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Acclimation, Health, High Altitude, Medicine, Mountaineering

Closer to the Sun: The Dermatological Benefits and Consequences of Living at High Altitude

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As many of us know, high-altitude living goes hand-in-hand with a multitude of outdoor activities like biking, hiking, and skiing. But with all that outdoor activity comes an insidious risk: radiation from the sun. According to an article interviewing Kim Guthke PA-C, a Physician Assistant working in Dermatology in Boulder, CO, “living at a higher elevation exposes us to approximately 25 percent more ultraviolet radiation when compared to sea level” (Guthke 2018). This means that with all the outdoor activities we enjoy, we must also be proactive about protecting our skin from high altitude sun and the increased risks of long-term skin issues it brings. 

Using thick UV-protectant clothing, sunglasses, and sunscreen (and reapplying it) are great ways to protect our skin from the sun. However, some new research has argued that we are actually hurting our health by staying away from the sun. In a revelational article from Outside magazine called “Is Sunscreen the New Margarine?”, Rowan Jacobsen uncovered a novel study claiming only the sun can provide the vitamin D we need. He claims that we are trying and failing to supply vitamin D with pills alone, and the pills just aren’t good enough. Vitamin D is a vitamin required for calcium absorption whose levels, if low, can increase one’s risk of “cancer, diabetes, obesity, osteoporosis, heart attack, stroke, depression, cognitive impairment, autoimmune conditions, and more” (Jacobsen 2019). Thus healthcare workers have concluded that supplementing it will obviously decrease the risk of these diseases. 

Jacobsen reports that multiple different studies have proven that supplementation of vitamin D just isn’t enough to lower that risk. The studies reported that even if supplementation raised vitamin D levels, the general health of the patient did not improve. There was no correlation between high supplemented vitamin D levels and overall health.

So, why was this?

Jacobson claims that vitamin D is actually just a marker for overall health. In other words, raising vitamin D by artificial supplementation does not make one healthier; rather, to raise one’s vitamin D level one must live a healthy lifestyle outside in the sun. Jacobsen states, “…what made the people with high vitamin D levels so healthy was not the vitamin itself. … Their vitamin D levels were high because they were getting plenty of exposure to the thing that was really responsible for their good health — that big orange ball shining down from above” (Jacobsen 2019). 

Soaking up the Vitamin D on Lake Dillon.

So, what are the implications of this study? Does this mean we all need to stop using sunscreen in order to absorb the most natural form of vitamin D and subsequently decrease our risk of dangerous diseases? Well, yes and no.

Yes, in that the best way to absorb vitamin D is from the sun and sunscreen does inhibit that absorption.

No, in that one day of playing at the beach and getting horribly sunburnt is not going to raise your vitamin D levels enough to benefit your health.

Unfortunately, the answer is quite complicated. I believe the implication of this new information is that we all need to start getting outside every day, exercising, enjoying the mountain air, and absorbing small amounts of sunlight each day, rather than just enjoying a single session of baking our skin to blisters. Living at high-altitude, I hypothesize that we don’t need as much time to absorb the same amount of beneficial sunlight as we would at sea level, so I feel there is still a need for sunscreen and protective clothing, if outside for an extended period. We should all try to absorb the sun’s rays daily, but we need to do it in a healthy way.

Cooling down on the way up Uneva Peak off Vail pass.

I encourage everyone to read Jacobson’s article, as it has points both for and against protection from the UV rays of the sun. In the meantime, there is one point Jacobson makes that I would like to argue. 

In his article, Jacobsen admits that increasing sun exposure does increase the rate of skin cancer, but then claims this is ‘okay’ because, “Skin cancer kills surprisingly few people: less than 3 per 100,000 in the U.S. each year … People don’t realize this because several different diseases are lumped together under the term ‘skin cancer.’ The most common by far are basal-cell carcinomas (BCCs) and squamous-cell carcinomas (SCCs), which are almost never fatal” (Jacobsen 2019). The reason I’m disagreeing with this point is due to my direct experience with the “non-fatal” skin cancers. I spent 12 months working with a board-certified dermatological surgeon performing Mohs micrographic surgery, a delicate and precise surgical procedure to remove said cancers from the face, ears, scalp, fingers and toes. Although it’s true BCCs and SCCs are rarely fatal, they can cause significant damage to one’s image. Depending on the location and size of the cancer, a “non-fatal” SCC in-situ has the potential to cause extensive disfigurement of the face, ears, or eyes. I strongly believe this is not something to take lightly, and I fear that saying skin cancer is non-fatal creates a false sense of security. This can be especially dangerous in high-altitude where the sun’s rays are exceptionally stronger than the majority of the US. 

All in all, I do believe that the sun is incredibly beneficial to our health, though in moderate portions. Living in the Colorado mountains gives us more opportunities to enjoy the mountain air, along with the sun, and allows us to lead healthier lives in general. I don’t think I’m going to stop using sunscreen in the near future, but I do know I won’t be so afraid of the sun anymore. I definitely won’t be letting the sun keep me from enjoying my time here in Colorado!

Delaney Schara is a Physician Assistant student at Des Moines University in Des Moines, Iowa. She hails from Fergus Falls, Minnesota, and obtained her undergraduate degree in Chemistry at Augustana University in Sioux Falls, South Dakota. Delaney gained valuable experience in medicine by working as a medical scribe in Dermatology prior to beginning PA school. After completing her pediatrics rotation with Dr. Chris, Delaney will have rotations in multiple Midwestern states before her graduation in June 2020. Delaney is an avid musician who loves singing in choir, playing the flute, and playing acoustic guitar. She also enjoys tasting new blends of tea, exploring rural communities, and spending time with loved ones. 

References

Guthke, Kim. “Sun Protection at Higher Altitudes.” Boulder Medical Center, 29 August 

2018, www.bouldermedicalcenter.com/sun-protection-at-higher-altitudes/

Jacobsen, Rowan. “Is Sunscreen the New Margarine.” Outside Online, 6 June 2019

www.outsideonline.com/2380751/sunscreen-sun-exposure-skin-cancer-science?utm_source=pocket&utm_medium=email&utm_campaign=pockethits

Health, High Altitude, Medicine, Mountaineering, Technology

Wilderness Medicine & Medicine for our Wilderness

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Our mission of advocacy and community building continues at our little mountain clinic as the aspen leaves have just begun to turn, and our passion for high altitude research has brought us to a unique and timely junction between the Wilderness Medicine Society‘s conference in Crested Butte, Colorado that Dr. Chris attended, and a recent conversation with the founder of The Sustainable Hiker, Summit County resident and voice of the Wilderness, Tom Koehler.

As health care providers in the high country, we see patients experiencing all kinds of reactions to the extreme altitude, residents and visitors alike. Even those who aren’t out climbing fourteeners or skiing can often experience symptoms of acute mountain sickness. Needless to say, we also see our share of injuries in the more adventurous outdoor-inclined. We ourselves make a point of regularly venturing out into the celebrated Colorado forests to experience this demanding environment first-hand, and it is not always without incident, in spite of our expertise and careful planning, and these past Spring and Summer seasons have been no exception, between hut trips, fourteeners, camping, kayaking, stand up paddle-boarding, cycling, lifting, yoga, and running at 9000′ and above! It is our due diligence and life’s work to share our experiences and the valuable research being done across the globe with you.

Dr. Chris and her contemporaries have returned from the Wilderness Medicine conference this year with some good and bad news. First, the good news:

Dr. Chris receives some impromptu wilderness medicine for a scrape on a recent trip to Harry Gates hut.
  1. There are no brown recluse spiders in Colorado, according to Kennon Heard, MD (although Dr. Chris’s sister-in-law disagreed with this expert’s statement).
  2. Most snake bites do not inject venom, so anti-venom treatment is only indicated if symptoms are noted. The anti-venom is very expensive, but treatment of the wound is important in order to control the cascade of events set off by the venom, starting with a diffuse reaction similar to a severe anaphylaxis, followed by neurotoxic fasciculations of muscles, along with a necrotizing wound causing pain and swelling at the site of the bite and ending in a full disruption of every clotting factor and cell in the body. The clotting disruption does not lead to hemorrhage. In layman’s terms, most snake bites aren’t shown to lead to symptoms, but should you experience any symptoms, things could escalate to life-and-death very quickly.
  3. Another useful talk was given by a specialist in foot care, Patrick Burns, MD, DiMM (Diploma in Mountain Medicine): He recommends wearing two pairs of acrylic socks and protecting areas of friction with paper tape. He rejected the ointments and gels as unproven. Don’t use duct tape, as it damages the skin, and moleskin tends to be too thick. Blisters should be left intact, although consider draining if pain is intense. Healing takes 120 hours.
  4. For accidents and injuries, studies show that irrigating wounds with water is as good as saline, and a well-filled Camel-bak makes an excellent splint for fractures. Pain was addressed by Alex Kranc, MD, FAWN (Fellow Academy of Wilderness Medicine): doses of acetaminophen 1000 mg and ibuprofen 400 mg or Naprosyn given together or alternately are as good as stronger prescription medicines in most cases. A system of acupuncture without needles that is light and compact has been shown to help with pain in combat situations (where, incidentally, many of these techniques and tools are developed). Think of a sticky patch that you apply to a pressure point behind your ears.
  5. Linda Keyes, MD discussed women at altitude, including some helpful tips for dealing with menstruation on wilderness treks: menstrual cups catch the flow and can be washed and used over again; taking the active birth control pills continuously will delay the onset of bleeding. Another piece of good news: bears (and sharks) are not attracted by menstrual blood.
  6. In a discussion about training for altitude events, Aaron Campbell, MD, MHS, DiMM, FAWM reviewed the role of sleeping in hyperbaric chambers or tents, which showed a mild improvement in adaptation. The best way to prepare for climbing Mt. Kilimanjaro, he said, is to climb a fourteener every week for 6 weeks!
A slide on improvising a Camel-bak bladder as a splint at the 2019 Wilderness Medicine conference in Crested Butte, Colorado.

The most exciting and spellbinding parts of the conference, according to Dr. Chris, were the descriptions of rescues from mountains, crevices, and ledges from Alaska to Boulder.

Now for the bad news:

Michael Loso, PhD gave a fascinating talk on the science of glaciology and water acquisition research in Alaska. Poo on the glacier gets buried and frozen, and lasts for years, if not decades, and they have even found traces of E. coli around certain base camps too high for drinking standards. This obviously can significantly compromise water quality, even at higher elevations, where we imagine the water from snowmelt is of the most pristine quality, a subject I also speculated about with Tom Koehler. This is why you should carry a proven filtration system. Tom’s preference, when possible, is an 8-minute boil.

Can you see the Rocky Mountain big horn sheep?

But what about the Wilderness itself? Colorado’s Continental Divide plays a major role in where our water goes, how it gets there, and in what condition. Sixty-eight percent of Colorado’s forests are federally owned and protected, one of the highest in the nation. With the continuing rise in residence and tourism, increased traffic through our precious forests is a double-edged sword.

“Summit County is really a microcosm, but an example of a larger issue facing Colorado: exponential growth, both in permanent population, as well as increase in guests to our land. So that, on a high level, has water managers scratching their heads, wondering, ‘How are we going to deliver the water we need for businesses and human health?’,” explains Koehler. “Summit is unique, particularly in the water issue, because we supply a significant amount of runoff into the Colorado River at the headwaters in Kremmling. And that arguably touches an estimated 40 million people all the way to California,” giving a rough estimate.

“A lot of Colorado is struggling to maintain their trails. We have about 430 miles of trails of all uses. In this county, we have a lot of trails to maintain, and arguably, that’s our first line of defense against erosion into our streams. It’s just a cascading effect (pardon the pun),” he says. “Most every park and forest in the West is under strain for maintenance. We just happen to be the most recreated, visited in the country, with 4.4 million recreational visits per year.”

Koehler’s passion for conservation and preservation of our forests and watershed was fostered in natural forests of Shenandoah Park, where he frequently escaped to while working as a research director for a wealth management firm in Washington, DC, while also dreaming of a career as a competitive skier in Park City, Utah.

“Once the opportunity arose to head out West with a couple of pennies in my pocket, I took it, and my move to Summit County was transformational in that I saw nature first-hand, right outside my door.” It transformed his outlook on how it benefits us all, even economically. He started volunteering with the Summit Huts Association, which provided him with “tremendous opportunity to really be in the backcountry”, the High Country Conservation Center, where he “really carved out an ethos for [himself] of stewardship”, and was even named the Friends of the Dillon Ranger District Volunteer Recruiter of the Year for 2015.

The Sustainable Hiker was founded as a response to recognizing that the efforts on a lot of fronts being made by organizations wasn’t as widely broadcast to both locals and guests. It’s mission: to be the leading voice for protecting Nature.

“I see the Sustainable Hiker as part of a number of organizations from the stewardship to the climate change advocacy groups to the local conservation groups, where you can find out what’s going on with your land and water here in Summit County.

“A healthier forest provides me with cleaner air and cleaner, more reliable water. It’s taken for granted. Kind of like a factory that turns out profits, it has to be maintained to continue yielding as high a profit.” Spoken like a true financier.

Setting off through the Eagle’s Nest Wilderness below Buffalo Mountain in Summit County, Colorado.

So what is one thing Colorado residents can do, immediately, to forward this movement of sustainability?

“Immediately, wherever you reside or are visiting, look at a nature or forest stewardship project, or educational events related to our forest or nature, and sign up.”

What is one thing we can stop doing that will contribute to the preservation and conservation of our forests and water?

“Stop, right now, taking nature for granted. Because we need it.

“Stop relying on your car for everything.

“Stop talking. In Nature … our time in Nature is a time to slow down everything, including our conversations. For two reasons: for the joy and peace we experience listening to the birds, and it gives the wildlife a break, too.”

Below treeline on the way up to Harvard and Columbia peaks outside of Buena Vista, Colorado.

I understand his point. While living in Japan, I learned a word, “shin-rin-yoku” (森林浴), literally translating to “forest bath”. The idea revolving around the practice is that by walking through the trees and water in the forest, you exchange ions with it, providing your body with a balancing recalibration. I believe this is also a vital part of high-altitude health.

The Sustainable Hiker provides insight into Koehler’s mission, at sustainablehiker.com, where you will also find information on organizations, events, and his newsletter, Nature’s Beacon, drawing attention to conservation projects you can get involved in.

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.

Acclimation, Child Growth & Development, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering, Technology

What’s Going On in La Paz?

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The 7th Chronic Hypoxia Symposium was held this year in La Paz, Bolivia, in February and March. La Paz, sitting at 11,942 ft. (3640 m), is home to one of the world’s leading researchers of the effects of chronic hypoxia, Dr. Gustavo Zubieta-Calleja, with whom Colorado’s own Dr. Christine Ebert-Santos was able to meet with during her attendance of the symposium. You can refer to her previous article on the gathering of experts from over 16 countries for her own account of Dr. Zubieta-Calleja’s impressive work.

Below is the renowned Dr. Sanjay Gupta’s own account on video of his introduction to the experience of hypoxia and altitude with Dr. Zubieta-Calleja.

Always keep in mind, there are many physiological reactions going on when your body and brain are at altitude, and the higher the altitude, the more extreme the effects. Benefitting from a hypoxic environment isn’t as simple as staying hydrated. When we talk about chronic hypoxia, we are typically referring to a population who have spent many years in a high altitude environment.

robert-ebert-santos
Roberto Santos on an epic powder day at the opening of The Beavers lift at Arapahoe Basin ski area.

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.

Child Growth & Development, Health, Medicine, Technology

Technology in Health Care: Interview with Family Nurse Practitioner Tara Taylor

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After over a decade of serving pediatric patients in the high country communities of Colorado as Ebert Children’s Clinic, we opened up our health care practice to serve the needs of the adult population several years ago. As Dr. Chris can attest to, the world of health care has grown and evolved incredibly since she first opened up her practice in Colorado in 2000, and we all continue to learn from the providers we welcome to our team as well as the students we mentor.

Family Nurse Practitioner Tara Taylor.

This past year, we’ve had the pleasure of having Tara Taylor, FNP on our staff. She’s brought a wealth of knowledge and unique experience from having practiced on a medical campus much, much larger than our little mountain clinic, and her insight into everything from patient care to our own high altitude research projects continues to be an invaluable asset to both our practice and our community. She was so gracious one afternoon to have a chat with me between patients:

How did you find yourself in Colorado’s high country health care community?

So, I have actually lived here since 2004, so I’ve lived here 15 years. I came out here for 6 mos to ski, and stayed for 15 years. I found myself loving it, bought my first house and decided to stay out here. I’ve actually commuted down to Denver all this time, because I had originally started in New Jersey in 2002 in Critical Care. So when I moved out here I wanted to be in the mountains, but I also couldn’t do Critical Care up here at that time. So I decided to commute down to Denver for three 12-hours shifts a week, and then live up here four days a week. So I had an apartment in Denver … when I went back to NP school, my goal was to work and live in my own community. I think that’s huge for me … and not only be serving the population of Denver, but to be serving the people of my actual community.

How long had you been practicing in Denver?

Since 2005, because I worked 6 months at Keystone Clinic, so I’ve been in Denver working for 14 years  prior to this in the ICU. And I’ve worked at Children’s hospital in the pediatric ICU, burn ICU’s, bone marrow transplant, open-heart surgery, neuro-trauma, multi-system trauma, all of it.

How is it different working up here, for a small clinic, at that?

This is a huge change … I’m still working down there once a month, so I get to go down and play and enjoy that type of intensity. But at the same time, coming back here, I think that the critical care aspect … it still plays a role here. And in my letter, when they said, “Why do you want to go from [being] an ICU nurse to family practice?” … I said for so long, I’ve seen patients in the ICU [whose] admission or … critical portion of their admission could have been avoided if they had better focus on primary care and had their needs met. If they had been on the right medications, if someone had spent the time — and sometimes it’s because of their own compliance — but with adequate primary care, we’re avoided what I was seeing in the ICU. 

Now, being in primary care, I get the stimulation I need from the independence of it, making these decisions, and I really enjoy finding out what’s going on with the patient, deciding what tests to run, and getting back these results and being able to properly refer them. I enjoy the time that I’m able to have with those patients here at a private practice. So each patient gets the time that they need to be properly cared for. 

And I’m just seeing extremely sick patients. I’m not seeing a lot of sore throats and earaches, unless you’re 2 years old; besides that, the adults have really complex diagnoses that require a lot of thought. And in its own respect, it’s critical to me.

Great segue: what are the greatest challenges you’ve seen practicing up here?

I think some of the biggest challenges that I have seen up here is limitation of services. That’s why this clinic is bringing up Nephrology, … [expanding] mental health services here, and then, to bring in … pain management specialty, and give them a place to practice … It’s really hard for these additional specialties. We have Cardiology up here, we have Pulmonology, but some of the smaller things like Rheumatology for rheumatoid arthritis, for osteoporosis and kidneys … how do you establish your practice up here? So hopefully, as focused as [Ebert Family Clinic] is in the community about being able to provide the care we want for our patients …  we’ll be able to get that door open for those specialties and help them establish their practice up here, which is our goal.

How do you get connected to these services like Genomind?

[This patient] came to me with Genomind. I had not heard of that before. He said, “I got on the right medications because this genetic testing gave [Compass Health] the ability to treat me properly.” [Certain health care providers in Denver] require it, almost, for every patient walking in their door as a prerequisite to help them make medication decisions. 

Genomind is a swab in the cheek. I think it’s huge, because we’re not able to “draw” neurochemicals. We’re not able to draw your blood and say, “oh, look, you’re deficient in serotonin.” Because that’s not an option, what’s the best way for us to figure out what’s the best medication for you? Because medications are very specific to what they’re treating. So the only thing we’ve been able to do for the last decade is to guess; to put you on something, and if it doesn’t work, then we know that’s not the thing. And that’s a terrible process, because it leads patients to trying five medications, over a ten-year period, and finally we get them on the right thing. But how frustrating that is for patients; they lose confidence in their providers, they lose confidence in the system, they feel neglected, they feel frustrated. And to have that stamina to even go through that process … I think we have a lot of patients drop off. [They] end up saying, “Forget it. Medications don’t work for me.” Then [they] become non-functional … their quality of life is hindered by their [unwillingness] to spend ten years trying five medications.

That is not the best process. And I think the people that went ahead and engineered Genomind said, “What else can we do? What if we went back to genetics? What if we went back to genes?” We can swab a 1-day old infant or a 95-year old man, and we are going to get their genetics. And when they did the Human Genome Project, and we got our entire genetic profile as human beings, the science behind Genomind was they were able to take anyone who’s been diagnosed with schizophrenia, people who are known bipolar, generalized anxiety disorder, major depressive disorder, took their DNA … laid them over each other, and said, “What gene is predominant in all these patients?”

So they were actually able to use hundreds of thousands of mental health patients to establish what genes these were that led to the cause of their mental illness. So now we’re able to send off DNA with a swab in the cheek. It’s not a perfect science, but it’s what we have.

Is this better than nothing? There’s so much controversy about this test. How can you think this is controversial when you come from a science background as a provider, as a physician. You’ve got this, or you have nothing to guide you for the mental health of these patients. If we have this over nothing, I will take this.

[Genomind testing] is not only [about] mental health disorders, but also [for] people [suffering from] eating disorders, difficulty losing weight, ADHD, alcohol addiction and propensity for opioid addiction. It would identify what patients we may never want to start on narcotics if at all possible. It tells us, “Don’t start this patient on this particular drug because they’re at risk for gaining weight with this drug, like as an atypical antipsychotic.” It would tell us which medications an alcoholic would respond to best, if they were wanting to quit drinking and needed medication assistance. We have a lot of kids who seem like they’re ADHD, but really they have signs of anxiety and depression as well. And it’s our job to distinguish [whether] it’s the ADHD that’s causing the depression and anxiety, or it’s the depression and anxiety that’s causing the inability to focus? It’s absolutely fascinating! I want the community to know that we’re offering that here at the clinic.

Is Genomind available to children?

We can test anyone of any age. We can swab the cheek of a one-day old. I actually had a mom in here that said she was tested positive for both genes for the lack of ability to metabolize L-methylfolate, which causes bipolar disorder or mood instability. She came in here with her 4-month old son and said, “When can I get him tested to know?”

So I actually asked Genomind, and Genomind said you could test a brand new newborn baby, which at some point may be the standard of practice!

But at this point, it’s hard to want to test that child, because we’re not able to treat that child [without symptoms]. Once that child becomes 6 or 8 years old, and they are having mood instability, they are showing signs of some sort of mental illness, we do realize we are able to identify this in children. We don’t need to wait until people are 18 to say they must have a mental illness. We are identifying that in the behavior of hyperactive two and three year olds, and we’re seeing them grow up to be bipolar adults. So we are seeing early signs and symptoms of mental illness in these children. 

Could we test a 6-year old who is showing signs of something and have them be positive for these genes and be able to supplement them with L-methylfolate or an approved psychiatric medication in the pediatric population based on their genetics? This is absolutely going in that direction. Genomind said they’re 100% approved for adult and pediatric testing.

How do you find balance for yourself and maintain a healthy lifestyle?

Tara with Dr. Chris (center) and Kristen Duffy, A/GNP, at Ebert Family Clinic.

Working at this clinic actually provides me with the exact hours I need to have good work-life balance. That’s extremely important to Dr. Chris Ebert-Santos. When I started working here, she said, “What are your husband’s days off?” And I said, “Sunday-Monday,” she said, “Okay, well you’re not working Sunday-Monday then.” I just honestly couldn’t believe it, that my happiness was that important to her. I work reasonable hours. [Dr. Chris] provides me with the days off that will match my husband’s. I have great quality of life due to my husband. He’s an amazing person, wonderful and spirited, and we get along great. So we have that, and we have our two dogs, and we live a comfortable life up here. We love to do all the great stuff that Summit Countiers do: snowboarding, hiking, biking, camping, just getting outside in general together and playing with our dogs. And that’s what’s most important.

What have been your greatest takeaways from working in Summit County so far?

I think it’s running into that patient at the supermarket who, I know in the back of my head I have their diabetes controlled. To know that I’m specifically helping patients in my community. That I’m doing yoga next to someone [whose] blood pressure is controlled now because of me. I think that’s something really special and it’s not something that I had before when I worked in Denver, and I would come home and I would never see those people again. And then, having the opportunity in this clinic to deal with so many pediatric patients, since this was originally a pediatric clinic [before] expanding to adult services as well, which is amazing. But the amount of pediatrics in this clinic really improves both my exposure to every age group. I love kids. To have patients hug me in this office who have had a very challenging diagnosis … that “thank you” from patients is something I cannot replace.

Tara continues to be a passionate advocate for mental, women’s and sexual health, and a valuable resource as a health care practitioner. Ebert Family Clinic is proud to have her.

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Roberto Santos on an epic powder day at the opening of The Beavers lift at Arapahoe Basin ski area.

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.

Acclimation, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering

Coloradans on the Annapurna Circuit

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One of our nearest and dearest, Shelbie Ebert, a certifiable high country local born at Vail Valley Hospital, has been an adventure guide for the last decade. She is currently working on her nursing degree, and is an Emergency Medical Technician. While she has done some multi-day backpacking in the past, she says her recent trip to Nepal was her “most ambitious journey to date.” I was able to sit down with her and her mother, Karen, and hear all about the literal ups and downs on the Annapurna Circuit, in the central mountain region of Nepal, where they reached the highest point at 17,769 ft (5416 m)! They were in Nepal from April 17th to May 17th.

This trek is of international fame, and there are many resources to inform those looking to embark on this historical, spiritual, mental, and physical adventure. All in all, they spent 14 days on the trail. But I was so curious what it was like for those more familiar with the unique challenges posed by Colorado’s high altitude environment.

Did you do anything different from others you observed on the trail?

Most people had porters; we decided not to do that. Even those who didn’t have porters hired a guide.

Having been born and raised at a higher elevation than most, did you notice a difference between your own process of acclimation and that of your colleagues?

I did get sick in Nepal, but it was mostly stomach sickness. No headaches or anything like that. Mom didn’t feel a headache until we got pretty high up. We noticed a lot of people dropping; a lot of people bused into Manang, and from there, it’s a two-day hike up to the base camp, and from there you cross the pass. They got on the trail from there. Manang is at about 10,000 ft. Those people definitely struggled more. 

A father and son hiked the trail side-by-side with us. They didn’t hire porters. Shortly after we got over [Thorung La Pass], the son got really, really sick. The pass tops out at about 17,200 ft. When we saw him at the top of the pass, his lips were bright blue. I think he started to get sick on the ascent. I think he was probably about my age, and he was a doctor. He had some drugs stocked up and he felt pretty confident about doing the hike. 

They started their hike at about 2600 ft. above sea level. In a matter of 10 days, they would climb to over 17,000 ft. over 70 miles.

How long did you take before you started hiking?

We flew into Kathmandu, spent two days there, then took a long bus to the city where we started hiking, and we started hiking as soon as we got off the bus. We did take an acclimation day in Manang, at 10,000 ft. We hiked to it, then we spent an extra day there, about 48 hours. 

What was the greatest challenge about this excursion?

How much constant up and down it was, with the altitude gain. The day that we went over the pass it felt like a good day to me, because it resembled hiking in Colorado. But those days of up and down prepared us well for the pass. 

Did you do any training in particular in preparation for this excursion?

No, absolutely not. I read a lot of blogs so I knew what to expect. I tried to have just a really good plan for what we could and couldn’t do, and when we got to Kathmandu, I stocked up on all kinds of drugs, because anyone can buy them. Diamox. I think I maybe only took one once on our ascension day, just to get ahead of the game. 

Did you change or adjust your diet at all to prepare for this excursion?

I thought I did. I looked up some Nepali food online and tried cooking it at home to prepare my stomach for the type of food that we would be eating, but I found it was nothing like actual Nepali lentils and rice. 

Learned some hard lessons about food. A lot of the lentils in Nepal made me sick. Luckily they have a lot of potato-based dishes. 

[There was a] surprising amount of good snacks available, [lots of pre-packaged cashews, nuts, cookies and snacks]. I would recommend for anybody to bring five or six cliff bars for the harder days.

Also kept some sugar on me: Snickers, chocolate, gummies … I forced Karen to eat some sugar when she wasn’t feeling well, and that seemed to improve her condition.

Karen did experience some symptoms of altitude sickness as they ascended the highest point of the trek, Thorung La.

In retrospect, is there anything you would have done differently in preparation and/or on the trail?

I would have packed a lot less. We had about 35 – 40 lbs. in our bags, and that was way too much — and totally unnecessary. Less is more on the trail. We did end up hiring a porter to carry my mom’s pack on our big day, and that was an excellent decision. 

Did you notice anything different upon your return to a much lower elevation?

I felt really strong! I was really grateful for my body. I think it was mostly a mental shift. I felt more capable doing most activities, whether it was mental or not. I started taking better care of myself. I started running in the mornings before school, which is something I never would have felt before. 

I thought, “I hiked 17,000 ft, I can probably run a mile and be okay in the morning.”

Any other advice you’d give in particular to other travelers intent on similar excursions?

You know what, go for it! It’s not as hard as you think. I came to a country I’d never been to before with a book in my hand, and we did it! I think anybody can really do it.

Shelbie is honored to have shared this experience with her wonderful, strong mother. And this isn’t the first or last adventure they will have been on together. True backcountry buffs, I can always find them on all types of gear on the snow, on the river, or on the trail.

Shelbie and Karen victorious at the height of Thorung La Pass.

If you’d like to read more details about their Annapurna Circuit Trek, Shelbie maintains a blog where you can find all kinds of tips and recommendations on backcountry gear at lahlahdesigns.com.

robert-ebert-santos
Roberto Santos on an epic powder day at the opening of The Beavers lift at Arapahoe Basin ski area.

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.







Acclimation, Doc Talk, Health, High Altitude, High Altitude Training & Fitness, Veterinary Medicine

Dogs at Altitude

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The mountain communities are home to more animals than people in Colorado. Every Spring, we’re likely to see everything from foxes to moose in our yards and on our streets. About a month ago, I watched a juvenile (but plenty large) black bear on an evening walk in front of the houses in our neighborhood, peeking into the garbage bins lined up for pick-up the following morning.

Claire Tinker with her Dachshund Baxter on Bierstadt.

Dogs are natural companions to many up here as well, with plenty of space to run around, smells to sniff, and communities that seem to welcome their company indoors as well as out. Having seen so many of our dog friends on trails all across the state, we’ve wondered how they might be coping with the altitude. 

Most recently, we ran into a German short-haired pointer named Moose on an ascent up Mt. Bierstadt, one of Colorado’s 14ers, sitting at 14,060 ft (4285 m). He and his human, Nick, moved to Colorado permanently about a year ago, after a two-week visit turned into several months. 

Moose is 13 years old, Nick tells me, “but you have to believe that my dog acts like he’s 6.” Nick and Moose have been enjoying a lot of time outdoors together since moving to Colorado, and Bierstadt was their first 14er together, which they did with some other friends from Louisiana, where they’re from. 

“It was awesome. Took [our friends] a long time to summit, but Moose did really well. He liked the breeze and the birds coasting right next to him. It would have been hard without a harness to [lead] him up to the top. He’s 65 lbs. Boulders weren’t too bad for him. Just have to be careful coming down, so he doesn’t slip and break a leg.” 

Moose and his Louisiana posse on their way up Mt. Bierstadt.

This is a very legitimate concern. Many hikers have found themselves carrying their canine counterparts: they get tired, the terrain is difficult for them to negotiate or too rough on their bare paws, etc. You definitely don’t want to have your hands full as you ascend or descend a 14er.

Dr. Danielle Jehr, who has been a veterinarian with Frisco Animal Hospital for years after studying and practicing in Nebraska, also recommends waiting to take your puppy on the longer, more strenuous hikes.

Dr. Danielle Jehn with hiking and car ride enthusiasts Libby and Liam.

“Unfortunately, we do not get a chance to discuss this with many owners unless there are new puppy owners. Usually, we just see the aftermath from a hike and help guide them for future incidences. I would love to be able to tell all new puppy owners that activity needs to be limited up until 6-8 months of age while they are experiencing enormous amounts of bone growth. This means no major hikes on uneven surfaces and no 10 mile runs while the owner mountain bikes. We just want the pups to grow normally without complications for them or the owners.”

And as you might have speculated, animals are also prone to certain risks at high altitudes, although, “In general, healthy animals do not function any different at high altitude,” says Dr. Jehn. “Animals and pets with known blood pressure, cardiac or respiratory disease can decompensate at higher altitudes, and we do see this in practice. Just as human hearts have a difficult time at altitude, so do cats, dogs and livestock!”

Ike, about 8 months old, seriously reconsidering his choices on his way up Mt. Bierstadt.

So how do you know if your furry buddy is struggling with acclimation?

“Most often, an owner will call and have a presenting complaint of their pet experiencing exercise intolerance while on a hike or constant panting/lethargy/anorexia since the pet has been up in Summit County. If a dog presents in any type of respiratory distress, we place them on supplemental oxygen, check their heart and lung sounds, heart rate, respiratory rate, blood pressure and ability to oxygenate. We do this by utilizing a tool in the clinic that measures the percentage of oxygen carried in the blood.” Sound familiar? “We always want to see a dog at over 92%. If the dog or cat cannot maintain that or better without being provided oxygen, we need to see other diagnostics for reasons why.

“Common canine ailments we see that are drastically exacerbated by altitude are: cardiac disease (heart murmur, pulmonary hypertension, congestive heart failure), general hypertension, lung disease (asthma, allergic bronchitis) or vascular volume abnormalities (i.e. anemia).”

The most common injuries Dr. Jehn sees, she tells me, are “lacerations and abrasions from the rough terrain. We also see exacerbated lameness after hikes that are too long for our canine friends that are not otherwise used to it (i.e. 14ers).”

Nick and Moose currently live in Boulder, at 5328 ft (1624 m), but they moved there from a house in Bailey, at about 7740 ft (2359 m). I ask Nick if Moose has ever had trouble with the altitude since they moved to Colorado. 

“Not at all. Not even when we first got here. He was ready to rock and roll. The only thing he didn’t like was the snow at first. Once he realized there were rabbits and stuff that went in the snow, he was about it.”

Being from Louisiana, one of Moose’s greatest challenges is the relative scarcity of water. Colorado doesn’t have as many lakes and ponds that Moose can cool off in and drink from, so Nick says he’s sure to carry water for him.

Nick also tells me that Moose is a pretty fit dog, and has never experienced any major health complications. He is careful, however, not to work him so hard that he’s limping the following day. I think it’s safe to say that’s something humans are wary of for themselves as well. If you’ve ever hiked a 14er, you already know. 

Dr. Chris with grand-dog Ike on their way up Mt. Bierstadt.

Another factor that affects Moose and people alike is exposure. “If there’s no shade or wind, it’s a lot harder on him,” Nick notes. We also relate over the challenge of descending a mountain, when the resistance of gravity is especially stressful on your knees and hips. Nick works for Sacred Genetics, a company that cultivates feminized hemp seeds, who are partners with a company, Verdant Formulas, that specializes in CBD products, utilitzing the relaxing, remedial properties of the oil from cannabis. Among other applications, balms and oils infused with CBD have grown in popularity as a naturopathic treatment for muscle soreness and inflammation. Incidentally, more and more similar products are being marketed for the same afflictions in dogs. Nick tells me it helps with his own post-adventure soreness.

My main takeaway from all this insightful doggo dialogue is that we are all the more similar. It certainly seems like the same precautions apply for avoiding a serious situation outdoors. And don’t forget, if anyone in your party is having trouble on your hike, it is not advisable to continue; you are only as strong as the weakest member of your team, whether that is a dog or a person. 

A last bit of advice from Dr. Jehn:

“I would also love to be able to tell all tourists to take it easy on their canine counterparts while visiting us in Summit County as well. Altitude sickness is real for humans and dogs, alike. Accomplishing a crazy hike with your dog should not be the first priority within the first few days at elevation. Dehydration and prior health conditions are real when experiencing altitude. If you know your dog has history of a heart or lung issue, especially, let them take it easy. We want you to enjoy Summit County for everything it has to offer….without the emergency visit!!”

Happy Trails, all you trailhounds and trail … hounds!

robert-ebert-santos
Roberto Santos on an epic powder day at the opening of The Beavers lift at Arapahoe Basin ski area.

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.

Acclimation, Health, High Altitude, Medicine, Mountaineering

Altitude and the Brain

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Our brain is a highly demanding organ that requires a constant supply of oxygen, evidenced by how quickly a drowning victim loses consciousness. But apart from being under water, many other places on Earth expose our brains to the low oxygen levels that cause hypoxia, or lack of oxygenated blood flow to the brain. The most common of these places is that of high altitude (current studies in the US often define this as above 8,000 ft.). But how does long-term exposure to the low oxygen levels in these environments affect our brains?  Recent studies have revealed new dangers from exposure to extremely high altitudes (15,000+ ft.), and they suggest that our brains also feel the impact at less extreme elevations as well. As concerning as these findings may be, further studies are being done to increase our knowledge of these effects and luckily, methods to prevent and avoid them do exist. But in order to avoid them effectively, we must first understand the dangers that high altitude presents. 

Extremely high altitude locations are some of the most impressive and breath-taking places in the world. They often serve as bucket list checkpoints for travelers and mountaineers everywhere.  However, in a 2006 study by Fayed et al, a new risk for extremely high altitude hikers (15,000 ft+) was revealed1. MRI scans were performed on the brains of those returning from locations including Mt. Everest, Mt. Aconcagua, Mont Blanc and Mt. Kilimanjaro1.  Shockingly, almost every Mt. Everest climber returned with brain changes on their MRI scans. They revealed cortical atrophy and enlargement of their Virchow-Robin spaces, processes that are usually associated with aging1. The amateur of the group seemed to suffer the most permanent changes with subcortical lesions as well1. Where there had been one unaffected hiker in the Everest group, none returned from the Aconcagua expedition without brain changes. Four hikers also showed subcortical lesions1. Unfortunately, and even more concerning, most of these changes were still present on MRI scans several years afterward as well1. 

A follow up study in 2015 by Kottke et al. examined mountaineers before and after a 7,126m (23,373ft) ascent and found that none had subcortical lesions afterward2. However, there were increases in cerebral spinal fluid fractions and decreases in white matter fractions in several of the hikers. They also took it a step further and related it to the hypoxic levels and mountain sickness symptoms that the individuals suffered and were able to correlate these episodes with more significant brain changes2. 

More research must be done to determine what these brain changes mean and how they will impact the lives of these individuals later in life. However, researchers have also found ways to approach altitude that seemed to lessen these effects. The number one suggestion that professionals share to prevent the possibility of permanent brain changes is simple; ascend slowly1. The studies that found permanent brain changes in extreme altitude hikers seemed to find worsened effects in the amateurs that ascended too quickly versus the professionals that had ascended correctly, over time1. Oxygen supplementation and other methods to prevent acute mountain sickness during the climbs seemed to help as well1. 

For those of us that refrain from scaling some of the world’s tallest mountains, but frequently visit or reside in moderately high altitudes, our brains can also be affected.  Abrupt elevations in altitude from a low level environment have been shown to affect people’s memory storage and recall3. It has also caused impairments in concentration, aphasia and finger tapping speed temporarily3. In a 2016 study that examined young, healthy individuals living at altitudes of 3650 m (11,975 ft) for a minimum of three years, significant impairments in attention were revealed4. Early and late stages of attentional processes were impacted in this study group when compared with a control group4. These impairments were also made more significant when larger amounts of perceptual input, or distractions, were added4. 

In terms of the long-term high altitude group, attention span data did show impairment in early and late stages, but interestingly, changes in brain activation on brain scans were proposed as possible mechanisms to attempt to compensate for this4. Moreover, it was also found that later stages of attentional processes showed less brain activation in the high altitude group, but they found that this discrepancy lessened the longer that the individual lived at altitude, suggesting adaptation was occuring4. 

Rather than residing at moderately high altitudes, traveling to them can also affect the brain. The same advice of ascending slowly at extremely high altitudes is also applicable here. Giving the body time for appropriate acclimatization is key to preventing any physical symptoms as well as any confusion, sluggish thinking, or difficulty concentrating and focusing1. Proper hydration, nutrition and the occasional oxygen supplementation can lessen symptoms as well. 

In conclusion, more research is needed to study the effects of permanent brain changes from extremely high altitudes as well as to determine if there really is a danger toward our attention spans, or any other cognitive processes, from living at high altitude. Although it is important to be aware of these risks, very few residents and adventurers let it hold them back from visiting and living in some of the most incredible places in the world. As long as we approach with an understanding of the dangers, prepare appropriately and always ascend slowly, not even our brains can hold us back from the adventures to be had in these amazing locations. 

Jenna Bradfield is a Physician Assistant Student at the University of St. Francis in Albuquerque, New Mexico. Prior to PA school, she completed her undergraduate studies at Southern Utah University where she played collegiate volleyball as well. She is currently completing her third clinical rotation in Pediatrics at the Ebert Family Clinic. As she is originally from a small town in Utah, she has and will be completing several more rotations in her home state along with other rotations in New Mexico and Texas. She grew up loving the outdoors and sports, and also enjoys physical fitness, music, reading and spending time with friends and family.

References:

1: Fayed, N., Modrego, P. and Morales, H Evidence of brain damage after high-altitude climbing by means of magnetic resonance imaging. American Journal of Medicine. 2006. 119, 168.e1-168.e6. 

2: Kottke, R. Hefti, JP. Rummel, C. Hauf, M. Hefti, U. Merz, TM. Morphological brain changes after climbing to extreme altitudes – a prospective cohort study. PLoS One. 2015; 10(10): e0141097

3: Hombein, TF. Long term effects of high altitude on brain function. Int J Sports Med. 1992;(13) Supple 1:S43-5. 

4: Wang, Y. Ma, H. Fu, S. Guo, S. Yang, X. Luo, P. Han, B Long-term exposure to high altitude affects voluntary spatial attention at early and late processing stages. Scientific Reports. 2014; (4) 4443.

Acclimation, Health, High Altitude, Medicine

Altitude as Asthma Treatment

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Can high altitude climate therapy (HACT) result in long term benefits for adults with severe asthma?

How much do you know about asthma? Have you ever considered that the air we breath every day is often filled with environmental triggers that worsen asthma symptoms making it more difficult for asthmatics to breath? Did you realize that at elevation many of those environmental triggers such as air pollution and pollen are gone? The rumors are true, mountain air really is better and residents at altitude are truly lucky to be breathing in fresh, clean, crisp mountain air on a daily basis. 

Based on data collected by The Global Initiative for Asthma (GINA), as of 2004 it was estimated that 300 million people of all ages worldwide suffer from asthma. That number is projected to increase to 400 million by 2025! In 2010, the CDC documented that 1.8 million people in the US alone visited the emergency department for asthma related care and of that number at least one third of them had to be hospitalized for severe symptoms. 

Asthma is characterized by: 1) Chronic airway inflammation, 2) intermittent and reversible airway obstruction, and 3) bronchial hyper-responsiveness (the tendency of airways to narrow in response to a variety of triggers in the air that have little effect on people without any respiratory disease). Patients with asthma often complain of intermittent cough, shortness of breath (or difficulty breathing), and wheezing. This classic presentation is often worsened by triggers such as allergens, pollutants, tobacco, cockroaches, pollen, mold, stress, upper respiratory infections, weather and/or exercise. Symptoms are alleviated with bronchodilator medications, which act to open the airways making breathing easier. 

Dillon Reservoir, sitting at over 9,000 ft. Visitors from all over the state and world alike come to enjoy Colorado’s reputably pure water and air.

Asthma is conventionally treated in a step-wise fashion, meaning that treatment escalates with increasing severity of symptoms. Patients who suffer from severe asthma on a daily and nightly basis are often on multiple medications in an attempt to control their symptoms. These usually include an inhaled corticosteroid medication, a long-acting beta-2 agonist. Some start oral steroids and some even require biologic or immune modulating agents. Patients that fall into this category often suffer from a decreased quality of life, multiple doctor or emergency room visits and have difficulty controlling their symptoms on a regular basis. 

Recently, researchers have been investigating different avenues to provide relief for patients suffering from severe asthma symptoms. Studies published on high altitude climate therapy (HACT) are showing positive outcomes for adults with severe asthma that are refractory to conventional treatment. 

An article published in 2018 in The European Journal of Allergy and Clinical Immunology conducted a study to determine if HACT resulted in long term benefits for asthmatics even after returning to sea level. Patients included in this study had to fall into the category of an adult with severe uncontrolled asthma symptoms despite conventional treatment methods. These patients were enrolled in a 12 week multi-disciplinary treatment program with environmental trigger avoidance in an alpine climate at an altitude greater than 1500 m (4921.26 ft). After the conclusion of the program, patients were followed for one year with repeat evaluations every 3 months to assess the long term effects of this therapy on their asthma symptoms.

This is the first study to show a decrease in exacerbations and improvement in asthma control up to 12 months!! This was measured in the number of asthma exacerbations, hospitalizations, and oral corticosteroid use before and after HACT treatment. The study showed a decrease in all three categories, which correlates to a positive outcome following this treatment.

While “trigger avoidance” has always been an important aspect of the conventional asthma treatment regimen, it is amazing to see how patients benefit when this is carried out effectively. It is hypothesized that allergens work to continually stimulate and maintain the airway inflammation in asthmatics. When these triggers are removed for a sufficient amount of time, the bronchioles have a chance to recover and decrease the process of ongoing inflammation.

Another proposed mechanism by which this treatment is effective is the decrease in air viscosity at altitude, which benefits the patient by decreasing the thickness of airway mucosa and may even reverse airway modeling. This makes breathing easier for patients and acts to decrease asthma symptoms. 

So who can benefit from this treatment? Are all asthmatics created equally?

Scientists and clinicians alike have identified three different groups of asthma patients: 1) severe atopic asthma, 2) persistent eosinophilic asthma, and 3) asthma associated with morbid obesity. While classically these different patient populations respond differently to asthma treatments, it has been found in another study, “Predictors of benefit from high altitude climate therapy,” that HACT improves the quality of life and respiratory function in all patients suffering from severe asthma symptoms. This study sought to investigate if different factors such as age, blood eosinophils (a type of white blood cell), and degree of asthma control prior to admission could predict how much a patient would benefit from high-altitude climate therapy. While this study is making steps in the right direction, it was determined that further patient characterization is required to clearly identify which patients will benefit the most from HACT. 

Finally, in a systematic review and meta-analysis on HACT, it was determined that patients experience a statistically significant improvement in lung function following this treatment modality. This review wanted to analyze the quality of research studies completed so far on this topic and also proposed some limitations of the publications so far.

“Shinrinyoku” (森林浴) is the Japanese word for spending time in nature, literally meaning “deep forest bathing”. It is believed the body exchanges and balances its ions with the ions present in the forest.

Some things to consider that are still being evaluated include: What is the optimal altitude and duration of treatment in order to see the most benefit? Which patients will experience the most improvement from this treatment? How does this treatment method compare financially with others considering that it is a resource-intensive intervention? 

Overall, research on HACT is making exciting headway! So far we have learned that adults with severe asthma can benefit from alpine treatment in some way regardless of phenotype. In addition, many patients experienced lasting improvement for up to 12 months. Be on the lookout as more research is published on this topic. As always, if you are patient suffering from asthma, check in with your primary care provider prior to making a trip to altitude to ensure your asthma is well controlled before arrival. While HACT has been shown to decrease asthma symptoms long term, arriving at altitude unprepared with uncontrolled symptoms could put an asthmatic at higher risk for high altitude sickness. As discussed at the beginning of the article, cold air can be a trigger for asthmatics as well and with that in mind it would be best to visit the mountains during the summer months! Lastly, always be prepared and carry your rescue inhaler with you, especially when traveling to altitude.

Author and PA Student Sarah Gordon

Sarah Gordon is currently a Physician Assistant Student at Midwestern University located in Glendale, Arizona. She plans to complete a one year fellowship at Mayo Clinic in otolaryngology/ head and neck surgery after graduation. Throughout her clinical year she has had the opportunity to travel to Denver and Frisco, Colorado, along with completing rotations located throughout the greater Phoenix area in Arizona. When she is not studying, she enjoys cooking new recipes, spending time with friends and staying active through fitness and outdoor adventures. 

References:

“Asthma | CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, www.cdc.gov/asthma/default.htm.

Fanta, Christopher H. “An Overview of Asthma Management.” UpToDate, Helen Hollingsworth, MD, www-uptodate-com.mwu.idm.oclc.org/contents/an-overview-of-asthma-management?search=asthma adult&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1.

Fanta, Christopher H. “Diagnosis of Asthma in Adolescents and Adults.” Www, Helen Hollingsworth, MD, www-uptodate-com.mwu.idm.oclc.org/contents/diagnosis-of-asthma-in-adolescents-and-adults?search=asthma definition§ionRank=1&usage_type=default&anchor=H2&source=machineLearning&selectedTitle=1~150&display_rank=1#H3.

Fieten, Karin B., et al. “Less Exacerbations and Sustained Asthma Control 12 Months after High Altitude Climate Treatment for Severe Asthma.” Allergy, vol. 74, no. 3, 14 Nov. 2018, doi:10.1111/all.13664.

Hashimoto, S., et al. “Predictors of Benefit from High-Altitude Climate Therapy in Adults with Severe Asthma.” The Netherlands Journal of Medicine, vol. 76, no. 5, July 2018, pp. 218–225.

Rijssenbeek-Nouwens, L. H., and E. H. Bel. “High-Altitude Treatment: a Therapeutic Option for Patients with Severe, Refractory Asthma?” Clinical & Experimental Allergy, vol. 41, no. 6, 2011, pp. 775–782., doi:10.1111/j.1365-2222.2011.03733.x.

Seys, Sven F, et al. “Effects of High Altitude and Cold Air Exposure on Airway Inflammation in Patients with Asthma.” Thorax, vol. 68, no. 10, 2013, pp. 906–913., doi:10.1136/thoraxjnl-2013-203280.

Vinnikov, Denis, et al. “High-Altitude Alpine Therapy and Lung Function in Asthma: Systematic Review and Meta-Analysis.” 6.2 Occupational and Environmental Health, 2016, doi:10.1183/13993003.congress-2016.pa4293.

Child Growth & Development, Health, High Altitude, Medicine

Stroke, High Altitude, and EPO

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A 2009 study from Switzerland found a 12% decrease in risk of death from stroke at 6430 ft. compared to 850 ft.  This result was more pronounced in men than women.  Since men are more physically active than women in Switzerland, it was thought the exercise at the more hypoxic conditions of higher altitude may benefit them more than for women.  The study also noted that being born at a higher altitude had a protective effect on death from cardiovascular disease1. 

Strokes occur when blood flow to parts of the brain is cut off causing neurons and other brain cells to die within minutes.  Strokes can either be ischemic or hemorrhagic.  80-87% of strokes are ischemic, which means that blood flow to the brain is cut off from a blood clot or other blockage of a blood vessel going to or in the brain.  Hemorrhagic strokes are caused by bleeding within the brain (intracerebral space) or in the space surrounding the brain filled with cerebrospinal fluid (subarachnoid space).  Risk of stroke is higher in individuals with previous transient ischemic attack (TIA), high blood pressure, previous heart attack, atrial fibrillation, enlarged left atria of the heart, smoking, heavy alcohol use, diabetes, obesity, high cholesterol, and stenosis of the carotid artery2.

Interestingly, on initial exposure to hypoxia at high altitude, blood flow to the brain increases which is split equally between gray and white matter.  After 4 to 5 days, blood flow to the brain decreases but is still 13% greater than at sea level.  The increased blood flow is needed to maintain adequate delivery of oxygen when the oxygen content of the blood is lower during hypoxia, until other acclimation mechanisms take effect3.

As noted in previous blog posts in response to hypoxia, erythropoietin (EPO) is also released, which increases the production of red blood cells to increase the oxygen-carrying capacity of our blood.  Other studies have found that EPO also has a protective effect on neurons.   Cerebrovascular endothelial cells have been found to have receptors for EPO and are thus able respond to EPO.  Other studies have found that EPO is also involved in brain development of a fetus in utero.  Animal studies suggest EPO not only protects neurons from cell death but may enable their regeneration as well.  If this translates into humans, it is an important effect for those at risk for stroke4.

In a small clinical trial, patients with middle cerebral artery stroke received IV EPO daily for 3 days after their stroke.  These patients had better neurological outcomes with increased physical functioning and independence as measured by Barthel index test results.  Following the EPO doses, the size of the cerebral infarct, the damaged area of the brain from blood being cut off during the stroke, was reduced as well4.

Based on this research, Ismailov hypothesized that in the United States, geographic variation in levels of EPO from altitude differences may account for the differences in risk of death from stroke.  He termed it the “stroke belt” in the Southeast, with higher rates of death from stroke compared to the Mountain states.  

The states in the “stroke belt” are Louisiana (LA), Mississippi (MI), South Carolina (SC), Alabama (AL), Georgia (GA), Arkansas (AK), Indiana (IN), North Carolina (NC), Kentucky (KY), Tennessee (TN), and Virginia (VA), and all are at lower altitude.  The mountain states have higher altitude and are North Dakota (ND), Kansas (KS), Nebraska (NE), Arizona (AZ), New Mexico (NM), Wyoming (WY), and Colorado (CO).   

Louisiana and Mississippi’s average altitudes are 100 and 300 ft. compared to Colorado and Wyoming with average altitudes of 6800 and 6700 ft4.  Since there is increased EPO released in individuals living at higher altitudes, perhaps there is more of a neuroprotective effect at higher altitudes, contributing to the observed lower risk of death from stroke seen in the Swiss study.  

Symptoms of Stroke5

Think F.A.S.T

Other signs are sudden

  • Numbness of face, arm, or leg and particularly numbness on one side of body
  • Confusion
  • Difficulty seeing out of one or both eyes
  • Difficulty walking
  • Feeling of dizziness, loss of balance, or coordination
  • Severe headache with no identified cause

For more information: https://familydoctor.org/condition/stroke/

o en Español: https://es.familydoctor.org/condicion/accidente-cerebrovascular/

Author and PA student, Stephanie Schick

Stephanie Schick is a Physician Assistant student at Rocky Vista University in Parker, CO.  She is born and raised in Fort Collins, CO.  She started off her clinical year working in pediatrics with Dr. Chris at Ebert Family Clinic.  The remainder of her clinical year will be spent closer to home in northern Colorado.   In her free time she enjoys spending time with her husband, friends, and family in the beautiful Colorado sunshine.

Acclimation, Alcohol at Altitude, Child Growth & Development, Health, High Altitude, High Altitude Training & Fitness, Medicine, Mountaineering

Spring Recap 2019

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We’ve learned a lot in the high country this season! For example, it isn’t too late or too warm for a snowstorm. We’ve conducted several interviews with professional, high-altitude athletes, athletic and tourism organizations in Summit County, physicians, podcasters, interns, and a local brewer. They’ve shed so much light on fitness, health, child growth & development, and acclimation at elevation, it warrants a re-cap:

  1. 8,000 ft. seems to be the pivotal elevation at which the body starts to experience a significant deficit in the oxygen and water it needs to function, affecting everything from sleep to metabolism.
  2. A plant-based lifestyle has benefitted athletes under extreme training and competitive conditions at altitude.
  3. Training at altitude significantly reduces your ability to reach cardiovascular and strength goals, even while preparing your respiratory and circulatory systems for the severe decrease in oxygen. “Live High, Train Low” is an effective strategy more and more athletes are advocating for.
  4. Preparation for backcountry excursions is as much mental as physical.
  5. Foods high in nitrates (like red beets, red bell peppers and arugula) can facilitate acclimation and recovery.
  6. Oily foods may inhibit your body’s ability to cope with a significant increase in altitude.
  7. We metabolize and experience the effects of alcohol differently at altitude.
  8. Current research suggests some people suffering from Parkinsons disease may experience some relieve from symptoms at higher elevation.
  9. Increased muscle mass requires increased oxygen. Being an athlete does not necessarily mean you will have an easier time acclimating.
  10. As always, the best way to facilitate acclimation and deal with symptoms of altitude sickness is to drink plenty of water, allow yourself ample rest, and monitor your blood oxygen saturation levels with a pulse oximeter.

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