One of the most enjoyable aspects of adventure medicine is keeping up with new developments in sport or exploration and figuring out how to best support our clients in pushing their boundaries. In this article, Matt Wilkes and Jake Holland review the adventure medicine considerations for paralpinism, considering each phase of the activity in turn.

Matt is one of the founders of Adventure Medic, and a visiting senior lecturer at the Extreme Environments Laboratory in Portsmouth. He loves flying paragliders in the high mountains, especially the Alps and the Himalayas. Jake Holland is a filmmaker and multisport athlete based in Chamonix, France. Jake is one of the athletes pushing paralpinism in the Alps, and all over the world. Check out his Instagram, and his latest film, The Magic of Freedom.

Paragliding is born

In June 1978, skydiver Jean-Claude Bétemps stood with his friend André Bohn on Mont Pertuiset, overlooking Mieussy in France. He took the risers of his parachute in his hands and ran headlong down the slope. The canopy filled with air, and Bétemps lifted off, flying to the valley floor. Bohn soon joined him, and paragliding was born.

Since that day, paragliding has evolved to become the dominant form of free flight. Free flight is flying without an engine, and includes sailplane gliding, hang gliding and wingsuit flying. The introduction of new materials, such as lightweight and durable fabrics and lines, as well as improved aerodynamic understanding, has revolutionised glider construction. The paragliding cross-country distance record is now 612 km in a single unpowered flight, and the (voluntary) altitude record is 8,407 m without oxygen.

Paragliding meets alpinism

Forty-four years after Jean-Claude and André, on 26 June 2022, paraglider pilots and alpinists Jake Holland, Will Sim, and Fabi Buhl took off on paragliders from the hot, dusty slope above the village of Karimabad in Pakistan (2,900 m). They used rising air to climb to over 6,000 m and flew 20 km along the south side of Ultar Sar. Putting on skis in midair, they landed on the glacier at the base of the Gulmit Tower (5,801 m). At 2 am the following day, Will and Fabi made the first ascent of the 900 m west face. The team flew back to Karimabad later that same day, although Fabi initially struggled to take off in the changing conditions. By flying in, they avoided the four-day, steep, avalanche-prone trek in and out that had hampered previous expeditions. The story is told in Jake Holland’s fantastic movie, A New Way Up.

Manufacturers are now releasing ultralight paragliding wings and harnesses specifically designed to support other mountain activities, like climbing or running, including single-surface descent wings weighing less than 1.5 kg. These advances have made paralpinism, a combination of paragliding and other mountain activities (sometimes called “combos” for short), a viable approach for alpine exploration. Athletes are using paragliders to access new lines, as well as routes which have become less accessible as the snowline recedes with climate change (for example, the Pas de Chèvre in Chamonix). This year, mountain guide Benjamin Védrines climbed K2 without supplementary oxygen in just 10 hours 59 minutes and 59 seconds – a new record – then flew down on a specially designed wing weighing just a kilogram. Some athletes, like Benjamin, use paragliders primarily for descent at the end of a route. Others, like Jake, Will and Fabi, use them to ascend, fly cross-country to access the route, and then to return home.

Training and preparation

Paragliding is a highly technical sport, as is alpinism. To combine them, athletes must acquire the necessary portfolio of technical skills, both in the air and on the ground, as well as physical fitness and suitable equipment. Sadly, there have been accidents precipitated by athletes without paragliding backgrounds not taking the time to learn the skills and the meteorology necessary to fly safely in the mountains. Athletes who only fly paragliders for descent in still air are sometimes caught out if they launch early or late, finding themselves in thermic conditions, strong winds or turbulent lee sides. Equally, paraglider pilots can find themselves ill-equipped if they land on a high, crevassed slope. On 26 June 2019, over 150 paraglider pilots took advantage of a high cloud base to land atop Mont Blanc (4,810 m), most without mountaineering equipment. Some struggled to launch again, becoming quickly exhausted due to the altitude. One pilot slid down the face of the mountain to his death. No matter their background, once in the air an athlete is a pilot, and once on the ground they are an alpinist, and therefore must ensure they are sufficiently skilled in both.

Take off and outbound flight

The first hurdle of paragliding is getting airborne. The pilot faces into the wind and lifts the glider above their head. The pilot then walks or runs forwards until the ground falls away beneath them and they take flight, supported by the glider. Strong winds or thermals, steep or uneven ground, or being heavily laden with equipment can make take-off a challenge. In the outbound flight, paralpinists may be flying with skis, climbing gear and camping equipment. The added weight increases airspeed, while lightweight mountaineering harnesses have limited (or absent) back and pelvis protection, compared to regular paragliding harnesses. Collectively, these increase the likelihood and potential severity of injury from a fall, or from being dragged along the ground following a failed take-off.

Once airborne, the paralpinist sets course for their objective. Flying paragliders in the high mountains is challenging, navigating strong thermals and equally strong areas of turbulence through complex terrain to the objective. The need to search for lift means success isn’t guaranteed; often a circuitous route is required, and athletes flying together can become separated. Paralpinists have the potential to gain over 5,000 m in altitude in flight, limited only by the height of the clouds and the strength of the winds aloft. In flight they can face hypobaric hypoxia, acceleration (G) forces, wind, cold, and UV radiation. There is even the (theoretical) potential for decompression illness, the bends, though there have been no documented cases.

Landing high

Landing at high altitude is technically demanding. Thermals coalescing at the top of the terrain can make it hard to touch down, with risks of overshooting or falling back into the lee side of the ridge, precipitating a wing collapse close to the ground. It is also possible to tumble on landing, especially if the ground is snowy or uneven. Landing on skis helps dissipate speed and maintain balance, but requires the paralpinist to put their skis on in the air before landing, removing their hands from the controls for several minutes to do so.

Once on the ground, the hazards depend on the planned activities, which are typically climbing or skiing on glaciated terrain. The final consideration is the return flight. If the wind drops to nothing, it can require considerable effort to take off at high altitude, as the wing requires a higher airspeed to generate lift. If the winds are too strong, become katabatic (a strong, cold, backwind) or the mountain becomes covered in cloud, then launching can be impossible. In either case, the paralpinist risks becoming stranded until the weather improves.

Antoine Girard’s ascent of Diran (7,266 m) on 3 July 2023, two years after his ascent of Spantik (7,022 m), typified these risks. Antoine took off at 2,900 m carrying 30 kg of equipment. He flew 23 km, landing at 2.35 pm at 6,750 m on Diran’s West Ridge. He cached gear and reached the summit at around 8 pm, first with skis, then with crampons. Antoine was insufficiently acclimatised to spend the night at the summit and so he descended in the dark to 6,450 m. Fighting exhaustion, he waited out the night in a tent, developing vomiting, mild confusion and loss of coordination, all signs of cerebral oedema. He had acetazolamide and dexamethasone but could not take either due to vomiting. He hoped to fly down at first light, but the winds were too strong at his altitude. A storm was coming, and he needed to get lower to have any hope of taking off. Antoine descended on foot, exhausted and ataxic, through heavily crevassed terrain. A snowbridge gave way beneath him, and he fell 2 m into a crevasse. He was able to self-rescue and continue down to a suitable take-off, launching from 6,150 m at 11:20 am, moments before the storm, and landing safely but exhausted in Karimabad 40 minutes later.

Adventure medicine considerations

Hypobaric hypoxia

In our experience, the relative ease of climbing to extreme altitudes in a paraglider, and the (mis)perception of being relatively unimpaired while in flight, can lead athletes to overestimate their degree of acclimatisation and underestimate the risks of hypoxia, and the challenges of a prolonged period of physical activity at altitude.

As medics, we should help athletes understand the insidious nature of hypoxia, and how symptoms and susceptibility can vary within and between individuals. This includes the potential “hangover effect” of hypoxia once back at lower altitudes. Athletes are often reluctant to use oxygen, as even systems designed for mountaineering are relatively complex, heavy and bulky. This places a premium on an effective acclimatisation strategy. In many ways, paragliding is actually quite enabling for acclimatisation. Repeated flights have the potential to be mildly acclimatising in themselves, as they often add up to several hours in hypobaric hypoxia. However, it is the opportunity to land at progressively higher altitudes, exercise, sleep, and then rapidly return to lower altitudes for further training and recovery that offers more flexibility than traditional alpinism. In effect, paralpinists can both live high and low, while training high and low. Anecdotally, we have found that ‘one night high, two nights low’ appears to balance acclimatisation alongside rest and recovery, optimising performance in paralpinists. Clearly, this strategy is dependent on finding suitable landing sites at progressively higher altitudes. Care should be taken to choose sites where walking down is a possibility if symptoms of altitude illness develop.

Environmental protection

Athletes need to manage both heat and cold. On takeoff, dressed for higher altitudes, athletes will rapidly start to sweat in the heat of a low, sunny takeoff. Once in flight, they will experience falling temperatures and increasing wind chill as they climb higher. Paraglider pilots fly with their hands above their heads, armpits and wrists exposed to the apparent wind and fingers looped around the control handles, so they are particularly vulnerable to cold hands. We need to strike a compromise between preventing cold injury while maintaining sufficient dexterity to control the paraglider and deploy a reserve parachute in an emergency. We have found a down layering system with a wind-impermeable outer shell, an insulated helmet and electrically heated gloves to be most adaptable to conditions. A harness with a leg cocoon effectively shields the lower limbs. A plastic bag, placed between the socks and boots, can prevent sweat soaking into the boots on takeoff and can be removed once landed at high altitude. Ski goggles suitable for bright light and a buff/balaclava offer UV protection. Paraglider pilots tend to produce an excess of dilute urine, likely due to cold, hypoxia, and semi-recumbent positioning in the harness. As in alpinism, we should encourage paralpinists to eat and drink to maintain performance. Nutritional requirements will depend on the planned activities, but in general, we would suggest a diet prominent in complex carbohydrates and hydration with an electrolyte-rich solution, both whilst in the air and on the ground.

Preparation for stranding

As with Fabi and Antoine, we need to make sure that paralpinists are adequately prepared for being unable to fly down. This might be due to adverse weather, terrain, damage to equipment, physical incapacitation or injury. In addition to progressive acclimatisation, it’s worth considering offering education and rescue medication in case of altitude illness (acetazolamide, nifedipine and dexamethasone). Ensure there is sufficient food, water and shelter. If equipment must be divided between several paralpinists, leave the last person to fly home in possession of the stove, shelter and rescue medication in case they become stranded.

Trauma and first aid

We suggest a minimalist first aid kit, suitable for treating bleeding and isolated limb injuries: typically, a trauma bandage, gloves, two flexible aluminium splints (SAM splints), gauze and zinc oxide tape. We have offered selected paralpinists training and access to methoxyflurane as a strong analgesic, given its light weight and ease of administration by non-medical personnel, particularly in facilitating splinting. There may even be an argument for tranexamic acid if an autoinjector becomes readily available.

Casualty evacuation and communication

The range of modern paragliders, alongside the possibilities of stranding, altitude illness and trauma, makes casualty evacuation planning complex. If the paralpinist cannot find lift during the outbound flight stage, they may land anywhere en route. At their objective, they may need to divert to another landing if the conditions are unsuitable. They may land somewhere inaccessible by foot, preventing the paralpinist from descending or a rescue party from reaching them. In many parts of the world, helicopter coverage is inconsistent, and the insurance situation is fluid. While the specifics of a casualty evacuation plan will vary by location, we stress the importance of detailed route discussion, including alternative landing sites, during the planning phase, then multiple channels of communication while underway.

Pilots typically fly with a variometer/GPS instrument to assist with thermal optimisation and navigation. We use Very High Frequency (VHF) radio for conversation in flight, and high-resolution 4G live tracking via mobile phone, backed up by a satellite tracker/messenger to transmit position (for example, Garmin InReach). Then, when the paralpinist is on the ground, a combination of local mobile phone, VHF radio and satellite tracker/messenger. Paraglider pilots often fly near one another, and alongside other soaring aircraft such as sailplanes. Flying paragliders into clouds is a breach of aviation law and risks collision with terrain or other aircraft. However, on occasion, pilots misjudge the strength of lift and can be sucked into clouds. This is highly disorientating. A ball compass can help maintain heading, and FLARM, an automated radio-based collision avoidance system, is being encouraged by aviation authorities to make paragliders electronically conspicuous to other aircraft nearby.

Paralpinism is an attractive new approach for mountain athletes seeking rapid access to new or otherwise inaccessible routes. Its popularity will likely increase as the equipment continues to improve and climate change pushes the snowline ever higher. It also makes for engaging social media content. There is rich potential for research, particularly into optimum acclimatisation and performance strategies, given athletes have the freedom to climb, camp and descend via paraglider. Paralpinism is also endlessly exciting to support from an adventure medicine perspective, combining the challenges of several sports at once, multiple environmental stressors, nuanced human factors and complex logistics.

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After completing their foundation training in the UK, Calum and Ellen moved out to New Zealand in 2022. They chose to swap life on the wards to explore the world of Urgent Care. Alongside varied case loads and improved work-life balance, they’ve also had the opportunity to adventure through the wilds of Aoteoroa.

What is Urgent Care? / Our Journey with a Move to New Zealand

We moved to Aotearoa in August 2022 after finishing Foundation Training in the UK. We had always wanted to relocate to New Zealand and started looking for jobs in late 2021. Whangārei, in the Northland region, caught our attention with its stunning beaches, surf breaks, and mild winters. So, we began making inquiries. Initially, we reached out to the local hospital and some locum agencies, but things were moving slowly, so we broadened our search. That’s when we discovered Whitecross Whangārei, an Urgent Care clinic, and decided to get in touch.

At that point, we didn’t know much about urgent care, so we had to do some research. Urgent care is a unique medical specialty in Aotearoa, New Zealand, sitting between General Practice (GP) and Emergency Departments (ED). It provides walk-in services for a broad range of conditions—from something as simple as paronychia to more serious concerns like chest pain, and everything in between. It’s a fast-paced and exciting field with excellent support and great working hours.

Things moved quickly once we contacted Whitecross Whangārei. We were connected with the recruitment team in Auckland, and after an interview, they helped us with the visa application process, indemnity insurance, clinic placements, and scheduling. We arrived in New Zealand in August 2022 and spent a couple of weeks in Auckland orientating ourselves. This time involved shadowing Urgent Care College fellows, getting familiar with clinic systems, and learning about the common cases seen in urgent care. We were surprised to find that many other Brits had also ended up in urgent care! In September 2022, we moved to Whangārei to begin our roles. The initial supernumerary roster provided a soft landing while we got used to a new healthcare system and a new country.

Since arriving in New Zealand, we’ve worked for Tamaki Health, one of the country’s largest primary care providers. They were incredibly supportive throughout our relocation and reimbursed our moving expenses. We typically work around 35 hours a week, with flexible shifts that offers the option to pick up extra hours if desired. After working long shifts and nights in the UK during the COVID-19 pandemic, the reduced hours and extra free time have been a welcome change. With three days off each week, we’ve had the chance to explore both the North and South Islands, especially the Northland region, including the Far North and Bay of Islands. The hiking, bikepacking routes, and beaches here are some of the most beautiful we’ve seen.

Varied Caseload

Urgent Care is the realm of the generalist and the caseload was very varied. Despite White Cross being only a 5 minute drive from the hospital, we would often see acute life threatening emergencies amongst the day to day minor ailments and GP overflow – one particular patient was adamant their chest pain was related to too much bodyboarding the day before, yet they were clearly in Rapid Atrial Flutter with a HR 220! Multiple health and inequality factors influence the acuity and presentations we have seen in Urgent Care in Whangārei. We have both seen presentations of Acute Rheumatic Fever, exposure to which we would not have had if we had continued working in Scotland. We have both managed patients presenting acutely with Meningitis, Subarachnoid Haemorrhage, Kawasaki Disease and Septic Arthritis. Working in a rural part of Aotearoa has also given us new skills which we hadn’t anticipated, such as, removing Kina spikes (sea urchin), suturing surfboard fin injuries and metal from corneas from backyard welding. Also dealing with unexpected results, such as a patient who had just walked a few kilometers into town after machinery fell onto him in his own garage two days prior, whose chest xray showed a ruptured diaphragm – never trust a farmer! However, in all of these cases we dealt with – we worked as a team, had support, excellent experienced staff on site and very helpful colleagues in the hospital for advice.

Careers in Urgent Care

Every day is different, and the saying “you never know what’s going to walk through the door” couldn’t be more accurate. The shift from hospital medicine to community care was a challenge at first, but we received excellent support from senior doctors at the clinic—many of whom are fellows of the Urgent Care College—as well as local GPs. The relationship between clinics and secondary care services is strong, ensuring that patients needing hospital care are referred appropriately.

New Zealand has its own dedicated training programme for Urgent Care, typically taken after foundation training. This pathway offers a chance to explore options beyond hospital medicine and can sometimes act as a stepping stone to a career in General Practice. You can secure a position in an Urgent Care Centre where you’ll start with supervision before working independently, however, senior staff are always available for advice if you face any tricky cases. Unsurprisingly, several colleagues who also relocated from the UK have since pursued the Urgent Care training programme, a four-year course that combines clinical work in Urgent Care clinics with experience as registrars in emergency departments. This provides a well-rounded experience across a wide range of medical cases.

Adventures

We were very fortunate that our amazing practice manager (Dan) organised our rota so we could work the same days and was very flexible with leave requests. This allowed us time to explore the North Island extensively when we first moved out, equally being the ‘Winterless North’ and coming from Scotland, we were able to comfortably continue our adventures late into winter. Highlights besides some new hobbies of fishing, golf, flying lessons and surfing, were our day hikes out to ‘huts’ aka ‘bothies’.

We recently completed an overnight hike on the Cape Brett Track. It’s a 16km track through native bush in Northland, through rough and steep terrain with amazing coastal and cliff views along the way. Bringing all of our gear was hard work, but worth the effort when we made it to the ‘hut’ which was an old lighthouse keepers house. From there you can fish, kayak and swim at the remote headland and folk often get the water taxi back to the nearest pier, however, with the wind and waves picking up that evening there was no way back apart from the track back to the start in the morning. The reward: we were treated to an amazing sunrise on our return and a hearty soup and a sandwich when we got back to Russell later that afternoon.

We also recently completed an overnight hike in Fowlers Pass staying at Stanley Vale Hut. We chose this primarily as we were able to bring our dog along with us too! This was another 16km track in Northern Canterbury in the South Island, the terrain/fauna/climate is completely different. Impassable in the winter due to risk of avalanche, we waited until Spring to complete this which made the multiple river crossings particularly chilly! However, despite wet feet we had glorious sun all the way and our dog Indie had such a blast. We camped outside the hut with Indie and her own sleeping bag (of course) and slept under the stars. We will definitely do this route again as it links up with other trails in the area for an extended multi-day hike and stay at the other huts in the area along the way.

Onwards to Primary Care

After two years in Whangārei, we decided to explore new opportunities for our GP training, and so, we’ve relocated to Ōtautahi (Christchurch). Working in Urgent Care has been a great foundation for moving into primary care. The variety of conditions seen—everything from infants to the elderly, and everything from orthopaedics to obstetrics, gynaecology, and ENT—has greatly expanded our skills. The day-to-day challenges are similar to what we encountered in the UK, though one key difference in New Zealand is the partial patient funding for healthcare, which can complicate decision-making when patients are unable to afford certain treatments or tests. Despite this, the skills and knowledge required are transferable between both countries.

UK vs NZ

We were eager to pursue GP training in New Zealand rather than the UK. Both countries offer three-year training programs, and UK graduates are welcomed into New Zealand’s programme. One of the key advantages of training in New Zealand is that no entry exams (such as the MSRA) are required after completing foundation training. The program is community-based, with no mandatory hospital rotations. The first year typically involves two six-month rotations, while the final two years are spent working within a practice arranged by the trainee.

Applications

The application process is straightforward: contact the Royal New Zealand College of General Practitioners, submit your application along with your CV and references, and if your qualifications align with the program’s requirements, you may be invited for an interview or directly offered a position.

Trainees can choose to be College-employed or Practice-employed for their first year. College employment is the standard route, offering a salary and covering costs for exams, registration, and access to the annual conference. Practice employment requires negotiations with a GP practice, which can be more difficult outside of New Zealand, but it offers the benefit of choosing the specific practice for training. In terms of teaching, New Zealand’s GP programme includes weekly in-person teaching days and 1.5 hours of in-house teaching each week with a GP supervisor.

Options to Explore

If you’re thinking about making the move to Aotearoa, Urgent Care could be a great option to explore!

Tamaki Health, one of the largest primary care providers in New Zealand, runs numerous clinics across both the North and South Islands. They list job openings on their website but you can also contact Carlos Jimenez directly with your CV, experience, and preferred location. While experience in both Emergency Departments and General Practice is usually expected, there’s flexibility depending on your previous experience and roles.

Throughout our journey, we’ve felt incredibly supported. Tamaki Health has been a fantastic employer, genuinely valuing its staff and their well-being. Living and working in such an incredible country has been a privilege, and if you have any questions or would like to know more, we’d be happy to help.

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Since graduating five years ago, Dr Munro Moffat has spent time working in Zambia, Gambia, and now Japan. He has a special interest in global health and expedition medicine and has been an expedition medic in Morocco and recently completed the Diploma in Tropical Medicine and Hygiene. Outside of work he is usually found rock climbing or scrambling around the north of Scotland. After stumbling across an Adventure Medic facebook post advertising the job, he found himself working at a ski clinic in rural northern Japan for the winter.

This winter I spent my weekends cruising down fresh powder snow and my weekdays reducing shoulders and assessing knee injuries. This was through the incredible sports medicine and general practice training programme at Niseko International Clinic, Japan. Niseko, situated in northern Japan, famed for fresh powder snow, is a world class destination for snow sports. During the busy winter months, Niseko transforms as seasonal workers and tourists descend on the area for their chance to ride on the slopes by day and enjoy the culinary delights of Japan by night.

What is the Niseko International Clinic?

Niseko International Clinic is a private medical facility providing medical care to tourists and residents during this busy time. With English speaking staff and a focus on snow sport related injuries, the clinic itself is one of a kind in Japan. For the past two years the clinic has taken on international doctors for a sports medicine and general practice training program, and I was lucky enough to be offered one of these roles for the 2024/2025 winter season.

What was working at the clinic like?

In the busy months there was an endless supply of snow sport related injuries. As a novice skier, this definitely forced a moments pause before venturing onto the slopes to learn to ski myself. The clinic could see over 150 patients a day, with somewhere between three to five doctors on duty. Although I have worked in emergency departments in the UK for over a year, I had never had the opportunity to reduce fractures or dislocations. Becoming proficient in these skills was perhaps the best aspect of my time here. With no radiographers at the clinic I was also expected to perform my own x-rays. Having immediate access to the x-ray machine and being able to easily gain extra views proved very useful at picking up more subtle fractures.

Beyond the trauma, the clinic also runs a fever clinic. This aims to funnel the coughing and febrile patients away from the main clinic. I was initially sceptical of the positive pressure trailer used to replenish air within it every 15 minutes and maintain airflow away from the staff. However, after seeing respiratory tract infections multiple times a day and remaining well throughout the season I have become more trusting of it. There was a daily barrage of influenza patients and being able to confirm the diagnosis with point of care testing made the inevitable conversation around antibiotics far easier. Japan is incredibly liberal at prescribing antiviral medications for viral infections such as influenza, including a single dose inhaled medication called Inavir; not licensed in the UK. People fly from all over the world to Niseko, bringing with them infections that would not otherwise be seen here. I saw three confirmed cases of Dengue fever during my time here, a disease which is not endemic to Japan.

Management of typical injuries

There are significant differences in the presentations from snowboarding and skiing related injuries. Common to both were rib fractures, head injuries, shoulder injuries, and lacerations from ski or snowboard edges. In my experience, concussion patients receive a relatively poor standard of care in the UK. This usually consists of telling the patient there is no specific treatment and warning them of red flags to look out for. One great aspect of the clinic was working closely with the sports physiotherapy team. They are much more proficient at managing concussion;  with their support we were able to offer our patients a more structured approach to both returning to daily life and returning to sport. We recorded their symptoms on the Sport Concussion Assessment Tool 6 (SCAT6), and provided them with a six step approach to returning to sport. The SCAT6 allows a more objective measure of their symptoms, helping any progress, or lack of, to be more easily identified.

Snowboarders commonly injure their wrists and ankles, while skiers commonly injure their knees or Achilles (one particularly unfortunate patient suffering from bilateral Achilles tendon rupture). Amongst the paediatric skiing population we saw a high number of mid-shaft tibial fractures. For wrist injuries we saw daily distal radial fractures, providing the opportunity to learn how to perform haematoma blocks to reduce these.

Japan has more MRI machines per head of population than any other country in the world making access to MRI as easy as you would expect. With this “on the day” or next day MRI service we were able to guide holiday makers through their choices concerning their injuries and ongoing travel.

The patients themselves presenting to the clinic vary in their financial means and background. The seasonal workers tend to have limited means and live in overcrowded accommodation. As a result, scabies was a constant battle throughout the season. Perhaps another consequence of the cramped living conditions was the ever increasing burden of STI’s as the season progressed. In stark contrast to this, the holiday makers tended to come from very affluent backgrounds, with celebrity and royalty passing through the clinic. 

How was it working in private practice?

Japanese health care runs on a government sponsored health insurance programme. You pay a monthly premium for your health insurance entitling you to 70% off your, already heavily regulated, medical bill. Tourists are not eligible for this and so for the non-resident patients the clinic runs as a private medical practice. Like most doctors practising in the UK, this was my first experience of working in private practice. Adding a list of billable items at the end of my notes was certainly a novel experience, but there were benefits. It facilitated more of a conversation with patients about their treatment. Offering them a range of services and explaining what they needed and then the available optional extras became part of my practice. An example of this would be getting an MRI. Even if an MRI was needed, there was often not a clinical need for it to be done in Japan and it could wait until that individual went home. However, patient preference may be to get some answers sooner in order to give them some diagnostic certainty to aid their ongoing holiday plans. 

Being in a position to advocate for physiotherapy was great. In the UK physiotherapy on the National Health Service is limited, and often reserved for those we feel really need it. On the other hand, it became very uncomfortable when you felt like a Japanese government health insurance holder would benefit from something such as physiotherapy or STI screening, only to inform them that this would not be covered and thus an additional cost.

What are the challenges of working at the clinic?

Given how well set up the clinic is (with x-ray facilities, ultrasound, and in-house blood testing), it is easy to forget how remote Niseko is. This sometimes means rationalising medical decisions to adapt to the limitations of the local health service; a daunting experience. With no official emergency department, the out of hours service at the local hospital could be run by anyone from a dermatologist to a general surgeon. On top of this, hospitals can, and do, refuse to take patients if they feel they do not have the capacity. Depending on the ailment of your patient, you need to have a much higher threshold for referring them for inpatient management out of hours. One patient attended with abdominal pain and with the onsite blood testing was diagnosed with pancreatitis requiring hospitalisation. At this stage we started calling local hospitals but the referral was repeatedly declined. The clinic has no inpatient facilities or out of hours service, but with no safe place for the patient to go, staff stayed until eventually a hospital over two hours away agreed to accept the patient.

One rather unexpected challenge of my time at the clinic was managing the regular medication supply issues that occur across Japan. Whilst I was there the country experienced shortages of antibiotics and the highly used lidocaine. Penthrox is not licensed for use in Japan and the standard management at the clinic was intra-articular lidocaine for reducing anterior shoulder dislocations. The shortages forced us to do reductions without supporting analgesia.

What do you do in your downtime?

Putting shoulders back in and reducing distal radial fractures is definitely satisfying, but it is the snow that draws people here. I came here as a total novice on the slopes, but spent most weekends skiing. If you are experienced then there is an incredible world of backcountry skiing to explore. Strapping on your skis and flying down the local volcano (Mt Yotei) is a rite of passage for travellers to the area, but well beyond my skillset! When I could pull myself away from the powder there were many other treasures to explore in this often overlooked part of Japan. I experienced various snow festivals in nearby towns (think building sized snow sculptures) and tried ice fishing on a nearby frozen lake. Many of my evenings were spent in onsens (Japanese hot springs) and delving into the incredible culinary world of Japan. One of the greatest delights of Japan is going to the toilet. Never again do I want to suffer through an unheated toilet seat!

How to get involved

At the time of writing, applications for the 2025/2026 winter season were open. The position is not salaried, but my flights and accommodation were covered and I was given a stipend which was enough money to live off and enjoy life here. Medical Indemnity is also provided through the clinic. The medical director, Dr Moroi, is very supportive and takes the training aspect of your time here seriously. Any qualified doctor with at least 3 years of practice behind them can apply. I came out here with my wife and son and we have had an incredible experience as a family. Other doctors have come out on their own. A background in general practice, emergency medicine, or orthopaedics would suit the position best.

If this sounds like your dream job and you are willing to move to Japan for the winter, then reach out to Niseko International Clinic through their website or facebook page.

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From hammocks, mosquitoes, and beaches in paradise, to health care and humanitarian work in the jungles of Panama. Noemi is a physician specialising in gynaecology and obstetrics. She has an interest in mountain and expedition medicine following successful completion of both Diploma in Mountain Medicine and Masters in Extreme Medicine. Her passion lies in providing humanitarian care in remote and rural environments. Noemi is especially keen to advocate for women’s health, and in this article describes her work with Floating Doctors in August 2023.

Why Humanitarian Work? And Why Floating Doctors?

Choosing to engage in humanitarian work is not a decision to be taken lightly; it is a deeply personal choice that requires careful consideration. You must recognise the responsibility it entails, as well as your own abilities and the potential challenges you may face.

Finding the right organisation that aligns with your values can be a complex task and demands thorough research. Ultimately, I chose to work with Floating Doctors. This organisation provides community-based healthcare to rural, indigenous communities, where issues such as women’s and maternal health are particularly significant.

About Floating Doctors

The foundation for Floating Doctors’ mission was laid in 2010 during the massive earthquake in Haiti. Floating Doctors travelled there in the converted aid ship Southern Wind with 20,000 pounds of medical relief supplies.

Since 2011, Floating Doctors in Panama has been working to build and establish a permanent, sustainable programme for rural health services and community development aid in Panama. The programme covers a large part of the many small islands of Bocas del Toro, some of the more remote rural areas and is often the only medical, veterinary, or dental help within a radius of several kilometres. The Floating Doctors mission is “To reduce the present and future burden of disease in the developing world, and to improve healthcare delivery worldwide.”

For more information about Floating Doctors, see here.

What to expect upon arriving in Bocas del Toro and at the Floating Doctors Base

From Bocas del Toro, a boat transports all the volunteers to the Floating Doctors Base on Cristóbal Island. I arrived on a Sunday accompanied by six other volunteers. After settling into our rooms and receiving a brief introduction we gathered for dinner. During the meal everyone introduced themselves, both volunteers and permanent staff. The atmosphere at the Base was warm and welcoming, which immediately created a positive vibe. The volunteers came from diverse backgrounds, including doctors, dentists, veterinarians, physiotherapists, and nurses, as well as non-medical volunteers who assist with logistics and the general upkeep of the Base. People had travelled from all over the world.

Life on the Floating Doctors Base

The Base is powered by solar energy. There is a volunteer house where all the volunteers sleep, usually in bunk beds, with rooms accommodating up to four people. During my stay however, each volunteer had their own room. The number of volunteers fluctuates regularly. Mosquito nets and fans are provided for comfort. There is also a large washhouse with showers and toilets, as well as smaller cabins by the seaside for the permanent staff. The central communal building houses the kitchen, dining area, pharmacy and there is also a small meeting room available for general use. Three meals are served each day on weekdays and the food is always delicious. In your free time you can play volleyball, enjoy the surrounding sea, go snorkeling or try fishing. You can also experience the stunning bioluminescence in the water and gaze at the breathtaking stars in the sky.

Days at Clinics

Every day after breakfast, the cayuco (a traditional boat) is loaded with all the necessary equipment for the clinics. Everyone pitches in to help carry everything. Clinic weeks are organised into single-day and multi-day clinics.

Single-day clinic from Tuesday to Thursday

Monday serves as an introduction day, providing time to prepare for the clinic days ahead. From Tuesday to Thursday, we load the boat in the mornings and travel to the community. Once there, we set up the clinic and treat patients throughout the day. Around 4:00-4:30 p.m., everything is packed up, the cayuco is loaded, and we return to the Floating Doctors Base where we primarily sleep.

Multi-day clinic from Monday to Thursday

For communities that are further away, where a return trip within a day isn’t possible, a multi-day clinic is organised and we stay on-site overnight. These communities are typically large, with the number of patients exceeding the capacity of a single day, so treatment is spread over several days. During a multi-day clinic, volunteers sleep in hammocks within the community, and local residents cook for us.

Depending on your proficiency in Spanish, you will be assigned a translator from the Floating Doctors team. The team makeup changes daily, which allows you to get to know a broad range of colleagues quickly. An additional table is set up for nurses during clinics to record the vital signs of all patients, which may also include tests such as pregnancy or blood sugar measurements if necessary. Dentists, veterinarians, and physiotherapists usually work in separate areas with their patients when possible. Each community is generally visited by the Floating Doctors team approximately every three months.

Common illnesses and presentations

The most common conditions we encountered included fever, worms, scabies, various rashes, coughs, hypertension, diabetes, cataracts, musculoskeletal pain, headaches, dehydration and contraceptive injections. We also saw rarer conditions, such as leishmaniasis and a cheek abscess.

In general all doctors work as general practitioners, though they also treat patients related to their specialties. Given my training in obstetrics and gynaecology, I primarily cared for pregnant women and women with gynaecological concerns. Whenever questions arose regarding unclear or complex medical cases during the clinic, we could always refer to the treatment guidelines to determine the best course of action according to Floating Doctors’ standards. If needed, we could also seek advice from the Lead Medical Provider.

Special Cases

Case 1:

A little girl, around 10 years old, came to us saying that something was stuck in her ear and moving. She was so frightened that she could barely allow us to examine her. After gathering her courage, we used an otoscope and discovered a cockroach in her ear canal, which was moving but stuck. We couldn’t reach it with forceps, and the girl was too afraid to let us use them, so our Plan B was to apply coconut oil overnight to help the cockroach “slip out.”

We offered the family the option to return the following day if the condition hadn’t improved. Since the family didn’t return, we assumed the cockroach had eventually made its way out of the ear.

Case 2:

A 19-year-old pregnant woman came to our clinic. It was her first pregnancy, and she had never had a prenatal check-up. She planned to give birth at home, as is common in these communities. She reported that she could barely feel the baby moving. Given the size of her abdomen, it was clear the pregnancy was quite advanced. At that moment, the ultrasound machine was broken, and we had no ear trumpet with us, so we couldn’t check the baby’s heartbeat. After further examination and calculating her due date, we realised she was already 21 days overdue.

From a medical standpoint, it was evident that she needed to be hospitalised immediately. However, as is common in these communities, the inhabitants were very poor, and the boat ride to the mainland was prohibitively expensive. As a result, the young woman initially refused to go to a hospital. After lengthy discussions and a lot of persuasion, we were finally able to convince her to take a boat to the mainland and seek medical care at a clinic as soon as possible.

The uncertainty about whether the birth went well or whether complications arose—potentially with serious consequences—is one of the most challenging aspects of humanitarian work. It is a concern for every medical professional dedicated to helping those in need.

In a humanitarian setting diagnostic and treatment options, as well as available equipment, are often very limited. You can only provide the best advice and care possible with the resources at hand. Ultimately, it is up to the patients whether they follow the recommendations or not. Since we only visit the same community every few months, we must wait to find out if the patients followed our advice or treatment plans.

Fridays and Weekends

On Fridays, the pharmacy is thoroughly checked, and medicines are restocked, including all long term medications for patients with long-term conditions who will be seen the following week. Every Friday at 2:30 p.m., the boat to Bocas del Toro departs, allowing all volunteers to enjoy a well-deserved weekend in and around Bocas Town.

There is much to explore in and around Bocas del Toro. While Bocas itself is known as one of the most famous party destinations in Central America, the natural beauty of the islands and the surrounding smaller islands is equally stunning. Whether you’re looking to surf, snorkel, dive, or simply relax on a Caribbean beach, there’s something for everyone to enjoy.

When is the best time in your training or career to work with Floating Doctors?

While there are no minimum requirements, it is recommended to have at least two years of experience working in a hospital. I also found it very helpful to have completed a humanitarian aid course from World Extreme Medicine, which provided valuable insights and preparation for the challenges of working in a humanitarian setting.

What preparation is necessary?

The organisation provides excellent preparation. You will receive online access to all treatment guidelines and standards, as well as tips on how to reach the remote base and a list of essentials for both the base and the clinic.

Tips and tricks on what you should definitely bring with you:

• Crocs
• Coconut oil for the sandflies (‘chitras’)
• Mosquito repellent
• Anti-itch cream
• Snorkelling equipment
• Water bottle and lunchbox
• Power bank
• Hat, sunglasses
• Sun cream
• Raincoat
• Drysack for boat rides to the communities

Is it possible to work with Floating Doctors in the long term or to help as a non-medical practitioner?

Yes. It is possible to take on a long-term position of 6 months or more, either as part of a fellowship or in a non-medical role at the base. There are several positions you can apply for, including:

• Volunteer Coordinator
• Facilities Manager
• Medical Director
• Lead Allied Healthcare Provider
• Lead Medical Provider
• Operations Manager
• Lead Veterinary Provider
• Health Education Coordinator
• Communications Coordinator
• Lead Dental Provider
• Pharmacy Manager
• Dental Coordinator
• Clinic Manager
• Base Supervisor
• Executive Director

Further details and requirements can be found here.

What is the application process for volunteering with Floating Doctors?

The application process was straightforward and completed directly on their website here. Within a few hours, I received a welcoming response from the organisation confirming my acceptance.

For physician applications, the following documents were required:

• A copy of the licence to practise medicine
• A copy of the certificate of graduation
• A background check with information on criminal history or child protective investigations
• A coloured passport photo
• A copy of a curriculum vitae
• Proof of vaccination against COVID-19
• Distribution Fee for Volunteers depending on the term of the stay

Is there any way to help without volunteering?

Yes! There is always the possibility to donate here.

My experience – would I recommend it?

Working with Floating Doctors was an unforgettable experience. The combination of beautiful Caribbean islands, incredible people, and the chance to provide medical care and support to local communities made it a truly enriching journey. While there were challenging emotional moments and encounters with patients facing serious health issues, there were also many rewarding treatments and individuals who left the clinic in better health. It was deeply moving to experience life alongside the locals, who welcomed me with open arms and warmth. This experience has been invaluable, and I would gladly work with Floating Doctors again in the future.

The post Volunteering with Floating Doctors in Bocas del Toro appeared first on Adventure Medic.

Kacylia Roy Proulx is a third year medical student at McGill University with an interest in expedition medicine. She took on the challenge of climbing Mount Kilimanjaro as both a personal endeavour and an opportunity to see physiology and mountain medicine in action. Here she shares what she learned preparing for and executing the climb. 

In July 2024, I embarked on one of the most transformative experiences of my life – climbing Mount Kilimanjaro. Standing at 5,895 meters, Africa’s highest peak is a challenge that demands both physical and mental resilience. As a third year medical student with an interest in wilderness, expedition and trauma medicine, this climb was more than just a personal goal. It was a unique opportunity to observe first hand the effects of altitude on the human body and connect these experiences to the research and lectures I had studied before the ascent. What I didn’t anticipate was how much the mountain would teach me – not only about medicine but also about perseverance and personal growth.

Understanding High-Altitude Physiology

Kilimanjaro is often described as one of the most accessible high-altitude climbs. It doesn’t require technical climbing skills, making it a popular destination for trekkers of all backgrounds, with approximately 35,000 to 50,000 climbers attempting the summit each year. However, while the trek itself may be non-technical, the altitude poses significant physiological challenges, reducing its success rate to about 65%.

With every 1,000-meter increase in elevation, oxygen levels decrease by around 3.5%, forcing the body to work harder to meet its oxygen demands and significantly increasing the risk of altitude sickness. To understand why, it is important to examine what happens during ascent. The percentage of oxygen in the air remains constant at 21% regardless of altitude. What changes is atmospheric pressure, which decreases with elevation. This reduction in atmospheric pressure lowers the partial pressure of oxygen – the driving force that moves oxygen into the bloodstream. At sea level, the partial pressure of oxygen is approximately 159 mmHg, but at 5,000 meters, atmospheric pressure is roughly halved, reducing the partial pressure of oxygen’s to around 80 mmHg. This explains the cascade of symptoms and physiological changes climbers experience at high altitudes.

Here’s how it works: the lungs rely on a pressure gradient to move oxygen from the inhaled air in the alveoli into the blood. When the partial pressure drops, less oxygen diffuses into the bloodstream, leading to hypoxaemia (low blood oxygen levels) and, consequently, hypoxia (low oxygen availability in the tissues).

The body has a host of physiological responses that enable it to adapt, or acclimatise, to these conditions. Within hours, heart rate rises to increase cardiac output and support oxygen delivery. The respiratory rate also increases. This hyperventilation increases both oxygen intake and carbon dioxide removal, leading to hypocapnia, which increases blood pH and induces a state of respiratory alkalosis. Whilst an alkalotic state actually shifts the oxygen-haemoglobin dissociation curve to the left, making it more difficult to unload oxygen to the tissues, the decrease in hydrogen ions that causes the alkalosis stimulates a compensatory mechanism in which 2,3-diphosphoglycerate (DPG – a compound found in red blood cells) levels are increased. This increase in DPG shifts the curve back to the right, facilitating enhanced oxygen delivery to the tissues.

Within weeks red blood cell production (erythropoiesis) accelerates and angiogenesis occurs, providing new capillaries to improve oxygen delivery to the tissues.

In the lead up to the climb, I immersed myself in medical literature on high-altitude physiology. I was fascinated by the body’s ability to adapt to extreme environments and determined to understand the mechanisms behind conditions like Acute Mountain Sickness (AMS). AMS, which can occur at elevations as low as 2,500 meters, arises when the body struggles to acclimatise quickly enough to reduced oxygen levels. Symptoms like dizziness, nausea, headaches, and difficulty sleeping are hallmark signs of AMS.

However, AMS isn’t the end of the story. If left unchecked, it can progress to severe and potentially life-threatening complications, such as High-Altitude Cerebral Edema (HACE) and High-Altitude Pulmonary Edema (HAPE), however not all who develop HACE or HAPE experience AMS symptoms. Although the pathophysiological mechanism of HACE is not fully understood, in simple terms it is thought to occur due to hypoxia-driven neurohormonal and haemodynamic changes which cause cerebral vasodilation and increased permeability of the cerebral vasculature, leading to cerebral oedema and a rise in intracranial pressure. This can present as confusion, ataxia, severe headaches, and, in extreme cases, coma and death.

HAPE, on the other hand, is caused by uneven vasoconstriction in the pulmonary arteries, a response to low oxygen levels. Hypoxia triggers pulmonary blood vessels to constrict, redirecting blood flow to better-oxygenated areas of the lungs. However, this process can occur unevenly, creating localised areas of high pressure. This increased pressure forces fluid out of the capillaries and into the alveoli thus impairing gas exchange. Symptoms of HAPE include shortness of breath, a persistent cough (classically producing frothy or blood-streaked sputum), and cyanosis. If untreated, the strain on the pulmonary circulation can lead to right heart failure, compounding the risk of fatal outcomes. Both HACE and HAPE require immediate descent and, if available, medical intervention to prevent further deterioration.

Understanding these risks heightened my vigilance during the climb as I closely monitored myself and my fellow climbers for any early warning signs. One climber in my group began experiencing altitude sickness as early as the third day of our trek, with severe vomiting, dizziness, and headaches. We immediately slowed the pace, increased her water intake, and ensured she was eating enough, as proper hydration and nutrition are essential for managing and preventing altitude sickness. While her symptoms were relatively mild, they were a stark reminder of how fragile the human body can be in extreme conditions. With rest and care she improved but remained vulnerable over the following days, requiring close monitoring for any further warning signs.

In addition to our personal vigilance, our guide implemented an important safety measure: taking the oxygen saturation levels of everyone in the group every evening. This provided an objective way to monitor how our bodies were coping with the increasing altitude. At sea level, healthy individuals typically maintain oxygen saturation levels between 95% and 100%. However, as we ascended, the reduced atmospheric pressure caused oxygen saturation levels to drop significantly. By tracking these levels daily, the guide could identify early signs of hypoxemia, which could signal an increased risk of severe altitude sickness. This allowed for timely interventions, such as slowing the pace, administering supplemental oxygen, or even descending to a lower altitude if necessary. It was fascinating to observe how individual responses varied, with some climbers maintaining relatively stable readings while others saw more dramatic declines. These small but critical measures underscored the importance of preparation, monitoring, and teamwork in tackling the challenges of high-altitude trekking.

The Role of Preparation

Preparation is the key to a successful and safe climb. For me, it became clear that understanding the medical principles behind these strategies, combined with careful personal preparation, made all the difference during my Kilimanjaro climb.

Physical fitness plays a crucial role in tackling the demands of high-altitude climbs. A higher level of cardiovascular fitness can be an advantage, particularly when adjusting to lower oxygen levels. Fitness improves circulation, endurance, and the body’s ability to handle increased strain. A prospective observational study at extreme altitudes conducted in 2023 found that climbers with higher maximal oxygen uptake (VO2 max) at sea level and moderate altitudes had a better chance of reaching the summit and a lower risk of experiencing severe altitude sickness.

Before the climb, I made sure to train specifically for the challenge. Although I maintain a baseline level of fitness, I knew that high-altitude trekking required some additional preparation. In the months leading up to the climb, I focused on hiking in the mountains near my home, particularly in the Adirondack Mountain Chain. This allowed me to simulate the conditions I would face on Kilimanjaro, testing not only my fitness but also my gear. On weekends, I would set off on longer hikes, carrying a loaded pack to get used to the strain of altitude while refining my pacing. During the week, I maintained my cardio fitness with activities like running and cycling, focusing on building endurance and strengthening my legs. Combining these different types of training helped me feel confident that I was physically prepared for the demands of the climb.

However, physical fitness alone isn’t enough to protect against altitude sickness. Even the fittest climbers are at risk, and that’s where pharmacological interventions like acetazolamide can be considered. Acetazolamide, a carbonic anhydrase inhibitor, is sometimes recommended to help prevent altitude sickness by stimulating the kidneys to excrete bicarbonate, leading to mild metabolic acidosis. As a prophylactic measure, this facilitates acclimatisation by stimulating ventilation and therefore increasing alveolar and arterial oxygen levels. Taken at altitude, this acidosis compensates for the respiratory alkalosis caused by hyperventilation, favouring increased oxygen delivery to the tissues which can help prevent and treat symptoms of AMS.

The Importance of Acclimatisation

With all aspects of preparation in place, acclimatisation became the final, essential piece of the puzzle for avoiding altitude sickness and reaching the summit. Initially, the body responds by increasing alveolar ventilation, helping improve oxygenation in the blood. As you climb higher, plasma volume decreases, which raises the concentration of haemoglobin, enhancing oxygen carrying capacity. Over time, this process stimulates the production of red blood cells, which further increases oxygen transport to tissues and organs.

Kilimanjaro’s Lemosho route, which we followed over 8 days, is renowned for its gradual ascent, allowing for improved acclimatisation. This slower pace is why the Lemosho route boasts a high success rate, ranging from 80-90%. On several occasions, we hiked to higher elevations during the day and returned to a lower altitude to sleep. This practice, called “climb high, sleep low,” is a key strategy to help your body adjust without overburdening it.

The Mental Health Component of Climbing

While physical endurance is essential for climbing a mountain like Kilimanjaro, the mental component is just as crucial – if not more so. The psychological toll of high-altitude trekking is something I hadn’t fully anticipated until I was deep into the climb. After several days of trekking, I began to notice the psychological effects of the altitude: sleep disturbance, irritability, and a constant, underlying sense of exhaustion that weighed on me more than I expected.

It wasn’t just the physical fatigue that affected me – it was the mental fatigue that came with it. The body’s struggle to get proper rest at high altitudes plays a big role. Research backs this up, showing that sleep quality significantly declines as you ascend. The lower oxygen levels make it more difficult for the body to enter the deep stages of sleep, which are essential for muscle recovery. I noticed that even when I did manage to fall asleep, I would wake up multiple times throughout the night, feeling restless and unrefreshed. This sleep deprivation, combined with the physical exhaustion, led to moments of mental struggle – times when my patience was tested, and my mood would fluctuate, making the climb feel even more challenging.

The cognitive effects at high altitude also became more evident as the days passed. It wasn’t just physical performance that I had to focus on, but mental sharpness too. Simple tasks, like remembering small details or keeping my attention on the path ahead, started to feel more challenging. Research has shown that cognitive function at high altitudes can suffer. Short-term memory, decision-making, and attention span can decline as the body adjusts to the reduced oxygen levels.

Despite these mental challenges, I found ways to cope. The climb itself, with its pole – pole, slow and steady rhythm, helped me focus on smaller, manageable goals rather than the overwhelming task of reaching the summit. I would focus on the next step, the next bend in the trail, or making it to the next camp. It was these small victories that kept me going.

The Risk of Hypothermia

As the mental and physical challenges of the climb continued to weigh on me, I was reminded that in high-altitude environments, the threat of hypothermia is ever-present. On the seventh day of our climb, we woke up at 1am, ready to start our summit push – a 7-hour climb in the dark and freezing temperatures to reach Uhuru Peak at 5,895 meters for sunrise. Despite the exhilaration of the summit, the biting cold was unrelenting. My gloves barely seemed to keep the cold at bay, and my fingers began to tingle ominously – a subtle but significant warning sign of frostnip, the precursor to frostbite.

Hypothermia becomes a real risk when heat loss exceeds heat production, especially as the body burns through energy reserves at an accelerated rate just to maintain basic functions. The body’s natural response to the cold is peripheral vasoconstriction, which diverts blood flow away from extremities to preserve core temperature. However, this process also sets the stage for frostbite in unprotected tissues.

As I stood there, I felt the conflicting pull between the desire to take in the breathtaking view and the urgent need to retreat from the unforgiving conditions. I could sense how exhaustion, combined with the freezing cold, could make it easy to overlook the early signs of hypothermia – shivering, clumsiness, and slowed thought processes. I tried to keep moving to generate heat, wiggling my toes inside my boots and flexing my fingers inside my gloves. Taking my gloves off for a quick photo was a painful reminder of how quickly the cold can penetrate; within seconds, my fingers felt as if they were being stabbed by needles, a stark indication of just how little time it takes for exposed skin to begin freezing. As I checked my hands for any signs of white or waxy skin, I was struck by how textbook symptoms suddenly felt very real.

Reaching the summit was euphoric, but the risks were impossible to ignore. The thin air and intense cold meant we couldn’t linger long. Descending felt like a race against time to escape the cold, and as I moved lower, the tingling in my fingers and toes slowly subsided, a reassuring sign that circulation was improving. This experience underscored the delicate balance between adventure and safety, between pushing limits and respecting the body’s fragility in the face of nature’s extremes.

A Summit of More Than Just Altitude

Reaching the summit of Mount Kilimanjaro was more than a personal achievement; it was a powerful first-hand lesson in the balance between human resilience, preparation, and the unpredictability of nature. The climb not only tested my physical and mental limits but also offered valuable insights that I continue to apply to my medical career. Understanding how the human body reacts under extreme conditions – whether due to altitude, trauma, or other stressors – will shape my approach to patient care.

But most importantly, Kilimanjaro, for all its beauty and challenge, has shown me that the journey to the summit is never just about reaching the top – it’s about the lessons learned along the way.

The post Where Medicine Meets the Mountain appeared first on Adventure Medic.

Theresa Menders is a documentary photographer, independent humanitarian advocate, and senior director at a global pharmaceutical company. She is earning her Doctorate of Public Health (DrPH) from the University of Illinois at Chicago and is co-author of “Psychological First Aid: Pocket Field Guide.”

When disaster strikes, whether it’s a natural calamity, forced displacement, conflict, or an individual emergency like a house fire or car accident, the immediate focus is often on addressing physical injuries and securing safety. However, the psychological wounds inflicted by such events can be just as debilitating as physical trauma. Psychological First Aid (PFA) offers a structured yet flexible framework for providing emotional support that anyone can learn. This vital skill enables individuals to assist people in distress, helping them to cope and begin their journey toward recovery.

What is Psychological First Aid?

PFA, as outlined by the World Health Organization (WHO), is a humane and evidence-informed approach designed to reduce initial distress and foster longer-term resilience. Rooted in principles of care, comfort, and communication, PFA is not a one-size-fits-all solution but rather a set of adaptable actions that can be applied across diverse contexts, from large-scale disasters to personal tragedies. Importantly, it is not therapy or professional counseling, but instead a practical, supportive response that anyone can provide.

How does it work?

PFA is based on the understanding that people affected by crises will have a wide range of reactions. Some may appear calm, others deeply distressed. Importantly, PFA does not assume all individuals are traumatized or require professional mental health interventions. Instead, it emphasizes providing immediate, compassionate support that respects the individual’s dignity, autonomy, and cultural context. Through my experience as a trained PFA provider and trainer, as well as in documenting humanitarian crises globally, I’ve witnessed firsthand the transformative impact of this approach. In refugee camps, for instance, displaced families often grapple with the compounded stresses of losing loved ones, homes, and livelihoods while navigating uncertainty about the future. In these settings, offering a listening ear, ensuring basic needs are met, and connecting people to further resources can significantly reduce feelings of helplessness and despair. Similarly, PFA is valuable in more localized emergencies. Consider a house fire where a family loses all their possessions or a car accident that leaves individuals shaken and fearful. Though less far-reaching than large-scale disasters, these situations still create immense stress for those involved. By addressing emotional needs alongside physical ones, anyone trained in PFA can provide holistic care that fosters senses of safety and stability.

Preparation for delivering PFA

Before helping individuals in distress, it is essential to prepare mentally and logistically. This includes learning about the specific context of the crisis, whether it’s a natural disaster, conflict, or an individual emergency. Preparation involves knowing your role and limitations, being aware of available resources, and ensuring your own safety and well-being. For anyone providing PFA, preparation may also mean understanding the cultural background of those affected and reflecting on personal biases to provide respectful and culturally sensitive care.
The WHO’s primary action principles of PFA can be summarized as “Look, Listen, and Link”. This approach helps guide practitioners on how they should assess and then safely enter a situation, engage with affected people, understand their immediate needs, and then connect them with the appropriate resources. These principles are designed to guide anyone, not just emergency personnel, in providing effective support.

Look, Listen, and Link

LOOK

The “Look” component involves assessing the situation and identifying who may need help. This includes: ensuring physical safety by checking the immediate environment is secure; observing for people in obvious distress, such as crying, agitation, withdrawal, or confusion; and identifying basic needs like food, water, or medical attention. Even in a local emergency like a car accident, scanning the scene and prioritizing who might need immediate support is a key first step.

LISTEN

Active listening is at the heart of PFA. This means approaching individuals respectfully, asking about their needs and concerns in a non-intrusive manner, and allowing them to share their experiences without pressure. Empathy and validation are key. Listening goes beyond just hearing words. It requires observing body language and tone, recognizing unspoken fears, and validating emotions. Simply by being present and attentive, anyone can provide reassurance and reduce feelings of isolation.

LINK

The final component, “Link,” involves helping individuals access additional resources and support. This might include providing information about available services, reconnecting people with family or community members, or referring those with severe distress to professional mental health services. Linking people to resources bridges the gap between immediate support and long-term recovery.

What PFA can offer

The benefits of PFA extend beyond the immediate aftermath of a crisis. For those receiving support, PFA can help restore a sense of control and normalcy. By addressing emotional and psychological needs early on, it reduces the risk of long-term mental health issues such as post-traumatic stress disorder (PTSD). Research shows that individuals who receive compassionate, practical support are better prepared to recover psychologically and reintegrate into their communities.

For those providing PFA, the experience can be deeply rewarding. Knowing how to offer effective emotional support fosters confidence and reduces feelings of helplessness in crisis situations. Moreover, learning PFA equips individuals with skills that can be applied in everyday life, such as active listening and empathy, which strengthen personal and professional relationships.

One of the strengths of PFA is its versatility. While the principles remain consistent, the approach can be adapted to different settings and populations. In the aftermath of hurricanes, earthquakes, or floods, PFA providers may focus on creating safe spaces, reuniting families, and addressing immediate concerns such as food and shelter. In refugee camps or conflict zones, the emphasis might shift to restoring a sense of stability and providing information about available resources. Even in individual emergencies, such as car accidents or house fires, PFA can help individuals process their emotions and connect with loved ones or local support systems. For example, during a massive power outage in an urban area, individuals trained in PFA might prioritize calming people who are panicking in elevators, assisting elderly residents who are stuck in high-rise apartments, or ensuring children feel safe in darkened spaces. Each scenario requires flexibility and sensitivity to the unique needs of those affected.

Practicing self-care as a PFA provider

While offering PFA can be incredibly fulfilling, it is not without its challenges. Providers often find themselves in emotionally charged and high-stress situations, which can take a toll on their own mental health. Recognizing and addressing this impact is critical to ensuring they can continue to serve others effectively. Practicing self-care is not a luxury, it is a necessity. Self-care begins with acknowledging your limits. Even the most compassionate helper cannot solve every problem, and accepting this reality can prevent feelings of guilt or inadequacy. Taking time to rest, reflect, and recharge after offering support allows providers to process their emotions and maintain their mental well-being. Simple practices such as mindfulness, adequate sleep, and regular meals can make a significant difference in resilience.

It is also important for PFA providers to build a support network. Sharing experiences with colleagues or trusted friends can offer relief and provide perspective. Many organizations emphasize peer support systems for debriefing after challenging situations. These conversations can help normalize emotional reactions and provide strategies for coping with future stressors. While it’s natural to want to help as much as possible, overextending oneself can lead to burnout so creating boundaries is essential. Setting clear limits on the time and energy devoted to crisis response ensures that helpers remain effective and can return to their personal lives back at home in a healthy state of mind. By prioritizing self-care, PFA providers not only safeguard their own well-being but also enhance their ability to support others in times of need.

Finding PFA training

PFA is not just for emergency personnel. It’s a skill that anyone can learn and use to make a meaningful difference in the lives of others. By integrating PFA into their communities, individuals can provide compassionate and practical support during times of crisis, helping people regain strength and hope in the face of adversity.

One of the most important aspects of PFA is its accessibility. Anyone can learn the skills needed to provide psychological first aid. The WHO’s PFA Guide for Field Workers is a comprehensive resource that outlines practical steps and strategies for offering effective support. The guide emphasizes that PFA is not therapy. It does not involve diagnosing or treating mental health conditions; instead, it focuses on humane and practical actions that anyone can take to help others in distress.

There are a number of online PFA courses available through different agencies and organizations. The UK Health Security Agency (UKHSA) offers both a general PFA course as well as a course focused on providing PFA to children and young adults in a crisis. U.S.-based Johns Hopkins University also offers a PFA course. The U.S. Center for Disease Control offers a PFA course geared toward radiation disasters, however, many of the same principles can be applied to general crisis situations.

Training in PFA typically covers scenarios ranging from natural disasters to individual emergencies. Participants learn how to use the “Look, Listen, Link” framework or similarly effective approaches, understand common reactions to crisis events, and practice communication techniques that foster trust and calm. Many organizations and communities offer free or low-cost PFA training programs, making it an accessible option for those who wish to contribute during times of need.

In a world where crises are increasingly frequent and complex, learning PFA is not just valuable, it’s essential. By equipping yourself with these skills, you can be a source of stability and resilience for those around you, transforming moments of chaos into opportunities for recovery and connection.

Links:

WHO PFA Guide for Field Workers
UKHSA general PFA course
UKHSA children and young adult PFA course
Johns Hopkins PFA course
Center for Disease Control

The post Psychological First Aid: a Valuable Skill for Everyone appeared first on Adventure Medic.

Dr Kalpanee Wijendra is working as an anaesthetics registrar in England but after the Covid pandemic and a long time working in UK ICUs she was looking to challenge her horizons. Her research and job applications took her to rural South Africa with the Tshemba Foundation where she worked alongside our very own Dr Alex Taylor. Here she explains the incredible work she was involved with, the challenges she faced and how these contributed to the truly bidirectional nature of the development and learning from such a job. 

Stepping Into The Unknown

In my experience, to go against the grain in a medical career requires bravery, determination and a sprinkle of imagination. The emphasis on trainees to meet portfolio requirements and pass exams is often at the expense of personal career goals. Although specialty training has its own challenges, demanding vast commitment and dedication, during the COVID-19 pandemic, I found myself completely exhausted from looping through the same day on ITU. I wanted a change. I was fortunate enough to stumble upon an email calling for Global Health Fellows to volunteer in low-resource settings. I sent off my application, received a place, and took a step into the unknown.

The fellowship offered multiple placements to choose from. I settled on South Africa, as I hoped it would ease my transition as an English speaker. Then I had to choose between working in a well-supported, busy hospital where my anaesthetic logbook would flourish or working in a remote rural setting, where I would be out of my comfort zone. Both scenarios were tempting for different reasons.  I chose the latter and embarked on my global health adventure. 

Tshemba Foundation

The Tshemba Foundation is a wonderful charity which provides volunteering opportunities for healthcare professionals to work in a rural hospital in Mpumalanga (Northeast South Africa). Volunteers work clinically whilst also contributing to health education and engagement in long-term local health projects. The ethos of the charity centres around sustainable change within the local community. Tshemba is unique because of its setting. The volunteers from around the world live together on a private game reserve alongside the ‘Big 5’: lions, leopards, rhinoceros, elephants and African buffalos.

For nearly 5 months I lived and worked with clinicians who had led unconventional yet fascinating lives. I was particularly inspired by a few clinicians whom I got to know very well and now regard as my mentors. A South African GP and author who has travelled the world and practiced medicine on every continent. She is a force of nature, who taught me to embrace the wilder life. Also a Dutch trauma surgeon shared his inspirational stories of treading the path less trodden and his career in the International Committee of the Red Cross (ICRC). Meeting and working alongside international volunteers were one of the many highlights of the Tshemba Foundation. They encouraged me to be fearless in taking the scenic career route, combining Anaesthesia with Global Health.

Tintswalo Hospital

Tintswalo, located in Acornhoek is a 423-bed District General Hospital in the beautiful province of Mpumalanga. Unlike hospitals in the UK, there was no consistent consultant supervising or on-call; instead, the hospital was run by medical officers of varying experience. From my observation, South African junior doctors are more generalist than their British counterparts. I was impressed to find that after only two years of postgraduate medical training, these doctors were independent in most procedures from giving a general anaesthetic to performing a caesarean section.

Challenges

The working conditions in rural hospitals are challenging for many doctors in South Africa. From my own experience and observation, South African doctors in low-resource environments, often work without basic medication and equipment. Overwhelmingly notable is the huge health inequality that exists between black and white people, even 30 years after the apartheid. These inequalities are far too complex to unpick in one article, however, I will explore a few examples that I encountered during my time in Tintswalo.

One of the biggest challenges is the long-standing water shortages which are the result of insufficient infrastructure to support the growing population. When these water shortages occur, no water is supplied to the entire Acornhoek area, unavoidably affecting the hospital. As a result, only emergency surgery such as caesarean sections can go ahead. These shortages can go on for weeks and often come without warning. The lack of water for drinking, cleaning and sterilising has a devastating impact on the local community. During my time at Tintswalo, the people of Acornhoek became so enraged that they protested outside of the hospital. This protest resulted in funds being mobilised to supply water containers for emergencies.

At the Tshemba Foundation, we were fortunate to not have water shortages, as the foundation was located half an hour away from Tinswalo Hospital in a small town called Hoedspruit. However, we regularly experienced power cuts or ‘load shedding’. The biggest personal challenge I found during load shedding was the disruption of communication with friends, family and colleagues due to cuts in the local and national power supply. Despite at times feeling isolated, the scheduled power cuts lasted only a few hours and I found the forced disconnection from the world rather peaceful, especially after the intensity of my clinical duties.

I had to alter my clinical practice based on these limitations. For example, due to a lack of availability of large-sized syringes, I had to use only 5ml and 2ml syringes when giving countless general anaesthetics and during the resuscitation of a patient in a makeshift ITU. At any given time, the hospital only had 3 units of O-negative blood available for resuscitation, therefore during surgery, I had to ensure high-risk patients were transferred to specialist hospitals and be very proactive in minimising blood loss by working closely in collaboration with the surgeons and utilising alternative products such as plasma expanders. 

I also had to adjust to working with limited medication available. For example, at the beginning of my time in Tintswalo the only available muscle relaxant was Suxamethonium, which is a short-acting muscle relaxant and unsuitable for long procedures which require prolonged intubation. I had to use muscle relaxant-sparing strategies to continue to safely anaesthetise patients. Another big adjustment was the limited analgesic options available in both the theatre and the wards. Where possible I used local anaesthetic, which was often available due to its limited use and encouraged the surgeons to do a local infiltration, which previously was not common practice in Tintswalo.

The limitations of equipment and medication, despite being inconvenient and challenging, were easier to adjust to than the emotional toll of systemic failures. These I found much more difficult to bounce back from. A particular case I found most upsetting was waiting 3 hours for an ambulance to pick up a pregnant patient whose unborn child was exhibiting signs fetal distress. Unfortunately by the time this patient presented to the hospital, we found no fetal heartbeat. Something potentially avoidable with more resource for pre hospital services.

Working Together

We often worked with the local doctors to overcome these challenges through shared decision-making. In these circumstances, it is common to feel alone and helpless, but I felt we had a lot of support from both the local doctors and the Tshemba Foundation. For example, when there is a critically unwell patient in the hospital, colleagues would rally together to help each other as there are no formal pre-allocated medical emergency teams. When the power failed and we had to stop the theatre after a spinal anaesthetic, the entire theatre team made the decision together to not operate in the dark, prioritising the safety of the patient and her unborn child. When I needed to transport a mother with fetal distress in a private vehicle, which belonged to the Tshemba Foundation, I had the full support of the group.

As a Foundation we had fortnightly debriefing sessions to jointly discuss all the challenges and barriers we were facing, and then we would work together to form solutions. This was an effective space to problem-solve and it was inspiring to see how the volunteers used their initiative and creativity to overcome challenges. For example, I wanted to encourage the identification of surgical patients earlier in the week to allow for optimisation and possible transfer to higher-level hospitals if they were not suitable for Tintsawlo. This had been historically challenging. One of the surgical volunteers after a debrief session initiated a grand round within the surgical team to identify potential patients for the semi-elective list later in the week. This changing of working culture by initiating MDT ward rounds was one of the biggest improvements within the surgical department during my time in Tintswalo, and it arose as a collaboration between the volunteers and resident doctors. 

Health Education Opportunities

During my placement, I noticed that there were gaps in nursing care in some of the medical and surgical wards. Unlike doctors, once graduated in South Africa, nursing staff are not obliged to complete further training, annual CPD courses or events. Educational activities are often not available due to a lack of funding and resources. As a result, some nursing practices are outdated and, in some cases, unsafe.

This fuelled me to devise a nurse training curriculum and deliver teaching alongside my Tshemba colleagues. We involved the senior nursing staff in the hospital and pitched the idea of a rolling teaching curriculum which covered basic observations and points of escalation. The curriculum consisted of 10 nursing topics which covered theory elements, demonstrations and opportunities to practice with each other. The sessions would last around 45 – 60 minutes, with each topic being covered a few times to enable staff from day and night shifts to attend. We set up a pilot session covering blood pressure measurement, which was observed by the head of nursing in the hospital. The pilot had a positive reception and the curriculum in its entirety was rolled out. Even after my time with Tshemba ended, the training programme has continued to be a successful initiative.

I was also able to support my junior colleagues who were thrown into complex anaesthetic cases with little experience and provided a safety net that they were not used to having. Unfortunately, I did not have any senior anaesthetic colleagues to support me, therefore the cases that I felt were beyond my capacity to resolve were highlighted to the clinical manager (the equivalent of the clinical director of a hospital), who then authorised the transfer of the patients to a higher-level hospital with consultant cover. I did find working without the direct supervision of consultants rather uncomfortable, so I ensured boundaries were established with the clinical manager about which cases I would not be able to lead on. 

The extensive knowledge of equipment needed for primary FRCA exams came in handy when I saw a donated French syringe driver lying about. I used my knowledge of equipment alongside translating apps to source consumables and write a working manual to get the syringe driver to work. This syringe driver and the manual have now been approved by the province to be used in the Tintswalo, offering the team a safe way of infusing medications.

Reflecting On My Experience At Tshemba

Upon arrival at Tinswalo Hospital, I became quickly aware that I was the most senior anaesthetist in the hospital. I realised that there were no consultants to ask for help or discuss my plans with. I felt well out of my comfort zone. The biggest adjustment for me was an awareness of the lack of safety netting which I had been used to in the way of having multilevel systems in place to prevent harm and consequently the weight of my independent decision-making. The circumstances required me to step up and take on a leadership role. There was no time to allow for self-doubt. I felt immense pressure in decision-making, especially trying to ensure I was making safe decisions in challenging circumstances.

During my time in Tintswalo and following my return to medicine in the UK, I did consider how the charity Tshemba fits into the wider picture of Tintswalo (a low-resourced district general hospital). I wondered if by volunteering we were helping bridge a service gap which potentially disincentivizes the health authorities to allocate funds to more doctors and services to help the local population. Once I understood the system more, I recognised that these systemic failures and lack of resources were present and unresolved years before the Tshemba Foundation. Also, sadly many of the local doctors are burnt out and demotivated, which means that processes such as quality improvement and education had fallen by the wayside and this is where I saw a real place for Tshemba. The projects I engaged in I felt were sustainable and hopefully contributed to ongoing patient safety. My contribution was a drop in the ocean, but I hope that it ultimately contributes to a wave of positive change.

This was the hardest anaesthetic placement of my career so far but equally the most rewarding. I felt that my presence really made a difference to the patients I looked after and the colleagues I worked with. I learnt how to adjust to an incredibly challenging environment and how to advocate for my patients and colleagues. In South Africa, I learnt to trust my anaesthetic skills and my instincts – perhaps my greatest lesson and what I treasure the most from my Global Health Fellowship.

Living and working for the foundation along with other international volunteer doctors was one of the greatest privileges of my career so far.  The Tshemba Foundation for me was a place of inspiration. My advice to anyone who is considering pursuing similar fellowships that are on offer is to go for it! Take the leap! It certainly will be the biggest challenge of your career but the best thing you will ever do.

Highlights:

• Living amongst the Big 5 in spectacular surroundings.
• Working in a low resource but highly rewarding environment.
• Travelling and making lifelong friends.
• Being part of a cause and collectively working towards supporting a community.
• Being able to do the job you love, somewhere else in the world. 

The post The Adventures of a Global Health Fellow in Tshemba appeared first on Adventure Medic.

Ben is currently working in remote primary and emergency healthcare in Papua New Guinea. The location is popular with adventurous surfers, divers, and billionaires arriving on superyachts. On occasion, they become unstuck and require emergency healthcare. Ben describes a recent case of acute febrile illness.

Abstract

This case review examines the diagnosis and management of a traveller experiencing an acute febrile illness in tropical Papua New Guinea. The case underscores the critical role of thorough pre-departure evaluation and adept management of febrile conditions in tropical environments.

The case describes a patient experiencing severe headaches, fever, and rigours on a luxury yacht cruise without appropriate malaria prophylaxis or knowledge of the risks associated with mosquito-borne diseases. The detection of malaria through a positive rapid diagnostic test (RDT) led to a treatment plan incorporating intramuscular artemether in addition to empirical antibiotics before private jet transfer to an overseas healthcare facility.

The review examines the literature on the diagnostic challenges of tropical medicine. It highlights the greater prevalence of non-tropical diseases in travellers compared to tropical diseases, while emphasising the significant burden of malaria to febrile illness and mortality in these situations. Furthermore, the review evaluates the accuracy of rapid diagnostic tests (RDTs) for diagnosing tropical diseases such as malaria, dengue, and typhoid in areas with limited resources. It outlines a management strategy for undifferentiated acute febrile illness in tropical locations.

Introduction

As the world’s population grows and the collective desire for adventure increases, more holidaymakers are exploring destinations worldwide. Many of these destinations are idyllic tropical settings, which offer an escape from the bitter cold of winter and the monotony of urban life. However, travel to these areas presents unique challenges. These include the risk of tropical infectious diseases, extreme environmental conditions that stress unacclimatised bodies, and often remote locations with limited access to medical care. As a result it is now essential for all healthcare professionals to understand the common causes and management strategies for acute febrile illnesses in tropical environments. Those working in non-tropical regions must be equipped to conduct pre-departure assessments as well as evaluate and manage febrile patients returning from travel. Similarly, health professionals in tropical areas must be adept at caring for febrile travellers, particularly in isolated and resource-limited settings.

Case Presentation

Patient Information

This case concerns a male in his late sixties of European descent, with a medical history including obesity, dyslipidaemia, hypertension, mild fatty liver disease, and benign prostatic hypertrophy. His medications comprised of antihypertensives, a statin, and tamsulosin-dutasteride for prostate management. He had no reported allergies.

Situation

The patient had embarked on a 14-day luxury superyacht cruise around Papua New Guinea’s remote islands. The 168-foot vessel hosted approximately eight guests and twelve crew members. The vessel was equipped with a comprehensive medical kit, which did not meet all of the requirements for Category A vessels as outlined by the UK Maritime and Coastguard Agency (MCA).¹  This discrepancy was likely due to a provision which permits adjustments based on the recommendations of a qualified health professional to suit the crew’s needs and the voyage’s specifics. The captain was responsible for medical care and had access to international maritime medical support. A private plane was utilised to transport guests to the yacht and was stationed on standby in Northern Australia for the duration of the cruise.

The cruise offered guests yacht-based activities such as snorkelling, diving, jet skiing, and occasional land-based adventures such as jungle hikes and white-water rafting. Throughout the journey, the health of all staff and the other guests remained stable, and no acute illnesses were reported. However, despite the voyage’s location and occasional land excursions into dense jungle, no malaria prophylaxis was provided to guests or crew, underestimating the mosquito exposure risk during onshore activities in Papua New Guinea. Furthermore, preventative measures against insect bites were not taken for land excursions, and guests were not informed about the risks of mosquito-borne diseases prevalent in this tropical region.

Clinical Assessment

The focus of this case, a male in his late sixties, started experiencing a mild headache and lethargy the evening before seeking medical care. Upon return from a remote health patrol, an Australian doctor volunteering in the province received a phone call informing them that the vessel was en route to port for medical care due to the patient’s worsening condition. Over the day, the patient’s headache intensified, becoming severe, accompanied by high fevers peaking at 39.8°C, rigours, and sinus tachycardia with heart rates ranging from 100-120 beats per minute. He remained normotensive. The patient reported no other symptoms in the previous three days, and neither the guests nor the crew had observed any further symptoms before this deterioration.

Upon boarding the yacht, a thorough examination and history revealed numerous mosquito bites within the past 14 days. The individual reported no respiratory, urogenital, cutaneous or gastrointestinal symptoms. They had not recently started any new medications. There was no reported recreational drug use or high risk sexual activity. The examination confirmed the patient’s account, noting only subtle suprapubic tenderness and persistence of the tachycardic but normotensive state, with fevers slightly reduced to the 38°C range after paracetamol.

Diagnostic Assessment

Before boarding the yacht, the doctor prepared a list of differential diagnoses, aiming to refine them through clinical evaluation and bedside testing. The primary considerations for fever in a visitor to Papua New Guinea included acute tropical and non-tropical infectious diseases and rare non-infectious causes such as medication side effects, hypermetabolic states like thyroid storm, or inflammatory conditions such as vasculitis.

The doctor requested and reviewed the yacht’s medical supplies list, noting an absence of malaria rapid diagnostic tests (RDTs) and antimalarial medications. This review enabled them to gather these crucial supplies, an intravenous cannula, and fluids before heading to the yacht. This ensured preparedness for as many potential diagnoses as possible. The doctor directed the crew to give the patient paracetamol and promote oral hydration to control fever and maintain fluid balance while they made it to the yacht.

In this remote part of Papua New Guinea, diagnostic options were limited. The absence of urine analysis, dengue and typhoid RDTs, and non-operational x-ray equipment at the local hospital further constrained diagnostic capabilities. The primary differential diagnosis in a man in his late sixties, presenting with severe headache, fever, and rigours after a 14-day trip to Papua New Guinea, was malaria. This was supported by a weakly positive RDT. Differential diagnoses included urinary tract infection, dengue, typhoid, and rickettsial infection. However, the lack of specific tests for these conditions required reliance on clinical judgment and the patient’s response to empirical treatment.

Management

Initial management involved administering paracetamol for fever and promoting oral hydration. Following assessment, targeted interventions began, including 3.2mg/kg of intramuscular artemether for suspected malaria. This was chosen for its once-daily dosing effectiveness and the practicalities of administration in a human resource-limited setting.²  Concurrently, to cover potential bacterial infections, 2g of ceftriaxone was given intramuscularly, empirically addressing alternative causes of fever, including urinary and respiratory infections, typhoid, rickettsial diseases, and meningococcal infections.^3-6 Oral artemether/lumefantrine was also supplied to allow continued treatment once a higher-level medical facility was reached, in anticipation of potential delays in accessing malaria treatment in non-endemic regions.

In the absence of glucose monitoring, the patient was advised to consume one glass of sugar-added fluids for every two of water to prevent hypoglycemia. The yacht crew monitored the patient every six hours for signs of deterioration, with thresholds set for seeking further medical assistance. Arrangements were made for expedited transfer the following morning to an overseas tertiary healthcare facility using the patient’s private plane, ensuring timely and safe transportation.

Follow-up and Outcomes

The patient showed improvement overnight, with reduced fever and tachycardia, but remained in a suboptimal location for ongoing management. Given the patient would arrive at the tertiary hospital within 24 hours and the continued effect of the administered artemether and ceftriaxone, no further doses were given pre-transfer. Stable and afebrile, he was deemed fit for travel without medical escort on his private plane from Papua New Guinea. He remained stable during the flight and recovered sufficiently at the tertiary facility. Unfortunately the precise cause of his fever, with its wide differential, was never communicated back to Papua New Guinea.

Discussion

This case required the doctor to navigate various diagnostic and therapeutic decisions with limited support and access to resources. Reflecting on this experience, a thorough review of the diagnostic and management processes has shed light on potential improvements and modifications to this doctors clinical practice while working in remote tropical locations. These insights aim to improve patient outcomes in similar situations encountered in the future. The details in the subsequent sections aim to share this knowledge with other healthcare professionals working in or aspiring to work in similar tropical environments.

Febrile Illness in Tropical Environments

This case underscores the difficulties in diagnosing and treating acute febrile illnesses in remote tropical settings like Papua New Guinea, highlighting the need for a comprehensive list of differential diagnoses for travellers with fever and nonspecific symptoms. In such cases, non-tropical infectious diseases, including respiratory and urinary tract infections, are the most prevalent cause, accounting for 39% of cases.⁷ Tropical infectious diseases follow closely at 33%, whereas non-infectious causes of fever represent a mere 0.5% of febrile illnesses in travellers to tropical regions.⁷ Malaria stands out as the predominant organism to cause fever in travellers to tropical regions (22%). It has a mortality rate of 0.2-0.5%, causing 25-55% of infectious disease related deaths among travellers, hence testing for and treating malaria is essential.^6-10

Dengue fever is the second most common organism to cause fever among travellers to tropical areas, constituting 5.2% of cases. However it does presents a significantly lower mortality and complication rate compared to malaria.^6-9  Other significant tropical diseases include enteric fever (typhoid and paratyphoid) and rickettsial infections.^6,7,9  Less common causes, accounting for under 2% of cases, include schistosomiasis, helminthic infections, amebiasis, viral haemorrhagic fevers, brucellosis, melioidosis, and borreliosis.⁷

To summarise, the primary causes of a fever in a traveller on a short, less than two week, tropical holiday include; ^6-17

• 39% non-tropical infectious diseases, such as respiratory and urinary tract infections
• 33% tropical infectious diseases
• 0.5% non-infectious diseases, such as vasculitides

The five most common tropical infectious diseases are listed in the table below.^6-17

Field Diagnosis of Tropical Infectious Diseases

Rapid Diagnostic Tests (RDTs) have revolutionised the diagnosis of acute febrile illnesses in resource-limited tropical settings. They provide accurate in-field confirmation of major causes like malaria, dengue, and typhoid. For malaria, RDTs show remarkable sensitivity and specificity, particularly for Plasmodium falciparum, with rates exceeding 95%. This helps facilitate immediate and targeted treatment, which significantly improves patient outcomes in remote areas.^6,13,18  Dengue RDTs demonstrate a sensitivity range of 76-93% and impressive specificity over 98%. Furthermore, Typhoid RDTs, such as Typhidot, achieve sensitivity of 95-97% and specificity above 89%.¹³ By minimising the necessity for complex laboratory tests and streamlining the diagnostic workflow, RDTs have expedited the delivery of disease-specific treatments, significantly reducing the morbidity and mortality linked to these infectious diseases.

Field Management of Acute Febrile Illness in a Tropical Environment

Managing undifferentiated fever in travellers to tropical regions involves a systematic evaluation for various potential diagnoses, emphasising identifying localising symptoms to quickly narrow down the differential.⁹ The Quick Sepsis-related Organ Failure Assessment (qSOFA) and similar tools are crucial for identifying patients at risk of severe sepsis and rapid deterioration, who need urgent care and empirical antibiotics.⁹

Malaria testing using RDTs or blood smears is mandatory for all travellers to endemic areas, with positive cases treated immediately with artemisinin-based therapies.⁹  If malaria is ruled out, available dengue and typhoid RDTs should be performed, and positive results should be treated accordingly.

After ruling out malaria, dengue, and typhoid fever, if possible, consider commencing empirical antibiotic therapy with ceftriaxone (100mg/kg/day IV or IM) and doxycycline (5mg/kg/day), with the option to add azithromycin (10mg/kg/day), pending transfer for further assessment and management.¹³  Upon reaching a suitable healthcare facility, repeat malaria testing is essential to ensure no missed diagnosis. If the patient’s condition worsens in the field, empirical malaria treatment should be started with parenteral artemisinin-based therapy and empiric antibiotics, including azithromycin, until transfer to a well-equipped healthcare facility.

Learning Points

1. Seek pre-departure health assessments, vaccinations, and travel advice from a tropical medicine specialist.
2. Non-tropical infections are the leading cause of fever in travellers to tropical areas.
3. Malaria is the most common tropical disease that causes fever in travellers.
4. Dengue, Typhoid, and Rickettsial infections are other significant causes of fever in these travellers.
5. Tropical diseases often initially present with non-specific symptoms, including headache, fever, rigours, and malaise.
6. Use rapid diagnostic tests for malaria, dengue, and typhoid when available. Plan to secure a supply in advance.
7. Diagnosing illnesses in tropical environments can be challenging. When faced with uncertainty, severely ill, or deteriorating patient, opt for broad treatment. This should include artemisinin-based therapy for malaria and antibiotics, including ceftriaxone and doxycycline, with azithromycin as an optional addition to the regimen if necessary.
8. Initiate early communication with transportation, retrieval services, referral hospitals, and global health agencies. The optimal care location is typically elsewhere for unwell travellers in tropical areas. Prompt transfer of the patient to a suitable medical facility is crucial for improving outcomes.

Conclusion

This case highlights the challenges of delivering medical care in remote tropical locations, where the range of possible illnesses expands but access to diagnostic testing diminishes, complicating accurate diagnosis. A broad understanding of potential causative agents enables the implementation of wide-ranging treatment protocols to optimise patient outcomes. The key to improving patient outcomes in this setting is the early identification and treatment of malaria, coupled with swift transfer. However, clinicians must remember that most acute febrile illnesses in these regions are caused by infections common to non-tropical areas.

Optimising care for acutely febrile travellers in remote tropical settings requires a broad knowledge base and skill set, foresight in planning and anticipatory decision-making, effectively utilising limited resources and evacuation coordination for at-risk or deteriorating patients.

References

1. Maritime and Coastguard Agency (MCA). Merchant shipping notice: MSN 1905 (M+F) Amendment 1 – Ships’ medical stores. Southampton, United Kingdom: Maritime and Coastguard Agency; 2012 [cited 2024 Mar 11]. Available from: https://assets.publishing.service.gov.uk/media/60ae23d48fa8f520c949b676/MSN_1905__M+F__Amendment_1_ships__medical_stores.pdf
2. Medicins San Frontieres. Essential drugs: Drugs potentially dangerous or obsolete or ineffective – Artemether injectable. Medicins San Frontieres; n.d. [cited 2024 Mar 11]. Available from: https://medicalguidelines.msf.org/en/viewport/EssDr/english/artemether-injectable-16682453.html
3. Dryden M, Miller A, Morgan C, Warrell DA. Treatment: infectious diseases. In: Johnson C, Anderson S, Dallimore J, Imray C, Winser S, Moore J et al. Oxford handbook of expedition and wilderness medicine. 2nd edition. Oxford (United Kingdom): Oxford University Press; 2015. P 455-514.
4. Therapeutic Guidelines. Early intervention for sepsis and septic shock: prehospital management. Melbourne: Therapeutic Guidelines; 2020.
5. Lokida D, Hadi U, Lau CY, Kosasih H, Liang CJ, Rusli M et al. Underdiagnoses of rickettsia in patients hospitalized with acute fever in Indonesia: observational study results. BMC Infect Dis [Internet]. 2020 Dec [cited 2024 Mar 11];20:1-2. DOI: 10.1186/s12879-020-05057-9
6. Fink D, Wani RS, Johnston V. Fever in the returning traveller. BMJ [Internet]. 2018 Jan [cited 11 Mar 2024];25;360-369. DOI: 10.1136/bmj.j5773
7. Buss I, Genton B, D’Acremont V. Aetiology of fever in returning travellers and migrants: a systematic review and meta-analysis. J Travel Med [Internet]. 2020 Dec [cited 2024 Mar 12];27(8),1-12. DOI: 10.1093/jtm/taaa207
8. Leggat PA. Assessment of febrile illness in the returned traveller. Aust Fam Physician [Internet]. 2007 May [cited 2024 Mar 12];36(5):328-333. Available from: https://researchonline.jcu.edu.au/2795/1/2795_Leggat_2007.pdf
9. Thwaites GE, Day NP. Approach to fever in the returning traveller. NEJM [Internet]. 2017 Feb [cited 2024 Mar 12];376(6):548-60. DOI: 10.1056/NEJMra1508435
10. Wilson, M. Fever in the returned traveller, CDC yellow book 2024: post travel evaluation. Centers for Disease Control and Prevention [Internet]; 2023 [cited 2024 Mar 12] . Available from: https://wwwnc.cdc.gov/travel/yellowbook/2024/posttravel-evaluation/fever-in-the-returned-traveler
11. NSW Agency for Clinical Innovation. Emergency care institute, New South Wales: returned traveller. NSW Agency for Clinical Innovation; 2024 [cited 2024 Mar 12]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/infectious-diseases/returned-traveller#:~:text=Severe%20respiratory%20symptoms%20associated%20with,%2C%20such%20as%20Legionnaires’%20disease
12. NSW Agency for Clinical Innovation. Incubation periods of common travel-related infections [Internet]. NSW Agency for Clinical Innovation; 2024 [cited 2024 Mar 12]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/286837/Incubation_periods_of_common_infections.pdf
13. Singhi S, Chaudhary D, Varghese GM, Bhalla A, Karthi N, Kalantri S et al. Tropical fevers: management guidelines. IJCCM [Internet]; 2014 Feb [cited 2024 Mar 12];18(2):62-69. DOI: 10.4103/0972-5229.126074
14. Wilson M. Evaluation of fever in the returning traveller. UptoDate [Internet]; 2023 [cited 2024 Mar 12]. Available from: https://www-uptodate-com.
15. Rathi N, Rathi A. Rickettsial infections: indian perspective. Indian pediatr [Internet]. 2010 Feb [cited 2024 Mar 12];47:157-64. DOI: 10.1007/s13312-010-0024-3
16. Mahajan SK. Rickettsial diseases. J Assoc Physicians India [Internet]. 2012 Jul [cited 2024 Mar 12];60(7):37-44. Available from: https://www.researchgate.net/profile/Sanjay-Mahajan-2/publication/235618717_Ricketsial_diseases/links/58f619554585158514b54ef9/Ricketsial-diseases.pdf
17. Haake DA, Levett PN. Leptospirosis in humans. Curr Top Microbiol Immunol.[Internet]. 2015 [cited 2014 Mar 12];387;65-97. DOI: 10.1007/978-3-662-45059-8_5
18. Mukkala AN, Kwan J, Lau R, Harris D, Kain D, Boggild AK. An update on malaria rapid diagnostic tests. Curr Infect Dis Rep [Internet]. 2018 Dec [cited 2024 Mar 12];20:1-8. DOI: 10.1007/s11908-018-0655-4

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Dr Emily Watts is working as a registrar in Emergency Medicine with special interest in Pre-Hospital Emergency Medicine based in Cumbria. She is developing her expedition and wilderness portfolio with a post graduate diploma, and has been involved with medical cover for ultramarathons in the UK and Europe. Outside of work, she can be found up a fell, on or in the water, or cycling the gravel tracks that make living in the Lake District so fantastic for any outdoorsman.

Clinical fellowship title, specialty and grade 

Title: Clinical Fellow in Emergency Medicine with Specialist Interest

During my fellowship, the role was advertised for those with a special interest in Pre-Hospital Emergency Medicine. This has now been broadened to include special interests in Pre-Hospital Medicine, Mountain Medicine, Simulation Medicine, Academic Medicine, Paediatrics, and Intensive Care Medicine.

Base Specialty: Emergency Medicine 

Grade: Post-FY2 – commonly as stand-alone FY3 or as an ‘out of programme experience’ for EM trainees.

Structure of the role

This role is a fixed-term contract for 12 months. My time was split as 70% Emergency Medicine and 30% special interest, which has changed to an 80% / 20% split since. My PHEM special interest time included experience with North West Ambulance Service and Mountain Rescue Teams. The opportunity to work with Great North Air Ambulance Service was unfortunately limited by the onset of the Covid-19 pandemic. This has since been re-established for more recent fellows.

The trust supports less than full-time working – ask on application if interested. 

Prerequisites for application  

This fellowship prerequisites are straightforward:

• 4 months experience in Emergency Medicine
• Completion of the foundation training programme
• Advanced Life Support (ALS) provider

This post is targeted at the post-FY2 / pre-specialty application doctor, and represents the majority of the applicants, but they are open to applications with higher levels of experience.

Location of fellowship

Clinical Fellows are based in Cumbria, in the North-West of England. The hospitals are in Carlisle (North East Cumbria) and Whitehaven (North West Cumbria), with the fellowship base hospital usually set as Carlisle. This is discussed on an individual basis and decided based on special interest preferences. As my interests included mountain medicine, my base was set as Whitehaven for my fellowship year.

Pre-hospital experience will be largely dependent on where you are based owing to the geography of the Lake District and Cumbria in general. I joined ambulance crews from bases local to the Whitehaven area and worked alongside the Wasdale mountain rescue team. The Great North Air Ambulance Service has bases in Langwathby and Eaglescliffe.

Brief description of the job role.

Emergency Medicine:

You will join the SHO rota, working alongside the clinical team and wider MDT to provide emergency care to the local and visitor populations. This roster includes working a range of shifts, including late and night shifts, as well as weekend working – this is unlikely to be surprising to applicants, given the prerequisite for ED experience. Both hospitals have mixed Emergency Departments, meaning there is an opportunity to work with the paediatric and adult patients. Owing to the rural location and nature of a district general hospital, there are limited specialty services on-site, especially at Whitehaven. Consequently, there is a greater emphasis on procedures and skills being taught and performed within the Emergency Department. The tertiary centre for many specialties will be in Newcastle, approximately 2 hours away by road from Whitehaven. 

Special Interest:

The fellowship was a new role when I joined, without any set format or criteria. This meant that there was a lot of work on my part initially to set up opportunities by email and phone calls. This is now a well-established role so there is more structure to facilitate the ease of taking up local opportunities. For applicants considering this role, I suggest you reach out to the recruiting team to see if they can cater to your area of interest and particular opportunities you would like to experience (I expect the answer will be yes!).

Within the rota, I was allocated a week at a time (roughly every 3 weeks) as my pre-hospital time. However, as long as I ensured I could account for my hours at the end of the year, the senior leadership team was happy for me to self-manage this time. I relished that I was given the freedom to do so, and it meant I got far more done. For example, attending a weekly training session with the mountain rescue team. Some weeks I ended up mixing clinical and pre-hospital elements, whilst others were almost rest weeks to compensate. The senior leadership team was incredibly supportive – making suggestions and options for ways to use my time, they were also able to help nudge opportunities along if I wasn’t getting responses.

Unfortunately, by the time I had arranged observer shifts with GNAAS, the COVID-19 pandemic had hit, so these and my observer shifts with the ambulance crews were put on hold. However, my pre-hospital time was protected despite the circumstances, and I was able to develop other areas of my portfolio: teaching, quality improvement projects, etc.

Academic accreditation

I did not receive accreditation for training for my fellowship year. I used this time to complete an appraisal, maintain my portfolio and prepare for specialty application. Contact the department for further discussion and information.  

Overall impression 

I was excited by this ‘sideways’ career move, as it offered a chance to develop on my career interests throughout my working week rather than cramming it into my rest days. After the usual challenges of relocation and settling into a new trust and department, it quickly became apparent that it was the best decision I could have made.

In my pre-hospital weeks, I had the chance to go on courses (yes, there was a study budget too!) and be an observer with the local ambulance crew. I also linked in with one of the local mountain rescue teams – helping with medical training, but also being accepted as a probationary member for callouts. I covered an ultramarathon in Belgium, with further events lined up for later in the year, and I liaised with the Great North Air Ambulance Service, to arrange exposure to the world of Helimed. 

When COVID-19 hit, it threw a spanner in the works and life as we all knew it ended, which included many of my pre-hospital opportunities. Due to lockdown, the lakes were quieter resulting in less footfall and, therefore, fewer injuries and accidents.

Outcomes of the fellowship

As well as confirming that the ED is where I want to be long-term, it demonstrated how beneficial it is to have allocated time to pursue courses and self-development opportunities is. It reignited my passion for medicine and allowed me to focus on optimising my application for specialty training, without sacrificing rest and recovery.

Ultimately, taking this job helped me to realise that I don’t want to rush through training and that I am happy to take a path less travelled. Whilst I returned to training the following year, this was largely due to the uncertainty around the Covid-19 pandemic. I had initially planned an ‘FY4’ to travel and pursue expedition and remote medicine opportunities. With world travel and a return to normality appearing uncertain, I decided that re-entering training instead would allow me to enhance my skill-set in preparation for future out-of-training options. As a result, I uncoupled training – making a natural break between core and higher training. With the completion of my core years now imminent, this is a decision that I am so glad I took. It allows me further time out to pursue a wide breadth of opportunities, without prohibiting return to higher training in due course.

Costs and potential funding

Travel: Cumbria is rural, with limited public transport options. Whilst it is possible to get around without a car, in my opinion, driving is fundamental to maximise the opportunities this fellowship offers.

Accommodation: Hospital accommodation is available. The human resources team and ED secretaries also have a list of local landlords with available properties for a variety of timespans and needs.

Courses: Applicants are encouraged to pursue areas of interest that can benefit their career. I completed APLS and would have also done ATLS (COVID-19 meant this was postponed to the following year). There is a study budget, but it is not unlimited. If an applicant has a particular course or degree in mind, I suggest discussing this before or during the application process.

Anything else you wish you’d known beforehand?

Bear in mind that Cumbria is rural. For many (myself included) this is a perk. However, this does mean that it’s not got everything at its fingertips. Deliveroo does not exist and there is no large shopping centre! Public transport can be unreliable, and is not as frequent as in cities.

Job application:

Advertised via NHS Jobs. Jobs can open as early as March, for an August recruitment. This last year (2024), applications opened in June.
Application found by searching here: https://www.jobs.nhs.uk/candidate  

The post Clinical Fellowship Review: Emergency Medicine with Special Interest in Pre-Hospital Emergency Medicine appeared first on Adventure Medic.

In this article, Juan reflects on his time volunteering as a medic for Floating Doctors in Panama. As well as tackling life in a new environment and challenging presentations, Juan speaks freely about his changing beliefs on what healthcare truly means.

Introduction

As far back as I can remember I’ve wanted to work in humanitarian aid. Born in Argentina and raised in Canada, I went to medical school in Ireland, before landing in Philadelphia where I currently train.

Amidst the COVID-19 pandemic in 2020, I flew across the pond from Ireland as a final-year medical student to work with Floating Doctors, a medical group treating native communities from boats off the Caribbean coast of Panama.

Floating Doctors is a volunteer-funded humanitarian medicine group that operates from the island of San Cristobal in the Bocas del Toro Archipelago. They provide care to the Ngabe-Buble indigenous groups living in hard-to-reach islands throughout the region. This population are so isolated that, over ten years ago, the Panamanian government reached out to Floating Doctors for help providing their medical care. Over time Floating Doctors have woven themselves into the fabric of the Ngabe communities, sailing from village to village and providing outpatient healthcare, as well as health education in their schools, midwifery training with local parteras, dental care, and physiotherapy. They are always receptive to new volunteers, although their economic model is built on donations and a pay-to-volunteer system.

I spent ten weeks travelling between the islands working with a population deprived of healthcare during the pandemic, and conditions were extremely difficult. As I saw more patients, I learned about the people and their environment, grew closer to their culture, and began to understand their day-to-day challenges. Throughout this, I waged perennial battles against the sandflies, jellyfish, cacao-crazed violent primates, and my own temperamental gastrointestinal tract. What I learned about myself, this job, life, and everything in between, was worth more than the entire eight years of training that had come before it. I was hooked and knew life would bring me back in due course.

Shaping a career around humanitarian work

With those lessons learned, I spent the first two years of my internal medicine residency in Philadelphia (think of residency like an accelerated training scheme that takes you from intern year to consultant in three or four years), focused on expanding a skill set for humanitarian work. I got involved with the state department delivering care to refugees, worked in clinics for the uninsured, and advocated heavily for people entrenched in the struggle with opioids.

About halfway through my second year, I felt that I was finally hitting my stride. With my eyes still set on the communities I had worked with in Latin America, I geared up to bring my newfound skills back to Panama. Like any physician, I was hyper-focused on exploring the nature of healthcare inequality through the tools I knew: my stethoscope and my medicines. Of course, I was still a trainee with a lot to learn, but despite not knowing everything, I felt I knew what was most important. I knew how to think clinically, I understood the basic essence of medicine.

Or so I thought.

Returning to Panama, with an emphasis on community

Arriving in Panama for a second time, I slotted right back into clinical work. Immediately it came back to me, the daily presentations with pelvic inflammatory disease, the traumas, the worms and their parasitic cousins, the infections, snakebites, arthritis, epilepsy, and all things in between. I was also met with new and surprising challenges, clinical and non-clinical. Notably, there were several more physicians this time around (now post-pandemic), and also a new division entirely: the veterinary group.

Initially, I had mixed feelings about the vet program as I struggled to understand its benefit to a medical group operating on a tight budget. This, however, gradually shifted when I saw how invested the community was in the wellbeing of their animals, garnering a far greater emotional response than with any tablet I could prescribe. I reflected on how healthcare doesn’t always give people meaning in their lives. People find real meaning through things like community, affection, and compassion. If anything, I might argue that the veterinary group was contributing more meaningfully to people enjoying life than the medical arms were.

These ruminations were accelerated the very next week, following one of our clinics in the village of Norteño. In the evening, the whole community came out after dark to celebrate the lighting of a community Christmas tree. People young and old lined the paths. They shared words and prayers, followed by a ceremonial lighting of candles. We were tremendously honoured as a group when they asked us to light the stocks as a sign of their appreciation for our work. When the tree was lit, it was quite a spectacle. Children, parents, church organisers, and the rest all blended into one living, breathing collective, enjoying the camaraderie of creating something beautiful together. The more I thought about it, the more this togetherness made sense. The houses that line the community are just metres apart. Voices carry from home to home all day long. Even if you wanted to, you couldn’t get away from your neighbours if you tried. This, combined with their shared tribulations, forms a tight-knit community of people who depend upon one another.

I thought about how ceremonies like these were few and far between where I grew up. I got to know just a few of my neighbours in the suburbs outside Toronto. Everyone gets into their own car, drives to work, takes their kids to school, and tries to live as un-influenced by those around them as they can. Why is that? Is it because technology makes it easier for us to do things without leaving the home? Is it because we no longer need support from our neighbours to live fruitfully? I don’t know. What I do know is that at that moment I thought about Philadelphia, a city that is hurting in so many ways. Where, despite so much wealth, so many are neglected and fall through the cracks. I thought about how despite endless attempts to build relationships with the people that live in my own building, I feel like everyone is just trying to mind their own business.

For all our advances, we have much to learn from communities like Norteño. Despite their seemingly worse metrics for healthcare inequality, I’d wager many of them are living more enriched and meaningful lives there than in the West. I asked myself what this meant about the nature of inequality as I understood it. What is inequality really? Financial inequality is easy to measure, to understand, but what about inequality of community, or inequality of meaningful connection? As I think about what it means to build health, I realise that maybe I have been looking at health the wrong way.

A Paradigm Shift

I had spent my career trying to fix people’s health on the promise that I was doing a fundamental good. In search of that, I had invested uncompromisingly in the metrics of classical medicine: blood pressure, blood sugar, chronic disease, and functional optimisation. I worked on the principle that health is important because people should have good health—yes, sure, but despite training for eight years and practising for two, I had never taken the time to really ask myself why is health important?

So, with a newfound sense of community, I sat and contemplated these things. This is it, I thought. This is what I am trying to capture in a bottle and bring to people in need. Health is not the end goal, meaning is. Our goal should not be to put health on a pedestal, but to build health as a means to augment people’s ability to live meaningfully through community. That is the essence of medicine. At that moment something clicked; I will never see or approach my work the same way again. If I had to choose between building community or building health, I’d reply that they’re too intertwined to have one without the other. Community is our reason for living; without it, health becomes seemingly less paramount. If we lose sight of that and obsess over healthcare metrics, we’ve missed the mark entirely. Of all of the things that Panama has taught me, this was the most powerful lesson of all.

Reflections

What exactly to do with this realisation, I am not sure. I know it will be hard to take these conclusions back to my place of work in America, to a system that pigeon-holes the best of us into electronic chart box-tickers. Maybe, for the right patients, I can worry less about healthcare metrics and invest my time in building meaning through personal connection, enjoying their presence to brighten their day, and inspire a spark that reminds them to enjoy life. Maybe in the future when I approach medicine at a population level, I will think harder about community building and education as the real goal before losing myself in ‘measurable healthcare outcomes’. In truth, this new understanding leaves me in some ways unsure how to proceed, like the systems that I work in leave little room for me to help people actually find meaning.

That’s the fun in this career though isn’t it, we get to take agency in enacting change. I may not see the path forward clearly, but I know which direction it’s going. Stethoscope in hand, not always plugging my ears, the quest for meaning carries on.

How to volunteer

Find out more about volunteering with them here.

The post Floating Doctors in Panama appeared first on Adventure Medic.

Dr Katharine Ganly worked as a medical officer with the British Antarctic Survey Medical Unit (BASMU) from 2019 to 2021. She experienced both summer and winter in Antarctica, and also spent time working as the ship’s doctor on the RRS James Clark Ross. In this article, Dr Ganly describes what it’s like to be a doctor with BASMU, sharing her advice and experiences of working in one of the wildest places on Earth.

Ever wondered what it is like to live and work at the very edge of the world? The British Antarctic Survey Medical Unit appoints doctors annually to deploy to Antarctica, working on remote research stations and polar vessels. This is a dream job for adventurous medics with a love of cold, remote places.

What is the British Antarctic Survey?

The British Antarctic Survey (BAS) is the UK’s national Antarctic program. It is part of the National Environment Research Council and is the responsible body for the UK’s scientific research in Antarctica. BAS is headquartered in Cambridge and conducts scientific research in several areas of polar science, including marine biology, oceanography, meteorology, and atmospheric science. BAS scientists are credited with the discovery of the ozone hole in the 1970s, drawing attention to the impact of human activity on the global environment. BAS continues to undertake several long-term data collection projects relating to the polar regions and climate change.

There exist five permanent BAS research stations: Rothera and Halley on the Antarctic peninsula and Brunt Ice Shelf respectively, and the island stations of Signy in the South Orkneys, King Edward Point (KEP) at South Georgia, and Bird Island (BI) research station. The three stations of Rothera, KEP, and BI are staffed year-round, whilst Signy and Halley are operational throughout the austral summer alone. In addition to these stations, there is ongoing scientific research conducted from temporary field-based summer camps and outposts. The UK’s new polar research vessel The Sir David Attenborough (yes, the one that narrowly escaped being called ‘Boaty Mc Boatface’, thanks to the humour of the British public) heads south annually in the autumn to arrive in Antarctic waters for the period of the Antarctic summer (typically November-May) and has the dual role of conducting polar research and providing the annual resupply of equipment and staff.

BAS deploys up to 600 scientists and staff to the polar south annually. Personnel are not limited to scientists and include everyone essential to keeping life running and research going at the remote extremes of the world: chefs, field guides, mechanics, electricians, diving and boating officers, management personnel, engineers, and (thankfully for those reading this) polar-loving doctors.

What is daily life like in the Antarctic?

The UK working week is impractical in the Antarctic and as such, work fluctuates according to the weather and season. Exact details of routine are specific to each station, but the Antarctic has a steady overall rhythm splitting summer and winter. Summer is busy: this is the time of maximal activity. At Rothera, this means there are over 200 people on station, with many more transiting through this Antarctic hub. Personnel arrive on station via Dash-7 plane from Punta Arenas, Chile (around 4.5 hours flying time), or from the UK on the RRS Sir David Attenborough (a voyage of many weeks) with the annual resupply. Onward travel to the field is via a Twin Otter plane. At KEP the population is smaller, with approximately 30 on station during summer. South Georgia is solely accessible by sea, and personnel arrive via ship from the Falklands (around four to five days if the sea conditions are good).

All stations eat meals in a central dining area, with a chef at the larger stations and a cooking rota for personnel on the smaller sites. There is ample access to recreation on all sites including gym equipment, the opportunity to ski, and access to books, movies, and other media. Station life is dependent on everyone helping to keep things running. As a doctor in the Antarctic, you will find yourself cleaning, cooking, and taking inventory as well as running clinics. If you are lucky, this is made up for by the opportunity to fly in a Twin Otter at Rothera or pilot a rigid-hulled inflatable boat (RHIB) around unchartered waters at KEP (yes, really). You’ll also get the privilege of seeing some of the most remarkable wildlife in the world: Antarctic marine mammals and birds are the most incredible you’ll ever see.

Winter is a quieter time, with core personnel of around 25 at Rothera and eight at KEP. Work continues, but the pace is slowed. Personnel finally get their own room after a summer of sharing space with another. It gets colder and darker, and often tempers shorten along with the daylight. Navigating this as a doctor whilst living amongst your patients does pose its challenges. It’s a unique, special experience. The winter solstice is a time of midwinter celebration amongst your small team, as you look forward to longer days and dream of the fresh food you haven’t seen for months.

What does the role of a BASMU medical officer entail?

Recruitment

The BAS Medical Unit is based at University Hospitals Plymouth NHS Trust. BASMU recruits Antarctic medical staff annually in the late summer, and three doctors get selected to become the season’s doctors for Rothera, KEP, and the RRS Sir David Attenborough. Station doctors spend between 12 and 18 months in the Antarctic, and the ship doctor deploys for around eight months.

Pre-deployment and training

All BASMU medical officers have six months of pre-deployment training in Plymouth, which takes place predominantly at Derriford Hospital. Though there are certain skills all doctors must learn, during these months of gearing up for departure, you are largely responsible for taking charge of your training. Your role is predominantly spent in the emergency department (ED) but you are in the privileged position of being entirely supernumerary. This means you get the opportunity to place yourself wherever you have a training need, be it dealing with minor injuries, joint manipulations and plastering, or getting stuck into resus. You can tailor sessions outside the ED with other specialties to gain exposure to any areas required, be it a week or two with ENT, learning basic hand surgery from plastics, or taking swabs and gram-staining in the sexual health clinic. All doctors undergo an intensive dental course where you gain the essentials in dental examination, hygiene, fillings, and dental emergencies including extractions. Equally, all doctors rotate through basic training in radiography and physiotherapy. You will also be taught how to operate a hyperbaric recompression chamber at the Diving Diseases Research Centre (DDRC), as diving for both science and construction takes place at the main wintering stations. In addition to all this, you get a modest study budget and study leave that you can use for any further courses or skills required for departure. Historically, some doctors have used this for associated ‘extracurricular’ skills such as baking (if you winter at KEP, you are expected to bake bread regularly!).

As if this wasn’t enough to get stuck into, you also go through BAS winter pre-deployment training, which involves generic skills for all personnel deploying to Antarctic stations. Depending on which position you are heading to, you may undergo other station-specific training such as sea survival certifications, powerboating qualifications, or crevasse rescue.

Other UK responsibilities include pre-departure medical screening for BAS personnel. This takes place at BAS Cambridge and usually works out as spending between one and two weeks a month in Cambridge in the months leading up to departure. Accommodation is provided and travel costs are reimbursed. There is a BASMU car that can be used for work travel, or mileage is reimbursed if your own vehicle is used. This allows you to meet some of the BAS personnel and identify any extra medical investigations or precautions that are needed before departure.

Working in Antarctica

Once deployed, your role as medical officer in the Antarctic is unlike any other you will have filled. For the vast majority of your deployed time, you will be the sole medic within hundreds of miles. My deployment to South Georgia meant I was the only doctor in the entire territory, with the nearest other physician being over 800km away on the Falkland Islands, at best a 4-day ship’s passage away over the roughest seas in the world.

Day-to-day medical work is light compared to jobs in the UK, and the bulk of your ‘office’ time is much more likely being spent taking stock of pharmacy, reviewing major incident protocols and equipment, and training your winter team in advanced first aid (you need to have someone who can give you a hand if an emergency occurs, or even to look after you should you break something). Your population in the Antarctic is small, medically screened, and largely risk-averse. Most consultations fall under the realms of general practice: GI upsets, sleep disturbance, dermatology, and some minor injuries. Dental complaints are relatively common occurrences and are rewarding to treat thanks to excellent pre-departure dental training. Other common consultations include psychological issues, sexual health, and support around general well-being for a population living in very unusual circumstances. Everything in the Antarctic is complicated by its remoteness. What would be considered a seemingly minor complaint in the UK requires more careful consideration on the ice. The potential for things to develop into something more concerning needs to be carefully evaluated when you know any definitive treatment may involve a medevac that could span weeks. Away from the hospital and the majority of diagnostic tools that we are accustomed to, reliance on good clinical skills becomes paramount.

Managing medical emergencies

Though infrequent, acute illness and major injury do occur. Recent seasons have faced major GI haemorrhage, respiratory emergencies, sepsis, and major lower limb trauma requiring evacuation. I was faced with a case of cold-induced angioedema: an unusual anaphylactoid reaction to extreme cold, and not something you want when the temperature rarely gets above freezing. Generally due to good training and PPE, other cold-related emergencies are uncommon, and hypothermia and frostbite are rarely seen amongst BAS personnel. Whatever situation arises, you need to be able to manage as a solo medic with limited resources. There are no CT scanners or biochemistry labs in your clinic. You will have plain-film X-rays (which you will learn how to take and develop yourself) and basic point-of-care testing. Most sophisticated medical equipment is not designed for the extreme remoteness of the far south, and some kit that works at the start of your deployment may no longer do so come winter. You will nonetheless have a pharmacy that is well-stocked with both emergency drugs and supplies for more common ailments. You will also have access to a team of enthusiastic first aiders, should you choose to train them.

Thanks to modern telecommunications, you have several experienced BASMU clinicians as well as specialists at your fingertips. Responses to clinical queries are normally within a few days. Telephone can always be used for more urgent concerns, with 24/7 top-cover support in an emergency. Video consultations have been used when the satellites are well aligned.

The role of a BAS medical officer requires a large degree of robustness and adaptability. Challenges include isolation, skill fade, unconventional patient-doctor relationships, and the unpredictability of Antarctic deployment. You have to be able to respond to anything, including the emergence of a global pandemic whilst deployed – not something any of the doctors had envisaged when travelling south in 2019. The benefits of learning a range of diverse skills, and the privilege of living in a truly awe-inducing location far outweigh any difficulties faced. The opportunity to work with a team of dedicated scientists and support staff, and to play a part in keeping vital research ongoing in such a special place makes this job truly one of a kind.

Practical Information

Candidate information: to meet the requirements, you’ll need to be a fully registered medical practitioner and have a minimum of 3 years post-qualification. Doctors from a wide variety of specialties and backgrounds are considered by BASMU for the posts. Acute specialty experience is probably useful, as you need to be able to keep calm under pressure, but not essential. Key useful traits are resourcefulness and flexibility.

Timelines: BASMU advertises at the end of summer in the BMJ, with interviews in the autumn. Jobs will then usually start on the 1st of May, with pre-deployment training running from May through to October. Deployment begins in November or December and is for 12-18 months. There is a huge amount of organisational development and expansion at BAS at present and the medical unit is required to be reactive and flexible to this. As such, the exact deployment duration and details are always subject to change.

Doctors in training: some deaneries will approve an OOPE (Out of Programme Experience) for BASMU employment, so it is worth applying even if you are in training. This allows you to keep your training number and return to your role when you are home. A benefit of this option is that you can usually access ‘supported return to training’ once you return to the UK, easing the transition back into hospital practice. I would recommend this.

Administrative info: as a BASMU doctor, your employer is Plymouth Hospitals NHS Trust. This means you retain your continuous NHS employment for the duration of this position. If you are deployed for over 12 months, you do not need to pay UK tax, although you will need to pay ‘BAT tax’ (British Antarctic Territory Tax) of 7% instead. You will have essentially no expenses when you are away.

Academic: the complete program of training, clinical responsibility and research is designed to enable doctors to obtain a certificate, diploma, or master of science degree in remote and global healthcare, awarded by the Peninsula Graduate School for Antarctic Deployments. Alternatively, you can use these funds to undertake another distance learning program of your choice. There is the opportunity to get involved with BASMU research, which recently has focused on cold injury, drug tolerance, and respiratory virus transmission.

Author Information

Dr Katharine Ganly worked as a medical officer for The British Antarctic Survey between 2019-2021. She overwintered at King Edward Point and was the first station doctor on Bird Island, where she spent her second Antarctic summer. Doc Kat was the ship’s doctor on the RRS James Clark Ross on her exit from Antarctica. She completed her MSc in Global and Remote Health whilst working for BASMU, alongside conducting research into drug stability in remote environments and respiratory viral transmission amongst an isolated population during the COVID-19 pandemic. She has now returned to work as an anaesthetics registrar in the west of Scotland.

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Having worked in a private sector emergency department for three years, Dr Amy Collyer (@dr.amylouise) wanted a change. She packed up and moved to Limpopo, volunteering for an NGO called the Tshemba Foundation. Whilst working there she got a call to move to Zululand and work in a public hospital. A week later she packed her life into her car and made the ten-hour drive, arriving ready to start a new challenge. 

An Introduction to Healthcare in Zululand, South Africa

Zululand is in the north of KwaZulu-Natal, one of South Africa’s nine provinces. It extends inland from the coast, and is home to almost one million people dispersed into cities, small towns and rural homesteads. Despite its’ middle-income status, there are significant inequities between South Africa’s public and private health services. Public healthcare tends to be poorly resourced, along with staff shortages and long ambulance delays. This is keenly felt in emergency medicine where a deep passion for the work is needed to survive. Here, we do early, late, and 19 hour-long “call” shifts. The latter is a misnomer, as they are long, busy on-site shifts that are made more tiring by the struggle for resources, including imaging and working technology, the language barriers and limited breaks. Despite these pressures, there is an unshakeable drive to do the best we can for each person who comes in through the doors.

A 19-hour emergency shift

Please note, this is a descriptive piece representing an accumulation of compiled memories and experiences that would reflect a typical 19-hour shift. It is not a true account of an actual shift. 

It’s 13:55 pm on a Friday, and I’m walking along the corridor towards the emergency unit to start my 19-hour shift, with coffee in hand, feet a little sore from the late shift yesterday, and eyes heavy. From the corridor I can’t hear any chaos, so I stop at the bathroom to use the toilet. There are few things as excruciating as doing handover with a full bladder, and who knows when the next opportunity will arise. On entering the ‘majors’ section I see that all fourteen beds are occupied, with two patients ventilated. As we only have two ventilators, this is not a good start to the weekend. All of a sudden I can hear shouting and see all the doctors and nurses moving frantically around the first resuscitation bed in the trauma bay. I can feel my heart beating faster. One of the doctors catches my eye and I see a glimpse of relief in theirs, “Amy, quick, put on gloves, take over CPR!”.

I fling my bags to one side and grab the closest box of gloves I can find. I fumble to put the unfortunately over-sized pair on, while climbing onto the step next to the patient. The monitors are alarming noisily. Words are flying across me, “1 amp of adrenaline given!”, “What is the glucose?”, “Keep the C-spine stabilised”, “Get ready for bilateral finger thoracostomies!”, “Someone fetch the bear-hugger!”, “Let’s get a second line!”.

Right hand over left, arms straight, positioned above the chest, I begin chest compressions, “One, two, three, four… what is the story here?” I pant while compressing. The short reply of “Motor vehicle accident!” is all I get from somewhere at the end of the bed, where doctors are applying a plaster cast for a seemingly mangled limb. “… Twenty-eight, twenty-nine, thirty, breathe”, I lift my hands from the chest so some air can enter the lungs as another doctor gives two squeezes of the bag valve mask. As I continue chest compressions, I look across to see a doctor performing a thoracostomy, in an attempt to relieve any underlying blood or air that could be compressing the lung and accounting for the patient being in cardiac arrest. From behind me someone says, “Amy, don’t mind me, I’m going to do the same thing this side, just move over slightly so I can access the chest wall.”

All I can think about is doing my compressions well while everyone else focuses on their tasks. We are like one dynamic organism, all working together to try to save this life. The doctor repeats the procedure on my side of the patient, and sticks their finger in to access the pleural space. Within seconds a large gush of blood, probably two litres, escapes from the patient and hits the floor. As I continue CPR, more blood leaves the patient with each compression. The doctor behind inserts a tube into the patient’s chest and and connects a Sinapi chest drain. Within seconds the drain is filled to the brim. Shortly afterwards I am relieved when a colleague takes over chest compressions.

Despite the drains, CPR, oxygen, fluids, straightening of broken limbs, provision of warmth, and more, the patient does not improve. As time goes on, it becomes obvious to everyone that there is nothing else left to try. Eventually, the team leader calls an end to the resuscitation effort. There are no signs of life. Gloves come off, and most of the team disperse to see other patients. One doctor remains to document the events and break the bad news to the family. A nurse stays behind to organise a mortuary transfer. As I take moment to change scrubs, I feel a wave of sadness for the loss of this life. But I am consoled by how much the team did to try to save them. Sadly, we can’t help everyone.

On returning to the minors unit, I wade past stretchers, wheelchairs, relatives and nurses to survey the two most important boxes in the departments: waiting to be seen and needing review. There are two unseen patients and six needing a review. But I can’t start with any of this because we still have to do the ward round and participate in teaching. The ward round is quick as everyone is tired, and afterwards we pull up chairs in a circle for our “five-minute teaching”. Today it’s my turn and I discuss the diagnosis and management of septic arthritis. After feedback, everyone except the late and call teams go home, but one consultant remains available after hours for advice.

After some hard graft in minors, it is time for a dinner break. The call room is a bubble of peace in the chaos. From here I can see the exquisite orangey-pink sunset descending over the community and distant rolling hills. Nearby taverns have already started to pump out very loud amapiano (a type of South African music), and taxis are whizzing along the main road that the hospital entrance gate leads onto. After eating, I try and put my head down for a short nap, but I struggle against the noise of the people and buses in the parking lot below. There are limited transport options in Zululand, and some patients live up to five hours away from the hospital. To help with this, intermittent hospital buses take patients who have been at the specialist clinics back to their base facility. It feels like I’ve just closed my eyes when my alarm sounds, signalling my return to the emergency department.

I survey the emergency department. Fortunately, most of the patients in majors unit are stable, so I head back to minors. Despite our hard work earlier, the boxes are full. I take one of the unseen files, a paracetamol overdose. This is, heartbreakingly, one of our “bread-and-butter” cases. The typical patient profile is a young adolescent who has engaged in deliberate self-harm. It is usually triggered by a fight with a lover, or after receiving subpar results in school. It can be serious, even life-threatening. But we see this presentation so often that the management is automated for me: consult, examine, counsel, evaluate suicide risk, take blood tests, start fluids, offer symptomatic treatment for any dehydration and vomiting, and decide on whether the antidote is required. These patients are either referred for hospital admission and ongoing management, or are sent to see a social worker before discharge home.

After this, I pick up the review files. Two can be referred onwards to surgery and internal medicine. The rest are still waiting on blood results. Time has flown by, and it is time for an evening telephone round with the consultant. They listen to the patient list and give advice on management, and on overcoming barriers to flow on the floor. After the late team leaves, a team of three to four is left to cover the next twelve hours until the morning. We head back to the minors unit and see that two patients from a motor vehicle accident have arrived with the paramedics on scoop stretchers due to concerns about spinal injury. My colleagues attends to them, so I continue with other unseen patients and answer calls from the clinic phone. The rural outlying clinics, some up to 50km away, often call for advice or to refer patients that are too unwell for them to manage. I accept a patient who has been stabbed in the chest with a broken beer bottle, giving the nurse on the other end some advice to make sure the patient is stabilised prior to being transferred.

In between my next few patients I make sure to rehydrate and refuel. It is easy to get bogged down by tasks and forget to look after ourselves. But I’ve no sooner closed my lunch bag when a concerned looking nurse approaches me. “Dokotela, (doctor in isiZulu) the patient in bed thirteen is becoming restless”.

It is a patient with head injury secondary to assault. Unfortunately, this is also a common presentation. This patient’s head injury is severe and they have been intubated and placed on a ventilator for prevention of secondary brain injury. I begin troubleshooting and looking for causes for restlessness in a head-injured patient. It could be pain, hypoxia, hypoglycaemia, low blood pressure, even seizures. Ruling these issues out, I decide to increase their sedation so that the patient will tolerate the ventilator better.

While I’m in the majors unit I decide to check on a patient with diabetic ketoacidosis (DKA). They came in really sick with a pH of 6.9 and are surrounded by drips and pumps. They need close monitoring of their sugars, electrolytes and acid-base status, while insulin and fluids brings down their high blood glucose, and we look for an underlying cause.

The rest of the night is a constant flow of sick and injured patients to sort out. The team is kept busy. Patients keep arriving. These include a patient with a snake bite for blood tests and limb elevation, a breathless, immune-compromised patient for oxygen and antibiotics, one with heavy chest pain for four hours management of a likely myocardial infarction, a patient with a dislocated knee for reduction, and a patient with an angle-grinder injury for tying off an arterial bleed and admission for amputation of two of their fingers. Eventually, the patient who was stabbed in the chest with a beer bottle arrives. They are drunk and frustrating to work with, but fortunately I can see on X-ray and bedside ultrasound that none of their vital organs are affected. I clean their wound, suture it closed, apply dressings, and give them fluids and a thiamine drip owing to their intoxication and chronic alcohol use. Later I send the patient home on pain medicine.

As the night wears on I can feel my concentration dipping and thought processes slowing. Caffeine helps but I’m willing time to speed up. Eventually, there is a lull. There aren’t many more expectant cases, especially no more red codes requiring laborious and heart-wrenching resuscitation efforts. Some of us sit, chat and laugh together, others put their heads down on the desk to rest their tired eyes.

6am rolls around. It is still two hours before the handover round but I can see through the glass windows that first light has emerged. This is my signal to make instant oats, and head outside to devour them while watching the sun rise over the community from the helipad. The air is fresh and I feel a renewed sense of hope. The night is almost over, and I’ll be home in my bed soon. Only to do it all again later that evening.

Interested?

You can apply for a job at Zululand hospitals through this website. Doctors will require a right to work in South Africa (see this page for advice), and registration with the HPCSA.

International medical students and doctors interested in emergency medicine experience in KwaZulu-Natal, either for university requirements or personal interest, can email mbanjwaa@ukzn.ac.za or go to this website to read more.

The post A 19-hour emergency shift in Zululand appeared first on Adventure Medic.

How do you become a team physician?

The most common route to become a team physician is to specialise in sports and exercise medicine first. Since 2014 sports medicine is an acknowledged specialisation in the Netherlands. It takes 4 years of specialty training and there are only 7 places available each year to start. In the UK it is a bit different. After foundation programme completion, you become eligible to apply to specialty training in sports and exercise medicine. There are 11 specialty training places available in the UK and completion will take a minimum of six or seven years. Although most team physicians finish sport and exercise medicine training, luckily it is also a possibility when you are a general practitioner like myself.

For me, it all started during a visit to the first Action Sports and Exercise Medicine Congress in Italy. After an interesting talk from the World Skate team I asked if I could get involved. A few months later I was accepted as a volunteer for the World Skate medical commission. Two years after my start in the medical commission I was able to join the International Olympic Committee (IOC) World Conference on Prevention of Injury and Illness in Sports in Monaco. This meeting is organised every four years. Here I got the chance to meet different team physicians and show my interest in this field of medicine. Thereafter, I stayed in touch and meanwhile I enrolled in a basic sports medicine course. Fast-forwards and I received a phone call with a great opportunity to apply for the role of team physician for the elite swimmers at the High Performance Centre in Eindhoven, the Netherlands.

Why become a team physician?

First of all, I find it a privilege to work with these highly motivated individuals who perform at the highest levels. It is inspiring to see how they can push their physical and mental boundaries to strive for excellence every single day.

Secondly, being a team physician means immersing yourself in a dynamic and fast-paced environment. Sports teams operate on tight schedules and face unexpected health issues, requiring you to be adaptable and quick-thinking. This constant dynamism keeps the role interesting and ensures that no two days are alike. On top of that, you get the opportunity to travel with the team for competitions and events, allowing you to experience different locations and cultures.

Lastly, being part of a team where all members have the same goal is very encouraging. As a team physician, you work in the same team composition for a longer period, which creates long-term relationships with athletes, coaches, and support staff. This continuity allows you to understand the individual health needs and challenges of each athlete, contributing to more personalised and effective medical care than you might normally be able to provide.

Teamwork

While as a doctor you might be used to working in a team, it can still be a different way of working as a doctor within an elite sports team. As a general practitioner, I am quite used to being the one on the receiving end of all the information from the other players in the medical field (doctors assistants, specialists, psychologists, nurse practitioners, dieticians, etc.). In elite sports, it is the coach that fulfils the central role. It makes it even more important to get to know everyone involved so you don’t get behind in what is going on. Besides the coach, the team consists of, but is not limited to: physiotherapists, strength and condition coach, sport psychologist, nutritionists, lifestyle coach, embedded scientists and different managers. Everyone has their own role in the team, but there are overlapping roles. For example, it is important to know the diet and supplements an athlete uses before deciding which blood tests to order.

Swimmer illness

As a team doctor, you will most likely encounter ordinary diseases like every other person who is not an elite athlete would. This is one of the main reasons why a general practitioner is suitable for this job. On the other hand, there are also sport-specific diseases in swimming. Otitis externa is really common in competitive swimmers for example. The mildly acidic cerumen normally provides a waxy coating that protects the auditory canal from bacterial and fungal infections. Prolonged water exposure and physical cleaning of the ear canals may cause a swimmer to scratch the pruritic ear canals, leading to superficial lacerations that become the portal for skin infections.

Exercise-induced bronchoconstriction is also more prevalent in elite swimmers. Swimming in indoor chlorinated pools can lead to airway chlorine allergen exposure and it is suggested that this generates airway epithelial damage, inflammation, and bronchoconstriction.

Swimmers injuries

Competitive swimming is unique because it is non-weight bearing and has a large dependence on upper extremity strength for propulsion (legs only count for 10-20%). This predominance of the upper extremities combined with high volumes of swimming training explains why shoulder pain is the most common musculoskeletal complaint in competitive swimmers.

The second most common musculoskeletal injury is breaststroker’s knee. It typically causes medial and/or anterior knee pain and results from the repetitive valgus load, which causes medial distraction and lateral compression of the knee compartments. A proper breaststroke kick technique, with optimal hip abduction angle range from 37 – 42 degrees, can prevent this. Groin pain is another injury risk and is caused by repetitive hip adduction. This movement puts significant stress on the adductor longus, brevis and magnus, pectineus and gracilis that can lead to overuse injury.

Prevention and Performance

In addition to illness and injury management, the team physician plays an important role in prevention and in optimizing the performance of elite swimmers. The main goal is to have as many healthy training hours as possible. It is crucial to recognise if performance is declining to reduce the risk of injury. Different tools are used to get a global idea of the performance of these athletes. Every week different strength measurements are done and compared to their personal mean. Another tool is an athlete self-reported daily questionnaire about subjects like their sleep, stress and mood to signal early signs of non-functional overreaching. The coach can also have a look at the acute to chronic workload ratio (ACWR). ACWRs are calculated by dividing the acute workload (total load over the last week) by the chronic workload (average of the last 6 weeks). The higher the outcome the higher the risk for an injury.

Mental Health

The pressure to perform at peak levels in combination with rigorous training regimens can have an impact on the mental health of elite athletes. The expectations placed on these athletes, both internally and externally, can lead to a range of mental health challenges. Anxiety, depression, eating disorders, injury related stress, social isolation and burnout are some examples. The pressure to continually perform better, coupled with the fear of failure, can have a big impact on the mental well-being of athletes.

As a team physician it is important to be extra aware during certain periods, because the athletes are more prone to mental health challenges. These include, yet are not limited to:

• When they are away from home for extended periods due to training abroad homesickness and loneliness can be a challenge.
• During major events like the Olympic Games or World Championships. These events can add extra pressure to perform and create a fear of failure.
• After a major competition or achievement, some athletes may experience a sense of emptiness also known as post-competition blues.
• Dealing with injuries and rehabilitation can lead to fear of not fully recovering and anxiety about returning to competition at the same level.

It is crucial to have a good relationship with the athletes and know their personal background. This will facilitate the identification of any out of the ordinary behaviour and also lower the threshold for them opening up to a conversation about mental health challenges. As a physician in elite sports, it is fundamental to be aware of signs of mental health challenges, open up the conversation and, if necessary, refer to a sports psychologist.

Antidoping

As a doctor, you are also responsible to promote a clean and fair environment in elite sports. Each year the World Anti-Doping Agency (WADA) publishes an updated version of the List of Prohibited Substances and Methods. This list contains all the substances that are prohibited at all times, in competition and specific sports. A substance can be added to the list if it satisfies two of the following three criteria:

1.     It has the potential to enhance or enhances sport performance

2.     It represents an actual or potential health risk to the athlete

3.     It violates the spirit of sport

Anabolic agents, oral corticosteroids, stimulants and diuretics are obvious examples. Beta-blockers are probably not the first to come to mind when thinking of prohibited substances. Though, when you think about it, it makes sense that this substance is prohibited in particular sports like archery, darts and shooting. Certain athletes may have an illness or a medical condition that requires particular medication. If this medication contains a substance that is on the List of Prohibited Substances and Methods, you can apply for a Therapeutic Use Exemption (TUE). A TUE allows the athlete to use the medication as it will not afford a competitive advantage but rather ensures the athlete to compete in a proper state of health.

Elite athletes often use several supplements and as the team physician, you should be aware of this. Supplements can be contaminated and cause a positive test. This is why there are several systems developed to check for a guaranteed clean supplement, such as: ‘Informed Sport’, ‘Banned Substances Control Group (BSCG)’, ‘National Sanitation Foundation (NSF) International’ and ‘Informed choice’.

Top tips to work as a team physician

• Get to know the sport. I listened to podcasts about swimming and read different biographies of famous swimmers to better understand the sport. Furthermore, I took lessons to learn freestyle swimming myself. Swimming is a technical sport. If you understand the technique you can also explain why certain injuries happen to certain athletes and make adjustments to prevent this.
• Get to know the supporting team. As mentioned before, there is a big group of supporting personnel and it is really important that you know the role of each person in this group. If an illness or injury is present you want to make sure you can tackle this as fast as possible so it helps to know who to consult in every situation. In elite sports, every missed training day is one too many.

Get started

In my opinion, the best way of learning is to learn on the job. Luckily for me there are many experienced professionals in the team who I can ask for advice. However, if you want to follow a course, the IOC Advanced Team Physician Course may be a good start.

The post Behind the Scenes of a Team Physician appeared first on Adventure Medic.

Rogier shares his journey from skateparks in Utrecht to surf medicine in Indonesia. He puts his qualifications to the test staffing one of the most remote surf clinics in the world, renowned for its formidable waves and furtive monkeys.

G-land, situated on the Eastern side of the Bay of Grajagan in Java, Indonesia, is home to internationally renowned left-handers and some of the biggest surf competitions in the world. But, G-land’s surfing credentials come at a cost: waves ranging from 2-20+ feet, shallow coral reefs and its remote location also produce some of the most dangerous surfing conditions in the world. Working as a surf doctor is not something that is taught at medical school, but for those that are interested, there are definitely ways to get started.

Why Surfing?

As a young kid, I was really passionate about skateboarding. I was addicted to the physical rush it gave me to land a new trick. I would literally eat, sleep, go to school, skateboard and repeat. Five years later, I was starting medical school and saying goodbye to the passion that had brought me so much joy. Thankfully, this would not turn out to be a definitive farewell from board sports.

During my time at university, I joined the board sports student association and tried snow-kiting, surfing and wakeboarding. I realised that I loved surfing. It was not just the physical rush of catching a great wave, but also the serenity of being out in the water that I fell in love with.

Training as a Surf Medic

I came across a group, back then called the European Association of Surfing Doctors (EASD), which spiked my interest immediately. EASD, now known as Surfing Medicine International (SMI), was founded as a non-profit organisation to connect doctors with a passion for surfing. SMI aims to contribute to the health of the surfer by developing surf medicine.

I joined SMI’s Advanced Surfing Life Support (ASLS) course in Ericeira, Portugal. It was great to meet like-minded doctors with an interest in practising medicine outside of the clinical environment. Our days were filled with lectures about topics from drowning to dive medicine, to infectious diseases and heat stroke. The workshops focussed on hands-on scenarios such as CPR, evacuating an injured patient and C-spine immobilisation. Following the acronym DR. MARCH (Danger, Response, Massive haemorrhage, Respiration, Circulation, Hike vs Helicopter/Hypothermia vs Hyperthermia) we had to assess and treat the simulated patient. This might seem similar to an Advanced Wilderness Life Support (AWLS) course but there was one big difference; lifeguarding is also an integral part of the course.  How would you get an unconscious surfer on to your board and out of the water as fast as possible?

G-Land

It took me a while to put my training to full use. After graduation, I worked in Emergency medicine and then in surgery, before finishing my training to become a general practitioner. The first thing I did as a fully qualified GP was start my journey to G-Land.

I contacted Surfing Doctors, a non-profit organisation that aims to provide medical care in dangerous and remote surf locations. G-land surf camp is located within the Plengkung Nature Reserve at the edge of Grajagan Bay in Java, Indonesia. Practically, it is a 3-hour fast boat from Kuta, Bali. G-land was discovered by an elite group of surfers in the mid-1970s and is considered one of the best lefts in the world. It produces dangerous surfing conditions that mean reef cuts, infections and trauma can happen in the blink of an eye.

Surfing Doctors has a roster to make sure a doctor is always on-site to provide the necessary medical care. There are three clinics each with basic medical facilities. For more serious injuries, patients are usually evacuated to Bali International Medical Centre (BIMC). BIMC can be reached in seven to ten hours overland, three hours by fast boat, or in more urgent situations, a short helicopter flight.

The Medical Clinic

When I was in G-land, I was the only doctor on site. My first priority on arrival was to visit the clinic and familiarise myself with the medical equipment. The clinic is funded by donations, often from injured surfers who after treatment, can donate to replace the medical equipment that has been used. The most common injuries seen in G-land are reef cuts, sprains and strains. These might seem like minor problems, but even the smallest, most harmless-looking reef cut has a high chance of developing into a serious infection if not treated correctly. This is why antiseptic cream and antibiotics are your best friends in G-land.

Marine life injuries are also common, especially from sea urchins which can leave their mark on a surfer’s foot. The needles are very fragile and can easily break or crush when you’re trying to remove them. On the contrary, shark attacks are really rare; you have a 1 in 63 chance of dying from the flu compared to a 1 in 3.7 million chance of being killed by a shark. Approximately 80 attacks occur worldwide each year, only 5 of which are fatal. To put this in stark perspective, humans kill an astonishing 100 million sharks every year.

Besides marine life, it is also important to be aware of the monkeys that inhabit the surrounding area and jungle. They are accustomed to humans and can transmit rabies through their bite. They are not to be fooled around with, especially the dominant males. At one point they came really close during a yoga session and stole my wallet. Thankfully for me, the only thing bitten was my driver’s licence.

Other common medical problems in G-land include sunstroke, sunburn, malaria, dengue fever and traveller’s diarrhoea. The Indian ocean at G-land can be extremely hostile: major traumatic injuries happen as a result of the enormous power of the waves, with surfers known to have suffered serious pelvic fractures in previous years. Luckily no major incident requiring evacuation occurred during my stay.

The Surf

During my stay, I had enough time to explore the surrounding jungle and catch some waves myself. When surfing anywhere, it is really important to understand and stick to surfing etiquette. It’s also important to respect surf culture and be aware of more unpleasant tendencies like ‘localism’. Surf localism, which I’ve only rarely encountered, is more common in crowded surf spots where locals object to ‘strangers’ catching ‘their’ waves. This mostly consists of verbal assault but has been known to escalate to intimidating signs, physical violence and vandalised equipment. Fortunately, G-land is not a crowded place and the locals were extremely accommodating. A big advantage of being the surf doctor was that a lot of the surfers were happy to see me in the line-up and would often ‘give’ me one of ‘their’ waves.

Surfing terms and etiquette

Doctor Becomes Patient

Unfortunately, on my last day in G-land I felt really sick. At first, I thought it was just seasickness from the ride on the fast boat back to Bali. Arriving at my hotel, I continued to feel nauseous, developed painful joints and felt feverish. A few hours later, I was vomiting and beginning to get dehydrated. I used some salt and sugar to make my own oral rehydration solution (8 teaspoons of sugar and 1 teaspoon of salt, dissolved in 1 litre of water usually does the trick). As time passed, I began feeling more and more drowsy and decided to head to hospital. I was so weak by this point that I remember struggling not to collapse whilst walking to the taxi. I was afraid I might have malaria or dengue fever but luckily, after a battery of negative tests, we presumed it was just ‘Bali belly’. Thankfully, I made a quick recovery and was able to enjoy the rest of the time I had left in Indonesia.

Top Tips for Working as a Surf Medic:

• Put your own safety first. Don’t go out there and surf in conditions that you are not capable of. Never forget that you are (most likely) the only medical doctor in an incredibly isolated spot and that you need to be in good condition to be able to help others.
• Prepare for the worst. Make sure you know your medical equipment inside out. Get acquainted with the equipment, environment and evacuation procedures as soon as you arrive, so that you don’t lose time when there is a medical emergency.
• Get to know the surfers and get out there. The more you get involved and earn their respect, the sooner they will come to you with a medical problem. It is always easier to treat a medical problem/wound (reef cut) at an earlier stage to prevent the need for evacuation.

More Information and Getting Involved:

• For specific enquiries, Surfing Doctors (glandsurfdocs@gmail.com) have information on current vacancies and opportunities in G-Land.
•  The World Conference on Surfing Medicine is a yearly event run by Surfing Medicine International – this year it was in April in Valdovino, Spain. 2024 venue TBA – more information can be found at https://www.surfingmed.com/world-conference-2023/
• Advanced Surfing LIfe Support courses are also run by Surfing Medicine International. Information can be found here https://www.surfingmed.com/smi-live-events/#2

The post From GP to G-land: Surf Medicine in Remote Indonesia appeared first on Adventure Medic.

It is in human nature to constantly strive for tougher challenges, push further, to increasingly extreme environments. Any running race longer than a traditional marathon (26miles or 42.2km) is classified as an ultramarathon. There are over 5000 ultramarathon races every year worldwide. Many of these are located in remote and inaccessible locations, and some take place over multiple days. With the complexity, duration and rural location of these events, medical cover is required to reduce risks to participants. This falls under the remit of both wilderness and sports medicine. 

The Highland Ultra Background

‘Beyond the Ultimate’ (BTU) hosts a 125 km ultramarathon in Knoydart, in the Scottish Highlands. The race is run over three days in particularly challenging terrain, with over 5500m of ascent.

The event is split into three stages. 54km, 42km and 29km. Basecamp, where runners sleep on the first and last nights, is located at Inverie, only accessible by ferry from Mallaig. At the end of the first and second stage runners camp at Kinloch Hourn. Aside from tents and drinking water provided at each camp, runners have to be self-reliant, and able to deal with any issues that arise on the trail. Clothes, sleeping bags, food and personal med kits must be carried by each runner.

Beyond the Ultimate specialises in arranging unique ultra-marathons across the world. The inaugural Highland Ultra took place in October 2021, and we attended during its second year. On this occasion, medical cover was provided by a team of 6 with a range of experience and backgrounds. This included a consultant team leader, three doctors, one physio, and one advanced nurse practitioner, however the composition of event teams can vary considerably.

Why Choose the Highland Ultramarathon as a Medic?

Working on the Highland Ultramarathon would be appealing to anyone who enjoys spending time in remote and beautiful places. There is no requirement to be any kind of runner; simply an appreciation of the Scottish highlands and a desire to combine professional skills and a passion for the outdoors.

Having worked for BTU in the past we understood its core ethos and values. They are a great team that take time to invest and support the local communities. For the Highland Ultra, event organisers source all food and beer locally from Inverie, plant one tree per entrant and reduce unnecessary waste by providing a water filter bottle to each runner.  There is an expectation that volunteer medics are self-sufficient; it goes without saying that medics must be able to look after themselves first and foremost. Much of your personal equipment you have to provide yourself, including basic camping and hiking equipment and food.

Role of the Clinician

So what does working at this event actually look like? There is no clear answer to this – the joys of a pre-hospital environment come from a varied and unpredictable workload. It is common to find yourself in a very remote environment with limited kit and communications and as a result the planning stage is a vital part of the work. Establishing each member’s skillset, experience and areas of practice is essential in planning your medical response.

Each stage of this event presented its own challenges, and therefore each evening the medical team would liaise with the event coordinators to plan activities for the next day. This included highlighting challenging terrain, where specific risks would be encountered by runners and deciding where medical bags would be strategically placed along the route.

There were three types of kit bag: trauma bags, checkpoint bags and resus bags. Trauma bags were based at the start and finish of each day, being too cumbersome to be carried on foot across challenging terrain. Checkpoint bags accompanied a medic at each checkpoint. Resus bags could be carried more easily and were used in responding to emergencies. At basecamp, a wider range of kit was available.

Minor ailments can wait until the checkpoints or the base camp but anything more serious may require a swift action response. Due to dead zones in the phone signal we relied on trackers that identify runners’ locations  and allow some basic messages to be sent. One potential emergency was encountered during the race and we received a message with no details at the time. We had to respond immediately to reach the runner, taking the resus bag. On arrival it was apparent it was a flare up of a pre-existing medical condition, and not in fact an emergency. The runner needed some supportive care and escorting off the route. No further intervention was required for this patient. However, this reinforced the necessity to be available and adapt to dynamically occurring incidents, sometimes with minimal information.

Tick Awareness

Working in any wilderness environment there always has to be consideration of the wildlife. Whilst there aren’t any exotic spiders in Scotland, there are ticks. Lots of ticks. The issue is that tick bites may lead to Lyme disease, with the iconic bulls-eye lesion (erythema migrans). Whilst ticks in themselves are not necessarily medical, the medical team has a role to play. The medical team can brief the runners about ticks, including some of the tips below. It is ultimately up to the runners to search for ticks themselves. We encouraged runners to correctly remove their own ticks where possible, some however felt uncomfortable and asked the medical team to assist. As a clinician some of the key points to remember are below.

Top ticks:

1. Always carry tick tweezers
2. Check for ticks in places where the sun doesn’t shine
3. Buddy up (might need this for tick 2)
4. Long. Trousers. Always.
5. Remind yourself about target lesions

Foot Care

Foot care and foot management was a common reason for presenting to the medics at the checkpoints and basecamps. Hot spots, blisters or toenails coming loose were experienced by most of the runners and had the potential to be race-ending issues if not managed appropriately. Having only had experience in secondary care, foot issues from running were not clinical presentations that we had come across previously.

Runners were encouraged to self manage their foot problems, given that they had the greatest experience with their own body. The medical team would only step in when they were unable to do so. There is little evidence available to guide foot care in long distance running; the only protective factor appears to be previous race experience¹. Cumulative experience of these types of events is in itself preventative, which emphasises the importance of self-management.

The general guidance that we were advised to implement was three-fold; Prevention, Hot spots, Blisters.

• Participants were advised to bring their own blister prevention or management kit (such as tape) so that if they became aware of their own foot hot spots, they could manage it themselves before seeking medical attention.
• If a participant presented with a hot spot, defined as an area where friction is evident, but no separation of the skin layers has yet occurred (normally red and painful), advice about reducing friction was provided². This included straightening out socks and/or the application of tape which would reduce further friction and hopefully prevent development to a blister.
• If the participant presented with a blister, advice was normally to avoid bursting/deroofing due to the risk of infection. If the blister was too big or too painful to allow the participant to continue, reducing the pressure by using a sterile needle and thorough cleaning was considered with close monitoring for infection. Thankfully very few blisters were encountered during the event that required this management.

For the future, and due to the lack of current research in the area, the medical team was keen to get a better idea on how to best advise and provide care to participants presenting with foot issues. Following this event, runners were asked to fill a research questionnaire to find out their experience of foot related issues and what steps they took to manage it, including self management as well as any intervention by the medical team. This research was carried out by a member of the BTU medical team with the intention of repeating the questionnaire after multiple BTU ultra events. This would provide a large patient sample size with demographics, variety of experience and interventions, to further understand what is the best method of preventing and managing these issues.

The Finish Line

Overall, the event progressed very smoothly, with nearly every runner crossing the finish line. For the medics there are long days with early starts and limited sleep. Unfortunately, one’s duty doesn’t quite end at the finish line. This is always the area where we needed to be the most vigilant. Runners’ mental resilience is put to the test as they fight to the end, but the pain they have been desperately trying to ignore may be a matter for concern. It is not uncommon to see runners fainting due to a mixture of sheer exhaustion, dehydration, low blood sugars, etc.

The icing on the cake is of course the well-earned rewards at the finish line. With the mood and spirits high it is very easy for medics to get caught up in the celebrations, but it is important to keep an eye out in case anything goes wrong. Luckily there were no complications, and everyone thoroughly enjoyed the evening with food and entertainment provided by the local community including pizzas and a folk band.

Interested?

This event ticked all the boxes for us. It was great fun with a competent group of medical and non-medical staff. The weather was marvellous (very fortunately) as was the scenery.  Beyond the Ultimate are a great organisation to work for. They are very supportive of the medical team, understand their limitations, and make the team feel valued by really incorporating the medics into the race team. They welcome medics to get involved with some of the wider race support during quieter times and foster a feeling of inclusion and teamwork. Any appropriately qualified individual with an interest in expedition medicine who wants to participate in exciting events within the U.K. should be reassured that there are many opportunities. The Highland Ultra is just one and we hope that this article and the pictures will inspire you to reach out and get involved.

For those new to expedition medicine, it is worth noting that most roles are on a voluntary basis. BTU provides a contribution to expenses, but it is always advisable to check what is and isn’t covered before signing up to these sorts of events.

Indemnity was free for both of us, but this is not always the case. As it was a voluntary role, with senior supervision, there was no issue in obtaining this from the MDU. It is worth arranging this well in advance of the event as the paperwork can take some time to be processed.

The main ways of hearing about these sorts of events are by word of mouth, by messaging companies directly, or by the adventure medic website. There are so many opportunities and events out there, the best thing you can do is express your interest early on and get involved in whatever you can.

Key Details

Timings

The event occurred over three days (Thursday-Saturday), however, the BTU staff were already setting up the event a few days beforehand. The medical and runners were expected to arrive the prior (Wednesday) in good time to run though briefings and kit checks. We all left on Sunday. Some staff and runners did stay within the area to do some more exploring of Scotland, unfortunately, limited annual leave and primary job responsibilities meant that we had to return home.

Logistics

Multiple methods of getting to the location were available. We opted to drive from Edinburgh due to time constraints. Our colleagues flew to Glasgow where we picked them up to drive to Mallaig. Some participants took the train to Mallaig (direct train from Glasgow) where the ferry left for Inverie (start location of the race).

Cost Breakdown

It is likely that your travel costs will be covered by BTU. It is best to check prior to committing how much BTU will reimburse for travel. This is the same for their overseas events as well.

Other costs include:

• Any camping/hiking equipment that you may need (see list below)
• Your own food and snacks. Food and drink was provided on the final evening
• Any drinks at the local pub after the event

Kit and Equipment Not Provided by BTU

Essentials:

• Sleeping bag
• Sleeping mat
• Water bottles (ideally ability to hold at least 2 litres of water)
• Hiking trousers and shirts
• Socks and underwear (and spares. It is best to have as little cotton made clothing as possible due to difficulty drying wet clothing)
• Warm clothing (base layer, mid-layer, hat, gloves)
• Wet weather clothing (jacket and trousers)
• Food (ration packs/dry foods best, lots of snacks)
• Bowl + cutlery
• Head torch (and spare batteries)
• Compass
• Notepad and pen
• Good pair of hiking boots
• Personal toiletries and sun cream
• Travel towel
• Dry bags
• Phone and power bank (+ cable)

Desirables:

• Blow up pillow
• Gaiters
• Small stove (for having a brew at the checkpoints; hot water was provided at the campsites)
• Swimming trunks/swimsuits
• Thermos
• Camera

Useful links

This list is by no means exhaustive and it is purely for interest and to guide further reading.

Guidance for Medical Provision for Wilderness Medicine is useful for those with limited previous experience, and describes logistics, communications, and most crucially the level of support that should be provided, including capabilities of lead medics.

BMJ Best Practice: Heat Illness. The participants in these races are often extremely motivated and will push themselves to the limit when taking part. Heat illness is potentially life threatening and high risk at these events.

DermNet: tick bites and Lyme disease. These were very common and anyone coming away from the event without a tick bite (whether racing or support staff) were by far in the minority. Dealing with ticks and their potential consequences are important to understand.

Oxford Handbook of Expedition and Wilderness Medicine: A very handy guide to emergencies and treatments in the outdoor environment.

References

1.Scheer, B.V. et al. (2014) “The enemy of the feet,” Journal of the American Podiatric Medical Association, 104(5), pp. 473–478. Available at: https://doi.org/10.7547/0003-0538-104.5.473.

2.Dack, D. (2022) Hotspots while running – how to avoid hot feet when running -, Runner’s Blueprint. Available at: https://www.runnersblueprint.com/hotspots-running/ (Accessed: December 16, 2022).

The post The Clinician’s Role at a Remote Ultramarathon – The Highland Ultra appeared first on Adventure Medic.

In this article Dr Constance Osborne and Dr Rebecca Webb share their experiences of working as race medics at Montane’s Summer Spine ultramarathon. From extreme foot care to asthma and hypoglycaemia, the race medic needs to be prepared to support runners with minimal resources at their disposal. Here, Constance and Rebecca share some of their highlights and insights from a challenging but rewarding race.

Introduction

The runner came through the door of our medical room in the small hours of the morning, guided by a concerned volunteer. She had been picked up on the side of the trail, battling nausea and exhaustion. A warm blanket placed around her shoulders, mug of tea in hand, the limited medical assessment could begin.

The history was unremarkable aside from several vomiting episodes. No trauma or predisposing medical conditions. Pulse and blood pressure within an acceptable range, temperature and blood sugar equally normal. What could be causing this overwhelming nausea? We made a makeshift bed out of a roll mat and continued to question her.

“I don’t know why I feel so awful,” she said, “I’ve drunk at least 10 litres of water today.”

Our new differential diagnosis: hyponatraemia secondary to overzealous adherence to the pre-race medical briefing warning against dehydration. After giving an anti-emetic, we observed her for half an hour and advised some rest after dinner. She emerged from the camp bunk bed three hours later feeling much better. We safety-netted her and then she was on her way again. Off running into the night.

The Montane Summer Spine Race

The Montane Summer Spine is a legendary course amongst trail runners. Starting in the bucolic town of Edale, athletes will navigate the full length of the Pennine way over six and a half days. From the Peak District to the Yorkshire Dales, across Northumberland National Park to the finish line at Kirk Yeltholm in the Scottish Borders, they will encounter some of the most difficult terrain in the UK. No section of this race is forgiving, but each is breath-taking. The full course is 268 miles and inevitably not everyone crosses the finish line. There are shorter, though no less arduous, iterations of the route that occur alongside the main event: the ‘Sprint’ and ‘Challenger’ races.

Participants range from first timers to seasoned trail runners. Each determined to test their mettle against the unforgiving elements. But even the most experienced runner may need some help along the way. This is where local volunteers and the medical team from Beyond the Ultimate (BTU) step in. BTU organises a growing repertoire of multi-stage foot-races and it is through them that we applied for medical volunteer roles in late June 2022.

Day to Day

The job of an ultramarathon medic is to ensure that runners are safe to continue racing. We are there to treat emergencies, which fortunately are rare. Occasionally a medic has the unenviable role of balancing a participant’s determination to finish the race with their health needs and the risks inherent to an endurance event. Prior to the event all medical personnel were briefed comprehensively on the contents of the kit bags and emergency protocols. These requirements were reiterated at each check-point to the runners. We had a clear chain of command and access to senior support at all hours.

Common things are common

The bread and butter of a race medic’s day is foot care. We became quickly acquainted with the nuances of K-Tape (a multi-purpose flexible tape used in high-performance sport). Musculoskeletal issues were frequent, ranging from twisted ankles to tendonitis. When assessing runners, we looked for features of stress fractures or signs that indicated the need for an x-ray. Anything that warranted further investigation meant withdrawal from the race. Inexplicable nausea and vomiting was also a routine complaint, something which often resolved with half an hour’s rest. Hypoglycaemia, asthma exacerbations, insect bites, lacerations and chafing all made their way to the medical team. However, where safe, athletes were encouraged to self-manage their issues. Occasionally this in itself led to difficulties with a few runners deciding to ignore the pre-race brief to avoid NSAIDs during the event due to recognised complications such as renal impairment and hyponatraemia.

The Race Environment

The effective management of an ultramarathon runner must incorporate a consideration of their surroundings. The continuous slog through a variety of weathers and landscapes leads to an equally varied range of pathologies. Uneven, rocky surfaces lead to falls and head injuries. Wet weather can lead to foot maceration. The Summer Spine is not always sunny despite its name and wind chill, rain and running through the night meant that hypothermia and its sequelae were important differentials. This year’s race featured some exceptionally hot days, with runners having to traverse exposed moors and trails for hours. The sustained nature of the exertion combined with high ambient temperatures can affect the thermoregulatory mechanisms of even the most experienced athlete. That said, we only saw a couple of cases of heat exhaustion towards the end of the race and thankfully none of heat stroke.

Weird and Wonderful

In the final days, we saw a couple of cases of ‘the ultramarathon lean’. This is when a runner leans anywhere up to 90 degrees to one side, leading to a banana-like posture. Another runner had such bad neck fatigue that he could not lift his head for the last 14 hours of the race. These issues were treated with an hour’s sleep where possible and an encouraging word or two as they continued onwards. Towards the end of the race, the cocktail of exhaustion and continuous stimulation sometimes led to hallucinations. Tree trunks, roots and rocks can take on a life of their own for an ultramarathon runner in these conditions.

How to get involved

Our experience as medic volunteers was unforgettable, not just the impressive blisters, but because of the athletes themselves. Being a medic allows a unique insight into the highs and lows of each person’s race experience, along with the chance to become a unique part of their story. The jubilation felt watching a runner that you have patched together cross the finish line is hard to describe. However this is not a volunteering role to take lightly. It is a tiring event with long and unpredictable hours. Most of the volunteers were there during their annual leave and returned to work more tired than when they left.

As junior doctors seeking experience in expedition medicine, this was the perfect opportunity for us to develop some prehospital skills. That said, anyone seeking to volunteer at this event below ST3 level may run into indemnity issues. The BTU medical team will assist you in arranging indemnity through a private broker, but this can take weeks, so please keep that in mind when applying.

Food and accommodation are provided throughout the event. Each volunteer is issued with a certificate of attendance. As it is a Montane race, opportunities for merchandise and a personal discount code are available. Fuel expenses are reimbursed and a further £100 contribution made for additional costs such as indemnity (rising to £350 if you do four or more days).

You can read more about the variety of events organised by Beyond the Ultimate here.

If you would like to inquire about volunteer opportunities, contact the team via email: info@thespinerace.com. Please have a CV prepared.

All photos included in this article were used with the owner’s permission. All medical photography has been included with the featured patient’s permission.

The post Montane Summer Spine Race: A race medic’s perspective appeared first on Adventure Medic.

Dr Hugh Roberts is an anaesthetic trainee currently working in the North East. He has worked as an expedition medic for the last 5 years. This started whilst taking time out of training to work as an emergency medicine and expedition medicine clinical fellow in Bristol. Now that he is back in training he has successfully continued to integrate his expedition work into his life as an anaesthetic trainee. In this article he uses his experience to explore the issues and options surrounding combining work as an expedition medic and specialty trainee. 

Years out of training after the Foundation Programme are often some of the most enjoyable of a doctor’s career, and stepping back into training can feel like the end of the adventurous lifestyle of those F3+ years. However, being a specialty trainee does not have to mean your expedition medicine career is put on hold. This article describes how you can balance a career in expedition medicine with specialty training, with specific focus on anaesthetics, emergency medicine and general practice.

We will begin by reviewing the current state of UK specialty training and examining the benefits that expedition medicine can bring to both trainees and training schemes. We will then consider the options available for taking leave from training, and finish with some case examples of doctors who have managed to successfully balance expedition medicine with their specialty training.

The State of UK Specialty Training

There is a retention crisis across UK specialty training. In 2020, the Royal College of Emergency Medicine (RCEM) published the document Retain, Recruit, Recover – our call to action to improve the urgent & emergency care system.¹ It reported that 36% of emergency medicine doctors in training were considering working abroad and 25% were considering changing specialty. In the same vein, in 2021 the Royal College of Anaesthetists (RCoA) released the document Respected, Valued, Retained – working together to improve retention in anaesthesia.² It reported that 25% of  anaesthetists in training were planning to leave the NHS within five years. It is a similar picture in general practice, with the Royal College of General Practice (RCGP) reporting that 22,000 GPs and GP trainees plan to leave the specialty in the next five years, citing exhaustion and burnout as key causes.³

These figures are stark and it is clear that training schemes need to make changes to improve retention. Although it is early days, it is encouraging that the Royal Colleges are acknowledging these problems and recognise that change is required. RCoA responded to the findings of its report by committing itself to improving work-life balance for trainees, increasing flexibility and supporting portfolio careers.² These changes would certainly make it easier to balance expedition medicine with specialty training, but exactly how these will be implemented remains to be seen.

The Benefits that Expedition Medicine can Bring to Training

The benefits to training schemes of making it easier to balance expedition medicine with training go beyond improved retention. Expedition medicine training and experiences can also bring many other benefits that increase a trainee’s value to the NHS:

• Working without access to investigations can enhance a doctors’ clinical acumen and problem solving.
• Working independently in remote settings can increase self-reliance and clinical confidence.
• Experience of medical screening and working in challenging environments can enhance understanding of risk and ability to conduct dynamic risk assessments.
• Exposure to other healthcare systems and pre-hospital practice can inspire quality improvement projects and research on return to the NHS.

RCEM considers expedition and wilderness medicine to be a branch of pre-hospital emergency medicine (PHEM), and in this article they describe many benefits that training emergency medicine doctors in PHEM can bring.⁴

How to Take Leave from Training for Expedition Medicine

General Principles for Taking Leave

There are some general principles that are important to be mindful of when taking leave during your training. You should be up to date or ahead with your competencies and portfolio, otherwise you stand little chance of having leave approved. Make sure you give plenty of notice for leave requests;  in most cases, several months advanced notice is required to facilitate the approval processes and prevent clashes with on-call commitments. When you do make it away on expedition, always keep your General Medical Council (GMC) registration, or you will lose your training number.

Options Available for Taking Leave

Option 1: Out of Programme (OOP)

The Gold Guide (also known as The Reference Guide for Postgraduate Specialty Training) details how to take time Out Of Programme.⁵ The GMC also has a useful guide on OOP.⁶ There are several types:

• OOPE (Experience)
• OOPC (Career break)
• OOPT (Training)
• OOPR (Research)

Information on OOP from RCoA can be found here, and from RCEM here. There should also be guidance available from your local deanery. There is no specific guide from RCGP, so you should refer to the GMC guide and your local deanery guidance.

OOPE

The purpose of OOPE is to gain professional skills that would enhance your future practice. It may benefit you (e.g. working in a different health environment/country) or may help support the health needs of other countries (e.g. with Médecins Sans Frontières, Voluntary Service Overseas, global health partnerships). GP training deaneries are offering opportunities for international OOPEs to locations such as South Africa, Zambia and India. There is also the National Global Health Fellowships Volunteer Programme, open to GP, paediatrics and ACCS trainees, offering posts in a number of African countries.

OOPC

OOPC allows you to step out of the training programme for a designated and agreed period of time to pursue other interests (e.g. domestic responsibilities, work in industry, developing talents in other areas or entrepreneurship). Dr Tamal Ray, a finalist from the sixth series of The Great British Bake Off, used an OOPC to join the show from anaesthetics training. An OOPC could also be used to pursue expedition interests.

OOPT

OOPT is clinical training, taken out of programme, that can count as time towards CCT provided certain conditions are met. For anaesthetics trainees, you need to be a higher or advanced level trainee to take an OOPT, which can count for up to one year towards CCT.⁷ RCEM do not specify at what stage of training you can take an OOPT.⁸ Specifically to support trainees wanting to undertake OOPT in a low-middle income country, RCoA has developed a unit of training Annex D – anaesthesia in developing countries to enable this to count for up to six months towards your general duties requirements. The criteria for this are quite rigorous, so you are probably better off joining an established project, such as those advertised here. 

OOPR

OOPR is research taken out of programme. If an expedition involves research, this may be an opportunity to take OOPR. Both RCoA and RCEM state that some OOPR time may count towards CCT, provided certain criteria are met.^7,8

How to Apply for OOP

You should refer to the relevant guidance described above. Unlike OOPT and OOPR, OOPE and OOPC cannot count towards your CCT and are approved at the level of the Local Education and Training Board (LETB), meaning you do not need Royal College or GMC approval.⁶ Your LETB will have its own OOP application process that you will need to follow. It is recommended that you discuss your OOP with your Educational Supervisor (ES) and Training Programme Director (TPD) at least six months in advance, so it is unlikely that these are going to be useful for last minute expeditions. Ultimately, approval for OOPE or OOPC is at the discretion of your TPD and Postgraduate Dean. This can work for or against you, depending on where you are training. Although it may seem unfair, that is the current system. It is important to note that for anaesthetics trainees, you are allowed up to a maximum of two years total in any mixture of Out Of Programmes.

Option 2: Study Leave

This is another option that requires a sympathetic ES, although it is easy to justify why study leave for expeditions or expedition medicine courses/certificates/diplomas/MSc programmes is reasonable:

• Expedition medicine teaches lots of ‘soft skills’ that are often specific learning outcomes for specialty training, such as: communication, leadership, teamwork, organisation/planning and situational awareness.
• Research and critical appraisal are usually components of specialty training curriculums and may be components of expedition medicine postgraduate certificates, diplomas or MSc programmes.
• Expedition medicine experience is useful for higher specialty training applications. ST4 anaesthetics self-assessment criteria include Domain 10: activities demonstrating leadership and/ or management inside or outside of work, with high scores for ‘commitment to leadership or management inside or outside of medicine such as expedition leadership’. A postgraduate certificate, diploma or MSc will also score points, and expedition medicine is a great topic to talk about at an interview!

Set expectations early by discussing your interest in expedition medicine with your ES at your initial meeting. Having a Personal Development Plan (PDP) that links your interests in expedition medicine with your chosen specialty is likely to help too. It is generally easier to get study leave for courses, diplomas or MSc programmes than it is for expeditions, although study leave for expeditions is not unheard of and so it is always worth asking. You should not expect to get any study leave funding, and shorter periods of study leave are more likely to be approved.

Option 3: Less than Full Time (LTFT)

73% of UK anaesthetists in training state that being able to work flexibly or work LTFT is important to encourage them to stay in the NHS, and 57% of emergency medicine doctors in training are considering reducing their working hours.^1,2 All doctors in training can apply for LTFT, either at the point of application for entry into training or at any point during training. It is important to note that when applying for LTFT at the point of application, it will not affect your chances of being appointed. Although you have to give a ‘well-founded individual reason’ to apply for LTFT, expedition medicine should certainly fall within this scope.⁵ LTFT is a great option if you want to complete a postgraduate certificate, diploma or MSc, or need time to be involved with a regular commitment such as mountain rescue. Information about LTFT can also be found in The Gold Guide.

Option 4: Weekends

We now move onto the first of two options that require you to give up your free time. The disadvantages of using weekends are obvious: you risk burnout, and lose time that you could be spending with friends and family, or pursuing your own adventurous interests! However, there are some advantages: it will not extend the duration of your training and you are not required to justify your weekend activities to your training programme. Charity challenge companies are always looking for volunteer medics for their weekend UK events, and these are a great way to foster your relationship with companies whilst continuing to gain expedition medicine experience and bolster your CV.

Option 5: Annual Leave

This is arguably the least attractive option. As specialty trainees, we deserve our time off; we work long and unsociable hours whilst balancing many other work commitments, such as audits, exams revision and portfolio management. RCoA agrees with this sentiment, advising that individuals should ‘take annual leave and time they need to look after themselves and recuperate’.² The advantage of this option is that your annual leave is yours to do with what you will, so there is no need for justification and approval from your training programme. Where possible, give your rota coordinator plenty of advanced notice to avoid clashes with on-call commitments. Make sure you include time for recharging on a sunny beach or ski slope as well!

Examples of Doctors Who Have Made It Work

In case you need proof of what you have read so far, here are some examples of doctors who have managed to strike the balance with specialty training and expedition medicine. Hopefully their stories will provide you with encouragement and inspiration, as well as some tips on how to make it work for you.

Dr Nikki Cox / Consultant Anaesthetist / Queen Alexandra Hospital, Portsmouth

What have you done during training?

I finally CCT’d in summer 2021, but I had plenty of gaps in my training! After completing core training, I took some time out and worked with a charity challenge company on UK events, an Everest Base Camp expedition and a London to Paris cycle ride. I also volunteered with Mercy Ships in the Congo and Madagascar. Once I started specialty training, I managed to continue with both of these companies, using annual leave for charity challenge events and taking a combination of study leave and an OOPE to teach in Senegal with Mercy Ships. I also took an OOPC to spend 6 months in Provence and improve my French language skills, ready for Senegal.

What was your experience of getting leave?

My TPD was very supportive. I think in anaesthetics, you tend to be recognised as a whole person rather than just as an anaesthetist. They are not trying to make us all into identical doctors. 

Any advice?

Once you have got your final exams, the training programme is very keen to keep you and that can help. On expeditions, you are pushed out of your comfort zone and often have to deal with the unexpected, so there is a lot you can learn that is relevant to work as an anaesthetist. Whilst you are in-programme, it helps to save money so you then have the flexibility to take six months off and be free to do what you want, rather than having to locum.

Do you think anaesthetics and expedition medicine complement each other well, and why?

Anaesthetics is a sessional specialty, and that makes it easier to take time off. Since CCT, I have been away again for a month to teach in Senegal. Just do not expect to get leave during the school holidays when everyone else wants time off!

Dr Ellie Debenham / CT2 Anaesthetics / Cumberland Infirmary, Carlisle

What have you done during training?

I went LTFT when I began ACCS. My reason for going LTFT was to do the Diploma in Mountain Medicine (DiMM) and to have more time to get out in the mountains. I have done the first three DiMM modules now and just have the alpine module left. I also planned to get involved with mountain rescue, but I am yet to join as I am enjoying my climbing too much! 

What was your experience of getting leave?

When I started ACCS, work-life balance was not considered a valid reason for going LTFT, so I had to sell it as doing the DiMM. That is definitely not the case anymore. Some people are very supportive and might say: “I am slightly jealous of your lifestyle, I wish I had made different decisions!”; others might say: “you are not committed, why are you even a trainee, why are you even a doctor?”. You have to stay true to what is giving you the lifestyle you want. Sometimes I have been able to get study leave for the DiMM modules, and sometimes I have had to take annual leave, it is variable.

Any advice?

One of the nice things about doing a postgraduate qualification like the DiMM is that suddenly, you have a network of channels that you can contact as you are in a room of like-minded people who want to have a career but also want to go on adventures! Once you have got the diploma, you have got it, and you do not know what opportunities it might open up in the future. I would like to go work at the Sherpa outpost hospitals. It is also helpful for higher specialty training applications – a diploma is another tick in the box, so why not do it in something really fun rather than something dull?

Do you think anaesthetics and expedition medicine complement each other well, and why?

I think that anaesthetics is the best career you can do in medicine, why would you want to do anything else?! It is the most fun and practical. With anaesthetics, you learn the ability to deal with horrendous situations and look after critically ill people. I also think having A&E experience is useful, for example for trauma management, and GP is useful for managing comorbidities or problems that might present to primary care.

Dr Alex Taylor / ST3 ACCS Emergency Medicine / Bristol Royal Infirmary, Bristol

What have you done during training?

During ST1, I worked on an event with Children in Need. Covid had cancelled another trip I was supposed to be on to Nepal and luckily the leave I had taken lined up with this UK challenge! In ST2, I spent two and a half weeks on a polar expedition in Greenland with a youth development charity. Most recently I worked in a rural hospital in South Africa for four months as part of a six month OOPE offered by Health Education England. I have also taken leave to teach on a variety of expedition and wilderness medicine courses.

What was your experience of getting leave?

The Children in Need event was annual leave. Greenland was a mix of annual leave, study leave and Educational Development Time (EDT). South Africa was an OOPE, and the role included reimbursed costs (up to a limit per month), funded accommodation and annual leave. For teaching on courses, I was granted study leave. In my experience, I have found it is definitely easier to get study leave for teaching than it is for going on expeditions.

Any advice?

Be prepared! Tell your ES about your interest in expedition medicine from the outset. It helps to write a PDP before your initial meeting which demonstrates a long-term interest, and support it with evidence. Your ES may not have any personal experience of expedition medicine, so having a discussion about what is involved (screening participants, preparing medical kits, leadership and teamworking, risk assessments, working in a resource poor environment) helps them understand that you are not asking for extra holiday leave! I also like to use Workplace Based Assessments (WBAs) as evidence of my clinical work on expeditions. You could arrange a Case Based Discussion (CBD) with your ES after your expedition, or with a senior medic on your expedition if there is one – it is all helpful for your portfolio.

Do you think emergency medicine and expedition medicine complement each other well, and why?

The cases you are likely to encounter on expedition are either problems that might present to GP, or emergencies, and the emergencies are the ones that people tend to worry about. Emergency medicine also teaches you a lot of ‘soft’ skills that are useful on expedition, like dynamic risk assessment, resource management, flexibility and leadership. Looking after an unwell patient on expedition usually requires the whole expedition team, so it is a lot like managing a busy emergency department!

Dr Jack Watson / GP / Cheltenham / @outdoormedics

What have you done during training?

I was interested in expedition medicine during foundation training, but did not feel I was cut out for it – looking after sick patients alone in a remote setting seemed like a lot of responsibility, and I was never the one fighting to the front at crash calls! I started GP training and after ST2, took a global health fellowship to rural South Africa. This was a huge change for me – I was caring for really sick patients and the buck stopped with me, so it gave me the confidence to manage prehospital cases on my own. When I returned to finish GP training, I felt inspired to gear everything towards expedition medicine. I started working events with a charity challenge company and built on my prehospital experience, including a case that summer when a spectator fell and broke her arm. I also enrolled on a BASICS course near the end of ST3. The events were a ‘foot in the door’ for me to get on my first international expedition to Kili in January 2019, a few months after I finished GP training. I have also spent time working as a rural GP in Shetland and the Outer Hebrides. There was lots of overlap with expedition medicine in that role, and having BASICS was really useful.

What was your experience of getting leave?

The South Africa global health fellowships are run by Health Education England, so it was easy to get study leave for the preparatory courses for that. The fellowship itself was an OOPE. There was no pay progression during the fellowship year, which was quite frustrating. I got study leave for the BASICS course and received funding of about £1500 to cover the course fees. My ES was very supportive, but was surprised that I got the funding approved! I sold it mainly as being useful for rural GP rather than expedition work, and I think that it also helped that by that time I had completed my Clinical Skills Assessment (CSA) and Applied Knowledge Test (AKT). I also did ALS during ST3, as I wanted to do some work in A&E, but the training programme would not fund that as GP training only requires ILS.

Any advice?

You have to fight your corner and be savvy. Show that what you are doing brings transferable skills and relate it to the GP training curriculum. Unfortunately there is big variability geographically, and what you get approval for depends on what region you train in.

Do you think GP and expedition medicine complement each other well, and why?

I am a big believer that GP is the best specialty to balance with expedition medicine as it is a short training scheme and then you can be your own boss. There is a big overlap in skills and 90% of problems you encounter on expedition are GP presentations.

Conclusion

There is no doubt that finding time for expedition medicine is harder as a trainee on a rota than it is with the complete freedom of working as a locum. However, hopefully this article has helped to show that there are ways that you can make it work. The Royal Colleges recognise the need to prevent trainee burnout and drop out, and want to work with trainees to fit their goals around their training and keep them in the programme. Use the options that are available to you, plan well in advance, engage with your ES and TPD, and expect that shorter expeditions, weekend events and postgraduate qualifications will be easier to fit in around your training than longer expeditions. Do these things, and the adventure does not have to end at CT1/ST1!

References

1. The Royal College of Emergency Medicine. Retain, Recruit, Recover – A Call for Action [Internet]. 2021 [cited 2023 Mar 1]. Available from: https://rcem.ac.uk/retain-recruit-recover-a-call-for-action/
2. The Royal College of Anaesthetists. Improving retention in anaesthesia [Internet]. [cited 2023 Jan 25]. Available from: https://www.rcoa.ac.uk/policy-communications/policy-public-affairs/anaesthesia-fit-future/improving-retention-anaesthesia
3. The Royal College of General Practice. Retention as vital as recruitment in addressing GP workforce crisis – College calls for urgent action to keep GPs in the profession [Internet]. [cited 2023 Mar 4]. Available from: https://www.rcgp.org.uk/News/Workforce-Retention-Statement
4. The Royal College of Emergency Medicine. What do RCEM committees do? Introducing the RCEM PHEM Professional Advisory Group [Internet]. 2021 [cited 2023 Mar 4]. Available from: http://president.rcem.ac.uk/index.php/2021/01/18/what-do-rcem-committees-do-introducing-the-rcem-phem-professional-advisory-group/
5. Conference of Postgraduate Medical Deans of the United Kingdom. A Reference Guide for Postgraduate Specialty Training in the UK – The Gold Guide 9th Edition [Internet]. 2022 [cited 2023 Jan 11]. Available from: https://www.copmed.org.uk/gold-guide/
6. General Medical Council. Out of programme guidance for doctors in training [Internet]. [cited 2023 Jan 11]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/out-of-programme/out-of-programme-guidance-for-doctors-in-training
7. The Royal College of Anaesthetists. Out of programme [Internet]. [cited 2023 Jan 11]. Available from: https://www.rcoa.ac.uk/documents/12-out-programme
8. The Royal College of Emergency Medicine. All UK Training Programmes [Internet]. [cited 2023 Mar 4]. Available from: https://rcem.ac.uk/emergency-medicine-training-programmes/

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Dr Sonia Henry is a General Practitioner who had been working in Sydney until a combination of personal events and the Covid-19 pandemic came crashing into her life. She found herself on an unexpected and completely off-the-beaten-track adventure into rural and remote Australian communities, where she was frequently the only doctor for hundreds of kilometres. Sonia has shared with us an extract from her book “Put your feet in the dirt, Girl” – an account of her time living and working in these communities (so far!). Here, she also reflects on the opportunities that a medical degree can provide to shape a life and career of your own, if you are brave enough to step out the door of the hospital systems and “put your feet in the dirt”.

Use your stethoscope as a passport

I read somewhere that the great thing about being a doctor is that you can use your stethoscope as a passport to travel the world. I think I was a medical student at the time, and looking for any sliver of hope that after the hard years of slogging my way through there was something to look forward to at the end of it all. I found this article with the line about the stethoscopes and passports, and I never forgot it.

My pathway to medicine was slightly unconventional. After working for a few years as a physio I decided I wanted a different challenge so applied for medicine. After ten weeks of my first year of medical school I wasn’t too sure about it and deferred. I got a job working for an offshoot of the London ballet company as a physio but two days before I left I broke my arm on a ski trip in Australia. That rendered my ability to work pretty useless (a sports physio without a functioning arm is like a surgeon without functioning hands), and a few months later I was running out of money. Had I not broken my arm I might have ended up loving the work so much I may never have returned to Australia, or medicine, – who knows?

The moment that sealed the deal was when my arm had healed, and I decided to head to Zermatt to ski the famous Matterhorn glacier, the only place really that had any snow left to ski as it was autumn. Despite the stress of the self serve T-bar ski tows, I also found myself sharing a room at the backpackers with a Spanish doctor called Sara. She’d driven her van from Spain to Switzerland and was doing a mountain rescue course. She enlisted my help in editing a PowerPoint presentation to make sure any English words she wasn’t as sure of were ok, and invited me out with the course attendees for drinks. Hearing the story of her life as a doctor, working in mountains, remote Europe and Spain really captured my imagination. She was also extremely humble and very kind. For the first time- I had met a doctor who had the kind of life and personality that I genuinely liked and saw myself emulating. So, with a healed arm, an empty bank balance, and this renewed enthusiasm for medicine, I returned to Australia and the rest, as they say, is history.

Feel free to live the life you want to

Some of us in this world have a wandering spirit, and I’ve learnt it is actually ok to be the person that you want to be and live the life you choose to live. Sure, there have been times I’ve definitely run away from my life, but when the dust has settled I have realised that I genuinely enjoy my ‘peripatetic’ existence. As a GP, I can work anywhere and settle anywhere, which allows me great freedom.

I have been lucky that as well as being a GP I have also been able to pursue my childhood dream of becoming a published author. I have published two books, one a novel loosely based upon my intern year, and the other a memoir about living and working as a GP around very remote parts of Australia.

I think there is much to be said for working in new environments. It doesn’t only make you a better doctor, I think it makes you a better person. I have always been a strong believer in the adage that change is as good as a holiday, because it is only by immersing ourselves in different places and with different people that we learn not just the art of medicine but also humility and humanity. It is unbelievable to me that when I lived in Sydney I could not even conceptualise places like those that I have worked and lived in now. Humanity is, by virtue, a tapestry of differing experiences. To truly understand or at least try to understand other people, to walk in their shoes, develops great empathy and also in turn your own self development.

How do you ‘put your feet in the dirt’?

After qualifying as a GP, I found that there were many, many job options with a wide variety of locations and experiences. For other GPs or doctors looking to do something a little different, I’d recommend finding a good locum agency, and researching some areas you are interested in working within. Often that will involve a bit of up-skilling, but there are plenty of courses available depending upon your interests. There is a shortage of GPs in rural and remote Australia, so there is a surplus of opportunities. I would particularly recommend the Kimberley region of Western Australia, known for its beauty and incredible scenery. Here the work you can do in First Nations communities is not only incredibly interesting, but also opens your mind both medically and personally to how difficult life can be in remote Australia. It also illustrates great discrepancies between metropolitan and remote health access, and the gap in health outcomes for First Nations Australians. For me, after having lived and worked in the places I have, remote medicine and First Nations health is no longer a concept or a chapter in a textbook, but very much a reality. It is only by spending time living within these communities that you can become a genuine advocate for equitable access to healthcare in these remote areas of Australia.

To any doctors reading this who want to try something new, go off the beaten track, have an adventure- I can only encourage you. Who knows- one day you might even write a book about it.

An extract from “Put your feet in the dirt, Girl”

My routine of swimming at Cable Beach is becoming slightly more stressful every morning. It seems that every day I see a another patient, usually a pearl diver, who has been stung by Irukandji, or wrestled sharks or spotted crocodiles – the big, scary ones, saltwater crocs.

‘I don’t think Irukandji really kill people,’ my pearl-diving patient tells me, ‘But (…) you want to want to avoid it if you can. I’ll never forget being stung by one of them. Got me on my finger. You can still see what it looks like.’

He shows me his thumb, which is deformed and permanently swollen.

‘I think it got infected or something,’ he says casually. ‘Anyway, that one was a few years ago. But it wasn’t really my thumb (…) that was so bad: it was the doom.’

I’ve read about this so have some idea of what he’s talking about. The toxin released by Irukandji jellyfish, creatures tinier than fingernails, has some neurotoxic effect that causes symptoms so severe and so bizarre there’s a name for it: ‘Irukandji syndrome’. The worst thing, my patient confirms, is the horrendous sense of impending doom. Apparently no one’s quite sure what causes this feeling, but it’s been suggested that the venom results in an uptake in adrenaline and noradrenaline, which are connected to anxiety.

‘That sounds absolutely horrendous,’ I say, feeling a little sick.

He nods at me. ‘I was crying on the phone to my Mum,’ he says. ‘It was so awful. I couldn’t stop crying. When they got me onto the beach they thought I was crawled up because of the pain, but it wasn’t that. It was just this sense that my whole world was collapsing.’

A few mornings later I come out of the water with a small, painful red lump on my leg. The water is warm, probably over 26 degrees, so I knew the Irukandji would be about and swam anyway. I’ve heard it takes about twenty minutes to determine whether it’s an Irukandji sting, so I head to the vinegar station, which is essentially just a seedy old bottle of vinegar near the surf club’s steps.

I don’t have a towel, so I use an old leaf I find on the sand to ineffectually rub vinegar onto my leg.

A man comes past, heading down the steps, and stops.

‘You right, mate?’

A typical Broome understatement, as we both know what it can mean if a person is throwing vinegar on themselves in a place like Cable Beach.

‘Guess I’ll know in about fifteen minutes,’ I tell him. ‘I’m ok now.’

Fifteen minutes later I’m still alive and haven’t started crying, so I put it down to sea lice and get ready for work. Another near-death experience narrowly avoided. If I were a cat, I’d be coming very close to nine up here.

From: put your feet in the dirt, girl by Dr Sonia Henry, published by Allen & Unwin in May 2023

Links

www.soniahenry.com.au
Instagram: @sonnie_h
You can buy Sonia’s book here

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Rosie is a British Doctor and Geographer with a passion for the outdoors. Earlier this year she was selected as an Analogue Astronaut for the UK’s first exploratory space analogue research mission. The project, based on a remote Scottish island, aimed to improve the delivery of healthcare for future long-duration space missions and in challenging environments at home on Earth.

Visiting Space, on Earth

In April 2022 I responded to an advert from UCL’s Space Health Risks Research Group, to join their pilot programme as an analogue astronaut. The first UK analogue space research mission would simulate the human exploration of another planet, right here in Britain. The purpose of the mission was to investigate health risks in space, and how best to deliver holistic healthcare in this challenging environment.

Analogue projects simulate particular aspects of space missions to identify problems and test solutions under challenging conditions before they are needed beyond our planet. Each analogue mission focuses on replicating specific potential difficulties so that future space flight can take place in a variety of environments. International examples include Mars 500, where 6 participants were isolated inside a mock-up spacecraft for 500 days in Moscow, and the NEEMO Project which sends astronauts to live in an underwater research station in Florida. Analogue studies not only benefit future space missions but also those living back home on Earth. Across the disciplines of navigation, communication, energy production and beyond, space research has driven innovation.

This particular project simulated the practical challenges of arriving on a new planet by landing participants on an uninhabited Scottish island. Parallels to space included limited healthcare services, scarcity of resources and delayed aeromedical evacuation if needed. After landing on the island, analogue astronauts undertook a series of tasks under the observation of researchers and artists. These tasks centred around providing prolonged field care for simulated patients across three case studies.

“Many of us seek opportunities to combine medicine with our passions beyond hospital walls. My background in Geography and love of the outdoors keep leading me happily astray. In spring 2022 while working as an F2 doctor, I chanced upon a unique opportunity to combine medicine, remote environments, research and art”.

The Application Process

I stumbled across this project in the most ironic place for advertising outdoor opportunities: Facebook. A quiet post in April 2022 in the group ‘Student Wilderness Medicine UK’ directed me to UCL’s Space Health Risks Research Group. A team of interdisciplinary researchers were calling for applicants to join their pilot project as an analogue astronaut.

For this project, applicants for the role needed to be healthcare providers with experience of working in remote environments. The project also recruited for simulated patients during the case studies, encouraging those who did not meet the eligibility criteria of analogue astronaut to apply for this. I completed a straightforward application form that asked about my technical skills, teamwork and leadership in the outdoors. Alongside this, I ranked my experience of pre-hospital healthcare provision in remote environments, with the options ranging from an entry-level advanced first aid course up to a consultant working full time.

The project was seeking a team from varied professional backgrounds, including doctors, dentists, pharmacists, nurses, allied health professionals and first aiders with no formal healthcare qualification. This was my first hint that this project was trying to do things differently. A week after the application deadline, an email landed in my inbox inviting me to join the team.

Pre-Mission Training

A few days after my invitation email, I was on my way to Plas-Y-Brenin Outdoor Centre for our pre-deployment training weekend in North Wales. This was a chance to meet the 5 other analogue astronauts, hear more about what our mysterious mission would involve and receive training to ensure we were prepared for the tasks ahead. The team met at a chilly campsite late on Friday night, travelling from across Europe to be there.

Our training was organised around the Remote Area Risk International’s (R2RI) Prolonged Field Care course, which focuses on how best to care for patients in “environments you don’t want to be in, for much longer than you want to be”. The course covered a wide range of topics, from perfecting your primary survey to nursing in challenging conditions and accurate field documentation. These were taught mostly in the classroom with an overnight patient care exercise on the hill. In teams, we cared for several patients through the night and extracted them to a sheltered place of safety to avoid a hypothetical storm. The challenge of balancing personal fatigue with the needs of the team and our patients soon became apparent, as did the practical difficulty of helping patients get warm and well in the darkness. On Sunday, a lake swim woke us up ready for further workshops.

The course was professional, comprehensive and well-taught. Around it, we had time to get to know the other analogue astronauts, hear briefings from our mission director and put our heads together with the team’s artist in residence to share kit design ideas. The weekend packed a punch and left us feeling that we’d only dipped our toes into the sleep deprivation and exhaustion we could expect from our task that lay ahead a few weeks later.

The Research Mission

Mid-May drew a team from around the world to Scotland for our space analogue research mission. The researchers kept the location of our project secret from us, so that when we arrived, our “new planet” it would be a truly alien environment. The team and I arrived at our meeting point, ready to be transported by boat with all the kit we would need to survive on our harsh new planet.

Once arrived on the island, the analogue astronauts hiked to set up camp in our new “habitat”. We conducted baseline recordings for several studies including testing non-invasive wearable technology, and for an astro-pharmacy focus group. From this point on, we would be observed in our activities but have decision-making autonomy. We had backup communications with “mission control” but with a time delay of a few minutes. Over the next 48 hours, we worked continuously through a series of tasks and patient cases. These tested us in numerous ways – sleep deprivation, navigation, teamwork, clinical care outdoors, camp craft and patient extraction, to name a few.

As with most expeditions, the most challenging aspect remained human factors whilst the team were tired, cold, wet and hungry. Making clinical decisions whilst under direct observation in these conditions certainly tested us. Our varied professional experiences and international backgrounds from the UK, Ireland, South Africa, Germany and Spain added complexity to group dynamics, leadership and organisation. These elements sometimes brought challenges, particularly to be able to effectively communicate under pressure, but ultimately became the strengths of our team.

The patient cases we encountered were equally diverse – from the expected musculoskeletal strains to multi-person trauma and space-specific injuries, such as radiation exposure. To provide good, prolonged clinical care for multiple patients we needed to share the workload across our team of five. Medical decision making was only a small part of this. The hardest elements of the work were giving continuous nursing care and the very physical work of patient extraction over rough ground whilst maintaining team morale, interest, and self-care. I chose to contribute to the creative side of our mission, which helped maintain my interest during long hours of monotony and tiredness. I used photography and a durable custom art kit made by our artist in residence to document our experience and progress with our tasks.

The exercise concluded with a particularly difficult case that involved moving our kit and an injured patient over a ridge, with the time pressure of hourly solar flares demanding we take shelter. This made the ending all the sweeter and we enjoyed an evening finally meeting the rest of the crew behind the scenes over a surprisingly delicious ration-pack dinner.

Post-Mission

The end of the field research was not the end of the project. We had remote sessions for final data collection, medical debriefs and an overall project evaluation, which was helpful to ourselves and the research. The mission debrief highlighted how unique this project was in bringing together such a diverse interdisciplinary team. It involved researchers, healthcare professionals and artists, all with a shared passion for remote environments. This was the first time I had seen art and science both given significant platforms in an expedition setting. In hindsight, they are natural partners and have the power to be symbiotic; the research was rich with creative ideas, whilst art had the power to translate research findings into engaging, digestible information for people beyond the project.

Since landing back on Earth, a creative exhibition telling the story of our mission has been displayed at the Royal Geographical Society and research is being written up. The outputs of this and future missions will contribute to healthcare training, policy and practice for remote and rural health systems. Individually, I have grown in confidence in delivering remote clinical care and operating as part of a diverse team under pressure.

This pilot analogue study showed the value of interdisciplinary and immersive space health research in the UK, for the benefit of future space travel, and remote communities at home on Earth. As a consequence, a new organisation has been established to take this forward in the future. Space Health Research has ambitious plans for longer analogue missions which will test health products and services to drive innovation for remote environment healthcare.

Future space analogue research missions will need skilled and motivated healthcare professionals with experience of remote environments to contribute – whether as analogue astronauts, simulated patients, or to test their own ideas for improving healthcare in remote environments. The call for applications to work with Space Health Research in 2023 will open at the end of January.

If you would like to be involved in remote healthcare and space research, visit https://www.spacehealthresearch.com/ to stay up to date with their news and progress.

2022 Supporters

Many individuals and organisations came together to create our UK analogue mission this year. It was made possible by the generous support of these sponsors:

• UCL Institute for Risk and Disaster Reduction
• UCL Institute of Advanced Studies
• UCL grand challenges
• ETHNO-ISS
• Remote Area Risk International
• Med Rescue Group
• EXPLOR Space Technologies
• Expedition Foods

Photo credit: Dr Rosie Baker, Dr Sarah Fortais

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Founded in 2021, Endeavour Medical is a new provider of wilderness and expedition medical training. Their large team of faculty boasts decades of experience in multiple extreme environments including mountain, jungle, polar, and desert with countless teaching and academic accolades to their name. Endeavour Medical delivers an array of courses, including global health and sports medicine courses as well as wilderness, expedition, and leadership offerings. The Expedition Medicine and Leadership course runs twice yearly; in Summer and Winter in Morzine, France. Led by Lucy Obolensky (Founder of Endeavour Medical) and co-directed by Dr Nics Wetherill (Army Medic and Leader of the Ice Maiden expedition) and Dr Alex Reid (currently an FY4 Doctor working in Intensive Care). Together they bring a huge array of experience in global health and expedition medicine both in civilian and military life, as well as holding qualifications from diplomas in tropical medicine to winter mountaineering climbing instructor and many in-between!

Key Facts:

Duration: Five days in total; one-day lecture-based (online learning) and four practical days in Morzine of scenarios, workshops, and discussions

Dates: Late June (Next date 18th-23rd June 2023)

Location: Chalet Beziere (Treeline Chalets), Morzine, France

Cost: £895 GBP Inclusive of luxury chalet accommodation (exclusive of travel). Discount available to students.

Qualification/Accreditation: Course attendance certificate, worth 40 CPD points. Plus, the opportunity to complete Supervised Learning Events (including case-based discussions and clinical evaluation exercises).

Delegates: 9 Delegates (medics and non-medics welcome)

Prerequisites: A moderate level of fitness and keenness to learn about expedition medicine and global health

The Course

Based in the centre of Morzine, in the French Alps, this alpine village is easily accessible from the UK. Just a 1-hour drive from Geneva airport and a 9-hour drive from Calais (for those wanting to drive from the UK). It’s a perfect gateway to explore the mountains and lakes of the Swiss-France Alps with a variety of activities right on the doorstep; mountain biking, road cycling, climbing, and swimming to name but a few.

Most delegates arrived on Sunday, ahead of the course starting on Monday morning. We were all warmly welcomed by the course leaders at the Chalet that evening where we had the opportunity to ask any burning questions about the week ahead.

Example Course Contents

Lectures Include:

• Expedition preparation, nutrition, and mental health
• Leadership in Practice
• Medical Kits
• Environmental lectures: Altitude, Cold and Heat illness, Tropical and Dive medicine
• Expedition Sustainability

Practical Content:

• Trauma and Primary surveys
• Packaging casualties
• Expedition orthopaedics
• Radio communications
• Rope skills and Basic navigation
• Sports medicine and taping

Monday morning started with a dip (or 2k swim) in Lake Montriond and a picnic breakfast to finish. As we were tucking into our pain au chocolat, scenario-based training kicked off with the rescue of a struggling swimmer and treatment of suspected hypothermia; putting the “burrito wrap” into practice. Throughout the rest of the day, there was a mix of indoor and outdoor brilliant teaching covering a multitude of topics. The evening was free for socialising in the local microbrewery.

The second day began with some free time to enjoy the mountains. Part of the team took off for some mountain biking up the Super-Morzine, whilst others ventured out on road bikes for a ride up Col de la Joux Verte, both finishing off with a slice of cake. Teaching then began with a sports medicine and taping session led by Physiotherapist Louise Paley. The session was practical and covered the key concepts required for effective taping. The session was so engaging that no one smelt the chickens roasting in the kitchen next door which lead us to our next scenario. The management of hyperthermia. We were split into two groups and raced to cool down our respective chickens who were found outside with internal temperatures of 42°C. This example highlights the creativity of the teaching by the Endeavour Medical team.
That evening we had an inspirational talk by Dr Alex Reid covering his vast experience in winter sports and expeditions. He holds the highest UK instructional qualifications in winter climbing, mountaineering, and ski mountaineering and has undertaken clinical work and personal challenges across the world. After we finished teaching, we began packing up our bags for our overnight hike to Refuge de Bostan. A few of us also managed to squeeze in a short run along La Dranse de la Manche, a river running through the centre of Morzine town, to a small waterfall where you could swim. Opportunities for exercise were not sparse and it was wonderful to be surrounded by like-minded outdoor lovers.

Hike to Refuge and Summit of Tête de Bostan:

Wednesday morning marked the start of our expedition. The group was joined by Neil, an international mountain leader (IML) who holds a wealth of knowledge and experience. Before we set off there was peer-to-peer navigation teaching, allowing the course delegates that held their mountain leader qualifications to share their knowledge and experience.

Throughout the hike up to Refuge de Bostan, Neil paused the group regularly for bite-size teaches on flora and fauna, geology, and history as well as taking time to answer a wide array of questions.  After a picnic break with a group exercise on sustainable development goals (SDGs), we were quickly put to work with another scenario. A storm had struck suddenly and we needed to care for a group of children in our storm shelter before evacuating them to the refuge using confidence roping and reassurance. This certainly put our rope-work skills to the test!

After arriving at the refuge we had a quick pit stop to enjoy the views with a refreshing beverage before hiking a little further. This time we were treated with a practical trauma and orthopaedics workshop packed with skills including key tips and tricks for relocating joints in a remote environment. Our skills were quickly tested with a team race to manage a casualty with a lower limb injury requiring traction (our team narrowly won- not that any of us were at all competitive!).

Once back at the refuge Lucy Obolensky led us through her mental health toolkit, building upon what we had learnt from Sophie Redlin in the pre-course lectures. This allowed for great discussions whilst acknowledging the importance of individual mental health needs in the remote environment. A delicious 3-course meal fuelled us through some very engaging and competitive card games!  Meanwhile, alpine foxes and marmots played in the meadows around us.

The final day led us up to the summit of La Tête de Bostan at 2400m in time for lunch. But before we left the refuge we were treated to a passionate and inspirational talk from Lucy Obolensky who spoke openly about her journey through her global health career thus far. This led to many open discussions on our walk to the summit and has inspired many of us to pursue further opportunities in global health.

After lunch, it was time for a long descent back to Morzine. However, we weren’t going to get away with a simple plod down. Mid-afternoon disaster struck as the faculty presented us with a trauma scenario. Two casualties had fallen in a river bed. Everyone got involved and it was amazing how much we had developed as a medical team since the start of the week. The group was faced with challenges from logistical and navigational difficulties to carrying a suspected spinal casualty down a river bed using a makeshift stretcher. After a thorough debrief and final descent the course came to a completion with a final workshop on expedition nutrition, including some tasters too! This again built on brilliantly from the pre-course lectures and fuelled us for the final goodbyes.

The Verdict

We would highly recommend this course to both medics, trainees, and non-medics. The course was holistic, flexible, and interactive. A large volume of teaching was covered in the pre-course learning which enabled shorter refresher sessions in person and scope to go further in-depth into delegates’ interests and needs. Wider skills such as leadership and human factors were inbuilt during the course.

There were numerous opportunities to discuss with both the leaders and other delegates future plans and career aspirations. Through this many networks and friendships were built that we will hopefully maintain beyond the course.

Top tips:

Arrive early to make the most of the Alps!
A moderate level of fitness will make the hike/exercise more enjoyable.
Take time to watch the pre-course lectures, they are very informative.
Complete a reflection and supervised learning event to add to your portfolio along with your course certificate.

To find out more about Endeavour’s Altitude in Practice  course in Morzine, see Endeavour’s website

Photos courtesy of Dr Lucy Longbottom and Dr Claire Hall

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Marc Robinson is a highly experienced global health and expedition nurse. He started his global health nursing journey at the London School of Hygiene and Tropical Medicine, undertaking the Professional Diploma of Tropical Nursing. Alongside this, he worked in critical care, emergency medicine and was deployed by a number of global non-governmental organisations. After gaining the knowledge and experience required for nursing in humanitarian and austere environments Marc joined the UK-Med register in 2016. UK-Med is a frontline medical aid charity; born of the NHS, working worldwide to ensure everyone has access to healthcare during disasters or crises. Marc’s main previous deployment with UK-Med was supporting the healthcare response to the Samoan measles outbreak in 2019. Here he recounts his experience working as a UK-Med Nurse and Medical Team Leader in East Ukraine during the current conflict.

“All groups of people in Ukraine are vulnerable and in need”

The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) Ukraine Situation Report: 19 May 2022 suggested that 12.1 million people in Ukraine needed health assistance, with 6.4 million reached thus far.¹

The same report advised that the priorities for the conflict-affected population are non-communicable diseases, crisis-attributable injuries, sexual and gender-based violence, mental health and psychosocial health, and infectious diseases.¹

Conflict-related physical trauma is placing pressure on hospitals. In addition, the low acuity hospitals and rehabilitation facilities are under pressure to take on more acute healthcare needs to support the larger hospitals across Ukraine. The pressure on the healthcare service and medicines is an unknown challenge due to the ongoing hostilities with unpredictable effects on the overall health status of Ukrainians in the coming weeks and months.

The Covid-19 pandemic had already led to an exacerbation of chronic mental health disorders, with the social perception of mental health across all age groups negatively impacting this further. A significant worry is the limited number of mental health care workers. Mental health is a taboo subject in Ukraine. Ukrainians have a “can-do attitude”, but the level of trauma they have experienced is now taking its toll. Ukrainian family doctors (GPs) typically manage basic mental health needs but many who are struggling have never been to their GP before.

To address this gap in healthcare provision, UK-Med is working towards a robust mental health and psychosocial support package. I was fortunate to be able to contribute to this. Identifying the start point of those most in need felt like an impossible task – all groups of people in Ukraine are vulnerable and in need.

The Realities of Working in a Conflict Zone

There are a very limited number of Non-governmental Organisations operating in Ukraine, primarily due to security fears. The frequent and chilling klaxon is a reminder of imminent attacks across the country. If that isn’t enough, the strong presence of uniformed military personnel everywhere and the multiple military checkpoints to navigate whilst traveling to deliver essential healthcare will trigger you.

Whilst working alongside the national staff, the physical and phycological scars of the current conflict alongside the 2014 conflict are very much apparent. Continual awareness and provision of psychological support to co-workers, ensuring their work isn’t re-traumatising them is essential. Many healthcare staff are internally displaced having fled from their homes for fear of losing their lives. They relive stories of losing loved ones and hiding in bunkers for days. Accounts like these reflect the enormity of their psychological health needs.

Connecting with some of those most in need in the East, where health systems have been devastated, remains near impossible. Our teams travel long distances to provide primary health care to occupied areas that have faced intense warfare. With national fuel shortages, there is an additional daily challenge and an extra level of difficulty in delivering and distributing medical help and supplies.

As a nurse and healthcare worker, nothing will ever prepare you for the feeling that you just can’t deliver care or aid to those most in need. Identifying the imminent challenges: psychological distress, moral injury, and the national staff’s mentality made it more manageable when starting out in Ukraine. In general, deploying with an open mind, clear brief, and working with established organisations like UK-Med assist with the obstacles faced by humanitarian workers.

Historical lessons of humanitarians, albeit with the best intentions, but delivering care that doesn’t meet the need or complicates an already complex situation play heavily on the minds of those in-country. It’s understandable for healthcare workers to think they will be delivering life-saving interventions on the frontline. However, this is far from reality. Instead, the benefit is gained by providing trauma first aid training to prehospital staff or phycological first aid to citizens who have lost everything. From the start of any humanitarian disaster, ensuring sustainability in the care and support that is provided means engaging with local staff to understand the want and needs of those we work for and with.

Globally, health care continually comes under attack. This includes health care facilities, supplies, transport systems, personnel, and patients. The World health organisation reported that there were 235 verified attacks on health care, resulting in 58 injuries and 75 deaths between 24 February and 18 May 2022.² The direct impact of conflict in Ukraine on their healthcare system requires some extraordinary efforts by their national staff. A story of a local Ukrainian midwife, Tatiana Sokolova, was featured in the newspapers in Ukraine. She worked in Mariupol, the North coast of Ukraine, in the basement during the shelling attacks. Across six weeks she assisted in the births of 27 children, facing the everyday tragedies of war and watching as women breastfed other babies when milk formula ran out. It’s stories like these all over the country that I will stick with me forever.

UK Med has a robust security assessment, keeping their deployed staff a safe distance from the front line at all times. However, there is always a risk associated with such work. Reality checks occur as sounds of bombs fall and the ground shakes from targetted aerial attacks 14km from my workplace. Yet, every day, the Ukrainian nationals show exceptional resilience in getting up and working together for a common goal – peace.

It’s impossible not to admire the resilience of Ukrainians and their understanding of bringing the nation together in the face of adversity. This isn’t just limited to humans. Patron the dog was recently presented with an award and medal by Ukraine’s President Zelensky at a ceremony in Kyiv. He’s a terrier who works with minesweepers and has located more than 200 devices. He has become a national hero and a symbol of Ukraine’s resistance.

What is UK-Med providing?

The responses are ever-changing, and health needs are frequently reviewed to ensure the most impactful activities are undertaken.

Currently, UK med are undertaking work to devise a strategy for psychosocial and mental health support. But first, we must understand the needs and culture of countries looking to collaborate and the services already delivering programs.

A key focus of our work in Eastern Ukraine is supporting the healthcare system by providing primary care directly to internally displaced persons.

Two key capacity-building workstreams are also ongoing concurrently. Firstly, training national prehospital staff in trauma first aid and mass casualty management across eastern Ukraine.

We have also provided bespoke capacity-building education programs to the local community-style hospital to help promote safe and effective care. As a result, they can take more acute patients and reduce the burden on the larger hospitals across eastern Ukraine.

As I write, the construction of a tented field hospital is underway due to donations to the healthcare system to temporarily replace hospital damage from the shelling.

Final thought.

Understanding the needs of the Ukrainian people is complex and ongoing. The conflict has now passed its 100th day with little sign of an ending. Organisation committing to providing support and aid means, as my Ukrainian co-worker said while wishing me farewell, “whilst you and UK-Med are here we at least don’t feel alone”.

References

1. Ukraine: Situation Report, 19 May 2022 [EN/RU/UK]. OCHA. 19 May 2022. https://reliefweb.int/report/ukraine/ukraine-situation-report-19-may-2022-enruuk
2. Ukraine: Situation Report, 20 July 2022. OCHA. 20 July 2022. https://reports.unocha.org/en/country/ukraine/

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In November 2021, anaesthetic trainee and adventure medic editor Dr Holly Andrews returned to Lesvos to volunteer at the medical clinic of Mauravani refugee camp. In this article Holly reflects on what she has learnt from her experiences, and explains why these volunteer roles and advocacy for refugees continue to be so vital. 

One memorable shift

It was approaching midnight on a warm Saturday night in the medical clinic within Mauravani, a refugee camp on the island of Lesvos. The team and I were tying up our consultations with the last few patients and I took the opportunity to reflect on what a gentle introduction my first shift as team leader had been.

These reflections were paused abruptly by an alert on the radio notifying the team of a patient arriving at the clinic gates looking severely unwell. The team sprang to action, taking the patient into our ‘red’ resuscitation room in a converted portable MRI unit. With a history of a ‘hit and run’ incident, extensive chest and abdominal bruising, and an initial BP of 80/40, I began to take the necessary steps of organising a transfer to the town hospital, while the team resuscitated the patient.

Just 5 minutes later, as I was engaged in a fraught 3-way translation with Greek ambulance control, our support crew lead opened the gate to a heavily pregnant woman. Propped up by her husband on one side and our gate post on the other, she was breathing heavily through intense contractions. It was obvious she didn’t have long before the need to push would become overwhelming and we would be welcoming a new life into the world, something we all knew would not be ideal with our limited resources.

Such thoughts were interrupted mere minutes later as the head began to crown. With only a scarf held around her, providing minimal privacy, this brave woman delivered her baby standing at the gate of our clinic. What happened next involved a cacophony of interactions with local ambulance drivers and balancing of cultural preferences with our medical knowledge, all the while keeping an eye on a pack of street dogs who were a little too interested in the proceedings.

Clinic life

Our medical team had assembled here from Afghanistan, the UK, Cameroon, Iraq, and the Netherlands. We worked together to provide safe medical care and support to a vulnerable group of people, thousands of miles from home and looking for safety and hope in Europe. Images and sound bites of our small team dealing with that night’s events often spring to mind, making me smile with the memory of solidarity and one of the most humbling shifts of my career.

Writing this article while sitting comfortably in a coffee shop back in the UK, I risk getting caught up in journalistic sensationalism. That Saturday night shift was certainly at the pointier end of emergency field medicine, but in reality most shifts were much calmer, treating minor injuries and primary care complaints. It was during these latter shifts that I came to realise that volunteering in this sort of setting required more than merely practising medicine.

Together with a translator, often living in the refugee camp themselves, we saw around 20-30 patients per shift. It didn’t take long to become acutely aware, from both patients and colleagues, of just quite how difficult is it to exist in this setting. Refugees continue to live with constant uncertainty for their futures; many of the goalposts for gaining asylum in countries where they hope to work and rebuild a life change constantly. Some refugees describe this limbo as ‘political torture’. Being kept in the dark about the legal and financial processes of seeking asylum, alongside the ever-changing rules and regulations regarding movement in and out of the camp, foster a persistent feeling of unrest, confusion, and uncertainty.

Recent media coverage of the surge of Channel crossings has served as a reminder of how dangerous migration routes can be for refugees. All the people that I treated in Lesvos had risked their life to arrive on the island. It seemed to me that even the small pieces of daily humanity and care that we all take for granted were missing from these peoples’ lives. At the clinic, we could provide a stable place where everyone was treated as equals and listened to. The clinic tent had had regular opening hours, which we adhered to, hoping that this provided a feeling of stability and reliability, amidst the instability and, at times, chaos. Through taking time to offer a warming blanket or a cup of tea to those in the waiting room, blowing up balloons with children whilst their parents were being treated, or simply sitting with and giving time to each patient, we hoped to create an atmosphere of care and community.

Reflections

My time in Lesvos has certainly fuelled my desire to volunteer in similar roles in the future. It has provided me with another building block of experience to what is a very complex and ever-evolving wall of knowledge. Although my presence only contributed to the continued turning of a very small cog in a much larger operation, I hope that the sum of all these small inputs will result in a global shift in attitudes towards, and conditions for, all refugees.

Working in this setting has challenged my perceptions of what being a doctor means. It has widened my perspective of my position within and contribution to healthcare systems. In conclusion, though by no means an exhaustive list, here are some of my thoughts that might keep doctors engaged in this kind of humanitarian work:

• We have the opportunity to be influential advocates as observers in such settings, by gaining a privileged insight into aspects of refugee camps that are not widely portrayed in the media. Challenging preconceived ideas, spreading the word, and inspiring others to do the same are among the most important steps we can take to strive for positive change.
• We are visitors both to the country and to our patients’ lives. Small acts of humanity and kindness go a long way to improving the lives of people who have travelled far from their homes and community.
• Frustrations with the wider system and global political problems need to be left at home. However, it is important to question both the actions of yourself and others and your reactions to situations. Talk with your team, team leaders and patients, and don’t be afraid to challenge others when you think things might be able to be done better.
• Keep your eyes open to what can be learnt from both colleagues and patients with a huge variety of backgrounds. Debriefing after shifts or consultations is an essential part of improving practice and team working. A supportive debrief will also help to maintain the morale and wellbeing of all involved.

Above all, in moments of reflection, it’s good to remind yourself that though we all stare up at the same moon and stars, there are many for whom the future is far less set.

Future thoughts

During a previous visit to Lesvos in 2019, there were 20,000 refugees in the old refugee camp known as ‘Moria’. In 2021 there were only 3000 refugees in Mauravani. As I was leaving there were many discussions about building a ‘closed’ prison-like camp for those remaining. The creation of this centre is extremely political and the future position of all NGOs, including those providing medical care remains uncertain. Despite this, migrants continue to arrive, week by week, on Lesvos and its neighbouring islands, and there is still a great need for help.

If you would like to read more about volunteering in a European refugee camp, take a look at this recent article from Dr Laura Chapman. It contains a helpful list of links to articles of interest, as well as a number of medical actors on Lesvos and non-medical NGOs active on other Greek islands.

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Dr Laura Clapham shares her experiences and reflects on the challenges of working in Moria Refugee Camp. People continue to make a treacherous journey across the Mediterranean Sea and Laura highlights considerations for those interested in volunteering along with the agencies who are active today.

Moria Refugee Camp is situated on the Greek island of Lesvos, just five miles off the coast of Turkey. It was Europe’s largest refugee camp until it was destroyed by a huge fire in September 2020. It has now been replaced by “Moria 2.0”, called Mavrovouni, built next to the sea on a disused military shooting range.

During my “F5” year, I spent five weeks from November to December 2019 volunteering in a medical clinic with the Dutch NGO, Boat Refugee Foundation(BRF). In that short time, the number of residents grew from 14,700 to over 17,000, including 1,100 unaccompanied minors, in a camp designed for 3,000. The vast majority came from Afghanistan and others from Syria, Iran, Iraq, Cameroon, Congo, Somalia and Eritrea.

BRF was established in 2015 in response to the European migrant crisis and the reports of people dying daily in the Mediterranean Sea. The two arms of their mission are emergency medical care and psychosocial support. Since the fire, they have re-situated the medical clinic inside a large container on the back of a lorry.

Day to day in Moria

Whilst I was there, the medical clinic consisted of a prefabricated box (similar to a shipping container) and a caged area, situated next to the camp police station and registration centre. The police were often called upon to break up fights, especially if there were patients from different gangs in the clinic at the same time. During the day, Kitrinos Healthcare ran a clinic from 8am until 4pm, staffed by GPs focusing primarily on chronic conditions. From 4pm until midnight, BRF ran a clinic offering acute and emergency care with a small team of doctors, nurses, psychologists, translators and support crew . Other medical actors in the camp included Médecins Sans Frontières (paediatric, antenatal and psychiatric clinics), Rowing Together (Obstetrics and Gynaecology) and occasionally a dentist and optometrist.

We saw between 150 and 220 patients per shift in the four consultation spaces, three triage areas and a dressings area. Ages ranged from infants to late 60s and I was impressed by both the physical and mental resilience of those I encountered. I often met older people who had severe osteoarthritis of hips and knees and yet still managed to hike through mountain ranges to reach safety. A consultation with a 19-year-old woman particularly stands out. She arrived with her 17-day-old baby who had been born in Turkey on the journey from Somalia. Despite the obvious difficulties of bringing a newborn into this harsh environment, it was heartwarming to see her cooing over her baby, just as any adoring mother would do.

Limitations

Although patients presented with all manner of complaints, including emergencies, the clinic had limited resources. Oral medications for most primary care complaints and minor injuries were available along with a small, select pharmacy of acute intravenous and intramuscular medications. There were two crash bags and an automated external defibrillator, cylinders of oxygen, a nebuliser, an ECG machine, and a basic ultrasound. However, perhaps unsurprisingly, at times it felt like the most useful items were the huge bags of salt and sugar used to prepare oral rehydration solution for gastroenteritis, as well as a large pot of honey to decant into smaller pots to soothe sore throats for the colloquially-termed “Moria flu”.

Common presentations

Common minor problems were coughs and colds (pre-COVID-19), gastroenteritis, fevers, scabies, lice, wound infections and miscarriages. The cases which had the biggest impact on me were patients with psychological presentations – panic attacks and conversion disorder – and trauma patients with injuries from fights in the camp.

Every person I treated had experienced trauma of some kind, having fled their country in fear for their lives. This trauma was compounded not only by a distressing journey from their home country, but also by the appalling conditions in the camp: inadequate shelter, food, warmth, running water or sanitation. Parents brought in their children with night terrors, mutism or developmental regression. Panic attacks were common and sometimes extreme. They would manifest in all sorts of ways. Some patients presented in a seizure-like state, others with stroke symptoms or dissociation (conversion disorder). I learned a little from the psychologists trained in trauma techniques about ways to help bring the patients out of re-experiencing and into the present moment through engaging their senses. We used ice blocks, elastic bands and the scent of hand sanitiser.

Stabbings from gang violence were frequent and would often occur in clusters. One of the most memorable examples was treating a 19-year-old man from Afghanistan. When I was called to help, I remember thinking that he was within minutes of dying. His eyes were glazed, his oxygen saturations were 72% on air and his systolic blood pressure was 80mmHg. He had subcutaneous emphysema on his back surrounding the stab wound, and no breath sounds on one side. My hands were shaking as I inserted a cannula to decompress a suspected tension pneumothorax. Upon hearing a ‘hiss’ I sucked out air through a 50mL syringe. Remarkably, his saturations recovered to 97% on oxygen, and blood pressure normalised. As we carried him on a stretcher to the ambulance, he was talking and almost chuckling through his oxygen mask. Sadly I never saw this patient again; I sincerely hope that he received his chest drain in hospital and made a full recovery.

On reflection, if the kit had been available, this man should have had a thoracostomy. NICE guidelines for ‘Major Trauma in the Pre-hospital Setting’ (current at the time of publication) are to “use open thoracostomy instead of needle decompression if the expertise is available, followed by a chest drain via the thoracostomy in patients who are breathing spontaneously.” This example highlights the difference between practising pre-hospital emergency medicine in a low-resource setting to an Emergency Department with the appropriate expertise, equipment, and ongoing care.

Personal Reflection

I learned a huge amount in the short time I volunteered in Moria. My skills as a doctor were challenged and honed. I became more adept at distinguishing epileptic from non-epileptic seizures, suturing, recognising sick neonates, and using skills learnt for psychological first aid. Non-technical skills were also essential when communicating with the police, paramedics and other NGOs, who came together as teams speaking different languages and from different cultures. I loved working and becoming friends with the translators; all of them refugees themselves with their own harrowing narratives to tell. Their dedication to the role was truly admirable.

I have heard so many refugees recount what drove their perilous journeys to such a difficult place as Moria, and I am left with a deep and enduring conviction that, had the lottery of our birthplaces been drawn differently, I could easily have been in their position and they in mine.

For those considering work within European refugee camps

Things to consider before applying:

What are your skills/specialty?

Have you had prior experience in a low-resource setting?

Can you safely operate relatively independently or with indirect supervision?

How much time can you give? It can take a while to settle in and learn the ropes.

Where is your time and money best focused?

What are your own motivations for going?

How is your own support network and own mental health? Will you need to schedule in time afterwards to decompress and reflect? Do you have a strong support network at home with whom you could discuss what you have experienced and how you have been affected?

Further reading and up to date information:

‘The New Odyssey’ – Patrick Kingsley
An insightful and emotive read whereby Kingsley, The Guardian’s former Migration Correspondent, alternates chapters between a factual chronology of where and why the European migrant crisis began with one man’s harrowing story of his journey across Europe looking for safety and security.

‘The Aegean Boat Report’
An official social media account ‘on the ground’ tracking and publishing accurate data on the migrant arrivals, pushbacks, and illegal deportations on the Greek islands.

‘A Doctor’s story: Inside the living hell of Moria refugee camp’
Published in the Guardian in 2020 – another medical report of time spent volunteering in Lesvos.

‘Choose Love’
An international charity providing a reliable and sustainable platform to donate to help refugees worldwide.

‘Lawlessness at the border mars Greece’s reputation over migration’
A recent publication in Aljazeera describes the current policy and politics towards refugees arriving in Greece.

‘Border violence.eu’
Border Violence Monitoring Network (BVMN) is an independent network of NGOs and associations that monitors human rights violations at the external borders of the European Union. They list the NGOs working in each border region and advocate to stop violence to people on the move.

Medical actors on Lesvos

Boat Refugee Foundation
BRF were a really positive NGO to volunteer with. They fostered teamwork and strong morale, were supportive and incredibly organised. Within Lesvos they provide emergency medical care from 1700-0000 every day.
BRF are in the process of setting up a clinic on the border of Ukraine and are always looking for both medical and non-medical volunteers.

Kitrinos
A Greek NGO providing acute care from 0000-0800 every night.

Medical Volunteers International
A German NGO providing acute and chronic care from 0800-1700 every day.

Medecins Sans Frontieres
An international organisation providing paediatric and specialist obstetric care in Lesvos. They also work on other Greek Islands.

Crisis Management Association
Set up in response to the fires in September 2020, CMA coordinates and provides healthcare in Mavrovouni.

Seeds of Humanity (Dentists for All)
Palestinian organisation who work in Athens, providing healthcare and education, and in Lesvos providing healthcare, specifically dentistry.

Non-medical NGOs on the Greek Islands

One Happy Family (Lesvos)
A vibrant community centre offering a safe, pleasant space for refugees – opportunities to play sport, use computers, enjoy the cafe, repair items and mend bikes, garden, etc.

Movement on the Ground
NGO focusing on making the refugee camp/reception centre safe through infrastructure support (building, sanitation, etc.) and supporting unaccompanied minors.

Still I rise (Samos)
An educational centre “Mazi” for refugee children aged 11-17 years.

Better Days (Lesvos)
A multi-faceted organisation providing education, legal aid, sports, gardening, and support for unaccompanied minors.

Because We Carry
Dutch NGO in Lesvos providing support and food to refugees, particularly mothers and families.

Attika Human Support
Distribution centre in Lesvos and Athens providing essential items.

Fenix Aid (Lesvos)
Holistic legal aid, including advocacy and mental health support.

Update on the situation – March 2022

There are currently 3,000 residents in Mavrovouni and the clinic now sees mainly acute healthcare complaints and psychological problems. The pandemic has meant that more refugees have been transferred to the mainland to reduce some of the pressure on island healthcare systems. While BRF’s mission in Lesvos is now much smaller than it once was, BRF are looking at supporting similar work in Samos (a neighbouring Greek island) in the coming months and still require medical support to run their clinics.

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David is a Special Rescue Paramedic currently operating overseas in a variety of extreme or austere environments. In 2016 David spent several months with special operations medical teams in Greece during the Syrian refugee crisis. He provided various aid roles from emergency medical care to small-boat and shore rescue. In this piece, David recounts his experiences working as a Special Rescue Technician at the height of the refugee crisis.

Recently, I travelled to Arkansas for my cousin’s wedding. Neither he nor his bride to be are from Arkansas, and I’d be lying if I said I had an interest in ever visiting. Bluntly put, Arkansas is a flyover state and one I was happy to seldom fly over. Upon arrival however, the little town of Bentonville had a few surprises for me, including a very liberal leaning populace (strange), a booming outdoor and adventure industry (stranger) and an art scene to rival any capital city (strangest). The wedding reception was held at a stunningly beautiful and fabulously curated art hotel.

The biggest surprise came during a small reception held for visiting family in the hotel lobby and galleries. There, prominently displayed by the front desk, was a massive print of Heat Map I, Idomeni by Richard Mosse. In it, Mosse uses infrared cameras to record the contours of heat generated by human bodies, campfires and ambient temperature. Combined, they create spectral photographs depicting refugees struggling to survive in the sprawling Idomeni refugee camp on the Greek/Macedonian border.

“Hey, David!” my uncle exclaimed. “Weren’t you in Greece around this time? It says 2016.”

I hadn’t moved a muscle after stepping in front of the photograph. I just stared, rooted to the floor by first a trickle and then a flood of memories. Memories of the sharp, rotting smell peculiar to refugee camps. The burning and tearing of my eyes as CS gas grenades sailed through the air. The casual strolls through the small satellite camps located in gas station parking lots throughout Northern Greece.

I knew exactly where the photo was taken. I had stood on nearly the exact same spot, surveying the sharp hills of the ravine, looking for the easiest egress to carry out a badly burned child who spilt hot water across much of his body. At another point, I hid inside a tent with a Kurdish family in that ravine for several hours as the police swept through the camp, kicking out many of the foreign NGO aid workers. I elected to stay behind and check in on several patients throughout the long, cold winter nights. Had I been caught, I would have been arrested.

The flood kept coming. Images and smells and feelings and tastes and victories and defeats piled one on top of the other, each seemingly more pressing than the last. Each vying for a few seconds of my undivided attention. All because of this one photograph in an Arkansas hotel.

“Hey, baby. Time to come back,” I heard in a soft but clear voice. I blinked and looked around. My uncle had wandered off long ago when I never answered his unheard questions. My wife and partner of 14 years stood next to me, one hand on my arm, smiling. I realised I’d been standing in front of the lobby desk for several minutes, silently stuck five years in the past.

This wasn’t the first time this had happened; me just kind of going away. Later my wife told me she knew I had just dropped down a memory hole and wasn’t experiencing an acute stress reaction or panic attack, both of which I have a history of. But she knew what to do. She knew she could gently pull me back to the present and that hopefully all the years of therapy and training would keep me around a little bit longer.

I’ve spent my entire adult life in emergency response and the last eight years in special operations as a Special Rescue Technician. I’m a combat medic, a firefighter, a rope rescue specialist, and several other descriptors all rolled into one neat little title. My wife has been with me every step of the way. Yet every step I have taken in the pursuit of the next job, the next patient, the next rescue has inexorably led me down the winding footpath of mental trauma.

I’ve been lucky in having an amazing support network of friends and family to help me understand and heal from this life of trauma. When I get scared of taking off in an aeroplane, I intellectually know why. I understand my brain freaking out at fireworks on the Fourth of July. I can fully justify and embrace a good cry after a patient has a poor outcome.

But what am I supposed to do about a photograph taken in a muddy ravine? I searched my internal database of trauma triggers and various responses but came up blank. Nope. Nada. Zilch. Giant art wasn’t in the mental resilience playbook. Especially not when it caused me to lose several minutes of my life. So I did what felt natural and shrugged it off. For about five minutes.

Over the next hour, I kept returning to the photo and kept remarking on how weird it was that I had been there. I stuck my face close, trying to parse details of faces and tents, searching for an identifying jacket, campfire or rubbish pile.

When the photo was taken, I had been working in Greece for the better part of three months; first in Lesvos leading beach rescue teams and then in Idomeni. It was challenging and rewarding. When finally home, it was one of the few recent deployments I could actively talk about with friends and family. Much of my other work at the time was, and still remains secret. It was wonderful to hear words of validation and approval. Yes, the situation was still dire, but I had done a small, little bit of good for people that needed a lot of help. And that can be incredibly rewarding. I am still proud to this day of the work my team and I did. But that doesn’t resolve the psychological trauma.

Kind words ringing through my ears didn’t help me sleep at night. It would take several years for me to come to terms and process the kaleidoscope of emotions, thoughts and actions of my time in Greece.

For the next few days, I drank more than I had in years. I used powerful relaxants to sleep even though they wouldn’t stop the dreams. I was irritable. I was a jerk. I was upset with myself. But I finally forgave myself. As medical providers, we are often quick to forgive everyone around us but rarely do we turn that compassion towards ourselves. We all have scars. We all know how to be kind. All we need to do is practice showing ourselves kindness. We deserve it, even if we’re feeling broken. Even if what broke us was a photograph in Arkansas.

Adventure Medic has published this article, credited with David’s first name only to respect his personal safety. All original photographs in this article have been provided by David. Individuals’ faces have been blurred to protect those still working in this environment.

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The call came at dawn on the morning of the twentieth day: “Wake up, Sir!” my guide Namgyel exclaimed, tugging on my tent door. “She is out!”

By “She,” Namgyel meant the imposing mass of Gangkhar Puensum, straddling the border of Tibet and the country I was hiking through; the tiny Himalayan Kingdom of Bhutan. At 24,829 ft, Gangkhar Puensum is not only the tallest peak in Bhutan, but also the highest unclimbed mountain in the world. Since we arrived at our campsite the day before, Namgyel had the task of “mountain watching” – with strict orders from the head chef to fetch us the moment Gangkhar Puensum appeared. I threw on my boots, grabbed my coat and camera and unzipped my tent door.

Bhutan is a small country, about half the size of Indiana, wedged between India and Tibet. Along with being the world’s most mountainous country, Bhutan is the last Buddhist Kingdom in the Himalayas, is governed by a policy of “Gross National Happiness,” does not have a single traffic light, and boasts one of the world’s toughest treks. At 216 miles and with 11 high mountain passes, (including seven over 16,000 feet), Bhutan’s epic Snowman Trek is a 24-day boxing match for the hiking boots. More climbers have scaled Mt. Everest than completed the Snowman Trek. Historically, less than 120 people attempt the trek each year, and of those, less than 50% finish. Just some of the challenges of the Snowman include: the sheer duration, notoriously unpredictable weather, high mileage, and the elevation of the camps. However, a lifetime of traveling has taught me that it is precisely these types of crucible situations that can reveal new aspects of your character and can reform your views of yourself and your environment.

Having had the good fortune of traveling to Bhutan four times in the last seven years, I’ve noticed a number of changes in myself since my first trip. I once struggled with greeting someone in Dzongkha, Bhutan’s national language, and yet, saying kuzuzangpo-la now seems as effortless as English. I also now intuitively walk clockwise around stupas (Buddhist monuments), praise the gods like a local by shouting “Lha Gyalo” from the high mountain passes and have the good, gastrointestinal sense to request Bhutan’s mild chilies with my meals. However, perhaps the most striking change has been in the pictures I now take when I visit the ‘Land of the Thunder Dragon’.

When I first visited in 2004 to complete the eight-day Chomolhari Trek, I returned with hundreds of photos of old-growth forests, glacial-fed rivers and majestic, snow-capped peaks. They were beautiful pictures but, when I returned to the USA and showed them to friends and family, something seemed to be missing. Perhaps it was the feeling of outsiders not fully grasping the country – of capturing its scenery but not its soul – that prompted me to return to Bhutan in 2007 to attempt the Snowman Trek. Over the course of that three week trip, as I slogged over 216 thigh-crying miles, I snapped photos of the natural scenery, but I also started taking pictures of my Bhutanese guides, horsemen, monks and villagers. While the photo album from that trip felt better in my heart, it still made little sense in my head. What was the difference?

Fortunately, my answer came in the months that followed. As I began writing a memoir about the Snowman Trek, I noticed all the key scenes and memorable moments crystallised around the people I’d met—getting lost in the swirling fog near a monastery only to meet two yak herder brothers who accompanied me back to the trail; joining the ladies in the village of Laya for a cultural dance; watching the Bhutanese school children sing the National Anthem in Lunana (a remote district that is a ten day walk from the nearest road and sealed off from the rest of the world by snow for four months of the year). While the Bhutanese architecture and scenery were equally awe-inspiring, I realised the true beauty of Bhutan lay with its people.

Consequently, when I returned to Bhutan to guide the Snowman Trek in 2008 and 2010, my camera had a distinctly people-driven purpose. Certainly, I continued to take photos of rivers, mountains and monasteries, but this time I included people in those images to give them scale, depth and soul.

After spending over three months trekking in Bhutan, I have seen examples of kindness that could soften even the most hardened heart—nomadic yak herders welcoming us into their tents on snowy afternoons to warm us with butter tea; monks inviting us into their temples to share a prayer and villagers lending us a horse so we could transport a sick trekker. While they may call themselves the “Dragon People” the truth is, when you travel in Bhutan, you will feel kindness in the people surrounding you everywhere.

As I crawled out of my tent that morning, I found the eight members of my trekking party already assembled and snapping photos of Gangkhar Puensum in the frosty air.

“Was she worth the wait?” asked Namgyel with a friendly nudge.

“You bet!” I replied, reaching for my camera.

One glance at the mountain had swept away all the sore muscle memories of the previous nineteen days. Gangkhar Puensum was breathtaking–at once seeming to explode from earth and float in the icy heavens. When Namgyel volunteered to take a picture of me, I eagerly handed him my camera and recited Bhutan’s way of getting someone to smile for the camera: “Yak Cheese!”

When I’m in the US, my friends often ask why I repeatedly return to Bhutan and, most importantly, what keeps me motivated to trek all those miles over the high, snowy passes. The same is true in Bhutan, where the Bhutanese routinely ask me what it is about Southern California that makes it so special. My answer in both cases is the same—I show them the friends and family in my photo album.

For more information about Kevin’s other works, visit Kevin’s website.

All original images have been provided by Kevin Grange; with permission from all subjects in the photographs to be published in this article.

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Becky is an ST5 Paediatric Specialist Registrar in the North-West of England. After completing her professional membership exams she took an Out of Programme for Experience (OOPE) to complete a Diploma in Tropical Medicine and Hygiene (DTM&H) at Liverpool School of Tropical Medicine (LSTM). She also spent six months in Sierra Leone with the Royal College of Paediatrics and Child Health (RCPCH) Global Links Programme from September 2020 to February 2021.

“Pomoi, Pomoi!” The excited children scream as you walk around every dusty street corner, running up to you while being chased by chickens kicking up swirls of red sand. As a white British female, it is impossible to blend in with the locals in the West African country of Sierra Leone. “Pomoi” means “white man” in the local tongue of the Mende tribe, which dominates the tropical South of the country where I was working in Kenema, Kailahun, Bo, Moyamba, and Pujehun.

A story of the struggle of Sweet Salone

Sweet Salone, as it is affectionately known by the locals, is a small country that has been through a lot. The name was coined by a Portuguese explorer in the 15th century who mapped the hills surrounding the now capital, Freetown, likening them to lions.

Following its European discovery, it became a key West African trading point, harvesting Sierra Leone’s natural resources including gold, spices, and sadly thousands of African slaves. Upon the abolition of slavery, many displaced African and West Indian people were sent back to Freetown, the “Province of Freedom”, forming the Krio ethnic group leading to conflicts between the remaining local African chieftains.

Sierra Leone remained a British colony with ongoing trade between the British and the Krios in commodities such as sugar, tobacco, and diamonds, until gaining independence from the British crown in 1961. The parliamentary system, however, remained and many years of conflict between the two main political parties culminated in a civil war, raging the country for 10 years from 1991 to 2002.

The country fought hard to recover from the atrocities which took place during the civil war. Unfortunately, it was badly affected by the 2014 West African Ebola virus epidemic and then by a series of mudslides in the capital in 2017.¹

After Ebola: capacity building in Sierra Leone

The Ebola crisis highlighted deep-rooted and long-running fragilities in Sierra Leone’s health system, which persisted despite several years of international aid. Following further research into building capacity in-country, the emphasis was shifted from building skills and knowledge at the individual and organisational levels to a more system-based approach considering politics and power.²

The Saving Lives in Sierra Leone project aims to improve access to and use of reproductive, maternal, neonatal, child and adolescent health services in the country. It is funded by the UK and implemented by the United Nations Population Fund (UNFPA), United Nations Children’s Fund (UNICEF) and World Health Organisation (WHO). The programme started in October 2018 and was planned to run through to March 2021.³ The RCPCH Global Links Programme is part of the Saving Lives project and was in its final phase of implementation when I joined as an International Mentor.

RCPCH Global Links and ETAT+

In my six-month placement with the RCPCH Global Links Programme, I joined National Nurse Mentors in delivering the Emergency Triage, Assessment, and Treatment Plus (ETAT+) Programme.

This programme is a WHO endorsed emergency paediatric care intervention, aimed at improving the ability of healthcare workers in resource-limited settings to identify and treat critically unwell children.⁴ This is similar in principle to Advanced Paediatric Life Support (APLS) in the UK. ETAT+ was initially developed in Malawi and has since been established as an emergency paediatric protocol in several African and Asian settings.⁵ ETAT+ has been delivered in Sierra Leone by the RCPCH since 2017 and has been associated with reductions in case fatality in Ola During Children’s Hospital, the tertiary Children’s Hospital in Freetown, from 12.4% to 5.9%.⁶

I was in Sierra Leone from October 2020 until February 2021, during the final phase of the programme. The emphasis then was handing over the programme to the Sierra Leone government and up-skilling the local nurses in the district government hospitals to continue to deliver the ETAT+ programme without the presence of RCPCH Global Links.

Life-saving lessons – from practice to pikin (child)

We worked with the incredibly passionate and skilled National and local Nurse Mentors to deliver a 16-week training program to a cohort of local nurses, healthcare assistants, and physician associates.  At the end of the weekly taught programme the candidates completed a thorough written and practical examination before receiving their certificates of completion if they passed both components.

The candidates attended in their own time pre-and post-shift, around the competing demands of childcare, cooking, and cleaning for their families. It was a pleasure to teach the enthusiastic healthcare workers, keen to help the many sick children seen in clinical practice every day. It was encouraging to see the direct translation of skills acquired in the classroom to real-life scenarios: from less than half of the candidates achieving chest wall movement during bag-valve-mask ventilation of an infant mannequin to almost all successfully doing so independently, both on the mannequin and unfortunately in the many arrest cases seen in resus daily.

Kusheo (welcome) – the importance of pleasantries and the bigger picture

Small talk is taken seriously in Sierra Leone. At the start of every meeting, be it personal or professional, people would genuinely enquire as to the health of one another and their families and with a simultaneous joint Muslim and Christian prayer. As part of the RCPCH Global Links programme we attended monthly meetings with the hospital management team to discuss barriers to implementing ETAT+ in their hospital, focussing not just on the knowledge but also the practicalities.

Across the hospitals there were recurrent themes of drug stockouts (most commonly antibiotics and antimalarials); resource limitations (intermittent electricity/generator power and lack of clean water); staffing issues; and equipment inadequacies (no batteries for pulse oximeters, no glucometer testing strips or malaria rapid diagnostic tests). To overcome such issues, equipment such as cannulas, syringes, airway adjuncts, and oxygen tubing had to be re-used.

We also undertook quality improvement projects, such as creating a checklist and implementing daily checks of the Resus trolley.  We collected data on morbidity and mortality; timings from gate to triage to treatment, and quality of care. Compiling this information, we created tailored Hospital Paediatric Improvement Plans alongside the National Nurse Mentors. Stakeholders were able to review progression across a range of key indicators to help with informed decision-making and local funding.

Conclusions – cultural context and decolonisation

I can’t emphasise enough the importance of cultural context when living and working in a country other than your own, particularly where colonisation has had such a huge part to play in its history. I think we need to be mindful and try to avoid the classical “white warrior” approach to humanitarian work and thus ongoing colonialism. It is often resources, not knowledge or skills, that is the limiting factor in these healthcare settings.

My six-month placement only scratched the surface and I would encourage anyone to spend at least this amount of time overseas in humanitarian work to help to contribute to a long-term change. Instead of “patching gaps” in the overstretched healthcare system (unbelievably there are more doctors from Sierra Leone practicing in Manchester than in Sierra Leone itself). Wherever possible try to choose a project focusing on local buy-in and longer-term improvements, with an emphasis on leadership from local people.

If you would like more information on volunteering with RPCH Global Links, please see their website for current opportunities.

References

1. “Sierra Leone”. Wikipedia, 5 January 2022,https://en.wikipedia.org/wiki/Sierra_Leone
2. “After Ebola: Why and how capacity support to Sierra Leone’s health sector needs to change”. Lisa Denney, Richard Mallett with Ramatu Jalloh, 1 July 2015, https://securelivelihoods.org/publication/after-ebola-why-and-how-capacity-support-to-sierra-leones-health-sector-needs-to-change/?resourceid=362
3. “United Nations Population Fund”. https://www.unfpa.org/saving-lives-sierra-leone-phase-2
4. “Updated guildine: paediatric emergency triage, assessment and treatment: care of critically-ill children”. World Health Organization, 2016), https://apps.who.int/iris/handle/10665/204463
5. “RCPCH Global 2014-2022. The evolution of RCPCH Global Programmes.” RCPCH, 2019. https://www.rcpch.ac.uk/sites/default/files/2019-02/rcpch_global_booklet_a4_20_web.pdf
6. “Reductions in inpatient mortality following interventions to improve emergency hospital care in Freetown, Sierra Leone”. Matthew Clark , Emily Spry, Kisito Daoh, David Baion, Jolene Skordis-Worrall, 19 September 2019,
   https://pubmed.ncbi.nlm.nih.gov/23028427/
7. “Life expectancy at birth, total (years)”. United Nations Population Division. World Population Prospects, 2019,
   https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=SL

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Robin shares his insights from the recent British Mountain Medicine Society (BMMS) winter webinar in October 2021 – ‘Sustainable Adventure in a Warming World’.

Narratives and stories are central to how we humans communicate and make sense of the world around us. Knowing this is also important in understanding and attempting to resolve the massive existential crisis that is the climate emergency. Stories give context and make things relatable – not just a distant issue, or someone else’s problem.

When I opened the recent webinar on, ‘Sustainable Adventure In A Warming World’ held by the British Mountain Medicine Society (BMMS), I wanted to offer a bit of my own journey and explain how I had a bit of a revelation in 2015 whilst living and working as a GP on the remote west coast of New Zealand’s South Island. Based in a tourist town like Franz Josef Glacier, the main attraction has been the glacier for the last 100 years. However, I realised that it had transformed into one of the worlds’ busiest heliports, as access to the rapidly retreating glacier became too perilous on foot.

I was anxious when I initially wrote my open letter to the BMMS forum proposing a ‘Climate Hui’. I was aware that the UN Climate Change Conference, COP 26, was coming up a few months down the line in November 2021. I wasn’t sure how my ideas might be received, particularly with Covid-19 pandemic occupying the minds of most of the population. However, that being said, the responses I received were overwhelmingly positive. So when I realised there was an appetite for my ‘Climate Hui’ proposition it dawned on me I had to make it happen!

Above all, the speakers I chose had to be credible. I had seen both Dr David Pencheon and Prof Hugh Montgomery give talks before and I knew that they had a deep understanding in this field. Adding an eminent climate scientist, Prof Chris Rapley; and a researcher, Dr Catherine Campbell, with recent audit experience in expedition sustainability seemed like a no-brainer.

The webinar itself was extremely well attended, and thanks must go to the British Mountaineering Council for providing additional publicity for the event.

After some time spent reflecting upon the event I am left with the following observations:

1. As clinicians, we increasingly have a moral and ethical duty to be proactive in global environmentalism and sustainability (‘do good, do no harm’ etc…)
2. Mountain Medicine guidelines, protocols and recommendations should reflect this wider duty of care to the environment and our planet.
3. The future of healthcare may increasingly promote ‘wellness’, rather than the curing of ‘illness’. Those of us with an interest in the outdoors and medicine may pioneer what it means to truly be a ‘well-being’, as well as leading the way for a ‘well-planet’.

The feedback from the event was very informative, and will no doubt be guiding our next steps. Perhaps the biggest outcome so far is that, combined with the actions of the Birmingham Medical Research Expedition Society meeting in September, the BMMS webinar has spurred on collaboration on a ‘Green Statement’ – a suggested framework for future sustainable medical expeditions. The work of Dr Catherine Campbell and co-ordination with Dr Jeremy Weber has been pivotal in its ongoing production.

The other reflection the event has left me with is that rather than the climate, and its associated healthcare emergency being seen as a ‘fringe issue’, it is now transitioning in the minds of the public (clinicians included) to be a ‘mainstream issue’. It is my hope that those who participated in the event became galvanised by science and motivated to act. It is the responsibility of everyone to solve this emergency and standing at the sidelines is no longer an option.

If you missed the ‘Sustainable Adventure in a Warming World’ winter webinar from the BMMS, watch the free recording of the evening here (Passcode: xdjaK!1Q).

Images courtesy of Robin Barraclough (author) and Rebecca Trimble (Adventure Medic editor).

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Adam recounts his adventures in Rwanda cycling the Congo Nile Trail, following three months completing the The London School of Hygiene & Tropical Medicine’s Topical Medicine Diploma. Adam takes us through the culture, history and what he gathered from the little-known Rwandan political agendas; through meeting its warm people and some spectacular places along the way.

Straight In The Deep End

“The pillow is not for sale. You have to give it back!”. It was 6.30am and we hadn’t slept. A twelve hour drive from Kampala to western Rwanda beckoned. I’d attempted to abduct a pillow before checking out of our hotel. The eagle-eyed receptionist foiled my plot. Reluctantly, I passed it through the van door and rested my head against the window.

I lived in East Africa for three months. The London School of Hygiene & Tropical Medicine’s Topical Medicine Diploma had been immersive to the end. The tense focus of revision, the strain of examinations, the release and celebration in the aftermath, the bittersweetness of graduation and parting. We stood on the lawn of Mulago Hospital, Uganda for the class photograph. Everyone wore something made of Kitengi, stitched from cuts of the same cloth. We all passed. It was done!

Before returning home though, Steven Leask, Tansy Wilkinson and I decided to make for Rwanda to cycle the Congo Nile Trail – a 257km trail with 5800m of climbing through the hills of western Rwanda. We left most of our luggage behind at Mulago Hospital, found a driver to take us across the border to Gisenyi, and hired bikes that would carry us through the wilderness. Logistical matters resolved, we fell asleep as Hussein’s old Toyota rumbled into Kampala’s morning traffic jam.

Crossing Into Rwanda

I awoke lying on my back. Didn’t know where I was. Terraces were cut into steep hillsides around me where thick forest had been hewn back. We turned fat bends in the road which wound through the mountains like a snake. I returned to sleep. On the Rwandan border a WHO checkpoint screened us all for fever. An Ebola outbreak in northeastern Congo was making neighbouring Uganda and Rwanda nervous. But for good reason. Viral haemorrhagic fever outbreaks are terrifyingly difficult to manage in any setting. And an Ebola outbreak in one of the most fragile, conflict-ridden states in the world presents an even more apocalyptic nightmare. Mercifully afebrile, we made our way across the border into the land of a thousand hills.

The Congo Nile Trail begins on the border of the Democratic Republic of Congo (DRC) at Gisenyi. Like Kigali, the town is quiet, sterile and orderly. Rwanda lacks the humming, riotous life of its neighbours but is spotlessly clean. The first and last Saturday of each month are devoted to ‘general cleaning’; wherein everyone flocks to the streets to sweep and pick up rubbish. Christian, one of our Rwandan friends working for Partners in Health in Kigali, says people generally don’t mind: “You get to know your neighbours, it builds the social fabric.” Collective cleaning also changes behaviour, according to the owner of a guest house we stayed in; “You feel ashamed if you clean one day and the next you are dropping your own rubbish.”

Although it is clean, Rwanda is no paradise. Progressive yet repressive, the Rwandan state stifles opposition and foments disintegration in neighbouring DRC to extract mineral resources. Rwanda exports coltan – a raw material for the smartphone in your pocket – with much of it smuggled from conflict areas across the Congolese border. Paul Kagame, commander of the Rwandan Patriotic Front which ended the genocide after the UN pulled out and the world fumbled, has proved skilful in mobilising the guilt of the international community to aid the rebuilding of Rwanda. Gaunt, bespectacled, disciplined; and autocrat of twenty three years.

The government recently paid £30 million to have ‘Visit Rwanda’ emblazoned on the sleeve of the Arsenal jersey. This provoked controversy: a country receiving £60 million in UK aid annually deciding to shell £30 million on a Premier League sponsorship deal. On Radio 4’s Today program, Clare Akamanzi of the Rwanda Development Board bit back: her country would invest its resources in whatever serves their interests. The deal would promote tourism. In a decade Rwanda has reduced the proportion of its budget derived from foreign aid from 80% to 17%. Tourism already supports 132,000 jobs and accounts for 12.7% of GDP, and there is now a direct flight from Gatwick to Kigali. But as Christian pointed out to me, the deal serves another purpose:
“Everyone thinks of Rwanda and they think of the genocide. Now you hear this tiny country is sponsoring Arsenal and it makes you think: what’s going on there? The point is to change the narrative.”

New Wheels

We went to the office of Rwandan Adventures. Joyce, allegedly the country’s only female bike mechanic, maintains a collection of Scott hardtail mountain bikes. And after carefully selecting our new wheels, we were introduced to our guide, Twizi, who spoke neither English nor French. We shook hands, slurped a large glass of something with a taste and consistency like sour cream, winced in unison, and set off.

Growing accustomed to the rough trail and our new bikes we rode past the Cyimbiri Waterfall and stopped for a lunch of beans, groundnut sauce, spinach and a fistful of small fish called isambaza. A couple of cyclists from Arizona offered some chilli oil called akabanga, which improved the fish greatly but nearly ignited my face. Robert H. Miller sported long socks, aviator glasses, a handlebar moustache, collared shirt and heavy cotton shorts. From beneath the brim of his hat he explained that he was a retired mountain guide, builder and author of the only guide to the Inside Passage: a kayaking route from Washington state to Alaska. He was cycling through Rwanda with his wife on a commission from Liberty Unbound, a libertarian magazine. Robert and his wife were the only other travellers we met that week.

Twizi had been a rider for Team Rwanda and was by any measure a strong cyclist. But as a guide he was completely ineffectual. Questions received one of three answers: “yes”, “no”, or “four minutes” – meted out at random. We never understood where we were going or what we might find when we got there. We did not have a map, and so we ploughed on and learned slowly to accept the mystery and the trail as it came to us out of the trees.

The equatorial sun beat down unflinchingly and by mid-afternoon I was burning. I had an Orkney wool blanket to fend off cold mountain nights but the prospect of shrouding myself under metres of tweed did not appeal. I ended up purchasing a lighter shawl from a nearby market stall after much negotiation with the seller. We finally reached the Kinunu Guest House; our destination for the night. In the garden beneath the Kinunu Guest House coffee grows with bananas, avocados, mangos, lemons, oranges, pineapples, papaya, apples and guava. I counted four cows and twenty chickens. I also counted four cows and twenty chickens. Walking among the fruit trees we met Chrysologue Karangwa, former Rwandan senator and university professor in Kinshasa and Burundi. At seventy-eight he’d retired from political life to look after his land. He explained that from January to June, hundreds are employed in the harvest across his land.

In the morning we drank coffee from the plantation, thick like treacle. Across the lake we heard shouts and songs of fishermen returning from the night, while Twizi briefed us on the route for the day – “up, up, up, down, up.” As villages became more dispersed the route narrowed blessedly to single-track. We forded small streams with assistance from local children and crashed our way through thick grass fields, breaking my bottle cage and water-bottle. However, a patchy combination of French, Swahili and gesticulation procured me three bottles of Fanta and a ripe pineapple later that morning. We climbed high above the lake until the air thinned and cooled. Children called to us in laughing voices – “Umuzungu! Umuzungu!” (white person in Kinyarwanda).

Trail Encounters

That night we slept in rooms belonging to an Ugandan expatriate called Ernest. Thin, garrulous, and energetic; Ernest was a man on transmit. I sat quietly in the night and enjoyed the sting of the whisky on my sunburnt lips. Beside a roaring fire we listened to Ernest talk of Rwandan history, the politics of the region, and why he came to live alone on the hill of Bumba village. “Because they knew they were coming from hell to life, they needed a plan for what to do. So they make it clean, they make it safe, they hope when you think of Rwanda you will come”.

He was talking about the genocide, of course. 1994. One hundred days. 800,000 Tutsis and moderate Hutus, probably more. Murdered by machete, spear, blunt tools, grenades, kerosine, rivers. Hard to believe these hills could have run with so much blood.

By any marker though, Rwanda is climbing out of hell. Ranked among the least corrupt countries on earth, with more female parliamentarians than any other nation, universal health coverage and a predictable, market-friendly government. Thousands have been lifted out of poverty. Life expectancy increased from forty-eight to sixty-seven in little over a decade.

The following morning I briefly exchanged bicycles with a courier riding a single-speed bike up the pass to Muramba. I instantly lost control, overcome by the high gear, but I narrowly avoided a ditch. It was a bone rattler of a bicycle: bent cranks, wobbly bottom bracket, one working pedal on the left and just an iron bar to press against on the right. It makes you wonder at the strength of the men and women who ride these contraptions through the hills day after day. We took a paved road though the mountains as a cold wind blew. The roads are beautiful, with sweeping bends and smooth tarmac, lines with tea plantations and Lake Kivu just in sight in the far distance.

With the assistance of Roger, the Arizonan couple’s English-speaking Rwandese guide, we learned that our guide Twizi was nine years old in 1994 and had received only three years of primary education when his schooling and childhood were ended by the genocide. He fled to Zaire and lived as a refugee with his mother. He made deliveries on his bicycle as a teenager and started winning weekend races. He qualified for Team Rwanda and rode with them for three years but received no language instruction. He had worked for Rwandan Adventures now for five years, who in turn have not provided him with access to English classes. So he rides almost mute – unable to communicate with those he travels with. Week after week, unable to share stories, explain his native land, or function as a guide.

Education

We spent that next night in a room attached to a boarding school. After a bucket shower I chucked a small rugby ball around the room with Tansy and waited for the large plumes of smoke and squabbling outside to turn into something resembling dinner. A young man wearing a Linkin Park T-shirt walked in and asked if he might be able to borrow pair of underwear. His name was Patrice and he was a teacher in the school. He was Brazilian-German, twenty years old, and teaching computing for a year before going to university. He’d returned from Kigali after a second failed attempt to renew his visa. It became clear through the conversation that we had commandeered his bedroom. Patrice was having a bad day.

Another day passed riding under the sun. Under a thatch bar beside the water at Ishara we met three Peace Corp volunteers, including Lucy. They’d come to Rwanda after college in the U.S. to teach in rural schools and had lived here for two years. They had mixed views of Rwandan education. In 2009, Kagame decreed the language of instruction would switch from French to English. Teachers, many of whom could not speak English, were given a month to learn and then teach their classes in a different language. This has not worked well. Lucy explained:

“I walk past classrooms and hear teachers speaking a mixture of French and Kinyarwanda. When they see me, suddenly they shout ‘now settle down class!’ It’s about the only English they know.” At the end of primary school, pupils sit an exam which determines the secondary school they will be eligible to attend. The exam is in English. “They’re being set up for failure.”

Rwanda is moving fast. Deciding to teach children English, the behemoth global language of science and business, is not necessarily a bad policy. But even good policies can be destructive if implemented poorly. Perhaps the transition will be made eventually and Kagame’s view of an anglophone, technologically-enabled knowledge economy will be realised. But the number of children who will fall needlessly between the cracks from this day to that is anyone’s guess.

Homeward Bound

The last three days of the route from Gisenyi south to the bottom of Lake Kivu are covered by tarred roads. We breathed air heavy with the smell of tea plantations and mulled the complexities of the land we rode through. Where would Twizi see fit to deposit us next? True to the spirit of the trip, the name of the town we finished in was different to the one we thought we were heading for. We shook Twizi’s hand, thanked him and clambered on the bus to Kigali.

The road to the capital was similar to the route we had cycled. The entire country spikes erratically into the sky as if the land were paper scrunched into a ball and then spread out haphazardly again. Occasionally we drove over unpaved sections and thick silver dust mingled with our bags and hair. The bus filled as we trundled through – stopping once to pick up sticks of maize grilled over a fire. Darkness came and I could no longer read. The girl beside me was sick on my leg. I opened the window to let away the smell. Our bodies were all sunscreen, bike oil, dust, forest. When I shaved that night, the dirt came off in streams. The bus filled up as we trundled through the mountains; stopping only once to snack on sticks of maize grilled over a fire.

Just A Line Through

We had drawn a line through Rwanda. With all the swiftness and superficiality that entails. But I am not a traveller who lays claim to places. I haven’t ‘done’ Rwanda. I haven’t scored it out on a map. We had moved safely, quickly and in relative comfort through this land which within my own short lifetime has known a season of blood. Our journey was no great burden. It was a cycling holiday; with all the laughter and small-souled glory they always contain.

For Ryszard Kapuściński, Africa did not exist. The continent was a “veritable ocean…an immensely rich cosmos” too vast to describe. All one could do was to write of “some people from there – encounters with them, and time spent together”. As this region slowly steeps into my bones, I draw gradually toward that conclusion myself. Shaped by the same historical forces, plagued by ills of similar kin, imagined for centuries in bland generalities. But life in Rwanda goes on. Wandering, faltering, but not lost.

Images provided by Adam Boggon.

For more work by Adam see his website: www.adamboggon.co.uk

For those interested in working in the tropics there are a number of diplomas available. The full time Diploma in Tropical Medicine and Hygiene in Uganda and Tanzania is not currently running (at the time of this publication) but the courses in London, Liverpool and Glasgow are.

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Three members of the Unique Expeditions team take us through some survival tips and jungle training that could be the difference between life and death in a remote rainforest. Logging countless visits to the tropics; they’ve experienced flash floods, jungle landslides, and close encounters with dangerous animals. Using these helpful tips, we too can learn how to explore spectacular environments, avoid danger, and keep morale high on expeditions.

What to expect

It will be hot, it will be humid, and you will be wet most of the time, but don’t let that put you off. There is so much going on that you have very little time to feel uncomfortable. Whether it’s navigating through the thick undergrowth, scaling steep ravines, abseiling down waterfalls, or cooling off in their plunge pools. There’s never a dull moment in the jungle, and that’s why we love it so much.

It has been said that “the jungle is neutral”. It provides fresh food, water, and offers you every opportunity to survive in relative comfort; whilst simultaneously exposing you to deadly hazards at every turn. Wild animals armed with sharp claws, teeth, and tusk roam freely between undergrowth and canopy. Insects laced with highly toxic venoms and poisons brush past you unnoticed. Prickly flora with 3-inch thorns are ready to cut, scrape and infect. There are infectious diseases, poisonous edibles, fatal flash floods, landslides, and of course the dreaded deadfall. The jungle is indeed a perilous place to spend your days, however, you will seldom find a more rewarding and natural environment to explore.

The methodical and somewhat ritualistic manner in which we operate in such demanding terrain is the key to our survival. Below are a selection of tips and tricks to help you sway the balance in your favour. Not written from a textbook but derived from experience, and ultimately learnt the hard way.

Tip 1: Acclimatise

Heatstroke and heat exhaustion are serious dangers in the jungle. People seldom realise that acclimatising to tropical weather can be as important and beneficial as acclimatising to the cold or altitude. Any seasoned jungle veteran will tell you that giving your body time to adapt to the heat and humidity, and shake off the jet lag will greatly improve your experience on an expedition. Landing in-country a few days early will give you this opportunity. These days will be a shock to the system but after a couple of days in the heat you’ll notice that you feel the effects less, you’ll be able to move and exercise more without tiring, and the salinity of your sweat will reduce – making your body a more efficient cooling system.

Some useful behaviours include turning off the AC in your room before you go to sleep. As brutal as this sounds it will be paid back in gold once you head under the canopy and spend that first night under a tarp! Go for walks in the heat – use it as an excuse to explore the local area, soak up some culture and condition your body in the process. In the meantime, try to avoid alcohol as it impairs the body’s thermoregulatory mechanisms.

Tip 2: Look up, look down, look around

Being aware of your surroundings is important on any expedition. One of the main reasons people want to explore jungles and rainforests is for the amazing plant and animal life, but some of it can be quite nasty if it takes you by surprise! To reduce the chances of getting hurt here are some simple yet effective rules to follow:

Look up / When you arrive at camp for the night make sure to look above for dead trees or hanging branches caught up in the vines, as these could easily fall onto your hammock. At some point during your time in the jungle, you will most likely hear the chilling sound of ‘deadfall’, produced by huge dead trees finally crashing to the ground. If you’re under a triple-layer canopy you won’t be able to see to the top, but you can minimse your chances of getting hit by setting up camp in less hazardous places amongst trusted/safe trees.

Look down / Are you surrounded by ants, leeches, or other critters? Carefully sweep away some of the leaf litter so you have a clear area beneath your feet; most insects and small animals are deterred from travelling across open ground.

As you’re travelling through the forest, if there’s a fallen branch or tree across your path then step on and over the obstacle. A fallen tree trunk provides a great habitat for a huge variety of species including scorpions and snakes, so you want to know nothing is waiting for you on the opposite side before you put your foot on it. Stepping on top of the obstacle first will allow you to scan the ground on the other side and make sure it is free from danger.

Look around / Remain vigilant and don’t put any body part where you can’t see it. This includes checking boots and shirt sleeves before putting them on. When securing your tarp or hammock to a tree, rather than reaching your hands behind it, walk the strap all the way around. There could be something waiting on the far side that you don’t want to disturb!

Tip 3: Get fit before you go

We’re not talking beach bodies and big muscles. Your cardiovascular fitness and endurance are key, so make yourself a gentle training regimen. You’ll be carrying a rucksack with everything you need for five to ten days, plus it will get soaked from wading through neck-deep water – this could add two to three extra kilos of “water-weight” to an already heavy pack. In addition, you’ll be trekking over uneven, muddy, rocky, and steep ground, so your body must be somewhat accustomed to this type of exertion. A good way to get in shape before you travel is to get out hiking in your local area with a bit of weight on your back, slowly increasing the distance, the difficulty of terrain, and pack weight. This also gives you time to test out your kit and see what you like or don’t like about it. It’s always better to notice something that’s not right when you still have time to fix it. By the time of the expedition, if you’re able to maintain 2 hours of brisk walking with your full expedition weighted backpack (that should be around 15kg) then you’re doing just fine.

Tip 4: Pack Light

One of the most frequent comments people make after their first exped is “next time I’ll seriously reduce my pack weight!”. The heavier your bag the more work you have to do to transport it around, the more energy you burn, and the more heat your body will generate. You’ll begin to loath every superfluous gram, unnecessary gas canister, and overly heavy toothbrush; especially when negotiating steep jungle terrain. You should pay attention to the brief on what to bring and leave all superfluous items at your base camp or in hotel storage. Before heading into the forest your expedition leaders should do a full kit inspection and ensure every item is fit for purpose and strictly necessary. The items to concentrate on are your hammock, tarp, boots, and rucksack, as the quality of these items will have the greatest impact on your comfort and wellbeing.

Packing the right kit is important but are you prepared to use it? Have you tested to make sure that your bag is waterproof, that your backpack is bombproof and packed so you can find things with your eyes closed? Have you practiced putting your sleeping system up in the dark and do you know how long your gas bottle lasts? Test your clothing, make sure your boots are broken-in and you can walk a distance in wet boots blister-free, that your trousers and shirt don’t chafe and that you have a full range of movement whilst dressed for the jungle. If you don’t know or you have a question about your kit then get in touch with one of our guides – we are always happy to help with your planning! Here’s a full Jungle Kit List assembled with more than a decade of jungle expedition experience, if it’s not on the list, you don’t need it!

Tip 5: Stay Hydrated

Okay, this is a bit of a long one but it is important to understand. Like with any sustained physical activity, keeping hydrated is key. For the first few days in the heat, your body will be adjusting to the climate; you will sweat more and that sweat will have a high concentration of electrolytes. As your body adapts you’ll sweat less with a reduced concentration of electrolytes (it even tastes less salty). In any case, you need to be aware of your fluid intake to keep replenishing this loss. A good way to keep on top of this is to bring effervescent electrolyte tablets – have one in your morning drink and at least one more throughout the day.

Much of the jungle we visit is untouched, primary rainforest. This dense canopy creates a lot of shade which is fantastic for collecting water, as the streams and rivers are refreshingly cool. Depending on where you are, you may have to drink warm water which is not exactly refreshing, so remind yourself to keep that water intake high. Even on rest days you should be consuming three to four litres (depending on your size) and more on active days. Ensure you take at least a couple of swigs from your bottle/bladder every hour.

Purifying drinking water significantly reduces the risk of water-borne illnesses. This is usually a two-step process:

1. Filtering out particulate matter (dirt, organic detritus, bacteria, and with some filters even viruses)
2. Chemical disinfection. Chemical disinfection is the “nuke” that will destroy any nasties left after filtration. The two most common chemicals are chlorine and iodine. You can find cheap chlorine tablets online or at your local outdoor shop. Iodine is also great, though should be avoided if you have thyroid problems. Both give a specific taste to the water that some people don’t like, so try both before you head out and see which you prefer.

There are many great portable water filters on the market. Many are also not fit for purpose in such a demanding environment, as they like to get clogged and can’t be solely relied on. Feel free to contact us for recommendations on which have worked for us and which to avoid. We’ll put our details at the end of this article.

And finally, never mix drinks! The ascorbic acid (Vitamin C) in many electrolyte tablets neutralises the effects of chlorine or iodine, meaning your water isn’t safe to drink. For this reason, you should keep one container for the sole purpose of disinfecting water. After disinfection, pour it into your cup or flask and add your juice/electrolytes to that.

Tip 6: Keep on top of personal admin

When everything around you is new and exciting it can be difficult to keep track of the day-to-day tasks that allow you to successfully finish an expedition. We tend to refer to these duties as “personal admin,” and its importance increases with the length of time you plan to live and travel through the jungle.

These little tasks are the kind of things you might decide to skip when you’re tired at the end of a long day, or rush over so you can get going in the morning. However, if they’re neglected, the effects on mood, morale, and even your health can start to become evident – and that’s when people stop enjoying an expedition. It helps to think as though each task is helping out the future you; the you that will wake up the next day and be glad you have washed the blister-causing sand and grit from your socks. If you slack on these tasks even for a couple of days, you’ll be doing yourself no favours in the long run.

Stay hydrated / Disinfect your drinking water at the end of the day so it’s ready for use in the morning. Waking up dehydrated will have a significant knock-on effect.

Organise your kit / Always keep your dry and wet items separated. If “dry kit” gets wet due to lazy packing it’s a massive morale-killer. The jungle will teach you that no dry bag is truly waterproof! So double dry bag your sleeping bag, pyjamas, and electronics. The greatest feeling in the world is washing off the day’s dirt before getting into your dry clothes and hammock as the rain hits the tarp above you.

Pack your bag each day with the items you’ll need first (lunch) at the top, and the items you will need last (tarp and hammock) at the bottom. Some days can be gruelling and you’ll be thankful for every ounce of energy saved.

Keep clean / Wash yourself and your clothes at the end of each day. There are few things in life more gratifying than a refreshing jungle shower. Whether you’re in the river with the current swirling around you, bathing under a gentle waterfall, or simply standing in the tropical rain, it is the best part of the day. Getting rid of the grit and grime will refresh you, keep your night clothes fresh and you’ll sleep much better as a result.

Treat each task as a ritual and stick to a mental tick-list of morning, on-the-go, and evening tasks. This may sound daunting but it’s simple once you’re in the rhythm, and simplicity is the key. One thing should lead to the next so it becomes an automatic sequence. And a good expedition leader will be constantly checking in and reminding you to keep the team happy and effective.

“An ounce of prevention is worth a pound of cure.” Benjamin Franklin

Tip 7: Work as a Team

This is a general tip for any expedition but applies to the jungle just as much, if not more than other environments. When the group works as a team and takes care of each other everything becomes easier. Tasks like cooking meals and setting up camp become more efficient, and everyone has more fun.

The jungle is often very dense so try and stick together. We use a call and response tactic where anyone can make a distinctive call if they lose sight of the team or find themselves lost. Anyone who hears the call issues a response call which acts as an echolocation so the lost party can easily find the group again.

When on the move, the group pace is the pace of the slowest person. Ensure to take frequent stops to check how everyone is doing, and plan multiple potential camps. Let someone know if you aren’t feeling at full strength and help someone out if they’re struggling themselves. You never know, it might be you tomorrow. The goal is for everyone to have a great experience and finish the expedition feeling tired but accomplished, and being great teammates is key to success.

Tip 8: Eat more than you think you need

You will burn a lot of calories in the jungle. Coupled with the appetite-suppressing heat; it becomes very important that you eat enough to offset this calorie deficit. Calorie-dense foods such as peanut butter, granola, nuts, and pasta are great because you get more calories per unit weight in your rucksack. High-quality, high-calorie, boil-in-the-bag meal packs are great and cut down on preparation time. Military ration packs are also perfect but can be hard to come by. On most expeditions, we make time in-country before the expedition starts to buy individual and group food to take into the jungle – this is a great time to ask for advice from the guides and other team members who have been in the jungle before.

Tip 9: Everything is enhanced in the jungle

We often describe the jungle as a mood magnifier, when spirits are high you’re hyper-aware of the sheer majesty of the jungle. You notice the colourful flashes of birds and butterflies, the spear-like bolts of sunlight piercing through the dense canopy, and the unquestionable beauty of the forest. Sadly, the polar opposite occurs when the mood drops as a result of sickness, poor personal admin, or flawed teamwork. Once the mind is consumed with doubt and discomfort the jungle has a harrowing ability to drown you in pain and suffering. But hard times also have the potential to sharpen the mind and make the good times feel all the more rewarding. Keep positive, keep helping, and keep your sanity. You will look back at these times wishing you could relive them.

Tip 10: Take time to appreciate it

To be able to explore untouched and unparalleled jungle ecosystems is a unique privilege as a human being. Most have remained fundamentally unchanged since the era of dinosaurs. They are a time capsule of another world. The only other ecosystem that can compete for species richness is the coral reef. Life of all imagined variety abounds here – in the rivers and streams, from the forest floor to the highest branches on the tallest trees – there is no other place on this planet where life is so varied, and in such abundance. There are more plant species on the jungle island of Borneo than on the whole continent of Africa. There are thirteen species of primate and so many endemic species of insect and amphibian, and new species are discovered and described in scientific journals on a weekly basis. It is nature’s greatest feat – its magnum opus – so take time to take it all in. It will be one of the most memorable experiences you will ever have.

Any questions? Want to join the Unique Expeditions team in the jungle? Feel free to contact us any time via email or WhatsApp.

The post Into The Jungle: Ten Tips to Help You Prepare appeared first on Adventure Medic.

Dr Sam Goodhand is an anaesthetics registrar and widely published opinion-piece writer with an interest in aero-medical retrieval. He worked with the Central Australian Retrieval Service in 2019. Here he tells us about the “Tyranny of Distance” in Australia’s Red Centre and how this contributes to healthcare inequalities suffered by the Aboriginal communities living days away from medical care.

All we have are vague reports of a serious car accident. We bump through our descent, and the corrugated grey homesteads beam back the early morning sun beneath our wingtip. It’s the first sign of life for over an hour of flight, which has taken us across glaring white salt lakes and the bulk of Uluru. The pilot orders silence for landing; giving me and the flight nurse a few moments to mentally prepare for the job ahead.

Grief was already echoing through the hills which enclose this remote Aboriginal community ever since a previous tragedy. My colleague had scrambled to the town weeks earlier to retrieve a suicide victim who had later succumbed despite the best efforts of the team. But today, a car has been found on its roof, with one seriously injured occupant and another passenger already dead. In the cool of the village’s tiny medical bay, the remote area nurses are busy at work. The wake of the last tragedy had led to alcohol being smuggled into the town in contravention of their self-regulated ‘dry’ status. Some teenagers had been drink-driving late at night and rolled it over. Due to the remoteness of the town, it was only at daybreak that they were discovered.

‘Golden hour’ urban medicine this is not. From the Royal Flying Doctor Service Base in Alice Springs – a small hub at the heart of Australia’s landmass – the Central Australian Retrieval Service covers an area the size of Germany. Helicopters would barely make a dent with their range, and have no role in providing healthcare to this thinly populated expanse of Outback. The ‘tyranny of distance’ is unforgiving and presents unique challenges – it may take many hours for us to reach our patients, by which time critical and traumatic illness have gained a firm grip. Whole weather systems and availability of airstrips influence our plans and dictate our time-window to administer treatment on the ground. Furthermore, the indigenous occupants of Australia’s ‘Red Centre’ suffer from a number of chronic health conditions which, according to the United Nations contribute to Aboriginal Australians dying up to twenty years earlier on average than their white immigrant countrymen.

We administer treatment to our trauma patient, and roll out to the medical centre’s Toyota ‘troop carrier’ – the ubiquitous Outback ambulance. This will take us back to our plane, for the 500km journey to the hospital in Alice Springs. The community stand quietly in vigil; with the occasional shout of farewell in their indigenous tongue. ‘We might see you again soon” the exhausted nurse says with foreboding. Several people have missed kidney dialysis sessions during the Sorry Business. “And there could even be payback when this patient returns”, she adds as an afterthought. Payback is a traditional physical punishment, dealt to those who have harmed others and broken customary law. This village’s chapter of tragedy and violence may not yet be over.

The threat posed to health by such enormous distance drove the Reverend John Flynn to establish the Royal Flying Doctor Service, in 1927. Ten years earlier, Flynn had been particularly moved by the case of ranch hand Jimmy Darcy, who fell from his horse in rural Western Australia. He was hauled on a cart for many miles, before being operated on by a local postmaster under instruction by morse code, from a doctor who resided hundreds of miles away in Perth. The distant mentor, Dr Joe Holland, then made an epic two-week journey by cattle ship, car and horseback to tend the patient himself, only to arrive hours after the unfortunate Darcy’s death. This fascinating story was well-publicised in Australia at the time, and was instrumental in Flynn’s desire to establish a ‘mantle of safety’ for rural Aussies.

Despite modern technology and methods, Dr Holland’s dusty travails would pop into my head on several occasions during my time with The Service. One spring evening sticks in mind. My tasking consultant phoned to tell me about a young patient who has been hit by a road-train lorry on a remote highway. There is a dirt airstrip several kilometres from the scene, but it’s entirely unsafe for night flying. We would need to improvise.

We would use Alice’s ambulance service, which has a mind-boggling catchment of some two hours driving time out of town. Driving North for almost ninety minutes, we arranged a rendezvous with a Troop Carrier. Inside the “Troopy” were two remote area nurses, who had driven forty minutes from their own post to load our critically injured patient from the roadside onto their gurney. They passed us so fast we almost missed them. Together we transfer their human cargo onto the ambulance stretcher; clinging desperately to life. Under the stars, lit only by iPhone torchlight and with the trolley rocking on the uneven brush of the roadside, we got to work. Decompressing the victim’s crushed chest, inducing anaesthesia and commencing ventilation for the two-hour trip home. The feeling of professional isolation and exposure is exhilarating and unsettling in equal measure. Cold is also a killer in trauma patients, and as we rack up the heating to maximum in the back of the ambulance, I wish I’d brought more than a small bottle of water.

Great distance is but one hardship. There’s the savage, inescapable heat – getting back into the cramped interior of a Pilatus PC12 in 46 degree heat is memorable. And then other extremes of weather – hailstones the size of golfballs, blinding sandstorms, and rains which almost overnight turn the red landscape chameleon-like to a verdant green when seen from the skies. All have deep implications for our patients.

To outwit the collusion of great distance and fast-changing conditions, we must be prepared to rapidly adapt. We found our unfortunate dirt-biking tourist in an empty ‘donga’ (shed) on the edge of our airstrip. He’d been driven there by a gold mine employee after hitting a trench and flying over the handlebars. We had barely clapped eyes on his unnaturally twisted forearms, before our pilot told us we must leave immediately, or be stranded for hours by the incoming storm. His hands had an intact circulation, so we abandon our plan to straighten and splint his arms, and opt to “scoop up and run”. We will have to hope that pain relief will make the bumpy flight bearable. Just as we prepare to leave, our pilot returns. Good news – we have a thirty minute window before the storm descends. The nurse and I work fast, administering ketamine through a drip in the motorcylist’s foot, and pulling both arms to a natural length, while our pilot grimaces and turns away. The man wakes with a drugged grin at 18,000 feet, with the nearby storm flashing into the cabin.

It’s not all trauma and critical illness, and not everybody is pleased to see us. Transferring patients with severe mental illness hundreds of miles to hospital for ongoing care poses one of the greatest challenges. We need to have great patience to stabilise the psychotic patient in their community, often with the support of town elders who may persuade them to travel “to town” with strangers for treatment. Usually, chemical sedation is also needed. Precision and care are key for the long flight home – despite the temptation for such reassuring control, intubation and ventilation is increasingly seen as over-invasive for these patients. We must maintain sufficient sedation to keep our patient calm with a stable airway and breathing, and to keep our aircraft and crew safe in the skies. As ever, we bargain on not being able to perform any intervention in the plane’s tight confines for the duration of flight. An intravenous sedative infusion and a reinforced restraining blanket are deployed in case of agitation at altitude, before the pilot gives the final say-so on safety to fly. It remained thankfully untouched, but I never made the trips without a syringe of propofol, paralysing agent and a supraglottic airway device in my trouser side pocket. It all sounds very hairy, but sometimes it was.

Arriving into the cool of the city hospital’s emergency department after a long mission is the bizarre collision of two worlds. There are few starker contrasts than Australia’s interior and too easily forgotten history, and its infancy as a modern nation. For the Outback’s custodians and occupants – the indigenous peoples and the white farmers, its red earth exerts a powerful magnetism. I will hand over to the hospital team and say my farewells to the patient – if they’re awake, you can bet they’ll ask me one final question – when can they get back “out bush”?

For anyone inspired by this piece, get in touch with the Central Australian Retrieval Service. Placements are generally 6-12 months, and benefit from a broad background with experience in emergency medicine, anaesthesia and critical care. Those with travel sickness need not apply.

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Dr Ella Bennet gives us a glimpse into living and working on Scotland’s northernmost island archipelago of Shetland. The Shetland Islands are home to remnants of viking strongholds, fair isle knitwear galore and some of the best birdwatching in the world. The remote location of the Shetland Islands makes for some stunning landscapes, but does add an additional challenge when providing for the healthcare needs of its population.

It was 2am and I was settled in the handover room attempting a nap, wedged between 1950s textbooks and old coffee cups. I’d just kicked off my shoes when the bleep vibrated – ‘Ella it’s Thelma, two peerie things; have you had your tea yet (by tea she meant her homemade kedgeree and at least eight traybakes) and have you heard about the respiratory arrest coming in?’. The answer was a firm no to both. I re-shoed hurriedly and made my way back to A&E, hoping that some cake might help me remember my ALS algorithms before the ambulance arrived.

On-calls in Shetland can be eerily quiet or very busy, a situation exacerbated by the fact that you cover A&E, two wards and sometimes a tiny HDU on your own. This, in my opinion, is one of the most interesting things about working remotely; you feel simultaneously both very alone and very supported. The nurses are fantastic, you know the paramedics by name and the consultants pop in on their way home from Tesco. In a situation like this though, it’s difficult not to become acutely aware of your own vulnerability. To manage an arrest as an FY3 is unusual. To manage an arrest without senior medical, anaesthetic, radiological or laboratory presence even more so. Working in Shetland offers a challenge clinically, in a role that has both variety and (relative) independence. It is also offers a chance to work closely within a community that is almost defined by stoic self-reliance; a characteristic shaped by one of the harshest, yet most magical landscapes in the UK.

The respiratory arrest turned out to be a loyal customer well-known to Thelma and Gwen (as if any Islander isn’t…). By the time he had arrived, the paramedics had given some aptly-timed naloxone and he was up and fighting to leave. No need to call the consultant, no need to wake the labs and no need to drag the radiographer onto a sunrise ferry. A win all round really. I breathed a large sigh of relief and we passed the next few hours mingling the usual A&E bread and butter with occasional calls from the wards.

Another unique aspect of working at the Gilbert Bain is that whatever your day-time speciality, out of hours you’ll see paeds, geriatrics, minor injuries, psychiatry cases, fishhooks (they deserve a speciality of their own), eyes – essentially, everything. Aside from this, part of your job is communicating with the Shetland GPs who phone for referrals and advice. Some of these GPs work in the tiny remote communities that live on Shetland’s smaller islands such as Unst and Yell. Unst, the most Northerly of the Shetland Islands, has a population of about 650 and is two ferries away from the Gilbert Bain. This is more accessible than some (see Fairisle), but still requires two boats to be called out if someone needs to be seen overnight. Not only does this add an unusual pressure to your telephone decision-making, but it also often leaves the patient a minimum of two hours away.

This geography is in some ways an asset: the Gilbert Bain is fortunate to be far enough away from the mainland that a degree of self-sufficiency is imperative, particularly as the weather is often too bad to fly anyone ‘Sooth’. This has to some extent, protected it from being down-sized to a GP-run community hospital as in many other, more accessible, rural areas; a shift that has undoubtedly reduced the number of jobs available to junior doctors wishing to work remotely. Shetland’s distance from the mainland means that GBH has to be, and will always be, a fully-functioning, CT-scanning centre with a reasonable number of juniors. Amongst other things, this helps the community, greatly improving the hospital’s social life, particularly for those with a love of cold water. Take a job in Shetland and you’re almost contractually obliged to try sea-swimming at least once, and you may well find yourself swimming with the GBH clan – and a few seals or ‘selkies’ – that congregate at sunrise. For warmer pursuits, Lerwick offers more than you would think. There is a fantastic sports centre, a good number of pubs and a weekly quiz for the consultants to beat you at. There’s even the UK’s most remote Parkrun where you will undoubtedly run (pardon the pun) into patients, colleagues and the occasional orca.

Unlike most of the nurses, only a few of the consultants are Shetlanders: many have moved over for work before becoming, either intentionally or unintentionally, honorary Islanders. As in most rural hospitals, they are supported by regular locums who often become part of the extended GBH-family. The lack of middle-grade doctors means that you work very closely with the consultants, many of whom are skilled generalists with a breadth of knowledge and experience that only exists in places with limited tertiary care. Equally important to this, is that the consultants are committed to welcoming, teaching and supporting their juniors, and are more than happy to introduce you to their own private island (and accompanying sheep!) when the weather allows.

Working at the Gilbert Bain is an opportunity to experience UK remote and rural medicine in all of its rugged, tree-less glory. It offers a glimpse into island life that, once you decipher the dialect, will make you forget what life was like without the weather, the people and above all, the puffins…

Intrigued? Interested in working in Shetland?

Every year Shetland offers a number of clinical fellow posts in both medicine and surgery (though be prepared to cross-cover overnight) and usually has around 3 trainees from Aberdeen per rotation. Your accommodation is free and NHS Shetland cover your travel expenses to and from the Island. For more information and contact details, see here.

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Dr Trease is an Australian Sport and Exercise Physician and the Unit Coordinator for Extreme Sports Medicine, a subject that will be offered for the first time in 2021 as part of the Healthcare in Remote and Extreme Environments program at the University of Tasmania, Australia. Lari is also a back-country skier, mountain biker and trail runner in her spare time.

In a recent collaboration between the University of Tasmania, School of Medicine, Healthcare in Remote and Extreme Environments faculty of doctors, Edi Albert, Glenn Singleman and myself; combined with the UK Diploma in Mountain Medicine crew of doctors, Jeremy Windsor and Stuart Allan, researched and published a practical guide to hydration for physical activity and endurance events at altitude (> 2,500m)‘ in the Clinical Journal of Sports Medicine earlier in March this year.

Dr Stuart Allan recently published his summary article based on our paper; ‘Myth-busting in Endurance Physiology‘ on Adventure Medic in May this year and promised a follow-up Adventure Medic article from the CJSM paper – specifically focussed on the ‘how-to’ for hydration up high. In this article I will attempt to answer these questions.

Summary of Recommendations from the CJSM Paper:

Weight loss at altitude does not imply dehydration but rather a readjustment of adaptive physiology

• Acclimatisation to altitude results in a bicarbonate diuresis and can cause subsequent reduction in body weight of up to 2-3kg ¹.
• Research study participants who failed to reduce their body weight when acutely exposed to altitude were more likely to develop symptoms of HAIs ^2.
• Research study participants who had their total body water increased had lower oxygen saturation and higher symptom scores for HAIs ³.
• We hypothesised that ‘euhydration’ at high altitude during endurance races could exceed 2-4%.

Hydration strategies recommended for sea level endurance activities, team sports, or sporting activities in the heat are not appropriate for direct application to high altitude cold environments

• The strategy of ‘drink to thirst’ (DTT) has been shown to be non-detrimental to performance in cold environments ⁴.
• On the other hand, ‘programmed drinking’ (PD) is more relevant to warm climates ⁵.
• Studies examining barriers and enablers to hydration in team sports are not applicable to individual pursuits in the mountains at altitude.

The clinical presentation of altered hydration status and High Altitude Illness’ is similar and could be difficult to distinguish in the field in the absence of point of care testing

• Mild Acute Mountain Sickness (AMS) and hydration disorders present with headache, light headedness, dizziness and gut disturbance ^(6-8).
• The distinguishing feature of dehydration is thirst, which is absent in AMS and hyperhydration (EAH) ⁸.
• High Altitude Cerebral Edema (HACE) and EAH encephalopathy (EAHE) both result in ataxia and confusion, headache and fatigue ^(6,9).

Hydration strategies for physical activity at altitude should include considerations for sourcing water

• Many mountainous regions have a lesser level of sanitation that can result in water-borne diseases.
• High altitude activities, above the snow line, can reduce accessibility to water and may require the carrying of fuel to melt snow.
• The weight of water should be considered in the planning of hydration strategies for self-supported events.

Hypohydration is a lesser health risk than hyperhydration

• Hyperhydration and subsequent EAH and EAHE has greater health risks in an austere environment than mild and moderate level dehydration which can be seen with prolonged physical activity ⁹.
• Often the high-altitude environment results in a reduced capacity to access prompt tertiary level medical support which lends weight to the argument of adopting the lowest risk approach to any problem.

Medications used for HAIs can affect health and performance and may be restricted under the WAD Code for elite athletes

• Acetazolamide has both performance and anti-doping considerations in elite athletes. It is a WAD (World Anti-Doping) code-S5 diuretic and masking agent, prohibited both in and out of competition ^(10-14).
• Ibuprofen: We discourage the use of Ibuprofen for HAI due to demonstrated exacerbation of EAH in endurance athletes at sea-level ⁴.

Elite athlete performance considerations

• The role of fluids for achieving other nutrition goals including carbohydrate intake and the use of ergogenic aids.
• The need for individual experience at altitude to understand personal physiological response.

The local experience

• Sherpas who compete in Everest Original Marathon consume butter tea and tsampa (a roasted barley dish) which are both high in fat and salt. They often also consume Chang beer, which acts as a diuretic and can counteract the increased ADH production associated with stress.

In summary, an individualised hydration approach, based on previous experience, tailored to the event and the conditions will result in the best opportunity for successful completion unhindered by physiological or pathological challenges.

References

1. Jain SC, Bardhan J, Swamy YV, Krishna B, Nayar HS. Body fluid compartments in humans during acute high-altitude exposure. Aviation, space, and environmental medicine. 1980;51(3):234-6.
2. Gatterer H, Wille M, Faulhaber M, Lukaski H, Melmer A, Ebenbichler C, et al. Association between body water status and acute mountain sickness. PLoS One. 2013;8(8):e73185.
3. Swenson ER, Bärtsch P. High-altitude pulmonary edema. Comprehensive Physiology. 2012;2(4):2753-73.
4. Cheuvront SN, Carter R, 3rd, Castellani JW, Sawka MN. Hypohydration impairs endurance exercise performance in temperate but not cold air. Journal of applied physiology (Bethesda, Md : 1985). 2005;99(5):1972-6.
5. Sawka MN, Burke LM, Eichner ER, Maughan RJ, Montain SJ, Stachenfeld NS. American College of Sports Medicine position stand. Exercise and fluid replacement. Med Sci Sports Exerc. 2007;39(2):377-90.
6. Loeppky JA, Icenogle MV, Maes D, Riboni K, Hinghofer-Szalkay H, Roach RC. Early fluid retention and severe acute mountain sickness. Journal of applied physiology (Bethesda, Md : 1985). 2005;98(2):591-7.
7. Bärtsch P, Pfluger N, Audétat M, Shaw S, Weidmann P, Vock P, et al. Effects of slow ascent to 4559 M on fluid homeostasis. Aviation, space, and environmental medicine. 1991;62(2):105-10.
8. Kenefick RW. Drinking Strategies: Planned Drinking Versus Drinking to Thirst. Sports Med. 2018;48(Suppl 1):31-7.
9. Hackett PH, Rennie D. Avoiding mountain sickness. Lancet (London, England). 1978;2(8096):938.
10. WADA. Prohibited list https://www.wada-ama.org/sites/default/files/resources/files/2016-09-29_-_wada_prohibited_list_2017_eng_final.pdf2017
11. Posch AM, Dandorf S, Hile DC. The Effects of Acetazolamide on Exercise Performance at Sea Level and in Hypoxic Environments: A Review. Wilderness & environmental medicine. 2018;29(4):541-5.
12. Elisabeth E, Hannes G, Johannes B, Martin F, Elena P, Martin B. Effects of low-dose acetazolamide on exercise performance in simulated altitude. International journal of physiology, pathophysiology and pharmacology. 2017;9(2):28-34.
13. Bradwell AR, Ashdown K, Rue C, Delamere J, Thomas OD, Lucas SJE, et al. Acetazolamide reduces exercise capacity following a 5-day ascent to 4559 m in a randomised study. BMJ open sport & exercise medicine. 2018;4(1):e000302.
14. Bradbury KE, Yurkevicius BR, Mitchell KM, Coffman KE, Salgado RM, Fulco CS, et al. Acetazolamide does not alter endurance exercise performance at 3,500-m altitude. Journal of applied physiology (Bethesda, Md : 1985). 2020;128(2):390-6.
15. Hydration Strategies for Physical Activity and Endurance Events at High (>2500 m) Altitude. Trease L, Singleman G, Windsor J, Allan S, Albert E. Clinical Journal of Sport Medicine. 2021. Accessed at: https://journals.lww.com/cjsportsmed/Abstract/9000/Hydration_Strategies_for_Physical_Activity_and.98885.aspx

Images provided by Lari Trease

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With a starting altitude of over five thousand metres, Bufo Ventures’ Mount Everest Marathon is recognised by the Guinness Book of World Records as the world’s highest marathon. Dr Nishma Shah shares her experiences of working within the team of doctors covering this unique event.

The Everest Marathon

The Everest Marathon was first organised in conjunction with Bufo Ventures, a company set up by Diana Sherpani in 1987, and has continued to run in the autumn since this time. With a starting altitude of above 5164m, it is recognised in the Guinness Book of World Records as the world’s highest marathon. I was fortunate to work as one of six medics covering two consecutive events in 2015 and 2017.

The Route

This unique race navigates the high Sherpa trails of the Khumbu valley, descending in altitude by over 1500m throughout its 26.2 mile course. The race start line is located at Gorak Shep, a frozen, sand-covered lake bed located at 5164m. This was the previous home of Mount Everest’s base camp. The surrounding mountains provide sublime views and magical light, undisturbed except for a few visible tea houses. The race route descends along the scenic trekking path, finishing at an altitude of 3440m in the Sherpa “capital” of Namche Bazaar. Despite its net descent in altitude there are undulations throughout, with river crossings, high altitude passes, and notable climbs to tackle en route.

As the “sweep doctor” in 2017, I completed the full marathon behind the last of the runners to ensure that everyone returned safely to Namche, with a total time of 11 hours on foot.

Preparation

As with most expeditions, preparation for this race started long before setting off to Nepal. Our chief medical officer carefully reviewed runners’ applications to ensure there were no medical conditions that could affect their ability to complete the race. Previous running experience along with time at altitude were also taken into account given the nature of this race.

As doctors it was essential for us to be well prepared and able to practice comfortably in this environment, with overnight temperatures dropping to -20 degrees Celsius at altitudes of greater than 4000m. Ensuring that our team were physically fit, with no history of altitude illness requiring treatment or evacuation, as well as being able to survive and thrive in a low-resource setting with basic facilities was crucial.

In the run-up to the race, much effort was put into ensuring that our medical kit was well stocked, relevant, and up to date. Specific medical kit considerations for this race included splints, a Gamow bag for altitude sickness, and oxygen cylinders, all of which were sourced from Kathmandu on arrival. We also identified the limited number of rescue posts on the trek and the facilities available at each, in the event that we may need to evacuate a participant. The nearest rescue posts are located at Machermo and Gokyo and the closest hospital facilities and clinics are near Namche and Phakding. Given the relatively basic facilities at the local hospitals, patients requiring evacuation for moderate to severe altitude sickness are generally evacuated to larger hospitals in Kathmandu.

On arrival in Kathmandu, we spent 2 days finalising our preparations, including sourcing the remaining medical equipment, as well as performing basic medical assessments on all participants to record their baseline vital observations. This gave us the opportunity to meet the race participants and discuss the race ahead.

Journey to the Start Line

The full journey spanned three to four weeks from start to finish which included a two-week period of acclimatisation for the runners and team members to adapt to high altitude prior to the marathon.

The two-week trek is designed for acclimatisation before race day and includes an enforced rest day for every 1000m gained in altitude. On arrival to Namche the participants are given the opportunity to take part in a six-mile fun run, which makes up the final loop of the marathon. Participants also have the opportunity to walk up to Gokyo Ri and Kala Patthar peak which are both above 5000m. The views from these peaks are simply breathtaking and provide a great opportunity to further acclimatise and prepare for marathon day.

Throughout the expedition and acclimatisation period, we recorded daily peripheral blood oxygen saturations as well as heart rates for each participant. There was a doctor on call 24 hours per day, with an additional doctor tasked to walk at the back of the group. Their role was to monitor those who may be struggling with the altitude, and assess and manage participants if medical issues arose. It is necessary that supervising doctors remain vigilant, as the initial symptoms of altitude sickness can be extremely subtle and varied, with rapid progression.

Memorable Cases on the Mountain

Case 1 – High Altitude Pulmonary Oedema (HAPE)

The most acutely unwell patient we looked after was a 48-year old male who started to experience difficulties trekking between 3500-4000m.  He was identified as looking slightly grey throughout the day, and on arrival at camp that evening his peripheral oxygen saturations were below 60% in air. After checking the probe multiple times and ensuring that his peripheries were warm and well perfused the saturations remained consistently below 60%. Clinically he was sitting up and talking in full sentences with no evidence of respiratory distress or cyanosis, which did not seem to be in concordance with his numerical medical observations.

Whilst in bed that evening he developed a cough and had some difficulty sleeping which was not raised with the medical staff overnight. The following morning it became clear that he was having difficulty getting up, was unable to lie flat due to breathlessness, and that his cough had progressed to being productive of frothy sputum.

We initiated symptom management for HAPE with oxygen and nifedipine on the mountain, whilst arranging emergency helicopter evacuation to hospital in Kathmandu, where he received supplementary oxygen and antibiotics for pneumonia.

Whilst this was a difficult decision to make, as a team we had identified that he needed to descend urgently and access treatment in a local medical centre, and we were able to arrange this whilst keeping the rest of the team and participants safe. We later found that this participant had experienced altitude illness on previous trips which had not been disclosed to the medical team. A consideration for this participant would have been prophylactic acetazolamide and very careful monitoring throughout the event if we had been aware of this.

The definitive treatment for HAPE is descent. HAPE can vary in degree from mild to potentially fatal, and a timely descent is essential in moderate to severe cases. A Gamow bag can be used as a temporary measure to simulate a descent until more definitive means to descend can be arranged. Mild presentations may respond to additional rest days, increasing fluid intake and reducing the speed of ascent, however careful monitoring is essential.

Case 2 – Acute Mountain Sickness (AMS)

The second case was mild altitude sickness in a young and very fit runner who ascended quickly from 2600m to 3444m on day two of the trek. This caused the candidate to experience severe headaches and nightmares, with difficulty sleeping. We managed the case conservatively and advised the participant to take time ascending slowly and steadily. It can be very tempting to walk quickly and arrive first at the destination, but the only prize in this case was a headache and mild case of AMS.

Gastroenteritis in Camp

An outbreak of gastroenteritis can prove difficult to manage in this remote setting, and puts participants at risk of dehydration and altitude sickness. Despite advice surrounding eating out and ensuring preventative measures such as optimal personal hygiene and sanitation, there was an outbreak early on in the 2017 event. The importance of handwashing is drummed into everyone throughout the expedition; with hot water and soap provided at the entrance of all tea houses and prior to meals.  Sharing food is discouraged and the use of serving spoons and individual plates for snacks is strongly encouraged. Campylobacter is a very common cause of gastroenteritis in Nepal, with multiple cases of resistance found in recent studies. With good sensitivity to the antibiotic azithromycin, we made sure to carry ample supplies in our medical kits. During the 2017 race we had an outbreak of at least ten participants suffering from diarrhoea and vomiting. As a result, I spent many evenings attending to patients with loperamide, azithromycin, and oral rehydration, as well as arranging for repatriation of some to Namche Bazaar.

Working on the Everest marathon was an amazing and enriching experience; highlighted by spectacular scenery, the personal and professional challenges of working in a low resource setting, and making great friends along the way. The journey tests you both physically and mentally, and you learn a great deal about yourself.

Take-home Messages

1. Actively monitor participants for subtle signs of altitude illness and initiate early management.
2. Encourage open and honest conversations regarding previous illness at altitude.
3. Have clear isolation protocols in place to prevent the spread of diarrhoea and vomiting throughout a camp.
4. Reflect on the expedition, keep clear records and ensure that a debrief takes place to discuss medical cases and changes required for future trips.

The post At the Height of Expedition Medicine; The Mount Everest Marathon appeared first on Adventure Medic.

How does one survive without fresh air for 14 days? Dr Wood recounts her experiences of quarantine between the four walls of her hotel room in Perth, Australia back in the summer of 2020.

The year is 2020. To obtain the luxury of a Coronavirus-free life you must first complete a challenge beyond any Hunger Games writer’s wildest dreams. Close your eyes. You are in a cave. A deep dark cave. The cave has a door. You step inside. The door closes firmly behind you. The quarantine commences. You are told to only open this door three times a day when a knock comes. This knock signifies a food delivery. You peer around the door frame to find a brown paper bag tightly wrapped up on the immaculate carpeted hotel floor. You snatch the parcel up, and seal the cave up again swiftly in one breath. The tepid contents of the “government approved” polystyrene containers will soon become the highlight of your days in isolation. Sealed within four walls, you can only dream a waft of that sweet tropical air outside. You will countdown the seconds, minutes, hours, and days until that fourteenth day arrives. This is quarantine.

Preparation

As one can probably imagine, the paperwork hoops requiring jumping through are plentiful and of variable difficulties. My top-tip is start early! A very helpful guide to follow is “Thinking of Straying to Straya? The Definitive Junior Doctors’ Guide to Living and Working in Australia” (article published by Adventure Medic in 2020) which I referred to on numerous occasions!

With flights booked and hotel reserved, the challenge now remains to obtain that all-important negative PCR Covid-19 test within 72 hours of departure. Numerous organisations offer this service; but with variable turnaround times. Posting this box containing the most valuable cotton-bud of your life was, without a doubt, the most stressful part of the whole process. 48 sleepless hours later and that all-important email arrived – a negative PCR test result – my green light to go!

A Covid-19 precautionary flight

Informed that we would be placed on a separate part of the plane, a small part of me hoped this may be that heavenly place that one is forced to walk through first when boarding. Alas, no business-class today. But, despite rumours of ‘restricted services’ due to the pandemic, I was pleasantly surprised with both the quality of the in-flight entertainment, and the food and drink service – that strangely exciting novelty that comes with long-haul flying. However as always; crooked necks, swollen feet, and that mind-bogglingly empty yet bloated feeling plagued me. Extended toilet trips, calf raises and lunges down the aisle became the new normal.

But at last. Touch down in my new home for the next year! I leap out of my seat, remembering what it felt like to extend my knees finally…only to be greeted with “all passengers please remain seated for a further hour whilst we wait for the police escort”. And soon enough, the entirety of Western Australia’s police force it seemed turned up; ready for action. Once escorted through various checkpoints in the airport, we made it out into the blazing sunshine and met by numerous flashing police cars which would guide us to our hotel and final destination for the next 14 days.

Room 628

I stepped in, closed the door behind me, and took a deep breath. Mentally preparing my fate for the foreseeable future. Despite being three days behind on sleep and feeling dehydrated to the point of nausea, I couldn’t help but be that excitable child just discovering the mystery of hotel rooms for the first time. I opened open every drawer, every cupboard, the fridge, assessed the bathroom facilities, before finally settling on the realisation that all hotel rooms really are the same.

A cold shower resurrected me after the long journey, but I still swooned over the ever-so tempting cool waters below; the hotel’s glimmering swimming pool shone in the evening sun directly below my window. I was determined to still live the next 14 days vicariously through those people outside – one of many bizarre mindsets I took on during this period.

Sure enough a knock came at last. I peered out and grabbed that brown paper bag without a breath leaking out into the hallway. As the days continued I realised I was lulled into a false sense of security on that first night by a gourmet spaghetti dish delivery. From then on, the reheated frozen vegetable medley (boiled until zero nutritional contents remained), or the tinned mushroom in gravy with rice would become prominent features in my diet. Sadly, food soon became one of the only things to look forward to in the day. But I found myself in an extremely fortunate position to have possibly the most generous family and friends who delivered ‘care packages’ of food and exercise equipment to fuel my 14 days. Otherwise I think I would have lost the plot.

Activities For Sanity

Day one consisted of a morning of home-making. Unpacking, interior decoration, personal touches etc. As the days rolled on it became clear that a structured routine would be key for survival.

Schedule: Wake up, breakfast, catch up on the latest news and drink numerous cups of tea. Allocating life-admin tasks to one or two per day meant I actually made progress. Ordering a sim-card and setting up a bank account for the rest of my stay in Australia were primary tasks to get sorted and are very achievable in this time. Looking for cars and arranging viewings for flats also became a daily occurrence.

Exercise: Having the bike set up on the turbo-trainer was a great addition to the room for me. Pedalling along to a podcast or doing a spin class used up time, and tested the air-con out! A daily workout, mixing it up and FaceTiming friends to sync workouts also kept me motivated. A skipping rope was also an extremely worthwhile piece if kit to pack and is small and lightweight in the luggage. However, after multiple skipping sessions I’d like to take this opportunity to personally apologise to room 528 (presumably below me!). Daily yoga practice and resistance band stretching also became a great way to unwind in the evenings.

Facemasks and FaceTime: A myriad of facemasks (think beauty; not PPE), feet exfoliation products, and bath-bombs proved again a great addition to the suitcase. An evening bath with a book made the stay actually feel like a holiday. And as soon as the afternoon approached and the UK stirred the time just flew; with schedule of people to talk to finally! With a cup of tea in hand, catch-ups with old friends, Zoom quizzes, and group calls all became crucial part of my daily routine and helped maintain my mental health. A daily call to my family gave me a sense of motivation and pride for being another day through this peculiar period. Podcasts, music, books, doodling, updating my CV, and sorting through old photos also provided a therapeutic release from the four walls surrounding me.

Freedom

As the double-figure day approached, there only remained one long weekend between me and the tropical paradise I’d been staring down at for days. I had a sudden overwhelming feeling that it had not just been a dream. I’d done it. I was a survivor. I opened the door, and stepped outside.

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In 2019 Tessa travelled to Nepal to work at the International Porters Protection Group (IPPG) rescue posts at Machhermo and Gokyo, in what turned out to be the final season for these clinics. Tessa describes two interesting cases she encountered there as well as her experience of witnessing the beginning of the end of these renowned establishments.

Setting the scene

Seeing your knickers frozen on a washing line is perhaps the best light relief to hard days

Since I was little, I have wanted to be two things; a doctor, and outdoors. By the time I got to university I gravitated towards the hiking club and chose optional study modules related to altitude. I undertook the Diploma in Mountain Medicine (DiMM) in 2014-15, during a couple of years out following foundation, before deciding on GP training. GP seemed a good “all-rounder” option, perhaps subconsciously allowing me to leave one adventurous foot in an open door.

I’d heard about the International Porter Protection Group (IPPG) whilst still a student and was really drawn to their work.  Aside from the intrigue I had towards altitude medicine, the story of their work was fascinating.

Throughout the Everest region there are caves and boulders that hold a history that trekkers would not perhaps be so proud of. Whilst western visitors would sleep in their tent or local lodges, the porters carrying their luggage (or even the materials used to build said shelters), would have to use these caves and boulders as their best option for cooking and sleeping quarters.

This happened until alarmingly recently. Cue the founding of IPPG, in collaboration with Community Action Nepal.

For 17 years, IPPG – supported by donations – ran two rescue posts offering affordable food, accommodation and, if needed, very cheap medical care from volunteer doctors.  These simple buildings made of stone and timber with corrugated roofing, served the villages of Machhermo (4,400m) and Gokyo (4,700m) and provided a significant upgrade in shelter and care for porters and trekkers alike.

Back to me at low-altitude university. I hoped I might be able to volunteer with IPPG for my elective and was gutted when the dates didn’t work out.  I would have to wait several more years before everything would line up and I could finally apply.  The wait was worth it, as having some experience under my belt gave me more to offer.  When I was offered a place all I had to do was convince my wife and pet guinea pigs that it was a good idea. They agreed, and in September 2019 off I went.

A friend of mine (Hywel) is an audio producer and, over a coffee before I left, he began to hint that it might be exciting to record the adventure and turn it into a podcast.   As I prepared to go, we did some trial runs of recording audio diaries and, convinced it would be unobtrusive and easy enough, I decided to record the journey. A year later we have a ten-part podcast documenting what happened.  Hopefully it captures the wonder and magic of going to such a special place, but also the unexpected tragedy and drama that unfolded.  It turned out to be ‘the last season in Nepal’ for IPPG, which seemed a fitting title for the podcast.

Kathmandu was the first leg of the journey, landing us in the monsoon season of a vibrant and hectic city. The transition from this, via one of the most dangerous airports in the world – Lukla – to mountain life is a swift and stark shock to the system. Upon landing you have several days of walking (and acclimatising) to the sound of yak bells and the gentle chatter of your companions, before you reach your home – the Machhermo post.

There is a simplicity to life at altitude.  Especially after the busyness of one’s life and the endless preparations and re-organisation of socks and thermals pre-departure.  The toilet is outside (I take you to it on one episode of the podcast), and the water comes to the rescue post via hose pipe from further upstream (another episode of the podcast focuses entirely on my obsession with water). You have a stove to keep you warm, and space in the “sun room” to hold the daily (free) altitude talk which trekkers, porters and guides attend. Education about prevention and appropriate management of altitude illness was a really important part of IPPG’s presence in the area. In terms of work-life, the surgery is a room with all the basics you need to treat anything from colds to head trauma. You live there with a handful of like-minded volunteer doctors and local staff.

Living at altitude brings pain in the form of cold and lack of everything you take for granted at home, but pleasure in its simplicity. It is an environment that lets you experience beautiful nature, from which your work emerges in the form of patients presenting with a full spectrum of conditions. We saw everything from altitude sickness to abscesses. Our caseload even included a local cow (true story). The environment can send you a patient at any time:

Case 1

I’m tucked up in bed at 1am in Machhermo and am awoken by our post manager Kanchha to attend one of the lodges to see a trekker. I quickly put on extra layers to keep me warm for the walk under crystal-clear night skies to the lodge and, potentially, the long night ahead.

The trekker had ascended to Machhermo from Dole the day before, and felt reasonably well on arrival. A few hours later he thought he was coming down with a cold, and went to bed at around 8pm. At 11pm he awoke feeling breathless and coughing with a headache. Help was called for an hour or so later when things were worsening.

On my arrival the man, about 50 years old, is propped up in his bed. He is drowsy but rousable and looks worryingly grey and breathless. Next to him on the floor is a plastic bucket which he has been coughing into – a layer of rust-coloured sputum at the bottom. His breathing is noisy – crackles audible without a stethoscope, and he is centrally cyanotic. We get the oxygen concentrator going. The batteries on these amazing portable devices last about 1 hour when they’re going full tilt (delivering up to 6L/min). Luckily, we have a spare but he’s going to need more than that given the hours left until daylight, when you can plug into solar power. There will need to be a constant system of recharging them and shuttling to and from the rescue post. I also administer nifedipine, acetazolamide and dexamethasone.

The trekker’s improvement with treatment was dramatic over the next couple of hours, both symptomatically and in terms of his respiratory rate and oxygen saturations, and we were able to reduce the oxygen flow gradually. The trekking guide arranged for a helicopter evacuation, and when it arrived at around 7.30am he was able to walk, albeit slowly and with support whilst on the oxygen, to the landing spot – very satisfying.

What struck me about this case was how text-book it was: the fairly quick onset after arrival at new altitude, cyanosis, rust-coloured sputum (which we hadn’t seen in any of our other HAPE cases so far) alongside the incredible response to oxygen (simulating descent) and nifedipine. This was altitude medicine in action.

Case 2

This time we are in Gokyo, it is evening and already dark, around 8pm. A guide arrives at the rescue post with two female trekkers. One has symptoms of moderate-severe acute mountain sickness. The other, 38 years old and usually well, has visual loss. They have come to Gokyo via the Renjo La (a pass at 5,350m), having started the day at Lungden at 4,380m, but had not had the usual additional rest day on the way up from Namche Bazaar. The trekker describes acute onset of blurred vision when nearing the top of the Renjo La which progressed until she could barely see a hand in front of her face. She had to be guided down to Gokyo, hence their late arrival time. She thinks the vision has improved a little since then but she is understandably very scared. There are no other symptoms of altitude illness. She is a contact lens wearer but has no other relevant medical history. On examination, her cornea is cloudy but there are no other abnormalities and her observations are as expected for the altitude. We treat her for suspected hypoxic corneal oedema, the risk of which is increased by wearing contact lenses. Luckily, the trekker had removed her contact lenses on the way down, thinking they might be part of the problem. By descending the 500m or so from Renjo La, her treatment has been started, so we continue aiming to improve the oxygenation to her cornea by placing her in the hyperbaric chamber (PAC). As the cornea gets most of its oxygen supply from the environment rather than a blood supply, we felt that enriching the environmental oxygen as much as possible would be more beneficial than administration via nasal specs, although we did need to alternate the two as she was only able to tolerate the PAC for short stints due to claustrophobia.

By the morning, the milky appearance of her cornea had improved to a certain extent, and her vision had vastly improved so that she was now able to read text and move around unaided. She was evacuated down to Kathmandu to expedite descent and recovery.

This case made us think on our feet, it was quite unusual and there is limited literature available on best management for altitude related hypoxic corneal injury. As with other altitude related conditions, descent or simulating descent with oxygen treatment until descent is possible is often the answer.

The last season in Nepal

The trip had two really upsetting moments for me.  The saddest was the death of a trekker, which I’ll leave to the podcast to explain.  The other was the quite sudden realisation that IPPG was facing a serious threat to its future.  During our time there it would lead to the demise of their work in Nepal.

One afternoon in Gokyo, we noticed a neon sign had been put up on one of the local lodges, offering health care. There had been rumours but nothing concrete until this moment when a rival clinic arrived, seemingly out of nowhere.  It was a private clinic owned by a private hospital in Kathmandu, with links to a helicopter company. Heli-vacs are fairly infrequent occurrences, which we only arranged for urgent cases. Not only is there great expense to the patient and their insurers, but they also pose a great risk to the helicopter pilots, and passengers, due to rapidly changing weather in the high-altitude mountain environment.  The first time I advised helicopter evacuation for a patient, my heart was in my mouth as it hummed and bounced low to the ground so as to avoid a descending fog. It is also foreseeable that, as a result of the clinic’s links to both the helicopter company and the private hospital in Kathmandu, the medics working there might feel pressured to arrange more treatments or evacuations than are necessary. If helicopter evacuations become more common, insurance prices could sky-rocket, ultimately having a detrimental impact on the whole trekking industry. We will see what happens in the future.

The arrival of this clinic meant that there was a Nepali company and a western charity both offering the same service. The charity has provided stable employment to Nepali staff for many years, and the volunteer doctors have experience of working at altitude.  The new private clinic has a relatively junior doctor working there, covering both day and night.  The locals who IPPG employ have relied on them to put their children through education, and the porters who have used the service for years have received next to free health care.  Whilst I am very aware that I’m a westerner commenting on a local issue in another country, it’s devastating that the upshot was that IPPG were no longer allowed to operate, and the private company is now the only medical support there. I really hope the new place can retain some of the IPPG ideals of porter rights and welfare, and continue to provide affordable yet good quality health care to those porters, guides, locals and visitors in the area.

It wasn’t until a couple of weeks after we got home that we received the official confirmation that the permission for the rescue posts to re-open had not been granted, spelling their forced closure and the end of an era for IPPG’s work in Nepal.

IPPG has faced several challenges over the years, from maintaining a steady stream of funds to keep the charity sustainable, to keeping abreast of an ever-changing political climate and dealing with the new medical council registration requirements for foreign doctors at short notice. However, through hard-work, support from CAN and good relationships with supportive locals, IPPG was able to continue with its valuable work, until this most recent insurmountable hurdle.

Since the forced closure of the rescue posts, the COVID-19 pandemic has pretty much wiped out two trekking seasons, and is likely to do the same to the upcoming seasons in 2021. The full impact of the absence of IPPG rescue posts in the area may only come to light once trekkers can return. The work of Community Action Nepal, however, continues and is more important than ever as these mountain communities cope with yet another disruption to their usual industries. You can support them (https://www.canepal.org.uk/howtohelp). Thank you if you do. Their website also contains details about volunteer opportunities.

Other options going forward to help support porters include KEEP (Kathmandu Environment Education Project), a non-profit organisation who run a porters clothing bank and regular education programs for porters about their rights and welfare, plus a lot more. See their website for more details on how you can help.

If you’re heading out to Nepal to trek or climb, use a reputable company and ensure they have a porter welfare “code of conduct” or similar. A reputable company should be able to answer any questions you have about what weight the porters are allowed to carry, their pay, where they will sleep and eat in the evenings and what insurance is provided for them.

The very point of adventure is that you don’t know what it will bring. For me it brought great peaks of mountains and happiness, and great troughs of cloudy valleys and changing times, all of it enriching. Seeing your knickers frozen on a washing line is perhaps the best light relief to hard days. That and the company of Kanchha, Samip and fellow volunteers Dan, Deb, Edi, Jen and Shankar, drinking steaming cups of sweet tea whilst watching as the sun rises over the mountains and glistens on the frosty turf. These are the things that I think of when I’m driving to the surgery on a dark and damp winter morning.

If you have the opportunity to take part in any similar trip, I couldn’t urge you more strongly.  Despite the difficult and emotional moments, I would leap at the chance to go again.

The associated podcast is less than 1 hour combined – we edited it down considerably to keep it light and brief.
The Adventure Medic also has a news article about the closure of the Machhermo and Gokyo rescue posts.

The post The Last Season in Nepal appeared first on Adventure Medic.

Dr Stuart Allan combines his day-job as a GP in Cumbria with teaching on the UK Diploma of Mountain Medicine, and runs…a lot! Having experienced first-hand the challenges in optimal hydration whilst completing in epic races such as the Frog Graham Round, Bob Graham Round, and the Ultra-Trail du Mont Blanc (UTMB), Stuart has learned through practice and subsequent research the truths behind hydration for optimum performance in endurance events.

Recently, I worked collaboratively with Jeremy Windsor, my faculty colleague on the UK Diploma of Mountain Medicine, as well as Edi Albert and colleagues from the Healthcare in Remote and Extreme Environments Program at the Tasmanian School of Medicine on a practical management paper discussing hydration during high altitude endurance events. It has recently been accepted for publication in the Clinical Journal of Sport Medicine. This project was hugely insightful and was excellent to carry out during lockdown.

The paper discusses the physiological changes in water homeostasis with changing altitude. Building on this it also examines the effects on poor hydration at altitude compared to sea level. We also investigated the controversial debate between “ad libitum hydration vs programmed hydration”. Both sides have their passionate supporters: read the paper to see which side our team agreed with…or maybe both have validity! We made recommendations on hydration strategies in high altitude environments and my colleague Larissa Trease will be discussing these in a follow-up article.

I am briefly going to discuss the myths around hydration at altitude in endurance events. This has been an interest of mine for many years after reading a plethora of inaccurate information on the internet, and it appears that I am not alone in my concern ¹. The controversy is over a condition called exercise-induced hyponatraemia (EAH), caused by over-hydration which can and does kill athletes ². Fluid consumption must be carefully balanced to maintain adequate hydration for athletic performance and health. For those interested in providing medical support in endurance races of any distance, practice guidelines have been published on this subject and should be essential reading before being involved in endurance events of this sort ³.

Myth 1: Maintaining body weight through drinking (euhydration) is essential to maintain performance

One study showed that half of the top 10 finishers in one 161km ultramarathon lost more than 2% body weight by 90km ⁴. Marty Hoffman and his colleagues also showed that athletes should ‘allow for weight loss up to 4–5 % of body weight during extended periods of exercise’ ⁵ ; largely due to weight loss from the energy gained from glycogen and other substrates. It is also worth mentioning however, that weight loss of up to 8% has not been shown to lead to adverse clinical or performance outcomes ⁵. Killian Jornet, the elite ultarunner, reportedly drank three litres of Coke and ate two Nutella and jam sandwiches in the 2008, UTMB (168 km), and won the race! This is obviously an extreme example relating to an athlete who by his own admission, has made numerous dietary-related mistakes in his sport, but it does call into question the perceived wisdom as well as the scientific basis behind hydration and performance.

The key message here is that weight loss should be expected during endurance events and should not be a yardstick for measuring performance. In conclusion, 2-4% weight loss is a reasonable measure of ‘euhydration’ given energy expenditure. With regards to altitude, it is worth reflecting that hydration status in mountaineering appears not to be related to summit success ⁶, and the risk of developing high altitude illness (HAI) is cut down by reducing total body water ⁷.

Myth 2: By the time the athlete develops thirst, it is too late and performance is affected

This is a statement I have often heard during endurance events and on sports internet sites. However, thirst is and has always been a safe and effective physiological mechanism to maintain adequate hydration ³. In our paper, our clinical recommendation is to use thirst as the driver behind an athlete’s approach to hydration – i.e the ‘drink to thirst’ hypothesis. But we are also aware that HAI may impact on an individual’s judgment and their ability to drink (e.g. confusion, nausea). In addition, access to adequate clean water supplies at altitude might also reduce the risk of over-hydration.

Myth 3: Athletes must take electrolyte supplements during exercise

There is good evidence now to support the avoidance of excessive sodium supplements in endurance races as well as their use at times of ‘high thermal stress’ ^4,8. Sodium supplementation has been proven ineffective in correcting the hyponatraemia caused by overhydration ⁹, however that being said, sodium supplementation may be required if total body weight loss exceeds 5% ³. It has also been shown that sodium-rich electrolyte supplementation is ineffective in alleviating exercise-related muscle cramp ¹⁰. The bottom line is that excessive or indeed regimented sodium supplementation is not required.

Clinicians must also be aware the potential adverse effects on renal and salt metabolism caused by consumption of acetazolamide and anti-inflammatory medications (e.g ibuprofen) ^11,12 which could subsequently have an impact on acclimatization and development of HAI.

Myth 4: Drinking regularly and without the driver of thirst (i.e. overhydration) is safe and inconsequential

This myth brings together some of the points made above. It’s sobering to realise that hyponatraemia is associated in endurance events with a 23% incidence (e.g Ironman Triathlon distances), and with a growing incidence at shorter distances ¹³. So, drinking beyond thirst is unnecessary and may in fact be detrimental.

Clinicians working in endurance events at high altitude should be aware that EAH has similar presenting symptoms and signs to AMS (nausea), HAPE (pleural effusion and breathlessness) and HACE (seizures, cerebral oedema). This further challenges medical assessment and decision making surrounding medical management. As always, question what you read, consider challenging perceived dogma, but above all enjoy the process of learning and adventuring!

References

1. Martin D. Hoffman, Theodore L. Bross III & R. Tyler Hamilton (2016): Are we being drowned by overhydration advice on the Internet?, The Physician and Sportsmedicine, DOI: 10.1080/00913847.2016.1222853
2. Lebus DK, Casazza GA, Hoffman MD, et al. Can changes in body mass and total body water accurately predict hyponatremia after a 161-km running race? Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 2010;20(3):193-9. doi: 10.1097/JSM.0b013e3181da53ea [published Online First: 2010/05/07]
3. Bennett BL, Hew-Butler T, Hoffman MD, et al. Wilderness Medical Society practice guidelines for treatment of exercise-associated hyponatremia. Wilderness & environmental medicine 2013;24(3):228-40. doi: 10.1016/j.wem.2013.01.011 [published Online First: 2013/04/18]
4. Hoffman MD, Stuempfle KJ. Hydration strategies, weight change and performance in a 161 km ultramarathon. Research in sports medicine (Print) 2014;22(3):213-25. doi: 10.1080/15438627.2014.915838 [published Online First: 2014/06/21]
5. Hoffman MD, Pasternak A, Rogers IR, et al. Medical services at ultra-endurance foot races in remote environments: medical issues and consensus guidelines. Sports Med 2014;44(8):1055-69. doi: 10.1007/s40279-014-0189-3 [published Online First: 2014/04/22]
6. Ladd E, Shea KM, Bagley P, et al. Hydration Status as a Predictor of High-altitude Mountaineering Performance. Cureus 2016;8(12):e918. doi: 10.7759/cureus.918 [published Online First: 2017/01/14]
7. Bärtsch P, Pfluger N, Audétat M, et al. Effects of slow ascent to 4559 M on fluid homeostasis. Aviation, space, and environmental medicine 1991;62(2):105-10. [published Online First: 1991/02/01]
8. Hoffman MD, Hew-Butler T, Stuempfle KJ. Exercise-associated hyponatremia and hydration status in 161-km ultramarathoners. Med Sci Sports Exerc 2013;45(4):784-91. doi: 10.1249/MSS.0b013e31827985a8 [published Online First: 2012/11/09]
9. Twerenbold R, Knechtle B, Kakebeeke TH, et al. Effects of different sodium concentrations in replacement fluids during prolonged exercise in women. Br J Sports Med 2003;37(4):300-3; discussion 03. doi: 10.1136/bjsm.37.4.300 [published Online First: 2003/08/02]
10. Hamilton R, Bross T, Hoffman M. Hydration Guidelines During Exercise: What Message Is the Public Receiving? Wilderness & environmental medicine 2015;26:e3. doi: 10.1016/j.wem.2015.03.009
11. WADA. Prohibited list https://www.wada-ama.org/sites/default/files/resources/files/2016-09-29_-_wada_prohibited_list_2017_eng_final.pdf2017 [accessed 13 September 2020.
12. Lipman GS, Krabak BJ, Waite BL, et al. A Prospective Cohort Study of Acute Kidney Injury in Multi-stage Ultramarathon Runners: The Biochemistry in Endurance Runner Study (BIERS). Research in Sports Medicine 2014;22(2):185-92.
13. Rosner MH. EXERCISE-ASSOCIATED HYPONATREMIA. Transactions of the American Clinical and Climatological Association 2019;130:76-87. [published Online First: 2019/09/14]

Images provided by Stuart Allan and Shona Main

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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

Phil Jackson

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.

Further Information

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.

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As well as a consultant anaesthetist and intensivist, Jeremy Windsor has been involved in climbing and mountaineering expeditions for more than twenty years. In 2007 he climbed Mt Everest as part of the Caudwell Xtreme Medical Research Expedition. He has completed an MD in high altitude medicine and written more than a hundred abstracts, book chapters and research papers on the subject. In this article, Jeremy questions how transplant patients’ physiology is affected by high altitude, and the steps that can be taken to mitigate against the risks in these patients.

Until recently, many of those with chronic medical problems were discouraged from heading to the mountains. This has now started to change. People with a range of conditions – from diabetes mellitus to epilepsy and asthma – have now found ways to manage the challenges of the mountain environment with enormous success which has only encouraged many others to do the same. From a medical perspective, initially this is a very positive step as it encourages expedition medics to gain new skills and knowledge, whilst facilitating a greater number of people who are safely able to enjoy the wildest of places.

I began pondering the management of complex and chronic medical problems on expeditions recently when I was prompted by an email I received from a keen hillwalker who wanted to know whether her recently transplanted kidney was going to be at risk during a forthcoming climb of Kilimanjaro (5895m). In particular, after many years of hypertension she wanted to know if her blood pressure was going to be a problem.

Unfortunately, like many aspects of mountain medicine, there exists only limited evidence  on which to base important decisions in a variety of very specific situations. However in recent years there has been a growing number of published case reports that show healthy and well prepared solid organ recipients have ventured successfully to high altitude.

In order to answer the specific question about the impact of altitude on the blood pressure of those with a transplanted kidney there is published work that sheds some light. Last year a case study in High Altitude Medicine and Biology highlighted the experience of a 57 year old man who 12 years earlier had received a cadaveric transplant after developing end stage renal failure from membranoproliferative glomerulonephritis¹. More recently, he had been diagnosed with hypertensive cardiomyopathy and treated with losartan and doxasozin. His recovery from surgery had been very good – not only was he back in the mountains within 6 months but he had resumed mountaineering just a year after his surgery. Since the transplant he has climbed above 6000m on several occasions and reached a maximum altitude of 6500m without any difficulties.

Andy Luks’ article on high altitude travel following organ transplantation can be found here. It contains lots of fascinating information – not least, the increase in risk of basal cell (x10) and squamous cell (x65) skin cancers amongst organ recipients. This is widely believed to be due to the immunosuppressive medication that is required to prevent organ rejection. Given high levels of UV radiation at altitude it is vital that those taking these drugs cover up and regularly apply high factor (50+) sunscreen to exposed areas of skin.

Non invasive blood pressure measurements were obtained regularly; both at sea-level and at high-altitude in Nepal (between altitudes of 2860 – 4300m). One to two measurements were taken per hour – during sleep, rest and exercise – over the course of approximately 48 hours. Systolic blood pressure did not increase with altitude exposure and more importantly the researchers were unable to identify what they described as “critically high systolic blood pressure measurements (>180mmHg)” at either sea level or high altitude. However, diastolic blood pressure did increase with altitude and rose from a mean of 70.3mmHg to 71.6 (2860-3440m) and 76.7 (3440-4300m). Digging a little deeper, this was largely due to a rise in nocturnal diastolic blood pressure. In fact, mean nocturnal diastolic exceeded daytime measurements. This phenomena is known as “reverse-dipping” and at sea level can be associated with poorer long term outcomes. Whilst the researchers commented that, “the short term significance of this phenomenon at high altitude is unknown”, the fact that it was short lived, of a small magnitude and only present at high altitude would suggest that a lasting effect was unlikely.

Whilst a single case cannot tell us how a future transplant recipient will cope with high altitude, it does show that it can be done safely and successfully. Using this knowledge as our starting point, we recommended a gradual progression to altitude, with exposure to easily accessible areas of moderate altitudes (2500-3500m) in the year leading up to the trip. This study also helped to address a few key questions that transplant recipients may have before going on expeditions to the high mountains:

1. Can I cope with the exercise?

The combination of years of chronic renal failure and major surgical procedures cannot be underestimated. There is no doubt that physical fitness will be affected. Starting small and gradually building up strength and stamina is vital. Two years on from the transplant, our trekker had made a good recovery and was already doing very well. She had been walking most days with her dogs and working with a fitness instructor at the local gym a couple of times a week. We recommended building longer hill days into her preparation and where possible, linking 2 or 3 days together. At the same time we encouraged her to start wearing the clothing, footwear and equipment that was going to be worn on Kilimanjaro. No kit should be traveling to high altitude if it’s not been used before!

Tacrolimus is commonly used to prevent rejection of transplanted organs. Getting the dose right can take time and close monitoring is required. Like many immunosuppressive drugs interactions are common. Drugs to aid acclimatisation should therefore be avoided. Spare immunosuppressive medications should always be taken to high altitude. This is particularly important with tacrolimus as preparations can vary significantly between different manufacturers, and finding the exact preparation to replace lost supplies may prove very difficult in the mountains!

2. Can I acclimatise?

Our trekker’s two previous trips to moderate altitude proved invaluable in this case. Kidneys play a vital part in the acclimatisation process and these prior trips to 3000 – 4000m altitude showed that the transplant could do the job. Rather than taking prophylactic medication which may interfere with the body’s natural acclimatisation process we encouraged the trekker to ascend slowly and take frequent rest days. The recommended ascent rate (500m per day and a rest day every 3 – 4 days) is only a guide and many people need longer. For Kilimanjaro, we recommended an ascent of neighbouring Meru (4562m) first and then a longer 10-day trek on the mountain itself. The Lemosho Glades route is a particularly good option for acclimatisation as it slowly circles the mountain and in the early stages climbs to a high-point each day before descending to lower altitudes to rest.

3. Can I minimise my risk of infection?

In order to prevent rejection of a transplanted kidney, the vast majority of recipients take lifelong immunosuppressive drugs. Whilst incredibly effective, these significantly increase the risk of infection which can be a real problem at high altitude. David Murdoch’s landmark study of 283 trekkers in Nepal revealed that a staggering 87% had reported symptoms of infection during their stay². Therefore in discussions with her transplant specialist we ensured that our patient was up to date with her vaccinations, prescribed antimalarial prophylaxis and had a “rescue kit” that contained antibiotics and instructions to treat the most common infections. In addition we followed Andy Luks’ advice and encouraged her to adopt the following hygiene measures:

1. Use boiled or bottled water only
2. Avoid ice in beverages
3. Do not share drinks with travel partners
4. Liberal use of hand sanitizer, particularly before meals
5. Avoid uncooked meats and vegetables
6. Avoid food sold by street vendors
7. Avoid fruits that cannot be peeled

With all these questions answered it was time to head to Kilimanjaro; safe in the knowledge of our training, preparation in altitude acclimatisation!

References

1. Travel to High Altitude Following Solid Organ Transplantation. Luks, AM. 2016. High Altitude Medicine & Biology. 17(3). URL: https://www.liebertpub.com/doi/abs/10.1089/ham.2016.0060
2. Symptoms of infection and altitude illness among hikers in the Mount Everest region of Nepal. Murdoch, DR. 1995. Aviat Space Environ Med. 66(2):148-51. URL: https://pubmed.ncbi.nlm.nih.gov/7726779/

📷 Images provided by: Alex Taylor, Instagram: @alex_expeditionmedic

Links

As well as his day-job and background in altitude medicine research, Jeremy is also co-founder of the Hathersage Mountain Medicine Festival and in 2018 launched the Anaesthetics, Critical Care and Mountain Medicine Fellowship at Chesterfield Royal Hospital.

And as if that wasn’t enough, Jeremy also runs his own website and educational Mountain Medicine Blog; ‘Surviving the death zone’; writing and publishing a regular articles covering a variety of interesting expedition medicine topics.

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Dr Stephen Fabes / ED Middle Grade / St Thomas’ Hospital

In 2010, Stephen took a rather large step off the medical conveyor-belt and embarked upon a six-year cycle-tour covering 75 countries and more than 53,000 miles; exploring the social context of health and disease through a blend of travelogue, memoir and human stories. Following the publication of his book, ‘Signs of Life’, he shares with us the difficulties he faced in returning home and how he overcame this to step back into the medical world.

In early 2016, my life – when I considered its objective facts – wasn’t looking so great. I was a thirty-something, balding, unemployed, single blogger, in debt to several friends, cohabiting with his mum. My credit card was maxed out and the Student Loans Company were sending me threatening letters as if they were about to send round bailiffs and repossess my shoes. For lunch I ate own-brand baked beans with alarming routine; the kind that taste like salty cork. I’d once been a junior doctor in a prestigious teaching hospital, surrounded by friends, in a city I loved. It was just hard to apprehend how it had all come to this, the spectre of loan sharks and scurvy.

Whatever the case, I supposed I only had myself to blame – myself and my entirely voluntary life choices. These are choices, I should add, that I mostly celebrate as plucky now, or at least reconcile as personally apt. There is no gnawing regret about the path I took, just a minor one: my blindness to its cost.

After medical school I skipped up the ranks in typical fashion and then spent two years happily in the process of Core Medical Training at Guys and St Thomas’ in central London. The other trainees, my friends, were about to reach up and grasp for the next hold on the towering wall of medical training, desperate for that dizzying overhang: Medical Registrar. I was excited about the prospect of greater responsibility too, but gradually other appetites felt overpowering. My greatest hunger of all was for uncertainty. I wanted a life less mapped out than my career ladder seemed to allow. And so I dared myself to leap away from the wall completely, hoping that I was still somehow attached, that the rope would hold, that I might swing into my old life once again should the adventures end, or not work out. The 5th of January 2010 was the day I blew up my life. I did so with the best intentions, and adventure on my mind.

It’s perhaps not important why I chose an adventure on two wheels. That cool January morning I was standing outside St Thomas’ Hospital, waving goodbye to colleagues, friends and family, sat astride a heavily loaded touring bicycle. With my new life contained in four bulging panniers, I was set to begin a journey around the world. I had no definite route or time frame in mind as I wobbled off across the hospital forecourt, tacking around tourists on Westminster Bridge. My only thought: “Whoa! It has begun”.

For the tale of the mountains, the dirt, and the wild ride I will refer you to my book, because I want to fast-forward now to another winter day six years on when I cycled back onto Westminster Bridge. I could just make out the huddled figures of my friends and family collected outside the hospital, this time to welcome me home.

After hundreds of nights camping in ditches and by roadsides and after months of inching across assorted landscapes – from wind-lashed hills to hushed stretches of desert – I recognised in me a feeling of deep, intractable fatigue. I was tired of waking in my tent, confused momentarily as I mentally pursued my place on the planet. I missed the people who had once lovingly populated my life and I thoroughly missed my job as a doctor too (if you’re reading this at the blurry end of a night shift I appreciate that this may be an imaginative leap too far but I promise, it is possible). I was glad of the adventure, but glad that it was over, and glad as well to be home.

This feeling, of course, didn’t last. Over that final meandering year on the road, hosts and fellow travellers alike had often asked me about my future, curious about how I’d cope when I finally returned home. Often there was a hint of concern, an implication perhaps, that I was a condemned man. I too wondered if I’d become institutionalised to ‘The Road’. Perhaps I’d cope with coming home by going away again. Perhaps one morning, during my short commute through London, I’d simply go missing. My mum might receive a phone call: the police had found a panicked man meeting my description 260 miles away, trying to construct a lean-to in a ditch using his scrubs and some tourniquets.

Change was inevitable in my absence. Friends had moved on, sometimes literally, jetting off to work in Australia; or by virtue of partnering up, investing in homes and painting conservatories. More than one had a golden retriever and when I made jokes about joining the parish council there were awkward laughs, as if to say: actually, not a bad idea. Even Tony Skank, my rapping friend, was now Mr Wall, Head of Geography.

There are so many obvious pleasures and boons to adventures in foreign lands that it feels slightly redundant to list them here, preaching to the converted. While I came home somewhat deficient in CPD, I had an abundance of experiences and stories instead. Not that I was entirely deskilled either: I was a writer and a public speaker now, skills refined through necessity – both were means to earn money as I moved. Though my personality had been fairly well set by my departure, at age 29, my perspective had been altered quite radically, not least through visiting a host of remote medical projects along the way. I felt blessed for what seemed to me a glut of time, time to consider the forces shaping the landscape of health and disease. I travelled with no phone and I found that time without technology was time to ponder the world at large and the larger questions therein. It was more valuable than I could have guessed. I discovered that wild places are stirring in a way that Dalston is not. I knew that now, home again, I’d miss the meditative hum of my wheels, and those slap-happy days, days luxuriously or agonisingly long. But always so long.

After a few months I was back at work in St Thomas’ and knowledge resurfaced more easily than I expected. My mind though, had meandered unbidden for years, so at first concentrating on a particular task seemed a challenge too far. Determined that adapting was a battle I would win, and now with a phobia of routine, I made variety my new goal, squeezing in as much as I could, terrified any less would feel like sinking. Newly passionate about my work, I took locum shifts at two hospitals across three specialties, mixing up my shifts so that they fell on different days and across different hours. I consoled myself that I was free to book a flight to Lesotho at 0300 in the morning if the mood took me (it never did). I joined four dating apps and five running clubs, the former resulting in further singledom, the latter in half marathons in less than 75 minutes.

Here’s the thing: I had neglected to prepare for the fact that life would be quite different on my return. I’d left home in my twenties, unwilling to accept that opening some doors closes others. I was young and credulous. I believed the advertisers, social media blowhards and all the other glib correspondents of modern life when they said that you can have whatever you want free of charge. That’s bunk, obviously. You can’t have the light without the shade. Recently I attended a clinical skills course in Leeds. A refresher. Quickly, it was revealed that I’d spent years out of medicine to travel and investigate healthcare in remote settings. ‘You did what?!’ Envy was roundly declared. I didn’t mention the living-with-my-mum-part or the own-brand baked beans.

For many doctors, myself included, it can feel as though life is one long chain of accomplishments to tick off, and that you should 1. Keep ticking and 2. Be grateful that this tick-list exists. For a few doctors I know, the weight of parental expectations remains a millstone well into adulthood. But for any of us quitting a job, vacating a training number or taking voluntary erasure from the medical register  – ie. blowing up your life – will feel rather tricky to pull off. It takes a kind of deliberate stupidity: be naive enough to start and stubborn enough to finish.

But keep a portfolio. Ten years ago we were less fussed with evidence but there is no excuse today. Make the rocky road home less rocky, this is in your control after all and so much is not. Practicing as a doctor, advancing forward, must always involve a process of silent, self-directed pep talks whereby you muster the self-confidence to proceed. Some of us are more capable of this than others and clinical capability itself has nothing to do with it. Expect that leaving medicine or practicing overseas might knock your confidence for a while when you get home, so be kind to yourself and do whatever it takes to regain it. Perhaps that’s enrolling in courses, scribbling revision notes, or landing a less than full time job with good supervision and plentiful support. But if you’re anything like me, you will revalidate feeling only half valid to begin with.

I have been back at work for four years now and I have still not progressed in the official sense. I’m still a middle grade but I have a book out (I’ll mention this again soon, it’s a tic), I have balance where there was once momentum and I have a plan. Those I trained alongside, my CMT peers at St Thomas’, are now consultants and I am subordinate to doctors who were once foundation level on my team. I do feel a pang of anxiety about this apparent inertia every now and then, but I remind myself that this is as much to do with the culture of medicine: relentlessly forward pushing, competitive and at worst adversarial, than it is to do with me. (Plus: I have a book out).

It’s understandable, I suppose, during the greatest health crisis seen in generations, to want to be part of the effort on home soil – to feel purposeful, to do what you’ve been trained to do and, of course, so that you have some war stories in thirty years time when nobody will care if you went ziplining in Costa Rica. But this will pass, borders will reopen, adventure will propose itself once again and adventure medics will be required in many corners and on many expeditions. There will still be sacrifices to make if you jump from the wall: perhaps financial, perhaps career and perhaps personal. Whether you can square these depends on your dreams and desires, your circumstances, and much more besides. They’re particular to you, like the specialty you choose, or the people you love.

There are procedures in medicine that are technically easy but may be hard because you don’t think to perform them or don’t have the courage to do so. A needle decompression for a tension pneumothorax. A front of neck when you can’t intubate or ventilate a patient takes nerve. I would like to include here a bike ride around the world. I’m not advocating this specifically (the saddle sores for one thing) only suggesting that it’s worth seeing time away from the UK and formal medical training as a possibility. I could restate here my own lack of regret but I’m aware that we all like to think this way. ‘I make wonderful life choices’ makes life more palatable. I only know that I am grateful for getting what I asked for, uncertainty galore, and for the wild, surprising adventure which I recall from time to time, in the quiet hours, then yearn again and smile.

‘Signs of Life’, by Stephen Fabes was published in August 2020.

Available on Amazon: Signs of Life: To the Ends of the Earth with a Doctor

Stephen’s website: stephenfabes.com

The post ‘Dromomania’; the Uncontrollable Impulse to Wander or Travel appeared first on Adventure Medic.

Hannah Schneiders recounts her experience on expedition to the Namibian desert with Exile Medics. Here she reflects on a week of desert survival skills and what she has applied in expedition medicine and medical education since.

Exile medics provide multidisciplinary medical cover for ultramarathons in extreme environments, with their medical education previously limited to their annual conference. In 2018, after two successful “Jungle Schools”, they launched their first “Desert School”, which I applied for in my F3 year. The group was a strong 19-man team in total, with a healthy mixture of skills and grades: paramedics, nurses and doctors at all stages of their respective careers. Teaching was led by an ED consultant and an ST8 orthopaedic surgeon, and logistics were provided by Kaurimbi Expeditions. This course ran the week before the Beyond The Ultimate: Desert Ultramarathon; a 230km, 5-day multistage unsupported race; supported by Exile Medics. Seven of our group stayed on to provide medical cover for the ultramarathon, something I am looking forward to doing in the future.

Life in the desert

We set off into the desert in an enormous rattling off-road bus, nicknamed the “G-wagon”. Stopping first at Erindi Wildlife Reserve to watch animals feed at the waterhole as dusk fell. We camped in dome tents that were to be our homes for the next week, and become increasingly sandy. Our first night in the true desert was spent in a valley between great boulder outcrops that dotted the plain like heaps of marbles. The following three nights spent in a dry river valley, sometimes graced by elephants walking past, and we finished by camping at the foot of the Spitzkoppe rock. The days were scorching causing my water bottle to quickly become a blisteringly hot tap. The nights were surprisingly cool, making me grateful for my fleece and 3-season sleeping bag.

The whole structure of our day was a concession to the desert environment. We quickly got used to being permanently sticky and dusty- a natural consequence of not being able to wash off the multiplying layers of suncream. We learnt that at 52 degrees celcius in the sun (46 degrees in the shade), the middle of the day is best spent napping, playing cards and swapping stories. Desert school teaching was thus scheduled for early morning and late afternoon to avoid the hottest part of the day.

Desert School

Our teaching covered an extensive range of topics within expedition medicine and hostile environment skills; delivered using a range of  methods. We gained a sound theoretical knowledge base and learnt practical skills applicable to the environment, the race and to future expeditions.

Skills-based Learning

It soon became clear that competitions were a successful teaching technique, although there were no winners in the dismally dry water collection race! One such team-based challenge was to design the safest and most robust base camp, focusing on hygiene and disease prevention. By reviewing each design we were able to recognise the importance of basics such as accessible hand-washing, with separate stations for toilet and kitchen areas. We also discussed the logistical challenges of patient-flow through medical tents, or quarantine tents (if required). These exercises demonstrated how expedition medics are often instrumental in preventing disease outbreaks in any camp. Another exercise involved designing the ideal medical kit to have on such an expedition. As a result I have a greater understanding of the planning considerations when designing medical kits in general; and specifically; the desirable and essential medications and equipment for a desert environment.

In the spirit of the ultramarathon the following week we had our own desert race in the form of a stretcher contest. Within twenty minutes, using materials from our kit or surroundings, we had to build a stretcher and put it to good use by carrying a team member across the line. Military bashas are heavier than lightweight tarps but they make excellent makeshift stretchers with their built-in handles, making carrying much easier. We then built a 12-foot outline of a body, again using any materials we could find. We used this to teach the other half of the group about sodium homeostasis, while they taught us about heatstroke. This resulted in an embarrassing moment of head-scratching over the precise mechanism of sodium homeostasis, but with a bit of help from those who had recently completed MRCP Part 1, we got it sorted!

Model building became a recurring theme as a useful and fun way to learn together in group tasks. One morning we set off to recce a 1km radius around the camp, returning with intel to build a 3D model of the area, using this to work through evacuation scenarios. I found this very useful, learning how to use pacing and contour line sketches to bring sound topographical information back to base for analysis.

The expedition medicine side of the course culminated in a night-exercise rescuing a lost person. One of our members mysteriously failed to return from watching the fiery sunset over the Spitzkoppe rock. As a team, we worked out how to safely and efficiently sweep and search an area whilst remaining in communication. Once we found the casualty, we split into two teams- ’clinical’: assessing the patient, initiating treatment and carrying the stretcher, and ‘operational’: ensuring the safety aspect of the rescue with headcounts and sweeping the route ahead for hazards. This exercise highlighted the necessary balance between leadership and teamwork required in a rescue call-out. We were all capable of showing both these characteristics in a crisis, perhaps used to assuming these roles in our day-jobs, and were keen to demonstrate this in simulation. In the post-exercise debrief we explored  cooperative team working, leadership, navigation, search line strategies, and how to utilise individual skills amongst the team to achieve a common goal.

Knowledge-based Learning

As well as ample practical learning opportunities we had seminars and discussions on topics such as infectious diseases, environmental challenges, and mental health on expeditions. It is not every day you have a teaching session conducted on a circle of canvas x-frame safari chairs in the diminishing shade of canyon walls! In particular, I found the mental health discussion interesting and invaluable. Consequently I am now completing an online course on psychology in extreme environments. I am also becoming a Mental Health First Aider to better my knowledge and understanding of this vital topic which can sometimes be neglected in expeditions.

Experiential Learning

Studying desert medicine hands-on in the Namibian desert provided opportunities for some truly spectacular and off-piste learning. A snake enthusiast visited us in his van one day, energetically waving snake after venomous snake he had rescued. He told astonishing anecdotes of envenomations and near misses, how to avoid startling snakes, and allowed us to hold the “only mildly venomous” striped skaapsteker. We were also fortunate to spend some time with the local San bushmen, teaching us how to drill ostrich eggshell beads, use fire sticks and shoot their grass-stem arrows.  Dancing around a campfire with them under the desert night sky is something I will never forget.

The Hidden Curriculum – Unintended Learning

The breadth of the intended learning outcomes for Desert School was impressive and I came away with an incredible wealth of new knowledge and skills. As with all learning experiences there was a ‘hidden curriculum’, which refers to the unwritten, and often unintended learning, that students pick up. Our desert days also taught us how to: layer up for the cold nights, how to mend a puncture with rope fibres, how to cook a steak on a bush-braai, and how to survive in the scorching heat. We learned to tread carefully- especially after a night walk with UV torches revealing the shocking density of scorpions. These lessons will inform my future expedition work alongside my more formal learning.

Take-home Messages

I learnt an enormous amount in Desert School and will apply my practical knowledge and skills to future expeditions. Indeed, the extreme environment skill of how to check a latrine very carefully for scorpions has already paid off on a more recent expedition to Costa Rica. I also collected stories and invaluable life experiences from other medical professionals operating outside the standard NHS structure which will help inform my future career path. I was pleased to find I did not suffer in the hot desert environment – in fact, once acclimatised, I liked it! Desert school opened my eyes to the richness and value of using a range of small group teaching methods and engaging students actively and as creatively as possible. This has enriched my practice within the NHS over the past two years as a professional medical educator,  as well as support with future expeditions. I am hugely thankful for the opportunity I was given, the knowledge and skills I have gained, and the memories I have made. I plan to return to cover the BTU Desert ultramarathon in the future.

Original photographs by Hannah Schneiders, Caroline Hook and Jess Fitzgerald.

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The seventh continent leaves many spellbound with its captivating beauty and unique wildlife. Expedition doctor Jodie Sage shares the challenges and rewards of medicine as the ship doctor from her experience operating at both Poles. 

Working as a ship doctor in the Polar regions is both the same and completely different from working in the Emergency Department. Anything can change at any second, 24-hours a day. The big difference is that you are on your own. Completely. Yes, you may have a few first aid trained individuals. Yes, you may be able to coax a telemedicine link from the communications kit. But there is no slick trauma team to receive and package a patient ready for the all-seeing CT eye. There is no nurse around to flick that important ‘ON’ switch that you have forgotten as you struggle to suction that vomity airway and wonder why the sats bipper continues to plummet (if you’re lucky enough to have a sats probe). It is you, whatever kit is on the ship, and possibly a satellite phone – if there is signal, which for large parts of these trips, there is not.

I mulled these limitations over as I contemplated the patient in front of me, waggling their dislocated finger at me expectantly. Aboard a ship a considerable number of miles south of Argentina, it suddenly felt very different from my day job.

Despite it being an incredible opportunity, it is not a light undertaking. 

The lure of the elusive seventh continent is unique. It has icy mountains, vast glacial ice sheets, and incredible, other-worldly wildlife. It is enough to make anyone overlook the daunting prospect of being the only doctor looking after 200 people with variable degrees of health, in what can be a challenging environment for a host of reasons.

With the wobbly finger in mind, I thought about the kit I had to tackle the problem.

When arriving on the ship there should be a handover from the disembarking doctor. This doesn’t always happen due to travel logistics. I hadn’t met the previous doctor, but they had written me a handover note including their challenges, some tips, and equipment/medical shortages they had encountered. The reality is that with less than 12 hours before cast off, kit shortages are not easy to rectify unless the previous doctor has had the insight to arrange an order/collection of any necessary kit in the days leading up to docking. 

After checking in with the captain and meeting the rest of the team (usually a hello in the corridor as they make their way hastily to land), you are shown to your doctor’s office and left to it. 

It can feel a little daunting looking around the room. This shoebox has to accommodate everything from minor GP-type consultations to full-blown trauma, extrication and evacuation. It’s definitely not a resus room, but it has some of the equipment you’d find there. There’s a hospital bed, a trauma scoop, some bottles of oxygen, a dodgy manual suction device, and an AED which may or may not give you a 3 lead ECG display if you know which buttons to press in the right order. Everything else is stowed in cupboards in a haphazard sort of way, almost as if it had exploded across the floor in high seas and been packed away in a hurry… I got fairly good at catching bits of medical equipment as they slid off a surface mid-consultation. My first few minutes at sea in this windowless room gave me sympathy for the cupboard packer. The movement sent me green around the gills, a serious consideration if you are to spend any protracted time in the ship’s ‘hospital’ in high seas. 

To minimise time in the room at sea I review the equipment whilst docked: what there is, where it is, and how I can get it when needed. There are two grab bags that I repack. One for day to day landings and the other for ‘excrement vs. fan’ type scenarios. To be honest, even the day to day one has to have a degree of fan-type kit. I repack these in a modular priority system, with the ‘catastrophic haemorrhage’ pod immediately accessible,  airway kit underneath and so on. Then I go through ‘worst-case scenarios’ to ensure I have them covered. 

What is the worst-case scenario? Well, it firstly depends on how remote you are. Throughout the expeditions the ship’s distance to land varies, evacuation time ranging from 6 hours to 2 days. If the weather is poor, a helicopter/fixed-wing extraction may be off the cards, potentially putting you a bumpy 2-3 day sail across the Drake Passage to Argentina.  

In a funny sort of way, the worst-case scenarios aren’t necessarily the worst medical predicaments.

A cardiac arrest would be bleak, but it’s fairly black and white. With evacuation sometimes days away, there’s no ability to manage CPR for long periods. 

I think the more challenging cases are where there is diagnostic doubt. I once received a handover from an outgoing doctor who was a little traumatised having managed a bowel obstruction as possible gastroenteritis before diverting the ship and evacuating the patient. There had been several cases of diarrhoea and vomiting on board. At handover, the patient was in Intensive Care in a Southern American hospital and had been to theatre twice already. Hindsight makes these cases easy to judge, but with no investigations available and no help nearby it’s important to do a worst-case analysis. The added pressure to keep the ship on course for the benefit of the other 199 paying passengers also means it is important to be aware of the influences that you are under that may affect your clinical decisions.  

So what kit and medication do you actually want available to you for this finger?

The stock is governed according to the Regulations of the Shipping Inspectorate – this also meant most drugs were labelled in other languages!

As I examined this passenger’s finger, it was obvious my quick ED management of Nitrox, a nice manipulation and splint was going to take slightly longer than it would in my day job. Not to mention the language barrier that often comes with these cohorts of clients. 

Needless to say in ED I’d start with an X-ray, obviously not available on the ship… so what’s the risk-benefit of pulling a deformed MCP with or without a fracture as opposed to leaving a deformed MCP as it is?

Documentation and discussion with the passenger/patient are paramount. 

All of these passengers and crew are supposed to know the risk of the expeditions and they are given strict information about what medical care is available. 

I attempted to explain this scenario and the options to the patient who was keen to just ‘get it fixed’. This also aligned with my opinion of ‘it needs reducing regardless of whether it’s fractured’. MUA here we come. I had a ring block and he had the grit of his teeth. Clinically I felt it was reduced. Seeing him at dinner that evening reminded me of my less than good splinting and bandaging job. Adequate, but I still have no idea how ED nurses make them look so neat!

Another dimension of these jobs is the fact that you spend your days and evenings socialising with your potential patients. Someone who invites you to join them for dinner can be knocking on your door seeking your professional advice minutes after you’ve finished digesting dessert. It’s a dynamic that you have to be comfortable with and able to adapt to. You are always at work, so when that wine gets passed around, or you are offered drinks at the bar you have to remain able to deal with any medical emergency at any point, regardless of how insisting the passengers have become! 

You’re given a radio on arrival with a spare battery and it is your responsibility to ensure it is always charged, not dropped in water (!!) and you are always contactable, any time of the day or night. The ship requires staff throughout the night to keep it running, and patients on board are no different from those in their homes. Getting up for a wee in the night is as risky on a ship as it is at home for some people!  

The ship is a highly complex working machine. The engine rooms have more moving, bone-crunching parts than I care to look at, therefore trauma is a very real potential for the work crew. Add to this a cohort of passengers who may be on a frailer side and some high seas with the boats pitching side to side, a NOF or head injury/C spine injury is very possible, and often in awkward, narrow spaces. And we haven’t even left the ship…

The environment is the reason we chose to go on these trips, yet it is something most of the passengers (and possibly yourself) have never experienced before; cold exposure, the climate, wild animals, moving to and from speed boats, alongside all the communicable challenges of being in a confined space with a population from various countries and you have a recipe for significant medical problems.  

It’s not exciting but there is a very real chance that gastroenteritis or heavens above a highly infectious respiratory virus, could spread through the ship.

So what qualities do you need? 

You need to be a competent doctor; undaunted by the above. You should be happy to deal with emergencies independently, to lead and be the one who decides to change the path of a ship and cause a very expensive medical evacuation. You also can’t expect to be a good expedition doctor if you aren’t autonomous and competent in your day job. 

Alongside this, it is paramount that you’re a team worker and you’re happy to muck in with whatever is needed. You’re on a ship, in a confined space with a limited number of people. You have to be able to simply, ‘get on’. If things change you need to be able to adapt and help out where it is needed. The majority of the time you won’t be doing anything medical and you can learn a lot by making yourself available to the rest of the team and being ‘keen’. I learnt about servicing rifles, Polar naval navigation, sea-level rise, driving Zodiacs, and shooting flare guns on my trips.

You need to be able to manage yourself and not increase the workload of the rest of the team. It’s your responsibility to be warm enough and have the kit you need. You need to be in a fit state to respond at any point: not too tired, or cold. Hands warm enough to put in a cannula and draw up drugs. Resistant to jet lag and the disorientating midnight sun.

And most importantly, you have to be able to manage your own seasickness, and to a level where you can cope with going below deck to see a vomiting patient when you feel like you may vomit at any point yourself. Rock and roll, literally!

If you can handle the above, the reward is truly spectacular. 

Not only do you become part of a close-knit team, but they are also specialists from around the world: experts in climate change, wildlife, flora and fauna, oceanography, and glaciers. The team run lectures on the ship on a whole world of history and exploration that never gets taught at schools, learning about Shackleton, Scott, Amunsden and Peary. Due to the confinement of the ship, it gives you a good opportunity to reflect on your very comfortable life and ponder exactly how you’re spending your time! 

You also get to experience all of these things first hand. Seeing these creatures in their home environment is truly breathtaking, both in the Arctic and Antarctic. Watching penguins waddle down their penguin highways, oblivious to your presence, bumping and sliding clumsily, styling out what was definitely a slip into an intentional belly glide. Seeing arctic foxes leap and jaunt from rock to rock while scouting for eggs, while polar bears trek across the ice in search of their next meal with tiny cubs trailing behind looking like cuddly teddy-bears! Seeing the largest mammals on earth bubble feed, taking huge mouthfuls of water and then fluke and slap their tails and trace them under the water until they’re in their own world again. 

The list is endless: walruses burping and lounging their days away, huge albatross gliding through the sky, guillemots swarming and flying/falling into the water with surprisingly small amounts of grace. Seals that look like velvet popping up meters from the boat gliding and moving more elegantly than ballerinas and then launching themselves onto glaciers and transforming into the most cumbersome creatures you can imagine. All set against a backdrop of dramatic ice falls that pop and crackle as you steam past.

So whilst it’s different from the day job, you do become part of a very different kind of team, and it certainly shares that element of unpredictability. It’s a challenge and a privilege to operate in Polar environments. I came back with more tools in my kit to face the daily trials of Emergency Medicine, not to mention refreshed, re-enthused and keen to share my experiences to protect these vulnerable areas. 

The post ED at Sea; Medicine in the Polar Regions appeared first on Adventure Medic.

After her first taste of working as a dive medic on expedition, Megan went on to develop her interest by working for the DDRC Healthcare hyperbaric medical facility in Plymouth. Here she gives us a fascinating insight into what goes on at the centre and the unique opportunities they offer for junior doctors interested in learning more about diving and hyperbaric medicine.

My journey to DDRC

I first became interested in diving medicine during my F3 year when I volunteered as an expedition medic for a marine conservation organisation. I was going to be looking after staff and volunteers who were diving every day in a remote location, and although I was already a keen diver, I knew that I would need to do some preparation and ensure I was able to manage diving related conditions. A scuba medic course at London Diving Chamber (which has now sadly closed) helped me to get ready for the expedition and also piqued my interest in pursuing diving and hyperbaric medicine further – eventually leading me to DDRC!

DDRC Healthcare (formerly the Diving Diseases Research Centre) is a hyperbaric medical facility in Plymouth and is one of only 10 chambers in the UK that provide emergency hyperbaric oxygen therapy (HBOT) as members of the British Hyperbaric Association. DDRC is a registered not-for-profit organisation and has three key aims: research into hyperbaric illnesses and treatments; education to improve diver safety and accident management; and treatment with HBOT for a range of emergency and non-emergency conditions. It is also one of the only places that junior doctors can train and work in diving and hyperbaric medicine in the UK, due to their unique SHO positions.

What is diving medicine?

Diving and hyperbaric medicine are not routinely taught in medical school nor as part of postgraduate training, and many doctors I speak to have little knowledge of the field. For readers of Adventure Medic, diving medicine will be most relevant to those of you who, like me, find yourself going off on diving expeditions as the medic, and need to know what do to in the case of diving emergencies – especially when working in remote locations. Managing patients with diving-related pathologies can be complicated, and appropriate and timely treatment can have a huge impact on the patient’s outcome and whether or not they are left with a lifelong disability. DDRC offers an expedition diving medicine course for this purpose, and are also happy to give advice to medics going on diving expeditions. I would recommend reading Adventure Medic’s article on decompression illness as a good starting point, written by previous DDRC doctors!

In addition to the treatment of decompression illness in divers, hyperbaric oxygen therapy is also recommended for many other conditions including carbon monoxide poisoning, arterial gas embolus, radiation cystitis, sudden sensorineural hearing loss, central retinal artery occlusion, problem wounds, and many more. At DDRC we treat patients with many of these conditions, and also deliver teaching to colleagues in emergency medicine and other specialities to increase knowledge and awareness of the uses of HBOT and ensure patients are being referred to hyperbaric centres when necessary.

Another key aspect of diving medicine is assessing fitness to dive. Registered dive medical referees are able to assess whether someone is able to dive safely, and with specialist knowledge can take into consideration things like the effects of medication under pressure, cardiovascular strain due to immersion, and respiratory pathology with the risks of gas trapping and pulmonary barotrauma. This is also the case for commercial divers who are required by the Health and Safety Executive to have specific medicals in order to work, and both diving and occupational physicians can be involved in diving medicine from this perspective. Specialists such as cardiologists, psychiatrists or respiratory physicians with experience in diving medicine can also be invaluable when assessing fitness to dive, particularly when someone has a pre-existing medical condition or complex medical history. There are only a few individuals in the UK who are able to provide this specialist diving medicine advice, and so the field is definitely in need of more doctors with diving medicine experience!

What can I do at DDRC?

The junior doctor position is a one year post working three days a week at DDRC. This allows you to use the rest of your time to work locum shifts in your chosen speciality, which is fantastic for maintaining your clinical skills. You receive excellent training in hyperbaric medicine, both from the experienced staff at DDRC and through formal teaching. The DMAC level I and IID courses (Diving Medical Advisory Committee) that are provided as part of the role are the only specific diving medicine courses for physicians in the UK, and allow you to work more independently and be part of the DDRC on call service.

The 24/7 British Hyperbaric Association emergency helpline is in my opinion the most exciting aspect of the job, where you may end up taking calls from divers, paramedics or coastguards from all over the country for advice regarding suspected decompression illness. Assessing and treating unwell divers at DDRC can be immensely rewarding, often with rapid resolution of severe symptoms. We also take referrals for elective patients, many of whom will receive around 40 treatments and will therefore come in every day for eight weeks. Looking after them for an extended period means that you can build strong relationships, and you’re able to spend more time with your patients than is possible in the NHS. Recently we discharged a patient who had been struggling with a chronic wound for years, and seeing the drastic improvement in their wound and quality of life was incredibly satisfying.

Learning about fitness to dive issues and providing advice to divers is another really interesting aspect of the job, and was a real eye opener for me. It certainly made me consider more carefully the effects of diving on someone’s physiology, and how different medical comorbidities can be affected. This is also vital to be aware of if you’re planning on going on a diving expedition as a medic, as participants with pre-existing conditions may need detailed medicals by a diving doctor before setting off!

DDRC provides training courses not only for doctors and other healthcare professionals, but also for commercial divers, hyperbaric technicians, offshore medics and more. You can gain a real insight into the world of commercial diving and offshore work, and many of the participants have very interesting stories to tell! The doctors at DDRC work alongside the training team to teach various aspects of the courses ranging from diving physiology and decompression illness, first aid and life support, to complex care of patients in remote environments including practical skills such as catheterisation and chest drains. This is a great opportunity to get plenty of teaching experience which will always be helpful for doctors, especially when you’re looking at future job applications!

At DDRC you are encouraged and given the time and opportunities to pursue individual projects, including research, audit, developing teaching programmes, or writing for different publications. DDRC doctors have presented work on diving and hyperbaric medicine at national conferences, and one of the current SHOs is working on an exciting study related to diver’s lung function following Covid-19 infection. The role is flexible and definitely suited to applicants with some initiative – you really do get out what you put in.

I would absolutely recommend working at DDRC, it’s a great opportunity to pursue your interests, build your portfolio, and explore a really interesting aspect of medicine!

Get involved

DDRC employs three junior doctors. If this role interests you, please visit www.ddrc.org/jobs/ for more information and application details.

The post Diving and Hyperbaric Medicine at DDRC Healthcare appeared first on Adventure Medic.

This article was originally published on 20/10/2020. It has since been updated ready for the 2024/5 application window.

Dr Ella Bennett / Anaesthetics Trainee / Edinburgh
Dr Jack Leach / IMT Trainee / Edinburgh
Dr Craig Miller / Emergency Medicine Registrar / Western Australia (2024 Update)

Whether you’re looking for a temporary adventure or a more long-term training plan, Australia is one of the most popular options for junior doctors moving abroad and it’s not hard to see why. Famed for it’s eternal sunshine, outdoor lifestyle and opportunities for remote and rural training, Australia is an adventure medic’s paradise. 

The draw of sunnier climes is all very well but making the move can be an intimidating prospect. With seemingly endless form-filling, a sizeable financial commitment and a daunting immigration process to navigate, Australia is not without its difficulties. Adventure Medic were delighted to team up with UK junior doctor Ella Bennett in 2020 to help guide you through the process, now with new updates from Craig and Emergency Medicine Registrar who moved to WA in July 2024. 

Contents

1. Checklists
2. The Australian System
3. The Application
   1. How to apply
   2. What to apply for
   3. Where to apply
   4. Important dates
4. Applying for Medical Registration
   1. AMC
   2. AHPRA
5. Visa Application and Visa Medical
6. Things you’ll need to start work
   1. Medical registration – completing AHPRA
   2. Indemnity
   3. Occupational Health (OH)
   4. GMC licence
7. Things you’ll need to live
   1. Relocation help/remuneration
   2. Accommodation
   3. Bank Accounts
   4. Tax File Number
   5. Superannuation/pension contributions
   6. Healthcare
   7. Car
   8. Phone
   9. Student Loans
8. Things to know about work
   1. Pay and working hours
   2. Annual leave and study leave
   3. AHPRA requirements
9. Fees and Finances
10. Additional Resources
11. About the Authors

Before you start

The key to a stress-free transition to Australia is being prepared. The following checklists detail everything you will need to find a job, get your health practitioner registration (AHPRA), secure a visa, and finally, move. The financial commitment is substantial (see Fees and Finances) and you will become a master of form-filling. Be prepared for small hiccups along the way and some un-anticipated delays. It can be a long and (occasionally) stressful process but don’t lose sight of the end goal; better working conditions, improved pay and days off on the beach! We promise it’ll be worth it…

1. Checklists

Documents for your applications

Documents for medical registration and visa application after you have secured a job

Once you have submitted your AMC, AHPRA and visa applications

Once you arrive in Australia

2. The Australian System

The Australian healthcare system is a mixed system; it has a universal public branch and a private, insurance-funded, branch. The public system is funded by Medicare, a form of public health insurance similar to National Insurance in the UK. This subsides approximately 75% of GP costs, 85% of specialist outpatient costs and 100% of public in-patient costs. 

The reality of this system is that all patients, regardless of their insurance status, present to public Emergency Departments before being referred on to either a private or public department. This is why most hospital sites in Australia contain neighbouring public and private hospitals. 

In the context of moving to Australia for work, this is relevant for two main reasons: firstly, you can choose to work in either a public hospital or a private hospital as a junior doctor and secondly, you will find yourself talking to patients about insurance for (probably) the first time in your career.

Australian Medical Grades

Australian medical grades can be confusing when you first start looking for work. Essentially, there are three grades: interns, residents, and registrars. Interns are equivalent to foundation year 1 doctors in the UK, resident medical officer roles start from PGY2, whilst junior registrar roles start from PGY3. There are variations between different states, however, the graphic below from Queensland Health provides a good overview of the medical grade structure in Australia. An important difference between Australia and the UK is junior registrar roles can start from post F2. A helpful guide to understand whether you are suitable for the role is to review the job description and expectations; most post foundation doctors will apply for resident grades with the opportunity to step up to junior registrar after 6-12 months.

3. The Application

(a) How to Apply

There are 3 main ways to secure a post in Australia:

1. Contacting hospitals directly
2. Recruitment drives
3. Online job adverts

1. Contacting hospitals directly

The most common way to find vacancies is to contact medical staffing for each hospital or email consultants directly. This is where you need to utilise your contacts: if you would like to work in a specific hospital and you’ve got a friend or colleague who’s worked there before; ask for an email of the head of department or medical recruitment. Many departments will be used to couples or groups of friends applying together and are happy to accommodate this where possible. Remember to attach a cover letter and CV to increase your chances of a reply.

2. Recruitment drives

Healthcare is delivered by individual states in Australia and therefore there are no country-wide recruitment dates so these must be found from state Health Board websites or by emailing medical staffing departments. Links to each of the state health boards recruitment pages can be found below:

• Western Australia
• Northern Territories
• New South Wales
• South Australia
• Queensland
• Australian Capital Territory
• Tasmania

3. Online job adverts

Health Boards will usually have a vacancies page on their main website advertising any posts available. These vary in how up to date they are, so it is always worth emailing the hospital if you are interested. Job adverts can also be found on websites such as seek and recruit. States will often advertise their recruitment campaigns this way too.

The fourth method, and anecdotally least common, of finding a job is through a locum agency, however, finding a job through an agency appears to be more common once you have been granted full registration in Australia (see ‘AHPRA requirements’ under Things to know about work). 

Regardless of how you find a job, most hospitals will want to interview you. This is usually done by phone, zoom or the dreaded Microsoft teams (on Aussie time!) so be prepared to put your work clothes over your PJs and stay up until 3 am. Most interviews are largely informal and often contain a brief clinical scenario such as assessment of a deteriorating patient.

(b) What to apply for?

Upon finishing foundation year 2 you will be eligible to apply for both resident and registrar posts in Australia (see table below).

Resident Medical Officers (RMO) are similar to FY2 and post foundation posts in the UK. They can be useful to gain experience in specialties you haven’t done during your foundation years, for example, more time in surgical specialties or emergency medicine. If you know which speciality you’d like to train in, then this can be a useful opportunity to gain experience and develop your application. For example, anaesthesia applications give points for 6+ months post-F2 in “complementary specialties”. Many doctors moving to Australia will start as an RMO and then progress into junior registrar or principal house officer positions. RMO posts don’t necessarily represent progression, they are useful to gain experience in a new healthcare system whilst you settle into your new life in Australia. RMO posts are usually available as both rotational posts across different departments or as stand-alone posts in one department depending on your preference.

Registrar or Principal House Officer posts are more like core-training jobs in the UK. They are great if you want a step-up from FY2, particularly if you know what you want to specialise in. They are better paid than RMO jobs as you would expect but give greater responsibility and are less supported. In addition to this, they usually require some experience in the specialty before applying. It is also worth noting that in most departments, particularly in medicine and ED, the registrar will be the most senior doctor in the hospital overnight so expect to advise and supervise juniors! This can be a great training opportunity, particularly in remote areas, if it is something you are interested in!

(c) Where to apply?

Australia has it all, from coastal cities to remote rainforest (and even a few ski resorts in between!). Where you apply is down to personal choice. With some perseverance, it is relatively straightforward to find a job in most of the bigger cities. These jobs tend to be more competitive, particularly in Sydney and Melbourne, and therefore usually less flexible. It’s worth widening your net depending on your circumstances: Adelaide, Brisbane and Cairns, for instance, have a reputation for being more accommodating of groups and couples than the bigger cities.  

Alternatively, jobs in smaller towns and rural areas are plentiful and many city jobs will offer a ‘half-way house’ option allowing you to include a rural rotation if this interests you. One of the major benefits of Australia’s huge size is that even the smallest towns usually have a regional airport making weekend trips, and longer escapes, very feasible. It’s also worth bearing in mind that ‘rural’ doesn’t always mean remote – a rural secondment could be a mere 40-minute drive from the city.

As a general guide, smaller cities and more rural locations will offer better remuneration packages for taking a post there, many health boards will offer rural relocation incentives or grants. Queensland, for example, offers posts with paid relocation expenses and assistance with accommodation payments for the first 4-8 weeks depending on circumstances. Tasmania offers similar relocation support. Bigger more popular cities like Sydney and Melbourne generally offer no financial help with moving, but it is worth noting that relocation expenses can be salary packaged once you start work (more about that later).

(d) Important Dates

The Australian medical year is divided into terms or rotations running from late January for RMO and early February for PHOs/registrars; RMO will usually have 5 terms per year whilst registrars have 3 or 4. The dates for these can be found on the health-board websites and generally do not vary between states. In practice, this does not restrict when you can start work as most Australian hospitals are used to recruiting doctors from the UK and therefore an August start, or otherwise, is entirely possible. There is generally a lot of flexibility with regards to start dates and contract duration. Term dates for different states can be found below:

• Western Australia
• Tasmania
• Queensland
• South Australia 
• New South Wales
• Northern Territories

4. Applying For Medical Registration

Applying for medical registration is a long process – buckle yourself in for lots of paperwork, emails and application forms. Most hospitals will have a medical recruitment team who are experts in the process and will guide you through. It can take over 6 months from offer of employment to obtaining your medical registration and visa.

If you can, it is well worth getting a credit or debit card, such as monzo, that gives you 0% on foreign transactions before you start. The fees will quickly mount up if you use a standard card. Refer to the checklist at the start of this article for a list of required documents.

(a) Australian Medical Council (AMC)  

The very first stage for international medical graduates (IMGs) applying for provisional registration in Australia is to establish an AMC portfolio. To do this you will be required to get your primary medical degree verified by EPIC: 

Step 1 – Create an EPIC account (Fee 130 USD)

To do this you will need: 

1. A colour photograph of your face.
2. A scanned, full-size colour image of the identity page of your passport
3. Details regarding your medical degree including issue dates and university student number 
4. GMC number and dates of registration

Make sure that you indicate that you plan to apply to the AMC when completing your request to establish an account. After you have registered, it usually takes a few days for the account to be established. At this point you will be issued with an EPIC I.D. Once you have an EPIC account, you must upload a completed EPIC Identification Form (EIF) to confirm that you were the person who set up the account. This is downloaded from the EPIC website and must be certified by NotaryCam, an online notary service (included in your EPIC fee). Instructions on how to do this are available on the EPIC website. 

Step 2 – Upload your final medical degree to your EPIC account for verification (Fee 100 USD)

When you upload your qualification, select the option to send an EPIC verification report to the AMC.

Please note that if any part of your degree is not in English (i.e. there are parts in Latin or another language) then you will need to get it translated before you upload it. There are various way to do this detailed on the EPIC website.

Step 3 – Set up an AMC portfolio (Fee 642 AUD)

The AMC will email your candidate number 3-5 days after you establish your portfolio. 

Step 4 – Proceed with your AMC application selecting the pathway that you are eligible for

Details of pathways can be found here

For most juniors, this will be the Competent Authority Pathway. This is also available to GPs and specialists but results in general registration with further steps required for registration as a specialist. 

To be eligible for the Competent Authority Pathway you must have been trained by an institution recognised by the AMC. In practice this includes all UK, Irish, Canadian, New Zealand and USA universities. For more information check the Australian Medical Board website.

Step 5 – EPIC will automatically send a report to the AMC once your qualification is verified

EPIC verification can take up to 12 weeks as they need to contact your university to obtain details of your student and graduation status. Be aware that some universities require an additional administration fee to verify your qualification which will need to be paid before EPIC complete verification. The AMC portfolio fee includes one qualification, your primary medical degree and once this is complete you will be notified that your verification status will have changed on the qualifications portal of your AMC portfolio.

Step 6 – Breathe a sigh of relief and note down your AMC candidate number as this will be required for the next stage…

(b) Australian Health Protection Registration Agency (AHPRA)

This stage requires a formal job offer. Be warned, this is the most complicated, form-heavy stage of the process, again, the medical recruitment team at the hospital will guide your through this process. If you are a junior doctor applying via the competent authority pathway, you will be applying for provisional registration. This lasts for 12 months and requires various workplace-based assessments to be submitted whilst you are in Australia (see ‘AHPRA requirements’ under Things to know about work). After 12 months and the obligatory (but not particularly difficult) hoop-jumping you can apply to AHPRA for full registration.

Stage 1: Preparation for AHPRA application

Before doing anything, download and print the AHPRA APRI-30 application form below and read it from start to finish. Pay particular attention to the checklist that details the documents that you will need to attach. Once you have a good grasp of what is required, start with the following:

1. Certify your documents using a notary public or a justice of the peace. A quick google search will give you several local options; it’s worth emailing and getting some quotes to ensure you’re getting the best price. Be certain you’ve got all the documents that require notarising for your application. Notaries charge per visit not necessary the number of documents – multiple trips to the notary can get expensive! A ballpark figure is £150, this facilitated notarising of 5 documents. Consult AHPRA’s guidance on certification: they will reject notarised documents that do not conform to their standards.
2. Obtain a criminal record check through an AHPRA approved provider such as Fit2work or AIS. These are valid for 3 months from the date of issue and need to be attached to your AHPRA application. These cost around 165 AUD and are quick to obtain. 
3. Put your CV into the AHRPA format and include the signed declaration detailed in the ‘Curriculum Vitae’ section on the application form. 
4. Obtain your Foundation Competencies Certificate (received at the end of FY1) and a Certificate of Good Standing from the GMC confirming you are fully registered. The certificate sent must be within 3 months of your start-date for work. If you apply too early, you’ll have to re-apply to get one within that 3 month time frame. It is free. It is an electronic certificate that is sent directly to the AHPRA. Simply request it through GMC Online. Once logged in, follow: My Registration ⇒ My CCPS Request ⇒ Request a CCPS. More information can be found on the GMC’s website. 
5. Make sure you have a copy of your Australian job offer to attach to the form

Stage 2: Fill out the AHPRA form for provisional registration and submit it to AHPRA (Fee 720 AUD)

Once you’ve filled out the form and gathered the relevant documents, these will be checked and signed by the relevant individuals at your prospective employer. You’ll then be given the green light to upload electronic copies to the AHPRA portal online.  You must provide payment details on the form when you submit it. The payment however will not be taken until the application is processed. Processing can take up to 8 weeks and you will be notified when your registration has come through.

5. Visa Application and Medical

Visa fee 1495 AUD (excluding medical check and police check)

If you’ve made it here – congratulations, you’re nearly there. Your employer will advise you with regards to visas, but you will most likely need to apply for a Temporary Skill Shortage (TSS) Subclass 482 Visa. This is an employer-sponsored work visa. You can apply once you are sent a ‘transaction reference number (TRN)’ by your new workplace. You can find more information about this visa through the Australian government immigration website. The visa overview page is updated regularly with approximate processing times but can take between 1 to 4 months. The visa costs either AUD1495 for the short term (2 year) visa or AUD 3115 for the medium term (4 year) visa. 

There is a very useful ‘step-by-step’ section on the website which details the information you will need to provide and associated documents for submission. The visa application is online and reasonably self-explanatory except for the following sections:

• Police check – ‘Character Reference’ section of visa application (Fee £65 for 20 day processing, £115 for 2 day processing)

Before applying for your visa, you will need to apply for a police check for every country (including your home country) that you have lived in for 12 months or more. This is cumulative – the 12 months do not need to be continuous – and applies to the last 10 years or since you turned 16 (if you are under 26). You can apply for the UK check online. Once processed it will be posted to you so that you can upload it to your visa application. If you require police certificates from other countries, particularly those in the developing world, this can be a long-winded and challenging process – it’s best to start early. The Australian immigration website provides guidance on where to obtain police certificates from different countries. 

• Visa health examination (Fees vary – expect to pay around £300)

Once you have submitted your application you will be issued with a HAP ID and a list of required tests by Australian Immigration. You will generally be required to undergo blood tests for HIV, hepatitis B and C, a medical examination and a chest x-ray though this can vary depending on your travel history. To book a health examination you need your HAP ID and you must use one of the panel physicians listed on the Australian immigration website.

It is worth shopping around as we found prices for visa medicals varied wildly! The clinic will send your results directly to the immigration office – a process that usually takes about 7 days. 

• Proof of health insurance

There is a visa requirement to provide evidence of health insurance whilst in Australia. Even if you are applying from a country with a reciprocal healthcare agreement such as the UK or Ireland, you still need to obtain health insurance for the duration of your stay in Australia. Compare Club is a good comparison website which has a specific ‘health insurance for visa holders’ section and will provide an array of options depending on your needs. Many opt for the cheapest due to the reciprocal healthcare arrangement but make sure this options suits your needs!

6. Things You’ll Need To Start Work

(a) Medical Workforce

Once in Australia, you will need to complete final checks at medical workforce with your employer. This will often involve identity verification, completion of payroll forms and any other induction processes.

(b) Indemnity

There are various indemnity providers in Australia and all appear to offer a similar level of cover. Prices for indemnity are fairly equivalent to that of UK indemnity costs.

(c) Occupational Health (OH)

Australian occupational health requirements are similar to those found in the  UK. The exceptions are varicella and whooping cough. You will need to provide evidence of varicella immunity and ensure you are vaccinated against pertussis. Both can be arranged on arrival in Australia by the occupational health team.

(d) GMC Licence

As an aside, it is worth considering what to do with your GMC licence. There are three options:

• Keep your licence: you’ll pay full fees (£455) but will remain eligible to work in the UK (including as a locum). You’ll also have to revalidate annually i.e. complete an annual return. This either means getting your current designated body to agree to keep you on their books and doing your revalidation meeting paying a fee to the GMC (£290) to do it.
• Relinquish your licence: you won’t have a licence to practice medicine in the UK, though you’ll keep your registration with the GMC. You’ll pay much less in fees (£163). You won’t need a designated body nor have to complete an annual return. To reinstate your licence to practise you will need to provide statements from employers since relinquishing your licence and a certificate of good standing/professional status from the medical council(s) you have worked under (e.g. Certificate of Registration Status (CoRS) available from AHRPA which currently costs 50 AUD. 
• Relinquish your registration: you won’t have a licence to practise and you’ll be removed from the GMC list of registered medical practitioners. Not really the done thing unless you’re leaving medicine entirely or plan to never return to the UK to practice medicine. You can re-register, but we wouldn’t really recommend this option.

More information can be found on the GMC website under Revalidation.

7. Things You’ll Need To Live

(a) Relocation Expenses

As mentioned above, many hospitals will offer relocation packages, particularly if you’re taking a rural post or you’ll be based north of the 26^th parallel. If you’re not offered a relocation package, fear not, as you can still recoup some of the costs through salary packaging your relocation expenses (see below).

(b) Accommodation

If your hospital includes an initial period of free accommodation, then obviously flat hunting is much easier. If your hospital doesn’t, many people choose a short-term holiday rental through companies such as AirBnb providing time to look for a more permanent solution once you arrive. A high turnover of expat doctors means there’s often houses or apartments serially rented to groups of medics – it’s worth checking out hospital mess facebook groups or the Fellowship Life Transplant Services page. The main ways to look for accommodation in Australia are through Flatmates for house shares or through various rental websites, such as Real Estate, if you’re looking for an apartment.

(c) Bank accounts

There are several Australian banks that allow you to set up a bank account from outside of Australia. The two main ones that allow this are Westpac and ANZ. When you arrive you will need to visit a branch with your passport and proof of address so they can issue a bank card and fully open your account. It’s usually easiest to use an account like Monzo, with zero overseas card transaction costs, to cover your time until your new Australian account receives the first pay check (you get paid every fortnight so it won’t be long to wait).

(d) Tax File Number

In order to pay the correct amount of tax you need to apply for a ‘Tax File Number’ (TFN). Your employer will likely help you with this when you arrive, but if not, the Australian Taxation Office provides all of the information you need. 

You will be expected to file a tax return each year which will be due at the end of October. You can do this yourself, but we recommend hiring an accountant to make the process easier. An accountant might cost 150 AUD but often results in a refund of several thousand dollars.

(e) Superannuation (pension contributions)

You are unable to contribute to your NHS pension from abroad. Australia does however have a number of very good superannuation schemes. Your employer will be a member of one, but you are free to choose your own if you wish. There is a large amount of information available online about these schemes It is worth noting that when you leave Australia, you are entitled to claim your pension contributions back as a lump sum. This is often a substantial amount so is well worth doing.

(f) Salary Packaging  

Salary packaging is a perk for public sector workers; it offers the opportunity to reduce your tax burden and is a government sponsored scheme. Essentially, you package certain living costs which is taken from your pre-tax salary which subsequently reduces your tax burden meaning more money in pocket. Moneysmart is one organisation that offers these services, they have an online calculator to demonstrate how much you could save. You can also package relocation expenses which allows you to recoup some of the cost of moving to Australia if your employer doesn’t offer a relocation package.

(g) Healthcare 

As mentioned in the visa section, you will need to maintain healthcare insurance for the duration of your stay in Australia. Ensure that the policy you take out suits your requirements.

(h) Car

The main websites for car buying in Australia are Car Sales, Autotrader and Gumtree. You can also try the wild west of Facebook marketplace (expect many scams and dodgy sellers), ask around the doctors who are heading back to the UK, or head to some local car dealers. Generally, cars in Australia are older and have done more kms often in harsh environments. It can pay to hire a mechanic to complete a pre-purchase inspection. Cars must be sold with a valid Roadworthy Certificate (RWC), but this is only an extremely  basic MOT – don’t rely on it as an indicator of a good car! and it is illegal for a seller to sell a car without one.

After you buy a car you will have to transfer the registration to your name within 14 days of purchasing it (7 days in WA and Tasmania). The process for doing this varies between states but usually involves filling in a purchase form, signed by both the seller and buyer, and taking it to our local transport and motoring customer service centre. You can drive on your UK licence for 3 months, after which you need to get an Australian licence which again, you need to head to the motoring customer service centre, so save yourself time and do both in one trip.

The equivalent of road tax in Australia is car ‘Registration’ (or Rego). This varies between states but in general is paid yearly and can be done online or at one of the above service centres. In addition to this, regardless of state, it is illegal to drive without Compulsory Third Party (CTP) car insurance and you cannot get a Rego without this. In most states, CTP is included in your registration fee so you usually don’t have to worry about this too much. The final thing to consider after buying a car is breakdown cover – we would advise getting this given the age of Australian cars and the remoteness of many of the roads!

(i) Phone

There are lots of mobile networks in Australia and it is easy to secure rolling monthly contracts that offer lots of flexibility. The large expat population means that many providers offer great deals on overseas minutes particularly to the UK and Canada. If you’re in a more rural location, it’s worth checking out coverage maps to see which network will serve you best.

(j) Student Loans

If you have a student loan, there is unfortunately no escaping paying it off. You will need to contact the student loans company to arrange payment once you arrive in Australia. Similar to working in the UK, they will calculate your repayments based on your income.

8. Things to Know About Work

(a) Pay and working hours

All doctors in Australia are paid every 2 weeks and most contracts are 80 hours per fortnight mean you can expect to work 4 days per week. The pay is generally much better than UK pay for the equivalent grade, as a general rule, you can expect to earn 1.5x to 2x your UK salary, particularly when salary packaging is taken into consideration. There is no Australia-wide pay scale for junior doctors, instead salaries are set by state governments. Pay scales can be found within industrial agreements and your offer of employment will detail your salary. It is worth noting, the pay scales determine your base salary and that is what will be quoted in your employment offer, this excludes additional payments received for out of hours work. The uplift for out of hours work is substantial and will increase your pay significantly. The Australian Medical Association has good guide to pay if you want to deep dive into the detail.

 (b) Annual leave and study leave

Annual leave allowances start at 4 weeks per year, this increases with on-call commitments, weekend working and bank holidays, as such most residents will have 5 weeks of annual leave per annum. In addition, 2 weeks of professional development leave can be utilised to attend conferences, sit exams, or undertake courses. If you’re planning a big trip, options include purchasing additional leave, taking unpaid leave or waiting until the end of your contract before starting another job.

(c) AHPRA requirements

Your employer will allocate you a supervisor and usually submit your forms to AHPRA for you. After 3 months of working, you are required to submit an Orientation Report for International medical Graduates (ORIG-30) and a Work performance Report for International medical Graduates (WRIG-30). These are relatively straight-forward and are completed together with your supervisor. After 12 months working, you will be eligible to apply to AHPRA for general registration. This will enable you to work unsupervised (e.g. take locum shifts).

Ensure your supervisors are happy to provide future references before you move on; many UK jobs you return to will require references for all jobs you have done in the last five years.

9. Fees and Finances

AUD: GBP exchange rate 1:0.51 at time of writing 

On top of the above, don’t forget to budget for rental deposits (typically 4-6 weeks rent), flights and car, which can add several thousands to the budget. The cost of moving may seem daunting but remember that everything can be salary packaged or may be covered by a relocation allowance. Even if you don’t get a relocation allowance, rest assured that the wages in Australia are more than sufficient to recoup the costs of moving.

10. Additional Resources

• BMA – Guide to Australia 
• Messly – Guide to working in Australia 
• Mind The Bleep – Thinking about Australia

11. About the Authors

Ella and Jack were F3/4s in Brisbane in 2019. Before their Australian adventure they spent some time working in New Zealand (why choose one when you can do both?) using their free time to cycle-tour and travel. After returning to the UK, they worked as clinical fellows in the Shetland Islands before heading back to the mainland to take up anaesthetics and IMT training posts in Edinburgh.

Craig is an Emergency Medicine registrar and moved out to Perth after completing ST4 in Cornwall. He’ll be working at Sir Charles Gairdner Emergency Dept (home of Life In The Fast Lane) for 6 months, before moving on to join the Royal Flying Doctor Service undertaking retrievals across Western Australia.

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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.

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Tales from travels in Uganda. Adam shares his experiences around his Tropical Medicine and Hygiene Diploma (DTM&H) in East Africa.

Running home in Kampala requires focus. Through a shoal of motorcycles and old Japanese vans the runner must evade potholes, goats, roosters and a miscellany of unaccountably armed men.

Weather here is definitive. It is either hot and bright or there is a storm. Heavy rain is insufficiently descriptive. The sky simply opens. For weeks I wondered why the gutters beside the roads are a metre deep. Now I understand. The red clay soil absorbs little of the downpour: it flies off rooftops, tumbles down hillsides, fills roadside trenches to the brim.

Taking a boda-boda through the city after the rain is hair-raising. I cling to the back of the 100cc motorcycle as it thumps on and off pavements, weaves between gridlocked trucks, heaves into great puddles of unknown depth. There are many accidents here: three thousand people die on Ugandan roads annually. More remarkable though are the crashes which do not occur. Drivers seem to feel their way through the dense traffic as if they were dancers, or water in an endless stream.

For two weeks in Kampala we studied HIV medicine and tuberculosis, outbreak control and meningitis. We donned hazardous materials suits to run a simulated Ebola Treatment Unit. The fog and sweat and heat were overpowering. I was soaked through – as if I’d been caught by a Kampala downpour or dunked in the Nile. Bear in mind that we were in a hotel conference room and our patients weren’t actually sick.
We drove to Jinja, a town on Lake Victoria at the source of the White Nile, for a travel medicine placement. Our accommodation was inauspicious yet lurid. The exterior of Hotel Paradise is screaming pink. Inside, a trail of ants ran around the doorframe of my room, which was full of someone else’s belongings. I requested another suite.

I borrowed a bicycle from a charity shop in the main street. The suspension was fused but the brakes worked and £2 per day was affordable.

My attempt to cross the Source of the Nile Bridge was truncated by a personable but extremely firm member of the Ugandan People’s Defence Force. Thinking it imprudent to quibble with a man in camouflage resting an AK-47 over his knee I turned around to find an alternative crossing.
On the road a group of cyclists rode past me. Teenagers. One of them called to me:
“You go with us!”
I hustled after them. Their bikes were rusty but the moving parts were oiled and carefully maintained.
“We train every day.”
“Tomorrow you ride with us to Kampala?”
“Sometimes we go to Kenya!”
“Give us your number. If there’s a race this week we’ll tell you.”

I apologised. I was going rafting.
The staff of the Nile River Explorers rafting company wear red t-shirts emblazoned in yellow ‘I love my job’. 
I spoke to Juma Kalikwani, who grew up in Jinja and was once a guide on the Findhorn river in the Highlands. Juma represented Uganda at a freestyle kayaking demonstration at the 2012 Olympics. He’s been a guide on the Nile for 18 years. Does he ever grow tired of it?

“The river is always different. The bends and rapids I know so well but still they can change and surprise you sometimes.”

We go through a set of induction drills. Forward, backward, pivot turn, hunker down, hold on. How to get back in the boat if ejected: haul on the side, lock your elbows, kick with your legs, upheave. Juma makes us aware of important warning signs:
“If you look in your boat and no one is paddling and people are just praying – this may be a problem.”

We learn observed patterns of rafting injury: shoulder dislocation, patella fracture, being pinned against rocks. This information is withheld until you’re on the river.
The opening rapid features a drop down a 7-foot waterfall. I take a deep breath and listen closely to the instructions:
“Forward paddle! Forward paddle! Stop! Get down!”
My heart enters my mouth as we go over the lip, the raft bends in the middle like a book, and springs back into shape as we emerge from the torrent.

The river flattens out. Becomes a fat mass of dark water. I hadn’t expected this: I thought rafting was all white water and shrieking. I zone out.

My thoughts turn to whisky. Phil, our course director, had given me a bottle of Bowmore as thanks for assuring the safe passage of course baggage from Moshi in Tanzania across the Kenyan and Ugandan borders to Kampala. This had been smooth sailing on the whole, save for a small matter concerning whiteboards on the Kenyan-Ugandan border at 5 o’clock in the morning.

We’d been on the road for twenty one hours. I’d carved a niche in a mass of bags at the back of the coach and had accepted half a sleeping tablet from one of my classmates. So when we pulled up to the border in the dead of night I was bleary-eyed and partially tranquillised. Not an ideal frame of mind to protect 80 bags of personal belongings and course material. We were instructed to unload all of the bags for inspection. These passed without question save for six large rectangular packages stowed near the engine.

“What are these?”
“They are whiteboards.”
“Why do you have so many whiteboards?”
“They help us to travel.”

We had been told by our programme director to keep tight-lipped at the Ugandan border. We were tourists; not doctors on a medical course. Travellers pay a low-rate visa but matriculated students are expected to fork out for the more expensive business version. Phil assured us no-one would care once we got to Kampala but if we let the cat out of the bag crossing the border we’d each take a $200 hit. I elected not to inquire if this was what people mean when they talk about corruption in Africa. 
We had our party line and were determined to stick to it. The whiteboards were a snag. What sort of tourist goes around East Africa with six whiteboards in their bus?
The customs official clearly had the same thought:
“We will have to keep the whiteboards here at the border.”
“No, the whiteboards are coming with us to Kampala.”
“But there is a special tax process for this item.” 
“But it’s a whiteboard!”

I wondered if this was going to be a matter of ‘kitu kidogo’ – a little something. Phil had given me an envelope with $50 with which to pay any necessary bribes. Before guiding the conversation in this direction I thought I’d run another tactic: cultivate bewilderment. 

“Do you want to know why we have the whiteboards?”
“Ok.”
“We are from many countries. You have seen our passports: Zambia, New Zealand, UK, Malawi. We met at a conference and decided to travel together.”
“What does this have to do with whiteboards?” 
“As we travel we like to stop and reflect on what we have learned. We use the whiteboards to write on to collect our thoughts.” 
“I see…”
“We can show you how we do it!”
The customs official had a wary look in her eye. 
“No. No. That will not be necessary. You take them. Goodbye.”

I doubt she believed us. But my excitable Zambian friend Shahin and I had turned up our smiles and pressure of speech and I suspect she concluded that it was 5am, she was tired, and this particular cabal of eccentrics were likely to rain down a hurricane of inconvenience if she impounded their stationery. Better not to bother. We loaded the whiteboards back on the bus and drove off into the darkness.

Approaching a chain of rapids the world regains focus. One’s mind stills. Reveries end. You listen to the briefing and hold on as the river begins to fizz and boil beneath you. The rapids are named: Bubogo, Itanda Falls, the Bad Place, Retrospect. Most go well – the rafts are buoyant and my grip is strong. But sometimes you get rinsed.

For some time afterwards I couldn’t work out exactly what happened on the Kulu Shaker rapid. It wasn’t the submersion – thrown deep in the thrashing water, relying on the buoyancy aid to tell up from down. Or the resurfacing – for an instant, gasping a breath, then clattering into the belly of another standing wave.
You let your body go slack and wait to rise again.
What puzzled me was the disorientation. We’d been careening down the line of rapids, the raft rolling and tumbling between huge broken waves. Sometimes a wall of water crashed into my face and torso and I closed my eyes.
Then my feet were above my head, my left arm gripping a paddle but nowhere near the boat, scattering into a maelstrom of helmets, bodies and flood. Then there was only the muffled tugging sound of fast water heard below the surface.

Speaking to Sophie afterwards, who had been at the back of the boat, she reckoned we hammered straight into a massive standing wave which fired us upwards. We crossed the vertical line and geometry defined the outcome: the boat flipped end on end.
But capsizing is to rafting what an element of farce is to any great adventure: the sine qua non. Hundreds of wayfarers have been unceremoniously dumped by the Kulu Shaker. Save the few who lose their teeth or unhinge their upper limbs in the process I doubt many would wish it otherwise. So it’s saddening to know that in a few weeks the great rapid will no longer exist.

The Isimba Dam will help relieve Uganda’s chronic energy shortages with a hydroelectric power station. But when the river is flooded much of the broken water will disappear. The rafting companies don’t know exactly how many of the rapids will vanish or how their businesses will adapt to the altered waterway.

Change is coming to this section of the White Nile. But this is as old as Heraclitus: you never step in the same river twice.

For more work by Adam see his website www.adamboggon.co.uk

For those interested in working in the tropics there are a number of diplomas available. The full time Diploma in Tropical Medicine and Hygiene in Uganda and Tanzania is not currently running (at the time of this publication) but the courses in London, Liverpool and Glasgow are.

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Final year medical student Marcus had the privilege of experiencing the highs and lows on his medical elective in Zambia in 2019. Here he recounts his experience of working in a resource-poor setting; from obstetric emergencies; to daily life in Lusaka; to weekend tips to Victoria Falls and safari in Botswana.

Lusaka Hospital, Zambia

Starting my medical school elective placement in Obstetrics & Gynaecology (O&G) in Lusaka was both daunting and exciting in equal measure. Upon arriving at the hospital one of the most immediately obvious differences was the ubiquity of white coats. The white coat has been long banished from the wards of NHS hospitals; but worn universally amongst doctors and medical students in Zambia. Wearing this white cloak felt like assuming a mantle of responsibility – a physical manifestation of a professional identity. It did little for my Imposter Syndrome, however in tough situations it felt like a suit of armour; protecting me from mosquitoes, but not from the Zambian dust!

Despite my initial nerves I was quickly made to feel welcome and a valued part of the team. The medical staff at the women’s hospital are organised in a firm-based system and I was attached to one firm for the whole five-week placement. This structure enabled me to get to know the doctors I was with. They were keen to get me as involved as possible; clerking patients and presenting on rounds, brushing up on my obstetric examination skills in antenatal clinics, as well as assisting in theatre. I also had the pleasure of being surrounded by a supportive group of local medical students. They were more than happy to share their notes, skills, and (perhaps most importantly) the best places to grab lunch on campus!

Difficulties presented in a resource-poor setting

The hospital in which I was placed was government-run and they struggled with a lack of resources. Before my placement in Zambia, I took for granted the abundance of equipment we have at our fingertips in the UK. There was no running water on the labour ward; nor were there bottles of alcohol hand gel sitting proudly at the end of every bed. Women laboured in open wards separated by thin curtains, lying on plastic sheets and brightly coloured local fabrics they brought from home. There were times when the resource limitations did become very frustrating. A CTG machine would be wheeled out only to find there was no paper on which to record a trace. The tap to the scrub-room would cut out while you were soaped to your elbows. Running to the blood bank in temperatures over 30 degrees Celsius only to find they have no blood available. 

These were but a few of the problems we experienced in our short five weeks. However, our Zambian colleagues walked this scalpel edge every day. They strove hard to do the best for their patients in a setting that often worked against them. Sometimes women would queue for an emergency caesarean section due to the lack of fully trained anaesthetists for more than one theatre to be operating at a time. This often led to tragically poor outcomes for mother and baby. One day a young woman exsanguinated to death following a placental abruption simply because the blood bank was empty. Experiences like these were a haunting reminder of our privilege and how dangerous childbirth can be in resource-poor and lower-income countries.

Despite all the obvious difficulties, the greatest resource in the hospital remains the staff themselves. The doctors I worked with were highly knowledgeable and in turn, demanded high standards from their medical students. The vast majority of teaching is done on the job, informally on daily ward rounds, where students would routine be grilled at the bedside. As well as developing my clinical knowledge, I learned more practical skills such as the ability to think on my feet and problem solve with limited resources to hand.

A ward round in Lusaka can feel like the contents page of the O&G textbook at times, and I was exposed to many things I would never see on placement in the UK. Stage 4 cervical cancer, severe symptomatic anaemia of pregnancy, eclampsia, and mothers suffering from malaria, tuberculosis and HIV but to name a few. Unfortunately, like many other areas in Africa the severity of disease was often due to late presentation to a tertiary centre as well as either the lack of, or financial barriers to antenatal care.

Down-time

Away from the highs and lows of the clinical environment, the Work the World house in Lusaka feels like a sanctuary. After a hard day on placement we would share hospital stories by the pool, or relax out on the terrace with a cold drink and read or reflect on the day. Weekends offered opportunities for amazing travel experiences. From visiting the spectacular Victoria Falls in Livingstone to crossing the border to Botswana for a safari; with my highlight being getting up close to a family of swimming elephants. Closer to home, Lusaka itself is a fun city to spend time in at the weekend; often finding ourselves overindulging in the busy and vibrant local bar, restaurant and club scene!

Work the World’s Village Healthcare Week

Relocating from Lusaka to Chirundu; a bustling border town on the banks of the Zambezi; this week was the cherry on the top of my time in Zambia. Following a warm welcome into the home of a wonderful host family, we were able to gain a valuable insight into daily life for many Zambians living outside the capital city. If you ever visit Chirundu, remember to bring your dancing shoes; the local school kids will show you how to bust a few moves – or at least try to!

Daytimes were spent at the small district mission hospital which was a stark comparison to the government hospital in Lusaka. Facilitated and ran by the Catholic Church, this small-town hospital is better resourced and has greater facilities. As well as O&G, I was able to spend time in the paediatric department, giving me insight into conditions such as childhood malnutrition.

I would encourage any student or qualified healthcare professional alike to take the opportunity to travel to Zambia. My experience provided me with valuable experience in a low-resource setting with the support of friendly and highly skilled medical staff. Even when I felt a long way out of my comfort zone, Zambia was a home away from home.

Top Tips

• You don’t always need fancy kit to get the job done. If you don’t have a Rusch Balloon to hand to manage a post-partum haemorrhage, a latex glove filled with normal saline will do the trick just as well!
• Our over-reliance on technology can cause UK doctors to become de-skilled. In Zambia I learned how to listen to the fetal heart rate manually using a Pinard stethoscope, a skill not often not taught in the UK as there are usually Doppler ultrasound machines available!
• The healthcare service in the UK can be very wasteful. Reflecting on my time in Zambia, I started thinking about the ways in which the NHS could minimise waste production and still maintain a high standard of clinical care. 

Further Information

Where / Lusaka, Zambia

When / March – April 2019

How Much / Roughly £2500 (excluding flights) for a 5-week placement and Village Healthcare Experience

Flights & Visas / Flight to Kenneth Kaunda International Airport (Work the World can provide more information on flights and visas)

Contacts / To find out how the Work the World service works, head to worktheworld.co.uk

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A longstanding outdoors enthusiast, Emily usually lives in Edinburgh with her family, squeezing in as many trips that her anaesthetic training and general life can allow. Having CCT’d earlier this year, she has taken the opportunity that a natural career break gives her to go travelling, and can currently be found in New Zealand, exploring what boulders, glaciers, mountains and seas can be clambered over on the other side of the world. A mum to three gorgeous kids, Emily and her husband have found ways in which they can safely include the entire crew, keeping their love of exploring, and their sanity, alive. Here, she gives us her tips on how to encourage a younger generation to have fun and stay safe, in her approach to adventure parenting. 

Firstly I should say that I am not an adventure medic, just a medic who loves adventures: rock climbing around the world; ski mountaineering; high altitude mountaineering; adventure racing; mountain biking; surfing. Then in 2011, I started on my next great adventure, parenting. Suddenly, there seemed to be a wide range of opinions on what an acceptable level of activity for this new chapter of our lives was, as photos that were previously welcomed of my husband and I partaking in perilous exploits were now met with concerns about the health of our unborn child. The crucial question here was: what is an acceptable level of adventure to partake in when you are a parent? What can and should we do when faced with a degree of real, or perceived, hazard?

I have many friends who had similar interests to my pre-child self and it has been interesting to see how different couples have approached this decision, with a full range of outcomes from no change to no adventure. It may depend on their requirement to get that occasional adrenaline rush, to have a little time being who they used to be, or on how supportive their partner is. Since falling pregnant with my first child back in 2011, my husband and I have continued to ski off-piste, mountain bike, climb, run races and surf. Albeit in a slightly more toned down, cautious manner than previously, and normally closer to home. Of course we took the necessary safety precautions to minimise risk to our children (such as no lead climbing, a full body harness for me, and no high altitude activities or busy pistes whilst pregnant), but we have always continued to have adventures. Through trial and error we have found some activities that work better than others with a family. For example, bouldering on the beach is infinitely more family-friendly than high altitude mountaineering. Having children has also inspired us to try some new sports that we can all enjoy together as a family. We bought an inflatable kayak and have taken the children sea and river kayaking, and we have cycle-toured the Outer Hebrides en masse. Four years ago we acquired a camper van and used six weeks of my next two maternity leaves to explore the west coasts of Ireland and France respectively, loading it up with all of our baby gear, bikes, surf boards, a bouldering mat, kayak and, of course, children.

Clearly adventures and children can be combined… but should they be? Are those of us who actively seek adventure bad parents? They’re understandable questions, and ones that have put us to the test. Personally I believe that it is the opposite. In a world of growing obesity and stress, it seems to me that physical activity is the best treatment that there is for improving both physical and mental health. Whilst pregnant I was ‘training for labour’ and then, once the children were born, I found that for me to be the best parent I could be, I had to have balance. I can enjoy baby music classes and toddler groups like any parent, but I enjoy them so much more if once in a while I get a little taste of being me – and this involves the great outdoors and a little adrenaline on the side. Happy parents are surely more likely to have happy children, and along the way, we are showing our children what a playground of a world it is that we live in. It is rare not to see them having as much or more fun than us on each trip. There is, of course, more risk assessment involved than there used to be when planning our trips. Looking after children is hard enough without doing it injured or worse, and we would never want to put our children in danger. It is also more important than ever to have the right activity and life insurance, and there have been times that I have opted not to partake in an activity for fear of injury. I definitely do not push my limits as much as I used to. Probably, and sadly, the most dangerous thing I have done in the last year was driving home from night shifts. You can see these extra consideration as restrictions to your fun, but a better way to look at them is that they are just new challenges which therefore make your adventures even more rewarding when you pull them off!

I believe that it is not just possible to be an ‘adventure parent’, but something to be encouraged. Get out there and have some fun, getting fit in the fresh air with your family. You will be all the better for it, and after a weekend of fun you may be even more ready for that next week of medicine…

My top tips for successful adventure parenting

(mostly gained from personal experience)

• Do your background research before you go. This includes checking any access issues, potential hazards, weather (including wind conditions), sea/river conditions that are relevant to your chosen activity… and adapt your plans accordingly.
• If you are trying a new activity with your children build up gradually. You don’t want to accidentally put them at risk or put them off because their first experience was too extreme.
• Make sure you have the right kit. You may need special child-sized equipment to enable your children safely partake in an activity. Pack plenty of snacks, dry clothes and entertainment. Avoiding your children becoming hungry, cold or bored will make you all have a better day.
• Be realistic – things take longer with small people in tow. Less is often more. You will all have more fun if you are not rushing. (This includes car journeys…)
• Plan your activities to fit into your childrens’ daily routine. Driving is easier when they are napping; activities are safer when they are not tired. Tired children can be unpredictable and dangerous especially in boats, on cliffs etc – avoid!
• Be flexible – be prepared to shorten the activity if it is not going well or taking too long.

Many activities are not suitable for young children. Most of these activities can still be enjoyed by ‘taking it in turns’, especially if there is somewhere child friendly for the rest of the family to hang out in the meantime. When taking turns remember:

• Be fair and supportive to each other – divide the time available equally and stick to your allocated time slot.
• Ideally pair up with another adult or parent team so that you have more adults around if someone gets into difficulties. If you are going solo, give your partner a plan and stick to it. They may have previously been able to help, but they are now looking after your children so when they call the emergency services they will need to have some idea where you might be.

Some age specific considerations…

• Babies are portable and easily entertained. Enjoy it while it lasts!
• One- and two-year-olds may not fancy the waves or snow. Stick to rock pools and do not despair! By three they will be bigger, more coordinated and ready for skiing and body boarding.
• Older children may have more ability and common sense but they also have more ability to get themselves into trouble and more confidence to give something a go! You can never fully relax.

And most importantly…

• Have fun! If it is not, reconsider points 1-11 and try again another day.

The post When the insane keeps you sane: A risk analysis of adventure parenting appeared first on Adventure Medic.

A keen road cyclist, Dr Renée Farrar leapt at the opportunity to provide medical support to the West Africa Cycle Challenge 2019: a challenging 500km journey through bustling towns, dusty open roads, lush greenery and beautiful beaches, whilst also visiting some of the important projects run by the organising charity Street Child.

(Photographs by Dr Renée Farrar)

Sierra Leone and Liberia are not the first places that come to mind when I think of road biking.  I’m used to the UK, the Alps and some remote parts of Europe, but I didn’t need much persuading when I was offered the opportunity to be the medic of the 2019 West African Cycle Challenge.

To my cyclist’s brain it was a chance to partake in one of my favourite sports whilst doing my job. I might even get to talk about sport gels and Lycra to people who find them interesting! My task was to accompany ten cyclists from Bo in Sierra Leone to the finish line in Robertsport, Liberia. With me would be team members from the organising charity Street Child, some NGOs, as well as a local support team.

Packing my hot weather gear and preparing to be the cycling domestique-style doctor was no mean feat.  There would be medical care available along the way, but it couldn’t be accessed quickly from the race route (four to six hours’ drive away) and we knew phone reception would be patchy. We anticipated a good deal of roadside pre-hospital medical care with road or air evacuation as needed. My kit was therefore extensive yet compact. It unpacked to many organised boxes of drugs and equipment plus a field bag for immediate care.

It’s not all about the Lycra

It is pretty tough cycling in 40 degree heat, where the dust is so red that it stains your t-shirts permanently and your knees for days.  The participants all had the necessary sense of adventure to cycle on mining roads and dust tracks, to cross rivers and travel on car ferries alongside trucks, chickens and precariously stacked crops.

It was important for the cyclists not to be precious about their bikes and to have an idea of when to ask for help from the very friendly, talented mechanic and cyclist Karim, a.k.a “Stylish Man”. He is currently Sierra Leone’s best cyclist, national team leader and champion of women’s empowerment. He helps women of all ages to get cycling and learn about bike maintenance, giving them their own means of transport, access to fitness and a chance to compete for national events.

Our meals were cooked for us, but we supplemented these with delicious snacks on the go. Fresh pineapple and locally-roasted nuts mid-ride were a lot more tempting than a squashed well-travelled muesli bar.  Water was provided in plastic bags – quite upsetting for the environmentally conscious, but difficult to avoid. Extra provisions were carried in the support trucks and offered at every stop.

A race to raise awareness

The race itself was four days with an additional day of preparation and a day of rest at the end. Individuals and the group as a whole faced challenges as we travelled through two stunning, but very different countries. Both Sierra Leone and Liberia have been war-torn and are affected by poverty and disruption. As the race was organised by the charity Street Child, we had the opportunity to be involved in family and youth visits all along the race route.  This allowed us to understand more about how safeguarding, illness and discrimination issues affect people in Sierra Leone and Liberia. It was humbling to visit families who had lost loved ones and been isolated due to the Ebola outbreaks. I personally found learning about the difficulties faced by many women, particularly some of the pressures and abuse they face, really difficult to hear.

What challenges face a cycling medic in the West African bush?

Diarrhoea and vomiting

As with anywhere that you’re eating unfamiliar food in a challenging climate, there is a risk of gastrointestinal upset.  The variety of local poisonous snakes and biting insects mean it’s not always an option to run into the bush at the side of the road for relief. My goal was to keep the cyclists and the rest of the team as well-hydrated and nourished as possible. I kept track of calories and nutritional intake of the cyclists each day.

I tried to prioritise monitoring fluid and electrolyte losses as quickly as possible, whether this was from lots of exercise and sweating or florid gastrointestinal illness. Meticulous hygiene from the team was essential. As the medic, I felt it my responsibility to reinforce the importance of this.  I wondered if I should buy shares in hand sanitising gel!

Potential cycling injuries

Falls off a bike can be anything from minor to catastrophic.  You only have to watch a downhill section of the Tour de France to see some epic falls, or go mountain biking for a day to see someone tumble off their bike.  Combine this potential for injury with heavy traffic and unconditioned roads, and the risk for trauma escalates. Fortunately, no one was significantly injured but I felt prepared with my medical kit and with access to evacuation if needed.

Local hazards

West Africa is beautiful, but not without its hazards and challenges. The Ebola risk had passed at the time of the race, however NaTHNaC had reported a few cases of Marburg virus disease in Sierra Leone. Rabies was always a risk, especially with many street dogs intrigued by passing cyclists. Various insects, worms and waterborne parasites such as bilharzia are endemic in the region and risk had to be considered. Oral anti-malarials were required, but general bite avoidance with nets and appropriate clothes was essential, especially at meal times and when relaxing around dusk.

Weather

The strong sun and high temperatures posed risk of heat illness and dehydration. Concomitant gastrointestinal upset only increased risk. Hot nights made sleep a challenge. Legs and arms became caked in mud, and this, along with the dust and wind, only added to the discomfort of the cyclists. We even had to be sure to check the timing of the tides when walking to explore shipwrecks on the beach to avoid being stranded in deep water.

Fatigue

WACC was a proper, open road race but without the comfy chalet stops that you find in the Alps. We loved the authenticity of staying at local guest houses and they provided well-needed rest. However, it was a 500 km race which resulted in pure fatigue. Many snacks were eaten, gallons of water were drunk and many rehydration mixes made. As with any endurance sport, getting tired and the risk of bonking (a cycling term meaning ‘hitting the wall with tiredness’) was high.

A whirlwind introduction to West Africa

I loved this trip. As a doctor, the mix of exposure to pre-hospital care and sports medicine was really interesting. I’d also recommend this race for keen cyclists wanting to get an insight into West African culture, customs and some of the sociopolitical problems the people face.

I’d like to thank Street Child, Exile Medics and the entire cycling team for being so great to work with.

If you would like to find out more about Street Child and the other challenges they have on offer such as their award-winning Sierra Leone Marathon or their upcoming cross-country cycle challenge Ride Sierra Leone visit their website.

Renée can be contacted at reneefarrar@doctors.org.uk

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‘It was 46 degrees in the desert. I was sleeping in my tent under a million stars when I heard the expedition leader shout my name. Someone who had been suffering in the heat had acutely deteriorated. He was dehydrated, his peripheries were cool and he hadn’t passed any urine for hours. We were over six hours from the nearest town or medical facility and it was dangerous to drive in the middle of the night. While everyone slept, it was my job to manage him…’ (Expedition diary, Sudan)

In January 2019 I set off for Cairo with my bicycle and two bags. I was excited and a little daunted by what was to be one of the biggest professional and personal journeys of my life.

The expedition began with nearly a week of preparations in Cairo; sourcing and organising the medical and expedition kit, getting our vehicles ready, meeting the staff team, briefing the participants and enjoying the luxury of beds and showers before the many nights of bush camping ahead. On January 17th, as the city of Cairo was waking in the beautiful morning light, we set off from the pyramids. There was an eerie silence as we cycled past the Great Sphinx of Giza. We were off. Direction: Cape Town. Distance: 11,220km.

Expedition medicine can be refreshing. You get to use your initiative managing patients with limited resources and in ever-changing environments. Being on call 24 hours a day and living with your patients is a truly unique experience. It was one week into my expedition that this really hit me. As we camped on the banks of the Nile, one of the team started to become unwell. She was pyrexial and becoming rapidly dehydrated with severe gastroenteritis. I monitored her and her fluid balance hourly, administered anti-emetics and antibiotics and started fluid resuscitation. At that moment, for the first time in my career as a doctor, I suddenly felt very alone. I had no mobile reception, no medical colleagues to run things by, no hospital protocol to follow and only finite medical resources by my side.

I realised the importance of giving myself some time to think over my differentials and my management plan. In the looming darkness I sat down next to some grazing donkeys and gathered my thoughts. What would I do if I was back in the UK? What can I do here? Where is my kit? Where is the expedition leader? How far are we from a hospital? In the morning we transferred the team member to a hospital in Aswan. She continued to improve such that a few days later she was fit enough to re-join the group. I loved nearly every day on expedition but this was probably one of my happiest moments. It is a privilege to be a doctor and incredibly rewarding to see someone recover from illness or injury to achieve their goals.

One of the most important things on such a long expedition was looking after my own wellbeing. This included regular time out to maintain an energy reserve. Running a daily clinic for non-urgent issues enabled this. Common presentations were saddle sores, minor wounds, muscle aches and chronic health complaints. As we cycled through the African continent it became clear to me that I was also there for the team’s psychological health. On the bicycle you have many hours to think and people often confided in me. This was a role I was humbled by. It was a new dimension to my role as medic and initially surprised me. I realised how broad the expedition medic skill set needed to be.

Throughout the expedition I gave advice to the whole team on preventative measures including hand hygiene, hydration, nutrition and cycle safety. Most of the group had one goal in mind; to reach Cape Town. It was my goal to make sure people could do this safely. Each staff member has their own important priorities, be it driving, cooking, logistics or filming. As medic you must be an advocate for everyone’s health and wellbeing throughout. Alongside my medical duties, I was also a general member of staff and expected to muck in with everything and anything. This included helping in the kitchen, sourcing water, food shopping at local markets, assisting with expedition logistics and, of course, cycling! One of my favourite moments was when we reached the Western Cape. I sat in the sunshine on the beach cooking 120 tortillas on the gas hob while watching dolphins jump in the Atlantic waves. I was one of the luckiest people on earth to have an office like this!

After four months on the road we reached Cape Town on 12^th May 2019. I was elated. I had witnessed a group of friends, strangers in January, overcome many challenges to complete an extraordinary personal and physical journey. Each day had been unique. From the flavours of each country to the array of different landscapes we cycled through. It was a truly magical experience.

My top tips for being a medic on a long expedition:

1. Establish early on if anyone else in your team has medical or first aid experience.
2. Maintain your standards and uphold your ethical principles
3. Always say thank you to those you meet along the way. You never know when you will need to call on them in the future.
4. Having some luxury items: mine were a pillow along with some photographs and cards from friends at home

The post Medicine under the stars: Cairo to Cape Town with Tour d’Afrique appeared first on Adventure Medic.

When Elizabeth was a medical student, she could not wait for her final year elective to gain some experience in expedition medicine. This drive took her to join Exile Medics to help provide medical support for a series of mountain trail races in Nepal, run by Impact Marathon Series. The Nepal Impact project involves participants in local development tasks, such as helping to lay pipelines for running water, before they embark on a challenging mountain run.

I have long been interested in remote medicine, but it wasn’t until hearing Professor Chris Imray and Dr Sundeep Dhillon describe their adventures, that I realised it was something that I could get involved in whilst still at medical school. Both of them spoke of their time in the Himalayas, which had inspired me to visit some of the most captivating mountains on earth. You can therefore imagine my excitement when I was invited to join the 11-strong team of doctors and paramedics to support runners of a mountain marathon in Nepal.

Before going to Nepal, I was naively confident of the complexities of facilitating a mountain marathon. I am a keen mountain walker and have volunteered to provide medical care at several prominent UK marathons. What could be so difficult in combining the two? Regardless to say, my eyes were opened to the challenges involved in running an event on this scale.

Arrival

I landed in Kathmandu on Wednesday 8^th November and was immediately enveloped into the chaotic bustle of the city.  The unpainted roads teemed with taxis and buses, while swarms of motorbikes swerved round potholes which littered the surfaces. People crowded the roadsides and sat outside shop fronts, many wearing face masks against the dust that choked the city in a yellow haze. That evening I met up with the rest of the team in a bright and busy rooftop restaurant in the city centre. Fairy lights adorned the terrace and mingled with the prayer flags that appeared to stitch together the narrow streets of Thamel. The group had decided that it could not pass on this opportunity to go hiking in the Himalayas, so had planned to go trekking together in the days preceding the race. The activity was highly beneficial for getting to know everyone in the team, their experiences, strengths and expectations, and it vastly helped our professional cohesion during the race itself. It also allowed us to become familiar with the terrain and acclimatise to the environment. Although I had thought the trek was simply a bit of fun, I now appreciate the importance of being comfortable looking after yourself in order to effectively care for other people.

The race itself was being held at Kakani in the Shivapuri National Park. Despite its proximity to Kathmandu, it took us well over two hours by minibus to bounce our way round precarious hairpin bends to our destination. It was an eventful journey to say the least: facing down lorries on dark single-track roads, knocking over electricity wires in one of the villages, and getting out to push the minibus up one particularly steep stretch of track. We were relieved to pull up at last, at the gateway to our campsite.

We were greeted enthusiastically by Nick Kershaw, founder of the Impact Marathon Series. He described the organisation as a way ‘to harness the power of running marathons and to link it with sustainably building communities and bringing people together, leaving a lasting impact on the world.’ Runners from all over the world can sign up to the Impact Marathon, and choose to run a distance of 42km, 21km or 10km to raise money for local charities. Over the next few days I saw the passion and energy that Nick channelled into the event, and the determination it inspired in the runners.

The joy of arriving somewhere late at night strikes you the moment you leave your tent the following morning. At 5.30am I swathed myself in my warmest layers and emerged to join the sunrise yoga session. We trekked up to a small plateau, isolated from the camp by trees on one side and open to the valley on the other. The rising sun glittered on the grass and threw shadows to define the mountains across the valley. Low-lying cloud flowed like white water, obscuring the valley floor and snowy peaks blurred into the pale blue sky. It was truly a beautiful sight.

Preparation

As the medical team, the responsibility of the runners’ safety lies with you. For example, if a runner is ill or compromised, it is your job to educate them on the risks of proceeding. If the race course is unsafe, you must liaise with the race directors to alleviate those risks. And if the appropriate emergency equipment and procedures are not in place, then the event cannot continue.

During the days preceding the race the team mingled with the runners who were staying on site, digging alongside them to bring running water to a nearby village in ‘Project Pipeline’ and joining them for meals in the evenings. Besides adding to the sense of community, it also gave valuable insight into the runners’ lives and helped us to identify potential issues prior to race day. One afternoon, as we worked on the pipeline, a lady was explained that she was taking acetazolamide for the prevention of acute mountain sickness (AMS). This revelation prompted us to give a shout-out during dinner that anyone taking altitude prophylaxis medication should visit the medics in clinic. Acetazolamide is a diuretic which although helpful for the management of AMS could lead to severe dehydration when coupled with endurance running and traveller’s diarrhoea. In addition AMS rarely presents below 2500m and as we were based at 2000m the use of prophylaxis was unnecessary. Our interactions with the runners prior to the race also meant that they felt more comfortable approaching us with their problems. This was especially noticeable with runners who developed diarrhoea and might otherwise have been too embarrassed to discuss it.

Every evening we ran a clinic in a small room just behind the dining hall. Everyone took turns hosting it and I volunteered for each one, eager to learn. It was predominantly people with gastroenteritis or requesting blister care. I enjoyed giving hygiene advice and providing reassurance to worried runners, as well as observing my colleagues at work which I felt would shape my own future interactions with patients.

Besides the obvious care-giving role, our team was also tasked with ensuring the race itself was safe. The day preceding the race we set off to walk the route. The course was a 21km loop which the marathon participants would run twice. It would take the runners through dense forest and along narrow tracks around the mountain and involved over 1000m of ascent.

We met our first obstacle about 4km when the path came to an abrupt halt by a waterfall. A 10m high cascade of water tumbled into a small pool, with a few stepping stones around its edge, before pouring over the edge and down the mountain side. That in itself looked like a risky route to send scores of runners across, which images of slips, twisted ankles or fatal falls coming to mind. However, the worst was yet to come as we discovered that the path beyond had been obliterated by a small landslide. More ground crumbled away as the team carefully traversed the missing section, holding on to wire netting which was bolted to the cliff face. Scenic as it was, we could not allow the race to pass this way.

About half way round the route, we came to another place where the path had been destroyed by a landslide. This section was more easily passable so it was decided that with the assistance promised from the military, and appropriate warnings to the runners, it would be acceptable to allow the pass to pass this way. It was also located close to the evacuation point, the only place with vehicle access on that half of the route.

Upon our return to camp our team leader initiated a discussion with the race directors about the state of the route. Following this discussion a smaller group headed out, before dusk fall, to find an alternative route to cross the waterfall that would not compromise on the safety of the runners. The experience highlighted to me that a race director’s objectives do not necessarily correlate directly with the medical team’s objectives, so robust lines of communication are key when providing an exciting race which does not compromise on safety. It was unsettling to discover that we had the power to call a halt to the entire event, but by working effectively with the race organisers a suitable solution.

That evening was a whirl of activity as we prepared our kit bags and discussed the allocation of medical teams along the route. Both location and distribution of expertise was carefully considered in light of the terrain, potential injuries and distance to the evacuation points. We had a mix of skill sets within our team including paramedics, emergency medics and orthopaedic trainees. As the most junior member of the team it was decided that I should be paired with one of the more experienced doctors, Andrea, to be stationed at a point halfway along the 10km course, at the bottom of a steep descent. The rest of the group were split so that there was one paramedic and one doctor at each checkpoint, the remaining two medics forming a moveable team based at the start/finish line.

Race Day

A few of the teams had to be up before dawn to trek out to their designated locations round the course. Andrea and I were lucky that we didn’t need to be in position before 11am, so spent a more leisurely morning before hiking down to our checkpoint. I quickly understood the value of familiarising yourself with the route beforehand. The 10km stretch that now formed part of the route for all three races, owing to the change of course, was the only section we hadn’t explored the day before. Consequently, Andrea and I were unsure about where would be best to base ourselves. We had no map, only instructions to situate ourselves at the bottom of the descent, where we anticipated we would see the greatest number of ankle injuries, and a description of the route as ‘going 5km downhill and then 5km back up’. As we set off we soon realised that that description didn’t do the route justice. It was over very steep and exposed terrain which was rocky, loose and uneven. After descending to where we judged to be half way we discovered a flatter patch of ground, with some shade and running water, which seemed an ideal spot to pitch a checkpoint. However, we could see the track continuing downwards, so I stayed to look after our kit bags while Andrea jogged off to confirm where the lowest point of the descent was. After half an hour she reappeared, breathless from running and bearing the news that she still hadn’t found the bottom. In the end we set up our medical station and the next food and water checkpoint a further 1km along. It was situated at crossroads where runners would loop back to re-join the track to the start, giving us a convenient vantage point from where we would see all the runners twice.

Good communication is essential in any situation. Whilst working in the UK, I would frequently rely on having phone or radio signal with which to communicate with my colleagues. Prior to arriving at the race, our team had been informed that the army and local police would be assisting with the marathon, and that individuals with radios would be stationed at each checkpoint. However, it transpired that the police were not allowed in this area of the National Park due to its proximity to a military base. We were later informed that the army would only staff the section with the landslide. It was just as well several members of our team had had the forethought to purchase a local sim card while in Kathmandu. One of the factors making the mountain marathon an extreme event, was the fact that there were large sections of route where the runners were completely isolated, perhaps with several kilometres to the next checkpoint. Therefore, if a runner were to be injured or fall ill along these sections we would have to rely on passing runners to relay the news to us so that we could investigate. As simple as this method sounds, it was a lot more challenging in practice.

At about 1pm, Andrea and I started hearing reports about an injured runner on the section of route beyond our station. We were currently busy at our checkpoint, and the accounts we were receiving were vague. With confusion over the location of the patient and nature of the injury we decided it was best to wait until more solid information could be gathered, instead of rushing to assist an ambulant runner and leaving the medical station unmanned. For me this was a key learning point, as it emphasised our lack of resources and the risks of spreading ourselves too thin. However, we needed to investigate, and so directed a couple of the race facilitators on a motorbike to scout out and transport the patient back to us. A quick assessment suggested it was a fractured ankle. We arranged for the ambulance to come down from the finish line to collect and transport the patient to hospital in Kathmandu.

Putting aside the medical treatment of this patient, I found it fascinating to reflect upon the challenges of resource allocation when responding to medical incidents. While we had the time to consider our response to this injured runner, the multistage approach to her evacuation meant we could also assess and evaluate the use of our resources. The patient was fortunate that her fracture was undisplaced and with appropriate immobilisation, relatively pain free. Thankfully this was the worst injury to occur during the race but we had to ensure that we were always prepared for a time critical medical incident, such as a cardiac arrest or major trauma. Therefore, it made me think how we might have responded to another more serious emergency while all our resources were being used to evacuate this runner.

All races finish with the sweeper who runs the course at the end and ensures that there is no one left on the route. A highlight of the day for me was joining the sweeper who had caught up with the final runner. Andrea and I packed up our checkpoint and ran alongside them. We provided encouragement as they determinately climbed to the highest point at the Stupa overlooking the village, and then accompanied them under the rippling streams of prayer flags for the final descent to the finish line. It emphasised how we weren’t just there for the physical health of the participants but also to improve their general wellbeing and motivation on what was a tough race.

Farewell

The whole trip flashed by much too fast and at the end of the week I was sad to bid farewell to the team. It was an incredible experience which has opened my eyes to the challenges of working in extreme and remote conditions and inspired me to include expedition medicine in my future career.

I enjoyed working for Exile Medics, an organisation that seeks to provide expert medical care for expeditions and sporting events all over the world, who I have found to be extremely supportive of students looking for experience in these fields.

Top tips

• A good sleeping bag! There is nothing more important than being able to have a good sleep at the end of a long and busy day, and being able to stay warm throughout the night is key. Similarly, a pair of ear plugs can also be handy.
• Bring a large bag of Haribo, or other sugary snack of your choosing which doesn’t melt. These are great for making friends and helping morale.
• It is always worth staying awake for that meteor shower despite the early start the next morning. You may be tired but you won’t regret it
• Do a bit of research about your country of destination before going. I always make sure to know what to expect from the weather, have a plan of what I want to see and do and to learn a few basic phrases in the local language.

The post Mountain Marathon Medicine in Nepal appeared first on Adventure Medic.

Marcus is a former president of the Oxford Wilderness Medicine Society, now working in Southern Mali. In April 2018, he successfully ascended to Everest’s North Col (7050m) as part of a charitable expedition to raise money for Community Action Nepal. Here’s how he found himself eating a Michelin-starred meal perched on top of the world.

The wind rattled my jacket as I stared up at the near-vertical final section of ice wall to Everest’s North Col. The exhaustion was unquenchable and, as I fought the desire to curl in the snow and sleep, my groggy, hypoxic brain reminded me again just what a shockingly bad idea it thought this was.

I was at 7000m, struggling for breath and coughing till I gagged, for a charitable endeavour (though in a professional capacity). A few months previously I had been asked to join Neil Laughton’s Highest Dinner Party expedition as team doctor. The plan (simple really) was to climb to Everest’s North Col before donning black tie and sitting down to enjoy a three-course, two Michelin Star meal washed down with champagne, Scotch and port. The highest black tie dinner party ever. All in aid of Community Action Nepal, Doug Scott’s powerhouse charity that’s been working to help Nepal’s mountain communities since 1991.

Kathmandu

Getting to Kathmandu (from Mali, where I currently work) involved 30 hours in the air, four airports, 80kg of medical and climbing kit and hours of arguments with Delhi Airport’s transfers’ desk to get it all safely onto my flight to Kathmandu. Arrival saw us crawling through Kathmandu’s glacial traffic before a quick shower and an eight-hour drinking session at the hotel bar as we all got to know each other.

The group, fifteen in total, was as diverse as it was interesting; a seven-summiting explorer; an adventuring architect; a Manhattanite future business titan; a globetrotting travel writer; a spearfishing city lawyer; and an Aston Martin-racing, space-visiting online entrepreneur and his sporting sons, an international bobsledder and an Aston Martin-crashing champion triathlete. An evening of stories washed down with beers, Black Russians and whisky set the stage for the next month, even if that stage were to change dramatically over the coming weeks.

Kathmandu was considerably more ramshackle and tumbledown than I expected, the whole city choking under the weight of enough cables and wires to encircle the world multiple times. Some telegraph poles were laden feet deep in what must have been decades of cabling detritus. Surely it couldn’t all be in use, I thought. It looked like a city-wide modern art project gone terribly wrong.

I used the few days in Kathmandu to source the majority of the medications I’d need for the trip and the last few pieces of equipment I hadn’t been able to buy in the U.K. Deciding what to take and what to leave at home had been difficult: it was crucial I had enough to manage the conditions I was likely to see but equally important that my equipment was compact enough to accompany me up the mountain. I sought advice from colleagues who’d climbed Everest, as well as the wealth of expedition medicine literature now available on the internet.

Kathmandu was also home to a good friend from university who had been in Nepal for the past year working with Partnership for Sustainable Development Nepal. It was great to escape Thamel, the tourist epicentre with its gap yah students and dreadlocked hippies. Over beers in a little bar overlooking Buddha Stupa we caught up on his work, and his trekking, ski mountaineering and mountain biking adventures over the past twelve months.

From Lhasa to Everest

We would be tackling Everest from the northern, Tibetan side so after a couple more nights out exploring Kathmandu we boarded a flight to the Tibetan capital Lhasa and were treated to our first glimpse of Everest and the high Himalaya.

Tibet’s most unexpected offering was its food. The jewel of Lhasa isn’t one of the ancient monasteries or other cultural attractions but a small, steep staircased restaurant, the Tibetan Family Kitchen. On the sharing table, a rather liberal approach to ordering offered up a wonderfully glutinous and varied selection. If you happen to find yourself in Lhasa, and if you’re able to locate the restaurant tucked away down an alleyway, try the Yak Momo. Delightful.

Restaurant reviewing aside, we also visited a number of the valley’s monasteries, including the expansive Potala Palace. Dating back to 1645, the palace was the home of the Dalai Lama until 1959 when he fled to India in the Tibetan uprising. Comprised of a thousand rooms it stands regal overlooking the Lhasa Valley. It was a fascinating glimpse into Tibetan culture and the role of Buddhism in shaping the region.

Being at 3650 m, we also got our first taste of Acute Mountain Sickness (AMS). I was mindful of Gonggalanzi et al.’s 2016 paper which showed an AMS incidence of 36% amongst tourists visiting Lhasa from lower elevations. A few of the group suffered mild symptoms, included headaches, sleep disturbance and nausea, otherwise we all adjusted very well. Many had been to altitude before but, as many hadn’t, we made sure to advise on ways to avoid and minimise symptoms.

Road tripping

The road trip to base camp involved a few more monastery visits, games of toothpaste roulette, questionable roadside food and some intergroup flirting with the Salomon Freeski Team, whom we’d met over dinner in another excellent restaurant. The five-man team, including Cody Townsend, were en route to the 6952m high unskied Colangma peak to attempt a first descent.

In Thingri, a two-day drive from Lhasa, we spent a morning scrambling up some of the surrounding foothills to a collection of prayer flags looking down on the town below. The amateur geologists in the group, of varying levels of self-appointed competence, marvelled at the rocks. Excellent examples of lava balls on show, according to Ralph. The rest of us admired the views.

Like many of the Tibetan towns we passed, Thingri was a structural dichotomy. A falling down, ramshackle high street alongside just-completed lines of whitewashed buildings. However, the new dwellings, rows and rows of them, were always eerily empty, never anyone in sight.

Prior to the trip various people had scoffed when I mentioned that on the northern side it was possible to drive to base camp, avoiding the trek in required on the Nepalese side. I had wondered whether we were to miss a major part of the Himalayan experience. How wrong I was. Top Gear may claim to have found the world’s greatest driving road – the Transfăgărășan Highway – but they clearly haven’t driven the Zhufeng Highway. Miles of achingly perfect blacktop spaghetti wound its way up and over 5000m passes, every hairpin leading us closer to Everest’s iconic North Face.

The tarmac ended just a kilometre from base camp, and we bumped and scraped the last few meters into our new home. Camp offered the best view yet of the mountain and was infinitely more picturesque than I had envisaged. Before the trip I’d read about the rubbish, human waste and mess that littered the mountain but here it was immaculate. Individual tents were laid out neatly under the burning sun with a carpeted mess tent for us all to eat together. Glamping at 5200m.

A place of essential simplicity

We had five days at base camp to allow for acclimatisation. We filled our time with treks on frozen lakes, a practice black tie dinner, sunbathing, reading and the odd team photo. Soon the group would split in half, eight of us would go onwards towards the North Col while the others would travel back to Nepal overland and fly home.

One evening, as I strolled from my tent to dinner I looked up at the face as the last light drained out of the valley. Everest was silhouetted against the blue-black sky. Might just provide the perfect background for a night-time shot, I thought. The following evening I layered up, set my camera on a mini tripod on a tray balanced on top of a camping chair and tried to turn my imagination into reality and shoot an image worthy of the setting.

“All around, the world’s biggest peaks soared into the night, the stars casting blue light upon their cold silhouettes. We were far from home, yet the place felt like home, or at least an extension of where I most wanted to be. It was a place of essential simplicity. There was up and down. There was light and dark.” — Robert Birkby

Beyond base camp the next major goal was advanced base camp (ABC), a two-day trek away. The route took us up the Rongbuk Glacier and onto the Magic Highway, where the track ran alongside the glacier’s towering ice pinnacles. The first day’s six miles ended at Interim camp where we spent a night camped amongst the yaks who’d followed the same trail we had, albeit carrying significantly heavier rucksacks.

By now many of us were riddled with Khumbu cough, our airways irritated and angry thanks to the frigid, dry air. Climbing out of my tent in the morning nearly always guaranteed a coughing fit as the change in air temperature tickled my bronchi. By mid-afternoon, snow had begun to fall, quieting the valley and muffling the coughs rising from our tents. Come morning the valley was transformed, orange tents dotted in snow, like overboard life rafts in a frothy ocean.

We trekked upward for another day, the path always rising and falling, twisting and turning, breathlessly wiggling up the valley. By the time we all arrived at ABC at 6440m the cloud and chill had descended and the snow belted us from behind, necessitating extra layers to keep warm.

Into thin air

Once over 6000m, life became painfully slow. Even the most mundane activities took minutes of puffing to recover from. Getting in a sleeping bag, getting out, standing up for dinner and packing a rucksack all seemed a colossal effort. In fact, in order to minimise activity as far as possible, I set up my bed at the far end of the mess tent, within centimetres of the table. Only the toilet required me to venture outside.

At over 6000m everybody’s health had begun to slowly deteriorate and the task of deciding who was sick became surprisingly difficult. All healthcare professionals pride themselves on an ability – gained from seeing thousands of patients – to instantly judge how unwell someone is. Sat in the mess tent trying to force down Spam and potatoes I realised that my medical judgement was uncalibrated for such an environment. Everyone looked exhausted, no one wanted to eat, we were all breathless, our faces sun burnt and puffy. Who should I be worried about?

I decided I needed some technological assistance and pulled out a saturations probe. We passed it round the table and I looked on as it muddied the waters. Saturations ranging from 40% to 70% with seemingly no correlation to one’s apparent health. Those with the lowest figures seemed to be the strongest climbers, and those who looked the most broken had the highest numbers. I decided that comparison offered the safest and most reproducible means of patient assessment. Looking around the group I made a subjective judgement of the baseline and then decided who deviated below it. It wasn’t perfect, but in an environment as warped and foreign as the upper reaches of the Himalaya it was the best I had.

Anyone with an interest in high altitude medicine will know about the research expeditions carried out by UCL’s Xtreme Everest group. Their pioneering work has revolutionised our understanding of high-altitude physiology and pathophysiology and the breakthroughs made on the sheer slopes of Everest have laid the groundwork for a deeper understanding of the role of hypoxia in critical care medicine. I had reread many of their papers as I prepared for the expedition, in particular their startling 2009 paper detailing the results of arterial blood samples taken at 8400m after successfully summiting. They showed arterial oxygen saturations as low as 34% to 70%, a staggering variation and a level of hypoxia previously thought incompatible with life.

Thanks to one or two hyper-social members of the group our mess tent became a meeting place for other climbers on the mountain, with tea and Pringles offered at all hours. While there were a number of large expeditions on the mountain there were a surprising number of independent climbers or small teams. We spent three days and nights days at ABC acclimatising further and preparing ourselves for the next part of the ascent, the fixed ropes to the North Col.

Having experienced the weather closing in on previous days, we convened a group discussion and decided to leave at first light, giving us ample time to hike out of base camp to the base of the face before tackling the fixed ropes to the col.

Shocked

During the preceding weeks the route up the fixed ropes to the north col had been described as anything from a ‘snow slope’ to ‘a little steep in places.’ However, as I stood at the base watching the single file row of ants moving up, it looked impossible. Walking on the flat was exhausting, let alone 600m of vertical ascent. I pleaded silently for something that would offer me a way out, a medical emergency that required my assistance perhaps? But the group plodded on and I resigned myself to the fact that the only way was up. I hadn’t come this far to give up at the mere thought of hours of breathless misery.

On the climb the weather alternated between brisk snow filled gusts and periods of skin peeling sun. I was either putting on suncream or a down jacket. Although both were an annoyance they necessitated stopping which gave me an excuse to stand – no, lie – and catch my breath. As the hours wore on, I tried myriad ways to distract myself, including thinking about what I’d write of the trip when I got back.

Through the hypoxic haze a quote from Krakauer’s Into Thin Air came floating back to me.

“Above the comforts of Base Camp, the expedition in fact became an almost Calvinistic undertaking. The ratio of misery to pleasure was greater by an order of magnitude than any mountain I’d been on; I quickly came to understand that climbing Everest was primarily about enduring pain.” — Jon Krakauer

By the time I crawled into the tent I was utterly spent. The fatigue was unlike anything I’d experienced before. At sea-level, after a marathon or a hundred-mile cycle the body is exhausted but knows what it needs to replenish and recover; food, water and sleep. At a touch over 7000m we were higher than every other mountain on earth, except those nestled in the Himalaya, and the exhaustion gnawed away inside me.

It took nearly 30 minutes to work up the energy to find and take the paracetamol and ibuprofen that I hoped would dull my throbbing head. Finding my stethoscope took as much time again. I’m not sure how accurate my subsequent auscultation was but I semi-confidently decided my tent mate wasn’t developing pulmonary oedema, despite his laboured grunting.

At various opportunities I had bored members of the group with my interest in high altitude physiology and I figured there was no better time to consider my deranged internal condition. I thought back to lectures at medical school and the textbooks I’d read.

In medical parlance, shock may be defined as ‘a condition where the tissues in the body don’t receive enough oxygen and nutrients to allow the cells to function.’ Understandably, if not reversed by prompt and appropriate treatment such an insult can lead to cellular death, organ failure and loss of life.

It occurred to me that high altitude mountaineering is the most effective way of pushing an otherwise healthy body into a state of recreational shock. Shock induced not by physiological dysfunction but by our species’ relentless desire for adventure and exploration.

Dinner is served

An utterly sleepless night was followed by one of the weirdest outfit changes of my life. Layers of thermals, fleece and goose down replaced by a creased shirt, crumpled dinner jacket and bow tie. The table was set and we assembled for dinner, albeit at 8am. Jane and Sadie were in their ball gowns and weren’t the only bare legs on the mountain, Jon endured the three-courses at -25℃ in his kilt. I had forewarned him that a mere kilt was not a suitable outfit for Everest, more specifically that I would not be responsible for treating any subsequent genital frostbite. If he looked down to find a blackened appendage in the coming days, he was to keep it to himself and silently curse his stupidity.

The setting couldn’t have been more different from our practice meal at base camp. The menu may have been the same – a Michelin starred selection of miso soup, lamb tagine and chocolate mousse rehydrated on a small gas camping stove – but the glaring sun and relaxed chatter were noticeably absent. However, despite the buffeting wind, swirling snow and crippling hypoxia the food was thoroughly enjoyed. Once record-breaking gastronomic procedures were complete we enjoyed a glass of champagne (opened by sabre), speeches from the expedition leader and our lead Sherpa and then some final unexpected and unplanned hilarity.

Our chairs were unstable at best, summer picnic furniture designed for a firm base and not the icy snow of the North Col. With almost perfect comedic timing our kilt wearing compatriot found the snow collapsing under his chair legs and slowly tilting backwards, crampons flying through the air as he rolled away from the table, his nether regions exposed to both the table and the icy Himalayan wind.

Guinness World Record suitably broken we prepared to descend back to ABC. Having set ropes up above 8000m the night before the Chinese Sherpas were descending haughtily, barrelling past us, moving achingly quick. Some were using up the remnants of oxygen cylinders they’d started higher up. One such cylinder, broken loose and cascading down the mountain in leaps and bounds narrowly missed Jon, glancing his shoulder before careering on. A nasty reminder of how quickly things can turn, sometimes through no fault of one’s own.

Down and out

With everyone safely back at ABC the relief was overwhelming. We still had a long day of trekking to descend to base camp but the hardest part was done. It was downhill from here, the air getting thicker every step of the way as we dreamed of hot showers, greasy burgers and a clean set of clothes.

By now we were under no illusion as to the superpowers our Sherpas possessed. Many were now close friends and we were in awe not only of their apparent indifference to the altitude but their never-ending compassion and selflessness. Some had been up to the col and back multiple times but their exhaustion rarely showed. It goes without saying that western mountaineering has long stood on the shoulders of the Sherpa community and it was a pleasure to climb alongside (well, behind) them. Some of the team were on their first expedition while others were high altitude veterans such as Phurba, who has stood on the summit an astonishing twelve times.

Twelve hours after arriving back at base camp we were on the road, squeezed into two minibuses en route to Kerung, perched on the Tibet-Nepal border. The road was as breathtaking as on the way in and negotiated at about three times the speed as before. The scenery changed all day, as though we were travelling through countless countries. Views of Everest gave way to wide, farmed, U-shaped valleys and finally steep, pine-lined river courses carved by the thundering power of Himalayan meltwater.

After dinner in Kerung we asked our Chinese minder where we could go for a few drinks. We ended up in a gaudily tiled, red velvet nightclub. The waiters, Bieber-inspired Nepalese boys in their late teens, alternated between serving drinks and competing in increasingly vigorous dance-offs, of which we obviously joined in. A big night was capped with the best street food I’ve ever eaten. Tibetan gastronomy, a true revelation.

At the border we exchanged Tibetan tarmac, efficiency and progress for Nepalese dirt, delays and stagnation. We left a cavernous, echoey, airport-esque border post, crossed the river and were greeted by a row of rusting corrugated iron shacks. The next sixty miles to Kathmandu took over fourteen hours as the rock strewn, mud-hole ribbon of road looped around the mountains and valleys. The views were stunning, as views generally are when you spend hours only meters from a free fall death into the valley below.

Back in Kathmandu and with only a few days before we all began departing for home we enjoyed the rich air and beer gardens. We were honoured to be invited by Doug Scott to a Community Action Nepal banquet on our final night, a celebration of the incredible work they’ve done over the past three years rebuilding after Nepal’s devastating earthquake.

We had spent the previous weeks intensely focused inwards on our goal and ourselves, everyday ensuring we made forward progress. It was fantastic to finally step out of that world, hear stories of selfless devotion and meet those who had dedicated years, or more often decades, to improving the lives of those living in Nepal’s beautiful, breathless and inhospitable mountains.

Pictures and Video: Marcus Stevens (Instagram: @ghystem)

The post Majesty and Misery: Dinner on the North Col appeared first on Adventure Medic.

In late summer 2018, undergraduate students Merlin Hetherington and Alex McMaster set off on their incredible 10,000km self-supported journey by tandem bicycle across Africa, on an epic mission to train health care workers to use Arclight, an innovative eye examination device.  Unfortunately, they have recently been forced to leave the saddle due to health concerns, but are valiantly continuing their mission using a combination of hand-drawn cart and ElliptiGO with Burley trailer.  We first covered their trip back in November, but recently caught up with Merlin, who told us a bit more about the device and their adventure so far.

How did the idea for the trip come about? Why did the Arclight inspire you?

I started getting interested in eye care services for low income countries as I was working on my dissertation project. A lot of blindness is preventable or treatable. I realised that protecting sight was a worthwhile cause that would have a positive impact on someone’s life and family, so I wanted to get more involved. My dissertation project involved the Arclight device and some associated training tools. This device is set to be quite ground-breaking for eye-care in low income countries but needs to be introduced to health professionals working in these places.

At the same time my flatmate and I were interested in undertaking big trip. We had done some touring on a tandem in Europe and felt like we wanted bigger. The prospect of big wilderness; deserts, mountains and forests; the unpredictability of travel in what is largely a developing continent excited us.

What exactly is the Arclight device?  How does it lend itself to use in a low-resource setting?

The Arclight is a combined ophthalmoscope and otoscope. Significantly it’s also solar-powered and much easier to use than traditional devices. It was designed by the University of St Andrews specifically as a tool for low-income countries and its very affordable. In the UK it retails for £48, but for low-income countries it can be acquired for just £10. Any profits from sales in the UK subsidise distributions to low income countries in Africa and South East Asia.

Ophthalmoscopes and otoscopes are typically designed for the needs of wealthy countries and tend to be expensive and require replacement parts. This means that very few practitioners in low-income countries have these essential tools.

The Arclight’s patented design means it is a much more compact device, making it easier to use and not require replacement bulbs or batteries. Studies have shown that it performs as well as traditional devices that are up to a hundred times more expensive. Dr Will Dean at the London School of Hygiene and Tropical Medicine described it as a “game changer” for the prevention of blindness in Africa.

If someone is familiar with direct ophthalmoscopy, it does not take long to show them how to use the device. Even newbies pick it up fairly quickly so we also carry with us small simulation tools also made by Arclight. These simple tools simulate 24 common disc and retinal pathologies. The teaching sessions end up being quite busy and interactive.

How have you identified healthcare teams or populations to target along the way?

We worked closely with Ronnie Graham who is an advisor for the International Agency for the Prevention of Blindness. Firstly, he was able to give us a much better idea on the eye care situation in each country and which groups to work with. We then started by contacting National Eye Care Coordinators in each Ministry of Health and allowed them to direct our training to where they felt there was most need.

We have trained a lot of medical students and optometry students. They will become the future of healthcare in their countries and will also be posted to the most remote and rural areas once they complete their training – with an Arclight in hand they have the agency to improve eye-care services.

How did you organise the logistics for such a significant trip? Will you have any in country support along the way?

The logistics have been mammoth and the whole project was nearly a year in the planning. As with any venture, things started with trying to secure the funding. Once that was in place we spent three months trying to line up distributions and contacts in each country. Luckily the university provided us with accommodation during this time and we had a lot of support from friends, family and university staff. We ended up taking a trip to Ethiopia to present at the conference for the College of Ophthalmology for Eastern Central and Southern Africa. This turned out to be extremely helpful for making contacts and when firming up plans with eye care representatives in the countries on our route. The finances, distributions, social media, risk assessments, insurance were all needed to be covered. Additionally we had the cycle itself to prepare for, specialist kit to get, route planning and a training schedule to stick to. I’m really glad we had the two of us were so focussed and the support of the University of St Andrews and the Scientific Exploration Society has been crucial.

What about considerations for your own health and wellbeing along the way?

Your own health and wellbeing should be the main concern in any expedition. Naturally, preparation and planning for this started before we left. We found the trip had many risks, from road traffic trauma and human threat to the extreme heat and exertion in a tropical environment – we had to consider many potential problems. It surprises a lot of people that in most of the countries we planned to go through there are no emergency response services, that an ambulance isn’t going to pick you up. Therefore we have a satellite device with us. This can alert a global response centre and coordinate a rescue and if we don’t make our daily check-in an alert will be raised.

We had situational awareness and self defence training through Personal Safety London. We also have tailor-made trauma protocols based on the kit we are carrying – chest decompression and improvised pelvic stabilisation. We have an acute trauma kit on a frame bag, quickly accessible on the bike. In addition we have an extensive first aid kit including antibiotics and a malaria self-test kit, packed away in one of the panniers.

Eight-months on a tandem is a long time to spend constantly with someone, even your best friend. For our own sanity and mental health and to have an enjoyable break we made plans for our parents and my girlfriend to come out for a visit halfway through.

Not everything can be planned for and one of the hardest decisions was recognising that continuing in saddle wasn’t a good idea. Hours of pressure on the perineum can cause numbness and tingling which can lead to long-term damage. When you’re so invested in something, it’s easy be in denial and ignore the need to change your plans. Thankfully, that is the difficult decision we have come to.

So what is next if you are not continuing on the tandem?

We took a few days to reflect but both agreed we still wanted to try and make it to Cape Town under our own steam and fulfil our Arclight objectives. We started trying to find alternative ways moving south towards Cape Town. The best solution we could find was to build a hand drawn cart and start walking. This has been an amazing twist for us and has seen us walking through some of the most isolated areas of the Masai Steppe. However it can’t be a long term solution as we still have thousands of miles still to go. It looks like we might be able to get help from Elliptigo and Burley to continue on wheels without the pressure of a saddle. They look like really interesting bikes that you ride standing up, without a saddle – a bit like a gym cross-trainer.

How can we follow your progress?

Instagram and Facebook are the best ways to follow us, we post short updates and photos fairly often. All these accounts can be found on our website where there is more information about our project and there is also have a live tracking map so you can see exactly where we are at any given moment!

How can we support you?

The value of all the Arclights we intend on distributing is £20,000 and we decided to be ambitious and try and raise that money through a crowdfunding page. So far we are about two thirds of the way there, so are looking for more support. The page has now closed, but people can donate to our cause through the University of St Andrews

However, our aim isn’t just to raise money and bring attention to the Arclight. We hope our project will inspire people, young and old, to be more adventurous and take on a challenge. We also hope to bring attention to issues that, in a globalised world, affect all of us and it is our collective responsibility to do something about. Therefore telling people about our trip, either on social media, at work or over the garden fence really helps us out, so please spread the word!

Further Information / www.arclight-tandemafrica.com

The post The Arclight Crosses Africa appeared first on Adventure Medic.

You may remember Ali Brookes as the calm and cheerful junior doctor on Bear Grylls’ reality survival series ‘The Island’ in 2018. Now back in O&G training in London, Ali tells us about the highs and lows of island life, from jungle critters to dehydration, epic thunderstorms and intense friendships. Surviving five weeks on The Island formed the spring board to an amazing adventure-fuelled year, from to trekking the 1300km Te Araroa trail in New Zealand, to travelling around South America and Canada. In her article, Ali discusses burnout, negotiating time out of training, the joys of freedom and navigating the return to work.

Taking time out of training is always a difficult decision. When is the best time to do it? Will they approve my application? Will I be able to afford to take the time out? Will it be detrimental to my training? Will I make an arse out of myself and commit career suicide by going on reality TV?! These were all questions that I asked myself at some point during this process.

I was an Obstetrics and Gynaecology ST2 when these thoughts starting ruminating around my head. I had recently got married and, faced with the increasingly daunting prospect of ‘grown-up’ life, I had incredibly itchy feet. I felt that I desperately needed time to tick a few things off my ever-growing bucket list.
I knew it wasn’t a good time to take an Out of Programme Career break (OOPC, or ‘Oopsie’ as it’s more often known). The progression to ST3 in most specialities is a difficult one and O&G is no exception. However, I weighed up all my personal circumstances (no kids, no mortgage, patient and understanding new husband) and decided that this was the time for me.

I was also experiencing burnout, something I’m sure other junior doctors have felt too. I had lost touch with almost all my extra-curricular passions, resented going to work, felt lost in an increasingly stretched system and needed a break from it all to figure out what my priorities were. Many of my friends from medicine had relocated to Australia and New Zealand and with the quality of life over there, I didn’t blame them. Others had left medicine all together, in pursuit of alternative careers less demanding on their time and emotions and more beneficial for their bank balance. I really wanted to find a way to reinvigorate my passion for medicine and allow me to continue working in an NHS that I am incredibly proud of.

Having made the decision in February 2017, I submitted my application for an OOPC well before the deadline with the required signatures from my Educational Supervisor, Training Programme Director and Head of School. Whilst these were rather intimidating conversations to have, everyone was very understanding. They were also remarkably interested in the fairly unorthodox provisional plans I had made. ‘Send me a postcard’ were the last words from Mr Ward, the London Head of School of Obstetrics and Gynaecology, as I skipped out of the door. (I actually feel bad that I never did send one!) With approval granted and formalised in writing the next day (never before have I experienced such efficiency within the NHS), I set about planning my year. I wanted adventure, I wanted extreme and I wanted to fit in as much of it as possible within the year.

I had always been a big fan of ‘The Island with Bear Grylls’, and was sitting in the pub with some fellow O&G trainees one evening when a friend piped up “Have you seen this advert Ali? It sounds like it would be right up your street.” For those who don’t know, it’s a reality TV show where Bear Grylls puts 16 people on a desert island for five weeks with just the clothes on their backs and a few basic tools. You have to survive by finding water, catching and killing your food and building shelter until he comes back to collect you. The crew live alongside you under the same conditions and there are definitely no hidden luxuries.

Sure enough, a few beers down, I wrote my application for ‘The Island’ on the bus on my way home. Not thinking much more about it, I continued to plan the main event of my year: the Te Araroa trail. This is a 1300km hike down the length of New Zealand’s South Island which I was planning to do with a friend.
A few days later I received a phone call from the television company and had a phone interview. I was then asked to go in for a face-to-face, filmed interview. It all started to get a bit real.

I was about to go to work on my final night shift in October when I received the call. “Ali? Are you sitting down? We want you to come on The Island with Bear Grylls!”
Sworn to secrecy by the television company, I went to my night shift jittering with excitement about where I might be spending the night in a few weeks’ time. The preparations for the show then began in earnest. Medical assessments, camera training, psychological reviews, meetings with the production company, sorting out kit and filming at home and work. It was amazing to have an insight into a completely different industry. We flew out to the filming location in late October. We had a few days of survival training where we were taught how to make fire by rubbing sticks together, build shelters that might protect us from the monsoon season (they didn’t, it turns out), humanely kill crocodiles and snakes, filter and boil murky ground water to enable us to drink without getting gastroenteritis and to identify which scorpions were poisonous and which ones would just really, really hurt. We were isolated from the other Islanders so I had no concept of who I would be spending the next five weeks with.

As an Obstetrics and Gynaecology trainee, I was more than a little nervous about the potential medical emergencies that I may be presented with on the island. There were the obvious contenders: diarrhoea, dehydration, sunstroke, infected bites, machete wounds. But would there be more difficult challenges? Snake bites, shark attacks, falls from cliffs (as had happened in the previous season), rip tides… All a little different to managing the labour ward in London! And would I be able to cope trying to help others whilst surviving on the bare minimum of food and sleep myself? Little did I know that there were two other doctors (both GPs) and a nurse who were also going onto The Island. Between us we managed to keep everyone in a state of relative health for the duration.

The day we got dropped off (or should I say thrown out of a boat into the rough sea 300m from shore) was such a mixture of nerves, excitement and apprehension. I was conscious that we would only be given 24 hours’ worth of water when we arrived, so I had drunk a lot of water in the morning. When the main man Bear Grylls arrived to take us out on his speed boat I ended up having to be lowered off the back of his boat to pee…twice! Not a good start.

My time on The Island was an absolute rollercoaster. Nothing can prepare you for the intensity of the experience. We spent the first night on the jungle floor, soaking wet after our swim to land, freezing cold and being eaten to death by jungle critters. We didn’t find any food other than coconuts (which unfortunately are a personal nemesis of mine) for eight days. The water we drank was from a muddy puddle. This would refill with each deluge of rain that occurred almost nightly for the first three weeks. It was impossible to sleep for more than half an hour at a time before being woken by the next thunderclap or downpour. I had one particular moment of desperation near the end of the experience when I was curled up on the beach at night and the heavens opened again! It was pitch black, our camp had flooded, the fire was at risk of going out, we hadn’t eaten anything more than a morsel of yucca for days, and I was wondering around in the dark trying to find dry firewood in the middle of a monsoon. “What the hell am I doing?”, I thought to myself. “No one forced you to be here. You are here by choice.” But even in those darkest moments, quitting never crossed my mind. Not only would I have felt like the ultimate failure, but after all my ‘tough girl’ talk to my friends and family back home, I never would have lived it down.

Whilst there were incredibly dark moments on The Island, I also had some of the best days of my life. Living on a beach on an uninhabited island in the middle of the Pacific Ocean, where we could watch the sunset every evening in total stillness, was a true privilege. Eating crackling off a freshly killed wild boar (which evaded our capture for longer than I would like to remember) roasting over an open fire; the pure elation at finding yucca for the first time; the sweetness of fresh pineapple after a month of no sugar; the relief when the rain came when our muddy puddle got empty. I made amazing friends. Living through that kind of trauma (and it was a trauma, albeit a self-inflicted one) means you get to know people very intensely and very quickly. Without the other Islanders keeping a smile on my face it would have been miserable. We told stories around the fire, sang songs, played rounders, had a talent show and held the first ever Island wedding. And we survived for 35 long days.
The night before Bear Grylls came to collect us at the end felt like all the Christmases I had ever experienced rolled into one. I couldn’t sleep, I was so excited. I cannot put into words the pure joy at seeing his boat pull up to collect us. We had done it. We survived. Yes, I stank. Yes, my hair looked like a bird’s nest. Yes, I only weighed 43kgs. Yes, I was beyond exhausted. But we had done it. It was a truly unique, once in a lifetime, money can’t buy adventure that I am so hugely grateful and honoured that I got to be a part of.

I flew home a few weeks before Christmas and spent time fattening up again with my family. It was the first year since I qualified as a doctor that I didn’t have to work any bank holidays around Christmas and I thoroughly enjoyed it!

Then came part two of my year of adventure. My good friend Liv and I walked the length of New Zealand’s South Island from Ship Cove to Bluff: 1300kms of trail through the mountains. We were completely self-sufficient, carrying our own food, tent and clothes and did not see civilisation for weeks at a time. I somewhat underestimated the physical toll that starving on a desert island would take and found the first few hundred kilometres (!) really tough. However, we soon found our hiking legs and went on to complete the walk in 68 days. Another truly wonderful experience.

For the final few months of my year off I went travelling around South America and Canada with my incredibly patient and oft neglected husband, Oli. He had also managed to take a three-month sabbatical. I came back to the UK in September feeling incredibly lucky to have had such an exciting, jam packed year with numerous points crossed off my (ever-growing) bucket list.

As October loomed and the end of my year drew to a close, I was very anxious about returning to work. Would I remember how to do a caesarean section? Could I still interpret a CTG? Would I remember my ePortfolio password?! Thankfully, doing a caesarean really is like riding a bike. I have been incredibly well supported during my return back to work and have had no negative feedback from consultants or junior colleagues for taking time out. Quite the opposite in fact.

Taking a career break is a big decision and there is a lot to consider when making that choice. But, in my opinion, it is a wonderful opportunity to see the world, do that challenge you have always wanted to do, go on reality TV if you so wish, and have your job waiting for you at the end of it. I was lucky enough to have a year filled with excitement, starvation, elation, desperation and great adventure. As a result, I feel much readier to come back into training and settle down to that ‘grown-up’ life people keep talking about.

Contact / You can follow Ali on Instagram @ali_wandering

The post From Labour Ward to ‘The Island with Bear Grylls’; How to take an OOPC and avoid an Oopsie appeared first on Adventure Medic.

Surgical Registrar Mr Matthew Doe, on the challenges and rewards of an Out of Programme Experience (OOPE) in Mbale, Uganda. From orchidopexy to burr holes: Matthew tells us about a typical week, and some of his memorable cases. With the right training and preparation, the difference that one person can make in the lives of others is profound.

Its 5pm on a Friday and I’m called to see an 8-year-old girl with severe burns. Helping her older sister cook while her father slept, she had made the fatal error of mistaking kerosene for cooking oil. 24 hours of bouncing between small health clinics and a long, bumpy motorbike journey culminated at Mbale Regional Referral Hospital, a 470-bed government institution in Eastern Uganda.

Calling her unwell would be an understatement. There are more than 60% burns of mixed thickness. Her peripheries are cold, her lips swollen and eyes red. A hasty calculation reveals she is short of eight litres of fluid and she expresses her desperate need in the characteristically direct East African way: ‘you give me water’. It’s a desperate situation.

Let’s go back a step. How did we get here? What led my wife and I to put our training on hold and spend the best part of a year in a corner of East Africa?

An Interest in Global Surgery

As a general surgery trainee with an interest in travel and charity work, I have watched with great interest the growing field of global surgery.

The concept gained its name and widespread recognition in 2015 with the publication of the Lancet Commission on Global Surgery report.(1) Thanks to this landmark research, we now know that five billion people currently do not have access to safe and affordable surgery. Moreover, there are four times more preventable deaths worldwide from surgically treatable conditions than from HIV, TB and malaria combined.

While the statistics seem to illustrate an insurmountable need, the cost-effectiveness of treating surgical conditions provides room for optimism. Surprisingly, surgical services more than pay for themselves in saved disability adjusted life years and subsequent economic growth. We now know that operations like repair of hernia or cleft lip and palate are far more cost effective than public health initiatives such as seatbelt awareness campaigns or even direct treatment of communicable diseases like HIV.(2)

My interest in this topic led me on two occasions to the Global Surgery Frontiers conference at the Royal College of Surgeons in London. Inspired by the stories of consultants and trainees working in partnership with colleagues in low-income countries, I decided to arrange a placement of my own. That said, I chose to take my time and wait until I was a little later in my training and more comfortable with emergency operating. The truth is that any doctor at any grade can be immeasurably helpful in the right place, but I chose to ensure my surgical skills were up to scratch before leaving.

Preparing for Launch

Being a numbered trainee, the best way to take time was to arrange an Out Of Programme Experience year (OOPE). I arranged to spend the first two months of my year shadowing in plastics, paediatrics and obstetrics, as well as locum on-call shifts to help fund the trip. I also did Mr David Nott’s ‘Surgical Training for Austere Environments’ course, which was fantastic cadaveric training that I’d recommend to any surgeons considering similar experience.

Mbale Regional Referral Hospital

My wife and I spent a few months researching where best to work, getting in touch with various hospitals and charities in East and Central Africa. In the end we settled on Mbale, Uganda. Mbale is a small town with a population of around 90,000, but it serves a much wider region right from the Kenyan border in the South to Soroti in the North. The hospital is a 470 bed government regional referral unit, and with a catchment of 4.7 million, it is the busiest of its kind the in the country.

The hospital is big, but by no means big enough. There is a busy casualty, 6 operating theatres and access to sub-specialist care such as ophthalmology, ENT and endoscopy. More than 60,000 patients are seen each year, 5000 of which undergo major surgery. That said, the majority of the services we take for granted in the Western world are absent – notably there is no intensive care and no CT scanner. Major staffing issues mean patients on a 50-bed ward are often cared for by only one nurse. Porters, scrub nurses and health care assistants are non-existent.

Supplies of drugs and sundries are limited and, while healthcare provision is theoretically free, patients will often have to purchase their own antibiotics, sutures or surgical gloves. The wide catchment area combined with an ingrained hesitancy to seek medical care means that many patients present very sick indeed – sometimes several days into a life-threatening illness.

A Typical Week

The work was tiring but unquestionably rewarding. A typical week would start with a morning outpatient clinic where I would see 30-40 patients. Every Tuesday was a grand round of our 50-bed surgical ward, followed by up to 12 hours of elective operating on a Wednesday and endoscopy on Thursday. Emergency admissions were ever present and there would often be two or more theatre cases every afternoon.

Theatre was a challenging working environment. Quality instruments were limited and the autoclave was temperamental. Any overnight rainfall would inevitably delay our list as the linen failed to dry in time. During the three months of dry season there was no running water and the temperature was typically over 30 degrees in an operating room with little airflow. Cotton gowns quickly soaked through with blood or bowel content so a thick apron was essential, as were masks, goggles and double gloving given the risk of transmissible illness. Sweat would drip from my forehead down my nose, meaning I would need to entrust a watching medical student to catch drips in a swab before they fell into the patient.

But despite these challenges the work was incredibly worthwhile. Sadly, patient’s expectations were often low. ‘This is Uganda’ was a common expression used to apathetically explain away the string of disappointments associated with accessing quality healthcare. This made it all the more rewarding when things did go well, especially when the team performed life-saving care in austere circumstances. I remember vividly the power and water shutting off late one afternoon just as we were to start three emergency cases across two theatres. Any developed hospital would have quickly moved the patients elsewhere, but with no other option the team ploughed on by the light of smart phones and with the little instruments and linen available. All the patients did very well and even left hospital later that week.

Memorable Cases

Being one of a handful of general surgeons serving five million people exposed me to a huge range of pathology. Common cases included gastric perforation, sigmoid volvulus, obstructed hernia and intususseption. Interestingly, tropical surgical complaints such as abdominal TB or typhoid perforation did occur, but were few and far between. General surgery in Uganda really is general and I quickly learnt to perform previously unfamiliar procedures such as split skin grafting, paediatric orchidopexy and burr holes for intracranial haematomas.

Quite often the small health centres in rural areas will have one or two medical officers assigned there. The work for them quickly becomes overwhelming, so it’s not uncommon for the poorer or less vociferous families to be ignored. One 7-year-old boy came to Mbale having been neglected at one of these centres an hour away. The puncture mark from a snake bite on his ankle 6 weeks previously had turned to an ulcer and by the time he’d reached us the leg was gangrenous and the thigh full of pus. He was cachectic, conscious, moribund. We performed an emergency high above-knee amputation, but had to leave the stump open, such was the extent of the infection. Amazingly, the child survived and it was joyous to see him return to clinic two months on, smiling, laughing and very confident on his new crutches.

Another success story came in the form of a six-month old baby with intususseption. At 10pm, after a long day’s elective operating, the baby was brought to the doors of theatre septic and distended. Uncomfortably fresh in the memory were our last two cases of infant intususseption, both ileo-rectal, both died the night following surgery. With no access to higher dependency care, the postoperative monitoring and attentive nursing care we need simply wasn’t available. That said, there was no option but to operate, it was their only chance. Once again the intususseption reached the rectum and once again the patient required a subtotal colectomy. Towards the end of the operation access was lost and we hastily fashioned an ileostomy as the baby came round. The baby was handed over the ward staff and I expected the worst. A feeling of dread came over me as I walked into the ward the next day, but miraculously found a crying baby with a functioning ileostomy. The baby was discharged a week later and is still going strong several months on!

Endoscopy, endoscopy, endoscopy

Thursday mornings were always spent in endoscopy. I initially worked alongside a gastroenterologist who was very proficient in upper GI procedures. This meant we could perform up to 16 tests each week, many of which would sadly reveal obstructing oesophageal cancer. However, my colleague was offered a promotion as part of a move to another hospital leaving me to run the department (!) It became clear that no one else in the region was trained to perform endoscopy so we were faced with the possibility of closing the only unit of its kind in the whole Eastern region once I left.

Fortunately the charity PONT that had set up the unit 10 years previously wouldn’t let this happen and they funded an endoscopy ‘camp’, which allowed us to perform 148 upper GI endoscopy procedures over seven days. Crucially, one of my colleagues was able to join in and he quickly became proficient. Since I’ve left he’s been in regular contact and the weekly list has been allowed to go on, saving hundreds of patients from a six hour journey to Kampala or, more likely, no test at all.

The First Surgical High Dependency Unit in Eastern Uganda

Working as a volunteer provided me with the freedom to make my own timetable and I spent my last three months focusing on development projects. Without any higher level of care we would often grit our teeth with anxiety as we handed over a very sick patient to the ward post operatively. A lone nurse on a 50-bed ward is never enough to safely care for these sick patients. The statistics back up our concerns too – an audit (4) carried out before I arrived in Mbale showed that 22.4% of patients (average age 25 years) were dying after laparotomy – twice as many than in the U.K. where the patients are typically older (average age 67 years) and 55% of high-risk patients are admitted to HDU.(5)

For this reason, it was a pleasure to co-lead a project fundraising and preparing the first surgical high dependency unit in Eastern Uganda. The idea had long pre-dated my time in Uganda but as an extra pair of hands I was able to help secure funding from the Royal College of Surgeons of England Christmas Appeal, procure specialist equipment and facilitate training. The whole project was incredibly rewarding and it was a special pleasure to attend the opening ceremony on my very last day in Uganda.

‘You Give Me Water’ continued…

But what of our 8 year old? Well we managed to get access via a neck-line and rapidly poured in fluid to replace her considerable losses. A slug of ketamine anaesthesia allowed us to clean and dress her wounds. She gradually came round in the arms of her mother who was able to finally to give her a drink and a cuddle. She was transferred to the specialist burns unit in Kampala and as far as I know, has survived the ordeal. Her sister was not so lucky and sadly passed away in the night. Such is the grim reality of this setting.

As I write these words I feel a familiar lump in my throat return. Working in Africa is a rollercoaster of emotions; I have never experienced such despair, but equally never experienced such hope. I would strongly recommend a similar trip to anyone considering it. I assure you that the difference you can make is far beyond what you can imagine. Anyone of any grade can be useful providing you choose the right placement. Please feel free to get in touch with me if you’re interested, I would also recommend linking up with the Global Anaesthetic, Surgical and Obstetric Collaboration, a group of trainees passionate about global surgery.

If you’d like to financially support the day-to-day work of the incredible team in Mbale RRH then please do donate to PONT or Born on the Edge, any donation large or small will go a long way to support a people in desperate need. You can get in touch with Matthew via Twitter: @drmatthewdoe. 

Photos: Matthew Doe, Vanessa Champion, Christopher Mullen.

The post Blood, Sweat and Intussusception: OOPE in Mbale, Uganda appeared first on Adventure Medic.

When Iona Taylor set off on her transatlantic voyage as Watch Leader on a 72 ft sailing yacht, she had little idea of the challenges that lay ahead for her and the crew. Weather and mechanical faults blighted their first attempts to make progress, returning them to shore twice. Subsequently, an unexpectedly unwell crew member required Iona to step up and manage and coordinate medical care, made specifically testing by their remote location, limited resources and challenging seas. Here, she recounts her journey, the challenges she faced, and lessons learned along the way.

The Atlantic Rally for Cruisers

Every year over 300 boats rock up in Las Palmas, Gran Canaria to take part in the annual ‘Atlantic Rally for Cruisers’ (ARC): a race, rally or cruise across the Atlantic for the novice or experienced sailor. This year, I participated as one of two Watch Leaders onboard a 72 ft yacht, alongside a professional skipper and mate, and twelve amateur paying crew members. This was a commercially run, unrestricted category zero yacht designed to face and withstand all elements. The medical supplies must conform to strict criteria and, alongside crew medical proformas, are checked prior to every offshore passage.

The crossing

Our ‘once in a lifetime’ Atlantic crossing started like a fairy-tale story with pods of dolphins lighting up the phosphorescence. We were way out in the front of the fleet and blissfully unaware of what was in store for us. After only three days, things started to go slightly downhill as our first issue reared its weary head: a key structural element holding our mast started to split, forcing us to retire from the racing division and head swiftly to the closest landfall for urgent repairs.

The repair was unfortunately faulty and after sixteen hours we were faced with an uncomfortable motor back upwind in heavy weather and big waves to get the whole system replaced. Even after this disheartening start and the loss of a few crew members along the way (retired due to personnel reasons and time constraints, not lost overboard), we finally left land ten days after our initial start, with a powerful optimism to cross this ever-expanding ocean, and the promise of rum on the other side. For the most part (of our now third attempt at crossing) we were blessed with steady north easterly winds, beautiful blue skies and great sun-bathing weather. Our progress was good, and morale was on the rise.

By day five, our luck started to run out yet again, this time in the form of an unwell crew member. He complained he had been feeling slightly under the weather (no pun intended) during his night watch. We agreed it was most likely due to the scorching hot temperature of the previous day and planned to see how he was feeling after some rehydration and time in the shade. Unfortunately, however, I was woken from my off-watch sleep six hours later to be faced with the unmistakable signs of an acute lower limb cellulitis, smack bang in the middle of the Atlantic Ocean. After consultation with the skipper and email communication with MRCC UK (British coastguard who provide offshore medical advice to British flagged vessels) we started an initial course of oral erythromycin. This proved futile given the severity of his infection and we promptly had to escalate treatment to IV benzylpenicillin.

The reality

As easy as this scenario would be to manage on-land, the reality, in this setting, was a completely different ball game. The obstacles we faced fell into three categories:

The ‘who, what, when, where, and why’

The overall responsibility for medical care onboard legally lies with the skipper (when a doctor is not officially employed onboard). In this scenario, I was asked by the skipper to be the primary provider of care. I had telecommunication support available to me provided by the coastguard in the UK and Martinique (our closest landfall and, of course, French speaking). The skipper and I discussed our limitations in effectively and safely managing the patient in the non-sterile, unstable environment on board the yacht, and decided that ongoing treatment on board was likely going to be challenging.

We had several theoretical evacuation options including a helicopter transfer, transfer onto a military vessel or a larger commercial vessel with better medical facilities. Unfortunately, we were six days away from being within helicopter range for a retrieval. There were also no military vessels in the area, therefore our only other evacuation option was to transfer onto another commercial vessel. It was decided that given the significant risks involved with a transfer, the fact that the patient’s condition was currently stable and with no guarantee of better treatment facilities at the other end, the best option was to continue treatment onboard with regular review.

The medical kit

Whilst alongside in Gran Canaria, the medical kit initially appeared reassuringly comprehensive and extensive, but its limitations became more apparent throughout its use mid voyage. Even the insertion of the first cannula was a memorable event on the downhill side of an unforgettably large wave. Issues began to arise whilst drawing up and mixing the antibiotics for injection. It turns out that cheap plastic syringes do not stand up well to the friction of mixing solutes, and with a limited range of syringes available, each injection was given via 5 x 2ml boluses to try to preserve the remaining stock.

With the injecting routine down to a fine art, the day to day maintenance of the line became the next difficulty. With temperatures below deck reaching 32 degrees and the sea state building, keeping the line clean, active and dressed became near impossible. The sticky back of a Tegaderm dressing supplied little resistance to the inevitable layers of sweat and no amount of duct tape and cling film kept it in place for long. With the constant attempted adjustments and reinsertions, I set up a regular IV infusion for boluses to ensure ongoing patency of the line and to preserve our diminishing supplies. Unfortunately, despite our best efforts, the first line (a nice friendly pink cannula on the dorsum of the hand) lasted less than twenty-four hours. The second cannula was therefore upgraded to a grey (with our total stock of 2 pink and 2 grey) located in the antecubital fossa with parts of a sawed-up broom handle as a make shift splint secured with a washing up sponge, yet more duct tape, cable ties and a few towels for comfort. Even with extremely careful rationing, our supplies of needles, syringes, alcohol wipes, gauze, cannulas, sterile water and saline started to run worryingly low.

Sailors always pride themselves with their ability to cope and survive in extreme situations, but even with the best improvisation, it is not possible to create sterile medical supplies, and once again we had to call for support. By contacting the race headquarters, within thirty-six hours we were able to achieve an alongside transfer of equipment with another vessel from the same rally. The pure adrenaline and excitement of receiving a sterile dressing pack and flare box filled with needles and syringes more than compensated for the stormy conditions and difficulties of the transfer itself. These resupplies gave us an extra day of IV treatment before we had exhausted our supply of penicillin. As the patient was showing significant signs of improvement and we were now only two days offshore, we were advised by our medical support to complete the last two days of our journey with once daily intramuscular Ceftriaxone. Without any IM (blue) needles I was restricted to an overgenerous green or inadequate orange. Given the persistent two metre swell and unstable conditions I decided the safest was a whole-hearted insertion of an orange. This whole series of events was unfortunately performed within our one and only spacious area around the saloon (living room) table, with some procedures occurring amidst an array of breakfast cereals or midnight watch change, attempting as best we could to preserve the patient’s dignity and others’ appetite.

Mid ocean isolation

When practising in a large medical multidisciplinary facility you bounce ideas of your colleagues, seek reassurance over a management plan and chat about concerns over a mid-morning coffee. When isolated in the middle of an ocean with professional sailors and a selection of business men there is little medical support immediately available. I was hugely thankful for our midday satellite emails and daily satellite calls providing brief spouts of reassurance, but for the remaining twenty-three hours every day, I could not have felt more alone. The development of some local lymphadenopathy suddenly appeared suspiciously like a groin abscess, and the erythema from the cannula site looked suspiciously like a line infection. Not to mention the rapidly developing oedema caused by the cellulitis making me question the possibility of a DVT. In some respects, it seemed isolating and yet in others, sharing a sailing yacht with ten other people all struggling to cope with the psychological demands of managing care for an unwell crew member, at times it felt crowded and as if there were nowhere to hide.

Conclusions

This ordeal was a demonstration of the camaraderie and strength that can be sourced from a team of complete strangers under challenging circumstances.
Medicine outside of the hospital environment will always churn up unexpected challenges and provide you with new priorities in care and safety. Working as a lone medical practitioner you are wholly reliant on your own skill set for clinical decision making and prescribing and administration of appropriate drugs. You must engage your initiative to provide safe and effective care in resource-limited situations and know when and how to call for help.
For anyone venturing on an expedition as the medic or as a crew or team member I’d advise to make sure you are familiar with your kit and your limitations, with a good understanding of the environment you are entering in to and methods of escape if necessary. But most importantly, to enjoy every single moment of it: the good, the bad and the ugly.

The post Mid Ocean Medical Challenges appeared first on Adventure Medic.

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.

Contact

Ninth Wave Global /  https://www.ninthwaveglobal.com/

Instagram / @steppingoutandbeyond

The post On Call On The River: Stepping into Expedition Medicine appeared first on Adventure Medic.

Momos trigger a memory

It’s not quite the momos that trigger a memory, but the spicy sauce that comes with it.  Mmmmm. Soft and warm, just perfect for a cold Scottish day, or indeed a cold Himalayan day, whichever takes your fancy. This memory takes me back to 2016, when I was setting myself up for a little adventure with The Wild Medic Project. This adventure took me to Nepal, to Kathmandu, Chitre, Dodin and Thalo and to the Helambu region – one of the worst hit regions of the April 2015 earthquake.

My name is Nathasha Basheer and I’m a paediatric trainee from the UK.  I fell in love with Nepal following my foundation training. On hearing about the earthquake I felt that I had to go back and do something, anything really. Being in the midst of MRCPCH examinations and various rota commitments I was unable to take the full six months that I had originally sought.  So, I found other ways and it’s been great!

The Wild Medic Project is an Australian based NGO who run volunteering programmes to Nepal and Vanuatu, though there are other projects in the pipeline.  I loved their enthusiasm, the fact that they accepted me as a paediatrician when previous volunteers had been paramedics, and most importantly, their projects ran for two weeks.  Through a combination of annual leave and study leave, not to mention a little luck, I was able to take the time off from work.

This project suits anyone with a recognised medical qualification – paramedics, nurses, allied health professionals, doctors.  This was the perfect trip for a first time expedition medic, like me. Wild Medic are very open to question and queries from anyone, including students.

The project itself

The projects generally last a fortnight. The first week is mainly orientation and expedition work, the second week involves a little trekking.  Do be warned – day-to-day itineraries can move around depending on local festivals and last minute school closures.  Be flexible and make the most of the opportunities whilst there.  This is, after all, the Nepalese way.

Health clinics are in remote and rural locations where access to health care is limited.  This showcases primary health care at its best.  The recurrence of regular teams allows for an element of continuity and  patients know what to expect. On our busiest day we saw up to 115 patients in a six hour period.  It could be very intense but was really enjoyable.

Teamwork was key and we had such a great skill mix.  There were five paramedics from Australia, myself as a paediatrician, a local Nepali doctor and a non-medical volunteer.  One of the paramedics was an ex-pharmacist so between us we revised the Drug Therapy Protocols and introduced a solid paediatric section.  Jeevan was our in-house guide and guru and DB, Bondari and Yuvraj were our guides, cooks and friends.  We met so many kind people along the way.

Besides health camps, we spent a day at a school carrying out health checks.  This day was insane – 240 kids in one day!  And here was me thinking my winter night shifts were busy.  I was lucky enough to spend some time with the older teenage girls, learn some basic Nepali phrases and get to know their future aspirations.

The second week was spent trekking.  I have to admit I was the first to say, ‘I want more time with the kids and patients’ but actually, this part of the trip was really crucial. It provides income, a job, a purpose and not to mention key tourism – important after the country had just suffered a major earthquake.  2175m was the highest elevation on the trek, so the altitude was not an issue.

A Wild Medic project costs between $1599-1649 AUD. All the money goes towards the project and expedition. Meals are cooked up by an wonderful team of local cooks and guides.  You can of course supplement at the end with tips (recommended) and bring extra for any goodies and souvenirs (also recommended).  Please note that flights and visa are not included, though assistance through Wild Medic can be sought for flight information.  Additionally fundraising is welcome though not essential.

A wide and varied case mix

There are a few stories really stand out in my mind.

The first was a 9 year old girl who presented half-limping, half-carried by her father.  She had a giant, weeping abscess in her left groin/upper thigh area which had tracked down to her knee..  It was clearly a nasty infection that required surgical debridement and aggressive IV antibiotics.  Thankfully our Nepali doctor was able to make a referral, though whether they made the journey to Kathmandu is unknown to me.

The second was an elderly lady who had previously suffered a injury after falling on an outstretched hand.  It had been fixed and put in a cast but she presented with on-going pain and tingling. It was visibly deformed and she was obviously incredibly distressed by it.  Tertiary level adult orthopaedics was not within the remit of our project and unfortunately, as our local Nepali doctor told us, even if she was able to make the long journey to Kathmandu, her high anaesthetic risk would make an operation unlikely.  We gave her every medicine we had from omeprazole to toothbrushes, but just not the medicine she needed.

The third was a 5 year old boy who had injured the underside of his big toe on some glass and had wrapped it in leaves and rags.  The wound was moist and most certainly not healing. Between translators, sign language, a mixture of English, Hindi and Nepalese we managed to, at the very least, clean and debride the wound with my paramedic colleagues bandaging it in gauze impregnated with betadine and lignocaine.  There was no way he would permit sutures, so a compromise was met.

However, my favourite patient was a four year old girl who, when asked why she had presented replied, ‘no problem!’.  She had just come for the craic because her whole village was getting checked out.  I sounded her chest and off she skipped with a handful of vitamin tablets that looked, though no doubt did not taste, like sweeties.

Memories made

I had a lot of fun, in an incredible country full of incredible, sincere, warm, generous and open people who are full of good humour.  There was a good bit of walking, some entertaining car journeys, camping (electricity provided) and the best food you will ever eat in your life.  I made a whole bunch of new friends and many, many great memories.  I also learned a little expedition medicine along the way.

There are the inevitable downsides – I wasn’t a massive fan of the spiders in my tent. Thankfully other people were less bothered and helped me out!  Some of the walking can be tougher than initially anticipated, but each group will be different.  And as already mentioned, Nepal has many festivals which means that closures do happen. Keep an open mind and everything will work out.

Working with The Wild Medic Project has opened up opportunities within the expedition medicine community that I had never dreamt would be open to me.  It’s a great family to be a part of, it’s 100% against the grain and that’s absolutely what I loved about it.

Nepal will not disappoint, I promise.  So, what are you waiting for?!

The post Wild Nepal appeared first on Adventure Medic.

“It’s your niggly coughs and upset tummies that are the bread and butter here” explained Brent over dinner to the trekker visiting us for the night at Everest Base Camp (5360m). Subs was on the phone to home and Dawa was still pushing his dinner around on his plate. Suddenly a Sherpa appeared at the dining tent, radio in hand, asking for urgent help. Other activities took second stage as the three doctors gathered to hear the news. There was a stricken climber at Camp 2 who wanted to talk with the Everest ER.

The climber had successfully reached the summit, but on his descent had developed extremely cold feet and had started to lose sensation in his toes. When he arrived at Camp 2, he took off his boots and much to his distress, discovered his toes were purple and completely numb: frostbite. The climber and the doctors all knew that there would be no option for helicopter evacuation in the dark and there was no point in further risking those frostbitten toes by walking down to Base Camp, another 5-6 hours in the dark and cold. The climber would have to manage at Camp 2 for the time being. “No rewarming” Brent instructed the climber, “We’ll have to get you a heli down to Kathmandu first thing tomorrow.”

The focus now shifted to the Base Camp manager for the climber’s team. He was advised to start making arrangements for a prompt helicopter evacuation for early the next morning.

Morning came around and the three doctors were nervous. They hadn’t seen or heard a helicopter heading up to Camp 2. Finally, news filtered through that the chopper was on its way. When the climber landed at Base Camp, the doctors finally got a look at his frostbitten limbs. The climber thanked the team for the medical advice they had given him on his ascent. This forewarning had given him a good idea of how to recognize and manage his symptoms when alone and exposed higher up the mountain. This feedback brought a great deal of satisfaction for the doctors; patient education and health promotion in action.

This is just one example of the type of case managed at Everest ER: a seasonal tent-based aid post which runs every year during the spring climbing season in the heart of ‘Tent City’: Everest Base Camp. Everest ER is a joint project of the USA and Nepali Himalayan Rescue Association (HRA). The HRA is a non-profit, non-governmental organization established in 1973. The HRA also runs two other aid posts; one in Pheriche in the Khumbu valley and another at Manang on the Annapurna Circuit.

Dr Luanne Freer established Everest ER in 2003 on the 50^th Anniversary of Edmund Hillary and Tenzing Norgay’s pioneering summit success. It has been running every spring since and in 2018 completed a 16^th successful season. The clinic provided much needed emergency response during the 2014 avalanche and 2015 earthquake, both of which had a devastating impact on Base Camp.

In the 2018 season, 397 patients received care from Everest ER. Almost ninety percent of the patients were male and sixty percent were Nepalese (Sherpa). Forty two helicopter evacuations were organized during the season, a few of them from Camp 2. The most common presenting complaints were upper respiratory tract symptoms followed by high-altitude (or “Khumbu”) cough. However, the variety of problems seen was wide, from the full spectrum of altitude illnesses to frostbite, trauma, cardiac problems, snow blindness, head injuries, the inevitable diarrhoea and a whole host of dermatological conditions.

There is no typical day at the Everest ER. The usual clinic-based consultations would be interrupted by tent calls, radio consults and sked carries at any time of day or night. Often people presented needing counseling or a motivating pep-talk. We even had intoxicated people to look after at times. You never knew what might stumble through the tent door! But that was the beauty of it. At the only organized medical facility in a 1500-strong Base Camp; a remote and extreme environment with limited resources, your clinical and improvisation skills become your most valuable tools.

The 2018 volunteer doctors were: Brenton Systermans; Emergency Physician from Geelong, Australia (back to the Khumbu after volunteering at Pheriche the previous year), Subarna (Subs) Adhikari; Orthopaedic Surgeon from Nepal, and me; Suvash (Dawa) Dawadi, General Practitioner from Nepal. We were valiantly supported by Lakpa Norbu Sherpa in his 16^th continuous year working as supporting staff and longline rescue specialist. This season also saw two firsts in the history of Everest ER; an all-male team and two Nepali doctors!

The team at Base Camp was very well supported by the HRA team in Kathmandu, working effortlessly to make sure we were comfortable and had all we needed to function, including organizing restock of medications by helicopter from Kathmandu.

As I now sit at home in Kathmandu, back to working in the “low altitude setting”, I realize how lucky I was to be a part of this medical marvel. Sure, there were no life-saving procedures or heroics this season, but we had fulfilled our purpose: to keep the mountain safe and the climbers healthy. Managing the ‘niggly little problems’ can actually make a big difference to the comfort and experience of those working and playing on the mountain. Educating passing climbers and support staff about common problems at altitude and in how to stay healthy in the mountains, and hopefully preventing lots of mishaps along the way, was immensely rewarding. The smiles on the faces of those we had treated and made better, the social interaction with a group of people with so much dedication, discipline and passion for the outdoors was an privilege to be a part of.

The adventure medic in me got to experience this amazing two month journey. If you are interested in finding out more about volunteering with the HRA or making a donation, head over to www.everester.org. As the Everest ER is a charitable project, every little helps. If you happen to be at Everest Base Camp during April or May, take a wander down to Everest ER (you may need to ask around for directions!) and experience it for yourself. You are sure to get a warm welcome.

About the author

Dr Suvash ‘Dawa’ Dawadi was one of the Everest ER 2018 volunteer doctors. He currently works in a general practice and emergency medicine setting at the CIWEC Hospital and Travel Medicine Centre in Kathmandu. He holds the Diploma in Mountain Medicine (DiMM). He tries to get out to do expedition medicine whenever he can.

The post Everest ER: Tent City’s Medical Marvel appeared first on Adventure Medic.

At the beginning of this year, Dr Sarah Wookey worked in a Syrian American Medical Society (SAMS) refugee camp on the island of Leros. Sarah was a GP in Oxfordshire for 30 years, following up her retirement by gaining the diploma in tropical medicine, working with MSF for 9 months in Africa, and then spending this 2 month spell as a medical volunteer in Greece. The camp in which she worked was set up in a former psychiatric hospital, run by the Greek authorities. Most of the occupants were from Syria, Iraq and Afghanistan, with multiple other countries represented. All were waiting while their applications for asylum were processed, an operation which could take months. The Greek government had asked for help from NGOs to provide services to the occupants of the camps; they were keen to avoid uncoordinated, fragmented interventions. Anyone interested in doing voluntary work in the camps was strongly recommended to do so under the auspices of a recognised organisation who could then take responsibility for ensuring appropriate standards. In this brief essay, Sarah reflects on a consultation with one of her patients: an example that showcases quite how desperately hard it is to look after the physical and mental health of those who have undergone trauma and geographical displacement.

Yasmin

As I entered the camp I was met with shrieks of merriment. Children tore around the open courtyard giggling and chasing one another. I recognised Yasmin’s* children amongst the crowd.

The courtyard is a slab of concrete surrounded by a 9 foot high fence topped with razor wire.  Police are on duty at the gate. The refugees’ dwellings are metal containers. There are no decorations and from a distance the place looks like a container port. On reflection I realise that this is exactly what it is. A people container port.

The facilities here are astonishingly good – by comparison. I saw the makeshift camps where, for a few terrible months in 2015 and 2016, tens of thousands of refugee families were abruptly halted in their flight from home by the decision to close the border leading from northern Greece into the rest of southeastern Europe. They consisted of families living in muddy fields with no facilities or security. An enterprising garage owner offered hot showers – for €15. The lucky ones had a tent or, perhaps, polythene sheeting. Here, in the quaint little island of Leros in the south east of the Aegean, the camp is basic but well ordered. Yasmin and her children are clean, dry, warm, adequately fed and, for the moment, safe. What will happen to her after her asylum application has been processed is unknown.

Later that day Yasmin came to see me in the camp clinic. One of the children had a trivial laceration on his head after tripping and hitting his head on a metal post. He was fine and he and his sisters, bright eyed and inquisitive, behaved the way normal children do in a consultation. That is, after shyly checking that I didn’t look cross, they listened to each others’ chests and tummies with my stethoscope and took my (happily, indestructible) otoscope apart. What was not normal, however, was the way in which they appeared unaffected by their mother’s behaviour. Staring blankly into space, with tears pouring down her cheeks, and twisting her veil over and over in her fingers, she explained that she could not sleep and had pains all over her body.

In my usual practice as a family doctor in Oxfordshire in the UK this would be a red flag the size of Texas. I would tell our receptionist that I was going to be running late and would try to probe further using standard techniques:

“Tell me more”

“You look unhappy”

“What happened?”

Often the most powerful tool of all is saying nothing and just waiting. I’d also be able to see her repeatedly over a period of time and build up a relationship with her.

Here in Leros I’m only here for a few weeks. I’m from a different culture; everything she says has to be painstakingly translated from Arabic to Greek and then from Greek to English, followed by the same in reverse for my replies. Goodness knows what nuances get lost in this process. Our interpreters are very professional, but as there are very few of them and they’re often needed elsewhere in the camp, there are time pressures.

Nearly every woman I see can’t sleep and hurts all over.

There is a psychologist in the camp but she is overwhelmed by the demands and is subject to the same problems with language and culture.

I was very reluctant to give Yasmin sleeping tablets as they’re addictive and can make depression worse. I was also concerned that if I gave her some, everyone else in the camp with the same symptoms would ask for some too. It’s very easy unwittingly to create the basis for a black market if there are known to be sleeping tablets in circulation.

I tried to explain to Yasmin that the symptoms she’s describing are what one might expect following very stressful experiences. She gave me a wry half-smile. We both knew it wasn’t enough.

Links

The Syrian American Medical Society is a non-profit, non-political organisation that aims to offer medical support during humanitarian crises for the people of Syria and the United States.

*Name has been changed for anonymity.

The post The New Normal appeared first on Adventure Medic.

Rebecca Trimble / University of Edinburgh Medical Student / Adventure Medic Student Rep & APEX 5 Volunteer

Altitude research is an amazing way to combine a love of the outdoors, travel, and education. Why not start getting involved as early as possible in your medical career? The APEX (Altitude Physiology EXpeditions) charity was founded in 2001 by Edinburgh medical students in order to explore the impact of altitude and low oxygen levels (hypoxia) on the human body. Many more students have followed in the footsteps of this first team, the most recent being APEX 5. They aimed to build on the work of those who had gone before, whilst enjoying the adventure and forging friendships along the way. Read about the team’s experience, and get in touch with Rebecca or APEX if you’re keen to be involved in the future or to learn more.

*The APEX 5 Organising Team: Christopher Graham, Rebecca Dru, Eleanor Lee, Gordon Paterson, Greig Torpey, Jason Young, Joe Wilson.

Last summer the APEX 5 expedition travelled to Bolivia, exploring hypoxia’s influence on the immune system, blood clotting, vision and cognitive function, as well as investigating the impact of personality traits on perceptions of altitude illness.

A team effort

Six University of Edinburgh medical students formed the APEX 5 organising team, and planning started in 2015. Chris Graham assumed the role of Expedition Leader, thanks to his leadership expertise and experience as an APEX 4 volunteer. Becky Dru was in charge of the books and finding willing backers for our inevitably costly expedition; Jason Young and Gordon Paterson took on the ethics applications and research logistics, in order to execute our ambitious research projects; Greig Torpey, with a wealth of experience with Scouts Scotland, was well suited to be Logistics Coordinator and organise our team-bonding weekend away; finally Ellie Lee, with her background as Yoga Society President, was in control of volunteer well-being. The organisers later welcomed Joseph Willson, Edinburgh PhD student, to assist with research.

Twenty-seven University of Edinburgh undergraduate students were then selected by interview to make up the team of research participants. Additionally, we recruited two experienced expedition doctors, Ailsa Stott and Nick Haslam.

A solid team.

The aim of the game

While expeditions make their names as life-changing experiences for all, the main aim of APEX 5 was high altitude research.

Jason led his neutrophil project, investigating the role of hypoxia in reprogramming immune response to bacterial infection. Gordon’s blood clotting research investigated how platelets are activated in hypoxia. Chris looked into the impact of hypoxia on the eye’s macula and fundus, and tested eye movements controlled by the brain to assess cognitive function. Finally Greig, with a helping hand from Becky and Ellie, undertook a psychology study investigating links between personality type and individual symptoms of acute mountain sickness.

Q&A Reflections

What was your main motivation to organise the APEX 5 expedition?

Inspired by the achievements of past expeditions, we formed APEX 5 to continue research into hypoxia and high altitude illness. Additionally, we all have a passion for the outdoors and expedition medicine, and were keen to get this exciting project off the ground and see it through.

What was your biggest challenge? How did you overcome this?

Aside from the steep learning curves for us all in areas such as logistics, ethical forms, financing an expedition, and the nitty gritty of scientific research abroad, we would say our biggest challenge was dealing with a last-minute change in location.

When the team arrived in La Paz, where we spent four days acclimatising, we met with our in-country logistician who had bad news. The road to Chacaltaya lodge (the destination for APEX 4, and our planned ‘laboratory’) was blocked off with snow and ice. This was uncharacteristic for the time of year. It was essential that we had safe road access for a rapid descent, in the event that a member of the team developed severe altitude illness. After some quick thinking and negotiation (and an attempt at digging/bulldozing our way to Chacaltaya) we secured an alternative lodge at the base camp of nearby Huayna Potosí Mountain (4,700m).

In what way did your research projects build on previous APEX expeditions?

Previous APEX expeditions have studied various aspects of both hypoxic physiology and high altitude illness, ranging from coagulation in hypoxia, to High Altitude Pulmonary Edema (HAPE). Our hypothesis for APEX 5 coagulation research evolved from the data gathered on these expeditions¹, aiming to uncover the physiological pathways up-regulated in platelets in hypoxia.

Will the results of your research have the potential to impact upon patient care?

The majority of our research projects investigated the effect of hypoxia on human physiology. By conducting our research in a healthy cohort at altitude, we were able to examine hypoxia in isolation, giving ‘clean’ data by removing confounding factors such as other diseases. We hope to relate these results to understand more about the impact and management of hypoxia in patients at sea level with ill-health, such as those with chronic lung disease and patients in the critical care setting.

For example, our neutrophil research may change our understanding of the immune system in patients with hypoxia and infection, such as patients with chronic obstructive pulmonary disease (COPD), which according to The British Lung Foundation affects an estimated 1.2 million in the UK. Laboratory experiments have shown that prolonged low oxygen levels in the presence of infection in mice can cause over activation of the immune system². However this does not happen if they were previously exposed to systemic hypoxia. This preconditioning of the neutrophil response thus seems to prevent a negative host immune response to hypoxia and infection. We hope to validate these findings in a human population with our results.

How did the volunteers fare at altitude?

We all came together and formed a fantastic team, able to look after each other when we had low points – we were pretty adept at making each other laugh when the going got tough.

We were lucky and extremely pleased that no volunteer had to be evacuated and that, despite the expected miserable symptoms of altitude sickness, everyone powered through and remained keen to stay involved in the research.

The team was also very thankful for our expert expedition doctors – Ailsa and Nick – who were crucial in keeping us all healthy and our morale high through good humour, many board games, and a few doses of painkillers throughout the expedition.

It was fantastic that our volunteers were keen to learn from our research. During research days, we offered half-day internships in the lab so that our volunteers could learn the science behind the research, improve their lab skills and ask any burning questions. This not only stands them in good stead for possible research-focussed careers, but also for the future of APEX.

What was the general atmosphere like at Huayna Potosí base camp?

Awesome! As said, our group got on amazingly well and the atmosphere was always very friendly. Our new place at Huayna Potosí was definitely cosier than Chacaltaya would have been, but it also allowed us the freedom to explore stunning surroundings. When not doing our research or out for a wander, there was always a card or board game being played, or a quiet space to read and reflect on the day’s events.

Can you describe a typical day at Huayna Potosí base camp?

After a tasty breakfast, it was questionnaire time, and on testing days this would be followed by blood tests, eye and vision testing, or helping out in the lab for the rest of the day. On research days there was a lot of work to be done with blood samples: preliminary analysis was undertaken on the mountain, and we prepared samples for transport back to the UK for comprehensive analysis – the laboratory team were kept busy!

After lunch, the afternoons were generally free, with some additional tests on research days. Many chose to chill out by the beautiful lake a stone’s throw from our lodge, play cards in the cosy dining room, or take a walk through the mountains. For days with less research it was necessary to become creative with your free time. The volunteers even wrote a parody (and recorded a music video) to Jordin Sparks’ “No Air”…

There was always time made to cuddle our two adopted expedition dogs – Nieve and Noche (Snow and Night – named for the colours of their coats) who lived full-time at base camp.

Following a traditional Bolivian dinner (always starting with soup), we often stayed together for a movie, a quiz, or even a spot of incredible stargazing. It would then be time to snuggle down in our sleeping bags looking forward to what tomorrow had in store.

What is your single best piece of advice for other students organising a similar expedition?

Find good mentors!

We would not have got the project off the ground without the help of Drs Kenneth Baillie and Roger Thompson, APEX founders, who provided us with so much support. Having their support and the support of other dedicated research supervisors was crucial in the planning and execution of such a unique trip.

What are you most proud of?

It is hard to sum up an expedition of this scale in just a few words. It took over two years of planning, many late nights and an awful lot of paperwork before we could even set foot in South America. From interviewing our volunteers and submitting complex ethical forms, to undertaking our ambitious multifaceted research in the Andes, we as a committee learned an unbelievable amount.

We are proud of everything that we achieved, of each other, of the volunteers, and of the fact that we organised an international medical expedition.

Keen to find out more?

For a taster of APEX 5 trip’s amazing surroundings, and their somewhat cheeky musical skills, see their YouTube music video.

If you’re interested in following up the results of their research, or are keen to contact the team who run APEX about future expeditions, visit their altitude.org website. Alternatively, drop Becky, our student rep and co-author of this article, an email on rebecca@theadventuremedic.com.

References

1. Thromboelastometry and Platelet Function during Acclimatization to High Altitude. Rocke et al. Thromb Haemost. 2018;118(1):63-71

2. Hypoxia determines survival outcomes of bacterial infection through HIF-1α–dependent reprogramming of leukocyte metabolism. Thompson et al. Sci Immunol. 2017;2(8): eaal286

The post APEX 5: Student Research at Altitude appeared first on Adventure Medic.

Tom wrote the winning entry for our 2017 Adventure Medic Elective Article competition. He penned this piece about his elective in the Himalayan mountains of northern India, where he travelled with the Himalayan Health Exhange. We hope you enjoy reading his lovely, reflective article as much as we did. If you’re considering this type of elective or trip yourself, enjoy his top tips at the end too. Thanks again to our competition sponsors who provided some superb kit as an incentive to write: Rab, Alpkit, Keela and Lifesystems.

The Himalayan Health Exchange

Last August, I was given the opportunity to join a month-long medical expedition in the Himalayan region of Kargiakh with the Himalayan Health Exchange (HHE). I joined them in their challenging mission to provide medical care to the underserved and often isolated peoples of the politically unstable Indian border state of Jammu and Kashmir. Each summer for over 20 years, by invitation of the local government, a team from HHE has visited the Zanskar region in order to deliver medical care to the local inhabitants, with primary and public healthcare objectives. Aside from direct medical care, the charity also uses proceeds from the trip to fund surgical procedures in the more southern city of Manali and also contributes to the training of Amchis: local providers of traditional holistic health care.

Our team included over 20 medical and physician-associate students from the UK, US and Canada as well as a core team of senior US doctors. We set out to visit villages far off the beaten track and our clinics were open to all, including local farmers, road workers, seasonal labourers from the valley, and even recreational trekkers. As access to many of the villages was only possible on foot, everything we needed for the trip was to be personally carried with the assistance of a small army of mules (47 of them to be exact).

Acclimatisation

To begin the expedition, we flew into New Delhi before connecting to the mountainous city of Leh to begin our acclimatisation period. Leh was largely comprised of traditional Buddhist architecture, with temples and palaces interspersed by winding alleyways, and strung together across the sky by colourful banners of prayer flags. This bustling tourist town provided a beautiful initial staging post for our team as we prepared for our weeks of trekking ahead. At our initial briefing we were reminded this would be the lowest point until the end of the trip, before which we would twice ascend to over 5,000m, breaching 5,400m at Phriste La Pass. Even in Leh at 3,505m elevation, a relatively modest height above sea level, the oxygen pressure in the air is around two thirds that at sea level. In practical terms this proved to cause one to become heavily short of breath on ascending the gentlest flight of stairs.

Physiological acclimatisation was an essential undertaking to reduce our risk of developing altitude related illnesses. These can be extremely debilitating and even fatal if not recognised and treated early. On previous trips, students had been evacuated due to illness after failing to follow acclimatisation instructions and exerting themselves too much early on; acclimatisation was viewed respectfully by everyone on the trip.

The best treatment for acute mountain sickness and its sequalae is descent, and the lead medics made it clear that their threshold for descent and evacuation was low. To help reduce the likelihood that we would develop altitude sickness, we were given strict orders. Rigorous hydration, rest, prophylactic acetazolamide (Diamox), and no alcohol. Remaining teetotal was to be no small feat for a group of medical students abroad (most post-finals) but given how far each of us had travelled, none was keen for an early and likely long and uncomfortable mule ride to the nearest road for evacuation.

To combat this real danger, we all submitted ourselves to the gruelling regimen and activities associated with acclimatisation. These included reading, drinking chai, regular naps and just lazily lounging about, trying not to exert ourselves. Surprisingly, even with added jet-lag, napping was perhaps the biggest challenge. Sleep at altitude is notoriously disturbed, with irregular and intermittent Cheyne-Stokes breaths causing sudden waking in the night, often to the alarm of an anxious tent-mate who may have just witnessed a very prolonged pause in breathing. In addition, we were all taking regular acetazolamide – a diuretic. As such, a night of undisturbed sleep was unheard of in the early part of the trip, as our bodies and kidneys took time to adapt physiologically to this new state of affairs.

Setting out

Setting out from Leh early in the morning, our fleet of 4x4s made light work of the initially well-constructed roads, ascending thousands of metres over the course of the day before we crossed the second highest road pass in the world, Taglang La (alt 5,328m), well before lunch. At this point members of the group were recording oxygen saturations of 69% and the first case of altitude-related sickness was spotted amongst our ranks. One of the senior medics who hadn’t spent much time in Leh due to a delayed flight hadn’t managed to acclimatise and was feeling very unwell. Fortunately, by the time he had become symptomatic our route ahead had begun to descend again. Camp was still hours away and so our driving speed increased significantly. He improved rapidly and completely following our sharp descent.

This gear shift seemed to coincide with a rapid deterioration in quality, or in some cases even presence, of the roads. This should have come as no surprise, we had overtaken the tarmac laying team earlier that morning and began to pass small teams of construction workers armed only with pick axes and shovels. Haste on these narrow and rudimentary roads felt like a recipe for disaster. Many of them were hand-cut from crumbling and landslide-prone Himalayan rock and barely allowed passage of a single 4×4, let alone the large oncoming trucks which often halted our progress and forced us to gingerly pass along the cliffs edges all too often. The multitude of poetically poignant anti-speeding/drink drive signs which punctuated the roadside did little to calm our nerves.

“Safety on the road means safe tea at home”

“Better to be ‘Mr late’ than ‘late Mr’”

“Don’t be risky, lay off the Whisky”

We eventually arrived safely on a windswept plateau just outside of Sarchu village, halting our thrilling and spectacular descent and providing a welcome respite from the motion sickness-inducing ride down. After setting up near to a local Indian army camp, we said goodbye to our vehicles and it became apparent that from there on, we were to be entirely self-sufficient and that all travel would be on foot or hoof. With that, we were also reminded we would be without phone signal, Wi-Fi, treated water, or a conventional toilet for the next three weeks, the latter of which would certainly take some getting used to. After pitching our tents for the first time, the early sunset and clear evening provided the first of a series of incredibly beautiful skies featuring the brightest of moons and clearest Milky Way that most of us had ever seen. The budding photographers amongst the group revelled in this, as the rest of the team turned in early before the first day of clinic.

Clinic days

Our first clinic days started soon after sunrise, with a huge pot of hot milky chai and an enormous breakfast spread to kick-start each session. Pancakes, French toast and fried eggs were a common treat.

Each clinic followed a similar format, with individuals rotated across all stations. A group provided initial triage, recording basic physiological observations and a main presenting complaint, before showing the patient to the relevant medical tent where they were seen by an assorted medical team. This team usually consisted of three students: a historian; a scribe; and an observer, with a supervising ‘resident’ and translator when possible. Patient evaluations were a team effort, which significantly helped as the process of taking a history via a translator (sometimes using three different languages at a time) was a challenge which was new to most of us. Each student would present the case to the supervising physicians and a shared plan was made, with the patients input. They were subsequently shown to the pharmacy station where appropriate medications and instructions were dispensed by our charming and cheeky resident monk – co-expedition leader and practical joker ‘Lama Ji’. He was a senior Buddhist monk, local teacher, and spoke a range of local dialects which proved invaluable throughout this often-convoluted process. In total we would see around 500 patients over 10 clinics throughout the trip, with nearly 90 seen on the busiest day.

After our first clinic in Sarchu, we continued through the valley and reached the Zanskar region, where we held clinics in Tangste, Khangsar, Testa, Kyng and Kargiakh villages. We were given a grand welcome at Phuktar Monastery, the site of one of our final clinics. Hundreds of years old, it was carved into the mountainside centuries ago and has since been home to around 70 monks and monklets (school-age monks in training).

Medical Experiences

Musculoskeletal, ophthalmological, gastrointestinal and dental problems were particularly common. The ‘HHE special’ was a common management option for many of the adult patients we saw. This consisted of sunglasses, eye drops, and ranitidine. Gastro-oesophageal reflux seemed to be almost universal in adults over 25, perhaps linked to the common habit of eating a single large meal, often very spice-heavy, at the end of the day just before bed. The presence of Pterygium, a fibrovascular growth of conjunctiva, was also particularly prevalent. Severe cases can lead to visual loss and its prevalence is greatest in dry climates with high UV exposure. Over 70 patients were seen with symptomatic and asymptomatic pterygium and those with conjunctivital symptoms were given a combination of sunglasses and eye drops. Asymptomatic patients and adults who worked outside were also given sunglasses as a prophylactic measure to help prevent direct UV damage.

After each clinic had packed up, we would debrief as a collective. This provided a forum to discuss specific challenges faced, scope for improvement, and particularly interesting cases. A memorable example includes the epidemic of ‘adolescent hypertension’ (aptly named Chai-pertension) in one village. It was thought this was due to the seven-a-day chai tea habit taken up by many of the children, some as young as four years old. We advised them to cut down but knew full well the hypocrisy of our advice. I was drinking a similar amount myself by this stage and didn’t consider holding back, it was delicious.

Survival in the Himalayas

Compared with the relative comfort of Leh, the effort and physicality needed to subsist in this region was evident. Twenty-year-olds looked forty, forty-year-olds looked seventy and I could count the number of overweight patients seen on one hand. The staggering scale and extreme nature of the physical environment clearly exerted a significant impact on the people living within it; severe osteoarthritis and other labour-related musculoskeletal problems were our most common presenting complaint.

Each path we trekked along lead us past mile upon mile of rock walls built to contain livestock, mainly yak and goats. These were interspersed with large religious shrines covered in thousands of engraved stones, some hundreds of years old. The time and effort invested into each of these structures was staggering.

Despite this, many of these people were not only surviving, but thriving, testament to their active lifestyle, their strong bond with the landscape and their ability to manipulate it to their benefit without desecrating or over-exploiting it. Each time we passed through settlements, we were able to see how entire local river tributaries were deliberately coaxed laterally across rock faces to supply local homes and crops. I was surprised to see valleys full of lush fields of barley and wheat, contrasting starkly with the arid brown rock in the higher climes. Yak patties (mud, yak manure, and straw) covered facades of buildings as they dried in the sun, ready to be used as an indoor stove fuel source. This practice is associated with myriad respiratory conditions but is by far the most widely accessible and cheap fuel option and as such, chronic cough was an all too common complaint.

The Inadequacy of overseas aid

However, in contrast to these established communities, the immigrant labourers and road workers we saw at the start and end of the trip were a heart-breaking sight at the road side, and later in clinic. These people were working long physical shifts, sleeping under tarpaulins and barely earning enough to feed themselves, let alone the families many had brought with them. Speaking with them in clinic, we realised many would never earn enough to escape their occupation, or this region. They were emaciated, malnourished and often desperate. Those that needed referrals to city clinics (about three days’ travel in good weather) were essentially hopeless cases. Despite being offered free care, we knew that few would be able to take time off work or have the money to pay for travel.

This provided me with my first appreciation that despite best efforts, sometimes overseas aid and charity work can be wholly inadequate in serving to address the specific health inequalities that are endemic in some areas. The health problems we glimpsed were symptomatic of a significant lack of infrastructure or a system to provide for the whole population. I took some solace knowing that proceeds from our contribution were going towards training new medical professionals elsewhere in the region.

Evenings and free time

Each clinic day we held 15-minute oral presentations which had been allocated and prepared prior to the trip. The topics included high altitude physiology, altitude related conditions, hypothermia, infectious diarrhoea, tuberculosis, HIV, local religious practises and alternative medicine, women’s health and women’s health rights in India, and a practical hyperbaric chamber demonstration. These sessions helped to supplement our clinical experiences and prepared us well for subsequent clinics.

On trekking days, we were free to use our evenings to recover. As well as excessive tea drinking, these time periods were revolved around competitive card games, diary writing, reading, listening to music and (attempting) yoga. We even adopted a curious local dog on the trip. ‘Trail Dog’, followed us for several days, snacking on leftover roti and providing much appreciated cuddles for the trekkers. Meals were freshly-prepared vegetarian dishes with Indochinese influence. They were of very high quality, and there was always plenty to go around, particularly important given that we were spending up to nine hours a day walking, ascending over 1000m on some.

One evening, we made use of an old cricket set the Sherpas who lead our trip had brought. It was an annual tradition that the Sherpas would play the students. As British students, there was certainly an expectation that we would field a reasonable team. Despite our questionable understanding of the specific rules we managed a decent result against a ruthless and clinical Sherpa side who showed no mercy. Fortunately, our US and Canadian counterparts made up for a lack of cricketing know-how with baseball style batting and fielding prowess, sending many a ball skyward for six with some spectacularly athletic diving one handed catches. This intro to cricket was a hilarious and invaluable bonding experience for the entire expedition team.

Why you should consider this (type of) elective

The Expedition to Kargiakh with HHE was filled with wonderful memories and was staffed by incredible people. We all treasured the bonds and friendships we developed whilst spending a whole month in the wilderness, and leaving everyone at the end was tough.

If you enjoy the outdoors, like a real physical challenge, have minimal personal hygiene needs, and an interest in expedition medicine or global health, this may well be the medical elective for you. I found an increased appreciation for the conditions, access to technology, global sanitation and medical care that we have in the UK, as well as deep respect for the people who call this harsh and beautiful area of the world their home.

Where / Kargiakh Valley, Ladakh, Jammu and Kashmir, India

When / August

How / All trip details and contacts and application forms can be found on the HHE website.

Price / The cost was £2,500 for the trip itself, which included all travel, meals and accommodation. Much of this money went towards the charity’s side project in the region (free surgery for those in need and training for local practitioners). An Indian Visa costs around £110. Return flights to New Delhi from the UK can be estimated at £500-£700 depending on when they are booked. Internal flights were about £40-60 each way to Leh.

Top tips

Final word

Writing this months later, I would honestly say the cultural, spiritual and environmental characteristics of this place are the most incredible I have been privileged enough to experience and it is strong wish of mine to return in the future. N.B The medicine was cool too.

The post Competition Winner: An Elective in the Himalayas appeared first on Adventure Medic.

In this article Will Duffin, a Bristol-based GP and expedition medic, recalls his recent experience of being caught in the path of a forest fire whilst providing medical cover for a charity trekking trip in Madagascar.

I stood with David, running fingertips busily through my hair as the flames bore down upon us. Now only metres away, billowing smoke was being whipped into a towering frenzy by the freshening northerly wind. With his eyes still fixed on the inferno, David asked hopelessly: ‘What do we do now, Will?’ I opened my mouth to speak, but all I could do was take in little gulps of air. Nothing in life had prepared me for this moment; it seemed certain we were all going to die.

Earlier that afternoon we had reached the 2000m high plateau of Andringitra National Park in Madagascar. It had been an incredible day of trekking through lush forest filled with chameleons and the promise of sighting ringtail lemurs. At camp the night before, huddled over steaming Lasopy, we gazed at flickering lights on the mountain above; small fires lit by ranchers living just outside the park. In the cool night air it was hard to conceive that the next day a ferocious wind would send them marching across the landscape towards us.

I turned to answer David’s question, but he was gone; lost in the dense, hot smoke that had now engulfed us. To my right, the thatched roof of the cook’s hut burst into flames. Only moments earlier we had been frantically tipping rice onto the hut floor to liberate steel bowls that we could fill with river water.

Behind me I heard the cries of two local porters. Chest-deep in a small brook, they threw their arms from side to side, ushering me to join them. There the three of us waited, half-submerged, for our fate to be announced.

I thought of the rest of our group, praying they had escaped to safety. I realised that in my haste to flee the smoke, I had abandoned my medical kit. If I survived, how would I treat the injured with only the river-sodden shirt on my back? I thought about my wife and her faith that I would always return safely from my self-indulgent adventures.

As flames began to erupt in the bush beside us, we flicked and splashed our limbs to extinguish them, like hapless tuna snared in a fisherman’s net.

Suddenly, a sliver of blue sky opened above. The two porters were smiling now, and when they shook my hand emphatically I knew we were going to be all right. I leapt onto the bank and made my way past the smouldering cook’s hut into a small clearing of unburned grass. The group was huddled together and very relieved to see me. The main blaze had now passed through and we stamped out lingering pockets of flames with our boots. I located the unscathed medical kit and applied a burns dressing to Andrea’s leg. I also treated three porters for foot and ankle injuries. They had been sprinting barefoot over the rough ground. Incredibly, no one had been seriously hurt.

The collective relief was euphoric. We hugged one another with vice-like enthusiasm, as though to welcome in a new year, except instead we were welcoming the joy of just being alive.

An hour later, darkness fell. We watched the flames climb up and over the high mountain ridges around us, electrifying the jagged contour in an eerie, backlit glow.  Even though most of our cooking equipment had succumbed, the porters still found a way to prepare curry for dinner.  A Lokanga (malagasy violin) and Kabosy (square-shaped malagasy guitar) came out and we sang and danced like lunatics.

The team of local guides and porters had saved our lives. In the dwindling minutes before the fire reached us, they had used their cigarette lighters to create an arc-shaped firebreak around the camp. The rim of burnt ground was just enough to prevent the flames from leaping across.

I had been just out of earshot at the back of the group when the instruction came for us to move forwards into the safety of the clearing. The cook’s hut burned down from embers kicked forwards in the wind and we had all been spared the ferocity of the main blaze.

Bush fire is just one of a number of threats that can befall even the best prepared expeditions and endanger everyone in an instant, often when you least expect it. As medics, we need to be ready to react and respond. But there may be times like this, when your options evaporate in front of you and you are left truly at the mercy of Mother Nature. We will forever be indebted to the local people who were our salvation.

Please note names of individuals in this article have been changed for anonymity.

Tips for managing wild fires on expedition

Links

National Geographic: Wildfire Safety Tips

Survival Kit Guide: Wildfire Survival Tips

Survival Life: Wildfire Survival Tips

wikiHow: How to Survive a Wildfire

The post Bush Fire on Expedition: A Personal Account appeared first on Adventure Medic.

Philippa Hardy is the author of website Escape Medic and is currently working as a locum in ED in preparation for a summer of expeditions. In 2016, she travelled to Nepal, spending time alongside Professors Upendra Devkota and Henry Marsh at the National Institute of Neurological and Allied Sciences (NINAS) in Kathmandu. At a general surgical camp in Ghorka District, she encountered a desperate situation with no easy answer, but all too common in developing world work.

Professor Upendra Devkota

Inspired by his mentor Dr Gongal, Professor Upendra Devkota left his district of Gorkha, Nepal to pursue a career in neurosurgery at the Glasgow Institute of Neuroscience under the expert guidance of Sir Graham Teasdale. He later continued his career at the prestigious Sir Atkinson Morley Hospital, the birthplace of the CT scanner, before deciding to take his expertise back to Nepal. In 2002, he founded the country’s first Neurosurgical Unit at the Bir Hospital, Kathmandu followed by Nepal’s first Neuroscience Institute in 2006.

At the time of Professor Devkota’s return to Nepal, the country was in political turmoil. The Royal Family had been massacred one year before and the government was grappling with six years of Maoist insurgency. There were a mere 400 physicians for a population of 15 million, most of whom lived and worked in Kathmandu. In the provinces, there was a breakdown in education and infrastructure and internal displacement from the insurgency. Malnutrition and gastroenteritis were common, with viral infections, parasites and tuberculosis contributing to most deaths.

By 2016, when I travelled to Nepal, there had been dramatic changes in Healthcare: life expectancy was 68 years and mortality amongst those under five had fallen to 40 per 1000 live births (from 209, 36 years before). Per capita expenditure on health had risen from $15 in 1995 to well over $70 in 2012 and death from lower respiratory tract infections and diarrhoeal illnesses had reduced significantly.

I was lucky to spend a short period of time alongside Professor Henry Marsh, as a guest of Professor Devkota at the National Institute of Neurological and Allied Sciences (NINAS) in Kathmandu. Whilst I can by no means comment on the overall healthcare situation of Nepal with any expertise, nor will I try too, I can give a small insight into my experience.

National Institute of Neurological and Allied Sciences

I spent the majority of my time at NINAS, where they have three operating theatres, all equipped with the latest neurosurgical technology. The have an excellent radiology department including a CT and MRI scanner, a 16-bed intensive care unit, four wards and daily consultant outpatient clinics. I was also privileged to join an exceptional team of 39 others from NINAS at a health camp in Gorkha District, the epicenter of the 2015 earthquake. The contrast from NINAS was stark: the region had just eight doctors spread across two underfunded district hospitals and three primary healthcare centres serving a population of 260,000.

In just three days in Gorkha, over 3,000 patients were seen and more than 40 general surgical operations performed, using donated equipment brought from Kathmandu, in a dilapidated post-earthquake building. The team included doctors, physiotherapists, pharmacists, dentists, nurses and the local women who provided food for the team each day. Some people travelled for up to three days to be seen by the specialists as they would otherwise have no access to healthcare at all, it being too great a distance to travel and too expensive.

The range of pathology was impressive. There were patients with large fungating tumours, which we sadly could not do anything for, breast lumps, cysts, syndactyly and polydactyly, hydroceles, varicoceles, spina bifida, diabetic ulcers, dental abscesses, back ache; the list goes on. Pregnant mothers were able to hear their baby’s heart beat for the first time with the ultrasound machine, and people were able to take medicine home free of charge.

I spent the majority of my time in the operating theatres, primarily due to the language barriers in clinics. Diathermy was sparse, so inguinal hernia repairs, saphenofemoral ligations and lipoma resections were all performed without it. I assisted with all of these operations, performed a spinal anaesthetic, intubation, hydrocele repairs, incision and drainage of abscesses as well as surgery for polydactyly under supervision. By the end of the camp I was leading some of the operations with minimal assistance. The term ‘see one, do one, teach one’ had never felt more apt.

Sumessha

On day three at the health camp I encountered Sumeesha, a young mother of a two-year-old boy plagued by rectal bleeding since birth, desperate for someone to save the life of her son. She had been walking from her small village for 50 hours; exhausted, she begged the professor to perform life-saving surgery on her son. It was a high-risk surgery when performed by specialist paediatric surgeons and almost unthinkable given the paucity of suitable equipment and absence of trained professionals to deal with potential complications.

She explained how her husband had been working in the United Arab Emirates for the last 18 months in order to send money home to them. She had no support, with little extended family. Not only was she unable to reach Kathmandu to seek medical help, the journey itself being far too expensive, but she would not be able to afford to see a doctor at all let alone pay for any necessary surgery.

The story was difficult to hear. I knew that without performing the procedure, the boy may have a catastrophic haemorrhage from his polyp some time in the future. Yet to perform it here, with limited equipment, no specialist care and no follow up in the event of complications… How could it even be considered? Especially given that the professor had turned away patients with hernias earlier that day: fairly routine procedures with little scope for disaster.

Stunned by the decision to go ahead, I could barely bring myself to watch surgical appliances more suited to an adult being used to attempt to remove a polyp. I felt there was an element of playing God and my conscience was slightly unsettled. I had to take a step back to reflect and to ask, ‘who am I to judge?’. In scenarios such as this, which are all too common in the developing world, this mother had no other choice. She cannot afford the journey to the general hospitals in Kathmandu or the appropriate treatment were she to arrive there. She had no option but to place her son’s life in the hands of a neurosurgeon with no recent experience in the operation he was about to perform.

It is easy to discuss these sorts of ethical dilemmas from the comfort of our seminar rooms, in a country where healthcare is free for all at the point of access. For people living in remote areas of Nepal, access to healthcare is almost non-existent. Surely a highly specialised neurosurgeon, with previous training in general surgery is capable enough of performing this procedure especially when the alternative is no procedure at all? Can we withhold treatment due to a potential risk of intra- or post-operative complications when the risk of those being fatal is lower than the risk of doing nothing?

Lost to follow up, I would never find out the eventual fate of the young boy but the image will remain forever in my memory.

The post See One, Do One, Teach One: Surgery in Nepal appeared first on Adventure Medic.

Eden

In 2016, I was offered a life-changing and unique opportunity: to take part in a ground-breaking social experiment. 23 strangers were to be placed into the wilderness, cut off from society, each with a different skill needed to form a new community called “Eden”. The experiment would be directed and produced by Keo North, and broadcast on Channel 4 as an observational documentary in ‘the construct of an alternative reality’. Also known as ‘reality TV’. I was kindly granted time out of Foundation Programme by Wessex Deanery during my FY2 year, who were highly encouraging about the experience, and off I went.

At medical school I had been voted “Most Likely to Present Embarrassing Bodies”… My ambition had always been to be a media doctor, and I found my opportunity on Adventure Medic, who advertised for the Eden casting on their website. And so here I was, one of two doctors practicing medicine in the wilderness, with limited equipment and investigations, far from secondary care, with cameras watching every move I made. Neither medical school, nor foundation training, had taught me how to do this particular job.

A tough environment

We had a psychological assessment before entering the environment, but nothing could have prepared us mentally for the cold, hunger and strenuous manual labour that was demanded of us. The environment itself was treacherous, comprised of steep mountains, wild coastal waters and waterlogged bogs in the rural Scottish Highlands. Every day offered new challenges and dangerous tasks, including tree-felling, chopping wood, fishing at sea and tending to large campfires. These tasks were undertaken by a group of people who were drained physically and mentally. We were hungry and stressed, and living amongst strangers who were not always united by a common goal.

Learning the ropes

I learned the different roles of being a medic on expedition, extending from simple medical care to an almost maternal role. I was surprised by how much I was leant upon, even for cuts, grazes and simple colds. My role was, however, vital at times – cleaning and dressing wounds from infected insect bites and preventing the spread of a bout of gastroenteritis with stringent hygiene measures. I had attended two expedition medicine courses before the project; everything that came up on those courses happened, and more. Luckily we had prepared well, had meticulously organised medical kit, waterproof documentation paper and ensured the medical stock was kept clean, dry and at the correct temperature at all times.

Under scrutiny

As a doctor in a TV programme, every examination you perform and every prescription you write could be shown to millions and is open to scrutiny by fellow colleagues. This is the risk of TV doctoring, and it can make you feel pretty paranoid. It was something I considered carefully and discussed with the production company before agreeing to the show.

The psychological well-being of the participants was of paramount importance. Everyone’s psychological health was compromised at some point, and this included my own, exacerbated when taking on other people’s problems. At times I felt myself getting paranoid and severely anxious; the cameras were on us at all times and I never forgot about them, which added to the stress. Support was available to us in the form of a clinical psychologist, who was contactable by phone – I used this to my advantage and encouraged others to follow suit.

Communications

As the spec said, we were “cut off from society”. However, the doctors were given our own radios so there was a direct link to the producers in the event of illness. I organised a simulation trauma scenario to test out this process, which was successful. We also taught basic life support to the other contributors, so that they could respond to an event. Luckily the radios were not needed for any major trauma, but I did have to call through a dislocated finger that had been crushed by a log. It was a significant challenge to explain the issues, from a doctor’s point of view, to a production team more familiar with the media industry than medical jargon.

Knowing when to stop

My time in Eden taught me a great deal about myself and about humanity. I felt that, as well as being the medic, my role in the team was one of morale booster. I was told that I frequently lifted the mood of the camp, whether with a ukulele song or a chat. Importantly, however, I also learned what my limits were. By four months, I felt I had gained enough and decided to withdraw myself from the process.

I do think it takes courage to sign up for something like this, but I believe it takes more guts to call it a day. I missed my friends and family, wanted to finish my FY2 training and was keen to see what else medicine had to offer me and vice versa. It also became simply too difficult to oversee the health of twenty others, whilst I was entrenched in a chronically stressful situation. Having the insight to acknowledge this, and then to make that decision to leave, is what I am truly proud of myself for. The remaining participants were looked after by the production team and the local GP in the area.

Reflections

Many people have asked if I regret the experience. I certainly don’t, as I think that every life event, good and bad, can teach you many things. My learning curve in those four months was so steep. I learned about morals and ethics, teamwork and leadership, social group dynamics, community, psychology and diversity. And I learned what is important in life: interpersonal human interactions and new experiences, versus material objects and home comforts.

My biggest insight was realising that I am an individual with my own goals and ambitions, and it is up to me to follow them. Many doctors feel trapped in their profession. Whilst always having respect for the decisions of those around me, I feel enabled to go down an unconventional path in my career, and live my life in a way that makes me feel happy and wholesome. Having lived in a community where we made our own rules, I now feel a new sense of freedom.

I have now completed my foundation training, and reintegration was not a walk in the park. After many months in social isolation it can take time to readjust to the hustle and bustle of normal working life.  I still find it strange that I participated in such a bizarre situation. If I were to give advice to those thinking of signing up for something similar, I would say go for it and take the risk… but be kind to yourself, and to others along the journey.

Feel like watching the controversial social experiment yourself? Catch up here on All 4.

The post An Alternative Career: Eden appeared first on Adventure Medic.

In 2010, Alison Jarman and Andrew Neal cycled in Kazakhstan as part of a 6500km trek through South Korea, Mongolia, Central Asia Turkey and Cyprus. They were in the throws of this epic, two-wheeled adventure across Asia and Europe, when reality struck in a way many of us might recognise: interview time… Here, Ali & Andrew recall, in the most eloquent of ways, what it’s like to be in your own time-out bubble, when an all-important call awaits.

Almaty

At 8.30 in the morning a haze danced above the highway ahead of us and the distant mountain range had faded to a washed-out blue. ‘Three bars,’ Andrew called out, and we plotted another point on our mobile phone reception map. ‘Hang on,’ I replied. ‘I might check my email again.’

Midway through our 10-month cycle trek – our grand adventure – the rude reality of future employment was starting to intrude upon our carefully crafted escape. Here on a remote highway in Kazakhstan we were trying to reconnect with the outside world with the aid of a smartphone, a dynamo hub to charge it and a local sim card. Spending a few days in cosmopolitan, expensive Almaty had been enough to convince us to get back on the road while we waited for someone in an office on the other side of the world to email out times for telephone interviews.

At the height of summer in 2010, we had crossed the Russian border into Kazakhstan. 1000km of arid steppe stood before us and the southern mountains of the country. Motorcycle tourists passing us in the opposite direction had spoken of tyre-melting heat and Jurassic-sized mosquitoes. We were convinced to get over our aversion to public transport and took the bus to Almaty. After 25 hours of bleached-dry grassland with barely a hillock in sight on a road with most of its surface pushed to the sides in ripples of tar, we felt vindicated. We extracted our bikes from their nook in the luggage compartment and launched into the centre of this rapidly evolving city.

With all the resources we could lay our hands on, we set to plotting a course that would both satisfy our cycling legs and allow us to return to gainful employment at the end of our journey. We had Google Earth, a topographical map in Russian, a schematic plot of SE Kazakhstan’s mobile reception and a helpful young Kazakh we hijacked in a local third wave café. Hopefully this would supply us with all the information we needed for a two-week jaunt into the now less unknown.

The south-eastern corner of this large, land-locked country contains as much geographical diversity as its western deserts contain sulphur-rich oil. Deep canyons meandering through semi-desert, snow-topped mountains and high grassy plateaus all lay within easy cycling distance of the capital. It looked great on paper. Pedal straight down the road to Charyn Canyon. Double back a few kilometres for supplies then turn off towards the Asy Plateau. Jump over a few contour lines, sail over the plateau, then coast down the valley on the other side. And somewhere on this path, at a time yet to be determined, take a call from Australia to secure a job for when I returned home. Although the ever expanding world of mobile telephony has swarmed into Central Asia, there are still some topographical features it has yet to surmount.

Leaving the city

We followed one of the main thoroughfares out of Almaty, cycling through town after indistinguishable town, all sandwiched on top of each other. Despite the convenience of roadside shaslik stalls, we were glad to move on to the more agricultural lands which would provide us with camping opportunities amongst the strips of vegetation between their fields. It also brought us back to the rural villages where foreigners were few and the famed hospitality to strangers was amply demonstrated in gifts of generous bags of fresh apricots. Luckily, these towns also provided mobile reception, and with it came the first email with a scheduled phone interview, some five days hence.

Riding on with some semblance of a plan, we passed regular market stalls stacked with fresh produce and enormous piles of Uzbek watermelons and eagerly anticipated restocking in the village beyond the approaching Kokpek Gorge. The heat bounced off the tarmac, cooking us on both sides as we rolled on through the gorge. Our pace was mysteriously slow and those luscious watermelons were feeling more and more distant. After a handful of painful kilometers Andrew pulled over to inspect what he was sure would be an ailing bicycle. No punctures. No mechanical issues. Only a prevailing look of befuddlement.

‘I can’t figure out why it seems such hard work when we’re going downhill,’ he exclaimed.

‘But we’re going uphill!’ I countered, only to be met with confident disagreement.

This back and forth entailed for several strange kilometers before our GPS altimeter stepped in to resolve the matter. 954m…956m…958m…960m…Steep triangular hills were flanking a winding road and the irregular horizon was only ever a few hundred metres away and clouded our sense of depth. It was an optical illusion that had Andrew fooled.

Emerging in the truck-stop town of Kokpek on the far side, we found that neither fresh fruit and vegetables nor mobile reception were to be had. This was the only town within reach of Charyn Canyon, our first destination, and where we would return to for supplies before setting out for the Asy Plateau. Supplied with pasta, tomato paste and sausage, we cooled ourselves in the shade and hoped that the steep hills we had just emerged from were blocking the signal.

Further along the road we reached the turn-off for the main road to China where we parted with most of our belching, motorized traveling companions. Here, on an expanse of scrubby grasslands between two spurs of the Tien Shan mountain range, was the best mobile reception to be had. A single tree and some crumbling buildings a little way off the road marked a likely camping spot, so we made a mental note and moved on into the sweaty day, stopping every few kilometers to check the strength of our reception.

Into the canyon

Around 13km along the washboarded road we found a pair of fellow cycle tourists, a Dutch couple who were also looking for the road down to the floor of the canyon. I made a test phone call exchange to my parents then we joined forces to find a vehicle track so steep that we all walked our bikes gingerly down the loose gravel, reigning in our trusty steeds before we could mount them again on the canyon floor. As the red sandstone plinths and turrets reached above us, our cantilever brakes (in need of adjusting) screeched rather tunelessly through the length of this natural concert hall. Known as Valley of the Castles (Dolina Zamkov), the 80km long canyon is a popular weekend destination for Almaty residents who picnic in droves by the tree-lined Charyn river.

And as we had coincidentally arrived on a weekend, we spent two days sharing the small patches of shade with coach tourists and rambling, extended families cutting cucumbers and searing chicken over beds of charcoal. By late afternoon the visitors began to filter out of the gorge until we were left alone with the long evening shadows and a silhouetted skyline by Gaudi on a Central Asian holiday. As it happened, the Dutch cyclists had left Almaty on a circuit similar to our own but travelling in the opposite direction. They spoke of the Asy plateau, our next destination, in hesitant terms. Yes, they would do it again, for the scenery outweighed the pain, but only just.

Taking the Asy (aka Tassy, Assy or Assey) Plateau route from Kokpek to Turgen had looked brilliant on the topographical map in the flat, air-conditioned café in Almaty. In fact, the closer we got to ‘the Asy’, the more enticing this route became. At some point, and it is hard to discern when exactly, it developed a life of its own. The Asy was not just a way to get back to Almaty, it was the way to return. It was the alternative to a flat, cycle back on a highway. It promised mountains and yurts. And, being a high plateau between two mountain ranges, it was unsurprisingly free of mobile reception. After our weekend in the canyon and a return to Kokpek for uninspiring supplies, we were looking down at where the highway gave birth to the road to The Asy. There was really no choice.

Over our evening meal of pasta, onions and tomato paste at the planned campsite, I rehearsed some likely questions and answers for the phone interview the following morning and tried to remind myself of why I wanted this job, or even what full time work entailed. Just a quick phone call, then on with the adventures. We slept, in what appeared to be the middle of nowhere, though in reality we were not far from a crossroads that once formed part of the Silk Road, and today links Kazakhstan with western China and Kyrgyzstan.

Interview time

At a respectable 7.30 am, local time, I sat on a rocky hillock, coffee in hand and awaited the call. 8 am, nothing. The coffee was now finished and my mind was wandering. 8.30, still no call. At 9 o’clock an anxious call to the human resources department was placed, worried that the elaborate plan for a panel of interviewers to make a call on speakerphone to a Kazakh mobile number may somehow have gone awry. Just an answering service, but one with no answers.

If we rode on, it would be several days before the next patch of reception. If we stayed, we would have to make some careful calculations on the remaining duration of our tourist visa and the distance we could cover on the rough roads. Our now near-dependence on mobile communications and constant availability made both remaining and moving on uncomfortable propositions.

We decided to stay in this remote patch of gerbil holes and eroding mud-brick walls, to await a response from the other side of the world. In the world of junior medical posts, the interview rounds tend to take place only once a year and the more coveted the position, the less flexible the interviewers are likely to be. I was already limited in my options by those who were willing to offer an interview by phone rather than in person. On the positive side, though, an afternoon return trip to Kokpek found the shop to have been visited by the weekly supply truck and so we acquired some eggs, chocolate biscuits and a vegetable or two to supplement our staples.

A night of fitful sleep threw up countless possible scenarios and potential alternative careers. Full-time cycling journalist, perhaps? The disappointment swirled around, and one tangential thought kept arising: that a somewhat retrospectively realized life’s ambition to show up to a job interview unwashed and in one’s pyjamas may have been thwarted.

In the dusty morning light, I checked my email and found that I had an answer, and from that, a new plan. At the last minute, one of the interview panel had been called away to a medical emergency so the interviews had been rescheduled for the following week. We planned to ride on to the Asy, and complete the circuit back to Almaty in time for the next early morning phone call.

To the plateau

Grateful for some clarity, we pushed off on the initially asphalted road to Lake Bartogay with a bulging mental dossier on the path lying before us. Some of the hospitable Kazakhs from a town on the road out of Almaty had poured over our map like their masculinity depended on it and given us some important tips regarding road choices. They also left us with these comforting words: “There are big rocks. They are sharp. They will cut your tyres”.

Finally, after skirting the southern border of Lake Bartogay, a turquoise alpine lake at the foot of our first climb, we passed two Belgians on bikes. Grazed knees and big smiles greeted us. They spoke of gorgeous passes and stunning rivers. It is possible Belgians are overly optimistic folk who don’t have the heart to warn fellow travelers of their impending pain.

We ascended up a valley whose mountain walls gradually closed in around us until we were winding through a narrow gorge. Millenia ago a river would have poured down between the hills either side of us, carving out the contours lying before us. The ancestry of our path was unfortunately well evident in the large, coarse rocks of the dry river bed we were following. Several kilometers of pushing soon brought us to the summit and revealed fold upon green fold of stunning alpine meadows, but, alas, no plateau.

There is something unique about being so high. We were only a mere mountain range away from a major road, and yet felt out of reach. Altitude and rough roads had us isolated and wrapped in silence. The sort of quiet where you start hearing a buzzing, white noise and can identify a scurrying mountain fowl hundreds of metres away. Being high gives a boost of potential energy: the higher you go, the more downhill you’ll be rewarded with.  With tall mountain peaks encasing our horizon these emotions were gliding in, until, out in the distance, we noticed a dirt path winding up and over a pass. Surely that’s not our route, we wished. Surely it was time for our plateau. Bravely turning on the GPS, we glanced at the preprogrammed path. It became evident that the hills were not done with us yet. As we rolled over another green fold the unexpected valley giving way to the unexpected second climb became brutally visible.

If pushing our bikes downhill over a dry river bed didn’t make it obvious enough. If the old troughs and tapped mountain springs dotting our path were a little ambiguous. Then, when two herders on horseback casually raced up and down our see-sawing path, it became painfully clear that we had chosen the wrong form of transport. Steel frames with no suspension do make for a sturdy ride, but we sensed that the four-legged variety was more suited to this environment.  On the floor of the valley we made a brief rendezvous with the Asy river and filled our water vessels. Dramatic rocks sculpted by years of wind lined the valley, like prehistoric layer cakes. While the water snaked down through sheer rocky gorges, our road trended in the upwards direction.

Nothing is quite as disheartening as pushing up a ridiculously steep patch of road, rounding a bend and then being sent back down to the same altitude only to repeat the same routine over again. ‘Why send us up, if you’re just going to slide us down?’ we asked the bike gods. There was no reply, and the two herders on horseback passed us again after their break in the valley. Thankfully the pretty mountain views kept our spirits buoyant and carried us up the pass, before dropping us rather roughly into the awaiting Asy Plateau.

The plateau turned out to be around 20km of rolling dirt road laced over numerous crests and troughs with a slow climb over a further 500m in altitude. The Asy river emerged through the mountain cracks and we now followed its crisp waters. We unloaded the bags and waded knee deep to cross its path, before darting over many of its tributaries over the coming kilometers. This plateau was a metropolis of yurts, livestock and shiny SUVs. Over the spring the shepherds would have negotiated these same mountain passes to bring cattle, goats and horses up from their winter feeding grounds on the lower altitude steppe.

We mingled with shepherds and weekend visitors from Almaty, our grateful and sweaty smiles signaling the achievement of a summit, of sorts. Following the meandering route through grazing pastures, we averted generous offers of freshly picked mushrooms we had no hope of identifying. Approaching one of the final crests, we noticed two young men on horseback loitering near the roadside apparently awaiting our arrival. This time they wanted a ride-off. And for one last time, the horsemen of the Asy left us floundering in their dust.

And beyond

As the plateau rolled to an end the mighty peaks of the Tien Shan had gathered a heavy dusting of snow. Kyrgyzstan was now mere kilometers away and the Turgen-Asy Observatory appeared on a nearby slope, a surreal apparition of high end technology in this largely rural environment. At this stage Andrew’s sarcastic suggestion to make a detour to the observatory was met with an appropriate groan from in front. The downhill was the sole item on our mental agenda. Following a cold night, we were eager to descent as far as possible today before darkness would bring the cycling to a halt.

The road flattened out over 50 metres before dropping haphazardly downwards. As Andrew perched at the beginning of our descent a Russian jeep pulled up alongside. With our rudimentary Russian and rather good charades we inferred that the driver hoped we had packed a good set of brakes. After several kilometers of constant steep descent, our fingers had similar hopes. Thankfully the 400m we dropped in altitude was enough for a slightly warmer night by the roaring Turgen river.

There is a level of fatigue beyond which heavy traffic, noisy neighbours or in our case gushing alpine rivers cannot penetrate your mind. It is a nifty defence mechanism the body develops to ward off anything threatening precious REM. We woke early from a night of such protection, eager to get back to Almaty that day. The morning saw us practicing more white-knuckle braking before the start of glorious asphalt and our smooth, speedy roll all the way to the floor of the Turgen valley. It was a descent we devoured as rapidly as the bag of fresh raspberries we bought from the roadside. Hello potential energy. Goodbye Asy.

And the following morning, back in a modest apartment on the outskirts of Almaty, our hosts slumbered in a nearby room as I sipped my coffee and waited for the call.

To read more of their adventure, and to see whether Ali bagged her job in the end, sneak a peak at her and Andrew’s charming blog.

The post Kazakhstan calling appeared first on Adventure Medic.

Medicine under the stars: Cairo to Cape Town with Tour d’Afrique

Tour de Force

West Africa Cycle Challenge: Sierra Leone to Liberia by bike

Stephen Fabes is a writer, doctor and storyteller. He currently shares his time between his desk, where he’s writing a travel book, and the A&E departments of St Thomas’ and Homerton hospitals in London. Between 2010 and 2016 he crossed 75 countries and 6 continents by bicycle. He now sleeps in a bed. Last week, Health Poverty Action launched their As One Campaign and Stephen tells us in his inimitable disarming way, first of his epic world tour on two wheels, and then how and why he supports As One.

Baby steps

Like most decisions of great consequence, my plan to cycle around the world was settled in a pub, pint in one hand, mini-atlas in the other. I’d finished work on the renal unit in Guy’s Hospital. That Friday feeling had perked up the streets outside, and Londoners were pouring out of offices, making little eddies of people in beer gardens. I joined them, and sat on a wooden bench outside the George pub amid a small band of my closest friends. I had a plan to pitch.

I opened my mini-atlas on a double page spread of the world, put my pen to London and gazed significantly around the table. ‘I reckon it’ll take about six years by bike’ I said. ‘You know, give or take.’ And with that, I was off: my pen skittering across roadless hunks of Sahara, over white and blue hoists of mountain, through jungles stocked with unwholesome parasites and toothsome fauna that there was definitely no need to mention at this stage. With a little flick of the wrist I winged it, unscathed, through the Darien Gap. Someone muttered something about war lords and drug cartels but I swiped at their fears with my pint-hand, dripping lager on Mexico, and I was soon merrily skidding about Alaskan tundra. In less than a minute I’d breezed back to London where, like a cross between Marco Polo and Gandalf in Spandex, I’d fondle my rambling beard and lapse into a thousand-yard stare.

At the time, I was clinging to my twenties and plodding through Core Medical Training at Guys and Thomas’ Hospitals. There were the usual professional quibbles. Yes, my social life had been contracted into a kind of anorexic myth, and what remained of my free time was stolen by revision for MRCP. But generally speaking, I loved my job. There was, though, a gnawing consciousness that I’d be working until 65 at least. I needed an adventure. A test. Something meaty and unsure that could end elatedly back in London in half a decade, or in some wild part of the Himalaya, lost, alone, barely enduring on the few moths I could skewer with a penknife. I didn’t think I’d regret an ending of emaciation and moth-kebabs. There was a romance in it.

I began saving money. My choice of flat went from Spartan to needy to perilous. At last I was wedged into an NHS-owned cupboard that was like living in the brig of a medieval warship. I found myself dreaming of adventure in spare moments (in the shower, on the bus, between resus calls). When Core Medical Training staggered to an end, I simply didn’t look for another job. I swapped time on the wards for time designing a flashy blog and researching which brand of rain jacket would be aptly expedition-grade. A vaccination for Japanese encephalitis appeared on my to do list, below ‘buy cheddar’. And I was careful to refrain from cycling. Cycling around the world would be hard, no need to endure months of training and physical conditioning as well.

So, TV dinner-unfit, I waved goodbye to my colleagues and loved ones from outside St Thomas’ Hospital. It was the 5^th of January 2010. We posed for photos. My companion was a new steel-framed, packhorse of a touring bicycle. Far too expensive, especially if it got robbed or fell under an Australian road train or got confiscated by the Russian security forces; all seemed faintly possible. A sleeping bag, roll mat, base layers, pots and pans, maps from here to Somalia, cameras and lenses, a medical kit (thank you NHS) and much more besides was stuffed into four panniers clipped onto her racks.

I leaped atop my bicycle – forty kilos of gears lurched worrisomely – and aimed myself away from the crowd. I took my first pedal strokes. I heard ‘Go on Stephen!’ and I was glad at this crucial moment my mum had elected not to call me ‘her little adventurer’. Theoretically, I was now cycling around the world. The thought was suddenly incredible. I was full of pluck and self-confidence, feelings which rushed with me to Westminster bridge, where they, like me, abruptly terminated. Unbeknownst to my friends, I pulled a quiet U turn. And then headed swiftly to the pub, where I spent the next four hours drinking through crushing self-doubt and wondering what I’d got myself into.

False starts aside

I did eventually get underway, pedaling fourteen long miles to a bed and breakfast in Bexley Heath where I collapsed onto a bed with a sore arse, and tried not to dwell on the six years of sore arses that loomed implausibly ahead. When I woke, it was to a snowscape. Serial weather charts for the next couple of days, if I’d bothered to look at them, would have revealed a pallid whorl infecting Europe from the north. Nasa satellites had snapped a ghostly Britain, southern parts encumbered by forty centimetres of snow. By the time the overnight temperature in Manchester had faded to minus 17 degrees Celsius, the army had been mobilised to assist stranded motorists. Weather forecasters were tagging it ‘The Big Freeze’ (the cold was so severe it had withered their imaginations) and nationwide, around eight thousand schools were closed. In Kent over 250 schools had delighted children by closing their gates and cancelling class. My first full day on the road was spent negotiating up to a foot of snow and gangs of children rampaging with snowballs. I was slow and preposterous-looking; the ultimate prize.

The most cherished moment in a child’s life, I have discovered, is this: you are playing in the snow. Your mum shouts “Hey Benny, school’s cancelled, too much snow! Come inside for apple pie!” “I’m coming Mum!” you shout, but as you put the finishing touches to the densest, roundest snow ball of your young life, a huffing, unbalanced-looking creature on a bicycle teeters into view: a Lycra-entombed sack of unmuscled blubber, weaving regretfully. Your best friends gather about you, forming a kind of platoon; he sees you all, pleads with his eyes, develops a look that suggests the slightest distraction might send him painfully crashing to the icy ground. He begs a little, in a string of whimpering ‘no’s’, but it’s too late for him, and he knows it. A silence falls as you take aim. Never will childhood be this joyous again.

That, anyway, was the teething phase of my journey. Fast forward six years and 221 punctures, I’ll emerge onto Westminster Bridge to end a bike ride that spanned 75 countries, six continents and 53,568 miles (three more than anticipated, having got lost behind some charity shops in Greenwich on the way home). That’s a distance equivalent to more than twice around the planet, or 61 times the length of Great Britain, or 23,808 laps of the Coventry ring road, or 9743 Mount Everests if you’d somehow cloned the mountain and laid it end to end in space. Whichever sounds most impressive. I was more calf muscle than man.

But not so fast

It took about four years on the road for the rot to set in. Four years for a swelling sense of burnout to reach its peak. Perched on the edge of Asia, I realized that all the potential small dramas and big vistas of the continent ahead didn’t excite me all that much.

There were clearly two possible solutions to this lassitude. I could: 1. Go home; Or 2. Invest my journey with a touch more purpose. You have a great deal of time to think on a bicycle, it’s the most meditative activity I know. Something about the spinning wheels which turn the cogs of a wandersome mind. And during these spare hours, I began to wonder if I could explore some aspect of healthcare on my way home, something I was genuinely passionate about. I could begin another journey, running in parallel with the physical one by bicycle.

Over the next two years in Asia, I visited remote medical clinics and healthcare projects across the continent as I travelled. They served people who were, in one or more respects, marginalized; living in the economic, geographical, cultural and political edgelands. My aim was not to swoop in and volunteer my medical skills in the short term, in communities I didn’t know or could hope to understand. Instead I planned to observe, learn a little, contrast and write about healthcare on the margins. Medicine would be a medium by which to dig beneath the surface, discover stories and bring a new perspective to the world I was pedaling through. And my bicycle seemed the perfect vehicle. It provided a lingering, backstage view of the world. It brought an appreciation of details that have a bearing on health.

On this parallel journey, I met Kalpana*, a young and beautiful recluse from a remote Himalayan community who’d lost all her fingers and toes, unaware for more than a decade that her alleged curse is leprosy, and who self-diagnosed after hearing a public health broadcast from her wind-up radio. I met Rimaal*, one of the street children of Kathmandu who stumbled through puddles and potholes in a gang, blitzed on glue scored at over the usual price from store owners recognising the market endowed by addiction, and intent on making a quick rupee. I met Narith*, a Cambodian fisherman living in a floating village with a tennis ball-sized tumour protruding from his neck, past the point of salvation and cure, even if he could afford treatment. And I met Aye*, a young woman from the Karen ethnic minority in Myanmar, ostracized and dumped outside a monastery. Emaciated, HIV positive and dying of lymphoma; alone but for the Buddhist monk holding her hand, ordered by an elder monk to resign his calling – as monks can have no contact with women – and care for her until death.

And after about five years of cycling, I met Afghanistan.

Afghanistan

I remember the morning after my first night in the northern Afghan city of Mazar-e-Sharif. The sounds of a city waking up drifted through my hotel window. The emerging sun restored colour to the domes of the Blue Mosque, as a man splayed a piece of cardboard onto the pavement, a makeshift mat, and began to pray. A tough gang of street kids were fighting over the fruits of begging, and a scattering of women wandered about on early errands, draped in blue burqas; rippled and shaped by the desert wind.

It was the trucks though which held my gaze, as they dragged their long shadows up and down the square of road that enclosed the Mosque. Gangs of men sat in the open-topped backs, slung with silvery-worn assault rifles, legs hanging over the side, their shemaghs wrapped around their heads and faces, leaving just a slit for the eyes. One of these wraith-like men per car attended a mounted machine gun that made my heart race. Some were police; others paid militias loyal to Atta Muhammad Nur, the famously wealthy city governor slash warlord, known as ‘the teacher’ and a former commander in the Mujahidin. At least I hoped that’s who they were. When the Taliban had attacked – as they had twice that summer – they had done so in a similar disguise.

I sought out the regional hospital which hid behind a tumult of fruit vendors. Women sat in clumps on the steps by the entrance, beturbaned men stood apart by the doors. A multiplicity of skin tones and faces, emerald and blackish eyes. In the hospital I was introduced to Dr Ali*, a bushy-browed, kind-eyed orthopaedic surgeon, India and Afghanistan-trained.

We walked and talked, pushing through a door stickered with a No Guns sign which led to the orthopaedic ward. ”Medical schools here can be a joke” he said. ”Doctors come out with virtually no experience, trained inadequately in one specialty by teachers of another. The difference between a teacher and a student is one night’s reading, I’m serious! Information is passed on like water is passed between hands, and after enough hands, there’s no water left.”

I joined the swinging tail of a ward round. On any given day around 70% of the patients here were victims of road traffic accidents, but the peril of the region’s hectic highways was old news. It was the 20% here, by actions of an insurgent Taliban, which was the fraction growing the fastest. And violence was infectious. Family feuds could be settled using guns, and Dr Ali* recounted stories of wedding party massacres, insisting this was never the case just five years ago.

We stopped then at the bed of an 11-year-old boy. As we gathered round his face clouded over with fear; his mother, a small lady in a white veil, reached for his hand.

Tanim* had been at the bazaar in the northern town of Maymana with his mother to buy new sandals when a woman detonated a bomb in a pressure cooker. The blast wave threw him into a nearby canal, where he lay with a head injury and broken femur. After being rushed to a private clinic with no expert orthopaedic surgeon, fixators were applied to adjoin the ends of fractured bone, but they were poorly sited. Dr Ali* held up an x-ray film for me to examine: ”totally unnecessary” he grumbled. He could have been referencing the misaligned pins, the incompetence, the lack of training, the bomb, the decades of war. When the bones failed to unite, Tanim* was taken by his mother to a mullah who proclaimed the boy to be cursed and responsible for his own pain and disability. Months later the boy had arrived here, where he waited for further surgery and psychiatric evaluation. At night he woke, screaming and tearing at his bedclothes.

I offered his mother a seat, but she refused, opting instead to crouch on the floor, gazing up at me past the chair and speaking through a white veil drawn half over her face. Before the bomb blast, she said, her husband had become addicted to opium and had left her to look after their six children alone. Now, after her son’s injury, her other children went to school for only half the time, for the other half they were forced to work, stitching together clothes to collectively raise two dollars a day for food. The violence would ripple through the generations.

But for now, her main concern was her son. ”He’s not normal” she told me, quietly, sending her words to the hospital floor. ”He screams. He talks to himself at night. I pray his leg will heal, but I worry most about his mind.”

As One

This is the brain drain. This is a poverty of resources. These are the shadows of those faceless WHO statistics. This, I hope you agree, is tragic and unacceptable.

When I first heard of the As One campaign, it was the orthopaedic ward in Mazar-e-Sharif that came to mind, but I’d seen the challenges of resource-poor settings many times before. We live in a world where capital can move unhindered, attaching itself to cheap labour and weak regulations, but where the movement of people is restricted and entire groups are demonized.

This has implications for our colleagues. Afghan doctors struggle to get visas to study abroad, and in resource-poor settings like this, with an intense work load and little time, money and opportunity, high quality training can be hard to come by. With so much experience of trauma, the flow of expertise could very easily be bilateral too. Mentoring, training materials, group chats: all can be empowering.

What is As One? / As One is a campaign run by Health Poverty Action – a charity designed & led by health professionals. It aims to support health workers in resource-poor countries, with a view to making health services better and equal for all – focusing on local development programmes, influencing policy and disaster/emergency responses. They ask you, health professionals from around the world, to support other health professionals from around the world. Follow their #AsOne campaign, and consider donating what you can. The cost of your weekly coffee? The price of a stethoscope? Visit their website to learn more.

Why support As One? / I support the As One Campaign because the medical profession needs unity to thrive, not just at home, but internationally. If you want to do so too, its quick, easy and, let’s be honest, it probably won’t dint your paycheck.

How to support As One? / Support them, advertise their campaign, and donate to their cause via their justgiving site. I know some doctors are donating money they earn through filling in cremation forms and the idea really appeals to me. It’s cash we hadn’t anticipated, that stems from a sad situation and can be used for a positive purpose. Without getting all mystical, I just feel there’s some good karma in that.

Advice for our readers considering their own epic journey / Simple. Just work out whether the cost of taking such time out is worth it. Without wanting to sound negative or whiny (obviously this was of my own volition and I don’t regret the choice at all) there were some prices to pay for taking six years out. I didn’t see friends for a long time, and relationships probably suffered. I was deskilled and broke. I arrived home in debt to everybody, a balding 36 year old living with his mum who took him clothes shopping like a ten year old. I had to re-train. Yes, it was worth it, but be realistic about the cost of taking a such a journey. It’s a very personal decision. If you deem it worth it: go for it! (also… retain some connection with the place you used to work in. Personally I’m also grateful MRCP was out of the way before I left.)

Useful kit for a long bike ride / Take an iPod, a journal, a constant supply of good books, and if you’re going to cycle across Mongolia in the winter time, bring a Thermos.

Want more inspiration from Stephen? / Visit his blog and peruse his may photos chronicling his trip on Flickr.

* Names have been changed to maintain anonymity.

Photos credited to Stephen Fabes; words are a mix of Stephen’s original writing for this article, excerpts from his blog, and with the odd editorial addition from Adventure Medic.

The post Cycling The Six; As One appeared first on Adventure Medic.

Dr Nick Carter has sailed over 50,000 nautical miles cruising on his own boat, racing or ‘adventure sailing’. He has crossed the Northwest Passage and the Southern Ocean from New Zealand to Uruguay. In this article, he tells us about a recent trip free diving in the Antarctic peninsula, and give his thoughts on being a ‘sailing medic’.

The Brief

The brief was very simple: in February 2016, take a bunch of British free-divers down to the Antarctic peninsula. Simple. Three blokes from London had chartered the yacht “Pelagic” from Puerto Williams in Southern Chile to sail south, past Cape Horn and across the Drake Passage to as far south on the peninsula as dictated by the ice. There, for a couple of weeks, they would free-dive amongst the ice and wildlife. Something which had not been done before.

I was hired as the “mate” and doctor. Together with skipper Magnus and chef Laura as professional crew (Pelagic Expeditions) we would attempt to facilitate what the boys had been planning for more than a year.

Preparation

Magnus and I had arrived in Puerto Williams mid-January, a month before the planned departure date, after a convoluted series of flights from the UK. We spent the month familiarising ourselves with the boat, taking a group of Russians on a short charter around Cape Horn, together with the usual maintenance, cleaning and provisioning over February and March. Pelagic was coded for commercial off-shore charter work. As such it was equipped with a Category A (no limit to trip distance or duration) medical kit in accordance with the Maritime & Coastguard Agency (MCA) regulations. Not surprisingly, it took a while to go through all of this and check which drugs were either out of date or in short supply.

With no shops or the opportunity to resupply for a month, we had to make careful preparation to feed six people (something like 550 meals). Water would be a key issue. Desalinators generally work well on yachts but much less so in polar regions. Micro-algae clog membranes quickly and the very cold sea temperatures render them pretty useless. Essentially, it meant cooking and cleaning in the galley with sea water, very limited showering, and taking every opportunity to re-water either from ice melt or (if we were lucky enough) being offered water from one or any of the Antarctic Research stations. But we would eat well, something like porridge/fruit for brekky, sandwiches at lunch and a big stew/chilli with pasta or rice at dinner.

Passage

Puerto Williams (540 56’S, 67036’W) sits in the Beagle Channel (Tierra del Fuego) on Isla Navarino, almost opposite Ushuaia, and is administered by the Chilean Navy. The Navy has the authority to restrict marine traffic leaving the port when bad weather is forecast. On the planned day of departure, 15th February, strong winds were forecast (Beaufort Force 10 or > 48knots) so we slipped our lines before the port was shut. Six or so hours later (40 nautical miles) we were tied up to the dock in Puerto Toro, the southern-most community in the world and waited for the heavy weather off Cape Horn (just a little to the south) to subside.

Cape Horn (55058’S, 67017’W) is not really a cape at all. In fact, it’s an island just off the tip of South America. “Isla de Hornos” is part of the Hermite group of islands south of Tierra del Fuego. The first reported sighting was way back in 1525 by Franscisco de Hoces sailing in the San Lesmes and again by Sir Francis Drake in 1578. Interesting that Drake didn’t actually sail through the passage named after him. I think it was formally recognised by a Dutch expedition of the Eendracht and Hoorn that left Holland in 1615. In January 1616 Cape Horn was spotted and named after the Dutch city of Hoorn – though the name has since been somewhat bastardised. As one of the icons in sailing, it is one of the three “great capes”, the others being Cape of Good Hope in South Africa and Cape Leeuwin in Australia.

We passed Cape Horn the following morning, still in 40 knots of breeze, with shortened sails and a very lumpy sea. What lay ahead was the Drake Passage before we would make land-fall in Antarctica. This narrow stretch of water (by ‘narrow’, I mean 600 nautical miles wide) sits between the Chilean Andes to the north and the Antarctic peninsula in the south. Not remarkable in itself other than around Antarctica there is no mass of land obstructing the westerly winds as they hurl around the bottom end of the world. The winds funnel and strengthen as they hit the high land off these two land masses. Add into that the continental shelf that sits at either end of it (upon which the waves mount) then this creates a much-to-be-respected body of water. Rather than heading due south, we wanted to pass by the west (windward) side of the peninsula as far south as we were able. This meant sailing a little more up wind for 850nm (six days), past the Antarctic Circle (66033’S) before we arrived in Marguerite Bay south of Adelaide island.

Magnus and I stood watch: four hours on, four hours off. The three chaps supported with three hourly watches, giving them each six hours off watch. This way, we could “rotate’ through each other, getting to know each other a little better. Sail changes often required a couple of hands on deck and if, as you’ll see in a moment, anyone was sick below deck, we could call on the least sleepy of the other crew to assist.

Seasickness

With a big swell and new crew who didn’t yet have their sea-legs, seasickness was likely to be an issue. It was. Two of the free-divers really felt it in the first couple of days of the crossing. My recommendation was to take Stugeron 12 hours before departure (cinnarizine 30mg initially, then 15mg 8 hourly). They didn’t. Not surprisingly, they developed fairly miserable symptoms early on. Despite efforts to get them up on deck and distracted whilst avoiding time in the galley, they suffered. For the sick, I favour Scopoderm patches (hyoscine hydrobromide 0.3mg/hour) which last for 72 hours. After applying the patches and following 24 hours of lying in their bunks drinking water, they were up and about, functioning and with renewed appetite. I also carried intra-muscular Stemetil (prochlorperizine 12.5mg) if the patches didn’t work.

Land

The first hints of land were the impressive icebergs as we closed land off the coast near to Adelaide island. We were unable to press further than 70ºS because of the floe (sea) ice. Even in Marguerite Bay, “bergy” ice from the Sheldon Ice sheet made navigation awkward, with a couple of detours required to find a reasonable lead. Approaching an ice-field often brings fog with it, making anchoring at night off Anchorage Island, a few miles from the BAS station at Rothera, something of a challenge.

Free-diving

The following morning, 22 February, we were greeted with the sight, sound and smell of the Southern Elephant seals on the island. The boys opted for a trial dive that morning. Pretty quickly came the revelation that the under-water visibility in Antarctica was poor and that cold tolerance would be an issue…! Sea water freezes at -1.80°C and as there was plenty of sea ice around the temperature couldn’t have been much warmer than that. Despite careful pre-dive preparation (thick wet-suits, gloves, boots and hoods), little more than an hour or so was the limit. In addition, after meeting the BAS team at Rothera that evening, it became clear that there was a real risk of attack from Leopard seals.

Over the next week or two, we gradually moved north and east up the peninsula: first the Argentine Islands, then the Russian research station at Vadansky, Port Lockroy, Neumeyer Straight, Paradise and Piccard Bays. The wildlife and underwater ice architecture were stunning.

The Austral summer was coming to an end, it was getting cooler and darker at night. When we rounded Adelaide Island to head north, we had 30+ knots of wind blowing from the southwest. Lovely downwind sailing with reefed sails. Watch-keeping was intense. Bergy-bits and growlers look remarkably like cresting waves and are even more difficult to differentiate in failing light. By the following morning, the wind had eased and shaking out the reefs should have been easy, had there not been the revelation that the rigging had frozen!

Ashore

Whenever we headed ashore from Pelagic, we always left someone on board the boat. We always set down a shore barrel (above the high tide mark!) containing tent, stove and fuel, tools, water, food, some warm items, radio, head-torch and spare batteries. In the event that the weather or ice should change for the worse and the boat needed to move, the shore party had a least some protection until they could be collected.

The International Association of Antarctic Tour Operators (IAARTO), amongst other regulations, are explicit about engagement with wildlife in that part of the world. For example, it is not permitted to approach close (less that 10 metres) to penguins or seals. If their behaviour changes, move away. IAARTO are clear on practices to avoid contamination in the region and prohibit removing “souvenirs” like feathers, bones and other items from the continent. All sensible stuff. Its permitted however, to sit down quietly some way off and if animals waddle over for an inquisitive look (as they did), to enjoy their company.

Return

After a couple of weeks, and now nearer to the northern tip of the peninsula, we tied up to the wreck of the whaling ship, Governoren that floundered in 1915. Here, we waited for a weather window to head back across the Drake passage to Chile. Two days later we left with reasonable forecast. However, for the last day or two we were battered by 45-55 knot winds as we approached Cape Horn once again. By mid-March, after nearly 2000 nm sailed, some minor damage to the sails and marked fatigue, there was nothing that couldn’t be remedied by a few beers, sleep and a little sewing.

Sailing Medic?

With good preparation and attention to safety whilst at sea, the risk of injuries is quite low. Often, sailing expeditions can ill-afford to fill a berth with a medic who may essentially be of limited use for long periods of the voyage. All the more so with the advent of telecommunications support via sat phone for medical advice. Many expeditions do, of course, value and feel re-assured by the presence of a medic. So, I think the best approach is to aim to be a valuable member of the crew, an experienced or better still professional sailor with additional knowledge of the type of boat and waters you maybe sailing in. Your medical knowledge then becomes an incredible bonus for the trip. Good luck!

Nick is part of the crew for Pen Hadow’s summer expedition, which has just set sail for the North Pole.

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Dr Meinir Jones, a GP from South Wales, has had a varied and exciting career, but in 2014 faced her most significant challenge yet: as the medic on a crossing of the polar ice cap. Testing enough, you might think, but this expedition was in support of Pete Bowker, a military veteran aiming to be the first amputee to cross the Greenland ice sheet unsupported. She tells us of the grit of her team mates, the joy of bacon, and the importance of a GSOH on expedition.

As a GP with a special interest in sports and musculoskeletal medicine, having spent several years as a middle grade in busy trauma centres across the globe, my career has often followed the path less travelled. Putting my hand up, trying new things, and letting the monkey out of its box has allowed me fantastic, memorable experiences. To date, these include being a ski doctor, cruise ship medic, V8 supercar medic, and covering the Olympic and Commonwealth Games. Next up, ‘settling’ with my young family into primary care medicine and dipping my hand intermittently into pitch-side cover and mountain running. Little did I know during my first meeting with Richie Morgan, Team Leader for 65 Degrees North, in a small but well known coffee house in Swansea back in the summer of 2014, three small words would seal my fate as the on-ice doctor for the team that crossed the Greenland ice cap. Expedition naïve, the only female and non-military person, “I can ski” were the words that made me the 5^th and final team member for what was to become my biggest challenge yet.

‘When someone offers you an amazing opportunity and you are not sure you can do it, say yes – then learn how to do it later’ – Richard Branson.

Background

Greenland has the world’s second largest ice cap, with over 600km of skiing from west to east, the threat of polar bears, crevasses, weather-enforced tent days, and temperatures of down to minus 40. In 2013 Peter Bowker, a 28yr old lower leg amputee and veteran from Afghanistan, decided to attempt to be the first amputee to complete an unsupported crossing of the ice.

Why Greenland? Pete had been about to leave the Army when he was given the opportunity to do his adventure training, and was informed he would be one of several crew sailing from Iceland to Greenland. Destination reached, and perched on a rock in Scoresbysund looking across the ice-cap, Pete made himself a promise that he would one day become the world’s first amputee to cross the ice on skis.

What followed was a slow and frustrating start, with dyslexia floundering his attempts to gain support and funding, and little in the way of replies to his emails and letters. Following the Hero’s Challenge in 2013, he forged a friendship with Richie Morgan, an ex-Royal Marine and serving police officer, who helped the project gather momentum and support. Within 18 months, funding had been secured from LIBOR, and endorsement gained from the Royal Foundation. A meeting with Prince Harry in November helped increase the media footprint and credibility for the project.

Pre-Expedition Medical

I have always been a firm believer that when seeking knowledge, you should speak to those with experience. You learn far more than from books. I spent time with several very experienced expedition medics, devised a ‘kit list’ which was vetted by Dr Dan Roiz de Sa (Doctor for Walking with the Wounded) and Dr Ian Davis (who has completed more expeditions than I have fingers and toes) and weeded everything down to a 4kg pack of essentials for the 28 day crossing. Their first-hand experiences were invaluable in preparing me and my team for what lay ahead. I also sought advice from Dr Nick Webborn, who has a wealth of experience in dealing with disabled athletes, and pointed me in the right direction for expert help with stump care and tissue viability.

“So who looks after the doctor when the doc goes down?” How do you prepare for that? I made it my job to ensure that everyone was capable in times of need. I printed laminated sheets of ‘How To’ manage common medical problems, within a clearly labelled, colour-coordinated kit bag.

Medicine on the Ice

I recorded everyone’s sleep, mood and resting heart rate, as well as daily injury/illness/concerns in the back of my diary. This would help me better anticipate any subtle changes which might have led to bigger problems, allowing me to act quickly to try to prevent the latter.

Pete’s stump rapidly broke down with the extreme conditions and increasing physical and mental demands of 12-hour days’ skiing. His analgesic requirements increased as we progressed and I opted to issue him with regular medication, rather than give him analgesia on an as required basis, which helped to keep him going. The pain, though not verbalised, was all too visible in his altered biomechanics and difficulty skiing.

He lost a lot of muscle mass around the stump as time went on, revealing new pressure areas throughout the crossing. This posed new challenges due to altered fit of the prosthesis which consequently affected his ski technique, giving him lower back and shoulder pain.

Daily ward rounds, wound management, stump inspections and blister care were the norm, with frequent alterations of Pete’s prosthesis using scalpels and nail files. Sjur Modre, our Norwegian guide, was able to use his carpentry skills in altering the socket, allowing for the subtle changes in the areas on Pete’s stump prone to pressure.

Foot care for everyone was vital, with taping to avoid blisters: they could be game-changing for the expedition, hindering our progress across the ice. The team had been advised to learn how to tape their feet before the expedition, and most of us were able to keep the same tape on for the duration.

Tent-enforced days due to poor weather conditions were a double-edged sword, delaying our progress but allowing much needed time for Pete’s wounds and stump to heal.

Challenges

Training

Pre-expedition work out: tyre pulling, weighted walking, mountain running – I even invested in a cross-country ski machine. The key was to spend time on your feet, with plenty of strength training thrown in. This was a real juggling act, with a full-time job and two young children with a busy social life of their own. A training week in Norway a few months before our May departure helped get the team up to speed with tent skills, pulk-packing and navigation: a mini expedition that helped give us a flavour of what lay ahead. It also helped team-bonding. We learned each other’s strengths and, maybe more importantly, our weaknesses, which really helped to prepare us for the challenge in Greenland.

Toiletting

The weather conditions necessitated learning to empty your bladder into a wide necked vessel whilst kneeling in a down sleeping bag. Imodium was my friend during the tent-enforced days of severe weather, of which there were several! Some top tips were given to me by Kate Philp, whom I met in the months leading up to Greenland. Kate was one of the team who completed the South Pole challenge with Help for Heroes with Prince Harry.

Nutrition

In order to keep going for the 10-12 hours of skiing, we ate protein-infused porridge for breakfast and snacked on protein bars, digestive biscuits, nuts and dried fruit. For our evening meal we ate reconstituted dehydrated Norwegian army scran. Luckily for us, Sjur, one of Norway’s finest guides, supplied a daily fix of bacon, camp-cooked muffins, and even smoked salmon on rye. This came from his Mary Poppins pulk bag, bringing much needed treats out like party tricks to keep morale afloat. I had advised the team to take probiotics for the month leading up to departure, to help build immunity and reduce the risk of gut upset. This, after blisters, is the second commonest cause of medical issues in such extreme environments.

Navigation

Navigating was often very challenging, especially in white out conditions. It was frustrating to watch as the worm of team members, following the nominated ‘worm’s head’, ended up back where we started. Especially when pulling a pulk weighing more than me! It was a real lesson in resilience. We used sastrugi lines in the snow to navigate, and if we were lucky, the sun cast shadows on them allowing us to follow an angle set out by our guide. It is so easy to get lost when everything in front of you is white, just white. We all took turns in navigating, with some faring better than others. It could be very demoralising when distance covered by skis didn’t correlate to the distance from our start to end-point. Straight lines turned into ‘wiggly worms’ when visibility was low.

A predicted 18-19 day crossing turned into 28 increasingly longer days, due to poor conditions. A highlight of my day was my daily diary entries, and reading the comments left by close friends and family, randomly placed on the otherwise blank pages. Poems from my daughter, funny stories from a friend, and even 21 single daily notes from my ‘bestie’ helped to trigger memories which filled my mind during the hour of skiing between 10 minute breaks.

Our evening communal dinners in Sjur’s tent were a real coming together, with Pete’s humour and the team’s recollection of their time in the military fuelling laughter and discussion. The pièce de résistance was a tiny map of the crossing that Sjur would carefully unfold and plot our whereabouts on, signalling progress across the ice cap.

The Inmarsat beacon gave us an invaluable connection to home, and provided an immensely important link with the outside world. It provided daily updates, and increased Pete’s media footprint in raising awareness and much needed funds for his nominated charity, Help for Heroes.

Final day dramas

With just over 40km skied that day, and only another two miles to reach our destination, Kirk ran into difficulties and found himself down a crevasse. It was a very hairy moment indeed, but demonstrated teamwork at its best, with me on camera duties to capture the moment. Crevasse rescue successful, we completed the day’s skiing roped up, and in over 2 hours laters arrived exhausted, hungry and elated.

An excerpt from my diary on the last day:-

Thursday 4^th June – Zero KM left, expedition complete!

I’m sat in Kullusuq airport – with the sun warming my back awaiting our boarding call. Yesterday was a mammoth day. After a delayed start due to awaiting phone call confirmation on our travel info, we commenced on what was to be our longest day, both in mileage and hours and time on feet and in skis.

As we descended to our final campsite, Sjur edged us all forward. Was quite symbolic in fact that the team were all connected by rope. We took a few steps, then let Pete take his glory in touching the rocks – the world’s first amputee to ski across Greenland, unsupported. I think we all got a little emotional – well no surprise that I did anyhow!

I’m totally and utterly exhausted today – no sleep from sentry/polar bear watch and kit organizing! No bears were sighted but we (Mick and I) did see a little solitary Arctic fox scuttling around the camp – peeping from behind the rocks above us. He must have sniffed some of the measly rations that we ate around 0230! Several hours passed quickly at Kullusuq airport – lots of laughter and reminiscing. I think Sjur has also enjoyed the challenge, us being somewhat different from his usual group. My God, how lucky were we in having him as our guide – his ‘Mary Poppins’ pulk, his calm and wise words, his ‘knowing’ of what to do next, his carpentry skills with Pete’s prosthesis. His words of encouragement and stability.

Pete’s determination, mental resolve humour and predictability with ‘one liners’, grit and strength of character make him, in my eyes, a true hero. And so, the expedition is over, we are up in the air – high as kites literally and metaphorically and about to really face the music. Patrons, family friends and other team members await our arrival in Iceland. A team decision made not to shower! To arrive as we had finished – in kit, smelly, unkempt and weathered! My only compromise; a wet-wipe wash and clean knickers, bra and thermals. My plait brushed, hair greasier than ever and  a small amount of mascara. I am good to go.

Our legs have felt like jelly today, from a combination of such a big day yesterday and so few ski-free hours on our feet over the last month. I even caught Mick trying to ‘glide’ across the airport lounge! I decided to reflect on the negative and positive aspects of the trip.

Homeward bound

And so what’s next? The question on so many’s lips after my return from Greenland.

Some time to pause and reflect. My involvement with the growing organisation that is 65 Degrees North continues. 65DN seek to encourage rehabilitation through adventure by inviting injured servicemen, with both physical and emotional injuries, to push boundaries, work as a team and assist their rehabilitation. It gives them back focus, not only in the present with the challenge, but also the skills to move forward in their own lives. Great support is being given by Swansea University and their team of psychologists. Mount Vinson is on the near horizon, with a team of five attempting what is oft termed the ‘Jewel in the Crown’ of the five summits. They depart January 5^th. This time I am their remote medic, staying in the warmth… but who knows next time?

Lessons learned

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Expeditions are rarely unqualified successes. Often it takes some time to truly appreciate the value of any experience. However, to avoid having a rough one, please read Erin Kilborn’s tale of a river trip to Puerto Prado in Peru and benefit from some of her lessons learned.

Looking for an adventure? Somewhere remote, exciting, and a road less travelled? What if you are interested in learning about new cultures, indigenous peoples, conservation and nature?

How would you feel then if an organisation approaches you offering exactly these? Particularly if, on the surface, their profile is impressive: trips to remote islands on sailboats, camping on isolated beaches and living off the land, travelling by down rivers through Mexican jungles, and an ethos that speaks to you.  They collaborate with artists, environmentalists, scientists and naturalists, sharing a common taste for discovery and working together with local people. They even have a TED talk. It may be vague but it is inspiring, and it grabs you.

Can you blame me that I got hooked? I thought I had experience: I’d been expedition medic for three months with Raleigh in Borneo in 2012. And the following year I’d worked as the medic for a burns unit in Port au Prince, Haiti, with MSF for six months. My background was primarily in emergency medicine, working as a doctor in a very large and busy Glasgow-based hospital, and I had just finished a year in anaesthetics and ICU – I felt confident.

The organisation’s founder and leader contacted me and we set a date for September 2015. I would be medic for a team of artists working in the Peruvian Amazon in a remote community of Cucama Indians. The plan was to travel down river for a couple of weeks and explore. I was so excited, I even bagged a place on the trip for my partner, an adventurous type I had had met working for MSF in Haiti. The selling-point was his good Spanish.

Planning

I wrote a pre-departure booklet with advice for the participants regarding vaccinations, antimalarial prophylaxis, all the usual advice based on my experiences with Raleigh and expedition medicine courses.  I sent out health questionnaires but never saw a single response, despite chasing them up.

The organisation sent me their kit list (it would all be provided). They had a reasonable selection of medications and dressings. Several items needed replacing, and some key things were missing. I contacted them with my feedback. Assured they’d take care of it, I later discovered that a young non-medical Mexican group leader would go to the pharmacy in Peru to track down the missing/perished items. Of course, things like EpiPens are not available in a remote river town in the Amazon basin, but somehow she found a vial of adrenaline, no dosage marked on it, and no date. I’d have to make do. Most of the medical kit ended up arriving several days after the team, various glass vials and boxes, packets and foil-wrapped pills all shoved together into a large dry bag with little protection. Nothing for disposal of sharps. A couple of bags of IV saline, no giving sets.

The team were all lovely, though perhaps slightly off-the-wall characters. One of the artists had spent the ten days prior to meeting us at an Ayahuasca retreat, so was still flying high when we met, complaining of a mild stomach upset that lasted about a week.

Food and Water

The Cucamo people hosting us in the village were incredibly friendly and very accommodating, preparing fresh food for us most days, though there was never enough. It was not clear to me what the arrangements for food were supposed to be, but we were quoted stories of previous trips where they’d gathered coconuts from the jungle and survived on handfuls of trail-mix made by the two young Mexican girls who were our stand-in ‘leaders’, as the guy who had called to recruit me wasn’t able to make it on this trip. Water too was an issue, as I discovered that each day we were in the village, it was the villagers who would go and fill a large container for us which would be purified and filtered.

There was no clear plan. Eventually, after several days of hard work trying to carve our own (way too heavy) wooden oars, we set out on the village leader’s fishing boat – a heavy motorised machine- that we were supposed to paddle. As we largely floated downstream slower than a lazy sloth, morale was variable. We did see pink river dolphin, and had the beautiful experience of a refreshing swim in the amazon near a shallow sandbank, watching jumping fish and local birdlife alongside the river.

But we didn’t have enough food, we didn’t have enough water, we didn’t know what lay ahead or where we would sleep. That was ‘part of the fun, part of the adventure’. Now, I’m all for adventure, but as a doctor, I know that lack of preparedness is what leads to problems. There was no communications equipment, not even a mobile phone that would function in such an isolated region, and certainly no radio or satellite phone. I wasn’t aware of a common pot of cash in case of emergencies, either.

Eventually, taking advantage of the kindness of an incredibly poor family, we were invited to set up hammocks for the night in their open wooden bungalow. As dusk fell, I have never seen so many mosquitos. We were offered food, and we repaid their incredible generosity with bracelets. Yes, bracelets. I’m still dumbfounded to this day.

MEDEVAC

The following morning, one of our team (incidentally, my boyfriend Basil) fell sick with a high fever. He felt slightly better with water and paracetamol, so we pushed on in the boat to another village, San Joaquin. We found a small shop and bought some warm cokes, but by now his temperature was rising despite the medication and he started vomiting.

After exploring the bare bones local clinic in the village, I decided we had to evacuate him. We were at least three hours downstream from the nearest town with a reasonable healthcare facility. I dosed Basil up with more paracetamol and antiemetics, which promptly came straight back up. I checked the medical kit: vials of cyclizine were all I had; there was no diluent.

The MEDEVAC was a nightmare. By the time we found a boat we could use to get back upriver to the larger town of Nauta, it was almost dusk. There was a storm brewing over the river with tempestuous heavy purple and black clouds overhead and a quickening wind.

We bundled a very weak, dehydrated Basil in between bags into the centre of the boat; essentially a dugout canoe with a motor on the end of it. The boatman’s wife sat with a small container, emptying water out of the back as the waves splashed up into the boat. The two Mexican leaders both decided to abandon the village and the rest of the team to accompany me, leaving the group of artists with not enough food, not enough water (and all the Lifestraws in one of the girls’ packs) and no communications. They did have the big heavy boat and the boat’s owners, our host village leader and his son, with them. And luckily, two of the artists were prepared with a supply of water purification tabs and a few cereal bars. To be honest, they had more expedition and outdoors wilderness experience than the two Mexican girls.

We made our way upriver, the storm gathering and night falling. Jumping fish all around the boat, one landed in my lap, another smacked one of the girls sitting up in front of me on the head. A large spider crawled out from between the bags and made its way up towards the girls, provoking mild panic. Luckily neither spider nor girl was harmed.

At points, the boat journey was strangely beautiful, with glow-bugs like little stars just above the water and birds and bats dancing in the sky catching insects. But as a thick, heavy darkness fell, and the pressure of the storm increased, we depended on the light of our head torches to navigate the inky black river and avoid the perilous driftwood. We arrived in Nauta just as the tropical rains finally burst and the river became un-navigable. The town roads became murky brown rivers.

Nauta Hospital

The hospital was a relatively good facility and the staff were knowledgeable and well trained. Basil was placed on a trolley, his legs poking off the end as Peruvians are generally not as tall as 6ft Frenchmen. He lay exhausted while they took blood for malaria and dengue fever and treated him with fluids and antibiotics. Luckily, it was nothing more sinister than a tropical gastroenteritis, but he had lost about six kilos in ten days and was very dehydrated.

We stayed in a hotel for two nights to give him time to recover, before returning to the village and finding the rest of our team. They were livid with the leaders, and rightly so. They decided to remain in the Cucamo village for the remainder of the trip rather than attempting further river excursions. Given their proximity to Nauta, the town with the hospital, I decided it was safe to leave with Basil and return to Lima. He needed time to rest properly and recover, especially as we had discovered after two days that food supply remained an issue. I too had lost about four kilos, and that was without being sick.

Lessons Learned

Despite all this, the trip had many beautiful moments. I ran a first aid workshop with the community and treated a handful of simple infections and mallet-finger injuries (the community played a lot of volleyball!). The jungle walks with the village leader’s son, a trainee shaman, were beautiful beyond words. Their knowledge of the environment and the medicinal plants was extraordinary. And the wildlife was spectacular. But there were some major lessons learned.

Do your research / It should have been telling that despite several requests to contact the last doctor who had worked with them, I was never given his contact information. I don’t know if this would have changed anything, but it is interesting in hindsight. The organisation was very media savvy: their website, Facebook and Instagram feeds were slick and professional, so it was hard to form an accurate impression.

Medical kits / If you are not providing your own kit, then ensure you get to see the organisation’s one prior to setting off. Although I thought we had done this through via email, they hadn’t upheld their end of the bargain. In case of doubt, bring your own medical kit with trusted equipment, drugs and dosages that you are familiar with. Simple things like a glass jar with a lid can be used to store sharps until you can dispose of them appropriately. Storage and labelling is key, especially in a jungle environment, and plastic containers and various small coloured dry bags are useful to store medications systematically.

Emergency planning / We didn’t have an exit strategy, no Plan A, never mind Plans B-Z! I tried to engage the leaders in planning for an emergency but was always brushed off. Stand your ground. If you think a trip is unsafe for any reason, whether it’s lack of planning and preparedness, poor kit, lack of supplies, or anything else – call it off. The expedition medicine community will back your decision. Ideally you should also try to familiarise yourself with medical facilities in the area and contact them before you set off.

Into the Unknown

At the end of the day, adventure and exploration are wonderful, but when you are the medic responsible for the wellbeing of a group, it is your job to be prepared.

I have purposefully not identified the organisation, as it’s hard for me to know if my experience was a one-off. Following our return, I tried to express my concerns to the head of the organisation but received a generic copy-paste reply that did not address any of the points raised over the safety of the trip. Never once did they ask how Basil was, or if he had recovered well.

The Unknown is a tantalising and seductive idea, but should not be an excuse for a total disorganisation. To me, the worst part of the expedition experience was the feeling that we took advantage of the indigenous people. Bringing the basics does not mean not sharing with the community, it simply means being less dependant on their kindness and charity. We could have offered more of our time and skills, instead of being a burden for basics such as food, water, sanitation and transport needs. The villagers needed time to concentrate on their own needs, not to meet the needs of outsiders as well. In all, I felt there was a severe lack of cultural awareness and sensitivity, and that was shameful for an organisation that prided itself on working with communities.

A happy ending

After the expedition, fellow participant Karen Lofgren, a California-based artist, took matters into her own hands to continue supporting the community, helping them to realise some of their development goals.

In November 2015 she set up a crowd-funding site to help raise finances to buy building materials for the community and create the ‘Amazon Samiri House’- an eco-lodge for visitors coming to the community. The project successfully raised all the necessary funds, and building is almost complete.

Since we left, the village of Puerto Prado has many new projects including a building that serves as a solar charging station/public living room for the community and visitors. They have added another new Maloca and bridge beside the Victoria Regia pond, and have built new fancy bathrooms behind them.

They also have now a partially-functioning clean water system, filtered from their spring to a large holding tank. The size of the pipes (too small to fill the tank in less than eight hours) and gas-fueled generator needed to pump the water means it’s not as effective, ecologically friendly, or sustainable as the community wanted. But it’s a step in the right direction.

Hopefully the community will continue to benefit from ongoing investment and development with the aid of various partner organisations and individuals, helping them protect and sustain their traditional way of life in parallel with an ever-modernising world around them.

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Upon completion of her training, and in pursuit of a short adventure which used her medical knowledge, Dr Susie MacDonald swapped middle England for Madagascar. With no more than a fortnight to try to make a positive and lasting difference, she describes the challenges and limitations of practicing ‘modern’ medicine in a place with few resources and an entirely different culture.

Madagascar and Me

I had not long qualified as a GP and desperately wanted to use what I had learned. With some time on my hands, I looked into arranging a trip to a low-resource setting, where my knowledge and skills might be useful. Ideally, it would be somewhere I’d always dreamed of exploring, with mysterious creatures that couldn’t be found anywhere else on the planet, with blue seas and white beaches. And crucially, it had to be somewhere I could actually be of help. Madagascar was all of these, and a lot more besides.

Madagascar is the fourth biggest island on earth. Due to its relative geographical isolation off the east coast of Africa, much of its flora and fauna exists nowhere else on earth. It is defined as a low-income country, ranking 154th out of 188 countries in the United Nations 2015 Human Development Report. Poverty in Madagascar is increasing and today 72 percent of the country’s estimated 22 million people live below the national poverty line.

Chronic malnutrition, and its associated illnesses, affects 47.3 percent of children under five years of age. Natural disasters can be blamed for some of this, as nearly a quarter of the population live in areas vulnerable to floods, cyclones and drought. However deforestation due to the use of wood and charcoal for cooking, and poor land management such as the “slash and burn” method, have led to the destruction of 85% of the rainforests and further food insecurity.

More than five years of political crises between 2009 and 2013 have had a disastrously negative impact on economic growth and development efforts. Corruption at all levels compounds this.

The Adventure Begins

My husband, James, is an Army officer who managed to be granted a sabbatical from his duties. We arranged to work, through the charity Edge of Africa, in a village on the South Coast: Analapatsy. It was a three-hour drive away from the nearest town, bouncing through dirt tracks, mud and sand, through flooded parts of the road that resembled lakes.

I had been a little suspicious of the vehicle we were in and its owners from the start. They were apparently friends of our translator, but their bus’ safety specifications left a lot to be desired: there were none. There were no seatbelts, although I’m not sure how useful they would have been as the seats themselves were not attached to the floor. The floor was rusty enough to put a foot through and the windows were stuck shut. I found my thoughts flicking between the thrill of the adventure we were embarking upon, and visions of us being trapped inside the minibus and burning alive.

Just when I thought I couldn’t take any more of the ear-hammering afro-pop from the stereo, and my legs were forever going to be stuck in what looked like a birthing position thanks to the luggage and supplies stowed under my feet, our relative peace was interrupted by a loud bang. A flash of flame rose up from the gear box near my toes, and the bus filled with smoke. Fortunately, it seemed that this was not the first time our drivers had experienced this hiccough with the engine, and somehow managed to get us moving again within half an hour. I can’t say that I was all that excited to get back in.

Analapatsy gave us an opportunity to see how most Malagasies lived – rurally, in wooden and straw huts, with little or no infrastructure to be seen. Our accommodation for the next fortnight was our tent, and we were given the great honour of being invited to camp in the compound of Analapatsy’s mayor. He, his two wives and various children and grandchildren lived in this dusty enclosure, accompanied by dogs, geese, chickens, cats and oxen.

It became pretty clear that staying well for the fortnight was going to be our biggest challenge, as infection control was not something that entered the minds of our hosts. Instead of asking for medical advice, when the children got diarrhoea they asked our interpreter to bring antibiotics back from the city for them. (Although remembering how my family and many of my patients ignore my medical advice, this made me feel quite at home.)

The villagers had been built five concrete latrines by an NGO a few years ago, but these were left unused. Their belief system required them to leave their faeces uncovered: as they buried their dead, they did not want to give the same respect to both. Instead they would relieve themselves in the fields, or anywhere around the compound. The area we were given to set up our camp was a rubbish heap which we, along with some children, moved and swept. Despite this, we were never far from human and animal excrement or detritus.

We were only the second group that the charity had organised to visit the village. Our presence caused a stir wherever we went, and we were fortunate enough, as we wandered around the village, to be met by welcoming shouts and warm smiles, as well as curious glances and excited children. It helped that we were joined on our trip by two interpreters, who spoke Malagasy (the local language), French (the official language) and English. That first evening we walked a mile over oxen-pastures down to the beach, and were able to wash off the grime of the road and the camp in the powerful waves of the Indian Ocean.

Straight to Work

The next morning, our work began. James went to the secondary school to help with teaching, and I joined the doctor in the clinic. Interestingly, the first thing he did was try to sell me a lobster, out of season. “It it always the way with you foreigners,” he said in Malagasy, “you are planning for tomorrow, we think only of today.”

It was some time before I discovered that he was not a doctor, but a nurse or clinical assistant. The villagers called him “Doctor”, however, and they respected his advice. There was certainly no shortage of demand, with a long queue already waiting for us as we arrived. They came with all the normal problems: coughs, back pain, sore throats, tiredness, and a lot of gastro-intestinal upset. There were also fevers, most commonly malaria, and for the first week I was there the clinic had run out of point-of-care testing kits, leaving the diagnosis down to guess-work and “treat and see”.

Malaria – the fight continues

Madagascar sees 27 in every 100,000 citizens die annually due to malaria, and immeasurable effects on economic and social welfare.

We were lucky enough to be in Analapatsy during the annual distribution of government and aid-funded mosquito nets. We listened as the Mayor, our host, explained the penalties for using the nets as fencing for livestock, on their farms, or for fishing. We were delighted to see women from all the surrounding villages arriving to collect their nets and were hopeful that these were going to be used for their true purpose, but there was really no way of knowing. It would only be with repeated education and encouragement that a change in behaviour would arise – beyond our scope in the fortnight we had in the village.

During consultations with patients with possible malaria, I was keen to ensure that they were asked if they had and used their mosquito nets. Most families had them, but not all the family slept under them. I noticed that within a few days of me repeating these questions, my Madagascan medical colleague began to ask these questions too. I could see change happening in front of my eyes.

For the want of a tongue depressor

On the second day a 12-year-old girl was brought to the doctor with a fever. She spoke like she had a hot potato in her mouth. The doctor was about to hand over some malaria treatment (for a fee), so I asked to look in her throat. This prompted a hunt for a tongue depressor, which resulted in a metal spatula being unearthed from a seemingly untouched Unicef box. Her tonsils were huge and covered in pus, and he seemed very interested in this examination as though he hadn’t seen it before. The treatment was discussed and she left with some antibiotics.

This was a moment to realise that my bread-and-butter was entirely different to his, and to gather how much we could learn from each other. The next week I returned with a box of plastic spoons for him to use as tongue depressors. Who knows if they were ever used? They may well be collecting dust like the instruments donated by Unicef.

Back to basics

Diarrhoea, often bloody, with abdominal pain, malaise and fever, was a common presentation. When questioned, patients would have blank faces when asked about using latrines, hand-washing, or ensuring the water that they and their children drank was clean. I watched the doctor consulting for days without ever seeing him wash his hands, despite there being a Unicef bucket with a spigot in the corner of his room. He said it was because it was on the floor, and difficult to get to. So we asked a local carpenter to make a raised table for the clinician and the midwife. Over the next few days I saw him use it a few times a day. Such a satisfying improvement in patient care, and visual education for the patients coming to him for advice.

However, useful change is easier said than done – the water was still the same water which the whole village collected from a bilharzia-infested sludgy waterhole a mile away. If there was a system for collecting rainwater from the roof of the clinic, then a safe and readily accessible supply would be assured. I wish I had had more time to work on this, but perhaps it is something for future volunteers to focus on. Perhaps, also, they could extend the “tippy tap” system that we set up at the mayor’s compound, which we used for washing our hands. It seemed to go down well with the children, even if the adults thought we were mad. They laughed and shook their heads as we used it – “crazy foreigners, who think that washing their hands is a sensible use of time”. We tried to convince them that it could save their children’s lives, but we were swimming against the tide. Any change of attitude will take time.

Contraception and delivery rooms

Family planning was something that was done very well at the clinic. The midwife was a well-trained, motivated woman, with a reasonable supply of contraceptive injections and pills. Every afternoon there were a handful of women attending her clinic, who seemed very happy with the free care they were getting.

The other side of this story, however, were the many young girls, often aged 12 or 13, who were married as soon as they started their periods and swiftly became pregnant. In this area, a girl was required to produce a child in her first year of marriage or her husband could reject her, and she would be virtually unmarriable from then on. This practice led to many complications, such as growth-restricted babies, obstructed labour and predictable consequences for the women afterwards such as fistulas and incontinence.

The delivery room in the clinic was horribly ill-equipped with only a dirty bed coated in grime, and walls smeared with brown and red marks. The few instruments were never washed and the midwife admitted to losing “some mothers and many babies”. There were sterilisers, but these were meant to be fuelled by a kerosene stove, which had sadly been taken by the previous doctor to use for cooking. Other options, such as boiling the instruments over a wood or charcoal fire, had not been explored. We discussed this huge topic, but were just too short of time to work on a solution. Another something for future volunteers to work on.

Overdiagnosis and overtreatment: a global problem

The clinician, with whom I was working, diagnosed a large number of patients as hypocalacaemic, without access to blood tests. He prescribed and received payment for countless packets of calcium supplements. Every patient left his room with at least four different medications. Often paracetamol and vitamin C tablets, which did not seem unreasonable for many of the conditions, but there were many other tablets sold for which I could see no clinical justification. Antibiotics, in particular, were used for many illnesses which we would consider are most likely to be viral. Other doctors I met in Madagascar over-prescribed in a very similar fashion. The clinician explained that patients in Madagascar expect multiple prescriptions from a doctor, and consider a consultation to be unsatisfactory if they leave with fewer than four medications. I could see this reflected in my own practice at home, when antibiotics are demanded, and can understand a reticence to spend valuable time explaining why no medications are required rather than prescribing and moving on. This would be particularly tempting when the patient is paying for the medications.

The problem was compounded by the availability of medications, and antibiotics in particular, to the public. At the local weekly market, alongside the vegetables and meat, were stands selling all sorts of tablets. Patients would present with the mildest of coughs having taken two days of amoxicillin already, or some other, less appropriate antibiotics. All making diagnosis and treatment more challenging.

I tried hard to educate the patients and the clinician about how basic hygiene, clean water, a nutritious diet and self-help measures are more useful than polypharmacy. I’m not sure how much of this information was taken in.

Toilet issues

At the secondary school where James was teaching he discovered early on that the children had no toilet facilities whatsoever. They relieved themselves in the surrounding fields, or in a small wooded area which held the tomb of a village elder. The mayor agreed heartily that this situation was unsatisfactory and was keen to be part of any solution we could arrange. We found a plan for a wooden latrine on the WHO website, did some calculations and determined that a hole 3m x 2m x 3m was required to last 3-5 years. We set off to the city for the weekend to buy supplies and on our return found that the hole was completely dug. “By whom?”, we asked the teacher. “The children”, apparently! They showed it to us proudly at the PE session on Monday morning.

Needless to say, we felt pretty guilty, but it did show that they were keen for this latrine to be built. The local carpenter agreed to build the structure, so long as he was helped. In a well-attended parents’ meeting, the parents organised a rota for them to assist the carpenter on different days. By the end of the week the latrine was nearly finished. Since then we have heard that it is completed and, in contrast to the previous charity-built toilets, in use, which feels wonderful.

Finishing Up

This trip was short, with just two weeks in Analapatsy village, but I feel we fitted a huge amount into our time there. I learned a great deal about working in challenging environments and the medical problems which present in these areas.

A surprising eye-opener for me was that as a qualified GP, I have so much more knowledge and experience than I realised. In this respect, education is the greatest and most sustainable gift that we can give. Seeing Unicef equipment languishing in the corner of filthy consulting rooms, and latrines unused in the family compounds, was a stark reminder that without some development of ideas and beliefs, improvement of health in the area was stagnant. This is why I didn’t see patients alone, but with the local clinician. By working together on each case we learned from each other, and created, I hope, some lasting changes.

Learning points and top tips

Be savvy / We went through a South African-based charity, Edge of Africa, and were attracted by the opportunity for James to teach and me to work clinically in the same place. The charity, it turned out, focused mostly on its Gap Year project in South Africa, and the Madagascan arm was very much in its infancy. We paid £2000 for what turned out to be a couple of days of unsanitary accommodation in the town, and our interpreters. Be aware of what is being provided for you when you pay an intermediary company; or organise it yourself. Madagascar was, however, a good choice for clinical work, and there is no complex paperwork barring clinicians from other countries working there.

Be safe / The infrastructure in Madagascar is worse than any African country I have ever visited, so be careful and allow time (usually days) for any travel. Flights often don’t take off, and roads are frequently impassable. We were on the south coast, which is a 3-day (which can become 7-day) journey from the capital city. We flew, but this is expensive (£280) and not very reliable.

Be helpful / Don’t underestimate the value of the education you have received. Even as a medical student, your knowledge of disease prevention and nutrition will stand you in good stead to help with most of the main issues facing people living in rural Madagascar today. We are very privileged to have this knowledge, and should not be shy to pass it on. It is more likely than any “wonder-drug” to save a life. However, always learn from and work with the people you are staying with. There’s only so much you can do in a short visit, and to create sustainable, genuinely helpful change, requires mutual understanding and compromise.

Photos

All photographs were taken with consent of the subjects.

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At Adventure Medic HQ, we have a near-religious devotion to nature documentaries and BBC Natural History Unit series in particular. With each incredible location, we wondered – who was the lucky medic? How did they get that gig? More than anything, how would they feel being the doc responsible for Sir David Attenborough on the latest Planet Earth II series?? So, we tracked her down. In our last article before the Christmas break, this is Dr Lucy Obolensky on the highs and lows of look after a 90-year-old National Treasure in a balloon.

Filming with Planet Earth II

It’s a beautiful sunny morning in Chateaux D’Oex in the Swiss Alps and the perfect morning for a hot air balloon ride. A hot air balloon ride with Sir David Attenborough.

I’ve been involved in remote and expedition medicine for over 15 years, initially leading expeditions for school groups, setting up and running my own expeditions for friends and colleagues, and now working for larger expedition companies. Through teaching at the Royal Geographical Society I’ve had the pleasure of training many camera crew who travel to remote locations for their filming. Often you don’t get to travel with them however, in recent years I’ve been lucky enough to get invitations to join some of their expeditions as team medic. The most exciting ones being those with the Planet Earth II team and Sir David Attenborough. I was lucky to get this gig. I’d just had a little girl earlier in the year, so my colleagues at Phoenix Expedition Medicine had taken the other Planet Earth II jobs, including my colleague James Moore who’d been camping for 16 days in penguin shit on Zavodovski island. Win some, lose some.

Being responsible for a National Treasure

Naturally, I was thrilled at the opportunity to meet and to work with Sir David, but equally slightly nervous that this could be a career-ender should anything go wrong! I needn’t have worried. Sir David was incredibly fit for his age, and I was there both for him and for the wider BBC team undertaking the balloon shoot.

My main role was sourcing and putting together the medical kit. I was quite used to this from my past expeditions and, as ever, the main things to consider were:

1. Where were we going?
2. What could we carry with us?
3. How we could get to the nearest definitive medical care?

Switzerland has an excellent pre-hospital care system with a network of well-supported hospitals. It was worth taking full resuscitation equipment and airway kit, very different to my next trip to Antarctica remote from any form of definitive medical care. I tend to take quite a lot of time over pre-departure medical questionnaires, and explain to the entire team why I need as much information as possible before the trip. This includes their thoughts on treatment escalation plans. Sometimes the team can be surprised by these kinds of questions, however these discussions are important when you are doing high risk activities, and even more so if you are in remote locations with nonagenarian naturalists.

Up, Up and Away

Whilst the team were preparing the balloon, I ran some errands, readied my kit and stowed it in the balloon’s basket. I had a chat with the balloon pilot about emergency landings (apparently, all balloon landings are ‘controlled emergencies’!) and where we could perform resuscitation should any of the crew have collapsed at altitude.

‘Good flexibility and steely quadriceps’

Job description.

Finally, it was time to go. Before I knew it we were off and away flying up to 10,000 feet above the Swiss Alps. It was so quiet and peaceful. Not for long however! Soon the chopper arrived and we had to crouch down inside the balloon, unseen for all the helicopter shots. ‘Good flexibility and steely quadriceps’ were definitely NOT on the job description and soon my thighs were burning and toes numb from squatting for so long. I caught the cameraman’s eye and we had a quiet little snigger together at the absurdity of the situation.

Then at last we could stand up again as the helicopter disappeared across the mountains. The producer and camera man filmed Sir David giving his lines for the opening scenes, along with some great shots of him looking out of the balloon across the Alps. Finally, it was time to land. Being pretty fit I was ready, braced next to Sir David thinking I’ve definitely got this covered. The next thing I knew, we’ve hit the ground unexpectedly and I’ve pretty much toppled on top of the 90-year-old National Treasure. Whoops!

That afternoon, we had a bit of down time whilst the team went through the footage. I made myself useful, getting coffees and moving and stowing bags, but was also fortunate to have the opportunity to spend some time with Sir David. He was absolutely wonderful; incredibly passionate and knowledgeable about his work and yet so humble. He treated everyone with utter respect and kindness, from the executive producer to the waiter who served us coffee.

He seemed not to really understand this tidal wave of adoration for him. I tried to explain saying ‘I think Sir David, it’s because you span generations. My nine-year-old nephew, my husband and my granny were all equally as excited about this opportunity as I was.’ He smiled but moved on to tell me about his latest role in sustainable energy. His position will be to encourage countries to work together to achieve the sustainable development goals, in particular to find a solution to the storage of sustainable energy. It was fascinating.

Flying too high

The only hairy moment came (typically) when we were least expecting it, yet in hindsight it was entirely predictable. With the balloon flight over and everyone breathing a sigh of relief, we were then going to ‘pop up’ the Aiguille du Midi in Chamonix for a bit of evening filming. The cable car takes you from the centre of Chamonix up to 3,842m in the space of about ten minutes.

Almost immediately after arrival the entire filming team were feeling the effects of altitude, including Sir David. I advised the team on how to do their own PEEP pursed lip breathing and had oxygen standing by whilst we waited for the cable car to return to take us down to the middle station where the executive producer made the decision to do all the filming from there.

Lots of people think that expedition medicine is a big action, high octane job. It’s not. Mostly it is about keeping people healthy both mentally and physically. On longer expeditions, you are usually dealing with stomach upsets and the mental pressures of the trip. However, on the rare occasions that there are trauma situations or medical emergencies you have to be able to deal with them in an austere environment.

You also can’t let down your guard. I could have predicted the onset of AMS and discussed my concerns with the producer. Instead though, with the focus on the balloon flight and the Aiguille du Midi being an added extra, I rather overlooked the risk. It taught me to always be prepared, particularly in the filming industry where plans can change rapidly and on the spot.

Sir David and the team did some incredible filming on the mountain. It was a real privilege to watch them at work. When we got the last cable car down, watching dusk settle over the Alps, it was beautiful.

Dr Lucy Obolensky is the Programme Lead for the Global and Remote Healthcare Masters in Plymouth University. She combines her academic role with working clinically as a locum ED staff grade and General Practitioner. Taking the plunge to do only locum work has enabled her to enhance her own career in global health and expedition medicine. Lucy sent this article through from a ship in the Drake Passage enroute to Antartica.

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This article is a brilliant reminder of why expeditions are such a challenging and interesting setting in which to practice medicine. Anna and Isla have done a great job of summarising the lessons to be learned, many of which will ring true to first-time and seasoned expedition medics alike.

I had just finished a job as a doctor for a commercial guided expedition to Mount Everest and was undertaking some personal travel in Nepal. Early one morning I found myself at a bus stop in a one-street village approximately three hours away from Kathmandu. It was a popular place for a coffee break and buses were frequently coming and going. The buses parked on a slope leading to the edge of a ravine through which flowed a raging river. I climbed aboard a bus and was awaiting its departure when the rock behind the rear wheel that served as a break was removed. The driver was not yet in his seat so the bus full of people started rolling backwards towards the edge of the ravine. As the bus was accelerating and our anxiety grew. There was a crash. Instead of going over the cliff edge, the bus collided with the side of another parked bus. Chaos ensued as passengers rushed to exit the vehicle through broken glass.

On disembarking, I heard a shout for a doctor. I walked towards the commotion and found a young woman screaming in agony. The bus had hit her lower leg as she was alighting from the other vehicle. I undertook a rapid assessment of the patient. It seemed that a minor wound and an excruciatingly painful left lower leg were her main problems. As we prepared to carry her to the local clinic on a stretcher, the bus moved away and another casualty was revealed. This male patient was less fortunate and had been sandwiched between the two buses. Even though I had initially carried out a scene survey, and understood the mechanism of the accident, I was unaware of the second patient. Similarly, many other eye witnesses who volunteered their help were also oblivious to a second casualty.

The second casualty showed no massive external hemorrhage, was conscious, tachypnoeic, pale and had a painful left thigh. I did not have my medical kit to hand so my primary survey was limited to “look, listen and feel”. I decided that he was stable enough to scoop and run to the local clinic, which was staffed by a doctor and consisted of an emergency room with two beds. The female patient was left to have a cast applied and she made personal arrangements to be transported by helicopter to Kathmandu where X-rays would confirm (or refute!) my provisional diagnosis of tibial and fibular shaft fractures.

After undertaking a secondary survey of the male patient, I suspected that he had isolated fractures of multiple ribs and a fractured pelvis. This was evidenced by the mechanism of injury, his vital signs and my physical examination findings. The local male doctor was unperturbed by the mechanism of injury and did not believe X-rays were warranted. He decided to arrange an evacuation to Kathmandu for further investigation. I was concerned that despite analgesia and 2L of supplemental oxygen, the patient’s oxygen saturations remained stubbornly at 96%. However, now in a local clinic, my role had diminished to merely communicating with both patients. Whilst I was unable to convince the in-country doctor to obtain a chest X-ray (he appeared more anxious about a possible pelvic fracture than hypoxia caused by thoracic trauma), I managed to persuade him not to airlift the patient. The patient’s condition did not deteriorate after I had lingered for several hours and I was assured an ambulance was enroute, so I left the local clinic to continue my travels.

The following week I discovered that due to the long wait for a road ambulance, a last minute decision was made to airlift both patients to Kathmandu in the same helicopter. During the flight no medical personnel were in attendance and the male patient began to drift in and out of consciousness. On arrival in Kathmandu he had developed a tension pneumothorax, requiring immediate treatment.

Lessons Learned

There are lessons to be learned from this tale:

Beware RTAs / Whilst on expedition, in-country transport is likely to pose the greatest risk to the health of you and your team mates. Road traffic collisions are a leading cause of death globally, and the main cause of death in 15–29 year olds. Furthermore, 90% of road traffic deaths occur in low- and middle-income countries despite these countries only having 54% of the world’s vehicles! (1)

Prepare for the worst / Be prepared to encounter the worst-case scenario, so that you are never taken by surprise when far from help, whilst being mindful of your safety, competence and the availability of other options for care. (2) Having a ‘grab bag’ to-hand will aid preparedness. This should comprise medical kit required for the pre-hospital treatment of medical and surgical emergencies and should be appropriate to your experience and level of training.

Situational awareness / Being situationally aware is imperative during the practice of extreme medicine. In the case above, despite being conscious of the physical dangers present and understanding the mechanism of the accident, we lost situational awareness through becoming distracted by and focusing on caring for a vocal casualty with a lower leg fracture. It’s a cliché, but when multiple casualties are present, those that shout the loudest are invariably not the most unwell.

Structure saves lives / We know, but often forget when out of hospital, that a structured approach will ensure that the greatest threat to life is identified and treated first. The local doctor did not follow this procedure and focused on addressing the hip pain that was causing the patient’s distress.

Communication with local docs / The differences between your training, experience and resources will inevitably have implications for patient care and require delicate communication on your part. (3) In this case, it was the appropriate use of imaging and the male doctor’s attitude towards female clinicians.

Introduce yourself and explain your role: be mindful that you are not likely to be communicating with these colleagues in their mother-tongue or in a language in which they have fluency.

Try to avoid misunderstandings by using appropriate language to communicate essential information in a concise manner. Declare what you believe to be the emergency and share your ideas, concerns and expectations.

Determine whether your colleague agrees with your diagnosis and management plan. Be prepared to listen and negotiate and try to resolve conflict, always keeping in mind that the best care possible for the patient trumps your own professional pride. (4)

Appropriate evacuation / When choosing the most appropriate mode of evacuation consider illness or injury severity, rescue and medical skills and the physical abilities of rescuers, available equipment and aid, potential dangers and pitfalls, time (influenced by distance, terrain and weather) and cost.

In this case, we might have predicted some form of underlying lung injury in the presence of tachypnoea, hypoxia and suspected multiple rib fractures. It should be borne in mind that helicopter cabins are not pressurised and that during ascent, atmospheric pressure (and the partial pressure of inspired oxygen) will decrease, enabling air-filled spaces such as pneumothoraces and endotracheal tube cuffs to expand! (5)

Anne Brants and her colleagues at Outdoor Medicine will be running the 3rd edition of their excellent Medicine in Extremes Conference on 13 January 2017 in Amsterdam. The theme will be Extreme Cold, and the program will include hypothermia, surviving Antarctica and injuries from the ski slopes.

References

1. World Health Organisation. Global Status Report on Road Safety. World Health Organisation: Geneva, 2015.

2. General Medical Council. Good medical practice. General Medical Council: Manchester, 2014.

3. Lowth, M. Ethnicity and Health [Online] 12/03/2015 [Cited: 12/09/2016].

4. Green M, Parrott T, Crook G. Improving Your Communication Skills. BMJ Careers. [Online] 01/25/2012 [Cited: 12/09/2016.].

5. Forgey WW (Ed). Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. Falcon Guides: Guilford, 2006.

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In April 2016, EMT and Mountain Rescue Team member Jamie Pattison competed in and won the Berghaus Iceman Polar Race: an event billed as the world’s toughest Arctic ski race. The race was based in North Eastern Greenland and involved teams of three skiing over 100km of remote Arctic terrain. He returned a changed man, having smashed his personal physical limits and learned the true value of just getting on with it.

It was December and I was looking at the coming New Year and what I hoped to achieve and do with myself in 2016. Researching into various locations and challenges around the world. One evening I opened my emails to find a message from one of my friends with the fateful words ‘How about doing this?’ along with a link to a website. I must admit the rather large red letters emblazoned across the header screaming ‘world’s toughest’ escaped my attention as my eye was more keenly drawn to the spectacular pictures of polar ice and smiling faces pulling pulks through perfect polar postcards.

That was it; I didn’t need any more convincing than that. My heart was set on attaining the finish line of this challenge. While this was all very romantic, I knew it would be a huge challenge personally. I would spend the next few months meticulously planning and training in the most varied and effective ways that I could. It would be a long road to even get myself to the start line.

Forged in Fire

I enjoy training. I studied sports’ science earlier in life. I try not to be too rigid with my planning; training schedules are as tedious and as boring as you want to make them. It basically comes down to all the small decisions you make every day. I planned long runs and many, many hours in gyms of various designs, boxing, Crossfit, with the best coaches and training partners I know. I liked to think of myself as a Formula 1 car: a big team, putting together many parts over a long period of time to build the optimal machine for the challenge ahead. Having brilliant people around me overcame the days when I didn’t feel like pushing myself. I also decided to incorporate every aspect of my life into training in some way for Greenland.

I have always wanted my life to be an adventurous one. I found that if you make training and adventure fit into your life, there is much greater reward and satisfaction gained. This resulted in my organising training trips to the Cairngorms in Scotland, Telemark in Norway and the French Alps. However there was always this ulterior motive for these trips besides preparing for the Iceman race. Two birds, one stone if you will.

The trip to the Cairngorms was originally planned as the annual Mountain Rescue winter skills training. We head there to train as it provides the best and most consistent winter conditions anywhere in the UK. There was a reason the Norwegian commandos of WW2 chose the same corner of our beautiful island to prepare themselves for their missions in fortress Europe. The conditions that year were ferocious. Low temperatures combined with high winds produced significant wind chill and temperatures down to minus 30 Celsius. Just being out on the hills in these conditions was a challenge on so many levels. But knowing I could operate, and look after myself and others in these conditions gave me confidence that I could cope when things became properly Arctic.

The second training trip was to Rjukan in Norway. Funnily enough where the aforementioned Norwegian commandos conducted some of their operations. I again had the opportunity to expose myself to real cold. Before each day’s climbing antics I would get myself up early while my friends slept, a challenge in itself, and would ski 5-10km around the local cross-country trails in the pristine conditions. I enjoyed seeing the sunrise before some challenging climbing for the rest of the day. This time was extremely valuable. I learned a lot in those lonely, cold hours.

I tweaked every bit of kit, laying them out in my living room for a number of days, before doing one final pack. Food was organised into separate meal bags ensuring I had at least 5000kcal per day for the least amount of weight.

Time to Go

All too soon the months of training were over and it was time to put boot to ski. Travelling to Greenland was an excellent affair. I had to get myself to Reykjavik in Iceland, where I met the rest of the participants and my teammates for the first time. We drove up the west coast of Iceland into the northern town of Akureyri where we caught a chartered Twin Otter plane to Constable Point in Greenland. The Icelandic airport is about the same size as the Costa in Heathrow. I was very impressed by the lone Icelander, who alternated between check in attendant, duty free server and airport security, changing his uniform each time.

Boarding the twin otter was where the adventure really begun. Taking my seat next to our pile of our skis and several bags of onions and (I’m quite sure) a box of live chickens, the pilot delivered a safety announcement over his shoulder and offered to turn the heating up should we need it.

The flight was cold but pleasant, with fine weather allowing us some spectacular views of northern Iceland. The sea started to fill with flecks of ice pretty quickly, developing into large icebergs and pack ice. The rugged Greenlandic coast of myth and legend was soon beneath us. It was truly a sight to behold.

Once we’d landed safely at Constable Point we met Paul Walker and the Snow Dragons team from Tangent Expeditions who’d organised the race. The baggage reclaim consisted of putting our kit into skidoo pulks and we were then taken to our base for a briefing. We discussed one of the big risks of operating in this environment, Polar Bears. To guard against them we would camp together every night inside a ‘bear fence’: a series of 5-6 posts around the tents, which support two lengths of string. Each piece of string is tied to an alarm. When a bear approaches the tents it will step through the string, pulling the pin from the alarm and alerting us of its presence. However more often than not, it would alert us to the fact that someone had got up to go to the loo in the night.

Other ‘anti-bear’ measures available to us were several levels and sizes of flare, which would (hopefully) deter any bear and scare them off. The last line of defence – and the last resort – was a rifle and ammunition. Each team carried a rifle, ammunition and flares throughout the race.

On the start line

After a day of sorting and drilling with our equipment we were all set to head to the start line. The weather in the morning of the race was clear as expected and about minus 10 degrees Celsius. The only bad weather predicted was for the second day, so the race organisers planned to halt the race until it passed as a safety measure during the polar storm. Known as a Pitteraq, these storms can tear your tent to ribbons.

As we lined up on the start line, everybody was in high spirits and with a burst from a shotgun we were on our way! For the first hour or so we were skiing over the edge of the fjord towards the entrance of a valley; myself and my team mates, Scott and Nat, forgoing the usual traditional single file polar plod, skied together side by side enjoying the bright morning.

Everyone experiences an adventure individually as well as part of a team. We’d agreed that if anybody needed to stop at any time then all that person need to do would be to just speak up. Quite early on I realised that my ski boots were a little too tight and slightly uncomfortable. I quickly loosened them off in an attempt not to slow us down: I really should have spent more time to ensure I had done them up properly, but the start line excitement still coursed through me and I adjusted them far too quickly.

After a couple of hours of skiing, the sun was high in the ski and it was a glorious day, which made balancing pace and managing personal management (such as eating, drinking and staying on the right side of chilly) challenging. Around lunchtime self-doubt began to creep in and I began to ask myself, “What am I doing here?” I had four more days to go and was already suffering on the first day.

At that point my team came across our first signs of polar bears – a set of large tracks entering the valley from the west and following the line we planned to take all the way to the end of the pass. These certainly occupied my mind.

We skied all the way through the valley until we re-joined the main fjord. I spoke up and mentioned I’d like to tape my feet. I was beginning to have a couple of hot spots, a sign of oncoming blisters, due to my rushed boot management earlier in the day. We skied onwards and down back on to the edge of the fjord, and began heading out to the Faroe Islands, across the sea ice, where our camp for the night would be. As we began to ski out to the islands, which lay roughly 5km away (but were clearly visible) the skidoo support team came across the fjord to say hello. Skiing on sea ice is a strange experience. You can see where you’re trying to get to from a very long way out, and after what feels like you’ve been skiing forever, you don’t seem to get any closer. The fact that you’re standing on just over a metre of ice and then several hundred metres of water is quite a thought too. Only when the skidoos turned back to the island did I comprehend the scale of the landscape around us.

Storm Bound

We arrived at the camp after skiing for about six hours. I sat down and began to question myself: why was I finding it so hard? Why didn’t I feel fit enough when I’d trained so hard? And would I be able to get to the finish line in four days’ time? I was sat on my pulk despairing and trying to catch up on fluids when the expedition cameraman came over, asking how my day had been. Despite (or perhaps because of?) my mental state, I decided to be honest and told him my day had been tough and that I had some things to think about. As the words left my mouth, I realised that the sun and cold had badly dried me out: I hadn’t managed my hydration very successfully. I realised I needed to step away pride and ego, that this really was the toughest thing I’d ever taken on.

I was nominated as inside man for the night. This was a blessing and I remember being so incredibly grateful to get the weight off my feet. My duties involved sorting out the inside of the tent for the rest of the team – setting out sleeping kit, getting the stove on and a brew started and organising the foam flooring for the tent. After sorting out our camp we settled down for the evening.

In the morning we woke to strong winds and very poor visibility. The Arctic storm had arrived as predicted. The race organisers decided, today, nobody would move and we would spend the day tent-bound. I was secretly a little pleased about this as it gave me a day’s grace to catch up and sort out feet, food and fluids. And despite being confined to my tent for 36 hours, I really rather enjoyed it. The next day we packed up our kit and were all set to go. I had just forced my painfully blistered feet into my cold ski boots when we were told that today would not go ahead either. The storm had not blown through as predicted. However, as a team decided that since we were ready, we would ski out to a cabin on the other side of the fjord and back again. It was satisfying to know that we could handle the demands of a polar storm.

Never Named, Never Climbed

After returning from the cabin (and another night spent in the tent) we were up the next day to glorious blue skies without a breath of wind. We had 20km to cover across the sea ice, then up into the Kalkdal valley and down to our camp at the tongue of the Horsens glacier. I was determined to manage myself better and be more vocal should I need to stop. The terrain was uphill for most of the morning and finished on a nice long downhill.

The Kalkdal valley is a beautiful part of the world with awe-inspiring mountains on either side. None have ever been named, let alone climbed. Once again we set off skiing together despite the nature of the terrain and having to break trail later in the day, and we found a brilliant rhythm skiing in traditional linear fashion.

Due to the hard ground and physical effort I skied much of that day in only a base layer. We arrived at the foot of the Horsens glacier after travelling for seven hours, pitched our tent and tried to dry out some gear. The next team arrived around an hour after us and everybody was in high spirits. The sun went down on the horizon and the temperature dropped significantly in the shadow of the mountain.

To the Limit

On the third day, we woke to very cold temperatures. The sun was still hiding out behind the mountain. It would be the final day of skiing due to the lost storm days. However the route ensured it would be the longest and hardest of the entire race. It would take us up the Horsens glacier for around 10km to a col (the lowest point on a mountain ridge between two peaks) where we would then drop down to the tongue of another glacier that flowed out into a fjord. From there we’d hang a right and start heading up another as yet unnamed glacier for 10km, then drop down the other side into the Sodal valley to the finish line. Due to the danger of crevasses and the nature of the terrain, we were roped together for the duration.

The morning started well and we left on time. It was comfortable working hard in the cold. We skied in single file to the col and started down the next glacier surrounded by unclimbed mountains and awe-inspiring scenery. Things went well despite some mishaps with pulks on downhill sections and were soon at the foot of the glacier.

With nothing to really do but put one foot in front of the other, there was plenty of time for new perspectives on life back home. I solved problems and thought through some deeply personal ideas. I certainly came back from the experience changed. I hope for the better.

Once we arrived at the glacier edge there were at least 8km of uphill skiing still to be done, and by now the sun was bearing down on the team. Again I skied for most of the day in a base layer, yet despite this I sweated hard. It was at the second last false summit of the tortuous glacier, when we checked the GPS and discovered we still had 6km to go, that my mental endurance reached its absolute limit.

With very painful feet and suffering from being too hot when moving and too cold when stopped, the little voice in my head became bullish. At our scheduled rest stop I took my skis off and sat down on my pulk. I’m not ashamed to admit I shed a few tears. I was in the middle of this place that I’d dreamed about coming to since I was a kid, I had been the weakest member of a team (which is not something I’m used to) and I’d pushed myself to my absolute limit. When you push yourself so hard, beyond all of your expectations, you enter a strange mental place.

Every step I took hurt more, despite the strong analgesia. The question of whether I’d be able to make it to the finish became louder in my head. I have nothing but admiration for my teammates. They gave me some time and helped me sort out my food and drink. They got me going again. Two pieces of advice kept running through my head. The first was from Jens-Anton Poulsson, a member of those Norwegian Commandos, who said:

“A man who is a man goes on until he can do no more and then he goes twice as far”

The other was a fragment of a conversation I’d had with an ex-special forces commander. When I had asked him how he coped with the mental anguish, when everything was going wrong, and everything seemed against him, he replied, “I’m sorry I have nothing else to say, you just get on with it”. The most simple, yet profound piece of advice I have ever been given. With this in mind I got up, strapped on my pulk, clipped into my skis and decided to get on with it. I hadn’t come this far to stop now.

We finally reached the top of the glacier and the finish line lay below. From here it was all downhill. We unroped and skied the last of the powder-covered glacier to the skidoo team in the distance. I was relieved to be done. To my horror, they said they would see us at the finish line… a further 2km down the valley. I could only laugh, grit my teeth and once again, ‘just get on with it’.

Finally, we crossed the actual finish line after skiing for over nine hours. We finished in the most beautiful orange light. We had done it. This is what we had been aiming for all of those days. I had pushed myself past every single limit and survived the Iceman Arctic race.

The post The Iceman appeared first on Adventure Medic.

Is there anything more badass than a polar volcano? Ask Dr Zoe Burton – she took a break from anaesthetic training in Portsmouth to be an expedition doctor in Antarctica. Zoe describes the life, the challenges and the medicine at the foot of Mount Erebus.

Boom! I feel a shockwave reverberate through the snow and ice beneath my tent. Ten minutes later we are racing up to the crater rim of Mount Erebus to find evidence of lava “bombs” that may have been thrown clear of the crater and landed on its flanks. It is 2am and around -40°C, but a beautiful still sunlit night with a fairytale carpet of cloud floating below us.

Soon enough we find a steaming honeycomb-coloured lava bomb, still warm enough to sizzle satisfyingly when snow is thrown on its surface. Tim takes an old aluminium ice axe shaft and hacks through the cooler crust into the red-hot molten core. At over 950°C it quickly starts to melt the axe shaft. It is phenomenal to see glowing molten lava ejected directly from the bowels of the earth, whilst thousands of miles of Antarctic snow and ice stretch out around us as far as the eye can see.

My Own Quest for Adventure

I am an Anaesthetics trainee with interests in high altitude medicine, medicine in the developing world and physiology in the extremes.  Most of my friends and family will tell you that I have had more time out of medicine than in training. Whilst this is not quite true, I have endeavoured to weave some more unusual medical experiences into the conventional career path. Since reading the tales of the early explorers in Chris Bonnington’s Quest for Adventure as a child, Antarctica has always held a particular fascination. Whilst I have worked as an expedition doctor in both the high Arctic and the Himalaya, where I undertook my research for a Masters in Mountain Medicine, Antarctica remained a somewhat elusive dream.

Many of us find it tricky to strike a balance between global adventures and advancement in medical training let alone professional exams, family commitments and medical rotas. However, in November 2014, the stars finally aligned and I first found myself in a position to work in the Antarctic at a high altitude camp on Ross Island. For the last two seasons now, I have worked at one of the most phenomenal natural sites in the world. Unbeknownst to many, on Ross Island exists an active volcano called Mount Erebus. It was first discovered in 1841 by Sir James Clark Ross and named after one of his ships. “Erebus” was a Greek god of darkness, the son of Chaos – a fitting name for a volcano with an exploding lava lake rising out of the vast expanse of white and ice at the foot of our earth.

Every year a team of 6-8 volcanologists, geo-physicists and technicians travel to the volcano to monitor its activity and conduct their research out of the Mount Erebus Volcano Observatory (MEVO). MEVO’s base is on the caldera at Lower Erebus Hut (3402m), which was built in 1992 after the previous hut was unexpectedly surrounded by huge lava bombs. All of MEVO’s operations are conducted through the United Sates Antarctic Program (USAP) with funding from the National Science Foundation (NSF). My role on Mt Erebus is as a field assistant providing support for scientific projects and as a doctor dealing with medical problems as they arise once in the field.

Training at McMurdo

Prior to field deployment, each team member undergoes training at McMurdo Station, the United States Antarctic Program’s largest base on the continent. This includes field safety training, helicopter safety, environmental and waste training, communications and skidoo training. Part of my role was to conduct the high altitude related illness training which included preventative measures, signs and symptoms, chemical prophylaxis and treatment. I demonstrated the use of the Gamow bag, oxygen cylinders and, in conjunction with field safety staff in McMurdo, I developed a simple Mt Erebus AMS flowchart guideline.

In terms of medical facilities, McMurdo General Hospital is staffed by a physician, a NASA Resident and two Physician’s Assistants. It has capacity for six in-patients, has a 2-bedded resus room, x-ray facility, a dental room, a hyperbaric chamber, facilities for basic lab tests and two ultrasound machines. On Mt Erebus itself there is a bountiful supply of oxygen and availability of two Gamow bags. Comprehensive field medical kits include a high altitude drugs pack, which constitutes nifedipine, dexamethasone and acetazolamide.

Fang Camp

In order to reach Lower Erebus Hut (3402m), the team passes through an acclimatisation camp called “Fang Camp” at just under 3000m. Traditionally we have spent two nights here prior to ascending to Lower Erebus Hut at 3402m.

It is worth mentioning the difference between “high altitude” in temperate climates and that at the poles. Due to the extreme cold (usually around -25-40°C in summer months) and latitude (77.5° South), the physiological altitude experienced is generally considered to be 300-400m higher than that measured above sea level. Thus the elevation at Fang is easily sufficient for people to experience symptoms of Acute Mountain Sickness (AMS) if not cerebral oedema (HACE) and/or pulmonary oedema (HAPE). The vast majority of all in-puts and take-outs from field camps in the US program are conducted by helicopter. Consequently, the ascent profile is initially from sea level directly to over 3000m. Historically, most people have experienced AMS at Fang and there has been at least one evacuation due to HACE. Whilst a slower ascent would be preferable, access other than by helicopter is limited by steep glacial terrain.

Over the last two years I have used the Lake Louise Score (LLS) for AMS in order to guide sensible decisions regarding further ascent to Lower Erebus Hut and further up the mountain to work on the crater rim at 3794m. Each team member completes a daily score sheet relating to their heart rate, oxygen saturations, symptoms, activity level and maximal and sleeping altitudes. My data show that most team members experience AMS at some point during the acclimatisation process.

Due to the fairly extreme ascent profile, the use of acetazolamide is common for both AMS prophylaxis and treatment. In several cases this year, I recommended an extra night sleeping at Fang camp for acclimatisation purposes in response to the data I collected. Subsequent self-reported AMS scores were lower as a result and scientists were able to start on scientific work at the crater rim sooner than previously.

Not Just the Altitude

Last year, I was called to Fang Camp to assist in an incident involving life-threatening carbon monoxide poisoning. This was due to partial combustion of propane whilst cooking in a tent on a windless night. This has since lead to significant changes in both stove training and the availability of safety equipment – audible carbon monoxide alarms and immediate availability of oxygen.

The incident served as a stark reminder of both the remote nature of Erebus and the confusing similarities between symptoms of carbon monoxide poisoning and HACE. The individuals concerned made a swift recovery with 100% oxygen therapy and co-ordination by satellite phone of a late night emergency medical evacuation by helicopter in marginal weather conditions to McMurdo (at sea level). Hyperbaric chamber treatment was available but not clinically necessary.

This season, I have thankfully had little to contend with aside from a couple of ophthalmic high altitude related issues and moderate AMS. I was able to take advantage of excellent remote advice from Dan Morris, an expert in high altitude related ophthalmic problems. The extremely experienced Diploma in Mountain Medicine (DiMM) community was also able to offer me support regarding the subsequent management of the carbon monoxide case last year, for which I remain grateful. Since I am a UK doctor with no licence to practice in the United States, my medical input here from a legal standpoint is largely limited to Good Samaritan acts. In the management of such cases I remain in close liaison with the McMurdo-based physician.

Goosebumps on Erebus

Mount Erebus is undoubtedly one of the most awe-inspiring and fundamentally beautiful places I have ever had the privilege to visit. It was first climbed in 1908 by members of Shackleton’s expedition. In 1912, Captain Scott’s Terra Nova expedition conducted a geological survey on Erebus. Circles of stones used to weigh down tent valances remain visible at two protected historic sites. These sites remain exactly as they did over a century ago since Erebus is a non-accumulation zone where there is no significant drifting of snow due to persistent high winds. As a result, environmental rules are strict and everything that is brought in must be taken out. This includes urine, so everyone rapidly becomes adept at peeing into a Nalgene bottle!

On a clear day from Erebus’ crater rim you can see across the Ross Ice Shelf and the sea ice of McMurdo Sound to the Trans-Antarctic mountain range. Ross Island is home to the historic huts of Scott and Shackleton at Cape Evans and Cape Royds respectively, and Mt Bird and Mt Terror, two other dormant volcanic peaks. The volcano’s crater itself is 350m deep and harbours a longstanding exploding convecting lava lake, of which there are only two others in the world.

It is possible to walk around the circumference of the crater in a few hours whilst peering into the bubbling cauldron which persistently vents a hybrid of volcanic gas. The plume can be seen travelling for miles depending on the ambient humidity. As gas escapes from the warm ground lower down the volcano, “fumaroles” form where hot vented air collides with the cold Antarctic atmosphere, condensing to form impressive ice towers. Underneath these towers exist a complex network of stunning ice caves. Entry to the caves is permitted for scientific mapping and gas sampling purposes.  Abseiling into these vast surprisingly warm caves feels otherworldly; quiet and windless caverns filled with huge intricately delicate feathery ice crystals, blue domed ceilings and imposing ice stalactites and stalagmites.

Glamorous as this all may sound, on most days my main role is to walk up the volcanic scree littered with Erebus crystals to the crater rim carrying anything from 30kg batteries, radar antennae to GPS equipment and solar panels in an effort to promote the furthering of science. We sleep in tents, cook in the warmth of the Lower Erebus Hut and for the most part get around by driving across the moonscape caldera on skidoos. Every now and then, the volcano reminds us of its almighty power and explodes producing an almighty bang! What follows is best described as a “bomb hunt”, the aim being for the bomb disposal team to record the highest temperature inside a lava bomb – thus giving some indication of the true temperature of the lava lake.

Whilst all this seems a bit far-fetched from Anaesthetics, it has been a fantastic medical adventure, another insight into physiology at the extremes and a rare opportunity to work in such a little visited part of the world. For now, Erebus’ breath-taking beauty gives me goosebumps whilst working on the crater on a daily basis. I am frequently reminded of what a privilege it is that my Antarctic dream has become a reality.

Acknowledgements

My husband Tim has worked for the US Antarctic Program for a number of years and for the British Antarctic Survey prior to that. It is largely due to Tim and Phil Kyle, the Principal Investigator for the MEVO scientific operation, that I was given this opportunity. I owe it to my open-minded Program Director and College Tutors in Wessex Deanery that I was able to take up this opportunity in 2014 at only four weeks notice. I am also grateful to the entire MEVO team for helping me gather AMS data and for sharing their knowledge of the volcano and their enthusiasm for scientific work in such an austere environment. Finally I would like to thank USAP and the NSF for funding this endeavour on Mt Erebus.

(Photos: Zoe and Tim Burton)

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Many of you will have taken acetazolamide (Diamox) and will know its effects, both good and bad. The Birmingham Medical Research Expeditionary Society’s (BMRES) 2016 expedition to Ecuador aimed to study its effects on the exercise tolerance of partially acclimatised individuals. They also hoped to climb Chimborazo – the furthest point from the centre of the Earth.

Their account makes for interesting reading, not least because the conditions managed to catch out the very experienced Chris Imray. We also have an interview with Hannah Lock, one of the medical students on the trip, telling us how she got involved, and her own high and low points.

It is 5am, we are at about 6100m and the temperature is between -20C and -25C.  We had been making slow upwards progress on the glacier for about six hours. The climbing involved front-pointing up an apparently interminable 45-degree boilerplate ice slab. We were inching towards the furthest point from the centre of the earth.

A series of unfortunate events combined with a couple of schoolboy errors meant that the situation was rather more serious than we had planned. The most immediately perilous being the lack of snow cover on the glacier (be it from global warming or the recent El Nino) and the resultant sheet ice being far more challenging than we had expected.  The unexpectedly severe cold, the altitude and the adverse effects of acetazolamide on performance in partially acclimatised individuals further compounded the situation.

Whymper in Ecuador

Through a quirk of geology and the result of the non-spherical (technically, ‘oblate spheroid’) shape of the earth, the summit of Chimbarazo in Ecuador (6310m), is 2220m further from the centre of the earth than the summit of Everest at 8848m.

When English mountaineer Edward Whymper climbed the Matterhorn in 1865, four of his party fell to their deaths on the descent.  As a consequence, Whymper re-directed his interests from climbing to studying the potential adverse effects of altitude. In December 1879, a European expedition consisting of Matterhorn veterans Edward Whymper, Jean Antoine and Louis Carrel arrived in the port of Guayaquil, Ecuador with the aim of climbing Chimbarazo. With difficulty, and after a 16-hour summit push, the three reached the summit. Louis Carrel suffered severe frostbite to his feet during the descent. At 6310m this was the highest peak to be climbed at the time (1880).

BMRES 2016

The BMRES 2016 trip to Ecuador was a return trip following an earlier expedition in 1978. The original expedition demonstrated the benefits of acetazolomide in acute exposure to altitude and resulted in a paper being published in the Lancet. The main aim of the 2016 expedition was to investigate the effects of acetazolamide on exercise performance in partially acclimatised individuals.

Flying to Quito

Leaving Birmingham for Quito via Schiphol was not straightforward, in that we thought we had two pieces of luggage booked onto the flight, one personal and one for the experimental equipment. After a protracted debate and discussions involving mouth-watering excessive baggage fees we finally left the UK, wallets intact.

Quito is at an altitude of 2850m and on our second day we took the Quito Teleferico to 4100m and then climbed up to the summit of Pichincha Volcano, altitude 4784m. This ascent profile, exceeding all recommendations, resulted in a number of headaches and lost appetites, but on returning to Quito most symptoms resolved.

Ascent to the Whymper Hut

The expedition ascent was by profile of 2800m, two nights at 3800m, 4800m by bus and then by foot to 5000m. This rapid ascent profile again resulted in moderate Lake Louise Acute Mountain Sickness Scores. In total, we spent five nights at 5000m completing the experimental program. The facilities of the recently refurbished Whymper Hut were excellent, with running water, flushing toilets, reliable solar power, and great catering. The support from John Paredes and his team made this a potential altitude research station to rival the Marguerita Hut, Italy (4559m), the Pyramid Research Station, Nepal (5050m) and Chacaltaya, Bolivia (5250m).

There were four days of exercise experiments, the first two days being a double-blind study of losartan vs. placebo and the second two days being an investigation of the effects on exercise of introducing acetazolamide to partially acclimatised individuals. There was an approximately 15% reduction in my maximal exercise test on acetazolamide. Indeed, when we set off at 11.30 pm for the summit, my extremities tingled with exertion and carbonated drinks had an unpleasant metallic taste.

Summiting Chimbarazo

Fredy and Marco, our guides, set a steady pace. I was initially able to match it, along with fellow expeditioners Owen, an FY2 and Cas, a freelance programmer/engineer. We climbed steadily through the night into the increasingly cold, thin air. Cas began to lag and decided at about 6000m to return back to the Whymper Hut with Marco. Owen, Fredy and I continued more slowly.

In the unexpectedly cold, thin atmosphere I was beginning to lose the feeling in both thumbs and a couple of fingers; my toes were not much better. My water bottle, inside my rucksack, had begun to freeze. Based upon a temperature recorded at 3800m of -5C, the temperature at 6310m was likely to have been -22C, reckoning -1C for every 150m altitude gained. Fortunately, there was no wind. I have lectured all over the world on frostbite and will often hold my hands up to declare that frostbite can be avoided by good preparation, equipment and an appropriate and timely decision to turn around. My current predicament felt like a series of school-boy errors misjudging the cold, the altitude, the ice and the adverse effect of acetazolamide on performance at extreme altitude.

Fortunately, we began to move a little more quickly as the gradient eased toward the summit and we arrived just as the sun began to rise. A few photos and then a rapid descent back to the Whymper Hut in time for a late breakfast. Cas had arrived back a couple of hours before us and had been diagnosed with mild High Altitude Cerebral Oedema (HACE) based on a headache and some ataxia. Owen and I had coughs and had developed comet tails on chest ultrasound consistent with extra pulmonary lung water or pulmonary oedema (HAPE).

In hindsight, being better acclimatised, not using acetazolamide when partially acclimatised, being better equipped for the cold and choosing to climb a route that was out of condition all contributed to making this a more challenging ascent than we had expected.

Owen has just started the UK Diploma in Mountain Medicine and is my mentee. In Dave Hillebrandt’s words he is looking for ‘quality mountain days’ and in my opinion this journey to the furthest point from the centre of the earth certainly qualifies.

A Medical Student’s Perspective – Hannah Lock

Had you done any research before? / I had never been involved in research of any kind before attending the monthly meetings of Birmingham Medical Research Expeditionary Society (BMRES). It crossed my mind that taking on extra work whilst in my final year of medical school was potentially a bad idea. However, when the group began to discuss the prospect of another major expedition I was extremely keen to be involved, even more so when Ecuador was picked as the destination. I had travelled in South America before, so was always on the look out for opportunities to go back. A trip combining my love of mountaineering and travel, with altitude medicine research sounded right up my street.

How did you get the time out to go? / As a medical student, getting a place on an expedition like this felt like a huge opportunity and a privilege. The main obstacle was convincing Warwick Medical School to let me take time out of my Obstetrics & Gynaecology block to go on the trip. I negotiated to make up the time over the Christmas holidays: sitting in a hysteroscopy clinic on Christmas Eve might not have been the highlight of my medical school career, but it was well worth it when my bags were packed and I was boarding the plane with the rest of the team two weeks later.

Did you know anyone on the trip? / The team consisted of Consultants and junior doctors from a variety of specialities, a couple of engineers, some physiologists and five medical students from three different universities. Although I knew some of them, there were some people I had only met briefly before the trip, and not many that I knew well. Still, slogging it up to 4700m from 3800m after a morning of blood taking and cognitive tests was a great way to get to know people better. The amazing mountain views, combined with mild nausea, headaches and shortness of breath really bonded us together.

We heard there was a race involved…? / The competitive streak of about half the group was tested on the descent when we decided to race down the valley back to our lodge. As I was running, trying to prove I could keep up, wishing I had my race pack and running shoes on instead of a large rucksack and B3 boots, I had the horrifying realisation that my 2L urine collection bottle with its very unreliable lid (part of a study!), was bouncing around in my bag. With the finish line in my sights, and my position in the race improving, I knew I had to forget about the potential spilt urine fiasco that awaited me and push on. Once in the valley bottom Chris joined my route and overtook me, the altitude taking its toll now we weren’t heading down hill. Luckily at the last minute I found some extra energy and we both crossed the finish line together. The prize for me was opening my bag to find the seal of my urine bottle had held, and by some miracle my bag was dry.

What did you learn? / Being both a researcher and a research participant on this expedition gave me great insight into the research process, especially since there were several studies running simultaneously. Every morning I helped on the blood team, taking 20ml venous blood samples from each participant, centrifuging the bottles, and taking serum samples from them.

This was a great chance to practice my venepuncture skills, but embarrassingly I still managed to miss a huge vein when Chris came for his bloods one morning, which I attempted to blame on the fact my head was a little fuzzy since it was our first morning at 5000m.

I also undertook my own small project looking into cognitive dysfunction associated with high altitude using a simple paper-based reading test called the King-Devick test. Due to the late application of my project to the ethics committee, it was touch and go as to whether I would get permission in time for the trip, but luckily, after several late night emails from a lodge at 3400m, I got the permission with only hours to spare before phone signal and internet access behind.

What were the highlights of the trip? / Spending a week in the Whymper hut at 5000m completing exercise tests and having a crack at the summit of Chimborazo a couple of days after Chris. Waking up to incredible sunrises, foxes hunting for food, and watching the weather and views of the mountain change over the course of the day.

Despite these, there was still a definite air of cabin fever by the end of our stay, so descending the mountain to spend our last two days in the beautiful town of Banos, with its huge supply of free oxygen (at an altitude of 1800m) was a great idea from our brilliant guide, Fredy.

After a night of sampling the local cocktails, half the group headed out for a morning of white water rafting which turned out to be a hilarious battle between the two rafts teams. Lush fauna covered the steep mountainsides either side of the river, with huge, wild orchids contributing stunning flashes of colour. Vultures circled above whilst some sat on the river banks, watching our progress and giving us the impression they were ready and waiting for one of us to fall out into the rapids. Luckily, although we had a few man-over-board scenarios, we managed to rescue our crew before the vultures got a look in.

This expedition to Ecuador reignited my love of South America, introduced me to some amazing people and great new friends, and opened my eyes to the endless opportunities and adventures that medical research can bring.

The Birmingham Medical Research Expeditionary Society is an inclusive society open to everyone, medically qualified or not. BMRES meets at the Medical School in Birmingham at 8.00 pm on the second Tuesday of the month. The Society tends to do one expedition to the Greater Ranges every two or three years, a European Alps based research expedition every two to three years as well as an ongoing UK based research program. BMRES is keen work collaboratively with other research groups and usually hosts a national altitude conference every few years, focusing on encouraging young researchers to present. The Summer Walk – an attempt on the Welsh 14 – is the next outdoor event planned for June 2016.

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There is bottleneck of refugees in Greece at the moment. The Macedonian border is closed. One hundred thousand more are predicted to arrive over the coming months. Having repeatedly watched the arrivals on the news, Dr Hannah Evans decided to volunteer. In the week that the Calais ‘Jungle’ is bulldozed, here is her moving account.

I raid my rucksack and, bleary-eyed post nightshift, remove the clothing I had so carefully packed the evening before. The formalwear for the conference I was planning to attend is replaced quickly with a makeshift medical kit, gathered hurriedly in the dimly-lit spare room and swaddled around some cold-weather gear. With minutes to spare I board the flight to London with the promise of a further flight to Greece that evening.  I’ve been watching the news for weeks, feeling useless and repeatedly imagining ‘what if that was my family?’.

On the overnight flight to Greece, I try to read on the plane, but cannot concentrate for thinking about the challenge that lies ahead. What will it be like? How will I be able to help with only a hastily collected medical kit? What sort of a difference will I be able to make, if any, in a week?

Lifejackets

We touchdown in Mytilini, the main port of the Island of Lesbos, a picturesque hub for Greek island travellers. The sea glints in the October sunshine and I catch my first glimpse of the iconic lifejackets, which plague the news and litter the shoreline.

After making contact with a volunteer who is already on the ground, I am escorted to the camp. The first thing that hits me is the litter, worse than anything after a music festival and smelling so terrible that it overpowers the fragrant sea breeze. Several carts, selling food and necessities are set up at the entrance by local people, trying to make some cash via inflated prices. The camp is a disused military barracks with some accommodation quarters: a depressing grey building set in olive groves in a small place called Moria.

Moria is where all arrivals must obtain what is essentially a piece of paper to register as a refugee. This process seems so protracted, with some families waiting three days to obtain it. Three days in this place must seem like a lifetime. The initial registration produces a numbered ticket, the numbers called out in order over the next 24-72 hours. Once your number is called out you are ushered into a queue and await the formal registration process.

Day 1

The first day is about finding my feet, taking it all in and helping dole out the meagre rations of biscuits, nappies and blankets we have. We walk around the camp. Cheap pop-up tents sit side by side. In between, plastic packaging lies discarded everywhere, mixed in with the mud on the ground from yesterday’s rainfall.

We distribute nappies and sanitary towels to families sitting in the mud, amongst the tents. One mother asks for a doctor; I rush over with my rucksack to find her son, a cute little boy of about two or three with blisters around his mouth. These look like herpes virus or cold sores, massively inflamed and made worse by sunburn, and certainly the worst I’ve seen on a toddler. I don’t have much to offer, only advice to stay out of the sun. They don’t appear infected, but if I had some child-friendly antibiotics I would have given them to her.

Continuing through the mess of mud and waste, we encounter another family who call me into their tent. Their baby has a cold and isn’t feeding well. They ran out of milk powder two days ago, but the child looks well hydrated. They give me an empty bottle and I go on a quest to find a supply of milk powder for them. After about thirty minutes of asking around, I find a tub kept locked away in an office. The next struggle is to find a kettle or a source of warm water to make up the bottle with. I eventually borrow keys to another office, make up the bottle and bring it back to the family along with a small supply of milk powder for the next few feeds.

The first day has already lasted 14 hours. I’m dead on my feet. Staying late at work is the norm for doctors in the UK. My partner and I have long stopped negotiating an optimistic time to have dinner together, but I can’t go home to my hotel yet.

A Bed for the Night

There is news that the barracks buildings may be available to take some of the most vulnerable families out of the rain and mud that night. I stay and help clear out the dirty mattresses from the bunk bed frames and give the bedrooms a basic clean. We then head back out into the olive grove to identify those most in need. Our initial criteria is to encourage families with young children and babies to come inside, however doing this without attracting too much attention is near impossible.

We find a family with three young children but soon enough several others pleading their case surround us. Everyone has different vulnerabilities and good reasons to need shelter. As difficult as it is, we acknowledge their plight and tell them to stay where they are as someone will come back if there is room once the families are catered for. This is a drill that will repeat every night; a mixture of fulfilment and guilt that someone remains in the cold.

It is nearly December. Although there is a sunny reprieve for a few hours, the nights are getting bitterly cold. The air is filled with the smell of burning plastic. Any plastic waste which will burn is used as fuel for fires, in order to warm freezing hands and feet. I can’t count how many people I see suffering with sore throats and coughs, likely from inhaling highly contaminated air.

I choose to stay out of the inevitable politics of running a camp. So many volunteers with good intentions, but lacking coordination and a steady supply of consumables to dole out. Nothing is ever straightforward.

Amongst the tents

We decide to wander amongst the tents in the surrounding olive grove.

Very quickly, a cry from a tent pierces the evening smog and brings with it a familiar tone. I guess that the perpetrator can’t be more than a few months old.

We call out outside the tent and a lady unzips the canvas door. She reveals a tiny, 25-day-old, heavily swaddled baby in her arms.  She tells me, through a translator, that she is experiencing some abdominal pain after her Caesarean section and asks if I could examine her abdomen. She is not breastfeeding and relying on handouts of milk powder.

The situation in Syria had been so bad, she had seen her village destroyed and experienced loss beyond imagination for her twenty-three years of life. I give her some analgesia and while I examine her, another few portions of formula are obtained.  We negotiate for them to get into the barracks that evening. I walk away, shaken with what I have seen.

I go back to my hotel room and cry myself to sleep.

Going Dutch

I sleep poorly. The next day I join a group of Dutch nurses who have arrived and we set up a ‘drop in clinic’ in the camp. They have brought a huge supply of basic medications and first aid supplies. We instantly click and make a brilliantly functional team. They highlight the fact that I know no Dutch, and I give them advice about the more complex of presenting problems. We meet some fantastic young refugees who translate for us for the whole afternoon.

I decide to stay later into the evening to meet the Human Appeal doctor who is in camp later at night. He is a UK graduate who dedicates his time working in conflict zones and areas of great humanitarian need. He speaks good Farsi and so we work through some consultations together. Understandably, there is so much anxiety, being in an unfamiliar country with nothing of your own and on top of that, to be unwell.

His makeshift office is on the outskirts of the barracks compound, which is enclosed by high fences and bolted gates. Some refugees used the fact that there was a doctor inside to get entry into the compound by feigning illness and then trying to dart through into the barracks. I can hardly blame them.

The local police have received a lot of negative publicity, however they have a job to do. They are working with people who are desperate and who do not speak the same language. It seems obvious that this is going to lead to frustration, and so conflict at times. The police try and maintain order in the queue to registration. I can’t say that I experienced much negativity from them. Most of the police officers I spoke with were sympathetic to the plight of the refugees.

Half way through my week, we are blessed with a Farsi speaker from London who has flown out to do what she can. This sudden new ability to communicate lifts my spirits and fuels my determination. We spend more time distributing snacks and toys, using the opportunity to get an overview of the general health of the family and treat where we can.

Our translator is asked to accompany the police and psychiatrist to the hospital – another boat has capsized leaving several lost at sea and families divided.

The psychiatrist has been flown in from Jordan and is accompanied by a psychologist, trying to help those who have experienced loss in such an acute sense; forced to watch their babies disappear into the darkness, into the sea. I cannot comprehend how you try to understand or help with that.   We manage to pair up some photos of children in the hospital with photos on phones of anxiously awaiting relatives. This feels like a small triumph, especially when reuniting the families.

What if it was my family?

Some people I meet are angry, seething that they are forced to wait in such squalid conditions, that they must wait to register and that everyday consumables are expensive. Others are distraught, displaying delayed grief reactions or real raw grief over those lost or separated. Some are just numb.

The tales told about the boats from Turkey are extraordinary. People describe being asked to pay sums in excess of 1500 Euros by threatening traffickers holding AK47s, urging more and more refugees into the boats when they were clearly over capacity already. What would you do if that were the only perceived way to safety? The boats are nothing more than a thicker, larger inflatable dinghy reminiscent of those my sister and I played in the sea with on a childhood holiday.

When I return, UK medicine angers me for the first few weeks. Demand is so high, expectation so great, frustration often over such trivial things and no reprieve in sight. It makes me want to give those with overly-unrealistic expectations or demands a glimpse of what is happening on our doorstep.

Life is so precious. Compassion costs nothing. I bite my tongue and plan my next trip to Greece.

Visit the International Rescue Committee (IRC) Greece page for updates on the situation. Click here for our recent article on working in the Calais ‘Jungle’ refugee camp.

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Last year, medical students James Penney, Hannah Russell and Anthony Howe and FY1 Steve Spencer spent seven weeks in a remote region of Madagascar screening school-children for schistosomiasis. They planned MADEX from scratch – coming up with the research aim, finding collaborators, convincing the Ministry of Health (MoH) Madagascar, and finally fundraising in order to pull the whole thing off. We asked them to tell us more about how they ran a large fully-funded expedition while still studying as medical students. Inspiring effort.

Why schistosomiasis?  Why Madagascar?

Steve’s mantra for expeditions is that you can start with either 1) a place, or 2) an aim. Once these two are matched up, you have the idea for an expedition. He had previously studied schistosomiasis, a parasitic infection carried in freshwater snails.  It is second only to malaria for parasitic diseases worldwide in terms of socio-economic impact. It’s a huge problem in much of Africa, where it has a high associated morbidity, particularly for children. It is easily treatable by a single dose of Praziquantal, however, many African countries, such as Madagascar, have poor infrastructure and inaccessible rural areas. This means many regions aren’t screened for the disease, and many more people aren’t treated. The most recent prevalence study in Madagascar was in 1987 where over 50% of people were found to be infected.

We’d all always wanted to visit Madagascar. It conjures images of biodiversity and intrigue as much as any country; the idea of going to there to do research was incredibly appealing, and so the idea for an expedition was born.

Planning a Student-led Expedition

The seed of an idea took over two years to turn to fruit. The first step was contacting MoH Madagascar to ask if there was any chance of a team of medical students coming out to do some research on schistosomiasis.

After a few months an email came back affirmatively – as simple as that! This set the wheels in motion. From here, we spent long hours researching the natural history of the disease, reading papers and guidelines, and emailing all the experts we could to find out more about the fundamentals of schistosomiasis research. Field diagnosis of schistosomiasis involves examining either urine or stool samples (depending on the species of schistosome) under the microscope to look for parasite eggs.

From reading and expert advice, our aim had emerged: to perform a prevalence study of schistosomiasis in a region of Madagascar, by screening school-aged children. Also to carry out education programmes in schools to raise awareness of the problem of schistosomiasis and how to avoid it, and to interview local health authorities to investigate the disease burden of the area.

We put together a proposal, and were able to negotiate with the medical school to allow us to use our ‘project option’ (an 11 week research block in the fourth year of medicine, usually an audit carried out locally) to go to Madagascar.

We had the beginnings of a plan but had many more questions; where to go?  Which species of schistosome to investigate? Did we need permits, and if so, from who? How would we contact the schools? Most importantly, was this actually going to happen, or were we going to have to do an audit in Manchester instead?

Collaboration with Durrell

Whilst at the Royal Geographical Society ‘Explore’ Conferencee, we met Dr Peter Long, a Zoology Fellow at Oxford who had been on various expeditions to, amongst other places, Madagascar. Peter worked with Durrell Wildlife Conservation, the longest-running conservation organisation in Madagascar, and thought that there was a chance of collaboration. After a few meetings with Peter and his Malagasy PhD student, Hery Andrianandrasana who oversees Durrell’s conservation in Madagascar, a plan started to emerge.

Durrell work with communities to protect ecosystems and environments.  Cooperation with local people is crucial for this and is facilitated by improving community health.  Durrell knew that schistosomiasis was a problem but had no idea of the scale of it, so they were keen for us to work in their projects and investigate the health burden. We could barely believe our luck – they have fantastic community links.

The work began in earnest. An exhaustive proposal had to be written and translated into French. We applied to a long list of funding bodies for support. A risk assessment had to be completed, detailing the risk of everything from gastroenteritis (9/10 likelihood, 3/10 gravity), to being raided by bandits (4/10 likelihood, 9/10 gravity) and ethical approval sought. We made contact with the University of Antananarivo, who were keen for some of their medical students to accompany us in the field. The validity of our methods and our familiarity with them was also crucial, so we were constantly emailing various experts (Dr Shona Wilson in Cambridge, Professor Russell Stothard at the Liverpool School of Tropical Medicine, Professor Andrew Macdonald in Manchester Immunology Department) for advice and to organise training in microscopy techniques.

This was hard work.  For the eight months before departure we were having long coffee-saturated weekly meetings, and firing off emails left right and centre to keep everything moving, but it was also very exciting.  The occasional mention of lemurs and vanilla rum helped keep the dream alive.

The Final Pieces of the Puzzle

It was great seeing all these details coming together, but the whole project rested on funding and permits. After a few disappointing rejections we didn’t allow ourselves to assume anything.  In April we had confirmation of funding secured.  From a combination of The British Medical and Dental Students Association, UoM and Manchester Medical School, plus some of our own fundraising, we had enough. Hery had also managed to secure us research permits, and so after months of bureaucratic uncertainty, we were on. We booked flights, and had just a few weeks to finalise everything.

The last month before we left was manic. We delegated roles to ensure everything was covered: I was research lead – amongst other things I had to source antigen-testing kits from South Africa, urine filtration kits from Seattle, and malachite green which was crucial to the methods but excruciatingly difficult to get hold of. Hannah was medical officer, so after attending a 4 day expedition-medic course, had to assemble our extensive medical kit and Anthony finalised everything to do with logistics and money. This was all done amidst exams, dissertation hand-ins, and moving house. Steve had managed to secure a mini-hospital’s worth of donated drugs from East Lancashire Hospital Foundations Trust, to take to the health centres in the villages we would be working in.  By the time we left we had surrendered ourselves to having surely missed something, but stepping on the plane felt fantastic and we were on our way.

Meeting and Greeting in Antananarivo

Touching down in Antananarivo (‘Tana’), we were abruptly thrust into the bustle of Malagasy life, as we spent our first week taxiing around the sprawling capital (the name means ‘city of a thousand hills’) meeting the people who we had spent over a year emailing.

The first of these was our primary contact, Dr Alain Rahetilahy, head for control of infectious tropical diseases in Madagascar. He met us in the main city square and took us through the thronging marketplace to his office, where we finalised research methods, and arranged the retrieval of 4000 tablets of Praziquantal, donated by the WHO.

Another taxi led us through the side alleys and up a steeply cobbled hill to the Durrell office, where we met Richard Lewis, Head of Durrell Madagascar, and Hery, to finalise our itinerary and logistics. It felt like a real honour to be in the headquarters of such a prestigious organisation. During the wet season, some of these areas are completely inaccessible, and we were cheerily informed that Marolambo, where we were headed, is the most isolated of the Durrell projects.

Day two involved a meeting with the Director General for Health, who seemed positive about our plans, approving our project and signing our permits. Another taxi (these were almost exclusively creaking 1960s Citroen 2CVs, often with a 2l coke-bottle below the dashboard acting as a fuel tank) took us to the University of Antananarivo to meet the Dean of the Medical Faculty, Professor Luc Samison. He introduced us to four medical students and doctors, whom we interviewed, and selected two to join the team, Daniel and Anjara.

The final few days were spent rushing around Tana, tying up all our loose ends: buying a generator to power the microscopes, picking up maps of the area, sorting out Daniel and Anjara with rucksacks, sleeping bags, and waterproof jackets, and trying to cram up on Malagasy.

Getting to Marolambo, By Hook or By Crook

Having spent a week driving round the bustling city, we were raring to get out into the fresh air, so leaving Tana was a relief. We hired a taxi-brousse and driver to take us, Dr Alain and our kit down to Mahanoro, a small sleepy town on the Indian Ocean about 250km from Tana. This was a gorgeous place to spend a few days soaking up the sea air. Durrell’s annual conference was taking place in Mahanoro over the week, so we were introduced to the local powers – the Environment Minister, the Education Minister, the Transport Minister and even the Mayoress, resplendent in a vivid purple dress. After a small final speech in my rusty French, we were given their blessing, and talked into the night with these inspiring people from all over the region who were all extremely passionate about their country. We bid au revoir to Dr Alain, who had become a grandfather-esque figure over the past weeks, smoothing all introductions with his humility, and initiating us to Malagasy with his insistence on karaoke sessions.

The next leg was to get to Marolambo, where our work would start. For this we had to hire a truck to take us up a jungle track into the mountainous interior, a journey which took us two full days. After an exhausting trip, we woke to a misty morning, looking down on the town from the priest house. Marolambo lies at the confluence of two rivers, surrounded by low-lying hills. Its painted-concrete town hall and cobbled streets gives an air of faded colonial grandeur amongst the corrugated-iron and wooden shacks lining the streets.

The Business of Schistosome Identification

We were looking for schistosomiasis by three different means – 1) looking for eggs in stool samples 2) looking for eggs in urine samples, and 3) testing urine for an antigen given off by all schistosome species. In addition to this Daniel and Anjara delivered an education programme to the schoolchildren on how to reduce the risk of schistomiasis. We also conducted interviews with local healthcare professionals, village chiefs, and headteachers, to discover more about attitudes to the disease, and to ask what interventions could be made to reduce its burden.

A typical village visit was as follows:

Day 1 / Introductions, distribute and collect 80 urine and 80 stool containers (it still amazes us how the kids managed to have all containers returned and filled within 20 minutes), carry out education programme, analyse urine samples under microscope

Day 2 / Prepare stool slides, start analysing stool slides

Day 3 / Finish stool slide analysis, clean all sample pots and slides, explore if time.

Smearing poo onto slides for 12 hours one in every three days isn’t everyone’s idea of a university summer well-spent. There were tactics to dampen the smell, but even with liberal Tiger Balm under our noses, it was pretty grotty work. Despite the smell, we managed to appreciate the unusual situation, and were even a little sentimental as we smeared our final stools, after three weeks and over 500 samples. The smell didn’t deter the kids, who were fascinated enough to spend whole days watching us through slats in the walls, as we smeared away, dreaming of pioneering an expanded Bristol Stool chart.

Once we had the results, we gave headmasters and the health centres the list of infected children, and instructed them to collect their free treatment of Praziquantal. As students, we frustratingly weren’t able to get permission to actively distribute treatment, so it was difficult to ensure that the children received the treatment they needed.

Finishing Off

Once the work in the villages was finished, we managed to charter a plane from Marolambo back to the Tana, a journey of 39 minutes, compared to the four days it had taken us to drive there. We spent a week in Tana to write up the project, and met with Dr Alain to discuss our findings, followed by a final karaoke session, before flying back to the UK.

What Did We find?

Over 90% of the children that we screened had schistosomiasis. We found extremely high egg counts, well above the WHO threshold for ‘intense’ infection.  On discussion of these results with experts, it is likely that children with this level of infection will be dying of the disease. These data vindicates our working in the region, demonstrating the need for follow-up projects.

What next for MADEX?

Our long-term goal is to reduce the level of schistosomiasis in the Marolambo region.

Reducing schistosomiasis in a population is difficult. The treatment is only effective until the individual is re-exposed to the parasite, so the recommended approach is to treat the whole population with Prazinquantal, every six months, until the level of infection is reduced.  However, limited resources and the remoteness of many of the regions makes treatment really difficult.  This is especially true in Marolambo where the people’s lives are inextricably linked with the river, meaning they are constantly re-exposed.

By advising MoH Madagascar of our findings, we hope to ensure that treatment is implemented in the region. In addition to this, with follow-up we also aim to reduce the disease burden by focussing on improving education and working with both the community and Durrell, to make interventions that will reduce exposure to the parasite.

This will hopefully be a long-term project, and to continue the collaboration between the universities of Manchester and Antananarivo. Planning for an expedition in summer 2016 is under way.

What Did We Learn?

Madex was a brilliant experience. It opened our eyes to the world of research and the possibilities of medical work in remote, unknown places. Being entirely responsible for a project and coming away with useful data has been very rewarding. We can’t wait to return, and try to ensure that the community really benefit from our work.

These are some of the most flagrant clichés going, but they held true for this expedition:

If you don’t ask you don’t get / It seemed bold to email the Ministry of Health Madagascar out of the blue, but there’s no reason why not to, and the worst that can happen is they say no.

Persistence pays off / There were a lot of barriers to this trip happening, but our determination in convincing people that the trip was worth their investment of time and money eventually worked.

Team attitude is the most important part of an expedition / Diarrhoea and vomiting from three weeks of dubious rice, or digging out dust-fleas from your feet with a scalpel, could ruin a trip for some, but if there is a positive attitude within the team, these difficulties can be turned into ‘experiences’ and dealt with.

Relationships with locals is crucial / Without Durrell and their contact with the communities, we wouldn’t have been able to work in these remote villages.

In-country team members help massively / We hadn’t anticipated how much help Daniel and Anjara would be. As well as translating and interviewing for us, they bartered prices, kept us aware of cultural sensitivities, and were just brilliant just to spend three weeks with, teaching us so much about Malagasy beliefs and customs.

You don’t have to have experience to be taken seriously / We had no prior experience of tropical diseases or microscopy, but we stuck to our methods and our findings are being used by MoH Madagascar, and are being considered for publication.

M’ora m’ora / The Malagasy way of life. Everything starts late, takes longer, and ends later, but everyone is so un-rushed and relaxed. We came away more relaxed ourselves, and wishing that life in the UK could follow suit.

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The Refugee Crisis may come to be seen as one of the defining human events of the 21st century. Desperate people are living in appalling conditions on our doorstep. As medics, we are in a position to help, through donating our skills, our voices, our money and our time. UK Doctors Morven Telling and Bryony Corbyn travelled to Calais and Dunkirk to offer what assistance they could to those in dire need – the experience was overwhelming. Their account here is particularly moving, and they also provide links for those looking to help, and those looking to donate.

As our train emerged through the Eurotunnel that links Dover and Calais, row upon row of high barbed wire fences came into view. Scraps of material tangled in between them; tattered reminders of the desperate attempts of people risking their lives as they try to reach the UK. We were on our way to two of the largest refugee camps in North West France: the Jungle Camp in Calais and the second in Dunkirk. Our trip had been planned spontaneously and in haste. We’d heard and read about the appalling conditions faced by refugees at our coastal border, just a few hours away from the warmth and safety of our own homes. It had been so difficult to imagine. Dismayed by the inaction and lack of official intervention surrounding this evolving humanitarian crisis, we decided to go and offer whatever aid we could. In the week before leaving, we contacted long-term volunteers though online social media groups and arranged a plan to divide our time between both camps. We would be attending to the medical needs of the thousands of refugees who would have very limited or no access to any other form of medical care during the time that we would be there. We anticipated the worst, knowing that these camps currently accommodate deeply traumatised individuals suffering exhaustion, malnutrition, infectious diseases and injuries, as well as a wide range of chronic health conditions. We were aware that their burden of suffering is far reaching, with physical and mental health problems accumulating during the traumatic journeys they endure: fleeing from their home countries, travelling long distances under stressful and harrowing circumstances before reaching the camp and enduring the desperate conditions that they now survive in. We hoped that between us, our skills as a general practitioner and psychiatric registrar would enable us to offer some aid and support.

Kit

We drove first to a warehouse where many of the donations sent to Calais are organised and sorted by volunteers. There we assembled a make-shift set of medical kits from shelves stacked with a random selection of donated supplies. There was an eclectic selection of dressings, first aid supplies and over-the-counter medication. Four final-year medical students and another doctor with medical and surgical experience joined our team. In preparation for the cold and wet conditions, we put on thermals, waterproofs, wellies, high visibility vests and with all the kit we could carry packed into rucksacks, we set off for Dunkirk.

The Dunkirk Camp

Sleeting rain and driving winds set an expectation of bleak, dire conditions. However, nothing could have prepared us for the level of suffering and despair we witnessed as we approached the Dunkirk refugee camp. Ahead of us; a sea of ankle-deep, slippery, foul-smelling mud, deep puddles of dirty water filled with rubbish and hundreds of tents desperately anchored into ground that would not hold them. Many tents lay flattened in the mud. The rest were being buffeted by strong winds, their resilience frequently tested by the gusts. We looked around; grim faced men, crying toddlers, everything wet and sodden. Amongst the trees, desperate people seeking shelter from the howling wind and freezing rain.

So many tents, where to begin? A few volunteers could be spotted in the camp, distributing donations and preparing building materials. One of them, a fireman from Lancaster, came over. Identifying us as first-aiders, he asked us to prioritise the tents with babies and young children first.

The babies and children are hungry… the mums give the babies milk from cartons and they get sick. Some of them have fevers.

Dividing up, we all set off towards different areas of the camp. Morven was shown to the area of tents where young children were based. She crawled inside a succession of filthy, damp tents examining babies with fevers, coughs and vomiting symptoms and many small children including a sobbing three year-old girl with tonsillitis who had been crying in pain for two days, a 15 month old with profuse diarrhoea and a young boy with asthma who had been coughing for several weeks. Whilst attending to the children she was also approached by their families; a young mother with severe toothache, a woman with symptoms of a urinary tract infection, a man with abdominal pain lying huddled and groaning beneath his blanket and many, many more.

“The inadequacy of the situation was overwhelming”

Taking her stethoscope out of her rucksack, Bryony barely made it a few steps before being approached and then surrounded by numerous, distressed people asking for help. They pointed to their throats, mouths, limbs and stomachs. Others pointed to their soaking wet, broken shoes or thin jackets, hoping she might have dry clothing to offer. The inadequacy of the situation was overwhelming. She attempted to find a bit of dry space under the edge of a wooden shelter and indicated for people to try to form a queue.

The first person in the queue was a man from Kurdistan. He opened his mouth, wincing in agony and showed her his rotting teeth.  He spoke a little English and she was able to give him some pain killers before having to tell him that she could not do anything else, there was no dentist coming today. Did she know when one would come? No, she didn’t even know if one would come.

By now her rucksack lay in the mud in front of her as she examined peoples’ chests, skin lesions and throats as best she could in the pouring rain. Her first patient agreed to stay and translate since many of the other refugees spoke no English at all.  Pain killers, cough syrup, rehydration sachets and skin creams were handed out in small, rationed quantities; we had such limited amounts and they had to stretch a very long way.

Despite the clear inadequacy of what we could provide, we received smiles and thanks from all.

For the rest of that cold, wet afternoon, we slid around in the mud, trying to protect our medical kits from the rain as we were stopped wherever we went by people asking for help. We crawled into tents to dress wounds and assess ill children and adults until darkness began to fall. Exhausted and conscious that for safety reasons we needed to leave the camp before it got dark, we had to leave many people still unseen. We headed out of the camp, promising to return early the next day.

Fire in the Jungle

Overnight a fire broke out in the Calais camp – most likely started by a candle. A call at 2am from volunteers on site asked the medical team to remain on stand-by. A badly burned man had to be carried out of the camp by other refugees to an ambulance that apparently would not come into the camp. Many tents had been destroyed leaving several families with small children and babies completely homeless, desperately seeking shelter in the pouring rain.

With news of the fire, we changed our plans and headed out early to the Calais camp in order to offer first aid to those who might have been injured by the fire. This was our first sight of the “Jungle” – thousands of tents, as far as the eye could see, overflowing portable toilets, burst water pipes creating muddy lakes, cooking smells mixed with the stench of waste and sewage.

We made our way to the camp first aid centre – three small caravans stocked with limited medical supplies. The caravans were parked in ankle deep water, mud and waste which the fast-growing queue of refugees had to stand in while they waited to be seen. We worked in one caravan, another doctor worked in the second, the third caravan was locked as there was no-one to staff it. We knew that when we left, ours would also be locked as there were no other medics to replace us.

Over the next few hours, our skills and experience were stretched to their limits. Trying to assess and treat so many ill people with such limited facilities. No antibiotics, no effective medication to treat the serious infections and illnesses that we saw, no translator other than fellow refugees who spoke broken English, no access to running water.

The Return

Leaving the first aid centre to go back to the Dunkirk camp was extremely hard. We just could not get to the end of the ever-growing queue of sick people desperate for help. We spent the remainder of the day and the next going between Calais and Dunkirk, seeing as many people as we could, replenishing our supplies at the warehouse before heading out each time. Traveling back to the UK on our final day, in utter exhaustion, there was little we could say. The experience had been overwhelming. We had been tested to our limits.

We could not do enough.

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Dr Karen Bevan-Mogg is a UK GP who has worked around the world in remote settings, through NGO and expedition work. Here she writes about travelling to a refugee camp in Kenya with Primary Care International. The aim? To teach health care colleagues in low and middle income countries about non-communicable diseases (NCDs) such as diabetes, cardiovascular disease, asthma and COPD. NCDs are becoming a huge burden in the developing world and PCI is currently recruiting NHS GPs to help deliver relevant and focussed education to community health workers. Read on and get involved!

Kakuma

For 90 minutes we fly north from Nairobi, over ridge after ridge of bleak mountains dotted with scattered bushes, scarred by dry river beds. There is no evidence of human habitation – no roads, no villages, no mines, no agriculture – until we bank sharply to the left to begin our descent. Then I see it: Kakuma camp. Hundreds of corrugated iron roofs, gleaming in the sun, arranged in regimented lines, home to 187,000 people waiting for a better life.

‘Kakuma’ is the Swahili word for ‘Nowhere’.  The camp sits next to a small town of the same name, in a remote area close to the borders of South Sudan and Uganda. The region is largely overlooked by the Kenyan government, which is much more interested in the productive farming country around Nairobi and Mt Kenya. Our short drive from the rough airstrip to the UNHCR compound demonstrates how diverse the population has become, with scantily clad local Turkhana people mingling with covered Muslim women and robed men from many nations. The majority are Dinka and Nuer people from South Sudan (between whom civil war broke out after independence); Ethiopians, Congolese and Somalis are the next largest groups, with a few Ugandans, and, increasingly, since the recent disturbances, Burundians.

The Challenge

I am here with two GP colleagues, Peter and Sarah, to support the International Rescue Committee (IRC) staff who provide health care for the camp and the local Turkhana. Although malnutrition and infectious diseases are still major problems, non-communicable diseases (NCDs) such as diabetes, cardiovascular disease, asthma and COPD now cause around a third of all deaths. In low and middle income countries NCDs cause more premature (<60yrs) death and disability than HIV, tuberculosis and malaria combined.

This shocking reality is the result of years of neglect by the international community (diabetes and hypertension aren’t sexy) and a lack of experienced clinical staff in settings where infectious diseases and acute medicine have historically been most significant. So our task is to deliver four workshops for doctors, nurses, clinical officers and Community Health Promoters (CHPs), to improve their understanding of NCDs and offer clinical and strategic guidance to improve prevention and patient care. We’ll follow-up with further dialogue and CME remotely.

Most NCDs are the result of lifestyle choices, or lack of choices if you happen to live in a refugee camp. How do you talk about the effects of smoking with a man who has lost everything except the clothes on his back? How do you advise a mother cooking World Food Program rations for her family of 12, about a suitable diet to help her diabetic sister and reduce everyone’s cardiovascular risk? I struggled with our position while I prepared for our first trip 18 months ago, when we worked with staff in Jordan’s Za’atri camp, for Syrian refugees. However, drinking (sweet) tea with a middle aged man whose diabetic toes had already been amputated and the stories told by countless doctors and nurses whose families have been affected by NCDs, convinced me that prevention and early treatment in the community is crucial –both clinically and financially to manage this growing epidemic.

Camp Life

Kakuma camp is divided into four sections, which consist of Zones and Blocks. Each section has an outpatient Health Centre, staffed by a clinical officer and a nurse, to deal with non-urgent cases and provide antenatal care. Emergencies and further outpatients are seen at the 130 bed field hospital, staffed by doctors and nurses.

Wherever we go, we try to understand the reality the staff are working in, by seeing as much as possible of the clinics and communities, and by meeting as many of the team as we can. I’m always humbled by how much our colleagues accomplish in the face of enormous challenges and Kakuma was no exception. The old Field Hospital is staffed by young, relatively inexperienced staff who (understandably) seem overwhelmed by their considerable burden of clinical responsibility. Access to basic diagnostic tools such as x-rays, ultrasound and lab tests, is very limited and senior supervision and referral opportunities are restricted to occasional visits from specialists. It is possible to fly a patient to Nairobi, but this is expensive and difficult, and amongst so much need deciding who should stay or go is tough.

Peter and I squeeze into a minibus with Community Health Promoters doing the polio vaccination campaign, to visit Zone 4, the newest section, where recent arrivals live. As we bump along, Patrick, a very tall, smiley Nuer, explains that they have vaccinated 48,000 children so far and there’s just one day left to reach the 60,000 target.

Q – How do they know who’s already been vaccinated?

A – They paint henna on the little finger nail, which lasts the length of the campaign.

Patrick arrived in Kakuma 10 yrs ago and was trained as a Community Health Promoter by IRC. Each CHP is responsible for delivering health education, collecting information and liaising between the health teams and community, giving them a crucial role in the struggle to prevent and treat NCDs like diabetes.

Zone 4 is ‘overflow’ zone, as the camp was designed for 100,000 refugees but currently holds 187,000 and is growing. Negotiations to extend further were underway between the Turkhana people and the Kenyan government while we were there. Dada’ab camp in Garissa county (to the east) is slowly emptying, forcing refugees who cannot return home to shift to Kakuma instead. Zone 4 is barren, dusty and divided into plots which each accommodate 2 huts, typically one for cooking and one for living in. A typical family of up to 18 people will be allocated their plot on arrival, given the tools to make earthen bricks and corrugated iron for the shiny roofs we’d seen from the air. Together with dry acacia-thorn fencing between plots and a complete absence of greenery, the resulting environment is far from welcoming.

In contrast, Zone 1 opened in 1992 and feels more like a village than refugee camp. Mature acacia trees and bushes provide some shade. The small brick houses have been grouped into households as families have expanded. At the centre is a thriving market area of small businesses selling most daily essentials: maize flour, plastic chairs, onions, even a place to charge mobile phones. We bought avocados and tomatoes from a grocer who told us how he had left Burundi in 2007 as an adolescent and gone to Nairobi, where he worked in a hotel and tried to study in his free time. Last year the Kenyan government insisted that all refugees live in camps, so he left everything once again and came to Kakuma. He and two compatriots make a living from the shop, selling washing powder, rice, maize flour and a few fresh items in the tiny quantities that people could afford with the little money they have.

‘I like it here with my friends; they are my brothers now,’ he said. ‘We are like family.’

Life is far from easy though. Ethnic conflict is a constant threat to security. Cattle rustling between refugees from different tribes, and between refugees and the Turkhana locals, results in more bloodshed. The climate is harsh. Most months are unremittingly hot, dry and dusty, but in January and February torrential rains fall on the mountains to the north and west, and pour huge volumes of water into the empty riverbeds, which are rapidly overwhelmed. Every year the camps (and the UNHCR offices) are flooded; houses, people and animals are swept away. Malaria flourishes in the pools left behind as the waters recede. Most refugees have set their hopes for the future on ‘resettlement’ – the good fortune to be offered sanctuary by countries such as the US, Canada or Sweden (but not the UK, incidentally).

Training

So with all this in mind, we spend the next eight days with all the available clinical staff in the sticky IRC and Lutheran Worldwide Federation staff canteens, conducting training about chronic diseases. Most know the theory but applying this to the reality of camp life is difficult. What practical advice can you give a 50 year old Muslim woman living in Zone 4, who needs to lose weight in a culturally acceptable way? How do you store insulin in 42 degrees heat? We introduce single page ‘Field guide’ summaries of evidence-based best practice, adapted to the camp setting to include the tests and drugs available (WHO Essential Medicines). These are used to discuss numerous case scenarios, which never fail to generate colourful discussions and ideas. Role plays are sometimes drowned out by the hefty canteen freezers but prove useful for practising consultations skills. Examination of the diabetic foot using home made ‘monofilaments’ (broom bristles of appropriate weight) takes place in the staff ‘chill out’ area by the pool table.

We have worked with partners in Jordan, Burkina Faso, Kenya and Somaliland and seen everywhere that the concepts involved in NCD care aren’t new: the need for the patient to understand their diagnosis; the importance of taking a good clinical history; the ability of nurses to share clinical tasks; the lifelong partnership between doctor and patient; the possibility of managing NCDs in the community instead of at hospital level; the ‘impossible task’ of educating patients and communities. None of this can happen if clinicians are not supported by the system they work in. So the health care teams also consider appointments systems, records, patient flow, staff training, data collection, audit, significant events (and all the other tasks we love to hate at home) as part of ‘the bigger picture’ influencing NCD care. In Somaliland and Jordan we worked with MoH officials and a ‘focal team’ of doctors to develop strategic ‘road maps’ for change, and trained some as trainers (ToTs) to cascade the learning to their peers.

In Kakuma Sarah spent time with the CHPs, focused on understanding each of the chronic conditions and teaching techniques to help patients change lifestyle behaviour, rather than simply delivering health education messages. At first, only one could think of someone he knew with diabetes. By the end of the course the majority realised that NCDs are causing disease in their block.

Transition

It is never satisfying to leave after a short visit. I always want to stay longer to support staff as they practise new skills in their clinics. Instead, as our new friends return to work, I find myself back at the gravel airstrip, waiting to board the World Food Program flight back to Nairobi. Turkhana women walk on the other side of the perimeter fence, with their brightly coloured neck beads and clipped hair (short at the back and sides, long and braided at the crown, to accentuate their long necks). The men wear a cloth draped casually over one shoulder and sport ostrich feathers on various pieces of headgear. They only recently started wearing ‘western’ clothes, just as some have abandoned their nomadic way of life to settle, for the children to go to school.

The Turkhana are a people in transition. Their dislocation from a traditional way of life will undoubtably be accompanied by problems, including the onset of NCDs. It is up to us as an international community to combat this threat with simple prevention and affordable care, so that future generations everywhere can look forward to a bright future.

Please click here for more information about Primary Care International, and how to volunteer for them as an NHS GP.

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Chris Imray is known to many in the adventure community for his expertise in frostbite and altitude illnesses, as well as his life-long dedication to the mountains. He is one of the editors of the recently-published second edition of the Oxford University Handbook of Expedition and Wilderness Medicine. In this article, Chris tackles the most remote and exotic of the Seven Summits, West Papua’s Carstensz Pyramid on a CME trip with Andes Mountain Guides. Read on for warring tribes, kangaroos in the trees, frogs in the pot and a 30 foot shark.

The End of the Line

When we finally stepped off the plane and onto the tarmac, we were confronted with an oppressive wall of heat. The fierce equatorial sun, combined with the intense humidity and the windless atmosphere immediately felt draining. It was our fourth flight connection within Indonesia and we had been flying all night. Nabire, a frontier town, seemed like the very end of the line.

We were a small expedition of six heading for one of the remotest and the most exotic of the Seven Summits, Carstensz Pyramid. At 4884m, the peak is the highest in Oceania and just getting to the base of the climb involves one of the world’s last real adventures. This mountain is as remote as it gets; with multiple flights on ever-smaller planes before eventually arriving in West Papua. From here the approach is a very challenging trek lasting five days through the dense jungle accompanied and assisted by members of Dani and Moni tribes. Past expeditions have been held up for days with tribal delays. Its extreme remoteness, combined with government restrictions, political instability in the region and frequent tribal warring, has meant that few people have climbed it since the first ascent in 1961 by Heinrich Harrer.

The battle of Sugapa

After a day in Nabire, we made our final flight on a single-engine plane into the Central Highlands of Papua. Landing at Sugapa was like moving into a film set for Easy Rider. To our amazement, we were met by a group of motorcyclists in leathers. Their job was to transport both us, and our kit on the dirt track roads as far as the road head. Although Coop, the expedition leader, had emphasised to the drivers that this was to be done cautiously, it rapidly turned into a mad Wacky Races charge to the end of the trail. During the bike journey we were held up for an hour or so as two different Dani tribes argued over the arrangements for the porterage for our group on the mountain trail. This readiness to argue over everything is a feature of their society:

‘Ritual small-scale warfare between rival villages is integral to traditional Dani culture, with much time spent preparing weapons and treating resulting injuries. Typically the emphasis in battle is to insult the enemy and wound or kill token victims, as opposed to capturing territory or property or vanquishing the enemy village.’

Wikipedia (October 2015)

We spent the night in a bright yellow hut within a village compound of more traditional ‘round houses’, which were co-occupied by the tribesman and their highly prized pigs. The following morning, a three and a half hour ‘debate’ between the two tribes began. It gradually developed and more and more people squeezed into the compound to participate. Axes, guns, bows and arrows all featured, as did a couple of individuals wearing only penis gourds. The heated debate became a vociferous argument and we wondered how it would end and if we would ever set off. Then all of a sudden, we were leaving on a five-day trek through the jungle up to base camp at 4300m, ably assisted by Arland, Joy and the Indonesian crew.

Enter the Jungle

I have never trekked through jungle and I found it both interesting and challenging in equal measures. The sheer physicality surprised me. The heat; the absence of any breeze; the lack of a view for more than 20-30 feet and the fact that virtually every step was climbing up, over, or through dense vegetation, took me by surprise. It was very difficult to establish any sort of rhythm and there was no feeling of covering any sort of distance; one just ‘walked‘ for two to three hours at a time.

The advised footwear was wellington boots, or in American parlance ‘rubber or rain boots’. Most of our group chose a fairly sedate green or black colour, but Margaret had found a pair of shocking pink Hunter boots, which drew great admiration, and I suspect longing, from the Dani tribesman. An intriguing approach that I am still not sure I fully understand was Australian Chris R’s hole that he had drilled in the sole of his boot that for ‘drainage purposes’- being English and used to mud, I just don’t get this- maybe we have the wrong sort of puddles in the UK!

River crossings were variable and often difficult, but we were relatively fortunate due to reasonably dry conditions. There is an ecological intimacy to jungle trekking, by virtue of being up close and personal with everything from exotic plants to butterflies and insects. The Papuan jungle appears to be relatively benign, with very few of the poisonous or dangerous flora and fauna often described. Birds of paradise were be heard but rarely seen, and tree-kangaroos (Dendrolagus matchiei) were rarely heard or seen but three were eaten after a night hunting expedition by the tribesmen.

The jungle gradually thinned as we ascended, and eventually we emerged into more open countryside. There were weird limestone rock formations, beautiful rivers and interesting marshlands. The Dani tribesmen were experts at finding local delicacies to eat, which ranged from a delicious ‘swamp spinach’ to more challenging crunchy culinary delights such as river frogs which were eaten smoked and whole by the more daring amongst us.

Summit day

Summit day started well before dawn with an alpine-style start. After a minor route-finding issue, we found the first pitch. This was indicated by a somewhat worn looking 11mm fixed rope, which led off around a vertical buttress. Jumaring up this feature set the tone for the next ten hours of climbing. Although the rock was steep, mainly solid, with high friction and most of the belay points reasonably sound, the ropes themselves were less reassuring. Despite new ropes, allegedly placed last year, there was alarming wear, right through the sheath in a number of places. The infamous Tyrolean traverse had been replaced with an equally exciting three-strand wire rope bridge with outrageous drop-offs.

We all followed the tortuous ridge to the summit arriving at about 8.30am. There were stunning views in all directions, and after the summit photos and the ubiquitous selfie for Margaret, we began the cautious and steady descent, trying to select the safest combination of worn abseil ropes and somewhat dubious fixation points. We made it down by 2.00pm and some celebrated with a quick swim in the turquoise blue glacial lake

The walk out was a delight. The Dani tribesman had visited the shop in the nearby goldmine and were stocked up with various ‘essentials’, including wellington boots, safety helmets, coloured bread and fizzy drinks. There was an end of term feeling as we descended back through the jungle. At one particular campsite, face painting with coloured muds gave us an insight into some of the behaviours for which the tribesmen are famous.

A couple of boys who were probably 10 years old, called Perri and Pas, entertained us (and I think we entertained them!) Ben in particular reverted to a similar age as they played games all the way down the mountain. Whether it was trying to knock tin cans over by throwing stones, using catapults to stun and catch birds, or sorting out our pathetic attempts to keep wet jungle wood fires going, they kept us thoroughly amused. Their enthusiastic and energetic approach to life was enlightening and uplifting, although one could not help but wonder what the future held for them. All too suddenly it was time to leave the jungle, the boys and the other Dani tribesmen who had carried our gear, looked after us, educated us in jungle traditions and techniques. Leaving was not easy and I hope a return may be possible.

Shark!

We managed to hitch a ride out of the jungle on a single-engine cargo flight; the first of five flights back to the so called ‘civilisation’ of Bali which seemed to be populated by obese tattooed Westerners, partially covering their beer bellies or cellulite with ubiquitous Bingtang singlets.

We had a day to spare in Nabire before we could catch the second flight out and Coop had heard there was a chance to swim with Rhincodon typus or whale sharks. Whale sharks can grow up to 12m in length and we had been told there was a possibility we might be able to find some. After a minimalist diving lecture, without a single unnecessary phrase, we had an amazing day of snorkeling and diving. In the languid midday tropical sun our boat approached an Indonesian fishing vessel in flat calm seas. A fisherman was sitting on the deck trickling seawater over the edge and occasionally throwing whitebait into the sea. As we got closer it became apparent that he was hand feeding two 8-9m whale sharks. This was an incredible sight in an idyllic setting and after a while we were able to join them in the water.

Donning snorkel and masks we drifted closer to the sharks and held on to the boats anchor ropes that hummed in the gentle current. The mooring lines curved into a deep blue oblivion, whilst shoals of whitebait glinted in the shafts of diminishing sunlight. We were fortunate that Blandonn caught much of this expertly on film.

What an end to an incredible expedition.

The Team

Coop / The cool, calm and relaxed mountain guide from Bozeman, Montana.

Margaret / Super-organised, super-fit radiology resident from Phoenix, Arizona (AKA Pinky Boots)

Chris R / the quiet and understated Australian travel doctor from Perth Australia who seemed to know everything there was to know about tropical diseases.

Ben / the energetic and enthusiastic ER consultant from Baystate Medical Centre, Massachusetts with a wealth of wilderness experience.

Blandonn / The thoughtful bearded Texan medic who has practiced all over the world.

Chris I / Ebullient vascular surgeon ‘and all around bad ass’ from UK who loves being in the mountains with friends.

Thanks to Mike Cooperstein and Andes Mountain Guides for the inspiration and fantastic organisational skills, as well as Arland, Joy and the Indonesian crew.

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Charlotte describes her decision to take a year out of medical training after completing FY2, and the challenges and rewards of working in the surgical department of a rural Zambian hospital.

Pre-meditation

A senior colleague once told me “the NHS is a sausage factory; the ingredients go in and you work your way along the conveyor belt”. As the end of FY2 approached, I knew I just didn’t want to become a sausage.

I had known throughout medical school that I wanted to have a career in surgery, but I also knew that going directly through training in the shortest route possible wasn’t for me. Having taken a year out between school and university I had already developed a taste for adventure, for new experiences and for life abroad. Following this with an elective in Uganda I felt very strongly that Africa was a place where I would like to spend more time.

I was told by several consultants that this would be career suicide and that I would struggle to get a place on a training programme if I took time out – especially to travel. I sought a range of senior opinions, including some significantly more encouraging. It was with a certain satisfaction that I was able to sit back and watch my colleagues lose sleep over job applications while I set about making plans for my year away.

There seemed to be three main options that were being bandied about amongst the ‘year off-ers’: to go travelling and try to avoid work as much as possible, to find paid work in New Zealand or Australia or to volunteer in a resource-poor country. I was in a minority amongst my peers in thinking that the latter option was the most enticing.

With my Foundation Training behind me, I knew I had a good grounding in the basics of medicine and surgery, but felt aware that I was still very junior in my experience and skill set. This motivated me to prepare as best I could – first by studying for the Diploma in Tropical Medicine and Hygiene (DTMH) at the University of Liverpool, and then to take the time to find the right hospital where I could be of use, but also have appropriate senior support. The DTMH set the tone for the rest of the year in terms of the challenges I would face, and my enjoyment of them. I would highly recommend it to anyone interested in working in the tropics, regardless of speciality.

Through useful contacts I’d made during my Foundation jobs and post-diploma locum work, I secured a position as SHO in General Surgery and Orthopaedics at St. Francis’ Hospital in Zambia, where I would start after attending my interviews for Core Surgical Training.

To Zambia

The five months I spent at St Francis’ brought with them great happiness but also immense and sometimes heartbreaking challenges, complex decisions, ethical dilemmas, many frustrations and a very steep learning curve. I worked alongside Zambian juniors under the supervision of a Dutch surgical professor and a British consultant surgeon, staffing the junior on-call and routine rotas.

Managing sick patients with minimal resources required adaptability, the like of which is rarely demanded in our comparably resource-rich NHS. The psychological pressure created by the nature of the workload could have been overwhelming if it weren’t for the strong support network created by the staff of the hospital community, all of whom live within the hospital grounds. Having senior support was a ‘must have’ for me as I did not want to put myself in ethically dubious situations of operating literally and metaphorically outside of my capabilities.

Some of the challenges I faced included life-threatening osteomyelitis, enterocutaneous fistulae following delayed presentation with typhoid, domestic violence, a 62-person RTA (the kind of major trauma scenario that even ATLS doesn’t dream up), deaths from snake bites (no antivenom available in the country) and scores and scores of open fractures, life threatening burns and delayed-presentation malignancies.

Basing operative decisions on individual functional need was absolutely fundamental to treatment in Zambia – one patient came to see a visiting orthopaedic surgeon complaining of a fixed extension deformity of his left elbow. Following discussion it was agreed that he would have this corrected and fused at 90 degrees, generally considered a position of more useful function. The day of surgery arrived, and as the patient was being wheeled into theatre he suddenly exclaimed ‘Stop!’. He had realised that his job as a farmer demanded long hours using a hoe, in which his left arm was extended and his right flexed. If we fixed his left arm in flexion he would no longer manage to work. He left, delighted with the realisation that he already had the best configuration of elbows.

Reflections

I’m sure I have gained personally far more from my relatively short time working in Zambia than I was able to contribute. So much of what I learned can be applied to work and life in the UK. A particularly poignant learning point for me was not to lose sight of the patient as a whole –  in Zambia, ‘life over limb’ came into play on many occasions, and I was reminded of a saying of an orthopaedic consultant I’d worked with in the UK: ‘it’s no good having the best looking leg in the morgue’.

There were many moments of great satisfaction: seeing patients discharged home after months in hospital, the gratitude of pain relieved by incision and drainage of a chronic abscess, the relief of a limb saved when a patient had been told at another hospital that amputation was the only option.

I would encourage junior doctors considering taking time out before specialty training without hesitation. My application to UK Surgical Training was in no way hindered by my year abroad – if anything it was enhanced. My experiences in Zambia have featured heavily in every interview I have had since my return, (not always because I have brought it up!) and never has it been received negatively. The only downside of taking time out is that once you have tried it, you will want to do it again. For the moment I am happy at work in the UK, but I’m sure it won’t be long before I recognise that familiar feeling of itchy feet…

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In July and August 2014, Nick Haslam was one of three doctors who joined a British Exploring Society Expedition to Ladakh, India; a remote high altitude desert. Nearing the end of their expedition, Nick found himself in a diagnostic conundrum, looking after a 17 year old girl with atypical high altitude cerebral oedema (HACE).

Background

The expedition was nearing an end. The first four weeks had seen a constant flow of minor medical complaints but thankfully nothing serious had come our way. We had spent 25 days sleeping above 4850m and were now well acclimatised to the high altitude. Most had climbed to 5800m or higher without medical difficulties and our symptoms of acute mountain sickness, present earlier in the expedition, were but a faint memory.

There were 48 people taking part in the expedition. Fourteen were leaders with a body of expertise in glacial and mountainous travel. Almost all the leaders had previous high altitude experience. The expedition participants were between the ages of 16-22 and had limited travelling experience, though about a fifth had been up to high altitude before.

We set our base camp at the mouth of the Zara valley: a remote location accessible by off-road vehicle thirty minutes from the Leh-Manali “Highway” (in reality, another dirt road). The nearest public hospital was in Leh, five hours drive away over the Tanglang La Pass (5328m) – the second highest motorable pass in India. A military base in Leh could provide helicopter evacuation if aircraft were available but RIMO, our in country contact, estimated a 24 hour response time due to the bureaucracy.

The expedition was equipped with several EPIRBs, two 2-wheel drive vehicles at base camp, three cylinders of oxygen (2 x 680 litres, 1x 1880 litres), two Gamow bags and a significant quantity of medication and resuscitation equipment.

All expedition members were required to return a structured medical questionnaire signed by their GP prior to departure.

We first flew to Leh (3500m) from Delhi and rested there for two nights. We then began a steady ascent profile via road over a period of three nights (Camp 1 3800m, Camp 2 4100m, Camp 3 4350m) before arriving at base camp (4851m GPS – N33 26′ 36.0 E077 47′ 05.3.). At this point the expedition was divided into three equal groups. During the expedition each group made several 3-4 day excursions from base camp over a period of three weeks and most managed to climb to above 6000m.

The Case

SC was a 17 year old girl with no previous high altitude experience. Her only regular medication was the progesterone-only pill and she had no current medical problems. Past medical history included pneumonia as a neonate requiring ITU admission, a benign heart murmur and two episodes of probable reactive arthritis. SC was physically fit (a fell runner) and had no history of migraines. During the expedition SC had suffered from only mild symptoms of acute mountain sickness on arrival at base camp, and one brief episode of blurred vision.

Twenty-five days after reaching base camp (4581m) we made an attempt on our last summit of the expedition – a glaciated peak of approximately 5900m. Prior to this SC had spent two comfortable nights sleeping at 5400m and ascended to 5880m without difficulties. That morning, she ate a normal breakfast and reported that she had slept well, with no headache, dizziness, nausea or visual disturbance.

SC now takes up the story in this recording made four days after the evacuation:

Evacuation

Once off the glacier, we continued our evacuation on foot to a temporary camp at 5100m where oxygen was available. We got there at 7pm, at which point SC had improved considerably and was able to walk on her own with two poles. She received intermittent oxygen (4l/min) through the night that appeared to give her some symptomatic relief, alongside oral dexamethasone (4mg QDS) and simple analgesia. In general, her condition remained stable although she began to describe the headaches as explosive and mostly retro-orbital.

Measurement of SC’s oxygen saturations at all stages of the evacuation demonstrated readings above 90%. And whilst her respiratory rate was variable throughout the evacuation her lung fields were clear and there was no evidence to suggest that SC was suffering from High altitude pulmonary oedema (HAPE).

At 6am the next morning we continued our descent to base camp at 4900m (Fig. 4). At basecamp, SC’s ataxia became more prominent and we decided to evacuate with oxygen by road to Leh hospital via the Taglangla pass (5,328m) (Fig. 5 & 6).

After arrival in Leh (3500m) SC was treated with intermittent oxygen therapy, oral dexamethasone 8mg BD, regular analgesia and rest. Over the following four days SC’s fatigue, ataxia, appetite and working memory all improved to some extent. However, as this video from four days after the event demonstrates, her headache, dizziness, cerebellar signs and diplopia remained despite treatment:

Aftermath

On arrival at Heathrow, five days after the event, SC was still mildly ataxic, fatigued and complained of a constant headache and sensation of dizziness. She also had retrograde amnesia.

We arranged for her to be followed up in the UK by a consultant neurologist fourteen days after the original event. At that point, her neurological signs had resolved. Her bloods were normal apart from a mild neutrophilia and a raised ALT. An MRI head and venogram were also normal. However, her headache and dizziness persisted, particularly at night and her parents (both physicians) reported that SC was still not ready for school 23 days after the event. In fact, it took six months for the symptoms to fully resolve and now, nearly a year later, she remains well.

So Was It HACE?

Ataxia at altitude is HACE until proven otherwise (2) and this was certainly the rule we used to treat SC on the mountain. However, in other ways the case fails to fit the classical description of HACE. For example it has been suggested that:

“Onset of illness after 3 days at a stable altitude, abrupt onset, trauma, focal neurological signs, high fever, stiff neck, and lack of response to treatment should all mandate consideration of other diagnoses.”

Hackett & Roach (2)

SC fulfilled three of these criteria. Her illness began after considerably more than three days at a stable altitude. It came on abruptly and didn’t really respond to treatment.

It made me question the diagnosis. After all, the incidence of HACE is related to the rate of ascent and degree of acclimatisation (3). SCs ascent rate was extremely conservative in comparison to most trekkers and climbers. Our expedition had the luxury of time and wild camping. This makes HACE less likely, though there are several cases of sudden-onset HACE reported in climbers above 5000m (4), (5), so we can’t exclude it on that alone.

Some consider AMS and HACE to be a spectrum, with HACE as the end point of worsening AMS. Generally, most cases of HACE are preceded by 24-48 hours of progressive AMS symptoms (2). So, SC’s presentation wasn’t typical. Again though, a number of cases of potential HACE associated with an abrupt onset of ataxia in the absence of AMS symptoms have been reported (6). Of course whether these cases were due to the same underlying mechanism as classical HACE remains debatable.

“The usual course is rapid recovery if treatment is started at the first sign of HACE and slower recovery when treatment is delayed”

Hackett & Roach (2)

Rapid descent, oxygen and dexamethasone are the cardinal treatments for HACE (2). The time between disease onset and treatment is related to both the rate and success of recovery. SC was already descending when she first developed ataxia, the key symptom of HACE. Before this her symptoms were only really in keeping with moderate to severe AMS. Oral dexamethasone was given within hours if not minutes of her symptoms worsening. Oxygen at 4l/min was provided after descending 500m vertical meters and approximately 6-7 hours after diagnosis. However, despite prompt treatment SCs condition showed only brief episodes of moderate improvement in the first 24 hours. Indeed, by the second morning of the evacuation SC was considerably more ataxic and fatigued. This progressed despite descending to base camp and prompted further evacuation to Leh that day. Once in Leh, her recovery was slow and full recovery took six months.

We know from the literature of other cases similar to SC’s. Rightly or wrongly, these cases have been clinically diagnosed as atypical HACE and that is the only diagnosis we were left with for SC. She became ill at high altitude, had normal imaging in the UK and then a complete (albeit prolonged) recovery.

Is HACE Always Preventable?

SC’s case leaves me with the question – is HACE always preventable? Increasing travel to high altitude (9) makes this question ever more pertinent, especially for expedition medics on large, organised tours. Before I went to Ladakh, I was under the impression that we could mitigate the risk of HACE if we ascended appropriately and monitored one another judiciously. After all, this has been confidently stated in the literature:

“It (HACE) is 100% preventable if climbers ascend slowly and ‘‘listen to their bodies’’ and descend in the face of increasing symptoms of headache, nausea, and tiredness.”

Graham LE, Basnyat B (10)

However, I believe SC’s case forces us to reconsider. Maybe HACE is not always preventable? Indeed, some experts would agree:

“At extreme altitude, onset of HACE may be abrupt, and prevention is not always possible.”

Hackett & Roach (2)

Learning Points

I can only conclude that from a practical point of view it is always safer to ‘never say never’. In this vein, the following are three key points I learnt from SC’s case:

1 / HACE classically develops on a background of AMS, but it can also present acutely.

2 / When at very high altitude (>5000m) [?extreme] HACE can present in the well-acclimatised climber or trekker.

3 / Appreciate that it might not be preventable and can come on quickly. Vital facts for travellers, clinicians and our friends in the medico-legal fraternity.

Author’s Note

SC kindly provided written and verbal consent for all information, images and video presented in this report. Nick would like to thank all those on the BES expedition for their teamwork and support. Particular thanks to Dr William Davies, Dr Nicola Carroll, Soo Redshaw (Expedition Leader), Martin Stitt (Expedition Deputy Leader) and James Dyer (UK BES Operations Manager).

References

1 / Norboo T, Saiyed HN, Angchuk PT, Tsering P, Angchuk ST, Phuntsog ST, et al. Mini review of high altitude health problems in Ladakh. Biomed Pharmacother. 2004 May;58(4):220–5.

2 / Hackett PH, Roach RC. High Altitude Cerebral Edema. High Alt Med Biol. 2004 May;5(2):136–46.

3 / Zafren K. Prevention of high altitude illness. Travel Med Infect Dis. 2014 Feb;12(1):29–39.

4 / Clarke C. Neurology at high altitude. Pract Neurol. 2006 Jan 8;6(4):230–7.

5 / Thomassen O, Skaiaa SC. High-altitude cerebral edema with absence of headache. Wilderness Environ Med. 2007;18(1):45–7.

6 / Wu T, Ding S, Liu J, Jia J, Dai R, Liang B, et al. Ataxia: an early indicator in high altitude cerebral edema. High Alt Med Biol. 2006;7(4):275–80.

7 / Basnyat B, Wu T, Gertsch JH. Neurological Conditions at Altitude That Fall Outside the Usual Definition of Altitude Sickness. High Alt Med Biol. 2004 May;5(2):171–9.

8 / Firth PG, Bolay H. Transient High Altitude Neurological Dysfunction: An Origin in the Temporoparietal Cortex. High Alt Med Biol. 2004 Mar 1;5(1):71–5.

9 / Mieske K, Flaherty G, O’Brien T. Journeys to High Altitude—Risks and Recommendations for Travelers with Preexisting Medical Conditions. J Travel Med. 2010 Jan 1;17(1):48–62.

10 / Graham LE, Basnyat B. Cerebral edema in the Himalayas: too high, too fast! Wilderness Environ Med. 2001;12(1):62.

11 / Hackett PH, Rennie D, Levine HD. The incidence, importance, and prophylaxis of acute mountain sickness. Lancet Lond Engl. 1976 Nov 27;2(7996):1149–55.

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Zoe is an Emergency Medicine and PHEM trainee from Edinburgh, currently working in pre-hospital care in Cambridge. In 2014, she flew north to spend six weeks flying with the Norwegian Emergency Services.

Our Nordic neighbours

There are many similarities between Norway and Scotland in terms of health care provision. Patient populations, disease epidemiology and geographical challenges have much in common, so this experience was an excellent opportunity to compare Pre-hospital and Emergency Medicine systems. During my six week placement I was based in Oslo but also visited Norway’s most northerly and most isolated island of Svalbard.

Pre-hospital and Retrieval Services in Oslo

Due to their geography, the Norwegians have developed a national pre-hospital care service to cope with a population size equivalent to Scotland but spread over nearly five times the geographical area. They aim to ensure that 90% of the population can be reached by a pre-hospital physician within 45 minutes. Within the Oslo area there are two pre-hospital based centres, one at Ullevål Hospital, the other at Lørenscog air base. Ullevål is also the base for Oslo’s Dispatch Centre, the Physician-Based Ambulance Service, Ambulance Leder (Ambulance Commander), city ambulance station and additionally the pre-hospital research centre. Lørenscog is the base for the Norwegian Air Ambulance helicopter (complete with a rapid response vehicle) and fixed wing ambulance service.

The Intensive Care Road Ambulance is used for secondary transportation of paediatric and adult critical care patients. It also has a special airflow system, allowing the vehicle to transport patients involved in chemical/biological incidents (including potential Ebola cases). It even has the capabilities to drive into a Sea King helicopter to allow air transportation if the patient is too unwell to be moved out of the ambulance during transfer!

Oslo’s coastline is scattered with fjords and winding roads, consequently primary and secondary transfers sometimes require the assistance of the Fire Brigade’s boat for transportation. Additionally, some of Norway’s more remote military bases have a physician rapid response car funded by the government health board for civilian incidents.

Norway has a fantastic patient transport service. Several large hospital buses operate throughout the day transporting patients between hospital sites. These are staffed by paramedics or nurses and can take up to five bedbound patients and approximately 30 walking patients per bus – all taking the strain off the emergency ambulance service.

The Dispatch Centre (AMK)

The Dispatch Centre at Ullevål Hospital receives approximately 145,000 emergency ambulance calls, in addition to patient transport calls from Oslo and Akerhus, and co-ordinates the dispatch of Emergency Ambulances, the Norwegian Air Ambulance, Fixed Wing Helicopter and Physician Ambulances. Emergency Call Handlers (typically nurses) triage calls according to the Norwegian Index (a reference guide for call operatives) and paramedics working within the call centre use their local knowledge to identify and dispatch the nearest and most appropriate emergency response vehicle. The “AMK Leder” is in charge of the overall co-ordination of the dispatch centre and services during a major incident.

Physician Ambulance – Oslo

During my fellowship I spent two weeks working alongside the Physician Ambulance based at Ullevål Hospital. The Physician Ambulance is a 24/7 rapid response vehicle manned by an Anaesthetist (as Emergency Medicine is currently not a specialty in its own right in Norway) along with a paramedic trained in critical care. The Physician Ambulance typically responds to approximately five call-outs per day, attending to critically ill medical and trauma patients, and all out of hospital cardiac arrests. In addition, the doctorprovides telephone advice to the ambulance service, and authorises the use of drugs such as morphine for trainee paramedics.

I also spent a day shadowing the “Operativ Leder” (Ambulance Commander), who in addition to co-ordinating all ambulance staff in the Oslo area and at major incidents including road traffic incidents, house fires, stabbings/shootings and ‘one unders’ (people jumping under trains). Their role is diverse, even including providing medical/psychiatric support for ambulance staff and bystanders after traumatic events.

Norwegian Air Ambulance Helicopter and Fixed Wing Service

The national Norwegian Air Ambulance service started as a charity in the 1970s and is now government funded. There are two operators – Norsk Luftambulanse AS and Lufttransport AS. The Air Ambulances operate 12 helicopters in 11 different locations across Norway. There are also a further nine fixed wing planes (all Beechcraft King Air B200) at seven locations. The largest service is at Gardermoen, just outside Oslo, with two fixed wing planes. Approximately 20,000 patients are transported by the Norwegian Air Ambulance services, totalling 18,000 flight hours annually with all services operating 24 hours a day.

A HEMS crew consists of an experienced pilot, a HEMS crewmember (or “Rescueman”) and a HEMS doctor. At Lørsenskog there are two HEMS crews working at any one time. The Rescuemen have the coolest job in the world – they are highly skilled critical care paramedics or nurses who additionally act as winchmen in search and rescue missions, assist the pilot and sometimes even get to fly the helicopters!

The pilots also have some medical training, so can help assist for Rapid Sequence Intubations, draw up medical drugs and fluids, and cannulate patients. Doctors are required to have two years’ pre-hospital experience (mostly through working with the Physician Ambulance Service) and complete aviation and helicopter safety training. They are usually consultant anaesthetists. The HEMS crew live on the base during their shifts as the shift pattern is pretty long and intense; the pilot and Rescuemen work a full week, with doctors typically working 48 or 72 hour shifts, with mandatory nine hour rest periods per 24 hours for all crew members.

The Fixed Wing Ambulance Service is primarily used for critical care (including neonatal) transfers (typically from small district general ITUs to the tertiary centres in Oslo). Each plane can transport two patients on stretchers. Within the more isolated areas of Norway, the fixed wing services are occasionally used for primary missions. Each plane is staffed by two pilots and an experienced ITU nurse (and occasionally an anaesthetist depending on the patient’s clinical condition). The service also uses the critical care road ambulance for shorter road transfers.

Legevakten and Hospital-Based Systems

Oslo’s Legevakten

In Norway, patients are can only attend hospital (including the Emergency Department) if they have been referred by a GP, by Legevakt or by the Pre-hospital Physician or Ambulance Services. The Legevakten is essentially a GP out-of-hours and emergency walk-in service. Patients are also taken to the Legevakten by ambulance if they are thought not to require direct admission to hospital (e.g. non-specific chest pain, allergic reaction, alcohol or drug intoxication). All patients attending the Legevakten have to pay a small fee of approximately 100-130 Kr per visit (around £10-13), or 250Kr (£25) at night, (which is similar to the fee Norwegians pay to see a GP or outpatient hospital specialist).

Oslo’s Legevakten receives approximately 90,000 patients per year, caring for approximately 300-350 per day through their GP service and small bedded unit. Doctors working within the bedded area in Oslo’s Legevakten (known as the Emergency Ward) are typically GP or general medical trainees, with the medical shift leader requiring at least 2 years experience of working in the Legevakt. Unlike other Legevakts, there are additional services including paediatrics, a consultant-led psychiatry service, a Minor Injuries Unit, an intoxication bed (allowing monitoring of drug/alcohol intoxications for 4 hours) and a 13-bed Clinical Decision Unit. The Legevakten also runs its own call-centre receiving approximately 30,000 non-urgent medical calls per year, providing advice and redirecting patients to either appropriate community-based services or direct referral to a hospital specialist. A twenty-four hour social work service is also provided, and is able to arrange emergency support/housing for patients even during the night. Approximately 20% of all patients seen at the Legevakten require referral and transfer to hospital.

Rickshospitalet and Ullevål

Within Oslo there are two main hospitals, Ullevål and Rickshospitalet. Ullevål University Hospital is the largest hospital in Scandinavia and Oslo’s Major Trauma Centre, receiving 1.2 million patients per year. Rickshospitalet is more like a tertiary specialist centre, receiving referrals from all over Norway.

Although both hospitals have an Emergency Department, there is currently no Emergency Medicine specialty within Norway (although this is something they are considering adopting). Currently Emergency Departments operate more like an acute admission unit with anaesthetics input for standby calls or critically unwell patients. All patients attending the hospital Emergency Department have to be referred directly to a specialist either by GP, the Legevakten or by the Pre-Hospital Ambulance or Physician Services. Although this potentially reduces time to specialist input, this can also have a negative impact on the patient if they are referred to the incorrect speciality due to the difficulty of quick decision making.

Ullevål hospital receives all major trauma from around the Oslo area. Patients arriving by helicopter land on the roof of the car park and are transported directly by a lift to the ED resuscitation rooms. Additionally, patients arriving by ambulance reach the ED through doors immediately outside the resuscitation rooms. The trauma resuscitation room is situated in close proximity to a CT scanner and an interventional radiology suite on the other, allowing critically ill patients to literally be wheeled next door for imaging or interventional radiology. Pre-hospital teams can mobilise either a small trauma team (consisting of a surgical team and anaesthetic SpRs, radiographers and phlebotomists), or large trauma team (with additional consultant input) depending on the patient’s clinical status. All patients receive x-rays with FAST scan during the primary survey prior to a decision being made regarding further imaging, interventional radiology or transfer to theatre.

Rural services – Svalbard

In addition to working within Oslo, I was interested to find out more about the provision of Pre-hospital and Emergency Medicine services in more remote areas of Norway, so I travelled north to Norway’s most remote island, Svalbard. Svalbard is approximately 1,318km from the North Pole, and has a population of approximately 2,600 inhabitants, 2,800 snowmobiles and 3,000 polar bears! The majority of Svalbard remains unpopulated, with the bulk of the population living in and around Longyearbyen (Svalbard’s main “town”) and Barentsburg (a Russian settlement inhabited entirely by Russian miners and their families). As the only roads on the island are in Longyearbyen and Barentsburg, helicopters (or skimobiles) are required to reach critically ill patients.

Svalbard has 2 Super Puma rescue helicopters based at Longyearbyen airport, with 2 crews being on-call at a time. Each helicopter crew consists of 2 pilots, a winchman, assistant winchman and a “rescueman” (HEMS crewman). There are no physicians based on the HEMS crew but the rescueman can request a doctor or nurse from the hospital if required. The rescue crew attend approximately 70-80 primary missions/year, mostly around Svalbard but occasionally provide medical support to ships, and even Greenland. Although medical missions are more common (e.g. cardiac arrest, myocardial infarctions and collapse), crews are often mobilised to trauma patients (including mountain and walking accidents, mining incidents and even polar bear attacks).

All medical emergency telephone calls in Svalbard are received directly by Longyearbyen Hospital. The nurse in charge of the hospital would contact the rescue helicopter, and in addition dispatch a doctor and/or nurse to the airport if required. However, before the helicopter can fly on a rescue mission, they have to contact the Sysselmannen (the Governor of Svalbard) for permission. After the patient is rescued, the helicopter returns to base at the airport, and is met by the one (and only) ambulance on Svalbard (driven by a volunteer fireman), and taken to the hospital in Longyearbyen (figure 7).

The hospital in Longyearbyen is the only medical facility on Svalbard (excluding the Russian hospital at Barentsburg which only provides medical care for the inhabitants of the Russian settlement). The hospital has a GP service, 5 hospital beds (including one “isolation” room), a one bedded Emergency Room, x-ray machine (but no CT), and an operating theatre, in addition to dental, physiotherapy, occupational health, district nurse and midwifery services. The Emergency Room, (set up like a resuscitation room), has a telemetry service to Tromsø University Hospital. X-rays are taken by the nursing staff and formally reported by a radiologist in Tromsø. The operating room is typically used for minor operations and previously has been used for ‘damage-control’ surgery in major trauma. As there are no anaesthetists on the island, anaesthetic nurses deliver the anaesthetic during the operation. The majority of patients are transported off the island (via the fixed wing ambulance from Tromsø) for medical treatment. However the hospital can admit typically well, ambulatory patients, (e.g. those requiring iv antibiotics, patients with fractures awaiting transport for surgical intervention on the mainland) and occasionally those requiring end-of-life palliation. The hospital employs a total of three doctors (2 GPs and 1 surgeon), 3 nurses and 2 anaesthetic nurses, with typically one doctor and 1-2 nurses covering each shift.

The Robin Mitchell Fellowship

I has this fantastic opportunity thanks to receiving the Robin Mitchell Travel Fellowship.

The Robin Mitchell Fellowship was set up to commemorate Dr Robin Gordon Mitchell, an Emergency Medicine Consultant who studied and trained in Edinburgh. He developed the first high fidelity simulator based course in Scotland and became the Training Programme Director and Regional Specialty Advisor for the South East Scotland Emergency Medicine training scheme. After working as an Emergency Medicine Consultant in Edinburgh, he made the move to Auckland City Hospital in New Zealand working alongside the Auckland Rescue Helicopter in providing training and clinical support to the paramedics, and constructing the educational framework for a retrieval programme. He was also appointed as Director of Emergency Medicine Training. Sadly, he died in 2010 from pancreatic cancer, and the Robin Mitchell Travel Fellowship was set up by his family to commemorate him. The Robin Mitchell Travel Fellowship is open to all Scottish Emergency Medicine trainees, allowing them to pursue a 4-6 week placement away from their base hospital, within the setting of Emergency Medicine or another associated clinical specialty to enhance their clinical experience and expertise.

Reflections

Comparing the Norwegian and UK Emergency Department systems has reinforced to me the important role Emergency Medicine doctors play in the management of acutely unwell patients. Doing EM training allows you to be open-minded to a number of possible differential diagnoses (both surgical and medical), whereas when patients are directly referred to a specialty team, it can sometimes take longer for the patient to end up in the correct place. Additionally, I think Emergency Medicine doctors have valuable skills in targeting appropriate investigation and triaging whether patients need to be admitted or discharged with appropriate follow-up. In the resuscitation room (particularly the medical resuscitations), I sometimes found it far more chaotic, and on occasion there appeared to be limited cohesion between the Physicians, Surgeons, Anaesthetists, and Nursing staff. Additionally, the specialists sometimes appeared more keen to make the diagnosis than managing the initial patient resuscitation.

Despite this, there are certain advantages for increasing the availability of direct referral to a specialist from the pre-hospital environment. There are a few situations which seemed to work particularly well. These included patients with ROSC (return of spontaneous circulation) following out of hospital cardiac arrest being transported directly to primary PCI and potential stroke thrombolysis patients being transferred directly to CT and being met by a Neurologist at the scanner. Additionally, early surgical input during trauma calls could additionally be beneficial for the patient in reducing time to theatre or definitive care.

This fellowship has been an absolutely fantastic opportunity for me to develop my interest and experience in Pre-hospital Emergency Medicine. Gaining insight into different Pre-hospital and Emergency Medicine systems has also enabled me to think more about our systems within Scotland and potential areas which we can develop to improve the service we provide our patients.

Special thanks and contributions

I would especially like to thank Robin Mitchell’s family, the Robin Mitchell Travel Fellowship committee and the Medic 1 Trust Fund for funding my travel fellowship, in addition to my supervisors Dr Dave Caesar and Dr Richard Lyon in Edinburgh, and Dr Theresa Olasveengen in Oslo. Additionally thanks to the staff at Oslo’s Dispatch centre, Physician Ambulance and Air Ambulance helicopter and fixed wing services and Oslo’s Legevakten, Riskshospitalet and Ullevål hospital who were all extremely helpful and made me feel so welcome.

References

1 About the National Air Ambulance Services of Norway. www.luftambulanse.no/printpdf/209
2 Ulleval University Hospital website http://www.oslo-universitetssykehus.no/om-oss/english.

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Operation Wallacea is one of the most popular first trips for expedition medics. James Coates talks about his first Opwall expedition to Honduras, where he was able to indulge his passion for photography whilst serving as medic for a big group in the stunning surroundings of Cusuco National Park. He also gives some great tips for those setting out on their first expeditions, as well as information on how you can get involved. We think you’ll agree – his wildlife pictures are stunning.

At the beginning of my F2 year I realised I had to get off the career conveyor belt for a year. It did not take me long to come across a plan which would fulfill several of my passions. Since childhood I have always been interested in wildlife; turning over rocks looking for creepy crawlies and reading nature books at bedtime. Then during my final year at medical school I had bought my first SLR camera and began to love photography. I wanted to go on an expedition that would allow me to see wildlife and take photos whilst doing some expedition medicine. I began trawling the internet looking for opportunities. I mulled over several different companies but one stood out head and shoulders above the rest, Operation Wallacea or Opwall.

Opwall is named after the Wallacea region in Indonesia where the organisation first started doing their research. The region in turn was named after the famous British naturalist, Alfred Russel Wallace. Operation Wallacea is a charitable organisation that takes a range of school and university students out to remote locations to perform biodiversity conservation management research in the field. This has the dual purpose of raising awareness and funding for areas where nature may be threatened, as well as providing academic opportunities for PhD or BSc dissertations. Whilst Opwall may have started with expeditions to Indonesia they have now greatly increased their repertoire and in 2015 they will be running projects in 15 countries. These projects take place in wide and varied environments, from tropical dive sites, to boat-based projects in the Amazon, to rainforests.

Cusuco National Park

I decided on an eight-week stint in the cloud-forests of the Cusuco National Park in Honduras. I had done a total of nine months A&E (divided between an F2 job and time in New Zealand), as well as an expedition medicine course, but I was still anxious about what I would be faced with. Opwall helped to alleviate this by having a pre-trip medical meeting where comprehensive risk assessments, kit lists and evacuation protocols were discussed. I was also given a list of staff and volunteers with their medical histories so I knew what to expect.

It was whilst I was sat on the back of the pick-up truck, bumping around, as we drove up into the national park that it began to dawn on me the full extent of what I was undertaking. I was going to be looking after up to 50-80 people, with my medical kit and my clinical skills and a four hour transfer to the nearest hospital. If someone was really sick or had been bitten by a snake then we would have to call in the Black Hawk helicopter from the local US Air Force base for a med-evac! Instead of jumping off the truck and running down the hill I rationalised it to myself; I just had to know what I could not deal with in camp, what I could not diagnose, what I could not treat – those patients would need to go to the hospital.

Prevention is better than cure

The medicine I practiced for those eight weeks was not what I had expected. The time on the plane reading and re-reading the section in the Oxford Handbook of Expedition Medicine on tropical illnesses and snakebites fortunately did not come in use – except to scare people about what could go wrong. Like medicine at home prevention is better than cure applied in the jungle, possibly more so. I would take part in the health and safety briefing: I was like a broken record when it came to hand washing, drinking fluids, washing up plates and using insect repellent and sun block. I was very good at dishing out rehydration salts, cleaning up cuts and grazes, dealing with vomit and being a shoulder to cry on. There were many people, especially amongst the staff members who were there for a longer period, who suffered with homesickness.

I was very lucky; there were no medical emergencies, no snakebites and no helicopter trips. The worst I had to deal with was a girl who cut her knee open, she had to go to hospital because she needed an x-ray for foreign bodies and sterile closure. Another case stands out in my mind due to the difficulties that I faced trying to make a diagnosis over a two-way radio, taking a history from a group of people in another camp. One of the university students had a rash, a headache and felt generally unwell – in my mind’s eye I had images of a seriously ill young girl with a purpuric rash and meningococcal septicaemia. It turned out that the camp just had a severe case of bed bugs. Sleeping bag-boiling and antihistamines were what the doctor ordered, not a Black Hawk helicopter evacuation.

The photography

With a short daily clinic and the odd medical discussion I was left with a lot of free time, and this meant I could get out there to indulge my real reason for being in Honduras – exploring and photographing nature! Each day I could go out walking with the teams of scientists looking for birds or reptiles or insects or mammals. Physically it was tough, lots of hills – and I think I lost a stone over the eight weeks due to all the trekking – but it was worth it. I saw such a varied amount of wildlife and was around such inspirational people that I was half tempted to ditch hospital medicine and take up a career as a full time expedition medic!

Preparing for expeditions: What I wish I had known

When reflecting back on my experiences during that expedition (as we doctors are frequently encouraged to do) there are things that I wish I had known and that I would advise people to think about, that would help in managing the commonest complaints

Physio / Spend a session with a physiotherapist on managing soft tissue injuries, especially rehabilitation exercises and strapping.

Wounds / Having a good understanding of managing minor wounds and understanding the choices of dressings.

Dentistry / Knowing the basics of expedition dentistry – although not a problem I encountered I realised it was probably more likely than snakebites. Adventure Medic has published a series of guides which are invaluable.

Common Ailments / Rather than worrying about the tropical rarities be confident in treating and diagnosing the common conditions e.g. skin infections, gastroenteritis, allergic reactions and insect bites.

Finally, I think the most important thing I could say would be to have a good understanding of your limitations and the medical kit you have to work with.

Further adventures and jungle training

I enjoyed my time with Opwall so much so that I had to go away with them again. Subsequently I have been privileged to be the medic on trips to Madagascar and Mexico, which allowed me to see even more different types of wildlife and take thousands more photos. I have had the opportunity to see wildlife that many may not see in a whole lifetime whilst acting under the guise of an expedition medic. So if you are looking for an opportunity to go on an expedition where your focus would be the expedition itself and the wildlife, whilst providing medical back-up, Opwall may be up your street.

Opwall have now set up a four week Expedition Medicine Experiential Course set in the cloud forest of Honduras. This includes jungle training, a course on forest ecology as well as a training course in expedition medicine concluding with working as a camp medic in a supervised role. Alternatively the charity does run specific medical elective placements.

About Operation Wallacea

Operation Wallacea accepts / Junior doctors beyond F2, ideally with experience of A&E; Nurses or nurse practitioners in primary care or A&E; Paramedics; Medical elective students.

You can expect to manage / Diarrhoeal illnesses; insect bites; dehydration; skin infections; minor psychiatric illness; minor injuries and (rarely) management of snake bites.

Season / The Opwall season ties in with school and university holidays, running through June and July.

Language / As the medical work is mainly with the volunteers and staff members you are not required to know the local language of the area you are visiting.

For further information please see the Operation Wallacea website or contact Caroline Acton who organises the medical staff for the expeditions on caroline.acton@opwall.com.

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Simon Greenfield is an Emergency Care Practitioner with the West Midlands Ambulance Service Hazardous Area Response Team. He joined Humanity First Medical in 2010 after seeing their report on the Haiti earthquake. Despite a young family and an impending wedding, Simon deployed to Gorkha with Humanity First Medical in response to the April earthquakes in Nepal this year. His story encompasses the highs, lows and administrative frustrations common to humanitarian work. In a short deployment, his team of twelve treated over one thousand people.

Within a few short minutes of the Nepal earthquake on 25 April this year, the Global Disaster Alert and Coordination System (GDACS) issued a ‘Red’ alert meaning that due to the depth, magnitude and vulnerability of the population, the likelihood of a high humanitarian impact was high. Reports soon came in of heavy damage to roads and buildings and multiple casualties, particularly in the rural areas but also in the capital. The Nepalese government put in a call for international assistance, as it quickly became apparent that hospitals were struggling to cope and with the multitude of aftershocks, as well as the damage to the roads delaying search and rescue operations.

The Call

On that sunny Saturday morning, I was packing and moving boxes with my fiancée Lucy, in the process of moving to our new home that weekend. Late morning, I received a phone call from a colleague from Humanity First (HF), an international NGO, telling me that international assistance had been requested for Nepal and that HF were in the assessment stage of putting a medical team together for deployment.

Lucy was within earshot of the conversation and obviously knew what was being said. I put the phone down, briefly told her what had happened, and without any hesitation she simply said to me “go”. Within a few minutes, an official HF email had been sent out asking for availability from its personnel to be a part of a team to deploy at short notice. A few frantic emails and phone calls were sent and within an hour, I had been granted permission to take leave from work at short notice. I replied to the email as being available.

The next few hours were spent packing, moving and cleaning the old house, interspersed with nervous conversation (mainly on my part) about going out to a disaster zone. I kept looking at the news and checking for updates on my phone; casualties started low then as the hours ticked by the numbers of those injured or killed grew constantly. By late afternoon the death toll was reported to be about 4000. In my mind I knew that HF would send a team, and in the late evening an email confirmed that we would deploy.

I have been in the ambulance service for over nineteen years and have been involved in humanitarian work in one form or another for well over a decade in countries such as Sierra Leone, Chad and Mozambique. But this was the first time that I had been to a disaster. My thoughts and emotions mixed excitement with fear and anxiety. We would be going into the unknown, with the risks of further aftershocks, landslides, dealing with human suffering at its worst and the fact that we could become casualties ourselves ever present. Would I cope? How would I feel once there? Would I be able to offer some support, comfort and care to those that needed it?

The next couple of days were spent sorting the new house, building furniture, packing for my trip and trying to spend what quality time I could with my family before travelling to London on the Tuesday morning, ready to fly out from Heathrow that evening. Lots of hugs and cuddles were given to Lucy and my seven-month-old son. I played Star Wars with my older stepson, explaining to him what I was going to do and showing him on a globe where I was going.

I truly realised the support that I had from my family the afternoon before I left. After school, my own Jedi Knight said proudly that he had told all of his school friends that I was going to “go and save some lives”. The support from my family, friends and colleagues was astounding.

Deployment

Tuesday afternoon was spent at the Humanity First HQ in London. All the team got together, equipment sorted and we held a full briefing. There were twelve of us, including surgeons, a GP, A&E consultant, paramedics, a firefighter, pharmacist and a logistics support member. We set off to Heathrow, our spirits high and hopeful that we would be able to do some good when we arrived.

Twelve hours later, we were in Kathmandu and registered with the government as a UK Foreign Medical Team (FMT). We were given accommodation on the outskirts of the city, a local family providing us with a roof over our heads while we checked equipment and gained as much information as possible about the country, infrastructure and casualties.

It’s important to note that in a disaster a foreign team can’t just turn up. The affected country has to first ask for help. Once there, the FMT can’t just pick where they want to go, go there and get on with the job. Much time was spent form filling, registering with the Health Ministry and attending meetings hosted by various United Nations departments and the World Health Organisation.

A walk around Kathmandu was eye opening. The city is full of history and culture but the forces of nature had shown no mercy. The earthquake did not discriminate. Ancient temples and modern buildings were destroyed, people were sleeping in open spaces, scared of going inside in case there were further aftershocks and buildings were cordoned off in case of further collapse. The smell of funeral pyres filled the air, following the mass cremations of those killed. Yet everyday life went on. People going about their business in the markets, the constant sound of vehicle horns and the chaos of traffic that you would encounter in any city the world over. All of this was mixed in with groups of police and soldiers searching buildings and clearing debris, dust filling the air. The experience was sobering.

Gorkha

Within a couple of days we were on a hired bus, the roof laden with our medical kit, tents and supplies, heading into the province of Gorkha at the request of the Health Ministry, close to the epicentre.

After a few hours travelling along winding roads, we reached the town of Gorkha and the local hospital. A Swiss Red Cross team were already there working closely with the staff. The hospital was well maintained, staffed and seeing a steady flow of patients. All appeared to be in good order. After a few discussions it was decided to carry on deeper into the province, higher into the mountains to a village called Badasse.

We had no idea what we would find. Reports stated that there was significant damage, that a high number of casualties were likely and that so far, no medical teams had yet reached the area. It was definitely the place to get to, but getting there was the issue. There was no tarmac beyond Gorkha. We were faced with dirt track roads barely wide enough for a single vehicle, rutted, rocky and crumbling. The only way to get there was by a mountain bus in a treacherous three hour journey. The hazards to the team were high, from aftershocks and landslides to the poor state of the vehicles. We felt the benefits outweighed the risks. We were there to do a job and we intended to get on with it.

Batase

A few hours later we arrived at Batase, after a bumpy, nerve wracking but scenic ride through the hills of Nepal. Some villagers and a small unit from the Nepalese army who were helping to clear the crumbled buildings met us. The school had been damaged and many of the houses had been destroyed. We were told that the injured had been treated locally or taken by their families to the hospital in Gorkha. However, it was possible that there was a need for medical assistance in the area. The sun was setting, so we decided to camp for the night and prepare a medical centre the next morning. It was hard to assess the level of need, but we intended to stay and offer assistance to those who needed or wanted it.

It turned out that word had spread. Early the next morning, we were met by a small group of villagers requiring medical assistance. The group steadily grew, until it became apparent that we would be doing what we came to do. We built our medical centre with tarpaulins, para-cord and bamboo sticks with the help of the locals and the army and by lunchtime, over one hundred people with a whole host of injuries and illnesses were waiting patiently to be seen – young babies and the elderly, mobile and infirm, male and female.

Our makeshift medical centre had a reception and seating area, triage and basic assessment, pharmacy, consultation and majors’ area with full resuscitation facilities. On that hillside deep in Nepal, we were able to provide an A&E department with the full scope of medical care to people who had been subjected to one of the Earth’s most powerful and destructive events.

By the end of that first day there was a quiet sense of achievement and comfort knowing that we had given help, support and treatment to well over one hundred people. The spectacular lightning storm that evening with a similarly striking sunset was surreal; in one direction the setting sun casting a warm glow over the terraces of the hills, in the other direction a partially collapsed school and homes flattened. There was frustration. Some of the patients told us that medical aid was still needed further on. Nearly a week after the earthquake there were still villages that hadn’t received any help, medical or otherwise.

The problem was getting to them. The roads were treacherous at best. The aftershocks were frequent and at times gut wrenching in their intensity. We felt one aftershock that caused a landslide in the next valley, sweeping three buses off the road. Helicopters were the only other real option but they were caught up with red tape. Our contacts in the cluster meetings in Kathmandu begged for the use of a helicopter and we even marked out a landing pad in the hope that sometime soon our request might be granted.

Hard work

The next few days were physically and mentally challenging. Still, ninety-degree heat, humidity, a hole in the ground as a toilet, dodgy bellies and a tap to wash under were minor discomforts compared to what the Nepalese had been through. By then, we had provided care to over a thousand people on that hillside, so we didn’t mind the discomforts.

Many patients presented with respiratory or mental health problems. They were scared about further quakes and many didn’t know what had happened to their families. There was trauma, infected wounds and dental issues. Whatever the injury or illness, concern or anxiety, we did all that we could to assist – from IV fluids to pain relief to simply holding a hand – we tried to give what was needed. The strength and resilience of the people was humbling. They walked through the mountains overnight for many miles, were carried on others’ backs or on makeshift stretchers to reach us. No one complained. No one pushed or shoved. They waited patiently to be seen and gave their thanks when they left.

Day Five

On our fifth day at the village, despite repeated requests for the use of a helicopter, we were told that it would be best to return to Kathmandu and hopefully catch a helicopter there. We set off as a team of four early the next day on a six-hour bus journey back to the capital, leaving the rest of the team to carry on with the work in the mountain. The plan for us was to get a helicopter to Lapu and carry out an assessment of the area, looking at food and shelter as well as medical need.

The journey back was cramped and hot on a public bus; people standing and clinging on to the roof. It was a true adventure, taking in the sites and imagining what it would be like to explore this stunning country.

We spent the following day at the cluster meetings trying to get a helicopter. However it soon became apparent that there would be no helicopter. The initial response phase seemed to be coming to an end. The concern of the UN and government was that in a few short weeks the monsoon season would have started. Food and shelter was gradually becoming the priority with medical aid taking a backseat. We trekked back to the house where we were staying to meet the rest of the team, after they had spent the day treating even more patients.

Home

The flight home was tinged with mixed emotions of sadness at leaving, not knowing what was going to happen to the people we had met, and the happiness at seeing our families. We had seen devastation and heartbreak. The elderly man who had walked through the night, bent double with age, using a walking stick, sent to get to us just to hear someone say you’ll be ok. The toddler with fear in his eyes. The snoring in our communal tent and endless mickey-taking. The images of the crashed buses and lorries on the mountain sides. The thoughts of going into the unknown and apprehension at the start of the trip from that first phone call. But, we had done it. We had given some support, comfort and care. A group of strangers with a common goal going out to help complete strangers.

Why did I do it? We are lucky in this country. We have the resources, knowledge and expertise. We have a health and welfare system. We have a special number that anyone can call at any time in times of distress in the knowledge that someone will come to help. And we have our families who support us on every step when we go into the unknown. Our families who will always have that help and support when needed. Many countries, for reasons of politics, economy or geography are not so lucky. Would I do it again? Try and stop me.

For more information, please see the Humanity First website, or contact simon directly at simon.greenfield@uk.humanityfirst.org.

The post Humanity First in Nepal appeared first on Adventure Medic.

Following the desperately sad and high-profile deaths of Dean Potter and Graham Hunt in May this year, BASE jumping once again hit the headlines. Polarising opinion across the world of extreme sports, it’s never been without its controversies and tragedies. The BASE jumping community is tight-knit, and one which would, by its own admission, balk at recommending its own sport to anyone. The road to jumping is neither quick nor easy, and here BASE #1863, a Trauma Fellow in Scotland, gives us some poignant insight into what it’s like for those who make the choice to jump.

If your friends jumped off a bridge…

On a sunny, blue-sky day in September of 2014 I sat alone with a pen and paper on a quiet street in a small town in Idaho. I slowly and carefully wrote my letters, one to my fiancée and one to my parents and, on finishing, I sealed and addressed them before handing them to a man I had only met the day before. In those letters I told my loved ones that I had been killed. I told them how much I loved them, how much I wanted them to be happy and to move on with their lives, how I had died doing something that brought joy to my life and how only I could be blamed for what had happened. I wrote those letters with tears in my eyes knowing they would be delivered upon my death and it remains one of the hardest things I have ever had to do.

On that day I started along the path to becoming a BASE jumper. BASE is an acronym (Building, Antenna, Span and Earth) which describes the four broad groups of objects which participants jump from with a single parachute to save them. There is no back up parachute and even if there were, there wouldn’t be time to use it before impact. As a result BASE is known as the most dangerous sport in the world. In one study, a fatality rate of 1 in 2,317 jumps was recorded at a popular jumping location in Norway. To put this into perspective, the fatality rate for skydiving Is closer to 1 in 300,000 jumps.

I’m not entirely sure why I was so drawn to BASE in the face of these facts but fortunately, or unfortunately depending on your outlook, I couldn’t resist it. I had read around various internet forums, met up with a local BASE jumper to discuss all involved, and ultimately packed my bags and flew to the US for three weeks of BASE instruction.

The day after writing my letters I stepped into the harness of my self-packed parachute and walked out on to the 486 foot Perrine bridge along with six or so other beginners. As we reached the midpoint over the lazy Snake River below we paired off and gave each other a final check. There was nervous joking and laughter punctuated by the passing cars honking their horns or, less generously, shouting to us that we were idiots and were all going to die. The moment finally came and I climbed over the railing to face out over the river. It’s a strange sensation as you cross that line and put yourself right on the edge. There’s a sense of settling your mind, accepting what is about to happen, and letting the calmness flow through you if you can. As I reached that state I stood up tall, looked forward as confidently as I could and jumped away from those new-found friends.

Over the last year, I have experienced that incredible sensation over and over again. The initial fear and nervousness gives way to calm acceptance and ultimately the exhilaration of the jump itself. As I leave the edge everything is still and quiet but this soon gives way to the building rush of air streaming past your accelerating body. I reach back to the small parachute stored just behind my right hip and grip tight knowing I have only one chance to throw it properly. This small pilot chute, as it’s known, acts as an anchor in the air to pull the pins on the container holding the large parachute which will save me. A hard throw of the pilot chute out to my side and my fate is sealed. The bridle linking it to the container seems to trail out to eternity and time slows down. There’s a moment of curiosity as to whether the parachute will ever open, and finally, when I’ve almost convinced myself that I’m going to impact, there’s a sudden catch as I’m lifted upright and begin to fly. I can’t imagine anything will ever exceed the rush of that moment.

In the months after that first jump I became a true BASE jumper, having collected a jump from at least one of each of the four objects.

The flying doctor

All of those on that first course did indeed survive their jumps. There were however a number of injuries during those first few weeks; fortunately mine extended only as far as a meniscal tear from a botched landing. On my first day in Idaho before I had even started my course I was handed a trauma bag bought from an army surplus store and asked, as the only person with medical knowledge, to play the role of first aider for two new jumpers. These two members of the Indian Special Forces still managed to look incredibly, and understandably, nervous as they were about to complete their first jumps from a 300 foot cliff. It was a little nerve wracking for me too, standing at the bottom of a rocky talus stretching out from the cliff, waiting for the pair to jump. The first jumper exited cleanly and symmetrically with a nice straight and level parachute above his head, allowing me to relax momentarily while he gently flew down to the small landing area we had chosen. His colleague however worried me much more by landing with a leg on either side of a barbed wire fence. Fortunately no sensitive areas were harmed in the process and I didn’t have to become overly familiar with these new acquaintances.

Further into my course a good friend turned his parachute sharply close to the ground causing him to swing out to the right and land at high speed on his left side. I watched this happen from the footpath on the bridge above and there was little doubt that it was a hard enough hit to do some real damage. I rushed over to my mentor, ahead of the queue of waiting jumpers, and offered to jump down and check him out. I had hurriedly thrown on my rig and was about to climb over the railing when he pointed out that I had incorrectly tightened the gear – a thoroughly good reminder to take a breath and gather yourself before approaching a medical emergency. As my friend lay still on the ground below I finally righted myself and jumped from the bridge. A quick flight later and I was standing beside him, 500 feet below the others, where he was talking and joking but obviously in a good deal of pain. He was lucky, and in the end had only sustained a few broken ribs. Not so luckily for him he fainted while I checked him out, instantly losing all street cred. Many a joke was made at his expense for weeks after.

Impact, preparation and decision-making

There is no mollycoddling in BASE. Your decisions and the consequences arising from them are entirely your own and I love that. Nothing is handed to you on a plate and the feeling of accomplishment is directly proportional to this. The hours of planning, preparing and climbing soon stack up, but for that brief rush it’s all worthwhile. You have put yourself to the test, beaten back the fear, and survived to jump another day.

I’ve met some incredible people throughout my beginnings in BASE. It’s a close-knit family, a group of people who share knowledge of something that very few others will ever know. They come from all backgrounds, from high-flying professionals to blue collar workers, but all share a level playing field. In the end they are all the kind of idiots whose idea of fun is jumping off high things – those are the kind of people who will help you build a lifetime of weird and wonderful adventures.

If, after reading all of this, you decide that you too want to become a BASE jumper my advice, in order of importance, is as follows:

1 / If you can live happily without doing it then don’t do it. It’s selfish and stupid. You are impacting upon everyone you love by participating in this sport. I put my loved ones through hell every time I go jumping and my fiancée cried reading the first paragraph of this article alone. I regularly question my motivations for doing this and whether I should simply stop.

2 / If you must do it then prepare properly. Learn to skydive and get good at flying a parachute. Don’t rush this step. The ability to accurately and safely pilot your parachute can and will save your life. This is going to take a lot of skydiving, so enjoy that sport and see if you can be happy with it alone and avoid BASE altogether. The kind of person that will survive in this world is the one who takes pleasure in being knowledgeable and meticulous in their preparation. Aspire to be that person.

3 / If you still can’t get rid of the BASE itch after your hundreds of skydives make sure to speak to experienced BASE jumpers to get their advice on how to proceed. Heed their advice and be patient. You really know nothing. Accept that fact and be humble. You will profit from that mindset.

And remember, as I said, your decisions and the consequences arising from them are yours alone. That feeling of being without a safety net is terrifying, but without it the feeling of accomplishment would never be as great.

Good luck. Maybe we’ll jump together some day.

The post Building-Antenna-Span-Earth: All About That BASE appeared first on Adventure Medic.

Dr Hannah Fox is a GP registrar training in Hackney, London. Over the last year, Hannah has taken time out of training to work at the Saroj Gupta Cancer Centre in Kolkata, India, and part time for the NGO Eastern India Palliative Care. In a country where poverty is rife and inequalities in healthcare are stark, Hannah describes her experiences of palliative care on both sides of the coin.