Rising 13,803′ (4207 m) from the surface of the Pacific Ocean, Hawai’i’s tallest dormant volcano, Mauna Kea, reaches well into its own unique high altitude environment. Measured from its base on the ocean floor, it is the tallest mountain in the world, about 33,000′ (10,000 m) in height.
A frozen Haleakalā silversword. PC: Lyle Krannichfeld & Pueo Gallery
You may never have thought to find a high altitude environment on the tropical island chain, but Mauna Kea is just one of four peaks that summit over 8,000′. The next three are Mauna Loa (13,679′), Haleakalā (10,023′), and Hualālai (8,271′), with Haleakalā (“House of the Sun”) on the island of Maui and the other three on the Big Island. Each of these dormant volcanoes is home to species of plants and animals found only in Hawai’i, many of them only found around their respective peaks.
Sacred lands, whose access was once restricted to only the divine rulers of Hawaiian society, Mauna Kea now hosts 13 observatories and research staff in addition to its foreign and local visitors, many of whom make the historic pilgrimage to the summit from sea level in a matter of hours via an access road established in 1964.
Visitors to Mauna Kea are advised to acclimate at the Visitor Information Center which sits at 9,200′, although a particular length of time is not specified. In addition to the more intuitive precautions regarding pregnancy or heart and respiratory conditions, visitors in Hawaii are also warned against making an ascent within 24 hours of having been SCUBA diving, which may not be so obvious. You can find this and more helpful tips consistent with current high altitude research on their Public Safety brochure, which includes information about symptoms of HAPE (High Altitude Pulmonary Edema, featured in a previous article, and very common in the Colorado high country).
In addition to the hypoxic conditions, Mauna Kea and its aforementioned counterparts are also prone to the dryness and weather systems we see in Colorado, with snowfall above 10,000′ as recent as the past few days, a visit from Poliahu, Hawai’i’s own goddess of snow, and the subject of songs and hula dances in her honor.
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 on a computer, 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.
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).
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.
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
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.
It’s no secret that people living in high elevation areas such as Summit County seem to be healthier than the general population. But aside from the active lifestyles of many people who choose to live in the mountains, could there be other effects from living at high altitude that result in healthier outcomes?
Several studies have been conducted to examine the association between living at high altitude and weight loss. The overall findings suggest simply ascending to a higher altitude generally results in a reduction of weight. Whether this is due to relative low pressure hypoxia or increased physical activity is another question examined by researchers. Overall, a higher energy expenditure and decreased appetite have both been seen in those living at higher altitudes. One study found that those living below 500 m elevation on average had a 4.6 times higher risk of obesity compared to those living above 3000 m while controlling for differences in exercise, diet, and lifestyle.
Leptin is a hormone produced by the body that results in suppression of hunger. When our bodies secrete more leptin our hunger decreases. Multiple studies have shown that when people not acclimated to altitude are brought to higher elevation, leptin increases and appetite decreases. One such study took ten obese males to altitude and allowed them to eat as much as they would like and also did not allow them to exercise more than their regular amount during the study. After one week the study found the males consumed on average 730 calories less than what they usually ate at lower altitude. This resulted in a 3 pound weight loss over one week, and on average, they kept two pounds off after returning to their base altitude a month after the one week study was completed.
Leptin levels were increased for a time after returning to lower elevation and appetite remained lower than their baseline.
A follow-up study looked to determine exactly what factor of altitude causes this increase in leptin and used a hypobaric chamber to simulate a hypoxic environment similar to Mt. Everest. Subjects in this experiment lived in low oxygen conditions for 40 days and had an average of 16.7 pounds of weight loss and consumed 1,347 fewer calories. This study helped to suggest hypoxia as the driving factor for increases in leptin at altitude, and also showed an increased effect with the higher elevations.
Another
possible factor leading to higher rates of weight loss at altitude could be
linked to an increase in basal metabolic rate. Basal metabolic rate, or BMR, is
the amount of energy or calories humans burn each day without accounting for
exercise or general physical activity. In the same study that measured appetite
and leptin levels in obese men brought to altitude for one week, BMR was also
measured. These measurements showed an increased BMR at the end of one week at
altitude and a return to baseline BMR two weeks after returning to lower
altitude. This means that people tend to burn more calories just by being at a
higher altitude, even without increasing exercise. This increased burning of
calories paired with decreased appetite are likely the main driving forces
between the weight loss seen in those newly introduced to altitude and lower
weights and BMI’s seen in those that have lived at altitude for a long time.
With these findings of weight loss and overall decreased appetite when coming to altitude, it is important for visitors from low altitudes to be aware of these changes and plan appropriately. First of all, in order to avoid unintended weight loss, those new to the mountains should be aware of just how much they are eating. Apps such as MyFitnessPal are great for tracking your calories and can even factor in exercise such as hiking and skiing that may be causing you to burn extra calories. Based on your BMR and exercise, you can see just how many calories you should be eating to maintain your current weight. It is also essential to be aware of the kinds of food you are eating. In the studies showing decreased appetite, it was also shown that study subjects had a decreased likelihood of choosing carbs in their diet. Carbohydrates are an excellent source of energy and should be a main staple of the diet for anyone coming to altitude, especially if they plan to partake in any of the great outdoor activities places like Summit County have to offer. Good examples of healthy carbs include fruits, vegetables, nuts, and whole grains like quinoa, oats, and brown rice.
Ultimately, ascent to higher altitudes has been shown to cause a decrease in appetite, increase in basal metabolic rate, and an overall decrease in body weight. Some of these factors return to closer to baseline after acclimatization, but this can take weeks to months depending on the person. Anyone who is traveling to higher altitudes or who has recently moved to a higher altitude should take good notice of their general nutrition and calorie intake to make sure they are giving their body the fuel it needs to succeed in these unique conditions.
Mitch Tiedke is a physician assistant student at the Red Rocks PA Program in Arvada, Colorado. He grew up in Oak Grove, Minnesota and achieved his undergraduate degree in Genetics, Cell Biology, and Development, with a minor in Public Health from the University of Minnesota-Twin Cities. He has previously worked as a personal care assistant for developmentally delayed adults and as a nursing assistant on a pediatric oncology, GI, and med/surg inpatient unit. In his free time he enjoys hiking, snowboarding, biking, and movies.
References
Buchzik, B. (2014). Hypobaric hypoxia causes body weight reduction in obese males, double-blinded, placebo-controlled study. European Respiratory Journal, 44(58). Retrieved from https://erj.ersjournals.com/content/44/Suppl_58/P3650.short
Lippl, F. J., Neubauer, S., Schipfer, S., Lichter, N., Tufman, A., Otto, B., & Fischer, R. (2010). Hypobaric Hypoxia Causes Body Weight Reduction in Obese Subjects. Obesity, 18(4), 675–681. doi: 10.1038/oby.2009.509
Palmer, B. F., & Clegg, D. J. (2013). Ascent to altitude as a weight loss method: The good and bad of hypoxia inducible factor activation. Obesity, 22(2), 311–317. doi: 10.1002/oby.20499
Rose, M. S., Houston, C. S., Fulco, C. S., Coates, G., Sutton, J. R., & Cymerman, A. (1988). Operation Everest. II: Nutrition and body composition. Journal of Applied Physiology, 65(6), 2545–2551. doi: 10.1152/jappl.1988.65.6.2545
Voss, J. D., Masuoka, P., Webber, B. J., Scher, A. I., & Atkinson, R. L. (2013). Association of elevation, urbanization and ambient temperature with obesity prevalence in the United States. International Journal of Obesity, 37(10), 1407–1412. doi: 10.1038/ijo.2013.5
With orthopedic surgeries becoming more common at higher altitudes, it is important that we understand the increased risks of surgery at higher elevations. Patients locally (Eagle, Summit, Pitkin, Grand, Lake and other high-altitude counties in Colorado) and those that travel from all over the world to undergo surgery by our orthopedic surgeons are at an increased risk for complications post-surgery. Patients that have surgery at a lower altitude and return to higher elevations post-surgery are also at higher risk for post-operative complications. These risks are higher for everyone having surgery at altitude regardless if you live at higher elevations or are from sea level.
High altitude is defined as 8-12,000 feet. However, increased surgical risks are seen
starting at 4000 feet. There are no differences for increased risk if you are acclimated to the
altitude (live here) or are visiting. The increased risk of surgery at high altitude is the same for
all.
High altitude increases the coagulation state of blood (clotting ability) and hyperventilation (breathe out more than you breathe in), and oxygen saturation of blood and tissues is 10% lower at high altitude compared to low altitudes, leading to a hypoxic state. The hyperventilation state promotes the hypercoagulable state which causes the immune system to respond with a pro-inflammatory state. Acclimation does occur, we adapt, are able to breathe easier and function normally as our bodies make more red blood cells to compensate for the lower available oxygen in the air. However, the hypercoagulability of blood remains, because the hyperventilation state is sustained at high elevations (even if you live here). At high elevations there are physiological differences in pulmonary circulation (blood through the lungs), heart function, and fluid imbalances which induce dehydration that accompanies blood changes contributing to the increased risk of surgery at high elevations.
Risk factors for blood clots from orthopedic surgery for the general population include: decreased mobility or sitting around more, length of surgery (greater than 4 hours increases blood clot risk), joint replacements, smoking, diabetes, and other illnesses.
In general, there is a 40-60% chance of a blood clot following knee or hip replacement surgery. At altitude that risk doubles. There is a 3.8 times greater risk of thromboembolism (blood clots) for knee surgeries at high elevations. Total shoulder replacement surgery also demonstrates a 2-times greater risk of pulmonary embolism at altitude or 39.5%, compared to a 15% chance at sea-level. For rotator cuff repair of the shoulder, there is also an increased risk for blood clots. There is a 1.4-times greater risk for pulmonary embolism (blood clot in the lungs) for lumbar fusions at high altitude. Higher elevation is an independent risk factor for blood clots which lasts up to 90 days post orthopedic surgery.
Anesthesia at high altitude has its own risk. The sustained hyperventilation state at high
altitude also leaves the patient more vulnerable to hypoxia and pulmonary edema with
anesthesia. These risks can be minimized, however remain elevated for surgeries requiring
general anesthesia above 4000 feet.
For patients returning to high altitude following surgery at lower elevations, there exists multiple risks due to hypercoagulable state, increased inflammatory response, and hyperventilation that higher elevations induce. Acclimatization to high altitude is lost within 2 days of being at a lower elevation and can take 3-4 months to achieve again. In as little as 2 hours after arriving at high altitude, the body initiates the above changes and this puts the post-operative patient returning to altitude at risk for a multitude of complications: dehydration, thromboembolisms, hypoxia, atelectasis, and pulmonary edema.
I recently spoke with a patient that grew up in Leadville (10,151 feet) and lives in Summit County (average of 7947 feet). She underwent hip surgery (twice) in Denver. Upon returning to Summit County, she developed high altitude pulmonary edema (HAPE) both times. When she underwent an ankle surgery in Edwards, the surgeon prophylactically treated her for high altitude sickness given her previous history. She did not develop HAPE, but was hypoxic and required oxygen therapy following surgery for a few days. She is a prime example that even those living their entire lives at altitude are susceptible to these increased risks from surgery.
These risks can be minimized by drinking plenty of fluids, using compression socks (TED hose) or sequential compression devices (SCDs), blood thinners (aspirin, Eliquis, or the like), doing ankle pumps and glute squeezes, and getting up and walking around every 1.5-2 hours for 10-15 minutes, all of which help decrease the likelihood that patients will experience blood clots following orthopedic surgeries.
To reduce respiratory or lung related complications it is important to do deep breathing exercises or incorporate the use of an inspirometer post-surgery, use supplemental oxygen if necessary, as well as continue to do these exercises after returning from a lower elevation for at least 2-3 weeks.
High altitude is an independent risk factor for orthopedic surgery complications. However, these increased risks have been seen in trauma patients and other surgical patients as well. The hyperventilation state, hypercoagulability, and elevated inflammatory response are not isolated to orthopedic patients, but exists in everyone living at and visiting higher elevations.
— Jessica Guthrie, BSN, RN
References
Cancienne, J., Diduch, D., & Werner, B. (2017). High altitude is an independent risk factor for postoperative symptomatic venous thromboembolism after knee arthroscopy: A matched case-control study of Medicare patients. Arthroscopy: The Journal of Arthroscopic and Related Surgery 33(2). https://dx.doi.org/10.1016/j.artho.2016.07.031
Damodar, D., Donnally, C., Sheu, J., Law, T., Roche, M., & Hernandez, V. (2018). High altitude an independent risk factor for venous thromboembolisms after total hip arthroplasty. Journal of Arthroplasty 33(8), 2627-2630. https://doi.org/10.1016/j.arth.2018.03.045
Damodar, D., Vakharia, R., Vakharia, A., Sheu, J., Donnally, C., Levy, J., Kaplan, L., & Munoz, J. (2018). A Higher altitude is an independent risk factor for venous thromboembolisms following total shoulder arthroplasty. Journal of Orthopedics 15(4). https://doi.org/10.1016/j.jor.2018.09.003
Donnally, C., Vakharia, A., Sheu, J., Vakharia, R., Damodar, D., Shenoy, K., & Gjolaj, J. (2019). High altitude is an independent risk factor for developing pulmonary embolism, but not a deep vein thrombosis following a 1 to 2 level lumbar fusion. Global Spine Journal 9(7) 729-734. https://doi.org/10.1177/2192568219828349
Tyson, J., Bjerke, B., Genuario, J., & Noonan, T. (2016). Thromboembolic events after arthroscopic knee surgery: Increased risk at high elevation. Arthroscopy: The Journal of Arthroscopic and Related Surgery 32(11), 2350-2354. https://dx.doi.org/10.1016/j.arthro.2016.04.008
Wani, Z. & Sharma, M. (2017). High altitude and anesthesia. Journal of Cardiac Critical Care 1(1), 30-33. https://doi.org/10.1055;s-0037-1604203
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.
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.
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.
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.**
Welcome to another Winter in the High Country! We’ve already had a series of snow storms in record-breaking cold temperatures across Colorado. On one hand, snow conditions are excellent! On the other hand, it’s sometimes cold enough to make you want to stay inside! One of the most effective ways to warm up is from the inside, out. Don’t forget about all the little opportunities you have to move your body and get your blood flowing, before, after, and even in the middle of a work day. Dr. Chris always has some valuable insight that she shared in a recent chat:
What keeps most of your patients from being more active during the Winter as opposed to the Summer?
Except for sledding and ice skating, Winter sports around here are very expensive. Not only is the equipment expensive, but having enough free time to actually go out and do something that takes more than one hour is very difficult for many of our families who are working two or three jobs, since Winter is the busiest season. Also, many of the parents did not grow up in a climate with snow, and came to Summit County for jobs, but not necessarily for recreation.
Is an hour your recommended duration for exercise?
Many studies have shown that 30 minutes a day of movement, whether it’s walking, running or dancing, can lead to adequate fitness. Personally, my goal is 14 hours a week. There are so many things that I want to do, and I want to do them fairly well and fairly intensely, so an hour a day isn’t enough for me to feel like I’m pursuing a maximum fitness level.
Aside from the obvious downhill skiing and snowboarding, what are some healthy activities you recommend during the Winter?
Shoveling snow, snow shoeing, hiking trails that are packed down, on Yaktrax “ice cleats” (inexpensive and very healthy, very good workout), hut trips (gives you a destination, which adds variety and camaraderie to your exercise; carrying a pack adds to your aerobic workout; on your way up, you’re getting the extra workout, but on your way home, it’s almost always downhill (and your pack is lighter), sledding, building snowmen or snow forts …
Do any of these activities provide benefits especially advantageous at altitude?
By doing any activity at altitude, you are increasing your cardiopulmonary fitness (heart & lungs).
If you’re just getting started, aim for 20 minutes a day, and add five minutes every week. Listening to podcasts, books or music makes everything less painful and more fun. Get a buddy to engage in these simple activities with you. Wear layers for the weather. Being outside doesn’t have to be uncomfortably cold, and you’ll be more inclined to exercise longer if you’re not freezing.
Pay a little more attention to how you can anticipate your hunger throughout the day. I try to keep some nuts, cheese, grapes, small chocolates at my desk, in my pocket, in my car for quick snacks. A smoothie or coffee in a portable cup really cuts the hunger over a good amount of time.
Take advantage of down time to do a few stretches wherever you are. This opens up circulation, allowing your body better access to the nutrients and oxygen your blood delivers.
Be on the lookout for The Doc, cross country skiing on snow day streets, sledding at Rainbow Park, or getting a good stretch in just about anywhere. And let us know if you have a favorite activity that’s easy to fit into a busy or cold, indoor day that you’d recommend!
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.
Martin, a 27-year-old African American male, presents to a rural mountain hospital with complaints of left upper quadrant abdominal pain. Martin arrived at altitude (9,400 feet) two days ago from Oklahoma City after a 12-hour drive. Shortly after arriving to his condo in the mountains, Martin developed a dull aching pain to his left upper quadrant. The pain is constant but radiates to his L flank intermittently. Martin tried snowboarding today but had to end his day early because the pain became too severe. Martin cannot identify any aggravating or relieving factors and states that ibuprofen “didn’t even touch the pain.” Martin denies associated nausea, vomiting, diarrhea, constipation, urinary symptoms, fevers, chills, enlarged lymph nodes, or fatigue. His medical history is significant sickle cell trait without active disease. He has a negative surgical history, takes no daily medications, and has no known allergies. *
Differential diagnoses considered include kidney stones, pancreatitis, gastritis, diverticulitis, splenic enlargement, an infarcted spleen, or mononucleosis. Laboratory tests ordered include a complete blood count, reticulocyte count (indicator of immature red blood cells production), lactate dehydrogenase (an indicator of red blood cell destruction), haptoglobin (a binding protein that binds free hemoglobin after red blood cell destruction), a complete metabolic panel, and a urine analysis. A CT scan of the abdomen with contrast was also ordered and performed.
Martin’s results showed an elevated white blood cell count, sickled cells on his blood smear, mildly elevated reticulocyte count and lactate dehydrogenase, low haptoglobin, and an elevated bilirubin. The remainder of his blood work was unremarkable. The CT scan showed a 40% infarction of his spleen. Martin was treated with oxygen, fluids, and IV pain medication and was promptly transferred to a larger hospital at lower elevation.
What caused all of this to happen?
Sickle cell anemia (SCA) is a mutation of the HBB gene that affects the development of normal hemoglobin, the major oxygen transporting protein in the body. SCA is an autosomal recessive genetic disorder which means that two copies of the abnormal gene have to be passed on from both parents in order for the disease to be active in the offspring. So, in other words, if both parents are carriers of the abnormal gene, their offspring have a 25% chance of developing the active disease and a 50% chance of becoming carriers themselves.
http://www.healthnucleus
The hemoglobin protein is made up of four subunits, 2 alpha-globin and 2 beta-globin. Sickle cell carriers will have a mutation of one of the beta-globin units, resulting in no clinical manifestations of the disease. These individuals live normal lives and are virtually unaffected by the mutation, as seen in Martin’s case. Individuals with active disease will have a mutation in both of the beta-globin subunits, creating sickling of their red blood cells. Sickling of red blood cells makes them less flexible in maneuvering through the vasculature, ultimately resulting in a blockage of blood flow to various tissues in the body. This is cause of severe pain that many individuals experience when in crisis. Sickled cells are also more prone to destruction leading to an anemic state and are inefficient oxygen transporters.
https://www.flickr.com/photos/nihgov/27669979993
The sickle cell mutation is typically found in certain ethnic groups which is thought to be related to the protective quality of sickled cells from the development of Malaria. The ethnic groups most likely to be affected include African Americans, Sub-Saharan Africans, Latinos, Indians, Individuals from Mediterranean descent, and those from the Caribbean.
But if Martin was a carrier without active disease, why did he develop sickle cell anemia?
Individuals with the sickle cell trait can cause their cells to sickle under extreme stress including during strenuous exercise, severe dehydration, and when at high altitude. The resulting consequence is the manifestation of all of the symptoms of active disease. Although Martin had never had any symptoms related to his sickle cell trait, he was now in full sickle cell crisis that required immediate intervention.
What are the implications?
Individuals from any of the ethnic groups listed above should be tested for the sickle cell trait to ensure they are not carriers. A carrier must exercise extreme caution in ascending to high altitude, should stay well hydrated, and avoid strenuous exercise to prevent the development of a sickle cell crisis.
*Case scenario is not based on any individual patient rather a compilation of varying presentations seen in the emergency department.
Liya is 3rd year Doctor of Nursing Practice Student attending North Dakota State University. She lives in Breckenridge, Colorado and works as a registered nurse in the Emergency department. Liya was born in Latvia and moved to the United States in 1991 with her family. She grew up in the Washington, DC area until she moved to Colorado in 2012. She is passionate about helping immigrant families and other underserved individuals gain access to basic healthcare services. She hopes to work in Family Medicine in a federally qualified health center in the Denver metro or surrounding areas. In her spare time, Liya enjoys hiking, snowboarding, biking, and camping.
References
Adewoyin A. S. (2015). Management of sickle cell disease: A review for physician education in Nigeria (sub-Saharan Africa). Anemia, 2015. doi:10.1155/2015/791498
American Society of Hematology. (n.d). Sickle cell trait. Retrieved from https://www.hematology.org/Patients/Anemia/Sickle-Cell-Trait.aspx
Mayo Clinic. (2018). Sickle cell anemia. Retrieved from https://www.mayoclinic.org/diseases-conditions/sickle-cellanemia/symptoms causes/syc-20355876
U.S National Library of Medicine. (2019). Sickle cell disease. Retrieved from https://ghr.nlm.nih.gov/condition/sickle-celldisease#inheritance
Yale, S.H,, Nagib, N., & Guthrie, T. (2000). Approach to the vasoocclusive crisis in adults with sickle cell disease. American Family Physicians, 61(5), 1349-1356. Retrieved from https://www.aafp.org/afp/2000/0301/p1349.html
Last year, 20% of U.S. adults experienced a mental health disorder (CDC). Mental illness is a leading cause of disease burden worldwide, and therefore, needs to be talked about. Mental health conditions, such as depression, anxiety, bipolar disorder, eating disorders, schizophrenia, drug/alcohol abuse, etc., have devastating consequences on the individual’s quality of life and overall wellbeing. Mental illness emerges from a complex interplay of genetic, psychological, lifestyle, and environmental factors. Environmental exposure is important to consider when looking at mental health, especially at high altitude. Up in the mountains, we must consider oxygen availability on the impact of our mental wellbeing.
Numerous studies have shown rates of depression and suicide to be higher at high elevations (Figures 1 & 2), even when controlling for other variables such as socioeconomic status and demographics (Kim et al., 2014).
Why is this?
Some researchers propose that low blood oxygen levels from lower atmospheric pressure at altitude (called hypobaric hypoxia) has something to do with it. Animal studies done on rats and short term human studies have found this connection (Kanekar, 2015), and altering brain bioenergetics and serotonin metabolism could have something to do with it. Both pathways are affected by depression, and both are affected by hypoxia (Hwang, 2019). Hypoxia may lead to suppressed mitochondrial functioning, resulting in a change of how our cerebrum uses its energy. Patients with depression have a harder time using energy in their pre-frontal cortex, which makes it harder to concentrate and fight off negative thoughts. If this is already the case at low altitude, being at higher altitude may make moods more unstable and focus even harder to obtain.
Second, hypoxia may lead to decreased serotonin levels in the brain, which is a very important neurotransmitter targeted in the treatment of anxiety and depression. These medications, known as SSRIs (selective serotonin reuptake inhibitors) allow more serotonin to hang around in the brain. If normal antidepressants are less effective at elevation, we need to take another look at the current treatment plan. Researchers are looking into a medication that is a precursor to serotonin that bypasses the oxygen-dependent phase of the reaction. It is called 5-hydroxytryptophan. Creatine monohydrate may also be effective in treating depression at altitude (Ramseth, 2019). This is an exciting opportunity in mental health at altitude research; one that may yield more effective treatment for people living in the mountains.
However, we cannot be certain that high altitude is causing the increased rates of depression and suicide (Reno, 2018). After all, correlation does not equal causation. There are multiple confounding variables at play, such as population density, characteristics of suicide victims, access to health care, religious beliefs, and ownership and access to firearms. Even though we do not know the cause, the correlation is clear. Because of this, clinical professionals at high altitudes need to be vigilant when exploring this concern with patients.
Looking at the flip side, multiple studies support positive effects of altitude on mental health. It is well known that physical activity is good for your body and mind. In general, exercise improves symptoms of anxiety, depression, and panic disorder, in addition to increasing quality of life and resilience (Hufner, 2018). An interesting report found that physical activity in the mountains has even more benefits on mental health than exercise at sea level (Ower et al., 2018). This was found to be because building a personal bond to an individual mountain enhances the positive effect of the outdoors on mental health. Think about that the next time you look up at a mountain you once stood on top of. In addition, a mountain hiking program in the Alps has been shown to improve hopelessness, depression, and suicidal ideation when added on to usual care in patients who were at high risk for suicide (Sturm et al., 2012). Programs like these utilize high altitude in a positive way to treat mental health conditions.
Overall, mental health at high altitude is a complex topic that needs more research. The most important thing we must all remember is to seek help when we need it, and to never feel ashamed if you are struggling with a mental health concern. Remember: You are doing your best.
If you or a loved one are in a crisis but don’t know where to turn, consider calling Colorado Crisis Service toll-free at 1-844-493-TALK (8255) or text TALK to 38255 to speak to a trained professional.
If you are interested in hearing more about this topic, here is an interview with reporter Rae Ellen Bichelle on NPR news discussing mental health at altitude:
Maggie Schauer is a 2nd year PA student studying at Des Moines University. She is from Pewaukee, WI and obtained her bachelor’s degree in psychology at UW-La Crosse. After completing her pediatrics rotation at Ebert Family Clinic, Maggie will be going around the Midwest until her final international medicine rotation in Belize! She loves cheese, the Packers, hiking, running, waterskiing, and almost anything outdoors. Her current plan is to become a physician assistant in psychiatry and live somewhere exciting (like the mountains), until eventually moving back to Wisconsin. Her dream is to hike every 14er in Colorado; she currently has two under her belt: Grays and Torreys.
References:
Ha, H., & Tu, W. (2018). An Ecological Study on the Spatially Varying Relationship between County-Level Suicide Rates and Altitude in the United States. International journal of environmental research and public health, 15(4), 671.
Hufner, K., Sperner-Unterweger, B., & Brugger, H. (2019). Going to Altitude with a Preexisting Psychiatric Condition. High Altitude Medicine & Biology, 20(3).
Hwang, J., DeLisi, L. E., Öngür, D., Riley, C., Zuo, C., Shi, X. , Sung, Y. , Kondo, D. , Kim, T. , Villafuerte, R. , Smedberg, D. , Yurgelun‐Todd, D. and Renshaw, P. F. (2019), Cerebral bioenergetic differences measured by phosphorus‐31 magnetic resonance spectroscopy between bipolar disorder and healthy subjects living in two different regions suggesting possible effects of altitude. Psychiatry Clin. Neurosci., 73: 581-589.
Kanekar, S., Bogdanova, O., Olson, P., Sung, Y., D’Anci, K. Renshaw, K. (2015). Hypobaric Hypoxia Induces Depression-like Behavior in Female Sprague-Dawley Rats, but not in Males. High Altitude Medicine & Biology; 16 (1)
Kim, J., Choi, N., Lee, Y. J., An, H., Kim, N., Yoon, H. K., & Lee, H. J. (2014). High altitude remains associated with elevated suicide rates after adjusting for socioeconomic status: a study from South Korea. Psychiatry investigation, 11(4), 492–494.
Ramseth, L. (2018, July 1). University of Utah research shows high altitude linked to depression and suicidal thoughts. In The Salt Lake Tribune. Retrieved October 17, 2019.
Reno, Elaine, et al. (2018). Suicide and High Altitude: An Integrative Review. High Altitude Medicine & Biology, 19(2).
