Drs. Kathy and Chris Wilson / Hamilton, New Zealand
Mental health problems are often underplayed when thinking of expedition medicine. Whilst in your expedition planning you are very likely to have an idea of how you might deal with trauma or toothache, planning for the event of acute mental illness might not be so much on your radar. In this interesting article, doctors Kathy and Chris Wilson explain why it should be, and share their experiences of the challenges in safely managing an episode of acute psychosis on a remote expedition with marine conservation NGO Blue Ventures.
Amidst the fanfare of speciality training applications and the day-to-day business of medical practice, we decided to indulge our interest in expedition medicine and seek some new challenges. Like many doctors before us, we started applying for work in beautiful New Zealand, but not without ensuring that the journey there was as interesting as possible. The Expedition & Wilderness Medicine course in Keswick provided an excellent foundation, and after weighing up the recommendations we decided on a trip to Andavadoaka on Madagascar’s west coast to work with the marine conservation NGO Blue Ventures.
Madagascar is the world’s fourth largest island, with many different ecosystems rich in biodiversity. Approximately 90% of all its plant and animal species are endemic. Volunteer expeditions with Blue Ventures are six weeks long and run throughout the year. The field site is at Andavadoaka, a coastal village where the Vezo people have fished the waters of the Mozambique Channel for generations. Prior to the expedition, a four day overland tour takes you from the capital, Antananarivo, to the village of Andavadoaka, stopping at several national parks and providing an opportunity to experience some of the fascinating environments and wildlife that the country is known for. The road network is a little rough around the edges, but the final eight hours of the journey to the village are an unadulterated off-road adventure!
Medicine and marine conservation
Volunteering as a medic with Blue Ventures is not restricted to medical duties; you participate in the marine conservation work with the other volunteers. This involves learning how to identify 150 different tropical fish species and the various benthic (seabed) organisms like corals and tunicates. It’s best to start learning before you go! Thankfully we also managed to cram in revision of barotrauma, decompression illness and common aquatic injuries; studying is much more enjoyable when it’s outside your usual field! On arrival at the Blue Ventures field site, we gave lectures to the volunteers on these topics and other common travelling ailments.
In an unexpected (and unwelcome) turn, some of the group (mercifully, a minority) decided they would give us daily bowel updates using their own interpretation of the medical lingo used in our talks. There was many a person struck down with ‘The Dee’ in those first few weeks. Day-to-day work also involved dive medicine, with several cases of middle ear barotrauma and assessments of fitness to dive. However, the one thing that really challenged us was something not mentioned at all in our initial lectures; mental health.
Mental health on expedition
One of our great team of volunteers had come to Madagascar following a series of significant life events. Within the first week he began to have intermittent anxiety symptoms with panic attacks. These were initially self-limiting and managed with benzodiazepines and cessation of diving. However, over the following week the anxiety symptoms became more persistent and severe and the decision was made to repatriate him. Given the remote location of the field site, his departure could not take place for a few days, and we planned to escort him back to Antananarivo where we would meet an aeromedical team arranged by the insurance company. Needless to say, we were very thankful for Blue Ventures’ requirement that every volunteer has travel medical insurance.
Unfortunately his symptoms worsened further in the days leading up to the planned evacuation. What had started as overvalued ideas (for example, “I’m going to die here”) progressed to unshakable persecutory delusional beliefs. He began to refuse benzodiazepine medication and exhibit marked paranoia and insomnia. We contacted our indemnity organisation who supported our assessment that he lacked capacity and needed to be medicated, but without any injectables all we could do was supervise him to ensure his safety in a potentially hazardous environment. This became increasingly difficult and eventually the three of us set up shifts around-the-clock to ensure no harm would come to him.
The insurance company’s medical team agreed with our assessment that he was developing psychosis, with no clear evidence of an organic cause; clearly we were going to need a more urgent evacuation. Poor infrastructure and the remote location threatened to hamper our efforts and resulted in tense discussions with the insurance company who were (perhaps understandably) unaware of the difficulties of overland transport to and from Andavadoaka. We had difficulty persuading them that the off-road 160km from Toliara to Andavadoaka would take eight hours to drive in each direction and was only possible during daylight hours. However, as the situation was urgent and deteriorating, we unilaterally arranged an emergency air evacuation using a Malagasy company that Blue Ventures had listed in their emergency evacuation protocol, and then set about getting our plan accepted by the insurer, which they did.
It was with great relief that we greeted the air ambulance when they touched down at daybreak at the local airstrip. The volunteer, now more settled having had parenteral antipsychotics, even waved goodbye as he was flown first to Antananarivo and then on to South Africa. Exhausted, we retreated to our hammocks, and looked forward to getting back to diving and the daily “dee and vee” updates. On reflection, it was satisfying to make the diagnosis, overcome difficulties with the help of the staff and volunteers and end up with a good outcome for our friend who had been beset by psychosis. The main issues that we encountered were medicating someone who lacks capacity, ensuring their safety in a hazardous environment and arranging evacuation from a remote area.
As Morenz states, “even in the absence of psychiatric disease, travel produces some level of stress in everyone.” Therefore, we would recommend that any expedition has access to oral benzodiazepines as a minimum, or perhaps an injectable anti-psychotic, which Shlim advocates is needed in every expedition medical kit. While our case was unusual, the unique stressors that travel brings, and the variety of reasons that people decide to take such a trip mean that anxiety is a common presentation and “psychiatric problems can emerge or become worse in response to the demands of wilderness experiences”.
Thankfully, we are pleased to report that the volunteer made a quick and complete recovery and returned to work without needing any longer term medication or follow-up.
We are very grateful to Blue Ventures for the opportunity and for very supportive staff, both in the UK and Madagascar. The advice we had been given at our EWM course was absolutely correct; for your first expedition (or if you are an inexperienced doctor) make sure you pick an expedition which has both the supplies and the support to help you deal with whatever it may throw at you! Thanks also go to our excellent fellow medic Dr Sam Gillet. The expedition threw us new medical challenges, but we have also learned much about marine life and conservation which still positively affects how we think about the sea and our interaction with it. The memories of the wonderful six weeks we shared with the Blue Ventures team and the volunteers will be with us for a long time.
Auerbach P. Wilderness Medicine, 2011, Volume 6, Chapter 35.
Mc Laughlin L, Braun K. Asian and Pacific Islander cultural values: Considerations for health care decision-making. Health and Social Work 1998, 23 (2), 116-126.
Shlim D. Wilderness Medicine Letter, Volume 18, Number 1, Winter 2001.
Please note the express permission of the volunteer in question was sought by the authors of this article.