Extreme Everest 2017: Reflections From a Scientific Expedition

Extreme Everest 2017: Reflections From a Scientific ExpeditionOn March 30, we (members of Duke Anesthesiology) left Durham to participate in Extreme Everest 2017, a scientific expedition to the Everest base camp and Kala Patthar in the Himalayas. This had been organized by a British team, including Professors Monty Mythen and Mike Grocott, who had summited Mount Everest and performed numerous groundbreaking studies in 2007 and 2013. In the current expedition, we headed for Nepal for the second time, this time joined by a Duke Undersea and Hyperbaric Medicine (UHM) fellow, Dr. Chris Martin, and former Duke UHM fellow, Dr. Nicole Harlan, along with Dr. Joe Wiater and Fran Cullen, a financial advisor in Durham. The aim was to trek from Lukla to Everest base camp over 11 days, while measuring pulse oximetry continuously in a cohort of 14 individuals.

Why do this? What can be achieved from an observational study during the field expedition? The answer is that no one knows the lower limits of acceptability on blood oxygenation. While tens of thousands of individuals have trekked to Everest base camp without a problem, their oxygen saturation values have largely been unknown. Several studies have incorporated spot measurement of SpO2 but no published studies thus far have measured it continuously. In 2013, we obtained some data using wrist oximeters; the plan this year was to extend those studies.

Our team flew to Kathmandu, arriving on March 31. Among the 46 members of the group, several were doing research projects. These included an investigation of the microbiome and echocardiography at three different altitudes. Another investigation was looking for antigens that might explain the ubiquitous ‘Khumbu cough’ as due to inhalation of aerosolized yak dung particles. For our study, we signed up a number of the trekkers and obtained overnight baseline measurements. On April 3, we made our way to Kathmandu airport for the 40-minute flight in a Twin Otter aircraft to Lukla, altitude 9,317 feet. The Tenzing-Hillary airport at Lukla is reported to be the most dangerous airport in the world because its unique runway is positioned between two cliffs which leaves no room for error on landing. However, we landed safely and after gathering in a coffee shop for a brief refreshment, we headed up the mountain toward Monjo. Hiking in North Carolina can be challenging, but it is nothing like this. Unacclimatized as we initially were, dyspnea was a constant accompaniment. After several hours of hard trekking, we reached Monjo in the dark, and the next day to Namche (altitude 11,283ft), where we spent three days. Glancing periodically at our pulse oximeters revealed measurements that were consistently in the 70s. Apart from the shortness of breath, we felt fine and were able to carry on up the trail. Namche is a small town and would be the last ‘comfort stop’ on the way to base camp: there were coffee shops, lattes and just about anything you might need to buy for the remainder of the trip. The guest house where we stayed was owned by a man who was completely deaf due to meningitis as a child. However, he was a brilliant lip reader and an even more brilliant photographer. He plans to use proceeds from the sale of his photographs to fund a museum.

After our mandatory acclimatization, we headed up the trail toward Debouche (altitude 12,369 ft) and then Pheriche (14,010 ft), where we spent three nights, again to acclimatize. Pheriche is the site of the Himalayan Rescue Association, a bare bones facility but regularly and effectively staffed by doctors from around the world. Although most of us felt okay, medical problems started to occur. The first was one of our co-trekkers who abruptly lost consciousness while sitting outside a teahouse waiting for lunch. A couple of days later someone on another trek was visibly ataxic as he walked along the trail. The diagnosis: high altitude cerebral edema – HACE. Dr. Chris Imray, one of the British medical leaders, administered dexamethasone, walked with him to a helipad and escorted him back to Kathmandu by helicopter. Later, two of our group members would suffer HACE themselves. Fortunately, in all instances, dexamethasone and descent did the trick.

Extreme Everest 2017: Reflections From a Scientific Expedition

Gorak Shep (altitude 17,126 ft), the original base camp for the Hillary-Tenzing expedition in 1953, was our last stop. The day after our arrival there, most of the group trekked on to the current base camp at about the same altitude. The two of us, along with four other trekkers, including Chris Imray and Jeet Sherpa, hiked up Kala Patthar (altitude 18,519 ft). The prize on this mountain is a spectacular view of four peaks: Everest, Pumori, Lhotse and Nuptse. Although we didn’t quite make the summit due to incoming inclement weather, we did get the view and a backdrop for the Duke Anesthesiology banner. The climb nevertheless was tough, and my pulse oximeter was reading its lowest value of the trek: in the low 60s.

The next morning was the planned start of the descent. Before heading down, several of the trekkers set out at 5 a.m. to climb Kala Patthar. We and the British medical leaders had waited until their return before setting out. Unfortunately, as it turned out, one of our trekkers returned with a case of HACE. It would have been impossible to evacuate by helicopter as it was snowing, so she was given dexamethasone and allowed to sleep. The cure was miraculous: a few hours later she and her doctor, Dan Martin, zoomed past us on their way to the next stop at Loboche.

The downhill trek seemed uneventful until we were a few hours past Dingboche. As we walked through a small village, we were debating whether to stop for coffee when we spotted a few of our fellow trekkers. In the end, we decided to sit down with them to enjoy a few minutes of rest, but a few minutes later we heard someone yelling for help. Both of us, along with Aine Burns, a London nephrologist, and her daughter Brid, a medical student, rushed up the trail as fast as we were capable, where we found a man lying on the ground. The sherpa who had been accompanying him reported that he had not felt well earlier in the morning and had been advised to hike slowly. Abruptly, he had fallen down, unconscious. Fortunately, Nima (our Sherpa) had the medical kit with which we were able to check the man’s glucose to exclude hypoglycemia and then administer IV dexamethasone for presumed HACE. The stars had lined up for this man as a Nepali Army platoon was hiking through the village and was able to request a helicopter and carry the man up the hill for evacuation.

That night was spent at Tengboche, then we headed to Namche and then Lukla followed by the short hop back to Kathmandu.

What about our study? The data is being analyzed, but we had clearly observed that normal hikers trekked at altitude for long periods of time at SpO2 values, which if seen in any of our hospital patients would elicit panic. However, it was great to get back to normoxia where we could climb stairs and walk up hills with relative ease. We hope that the eventual publication, which might be entitled, “Oxygen saturation: How low can you go?” will elicit conversations as to alternative strategies for treating hypoxia in patients.

By Drs. Richard Moon and Eugene Moretti

Chris KeithExtreme Everest 2017: Reflections From a Scientific Expedition
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Duke Anesthesiology Career Service Awards

Duke Anesthesiology proudly recognizes members of the department who have demonstrated outstanding service and dedication to Duke! We thank them for their commitment to this team and the patients we serve!

Janet E. Goral

Narda Croughwell
Dianne L. Scott

Robin B. Coleman
Gary W. Massey

Christine Eaton
Nancy W. Knudsen
Jonathan B. Mark
Mark F. Newman

Jennifer Parsons
Allison K. Ross
E. June Santa
Christopher Young

Patricia M. Allushuski
Maurice L. Begin
John B. Eck

Nancy M. Kota
John F. Pierce
Melanie M. Sennett

Laura L. Booth
Karen Clemmons
Stuart A. Grant
Victoria Grossman
Paula Hawkns

Katharine S. Heinkel
Carrie A. Hines
William P. Norcross
Caswell S. Patmore

Earl S. Ransom
Jennifer Sanford
Cheryl J. Stetson
Marcy S. Tucker

Debra T. Allen
Wendy Bush
Natalie S. Clarke
Brian J. Colin
Sonia B. Crabtree
Charles E. Creel

Allan S. Fabito
Ilene B. Farkas
Patricia P. Fletcher
Stephen M. Melton
Sarah Miller
Timothy E. Miller

Allison Mooney
Michael A. Neal
Srinivas Pyati
Aaron J. Sandler
Mark W. Schontz
Erlinda Yeh

Rory Camasura
Shannon Currie
Jennifer Dominguez
Jennifer Easterling
Eric Ehieli
Lisa M. Einhorn
Reginald Enierga
Merrie Gough
Kirk Hamilton
Scott Helms

Lori A. Hester
Ru-Rong Ji
Amber Johnson
Courtney H. Kalkhof
Kelly A. Machovec
Erin Manning
Janina Marcenaro
Karen McCain
Collins Mogbo

Rachel E. Morales
Jennifer Neifeld
Karthik Raghunathan
Richard Runkle
Zaneta Y. Strouch
Dharamdeo Surujpaul
Zebulon Thomeczek
Elizabeth Wilder
Magan Zani

Chris KeithDuke Anesthesiology Career Service Awards
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Dr. Berger Receives Prestigious K76 Award

Miles Berger, MD, PhDThe National Institutes of Health has awarded Duke Anesthesiology’s Miles Berger, MD, PhD, and his team of investigators a Paul B. Beeson Emerging Leaders Career Development Award in Aging (K76); a five-year, $1,195,505 grant for their project, titled “Neuro-inflammation in Postoperative Cognitive Dysfunction: CSF and fMRI Studies.”

According to the project description, each year, more than 16 million older Americans undergo anesthesia and surgery, and up to 40 percent of these patients develop postoperative cognitive dysfunction (POCD), a syndrome of postoperative thinking and memory deficits. Although distinct from delirium, POCD (like delirium) is associated with decreased quality of life, long term cognitive decline, early retirement, increased mortality, and a possible increased risk for developing dementia, such as Alzheimer’s disease. Strategies are needed to prevent POCD, but first, we need to understand what causes it. A dominant theory holds that brain inflammation causes POCD, but little work has directly tested this theory in humans. Dr. Berger and his team’s preliminary data strongly suggests that there is significant postoperative neuro-inflammation in older adults who develop POCD.

In this K76 award, the team of investigators will prospectively obtain pre and postoperative cognitive testing, fMRI imaging and CSF samples in 200 surgical patients over the age of 65. This will allow them to evaluate the role of specific neuro-inflammatory processes in POCD, its underlying brain connectivity changes, and postoperative changes in cerebrospinal fluid (CSF) Alzheimer’s disease (AD) biomarkers, such as the microtubule-associated protein tau. This project will advance understanding of neuro-inflammatory processes in POCD and clarify the potential link(s) between these processes and postoperative changes in AD pathology, in line with the National Institute of Aging’s mission to understand aging and fight cognitive decline due to AD.

The K76 is a mentored career development award; Dr. Berger’s mentoring team includes Drs. Joseph Mathew (chairman of Duke Anesthesiology) and Harvey Cohen (director of the Duke Center for the Study of Aging and Human Development ), as well as Drs. Roberto Cabeza (from the Duke Center for Cognitive Neuroscience), Kent Weinhold (vice chair for research of Duke Surgery), and Heather Whitson (deputy director of the Duke Center for the Study of Aging and Human Development). Co-investigators and collaborators include Drs. Niccolò Terrando (Duke Anesthesiology), Jeffrey Browndyke (Duke Psychiatry & Behavioral Sciences) and David Murdoch (Duke Medicine).

During this K76 grant period, Dr. Berger, an assistant professor of anesthesiology, will also complete an individually-tailored MS degree in translational research that will include training in immunology methods, fMRI imaging, cognitive neuroscience, geroscience, and physician leadership. This career development plan will provide him with transdisciplinary skills to pursue his longer term goal of improving postoperative cognitive function for the more than 16 million older Americans who have anesthesia and surgery each year.

Chris KeithDr. Berger Receives Prestigious K76 Award
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Dr. Zhang Wins Poster Award at Inaugural Pain Meeting

Dr. Zhang with is award winning poster.

Dr. Zhang with is award winning poster.

Duke Anesthesiology’s Xin Zhang, MD, PhD, received an award for “Outstanding Poster” at the first Translational Pain Research Symposium, held on June 21 – 23 at Duke Kunshan University in China. His poster is titled, “Activation of peripheral β2 and β3ARs leads to increased nociceptor activity.”

Zhang and Nackley China June 2017

Zhang and Nackley China June 2017

As noted in the abstract, Dr. Zhang’s research shows that i) COMT inhibition leads to pain sensitivity, in line with increased ERK phosphorylation in DRG neurons and strengthened nociceptor activity in response to noxious stimuli, ii) COMT-dependent increases in pain sensitivity and nociceptor activity are driven by peripheral β2- and β3ARs, and iii) treatments targeted towards peripheral β2- and β3ARs and downstream effectors may prove useful in the management of functional pain syndromes. The team of investigators includes Duke Anesthesiology’s Andrea Nackley, PhD, Seungtae Kim, MD, PhD, and Sandra O’Buckley.

Dr. Zhang is a postdoctoral fellow with The Nackley Lab, part of Duke Anesthesiology’s Center for Translational Pain Medicine which is dedicated to unraveling the causes of painful conditions to better improve patient care. The Translational Pain Research Symposium was held on the new state-of-the-art campus of Duke Kunshan University. The goals of the conference were to present recent advances in basic science research of pain mechanisms, introduce cutting-edge techniques in pain research, and bridge the gap between basic research and clinical applications.

Chris KeithDr. Zhang Wins Poster Award at Inaugural Pain Meeting
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