Friday, January 24, 2014

A Sense of Place

Platte Clove, one of the places where I've ice climbed the most, will always remain special. This rugged, unique ravine has more ice in it during a good winter than most other places around the northeast. In fact, it's a little bit like the Shawangunks to the south. The route concentration is high and many of the climbs are very good.

Huge hemlock trees, on slopes so steep loggers couldn't access them, adorn the walls of Platte Clove. Normally, hemlocks are part of the undergrowth. They prefer the shade and cooler temperatures than most other trees found in the Catskill forests. In Platte Clove many of the Hemlocks, especially on the north-facing slopes, have trunks that are 2-4' in diameter.  I stop frequently to admire them.

They mottle the sunlight, and create a wooded, almost mystical climbing experience - something that's rare here, where our forests are composed largely of deciduous trees. In the Devil's Kitchen and near Bridalveil Falls this makes the light very yellow in the afternoon. At the Dark Side and in the Black Chasm the trees make it feel almost like it's dark outside, even on a bright day

Every time I traverse the north-facing slope on my way to the Dark Side, or pass the old stone quarry on the way to the Chasm, or stop next to the old stone bridge to put my crampons on before entering the Kitchen I'm reminded that Platte Clove is one of my favorite places.

The climbing there is good too. Over the past decade or so I've climbed in the clove a lot yet the place still yields new lines, and cliffs keep getting discovered (perhaps re-discovered). Over the long weekend I spent four days in the Catskills. Three of them were in Platte Clove and I had an incredible time climbing with good friends. After many years it amazes me that I can go to a place I've been to hundreds of times before and climb new climbs. Many of the established climbs are very fine too.

There comes a time in every person's life when the invincibility of youth is replaced by a sense of realism. Some folks have this reality forced upon them early. Others, not so much. My bout of paroxysmal a-fib (I chronicled this in my last post) reminded me not to take for granted my mobility and the ability to scramble, explore and climb in wild places. At some point this ability is taken from all of us and I want to enjoy every visit to special places like Platte Clove.

Sunday, January 12, 2014

Athletes, AF, and Heart Rate Monitors

I haven't run much since late September. Instead I've chosen to focus on climbing, and on increasing strength in areas of my legs that feel weak and present with chronic tightness. As a result I'm not in tip-top running form. On December 24th I went for an evening run. It was already dark outside. My plan was to keep the pace easy and run a few miles on the lighted streets in town before heading into holiday eating binge season.

As I ran up the first hill, less than a quarter mile from my house, I was completely breathless. Struggling to keep my form and stay relaxed, I slowed the pace to a crawl. Two miles, and a long time later, I still wasn't warmed up. My arms and hands were cold and I wasn't sweating. My heart, beating wildly, felt like it was going to leap from my chest. Something was wrong. I walked the last half mile back to my house.

After showering to warm my chilled body, I strapped on my heart rate monitor. According to the monitor my pulse was fluctuating wildly and hovering above 100, even at rest. My resting pulse rate is normally in the mid 40's. Sitting still with a resting pulse two and a half times my normal rate left me short of breath. Standing up made me dizzy. My heart pulsed rapidly, and I could see and feel the beating through my lower left chest wall.

I'd had this feeling before, but never during cold weather, and never before a run. Sometimes after hard running races or workouts, during hot weather, I've had heart palpitations. Normally they go away by the end of the day. While they didn't seem quite normal, running your body nearly to exhaustion isn't quite normal either. I thought it might be some sort of recovery response to my extreme efforts. I'd also had the feeling one other time - during hot weather in the Cascades. I thought I might have had heat stroke. I didn't cool down for hours after finishing a long, fast hike.

I went to bed, hoping the feeling would subside overnight. The following morning my heart rate was still high - about 110 beats/minute at rest. That evening (Merry Christmas Ryan!) I checked myself into the emergency department at my local hospital. They take cardiac issues quite seriously. I was admitted and given an EKG immediately. The EKG showed an arrhythmia called atrial fibrillation.

Atrial fibrillation, the most common type of arrhythmia, occurs when the electrical pathways controlling how the heart pumps are interrupted or scattered as they travel across one's heart. This causes uncoordinated contractions, especially in the top chambers, called atria. The lower chambers, called ventricles, do most of the circulating, and have to work extra hard when the atria don't help out. A-fib or AF, as it's often called, is a serious issue. Anytime blood stops flowing smoothly it can clot. A clot in the atria could cause serious heart problems. If the clot is ejected it could cause a pulmonary embolism (a clot that attaches itself to the surface of the lungs), stroke (a clot in an artery in the brain), or thrombosis (blockage of an artery and eventual tissue death). These are life threatening and need to be taken seriously.

I was monitored while the ED doctor consulted with a cardiologist. The doctor briefly explained AF to me. It's not common in younger individuals (it affects about .5% of the population), stress, alcohol, and stimulants (caffeine) can trigger AF, and there are treatments that are effective, especially when you're young and there are no other cardiovascular issues. Afterward I was given the OK to go home, on the conditions that I would see a cardiologist ASAP.

On December 27th I met with a cardiologist who confirmed again that AF was my problem. I was going on day 4 with a resting heart rate of about 90-105. He scheduled an echocardiogram (an ultrasound of my heart) and a procedure called cardioversion to electrically reset my heart (like an automated external defibrillator does).

I took the entire four days in stride and tried not to worry. After all, people can live with a slightly higher than normal heart rate, and drugs can be used to prevent clotting, control your rate and convert your rhythm. However, the thought of living without exercise scared the shit out of me. I can live without running competitively. Honestly, I could probably live without running at all. Climbing though, that's a completely different story. All of my friends are climbers, my partner is a climber. It's what I do for work. It's one of the things I love most about life. In a way it seems so silly and vain, but it's reality for many of us as climbers - we participate in all-encompassing activity that becomes a huge part of who we are as people.

In the weeks following this paroxysmal AF I've learned a lot about my heart's little issue. My rhythm has returned to normal, and my resting pulse rate, measured using a heart rate monitor, is around 46. I've spoken with my mother and maternal grandfather about this too. It turns out my grandfather and all of his surviving siblings (4 of them in total) all have AF. There's a good chance it will show up in my mom's siblings as they reach old age too. There is some evidence that AF, which is not well understood and not attributable to any single gene, is familial.

Here is where things get a bit strange though.  It isn't random, although the people that get it are usually predisposed to it. There are triggers for AF. Stimulants can trigger paroxysmal AF. I drank a lot of coffee. Check that box, Doc. Alcohol is a trigger too. I like beer, and probably drank too much. Check that box too Doc. Both sodium and potassium imbalances can trigger AF. After big exercise days I've had bad muscle cramps. I'm not talking about little cramps, I'm talking about hamstrings staying locked, rigid, and bulletproof for up to five minutes at a time. Check another box on the ol' list. Endurance athletes are 5-10 times more likely to get AF than the broader population. This is not well understood, but it's believed that fibrosis, the thickening of of cardiac tissue as a response to extreme amounts of exertion, may create additional electrical pathways that divert the heart's normal electrical signal. Oops. Put another check box on there. A lack of sleep, or sleep disturbances can also trigger AF. I'm not the most normal sleeper. I've always tended to do short nights (5-6 hours) several times in a row, knowing that I could catch up at some point later on. Check another box there Doc. Add in the fact that I have a familial predisposition and it becomes apparent that AF may rear it's head early in my case.

I've begun running again, and I feel normal. Understandably, I'm going to approach racing a bit more cautiously from now on. I've cut way back on my coffee consumption. I now have one cup of half-caff in the morning, and decaf after that. The same goes for alcohol. A few nights each week I'll have a single drink. Over the past year or two regular sleep has become more important (and enjoyable) and I strive to get anywhere from 7 to 9 hours each night. I've begun drinking more water, and in conjunction with much lower alcohol and caffeine consumption, staying hydrated is easier.

In a way, the whole ordeal was a good thing, I needed to be more careful about how I treat my body, especially because sports are an essential part of my life. The decision was easy. In order to continue doing the things I love as long as possible I needed to change my habits. I feel better and I don't really miss the extra coffee and beer. Besides, I'm spending a bit less money now that $10 microbrew 6-packs pass through my hands very slowly.

AF was pretty easy for me to identify because I have no other health issues that might present similarly. However, if you've had panic attacks, anxiety or chest tightness as a result of stress, AF might feel the similar to them. A heart rate monitor, one of my really useful training tools, confirmed my suspicions and might not be a bad tool to have in the box if you're into endurance training and racing. From now on I'll be paying much closer attention to how I treat my body before and after exercise, and everywhere in between.

As usual, I feel like I'm left with more questions than answers. How many other endurance athletes have had this feeling before? Are there others who've been in my position and done nothing, knowing the feeling would subside? How healthy is extreme endurance training? Is it really good for us, or is it actually shortening the working lifespan of our hearts? Everything in moderation, and abstinence in certain things (like alcohol) seems like a very good idea to me now.

Thursday, January 2, 2014

Wilderness EMT Courses and Professional Outdoor Guides

In the outdoor industry the standard wilderness medical training certification is the Wilderness First Responder. It's an 8-10 day course that focuses on managing the types of injuries an individual will most often see in the backcountry - minor issues like wound care, dealing with bites and stings, improvised splinting and how to manage an evacuation. I took my first WFR course in 1998. Since then I've taken the course again and recertified my WFR four times. During that time I led many different wilderness trips and guided many days of climbing. I became familiar with the most common climbing accidents, how to avoid them, and also how to manage them when they occur.

This experience kept me familiar with much of the WFR curriculum and gave me the confidence to approach and deal with most minor climbing-related injuries. If I hadn't used my skills, I think the knowledge I gained during my wilderness medical training would have been forgotten.

I still lacked the confidence to manage a major traumatic injury well. Unless you're a professional rescuer you don't use the patient assessment, treatment and management skills enough to feel good about what you're doing. I was always left thinking "Am I doing this correctly?", or "What if I've missed something?". I had to think really hard about the sequencing of important things (airway, breathing and circulation always come first) and make sure I didn't miss anything important along the way.

As an outdoor professional I like to feel confident in my skills. So, lacking confidence in an area like this didn't feel quite right. I suspect many other outdoor professionals feel the same way - managing a life threatening injury would be really hard to do well. Nevertheless, I put off taking a Wilderness EMT course because I worried it wouldn't be necessary for me to do my job well. I argued it was too expensive, too great a time commitment, or that it would be hard to maintain. These things are all true, and if everything goes just right every day you work as an outdoor professional you will never need EMT skills. Every single day isn't going to go "just right" though. Guides help rescue other climbers at the cliff, participate in search and rescue, and manage their own guest's safety all the time. When things go way wrong, which can happen, it's good to have additional skills and the confidence to use them quickly and effectively.

Practicing the transfer of a patient to a longboard for spine

I mentioned in a previous post that I'm in the midst of a career change. I am not going to stop guiding anytime soon, but I don't want to rely on it as my sole source of income (a wise maneuver). A few years down the road I'd like to be working as a nurse or physician assistant. As a prerequisite it's suggested that you work in a healthcare environment before entering most programs. An EMT program is one of the ways many people begin their patient care training. Last month I took a 20-day Wilderness EMT Course at SOLO in Conway, NH to begin my own career-change track. It was a great experience all-around, and gave me a lot more confidence in my own emergency medical response skills

SOLO offers many wilderness medicine courses around the US throughout the year and has a staff dedicated to teaching Wilderness EMT Courses at their base in Conway. The instructors have a very thorough knowledge of the curriculum and a lot of real-life emergency medical response experience. The typical SOLO student is interested in being an outdoor professional and has a genuine interest in outdoor activities. This makes the group more cohesive because everyone shares some common interests in the outdoors. In my course there were wilderness trip leaders, university outdoor program instructors, park rangers, wildland firefighters, climbing instructors and some folks that were there just to take the EMT course there because SOLO is known for offering great programs.

Playing with the lights on Conway Fire and Rescue's rescue vehicle

SOLO's Wilderness EMT course combines the WFR coursework and the NREMT EMT-B coursework. The first half of the course focuses mostly on the wilderness aspects of patient care while the second half looks in greater depth at human anatomy and physiology and helps students prepare for the practical and computer-based EMT-B tests.

I found that 20 days, stretched out over four weeks felt like a really long time. I was ready to be done by the end. However, the practice doing patient assessments, splinting fractures and dislocations and performing CPR was incredibly useful. For me this is what separates the EMT (and wilderness EMT) from other wilderness medical courses like WFR and WFA. You gain much greater confidence in your skills as a rescuer.

One of the arguments against outdoor professionals having EMT certifications is that it's hard to maintain the certification if you're not a professional rescuer. This is true, but many of the other professional development activities we do for continuing education as guides will also count for continuing education as an EMT. Continuing education and professional development are important and often overlooked aspects of our work as outdoor leaders.

Realistically, the likelihood of a serious accident occurring is very low, but being able to think quickly and make the right decisions is really important.  If you're like me (I have a strong desire to be good at my job and I'm a little nutty about organization) then consider taking an EMT course. It will give you greater confidence in your rescue skills should a real accident occur at the crags or on the trail.