A Life at High Altitude: A Conversation With Todd Bull and Peter Hackett

In this special discussion for the PHA, Guest Editor Todd Bull, MD, spoke with Peter Hackett, MD, of the Altitude Research Center, Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Anschutz Medical Campus in Aurora, Colorado. Dr Hackett is a leading authority on altitude illness with years of experience in high-altitude settings both abroad and in the United States.Dr Bull: It’s a pleasure to be talking to Dr Peter Hackett, who is, without a doubt, one of the most renowned altitude researchers here in the United States, with a long and storied career. He has greatly contributed to what we know about the physiology and impact on humans as they ascend to higher and higher peaks. We’re going to discuss aspects of his career and interests, exciting moments, and directions that we think the field is moving toward.Dr Hackett, welcome. Let’s start with a question about your early career. How did your work in altitude initiate? Where did your interest in the area stem from, and how early on did you find yourself investigating the physiology of high altitude in humans?Dr Hackett: I’ve had a pretty unusual career. My love for the mountains is what propelled me into high-altitude medicine. That started at a young age when my grandparents took me to Colorado on a camping trip and I fell in love with the mountains. After medical school, I decided to go to San Francisco for my postgraduate training because it was close to Yosemite. Of course, during those years, I think I got 3 days off in my first year of training and was able to run up to Yosemite a couple of times.After my internship year, I decided to take a break and went to Yosemite and became a helicopter rescue doctor. My training then was mostly in trauma and emergency medicine. I had a great summer fighting fires and doing rescues from this tiny helicopter. This was back in the mid-1970s, before it got very sophisticated.One fellow I rescued, who had fallen on a climb and broken some ribs, owned a company called Mountain Travel, and he needed a doctor to go to Nepal with a trekking group for 3 months. At that time, I decided not to return to my medical training and went to Nepal. I ended up staying for most of the year, working as a volunteer doctor at this little aid post at 14 000 feet on the way to Mount Everest. There were about 3 or 4 families in this tiny little village, and I stayed there for most of the year.I saw all these people coming down with this weird virus on their way to Everest. When they got to about 14 000 or 15 000 feet, everybody started getting headaches and some nausea and vomiting, and they weren’t sleeping and were short of breath. I couldn’t understand what was going on until it finally dawned on me that this was altitude sickness. At that time, it was very little known. There was one paper in the New England Journal of Medicine from the experience of the Indian Army, Indira Singh, talking about altitude sickness, and that was about it.I realized I was in a unique position to start collecting data and epidemiology and risk factors, and even treatment. I didn’t quite know what I was doing, but I got a little help from John Dickinson, who was a British missionary doctor in Kathmandu at the time. When I eventually came back to the States, I had this box full of questionnaires and physical exams, and I took it to Drummond Rennie in Chicago; he had published on high-altitude physiology and retinal hemorrhages and a little bit on cerebral edema. I collaborated with him, and we wrote up a paper, and it was the lead paper in The Lancet in 1976, called “The Incidence, Importance and Prophylaxis of Acute Mountain Sickness.” That launched my career, really. I became published at the age of 27 in a lead article, and it was a great opportunity. Then I had to make a decision about what I was going to do because I was developing a passion for the mountains and for altitude illness and keeping people safe.I saw a number of deaths, and it really impressed upon me that perfectly healthy young people could go to altitude and die of pulmonary edema for no reason other than that they’d gone up a little too quickly. I was totally engrossed in this and decided I really needed to learn more about it. I approached Bob Grover and Jack Reeves, who were at the University of Colorado in the Cardiovascular Pulmonary (CVP) Research lab. They agreed to take me on as a fellow. A few months of that fellowship was taking them to Nepal to collect data and samples. We did hundreds of hypoxic ventilatory response tests manually with spirometry, and we had one of the early Hewlett-Packard ear oximeters, and we were able to do urine and plasma osmolality. We published a bunch of papers out of this research in Nepal, having to do with altitude illness.With Grover and Reeves, I really learned about research, about how to critically review literature, how to do literature reviews, form hypotheses, how to test things, learned some statistics. That really was what launched my career in high-altitude medicine. After that, I worked clinically in emergency medicine and became boarded in emergency medicine, but I always had this interest in pulmonary physiology, especially the pulmonary circulation.From there, I eschewed academic departments. It wasn’t consistent with my lifestyle of going on expeditions every year as well as interests in field research. That took me to places like Mount Logan in the Yukon with Charlie Houston, and I started a project at a 14 000-foot camp on Mount Denali, funded by the National Institutes of Health, where we saw quite a few very ill climbers with pulmonary and cerebral edema. It was there that we did the first bronchoalveolar lavage in high-altitude pulmonary edema (HAPE) and also studied vasodilators for treatment. I was there for 8 summers. I was with John West and his American Medical Research Expedition to Everest in 1981, in which I summited Everest and collected data all the way to the top. We made quite a mark in the field of high-altitude physiology and published a large number of papers and a book that many of the American Thoracic Society people will be familiar with.So that’s how I got started. It was my love for the mountains and a burning intellectual curiosity. What is it about high altitude that causes people to develop these life-threatening conditions? How do we make high altitude a safer environment and practice clinical medicine in the mountains? It was a nice combination of a passion for wanting to help people as a physician and my love for the mountains and climbing activities and trekking.Dr Bull: That’s a fantastic story and intro, and actually, it highlights a couple of important points. One is that research favors the prepared mind. Here you were at a clinical station, and you noticed a series of events, this viral illness, and you decided to dig into it and developed questionnaires regarding it and looked into physical findings, leading to an important early publication. So your clinical observations and then curiosity launched this career.The other fascinating aspect to me is that I imagine, after your fellowship, there was probably some pressure to move on to a junior faculty position and start writing grant awards and work your way up the academic ladder, but you followed your passion and went in a different direction that was highly productive and successful. Was that encouraged or discouraged? Did people say, “There’s no way you’ll stay in research if you go in that direction”?Dr Hackett: I thought you might pick up on that as an academician. There a of young faculty and out there that, with the and of It’s to be in academic research at a medical and be both a and a It was made to me at the that a research junior faculty and writing as an and of the and the academic but it was also to me that I wasn’t really out for I had to in the and a take at 3 months a I wasn’t going to that medicine the at that because it was then a and it was to a and then back and The of not in an academic were that I didn’t all these didn’t to to a or a I could do my and didn’t to be in The of course, was that were more without I had to review I always be with a in some that I could their great if you a that you to about the or That’s when an and not in an academic but I was able to develop a of people I was working with in this I had to do it all I more productive if stayed in I published I a of data I a of papers I published I probably more the other I not had quite the career There Bull: What I my in talking about their is that you to find a and then if you your research on the that is the most way to because it your and my about to find the the clinical work many of also keeping the research going to help you the that always when you the prepared some will you to in on research, but where the or the is at the the that and then to It me that you were doing what you to do but then saw clinical that doing that, fascinating that you these the New England Journal paper about you a bit more about How did that about and what data were you Hackett: So this into humans at you do where you people into large for days or at a and the which is very and but more do hypoxic which not the as but it be and you do field where you take humans to high altitude to take people to high altitude to pulmonary but you do what I did in Nepal and which is by the as people by them because Everest by John was funded by the National Institutes of and the and the American and American and National and all of We had a large was to the of especially This was in At that time, there were not really of pulmonary but we did a of physiology, and and we looked at at altitude and and and and of different of the we made was the of the We didn’t a but we got with the of a special on the We into this and it a and then it. a to it. We collected and we also made the first of pressure on the which was higher than on the this how it could be without at that of year but also it be to climb in the pressure is at the very of hypoxic and the pressure and in were there in and like on all of these or Mount Logan or Everest or always always risk in going to that of altitude and yourself to that of We had a pretty time, and there was a of at the of the trip in we to the with We had a of work at camp at 000 feet and in the at 000 At 000 feet, the is in the high and we were doing was one of the few people that had or the of the trip to for a There were of a from and and We out for the and had a bit of an time. I ended up going to the by because the who was with me thought he was getting on his he and his were of and I couldn’t I ended up going by those there were no It wasn’t like it is with a all the way up to the top. It was a bit and his made it to the and on the way down they into I had gone out of and I we probably all go down for when you going to be this close to the I out of It out his had at He me an and I up my off was about and on it was more like or with at The of is on the we in these of hypoxic the to than My for was with a of and an of or a in the to the and more at the which is getting to the after a bit of on the which is a aspect of the It’s an about feet the This is where a of and we didn’t but I was able to it and realized I was going to to the because on the and I might not be able to about it because I had no and could die on the way It’s to like that than it is to climb up it.I and I was by I had to a to I was I took a down on the a It was quite and as you imagine, and it was getting about in the I had to out of the way I I was for about an off the when my got a little of and I was It was a I was able to eventually after doing what about I got my in a little of me and then was able to work my way down to the of the to who had for me a couple feet We made it back to high camp had to at all that because my was in my and I couldn’t it my because I had all this I had a and and That I had a I started and thought I had because I was in and I thought I was going to I ended up up a of my a my that’s one of the I’ve I had this that had my that then I could down and the and eventually the trip down to That was one of my I really like I from the and I was very John West is that I didn’t die because it the Bull: he had his in That’s quite a really had an what your was when you were doing on the Hackett: It was very you ascend to higher the and the The to do work is at which is what the of Everest My was about at that It was back When I it didn’t that, but my was about I could do about of Of course, it has to do with not The a which I at I was in an altitude at with and Peter doing a with a at 000 feet altitude on a at and I developed a and they thought it might the my or some of but then I went back and my from and I had a at 000 feet as Bull: Did you you were getting on this and doing as you were climbing to these high Hackett: we didn’t do We collected a on the at 000 feet before going to the and then we did the samples. were back to San and with We that the data quite We the down to the at at 000 feet, and then the other to and his in a project called Everest did do at 27 They couldn’t do them on the for They published their in the New England Journal because it was and they the that we than and from to about and of or It and I to it to them for doing those Bull: That’s that high and your as well as all that that was the data that your group published in and other as Hackett: It ended up in a few John West was the first on many of and he also published a book called The we published about papers from the Bull: What other you as of Hackett: I’ve clinical research to the of Mount with and in Colorado. That’s not an because you up there, but it has you there people expeditions were to American to the and in where we did a We in there with every year on and came off every be there for months. from the University of Colorado and I did that We were able to quite a bit of work We looked at the of on pulmonary pressure in people with and We people by in which out to be a very We in which is also not a did the first bronchoalveolar lavage in from University of in with and the we had to a one and take of it is an the was in and in It’s the in the a of was to We had to to stay out of the and we had very ill that we had to take but it was all very exciting and as was the Mount Logan project with Charlie in the We Mount Logan at feet, some and the to getting One of from there was published in the New England The was I into feet and that we my with the Hewlett-Packard ear and into the and The I took and we that it totally the and the of In the New England Journal article, the the on and the other without of my that was a very there were was but and on a at feet is Charlie was very as was John were very and we were really that you be familiar with the altitude that up in where you the the the you make it take people to 000 feet in a highly a safer to the for those who in high-altitude medicine, I think the field is really your interest is in or or or there is that be in of both clinical and the research, at and with which had a to do with high-altitude There is the clinical work with hypoxic in or the in a or in the There is to be learned about people at high altitude here in Colorado. We know the of pulmonary to the altitude in We know the of in in these We know about the and pulmonary We know how many people to the mountains because they and their as they and we know the there, but I take of a of those and some of them I to you at the University of Colorado Pulmonary for to at their pulmonary a to be and if your passion is of these that could be with high or like to be in the then it be a great Bull: What other do you for those the field Hackett: The I is to the training to start and find the It’s not There not many people doing high-altitude research, and not a of for it to go after the and find the and the if one is going to do research, they some training in research and and all that with it. My if is really about a by doing clinical or research, is to really down and some training in research before to do it or Bull: What the in of work or research in the Hackett: as with other to do with medicine has a bit of an It probably a of in the It’s more but it has to this that who do high-altitude research for an to go in the mountains. The way to that is with in research and really work because there is some to that I make a for getting really in research. That’s one in to and then the it for field the the with people critically ill with but you take of them if they it on their if you in the at the time, which is where my work came in and was also very and a great way to go because they be and you more but we worked out the and That’s a great in a who to in this they to find a of their or who the interest or at about high-altitude medicine. It’s very to go into a where you or you that there There not many places doing high-altitude research A young and passion to it going and develop their and break as we in the Bull: where do you think the What do we really to understand or know in the if you could a research Hackett: The important from to One could take their but one of the more fascinating is at altitude a great because perfectly It great The in high-altitude medicine in some aspects is to find by these of healthy humans at altitude or humans at altitude for your work in the That really is a a of work going at the of illness at altitude and and people with and and that of and That’s one a question you might from the and out how you could humans at altitude as a to help that, a got got hundreds of of people feet in Colorado and very little on what to their for and the for really more of a risk at or feet than at I all the from the and there is not a a of important work to be people in the mountains they their or those in or at with hypoxic or or other of Bull: I think the physiology of and pulmonary at altitude could help what doing or help in directions for those who or develop pulmonary Hackett: I think for a research project is at pulmonary is a in at high from my clinical practice that hypoxic pulmonary or high-altitude pulmonary a in in people and that, if you it with pulmonary talking about people in or in a has The to in or high altitude with for were not in of in and they no on It’s an important clinical question for Bull: also like to your on There were to the that this was like where altitude could like to your on or not that is the at with Hackett: There has some literature and a of discussion about is the as both pulmonary edema with There but the is one is a edema to hypoxic pulmonary with or as as we and the other is a viral with and of hypoxic pulmonary in with or with as and I published on that, and and and also for the for is and also in for but it pulmonary pulmonary and edema it not the of that pulmonary vasodilators that in might be in or at and I think where the altitude has the on the is in them that, like at high these not be and not but of the with at In these be than because they had some to to to at high I think with if it more than 3 or 4 days to develop they could it pretty well as long as not and not in with altitude experience to people with in the and of that be for the for the altitude and without clinical there and other but the to which people is think in New and other places at that experience of people that and to with of or pulmonary or other I do think that the altitude be these It’s the that humans them and you to that make Bull: The I think has to from how we in the the decision to is made on at the and taking in when first there was discussion after what was out of not what we were with to I think there and the at that do think an important I go back to the early days of and say, we didn’t to them on the when they 8 of or of of that, was that we were not to on or because we about the virus and at but we learned that the to was question I was going to is, what you most of to Hackett: I think the and the with to altitude illness for people going into the mountains. My paper in The Lancet in was and it to a that perfectly healthy people do when they go to the and they At that time, there were a of research, to the Medical Society and the Society for Mountain Medicine and the I that I’ve really to make going to altitude safer for people the not for but for and and everybody or at think I also the from physiology to the in the when I started writing about the of sickness, and research has on going on in the not a thought in the field has I about what I’ve able to in that One of my is that people going to help the to and if they out there, these and love the what they of I know what not getting the into publication. There in the because I wasn’t in I didn’t develop a of young or researchers coming up in this field to take and with clinical as well as high-altitude research. There many young wanting to into the and there many for of at academic and that’s probably my I had in we a with a of people coming up in the but there and an in high-altitude medicine all of that going to at altitude and for I a with on and published with the paper on cerebral and sickness. I on high-altitude the first and the first the in an as well as a to and many other all these fascinating taking at high people for in high-altitude of them was the and going to in wanting on with the that got me up with and I’ve one of their for many That’s a as they in the and fascinating how the of high-altitude medicine take you many

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