Dr Khan is a dedicated expedition medic who served 31 years as a General Practitioner in the British Army. He specialised in providing Primary Healthcare and Prehospital Emergency Care in some of the world’s most remote and challenging environments. His operational and expedition experience spans six continents, with plans underway to complete the seventh in Antarctica. A recognised authority in wilderness and expedition medicine, Dr Khan founded and chaired the special interest group in this field and contributed significantly to the Joint Service Expedition Medical Advisory Group. His expertise is formally recognised by the Fellowship of the Royal Geographical Society (2016) and the Fellowship of the Academy of Wilderness Medicine (2021). He also serves as a trustee for Equal Adventure and supports veterans through The Not Forgotten and the Royal British Legion. Dr Khan maintains a strong affinity for the wilderness, particularly high altitude trekking and diving.

A diver surfaces, breaking the water’s calm. She is streamlined, powerful, and completes her surface protocol with practiced efficiency. Moments later, another diver emerges from a deeper, more demanding dive. He removes his mask, takes his first recovery breaths, but something is not quite right. His head begins to roll, and his arms exhibit uncoordinated, jerky movements. Within seconds, his safety diver is there, securing his airway and offering support. The episode passes as quickly as it began; colour returns to the diver’s face, and lucidity is restored.

As the medic observing from the boat, you have just witnessed a classic, well-managed loss of motor control. What physiological cascade has just reached its critical point? And what is your immediate concern?

More Than Just Holding Your Breath

Freediving, the discipline of underwater diving on a single breath, is often misrepresented in popular media as a daredevil pursuit. In reality, it is a sport of immense skill, equanimity, and profound physiological adaptation. For remote medicine practitioners, whose work often places them in environments where such activities occur, moving beyond the sensationalism is crucial. This article aims to equip you with a foundational, clinically relevant understanding of freediving physiology and the key medical considerations you might encounter, enabling a more informed medical practice.

The Body’s Aquatic Blueprint: Understanding the Mammalian Dive Reflex

At the core of a freediver’s ability to explore depth is a remarkable set of innate adaptations known as the Mammalian Dive Reflex (MDR). Far from being an anomaly, this is a conserved physiological response hardwired into our genetics, which is voluntarily honed by freedivers to a remarkable degree. The primary components include:

• Bradycardia: Upon facial immersion in water (particularly cold water), the heart rate slows profoundly, in some elite divers dropping to below 30 beats per minute. This powerful vagal response dramatically reduces myocardial oxygen demand, conserving precious reserves for the dive.
• Peripheral Vasoconstriction: The MDR initiates a powerful, systemic shunting of blood away from the peripheries—the muscles of the limbs and skin—towards the vital organs of the central circulation, namely the brain and the heart. This intelligent redistribution ensures that oxygenated blood is directed where it is most critically needed.
• The Spleen Effect: One of the most fascinating components is the contraction of the spleen. Acting as a biological scuba tank, the spleen stores a reserve of concentrated red blood cells. During a dive, it contracts, releasing this oxygen-rich blood into circulation and significantly boosting the body’s oxygen-carrying capacity.

The Pressure Gradient: Key Pathophysiology for the Expedition Medic

While the MDR is protective, the rapid changes in ambient pressure create the primary pathological risks. A sound understanding of these mechanisms is essential for any medic providing cover.

Barotrauma: The Physics of Squeeze

Barotrauma results from the failure to equalise pressure in the body’s air-filled spaces with the surrounding hydrostatic pressure.

• Middle-Ear and Sinus Barotrauma: This is the most common malady affecting novice and experienced divers alike. Failure to introduce high-pressure air into the middle ear via the Eustachian tubes during descent creates a negative pressure gradient, leading to pain, tympanic membrane oedema, haemotympanum, and potential perforation. Sinus squeeze presents similarly with sharp, localised facial pain.
• Thoracic Barotrauma: A far more serious concern, lung squeeze occurs when a diver descends to a depth where the ambient pressure compresses the thoracic cavity to a volume below the lungs’ residual volume. This can cause transudation of fluid and blood into the alveolar spaces. The primary clinical sign is post-dive haemoptysis, which can range from blood-streaked sputum to more significant bleeding and requires immediate cessation of diving.

Hypoxia and Its Manifestations

The entire discipline is a dance with hypoxia. Understanding its presentation is critical.

• Hypoxic Blackout (BO): Often termed ‘shallow water blackout’, this loss of consciousness is typically not a result of running out of oxygen at depth. Instead, it occurs during the final 10-15 metres of ascent. Due to Boyle’s Law, as the diver ascends and ambient pressure rapidly decreases, the partial pressure of oxygen (PO2​​) in the lungs drops precipitously. If this PO2​​ falls below the level required to maintain consciousness (~30 mmHg), a blackout will occur, usually without any warning sensation.
• Loss of Motor Control (LMC / “Samba”): As witnessed in our opening vignette, an LMC is a visible sign of significant, near-critical hypoxia. It represents a point on the hypoxic continuum just prior to a full blackout. The uncoordinated movements are a sign that the motor centres of the brain are failing, and it is a critical moment for intervention by a safety diver. Rapid recovery is typical once breathing is restored, but it is a clear indicator that the diver has reached their absolute limit for that dive.

Gas-Related Issues

While more commonly associated with scuba, certain gas-related problems are relevant to freediving.

• Nitrogen Narcosis: At depths typically beyond 30-40 metres, the increased partial pressure of nitrogen can exert an anaesthetic effect on the central nervous system, leading to euphoria, impaired judgement, and reduced coordination. This can compromise a diver’s ability to execute their dive plan and recognise warning signs.
• Decompression Sickness (DCS): Though uncommon in most recreational freediving profiles, DCS is a recognised risk, particularly for professionals engaged in repetitive deep dives with short surface intervals or prolonged ‘hang-out’ dives for photography or work. The pathophysiology is familiar: inert nitrogen absorbed into tissues under pressure comes out of solution as bubbles upon ascent if the ascent is too rapid or the cumulative bottom time is too great. The presentation can range from joint pain and skin mottling to serious neurological or cardiopulmonary symptoms.

An Informed Perspective on a Profound Sport

Freediving is a sport defined not by recklessness, but by incredible physiological control, rigorous training, and an intimate understanding of one’s own body. For the expedition medic, the key is to appreciate the unique physiological stresses and recognise their specific clinical manifestations.

The risks, while real, are largely manageable through education and strict adherence to safety protocols. The most important of these is the cardinal rule of the sport: never dive alone. The presence of a qualified and attentive safety diver is the single most critical factor in preventing a hypoxic incident from becoming a fatality. As a medical professional, your role is enhanced by viewing this remarkable activity not just through a lens of pathology, but as a masterclass in human potential and applied physiology.

The post From Bradycardia to Barotrauma: An Expedition Medic’s Guide to the Physiology of Freediving appeared first on Adventure Medic.

Jonathan is an Aeromedical Transfer and Critical Care Consultant at University Hospitals Birmingham, UK. He completed his undergraduate degree in the UK and postgraduate training in New Zealand. He has worked as the doctor on a dozen expeditions across six continents, avoiding North America for a growing number of reasons. He has the International Diploma in Mountain Medicine. The most common question he is asked is “Why Birmingham?” Other questions can be asked if you find him on Instagram @jonadventuremedic

Continuous dynamic risk assessment and management

Rolling around some cross-country trails on touring bicycles, I heard “ROCK!” up ahead, before a hollow thud. I approached, and found the rider had hit that very rock he was warning about, careened off the track and embraced a tree. This is an example of (admittedly poor) dynamic risk assessment and management.

Risk is inherent in everything we do in adventure medicine and is the main rationale for our employment. If there is no risk, it is hard to justify the cost of an expedition medic. Our job is to work with the expedition leader to assess and minimise the risks associated with the expedition, and to be prepared for their eventuality. Knowing the risks informs the packing of a medical kit and the establishment of escalation and evacuation plans.

I went to help the unfortunate cyclist, now half covered in foliage and half covered in bicycle, with a very bruised bottom and a tender anatomical snuffbox. Fortunately, I had anticipated the possibility of trauma on a cycle tour in pre-departure planning and carried some splints and bandages. I had also acknowledged the ready availability of NHS hospitals along the length of our Lands End to John O’Groats route and hadn’t packed Plaster of Paris. Together with the patient, we weighed up a number of risks and options and decided to continue the ride, albeit on a relaxed detour, with a splint available for comfort if the pain persisted, and a visit to a local A&E if worse still.

Opportunity cost

One of the risks often not discussed is that of missed opportunity. It is simple to choose the most medicolegally defensible option to cancel someone’s trip because of a risk, but if you set your acceptance of risk very low, you defeat the purpose of an expedition medic. We are there to support clients on their adventures as best we can. In an ideal world, I would sit down with each client beforehand and discuss their specifics in terms of appetite for risk, past medical history, and fitness, and tie this in with the itinerary to make an advanced care plan, much like I would hope happens for my NHS patients.

Unfortunately, we do not live in an ideal world, and much like my clients in intensive care, manifests arrive with incomplete medical histories and missing contact details. We meet our potential patients for the first time at the departure airport, or as the ship pulls out of the port, and these discussions are deferred to the moment of crisis. I suspect my plans for developing a national Risk Summary Plan for Expedition Care and Treatments (RiSPECT) form will not catch on.

A balancing act

A client had the foresight to message me prior to departure on a hike around the Annapurna Circuit about some recent blood tests and we were able to have this conversation. She had moderately deranged liver function tests after a routine private health check-up, and her specialist had said it was likely gallstones. She was told not to worry until her booked ultrasound scan in six weeks. While this was an appropriate stance while working in an office in Bristol, the balance of risks changes substantially while trekking through Nepal. She was keen to continue, so I discussed with her the small risk of it not being gallstones, or indeed it being gallstones that proceed to obstruct, or her liver function worsening by contracting hepatitis A, all while being relatively remote from healthcare, which was itself delivered at a different resource level than in the UK.

With this discussion, we can hit the somewhat clichéd buzzwords of “shared decision making” and “patient centred care” to support the client/patient into making a decision they will be happy with. Hypothetically, I would have been happy to travel with her should she have accepted the serious risks, and should we have been able to demonstrate that her developing an illness would not significantly interrupt the itinerary of her fellow travellers, but this would require very careful documentation, and probably some intimidating consent forms with “death” and “financial ruin” in bold and capitals for my own medicolegal protection. It is our right as people with capacity to make our own decisions after all, even if they appear to be foolish, but this should not be to the detriment of other travellers or the communities and environments to which we travel. Ultimately, she was unable to travel as her insurer would not cover her for biliary related issues, and she fairly sensibly determined the risk was too high.

Time for introspection

When having these discussions about risk, it’s exceptionally important to consider one’s own limitations. None of us are perfect expedition medics. I come from an intensive care background, so feel comfortable discussing the various potentially life-threatening conditions, but am more unfamiliar with broken wrists. General practitioners on the other hand might feel very comfortable with rashes, but less with acute life-threatening asthma, and physiotherapists might be excellent at strapping knees but less comfortable with the risks of antibiotics for traveller’s diarrhoea. When discussing risk with clients, be up front about your own limitations and uncertainties.

Balancing with the day job

I am often asked how I manage to undertake expeditions around my day job, as if the day job is a barrier to employment on expeditions. While it does cut down on the time available, I wouldn’t be able to safely undertake my expedition work without it. There are clinicians who frame themselves primarily as expedition medics, but expeditions alone do not allow one to keep up to date with the rare but serious conditions that are used to justify our employment. Parallel acute clinical work is mandatory to ensure this exposure.

As a resident doctor in New Zealand, I used about half of my annual leave to do expeditions, with the other half reserved to recuperate. As a critical care consultant in the United Kingdom, due to an annualised hours contract, I am able to front load a lot of my work and ensure good periods of time off where I can either recuperate or work on expeditions. In this way, I can maintain a full-time domestic job which helps build clinical experience, and still complete expeditions, which mostly develop team working and interpersonal skills. I suggest we build our experience in both expedition and domestic work to balance our own professional risk.

The riskiest trip

I travelled to Antarctica on a tall ship in January as the sole medical cover, and on paper this was the riskiest trip I have undertaken. Some of the clients were anticoagulated, others on immunotherapy for metastatic cancer, and everyone was climbing up the rigging untethered some twenty metres above the deck – or above the deep dark ocean when there was a more aggressive heel to the boat. We were at our farthest approximately three days’ continuous motor cruising from the nearest hospital, with no realistic prospect of an airborne rescue.

The Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh publish guidelines for the degree of experience suggested for expedition medics, and quite rightly this trip featured in the highest risk and highest consequence categories of their risk matrix. For this expedition, the faculty suggest experience working in the leadership of expeditions, with specific environmental experience, advanced experience in any undertaken activity, and the title of a consultant doctor, highly experienced in expedition medicine. Acknowledging this, I signed up for a trip as expedition and ships doctor on a more resourced trip around the Arctic in the previous year to build the specific experience suggested. This helped me to manage my own risk by building my exposure gradually.

Top tips

Dom Hall wrote about risk management over a decade ago for Adventure Medic as a non-clinician. He provides four top tips; I’ll add my own to take it to eight:

1. Consider the interplay of your patient’s medical history, the environment, the activity, and your own experience when determining risks; both for you and your clients
2. Work with the expedition leader and the clients to negotiate an acceptable level of risk
3. Pack a medical kit that covers the likely eventualities
4. Finally, consider how it would look if it went to court. Would you expect others in the field to stand behind you and agree they would have done similar, or do you need to build your own experience first?

For me, I’ll continue to work in my day job, pick up expeditions where I can, and pop down to the Emergency Department from time to time to remind myself where the scaphoid is.

Afternote

Details have been changed about the patients and expeditions to maintain anonymity.

The post Risk Management and the Expedition Medic appeared first on Adventure Medic.

Dr Abigail Wrathall / EM Registrar / North of Scotland

Original Article:

Chris Imray / Consultant Vascular Surgeon, Coventry and Warwickshire NHS Trust

Andy Grieve / Deputy Senior Medical Officer, RAF Valley, Anglesey

Charles Handford / RAMC, Medical Student, University of Birmingham

Ben Cooper / Charge Nurse, A&E, Northern General Hospital, Sheffield

Sean Hudson / General Practitioner, Maryport

In 2013, Adventure Medic published this review of frostbite, with a detailed breakdown of the condition and the evidence for its identification and management. This is an update to that article, with thanks to the original authors.

Frostbite is a vascular injury, as a result of exposure to cold temperatures. Risk increases with reductions in temperature, and so as expedition and extreme medicine providers we must be aware of the condition, especially the avoidance, recognition and early management whilst out in the field. As humans push further into wild environments and sadly as large numbers of people become unhoused due to socio-economic circumstances, politics, and war; frostbite is set to become an increasingly frequent presentation, and has significant long term effects on quality of life and function.

How, why and where?

Frostbite most commonly affects the feet and hands, however can be identified in many other places across the body: nose, ears, chin, buttocks, and the penis. These reflect the activities undertaken in cold environments: mountaineers and adventurers exercising in extreme cold and high altitude; and sitting on cold surfaces, especially in people experiencing homelessness.

There are four phases to frostbite:

Pre-freeze: where the tissues cool, vessels vasoconstrict and blood flow is reduced leading to ischaemia. There may be paraesthesia at this stage.
Freeze-thaw: ice crystals form during the freeze, causing deranged proteins, lipids and electrolytes, disruption of cell membranes and eventually cell death. During thaw, there is further ischaemia with reperfusion injury & massive inflammatory response.
Vascular stasis: blood vessels cycle between vasodilation and -constriction, with fluid & protein leaking due to vessel wall damage and intravascular coagulation.
Late ischaemic: inflammatory cascade leads to progressive tissue ischaemia and infarction, intermittent vasoconstriction and vasodilation results in continued reperfusion injury, and emboli & coagulation in downstream vessels.

The inflammatory cascade is responsible for much of the damage caused by frostbite. This is mediated by a number of factors, including histamine, bradykinin, thromboxane A2 and prostaglandin F2alpha. The disruption of vascular function and destruction of microcirculation results in cell death. If repeated exposure to freezing is experienced, the damage is compounded.

Prevention and avoidance

Before discussing identification and treatments, it is important to note that there are several things that can be done to avoid frostbite all together. As ever, prevention is the best cure. The core of prevention is a combination of maintaining perfusion and reducing heat loss. The use of exercise to avoid frostbite is a recommendation to be applied with caution. There is ongoing research into chemoprophylaxis for frostbite.

Perfusion

There are several ways to maintain perfusion. Ensuring adequate core temperature; good hydration and nutrition; reducing exposure by covering all skin and avoiding restrictive clothing, including too-tight footwear and tight cuffs on jackets. There is also some evidence for using supplemental oxygen in high altitude environments to improve perfusion & oxygenation of peripheral tissues – this appears to be predominantly due to an inability with hypoxia to maintain a sufficient core temperature. In addition, mountaineers not using supplemental oxygen for summit attempts are breathing more rapidly and deeper, leading to increased volume of cold air exposure.

Reducing heat loss

Simple tactics can make the biggest difference in terms of safety in extreme cold. Ensuring appropriate clothing is being used by individuals; replacing clothing – especially gloves – which become wet (including with perspiration); avoiding sweating by using appropriate layering for the environment; encouraging individuals to avoid the use of alcohol and drugs; recognising signs of hypoxaemia that may alter behaviours; use of electrical and chemical warming devices, including heated socks/gloves, and hand/foot warmers (with caution to avoid direct skin exposure and reduced blood flow due to tight footwear). Recognition of early signs of frostnip/frostbite is also key to avoiding further damage.

Exercise

There is no doubt that exercise raises core body temperature, and therefore can increase blood flow and perfusion of extremities. However, exercise often causes perspiration, leading to increased heat loss as detailed above. It also increases energy use and in extremes can lead to exhaustion, exacerbating rapid heat loss. It can be a helpful method to avoid cold injury in moderation.

Chemoprophylaxis

The use of prophylactic medication is not commonplace, and is still an area lacking in research. There have been mouse studies into ‘antifreeze’ proteins, however as it stands there are no available or recommended medications for preventing frostbite in humans.

Classification and recognition

Frostnip

This is a superficial cold injury, with vasoconstriction in areas of skin exposed to the cold air, usually on the face. There may be frost visible on the skin surface. Rewarming leads to recovery of blood flow and therefore resolution of the symptoms of numbness and skin pallor. It can precede frostbite, and when frostnip is identified indicates that there is high risk of developing frostbite.

Frostbite

The longstanding 4-tiered classification system for frostbite is based on both clinical and radiological findings. There is a more recent 2-tiered classification, more appropriate for use in the field. This describes the prognosis following rewarming, but prior to imaging, which represents a more common realistic scenario in the world of extreme & expedition medicine.

• Superficial: represents no or minimal tissue loss
• Deep: anticipated tissue loss (corresponding to 3rd- and 4th- degree injury)

The Cauchy classification system can be used at day 2 post-injury to predict prognosis and therefore plan for evacuation, if required. The full details of this can be read here. However in brief, the more proximal the lesion is and/or the presence of haemorrhagic blisters, are both negative prognostic indicators and increase the risk of amputation, systemic involvement and sepsis. The use of bone scanning in these patients is beneficial, but obviously unavailable in a remote context.

Signs & Symptoms

Initially, the individual will experience sensory loss of the affected extremity or digit. Often described is the feeling of clumsiness, as a result of a loss of proprioception. There can be severe pain, especially during the thaw cycle and the resulting reperfusion. Some experience paraesthesia in the days following the injury.

Clinically, skin is often pale but otherwise can appear relatively normal during the freeze stage however following this, blisters can appear, which are haemorrhagic in severe cases. On re-warming, tissues can appear blue, yellow-white, or waxy. If the extremity undergoes rapid rewarming, then erythema can occur.

Management

This will be divided into treatment options in the field (with the caveat that ability to provide these interventions may be variable based on resources), followed by hospital-based management. The Gold Standard for treating cold injuries remains the State of Alaska cold injuries guidelines.

Field management

Thawing: The first decision to be made is whether to thaw the tissues. While it may seem like the obvious start, if the extremity cannot be adequately protected from the risk of refreezing occurring, then it is not recommended to commence thawing. Instead, protect from physical injury by avoiding use, and remove restrictive jewellery and constrictive clothing. The extremity should not be placed in ice or snow, and there is no evidence that dressings have any therapeutic benefit. Any dressings which are applied should not be restrictive or damaging to the skin.

The following treatments can be applied whether the intention is to thaw the tissue or not. Most frostbite will spontaneously thaw. Do not rub the extremity or directly expose to heat.

Treat hypothermia: Moderate to severe hypothermia should be managed prior to treating a cold based injury; mild hypothermia can be treated concurrently. See our hypothermia article for more details on this.

Rehydration: Good hydration status reduces the risk of developing frostbite, however there is little evidence of treatment once the injury occurs. Maintain fluid intake orally, or if unable to drink then with (ideally prewarmed) boluses of IV fluids targeted based on urine output.

Ibuprofen/Aspirin: There is poor quality evidence to recommend these therapies, which in theory may improve circulation, however aspirin can inhibit prostaglandins necessary for wound healing. Commencing ibuprofen at 12mg/kg/day (max 2400mg/24hr) is the current recommendation.

Low Molecular Weight Dextran: No longer recommended.

If the intention is to rewarm/thaw, then the following treatments can also be applied in the field. If rapid rewarming is not available, then spontaneous thawing & rewarming should be allowed.

Rapid rewarming: The ideal way to do this is by warm bath immersion; other methods have increased risk of heat injuries. The water should be heated to ~37 to 39 degrees centigrade, ideally using a thermometer to maintain this range. This can be checked without a thermometer by immersing the hand of someone other than the casualty for 30 seconds to ensure the temperature is tolerable. Water should be stirred and regularly reheated to maintain the adequate temperature, although reheating water should be avoided while the extremity is immersed. Alternating between two containers is one way to avoid this. The rewarming process is normally completed within 30 minutes, and the extremity will appear red or purple with tissues being palpably soft. Following this, gentle drying should take place, taking care not to cause damage to the skin.

Antiseptics: If available, addition of an antiseptic solution to the rewarming water may reduce the risk of developing cellulitis, however there is no evidence for its use in frostbite.

Topical Aloe Vera: May theoretically be beneficial, and if being used should be applied prior to any dressings.

Analgesia: Based on the WHO pain ladder and the patient’s symptoms.

Debridement of blisters: This is not recommended in the field due to risk of infection. If there is a tense blister at risk of rupture, then aseptic aspiration can be performed, however deroofing should not be carried out. Haemorrhagic blisters should not be aspirated or debrided.

Dressings: Dry gauze dressings should be applied to the affected areas, with care not to wrap circumferential dressings tightly due to progressive oedema. Any such dressings should be checked regularly to ensure they are not restrictive.

Elevation: Raising the affected area above the level of the heart to reduce tissue oedema is recommended.

Ambulation: Use of the affected extremity should be avoided unless absolutely necessary for safe evacuation, as it can worsen tissue damage and increase the risk of amputation.

Oxygen: As discussed in the prevention section, hypoxia worsens tissue perfusion. However, it can also cause vasoconstriction. The recommendation is to apply supplemental oxygen in cases of hypoxia or at high altitude, but to avoid otherwise, however the evidence for this is weak.

Additional field management options are currently under research, including peripheral nerve blocks. There is currently no evidence for their use in frostbite.

Hospital management

Some treatments remain the same once hospital is reached: treatment of hypothermia, hydration, low molecular weight dextran, ibuprofen, aloe vera, and rapid rewarming. If thaw has been achieved, further rewarming is not of benefit.

The Helsinki Frostbite management protocol can be useful if in a centre with access to angiography, as a stepwise approach to management in tertiary care.

Blisters: As in the field, haemorrhagic blisters should not be aspirated or deroofed. Clear or cloudy blisters can be reduced by needle aspiration once in hospital, however there is limited evidence of benefit to carrying this out. Application of sterile dressings to open blisters reduces the risk of secondary infection.

Antibiotics: Prophylaxis is not routinely recommended; initiate if major trauma, high risk of infection due to other causes, or evidence of cellulitis or sepsis.

Tetanus prophylaxis: Should be administered, see Green Book guidelines for use of booster vaccine vs immunoglobulin depending on patient’s vaccination history.

Iloprost: This is the mainstay of drug treatment for frostbite, and its use is now widespread across the world. It is a vasodilator that reduces inflammation and platelet aggregation. There is a randomised controlled trial that demonstrated it was more effective than combination therapy with tPA, or alpha blocker monotherapy, at reducing amputation rate. Its use is also supported by case series in Canada, Finland and the Himalaya. It should be considered the first line treatment where available; where it is not then thrombolysis with tPA is second line.

Thrombolysis therapy: Tissue plasminogen activator (tPA) administered IV or intra-arterial may be of some benefit in the first 24 hours following tissue thawing. The standard risks of thrombolysis accompany the treatment, with the addition of increased risk of compartment syndrome. There is no high level evidence for its use, however the available evidence suggests a reduction in amputation rates.

Vasodilators: The use of vasodilators is restricted to adjuvant therapy, rather than first or second line monotherapy.

Long term management

There are various longer term treatments that have variable evidence supporting their use in reducing the morbidity and sequelae of frostbite. These include:

• Hydrotherapy
• Hyperbaric oxygen therapy
• Imaging (for prognostication and surgical planning)
• Sympathectomy
• Fasciotomy (to treat compartment syndrome)
• Surgical debridement or amputation (should be delayed until definitive demarcation of necrotic tissue, unless sepsis requires more urgent intervention)

These interventions should only be undertaken in specialist centres with expert advice taken.

Telemedicine

There is advice available via phonecall/email from anywhere in the world via three UK experts in frostbite. See here for details. Any decisions for surgery or repatriation should ideally be discussed with one of the experts here prior to action undertaken.

Conclusions

Frostbite is a predominantly avoidable condition with significant sequelae affecting morbidity and quality of life. Early recognition, prompt effective field management, and appropriate hospital transfer and treatments can all reduce the individual’s risk of amputation, and improve their level of function following the injury. Whilst there is gradually increasing research into novel treatments, by knowing the basics and getting them right, as a medic providing care in extreme environments, we can make a difference.

Useful Resources

Canadian Frostbite Care Network (CFCN)

“Frostbite injury can have significant functional impacts on affected individuals, including the possibility of amputation, increased risk of future cold injuries, chronic pain, and challenges in wound healing in severe cases. Our research has identified a pressing need for easily accessible, evidence-based information on frostbite treatments and protocols. Community hospitals see the majority of frostbite cases, which frequently includes marginalised and homeless populations, who stand to benefit the most from improved awareness and treatment protocols. To address this need, the Canadian Frostbite Care Network launched in October 2024, providing an information and collaboration hub for the public and healthcare professionals to enable timely access to high-quality frostbite care. The Canadian Frostbite Care Network is dedicated to improving frostbite treatment across Canada by promoting best practices, fostering expert collaboration, and supporting ongoing research and education.”

Adventure Medic would like to thank the CFCN for the use of their photographs in this article. The CFCN resources can be accessed here: https://frostbitecare.ca

Dr Chris Imray in The Alpine Journal

“In the UK, the British Mountaineering Council Frostbite Service has been operating for 20 years. This service, which is run by Dave Hillebrand, Paul Richards and myself, offers expert advice over satellite phone or by email to those dealing with frostbite. All three of us hold the UIAA Diploma in Moun- tain Medicine and have practical expedition experience. We provide remote advice for affected individuals both locally in the UK and on expeditions abroad. The aim is to support and advise local providers or offer to take over care where appropriate. Contact details for all three of us are available via the BMC website.

However, even the best advice will be of little use if you can’t access the right treatments. Throughout this article, I’ve repeatedly mentioned the frostbite drugs iloprost and rTPA. In recent years, these drugs have revolutionised the care of those with more serious frostbite. Time is crucial and treatment with them should ideally be started within 24 hours of injury. The longer the delay, the less effective the treatment becomes as the frostbitten extremities die without a blood supply. Doctors use the phrase ‘time is tissue’ to indicate that the longer something is left untreated, the more tissue will be lost.

Speed is not the only consideration. It is also very important to go to a unit familiar with these modern treatments. Sadly, there have been a number of cases recently where climbers have been taken to units that do not offer iloprost, despite the presence of units offering the treatment within the same city. Because this information was not volunteered, digits were lost when they needn’t have been.

To try and get around this issue, the recently set up International Freezing Cold Injury Working Group is establishing a worldwide database listing the units that offer iloprost and other complex frostbite treatments as well as a second database of clinicians who regularly advise on cold injuries.

Until recently, this first database would not have included sites in the USA as iloprost was not approved for use there. This changed in February 2024, when the US Food and Drug Administration (FDA) approved the use of iloprost for the treatment of severe frostbite. You can now visit Alaska safe in the knowledge that, should you face a case of severe frostbite, regulation will not prevent you from receiving the best treatment currently known to science.

Dr Imray’s article can be found here,

UK Frostbite Care

“At UK Frostbite, we are a dedicated team of medical doctors and researchers focused on providing accurate and comprehensive information about frostbite prevention and treatment. Our expertise ensures that you receive reliable guidance to protect yourself and others from frostbite-related issues.”

The UK Frostbite Care site can be accessed here.

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6. Joshi K, Goyary D, Mazumder B, Chattopadhyay P, Chakraborty R, Bhutia YD, Karmakar S, Dwivedi SK. Frostbite: Current status and advancements in therapeutics. Journal of Thermal Biology. 2020 Oct 1;93:102716.
   Sheridan RL, Goverman JM, Walker TG. Diagnosis and treatment of frostbite. New England Journal of Medicine. 2022 Jun 9;386(23):2213-20.
7. Zaramo, Taborah Z. BS; Green, Japjit K. MD; Janis, Jeffrey E. MD, FACS. Practical Review of the Current Management of Frostbite Injuries. Plastic and Reconstructive Surgery – Global Open 10(10):p e4618, October 2022. | DOI: 10.1097/GOX.0000000000004618
8. Lindford A, Valtonen J, Hult M, Kavola H, Lappalainen K, Lassila R, Aho P, Vuola J. The evolution of the Helsinki frostbite management protocol. Burns. 2017 Nov 1;43(7):1455-63.
9. Cauchy E, Davis CB, Pasquier M, Meyer EF, Hackett PH. A new proposal for management of severe frostbite in the austere environment. Wilderness & environmental medicine. 2016 Mar;27(1):92-9.

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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

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Public Health England (PHE) have published updated guidance on malaria prevention for travellers from the UK. You can read the full guidance via this link.

Here are some take home messages:

A  Avoidance of travel to malarious areas if the person is at high risk of severe or fatal malaria. For example pregnant women, children, the elderly, people without a spleen and those with complex comorbidities or immunosuppression.

B  Bite prevention. Reducing the number of bites you receive reduces your chance of developing Malaria.

• Full-length, loose-fitting clothing and socks.
• Particular caution at dusk and dawn.
• Screening of doors and windows.
• 50% DEET (N,N-Diethyl-meta-toluamide) based insect repellent is first line on exposed areas of skin. This should be applied after sunscreen. Alternatives to DEET are available including Icaridin and IR3535.
• Bed nets. The World Health Organisation (WHO) have made strong recommendation that pyrethroid-only long-lasting insecticidal nets (LLINs) should be deployed for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission. Pyrethroid-chlorfenapyr insecticide treated nets (ITNs) should be deployed instead of pyrethroid-only LLINs for prevention of malaria in adults and children in areas with pyrethroid resistance.
• Indoor residual spraying (IRS). The WHO also makes recommendation for IRS where certain listed requirements are met, including that people mainly sleep indoors at night.
• If electricity is available, an electric pyrethroid vapouriser or coils can be used.

C Chemoprophylaxis should be prescribed based on an individual risk assessment. Consider the need for standby emergency medication if a person will be in a remote area. This is not a replacement for chemoprophylaxis, it is an adjunct.

D Diagnose promptly and treat without delay. The WHO Global Malaria Programme will be the focus for malaria control and elimination. The key message is Test, Track and Trace.

Vaccination

Despite research since the 1960s, the international community has struggled to produce a malaria vaccine. This was partly due to the complexity of the life cycle of Plasmodium and its high mutation rate, but more importantly the long-standing lack of urgency and funding behind malaria research in general. In 2015 the final results from breakthrough Phase III trials were published in the Lancet; they showed that children from 5 to 17 months old who received three doses of the RTS,S/AS01 (RTS,S) vaccine plus a booster, would have a 29% reduced risk of severe malaria.

In 2019, the WHO introduced a pilot implementation of malaria RTS,S vaccine in Malawi, Ghana and Kenya. Four years on, over 6 million doses of vaccine have been administered through the Malaria Vaccine Implementation Programme (MVIP), coordinated by WHO and funded by Gavi, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Unitaid.

Demand is very high for the first malaria vaccine, RTS,S, recommended by WHO for the prevention of Plasmodium falciparum malaria in children living in regions with moderate to high malaria transmission. It is the first licensed vaccine against human parasitic disease. Also known as Mosquirix, the vaccine is given to children aged 6 weeks to 17 months to protect against malaria caused by Plasmodium falciparum.

It consists of two parts. The first is a recombinant protein which is normally secreted by the Plasmodium parasite during its sporozoite phase; this is the phase in which the parasite enters the human body from the mosquito. This protein is combined with the surface antigen of the hepatitis B virus (HBsAg) to form a soluble, virus-like particle. The second part of the vaccine is an adjuvant chemical which helps to boost the immune response.

Impact and evidence supporting RTS,S malaria vaccine

• Pilot introductions resulted in a 13% drop in mortality among children age-eligible for vaccination and substantial reduction in severe malaria.
• Estimated 1 life saved for every 200 children vaccinated.
• Phase 3 trial (2009-2014) of vaccine showed malaria cases dropped by over half in the first year after vaccination and a 40% reduction in malaria episodes over 4 years of follow up.
• Phase 3 trial (2017-2020) of vaccine provided just prior to peak malaria season in areas with highly seasonal malaria found vaccine efficacy similar to efficacy of Seasonal Malaria Chemoprevention (SMC), shown to prevent around 75% of malaria cases.
• Safety demonstrated after nearly 4 million vaccine doses given to more than 1.2 million children

The RTS,S vaccine is prequalified by WHO. Gavi is investing an initial nearly $USD 160 million for broader vaccine roll-out in endemic countries (2022-2025). Click this link to explore the Framework by which vaccine doses are being allocated.

Further Vaccination

In July 2022, Gavi, the Vaccine Alliance, opened a funding window to support Gavi-eligible countries in rolling out this vaccine and other malaria vaccines as they become available. Since then, over 28 countries expressed interest. Fourteen applications, submitted to Gavi by countries in the first two application opportunities, were recommended for approval by Gavi’s Independent Review Committee (IRC) following the standard Gavi processes. The available vaccine supply for the period 2023-2025 is currently limited to 18 million doses.

WHO has added the R21/Matrix-M malaria vaccine to its list of prequalified vaccines, recommending it’s use in October 2023. This prequalification allows vaccine procurement by UNICEF and funding support for deployment by Gavi, the Vaccine Alliance. This second malaria vaccine is approved by WHO for widespread use for the prevention of malaria in children following the advice of the WHO Strategic Advisory Group of Experts (SAGE) on Immunization and the Malaria Policy Advisory Group. It has been shown to have high efficacy when given before the high transmission season and in an age-based schedule. This new malaria vaccine, R21/Matrix-M, had over 75% efficacy against clinical malaria with seasonal administration in a phase 2b trial in Burkina Faso. Further reporting on safety and efficacy of the vaccine in a phase 3 trial enrolled over 4800 children across four countries followed for up to 18 months at seasonal sites and 12 months at standard sites.

WHO currently recommends the programmatic use of malaria vaccines for the prevention of P. falciparum malaria in children living in malaria endemic areas, prioritizing areas of moderate and high transmission. This now applies to both RTS,S/AS01 and R21/Matrix-M vaccines.

There has not yet been a trial that directly compares the RTS,S and R21 vaccinations, yet both have demonstrated good efficacy and will tackle the fact that demand outweighs supply for these life-saving vaccines. Both vaccines are shown to be safe and effective in clinical trials, for preventing malaria in children. When implemented broadly, along with other recommended malaria control interventions, they are expected to have a high public health impact.

Climate

Each year, WHO’s World malaria report provides a comprehensive and up-to-date assessment of trends in malaria control and elimination across the globe. This year’s report includes, for the first time, a dedicated chapter focused on the intersection between climate change and malaria. Malaria places a particularly high burden on children in the African Region, where nearly half a million children die from the disease each year. Globally, in 2022, there were an estimated 249 million malaria cases and 608 000 malaria deaths across 85 countries.

Climate variability, such as changes in temperature and rainfall, can impact the behaviour and survival of the malaria-carrying Anopheles mosquito. Extreme weather events such as heatwaves and flooding may lead to increases in the transmission and burden of the disease.

A changing climate has indirect effects on malaria, too. As an example, population displacement may lead to more malaria as people without immunity migrate to endemic areas. Climate variability has also led to malnutrition in many places, a risk factor for severe malaria among young children and pregnant women.

WHO World malaria report conclusions

Last year, 49 million children were reached with seasonal malaria chemoprevention in 17 African countries, up from just 170,000 in 2012. Additionally, a new generation of dual-ingredient insecticide-treated bed nets, recommended earlier this year by WHO, has been shown to have greater impact against pyrethroid-resistant mosquitoes compared to standard pyrethroid-only nets.

Meanwhile, the goal of malaria elimination has been achieved in a widening circle of countries. This year alone, three more countries were certified by WHO as malaria-free: Azerbaijan, Belize, and Tajikistan. Several others are on track to eliminate the disease in the coming year.

These and other advances are a testament to both national commitment and global resolve to control and eliminate the disease. However, amid extreme weather events, scarce resources and a growing number of biological threats, there is still a long way to go to achieve our vision of a world free from malaria.

A substantial pivot with much greater resourcing, data-driven strategies and new tools is needed to rebuild momentum in the fight against malaria. With the added threat of climate change, sustainable and resilient malaria responses are needed now more than ever.

References

• https://cks.nice.org.uk/topics/malaria/
• https://www.fitfortravel.nhs.uk/advice/malaria
• https://www.nathnac.net/
• https://www.bug-off.org/
• https://www.who.int/news-room/fact-sheets/detail/malaria
• https://cks.nice.org.uk/topics/malaria-prophylaxis/diagnosis/assessment/
• https://www.ema.europa.eu/en/opinion-medicine-use-outside-EU/human/mosquirix
• https://www.smithsonianmag.com/science-nature/why-did-it-take-35-years-to-get-a-malaria-vaccine-180980151/
• https://www.newscientist.com/lastword/mg25233643-900-if-mosquitoes-were-eradicated-what-would-be-the-consequences/
• https://cdn.who.int/media/docs/default-source/immunization/mvip/infographic_rtss-malaria-vaccine_english_april-2023.pdf?sfvrsn=b9a755ae_14
• https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2023
• Efficacy and safety of RTS,S/AS01 malaria vaccine with or without a booster dose in infants and children in Africa: final results of a phase 3, individually randomised, controlled trial. The Lancet. 2015; 386(9988), 31-45
• Datoo, M. S., Natama, M. H., Somé, A., Traoré, O., Rouamba, T., Bellamy, D., … Tinto, H. Efficacy of a low-dose candidate malaria vaccine, r21 in adjuvant matrix-M, with seasonal administration to children in Burkina Faso: A randomised controlled trial. The Lancet. 2021; 397(10287), 1809–1818
• Chandramohan, D., Zongo, I., Sagara, I., Cairns, M., Yerbanga, R.-S., Diarra, M., … Greenwood, B. Seasonal malaria vaccination with or without seasonal malaria chemoprevention. New England Journal of Medicine. 2021; 385(11), 1005–1017
• Datoo, M., Dicko, A., Tinto, H., Ouedraogo, J-B., Hamaluba, M., … Olotu, A. Safety and efficacy of malaria vaccine candidate R21/Matrix-M in African children: a multicentre, doubleblind, randomised, phase 3 trial. The Lancet. 2024; 403: 533-44

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The importance of note-keeping is well documented (pardon the pun). Maintaining good clinical records is the cornerstone of exemplary patient care and should not be overlooked, especially on expedition. This article, the second in our masterclass series, provides an overview of the approach to clinical records and documentation on expeditions.

The context

The General Medical Council (GMC) stipulates that maintaining clear and accurate records is a key responsibility of any doctor providing medical care. These requirements are outlined in ‘Good Medical Practice’, succinctly and clearly.¹ In brief, clinical records should include the following:

• Relevant clinical findings
• The decisions made and actions agreed
• Who is making the decisions and agreeing the actions
• The information given to patients
• Any drugs prescribed, other investigations, and treatment
• Who is making the record and when
• Clear, accurate, and legible information
• A record of the time of events

If your practice is under the governance of the Nursing and Midwifery Council (NMC) or the Health and Care Professions Council (HCPC), both organisations also produce guidance regarding clinical record keeping. This can be found in either the NMC’s ‘The Code’ or HCPC’s ‘Standards documents’.^2,3 These standards can, and should, be applied in the context of wilderness medicine, and should constitute fundamental considerations before and after an expedition.

Prior to the Expedition

Expedition medical planning should take place significantly in advance of departure. Usually this means at least three to six months prior to the departure date. Designing, and deciding how to manage, medical documentation should take place in this planning phase. The discovery of poor medical documentation policies, and an unwillingness to address them, should cause a medic to question their participation in the planned expedition.

During the planning phase there are several considerations with regards to medical documentation:

1. Determine whether the expedition intends to use paper or electronic notes (or both)
   Each note keeping method has its advantages and disadvantages, so consider the expedition setting. Larger expeditions, with a base camp, may favour electronic notes, as they will have the required resources, power and hardware. Smaller, roaming expeditions may be better suited to old fashioned paper notes.
2. Consider protection of your notes from the environment
   Remember water and paper mix poorly. Medical notes are legal documents and should be kept in the best possible condition. Your medicolegal defence is only as good as your notes. Similarly, batteries are rapidly depleted with cold exposure.
3. Consider the documents that will assist your note-keeping whilst on expedition.
   Observation and drug charts, patient assessment proformas, and transfer of care documents improve the quality of documentation within the hospital setting. Consider producing pre-made forms for the expedition. These are extremely useful in austere or challenging environments, or during time-critical incidents to ,ensure all required information is captured.
4. Consider the security of medical information before, during and after the expedition.
   Pre-expedition medical screening creates the first medical notes for an expedition, and these are often electronic. Determine how you intend to store these medical notes securely before, during and after the expedition. Participant’s medical screening should include past medical and surgical history, drug history, allergies, immunisations, and emergency information such as passport/ insurance/ next of kin. This needs to be kept securely, but be readily accessible to the expedition medic. There’s little value in taking this information on expedition if you are unable to locate it in an emergency. Similarly, be wary of accessing this information via the organisation’s headquarters, as this relies on an individual picking up the phone, or answering an email, often out-of-hours or in a different time zone. Patient confidentiality and a difficulty with security clearance over the phone will often limit what information can be given.
5. (Note storage after the expedition is discussed later.)

Clear clinical note management is complemented by other aspects of the expedition preparation. These include documentation focusing on the expedition medical kit and medicine storage, specific expedition guidelines, risk assessments, and a comprehensive emergency response plan.

The British Standard 8848 (BS8848) is the gold standard for expedition planning for UK based organisations.⁴ It’s a huge document but thankfully the Faculty of Pre-Hospital Care have produced an easily digestible review, and this should be read alongside FPHC’s own Updated Guidance for Medical Provision for Wilderness Medicine. ^5,6

During the Expedition

This may be the easiest aspect of expedition medical note management, provided there is commitment to good clinical note keeping. Here are some important considerations:

• Ensure patient details (name and DOB) are present on your documentation, alongside time and date.
• It may be relevant to include specific environmental information: location, altitude, temperature/weather.
• Remember to sign off your documentation with signature, name, and professional registration number.
• If you’re an expedition doctor, don’t forget what our incredible nursing and allied colleagues do every day. Documentation of observations, medicines administered, and personal care should all be recorded.
• You may be the only clinician present, so it is important to document uncertainty in diagnosis and the rationale for decisions around treatment or evacuation.
• If you can’t keep contemporaneous notes, consider asking an appropriate member of the expedition to scribe. Alternatively, use your phone for voice or written notes which you can transcribe later.
• Document discussions with the expedition leadership team, medical supervisors and patients . This is of paramount importance when there are areas of conflict. For example, sending a participant down from a seven summits attempt due to altitude illness, or when health takes precedence over other agendas.
• Adverse or serious incidents require additional documentation and should include a factual history of what happened and when, what actions were taken, and the resultant outcome.
• Detailed notes may be necessary for insurance claims for the patient, and will benefit you if you are asked to write a report to support their claim.
• Remember photos and videos can be helpful adjuncts to your written clinical notes. For example, ongoing care of a wound. These must be securely stored and can only be taken with patient consent.
• Additionally, photography at the scene of a major trauma scenario may seem like a breach of confidentiality, but if sensitively conducted may later help the patient to process and recover from the event.

Some expedition companies provide a template for assessments, or you can make your own to take with you.

After the Expedition

Upon returning home from a (hopefully!) successful expedition, your responsibilities as a wilderness medic aren’t over yet. Depending on the events of the expedition, you may be required to contact a participant’s GP if there have been any clinically significant illnesses that require onward care or further investigation. Furthermore, it is also important to write a letter to a participant’s GP regarding significant although resolved episodes, so they are able to update their permanent medical records. For example, a dislocated shoulder which has been relocated on expedition.

Additionally, the post-expedition report may require a breakdown of illnesses and injury diagnoses that occurred. This helps the organisation to tailor their medical kit and tweak risk assessments for future, similar expeditions. Once you’ve completed any necessary GP letters, and finalised the post-expedition medical report, consider the storage of expedition medical notes. Unsurprisingly, the GMC has advice on this;⁷

“You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection law requirements.”

There are several pieces of guidance and legislation to be aware of when considering medical documentation storage. These include:

• The GMC’s ‘Good Medical Practice’ and ‘Confidentiality: good practice in handling patient information’ ^1,7
• General Data Protection Regulation (GDPR)⁸
• Health and Social Care Act (2012)⁹
• NHS Records Management Code of Practice (2021)¹⁰
• The Private and Voluntary Health Care (England) Regulations (2001)¹¹

As discussed, the GMC determines the professional standards with regards to medical documentation. The other pieces of legislation or guidance refer to the legal requirements of clinical note storage both within the NHS and private practice. This legislation and guidance is limited to UK jurisdiction, and most expeditions occur outside of these areas. However, it can be reasonably assumed that these documents would be the standard for practice in expedition settings. For example, for a UK doctor the GMC’s guidance holds true for other aspects of expedition medical work, even if outside the UK.

This is a complex area, but the bottom line is that medical documentation should be stored, post-expedition, for a minimum of 8 years. In addition, there are also conditions under which the notes should be held. Correct and proper storage of medical notes is the primary responsibility of the ‘data controller’, which is the individual or organisation who is tasked with storing the notes. The clinician should be content that their notes will be held appropriately by the organisation’s ‘data controller’. Importantly, GDPR determines that medical documentation should be:⁸

“processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organisational measures.”

As such, it is important to determine, when accepting an expedition medic position, who will be responsible for medical note storage post-expedition. This may be straightforward if travelling with a large organisation, as they should have a suitable system and policy in place, but don’t assume and do check. If it is a smaller expedition, be aware that you may be required to be the ‘data controller’, which comes with significant responsibility and commitment. For more information and advice, speak to your defence union.

The Medical Protection Society (MPS) were approached for comment and provided information relevant to storage of medical notes which aligns with the above information. The Medical Defence Union (MDU) also produces guidance on record keeping.¹² Both are happy to be approached for assistance.

Take home messages

• Remind yourself of your professional body’s expectations for good note keeping.
• Decide how you intend to create and store notes for the expedition, and tailor this to your environment.
• Medical notes require storage for 8 years post expedition.
• Consider who is the ‘data controller’ when planning the expedition, as this determines who is responsible for storage of all medical notes from the expedition.
• Contact your medical defence provider to clarify any legal elements of clinical note storage.

References

1. General Medical Council (2013). Good Medical Practice. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice (Accessed August 2023)
2. Nursing and Midwifery Council (2015). The Code. Available at: https://www.nmc.org.uk/standards/code/ (Accessed August 2023)
3. The Health and Care Professions Council (2023). Standards: Record Keeping. Available at: https://www.hcpc-uk.org/standards/ (Accessed August 2023)
4. British Standards Institution (2014) BS8848: Safer adventures: Managing the risks of adventure travel. Available from: https://www.bsigroup.com/localfiles/en-gb/consumer-guides/resources/bsi-consumer-brochure-adventurous-activities-uk-en.pdf (Accessed August 2023)
5. Royal College of Surgeons of Edinburgh (RCSEd): Faculty of Pre-Hospital Care (2020). A brief review on BS8848: 2014 and its relevance to new or inexperienced expedition ‘medics’. Available at: https://fphc.rcsed.ac.uk/media/2966/bs8848.pdf (Accessed August 2023)
6. Royal College of Surgeons of Edinburgh (RCSEd): Faculty of Pre-Hospital Care (2020). Updated guidance on medical provision for wilderness medicine. Available at: https://fphc.rcsed.ac.uk/media/2781/updated-guidance-on-medical-provision-for-wilderness-medicine.pdf (Accessed August 2023)
7. General Medical Council (2017). Confidentiality: good practice in handling patient information. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/ (Accessed August 2023)
8. General Data Protection Regulation (GDPR). Available at: https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/ (Accessed July 2023)
9. Health and Social Care Act (2012). Available at: https://www.legislation.gov.uk/ukpga/2012/7/contents/enacted (Accessed July 2023)
10. NHS Records Management Code of Practice (2021). Available at: https://transform.england.nhs.uk/information-governance/guidance/records-management-code/ (Accessed July 2023)
11. The Private and Voluntary Health Care (England) Regulations (2001). Available at: http://www.legislation.gov.uk/uksi/2001/3968/contents/made (Accessed August 2023)
12. Medical Defence Union (2013). Good record keeping. Available at: https://www.themdu.com/~/media/Files/MDU/Publications/Guides/UPDATED%20Consultant%20pack/B4%20Good%20record%20keeping.pdf (Accessed July 2023)

The post Note-Keeping on Expeditions appeared first on Adventure Medic.

Dr Hannah Lock is a Senior Clinical Fellow in Emergency Medicine at Ysbyty Gwynedd, Bangor. Since 2018 she has also worked as an Expedition Doctor, specialising in high-altitude environments, and has been involved in medical research on three high-altitude research expeditions. Hannah is part of the teaching faculty for UCLan’s Diploma in Mountain Medicine and World Extreme Medicine. In 2023 she launched an online learning platform called Humans At High Altitude, sharing knowledge about high-altitude medicine with both medics and lay adventurers. 

Introduction

Whether you’re planning a personal high-altitude adventure or taking a job as a medic on a high-altitude expedition, a thorough understanding of how this environment affects us is key to preventing, assessing, and managing medical issues. This article aims to summarise the basics of high-altitude medicine to get you started.

In 2018 I was trekking in the Khumbu region of Nepal with a friend and one porter. We had been walking for seven days to reach the little village of Chukhung (4730 m) and I was tucking into my evening meal in the cosy tea house when our porter, Bishal, came over looking concerned. He had been chatting to the owner of the tea house who was worried about one of the other guests and knowing I was a doctor, Bishal came to ask if I would help. 

The normally fit and well 21-year-old man was lying on his bed, looking pale and unwell. He told me he had vomited, had a severe headache, and felt very tired. He and his two friends had walked from Lukla (2800 m) to Chukhung (4739 m) in three days and none of them felt great but he was the worst. They had no prior experience at high altitudes and minimal knowledge of altitude illness. They planned to trek over the Kongma La, a pass at 5555 m, and walk down to Lobuche (4910 m) the following day. 

After a more detailed history and brief examination, I concluded that the man was suffering from moderate-severe Acute Mountain Sickness and explained to him what this meant. I gave him some of my own Acetazolamide, Ondansetron, and Paracetamol. I made him a litre of fluid with electrolyte mix and told him to drink this over the next couple of hours.… Read on to find out what happened to him at the end of the article… 

Basic Altitude Physics

Figure 1: Widely accepted definitions of altitude zones

Simply put, as altitude increases, the barometric pressure decreases. At lower pressures, gas molecules are more spread out in any given space. This results in there being fewer gas molecules in each breath we take in at high altitudes, which includes lower amounts of our favourite gas, oxygen. Oxygen still makes up 21% of the total molecules in that breath of air, but compared to at sea level the actual quantity gets lower as we ascend. Make sense?

To give us some relatable numbers, compared to at sea level there is effectively only two-thirds as much oxygen available by the time you reach 3000 m, only half by the time you reach 5500 m, and only one-third at the summit of Everest! So how do humans cope with this huge reduction in available oxygen? The answer lies in adequate acclimatisation. 

Acclimatisation To High Altitude 

Some Indigenous populations have lived at over 2500 m for thousands of years and have evolved genetic adaptations to cope with high altitudes. Lowland populations do not have these adaptations and are not automatically physically prepared for high-altitude living.

Acclimatisation to high altitude describes the physiological processes of adaptation to low oxygen levels. The body is forced to adapt and work hard to cope with worsening hypoxia. Acclimatisation is a gradual process that takes days to weeks and the rate of acclimatisation differs between individuals. A well-acclimatised person can tolerate altitudes that would kill a person that has just arrived. Poorly acclimatised people are most at risk of altitude illness. 

Within hours of being at high altitude, our hypoxic ventilatory response reacts to the decreased partial pressure of oxygen in the arterial blood, and the result is an increased respiratory rate and depth of breathing. Our heart rate and stroke volume also increases. More fluid is excreted from the renal system to increase the concentration of haemoglobin in the blood. 

In the following days, oxygen is released more readily from red blood cells to be utilised in the tissues, we increase blood flow to vital organs such as the brain, and we start to produce more erythropoietin to stimulate the production of more red blood cells to increase our oxygen carrying capacity. 

Altitude Illness Overview

Acute Mountain Sickness (AMS)

AMS is a collection of symptoms generally starting 6-12 hours after arriving at an altitude greater than 2000 m. The diagnosis of AMS is a Headache + 1 more of the following symptoms:

• Nausea and/or vomiting
• Reduced appetite
• Fatigue
• Dizziness

The headache tends to be throbbing in nature, worse on exertion and at night. AMS is common when ascending > 2500 m rapidly and gets more common at higher altitudes. 

Risk factors for AMS include rapid ascent, altitude > 4500 m, previous altitude illness, physical exertion at high altitude, pre-existing lung condition, young age, and limited knowledge of the condition. 

The treatment for AMS tends to be relatively simple – stop ascending, rest, simple analgesia, antiemetic if required, and rehydration. Descent should always be considered, especially in severe cases. If the casualty shows no improvement overnight then descent should be arranged. Additional management strategies for moderate to severe cases include Acetazolamide (Diamox) 250 mg BD PO, Dexamethasone 4 mg QDS PO, supplemental oxygen, and portable hyperbaric chamber use. None of these replace the need for descent in severe cases. Descent is the gold standard treatment for all severe altitude illnesses. 

High Altitude Cerebral Oedema (HACE)

HACE is a rare but life-threatening high-altitude illness that must be recognised and acted on urgently. HACE is most commonly seen at altitudes over 5000 m, however, there have been rare cases seen at altitudes as low as around 2500 m. As with AMS, the pathophysiology is not completely understood but HACE is thought to be a continuation of AMS with both vasogenic and cytotoxic mechanisms hypothesised. 

HACE is diagnosed by the presence of current or recent symptoms of AMS plus any new neurological signs. Often the sufferer may not be aware of their condition and it may be team members who first notice the signs. The most commonly recognised neurological signs are:

•  Ataxia 
•  Confusion or disorientation
•  Speech disturbance
•  Behaviour changes e.g. withdrawn, violent, euphoric
•  Urinary incontinence or retention
•  Seizures (late sign)
•  Reduced consciousness

Unless there is an obvious, reversible alternative diagnosis (e.g. hypoglycemia in a known diabetic and the casualty improves fully with glucose administration), any of these signs at an altitude greater than 2000 m should be managed urgently as HACE. 

Risk factors are very similar to those of AMS, with a rapid ascent to high altitude being the most important. 

Managing HACE always involves organising urgent descent to an altitude of at least 500 m lower than the point at which symptoms or signs of HACE occurred. Preferably the casualty should be carried rather than walked down, or a helicopter called if available in the region. In addition, Dexamethasone 8 mg PO initially (followed by 4 mg QDS) should be started and supplemental oxygen administered if available. They should not be left alone and good supportive care is essential. If descent cannot happen immediately e.g. too dangerous to move the to group due to weather conditions, a portable hyperbaric chamber can be used if available. 

A portable hyperbaric chamber (see picture below) is a sealed bag in which a conscious casualty can be placed for several hours at a time. By pumping air into the bag, the pressure inside increases, and this simulates a lower altitude than the true elevation of the environment, hence increasing the available oxygen inside the bag. Most bags or chambers can simulate altitudes significantly lower than the true altitude, enough to improve someone’s symptoms significantly in many cases. This is only a holding method, however, because as soon as the person leaves the bag, their hypoxia and symptoms can return rapidly. Note that this is not appropriate management for unconscious patients.

High Altitude Pulmonary Oedema (HAPE)

HAPE is another potentially life-threatening high-altitude illness that must be managed with urgency. It generally occurs a few days after the ascent to >2500 m, with the incidence increasing with altitude. Some data suggests the incidence is about 15% at 5500 m. This is a non-cardiogenic pulmonary oedema thought to be caused by a patchy distribution of vasoconstriction across the lungs in response to hypoxia. The uneven spread of vessels contracting leads to stress failure of the membranes and fluid leaking from the capillaries into the alveoli.

Symptoms may start mildly but can rapidly progress to severe: 

• Significant fatigue
• Shortness of breath, which does not recover with rest
• Cough, which is initially dry but can become productive
• Haemoptysis 
• Chest pain
• Low oxygen saturations and increased respiratory rate (often useful to compare to those of people feeling well who have had a similar ascent rate)
• Crackles on auscultation, often mid-zones worse
• AMS symptoms commonly occur

Risk factors for HAPE are the same as for AMS plus altitude > 4500 m, recent or current inflammatory or infectious lung condition, male sex, cold, previous HAPE, small lung volumes, conditions predisposing to pulmonary hypertension e.g. structural heart defects, COPD, pulmonary fibrosis.

As with HACE, managing HAPE always involves organising urgent descent. Consider differential diagnoses but when in doubt, treat them as HAPE. The casualty must not be left alone, keep them sat up and avoid any further exertion. Supplemental oxygen should be administered if available and Nifedipine 30 mg given. There is no role for diuretics in the treatment of HAPE as this is not a cardiogenic fluid overload and often the casualty will have intravascular volume depletion. If descent cannot happen immediately (e.g. too dangerous to move the to group due to weather conditions), a portable hyperbaric chamber can be used if available. A chamber can also be used to stabilise a casualty whilst descent is organised but its use must not delay the evacuation.

Preventing Altitude Illness

As with any medical condition, prevention is better than cure. There are several ways in which to prevent high altitude illness but the most important is to allow adequate acclimatisation by gradual ascent. 

The consensus from most medics including the Wilderness Medicine Society panel of experts is that above 3000 m, you should not not increase sleeping elevation by more than 500 m per day. This doesn’t mean you can’t ascend more than this during the daytime (e.g. walk up and over a pass gaining 800 m height), but that you must descend again to sleep no higher than about 500 m from the altitude of the previous night (e.g. descend 300 m vertical height down the other side of the pass you just climbed in the above example). 

It is also advised to include a rest day every 3 – 4 days to aid acclimatisation. During this rest day, gaining altitude on a day trip is fine, so long as there is no increase in the sleeping altitude. Vigorous exercise is not recommended for a day or two after arriving at a modest altitude. 

Managing risk factors is also important e.g. maintaining adequate hydration and ensuring good food and hand hygiene to reduce the risk of any concurrent illness. 

Medical Prophylaxis

The only drug that aids acclimatisation to reduce the risk of altitude illness is Acetazolamide (mentioned earlier in the treatment of AMS). Other drugs can reduce the risk of HACE and HAPE but do not work by speeding up acclimatisation. Acetazolamide increases the hypoxic ventilatory response by inducing metabolic acidosis, leading to oxygen availability. 

One of the most common questions I get asked is whether someone should take Acetazolamide to aid them on their high-altitude adventure. Of course, this must be answered on a case-by-case basis taking into account medical history, medication list, etc. The WMS approach to answering this question recommends a risk stratification approach. The assessment must include their planned ascent profile and previous history at altitude to conclude their risk level. See Figure 2 for the WMS risk categories for AMS.

Figure 2: Copied from the Wilderness Medicine Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update.

Summary

Prior knowledge of altitude illness and gradual ascent to high altitude remain the best ways to prevent all altitude illnesses. Acetazolamide aids acclimatisation but is not a magic bullet and does not replace the need for safe ascent profiles. Any new neurological signs at high altitude should be treated as HACE until proven otherwise. HACE and HAPE are life-threatening conditions and someone displaying signs of either (or both) of these requires urgent support and evacuation to lower altitudes. Descend. Descend. Descend!

What Happened To The Man in Chukhung?

I had formulated some evacuation plans in case my unexpected patient had not improved or had deteriorated, but when I went back to see the young man I was relieved to find him looking a bit better. He had managed to keep down the fluids with no further vomiting and his headache had reduced from severe to moderate.

The following morning I checked on him before setting off for my own trek and was pleased to find he was feeling much better but still very tired. I advised him not to trek that day, but to rest, hydrate and acclimatise to the current altitude. I gave him another dose of my own Acetazolamide and advised him that only if he felt well the following morning should he attempt to continue the trek and that if he started to feel worse again to descend. I spent some time with him and his friends explaining some basic altitude physiology and medicine. I didn’t see them again after this so I don’t know what happened later but I do know that this illness could have been prevented with a little bit of knowledge and a slower ascent rate. 

Where To Learn More…

To gain a deeper understanding of altitude medicine and gain confidence and knowledge before working as a medic at high altitude, my online course An Introduction To Humans At High Altitude is ideal. This is the resource I was looking for when I started my expedition medicine journey. It’s a self-directed course/e-learning package with over five hours of pre-recorded videos, practical activities, and case studies broken down into bite-sized chunks. It covers everything from altitude physiology, illnesses (beyond those in this article), route planning, sleep, and nutrition, how to prepare for the high altitude environment, medical kits, equipment, and managing emergencies. Once you sign up, you have lifelong access. 

Students get a 50% discount off my online courses! Get in touch with me via my website to ask for a student discount code.  

I’m currently creating a second online course, Women’s Health On Mountain Adventures And At High Altitude which will be launched in Spring 2024. 

Website: drhannahlock.co.uk

Instagram: hannah_lock_exped_doc

LinkedIn: Dr Hannah Lock

The post High Altitude Medicine Overview appeared first on Adventure Medic.

The process of acquiring indemnity or insurance for expeditions has become increasingly opaque. Whilst medics are still gaining indemnity or insurance without issue, anecdotally the pandemic brought expedition work under scrutiny and refusals are occurring. As individuals who are passionate about adventure medicine in all its forms; Adventure Medic has produced this guide to help with the indemnity process. This is the second in our ‘Masterclass’ series designed to help practicing expedition medics navigate some of the roadblocks we all encounter.

Whilst this is UK-focused, it highlights considerations relevant to those worldwide. Be mindful that this guidance is dynamic and specific advice will likely change. Please continue to enquire with indemnity organisations and let us know if updates are required.

What is indemnity?

Indemnity is designed to provide financial protection to medics against legal and compensation costs that may arise out of claims due to negligence, mistakes, or malpractice. In practice, on expedition, if you make a clinical call and that patient comes to harm because of this, they can claim against you. An extreme example would be allowing a patient with overt signs of heat illness to continue to run a jungle marathon, who later collapses and has a seizure.¹

In the NHS, doctors’ indemnity is provided through clinical negligence schemes.²

“Under the law, a doctor must have cover against liabilities that may be incurred in practicing medicine having regard to the nature and extent of the risks. The type and level of insurance or indemnity a doctor requires depends on factors including where a doctor works, whether they are employed (and, if so by whom and for what services) or self-employed, and the nature of work they do.”

Often this indemnity is extended through an additional policy with a medical defence organisation. The defence organisation can assist with a wider range of legal and ethical issues relating to professional practice. The scope of this is more extensive, for instance, the Medical Protection Society states members can request assistance with;

“clinical negligence claims, complaints, medical and dental council inquiries, legal and ethical dilemmas, disciplinary procedures, inquests and fatal accident inquiries.” ³

For GPs state-backed indemnity provides indemnity for clinical negligence claims arising from primary care within the NHS in England or Wales. The scope of this is, again, specific and does not extend to other areas such as guidance with coroners’ inquests.⁴

How does indemnity compare to insurance?

Medical malpractice insurance is usually provided as a stand-alone policy and is tailored and specific to the job (e.g. an expedition medic role).⁵ It usually comes from a commercial insurance company unlike indemnity which is provided by membership-based not-for-profit medical defence organisations. Further information can be found at this link.

Why do I need indemnity or insurance on expeditions?

Expedition medicine and voluntary work often cover areas of practice extending beyond those specified in day-to-day indemnity protection. As such, expedition medicine and voluntary work fall under the remit of private practice. They therefore require additional indemnity or an extension to existing protection. This is true regardless of whether the work is in the UK or not, as for many hospital doctors their indemnity confines their work to within their state (e.g. NHS) hospital in alignment with their job specification.

Failure to acquire indemnity or insurance could lead to claims that may not be covered. This could impact practitioner finances, security, and medical registration significantly. This is often cited as one of the arguments that supports fair remuneration for doctors on expeditions.

Adventure Medic provides further information on the remit of an expedition medic and why this is pertinent here. Adventure Medic is also currently producing an article on pay for expedition medics – please look out for this publication shortly.

How do I acquire indemnity or insurance?

Acquiring indemnity or insurance can be a complex process and it is advisable to start early. This ensures there are no surprises and it allows you to confirm with the expedition company that you can cover the trip. Quotes acquired can be held on file by some companies for purchase at a later date.

Doctors

Defence unions
Indemnity covering expedition work can be an extension of indemnity protection you already hold or obtained through a new provider. This is achievable with the following not-for-profit medical defence organisations:
– Medical Protection Society – MPS
– Medical Defence Union – MDU
– Medical and Dental Defence Union of Scotland – MDDUS
The MDU has advised that all applications will be considered individually. They will endeavor to cover expedition medics where possible. They have offered this article to any seeking MDU indemnity.

Expedition company
Alternatively, the expedition company or other companies supplying healthcare practitioners may be able to subcontract the practitioner covering them under their own insurance.

Insurance providers
Insurance for expedition cover and approaching insurance companies directly is an option where other avenues have failed. Two companies which can provide this are:
– Saepio
– Beazley – contactable directly or through ADF insurance

Societies
Additionally, gold members of the British Mountain Medicine Society can access indemnity or insurance as part of their membership provided they:
–  Have paid for ‘gold membership’
–  Hold the Diploma in Mountain Medicine (DiMM)
–  Cover has been confirmed with the society
–  Are not undertaking an expedition in the USA

Gold members must complete a short declaration form which is sent to the insurers to confirm their eligibility and to grant indemnity insurance. Silver members can also access indemnity insurance, but the applications must be individually vetted to ensure their experience is adequate. Prices can currently be found here.

There is some consideration of equivalent qualifications to the DiMM. Recently the Diploma in Expedition and Wilderness Medicine has been authorized as holding equivalence to the DiMM by the Society and therefore is eligible with gold membership for indemnity insurance. For other qualifications, the final decision lies with the BMMS underwriters.

Paramedics

For paramedics we have been told cover is often automatic because the remit of their work allows them to work in pre-hospital environments. This is mostly provided by the College of Paramedics. Further information for expedition paramedics can be found here. It is worth being mindful that a pre-hospital environment in the UK streets may not hold equivalence with that in a jungle or polar environment (for example). Aim to clarify with the college your cover and disclose trip details before departing.

Nurses and allied healthcare practitioners

Our insight into indemnity for nurses and physiotherapists is currently lacking. If you’d like to share this information and support Adventure Medic in supporting your fellow practitioners, do get in touch.

How do I ensure the policy covers what I need?

It is essential to thoroughly read and confirm the protection offered will cover the remit of your work. For example; some may state that protection ends on the last day of your expedition and therefore claims falling after this are not covered! Clarify this fully with the company to ensure there are no exceptions. Check if the cover includes your pre-screening – which will fall prior to the start date of the expedition.

How do indemnity or insurance providers assess if they can provide cover?

After providers have collected details from you they make an assessment called the ‘rating factor’ based on the activities and details given. This is dynamic and can change throughout the year. For instance, since COVID-19, medical cover on seafaring vessels that cross oceans and are not within easy reach of land has increased in risk. The new rating factor means many indemnity organisations or insurers will not provide indemnity or insurance. However, where your application has been made to an insurer, rather than an indemnity organisation, these are businesses. They may adjust rating factors and risk assessments if they see demand and that there is money to be made. Never be shy about asking for quotes as requests can alter the market for the good of all.

If your case is being deliberated or is complex, which, often expedition requests are, then it may be sent to the underwriters for the organisation. They will make a case-by-case assessment of whether they feel they can offer protection for the role. They may request additional information to ensure they have a full understanding of the role you are undertaking. In some organisations they are not directly contactable over the phone and prefer to come back to you via email. They will often offer the final say on whether indemnity is provided.

Beware; this process can take 2-3 weeks so it is strongly advisable to try and acquire a quote for indemnity or insurance well in advance of your trip. This can be held on file and paid for later. It also allows time to approach other organisations if adequate protection cannot be provided.

What things will the indemnity providers or insurers need to know to assess me?

Short list

The information which indemnity providers or insurers will require to assess eligibility:

• Destination
• Dates of trip
• Organisation you are working with – charity, institution, company, hospital, etc
• Details of your seniority, experience, training, or relevant qualifications
• Whether you have shared or overall clinical responsibility
• Will there be any supervision of the role?
• Is this supervision remote or on-site?
• A brief description of your work and role on the expedition
• Whether the role is paid (and if paid how much)
• A brief description of those you will care for (nationalities, ages, celebrities, pregnancies)
• Any indemnity or other insurance you already hold, or if any indemnity or insurance is provided by the event organiser/company

Destination

The legalities of what cover can be provided and in what locations are nuanced. By and large a license to practice in the UK is accepted by indemnity organisations and insurers as a sufficient qualification to allow you to cover your own group on expedition. However, different countries have different legal, insurance, regulatory, or licensing requirements to practice in their countries. Ideally, these should be known. It is essential to explore this where your work includes any of the following:

• Involves caring for the local population
• Is humanitarian work
• Is officially paid (as opposed to voluntary)

This is illustrated by the arrest of Sarah Kemp,⁶ an Australian doctor who was working in a travel clinic in Nepal attending to foreign diplomats, tourists, and aid workers. Allegedly she was arrested along with 17 other foreign doctors as she did not hold a license to practise medicine within Nepal. Following this one charity operating in Nepal, the International Porter Protection Group (IPPG), began registering its volunteer doctors in Nepal. A process that initially took 35 days. This is a lengthy time to build into a trip if required to safeguard your work and is on the shorter end of the spectrum with some registrations taking 3-6 months.

Different countries may have different legal, regulatory or licensing requirements that need to be met to allow a doctor to practice medicine in that country. It remains the medic’s responsibility to ensure that they meet any such requirements. For example, if insurance is a legal requirement in the country you are travelling to (rather than discretionary indemnity), you may be advised to seek an alternative provider.

Provider specifics
At the time of writing  MDDUS specializes in the separate legal jurisdictions that exist within England, Scotland, Wales, Northern Ireland, the Channel Islands, and the Isle of Man, and does not offer membership benefits outside of these jurisdictions, other than in respect of GoodSamaritan acts, humanitarian work and limited voluntary or expedition medicine. Upon request and subject to underwriting review, membership can be extended to provide access to indemnity for bona fide humanitarian work. This work can take place globally but access to indemnity is provided on the basis that claims must be brought in a court within the UK, Channel Islands, or Isle of Man.

Saepio requires a pre-agreement to provide cover in the USA and Canada.

There may be some flexibility in registration requirements where you work in a supervised or ‘fellowship’ position under the guidance of a senior in-country doctor who can sign off your practice. This must be clarified with the provider of the indemnity cover.

Duration of trip and cover

For some indemnity providers indemnity costs will vary based on whether the medic has overall clinical expedition responsibility or shared clinical responsibility. The former is considered higher responsibility and risk. Cost is mostly decided on a case-by-case basis, and due to fluctuations organisations could not offer further insights with long-term accuracy.  

It is important to clarify the duration of protection required for the indemnity or insurance, as different companies may have different limits. Most indemnity organisations offer occurrence-based protection. MPS members for example:

“remain entitled to request advice and assistance for any matters arising from their expedition work at any time, even if they have since left MPS membership or ceased practicing.”

Saepio covers a year post-expedition by default but can extend this on asking.

This is not true of all providers and the utility of a policy that ends on the day your trip finishes is debatable!

Experience and responsibility

These are both extremely nuanced. Some indemnity or insurance companies more readily understand seniority in terms of career progression or profession. For example; a registrar doctor may be treated as more independent and experienced in seniority even if working with a senior prescribing nurse who has done multiple expeditions and has multiple expedition-related qualifications. This is because these qualifications are not always considered by indemnity providers.

Some organisations prefer to consider cover based on the number of years post-graduation and will set a threshold before you can be considered for more senior roles such as overall clinical responsibility.

Provider specifics
MPS advises that it reviews each application for indemnity for expeditions on a case-by-case basis and takes into account multiple factors, including clinical experience, relevant training and qualifications, and level of responsibility/supervision.

One organization, the MDDUS, advises that for UK-based expeditions it would consider work on a case-by-case basis looking at the trip, and the practitioner’s qualifications and experience. This usually requires referral to the underwriters – the process for which is detailed below.

Lastly, Saepio will utilise your CV to make a personal assessment of your request.

Supervision

For some practitioners, supervision may be required to obtain indemnity or insurance. This varies on a case-by-case basis and may require a supervisor to be sourced of a certain seniority. This person often needs to be sourced by the practitioner if one is not immediately linked to the role. The supervisor may be remote or on-site depending both upon what the indemnity or insurance provider requires, and what the employing company can subsidize. Ensure, if you are sourcing your own supervisor, that they have full awareness of what you are doing, are happy to be on-call to advise at all hours, and feel comfortable advising within the remit of your expedition. For instance, an altitude expedition will benefit from a supervisor who has altitude illness experience.

Nationalities

Some indemnity or insurance companies will not indemnify care provided to attendees of certain nationalities. Usually, this pertains to citizens of countries where legal cases against practitioners are common and expensive, for example, the USA and Canada. This often requires clarification with the provider but can be an expensive minefield.

Most policies contain a clause that navigates this by stating that indemnity or insurance will be provided only if claims are made in the country of “ membership.” This refers to the country in which a member holds membership for the purpose of their regular medical/clinical practice.

The nationality of the expedition company should not affect the support indemnity providers can deliver, so long as the claim is made in the practitioner’s home jurisdiction/country of core membership.

If a claim is made out of the practitioner’s home jurisdiction then some indemnity providers will assist in moving it to the home jurisdiction. Not all will do this.

Special populations

MDDUS and BMMS memberships advise that they can indemnify for the care of participants of any age. Saepio will make an assessment based on ratios – if your trip is predominantly children, it is unlikely to be covered, but if the trip is predominantly adults (60:40) it may be covered. 

Pregnant women and high-profile participants may not be covered by policies or will incur vastly increased costs.

Dual insurance

If the expedition company or your own insurer is already providing insurance then this may invalidate further policies which are taken.

Subcontracting

If you are working for another company, for instance, a production company that has subcontracted you on behalf of another provider, then you need to ask your indemnifiers if they offer ‘company indemnity to principle’. This determines if your insurance for negligence will extend to the company subcontracting you. If it will not, then technically the company you are working for could also sue you for negligence if you leave them exposed.

Additional questions may be asked:

• Will the work involve any new or experimental treatment?
• Will the work involve prescribing any drugs off-license?
  – For instance penthrox in under 18s – widely used on expeditions but not officially licensed
• Confirming if you will be undertaking any of the following:
  – An expert demonstrating a procedure for the benefit of local practitioners
  – An expert providing treatment to a patient or patients that would not otherwise be available in that country
  – Cosmetic medicine/surgery
  – Highly paid work in a developed country
  – Neurosurgery
  – Obstetrics
  – Orthopaedics
  – Teaching/educational work
• Confirming that local indemnity cannot be sourced in the destination country
• Providing a CV
• Are any of your patients or clients elite or professional athletes?
• Are any of your clients high profile? – these participants can be especially hard to cover

Are there limits and excesses to this insurance?

Often excesses are not a feature of indemnity, but do ask as one insurance provider has an excess of £1000 per claim. 

Limitations should be specified by the provider. For instance, an example would be: :
– Indemnity covers only members of the organised group you are accompanying
– Assistance is provided only with claims brought against you in your home jurisdiction
– You must act within your competency. For assessing this and an expedition opportunity please see here. (hyperlink article for assessing an expedition opportunity)
– You need to meet legal, regulatory, or licensing requirements to practice in the country you are travelling to
– You are not managing any declared pregnancies

Can medical directors be covered?

Some companies (e.g. Saepio) will grade cover for medical directors based on the trip and rating factor and can supply it on a case-by-case basis. Other organisations should be contacted directly with inquiries. 

Are local guides and people employed by the expedition company covered?

The assumption is that anyone who is present solely for the purpose of the expedition should be counted as part of the team and therefore covered under indemnity.⁷ Saepio and MPS confirmed this is their policy.

What if I have been refused indemnity insurance?

Previous refusal for trips should not stop you from being granted expedition indemnity insurance from the same company in the future. Nor should it prevent you from approaching other companies for quotes.

Provider specifics
However, some companies, such as MPS, require you to have held core membership with them for 6 months prior to acquiring expedition protection. MDU, MDDUS, and BMMS also require membership (BMMs members must be gold). Some organisations will also require disclosure if you have had previous refusals. Saepio does not require membership and is happy to consider all requests.

Where these usual avenues have been exhausted, exploring subcontracting or private quotes for insurance through Beazley or ADF insurance can reap rewards.

Summary

The world of indemnity and insurance can be complex and a headache for many expedition medics. We hope this guide will help you navigate indemnity and insurance in the future to safeguard your own practice in adventurous medicine. Please utilise it and share it widely with others who could benefit. Above all, don’t be afraid to approach indemnity organisations and private insurers and ask. Assessments for indemnity are ever changing, and requests are often considered on a case-by-case basis. Your request may open doors for others in the future. 

We are acutely aware that information regarding indemnity and insurance for humanitarian work, dentists, nurses, and physiotherapists is lacking, although, many indemnity organisations are willing to provide protection for these roles.  As people who are passionate about protecting our future in this field, if you have found any information you feel would be useful to the community, please do get in touch.

References

1) Insurance, indemnity and medico-legal support. General Medical Council.
Available from: https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/information-for-doctors-on-the-register/insurance-indemnity-and-medico-legal-support
Accessed [26/03/2023]

2) What is indemnity insurance? Securenow_insuropedia
Available from: https://securenow.in/insuropedia/what-is-medical-indemnity-insurance/
Accessed [26/03/2023]
Updated 28/11/2022

3) About us. Medical Protection Society. Available from:
https://www.medicalprotection.org/uk/about
Accessed [ 26/03/2023]

4) State-backed indemnity. The Medical Defence Union
Available from: https://www.themdu.com/mindthegap#:~:text=What%20does%20the%20state%2Dbacked,duties%20in%20England%20and%20Wales.
Accessed [26/03/2023]

5) Medical Defence Organisations vs. Insurance Companies for Medical indemnity – Which is right for you? Medicas
Available from: https://www.medicas.co.uk/resources-guides/medical-defence-organisations-vs-insurance-companies-for-medical-indemnity-which-is-right-for-you#:~:text=One%20of%20the%20main%20disadvantages%20of%20medical%20malpractice%20insurance%20is,need%20to%20make%20a%20profit.
Accessed [26/03/2023]
Last updated 1/3/23

6) Australian doctor Sarah Kemp arrested in Nepal for practising without proper accreditation. Heanue S,
Available from https://www.abc.net.au/news/2018-02-01/australian-doctor-sarah-kemp-arrested-in-nepal/9381862
Accessed [26/03/2023]
Updated: 1/2/2018

7) Moore J and Winser S. Caring for people in the field. In: Johnson C, Anderson S, Dallimore j, Imray C, Winser S, Moore J, Warrell D. (eds) Oxford Handbook of Expedition and Wilderness Medicine. 2nd Ed. Oxford University Press; 2016. p.81-110

The post Indemnity or Insurance on Expeditions appeared first on Adventure Medic.

The field of expedition medicine is vast. Expeditions encompass a variety of remote locations, climates, agendas, and participants. They may differ hugely in the range of skills the medic requires. We’ve put together guidance on assessing expedition opportunities in order to decide on the right expedition for you.

Contents

1. You

Your first responsibility and obligation under Good Medical Practice¹ is to ensure you are acting within your competency. You should have the necessary skills, knowledge, and experience for the environment and expedition. If in doubt the Faculty of Pre-hospital Care, Royal College of Surgeons Edinburgh guidance for medical provision for wilderness medicine² can guide your choices. These guidelines give an idea of what competencies will be expected of you and can identify areas in your knowledge and skill base that need some buffing.² The below list can help target areas to improve your proficiency and confidence as the medic.

1.1 Education

An expedition medicine course is extremely useful if you think your knowledge and skills could be improved. Remember that being an expedition medic is often more about logistics – casualty evacuation, communications, supplies – than injuries and medical conditions. Courses should cover these aspects.

There are a variety of expedition and wilderness medicine courses and diplomas on offer, and choosing one is almost an article in itself. Adventure Medic has published a number of recent and informative reviews which are all written by previous course delegates. As a minimum, most expedition companies look for a week-long course. A list of courses can be found here on our resources page.

Although going on an expedition/wilderness medicine course will provide you with the basics it is unlikely to be tailored to your specific expedition and environment. In addition, these courses can be expensive, and if expeditions are your only income you will be unlikely to earn this money back. Scrutinise course contents before selecting to make sure it meets your own learning objectives.

1.2 Expectations vs Proficiency

Get a thorough understanding of the nature of the trip and the participant demographics before accepting. Be honest about your own experience in relation to this. You should be clear on the company’s expectations of the expedition doctor. Ensure these are reasonable and that you have capacity to meet them. If you claim to be a ‘mountain medicine expert’ then you may be expected to take on roles and responsibilities which are outside of your competence.

You should be familiar with all the medical kit you carry. For example, if based remotely for many months with a dental kit then having some experience of removing teeth is important.  A caveat to this is telemedical support which is an ever-expanding area in expedition and wilderness medicine.

Experience also covers your own comfort and capability in the environment or activity. It is easier to look after others if you are able to look after yourself, you should be at least as proficient, if not better than the clients you are looking after in any expedition activities. Your workload will likely involve caring for others between your own personal admin. Famniliarity and experience allow you to keep some head-space free for the medical aspects of the trip, and any other problems you might encounter along the way. Taking a job as a ship medic only to find out you are susceptible to seasickness is one example of a less-than-ideal situation.

However, experience expands beyond medical and environmental skills. Generally, the bread and butter of being an expedition medic involves:

• Dynamic risk assessments –  hazard awareness and safely managing scenes
• Prompt decision-making in the management of patients
• Evacuation planning
• Situational awareness including human factors
• Screening and briefing
• Liaison and communications skills with all team members

These are probably the most important skills of a successful expedition doctor.

1.3 Personal Health

Ensure you are healthy enough to support the expedition. A good baseline level of physical fitness is mandatory. If you think your physical fitness could use some work, start early – you may need to push yourself to get to casualties on expedition. In the time leading up to your medical expedition career, get outside and put your outdoor skills to practice in activities you hope to work as medic in; for example tyre hauling as a surrogate for pulk pulling.
Finally, remember to pack your own personal medications if you have any medical conditions.

Mental health is often an overlooked aspect of self-care on expeditions. Remember, you are often out with your own comfort zone; environmentally but also geographically, and emotionally distanced from loved ones. Expeditions are exhausting; the physical strain of the activities combined with sub-optimal sleep and the daily mental responsibility of looking after the health and safety of the group can be extremely energy-demanding. Acknowledge this and look after yourself. A top tip is to find some quiet time in and amongst the hectic expedition day to reflect on how you are feeling and the events of the day. Keeping a journal is a good way to decompress  – and also provides a record of memories and funny stories to recount later.

2. The Expedition

2.1 The Expedition Company

Make yourself familiar with the expedition company. Explore their website to assess what their company experience is and what they are advertising. Speak with colleagues who have been on expeditions with them – this provides invaluable insights and tips for approaching practicalities.

Set up a phone call to discuss the expedition in detail with a member of the expedition company. List questions to ask them in preparation. The level of understanding and response to your questions can be very revealing. Participant welfare, health, and safety are your priority, however, this may not always be the expedition company’s top goal. Ensure your company has clear risk assessments and evacuation plans. These should cover emergency medical evacuation protocol, relevant natural disasters (floods/tsunamis/storms/hurricanes), civil unrest, missing participants, lost passports, and missing flights to name a few possibilities. Clarify when you will expect to receive documents such as; participant health declarations, evacuation plans, and flight information. It is imperative to know about the logistics of all evacuation plans, and which personnel from your expedition company will be involved. Poor risk assessments and evacuation plans are the most likely aspects of expeditions to let you down.

Ensure that their protocols meet with your own ethical and moral standards – for example; their policy on treating local staff. At Adventure Medic, we strongly believe that you are responsible for the well-being of everyone on your trip, including porters. The International Porter Protection Group made recommendations for trekkers and porters on their trip. Although this organization is no longer operating Adventure Medic stands by the principles which can and should be referred to here.

It might also be helpful to make yourself aware of the Specification for the Provision of Visits, Fieldwork, Expeditions and Adventurous Activities Outside the United Kingdom (BS8848, 2014).³ This is the national standard for managing risks on expeditions out with the UK and draws up specifications to ensure effective operational systems are in place to assess and manage the risks associated with overseas adventures.

2.2 Medical Director

Many expedition companies will have a ‘medical director’. However, this title does not indicate a standardised job specification and this role varies hugely between different companies. Larger or longer-standing companies are likely to have one, and clarifying their role is essential so that you know when to call on their assistance. Some will be involved with medical kit building and guidance, some with screening, and some on-call for remote advice, evacuation guidance, and logistics. If there is no on-call medical director you will need to establish if you require a supervisor on-call (which you may need to source yourself if you are more junior, in order to facilitate your indemnity insurance). Consider exploring if there is a remote telemedical service provided for support and guidance.

2.2 The Environment

The expedition environment will have a significant impact on the medical conditions you may encounter, and the contents of your medical and personal kit bag. An awareness of how remote and exposed you will be and for how long will influence what you wish to carry. Ensure again that you are comfortable with this and the evacuation times before taking on the expedition.

2.3 The Expedition Guides and Leadership

Thankfully, on almost all commercial or charity expeditions guides are employed. Guides may be in-country, out-of-country or you may have both. The expertise they bring to trips is often invaluable. They usually take the reigns of leading the group which allows you to prioritise medical decisions. It is worth establishing the background of the guide you are working with and what their qualifications allow. Contact them in the run-up to the trip as you will be working closely together. Avoid taking the chief leadership role on the expedition unless you have been specifically employed to lead the group, you feel the leader is compromised or you need to assert leadership due to health and safety. If this is an area you wish to expand on to build your own confidence prior to the expedition then the Summer Mountain Leader (and similar qualifications) are fun and viewed favourably by expedition companies. Some will use this as a benchmark to employ you as a joint group leader and medic which may increase your pay. Be wary of this role as it should be reserved for small groups only and where the medic feels they have the capacity to deliver both aspects. Regardless of additional leadership qualifications a broad outdoor skills base and common sense will stand you in good stead as the medic on any expedition.

3. The Participants

Make sure you know exactly how many participants you are responsible for and their ages. The ratio of participants to guides and participants to medics on the trip should not be excessive, and the ratios you’re comfortable with will vary depending on the trip. This information will help you anticipate their likely fitness levels, the medical input they will need, and the expected supervision level from guides. Knowledge of when and how you will receive their pre-expedition health questionnaires (or if you need to write one of these) is important as it will likely influence your risk assessments, medical kit preparation, and optimisation of the participants.

4. Health, Safety, and Logistics

4.1 Medical Kit

As medics, we are used to having access to kit in hospitals but we have to economise on expeditions. A fair bit of questioning is required to ensure the kit is correctly provided and is tailored to your trip and participants. The expedition company should be able to comprehensively answer the following:

• Does the expedition company provide you with a medical kit, or are you required to provide or assemble this yourself? If so, will they cover the costs of you supplying all the kit and also your time for putting it all together?
• When was the medical kit made? When was the kit last updated? How often does the medical kit get thoroughly checked for inventory and expiry dates? And by whom?
• Is the medical kit bag designed specifically for the location you are going to, and at that time of year? A medical kit bag for a trip to the saharan desert is vastly different from that for an expedition to altitude.
• What level of care does the medical kit provide? A full inventory is required for all items and if the company has a pre-assembled kit they should be able to send this to you.
• How big a group is the medical kit designed for? Are participants also advised to bring their own personal medical kits and spares of their own medications?

5. Financial

5.1 Indemnity

Indemnity insurance covers you legally for your medical work on an expedition and safeguards you and your career. Enquire about suitable indemnity cover early. If you are unable to access indemnity insurance it will prohibit you from acting as a medic. The insurers want to know if you are the sole or lead medic, the number of participants, your ‘grade’ or experience, the duration and destination, and the number and nationalities of the participants. You can find out a lot more information about this in our Guide to the Legal Aspects of Expedition Medicine and upcoming indemnity article.

Ask your expedition company if they will reimburse you for indemnity, as it can be a considerable cost. Expedition companies can often forget that this is a necessary part of being a doctor and that it safeguards the medic in a way travel insurance doesn’t.

5.2 Payment / Non-payment

Be clear about the deal you are being offered as expedition companies vary wildly in their willingness to cover costs. Get in writing a record of costs that will be covered, this should include:

• All flights
• Accommodation in-country
• Airport hotel stay / meals
• Transport fees in-country
• Medical indemnity insurance
• In-country expenses
• VISA costs
• The medical kit you have ordered

Often, the cost of personal kit, indemnity, and preparation time will be considerably more than the company thinks and may detract from your enjoyment of the expedition or leave you out of pocket. The latter should not happen.

Look out for our upcoming article on pay for expedition medics. To briefly summarise: our position at Adventure Medic is that being an expedition medic is a job, with professional risks and responsibilities. Ideally, it should include a daily pay rate, in addition to reimbursement for necessary kit purchases and indemnity costs. Fundamentally, expedition companies are paying for your time (both in the planning stages and in-country) as well as your knowledge, skills, and expertise. It is in the best interests of the expedition company to hire a reputable, professional, and thorough doctor with sound-decision making skills for their expedition.

As doctors, we have a professional responsibility and are influential in the field of expedition and wilderness medicine. We need to be advocates for each other and ensure that we are well respected, represented, and supported in the field. And thus, we should not be hesitant to expect payment for expeditions. It may also be appropriate to ethically question the payment of the expedition guides and how this compares to the payment of the expedition doctors.

Whatever expedition you choose though, and whatever costs your expedition company covers please make sure that you feel protected, and adequately compensated for your work. As a minimum, charity work / expeditions should cover expenses and personal time in the planning / preparation stages. Expeditions with charities often have limited budgets and as such these situations may be those in which it would be acceptable to not be paid a wage. However, you should never lose money on any expedition.

6. Summary

• Ensure that you have the right knowledge, skill set, and environmental expertise to fulfil the required competencies on the expedition – the faculty of prehospital care guidance can assist.
• Discuss with the expedition company their expedition, risk assessments. Evacuation protocols will often give insights into their proficiency.
• Establish the roles of the guides and medical director as you will rely on them for support during your expedition.
• Keep in mind the priorities of the expedition company and directors, as these will not always match with your own ethics and prioritisation of health and safety.
• Clarify the headlines regarding patient demographics and the medical kit so you tailor and prime each as needed.
• Open conversations early to ensure you are financially reimbursed and safeguarded with indemnity insurance.
• Early research and preparation when choosing an expedition will reduce stress and increase enjoyment in-country.

For your convenience, Adventure Medic has compiled a list of specific jobs and volunteering positions which is updated regularly.  A list of some expedition medicine providers is also a good place to start looking for your first expedition job. (Please note, however, we do not endorse organisations, or the contents of external websites or offer any adventure medicine work ourselves.) If you don’t find what you are looking for here, then try contacting some of these organisations directly, or alternatively peruse through the various expedition articles we have published on Adventure Medic’s Adventures page to see what others have done before and get some inspiration. Please mention us if you find your job through Adventure Medic. It keeps the wheels turning. Happy expeditioning.

References

1. Good Medical Practise, Domain 1: Knowledge skills and performance, General Medical Council
   https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-1—knowledge-skills-and-performance [Accessed 5/6/23]
2. Updated Guidance for Medical Provision for Wilderness Medicine, Faculty of Pre-hospital Care, Published 2019, pp 7
   https://fphc.rcsed.ac.uk/media/2780/updated-guidance-for-medical-provision-for-wilderness-medicine.pdf [Accessed 5/6/23]
3. BS 8848:2014, Specification for the provision of visits, fieldwork, expeditions and adventurous activities outside the United Kingdom. Published March 2014, BSI, https://knowledge.bsigroup.com/products/specification-for-the-provision-of-visits-fieldwork-expeditions-and-adventurous-activities-outside-the-united-kingdom-1/standard, [Accessed 5/6/23]

The post Adventure Medic’s Guide to Choosing an Expedition Medicine Job appeared first on Adventure Medic.

Third year medical student, Georgina takes us through a review of the literature regarding the aetiology, diagnosis and management of the most common otological conditions; barotrauma and decompression sickness.

Over recent years, the number of people recorded to have taken part in scuba diving has decreased with an estimated 2,717,000 divers in the United States in 2019 showing a 4.63% decrease from 2018. ⁽¹⁾ However, according to a 2021 Sports and Fitness Industry Report, although the number of casual divers (one to seven dives per year) decreased by 6.7% from 2019 to 2020, the number of more serious divers (eight or more dives per year) increased by 1.3% among the American population. ⁽²⁾

Dive injuries occur primarily due to the effects of pressure when moving through the water. There is an extensive medical questionnaire which divers are required to fill in before in order to go some way to mitigating these injuries.

When done correctly with experienced guides, diving is usually not an unsafe activity. Nevertheless, incidents do occur, even with professionals. In a report by Divers Alert Network (DAN) between 2010 and 2013, 43.75% of injuries were head and neck related and of these, 72.53% were injuries to the ear. ⁽³⁾

Injuries relating to the ear such as barotrauma (injury due to pressure change) and decompression sickness (DCS) are more common dive issues.

This review discusses the aetiology, diagnosis, and management of common otological consequences of diving with a specific focus on inner ear decompression sickness (IEDCS), inner ear barotrauma (IEBt) and middle ear barotrauma (MEBt).

Incidence

Dive injury incidence is low. In a study by the DAN, who looked at 9,000 divers who did 135,000 dives, decompression illness occurred at a rate of 0.03%. ⁽⁴⁾ The study was conducted following safe and accepted dive procedures. When an injury occurs though, rapid diagnosis is beneficial. This can be a challenge due to the diverse range of symptoms and severity. Decompressing after a dive is important but one should also pay close attention to symptoms that may arise afterwards.

Figure 1 shows the anatomy of the middle and inner ear for reference.

Physics

Decompression Illness

Decompression illness is an umbrella term for two distinct aetiologies: decompression sickness and arterial gas embolus.

Decompression sickness is more relevant to otology and is largely impacted by Henry’s Law.

Henry’s Law states, ‘as the partial pressure of a gas above a liquid increases, that gas becomes proportionally likely to dissolve in that liquid’.

Due to the increased pressure that divers are under, the gas they inspire has a higher pressure. This can cause supersaturation of tissues meaning that they are at their capacity for the amount of inert gas they can hold. ⁽⁴⁾

Decompression sickness most commonly occurs when divers surface too quickly as the gas in tissues isn’t given enough time to be released slowly leading to supersaturation and bubble formation. These bubbles of evolved gas can cause a direct or indirect effect. The direct effect results in damage as the bubbles can occlude vessels, leading to ischaemia. The indirect effect is caused by an inflammatory response which activates the clotting cascade. Decompression sickness can occur at different levels of severity, but at worst can cause serious damage to the central nervous system and the cardiorespiratory system. ⁽⁵⁾ Arterial gas embolus can occur as a consequence of DCS. It is when the alveoli become over inflated and nitrogen bubbles enter the bloodstream and travel to the brain, for example, potentially blocking major vessels. This is usually less relevant to otology.

Barotrauma

Barotrauma, the damage to tissues caused by the direct effects of pressure, follows Boyle’s Law.

Boyle’s Law explains that, ‘as you descend deeper into water, the volume of a gas decreases but the pressure increases substantially’.

All enclosed spaces in the body such as the paranasal sinuses and the inner and middle ear can be affected by this increase in pressure. If this pressure build up is left, it can lead to pain, haemorrhage and perforation of anatomical structures.⁽⁵⁾

Divers are taught to equalise early and often as they descend, using the Valsalva manoeuvre, to avoid barotrauma.⁽⁶⁾ This manoeuvre equalises pressure across the tympanic membrane. When equalising, the air is forced through the eustachian tubes into your middle ear. This increases the volume of gas in your middle ear and decreases the pressure. This happens because as the diver ascends the trapped air expands by three to five times in volume, dependent on dive depth. ⁽⁷⁾

Middle Ear Barotrauma

Aetiology

The most common difficulties experienced by divers are middle ear barotrauma (MEBt) and eustachian tube dysfunction. ⁽⁸⁾ Eustachian tubes connect the middle ear space to the throat. This connection allows the pressure in the middle ear space and the external auditory canal to remain balanced or equalised. On the descent, pressure release is an active process. On the ascent, however, it happens passively. Disruption to the release of pressure can cause issues.

As divers descend, ambient pressure increases meaning that the volume of the gas in the middle ear decreases. This creates a vacuum. If equalisation cannot sufficiently compensate for this, MEBt occurs. The vacuum created causes blood flow to local vessels to increase in turn causing inflammation. ⁽⁸⁾ Blood vessels can then rupture and with the subsequent pressure increase, perforation of the tympanic membrane occurs.

Diagnosis

MEBt can present with difficulty equalising, discomfort and a stuffy sensation in the ear. ⁽⁹⁾ Diagnosis is difficult as often requires symptom reports from the patient which can be subjective. If suspected, an otoscopic examination is required to determine the grade of the injury.

There are three grading systems for MEBt: the Teed, the modified Teed and the O’Neill. The Teed Classification (1944) has been modified over the years but the current and most relevant is the O’Neill Classification. ⁽¹⁰⁾ The O’Neill consists of three grades as shown in Table 1.

Table 1 – The O’Neill Classification (8)

Management

Most cases of MEBt are transient and may only require rest, a course of steroids or antibiotics. Grades 0-1 are mostly treated conservatively. In more severe cases, such as tympanic membrane perforations surgery might be considered. Diving should not be considered until injury and symptoms are fully resolved and in the case of perforation, the tear is fully closed. ⁽¹¹⁾

Inner Ear Barotrauma (IEBt) and Inner Ear Decompression Sickness  (IEDCS)

Aetiology

As the external pressure increases during descent, the tympanic membrane is pushed inwards. This increases the pressure in the cochlea. When the pressure differential rises above 90mmHg the ET tubes are no longer functional meaning the equalising of pressure can no longer take place. ⁽¹²⁾ IEBt can be termed implosive or explosive. The perilymphatic duct connects the cochlea to the subdural space in the superior cranial fossa. Subsequent failed Valsalva manoeuvres can therefore increase the intracranial pressure and the pressure in the cochlea. An increase in perilymphatic fluid pressure causes an explosive rupture whereas a decrease leads to an implosive rupture. Implosive rupture especially can have many subsequent effects such as tearing the internal cochlear membrane or basilar membrane.

A study by Nachum et. al. revealed that of divers diagnosed with IEDCS, 48% of them were suffering from other decompression illness symptoms. ⁽¹³⁾ Although not fully understood, IEDCS is believed to occur due to the formation of a bubble of compressed gas in the endolymphatic and perilymphatic spaces due to the supersaturation of local tissues. ⁽¹⁴⁾ A correlation between persistent foramen ovale (PFO) (a right-to-left shunt) and IEDCS has been seen suggesting that gas bubbles can enter the arterial circulation from the venous circulation rather than being exhaled from the lungs. This can cause ischaemic events due to gas emboli. In a study by Mitchell et. al., in cases where IEDCS was detected, 77% were also found to have a large right-to-left shunt. ⁽¹⁵⁾

Diagnosis

IEBt can present with problems with balance and coordination as well as tinnitus, sensorineural hearing loss and vertigo. ⁽¹⁶⁾ Surgery may be required if the symptoms do not improve over an observational period, usually of about ten days. Some injuries relating to IEBt have been seen to spontaneously resolve over several days, although instances of this are thought to be underreported due to less severe symptom presentation. ⁽¹⁷⁾

The overlap in symptoms between IEBt and IEDCS leads to misdiagnosis. Divers are often divided into risk groups considering various factors:

• Previous dive incidents
• Use of decompression stops with a controlled ascent
• The time of onset of symptoms after the dive
• Diving with mixed gas

The presence of these factors makes a diagnosis of IEDCS more likely. There is a criterion known as HOOYAH, as seen in Table 2, which is used to understand the aetiology of a presenting patient and differentiate between the diagnoses of IECDS and IEBt.⁽¹⁹⁾

Table 2 – HOOYAH criteria used to differentiate between IEBCS and IEBt ⁽¹⁹⁾

Important differences which aid in distinguishing between Inner Ear Decompression Sickness (IEDCS) and Inner Ear Barotrauma (IEB) are as follows:

Management

The importance of differentiating between the two becomes apparent when looking at their treatment methods. ⁽⁸⁾ The gold standard treatment for IECDS is urgent recompression using hypobaric oxygen treatment.

This works by increasing the pressure of the environment and consequently decreasing the size of the gas bubble (usually nitrogen) allowing more oxygen to be delivered to tissues and aiding dissolved gas offloading. ⁽¹⁴⁾ Until this can be administered, 100% oxygen must be given. ⁽²⁰⁾ Steroids to reduce inflammation can be given as an adjunctive treatment option. 

The incidence of PFO is higher in a patient with IECDS compared with the general population. This is a good indication for screening using Doppler sonography. However, a diagnosis of PFO would not necessarily restrict further diving as it is possible for people with PFO to dive following the ‘low bubble diving’ guidance. ⁽²¹⁾

For acute IEBt, bed rest and avoidance of actions that induce pressure transmission are advised. Suggested treatment for IEBt is usually a course of steroids at a high dose, for example, 250mg prednisolone for three days, followed by a steroid taper course. ⁽²²⁾ In circumstances where the patient’s hearing continues to deteriorate, further investigation is required, often by surgery. This is also the case if there is thought to be a perilymphatic fistula. For any patient experiencing IEBt, a high-resolution CT scan of the temporal bone is required to rule out further complications. ⁽²³⁾

After treatment patients are to be counselled on the further risks of diving and really that they should try to avoid it all together. However, a paper by Parell et. al, suggested that this advice might be ‘unnecessarily restrictive’. ⁽²⁴⁾ This study looked at twenty-one patients who, after receiving counselling, still decided to continue diving despite their IEBt diagnosis. They were taught effective middle ear equalisation techniques. After yearly follow-ups no further damage was seen in the inner ear of any of these patients posing a potential challenge to the conventional teaching advice on this. 

Conclusion

Diving carries a relatively high incidence of otological consequences. It is not only important that clinicians and instructors are aware of these but also divers themselves. More research into how we can improve patient management and what can be done to decrease the incidence of these pathologies needs to be conducted and published. It is also critical that these findings are presented to divers in a clear and timely fashion.

Patients should be appropriately counselled on prevention such as correct equalisation techniques and the importance of following guidance. The effects of diving irresponsibly can be devastating. Even in situations where otological injury is not severe, it can cause panic and the cascade of much more dangerous consequences.

Bibliography

1. 2020 Outdoor Participation Report Outdoor Industry Association; 2020 [Available from: https://outdoorindustry.org/resource/2020-outdoor-participation-report/.
2. 2021 Sports, Fitness, and Leisure Activities Topline Participation Report Sfia.org;  [Available from: https://www.sfia.org/reports/900_2021-Sports%2C-Fitness%2C-and-Leisure-Activities-Topline-Participation-Report.
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15. Mitchell SJ, Doolette DJ. Pathophysiology of inner ear decompression sickness: potential role of the persistent foramen ovale. Diving Hyperb Med. 2015;45(2):105-10.
16. Clayton S, Walklett C. Decompression Illness. RCEM Learning2019.
17. Love JT, Waguespack RW. Perilymphatic fistulas. Laryngoscope. 1981;91(7):1118-28.
18. Elliott EJ, Smart DR. The assessment and management of inner ear barotrauma in divers and recommendations for returning to diving. Diving Hyperb Med. 2014;44(4):208-22.
19. Rozycki SW, Brown MJ, Camacho M. Inner ear barotrauma in divers: an evidence-based tool for evaluation and treatment. Diving Hyperb Med. 2018;48(3):186-93.
20. Talmi YP, Finkelstein Y, Zohar Y. Decompression sickness induced hearing loss. A review. Scand Audiol. 1991;20(1):25-8.
21. Torti SD, Kraus MD, Völlm E. Swiss Underwater and Hyperbaric Medical Society (SUHMS) Patent Foramen Ovale 2019 [Available from: https://suhms.org/wordpress/wp-content/uploads/2019/02/K_PFO_E_19_02_CMYK.pdf.
22. Klingmann C, Praetorius M, Baumann I, Plinkert PK. Barotrauma and decompression illness of the inner ear: 46 cases during treatment and follow-up. Otol Neurotol. 2007;28(4):447-54.
23. Shupak A. Recurrent diving-related inner ear barotrauma. Otol Neurotol. 2006;27(8):1193-6.
24. Parell GJ, Becker GD. Inner ear barotrauma in scuba divers. A long-term follow-up after continued diving. Arch Otolaryngol Head Neck Surg. 1993;119(4):455-7.

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The Mountain Leader (ML) award is the qualification for leading groups of people walking in the UK hills. It is run by the Mountain Training Association, and requires a detailed logbook, attending a training course and passing a multi-day assessment. Here Abbey shares the benefits the qualification has had for her as a medical professional.

Why Mountain Leader?

Like many others, as I progressed through university, I began to look for inspiration on how to personalise my medical career. Many of the options I found involved either being highly qualified in post-graduate medical training, or paying vast amounts of money to travel to far flung places in the world. Both of these were prohibitive to me as a student, and did not fit into how I saw myself working in the future.

I got involved with my University’s Duke of Edinburgh centre, first by finishing the Gold Award, and then by running the award for participants for several years. It was there where I heard about the ‘Mountain Leader’ – the people that kept our groups safe whilst completing the expedition aspect of the award in the Scottish hills and mountains.

The Training Process

Fast forward to my Foundation Years. I became captivated by ‘Munro Bagging’ – trying to reach all the summits over 3000 feet in Scotland. A list that is updated every few years but with a current total of 282 peaks. Whilst looking for ways to spend my annual leave, and the impossibility of coordinating time off with friends, I decided to book onto Mountain Leader training in North Wales.

What followed was one of the most fulfilling and well rounded training courses I have been on both within and outside of medicine. The focus was on leading a team whilst maintaining oversight and an awareness of each individual’s competency and capacity to deal with the task at hand. Doing all this while exercising, carrying a heavy pack, with wet feet, and the wind and rain in your face but still having fun!

The following summer, I moved further North to take up a Clinical Fellow ‘FY3’ post in the Scottish Highlands. There I completed my consolidation period, and passed the five day assessment in the Cairngorms, finishing my ‘Munro Bagging’ goal in the process.

Transferable Skills

Part of the consolidation period between training and assessment requires pushing yourself to head out into the mountains in bad weather and confidently manage and maintain safety often for groups of inexperienced people. I regularly took friends and colleagues from work out into the hills to show them how wonderful it could be for physical and mental health.

Without noticing, over time these skills spread into my working life. I found myself naturally gravitating towards leadership roles, and felt more comfortable doing so. The skills and theory I had learnt during the training week and honed out in the hills had undeniably given me a greater understanding of effective leadership and team working and the confidence to put these skills into practice in all aspects of my life.

What Comes Next?

The opportunities that arise from the qualification are wide ranging and very individual. Having expertise in both medicine and in enabling people to enjoy the outdoors safely is desirable for many branches of work. Proving that you can look after yourself in physically and mentally challenging conditions is invaluable, and the Mountain Leader scheme is one way of evidencing this. It also does so without shelling out thousands of pounds to big companies, having to be away for weeks at a time, or needing any amount of post graduate experience.

The opportunities for further development are extensive. Mountain Training provides a wide array of complimentary qualifications and skill sets, including rock climbing and winter hillwalking. As with the summer ML these qualifications are wonderfully flexible and are often looked for by expedition companies looking for leadership staff. Outside of the training and assessment weeks, the logbook requirements can be obtained in your own free time.

The practicalities

Requirements for training:

• Minimum one year experience of UK hillwalking
• Membership of the British Mountaineering Council, Mountaineering Scotland or Ireland
• A logbook of minimum 20 ‘Quality Mountain Days’ (QMDs) defined by Mountain Training, QMDs include (but not limited to) the use of map & compass, navigating in poor visibility/weather and full involvement in planning of the route.

Requirements for assessment:

• Completion of a recognised Mountain Leader Training course
• Completion of an in-person 16 hour First Aid course (special exemptions can apply on an individual basis for doctors)
• An additional 20 QMDs after training, logged in multiple different mountainous areas of the UK.
• A logbook of 8 nights camping, with a minimum of 4 nights wild camping

Time commitment:

• Six days for training
• Five days for assessment
• Minimum 40 days of hillwalking (can be logged over many years)
• Additional time consolidating navigation and rope work skills

Costs:

• Training course, from £375
• Assessment, from £375
• Costs of fuel & accommodation in achieving logbook requirements
• Gear/kit costs

Resources

Mountain Training

British Mountaineering Council

Mountaineering Scotland

Mountaineering Ireland

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A good expedition medic is so much more than just being a good clinician. We need to have a mix of clinical, interpersonal, leadership and expedition skills relevant to that environment. This article will focus on these ‘expedition’ skills; explaining what they are, understanding why they are important and giving you a few ideas of how you can gain them and demonstrate your competence.

What are ‘expedition’ skills?

Expedition skills allow us to comfortably work within and travel safely through the environment we are in. For example, on a canoeing expedition down the Amazon, to have the ability to be able to manoeuvre a canoe and assist the leader with rescuing other members of the team if they got into difficulty. We would also need to be comfortable living in a jungle environment, with an awareness of how to keep ourselves and others safe, knowledge of the fauna and flora and how to use required tools safely, e.g. a machete.  We want to know we can always be ready ahead of the team, so we can support them each morning with any medical queries.

Why are they important?

The Faculty of Pre-Hospital Care (FPHC) gives guidance on the skills and competencies an expedition medic should possess depending on the expeditions’ remoteness and risk. It is essential reading for anyone considering work in the field.

The FPHC cites examples of the expedition medic not having all these skills. For example, the medic on a high-altitude expedition having no prior altitude experience, then struggling and becoming unwell before being evacuated off the mountain, so leaving the team without a medic. Other examples include the medic not having the technical skills such as being able to get through rocky scrambling terrain to reach a casualty.

Finally, we know as medics that prevention is better than a cure. If you understand the activity and environment, you can work with the team to prevent injury and illness far more effectively. Basic camp skills like knowing how to purify water, safely prepare food, manage fires and stoves and waste disposal are absolutely necessary if you plan to work anywhere that these may be required.

Gaining skills and demonstrating competence

Outdoor qualifications, a logbook of experience, courses and formal postgraduate diplomas and masters programmes all have their place.

Qualifications are often required for client-to-staff ratios and quickly demonstrate your interest and base ability to a company. Some companies only take medics who already have certain industry-standard qualifications. For example, British Canoeing 3* would show your ability to paddle on moving water in a canoe or a Mountain Training summer Mountain Leader qualification would show your ability to safely lead groups in the UK mountains in non-winter conditions.

A logbook would be another way to show someone your experience when applying to be the medic on an expedition. If you can present them with details of the types of vessels you’ve sailed alongside the locations and weather or scuba dive types, profiles and conditions this may be more valuable than a qualification as it shows your ongoing currency and development. However, it doesn’t necessarily show you have learnt the ‘correct’ way to do things in the same way an industry standard course may. A course with a certificate of attendance, again, would show that you have attended formal training. For example, if you were to book a jungle survival course, you could also ask the instructor leading the course to write a reference or letter of recommendation.

Diplomas and Masters programmes can demonstrate competency, such as the Diploma in Expedition and Wilderness Medicine or the Diploma in Mountain Medicine. They show an employer that you have invested significant time and interest into the field, are up-to-date with academic findings and guidance and have been assessed and met certain criteria for work in a particular environment.

Next steps

• Start a logbook
• Consider which activities you would like to try or develop
• Check out the Adventure Medic resources with recognised industry-standard outdoor qualifications to work towards
• See our course reviews section on our events page to help you decide which courses may be for you
• Visit our resources section on the plethora of formal post-graduate diploma and masters programmes now available

Whether you join a mountaineering club, find a kayaking course or join an expedition medicine course based on the slopes, we wish you happy adventures. If you have been on a course or completed a diploma that you’d like to review, please get in touch and we’ll send you our proforma for these. We have all benefited from the gems on Adventure Medic and are keen to keep sharing opportunities and your insights. We look forward to hearing your suggestions and what you get up to next.

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How much thought have you ever put into your sunglasses choice, beyond the shape of the frame? In an aging population, protecting our future eye health is more important than ever, especially in a world with a depleting ozone layer, ever-changing climates, and infinite opportunities to travel. Dr Josie Hollywood helps to unravel the crucial points when it comes to choosing your perfect pair of sunglasses.

Eye Health

As well as ensuring a comfortable viewing experience in the sun, sunglasses also offer vital protection against ultraviolet radiation (UVR) reaching the eyes. This is important for preventing an array of eye problems that have all been shown to be associated with ocular exposure to UVR.^1,2

Short-Term Problems:

Photokeratitis: essentially sunburn of the cornea, also known as “snow-blindness”

Long-Term Problems:

Pterygium: part of white conjunctiva growing over into the cornea
Cataracts: clouding of the lens- the leading cause of blindness worldwide
Macular degeneration: degeneration of the central portion of the retina
Eyelid malignancies: melanoma, basal cell carcinoma, squamous cell carcinoma

So What Is UVR?

Sunlight is the only naturally occurring form of UVR. UVR contains more energy than visible light rays but plays a minimal, if any, role in vision. It sits between visible light rays and X-rays on the electromagnetic spectrum in terms of the amount of energy involved. UVR is typically classified into bands according to wavelengths, with shorter wavelengths containing more energy and therefore being more dangerous.

The three bands of UVR are:

UV-A (315-400nm): least energy
UV-B (280-315nm)
UV-C (100-280nm): most energy

The ozone layer currently absorbs almost all UV-C wavelengths, preventing this from reaching Earth’s surface. Because of this, the UVR wavelengths that reach us, are made up of 95% UV-A and 5% UV-B. Even just these small proportions of UV-B can have significant adverse heatlh effects. With the amount of UV-B absorbed being dependent on the ozone, the depleting ozone layer becomes a prominent issue for our eyes too.³

What Affects How Much UVR Reaches Our Eyes?

The amount of sunlight, and therefore UVR, reaching our unprotected eyes varies according to the ease of the path of the sun’s rays. This means the degree to which our eyes are exposed to UVR varies according to a few important factors, largely relating to the elevation of the sun.⁴

Time of Day:
Somewhat counter-intuitively, the highest elevation of the sun around midday doesn’t equal the highest level of exposure. This is because your eyebrows and eyelashes do an excellent job of protecting your eyes from the sun directly above. The sunlight has a more direct path to your eyes when solar elevation is low, bypassing more of the eyebrows and lashes, with morning and late afternoon delivering the highest amount of exposure.
Altitude:
This one does make sense: the higher the altitude, the closer you are to the sun, therefore the shorter the path of UVR rays to your eyes.
Season:
There is around 3.5% more exposure to UVR in summer compared to winter, likely due to daylight hours and cloud cover. Conversely, 3.5% is a relatively small difference, highlighting the importance of ensuring adequate eye protection even in the winter months.
Ground reflection:
This is an important one. The two biggest culprits are snow and sand, both of which reflect significantly more UVR than typical day-to-day materials such as pavement or grass. Especially important because people tend to spend more time at the beach in sunny weather or climates, and are usually sat on the sand, thus closer to the point of reflection. In snow, this highlights the importance of always wearing snow goggles during winter sports, even when the sun isn’t out. Especially as these activities are often performed in mountainous areas: at higher altitudes.

So, What To Look For When Buying Sunglasses?

The single biggest controllable factor affecting your eye’s UVR exposure is adequate eye protection – usually in the form of sunglasses. However, caps and wide-brimmed hats also offer enhanced protection, ideally in combination with a proper pair of sunglasses.

UV Protection

Protection from UVR is now usually embedded into the lens of the glasses, rather than a protective film. Most well-known sunglasses brands will offer 100% UV protection as standard, but there is a huge amount of variation, especially amongst cheaper non-branded sunglasses, so it is always important to check.

The keywords to look for are:

• 100% protection against UV 400 (All wavelengths up to 400nm, which includes UV-A and UV-B)

• 100% UVA & UVB

Categories

When browsing, you may see a category provided alongside each pair of sunglasses, which can be a little confusing. This doesn’t actually have any relation to the amount of UV protection. It instead refers to the amount of light that is transmitted through the lenses; the tint of the lenses. You may also see the acronym VLT, meaning Visible Light Transmission, which determines the percentage of light allowed through by the lens. The category, or degree of tint in the lenses, therefore simply affects the comfort of the eye in bright conditions.⁵

Category 0
80-100%
Clear/very light
Safety goggle

Category 1
43-80%
Light
Casual or fashion use

Category 2
18-43%
Medium
General or sport – most common

Category 3
8-18%
Dark
Open-mountain ranges                                                                                                                         Reflection from snow, sea & sand

Category 4
3-8%
Very dark
High-altitude trekking or mountaineering                                                                                               Cannot be used for driving

It is important to remember that lens tint has zero impact on the amount of UV protection offered. It is possible to have a pair of clear, category 0 sunglasses which still offer 100% UVR protection, and also possible that cheaper or non-branded sunglasses may have a darker tint and yet offer inadequate UV protection.

Polarised sunglasses

Polarisation is the blue-green reflection you see on some sunglasses, usually making them mirror someone looking at them. Again, this feature has no effect on UV protection. Polarised lenses simply filter out more of the glare caused by the sun’s rays bouncing off flat surfaces. They improve the viewing experience of bright reflective environments, reducing eyestrain and increasing the contrast of the image you see. This can be especially helpful when driving, and for winter sports in the snow; it is common for snow goggles to have a polarised lens for this reason.

Positioning

Positioning and size are also extremely important, and for this reason, it can be helpful to try on at least a few different brands in a shop before buying. Sunglasses that leave a gap of as little as 6mm between your forehead and the frames can lead to up 20% more UVR reaching your eyes.⁴ It is important to ensure the sunglasses sit comfortably on your nasal bridge – everyone is different with unique facial proportions. Another important feature is for sunglasses to cover as much of the lateral aspect of your face as possible; to wrap around to protect the sides of your eyes. Most sports-specific sunglasses tend to offer this as standard, however, fashion brands often have limited options and rarely cover much more than just the front of your face.

A few take-home points

1. 100% UV protection is a must (“100% UV400” or “100% UVA & UVB”)
2. The “category” relates to the degree of lens tint – not UV protection
3. Polarised lenses reduce eyestrain but don’t increase the UV protection
4. Fit is important – try before you buy! This is important for everyone, but especially medics spending any significant time traveling in remote regions, which are typically warmer, sunnier climates and/or at higher altitudes.

Your eye health is important in both the short and long term, and sunglasses are a quick and easy way to reduce the risk of eye-related problems on expeditions, as well as in the future.

Hopefully, you now feel fully equipped to tackle your next sunglasses purchase!

References

1. Ivanov IV, Mappes T, Schaupp P, Lappe C, Wahl S. Ultraviolet radiation oxidative stress affects eye health. Journal of Biophotonics. 2018 Jul;11(7):e201700377.

2. Coroneo M. Ultraviolet radiation and the anterior eye. Eye & contact lens. 2011 Jul 1;37(4):214-24.

3. Solomon KR. Effects of ozone depletion and UV‐B radiation on humans and the environment. Atmosphere-Ocean. 2008 Jan 1;46(1):185-202.

4. Izadi M, Jonaidi-Jafari N, Pourazizi M, Alemzadeh-Ansari MH, Hoseinpourfard MJ. Photokeratitis induced by ultraviolet radiation in travelers: a major health problem. Journal of postgraduate medicine. 2018 Jan;64(1):40.

5. Ultralight Outdoor Gear. 2022. Choosing Sunglasses – UV, LVT and Lens Categories explained. [online] Available at: <https://ultralightoutdoorgear.co.uk/choosing-sunglasses-uv-lvt-and-lens-categories-explained-i326> [Accessed 28 June 2022].

Photo credit: Dr Josie Hollywood

The post Demystifying Sunglasses appeared first on Adventure Medic.

Nigel Williams has over four decades of winter mountaineering and polar experience with multiple trips to Greenland and the Himalayas. He currently supports the charity Polar Academy in delivering life-changing expeditions to young people. A sage on navigation and cold environments he offers his survival tips for polar expeditions, so we too can enjoy these spectacular environments, and look after ourselves to better care for others.

In 1888 the Norwegian explorer Fridtjof Nansen crossed the Greenland Ice Cap with 5 companions, it took them around 30 days. Their equipment was extremely basic; there were no dehydrated foods, down sleeping bags or sophisticated kits. Once they were over halfway there was no turning back, they had to get to the west coast or risk losing their lives. By contrast, thirty-three years later in 1921 Mallory and Irvine attempted Everest. This presented different challenges; cold being one. However, at any stage, they could choose to retreat down to base camp and safety within a day.

In the polar regions, we find perhaps the most challenging and remote environments on earth. This makes travelling and surviving in them both a testing and hugely rewarding experience. There is great beauty in these often barren landscapes. Preparation, routine and self-discipline are key to comfort and survival.

In this article:

• The Environment
• Terrain
• Fitness
• Equipment:
  Clothing
  Camping
  The tent
  Cooking, water and food
  Digging tools
  Sledges and packing
• Hygiene
• Navigation
• Communication

Environment

Many Arctic regions are free of snow in summer. However, in winter the climate is cold and dry with temperatures often too low for rain. The wind is the real enemy, creating windchill which greatly exacerbates the effect of the cold and raises the risk of cold weather injuries. It is possible to get sunburn and snow blindness (sunburn of the retina) at the same time as frostbite even on cloudy days. Adequate protection for both eventualities is encouraged.

The natural shelter available is sparse. There is no vegetation and little wildlife except around the coasts. Survival depends on the resources you travel with; routine and discipline are key to everything you do. Between you and freezing to death is your clothing, tent, cooker, pot, fuel and means of creating a spark. All water comes from melting snow, and you need lots of it. This may seem uninviting.

The good news is that on foot or skis with a sledge you can travel self-sufficiently for several months and cover vast distances. A 100kg sledge or ‘pulk’, is a heavy burden but on flat snow, it glides with relative ease. Pulling tyres around forest tracks and on beaches provides good preparation and often proves more arduous.

The Norwegians talk about the draw of the polar light which pulls those who have experienced it to return to these regions. There are stunning atmospheric phenomena such as whitebows instead of rainbows, the Aurora Borealis and sundogs (mock suns). The latter is known as parhelion (plural: parhelia) caused by the refraction of sunlight by ice crystals in the atmosphere. The hum of complete silence, the sculptured snow patterns and the glinting crystals can be utterly beguiling.

Terrain

The Polar climates reveal many different terrain challenges from blue ice to deep soft snow, hidden crevasses to sastrugi (windblown ribs of hard snow several feet high). There are also rivers with smooth ice sides and bottoms which disappear down deep holes under the ice known as ‘moulins’. With climate warming, increasing amounts of unmapped surface water are present and can be difficult to avoid without a drone. All these factors make any travel difficult and exhausting.  Depending on the terrain and expected hazards; crevasse rescue, avalanche awareness and winter skills are essential pre-expedition training. In deep fresh snow or crevassed areas, it is a good idea to take off one ski at a time checking whether you can stand on the snow before taking the other off. Skis distribute weight over a larger area and removing them can lead to some surprises.

On the plus side, there are no creepy crawlies or spikey poisonous plants. Instead, we have penguins, polar bears, (not in the same hemisphere), curious seals, thieving arctic foxes, dive-bombing skewers, walrus, reindeer, musk ox and sled dogs. Keep your distance from the latter, they are not pets, and often live a pack life outside in all weather. Polar bears are by far the most dangerous hazard in the Arctic and they have been known to travel far inland if they get a scent. Some understanding of bear behaviour, tent positioning, carrying of appropriate weapons, a bear fence and training in these items is essential.

Fitness

Fitness is an important element of polar travel. We want to avoid over-exertion and resultant sweating which causes damp clothing. This creates considerable chill if cold temperatures seep in.

In addition, breathing heavily creates a build-up of ice around face coverings and facial hair including eyelashes. This can freeze zips and make clothing challenging to adjust. Goggles are essential. Adjustments to layering and level of exertion are two other ways to reduce this, but a good level of fitness will give the body an advantage.

Equipment

Clothing

A key principle of clothing in the cold is that multiple thin layers of clothing are better than one thick layer. These trap more air to provide insulation which keeps us warm. As the climate is essentially dry, long windproof smocks rather than waterproofs are the preferred outer layer. These are usually heavy materials such as Ventile (a densely woven cotton) or “Paramo” type clothing. These are much warmer than typical breathable waterproofs for instance.

Down is the best insulator, a good long jacket and mittens are essential, whilst booties are great in the tent. Down trousers are only for the coldest conditions. If down becomes wet it loses its insulative properties. Any wet clothing can be hard to dry especially on overcast weather days, the garment will simply freeze and be unwearable.

Woollen underwear and thermals are the norm as they smell less and washing clothing is impractical. If wool is too scratchy against the skin then the thinnest silk or manmade wicking thermal under the wool works. Cotton holds moisture and is not advised as this will make the individual cold.

Feet naturally sweat; the inside of boots and socks in particular get damp which conducts cold. Vapour barrier socks are waterproof nylon bags styled as socks with a drawcord to stop them from loosening. They are usually worn between two layers of socks, a thin pair against the skin and the warm woollen one over the top. The thin pair will be wet at the end of the day but easy to dry. The outer pair and inside of the boot will be dry reducing cold conduction to the feet and limiting the risk of cold injuries.

Gloves and boots need to be a size or so larger than normal to cope with added layers. Tight-fitting clothing reduces blood flow to extremities and increases the risk of cold injury. Strap-on crampons for crossing large swathes of hard ice can have the same effect. Cross-country skis with only the toe of the boot attached enable feet to flex and generate warmth and blood flow. There are anecdotes of interesting frostbite issues for kite skiers due to a lack of foot movement in their more rigid foot bindings.

A good range of hats, gloves and mittens are required. Mittens are warmer than gloves as finger heat is shared. A pair of thin inner gloves are essential for doing more fiddly jobs and avoiding cold burns from touching metal. (Never try to melt anything frozen by licking it.) On a long trip, inner gloves get trashed so take more than one pair. It is normal to attach the outer mittens with a wrist loop so they can’t blow away in the wind if you remove them briefly. Gloves do not need to be expensive – ‘Chamonix bin men gloves’ are nicknamed for a reason, and rubber gardening gloves are good for handling ice blocks without dampening your mittens.

People often asked what is the most important piece of clothing. Everything you are wearing has a purpose but ski goggles are probably top of the list. If you are travelling into the wind with snow crystals blasting you in the face then you cannot open your eyes to carry out any task from navigating to erecting the tent. Goggles also prevent snow blindness which can be extremely painful and will prevent you and the team from travelling.

Camping equipment

A good sleeping mat is essential – these now come with insulation ratings and the best contain down. Do not blow air into them, your breath has moisture in it and that will freeze inside. Use either an inflation bag or a miniature rechargeable battery-powered pump.

Give the sleeping bag a good shake to puff it up, and do some rapid exercise before getting into it so your body warms the air in the bag. For a similar reason sleep in your thermals, and do not put on additional clothing as it prevents your body from warming the air between you and the down. Keep gloves, hats, boot insoles or inner boots in your sleeping bag. Your body heat is needed to keep these things warm and dry. Electronic devices lose battery life rapidly in cold weather and gas cylinders heat food slowly when cold – both these items can also go in the foot of your sleeping bag.

Rechargeable electronic devices are much better than carrying batteries. Head torches, solar inflatable tent lanterns, sleeping mat pumps, and GPS are all rechargeable. Solar chargers are variable but a powerpack the size of a mobile phone will last a couple of weeks. Solar chargeable inflatable lamps make a good tent addition.

The tent

A good tent will have a snow “Valance” or skirt to throw snow on to help anchor the tent.  Big snow pegs are essential as they can be placed as a normal peg or horizontally in a slot in the snow with the guy rope clove-hitched around the middle. Skis also make good snow anchors but make sure the ski base faces the tent to avoid the guy lines being cut on the sharp ski edges. The very best tents come with large pole sleeves and two sets of poles. In bad weather doubling poles gives added strength and you have some backup if one pole does get broken.
Be sure to stamp the snow down in the area you intend to assemble the tent, or you will be in for a lumpy night.

Cooking, water and food

Water is essential for life. Keep hydrated and always have extra water available. Roughly 5 pots of fresh snow will make one pot of water, the wetter or more icy the snow the better the ratio. Always start melting snow with a few centimetres of water in the bottom of the pot. A pot stuffed with dry snow is in danger of being damaged or even melting in the first minute. Once water is boiling a measuring jug is useful for scooping the water out, freeze-dried meals are the norm and you can get the water quantity right to avoid runny meals. The measuring jug can also be a spare mug if one breaks and can monitor how much liquid you are drinking.

1 litre “Nalgene” bottles make great hot water bottles and provide a good source of water for a first brew in the morning. 2x 500ml Nalgene bottles can fit in gloves, socks or boots to help dry or pre-warm them. Camelbaks and drinking tubes freeze, limiting hydration. A good combination is a 1-litre thermos, and one 1-litre and two 500ml Nalgene bottles. Nalgene bottles have a wide opening and are genuinely watertight so can be trusted in a sleeping bag. Some cheaper look-a-likes are not. Metal bottles tend to have small openings and are too hot to handle. If a lid does freeze just dip it in a pot of hot water. A Nalgene bottle filled with moderately hot drinking water at breakfast will retain some warmth throughout the day if wrapped in clothing in the sledge.

Depending on the distances travelled and weight carried, nutritional demand is likely to be high. Dehydrated meals are lighter to carry but high-energy snacks are often also needed to meet energy requirements. Be mindful of which snacks will freeze solid, making consumption difficult.

Expeditions tend to use petrol stoves such as the MSR GKX. Their base gets hot and will melt down into the snow until the pot falls off. Many sledges come with a wooden board which is very useful for placing the stove on and making a seat at the tent entrance. Do take a foam seat mat for insulation as well whether sitting or kneeling. Some trousers come with knee pads sewn in for insulation when kneeling.

It is advisable to hone your striker skills so you can make a good spark and familiarise yourself with your cooking equipment before setting out. This will benefit both you and your companions.

It is common to cook near the entrance of the tent, and in bad weather; in the porch. Keep the doors open to prevent carbon monoxide poisoning. As team medics, keep an index of suspicion for this illness. Anecdotally, cases have been missed at altitude where carbon monoxide poisoning has been misdiagnosed as altitude sickness. Cooking outside the tent is the safest option in fine conditions.

Make the tent area comfortable by digging out the porch down to knee height. This makes cooking, dressing and entering/exiting the tent much easier. A dishwashing brush is useful for brushing snow off boots and clothing before entering the tent.

Digging tools

Two essential tools are a strong, long-handled shovel with a D-grip and a snow saw; better known as any good garden pruning saw (around £20). Avalanche snow saws cost 3 times as much and make no difference. Learn to cut really good square/oblong building blocks. It is a useful skill that takes time and effort to master. Building toilet shelters, windbreaks etc is all a part of winter expeditions and those two tools enable one to make a snow shelter. The layers of the snowpack can vary considerably in density and moisture content – not all snow makes good blocks. It is essential to make sure the foundation blocks are well-shaped and of the densest snow available, which may require digging and forming a “mine”. Cutting snow blocks from a mine for the toilet wall and tent windbreaks, well over 100 blocks can be required.

Sledges and packing

Sledges vary, North and South Pole trips will use glass fibre or carbon fibre ones that one could sleep in. Plastic sledges with a wooden board re-enforcement are fine for most other trips. A dry-line plastic polypropylene cord attached to a harness or even a rucksack works for pulling the sledge. However, it is important to have a piece of elastic bungee in the system to give a smooth pull as you stride along.

The real beauty of the sledge is that it has a large bag with a full-length zip and doesn’t need to be neatly packed. Organise your sled bag into areas to help personal admin in cold temperatures (when “faffing is fingers”). All food goes at the back end in a rucksack as this tends to be the heaviest item. The rubbish bag and the cooker (which can remain assembled to the fuel bottle) also go at the back. Spare clothing, sleeping bag etc. go in a large waterproof bag in the middle. Then the tent and sleeping mat (only half deflated to hasten re-inflation) are just thrown in on top (no packing, folding, or rolling). Lastly, anything for the day goes to the front. When stopping one can ski backwards with a foot on either side of the sledge until they can sit on it. You then unzip the front of the bag between your legs to access water, food, a warm jacket, and spare gloves. There is no need to take your skis off. The shovel goes on the outside of the bag. It is useful to carry a bum bag attached to the top of the sledge bag with a map, binoculars, sunscreen, glasses and GPS for quick access.

Hygiene

Personal hygiene is of course important, but wet wipes will freeze into a solid brick unless kept warm. Water-activated dry cloths, dipped into about 100ml of warm water in a small plastic sandwich box are effective. A small towel, toothpaste, 2 toothbrushes (a loss I’ve not forgotten) and anti-fungal powder are useful. Powdering feet at night helps to ensure you are reviewing your extremities for cold injury and encourages drying.

A 1-litre Nalgene bottle is ideal for a pee bottle, wrap a couple of turns of duct tape around it so you can identify it by feel. After using either empty it immediately under the tent fly sheet or keep it in the sleeping bag. Do not just leave it in the corner of the tent for the rest of the night. A litre of frozen urine adds a kilo of weight to drag and you can’t refill the bottle.

Navigation

Especially in a whiteout, navigation is extremely challenging. There are no reference points and it can feel like walking around inside a giant ping-pong ball. The lead person can struggle to maintain the optimal direction, meanwhile, the person at the back gets frustrated observing constant changes of direction. Using a GPS can be helpful but if the destination point in the GPS is set for several hundred Kilometres away, a deviation of 100m will not register. If there is some sunlight the position of your shadow works for maintaining direction although it changes position during the day. When skiing, a compass board to hold the compass and a watch can be helpful.

Communication

A satellite phone is essential for communication and allows a conversation if needed. However, these can be expensive. Spot devices are also available such as Garmin and as technology advances devices will become more sophisticated and accessible.

Summary

The Polar regions pose challenges and a need for resourcefulness and teamwork. Skis provide the only way to travel great distances under one’s own steam. For the prepared and forewarned these environments can be a winter wonderland. Silence, beauty and light provide ample time for reflection and for forming powerful memories that will stay a lifetime.

All images: Nigel Williams

The International Polar Guides Association IPGA produces guidelines on severe cold and wind management. These may be useful for further information: www.polarguides.org

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Delivering advanced medical care in austere and resource deplete environments can be difficult with the constraints of a small medical kit bag and sometimes we are faced with hypotension unresponsive to fluid therapy alone.

In this succinct article our very own patron, Dr Edi Albert shares his recipe for delivering adrenaline as a vasopressor when faced with acutely unwell patients in the field.
Of note, this features as an interest article only for many unless you are trained and experienced with inotropes and remains a last resort treatment method in the field. 

There’s no doubt that there has been a blossoming interest in expedition and wilderness medicine, and increasing opportunities to get involved in a range of settings from scientific maritime and diving expeditions to journeys across deserts and up into the high mountains. It isn’t surprising that many of those interested in pursuing this interest come from a critical care background. Although much of the time expedition medicine is about prevention, planning and primary care, patients can and do become very ill and it’s here where some knowledge and skill in higher level care is useful.  

Modern medicine has become increasingly protocol and algorithm driven, which can work very well in a predictable and defined context, but leave you stumped when things are less predictable and well-defined. We are often told to “think outside the box”, but that can be hard to do when you have only ever seen what is inside the box. This article attempts to give you a glimpse of what might lie outside.

Consider the following case of a 67 year old woman who is a scientist on the expedition that you are accompanying as a medical officer. 

You have the limited medical kit you might expect, but as you have an established base camp and road access, it is somewhat larger than if you were trekking. But no monitor, no point of care ultrasound (POCUS), no point of care testing (POCT), no infusion pumps, no ventilator and no ICU nurse to help you. It’s a bumpy 6 hour jeep ride to the nearest local clinic, and probably the same again to the nearest hospital that can provide a good standard of emergency care. And it’s unfortunately out of the question that there is a helicopter hovering somewhere nearby. 

She looks unwell, pale, clammy and peripherally shut down. “Do the sepsis six” is jingling loudly inside your head and a sense of unease arises in your chest. A quick history tells you that she has had dysuria and frequency for several days but has been ignoring it. Her temperature is 39.5C, pulse is thready at the wrist and the portable monitor that you have doesn’t display a good trace but gives a reading of a heart rate of 125bpm and 81% oxygen saturations. You don’t really believe the oxygen saturations based on the tracing but equally you know that she is very unwell. You do have a urine dipstick available and despite her shocked state she manages to give you a small sample. Using the colour chart on the bottle it is immediately obvious that the stick has lit up like the proverbial Christmas tree. This, combined with a clear chest, no neurology and no skin signs, suggest that this is urosepsis. Although more used to practising medicine in temperate climes, you know that the tropical environment is one in which infections are more common and more severe. You decide that you should start broad-spectrum antibiotics – you only have a couple of vials of ceftriaxone and hope that the bugs will be sensitive. You pop in an IV cannula successfully, but knowing that if you are struggling you can still give the ceftriaxone IM mixed with 1-2mls of 1% lignocaine to reduce the pain of the injection.

After giving the antibiotics you give a 500ml fluid bolus followed by a further 500ml a little slower. You are now left with only one further bag of saline in your kit and are mindful that continuing pure fluid therapy in distributive shock may start to have adverse consequences. You go back to check the response of your initial treatment and find your patient still has a heart rate of 125 bpm and her radial pulse is difficult to palpate suggesting a systolic blood pressure in the order of 80mmHg. What next?

Take this opportunity for a pause in your reading and think what your next steps might be. Unfortunately the helicopter is still not an option and our patient remains in shock. Open up that box and have a think outside it. How can you modify and make do with the kit that you do have?  

In Central Australia where I work from time to time (and recently brought to life by Dr Sam Goodhand in his article The Tyranny of Distance – A Flying Doctor in the Heart of the Outback – Adventure Medic) a slightly different version of this scenario plays out on a not infrequent basis. Our remote area nurses deal with septic Indigenous patients in small communities several hours away from a hospital on a regular basis. They are better set up than the jungle scenario with monitors and iSTAT for point of care testing, but certainly none of the bells and whistles of a hospital. Most patients do of course respond positively to a bolus of fluid, some paracetamol and a dose of IV antibiotics. However, when they don’t, we do know what to do next, long before a retrieval plane can land. We call it dirty adrenaline. 

You made sure you had some vials of adrenaline 1mg/ml (1:1000) for treatment of anaphylaxis in your expedition kit bag and you’re well acquainted with the use of adrenaline infusions in the ICU, so now it’s time to combine them with a bit of “out of the box” medicine. You are going to set up a dilute peripheral adrenaline solution and run it through a normal giving set. Although this is a solution of last resort and might sound somewhat concerning, it is in fact a well tried and tested approach.

Here is what to do:

• Put 1ml of 1mg/ml adrenaline into 1000ml of normal saline.
  Bingo, you have a 1 mcg/ml solution.
  (Technically you have a 1mg in 10001ml solution but the error is not relevant in this situation.) 

•  Start with 1 mcg/kg/hr  (1 ml/kg/hr) and titrate upwards to effect.

Don’t be shy, this is a technique of last resort. It is a very dilute solution compared to what you are usually used to and thus there is a much wider tolerance in the infusion rate.

• Calculate your hourly rate based on the patient’s weight as usual.
  Weight: 70kg
  Dose: 1mcg/kg/hr = 70mcg /hr
  Strength: 1mcg/ml
  Starting rate: 70ml/hr
  Very simple maths for when your brain is potentially overloaded.

At this point you will be thinking about how you judge the rate using an ordinary giving set. There are two ways:

Drop factor calculation:

The Drop Factor

This is printed on the packaging of your giving set and tells you how many drops of fluid make up 1ml.
Common drop factors are 20 and 60. 

Drip rate

Drops per minute = (volume of IV fluid prescribed / time to run in hours) x (drop factor / 60) 

• Let’s say you have a giving set with a drop factor of 20. The drip rate for this 70kg woman will be:
  70/1 x 20/60 = 23 drops per minute. 

That’s a little under one drop every three seconds, and something you can realistically set up and check. 

‘Winging it’:

If you’re still struggling with the thought of giving IV adrenaline peripherally in this manner, then the idea of “winging it” in a time of dire stress, when you can’t remember the drop factor calculations will seem anathema. But think about it, the starting dose is 2 or 3 drops a minute and if the patient isn’t responding you can just double it to 5, then 10, 20 or 40 drops per minute. Remember, you have to give the patient a whole litre of fluid before they get 1mg of adrenaline.

The good news is that you are able to MacGyver your adrenaline infusion, the antibiotics kick in, she survives the night and is driven to the hospital 12 hours away at first light. 

Of course it doesn’t have the finesse of an infusion pump – which is why it is ‘dirty’ adrenaline, but it is more than fit for purpose. It has been used many times in rural and remote settings for a range of life-threatening problems from sepsis to anaphylaxis and from complete heart block to a post-resuscitation treatment. It might just help you too one day.

For more information tap into this great resource:

Adrenaline (Epinephrine) Infusion PHC Remote Guideline, 2018.
Northern Territory Government, Department of Health

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Telemedicine is an expanding field and increasingly relied upon. Dr Grace explores its relevance to expedition medicine and its innovative uses in improving global health. He introduces ‘The Virtual Doctors‘, a telemedicine charity that supports rural health centres in Zambia and Malawi through connections with UK doctors and discusses medicolegal and ethical considerations for those considering utilising telemedicine technologies in their practice. 

What is telemedicine?

Telemedicine is defined as “the remote diagnosis and treatment of patients by means of telecommunications technology¹”. Telemedical interactions can occur between two clinicians, between a patient and a clinician or between a patient and their remotely monitored wearable health technology².

Telemedicine emerged in the early 1960s, and mainly consisted of still image transfer with some early video conferencing. It was mostly limited to visual specialties like radiology and dermatology​ but has become ubiquitous as technology has progressed.

It was initially adopted by the military, private healthcare companies and offshore oil and gas industries to provide remote medical ‘top cover’. With the COVID-19 pandemic and concerns regarding infection control and isolation, interest in telemedicine increased exponentially. Remote consulting is now commonplace and has arguably changed the face of medicine forever.

Telemedicine in austere and wilderness environments: considerations

Telemedicine can be applied to a wide range of scenarios. It can be used for remote consultation, diagnosis and prescribing, clinical image sharing, electrocardiograms, real-time telemetry and radiological interpretation. In theory, telemedicine offers a perfect solution for medicine in remote and wilderness settings, with access to every medical speciality on demand. In reality, there are some key logistical challenges to appreciate.

Cost can be a significant obstacle and depends on two main factors: the type of telemedical equipment being used and the way data is transferred.

Simple telemedical systems offer an email-based or bespoke messaging system to exchange clinical information. These systems run on a user’s smartphone, tablet, or computer, with data being transferred through an internet connection. The cost depends on the amount of data transferred with large video files being the most expensive.

Systems that use video-calling technology require much higher data transfer rates and bandwidth capabilities. Most commercial platforms used within the NHS and private sector tend to use this set-up, however, they have the advantage of country-wide broadband and 3G-5G infrastructure. In contrast, remote and wilderness locations rely on cellular or satellite data transfer and so costs, speeds and reliability can vary hugely.

Telemedical systems can be synchronous (real-time) or asynchronous. There are pros and cons to both strategies. Synchronous approaches are better for real-time diagnosis and management advice but require constant clinician or admin staff availability. This adds expense and can be challenging if multiple expeditions are occurring in different time zones.

The quality of telemedical platforms and the quantity and detail of data that can be delivered is important. It impacts on the quality of advice offered by the remote clinician and therefore on the patient experience.

Progressing from sole text or video-based services; devices such as the TytoCare medical examination kit³ can be bought for $299 (£238). These allow clinicians to remotely examine the ears and throat and auscultate the heart and chest. However this particular device is only available in the USA at the time of writing, and such products appear to be geared towards use predominantly in the home.

The military are pioneers when it comes to technology and innovation due to the environments they operate in. The US military used a $14 million grant to connect surgeons to frontline combat medics using a device called the Lifebot 5.^4,5 This device, offers multi-lead ECG, oxygen sats, non-invasive and invasive blood pressure readings, end-tidal carbon dioxide, temperature, multiple exam cameras, embedded ultrasound with a plug-in probe, and an onboard server to record the full patient history. However, the Lifebot 5 retails for around $20,000 (£15,945) which is prohibitively expensive for most organisations.

In addition, as the technology becomes more sophisticated, the power requirements increase. Whilst it may be possible to use a device such as the Lifebot in a field hospital or an offshore oil rig, where there is a definitive power source, it will be difficult in an off-grid wilderness setting. The use of solar panels or similar may assist but require pre-expedition planning, budget and probably a static base camp.

Telemedicine in austere and wilderness environments: case studies

The Yale-Mount Everest telemedicine project

In 1999 the Yale-Mount Everest Telemedicine Project used two Inmarsat phones to transmit video and audio data from base camp, via a folding satellite dish, to the INMARSAT satellite above the Indian Ocean.⁶ The team discussed several cases using this set-up with three stand-out cases as follows.

Firstly, a patient with reduced visual acuity and retinal haemorrhages​ was remotely reviewed, diagnosed with high altitude retinopathy and advised not to ascend further.

Secondly, a patient with suspected high altitude pulmonary oedema had their chest ultrasound and i-stat readings remotely assessed by an ITU doctor who advised on management.

Lastly, a sherpa with a traumatic shoulder injury from a yak was remotely diagnosed, via ultrasound, with a supraspinatus tear, and treated with a steroid injection.

These cases were a useful illustration of telemedicine’s capabilities but it is debatable how much they changed the clinical management decisions.

Real-time tele-echocardiography

A 26-year old man, stationed at the USA Mcmurdo Antarctic research base, presented to the medical clinic complaining of chest pain⁸; worse when lying flat. He was haemodynamically stable with normal blood results.​ His ECG showed ST elevation in leads II, aVL, and V2–V6.His CXR showed an enlarged cardiac silhouette.​ He had a working diagnosis of pericarditis with a possible pericardial effusion.​ An echo was performed which was reported remotely as showing a ‘‘small pericardial effusion, of approximately 1 m in thickness.’’​

Four days later, the scan was repeated, this time with telemedical input from a cardiology team in the Emergency Telemedicine Suite at the University of Texas.​ A video feed of the clinic room allowed the cardiologists to coach the operator to achieve optimal views.​ This scan showed normal left and right ventricular systolic function with no evidence of tamponade, avoiding the need for costly extraction.​

Swimming the Amazon​

In 2009, Slovenian Martin Strel swam the entire length of the Amazon River from high in the Andes to Belém, Brazil.​ There was one physician on the support boat, supported remotely by the Amazon Virtual Medical Team (AVMT).​ 129 real-time consultations took place during the journey over a 66 day period.¹⁰

Remotely guided ultrasonography on Everest

An ultrasound system was connected via satellite phone to a laptop, this streamed a video to an advanced ultrasound operator. ​ The expert guided novice operators in performing pulmonary surveys on two asymptomatic participants. ​The equipment performed well despite the cold, hypobaric conditions, and the remote expert was able to guide and identify comet tails suggestive of pulmonary interstitial fluid within 25 minutes.¹¹

The Virtual Doctors

The Virtual Doctors are a UK-based charity that uses a smartphone app to connect clinical officers working in rural Zambia with volunteer doctors, based predominantly in the UK (see slideshow images). They offer remote diagnostic and treatment advice for complicated patient cases; aiming to improve rural healthcare provisions. The charity currently supports 233 health facilities ​in 37 Districts ​across 5 provinces. It covers a population of about 3.5 million people, around 20% of the population.

It aims to reduce unnecessary hospital referrals and develop a sustainable system that can be incorporated into existing healthcare systems. There are currently around 200 volunteer NHS doctors who give up their time to support the charity across many specialties.

The service has been hugely beneficial with one user commenting that the service has changed the way she works. She can now treat more patients in the clinic, saving them time, transport costs and the stress of being away from their families. Another user reports that patients receive a diagnosis as if there was a doctor at the facility. They feel this helps patients recover faster and return to their livelihoods, which in turn contributes to national development.

This simple yet effective telemedical solution has been such a success in Zambia, that the charity is rolling out their scheme in Malawi later this year. To get involved please see the end of the article.

Robotic Dogs

Spot, a four-legged robot from robotics company Boston Dynamics, was used at Brigham and Women’s Hospital in Massachusetts during the coronavirus pandemic.¹² ​With an iPad and two-way radio on the robot, healthcare workers were able to have a video conference with patients and remotely control Spot as the robot walked through rooms with isolated patients.​

Medicolegal and Ethical Considerations

Clinicians consulting via a telemedicine platform must ensure that they adhere to the GMC’s ‘Good Medical Practice’ guidelines¹³ (or their registered body’s equivalent) and that they act within their professional competencies.

Clinicians may require different levels of training, experience and seniority, depending on the type of advice being given and the relative experience, knowledge and expectations of the receiving party.

For example, to ensure that appropriate specialist advice is given, The Virtual Doctors looks for doctors who have either completed or are approaching their CCT, or those who have worked in a low resource, tropical medicine setting.

As with all clinical work, it is important to have appropriate medical indemnity to cover your practice. Arrangements vary between organisations, countries, roles, and with the degree of senior support provided. It is best to discuss this directly with indemnity organisations – try both those of your home country and those of the host country.

Similarly, if you are providing international medical advice, you may need to be registered as a practitioner in the “receiving country.” It is wise to consult with the organisation that authorises registration in your field of practice within that country.

Data security, transmission and retention are important and complex medicolegal issues to consider. These usually become apparent during the initial set-up of a telemedicine service and are important to have clear policies for. This is a vast topic, but briefly, some points to consider are:

• Where is data stored and is this secure?
• Which country are the servers located in?
• How long will data be stored?
• Can data be exported overseas?
• Who has access to the data?
• Is there a safeguarding policy?
• What happens if data is hacked?
• Are their means of transferring data secure?

The above list is by no means exhaustive, but it gives an insight into the non-medical logistical demands of establishing a robust telemedical service.

Take Home Messages:

1. Telemedicine is an exciting area that is rapidly changing the way we practice medicine​.
2. Technology will continue to evolve but cost remains a barrier to its widespread use​.
3. Education of local care providers may be more cost-effective and will improve health inequities.
4. Value is only added if input from remote sources will change clinical management decisions on the ground.​
5. Having good telemedical support, or top cover is valuable for expedition medics and may impact favourably on indemnity provision and costs.​

Daniel works as a portfolio GP, a travel health physician, and a trainee BASICs doctor. He is also proud to be the volunteer medical director for The Virtual Doctors. If you are interested in volunteering with them please contact daniel.grace@virtualdoctors.org

References

1) Catalyst N. What Is Telehealth? NEJM Catalyst [Internet]. 2018 Feb 1 [cited 2022 May 21] Available from: https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0268

2) Tuckson RV, Edmunds M, Hodgkins ML. Telehealth. New England Journal of Medicine. 2017 Oct 19;377(16):1585–92
DOI:10.1056/NEJMsr1503323

3) TytoCare | On Demand Medical Exams. Anytime. Anywhere. [Internet]. TytoCare. [cited 2022 May 25]. Available from: https://www.tytocare.com/

4) LifeBot 5 – LifeBot [Internet]. [cited 2022 May 25]. Available from: https://www.lifebothealth.com/products/lifebot-5/

5) Murray P. LifeBot 5 – The Portable Emergency Room [Internet]. Singularity Hub. 2012 [cited 2022 May 25]. Available from: https://singularityhub.com/2012/12/26/lifebot-5-the-portable-emergency-room/

6) White AP, Angood P. Advancing technologies in clinical medicine: the Yale-Mount Everest telemedicine project. Yale J Biol Med. 1999;72(1):19–27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2578958/

7) Bhende MP, Karpe AP, Pal BP. High altitude retinopathy. Indian J Ophthalmol. 2013 Apr;61(4):176–7.
https://journals.lww.com/ijo/Fulltext/2013/61040/High_altitude_retinopathy.7.aspx

8) Otto CA, Shemenski R, Drudi L. Real-time tele-echocardiography: diagnosis and management of a pericardial effusion secondary to pericarditis at an Antarctic research station. Telemed J E Health. 2012 Sep;18(7):521–4.
https://doi.org/10.1089/tmj.2011.0266

9) McMurdo Station Antarctica (photo credit: Tas50) https://commons.wikimedia.org/wiki/File:McMurdo_Station_Antarctica_Station_Sign.jpg

10) Telemedicine for Patient Management on Expeditions in Remote and Austere Environments: A Systematic Review – PubMed [Internet]. [cited 2022 May 25]. Available from: https://pubmed.ncbi.nlm.nih.gov/33423896/

11) Otto C, Hamilton DR, Levine BD, Hare C, Sargsyan AE, Altshuler P, et al. Into Thin Air: Extreme Ultrasound on Mt Everest. Wilderness & Environmental Medicine. 2009 Sep;20(3):283–9.
https://pubmed.ncbi.nlm.nih.gov/19737030/

12) Statt N. Boston Dynamics’ Spot robot is helping hospitals remotely treat coronavirus patients [Internet]. The Verge. 2020 [cited 2022 May 25]. Available from: https://www.theverge.com/2020/4/23/21231855/boston-dynamics-spot-robot-covid-19-coronavirus-telemedicine

13) Good Medical Practice, General Medical Council [Internet]. 2019 [cited 2022 Aug 27] Available from:
https://www.gmc-uk.org/-/media/documents/good-medical-practice—english-20200128_pdf-51527435.pdf

The post Telemedicine in Remote and Wilderness Environments appeared first on Adventure Medic.

Dr Lucy Obolensky works in Emergency Medicine and General Practice and has a wealth of experience within the field of Global Health. Lucy is programme lead for the Global Health Masters at Plymouth University, and co-founder of both Future Health Africa and the Global Health Collaborative. From twenty years spent setting up healthcare improvement projects in remote environments, Lucy shares her invaluable advice when considering such work, in the form of a handy ten-point checklist.

In arid, rural Kenya where access to clean water, good grazing for cattle and education for children is sparse, how do you support the delivery of quality and sustainable healthcare to communities?

Since 2000, I have been working with local conservation organisations to improve the health outcomes of rural communities in Kenya. In this article I will share with you some of my experiences, the challenges we have faced and lessons learnt.

A background to tribal culture.

Before envisaging a health system it is first essential to understand the people and the culture that you are working with. I was just 17 years old and about to embark on my medical degree, when I first visited the community of Leparua in Northern Kenya. Since then I’ve spent many months of my life based at their clinic. They have seen me grow up, graduate as a doctor, then a surgeon, get married, have children and ultimately bring my own children to their community. I feel privileged when I consider how I have been allowed to develop a depth of understanding of their culture that not many have the opportunity to. Yet, every time I visit, I am still learning about the traditional practices and beliefs that define their health needs and outcomes.

The communities that I have spent the most time working with are the Maasai and Samburu. These pastoral nomadic tribes live in manyattas (a type of wood and mud hut). Their wealth is demonstrated by the number of livestock they own or if they have a tin roof on their manyatta. Large families, of five or more children, are common. When a daughter gets married, her family receives a dowry in the form of cattle. Domestic violence is not uncommon, nor is female circumcision. Traditional birthing attendants perform most of the deliveries and traditional healers or witch doctors are commonly consulted. There is frequent intertribal fighting and cattle rustling, which is increased during times of drought and poor grazing.

New horizons

However, times are changing in these communities. Tribal elders are starting to see the importance of women as leaders. They believe that the education of girls as well as improved access to healthcare and education for all will help to achieve this. Our aim is to work side-by-side with communities, conservation NGOs and the Ministry of Health, to both improve provision of healthcare and support this positive cultural change.  It takes time, patience and support from many sectors for communities to find a new path which adheres to their traditional values. The journey is long, but overall there have been many sustainable achievements.

The Northern Rangelands Trust

The Northern Rangelands Trust (NRT), a conservation organisation that I work with, has taken a holistic approach to public health for some time.  The NRT aims to enhance people’s lives through building peace and conserving the natural environment.

They have worked in union with tribal elders to prioritise the needs of the local community, stating these needs as:

⦁    Grazing for livestock and fair trading of animals

⦁    Peace and security for homes and villages

⦁    Access to clean water, healthcare and education

Perhaps unsurprisingly, these priorities are closely aligned with the 2015 Sustainable Development Goals developed by the United Nations General Assembly.

Delivering Community Healthcare

So, in practice, how do you work with communities to improve the provision of healthcare, address the wider needs of the community and support cultural beliefs, all on a background of limited funding?

You can install a bore hole into a village, but if there is risk of fighting or cattle rustling the tribes will be forced to move away from this clean water supply. You can offer education, but if there is no nearby grazing children will be required to help the family, herding cattle far away, rather than attend school. You can offer healthcare, but it is essential to assess its accessibility and cultural acceptability.

A checklist for designing and implementing community health projects:

From my 20 years of experience in delivering community healthcare to remote locations and austere environments, I have developed a ten point checklist that I use for any project.

In order to better illustrate this checklist, I will use it to talk through a Family Planning Programme that we set up in 2010 in Kenya.

What do the communities want?

I have spent many long days sitting under a shady tree, drinking a heady concoction from a gourd poured by a wizened tribal elder, waiting and listening to get to the bottom of what the residents would really like to see in their community. The lesson is that embarking on any healthcare implementation project, however important you see it to be, without the buy-in of the communities will be doomed to fail.

In this instance the community elders said they wanted to have access to family planning within their community. At the time this was only offered at a clinic which is a 6 hour walk or 3 hour drive away.

Evaluate unmet need.

‘White elephant’ health facilities and pieces of medical equipment from charitable donors may be gratefully received at the time of giving, but, without the resources to staff the centres and maintain the equipment, risk sitting around gathering dust.

Once you have a clear understanding of what the residents would like to see in their community, it is imperative to continue to work together with the communities to evaluate the unmet need for the project. This is an exercise best undertaken with a Ministry of Health representative, in order to understand what resources are available.

In this example, there certainly was an unmet need for family planning. The existing clinic was a long walk away and many women have 5 children. Subsequently, they spent much of their adult life pregnant or post natal, often with associated anaemia or nutritional deficiencies.

What is the National Strategy?

If your project is not being undertaken on behalf of the government, it is vital that you engage early with local government health officials (most likely the regional public health officer or a county minister of healthcare). By approaching this in the correct manner, it is likely that the local government will be delighted that you are offering to support their health service. Your project should, however, either enhance or develop what is already in place, or be in keeping with priorities of the national health strategy.

In this case, there was a big government drive to deliver family planning to all remote settlements. They were struggling to deliver this project due to funding and logistical challenges, and multiple other factors inherent to delivering healthcare in low and middle income countries that are beyond the scope of this article.

We visited the County Minister of Health to discuss the scope of our project, and the memorandum of understanding (MOU) we already had in place with the local communities involved. He disclosed that the government would be able to provide all the contraceptive implants and medications once the programme had been approved and commenced. This was a positive start, but not all planning meetings are so straightforward.

During the family planning project development stages, we had proposed to develop training for Traditional Birthing Attendants (TBAs). Our idea was to upskill the TBAs to recognise early complications of labour and bring women into the clinic earlier. This seemed like a good idea in theory, however, the government had recently made working as a TBA illegal, citing them as one of the reasons for raised maternal mortality in rural villages.

Proceeding to train TBAs without consultation of the National Women’s Health Strategy and discussion with the government health official would have been to undermine government regulations. Instead, we worked together to train TBAs within government guidelines and offered incentives for TBAs to bring struggling women into the clinic promptly when indicated. This empowered the TBAs, ensured the safety of women in labour, and ultimately brought down maternal morbidity and mortality rates in the community.

Partnership and Governance.

It is important to identify all your stakeholders early in the process. Ideally you will form a partnership with the host party (MoH or NGO) and develop a MOU. It is also useful to be aware of the ‘9 Principles of a Partnership’, written by the Tropical Health Education Trust, and use these as a guide for both parties to abide by.

If you have a signed MoU then you are likely to have at least considered your governance. My general approach is to work through this with the local team, being very clear about your boundaries, roles and responsibilities. There are plenty of examples of MoUs from other partnerships online, so take a look at these MoU before you try to reinvent the wheel. You can find guidance on writing a MOU from THET here.

It would also be prudent to include medical indemnity under governance. It is important to ensure that the organisation that you are planning to work with has an agreement with their government, or is working in partnership with a recognised non-governmental organisation (NGO). If you are going to be working in a clinical capacity, which tends to mean any work involving patients, then you will need to be registered with the health system of the country you are working in. In the UK this is equivalent to being registered with the General Medical Council (GMC). Alternatively you will need a letter from the minister for health for the region you are working in, stating that you are working under their supervision. If you are not working clinically, your usual indemnity organisation should be able to cover you, although this will depend on their individual policy. You do need to contact them to let them know what you will be doing and discuss the available indemnity options for you. Some indemnity providers may offer a reduced fee for indemnity cover while you work with global health partnerships or with humanitarian organisations.

Keep it Simple.

So now you have a project, a partner and a goal. As you embark on your healthcare delivery project, it is highly likely that you will come across other equally important unmet health needs that require action.

While implementing our project, it was not uncommon to see malnourished children accompanying their mothers to the family planning clinic. It is difficult not to intervene but I would caution you not to step outside the remit of what you have set out to achieve, and what you will realistically be able to implement within your timeframe and budget. Malnutrition in children is a hugely important issue, but needs to be undertaken with the same careful planning and consideration as your primary project goal.

It is helpful to use the SMART criteria: your objectives should be specific, measurable, achievable, relevant and time-bound.

Taking time to understand local culture

I cannot stress this point enough, nor can I stress how long this can take as an outsider to an unfamiliar culture. As mentioned previously, I have been working with one community for over twenty years, and yet on many occasions I realise that my cultural knowledge only scratches the surface.

Limitations and challenges

You are bound to encounter problems with the programme. The question is whether you can pre-empt these and do anything to mitigate them. It could be funding, the logistics of supply and demand, or getting buy-in from the community as a whole. Like any community or organisation, what the elders want doesn’t always align with everyone’s wishes.

In the case of the Family Planning project our problem turned out to be buy-in from the whole community. To facilitate acceptance of the family planning clinic by the wider community we had arranged education sessions carried out by specialists from the same tribe and culture. We also held open forums to discuss what family planning is and what it means for the women, the man, and the whole family.

On the day that the clinic opened a long queue of women was waiting outside to be seen. There was excitement in the air and it seemed to be an encouraging beginning. Sadly it was not all plain sailing.

I returned four months later to carry out follow-up of the project, and initially was informed by a delighted nurse how good uptake the uptake had been. I saw a couple of women enter the clinic,  but interestingly the nurse had their records in her desk drawer. When another woman came in without her card I pointed out that these should stay with the women, rather than at the clinic. Both the nurse and the woman looked very concerned.

I then noticed that this woman had bruising to her face and was holding her arm in her kikoi (cloth garment worn around the waist) due to an injury (she had an ulna fracture). When I asked her about it she explained that her husband had beaten her when he found out she was on contraception. He told her that this would make him impotent. My heart sank. I later found out about another woman who had been admitted to hospital with a head injury for the same reason. I was faced with the realisation that we had implemented a programme that was ultimately causing women harm.

I initially felt very strongly that the project should stop, or at least be put on hold until we could resolve this serious issue. However, when we met with the local women’s group they were  adamant that the programme should continue and felt that huge gains had been seen already.

I supported this decision on the agreement that we, with immediate effect, provided ongoing education sessions, with some men-only sessions delivered by male nurses from the neighbouring clinic. This was much better received, and myths such as ‘having sex with a women who is on contraception will make you impotent’, and that ‘women on contraception can never give birth to boys’, were able to be voiced in an open forum, discussed and dispelled by the education specialists.

The following year I visited  the clinic. Whilst I was chatting to the nurse a man brought his wife into the clinic. The nurse went in to see them and, while popping back out to collect some equipment, spoke to me. “You see doc” she said with a smug grin on her face, “now they all bring their wives here for family planning!”.

Within six years of starting the programme we had over 85% uptake of family planning services, with the remaining 15% accounting for times when the tribes may have moved on for grazing. After ten years we began to see a reduction in the number of children per family, accompanied by a reduction in maternal mortality.

Follow-up, evaluation and improvement

Whatever your project, you will need to think about how you are going to carry out follow-up, evaluate it and make any necessary improvements. As per point 4, you need to consider all your stakeholders: what are you giving? What are you gaining? What can be learnt?

Monitoring and evaluation are vital to all projects, but you need to consider who will be able to implement this. Do the local teams have the skills to do this as part of a quality improvement cycle? If not, then part of your project plan should be to train nurses, community health workers and community members to carry this out.

In the case of our family planning project we were lucky to have all of the above to help gather information so that collectively we could review and agree on any changes that should be implemented. We also continued to involve the government from the outset which, as you will see from the points below, is fundamental to the success of any project.

Local sustainability and having an End Point.

These two final points need to be considered together. In my view, many ‘Western’ charities make the mistake of embarking on health improvement projects before really considering where their input will end.

To be truly successful and sustainable, projects cannot continue relying on overseas grants, aid and resources. Any programme must have the capacity to be locally sustainable and be fully owned, delivered and governed by the in-country team. Therefore, at the very start of any programme you need to know the ending. What will mark the end of your time with a project? When you can confidently withdraw knowing that the project is sustainable and self-sufficient.

We alone did not define the end point of our family planning project. We sat with the Public Health officer of the county and agreed on a series of indicators, including numbers trained, percentage uptake or services, presence of mobile clinics, etc. It became apparent that the more successful the early stages of the project were, the more funding the government would invest in subsequent years. Within five years the entire programme was provided and funded by the government. This includes ongoing training, which we all hope will help to maintain sustainability of the programme long into the future.

Conclusions

Planning and implementing community health improvement projects in remote environments is complex. Working with these communities has demonstrated to me the importance of ‘One Health’. The ‘One Health’ approach, as adopted by the WHO, is “an approach to designing and implementing programmes, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes.”

Failing to deliver health improvement projects in accordance with the One Health approach is likely to result in a failed programme. All services should be implemented and delivered in a holistic manner, with health considered as only one piece of a much wider jigsaw, to ensure long term, sustainable and positive health outcomes.

Dr Obolensky is also the founder of Endeavour Medical. The team at Endeavour Medical run scenario based training courses to explore and teach the knowledge and skills required to provide medical cover in remote locations. One of their core values is a belief in Universal Health Coverage. For this reason they have committed to supporting Global Health Projects in Kenya, like the one you have just read about.

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Dr Rosie Stokes specialises in diving and hyperbaric medicine at DDRC Healthcare’s hyperbaric facility in Plymouth. Here she shares some fictional cases following one of the busiest autumns at DDRC as UK scuba diving returned post lockdown. Whether they present to your Emergency Department, GP practice or on an expedition, here’s what to look out for and who to call. 

What is dive medicine? 

Most people have heard of ‘the bends’, or decompression illness. 

Decompression illness is the umbrella term for both decompression sickness (an evolved gas issue) and arterial gas embolism (an escaped gas issue):

• Decompression sickness tends to present any time from the diver leaving the bottom to 24-72 hours later. The severity of symptoms relates to the depth and time of the dive. 

• Arterial gas embolism presents within 20 minutes of surfacing, usually after a rapid ascent. It is unrelated to time or depth and can even occur in a swimming pool!

Presentation of decompression illness can vary, depending on the area of the body that the bubbles have affected. If you are a medic working at a dive site, near the coast (or even near an airport), it is worth having some basic knowledge of dive medicine, so that you know what symptoms to look out for. 

If in doubt, the British Hyperbaric Association emergency line is available 24/7 for advice. You can speak to a dive doctor directly and, if needed, we can arrange for assessment at the nearest hyperbaric chamber. 

Here are a few examples of some typical cases of divers that may present to DDRC. These cases are entirely fictional and any similarity to real patients are coincidental.

Case 1 – Cord Compression: Spinal Decompression Illness

A 60 year old male, JX, was on his first day of a dive trip, on a boat off the southwest coast of the UK. JX was a relatively new diver and had an enjoyable dive down to 15m. On his ascent his inflator stuck, allowing more air into his BCD (buoyancy control device). He was unable to control his ascent and rapidly arrived at the surface, in a panic. 

The boat crew got him out of the water and removed his scuba equipment. He reported feeling weak and complained of some back pain. The skipper put 100% oxygen on him and called the coastguard.

The coastguard rang the BHA who advised that the JX be taken by air ambulance to an emergency department. He had a chest x-ray to rule out a pneumothorax, which can result from a rapid ascent. He had weakness in his right leg with loss of sensation. He also had urinary retention. A urinary catheter was inserted and he was given IV fluids.

JX was transferred to the hyperbaric chamber where he had an extended treatment of over eight hours. His symptoms persisted and he returned to hospital to have an MRI spine, which did not find any other pathology. His symptoms slowly improved but it took three weeks of daily treatments before he felt back to normal. He was left with some loss of sensation in his right foot.  

Case 2 – Off Balance: Audiovestibular Decompression Illness

RS, a 50 year old man, was on the third day of his dive holiday. He had been breathing nitrox (32% oxygen) using normal open circuit scuba equipment. He had a moderate level of dive experience with 70 previous dives. The dive was uneventful, exploring a shipwreck. On returning to the boat he suddenly became very nauseous. He lay down on a bench and was unable to sit up or stand without falling. He vomited several times. 

The skipper informed the coastguard, who contacted BHA five minutes later. The boat returned to shore and was met by an ambulance. RS was transferred to the chamber for assessment on high-flow 100% oxygen.

On examination he was unable to stand and kept his eyes closed. He had horizontal nystagmus, and his extreme nausea and dizziness limited the rest of the examination. He was given anti-emetics and IV fluids and put into the recompression chamber for treatment. 

During treatment his dizziness and nausea continued and the treatment was extended to eight hours  Due to persistent severe symptoms he required two weeks of daily treatments before he could walk normally and had stopped having bouts of vertigo. 

Neurological decompression symptoms can be associated with a patent foramen ovale, and a large PFO was found on bubble echo.

Case 3 – Overloaded: Immersion Pulmonary Oedema

Decompression illness is not the only emergency that we are called about. Many things can go wrong when you are submerged underwater. We also advise on other emergencies such as immersion pulmonary oedema, barotrauma or rebreather/gas contamination issues.

TR, a very experienced 65 year old female diver, entered the water from the shore with her two dive buddies. They swam to a cluster of rocks where they had planned to dive near a kelp forest. During the surface swim she began to feel breathless, but decided it was due to lack of exercise and recent weight gain. She paused to catch her breath but couldn’t. She began to cough up a clear, frothy fluid. Her buddies noticed her struggling, so swam her back to shore and removed her scuba equipment. Her breathlessness continued and she began to look blue. A passer-by rang for an ambulance.

When the ambulance arrived she was hypoxic with oxygen saturations of 86%. She was placed on 100% oxygen and taken to hospital. On arrival she had a chest x-ray which was consistent with pulmonary oedema. She was given IV diuretics and her symptoms improved. The ED consultant rang the BHA line to discuss the incident with a dive doctor. 

This was a case of immersion pulmonary oedema, which can often be mistaken for drowning in sea swimmers and divers. Immersion in cold water causes an increase in cardiac preload, inducing pulmonary oedema. It is thought to be more common in people with uncontrolled hypertension.

This lady made a full recovery but has decided not to return to diving after a discussion with a dive doctor.

Case 4 – Under pressure: Barotrauma

GR, a 19 year old newly qualified diver, was with a group of more experienced divers. He had a bit of a runny nose but it didn’t bother him too much. During descent his right ear felt blocked and he couldn’t equalise. The divers ahead of him had almost reached the bottom, so he ignored his discomfort and continued to descend.

On reaching the reef he felt sudden relief of the pain and he forgot about his ears. The dive was uneventful with no other issues but on ascent, his right ear felt a little odd again. He surfaced without a problem. 

On the boat he noticed that he had a fullness in his right ear and noises seemed dull. His ear felt painful and sensitive and he began to worry.

GR contacted the BHA who advised him to see his GP.  He was found to have a perforated eardrum. It healed quickly and, luckily, he has no long-lasting damage to his hearing. 

Having a common cold or structural issues with your eustachian tubes can make it difficult to equalise the middle ear. Any air that is trapped in a confined space in the body has the potential to cause damage as the volume of air changes under pressure. As this diver descended the middle ear would have been squeezed, disrupting the tympanic membrane and ultimately causing a perforation. 

Who to call:

These cases illustrate the breadth of diving-related illness. It presents in multiple ways and can be tricky to identify, as it resembles so many differential diagnoses.

If you are looking after a diver in the UK then the British Hyperbaric Association emergency line is available 24/7 for advice:

• England and Wales: 07831 151523

• Scotland: 0345 408 6008

If you are outside of the UK then divers should be advised to speak to their nearest hyperbaric chamber or if they have DAN insurance (Divers Alert Network) they should ring +1 (919) 684-9111.

If you are providing medical cover on a dive expedition then make sure you have a thorough knowledge of the evacuation plan and access to a supply of oxygen that will last for the length of time that it takes to get the diver to the nearest medical facility or hyperbaric chamber. Hyperbaric facilities vary greatly and it is worth investigating what treatment they can provide and how accessible this is.

More advice can be found here: Diving: Managing Decompression Illness in Remote Locations.

If you want to learn more about dive and hyperbaric medicine please visit our website at: www.ddrc.org or follow us on Facebook: www.facebook.com/DDRCPlymouth

If you are interested in working at DDRC we periodically advertise for junior doctors and nurses. Keep an eye out on the job section of our website: www.ddrc.org/jobs and take a look at this article by one of our previous DDRC doctors: Diving and Hyperbaric Medicine at DDRC Healthcare.

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As a self-confessed planner, organiser and advocate for travel off the beaten track, Chris admits that he doesn’t really “do holidays”; at least not in the classic sense. He has worked in diverse and exotic environments such as the Gobi desert, rainforests of Central America, the High Atlas Mountains and the Himalayas. A highly experienced UK paramedic, Chris shares how expedition medicine has been his gateway to travelling the world.

Paramedics have an important role to play in the world of expedition medicine and offer a wealth of emergency experience, diverse clinical skills, and leadership in challenging environments. However, whilst there is an increasing amount of accessible information regarding the responsibilities and experiences of expedition doctors, there is relatively much less guidance available focusing on the issues faced by paramedics, and for those who seek to deploy them for expedition work.

When I started working in the UK’s NHS ambulance service twenty-two years ago, paramedics were largely protocol-driven, working with a restricted skillset, limited drugs and minimal equipment. The overall ethos was to “bring the patient to hospital”, whether the patient needed it or not. Over the last two decades, the role of a paramedic has evolved to be delivered by autonomous healthcare professionals educated to at least degree level.  Combining this with improved access to drugs and equipment enables us to make independent, patient-focused clinical decisions we only dreamed of before.

On expedition I often draw on many of the skills I honed as a paramedic of old; working with less sophisticated equipment, improvising and problem-solving in austere environments, and working with less patient information than we are accustomed to in the present-day NHS.

As a paramedic taking my first steps into expedition medicine, I started by asking myself a number of questions:

What level of supervision did I need?

From a personal point of view, I was happy that I could look after myself on an expedition. I’d been around the block, travelled around Europe, and made a trip to Africa long before the internet and smartphones were ubiquitous. I considered myself relatively streetwise but what about medical supervision? My career had equipped me to deal with what was in front of me, but what if something went wrong?  Who could I turn to for advice?  Who would be there to clinically supervise me and provide reliable, accountable advice?

The first company I was deployed with provided round-the-clock online, remote, clinical advice from a cadre of consultants.  As far as I am concerned, this set the bar for me and is now something I always ask of the companies I work with.  Depending on the size and skill set of the team, we would often have at least one senior doctor in the country with us, though perhaps not alongside us. Knowing that there is someone to turn to for clinical advice and “top cover” is of inestimable reassurance.

Would my status be recognised internationally?

UK paramedics are registered by the Health and Care Professions Council (HCPC), but there is no guarantee that this status has any meaning outside of the UK.  Some countries with developed healthcare systems such as Australia, Canada, South Africa and the USA have paramedics whose scope and role is broadly similar to ours, whereas in other countries paramedics are no more than taxi drivers.  It is key to research the country you are deploying into to ensure you do not fall foul of any protected titles or restrictions of practice. Whilst there are many countries that we are able to practice in, step foot into the USA with a bag of medication and your UK title will not protect you. The first step is to research the country’s regulatory body and perhaps seek guidance from other health care professionals who have done similar work in-country.

The HCPC do not regulate paramedic practice outside of the UK, though they will provide a letter confirming your UK status as a paramedic should a foreign company or regulatory body require one.  This would be particularly useful if you were intending to practise in Europe, as a paramedic’s HCPC status can be compared with the EU’s European Professional Qualifications Directive.  However, if paramedics are considering practising in the EU they would be well advised to seek up-to-date advice in the planning stage as the situation between the UK and EU could change rapidly and without much warning.

The HCPC would not have jurisdiction should something go wrong in another country. However, should a paramedic’s fitness to practise be under question on their return to the UK, what happened in-country would be of interest to the regulatory body.  One hopes that the austere and unusual environments of wilderness or expedition medicine would be taken into account however there are few relevant previous hearings to use as precedent.

What indemnity cover did I need?

For paramedics starting out along the expedition route, the College of Paramedics’ indemnity cover, currently provided by James Hallam Pro Med is suitable for the vast majority of needs. However, it is vital to read the small print to familiarise yourself with what you are covered to do. The medical malpractice and public liability insurance is intended for voluntary and low-key professional work in the UK and abroad but until recently didn’t cover certain patient groups, for example, elite athletes. If your trip has specific requirements, it would be advisable to contact the indemnity provider directly to discuss your expedition.  It is also important to know if there are any territorial restrictions (i.e. will they cover you in North America?) and what is the jurisdiction of claims (usually just the UK).

What equipment would I require?

I have never operated with a company or organisation who have required me to provide my own drugs or medical equipment, except for my own stethoscope.  The medical kit provided by an organisation can vary greatly depending on the specific expedition, environment and group of participants. There’s been a huge variation in the range and level of equipment provided across the expeditions that I have worked on.  For example, working as a team of five paramedics travelling independently in Nepal, we took more kit with us than when I was part of a multidisciplinary team of ten looking after fifty travellers in Sierra Leone.

Much of the variation in equipment levels is due to the specific requirements of an organisation and their risk assessment.  Specific considerations might include some of the following questions:

Is the intention to answer every primary care need for a party of children on a month-long expedition?  Is the role to be the safety net, providing solely life-saving interventions, for elite athletes pushing themselves to the edge on a 400km ultra-marathon? Are you close to civilisation and able to extricate patients to a modern hospital?  If so, will that journey be on the back of a mule or a pick-up truck?  Is the nearest ICU an aeroplane ride away to another country?

I’ve always been comfortable travelling with minimal equipment.  I know that if I have to carry everything on my back for a few weeks I will end up resenting the oxygen bottle (which would only last for twenty minutes and cause no end of logistical concerns anyway).

At the end of the day, if you don’t have it, you can’t use it.

Nevertheless, this means you need to know how to use every bit of equipment you have properly and understand its limitations. If there is something you don’t have, what do you plan to use instead?  For example, if you don’t have traction splints will you consider the option of applying manual traction for hours on end (untrained helpers are useful and don’t take up space in your medical bag!) or will you improvise splints and traction devices using readily available materials? Are you familiar with all of the medications that you are taking with you?

My advice is to familiarise yourself with your kit bag before deployment and be comfortable with minimal kit. For the most austere environment, you may only have a simple first aid kit and selected uncontroversial drugs to see you through the first hours of a serious incident.  Plan ahead and think about how you would manage different scenarios.

What about drugs?

In normal practice, most paramedics will operate under the Joint Royal Colleges Ambulance Liaison Committee (JRCALC) medicines guidelines. In addition to the eighteen Schedule 19 medicines, the Human Medicines Act 2012 allows paramedics to stock and administer 24 non-parenteral drugs, and to be supplied with pharmacy drugs (“P drugs”) under the supervision of a pharmacist.  Where this does not fulfil a particular requirement and exemptions are required, supplementary patient group directions (PGDs) may fill the gap.  These are formal written instructions and are often substantial documents.  This may take a lot of resources to create and therefore be outside of the reach of smaller providers.

When considering medication requirements, it is vital to research the legality of our common drugs in other countries.  Take morphine, codeine or tramadol into Egypt or Thailand and there’ll be problems.  Take any of these, plus a range of over the counter medicines into the UAE without perfect documentation, and you will be in another world of pain.  It may be an option to buy drugs in-country – anyone can walk out of a shop in Nepal with a bag of medicines that would make a UK pharmacist raise their eyebrows.  But can you be sure that it has been stored correctly, or that it is not counterfeit?

Do I need any additional training or skills?

I was a late addition to my first expedition. A last-minute cancellation left me with just over a fortnight to arrange release from my day job, and ensure that I was adequately kitted out and immunised for Sierra Leone, one of the poorest counties in the world, devastated by Ebola and civil war.

As soon as I was back in the UK I knew that I wanted to do more. I approached the operations director of an expedition medicine company and asked if I would be a more attractive candidate if I had a wider range of medical skills – should I learn more advanced wound care and suturing perhaps?  She told me no.  If I was deployed by her organisation I would be part of a multidisciplinary team with other healthcare practitioners who would bring those skills.  I would be more valued for the skills I brought as a paramedic, managing incidents and dealing with a wide range of emergencies, in which other members of the team may not be so comfortable or experienced.  I was the “get out of jail free” card to be pulled out of the back pocket when things got tough.

However, when working in a smaller team, or solo, a wider skill set would be really useful so it is worth considering how to increase the depth or range of your clinical abilities to make you more attractive as a paramedic to organisations. It is vital to ensure that you can learn and maintain any additional skills to a suitable UK standard and to reflect your new competencies within the evidence of your portfolio of continual professional development.

Finally, if you are new to the expedition world or considering becoming involved, there are lots of brilliant courses available to help equip you with basic expedition skills which I would recommend to give you a broader understanding of the various considerations when joining an expedition.  Many of these courses are delivered by sporting bodies and mountaineering organisations but increasingly universities and medical societies are producing modules and courses from basic to masters-level offering expedition knowledge and skills for medical providers.

Would my boss approve the trip?

Having secured the leave, which for some staff can be a battle in itself, paramedics must be sure they are not infringing any of their employer’s policies.  Even voluntary work may impinge on NHS trusts’ “secondary employment” policies, and private companies may be concerned about potential competitors.  Furthermore, during the COVID pandemic, we’ve had to account for a quarantine period before returning to work, which can make expedition work more tricky.

By and large, I’ve found my bosses to be incredibly supportive – if your manager needs convincing, remember to highlight what benefits the trip may bring; such as improvement to your skill set and transferable skills for potential career development within your organisation.  If your section of the organisation doesn’t provide a range of fulfilling CPD opportunities, gently remind your boss how important CPD is to your registration and future practice.

Preparation is key

It’s probably clear by now that I’m a planner.  In fact, if I’m not actually on an expedition then I’m planning for a future trip.  One of my most important tips is to practice in your day-to-day work with checklists and mnemonics, to help give structure to the chaos.  One of my favourite mnemonics is CSCATTT – take control, ensure safety, communicate, assess risks, triage, treat and transport.  It’s intended for use by ambulance commanders at major incidents but it becomes second nature if you use it routinely to deal with any unplanned occurrence.  It’s brilliant for expeditions.

Another worthwhile exercise is to think about everyday incidents that you deal with in your role as a paramedic and to identify what you would need to do differently if you encountered a similar situation in an expedition environment.  I found it very useful to take myself out of my comfort zone and run through how I would manage expedition scenarios, for example:

When do you call backup for support?  When do you escalate to a high clinical resource?  When do you decide to divert from the nearest district general hospital to a regional centre further away?

Now imagine you are somewhere so austere that the nearest hospital with full surgical and intensive care facilities isn’t just in a different region but in a different country!

When do you pull a fractured leg?  When do you reduce a dislocation?  In what circumstances do you start or cease resuscitation?

Having run through all these scenarios in the comfort of an armchair, you’ll feel so much more prepared and confident as you take your first steps into expedition paramedicine.  Perhaps it’s not as extreme as it first seems.

As well as being an operational paramedic, Chris has undertaken NHS management roles at local and national levels and is an experienced incident commander and team leader of an NHS Hazardous Area Response Team. Chris has worked with Exile Medics for some years, first as a volunteer paramedic, then as a team leader and now as the company’s expedition paramedic lead. Chris also works on a freelance basis for MSS Ltd. providing TV/film and stunt safety cover. What little spare time he has, Chris fills with long-distance running and studying for his Masters. Chris is married to Helen, his childhood sweetheart, and their family is completed by two Serbian rescue dogs.

You can follow him on Twitter and connect on LinkedIn.

The post Life off the Beaten Track; Expedition Medicine for Paramedics appeared first on Adventure Medic.

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.

The COVID-19 pandemic arising in 2020 changed the world as we know it. The way we think about and execute overseas expeditions has and needs to take account of this. With the advent of vaccines, the world is slowly opening up again. However, with global inequity of vaccinations and rapidly appearing new variants of COVID-19, the purpose, justification and accomplishment of any expedition require careful consideration.

Endorsed by the Royal Geographical Society, this guide is for teams looking to go on expedition during the COVID-19 pandemic. Considerations for each step of the expedition are discussed with possible suggestions and protocols on how to pragmatically factor these into the expedition plans.

Contents

1. Should this expedition take place?
2. COVID-19 risk assessing
3. Minimising the risk of contracting COVID-19 pre-expedition
4. Expedition Amendments
5. Roles and Responsibilities 
6. Insurance
7. Agreeing to go on expedition
8. Minimising transmission risk on expedition 
9. Policy for COVID-19 symptoms on expedition
10. Expedition closure 
11. Useful sources of information
12. Example protocols
13. Suggested COVID-19 medical questionnaire 
14. About the author

1. Should this expedition take place?

Considerations:

• The urgency of the expedition – why does it need to be done now?
• The overall COVID situation in the host country
• The health and risk to each member of your team
• The health and risk to the in-country team and local communities you are visiting or passing through
• The extent that COVID restrictions will limit what can and cannot be done on expedition
• The additional financial cost of going during a pandemic
• The mental health/anxiety impact on team members and in-country teams
• The duration of the expedition and time needed for potential quarantining
• Availability of vaccines for expedition members and in-country teams

The expedition stakeholders need to question: should this expedition be taking place and is now the right time? This will depend on many factors, not least the overall aims of the expedition itself.

Morals and ethics

When deciding whether to proceed with your expedition, you must weigh up the benefits of going on expedition now versus the health risks to the expedition members and the host community. This is covered further in the COVID-19 risk assessment.

Logistics

COVID-19 will likely impact upon the parameters of your expedition. If the expedition plan was for your team to integrate with local communities or travel across borders you may find you are unable to do so during a pandemic. Depending upon the situation in the host country, it may be sensible for your team to significantly limit the amount of contact they have with locals to minimise risk. Are any of the restrictions COVID-19 puts on your expedition going to impact your ability to complete the expedition’s aims?

The timeframe of the expedition may be impacted by COVID-19. For example, if someone on your expedition develops symptoms of COVID-19 they will have to self-isolate and if they test positive this will be for a minimum of 10 days. Similarly, if the host country becomes red-listed by the UK government and you need to quarantine on returning to the UK, or the host country’s government changes its travel policies, this will lengthen your expedition.

Finances

The cost of an expedition during a pandemic may well be higher than it would be if it were postponed. Additional costs may include COVID-19 testing, travel insurance, PPE, additional medical equipment and potential quarantine on both entering the country and if expedition members develop symptoms and need to self-isolate (if not covered by insurance).

2. COVID-19 risk assessing

Expedition member considerations:

• Each team member’s medical and drug history including age, fitness level and other medical conditions.^1,2,3,4
• Have they previously tested positive for COVID-19?
• Do they suspect they have previously had COVID-19?
• Have they had a COVID-19 vaccine? How many? Which vaccine? How effective is this vaccine?
• Are they at high risk from COVID-19?^1,2
• Who is in their household? Are they at high risk/shielding?
• Their occupation and who they work with.

A COVID-19 risk assessment should be conducted for each individual on expedition, this is especially important if the expedition is going to areas with high levels of COVID-19. It should include each member’s risk of developing symptoms, becoming more seriously ill and developing complications.^1,2,3,4 A suggested COVID-19 medical questionnaire can be found below.

All expedition members should be informed of the COVID-19 rates in the host country/area and at which points during the expedition the risks of infection are highest. Expedition members should be informed of COVID-19 risks and worse case scenarios – for example, becoming seriously unwell with COVID-19 whilst in a remote environment with no access to a hospital. They should each understand and acknowledge the risk before deciding whether to be part of the expedition.

You may want to consider making it a prerequisite that all expedition members must have had a full course of COVID-19 vaccinations before the expedition’s start date or they will not be allowed on expedition.

Local community considerations:

• Is the local population a particularly vulnerable community?^1,2,3,4
• What is the distance to the nearest hospital with definitive care for COVID-19 patients?
• Is there equitable health provision for UK and in-country teams including insurance/finance for treatment/travel and loss of work?
• Are individuals from the community likely to seek medical help if they become unwell with COVID-19? This is a complex question, with many cultural nuances, but does need consideration by the expedition stakeholders.
• Is the community currently free of COVID-19 with your expedition risking being a new source of infection?
• If so, are all isolation and testing measures in place and agreed to be of gold standard?
• If known, what is the natural immunity to COVID-19 in this population, and does this change any of the expedition planning?
• Are the local community social distancing and if so, is this practical on expedition?
• Is PPE available and is it practical to use this on expedition?
• What percentage of the local population is vaccinated and has this been shown to be effective?
• Are there cultural barriers to vaccination and COVID-19 information?
• To what extent will your expedition integrate itself with this community?
• How likely is your expedition to bring new cases of COVID-19 to this community – are you travelling to high-risk areas before going here?

Information such as this may be difficult to find or not available. However, it is important to take each of these points into account when assessing the risk to the host community. You might want to seek out information on whether the community has a large population of individuals with risk factors for severe COVID-19 such as: high age, cardiovascular disease, diabetes, respiratory disease (including severe asthma), obesity, a history of haematological malignancy or recent other cancer, kidney, liver and neurological diseases, and autoimmune conditions.¹

Low-income or middle-income countries (LMIC) considerations:⁵

• The distance to the nearest hospital/medical centre
• The capacity of the nearest hospital/medical centre
• How easily available is transport to the hospital/medical centre
• The financial implications of treatment and travel

In LMICs professional medical care can be days away. Depending on your destination, transport to medical centres may be difficult. There may be little access to private vehicles and minimal/unreliable public transportation or ambulance services.^5,6,7 You may wish to carefully plan your mode and location of evacuation in the event an expedition member becomes unwell.

Expedition Environment

What are the living conditions of the local team and host community like? Are they well ventilated/shared tents/densely populated?

Ideally, a separate risk assessment should be performed for each different community you may encounter. If after completing each risk assessment you deem that the risk of your expedition introducing a new (and perhaps different) strain of COVID-19 is high, you may wish to rethink this section of your expedition.

If you’re only passing through a (high-risk) community is there a different less risky route you could take? Or if you must come into contact with a (high-risk) community, what can you do to negate the risks you pose? Can you quarantine for several days before travelling to this community? Can you ensure you keep your distance from them? Can you realistically wear PPE for long periods in this environment?

3. Minimising the risk of contracting COVID-19 pre-expedition

Considerations:

• Expedition members self-isolating in the days prior to the expedition to reduce risk
• Expedition members having appropriate/country-specific COVID-19 tests prior to the expedition (also consider the timing of the tests – will you need documented proof of a negative result?)
• Has an expedition member been in close contact with an individual who has since tested positive for COVID-19?
• How are expedition members getting to the departure venue?
• Changes or additions to the medical kit

Having all members of the expedition (and their household) self-isolate in the run-up to the expedition is an effective way to negate the risk of an expedition member catching COVID-19 before the start date. You should check how high your local infection rate is to aid this decision. In reality, the rates may be very low, and it may be impractical to self-isolate for several days prior to the expedition. Use your sensible judgement – being more conscious about social distancing and minimising close contacts prior to the expedition may be all that is necessary.

If you do decide that expedition members should self-isolate prior to the expedition, check the current guidance on how many days this should be for. You may wish to consider having all team members isolating together before the expedition – this could be good for team building and may reduce the likelihood of an expedition member becoming apprehensive about the expedition and deciding not to go at the last minute. On the other hand, if any individual brings COVID-19 to the group this may quickly spread and mean the entire expedition must be cancelled.

Expedition members should take COVID-19 tests before they leave the UK. Testing before international travel may be needed by law before being allowed entry to that country. This sort of COVID-19 testing is not currently available on the NHS and is only available from private providers.¹⁰ When booking testing, you should ensure that it is carried out by a laboratory accredited by the United Kingdom Accredited Service (UKAS). To know which type of test to book check the host countries government’s guidelines or the UK governments foreign travel advice.¹²

Each expedition needs to have a clear policy in case of a positive test result. The expedition member who returned the positive test should follow government advice and remain in isolation for the appropriate time. This may mean that part of your team is unable to go on the expedition. You should be wary of this situation and develop contingency plans. Do other team members possess sufficient skills to fill in for the expedition member who is self-isolating? Alternatively, do you know anyone who could replace this team member and fulfil their role at short notice? It would be wise to have reserves should anyone be unable to travel. Depending on the expedition parameters the individual(s) who tested positive may be able to reconvene with the expedition once they are clear of the virus. This could be factored into the planning but may be too impractical in reality.

How expedition members are getting to the departure venue should be considered. Ideally, they should be driven by car by a member of their household to minimise the risk of contracting the virus. Public transport should be avoided.⁹ Research has suggested that imported cases of COVID-19 infections from international travel are likely to contribute little to local COVID-19 epidemics. The exceptions are in countries with low COVID-19 rates and large numbers of international travellers, or in countries where epidemics are close to reaching a tipping point, which if reached, would lead to an exponential growth in cases.¹¹ Separate research has stated that the risk of COVID-19 transmissions in flights, especially short and medium-haul flights, is low and can probably be reduced even further by the use of face masks and social distancing onboard.^13,14

A final pre-expedition requirement is ensuring the medical kit has sufficient equipment for dealing with a COVID-19 infection.¹⁵ This may include: an extra supply of PPE (gloves, mask, apron, eye protection), a pulse oximeter, spare COVID-19 tests, a contactless temperature monitor, hand gel, antimicrobial wipes/cleaning products.

4. Expedition Amendments

Politico-legal considerations:

• Does travel to the country/state need to be permitted by local authorities? How far in advance?
• Does permission need to be granted by the country’s authority or the regional one or both?
• Should insurance be in place to cover your expedition’s work (even if it is voluntary)?
• Do expedition members need to be vaccinated before being allowed to enter the country/state?
• What are the travel regulations for the host country?
• What are the travel regulations for returning to the UK?
• Ensure you know the consequences if you are found to be breaching local COVID-19 laws

What are the host country’s regulations when it comes to mandatory self-isolation periods, vaccine passports and COVID-19 testing requirements for individuals arriving from the UK? If you need to quarantine on arrival to the host country how does this work – do you have to organise the place of quarantine and pay for it yourself?¹² Again, be aware that these guidelines are constantly changing so keep checking for the most up to date information.

Be wary that countries may be forced to open their borders for financial reasons – to the detriment of health. Consider if this is likely the case in the country you are travelling to – is the host country allowing individuals from countries with high levels of active COVID-19 infections entry? What percentage of the local population is vaccinated? Knowing this will help determine how prepared the country is for an influx of tourists who may bring COVID-19 with them. A country opening its borders for financial reasons will likely lead to COVID-19 rates increasing, and therefore a higher risk of your expedition contracting COVID-19. The knock-on effect of this could see hospitals overrun with less medical provision available should you need it. In this instance, you may wish to consider delaying your expedition.

It is also worth bearing in mind the travel regulations in the UK for when you return. Will travelling to your host country mean you have to self-isolate on returning to the UK? If not, is this situation likely to change?

Lastly, understanding the local laws regarding COVID-19 is essential. Expedition plans may need to be changed or kept flexible and abiding by these laws must be stressed to all team members. Be aware that these laws change frequently so keep checking for the most up to date guidance.

5. Roles and responsibilities

The individual chosen to lead the expedition should be selected as they possess skills (both technical and non-technical), qualities and experiences relevant for the expedition. If appropriate, this too should be the case for the expedition members.¹⁶

Responsibilities of the team leader:¹⁶

• Supervising and managing individuals and the group
• Making decisions about the best next course of action for the expedition
• Conducting dynamic risk assessments throughout the expedition, including of transport and accommodation
• Managing risk and implementing contingency plans to do so
• Communicating required actions to the expedition team

Competencies required of the team medic/first aid leader should be assessed through a combination of the following:¹⁷

• Experience of an expedition of a similar nature
• Activity proficiency
• In-house training and assessment
• A relevant and current national or international qualification or award showing wilderness medicine expertise
• Ability to read and interpret a pulse oximeter
• Have a good overview of respiratory diseases, understand basic treatments and be able to assist in improvising delivery devices; appreciate simple assessments of respiratory rate and shortness of breath and make rational decisions on the need for, and mode of evacuation
• Be able to assess and interpret respiratory symptoms and signs, and differentiate common ailments
• Be able to diagnose a COVID-19 infection, assess the infection’s severity and make decisions regarding the necessity of hospital evacuation

Responsibilities of team members:¹⁷

• Taking reasonable care of themselves and others, including actions required of them arising from risk assessment
• Following instructions from the expedition leader
• Bringing concerns about their own safety, health and well-being and those of others to the attention of the leadership team or supervisors
• Complying with the code of conduct of the expedition and that required in the host country.

6. Insurance

When buying travel insurance to cover the expedition there are several considerations. At the time of writing this document, the travel insurance situation is still unclear. The following advice is a good basis to start from. It is important you check the travel insurance policy thoroughly before buying in, and ensuring it covers claims related to COVID-19 for:

• Emergency medical costs – it is frequently recommended that you look for medical cover of at least £2m for Europe and £5m for worldwide. You’ll also want to ensure your insurer has a 24hr emergency helpline.
• Repatriation costs
• Disruption and cancellations – including cancellations because you have been told to self-isolate or are diagnosed with COVID-19 just before travelling; at the time of writing few policies include this.¹⁸ It is recommended you look for cover of at least £3,000 or the value of your trip. Make sure the cover will reimburse costs caused by delays, missed departures or being forced to remain at your destination for longer than planned (including extra accommodation costs if your trip is extended) – this may come as an add-on to the main policy. Make sure to read the small print as some cancellation policies only cover an incredibly narrow range of circumstances.
• Scheduled airline failure insurance (SAFI) – look for the same level of cover as you would for cancellation. This will cover you if your airline goes bust before you fly. Booking flights over £100 with a credit card also gives you protection under Section 75.
• If the Foreign Commonwealth & Development Office (FCDO’s) advice about travel to the destination changes

Not all policies will cover all of these things, so make sure you know what is covered and what is not. Choose your policy based on the features of COVID-19 cover you think are most vital for your expedition.

If your expedition is travelling to a destination where the FCDO is advising against travel, then it is likely you won’t be covered by insurance.¹⁸ The costs will also not be covered if you book a trip while border closures and travel restrictions are in place and these restrictions are not lifted by the time you commence your expedition.

Finally, it is worth bearing in mind ‘excess’ when choosing your cover. ‘Excess’ means if you claim on insurance the excess sum will be subtracted from the amount the insurer pays you. For example, if you had a £3,000 cancellation claim and a £250 excess, you would get paid £2,750 from your insurer. Higher excesses often make the insurance cost for you cheaper but may dissuade you from claiming for smaller amounts.

7. Agreeing to go on expedition

Due to the changing situation of COVID-19, team members may be constantly questioning whether they actually want to go on the planned expedition and whether it is safe to do so. There comes a point as a group where the decision of whether to go or not is made – this decision is often marked by putting parts of your plan into action, such as buying plane tickets or booking accommodation. We recommend that you and your team set a date in the future on which the group decides together if they want to go ahead on expedition. On this day arrangements such as accommodation and travel can be organised and paid for.

We also recommend that if you decide to go ahead and book your expedition to make a list of criteria, which if met between now and the date the start date of the expedition, would mean you will cancel your trip (such criteria may include infection rates and hospital capacities in the host country).

8. Minimising transmission risk on expedition

Possible protocols:

• Blanket testing all expedition members at predetermined points on expedition
• COVID-conscious transportation protocols¹¹
• COVID-safe protocols are in place for anyone joining the expedition after it has begun

It would be sensible to blanket test expedition members at predetermined points (using the tests packed in the medical kit), such as after leaving a higher risk area, or before entering a new community. If you choose to do this, you need clear protocols about what to do should a positive test be returned (see next section).

COVID-conscious transportation policies could include minimising the use of public transport, reducing vehicle capacities, ensuring the vehicle is well ventilated (windows open).¹¹ Before the expedition you should check whether any transportation policies are already in place in the host country – if they are not you may want to avoid public transport entirely – especially buses or trains where many people may be crowded together in a small indoor space.

Anyone joining the expedition after it has started (such as an individual who is already in the host country) should comply with the policies your expedition has in place to minimise the COVID-19 risk. You should ensure the person joining the expedition has self-isolated for the appropriate time prior to joining your expedition, and they should pass a COVID-19 test before integrating with your group (these are the same policies all expedition members followed).

9. Policy for COVID-19 symptoms on expedition

Considerations:

• A plan for if an expedition member(s) develops minor symptoms of COVID-19
• A plan for if an expedition member(s) becomes more seriously ill with COVID-19
• If a member of the expedition becomes ill and withdraws, will you carry on with the expedition? And does the remainder of the team have sufficient skills to fill in for the absent team member?

If an expedition member develops minor symptoms of COVID-19 they need to inform the expedition leader immediately and be isolated from the rest of the group. All group members should take a COVID-19 test and the team member with symptoms ideally needs a PCR test and a suitable place to isolate until the PCR result comes back. You need to follow the local public health guidance for what to do if someone gets COVID-19 symptoms. If someone falls ill, you should also call your health provider/insurance company to discuss the next course of action.

Remember that COVID-19 symptoms do not necessarily mean you have COVID-19 – there could be other causes; if you are in a malaria-affected area it is important to exclude malaria (with a blood test).²² A team member becoming infected may mean that the expedition member(s) must stay in the country longer than was planned. Once the expedition member has fully recovered, you should check with your health provider that they are fit to travel, before choosing your next steps.

If an expedition member becomes more seriously ill with COVID-19, a medic will need to determine if evacuation to a hospital is necessary. Determining where the nearest hospitals are, their capacity and quality and the local emergency numbers is essential pre-departure.

If an expedition member becomes ill in a remote area, a medic needs to assess whether evacuation is necessary (and by which route: air vs road). Evacuation teams should be alerted that an expedition member has developed COVID-19 symptoms and may potentially need evacuating in the near future. The team member with symptoms should be isolated. In a remote environment, it is unlikely the team will be able to escort the unwell team member back to a safe area where they have easy access to more advanced medical care – especially as it is unknown whether their health will deteriorate. An unwell COVID-19 patient in a remote area will likely need to be evacuated by a specialised team.

It is important to consider the impact an evacuation will have on the remaining expedition team. Will the expedition be able to continue? And indeed, is it safe to do so? Will anybody else be infected as well? You and the team should have discussed whether the expedition would continue if team a member/members are evacuated or withdraw pre-departure. When in the field, factors such as team morale should also be considered. If possible, remaining members should take COVID-19 tests to determine whether they too need evacuating with the symptomatic individual.

In the event a team member falls ill with COVID-19 symptoms and needs care from their team, one individual should be selected as the designated caregiver. They should wear a fitted N95 mask, eyewear, nitrile or latex gloves and a disposable gown/apron when caring for the unwell member.²³ If possible (depending on how unwell the infected person is) the infected member should wear a mask or face covering over their mouth and nose when in close contact with the caregiver.

Some patients with COVID-19 are hypoxic yet seem well and lack shortness of breath. These patients are sometimes referred to as ‘happy hypoxics’ or ‘silent hypoxics’. The disconnect between the severity of hypoxaemia and the mild respiratory discomfort a ‘happy hypoxic’ reports is contrary to what a clinician would normally expect in respiratory failure.^24,25

‘Happy hypoxics’ may remain clinically well as they continue to compensate for their hypoxia until they reach a point where they can no longer compensate and deteriorate rapidly. Warning signs for impending respiratory failure may include an increased respiratory rate (tachypnoea), signs of hyperventilation and a dropping oxygen saturation.²⁵ Therefore, if a member of your expedition is found to have COVID-19, them reporting that they feel well in themselves and do not feel short of breath is not a reliable measurement of severity. Research suggests paying close attention to respiratory rate and oxygen saturations to establish how severely unwell the expedition member is and how urgently they may need evacuation.²⁵

If your expedition is at high altitude, then oxygen saturations and respiratory rate are likely less reliable indicators of wellbeing.²⁶ Despite some (disputed) evidence suggesting that there is a lower incidence of mortality in patients at high altitude, altitude/hypoxia is likely associated with elevated risks for patients with COVID-19 and therefore descent from altitude is probably advisable.²⁷ Interestingly, some research suggests that COVID-19 transmission is lower at high altitudes, possibly due to the body’s physiological responses to altitude and/or environmental factors – but this too is disputed.²⁸

10. Expedition Closure

Considerations:

• After the expedition are team members returning home or remaining in the host country for further travel?
• The current government guidance about re-entering the UK
• Travel insurance
• Follow up

It is common for expedition members to plan further travel post-expedition. Travel insurance to cover this period should also be checked. Re-entry guidelines and protocols should be made clear to expedition members, including whether or not testing or quarantining are required on returning to the UK. Expedition members should have a clear understanding of UK re-entry requirements, and any requirements the host country has on leaving. Expedition members should also be made aware of any special requirements needed if the expedition has travelled through a country on the UK’s banned travel list (‘red list’). They should also be informed of whether the host country is likely or not to become ‘red listed’ by the UK, and if so, how this would change re-entry and indeed whether the host country would allow anyone to leave.

Finally, you should consider following up expedition members 14 days post-expedition to declare if any members of the expedition (UK or host country) develop any COVID-19 symptoms.

11. Useful Sources of Information

FCO Travel Advice

Government COVID travel advice

Government COVID air travel advice 

Coronavirus Travel Rights

John Hopkins COVID resources

World Health Organisation COVID resources

CDC COVID resources

COVID travel regulations by country

COVID vaccinations by country

European Centre for Disease Prevention and Control (this includes data on hospital admissions and ICUs amongst other things)

UKAS accredited labs

12. Example protocols

NOLS Wilderness Medicine 

Raleigh International

World Expeditions 

National Geographic

13. Suggested COVID-19 medical questionnaire

The following COVID-19 medical questionnaire should be used IN ADDITION to another medical questionnaire

We recommend cross-referencing expedition member’s medical forms to the known risk factors for severe COVID:

Age, cardiovascular disease, diabetes, respiratory disease (including severe asthma), obesity, a history of haematological malignancy or recent other cancer, kidney, liver and neurological diseases, and autoimmune conditions.¹

14. About the Author

James Taylor is a final-year medical student at The University of Sheffield. He chose to get involved in the world of expedition medicine during his medical elective. When the pandemic changed his plans he was invited to construct a protocol on how to conduct COVID-safe expeditions by the Royal Geographical Society’s expedition medicine advisory group.

Living on the edge of the Peak District James can often be found climbing, mountaineering and fell-running. He has an interest in Pre-Hospital and Emergency Medicine, and plans to combine his love of the outdoors with medicine by working an expedition medic during his career.

If you have any feedback or comments, feel free to send them to:
c/o Mrs Shane Winser, Royal 1Geographical Society, 1 Kensington Gore, London SW7 2AR; or email: go@rgs.org

References

1. Williamson EJ, Walker AJ, Bhaskaran K, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature 2020; 584: 430–436 https://doi.org/10.1038/s41586-020-2521-4
2. Hashim MJ, Alsuwaidi AR, Khan G. Population Risk Factors for COVID-19 Mortality in 93 Countries. J Epidemiol Glob Health. 2020;10(3):204-208 https://doi.org/10.2991/jegh.k.200721.001
3. Wolff D, Nee S, Hickey NS, et al. Risk factors for Covid-19 severity and fatality: a structured literature review. Infection 2021; 49:15–28 https://doi.org/10.1007/s15010-020-01509-1
4. Rashedi J, Mahdavi Poor B, Asgharzadeh V, Pourostadi M, Samadi Kafil H, Vegari A, Tayebi-Khosroshahi H, Asgharzadeh M. Risk Factors for COVID-19. Infez Med 2020; 28(4): 469-474.
5. Baart J, Taaka F. Barriers to Healthcare Services for People with Disabilities in Developing Countries: A Literature Review. Disability, CBR & Inclusive Development 2018; 28(4), pp.26–40. http://doi.org/10.5463/dcid.v28i4.656
6. Orach CG. Health equity: challenges in low-income countries. Afr Health Sci. 2009;9 Suppl 2 (Suppl 2): S49-S51.
7. Peters DH, Garg A, Bloom G, Walker DG, Brieger WR, Rahman MH. Poverty and access to health care in developing countries. Ann N Y Acad Sci. 2008; 1136: 161-71. https://doi.org/10.1196/annals.1425.011
8. Lewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. Lancet Infect Dis. 2020; 20(6): 631-633. https://doi.org/10.1016/S1473-3099(20)30190-0
9. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development.  Lancet 2015; 386 (9993): 569–624. https://doi.org/10.1016/S0140-6736(15)60160-X
10. Department for Transport. Coronavirus (COVID-19) testing before you travel to England. [Internet]. 2021 [cited 23/7/21] Available from: www.gov.uk/guidance/coronavirus-covid-19-testing-for-people-travelling-to-england
11. Shen J, Duan H, Zhang B, et al. Prevention and control of COVID-19 in public transportation: Experience from China. Environ Pollut 2020; 266 (Pt 2): 115291. https://doi.org/10.1016/j.envpol.2020.115291
12. Coronavirus (COVID-19) Guidance and Support. Foreign Travel Advice. [Internet]. 2021 [cited 21/7/21] Available from: www.gov.uk/foreign-travel-advice
13. Blomquist, PB,  Bolt, H,  Packer, S, et al.  Risk of symptomatic COVID-19 due to aircraft transmission: a retrospective cohort study of contact-traced flights during England’s containment phase. Influenza Other Respi Viruses 2021; 15: 336– 344. https://doi.org/10.1111/irv.12846
14. Freedman DO, Wilder-Smith A. In-flight transmission of SARS-CoV-2: a review of the attack rates and available data on the efficacy of face masks. J Travel Med. 2020;27(8): taaa17 https://doi.org/10.1093/jtm/taaa178
15. World Health Organization. Priority Medical Devices List for the COVID-19 Response and Associated Technical Specifications: INTERIM GUIDANCE. World Health Organization, 2020. [Accessed 23 July 2021] Available from: www.jstor.org/stable/resrep27993
16. Russell TW, Wu JT, Clifford S, Edmunds WJ, Kucharski AJ, Jit M; et al. Effect of internationally imported cases on internal spread of COVID-19: a mathematical modelling study. Lancet Public Health. 2021;6(1): e12-e20. https://doi.org/10.1016/S2468-2667(20)30263-2
17. British Standards Institute, 2007. BS 8848. Specification for the provision of visits, fieldwork, expeditions and adventurous activities, outside the United Kingdom. British Standards Institute, London. 2007.
18. Which. Coronavirus travel insurance: who has the best ‘Covid cover’? [Internet]. [updated 2021 July 12; cited 2021 July 23]. Available from: https://www.which.co.uk/news/2021/07/coronavirus-what-it-means-for-your-travel-insurance/
19. Bulfone TC, Malekinejad M, Rutherford GW, Razani N. Outdoor transmission of SARS-CoV-2 and other respiratory viruses: a systematic review. J Infect Dis 2021; 223: 550-561. https://doi.org/10.1093/infdis/jiaa742
20. Leclerc QJ, Fuller NM, Knight LE, Funk S, Knight GM, CMMID COVID-19 Working Group. What settings have been linked to SARS-CoV-2 transmission clusters? Wellcome Open Res 2020; 5:83. https://doi.org/10.12688/wellcomeopenres.15889.2
21. Scientific Advisory Group for Emergencies, Public Health England. PHE Transmission Group: Factors contributing to risk of SARS-CoV2 transmission in various settings, 26 November 2020. 18 Dec 2020. www.gov.uk/government/publications/phe-factors-contributing-to-risk-of-sars-cov2-transmission-in-various-settings-26-november-2020
22. Chanda-Kapata P, Kapata N, Zumla A. COVID-19 and malaria: A symptom screening challenge for malaria endemic countries. Int J Infect Dis. 2020; 94: 151-153. https://doi.org/10.1016/j.ijid.2020.04.007
23. Tian Z, Stedman M, Whyte M, et al. Personal protective equipment (PPE) and infection among healthcare workers – What is the evidence? Int J Clin Pract. 2020; 74: e13617. https://doi.org/10.1111/ijcp.13617
24. Wilkerson RG, Adler JD, Shah NG, Brown R. Silent hypoxia: a harbinger of clinical deterioration in patients with COVID-19. Am J Emerg Med. 2020; W.B. Saunders. http://doi.org/10.1016/j.ajem.2020.05.044
25. Dhont S, Derom E, Van Braeckel E, et al. The pathophysiology of ‘happy’ hypoxemia in COVID-19. Respir Res 2020; 21: 198. https://doi.org/10.1186/s12931-020-01462-5
26. Crocker M, Hossen S, Goodman D, Simkovich SM, Kirby M, Thompson LM. Effects of high altitude on respiratory rate and oxygen saturation reference values in healthy infants and children younger than 2 years in four countries: a cross-sectional study. Lancet Glob Health 2020; 8(3): E362-373. https://doi.org/10.1016/S2214-109X(19)30543-1
27. Millet GP, Debevec T, Brocherie F, Burtscher M, Burtscher J. Altitude and COVID-19: Friend or foe? A narrative review. Physiol Rep. 2021; 8(24): e14615. https://doi.org/10.14814/phy2.14615
28. Stephens KE, Chernyavskiy P, Bruns DR. Impact of altitude on COVID-19 infection and death in the United States: A modelling and observational study. PLoS One. 2021, 16(1): e0245055. https://doi.org/10.1371/journal.pone.0245055

Featured photograph by Dr Lucy Obolensky, with permission.

The post COVID-Safe Expeditions appeared first on Adventure Medic.

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

The post Hydration Strategies at Altitude 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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Far from help and faced with a patient in acute pain; what are your options for analgesia in the remote setting? Craig Miller is an Emergency Medicine and Expedition Doctor with experience ranging from high altitude to remote diving, and many environments in between. Craig discusses the rationale for including Penthrox® in his remote medical kit.

Approach to Pain in the Wilderness

The role of the expedition doctor begins long before arriving on-site, bags packed ready for the next adventure. Taking the time to thoroughly plan and familiarise yourself with your medical kit will help to lay the foundations for a successful expedition.

Analgesia in the wilderness can be challenging given the limited interventions available, both pharmacological and non-pharmacological, therefore it is important in the planning phase to consider the different options for pain management and anticipated aetiologies.

Many of us will be familiar with the WHO pain ladder which was initially designed for the management of cancer pain and has since been adapted for the management of acute pain of varying aetiologies. The Wilderness Medical Society (WMS) has adapted the ladder to create a ‘pain pyramid’ which forms the basis for their guidelines on the management of pain in the wilderness setting¹ [Figure 1].

Severe Pain in the Remote Setting

Management of acute severe pain can be extremely challenging for the remote medic. Whilst opiate medications are often utilised for severe pain in the UK, having morphine or fentanyl in the expedition medical kit can be fraught with issues. Parental opiates are controlled drugs in the UK and accordingly remain subject to strict legislation on their supply, requiring an export license from the Home Office if they’re being taken overseas². Transit and importation of opiates is similarly complex with different regulations for each country or territory. For example, UAE will not allow transit of opiates and these will be seized by customs³. Indonesia classifies codeine as a narcotic and requires appropriate licenses from various government agencies and police departments. Having spent six months on expedition in West Papua I’ve been exposed to the logistical and bureaucratic challenges of even the most simple paperwork; importing opiates in your medical kit would be no small feat. Even worse, there are extreme repercussions under Indonesia’s narcotics trafficking laws, with maximum punishment including the death penalty or life imprisonment⁴ – not a situation to be getting into. These barriers limit parental opiates to expeditions with significant logistical and organisational support. Thankfully, there are alternatives!

Penthrox® (Methoxyflurane)

Methoxyflurane is a volatile anaesthetic agent that can be used to treat moderate and severe pain. It was initially developed in the 1940s as a general anaesthetic, preferred over other agents for its cardiovascular stability and post-operative analgesic properties. Due to its analgesic properties at sub-anaesthetic doses, a disposable inhaler was initially developed for the management of pain during labour. Unfortunately, evidence of nephrotoxicity at high anaesthetic doses (upwards of 15 mL) was demonstrated and ultimately resulted in its removal from the market⁵. Australia and New Zealand continued to use methoxyflurane as an analgesic agent at much lower doses (3-6 mL) predominantly in the prehospital setting. Studies have demonstrated Penthrox® to be a safe and effective medication for pain management, with almost no risk of significant nephrotoxicity at low doses. Otherwise known as the ‘green whistle’, it is an alternative to parental opiates in the management of moderate to severe pain secondary to trauma in conscious adults.

Using Penthrox®

Penthrox® is a portable and lightweight single-use inhaler that is used for the delivery of methoxyflurane. The kit contains one green inhaler device with an absorbent polypropylene wick and a vial containing 3 mL of methoxyflurane – you simply assemble the inhaler and charcoal scrubber, pour the liquid onto the absorbent wick and it’s ready to be used. The patient self-administers the medication by inhaling the vaporised liquid through the mouthpiece, enabling them to titrate administration and achieve adequate pain control. Rapid onset analgesia will begin within 6-10 inhalations from the 3ml vial, which will provide approximately 30 minutes of analgesia with continuous use, extending to 1 hour with intermittent use⁵. The maximum daily dose is 6ml, allowing for the administration of two vials over a 24 hour period. Note the maximum weekly dose of 15mL, ensuring that it is not used on consecutive days in order to limit the risk of nephrotoxicity.

Side Effects and Contraindications

The side effect profile of Penthrox® is relatively modest with dizziness being reported as a very common side effect, followed by headache, somnolence, dry mouth and nausea, which are reported as common^6. The self-administration of Penthrox® makes it simple for patients to reduce inhalations and limit side effects, whilst titrating for desired pain control. Contraindications are shown in Table 1, and helpfully there is a contraindication card included in the Penthrox® packs for the health professional and patient.

Benefits in the Remote Setting

By their very nature expeditions head into the wilderness with challenging environmental conditions. Ideal expedition medications are compact, lightweight, and durable with minimal side effects. With Penthrox® fulfilling these criteria the last important consideration is environmental stability. Penthrox® does not require specific temperature storage conditions and is stable even at low ambient temperatures. Again this is advantageous in comparison to nitrous gas which separates at low temperatures, meaning a hypoxic mix could be delivered to the patient. Wilkes et al. report the successful use of methoxyflurane at high altitude (4470m) for procedural sedation, demonstrating stability at altitude and extreme temperature⁷. Porter et al. report proven stability in temperatures ranging from –20°C to 40°C and suggest Penthrox® is “suitable for emergency situations in extreme environments”⁵.

Given the challenges surrounding opiates on expedition, including importation and supply as well as administration in austere environments (i.e. intravenous cannulation), methoxyflurane represents an excellent alternative in the management of severe pain⁸. Additionally, there is the advantage of inhalers being more compact and transportable than a nitrous cylinder.

Penthrox® is being used increasingly in Emergency Departments across the UK for the management of severe pain and procedural sedation, thus opportunities to use methoxyflurane in a controlled environment are increasing. The characteristics of methoxyflurane are ideal for use in the wilderness setting, representing an excellent alternative to opiates and Penthrox® is now a must for my expedition medical kit.

References

1. Russell KW, Scaife CL et al. Wilderness Medical Society. Wilderness Medical Society practice guidelines for the treatment of acute pain in remote environments. doi: 10.1016/j.wem.2013.10.001. PMID: 24462332. https://pubmed.ncbi.nlm.nih.gov/24462332/
2. Government Export License – https://www.gov.uk/guidance/export-drugs-and-medicines-special-rules
3. UAE Transit Medications – https://www.uae-embassy.org/sites/default/files/Guidelines%20for%20carrying%20medecines%20to%20UAE.pdf
4. Indonesia Narcotics Customs – https://www.balitourismboard.org/custom_service.html
5. Porter KM, Dayan AD et al. The role of inhaled methoxyflurane in acute pain management. Open Access Emerg Med. 2018;10:149-164. doi:10.2147/OAEM.S181222 ncbi.nlm.nih.gov/pmc/articles/PMC6200081/
6. Penthrox EMC information – https://www.medicines.org.uk/emc/product/1939/smpc
7. Wilkes M, Heath EC et al. Methoxyflurane for Procedural Analgesia at 4470 m Altitude. Wilderness Environ Med. doi: 10.1016/j.wem.2018.02.011. PMID: 30057014. https://www.wemjournal.org/article/S1080-6032(18)30054-1/fulltext
8. Middleton PM, Simpson PM et al. Effectiveness of morphine, fentanyl, and methoxyflurane in the prehospital setting. doi: 10.3109/10903127.2010.497896. PMID: 20809687. https://www.tandfonline.com/doi/full/10.3109/10903127.2010.497896

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Taking the science of medical error analysis and systems-based thinking out of the hospital, our very own Adventure Medic patron, Dr Edi Albert takes us through a case-based account of how we can learn from and ultimately prevent mistakes when on expeditions or in the wilderness. We also learn that sometimes the most valuable skills any expedition medic can bring to the table are of the ‘non-technical’ variety, and that these factors have the power to potentially avoid fatal outcomes.

Non-Technical Skills

Expedition and wilderness medicine education rightly focuses on “hard” knowledge and skills: reliable and reproducible algorithms and approaches for patient assessment, and for example, when to and how to use an Epipen or improvise a splint for a fracture ¹.

These “hard” skills are all necessary, but not sufficient. We need to know when and when not to use our skills. We need to learn not only how to make decisions, but importantly to understand the basis of our decision making, and how as humans we interact both with our environment and with the other humans around us ².

Case based learning with small groups can be used to teach these “non-technical skills” by focusing less on the clinical medicine, and more on the context of the case and how it was managed ³. This article describes the case of a man with severe high-altitude pulmonary oedema and identifies the problems with reasoning and decision making that ultimately led to his death.

A previously fit and healthy 26 year old man was carried down by porters from the 5300m pass he was attempting to cross. He was brought into the village (4800m) at 6pm, just as the sun was setting. He was given some pills by the guide and was put to bed, awaiting a helicopter at first light. By 11pm he had been declared dead. The resident doctors in the village were unaware of the unfolding catastrophe until it was too late.

Systems Approach

Most healthcare professionals will be familiar with the Swiss Cheese Model of medical error. This is the idea that in a healthcare (or trekking company) system there are various checks and balances that occur during conventional patient care (or operation of a trek), and that all of these must fail for a bad outcome to occur: in other words, all the holes in the cheese line up ⁴.

A similar concept exists in the world of mountain rescue and in the root-cause analyses of mountain accidents. It is rare to find a single cause for such an accident. There is usually a chain of bad decisions each exacerbating the effect of the following ones, culminating in the final event: fatal or otherwise ⁵.

In the modern world it is customary to point the finger, avoid understanding the complexity, and find somebody or something to blame. In a complex system such as a hospital, we cannot, or should not, usually find a single individual or event (or hole in the cheese) to blame ².

Similarly, in mountaineering, and mountain accidents we should avoid simplistic explanations. They may be easy and hence seductive, they may fit nicely into a newspaper headline, but they can unfairly malign (or indeed exonerate) those involved, and most importantly there is nothing we can learn that will help us next time. Systems thinking describes the process of understanding how things influence one another and provides a useful approach to understanding, and learning from, complex processes ⁶. A systems thinking approach is used to reflect upon this case. The Iceberg Model is particularly apt for our purposes.

The young man in question (we’ll call him Simon) was on the “trip of a lifetime”, happy, healthy and brimming with enthusiasm and energy.  He was also, like many with that combination of youth and a Y chromosome, ignorant of his situation and with a misplaced sense of invincibility.

The first hole in the cheese didn’t even look like a hole: just an unfortunate, and perhaps annoying inconvenience. The trekking group had booked through an agency that advertised a guide from their own country as well as a local guide from the country they were to be visiting. On this occasion there had been a mix up and only the local guide was available.

Early on in the trip Simon became unwell with a simple upper respiratory tract infection (URTI). A common enough occurrence, and in Simon’s view nothing to worry about. The guide, however, had sufficient insight to recognise that the combination of an URTI with the continued exertion and gain in altitude was not a good idea. He said that he tried to convince Simon to stay put and rest for a day or two. He said that Simon had been pushy and insisted on continuing.

Let us consider for a moment, from the perspective of the company supplying the local guide, would it seem reasonable to provide a less experienced guide on the basis that another, experienced international guide would be present? Indeed, might it have provided a reasonable opportunity for a less experienced guide to gain more experience in a setting of safe supervision? Did the local guide on this particular trip have insufficient knowledge and skills to do the job? Was he out of his depth even before the trip started? We don’t know, but it is possible.

What information had the group been provided with, and what “homework” of their own had they (and especially Simon) done? How “tight” was their itinerary? We don’t know, but ignorance of the effects of altitude combined with tight itineraries are a recipe for disaster.

Graded Assertiveness

How did their individual personalities and conflict resolution skills influence this conversation? What exactly went on between them that resulted in the decision to continue? We don’t know. We can imagine that the guide backed down.

Graded assertiveness is a technique that allows somebody to improve their assertiveness, particularly in crisis situations. It is now widely taught in critical care medicine.

Even armed with such techniques, the situation has to been seen through the lens of a wider cultural context (the lower levels of the systems thinking iceberg). I have heard time and time again from Nepalese guides who try to advise their clients and are frustrated that they are not listened to. This client-guide relationship is clearly different from some other guided settings around the world: one can’t imagine the advice of a Swiss IFMGA guide on the Hörnli Ridge of the Matterhorn being ignored by her client.

Simon and his group pushed onwards and upwards and whilst we don’t have full details of what went on during that fateful ascent (of 900m) and descent (of 600m), we do know that he became unwell and sufficiently incapacitated that he had to be carried down. He was brought into the village at 6pm, taken to a lodge and briefly sat down in the corner of the dining room. Two paediatricians from another group saw him and became concerned. They reported that he had a decreased level of consciousness and a respiratory rate of 60 breaths per minute.

When questioned by the paediatricians, the guide seemingly became defensive, declared that he had given Simon some treatment with Diamox (acetazolamide) and had arranged for a helicopter evacuation at first light. The two doctors were seemingly placated and went back to their own business. The lodge owners were not made aware of his condition. Two doctors from the local clinic, on duty with radios switched on, and with appropriate experience and equipment to treat severe altitude illness were sitting in a nearby lodge awaiting their dinner, oblivious to the existence of this critically, indeed terminally, ill patient. Had the lodge owners been informed they would have taken matters into their own hands and called the local doctors.

Let us stop for a minute, and gaze down on this scene. Hopefully the combination of altitude gain, decreased level of consciousness, and respiratory rate of 60 are ringing some mighty serious alarm bells in the head of you, the reader. Lest you are unfamiliar with altitude illness and indicators of severe illness, let us quickly dispense with the medicine, as that should actually be the easy part, and isn’t the real focus of this article.

In the context of a recent gain in altitude and significant exertion, especially on the background of a respiratory illness, acute high-altitude illness must be suspected. The extremely high respiratory rate at rest points to high altitude pulmonary oedema (HAPE). The decreased level of consciousness points to either severe hypoxia secondary to HAPE, or high-altitude cerebral oedema, or a combination of both. The initial action of carrying the patient down was the correct one. The differential diagnoses had been correctly identified.

It’s what happened next that is concerning. Even in the absence of the issue of altitude, a respiratory rate of 60 in an adult is indicative of a critical illness and impending respiratory failure.  Even in the absence of both altitude and respiratory rate, the decreased level of consciousness is indicative of significant cerebral dysfunction. How were these warning signs indicating that this young man was heading rapidly for a peri-arrest situation missed by people who should have known better?

Cognitive Bias

Before we attempt to unravel this, let’s make sure that we understand the concept of cognitive bias. Put simply, a cognitive bias is a systematic error in thinking that occurs when people are processing and interpreting information in the world around them and affects the decisions and judgments that they make. If that doesn’t sound simple go back and read the above sentence again until it makes sense and then click on the link above. Even if you think you know about cognitive bias, I bet you didn’t know there are four broad, usually inter-related causes of cognitive bias.

1. Cognitive overload – too much going on for one brain to handle.
2. Heuristics – these mental shortcuts can be very useful when used appropriately – but can get us in a world of trouble when not.
3. Peer pressure – well, we all know about that surely?
4. Individual motivation – making a particular decision may lead to an outcome that is not favourable for the decision maker, and therefore any reason not to make that decision will be seized upon and clung to.

Normalcy Bias

So, using what we know about cognitive biases and heuristics, can we hypothesise about what went on that evening? And importantly, can we learn from it? A good starting point to unravel this puzzle is probably normalcy bias – the concept of underestimating the possibility of a disaster happening to somebody based on the fact that it has never happened to you before. In this case perhaps the guide was used to seeing unwell trekkers and calling a helicopter and giving them Diamox and getting a happy ending (so to speak). Similarly, with the paediatricians, was it hard for them to fathom just how serious it was because they had never encountered this before?

Biases need not act in isolation: and almost certainly didn’t that night. Perhaps the Dunning-Kruger effect was at work; in which under-skilled people over-estimate their ability and highly-skilled people over-estimate the ability of others. Was the guide over confident and did the paediatricians discount their own concerns thinking that the guide knew more than they did? It seems very likely.

Similarly, the affect heuristic was also influencing decision making. This is where a current emotion – fear for example – shortcuts a systematic and rational approach to decision making, and in this example that fear paradoxically led to a worse outcome.

Interoceptive bias no doubt had a role to play with the whole ensemble: guide, paediatricians and the rest of Simon’s group (not least his girlfriend). Interoceptive bias is perhaps most famously linked with the study of parole judges that demonstrated that they were consistently more lenient just after lunch when well fed and rested. In this case, the sensory inputs of fatigue, hunger, cold and possibly other symptoms related to high altitude, had a negative impact on decision making; think, ’you’re not you when you’re hungry’.

Finally, group think clinched it. Harmony and conflict minimisation in small groups is usually a good thing on treks. However, conformity and consensus decisions may result in adverse outcomes.

But a respiratory rate of 60 in an adult you say?! I have seen numerous infants with a respiratory rate of 60 and have not been too concerned: no doubt these paediatricians have seen many more than me. Indeed, their whole medical practice involves a very different set of norms from adult medicine. Could it have been that they simply relied upon their usual heuristic decision making processes: fine for the little ones but disastrous for an adult? On its own perhaps this is unbelievable, but combined with all these other factors it would seem possible.

Simon was helped to his room by his girl-friend and a couple of friends. We know very little about the next few hours. We presume that he was tucked up in bed and slowly deteriorating. What was going through his girl-friends mind we never found out. At 10:30pm he made his final trip to the toilet where he collapsed. A commotion ensued, involving his friends, the aforementioned paediatricians, and also, finally, the lodge owners became aware of the unfolding disaster. They were of course unencumbered by the biases described above (biases may be fairly fixed but can also be very context specific).

They immediately called the village’s two resident doctors who were on scene within a few minutes to witness the young man receiving CPR. He had fixed dilated pupils and no discernible cardiac output. They completed several cycles of CPR, but he was pronounced dead at 11pm; cardio-respiratory arrest secondary to HAPE. A black helicopter flew the body out the next morning. A sobering story: a disconcerting and uncomfortable one.

Overcoming Bias

If you’re reading this and thinking “that couldn’t happen to me” well, then… you’re wrong! Remember the Bromiley case? If two consultant anaesthetists could have that happen to them on their own comfortable familiar turf during a simple routine operation, how much more likely is an equivalent scenario at high altitude after a long and tiring trek when you are hungry, thirsty and fatigued?

1. We are all subject to a multitude of biases, so how do we get past that? How do we make sure that this doesn’t happen to us? The first step is undoubtedly to recognise that these biases exist, be aware of the most common ones, and understand the causes and pre-conditions for when cognitive bias is likely to affect decision making. Obviously overcoming these biases isn’t easy. A good place to start would be to put twenty minutes aside and watch Glenn Singleman’s presentation “Cognitive Bias and Risk Management” and take note of the general and specific debiasing techniques; learn how to work with them and incorporate them in times of difficulty.
2. Emotions serve a number of purposes and in this setting we can use the emotions of fear, disquiet, or unease as an alarm bell to trigger a slowing down of our thought processes. Let’s apply some of these concepts now to Simon’s case. One can imagine a chaotic, emotionally charged scene. So stop and take a breath. Stop and critically analyse the situation; rather than riding the emotional rollercoaster as others may do. Realise that, just ‘hoping” doesn’t work as a strategy.
3. Use your emotional intelligence to pick up non-verbal cues: those indicating his own anxiety and fear shouldn’t be beyond the capacity of even the averagely sympathetic climber. Simplify the concepts and decisions that need to be made. Discard things that are merely a distraction. Simple questions can help, escalated slowly if needed: “Have you treated somebody this sick before?” “Can we help you make a decision?” “Is there a local doctor who can help us?” “Should we be doing something else to help him?”
4. Metacognition is a central skill. Think about your thinking; examine both your thoughts and emotions. Don’t just take them for granted and follow them. Be your own devil’s advocate. And while you’re doing it, sit down with your buddy, and order a hot drink and some food whilst you chew it over together.
5. Take accountability yourself; don’t let it become diluted throughout the group until that accountability vanishes. Being accountable and accepting that accountability flicks a switch inside you and helps you step up to the plate. Summarise the facts as you know them. Get meaningful feedback from others and gain clarity in your own head.

If this all sounds overly complex and difficult, there is actually an optimistic note on which to finish: it seems likely that if just one person had done one thing differently, then Simon’s care may have taken a different trajectory and he may have survived. To extrapolate that into the future and to keep you from making the same mistakes, I will leave you with this thought; you don’t have to get it all right – you just have to get some of it right. And that is eminently achievable for all of us.

References

1. Schrading, WA. et al. Core Content for Wilderness Medicine Training: Development of a Wilderness Medicine Track Within an Emergency Medicine Residency. Wilderness Environ Med. 2018;29(1):78 – 84.
2. Mellor, A., Dodds, N., Joshi, R. et al. Faculty of Prehospital Care, Royal College of Surgeons Edinburgh guidance for medical provision for wilderness medicine. Extrem Physiol Med. 2015; 4(22).
3. McLean SF. Case-Based Learning and its Application in Medical and Health-Care Fields: A Review of Worldwide Literature. J Med Educ Curric Dev. 2016;3.
4. Reason J. Human error: models and management. BMJ. 2000;320(7237):768‐770.
5. Chamarro A, Fernández-Castro J. The perception of causes of accidents in mountain sports: A study based on the experiences of victims. Accident Analysis and Prevention. 2009;41(1);197-201.
6. Senge PM, The Fifth Discipline: The Art and Practice of the Learning Organization. New York; Currency, 2006.

Edi Albert is generalist in rural and remote medicine, based in Tasmania, but regularly working in various remote locations around Australia including aero-medical retrieval with the Royal Flying Doctors Service, at Perisher Ski Resort, and has previously deployed to Antarctica. He is director of the Healthcare in Remote and Extreme Environments Program at the University of Tasmania and a founding director of the pre-hospital care charity Sandpiper Australia. He travels widely and enjoys climbing, kayaking, hiking, skiing and sailing.

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With so many opportunities available for experience around training programmes there can be difficult decisions for junior doctors deciding, if, when and how, to best combine their other interests with their medical career. Here, we proudly present Adventure Medic’s Updated Guide to Taking Time Out From UK Training.

More and more UK doctors are opting to take time out of training in order to pursue medical and personal interests all over the world. The number of doctors requesting certificates of good standing (needed to register with an overseas medical council) was 4,804 in 2016 when the GMC last released data on this. According to the Foundation Programme survey, numbers entering speciality training directly from the Foundation Programme have continued to fall with only 37.7% of doctors remaining in training in 2018. A schematic summarising the changes over the last eight years was published by the BMJ (Figure 1). Later career breaks have also become more common, with Health Education England stating that this should be expected and recognised as a normal part of many doctors’ progress. There has been a culture shift with many colleges now actively supporting opportunities around the traditional training pathway.

Here at Adventure Medic, we feel passionately about the personal and professional benefits to be gained by taking time out from medical training in the UK – whether your motivation is to broaden your clinical exposure, to experience developing world medicine, to resolve specialty or career indecision, to pursue personal interests, or even just to exercise some autonomy over your work and professional development. Not to mention the (very valid) reasons of travel and adventure for their own sakes.

The British Medical Association proposes that the key question to ask yourself is, ‘will you be better equipped at the end of your time out than at the beginning?’. If you’re organised and motivated, it’s very easy to ensure the answer to this question is a firm ‘yes’.

When to take time out?

Before Foundation / Unless there is an opportunity that will not wait, it’s not advisable to delay the move from medical school into Foundation Training. The support of your Medical School during the Foundation Programme application process is invaluable. The transition from student to FY1 is a steep and often daunting learning curve, and one best travelled with the support of your peers. In addition, whilst you have graduated with a medical degree, until you’ve completed your first year of the Foundation Programme, you are only registered in a provisional context by the GMC. In other words, you are not eligible to practice medicine independently or outside your place of supervised employment. If you’re still considering it, information regarding the requirements for time out at this stage can be found on the GMC and UKFP websites.

Between FY1 and FY2 / Some Foundation Schools will support time out between FY1 and FY2, or accredit an FY2 year abroad. If you are interested, it is best to make your enquiries early with your Foundation School Director, as there is considerable variation across schools. In 2019 only Wessex, Severn and Peninsula advertised an allowance for FY2 training abroad. Note that due to Australian immigration laws, you can currently only work in Australia after two years of employment. This makes an FY2 year here impossible unless you hold Australian citizenship. New Zealand and South Africa remain options. See the individual Foundation School pages on the UKFP website for more information.

After FY2 / Probably the most popular time to head away is after completing FY2. At this stage, you have full registration with the GMC, a broad base of general medical skills and you are at a natural break in the job ladder. It’s also a time when many junior doctors experience doubt over choice of specialty (or even over choice of career), so the opportunity to experience medicine in a different context or continent can be invaluable.

After Core Training / For non run-through specialties such as Core Medical, Anaesthesia and Surgery, completion of the CT2 year is also a natural break in the system, and many doctors choose to divert at this point, with the advantage of another couple of years experience under their belt.

In Specialty Training / Most specialty training programmes enable Out Of Programme Experience (OOPE), Out of Programme Training (OOPT), Out of Programme Research (OOPR) and Out of Programme Career Breaks (OOPC). Availability varies by Local Education and Training Board (LETB) and in some specialties OOP is becoming more difficult to get due service provision pressures. Again, if you’re interested, it is worth expressing interest early and enquiring of your Postgraduate Dean before you enrol on a particular programme. You may also have the opportunity to do a fellowship abroad in an area of special interest during your advanced specialty training.

Where to go?

It can seem daunting to know which direction to go in, given that there is a whole world outside. There are lots of wonderful opportunities, and part of the fun is designing your own unique adventure. After all, when else in medicine will you be the master of your own fate? In the meantime though, here is some basic information on some of the routes better travelled to get you started.

Australia / The Australian job market has tightened up somewhat in recent years as word of the glorious sunshine, pay and hours has filtered up to the beleaguered inhabitants of the Northern Hemisphere. However, there are still some jobs to be had. You are eligible to apply if you are a UK citizen and UK graduate, but Australia has explicitly chosen to give priority to Australian and New Zealand candidates over us Brits. Jobs are advertised state by state, and within states there are centralised online application websites. While the design, layout and deadlines vary from state to state, the basic process is the same all over the country. Typically, jobs are posted online from late June to early August. Interviews take place from late August to Mid-September and offers are made by early October. Jobs then start between mid-January and mid-February. A sensible approach is to choose the city or area that appeals and then get a list of all the hospitals in a 20-100 mile radius (depending on location). Call (rather than e-mail) each hospital and try and get through to the medical workforce unit. Follow up your call with an email and your CV. Don’t be discouraged and keep at it. It is also possible to get jobs through the year via ‘unofficial’ pathways, particularly between September and November as people start to resign posts and places free up before the end of the year. Make sure you leave yourself plenty of time as you need to get registered with the AHPRA (Australian Health Practitioner Regulation Agency) to start work and this can take 6 months.

New Zealand / You are eligible to apply to New Zealand if you are a UK citizen and a UK graduate. You can apply for a post as a House Surgeon or a Registrar. House Surgeons are roughly equivalent to FY2’s, but Kiwis may spend several extra years at that grade getting experience in a wide range of specialities. Registrars are equivalent to CT1/ST1 and upwards. As specialty training in New Zealand is typically five years rather than seven, you will be worked quite hard at Registrar level and given somewhat more responsibility. However, it is a great way to get experience. Sometimes UK doctors will start out as House Surgeons and then choose to join the Registrar rota once they have found their feet. Applications for New Zealand are usually in April/May with offers in August for end of November (House Surgeons)/early December (Registrar) starts. Apply direct to hospitals via the RMO Office. After getting an offer, you can then apply for registration with the New Zealand Medical Council, get your visa and indemnity and finally book your flights. If you are going for longer than one year, you will require a medical for the visa, but that can also be done in New Zealand and your visa subsequently extended. Keep all the receipts, as the hospital will reimburse you. For more information on working in NZ, see our guide.

Europe / Given that it is on our doorstep, surprisingly few doctors go to Europe. While language is still the main limitation to crossing the Channel, Brexit has made it harder to do so. There is no longer freedom of movement and your qualification is not automatically transferrable. However, it is still possible! We recommend contacting the relevant country’s regulatory body for advice on obtaining a license to practice. You may need to have your qualification translated and verified by the regulatory body. Once you have the right to practice, you’ll need to apply for a VISA through your chosen country’s embassy. Be aware about different medical systems, indemnities, registration requirements and speciality structures. Finally, in some European countries, there are quite high levels of medical unemployment, so finding a job may be difficult. However, for those with good language skills and a thirst for the Continent, don’t be put off.

North America / Love red tape? Exams? Hard work? Then North America is for you. The BMA provides excellent online guides to working in the USA and Canada which are good places to start. Broadly, the issues are eligibility to work and visas, training requirements, exams and competing with homegrown candidates. For those looking for a short fix, research posts and some fellowships are a good way to spend time working in North American institutions, while avoiding the exams.

Developing World Work / Developing world work can be an immensely satisfying way to consolidate your medical skills and get some love back for being a doctor. Work can either be arranged yourself, or through an organisation or NGO. Different posts will have different professional requirements, and some ask for additional qualifications such as a tropical medicine diploma. Whatever the organisation’s requirements however, you have to satisfy yourself that you are the right person for the job. Consider whether other doctors of similar experience have gone before you, what supervision will be in place, and what the arrangements are regarding salary or expenses. You will likely have to register with the country’s medical council, which can take some time. The best advice for arranging a developing world placement is to start early and be persistent. Please visit our Resources Section for details of some charities and organisations who may be of interest.

Expedition Medicine / Expeditions are a particular passion of ours here at Adventure Medic HQ. In theory, any doctor with a license to practice (i.e. post- Foundation) can go on an expedition and many do. However, there are a number of ways to keep yourself right. First of all, make sure you are up to the job. Get a thorough understanding of the nature of the trip and the participants before accepting, and be honest about your own experience. Expedition docs are subject to the Bolam Test (Hunter vs. Hanley for Scots) – in other words, your actions will be judged against your peers. If you bill yourself as a ‘mountain medicine expert’, expect to be judged against other experts should the worst happen and you end up in court. For your first expedition, it may be good to go with one of the more well-known organisations, such as Raleigh International or Blue Ventures, as they are used to junior doctors. Whoever you go with, make sure that they are clear about the deal that they are offering. Do they include flights? Kit? Indemnity? Expenses in country? A salary/per diem? Be wary of operators who offer you ‘10% off’ off the cost of the trip if you are willing to act as doctor. Often, the cost of kit, indemnity and preparation time will be considerably more than the 10% and may detract from your enjoyment of the expedition. A good way to take the stress out of being an expedition doctor is to go on a course first. There are a number listed in our Resources Section. As well as teaching you some of the skills, courses are also great ways to make contacts in the expedition world. Good luck, and let us know how you get on!

Staying in the UK / Many people choose to take time out of training and remain in the UK. This can be a great choice for those who wish to stay a little closer to home but want a break from or aren’t ready to enter a formal training programme. Ad-hoc locum work can give you flexibility to travel, do additional courses or qualifications or even expedition or voluntary work abroad. Additionally, there is a dizzying array of ‘fellowship’ type posts that have appeared in the last 5 years which offer a fixed term contract with training opportunities and additional perks built in. These can offer fantastic opportunities to gain valuable experience and skills, or to try your hand at specialties that perhaps you didn’t have an opportunity to do previously.

Recruitment Agencies / Recruitment agencies can take a lot of the hassle out of arranging work abroad. However, be aware that they are a bit like budget airlines – they often take you somewhere near to where you want to go. Be very sure where you are being placed. Remember also that agencies make a lot of money for every doctor they place, so you are doing them a favour not the other way around. Drive a good bargain.

Tempted?

Adventure Medic talked to an eclectic bunch of medics who’ve successfully deviated from the straight and narrow at various points in their medical careers. Between them they’ve mountain biked the Simien mountains, lived the dream in New Zealand, dived or sailed off every continent and driven across the African plains. They hope to provide you with encouragement, ideas and inspiration. They’ve also provided us with a wealth of helpful tips including things to consider when taking time out and how to ensure you keep yourself right.

Can I be adventurous with medicine without taking time out?

For various reasons, time out from training might not be for everyone. Albeit often a little constrictive in terms of timings, with a little imagination and forward planning, it is possible to develop a keen interest in expedition and event medicine without taking ‘formal’ time out.

Some lucky few have managed to be granted study leave by training programme directors and educational supervisors. The skills you develop are easily applicable to any training pathway although some lend themselves to this better, notably ED and GP. Make sure your personal development plan includes pre-hospital/remote work and you show how the experience will benefit you as a trainee and the NHS in due course. For them to grant you this leave you will need to be achieving all of your competencies, be ahead with your portfolio and show you know what you are taking on.

Most still use annual leave for expeditions as it requires less hoop jumping. Aiming for one-two trips per year has been feasible for some of the team at AM. Booking leave with rota coordinators months in advance can be tricky, particularly if it’s for a future department you aren’t even working in yet. Try to make contact early and get the dates saved – you can always look to convert it to study leave later on.

Dream big but be realistic with how much you can take on. Shorter trips may be approved more easily and fit better with even the tightest of rotas. There are also numerous companies you can work for providing medical cover at 1-2 day events.

Adventure Medic’s Top Tips for Taking Time Out

Useful links

We have a comprehensive list of links in our Resources Section but these are some to get you started.

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The working group from the RCSEd Faculty of Prehospital Care has released updated guidance for medical provision for wilderness medicine. Their initial work covered best medical care in expedition environments, ‘benchmark’ skills required by practitioners and recommendations for expedition organisers on selecting appropriate medical cover. The revised 2019 version includes updates to the skills framework and expedition risk matrix, and broader consideration of competencies beyond purely medical skills. It’s useful reading for aspiring and established medics, as well as for expedition organisers.

The guidance is freely available here.

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Sarah, Claire and Becca work at DDRC Healthcare, the hyperbaric medical facility in Plymouth. Combined they have a wealth of experience in diving across the world and in remote locations. Trained to a level of DMAC Level IID and with first-hand experience of treating decompression illness, they are keen to share some of their knowledge with the wider expedition medicine community to increase the confidence of medics who may be treating divers.

Imagine it. You are the medic on a dive site in Fiji. On a remote tropical island, you are with a research expedition team studying manta rays. You are twelve hours from the nearest decompression chamber and fast asleep. It’s been a long day. You’ve had a lovely couple of dives, a delicious dinner and are in your little beach hut dreaming about fish.

That is, until one of the marine biology students bursts into your room. “Doc, doc wake up. I can’t sleep. My elbow hurts so badly!” What are you going to do next?

Introduction

Operating in the marine environment presents unique challenges: (1) pressure, immersion and temperature can significantly alter physiology, (2) divers usually have a limited supply of breathing gas, and (3) there are, of course, some potentially dangerous fauna and flora.

The idea of spending weeks diving in tropical waters in some remote and beautiful corner of the world is understandably enticing to a lot of people. As well as having a thoroughly enjoyable trip however, it is worth being familiar with some of the problems you may come across to ensure your patients are in safe hands. Here we will look at some of the basic science underpinning diving medicine, decompression illness and the management of sick divers.

Basic Physics and Physiology of Diving

Understanding the physics and physiology of diving is crucial to get a firm grasp of dive medicine. Although possibly daunting at first, once understood, it explains divers’ clinical presentations and why we treat them as we do. Knowledge of the basic science will also really help in deciding whether a problem in a diver is dive-related or not.

The most important concept to understand in diving medicine is pressure. At sea level, the pressure is 1 atmosphere (1 ATA). With every 10m of seawater, this pressure increases by 1 ATA: 0 m is 1 ATA, 10m is 2 ATA, 20m is 3 ATA etc.

The gas laws underpin diving physics and physiology. The most important are Boyle’s law and Henry’s law.

Boyle’s Law / The volume of gas is inversely proportional to the absolute pressure. This means that if you increase pressure (i.e. descend deeper), you reduce the volume of a gas filled space. On ascending, the volume of the space increases again.

Henry’s Law / The amount of gas that will dissolve in a liquid is proportional to the partial pressure of the gas over that liquid. In other words, the higher the pressure, the more gas will dissolve in a liquid. Equally, when the pressure reduces on an ascent, the dissolved gas will come out of the liquid again.

Decompression Illness

We can now look at how these gas laws explain decompression illness (DCI).

DCI is caused by a reduction in ambient pressure. In diving, this reduction in pressure happens when you ascend to the surface. DCI encompasses two separate disease processes:

1. Decompression sickness (DCS): ‘evolved gas’
2. Arterial gas embolism (AGE): ‘escaped gas’

Decompression Sickness / As a diver goes deeper underwater, the pressure will increase. According to Henry’s law, this means that nitrogen, the inert gas in their air supply, will dissolve in increasing quantities in their blood. However, when they ascend, the pressure will fall again, this gas will come out of solution, creating lots of tiny bubbles of nitrogen. This is often described as ‘evolved gas’. These bubbles may block vessels or collect in tissues triggering local inflammatory changes, leading to DCS. It can occur in almost any part of the body but is most frequently seen in the joints and spinal cord.

Arterial Gas Embolism / The pathophysiology of AGE also involves bubbles but this time in the arterial circulation. This typically occurs due to pulmonary barotrauma, which can be explained by Boyle’s law. As a diver ascends, the pressure decreases and so the volume of air in their lungs will increase. If the diver holds their breath, or has lung pathology causing gas trapping, this may cause an over-inflation injury. The alveoli burst, leading to a pneumothorax. The gas from the pneumothorax can then find its way in to the pulmonary circulation, and back to the left side of the heart, where it is pumped out in to the systemic (arterial) circulation. The gas embolism may go anywhere in the body, including the brain.

Some divers have a communication between their right and left circulations, such as a patent foramen ovale (PFO). In these divers, arterial gas embolism may occur without pulmonary barotrauma. This is because bubbles formed in the venous circulation (as per Henry’s law) may pass through the shunt into the arterial circulation. Unfortunately, little is known about the effects of pressure on PFO patency. It has been suggested that PFO patency may increase with age, meaning older divers may be more at risk. However, further research is still required in this area.

AGE is often described as ‘escaped gas’ as there does not need to be a big accumulation of inert gas in the blood for it to occur. A single bubble of sufficient size in the arterial system can have catastrophic effects.

How does DCI present?

As bubbles can reach almost any part of the body, DCI can present with almost any clinical picture.

The most common presentations, in order of frequency are:

1. Neurological: weakness, numbness, unconsciousness
2. Musculoskeletal: joint pain
3. Constitutional: headache, malaise, loss of appetite etc
4. Cutaneous: a blotchy, marbled rash
5. Chest pain or breathing difficulties: this may be a sign of pulmonary barotrauma

90% of cases present within the first six hours following a dive. AGE tends to present more rapidly than DCS.

Management of DCI

In a remote area with limited access to healthcare, the initial first aid of divers is of paramount importance. If you suspect decompression illness, do the following:

100% oxygen at 15 L/min / If possible should be given to patients regardless of their saturations. Saturations are not a particularly helpful guide as the aim is not to increase the patient’s oxygenation, but instead to establish a pulmonary ventilation-perfusion gradient, so excess nitrogen diffuses out of the capillaries and is exhaled. A high partial pressure of oxygen establishes a diffusion gradient even at normal pressure. This means excess nitrogen can be exhaled more efficiently.

Fluids / Oral is usually ok, but consider IV if they are vomiting, dehydrated or unconscious. Due to immersion diuresis, alcohol or divers deliberately reducing their fluid intake (nobody wants to pee in a drysuit on a long dive!) most divers are dehydrated. Fluids help correct dehydration and manage third space losses due to oedema and inflammation resulting from DCI.

Get Help / In the UK, you can call the National Diving Accident Helpline on 07831 151 523. If you are abroad, ensure you have found out where your nearest chamber is in advance and call them for further guidance. The Divers Alert Network (DAN) can help put you in contact with a nearby chamber.

Arrange a casualty evacuation (CASEVAC) / The only definitive treatment for DCI is recompression therapy and so it is important to evacuate divers to the nearest hyperbaric chamber as soon as possible. In-water recompression (i.e. taking them underwater again) is not recommended due to safety concerns.

Key Learning Points

1. Oxygen is the very best first aid you can give to a patient with suspected decompression illness. Give at the highest possible flow rate, regardless of oxygen saturations
2. Know the location and phone number of your nearest hyperbaric chamber before embarking on a dive expedition
3. Decompression illness can present in so many different ways, from just not feeling quite right, to a rash, joint pain, neurological symptoms, and even unconsciousness (and possibly death). Always have it in the back of your mind when assessing divers
4. Cerebral arterial gas embolism can present very similarly to stroke. Both conditions are time critical so getting advice from a diving doctor early if a patient presents after diving can be very important to secure a speedy diagnosis.

If this brief introduction to dive medicine has whet your appetite, please take a look at DDRC’s Expedition Dive Medicine Course which is being run on the weekend of 6-7 April 2019. The course is aimed at doctors, nurses and paramedics planning on going on dive expeditions to give them the skills and confidence to safely manage divers in the field. It’s set to be a fascinating couple of days and will prepare you for any diving medicine opportunities which crop up in beautiful locations across the globe.

Photos: Tom Everett and Sarah Clayton

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Harriet is bang in the midst of her first year of anaesthetic training in the south east of Scotland. For the past nine years, in-between the ubiquitous night-shifts, day-shifts, exams and general life tasks of medical training, she’s been taking to the hills with Ski Patrol in Scotland. Here, she gives Adventure Medic some fascinating insight into the equipment the mountain first response teams have at their finger tips. That, plus a few tips for your own trip off-piste.

Many of you may know that skiing in Scotland can be somewhat variable. Beautiful sunshine in the morning can often be followed by torrential rain, washing away the snow in minutes; a firm or icy slope can rapidly turn into sticky, heavy snow. Heather-bashing and rock-hopping provide memorable experiences. These varying conditions give rise to very different injury types, and thus management strategies. When injured, you become reliant on ski patrol services to get you back down to the base station: whether that be for a cup of warming hot chocolate, or further medical help.

I’ve been involved with Ski Patrol in Scotland for 9 years, having completed a British Association of Ski Patrol (BASP) training course as a medical student. Currently as a CT1 in Anaesthetics, I enjoy spending my free time and weekends off in the mountains volunteering with Glenshee ski patrol, as well as collecting data on Scottish ski injuries. I cannot think of a better way to pass a weekend than enjoying both the first and last run of the day, and working with a truly inspiration group of fellow patrollers.

Ski patrolling in Scotland provides many different challenges to the majority of Europe and Australasia. All of the evacuation and medical services that we provide are volunteer-run and funded, rather than through insurance companies. In such harsh mountain environments, poorly manufactured equipment often breaks so we use plenty of basic resources to help manage casualties. Sometimes the most simple splint and equipment can prove to be the most valuable. The classic balance between “ staying and playing” and “grabbing and going” must often be reached; in cold and often windy environments the priority is to evacuate the patient safely to the treatment room for further assessment and definitive management. Each ski patroller carries their own basic first aid kit, primarily bandages, slings and splints. We have several “majors bags” including a trauma bag with spinal immobilisation equipment, a haemorrhage control pack (celox gauze and lots of dressings), an airway and cardiac arrest bag and a lower limb grab bag containing a traction splint.

Evacuation equipment

The majority of casualties are evacuated from the piste by Tremont sledges: a simple 2-handled sledge driven by a single patroller, with the assistance of a back rope on particularly steep or icy slope. Braking is provided by a chain which can be deployed under the belly of the sledge, but once deployed the sledge has to be lifted to release it on any flat slope. Casualties are packaged in the sledge on an insulating mat, wrapped in a thick casualty bag. This is relatively easy on the main slope faces, but within a distant valley can be difficult with the casualty having to be taken uphill by a patroller (which is exhausting) or behind a skidoo.

Seriously injured casualties can be loaded onto a snow groomer, either within a specialised front loaded cab adapted to contain a loaded stretcher and patroller, or on the back of a groomer. The former method has the significant advantage of reducing exposure to snow and the cold in adverse conditions.

Orientated, ambulant casualties may be evacuated by skidoo by one of the operating “Oscars”, the on site mechanical engineers. This in itself can be quite an experience, and one that the majority of casualties really quite enjoy. A ski patroller often follows the casualty down afterwards, carrying their skis and equipment.

Splints

Spinal or trunk injuries require immobilisation in a vacuum mattress: a plastic-coated bag full of polystyrene balls. Removing air from the splint forms it firmly around the casualty, providing an immobilising and comforting cocoon. Hard backboards are seldom used now, owing to discomfort and subsequent risks of long transfer to hospital (often 2-3 hours). However we still occasionally use scoop stretchers for shorter transfers. Increasingly, cervical collars are not being used, replaced with good immobilisation; they are now frequently deemed unnecessary by using NEXUS criteria to exclude cervical spine injury.

The most effective method of splinting used on the hill is a simple, home made box splint: 2 pieces of foam attached to marine grade ply, joined together to form a sandwich. The whole leg, knee or lower leg can be splinted within the box to provide stabilisation, and thus good analgesia and a bit of protection. Soft tissue knee injuries are the most common type of injury within Scotish resorts, occurring particularly in beginners and in soft snow conditions. Knees can be stabilised very well within these boxes. Some resorts are also moving onto more expensive vacuum style limb splints which work in a similar way to the spinal splints. However in our experience these splints are relatively expensive and can often leak, reducing support provided.

Seldomly, traction splints are used on the slopes, with modified foot straps for use with large ski boots. Both Thomas and Kendrick splints are used, and I personally prefer the Thomas splints – despite them being more cumbersome, they provide more stability and protection from external blows than the lower bulk Kendrick splints.

Upper limbs are generally splinted with simple measures including SAM splints and bandages. Triangular bandages can be used as slings, or simply inverting the bottom of a ski jacket can provide good support too. Improvisation is very much the order of the day.

Resuscitation

Basic Life Support (BLS) and Immediate Life Support (ILS) equipement is kept on site: there are 3 defibrillators in the resort (one in each main cafe; one at base). We have oxygen and a basic airway kit, up to and including i-gel laryngeal mask airways which ski patrollers are trained to use annually. Our main problem in a cardiac arrest situation is organising retrieval from such a remote location. Thankfully in the last 10 years we havn’t had to organise this, although Glencoe have used theirs for a gentleman having a heart attack. The prospect of using resus equipment on the steel platform of a piste groomer is somewhat daunting.

Of note, the International Committee for Alpine Rescue have produced comprehensive guidelines for hypothermic cardiac arrest, which provide definitive guidelines for first responders in these situations.

Analgesia, drugs & gases

Simple analgesia is available within most resorts for casualty self administration within treatment facilities. Currently entonox is the only strong analgesic available on the hill, which can provide good, rapid pain relief. However, caution has to be used owing to separation of the gases on particularly cold days. Occasionally, a local GP may be called if no patrol doctors are available on the day to administer stronger analgesia. As an organisation, BASP is currently looking at expending analgesia options, and this year we are trialling Penthrox for the first time (methoxyflurane, a hand-held inhalational pain killer), which should be interesting.

First aid top tips

My top tips for those who are off skiing in a remote area or are heading off-piste are:

• Keep it light and simple, most kit can be improvised from other items you are carrying. Ski poles and ice axes make great splints; clothing good bandages or slings.
• Wrap some gaffa tape around a ski pole or water bottle – such a handy piece of kit.
• Always carry an emergency shelter or warming blanket: the worst thing is the cold whilst waiting for help to arrive. It can also be used for an improvised carry out if needed.
• Plan for the worst. Know what medical resources are around and how to contact them.
• Be aware of pre-existing medical conditions in your group, and think about the kinds of injury you may be faced with – plan ahead!

Getting involved

If anyone is interested in getting involved volunteering with Ski Patrol, I’d recommend visiting the British Association of Ski Patrollers (BASP) website and attending their annual training course to develop some of the basic casualty evacuation skills needed for the job!

Photos are credited to Harriet Gray-Stephens unless otherwise stated. Taken with casualty permission.

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In one of our first ever Adventure Medic articles, Queenstown GP Tonya Cruikshank gave us some basic tips on how to respond when first arriving at an accident on the ski fields. Now, in this three part series of articles Edi Albert will look at what happens next. Edi has worked at Perisher Ski Resort (the largest in the southern hemisphere) for the past eight winters. He also co-ordinates a multi-disciplinary Masters programme in Remote and Polar Health at the University of Tasmania.

In his first article, Edi discusses the ‘at risk’ groups, common injury patterns in skiers and snowboarders and injury prevention. Timely stuff, winter is fast closing in on the Northern Hemisphere and soon hopes of fresh snow and blue ice will be all that keep us sane.

Introduction

You may be the doctor in a group doing some back-country ski touring; you may be the nurse amongst a bunch of friends faced with a swollen knee over breakfast the next morning, or you may be as lucky as me – and get a job in a clinic in a ski resort.

Clearly, a few articles can’t replace hands on experience and training, but can hopefully help with a few key pointers and concepts that aren’t usually found in the first aid manuals or medical text books.

We will start by considering the different patterns of injuries experienced by skiers and boarders and relate these to the mechanism of injury and to some extent the age of the patient. Examination can be difficult out on the slopes, or even in the clinic with a freshly injured patient, so a good history and a good understanding of mechanism can go a long way to help with the diagnosis.

We will then consider assessment and management of knee injuries, shoulder injuries, and also along the way, a selection of other injuries that may pose diagnostic and management pitfalls.

Injury rates and ‘at risk’ groups

Alpine skiing and snowboarding are, despite intermittent media hype, relatively safe sports with injury rates in the region of 3-5 per 1000 days. These are considerably lower than for other “normal” sports such as football and rugby. Patterns of injury vary between different snowsports and should be understood by those involved in their medical treatment. These sports, by their very nature, can involve high velocity, high energy impacts – especially in the terrain parks.

LESSON 1 / Injuries can involve very large forces. Take a good history to understand the mechanism of injury, have a low threshold for x-rays where significant forces are involved, and a high index of suspicion where a “normal” x-ray just doesn’t correlate with your clinical findings.

There are a few groups that have been shown from studies to be at higher risk – children, beginners, and elite competitive athletes. This makes injury prevention strategies and protective equipment particularly important for these groups (see the section on injury prevention).

From my own experience there are two other groups who end up flat on their backs in our clinic:

The first are overweight mothers who have been dragged on to the ski slopes by a keen husband and even keener teenagers. They would have preferred a nice beach holiday, do no regular exercise of any kind, and certainly haven’t thought about preparing for their ski trip. They are often baffled that they are lying injured as they thought they were “just taking it easy”.

LESSON 2 / Beware of the low speed, slow twist knee injury in particular (see article 2 on knee and shoulder injuries) – it’s one of the best ways known to man to bust your ACL

The second ‘at risk’ group are the older skiers. Whilst it is fantastic, and personally very encouraging, to see more and more people still skiing in their sixties, seventies, and even eighties, and whilst they do tend to keep fit, take care, and ski carefully, their bodies are much more vulnerable.

LESSON 3 / “Senior” skiers can do themselves a real mischief with minimal force. Their apparent vigour and vitality is not matched by the integrity of their bones and connective tissue. Have a low threshold for investigation.

Injury patterns in skiers and snowboarders

Look out of the window in the morning and you can almost predict how your working day will unfold: a soft blanket of overnight snow will provide a forgiving medium that makes everyone feel invincible and keep the clinic quiet, that heavy, claggy “porridge” we get in warm, wet, windy Australia is wonderful for destroying knees, and a few days of freeze-thaw conditions will generate a hard surface such that snowboarders with broken wrists turn up in their droves.

From a bio-mechanical and injury perspective, skiing and snowboarding are two quite different sports. Of course both can fall over and bang their heads, both get meaty slices through their limbs from sharp edges, and both can “scorpion” on a jump and end up with a wedge fracture at the thoraco-lumbar junction. But, in general, injury patterns are quite different, so understanding them can guide the clinician towards a quicker diagnosis, with more appropriate imaging, and a lower chance of missing something. What follows is necessarily a generalisation: clinical acumen should allow you to pick up those presentations that don’t follow these generalisations.

Put simply, skiers spend their time on awesome torque inducing over-sized lolly-pop sticks, whereas boarders stand sideways on a tea tray and keep falling over forwards or backwards.

The skier is at risk from anything that interferes with the controlled movement of their skis. Catching an edge, crossing your skis, or having someone else run over the back of one of them can create huge rotational forces from the foot, all the way up the leg. In children and older adults the tibia may give way with spiral boot-top fractures occurring. In older children and adults, the tibia tends to pass the force up the way and it is the knee that suffers: MCL, meniscal, and ACL injuries can occur in isolation or combination.

Assuming the snowboarder has his or her back foot strapped in (which isn’t the case getting on and off lifts) then the knees are fairly protected against over-rotation and you are unlikely to get more than a grade 1 MCL injury.

When snowboarders fall, those that haven’t “learnt how to fall” usually fall forwards onto out-stretched hands – or backwards onto outstretched hands. Injuries then reflect transmission of force – distal radius or scaphoid fractures, fracture dislocations of the elbow or further up into the shoulder (see my next article on knee and shoulder injuries).

LESSON 4 / Always assume the relocated elbow conceals a fracture – even if you can’t see it on X-ray, commonly a coronoid process fracture – so get a CT. The one above is easy to spot on this post-reduction film.

Falling onto the shoulder is a common way to protect the wrists but then puts the snowboarder at risk of shoulder dislocation, ACJ injury, rotator cuff injury, and clavicle fracture.

When skiers fall, they can, like the snowboarder, do a high speed “superman”, but often they are sideways onto the slope and either fall uphill or downhill onto their shoulders. The classic Skier’s Thumb occurs when the thumb is forced back by the presence of the ski stick held in their hands.

LESSON 5 / With a Skier’s Thumb presentation look for a UCL rupture or fracture at the base of the 1st meta-carpal. Stress x-ray views may be appropriate when USS or MRI is not available. To examine the UCL you need to “fix” the 1st MC so it doesn’t move when you wiggle the thumb.

Finally, a word on falling from heights: which is something that both skiers and boarders do quite regularly when they get into the terrain parks and when there is a confidence-competence mismatch. An undershoot on a jump results in an unexpected flat landing on the “knuckle” and an overshoot can result in an unexpected landing way beyond the “sweet spot” with disastrous consequences. Forces start at the heels and then travel up the legs, into the pelvis and on up the spine. Look for fractures in all these places, and anticipate more than one fracture.

LESSON 6 / A man with “groin strain” who can’t weight bear has a fractured pelvis – even if his plain x-rays are normal.

Injury prevention

Be physically fit, don’t drink and ski, maintain situational awareness, don’t do that “last” run before lunch or the end of the day, don’t have music blaring through your headphones, don’t drag your girlfriend to the top of a black run on her second day so you can show her how good you are, don’t let your friends teach you or lend you their gear…  blah… blah… blah. Good advice seems to fall on deaf ears. This is okay by me of course, otherwise I wouldn’t have a fun job in a ski clinic.

A discussion around injury prevention is bound to focus on helmets and wrist guards. Both are hotly debated and use of both is becoming more common.

If you want to read the science and evidence behind this then head for Mike Langran’s comprehensive ski-injury.com site. The following is just a brief synopsis.

Helmets / Helmets do not make you invincible and probably do not reduce the risk of death. Let’s face it, if you hit a solid object hard enough (which is easy to do on skis) there’s nothing much that a helmet can do. It has been demonstrated that in order to protect the head from a direct impact at (only) 50km/h you would need a helmet 18cm thick that would weigh 5kg! But these sorts of injuries are very rare.

Much more common is falling over backwards and hitting your head, or when somebody pulls down the restraining bar on the chair lift before you’ve got on properly, or when tree skiing and your duck just isn’t quite enough.

Now, are you seriously going to tell me that a nice, colour co-ordinated helmet with built in speakers that can Bluetooth to your phone, keep your head warm, and reduce the morbidity from common incidents isn’t worth having? I’m not worried so much about what I might I do wrong, but what some other idiot might do to me.

Helmets don’t increase the risk of neck injury, they don’t reduce the field of vision, and don’t impair your sense of hearing. They do make sense: especially for those ‘at risk’ groups.

Wrist guards / Wrist guards are designed to prevent wrist fractures in snowboarders. Wrist guards reduce both the incidence and the severity of fracture. Sure, some people do still break their wrists under the guards but these are always less severe than if they had had no guard on. There is still a myth out there that wrist guards transfer the force up the arm – typically that you break your mid forearm at the end of the guard. The research evidence does not support this. You can make a good argument for an experienced boarder not wearing them. You can’t make any sort of rationale argument for beginners and children.

LESSON 7 / If your boyfriend or girlfriend breaks both wrists then it will be quite a while before they can wipe their bottoms again. Which means that you will have to do it. Treasure this opportunity: it’s a wonderful relationship tester! Either that or insist on wrist guards.

And, finally…

LESSON 8 / The golden rule of the ski slopes – always wear waterproof mascara – there’s nothing worse than treating patients whose tears have transformed their faces into something reminiscent of a KISS concert.

Further resources

Practical Approach to Snowsport Injuries Part II

Practical Approach to Snowsport Injuries Part III

Your one-stop shop for snowsports injury and injury prevention is Mike Langran’s www.ski-injury.com. It covers many of these topics in much more detail.

You can contact Edi by email: edi.albert@hotmail.com.

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Last year, Dr Sarah Richardson removed a three inch-long leech from Daniela Liverani’s right nostril. The story went viral. Over 120 articles were published internationally, along with 100,000 shares on social media sites. Sarah spends much of her time working as a General Physician in Uganda, so is no stranger to parasites. However, the reaction of both the ED staff and the general public got her thinking: parasitic infections are out of most of our comfort zones, but actually they are common and quite easily managed if you know how. So, here’s Sarah’s Guide to All Things Creeping and Crawling:

Anyone who has travelled in the developing world will tell you how the environment is always creeping into your life. Sometimes, it is the lines of ants chasing the smallest crumbs on a surface. At other times it is the pleasing sight of several large spiders, left undisturbed in a house to ‘keep the mozzies under control’. Contrast this with the developed world. In the UK, we now have 57 insects on the endangered species list and we do our very best to sterilise the bubbles we live in.

As a physician in Africa, you would think that the most common things I see would be malaria, typhoid, cholera, haemorrhagic fevers and all the other tropical illnesses lurking in the deep depths of the ‘dark continent’. In reality the most frequently seen ailments are often much more minor and related to the various creepy crawlies that have worked their way into our daily lives. Given that little time is spent on these conditions during conventional Western training, I thought I’d share my top tips for treating the more commonly seen diagnoses, from the simple to the slightly more challenging.

Ringworm

Not actually a worm, but extremely common. Whilst we do see this in the Western world it is by far more common in Africa, and plagues both locals and returning travellers. Typically starting with a small erythematous papule, the infection spreads out with an inflamed scaly edge and a pale centre. Highly infectious, multiple children within a family are usually infected with the scalp being a particularly common place.

There are two classical presentations of ringworm in travellers and tourists. The first involves unclean bed linen and dirty hostels, with the infection presenting on areas such as the thighs, after they have pressed against the unclean edges of a bed. The second (and most typical) is from hugging small children (with infected heads) whilst wearing a low necked top, resulting in cleavage infection.

Treatment is simple: a topical anti-fungal such as ketoconazole, clotrimazole or miconazole applied until the symptoms have resolved, then for a minimum of a further two weeks to avoid recurrence. If you are treating scalp ringworm, use an anti-fungal shampoo but for extensive disease, oral treatment may be needed.

Jigger Worms

Itchy to the point of pain, the Jigger worm is actually the parasitic chigoe flea found in Central and South America and sub-Saharan Africa. As the flea can’t jump very well, the larvae bury into the skin of feet, particularly around the toes and under the toenails. Patients usually don’t notice the initial infection, so present several weeks later with one or more intensely itchy (or painful) pea-sized papules. The papules have a black dot, which is the flea’s respiratory organs. They are often secondarily infected at the time of presentation, with some patients presenting after they have noticed tiny eggs and faeces being secreted from the area.

To remove the larvae, clean the area. Then, take some simple tweezers or a needle and make a larger hole around the black dot. Remove the top layer of dead skin on top of the Jigger. Then using forceps, grab the Jigger as close to the head as possible and slowly pull it out. Try to always remove it as intact as possible to prevent infection. The larvae will have been producing eggs so ensure none are left in the wound. Be warned, sometimes multiple jiggers have worked their way into the same hole so make sure you remove them all before cleaning and dressing the remaining wound.

Tape worm

“There’s something hanging out of my bottom doctor…”

Pretty rare in the UK, tapeworms are relatively common throughout the developing world. Caused by parasitic cestodes flatworms, they are consumed as larvae in contaminated food such as pork or beef. Once in the digestive tract, they can grow to up to 17m long. They are usually asymptomatic though sometimes complications can occur.

Patients usually present either with abdominal pain or, more commonly, after finding segments of the tapeworm in their faeces. These are usually shedded proglottids, but in one case I had a patient with almost a metre of tapeworm shedded at once. Simple infections are treated with praziquantel or albendazole (readily available in Africa and other developing countries, though only accessible on a named patient basis in the UK). Faeces should be monitored to ensure the head and neck of the worm is passed, then rechecked after one and three months to ensure there has been no recurrence.

Mango worms – Bot flies and other myiasis

The mango fly or tumba fly is found mostly in central and eastern Africa. These flies generally lay their eggs on soil, damp clothing or linen that is being dried outside. The larvae hatch 2-3 days later, attach themselves to unbroken skin and then burrow under the surface. They classically pupate in the skin of the buttocks, waist and lower back – usually in areas where clothes are relatively tight fitting.

Bot fly larvae present in a similar way, after laying their eggs directly on the skin. Patients commonly dismiss the initial swelling as being caused by a mosquito bite. It is only after the larva grows and a boil-like swelling develops that they seek medical advice. The area initially may appear like a typical furuncle, but on closer examination there will be a hole for the maggot to breathe and for excretion of waste products.

Small larvae may be squeezed out if they are noticed early enough. With larger larvae, it may be too painful to squeeze it out due to local swelling. However, even gentle squeezing of the area will reveal a squirming maggot that retreats quickly, confirming the diagnosis. The best treatment is to put a large amount of Vaseline over the breathing hole. The maggot then usually climbs through this to reach fresh air and can be easily plucked from the area.

If this fails then the area can be incised under local anaesthetic and the maggot removed whole. Given that flies lay 100-300 eggs at a time, check the patient over for any further signs of potential larvae before discharging them.

Loa Loa

Loa loa is not for the faint-hearted. It is a blood dwelling roundworm, generally found in Africa and spread by mango flies (or deer flies). Once developed, the adult worms wonder through the subcutaneous tissues, finding their way to the conjunctiva and growing up to 20cm in length. Patients often are unaware of a worm until they notice them in their conjunctiva. Sometimes, they see the worm crawl across their vision. Swelling and oedema can occur in the subcutaneous tissue at any site where the worms have died.

Treatment is usually quoted as being surgical removal of the worm, after paralysis of the worm in the eye. I’ve found that in the developing world where surgical settings are not ideal and paralyzing drops not available, the locals have come up with a reliable way of getting the worms out with a lot less fuss.

1. Get a large chunk of meat (usually goat, because its cheaper than beef)

2. Warm it in the African sun but make sure it remains nicely moist

3. Open the patient’s eye that contains the worm and place the meat onto the open eye

The worm will usually crawl into the meat if left on the eye for about 15-20 minutes. If it doesn’t, you may need to make a small incision in the conjunctiva for it to crawl through. After removing the adult worms, the microfilariae should be cleared with DEC (diethyl-carbamazine). This can be difficult to get in the developing world, in which case albendazole can also be used.

Leeches

Let’s face it; leeches in bodily orifices are pretty rare. However, I couldn’t finish this article off without a tip about how to get them out. It’s my claim to fame, after all. Leeches are generally found in freshwater environments, where they attach with their sucker to an external area of skin. They will either drop off once they have had their feed (usually taking between 20 minutes and two hours), or you can flick them off the skin, interrupting the suction under their sucker. If a leech has made its home in an orifice such as the nose, then:

1. Get direct vision of the leech using a nasal speculum (or similar)

2. Using fine suture forceps attempt to grab and remove the leech

If the leech disappears up the patient’s nose, then move into an area with a sink. Run the hot tap of the sink to create steam (some leeches love steamy environments). If you still can’t remove the leech then get some form of foam or absorbent material and soak it in water hot enough to create local steam. Hold the foam under patient’s nose to encourage the leech to come more anteriorly, then remove it with forceps. You may need to tug a little.

If all else fails, then either refer for a scope or use the meat trick, so lovingly described above.

In summary

Worms and parasitic infections are extremely common in the developing world and in those returning from the area. If you come across them at home, then don’t panic or freak out. If you’re in doubt, call your local regional tropical medicine registrar – they probably have a few tips. If you are feeling bold, then gently warm up some meat and get stuck in.

(Cover photo: Gastrophilus equi – Wikimedia Commons)

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Barry Roberts / Expedition Skier

Winter is here again and with it the promise of glorious powder and crisp, blue, water ice. As we all know, avalanche safety and management are core topics for the medic in winter. So, we asked Harvey Pynn and Barry Roberts to remind us of the fundamentals. Harvey Pynn is a Consultant in Emergency Medicine and Pre-Hospital Care in the South-West, with extensive expedition experience. Barry Roberts is an experienced expedition skier (Greenland, Nepal, Pakistan and Tibet), the co-author (with Doug Gurr) of Staying Alive Off Piste and the Commercial Director of Wilderness Medical Training.

Introduction

Like a climber, pushing their grade with sketchy protection and being confronted with a sudden possibility of a bad fall, the back country skier’s situation can quickly go from a state of pleasure and flow, to one of fear and panic when they realise they are in dodgy terrain. Retreat is usually not easy. Carrying on may be lethal.

Avalanche safety is a big topic. Indeed, people have devoted their professional lives to snow pack analysis, snow crystal metamorphosis and optimal search and rescue strategies. For this article, we have purposely steered clear of these areas (interesting and important though they are), choosing to focus instead on three tried and tested axioms to help to keep you safe in the back country. We will then go through the medical management of the avalanche victim.

Axiom 1 – Don’t go if you don’t know

In a managed ski domain, professional ski patrollers monitor, assess, manage and publicise the risks over the ski season. Once you venture out of bounds, you’re on your own and this especially applies to the remote expedition setting above the snowline, which may be winter or summer in the highest mountains. You have to rely on your judgment. Look out for red flags including:

Obvious avalanche activity / Clearly evidence of instability

Recent significant snowfall (+10-20cm) / Especially if associated with strong winds. Wind moves the snow around, “loading” certain slopes and aspects with packed snow. This is particular true in the lee of the wind.

Rapidly rising temperatures / Increase instability.

Most areas publish a local hazard level, based on a professional assessment of the snowpack. It is worth noting that while a hazard level of ‘3’ on a five-point scale may seem ‘average’, the risk is actually described as ‘considerable’. Indeed, most avalanche accidents happen when the risks are rated at 3. The ratings can change daily. For example, over the recent Christmas 2014 period in Chamonix the hazard level ranged from 1-4.

Everyone in the party should be equipped with an avalanche shovel, transceiver and probe. Don’t head out if you can’t use these confidently

Axiom 2 – Think terrain, not snow

If snow is the problem, then terrain is the solution. Plan and follow a route that avoids:

Steep slopes / Over 20°-25°

Convex slopes / The snowpack is weakened by the arc or “bend” over convex terrain.

Slopes loaded by snow / For example, lee-side slopes.

Terrain traps / Any ground feature that makes being caught in an avalanche more lethal. For example in a couloirs that funnels the snow, or being swept into a bowl, over a cliff or into a boulder field.

So, follow a low angled route, over high ground where the snow is shallow. Plan your route to travel between “islands of safety” avoiding steep slopes, gulleys and terrain traps.

(Image: New Zealand Avalanche Centre)

Axiom 3 – Human Factors

No group is immune to human factors. Group dynamics, leadership and experience all play a part in safely navigating avalanche terrain. Indeed, the concept of heuristic traps is a hot topic in avalanche safety. Heuristics are problem solving strategies, short-cuts and rules of thumb developed from experience. We use them to deal with complex yet familiar situations when there isn’t time or the mental capacity to consciously analyse everything.

They become heuristic traps when they are unconsciously applied to situations for which they are inappropriate. Ian McCammon has suggested six heuristic traps that off piste skiers may fall into. Here are just three of them. They should ring true no matter what your outdoor sport.

Familiarity / In avalanche terrain, familiarity can lead us to take chances we might not take in otherwise unfamiliar territory. “I’ve never seen that slope slide”. “I’ve skied this before in fresh snow and it was OK”.

Consistency / Consistency is rooted in “staying the course” and persisting with a plan of action even in the face of contradictory information. The “stick to the plan – no turning back” mentality is particularly hazardous in areas where the weather changes very rapidly, such as the Scottish Highlands, or on competitive expeditions to a set goal. 

Expert halo / Interestingly, McGammon also found that groups without a recognised leader exposed themselves to less risk than those with clear leadership. Designating a leader, and following them, simplifies the group response to a challenging situation. However when we follow someone because of their personality and ‘perceived expertise’ rather than their actual skills and qualifications we can be lead astray.

Medical Management and the ICAR Guidelines

In Europe and North America, approximately 150 people are killed each year by avalanches, most often triggered by skiers, climbers and snowmobilers^[1]. The number of victims in the developing world far exceeds this figure. Indeed, we will all be familiar with the tragic events in the Khumbu icefall, Manaslu and the Annapurna region of Nepal this last year.

The Medical Committee of the International Committee of Alpine Rescue (IKAR-MEDCOM) have developed extensive guidelines and algorithms regarding the medical management of Avalanche victims.^[2] So, what should our strategy be when faced with the victims of an avalanche?

Dig, Dig, Dig…

The overall survival rate of Avalanche victims is 77%.^[3] Survival depends on the duration and depth of burial as well as the degree of asphyxia, hypothermia and other traumatic injuries.

Being in an avalanche is akin to being in a washing machine. The physical forces exerted on the body by the turbulent snow, notwithstanding any obstacles such as trees that are in the path of the falling victim, can cause high acuity traumatic injuries.

Alongside the high incidence of trauma is the high risk of asphyxia due to being buried. The single biggest predictor of survival is how deeply a person is buried. According to a Swiss study, 39% of individuals were buried in avalanches overall, but there was a 95% chance of survival if the head was above the snow, compared to only 50% if completely buried.

There is a progressive, non-linear reduction in survival as duration of burial increases. As the graph above^[2] shows, there are three distinct phases. There is a survival phase for the first 10-18 minutes of the burial whereby survival approaches 80% if the patient is extracted in this time. Death in this first phase is due to trauma. Then, casualties will enter the asphyxia phase where mortality increases. Finally, there is another increase in mortality at approximately 90 minutes due to hypothermia, in conjunction with hypoxia and hypercapnia, in those patients who may have initially had the benefit of an air pocket. The times for each phase will vary with snow densities and the geographical region of the world.

The message from these death rates is clear: survivors of avalanches or those first on scene must make every effort to extract casualties as quickly as possible for the best hope of resuscitation. Hence, dig, dig, dig.

Assess the airway / Decide whether to commence CPR

A systematic review^[4] found that a patent airway (and air pocket) was essential for survival with burial times greater than 35 minutes. Those casualties who are extricated beyond 35 minutes with a non-patent airway/air pocket will be unlikely to survive. However, it can be difficult to tell in practice, as often any air pocket that was present will be destroyed by digging.

Any attempts at resuscitation in cardiac arrest following an avalanche must involve attempts at oxygenation. Compression only CPR (as advocated in ALS 2010 for ‘standard’ cardiac arrest patients) will not be successful. Those buried for >35 minutes in an asystolic rhythm with an obstructed airway may have CPR commenced but consideration for termination should be made even if the patient is hypothermic. This is in contrast to the ‘a patient is not dead until they are warm and dead’ adage but reflects the importance of oxygenation in survival and the risks to rescuers of CPR in the field.

Interventions to secure and protect the airway should be undertaken as soon as safely possible if the patient is in cardiac arrest if the appropriate skill set is available. Endotracheal intubation will allow for more effective ventilation and subsequent oxygenation and also protect against aspiration. If it is not possible, a supra glottic airway device should be considered.

If the body temperature is below 30 degrees, defibrillation in cardiac arrest may not be successful. The costs of applying repeated pulses of electricity to a cold unstable myocardium may outweigh the benefits (if 3 shocks are unsuccessful, withhold further shocks until the body temperature is >30 degrees). In addition, as the benefits of adrenaline in cardiac arrest are questionable even in normothermia, withholding adrenaline in a cold vasoconstricted patient should be considered.

Serum potassium can be used to predict outcomes in avalanched patients in hypothermic cardiac arrest. Given the efforts involved in remote rescue, point of care testing may particularly helpful in making management decisions. A serum potassium of <8 mmol/l should indicate continued resuscitation whereas >12 mmol/l would indicate termination of resuscitation. A figure between would necessitate consideration of other factors.

Patients in cardiac arrest should be transferred to a hospital with intensive care facilities. The use of a mechanical chest compression device will enable more effective compressions to be delivered in transit.

Identify and manage traumatic injuries

Traumatic injuries are extremely common in avalanched patients. Trauma was the principal cause of death in 5-25% of avalanche victims. Variation will depend on factors such as open versus forested slopes. Spinal injuries should be suspected and patients should be carefully moved and packaged. Rescuers should be comfortable managing catastrophic haemorrhage, advanced airway management as well as the aggressive initial management of traumatic cardiac arrest.

Deal with hypothermia

Hypothermia is a significant complication of avalanche. It is rarely the sole cause of death and in fact there may be some protection of being hypothermic if in cardiac arrest. The cooling rate during burial is exacerbated by light, sweaty clothing in an exhausted casualty. The ‘3 H’ spiral of hypoxia, hypercapnia and hypothermia must be broken as soon as possible to decrease the cooling rate, which can otherwise be as much as 9°C per hour.^[5]

The measurement of body temperature in the hypothermic patient presents challenges. The most accurate is a temperature probe placed in the lower part of the oesophagus in an intubated patient. Epitympanic membrane thermometers are reasonably accurate in non-intubated patients if the ear canals are not full of ice. Rather than worry about temperature measurement in the field, we can use the Swiss staging classification, which is based on clinical findings (Table: Brugger 2013): ^[2]

Exercise caution

It is of paramount importance to rescue hypothermic patients with care. Otherwise, they may suffer post-rescue collapse. Post-rescue collapse can occur for a number of reasons:

Mechanical irritation / Patients cooler than 32 degrees are at risk of VF from rough handling.

Lifting / Lifting patients upright can cause a brief reduction in venous return, leading to cardiovascular instability. Always transport patients horizontally.

Afterdrop / Occurs when increased venous return from warming extremities leads to a further drop in core temperature. Help prevent this by removing wet clothes and wrapping patients in wind proof and water resistant outer shells preferably with active warming (e.g. chemical heat packs).

Administration of oxygen may reduce post rescue collapse by improving myocardial stability.

Summary

1 / Gather information on the weather and snow pack

2 / Think about the terrain

3 / Be mindful of human factors

4 / Dig patients out quickly then extricate them gently

5 / Assess the airway – if obstructed and the patient is in asystolic cardiac arrest following a prolonged burial, consider the futility of commencing resuscitative efforts. If resuscitation of an arrested patient is commenced, transport to a hospital with ECMO or bypass facilities taking into account serum potassium.

6 / Assess degree of hypothermia using Swiss staging classification

7 / Actively rewarm and transport conscious casualties to the nearest ED

References

^[1] Etter HJ. Report of the Avalanche subcomission at the general meeting of the ICAR. 2010

^[2] Brugger H et al. Resuscitation of Avalanche victims. ICAR MEDCOM. Resuscitation 84(2013) 539-546

^[3] Brugger H et al. Field Management of Avalanche victims. Resuscitation 2001;51:7-15

^[4] Boyd et al. Prognostic factors in avalanche burial: a systematic review. Resuscitation 2010;81:645-652

^[5] Oberhammer et al. Full recovery of an avalanche victim with profound hypothermia and prolonged cardiac arrest treated by ECMO. Resuscitation 2008;76:474-80

You can learn more from Harvey and Barry at WMT’s new Mountain Medicine on Skis Course (8-12 Feb 2015). The course includes four intensive days of technical on-slope ski instruction and coaching including off-piste skiing and an introduction to ski touring. An hour a day on the mountain will be dedicated to practical mountain medicine training in addition to 8 hours of intensive medical seminars après ski. Non-medic partners are welcome. For more information, you can contact Barry by email on wmt@wildernessmedicaltraining.co.uk.

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BS 8848, the Specification for the Provision of Visits, Fieldwork, Expeditions and Adventurous Activity was introduced in 2014 and reviewed without change in 2019. BS 8848 is an important document and those working as expedition or event medics need to become familiar with it. However, it is also 48 pages long and costs £100 (plus VAT). Fortunately for us, Jim Moonie bought it (and read it!) so he can tell us what it is all about.

What are British Standards?

Here is some background for the curious few. British Standards are ‘an agreed way of doing things’, a necessarily vague description given their breadth of coverage.

They vary from a standardised ‘recipe’ for manufacturing processes, to a distillation of expertise, or as a suggested ‘best way’ to guide others in their search for best practice. Examples range from, the ‘Specification of… Steel Boiler Tubes for Locomotive Boilers’to the standard for ‘Preparation of a Liquor of Tea for Use in Sensory Tests’. For practical examples, think of specifications for plugs and phone sockets.

They are not laws, but can used as reference points so that in some cases they come to represent the opinion of the law. They may be expanded from British Standards (BS), to become European (EN) or even global standards (ISO). The dimensions of identity cards are, for example, standardised under ISO/IEC 7810 such that credit cards, passports and SIM cards abide by the same physical characteristics worldwide. Similarly, toys are governed by BS EN 71, and newly manufactured toys must be compliant to be sold in the European Union. These toys bear the CE logo that you will no doubt remember from that cuddly Care Bear you had as a child.

BS8848: Some context

In 1993, four school children drowned during a supervised kayaking trip in Lyme Bay. Prosecutions followed, with the activity centre and its owner being found guilty of corporate manslaughter.

Two years later, after much discussion in government, the Activity Centres Act was passed and the Adventure Activities Licensing Authority (AALA) was formed. The AALA applies only to those charging for adventurous activities for under 18 year-olds and, therefore, is not entirely inclusive. School groups led solely by teachers are not covered. Still, it is generally thought that it could be used as the standard in court irrespective of this. It only applies to activities taking place within the UK.

BS 8848, the specification for the provision of visits, fieldwork, expeditions and adventurous activities outside the United Kingdom, takes its title from the height of Everest in metres and is a good practice guideline for those organising overseas trips. It differs in many respects from the AALA, particularly as overseas trips are governed by the laws of the country being visited. BS 8848 then can only be a recommendation and is not legally binding. Equally though, simply being compliant does not make a trip immune to legal action.

The original 2007 BS8848 standard, like the AALA, emerged from tragedy. It was instigated by Peter Eisenegger, after his daughter Claire died of heat stroke on a gap year project in 1999. Developed with input from the Royal Geographical Society, it offered a set of guidelines that aimed to minimise risk of illness or injury for those undertaking educational or adventurous activities overseas. It also gave the activity organisers a means of demonstrating their compliance with agreed guidelines. The standard went on to be revised in 2014.

The 2014 update

Here are some definitions and examples. The examples are not exhaustive lists, but do give you an idea.

Venture providers / Any UK organisation including schools, universities and charities.

Ventures / Expeditions, fieldwork, gap year schemes and educational trips.

Participants / Students, adults, vulnerable adults, children.

Environment / Mountain, desert, sea.

Key points

The venture provider is accountable for all aspects of the trip. This includes any third parties, such as those providing food, transport and accommodation.

It is their responsibility to ensure that the leaders (or leadership team) are competent to fulfill their roles. In this way, the leaders should be right for the participants (e.g. mixed gender leaders for mixed gender groups, fully screened if accompanying children) and for the environment (e.g. suitably-qualified climbers for certain mountain activities).

Participants should be adequately informed about the nature of the risks (e.g. altitude sickness or infectious diseases) that they are undertaking. This should enable them to make an informed decision as to whether it is suitable for them and allow them to plan accordingly with vaccinations, fitness training, financial planning etc.

Much of the above is reliant on proper planning. This should include the safety implications of all aspects of the trip, itinerary, budgeting, screening and local medical considerations. As well as informing participants, it allows the venture providers to risk assess them and ensure that they are emotionally, psychologically, physically and medically suitable for the venture. There should be contingency planning in the event of an emergency. This could range from an individual medical crisis including death, to political instability or a natural disaster. All leaders should know what to do in an emergency and who to contact.

It remains the responsibility of the participants to uphold reasonable behaviour – for example, deciding not to wear a seat belt against the advice of the leader would be unreasonable.

The Small Print for Expedition Medics

There are eight subheadings in the medical section of the document: General, Medical Planning, Pre-existing Medical Conditions, Prevention of Ill Health, Environment-Related Illness, Medical Expertise and First Aid. Most of these have been touched upon already, but it is worth drawing your attention to a few points:

1. The venture provider should have access to medical support, but there does not necessarily have to be a doctor on the team.

2. A thorough medical risk assessment and screening process should be undertaken. This should be approved by a medical professional with expertise relevant to the venture.

3. If screening reveals any pre-existing conditions that may be exacerbated by the venture the participant’s doctor needs to provide a letter confirming fitness to participate. It is the responsibility of the venture provider to give the doctor enough information such that they can make an informed decision.

4. Participants should be advised regarding vaccinations and any recommended prophylaxis and directed to a suitable health care provider (GP, travel clinic etc).

5. The venture provider must inform the leaders and participants of any significant risks and how to prevent and manage them. Those highlighted are dehydration, altitude sickness, heat illness and malaria.

6. Medical services must be provided by a medical practitioner with expertise relevant to the venture. The team on the ground must have access to this expertise at all times. If the venture is particularly remote then a medical professional should accompany the team. It does not stipulate that this professional need have expertise relevant to the venture, though it would seem wise.

7. First aid, and someone suitably qualified to administer it, should be available during the venture. This should have been planned with the specific venture in mind by a medical professional with expertise relevant to the venture.

8. Medical protocols relevant to the venture should be carried and understood by the leadership team.

Some thoughts

BS 8848 is a set of recommendations and not a law. However, that does not mean that it cannot be used by the law.

Some points are open to interpretation, but most are fairly clear cut. ‘Expertise relevant to the venture’is important – indeed, as expedition medicine develops as a specialty, ever greater levels of expertise and training are likely to become expected.

At first glance, prescriptive devices such as ‘Standards’ can seem rather at odds with the nature of adventure. However, we would advise you to think again. BS8848 is not a standard for elite mountaineers, but for lay people stepping out of their comfort zones and into the care of perceived ‘experts’. It is right that they should know what they are getting themselves into and with whom.

BS8848 may seem tedious, but it is here now. It may not yet have the reputation that it deserves, but this will change, so, know that it exists and use it – and choose companies that use it too. And don’t let it stop you. As the foxes say to the wolf at the end of Wes Anderson’s Fantastic Mr Fox – ‘Good luck… Good Luck out there’.

If this article has piqued your interest, then you can pick up your own copy of BS 8848 here.

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Dr Harvey Pynn is a Consultant in Emergency Medicine at Bristol Royal Infirmary, Honorary Consultant in Pre-Hospital Emergency Care with the Great Western Air Ambulance and Medical Director of Wilderness Medical Training. With an expansive array of expedition experience across mountain, desert and jungle, he knows his stuff when it comes to planning for and dealing with medical problems in the wilderness. Adventure Medic is proud to present to you Dr Pynn’s pearls of wisdom for well-prepared expedition medics. Take note.

In remote environments, alone and miles from higher echelons of medical care, with no tests, expensive investigations or treatments to fall back on, medical care relies on clinical acumen, lateral thinking and improvisation. Before putting yourself in such an environment, why not hone your trade and gather some new skills to equip yourself for the trip ahead.

Six months experience in emergency medicine is often essential prior to embarking on any wilderness expedition as the medic, but failing that, why not join a course or conference such as those run by Wilderness Medical Training (Chamonix, Morocco or the UK) to develop the necessary skills and much more besides.

I’ve put together a list of helpful hints that will stand you in good stead to be the medic on an expedition. The first few are generic qualities that will make you an attractive proposition to an expedition leader. The remainder are, in my experience, the top skills you need to master in order to be able to confidently deal with the most common injuries and ailments on an expedition.

Words of advice

Be able to look after yourself and understand your environment

Be able to put up your basha in the trees if you’re going to the jungle, be able to dig a snow hole if you’re going to the mountains, be able to navigate using a map and compass and be able to set up and use a radio, GPS or satellite phone. Being a medic on a trip is a privilege but remember you are also a member of the team and as such, must have other skills to bring to the party.

Get to know your team before you go

An evening get-together or weekend away can be more valuable than a pre-travel medical questionnaire sent in the post. You will glean a great deal of information from team members as well as observing team dynamics. With developments in the transport industry and a boom in interest in adventure travel, remote destinations are becoming more accessible to the general public. Subsequently, pre-existing health problems amongst wilderness travellers are becoming more common. Be aware of these and seek practical specialist advice from doctors who understand the rigours of expeditions. A list of Diploma in Mountain Medicine (DiMM) holders can be found at www.medex.org.uk. A travel and expedition history should be an important part of your history taking – someone with diabetes who has travelled with success to altitude before is likely to cause far fewer problems than an arthritic who has done their pre-expedition training on a treadmill in the local gym.

Know where to look for resources

The National Travel Health Network and Centre (NaTHNaC) is a UK Government sponsored organisation that has a comprehensive website for healthcare professionals, giving up-to-date information on all matters of travel medicine. The Health Protection Agency (HPA) also provides useful resources, such as malaria prevention guidance for travellers and rabies post-exposure prophylaxis guidelines. There are also lots of useful links listed in the Adventure Medic Resources Section.

Top ten medical skills to master

1. Understand the importance of the respiratory rate

Always measure it accurately in illness or injury. It is the first physiological parameter to alter. Doctors are notoriously poor at measuring or documenting it correctly. Omit it at your peril! Dyspnoea points to a respiratory problem, whereas a tachypnoea may point to a metabolic issue. For the doctors out there, there will be no nurse to rely on so get accustomed to completing an observation chart to look for trends.

2. Know some basic ophthalmology: revise the anatomy and how to examine an eye

• Always check visual acuity and beware those who report a significant reduction in their visual acuity.
• Know the difference between the conjunctiva and cornea.
• Know how to instil local anaesthetic eye drops and fluorescein to look for corneal defects under blue light – know the difference between an abrasion and a dendritic ulcer
• Know how to evert the upper eyelid to check for a foreign body
• Practice removing a foreign body with a cotton wool bud.
• Beware contact lens wearers on an expedition – they are prone to development of corneal ulcers (ulcerative keratitis) that can be sight threatening if overlying the visual axis and not addressed immediately.
• Remember a ‘lost’ contact lens usually finds its way to the upper outer quadrant.
• Ointments are preferable to drops in an expedition setting.

3. Know how to ‘clear’ a neck

Fracturing the cervical spine requires significant force. Not all patients need to have their cervical spine immobilised. Remember having an immobilised neck will require a patient to be log-rolled and evacuated by stretcher, utilising considerable resources. Know the Canadian C-spine rules and NEXUS guidelines to help you decide whether you can ‘clear’ the neck without having to resort to immobilisation and imaging.

4. Revise the Ottawa ankle rules

Soft tissue injuries are common on an expedition. Of these, inversion injuries of the ankle are the most common. Knowing the Ottawa ankle and foot rules will allow you to exclude a significant fracture and treat the injury as a sprain. The most common tissue injured in an inversion injury is the anterior talofibular ligament (ATFL) complex on the anterolateral aspect of the foot.

5. Know how to strap a sprained ankle using zinc oxide tape

• Place an anchor strap around the mid shin (not completely circumferentially) and around the forefoot
  
• Place a stirrup strapping around the foot with the foot placed in very slight eversion if an inversion injury.
  
• Add support strapping over the ATFL complex (3 strips of tape) and secure the stirrup by placing a ‘locking’ strip of tape.
  
• It may be appropriate to add a further stability figure of eight strap around the heel depending on how secure the ankle feels to the patient.
  
• The zinc oxide tape will lose its tension and so will need to be replaced every day.
• Hint – shave hairy legs before applying strapping for comfort and also to prevent minor trauma and risk of folliculitis.

6. Know how to apply a high arm and a broad arm sling and the indications for each

• High arm slings are applied for hand injuries to enable swelling to reduce.
• Broad arm slings are used to maintain comfort in forearm, shoulder and clavicle injuries.
• For fractures of the humerus, a collar and cuff is a more appropriate method of splintage.

7. Know how to prevent and treat travellers’ diarrhoea

The majority of travellers to wilderness settings will be afflicted by a diarrhoeal illness. Educating on preventative measures is the responsibility of the medic. You should emphasise the importance of rigorous hand washing, filtration and purification of water, avoidance of uncooked or unpeeled food (particularly salads) and ice in drinks.

• In the event of persistent diarrhoea (>24 hours), prescribe a stat dose of ciprofloxacin (500 mg – caution in athletes) or a short course of azithromycin (500mg od for 3/7 – if in Asia).
• The presence of blood in the stool is suggestive of colitis, which if infective, will need a longer course of antibiotics.
• Loperamide (or similar) can be used (2mg after each loose stool) but be aware of the risks of ileus.

8. Learn some basic dentistry

Dental treatment falls outside the remit of the majority of practising doctors. Everyone should have a dental check-up and preferably an x-ray of their teeth before travelling but toothache is still common despite the best laid plans. Persistent pulsing pain, often in response to thermal stimuli is a sign of irreversible pulpitis, whilst tenderness of the affected tooth suggests periodontitis. In either case, examine the teeth under good light. A previous filling may be loose or there may be a new hole or crack in the enamel of a tooth. All expedition medical kits should contain a rudimentary temporary filling kit. Ensure the tooth is a dry as possible (use a cotton wool bud to dry the tooth) and know how to apply a small amount of filling to seal any defect to enable the patient comfort whilst a more permanent dental solution is sought. If a tooth abscess develops, treat with amoxicillin and metronidazole and be aware of the signs of Ludwig’s angina. (See also Adventure Medic’s Guide to Expedition Dentistry for more information.)

9. Take good care of feet

On an expedition, foot problems can curtail the trip. It may be necessary to do foot inspections regularly.

• Prevent blisters by ensuring everyone has suitable worn-in footwear.
• If people are prone to blisters, use zinc oxide tape to protect those areas of the feet.
• If hot spots develop during activity, stop and tape up affected areas before blisters occur.
• If blisters do form, use a sterile needle to decompress them, spray the area with antiseptic and apply zinc oxide tape. Once applied, do not remove it and allow it to fall off when the underlying skin has healed -continuous removal and reapplication of tape will lead to further trauma and risk of infection.
• Ensure people change their socks regularly and powder their feet with an antifungal foot powder twice a day especially in humid environments.
• Check that everyone knows how to cut their toe nails to reduce the chance of ingrowing toenails developing – the nail should be cut level rather than dome shaped. In the event of an ingrowing toenail, know how to perform a wedge excision under local anaesthetic ring block.

10. Know how to give an intramuscular injection

Those of us working in hospital medicine rarely use this mode of drug delivery. Don’t forget the benefits of this in an expedition settings – anti-emetics and analgesics are the most common drugs to be delivered in this manner. Bioavailability and speed of onset are excellent if administered into the deltoid muscle. Become re-accustomed with this skill by asking a nurse or GP to remind you of the do’s and don’ts.

A final thought…

Finally, keep in mind that road traffic accidents are the most common cause of death in travellers. Do a risk assessment on vehicles and drivers before you eagerly leap aboard. Make sure someone in the group is awake at all times and have in your mind what your actions will be in the event of an accident.

The post Top Ten Skills to Master for the Expedition Medic appeared first on Adventure Medic.

We are proud to present the first part of a series on expedition dentistry for wilderness medics by Burjor Langdana, Dental Surgeon at the British Antarctic Survey Medical Unit and Matt Edwards, Registrar at London Air Ambulance. In this article, they cover: prevention, preparation, dental history taking and examination, diagnosis and management of common conditions. They also include a kit list at the end. The slide show at the below of the article expands on some of the key points – you can click on an image to enlarge it.

Dental problems are common on expeditions and anxiety provoking for the lone practitioner. This is generally because there is a lack of exposure to dental presentations and procedures in clinical practice. Patients, on the whole, go to dentists if they have a dental issue. Doctors employed for prolonged remote placements, e.g. the British Antarctic Survey, undergo formalised dental training prior to deployment. Luckily dental issues on expeditions can be made very simple for the non-dental practitioner and the purpose of this article is to help create a framework to help you decide what you can deal with, what you cannot, what kit to take and the relative urgency of any medevacs that may be required.

Consider this scenario: it is the end of day four of your expedition. Your team has just reached base camp. A team member complains of throbbing pain in his mouth. You are all exhausted and dental problems are a little out of your comfort zone. The questions you should be asking at this stage are:

1) Why did this happen?

Dental problems are common on expeditions. Diets change with increase in amount and, most importantly, frequency of sugar intake. Participants often have dry mouths with increased respiratory rate and inadequate fluid intake. Oral hygiene often becomes a secondary consideration when people are tired. There may be exposure to extreme cold (or heat) so teeth sensitivity becomes a major issue. Finally, teeth may be subject to trauma e.g. frozen chocolate is a common culprit.

2) Could this have been prevented?

Prevention is certainly possible for the vast majority of dental issues. Often pre-existing problems suddenly get worse due to the environmental stressors, and remember, this can happen to you as well.

Three months before the expedition: advise a proactive dental check up with chartings and necessary radiographs. Follow this up one month later and request dental chartings.

In your pre-expedition briefing, reinforce:

1. Twice a day 2 minute brushing
2. Flossing
3. To spit out excess toothpaste, not rinse it out

Finally, when you are on expedition, for those with any known sensitivity advise Anti-Sensitivity Toothpastes (Sensodyne,Colgate, OralB).

What questions help you in the history?

As in medicine, if you suspect a dental problem, first take a history including:

Previous dental history / Hopefully you will know this already

Location / Teeth or gums? Can he localise it at all?

Sensitivity / To what? Does it disappear immediately when stimulus removed or persists for a few minutes or longer?

Character / Is it constant or throbbing ache? Can biting down help localise the correct tooth?

Performing an examination

Next, examine the patient.

Lighting / During the day, position the patient facing the sun and leaning against a good back rest. At night, use a head torch within a closed tent. Bugs rarely help dental examinations.

Positioning / Make life easy and comfortable. Get padding for patient and for your knees. Get a willing volunteer to help you, preferably two. If examining the lower teeth, then position the patient sitting up with lower teeth parallel to the floor, uppers at an angle of 45 degrees to floor. If you are looking at the upper teeth then lie the patient supine, with the neck fully extended.

Achieving dryness / Position multiple cotton rolls on the cheek side of upper first molars (i.e. next to the parotid duct), under the tongue for the submandibular ducts and to attempt to hold the tongue out the way and on the buccal side of the tooth needing treatment. Rotate head to the opposite of the working side, to reduce poolage. Suction is great if you have it, otherwise a rubber camera lens-blower can be helpful. Don’t forget to use your assistants and ask the patient politely to try to control their tongue.

Equipment / See the list at the end of the article.

Diagnosis and Management

Managing these problems will, for the vast majority, be a temporising measure, buying time before the patient can get to a dentist. But seeing as there are rarely ‘expedition dentists’ coming along with you, then you will likely need to do something.

In order of seriousness of the problem, the most common issues on expedition will be these:

Caries and Infection

Initial caries, not down to dentine, will leave the patient sensitive to cold (less than one minute) with a brown spot (demineralised patch) on the tooth. Manage with a high fluoride toothpaste (Duraphat) and/or anti-sensitivity toothpastes, alongside oral hygiene advice. Follow up with a dental hygienist. Dentine caries causes more severe sensitivity and pain, with a darker, deeper and softer lesion. Clean away the soft debris and fill the hole with filling material, then follow up with a dentist for a formal restoration.

Pulpitis / Apical Abscess

These cause pain over side of face, prolonged periods of sensitivity and the patient will be unable to eat on the effected side, though it may be difficult to locate the responsible tooth. There are no proprioceptive receptors in the pulp, only outside. Once it infiltrates local tissues or forms an apical abscess then it will become easier for the patient to localise. It is likely to have caries, or previous large restorations and may be tender to percussion. If you can, get ice and place it on each tooth. The diseased tooth should respond painfully.

You should seriously consider evacuating the patient. First line treatment is antibiotics, analgesia, no eating on that side and urgent dental review. Second line is Ledermix temporary filling (antimicrobial steroid dressing). Finally, third line would be tooth extraction, though this is a last resort and should be avoided. For follow up, standard UK treatment for this would be is either root canal treatment or extraction.

Abscesses

Severe pain and swelling on a gum. It is very difficult to differentiate between a tooth abscess (a decayed tooth and a dead pulp causing an apical abscess) and a gum abscess (food debris in the periodontal pocket, forming an abscess to point on the gum). Management is incision and drainage (see slide show above for technique), trimodal analgesia (NSAIDS, paracetamol, opiates) and antibiotics (see below). Follow up with an urgent dentist review for tooth abscesses. Gum abscesses should settle with simple management at home but prompt dental review is still important.

Gingivitis

Bleeding on brushing, mild discomfort from the gums with inflamed friable gums on examination. Remember to always check behind back molars, as debris often collects there. Manage by encouraging more brushing, not less, flossing and mouthwashes. Follow up with a dental hygienist.

Pericornitis

Severe pain, facial swelling, restricted mouth opening. Look for swelling around and posterior to back molars. There is little you can do in the field here with established infection – evacuate the patient. In the meantime, examine thoroughly behind molars and irrigate with mouthwash. Give regular trimodal analgesia and antibiotics. Once evacuated, follow up with a dentist or potentially maxillofacial surgeons.

Preparing for dental issues on expedition

Your preparations for dental issues on expedition will depend on multiple factors. A qualified dentist with good equipment can still perform complex treatments in the middle of nowhere and they regularly do. A non-dentally qualified practitioner working where evacuation might be impossible for prolonged periods might be expected to perform some reasonably complex dental procedures. That, however, assumes that they have had the appropriate pre-expedition training and can get some advice remotely. In the case of smaller trips or where evacuation is reasonably straightforward, advanced training and equipment cannot really be justified. Still, basic diagnosis and simple symptom management and will greatly help patients until evacuation or definitive care can be arranged. A way of thinking about the level of dental capabilities we would recommend are as follows:

Analgesia

Oral analgesia according to the standard pain ladder is normally sufficient. Need for strong opiates is rare. Use regular trimodal dosing i.e. NSAIDS, paracetamol and opiates.

Anti-sensitivity toothpastes can be used if increasingly uncomfortable twinges of pain are being generating by contact between hot, cold or sweet stimuli and an area of a tooth where temporary filling is not possible. Retaining the toothpaste in that area for as long as practical helps to reduce the sensitivity.

Clove oil on a cotton plug placed into a cavity is often temporarily soothing.

Duraphat, a high fluoride varnish applied to dry tooth surfaces reduces sensitivity.

Local anaesthesia, either as a nerve block or infiltration around the tooth can provide temporary respite.

Ledermix paste – contains the broad spectrum antibiotic demeclocycline and triamcinolone acetonide as an anti-inflammatory, can be used when there is an unremitting pulsating toothache, such as that associated with a large deep cavity, a lost filling, or a loose filling that can be easily be removed. The tooth is cleaned of all the soft debris, Ledermix paste is applied with a small cotton pledget to the depth of the cavity, and the cavity then sealed with a temporary dressing, such as Cavit.

Antibiotics

Dental infections are typically caused by anaerobic bacteria and require treatment with a broad spectrum antibiotic. When in remote locations strongly consider higher doses than routinely prescribed. Antibiotics will generally reduce swelling and associated pain in 2–3 days. At this point the dose of anti-inflammatories can also be significantly reduced.

When there is an acute dento-alveolar infection, the treatment of choice is to drain the pus, by means of a gum incision into pointing abscesses or by extracting the affected tooth. If these local measures have proved ineffective or there is evidence of cellulitis, spreading infection or systemic involvement, one of the following first-line antibiotics can be prescribed. Local gum disease can be treated by debridement and irrigation together.

The antibiotics of choice if patient can take them are:

1. Co-amoxiclav 375-625mg three times daily for 5 days
2. Amoxicillin 250-500mg and metronidazole 200-400mg three times daily for 5 days

If the patient is penicillin allergic:

1. Metronidazole alone, 200-400mg three times daily for 5 days, doubled in severe infection. Avoid alcohol as they may interact rather unpleasantly.
2. Erythromycin 250-500mg four times daily for 5 days; may cause nausea, vomiting and many organisms are nowadays resistant.

Mouthwashes

Dental pain may also arise from infections of the gum structure associated with poor oral hygiene around buried or partly erupted third molars. The gums will appear swollen reddish-purple in colour, may bleed spontaneously or on touch with an instrument, and may smell foul. Having diagnosed periodontal infection,. it is essential to minimize bacteria between the teeth and along the gum margins.

Mouthwashes are used as an adjunct to improved oral hygiene in the treatment of gum disease in particular. The patient should be encouraged to brush the painful area vigorously despite bleeding and discomfort. A case of being cruel to be kind.

1. Warm salty water: half teaspoon salt in half a cup warm water, temperature of tea.
2. Chlorhexidine gluconate 0.2% mouthwash: 1-2 min, two to three times daily.

Fillings

Temporary filling materials are used to insulate the pulp from temperature, hypertonic solutions, chemicals or irritating foods. It will make the tooth feel much better. If a tooth is damaged during an expedition – whether through a lost or broken filling, decayed dentine, or cracked or broken enamel – but is not giving symptoms, then a temporary filling can still be useful as a preventive measure. Temporary filling materials suitable for placement when in a remote location fall into three categories:

Premixed

Supplied in a sealed tube; squeeze out and apply. The premixed materials (e.g.‘Cavit’) are easier to use but have less structural strength. They requires a mechanically retentive cavity to stay put. i.e. a hole with walls. The material also erodes and may require replacing as often as every few days. The cavity can be a little damp but not wet.

Materials requiring mixing

Examples include IRM (Intermediate Restorative Material) or any glass ionomer filling material which is fussy, but also very sticky and retentive.

Consider the following before starting:

1. Isolating and drying the cavity.
2. The exact ratio of powder to liquid is critical.
3. The mixing time is about 1 min and the setting time is similar.
4. Mix on a glass/shiny plastic slab with a flat spatula into a dough-like consistency.
5. Apply and compress into a dry cavity, immediately removing all excess material from the biting surface. A Vaseline coated finger in ease of smoothening and shaping the filling.
6. IRM may be colour-coded: white for a clean cavity, blue for decay present, red for pulpal symptoms.
7. The same glass ionomer filling materials, if mixed into a ‘double cream-like’ consistency, are excellent for reseating and cementing crowns. For greater effectiveness, after removing excess cement, seal the margins of the cement around the crown, whilst setting, with vaseline to protect from saliva erosion.

Improvised materials

Improvisation can be attempted. Dip cotton pellet into oil of cloves or Eugenol. Swab the depth of the cavity. Then seal the cavity with candle wax, ski wax or sugarless chewing gum. Expect limited success, of a very short duration.

Expedition Dentistry Kit List

Instruments

Dental mirror
Flat-plastic spatula (for placing dental filling material onto tooth)
Pair of tweezers or forceps
Spoon excavator (medium) – for scraping out soft caries
Fine curved surgical scissors
Cement mixing spatula
Glazed mixing paper pad/or glass slab

Medicaments

Temporary filling materials: Glass Ionomer powder + liquid or Intermediate restorative material (IRM), Cavit
Chlorhexidine 0.2% mouthwash
Duraphat (high fluoride varnish)
Ledermix paste
Antibiotics: Co-amoxiclav 625 mg, Metronidazole 400mg
Painkillers: ibuprofen, paracetamol, codeine-phosphate
Dental local anaesthetic cartridges: 2% Lidocaine with 1:80,000 adrenaline
Toothpaste for sensitive teeth
Eugenol( oil of cloves) Topical Analgesic

Others

Sterile gloves
Cotton wool rolls
Stainless steel wire for eyelet wiring (24G for eyelets, 26G for ligatures) or electrical cord for harvesting copper wire
Safety-plus disposable syringes: 27G long (can be used in upper and lower jaw)
5ml syringe with blunt needles (for irrigation and flushing out debris below operculum)

Practicals

Gas aerosol suitable for camera cleaning – ideal for drying teeth and cavities

Optional equipment for the experienced

Upper single root extraction forceps
Upper molar extraction forceps left and right
Lower molar extraction forceps
Lower single root extraction forceps
Fine Luxator or Elevator-Coupland

Next time

Still to come in this series: dental anaesthesia, trauma and management of an avulsed tooth, and dental extrations.

Featured image: Roadside false teeth seller, Nepal, Matt Wilkes.

The post AM Guide to Expedition Dentistry for Medics appeared first on Adventure Medic.

Even amongst the general public just the words risk assessment are enough to create a range of reactions from a scowl, a yawn or even an angry growl. So trying to use the words amongst the fun loving, live and let live, freedom and self-determining adventure world can be a real challenge. Images are conjured up of crags closed to rock climbers, remote mountain sides strewn with ‘Mind the Gap signs’ and mountaineers huddled over laptops writing risk assessment spreadsheets as the weather draws in. At best it can be seen as a paper pushing nuisance and worse still as a barrier to people’s passions and dreams or even to their safety.

As an outdoor instructor and expedition leader over the last 15 years I am in many ways no different. I have seen a huge change from my first expeditions which were armed with little more than an envelope of money, a list of participant names and communications amounting to an occasional visit to the village community phone or a sat phone which was used more as an onion chopping board than as a communication device. Expeditions and outdoor activities can now can be awash with paperwork and on occasion over burdened with rules, regulations, systems and paperwork which is not only alien to the practical, hands-on approach of many of its participants, but at worst can hamper the common sense approach which is key both to the purpose of these activities, and their safe execution.

So it perhaps has come as rather a surprise even to me that I have spent much of the last five years as a proponent, you could even say evangelist of risk assessment. My role involves training people from school teachers and expedition leaders to exploration geologists and university staff and students in practical safety management on school trips, expeditions and field work. Perhaps much of my conversion to the risk assessment process has come through a realisation that risk assessment is far more than the piece of paper that we normally associate with the words, it is a way of thinking, a conscious process and very much contains the common sense, dynamic approach which people too often feel is superseded by the paperwork.

If you want to plan an adventurous expedition to a remote mountain range it would be pretty foolhardy to set off with no prior planning, to jump on a plane, with no kit or equipment, no idea what to expect, what the conditions are likely to be like etc. (Though this may sound like the archetypal adventure and is the picture some adventurers try to paint if you look a bit closer you’ll normally find even the wildest of true expeditions started with a fair bit of reading, planning and researching!). This phase of the trip is your pre-planning risk assessment phase – you may not call it that but if you are considering issues such as what the weather may be like, and what equipment you’ll need to cope with that, what climbing conditions to expect, plan routes and alternatives, and consider some of the things which could go wrong, plan ways to minimise those risks and decide on appropriate kit and equipment to reduce those risks or deal with their occurrence – you are risk assessing – long before you go near a form or a spreadsheet.

At the same time it would be equally fool hardy to expect that pre-planning to be one hundred percent accurate, or to answer every eventuality. When you arrive you will assess on a daily basis the weather conditions, the terrain you find on the mountain, your fitness and that of others in the team and 101 other factors. This is your dynamic risk assessment, applying the research you did in advance alongside practical, common sense decisions based on your skills and experience in that environment. This is very much the way risk assessment should work – good sensible pre-planning with creation of a plan, equipment list and a way you want the trip to run. But this plan must be executed alongside good dynamic decision making – both elements together are a powerful and effective combination but try making dynamic decisions without full information or, worse still, blindly follow your pre-planning without sensible and flexible changes and you will come unstuck.

Doing  a risk assessment

There is no one way to do a risk assessment – the important bit really is the thought process you go through but from a legal point of view you need something written down to demonstrate that thinking has been done, to give an idea how the risks have been assessed, which were considered the most serious, and how you propose to manage them. This normally results in some kind of table showing at the most basic level – hazards, risks and control measures:

However, the above is quite generic – the same line could appear on any risk assessment and therefore you may wonder how it will really help you to run a safe trip. If you can make it more specific it will normally make it more useful:

It is also common to try to quantify the level of risk, normally in terms of likelihood of an incident (rated for example low, medium, high or with numbers 1 to 5) and severity (for example minor injury, major injury, death). Obviously the most serious are situations in which we have both high severity and likelihood – think perhaps of Felix Baumgartner jumping from space!

However that doesn’t necessarily stop you doing things – Baumgartner afterall did jump from space – and not on a whim but in a highly thought through, corporately sponsored venture. Of course the key then is to come up with practical, implementable control measures to reduce the severity and likelihood to levels at which they become acceptable when set against the benefit to be gained from the activity.

Top tips

This principle is pretty simple but can be difficult to apply in practice so some top tips for risk management for adventure:

1. Particularly if you are planning or running adventurous activities or trips for others you must have a written risk assessment – it’s your legal proof that you made sensible and reasonable steps to do it safely
2. But remember it is just that – sensible and reasonable things – don’t try to write down every possible eventuality or reams of paperwork, it should be a usable, practical and most importantly flexible document
3. Think of practical and simple ways to build dynamic risk assessment into your every day activity, keep your eyes open for changing circumstances, use team meetings to discuss changing plans, or keep an expedition diary or log
4. Involve everyone in practical solutions for risk management – it is a culture and not a piece of paper.

Dom Hall manages Training Expertise, a training company specialising in preparing people to work in the outdoors and in remote environments. They run unique and innovative training in field safety, outdoor first aid, wilderness first aid and driver training. If you’d like more information about what they do you can have a look at their website or get in touch on info@training-expertise.co.uk.

The post Risk Management for Adventure appeared first on Adventure Medic.

Altitude illness is a core topic for expedition medics. In this article, Dr Kitty Duncan introduces us to some of the key points, including definitions, the Lake Louise Score and the treatment of AMS, HACE and HAPE. Kitty Duncan is a consultant anaesthetist and mountaineer who has worked at altitude in Nepal, holds the Diploma in Mountain Medicine and a Postgraduate Certificate in Aeromedical Retrieval and writes the ‘Mountain Doc’ column at altitude.org.

Millions of people are exposed to high altitude every year, not only the increasing numbers of commercial trekkers and mountaineers but also those living and working at altitude. Most people can function normally despite increasing environmental hypoxia until an oxygen pressure of around 67kPa is reached. This level is 66% of sea level atmospheric pressure or roughly equivalent to 3500m/8000ft, which is why commercial aircraft are pressurised to just below this level.

The term altitude illness encompasses Acute Mountain Sickness (AMS), High Altitude Cerebral Oedema (HACE) and High Altitude Pulmonary Oedema (HAPE) which are all caused by acute exposure to high altitude hypoxia. AMS typically develops at altitudes greater than 2500m, HAPE greater than 3000m and HACE greater than 4000 to 5000m. Approximately 50% of un-acclimatised people who ascend from sea level to 4500m will have some symptoms of AMS. HACE and HAPE are much rarer but serious conditions with a very approximate incidence of 0.1-4%.

Acute Mountain Sickness and HACE

AMS is common, benign and should be self limiting if recognised and treated promptly. The risk of suffering from AMS depends on speed of ascent, altitude reached, degree of prior acclimatization, age and individual inborn susceptibility

For diagnosis a person must have recently ascended to altitude above 3000m, have a headache and some or all of the following symptoms: nausea/vomiting; fatigue; dizziness; and difficulty sleeping. Symptoms usually present at 8-24 hours after ascent to a new altitude.

A Lake Louise Score (LLS) can be calculated from these symptoms and AMS graded as mild, moderate or severe. The LLS was originally developed as a research tool but is helpful for making decisions about treatment. Symptoms are non specific and can be related to other conditions that are common at altitude, especially dehydration and hypothermia. When treating a patient these should always be addressed, and dehydration alone increases the risk of developing AMS.

HACE is defined as all the above symptoms, usually in their severest form, with the addition of ataxia and confusion. At lower altitudes it usually only occurs if a patient with AMS ascends higher without treatment, but can present rapidly at very high altitude without obvious prodromal AMS.

It is likely, although not proven, that AMS and HACE share a common pathophysiological pathway, with HACE being at the severe end of the spectrum. Despite much research the exact mechanism is unknown, but we know that brain oedema occurs in HACE.

Prophylaxis and Treatment of AMS

The best way to avoid getting AMS is to ascend slowly. Recommended guidelines for ascent were published by the Wilderness Medical Society in 2010. Once above 3000m, un-acclimatised people should ascend no more than 300-500m per day sleeping at altitude, with an additional rest day every 1000m or 3 days. The majority of people should remain symptom free with this ascent profile; however some people may still have symptoms.

The only recommended pharmacological treatment for AMS is Acetazolamide (Diamox) which can be used for prophylaxis and treatment. Acetazolamide works by altering the biochemistry of the carbon dioxide pathway, speeding up respiratory rate and therefore aiding a person’s acclimatisation to a new altitude. It does not mask worsening symptoms and is a safe drug. The only common side effects are tingling in the hands/feet and increased urination. Anaphylaxis has also been described.

Prophylactic Acetazolamide is only recommended in certain circumstances:

1. It can be used to help insomnia. Poor sleep at altitude can be caused by a number of things. One is a type of Cheyne-Stokes breathing caused by hypoxia. The sufferer is roused multiple times during the night gasping after a period of apnoea. Acetazolamide stimulates the breathing centres, promoting regular breathing and uninterrupted sleep.
2. Diamox can be used by those who have had problems with AMS before despite slow ascent (I myself am one of these people). A prophylactic dose of 125mg BD can be taken from the altitude at which they have previously had symptoms. This should then be continued until they are acclimatised at a final altitude (around 4 days) or until they are descending again.
3. Diamox can also be used as prophylaxis if a person has no choice but to ascend quickly, for example if they are on a rescue team or in a military situation.
4. Lastly, Diamox can also be used if someone is suffering from very mild AMS symptoms, i.e. those which are generally improving after 24hours at a given altitude but return on further ascent (i.e. they are acclimatising but slowly). Examples include mild loss of appetite and or a headache that appears in the evening but is gone by the next morning.

Diamox is also used for treatment of AMS, at a dose of 250mg BD. Treatment depends on the severity of the symptoms.

• Mild: (LLS <3) In general those with mild symptoms should remain at their current altitude for at least 24 hours, commence Diamox at treatment dose, rest, drink plenty of fluid, keep warm and eat well. If they improve they can then ascend. If not they should descend.
• Moderate: (LLS3-6) These people should be commenced on Diamox. Oxygen can be given if available and usually helps symptoms rapidly. They should not ascend further and should descend as soon as possible. Treatment should not delay descent, but aid it.
• Severe: (LLS>6): These patients need immediate treatment and descent as soon as possible, oxygen if available, Acetazolamide 250mg BD rest and hydration. A portable pressure chamber (for example a Gamow bag) can be used instead of oxygen. If severe, and descent is not possible immediately, it is reasonable to give a dose of Dexamethasone (8mg stat then 4mg 6hourly).

Dexamethasone has also been shown to work for prophylaxis of AMS (2mg 6 hourly), but because of its side effects it is only recommended for emergency treatment and for prophylaxis if a person is allergic to Diamox (or other sulpha drugs).

There is no contraindication for taking simple analgesia for altitude headache and it does not mask severe symptoms.

Treatment of HACE

If a patient develops HACE they need to descend as soon as possible, at least 500-1000m. This means day, night, storm or snow! Treatment should not delay descent but Dexamethasone (8mg stat then 4mg 6hourly) should be given. Oxygen or a Gamow bag can be used whilst waiting for evacuation. Care should be taken with the airway if they become unconscious.

HAPE

High altitude pulmonary oedema (HAPE) is a life-threatening non-cardiogenic pulmonary oedema.
It usually starts two to five days after ascent to altitude. The incidence of HAPE depends primarily on rate of ascent, intensity of exercise and absolute altitude attained however some people are genetically susceptible and will have symptoms lower and earlier than others.

Early symptoms are excessive shortness of breath with a dry cough on exercise. This progresses to dyspnoea at rest, high heart rate, low grade fever and variable hypoxaemia. Pink, frothy sputum is a late sign.

The pathophysiology is entirely separate from that of AMS/HACE and is complex. The current leading theory is that an excessive and uneven hypoxic pulmonary vasoconstrictor response causes patchy regional over-perfusion leading to stress failure and leakage from the microvasculature. Other important factors are nitric oxide productions abnormalities and reduced transepithelial water/sodium clearance from the lungs.

Prophylaxis

Pharmacological prophylaxis of HAPE remains a controversial area. As per the Wilderness Medical Society recommendations, a gradual ascent profile should be the primary method of preventing HAPE . Nifedipine, 60mg SR in divided doses, commencing from 24 hours before ascent is recommended only for those who are known to be HAPE-susceptible.

Treatment

The best treatment is descent. This cannot be overemphasised. Oxygen or hyperbaric treatment should only be used as a temporising measure to allow descent. Keeping the patient warm and minimising exertion will reduce any additional sympathetic contribution to the condition. The only current medication with good evidence base is Nifedipine, 60mg SR in divided doses. Its main side effect is systemic hypotension, which is a risk as these people tend to be dehydrated.

Phosphodiesterase-5 (PDE-5) inhibitors are pulmonary vasodilators and Sildenafil and Tadalafil have both been studied for HAPE prophylaxis in susceptible individuals. As yet there are no clinical trials of PDE-5 inhibitors for the treatment of HAPE; therefore these drugs cannot yet be recommended for first line use in the field.

It should be remembered that up to 50% of patients suffering from HAPE may also have symptoms of AMS, and such people should also be treated with Acetazolamide as well.

Conclusion

Acute altitude illness remains the bane of climbers across the continents, and the increasing ease of global traffic and altitude tourism prompts the suspicion that its prevalence will continue to rise. It covers a spectrum of disorders ranging from the irritating to the life-threatening, but the elusive pathophysiology means that knowledge is limited, and further research into the cause, personal susceptibility and management is warranted. Despite this, with the sensible adherence to ascent guidelines where possible, a savvy approach to symptom recognition and the prompt initiation of prophylaxis and treatment (including descent), altitude morbidity and mortality can hopefully be reduced and kept to a minimum.

References

1. Hackett and Roach. High Altitude Illness. New England Journal of Medicine Vol 345:107-114. 2001
2. Wilderness Medical Society Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness. Andrew M. Luks, MD; Scott E. McIntosh, MD, MPH; Colin K. Grissom, MD; Paul S. Auerbach, MD, MS; George W. Rodway, PhD, APRN; Robert B. Schoene, MD; Ken Zafren, MD; Peter H. Hackett, MD. WILDERNESS & ENVIRONMENTAL MEDICINE, 21, 146–155 (2010).
3. High Altitude Pulmonary Oedema. David P. Hall, Kitty Duncan, J Kenneth Baillie. Journal of the Royal Army Medical Corps. Volume 157;No 1; March 11 – Medicine and Physiology at High altitude

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Prevalence and pathophysiology of frostbite

The prevalence of frostbite amongst the civilian population has risen in part because of an increase in the numbers of homeless, but also because of greater ease of air travel, participation in winter sports, and ascents to high altitude.

The feet and the hands account for 90% of frostbite injuries reported. Frostbite also affects the face, particularly the nose, chin, earlobes, cheeks and lips, the buttocks/perineum from sitting on metal seats and the penis in joggers.

The pathophysiological processes have been studied extensively using both human and animal models. Local cold injury produces a succession of changes which are commonly divided into:

1. Prefreeze phase
2. Freeze–thaw phase
3. Vascular stasis phase
4. Progressive or late ischaemic phase

Skin sensation is lost around 10-15°C. With further cooling, vascular contents become more viscous, there is microvascular constriction and transendothelial leakage of plasma. As skin cools further (0°C), freezing occurs and frostbite develops. Low ambient temperatures, wind and moisture accelerate this rate.

Unless freezing is very rapid, ice crystals form first in the extracellular fluid spaces. Extracellular osmotic pressure increases, drawing free water across the cell membrane. This causes intracellular dehydration and hyperosmolality.

As freezing continues, there are extra- and intracellular electrolyte and pH changes, dehydration, and destruction of enzymes. Cell volume reduction and possibly direct damage from ice growth occur. Cell membranes are damaged, microvascular function is compromised and endothelial cells are injured, with the endothelium separating from the arterial wall lamina.

Depending on the method of rewarming, hyperaemia, ischaemia, cyanosis, or total circulatory failure develops. Blebs or blisters may appear secondary to vasodilatation, oedema, and stasis coagulation. Platelet and erythrocyte aggregates clog and distort the vessels in viable tissue. Associated injury may cause increased compartment pressures.

As is seen in burns, reperfusion injury occurs. This may involve oxygen-free radicals, neutrophil activation, and other inflammatory changes.

Prostaglandin F2a (PGF2a) and thromboxane A2 (TXA2) cause platelet aggregation and thrombosis which results in ischaemia and elevated concentrations of PGF2a and TXA2 are found  in frostbite blister fluid. These eicosanoid derivatives have been heavily implicated as mediators of progressive dermal ischaemia in burns, frostbite and ischaemia/ reperfusion injuries.

Depending on the degree of microvascular damage, one of two processes occurs: either vascular recovery with dissolution of clots, or vascular collapse which results in thrombosis, ischaemia, necrosis and gangrene.

Clinical Presentation

Symptoms / Patients initially describe a cold numbness with accompanying sensory loss.  The extremity feels cold to touch and it feels clumsy, “like a block of wood”.  Thawing and reperfusion is often intensely painful. Residual tingling sensation starting after one week has been described and may be due to an ischaemic neuritis.

Signs / Initial appearances are often deceptively benign. However with thawing, frozen tissue may appear mottled blue, yellowish-white or waxy. Following rapid rewarming, there is an initial hyperaemia even in severe cases.

Classification / Frostbite injury has been classified as either mild/superficial (no tissue loss) or severe/deep (with loss of tissue), and this classification is based upon final outcome. Cauchy of Chamonix proposed a predictive classification system that is based on the topography of the lesion(s) and early technetium-99 bone scanning. Using these techniques it is now possible to predict the likely outcome as early as two days.

Treatment

Treatment of frostbite can be divided into three phases: field care, immediate hospital care, and post thaw care. Rapid evacuation, usually by helicopter, from mountain to hospital eliminates the first phase.

Field Care / If there is a possibility of developing frostbite the subject should move out of the wind and seek shelter. A combination of warm drinks, removal of boots (consider problems with replacement if swelling occurs), and replacement of wet gloves and socks with dry ones,  warming of the  cold extremity by placing in companion’s armpit or groin for 10 minutes only, finally putting the boots back on should help.

Aspirin (150-300mg) or ibuprofen (400mg) may improve the circulation. Do not rub the affected part, or apply direct heat. If sensation returns, one can continue to walk. If there is no return of sensation, go to the nearest warm shelter (hut or base camp) and seek medical treatment. If at high altitude, give oxygen, fluids and descend.

Field Rewarming / Field rewarming should only be undertaken if there is minimal risk of refreezing since refrozen tissue almost always dies. The decision to thaw the frostbitten tissue in the field commits the provider to a complex course of action involving pain control adequate warming and hydration in a hostile environment and subsequent protection of frostbitten tissue from further injury during evacuation. Frostbitten extremities cannot be used for ambulation once rewarmed.

Hypothermia and concomitant injuries should be evaluated and systemic hypothermia should be corrected to a core temperature of 34°C. Patients are often dehydrated; moreover, hypothermia causes cold diuresis due to suppression of antidiuretic hormone, so intravenous fluids are often advisable.

Post-Thaw Care / Blisters containing clear or milky fluid should be debrided and covered in aloe vera, a potent antiprostglandin agent 6 hourly. The limb(s) should be splinted, elevated to reduce reperfusion oedema, and wrapped in a loose, protective dressing. Padding should be put between the patients’ toes.

Haemorrhagic blisters should be left intact to prevent desiccation of the underlying tissue. If they restrict movement they can be drained with their roofs left on.

Tetanus toxoid and opiate analgesia should be given if indicated. Ibuprofen (400mg orally, every 12 hours) provides systemic antiprostaglandin activity that limits the cascade of inflammatory damage. Antibiotics should be prescribed if there is evidence of infection.

Thrombolytic Therapy / There is emerging evidence that treatment of severe frostbite injuries with intra-arterial thrombolytic agent (tPA) or synthetic prostacyclin analogue (Iloprost) improves outcome. Patients to consider for thrombolysis/Iloprost are those presenting within 24 hours of original exposure with apparently severe injuries where digit / limb loss is predicted.

A review of absolute and relative contraindications of t-PA should be undertaken. The treatment should occur in a facility with vascular surgery and HDU/ITU monitoring capabilities.

Early Surgery / Fasciotomy should be performed if a compartment syndrome develops, but amputation should be delayed for up to three months, and certainly until the level of demarcation is clear. However systemic infection resistant to intravenous antibiotics warrants early surgical debridement/amputation.

Nursing Care / Goals include keeping the patient comfortable, pain free, well nourished and adequately hydrated. Twice daily antibacterial whirlpool baths encourages the blister eschars to separate from underlying healthy tissue. Early mobilisation with help of physiotherapists is beneficial but further trauma must be avoided.

Amputation / Failure to delay surgery remains a major cause of avoidable morbidity. Better long term functional results are achieved with the early involvement of a multidisciplinary rehabilitation team. Early mobilisation of patients with partial foot amputations on weight bearing custom made orthoses has shown promising results.

Telemedicine / A recent development in accessing expert advice, which has been driven both by the patient’s themselves and also those clinicians with a more limited experience of frostbite, is the use of the internet. A virtual opinion can be sought from anywhere in the world. The UK based service can be accessed via the Diploma in Mountain Medicine or the British Mountaineering Council websites.

Conclusion

Although still potentially a disastrous injury associated with a high morbidity, frostbite can now be treated more effectively to ensure tissue loss is minimised and functional outcome maximised. With adequate preventative measures the risk of frostbite injury can be reduced.

With the rising prevalence of frostbite, future research remains important. However, a number of factors mean that progress is likely to be slow. Injuries tend to be variable and unpredictable, presentation is often significantly delayed and often to a wide range of different centres, there is no good animal model for basic research, and apart from the  military there is little likelihood of achieving significant funding for research programmes.

Research over the past 15 years has led to a new understanding of the pathophysiology of cold injury. Understanding of the role of inflammatory mediators, such as PGF2 and TXA2, has led to new active medical regimens such as the use of ibuprofen and aloe vera. Improved imaging assessment using MRA, and technetium scintigraphy, coupled with further research into the use of adjunctive therapies such as the use of thrombolytic agents and vasodilators further advancement in the treatment of frostbite.

However, prevention, early warming, early medical treatment and delayed surgery are likely to remain the mainstays of treatment for the foreseeable future.

References

1. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite. McIntosh SE, Hamonko M, Freer L, Grissom CK, Auerbach PS, Rodway GW, Cochran A, Giesbrecht G, McDevitt M, Imray CH, Johnson E, Dow J, Hackett PH; Wilderness Medical Society. Wilderness Environ Med. 2011 Jun;22(2):156-66
2. Cauchy E, Chetaille E, Marchand V, Marsigny B. Retrospective study of 70 cases of severe frostbite lesions: a proposed new classification scheme. Wilderness Environ Med 2001;12:248-55
3. Cauchy E, Cheguillaume B, Chetaille E. A controlled trial of a prostacyclin and rt-PA in the treatment of severe frostbite. N Engl J Med. 2011 Jan 13;364(2):189-90
4. A clinical review of the management of frostbite. Grieve AW, Davis P, Dhillon S, Richards P, Hillebrandt D, Imray CH. J R Army Med Corps. 2011 Mar;157(1):73-8
5. Managing frostbite. Hallam MJ, Cubison T, Dheansa B, Imray C. BMJ. 2010 Nov 19;341:c5864. doi: 10.1136/bmj.c5864
6. www.thebmc.co.uk/how-to-get-expert-frostbite-advice
7. Cold damage to the extremities: frostbite and non-freezing cold injuries. Imray C, Grieve A, Dhillon S; Caudwell Xtreme Everest Research Group.Postgrad Med J. 2009 Sep;85(1007):481-8.

 
27.05.14 Note from editor / If you enjoyed reading this article, the authors have recently published a more in-depth review of frostbite management, giving advice on novel therapies. It can be accessed online for free, just follow this link.

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Alistair Simpson, former Medical Officer with the British Antarctic Survey tells Adventure Medic what we need to know about hypothermia. Alistair has lived for more than 16 months in Antarctica.  He has also served on a number of expeditions, including an unsupported ski crossing of the world’s second largest icecap and two high altitude research expeditions in the Bolivian Andes.

Hypothermia

The expedition doctor faces many challenges, in particular the environment to which his charges are exposed.  With increasing ease of access to high altitude and polar regions, cold exposure is a genuine concern.

Humans are poorly adapted to cold. Since physiological homeostasis mandates a core temperature of 37°C, insulation from the environment is required in temperate or cold climates. However, when insulation is inadequate or the environment becomes more severe, homeostasis can fail resulting in cold injury.

Cold injury can be categorised into hypothermia, non-freezing injury and frostbite.  This article will focus on the first of these injuries.  Hypothermia is classically defined as a core body temperature below 35°C. (1,2)

Causes

Body temperature is maintained by a balance of heat gain and heat loss.  Regulation is under hypothalamic control, with peripheral temperature receptors sending signals to the hypothalamus which are then relayed via the sympathetic nervous system to effectors in the peripheral vasculature, piloerector muscles and sweat glands, as well as the brainstem (shivering) and higher centres. (3)

Following exposure to cold, this process leads to peripheral vasoconstriction, redistribution of blood flow centrally, cooling of the extremities and shivering. Under normal conditions, body temperature can be maintained by wearing clothes, seeking shelter, shivering and exercise. Adult humans do not exhibit significant non-shivering thermogenesis.

Exercise is very effective at maintaining body temperature and can increase heat production from 100 to 1200 Watts.(4) Clothing can insulate the body to the extent that it creates a warm microclimate next to the skin.5  Sufficiently warm shelter can obviate cold environmental conditions entirely.  Shivering can increase heat production to 500 W, increasing energy consumption by the equivalent of five times resting metabolic rate. (4,6)

Heat homeostasis is the result of a balance between heat production and heat loss.7  Therefore if heat production is impaired or heat loss increases, a fall in core temperature will result.

Wet skin or clothing increases thermal conductance and increases heat loss by convection and evaporation.8  Water immersion can produce a dramatic and rapid reduction in body temperature and causes 100 000 deaths worldwide per annum.4  Windchill can dramatically reduce relative temperatures due to convective losses: at an ambient temperature of 0°C, a wind speed of 30 knots will produce a relative temperature of -20°C. (9)

Although exercise will increase heat production, if fatigued, body glycogen stores are depleted resulting in a decreased capacity for shivering and further exercise.  A low blood sugar can also impair hypothalamic responses to cold.4,8  Body habitus can predispose to hypothermia.  While obese people are well insulated by subcutaneous fat, slim individuals will lose heat more rapidly and will rely more on other methods of insulation and heat production. (4,8)

Physical fitness per se does not confer improved tolerance of cold, although it will allow exercise to be maintained for longer, which may help due to increased thermogenesis. (8)  Alcohol ingestion can predispose to hypothermia by inhibiting vasoconstriction and impairing shivering. (10)

It is worth noting that whilst peripheral vasoconstriction and cooling reduces core body temperature loss, it also reduces dexterity significantly and this can have risks in its own right for the individual in a challenging environment.

Prevention of hypothermia

• Ensure adequate preparation and risk assessment, especially as regards kit selection
• Take adequate clothing
• Have a means of providing rewarming, for example sleeping bag, warm bottle or stove
• Avoid saturation of clothing with water or sweat – especially if windy
• Change wet clothing as soon as able
• Take adequate food supplies
• Keep moving where appropriate
• Seek appropriate shelter when conditions deteriorate
• Use a buddy system
• Be aware of the possibility of hypothermia

Symptoms and Signs

Symptoms of hypothermia are generally related to core body temperature and are progressively more severe as temperature falls.  With mild hypothermia, shivering begins and mental status is altered – individuals may be lethargic or mildly confused.

As temperature falls, shivering becomes maximal, walking is impaired and speech becomes slurred.  Confusion and drowsiness will become apparent and behaviour becomes irrational, including paradoxical undressing.

With severe hypothermia, shivering stops, further exacerbating temperature loss.  Pupils may become fixed and dilated and the affected individual comatose.  The appearance of the individual can mimic death. Cardiovascular instability is also a feature, particularly ventricular fibrillation (which may be provoked by rough handling or sudden changes in posture and cardiac arrest. (7)

Once core temperature reaches 24°C, survival is unlikely.  However, survival has been recorded following a core temperature as low as 13.7°C.11  Note that there can be significant inter-individual variability in symptoms for a given core temperature. (12)

Management

Accurate core temperature measurement will assist in management of a hypothermic patient.  Oral, tympanic and axillary temperature recordings can be inaccurate; oesophageal, urinary bladder or rectal measurement is preferable. (4,7)

First aid methods should be employed, including seeking shelter (especially from wind and rain), insulating from the ground, removing wet clothing and providing external heat, such as via a stove or by contact with another individual.  Warm drinks may also help.

Of note, metallic ‘space blankets’ are of no proven benefit.4  Wrapping the victim in dry sleeping bags and insulating using a roll mat and bag will help.

Chemical heat packs or bottles filled with hot water may also be used with caution so as to avoid burns; wrap bottles first before applying to skin. (7)  There are differing opinions as to whether warm baths should be used; core temperature can fall due to blood flow to cold peripheries (afterdrop) and the vasodilatation may also cause profound hypotension and provoke dysrhythmias. (4,7) If used, great care should be taken and the patient monitored closely.

Such active external warming techniques are likely to be most appropriate for mild rather than severe hypothermia. (10) Invasive warming techniques include warm intravenous or peritoneal fluids and cardiac bypass. If hypothermia was of slow onset or prolonged, rewarming should be gradual and undertaken with care.

A cold diuresis can result in fluid loss and hydrostatic effects can exacerbate this in immersion victims. These patients should be extracted and nursed recumbent to avoid causing severe postural hypotension.  Cell membrane instability can result in significant ion flux, especially of potassium.  Pancreatitis and rhabdomyolysis are also recognised complications. (4)

Pronouncement of death is difficult due to the appearance of the severely hypothermic patient. (9)  Patients should therefore be rewarmed before death is declared (the victim is ‘not dead until they are warm and dead’).  Very prolonged resuscitation may be required. (11)

Conclusion

Cold exposure can result in a number of injuries.  However, with appropriate planning preventative measures can be taken to reduce the impact of low environmental temperatures.  If hypothermia develops, it should be recognised and treated as soon as possible.  Familiarity with management principles can reduce morbidity and mortality.

Take home messages

• Cold exposure can result in a number of injuries, including hypothermia, non-freezing injury and frostbite
• When heat loss is greater than production, hypothermia will ensue
• Hypothermia must be recognised early
• Suspect hypothermia in individuals displaying any signs, including slow mentation, withdrawal or confusion
• Instigate early appropriate management: isolate the victim from the environment and rewarm as appropriate to the degree of hypothermia
• Pre-expedition planning and risk assessment are essential and may reduce the risk of hypothermia developing
• Consider selecting equipment for managing hypothermia, including thermometers and rewarming equipment
• Declaration of death is difficult in the severely hypothermic victim; rewarm patients before death is declared

Getting cold up high

Avinash Aujayeb / SpR in Respiratory Medicine.

Three hours before summiting Spantik, 7031m in the Karakorum I turned around. I just couldn’t get warm.

That morning an early start had meant the snow was hard underfoot and made for fast climbing. The alpenglow had mesmerised us at sunrise and then the sun made its appearance. Now, though, on the summit ridge, we were being hampered by soft, waist deep snow and were being forced to dig a trench up the mountain to ascend. A slight wind was blowing and at nearly 7000m, this chilled us to the core.

Lagging behind the front two climbers, I was slowly making my way up, wrapped in my own psychological and physical battle against the elements. Any exposed flesh was literally freezing. My balaclava and buff kept the wind off my face, but were suffocating me, so I had to keep taking them off to breathe. My down jacket felt like no more than a cotton t-shirt and I had to alternate hands to wield my ice axe as its cold penetrated my gloves, even though I had taped the metal parts up. We had stopped earlier, to sun ourselves but nothing remained of that warmth. This was my first big mountain but between them, my two friends had both had forays up eight 8000m peaks and were far more experienced than me and more accustomed to the cold and the hardship.

Somewhere further up the slope, I stopped to wriggle my now partially numb toes and to rotate my arms. I looked up and saw a foot being warmed in an armpit! Snow had been filling up the boot of the trailbreaker due to a loose boot. I waded up to them, rested and when we all felt better and the feet rewarmed, continued.

At that point, I had been going for about nine hours and had reached a personal high of about 6710m, a mere 300m below the summit. However, despite my efforts and whatever I was doing, I could not get warm. My toes had gone, my hands were cold and every time I stopped, I would be shivering. I had no more layers to put on. Our leader, Brad, had graciously offered me another down jacket but now he was himself too cold to be without it.

I knew then I would not make the summit. I was exhausted and hypothermic. After a brief conversation with Brad and an exchange of encouragement, I started descending.

The decision to turn round had been a pragmatic one, without any emotion on my behalf. I might have been able to get up to the top, but probably not down again. I was hypothermic and didn’t want to get frostbite. Once I had descended the final slope back to camp, I had warmed up considerably and I sat down in the snow just above the tent. It was only then I welled up, as I realised what had just happened in all its intensity. It had taken six months of planning and training to get here and it was almost too much for me. However after just a few hours, warm and rehydrated, I was able to share the joy of my friends’ summit success and had already started thinking of next time.

References

1. Avellanas ML, Ricart A, Botella J, Mengelle F, Soteras I, Veres T, et al. [Management of severe accidental hypothermia]. Med Intensiva. 2012 Apr;36(3):200-12.
2. Danzl DF. Accidental Hypothermia. In: Auerbach PS, editor. Wilderness Medicine. 6 ed. Philadelphia: Elsevier; 2012.
3. Yentis SM, Hirsch NP, Smith GB. Anaesthesia and Intensive Care A-Z. 3 ed. Edinburgh: Butterworth-Heinemann; 2004.
4. Stoud MA. Cold. In: Warrell DA, Timothy M. Cox, Firth JD, editors. Oxford Textbook of Medicine. 5 ed. Oxford: Oxford University Press; 2012.
5. Budd GM. Cold stress and cold adaptation. Journal of Thermal Biology. 1993;18(5/6):629-31.
6. Haman F. Shivering in the cold: from mechanisms of fuel selection to survival. J Appl Physiol. 2006 May;100(5):1702-8.
7. Davis PR, Byers M. Accidental hypothermia. J R Army Med Corps. 2005 Dec;151(4):223-33.
8. Castellani JW, Young AJ, Ducharme MB, Giesbrecht GG, Glickman E, Sallis RE. American College of Sports Medicine position stand: prevention of cold injuries during exercise. Med Sci Sports Exerc. 2006 Nov;38(11):2012-29.
9. BASMU. Kurafid – The British Antarctic Survey Medical Handbook. 6 ed. Grant IC, Cosgrove H, Thomson L, Guly H, editors. Plymouth: British Antarctic Survey; 2005.
10. Keim SM, Guisto JA, Sullivan JB, Jr. Environmental thermal stress. Ann Agric Environ Med. 2002;9(1):1-15.
11. Gilbert M, Busund R, Skagseth A, Nilsen PA, Solbo JP. Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest. Lancet. 2000 Jan 29;355(9201):375-6.
12. Mallet ML. Pathophysiology of accidental hypothermia. QJM. 2002 Dec;95(12):775-85.
13. Smith LO. Alpine climbing: injuries and illness. Phys Med Rehabil Clin N Am. 2006 Aug;17(3):633-44.

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