Category Archives: Exposure

Nail Abnormalities at High Altitude

With summer just around the corner, more people will be hitting the mountains for some high altitude hikes and 14ers. There have been numerous anecdotal findings of mountaineers with changes to their fingernails after ascending the world’s tallest peaks, with the most common abnormalities being Mees’ lines, Muehrcke’s lines, and Beau’s lines. While the peaks in Colorado do not compare to those of the Himalayas, there is always a chance, albeit very low, that you may notice some changes to your nails after a high altitude expedition.

Both Mees’ lines and Muehrcke’s lines are types of leukonychia, which means “white nails”. Mees’ lines present as a single horizontal white band, sometimes multiple, located in the nail plate and are non-blanching. Throughout history, Mees’ lines have been associated with drug toxicity, such as from arsenic or thallium.4 Additionally, there are many systemic diseases that have been associated with Mees’ lines in which the body is experiencing high amounts of stress, such as with myocardial infarction, sickle cell crisis, and tuberculosis.4

Mee’s lines

One case report, “Mees’ lines in high altitude mountaineering”,  by Avinash Aujayeb details how a 27-year old man developed Mees’ lines after he traversed high altitudes in the Pakistani Karakorum range, attempting to scale a summit of 7031 meters.1 He acclimated to altitude at a camp located at 4000 meters,  and stayed for a total of 21 days. No medications were used for acclimatization. In his attempt to reach the summit, he became extremely fatigued and hypothermic, and turned around at 6900 meters. Upon return to sea level, he lost about 17 pounds of weight. Six weeks after his expedition, he developed non-blanching horizontal white lines on his nails, consistent with Mees’ lines. The lines eventually moved distally and completely disappeared. While the paper does not go on to hypothesize the cause of this man’s development of Mees’ lines, it seems reasonable that they appeared due to the stress the man endured as evidenced by his need to turn around early from fatigue and hypothermia, and likely hypoxia given the extreme altitude.

Muehrcke’s lines present as a pair of horizontal white bands located in the nailbed, the skin beneath the nail plate, making them blanchable (unlike Mee’s lines which are located within the nail itself). Muehrcke’s lines usually present on the 2nd, 3rd and 4th fingers, and typically spare the thumb. Historically, these lines are most associated with hypoalbuminemia as seen in a protein-losing condition of the kidney called nephrotic syndrome.4 They have also been found in disease states of systemic immunosuppression, such as in HIV, where the metabolism of the body is stressed and has decreased ability to make proteins. 4

Muehrcke’s lines

The discovery of Muehrcke’s lines was first published in the British Medical Journal in 1956 by Robert C. Muehrcke.4  In the paper, he details a study in which he compared 750 adult patients and healthy volunteers who had normal serum albumin against 65 patients known to have chronic hypoalbuminemia.  He saw that the pair of white horizontal lines were only in those with the chronic hypoalbuminemia, most specifically those with a serum albumin below 2.2 g/dL.4 Once these patients were treated and their albumin concentrations increased, the lines disappeared after a few weeks. He thought the findings suggested that Muehrcke’s lines were from an albumin deficiency due to poor nutrition.

In a letter to the editor of High Altitude Medicine and Biology, authors Windsor, Hart, and Rodway describe the presence of Muehrcke’s lines on Mount Everest after a 38 year old with no significant medical history noticed their appearance a few weeks after he had returned to sea level.3 There were two parallel horizontal lines under the nails of his 2nd, 3rd, 4th, and 5th digits, sparing the overlying nail. They believe the development of these nail findings were indeed from hypoalbuminemia , however do not believe it was from a nutritional deficiency as Muehrcke first described, because the climber had been healthy throughout his expedition and he maintained good nutrition.3 They attribute the findings to peripheral edema, which is a common finding in high altitude mountaineers. With this edema, fluid levels in the tissues increase. The authors believe this may have inhibited the growth of the nailbed, which then resumed with return to sea level.

Another nail finding from high altitude mountaineering is called Beau’s lines, which are an indented groove across the span of the nail horizontally, beginning at the base of the lunula. The lines result when nail formation is temporarily halted during episodes of stress, and usually present several weeks after the stressful incident.2 They are generally caused by local trauma to the nail, extreme temperatures, and toxicity from chemotherapy.4

Beau’s lines

There was a prospective study completed by authors Bellis and Nickol in High Altitude Medicine and Biology where the study participants were completing a research expedition in eastern Nepal in April and May of 2003.2 The maximum altitude reached varied from 5,142 to 6,476 meters and the length of stay of each individual also varied. The study found Beau’s lines developed in 1 out of 56 participants at 4 weeks, however by 8 weeks, 17 out of the 52 (or 33%) developed Beau’s lines. The authors hypothesized that the changes were possibly due to the hypoxic as well as hypobaric environment which could diminish the activity of the nail matrix. However, they did acknowledge the fact that there were other factors that could have resulted in the Beau’s lines, such as extreme cold conditions and possible injuries to the fingers due to the nature of the work of the researchers. No participants reported frostbite or any damage to the hand, however at night temperatures dropped as low as negative 20 degrees Celsius.

Clubbed fingers

These nail abnormaltities are less likely to be found during expeditions within the United States unless hiking in Alaska, which has Denali, the tallest peak in the US at 20,310 meters. Outside of Alaska, the tallest peak is Mount Whitney in California, which pales in comparison at 14,505 meters. Most of the case reports completed on these nail findings were from several week-long expeditions in the Himalayas. However, condition you may already be aware of is clubbing of the fingers. This presents as a bulbous enlargement of the fingertips caused by chronic hypoxia. During my five-week visit here, I have anecdotally heard from two different Summit County residents that they have many healthy and young friends with clubbed fingers. Unfortunately, I was unable to find any research on the prevalence of clubbed fingers among individuals living at high elevations, but I believe it is something that deserves to be looked into deeper. 

References

  1. Aujayeb, A. (2019). Mees’ lines in high altitude mountaineering. BMJ Case Reports, 12(3), 1. doi:10.1136/bcr-2019-229644
  • Bellis, F., & Nickol, A. (2005). Everest Nails: A prospective study on the incidence OF Beau’s lines after time spent at high altitude. High Altitude Medicine & Biology, 6(2), 178-180. doi:10.1089/ham.2005.6.178
  • Windsor, J. S., Hart, N., & Rodway, G. W. (2009). Muehrcke’s lines on Mt. Everest. High Altitude Medicine & Biology,10(1), 87-88. doi:10.1089/ham.2008.1079
  • Zaiac, M. N., & Walker, A. (2013). Nail abnormalities associated with systemic pathologies. Clinics in Dermatology,31(5), 627-649. doi:10.1016/j.clindermatol.2013.06.018

Makenna Schmidgall is a second-year physician assistant student at the Midwestern University Physician Assistant Program in Glendale, Arizona. She grew up in Gilbert, AZ, but left her desert home to attend New York University in the Big Apple where she earned a bachelor’s degree in Global Public Health/Biology. During her junior year of college, she began working as an ER scribe in multiple emergency departments of the Mount Sinai Health System in New York, NY. She enjoys gardening, hiking and playing with her new Labrador retriever puppy “Piper”.  

Doc Talk: ALTITUDE AND THE EYES, AN INTERVIEW WITH DR. PAUL COOK, OD

Have you ever wondered why a bag of chips will swell almost to the point of bursting when you travel from a lower elevation?  As the altitude increases  the barometric pressure decreases. The difference between the high pressure inside the bag and the low pressure outside causes the bag to swell (and sometimes burst) to reach equilibrium with the surrounding environment.

The same concept applies to our biological tissue, including our eyes. Luckily there is not normally gas in our eyes, but there are procedures where air bubbles are injected into the eye, such as a vitrectomy: part of the vitreous humor of the eye is replaced with air so that a nearby site has the chance to heal. Common indications include a retinal detachment, macular hole or removal of scar tissue. It’s important to remain at the elevation your ophthalmologist or optometrist indicates because you don’t want your eye to suffer the same fate as a bag of chips!

This was one of many interesting things I learned while speaking with D. Paul Cook, OD and his wife and practice manager Karen Cook at Summit Eye Center on Main Street in beautiful Frisco, CO. The following is my interview with Dr. Cook, Karen Cook, and my preceptor Christine Ebert-Santos, MD, MPS.

How many years have you been practicing optometry in Frisco, CO?

I don’t recall the exact year, but I remember it was the year the Broncos lost the Superbowl.

Dr. Paul Cook at the entrance of Summit Eye Center.

I did a little research and this must have been either the 1986 or 1987 season, as the Broncos lost both of those Superbowls. Fortunately, those Superbowl losses were not a bad omen as Dr. Cook has successfully served the Frisco area every year since.

What conditions do you see commonly here at altitude?

One thing I see commonly here is recurrent corneal abrasions. The classic patient lives at a lower altitude and previously had a corneal abrasion. They received treatment but the abrasion site never completely heals. After arrival in the high country where it’s extremely dry that abrasion site dries up and becomes inflamed.

Usually what I do is give a bandage contact lens to cover up that recurrent corneal abrasion, which usually works, but if it’s extremely painful, we can use amniotic membrane, which is expensive. But it is effective.

The cornea is the outermost layer of the eye (if you don’t count the tear film). A corneal abrasion occurs when any foreign object scrapes the corneal surface. Symptoms include a foreign body sensation, pain, clear discharge, blurry vision and sensitivity to light. A corneal abrasion needs a healthy, moist environment in order to heal. You can see how the dryness that comes along with altitude could lead to a recurrent corneal abrasion.

I also see a fair amount of snow blindness, usually in the spring though.

I suppose it has to do with the sun being higher in the sky and people being out and about hiking. When people are out skiing in the cold winter they wear their goggles, but if it’s spring time and somebody’s hiking they might forget their glasses.

Snow blindness is only one potential cause of a disease called photokeratitis. Other causes are staring at the sun, looking at an arc welder, or catching too many refracted UV rays from surfaces such as sun, water, ice and snow. The pathophysiology for each disease is the same: too many UV rays are focused onto the cornea at one time which causes damage. Symptoms include pain, redness, blurriness, sensitivity to bright light, headache, and occasionally temporary vision loss. Treatment for photokeratitis caused by snow blindness is supportive, but the most important thing is resting your eyes. Try to get into a dark room and avoid anything that makes your eyes uncomfortable. In a few days your cornea should heal.

Prevention  is straightforward: wear sunglasses or ski goggles with adequate sun protection.

Are cataracts a more common condition at altitude?

Oh yes, because of sun exposure and our aging population here. The people of Summit County are so active, which increases their exposure to the damaging rays of the sun. We’re also treating cataracts so much sooner than we used to, so that’s part of what makes it more common.

Do you have any recommendations for healthy aging at altitude as it relates to the eyes?

Karen: Getting your annual eye exam. We always tell patients there are a lot of things we can do to preserve your vision, there’s almost nothing we can do to give it back to you.

So if you live in Frisco, CO and don’t have an optometrist, make sure to see Dr. Paul Cook!

Is blurry vision a common malady in patients that have recently received a LASIK procedure and then ascended to higher elevations?

I have not seen that with LASIK. About 30 years ago though there was a procedure called Radial Keratotomy (RK) that involved a surgeon making radial cuts on the cornea in order to correct nearsightedness. Those patients used to require one pair of glasses for where they lived at lower elevation and one pair of glasses at higher elevation. It’s not a procedure commonly done nowadays but patients that had RK roughly 30 years ago may have that problem.

LASIK stands for Laser Assisted In Situ Keratomileusis. It essentially means that the surgeon will use a laser to reshape the cornea so that the light refracting through it will be appropriately concentrated on the retina. LASIK is faster, cheaper, safer and more effective than RK. It has largely usurped RK for surgical treatment of nearsightedness or farsightedness.

What are some interesting cases you have seen over your years of practice?

I treated a patient that traveled from the Midwest and had a genetic condition called retinitis pigmentosa. Clinically that means the patient had limited peripheral vision at baseline.  He and his wife decided to hike the Colorado Trail. Unfortunately during the hike he developed blurred vision and ended up coming into my office. Turns out he had macular edema and I referred him to an ophthalmologist down in Denver because the altitude was probably the cause of his macular swelling. I called him a few weeks later and his vision had returned to normal.

Another  patient came into the office because his wife had noticed growths on his iris that turned out to be nevi (colloquially known as moles when they’re on the skin). So I dilated his eyes and noticed growths on his retina. I referred him down to oncology in Denver for a biopsy and it turned out to be melanoma. I think they’re closely monitoring that melanoma at this point. It’s uncommon to see cancers of the eye but I see them once every few years.

Dr. Cook performing an eye exam on me.

For my last question, do you have any general recommendations for residents or visitors?

Wear sunglasses, eat your vegetables, eat your fish at least two times per week, keep your cholesterol in check, keep your sugars in check, take breaks from looking at the computer, don’t sleep in your contacts, and see your optometrist once per year.

Seth Selby is a second-year physician assistant student at Des Moines University. He was raised in Eaton, CO and attended Colorado State University with a bachelor’s degree in Health and Exercise Science. Prior to PA school, Seth worked for 3 years as a Cardiovascular Technician at Boulder Community Hospital. In his spare time Seth loves backpacking, hunting, fishing, skiing and astronomy.

Paraguay Takes On Colorado’s Fourteeners

After a horrendous Autumn of forest fires in Colorado, we’ve received well over a foot of snow in a series of storms, and it’s safe to say Winter has arrived. Hiking season is never truly over in the Rockies, but Colorado’s famed Fourteeners are now blanketed in snow, increasing the risk of any attempted ascent exponentially. But through the fire and ice, the Summer yielded ample opportunity for at least one enthusiast to check off more of her bucket list adventures.

Since leaving her home in Paraguay, mountaineer and hiking expert Clarissa Acevedo Santos has spent over a decade ascending Colorado and Hawai’i’s highest peaks. In addition to her excursions in the Ko’olau and Kahalawai ranges including Maui’s Haleakalā crater, she has summited well over half the 58 peaks in Colorado over 14,000 feet, making her the first from her country of record to do so.

She was invited on her first Fourteener years ago when friends took her up Quandary outside of Breckenridge, CO, at 14,271′ (4350 m).

“When I hiked that first mountain, it was hard, because I wasn’t used to gaining that much elevation. I didn’t really enjoy it so much because of how cold it was on the summit. Even though I made it to the top, I wasn’t really having fun with not feeling my lips and not feeling my fingers because it was really, really cold. I could barely smile, and we couldn’t even enjoy the summit because of how windy it was!

“After that hike, I didn’t hike for a while, and I got invited again to climb Mt. Elbert in 2012. It was actually much more enjoyable because it was with a big group of college kids from Summit and the weather was just perfect. We were able to summit it and enjoy the day and have lunch up there. So that’s what started to change my mind about hiking Fourteeners because I enjoyed my time up top. That’s when I realized it’s not always difficult to be up there. I think I got what all the hikers call ‘Peak Fever’. So after that is when I feel like I started going non-stop, and I met more friends that were into hiking, and researched more about the mountain before I go.

“I always go with people who knew more about it, so I started learning more with other friends and other hikers. And I started feeling actually great when I got higher. It was always harder to get started close to the beginning [of the trail], just to gain all that elevation. But then when I was getting close to the summit, I just got more energy. I just got more excited to be at the top. That’s the goal. It’s a great feeling.”

Clarissa has an app that she uses to record all her summits called Colorado 14ers that allows her to keep record of and upload photos from every Fourteener she’s hiked. She pulls it up as she recounts year after year of more and more summits, some she’s even done more than once.

There is a class system rating every trail by level of difficulty, Class 1 being the easiest and Class 4 being the most difficult. The most difficult peak Clarissa recounts climbing is Long’s Peak, as well as the most dangerous weather she’s climbed in.

“It was a little bit late to summit it. It was not a good idea. If the rocks got wet, it could be very dangerous. There were people turning around. We decided to wait on a ridge. There were three [of us], and one turned around. He wasn’t feeling good, he was getting tired, he wasn’t used to hiking that many hours.

“We decided to wait for the clouds to go away. After that we just kept going. It did not rain on us, thankfully.”

Clarissa has seen her share of altitude sickness as well. One of her frequent hiking companions repeatedly gets stomachaches and headaches everytime they hike, in spite of being an experienced hiker as well.

“I always ask [one of my friends in particular] if she wants to stop or if she wants something. She normally doesn’t eat before she starts a hike. No breakfast. But I also carry ginger candy … I learned that from other hikers telling me it can help settle your stomach a little bit. It’s everywhere, in all the stores. Now they’ve created gums. I’ve started chewing them on my hikes just in case. You never know. I’ve seen people who hike all the time, and they ate something that didn’t digest well, and they feel sick and get a little dizzy.

“I’ve never experienced any headaches on the way up. The only time I remember having a headache is when I ran out of water. I hiked Oxford and Belford in the Saguache range in the same day. My head hurt and it lasted for that night. Now I take a filter with me so I can fill my [Camelbak] bladder. And I also take electrolytes. And I’ve started hiking with poles more as well, just because you put alot of weight on your knees when you’re hiking down. It’s very smart to start using poles.”

When it comes to preparing such demanding ascents, Clarissa recommends spending some time at an intermediate altitude before hitting the trail, and staying well-hydrated. Caffeine and alcohol the night before doesn’t typically help.

Clarissa with her husband on their way up Mt. Shavano in September 2019.

“It doesn’t matter how fit you are … you can still get really sick. I’ve heard of people who get headaches for several days because [they’re] not used to [the elevation here].”

She also says it’s important that you start any hiking at all to build the strength in your lungs.

“It does hurt,” she says about the stress on your respiratory system. “I remember when I was hiking Quandary, my chest was so pressed, my heart was [beating] so fast, my stomach was feeling weird, like I had to pee or I had to do number two or something. It was such a difficult part of … gaining all that elevation.”

“You’ve gotta find a good pace for yourself. I see many of my friends going really fast ahead of me, then they’re very tired and they have a hard time getting to the top. I’ve waited for many people because they are struggling so much at the end. Take as many breaks as you think [you need]. Carry enough water!

Clarissa keeps seeing a lot of hikers running out of water. “They just bring a tiny plastic bottle. That’s a huge mistake. And bring food, too. You will get hungry after a mountain. It’s so funny how many people are unprepared. If I’m hiking with newbies, I make sure they have everything, and they’re always thankful.”

When it comes to clothes and shoes, Clarissa recommends really good traction. She’s tried some more affordable brands, but says the durability is worth paying more for.

Don’t ever hike in new hiking shoes before you’ve broken them in. Good hiking socks also have more padding at the heels and toes and help prevent blisters. She also will double-up on socks, or even bring an extra pair to help mitigate possible cold.

“I reapply sunscreen on my hikes two to three times. Many times my nose will burn. I always carry sunglasses. You’re so close to the sun, you don’t realize. You don’t want to burn your eyes or your face. Even with the sunglasses, having a hat on top of it doesn’t hurt. Even in the Summer in the mountains, carry additional gloves or layers, because you don’t know what the weather could be. Temperature changes quick.

“I just recently purchased a nice puffy Northface that helped me. I will always have a thin layer underneath because you get hot and cold. You’re gaining elevation, you get hot, then you get cold in the middle …”

When it comes to navigation, Clarissa’s main resource is 14ers.com, which allows you to download offline maps, so you aren’t relying completely on having cell service.

“Even though I have hiked many of them, I want to be sure I’m going the right direction … I just love reading everything I can beforehand. I read about the class, how much exposure, how long it’s going to take, then I download the maps, look at the maps, what kind of road it’s going to be, if my car can make it up higher or if I have to hike longer.”

Clarissa has heard of other Paraguayans hiking around the world, but has never met another one on a Fourteener personally. But she does meet a lot of people from around the world on these ascents who ask if there are mountains in Paraguay. The highest is Cerro Peró at 2762′ (842 m) in this landlocked country known more for its rivers and the hydroelectricity they provide for Paraguay and its neighboring countries, including Brazil and Argentina.

Clarissa says she’s learning more and more each year about mountaineering and advocates learning as much as possible about each ascent before you go. The weather may be different every single time.

Bring the layers, whether you think you’ll need them or not. And leave no trace.

Thank you, Clarissa, for sharing your continuing legacy, and be safe up there!

robert-ebert-santos
Powder ‘stache.

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. Clarissa is his wife who is increasingly a much faster, more experienced mountaineer than he is, but he will occasionally feel ambitious enough to join her on a Fourteener, at the top of which they both enjoy a delicious cider, weather permitting.

Acetazolamide

Typical symptoms of acute mountain sickness (AMS) are headache, loss of appetite, disturbed sleep, nausea, vomiting, fatigue, and dizziness. However, more serious conditions such as high altitude pulmonary edema (HAPE) or cerebral edema (HACE) can present with this illness. Avoiding these unpleasant symptoms while at elevatione is possible through gradual pre-acclimatization when possible (what science recommends!), or there are specific medications that can potentially prevent the development of AMS, such as acetazolamide. This article will address how acetazolamide (also known as Diamox) can help prevent AMS, discuss the physiological effects of the medication, some side effects, and whether or not this drug can enhance physical performance.

 How does it work?

Acetazolamide is a carbonic anhydrase inhibitor. Carbonic anhydrase regulates kidney absorption of sodium bicarb and chloride. Acetazolamide works by inhibiting carbonic anhydrase, preventing the reabsorption of sodium bicarb and chloride, causing acidosis in the blood. When experiencing AMS, the body is in a state of respiratory alkalosis. By taking acetazolamide, which causes metabolic acidosis it drives receptors in the body to increase the patient’s minute ventilation by as much as 50%, improving arterial PO2 and increasing oxygen saturation.

How can I obtain acetazolamide and when should I start taking it?

Acetazolamide requires a doctor’s prescription, and the typical dose for the prevention of AMS is 125 mg twice daily. The typical recommendation is to start taking acetazolamide one day before your exposure to high altitude and continue usage throughout your trip. When taken one day before exposure, studies show that acetazolamide reduced AMS incidence and enhanced tolerance to submaximal exercise on the first day at high altitude versus starting administration the day of arrival.2 However, if, for some reason, the medication isn’t started a day before arrival to high altitude, then the medication should be started upon arrival, which still shows a decreased incidence in the development of AMS. 

Allergies & Side Effects

Acetazolamide belongs to a classification of drugs known as sulfonamides, which is broken down further into two categories: antibiotics and nonantibiotics. Acetazolamide is considered a nonantibiotic sulfonamide, which varies significantly from sulfonamide antibiotics because these antibiotics contain what is known as an arylamine group in their chemical structure. This arylamine group is a key component of the allergic response to sulfonamide antibiotics (sulfamethoxazole, sulfasalazine, sulfadiazine, and the anti-retrovirals amprenavir and fosamprenavir); however, this structure is not present in other sulfonamide drugs like acetazolamide.1 There is available evidence that suggests patients who are allergic to arylamine sulfonamides do not cross-react to sulfonamides that lack the arylamine group and so may safely take non-arylamine sulfonamides.1 Patients with known allergies to sulfonamide drugs should consult with their healthcare provider before taking acetazolamide.

Like all other medications, there are risks that side effects will occur with acetazolamide’s administration. The common side effects are fatigue, malaise, changes in taste, paresthesia, diarrhea, electrolyte disorders, polyuria, and tinnitus. While conducting research, I found 3 – 4 people from my hometown, located at 69 feet above sea level, who have taken acetazolamide while rapidly ascending to 8,000+ feet to ski or hunt. When asked how their experience was taking acetazolamide, the common response was that they stopped using it within the first two days due to the change in the taste of their beer! The pleasurable “fizz” in our carbonated drinks is attributed to chemical excitation of nociceptors in the oral cavity via the conversion of CO2 to the carbonic acid in a reaction catalyzed by carbonic anhydrase. So administering a carbonic anhydrase inhibitor like acetazolamide results in flat-tasting carbonated drinks, or, as described by the aforementioned subjects, a “nasty beer”!4 While a bad tasting beer is no fun, AMS is a lot less fun, and one would be best advised to continue taking acetazolamide while at high altitude.

Can taking acetazolamide increase physical performance and endurance at high altitudes?

Though enticing, it doesn’t seem to work out that way. There are multiple studies on exercise endurance in hypoxic conditions with the administration of acetazolamide, but the produced results are confounding. The majority of the studies show that for a non-acclimated person taking acetazolamide in hypoxic conditions, endurance and exhaustion time were increased with submaximal and maximal exercise. A few reasons this may be true are the induction of metabolic acidosis and its effects on muscle cells, the diuretic effect of the drug inducing dehydration, and additional increases in work of breathing cause vasoconstriction in locomotor muscles, which can impair exercise performance.3 Regardless, this medication’s proven science in the prevention of AMS should not be mistaken with the multiple confounding studies on exercise endurance.

Scott “Scotty B” Rogers, FNP-S

From Opelousas, Louisiana, Scott Rogers is currently a Family Nurse Practitioner student at Walden University after having practiced five years as an RN following his BSN from the University of Louisiana at Lafayette. He has lived in Colorado for the past four years where he enjoys hiking with his wife and dog, snowboarding all the resorts in Summit County, and basketball, and hopes to pursue more work with acute physical rehabilitation, orthopedics, and sports medicine.

References

1. American Academy of Allergy Asthma & Immunology. (2019, June 23). Acetazolamide and sulfonamide allergy: AAAAI. Retrieved November 13, 2020, from https://www.aaaai.org/ask-the-expert/acetazolamide

2. Burtscher, M., Gatterer, H., Faulhaber, M., & Burtscher, J. (2014). Acetazolamide pre-treatment before ascending to high altitudes: when to start?. International journal of clinical and experimental medicine, 7(11), 4378–4383.

3. Garske, L., Medicine, 1., Brown, M., Morrison, S., Y, B., G., B., . . . Zoll, J. (2003, March 01). Acetazolamide reduces exercise capacity and increases leg fatigue under hypoxic conditions. Retrieved November 13, 2020, from https://journals.physiology.org/doi/full/10.1152/japplphysiol.00746.2001

4. Jean-Marc Dessirier, Christopher T. Simons, Mirela Iodi Carstens, Michael O’Mahony, E. Carstens, Psychophysical and Neurobiological Evidence that the Oral Sensation Elicited by Carbonated Water is of Chemogenic Origin, Chemical Senses, Volume 25, Issue 3, June 2000, Pages 277–284, https://doi.org/10.1093/chemse/25.3.277

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

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

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

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

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

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

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

Deep Frostbite

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

Stages of Frostbite

What can you do in the field for Frostbite?

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

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

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

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

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

References:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

robert-ebert-santos

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

WMS Blog entry No. 1: The Rule of 3’s and other pearls from the annual Wilderness Medical Society Conference 2020

Over 800 participants from 25 countries joined the virtual conference this year which included Dr. Chris’ poster presentation on growth at altitude. Over the next several months we will extract the most relevant information to publish in our blog, starting with:

The Rule of 3’s

You can survive 3 minutes without oxygen

                              3 hours without shelter in a harsh environment

                              3 days without water

                              3 weeks without food

Dr. Christine Ebert-Santos presents her research on growth in children at high altitude, “Colorado Kids are Smaller.”

We will be sharing some of the science, experience and wisdom from these meetings addressing how to survive. For example, Dr. Peter Hackett of the Hypoxia Institute reviewed studies on how to acclimatize before travel or competition in a low oxygen environment.

Susanne Spano, an emergency room doctor and long distance backpacker discusses gear, how to build an emergency shelter in the wild, and when it is OK to drink from that refreshing mountain stream.

Michael Caudell presenting on plant toxicity.

Michael Caudill, MD shares what NOT to eat when you are stranded in the wilderness in his lecture on toxic plants.

Presentations included studies of blood pressure in people traveling from sea level to high altitude, drones delivering water to stranded hikers, an astronaut describing life and work at 400,000 m, what is the best hydration for ultra athletes, how ticks can cause meat allergy, and, as always, the many uses for duct tape.

Duct tape for survival.

We will also update you on the treatment of frostbite as well as a discussion about “Climate change and human health.”

Sign up for our regular blog updates so you can be updated on wilderness and mountain medicine!

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

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.

Backcountry & Avalanche Safety: Insight from Backcountry Athlete Dan Beerman

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.

Medicine Man: Ski Patroller & EMT Jonathan Sinclair’s Elevated Experience

“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 them when 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.

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.