Ep. 16 - Medications for Alpine Hut Trips

In this episode, I share an intense story of dealing with a suprise medical condition during a backcountry hut trip in Colorado. I walk through the diagnostic process, treatment options, and the importance of preparation for stays in remote places. Essential medications and tools needed for handling such emergencies in remote settings are discussed, along with advice on how to prepare for future expeditions.

My articles on The-High-Route.com

The Hut Medication Card

Chapters: 

00:00 Introduction and Personal Update

01:31 The Backcountry Hut Trip Begins

03:19 Will's Health Deteriorates

04:38 Diagnosing the Problem

07:04 The Emergency Descent

09:16 Lessons Learned and Preparedness

10:37 Essential Medications for Wilderness Trips

16:19 Final Thoughts and Conclusion

As always, thanks for listening to Wilderness Medicine Updates, hosted by Patrick Fink MD FAWM.

Connect with us by email at wildernessmedicineupdates@gmail.com.

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Transcript

0:20

Hello, and welcome back to Wilderness Medicine Updates, the show for providers at the edges. I'm your host, Patrick Fink. Today, a story, a true story, one that led me down a path of some thinking and some doing. But first, an update. I had a fun week last week. I managed to herniate a disc in my back, which within about 24 hours was causing new weakness in my left foot. And because of that, I'm now two days post op from spinal surgery. A very kind neurosurgeon pulled the extra bit of herniated disc off of my L5 nerve root, and now I can move my foot again. So for the next six weeks, I have some pretty significant activity restrictions, and hopefully that means some more time for some more podcasts. I've also been doing some writing for the high route.com. That's the hyen high hyen route.com, and you can find some of those articles in their avalanche department section. I'll put a link in the show notes as well. Hopefully I'll be back to skiing by the middle of spring, but we'll see now to the story. This story begins a few years ago in Utah on a backcountry hut trip with friends and family. As with many hut trips, several small groups were convening from different corners of the Rockies to meet up for some good skiing and good times in the mountains. My wife and I traveled with our two year old daughter from Salt Lake City through western Colorado to Ouray at the base of the San Juan Mountains. After a night in town, we drove up the beautiful but fairly harrowing Red Mountain Pass Road into the San Juans. If you've never driven on Red Mountain Pass, the road as it leaves Uray is incredibly precipitous, with an absolutely imminent plunging fall off the shoulder into a huge open gorge. It feels for all the world like those videos you see of insane roads in Pakistan, but you're minutes outside of Uray. Anyways, we headed up this road to the trailhead for the Thelma Hut. The Thelma Hut is a beautiful glass sided mountain hut that began its life as an architect's proof of concept for a prefab home, and while it never went into production, its high ceilings, bare wood accents, and openness to the mountains is still spectacular. The hut is a mere 1, 200 feet above the road, and while it's a few zigzagging miles by summer road, it's only about a half mile or so in the winter, when a more direct route is available over snow. Like almost anything on Red Mountain Pass, it's high by any standard perched at around 11,200 The trip began with beautiful, clear weather and for the first afternoon and the day following. We skied recrystallized powder above the hut before venturing further into the adjacent drainage to ski some cruiser long low angle runs. On our first day out after spending the night in the hut, Will was his usual athletic and talkative self. But on the third day, after a second night at the hut, he was dragging. It wasn't clear if he was just tired or if he was maybe just not as fit as I'd thought. He'd made no complaints, so it didn't seem like altitude illness was a factor. We didn't discuss the pace, and I assumed he'd get his legs under him. That third night at the hut was capped with a warm fire and some mescal mules, and everyone went to bed, seemingly in good spirits. As we retired, an expected storm arrived with substantial winds and heavy snow. We anticipated some good skiing in the morning, and my wife and I laid our daughter down in her pack and play and crashed out under a thick comforter, dead to the world. Sometime during the night, however, I was woken by Nico. Wake up, he said. Will isn't doing so well. I snuck out of our room and found Will seated on the edge of his bunk, looking a bit unwell and a bit worried. Nico filled me in. Around the time that he went to bed, Will started to feel not just tired, but a bit short of breath. It didn't take long for him to figure out that if he laid down to try to sleep, his shortness of breath got even worse. I listened to his chest, Nico said, and he's got crackles on both sides. It was at that point that I noticed Will was breathing a bit quickly as well. So let's pause here for a moment. Consider for yourself what you think is going on here. What do you think is the diagnosis and what treatment would you give Will? Diagnoses we might consider would include altitude illness, possibly some kind of infectious cause of shortness of breath like a pneumonia, and maybe if Will wasn't a healthy early 30s guy. We could add heart failure, kidney failure, heart attack, maybe a spontaneous pneumothorax to the list. But in this case, there's another altitude related illness that's the real issue, and that's high altitude pulmonary edema, or HAPE. Will's prodrome of nonspecific fatigue might have met a definition of acute altitude illness the day prior. But as soon as he becomes short of breath, becomes orthopnic, which is to say that he can't breathe when he lays flat, and he starts having crackles on his lung exam, HAPE becomes the big concern. Now technically, the pathophysiology of HAPE isn't fully understood. But I think that it's reasonably similar to pulmonary hypertension and heart failure, such that I can explain briefly what happens. Essentially, the lungs are a well regulated organ that automatically move blood to areas of the lung that are well oxygenated, like the upper lung when we're sitting upright, or the anterior lung when we're lying on our back. The way this is achieved is by a process called hypoxic vasoconstriction, meaning that in areas of the lung deprived of oxygen, pulmonary vessels will constrict and limit blood flow. In HAPE, the lung is exposed to a hypoxic environment, altitude. And that causes widespread vasoconstriction. That, in turn, leads to an increase in the pressure in those pulmonary blood vessels, causing a backup of fluid and leaking from those fluid vessels into the lung space. That causes the crackles we hear in the chest as the little alveolar air spaces become wet, and we hear them pop open and close with each breath. Why this would happen to Will during the trip and not to Nico or to me remains a mystery, and we can only say that someone is more likely to get HAPE if they've had it in the past. Other risk factors for HAPE aren't that individualized and are similar to altitude illness, i. e. if you ascend quickly to altitude, your risk of illness is higher. So there we are, sitting in this hut at 11, 200 feet with Will, who's getting progressively more short of breath, and we're in the middle of a snowstorm. I wish we could say that we had an oxygen tank, an evacuation sled, a bunch of meds, and a crew of people to help get Will down, but we didn't. Looking back at it, it's remarkable that Will made it out okay. He and Nico made the decision that they'd ski down together in the dark to reach their car. From there, they'd try to descend as much as possible and get Will to a hospital. Recall that this was the middle of the night, in the middle of a snowstorm, on what has to be one of the worst roads in the continental US in the winter. Will told me later that he passed out twice on the way down to the car, blocking out briefly from the exertion of skiing. When they reached their snowed in cars, Will and Nico had the great fortune of being able to flag down a passing plow driver, who, when he learned of their situation, escorted them down off the pass and into Yure, where another plow met them and led them down the road to Ridgeway and lower altitude. Without the plow, who knows what might have happened to the two of them. I'm grateful to CDOT and their plow drivers for saving the day. Now, by the time that Will made it to the hospital in Montrose, he was already feeling much better. A chest x ray confirmed that he had bilateral pulmonary edema, but that he didn't need to be hospitalized. He'd never before had HAPE, but now he knows that he's at risk for it if ever returning to altitude. So why did I tell you this story? Well first, it's because before this happened to us, I had thought of HAPE as an illness of the greater ranges. The kind of illness that you might see in the Alaska range, but much more commonly in the Himalaya. So I'd like to begin by highlighting that HAPE has been seen in travelers at altitudes as low as 8, 000 feet. And that the real magic seems to be a rapid ascent to altitude. In our family's case at the Thelma Hut, we went from around 4, 000 feet in Salt Lake City to 11, 200 feet in two days, and Will made that trip in one day. A staged ascent to altitude in which one spends several days at 7, 500 to 9, 000 feet prior to going higher is the only approach that has been shown to actually lower the risk of subsequent altitude illness, including hape. Just staying a single day hasn't been shown to be terribly beneficial. The second reason that I relate this story is that it made me think about what I'd want to have with me at that hut if I was there again, particularly if we were in a situation where we felt like we couldn't leave. We've already mentioned what Will needed most, which is to descend. If he couldn't descend, the next most useful therapy would be oxygen. So as a hut operator, I would consider stocking an oxygen concentrator as well as bottled oxygen for an evacuation. And I definitely have some kind of rescue sled so that we could get Will down the hill without him exerting himself. But perhaps the weather or avalanche hazard is just too severe to be able to travel, and Will is there in the hut with us, starting to get pretty sick. To improve my thinking about what we might want to have with us in the future, I've made a medication card that you can find in the show notes. This is probably as good a time as any to remind you that I'm not providing you with medical advice, nor are the medications or doses on that card going to be appropriate for everyone out there. So if you're headed out on an expedition or hut trip, you should speak with a licensed physician in your state to review your medication plan and obtain prescriptions. I'm not your doctor. But let's talk about the rationale for what I have on that card. The meds on the card can be divided into a few categories. medications for management of noxious symptoms, altitude and cold illness medications, an antibiotic, and epinephrine. Let's address each of those in turn. As far as noxious symptoms go, my goal is to be able to manage pain, nausea, vomiting, and diarrhea. For pain, ibuprofen and acetaminophen in combination are going to be my go to, with oxycodone available for management of significant pain due to an orthopedic injury or similar significant traumatic injury. Ibuprofen and acetaminophen also handle fever, and ibuprofen is useful after frostbite as well. I'll always consider that oxycodone can make people sleepy and dizzy, and that's not always a good thing, particularly for an evacuation. For nausea, there's no beating sublingual andansetron, or Zofran. which is a relatively harmless medication overall. For keeping someone hydrated when altitude sick, I want to have that anti emetic with me. And depending on the duration of the trip, I'd also strongly consider bringing liparamide, trade name hemodium, as diarrhea can become rampant in a group that has poor hand hygiene, and if it threatens hydration, it can really be a problem. I also throw a bottle of preparacane topical eye anesthetic in there. That'll make the ophthalmologists out there mad, but my own experience with corneal abrasions tells me that it can be debilitating. But Proparacain can turn that around and help someone who would otherwise be basically blind be able to walk out on their own. It's certainly safe for short term use, as in a couple of days. So that addresses symptom management. How about altitude illness? Acetazolamide and dexamethasone are going to be the best recognized medications here. Acetazolamide has a role to play in altitude illness prophylaxis, if you know that your ascent profile is going to place you at risk of acute mountain sickness, but it can also be given for acute mountain sickness to help manage symptoms. The steroid dexamethasone is a staple of treatment of altitude illness from acute mountain sickness to high altitude cerebral edema, so I have plenty of that with me too. with different dosing schedules for different indications. I also include nifedipine, a calcium channel blocking medication that's used primarily for HAPE prophylaxis and treatment, and we can also use it to treat will here. I'd also bring a few aspirin, depending on the group, even though it's not the preferred medication for frostbite, it can be used for that, but most importantly, it's basically the only useful medication if you think someone's having a heart attack or angina. Now, we could probably do an entire podcast debating different antibiotics for travel indications, but if I have to pick one to bring to this alpine hut with me, I'm going to bring clindamycin. This one works reasonably well for UTI, pneumonia, soft tissue infection, and is generally well tolerated without lots of allergies. You could make arguments for cephalosporins, azithromycin, doxycycline, and others depending on your environment, But for Mountain Hut, this is a reasonable choice. And finally, I'm going to bring epinephrine. There are few illnesses that can definitely cause imminent death, but also be so readily reversed as anaphylaxis. I want two doses of epinephrine with me in whatever form, be that an EpiPen or a vial with syringes. And to complement that, I'm bringing some diphenhydramine, aka Benadryl, for management of milder allergic symptoms, but the Epi is the real money. If you take a look at the dose card, you'll also see that I've given myself a reminder column, that for many of these meds, if I'm giving them, I should either be considering evacuation, or actively working to evacuate my patient. I've also listed some of the absolute contraindications to each of the meds, because the less that one has to remember, the better. To bring this back to Will, if I had everything that I'd want in that situation, I'd begin by putting Will on supplemental oxygen at the hut. at whatever is the highest flow that powered concentrator can give me. As soon as I can start delivering a higher partial pressure of oxygen to his lungs, we can start relieving some of that hypoxic vasoconstriction and at least prevent him from forming additional edema. We really want to get him down, but if we can't get him down, oxygen is the best next choice. I'd plan to evacuate him and in the meantime, I'd also give him a dose of nifedipine, 30 milligrams extended release. That's to treat the pulmonary edema. Though it's thought to have more of a preventative role than a role in treatment, I'd probably also give Will 8mg of dexamethasone as well, because if it helps, it helps, and I don't see a downside in this situation where we're running out of options. I'd then work to package Will warmly in an evac sled, and prepare to use any bottled oxygen that we have to get him down to a vehicle in a lower altitude ASAP. This still ends up being a bad situation. even with more tools, toys, and meds. But we might as well be prepared and control the variables that we can. So take a look at the med card. Let me know what you think. Is there anything else that you'd bring or that you would add? I bet there's some opinions out there. And just a reminder, I'm not your doctor, and this isn't medical advice. The medications that would be appropriate for your trip, your health, and your group is something that will be unique to you. Talk to your physician about it. And that's it for this episode of Wilderness Medicine Updates. Thanks for listening. I'll be back soon with some more mountain medicine content straight to your ears. In the meantime, if you enjoy the show, the best way that you can show your support is to share the show with someone you think would enjoy it. Pass it along to another doctor, nurse, ski patroller, med student, EMT, paramedic, SAR member, skiing buddy, or family member. And if you have a moment, give the show a 5 star review on Apple Podcasts or Spotify. If you want to reach out to me, I always love to hear from listeners with comments, questions, or ideas for future shows. Send me an email at wildernessmedicineupdates at gmail. com and I'll get back to you soon. Until next time, stay fit, stay focused, and have fun.