Alexandra Williams, University of British Columbia, Canada

https://doi.org/10.36866/pn.112.30

Global Research Expedition on Altitude Related Chronic Health, or Global REACH, is an international collaboration of academics and physicians from 14 institutions across Canada, the UK, the US, Peru and Nepal. While the ‘Global REACH’ title is relatively new, its leaders have conducted a multitude of expeditions over the last decade to Nepal’s Himalaya, California’s White Mountains and now Peru’s Andes. With a collective interest in heart, lung and vascular health and altitude medicine, Global REACH’s collaborations ultimately aim to understand how the human body adapts, or maladapts, chronically to the low oxygen environments of earth’s highest altitudes.

I am writing this from 4,330 m, at the Laboratorio de Cerro de Pasco and Institutio de Investigaciones de la Altura in Peru. Our team of 40+ researchers, trainees, PIs and physicians are currently conducting ~20 studies examining heart, lung and brain physiology in lowlanders (us) and Andean highlanders with and without chronic mountain sickness. This article, however, does not intend to outline our experiments or specific scientific findings, which have been described in a recent issue of Physiology News. Instead, the reader will get a raw,
‘behind-the-scenes’ look at what transpires on these expeditions: the challenges we face, the experiences we gain, and most importantly the team values that drive the success of these international collaborations.

30 June 2018, day 1 at altitude.

Yesterday, the last of three groups of the Global REACH team drove from sea level in Lima up to 4,350 m in Cerro de Pasco, Peru. Amongst the team, some individuals are feeling ‘okay’ (say, a rating of 7/10), others have been in bed with splitting headaches for more than 24 h. We would later discover that one, in fact, had a bout of pneumonia. Nevertheless, one thing remains constant across the team – the excitement. It is palpable. Seven lab bays are set up, participants are being scheduled in, the equipment is (mostly) accounted for and working. Data collection has already begun today, and our first Andean participants are coming in tomorrow morning. This is what we came for, and we’re ready for the fun to begin.

For those who haven’t experienced the thin air of Earth’s highest mountain ranges, a 7-hour jump from sea level to over 4,300 m altitude is significant, one which often eaves individuals feeling much worse than‘not great’. Yet, with advanced knowledge of the side effects of altitude and hypoxic exposure, Global REACH members have joined forces to answer a plethora of physiological questions. For many, this will mark more than four expeditions to high altitude, a select few even in the double digits. In the first few days, most – including our team leaders – will have headaches, nausea, sleep disturbances and apneas. The inter-individual variability of these symptoms is quite high, as a select few may feel fine, most will feel some magnitude and combination of the list, and others will be periodically out of commission.

So, why do we do it? Why do we involve ourselves with the potential suffering at altitude and any additional risks (i.e. transport, illness) kindred to these trips? From my experience, three fundamental elements outweigh the risks and define the successof expeditions and collaborations like Global REACH: the science; the experience; the team.

Science

1 July 2018, day 2 at altitude; 08:32 h

‘MAS FUERTE MAS FUERTE, yeah Johnny!’ Johnny, our first Andean participant is
laying on the bed of testing Bay 1, currently practising a handgrip protocol for a vascular study. Johnny already has a venous catheter placed in his forearm and will be shuttled through a screening circuit: ultrasound imaging (cardiac, ocular and vascular), a maximal exercise test and assessment of total blood volume. Our Spanish skills are currently dismal, but we’re managing to compliment the amazing work of our translators to collect a large cardiovascular dataset on ~50-60 Andean participants.

3 July 2018, day 4 at altitude.

Four of us are working in the bloods room to measure total blood volume, hematocrit and viscosity. We knew from previous reports that Andeans would have augmented total blood volumes and hematocrit levels compared to us lowlanders but seeing those bloods ourselves was staggering. ‘A hematocrit of SEVENTY-EIGHT per cent!’ a colleague yelled, astounded. For reference, a lowlander’s normal hematocrit is ~40%. (Fig. 1) 

An undeniable passion for physiology underpins collaborations like Global REACH. The energy amongst the group drives impressive productivity and allows us to complete multiple studies in relatively restricted time periods. During the 2016 Nepal Expedition our team conducted 18 major studies, including a total of 335 study sessions in just three weeks at 5,050 m (further to multiple sea level and ascent testing sessions). This high-density data collection is relatively uncommon outside of field work and is only made possible by the vast breadth of technical fluency, specific expertise and research experience amongst the team. The expeditions allow us to not only answer our current questions but further breed a multitude of ideas for future study. ‘We could answer that one next, Ethiopia 2020? Another Nepal expedition?’

Of course, these expeditions allow us as trainees and investigators to be productive, and to present and publish high-quality data and exciting findings. They strongly contribute to our development and career progression in academia. But what is undoubtedly most important is the greater aim of Global REACH: to understand altitude health on a ‘global’ scale. This collaboration and research ultimately aims to understand why chronic mountain sickness occurs, how different high-altitude communities have adapted (or maladapted) to low oxygen, and what might ultimately be done to improve the health of individuals exposed to acute or chronic hypoxia.

Experience

1 July 2018, day 2 at altitude; 13:17h

The viscometer is being set up in the bloods room and is a key weapon in our arsenal for primary outcome measures in multiple studies. Due to voltage differences (compared to Canada) the unit needs to be connected to a step-down. We connect the viscometer, water bath and the step-down, and at first all seems to be functioning well. A few minutes later, an odd scent emerges. Ah, the step-down is smoking, not good! This unfortunately is not the first fire hazard we’ve encountered. In Nepal, one of our technicians had to rewire most of the outlets to ensure they wouldn’t catch flame. A few days ago, an outlet connected to a locally-made space heater went alight. We are constantly having to double- and triple-check that our equipment doesn’t melt due to poor electrical wiring, or mismatched voltage inputs/outputs. At the same time, though, we more often find ourselves very thankful that we have electricity to power the large volume of studies being conducted in these remote locations.

Figure 2. Performing a carbon monoxide rebeathe test to measure red cell volume and total blood volume with an Andean participant in Cerro de Pasco. This method is technically challenging, and is made more difficult with a significant language barrier.

These expeditions provide comprehensive research experience and encourage growth amongst the team and its individuals. Things are not always sunshine, rainbows and unicorns, though the many logistical hurdles provide an opportunity for learning and developing our problem-solving abilities.

We often must think outside of the box and utilise our creative capacities to circumvent roadblocks, technical difficulties and unexpected challenges.

Aside from common technical conundrums, there are often cultural barriers that are both interesting and of course region-dependent. One obvious challenge is language – in Nepal, this was less obvious because many of the porters and Sherpa required some English for their work in tourism. Surprisingly to us, Peru has proved much more difficult, as virtually no one in Cerro de Pasco speaks a language other than Spanish. In fact, the local residents have an accent that is ‘poquito’ difficult for our translators to understand, so trying to explain protocols can be tricky. For example, measurements of total blood volume using the carbon monoxide rebreathe technique require the participant to complete a few steps: fully empty the lungs; attach to the spirometer mouthpiece; turn the valve; rapidly fill the lungs and hold for ten seconds; breathe normally for two minutes into the spirometer; then empty the lungs and turn the valve to close the system… all without breaking the glass spirometer (Fig. 2). Simple, right? Not so much. Despite our efforts to perform practice runs and explain the protocol several times over with physical demonstrations and translators, this is notably challenging.

While these international expeditions allow us to become immersed in a different geographical and cultural environment, certain local traditions or values unbeknownst to us can provide unexpected barriers. In Nepal, the Sherpa were incredibly kind, and almost always smiling. They would seldom show negativity or utter complaints. One of our prime focuses on these expeditions is to examine blood markers of inflammation, blood gases and hematocrit concentration. In Nepal we collected serial arterial and venous blood samples at every stop during our ascent, but in Pheriche, one stop before the Pyramid, the Sherpa began to show concern, some requesting to skip the blood draws. We would find out the Sherpa perceived blood as their lifeforce, and that once lost, blood could not be replaced. They believed the loss of blood would weaken them and impair their state of being. One translator mentioned the word ‘vampire’ and explained the concern that their blood might be sold. Luckily, with the help of our lead Sherpa and a few of the elders, we were able to convey that the bloods were solely used for research purposes and that we would never take more than necessary for study.

1 July 2018, day 2 at altitude; 16:05 h

I look over after completing one great blood volume test on the fourth Andean participant today (we’re getting more effective at translating) and the viscometer is now working, with a step-down that isn’t smoking! Turns out the previous step-down was pulled off the shelves of the Cerro lab. We’ve found one of our own from Canada and it has worked like a charm. With a bit of flexibility and a sprinkle of luck, these things often happen to work out.

Despite the aforementioned challenges, these expeditions provide overwhelmingly positive experiences, opportunities for personal growth and adventure. As researchers, we gain incredible organisational skills: much like a game of Tetris, we learn to schedule participants amongst multiple studies, ensuring a fine balance between efficiency and crossover, i.e. that no measures conflict with other studies. Our communication skills grow as we continually coordinate between our local contacts, the P.I.s and the rest of the team. Even when things go completely off-plan, we learn to utilise flexibility and make the best of challenging situations. This field-based research teaches us quick-thinking, adaptability (no pun intended) and resourcefulness. The challenges themselves provide strong learning experiences to be applied moving forward.

Perhaps the most obvious and enticing draw of these expeditions is the element of adventure. Not surprisingly, team leader Phil Ainslie’s initial involvement in altitude research was borne from his job as a mountain guide before attending university. ‘The first (trip) was when I was 22 or 23… I was running a trip in northwest India to some peaks at 6,000 m or 7,000 m. Damian (Bailey) was my instructor and he asked, ‘would you collect some blood samples’? And I said, ‘sure’. I spun samples down with a hand-crank centrifuge at 5,000 m on 25 people and took (saturation) measures, just me. And brought it all back. I’ve gone back (to altitude) every few years since.’ Following Phil’s lead, these expeditions allow us to explore incredible regions and share awe-inspiring experiences with our international collaborators. Visiting Everest Base Camp or climbing a (slightly dangerous) hill to look out at the Andes creates a bond of friendship and provides the foundation for long-lasting international collaborations that define Global REACH.

Team

9 July 2018; 21:53 h

Myself, Phil Ainslie (University of British Columbia), Mike Stembridge (Cardiff Metropolitan University), Craig Steinback (University of Alberta) and Jonathan Moore (Bangor University) are sat in the lobby of our hotel, chatting over a few Cusqueña beers. While discussing the 2016 Nepal Expedition, I explained how impressed I was that a group of 37 individuals had worked so well together, with no obvious dramas despite living in a harsh environment.

It’s similar to the New Zealand All Blacks values… basically the ‘no dickheads’ rule’, one of us said. We all laughed, then nodded in agreement. ‘Well, much like in mountaineering leadership, a mantra of the All Blacks rugby team is that they ‘sweep the sheds’, meaning that it doesn’t matter if you’re the star player – everyone on the team cleans the dressing room. If you’re a dickhead, if you’re not a team player, you’re not part of the
All Blacks.’

Phil has explicitly provided permission to include this conversation in the article, because while blunt, this type of value characterises the core of our collaborations and ensures the success of the expeditions. When everyone works together, dismisses ego and shares positive energy, the team thrives. Sixteen-hour testing days become relatively easy when you’re having fun.

Our team is at the heart of our success. We embrace collaborators with infectious personalities that border on the sides of eclectic and hyperactive: those with a genuine passion for research and zest for life. Team members remind each other to look beyond the academic pressures of funding and publication for the sake of career progression and light a fire and excitement for discovery. Our peers drive us to new heights, literally and figuratively, in our academic prowess. We find less pride in our individual successes than in those of our teammates.

Our leaders – Phil Ainslie, Mike Stembridge and the late Christopher Willie – continue to inspire us. Their energy brings the continents together to create impressively cohesive and brilliant multidisciplinary collaborations. Their teams will continue to go global and reach for answers to important health-related questions at Earth’s highest altitudes.