Friday, February 5, 2016

Is measuring Blood Pressure important at 24,000 feet?

I have often thought that much of what we end up measuring in the operating room is because we stumbled at one point in medicine on learning how to keep track of certain variables. In the past, EKG was king - that is until SpO2 came along. If I have to choose today between the two, I will go for oxygen saturation. But in fact, if I could really chose, I would much rather know the value for SvO2 (mixed venous saturation) which is a really good indicator of how much oxygen is being used in our cells, and therefore a great indicator of a healthy perfusion and cell metabolism. (Today we estimate a good perfusion practically by just taking somebody's blood pressure (BP).

But we don't have the luxury of measuring this easily and certainly not routinely, so I follow what we know how to measure as long as it's practical.

The same goes for BP at altitude. Can we measure it? Sure. (See the picture below). Is it practical? Probably not, since placing and or wearing a blood pressure cuff in your arm while you are freezing in a tent or while climbing is simply not practical.  Wrist monitors are rather inaccurate, so let's forget about using these when we know they generate data that one cannot trust.

Withings Bluetooth Blood Pressure Monitor

But let's assume that we had a simple way of measuring blood pressure - as easy as the measurement of heart rate. What would I do with the number?

I think up above 20,000 feet, your blood pressure becomes almost a binary problem. Either you have one, and you are moving along and are conscious, or you are passed out, with a weak pulse, and it's really low. If I see you climbing, that probably means your blood pressure is fine and it will stay so without telling us that other problems are at hand. (Dehydration for instance, will eventually lower your BP, but a much better indicator would be an abnormally high heart rate, a dry tongue, loss of skin turgor, and a recent bout of diarrhea.)

Your BP could be even high due to your exertion, and it won't require any intervention. Of course it could be really high, so high that you spring a leak in one of your cerebral vessels. And if this happens, how can I help you up there by simply measuring your blood pressure?

If your BP is low and you have passed out, knowing the exact number won't really help me up there - unless I am carrying in my backpack the drugs I usually have in the operating room. These will then allow me to pick one from my arsenal of medications in order to help revive you.

In short, just by feeling your pulse, I will know if it's weak (low blood pressure), its rate, and that is probably enough for me to make an accurate assessment as to the causes of your collapse.

In CPR, you learn 3 basic steps to resuscitate somebody: Airway, Breathing, and Circulation. Blood pressure comes in last, and up in the mountain, you should ensure that the climber has a patent airway. You can then administer oxygen knowing that it will reach the climber's lungs. You then need to assess if he/she is breathing in order to get the O2 in and the CO2 out. And finally, you should check the climber's pulse to assess his circulatory status (is the heart pumping blood, and if so, is it able to generate a blood pressure which will move the blood to the O2 starved organs.

In short, just because we can measure something, it does not mean that its useful, and if one is at 24,000 feet, I'm not sure blood pressures are telling me much I can't see clinically.

If you insist on measuring your blood pressure while climbing, WiCis-Sports can do it. But I'd rather know your heart rate, temperature, and SpO2 to make a quick diagnosis.

EKG streaming in the very near future may reveal that many climbers are having arrhythmias and this is why they don't respond to oxygen as quickly as we would want them to. So again, that is more important in my mind than blood pressure.

In short, let's be practical about what we measure for climbers. Just because we can measure something, it does not mean that it is useful. And as most expedition leaders know - just by lookng at a climber, and talking to him, you already have much information as to how his body is tolerating altitude.

Climb safe, be smart, and measure numbers that are really useful.

Thursday, February 4, 2016

What to monitor in a mountain climber at 24,000 feet and then stream his data to any device on the planet with a one second delay

A climber at 24,000 feet faces many challenges and for most of these he/she is completely unaware of their risks or of their possible outcome.

In order to decrease these risks, one can monitor certain vital signs that will help us make better decisions up there. We have to decide what vital signs are useful to us, we have to be able to read them, and in real time, send them down to base camp or elsewhere in the world where somebody who is trained and is not hypoxic, can help us with the right decisions.

Aviation has faced a similar dilemma, and the cockpit on the plane that flew you to Kathmandu or Lhasa has many instruments that have evolved over time to make aviation safer. Before your pilot takes off, he also has a weather briefing that is updated while in flight, to keep him informed of the big picture.

The situation on the mountain is no different. Until recently, we were climbing with poor weather forecasts, and even today, a climber has few instruments to tell him of his real health status while making a final summit push.

WiCis-Sports is offering a solution which allows the climber to be monitored, no differently than they way one monitors an airplane. Data today can be streamed to base camp or anywhere in the planet where it can be analyzed intelligently.

What can we easily measure today AND stream? Temperature, heart rate, and hemoglobin oxygen saturation (SpO2). The WiCis-Sports App has will also send your exact geo-location (in case you are lost in a blizzard), your altitude, your bearing, and your speed. In other words, you can be in what in aviation is called IMC (instrument meteorological conditions) and still have a chance of being guided down.

Your body temperature is a crucial number to know, but perhaps for reasons that you don't know. Although your body's metabolism slows down with a decreasing temperature, something more important occurs in what is called your oxygen-hemoglobin dissociation curve. The colder you get, the less your hemoglobin likes to release oxygen (left shift) and your cells will become more oxygen starved. You also don't want to get into a situation in which you shiver (that greatly increases your oxygen consumption) further aggravating the problem. So where do you want to be on the mountain? I would say very slightly hypothermic (1 degree below normal?) since this will not give you a major shift to the left on your O2-Hgb dissociation curve, you will decrease your O2 consumption, and you will not shiver. This is simply a conjecture, but it's one that makes sense.

Bluetooth Temp Monitor - 4 cm diameter
Heart rate is another number to follow, and again for perhaps reasons that you have not thought of. For an anesthesiologist, increased heart rate means two things: 1) decreased coronary perfusion (your heart's vessels have less time to fill since they fill in diastole, the time between each contraction) and 2) increased O2 consumption. So if you are up at 24,000 feet, and your heart rate is speeding at 160, and you either feel a slight pain in your chest or you are totally short of breath, you now understand what is going on - your heart, like your sore thigh muscles, is getting tired with not enough oxygen, and you could end up getting a heart attack or going into an awkward rhythm. All this translates into you slowing down or stopping until your heart rate is slower, its perfusing better, and your O2 consumption is down.

Chest Heart rate Monitor

Oxygen saturation would seem to be very important. And it is! But here is the catch. At 24,000 feet, your saturation will probably be below 75%. Most pulse oximeters become wildly inaccurate below 70%. Also, at 70%, you are in the steep part of the O2-Hgb dissociation curve, so the slightest change in your pO2 in your blood will drastically change your saturation. What I am getting at is that if you see a number below 70% - it's probably not accurate, but it does mean that things are not looking good. If you see 70% at base camp (18K), you are probably suffering from HAPE. In short, monitor this number, but if it's low, look at it with a grain of salt...

What else would I like to look at? I think streaming EKG (electrocardiogram) signals may be very useful. We can stream EKG from base camp. But why, you may ask, do I want it from somebody at 24K? I am thinking of babies and SIDS (sudden infant death syndrome). For years we believed babies were passing away because they just stopped breathing. We now know that a certain percentage of them in fact have an arrhythmia that leads to a cardiac arrest, and of course then they stop breathing. For all I know, climbers who get into trouble in the so called "death zone" are in fact developing abnormal cardiac rhythms which then translate into HAPE. In the operating room, a common side-effect of hypoxia is arrhythmias, so I would expect to see the same at altitude. We may be able to have EKG streaming for the 2016 season - and this will provide us with a whole new way of looking at problems at altitude.

WiCis-Sports Base Camp solution streaming EKG (bottom center)
In conclusion, because we have not had continuous monitoring at altitude for the above parameters, we are simply guessing as to how one's body is about to tolerate a final summit push. Turning up the oxygen may be a solution, but with the proper monitors, turning AROUND may be another one, since if you develop an abnormal heart rhythm, this may require very different management.

Climb safely - but most importantly - make it down.

Wednesday, February 3, 2016

How to monitor somebody at Base Camp from afar by an Anesthesiologist

Anesthesiologists (anaesthetists in the UK) are doctors that spend much of their day looking at monitors whether in the operating room (theater) or intensive care unit, in order to make decisions about their patients.

Doctors such as these are trained to monitor, interpret, and then make a decision for their patients very quickly.

So it should be no surprise that the WiCis-Sports system was developed in conjunction with doctors from this specialty. What do the WiCis-Sports solutions share in common with what goes on in an opertaing room while you are having surgery? The answer is, just about everything!

Data that your doctor sees in the operating room is being read by sensors placed on the patient and displayed in real time for him to interpret it.

What does an anesthesiologist do with this information? He keeps you alive - that is what these doctors really do. How do they do it? By measuring certain vital signs.

Take a look at a closeup of the monitor on the top left.

Let's review what is being followed in this monitor during a real surgical procedure:

1. Electrocardiogram waveform (patient is in sinus rhythm - normal)
2. Heart Rate (55 - the lower your heart rate, the lower your oxygen consumption)
3. End Tidal CO2 (36 - the EtCO2 is a measurement of how much CO2 the patient is breathing out.)
4. Pulse Oximeter waveform (normal, rhythmic)
5. Pulse Oximeter O2 saturation (97, meaning your hemoglobin is 97% saturated with O2)
6. Pulse Oximeter pulse rate (55 - matches your EKG rate)
7. Blood Pressure (107/64 with a mean of 81)
8. Other values such as FiO2 (in this case 47% meaning he is getting more than twice as much as room air which is 21%)

So it is with this kind of data that an anesthesiologist keeps you alive for, in the above, case, a plating of a distal radial fracture.

How would an anesthesiologist follow you if you are at 18,000 feet, at Base Camp, when you have fallen ill? No differently if he could! Because with this data he can give you the best chance you could ever have of surviving. And with the WiCis-Sports Base Camp solution, your local doctor will also be able to consult with any other doctor in the world about your health status - in real time!

Take a look at this now: (A dashboard from the WiCis-Sports Base Camp solution)

Look familiar?

Note what the demo feed from our WiCis-Sports Base Camp Solution can follow at your BC.

1. EKG
2. EKG rate
3. Pulse oximetry wave
4. Pulse oximeter rate
5. Pulse oximeter saturation
6. 2 Temperatures
7. Blood pressure

For all of the above, one can set alarm limits.

But more importantly, and here is the big difference with a medical monitor - all data is being streamed to the internet, all data is being saved, and all data can be replayed at any time!

In short - with the WiCis-Sports Basecamp Solution, you can be cared for no differently than if you are in a modern operating room in Silicon Valley in the United States in 2016.

Check our our WiFi monitor that streams all of its data to our server:

It streams, it's wifi, it's compact, it runs on batteries, and we've tested it extensively. And it does EKG, 2 temps, SpO2, and blood pressure. It has it's own screen, but all the data is also streamed once it connects to a satellite hotspot, to our server, and then to you.

Why cut corners when you don't need to anymore? Want to see a live demo? Click here  user: demo password: demo  Select Thuraya Base Camp - to the right of the mWidget button, to select the basecamp dashboard... (By the way, the demo data stream you are watching, is coming from the UK - if you have a fast internet connection, you should be seeing a delay of less than one second.)

In our next article we'll discuss how to track somebody who is on the mountain.

WiCis-Sports - share your body's vitals and return safely.
Displaying 20160203_132342.jpg
Displaying 20160203_132342.jpg
Displaying 20160203_132342.jpg

Tuesday, February 2, 2016

Adventure is about to get SAFER

I have been around mountains for most of life, sometimes climbing them, sometimes trekking them, mostly flying off them, and I have always held them in deep respect.

My 10 year old on his way to Job's peak near Lake Tahoe for his first 10,000 footer
But as a medical doctor, I have always felt amazed as to how fragile our body is when we confront the elements. I am reminded of Nietzche's line that God must have felt so sorry when he had finished creating man, that he gave him a mind to make up for his scrawny appearance.

So it is with our mind that we have been able to climb the highest summits. And it is with this mind that we have created solutions at WiCis-Sports that allow us to better know how our body is behaving at altitude and then sharing that data with those who can interpret it.

Today, while you climb, we can monitor your body temperature, your heart rate, your oxygen saturation, and stream these numbers every second to a server where only one second later, one can view this data plus your altitude, geo-location, body position, bearing and speed - anywhere in the planet.

But our concern at WiCis-Sports has been that this data must be valid - data that specialized caregivers can use to monitor your climb and aid in your decision making. We offer REAL DATA in REAL TIME.

Job's Peak summit with Tahoe in the distance - 10,600 ft.
No climber today attempts an important summit without a weather forecast. But did you know that by following certain vital signs, we can also predict your chances for success?

So before a climb, get a weather forecast. And before and during a climb, follow and stream your body's vitals. And improve your chances of coming back.

Streaming to Facebook with the wicis-sports App
WiCis-Sports - share your body's vitals and whereabouts, and then return safely.