#41: Lessons from the Field and the Literature

0:00This is the March 2026 edition of the wilderness medicine podcast, where we talk about the latest and greatest developments in wilderness and austere medicine. Hey, please don't mind my rough voice, I think my career as a singer is over, but at least I'm no lady Gaga. On a more serious note, we're going to discuss one of the papers in the journal concerning avalanches, and then we're going to touch on what has been going on with all these avalanches lately. Then we're going to get to our seamy article, environmental exposures and risk during pregnancy, where our co-host Fred will take you through. Then we're going to South America, but we don't have to fly. We're going to talk about rescue efforts that were done in the Chilean Patagonia area, where it's the Bainé, with Marcelo Noria. As we examine the potential causes, as well as the rescue efforts that occurred and what

1:02many would call a mass casualty wilderness disaster last November. I did the same interview with Marcelo in Spanish, so that podcast will be coming out soon. And to finish the South American theme, we'll talk to Dr. Aaron Brillhart, who will give us an update on what is happening on Mt. Aconcagua, examining some of the issues that climbers have faced over the past few years, definitely salient, since there have been a few notable deaths in the past two months, presumably from fatigue. We're going to figure out what's really going on, so let's go. One of the papers in the journal this month, which is very salient for current events that's happened and is happening, is the paper entitled Acceptance of Risk and Confidence Assessing Avalanche Terrain in Conditions, a large cross-sectional study by Schonard et al. These authors investigated and they quantified the relationship between backcountry skiers and snowboarders willingness to accept risk, what we would term risk propensity and their

2:09self-reported, yes, self-reported confidence in assessing any terrain and conditions. This was done amid the COVID pandemic in the month of March 2021, with the pandemic's impact on increased backcountry activity. The authors analyzed almost 4,800 anonymous responses, the actual number was 4,792. These responses came from U.S. and Canadian participants, they had to be age 18 and above, and they found positive correlations between higher risk tolerance with factors such as advanced Avalanche training, more years of experience, and frequency of backcountry day skied, yikes, woo! But something interesting was also found, there was an overconfidence in 30% of those without basic level one training, who claimed confidence on complex terrain, double yikes. Of course testosterone poisoning was probably the cause and the males had a higher risk tolerance

3:14which kind of supports this idea, and they also had self-reported confidence, more so than females. This paper tells us that overconfidence in a certain population is considerable, remember the Dunning Kruger effect that the authors discuss where you might have a newbie who thinks they know something but they really don't, well that is definitely a recipe for disaster. But at any rate, this helps education programs look at this issue, helps guides look at this issue, and perhaps they themselves could mitigate overconfidence and enhance safety with the increase in backcountry use. My next topic is going to analyze a noteworthy incident that happened in February, perhaps. This paper does shed light on that and it certainly will as investigations come out. But I'm not going to get ahead of myself right now, don't let me do that. Just look at this paper and if you're driving please don't read this but I want you to look at this in the safety of wherever you would like to read.

4:18And there's an interesting figure, figure one, it's a very colorful figure. What I'm going to do is go through this figure to help explain what it means. The figure shows a distribution of self-reported confidence in assessing risk in avalanche terrain on that y-axis. That's the vertical up and down axis and then there is the x-axis, which is the axis on the bottom. It's the horizontal line, the horizontal axis. It asks how much risk on this x-axis, how much risk is a backcountry skier or snowboarder willing to take risks from a scale of 0 to 10, 0 many, no risks, baby, to 10. Oh yes, let's get them, very willing. This color legend that accompanies the figure has four categories. There's a non-confident to assess dangerous terrain and that color is shown in teal green with black diamonds. Then the next legend is simple terrain.

5:18These people could evaluate simple terrain with a color of orange with black stripes, ho-go tigers. Then the third color is confidence to assess more complex terrain with a blue color and black dots inside and lastly, check this out. I feel confident in any condition in terrain marked with pink and black vertical lines. Now I'm not sure why the color codes are so complex. It's kind of hard to decipher, I think, but maybe the authors have some hidden artistic flair, I don't know. There does seem to be a clear trend if we can get through the interesting colors and that is as the willingness to accept risk increases, the proportion of those surveyed who report having higher confidence levels grows. So yeah, those who have higher confidence are more willing to accept risk. We probably implicitly know that but it's nice to have this down in a large sample size.

6:22Those who report less willingness to take risks, that's the first three columns on that x-axis. They're dominated by those with no ability or a simple ability to evaluate potential avalanche conditions. Okay, very good. The ones who claimed that they're very confident or confident, I should say, I don't want to overstate this, but they state that they are confident in assessing terrain, the quote and quote, all pink with black vertical line people. Well maybe they expressed a 10% confidence in actually taking risks. So on the left hand side of this graph, they're prudent people there. On the other side, on the right side are those where more and more individuals were confident in assessing any terrain and they also had greater self assurance. That is willing to take risks in any terrain, whether it be safe or sketchy. So as I've mentioned, I like that large sample size because it gives good power to the

7:23analysis, integrating those variables such as the training level, the years of experience and days per season, for instance, gives us insights into the factors influencing confidence and risk. That's the human factor folks and the statistics seem pretty good as well. The findings are also to the point that avi safety programs should address over confidence issues among novices, which comprised over 30% of those without basic level one training, yet they still claim competence in complex terrain again. This underscores that manuscripts emphasis on a Dunning Kruger effect. Dunning Kruger or Dunner Mifflan, which is it? Hey everybody, I just want to welcome you all to the premiere of the real Dunner Mifflan commercial. The Michael Scott director's cut. It all starts with an idea. But then there's the other extreme. There might have been some overconfidence in the most experience as well. In fact, we do see that. Could this pose risk behavior where a confident guide takes clients into the backcountry in

8:26risky terrain? Well, let's go back to that. But first, I want to say that there was probably a likely sampling bias where the survey was distributed through avalanche centers and organizations. Maybe this represented or overrepresented educated savvy, avi folks, which could skew things toward higher confidence levels. And the definition of simple, moderately complex, all conditions, we have no idea where these definitions came from, who decided what was simple, who decided what was complex. And it's too bad that the study didn't last for a few seasons, including this very season. So I'm going to get back to the idea that do overconfident guides take clients into the backcountry in risky terrain. This is a topic that is currently worrisome as of the end of February. There has been, as you know, a very strange weather pattern of dry, warm temperatures, then large snow jump, especially on the west. Then pretty significant avalanches have resulted where we might ask ourselves, whiskey, tango,

9:33foxtrot, what is going on? There have been several high-profile avalanche fatalities in Utah, Idaho, Wyoming, and California, including British Columbia as well. Don't want to leave those guys out because they've had an issue too and so has Europe. But in California, there have been 19 avalanche fatalities reported up to February 26th per avalanche.org. California, unfortunately, has been overrepresented with an event that happened on February 17th near Tahoe, specifically near Frog Lake and Castle Peak. I'm sure many of you have heard about this. And what ended up happening is that there were 15 backcountry skiers and guides, four guides specifically, and six individuals were rescued and evacuated, and nine body recoveries happened, according to the Nevada County Sheriff. So what really happened is that a total of 12 were caught in the slide, and the remaining three had to perform companion rescue to the three who lived, and then they would uncover

10:34some of their other friends who unfortunately did not live. Since there was no cell service, the survivors used their iPhone satellite feature to call for rescue, which was a pretty good idea. Now, I don't want to comment on much else concerning this event. We know that maybe there was too much snow. We've heard about that. We've heard about the wind, but I think there's been a lot. Probably too many articles in the popular press, likely serving as clickbait. Again, we know that the large snowfall, the very high winds, and the very unstable snow pack on the bottom, as well as some of the terrain considerations made for a highly probable Adelante condition. And yeah, one can argue that the group probably should have been spaced out more because these individuals were puddled in a group. And hopefully we are going to have more official reports from the investigations in the coming month or months to be able to learn from this. But personally, I don't know anyone who has involved in the rescue mission.

11:35So all I can say is based on the plethora of things to get you to read and a lot of conjectures and a lot of opinions, well, I don't think it's wise to go there right now because most of this is conjecture. The snow pack, the weather, the train, and human factors in decision making, likely elicited this chain of events leading to systematic failures. These are themes that we're going to discuss at the latter end of this podcast when we go to Patagonia chili. For now, let's go to our seamy article, Environmental Exposures and Risks During Pregnancy, which is an article that we want to do the last podcast time, but we are unable to. My co-host Fred is going to take you through this good article and then we will see you on the other side. This is Fred Bossert, one of your co-hosts, bringing you some information on environmental exposures during pregnancy. As you all know, I'm an OBGYN and with me today is my wife who is also an OBGYN, Dr. Aaron Scarborough. Hello. Aaron, tell us a little bit about yourself.

12:37Well, when I'm not in the office or the delivering room or the OR, we own and operate a cut flower farm up on a mountain top in Tennessee. I love spending time outside on the farm, on the trail and on the water. I first learned about wilderness medicine through Fred and it just made sense to broaden our medical knowledge base with all the activities that we like to do in the wild. I couldn't have said it better myself. You know, as an OBGYN with a deep interest in wilderness medicine, many of my colleagues in the OBGYN community initially, and I think sometimes they still think this, assume that my interest with WMS lies solely with the possibility of doing a delivery of a baby on a remote trail in the mountains. That sounds amazing. It's like the dream. I just pray somebody will deliver on the trail. Yeah, and we're just there to help them. Although, you know, it's not ideal unless it works out. Yeah, no, we're talking, we're talking, like, low risk full-term delivery. That's right, yeah. No, that would be nice, yeah. But clearly, there's so many more reasons for an OBGYN or any healthcare provider from any specialty to have an interest in WMS.

13:39While the December 2025 issue of WEM had a special topic section on women's health, and if you have not had a chance to read it, I recommend jumping online and reading it as it has many excellent articles covering various aspects of women's health in the wild. The CME article in that issue is one that we're going to cover today, environmental exposures and risks during pregnancy by Sarah Schlein at all. I'm going with the traditional German pronunciation of Sarah's name, so forgive me if I'm wrong. I mean, you are part German. Yeah, I think so. It just kind of comes naturally, yeah. One of the issues we face in obstetrics across the board with regard to research is that it's a population that's a little more difficult to research due to the various situational aspects ethically, as well as the degree of actual volunteers for study and potentially limited areas of focus. For example, as with any study, you want a lot of participants, but some of the issues with pregnancy may not be as common in finding the correct power for a study can sometimes be difficult or take many years to accumulate enough data.

14:43Or perhaps there's a new drug like GLP1s that are now so prevalent. How do you walk the tightrope of ethics with IRB approval to study an unknown drug in this population? Well, that said, there's still a vast amount of studies that do exist. We also have a great deal of expert opinion that supports and drives guidelines and conjunctions with the research that already exists. In this article, Dr. Schlein and a research team reviewed the literature for the best available evidence and included observational studies, case series, controlled trials, and extrapolation from physiological data. Yeah, and so this sort of specifically discusses pregnancy concerns regarding extreme environments, including high altitude, hypothermia, hyperthermia, lighting strikes, scuba diving and venomations and common outdoor exposures. One of the things I hadn't really given a lot of deep thought to was the first point in the article, which is in regard to the benefit of the outdoors and in natural environments. Yeah, it's interesting because the strongest evidence in this area demonstrates that a greater access to green space is associated with improvements in birth weights, increased maternal physical

15:47activity, and lower levels of maternal depression. So in general, being outdoors is good, and I don't think you have to convince too many listeners of that. No, I agree. I think that's an easy sell outdoors good. Yeah, so let's get into some of the environmental exposures. Okay, let's start with hypothermia. So fetal exposure to maternal hypothermia, and this is mostly studied with maternal fevers at 39 degrees C and above in the first trimester, is associated with fetal embryonic malformations, including neural tube defects, ADHD, and autism. And then to get into the general environmental part of it, heat waves. So a study showed that for every one degree C rise in ambient temp, the risk of preterm birth increased. Unfortunately, there's not enough data really to it or evidence really to explain these findings physiologically, but it's good to know that there's that correlation there. What about the sauna? Love the sauna. Love the sauna. Not if you're pregnant, but I love the sauna.

16:48Spoilily, not if you're pregnant. And this is partially where guidelines do exist for advice against the use of sauna and hot tubs in pregnancy. There's an association of increased neural tube defects, intestinal defects, and brain malformations in the first 12 weeks of pregnancy. Okay, so what about strenuous activity, like exercise and running a marathon, right? We get patients that ask this a lot, is there an indication to avoid this activity? Theoretically, it would increase your core temperature, but you don't necessarily need to avoid it based on two separate studies that produce maternal hypothermia above 39 degree Celsius in these studies. Okay. What about like a max ambient temp? Data suggests moderate exercise in pregnancy is likely safe up to 32 degrees Celsius, which correlates to about 90 degrees Fahrenheit. Okay. Well, let's take it to the opposite direction, hypothermia, right? There's very limited data in hypothermia, but Dr. Schlein references a case report from Rosenthal of a primacravida, so a first-time pregnant person at 32 weeks.

17:50In this case, report, the patient was exposed to prolonged temps at negative 30 degrees Celsius, so negative 22 degrees Fahrenheit. Her core temp dropped to 29.8 degrees Celsius, around 86 degrees Fahrenheit, with associated fetal bradycardia, which makes sense. That's every warming was undertaken with forced warm air blankets and warmed IV fluids. The fetal heart rate normalized once normal thermia was achieved. So serial fetal assessment showed appropriate growth and normal Doppler studies. She went on to deliver a healthy term infant. This case really highlights the conservative management and prioritizing of maternal well-being with good maternal outcome and fetal outcome. And this is a general rule at obstetrics. We see this again and again. The kicker mom first, and typically the baby will follow. Yeah, and that's very true, and it's hard because if you're not used to dealing with obstetrics, there's a lot of, you know, what do we do? How is it different?

18:51And some things are different, just like pediatrics, but some things are still the same and some things, you know, you can just follow, but that's a key thing to remember. Well, why don't we go transition into high altitude? So we're going to go up and talk about patients residing at high altitude. So residents of high altitude areas show higher rates of preterm labor, low birth weight, intrauterine growth restriction, or small babies, need for supplemental O2 at birth, NICU admission, and hypertensive complications of pregnancy. For every 1,000 meters of elevation gained, there's a corresponding 100 gram drop in birth weight. That's interesting. I mean, we've known that from some of training we've had, but it's an interesting thing to kind of think about that correlation, right? That's a lot. It's significant. Yeah. For sure. Well, what about short-term visitors? People are just traveling to these, these sort of higher altitude locations. Well, healthy pregnant people, uncomplicated, low-risk pregnancies, they're likely at low

19:53risk for complications. There may be a possible increased risk of preterm labor and need for supplemental oxygen at birth, but the data is really scanned on this. All right. Well, so from an overall risk management standpoint, ACOG, the American College of OBGYN, lines say that healthy active people with uncomplicated pregnancies can safely travel and exercise up to 6,000 feet, or around 1,800 meters, slow acclimatization is recommended over three days with appropriately staged ascent, though. Women with higher risk or complicated pregnancies and women with chronic lung or cardiac disease and anemia, they should use caution when considering exposure to high altitudes. Yeah. And pregnant individuals who resided high altitudes should be closely monitored for complications, and that's pretty typical standard to care in those areas. One thing that you run into sometimes is acute mountain sickness or AMS, and one of the things that is frequently used to prevent or even treat AMS is a seatle's oil mine. So this has historically not been recommended in pregnancy due to the risk of potential

20:54congenital malformations reported in animal models. However, while it is known to be teratogenic in rodents, it's not known to be teratogenic and monkeys, and with small case studies in humans used for non-altitude-related reasons without seeing any teratogenesis has been established. So one study of a seatle's oil mine used for intercranial hypertension in a case series of 12 pregnant people showed no evidence of fetal harm for what that's worth. Well, let's go from the heights to the depths. You're going to make fun of me, but she really wants to make eye-knows myself. She was so excited to say that. I know. And it was one of my favorite areas too. Yeah, you will learn as medicine people, y'all love talking about scuba diving. It's so fun. I feel like ever since you started this journey, I can hear you up in the office on these podcasts and reviewing these articles, and it's always something about scuba diving and diving and mountains, you know? Love it. Yeah, yeah, yeah. Well, so as far as scuba diving is concerned, concerns here would be that fetal pulmonary circulation cannot filter bubble formation, so there's a significant theoretical risk

21:58of fetal arterial gas symbolism. Animal data suggests adverse fetal effects due to fetal decompression and hyperbaric oxygen exposure leading to premature closure of circulatory shunts that need to be open until they don't, right? So getting into risk management and some of these, you'll sort of see a theme develop here. Diving and pregnancy is not recommended due to the high theoretical risk in humans and known risk in animal models. So ACOG recommends against scuba diving in pregnancy. But what about, what if there was a dive when the person didn't know they were pregnant? Pregnancy termination, it's not recommended following inadvertent scuba diving. There are case reports that exist, a woman who went unknowingly diving during pregnancy without any adverse outcomes. Yeah. And just to be clear, it's unknowingly diving while not well pregnant, it's their folks that did know they were pregnant that were diving, not people that were pregnant that

23:00didn't know they were diving. You know, it wasn't a situation where they knew they were pregnant and they just came up from 100 feet and were like, whoa, that was weird. What just happened? Yeah. So there are two people that didn't know they were pregnant and went on a dive. And again, just to be clear, it's not recommended for, you know, even though there's a theoretical risk here of what's going on, it's pregnancy termination is not recommended at that point if that were to happen. So let's move it on to lightning strikes. Back to the sky. Back to the sky. So lightning strikes are associated with intrauterine fetal demise, uterine rupture, newborn death, and ischemic brain injuries. And the risk management for this one is similar to some of the other ones again. Pregnant lightning strike survivors must seek emergency care with trauma evaluation and field monitoring and in general pregnant people and also non-pregnant people should take care to minimize risk of lightning strikes. Yeah. That's pretty good. It's pretty good advice. I think across the board. In general pregnant and pregnant and not try to do a try not to get stricken struck. Struck? Yeah.

24:01Struck down. Stricken. Yeah. By lightning. I don't know. I don't know. Smited? I don't know. That's something else. So inventions are next on the list and are a good one, but follow the theme. But reported risks include increased fetal mortality and respiratory failure. So what's the risk management with this one? Try not to get bitten by something venomous. Yeah. I do. I try to take proper precautions to avoid venom exposure. And then any invented pregnant patient should receive the proper treatment, including anti-venom, anaphylaxis treatment, and supportive care. Yeah. All right. And then moving on to more common outdoor exposures. So we'll start with the sun. What about the sun? Do you ever get patients that ask you about sun exposure? Well, I would say more likely I get patients that ask me about, hey, is it safe for me to go to this vacation to Mexico, to the Caribbean, et cetera? And sun exposure and pregnancy really sets you up high risk for maternal, thermal burns,

25:03dehydration, and skin cancers. So I always advise my patients, especially first time moms, I haven't been through this before. In pregnancy, you're much more likely to burn than in the non-pregnant state. You're going to burn quicker, you're going to burn deeper. So you really want to be careful. Use high SPF sunscreen, sun protective clothing, stay in the shade as much as possible, because that sun will really burn you very quickly when you're pregnant. Yeah. And you want to stay hydrated, right? So that also leads us to the next thing. What about contaminated water? So there's bacteria, protozoan, viral infections, of course, the same with non-pregnant patients. The key point here, rather, is that purification with iodine specifically is associated with fetal thyroid dysfunction. So pregnant people should use safe water purification methods such as chlorination, boiling water, or a small pore filtration, but really, iodine should be avoided. Yeah. So in conclusion, Dr. Schlein's team provides a great overview of pregnancy exposures and some of the risk mitigation strategies that are definitely worth keeping on hand or

26:05a quick review before or during an excursion. Yeah, it's a great paper and I'm so glad that it was included in the journal. Thank you to our guest host, Dr. Scarborough. It was great having you on the podcast. Oh, it was great to be here. Thank you. We had seen weather reports of weather of winds high winds predicted up to gusts of 100 kilometres per hour, which we like this does not look good. We checked with all the members of staff at each individual refuge at campsite about the weather and consistently we were told that the past was open that day and it was safe to proceed. It wasn't until we were several kilometres into the trek on the steeper section when the weather really closed in a terrifying speed. I'm talking winds far stronger than predicted. I think it was reported up to 193 kilometres an hour, which is a category three hurricane and to add to that, which wasn't predicted, loads of snow, ice and a total white out.

27:08For one, the wind is so strong you can't move, you have to kind of into a ball and put your back towards the wind just to keep you safe from moving on the mountain. When the gust reached that high, you can't see it's extremely cold and descending down a mountain in those kind of conditions are much worse. So we continued up but very close to the past, perhaps 50 metres altitude from the past, the weather became just impossible. We had no option but to turn around and go all the way back down to the campsite. I believe the wind must have just blown away all the top level of snow, so it's extremely slippy and hard ice and people were just falling down the mountain at one point, I slid all the way, I stood quite far down the mountain and was just accelerating and accelerating and I remember thinking if I don't stop myself accelerating, I'm just going to keep on going and hit something and that will be the end of it. In November 17th of 2025, a sudden blizzard with winds over 190 kilometres per hour.

28:13That's about 120 miles per hour for all you folks down here. Struck the famous but remote O circuit trail in Chile's Torres del Bainet National Park, affecting several hikers from all over the world who were starting the trek about the same time on November 13th. Some headguides, but many went independently. There were five hikers from Mexico, the United Kingdom and Germany and unfortunately these hikers died on November 17th. None of these individuals had guides, plus there were 27 additional hikers who required medical attention. Many would say that this was the worst disaster to happen since 2011 when a wildfire claimed the life of a national park ranger. Now the interesting thing in common was that many of these hikers were doctors, air physicians to help us understand how the tragedy might have happened and how it could have been prevented. I have a friend of mine who teaches the Chile them with me, Marcelo Noria, who eloquently

29:15described the event to a national and international news programs in Chile and CNN. He has the vast experience as a mountain guide and he's the executive director of the Cuertbo de Socorro Andino de Chile that's the Andean Mountain Rescue Relief Corps of Chile. Who knows this area of Patagonia and the Magalan or Magellan region well. Now that's the tip of Chile that faces Chilean Antarctica and we discussed this event while we were together last month in Chile and I wanted to bring him on to discuss this for many of us in North America. It might be beautiful Instagram pictures of the iconic Torres del Pinede thinking that the trek in the summer is simple it's safe Marcelo it is great to have you and our podcast my friend. Dari thank you so much for that incredible opportunity for first talk with you and second share some one of my experience about that tragedy in Torres del Pinede national park like you say in incredible place but sometime the picture are a little I don't say fake but the weather

30:19condition it's always always been different condition okay thanks so much. Well Marcelo could you give us any details for the story and describe briefly the O circuit and the W trek that are the famous hikes in the Torres del Pinede and what could possibly be so difficult on these trails I mean these photos look like oh it's easy what do you think what do you say to this. Okay first the Torres del Pinede national park is in Patagonia that's mean Patagonia is a complete different weather condition of the rest of Chile because we are near to Antarctica that's mean our weather condition change in any moment we can have the four season in one day and the circuit the circuit have a special special things. We start in 100 meters over sea level in the east portion of the Torres del Pinede

31:20range they call Massiso Pinede range and you are protected because you have this big mountain near to 2,600 meters over sea level and then you start walking and you go around the massive Torres del Pinede and when you do the round you are in front of the high sphere of the south if you have this kind of massive glacier it's a cold cold region and like you say before and we're talking about the people taking an incredible sunny day picture but maybe it's just a few moments in the day maybe in a couple of hours after you have a lot of wind or maybe you have a rainy day and a snow day that's happened in Torres del Pinede that that is the more important things the weather condition change so so quickly and you need

32:21to be prepared for this kind of condition. So the change is there in the south of Chile very unstable you can have a sunny day and then suddenly because you're so close to Antarctica and the Cape Horn you can experience crazy weather and so it's very unpredictable. Now I'm thinking after looking on the internet that the terrain is actually quite difficult and the weather can become very dangerous as you've stated but yet the photographs the advertisements I see on the internet they describe this oh circuit as beautiful easy in the summer maybe a little difficult some sources say some say easy some say very difficult you can do it in six seven eight nine ten days I don't know these descriptions are confusing because they do not agree with one another they're inconsistent but maybe we can talk about the area in question we can narrow this down to where the incident happened this past called the John Gardner pass as these individuals were

33:26trying to go to the Los Perros glacier and this area is only 15 kilometers yeah and it's not very heights 1200 meters that that is difficult how how could this event have happened yeah there's many many of this kind of description you can find in internet we don't have we are not sure what is the sources the resources coming sometimes it's an expert mountaineering and for sure for an expert mountaineering doing that circuit with sunny day or not sunny day cloudy day or windy day with a good equipment and good preparation for sure is easy but when you saw that description in internet we don't know who is the people behind the laptop or the tablet or the social media and maybe it's an idolman people maybe it's a running people and that's mean maybe can be an expert or maybe can be a people without experience and that the reason is the resources never been

34:31agreed the our our internet study for say that example but the more important things when we do the W that is the more visitor place is all the time are the east side of the torus del Paine massive that means you are protect because you have this big wall of mountain protect you against the wind where the big silquick they call oh the big silquick you take a round of the massive and you don't have this world protection that's brain protection and you are in front of the ice south and that means a cold weather receiving all the time the western list that is the strong wind from the Antarctica coming right to our region in Patagonia oh I see that makes sense

35:34so the W trek is on the east side and the mountains protect this trail from the harsh environment but you can go beyond the W and all around the national park and do this oh trail and as I see on the map this oh trail goes to the north of the torus del Paine massive and then it circles around to the unprotected northwest end of the park that's exposed to the harsh Antarctic climate and the westerly winds and it looks like to make the circuit you have to go over this 1200 meter pass that doesn't seem to tall the John Gardner pass and then you descend down into this glacier that's called the gray glacier then back to the start yeah like you say you know is is only but but but it's only 1000 meters and 200 you are near to Antarctica that's mean our weather condition

36:37is sub Antarctic and if you coming to the torus del Paine between November and March is the more windy season in Patagonia and it's pretty important to know the shield of the the wind is always below zero if you are in front of a glacier and that is something happened here is it's a and I have a okay and not science and and try to be I try to be polite always with my government in that in that strategy we're talking about we're talking about the perfect stone because it's almost 200 kilometers per hour wind in that portion of the park and that means the weather condition is the worst we have in many many years and the other thing is what happened with the

37:37global warming maybe it's an important thing because we don't have that information and that is one of the the maybe the the more important things because we are not sure what is the the that worst condition in December you know because when November but is in is inside of the the more windy season in Patagonia okay that is one one of the important things here the summer so summer is more windy than maybe the winter in Patagonia yeah yeah that's is that is true because in between November and March we received the western list that is the wind coming right to the Antarctica to the South America Patagonia place that's interesting so with the climate change so maybe let's say over a 15 year period maybe you've seen more rescuers or more rescuers not rescuers probably

38:38more rescuers I hope but more rescuers I hope yeah I hope more rescuers no more rescues maybe because of the climate change more missions but do you think that the increasing popularity of Doris del Pinede is also contributing to having more missions more things like this happening yeah yeah without about any years we received more visitors and when you have more people in some place with this kind of risk the exposition grow oh yeah the exposure I don't have the statistic because we we are so sorry about the world but we are so primitive about the the statistic here really we start talking about the statistic in the last maybe five years and that's we have the number of visitors but we don't have the number of the rescue or of of procediment

39:40or the system working and that's is an important thing so there were two deaths from Mexico I understand they were doctors there was somebody from the United Kingdom two from Germany that died do we have any information of the cause of these five deaths the hypothermia was it trauma yeah the prosecutor's office is working on that but the medical the legal system is hypotherm oh yeah hypothermia hypothermia yeah because they are under wind 200 kilometers per hour for at least two hours and with that the exposition is huge and that's maybe the only true we know hypothermia hypothermia from yeah exposure terrible winds things like that so yeah the winds were

40:42190 kilometers per hour that's crazy and the windshield must have been terrible maybe 20 30 below who knows so what was the response of the national park I've heard various things like think it's called Konaft that's responsible they're the keepers and I understand that there was a national presidential election that day so how was that rescue carried out not just for the recovery of the five victims but of the remaining I think it was 27 victims that needed transport to the hospital yeah first we have a local system and one important thing is in Chile we have a emergency number is one three three is the number of the police system and when something's happened here in Chile the emergency number is one three three but what's happened in Chile with

41:42that is more than 90% of the people who call to the one two three is a bad joke is false and that's mean when the system for mean these pages for for go they need to be sure the alarm is true and know about joke so these dispatchers have to verify that okay 90% of the calls they're false and then 10% are real and they have to verify that yeah yeah and and the on the other big different between our country because we are so so primitive again I repeat that I look so much my country about that's true and the that number one two three is they receive a lot of my cat is in the tree I need help I miss in my dog and then that's mean we have a lot of these tiny things and when

42:52we have this kind of emergency situation they need to be sure because that mean move a lot of resources and we don't have a lot of resources that's maybe the more important thing and our region is huge when something happened in any part of my region move resources is a hard decision for the authority because everything needs money and after they move something they have a lot of prosecutor office of the government asking for what do you do with the money and that the reason we need to be sure but when it's true emergency and we are sure the system is starting with the police officer fears and the caravaneros and the police officer here they have an special group called gope is like a group operational police emergency and they have the skill for emergency

43:55mountaineering they they are specialists but we are in the faraway region from Chile and we have all our resources like country in Santiago because it's the capital and in the region we have four or five from this specialist and in this kind of huge region that is a few few people for working and the system have the second in command the military army and the third in command the socorrandino like volunteers specialist in mountain and after that we have a couple of ONG working on emergency system but first is mandatory go the caravaneros the police officers and after that the system the incident command system is start working and the first we can do is being prepared like volunteers narrow the search area that that's the more important things because

44:57the people asking for help to towards the pain and towards the pain is huge 200,000 acres and if you ask me I need help okay but when and where that is the first step narrow the search area being sure and sending the team with specialities for the north of the south so the narrow things down you have one team coming from the north and one team coming from the south of the park but what about helicopters we have a lot of wind that means we don't have a helicopter all the time available the distance between Punterenas and Torres del Pinede is 400 for 100 kilometers by car is five hours that is one of our things here so you are deployed the cash is 400 kilometers away and yeah Magellan is a very large region and wow yeah so then as rescuers how could we have

45:58done better to carry out this rescue look when we when we're talking about this tragedy in inside of the group of victims they have a lot of doctors but you know maybe they are an incredible specialist when they have the infrastructure but when you are in this kind of situation in the mountains situation you need to be prepared for that like the diplomating mountain medicine that is maybe the the best example now we have a lot of people with warfare wf air or maybe a lot of more courses and for sure that is an incredible tool but we need to be more especially for being in this kind of decision and for that we have another kind of tools for planning well it's interesting you mentioned these courses the dim the woofer now most of these

46:59victims were doctors or yeah doctors and you know they do well in the hospital many of us think I've thought myself that as a doctor we can make good decisions about how to keep safe you know as doctors we are proud of our ability to improvise things when conditions are difficult but there was something lacking I wonder what it was where they unprepared bad luck what do you think about that do you have any comment yeah I told you before I don't try to be polite all the time I try to be more more correct more honest and always humble but in this kind of position maybe you are an incredible specialist in in something but in mountain terrain everything change and everything change quickly including your point of view and for that maybe the more efficient one of the more efficient tools for take decision it's a method it's a reduction risk method is that is one of the

48:08maybe the more incredible books where we can read Bernan Munster is a skier professional skier in Switzerland and they lost a lot of friends in Avalanche and they start a matrix and that's matrix called three by three and with that they start collecting data and the the courses always repeated always be the same oh my goodness and with that they start doing the statistic and we thinking in how can you use that statistic because it's so different when we're staying my house planning my trip drinking coffee with music and my cat with me that you're that with you it's completely it's completely different and when you are on field and they start thinking okay

49:14what we can use and they invented this matrix three by three and first in my house I start searching for the weather condition in the park or the mountain I go I recommend using three websites different mountain forecast or windy aqua weather or whatever I don't want to be in the resources but right three apps oh yeah yeah three three apps and if the three apps say it says no day what do you think it says no day don't don't try to be a magic don't try to be a magician that's mean I can in my house I put this three by three and I say in my house local I'm sitting I'm sitting down here drinking coffee and put the weather in the position I go okay I have three apps second what is the terrain I know the terrain if you have no idea where you go

50:19use a local guide or go with people who knows or talking with the guy talking with the local people and asking the days after you visit and before you visit sorry asking for a how is the weather how is the terrain how is the mountain and with that you have a nice information not only using social media because like we talking before the social media we are not sure what is the resources they use maybe some experts describe the circuit like the more easy all working in a park but it's a mountaineering and at the opposite is it's a the worst experience in your life you can read something like don't go is for die and that's the important thing talking with the local people talking with the people who work in there who live near and with that you have information but the the more important thing is have a map learning to use an apps like a guy for say some

51:24example cast opo or something like that have the information use the information in in the in the right moment and finally the more important thing is the human factor and in the human factor I hear sit down in my house I searching for who is my friend I go I know pretty well maybe a little if you don't know pretty well a people and if you try to go to some experience in the wilderness is a mistake because you don't know is maybe is a snorkel people at night and the and the other day you want to kill them is the people who have a bad habit maybe they use the same underwear all the day and you share the tent and you don't like that you know is it's a funny thing here in our comfort place but when you stay in wilderness you change that's it the human

52:29factor we need to be sure what is my partner first second my partner have the same condition like they running they go to climbing frequently or is a sedentary man and that's an important thing because you walk walk walk walk and your friend die and that is the human factor and finally they have the techniques they they have the knowledge about how is the equipment we use you are sure they have the equipment this is the one look this we are in the first step of our planning the second step when I'm I have green light okay the weather is acceptable okay green light the terrain I know the terrain no but I have the apps and I go with them up okay green light and the human factor do know the people yes it's a friend of mine okay green light second step when you stay

53:30looking the place you are in the place you are in the park you are in the mountain wherever you go and you take a look the weather conditions it's like you research yes it's a sunny day perfect green light but what happens if you go prepare for sunny day and it says no day like torres del Paine maybe it's not a red light maybe it's a yellow light but depend if you have the equipment if you have the equipment like the nice equipment for snow good boots okay that's mean you have a green light and the terrain is like you research no it says no you have the equipment for snow yes I have okay green light no I don't okay stop and think that's mean take a look of the situation situation and awareness take a look of the 360 not only in you take a look of the all situation because maybe you have a good equipment maybe your partner no and that is our rules

54:36all the time situation and awareness but okay we have green light because the terrain is like we research and finally the human factor you take a good rest you have a good trip you are with jetlab all this kind of factor is mandatory you win prepare and sure and if you have if you have green light okay finally you are in the trip you are leaving your experience but include in your leaving your experience all the time you can evaluate what happened with the three by three the weather condition is like you research it's like you waiting maybe I told you in terms of panic you have four seasons in one day that's mean in your backpack you are prepared for everything okay perfect the terrain is is changed but your apps is functioned you are on the route you are on there you are scheduled everything is fine green light and the human factor you are happy you take a good rest you have a good meal everything is inside of the trip by three and finally

55:42if you have a green light in all this kind of state you maybe can take a good decision about that in this kind of trip by three you have a lot of red light that's mean you can stop and maybe you come back but here is an important thing sometimes the people who who have this big trip they invested a lot of money and they feel push it and they feel it's mandatory to go it's mandatory to do that and maybe that is one of the reason we can talking about this tragedy you know the matrix that you're explaining reminds me of what we use in North America it's called the Gar risk assessment GAR it's green amber red amber can be yellow green yellow red and this allows at least for rescuers time critical risk assessment and what this does is it generates communication with one another with regard to to mission risk so it's kind of the same idea so

56:46that we can reduce any bad outcomes during a some sort of an operational situation it's for leadership and so it isn't easy I bet Marcelo to be a guide or a leader sometimes because some people might say sure I can hike eight kilometers but have you hiked eight kilometers with a 30 kilogram backpack I don't know how many pieces of footwear do you have oh I only have one I have 10 issues I have my running shoes well that's obviously another red light as well ah you know I've invested a lot of money in this trip I don't have a lot of time so we have to get on this mountain or this track we have to see Doris Elpine and those are red situations as well so yeah but but you know that's that's is our maybe a specific conversation about what is the more important things training all the time be prepared and being honest I think that's

57:49a more important thing because when we're talking about what is the last time you do the eight kilometers with backpack no I I do always and then you go and and the first half an hour your partner want to kill you yeah well obviously we taught the the dem the diploma of mountain medicine together in Chile that's a good start on how educated people who might think that they're medical education is sufficient we should actually obtain education capacitation in surviving in the mountains are there any other things that you would recommend for people who you know need more I guess experience yeah I think I start that phrases with bin humble first bin humble because the nature is a big thing and we are like a little point in the this incredible

58:52world and it's mandatory be to be humble sometimes we we feel we are humble and that is it's not true and the more important for me is the experience and keep doing courses exactly what do you say about the team the that diploma in mountain medicine is an incredible opportunity for our local people for development and other skills but the theory and these kind of experience we need practice all the time practice and more practice because when you are master is a big big war but more practice more confidence you have in your skills and more practice you have I don't want to see to say sorry less fear but of course of for sure you have more confidence in yourself because

59:55when you have a lot of practice when you are in a stress in front of a stress situation you know you have the tools and that is practice all the time and flying hours like the pilot say we need flying hours in mountain we need flying hours in practice in what we want to do if something happens and recently I'm talking about the situation and awareness and that's for me maybe is one of the more important things all the time being prepared not for but lack not for thinking something happen always not in that way it's just in case your mind being prepared and and that is part of being a guide that is part of being a diplomate in mountain medicine that is part of people like us who really want to live the experience share the experience but do that wilderness

1:01:01more open to more people maybe that is my finally idea about that yes I agree more training can make the wilderness more accessible to many of us well thanks so much Marcelo for joining us and enjoy your summer down there as we enjoy our winter up here okay Darryl again I give you a big big hug and I hope see you again we're going to be able to support you we've got a very interesting talk with one of my friends Aaron Brillhart and he's from Wayback East he just finished a medical support for a schema race it was it in Vermont it was this morning yeah nice and icy plenty cool so Aaron I want you to tell us a little bit about yourself and tell me about your background

1:02:02with the medical service especially as we segue into discussing Akankawa well I'm an emergency physician with the University of Vermont I also work at another community hospital locally in Vermont I am medical service medical director for Stowe mountain rescue which is our most technical Northern Vermont team and also the regional medical advisor for the Northern Vermont ski patrols of NSP and over the past few years we've been involved with a program on Mt. Akankawa from the University of Vermont we've been taking fellows and residents down to integrate with the medical service to help them with their medical education and also learn from the medical service on Mt. Akankawa it is a very active medical service of up to 30 physicians on a large mountain we can talk about that too but that's been my background over the past few years so how did you get to be associated with those on Akankawa did you just show up and the plus of them will listen say

1:03:04I'm here or how does that work well I reached out a few years ago many years ago I studied briefly in a medical school in Chile and also climbed in the early 2000s on Akankawa and so I knew about it and a few years ago when we developed our wilderness medicine fellowship at the University of Vermont I reached out to the medical service and to the park to see if we might be able to do an academic experience down there and they were agreeable to that I should mention too there are others not just myself in this space I know that you do a lot of training in Chile yourself and have been active with their wilderness medicine community there as well the University of Colorado and the University of Utah have been involved with education on Mt. Akankawa in fact demand is in the University of Colorado is currently down there running a program let me ask you this so let's say I wanted to do Akankawa I've heard about it I heard about this lady a couple weeks ago that ran

1:04:05up the mountain I'm like oh I'm gunning it but I don't think I want to run up it I don't think that'd be wise but say I just want to go up Akankawa so what do I need to know how high is this mountain what is the normal route how long do you think it would take me just as a normal and acclimatized person living at sea level although you people know I live at 6300 feet and you know what about the medical service will I have good medical service and rescue should I need it Darrell these are great questions and they're asked by so many people Akankawa is an exciting mountain and it's almost 7,000 meters high 6,961 meters is where the condor statue stands on the summit good cross with lots of flags on it very exciting summit beautiful mountain it's the tallest peak in the world outside of Asia it's the highest peak in the Americas it's almost 3,000 feet taller than

1:05:08Denali this climb is mostly a non-technical climb which means it's a walk up over a scree and dirt and also snow it's obligatory to wear crampons but not necessarily to use an ice axe although many climbers will also climb with an ice axe this is on the normal route that most climbers climb there are also some scary routes like on the steep south face and the Polish glacier is another well-known route on on Mt. Akankawa that is climbed less frequently these days but also available to climbers with more technical elements every year there are thousands of climbers that try to get to the summit of Akankawa they all have to register with Akankawa provincial park that controls access the main season goes from November until about now when we're doing this podcast which is very early in March and that's their summer that's their southern summer season of the 3,000

1:06:16climbers the success rate is a little more than half so not everybody gets to the top and one of the main reasons for that is that it is so high in elevation and that also gives us some exciting things to talk about regarding medical care on the mountain because the elevation really matters for climbers and their health the medical service is basically a private contracting group that works with Akankawa provincial park and they assign the medical service to work for them for you know a period of multiple years currently a company called Extreme Medicine does that and they are owned by doctors Avramore and PRONCE to very experienced climbing mountaineering physicians in Argentina and in their medical service they have about 30 physicians that rotate at various

1:07:16camps on different parts of the mountain to check climbers all throughout this really busy summer season some of these camps because it takes so long to acclimatize can have hundreds and hundreds of climbers there at any given time because they're there for multiple days so the mountain is very busy basically and that is one one part of the climbing experience there besides it's amazing natural beauty it's also very busy with other climbers during the summer season on the normal route anyway there's also a police rescue service that is stationed up at the 5,500 meter camp which is Nido de Condores and that's at about 18,000 feet and they are available to rescue climbers mostly the these rescues happen on the normal route but they work in conjunction with the park medical service and the park rangers to assist climbers in need of high on the mountain the medical services

1:08:19camps are at 3 400 meters oh I should mention the park entrance is at 3000 meters so basically 10,000 feet and then there is about a 6 kilometer walk into the first camp on a normal route called Confluencia and that's at about 3,400 meters or over 11,000 feet and then there's an 18 kilometer walk that goes up to Plaza de Mulas which is the main base camp at 4,300 meters services there guides porters many people use mules to help transport their gear back and forth because it's such a long dusty trail to get up there you'll notice that between these camps there's quite a bit of elevation gain your first night in the park is already over 11,000 feet at 3,400 meters your second camp is a 900 meter jump which is quite a lot at Plaza de Mulas base camp and so climbers will have to spend multiple days at these camps before switching camps or climbing to a higher elevation

1:09:23the medical service control checkpoints are at Confluencia and Plaza de Mulas where a climber such as yourself Darrell if you want to attempt a mountain would stop and meet with a physician with the park medical service and they would take your vital signs and they would listen to your lungs and ask you how you're doing and talk about any major medical problems or medicines that you take and ensure that you are you seem to be acclimatizing well and don't have any other specific needs or questions it's also an opportunity for education for climbers about the altitude if they have questions so that happens at camp Confluencia and then at Plaza de Mulas camp now the medical service also has probably the highest medical outpost in the world over 18,000 feet at which is 5,500 meters nido de condoresce it's a tiny bit higher than ever at space camp it's not as equipped as ever at space camp it's just a physician stationed up there with some equipment and oxygen and the like if climbers were to need them there's also Rangers and

1:10:29rescue service that are up there too so that's more or less what you might be expecting or you might expect on the normal route and the time to climb or the amount of time required to climb on the normal route to acclimatize properly if you're coming from sea level or even 6,000 feet like you mentioned can be 10 to 14 days so let me ask you something else and we didn't talk about this previously but let's say that an individual wasn't doing good you know for whatever reason to the police the Rangers who has the authority to say sorry dude you're not going any further or does that happen so it's rarely so controversial there can be times when people don't when people are really sick and they don't want to go down but usually they get the message especially they can't breathe or walk very well in general it's the access is controlled by the park rangers and the rescue services they are not as police to give you a ticket they're there just because the rescue service is under the heading of the Mendoza police also if you're really

1:11:35going you really want to try to work with the medical service there if they're giving you advice one way or the other it's probably for a reason one of the interesting things about Akankago is that even though it's normal route is non-technical there are quite a bit of climbers that require assistance in fact we looked at evacuations on the mountain over two full seasons and there were over 300 climbers evacuated we found that the rate of evacuation was almost 5% of all climbers 4.7 percent of all climbers needed to be flown off the mountain for an urgent medical problem and half of them the percentage was actually 2.3 percent of all climbers that attempt Mt. Akankago developed high altitude pulmonary edema and that was the most frequent reason for medical evacuation over the past few years so developing high altitude pulmonary edema is the most life threatening and frequent altitude illness that we see on Mt. Akankago it made us look also at why climbers are

1:12:40developing high altitude pulmonary edema we did a survey of 17 climbers it took only like two or three weeks to get 17 climbers because so many people require medical assistance there and there's so many climbers on the mountain we surveyed them about their demographics and climbing characteristics and we found a couple of interesting things that our audience might be interested in in order to help climbers avoid developing high altitude pulmonary edema or help medical providers advise climbers how not to develop high altitude pulmonary edema and we found was insufficient nights at base camp acclimatizing was associated with the development the more likely development of high altitude pulmonary edema and also ascending through symptoms of unresolved acute mountain sickness made climbers more likely to develop high altitude pulmonary edema we found that in this study a couple of years ago so those are two take-home messages for ape avoidance and the main one

1:13:42is what we think of with regard to a centrate and spending enough time acclimatizing while going up this mountain it's tempting Darrell I know you're in shape you can run pretty fast but that is not the runner that ran up the mountain in a few hours however however it's the tempting non-technical nature of the mountain and these elevation changes between camps that can be so risky for for the average climber on the mountain in general anyway so we tempt fate if that's the proper term by by trying to ascend too rapidly on mountain kagwa well and being in shape doesn't necessarily confer acclimatization because of success either so there's that thing to deal with as well a very important point right yeah yeah so going slower up the mountain is how we avoid illness altitude illness not necessarily training training might help you with summit success but it doesn't help us avoid altitude illness oh we also looked at you know the end outcome for

1:14:44these illnesses you know why how can we help climbers come back from a successful expedition without illness injury or mortality and we looked at mortality again over the past few years since 2013 actually to better understand what climbers can do to keep themselves safe to help advise the park on the types of deaths that are experienced on agon kagwa and to help the medical service also work on educational initiatives if necessary I should also point out that any of the research that we've been doing through the University of Vermont or Utah is always integrated with the local physicians there it's their research too we I've tried to bring some of these research projects forward but this is the research of the park physicians themselves this is all in cooperation with them I wouldn't want to bring a study forward from out agon kagwa that didn't have their full

1:15:45support they do so much and they are the boots on the ground that really assist climbers on a day-to-day basis and we just have an academic involvement there but in any event we'd looked at agon kagwa mortality recently and there were a couple of findings that we noted your audience might be interested in knowing that the mortality rate on agon kagwa is about 1 in 1400 climbers and if you think that every year there's 3000 climbers on the mountain that's simple math but that percent is just under 0.1 percent of climbers so it's actually 0.07 percent is the death rate there which is about 10 times less than Everest and maybe three times less than Denali a little bit more but it's more than Kilimanjaro so in comparison to other high mountains what we found is now in the last recent decade and a half is that most of the deaths on the mountain are happening

1:16:46on summit day 90 percent of the deaths from 2013 to 2024 happened over 6,000 meters so that's higher than the upper camp which is generally around 6,000 meters and it's between there and the summit which is 69 61 meters and most of the deaths on the mountain are medical so a hair over 70 percent as opposed to on Denali where trauma deaths would be more common and we found some statistics that were also notable for climbers to be aware of climbers over 50 have five times the risk of dying on the mountain we noted that climbers from the US also had an increased risk of dying on the mountain and this is not because of more climbers from the US this is incidents so per climber the risk was higher interesting and we do we know why those factors exist we don't we can it's probably easier for us to speculate on age than than it would be nationality I think what we need to do right now is

1:17:50look forward to some future research topics and and those items may be addressed again in another future climber survey are there characteristics of certain populations that are important the one important point here to know though is that because 90 percent of deaths are happening over 6,000 meters on the mountain and this is summit day we want to think about how we can prepare for summit day to reduce our risk and the main thing there is acclimatizing well taking time to acclimatize on the mountain being aware of the rapid change in weather that occurs once you reach that elevation where the approach to base camp is hot dry and dusty and all of a sudden when you're high up on the mountain then summit day happens it's dark you're up at three in the morning it's minus 18 Celsius or zero Fahrenheit the wind is blowing potentially hard or moderate on a normal day frostbites a real risk is very taxing on the body when we try to climb and most

1:18:56most climbers will climb without oxygen on the mountain derelict as you probably know when we climb in that hypoxic environment our bodies just function differently then they do when we try to climb a 14 or in Colorado we really can't recruit the work that our bodies are used to doing in Colorado when we're high up on Mt. Aakinkago because things become we we become more affected by that altitude in our in our in our pace of slows and our ability to keep ourselves warm slows all at the same time and so that's really stressful on the body preparing both mentally and with your climbing party for that extreme day a summit day over 6,000 meters is one really important take-home message that I think we we could impart from the study that we that we had done there yeah and I'd be interesting to see how many of those who had success were able to have a previous ascent at 6,000 meters that would probably confer some modicum of success for those versus the

1:19:57newbies who may not there was a study a few years ago that looked at that looked at altitude experience among climbers on Aakinkago and many climbers do see Aakinkago since it's a non-technical climbing route on the normal route as a precursor to high other high mountains including other seven summit high mountains like Denali or Everest so climbers on Mount Aakinkago may have less experience with high altitude or extreme altitude exposure then perhaps on some other high mountains remember though this is higher than Kilimanjaro so right just because you're climbing Kilimanjaro went well doesn't necessarily mean that the same acclimatization schedule on Aakinkago will work for you right well those are good do you have anything else you'd like to add Aaron I think one of the interesting things looking forward into the future to think about is how we can bend the curve on either the rate of evacuation for high altitude pulmonary edema the rate of

1:21:00morbidity for that or the rate of mortality on the mountain I think looking at climber demographics and looking at a centrate and looking specifically perhaps with a survey or the like of patients a larger survey of patients on the mountain I think that that could really help inform the park and the medical service and climbers on the mountain with better background or understanding I think that would be the term of the risks that we can help to control or mediate while in the mountain my hunch is that what we know now is that it's a lot about a centrate and keeping your a centrate slow but why certain climbers might be at higher risk we don't necessarily know yet so those are some exciting future concepts for potentially research also I think one of the things we didn't mention is that some type of academic exchange down the mountain can really help share ideas with us from WMAS or North America and our fellow physicians in South America or

1:22:08the Southern hemisphere I think that can be helpful to bring the world closer together it's also a lot of what you've been doing yourself with working with the Chilean groups too yeah those are great ideas yeah help other people develop their career too well I definitely appreciate your time Aaron that was great thanks Dale thanks so much for hosting here on your podcast well that'll do it for the wilderness medicine podcast a production of the wilderness medical society get your CME credits by filling out the CME form and do the questionnaire for credit until then see you next time