Dr Emily O’Neill / Anaesthetics Registrar / South Yorkshire
My road to Mount Kilimanjaro started over a year ago when I signed up to an adventure events company. After working as a medic on pitstops on their UK based ultra-endurance events, I found myself offered the opportunity to go to Tanzania as Expedition Medic on a trek up Kilimanjaro. This was a proposition that I found both incredibly exciting and terrifying at the same time. After much deliberation (about 3 hours) I decided to just go for it and accepted the offer.
For the medic, the expedition really starts well in advance of boarding the flight. Four or five weeks prior to leaving, you are introduced to the Expedition Leader who will be travelling with you and also put in touch with the expedition participants by email. This is important as it means you can introduce yourself and send out relevant medical information and advice that you think they should know prior to departure. It is also the time to find out more about who you’ll be looking after on the trip and their existing medical conditions, so that you can prepare yourself practically and psychologically for what you might face when you are out there. I had many email conversations with participants about altitude and training prior to the event, along with providing information on altitude illness prophylaxis and discussing the importance of adequate caloric intake and hydration whilst trekking at altitude.
I was trekking the Lemosho route (seven days, six nights) with 27 participants under my care. Preparation of the participants started with ensuring they all had the appropriate kit. This responsibility fell mainly to the Expedition Leader, but I joined in to ensure that everybody had enough in terms of snacks and appropriate liquid receptacles. This was followed by an overview of what to expect on the trek. As the medic, I also delivered a medical briefing of important considerations for the trek, including hand hygiene, malaria prophylaxis, altitude prophylaxis (if the participants were choosing to take it), and the all-important oral intake. I really emphasised the importance of adequate calorie intake, even when the effects of increasing altitude cause appetite to decrease. I also strongly reiterated the importance of adequate hydration, aiming for “clear and copious” urine! Participants initially seemed to think that I was exaggerating about how much fluid you needed to stay hydrated and well throughout the trip, but I was proven right time and time again. “Clear and copious” soon became the catchphrase of the trip.
And they’re off!
So, the day had come to set off on the trek. After an amazing introduction to our many porters, I was introduced to Hamza, my personal ‘Ambulance Man’. He was my rock, carrying my medical equipment bag, oxygen and staying by my side helping me throughout the trip. This meant if I needed anything for a participant, he was right there. After our last meal at the Gate Entrance, the group set off in great spirits and very quickly established an easy dynamic. Luckily, everybody got on well, despite the wide range of ages (23-66) and backgrounds. Banter quickly got flowing and, due to my constant badgering, most people maintained the “clear and copious” rule. Throughout the trip, we had an amazing group of porters looking after us. Running ahead to set up the water breaks and lunch stops. Our first night felt like a big milestone as we had settled in and now knew what to expect.
The Lemosho route is a nice gradual climb with a few days for acclimatisation built-in. Even though you gain a lot of height in the first two days, from there on you may ascend 400-1000m per day but sleep at very similar altitudes. Whilst this was a source of irritation for the participants as they felt like they weren’t getting any closer to the summit, I explained that this profile of ascent is the best for acclimatisation and to try and limit altitude illness.
As the doctor, as well as badgering people to eat and drink sufficiently, I was mainly dealing with minor injuries and illnesses. These included blisters, constipation (from a new diet), and coughs and colds (which can be very debilitating at altitude). I ran a drop-in clinic from my small two-man tent the hour before and immediately after dinner every evening and would invite those who wished to come and see me and talk to me confidentially.
However, in this kind of environment and with a group of people who spend so much time in each other’s company, bonding occurs quickly and you often find out things about people that you don’t know about some of your closest friends back home. You also get very comfortable talking about bodily functions and usually travel in groups to “use the facilities” For women, this involved finding a big enough boulder to squat behind and for the men, it seemed to be more about finding something to aim at. There were toilets at the campsites, but these were porter toilets with a small tent around them. Privacy was definitely not exemplary, and they weren’t something you tried to visit after dark.
Without a doubt, the most challenging day of the trip was the summit day. You arrive at the camp the evening before trying to get as much sleep as possible, before the 11.30 pm start for the summit push, with the aim of being there by sunrise. To my surprise, I bumped into one of my old university friends at this camp. She was also trekking as a group doctor and, as it turned out, would come in very useful 24 hours later.
So, to the summit!
The summit climb involves plodding very slowly up a scree incline for hours in the dark. Maintaining morale and motivation on this night was difficult. You climb quickly, ascending almost 1000m. This was the night when everybody started to feel at least some effects of the altitude. It is dark, so you have no view to distract you, the temperature is plummeting the higher you go and everybody is too tired to take part in the lively conversations that had kept us going through the rest of the trip. Luckily, I didn’t get altitude sickness, I just felt a bit tired and lacking in appetite. This made trying to encourage the rest of the group a lot easier because I had something else to focus on throughout the summit climb. Hamza and I were walking from the front to the back of the group constantly, picking up people when they were falling, dishing out necessary medication and deciding when people had pushed themselves to their limit. Hamza was looking after me, ensuring I ate and drank whilst I did all of this. This was so appreciated because, as a medic, you do often forget yourself as you are so focussed on your patients, no matter where you are in the world.
The most difficult thing about this stage was deciding when people had pushed themselves to their limit and were not going to be able to continue to the summit. Obviously, by this point, everyone has put themselves through it over the past five and a half days –trekking for 8-12 hours a day, getting used to a new environment, walking through all kinds of weather and getting comfortable with the lack of home comforts. This made it very difficult to tell people who were on the brink of severe acute mountain sickness (AMS) that they had to turn back. Unfortunately, two of our participants had to descend at this point. They both burst into tears (emotions are on the edge at altitude) but accepted that if they continued, their health may be in serious danger.
I’m not ashamed to say that I cried when I got to the peak. It felt like such an achievement. However, this day was to become one of the more challenging days of my career.
Elation is often short-lived
At the summit, one of the participants who had been fine until this point suddenly dropped her GCS to 9 (E2, V2, M5). Four porters carried her by her limbs over to me and asked me what to do. I simply said “down, NOW” and off we went. They picked her back up and together we started running down the mountain. They were incredible at managing to get down the scree without injuring her. Hamza was close behind me with all my medical kit and had even picked up my rucksack as I had left this at the summit as I was concentrating on my patient. Getting down the scree at speed was bizarre and felt like skiing but without the skis on your feet. By the time we got to the first camp, we had descended over 1000m in approximately 15 minutes, covering about a mile of ground. We had radioed ahead and there was a stretcher waiting for us here, along with the other participants who had had to turn back. The patient had improved drastically with the descent. Her GCS had improved to 13 and she was managing to take sips of fluid. At this camp, I quickly gave her some treatment for HACE and HAPE and on we went. I was radioing to the group leader every five minutes to let him know of our progress and checking that everybody else was alright and didn’t need any medical attention.
We carried on downwards and by the time we were down to 2500m altitude, the patient was much improved, but still nauseated, vomiting and complaining of a headache. This was the point where I had to decide: do I let her carry-on descending on a stretcher without me whilst I wait for the rest of the group, or do I continue down with her? I discussed with the Expedition Leader. No-one else was ill or needing medical attention and they were all safely back at the first camp after the summit. As there were no medical personnel at the bottom of the mountain, together we decided it was best if I continued with the patient down the mountain considering she was requiring ongoing medical assistance.
A few hours later, however, I got a radio call from the Expedition Leader informing me that another participant had become very confused. A number of differentials were running through my mind, but without being able to see the patient for myself, it was difficult to know how best to proceed. Fortunately, I was able to get radio contact with my old university friend, who I’d bumped into the previous day, and she kindly checked over my participant for me, ensuring he was adequately rehydrated and monitored him until his confusion resolved. Until they found her, though, I have never felt more helpless in my life. I had a duty of care for this man and felt unable to help him as I was miles away from him with another patient. In a hospital environment, reprioritising patients is much easier because, no matter how large the hospital, they are all in relative proximity. In this kind of environment, you must make split-second decisions and even if this is the right decision for the person in front of you, it can impact on others at a later point in time. Therefore, if this is not something you could deal with, expedition medicine is not for you.
Overall, the trip was thoroughly enjoyable and I would definitely recommend it, especially to someone who is new to altitude medicine. I’d advise choosing a trip which takes one of the longer routes, as it gives you chance to acclimatise a bit more, meaning the participants (and you!) are less likely to get sick, and more likely to reach the summit. The views from the mountain are beautiful and the friends you make are absolutely for life – I am going to a wedding next year for one of the participants and am still in weekly contact with Hamza, my Ambulance Man. It was a thoroughly rewarding experience both professionally and personally and one I would quite happily repeat.