Adventures — 12 March 2017 at 8:05 pm

Expedition Medicine (Dis)Organisation

Erin Kilborn / Registrar in Emergency Medicine / QE University Hospital, Glasgow 

Expeditions are rarely unqualified successes. Often it takes some time to truly appreciate the value of any experience. However, to avoid having a rough one, please read Erin Kilborn’s tale of a river trip to Puerto Prado in Peru and benefit from some of her lessons learned.

Looking for an adventure? Somewhere remote, exciting, and a road less travelled? What if you are interested in learning about new cultures, indigenous peoples, conservation and nature?

How would you feel then if an organisation approaches you offering exactly these? Particularly if, on the surface, their profile is impressive: trips to remote islands on sailboats, camping on isolated beaches and living off the land, travelling by down rivers through Mexican jungles, and an ethos that speaks to you.  They collaborate with artists, environmentalists, scientists and naturalists, sharing a common taste for discovery and working together with local people. They even have a TED talk. It may be vague but it is inspiring, and it grabs you.

Can you blame me that I got hooked? I thought I had experience: I’d been expedition medic for three months with Raleigh in Borneo in 2012. And the following year I’d worked as the medic for a burns unit in Port au Prince, Haiti, with MSF for six months. My background was primarily in emergency medicine, working as a doctor in a very large and busy Glasgow-based hospital, and I had just finished a year in anaesthetics and ICU – I felt confident.

The organisation’s founder and leader contacted me and we set a date for September 2015. I would be medic for a team of artists working in the Peruvian Amazon in a remote community of Cucama Indians. The plan was to travel down river for a couple of weeks and explore. I was so excited, I even bagged a place on the trip for my partner, an adventurous type I had had met working for MSF in Haiti. The selling-point was his good Spanish.

Planning

I wrote a pre-departure booklet with advice for the participants regarding vaccinations, antimalarial prophylaxis, all the usual advice based on my experiences with Raleigh and expedition medicine courses.  I sent out health questionnaires but never saw a single response, despite chasing them up.

The organisation sent me their kit list (it would all be provided). They had a reasonable selection of medications and dressings. Several items needed replacing, and some key things were missing. I contacted them with my feedback. Assured they’d take care of it, I later discovered that a young non-medical Mexican group leader would go to the pharmacy in Peru to track down the missing/perished items. Of course, things like EpiPens are not available in a remote river town in the Amazon basin, but somehow she found a vial of adrenaline, no dosage marked on it, and no date. I’d have to make do. Most of the medical kit ended up arriving several days after the team, various glass vials and boxes, packets and foil-wrapped pills all shoved together into a large dry bag with little protection. Nothing for disposal of sharps. A couple of bags of IV saline, no giving sets.

The team were all lovely, though perhaps slightly off-the-wall characters. One of the artists had spent the ten days prior to meeting us at an Ayahuasca retreat, so was still flying high when we met, complaining of a mild stomach upset that lasted about a week.

Food and Water

The Cucamo people hosting us in the village were incredibly friendly and very accommodating, preparing fresh food for us most days, though there was never enough. It was not clear to me what the arrangements for food were supposed to be, but we were quoted stories of previous trips where they’d gathered coconuts from the jungle and survived on handfuls of trail-mix made by the two young Mexican girls who were our stand-in ‘leaders’, as the guy who had called to recruit me wasn’t able to make it on this trip. Water too was an issue, as I discovered that each day we were in the village, it was the villagers who would go and fill a large container for us which would be purified and filtered.

There was no clear plan. Eventually, after several days of hard work trying to carve our own (way too heavy) wooden oars, we set out on the village leader’s fishing boat – a heavy motorised machine- that we were supposed to paddle. As we largely floated downstream slower than a lazy sloth, morale was variable. We did see pink river dolphin, and had the beautiful experience of a refreshing swim in the amazon near a shallow sandbank, watching jumping fish and local birdlife alongside the river.

But we didn’t have enough food, we didn’t have enough water, we didn’t know what lay ahead or where we would sleep. That was ‘part of the fun, part of the adventure’. Now, I’m all for adventure, but as a doctor, I know that lack of preparedness is what leads to problems. There was no communications equipment, not even a mobile phone that would function in such an isolated region, and certainly no radio or satellite phone. I wasn’t aware of a common pot of cash in case of emergencies, either.

Eventually, taking advantage of the kindness of an incredibly poor family, we were invited to set up hammocks for the night in their open wooden bungalow. As dusk fell, I have never seen so many mosquitos. We were offered food, and we repaid their incredible generosity with bracelets. Yes, bracelets. I’m still dumbfounded to this day.

MEDEVAC

The following morning, one of our team (incidentally, my boyfriend Basil) fell sick with a high fever. He felt slightly better with water and paracetamol, so we pushed on in the boat to another village, San Joaquin. We found a small shop and bought some warm cokes, but by now his temperature was rising despite the medication and he started vomiting.

After exploring the bare bones local clinic in the village, I decided we had to evacuate him. We were at least three hours downstream from the nearest town with a reasonable healthcare facility. I dosed Basil up with more paracetamol and antiemetics, which promptly came straight back up. I checked the medical kit: vials of cyclizine were all I had; there was no diluent.

The MEDEVAC was a nightmare. By the time we found a boat we could use to get back upriver to the larger town of Nauta, it was almost dusk. There was a storm brewing over the river with tempestuous heavy purple and black clouds overhead and a quickening wind.

We bundled a very weak, dehydrated Basil in between bags into the centre of the boat; essentially a dugout canoe with a motor on the end of it. The boatman’s wife sat with a small container, emptying water out of the back as the waves splashed up into the boat. The two Mexican leaders both decided to abandon the village and the rest of the team to accompany me, leaving the group of artists with not enough food, not enough water (and all the Lifestraws in one of the girls’ packs) and no communications. They did have the big heavy boat and the boat’s owners, our host village leader and his son, with them. And luckily, two of the artists were prepared with a supply of water purification tabs and a few cereal bars. To be honest, they had more expedition and outdoors wilderness experience than the two Mexican girls.

We made our way upriver, the storm gathering and night falling. Jumping fish all around the boat, one landed in my lap, another smacked one of the girls sitting up in front of me on the head. A large spider crawled out from between the bags and made its way up towards the girls, provoking mild panic. Luckily neither spider nor girl was harmed.

At points, the boat journey was strangely beautiful, with glow-bugs like little stars just above the water and birds and bats dancing in the sky catching insects. But as a thick, heavy darkness fell, and the pressure of the storm increased, we depended on the light of our head torches to navigate the inky black river and avoid the perilous driftwood. We arrived in Nauta just as the tropical rains finally burst and the river became un-navigable. The town roads became murky brown rivers.

Nauta Hospital

The hospital was a relatively good facility and the staff were knowledgeable and well trained. Basil was placed on a trolley, his legs poking off the end as Peruvians are generally not as tall as 6ft Frenchmen. He lay exhausted while they took blood for malaria and dengue fever and treated him with fluids and antibiotics. Luckily, it was nothing more sinister than a tropical gastroenteritis, but he had lost about six kilos in ten days and was very dehydrated.

We stayed in a hotel for two nights to give him time to recover, before returning to the village and finding the rest of our team. They were livid with the leaders, and rightly so. They decided to remain in the Cucamo village for the remainder of the trip rather than attempting further river excursions. Given their proximity to Nauta, the town with the hospital, I decided it was safe to leave with Basil and return to Lima. He needed time to rest properly and recover, especially as we had discovered after two days that food supply remained an issue. I too had lost about four kilos, and that was without being sick.

Lessons Learned

Despite all this, the trip had many beautiful moments. I ran a first aid workshop with the community and treated a handful of simple infections and mallet-finger injuries (the community played a lot of volleyball!). The jungle walks with the village leader’s son, a trainee shaman, were beautiful beyond words. Their knowledge of the environment and the medicinal plants was extraordinary. And the wildlife was spectacular. But there were some major lessons learned.

Do your research / It should have been telling that despite several requests to contact the last doctor who had worked with them, I was never given his contact information. I don’t know if this would have changed anything, but it is interesting in hindsight. The organisation was very media savvy: their website, Facebook and Instagram feeds were slick and professional, so it was hard to form an accurate impression.

Medical kits / If you are not providing your own kit, then ensure you get to see the organisation’s one prior to setting off. Although I thought we had done this through via email, they hadn’t upheld their end of the bargain. In case of doubt, bring your own medical kit with trusted equipment, drugs and dosages that you are familiar with. Simple things like a glass jar with a lid can be used to store sharps until you can dispose of them appropriately. Storage and labelling is key, especially in a jungle environment, and plastic containers and various small coloured dry bags are useful to store medications systematically.

Emergency planning / We didn’t have an exit strategy, no Plan A, never mind Plans B-Z! I tried to engage the leaders in planning for an emergency but was always brushed off. Stand your ground. If you think a trip is unsafe for any reason, whether it’s lack of planning and preparedness, poor kit, lack of supplies, or anything else – call it off. The expedition medicine community will back your decision. Ideally you should also try to familiarise yourself with medical facilities in the area and contact them before you set off.

Into the Unknown

At the end of the day, adventure and exploration are wonderful, but when you are the medic responsible for the wellbeing of a group, it is your job to be prepared.

I have purposefully not identified the organisation, as it’s hard for me to know if my experience was a one-off. Following our return, I tried to express my concerns to the head of the organisation but received a generic copy-paste reply that did not address any of the points raised over the safety of the trip. Never once did they ask how Basil was, or if he had recovered well.

The Unknown is a tantalising and seductive idea, but should not be an excuse for a total disorganisation. To me, the worst part of the expedition experience was the feeling that we took advantage of the indigenous people. Bringing the basics does not mean not sharing with the community, it simply means being less dependant on their kindness and charity. We could have offered more of our time and skills, instead of being a burden for basics such as food, water, sanitation and transport needs. The villagers needed time to concentrate on their own needs, not to meet the needs of outsiders as well. In all, I felt there was a severe lack of cultural awareness and sensitivity, and that was shameful for an organisation that prided itself on working with communities.

A happy ending

After the expedition, fellow participant Karen Lofgren, a California-based artist, took matters into her own hands to continue supporting the community, helping them to realise some of their development goals.

In November 2015 she set up a crowd-funding site to help raise finances to buy building materials for the community and create the ‘Amazon Samiri House’- an eco-lodge for visitors coming to the community. The project successfully raised all the necessary funds, and building is almost complete.

Since we left, the village of Puerto Prado has many new projects including a building that serves as a solar charging station/public living room for the community and visitors. They have added another new Maloca and bridge beside the Victoria Regia pond, and have built new fancy bathrooms behind them.

They also have now a partially-functioning clean water system, filtered from their spring to a large holding tank. The size of the pipes (too small to fill the tank in less than eight hours) and gas-fueled generator needed to pump the water means it’s not as effective, ecologically friendly, or sustainable as the community wanted. But it’s a step in the right direction.

Hopefully the community will continue to benefit from ongoing investment and development with the aid of various partner organisations and individuals, helping them protect and sustain their traditional way of life in parallel with an ever-modernising world around them.