Category Archives: High Altitude Training & Fitness

What are the challenges and benefits of recreation and training in a high altitude environment? How does it affect your body’s physiology? What are the inherent risks?

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!

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.

Aconcagua: an Athlete/Medical Scientist’s Narrative in Symptoms

“Day 10: I walked for maybe an hour up to Camp 3 (19,258’/5870 m) from Camp 2 (18,200’/5547 m). I became the slowest person. I had tunnel vision. It was bad. It took a lot of willpower. I do a good job of not telling people how bad I really feel. After about a mile, I told them I had to stop, and me and Logan turned around. We had that conversation,

‘I don’t think I should go up anymore. It’s not safe for me, and it’s not safe for the group.’

Barely able to move, about an hour above Camp 2.

“The others didn’t go all the way to Camp 3, but continue on a bit more. Angela said she got a headache really bad and couldn’t see out of her right eye. I had already pretty much decided — I was devastated — after two nights and two days of not acclimating. Alejo had a stethoscope and said my left lung was crackling. We thought I might develop some really serious pulmonary edema.”

Keshari Thakali, PhD is an Assistant Professor in the Department of Pediatrics at the University of Arkansas for Medical Sciences in Little Rock, AR. She is a cardiovascular pharmacologist by training and her research laboratory studies how maternal obesity during pregnancy programs cardiovascular disease in offspring. When not at work, you can find her mountain biking, rock climbing, hiking or paddling somewhere in The Natural State. She has a long-term career goal of merging her interests in mountaineering with studying cardiovascular adaptations at high altitude. She has climbed to some of the most extreme elevations in the Rocky Mountains, Andes and Himalayas. Last December, she flew down to Mendoza in Argentina for an ascent up Aconcagua.

Sacred in ancient and contemporary Incan culture, and the highest peak in the Americas, Aconcagua summits at 22,837′ (6960 m). Current statistics show only 30 – 40% of attempted climbs reach the top of this massive mountain in the Andes, in Principal Cordillera in the Mendoza Province of Argentina.

Sunset on Aconcagua from Base Camp.

The day following Keshari’s decision not to summit, she hiked back down to Plaza de Mulas (14,337’/4370 m) from Camp 2, carrying some of her colleague’s gear that he didn’t want to take up to the summit as he continued to ascend. Plaza de Mulas is a large base camp area with plenty of room for tents, available water, and large rocks that provide some protection from the wind as climbers take time to acclimate before continuing their ascent.

“Even though my oxygen [saturation] was low, I was functional. As you go down, everything gets better. The others continued up to Camp 3. They spent one night there, then summited the next day. It took them 12 hours.

“The day the others came back to Plaza de Mulas, I think that’s when everything hit me. I felt like a zombie. I did some bouldering and got so tired I had to sit down and catch my breath often, probably because I had been hypoxic and we were at over 14,000′.

“[The next day] we did the really long hike from Plaza de Mulas all the way to the entrance of the park. It probably took about 8 hours to walk all the way to the park entrance.

“We drove to Mendoza that night. I felt like my body was tired, but my muscles were functioning just fine. It’s hard to describe.”

They had done everything right and had taken every precaution. Each of Keshari’s colleagues boasted significant backgrounds in climbing and mountaineering, their cumulative accomplishments including Mt. Elbrus (18,510’/5642 m), Cotopaxi (19,347’/5897 m) and Denali (20,335’/6198 m), their ages 30 to 65. They weren’t initially planning to hire porters, “but they ended up carrying a lot of our stuff. In the end, it just makes sense to hire these porters to increase your chance of success.”

They gave themselves about two weeks to make the ascent and return. There was ample time for them to stop at each camp and spend time acclimatizing, including day hikes to the nearby peaks of Bonete and Mirador.

“Day 4 [we did an] acclimatization hike to Bonete (16,647’/5074 m), pretty much the same elevation of Camp 1. You look at the mountain and it looks pretty close, but … in mountaineering, you don’t do distances, you do time. Did the hike in mountaineering boots, which were heavy and clunky, but I learned how my boots actually work. You walk differently in these than a shoe with a flexible sole. The last part of the mountain is pretty rocky and it looks like you’re almost to the top, but you still have to walk an hour to the summit. It took about five hours to go up. We were walking slow, I felt fine. From the top of that mountain, looking away from Aconcagua, you can really see Chile and the Chilean Andes.”

Summit of Bonete.

All the way through their first week of climbing, including a day of resting and eating after their hike up Bonete, Keshari was feeling fine.

“Day 8, we made the push to Camp 2 (18,200’/5547 m). None of these hikes made me tired. I was plenty trained. We were carrying packs, but they were still pretty light, packed with stuff for the day. We spent the night at Camp 2, took oxygen mostly at night. [My] first reading at Camp 2 was low. We were at over 18,000′. I thought maybe I’ll just go to sleep and it’ll get better.

Looking down on Camp 2 covered in snow.

“Day 9 was a rest day at Camp 2 because the weather was really bad. All I did was sleep that day. If you’re gonna go to Camp 3, that means you’re gonna do a summit push the next day, because Camp 3 is so high. You’re just struggling to stay healthy. I felt really bad in the tent, but if I went outside to pee or walk around, I felt better. My pulse ox was still pretty low that day. That night, a snow storm blew in and it snowed a lot.” And it was the following day of their ascent to Camp 3 that Keshari made the decision not to summit.

Since returning from her expedition, she’s reflected on some other variables. “I swear I was hyponatremic (an abnormally low concentration of sodium in the blood). We went through four liters of water a day with no salt in the food. I was having these crazy cramps in my abs and my lats and places I don’t typically get them. To me, that has to do with electrolyte imbalance. Next time, I’m taking electrolyte tablets, not just stuff to mix in my water.

“I’m not very structured in my diet. In general I eat pretty clean, but I don’t count calories. I eat vegetables, but I also hate going grocery shopping. I feel like I eat a pretty balanced diet. If I buy meat, I’ll buy a pack of chicken and that’s my meat for a week or two.

“On the mountain, in general, I felt like they fed us way more fiber. In Argentina, they eat a lot of meat. They’re meat-eaters. They didn’t feed us steak on the mountain, but … at Base Camp, I felt like they were overfeeding us. We had pork chops one night, but on the mountain, I felt like it was mainly lentils and noodles. Even though you’re burning calories, how your body absorbs them is different. They really try to limit your salt intake because they’re concerned about having too high blood pressure. At Base Camp, breakfast was always scrambled eggs with bacon and toast. Lunch and dinner were always three course meals starting with a veggie broth soup. They fed us like kings … I brought Clif blocks with caffeine in them for hiking snacks, Lara bars.”

I ask about her main takeaway from it all:

“I think I need more time to acclimate. I don’t know how much more time, but maybe more time at about 16,000′. Maybe take Diamox. Someone suggested I should have been on an inhaled steroid, especially because my asthma is worse in the cold. If I were to go next time, I would want a couple more days at 15,000 – 16,000′. Maybe the Diamox is something I would need to use next time.

“The nerd in me wants to measure pulmonary wedge pressures (via very invasive catheters; you could go through the jugular), nothing practical,” she laughs. “The pulse oximeter is the easiest tool.”

One last thing she’d do differently? One of her colleagues bought a hypoxic generating system from Hypoxico, “which I think puts CO2 back into your system; sleeping high, training low. That might have been the best thing.”

Keshari went sky-diving back in Mendoza the day after returning from their descent. “I was expecting a lot of adrenaline jumping out of an airplane, but there was none. I enjoyed the freefall, but when the parachute went up, I got really nauseous. Maybe I had just been stressed for so long, there was no more adrenaline left. I was like, ‘Where’s the risk involved in this?'”

An illustrated oxy-journey.

Keshari also summited Cotopaxi earlier the same year. Read her own account here.

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.

Understanding the effects of nocturnal hypoxemia in healthy individuals at high altitude: A chance to further our understanding of the physiological effects on residents in Colorado’s mountain communities

The population of Summit County, Colorado is projected to grow by 56% between 2010 and 2030. Along with adjacent Park and Lake Counties there are now over 40,000 people living above 2800 meters elevation. This is the largest high altitude population in North America. As opposed to native populations in South America, Africa and Asia who have been residing above 2800 m for centuries, the North American residents are acclimatized but not adapted. Symptoms related to hypobaric hypoxemia are notable above 2500 m.  Recognized conditions associated with altitude include central sleep apnea leading to hypoxemia (abnormally low oxygen level in the blood) which activates the sympathetic nervous system. In susceptible persons this can cause systemic and pulmonary hypertension. The incidence of this potentially devastating side effect of mountain living is unknown.  In order to better understand the potential side effects of nocturnal oxygen desaturation in healthy individuals, it is beneficial to investigate the normal physiological changes that occur during sleep, which leads to low oxygen levels in all individuals.

When the body enters the sleep state, many of the behavioral mechanisms that are active during wakefulness are blunted, and it’s been found that different sleep stages have varying effects as well.  One of the major changes is a diminished response to hypercapnia (high carbon dioxide levels in the blood) and hypoxia.  During sleep, the CO2 set point is elevated from 40 mmHg to 45 mmHg, which results in reduced alveolar ventilation.   It’s also observed that minute ventilation is reduced, which is due to decreased tidal volumes that is normally compensated for with an increase in breathing frequency during wakefulness.  Also, during sleep, there tends to be upper airway narrowing that is normal and there is reduced reflex muscle activation of the pharyngeal dilator muscle.  All of the above factors contribute to decreased ventilation during sleep. 

A lot of what is understood about the effects of nocturnal hypoxemia is due to extensive studies in individuals with underlying diseases, and these studies are not always conducted at higher altitudes.  One such study investigated the effects of nocturnal desaturation (SaO2 < 90% occurring for > 30% of the sleep study) in chronic obstructive pulmonary disease (COPD) patients without a diagnosis of sleep apnea.  The authors found higher rates of dyspnea, increasing rates of worsening COPD symptoms, poorer quality of sleep and health-related quality of life.  Another such study found that some patients with COPD experience increased transient arterial hypoxemia (TAH) during rapid eye movement (REM) sleep.   In this study, the authors observed that the study subjects experienced increased pulmonary vascular resistance (which can lead to pulmonary hypertension) and a few subjects experienced an increase in their cardiac output. The authors found that individuals could experience a decrease in this phenomena by using nighttime oxygen therapy.

Studies, such as above, do not assist in identifying healthy individuals that may need early intervention due to nocturnal hypoxemia at altitude.  What about the healthy individuals without underlying diseases?  In the study conducted by Gries and Brooks in 1996, the authors collected data from 350 patients.  Their recorded average low saturation in the study of 350 subjects was a reported 90.4% lasting an average 2 seconds.  This study was conducted at the Rainbow Babies and Children’s Hospital located in Cleveland Ohio, at an elevation of 653 feet (198 m). This is one of the largest studies done to assess normal oxygen levels observed during sleep, and the results, along with results from other studies are displayed in Table 1.  As of right now, there is no equivolent study for subjects at elevations like that of Summit County, CO, which is at an average of 9110 feet (2777 m). Aside from the normal physiological changes noted above, the rates of developing underlying central sleep apnea leading to systemic and pulmonary hypertension is unknown.  Further, there are no guidelines as to initiating treatment in patients that may be experiencing adverse effects of high altitude nocturnal hypoxemia, because there is a lack of data to establish baseline normal values observed at this elevation.  This leads to unnecessary sleep studies, and further involvement of a myriad of healthcare professionals that have no specific guideline to reference when approached by one of these patients. 

In order to further our understanding of the effects of high altitude and nocturnal hypoxemia in healthy individuals, like that of Summit County, there has to be preliminary and ongoing research in these individuals.  Dr. Chris Ebert-Santos is currently conducting an overnight pulse oximetry study, which aims to recognize which symptoms they may or may not be experiencing, that are related to high altitude or sleep disorders, so that they may receive treatment, feel better, and remain active. 

At this moment, initial study results reveal a decreased average low night oxygen saturation from that of the study conducted by Gries and Brooks.  In a sample of just 14 individuals, the average low SpOs recorded overnight is at 81.3%, which is 9% lower than that recorded by Gries and Brooks (Graph 1).  The study is also revealing a trend in lower night oxygen saturations in individuals that have lived at elevation for a longer period of time (Graph 2). These findings suggest the need to expand and build on the current study being conducted by Dr. Chris and her team at Ebert Family Clinic. If interested, you may apply in-person at Ebert Family Clinic, where you will be required to fill out a health questionnaire on your length of residence at altitude, medical history, and possible symptoms related to high altitude.  Your basic vitals will be logged at the appointment.  After the first study, you will then be rescheduled in 12 months for a follow-up overnight study to monitor for any changes.  Overall, this study is designed to help with an understanding on the potential impact of high altitude on healthy individuals that are acclimated, but not necessarily adapted, to this environment.

Robert Clower is a second year physician assistant student at Red Rocks Community College in Arvada, CO.  His undergraduate degree was in Biology, which incorporated both medical health science courses as well as independent research courses in general biology and ecology.  While attending school at the University of North Georgia, Robert served in the Army National Guard for a cumulative time in service of 8 years.  After completing his undergraduate degree, Robert gained medical experience as an operating room assistant, which included assisting support staff with surgical preparation and patient transport throughout the hospital for surgical appointments.  Outside of his studies, Robert enjoys snowboarding, hiking, snowshoeing, exercising and spending time with family and friends. 

Sources

Summit County Population Projections: Summit County, CO – Official Website. Summit County Population Projections | Summit County, CO – Official Website. http://www.co.summit.co.us/519/Population-Projections. Accessed March 3, 2020.

Tintinalli JE, Ma OJ, Yealy DM, et al. Tintinallis Emergency Medicine: a Comprehensive Study Guide. New York: McGraw Hill Education; 2020.

Gupta P, Chhabra S. Prevalence, predictors and impact of nocturnal hypoxemia in non-apnoeic patients with COPD. 52 Monitoring Airway Disease. 2015.

Lemos VA, Antunes HKM, Santos RVT, Lira FS, Tufik S, Mello MT. High altitude exposure impairs sleep patterns, mood, and cognitive functions. Psychophysiology. 2012; 49 (9): 1298-1306.

Cingi C, Erkan AN, Rettinger G. Ear, nose, and throat effects of high altitude. European Archives of Oto-Rhino-Laryngology. 2009; 267 (3): 467-471.

Altitude Training 101

High elevation prompts physiologic changes in the body. As elevation increases, oxygen concentration in the air decreases; this is why some people suffer from altitude sickness when travelling to high altitude environments like Summit County, Colorado from a lower elevation. Training and/or living at elevation increases our red blood cell mass in order to compensate for the lower oxygen concentration, thus increasing our oxygen-carrying capacity. Red blood cells are like microscopic rafts that flow down the rivers of our blood vessels, picking up oxygen from our lungs when we breathe and then transporting it to all the muscles and organs that need it to function properly. For athletes, this physiologic concept can be used to their advantage in order to improve their performance. If they can train their blood cells to carry more oxygen by forcing them to grow in a more hypoxic (low-oxygen) environment, then they can have more oxygen available to their muscles to perform in any activity.

There is a modern training model that some athletes have adopted called “Live High, Train Low”. This means that the athlete performs high intensity training sessions at a lower elevation, but maintains general training and living at higher altitude. Your body begins making metabolic changes immediately when exposed to high altitude and hypoxia, but it can take a couple weeks for the maximum effect. Expert Dr. Gustavo Zubieta-Castillo, who spoke in La Paz, Bolivia at the 7th Annual Chronic Hypoxia Conference that Dr. Chris attended in 2019, claims that it takes him about 40 days to build up his hematocrit to be back to functional in La Paz which is situated at nearly 12,000 ft. All in all, the goal of living and/or training high, while including high intensity sessions at lower altitude, is to give your body enough time to build up some acclimatization to the hypoxic environment. Several studies in the last 25 years have taken various groups of athletes and placed them on different training regimens over 4 weeks. Some would live at low altitude and also train low, some trained low and lived high, and others trained high and low while living at high altitude. One study completed in 2008 concluded that athletes who either live high and train low, or live high while training low and high, showed about a 1.4% improvement in sea level endurance performance.

How high is too high, and how low is too low?

Snowshoeing above 9000 ft., Summit County, Colorado.

It was found in this same study, that there is in fact a “sweet spot” for implementing the “Live High, Train Low” paradigm. If subjects were living lower than 1800 m, there was not a significant improvement in athletic performance. On the other hand, if subjects were living too high, they could not adequately recover from training and therefore did not show improvement because their bodies struggled to keep up with the hypoxic environment. The best elevation to live and/or train at in order to increase RBC (red blood cell) production, RBC mass, and oxygen-carrying capacity is between 2100 m-2800 m, or about 7000 ft-9000 ft.

What does this mean for athletes in Summit County who live high and train high?

Great news! There are still major benefits to those who live and train in Summit Country, as well as for people who visit the mountains and train while they are in town. This is because of a physiologic process called autophagy. Autophagy is described as our cells’ process of degrading old proteins and damaged cell parts. This is a normal process that modulates cell survival, is important for cell renewal, and is also a promoting factor of exercise performance from altitude training.

When exposed to a hypoxic environment, our cells produce adaptive responses that ramp up autophagy and cell renewal elements. These responses include factors that promote skeletal muscle growth, boost skeletal muscle capillary concentration, and enhance coronary arteries (the arteries that feed your heart). Living and training at altitude is good for your heart and it can help build muscle while decreasing body fat mass. It also shows significant increase in cardiac output and strength of your heart stroke.

However, excessive exercise and especially excessive exercise at altitude can prove harmful to our skeletal muscle. It has been observed in male subjects running 20 km that the excessive exercise induces autophagy too much which leads to degradation of muscle protein, damage, and eventual loss of skeletal muscle all together. Therefore, just as there is a sweet spot for altitude training, it is also a good idea to monitor training in order to maximize the benefits of training in a place like beautiful Summit County.

So, how should I be training if I live in Summit County or if I am visiting for some time?

I had the pleasure of speaking with Mary Scheifley about this particular strategy. Mary is the owner of Peak One Fitness, a 24-hour gym in Frisco, Colorado (9000 ft.). She has over 20 years of experience in fitness and athletic training. She competed semi-professionally in mountain bike racing, and continues to bike today as well as cross-country ski, snowboard, weightlift, hike, and anything else that keeps her active. She loves Frisco and has found that being outside and active is almost spiritual. She is passionate about fitness and nutrition, and she works extremely hard to tailor her training regimens to each of her clients based on their individual needs or goals.

Cardio machines at Peak One Fitness, Frisco, Summit County, Colorado

When she trained people in Denver, she typically was running high-intensity aerobic classes. However, here in Frisco, she prefers to focus on strength and only include high-intensity interval training (HIIT) in short spurts. She believes that you don’t need to be over-exerting your body to see a positive response. She has a client who lives near sea level for most of the year where her main training regimen includes Cross Fit. When she comes to Frisco though, she can see a significant decrease in BMI and body fat index in just two months of lower-intensity training. Though frustrated that she cannot run on the treadmill as fast or as long as she can at home, by the end of her stay in Frisco, this client understands that difference of the elevation and appreciates the process that Mary provides for her.

Mary recognizes that fitness is not “one size fits all”. She typically likes to start people out at 80% of their maximum heart rate when exercising, but there are factors that may change this. Her clients that live in Summit County have already been acclimatized to the elevation so she can add a little to their 80% max heart rate because for them, 80% may feel like 70%. On the flip side, if you are visiting from sea level, she may have to decrease your 80% of maximum because of the hypoxia at elevation. Other factors that play a role in how Mary develops her training regimens include age, the client’s goals, their previous fitness level, and their overall reaction to altitude.

I also asked Mary about her experience with competition and professional athletes. Personally, she could tell that her endurance was superior to her competition when she raced at altitude against bikers from Denver. She also noticed that when she was in Denver, the racers there were stronger and bulkier than her. She also has experience training athletes who are preparing for competitions such as the Leadville 100 or who are professional skiers who tell her that it is more beneficial for them to come to altitude about 3 weeks prior to competition in order to prepare rather than just training at lower altitude. This is because their body will better adapt if they give it a little more time before competition while training.

At the end of the day, whether you are training for a competition, or just trying to stay healthy, being at altitude can pose challenges as well as benefits to our bodies. The following are some tips from Mary on maximizing your workouts at altitude without compromising your health and wellness.

Mary’s tips for athletic training and exercising at high altitude:

  • Increase water intake, even before you come to elevation. You should be drinking at least 3-4 liters of water per day.
  • Increase caloric intake. At altitude you are burning more calories than at sea level, and if you are wanting to train you need to fuel your body appropriately. Especially increase protein intake.
  • No alcohol. If you enjoy one drink here and there you should be fine, but if you are wanting to train at a high level alcohol should not be on the menu.
  • Add electrolytes. In addition to increasing water, you need to make sure you are replenishing your body with the salts it requires.
  • Take it slow. Maybe start with some yoga or moderate stretching before moving into running or HIIT classes. You may need to decrease your level of training by 20%.
  • Consider spending a night in Denver before heading up the mountain to Summit County. Dr. Chris has expressed this frequently to travelers and visitors of Frisco; it gives your body a chance to acclimatize prior to ascending to 9,000+ feet.
  • Don’t expect to be at your “home” level of endurance or fitness. Do not get discouraged if you cannot run your typical 7-minute mile, or you can’t easily warm up with a set of 10-15 squats. Your body needs to adjust, and you may need to just take it easy in the altitude. Ultimately, have fun and enjoy the beautiful outdoors!

Sarah Brzecezk is a 2nd year Physician Assistant student attending Midwestern University in Glendale, Arizona. She graduated from Northern Arizona University in Flagstaff, AZ with a Bachelor’s in Biomedical Sciences and then worked as a medical assistant in Internal Medicine prior to starting PA School. She is passionate about healthy eating and maintaining a physically active lifestyle, and she hopes to specialize in Orthopedics when she graduates this Fall. During her 6 weeks at elevation in Frisco, Colorado, she has enjoyed numerous hikes, two hut trips, yoga classes, and running in the gorgeous outdoors. Her goal as a provider is to help others overcome injury and illness in order to return to physical activity and athletics, enabling them to combat chronic illness and stay healthy for their future years.

References

Zhang, Y., & Chen, N. (2018). Autophagy Is a Promoter for Aerobic Exercise Performance during High Altitude Training. Oxidative medicine and cellular longevity, 2018, 3617508. doi:10.1155/2018/3617508

Brocherie, F., Millet, G. P., Hauser, A., Steiner, T., Rysman, J., Wehrlin, J. P. & Girard, O. (2015). “Live High–Train Low and High” Hypoxic Training Improves Team-Sport Performance. Medicine & Science in Sports & Exercise, 47(10), 2140–2149. doi: 10.1249/MSS.0000000000000630.

Stray‐Gundersen, J. and Levine, B.D. (2008), Live high, train low at natural altitude. Scandinavian Journal of Medicine & Science in Sports, 18: 21-28. doi:10.1111/j.1600-0838.2008.00829.x

Section House in December: Moose Country

Section House sits at 11,481′ (3499 m), on Boreas Pass, just south of Breckenridge, Colorado. It isn’t the highest hut in the Summit Huts system, but its unique location and history is what makes it one of the most challenging.

Many of the huts in the Summit and 10th Mountain Division systems sit on a hillside, below tree line, which provides a significant amount of weather mitigation. Section House is right at the tree line, on the pass, which means any wind and weather will likely be funneled right into you. And because you are in one of the highest counties in the United States, weather is highly variable.

I’ve done this hut in a blizzard before, arriving to find the padlock on the front door was frozen shut. That may have been the most I’d ever despaired in my life up until then.

Even in great weather, however, the temperature alone is a liability. When we set out from the trailhead this time, it was sunny and relatively balmy for December, in the 30’s (Fahrenheit). But the temperature in the shade can be several degrees lower, and as the sun sets below the Ten Mile Range, the temperature starts to drop by the tens of degrees really quickly.

The Stats

Distance: a little over 6 miles; GPS and some maps may differ by tenths of a mile. If you tell your friends 6, they may resent you.

Timing: the same hike has taken me a couple hours with no weight on my back besides water, on well-packed snow. This time, it took over an hour a mile, including frequent breaks, thanks to all the weight I was carrying and pulling. Additionally, we constantly had to redistribute weight among sleds and backpacks to relieve shoulders and keep sleds from tipping over. If you decide to pull a sled, keep the weight low and as evenly distributed as possible. The other very limiting factor was the last half of the trail was covered in at least a couple feet of unpacked, fresh powder. Our lead was breaking trail in snowshoes.

While the grade going back down to the trailhead isn’t steep enough to keep momentum without skating, it is significantly easier and faster, and took us half the time even after waiting for moose to safely cross our path.

Elevation gain: about 1100′.

Capacity: 12 people.

Packing

I’ve pulled a sled both times I’ve done this hut. I don’t regret it, but it is challenging at best in calm weather. Unless you are going for more than a couple nights, I’d recommend packing everything into a backpack.

Because the elevation gain is so gradual, the challenge with weight is the distance. Pack your weight so it will still be comfortable on your shoulders after three miles. The advantage of pulling a sled was having less weight on my shoulders, but after several miles, even minimal weight can dig into your muscles.

The only source of water around this hut is the snow you melt, which is why it isn’t open in the Summer season. Water purifying filters are the quickest way to refill all your containers at the hut, but you will want plenty of water for the hike in alone. Running out of water on the trail is dangerous. An added risk: when the sun went down on us after the first three hours in, the water in our CamelBak nozzles started freezing if we weren’t regularly sipping on them.

Bring a sleeping bag. Most huts I’ve been to have blankets and pillows on the mattresses, but this one does not. This is also one of the oldest and coldest cabins; built in 1882, it takes hours to heat up by wood stove, especially if no one has been in it recently.

Moose

Now forget all the advice I just gave you and center your whole packing strategy around how you plan to evade a charging moose.

This region is moose country: high, high meadows filled with willowy wetlands. They don’t care how cold it is. In the dead of night, one of us opened the front door to use the outhouse and a young bull was standing right in front. On the trail back, two different parties ran into a moose and her calf right on the trail. They are not in the way. You are on their trail.

But seriously, pack to be prepared for your comfort and sustenance on the trail and at the hut. The only thing you can do about the moose is give them a lot of space while avoiding any confrontational, jerky movements that may suggest any predatory intent. If moose perceive a threat, they are liable to charge, male or female. If they charge, drop everything weighing you down and pray-run (praying while running).

When we ran into the moose on the trail, we stayed over 50 meters away and just waited while the moose wandered further off our path. As soon as they were about 50 meters off our path, we proceeded with caution. But we waited for over 30 minutes, and would have waited longer if we needed to.

Skis vs. Skins vs. Snowshoes

This was the most highly contested logistical conversation among our party. In the end, four of us were on cross country skis (without skins), one was on skis with skins, one was on a split-board with skins, and one was on snowshoes.

This really depends on the conditions. Two weeks prior, three of us hiked the trail in boots, on well-packed snow after days of warm, dry weather. Days before we left for the trip, however, a series of storms blew several feet of snow in, which changed everything. Boots alone were definitely not an option.

Most people, who aren’t hiking to the hut, will stop and turn around at the halfway mark where historical Baker’s Tank stands. This means the trail up until that point will reliably be pretty packed down. Because of the recent snow, however, no one could be sure what conditions would be like for the second half of the trail.

Freshly-broken trail through fresh snow past the midway point to Section House.

Sure enough, Baker’s Tank to the hut was unbroken trail through deep, soft snow. Our lead, on snowshoes, was cursing all the way to the hut as he carved the path for the rest of us. But in deep snow, snowshoes are sometimes the most comfortable option for an ascent, especially if you are inexperienced on skis and skins.

The advantage to skinning up on a split-board or downhill skis is the width of the blades. They are wider than cross country skis, which makes balancing the extra weight more comfortable and stable.

On a packed track, cross country skis were relatively comfortable, if narrow. The boots are more similar to normal footwear, so are more flexible and comfortable than ski or snowboard boots. Price was also a determining factor: renting skis or a split-board can cost upwards of $45 per day at most rental shops. We found cross country skis for $10 per day at Wild Ernest Sports, above Silverthorne, and they worked well. One thing about cross country ski boots, however, is that they aren’t as well-insulated as downhill ski or snowboard boots. Trekking through deep snow in them requires much better waterproofing and insulation than we were prepared with.

Jupiter rising in the dusk on the way up to Section House.

As for skins, although the trail grade is very gradual, there is enough of a grade at times that you will be thankful for the traction that skins provide. So unless you’re on cross country blades, you’ll want some skins.

Altitude & Acclimatization

One advantage of carrying all the weight we did was that it forced us to make a slower ascent and take frequent breaks. These are two things you can do to minimize the affects of the altitude on any ascent. In our party, all but one of us have lived at an altitude over 7,000′ for at least one year. Most of us have lived over 9,000′ for several years. But this was the first hut trip over 10,000′ for three of us, one of whom flew in two days before from sea level.

Fortunately, no one in the group experienced any severe symptoms of acute mountain illness, and I credit that to our meticulous supervision of each person’s blood oxygen saturation as well as our slow ascent. The first night we were at the hut, the lowest oxygen saturation we saw was 85%, but most were between 85 and 90%, which, at over 11,000′ is not surprising. If some slow, deep breaths hadn’t brought oxygen levels up, I would have been more concerned.

Hitting kickers behind Section House.

As seems to be tradition on our expeditions, we arrived well after dark. But these days, sunset is at 4:30 pm. Luckily, the weather was calm, and the trail is quite obvious. Our biggest concern after dark was the tremendous drop in temperature. With no cloud cover and a recent cold front, it was well below freezing, and the only thing that kept us from freezing was the constant movement, which kept us progressing forward.

Ken’s Hut, next to Section House.

By the time we had all made it to the hut and built up a fire warm enough to kick our boots off, our socks were steaming in spite of how cold our extremities were. It took well into the night to heat up the hut, and we all spent the first night sleeping around the wood stove. Yes, it took seven hours for the last of us to make it to the front door of Section House, but the spring trip to the Benedict Huts outside of Aspen was still loads more difficult — and we didn’t even pull any sleds! The next day was windless, sunny, clear, and warmer outside than it was inside, which allowed us to get back out on our skis and snowboards to enjoy the backcountry without weight on our backs.

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.

Doc Talk: Nutrition & Oxygen as Preventative Medicine

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.

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.

High Country Healthcare’s Guide to Altitude and Acclimatization

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.**

Dr. Chris’s Tips for Staying Active Through the High Country Winter

Welcome to another Winter in the High Country! We’ve already had a series of snow storms in record-breaking cold temperatures across Colorado. On one hand, snow conditions are excellent! On the other hand, it’s sometimes cold enough to make you want to stay inside! One of the most effective ways to warm up is from the inside, out. Don’t forget about all the little opportunities you have to move your body and get your blood flowing, before, after, and even in the middle of a work day. Dr. Chris always has some valuable insight that she shared in a recent chat:

What keeps most of your patients from being more active during the Winter as opposed to the Summer?

Except for sledding and ice skating, Winter sports around here are very expensive. Not only is the equipment expensive, but having enough free time to actually go out and do something that takes more than one hour is very difficult for many of our families who are working two or three jobs, since Winter is the busiest season. Also, many of the parents did not grow up in a climate with snow, and came to Summit County for jobs, but not necessarily for recreation.

Is an hour your recommended duration for exercise?

Many studies have shown that 30 minutes a day of movement, whether it’s walking, running or dancing, can lead to adequate fitness. Personally, my goal is 14 hours a week. There are so many things that I want to do, and I want to do them fairly well and fairly intensely, so an hour a day isn’t enough for me to feel like I’m pursuing a maximum fitness level.

Aside from the obvious downhill skiing and snowboarding, what are some healthy activities you recommend during the Winter?

Shoveling snow, snow shoeing, hiking trails that are packed down, on Yaktrax “ice cleats” (inexpensive and very healthy, very good workout), hut trips (gives you a destination, which adds variety and camaraderie to your exercise; carrying a pack adds to your aerobic workout; on your way up, you’re getting the extra workout, but on your way home, it’s almost always downhill (and your pack is lighter), sledding, building snowmen or snow forts …

Do any of these activities provide benefits especially advantageous at altitude?

By doing any activity at altitude, you are increasing your cardiopulmonary fitness (heart & lungs). 

If you’re just getting started, aim for 20 minutes a day, and add five minutes every week. Listening to podcasts, books or music makes everything less painful and more fun. Get a buddy to engage in these simple activities with you. Wear layers for the weather. Being outside doesn’t have to be uncomfortably cold, and you’ll be more inclined to exercise longer if you’re not freezing.

Pay a little more attention to how you can anticipate your hunger throughout the day. I try to keep some nuts, cheese, grapes, small chocolates at my desk, in my pocket, in my car for quick snacks. A smoothie or coffee in a portable cup really cuts the hunger over a good amount of time.

Take advantage of down time to do a few stretches wherever you are. This opens up circulation, allowing your body better access to the nutrients and oxygen your blood delivers.

Be on the lookout for The Doc, cross country skiing on snow day streets, sledding at Rainbow Park, or getting a good stretch in just about anywhere. And let us know if you have a favorite activity that’s easy to fit into a busy or cold, indoor day that you’d recommend!

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.