Adventures — 9 December 2016 at 10:28 am

The End of the Road

Dr Anne Brants / Emergency Physician, Netherlands

Dr Isla Madeleine Wormald / ACCS Trainee, UK

This article is a brilliant reminder of why expeditions are such a challenging and interesting setting in which to practice medicine. Anna and Isla have done a great job of summarising the lessons to be learned, many of which will ring true to first-time and seasoned expedition medics alike.

Anne Brants EBC

I had just finished a job as a doctor for a commercial guided expedition to Mount Everest and was undertaking some personal travel in Nepal. Early one morning I found myself at a bus stop in a one-street village approximately three hours away from Kathmandu. It was a popular place for a coffee break and buses were frequently coming and going. The buses parked on a slope leading to the edge of a ravine through which flowed a raging river. I climbed aboard a bus and was awaiting its departure when the rock behind the rear wheel that served as a break was removed. The driver was not yet in his seat so the bus full of people started rolling backwards towards the edge of the ravine. As the bus was accelerating and our anxiety grew. There was a crash. Instead of going over the cliff edge, the bus collided with the side of another parked bus. Chaos ensued as passengers rushed to exit the vehicle through broken glass.

On disembarking, I heard a shout for a doctor. I walked towards the commotion and found a young woman screaming in agony. The bus had hit her lower leg as she was alighting from the other vehicle. I undertook a rapid assessment of the patient. It seemed that a minor wound and an excruciatingly painful left lower leg were her main problems. As we prepared to carry her to the local clinic on a stretcher, the bus moved away and another casualty was revealed. This male patient was less fortunate and had been sandwiched between the two buses. Even though I had initially carried out a scene survey, and understood the mechanism of the accident, I was unaware of the second patient. Similarly, many other eye witnesses who volunteered their help were also oblivious to a second casualty.

The second casualty showed no massive external hemorrhage, was conscious, tachypnoeic, pale and had a painful left thigh. I did not have my medical kit to hand so my primary survey was limited to “look, listen and feel”. I decided that he was stable enough to scoop and run to the local clinic, which was staffed by a doctor and consisted of an emergency room with two beds. The female patient was left to have a cast applied and she made personal arrangements to be transported by helicopter to Kathmandu where X-rays would confirm (or refute!) my provisional diagnosis of tibial and fibular shaft fractures.

After undertaking a secondary survey of the male patient, I suspected that he had isolated fractures of multiple ribs and a fractured pelvis. This was evidenced by the mechanism of injury, his vital signs and my physical examination findings. The local male doctor was unperturbed by the mechanism of injury and did not believe X-rays were warranted. He decided to arrange an evacuation to Kathmandu for further investigation. I was concerned that despite analgesia and 2L of supplemental oxygen, the patient’s oxygen saturations remained stubbornly at 96%. However, now in a local clinic, my role had diminished to merely communicating with both patients. Whilst I was unable to convince the in-country doctor to obtain a chest X-ray (he appeared more anxious about a possible pelvic fracture than hypoxia caused by thoracic trauma), I managed to persuade him not to airlift the patient. The patient’s condition did not deteriorate after I had lingered for several hours and I was assured an ambulance was enroute, so I left the local clinic to continue my travels.

The following week I discovered that due to the long wait for a road ambulance, a last minute decision was made to airlift both patients to Kathmandu in the same helicopter. During the flight no medical personnel were in attendance and the male patient began to drift in and out of consciousness. On arrival in Kathmandu he had developed a tension pneumothorax, requiring immediate treatment.

Lessons Learned

There are lessons to be learned from this tale:

Beware RTAs / Whilst on expedition, in-country transport is likely to pose the greatest risk to the health of you and your team mates. Road traffic collisions are a leading cause of death globally, and the main cause of death in 15–29 year olds. Furthermore, 90% of road traffic deaths occur in low- and middle-income countries despite these countries only having 54% of the world’s vehicles! (1)

Prepare for the worst / Be prepared to encounter the worst-case scenario, so that you are never taken by surprise when far from help, whilst being mindful of your safety, competence and the availability of other options for care. (2) Having a ‘grab bag’ to-hand will aid preparedness. This should comprise medical kit required for the pre-hospital treatment of medical and surgical emergencies and should be appropriate to your experience and level of training.

Situational awareness / Being situationally aware is imperative during the practice of extreme medicine. In the case above, despite being conscious of the physical dangers present and understanding the mechanism of the accident, we lost situational awareness through becoming distracted by and focusing on caring for a vocal casualty with a lower leg fracture. It’s a cliché, but when multiple casualties are present, those that shout the loudest are invariably not the most unwell.

Structure saves lives / We know, but often forget when out of hospital, that a structured approach will ensure that the greatest threat to life is identified and treated first. The local doctor did not follow this procedure and focused on addressing the hip pain that was causing the patient’s distress.

Communication with local docs / The differences between your training, experience and resources will inevitably have implications for patient care and require delicate communication on your part. (3) In this case, it was the appropriate use of imaging and the male doctor’s attitude towards female clinicians.

Introduce yourself and explain your role: be mindful that you are not likely to be communicating with these colleagues in their mother-tongue or in a language in which they have fluency.

Try to avoid misunderstandings by using appropriate language to communicate essential information in a concise manner. Declare what you believe to be the emergency and share your ideas, concerns and expectations.

Determine whether your colleague agrees with your diagnosis and management plan. Be prepared to listen and negotiate and try to resolve conflict, always keeping in mind that the best care possible for the patient trumps your own professional pride. (4)

Appropriate evacuation / When choosing the most appropriate mode of evacuation consider illness or injury severity, rescue and medical skills and the physical abilities of rescuers, available equipment and aid, potential dangers and pitfalls, time (influenced by distance, terrain and weather) and cost.

In this case, we might have predicted some form of underlying lung injury in the presence of tachypnoea, hypoxia and suspected multiple rib fractures. It should be borne in mind that helicopter cabins are not pressurised and that during ascent, atmospheric pressure (and the partial pressure of inspired oxygen) will decrease, enabling air-filled spaces such as pneumothoraces and endotracheal tube cuffs to expand! (5)

Anne Brants and her colleagues at Outdoor Medicine will be running the 3rd edition of their excellent Medicine in Extremes Conference on 13 January 2017 in Amsterdam. The theme will be Extreme Cold, and the program will include hypothermia, surviving Antarctica and injuries from the ski slopes.

References

1. World Health Organisation. Global Status Report on Road Safety. World Health Organisation: Geneva, 2015.

2. General Medical Council. Good medical practice. General Medical Council: Manchester, 2014.

3. Lowth, M. Ethnicity and Health [Online] 12/03/2015 [Cited: 12/09/2016].

4. Green M, Parrott T, Crook G. Improving Your Communication Skills. BMJ Careers. [Online] 01/25/2012 [Cited: 12/09/2016.].

5. Forgey WW (Ed). Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. Falcon Guides: Guilford, 2006.