Dr Mina N Arsanious / ACCS CT2 Anaesthetics / North East London
Dr Mina Arsanious describes his experience as an expedition medic with Raleigh International in Costa Rica; taking us from a community project to a conservation project to a twenty-one day Dragon Trek. Mina offers his advice on how good preparation can help avoid large medical mishaps (in his words – ‘dragons’) and how you can fend off similar mishaps along the way!
A call to adventure
It does not do to leave a live dragon out of your calculation if you live near one
Gandalf The Grey
It is often taught in expedition medicine that “proper preparation prevents poor performance”, but I never truly appreciated this phrase until I worked as an expedition Medic with Raleigh International in Costa Rica. Over three months I served on three different expeditions. The first was a conservation project deep in the rainforest. The second involved building a school with the local indigenous community in the mountains. The third was the infamous ‘Dragon Trek’; a twenty-one-day expedition winding through the Costa Rican jungles, mountains and rural village towns towards the Pacific coast.
It was during this varied experience that I came to respect the sentiment of the ‘5 Ps’ and learnt to apply them to our own ‘dragons’ or medical ‘worst-case scenarios’ as they are more commonly known.
Raleigh International is a global charitable organisation that looks to empower youth and local communities to make lasting change through three arms; community, environment and adventure. Programmes like the one in Costa Rica bring together young people aged 17-24 from across North America, Europe and the host countries. They engage in projects that build upon each other to make a lasting impression in the communities and environments they operate in and in the experiences of those volunteering. The reality of being a medic in such an ambitious project; rotating 120 volunteers through three different expeditions across various sites is often an amalgamation of problem-solving, planning and preparation.
That said, the impact of each expedition and the experiences gained hold so much worth that the memory of those exploits rarely are accompanied by any ill-feeling. I have served as an expedition medic with other organisations and in other climates, but it is the pearls from my time with Raleigh that have given me the foresight to prepare for unsuspecting ‘dragons’ hidden along the way.
Preparation – The Cardinal ‘P’
Spectacular achievement is always preceded by unspectacular preparation
Robert H. Schuller
Something that sets Raleigh International apart from other organisations is how early the planning begins. Nearly six months ahead of the flight out to the country, myself, my now wife and four other medics were assembled as the medical team for the Costa Rica Project. We were well informed of what to expect, the prevalent diseases and the health risks that came with the expeditions we would be working on. We were briefed about standard operating procedures, local resources and the medical kit and equipment we would have available. This allowed me to seek out clinical experiences in the Emergency Department that would be most relevant to my expedition role as well as speaking with physios and nurses about their approaches to various medical issues.
When the time came to fly to Costa Rica, even more credence was given to effective preparation. We were afforded the luxury of two weeks with the project managers and team leaders before the arrival of our young volunteers. This was essential for us as a medical team; we checked medications and equipment stocks, reached a consensus on how to approach various clinical scenarios and, most importantly reviewed the medical questionnaires of all those arriving.
With only one medic per expedition, it was clear from the outset that should an emergency arise, co-ordinating a rescue with the help of the whole team would be essential. We prepared for various scenarios ranging from navigating the various compartments of the 60L dry bag that was to be our ‘hospital supply cupboard / drugs cabinet’ to the more pressing ‘casevac’ where the patient would need evacuation from the expedition. These scenarios were rehearsed repeatedly with the volunteers pre-deployment, and then again with every expedition and each new group of volunteers, with our mantra taking hold; “proper preparation prevents poor performance”. On the final expedition – the Dragon Trek – we ran a scenario where both I and the expedition leader were stung by bees and progressed to anaphylaxis. It was gratifying to watch the group break down into two small troupes and perfectly coordinate management plans including; assessing vital signs every 3-5 mins, administering adrenaline and contacting field-base with a concise handover of the situation and the need for a casevac.
With longer-term expeditions like Raleigh international it is easy to see why the in-country risk assessment ‘missions’ are even more vital. The longer and further away you are isolated from definitive medical care on an expedition the greater the risk. How many people would take a first aid kit with them on a short morning ramble in the countryside? But should that countryside ramble last for several weeks, without phone signal and hours from the nearest hospital, then the need for an extensive first aid kit and additional medical and emergency supplies becomes much more palpable.
In Country & On the Ground
The project leaders and I were allocated first to the ‘community’ expedition. We were driven three hours from the closest town to a small village of indigenous people at the very end of a dirt track that challenged the jeep’s claims of being ‘all terrain’. Here we spent three days living with Froylan; one of the fathers in the community who was also one of the few villagers who understood Spanish. My day was spent making preparations for 16 young people to live here without electricity, running water or phone signal whilst building a school for the community. I would say less than 1% of my risk-assessment came from anything I was taught at medical school or encountered in my day-job since. Planning latrines, and arranging for water to be piped down from the nearest main did not feature much between anatomy and physiology. Yet, without a doubt the lion’s share of the healthcare delivered as medics came from the two weeks we spent planning and preparing for everyone’s arrival.
The most surreal part of the ‘risk assessment mission’ was planning for an emergency evacuation. No one in the village-owned a car or quad bike and our jeep was not going to be staying with us for the expedition. Froylan assured me that the jeep would be useless anyway if it rained because the dirt track would quickly disintegrate into a mud river. We did away with any lofty thoughts of London Ambulance Service’s 8 minute response time – the best casevac scenario we could muster was a 90-minute mule ride to the nearest highway where a jeep or regional ambulance would meet us. The thought was sobering to say the least. My experience of expedition medicine up until this point had mostly been short excursions, but never this isolated.
One of the things I found most incredible and appreciated about working with Raleigh was the support they offered me in my role. Whilst they expected me to make a definitive decision on the best course of action in the event of a casevac they were keen to problem-solve to come to the optimal solution in each case. After discussing the risk assessment with the field-base office, Raleigh was able to arrange for a large area on the hillside to be cleared and levelled off so that in a worst-case scenario a helicopter could land. However, this remained on the proviso that the weather permitted a safe flight, meaning that we couldn’t quite throw the 90-minute mule ride out of the crisis plan. At the end of three exhausting days I had a 14-page document of potential scenarios… plans…contingencies… coordinates and contact details. It hadn’t been quite the glamour of expedition medicine I’d imagined; parachuting into a rescue like Arnold Schwarzenegger striding away calmly from an explosion – but then we had wrangled ourselves a helicopter landing site! When we returned a fortnight later for the expedition the new landing site had new uses as a football pitch and football fast became the most intuitive language between the volunteers and the indigenous people of Dorbata.
Phase 1: Community Expedition
In both of my initial expeditions – the school building, and the conversation project, most of the “expedition medic work” was preventative and had taken place when we looked at sanitation and risk assessments. Thereafter despite having daily evening ‘walk-in clinics’ the burden of work wasn’t too taxing. The prevention continued; encouraging frequent handwashing and sensible behaviour were the mainstay, but generally, I was a lot freer to help out with the expedition goals and getting to know volunteers.
In Dorbata, mornings were spent either learning simple Spanish and Cabecar (the indigenous language) or organising various outreach days for the community; part of this was venturing out onto the surrounding trails to map out where people lived within the locality of the hills and inviting them to get involved with the new school. The afternoons that were not spent napping in the sun were invested into digging foundations, cutting and preparing wood for the school. Before dinner, we would walk the 20mins up the slopes to the ‘helipad football pitch’ for a game of football with every stratum of society. Elders, toddlers and several women played and despite their diminutive demeanour on the building site, they could deliver ferocious tackles on a pitch. This daily gathering formed bonds with the community and made the entire project much simpler: for our group and all future Raleigh groups visiting the village.
Often, I’d forget I was there as a medic and not part of the volunteer group or even part of the village. On only one occasion was I required to slip fully into ‘medic mode’; the foreman of the building site came out of a football challenge with a dislocated thumb. I relocated the joint and advised a hospital visit, to which he smiled and nodded at the interpreter before trotting back onto the field to score a volley. He arrived back on the building site the next day, declining analgesia and keen to finish his work to be back on the pitch that evening.
After 3 weeks our phase in Dorbata was finished. With only the briefest return to field base to update project managers and refresh supplies, we were off to the next phase – the conservation project in La Cangreja national park.
Phase 2: Conservation Expedition
With our new camp within the jungle, the risk assessments concentrated more on flora and fauna. I had never pictured myself as a dermatologist but whilst the volunteers spent their evenings resting from long days of clearing trails, I was looking at bites and scratches and trying to differentiate ‘normal expected inflammation’ from something more sinister. I studied everyone’s exposed bites and rashes religiously for alterations or variation. Plasters and bandages were useless as the humidity ensured that any dressing would slip off the desired area, slick with sweat and moisture.
Unfortunately for one volunteer a trial of antihistamines and a course of antibiotics did not calm the angry skin around the petulant open bite and I made a joint decision with the field base medic to take them off the project. On expeditions, these choices are hard because having spent time with the volunteers you become invested in offering them the best experiences. I was also painfully aware that for our remote location a medivac would prevent the volunteer from returning to the project until the rotation. It was challenging to separate a medical decision from an empathetic one. As ever, Raleigh was supportive of these challenging medical decisions. Every morning a telephone medical update almost akin to a ward-round was conducted with the field-base medic who provided an invaluable alternative perspective. This shared decision-making allowed the volunteer with the swollen bites to miss only five days in the jungle without risking their health.
It is very hard to plan for every eventuality. I was, therefore, grateful for the Christmas present I received from my parents before flying: the ‘Oxford Handbook of Expedition and Wilderness Medicine’. It served as a quick reference guide and acted as an additional source of reassurance. One particular night it came in useful; I was awoken frantically by one of the girls who said her tent mate was behaving ‘strangely’. I peered into the dim tent where I saw the girl rocking back and forth under the lamplight. She was agitated and said she could feel something ‘biting the inside of her head’. At 0300 it seemed more like a psychiatric presentation but having been with this particular volunteer for both phases and with no previous behavioural concerns I was suspicious of other causes. She kept repeating ‘something’s biting my brain’ and motioning to the left side of her head. With more encouragement and reassurance, she explained the biting had started in her ear but now felt like it was inside her head. A quick flip through the handbook told me what to do. Calmly and quietly, myself and another leader asked her to lay her head on her right side. We poured cooking oil into her ear and let the canal fill up – and a few moments later a drowning ant about the length of my thumbnail welled up out of her ear. With the bluff of a medical student in their clinical exams, I accepted the gazes of amazement from the volunteer and the manager for identifying and solving the problem. Immediately the volunteer felt relief, but in horror refused to sleep without earbuds for the rest of the phase. I too pulled my sleeping bag hood more tightly around my head for the remainder of the jungle nights…
Phase 3: the Dragon Trek Expedition
The Strength of a team is each individual member, the strength of each member is the team
After a short return to field-base and once more faced with a new set of risk assessments and volunteers to manage we embarked on our final expedition; the ‘Dragon Trek’. Unlike the two previous projects, this one did not have the luxury of a single location and our camp each night would be wherever we decided. I was much more judicious with the medical supplies knowing that the 60L dry bag would be carried on my shoulders and not by jeep along the undulating hills of Costa Rica.
One of the more significant challenges as an expedition medic on a trek was managing team health and safety when it was directly related to the team dynamic. On the first trekking day volunteers quickly polarised themselves into a group eager to break a land-speed record and less athletic volunteers who tarried on behind. It wasn’t long before groups separated by a few miles; jeopardising communication. Resultantly, some volunteers had taken a two-hour accidental detour from poor route planning, and we had lost track of where each volunteer was as the groups disintegrated, spreading randomly across the hill side. I felt my medical duty of care was compromised knowing there was an asthmatic among the lagging volunteers and no supervision of the faster ones. Both the project manager and I felt uncomfortable with how riskily the expedition had started. That evening we debriefed with all the volunteers. Some of the younger volunteers felt the solution lay not in the team but in other individuals who needed to do better. Despite the overtones of indignation, there was a shared belief that the two-hour detour in the midday sun and arrival at camp after sunset was not ideal. We closed with a shared subscription to the idea that tomorrow could be better through change: roles were created, tasks were assigned and there was a commitment that the trek would not be completed unless completed together. It took nearly a week for the undercurrents of resentment to dissipate and for the mechanics of the trek to bed in. But soon enough, setting up and breaking down the camp, route mapping and sharing the kit load became slick and smooth.
That first evening’s discussion later made all the difference when one of the volunteers had an unfortunately timed asthma attack at a jungle gorge crossing with no land or air access. The youngest volunteer (and the staunchest opponent to the first night’s conclusions) was the ‘trek leader for the day’. However, without his proactive leadership, the day would have panned out very differently. The asthmatic volunteer’s bag was quickly divided among the group and the pace was slowed to tax her lungs as little as possible. Instead of the usual groans that came with each stop early in our trek, each pause to auscultate and give more puffs of her inhalers was levied by rounds of encouragement and positivity. We made it out of the gorge with hardly a wheeze to be heard and not a whisper of complaint. In the security of a now cohesive team, and upon legs that grew sturdier and surer each day we met most sunrises gregariously, and pitched camps well before sunset in equally affable spirits. Porridge became more palatable and waking up in darkness to make the most of the cool hours became less wearisome. Everyone made it through the trek safely with most making it to the top of Dragon Mountain.
Having had three very different expedition experiences with Raleigh there was a common theme: prior preparation paid dividend later. Whether it related to resources in Dorbata; expertise in la Cangreja; or team dynamic along the Dragon Trek; without forethought and planning the challenges met would have been formidable. Saved from poor performance, planning and preparation provided a pretty pleasant end product. Whilst you can’t plan for everything, planning for the big things often helps prevent the smaller dragons that one may encounter along the way.
Where / Costa Rica, based in Turrialba but expeditions are throughout the country.
When / Jan – April
Costs / I was expected to raise £2025 towards the charity as well as pay for my own flights. Per diem was provided for but back at field base it was hard to resist a trip to the local supermarket for creature comforts such as oreos, cans of coke and meals in restaurants after the volunteers leave. Approx. £100 or so should cover it depending on how extravagant you want to be.
Weather / On trek and in the jungle, temperatures are 30+ degrees and very humid. On the parts of the trek at higher altitudes and in the community projects temp is 15-25 degrees with frequent showers (this becomes much heavier in rainy season from May – Nov).
Vaccinations / All standard UK vaccinations. Hepatitis A and Tetanus/Diphtheria/Polio booster advised before visiting. I was also recommended rabies immunisations as several of the communities had stray dogs.
Accommodation / At fieldbase, and on all the different projects we slept on roll mats in tents – get comfortable sleeping on the floor.
Essential items / Good quality boots and backpack, mosquito net, sun cream, waterproofs – camera phone for all the memories.
Addition items / You will need to make a formal application as well as attend an adventure weekend prior to selection for country projects. Part of this will include DBS and references.
Contact / Formal applications can be made at raleighinternational.org – to fill out the application form click here.