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On our way out of the Sno-Park today after a day on St. Helens, we found a pair of AT boots sitting in a parking stall as if they were left behind. We brought them down to the Lone Fir Resort Cafe in Cougar where you register/sign-in to climb St. Helens. We were told they would be brought to the Forest Service office in Amboy in the next day or two (360-247-3900).

The control of breathing is actually quite a complicated process that involves multiple regulatory factors and multiple control centers in the brain. There is, in fact, an automatic aspect (rhythm controller) that operates independent of other factors and keeps you breathing in the absence of other stimuli. Oxygen and carbon dioxide do play an important role, however. Decreases in the partial pressure of oxygen in blood stimulate increases in breathing as do increases in the partial pressure of carbon dioxide. Rising carbon dioxide levels are actually a much more potent stimulus to breathe than low oxygen levels. For example, rather than a dropping PO2, it's the rising CO2 that is the main reason you need to come up to the surface when you hold your breath under water. Various other factors such as blood pH also play a role in controlling breathing. The mechanism behind Cheyne-Stokes respirations has actually been fairly well worked out. It occurs as a result of instability in some of the main feedback loops controlling breathing in the brain. The phenomenon is referred to as abnormal "loop gain." Individuals who develop this breathing pattern are hyperventilating at the start of the process. This causes their blood CO2 levels to fall significantly. When they fall below what is referred to as the "apnea threshold," the brain stops sending signals to your respiratory muscles to breathe. At this point the person is "apneic" (not breathing). During the apnea, CO2 levels start to rise again and when they cross the apnea threshold level on their way up, the brain starts sending signals to breathe again. The problem in the people who develop Cheyne-Stokes is that the signals and the breathing response that results are too strong, leading the CO2 levels to drop below the apnea threshold again... and the process just keeps repeating itself. Hypoxia likely triggers the entire process at the start because hypoxia sets the hyperventilation in motion. Those people that have the stronger hypoxic ventilatory responses, as this phenomenon is referred to, tend to have more prominent Cheyne-Stokes respirations.

A trip like this with multiple moves up to very high altitudes will certainly help with acclimatization and prevention of AMS on subsequent trips if they occur within a short time frame of those climbs (days to weeks depending how long you spent at high altitude on the first set of climbs). It will not, however, help at all with altitude acclimatization and altitude illness prevention for a trip to Denali, say, one year later. Susceptibility to high altitude illness is somewhat wired into our genetic make-up (although people have not really worked out the precise mechanisms behind this). Susceptibility doesn't go away because of trips to altitude taken long ago, although you can alter the risk by doing things like making preacclimatization trips to higher elevations close the planned expedition or slowing one's ascent rate. That all being said, another benefit of doing trips like the climbs in Ecuador and elsewhere is that it helps one learn their how their body responds at altitude, information they can use to better plan for future travel and climbing there.

Trip: Silver Star - South Gully Date: 9/23/2012 Trip Report: Scott K and I headed up to do Silver Star this weekend. Unsure about what shape the Silver Star Glacier was in, we opted to forego the Burgundy Col route and do a scramble via the South Gulley instead. We didn't find many reports on this beforehand and figured we'd post a TR for the climb. The beginning of the route is exactly the same as the route to Burgundy Col with about the least pleasant first 100 m of an approach hike you can imagine. One of the few descriptions we found said that once across Early Winters Creek head due east and uphill. Rather than doing this, we opted to follow the trail to Burgundy Col for about a quarter mile. When the trail came right along side Burgundy Creek for the first time at about 4,300 m or so, we cut across the creek and started working our way up hill on an easterly trajectory. If you don't cross here, the creek bed gets very steep on either side and would be tough to manage for a ways. Regardless of how you go in this early part of the approach hike, the objective is to start working up a west-running ridge that comes off the southwest buttress of Silver Star (shown in the photo below). You climb and run along this ridge for a good while. The climb up to and on the ridge is pretty mellow at first but becomes fairly steep between 4,800 and 6,000 feet. It was a little brushy in spots but overall it's fairly easy travel with little in the way of bushwhacking. Above 6,000 feet, the ridge mellows out making for very pleasant hiking in thinning forest with larches and great views of the Wine Spires to one side and Kangaroo Ridge, Liberty Bell and the Early Winter Spires to the other. Visibility was pretty poor due to the smoke but there were lots of great fall colors. You can run the ridge until about 7,800 feet sticking pretty much on or close to the top of the ridge the entire way. At about 7,800 feet, drop to the right/south side of the ridge and then traverse up to an obvious col at 8,000 feet on the ridge between Silver Star an Snagtooth Ridge. From that saddle, we headed left toward the peak and the South Gully. The description we had said to drop about 100 feet off the col and move left underneath a set of cliffs but we found we could traverse straight across (arrow in the photo below) and access a nice system of shelves and benches that took us on a rising traverse up to the South Gully shown by the arrow in the photo below. After a traversing up a few hundred feet in elevation we came to the area where the gully started. There actually appear to be three gullies as you approach this. We did not look at the one on the far right. We tried the one in the middle but got turned around by some chock stones and other obstacles and ultimately found the best way up was the gully on the left side. We stayed on the left side all the way to the saddle between the two peaks of Silver Star, crossing largely Class 2 terrain with some sections of Class 3 with no exposure. Lots of loose rock and scree making for plenty of 1 foot up/6 inches down climbing. Later, on our way down, we realized that rather than staying to the left to get to the saddle, you can follow a gully towards the right side that ends a little of the ways up the ridge towards the summit from the saddle. This would avoid one section of tricky scrambling to access the summit ridge directly from the saddle. Once on the saddle, we initially tried to walk across the snow to what we thought was the best entry to the scramble to the summit but found the snow on the firm side. We had left the crampons and axes behind and did not like the run out associated with a fall in that area so we backtracked and found a way onto the summit ridge closer to the saddle proper. From there we followed what seemed like very straightforward Class 3 rock towards the summit. We trended a little to climber's left approaching the summit, following what seemed like an easy path. About 50 feet or so shy of the summit, there is a slabby area that was easy to ascend to just below the top. However, this left us just below the summit block looking at what appeared to be a difficult set of moves to get on top that didn't correspond to what we read in other reports. We doubled back to that slabby section and moved climbers right on the ridge and found straightforward Class 3 climbing on that western side to just below the summit block and what then seemed like the remaining move or two described in most route descriptions. Overall, the summit scrambling was as described. Mostly Class 3 if you pick your way wisely but plenty of opportunities to find Class 4 and even Class 5 stuff depending how you go. We were on top 5 hours 15 minutes after we left the TH. Once there, we could see that it would likely still be possible to do the route from Burgundy Col as there was still snow on the glacier and only a few cracks that looked like they were easily passed. We couldn't see the entire glacier, however. After a half-hour on top, we headed back down. It was on the way down that we found that alternative gully mentioned above that brings you to the summit ridge from the South Gully. This leaves you at a very easy spot on the ridge from which to start the summit scramble if you opt to come up this way. The easiest way down from the saddle at 8,000 feet is probably just to retrace the route. We took a slight variation of that, dropping down to the basin below Snagtooth Ridge before traversing back to the main ridge we came up at about 6,400 feet but that didn't save us much time or effort in the end. About 3 hours and 15 minutes back to the car. Route Notes: - The South Gully approach is entirely snow free right now but would not be so earlier in the season - There is no water on the route once you leave the creek down low - Axe and crampons are not necessary for the route but if you want to gain the scramble to the summit ridge from a bit north of the col then they would be useful to deal with the firm snow needed to cross over to the other access points.

Denali no longer has pit toilets at either the SE Fork of the Kahiltna or 14K. All climbers must use the clean mountain cans at all locations. With the exception of 17K, the CMC bags get tossed in designated crevasses near the camp. For 17K, they're supposed to be carried down and disposed at 14K. Given the volume of waste involved in the length of time required to do Denali, asking groups to carry out their waste would likely not be very well-received.

Haven't climbed it recently but here's what it looked like from the top of Whitman Crest today (8/12):

Trip: Snowfield Peak - West Ridge Date: 8/10/2012 Trip Report: Steph Abegg posted a nice recent report of a more extensive trip into the area just a few weeks back so I'll just keep this at a conditions update on the Snowfield Peak climb as of 8/9/12 for anyone planning to go up there in the next few weeks. Approach Trail to Toe of Colonial Glacier: Snow free until the last bump that gets you to the base of Pyramid Peak. On the traverse over to the toe of the glacier, it's a mixture of rock/loose talus/scree and snow . Colonial Glacier: No crevasses on the route to the Colonial Neve Col. Getting around the lake requires going over the rocky ridge on the east side of the lake and descending a ramp to the snow beyond the lake, as there are a lot of cracks opening up on the edge of the lake. Neve Glacier: The crevasses are starting to open up but it's still very easy to navigate around everything. Several cracks starting to open where you drop onto the Neve Glacier from the Colonial-Neve Col at ~6,500 feet. More substantial crevasses at about 7,000 feet including one or two deep and long ones. Lots of space to get around them, however. Above that, there are a lot of cracks opening but no suspect bridges and you can still take a straight shot for the west ridge of Snowfield just stepping over all of them. The Neve Glacier from the Colonial-Neve Col: Crevasses at 7K on the Neve Glacier Water: Running water is easily accessible from the bivy site at the toe of the Colonial Glacier and there's still plenty of running water up at the bivy site on the Colonial-Neve Col. A few unappealing stagnant ponds on the way from Pyramid Lake to the bivy site. Some running water could be found off the north side of the ridge approaching the base of Pyramid Peak at about 5,400 feet.

There isn't very good evidence in the literature that Ginkgo does anything for altitude illness prevention. A few positive studies showing benefit but an equal number of studies showing it's no more effective a sugar pill. The reason for the conflicting data is likely due to variability in the gingko preparations used in the studies. Being an herbal supplement, it's regulated differently than a medication like acetazolamide (Diamox). As a result, manufacturers do not have to adhere to certain production standards so when you buy the stuff at GNC or wherever, who knows what you're getting. Extremity circulation and inadequately thin blood are not really the key physiologic issues at work in AMS, although the truth is, no one really has a good bead on what causes AMS. Diamox is actually pretty well tolerated by most people, particularly at the lower dose that is now more commonly recommended (125 mg twice a day) which fewer side effects than the higher doses

Vicodin or any other narcotic medication would be a bad idea to help with sleep if you're climbing at high altitude. These medications can lead to depressed breathing during sleep which is not generally a good idea for acclimatization.

PM Sent

That would be incorrect. HACE is actually pretty rare at almost any elevation, but can certainly be seen well below 20,000 feet and at elevations that can be reached in the Sierra, on Rainier, Colorado etc. One reason we may not see a ton of it here is that with severe altitude illness (HACE, HAPE), there's an important interaction between the altitude you reach and the time you spend there. It's not just a question of how high you go. It's easy to get into a range where HAPE and HACE can occur on Rainier but the nature of the climbs is such that most people hit the summit and come down soon thereafter, not allowing as much time for the problems to develop. This is different than trekking/climbing in Nepal where you might travel and stay above 14K for many days. Travel to and sleep in the summit crater on Rainier and the risk of those problems is higher than the standard ascent and descent soon after. "Epic efforts" don't bring on AMS itself. What epic efforts do is bring on dehydration and/or physical exhaustion, whose symptoms can resemble the non-specific symptoms of AMS.

Given that Whitney is on the southern end of the Sierra, another option is to fly into Riverside (LA/Ontario) and drive up from there. Open, fast driving to Lone Pine. That being said, the drive down from Reno is really beautiful and takes you past plenty of other great areas to climb... as well as the Whoa Nellie Deli.

Acetazolamide and dexamethasone are both safe, well-tolerated medications for preventing altitude illness in those known to be susceptible or pushing a faster than recommended ascent rate. They also have pretty good data from randomized trials not only demonstrating their safety, but more importantly, demonstrating their usefulness for preventing altitude illness. I think CBS is right... it might be time to put your reluctance to use prescription meds to rest on this one and use them to decrease your risk of getting sick and help you enjoy the climbs more. If you still don't want to use them... the primary option will be to lengthen your ascents and give your body enough time to acclimatize. There are no good over the counter products that will prevent altitude illness. Gingko has been studied and, although there are a few positive trials, there are several negative trials as well and it should not be relied on for this purpose. There is no evidence to support using Vitamin E, TUMS or a variety of other things you might hear people argue works for them at altitude. Unfortunately, the response to altitude and the ability to acclimatize varies a lot from person to person which explains why your friends do better than you do in this respect. That's hard to change as there's a strong genetic component to this (although no one has found the exact genes yet) Being in good physical shape also does not protect against altitude illness, but it does at least make it easier to perform physical work at altitude. As for "pressure breathing"... it's often mentioned as a tool to help the body adjust to the altitude but is not worth much. There are actually a few different breathing techniques that get labeled as "pressure breathing" when you talk to people out on the trail. The notion of exhaling really hard to clear your lungs is one of them... that concept makes no sense physiologically and only serves to expend energy on the forceful exhalation that you should conserve for other things while climbing. The other type is when someone purses their lips (brings their lips together) and breathes out against them. This creates back pressure in the airways that stents open the small airways and alveoli (air sacs) in the lungs. This can help improve oxygen levels (if you measured them using a finger pulse oximeter while doing it at altitude for example) but is hard to keep up for the long periods of time that might be necessary for it to make a difference and would be extremely hard to do while actually climbing when your body wants to be ventilating to a much greater extent than if you were sitting at rest.

The money for such a project is likely not out there but it's not an insignificant question. If you look beyond the climbing community and consider the wider group of people traveling to high altitude to ski at resorts, trek to places like Macchu Picchu and do a variety of other things, there are actually a lot of people on warfarin because of atrial fibrillation or deep venous thromboses who travel to or would like to travel to high altitude. Understanding what happens to their INR on such trips would be important as the implications of a recurrent stroke or DVT or bleeding can be pretty severe in some cases.

The hypothesis in this case is wrong. The hemoglobin concentration or hematocrit (both of which rise with long enough stays at high altitude) will not affect the INR. The INR is a function of other factors. The liver uses Vitamin K to make proteins that affect the major blood clotting pathways. Warfarin (aka coumadin) works by blocking the effects of vitamin K. This decreases the liver's ability to synthesize enough clotting factors and the blood's ability to clot and stop bleeding is impaired. If someone is taking warfarin and the markedly increases their intake of vitamin K, this will counteract the effect of warfarin to some extent and make the blood clot easier. If, however, someone's diet changes and their intake of vitamin K goes down, or they take antibiotics which kill bacteria in the GI tract that normally produce Vitamin K, then the effects of warfarin is enhanced and the blood is thinner than it should be.

Hypoxia itself should not lead to alterations in the INR given the way that warfarin works. Warfarin works by blocking the effects of vitamin K on the liver's production of important clotting factors. There is no clear evidence at this point about the effect of hypobaric hypoxia on synthetic liver function so it's unclear how hypoxia might affect the liver's ability to make important clotting proteins. The key issue for Spotly is whether his INR will get out of the therapeutic range (either too high and associated with an increased bleeding risk or too low and associated with an increased risk of clots and stroke) during his climbing trips. I doubt hypoxia has much to do with the risk of that happening but think it is more likely due to what happens to his vitamin K intake during his longer climbing trips (e.g., multiday trips). Changes in dietary intake of Vitamin K relative to the normal intake at home will likely occur as a result of having a very different diet on the trail. This will lead to alterations in the INR (either sub- or supratherapeutic depending on whether he gets more or less vitamin K in his trail diet). My hunch is that the findings of the study referred to in an earlier post about changes in INR in patients with atrial fibrillation around travel to high altitude were due to changes in dietary intake of vitamin K that occurred with travel rather than hypoxic exposure. This study is relevant in this discussion even though it was in patients with afib. Regardless of the reason you're taking warfarin, the key issue remains the same... will the INR go up or down with travel to high altitude. Of course, the biggest risk, as others have noted, remains the risk of significant bleeding with any trauma. A helmet is a must and the threshold for putting it on should be very very low.

The time frame for how long you'll need to lay off heavy activity and climbing depends on the particular technique your surgeon used to do the hernia repair. If they did a laparoscopic technique in which they entered the skin of your abdominal wall but never entered what is referred to as the peritoneal cavity, then you can usually be back to activity after a week of rest. If they did an open repair (bigger incision) or a type of repair in which they entered the peritoneal cavity then, in fact, a longer period of rest is necessary before one can get back to full activity. I suspect you had the latter given what your surgeon recommended in terms of rest time but you would have to ask them specifically to confirm this. It would be a wise move to listen to their advice and dial things back for the recommended time period. Getting back to heavy activity too early can lead to breakdown/failure of the repair which will only lead to more problems down the line... which will keep you out of action even longer.

It is worth taking care of this. These can remain silent for long periods of time but you would not want to deal with one of the possible complications of a hernia... particularly if it occurred on a trip off in some remote area. That would be a situation -- called an incarcerated hernia -- in which part of your intestine slips down into the hernia sac and can't get back out. Incarcerated hernias can lead to "strangulated hernias" in which the blood flow to the intestine is cut off. That is not a good situation. It's not necessarily a likely scenario but if it occurs, it's not good. The hernia will not go away on its own and often gets bigger with age and lots of heavy lifting over time. Depending on how the surgery is done, the recovery time does not have to be that long. If you choose to have it done laparoscopically (i.e., via instruments inserted through very small incisions, requires general anesthesia) there is an option whereby you can be back to physical activity within a week. An open procedure (single, larger skin incision) can be done under local anesthesia in some cases, but you'll be out of commission for a month afterwards with only a graded return to heavy activity after that.

I used Opticus for a pair of glasses last year and was quite impressed with the quality of the service they provide. If you have a strong prescription, these are good folks to check out.

There are certainly many simple ways to measure pulmonary function using spirometry devices but none of the information you get from spirometry has any utility in predicting who is susceptible and not susceptible to HAPE or other forms of altitude illness. The key thing with people who get HAPE is that their pulmonary artery pressures (i.e., the blood pressures in the lungs) rise much higher in hypoxia (or exercise at sea-level for that matter) than people who are not susceptible to HAPE. Why that occurs is not clear but it's this marked rise in these pressures that is critical to the development of HAPE. Under these high pressures, fluids leaks out of the pulmonary capillaries into the lung tissues. Finding an easy way to predict whether someone will have these pulmonary artery pressure responses has been a challenge. It will be interesting to see the results of Eric's study.

Completely independent study going on up there.

Don't blow that next big climbing, backpacking or trekking trip at high altitude because you had no idea how to deal with the altitude issues... Title: Safe Travel at High Altitude Speaker: Andrew Luks, MD Pulmonary & Critical Care Medicine University of Washington Date: Thursday March 10, 2011 Location: Seattle REI Time: 7:00PM Free to the Public

Long thread about this on TAY for several days now... a very sad story. http://www.turns-all-year.com/skiing_snowboarding/trip_reports/index.php?topic=19425.0

Don't blow that next big climbing trip at high altitude because you had no idea how to deal with the altitude issues... Title: Safe Climbing at High Altitude Speaker: Andrew Luks, MD Pulmonary & Critical Care Medicine University of Washington Date: January 27, 2011 Location: Seattle Mountaineers Time: 7:00PM

If you're not limited to the Pacific Northwest, the Sierra Nevada had loads of great multi-day tour possibilities in some fantastic ski terrain.