Category Archives: Backpacking

Acclimation, Altitude Science, Athletic Training, Backpacking, Doc Talk, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering, Naturopathic Medicine

The Plants We Need Are There: A Naturopathic Approach to Acute Mountain Sickness

Leave a comment

Acetazolamide is already known for its success with treating Acute Mountain Sickness (AMS) and helping patients with their transition to higher altitudes, but what other options are available? What about those who don’t want a prescription, that are looking for other alternatives to help them with AMS and being at high altitude?

During my time in Frisco, Colorado (9000’/2743 m) I was fortunate enough to interview two resident Naturopathic Doctors. Mountain River Naturopathic Clinic on Main Street of this little mountain town is a wonderful oasis for anyone in Colorado’s Summit County looking for alternative care and treatment for their mind and body.

Dr. Kimberly Nearpass, ND and Dr. Justin Pollack, ND took the time to educate Dr. Chris Ebert-Santos, my classmate Rachel Mader, and myself about all the naturopathic remedies available for AMS and residents at altitude.

Tell us about Naturopathic medicine and why you picked this path of medicine?

Dr. Kimberly Nearpass: I thought I was going to be an OBGYN and then I did more research. I talked to doctors, midwives and herbalists and found that the Western medicine model didn’t feel right to me. So I thought, “Do I go to medical school and try to operate functionally from the inside or do I find another track?” I did not know about naturopathic medicine until a few years later. I took some time off; I traveled and went to the Peace Corps and then I discovered naturopathic medicine and loved it. I had lived in Ecuador in the rainforest as a naturalist guide so I learned a lot about traditional medicine that way. I learned a lot about traditional medicine when I lived in rural Africa as well. Living in these rural areas and watching the indigenous people — and they certainly use modern medicine — but they did not have a lot of access. Especially in the rainforest, they were using a lot of plants and I was fascinated by that. But I still wanted the medical training. Then I discovered naturopathic school. So, it’s four years of medical school, we get the medical training, but we also have that more holistic, natural, herbal based approach.

What naturopathic remedies are available for acute mountain sickness (AMS)?

Dr. Nearpass: So I will tell you Acli-Mate is our go-to. I’m not tied to this product, a friend of mine, it is her company, she is a naturopathic doctor in Gunnison. She formulated this, she started it out as a high-altitude electrolyte drink. Everybody that comes in our door, we start with this. This stuff works AMAZING. We rarely have to go anywhere else. I think the combination of the electrolytes and that it is hydrating has a great benefit. It helps with the headache and the nausea. For mild to moderate symptoms of AMS it is incredible. What we do is if we have family coming to visit from sea level is we have them start drinking it before they come.

Acli-Mate is found to be highly effective at helping people who are suffering from AMS. The blend includes herbs Ginkgo biloba and Rhodiola, both of which have proven effective in preventing and treating altitude related sickness. Both herbs seem to improve circulation, especially through cerebral vessels, and cellular energy function through improved uptake and utilization of oxygen, reducing toxic brain edema. Ginkgo has also been shown to inhibit platelet clumping, keeping red blood cells evenly dispersed, which improves delivery of oxygen to tissues, while Rhodiola appears to help the body deal with stress.

Nutrients in Acli-Mate: Vitamin C, and many of the B vitamins: thiamin (B1), riboflavin (B2), niacin (B3), pantothene (B5) and cobolamin (B12).

Acli-Mate in a variety of applications.

Have you noticed that when you have patients drink it before they arrive at high altitude, they have a better outcome?

Dr. Nearpass: Yes. And I have a patient who is 70 now and 5-10 years ago she went with some girlfriend to hike Mount Kilimanjaro. She had all her girlfriends take it and emailed me after saying, “We all did great!” And I don’t want to put all my eggs in one basket but this is almost always all we need.

Dr. Justin Pollack: There is something about that blend of Rhodiola, Ginkgo and the B vitamins that seems to work. We’ve had tons of people use it clinically.

Dr. Nearpass: For other options, I think Rhodiola is a good one. It’s interesting to me because Rhodiola grows in Mongolia, it grows in high altitude. One of the things we talk about in herbal medicine is often the plants we need are there. For example, dandelion root grows everywhere and it is good for liver detox and helps with hepatic function. So, it is interesting to me that dandelion is popping up on the side of the highways and in areas that we could probably use a little cleansing and detoxing.

Dr. Chris Ebert-Santos: What about Coca?

Dr. Nearpass: Oh yes! Coca works amazing. It is a plant that grows in the high altitudes of South America and when I was living in Ecuador the folks that live in the Andes drink coca tea all the time. They also take coca leaves and shove a wad in their mouth like chew. While they are doing work, cardiovascular work, they just put it in their mouth and that is their medicine. It gives them more stamina and reduces fatigue. There is not much research on it because you cannot even get it in the states.

Is there a reason you can’t get it here?

Dr. Nearpass: Because it’s the same plant as cocaine. We used to have a homeopathic version of it. Do you know what homeopathic medicine is? You take a remedy and you dilute it until you don’t have any molecules of the original substance but you basically are getting an energetic imprint. For example, Rhus tox, poison ivy, the homeopathic rhus tox is used to treat red itchy inflamed poison ivy type symptoms. But with coca, even homeopathically, the herb is used in concentrated doses to treat high altitude sickness and increase energy and stamina. But because there is such a control over coca, we can’t even get the homeopathic version, which is ridiculous because there is not a single molecule of the plant in the remedy.

Dr. Pollack: When Kim and I were on our honeymoon, we passed through Bolivia and Peru. In Bolivia in la Paz there was a coca museum. It was really fascinating because something around 1,000lbs of coca leaves must be distilled down into 1 gram to make cocaine. When you make tea out of the raw leaves it seems to have the subtle effect of suppressing appetite and allowing people to do better at altitude. Marijuana has a whole stigma around it, even though it has been legalized, and so the research and researchers are stigmatized, yet there are a lot of useful compound coming out of the plant. So, I’m sure that coca is the same, and hopefully somewhere down the line we will be able to use coca leaf for altitude.

Dr. Nearpass: And certainly, coca is the number one herb in the Andes that people use. You can get it everywhere, it’s like black tea down there.

So because coca is not available for your patients, and if you found Acli-Mate was not successful, what would you recommend?

Dr. Nearpass, a woman in a white hoodie, long brunette hair, and a maroon mask, stands in front of a wall of shelves of naturopathic medicine in brown glass jars with black lids at the Backcountry Apothecary in Frisco, CO.
Dr. Kimberly Nearpass

Dr. Nearpass: This is the thing about naturopathic doctors, we look at each individual. If it’s a resident, per se, we are going to draw blood work. We are going to try to figure out what’s going on, what is the underlying issue. Do you have relative anemia? We will run iron but also ferritin. They may have normal blood cells, normal H&H but their ferritin is a 2. One of the things that is tricky about being a naturopathic doctor is, we will be at a party and someone will ask, “Well what do you do for hypertension?” or “What do you do for digestive issues?” We always say we don’t treat symptoms; we don’t treat disease, we treat people. If someone is having recurrent altitude sickness, we are going to look at the individual and look at what is going on. What’s their diet? Are they hydrated enough? Are they drinking too much alcohol? Do they have subclinical hypothyroidism that might affect their metabolism and their ability to adapt when they get here? Might their ferritin levels be really low? And then we would sit down with the patient and say, “Well what are your symptoms? Is nausea the main symptom? Is headache the main symptom?”  And then, what other factors could be contributing to these symptoms? If it’s headache then CoQ10 would be what I would go to.

Dr. Chris Ebert-Santos: And what do you look for on physical exams on residents that are having trouble with altitude?

Dr. Nearpass: On physical exams we are doing the standard physical that you would do but we are also looking at the tongue. I am not a Chinese Medicine doctor but the tongue does give you some insight on what is going on in the digestive tract. If we are seeing inflammation or glossitis or geographic tongue, we are thinking, “Oh, this person may have some underlying digestive issue.” We might look at Arroyo’s sign, it’s a traditional sign when you shine a light on someone’s pupil and most of the time their pupil will constrict, but Arroyo’s sign is both pupils will stay dilated. This is a red light for adrenal issues, for hyper cortisol output or adrenaline output. If someone is in a chronically stressed state, their pupils are going to be dilated all the time. If it looks like someone has chronic stress, it takes you out of the parasympathetic, and so their digestion is going to be weaker. The way we look at it is the body has to prioritize, and there is only so much that one body can do. And I suspect that living at high altitude puts chronic stress on the body. I see this huge lack of libido in the women. I see women in their 20s, 30s, 40s, 50s. But it kind of makes sense right? If the body is chronically stressed, having a baby is a huge energy output for a woman. So, I think we may see the chronic stress impacts of living at high altitude.

Dr. Chris Ebert-Santos: So what do you do for the libido?

Dr. Nearpass: That is one that if I could invent one pill, it would be that one. Libido is really hard, especially in women. Unfortunately, what I see is its one of the first things to go in women and it’s one of the last things to respond. So, my suspicion is that this altitude is another physical stress on our bodies. I think we can see multiple systems being affected by it, maybe not severely but still.

Rachel Mader PA-S: Is there anything for sleep at altitude? I know a lot of people struggle with that.

Dr. Nearpass: Yes, again for us there is no magic bullet. Melatonin is very well known and that can be very helpful for some people, but it sure doesn’t work for everybody.  When patients come in and say, “What do you use for sleep?” I want to take every person back and have a conversation with them. Ask, “Are you having a hard time falling asleep? Are you having a hard time staying asleep? Are you waking up to go to the bathroom?” Right? So, there isn’t a magic bullet that will work for everyone. Breaking it down, I think you could have 50 people with altitude sickness and we’re going to do 50 different things. I mean, I would start with Acli-Mate, but every patient will be different.

Do you think there’s benefit to adding Acli-Mate in combination with an Acetazolamide prescription?

Dr. Nearpass: As far as I know, there’s no issue combining the two. Most people that come to us are usually trying to avoid medication, but what I always say to them in that situation is, “Try this other stuff to see if it helps.” But if it’s someone who had trouble in the past with AMS, I’ll say go to your medical doctor and get the prescription so that you have it if you need it. I think another issue is that people fly here right from Texas. They fly to Denver, they get right on the shuttle, and they drive right up here. If they’ve had trouble in the past, they should drive here and take their time. Spend a couple days in Denver if they have to. That does seem to help people.

Thank you so much Dr. Nearpass. Is there anything else about naturopathic medicine and high altitude you would like to share with us?

Dr. Nearpass: I guess I would say again that from a naturopathic perspective it is really about looking at the individual.

Is there anything that could specifically help with nausea symptoms of AMS?

Dr. Nearpass: Ipecacuanha! Ipecac syrup — which in full doses will make you throw up, so the homeopathic Ipecacuanha we use for nausea — that is one I have actually used quite a bit for people who have that aspect of AMS. It is really good for nausea and pregnancy too.

PA student Hannah Addison with Dr. Pollock, Dr. Nearpass and Dr. Chris in front of the Naturopathic clinic and apothecary in Frisco, CO.

The way I see Healthcare is a full spectrum, and on one end you have the brain surgeons and on the other end you have the Reiki energy healers. Then you have everything in between. I see us sitting in the middle. For patients, the best thing is to be aware of where they belong on that spectrum. I’m not going to replace a brain surgeon, but sometimes a little bit of massage and energy can do the trick. It is so great for us as practitioners to be able to talk and converse with the medical doctors. We’ve been really lucky in this community.

Visit Mountain River Naturopathic Clinic’s website or stop by their shop and clinic: http://www.mountainriverclinic.com

Available research articles on Naturopathic Remedies and AMS:

Zhang DX, Zhang YK, Nie HJ, Zhang RJ, Cui JH, Cheng Y, Wang YH, Xiao ZH, Liu JY, Wang H. [Protective effects of new compound codonopsis tablets against acute mountain sickness]. Zhongguo Ying Yong Sheng Li Xue Za Zhi. 2010 May;26(2):148-52. Chinese. PMID: 20684264.

Tsai TY, Wang SH, Lee YK, Su YC. Ginkgo biloba extract for prevention of acute mountain sickness: a systematic review and meta-analysis of randomized controlled trials. BMJ Open. 2018;8(8):e022005. Published 2018 Aug 17. doi:10.1136/bmjopen-2018-022005

Gertsch JH, Basnyat B, Johnson EW, Onopa J, Holck PS. Randomised, double blind, placebo-controlled comparison of ginkgo biloba and acetazolamide for prevention of acute mountain sickness among Himalayan trekkers: the prevention of high-altitude illness trial (PHAIT). BMJ. 2004;328(7443):797. doi:10.1136/bmj.38043.501690.7C

Ke T, Wang J, Swenson ER, et al. Effect of acetazolamide and gingko biloba on the human pulmonary vascular response to an acute altitude ascent. High Alt Med Biol. 2013;14(2):162-167. doi:10.1089/ham.2012.1099

Wang J, Xiong X, Xing Y, et al. Chinese herbal medicine for acute mountain sickness: a systematic review of randomized controlled trials. Evid Based Complement Alternat Med. 2013;2013:732562. doi:10.1155/2013/732562

Lee SY, Li MH, Shi LS, Chu H, Ho CW, Chang TC. Rhodiola crenulata Extract Alleviates Hypoxic Pulmonary Edema in Rats. Evid Based Complement Alternat Med. 2013;2013:718739. doi:10.1155/2013/718739

Hannah Addison, PA-S

Hannah Addison (she, her, hers) is a second-year physician assistant student at Red Rocks Community College Physician Assistant Program in Arvada Colorado. Hannah was born and raised in the South Denver area of Colorado. She spent four years getting her bachelor’s in biomedical science at Colorado State University in Fort Collins, CO where she decided her life career goal was to become a PA. After graduating and while applying for PA programs, Hannah worked at Littleton Adventist Hospital of Centura as a CNA, Telemetry Technician and Unit Clerk. In her free time, Hannah enjoys hiking and discovering all the delicious food and drink Colorado has to offer.

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

WMS Blog Entry No. 5: Advances in Frostbite, a Synopsis of Dr. Peter Hackett’s Lecture

Leave a comment

Frostbite is an injury caused by freezing of the skin and underlying tissue. The main pathophysiology of frostbite is ischemia. Basically, where there is blood flow there is heat and where there is no blood flow there is no heat to that area. The vasoconstriction and loss of blood flow to the skin predispose the skin to becoming frozen. Heat transfer depends on blood flow and blood flow depends on sympathetic nerve tone. In our extremities, there are only nerves that cause vasoconstriction. Exposure to cold or a drop in the body’s core temperature can induce vasoconstriction from these sympathetic nerves in which decreases the amount of blood flow to the extremities to keep the central aspect of the body warm and central organs well-perfused to help to maintain the body’s core temperature.

Frostbite usually occurs in the apical areas of the skin also called glabrous, which is Latin for smooth because these areas have no hair. These areas include the face, palmar surface of the hand, and the plantar surface of the foot. These areas of the skin are rich in arteriovenous anastomoses, which are low-resistance connections between the small arteries and small veins that supply the peripheral blood flow in the apical regions of the skin. These anastomoses allow the blood to flow into the venous plexus of the skin without passing through capillaries, and play a major role in temperature regulation.

Causative factors of frostbite include inadequate insulation, circulatory compromise, dehydration, moisture, trauma, and immobility. All of these factors in combination can result in frostbite.

The behavioral risk factors include mental illness, alcohol/drug use, fear, apathy, and anxiety. All of these risk factors can contribute to frostbite, generally, from poor self-care.

Frostbite is said to kill twice during its two phases that occur. The first phase is the frozen phase in which ice crystals form in the intracellular compartment at about 29 degrees Fahrenheit. These ice crystals will suck the fluid out of the endothelial cells and become enlarged causing the endothelial cells to lyse from dehydration and interrupt microcirculation. The second phase is the rewarming phase in which the skin thaws and is at risk for microthrombi production and necrosis due to prolonged injury to those endothelial cells.

The usual phase at which we see frostbite in a clinical setting is after thawing, in which the skin looks flushed pink, red, with the appearance of blebs that form one hour to twenty-four hours after thawing. These blebs can rupture spontaneously in 4-10 days and shortly after, a cast-like eschar forms. Then the eschar usually sheds in 21-30 days.

Deep Frostbite

Frostbite is classified based on the depth of tissue damage, from superficial with no tissue damage being mild and deep tissue damage including muscle, bone, or tendon being classified as severe frostbite. The mildest form of frostbite is called frostnip. Frostnip is freezing of the skin but there is no actual freezing injury and doesn’t cause permanent skin damage.

Stages of Frostbite

What can you do in the field for Frostbite?

It is important to provide supportive care with IV or PO hydration to prevent dehydration. If the affected area is frozen with no imminent rescue, it is recommended to thaw the area with warm water and try to avoid refreezing. You can give NSAIDs, such as Ibuprofen, 400 mg every 8 hours, or ketorolac 30 mg IV. If the person is at altitude and their oxygen saturation is low you can provide oxygen. However, the individual must be taken to the nearest hospital for further treatment, especially in cases of severe frostbite.

New research studies have been exploring the use of thrombolytics in the treatment of frostbite. Many of the research studies have shown that IV TPA or iloprost may be of benefit to administer in a hospital setting. However, iloprost is not approved for IV use in the United States and other prostacyclins have not been studied for the use of frostbite as of yet. There are current literature and guidelines that have been published for the prevention and treatment of frostbite, however, more research is needed to further support standardized treatment of all patients with frostbite with thrombolytic therapy. Hopefully, these new studies will encourage more research into using thrombolytics and prostacyclins for frostbite.

In the meantime, it would be best to stay warm to prevent frostbite. Tips to help in frostbite prevention include:

  • Limit time you’re outdoors in cold, wet, or windy weather. Pay attention to weather forecasts and wind chill readings. In very cold, windy weather, exposed skin can develop frostbite in a matter of minutes.
  • Dress in several layers of loose, warm clothing. Air trapped between the layers of clothing acts as insulation against the cold. Wear windproof and waterproof outer garments to protect against wind, snow, and rain. Choose undergarments that wick moisture away from your skin. Change out of wet clothing — particularly gloves, hats, and socks — as soon as possible.
  • Wear a hat or headband that fully covers your ears. Heavy woolen or windproof materials make the best headwear for cold protection.
  • Wear socks and sock liners that fit well, provide insulation, and avoid moisture. You might also try hand and foot warmers. Be sure the foot warmers don’t make your boots too tight, restricting blood flow.
  • Watch for signs of frostbite. Early signs of frostbite include red or pale skin, prickling, and numbness.
  • Eat well-balanced meals and stay hydrated. Doing this even before you go out in the cold will help you stay warm.

Lauren Pincomb Apodaca is a second-year Physician Assistant student in the Red Rocks Community College Physician Assistant Program. Originally from Las Cruces, New Mexico, she graduated from New Mexico State University with a Bachelor of Science in Biochemistry and a Bachelor of Art in Chemistry. After obtaining her undergraduate degrees, she was accepted as a Ph.D. fellow in Pharmacology at the University of Minnesota where she conducted research in a biomedical laboratory doing cancer research. She then realized that she wanted to make a difference in people’s lives through hands-on experience rather than working in a laboratory. She went back to New Mexico and received her certification as a nursing assistant and started from the ground up to reach her ultimate goal of being a Physician Assistant. She has enjoyed living in Colorado and the many outdoor activities that Colorado has to offer. Her favorite are kayaking, fishing, and hiking. She is looking forward to graduating soon.

References:

Hill, C. (2017, December 22). Cutaneous Circulation – Arteriovenous Anastomoses. Retrieved September 27, 2020, from https://teachmephysiology.com/cardiovascular-system/special-circulations/cutaneous-circulation/

Frostbite. (2019, March 20). Retrieved September 27, 2020, from https://www.mayoclinic.org/diseases-conditions/frostbite/symptoms-causes/syc-20372656

Backcountry, Backpacking, Health, High Altitude, Medicine, Mountaineering, Wildlife

WMS Blog Entry No. 4, Part I: Tick Bite Prevention and Proper Removal

Leave a comment

Ticks are blood feeding parasites. Ticks are known as vectors because they can transmit different pathogens responsible for several diseases including Colorado Tick Fever, Rocky Mountain Spotted Fever (RMSF), Tularemia and relapsing fever. While there are 27 species of ticks in Colorado, almost all human encounters w/ ticks in Colorado involve the Rocky Mountain wood tick, a tick that only lives in the western U.S. and southern Canada at elevations between 4,000 and 10,000 feet. Another highly prevalent tick is the brown dog tick which is specific to dogs.

Before you go out!

DO:

  • Wear protective clothing! Wearing long sleeved shirts, long pants tucked into your socks and close toed shoes can keep ticks from getting onto your skin, as ticks are usually acquired while brushing against low vegetation.
    • wear light colored clothing, as this makes it easier to find ticks that have been picked up
    • Treat clothing w/ permethrin as this can help kill or repel ticks for days to weeks! Do not apply directly to skin.
  • Use Tick repellent. This includes the well-known DEET along with picaridin, IR3535 and oil of lemon eucalyptus
    • Repellent can be applied either directly to skin or to clothing, AND is most effective if applied to the lower body that is likely to come in contact with ticks first!
    • If applying repellents to skin:
      • DO NOT use high concentration formulas on children (DEET concentration > 30)
      • AVOID applying repellents to your hands or other areas that may come in contact with your mouth
      • DO NOT put repellent on wounds
      • ALWAYS wash skin that has had repellent on it.
  • Remember: Dogs can get ticks too! Don’t forget to consult your veterinarian about how to protect your furry friends against ticks.

When you go out: DO NOT assume that you won’t get bit.

  • Avoid tick habitat
    • Ticks are most active in spring and early summer and are concentrated where animal hosts most commonly travel, including areas of brush along field and woodland edges or commonly traveled animal host paths though grassy areas.
      • DO try to avoid exposure in these areas by staying in the center of marked trails when hiking to avoid brushing vegetation that ticks may be perched on waiting for you!
    • If possible, avoid these sites during tick season.
    • If you live in known tick territory, you may even get a tick bite in your own backyard! Decrease this risk by creating a tick-free zone around your house by keeping your lawn mowed, eliminating rodent habitats (wood or rock piles) around your house, and placing wood chips between your lawn and tall grasses or woods.

After coming back inside

  • Perform a tick check which includes botha visual and physical inspection of your entire body, as well as your gear and pets. Because ticks take several hours to settle and begin feeding, you have time to detect and remove them. You tend to not feel ticks because their saliva has histamine suppression and analgesic effects. Ticks like warm, moist and dark areas but can latch anywhere.
    • Examine your scalp, ears, underarms, in and around the belly button, around the waist, groin/pubic area, buttocks and behind your knees.
    • If camping, perform tick checks daily on humans AND pets, making sure to examine children at least twice daily. Again, pay special attention to the head and neck and don’t forget to check clothing for crawling ticks.
    • Shower and wash your clothes after returning home from the outdoors.

If you or a family member get bit by a tick: DO NOT PANIC, and DO NOT immediately rush to the emergency room! If the tick has been attached for less than a day, the chance of the tick transmitting one of these diseases is low. Removing ticks can be tricky, as they use their mouthparts to firmly attach to the skin.

Best method for tick removal -> remove as quickly as possible!

1. Grasp the tick with fine tipped tweezers as close to the skin as possible. If tweezers are not available, use a rubber gloved hand or place tissue or thin plastic over the tick before removing it to avoid possible transmission of disease.

2. Pull tick SLOWLY and with STEADY PRESSURE STRAIGHT away from the skin

  • DO NOT:
    • Crush, puncture, twist or jerk the tick as you remove it. This may increase risk of the tick regurgitating infected body fluids into the skin or leaving mouthparts in skin

3. After the tick is removed, disinfectant the attachment site on skin and WASH YOUR HANDS. Dispose of the live tick by placing in a sealed bag/container and submersing it in alcohol, then wrapping it tightly and crushing it in duct tape, OR flushing it down the toilet.

  • DO NOT:
    • crush the tick in your fingers
    • try to suffocate the tick still on the person by covering it with petroleum jelly OR touching it with a hot match to suffocate -> these methods can cause the tick to burst and INCREASE time the tick is attached, as well as making the tick more difficult to grasp

Remember: the goal is to remove the tick quickly from the host as opposed to waiting for it to detach on its own.

If you remove the tick and are worried, you can always put the tick in a sealed container with alcohol and bring the dead tick to your medical provider.

If you develop a rash or flu-like symptoms (fever, fatigue, body aches, headache) within several weeks of removing tick, see your medical provider and tell him/her about the recent tick bite, when it occurred and where you acquired the tick.

Remember: These diseases are very treatable if caught early enough!

Graphic taken from https://www.cdc.gov/ticks/pdfs/FS_TickBite-508.pdf

Stay tuned for next month’s explanation of the tick life cycle and tick-borne diseases in the high country!

References

1. Colorado Tick and Tick Born Diseases fact sheet. https://extension.colostate.edu/topic-areas/insects/colorado-ticks-and-tick-borne-diseases-5-593/ Accessed on 8/8/20

2. Peterson J., Robinson Howe. P. Lyme Disease: An Uptick in Cases for 2017. Wilderness Medicine Magazine: https://www.wms.org/magazine/1213/Lyme-Disease. Accessed 8/8/20

3. Do’s and Don’t’s of Tick Time: https://awls.org/wilderness-medicine-case-studies/dos-and-donts-of-tick-time/ Accessed 8/8/20

Laurie Pinkerton is a 3rd year Physician Assistant Student studying at Drexel University in Philadelphia, PA. Originally from Northern, VA, she graduated from the University of Mary Washington in Fredericksburg, VA with a degree in Biology in 2014. She moved to Keystone to live that ski life and stayed for 2 years, working as a pharmacy tech at Prescription Alternatives and as a medical assistant at Summit Cardiology. Prior to starting PA school, she moved to Idaho where she learned about organic farming and alternative medicine.  She has loved every second of being back in Summit County and learning here at Ebert Family Practice. She looks forward to practicing Integrative Medicine in the near future.

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

WMS Blog Entry No. 3: Pre-acclimatization, A Synopsis of Dr. Peter Hackett’s Lecture

1 Comment

What is pre-acclimatization? It is a process of adjusting to a new climate, usually higher elevation, reducing hypoxemia in high altitude settings in turn saving time, money, and most importantly, reducing altitude sickness. It can also allow for better sleep/comfort and physiological/cognitive performance at a high altitude. Acclimatization is a time-dependent process as over 5,000 genes are impacted by a large shift in elevation affecting ventilation, plasma volume, and hemoglobin mass, among other things. The whole process is not completely understood, but one key element is the hypoxic ventilatory response (HVR). HVR is activated by the aortic artery baroreceptors, as oxygen in the blood reduces it triggers an increase in respiration. This happens immediately as you ascend in altitude and maximizes at 7-14 days. Arterial oxygen increases by an increase in ventilation/saturation and also by dropping plasma volume, increasing hemoglobin concentration, and then later on, increasing overall Hgb production which in theory, overall decreases altitude sickness.

So how can you prepare yourself or pre-acclimatize?

Some of the better-known methods are spending time at higher altitudes prior to your destination, using a hyperbaric or normobaric chamber, blood doping, hypoxic exercise training, and a few pharmaceutical methods. All of these are options, but the key question is, which ones truly work?

Pre-acclimatization with actual altitude is the most useful. Generally speaking, you would pick your maximum sleeping altitude at your destination and slowly work your way towards that altitude. You pick an ascent profile which preferably would be spread over a week or more to be most useful. This pre-acclimatization should be completed no more than 1-2 weeks prior to your destination so that any pre-acclimatization gained doesn’t wane prior to your trip.

Simulated altitude is another option which includes hypoxic tents, hypoxic rooms/homes, hypoxic exercise chambers, and hypoxic masks. Out of these four, hypoxic tents or hypoxic rooms/homes, where exposure is over a long duration, are by far the most effective. Hypoxic masks and exercise chambers are not very effective as their short duration does not give the body enough time to make the proper adjustments and although might be beneficial in respiratory muscle training/performance, do little in the way of pre-acclimatizing your body. Studies show more benefit from hypobaric hypoxia training vs normobaric hypoxia training but keep in mind studies are very limited and warrant much further research. Overall, simulated altitude minimum requirements look to be somewhere in the range of 1 week of exposure, 7 hours per day, and a minimum effective altitude of 2200-2500 m and being no more than 1500-2000 m below your target sleeping altitude. Shorter term protocols can attenuate altitude sickness but not the incidence some studies suggest. As to why hypobaric methods are more effective than normobaric methods, no one really knows yet and more research is needed.

Changing your living destination to something at a much higher elevation and exposure over years or moderate altitude residence (MAR), is the most effective method according to some studies, but this is far from feasible for most. There are studies to show epigenetic changes for those who relocate to higher elevations for long periods and these appear to be much less than those who have genetically adapted to higher elevation over generations but still more effective than the previous mentioned short-term options.

Hikers often camp at the Angel of Shavano campground before ascending Mt. Shavano, one of Colorado’s famed fourteeners.

Oxygen saturation is maximal at 11 days of exposure to a specific elevation. Diamox (acetazolamide) increases ventilation and can help with acclimatization but there isn’t much data on how using this pharmaceutical compares to other methods mentioned. World-renowned high altitude expert and pioneerDr. Peter Hackett theorizes that it may fall just short of MAR, but again, more research is needed. Short-term altitude exposure shows benefits at 7 days but a longer exposure such as 15 days has been shown to be much more beneficial.

Blood doping with EPO can be somewhat effective over a 4+ week treatment and can potentially decrease AMS and potentially increase exercise performance but the data is limited and conflicting on this. Also, it appears that it is only effective up to 4,300 m but not beyond that as arterial oxygen content is not the determining factor for sleep and cognition performance at high altitudes but rather oxygen delivery which is affected by hematocrit and viscosity of blood.

Hypoxia inducible factor (HIF) is a regulatory factor in cells that respond to a reduction in oxygen, causing changes in about 5000 different genes to help the body adjust to meet oxygen requirements. It is suggested that we could pharmaceutically activate this factor prior to destination in order to acclimatize the patient allowing for less complications and better results at higher elevations. Currently there are some drugs in trials but nothing specifically FDA approved.

Overall, data and studies are limited but the most effective current pre-acclimatization method is long-term altitude training (real or simulated). If possible, plan your ascent trip to be slow and steady to obtain best results with the least amount of complication.

Joel Miller is currently preparing to graduate from Red Rocks Community College’s reputable Physician Assistant program this Fall. He has been a resident of Colorado for four years where he has immensely enjoyed the outdoors camping, fishing, hiking, hunting, and exploring Colorado’s wide variety of breweries.

Athletic Training, Backcountry, Backpacking, Doc Talk, Exposure, High Altitude, Mountaineering

WMS Blog Entry No. 2: Long Distance Backpacking, the Wisdom of Dr. Sue Spano

Leave a comment

Graduate of Temple University School of Medicine, Director of Wilderness Medicine Fellowship at University of California San Francisco Fresno Department of Emergency Medicine, Sue Spano, MD, FACEP, FAWM presented twice this year at the Wilderness Medicine Society’s annual (virtual) conference. Boasting the experience of about a thousand miles of the Pacific Coast Trail in Oregon and California and other recreational excursions, she shared a wealth of advice and personal recommendations for long distance backpacking.

To put it all into perspective, she referenced the Pacific Coast Trail (PCT), John Muir Trail (JMT) and the Appalachian Trail, each covering 2650 mi, 211 mi, and 2200 mi respectively. These are trips that last, easily, months. The general time frame for many of her recommendations is about five to six months.

Not surprisingly, the issue of weight comes up frequently for travelers. There are a number of studies done on this, from body mass index to base pack weight, and every ounce counts. While fitness level does not directly correlate to the incidence of injury, increase in BMI does correlate directly to increased risk of illness, injury, and trail evacuation. It is notable, however, that in a poll, about 2/3 of those hiking the PCT and well above those on the JMT trained before embarking on the trail, and most of them considered themselves to be “above average” in their level of fitness (7 or 8 on a scale of 1 to 10).

Although Dr. Spano does recommend carrying backups of three things — lighters, water treatment systems, and first aid — when it comes to base weight, there are several items that may be worth a little more investment for fewer ounces. Right off the bat: trail runners over boots. The mere difference in ounces becomes significant after so many miles, and the flexibility of softer shoes helps prevent a lot of discomfort (blisters, for example). She also notes that trail runners are more breathable and dry more quickly, sharing that she doesn’t typically bother to take them off to cross water or in snow as they will dry right on your feet along with your socks. It would be interesting to hear accounts of the footwear of preference on the Colorado Trail, where elevations are frequently higher and there may likely be more snow in general.

In another poll, 21.8 lbs was the base weight carried by packers, most of whom would have carried less in hindsight. This can be achieved by investing in lighter backpacks, tents, hiking poles, sleeping bags and sleeping pads, specifically. ULA Equipment out of Logan Utah makes an ultra-light pack that Dr. Spano prefers, “no conflict of interest”, just her personal favorite.

Skip the toothpaste, Spano urges. It doesn’t actually clean your teeth, so you might as well just brush with water.

Something else we’re seeing more and more of on distance excursions is tents that incorporate hiking poles as tent poles. Hiking poles themselves are recommended more and more as well, as they distribute more weight away from your legs.

Toilet paper must be packed out with you on much of the trail these days! Thus, the rise of the “backcountry bidet”, which you can make yourself by poking holes in the cap of a plastic liter water bottle. “You come out feeling like you had a full shower,” Spano testifies, and the water you use does not have to be filtered or potable.

Water! Know where your next water source will be. “Camel up at water sources … When you get to a water source, spend some real quality time there soaking your feet, cleaning your bandana, drinking as much water as you possibly feel like you want. Because the only time that your water is going to be ice cold is when you’re at that stream. Anything that you carry with is going to get really warm … Your easiest way to carry water is in your belly.”

When it comes to long distance backpacking, one of the finest pieces of advice Dr. Spano offers is that you should always be upgrading and optimizing your strategy:

“A person who hasn’t changed their backpacking practices in the last 10 years is not a person that I would really want to backpack with. A person who practices medicine the same way they did 10 years ago is not someone I want to practice medicine with. You should always be improving your gear, improving your behaviors, improving the way you approach the same challenge so that you’re a better backpacker as a result.”

Her hour-and-a-half practicum is available on the Wilderness Medicine Society website.

robert-ebert-santos

Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.