Can I ever return to high altitude? Do I need to move down to a lower elevation?
Disease processes often differ at high altitudes. Some conditions have only been known to occur at high elevations. Most of the resources cited in this blog refer to ‘high altitude’ being at or above 2,500 meters or 8,200 feet.
Ebert Family Clinic in Frisco, Colorado is at 9,075 ft. Many areas in the immediate vicinity are over 10,000′, with some patients living above 11,000′. Two of the more common conditions seen in patients at Ebert Family Clinic are high altitude pulmonary edema (HAPE) and high altitude resident pulmonary edema (HARPE), similar conditions that affect slightly different populations in this region of the Colorado Rocky Mountains.
In “classic” HAPE, a visitor may come from a low-altitude area to Frisco on a trip to ski with friends. On the first or second day, the person notices a nagging cough. They might wonder if they caught a virus on the plane ride to Denver. The cough is usually followed by shortness of breath that begins to make daily tasks overwhelmingly difficult. One of the dangerous aspects of HAPE is a gradual onset leading patients to believe their symptoms are caused by something else. A similar phenomenon is seen in re-entry HAPE, where a resident of a high altitude location travels to low altitude for a trip and upon return experiences these same symptoms [1].
In HARPE, a person living and working here in Frisco may be getting ill or slowly recovering from a viral illness and notices a worsening cough and fatigue. These cases are even more insidious, going unrecognized, and so treatment is sought very late. Dr. Christine Ebert-Santos and her team at Ebert Family Clinic hypothesize that while residents have adequately acclimated to the high-altitude environment, the additional lowering of blood oxygen due to a respiratory illness with inflammation may be the inciting event in these cases.
In both cases, symptoms are difficult to confidently identify as a serious illness versus an upper respiratory infection, or simply difficulty adjusting to altitude. For this reason, Dr. Chris recommends that everyone staying overnight at high altitude obtain a pulse oximeter. Many people became familiar with the use of these instruments during the COVID-19 pandemic. The pulse oximeter measures what percent of your blood is carrying oxygen. At high altitude, a healthy level of oxygenation is typically ≥90%. This is an easy way to both identify potential HAPE/HARPE, as well as reassure patients they are safely coping with the high-altitude environment [2].
HAPE and HARPE are both a direct result of hypobaric hypoxia, a lack of oxygen availability at altitude due to decreased atmospheric pressures. At certain levels of hypoxia, we observe a breakdown in the walls between blood vessels and the structures in lungs responsible for oxygenating blood. The process is still not totally understood, but some causes of this breakdown include an inadequate increase in breathing rates, reduced blood delivered to the lungs, reduced fluid being cleared from the lungs, and excessive constriction of blood vessels throughout the body. These processes cause fluid accumulation throughout the lungs in the areas responsible for gas exchange making it harder to oxygenate the blood [3].
We do know that genetics play a significant role in a person’s risk of developing HAPE/HARPE. Studies have proposed many different genes that may contribute, but research has not, so far, given healthcare providers a clear picture of which patients are most at-risk. Studies have shown that those at higher risk of pulmonary hypertension (high blood pressure in the blood vessels of your lungs), are more likely to develop HAPE [4]. This includes some types of congenital heart defects [5,6]. High blood pressures in the lungs reach a tipping point and appear to be the first event in this process. However, while elevated blood pressures in the lungs are essential for HAPE/HARPE, this by itself, does not cause the condition. The other ingredient necessary for HAPE/HARPE to develop is uneven tightening of the blood vessels in the lungs. When blood vessels are constricted locally, the blood flow is shifted mainly to the more open vessels, and this is where we primarily see fluid leakage. As the blood-oxygen barrier is broken down in these areas, we may also see hemorrhage in the air sacs of the lungs [3].
One observation healthcare providers and scientists have observed is that HAPE/HARPE can be rapidly reversed by either descending from altitude or using supplemental oxygen. Both strategies increase the availability of oxygen in the lungs, reducing the pressure on the lungs’ blood vessels by vasodilation, quickly improving the integrity of the blood-oxygen barrier.
In a preliminary review of over 100 cases of emergency room patients in Frisco diagnosed with hypoxemia (low blood oxygen content) Dr. Chris and her team have begun to see trends that suggest the availability of at-home oxygen markedly reduces the risk of a trip to the hospital. This demonstrates that patients with both at-home pulse oximeters and supplemental oxygen have the capability to notice possible symptoms of HAPE, assess their blood oxygen content, and apply supplemental oxygen if needed. This stops the development of HAPE/HARPE before damage is done in the lungs. In the case of many of our patients, these at-home supplies prevent emergencies and allow patients time to schedule an appointment with their primary care provider to better evaluate symptoms.
Additionally, Dr. Chris and her team have observed that patients with histories of asthma, cancer, pneumonia, and previous HAPE/HARPE are often better educated and alert to these early signs of hypoxia and begin treatment earlier on in the course of HAPE/HARPE, reducing the relative incidence identified by medical facilities. There are many reasons to seek emergent care such as low oxygen with a fever. Patients with other existing diseases causing chronically low oxygen such as chronic lung disease may not be appropriately treated with supplemental oxygen, although this is a very small portion of the population. Discussions with healthcare providers on the appropriate prevention plan for each patient will help educate and prevent emergency care visits in both residents and visitors.
Studies of larger populations have yet to be published. A review of the case reports in smaller populations suggests that the previously estimated recurrence rate of 60-80% is exaggerated. This is a significant finding as healthcare providers have relied on this recurrence rate to make recommendations to their patients who have been diagnosed with HAPE. A review of 21 cases of children in Colorado diagnosed with HAPE reported that 42% experienced at least one recurrence [7]. This study was conducted by voluntary completion of a survey by the patients (or their families) which could lead to significant participation bias affecting the results. Patients more impacted by HAPE are more likely to complete these surveys. Another study looking at three cases of gradual re-ascent following an uncomplicated HAPE diagnosis showed no evidence of recurrence. The paper also suggested there may be some remodeling of the lung anatomy after an episode of HAPE that helps protect a patient from reoccurrence [8]. Similar suggestions of remodeling have been proposed through evidence of altitude being a protective factor in preventing death as demonstrated by fatality reports from COVID-19[9].
Without larger studies and selection of participants to eliminate other variables like preexisting diseases, we are left to speculate on the true rate of reoccurrence based on the limited information we have. Strategies to reduce the risk of HAPE/HARPE such as access to supplemental oxygen, pulse oximeters, and prescription medications [10] are the best way to prevent HAPE/HARPE. Research should also continue to seek evidence of individuals most at risk for developing HAPE/HARPE [11].
Taylor Kligerman is a third-year medical student at Rocky Vista University with plans to complete a residency in emergency medicine. She was born and raised in Flossmoor, IL, and became interested in medicine following her first medical mission trip to Gonaïves, Haiti in 2010. Taylor has extensive experience in wilderness and remote emergency medicine. Before starting medical school, she was certified as a wilderness EMT and gained experience in remote areas of Canada and Western North Carolina on whitewater expeditions and as a volunteer with local search and rescue. Her personal interests include camping, skiing, and all paddle sports.
References
Ucrós S, Aparicio C, Castro-Rodriguez JA, Ivy D. High altitude pulmonary edema in children: A systematic review. Pediatr Pulmonol. 2023;58(4):1059-1067. doi:10.1002/ppul.26294
Deweber K, Scorza K. Return to activity at altitude after high-altitude illness. Sports Health. 2010;2(4):291-300. doi:10.1177/1941738110373065
Bärtsch P. High altitude pulmonary edema. Med Sci Sports Exerc. 1999;31(1 Suppl):S23-S27. doi:10.1097/00005768-199901001-00004
Eichstaedt C, Benjamin N, Grünig E. Genetics of pulmonary hypertension and high-altitude pulmonary edema. J Appl Physiol. 2020;128:1432
Das BB, Wolfe RR, Chan K, Larsen GL, Reeves JT, Ivy D. High-Altitude Pulmonary Edema in Children with Underlying Cardiopulmonary Disorders and Pulmonary Hypertension Living at Altitude. Arch Pediatr Adolesc Med. 2004;158(12):1170–1176. doi:10.1001/archpedi.158.12.1170
Liptzin DR, Abman SH, Giesenhagen A, Ivy DD. An Approach to Children with Pulmonary Edema at High Altitude. High Alt Med Biol. 2018;19(1):91-98. doi:10.1089/ham.2017.0096
Kelly TD, Meier M, Weinman JP, Ivy D, Brinton JT, Liptzin DR. High-Altitude Pulmonary Edema in Colorado Children: A Cross-Sectional Survey and Retrospective Review. High Alt Med Biol. 2022;23(2):119-124. doi:10.1089/ham.2021.0121
Litch JA, Bishop RA. Reascent following resolution of high altitude pulmonary edema (HAPE). High Alt Med Biol. 2001;2(1):53-55. doi:10.1089/152702901750067927
Gerken J, Zapata D, Kuivinen D, Zapata I. Comorbidities, sociodemographic factors, and determinants of health on COVID-19 fatalities in the United States. Front Public Health. 2022;10:993662. Published 2022 Nov 3. doi:10.3389/fpubh.2022.993662
Luks A, Swenson E, Bärtsch P. Acute high-altitude sickness. European Respiratory Review. 2017;26: 160096; DOI: 10.1183/16000617.0096-2016
Dehnert C, Grünig E, Mereles D, von Lennep N, Bärtsch P. Identification of individuals susceptible to high-altitude pulmonary oedema at low altitude. European Respiratory Journal 2005;25(3):545-551; DOI: 10.1183/09031936.05.00070404
The 8th Chronic Hypoxia Symposium is recently took place in La Paz, Boliva, and I had to pleasure of hearing Dr. Jorge Luis Velez’ presentation on altitude, obesity, and COVID-19 survival rates. Dr. Velez is an intensive care doctor and the head of critical medicine at Pablo Arturo Suarez Hospital in Quito, Ecuador, as well as being a professor at the Central University of Ecuador. With Quito being the second highest in elevation capital in the world at 9,350 feet, Dr. Velez understands the effects of altitude on the human body.
Dr. Velez conducted a study among 340 unvaccinated adult patients with severe COVID-19 infections requiring intubation. Of the 340 patients, 45% were obese, 43% were overweight, and 12% were of normal weight. The results of the study showed that obese patients had significantly reduced mortality rates and higher rates of successful extubation when compared to the overweight and normal weight groups. Successful extubation is commonly described as extubation without the need for re-intubation within 72 hours. Obese patients were found to have a 31.17% mortality rate and an 81.03% rate of successful extubation. Overweight patients were found to have a 40.14% mortality rate and a 73.00% rate of successful extubation. Patients of normal weight were found to have a 48.72% mortality rate and a 53.85% rate of successful extubation.
These results are surprising given that obesity is a widely accepted risk factor for high severity COVID-19 infections and increased mortality. Other factors that may have contributed to the increased survival rates of obese patients with severe COVID-19 infections is that in their study, the obese patients happened to be on average younger and a higher proportion of males. Despite variables in age and sex, Dr. Velez still concludes with statistical significance that “patients with obesity had a 52% less probability of dying in relation to those of normal weight.”
Despite this emerging research, we still recommend maintenance of a healthy weight and lifestyle, as the effects of a healthy weight have been extensively researched and proven to be beneficial for a heart health, joint health, mental health, sleep, the digestive system, and more.
Family Nurse Practitioner Ana Sofia Bedoya administering the new bivalent COVID-19 vaccine to Dr. Chris in her office at Ebert Family Clinic in Frisco, CO.
Looking for other ways to protect yourself from COVID-19?
The new bivalent vaccine uses the same technology with upgraded protection against the omicron variant. The vaccine is the best way to reduce risk for you and your family during the holiday season, as well as protecting from reinfection if you’ve already had COVID-19.
References
Luis Velez, J., 2022. Altitude Promotes Better Survival Rates in Critically Ill Obese Patients with COVID-19.
Artime, C. A. A., & Hagberg, C. A. H. (2014, June). Tracheal Extubation. Respiratory Care, 59(6), 991–1005. https://rc.rcjournal.com/content/respcare/59/6/991.full.pdf#:~:text=Successful%20extubation%20is%20dependent%20on%20two%20factors%3A%20the,a%20planned%20extubation8%3B%20however%2C%20this%20definition%20does%20not
Cameron Santiago is a second-year Physician Assistant Student at Red Rocks Community College in Arvada, CO. He grew up in Colorado Springs and received his undergraduate degree in Biology from Colorado State University. Prior to PA school, he was an inpatient phlebotomist and urgent care technician. In his free time, he enjoys fishing, hiking, and spending time with his dogs and family.
As the COVID-19 pandemic continues and new strains are being discovered every day, there is a rush in the world of science and medicine to uncover how to best prevent and treat those who have been affected. This is a worldwide problem, not solely isolated in one location. However, because the world is not uniform and environments and terrains people live in differ, are there those who live in certain areas better adapted to fighting off COVID compared to others if they were exposed? There have been rumors that those living in high altitudes (2,500m+) have some risk reduction factors associated with less infection and lower COVID-19-related mortality. One example is that people living in high altitudes have physiological traits such as increased erythropoietin production seen within their tissues that decreases the effects of COVID-19 on the human body.
A study was conducted in Ecuador between March 2020 and March 2021 to find a relationship between altitude and COVID-19 mortality rates. This study compared 221 cantons in Ecuador ranging from sea level to above 4,300 meters. Each canton was categorized as either low, moderate, high, or very high altitudes based on their location. During the one year of study, trends based on all-caused deaths and deaths relating to COVID-19 were collected and recorded. At the end of the study, it was shown that there was a 24% higher mortality rate in cantons located below 2,500m of altitude compared to cantons located above 2,500m of altitude. 1 However, when this was broken down into narrower categories, it was found that cantons located at “high altitudes” reported the second highest mortality rates due to COVID-19 compared to cantons located at “moderate and very high altitude” which reported the lowest mortality rates due to COVID-19. These results were confusing and showed conflicting information. In addition, two studies done in America and Peru showed that altitude had no protective factors against COVID-19 mortality rates, while another study in Peru demonstrated that there were “strong protective effects of altitude” against COVID-19. 2,3,4
Mixed results and debates have occurred regarding altitude and COVID-19 mortality rates since studies in this area have been limited. Multiple factors that were not accounted for in different studies could be the reason why. Overestimation, underestimation, unreported, and undiagnosed cases can greatly affect the statistics. Not accounting for underlying illnesses such as diabetes or cancer in relation to COVID-19 deaths is another factor that can contribute to the discrepancies in the research. Not to mention, there were some obvious reasons that may contribute to low mortality rates due to COVID-19, too. Two being that there may be a lower population density in higher altitudes compared to cities/countries near sea level resulting in reduced spread of the virus and that there may be less chronic conditions with people living in higher altitudes that are not exacerbated when they are exposed to COVID-19.
Ultimately, few studies have been conducted relating COVID-19 mortality rates to people living in high altitudes. A variety of theories were proposed as to the reason why people living in higher altitudes have a lower mortality rate when exposed to COVID-19, but the sample size and methods used to conduct the research led to gaps in the study. These gaps were refuted resulting in starting at square one again. Until there is more research done, and more data is collected, we cannot conclusively say that those living in higher altitudes have a lower mortality rate when exposed to COVID-19 compared to those who live at altitudes below 2,500m. The corona virus continues to evolve every day and is still affecting the lives of millions. If the virus continues at this rate, more research could be done to see if people living in high altitudes have protective factors against the virus. However, the main goal is to find a cure against this virus. This area of study can change how people live, and high altitude environments may be the next location people will want to move to.
References
Ortiz-Prado E, Fernandez Naranjo RP, Vasconez E, et al. Analysis of Excess Mortality Data at Different Altitudes During the COVID-19 Outbreak in Ecuador. High Alt Med Biol. 2021;22(4):406-416. doi:10.1089/ham.2021.0070
2. Cardenas L, Valverde-Bruffau V, Gonzales GF. Altitude does not protect against SARS-CoV-2 infections and mortality due to COVID-19. Physiol Rep. 2021;9(11):e14922. doi:10.14814/phy2.14922
3. Woolcott OO, Bergman RN. Mortality Attributed to COVID-19 in High-Altitude Populations. High Alt Med Biol. 2020;21(4):409-416. doi:10.1089/ham.2020.0098
4. Thomson TM, Casas F, Guerrero HA, Figueroa-Mujíca R, Villafuerte FC, Machicado C. Potential Protective Effect from COVID-19 Conferred by Altitude: A Longitudinal Analysis in Peru During Full Lockdown. High Alt Med Biol. 2021;22(2):209-224. doi:10.1089/ham.2020.0202
Alex Fan was born and raised in Southern California. It was his grandmother who led him on the path towards medicine. In his free time, he enjoys going to the beach, trying new food locations, playing volleyball, and catching up with friends and family. He is currently a Drexel PA Student hoping to work with the underserved community in the near future.
Prior to COVID-19, I would hike the beautiful mountains of Colorado known as 14ers, a name given to these mountains for being over 14,000 ft. I, like most high-altitude travelers faced the more common concerns associated with hiking such as acute mountain sickness (AMS), high altitude cerebral edema (HACE), and high-altitude pulmonary edema (HAPE). With the increase in high-altitude travel, I wondered if there are any new precautions that we should consider before resuming the activities that we love.
The purpose of this article is to highlight the recommendations for patients who wish to return to high-altitude travel after a COVID infection. Not everyone needs an evaluation after a COVID infection. The recommendations noted in this article are based on the duration and severity of the illness of each individual person.
So, who should receive an evaluation before high-altitude travel?
Individuals with symptoms after 2 weeks of a positive COVID-19 test without hospitalization,
Individuals with symptoms after 2 weeks after hospital discharge,
Anyone who required care in the intensive care unit (ICU), and
Anyone who developed myocarditis or thromboembolic events. The recommendations are to undergo pulse oximetry at rest and with activity, spirometry, lung volumes, and diffusion capacity for carbon monoxide(DLCO), chest imaging, electrocardiography (EKG), B-type natriuretic peptide, high sensitivity cardiac troponin (hsTn), and echocardiography.
It is expected that people with lower oxygen levels (hypoxemia) at rest or with exertion in lower elevations will experience greater hypoxemia with ascent to high altitude. It has been shown that ascent to high altitude causes a decrease in barometric pressure leading to a decrease in ambient and inspired partial pressure of oxygen. The decrease in partial pressure of oxygen in alveoli (PaO2) will trigger vasoconstriction of pulmonary arterioles that slows the rate of oxygen diffusion and activates chemoreceptors that increase minute ventilation from hypoxia. However, it is still unclear whether people with low oxygen levels at low elevations are at greater risk for acute altitude illness after ascent. The recommendation is to monitor pulse oximetry after arrival of high altitude.
Individuals with abnormal lung function tests don’t have to avoid high altitude travel as previous studies have shown that patients with COPD with abnormal lung functions tolerate exposure. Furthermore, in people with mild to severe COVID-19 symptoms, the lung mechanic markers such as forced expiratory volume (FEV1), forced vital capacity (FVC) and total lung capacity (TLC) normalize in up to 150 days of infection. However, if individuals have severe limitations with exercise capacity, they should monitor their oxygen levels with pulse oximetry after ascent. Reduction in exercise capacity is possible after COVID infection and depends on the severity of the illness. Blokland et al., 2020 has shown that previously intubated individuals had a median VO2 max of 15ml/kg per min (average male 35 to 40 and average female 27 and 30), roughly 57% predicted immediately after hospitalization.
In acute hypoxia, the heart rate increases, which leads to an increase in cardiac output. Individuals with reduced ventricular function from COVID infection do not have to avoid travel. Previous research has shown that individuals with heart failure can tolerate exercise with hypoxia. Moreover, data has shown that individuals with COVID infection maintain preserved left ventricular function and only 3% show a reduced ejection fraction. Individuals with abnormal EKG rhythms and ischemia should be referred to cardiology. If high sensitivity troponin was abnormally elevated, this would require evaluation for myocarditis with a cardiac MRI. Knight et al., (2020), found that 45% of patients with unexplained elevations of high-sensitivity troponin were found to have myocarditis during hospitalization. It is still unclear how long these abnormalities will last and how it will affect people.
A concerning finding on ECHO is pulmonary hypertension, as previous research has shown an increased risk in developing HAPE. A study reported that 10% of patients hospitalized for COVID without mechanical ventilation had right ventricular dysfunction for over 2 months. Several studies reported that 7-10% of individuals may have pulmonary hypertension after COVID infection. A vasodilating drug such as nifedipine can be given prophylactically if pulmonary hypertension is unrelated to left heart dysfunction but nifedipine can worsen hypoxemia.
The recommendation for patients who developed myocarditis from a COVID infection is to have an ECHO, Holter monitor, and exercise EKG 3-6 months after illness. Travel can resume after a normal ECHO, no arrhythmias on exercise EKG, and after inflammatory markers (ESR and/or CRP) have normalized. Previous studies suspected that areas with low atmospheric pressures (e.g., high-altitude) that induce hypoxia have increased risk for clot formation. However, this suspicion has never been firmly established; therefore there is no reason to believe that high-altitude will increase the risk for clot formation in individuals who developed an arterial or venous clot from COVID infection.
A few things to consider before planning a high-altitude excursion includes planning to visit areas with access to medical resources or the ability to descend rapidly. If you are new to high altitude, it is recommended to slow the ascent rate. Traveling to high elevations (>4000m) should be avoided until tolerance has developed with moderate elevations (2000-3000m). A more gradual return to physical activity at high altitude is recommended rather than immediate resumption of heavy exertion. As the pandemic subsides and with increase in mountain travel, more research will develop that can better address these risks.
Good news! The Ebert Family Clinic in Frisco, CO provides pulse oximeters for free. So, make sure to visit and grab your pulse oximeter before your next ascent.
Quick Summary of Recommendations
Individuals who require evaluation prior to high-altitude travel:
Individuals who have symptoms after 2 weeks of a positive COVID-19 test without hospitalization
Individuals who have symptoms after 2 weeks after hospital discharge
Any patient who required care in the intensive care unit (ICU)
Any patient who developed myocarditis or thromboembolic events
General recommendations for anyone before high-altitude travel:
Monitor pulse oximetry after arrival of high altitude, and access care or descend if symptoms worsen.
Rest and avoid high-altitude travel for at least 2 weeks after a positive test, and consider a gradually return to physical activity at higher altitudes.
All individuals planning high-altitude travel should be counseled on how to recognize, prevent, and treat the primary forms of acute altitude illness (AMS, HACE, and HAPE)
Limit the extent of planned exertion after ascent and, instead, engage in graded increases in activity that allow the individual to assess performance and avoid overextending themselves.
Reasons to forgo high-altitude travel:
Severely elevated pulmonary artery pressures may be a reason to forego high-altitude travel altogether.
High-altitude travel should likely be avoided while active inflammation is present in myocarditis.
Patients who experienced arterial thromboembolic events due to COVID-19, (e.g. myocardial infarction or stroke) should defer return to high altitude for several months after that event or any associated revascularization procedures.
References:
Andrew M. Luks and Colin K. Grissom. Return to High Altitude After Recovery from Coronavirus Disease 2019. High Altitude Medicine & Biology. http://doi.org/10.1089/ham.2021.0049
Christensen CC, Ryg M, Refvem OK, Skjønsberg OH. Development of severe hypoxaemia in chronic obstructive pulmonary disease patients at 2,438 m (8,000 ft) altitude. Eur Respir J. 2000 Apr;15(4):635-9. doi: 10.1183/09031936.00.15463500. PMID: 10780752.
Blokland IJ, Ilbrink S, Houdijk H, Dijkstra JW, van Bennekom CAM, Fickert R, de Lijster R, Groot FP. Inspanningscapaciteit na beademing vanwege covid-19 [Exercise capacity after mechanical ventilation because of COVID-19: Cardiopulmonary exercise tests in clinical rehabilitation]. Ned Tijdschr Geneeskd. 2020 Oct 29;164:D5253. Dutch. PMID: 33331718.
Jesse Santana is a second-year PA student at Red Rocks Community College in Denver, Colorado. He grew up in Colorado Springs, CO and attended the University of Colorado-Colorado Springs where he earned a bachelor’s in Biology and Psychology. Jesse worked as a Certified Nursing Assistant for two years before pursuing a Master’s in Biomedical Sciences at Regis University in Denver. Shortly after, he coordinated clinical trials in endocrinology and weight loss as a Clinical Research Coordinator at University of Colorado Anschutz Medical Campus. He enjoys hiking Colorado’s 14ers, spending time with family and friends, and camping.
Maybe you are planning to ski or hike a 14er. Taking a leap of faith and moving out of the city and into the mountains. Or maybe it’s just taking a flight in a pressurized airplane cabin. Maybe you just spent 10 days in the hospital with rib fractures and are now anxious to return home to 9000 feet in elevation. You could be an individual that is worried you will miss out on that incredible work retreat to a beautiful mountain sanctuary due to your apprehension about your Chronic Obstructive Pulmonary Disease COPD.
Wouldn’t it be nice to know how you would respond to altitude prior to reaching your destination, so you could be better prepared?
There is such a test. It is called HAST: High Altitude Simulation Testing. This test can simulate 8000 feet in elevation, in the safety of a doctor’s office at lower elevations. HAST is a diagnostic test that can effectively calculate an individual’s supplemental oxygen needs prior to traveling to high altitude. The California Thoracic Society recommends that individuals diagnosed with severe airway disease, cystic fibrosis, neuromuscular disease, kyphoscoliosis, individuals who have been hospitalized for acute respiratory illness within the last 6 weeks, individuals with previous air travel intolerance, COPD, or cerebral vascular disease would benefit from a HAST prior to traveling to altitude (Corby-DeMaagd, 2020).
This test is performed by obtaining a patient’s blood pressure, heart rate/rhythm, and oxygen saturation at baseline. Once baseline vitals are complete the patient is monitored while breathing in a mixture of gases containing approximately 15.1% oxygen, simulating the FiO2 at an elevation of 8,000 feet. A patient;s oxygen saturation levels can be recorded by an arterial line (large IV in the wrist) monitoring the patient’s arterial blood gasses, or by an oxygen monitor attached to the patient’s finger or on a nasal cannula. This allows the physician to screen for hypoxia, arrhythmias, or other significant symptoms. If the patient becomes symptomatic, the oxygen levels are reassessed while providing the patient with supplemental oxygen to identify exactly how much oxygen would be needed to keep the patient comfortable at a higher altitude. This test on average takes 2 hours to complete (Corby-DeMaagd, 2020).
According to Mark Fleming, the supervisor of the Pulmonary Physiology Services at National Jewish Health in Denver, Colorado, for an individual to receive a HAST they would need a referral from a provider. National Jewish Health is one of the few facilities in the nation that provides this service. Most patients that request this test in the state of Colorado are pilots that have had a recent ailment and need a work clearance prior to being exposed to the airplane cabin pressure, those that are interested in relocating to the mountains, planning on a high-altitude vacation and currently on supplemental oxygen, or those with a history of pulmonary embolism or lung resections. Fleming states that they are anticipating an increase in High Altitude Simulation Testing being needed for patients that have recovered from COVID-19.
However, there may be a vulnerable population that is not receiving the benefit of this test. Newborn babies that are delivered at 5000 feet but must return home to 8500 feet. Those that have experienced a chest trauma and must return home to altitude. Or maybe even those that have experienced an invasive surgery that involved the lungs, chest, spine, or abdomen. These are all individuals that would benefit from knowing if they would need oxygen once they return back to elevation. Hopefully as people continue to heal from COVID the word will spread that this test is available to the public for those that are concerned about journeying to altitude.
Amanda Bergin is currently in her second year of her Family Nurse Practitioner Program for the Rural and Underserved at Regis University. She is a member of the class of 2021 and will be graduating in August. She started her medical career as a corpsman in the United States Navy and after the completion of her service, she returned to school to complete her bachelor’s degree of Science in Nursing at the Denver School of Nursing. Amanda currently lives in a rural mountain community with very limited healthcare, and dreams to help her community start a family practice clinic. In her free time, she loves spending time with her family, fishing, camping and raising dairy goats.
While doing a clinical rotation with Dr. Chris at the Ebert Family Clinic in Frisco, CO I had the pleasure of interviewing local emergency medicine physician, Dr. Jack Gervais.
To start off, if you don’t mind just telling us about yourself, where you work, and how you got into the ED …
Dr. Jack Gervais:I grew up in Summit County and then did my undergrad at the University of Denver, and then medical school at University of Colorado in Denver as well, and then did a three-year residency for emergency medicine in Portland, Maine. Then I came back to Frisco in 2011, so this was my first job out of residency, and I’ve been here ever since. As far as what got me into emergency medicine, it just kind of seemed like a good mix of everything, really, and I like doing procedures but didn’t necessarily want to be a surgeon, and so I kind of gravitated towards that.
What percent of your practice involves tourists?
Dr. Jack Gervais:It depends on the season. Obviously during the higher tourist seasons it goes up, but I would say probably on average maybe 50-60% and then during the heavy winter tourism times it’s probably more like 80%, and fall and spring much less.
Let’s say that there is a visitor in Frisco who brought a pulse oximeter with them. At what point, with either their O2 saturation or their symptoms, would you recommend that they go to the ER or seek oxygen administration?
Dr. Jack Gervais:It really depends primarily on the symptoms. People can be symptomatic with a fairly typical kind of mountain sickness symptoms and have a normal oxygenation. We consider anything above 88-90% acceptable. We get a lot of patients that come in with an ankle injury and their O2 saturation is 85% and they’re really asymptomatic.
Certainly, anybody who’s symptomatic we will offer O2 to them even if they have a normal saturation. Anybody around 85-86% if they’re not having symptoms and they’re going home in a day or two, I offer oxygen to them, but I don’t necessarily say “oh you have to be on oxygen ’cause you’re 85%”. Anybody who’s under 80%, I would say absolutely should be on O2 regardless ’cause they’re going to end up getting worse.
Let’s say they’re skiing, they check their oxygen saturation, and it’s 85% but they feel fine. Would you say “keep going and be aware if you develop symptoms”?
Dr. Jack Gervais:Yeah, I think that’s reasonable. People tend to do worse at night, so someone is 85% when they’re standing in the day, they’re probably in the 80s at night. So, what I’ll often do with people with those kind of borderline sats is offer them oxygen. It’s really easy to get the delivery from the various companies so it’s pretty straightforward, more of a cost issue for some people, but I tell them “use it when you sleep the whole time you’re here”. Probably most tourists would benefit from sleeping on oxygen regardless because you don’t know how low they’re getting at night. I would guess most people are sleeping in the mid 80s and don’t realize it. That leads to the headaches and waking up at night and those sorts of things that we see a lot.
What conditions do you see here at altitude and how commonly, i.e. cases of Acute Mountain Sickness (AMS), HAPE (High Altitude Pulmonary Edema), HACE (High Altitude Cerebral Edema), sleep problems, blood pressure issues, etc.?
Dr. Jack Gervais:Typical AMS would be shortness of breath, headache, and nausea being the most common. Any combination of those in people who recently traveled from lower elevation or when locals come back from as few as 4 days of vacation can be AMS. People reset really quickly after they descend, we see a lot of people who get reentry HAPE. Kids will go down for spring break in Florida and come back and get HAPE.
It’s tough to say exactly what incidences, I would estimate probably 20-25% at least people visiting from lower elevation — and that’s when it’s just semantics, but it’s elevation, not altitude, and everybody says “altitude sickness”. Altitude is your height above the ground used by pilots. Elevation is how high you are above sea level, but anyway we see that all the time. That’s pretty simple, you know, basically treat the symptoms: something for nausea and actually ibuprofen has been studied in comparison to acetazolamide and is essentially as effective at preventing acute mountain sickness. I tell everyone just put yourself on an NSAID as long as there’s no clear contraindications to it.
I see at least 12 patients a month with HAPE, so it’s something we see really commonly. This year is kind of weird though ’cause we’re not having as much tourism. We see a lot more when a storm comes in ’cause the pressure drops-so that 10% drop in barometric pressure is like going up another 500 feet, and so that will often kind of push people over the edge. Again, we tend to see a lot of people who get worse at night because they sleep with low O2 saturation or they struggle through the night and come in first thing in the morning saying “I didn’t sleep at all last night, I’ve got this terrible headache, I’ve got this cough”.
HACE is fairly rare here, but not impossible at this elevation. It’s certainly seen more in high trekkers on Everest and in South America. I would say at the hospital we probably have maybe 3-4 cases a year.
Sleep problems are super common, a lot of people wake up feeling short of breath, they’re dehydrated, they get headaches and of course everything else people are doing on vacation exacerbates all that. We actually have this joke of the Summit County Syncope Syndrome: visiting from low elevation, hot tub, alcohol, overexertion, and cannabis. If you have 3/5, there is no way that your syncope is a dangerous cause!
I don’t know why people bring their blood pressure monitors on vacation, but we definitely see a rise in baseline blood pressure at higher elevation. They say, “I have a little headache” (it’s probably from their acute mountain sickness), they check their blood pressure and its 160 and they end up in the ER, which they don’t need to be.
There are actually some folks at the altitude research center in Denver [who] have a little publication about it, but I certainly see a lot of first-time seizures or breakthrough seizures in people who have never had a seizure before. I think it’s just that little bit of change in oxygenation to the brain if you have a seizure predisposition. We see a lot of people that either have their first-time seizure, and there’s nothing else going on, or they’re really well controlled at home, come up and have a breakthrough seizure a couple of days in.
One other thing about HAPE that’s interesting is people will come in and they’re like, “oh I haven’t slept for the last two nights, I feel terrible, I’ve had a splitting headache,” and I assume they’ve had that for 24-72 hours before they actually come in. Which means they’ve been sitting around with [low oxygen] — most of the HAPE we see is certainly below 80%. I presume these people have been walking around with sats in the 70s for 24-48 hours and it’s amazing that they’re fine. If you were walking around with your O2 saturation in the 70s at sea level, you’d be dead! So, it’s not just a hypoxia that kills people when they have respiratory illness, it’s got to be the hypercarbia and acidosis and all the other stuff that goes along with it.
HAPE tends to also settle in around day 2-3, some people get it quickly but most of the people say I felt fine on day one, I skied yesterday, felt a little crummy night 2, and then day 3 they feel terrible, night 3 can’t sleep and they’ve got HAPE.
It’s interesting to see the nurses check in a patient with an O2 sat of 50% and it is really no big deal, just put him in any room — it’s not like a big STEMI activation or something. We stick them on oxygen and no one freaks out. People freak out on their first shift if they’re new and it took me a good year to kind of get used to that.
Often, we don’t really need to do anything if we can fix them with oxygen and determine from history and physical that there’s nothing else going on. But that gets tricky ’cause you always worry all these people traveling and they’ve got a little bloody cough, they’re tachycardic and hypoxic, so trying to figure out who we want to work up for a PE (pulmonary embolism) is probably our biggest conundrum. A lot of people will get a little bit of a troponin bump just from probably that hypoxic constraint on the heart so that can be a little tricky to figure out who needs to go get a cardiac work up.
What does a classic HAPE patient look like?
Dr. Jack Gervais:A healthy 26-year-old male who’s got the classic story of progressive increase in shortness of breath, feel like there’s fluid in their lungs, a raspy cough, a little pink sputum, and their sat’s 65% and they get better pretty quickly on oxygen.
What is the typical treatment for HAPE?
Dr. Jack Gervais:The treatment for HAPE patients is to put them on high flow oxygen, around 15 liters. So, with HAPE, patients get inflammation and acute pulmonary hypertension which causes fluid buildup in the lungs. So, oxygen is really good at reversing that. We oxygenate the lungs which opens up those blood vessels, reduces the pulmonary hypertension, and that fluid can start to resorb in the lungs.
The typical HAPE patient is in the emergency department for 1-3 hours depending on how bad they were and how they’re doing on the high flow oxygen. We wean them down, with a goal of getting them on a nasal cannula with 3-4 liters of O2, which is what the O2 concentrators and portable O2 tanks can manage. And if we can keep someone above 90% on 3-4L they go home with an oxygen prescription. I tell those people to be on oxygen for 24 hours and to just rest and see how it goes, see how you feel. If you start feeling bad again you should be on oxygen. Rarely we see patients come back in because they aren’t doing well, and those people who do, we tell them, “OK you’re out, time to go down to Denver until your plane leaves”.
Are there any medications you use to treat high altitude illnesses?
Dr. Jack Gervais:I don’t tend to use a lot of other medicines. If the oxygen works, why bother adding a bunch of side effects from medications. Some providers tend to be a lot more into giving nifedipine, a calcium channel blocker, which does reduce pulmonary hypertension. A lot of them will use dexamethasone, but it doesn’t so much help with the respiratory component it tends to help more with the headache aspect, but the oxygen will often fix that too. Dexamethasone is also the temporizing treatment for HACE, but they need to descend immediately. People will use Acetazolamide (Diamox), but it’s really only effective if you start it 2-3 days before you come up to the higher elevation. Starting it after you’ve already got acute mountain sickness is probably worthless and it’s got some funky side effects that makes anything carbonated taste weird and it’s a diuretic so you’re adding dehydration to someone who’s already a little dehydrated.
I tend to be more of a minimalist, so I treat the symptoms and give oxygen if they need it and pretty much leave it at that. I was just listening to a podcast talking about inhaled vasodilators. Inhaled/nebulized nitroglycerin — it goes directly to the pulmonary vessels as a vasodilator, but you don’t get the systemic vasodilation that you would with nifedipine or oral nitroglycerin. This was talking more for acute exacerbations of chronic pulmonary hypertension among other things, but I have to wonder if that would work for our patients.
I know you mentioned ibuprofen, but are there any other over-the-counter options you might suggest someone try for AMS?
Dr. Jack Gervais:There are a whole bunch of supplements and stuff that claim to help with altitude sickness, they’re just not studied in any real scientific way to know for sure. For me it’s really just treating the symptoms, so I usually use Zofran for the nausea or Phenergan if there’s a contraindication, and then alternating Tylenol and ibuprofen and oxygen if needed. So, nothing else as far as a preventative that I’m aware of. If you kind of get into the naturopathic realm there’s probably a whole bunch of suggestions out there.
Everyone fixates on staying hydrated which is important. You’re losing extra fluid and if you’re used to living in Florida, you’re going to lose A LOT of fluid when you come up to higher elevation because of the dry air. I tell most people to try and double what you would drink at home. Hydration is really most effective with the headache part of it. It doesn’t change whether you’re going to get HAPE or not.
Oh, and the little oxygen cans you see in the convenience stores … those are garbage! For oxygen to be effective it needs to be on continuously. Even if you puffed on that thing for a minute and could get your O2 saturation up from 85% to 90% it’s going to drop right back down. In the hospital, if you turn the oxygen off, their saturation will be back where it was within minutes, so yeah, those things are just a total waste of money.
What has been your experience with COVID-19?
Dr. Jack Gervais:Luckily, we have had it much better off than places like New York, LA, and even down in Denver. I think that part of it is that overall, we have a pretty healthy population compared to a lot of the bigger city areas and suburbs. There have been some studies out there suggesting that people living in higher elevations do better with COVID than lower elevations and I don’t know if it’s just ’cause your body and your pulmonary system has adapted in some way that helps you deal with COVID, but we’ve certainly had some perfectly healthy local folks get pretty sick from it.
When the tourists were gone back in March/April/May it was great because everyone is local and if you had respiratory symptoms it was probably COVID. Now that the tourists are coming back, it’s a lot harder to tell clinically, and the other thing is the x-ray in HAPE and the x-ray in COVID look very much the same.
We had one patient in particular who came in and said, “I got here yesterday, had a positive COVID test 14 days ago,” and of course they thought they were fine to come up to the mountains, and sure enough they were short of breath. The people who are foolishly traveling either with active COVID or on the tail end of it do not adapt very well when they get up to this elevation, but most of them just need some oxygen.
We finally have rapid tests at the hospital, so it makes it much easier to kind of tell people “this is just altitude” or “this is altitude plus COVID” or “this is straight-up COVID”. In the summer when we didn’t have a rapid test, we’d get these people who have the overlapping symptoms that could be either. It’s tough to tell them what they should do as far as self-quarantine and isolation. Can you travel? Can you go try to ski tomorrow because it was just altitude sickness?
The treatment for COVID ends up being the same: oxygen if you need it and then actually dexamethasone has shown to be effective for patients with COVID who are requiring oxygen.
Even before COVID we would send patients home on oxygen with pneumonia or URI symptoms fairly routinely, which is really not a thing in other places. If you need oxygen with pneumonia in Portland, ME you’re getting admitted. If I called Dr. Chris and said I’ve got a kid of yours who looks like they’ve got bronchiolitis or a URI or even COVID, their sat’s 85% — the answer is almost always going to be “oh, put them on oxygen and if they are OK on a reasonable amount of oxygen they’re probably OK to go home”.
Do you admit COVID patients to the hospital up here if needed?
Dr. Jack Gervais:It’s been really tricky for us to figure out who we can reasonably admit here versus transfer to Denver. Both need to have a higher level of care and be at lower elevation. We have kept COIVID patients here successfully. The thing is, even if you live up here and are used to the altitude you’ve got a respiratory process and you’re hypoxic as a result, it makes sense that you would probably do better down in Denver and probably have less of an oxygen requirement and hopefully not progress to high flow oxygen. You can get someone on high flow here but then they’re stuck here until they get better or they get intubated to be transferred.
What is the most memorable case that you have seen in the ER related to high altitude?
Dr. Jack Gervais:So, I had a professional snowboarder who had gone back to sea level for the summer and then flew back out here and had a shoulder surgery in Vail and was staying in Summit County. He was a day or two post-op and had probably been back in the mountains for three or four days so kind of fit the time frame to develop altitude sickness, and he’s probably on a muscle relaxant, some opiates, some respiratory depressants. So, this is the very end of the night shift, I had a STEMI going on in the other room and this guy comes in at 84-85%. He didn’t look super sick but needed some oxygen. I’m like, “oh, he probably took too much oxycodone,” and so I throw him on some oxygen while I go back and deal with this STEMI.
I go back, and he wasn’t any better! He was still at like 86% on high flow oxygen. So, we got a chest x-ray and he had a little bit of fluid here and there, so it looks like probably early HAPE, or potentially pneumonia, but fit with more of an altitude issue exacerbated by his post-op care. So, we put him on Bipap and he’s not getting any better and now he’s low 80s on Bipap, so we intubate him.
Now he’s getting worse and now he’s dropping his blood pressure. This is over probably an hour, so this guy is sick, and we could not get him oxygenated even on max vent support. We were begging him, and I thought he was going to just die right in front of me. Finally, he dropped his blood pressure more and we’re like “well, maybe he’s septic, maybe he aspirated, and this is pneumonia.” So, we give him norepinephrine, which is a vasopressor, it constricts all the blood vessels to help increase the blood pressure and adds ionotropic support to make the heartbeat stronger. Then his blood pressure finally got better, and his oxygen got better, and he went down to the ICU in Denver and I’m like, “thank God I didn’t kill this guy at the end of a 13 hour night shift”.
So, it turns out — and this is what makes it the most interesting — he had a PFO, patent foramen ovale — so, a hole in his heart. It’s very common, but people tend to not notice because in general, the pressure in the left side of your heart outweighs the pressure in your right significantly so that patent foramen ovale stays closed against the septum.
Like I was saying earlier, HAPE is caused by acute pulmonary hypertension which then raises the pressures on the right side of your heart. So, he blew open his PFO and now had a right to left shunt — so blood from the right side of the heart doesn’t go up through the lungs and oxygenate, it goes straight to the left and goes back out into the body unoxygenated. That’s why everything we did made him worse. When you put someone on Bipap, and especially when you intubate them, you’ve got that positive pressure that increases the intrathoracic pressure, which increases the preload on the heart.
Dr. Chris Ebert-Santos:30% of the population may have PFO!
Dr. Jack Gervais:Coincidentally, the norepinephrine that I put him on trying to treat as sepsis increased the after load — the arterial resistance, which then increased the pressure on the left side of the heart enough that it was able to squeeze his PFO back down.
Dr. Chris Ebert-Santos:The ironic thing is that it’s so random! All of this altitude stuff is SO random, even people who have had AMS or HAPE or whatever they may never get again. I mean 90% probably never have a recurrence.
Dr. Jack Gervais:Yeah people get really frustrated and say “I’ve been here 10 times before, it can’t be altitude sickness” — that can happen, and it does. People have this myth of like, “I used to live here, I’m fine,” and it’s absolutely false.
Another interesting thing you see at altitude is people with sickle cell trait (so not full-blown sickle cell disease, generally thought to be a harmless and completely asymptomatic condition) will get splenic infarcts when they come up. You almost can’t even find reports of it in the literature, but I probably see 8 or 10 a year. It’s kind of easy to pin down, the person is like, “I just got here, I’ve got this left upper quadrant pain, no trauma” — not much in your left upper quadrant, so most of the time the minute they hit triage you know what’s going on. We treat just like you would any sickle cell crisis: fluids, pain medicine, oxygen.
I know you mentioned the myth about people who have lived here before believing they aren’t able to get mountain sickness, but do you have any other myths that you frequently have to clarify?
Dr. Jack Gervais:The big one we run into is people who are taking acetazolamide wrong and are surprised that they’re having altitude sickness. People start getting symptoms and they call their doctor and they may prescribe it too late and I just tell them, “don’t bother”.
People who think they’ve got an infection or bronchitis so their doctor back home calls in antibiotics, which they don’t need even if it is bronchitis. Or the people who ignore it for 2-4 days to assume it’s the bronchitis and say “the antibiotics aren’t working, doctor what’s wrong?” Well, your lungs are filling up with fluid! The good news is HAPE tends to be gradually progressive over hours to days, not minutes. Very rarely we see patients who are really actively dying from HAPE. In 10 years I have probably seen hundreds if not 1,000 HAPE patients and I’ve only probably had 2-3 who were really, really hard to fix. Probably 10-20 that I’ve had to put on Bipap and transfer down. I think I’ve maybe only intubated 1-2. People get in trouble if they’re up high — 20,000 feet on Mount Everest, don’t have oxygen, that’s where you’d end up dying with HAPE.
Dr. Chris Ebert-Santos:And how many die at home?
Dr. Jack Gervais:I would say a handful. I’ve had at least one lady who was camping. Had HAPE-like symptoms and came in dying, she was the one I intubated, and she actually lived. I had a guy camping last summer who sounded like (from what his mom described) altitude-related symptoms, although he was just up from the Front Range. I don’t know what they ever found on him, but he was dead when the paramedics got to him. I would say it’s a handful, but not dozens a year.
Thank you for your time Dr. Gervais. Is there anything more you would like to share about high altitude medicine?
Dr. Jack Gervais:I would say probably anybody with any serious cardiac or pulmonary comorbidities who is going to vacation here should really be on oxygen at least at night. That would prevent a huge number of these problems. I actually see a lot of people (locals) who sleep on oxygen at night even if they’re 40 and healthy and don’t really have any issues and they just sleep much better.
And the other thing is you know, especially the people who have lived up in Leadville for 60 years tend to develop a gradually progressive chronic pulmonary hypertension which adds to blood pressure management issues and so that’s an issue we definitely see. So I tell anybody who has any sort of symptoms and is going to be here for a while, “just buy yourself a (oxygen) concentrator, keep it at your house,” that way when they come up for a week vacation every winter they’ve got it and just sleep with O2 every night and avoid all the hassle. And don’t bring your blood pressure cuff on vacation!!
There’s a cardiologist who works over in Vail, he was really convinced that living at altitude is really bad for your chronic blood pressure issues.
Dr. Chris Ebert-Santos:Our interview with three other high-altitude physicians in primary care and cardiology say their standard is “if you’re 50 and you’ve lived here 10 years and you want to live here for another 10 years you should be sleeping on oxygen.”
Rachel Mader is a second-year physician assistant student at Red Rocks Community College. She was born and raised in Colorado Springs and attended Colorado State University where she graduated with a bachelor’s in biology. Before starting PA school, Rachel worked as a Physical Therapy Aide at CSU Health and Medical Center, a CNA at a nursing home, and a Clinical Assistant at Children’s Hospital in Colorado Springs. In her spare time she enjoys spending time with her family, friends, and pets, and eating at new restaurants.
As the nation experiences its second, and by far more significant, increase in COVID-19 cases, visitors continue to flock to the Colorado Rocky Mountain region, while advisories from the CDC and government officials across the world continue urging people to stay isolated and home for the holidays. Unlike the Northern Mariana Islands or New Zealand, where physical distancing, the use of masks, travel bans and mandatory quarantines have allowed these island nations to maintain zero community spread, Colorado remains open to the potentially millions of travelers it sees every Winter season, and with far fewer mandates to control infection.
Although the beginning of the pandemic saw facilities managing to protect their staff with protective equipment and protocols, during this dramatic second wave of reported cases, we are seeing an increase in cases among essential health care workers. And with the regular flu season well underway, it seems more critical than ever that we do everything we can to limit exposure.
Ebert Family Clinic, in the heart of Summit County, Colorado, surrounded by world-class ski resorts drawing visitors from all over the world, has successfully managed to avoid infection among all its staff, in spite of continuing to serve its patient population since the initial lockdown this past March.
How?
“First of all, we kept our door locked. You can only come in one at a time, we meet you at the door, screen your temperature, ask if you have any symptoms; we screen when you make an appointment and make sure if anyone in your household is sick, you reschedule your appointment. If so, we made you a telehealth appointment,” says pediatrician and president Christine Ebert-Santos, MD, MPS.
And the telehealth appointments have been a success all year, saving a lot of travel and risk of exposure, making primary health care even more accessible.
Even now, Ebert Family Clinic’s pandemic protocol hasn’t changed. “But just as importantly, all of our employees are maintaining a bubble with close contacts,” adds Dr. Chris.
Operations weren’t always smooth: “Two times, when someone close to a staff member, like in our family, was sick, we stayed home,” says The Doc about having to close the clinic. I stayed home until [my husband’s] test was negative, [our nurse practitioner,] Tara stayed home until her husband’s test was negative; until we knew we didn’t have COVID. We based the risk of COVID on the standard that is described of having been within six feet of an infected person in a closed space.”
Is the vaccine going to change protocols?
“The vaccine isn’t going to change anything. The announcement from Public Health today tells exactly how many doses. That’s a drop in the bucket. What’s that when we have 30,000 residents and 90,000 visitors? It’s going to be six to nine months before we see any protection from this vaccine,” Dr. Chris confirms.
“Essential workers all have their protocols, and they’re just as important as ever. [If you can’t work] — all the parents who have to stay home with their kids, or the restaurant servers who are laid off — I’m hoping that the people who are doing well in our community can continue to help those who are suffering. There is a big sector of our community, like real estate or repairs or construction workers who have been able to continue working through this pandemic. I think [these people who are out of work] are getting help from the FIRC or applying for rent assistance. I haven’t had anyone say that they’re really struggling. And we conduct social welfare interviews, “Do you feel safe? Do you have food?” We’re doing anxiety and depression screenings on everybody. And there is a high level of anxiety among all ages.
“We had a meeting with Heart-Centered Counseling, and now we’re plugged in with them. We have their brochures, and we’ve just signed care coordination to connect people with providers [who can help in this situation].”
Dr. Chris encourages everyone in the community to reach out with their needs. Ebert Family Clinic and other health care institutions have done very well maintaining a cohesive network of resources for everyone in search of financial, physical, mental, and emotional assistance.
Feel free to inquire about appointments or referrals to local resources at info@ebertfamilyclinic.com, or call the clinic at (970) 668-1616.
Dr. Chris with her granddaughter, comfy-cozy.
“Everybody enjoy their Christmas Zoom with their relatives. As for us, we are having a small family Christmas with six of us who work and live together, and we’re all wearing hoodie-footie flannel jammies.”
Happy Holidays from Dr. Chris, Ebert Family Clinic, and highaltitudehealth.com!
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.
Ski resorts have opened in Colorado, and with more holidays around the corner, it is essential to remember that we are still currently amid a pandemic that is surging with cases here in Colorado. So what does that mean for those that live in the mountains and at altitude?
When it comes to the coronavirus, there are advantages and disadvantages to living at altitude. While research does show that COVID-19 has a more challenging time affecting mountainous populations, Summit County, Colorado has its own set of dangers. With the influx of skiers, travelers, and increased indoor activities, it is essential to remember how to protect yourself and your neighbors here in Summit.
Research shows that populations living at higher altitudes are at less risk of transmission and have better adaptations to hypoxia than those living at lower altitudes (Pun et al., 2020). Interestingly, people living in high altitude environments live in a state of hypoxia or lower oxygen levels, and the lungs of these people generally adapt to conditions of decreased oxygenation. However, this has not been proven to be a saving grace, especially if the person has comorbidities like asthma, hypertension, diabetes, kidney disease, or COPD. Research has also shown that the environment is often colder and drier at higher altitudes with increased UV radiation, which can help slow the spread of the virus. However, this is only relevant when you are outside and does not diminish its spread indoors. While all these facts are unique to living at altitude, we must remember that Summit County is a tourist destination, is densely populated and requires the utmost protection despite these factors.
So how do you protect yourself this upcoming winter in the mountains? With ski resorts initiating strict policies and physical distancing, what are ways that we can help keep these businesses and resorts open?
Some might blame the tourist for bringing COVID to the mountains; however, the increase in numbers can be tracked down to Summit County residents spreading it to one another through social events and large gatherings. It is important to remember to wear a mask, stay at home whenever possible, wash your hands if you feel sick, get tested, isolate, and make sure to get your flu shot. It is essential to listen to public health orders as they change throughout this second surge of COVID-19 infections. Going into the holidays, the CDC recommends not traveling to see your family and only celebrating the holidays with family members that live in your house. It is essential to stay vigilant as we go into the winter months so the mountain communities can stay safe.
Caitlin Endly is a Texas transplant that has lived in Denver, Colorado for the past three years going to school to become a Family Nurse Practitioner at the University of Colorado. She has been a Registered Nurse for five years and currently works as a Neuro Trauma nurse at St. Anthony’s Hospital in Denver. She graduated with her Bachelor’s of Science in Nursing from Texas State in San Marcos, Texas and has worked as a neuroscience nurse since graduating. In her free time she likes to dance, snowboard, and listen to live music.
As the gateway to Machu Picchu, the city of Cusco, Peru attracts over 3 million tourists from all around the globe each year. With this many people passing through the city, you can imagine why local residents feared the worst when the COVID-19 outbreak began. However, out of a population of approximately 429,000 people, the city has only four COVID-19 related deaths – three tourists who traveled to the area and one native with previous risk factors.
Machu Picchu
Machu Picchu, a UNESCO World Heritage Site, brings 3 million tourists from around the world to the Cusco region of Peru every year.
One death out of 196 confirmed cases for the city makes for a remarkably low fatality rate of 0.5% for the native population. Peru as a whole has a fatality rate closer to 3% with over 6,000 deaths, making it one of Latin America’s most affected countries. Many believe the fatality rate to be even higher as testing has not become widely available in the country.
To understand why Cusco is such an outlier when compared to the rest of the country, there are several factors to take into consideration. One of those factors that researchers haven’t quite been able to figure out, but believe plays a role, is altitude. The Cusco region of Peru sits at 11,152 ft elevation compared to the capital city of Lima that sits at only 512 ft elevation.
Research comparing the high-altitude regions of Tibet, Bolivia, and Ecuador has revealed similar trends. A study completed April 22, 2020 and published in the June 2020 scientific journal “Respiratory Physiology & Neurobiology” indicates that populations living above 9,842 feet elevation reported significantly lower levels of COVID-19 cases than populations living at lower elevations. The research showed the infection rates in the Andes Mountains of Bolivia were one third the infection rates the rest of Bolivia, and the infection rates in the Andes Mountains of Ecuador were one fourth of the rest of Ecuador. In both Bolivia and Ecuador, the areas with the highest concentration of COVID-19 cases were located at an elevation close to sea level.
At an elevation of 11,942 ft, La Paz, Bolivia is the highest capital city in the world.
Why populations living at higher altitudes are experiencing lower infection rates is still not well understood, but there are a few theories at play. It is hypothesized that people living at altitude are able to live in a state of chronic hypoxia, or a state of chronically low oxygen in the blood. Hypoxia is one of the conditions caused by COVID-19, and if a person’s body is already used to low levels of oxygen, their symptoms may not be as severe. There are other environmental considerations at altitude that may shorten the life-span of the COVID-19 virus, including high levels of UV radiation that can kill the virus, low barometric pressure that does not support the weight of the aerosolized droplets that the virus lives in, and dry thin air that does not support the transmission of aerosolized droplets.
However, as intriguing as the effect of altitude on COVID-19 statistics is, it is important to note that there are several other proven factors that come into play when looking at these populations. First, most high-altitude towns and cities tend to be rural. When population density per square mile drops, the rate of transmission of infectious diseases also drops – rural settlements allow for natural social distancing. Second, populations living at higher altitudes have lower rates of obesity and generally have better overall health. Living at high altitude causes a reduction in the hormones that signal hunger, leading to consumption of fewer calories. Additionally, completely normal daily activities in a state of chronic hypoxia due to low levels of available oxygen in the air raises the body’s resting metabolic rate, leading to burning more calories. The healthier a person is prior to contracting an illness, the more likely their body is to be able to fight it off successfully.
Research regarding how altitude affects COVID-19 transmission, infection, and recovery rates is ongoing. It may be too soon to tell exactly why or how altitude comes in to play, but early findings are suggesting that now is a great time to be a resident of the great Rocky Mountains – but then again, when is it not?
Megan Schiers is a 3rd year Physician Assistant student studying at Midwestern University in Glendale, AZ. She graduated from Idaho State University in Pocatello, ID with a Bachelor of Science in Dental Hygiene and worked as a dental hygienist in Strasburg, CO for two years prior to starting PA school. She is passionate about increasing access to healthcare in rural areas and hopes to specialize in emergency medicine or cardiothoracic surgery following graduation this fall. During her six weeks in Frisco, CO, she has enjoyed hiking in the beautiful mountains, camping at Camp Hale Memorial, visiting Maroon Bells, and checking out Black Canyon of the Gunnison National Park.
Last week we were privileged to have a Zoom discussion with two high altitude experts from the Instituto Pulmonar Y Patologia de la Altura (IPPA) founded in La Paz, Bolivia in 1970. Dr Gustavo Zubieta-Calleja and Dr. Natalia Zubieta-DeUrioste answered our questions about their recently published article, Does the Pathogenesis of SAR-CoV-2 Virus Decrease at High Altitude?. They and the seven coauthors presented data comparing COVID cases in high altitude areas of China, Bolivia and Ecuador showing a marked reduction in numbers compared to low altitude areas in the same countries, with dramatic, colorful topographic maps.
Drs. Zubieta-Calleja and Zubieta-DeUrioste and their colleagues theorized four reasons why altitudes above 2500 m could reduce the severity of the corona virus. (Note: Frisco, CO is at 2800 m, Vail 2500 m). As described in their previous paper published in March, the intense UV radiation at altitude as well as the dry environment likely reduce the viability of the virus in the air and on surfaces.
Dr. Zubieta-Calleja on a Zoom chat with Dr. Chris explaining a chart comparing UV exposure in La Paz, Bolivia (top line) and Copenhagen, Denmark (bottom line).
Dr. Chris with Dr. Gustavo Zubieta-Calleja and other altitude experts from the Hypoxia Conference in La Paz on the Camino Chacaltaya, which reaches an elevation of 17,785’/5421 m.
The low barometric pressure causes air particles to be spaced more widely, which would also decrease the viral particles inspired with each breath, reducing the severity and frequency of infections.
Furthermore, residents accustomed to chronic hypoxia may express reduced levels of angiotensin converting enzyme 2 (ACE2) in their lungs and other tissues. This enzyme has been found to be the entry path for the corona virus into cells where it replicates. Finally, the normal adaptation and acclimatization of populations with prolonged residence above 2500 meters may reduce the severity of the disease in individuals, and reduce mortality. This includes increased ventilation, improved arterial oxygen transport, and higher tissue oxygenation mediated by increased red blood cells produced under the influence of erythropoietin, which could be explored as a possible therapy.
Dr. Zubieta-Calleja with statistics reflecting the number of COVID-19 infections at different elevations in Bolivia. Note the most infections occur at a lower elevation.
As we stated in our interview quoted in the Summit Daily News March 17th, none of these factors can be relied upon to protect every individual. Therefore it is important to continue frequent hand washing, wearing masks, social distancing, and avoid touching your face.
