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Home / Articles / Adventure / Adventure /  A mountain of preventive medicine
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Thursday, October 24,2013

A mountain of preventive medicine

Professional guiding association adjusts, adding unprecedented high altitude medicine seminar

By Elizabeth Miller
Photo by Dylan Taylor
The AMGA is striving to professionalize guiding.

Nothing compares to the experience of being in the mountains at altitude, taking in the views, breathing crisp, clean air, hearing the first bubble of a stream at its nascent spring and seeing the tundra climate shrink our world down to miniature — tiny flowers, tiny shrubs, tiny pikas running among them. It’s priceless.

And it’s an experience some people will pay a lot of money to have.

An increasing number of people, according to the American Mountain Guides Association (AMGA), are turning to guides to provide these experiences. The organization reports an annual growth rate of 10 percent. As the presence of people, guided or not, in the wilderness increases, AMGA directors are looking to rebrand their organization by adjusting what they offer to member guides, and therefore, what those guides offer to their clients. High on the list of concerns is making sure that the people who go into those environments come safely home from them — the AMGA’s focus being about providing an experience that mitigates the unnecessary risks related to inherently risky sports. The AMGA is starting that battle on two fronts, first, with demonstrating the need for professional guides to have an organization that provides the equivalent of professional licensure, and then with convincing the American public, those guides’ potential clients, that when they hire someone to take them into the woods, they ought to be checking that person’s credentials.

“Any other profession, they have to be licensed — even if you’re a plumber or a hair stylist, you have a license, and for some reason in the United States, guiding is not seen as a profession that needs licensure,” says Betsy Winter, executive director of the AMGA. “Anyone can hang a shingle and call themselves a guide and take people out climbing, take their lives in their hands. For some reason, the American public doesn’t question the credibility of that individual or the training of that individual. Somehow we’ve accepted that. And the AMGA, we really feel there should be minimal standards, so that’s why we were founded 30 years ago.”

To become a fully certified AMGA guide takes more than three months five years and $30,000 — the cost of a full degree, Winter says, and that doesn’t include the avalanche training and Wilderness First Responder certification required in addition to the AMGA classes.

Winter acknowledges that it’s a tricky middle ground, even for an organization founded by groundbreaking climbers Yvon Chouinard, Jim Donini and Peter Lev, to recruit climbers and ski mountaineers into the fold.

“Guides, by nature, are anti-conformist, so they’re independent, they don’t want to be told what to do. They want to guide because they like the freedom of that lifestyle,” Winter says. “So the AMGA is somewhat at odds with its membership and with its customers because we are trying to standardize and give structure and organization because you need that to make it professional.”

And making it professional could mean turning the tide on some of the results from a survey of guides the AMGA conducted this year, the “State of the Guiding Industry,” which found that only half of guides think they can make a sustainable living as a guide. More than two-thirds of guides have a second job. Of survey respondents, 72 percent believed AMGA-certified guides make more money, which boils the question back down to the bottom line: if guiding becomes a profession with a professional licensure required, or at least expected, then will it make guides more money?

“If it’s just a bunch of dirtbag climbers out there, it’s not going to be viewed as a profession. You’re not going to be able to make a living doing it,” Winter says. “That’s one of the greatest cruxes within our organization is creating that structure — because that’s what guides want. They want to be able to make a living as a guide, but in order to do that you have to professionalize the trade, and when you professionalize a trade, you give it the structure and organization that kind of goes against the grain of what makes a guide a guide.”

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Guides ascending a mountain. | Photo by Dylan Taylor

Following the “State of the Guiding Industry” brand audit, which included interviews with current, potential and former members, the organization started to adjust what it offers in the way of education and training to broaden beyond the technical skills necessary to guide novices in alpine environments or take a group of first-timers top-roping.

“We offer courses and exams and we train guides, but now we need to be doing more,” Winter says. “We need to help them develop their businesses, help them market themselves, help them gain skills beyond the technical skills, so the high altitude symposium and our annual meeting is part of that initiative.”

The AMGA is rebounding in a couple of ways — by embracing that tension between the organization and its members; by finding ways to let guides bring their personalities to their work while maintaining professionalism; and by providing members with a caliber of education that’s nearly unparalleled.

So when Dr. Peter Hackett, director of the Institute for Altitude Medicine at Telluride, approached the organization with the idea for a day-long seminar focused exclusively on high altitude medicine, the answer was an easy “yes.”

Hackett started as a climber and took his first job after medical school as a helicopter rescue doctor at Yosemite National Park. Nearly 40 years later, he’s looking to reduce the number of calls the doctor in that position now has to take.

“My goal is to eliminate all deaths from high altitude illness and even go further, eliminate evacuations for high altitude illness, so the target group where I’m going to have most impact is by training the guides,” says Hackett, who is course director of the Advanced Mountain Medicine for Guides’ Lhotka Conference held at the National Center for Atmospheric Research in Boulder on Oct. 24 during the AMGA’s weeklong annual meeting, held in Boulder beginning Oct. 21. “It’s the guides that have to deal with the altitude illnesses, and they’re the ones that have to recognize it and make decisions on how to treat it.”

High altitude illness falls into two categories, common mountain sickness, which feels like a bad hangover, and serious altitude illness, high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE). HACE affects the brain, causing it to swell, and as it does, the symptoms look similar to intoxication — goofy behavior, inability to walk a straight line, coordination that’s off. HAPE affects the lungs, which fill with fluid and prevent enough oxygen from getting into the bloodstream. Symptoms, like coughing and a shortness of breath even at rest, can be confused with a cold.

To be successfully treated, either condition has to be recognized before it becomes too advanced — and recognizing the signs early is the focus of the seminar.

“You have to recognize it so you can stop going up and start heading down, that’s number one,” Hackett says. Treatment may also include oxygen or certain medications.

“It’s not rocket science. If they narrow it to pulmonary or cerebral edema, then they know they have to get somebody down, they have to get them oxygen if it’s available,” Hackett says. “The problem is, recognizing it when it’s subtle can be difficult sometimes, and people who have paid a lot of money to climb a mountain or go on a trek don’t always want to be forthright about their symptoms. So we teach the guides also how to recognize it in somebody who’s trying to deny it.”

Even if a person lies, a pulse oximeter won’t. The device affixes to a fingertip and measures the amount of oxygen in the blood.

“In the field, you can diagnose high altitude pulmonary edema in about 10 seconds with these devices,” Hackett says. “So we think we’re going to save lives and evacuations just by providing these devices and how to use them.”

He approached the AMGA with the idea for this high-altitude medicine seminar, which provides a much more specific high altitude training on top of the Wilderness First Responder — first aid in the woods — training that guides are required by AMGA to obtain. It’s so specific, in fact, he had doctors call and ask to register for the one-day conference, which will include among its faculty Dr. Peter Bartsch, considered the world-wide authority on HAPE.

“It points to the fact that this kind of training isn’t very available,” Hackett says of the interest in other doctors in attending the course. “There really aren’t any conferences for doctors or guides or anyone else devoted specifically to high altitude medicine, this is the first. … I think there’s a huge market for it, a pent-up demand, so to speak.”

Part of that demand comes from the fact that, for example, on Hackett’s own first trip to Nepal, which sparked his interest in high altitude medicine four decades ago, the number of people trekking there was only a few hundred. Now, tens of thousands of people visit base camp at Mount Everest each year.

“The population of people at risk has increased dramatically and medical research has increased dramatically, and we now know how to diagnose and treat all the forms of altitude illness and we have a pretty good handle on what causes the problem,” Hackett says. “But it hasn’t been translated into effectively reducing deaths and evacuations in the field because we haven’t spent enough time educating the guides and the climbers themselves.”

And the funding for the conference comes from one family who knows that reality all too well.

In 2007, Jason Lhotka, a sheriff from Grand Junction, turned back from his summit attempt on Mount Kilimanjaro because he felt unwell, but no one identified his symptoms of high altitude pulmonary edema until too late. Lhotka died.

“He was a young, healthy guy who had no medical problems and died purely because he went too high, too fast, for his own body, and that’s the way it often is, and it’s often young, healthy people, vigorous people that succumb to pulmonary edema,” Hackett says. “The problem wasn’t recognized and he didn’t receive emergency medical care for pulmonary edema and that’s why he died, and that’s usually the situation, the problem isn’t recognized for what it is. People on the trip think it’s a cough or a cold or a flu or just tiredness. So that’s why we’re training these guides to become really proficient at recognizing somebody who has serious altitude illness.”

The family wanted to do something to prevent similar unnecessary deaths, so they funded the Institute for Altitude Medicine for the one-day conference, which is free for AMGA members, and purchased pulse oximeters for attendees.

“I think it really will make a difference,” Hackett says. “Mountain guides in general are becoming more and more professional and the AMGA is their professional society, so it’s evolving to where you hire an AMGA guide, you expect to have someone who has expertise in high altitude medicine, that knows how to use a pulse oximeter. ... There are still plenty of great mountain guides who really know about medicine who aren’t AMGA, but in general, the AMGA is helping the guides become more professional and better trained. I’m all for better training and education of these people who have a lot of responsibilities on any kind of trip, but especially a high altitude trip.”

Additional training in high altitude medicine, and additional confidence in that knowledge, can also support a guide who’s addressing a sick client who doesn’t want to be sent home from a summit attempt and persuade that client it’s really time to go down.

If more people knew the warning signs of severe problems, they could make wiser decisions for themselves — decisions that start with biting back summit fever and heading for lower elevations. Because high altitude illnesses can kick in as low as 8,000 feet — roughly the elevation of Nederland and 2,000 feet below Leadville — the general public, particularly in Colorado, could use an education in these issues as well.

“People need to know, when they’re going to high altitude, about when to get help, when to go down, when to stop ascending,” Hackett says. “How long did it take, 40 years, to teach the American public that chest pain could be a heart attack or that a droopy mouth could be a stroke? Those are two major education efforts that have gone on for the American public in the last 10 years, major, major efforts with millions and millions of dollars. And of course I’m not saying altitude is anything like that, but it’s the same principle. There are a few very simple red flags that if recognized, if everybody going into the mountains, nobody would die, and very few people would have to be evacuated.”

Join the AMGA annual meeting at Upslope Brewery for a slideshow by outdoor photographer Dylan Taylor. The event will include free food and beer, a silent auction and an award ceremony and begins at 5:30 p.m. Oct. 26.

Respond: letters@boulderweekly.com


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