Category Archives: Doc Talk

Acclimation, Altitude Science, COVID-19, Doc Talk, Health, High Altitude, Medicine, Pandemic

Oxygen

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It has everything to do with how well the body functions at increasing elevation. In Summit County, Colorado, we live at an average elevation of 9000′ (2743 m). Most bodies start a significant physiological response to 8000′ (2438 m). Even healthy athletes experience shortness of breath during certain activities that wouldn’t be noticeable at lower elevations. The body compensates by circulating more oxygen-carrying red blood cells, because there isn’t as much oxygen packed into each breath you take. Heart rate increases, you take quicker breaths, speeding up your ventilation. You are hyperventilating. If you manage well enough for a couple weeks, your body will eventually start creating more red blood cells to circulate more oxygen throughout your body at all times. This process will peak at about three months.

We often get questions about the canisters of oxygen sold at convenience stores, souvenir shops and gas stations across Colorado and whether or not they make any difference. There is a 100% consensus among every physician, athlete, EMT and ski patroller we have ever interviewed that they do not.

Why not? Dr. Chris has been practicing medicine at 9000′ for 20 years in Frisco, CO, so I asked her a couple of the questions that have come up at our clinic and on our blog recently and frequently.

How much oxygen is needed to actually mitigate symptoms of altitude sickness?

For someone with low blood oxygen saturation, our target would be 90% . They should be put on a concentrator or a large tank [of oxygen]. The adult dose is 2 to 4 liters per minute, the pediatric dose can be between 1/4 L per minute and 1 L per minute, 24 hours a day, for up to a week, or until their oxygen saturation can maintain at 90%. Less than that, and usually, it will drop again after 10 minutes off oxygen; and it’ll often be lower when you sleep, too.

What if I bought ten of these canisters of oxygen available at the gas station and breathed all of them in, one after the other. Would that make a difference?

You might get three hours worth of oxygen if you bought ten of those store-bought cans, which might help an altitude sickness-induced headache. But again, your oxygen would likely drop shortly thereafter, and you would be experiencing the same symptoms.

What happens if someone struggling with acclimatization also contracts COVID-19 or another disease with associated respiratory complications?

We don’t know. Their oxygen requirement might be higher. All of us at altitude might be at greater risk than someone living at sea level.

When do you make the decision to send someone to a lower elevation? How low?

If they are having trouble breathing in spite of being on 4 L of oxygen per minute. If they need more than that, we would send them to a lower elevation. Most people are fine going to Denver. By Georgetown (8530’/2600 m, a town between Summit County and Denver), they’ll experience an improvement. It’s above 2500 m where altitude issues become problematic.

Research in recent years, including our own, is revealing many other different variables that may affect an individual’s ability to acclimatize to high elevations, including different hormones, genetics, and muscle mass. We continue to advise anyone traveling to the Colorado mountain region above 7000′ from lower elevations to stay hydrated and well-rested, and time a slow ascent, planning to spend at least 24 hours in Denver, or another comparable lower elevation, before arriving at your final destination.

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.

COVID-19, Doc Talk, Health, High Altitude, Medicine, Pandemic

COVID-19 at Altitude Update

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This is a Corona virus update from Children’s Hospital of Colorado and Ebert Family Clinic as of March 27, 2020.

Dr. Chris attended the weekly Children’s Hospital providers update webinar last night.  The good news is that the number of admissions and outpatient visits for children with respiratory illness is down by 50% compared to this time in previous years.

Another hopeful report about COVID transmission is that only 10% of family members develop symptoms when someone in the household becomes ill.

Testing priority update:

  1. Hospitalized patients and health care workers with symptoms;
  2. People in long term care and/or over age 65 with underlying health conditions, first responders and those working with seniors AND symptoms;
  3. Others with milder symptoms.

Testing involves inserting a swab deep into the nasopharynx. This requires having the swabs, tubes, protective equipment for the care provider, test kits and coordinated delivery of the specimens. There are shortages in all these areas, along with the risk to the health care worker. Thus, in Colorado at Children’s Hospital and in Summit County there are very limited controlled locations where respiratory specimens are collected. Currently, this is at the Summit County Community Care Clinic at a station behind the medical office building.

Anyone needing a test or face-to-face exam for respiratory symptoms must call ahead to any of these locations providing care: 970-668-4040.

Both the American Academy of Pediatrics and the Center for Disease Control recommend we continue providing well child care to those under age 2 in order to maintain vaccination rates at a level that will reduce the risk of another outbreak, such as measles or pertussis. If the child or any family member has respiratory symptoms, the visit should be rescheduled.

Telehealth visits for everyone with mild or moderate respiratory illness are being offered at Ebert Family Clinic and most other facilities. Because the illness can rapidly worsen, even after five days, IT IS CRITICAL THAT YOU HAVE A PULSE OXIMETER TO MONITOR YOUR OXYGEN. Blood oxygen saturation level is a critical vital sign that greatly aids in medical assessment. You can obtain a pulse oximeter at any pharmacy or at Ebert Family Clinic: (970) 668-1616.

Most patients can be treated at home with oxygen if they have saturation readings in the 80’s or high 70’s, but a rapid increase in oxygen requirement, shortness of breath, and readings below 75% merit an evaluation in the Emergency Room. CALL BEFORE YOU GO! (970) 668-8123. 

Health care providers in the mountains can evaluate your breathing effort by phone and video, and order oxygen to be delivered to your home.

Ibuprofen is safe (barring allergy), and along with acetaminophen, are the only medications recommended to treat the fever and pain (headache, backache, earache) of COVID-19, according to the infectious disease experts at Children’s Hospital. Other medications mentioned in the news are experimental, used on very ill patients in the hospital, and could possibly make an individual’s condition worse.

COVID-19, Doc Talk, Health, High Altitude, Medicine, Pandemic

COVID-19 at Altitude

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I am here at the Ebert Family Clinic waiting for the Public Health nurse to arrive for our staff training. Our plan is to set up an outdoor facility to screen individuals for COVID-19, Influenza, Strep, and Respiratory Syncytial Virus, when symptoms indicate to do so. The guidelines are ever-changing, but we are staying updated on the daily, even hourly changes. We are following guidelines published March 15:

  1. If you have mild respiratory symptoms – stay home!
  2. If you have a fever over 100.4° with respiratory symptoms (cough), but no shortness of breath or trouble breathing – stay home! Testing for COVID-19 is reserved for health care workers or senior services at this moment.
  3. If you have a fever, respiratory symptoms and trouble breathing – call the Emergency Room to set up a time to be screened and examined. If symptoms are severe – call 911.

EVERYONE AT ALTITUDE MUST HAVE ACCESS TO A PULSE OXIMETER!

Pulse oximeters are available at pharmacies and most stores. If you are unable to find one, please let us know. Your oxygen saturation is the key to assessing the severity of your illness.

Respiratory infections (such as influenza or COVID-19) puts high altitude residents at higher risk for pulmonary edema. Symptoms of pulmonary edema are cough, shortness of breath, and an oxygen saturation below 89%.  Supplemental oxygen is the treatment, but it must be ordered by a physician.

Resources such as laboratory testing, x-rays, antibiotics and inhalers may be limited during this pandemic.  As a physician, I use clinical judgement when sending patients for additional testing and treatment. I will take extra caution when sending stable patients to the hospital if they can be treated without an x-ray or lab test, or when no treatment is available. I am conservative in prescribing inhalers to people without a clear indication in order to conserve these for patients with definite reactive airways disease that respond to these treatments (i.e. asthma). These individuals should make sure that they have their medications on hand.

Viral pneumonia and pulmonary edema look the same on an x-ray, and clinical standards of care do not require an x-ray for diagnosis. The health care provider will prescribe antibiotics based on clinical suspicion and risk factors since chest x-rays do not always indicate whether someone has pneumonia.

Eagle County has 50 confirmed cases, so far, and several who were severely ill had to be transferred to Denver. As Governor Polis stated, the small mountain hospitals will be quickly overwhelmed as cases increase. There will also be a time when the hospitals in Denver are full and cannot accept transfers.

Ebert Family Clinic will continue seeing patients for preventive care. Wellness visits are scheduled in the morning and sick visits in the afternoon. Patients are not left to mingle in the waiting room as they are taken immediately back into a room. If they wish, they may also stay in their car or outside until we are ready for them to be roomed. Specific rooms are reserved for well visits. Deep cleaning and sanitization is performed after all visits and at the end of the day.  We ask that you also take preventative measures, like covering your cough, staying at home, and washing your hands.

Dr. Christine Ebert-Santos and an MA assess a patient and test a sample for COVID-19 in the parking lot in front of Ebert Family Clinic, Frisco, CO.

Influenza vaccines are important and available. There are cases of combined COVID-19 and Influenza, both of which attack the respiratory system, which is serious. Other vaccines that also prevent respiratory illnesses, such as pneumococcal, pertussis and HIB, can be LIFE-SAVING! These important vaccinations are administered at 2 months, 4 months, 6 months, and 1 year of age. Adults over 50 should receive the pneumococcal and flu vaccines. Children under 18 years have not had severe cases of COVID-19, but they are very contagious, even when they have no symptoms.

If you or your child are otherwise well and do not need vaccines, it is reasonable to postpone contact with the medical system and to reschedule routine checkups.

Dr. Chris is always available on her cell outside clinic hours for advice and treatment to continue her epic and ongoing efforts to keep patients healthy and out of the emergency room.

Please monitor our Facebook site for updates from our viewpoint.  Read our blog for a wealth of information on living in a low-oxygen environment, including interviews with local physicians practicing here for 20-30 years.

Acclimation, Altitude Science, Asthma, Child Growth & Development, Doc Talk, Health, High Altitude, Medicine

Dr. Chris’s HAPE Cheat Sheet

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Inflammation and altitude can cause low oxygen. Inflammation is commonly caused by viral infections such as colds or influenza, but can occasionally occur with bacterial infections such as strep throat or pneumonia. Low oxygen, or hypoxia, is the result of fluid collecting in the air sacs of the lungs, called pulmonary edema.

There are three types of high altitude pulmonary edema (HAPE).

  1. Classic HAPE, recognized for over a century. occurs in visitors to altitudes above 8000 ft (2500m) beginning during the first 48 hours after arrival. Symptoms include cough, congestion, trouble breathing, and fatigue, all worse with activity.
  2. Re-entry HAPE occurs in people who are living at altitude, travel to lower altitude, and develop symptoms during the first 48 hours after returning home
  3. High Altitude Resident Pulmonary Edema (HARPE) is a recently recognized illness that occurs mostly in children who have an underlying respiratory illness and live at altitude, with no recent history of travel. They have oxygen levels below 89 and lower but do not appear toxic. They are fatigued but rarely have increased work of breathing.
Parents are often worried their children won’t wear a canula for oxygen, but they don’t typically mind.

Treatment of HAPE is oxygen. There may also be signs of asthma or pneumonia which are treated with bronchodilators and antibiotics. Most people with pneumonia at altitude do NOT have hypoxia. All three types of HAPE can reoccur, but typically not with every arrival at altitude or viral illness. Many of these patients are told they have pneumonia again and again, or severe asthma, and are treated with inhalers and steroids. Usually, this adds nothing to their recovery.

A chest x-ray may show typical infiltrates seen with pulmonary edema, but in mild or early cases, can look normal. There is no blood test for HAPE. Oxygen should be used continuously at a rate that raises the oxygen saturation into the 90’s. Length of treatment may be as short as 2 days or as long as ten days

Most importantly, owning a pulse oximeter and measuring oxygen levels in anyone at altitude with symptoms of cough, congestion, fatigue and trouble breathing with exertion can keep people out of the ER and ICU. HAPE can rapidly progress to respiratory failure and death if not recognized and treated expediently.

Acclimation, Alcohol at Altitude, Altitude Science, Doc Talk, Health, High Altitude, Medicine

Doc Talk: The Art of Saving Vacations

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In 1986, Dr. David Gray was asked to join a team of rafters on an exploration of the Yangtze River in China. Their goal, simple: to reach the undiscovered source of the Yangtze river and raft all the way down. Although simple is quite the understatement. The Yangtze River is the 3rd longest river in the world, and the source of the river is at approximately 19,000 feet (5791 m) above sea level. 

Dr. Gray, a young physician at the time, agreed to join the mission after being told by the mission frontman, Ken Warren, that “we want you there for trauma”. Dr. Gray, however, had an inkling that the high elevation could present some interesting challenges. He consulted with two pulmonologists, but at the time, understanding of treatment at high altitude was limited–he got little advice. With eagerness and reassurance that he would “have the final say on all things medical”, he began the mission. 

The team was comprised of an eclectic group of gentlemen. From 4 Chinese Olympic athletes, to a camera man from National Geographic, the crew set forth to uncharted territory. The took a bus up the first 14,000 ft, and they learned quickly about the effects of altitude. “Everyone was sick. I’m treating headaches with narcotics, treating vomiting with phenadrine, and guess what I had for pulmonary edema: lasix!” Despite the chaos, everybody improved and the crew trudged forward. 

In their slow ascent, there came a point when the snow was nearly six feet deep — vehicles were no longer an option. The rest of the mission would be on foot. On foot, with yaks carrying their gear, the crew moved up the glacier to what they presumed was the source of the river. The photographer from National Geographic, David Schippe, had not been doing well. As the mission progressed, Dr. Gray could hear crackles in the base of his lungs through a stethoscope and sent him down to receive medical attention. This was a case of  high altitude pulmonary edema (HAPE); he was diagnosed with pneumonia.

The rest of the crew reached the presumed source, “Tigers Leak Gorge”, which turned out to be one of the many Yangtze tributaries. On their decent down on “duckies”(blow-up rafts), they stopped at base camp and found David Schippe, the photographer that was supposed to have headed back to receive medical care. Their next checkpoint was at 11,000 ft; it was 600 miles away and they had no choice but to continue down with Schippe alongside. 

Unfortunately, this would be David Schippe’s last journey. “On the second day, Schippe started coughing; he gets very sick, and is put on IV. I said, ‘we need the helicopter,’ but there was no helicopter; that was all a lie. [Ken] had a short-wave radio, but he used the money for the emergency helicopter to pay his mortgage.” Dr. Gray, feeling the weight of this terrible deception, knew this would be the end of Schippe’s life.

We buried him on the river.

Dr. Gray distinctly remembers Ken Warren, the expedition leader’s announcement of their crew member’s death.

He said, ‘Dave’s dead. Suck it up, or you could be next.’

That was confirmation to Dr. Gray that this mission was not being run with any regard for crew safety. When they got to their checkpoint, Dr. Gray said “adios”. 

And so went Dr. Gray’s introduction to Altitude Medicine.

Fast forward to today, in a local brewery, Dr. Gray, equipped with the wisdom of 20 years of practice in Summit County, Colorado, after 25 years of Emergency Medicine in Corpus Christi, Texas, shares some of the essential knowledge for working in the hypoxic conditions of high altitude. An advocate for accessible and affordable health care, much of his practice involves bringing his medical services straight to his patients.

Has anything changed about what you put in your medical bag since you first started doing mobile health care?

No. I had a select group of medications I use that cover almost everything. I get an antibiotic prescription, so I can hand them their ZPak (my “go-to” medication).  I carry ventil, decadron, nubain (a synthetic narcotic) — it has some narcotic antagonist effects, so you have to be careful if you put someone on opioids on it, because it’ll put them in immediate withdrawal — Benadryl, and epinephrine.

First case of HAPE in Summit County?

He was from Scotland or somewhere in the British Isles. I sent him to the hospital, he gets in the ambulance, spends two days in the ICU in Denver, and $30K later, they send him back up!

Dr. Chris mentions that even physicians in Denver aren’t always familiar with high altitude care, and can order extensive testing for symptoms that are classic presentations of high altitude pulmonary edema. 

I got a guy from Austin; he was in his late 40’s. He had pulmonary edema, and  his O2 sats were maybe in the 70s. I said, ‘you need to go to the hospital, get out of the altitude, and go to Denver.’ He said, ‘I don’t want to leave my family, do I have to leave?’

I told him, ‘I’m going to work with you, but you have got to do everything I say. I’ll be back in the morning to give you another dose of decadron and you don’t get to sue me if this doesn’t end well.’

I see him the next day, give him another shot of decadron. He was one of the first people I allowed to stay at altitude. I wouldn’t leave anybody with that treatment if I couldn’t get him up to the high 70s.

Dr. Gray typically puts these patients on oxygen full-time at approximately 5 liters, monitors them closely, and finds patients’ oxygen saturations will typically go up into the 90’s.

I got confident with what I was doing.

He also makes a point that it’s essential to re-check vitals in these patients and to pay attention to symptoms. Too often, patients present with an acceptable oxygen saturation, around 93, and end up coming back hypoxic:

The oxygen can present normal initially because patients are hyperventilating! The respiratory muscles cannot maintain that work of breathing, and later, their oxygenation will drop! 

Dr. Gray and his own family have had their own experience with re-entry HAPE, as well:

We were back in Texas for a few weeks. I took them to the [alpine slide] back in Breckenridge, and Dillon (Dr. Gray’s son), who always got headaches, comes up to the car and throws up a bunch of red vomit. I told his sister, ‘Please tell me he drank a red soda before this.’ (He had.) Then we go home and he’s just feeling bad. I just figured, it’s his headache, or it’s a viral bug, then luckily, I put him in bed with me. At about 10 pm that night, he was coughing so much it was keeping me up. I put a stethoscope on him, and it was like a washing machine! His oxygen was 38!

I put him on five liters of oxygen and he quit coughing. The cough reflex was there because the lungs were trying to do anything to get more oxygen!

It’s not that the pulmonary edema was getting better quickly, necessarily; it took about three days for him to get better.

“It ain’t about water; it’s diet.”

What I believe happens when you come two miles in the sky as abruptly as people do: most Americans are dehydrated anyways. When they get here, the body goes into defense mode. It shunts blood and oxygen into your heart and kidneys and consequently … away from your stomach. Then, they (visitors) eat restaurant portion meals and greasy steaks on vacation. That’s why vomiting is sometimes the primary symptom. 

What I tell people is if you stop in a restaurant on your way up here, choose high carb, low fat, low protein meals — carbs are easy to transport through the system. Choose smartly, eat half of what they put on your plate, and take the rest home. The last meal should be at 5 pm. 

Also, alcohol is a mild diuretic at best! The real issue is that it’s a respiratory depressant! If you need to drink on this trip, drink in the morning!

Who gets acute mountain sickness? 

Young fit males. They come up here with a resting pulse of 52 beats per minute. A well-exercised person can’t get their heart rate up to counteract hypoxia. Then they ignore their symptoms because that’s what athletes do. As for athletes, I’ve given up on that. They go 100%, and they are not going to hold back.  

Another point that Dr. Gray emphasized was the seasonal factors: 

We see a marked difference in acute mountain sickness in Winter and Summer. You are by necessity in a hyper-metabolic state in the cold. Your body is working hard using oxygen to stay warm.  Plus, people are overusing muscles they haven’t used all year. In the summer, they come up in cars and ‘meander’ up. In the winter, they fly and ascend within hours. [Ages ago], you didn’t see any altitude sickness because they came on donkeys! Very slowly! 

And if you’re not sick by day two, you probably won’t be.

By the age of 50:

Everyone who lives here should sleep on oxygen. If you haven’t been here for generations, you need to be on night time supplemental oxygen. The only exception to this is in COPD patients due to oxygen deprivation driving respiration and CO2 retention.

I tell full-time residents, ‘you need an oxygen concentrator.’ It’s a night time problem. During the day, you’re ventilating. At night, you go into a somnolent state and your breathing goes down.

Muscles are healthier when you use them, that goes for the heart too. We (Summit county residents) are hyper-dynamic, cardiac-wise. If you supplement with oxygen at night, you keep the process of pulmonary hypertension from developing. 

Advice to the Traveler

Diamox: it changes your acid base chemistry, acidifying your serum, which, essentially, turns you into your own ventilator. Some people are aware of their increased respiratory depth and it may bother them. 125 mg twice a day, beginning two days before travel. Any dose greater than that will just increase side effects. 

The Water Issue: you can’t make up for chronic dehydration during the day. The biggest loss of fluid from the human body is insensible loss – moisturizing the air you breathe! Altitude also produces diarrhesis, as well as a lot of intestinal gas. The poor bacteria in your GI are also hypoxic.

Talking Altitude Medicine with Dr. David Gray

Dr. Gray opened his own practice in Breckenridge, CO caring primarily for travelers. With the motto “We save vacations,” he expresses a true passion for the demographics of the population and practice at high altitude. He developed his practice by networking closely with local ski industry workers, from lifties to ski shop employees, and provides fee for service immediate care to his patients. 

Autumn Luger is a physician assistant student at Des Moines University. She grew up in the small town of Bloomfield, Nebraska where the population of cattle vastly outnumbered humans. From there, she moved on to study biology and chemistry and eventually receive her bachelor’s degree at the University of Sioux Falls in South Dakota. She enjoys leisurely running, competitive sports, hikes in beautiful locations, attempting to bake, thrift shopping, and expressing creativity through art. Since being in Summit County, she has discovered some new interests as well: snowshoeing, hot yoga, and moonlit hikes.

Acclimation, Alcohol at Altitude, Altitude Science, Doc Talk, Genetics, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering

Doc Talk: Nutrition & Oxygen as Preventative Medicine

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Dr. C. Louis Perrinjaquet has been practicing in Summit County, Colorado’s mountain communities since the 80’s, when he first arrived as a medical student. He currently practices at High Country Health Care, bringing with him a wealth of experience in holistic and homeopathic philosophy, such as transcendental meditation and Ayurvedic medicine, as well.

This past week, Dr. Chris managed to sit him down over a cup of coffee in Breckenridge to talk Altitude Medicine. And not a moment too soon, as PJ is already on his way back to Sudan for his 11th trip, one of many countries where he has continued to provide medical resources for weeks at a time. He’s also done similar work in the Honduras, Uganda, Gambia, Nepal, and even found himself out in the remote Pacific, on Vanuatu, an experience overlapping Dr. Chris’s own experience spending decades as a physician in the Commonwealth of the Northern Mariana Islands.

Experience is everything when it comes to High Altitude Health. I asked PJ if there was any such thing as a “dream team” of specialists he would consult when it came to practicing in the high country: more than any particular field, he would prefer physicians with the long-served, active experience that Dr. Chris has in the mountain communities.

Complications at altitude aren’t always so straight-forward. Doc PJ sometimes refers to the more complex cases he’s seen as “bad luck”, “Not in a superstitious way,” he explains, but in “a combination of factors that are more complex than we understand,” not least of all genetics and hormones.

At this elevation (the town of Breckenridge is at 9600’/2926 m), he’s seen all cases of High Altitude Pulmonary Edema (HAPE): chronic, recurring and re-entry. The re-entry HAPE he sees is mostly in children, or after surgery or trauma, which Dr. Chris speculates may be a form of re-entry HAPE.

He’s seen one case of High Altitude Cerebral Edema (HACE), a condition more commonly seen in expeditions to even more extreme elevations (see our previous article, Altitude and the Brain). In this case, “a lady from Japan came in with an awful headache, to Urgent Care at the base of Peak 9 … she lapsed into a coma, we intubated her, then flew her out.”

How common are these issues in residents?

It’s probably a genetic susceptibility. More men come down with HAPE at altitude, or estrogen-deficient women. Estrogen may protect against this. When I first moved up here, we used to have a couple people die of HAPE every year! The classic story is male visitors up here drink on the town after a day of skiing, don’t feel well, think it’s a cold, and wake up dead. A relatively small number of the population up here has been here for decades. Most move here for only 5 – 10 years; even kids [from Summit County] go to college elsewhere, then move away.

In addition to hypoxia, severe weather and climate are also associated with extreme elevation. Do you observe any adverse physiological responses to the cold or dryness, etc. at this elevation?

Chronic cold injury probably takes off a few capillaries every time you’re a little too cold.

At this, Dr. Chris chimes in, “People who have lived here a long time may have more trouble keeping their hands and feet warm.”

Do you have any advice for athletes, or regarding recreation at altitude?

Don’t be an athlete up here very long. Don’t get injured. You can train yourself to perform a certain task, but that might not be healthy for you [in the long term]. Really long endurance athletes – that might not be good for your health, long-term. I see chronic fatigue often, they kinda hit a wall after years: joint issues, joint replacement, …

We’re observing a relatively recent trend with many high altitude and endurance athletes subscribing to a sustainable, plant-based diet. We’ve also encountered a lot of athletes consuming vegetables and supplements rich in nitrates to assist with their acclimatization. Do you have any experience with or thoughts on these techniques?

Eat a lot of fruits and vegetables, not a lot of simple carbohydrates, not a lot of refined grains. Eat whole grains. I’ve been vegan for a while; it’s been an evolving alternative diet.

Do you ever recommend any other holistic or homeopathic approaches to altitude-associated conditions, healing or nutrition?

Why don’t you get some sleep? Eat better? Don’t drink? Pay attention to your oxygen? Sleep with air? … If you’re over 50 and plan to be here a while, you might sleep on oxygen. I can’t imagine chronic hypoxia would benefit anyone moving here over 50. It may stimulate formation of collateral circulation in the heart, but we’re probably hypoxic enough during the day. It might benefit athletes that want to stimulate those enzymes in their bodies, but even that would be at a moderated level, not at 10,000 ft.

We’re onto something here: Dr. Chris has seen a lot of benefits in some of her patients sleeping on oxygen. If you haven’t already heard, Ebert Family Clinic is currently deep in the middle of a nocturnal pulse oximeter study, where subjects spend one night with a pulse oximeter on their finger to track oxygen levels as they sleep. This will provide more data on whether certain individuals or demographics may benefit from sleeping on oxygen.

In the case of pulmonary hypertension, probably 50% of people who get an electrocardiogram may experience relief from being on air at night. Decreased exercise tolerance when you’re over 50 might be a good case for a recommendation. I don’t think we ever have ‘too much oxygen’ up here; ‘great levels of oxygen at night’ are about 94%. Humans evolved maintaining oxygen day and night [in the 90s], same with sodium, potassium, etc., at a fairly narrow tolerance.

Are there any myths about altitude you find you frequently have to clarify or dispel?

Little cans of oxygen! it’s predatory marketing! It’s so annoying! We’re littering the earth and taking people’s money for ‘air’! Just take some deep breaths, do some yoga for a few minutes … sitting for 30 minutes at an oxygen bar might help. There’s no way to store oxygen in your body, so within 15 minutes, it’s out, but the effects might last, but it gives a false sense of security. 

Also,

IV fluids! DRINK WATER! Or go to a place where you can get real medical care. Most vitamin mixtures, or ‘mineral mojo’, is not real. First of all, don’t get drunk! Drink way less. Dr. Rosen, a geriatric psychiatrist, sees a lot of older guys with MCI (mild cognitive impairment), they’ve had a few concussions, have a drink a day and have lived at altitude for a while. He sees more of these guys here than at low altitude. It’s part of my pitch for guys to sleep on oxygen and minimize alcohol. We don’t have the science to take one or two drinks a week away, but just add oxygen.

Do you have to change the way you prescribe medications due to altitude? Has anything else changed about your practice after moving to altitude?

I don’t [prescribe] steroids as much. Even if it’s rare, I don’t think [steroids] are as benign as other doctors. I avoid antibiotics if possible.

Do you yourself engage in any form of recreation at altitude? How has the altitude played a role in your own experience of this?

I didn’t exercise much until I was 40. [Now] I trail run in the summer, which I think is better than road running (‘cave man’ didn’t have completely flat pavement to run on for miles and miles). In the winter, I skin up the mountain almost every morning; [also] mountain biking. 

Ease in to exercise gradually. Exercise half an hour to an hour a day, but do something every day, even if it’s 10 minutes. And don’t get injured.

Doc PJ also has a handout he most often refers his patients and visitors at High Country Health to, here.

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.

Acclimation, Alcohol at Altitude, Altitude Science, Doc Talk, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering

High Country Healthcare’s Guide to Altitude and Acclimatization

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Welcome to Summit County! At the high elevations of the Colorado Mountains, everyone is affected by altitude to some degree. As you go to higher altitudes, the barometric pressure decreases, the air is thinner and less oxygen is available. The air is also dryer and the ultraviolet rays from the sun are stronger. At elevations of 8,000 plus feet your body responds by breathing faster and more deeply, resulting in shortness of breath, especially on exertion. Many people develop mild symptoms of headache, nausea, trouble sleeping, and unusual tiredness, which we call acute mountain sickness or AMS. These symptoms usually go away in a day or two. If symptoms are severe, persist or worse, you should consult a doctor. A short visit to a physician may save the rest of your vacation.

A more serious condition is called high altitude pulmonary edema or HAPE. This condition is recognized by a wet cough, increasing shortness of breath, and the feeling of fluid building up in your lungs. Other symptoms may include disorientation or confusion. If you feel any of these symptoms developing you need to seek medical attention immediately. HAPE is easy to treat but can be life threatening if left unattended.

The effects of high altitude can be decreased by following these recommendations:

  • Increase Fluid Intake – drink two or three times more fluid than usual, water and juices are best; adequate hydration is the key to preventing altitude illness. You should drink enough fluids to urinate approximately every two hours.
  • Avoid alcohol and minimize caffeine on your day of arrival and one to two days thereafter; be very careful if consuming alcohol, and remember, at this altitude, you may be much more sensitive to the effects of alcohol and sedatives (caffeine and alcohol are dehydrating).
  • Decrease salt intake – salt causes your body to retain fluid (edema), which increases the severity of altitude illness.
  • Eat frequent small meals high in carbohydrates, low in fat, and low in protein.
  • Moderate physical activity and get plenty of rest.
  • Medications and oxygen can help you feel much better. Diamox is a prescription drug which prevents the unpleasant symptoms for many people. Recent experience suggests that a small dose of Diamox suffices: 125 mgs in the morning before you arrive at altitude, again that evening, and each morning and night for two days after arrival. It is generally a well tolerated medicine with few side effects. It should not be taken by anyone who is allergic to the sulfa class of medicines. Some people may experience a tingling sensation in their fingers, toes and around their mouth. You may also notice a subtle change in your sense of taste; especially carbonated beverages may taste flat. As with any medication, take only as directed and discuss any potential side effects with your physician.
  • Studies have shown that spending 1 -2 nights at a modest altitude of 5000 – 6000 feet decreases symptoms when you go higher.
  • The effects of the sun are also much stronger at high altitudes, even in cold weather! Be sure to use sunscreen of at least SPF 15 to avoid sunburn.
  • Have fun and enjoy the mountains!

**This was taken from a handout provided by Dr. C. Louis Perrinjaquet at High Country Healthcare in Summit County, Colorado.**

Acclimation, Doc Talk, Health, High Altitude, High Altitude Training & Fitness, Veterinary Medicine

Dogs at Altitude

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The mountain communities are home to more animals than people in Colorado. Every Spring, we’re likely to see everything from foxes to moose in our yards and on our streets. About a month ago, I watched a juvenile (but plenty large) black bear on an evening walk in front of the houses in our neighborhood, peeking into the garbage bins lined up for pick-up the following morning.

Claire Tinker with her Dachshund Baxter on Bierstadt.

Dogs are natural companions to many up here as well, with plenty of space to run around, smells to sniff, and communities that seem to welcome their company indoors as well as out. Having seen so many of our dog friends on trails all across the state, we’ve wondered how they might be coping with the altitude. 

Most recently, we ran into a German short-haired pointer named Moose on an ascent up Mt. Bierstadt, one of Colorado’s 14ers, sitting at 14,060 ft (4285 m). He and his human, Nick, moved to Colorado permanently about a year ago, after a two-week visit turned into several months. 

Moose is 13 years old, Nick tells me, “but you have to believe that my dog acts like he’s 6.” Nick and Moose have been enjoying a lot of time outdoors together since moving to Colorado, and Bierstadt was their first 14er together, which they did with some other friends from Louisiana, where they’re from. 

“It was awesome. Took [our friends] a long time to summit, but Moose did really well. He liked the breeze and the birds coasting right next to him. It would have been hard without a harness to [lead] him up to the top. He’s 65 lbs. Boulders weren’t too bad for him. Just have to be careful coming down, so he doesn’t slip and break a leg.” 

Moose and his Louisiana posse on their way up Mt. Bierstadt.

This is a very legitimate concern. Many hikers have found themselves carrying their canine counterparts: they get tired, the terrain is difficult for them to negotiate or too rough on their bare paws, etc. You definitely don’t want to have your hands full as you ascend or descend a 14er.

Dr. Danielle Jehr, who has been a veterinarian with Frisco Animal Hospital for years after studying and practicing in Nebraska, also recommends waiting to take your puppy on the longer, more strenuous hikes.

Dr. Danielle Jehn with hiking and car ride enthusiasts Libby and Liam.

“Unfortunately, we do not get a chance to discuss this with many owners unless there are new puppy owners. Usually, we just see the aftermath from a hike and help guide them for future incidences. I would love to be able to tell all new puppy owners that activity needs to be limited up until 6-8 months of age while they are experiencing enormous amounts of bone growth. This means no major hikes on uneven surfaces and no 10 mile runs while the owner mountain bikes. We just want the pups to grow normally without complications for them or the owners.”

And as you might have speculated, animals are also prone to certain risks at high altitudes, although, “In general, healthy animals do not function any different at high altitude,” says Dr. Jehn. “Animals and pets with known blood pressure, cardiac or respiratory disease can decompensate at higher altitudes, and we do see this in practice. Just as human hearts have a difficult time at altitude, so do cats, dogs and livestock!”

Ike, about 8 months old, seriously reconsidering his choices on his way up Mt. Bierstadt.

So how do you know if your furry buddy is struggling with acclimation?

“Most often, an owner will call and have a presenting complaint of their pet experiencing exercise intolerance while on a hike or constant panting/lethargy/anorexia since the pet has been up in Summit County. If a dog presents in any type of respiratory distress, we place them on supplemental oxygen, check their heart and lung sounds, heart rate, respiratory rate, blood pressure and ability to oxygenate. We do this by utilizing a tool in the clinic that measures the percentage of oxygen carried in the blood.” Sound familiar? “We always want to see a dog at over 92%. If the dog or cat cannot maintain that or better without being provided oxygen, we need to see other diagnostics for reasons why.

“Common canine ailments we see that are drastically exacerbated by altitude are: cardiac disease (heart murmur, pulmonary hypertension, congestive heart failure), general hypertension, lung disease (asthma, allergic bronchitis) or vascular volume abnormalities (i.e. anemia).”

The most common injuries Dr. Jehn sees, she tells me, are “lacerations and abrasions from the rough terrain. We also see exacerbated lameness after hikes that are too long for our canine friends that are not otherwise used to it (i.e. 14ers).”

Nick and Moose currently live in Boulder, at 5328 ft (1624 m), but they moved there from a house in Bailey, at about 7740 ft (2359 m). I ask Nick if Moose has ever had trouble with the altitude since they moved to Colorado. 

“Not at all. Not even when we first got here. He was ready to rock and roll. The only thing he didn’t like was the snow at first. Once he realized there were rabbits and stuff that went in the snow, he was about it.”

Being from Louisiana, one of Moose’s greatest challenges is the relative scarcity of water. Colorado doesn’t have as many lakes and ponds that Moose can cool off in and drink from, so Nick says he’s sure to carry water for him.

Nick also tells me that Moose is a pretty fit dog, and has never experienced any major health complications. He is careful, however, not to work him so hard that he’s limping the following day. I think it’s safe to say that’s something humans are wary of for themselves as well. If you’ve ever hiked a 14er, you already know. 

Dr. Chris with grand-dog Ike on their way up Mt. Bierstadt.

Another factor that affects Moose and people alike is exposure. “If there’s no shade or wind, it’s a lot harder on him,” Nick notes. We also relate over the challenge of descending a mountain, when the resistance of gravity is especially stressful on your knees and hips. Nick works for Sacred Genetics, a company that cultivates feminized hemp seeds, who are partners with a company, Verdant Formulas, that specializes in CBD products, utilitzing the relaxing, remedial properties of the oil from cannabis. Among other applications, balms and oils infused with CBD have grown in popularity as a naturopathic treatment for muscle soreness and inflammation. Incidentally, more and more similar products are being marketed for the same afflictions in dogs. Nick tells me it helps with his own post-adventure soreness.

My main takeaway from all this insightful doggo dialogue is that we are all the more similar. It certainly seems like the same precautions apply for avoiding a serious situation outdoors. And don’t forget, if anyone in your party is having trouble on your hike, it is not advisable to continue; you are only as strong as the weakest member of your team, whether that is a dog or a person. 

A last bit of advice from Dr. Jehn:

“I would also love to be able to tell all tourists to take it easy on their canine counterparts while visiting us in Summit County as well. Altitude sickness is real for humans and dogs, alike. Accomplishing a crazy hike with your dog should not be the first priority within the first few days at elevation. Dehydration and prior health conditions are real when experiencing altitude. If you know your dog has history of a heart or lung issue, especially, let them take it easy. We want you to enjoy Summit County for everything it has to offer….without the emergency visit!!”

Happy Trails, all you trailhounds and trail … hounds!

robert-ebert-santos
Roberto Santos on an epic powder day at the opening of The Beavers lift at Arapahoe Basin ski area.

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.

Acclimation, Doc Talk, Health, High Altitude, Medicine, Technology

Kidney Function at Altitude: An Interview with Nephrologist Dr. Andrew Brookens

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How much do you know about the role your kidneys play? Does elevation affect their function? How do your kidneys help you adjust to high altitude environments?

The remote mountain communities have a new hero. Altitude Kidney Health just opened their practice at Ebert Family Clinic in Frisco, Summit County, Colorado this week. Dr. Andrew Brookens, a native Coloradan, grew up in the Denver suburb of Englewood, and spent years living at twice the altitude in Bolivia with the Peace Corps before dedicating his career to bringing his current legacy of accessible kidney health care back to Colorado. His passion for providing service to the Colorado high country and beyond and his appreciation for his cross-cultural heritage is powerful in a recent talk between patients and publicizing.

What do you want people to know about you and your background?

I was born in Englewood, Colorado, and I knew pretty early on that I wanted to be helping people, in health care. But the first job I took was as a waiter. I thought that was just great.

God bless you! I know just how valuable that is.

But it’s funny, because I don’t consider serving patients too much different than waiting tables and serving clients there. So, what I did was I had to sort out whether I truly wanted it. And I went to college out East, and I decided to do the coursework for medicine and medical school. But I decided at the end of medical school, I think there’s more to life than just going straight through and being a science junkie. So I got a degree in Public Policy and Spanish, and I lived in South America and did the Peace Corps for two and a half year.

I went to Cherry Creek High School in Englewood. I went to Duke University in North Carolina. I went to Bolivia [for the Peace Corps], which was great, because a second goal was to learn Spanish fluently. My grandfather is from Puerto Rico, my grandmother’s from Dominican Republic, and a lot of family speaks Spanish only, and I decided, you know what, I could just go straight on through and be a science junkie, or I can learn a little bit about the world, you know, some of this cross-cultural reality that is in my family. And I decided I just need to figure some stuff out for myself first.

And I’ve heard Bolivia is another undiscovered gem in South America.

Yeah, exactly. Bolivia is one of two landlocked countries in South America. And it has three main areas from the high plains — they call it the altiplano — but it’s up at about 12,000 – 14,000 ft. It’s intense. And it’s totally flat land, as you look out across the landscape. It’s like the Great Plains of the States, but flatter. And then there’s the mountain valleys and then there’s the Lowlands, which are tropical. And so I lived in the mountain valleys at 10,000 ft. And it’s beautiful, and I of course went there to learn Spanish, and I got placed in a village where Spanish was the second language. The first language was Quechua, so I had to learn Quechua to survive!

I did two and half years there doing youth education and local economic development. I worked with women weavers to help them sell their weavings, and market it in the cities. And I worked with the tourism committee to help bring more tourists to their lands, because agriculture was a declining economy, and we wanted to help them develop ways to generate income in their own villages.

I loved the service work abroad, but wanted to anchor myself to somewhere closer to Colorado. Back at home, my brother helped reopen my eyes to considering the long-term career I’d once dreamt about as a child: medicine. And so while working as a consultant and waiter again, I applied and was accepted to medical school at CU in Denver, and we were the first class to transfer out from the Denver campus to Aurora. It was a wonderful experience: the peer group, as well as experiencing the new campus and all of the things they had to offer afforded a variety of learning opportunities.

During that experience, I got to travel to the mountains of Colorado and do a clinical rotation in Steamboat [Springs], which was fascinating for me. Because it was about seeing the community and not just seeing the next test and my studies. And as a guy who’s from CO, going out there and seeing what the mountains were like and what the needs were like … one of the docs who I worked with, who’s still in practice there, is this fascinating doctor who trained himself to do some specialty procedures because otherwise he had to send patients down for these procedures who couldn’t afford to spend the night in the city, and it was just complex. And he has pioneered the offering of some specialty services in addition to his general medical practice in that part of the state. It just opened my mind to this reality of what the need is in parts of Colorado and in many states, frankly, that don’t have access or aren’t right next door to a major medical center.

Was he a nephrologist as well?

No, he was a general internist, and he was doing gastrointestinal procedures: colonoscopies and things like that. So that kinda sparked a flame, and I decided to follow my soon-to-be-wife to Seattle where I finished my training. I did Internal Medicine residency, and then kidney, or nephrology, fellowship in Seattle, Washington. And at the end of five years there, my wife, who’s also from Colorado, and I had made a decision … we decided to go back to Colorado. And so we moved back to Colorado in 2016, I took a job with a large Nephrology practice in West Denver. I loved my job, it was a great group of colleagues, and yet I still felt like there was more to pursue, going back to that same experience that I mentioned, which is we could be doing more for our patients who live in the far flung areas of the state.

To ask a patient to come in, driving six hours or five hours from Craig, for a 15 minute visit with me, it felt like the greatest disservice. Why would a patient conceivably wanna lose a day or two, trek all the way down here, pay me to see me, and then maybe return home, maybe not necessarily better off. I just didn’t feel like that was making sense. I don’t wanna be naive about it, but it was my deep-seated belief that we could do more to bring health care to Coloradans everywhere, no matter where they are. And that’s why I decided this is the time. So in late 2018, I decided to resign my position and set out to make this company, which is Altitude Kidney Health. This is the dream that I’ve had all the way back to the days when I thought I wanted to just help people and started waiting tables. I felt like creating a practice that delivers health care to Coloradans like I can no matter where the Coloradans are is … I feel like the luckiest guy in the world.

So as I go through the community evangelizing our new Nephrologist, a lot of people don’t know the term “Nephrology”. What are some things about Nephrology that affect more people than they realize?

I love that. It’s a great question because a lot of providers don’t know some of the things that are most intimately related to Nephrology, too. The kidneys have their hands in tons of pots in the body. Not only do the kidneys clean your blood — so when you pee, that is a fluid that’s made by your kidneys and stored in your bladder until you pee it out. And what it does is it gets rid of waste products and toxins, everything from the breakfast burrito you had to the glass of wine you’ll have tonight.

But in the same way that it cleans toxins out of your body, it’s finely tuning electrolytes. If you watch the Gatorade commercials about electrolytes and things, the kidney has the job of balancing those electrolytes so finely that they really shouldn’t vary more than a couple iotas off normal, and that’s thanks to the kidney. Everything from potassium to acid levels in your blood, sodium levels and the amount of water that’s in your body.

When you feel thirsty, because you haven’t drunk, or because you just had this delicious, massive pizza, or you’re working out, that is your kidney in that signaling process. Kidneys help you understand that you’re thirsty and it’s time to drink.

In addition, kidneys control many functions. Up here at altitude, we know that patients make more blood cells. The kidneys are one of the first steps in the creation of blood cells, which are made inside your bone marrow. The kidneys signal that. We see patients with kidney disease not only suffer from imbalances of electrolytes and a build up of toxins as kidney disease progresses, along the lines of those two main functions I mentioned, when your kidney disease progresses, I see patients start to lose blood cells. They make less and less, and that’s because signals weaken coming from the kidney in patients who have kidney disease. I also see patients develop weaker bone structure or musculoskeletal disease from kidney disease, and that’s something that’s intimately regulated by the kidney because it helps to balance minerals like magnesium and phosphorus and calcium in your body.

And in addition, I think the kidney has its hand in a really key element that most providers are aware of but maybe patients not: blood pressure. Your blood pressure’s regulated in a tight range, and the kidney allows that; it’s the one that determines how long that leash is. How long can it go, how high can it go? Outside of that range, there may be other factors. If you’re truly dehydrated, maybe your blood pressure drops. Or there are other things that can cause your blood pressure to elevate, including aging, and this stiffening of your arteries. But even so, despite all these other processes, the kidney is the main determinant of your body’s blood pressure.

One of the key features I ask all of my patients is about blood pressure. It’s also one of the things we discovered we can do better for patients with because many times we’d ask patients to check their blood pressure, but they either didn’t know how to, didn’t have the system, or didn’t have the time to send the data back to us in the clinic. So that’s one of the things that we’re also [doing], in addition to trying to reach more patients: using a clinic in the mountains and Telehealth, so that we can see any patient any day. We also have a blood pressure recording system, so that way, patients who get one of these kits from us can simply step on a scale or record their blood pressure, and instantaneously, that data point is sent by bluetooth to our clinic.

I think that’s something, because what I’ll find is patients who don’t necessarily have known kidney disease, but they’ve maybe dealt with blood pressure for years, and they’ve found it harder and harder to deal with or control over the years. Those are patients who would greatly benefit from a kidney analysis or kidney care and blood pressure management. That’s what we can do.

Good segue: I wanted to ask you more about the tools that you use as a Nephrologist that might be distinct to your practice. Up in the mountains, we’re obsessed with pulse oximeters, because we’re constantly watching blood oxygen saturation. Is there anything else that you use specific to your practice?

The pulse oximeter is something we use also, especially because it relates to the oxygen-carrying capacity of the blood or how much blood you have. And it also relates to how the kidneys are balancing and helping manage what your respiratory status is. So we look at that.

The blood pressure is the most important vital sign for me. Weight is the second most important vital sign for me. The reason that’s second most important is because many patients who get blood pressure or have heart disease, and patients who have certain types of kidney disease, will get swelling. I’ll sometimes see my patients gain 5 lbs. in a day or two, and that’s all from salt in the diet and swelling. So weight and measuring your weight, especially if you’re a person who’s swelling, is a big deal because these are patients who — we especially see it after a big barbecue or holiday meals, where food is delicious and salty — those are the patients who are most vulnerable. We’ll see those patients have a much higher risk of having blood pressure changes and even becoming sicker to where they are hospitalized. With close monitoring of their blood pressures at home, we can often take patients who’ve been in and out of the hospital once, twice, or even ten times in a year, and we can help them stay out of the hospital, just through close monitoring and prevention.

So what we do is our nurse at the clinic will often be in touch with the patients, monitoring their blood pressures and weights, and if the patients don’t notice it, she may notice and … reach out to [them] and tell them, “I’m concerned about the 5 lb. weight gain you’ve had in the past few days,” and then talk through it. If a medicine change is needed, we can make it there on the spot, or whatever else.

In addition, communication and close contact to patients. The Telehealth system we use allows patients to take a kidney appointment from the comfort of their living room couch or office. Or they could go to their local doctor where they live and get on the computer screen with them and have what is a video visit, kinda like FaceTime, and they can dial right into our clinic and access us. And that tool isn’t a clinical tool, but it is an access tool. Access is maybe half the battle. Using that and the remote vitals monitoring collapses the distances between us and our patients to minimal or no barrier.

Is there anything distinctive about how high altitude changes the physiology when the kidneys are concerned?

Love it. So, the kidneys balance acid in the blood. Many patients up at high altitude not only have lower oxygen levels, they may have higher blood counts in order to improve their oxygen-carrying capacity. Especially your typical person who comes up for a ski trip and they’re not used to the altitude. It takes a few weeks for your body to make the blood cells to compensate for that. So those people especially may struggle to survive or breathe up here at altitude. And so the pulse oximeter is helpful.

What happens is when the body breathes faster to get more oxygen, the kidneys compensate. So what you end up doing is … breathing more quickly to get more oxygen, and it also lowers the carbon dioxide and the acid levels in your body, so we end up often seeing that the kidneys … adjust the level of bicarbonate. And bicarbonate is simply baking soda, dissolved in your blood. That’s a kidney response. As you breathe more quickly, you get rid of acid, and then the kidneys will adjust by peeing out some of the bicarbonate or the baking soda.

When you breathe out acid, which is carbon dioxide in your breath, your body becomes more basic. Your body becomes more full of baking soda.

In addition, we also see the kidneys responding through blood pressure changes. I think blood pressure will often fluctuate. It’s probably varying by individual, but we see many patients’ blood pressure increase at altitude. And the kidneys are constantly adjusting and titrating that, too.

So, that being said, what do you advise in general to maintain kidney health?

A lot of patients who don’t have advanced kidney disease are advised, appropriately so, to hydrate well. Many patients might be told to drink more water, and I think, in general, that’s a great recommendation. Many patients who are constantly light-headed or dizzy or dehydrated or don’t drink enough water, they could know it because they’re feeling [that way], or even had an episode where they blacked out or passed out and fell down. These are patients where a little bit more water — I’d even add that saltwater, so broth or a soup — is a great way to treat that, by giving yourself more salt and water, which helps to elevate your blood pressure.

Now, the caveat is patients who have swelling and heart problems would be well-served to avoid extra salt. If it gets more tricky, and patients are thinking, “… this is really too confusing,” that’s where we often recommend having a chat with your regular doctor, and if need be, with a kidney doctor to sort out a personalized recommendation.

The converse recommendation is also true. In patients with advancing kidney disease, hydration is good, but minimizing salt is the most important thing you can do. For patients who have known kidney disease that’s moderate to severe, minimizing salt intake is the number one recommendation.

The number two recommendation for patients with known kidney disease, as well as for patients generally, is “less is more”. I have a number of patients that come into the office who take two Advil or two Aleve, … and maybe they take it two times a day or four times a day. And unbeknownst to them, they’re scarring their kidneys down. Just from taking regular over-the-counter pain relievers. Tylenol has its own risks, but it is far safer as a pain reliever than Advil, Ibuprofen, Neproxin, Aleve, and Motrin and things like that.

Along those lines, many patients will come into my office and I ask them all to bring pills that they take. They may come in with a grocery bag full of twenty supplements, because they go to a naturopath … not to knock on naturopaths. I’m a person who deeply believes in the value of some of these alternative therapies and non-Western therapies. But at the same time, I often see patients in my clinic who, by the time they’re taking more than a couple supplements, are putting themselves at big risk of the two supplements or multiple supplements interacting with each other, or interacting with their life-saving vital medicines that they take, prescribed by a provider. The more pills you take, the more chance there is for a bad reaction. So in general, I find that [with] patients who come to me with kidney disease, I often find myself recommending that they reduce or eliminate supplements. Because some of these supplements are known toxins to the body or kidneys, even though they may help you with cholesterol or libido or something like that. But most supplements are not proven, not tested, and they’re definitely not signed off by the FDA. And that is risky to patients.

Speaking of medications, we often advocate for people who are prone to altitude sickness to be on Diamox pretty regularly. As far as we know, it’s very low-risk as far as side effects go. Does it pose any particular risk when it’s taken often?

The two things Diamox does, that I understand, to help you with altitude sickness is it gets rid of fluid — it’s a diarrhetic — and it also gets rid of bicarbonate, the baking soda in the body. It actually helps that process of adjusting the body in response to going up to altitude. For patients who hydrate well and don’t have that risk of falling down from low volume or depletion, commonly known as dehydration, Diamox should be fairly safely tolerated There are not a lot of known allergies.

Recently, I’ve come to know a couple people who have lost or donated a kidney. Have you ever encountered patients with “phantom pains” where a kidney used to be?

That’s a great questions for a couple reasons. Phantom pains occur. There are some rare cases where patients who get phantom pains from surgical removal of an organ would be well-served to return to the surgeon, or a provider that they trust, and discuss about whether they would benefit from repeat imaging.

It’s possible that a fluid bubble, what’s called a seroma, or a complication, like an infection … could arise in that space. Most of the time, phantom pains are things we don’t have a good response for. Again, I think a “less is more” approach is good. And that’s actually why I recommend complementary therapy. In addition to taking the Tylenol, I have many patients that find their pains relieved by acupuncture or massage or other things that don’t put yet another pill in their body.

But it brings up another important topic: patients who progress along the spectrum of kidney disease to more severe kidney disease, where their kidneys start to shut down and are no longer working enough to support them, need some sort of advance therapy known as dialysis to treat them. And not everybody wants or needs dialysis, but for those who do, transplant is a great option. So we often refer patients promptly for transplant evaluation, because the waiting list for transplant is often many years. Standard around the country would be in the order of 3 – 6 years, and in some states, it’s going to be closer to 10 years.

But live donation of an organ, a kidney, is one of the future visions I see for patients with kidney disease. Dialysis is a therapy that is truly invasive: timewise, personally, personal space, blood … it’s really hard on patients, but it’s something that like any skill you learn, like riding a bike, can be learned. I can imagine a world … [where] most of us will be able to donate a kidney and will never know we lost a kidney. We won’t feel it. We won’t suffer the medical consequences of it. And the national transplant registries have changed the order of prioritization of organs such that if you are a person who donates a kidney, in the future, if you suffer a kidney failure yourself, you have a higher priority level for receiving a transplant, because of the gift you gave earlier in life. And that’s really important because a patient who’s facing years of dialysis on that wait list for a transplant, if they ask their friends and family members whether they’d consider being tested to see if they’re a candidate to donate their kidney, I imagine a future world in which few or no patients are on dialysis. The moment a patient is seen to be heading toward needing dialysis, they are prepared for a live kidney transplant, and then they get paired up with somebody across the country or even somebody in their own backyard … who can donate. Once you get a transplanted kidney, you have to be on medicines that control the immune system, but you never have to spend a day thereafter in a kidney dialysis center. And that’s a really useful thing, because many patients don’t have the time, or they risk losing jobs or spending time with their loved ones because of the amount of time they spend on dialysis.

So, the kidney phantom pains are an issue, but truly patients who donate organs are patients who have given the gift of life, and most of the time don’t suffer a single side effect or consequence of that donation. And they should feel like they have the right to follow up with the surgeon or the team that helped them facilitate that to get their needs met or their questions answered, including phantom pains. Because often, that’s something worth looking at.

What do you enjoy doing in your freetime?

I am father of a four-and-a-half year old, so there’s nothing better than spending time with my wife and my son, who I’m now trying to teach to play tennis and ski, because those are my two favorite activities.

Last question: do you have a favorite ski hill?

I don’t. I used to. I grew up skiing Vail and Beaver Creek, but these days, we do everything we can to avoid the I-70 ski traffic on ski weekends. And if that means going to a Front Range ski area, or a ski area off the beaten path, we love exploring the deep reaches of the state. Any day I’m not on my skis or with a tennis racket, you can find me on a road cycle if I’m not at work.

We’re excited to be here. We’re a growing company and have hired another Nephrologist in our practice (Dr. Eileen Fish), so we are always looking to see how we can help communities solve their needs for kidney health.

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

Acclimation, Altitude Science, Child Growth & Development, Doc Talk, Genetics, Health, High Altitude, Medicine

Adaptation v.s. Aclimatization

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Why don’t babies in Nepal and La Paz need oxygen? 

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Dr. Chris in La Paz with 20 year old Maria and her mother

Research comparing ethnic groups that have lived at high altitude for centuries, such as native Tibetans, and more recent immigrants such as the Han Chinese in Tibet, showed changes in adaptation. People living in the Andes, Himalayas and mountains of Ethiopia have higher lung volumes, more nitric oxide in the blood, high oxygen-carrying hemoglobin levels and increased respiratory rates which are genetic.

Those of us living in the mountains of Colorado have been here at the most 150 years, not long enough to establish gene-based adaptation. We do acclimatize over weeks and months with changes in hemoglobin levels, respiratory rates and lung volumes but not to the extent of the above populations.

During my travels to La Paz Bolivia and Cuzco, Peru I noticed the people were smaller. At Ebert Family Clinic we analyzed over 10,000 pieces of growth data on children up to four years old from our electronic medical record. A high percent are below the standard growth chart: seven percent compared to three percent. Most catch up by age two years.