Raju Raman and Zoe Hulme
Coral Cay is a marine conservation charity with projects in the Philippines, Cambodia and Montserrat. In this article, Raju Raman and Zoe Hulme tells us about their time with them as Medical Officers on the island of Southern Leyte in the Philippines – from anemones to ear infections.
Between February and August 2013 we were employed as Medical Officers on the island of Southern Leyte, in the Philippines, with the UK-based not-for-profit organization Coral Cay Conservation. We had had various overseas jobs in the past: one of us as a field biologist, the other a divemaster, and both had worked as boat hands. Our medical/nursing training had been in the UK, though our most recent jobs (as A&E SHO and ICU nurse) had been in Aruba, in the Caribbean. Whilest searching for work online, we stumbled across the Medical Officer post with Coral Cay:one skype interview later, we were on our way to a job combining field biology, diving, boats and medicine, in the land of palm trees, pristine coral reefs and eternally smiling people.
Coral Cay Conservation runs three international projects (in the Philippines, Cambodia and Montserrat) where environmental survey work is combined with local awareness-raising and education to promote the sustainable use of rainforests and coral reefs. At each site, a core team works alongside a variable number of volunteers, most of who come from Western Europe or North America. Although staff members have different roles (e.g. science, education, medical) all are encouraged to undertake an intensive, two week Skills Development Programme (SDP) on arrival. Staff who have not dived before should also be prepared to take PADI dive courses. Once SDP and dive training have been completed, all staff are expected to dive twice a day as part of reef survey teams, as well as helping new volunteers through their own SDP.
At the reef
Our first 12 hours on site involved a handover from the outgoing medical officer, a general induction from the Field Based Manager, and a fascinating lecture from the project scientist on the many venomous creatures inhabiting the reef. We wondered how long we could keep someone alive if they were bitten by a sea snake or a cone shell (common reef inhabitants, and some of the most venomous animals on earth) many hours from the nearest hospital… It is for this reason that Coral Cay recruits medically qualified staff, and provide a comprehensive medical kit including oxygen, fluids, adrenaline and other drugs. Evacuation plans are in place at all sites to transport casualties to a receiving medical facility, and everyone on site has to undergo a one day remote-area first aid course to be able to assist.
After handover and induction, we launched straight into SDP. With heads buried in fish identification books and reef guides several hours a day, a list of over 40 Latin names of corals to learn, and pass-marks of 80-90% for both written exams and in-water validations, this was easily the most serious studying either of had done for a very long time! But the programme was hugely rewarding. No matter how much you have dived, a coral reef becomes even more exciting once you start to understand how it works: how a clownfish avoids being stung by the anemone in which it lives; how corals harness solar energy through tiny, symbiotic algae living inside them; how this fantastic, fragile ecosystem is affected by environmental change; and how it can be protected.
The surgery is open
We received a daily trickle of consultations. Headaches, diarrhoea, minor allergies – the usual ailments of any expedition in a tropical region. More interestingly, skin infections. Everybody, without exception, gets infected. Soft tissue infections would start as either insect bites or minor wounds, often abrasions obtained while entering and exiting the water. In the humid tropical environment, and with constant exposure to seawater, these wounds would fester very quickly, frequently becoming abscesses. To avoid every member of the expedition relying on antibiotics all the time, we promoted old-school methods: hot compresses to help expel pus, iodine, topical antibiotics. On many occasions, this worked well, at least for a while, but often the patient would end up febrile and we would be forced to raid the drug cabinet. Antibiotic choices were not straightforward. Flucloxacillin was rarely available locally to replenish our stores from the UK, and extremely expensive when it was. Amoxicillin was cheap, co-amoxiclav very expensive. In the end, we relied heavily on erythromycin (readily available and cheap, while clarithromycin was rare and expensive), with which we made a lot of people either very hungry or very sick.
A more important problem was “marine” infections: the marine microbiome is very different from the terrestrial, containing (for example) many Vibrio bacteria which are not sensitive to beta lactams and macrolides. They require other antibiotics such as doxycycline (not fantastic in the sunny tropics), co-trimoxazole (with its many side effects) or ciprofloxacin. In the absence of a lab, the antibiotic “trial” was the only investigation we had, and we frequently found ourselves switching drugs when infections worsened or failed to improve. Occasionally, incision and drainage was needed, and we were lucky to have plenty of lignocaine, as well as bleach and boiling water to sterilise instruments.
Just as there was no-one who did not get infected, there was no-one whose tympanic membranes we did not become intimately familiar with. Ears are a huge issue with daily diving: middle-ear barotrauma happens easily with constant pressure changes, and the warm, bacterial ocean seeds a lot of otitis externa. Occasionally, someone would manage to bloody their middle ear quite impressively, and would have to be kept out of the water. But “grounding” volunteers for every niggle in their ear would have trashed their expedition, and on many occasions we would advise people that they could dive, provided they descended extremely slowly, equalised often, and aborted their dive if they experienced any pain. “Just how red does an ear have to be to prevent diving?” was perhaps the most difficult question we faced: honest discussions of risks, strict advice on descent, and regular review (three or four times daily if necessary!) were the only solution.
Very rarely, we would be required to assess a diver who had ascended too quickly. There are very strict standards governing dive times and depths, but occasionally an untoward situation can cause a diver to panic and ascend too quickly, risking lung overexpansion injury and decompression sickness. These, along with the bites of venomous creatures, are the primary life-threatening illnesses for which medical cover is needed on dive expeditions. Our nearest decompression chamber was on the island of Cebu, and as helicopter rescue is rarely available in Southern Leyte, this would have meant a journey of up to 12 hours by land and sea. Happily, the few dive “accidents” that occurred when we were there did not require transfer to the chamber, requiring only observation and regular re-assessment at the site. We benefited hugely from the remote advice provided by the UK-based Diving Diseases Research Centre (DDRC), whose work is described in detail by Dr Louise Wade in a previous Adventure Medic article. Access to this as an expert backup facility was handily provided, as well as a remote telemedicine service to obtain support from UK-based doctors whilst overseas.
Do it yourself
Coral Cay Conservation regularly recruits medical officers for all three of their international sites. If you are interested, the post is open to nurses, doctors or paramedics, and some experience of emergency medicine is desirable. We would advise anyone considering the post of medical officer to do some serious reading about marine emergencies. Be prepared for a good deal of clinical uncertainty, and be flexible with treatment plans; be interested in coral reefs, conservation, and people; and you must be happy to get stuck in to some serious science training in the process. For more information about working with Coral Cay, visit their website, where you can also read their statement about how the recent horrific disaster in the Philippines has affected them and the work they do.