Category Archives: Health

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

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

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

Before you go out!

DO:

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

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

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

After coming back inside

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

So how can you prepare yourself or pre-acclimatize?

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

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

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

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

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

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

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

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

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

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

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

COVID-19 Update: A Look at How the World’s Highest Altitude Populations Have Been Affected

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As the gateway to Machu Picchu, the city of Cusco, Peru attracts over 3 million tourists from all around the globe each year. With this many people passing through the city, you can imagine why local residents feared the worst when the COVID-19 outbreak began. However, out of a population of approximately 429,000 people, the city has only four COVID-19 related deaths – three tourists who traveled to the area and one native with previous risk factors.

Machu Picchu

Machu Picchu, a UNESCO World Heritage Site, brings 3 million tourists from around the world to the Cusco region of Peru every year.

One death out of 196 confirmed cases for the city makes for a remarkably low fatality rate of 0.5% for the native population. Peru as a whole has a fatality rate closer to 3% with over 6,000 deaths, making it one of Latin America’s most affected countries. Many believe the fatality rate to be even higher as testing has not become widely available in the country.

To understand why Cusco is such an outlier when compared to the rest of the country, there are several factors to take into consideration. One of those factors that researchers haven’t quite been able to figure out, but believe plays a role, is altitude. The Cusco region of Peru sits at 11,152 ft elevation compared to the capital city of Lima that sits at only 512 ft elevation.

Research comparing the high-altitude regions of Tibet, Bolivia, and Ecuador has revealed similar trends. A study completed April 22, 2020 and published in the June 2020 scientific journal “Respiratory Physiology & Neurobiology” indicates that populations living above 9,842 feet elevation reported significantly lower levels of COVID-19 cases than populations living at lower elevations. The research showed the infection rates in the Andes Mountains of Bolivia were one third the infection rates the rest of Bolivia, and the infection rates in the Andes Mountains of Ecuador were one fourth of the rest of Ecuador. In both Bolivia and Ecuador, the areas with the highest concentration of COVID-19 cases were located at an elevation close to sea level.

At an elevation of 11,942 ft, La Paz, Bolivia is the highest capital city in the world.

Why populations living at higher altitudes are experiencing lower infection rates is still not well understood, but there are a few theories at play. It is hypothesized that people living at altitude are able to live in a state of chronic hypoxia, or a state of chronically low oxygen in the blood. Hypoxia is one of the conditions caused by COVID-19, and if a person’s body is already used to low levels of oxygen, their symptoms may not be as severe. There are other environmental considerations at altitude that may shorten the life-span of the COVID-19 virus, including high levels of UV radiation that can kill the virus, low barometric pressure that does not support the weight of the aerosolized droplets that the virus lives in, and dry thin air that does not support the transmission of aerosolized droplets.

However, as intriguing as the effect of altitude on COVID-19 statistics is, it is important to note that there are several other proven factors that come into play when looking at these populations. First, most high-altitude towns and cities tend to be rural. When population density per square mile drops, the rate of transmission of infectious diseases also drops – rural settlements allow for natural social distancing. Second, populations living at higher altitudes have lower rates of obesity and generally have better overall health. Living at high altitude causes a reduction in the hormones that signal hunger, leading to consumption of fewer calories. Additionally, completely normal daily activities in a state of chronic hypoxia due to low levels of available oxygen in the air raises the body’s resting metabolic rate, leading to burning more calories. The healthier a person is prior to contracting an illness, the more likely their body is to be able to fight it off successfully.

Research regarding how altitude affects COVID-19 transmission, infection, and recovery rates is ongoing. It may be too soon to tell exactly why or how altitude comes in to play, but early findings are suggesting that now is a great time to be a resident of the great Rocky Mountains – but then again, when is it not?

References

https://www.washingtonpost.com/world/the_americas/coronavirus-andes-peru-ecuador-bolivia-tibet-high-altitude/2020/05/31/0b2fbf98-a10d-11ea-be06-af5514ee0385_story.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207123/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7175867/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5094724/

https://en.wikipedia.org/wiki/Machu_Picchu#/media/File:80_-_Machu_Picchu_-_Juin_2009_-_edit.2.jpg

https://en.wikipedia.org/wiki/Machu_Picchu#/media/File:80_-_Machu_Picchu_-_Juin_2009_-_edit.2.jpg

Megan Schiers is a 3rd year Physician Assistant student studying at Midwestern University in Glendale, AZ. She graduated from Idaho State University in Pocatello, ID with a Bachelor of Science in Dental Hygiene and worked as a dental hygienist in Strasburg, CO for two years prior to starting PA school. She is passionate about increasing access to healthcare in rural areas and hopes to specialize in emergency medicine or cardiothoracic surgery following graduation this fall. During her six weeks in Frisco, CO, she has enjoyed hiking in the beautiful mountains, camping at Camp Hale Memorial, visiting Maroon Bells, and checking out Black Canyon of the Gunnison National Park.

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

COVID in Colorado Update: Reasons high altitude residents may be less susceptible

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Last week we were privileged to have a Zoom discussion with two high altitude experts from the Instituto Pulmonar Y Patologia de la Altura (IPPA) founded in La Paz,  Bolivia in 1970. Dr Gustavo Zubieta-Calleja and Dr. Natalia Zubieta-DeUrioste answered our questions about their recently published article, Does the Pathogenesis of SAR-CoV-2 Virus Decrease at High Altitude?. They and the seven  coauthors presented data comparing COVID cases in high altitude areas of China, Bolivia and Ecuador showing a marked reduction in numbers compared to low altitude areas in the same countries, with dramatic, colorful topographic maps.

Drs. Zubieta-Calleja and Zubieta-DeUrioste and their colleagues theorized four reasons why altitudes above 2500 m could reduce the severity of the corona virus. (Note: Frisco, CO is at 2800 m, Vail 2500 m). As described in their previous paper published in March, the intense UV radiation at altitude as well as the dry environment likely reduce the viability of the virus in the air and on surfaces.

Dr. Zubieta-Calleja on a Zoom chat with Dr. Chris explaining a chart comparing UV exposure in La Paz, Bolivia (top line) and Copenhagen, Denmark (bottom line).
Dr. Chris with Dr. Gustavo Zubieta-Calleja and other altitude experts from the Hypoxia Conference in La Paz on the Camino Chacaltaya, which reaches an elevation of 17,785’/5421 m.

The low barometric pressure causes air particles to be spaced more widely, which would also decrease the viral particles inspired with each breath, reducing the severity and frequency of infections.

Furthermore, residents accustomed to chronic hypoxia may express reduced levels of angiotensin converting enzyme 2 (ACE2) in their lungs and other tissues. This enzyme has been found to be the entry path for the corona virus into cells where it replicates. Finally, the normal adaptation and acclimatization of populations with prolonged residence above 2500 meters may reduce the severity of the disease in individuals, and reduce mortality. This includes increased ventilation, improved arterial oxygen transport, and higher tissue oxygenation mediated by increased red blood cells produced under the influence of erythropoietin, which could be explored as a possible therapy.

Dr. Zubieta-Calleja with statistics reflecting the number of COVID-19 infections at different elevations in Bolivia. Note the most infections occur at a lower elevation.

As we stated in our interview quoted in the Summit Daily News March 17th, none of these factors can be relied upon to protect every individual. Therefore it is important to continue frequent hand washing, wearing masks, social distancing, and avoid touching your face.

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

COVID in the Mountains: What are the Risky Situations to Avoid as We Start Leaving Our Homes?

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We are on the back slope of the epidemic, according to University of Massachusetts Dartmouth Professor of Biology Erin S. Bromage, Ph.D. He explains what to expect and where not to go in an article this week which was cited in the New York Times: The Risks-Know Them-Avoid Them. The bad news is that the back slope can have as many deaths as the upslope.

The good news is that you don’t get COVID outdoors, as long as you are not standing close to someone who might have the virus for a period of time, perhaps over ten minutes. Bromage reviews a series of epidemiologic studies tracing the spread of the disease in situations including standing outside talking to someone (one case), church choir practice (45 of 60 infected, 2 died), indoor sports, specifically a curling tournament in Canada where 24 of 72 attendees became ill, birthday parties and funerals (high rate of infection and many deaths related to hugging, kissing and sharing food), grocery stores (safe for shoppers but employees get infected), and restaurants (50% infection rate after sharing a meal with nine at the table). He also reported details about the spread of disease at meat packing plants, a call center and a medical conference.

The risk of infection increases with exposure to a larger number of virus particles over a longer period of time in a smaller space with poor air flow. This is why shopping and outdoor activities are not likely to be dangerous. Breathing releases a small number of virus, between 50-5000 droplets per breath. Talking expels more and  singing is definitely a means of spreading virus. A single cough releases 3000 droplets traveling 50 miles per hour, mostly falling rapidly to the ground. In contrast a sneeze may release 30,000 droplets at 200 MPH, many of which are smaller and stay in the air longer.

Dr. Bromage writes that 44% of infections come from people who have no symptoms at the time.  The virus can be shed up to five days before a person becomes ill. Most people contract COVID from a family member who brings it home. Children are three times less likely to become ill but three times more likely to spread the virus.

I wondered if the lower barometric pressure at altitude could cause viral particles to be less compact. I called Peter Hackett, MD of the Hypoxia Institute in Telluride and he agreed that theoretically the less dense air would not carry as many particles. We also discussed antibody tests, which are still experimental, not recommended and difficult to interpret. The population screened in Telluride showed a 0.5% positive rate, but when a disease has a low prevalence there are more false positives. They did blood tests on some 5,000 people early in the outbreak. They were not able to repeat the serology due to staffing problems at the lab where many technicians contracted the illness.

My advice is to wear masks anytime you are out of the house, except if you are biking, hiking, running where the viral particles will be dissipated rapidly. Wearing a mask during these activities is still a kind gesture  to reduce the anxiety of others. Continue with frequent hand washing, avoid touching your face, practice social distancing, and when the churches reopen we should hum instead of sing.

COVID-19, Doc Talk, Health, Medicine, Mental Health, Pandemic

COVID-19 Update: Accordion Theory and Preparing for Next Steps

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Today, I am going to share news gleaned from meetings and publications that address the importance of preventive care, returning to daycare, pulse oximetry as a screening tool for COVID, and the Accordion Theory.

Every Thursday the Children’s Hospital of Colorado presents a panel of experts with updates and answers to questions.

“Your offices are the safest place in the country,” they proclaimed. With social distancing many parents and patients are delaying routine care which has led to the largest drop in vaccination rates in 50 years. This could result in outbreaks of measles, whooping cough, pneumococcal and other infections. With the loss of revenue, small clinics may go out of business, and large clinics and hospitals are laying off workers by the hundreds. If there is a large outbreak of preventable disease, on top of a resurgence of COVID, there could be a devastating shortage of providers to care for the victims. Now is the time to call your clinic and set up appointments for check ups and vaccines. If you don’t feel safe yet you can do a Telehealth visit initially and schedule the vaccines and hands-on portion of the exam in a month.

Another reason not to delay preventive care is the increase in stress, isolation, and anxiety which can cause serious depression. We had a tragic teen suicide in the county this month. Students from middle school through college should be seen annually for mental and physical health screening as well as vaccines. One mother told me that the depression screening done at our office “saved my daughter’s life.”

More daycares are opening soon. Parents are asking me whether to send their child back. These facilities follow strict public health guidelines to prevent infection. Children are not likely to be affected by COVID. Any child with symptoms should be tested. Enrollment should be diminished due to parents preferring to keep their child at home.  However, if there is a high risk family member, I advise not to return to daycare yet.

School age children should be limited to playing with friends and family members who have been part of their social circle during the last two months. To borrow a slogan from the AIDS campaign, “KNOW YOUR NETWORK”.  This is not the time to expand friendships. There will be no team sports this summer. Children should play outside and not share toys or balls.

An emergency physician in New York, Richard Levitan, published an editorial in the NY Times on April 20 advocating the use of pulse oximeters to screen for COVID. Citing the many patients with low oxygen levels and abnormal x-rays who did not complain of trouble breathing, the delay in obtaining results and inaccuracy of the COVID testing, he sees the simple pulse oximeter as a source of immediate information as to who needs medical attention. I’ve been speaking and writing about this for weeks.

Finally, one of the panelists at Children’s mentioned the accordion phenomenon. As we reduce social distancing restrictions and open commerce and travel, there will inevitably be more cases of COVID. It is likely that restrictions will be imposed again, and this may occur in cycles during the next year(s). We may be able to decrease future shutdowns by wearing masks and gloves when we go out, using hand sanitizer, soap and water, not touching our face, covering our coughs and sneezes, and limiting exposure to large groups of people. I hope all these will be permanent behavior changes except the masks and the large groups (I love the Lake Dillon Amphitheater and the BBQ challenge).

Take care, stay engaged, and have another safe week!

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

COVID-19: Where Are We At Now?

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A panel of experts at the University of Colorado School of Medicine had some good news this morning: we may have passed our peak here in Colorado.

Of the 8,675 cases there are 374 deaths. Less than 2% of those with the illness are under age 18, compared to the population of 22% children. This week there are only 4 children admitted to Children’s hospital with COVID-19, two in the ICU. There is a leveling-off of patients presenting to the hospitals and less ICU admissions.

So social distancing has flattened the curve and no hospitals were overextended or lacked ventilators. The initial R naught (the number of people infected from one individual) of each infected person spreading to 4 is now down to 1.5. A study from Singapore showed that 7% of cases came from presymptomatic persons. The infection can be transmitted 2 to 3 days before symptoms show. Of 121 healthcare workers exposed 35% developed symptoms but only 2.5% tested positive.

Our own experience with testing has been equally frustrating. The virus can be present for weeks but usually rapidly declines after 7 days. The PCR test (polymerase chain reaction test – the standard nasal swab being conducted to test for Corona virus) is said to be 75% accurate in detecting viral RNA. Even patients we’ve tested during the first 4 days of typical symptoms have been negative. Other viruses identified at Children’s Hospital in the last month include rhinovirus, adenovirus, enterovirus and human metapneumovirus, which can all cause fevers and respiratory illnesses.

However, many people we are treating have the unusual symptoms and course that seems unique to COVID. Not all have fever. They experience chills, fatigue, sore throat, then improve. A day later they are having chest tightness, trouble breathing, making it difficult to talk or walk, and upper abdominal pain. They feel worse at night and better in the morning. Symptoms can last for weeks. Lung specialists describe several different effects the virus can have. ARDS (adult respiratory distress syndrome) is a diffuse loss of protective protein that causes the air sacs to collapse. The pulmonary disease in the second week is described as a cytokine storm, where the immune system overreacts and damages the lungs.

Testing is less accurate when the prevalence of a disease is low. In Colorado 1.4% have been affected, in comparison with Wuhan where 5-10% were. Experts and individuals are waiting for antibody testing to see if they are immune and if so for how long. Immunity in similar infections has been shown to last anywhere between 3 weeks and 3 months, as opposed to diseases like measles and chickenpox which confer lifelong immunity.

Pediatricians are seeing few patients in the office these days, which raises the concern for a future epidemic of preventable diseases from a delay in vaccinations. Most clinics, like Ebert Family Clinic, are only seeing healthy patients or those with noninfectious complaints such as eczema and lacerations. Anyone with respiratory symptoms or fever is seen by Telehealth. This is effective because COVID, like most illnesses in the community, is usually mild and self-limited. Antibiotics are rarely indicated. A recent study showed that of several hundred children diagnosed with community-acquired pneumonia, those given antibiotics had the same outcomes at those who were not treated, with 4% of each group needing hospitalization for worsening symptoms.

Telehealth does not allow for auscultation of the heart and lungs (listening with a stethoscope), but the vital signs including oxygen saturation, heart rate and temperature along with the patient’s history usually give the provider enough information to make treatment and testing decisions. A face-to-face video interaction is ideal, protecting the patient and provider from exposure to infection. The expanded use of Telehealth is one of the good outcomes of this pandemic, especially in states like Colorado with far flung rural populations.

 The University of Colorado is doing 3000 telehealth visits daily. Specialists at Children’s are ramping up their services online while accepting the sickest patients in the state for inpatient care. They have the largest number of doctors in Colorado, many of whom are in research and can transfer to frontline and ICU duties. The University does 500 million dollars of sponsored research every year, with over 1000 studies. Many of these are on hold now, but with the capacity to initiate new trials within a week and laboratories adjacent to clinical care sites, CU has been tapped for many COVID-related studies. They are testing several antiviral drugs, including the new product from Gilead laboratories Remdesivir. There are also studies on disease modifying treatments such as steroids to prevent future problems caused by the infection. Other trials focus on sample collecting and processing. Some studies may show results within weeks but others take months or years to determine effect.

The University was one of the first centers to use convalescent plasma to treat COVID. The hope is that antibodies from previously-infected and recovered individuals can be lifesaving for severe cases, although the best timing of such treatment, originally used one hundred years ago in the influenza epidemic, is not yet determined. Plasma donations can be arranged by visiting the UC Health website. Since most people will not need hospitalization, instructions for home care can be found on the CDC website.

Vaccine development will proceed over the next 12 months. Until then, lifting of current social restrictions will depend upon having adequate and accurate testing to find cases early enough to quarantine patients and public health workers to trace contacts. Antibody testing must be done and repeated over months and years to determine susceptibility. Continued use of masks in public and the prohibition of large gatherings may continue for a year.

Acclimation, Athletic Training, Avalanche Safety, Backcountry, COVID-19, Exposure, Health, High Altitude, High Altitude Training & Fitness, Huts, Mountaineering, Pandemic

Backcountry & Avalanche Safety: Insight from Backcountry Athlete Dan Beerman

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Another Spring season in Colorado. The ski resorts have closed early per the COVID-19 protocol, along with most other establishments. Even on the normal schedule, most ski resorts would have been closed for the season by now, bringing more people to the backcountry. But this year seems to have seen an upswing in backcountry activity, where many people are going to stay active while limiting exposure to others. Just over a week ago, a team of 20 search and rescue volunteers rescued a 26-year-old man who had fallen hiking on steep terrain around St. Mary’s Glacier, Colorado. Last year, a total of 10 snowmobilers were killed in the backcountry in avalanche slides. Only one was wearing a beacon.

Backcountry and Avalanche Safety resources, thankfully, are growing more plentiful and accessible, and last winter, we published an article on the basics. Earlier this winter, I spoke with backcountry athlete and web development colleague Dan Beerman, whose experience in the backcountry really broadened as a backpacking guide in New Mexico during the summers 12 years ago, followed by a position as a climbing instructor.

Dan Beerman on the Pacific Crest Trail

When I was a backpacking guide, I was on the search and rescue if I didn’t have a crew … We had a radio, so we were the point of contact for finding and doing extraction. That’s when I learned the most and was exposed to the most. I took my Wilderness First Responder course in 2014, and that was through the Wilderness Medical Institute.

Dan’s also a fellow hut tripper, and we’ve been talking about doing one together (when we’re on the other side of the current pandemic). He’s spent the last two New Year’s in huts, backcountry skiing or snowshoeing tours. This past year, he skied Buffalo Mountain’s Silver Couloir, in the Gore Range, and made an attempt at a couloir on Mt. Torrey’s. And there have got to be some good “couloir” puns out there.

Beerman on Buffalo, Summit County, CO.

I have aspirations to do the Colorado trail quickly, but I don’t know if I wanna do that in a competitive way or just recreationally backpack it. It’s hard to balance summer objectives, or climbing objectives vs. winter backcountry goals vs. alpine mountaineering objectives.

And he makes a great point:

In Colorado, your recreation is so close to becoming high-consequence all of the time! If the weather changes from the trailhead, that could be a really big problem.

I’m familiar. Nothing really teaches you as much or as quickly as getting caught in Colorado’s extreme weather patterns.

Avalanche Safety

Dan took an Avalanche Awareness and Safety class through Colorado Mountain School, held up in Rocky Mountain National Park over two field days after two nights of class in Boulder. His main takeaway:

Check an avalanche conditions snow report daily. Observing the snowpack over the season is going to make your confidence on the day of your excursion a lot higher. I’d had no context for why avalanches were happening, where and why it’s dangerous. Having that lens through which to view weather events in terms of avalanche conditions is so valuable. It’s an intuitive thing about paying attention to the weather.

This is my first season getting out at Copper, for example, and they all have that double-black diamond terrain in the back bowls that are labeled ‘EX’ on it. There’s a sign that says, ‘Ski with a partner,’ and I just thought, ‘Oh, shit, that sign should probably be much bigger!’

Beacon, shovel, probe are the mandatory avalanche terrain items — you’re putting other people at risk if you don’t have [them], because even if you observe a slide, you can’t do anything about it. Additionally, if you don’t have a beacon in a slide, others can’t find you. You’re not contributing to a rescue, nor can you be rescued. In Colorado, there’s an increasing awareness for that. I typically will bring that with me all the time, it’s just always in my ski bag. Having some snacks, having some water, those are the kinds of things: you should never not have them.

Beerman in his beacon.

Training

I’ll take the goals of the expedition and plan accordingly. If I’m doing a ski trip, I’ll wanna get out and do hikes with weight or runs where I’m doing elevation several times. I like to do six weeks out, of four weeks of training and two weeks of tapering down.

Nutrition

I tend to be in a constant attempt to gain weight. On the Pacific Crest Trail I tried to gain weight prior, eating a lot of fatty foods, that kind of thing. Jonathan and I came up with this metric: calorie-per-dollar-per-ounce. Lightweight food that’s affordable, easy to ingest, easy to prepare, and you aren’t having to burn a lot to carry that with you to the backcountry.

[On the trail], peanut butter is always a winner. Olive oil is one of the highest calorie-per-ounce [food]. I have literally drank it before, but just add it to everything. I do eat a lot of standard trailmix, it’s easy and accessible. I’m a big fan of pumpkin seed mix or stuff with chocolate in it. I like CLIF bars. I do not like Luna bars because I’ve eaten so many of them. I can’t eat pop tarts anymore because they used to be in the meals that were issued when I was a guide. Snickers bars are a great calorie-per-dollar-per-ounce deal. I eat a Snickers bar or two before bed when I’m sleeping at altitude so my body has calories to stay warm.

I’ll make these mass-gainer complex food supplements. It’s like protein powder, but it also has carbs, like a workout and performance powder. And I would add that to water with coffee, and that would be a breakfast while hiking. There’s a lot of different kinds of powders and mixes you can add, but when you’re in calorie-burning mode, I do recommend this. If you’re hiking 20+ miles in a day or 4000+ feet of elevation in a day, you’re burning greater than 4000 calories, so you really have to eat more than you think you can.

Acclimatization

I wouldn’t say that I had HAPE (high altitude pulmonary edema) or HACE (high altitude cerebral edema) … Definitely, especially when I was younger … I would travel from 4000′ to 10,000′ in a 24-hour period. I’ve actually had search and rescues where someone was having night-terrors or hallucinations [due to HAPE or HACE]. I was a backountry professional for the Boy Scouts at a camp at 10,800′ (one of the first backcountry camps, in New Mexico). I’ve experienced dizziness, nausea, insomnia, weakness of the knees, elevated heart rate … and I’m a runner, I’m in decent shape. But you should acclimatize before setting out on a trip.

Skiing down the Silver Couloir.

One last piece of advice,

Learn the Leave No Trace principles. We live in a state where impact is so concentrated that the more that everybody knows, the more likely it will be there for the next generation.

Dan and his backpacking, backcountry cohorts keep a blog full of breathtaking landscapes and telling captions on CaptainsofUs.com.

There will be plenty of time to escape to the backcountry again after the risks of COVID-19 have subsided. The current time is a good time to start preparing mentally. Know before you go.

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.

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

COVID VS HAPE: Experts Analyze Effect on Lungs

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Dr. Chris with Dr. Eric Swenson from the University of Washington

An article published yesterday, April 13, 2020 in the Journal of High Altitude Medicine and Biology clarifies misconceptions in the media comparing high altitude pulmonary edema (HAPE)and COVID lung injury. The six authors include two critical care pulmonologists from the University of Washington: Andrew Luk MD and Eric Swenson MD, as well as Peter Hackett MD of the Hypoxia Institute in Telluride and the University of Colorado Altitude Research Center. Dr. Swenson is the editor of the journal and has given presentations in Summit County on altitude. Both Dr. Hackett and Dr. Swenson personally communicated with Dr. Chris yesterday.

Dr. Chris with Dr. Peter Hackett of the Hypoxia Institute in Telluride, CO

Severe viral pneumonia, as seen in COVID-19, can cause Adult Respiratory Distress Syndrome (ARDS) leading to respiratory failure and the need for ventilator support. As with HAPE, this is a form of non-cardiogenic pulmonary edema, where the air sacs in the lung fill with fluid due to conditions not related to heart failure, the most common cause of pulmonary edema. Other causes include bacterial pneumonia, near-drowning, nervous system conditions, re-expansion, and negative pressure edema. Radiographic findings are similar in all these cases with diffuse bilateral densities in the lungs. All these patients have severe hypoxia.

At altitude, hypoxia can lead to uneven pulmonary vascular constriction, (hypoxic pulmonary vasoconstriction or HPV). In the areas with the highest pressure, fluid leaks from capillaries into the alveoli. With COVID, alveolar inflammation reduces the protein surfactant that maintains expansion of the alveoli. The alveolar collapse causes hypoxemia, low blood oxygen. Severe viral and bacterial infections also cause inflammation in other organs, such as the liver, kidneys, and brain, which is not seen with HAPE.

Medications used to treat HAPE are not likely to be useful in treating COVID pneumonia and may have harmful effects such as increasing perfusion to damaged areas of the lung that are not oxygenated.

Both these conditions likely have large numbers of patients with mild symptoms who recover without seeing a medical provider. However, both HAPE and COVID can cause a sudden, rapid deterioration with severe hypoxia and death.

ACCESS TO A PULSE OXIMETER TO TRACK OXYGEN SATURATION IS VITAL.

Oxygen levels below 90% merit medical attention. Pulse oximeters can be purchased online, at drug stores, or at Ebert Family Clinic.

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

COVID Vs. HAPE: Frontline Theories on Treatment

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A good friend in Hawaii recently sent me a YouTube video referencing Dr. Cameron Kyle-Sidell, a critical care and emergency room physician at Maimonides Medical Center in NYC.  Dr. Kyle-Sidell was discussing his findings while working with COVID-19 patients in NYC and compared those findings to altitude sickness. I did a search and found he had posted several videos on social media comparing Acute Respiratory Distress Syndrome (ARDS) in COVID-19 patients to altitude sickness and reconsidering how these patients are treated. Altitude sickness is something I see and treat frequently here in Summit County. Based on the similarities between the two conditions, the same treatment for altitude sickness and high altitude pulmonary edema (HAPE)[1] may be beneficial to COVID-19 patients.

In an interview with Dr. John Whyte, Dr. Kyle-Sidell described the acute ARDS he is seeing in COVID-19 patients as atypical and not responsive to standard treatment, specifically in regards to ventilator use and settings. He describes some of his patients as alert, talking in full sentences, and not complaining of shortness of breath but have oxygen saturation levels in the 70s (John Whyte & Cameron Kyle-Sidell, 2020). Normally, that is not the case when a person has an O2 saturation[2] in the 70s and is in respiratory distress. However, this is not abnormal in patients with altitude sickness and HAPE. There are certain protocols in hospitals regarding when to intubate a person and to put them on a ventilator. According to Dr. Kyle-Sidell, these protocols apparently aren’t always helpful for COVID-19 patients with ARDS, and can at times be harmful.

The similarities between findings with COVID-19 and HAPE are remarkable. These similarities include: hypoxia (low oxygen levels), low CO2 (carbon dioxide) levels, tachypnea (rapid respiratory rate), patchy infiltrates seen on chest x-ray, bilateral ground glass appearing opacities on chest CT, fibrinogen levels/fibrin formation, aveolar compromise[3], decreased Pao2:FiO2 ratios[4], and ARDS in severe disease (Solaimanzadeh, 2020). Noting these similarities may be helpful when approaching treatments for COVID-19.  Acetazolamide (Diamox), Nifedipine (Procardia) and Phosphodiesterase inhibitors (Viagra, Cialis etc.) have been used in treating HAPE and could possibly be beneficial in treating COVID-19. For example, Acetazolamide potently decreases the constriction of small vessels in the lungs that contribute to fluid build up (edema) seen in both HAPE and COVID-19 patients (Solaimanzadeh, 2020).

In our house call practice, we treat quite a bit of altitude sickness due to our elevation here in Summit County. During the ski season, we may see 3-4 patients per month that develop HAPE. The majority of the time, these patients can be safely treated and monitored in their residence or hotel room. Treatment for both altitude sickness and HAPE consists of oxygen, usually 2-5 L/min via nasal cannula continuously while sleeping or resting. We also treat our patients with an injection of a steroid, Dexamethasone. We closely monitor them and may repeat the dose of Dexamethasone or prescribe an oral steroid. These patients usually see some improvement by the next day and significant improvement when they descend in altitude. I have read recommendations for and against steroid use with COVID-19.  More studies need to be done, which I will be following closely as future recommendations may change how I treat HAPE when there is also a suspicion of COVID-19.

The key to treatment is oxygen! We’ve seen patients with O2 saturation levels in the 40s and 50s and lungs that sound like a “washing machine”, as Dr. Gray, has described it (in a previous Doc Talk article). If we can get their oxygen saturation up into the mid 80s or 90s on 5L/min (of O2) or less via nasal cannula, typically, they can avoid an ambulance ride and emergency room visit. As Dr. Kyle-Sidell notes, many of the COVID-19 patients he sees are talking coherently and not in severe respiratory distress. A friend who is an EMT in New York described a man he recently transported to the hospital, in his 50’s, with presumed COVID-19. He had no respiratory distress, walking and talking coherently, no chronic medical problems but his oxygen saturation was in the 60s. He said they took him to the emergency room and he was intubated and placed on a ventilator. Apparently, this is a common occurrence from what he has seen. I am still amazed when a patient calls, gives me their address and directions to where they are staying and when I arrive, their oxygen levels are in the 40s. It is a very rare occurrence that I need to send a patient to the hospital, which they always appreciate. We monitor our patients very closely until their departure and have them call anytime, day or night, with any changes in condition.

Dr. David Gray, who started our business, has been treating these patients for over 18 years. He states that in a few of the HAPE patients that he has treated, including his own 13-year-old son, he has seen O2 saturations in the 30’s & 40’s. In these few patients, he was only able to get their O2 saturation up to high 60’s, low 70’s, on 5 liters. They were so much improved, clinically, that he accepted those levels. A large dose of Dexamethasone & 12 hours of rest, on nasal oxygen, resulted in marked improvement by the next day, every single time. His rule, as in patients with DKA, is “if the pathology didn’t happen rapidly, you don’t necessarily have to reverse it rapidly.”

Dr. Kyle-Sidell suggests not putting COVID-19 patients on ventilators based solely on numbers (John Whyte & Cameron Kyle-Sidell, 2020). Treating these patients with prone positioning, oxygen via nasal cannula, high flow on a non-rebreather mask or CPAP[5] along with careful monitoring and a little patience may be preferable to a ventilator (John Whyte et al, 2020). If a ventilator is needed, using less pressure to reduce lung damage and higher oxygen levels may prove to increase the likelihood of a better outcome (John Whyte et al, 2020). There is so much to learn about COVID-19 and how to treat it. Treating it as you would with HAPE is certainly something to consider. I appreciate providers who are sharing their personal experiences in treating these patients. As healthcare providers gain more experience treating this virus and share their experiences, protocols will change and I suspect ventilator use as well as the death rate will decrease.

[1] A complication of altitude sickness in where the lungs fill with fluid and small amounts of blood

[2] Blood oxygen level

[3] Damage to the tiny sacks in the lungs where gas exchange occurs

[4] partial pressure of arterial oxygen: percentage of inspired oxygen ratio used to determine ARDS and lung damage

[5] Continuous positive airway pressure

Danielle Shook MSN, NP-C is a board-certified Family Nurse Practitioner. She has been in nursing for over 27 years. She earned her Master’s Degree at University of Colorado, Colorado Springs through Beth El School of Nursing. Her nursing experience includes 10 years in Obstetrics and 7 years in Hospice home care. She has over 9 years experience as an NP which includes Family Practice at the Air Force Academy, Urgent Care, Acute and after hours care with the Army Premier Clinic as well as house calls.

References

John Whyte, Cameron Kyle-Sidell. Do COVID-19 Vent Protocols Need a Second Look? – Medscape – Apr 06, 2020.

Solaimanzadeh I (March 20, 2020) Acetazolamide, Nifedipine and Phosphodiesterase Inhibitors: Rationale for Their Utilization as Adjunctive Countermeasures in the Treatment of Coronavirus Disease 2019 (COVID-19). Cureus 12(3): e7343. doi:10.7759/cureus.7343