Adventures — 13 January 2019 at 12:47 pm

On Call On The River: Stepping into Expedition Medicine

Vari McCall / Expedition Leader, Nurse and Paramedic / Ninth Wave Global

For the past three years, nurse and paramedic Vari McCall has been working overseas as an expedition leader and medic. Following trips with Exile Medics, Adventure Medicine and Raleigh International, she became involved with Ninth Wave Global, sailing to America from Greenland, canoeing along the Mississippi, horse riding in the outback of New Mexico and spending time with rural communities in Mexico and Peru. We asked her about her expeditions, as well as how she fits these trips in with life and work in the U.K.

Hi Vari, please tell us, why Ninth Wave Global?

I had heard positive feedback from a friend who had been involved with them and after finding out more, I liked and respected their ethos. Ninth Wave Global is a non-profit, independent and international organisation. They travel to remote places, generating space for investigation and positive change in environmental, community and social settings. Their aim is to reimagine exploration not just as a tool for positive change but also as a practice which is a global experience, accessible and beneficial to all. This all felt very important to me. I didn’t want to get involved with a commercial tourist company or an organisation who were in and out of the community quickly, never following up on their work. Ninth Wave provide ongoing support to the local communities and initiatives in all the areas that they journey to. So, with my 40L backpack, I headed off for a whole month to see what the organisation was about. I stayed for five months! Two years on, I am still involved with the organisation as an expedition leader. I also run some journeys with a wilderness medicine component, enabling students, doctors and other individuals to gain experience in expedition medicine work.

Where do your wilderness medicine journeys take you?

The main wilderness medicine journey begins at Ninth Wave Global’s base in Campeche, Mexico, then heads on down the Usumacinta River. The organisation has a volunteer house, where individuals on local projects and pre and post river journeys can stay. This particular journey is 1-2 months. It includes a session learning about natural medicine with local plants and extracts by a local Shaman. This helps the group identify which local plants might help with common ailments, including high blood pressure, diabetes, dehydration, mosquito prevention and bites. It is useful information when working in remote communities who may not have access to a regular doctor and medicine. There are also wilderness medicine workshops throughout the programme and whilst on the river.

Ninth Wave Global also work closely with the Red Cross, who operate the local ambulance service with volunteer paramedics. The participants have an opportunity to go out with a crew on a day or night shift, or both if they wish. The experience highlights how little medicine the ambulances carry, and the limited range of treatments they can give, mainly due to lack of funding. All the paramedics also have other jobs, which makes what they do even more commendable. A local doctor, Doug, has been involved with Ninth Wave Global for several years and he allows people on the programme to sit in on his clinics in a local GP surgery.

Who goes on the journeys?

They vary. The most recent journey I ran in Mexico had three medical students, a doctor, a photographer and a biologist. The mix made it interesting, as everyone had different skills to offer.

What’s a typical day like on the river?

There isn’t one! That’s what I love the most. There are certain aims and defined places to visit, but the itinerary is adaptable, depending on the group, the weather and who we meet along the way. Given the culture and the way of life in these areas, it seems to work better being more organic. There are certain clinics organised and follow ups with previous patients, but others emerge throughout the journey.

Here is a little insight. One day we got up early, packed up our hammocks and hit the water before it got very hot. We hadn’t been paddling long on the river before we were passing large bright orange iguanas, balancing on thin branches at the tops of the trees. Listening to the howler monkeys in the distance reminded me of a scene from Jurassic Park. Stopping for lunch, we got chatting to an older gentleman who owned the field we had stopped at. He was in his mid-seventies and complaining of near-daily back and knee pain. He mentioned that the nearest doctor was three hours away and explained that it was not even guaranteed that you would be seen on the day, so to visit meant staying overnight in another community. Many of his family also had chronic, untreated health problems. Conditions such as diabetes and high blood pressure are very prevalent in the area. Though people are sometimes given medication, they are not typically advised on the lifestyle changes that might be beneficial to them. We met with his family, took their observations and offered some self management advice. I felt comfortable giving this advice. Next time we pass by on a journey, another leader or I will stop by to follow up on the health and lifestyle advice given. There is no point us giving them lots of medicine that they then may not be able to continue to obtain or afford. We recognise the problems that can occur when visiting medics arrive in remote communities.  We always strive to work with communities to ensure the most beneficial interventions for all involved.

How do you find life as an Expedition Medic?

I have nearly twenty years experience as a nurse and seven years as a paramedic. I have also completed a variety of wilderness medicine and jungle survival courses. Depending on the journey, I will sometimes have another expedition leader working alongside me with advanced first aid training. Although I feel I am able to deal with most eventualities, I only work within my capabilities. I like to be open with any group participating on a journey, regardless of their background or experience. Before we set out on the river, I organise a group discussion to go over each other’s medical conditions (with prior consent). We talk through how to deal with and treat common ailments and what to do if first on scene. Medical problems have varied from asthma to epilepsy and Ninth Wave has also had a person with paraplegia participating on a past journey. Sometimes there are also minor issues like dehydration, sun burn, headaches or occasionally diarrhoea. If there are no issues or unwell participants, I see that as a positive outcome. It means that planning ahead has been successful. 90% of the time I’m just part of the team like everyone else: fire maker, cook, paddler, water bailer and bad joke teller. I wouldn’t have it any other way.

What do you do about indemnity insurance?

My indemnity is via the College of Paramedics. They cover me for expedition medicine and for the places I go to. Certain aspects aren’t covered, so always check clauses carefully. For instance the indemnity is only for voluntary work, and doesn’t cover treating professional athletes. Some companies only cover certain countries and the length of cover can vary.

I am also with Unison, which covers both my nursing and paramedic registration. I had to specify dual registration and require my own cover since I do bank/agency work when home. Some hospitals cover your indemnity, but most private work requires you to hold your own indemnity insurance. Unison covers volunteering abroad on expeditions, but I have found their policy more restrictive than the College of Paramedics. Most companies I have looked at only cover volunteering, not paid work. Remember though that being reimbursed for expenses can still be classed as volunteering.

Do you have a defined scope of practice?

I always work within my own scope of practice and skill set. A doctor can prescribe Prescription Only Medicines (POMS) for you to dispense on expedition. [See this article by James Moore for more information].

Most important is to use your judgement: weigh up the situation/emergency, what you are able to do to help, how to manage the situation and how far you are from help. Remote care work is very different even from pre-hospital care in a town or city. I feel it is important to always have the best intentions for your patient and to do everything to the best of your ability. Then you can justify your actions, as well as keeping peace of mind. The majority of the time, most of the work is preventative.

How do you fit your expeditions into your life as a working NHS nurse and paramedic? 

We all know that CPD and hours of work are important to keep our registrations active. What some don’t realise however is that volunteering can still count towards your hours, depending on what you are doing, it doesn’t all have to be direct care. It can include teaching and managing teams. The NMC cover this online within their revalidation information. The new guidelines are really informative regarding skills and the type of work which can be counted. It is also important to check where you are registered, as different countries may vary slightly. Paramedics also have guidelines to adhere to and CPD to achieve. I find the College of Paramedics very helpful regarding courses and indemnity information, I can also use my hours and experience abroad.

I remain on staff bank/agency ‘books’ with both my paramedic and nursing in the U.K. They allow me to stay on the payroll, so long as I work with them every 6-9 months. For some agencies, that is every three months. I have found chatting to these organisations to explain my situation has helped me stay on their books for longer. One of their main concerns is that you are going to return to work for them. When I return every 6-9 months, I typically work full-time for two months to build up my hours and CPD, which within my nursing role is now totalled over three years: although they ask for 150 hours a year, as long as you can show you have done 450 hours within three years, you can do more or less one year than the one before.

If you plan your expedition work in advance, then you can work your CPD and hours around it. I am also required to complete core skills and clinical updates, but I am able to do this online via e-learning. I also attend courses when I return to the U.K. for my CPD. It does take some organisation, but it is possible.

What are your top tips from your expedition experience?

Don’t rely on plasters! Learn to improvise! Duct tape or electrical tape works great. I definitely cover wounds to a greater extent than I would do normally due to dirt. A lot of our journeys also involve water or very humid environments, so I also check wounds more often. It is really important to make sure you document everything as you would within your normal role.

Use the skills and knowledge of everyone involved. Don’t expect to know everything regarding logistics, or even from a medical point of view. Be honest: problems arise when you pretend to know things you don’t! You might have the medical ‘final say’ but someone might see something differently to you, so work as a team.

Research where local medical facilities are prior to leaving for the expedition. Mock scenarios are a great way to practice evacuations and seeing how the group works as a team. After all, it could be you that’s ill! It’s reassuring to have your team prepared and confident should an incident arise.

Gather information from locals regarding any current infections or common illnesses. For instance, during one journey on the Usumacinta River there was a local epidemic of conjunctivitis which is very contagious. It was therefore important to educate people. It was also helpful to be aware that this infection was active within the area, both for the participants and the journey, as well as the communities we visited.

How about any tips for getting involved in expedition medicine?

You have to love the outdoors no matter the weather. Even if you haven’t been a medic on expeditions, showing companies that you are passionate about the outdoors and being fit to climb hills and trek are definite pluses. If you have outdoor skills or instructor qualifications, then even better. The key point is that you can be an excellent doctor, paramedic or nurse, and have experience in prehospital care, but if you are the breathless one everyone is waiting for at the top of the hill, or the one unable to put up their hammock, or scared of using the wilderness as a toilet at night, then you probably aren’t best suited for this role. The more outdoor adventures you can do, even wild camping near home, the better.

I’d also suggest taking part in journeys with a company that you would be interested in working with in the future. It’s a great way to get yourself known. It also lets you see what their journeys are like. Then, when a position comes up, they will know that you are reliable and will fit in with the rest of the team.

If you are a student; doctor, paramedic or nurse then a lot of organisations now take students on journeys to work alongside other medics. Enrolling in wilderness medicine courses and learning orienteering are also useful.

In all, it’s hard work, but you can’t beat doing what you love as a profession and seeing the world along the way.



Ninth Wave Global /

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