November 5, 2024 • 17 mins
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.
You can pay us a compliment and share the show with a new listener on any popular platform here.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:20):
Hello, and welcome back toWilderness 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 inmy back, which within about 24
(00:43):
hours was causing new weaknessin my left foot.
And because of that, I'm now twodays post op from spinal
surgery.
A very kind neurosurgeon pulledthe extra bit of herniated disc
off of my L5 nerve root, and nowI can move my foot again.
So for the next six weeks, Ihave some pretty significant
activity restrictions, andhopefully that means some more
(01:05):
time for some more podcasts.
I've also been doing somewriting for the high route.com.
That's the hyen high hyenroute.com, and you can find some
of those articles in theiravalanche department section.
I'll put a link in the shownotes as well.
Hopefully I'll be back to skiingby the middle of spring, but
we'll see now to the story.
(01:31):
This story begins a few yearsago in Utah on a backcountry hut
trip with friends and family.
As with many hut trips, severalsmall groups were convening from
different corners of the Rockiesto meet up for some good skiing
and good times in the mountains.
My wife and I traveled with ourtwo year old daughter from Salt
Lake City through westernColorado to Ouray at the base of
the San Juan Mountains.
(01:53):
After a night in town, we droveup the beautiful but fairly
harrowing Red Mountain Pass Roadinto the San Juans.
If you've never driven on RedMountain Pass, the road as it
leaves Uray is incrediblyprecipitous, with an absolutely
imminent plunging fall off theshoulder into a huge open gorge.
It feels for all the world likethose videos you see of insane
(02:15):
roads in Pakistan, but you'reminutes outside of Uray.
Anyways, we headed up this roadto the trailhead for the Thelma
Hut.
The Thelma Hut is a beautifulglass sided mountain hut that
began its life as an architect'sproof of concept for a prefab
home, and while it never wentinto production, its high
(02:36):
ceilings, bare wood accents, andopenness to the mountains is
still spectacular.
The hut is a mere 1, 200 feetabove the road, and while it's a
few zigzagging miles by summerroad, it's only about a half
mile or so in the winter, when amore direct route is available
over snow.
Like almost anything on RedMountain Pass, it's high by any
standard perched at around11,200 The trip began with
(03:01):
beautiful, clear weather and forthe first afternoon and the day
following.
We skied recrystallized powderabove the hut before venturing
further into the adjacentdrainage to ski some cruiser
long low angle runs.
On our first day out afterspending the night in the hut,
Will was his usual athletic andtalkative self.
But on the third day, after asecond night at the hut, he was
(03:22):
dragging.
It wasn't clear if he was justtired or if he was maybe just
not as fit as I'd thought.
He'd made no complaints, so itdidn't seem like altitude
illness was a factor.
We didn't discuss the pace, andI assumed he'd get his legs
under him.
That third night at the hut wascapped with a warm fire and some
mescal mules, and everyone wentto bed, seemingly in good
(03:43):
spirits.
As we retired, an expected stormarrived with substantial winds
and heavy snow.
We anticipated some good skiingin the morning, and my wife and
I laid our daughter down in herpack and play and crashed out
under a thick comforter, dead tothe world.
Sometime during the night,however, I was woken by Nico.
(04:04):
Wake up, he said.
Will isn't doing so well.
I snuck out of our room andfound Will seated on the edge of
his bunk, looking a bit unwelland a bit worried.
Nico filled me in.
Around the time that he went tobed, Will started to feel not
just tired, but a bit short ofbreath.
It didn't take long for him tofigure out that if he laid down
to try to sleep, his shortnessof breath got even worse.
(04:27):
I listened to his chest, Nicosaid, and he's got crackles on
both sides.
It was at that point that Inoticed Will was breathing a bit
quickly as well.
So let's pause here for amoment.
Consider for yourself what youthink is going on here.
What do you think is thediagnosis and what treatment
would you give Will?
Diagnoses we might considerwould include altitude illness,
(04:51):
possibly some kind of infectiouscause of shortness of breath
like a pneumonia, and maybe ifWill wasn't a healthy early 30s
guy.
We could add heart failure,kidney failure, heart attack,
maybe a spontaneous pneumothoraxto the list.
But in this case, there'sanother altitude related illness
that's the real issue, andthat's high altitude pulmonary
edema, or HAPE.
(05:14):
Will's prodrome of nonspecificfatigue might have met a
definition of acute altitudeillness the day prior.
But as soon as he becomes shortof breath, becomes orthopnic,
which is to say that he can'tbreathe when he lays flat, and
he starts having crackles on hislung exam, HAPE becomes the big
concern.
(05:35):
Now technically, thepathophysiology of HAPE isn't
fully understood.
But I think that it's reasonablysimilar to pulmonary
hypertension and heart failure,such that I can explain briefly
what happens.
Essentially, the lungs are awell regulated organ that
automatically move blood toareas of the lung that are well
oxygenated, like the upper lungwhen we're sitting upright, or
(05:55):
the anterior lung when we'relying on our back.
The way this is achieved is by aprocess called hypoxic
vasoconstriction, meaning thatin areas of the lung deprived of
oxygen, pulmonary vessels willconstrict and limit blood flow.
In HAPE, the lung is exposed toa hypoxic environment, altitude.
And that causes widespreadvasoconstriction.
(06:17):
That, in turn, leads to anincrease in the pressure in
those pulmonary blood vessels,causing a backup of fluid and
leaking from those fluid vesselsinto the lung space.
That causes the crackles we hearin 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 Willduring the trip and not to Nico
(06:39):
or to me remains a mystery, andwe can only say that someone is
more likely to get HAPE ifthey've had it in the past.
Other risk factors for HAPEaren't that individualized and
are similar to altitude illness,i.
e.
if you ascend quickly toaltitude, your risk of illness
is higher.
So there we are, sitting in thishut at 11, 200 feet with Will,
(07:00):
who's getting progressively moreshort of breath, and we're in
the middle of a snowstorm.
I wish we could say that we hadan oxygen tank, an evacuation
sled, a bunch of meds, and acrew of people to help get Will
down, but we didn't.
Looking back at it, it'sremarkable that Will made it out
okay.
He and Nico made the decisionthat they'd ski down together in
the dark to reach their car.
(07:21):
From there, they'd try todescend as much as possible and
get Will to a hospital.
Recall that this was the middleof the night, in the middle of a
snowstorm, on what has to be oneof the worst roads in the
continental US in the winter.
Will told me later that hepassed out twice on the way down
to the car, blocking out brieflyfrom the exertion of skiing.
When they reached their snowedin cars, Will and Nico had the
(07:43):
great fortune of being able toflag down a passing plow driver,
who, when he learned of theirsituation, escorted them down
off the pass and into Yure,where another plow met them and
led them down the road toRidgeway and lower altitude.
Without the plow, who knows whatmight have happened to the two
of them.
I'm grateful to CDOT and theirplow drivers for saving the day.
(08:06):
Now, by the time that Will madeit to the hospital in Montrose,
he was already feeling muchbetter.
A chest x ray confirmed that hehad bilateral pulmonary edema,
but that he didn't need to behospitalized.
He'd never before had HAPE, butnow he knows that he's at risk
for it if ever returning toaltitude.
So why did I tell you thisstory?
Well first, it's because beforethis happened to us, I had
(08:29):
thought of HAPE as an illness ofthe greater ranges.
The kind of illness that youmight see in the Alaska range,
but much more commonly in theHimalaya.
So I'd like to begin byhighlighting that HAPE has been
seen in travelers at altitudesas low as 8, 000 feet.
And that the real magic seems tobe a rapid ascent to altitude.
In our family's case at theThelma Hut, we went from around
(08:51):
4, 000 feet in Salt Lake City to11, 200 feet in two days, and
Will made that trip in one day.
A staged ascent to altitude inwhich one spends several days at
7, 500 to 9, 000 feet prior togoing higher is the only
approach that has been shown toactually lower the risk of
subsequent altitude illness,including hape.
(09:11):
Just staying a single day hasn'tbeen shown to be terribly
beneficial.
The second reason that I relatethis story is that it made me
think about what I'd want tohave with me at that hut if I
was there again, particularly ifwe were in a situation where we
felt like we couldn't leave.
We've already mentioned whatWill needed most, which is to
descend.
If he couldn't descend, the nextmost useful therapy would be
(09:34):
oxygen.
So as a hut operator, I wouldconsider stocking an oxygen
concentrator as well as bottledoxygen for an evacuation.
And I definitely have some kindof rescue sled so that we could
get Will down the hill withouthim exerting himself.
But perhaps the weather oravalanche hazard is just too
(09:55):
severe to be able to travel, andWill is there in the hut with
us, starting to get pretty sick.
To improve my thinking aboutwhat we might want to have with
us in the future, I've made amedication card that you can
find in the show notes.
This is probably as good a timeas any to remind you that I'm
not providing you with medicaladvice, nor are the medications
or doses on that card going tobe appropriate for everyone out
(10:17):
there.
So if you're headed out on anexpedition or hut trip, you
should speak with a licensedphysician in your state to
review your medication plan andobtain prescriptions.
I'm not your doctor.
But let's talk about therationale for what I have on
that card.
The meds on the card can bedivided into a few categories.
medications for management ofnoxious symptoms, altitude and
(10:40):
cold illness medications, anantibiotic, and epinephrine.
Let's address each of those inturn.
As far as noxious symptoms go,my goal is to be able to manage
pain, nausea, vomiting, anddiarrhea.
For pain, ibuprofen andacetaminophen in combination are
going to be my go to, withoxycodone available for
(11:00):
management of significant paindue to an orthopedic injury or
similar significant traumaticinjury.
Ibuprofen and acetaminophen alsohandle fever, and ibuprofen is
useful after frostbite as well.
I'll always consider thatoxycodone can make people sleepy
and dizzy, and that's not alwaysa good thing, particularly for
an evacuation.
(11:23):
For nausea, there's no beatingsublingual andansetron, or
Zofran.
which is a relatively harmlessmedication overall.
For keeping someone hydratedwhen altitude sick, I want to
have that anti emetic with me.
And depending on the duration ofthe trip, I'd also strongly
consider bringing liparamide,trade name hemodium, as diarrhea
can become rampant in a groupthat has poor hand hygiene, and
(11:45):
if it threatens hydration, itcan really be a problem.
I also throw a bottle ofpreparacane topical eye
anesthetic in there.
That'll make theophthalmologists out there mad,
but my own experience withcorneal abrasions tells me that
it can be debilitating.
But Proparacain can turn thataround and help someone who
would otherwise be basicallyblind be able to walk out on
(12:06):
their own.
It's certainly safe for shortterm use, as in a couple of
days.
So that addresses symptommanagement.
How about altitude illness?
Acetazolamide and dexamethasoneare going to be the best
recognized medications here.
Acetazolamide has a role to playin altitude illness prophylaxis,
if you know that your ascentprofile is going to place you at
(12:28):
risk of acute mountain sickness,but it can also be given for
acute mountain sickness to helpmanage symptoms.
The steroid dexamethasone is astaple of treatment of altitude
illness from acute mountainsickness to high altitude
cerebral edema, so I have plentyof that with me too.
with different dosing schedulesfor different indications.
(12:49):
I also include nifedipine, acalcium channel blocking
medication that's used primarilyfor HAPE prophylaxis and
treatment, and we can also useit to treat will here.
I'd also bring a few aspirin,depending on the group, even
though it's not the preferredmedication for frostbite, it can
be used for that, but mostimportantly, it's basically the
only useful medication if youthink someone's having a heart
(13:10):
attack or angina.
Now, we could probably do anentire podcast debating
different antibiotics for travelindications, but if I have to
pick one to bring to this alpinehut with me, I'm going to bring
clindamycin.
This one works reasonably wellfor UTI, pneumonia, soft tissue
(13:32):
infection, and is generally welltolerated without lots of
allergies.
You could make arguments forcephalosporins, azithromycin,
doxycycline, and othersdepending on your environment,
But for Mountain Hut, this is areasonable choice.
(13:55):
And finally, I'm going to bringepinephrine.
There are few illnesses that candefinitely cause imminent death,
but also be so readily reversedas anaphylaxis.
I want two doses of epinephrinewith me in whatever form, be
that an EpiPen or a vial withsyringes.
And to complement that, I'mbringing some diphenhydramine,
aka Benadryl, for management ofmilder allergic symptoms, but
(14:18):
the Epi is the real money.
If you take a look at the dosecard, 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 eitherbe considering evacuation, or
actively working to evacuate mypatient.
I've also listed some of theabsolute contraindications to
each of the meds, because theless that one has to remember,
(14:39):
the better.
To bring this back to Will, if Ihad everything that I'd want in
that situation, I'd begin byputting Will on supplemental
oxygen at the hut.
at whatever is the highest flowthat powered concentrator can
give me.
As soon as I can startdelivering a higher partial
pressure of oxygen to his lungs,we can start relieving some of
(14:59):
that hypoxic vasoconstrictionand 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 inthe meantime, I'd also give him
a dose of nifedipine, 30milligrams extended release.
That's to treat the pulmonaryedema.
(15:21):
Though it's thought to have moreof a preventative role than a
role in treatment, I'd probablyalso give Will 8mg of
dexamethasone as well, becauseif it helps, it helps, and I
don't see a downside in thissituation where we're running
out of options.
I'd then work to package Willwarmly in an evac sled, and
prepare to use any bottledoxygen that we have to get him
down to a vehicle in a loweraltitude ASAP.
(15:45):
This still ends up being a badsituation.
even with more tools, toys, andmeds.
But we might as well be preparedand control the variables that
we can.
So take a look at the med card.
Let me know what you think.
Is there anything else thatyou'd bring or that you would
add?
I bet there's some opinions outthere.
And just a reminder, I'm notyour doctor, and this isn't
(16:05):
medical advice.
The medications that would beappropriate for your trip, your
health, and your group issomething that will be unique to
you.
Talk to your physician about it.
And that's it for this episodeof Wilderness Medicine Updates.
Thanks for listening.
I'll be back soon with some moremountain medicine content
(16:25):
straight to your ears.
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can show your support is toshare the show with someone you
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Pass it along to another doctor,nurse, ski patroller, med
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And if you have a moment, givethe show a 5 star review on
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(16:46):
If you want to reach out to me,I always love to hear from
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gmail.
com and I'll get back to yousoon.
Until next time, stay fit, stayfocused, and have fun.
Hello, and welcome back toWilderness 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 inmy back, which within about 24
(00:43):
hours was causing new weaknessin my left foot.
And because of that, I'm now twodays post op from spinal
surgery.
A very kind neurosurgeon pulledthe extra bit of herniated disc
off of my L5 nerve root, and nowI can move my foot again.
So for the next six weeks, Ihave some pretty significant
activity restrictions, andhopefully that means some more
(01:05):
time for some more podcasts.
I've also been doing somewriting for the high route.com.
That's the hyen high hyenroute.com, and you can find some
of those articles in theiravalanche department section.
I'll put a link in the shownotes as well.
Hopefully I'll be back to skiingby the middle of spring, but
we'll see now to the story.
(01:31):
This story begins a few yearsago in Utah on a backcountry hut
trip with friends and family.
As with many hut trips, severalsmall groups were convening from
different corners of the Rockiesto meet up for some good skiing
and good times in the mountains.
My wife and I traveled with ourtwo year old daughter from Salt
Lake City through westernColorado to Ouray at the base of
the San Juan Mountains.
(01:53):
After a night in town, we droveup the beautiful but fairly
harrowing Red Mountain Pass Roadinto the San Juans.
If you've never driven on RedMountain Pass, the road as it
leaves Uray is incrediblyprecipitous, with an absolutely
imminent plunging fall off theshoulder into a huge open gorge.
It feels for all the world likethose videos you see of insane
(02:15):
roads in Pakistan, but you'reminutes outside of Uray.
Anyways, we headed up this roadto the trailhead for the Thelma
Hut.
The Thelma Hut is a beautifulglass sided mountain hut that
began its life as an architect'sproof of concept for a prefab
home, and while it never wentinto production, its high
(02:36):
ceilings, bare wood accents, andopenness to the mountains is
still spectacular.
The hut is a mere 1, 200 feetabove the road, and while it's a
few zigzagging miles by summerroad, it's only about a half
mile or so in the winter, when amore direct route is available
over snow.
Like almost anything on RedMountain Pass, it's high by any
standard perched at around11,200 The trip began with
(03:01):
beautiful, clear weather and forthe first afternoon and the day
following.
We skied recrystallized powderabove the hut before venturing
further into the adjacentdrainage to ski some cruiser
long low angle runs.
On our first day out afterspending the night in the hut,
Will was his usual athletic andtalkative self.
But on the third day, after asecond night at the hut, he was
(03:22):
dragging.
It wasn't clear if he was justtired or if he was maybe just
not as fit as I'd thought.
He'd made no complaints, so itdidn't seem like altitude
illness was a factor.
We didn't discuss the pace, andI assumed he'd get his legs
under him.
That third night at the hut wascapped with a warm fire and some
mescal mules, and everyone wentto bed, seemingly in good
(03:43):
spirits.
As we retired, an expected stormarrived with substantial winds
and heavy snow.
We anticipated some good skiingin the morning, and my wife and
I laid our daughter down in herpack and play and crashed out
under a thick comforter, dead tothe world.
Sometime during the night,however, I was woken by Nico.
(04:04):
Wake up, he said.
Will isn't doing so well.
I snuck out of our room andfound Will seated on the edge of
his bunk, looking a bit unwelland a bit worried.
Nico filled me in.
Around the time that he went tobed, Will started to feel not
just tired, but a bit short ofbreath.
It didn't take long for him tofigure out that if he laid down
to try to sleep, his shortnessof breath got even worse.
(04:27):
I listened to his chest, Nicosaid, and he's got crackles on
both sides.
It was at that point that Inoticed Will was breathing a bit
quickly as well.
So let's pause here for amoment.
Consider for yourself what youthink is going on here.
What do you think is thediagnosis and what treatment
would you give Will?
Diagnoses we might considerwould include altitude illness,
(04:51):
possibly some kind of infectiouscause of shortness of breath
like a pneumonia, and maybe ifWill wasn't a healthy early 30s
guy.
We could add heart failure,kidney failure, heart attack,
maybe a spontaneous pneumothoraxto the list.
But in this case, there'sanother altitude related illness
that's the real issue, andthat's high altitude pulmonary
edema, or HAPE.
(05:14):
Will's prodrome of nonspecificfatigue might have met a
definition of acute altitudeillness the day prior.
But as soon as he becomes shortof breath, becomes orthopnic,
which is to say that he can'tbreathe when he lays flat, and
he starts having crackles on hislung exam, HAPE becomes the big
concern.
(05:35):
Now technically, thepathophysiology of HAPE isn't
fully understood.
But I think that it's reasonablysimilar to pulmonary
hypertension and heart failure,such that I can explain briefly
what happens.
Essentially, the lungs are awell regulated organ that
automatically move blood toareas of the lung that are well
oxygenated, like the upper lungwhen we're sitting upright, or
(05:55):
the anterior lung when we'relying on our back.
The way this is achieved is by aprocess called hypoxic
vasoconstriction, meaning thatin areas of the lung deprived of
oxygen, pulmonary vessels willconstrict and limit blood flow.
In HAPE, the lung is exposed toa hypoxic environment, altitude.
And that causes widespreadvasoconstriction.
(06:17):
That, in turn, leads to anincrease in the pressure in
those pulmonary blood vessels,causing a backup of fluid and
leaking from those fluid vesselsinto the lung space.
That causes the crackles we hearin 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 Willduring the trip and not to Nico
(06:39):
or to me remains a mystery, andwe can only say that someone is
more likely to get HAPE ifthey've had it in the past.
Other risk factors for HAPEaren't that individualized and
are similar to altitude illness,i.
e.
if you ascend quickly toaltitude, your risk of illness
is higher.
So there we are, sitting in thishut at 11, 200 feet with Will,
(07:00):
who's getting progressively moreshort of breath, and we're in
the middle of a snowstorm.
I wish we could say that we hadan oxygen tank, an evacuation
sled, a bunch of meds, and acrew of people to help get Will
down, but we didn't.
Looking back at it, it'sremarkable that Will made it out
okay.
He and Nico made the decisionthat they'd ski down together in
the dark to reach their car.
(07:21):
From there, they'd try todescend as much as possible and
get Will to a hospital.
Recall that this was the middleof the night, in the middle of a
snowstorm, on what has to be oneof the worst roads in the
continental US in the winter.
Will told me later that hepassed out twice on the way down
to the car, blocking out brieflyfrom the exertion of skiing.
When they reached their snowedin cars, Will and Nico had the
(07:43):
great fortune of being able toflag down a passing plow driver,
who, when he learned of theirsituation, escorted them down
off the pass and into Yure,where another plow met them and
led them down the road toRidgeway and lower altitude.
Without the plow, who knows whatmight have happened to the two
of them.
I'm grateful to CDOT and theirplow drivers for saving the day.
(08:06):
Now, by the time that Will madeit to the hospital in Montrose,
he was already feeling muchbetter.
A chest x ray confirmed that hehad bilateral pulmonary edema,
but that he didn't need to behospitalized.
He'd never before had HAPE, butnow he knows that he's at risk
for it if ever returning toaltitude.
So why did I tell you thisstory?
Well first, it's because beforethis happened to us, I had
(08:29):
thought of HAPE as an illness ofthe greater ranges.
The kind of illness that youmight see in the Alaska range,
but much more commonly in theHimalaya.
So I'd like to begin byhighlighting that HAPE has been
seen in travelers at altitudesas low as 8, 000 feet.
And that the real magic seems tobe a rapid ascent to altitude.
In our family's case at theThelma Hut, we went from around
(08:51):
4, 000 feet in Salt Lake City to11, 200 feet in two days, and
Will made that trip in one day.
A staged ascent to altitude inwhich one spends several days at
7, 500 to 9, 000 feet prior togoing higher is the only
approach that has been shown toactually lower the risk of
subsequent altitude illness,including hape.
(09:11):
Just staying a single day hasn'tbeen shown to be terribly
beneficial.
The second reason that I relatethis story is that it made me
think about what I'd want tohave with me at that hut if I
was there again, particularly ifwe were in a situation where we
felt like we couldn't leave.
We've already mentioned whatWill needed most, which is to
descend.
If he couldn't descend, the nextmost useful therapy would be
(09:34):
oxygen.
So as a hut operator, I wouldconsider stocking an oxygen
concentrator as well as bottledoxygen for an evacuation.
And I definitely have some kindof rescue sled so that we could
get Will down the hill withouthim exerting himself.
But perhaps the weather oravalanche hazard is just too
(09:55):
severe to be able to travel, andWill is there in the hut with
us, starting to get pretty sick.
To improve my thinking aboutwhat we might want to have with
us in the future, I've made amedication card that you can
find in the show notes.
This is probably as good a timeas any to remind you that I'm
not providing you with medicaladvice, nor are the medications
or doses on that card going tobe appropriate for everyone out
(10:17):
there.
So if you're headed out on anexpedition or hut trip, you
should speak with a licensedphysician in your state to
review your medication plan andobtain prescriptions.
I'm not your doctor.
But let's talk about therationale for what I have on
that card.
The meds on the card can bedivided into a few categories.
medications for management ofnoxious symptoms, altitude and
(10:40):
cold illness medications, anantibiotic, and epinephrine.
Let's address each of those inturn.
As far as noxious symptoms go,my goal is to be able to manage
pain, nausea, vomiting, anddiarrhea.
For pain, ibuprofen andacetaminophen in combination are
going to be my go to, withoxycodone available for
(11:00):
management of significant paindue to an orthopedic injury or
similar significant traumaticinjury.
Ibuprofen and acetaminophen alsohandle fever, and ibuprofen is
useful after frostbite as well.
I'll always consider thatoxycodone can make people sleepy
and dizzy, and that's not alwaysa good thing, particularly for
an evacuation.
(11:23):
For nausea, there's no beatingsublingual andansetron, or
Zofran.
which is a relatively harmlessmedication overall.
For keeping someone hydratedwhen altitude sick, I want to
have that anti emetic with me.
And depending on the duration ofthe trip, I'd also strongly
consider bringing liparamide,trade name hemodium, as diarrhea
can become rampant in a groupthat has poor hand hygiene, and
(11:45):
if it threatens hydration, itcan really be a problem.
I also throw a bottle ofpreparacane topical eye
anesthetic in there.
That'll make theophthalmologists out there mad,
but my own experience withcorneal abrasions tells me that
it can be debilitating.
But Proparacain can turn thataround and help someone who
would otherwise be basicallyblind be able to walk out on
(12:06):
their own.
It's certainly safe for shortterm use, as in a couple of
days.
So that addresses symptommanagement.
How about altitude illness?
Acetazolamide and dexamethasoneare going to be the best
recognized medications here.
Acetazolamide has a role to playin altitude illness prophylaxis,
if you know that your ascentprofile is going to place you at
(12:28):
risk of acute mountain sickness,but it can also be given for
acute mountain sickness to helpmanage symptoms.
The steroid dexamethasone is astaple of treatment of altitude
illness from acute mountainsickness to high altitude
cerebral edema, so I have plentyof that with me too.
with different dosing schedulesfor different indications.
(12:49):
I also include nifedipine, acalcium channel blocking
medication that's used primarilyfor HAPE prophylaxis and
treatment, and we can also useit to treat will here.
I'd also bring a few aspirin,depending on the group, even
though it's not the preferredmedication for frostbite, it can
be used for that, but mostimportantly, it's basically the
only useful medication if youthink someone's having a heart
(13:10):
attack or angina.
Now, we could probably do anentire podcast debating
different antibiotics for travelindications, but if I have to
pick one to bring to this alpinehut with me, I'm going to bring
clindamycin.
This one works reasonably wellfor UTI, pneumonia, soft tissue
(13:32):
infection, and is generally welltolerated without lots of
allergies.
You could make arguments forcephalosporins, azithromycin,
doxycycline, and othersdepending on your environment,
But for Mountain Hut, this is areasonable choice.
(13:55):
And finally, I'm going to bringepinephrine.
There are few illnesses that candefinitely cause imminent death,
but also be so readily reversedas anaphylaxis.
I want two doses of epinephrinewith me in whatever form, be
that an EpiPen or a vial withsyringes.
And to complement that, I'mbringing some diphenhydramine,
aka Benadryl, for management ofmilder allergic symptoms, but
(14:18):
the Epi is the real money.
If you take a look at the dosecard, 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 eitherbe considering evacuation, or
actively working to evacuate mypatient.
I've also listed some of theabsolute contraindications to
each of the meds, because theless that one has to remember,
(14:39):
the better.
To bring this back to Will, if Ihad everything that I'd want in
that situation, I'd begin byputting Will on supplemental
oxygen at the hut.
at whatever is the highest flowthat powered concentrator can
give me.
As soon as I can startdelivering a higher partial
pressure of oxygen to his lungs,we can start relieving some of
(14:59):
that hypoxic vasoconstrictionand 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 inthe meantime, I'd also give him
a dose of nifedipine, 30milligrams extended release.
That's to treat the pulmonaryedema.
(15:21):
Though it's thought to have moreof a preventative role than a
role in treatment, I'd probablyalso give Will 8mg of
dexamethasone as well, becauseif it helps, it helps, and I
don't see a downside in thissituation where we're running
out of options.
I'd then work to package Willwarmly in an evac sled, and
prepare to use any bottledoxygen that we have to get him
down to a vehicle in a loweraltitude ASAP.
(15:45):
This still ends up being a badsituation.
even with more tools, toys, andmeds.
But we might as well be preparedand control the variables that
we can.
So take a look at the med card.
Let me know what you think.
Is there anything else thatyou'd bring or that you would
add?
I bet there's some opinions outthere.
And just a reminder, I'm notyour doctor, and this isn't
(16:05):
medical advice.
The medications that would beappropriate for your trip, your
health, and your group issomething that will be unique to
you.
Talk to your physician about it.
And that's it for this episodeof Wilderness Medicine Updates.
Thanks for listening.
I'll be back soon with some moremountain medicine content
(16:25):
straight to your ears.
In the meantime, if you enjoythe show, the best way that you
can show your support is toshare the show with someone you
think would enjoy it.
Pass it along to another doctor,nurse, ski patroller, med
student, EMT, paramedic, SARmember, skiing buddy, or family
member.
And if you have a moment, givethe show a 5 star review on
Apple Podcasts or Spotify.
(16:46):
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 atwildernessmedicineupdates at
gmail.
com and I'll get back to yousoon.
Until next time, stay fit, stayfocused, and have fun.
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