Often, at high altitude we hear complaints of gas pain and increased flatus in our infant population. Parents often wonder, are we doing something wrong? Is my child reacting to breastmilk, or showing an intolerance to certain foods? Actually there is another explanation for increased flatus and gas pain in the high-altitude region of Colorado.
The term HAFE was coined by Dr. Paul Auerbach and Dr. York Miller and published in the Western Journal of Medicine in 1981. Their discovery began In the summer of 1980, when the two doctors were hiking in the San Juan Mountains of Colorado on a quest to summit three 14ers. During their ascent they noticed that something didn’t smell right! As the pair continued to emit noxious fumes, they began to put their scientific brains to work and discovered HAFE. The symptoms include an increase in frequency and volume of flatus, or in other terms an increase in toots! We all have familiarity in watching our bag of potato chips blow up when reaching altitude or our water bottle expanding as we head into the mountains. This reaction is due to a decrease in barometric pressure. Based on Boyle’s law, decreased barometric pressure causes the intestinal gas volume to expand, thus causing HAFE (Skinner & Rawal, 2019).
To my surprise, a gas bubble the size of a walnut in Denver, Colorado (5280 ft) would be the size of a grapefruit in the mountain region of Summit County, CO (8000+ ft)! Trapped gas is known to lead to discomfort and pain. The use of simethicone may have merit in mitigating the effects of HAFE. Simethicone works by changing the surface tension of gas bubbles, allowing easier elimination of gas. This medication, while benign, can be found over the counter and does not appear to be absorbed by the GI tract (Ingold, C. J., & Akhondi, H., 2022).
While this phenomenon may not be as debilitating as high-altitude pulmonary edema (HAPE), it deserves recognition, as it can cause a significant inconvenience and discomfort to those it inflicts. As the Radiolab podcast explained in their episode The Flight Before Christmas , expelled gas in a plane or car when driving up to the mountains can be embarrassing. While HAFE can be inconvenient, it is a benign condition and a matter of pressure changes rather than a disease or pathological process. We would love to talk more about HAFE at Ebert Family Clinic if you have any questions or concerns!
A bald eagle flies toward its nest atop a bare lodgepole pine.
As always, stay happy, safe, and healthy 😊
Taylor Hollingsworth is finishing her final semester as a family nurse practitioner (FNP) student at Georgetown University. Originally from the east coast, Taylor plans to start her FNP career in North Carolina close to family. She has a passion for pediatric and family wellness and has worked as a pediatric intensive care unit nurse for 6 years! In her free time, Taylor loves to hike, fly fish, run, and spend time with her fiancé Logan.
References
Auerbach, P. & Miller, Y. (1981). High altitude flatus expulsion. The Western Journal of Medicine, 134(2), 173-174.
After his father-in-law arrived in the mountains, Thomas noticed later that night he seemed intoxicated despite not seeing him drink alcohol. Thomas woke up the next morning to see him reading the paper in nothing but black socks and a black tie. Thomas knew right away he wasn’t drunk, he had high altitude cerebral edema (HACE). HACE is a complication of acute mountain sickness (AMS). HACE can occur from increased pressure in the blood vessels in the brain, leading to fluid leakage and swelling (edema). This increased vessel pressure can result from the lower atmospheric pressure at high altitude1. Breathing in lower atmospheric pressure gives you less oxygen molecules per breath. Thomas estimates that EMS in Summit County see one case of HACE a year. EMS look for two hallmark signs of HACE, altered mentation and ataxia. When EMS arrive to a patient with altered mentation, they have the patient walk heel-to-toe to evaluate for ataxia. If ataxia is present, immediate descent is necessary. Rapid descent is necessary because HACE can progress rapidly. Years ago, Thomas had a patient walk into the emergency department and die within 10 minutes after arrival. Unlike high altitude pulmonary edema (HAPE), descent is the only cure for HACE.
HAPE is a more common complication of AMS. Similar to HACE, edema occurs from the high pressure inside pulmonary blood vessels pushing fluid into the lungs. The high pressure is caused by a rapid vasoconstriction response to hypoxia or low oxygen partial pressures. Luckily, HAPE has a simple treatment, oxygen. Therefore, visitors with HAPE do not need to descend to lower altitude as with HACE. HAPE is much harder to recognize than HACE and EMS is well trained in how to recognize it. Often, headache is the only symptom2. Thomas explains the HAPE protocol for EMS: In the first 20 seconds of arriving, an oxygen saturation is obtained; they obtain vitals in the next two minutes and then start high flow oxygen if the saturation is below 89%; they then listen to the lungs for signs of fluid. EMS does not treat HACE or HAPE with any medications since descent and oxygen are the effective treatments.
So, who is prone to AMS?
Unfortunately, better physical fitness does not protect you from AMS. Thomas reports that athletes with resting heart rates of 40 or below have a difficult time acclimating. Younger age also doesn’t mean easier acclimation. According to Thomas, the best age for acclimation is late 30s/early 40s. Surprisingly, previous hypoxia can help acclimation to high altitude. For example, Thomas reports that smokers have an easier time acclimating because their body is used to having the vasoconstriction response to hypoxia and breathing faster and deeper to get adequate oxygen intake.
But don’t worry, your conditioning wasn’t for nothing. A healthy diet and regular exercise prevents heart disease. Thomas estimates there are about 12 acute MI’s on the ski hill each year. These patients usually have to be transported to Denver for a stent to be placed. Exacerbation of coronary artery disease (CAD) is so common that EMS refers to altitude travel as the “altitude stress test.” This mimics a cardiac stress test in those with CAD, producing chest pain that wasn’t present at lower altitude.
Those with sickle cell disease are at risk of developing sickle cell crisis when traveling to high altitude. The lower atmospheric pressure allows the normal red blood cells to lose their integrity and become sickle. Thomas reports that EMS encounters this every couple months in patients (usually of Mediterranean descent) that present with diffuse abdominal pain with no obvious cause. This pain results from the sickle cells aggregating together and causing an occlusion. The occlusion leads to tissue hypoxia and ischemia3. These patients are transported to the hospital for treatment.
How can mountain tourists avoid AMS?
Thomas’s first recommendation is to take a staggered stop for one night at an elevation of 5,000-6,000ft, like Denver. When arriving to altitude, take it easy the first 3 days: don’t drink alcohol and do light activity. Save the long hike for the end of the trip. Also avoid substances that blunt the respiratory system like alcohol, opioids, benzodiazepines, etc. Prepare by hydrating the week before and keep drinking plenty of water while on the trip. If you have had a previous episode of AMS, you can speak to your medical provider about prophylactic medication to take before arriving at high altitude.
2. Schafermeyer, R. W. DynaMed. Acute Altitude Illnesses. EBSCO Information Services. https://www.dynamed.com/condition/acute-altitude-illnesses. Accessed November 19, 2021.
3. Sheehan VA, Gordeuk VR, Kutlar A. Disorders of Hemoglobin Structure: Sickle Cell Anemia and Related Abnormalities. In: Kaushansky K, Prchal JT, Burns LJ, Lichtman MA, Levi M, Linch DC. eds. Williams Hematology, 10e. McGraw Hill; 2021. Accessed November 23, 2021. https://accessmedicine-mhmedical-com.ezproxy2.library.drexel.edu/content.aspx?bookid=2962§ionid=252529206
Samantha Fredrickson is currently a student in Drexel University’s Physician Assistant program.
As someone with family history of cardiac illness and a personal history of both supraventricular tachycardia (SVT) and high blood pressure, I have always tried to manage my modifiable risk factors through a healthy diet and exercise. Over the past year or two, most of my exercise has been in the form of running, since it is more conducive to the schedule of a physician assistant student during COVID restrictions. However, in the past I have been a regular rock climber and soccer player. Through my own personal experience I have noticed that when I stick to a healthy diet, not giving in to my sweet tooth, and keeping up with regular exercise that my episodes of SVT are less frequent. However, recently I traveled up from Denver, Colorado for a rotation at the Ebert Family Clinic in the mountain town of Frisco, and in the first two days at high elevation experienced an episode of SVT for the first time in nearly 6 months.
In my first day at over 9000 feet, I experienced a slight headache after a full day seeing patients, but did not think much of it or even consider it to be a side effect of the altitude. I spent my first day at altitude without exercising but I decided that on day two I had acclimated enough to go for a short run. Midway into my run, and shorter of breath than I expected, I experienced an episode of SVT that lasted for about 2-3 minutes and forced me to sit for several more minutes to catch my breath. Catching my breath afterward took slightly longer compared to my normal episodes, which made sense to me given the reduced availability of oxygen, but it did lead me to wonder if the altitude was a contributing factor to precipitating an episode of SVT after several months without one.
About one year ago, High Altitude Health interviewed Dr. Peter Lemis, a cardiologist in Summit County, Colorado about his thoughts and findings practicing cardiology at elevation. The discussion included questions about arrhythmias at altitude and Dr. Lemis stated that “studies have shown that cardiac arrhythmias are increased initially, but people become acclimated after about 3-5 days and the risk returns to baseline”. However, Dr. Lemis also states that the studies may not have been conducted for a sufficient length of time due to his personal experience of seeing a great deal of both atrial fibrillation and atrial flutter in his own practice. He states that the hypoxia leads to an increase in arrhythmias, but that for atrial arrhythmias, patients may experience relief from them when placed on nocturnal oxygen. Dr. Lemis also notes that “many people have central apnea during sleep at altitude due to the brain’s blunted response to high CO2 and low O2”, which can be a risk factor for the development of heart problems. The use of Diamox can be helpful in acclimating to altitude due to making “your blood a little acidotic which increases your respiratory drive” and the use of nocturnal oxygen can also help with acclimatization to altitude.
In March of 2021, the journal of Frontiers in Medicine published an article titled Nocturnal Heart Rate and Cardiac Repolarization in Lowlanders with Chronic Obstructive Pulmonary Disease at High Altitude: Data from a Randomized, Placebo-Controlled Trial of Nocturnal Oxygen Therapy by Maya Bisang, Tsogyal Latshang, Sayaka Aeschbacher, et al. This study compared COPD patients at altitude with and without oxygen therapy at night and COPD patients not at altitude without oxygen looking at QT interval, heart rate, and SpO2. The results of the study found that without oxygen use at altitude patients experienced an increase in heart rate, a lengthened QT interval, and naturally, a lower SpO2 at night compared to those at altitude who utilized oxygen and those that were not at elevation. This study was observing patients that had COPD. The results could potentially be relevant to younger patients without COPD, like myself, but would need further research.
I also looked into information regarding high blood pressure at altitude and found some helpful information from the Institute for Altitude Medicine. They state that for patients visiting altitude with a history of hypertension (HTN), even if it is well controlled on pharmacotherapy, may still experience a temporary increase in blood pressure at altitude. “One explanation for this is due to the higher levels of adrenaline or stress hormones in your body due to lower oxygen levels,” as they describe. Their research has also found that increases in blood pressure at altitude generally return to base line after 1-2 weeks. In order to help manage HTN at altitude they recommend ensuring that blood pressure is well controlled at sea level, reducing salt from the diet, remaining on any medications for HTN, checking blood pressure at altitude, and observing for symptoms of HTN that would need medical care such as headache, dizziness, chest pain, or shortness of breath.
Through my research regarding effects of altitude and the possible role of them in my recent episode of SVT, I have found that altitude can have several different impacts on cardiac function that definitely could have played a role in triggering an episode. Coming to altitude, I likely had an increase in blood pressure to compensate for the reduced availability of oxygen that increased strain on my cardiac muscle. I may have had EKG changes overnight related to decreased responsiveness of my central nervous system to CO2 levels. I also had an increased risk of arrhythmia based on coming to elevation. It is possible that any or all of these effects could have contributed or triggered my episode of SVT. Thankfully, after almost a month of staying at altitude I have adjusted more and have not experienced another episode. I have continued to exercise after a short break to allow more time to acclimate, but I have not pushed myself as hard.
I have learned that no matter how healthy you are or what your risk factors are, there are important steps to stay healthy when coming to altitude. If possible, at least one day at an intermediate altitude can help your body begin to adjust to the change. Drinking plenty of water to stay hydrated and avoiding alcohol can lead to a more comfortable stay and more rapid acclimatization. Meeting with a healthcare provider could also allow you to start a prophylactic course of Diamox or supplemental oxygen use. Utilizing a personal pulse oximeter allows you to monitor your SpO2 level and determine if nocturnal supplemental oxygen could be useful as well. If you have risks for cardiac conditions or already have a diagnosis of heart disease, these recommendations are even more important to prevent poor outcomes including myocardial infarctions due to reduced oxygen availability. Finally, it is important to remember that traveling to altitude is not a benign choice and a discussion with your healthcare provider is important to be sure that your personal risks are appropriately managed so that you can enjoy your trip to high elevation.
Justin Frazier is currently in his second year of PA school at Red Rocks Community College in Arvada, CO, a member of the class of 2021 graduating in November. He attended Appalachian State University in Boone, NC for his undergraduate degree majoring in Cell and Molecular Biology with a double minor in Chemistry and Medical Humanities. During his undergraduate he worked for two and a half years as a CNA at a local nursing and rehabilitation facility. After completing his undergraduate degree he started working as an EMT for almost a year before transitioning to work in a family medicine office where he worked as a Medical Assistant until starting PA school. He enjoys working in a primary care setting where he can help to keep people healthy throughout their lives and wants to pursue a career in pediatrics after graduating this year. He enjoys hiking, camping, rock climbing, and spending time with his wife and young son.
While doing a clinical rotation with Dr. Chris at the Ebert Family Clinic in Frisco, CO I had the pleasure of interviewing local emergency medicine physician, Dr. Jack Gervais.
To start off, if you don’t mind just telling us about yourself, where you work, and how you got into the ED …
Dr. Jack Gervais:I grew up in Summit County and then did my undergrad at the University of Denver, and then medical school at University of Colorado in Denver as well, and then did a three-year residency for emergency medicine in Portland, Maine. Then I came back to Frisco in 2011, so this was my first job out of residency, and I’ve been here ever since. As far as what got me into emergency medicine, it just kind of seemed like a good mix of everything, really, and I like doing procedures but didn’t necessarily want to be a surgeon, and so I kind of gravitated towards that.
What percent of your practice involves tourists?
Dr. Jack Gervais:It depends on the season. Obviously during the higher tourist seasons it goes up, but I would say probably on average maybe 50-60% and then during the heavy winter tourism times it’s probably more like 80%, and fall and spring much less.
Let’s say that there is a visitor in Frisco who brought a pulse oximeter with them. At what point, with either their O2 saturation or their symptoms, would you recommend that they go to the ER or seek oxygen administration?
Dr. Jack Gervais:It really depends primarily on the symptoms. People can be symptomatic with a fairly typical kind of mountain sickness symptoms and have a normal oxygenation. We consider anything above 88-90% acceptable. We get a lot of patients that come in with an ankle injury and their O2 saturation is 85% and they’re really asymptomatic.
Certainly, anybody who’s symptomatic we will offer O2 to them even if they have a normal saturation. Anybody around 85-86% if they’re not having symptoms and they’re going home in a day or two, I offer oxygen to them, but I don’t necessarily say “oh you have to be on oxygen ’cause you’re 85%”. Anybody who’s under 80%, I would say absolutely should be on O2 regardless ’cause they’re going to end up getting worse.
Let’s say they’re skiing, they check their oxygen saturation, and it’s 85% but they feel fine. Would you say “keep going and be aware if you develop symptoms”?
Dr. Jack Gervais:Yeah, I think that’s reasonable. People tend to do worse at night, so someone is 85% when they’re standing in the day, they’re probably in the 80s at night. So, what I’ll often do with people with those kind of borderline sats is offer them oxygen. It’s really easy to get the delivery from the various companies so it’s pretty straightforward, more of a cost issue for some people, but I tell them “use it when you sleep the whole time you’re here”. Probably most tourists would benefit from sleeping on oxygen regardless because you don’t know how low they’re getting at night. I would guess most people are sleeping in the mid 80s and don’t realize it. That leads to the headaches and waking up at night and those sorts of things that we see a lot.
What conditions do you see here at altitude and how commonly, i.e. cases of Acute Mountain Sickness (AMS), HAPE (High Altitude Pulmonary Edema), HACE (High Altitude Cerebral Edema), sleep problems, blood pressure issues, etc.?
Dr. Jack Gervais:Typical AMS would be shortness of breath, headache, and nausea being the most common. Any combination of those in people who recently traveled from lower elevation or when locals come back from as few as 4 days of vacation can be AMS. People reset really quickly after they descend, we see a lot of people who get reentry HAPE. Kids will go down for spring break in Florida and come back and get HAPE.
It’s tough to say exactly what incidences, I would estimate probably 20-25% at least people visiting from lower elevation — and that’s when it’s just semantics, but it’s elevation, not altitude, and everybody says “altitude sickness”. Altitude is your height above the ground used by pilots. Elevation is how high you are above sea level, but anyway we see that all the time. That’s pretty simple, you know, basically treat the symptoms: something for nausea and actually ibuprofen has been studied in comparison to acetazolamide and is essentially as effective at preventing acute mountain sickness. I tell everyone just put yourself on an NSAID as long as there’s no clear contraindications to it.
I see at least 12 patients a month with HAPE, so it’s something we see really commonly. This year is kind of weird though ’cause we’re not having as much tourism. We see a lot more when a storm comes in ’cause the pressure drops-so that 10% drop in barometric pressure is like going up another 500 feet, and so that will often kind of push people over the edge. Again, we tend to see a lot of people who get worse at night because they sleep with low O2 saturation or they struggle through the night and come in first thing in the morning saying “I didn’t sleep at all last night, I’ve got this terrible headache, I’ve got this cough”.
HACE is fairly rare here, but not impossible at this elevation. It’s certainly seen more in high trekkers on Everest and in South America. I would say at the hospital we probably have maybe 3-4 cases a year.
Sleep problems are super common, a lot of people wake up feeling short of breath, they’re dehydrated, they get headaches and of course everything else people are doing on vacation exacerbates all that. We actually have this joke of the Summit County Syncope Syndrome: visiting from low elevation, hot tub, alcohol, overexertion, and cannabis. If you have 3/5, there is no way that your syncope is a dangerous cause!
I don’t know why people bring their blood pressure monitors on vacation, but we definitely see a rise in baseline blood pressure at higher elevation. They say, “I have a little headache” (it’s probably from their acute mountain sickness), they check their blood pressure and its 160 and they end up in the ER, which they don’t need to be.
There are actually some folks at the altitude research center in Denver [who] have a little publication about it, but I certainly see a lot of first-time seizures or breakthrough seizures in people who have never had a seizure before. I think it’s just that little bit of change in oxygenation to the brain if you have a seizure predisposition. We see a lot of people that either have their first-time seizure, and there’s nothing else going on, or they’re really well controlled at home, come up and have a breakthrough seizure a couple of days in.
One other thing about HAPE that’s interesting is people will come in and they’re like, “oh I haven’t slept for the last two nights, I feel terrible, I’ve had a splitting headache,” and I assume they’ve had that for 24-72 hours before they actually come in. Which means they’ve been sitting around with [low oxygen] — most of the HAPE we see is certainly below 80%. I presume these people have been walking around with sats in the 70s for 24-48 hours and it’s amazing that they’re fine. If you were walking around with your O2 saturation in the 70s at sea level, you’d be dead! So, it’s not just a hypoxia that kills people when they have respiratory illness, it’s got to be the hypercarbia and acidosis and all the other stuff that goes along with it.
HAPE tends to also settle in around day 2-3, some people get it quickly but most of the people say I felt fine on day one, I skied yesterday, felt a little crummy night 2, and then day 3 they feel terrible, night 3 can’t sleep and they’ve got HAPE.
It’s interesting to see the nurses check in a patient with an O2 sat of 50% and it is really no big deal, just put him in any room — it’s not like a big STEMI activation or something. We stick them on oxygen and no one freaks out. People freak out on their first shift if they’re new and it took me a good year to kind of get used to that.
Often, we don’t really need to do anything if we can fix them with oxygen and determine from history and physical that there’s nothing else going on. But that gets tricky ’cause you always worry all these people traveling and they’ve got a little bloody cough, they’re tachycardic and hypoxic, so trying to figure out who we want to work up for a PE (pulmonary embolism) is probably our biggest conundrum. A lot of people will get a little bit of a troponin bump just from probably that hypoxic constraint on the heart so that can be a little tricky to figure out who needs to go get a cardiac work up.
What does a classic HAPE patient look like?
Dr. Jack Gervais:A healthy 26-year-old male who’s got the classic story of progressive increase in shortness of breath, feel like there’s fluid in their lungs, a raspy cough, a little pink sputum, and their sat’s 65% and they get better pretty quickly on oxygen.
What is the typical treatment for HAPE?
Dr. Jack Gervais:The treatment for HAPE patients is to put them on high flow oxygen, around 15 liters. So, with HAPE, patients get inflammation and acute pulmonary hypertension which causes fluid buildup in the lungs. So, oxygen is really good at reversing that. We oxygenate the lungs which opens up those blood vessels, reduces the pulmonary hypertension, and that fluid can start to resorb in the lungs.
The typical HAPE patient is in the emergency department for 1-3 hours depending on how bad they were and how they’re doing on the high flow oxygen. We wean them down, with a goal of getting them on a nasal cannula with 3-4 liters of O2, which is what the O2 concentrators and portable O2 tanks can manage. And if we can keep someone above 90% on 3-4L they go home with an oxygen prescription. I tell those people to be on oxygen for 24 hours and to just rest and see how it goes, see how you feel. If you start feeling bad again you should be on oxygen. Rarely we see patients come back in because they aren’t doing well, and those people who do, we tell them, “OK you’re out, time to go down to Denver until your plane leaves”.
Are there any medications you use to treat high altitude illnesses?
Dr. Jack Gervais:I don’t tend to use a lot of other medicines. If the oxygen works, why bother adding a bunch of side effects from medications. Some providers tend to be a lot more into giving nifedipine, a calcium channel blocker, which does reduce pulmonary hypertension. A lot of them will use dexamethasone, but it doesn’t so much help with the respiratory component it tends to help more with the headache aspect, but the oxygen will often fix that too. Dexamethasone is also the temporizing treatment for HACE, but they need to descend immediately. People will use Acetazolamide (Diamox), but it’s really only effective if you start it 2-3 days before you come up to the higher elevation. Starting it after you’ve already got acute mountain sickness is probably worthless and it’s got some funky side effects that makes anything carbonated taste weird and it’s a diuretic so you’re adding dehydration to someone who’s already a little dehydrated.
I tend to be more of a minimalist, so I treat the symptoms and give oxygen if they need it and pretty much leave it at that. I was just listening to a podcast talking about inhaled vasodilators. Inhaled/nebulized nitroglycerin — it goes directly to the pulmonary vessels as a vasodilator, but you don’t get the systemic vasodilation that you would with nifedipine or oral nitroglycerin. This was talking more for acute exacerbations of chronic pulmonary hypertension among other things, but I have to wonder if that would work for our patients.
I know you mentioned ibuprofen, but are there any other over-the-counter options you might suggest someone try for AMS?
Dr. Jack Gervais:There are a whole bunch of supplements and stuff that claim to help with altitude sickness, they’re just not studied in any real scientific way to know for sure. For me it’s really just treating the symptoms, so I usually use Zofran for the nausea or Phenergan if there’s a contraindication, and then alternating Tylenol and ibuprofen and oxygen if needed. So, nothing else as far as a preventative that I’m aware of. If you kind of get into the naturopathic realm there’s probably a whole bunch of suggestions out there.
Everyone fixates on staying hydrated which is important. You’re losing extra fluid and if you’re used to living in Florida, you’re going to lose A LOT of fluid when you come up to higher elevation because of the dry air. I tell most people to try and double what you would drink at home. Hydration is really most effective with the headache part of it. It doesn’t change whether you’re going to get HAPE or not.
Oh, and the little oxygen cans you see in the convenience stores … those are garbage! For oxygen to be effective it needs to be on continuously. Even if you puffed on that thing for a minute and could get your O2 saturation up from 85% to 90% it’s going to drop right back down. In the hospital, if you turn the oxygen off, their saturation will be back where it was within minutes, so yeah, those things are just a total waste of money.
What has been your experience with COVID-19?
Dr. Jack Gervais:Luckily, we have had it much better off than places like New York, LA, and even down in Denver. I think that part of it is that overall, we have a pretty healthy population compared to a lot of the bigger city areas and suburbs. There have been some studies out there suggesting that people living in higher elevations do better with COVID than lower elevations and I don’t know if it’s just ’cause your body and your pulmonary system has adapted in some way that helps you deal with COVID, but we’ve certainly had some perfectly healthy local folks get pretty sick from it.
When the tourists were gone back in March/April/May it was great because everyone is local and if you had respiratory symptoms it was probably COVID. Now that the tourists are coming back, it’s a lot harder to tell clinically, and the other thing is the x-ray in HAPE and the x-ray in COVID look very much the same.
We had one patient in particular who came in and said, “I got here yesterday, had a positive COVID test 14 days ago,” and of course they thought they were fine to come up to the mountains, and sure enough they were short of breath. The people who are foolishly traveling either with active COVID or on the tail end of it do not adapt very well when they get up to this elevation, but most of them just need some oxygen.
We finally have rapid tests at the hospital, so it makes it much easier to kind of tell people “this is just altitude” or “this is altitude plus COVID” or “this is straight-up COVID”. In the summer when we didn’t have a rapid test, we’d get these people who have the overlapping symptoms that could be either. It’s tough to tell them what they should do as far as self-quarantine and isolation. Can you travel? Can you go try to ski tomorrow because it was just altitude sickness?
The treatment for COVID ends up being the same: oxygen if you need it and then actually dexamethasone has shown to be effective for patients with COVID who are requiring oxygen.
Even before COVID we would send patients home on oxygen with pneumonia or URI symptoms fairly routinely, which is really not a thing in other places. If you need oxygen with pneumonia in Portland, ME you’re getting admitted. If I called Dr. Chris and said I’ve got a kid of yours who looks like they’ve got bronchiolitis or a URI or even COVID, their sat’s 85% — the answer is almost always going to be “oh, put them on oxygen and if they are OK on a reasonable amount of oxygen they’re probably OK to go home”.
Do you admit COVID patients to the hospital up here if needed?
Dr. Jack Gervais:It’s been really tricky for us to figure out who we can reasonably admit here versus transfer to Denver. Both need to have a higher level of care and be at lower elevation. We have kept COIVID patients here successfully. The thing is, even if you live up here and are used to the altitude you’ve got a respiratory process and you’re hypoxic as a result, it makes sense that you would probably do better down in Denver and probably have less of an oxygen requirement and hopefully not progress to high flow oxygen. You can get someone on high flow here but then they’re stuck here until they get better or they get intubated to be transferred.
What is the most memorable case that you have seen in the ER related to high altitude?
Dr. Jack Gervais:So, I had a professional snowboarder who had gone back to sea level for the summer and then flew back out here and had a shoulder surgery in Vail and was staying in Summit County. He was a day or two post-op and had probably been back in the mountains for three or four days so kind of fit the time frame to develop altitude sickness, and he’s probably on a muscle relaxant, some opiates, some respiratory depressants. So, this is the very end of the night shift, I had a STEMI going on in the other room and this guy comes in at 84-85%. He didn’t look super sick but needed some oxygen. I’m like, “oh, he probably took too much oxycodone,” and so I throw him on some oxygen while I go back and deal with this STEMI.
I go back, and he wasn’t any better! He was still at like 86% on high flow oxygen. So, we got a chest x-ray and he had a little bit of fluid here and there, so it looks like probably early HAPE, or potentially pneumonia, but fit with more of an altitude issue exacerbated by his post-op care. So, we put him on Bipap and he’s not getting any better and now he’s low 80s on Bipap, so we intubate him.
Now he’s getting worse and now he’s dropping his blood pressure. This is over probably an hour, so this guy is sick, and we could not get him oxygenated even on max vent support. We were begging him, and I thought he was going to just die right in front of me. Finally, he dropped his blood pressure more and we’re like “well, maybe he’s septic, maybe he aspirated, and this is pneumonia.” So, we give him norepinephrine, which is a vasopressor, it constricts all the blood vessels to help increase the blood pressure and adds ionotropic support to make the heartbeat stronger. Then his blood pressure finally got better, and his oxygen got better, and he went down to the ICU in Denver and I’m like, “thank God I didn’t kill this guy at the end of a 13 hour night shift”.
So, it turns out — and this is what makes it the most interesting — he had a PFO, patent foramen ovale — so, a hole in his heart. It’s very common, but people tend to not notice because in general, the pressure in the left side of your heart outweighs the pressure in your right significantly so that patent foramen ovale stays closed against the septum.
Like I was saying earlier, HAPE is caused by acute pulmonary hypertension which then raises the pressures on the right side of your heart. So, he blew open his PFO and now had a right to left shunt — so blood from the right side of the heart doesn’t go up through the lungs and oxygenate, it goes straight to the left and goes back out into the body unoxygenated. That’s why everything we did made him worse. When you put someone on Bipap, and especially when you intubate them, you’ve got that positive pressure that increases the intrathoracic pressure, which increases the preload on the heart.
Dr. Chris Ebert-Santos:30% of the population may have PFO!
Dr. Jack Gervais:Coincidentally, the norepinephrine that I put him on trying to treat as sepsis increased the after load — the arterial resistance, which then increased the pressure on the left side of the heart enough that it was able to squeeze his PFO back down.
Dr. Chris Ebert-Santos:The ironic thing is that it’s so random! All of this altitude stuff is SO random, even people who have had AMS or HAPE or whatever they may never get again. I mean 90% probably never have a recurrence.
Dr. Jack Gervais:Yeah people get really frustrated and say “I’ve been here 10 times before, it can’t be altitude sickness” — that can happen, and it does. People have this myth of like, “I used to live here, I’m fine,” and it’s absolutely false.
Another interesting thing you see at altitude is people with sickle cell trait (so not full-blown sickle cell disease, generally thought to be a harmless and completely asymptomatic condition) will get splenic infarcts when they come up. You almost can’t even find reports of it in the literature, but I probably see 8 or 10 a year. It’s kind of easy to pin down, the person is like, “I just got here, I’ve got this left upper quadrant pain, no trauma” — not much in your left upper quadrant, so most of the time the minute they hit triage you know what’s going on. We treat just like you would any sickle cell crisis: fluids, pain medicine, oxygen.
I know you mentioned the myth about people who have lived here before believing they aren’t able to get mountain sickness, but do you have any other myths that you frequently have to clarify?
Dr. Jack Gervais:The big one we run into is people who are taking acetazolamide wrong and are surprised that they’re having altitude sickness. People start getting symptoms and they call their doctor and they may prescribe it too late and I just tell them, “don’t bother”.
People who think they’ve got an infection or bronchitis so their doctor back home calls in antibiotics, which they don’t need even if it is bronchitis. Or the people who ignore it for 2-4 days to assume it’s the bronchitis and say “the antibiotics aren’t working, doctor what’s wrong?” Well, your lungs are filling up with fluid! The good news is HAPE tends to be gradually progressive over hours to days, not minutes. Very rarely we see patients who are really actively dying from HAPE. In 10 years I have probably seen hundreds if not 1,000 HAPE patients and I’ve only probably had 2-3 who were really, really hard to fix. Probably 10-20 that I’ve had to put on Bipap and transfer down. I think I’ve maybe only intubated 1-2. People get in trouble if they’re up high — 20,000 feet on Mount Everest, don’t have oxygen, that’s where you’d end up dying with HAPE.
Dr. Chris Ebert-Santos:And how many die at home?
Dr. Jack Gervais:I would say a handful. I’ve had at least one lady who was camping. Had HAPE-like symptoms and came in dying, she was the one I intubated, and she actually lived. I had a guy camping last summer who sounded like (from what his mom described) altitude-related symptoms, although he was just up from the Front Range. I don’t know what they ever found on him, but he was dead when the paramedics got to him. I would say it’s a handful, but not dozens a year.
Thank you for your time Dr. Gervais. Is there anything more you would like to share about high altitude medicine?
Dr. Jack Gervais:I would say probably anybody with any serious cardiac or pulmonary comorbidities who is going to vacation here should really be on oxygen at least at night. That would prevent a huge number of these problems. I actually see a lot of people (locals) who sleep on oxygen at night even if they’re 40 and healthy and don’t really have any issues and they just sleep much better.
And the other thing is you know, especially the people who have lived up in Leadville for 60 years tend to develop a gradually progressive chronic pulmonary hypertension which adds to blood pressure management issues and so that’s an issue we definitely see. So I tell anybody who has any sort of symptoms and is going to be here for a while, “just buy yourself a (oxygen) concentrator, keep it at your house,” that way when they come up for a week vacation every winter they’ve got it and just sleep with O2 every night and avoid all the hassle. And don’t bring your blood pressure cuff on vacation!!
There’s a cardiologist who works over in Vail, he was really convinced that living at altitude is really bad for your chronic blood pressure issues.
Dr. Chris Ebert-Santos:Our interview with three other high-altitude physicians in primary care and cardiology say their standard is “if you’re 50 and you’ve lived here 10 years and you want to live here for another 10 years you should be sleeping on oxygen.”
Rachel Mader is a second-year physician assistant student at Red Rocks Community College. She was born and raised in Colorado Springs and attended Colorado State University where she graduated with a bachelor’s in biology. Before starting PA school, Rachel worked as a Physical Therapy Aide at CSU Health and Medical Center, a CNA at a nursing home, and a Clinical Assistant at Children’s Hospital in Colorado Springs. In her spare time she enjoys spending time with her family, friends, and pets, and eating at new restaurants.
“I’ve been here 25 years,” Sinclair shares with me over coffee at the Red Buffalo in Silverthorne, Colorado (9035’/2754 m). “Born and raised on the East Coast in Philadelphia.” The software company he had been working for moved him out to Colorado Springs. He hadn’t ever skied in his life until then. Shortly after, “on a whim”, he moved up to Summit County and started working on the mountain as what we used to call “Slope Watch”, the mountain staff often in yellow uniforms monitoring safe skiing and riding on the mountain. After a month, he got really bored, “and I said, ‘How do I get to be a patroller?'”
Sinclair then went to paramedic school to get qualified as an Emergency Medical Technician, then spent 19 years as an EMT and 9 years as a Medic. For the last six years, he’s worked for the ambulance service in Summit County, one of Colorado’s highest counties, with towns at above 9000′. He has also worked as a ski patroller at Copper Mountain, Keystone, and Park City (Utah). This year is the first he hasn’t been patrolling in 18 years. During the summer, he is a wildland fire medic, where he often works with crews that are shipped in from lower elevations, including sea level.
Although he’s decided to take this season off, he still maintains a very active relationship with the outdoors, travelling around the backcountry on expeditions to remote mountain cabins, and has made a recent trip to Taos, New Mexico (6969’/2124 m). He’s witnessed his share of altitude complications.
What are the most common altitude-related complications you see?
You see the families coming up to go skiing … Usually 90% of them are fine. Altitude doesn’t seem to bother them at all – they’re either healthy enough or lucky enough. They get in, they ski, they get out. But there’s that one family or that one couple that just don’t acclimatize. They don’t realize that they don’t acclimatize, and the rest of their group doesn’t realize. A couple of days go by and they think, ‘Geez, I feel awful,’ then they go ski, or do something active, and their condition is exacerbated. Or ‘Geez, I haven’t slept,’. you get that story over and over.
And you’re having this conversation on the hill as a patroller?
Or they’ve called 911 on their way [up to the mountains]. They have no idea. Just no idea. I ask them what they’d had to eat. They had a donut or a pastry or just coffee before the plane ride. I ask themwhen was the last time they peed. You’re trying to find the physiology of what’s happened.
I tell them, ‘You need to sit down or go back to your condo. You need liters of water. You need liters of Gatorade. No fried foods, no alcohol, no coffee. No marijuana. Let your body catch up. Wherever you’re staying, tell them you need a humidifier. Put it in every bedroom, crank it up and leave it on. You’re gonna have trouble sleeping.’
And they never wanna hear it. They never wanna take a day off, but by the time you see them, they’ve taken the day off anyway, because there’s no way they’re getting back up there!
Sinclair also expresses some frustration with the lack of resources provided by the ski industry itself:
How do you educate them? The marketing people don’t want to. Because if they have to spend a day in Denver [to acclimate], that’s one less day up here [at the ski resort]. They don’t want to publicize that [altitude sickness] can happen, that it’s common. People ask, ‘How often does this happen?’ Easily, at any resort in a day, Patrol probably sees 20 – 25 people, whether they called, they walked in, you skied by them and started talking to them. ‘You’re dehydrated. You’re at altitude. It means this …’ The resorts don’t want that many to know, otherwise, you’re gonna go to Utah or California, where it’s lower.
You get such misinformation. ‘At 5000 ft., you have 30% less oxygen.’ No, the partial pressure is less, there is still 21% O2 in the air. You just have to work harder to get the same volume. The real physiology of what’s going on is systemic. [People experiencing altitude sickness] don’t know why they feel like crap. They think it’s because they’ve been drinking too hard.
How do you mitigate their symptoms on the mountain?
We do a lot, but it’s reactive, not proactive. I hate to bash the oxygen canisters, but it’s not doing anything for you. It’s not gonna make you feel better, other than what you’re sucking up. At 10,000′, it’s questionable. We’ll be at the top of Copper [Mountain] giving them two to four liters of oxygen, then they’ll ski down and feel great.
Sinclair refers to the Summit County Stress Test, which was the first I’d heard of it:
You’re 55, you’re 40 – 50 lbs. overweight, and you come up for your daughter’s wedding. You walk over to Keystone [Ski Resort], you take the gondola over, then all of a sudden, you find out you have a heart condition. You find out whatever else you have going on. We’ve done it over and over and over. They go ski, they call us at 3 in the morning, we find out they’ve got a cardiac issue, or they’ve irritated the pulmonary embolism they’ve had for years.
I had a guy last year, at the Stube at Keystone for lunch.
Keystone’s Alpenglow Stube is a reputable restaurant that sits in the resort’s backcountry at 11,444′ (3488 m).
He had some food, alcohol, he’s having a great day. Ski patrol gets a call, ‘Hey, my husband doesn’t feel well.’ This guy looks bad, sitting on the couch, sweating profusely, and he can hardly tell what’s going on. It’s the classic presentation of an inferior heart attack.
‘I don’t have any heart conditions. I saw my cardiologist.’ You saw a cardiologist, but you don’t have any heart conditions?!
And there are a lot we don’t see. People who go home because they think they have the flu.
Have you seen any rare or surprising complications?
We see HAPE (High Altitude Pulmonary Edema) now and again. That seems to be a walk into the hospital where [their blood oxygen saturation is] at 50 – 52. We’re not in the zone to see HACE (High Altitude Cerebral Edema). We’re just not at the altitude.
HACE is more typical above more extreme elevations, above 11,000′. Colorado’s highest peaks are just above 14,000′. Most ski resorts in Colorado are below 12,000′.
I’ve only seen one HAPE case on the hill. In their 50s. You listen to their lungs, and they’re getting wonky. A guy who was reasonably fit, but you look at him and go, ‘Hm, this is bad.’ But he was responsive and talking. Then you start seeing the things like the swaying, getting focused on something else [in the distance]. One of those [situations] where you’re like, ‘Let’s get out of here.’ [We need] tons of oxygen. Again, ‘I didn’t feel good yesterday, but I decided to go skiing today.’ He was sitting at the restaurant at the top of Copper [Mountain].
People do not realize that their diabetes, their asthma, their high blood pressure, things that they commonly manage at home, are exacerbated at 9000′. By the time they realize it, they’re calling 911. At that point, your best bet is to get out of here.
What tools or instruments do you use the most as a paramedic and ski patroller?
Cardiac monitor. It’s got a pulse oximeter. [Also] simple things you ask. ‘Hey, do you know what your blood pressure is?’ I use a stethoscope all the time. Sight and sound. Are they talking to me? Are they having a conversation with me? Are they distracted by what’s happening to them? When was the last time they peed? Was it regular color? Did it smell stronger than usual?
People ask, ‘How much water do I need?’ How much water do you drink in a day? If I’m outside and I’m moving, I probably have 10 liters. If I’m on a roof laying shingles, I probably have 4 or 5 liters before lunch. It’s those little tools. You don’t even have to touch somebody.
Do you have any personal recommendations for facilitating acclimatization at altitude?
Workout, be in shape, go harder than you normally do that month before you get here. Get the cardiovascular system more efficient before you get here. If you have any kind of medical concerns, make an appointment with your doctor and say you’ll be at 10,000′ to sleep. Just ask, ‘What do I need to do?’ The day before you get on the plane, stop drinking coffee and start drinking water. Hydrate before you get here. They humidifier thing. Make sure the place you’re going has one. Find out. Go to Walmart and spend $15 to buy one.
Watch your diet. Just so your body’s not fighting to get rid of fat and crap.
When we’re getting ready for a hut trip, we are mostly vegetarian (although we do eat meat), but we ramp protein up a week prior, pushing more chicken, more red meat. We tend to eat fish normally, but there’s always at least one fish meal at the hut. We don’t do crappy food at the hut. I don’t care if I have to carry another 10 lbs. In addition to going to the gym, go for a skin, go to 11,000 – 12,000′ for a couple hours. Ramp up the altitude work.
What do you eat on the trail?
Pre-cooked sausage, usually some kind of chicken sausage. Cheese. Whole grain tortillas, and if we’re feeling spunky, some kind of hot sauce or pico [de gallo]. For me, it’s just a handful of nuts and raisins. If I feel like something else, I’ll throw in some chocolate or white chocolate. I hate the packaging, the processed foods, the bars. Somebody usually makes granola for on-the-way-out food. And I tend to carry dried fruits. Lots of peaches during Palisade peach season. I used to take a lot of jerky.
A recent topic that comes up alot in altitude research at our clinic is Aging.
I have to work harder to stay at the same place. I’m sitting here and I can feel my right knee. I was at a 15″ [of snow] day in Taos, and I caught something [skiing]. It’s been weeks, and it’s not weak or anything, but I just know. It takes longer. I find I need more sleep. I was a 4 or 5 hour a day guy for a long time. Now I’m at 7. The days I get 8 are awesome. Luckily enough, I’m still healthy, fit. If I’m up at night, it doesn’t shatter my day. Haven’t slept on oxygen yet. Don’t want to find out.
He laughs.
As I get older, I’m adding more supplements: fish oil, glucosamine, glutine (for eye health). My eyes are bad anyway, and I’m constantly standing outside against a big, white mirror (the snow). And I’m cautious of the bill of a hat vs. a full-on brim during the summer. Other than my face, everything’s covered during the winter. The color of the bill on your hat can be way more reflective. A black bill will cut the reflection. Little things.
I’ve rounded out my workouts. They’re more whole-body. I concentrate on cardio. I’m conscious that I’m not as flexible as I was. I’d like to say we’re regularly going to yoga, but at least we’re going.
The gauge for me is you go on a hut trip with our friends in the middle-age category, but we’ll take some younger folks [too]. I kinda monitor who’s doing what – chopping firewood, who’s sitting more than who. It’s not out of pride. I need to realize.
I’m colder. You start to notice. It’s not that your feet are cold, it’s that your calves are cold. I succumbed to boot heaters a few years ago.
Year after year, in every season, visitors from all over the state and all over the world come to Colorado’s high country. For many of them, it’s the highest elevation they’ve ever visited, and often ever will. The dryness, the elevation, the air pressure, the intense sun exposure and the lack of oxygen demand a lot of compensation from the body. Sinclair’s experiences at altitude are consistent across every conversation I’ve had with physicians, athletes and other professionals when it comes to preparing your body to be active at altitude, from getting plenty of water to controlling the speed of your ascent to any elevation above 7000′ to consulting with a specialist regarding any pre-existing cardiac or respiratory conditions to how much oxygen one needs to mitigate symptoms of altitude sickness to decreasing elevation in case of an emergency. Any one of these experts will also tell you that the best ways to prepare your body for altitude is to get plenty of sleep, exercise regularly, and limit foods containing a lot of oil, grease and fat that will demand more from your body.
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.
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.**
We’ve published a series of accounts from Dr. Chris’s recent attendance at the 7th Annual Chronic Hypoxia conference in La Paz, Bolivia , conducted by Dr. Gustavo Zubieta-Castillo. He is one of the world’s leading experts of altitude medicine and Dr. Chris’s collaboration and contact with him has added literally phenomenal insight into our own high altitude research.
Dr. Chris “en Teleférico” with fellow altitude researchers Vanessa Moncada, Diana Alcantara Zapata, Dzhunusova G. S., Oscar Murillo, and Alex Murillo. Photo courtesty of Dr. Zubieta-Castillo.
There is something literarily romantic about the scientists who are compelled to remind you, “I’m not crazy!” Dr. Zubieta-Castillo has held soccer games at 6,542 m (21,463′), proving the remarkable adaptability of the human body. He maintains a high altitude training lab, called the Chacaltaya Pyramid, at 5,250 m (17,224′). In his recent video (below), he illustrates the connection between longevity and elevation, where citizens of the highest cities in South America live to be well over 100.
It’s notable that a city known for its wine at 2,790 m (9,153′), called Chuquisaca, boasts some of the oldest residents. Not surprisingly, our research has led us to some speculation on the relationship between alcohol and the body at altitude. Additionally affirming is Dr. Zubieta-Castillo’s father, nicknamed “El Guru de la Montaña”, who began his legacy of altitude research and medicine by examining the hearts of dogs at altitude (sound familiar? See our article on Dogs at Altitude), as well as Dr. Zubieta-Castillo’s own testament that asthma can be and has been treated by altitude (see Asthma at Altitude).
His latest correspondence with Dr. Chris and their mutual colleagues reads like letters written by history’s greatest scientists, beginning,
Dear Colleague Scientists:
The 7th Chronic Hypoxia Symposium, thanks to your outstanding participation was a great success !! We shared great scientific, friendship and enthusiasm from 16 countries, along with travel and conferences in fascinating environments, all at high altitude.
The letter ends with an invitation to all colleagues to contribute their own research to the first chronic hypoxia-dedicated issue in a top medical journal, so be on the lookout for Dr. Chris’s contribution (which we will be sure to share here).
The video below is a fascinating look into some of Dr. Zubieta-Castillo’s latest research, including his theories and recommendations on conditioning humans in space with hypoxia, a dissertation that was initially dismissed as irrelevant, then subsequently published. Enjoy!
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.
We’ve learned a lot in the high country this season! For example, it isn’t too late or too warm for a snowstorm. We’ve conducted several interviews with professional, high-altitude athletes, athletic and tourism organizations in Summit County, physicians, podcasters, interns, and a local brewer. They’ve shed so much light on fitness, health, child growth & development, and acclimation at elevation, it warrants a re-cap:
8,000 ft. seems to be the pivotal elevation at which the body starts to experience a significant deficit in the oxygen and water it needs to function, affecting everything from sleep to metabolism.
A plant-based lifestyle has benefitted athletes under extreme training and competitive conditions at altitude.
Training at altitude significantly reduces your ability to reach cardiovascular and strength goals, even while preparing your respiratory and circulatory systems for the severe decrease in oxygen. “Live High, Train Low” is an effective strategy more and more athletes are advocating for.
Preparation for backcountry excursions is as much mental as physical.
Foods high in nitrates (like red beets, red bell peppers and arugula) can facilitate acclimation and recovery.
Oily foods may inhibit your body’s ability to cope with a significant increase in altitude.
We metabolize and experience the effects of alcohol differently at altitude.
Current research suggests some people suffering from Parkinsons disease may experience some relieve from symptoms at higher elevation.
Increased muscle mass requires increased oxygen. Being an athlete does not necessarily mean you will have an easier time acclimating.
As always, the best way to facilitate acclimation and deal with symptoms of altitude sickness is to drink plenty of water, allow yourself ample rest, and monitor your blood oxygen saturation levels with a pulse oximeter.
Be sure to subscribe to keep up with what this summer has in store for your elevated experiences at altitude! And if you have any questions or are eager to read more about a particular topic, let us know in a comment!
