Category Archives: Exposure

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.

Skin at Altitude

Both residents and visitors of the high altitude of Colorado are faced with the frustration of applying lotion and Chapstick frequently throughout the day and yet continuing to experience dry, irritated skin and chapped lips. Although this can be contributed to by uncontrollable factors such as dry climate and cold temperatures, there are daily modifications that can be made to help treat and prevent persistent dry skin. It is important to recognize that varying factors including environment, chemical exposure, diet, and genetics have a role in the progression and persistence of dry skin and other related skin conditions. To discuss some of these different common skin problems and the multitude of “therapies” and “myths” that surround them I had the opportunity to meet with Kelly Ballou PA-C from Renew Dermatology

A recent study performed in Vail, CO revealed that at higher altitudes, SPF 100+ sunscreen was more effective at protecting against sunburn compared to SPF 50+. The information found in this study differs from the American Academy of Dermatology recommendations of using water resistant SPF 30 or higher. Kelly expressed her wishes for more dermatologic studies to be performed at higher altitude communities like Summit County, Colorado in the future as there is known increased UV exposure risk with higher elevations. Whether it is snowy, sunny, rainy, or cloudy, it is important to be compliant with frequent sunscreen application as recommended on the bottle and barrier repair lotions to achieve the greatest benefit with sun damage prevention (which can develop as brown spots, fine lines, loose skin or precancers) and hydrated skin. Kelly stated how “Even when it is a blizzard in Summit County, the UV exposure is still 80-90% compared to the UV exposure at sea level.” She recommended “setting an alarm while hiking, fishing, or skiing as a reminder to re-apply sunscreen frequently during outdoor activities.” Recognizing and modifying factors such as frequent hand washing and bathing, forced air heating, chemical exposure, and overuse of soaps can help to reduce dry skin.

There are a multitude of moisturizers available over-the-counter which can be overwhelming to choose from. It is recommended to choose moisturizers that are plain “no scents or oils added” such as Eucerin, Aquaphor, Cetaphil, or CeraVe. It is encouraged to apply moisturizers 2-3 times daily as needed to avoid dry, cracked or painful skin. For irritable dry skin, scratching and itching are highly discouraged as this can result in increased risk of infection or scarring. Trimming of nails and applying bandaging over dry areas can help to reduce these tendencies and associated risks. If there is a severe urge to itch, over-the-counter antihistamines such as Zyrtec and Claritin can provide some relief. To avoid daytime “tiredness”, Claritin (less-sedating) is recommended during the morning and afternoon hours, while Zyrtec (possibly more-sedating) can provide relief at night.

Kelly Ballou, PA-C, with Renew Dermatology in Frisco, CO, has over 10 years of Dermatology experience. She’s holding one of her top recommendations for altitude skin care, Epionce Renewal Calming Cream.

Kelly and I discussed how Epionce has a medical grade product called Renewal Calming Cream which has shown incredible results with treating not only eczema, but many other conditions associated with dry and irritated skin. It is a product which utilizes multiple natural ingredients that is able to be sold at medical practices but does not require a prescription. Kelly described how, in her experience, it “works on most anything red, can reduce itching and dryness quickly over damaged skin exposed to the outdoors, and is one of the best moisturizers – much more effective than any over-the-counter moisturizers or other products.”

As parents may well know, kids can present with odd skin conditions that are persistent despite efforts of frequent moisturizing. For conditions such as Keratosis Pilaris, Cradle Cap, and Atopic Dermatitis (Eczema), there are additional recommendations other than just applying frequent lotion and sunscreen throughout the day.

Keratosis Pilaris:

Keratosis Pilaris is a chronic condition that can present as dry skin that appears on upper arms, thighs, and buttocks. It is commonly described as “rough sandpaper with tiny bumps”. It is often made worse by soaps that remove the skin’s natural oils, thus disabling the skin from holding onto necessary moisture. Avoiding bubble baths, strong soaps, and creams with fragrances can help to improve Keratosis Pilaris. Dr. Ebert-Santos recommends room humidifiers and applying moisturizing cream within 3 minutes after bathing  at least 2 times throughout the day for optimal results. 

Cradle Cap:

Cradle Cap is best described as red patches on the scalp covered with oily, yellow scales or “crusts”. It is the result of hormones causing over production of oil and can be linked with an overgrowth of yeast. Eventually, cradle cap will go away on its own within 6 to 12 months of age, however, best treatment can include antidandruff shampoo twice per week or nonprescription Hydrocortisone 1% cream for resistant cases. Kelly often informs her patients that “oil treatments are not effective for resolving cradle cap” in her experience, but rather she recommends prescription antifungal shampoo which can be applied for at least 20 minutes and then rinsing shampoo off for optimal results. If not resolved with just the shampoo, a combination of Ketoconazole cream and Epionce Calming Cream has additionally shown positive results.”

Atopic Dermatitis (Eczema):

Eczema is a red, itchy rash that can appear as early as birth or can start at any time throughout life. The rash can be found anywhere on the body.  The overall treatment for eczema may involve steroid creams,  moisturization, as well as avoiding frequent use of bathing soaps and anything with fragrance. To prevent further aggravation of eczema, keep shampoo off the rash and try to use non-drying soaps such as Dove, CeraVe or Cetaphil. It may take trialing different therapy regimens to find what works best for each individual. However, if the rash weren’t to improve after a few days of treatment, or the rash were to become raw and appear infected it is recommended to follow up with your doctor. 

Breeann Backer is a second-year physician assistant student at Red Rocks Community College. She graduated from Colorado State University in Fort Collins, CO with a Bachelor’s in Health and Exercise Science. Before PA school she completed an internship at Cardiovascular and Pulmonary Rehabilitation and thereafter worked as a medical assistant in outpatient cardiology for 2 years in Denver, CO. She enjoys any excuse to stay active outside and loves calling Colorado home. Her hobbies include photography, exploring, and trying new foods. 

References: 

Keratosis Pilaris: Schmitt BD. My Child Is Sick!: Expert Advice for Managing Common Illnesses and Injuries. Elk Grove Village, IL: American Academy of Pediatrics; 2017.

Cradle Cap: Schmitt BD. My Child Is Sick!: Expert Advice for Managing Common Illnesses and Injuries. (2018). Cradle Cap Patient Education. Change Healthcare.

Atopic Dermatitis: Schmitt BD. My Child Is Sick!: Expert Advice for Managing Common Illnesses and Injuries. Elk Grove Village, IL: American Academy of Pediatrics; 2017.

Eske, J. (2019, April 10). Top 6 Remedies for Dry Skin on the Face . Medical News Today. Retrieved from Medicalnewstoday.com

Confused about sunscreen? Get the facts. (2019, May 21). https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/best-sunscreen