Ultrasound itself is not an unfamiliar technology to most, having been used in obstetrics and gynecology (OB/GYN) for many years. Newer research is now showing that ultrasound imaging may have good applicability in both high-altitude pulmonary edema (HAPE) and high-altitude cerebral edema (HACE). Pulmonary edema (or fluid in the lungs) is identified as “B-lines” or “comet tails” and is easily distinguishable on ultrasound (Gargani, 2019).
Gargani, 2019
Using ultrasound to measure the diameter of the optic nerve can also assist with a diagnosis of HACE, as an increased diameter indicates increased intercranial pressure from HACE (Shookahi et al., 2020). The advantages of ultrasound over traditional imaging include being highly portable and usable in austere environments (such as back country), no radiation like many other imaging techniques, accurate for diagnosing pulmonary edema and other conditions, and takes little time for providers to master. Ultrasound also has a significant cost savings as the machine itself is relatively inexpensive, does not require special construction like adding lead to an Xray room, and is applicable in many other diagnoses (including kidney disorders, gallbladder disease, pneumonia, trauma, muscular disorders, and gynecological complaints). Ultrasound also has the capability to differentiate types of pulmonary edema, as well as other lung disorders, and generally much faster than a traditional Xray as there is no radiographic lag between clinical onset and ultrasound changes.
Pulmonary Edema on Xray, Mayo Clinic, 2024
Pulmonary Edema on Xray Mayo Clinic, 2024
In HAPE, an increase in the number of B-lines indicates an accumulation of fluid in the lungs. Healthy individuals acclimating to the altitude have been shown to have a physiologic increase in B-lines during the first 4 days of high-altitude exposure as well as pregnant individuals having an increase in their baseline b-line count. Keeping these differences in mind, an increase of B-lines of more than 3 in a lung field, in more than 2 lung fields indicates an increase in extravascular lung water (EVLW) and could support a diagnosis of HAPE. Correlating this with clinical signs and symptoms of altitude sickness (HA, dizziness, fatigue, shortness of breath, nausea/vomiting), as well as HAPE (hypoxia, cough, exercise intolerance) can support a more rapid diagnosis of HAPE as well as assist with deciding need for oxygen and/or altitude descent (Yang et al., 2018; Heldeweg et al., 2022). The provider can also use the ultrasound to monitor resolution of the pulmonary edema to help support decisions to discontinue oxygen or to encourage altitude descent. Those with comorbidities such as heart failure can also be monitored for early signs that their treatment plan is not adequately addressing their EVLW and can receive correction prior to needing hospitalization (Chiu et al., 2022).
Pulmonary Edema on Xray Mayo Clinic, 2024
HACE, as a disorder including altered mental status, ataxia, headache, loss of consciousness, and seizures, is a serious complication of high altitude. As the symptoms suggest, rapid identification is key to reducing other problems, including death, from HACE. The use of ultrasound is relatively new in assisting with diagnosis, but an increase in optic nerve diameter on ultrasound above 5 millimeters indicates that there is a good chance of brain swelling (or cerebral edema) and subsequent increased intracranial pressure. Identifying this early allows for rapid decision making the descent to a lower altitude or using a more rapid evacuation method (helicopter or rapid ground transport). Increased intracranial pressure can also result from head injury or trauma and thus can be useful in settings where an injury may have occurred. This makes this a tool that could be invaluable in search and rescue operations or for first responders (Shookahi et al., 2020).
Gargani, 2019
Keeping these benefits in mind, remember that diagnostic imaging is a support tool and not the complete answer to all health problems. Hopefully soon we will see this tool being used with more frequency to help aid our healthcare providers in determining a more accurate cause of symptoms!
References
Chiu, L., Jairam, M. P., Chow, R., Chiu, N., Shen, M., Alhassan, A., Lo, C.-H., Chen, A., Kennel, P. J., Poterucha, T. J., & Topkara, V. K. (2022). Meta-Analysis of Point-of-Care Lung Ultrasonography Versus Chest Radiography in Adults With Symptoms of Acute Decompensated Heart Failure. The American Journal of Cardiology, 174, 89–95. https://doi.org/10.1016/j.amjcard.2022.03.022
Heldeweg, M. L. A., Smit, M. R., Kramer-Elliott, S. R., Haaksma, M. E., Smit, J. M., Hagens, L. A., Heijnen, N. F. L., Jonkman, A. H., Paulus, F., Schultz, M. J., Girbes, A. R. J., Heunks, L. M. A., Bos, L. D. J., & Tuinman, P. R.. (2022). Lung Ultrasound Signs to Diagnose and Discriminate Interstitial Syndromes in ICU Patients: A Diagnostic Accuracy Study in Two Cohorts*. Critical Care Medicine, 50(11), 1607–1617. https://doi.org/10.1097/ccm.0000000000005620
Shokoohi, H., Pyle, M., Kuhl, E., Loesche, M. A., Goyal, A., LeSaux, M. A., Boniface, K. S., & Taheri, M. R. (2020). Optic Nerve Sheath Diameter Measured by Point-of-Care Ultrasound and MRI. Journal of neuroimaging : official journal of the American Society of Neuroimaging, 30(6), 793–799. https://doi.org/10.1111/jon.12764
Yang, W., Wang, Y., Qiu, Z., Huang, X., Lv, M., Liu, B., Yang, D., Yang, Z., & Xie, T.. (2018). Lung Ultrasound Is Accurate for the Diagnosis of High-Altitude Pulmonary Edema: A Prospective Study. Canadian Respiratory Journal, 2018, 1–9. https://doi.org/10.1155/2018/5804942
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 fundamentals of vitality include food, water, air, shelter, and sleep. Sleep, though often underappreciated, can influence our physical and mental health, complex and easily impacted by outside factors. Living at a high altitude may be wonderful but what is gained in beauty and adventure, is compromised with reduced quality sleep. With increasing elevation comes more nighttime awakenings, brief arousals, nocturnal hypoxemia, and periodic breathing. Light sleep increases and slow-wave and REM sleep decrease.
The current gold standard for diagnosis of suspected sleep disorders includes polysomnography: seven or more streams of data at a hospital or sleep center. The SleepImage System allows for more flexibility with children, adolescents, and adults. Currently, Dr. Chris Ebert-Santos of Ebert Family Clinic in Frisco, Colorado, USA (9000′) is using this technology primarily to assess some of the most common forms of Sleep Breathing Disorders and secondly, to analyze the percentage of oxygen desaturation of her patients while in their homes.
The SleepImage System measures several variables that construct a summary for each individual. Sleep quality is generated using Sleep Quality Index (SQI) biomarkers. Pathology markers measure sleep duration, efficiency, and latency. Central Sleep Apnea (CSA) and Obstructive Sleep Apnea (OSA) are assessed together as Sleep Apnea Hypoxia Index (sAHI). Periodic and fragmented sleep pathology are reported and can be used to assess disease management long-term.
Recently, the clinic analyzed Patient X’s sleeping patterns without and with supplemental oxygen. The theory: adding a steady flow of oxygen to the nightly sleep regimen reduced the total amount of time desaturating and severity of sleep breathing disorders. On the night preceding treatment, Patient X experienced an SQI of 17 (expected >55) and efficiency at 95% (expected >85%) for overall sleep quality. Sleep opportunity demonstrated a 0h:02m latency (expected <30m), and duration of 5h:47m (expected 7-9h); sAHI was marked as severe for both 4% and 3% desaturation with values at 34 and 61, respectively (severe= >30.0 in adults). Fragmented sleep was at 55% (expected <15%) and periodicity at 22% (expected <2%). Lastly, Patient X spent 25% of his night’s sleep under 90% SpO2, 18% under 88% Spo2, and 4% under 80% SpO2. Ideally, a healthy night’s sleep should aim to remain above 90% SpO2 for the majority of the time in bed.
When oxygen supplementation was introduced, improvements were observed. Sleep quality showed a slight change, SQI increased to 31 (previously 17, expected >55), and efficiency decreased to 87% (previously 95%; expected >85%) while remaining at a target value. Sleep opportunity showed a slight increase during latency to 0h:12m while remaining within the expected value of <30mins; duration jumped to 8h:14m but that could be attributed to an early bedtime. Fragmented sleep remained in the severe range but decreased by 5%; periodicity improved to 0%, removing it from both the severe and moderate range. The most notable improvement was observed with sAHI, both the 3% and 4% desaturation categories improved to the moderate range with values of 9 and 14, respectively. Time under 90% SpO2 also improved to only 4% throughout the night and 0% below 88% SpO2.
Since data is collected while patients sleep, skewed results from the placebo effect can be reduced or eliminated. Increased duration could be attributed to longer time in bed, as mentioned above, and should be examined more in-depth longitudinally. Latency for sleep increased with oxygen treatment but that could be attributed to discomfort from the nasal cannula or greater tiredness one day over the other. Similarly, latency should be examined longitudinally.
The results seen with this patient are common in our population. Many people report they slept significantly better their first night on oxygen. Many patients studied on and off oxygen show the same dramatic decrease in their sleep apnea index. The gold standard for treating sleep apnea involves a mask to increase the pressure in the airway and prevent the collapse and narrowing that occurs during relaxation and sleep. Does the supplemental 2 liters per minute of oxygen cause enough increased airway pressure to prevent airway narrowing? Supplemental oxygen would not be considered for an intervention or treatment in other locations where sleep studies are conducted because they are not usually showing significant hypoxia. Does the improvement in oxygen, even if it is the difference between oxygen saturations in the high 80’s and low 90’s increasing to the mid 90’s affect the balance of oxygen and carbon dioxide in a way that changes the incidence of apnea and drive to breathe during sleep?
Long-term, this easy-to-use SleepImage System can assess sleep disorders across all age groups and contribute to long-term management for many people living at altitude. Oxygen, a simple intervention that is widely available and relatively inexpensive, requiring no special visits to fit and adjust, has the potential to improve symptoms and sleep greatly.
References
Introduction to SleepImage https://sleepimage.com/wp-content/uploads/Introduction-to-SleepImage.pdf
Diagnosis and treatment of obstructive sleep apnea in adult https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5714700/
Sleep and Breathing at High Altitude https://pubmed.ncbi.nlm.nih.gov/11898114/#:~:text=Sleep%20at%20high%20altitude%2 0is,REM%20sleep%20have%20been%20demonstrated.measure
Ashley Cevallos is a second-year Physician Assistant student at Red Rocks Community College in Arvada, CO. She received her undergraduate degree from University of Maryland, Baltimore County. Before PA school, she worked as a vestibular technician and research coordinator for Johns Hopkins department of Otolaryngology. She was born in Ecuador and raised in Maryland. In her free time, she enjoys hiking, yoga, discovering new plants/animals and picnics.
HAPE can affect long term locals too. There is no specific test to diagnosis HAPE leading to delayed treatment or improper treatment, including death.
HAPE is defined as fluid accumulation in the lungs when an individual spends about 48 hours at elevations of 8,200 feet or higher. This can occur when 1) tourists who are not accumulated to high altitudes appropriately 2) locals who re-enter high altitude after being at lower elevation for a period of time or 3) long term residents who develop an illness.
What are the signs and symptoms you ask? Exhaustion, dyspnea on exertion, productive cough, tachypnea, tachycardia, low oxygen saturation levels, and crackles upon lung assessments are the most common to be seen. These are very generic symptoms and resemble many other diseases, such as pneumonia and asthma, leading to misdiagnosis and improper treatment.
How is HAPE treated?
The answer is simple, oxygen. The body is being deprived of oxygen and is unable to feed our cells. By giving oxygen (either through an artificial source or returning to lower elevation) and allowing the body to rest, the body is able to meet its demand for oxygen and symptoms resolve. If one receives oxygen and symptoms do not improve, there is most likely an underlying cause that is contributing to the symptoms unrelated to HAPE.
A pulse oximeter is the easiest way that one can monitor their oxygen levels at home. This device can be purchased over the counter, relatively inexpensive, and easy to use. By placing the pulse oximeter on one’s finger, the device will read the individual’s oxygen level which should be greater than 90% (when at altitude). The heart rate will also be recorded which tends to be between 60-100 beats per minute when at rest for adults.
References
A new mechanism to prevent pulmonary edema in severe infections. Lung Disease News. (n.d.). Retrieved September 2, 2022, from https://lungdiseasenews.com/2015/01/14/researchers-discover-a-new-mechanism-to-prevent-pulmonary-edema-in-severe-infections/
Bhattarai, A., Acharya, S., Yadav, J. K., & Wilkes, M. (2019). Delayed-onset high altitude pulmonary edema: A case report. Wilderness & Environmental Medicine, 30(1), 90–92. https://doi.org/10.1016/j.wem.2018.11.002
Fixler, K. (2017, October 12). Colorado doctor: Health effects of living in mountains unknown to medical establishment. SummitDaily.com. Retrieved September 2, 2022, from https://www.summitdaily.com/news/summit-county-doctor-makes-a-case-for-high-altitude-disorder-that-affects-even-the-acclimated/
I had the honor of interviewing Andrew Breithaupt who recently retired from US Customs and Border Protection in the Department of Homeland Security where he served as an Air Interdiction Agent piloting multiple types of aircraft. He currently serves as a Lieutenant Colonel on active duty for the US Army, stationed in Minneapolis, MN. He began Army flight school in 1992 to become a helicopter pilot, ultimately qualifying in 4 different types of Army helicopters including the UH-1H, OH-58, AH-1, and the AH-64 Apache for which he became an Instructor Pilot training new Army aviators at Fort Rucker, Alabama. Later he began his transition to fixed-wing aircraft in the civilian community. After nearly 10 years of Army active duty and multiple overseas tours, he was selected to enter service for US Customs and Border Protection where he served as a federal law enforcement agent for over 20 years, retired in December of 2021. He holds his commercial pilot license for single engine & multi-engine fixed wing as well as rotorcraft with instrument privileges and aircraft type ratings. He has over 30 years of aviation experience and more than 2,500 hours of flight time over his career. I sat down to chat with him about his accomplished career and learn more about his aviation and altitude expertise.
In army flight school, specifically aeromedical training, he was taught the effects of aviation on the body. One of the first lessons they learned in their training was how to recognize the early warning signs of hypoxia. These include shortness of breath, dysphoria, nausea, vomiting and lightheadedness. This type of training is often done in altitude chambers, so trainees can experience these effects before they are in the air, including how aviation can affect your vestibular senses. A position change as simple as looking down to change a radio or instrument can completely disorient a pilot due to the change in direction of the fluid within the inner ear against the cilia. This can lead to the sensation that the plane has rotated and flying sideways. They are taught to trust their instruments because an overcorrection can lead to what they teach in flight school as a “death spiral.” The training is often done in a Barany Chair and simulates vestibular senses experienced during flight.
Elevation in Summit County, Colorado ranges from 7,947 feet to 14,270 feet, the highest peak being Gray’s Peak. With people living as high as 11,200 feet, as Andrew does at his home in Blue River located south of of Breckenridge, CO. Andrew shared some very interesting aviation altitude requirements which might surprise some. He spent much of his career operating non-pressurized helicopters and Federal Aviation Regulations prohibited him from going between 10,000 feet to 12,000 feet for more than 30 minutes without oxygen. When flying above 12,000 feet, pilots are required to have supplemental oxygen regardless of the amount of time spent at that elevation depending on the category of aviation being conducted such as commercial operations. This is according to the CFR (Code of Federal Regulations) Part 135 which governs commercial aircraft operations. How interesting is it that pilots have these regulations, yet many people who live in Summit County or those summiting 14ers (peaks at 14,000 ft. or above) are at or above these elevations with no supplemental oxygen on a daily basis. When flying private aircraft, CFR part 91.211 specifies flight crew can fly without pressurization or supplemental O2 below 14,000 feet and passengers below 15,000 feet.
While in the Army, Andrew would rarely operate aircraft above 8,000 feet and would typically not have supplemental oxygen on board. They were trained to begin descent immediately if they were to notice the early signs of hypoxia. Keeping a pilot’s license requires strict annual or even semi-annual FAA physicals and continued training to ensure their bodies can withstand the effects of aviation. As you can imagine those holding these licenses are some of the most fit men and women in the country. Andrew rarely felt the effects of altitude even with altitude changes as great as 8,000 feet coming from sea level. He would typically remain at these elevations for two hours or less piloting non-pressurized aircraft.
To give some perspective, when you hop on a commercial flight for your next adventure these planes typically fly around 28,000 to 36,000 feet of elevation. When beginning the ascent, the aircraft pressure stabilizes at 6,000 to 8,000 feet, approximately when the dreaded “popping of the ears” is felt. Supplemental oxygen and quick donning masks are required on all these aircraft in case depressurization were to occur due to the rapid hypoxia which would occur at such high altitudes.
Andrew moved to Summit County in November of 2021 from Stafford, VA with his wife and five sons ages 24, 22, 19, 14, and 11. Andrew and his family spent a significant amount of time in Summit County for snowboarding and skiing competitions and quickly fell in love with the area prior to spending the last 5 years living in Stuttgart, Germany. This is when they decided one day, they would become full-time residents of the county. They moved here for the “people, climate and lifestyle,” a combination I am learning is hard to beat outside of Summit County. With ski and snowboard season right around the corner, he and his family are excited to get back out on the slopes. Andrew currently travels between his home in Blue River and Minneapolis for his position in the Army. With each trip back he feels his body more quickly adjust to the altitude changes. Thank you for your service Andrew, and welcome to the community!
Ellie Martini grew up in Richmond, VA and is currently a second-year Physician Assistant student at Drexel University in Philadelphia, PA. She completed her undergraduate degree at The College of William and Mary in Williamsburg, VA where she received her BS in Biology. Before PA school she worked as a rehab tech and medical scribe at an addiction clinic. In her free time she enjoys hiking, biking, group fitness, traveling and spending time with friends and family.
The nuances of wound healing at high altitude is a topic that has already been explored on this platform (see Eric Meiklejohn’s “Wound Care at Altitude”). Identifying the impact that impaired oxygen delivery can have on healing time, tissue regeneration, and infection rates offers great insight into the roles health care providers can assume to support our high-altitude patients. For this interview, I was able to speak directly with a Summit County resident who had firsthand experience with these processes.
I’ve heard a bit about your experiences with wound healing at high altitudes I will ask some preliminary questions,. This entire experience was more of a marathon than a sprint. How long have you been living at this altitude, and how old were you at the time of your procedure? I’d lived at high altitude for over twenty-six years before I was diagnosed with breast cancer. I was Fifty-three when I had my surgery. I was in great shape, exercising regularly, and eating really well.
Tell me about your procedure: Well, the initial procedure was in January 2018 down in Denver. I had a bilateral mastectomy done to remove the cancerous tissue, and bilateral expanders were inserted during that surgery so that down the line I could have implants placed. Within the first week we started noticing some necrotic changes to my incisions, and that they were not healing well. The expanders were inflated with air, and it was thought that my traveling back to high altitude from Denver could have increased the pressure inside them. By the end of week one I went back in to see my doctor, who deflated my expanders pretty significantly.
Have you ever been diagnosed with a medical condition that could affect wound healing, such as Diabetes or Hypertension? No. Breast Cancer was my first real medical diagnosis.
Had you ever had surgery while living at this altitude before? And if so, what was the outcome? Yes, I’d had surgery for an umbilical hernia and that went very well. No complications at all, everything healed just fine. I’d also had tendon damage in my right hand after a fall, and I recovered really well after that surgery at this same altitude.
Regarding healing after your mastectomies, describe the anticipated wound healing time and wound care directions. The time estimate for recovery was four weeks. I was to rest for two weeks, increase activity slightly for the second two weeks with minimal physical therapy, then by the end of that fourth week the projection was that I would be mostly recovered. I was given strict precautions against heavy lifting, restricting arm movements, and not driving. For wound care I was doing daily dressing changes, not submerging the area in water, and applying Silvadene cream twice daily.
Following the removal of the expanders, what was the rest of the healing process like? Over the next two months I cared for my wounds at home. They were open and oozing, and over time the daily dressing changes and medication applications became quite taxing, both physically and emotionally. It took a lot out of me, and really interfered with my day-to-day life…not to mention the pain. On March 9th, 2018 I underwent an incision revision and resection procedure for the necrotic tissue. At that point my breast tissue had manifested itself as far as which parts were healthy and which would die, so they went in and resected the areas that were not viable. On the left side I lost most of the top surface of the breast, including the entire nipple area. Two weeks after that, I had a [chemo therapy] port placed in my arm so I could begin treatments, but that incision also had a difficult time healing. That eventually led to a one month delay in my chemo therapy.
In March and April the incisions on the right breast eventually healed, but because of all the tissue loss and necrosis on the left side those wounds did not heal. There was still a lot of drainage from that breast and it was mostly still open so I had to keep the bandage on. By early May (after this wound had been open for 5 straight months) my doctor and I started seeing more signs of infection to that breast, so around May 12th of 2018 he called me in for an emergency procedure and I had the expander completely removed from my left breast. I continued chemo and eventually that left side began to heal in the absence of the expander.
During this time, from March until I finished chemo in August, the port site never healed. The whole reason behind having the port placed was so it could heal over and I could go back to a normal life between chemo sessions. But instead I walked around with a bandage for those six months because my port site remained open. I had Her2 positive cancer, so after my six months of chemo I needed to continue taking Herceptin for one additional year. I opted to have the port removed after six months and had an IV placed every three weeks for my treatments. It was very hard on my veins, but I felt I had no choice.
In late August, with the port out and the left expander out, the last of my open wounds really started healing. I started looking at what I could do to help my tissue heal even better- my thought was that when this is all done and I am all well healed I would like to have my expanders placed and inflated again, but I don’t want to have to go backwards through this process. I did all this research, and that’s where I learned about hyperbaric therapy. That changed everything for me.
What did you learn about Hyperbaric therapy, and what was your experience with it? I did a lot of independent research online and came up with two options that I wanted to discuss with my doctor. The first was a topical option for applying oxygen directly to the wound, which was a very complicated and involved process -and the second was hyperbaric therapy.
I discussed this with my oncologist who was very familiar with hyperbaric chamber treatment centers in Denver, and who wrote me a referral to be evaluated at the one in Presbyterian St. Luke’s Medical Center. I was evaluated by their team, showed them all the photos I had been taking throughout this entire ordeal, and they seemed hopeful that they would be able to help me. I really wish I’d gone there sooner.
My plan was to use this to help me recuperate a little bit so I could give the expander one more shot on the left side. After having the left expander placed, the second phase of my plan was to get another course of hyperbaric therapy to aid in recovering from that procedure. It was eventually prescribed and accepted by insurance, who approved 27 hyperbaric sessions following my surgery.
I underwent the left expander placement in February of 2019, observed the same restrictions, and had identical at-home wound care as my initial surgery in January 2018, but with the addition of hyperbaric therapy my results were night and day. The day after surgery I started hyperbaric, and in so much less pain. I was off all pain medications within 48hours. I was able to get out, walk, function in my daily life, and the tissue healed really well. It was amazing! I felt great, had tons of energy, and it was just a completely different experience. It was nothing short of miraculous.
What was your hyperbaric chamber treatment like? It was five days a week in Denver. Being there was for me a huge learning experience. There were people there being treated for diabetic wounds, hearing loss, adjunct therapy for various types of cancer, joint and tendon disease, tissue necrosis, concussions, head trauma, and so many other things. I hadn’t known that this therapy could be utilized in all these different areas.
After your successful left expander placement, how was your transition to breast implants? Months after the left expander was reinserted, I did transition to breast implants (summer 2019) but even then, I insisted on post operative hyperbaric therapy. I was only approved for ten sessions that time, but the results were the same. Rapid healing time, noticeable decrease in pain after starting therapy, and the ability to function throughout the day. Of all the factors that played a role in this process for you, what variable would you most want to adjust? Honestly, I just wish I’d started hyperbaric therapy sooner. If there was a way to get providers who work with high altitude dwellers to recommend hyperbaric treatment as a part of their primary or secondary treatment course, that’s the one thing I would change.Well, I am very happy to know that despite the difficulty you experienced in this process, you are now three years post op, well healed, and satisfied with your results. Thank you again for sharing your story. My pleasure. If my sharing can help someone else find hyperbaric therapy or open them up to alternative methods of treatment sooner so as not to have to experience what I went through in those first few months, then it was all worth it.
Janell Malcolm is a second year Physician Assistant student in the Red Rocks PA Program in Arvada, Co. A Jamaica native, she loves the ocean, tropical fruit, and 100 degree weather. You will likely find her spending her free time with family or reading/re-reading Jane Eyre. Her personal and career goals are geared towards providing adequate medical care to underserved communities. Special interests post graduation: Labor & Delivery, General Surgery.
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.
“Day 10: I walked for maybe an hour up to Camp 3 (19,258’/5870 m) from Camp 2 (18,200’/5547 m). I became the slowest person. I had tunnel vision. It was bad. It took a lot of willpower. I do a good job of not telling people how bad I really feel. After about a mile, I told them I had to stop, and me and Logan turned around. We had that conversation,
‘I don’t think I should go up anymore. It’s not safe for me, and it’s not safe for the group.’
Barely able to move, about an hour above Camp 2.
“The others didn’t go all the way to Camp 3, but continue on a bit more. Angela said she got a headache really bad and couldn’t see out of her right eye. I had already pretty much decided — I was devastated — after two nights and two days of not acclimating. Alejo had a stethoscope and said my left lung was crackling. We thought I might develop some really serious pulmonary edema.”
Keshari Thakali, PhD is an Assistant Professor in the Department of Pediatrics at the University of Arkansas for Medical Sciences in Little Rock, AR. She is a cardiovascular pharmacologist by training and her research laboratory studies how maternal obesity during pregnancy programs cardiovascular disease in offspring. When not at work, you can find her mountain biking, rock climbing, hiking or paddling somewhere in The Natural State. She has a long-term career goal of merging her interests in mountaineering with studying cardiovascular adaptations at high altitude. She has climbed to some of the most extreme elevations in the Rocky Mountains, Andes and Himalayas. Last December, she flew down to Mendoza in Argentina for an ascent up Aconcagua.
Sacred in ancient and contemporary Incan culture, and the highest peak in the Americas, Aconcagua summits at 22,837′ (6960 m). Current statistics show only 30 – 40% of attempted climbs reach the top of this massive mountain in the Andes, in Principal Cordillera in the Mendoza Province of Argentina.
Sunset on Aconcagua from Base Camp.
The day following Keshari’s decision not to summit, she hiked back down to Plaza de Mulas (14,337’/4370 m) from Camp 2, carrying some of her colleague’s gear that he didn’t want to take up to the summit as he continued to ascend. Plaza de Mulas is a large base camp area with plenty of room for tents, available water, and large rocks that provide some protection from the wind as climbers take time to acclimate before continuing their ascent.
“Even though my oxygen [saturation] was low, I was functional. As you go down, everything gets better. The others continued up to Camp 3. They spent one night there, then summited the next day. It took them 12 hours.
“The day the others came back to Plaza de Mulas, I think that’s when everything hit me. I felt like a zombie. I did some bouldering and got so tired I had to sit down and catch my breath often, probably because I had been hypoxic and we were at over 14,000′.
“[The next day] we did the really long hike from Plaza de Mulas all the way to the entrance of the park. It probably took about 8 hours to walk all the way to the park entrance.
“We drove to Mendoza that night. I felt like my body was tired, but my muscles were functioning just fine. It’s hard to describe.”
They had done everything right and had taken every precaution. Each of Keshari’s colleagues boasted significant backgrounds in climbing and mountaineering, their cumulative accomplishments including Mt. Elbrus (18,510’/5642 m), Cotopaxi (19,347’/5897 m) and Denali (20,335’/6198 m), their ages 30 to 65. They weren’t initially planning to hire porters, “but they ended up carrying a lot of our stuff. In the end, it just makes sense to hire these porters to increase your chance of success.”
They gave themselves about two weeks to make the ascent and return. There was ample time for them to stop at each camp and spend time acclimatizing, including day hikes to the nearby peaks of Bonete and Mirador.
“Day 4 [we did an] acclimatization hike to Bonete (16,647’/5074 m), pretty much the same elevation of Camp 1. You look at the mountain and it looks pretty close, but … in mountaineering, you don’t do distances, you do time. Did the hike in mountaineering boots, which were heavy and clunky, but I learned how my boots actually work. You walk differently in these than a shoe with a flexible sole. The last part of the mountain is pretty rocky and it looks like you’re almost to the top, but you still have to walk an hour to the summit. It took about five hours to go up. We were walking slow, I felt fine. From the top of that mountain, looking away from Aconcagua, you can really see Chile and the Chilean Andes.”
Summit of Bonete.
All the way through their first week of climbing, including a day of resting and eating after their hike up Bonete, Keshari was feeling fine.
“Day 8, we made the push to Camp 2 (18,200’/5547 m). None of these hikes made me tired. I was plenty trained. We were carrying packs, but they were still pretty light, packed with stuff for the day. We spent the night at Camp 2, took oxygen mostly at night. [My] first reading at Camp 2 was low. We were at over 18,000′. I thought maybe I’ll just go to sleep and it’ll get better.
Looking down on Camp 2 covered in snow.
“Day 9 was a rest day at Camp 2 because the weather was really bad. All I did was sleep that day. If you’re gonna go to Camp 3, that means you’re gonna do a summit push the next day, because Camp 3 is so high. You’re just struggling to stay healthy. I felt really bad in the tent, but if I went outside to pee or walk around, I felt better. My pulse ox was still pretty low that day. That night, a snow storm blew in and it snowed a lot.” And it was the following day of their ascent to Camp 3 that Keshari made the decision not to summit.
Since returning from her expedition, she’s reflected on some other variables. “I swear I was hyponatremic (an abnormally low concentration of sodium in the blood). We went through four liters of water a day with no salt in the food. I was having these crazy cramps in my abs and my lats and places I don’t typically get them. To me, that has to do with electrolyte imbalance. Next time, I’m taking electrolyte tablets, not just stuff to mix in my water.
“I’m not very structured in my diet. In general I eat pretty clean, but I don’t count calories. I eat vegetables, but I also hate going grocery shopping. I feel like I eat a pretty balanced diet. If I buy meat, I’ll buy a pack of chicken and that’s my meat for a week or two.
“On the mountain, in general, I felt like they fed us way more fiber. In Argentina, they eat a lot of meat. They’re meat-eaters. They didn’t feed us steak on the mountain, but … at Base Camp, I felt like they were overfeeding us. We had pork chops one night, but on the mountain, I felt like it was mainly lentils and noodles. Even though you’re burning calories, how your body absorbs them is different. They really try to limit your salt intake because they’re concerned about having too high blood pressure. At Base Camp, breakfast was always scrambled eggs with bacon and toast. Lunch and dinner were always three course meals starting with a veggie broth soup. They fed us like kings … I brought Clif blocks with caffeine in them for hiking snacks, Lara bars.”
I ask about her main takeaway from it all:
“I think I need more time to acclimate. I don’t know how much more time, but maybe more time at about 16,000′. Maybe take Diamox. Someone suggested I should have been on an inhaled steroid, especially because my asthma is worse in the cold. If I were to go next time, I would want a couple more days at 15,000 – 16,000′. Maybe the Diamox is something I would need to use next time.
“The nerd in me wants to measure pulmonary wedge pressures (via very invasive catheters; you could go through the jugular), nothing practical,” she laughs. “The pulse oximeter is the easiest tool.”
One last thing she’d do differently? One of her colleagues bought a hypoxic generating system from Hypoxico, “which I think puts CO2 back into your system; sleeping high, training low. That might have been the best thing.”
Keshari went sky-diving back in Mendoza the day after returning from their descent. “I was expecting a lot of adrenaline jumping out of an airplane, but there was none. I enjoyed the freefall, but when the parachute went up, I got really nauseous. Maybe I had just been stressed for so long, there was no more adrenaline left. I was like, ‘Where’s the risk involved in this?'”
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.
“I’ve been here 25 years,” Sinclair shares with me over coffee at the Red Buffalo in Silverthorne, Colorado (9035’/2754 m). “Born and raised on the East Coast in Philadelphia.” The software company he had been working for moved him out to Colorado Springs. He hadn’t ever skied in his life until then. Shortly after, “on a whim”, he moved up to Summit County and started working on the mountain as what we used to call “Slope Watch”, the mountain staff often in yellow uniforms monitoring safe skiing and riding on the mountain. After a month, he got really bored, “and I said, ‘How do I get to be a patroller?'”
Sinclair then went to paramedic school to get qualified as an Emergency Medical Technician, then spent 19 years as an EMT and 9 years as a Medic. For the last six years, he’s worked for the ambulance service in Summit County, one of Colorado’s highest counties, with towns at above 9000′. He has also worked as a ski patroller at Copper Mountain, Keystone, and Park City (Utah). This year is the first he hasn’t been patrolling in 18 years. During the summer, he is a wildland fire medic, where he often works with crews that are shipped in from lower elevations, including sea level.
Although he’s decided to take this season off, he still maintains a very active relationship with the outdoors, travelling around the backcountry on expeditions to remote mountain cabins, and has made a recent trip to Taos, New Mexico (6969’/2124 m). He’s witnessed his share of altitude complications.
What are the most common altitude-related complications you see?
You see the families coming up to go skiing … Usually 90% of them are fine. Altitude doesn’t seem to bother them at all – they’re either healthy enough or lucky enough. They get in, they ski, they get out. But there’s that one family or that one couple that just don’t acclimatize. They don’t realize that they don’t acclimatize, and the rest of their group doesn’t realize. A couple of days go by and they think, ‘Geez, I feel awful,’ then they go ski, or do something active, and their condition is exacerbated. Or ‘Geez, I haven’t slept,’. you get that story over and over.
And you’re having this conversation on the hill as a patroller?
Or they’ve called 911 on their way [up to the mountains]. They have no idea. Just no idea. I ask them what they’d had to eat. They had a donut or a pastry or just coffee before the plane ride. I ask themwhen was the last time they peed. You’re trying to find the physiology of what’s happened.
I tell them, ‘You need to sit down or go back to your condo. You need liters of water. You need liters of Gatorade. No fried foods, no alcohol, no coffee. No marijuana. Let your body catch up. Wherever you’re staying, tell them you need a humidifier. Put it in every bedroom, crank it up and leave it on. You’re gonna have trouble sleeping.’
And they never wanna hear it. They never wanna take a day off, but by the time you see them, they’ve taken the day off anyway, because there’s no way they’re getting back up there!
Sinclair also expresses some frustration with the lack of resources provided by the ski industry itself:
How do you educate them? The marketing people don’t want to. Because if they have to spend a day in Denver [to acclimate], that’s one less day up here [at the ski resort]. They don’t want to publicize that [altitude sickness] can happen, that it’s common. People ask, ‘How often does this happen?’ Easily, at any resort in a day, Patrol probably sees 20 – 25 people, whether they called, they walked in, you skied by them and started talking to them. ‘You’re dehydrated. You’re at altitude. It means this …’ The resorts don’t want that many to know, otherwise, you’re gonna go to Utah or California, where it’s lower.
You get such misinformation. ‘At 5000 ft., you have 30% less oxygen.’ No, the partial pressure is less, there is still 21% O2 in the air. You just have to work harder to get the same volume. The real physiology of what’s going on is systemic. [People experiencing altitude sickness] don’t know why they feel like crap. They think it’s because they’ve been drinking too hard.
How do you mitigate their symptoms on the mountain?
We do a lot, but it’s reactive, not proactive. I hate to bash the oxygen canisters, but it’s not doing anything for you. It’s not gonna make you feel better, other than what you’re sucking up. At 10,000′, it’s questionable. We’ll be at the top of Copper [Mountain] giving them two to four liters of oxygen, then they’ll ski down and feel great.
Sinclair refers to the Summit County Stress Test, which was the first I’d heard of it:
You’re 55, you’re 40 – 50 lbs. overweight, and you come up for your daughter’s wedding. You walk over to Keystone [Ski Resort], you take the gondola over, then all of a sudden, you find out you have a heart condition. You find out whatever else you have going on. We’ve done it over and over and over. They go ski, they call us at 3 in the morning, we find out they’ve got a cardiac issue, or they’ve irritated the pulmonary embolism they’ve had for years.
I had a guy last year, at the Stube at Keystone for lunch.
Keystone’s Alpenglow Stube is a reputable restaurant that sits in the resort’s backcountry at 11,444′ (3488 m).
He had some food, alcohol, he’s having a great day. Ski patrol gets a call, ‘Hey, my husband doesn’t feel well.’ This guy looks bad, sitting on the couch, sweating profusely, and he can hardly tell what’s going on. It’s the classic presentation of an inferior heart attack.
‘I don’t have any heart conditions. I saw my cardiologist.’ You saw a cardiologist, but you don’t have any heart conditions?!
And there are a lot we don’t see. People who go home because they think they have the flu.
Have you seen any rare or surprising complications?
We see HAPE (High Altitude Pulmonary Edema) now and again. That seems to be a walk into the hospital where [their blood oxygen saturation is] at 50 – 52. We’re not in the zone to see HACE (High Altitude Cerebral Edema). We’re just not at the altitude.
HACE is more typical above more extreme elevations, above 11,000′. Colorado’s highest peaks are just above 14,000′. Most ski resorts in Colorado are below 12,000′.
I’ve only seen one HAPE case on the hill. In their 50s. You listen to their lungs, and they’re getting wonky. A guy who was reasonably fit, but you look at him and go, ‘Hm, this is bad.’ But he was responsive and talking. Then you start seeing the things like the swaying, getting focused on something else [in the distance]. One of those [situations] where you’re like, ‘Let’s get out of here.’ [We need] tons of oxygen. Again, ‘I didn’t feel good yesterday, but I decided to go skiing today.’ He was sitting at the restaurant at the top of Copper [Mountain].
People do not realize that their diabetes, their asthma, their high blood pressure, things that they commonly manage at home, are exacerbated at 9000′. By the time they realize it, they’re calling 911. At that point, your best bet is to get out of here.
What tools or instruments do you use the most as a paramedic and ski patroller?
Cardiac monitor. It’s got a pulse oximeter. [Also] simple things you ask. ‘Hey, do you know what your blood pressure is?’ I use a stethoscope all the time. Sight and sound. Are they talking to me? Are they having a conversation with me? Are they distracted by what’s happening to them? When was the last time they peed? Was it regular color? Did it smell stronger than usual?
People ask, ‘How much water do I need?’ How much water do you drink in a day? If I’m outside and I’m moving, I probably have 10 liters. If I’m on a roof laying shingles, I probably have 4 or 5 liters before lunch. It’s those little tools. You don’t even have to touch somebody.
Do you have any personal recommendations for facilitating acclimatization at altitude?
Workout, be in shape, go harder than you normally do that month before you get here. Get the cardiovascular system more efficient before you get here. If you have any kind of medical concerns, make an appointment with your doctor and say you’ll be at 10,000′ to sleep. Just ask, ‘What do I need to do?’ The day before you get on the plane, stop drinking coffee and start drinking water. Hydrate before you get here. They humidifier thing. Make sure the place you’re going has one. Find out. Go to Walmart and spend $15 to buy one.
Watch your diet. Just so your body’s not fighting to get rid of fat and crap.
When we’re getting ready for a hut trip, we are mostly vegetarian (although we do eat meat), but we ramp protein up a week prior, pushing more chicken, more red meat. We tend to eat fish normally, but there’s always at least one fish meal at the hut. We don’t do crappy food at the hut. I don’t care if I have to carry another 10 lbs. In addition to going to the gym, go for a skin, go to 11,000 – 12,000′ for a couple hours. Ramp up the altitude work.
What do you eat on the trail?
Pre-cooked sausage, usually some kind of chicken sausage. Cheese. Whole grain tortillas, and if we’re feeling spunky, some kind of hot sauce or pico [de gallo]. For me, it’s just a handful of nuts and raisins. If I feel like something else, I’ll throw in some chocolate or white chocolate. I hate the packaging, the processed foods, the bars. Somebody usually makes granola for on-the-way-out food. And I tend to carry dried fruits. Lots of peaches during Palisade peach season. I used to take a lot of jerky.
A recent topic that comes up alot in altitude research at our clinic is Aging.
I have to work harder to stay at the same place. I’m sitting here and I can feel my right knee. I was at a 15″ [of snow] day in Taos, and I caught something [skiing]. It’s been weeks, and it’s not weak or anything, but I just know. It takes longer. I find I need more sleep. I was a 4 or 5 hour a day guy for a long time. Now I’m at 7. The days I get 8 are awesome. Luckily enough, I’m still healthy, fit. If I’m up at night, it doesn’t shatter my day. Haven’t slept on oxygen yet. Don’t want to find out.
He laughs.
As I get older, I’m adding more supplements: fish oil, glucosamine, glutine (for eye health). My eyes are bad anyway, and I’m constantly standing outside against a big, white mirror (the snow). And I’m cautious of the bill of a hat vs. a full-on brim during the summer. Other than my face, everything’s covered during the winter. The color of the bill on your hat can be way more reflective. A black bill will cut the reflection. Little things.
I’ve rounded out my workouts. They’re more whole-body. I concentrate on cardio. I’m conscious that I’m not as flexible as I was. I’d like to say we’re regularly going to yoga, but at least we’re going.
The gauge for me is you go on a hut trip with our friends in the middle-age category, but we’ll take some younger folks [too]. I kinda monitor who’s doing what – chopping firewood, who’s sitting more than who. It’s not out of pride. I need to realize.
I’m colder. You start to notice. It’s not that your feet are cold, it’s that your calves are cold. I succumbed to boot heaters a few years ago.
Year after year, in every season, visitors from all over the state and all over the world come to Colorado’s high country. For many of them, it’s the highest elevation they’ve ever visited, and often ever will. The dryness, the elevation, the air pressure, the intense sun exposure and the lack of oxygen demand a lot of compensation from the body. Sinclair’s experiences at altitude are consistent across every conversation I’ve had with physicians, athletes and other professionals when it comes to preparing your body to be active at altitude, from getting plenty of water to controlling the speed of your ascent to any elevation above 7000′ to consulting with a specialist regarding any pre-existing cardiac or respiratory conditions to how much oxygen one needs to mitigate symptoms of altitude sickness to decreasing elevation in case of an emergency. Any one of these experts will also tell you that the best ways to prepare your body for altitude is to get plenty of sleep, exercise regularly, and limit foods containing a lot of oil, grease and fat that will demand more from your body.
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.
There are seven establishments up here in Summit County, Colorado that offer auto maintenance. That means you will be on a waitlist weeks out to schedule any work you need done during the peak seasons. I finally got an appointment at High Country Auto in Frisco after my SUV started shaking when I drove over 40 mph. My undercarriage was caked in enough frozen mud and dirt that it was causing the car to rock. According to Carrie, who started the business with her husband Steve in 1998, this is a relatively common scenario in the high country. Something else she sees a lot up here is people from sea level putting water in with their washer fluid, which easily freezes on colder days. “The only way to unthaw it is to leave it in the garage overnight,” she says.
This prompted more conversation about how cars respond to the extremity of the altitude, incline and lack of oxygen up here.
“A lot of people up here try to run 91 Octane, the high-octane gas. But we don’t have enough oxygen up here to burn it. So they gum up their fuel injectors, they gum up their fuel system because they’re running too high of octane.
“The other thing people think that they can do is they think that they can chip their car to make it go faster … they try to bypass parameters on the computer to make it go faster. But it doesn’t work up here, because you need to have more oxygen.
“The other problem, too, is that they load their cars down with ten million people and all their [stuff], and then they try to go up the hills. And their car can only go so fast, because it can only take in so much oxygen, it can only process so much, plus they’re already fully weighted down. And then they hit altitude and their cars are [struggling].” (Insert Carrie’s imitation of a car struggling.)
“It’s like a big … 500 lb. guy going up four stories, and he gets up the first floor and he has a heart attack. Well, why? It’s because he’s exerting himself at altitude. It’s the same thing with cars. If a car has a little bit of a problem up here, and then you load it down with people and you try to get it to go up to 12,000, it overworks the car. And a lot of people don’t realize that cars have to work harder up here, just like people do.”
So what do you have to do to “prepare” your car for a trip up to altitude?
“Don’t overload it. And don’t push your car. Don’t try to go faster. When you’re going up a hill, be nice to your car. It’s like when you’re going down a hill, try to go into 3rd gear to let your transmission slow you down, take your foot off the brakes.
“The problem up here is people try to haul their trailers with Subarus. I’ve seen fifth-wheels being hauled with little, tiny cars. It doesn’t work up here … it can’t get enough oxygen for the car to process it. The biggest mistake people make up here is they overload everything.“
Another little thing you can do to take extra care of your car up here, she mentions, is let it warm up for two to five minutes when you first start it up in the morning. As the water freezes, all the fluids tend to gel, and it’s in your best interest to get these fluids warm again.
“When it’s 20-below, it takes a lot for the car to warm up. Just like us getting out of bed,” she laughs.
“This is not the place to push your car. If your car is gonna break down, it’s gonna break down up here.”
And if you’re an ASE-certified Master Technician, Carrie’s been looking to hire more mechanics for much more than they’re paid in the city. There used to be over 20 repair facilities in Summit County, but since it’s dwindled down to under 10, there is plenty of work for qualified mechanics up here.
And if you need your own blood oxygen, blood pressure, or undercarriage checked out, Ebert Family Clinic offers the former two for free!
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.
