Tom Yeoman / Clinical Fellow in Anaesthesia / Chesterfield Royal Hospital
We get emails every day from readers asking how to get into expedition medicine. The first step is always the hardest: once you have that first trip under your belt, everything that follows becomes far easier. In this article Tom Yeoman tells us of his first expedition, and the steps he took that led to the summit of Kilimanjaro and the office with the best view in the world.
If you’re reading this magazine from an internet café in Pokhara, having recently coordinated a rescue effort on the South Face of Annapurna then this article probably isn’t for you.
But if, like me, you are a mere mortal sitting on a night shift in a district general hospital, reading yet another article on challenging medicine in austere and beautiful locations, you may find yourself thinking: how do people get these gigs? Were they born in a crevasse?
In August of 2014, I had finished basic anaesthetic training, and was looking for adventure. Three months later I was standing on the summit of Kilimanjaro with a 2-metre radio, a jacket with ‘Medic’ written on the back, and a big (slightly cyanotic) smile on my face.
I thought I would explain the steps I took towards getting a foot on the adventure medicine ladder. I hope this article will be helpful to anyone wanting to do the same.
Any internet search for adventure jobs will deliver a vast range of opportunities – from flying doctors in Kenya, to Marine conservation projects in Fiji – all looking for medics. Look closer at the application, and most will require some previous experience of having worked in a similar environment.
I quickly realised I was going to need some basic training, so I booked onto a course with Expedition and Wilderness Medicine Ltd – a UK based company providing expedition, wilderness and remote medicine training courses for medical professionals.
The EWM Course
EWM run their four-day courses in outdoor activities centres in Dartmoor, Snowdonia and the Lake District. I joined their Dartmoor course alongside around 50 other people; mostly FY2-ST3 doctors, but also nurses and paramedics from both the UK and Europe. Some already had a trip planned, others were looking for inspiration and a chance to test their skills outdoors.
The faculty consisted of experienced expedition medics, whose field experience included British Antarctic Survey, Namibian ultramarathons, Polar expeditions and research projects on Everest.
Teaching was delivered as a mixture of lectures, seminars and practical sessions. Topics included planning and preparation, client medical assessment, trip logistics and evacuation, as well as some of the medical problems specific to various world climates.
Practical sessions included wound and fracture management, dental care and organisation of medical supplies. Out on the moors, we covered basic navigation, ropework, radio communications and GPS. In the evenings you could grab a beer and be treated to lectures by guest speakers with inspirational tales of epics and adventures.
On the last day we got to practice our new-found skills with a mock search and rescue operation. We located, stabilised and stretcher-carried five injured ‘parachutists’ from the moors. In four days our team had gone from Duke of Edinburgh novices to mountain rescue heroes!
The Next Step
The course was fantastic, and left me completely inspired. I started to look for that first trip to test my new skills. Kilimanjaro had been mentioned many times on the course and I have always wanted to climb it. I felt like it ticked a lot of boxes: established trekking companies, working in a developing country, and a test of my physical and clinical skills in a high altitude mountain environment.
A friend had mentioned a charity climb with a group 14 trekkers, run by a UK-based adventure company, Action Challenge. I approached the medic responsible for the trek, a GP in the Royal Marines. He was happy to have me along, but instead of purely shadowing, invited me to be the Medical Officer, as he was considering becoming Team Leader. This was great opportunity for me to take full charge of the medical provision for the trip, but with the support of an expedition doctor if needed.
Preparing for the Climb
The next two months were busy! I attended meetings in London with Action Challenge, where we defined roles for the trip, discussed logistics, contingency plans, communications and casualty evacuation procedures.
The wilderness medicine course had drilled into us the importance of gathering information on all members of the trip. I contacted each individual, which led to the discovery of several conditions which were not mentioned on their medical questionnaires. These included Raynaud’s phenomenon and chronic knee pain, which may sound relatively innocuous, but could have caused misery on the mountain without adequate preparations. I also sent out an information sheet to all trekkers, covering prevention and treatment of common altitude and exposure-related problems.
For the rest of the time I tried my best to update my practical skills and knowledge base. The Oxford Handbook of Expedition and Wilderness medicine was invaluable. I also had a few friendly nurses to talk me through bandaging, strapping and wound care – all basic skills, but I’m a gas man and it’s not on my syllabus!
Sorting out the kit
The team at Action Challenge UK supplied the medical kit. It included bandaging and strapping for minor musculoskeletal injuries, sterile suture packs for wounds, dressings for burns and a ‘SAM’ splint for fractures.
Pharmaceuticals included antiemetics (PO and IM), oral analgesia including tramadol and broad spectrum oral antibiotics. Acetazolamide and nifedipine were supplied for treatment of acute mountain sickness.
When an anaesthetist and a GP from the Royal Marines sit down and contingency plan for any trip, it’s easy for all sorts of hellish scenarios to be played out as possibilities (particularly when the latter is used to more explodey, bullety environments). A balance needed to be struck between the sheer weight and volume of kit and the likelihood of needing to use it. In the end, the Action Challenge med-bag was more than adequate. However, with access to Her Majesty’s kit locker, our team leader included chest drains, laryngoscope, ET tubes and a Kendrick splint – just in case the airport bus rolled!
We decided against taking intravenous opioids. Our options for supply would have either come via the UK (with the attached bureaucracy), or picking it up in Tanzania with no guarantee of its quality. Furthermore, our flight was to connect via the United Arab Emirates, where declaration of controlled drugs was likely to lead to their confiscation at best or jailtime at worst. If a long-bone fracture was to occur, our plan was to do our best with oral analgesia and splinting, and concentrate on a speedy evacuation to Kilimanjaro Christian Medical Centre where morphine should have been available.
On the Mountain
I met our group at Heathrow, and we travelled together to Tanzania. There was a mix of ages, abilities and experience. The group dynamic was fantastic, everybody pulled together from day one and it made for a truly memorable experience.
The night before the trek, after checking through the medical kit, I gave a final briefing to the group. This was mostly to reinforce the topics I had discussed over the previous weeks by phone and email. It was obvious that the group were clued-up and prepared, which was a big weight off my mind.
After an acclimatisation day, we set off on the hike. We carried pathetically light packs through beautiful rainforest, while an army of porters jogged past us, carrying the contents of the most luxurious campsite imaginable – mess tents, dining tables and even chemical toilets.
After we arrived in each camp, I would run my tent as an open-access clinic. It proved surprisingly well-attended by the group. There were a few blisters and musculoskeletal pains, but most required reassurance for normal altitude-related symptoms: loss of appetite, mild headaches and nausea.
The local guides were impressively clued-up about acute mountain sickness. They kept the pace of the hike deliberately slow, and encouraged us constantly to drink water. After dinner, we recorded Lake Louise scores and pulse oximetry results.
The summit push was a long, slow, slog in the darkness. We still had the equivalent of Ben Nevis to climb, and the air was thin. Setting off at midnight, we trekked for six pre-dawn hours in temperatures below zero. The whole group battled fatigue and nausea, and it was difficult to just keep moving.
Above 5000m, I became aware that my ability to perform mental tasks had become significantly reduced. It was at this stage that the Tanzanian guides really shone through. Super-fit and acclimatised, they would have been absolutely crucial if any rescue effort had been required. While our group slogged away (and occasionally vomited), the guides would jog alongside, carry people’s backpacks, crack jokes and dole out ginger tea. All life-saving stuff at 18,000ft.
Half way up to summit, the decision was made to split the group into two. I was asked to lead the slower group. At first this felt daunting, but I soon found the responsibility gave me the focus I needed – there’s nothing like trying to motivate others to forget how rough you feel yourself. I stayed in radio contact with the team leader and we plodded on.
And then the equatorial sun shot up over the horizon, and suddenly everything was glorious. Euphoria set in and gave us the boost to push for the summit plateau. We were certainly slow, (and at one point I wondered whether ‘Big Kev’ was going to need the GTN spray I had squeezed into my jacket pocket), but we made it to Uhuru peak. The summit was sunshine and happiness, photos and tears, and at that particular moment: the greatest place on planet Earth. Now we just needed to find that cablecar back down.
In the last few months I have learned a lot about myself, both physically and mentally. It feels great to have tested myself outside of my comfort zone, and it’s a buzz to be one of the staff when your office window looks so beautiful.
There are so many ways to do something different with your medical skills. There is a wealth of information and support out there, including some great past articles in this very magazine. My advice: get yourself on an expedition medicine course and see where it takes you. It could be the most exciting time of your career.