest from the Mayo Clinic labelled cardiogenic and HAPE/noncardiogenic from left to right.

Pulmonary Edema on Xray Mayo Clinic, 2024

HACE, as a disorder including altered mental status, ataxia, headache, loss of consciousness, and seizures, is a serious complication of high altitude. As the symptoms suggest, rapid identification is key to reducing other problems, including death, from HACE. The use of ultrasound is relatively new in assisting with diagnosis, but an increase in optic nerve diameter on ultrasound above 5 millimeters indicates that there is a good chance of brain swelling (or cerebral edema) and subsequent increased intracranial pressure. Identifying this early allows for rapid decision making the descent to a lower altitude or using a more rapid evacuation method (helicopter or rapid ground transport). Increased intracranial pressure can also result from head injury or trauma and thus can be useful in settings where an injury may have occurred. This makes this a tool that could be invaluable in search and rescue operations or for first responders (Shookahi et al., 2020).

Four Ultrasound images of the lungs illustrating use as a densitometer: different ultrasound patterns for different levels of lung aeration. Below the images, a graph indicating lung air content from 100% on the left to 0% on the right.
Gargani, 2019

Keeping these benefits in mind, remember that diagnostic imaging is a support tool and not the complete answer to all health problems. Hopefully soon we will see this tool being used with more frequency to help aid our healthcare providers in determining a more accurate cause of symptoms!

References

Chiu, L., Jairam, M. P., Chow, R., Chiu, N., Shen, M., Alhassan, A., Lo, C.-H., Chen, A., Kennel, P. J., Poterucha, T. J., & Topkara, V. K. (2022). Meta-Analysis of Point-of-Care Lung Ultrasonography Versus Chest Radiography in Adults With Symptoms of Acute Decompensated Heart Failure. The American Journal of Cardiology, 174, 89–95. https://doi.org/10.1016/j.amjcard.2022.03.022

Gargani L. (2019). Ultrasound of the Lungs: More than a Room with a View. Heart Failure Clinics, 15(2), 297–303. https://doi.org/10.1016/j.hfc.2018.12.010

Heldeweg, M. L. A., Smit, M. R., Kramer-Elliott, S. R., Haaksma, M. E., Smit, J. M., Hagens, L. A., Heijnen, N. F. L., Jonkman, A. H., Paulus, F., Schultz, M. J., Girbes, A. R. J., Heunks, L. M. A., Bos, L. D. J., & Tuinman, P. R.. (2022). Lung Ultrasound Signs to Diagnose and Discriminate Interstitial Syndromes in ICU Patients: A Diagnostic Accuracy Study in Two Cohorts*. Critical Care Medicine, 50(11), 1607–1617. https://doi.org/10.1097/ccm.0000000000005620

Mayo Clinic (2024). Pulmonary Edema. Mayo Foundation for Medical Education and Research. Retrieved February 27, 2024 from https://www.mayoclinic.org/diseases-conditions/pulmonary- edema/symptoms-causes/syc-20377009

Shokoohi, H., Pyle, M., Kuhl, E., Loesche, M. A., Goyal, A., LeSaux, M. A., Boniface, K. S., & Taheri, M. R. (2020). Optic Nerve Sheath Diameter Measured by Point-of-Care Ultrasound and MRI. Journal of neuroimaging : official journal of the American Society of Neuroimaging, 30(6), 793–799. https://doi.org/10.1111/jon.12764

Yang, W., Wang, Y., Qiu, Z., Huang, X., Lv, M., Liu, B., Yang, D., Yang, Z., & Xie, T.. (2018). Lung Ultrasound Is Accurate for the Diagnosis of High-Altitude Pulmonary Edema: A Prospective Study. Canadian Respiratory Journal, 2018, 1–9. https://doi.org/10.1155/2018/5804942

Altitude Science, Backpacking, Exposure, Health, High Altitude, Mountaineering, Wildlife

­­Avon skin so soft as a mosquito repellent? It’s not just an old wives’ tale!

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by Megan Furry, PA-S

The common thought that mosquitos do not live at higher elevations may no longer be true. With temperatures slowly rising, we are seeing a rise in mosquito populations at higher elevations and farther north than we have before.1 Mosquitos are having luck finding their ideal conditions with standing water, higher temperature, and humidity at higher elevations.

As of June 27, 2024, the state of Colorado had already seen its first case of West Nile Virus for the year, something that does not usually occur until late in the summer. In 2023, Colorado dealt with its worst West Nile virus outbreak ever recorded.2 As we are beginning to see more and more mosquitos in our community, people are looking for the best and safest mosquito repellents.

The most common big hitters when it comes to bug spray are DEET-containing bug sprays and those that say DEET-free. If your mom is like mine and used to tell you that Avon Skin So Soft is a great mosquito repellent, I’m here to help you determine if it actually does work. A study published in the BC Medical Journal compared DEET-containing mosquito repellent, Avon Skin So Soft bath oil, and a “special mixture” containing a combination of eucalyptus oil, white vinegar, Avon Skin So Soft, and tap water, against a placebo. They found that both DEET and Avon Skin So Soft protected against mosquito bites significantly more than the “special mixture.” In this study, Avon Skin So Soft was 85% as effective as DEET at protecting against mosquito bites. Looking strictly at the numbers, DEET had 0 mosquito events (both bites and mosquitos landing on the skin), Avon Skin So Soft bath oil had 6 events, the “special mixture” had 28 events, and the placebo had 40 events.3

From personal experience, I have tested out Avon Skin So Soft and its mosquito repellent properties. In August 2019 I ventured halfway across the world to Thailand for a post-undergraduate adventure. With limited packing room and a dislike for the smell of bug spray, I brought Avon Skin So Soft body moisturizer with me and was pleasantly surprised with how well it kept the mosquitos away.

Avon has made a specific bug repellent line of products that claims to protect against mosquitos, deer ticks, black flies, gnats, and biting midges.

For our furry friends that tag along with us on all of our outdoor adventures, remember that they too can get bitten by pesky insects. They are still susceptible to mosquito bites as well as ticks and fleas. At altitude we see less ticks and fleas in our communities due to the dry air, however they are still present, so it is important to protect your animals like you do yourself. Some veterinarian recommended tick and flea prevention include Simparica Trio or Nexgard chewables.

References

  1. Today E. Mosquito Migration: Study Finds More High-Altitude Dispersal of Disease Vectors in Africa. Entomology Today. Published May 5, 2023. https://entomologytoday.org/2023/05/05/mosquito-migration-more-high-altitude-dispersal-disease-vectors-africa-malaria/#:~:text=The%20studies%20leave%20no%20doubt
  2. UCHealth KKM. Colorado records first 2024 West Nile case, after worst U.S. outbreak in 2023. UCHealth Today. Published June 27, 2024. https://www.uchealth.org/today/west-nile-virus-in-colorado/
  3. Mosquito repellent effectiveness: A placebo controlled trial comparing 95% DEET, Avon Skin So Soft, and a “special mixture” | British Columbia Medical Journal. bcmj.org. https://bcmj.org/articles/mosquito-repellent-effectiveness-placebo-controlled-trial-comparing-95-deet-avon-skin-so
Accessibility, Acclimation, Backpacking, Doc Talk, Health, High Altitude

The High Altitude Doc Visits Norway

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Founder of Ebert Family Clinic in Frisco, Colorado at 9000′, Christine Ebert-Santos, MD, MPS spent a part of her Spring 2024 backpacking across Norway:

At 2,469m (8,100 feet), Galdhøpiggen mountain in Norway is not high enough to cause altitude sickness for most people. The 300 mountain peaks over 2000m make Norway a popular destination for downhill skiing and snowboarding, as well as Nordic skiing. The long days of sunshine at this latitude allow skiing in swimsuits and summer clothes in the spring.

Norway also has the largest glacier in Europe, Jostedalsbreem. Briksdalbreen is a finger of this glacier that is a short hike in the Jostedalsbreem National Park. There are 1,600 glaciers covering one percent of Norway. Several have resorts advertising summer skiing for the whole family.

View of a backseat passenger of a driver and front seat passenger looking over a navigation screen out toward a tunnel extending beyond the car windshield before them.

 

There are 900 tunnels in Norway, including the longest tunnel in the world. Compared to Eisenhower Tunnel in Colorado at 11,112 feet elevation and 1.67 miles long, Laerdal tunnel, opened in 2000, is 15 miles long with pullouts featuring colored lighting to imitate the sunrise. Some of these tunnels, like the one between the airport and downtown Oslo, go as deep as 958 feet underwater. All have phones and excellent cell phone reception. In fact, we experienced excellent reception everywhere in Norway despite the mountains and tunnels, in contrast to my sister’s house in Centennial, Colorado and many parts of Colorado.

A bright-orange-beaked puffin sits in grass amidst stones with its bright orange feet sticking out from under its black wings and white-feathered breast.

 Our last night in Norway was special. We drove two hours over narrow roads, through tunnels, over one lane bridges to Ronde Island. With a population of 150, the island is a famous bird sanctuary. We arrived just in time to see the puffins return to their nests at 8 pm.  These colorful birds spend their lifespan of 30-40 years flying over the ocean, sleeping on the waves, returning to land once a year with the same mate.

An aerial view of large, snow-capped mountains over a town down in the valley of a deep fjord with blue, sunny skies with billowy, bright clouds.

The fact that Norway provides such amazing access to even this tiny town tells me how much they respect individuals. They have an average lifespan of 83 years (76 years in the USA), universal health care, one year paid leave for parents with a new baby, universal pensions, free education through college, daycare for less than $15/day, and much more. How much do they pay in taxes, you might ask? Less than what we pay when you consider the cost of health insurance, day care, school loans, with 60% of Americans who do not have anything saved for retirement.

Acclimation, Altitude Science, Athletic Training, Backpacking, Child Growth & Development, Doc Talk, Exposure, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering

Interview with Dr. Christine Ebert-Santos on High Altitude Pulmonary Edema

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by Cody Jones, Summit Daily News

“‘The first sign is usually a cough,’ Ebert-Santos said. ‘Followed by shortness of breath with any effort — even just walking — and fatigue. You just want to lie on the couch.’

If left untreated the early warning signs of high altitude pulmonary edema can rapidly progress into having fluid build up in the lungs, which will then lead to a patient’s oxygen saturation levels rapidly decreasing. If the individual does not seek treatment quickly, the condition can be fatal.”

Read the whole article here.

Acclimation, Altitude Science, Athletic Training, Backcountry, Backpacking, Child Growth & Development, Exposure, Health, High Altitude, High Altitude Training & Fitness, Hyperbaric Therapy, Medicine, Mountaineering, Sleep at Altitude

What is Acute Mountain Sickness?

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Acute mountain sickness (AMS) is a condition that can occur when individuals ascend to high altitudes rapidly, typically above 2,500 meters (8,200 feet). The symptoms of AMS are due to the body’s struggle to adapt to the decreased oxygen levels at higher elevations. More specifically, the symptoms are caused by cerebral vasodilation that occurs in response to hypoxia, in an attempt to maintain cerebral perfusion.1

The typical symptoms of AMS include headache, nausea, vomiting, anorexia, and fatigue. In children the symptoms are less specific including increased fussiness, crying, poor feeding, disrupted sleep, and vomiting. Symptom onset is usually 6-12 hours after arrival to altitude but this can vary.

AMS affects children, adults, males and females equally, with a slight increased incidence in females. It is difficult to believe, but physical fitness does not offer protection against AMS. However, people who are obese, live at low elevation, or undergo intense activities upon arrival to elevation are at increased risk.1

Treatments for Acute Mountain Sickness

Descending

Descending and decreasing altitude is a vital treatment for people with severe symptoms of AMS. By decreasing altitude there will be more oxygen in the air and symptoms will not be as severe..2 

Oxygen

Since the main cause of AMS is hypoxia, oxygen supplementation is an effective treatment when descent is not wanted or possible. Supplemental oxygen even at .5L to 1L per hour can be effective in reducing symptoms.1  It can be prescribed for short periods of time or to be used only during sleep  In the central Colorado Rockies, this may be a practical solution for “out of towners” who have traveled up to the town of Leadville (10,158’/3096m) for vacation, but in an austere environment supplemental oxygen may not be a reasonable treatment option. There should be symptomatic improvement within one hour.

Acetazolamide

Acetazolamide is a carbonic anhydrase inhibitor which causes increased secretion of sodium, potassium, bicarb, and water. This mechanism of actions lends beneficial to the treatment of AMS because it decreases the carbonic anhydrase in the brain. 3There is evidence to support the use of acetazolamide in the prevention of AMS, but minimal evidence pointing towards it’s role in treatment. Dosing is inconsistent but is usually prescribed at 125-250mg BID.

Hyperbaric Therapy

Many people consider hyperbaric chambers to be large structures in hospitals, however there are portable and lightweight hyperbaric chambers that can be used in austere environments or during expeditions. The mechanism of action of hyperbaric therapy is a simulated decrease in elevation, of approximately 2500 meters. These chambers will remove symptoms within approximately one hour of use but symptoms are likely to return. They are useful in the field but not frequently required in a hospital setting.1

Lynde Tucker is a third year medical student who grew up in Lake Tahoe California, and moved to Colorado for medical school. She is grateful for the opportunity to be back living in the mountains and working in a mountain community.

References

  1. https://www.uptodate.com/contents/acute-mountain-sickness-and-high-altitude-cerebral-edema?search=acute%20mountain%20sickness&source=search_result&selectedTitle=1~15&usage_type=default&display_rank=1#H35
  2. https://my.clevelandclinic.org/health/diseases/15111-altitude-sickness
  3. https://www.uptodate.com/contents/acetazolamide-drug-information?search=acetazolamide%20altitude&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#F129759
Backcountry, Backpacking, Exposure, Health, High Altitude, Huts, Mountaineering, Summit Huts

Lightning Strikes in Colorado

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My love for hiking developed during my childhood explorations of the breathtaking landscapes of the Sierra Nevada. As I ventured into the rugged mountains and hiked along scenic trails, I couldn’t help but feel a deep connection with nature. However, my passion for hiking was not without its moments of caution. On several occasions, I witnessed the awe-inspiring yet intimidating power of lightning storms dancing across the vast mountain skies. These encounters instilled in me a profound curiosity about the risks associated with lightning strikes in high-altitude regions.

When I moved to Colorado for PA school, my awareness of the dangers posed by lightning strikes grew even stronger. The dramatic topography and frequent thunderstorms in Colorado amplify the risk for individuals exploring high-altitude areas. It was during my last clinical rotation at a burn unit that I had the opportunity to care for several patients who had been struck by lightning. Witnessing the effects firsthand fueled my determination to educate the public about the actionable steps they can take to stay safe during lightning storms.

Lightning strikes

​Lightning possesses an immense amount of energy, with a voltage of over 10 million volts (in comparison, most car batteries measure 12.6 V).1 Additionally, a lightning bolt reaches incredibly high temperatures, reportedly up to 30,000 Kelvin (53540.33 F).1 Lightning injuries occur in different ways, including as direct strikes, side splash, contact injuries, or ground current. 

Direct strikes are uncommon, accounting for only 5% of cases, and happen when a person is directly struck by lightning.2

Contact injuries occur when a person touches an object that is struck by lightning. 2

Side splash injuries occur when the current jumps or “splashes” from a nearby object and then follows the path of least resistance to reach the individual. These injuries make up about 1/3 of all lightning related injuries. 2

Ground current is the most prevalent cause of injury, accounting for half of all cases, and occurs when lightning strikes an object or the ground near a person and subsequently travels through the ground to reach the individual. 2

In Colorado, an average of 500,000 lightning flashes hit the ground each year. Based on data since 1980, lightning causes 2 fatalities and 12 injuries per year throughout the state.3According to data since 1980, lightning causes an average of 2 fatalities and 12 injuries annually throughout the state. 3 Colorado ranked third in the United States for the number of lightning fatalities between 2005 and 2014, as depicted in Figure 1.

Fig. 1. Lightning fatalities by state. 3

The high number of injuries attributed to lightning in Colorado can be influenced by several factors. One of these factors is the easy access to high elevation terrain, such as 14ers (mountains with a peak elevation of at least 14,000 feet). This accessibility allows inexperienced outdoor enthusiasts to venture into potentially dangerous situations due to their lack of knowledge and preparation.

For instance, individuals who are not familiar with summer weather patterns may embark on a hike above the tree line late in the day, underestimating the risk of a storm forming. This lack of understanding puts them in an exposed and perilous position should adverse weather conditions arise.

Even with thorough preparation and extensive knowledge of weather patterns, it is still possible to find oneself in a situation where you have to weather a storm. Given that a significant proportion of Colorado’s hiking trails are located above the tree line, where appropriate shelter is sparse, hikers are more susceptible to lightning strikes in these exposed areas. 

Pathophysiology of Lightning Strike Injuries

The overall ratio of lightning injuries to deaths is 10:1 and there is a 90% chance of sequelae in survivors.4 The primary mechanism of injury in lightning strikes is the passage of electrical current through the body. The high voltage and current can cause tissue damage through several mechanisms, including thermal injury, electrical burns, and mechanical disruption of tissues. The severity of the injury depends on factors such as the voltage and current of the lightning bolt, the duration of contact, and the pathway the current takes through the body.

Lightning strikes can cause various types of injuries, with cardiac and respiratory arrest being the most common fatal complications.5 The path of least resistance determines the flow of electricity through different organs in the body, with nerves being the most conductive, followed by blood, muscles, skin, fat, and bone. 5 When lightning strikes, the electrical surge can induce cardiac arrest and cessation of breathing by affecting the medullary respiratory center. As a result, most patients initially present with asystole and may progress to different types of arrhythmias, commonly ventricular fibrillation. 5

Interestingly, there have been case reports documenting successful resuscitation of lightning strike victims who were initially apneic and pulseless for as long as 15 to 30 minutes. 5This has led to the recommendation that in the immediate aftermath of a lightning strike, individuals who appear to be dead should be prioritized for treatment.

Superficial skin burns are experienced by around 90% of lightning strike victims, but deep burns are less common, occurring in less than 5% of cases. A characteristic skin manifestation of a lightning strike is the Lichtenberg figure, which is considered pathognomonic. Neurological symptoms can also occur, including keraunoparalysis, which is a transient paralysis affecting the lower limbs more than the upper limbs. This paralysis is often accompanied by sensory loss, paleness, vasoconstriction, and hypertension, and is thought to result from overstimulation of the autonomic nervous system, leading to vascular spasm. In most cases, this paralysis resolves within several hours, but in some instances, it may last up to 24 hours or cause permanent neurological damage. 5

Additionally, it is common for lightning strike victims to have a perforated tympanic membrane (eardrum) or develop cataracts immediately following the incident. These injuries to the ear and eyes are associated with the intense energy of the lightning discharge. 6

What can hikers do to stay safe?

Preparation

Monitor weather forecasts: Stay updated on weather conditions before engaging in outdoor activities, especially in areas prone to thunderstorms. Pay attention to thunderstorm warnings or watches issued by local authorities. Having a mobile or handheld NOAA Weather Radio All-Hazards (NWR) can also be helpful as it can transmit life-saving weather information at a moment’s notice. 

In Colorado most thunderstorms develop after 11 am, so it is best to plan your trip so that you are descending by late morning.7 Fig. 2 shows number of lightning fatalities by time of day in Colorado between 1980 and 2020. The vast majority take place after the 11 am threshold.

Fig. 2  Lightning fatalities in Colorado by time of day3

What to Do If Caught in a Storm

If you can hear thunder, you are close enough to be struck by lightning. Lightning can strike up to 25 miles away from the storm. 7 Once you hear thunder, if possible quickly move to a sturdy shelter (substantial building with electricity or plumbing or an enclosed, metal-topped vehicle with windows up). Avoid small shelters, such as picnic pavilions, tents, or sheds. Stay sheltered until at least 30 minutes after you hear the last clap of thunder.

Fig 3. Areas to avoid when sheltering from lightning.

If you are outdoors and cannot reach a suitable shelter, avoid open areas, hilltops, and high places that are more exposed to lightning strikes. Seek lower ground and stay away from tall objects, such as trees, poles, or metal structures. Bodies of water, including lakes, rivers, pools, and even wet ground, are conductive and increase the risk of a lightning strike. Move away from these areas during thunderstorms. Separate group members by at least 20 ft as lightning can jump up to 15 feet between objects.

​If a strike is eminent (static electricity causes hair or skin to stand on end, a smell of ozone is detected, a crackling sound is heard nearby), the current recommendation is to assume “lightning position”, pictured in Fig. 4.

Fig. 4. Lightning position8

To potentially reduce the risk of ground current injury from an imminent lightning strike, another strategy is to insulate oneself from the ground. This can be done by sitting on a pack or a rolled foam sleeping pad. However, it’s important to note that this and the lightning position should be considered a strategy of last resort and not relied upon as the primary means of prevention. Maintaining this position for an extended period can be challenging, and it’s crucial to prioritize seeking proper shelter and following established lightning safety guidelines to minimize the overall risk of injury. 5

Case Study

25 YO F presents to the Burn Unit as a transfer from Cheyenne Regional Medical Center s/p lighting strike. Patient (pt) was caught in a thunderstorm on a hike and sheltered under a tall tree. Suddenly, she felt like she was being lifted up into the air and then dropped. Pt had a brief (<5 sec) loss of consciousness (LOC). When she woke up, she was completely numb and couldn’t move any of her extremities. Witness (friend) states the lightning splashed from the tree to the pt. Pt denies hitting her head with the fall. She denies taking blood thinners. She has no past medical history (PMHx) or past surgical history (PSHx).

Physical exam 

Neuro: AOX4, No CN deficit on exam, LE paralysis resolved, LE paresthesia improving but still present

HEENT: L ruptured tympanic membrane, hearing loss on L side

CV: RRR

MSK: Soft compartments diffusely

Skin: Lichtenberg figures on bilateral LE 

Fig. 6. Lichtenberg figure on LLE

V/S: BP: 128/92, HR: 96, RR:18, SPO2: 98%, Temp 98.1F. 

CBC, CMP, troponin were all WNL. Serum hCG negative. CK mildly elevated (222) 

EKG showed NSR.

CXR, CT brain, and c-spine neg for acute injury

She was admitted to the UC Health burn center for observation with tele. Her lab work and vitals remained stable throughout her hospitalization. She was evaluated by the trauma team with a negative trauma work up. The day of discharge, she was tolerating a regular diet, ambulating and sating well on room air. She was deemed appropriate for discharge home without patient audiology and ophthalmology follow up. 

References

1. US Department of Commerce N. Understanding lightning science. National Weather Service. April 16, 2018. Accessed July 8, 2023. https://www.weather.gov/safety/lightning-science-overview. 

2. Cooper MA, Holle RL. Mechanisms of lightning injury should affect lightning safety messages. 21st International Lightning Detection Conference. April 19-20, 2010; Orlando, FL. 

3. US Department of Commerce N. Colorado Lightning statistics as compared to other states. National Weather Service. March 4, 2020. Accessed July 7, 2023.https://www.weather.gov/pub/Colorado_ltg_ranking. 

4. US Department of Commerce N. How dangerous is lightning? National Weather Service. March 12, 2019. Accessed July 8, 2023. https://www.weather.gov/safety/lightning-odds. 

5. Chris Davis, MD; Anna Engeln, MD; Eric L. Johnson, MD; Scott E. McIntosh, MD, MPH; Ken Zafren, MD; Arthur A. Islas, MD, MPH; Christopher McStay, MD; William R. Smith, MD; Tracy Cushing, MD, MPH. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Lightning Injuries: 2014 Update. WILDERNESS & ENVIRONMENTAL MEDICINE. 2014; 25, S86–S95 

6. Flaherty G, Daly J. When lightning strikes: reducing the risk of injury to high-altitude trekkers during thunderstorms. Academic.oup.com. Accessed July 8, 2023. https://academic.oup.com/jtm/article/23/1/tav007/2635599. 

7. NWS Colorado Offices – Boulder G. Colorado Lightning Awareness Week june 19-25, 2022. ArcGIS StoryMaps. June 25, 2022. Accessed July 8, 2023. https://storymaps.arcgis.com/stories/11d021f1b800429a869ead2dc32c0f96. 

8. McKay B and K. How to survive A lightning strike: An illustrated guide. The Art of Manliness. April 25, 2022. Accessed July 8, 2023. https://www.artofmanliness.com/skills/outdoor-survival/how-to-survive-a-lightning-strike-an-illustrated-guide/. 

A woman with long, light brown hair over her shoulders wearing a blue, sleeveless shirt with red details smiles with blue eyes.

Sophia Ruef is a Physician Assistant student at Red Rocks Community College in Arvada, CO. She grew up on the central coast of California and earned her Bachelor of Science degree inBiology with a concentration in anatomy and physiology from Cal Poly San Luis Obispo. She worked as an EMT and a tech in the Bay Area after her undergraduate education. In her free time, she enjoys hiking, backpacking, canyoneering, and spending time with family and friends.