As winter took hold in Edinburgh, the Adventure Medic team descended on the city for the 2025 World Extreme Medicine Conference. We were there all weekend, meeting medical professionals from across the world, sharing experiences of the challenges and triumphs of expedition, humanitarian and wilderness medicine.

What is it?

The annual World Extreme Medicine (WEM) conference is a three-day event that welcomes attendees from a huge range of backgrounds within the world of extreme medicine. It prides itself on diversity – both professional and experiential – and in recent years, has focussed as much on practical workshops as the traditional conference lectures. WEM takes place in the shadow of Edinburgh’s spectacular Salisbury Crags, at Dynamic Earth, the city’s science centre. It is an opportunity to network, learn new skills, participate in panel debates and of course, dance your socks off at the legendary ceilidh.

Conference Highlights

This year’s WEM was a celebration of community, diversity and non-traditional medicine. The Adventure Medic (AM) team were privileged to attend a wide range of workshops – from burns management and rope rescue to cold-water submersion, all in authentically freezing Scottish weather. We listened to keynote speakers who brought their dogs, attended discussions on sleep and self-care, and participated in many animated panel discussions. Below are the AM team’s speaker highlights from this year – a list difficult to narrow down, but will give the reader a taste of the essence of WEM.

Blood Polar: When the Period Hits, Be Ready

Dr Noemi Welsch

Dr Welsch is a resident doctor in Obstetrics and Gynaecology. She discussed her own experiences of the ‘bloody mess’ of menstruating on expedition, and her subsequent motivation to foster discussion and curiosity around women’s health in extreme environments. Her talk was structured around case studies from her expedition work and sparked a lively discourse on planning for menstruation, contraception and perimenopausal participants. She covered a huge breadth of topics including missed pills due to time-zone changes, storage of contraception at extremes of temperature, sourcing sustainable period kit and communication around female urination.

Dr Welsch expertly led a refreshingly candid discussion, lending her expertise and practical tips to a packed room of experienced and novice practitioners alike. For more from Dr Welsch, check out her article on working with the Floating Doctors in Bocas Del Toro here and look out for her upcoming article due to be published as part of our new Women’s Health Series.

Asylum Seeker & Refugee Health in the UK

Dr Aisha Malik

Dr Malik is a GP with Extended Role in asylum seeker and refugee health based in Blackpool. She gave a passionate and harrowing insight into working as clinical lead for the Blackpool Metropole Hotel. This hotel housed 468 asylum seekers during the pandemic, a number which included 200 under 18s and 30 pregnant women, despite legal limits being set at 10. She spoke of the pitifully small allowances provided by the government as just one dimension of what she described as ‘state-sponsored neglect’. A lifelong advocate for equality, Dr Malik reflected on the concept of ‘medicalising misery’ and the challenges of navigating an increasingly dispassionate immigration system. She has clearly found her calling, describing her work in one of the most under-recognised areas of UK healthcare as “medicine and health inequality on steroids… you have to be mentally and emotionally tough, but it makes you a better doctor, and a better human.”

Breaking the Ice: Gender, Barriers and Belonging in Polar Expedition

Cat Burford

It was an absolute joy to watch Cat Burford, dentist and explorer, champion women in polar exploration. She opened by reflecting on female polar explorers going back to the 1770s, when male disguises were often a necessity, and shared a selection of memorable quotes, including the 1960s assertion that ‘women wouldn’t like the Antarctic as there are no shops or hairdressers’. Cat went on to address current challenges: the lack of female-specific equipment and research, and her own experiences of misogyny and entrenched societal expectations. Among her most frustrating recurring experiences is being asked whether she feels guilty for leaving her family or whether her husband funds her expeditions (he does not). You can find Cat’s website here or follow her on Instagram @themolarexplorer.

The WEM Community

One of the most inspirational aspects of every WEM conference is the sense of community that the event cultivates. The informal atmosphere that it is renowned for encourages discussion, integration and genuine connection. This year was no different. We met nurses, scientists, astronauts and journalists, and were reminded that whether you are completely new to medicine outside hospital environments or a seasoned expedition medic, there is always something to learn and someone new to meet.

The emphasis is on positive change, self-reliance and treading a path less travelled felt particularly resonant during a dreary November weekend. We left feeling impassioned and invigorated, with a satisfyingly long list of potential new contributors.

Thank you to everyone that came to meet us, and to all of those who offered expertise and articles – we look forward to sharing your experiences with the Adventure medic community.

Get Involved

Inspired by WEM and want to contribute? We’d love to hear from you. Get in touch at contact@theadventuremedic.com

The World Extreme Medicine Conference returns to Edinburgh from 14–16 November 2026. Book your tickets here.

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In this interview, Dr Ben Alba explains how the Ubuntu Network came to be, what it is, and how you can get involved. An emergency medicine middle-grade with an interest in high-altitude medicine, Ben formed the Ubuntu Network following a challenging case whilst working at Everest Base Camp. As the medic, he was closely involved in remotely managing a cardiac arrest of a participant for another tour operator, who unfortunately died. After returning home, Ben sought support from the expedition medicine community, but found that practitioners often operated independently without coming together to share experiences or lessons learned. This led to the birth of the Ubuntu Network, a community and collective where cases are shared and discussed amongst like-minded medics, with a focus on the human factors, leadership and decision-making challenges that are uniquely faced in remote medicine. Ubuntu is a southern African word meaning ‘humanity’ or ‘I am because you are’, and the network holds online events regularly throughout the year where a presenter speaks about an experience they’ve had while practising remotely alongside a facilitator who brings in the audience for constructive discussion.

Imara: Thank you, Ben, for taking the time to tell us all about the Ubuntu Network! I’ve been a big supporter from the beginning and feel that the community you’ve created is supportive, informative, and certainly needed in the expedition medicine world. It sounds like the experience you had at Everest Base Camp was particularly challenging, and it’s inspiring to see how that has spurred you to create Ubuntu in the aftermath. It must have been difficult speaking about the case in an open forum. Could you tell us a bit about how Ubuntu works and what people joining an event can expect?

Ben: Thanks, Imara, and as you are a key part of the team at Ubuntu, it wouldn’t be where it is now without your support! And yeah, it is hard to talk about these things, which I guess is part of what makes Ubuntu such a special space. That being said, we aren’t looking for presenters to be in the emotive and emotional stage of dealing with the issue. I think if I’d spoken on the Ubuntu the week after I got back from Everest, I probably would have cried, but the fact that I could take some time to process the experience before presenting was an important step in coming to terms with what had happened to me and getting my own support network going as well. But I agree with you, I think Ubuntu offers a really valuable resource as a place where people can come together and talk about difficult things and feel supported in a non-judgmental space. I think the way we run an event is very involved and discussion-based and not focused on people’s mistakes or decisions, but actually just listening to and engaging in a really interesting perspective from someone who’s had a lived experience.

An important part of that is that it’s not necessarily something drastic, you know? It doesn’t have to be a man getting mauled by a bear in the Grand Teton National Park. It can be 15 people who get diarrhoea and vomiting, and that’s the whole expedition over, and trying to deal with that. It’s those real things that we see in expedition medicine, and their unique logistical challenges. I’ve always said that expedition medicine boils down to coughs and colds, diarrhoea and vomiting and some minor trauma. I still stand by that, really, most of the stuff you see is that, and it’s not very exciting. But you’ve got to get through the often boring times or the often easy days to get to those hard bits when someone does have frostbite, and there is a really difficult management decision to make about whether we get them out and how quickly we do it.

These are all equally important to discuss, and I think the more we can talk about them and support people’s decision-making, the more we learn. Because there’s not much research out there really for expedition or wilderness work, a lot of it is derived from in-hospital research, and sometimes it’s very difficult to translate it to the remote setting.

In terms of how the network runs, we currently have a highly active WhatsApp group, where we advertise our events and disseminate other information, as well as advertise through our social media on Instagram. In the background, the Ubuntu team work to get a case presenter and a facilitator prepared. Essentially, on the night, the case presenter presents a case of something that’s been difficult in a remote environment. We’ve had snake bites in the desert, altitude cases, rabies in the Indonesian rainforest, and a case where the medic has become unwell and had to consider their position in the group. Some really varied cases. And again, as I stressed before, this isn’t about medical management and making the right medical decision. A lot of these cases essentially have human factors and logistical challenges at their core, because in reality, these are what you have to manage in remote care. How are you going to maintain their airway? How are you going to move them somewhere else? Are you going to deplete your stock of drugs by treating this one person when you have 30 other people to look after for the next two months? Are you going to use up the resources of the local community? What security risks do you have to consider?

Everyone can read an algorithm on how to manage the stages of septic shock, for example, things like that you can review in your own time, but actually what we’re trying to get at here is the real-time experience from someone who’s been in this place and had this experience and understand what their thought processes were; a virtual simulation so to speak.

The way we initially ran sessions was one person discusses a case and goes through it with a facilitator, asking prompting questions and bringing in a collaborative discussion at the end, and it’s worked really well. At the WEM conference last year, we decided before that we would pause halfway through and open it up to the audience to see where their thoughts were at. So, we’re aiming for a hybrid mix now, depending on the case. The main thing we are trying to get is engagement, and the best way to manage this has been through getting the audience to ask questions about what their thought processes are, as if they were themselves in the situation posed to them. We want it really to be a discussion and not a lecture, and invite people to bring in their own experiences too. There is no right or wrong answer in these situations; these are just discussions and a place for people to connect.

Imara: I think the exciting thing about wilderness and expedition medicine is that it’s the things that people might consider simple, like your diarrhoea and vomiting, that in certain contexts can actually be quite devastating. Depending on the situation, each scenario will play out so differently, and as you say, there are no right or wrong answers when it comes to the management of complex cases in the field. And reiterating that there is so much we can learn from each other.

What kind of direction do you see Ubuntu going, and what would you like it to look like in the future? Have you got any new exciting cases coming up?

Ben: I suppose initially the plan was to simply gather interest, but now we are in a period of moving to WhatsApp as our main hub of activity to increase that sense of community and engagement. We want to focus back on our key model of gathering not only the expedition but humanitarian, wilderness, and rural medical communities, in the UK and beyond.

The WhatsApp group is where event updates are posted with links to the sessions on Teams. Jonny Milton has also come on board to run an interactive journal club through the WhatsApp group to further the general discussion. We have already seen an influx into the group of medics from all backgrounds, from medical students to paramedics to mountain guides, all the way through to consultants and bona fide experts in their field. Having that spectrum really brings people together, and we hope it can become a space where people can get advice, ask for support and just generally network with their peers.

We had our first in-person independent Ubuntu event in Bristol in late February, and with online cases already lined up for April, June, and September, the year is looking full to the brim with great speakers and discussions. We will be at WEM again in November, and it looks like this will be a yearly date for us, which we are delighted about. We are even having people come to us now to ask to share information, be that presenting a case, or, for example, in April, Hannah Lock is doing a frostbite update through Ubuntu, which again is a testament to the ripples we are making through the community.

So you know, we’re slowly growing, and I think hopefully in the coming year we will see a kind of explosion through different methods of reaching out to people. You can’t force engagement, but we can make it easier for people to get involved, and so fingers crossed our move into WhatsApp will encourage that.

Imara: Amazing, it sounds like the future is very bright for Ubuntu, there’s a lot going on and different ways that people can engage and get involved, be it on your WhatsApp group, Instagram, conferences or events. It’s a really exciting time! Thanks, Ben, for taking the time to chat about Ubuntu and what you’ve created, and it’s certainly a space to watch…

Access the Ubuntu Network WhatsApp here

Access the Ubuntu Network Instagram here

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

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

Paragliding is born

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

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

Paragliding meets alpinism

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

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

Training and preparation

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

Take off and outbound flight

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

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

Landing high

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

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

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

Adventure medicine considerations

Hypobaric hypoxia

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

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

Environmental protection

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

Preparation for stranding

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

Trauma and first aid

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

Casualty evacuation and communication

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

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

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

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Grace is a clinical teaching fellow working in Birmingham with an interest in humanitarian medicine. They spent three months volunteering as the field co-ordinator for First Aid Support Team (FAST), a non-governmental organisation providing first aid to displaced people in Calais and Dunkirk. Grace shares their experience in the role for those interested in gaining humanitarian medicine experience early in their careers. 

The context

Migration of those seeking asylum in Europe from regions affected by war, famine, or economic difficulties presents a complex array of challenges, one of which is providing adequate humanitarian assistance. In 2024, approximately 37,000 people entered the UK by undertaking perilous journeys across the English Channel on small boats. This accounts for approximately half of the 84,000 asylum applications in 2024 and represents only five percent of net migration to the UK in the year ending June 2024. The UK-France border only sees 5% of the total displaced people entering Europe. They arrive looking to seek asylum, a right enshrined by international law, with most of those aiming to come to the UK due to familial or language connections. A disparate group of people at various stages of asylum, whether to the UK or France, wait at the border, living in tents and relying mostly on non-government organisations (NGOs) for food, water, shelter, and healthcare.

The number of people in Calais attempting to cross at any one time is difficult to estimate; however, for the three months I was field co-ordinator for FAST, we saw on average nearly 200 individuals per day. The numbers are seasonal: lower during winter and peaking in the summer months when conditions are more favourable for crossing the Channel. The majority of the people waiting to cross at the border in Calais are Sudanese, fleeing a devastating humanitarian crisis, with a third of the population displaced. There are also significant numbers of people from Syria, Afghanistan, Iraq, Türkiye, Kurdistan, Eritrea, Ethiopia, Somalia, and Libya. While the majority of displaced people are young men and boys, there are also many women, girls, and young children.

The set-up

The needs of the displaced population are vast and often mismatched by the services provided. FAST, for example, is operated out of a single shipping container, which provides space for running clinics, storing stock and equipment, as well as an office for the team. The day-to-day involves mornings at the container preparing for the clinic, completing stock checks, cleaning equipment, printing advice leaflets and referral letters in varying languages, in addition to loading the vehicle for outreach services. Other days, sourcing stock is required, often involving some confused locals as you order hundreds of toothbrushes. The afternoons involved running a mobile clinic out of the back of the car, either directly at the camps or at distribution points/day centres with other NGOs. As co-ordinator, my week also involved board meetings, coordinating with other NGOs operating in Calais, and teaching first aid to other volunteers and humanitarian workers. FAST operates six days per week, with Friday always kept clear for a much-needed decompression time.

The needs

Many individuals came simply for requests of hygiene items, such as tissue, toothbrushes, and soap. Consultations for conditions created or worsened by living in crowded, damp conditions and walking long distances were incredibly common; mostly, we saw respiratory, musculoskeletal, and dermatological conditions. Wound and foot care were also a key part of our practice. In between the fungal skin infections, common colds, and scabies, some patients presented with more serious (and for a UK clinician more unusual) conditions such as cutaneous diphtheria and non-freezing cold injury i.e. trench foot.

It was fairly rare to have chronic disease consultations, likely due to the arduous journey required to get to France, and the fact that people do not focus on their health conditions while they are actively attempting to cross a border. However, requests for long-term medications were reasonably common, as were pregnant women seeking antenatal care, most of whom had received none despite their advanced pregnancies.

To meet these needs, we came well-stocked with simple hygiene items, creams and dressings for wound and foot care, cold remedies, joint supports, and toys for the children. We worked in concert with the other NGOs and, to a limited extent, the French healthcare system. Conditions FAST we were unable to deal with were sent to La Pass (Permanence d’accèss aux soins de santé); a clinic run by the French healthcare system that does not require documents or money to access. While I was in Calais, they were open weekdays; otherwise, patients would have to attend the emergency department for more urgent medical issues. La Pass also had dentist appointments around two days per week, although there were only ten appointments per clinic, which is woefully inadequate when compared with the need for dental services. MSF and the Red Cross also conducted one mobile clinic each week in Calais, although the majority of their work was in neighbouring Dunkirk. The impressive MSF psychology team worked with the displaced population alongside the Refugee Women’s Centre for women and children, and ECPAT for unaccompanied minors. The network of NGOs working in Calais did their utmost our best to provide holistic, joined-up care, in a challenging, often difficult environment. This was underpinned by the incredible work of the Channel Information Project, providing up-to-date guides for both displaced people and aid workers in Calais, and ‘Utopia 56’ providing transport to medical facilities and immediate aid after failed crossing attempts.

Challenges

With such a diverse group of patients, translation was a key difficulty. The majority were Arabic speakers, but there were also many Tigrinya, Amharic, Somali, Kurdish, Farsi, Dari, and Pashto speakers. We unfortunately did not have professional translators, so we relied on the language skills of the team and improvising with translation apps. Often, a displaced person with language skills would assist with translation, which was an immense help! The constraints and ethical challenges of these forms of communication are obvious, but the alternative is further restricting access to already limited healthcare.

Regrettably, very few displaced people in Calais had heard of La Pass or knew how to access it, and many were unwilling to go even when it was an option, often due to fear of French authorities or difficulty with transport and timing around traveling for food, water, administrative appointments, and attempting to cross.

Provision of humanitarian healthcare doesn’t occur in a vacuum; addressing the health needs of a displaced population is also impacted by the geopolitical environment. The Compagnies Républicaines de Sécurité (CRS) or Police Nationale regularly evicts camps, removing tents and belongings of displaced people. This disruption to a vulnerable population has consequences. On one occasion, I met a very distressed man who told us he had his tent and belongings taken by the CRS, which sadly included his insulin for his diabetes as well as and his reading glasses. On another occasion, we encountered a 15-year-old unaccompanied boy with a severely infected wound on his leg. He had no access to transport, did not speak French, and had no method of communication. We attempted to transport him to hospital, but on passing one of the camps with a heavy police presence, the car was stopped, the injured boy forced to get out, and my colleague was questioned for around an hour before being allowed to leave. The lack of reliable, safe options to get medical aid for an unwell child was astounding and left the team shaken. 

A further challenge was the resource limitations of all the NGOs in Calais, borne from the crisis on the border, the lack of safe passage to claim asylum, and the reduction in donations across Europe. The impact of this situation on displaced populations is profound – I remember when I encountered a crying boy of around eight and his mother. I asked if they had any medical needs, and his mother told me that he was scared of going back to the sea and the boats. I offered a referral to the MSF psychology team, which they refused, and I then had nothing else to offer them. I gave him a toy and left, leaving him to go on a journey that has killed many children his age. I have never felt more impotent.

My experience

Despite the long hours and tears shed, I would undoubtedly say that co-ordinating for FAST Calais is the best job I’ve ever had, which is saying a lot as it was unpaid! Initially, the complexities and ever-changing demands of coordinating were overwhelming, and it was intimidating to often be the most senior clinician in the field this early in my medical career. However, through the support of previous co-ordinators and the wider FAST organisation, I can say the experience was overwhelmingly positive. Day-to-day interactions with patients were incredibly fulfilling and usually filled with respect and generosity; if I encountered people cooking or eating outside their tents in the camps, I was almost always offered food.

One day, in torrential rains in a car park (our usual distribution point), volunteers and displaced people alike all joined in dancing. After a valiant attempt at teaching us a dabke (a traditional Levantine dance), the British volunteers expertly demonstrated our lack of rhythm performing the ‘Macarena’ (a British dancefloor classic). The whole afternoon overall is one of my favourite memories of my time as co-ordinator, and most clinics contained overwhelming feelings of community, joy, and generosity, even in the background of desperation and injustice. 

How to get involved

FAST will always be in need of donations and volunteers! The co-ordinator position must be a nurse, doctor, or paramedic, but medical and nursing students in clinical years and other professions (such as podiatrists) can be a vital addition to the team as volunteers. One week is the minimum volunteering time if you’ve never volunteered with FAST before, and then there’s no minimum time for returning volunteers. The co-ordinator position is usually for 3 months. You can apply to volunteer and donate directly through the website.

You can also volunteer as a medical professional with a similar organisation operating in Dunkirk called No Border Medics, and with the Boat Refugee Foundation operating in the Greek Islands. Medical Volunteers International is another similar organisation operating in multiple European countries, both on borders and with more settled populations in camps. 

There are also loads of opportunities to volunteer with non-medical organisations, such as Care4Calais, Refugee Community Kitchen, and Calais Food Collective.

The post Humanitarian Healthcare in Calais appeared first on Adventure Medic.

Living in Emergency – Stories of Doctors Without Borders

Where: Vimeo

About: It’s a documentary that portrays the experiences of healthcare professionals working with Doctors Without Borders (Médecins Sans Frontières) in conflict and crisis regions. It sheds light on the difficulties, moral challenges, and emotional strain they encounter while providing critical medical services in hostile and extreme environments. The film highlights the dedication and strength of these medical workers as they work tirelessly to save lives amid chaos, violence, and scarce resources, revealing both their unwavering humanitarian commitment and the tough conditions they face while delivering aid in emergency situations.

Why: It is inspiring to see what motivates these doctors to give up their more comfortable lives to live remote in these extreme environments treating patients who need it most. Doctors who are depicted in the documentary give their honest opinions about what it’s like to work for MSF which gives you a real insight: ‘I could never have imagined what it’s like being the doctor. For some patients I am the first doctor they have seen in 27 years.’ ‘Everything is supersized in perspective to severity.’ ‘The huge responsibility you have suddenly, where you would normally share this with 5 other doctors who know something about their own small area of medicine.’ ‘It’s tremendously frustrating, we have to compensate how we practise medicine. The things that we do, are not as good as they could be.’ If you are paralysed by indecision, you can’t do this job. So you have to be able to live with wrong decisions, and that is really hard to do.’ I’m really convinced that one the reasons why people need to have so much sex when they are on a mission is because they are facing very difficult situations that they are not used to. 5-10 patients are dying every day.

In summary, it’s a must-watch to get a glimpse of what it really means to work for an NGO like MSF.

Book:

Hope in Hell: Inside the World of Doctors Without Borders

About: ‘Hope in Hell’ offers an inside look at the work of Médecins Sans Frontières (MSF), or Doctors Without Borders, a global organisation providing medical aid in crisis zones. Dan Bortolotti traces MSF’s founding in 1971 and highlights its mission to deliver urgent care while speaking out against human rights abuses. Rather than portraying MSF volunteers as heroes, the author presents MSF workers as ordinary people driven by compassion and determination. Overall, Hope in Hell provides a powerful and honest portrait of humanitarian work and the courage it takes to bring help and hope to those in desperate need.

Why: The book highlights the challenges of delivering care in war zones, refugee camps, and disaster areas while showing the resilience and compassion required to save lives. It provides valuable insight into global health, medical ethics, and the emotional demands of humanitarian work. In the first chapter, we immediately learn about the important role of MSF. It is about Maternité Solidarité in Port-au-Prince, Haiti, and shows you how they were able to move a complete hospital. When the tsunami hit in 2010 they were able to build a 9000-square foot inflatable hospital in only 48 hours. On the other hand, the book openly addresses the possible drawbacks of working for MSF. In one of the last chapters, they highlight the possible dangers: ‘Aid workers are also at risk for malaria, typhoid, even HIV. But these illnesses, along with landmines, plane crashers and stray bullets, are occupational hazards that MSF field workers are prepared to confront. ‘Most MSF field workers are never abducted or physically assaulted, but they all know someone who has been. Many have their own stories about close calls: moments when they thought their number was up.

Returning from a mission to Western society can be highly challenging, as one MSF worker explains, describing the difficulty of dealing with patients who display entitlement and selfishness: ‘You know, your health care is some of the best in the world, and it’s free. So shut up’. These honest accounts from MSF workers are what truly make this book a must-read!

Podcast:

Working for Doctors Without Borders (MSF) with Dr Michael Malley

Where: Spotify & Geeky Medics

About: Dr. Micheal Malley, UK paediatrician, discusses how he became involved with MSF. He did five projects and four missions, starting in Iraq in 2018. He talks about his latest mission in South Sudan, where he spent four months in a rural area dealing with, amongst others, malaria and malnutrition.

Why: The podcast delves into what it’s really like to practise medicine in settings where patients are far sicker and resources are scarce. Through firsthand accounts, you’ll hear about working side by side with experienced local healthcare professionals and the invaluable skills that come from those collaborations. Dr. Malley also shares the emotional adjustment of returning home, moving from the relief of reuniting with loved ones to the shock of an over-abundant society where even butter comes in twenty varieties. Along the way, listeners gain practical insight into the limits of medicine and the complex ethical challenges, including “white saviorism.”

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘Hope in Hell: Inside the World of Doctors Without Borders’.

The post AM Team Recommendations October 2025 appeared first on Adventure Medic.

Dr Zoe Carter Tai / ED Global Health Clinical Fellow / Bristol

Dr Constance Osborne / Evidence Explorer Lead / London

Contents

• Introduction and Collaborators
• Expedition and Wilderness Medicine Section
• Global Health and Humanitarian Medicine Section
• Want to get involved?

We are changing the publication schedule of the Evidence Explorer from now on. Instead of quarterly, we will be producing an article biannually, with all the best research the wilderness and global health medicine.

Thank you to our contributors and a particular shout out to Dr Murdoch for providing the accompanying images.

Dr Katherine Murdoch is an ED expedition clinical fellow in Bristol. In the past year, she has beens a medic on an ultra-marathon in the Jordanian desert, a camp medic in the Mexico Jungle, and worked as a festival first responder. More recently, she has been part of the paediatric blast injury partnership, assisting on the prehospital paediatric trauma course abroad. In her spare time she enjoys cycling, and last year she cycled unsupported across Japan and Korea.

Wilderness and Expedition Medicine

In this evidence explorer, we start by reviewing the role of tranexamic acid, and note that women and the elderly were less likely to be given the drug compared to men in the study. Tranexamic acid is often used in pre-hospital settings, yet it is less likely to be present in most expedition doctors kit bags. Time and more evidence may change that. Next up is a systematic review looking at the efficacy of expired anti-venom, which was largely positive, however, more evidence is needed. An article looking at the role of rashes in decompression sickness shows that any rash should be taken seriously and may indicate concurrent neurological effects. Ever wondered what a plane medical kit bag may contain? An American article outlines the kit list which has not been updated since 2006 and argues that there should be some important additions. Finally, a systematic review outlines a likely positive predictive relationship between pulse oximetry and acute mountain sickness. 

Evaluation of the prehospital administration of tranexamic acid for injured patients: a state-wide observational study with sex and age-disaggregated analysis

Girardello C, Carron P, Dami F, et al. EMJ. August 2024

Tranexamic acid is an antifibrinolytic which has been shown to reduce mortality in trauma patients. It is not routinely available in expedition medicine kit bags but this may change in the future. This study was a retrospective observational study in Switzerland between 2018 and 2021. The study looked at all patients who had an ambulance/helicopter dispatched who should have received tranexamic acid according to their BATT score – Bleeding Audit for Trauma and Triage. A total of 2401 patients were identified to be at risk of death from bleeding, however, only 11% received tranexamic acid. It was more likely to be given with higher BATT scores. However, women and elderly were significantly less likely to be given tranexamic acid.

The study had a large sample size, although it was carried out in Switzerland rather than the United Kingdom so it is unclear if the research is applicable to our population. Statistical analysis was clear and the confidence intervals were statistically significant. The study calls for qualitative research to understand why there was a difference in tranexamic acid administration between women and men.

Preclinical testing of expired antivenoms and its uses in real-world experience: a systematic review

Sutinee Soopairin, Chanthawat Patikorn, Suthira Taychakhoonavudh. EMJ. September 2024

Managing a patient with a suspected venomous snake bite relies upon prompt availability of anti-venom. This paper wished to assess whether the quality, efficacy and safety was degraded with expired anti-venom. They approached the study question by undertaking a systematic review in 2023 using four databases (PubMed, Scopus, Web of Science and Embase). A total of 15 studies were included, which was made up from 10 pre-clinical studies and five articles which described their use in the real world. The storage time ranged from two months to twenty years.

One of the studies assessed the quality of expired anti-venom and found it comparable to unexpired anti-venom. Five of the studies looked at the venom binding capacity and found this was comparable, with the caveat that efficacy declines with time from expiration.  The evidence for the systematic review was poor with small sample sizes and anecdotal evidence. The authors concluded that their findings are ‘inconclusive’ and more research is required in the future.

Potet responded to the article succinctly commenting that the ‘data, although incomplete, could also be helpful for national regulatory drug authorities to conduct a benefit-risk analysis and make informed decisions on a case-by-case basis about exceptional off-label use of expired vials, when non-expired antivenoms are unavailable. Obviously, use of expired antivenoms should be ‘the exception, not the rule’.

Clinical Significance of Mottling Rashes in Diving Decompression Sickness

Breen, Ilana D.; Stepanek, Jan; Marks, Lisa; Yale, Katerina; Mesinkovska, Natasha; Swanson, David. Aerospace Medicine and Human Performance. September 2024

Decompression sickness in divers occurs during ascent when the inert gas nitrogen enters tissues. The mechanism is poorly understood with the thought that the primary effect of nitrogen damages tissues by occlusion and the secondary effect is an inflammatory response causing further damage. Symptoms can include joint pain, chest pain, neurological deficit, headache, fatigue and a rash. (Decompression illness, RCEM learning)

This article carried out a systematic review to understand the relationship of the rash in decompression sickness and two outcomes – (1) paradoxical embolism across a right to left shunt (RLS) and (2) neurological effects. Four databases were searched over a sixty year period with a total of 31 articles meeting the inclusion criteria. Of the 128 pooled patients, 63 had neurological deficits and 76 had RLS. The majority recovered with hyperbaric oxygen treatment (84%) and there were four deaths.

Positively, the systematic review looked at a range of databases over a long period of time. However, there is a small sample size and the included studies were of varying quality. There was no mention of the limitations of the study or statistical analysis.

Clinicians should be aware that a rash in the context of suspected decompression sickness should be taken seriously and it should be a trigger for investigating for any other signs and symptoms.

Recommendations for Updates to Emergency Medical Kits for Commercial Aviation

Alaina Brinley Rajagopal, Adam Pissaris, Katharine Clark, Andrea Merrill, Robert Glatter, Amy Ho, Daryn C Towle, Justin Yanuck, Sari Lahham, Lindsey Ulin, Chanel Fischetti, Luke Apisa. Aerospace Medicine and Human Performance. October 2024

Have you ever been concerned when boarding a plane that they will call for a doctor to assist with a medical emergency? You’ve left your seat and wandered down the aisle apprehensively. You are given the on board medical bag and expected to assess the passenger.

There is a lot of planning involved in deciding what equipment and medications you will take on an expedition. You would expect the same level of planning for medical kits on commercial flights. This American article comments that the medical kits, although standardised by the Federal Aviation Administration, have not updated the contents list since 2006. You may notice that an automated blood pressure cuff, pulse oximeter, glucose meter and epipen are not included. The authors advocate for their inclusion in the article and for the introduction of a centralised data collection of all medical emergencies on commercial flights.

Next time you board a flight, you may need to remember how to draw up the correct dose of adrenaline and dig out the manual blood pressure skills from medical school.

Pulse oximetry for the prediction of acute mountain sickness: A systematic review

Johnathan S. L. Goves, Kelsey E. Joyce, Sophie Broughton, Julian Greig, Kimberly Ashdown, Arthur R. Bradwell, Samuel J. E. Lucas. Experimental Physiology. September 2024

Any individual at high altitudes is at risk of acute mountain sickness. The diagnosis is mainly a clinical one using a scoring system. This article carried out a systematic review using 7 databases to include any studies which involved human participants from lowland locations and monitored oxygen saturations to high altitude. The primary research question was ‘Is there a predictive relationship between oxygen saturation and subsequent development of AMS?’.

The study found ‘a predictive relationship between decreased resting ?p⁢O2 measured around 3500 to 4000 m and the risk of developing AMS at higher camps’. Therefore, measuring oxygen saturations may be a useful tool with your clinical assessment when deciding if a participant should continue on a high altitude expedition.

There was an assessment for bias (low for six and moderate for one study), heterogeneity and there were transparent research methods outlined. It is noted that the times for when the measurement was taken varied between all the studies and this was raised as a limiting factor.

Heat Alert! These Medications May Influence the Risk of Heat Illness

Ashley Hedges, PharmD, BCPS, BCCCP. Wilderness Medicine Magazine. July 2024.

Finally, we came across this handy table to remind expedition doctors of medications which may affect heat illness. Further details available in the full article above.

Global Health Section

This section looked at six papers in total. The first explores perceptions of cancer in Ethiopia. We assessed the role of strong caregiver relationships in reducing post-conflict trauma in Congolese Youth. We reviewed two papers which used predictive technologies to identify patterns of disease. We reviewed strategies used to decrease sex-workers’ risk of HIV/AIDS in Zimbabwe. Finally we discuss how up-skilling medical workers in rural areas in Nepal can improve obstetric care.

Perceived causes of cancer in a rural community of Ethiopia: a qualitative study

A.Wondimagegnehu, M.Gizaw, L.Abebe, et al. Global Health Action. September 2024.

Cancer incidence is increasing worldwide and is projected to reach 30.2 million cases over the next two decades, with two-thirds occurring in low- and middle-income countries. In 2020, Ethiopia was estimated to have over 77,000 new cancer cases and more than 50,000 cancer-related deaths, with breast and cervical cancers being the most common. Community-based studies in southern Ethiopia have shown that cancer knowledge is approximately 11%, with rural residents displaying lower overall awareness—likely due to limited education and access to basic healthcare services. This is reflected in the frequent late presentations of cancer and the continued reliance on traditional healers and religious leaders.

This study aimed to fill a gap in qualitative data regarding perceptions of cancer, with the goal of improving early identification and treatment. Researchers surveyed 58 participants from four remote villages located 135 km from the capital. The participants included a diverse group, ranging from health professionals to community members. Each participant took part in two semi-structured interviews exploring their perceptions of cancer, including its causes, signs and symptoms, transmission, treatment, and prognosis.

Data were collected through focus group discussions and in-depth interviews conducted in various configurations to ensure participants could freely express their views—for example, within maternal and child health groups, and in gender-specific sessions. Data collection continued until saturation was reached, meaning no new themes emerged. The findings were categorized into four areas within each broad theme: (1) desirable and beneficial, (2) undesirable and harmful, (3) non-existent or incomplete, and (4) benign perceptions.

Many participants described cancer as a very dangerous disease that is difficult to treat, often referring to it by the local term “Nekersa.” Most recognized weight loss as a significant symptom of cancer. While there was general awareness of breast and uterine cancers, few participants mentioned cancers of the brain, neck, lungs, abdominal organs, bones, or legs. Participants believed cancer could be caused by “bad air,” but also expressed several other misconceptions, categorized as undesirable and harmful—for example, exposure to sunlight during breastfeeding, and transmission through sharp objects or breastfeeding.

Benign perceptions included beliefs such as cancer being caused by exposure to bad air, sunlight after preparing traditional alcohol, storing coins under the bra, or urinating in the direction of the sun or moon, or on dirty ground. A recurring belief was that urinating on contaminated soil would allow dust or ash to enter the uterus, causing cancer. Cancer was most often associated with the appearance of a visible wound as the first sign of disease. Additionally, there was confusion between cervical cancer and other conditions such as menstrual bleeding, hemorrhoids, fistulas, and sexually transmitted infections, due to overlapping symptoms.

This study will contribute to the design of more effective public health campaigns by addressing and correcting community misconceptions about cancer.

Close relationships with caregivers as protective factor for the mental health and functioning of war-affected Congolese youth

F.Scharpf, R.Haer, T.Hecker. Conflict and Health. October 2024.

Conflict-affected youth face significant risks to their well-being due to high levels of trauma exposure and, in many cases, involvement in violent acts as members of armed groups. This regression study examined the association between the quality of caregiver relationships and the protective effect these may have on the link between traumatic experiences and various indicators of adjustment—specifically, post-traumatic stress symptoms (PTSS), emotional problems, behavioural issues, and criminal behaviour.

As of 2022, over one in six children globally were estimated to live in conflict-affected areas, alongside a rise in child soldier recruitment. War-related trauma is a well-known risk factor for poor mental health, with greater exposure correlating with a higher likelihood of aggressive and violent behaviour.

The study assessed 268 war-affected youth in the Democratic Republic of Congo, around half of whom were former members of armed groups. Participants were recruited through local child protection organisations using convenience sampling. Data were gathered via individual, structured quantitative interviews, and participants received $5 compensation. Mental health referrals were provided as needed. The questionnaire evaluated socioeconomic characteristics, war-related trauma exposure and violence perpetration, perceived caregiver relationship quality, PTSS, emotional and behavioural problems, and criminal behaviour.

As expected, higher trauma exposure was significantly associated with increased PTSS and emotional problems. Greater perpetration of violence was linked to higher rates of PTSS, behavioural issues, and criminal behaviour.

A better-quality caregiver relationship was associated with lower levels of these problems, especially in cases of high exposure. The findings show that perceived caregiver relationship quality moderates the link between war-related trauma and youth adjustment. This reinforces the importance of a supportive home environment as a key protective factor for mental health and functional recovery.

Youth rated caregiver relationships highly when they were emotionally warm and supportive, helping them process and cope with trauma. Maladjustment was partly linked to community and family stigma. Caregivers who showed forgiveness and acted as mediators in their communities helped reduce stigma and support reintegration, aiding the healing process.

Use of Open-Source Epidemic Intelligence for Infectious Disease Outbreaks, Ukraine, 2022

A.Kannan, R.Chen, Z.Akhtar, et al. Emerging Infectious Diseases. September 2024.

During conflict, public health surveillance is often disrupted, hindering epidemic tracking and increasing outbreak risks. Even before Russia’s invasion in early 2022, Ukraine had some of the world’s lowest vaccination rates (for COVID-19, polio, and measles) and high rates of TB and HIV/AIDS—partly due to ongoing conflict since 2014. The invasion worsened these issues by disrupting vaccination programs, limiting testing, and causing displacement and overcrowding.

The conflict also damaged access to clean water, housing, nutrition, hygiene, and sanitation. Formal disease surveillance largely ceased post-invasion. This study explored the use of open-source data—including news, social media, and medical reports—combined with AI to generate early warning signals and provide epidemiological data over two years, spanning before and after the invasion.

Researchers used EPIWATCH, a system that scans 200 disease-related terms in 46 languages; 70% of data came from non-English sources within Ukraine. Reports were included only if they involved confirmed, probable, or suspected infectious or zoonotic diseases. The top eight most reported diseases were compared to official surveillance data from the same period.

Between February–July in 2021 and 2022, outbreak reports increased by 447%. Gastroenteritis cases, including cholera and dysentery, rose notably. A meningitis report from July 31, 2021, indicated a rise in viral and bacterial meningitis cases since pre-invasion.

The disease profile shifted post-invasion—from COVID-19, influenza, and polio, to COVID-19, cholera, botulism, TB, HIV/AIDS, salmonellosis, and diphtheria. Cholera had not been reported before the conflict. Most diseases were not formally reported during the invasion, except for botulism, TB, and diphtheria. Botulism was more prevalent in formal reports than EPIWATCH, while TB was vastly underreported (5,647 cases in EPIWATCH vs. 113 officially reported). Both sources recorded two diphtheria cases.

The study also underscored how worsening hygiene and sanitation contributed to outbreaks like cholera and gastroenteritis. Ultimately, this study demonstrated the utility of combining AI with open-source intelligence to detect and monitor disease outbreaks during conflict, especially when formal surveillance is compromised.

Cost-effectiveness and health impact of screening and treatment of Mycobacterium tuberculosisinfection among formerly incarcerated individuals in Brazil: a Markov modelling study

A.Titan, F.Klaassen, D.Pelissari et al. The Lancet Global Health. September 2024.

This study modelled the health impact and cost-effectiveness of TB screening and treatment among previously incarcerated individuals in Brazil—a group currently ineligible for TB prevention despite their high incidence rates. The aim was to evaluate whether implementing a TB screening and preventive treatment (TPT) program in this population could reduce disease burden and be cost-effective.

Prisons act as TB amplifiers due to overcrowding, poor ventilation, and higher baseline disease prevalence. Incarcerated individuals also face increased TB risk due to malnutrition, untreated comorbidities, smoking, and drug use. In Brazil, TB notification rates are 40 times higher among incarcerated individuals. Brazil has committed to the WHO’s End TB Strategy, aiming to eliminate TB by 2030.

Using a Markov state-transition model, the study simulated TB-related health outcomes and costs in the previously incarcerated population. It compared several infection tests and TPT regimens against a no-screening scenario. Outcomes included reductions in TB cases, deaths, and disability-adjusted life years (DALYs) per 1,000 people. Costs (in USD) were estimated by comparing intervention and baseline scenarios, and results were expressed as the incremental cost per DALY averted. The model population had a mean age of 30, had been incarcerated for at least two years, and had been released three months before the intervention.

All TPT strategies were found to be cost-effective compared to no intervention. TB incidence dropped from 225 to 184 per 100,000 with intervention. DALYs averted were greatest among younger individuals and those tested soon after release, particularly if incarcerated for two years or less. Any combination of testing and treatment was more beneficial than no screening. IGRA testing offered greater health benefits than TST, and shorter TPT regimens were more effective than longer ones.

Limitations included not accounting for reincarceration, a wide range of uncertainty due to limited data, and omission of TB drug resistance. However, these did not significantly affect the cost-effectiveness estimates. The study concluded that resources should be directed toward TB screening and treatment in formerly incarcerated populations.

A risk-differentiated, community-led intervention to strengthen uptake and engagement with HIV prevention and care cascades among female sex workers in Zimbabwe (AMETHIST): a cluster randomised trial

Prof F.Cowan, F.Machingura, M.Ali et al. The Lancent Global Health. September 2024.

Female sex workers are disproportionately affected by HIV. This study assessed the effectiveness of peer support for female sex workers in Zimbabwe in reducing their risk of acquiring or transmitting HIV over just over two years (May 2019 to December 2021). It was a cluster-randomised, open-label, controlled trial involving 22 clinics dedicated to female sex workers, each within a government health facility, randomized to either standard care or the AMETHIST intervention.

Standard care included HIV testing, pre-exposure prophylaxis (PrEP), referral to government antiretroviral therapy (ART) services, contraception, condoms, syndromic management of sexually transmitted infections, health education, legal advice, and peer support. The AMETHIST intervention added peer-led microplanning tailored to individual risk and self-help groups. Data reviewers were blinded to intervention status, although program implementers were aware.

Participants were followed up after 28 months via survey to assess the primary outcome: the proportion of sex workers at risk of acquiring or transmitting HIV. Risk of transmission was defined as HIV-positive individuals who were not virally suppressed and inconsistently used condoms. Risk of acquisition was defined as HIV-negative individuals who inconsistently used condoms or PrEP.

The study found no overall reduction in combined risk of transmission or acquisition from the intervention. However, viral load suppression improved in the AMETHIST group, suggesting better ART adherence.

Successful task shifting: a mixed-methods cross-sectional evaluation of an emergency obstetric care program to increase access to caesarean sections in rural Nepal

R.Budhathoki, A.Knoble, S.Tamang, Et Al. Global Health Action. December 2024.

In 2020, an estimated 800 women died daily worldwide from preventable childbirth-related causes, mostly in low- and middle-income countries (LMICs). Approximately 86% of these deaths were due to obstetric complications. Nepal’s maternal mortality ratio (MMR) remains high, with 12% of deaths among women of reproductive age attributed to preventable obstetric causes and a shortage of doctors. Improved access to medical interventions like cesarean sections (CS) could reduce MMR by 63% in low-income countries. The WHO recommends CS rates of 10–15%, but Nepal’s rate was only 5.9% in 2020, partly due to uneven distribution of skilled healthcare workers.

To address this, a Nepalese NGO and the National Health Training Centre developed a 70-day Advanced Skilled Birth Attendant (ASBA) program in 2013 to train non-specialist medical officers (MOs) to perform safe CS and manage obstetric emergencies. Graduates were placed in facilities with emergency obstetric care and operating theaters. This mixed-methods study used surveys, interviews, and focus groups to assess the program’s effectiveness and barriers to CS availability.

Of 234 ASBA graduates surveyed, 93 responses were analyzed. Over 90% performed CS after training, 75% did so unsupervised, and 65% continued performing CS up to 10 years later. Factors supporting ongoing CS practice included temporary contracts, presence of another ASBA, and longer facility tenure. Where CS was not performed, over half cited the lack of a functional operating theater. The presence of ASBAs increased patient presentations and reduced referrals, especially in rural areas and where multiple ASBAs worked.

Barriers included presence of specialist teams, hospital level, and lack of infrastructure such as blood banks. Participants suggested adding abortion care and emergency hysterectomy training to the curriculum, along with follow-up and refresher courses.

This study supports training MOs through ASBA-style programs to fill human resource gaps, improve safe obstetric care, and enhance rural hospital conditions in LMICs.

That’s all folks! We will be coming back at you better than ever in the next few months with a new edition of the Evidence Explorer.

The post Evidence Explorer: Updates and news from the academic community, Winter 2024 appeared first on Adventure Medic.

Loved By All: The Story of Apa Sherpa

Where: Vimeo

About: The film traces the journey of Apa Sherpa, a Nepalese mountaineer who holds the world record for climbing Mount Everest 21 times. Yet behind this extraordinary accomplishment lies a story of hardship; Apa was forced to leave school at the age of 12 and work as a high-altitude porter after his father passed away.

Why: While many mountaineering films focus on the triumphant climber who conquers the summit after overcoming great odds, this documentary takes a different path. It’s a human tale of resilience, sacrifice, and the unsung heroes behind those iconic ascents. By shifting the spotlight to the Sherpa community, the film highlights the harsh economic realities and social pressures, particularly the difficult trade-offs between pursuing education and taking on risky, high-altitude work.

Book:

The Modern Explorers

About:  The book is about forty contemporary adventurers who continue to push the boundaries of exploration in the modern world and challenge the notion that the world has no frontiers left to explore. The book is organised into nine themed sections, such as Polar, Desert, Ocean, Rainforest, highlighting expeditions in extreme and remote environments. Each explorer shares first-hand accounts of their journeys, offering insights into both physical challenges and personal motivations.

Why: Because most of the stories are told by the explorers themselves, they come across as vivid and deeply authentic. For anyone fascinated by modern-day adventurers embarking on remarkable journeys to the world’s most remote places, this book offers powerful inspiration. As seasoned explorer John Blashford-Snell aptly says: ‘In these dark days of world tension, this expedition showed that people of many nations, inspired by a sense of adventure and with a healthy contempt for difficulties and dangers, can come together and perform a worthwhile task.’

Podcast:

CoROM Podcast – Expedition Dentistry with Burjor Langdana

Where: Spotify

About: Aebrhric O’Kelly, a critical care paramedic and former Green Berett talks to Burjor Langdana about Wilderness and Expedition Dentistry. Burjor trained in maxillofacial surgery in India and later worked in Oman, the UK, New Zealand, and Malawi, gaining extensive experience in well-resourced and extremely limited settings. He shares his passion for providing dental care in an austere setting, teaching others how to do so and is an Adventure Medic patron. He also created the Wilderness Dentistry website, offering free videos, articles, and downloadable materials for remote dentistry.

Why: Most medics and paramedics receive little or no formal training in dental emergencies, despite the fact that dental problems are common and can become serious in the field. In this podcast Burjor Langdana shares practical lessons from years of delivering dental and facial trauma care in some of the world’s most challenging environments like Antarctica.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘Modern Explorers’.

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Last Breath

Where: Netflix

About: The documentary is about a near-death experience in commercial diving, focusing on the incredible story of saturation diver Chris Lemons. While performing underwater maintenance work at a depth of over 100 meters (328 feet) on the seafloor of the North Sea, his diving umbilical, which supplies him with breathing gas, warmth, and communication with the diving bell, is accidentally severed. This leaves him with only five minutes of breathable gas in his backup tank and he has no chance of being rescued by his crewmates for more than 30 minutes.

Why: Saturation diving is not for everyone and can be a stressful profession with significant risks. You live in pressurised chambers for weeks, descending to incredible depths to repair oil rigs and pipelines. It’s hard to imagine what saturation diving entails, but through ‘last breath’ you get a feeling of what it’s like and what could go wrong.  With a blend of real footage, reenactments, and interviews with Chris Lemons and his colleagues, it feels incredibly authentic and keeps you on the edge of your seat.

Book:

Adventure Mind

About: The book delves into how adventure can profoundly enhance mental health and well-being. Drawing on over twenty years of experience leading expeditions across the globe, Kirk demonstrates how participating in adventurous pursuits can alleviate anxiety, conquer fear, boost self-esteem, and strengthen relationships. It covers a well-being theory called the PERMA model, which identifies five independent components: Positive emotions, Engagement, Relationships, Meaning, and Accomplishments. Adventure, she poses, supports every single one of them. By actively seeking challenges, choosing to face fear and uncertainty, engaging in adversity and risk, we get to feel really, truly alive.

Why: It’s inspiring that the book’s author is the perfect example of how adventure can change a fixed mindset to a growth mindset and change your life for the better. She explains how adventure changed her from feeling like a victim with low self-esteem to becoming an  empowered and confident woman. As a teenager, she felt she wasn’t good enough having suffered physical abuse. The turning point was a hiking and camping school trip when she was sixteen. This made her leave her comfort zone and enter the ‘stretch zone’ where personal growth happens. At eighteen, she went on her first big adventure and joined a yearlong expedition to Tanzania to study wild monkeys. It was at that moment that she learned that putting yourself out there, outside of your comfort zone, is how you get to experience magic.

She claims that predictability and boredom have nowadays replaced uncertainty, so much that we have become unaccustomed to the unknown or unplanned, even fearful of it. Also, rather than protecting us, becoming unaccustomed to dealing with risk makes us less equipped to cope with the inevitable challenges of life.

In summary, this book offers invaluable insights and motivation to embrace adventure as a transformative force and shows us why we should implement it into our own lives. So the question is, how are you going to add more adventure to your life?

To end with a quote from the book: ‘If you think adventure is dangerous, try routine, it’s lethal’.

Podcast:

Fitness in Diving Podcast

Where: Spotify

About: This episode of ‘Fitness in Diving’ features Dr. Kelly Johnson-Arbor. She is a physician board-certified in Emergency Medicine and Undersea and Hyperbaric Medicine. She serves as the Medical Director of the Hyperbaric Medicine program at MedStar Health in Washington, D.C. In this episode, she will share her expertise in treating injured divers in a hyperbaric chamber. The discussion will cover the effects of decompression sickness on divers and the role of hyperbaric oxygen therapy in their recovery.

Why: The overall risk of decompression sickness in recreational diving is estimated to be 1-3 cases per 10,000 dives (0.01–0.03%). The risk increases in technical diving to an estimated 1–10 cases per 1,000 dives (0.1–1%).

Do you know the difference between type I, type II and type III decompression sickness? When you experience symptoms after diving, do you call DAN (Divers Alert Network) or is it better to call the emergency department? What is the benefit of a multiplace hyperbaric chamber when treating decompression sickness? If you do not know the answers to these questions this podcast is worth checking out. Diving is still increasingly popular and your next patient might be a diver. And we all know that proper preparation prevents poor performance.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘Adventure Mind’.

The post AM Team recommendations February 2025 appeared first on Adventure Medic.

As a matter of tradition, everybody with an adventurous mind has been looking forward to this weekend since the beginning of the year. The World Extreme Medicine (WEM) conference is a three-day conference where medical professionals from diverse backgrounds explore the practice of medicine in challenging and resource-limited environments. Hosted annually at Dynamic Earth in Edinburgh, the conference offers a unique blend of hands-on experience and cutting-edge education across multiple streams, including expedition and wilderness medicine, humanitarian and disaster medicine, and more.

The World Extreme Medicine Conference stands out as a unique medical event. Its dynamic program, featuring workshops, keynote speeches and panel discussions, keeps you informed on the latest research in the field. What truly sets it apart, however, is the welcoming, informal atmosphere and the ease of connecting with others. It’s not just any crowd, you’ll find some of the most fascinating and adventurous individuals from around the world gathered here.

Whether you’re completely new to the concept of ‘extreme medicine’ or a seasoned expedition medic, there is something to boost everyone’s knowledge here. It was emphasised  to become self-reliant and dependable in your desired environment. You need the physical and mental stamina to be reliable and have the capacity at the end of the day to look after your team.  Firstly consider yourself a ‘rescue personnel’, and the medic as a bonus. Particularly for those hoping to enter into this world, it will make you desirable to employers. Being a generalist and simply being a nice person might seem like stating the obvious, but is easy to forget! After all, who would want to spend weeks on a mountain or aboard a ship with someone they don’t enjoy being around?

As has been the case for many years now, some of the Adventure Medic team were in attendance over the weekend. Thank you to all who came to say hello to us on our stand and around the venue.  What an inspiration to meet so many different types of people with the same passion. We spoke to doctors, nurses, medical students, paramedics, first responders, scientists, astronauts, psychologists, journalists and many more. Not only did we get a chance to hear the stories of their latest expeditions and adventures, but some of them also agreed to write an article for our website in the future. When we weren’t manning the stand, we thoroughly enjoyed immersing ourselves in the conference. With so many excellent presentations, it’s difficult to pick just a few highlights from the conference – but we’ve given it a go!.

Conference highlights

The Big Debate: What are YOU Worth as an Expedition Medic? At the moment, there is no standard for expedition medical pay. There is a concern about the potential exploitation of medics who are eager to gain experience and grateful for the opportunity to get a foothold in the field. Although guiding standards, professionalization and pay have increased in the past decade, medic pay has lagged far behind. If you want to dive deeper into this topic, check out this recently published first part of our Masterclass series on Pay in the Expedition Medicine Community.

Shawna Pandya is an inspirational Canadian physician, who became Canada’s first named female commercial astronaut and is scheduled to fly with Virgin Galactic to advance space-based biomedical and physiological research. She shared her journey as a doctor and astronaut, and the 10 key lessons from operational environments she learned in the process. For example, during underwater spacewalk training, being suspended upside down underwater, with a leaking facemask, juggling a task and communicating with colleagues taught her how to be comfortably uncomfortable.

IED (Improvised Explosive Devices) was a scenario-based training where participants were divided into two groups. One group, acted as the field’s first responders. Armed with medical kits, they focused on addressing the most life-threatening conditions first. The chaos of the screaming sounds of the casualties and blaring sirens from the speakers and thick smoke heightened everyone’s adrenaline and added to the realism of the scenario. After performing critical life-saving measures, such as applying tourniquets, the team collaborated to transport the injured to medical tents, where the other group took over care as a field hospital of sorts.  This was followed by a debrief and a discussion, with some excellent feedback and lessons learned.

The WEM Ceilidh is optional when booking the conference, but highly recommended. It is a traditional Scottish social gathering that features lively folk music and a lot of dancing. Don’t worry if you think you can’t dance, a “caller” guides participants through the steps. It’s always very enjoyable, and much more fun when everyone gets stuck in.

Get Involved

If you came up and spoke to us at our stand and would like to get involved, please contact us at contact@theadventuremedic.com.

If you want to get involved in expedition and wilderness medicine or humanitarian and disaster medicine this is your next best step. The WEM conference gives you the chance to connect with hundreds of ambitious like-minded medics and ignite ideas for your next expedition!

Don’t want to miss out on next year’s opportunity to attend the conference in person? The WEM conference will be in Edinburgh once again from the 15th-17th of November 2025. Secure your tickets here.

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This is the first article in a series on pay and considerations when employing a medic. They have been written for both medics and employing companies to improve on the understanding of the profession in the expedition field. The next article, ‘Employing an Expedition Medic’, will be published soon.

Introduction

Adventure Medic has long been aware of the battle for remuneration for expedition medicine work and the challenges of securing fair pay.

There are an ever-increasing number of commercial providers organising trips to exotic destinations and requesting an accompanying medic. This is in part due to changing societal expectations and insurance requirements, alongside the general growth of adventure tourism.

We are healthcare professionals with extensive training and experience, taking professional risk. However, remuneration for expedition medics varies greatly with no guidance or standard set by a professional body. It is important that both medics and expedition providers understand each other’s perspectives as we carve a way towards fair remuneration.

This article will set out why pay is a complex issue, and how to advocate and negotiate for remuneration for our work. This is the first in our Masterclass series on ‘Pay in the Expedition Medicine Community’.

Current Factors Affecting Expedition Pay

At present, there is no standard for expedition medic pay. Financial arrangements can range from voluntary to a competitive salary. Most companies will offer reimbursement for expenses, although sometimes with exceptions (e.g. indemnity or flights) leaving a medical professional at a financial loss. A daily wage in addition to expenses is, however, becoming increasingly common amongst more professional and ethical companies. Below is a diagram demonstrating the range of pay:

Sometimes financial arrangements are unclear from the outset. If pay is available, it may be hourly, daily or a flat rate. In addition, significant pre-expedition tasks such as screening or building a medical kit may or may not be included in paid time.

Recommendations for specific pay come with difficulties. They must be viewed as fair and also fit within the culture and context of the expedition community. Where a cheaper medic is available, providers may choose them without factoring in aspects such as experience or trip remoteness, both key factors highlighted in the Faculty of Prehospital Care framework. Often, this is simply because, to those outside healthcare, a medic is a medic. We need to play our part as a community in educating providers, an standing together for fair pay.

Cultural Attitudes to Pay Amongst Medics

It is important to consider the ecosystem in which we operate. It encompasses everything from aspiring medics to experienced expedition sages on one side, and new and established commercial companies on the other. The narratives, relationships and economic contexts in which these providers and medics sit will affect any drive for changes to pay.

Some medics may feel that the opportunity to travel is a sufficient price for their services. Others may believe they will lose a ‘foot in the door’ to the expedition world if they advocate for pay. Many believe that due to the desirable nature of expedition work, companies often have no shortage of interested parties to fill roles, and so hold the court on pay. Few consider the risks to their future livelihood, should a legal claim be brought against them.

There is a risk that in not offering remuneration, providers attract only the most junior or inexperienced medics who are looking for their first opportunity to start their expedition medicine careers.

Even with experience, we may still be tempted into unpaid roles for scarce opportunities, or in support of research data collection or charity fundraising. In such situations sometimes all staff are voluntary. However, if there is an intermediary company hiring the medic and supporting a separate charity with expedition logistics, then this company is often commercial. We should not assume that because we are unpaid, everyone else is unpaid: “what is the day rate for the expedition leader?” is often a very revealing question.

Cultural Attitudes to Pay Amongst Providers and Companies

Many expedition companies have narrow margins, and an anxiety that paying the medic will drive costs up, raising prices, and putting off clients. The pandemic and economic instability have amplified this concern.

It would be unfair to tar all providers with the same brush. Some will pay their medics in line with the pay of other leaders, acknowledging the hard work, legal risk and responsibility. However, others will use the financial argument above to justify leaving the medic out of pocket (indemnity or insurance, flights or food and accommodation). Still others will extol their desire to pay medics but call it unaffordable. Some assume that the medic is being paid for a day job elsewhere to fund their costs of living.

What is Fair Pay?

In the last year, this discussion has gained momentum and provoked a range of opinions in the expedition community. We all appreciate that commercial expedition companies must break even and have struggled with losses during the pandemic. Equally, a skilled medic working on the trip should be fairly compensated for their work commitments, and professional risk.

Comparisons are sometimes drawn between pay for medics and other leaders, such as guides, in the same expedition team. This is a starting point, and a reference point as to what may be ‘fair’ in that particular context. Pay will vary between expedition leaders, assistant leaders, local ground handlers and others. Nonetheless, we believe the approach to remuneration for skill and experience, work and risks, should be transparent and fair across all staff involved in making an expedition a success. For example, if the medic is covering two roles (leader and medic), we believe they should be fairly remunerated for carrying the extra burden of responsibility.

By example, we have put together the table below, based on trips that the Adventure Medic team and others have worked on:

*Expenses should be all expenses including indemnity. Travel days should also receive 50-100% of the day rate.

Legalities of Paid Work

Medics may receive payment for expedition work alongside a wage for another job provided the trip was conducted during off and annual leave days. If using contracted study leave or educational development time, they cannot be paid for the same day of work by both their regular employer and an expedition company. The situation is more complex where a mixture of day “types” is used, in this case the medic can be paid for only those that are off or annual leave days. In other words, we can’t “double dip”.

Negotiating Pay

Negotiating for fair pay is complex and nuanced. This should not put us off asking the question however. Steps and tips for negotiating:

1. Begin by discussing the trip, including the clients, leaders, itinerary, risks and goals.
2. Be explicit in your experience, and the services you will provide, pre-, during and post-expedition to support these clients in their goals. This is a good opportunity to discuss other potentially contentious issues, including the care of local staff.
3. Clarify the current offer. Does it match the table above? Is indemnity covered? Is the kit provided? Are food and accommodation included including on travel days? Is travel covered from your front door to the destination? Are there any hidden expenses? Be explicit in your questioning.
4. Ask whether other team members are remunerated in the same way – if not, gently ask the provider to explain the differences in their approach.
5. Take a step back, and think whether the remuneration is right for you – are you happy to do this trip? In your annual leave, and on the terms given? You can always walk away, and there will always be other trips – no matter how it seems. Further information on Assessing an Expedition Opportunity is available here.

Below is a written example of how you might advocate for your work:

“I am grateful for the opportunity to join your expedition and to work with your clients. I would like to clarify remuneration, and the reimbursement of costs.

In the [X] years I have worked in healthcare, I have gained additional skills including [X] and achieved formal qualifications in [X]. This puts me in a strong position to offer medical support to your team and I’m looking forward to doing so.

Having an experienced medic is reassuring to clients and attracts bookings. It reduces cognitive bandwidth for the expedition leader, and clients appreciate the additional moral, as well as medical, support from a medic. Some companies find that having a medic reduces their insurance costs. Please also bear in mind that, in acting as medic, we take on significant medico-legal risk. If issues occur, they have the potential to impact our entire career.

I will of course do my utmost to safeguard against this and to protect your company and your clients. I will assist with pre-expedition screening and medical kit prep. I will be on-call throughout the trip for clients’ medical and psychological needs. Post-expedition I will produce a report, and arrange handover to clients’ regular medical practitioners, where necessary.

In return for the skills and experience I bring, and for giving up my annual leave to work on your expedition, I hope your company will reimburse my costs and consider remuneration for this work. For a similar expedition, I would typically look for a day rate of x / day, plus expenses.

I look forward to hearing from you so we can agree on a contract for this work, and I can begin supporting your expedition.”

Protecting Ourselves

We must protect ourselves from expeditions that exploit us. If the enjoyment, remuneration and energy required do not outweigh the cost and sacrifices, is the trip worth it? If a provider does not value our time, energy and skills then we should see this as a red flag and strive to protect ourselves. This holds particularly true for those under significant strain in their “day jobs”, where the additional stresses of a challenging expedition may increase burnout risk and pressures at home.

Some situations develop insidiously, with hidden costs gradually revealed through the trip. We should not shy away from advocating for ourselves and feeding back to the provider about our treatment and our worth. Always do so with an open and empathetic mind – the provider may simply need the opportunity to adapt and adjust.

Sadly, there is no formal governing body to report mistreatment. However, the expedition community is small and news travels fast. Opportunities with providers who support and remunerate their medics fairly will become highly sought after. Equally, there will always be other opportunities. By turning a blind eye to exploitation, we help neither ourselves nor those who follow in our footsteps.

Caveats

This article features information gathered from the experiences and opinions of medics within the expedition community. Adventure Medic acknowledges that the situation is dynamic and expedition medics and providers are striving to improve standards across the industry. This includes pay for medics.

Reference:

1. Updated Guidance for Medical Provision for Wilderness Medicine. Faculty of Pre-Hospital Care. Royal College of Physicians and Surgeons of Edinburgh. 2nd Edition. 2023.

The post Pay in the Expedition Medicine Community appeared first on Adventure Medic.

Vivienne Mathews / Scotland / Medical Student

Dr Constance Osborne / London / Evidence Explorer Lead

Contents

• Introduction and Collaborators
• Expedition and Wilderness Medicine Section
• Global Health and Humanitarian Medicine Section
• Want to get involved?

Thank you for joining us once again at the Evidence Explorer. As an academic amuse-bouche, we’re opening this edition with an FAQ page on ‘Women at Altitude’. This piece was written by members of the UIAA Medcom, who undertook a large scale evaluation of medical evidence on women’s health at altitude. They presented their work earlier this year at the International Society of Mountain Medicine Congress held in Utah. If you would like to peruse a more detailed review of the topic, it can be found in the journal of ‘High Altitude Medicine and Biology’.

Now, onto the main course! The articles in this edition were selected and appraised by our wonderful collaborators over the course of the summer.

Dr Jake Warrington is a FAWM certified doctor currently living and working in Sheffield, where he is completing an emergency medicine fellowship. When not at work, he can be found in the Peak District with his young family. His interests include trad climbing, cycling, surfing, paddleboarding and woodworking. He spends winter weekends attempting to tick off different icy routes up Ben Nevis.

Vivienne Mathews is a medical student in Scotland and a biomedical scientist. She has an interest in adventure medicine, which was ignited through the KCL Wilderness Medicine Society during her undergraduate degree. She loves combining medicine with travel and adventure! Viv likes to explore the Scottish outdoors, ski, surf and climb. She has also volunteered across several African countries including Zambia, Zimbabwe, Uganda and most recently Madagascar.

Wilderness and Expedition Medicine

In this quarter, we will be exploring both ends of the spectrum of temperature illness. We will take you from a case series looking at rescue techniques in hypothermic hill walkers, to sweaty Sicilian runners and the physiological stresses experienced by a healthy volunteer exercising in a heat wave. Sticking with the temperature theme, we will be presenting the 2024 update to evidence-based guidance on the management of cold injury. In fact, it’s been a summer for new evidence based guidelines, which means we will also be presenting the updated WMS guidelines on acute altitude illness. To finish off, we will investigate the effect of alcohol and smoking on the incidence of Acute Mountain Sickness on Mount Fuji.

The Outcome of Walking Cold Patients with Potential Mild Hypothermia to Safety: A Mountain Rescue Case Series

Greene M, Dodds N, Gordon L et al. Wilderness and Environmental Medicine. 14 June 2024.

Laboratory experiments into hypothermia have previously suggested that mobilising patients with even mild hypothermia could potentially be dangerous due to the risk of afterdrop and cardiac arrhythmias. However, these experiments have often utilised immersion cooling in well rested volunteers, which doesn’t quite match up to the slowly cooled, exhausted walkers that find themselves requiring rescue in the British hills. It is thought that a delay in extraction in these people may lead to greater exposure time and more cooling. Greene et al. collected data on all rescues where casualties were exhibiting signs of hypothermia (as defined by the Swiss staging system for accidental hypothermia) and compared the outcomes of those that were walked out immediately versus those that received an element of warming or delayed extraction. Data was collected from various Mountain Rescue teams and the authors admit that there were differences in the completeness of the data and that the core temperatures of the casualties involved may have been different. Despite this, the patients included all displayed clinical features of hypothermia and were in an environment where this was possible. This case series showed no difference in the outcome of patients that were mobilised immediately or received delayed transfer and whilst further study is needed, it provides an interesting perspective on the practicalities of rescue in this scenario.

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update

McIntosh S, Freer L, Grissom C et al. Wilderness & Environmental Medicine. April 5 2024

The Wilderness Medicine Society has reconvened its panel of experts for a number of evidence reviews and updates this summer and we will present you with two of them in this edition of the Evidence Explorer. The first drops the mercury level into frostbite territory and addresses the prevention, diagnosis and management of cold injury. This guideline represents an update on the 2019 edition and is accompanied by strength of recommendation and evidence base for the points put forward. It is comprehensive and a summary that does it justice would not be possible in this piece. Instead, we will simply outline its scope and depth for those of you who’d like to dip your toes into the freezing waters before taking the plunge!

The review covers the pathophysiology of the stages of freezing injury and their classification in the early stages. Formal classification can be difficult in the field and the authors have therefore recommended a two-tier field classification system which can be completed after rewarming but without need for imaging. Preventing frostbite is clearly better than trying to treat it.The various methods for prevention and their effectiveness are discussed in the next section of the review with the options for treatment depending on whether the frozen part has the potential to refreeze or not. Naturally, the early treatment options expand once a person has reached a hospital or high level field clinic. This review covers the management of hypothermia, hydration, rewarming and blisters as well as the use of low molecular weight dextran, aloe vera, antibiotics, tetanus, ibuprofen, thrombolysis, iloprost, heparin and other vasodilators in this setting. Post-thaw therapies are outlined in the final section of the review.

The need for further research into peri-thawing procedures and post-thaw therapies to improve outcome is identified in the review. Overall, it provides a thorough evaluation of the current treatment options available today and is well worth a read to those with an interest in taking people to cold places.

A case report on the physiological responses to extreme heat during Sicily’s July 2023 heatwave

Filingeri D, Valenza A, Ficarra S et al. Physiological Reports. 7 June 2024

You’ll be pleased to hear that things are starting to warm up a bit in this case study, which looks at the physiological response to heat in a healthy volunteer during the July 2023 heatwave in Sicily, where temperatures reached highs of 47 degrees celsius. The reports aimed to look at the effects of physical work or exercise when environmental factors such as solar radiation and airflow are taken into account; all difficult to replicate in laboratory experiments into heat tolerance. The participant was tested on two separate days, one with the highest level of heat warning possible issued by the Sicilian authorities and another where no warnings were in place. As you would expect, they found that exercise in the hotter temperature caused greater physiological stress. However, even on the cooler day, with no health warning, the volunteer still experienced a significant level of physiological stress. Filingeri et al. argue that the current advice regarding heat warnings may underestimate the thermal stress placed on even healthy people during exercise. Whilst this is a case study and represents data from a single participant, it provides good food for thought when planning a trip to warmer climates and considering the effects of rising world temperatures on sporting events.

Summary of Wilderness Medical Society Practice Guidelines for the Prevention, Diagnosis and Treatment of Acute Altitude Illness: 2024 Update

Rodway G, and Luks A. Wilderness Medicine Magazine. 8 July 2024.

We’re heading back to the updated WMS guidelines for this next article with a review of acute altitude illness. Once again the available evidence has been analysed and is presented by a panel of experts to help with prevention, diagnosis and management of Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE). Naturally there is a fair amount to work through here but the review is divided into clear sections looking at the different presentations. AMS and HACE are discussed together in the first half of the review due to the latter representing a rather extreme progression of the former. HAPE, and concurrent HAPE and HACE are covered in the later sections of the review. The treatment of these conditions depends on the severity of symptoms and whilst it is acknowledged that gradual ascent or even descent are usually the best options, the merits and indications for the various pharmacological approaches are also discussed in detail. This is once again a thorough and detailed review of altitude illness and a highly recommended read for any medic accompanying an expedition in the mountains.

Influence of Smoking and Alcohol Habits on Symptoms of Acute Mountain Sickness on Mount Fuji: A Questionnaire Survey-Based Pilot Study

Horiuchi M, Mitsui S & Uno T. High Altitude Medicine & Biology. 14 June 2024

The possible effects of different comorbidities on an expedition group is something that any medic needs to consider when planning a trip. However, Horiuchi et al make it clear that an individual’s recreational behaviour should also be taken into consideration. This paper looked at how smoking and alcohol consumption affect the incidence of AMS in hikers climbing Mount Fuji. The climbers were given questionnaires to collect data on smoking and alcohol use as well as general demographic data. Results from 887 hikers were analysed.

Symptoms of AMS were present in 45% of participants surveyed. Younger climbers (aged 20-29) were statistically significantly more likely to develop AMS. All ages of climbers were more likely to develop AMS if they had also been smoking during the ascent. The effects of alcohol consumption varied depending on age group. Younger climbers were no more likely to develop AMS with alcohol consumption (though they are already at increased risk in their own right). Middle-aged (50-59) climbers’ risk of AMS did increase with alcohol consumption.

Whilst the results of this study relies on self-reported behaviours, which leaves it vulnerable to bias, it does provide a useful insight into the possible effects behaviour and habits can have on the incidence of AMS within a group.

Global Health and Humanitarian Medicine

This section discusses two neglected tropical diseases, Rift Valley Fever and onchocerciasis. We investigate trends in opiod consumption across Africa and delve into the human factors behind mosquito net adherence. Finally, we explore the relationship between internet use and frailty.

Widening geographic range of Rift Valley fever disease clusters associated with climate change in East Africa

Situma S, Nyakarahuka L, Omondi E, et al. BMJ Global Health. June 2024

Rift Valley Fever (RVF) virus can cause haemorrhagic syndrome, jaundice and encephalitis. It is transmitted by mosquitoes and is found in humid areas. As this climatological profile is met by much of East Africa, the study focused on Kenya, Uganda and Tanzania to assess the relation of weather and RVF prevalence in humans and livestock. Previous studies established that extreme weather which enhances humidity (e.g. flooding) increases vector populations and can trigger epidemics in these regions. There is growing concern that climate change in East Africa will lead to an expanded geographic disease range. This study evaluated 100 disease events from 2008 to 2022. It found that 35% of identified RVF clusters were reported in areas that previously had no RVF history. The results of the study suggest that the combination of increasing temperature, increasing rainfall trends and a decrease in the annual number of dry days is a driving factor behind the escalating public health risk of RVF disease in Uganda. Similar patterns were observed in Kenya. A limitation is that many clusters represent as few as 1-3 human cases, drawing grand conclusions from a small sample size. In addition, the relationship between weather and prevalence is correlative and needs further research to establish if it is truly causal. Finally, due to lack of healthcare infrastructure, it is also necessary to acknowledge that case-reporting may not always reflect true prevalence, and that perhaps by comparing past to current datasets, the study is simply reporting an increase in monitoring.

Elimination of transmission of onchocerciasis (river blindness) with long-term ivermectin mass drug administration with or without vector control in sub-Saharan Africa: a systematic review and meta-analysis

Mutono, N., Basáñez*, M.G., James, A., et al. The Lancet Global Health. May 2024

Onchocerciasis or ‘River blindness’ persists in many countries despite half a century of programmes to decrease disease burden. More than 99% of onchocerciasis cases are found in sub-Saharan Africa. WHO has set an elimination goal by 2030. This systematic review collated data published on sub-Saharan Africa, in which a decade or more of ivermectin mass drug administration had been established (with or without vector control). Of 1525 articles screened after the removal of duplicates, 75 provided 282 records from 238 distinct foci in 19 (70%) of the 27 onchocerciasis-endemic countries in sub-Saharan Africa. It aimed to identify factors which contribute to successful elimination of transmission. The factors contributing to ongoing transmission included lack of vector elimination and holoendemicity. This suggests that long-term larviciding of blackfly-species breeding sites can significantly affect transmission of onchocerciasis. Furthermore, the areas in which continuous treatment with effective therapeutic coverage was established in 80% or more of the eligible population, improved the likelihood of achieving the elimination. Perhaps unsurprisingly, the results of the study indicate that  drug administration and blackfly vector control are key.

A proportion of these findings based on self-reported cases, the accuracy of which is difficult to ascertain. Additionally, due to the inclusion criteria, grey literature sources were not included (instead focussing on peer-reviewed articles), which is thought to explain the lack of data on eight onchocerciasis-endemic countries in sub-Saharan Africa. Nevertheless, the results are useful in providing guidance for the implementation of effective measures and can provide data for future transmission modelling studies on onchocerciasis.

Analysis of opioid analgesics consumption in Africa: a longitudinal study from a 20-year continental perspective

Hadjiat, Y., Toufiq, J., Ntizimira, C., et al. The Lancet Global Health. July 2024

Opioid analgesics have been listed as an essential medicine for palliative care and pain relief by the WHO. However, only 8% of available opiates are consumed by those in low/middle-income countries, compared with the remaining 92% being consumed by the high-income countries (who make up 17% of the world’s population). Several factors may contribute to this, though opioid expense underlies many of them. Healthcare professionals across many African countries seem reluctant to prescribe opioids (perhaps also due to cost), favouring non-steroidal anti-inflammatories (NSAIDs), even in cases where opioids would be indicated as first-line treatment. Individuals, aside from cost, may also reject opioids due to the stigma of pain endurance, palliative care and fear. Although cancer incidence and mortality in Africa has consistently risen during the last 20 years, the consumption of opioids remains almost unchanged.

The worldwide use of opioids has doubled each decade, mainly driven by high-income countries. This paper is the first to evidence the low and stagnant use of opioids in African countries between 1999 and 2021, and although it struggles to distinguish between the indications for opioid use, the increase of cancer and mortality strongly imply an increased need for opioids. Quality of data appears to be the study’s most significant drawback. For example, as tramadol is not under international control, it is not reported by the International Narcotics Control Board (INCB), meaning that no conclusions regarding this opioid could be made, and was therefore excluded. In addition, there is uncertainty in the consumption estimates due to imprecise population estimates and the number of stockpiled or unused opioid medications. Nonetheless, given the data and resources this research group did possess, it produced a compelling paper which suggests underconsumption of opioids in many African countries.

Reasons for mosquito net non-use in malaria-endemic countries: A review of qualitative research published between 2011 and 2021

Ladu, H.I., Shuaibu, U., and Pulford, J. Tropical Medicine and International Health. July 2024

Mosquito nets are the recommended method of vector control, yet they are not always used as advised and access to insecticide-treated nets is lacking. In this review, the lack of use of all forms of mosquito nets was analysed, using the qualitative data collated from literature between 2011 and 2021. It seems that the most common reasons for the non-use of mosquito nets were: lack of comfort (from heat and/or sharing one net between whole families), as well as perception of low mosquito levels. Furthermore, insecticide-treated mosquito nets were also underused due to the perception that malaria-risk was low or, conversely, that they needed to be saved for future use. However, the study only included English language publications and focused mainly on rural populations. When evaluating a qualitative study, it is important to remember that the quotes included are also subject to translation and potential bias. Nonetheless, this is an in-depth and analytical review presenting an insight into the under-use of mosquito nets and is unique for its focus on qualitative data, allowing greater insight into human drivers behind non-adherence. This research can guide future interventions to improve mosquito-net use.

Internet use and frailty in middle-aged and older adults: findings from developed and developing countries

Li, L. Globalisation and Health. July 2024

The term ‘frailty’ encompasses the decline in multiple physiological functions of the body, often leading to complicated care plans and burden on healthcare systems. In this unique multi-cohort study, Li investigated the longitudinal correlation between internet use and frailty across 32 countries. These cohorts encompassed a range of digitalisation, with the rates of internet use starting from 5.56% in China to 83.46% in Denmark. The results demonstrated that a country’s degree of development is also reflected in their rates of internet usage, but perhaps unexpectedly, also showed an inverse correlation between internet usage and frailty in middle aged and older adults. I say unexpectedly, as in younger generations, increased internet usage is often an indicator of poorer health (associated with lack of physical activity for example), yet there are many factors that can attempt to explain why in middle-aged/older adults this has the opposite effect in terms of frailty.

The finding that internet use correlated negatively with frailty is up for interpretation and further investigation. Li suggests that internet use mitigates social isolation (which accelerates frailty) and is a convenient source of information on healthy eating, exercise and medical information, which is what this demographic of adults tended to search. The correlation itself is robust, with the extensive sample size and data from 32 countries. Nonetheless, it is difficult to avoid some recall biases in this study, as the data was largely gathered from self-reports. Additionally, some datasets had presented internet use as a household rather than individual, meaning that the higher internet use of younger generations in the household may have skewed the outcome. Finally, this paper does not delve into whether increased internet use amongst the older demographic is in fact, preventing risk of falls or hospitalisation (which also define frailty), due to inactivity. It does however acknowledge the potential limitations and perhaps even negative implications of internet use and urges these to be taken into consideration in future research. Overall, the paper does provide a unique insight into the new and developing relationship between middle-aged/older adults and the internet era, furthering questions about how the two may work together to increase quality of life for this demographic.

The post Evidence Explorer: Updates and news from the academic community, Summer 2024 appeared first on Adventure Medic.

The man who wanted to see it all

Where: Netflix

About: On August 22, 1962, Heinz Stücke left Hövelhoff in Germany with his bicycle and a tent. Driven by an insatiable desire for adventure, he navigates diverse cultures and landscapes, forming connections with locals and confronting personal challenges along the way. Now, he returns home for the first time after more than 50 years of nomadic life without ever established in any one place. The film is a trip through his memories, and an introduction to the people he met during his lifetime, who have become his global family.

Why: The film beautifully captures the essence of adventurous trips, emphasizing the richness of diverse cultures and the connections we make along the way. It’s not just about the destinations; it delves into the personal growth and transformative experiences that come from stepping outside your comfort zone. It’s a reminder that sometimes the journey matters more than the destination!

Book:

The Art Of Risk

About: Dr. Richard Harris, an anesthesiologist and cave diver who played a crucial role in the Tham Luang cave rescue in northern Thailand, takes us into the lives of other ‘risk-takers’ to find out why they do what they do. Through five chapters, named Metal, Earth, Water, Air and Fire. All of these people are associated with a high level of risk involved in their professional, or recreational life, such as the free solo climber Alex Honnold.

The author frequently shares stories about his own passion for cave diving and how difficult it is for others to fully grasp: ‘Now and then, when learning about my sport and what it entails, people tell me I must be crazy. It turns out there are many people – who are otherwise perfectly polite – who aren’t shy of making this assessment. To the best of my knowledge, none of them were practising psychiatrists, but that doesn’t stop them from editorialising about my mental health.’

In this book he tests his scientific hypothesis that people who take seemingly huge risks are just like him:  not reckless adrenaline junkies, but careful, measured risk takers.

Why: This book brings valuable insights in the minds of the world’s leading risk-takers like big-wave surfers, free solo climbers, base-jumpers and many more. Like free solo climber Alex, who draws a distinction between risk and danger. ‘He thinks of risk as having two components – the likelihood of a dangerous event occurring and consequences of that event. For example, it’s highly unlikely that your commercial aeroplane will crash, but if it does, the consequences will be devastating. Because the risk-to-consequence ratio is extremely low, people continue to jet all over the world. According to Alex, a lot of his free-solo climbing isn’t particularly risky, because he knows, based on his record of previous successful climbs, that he has an incredibly low likelihood of falling.’

If you want to know more about how these people perform near-superhuman physical feats, mitigate risks and step out of their comfort zone into their ‘stretch zone’, then this is a must-read!

Podcast:

The Flying Doctor #77

Where: Spotify

About: Dr. Katrina Starmer tells the story of how she was inspired to become a Flying Doctor with the Royal Flying Doctor Service (RFDS) in Queensland, Australia. Her journey began as a teenager during a personal medical emergency, when she first encountered the RFDS. This experience motivated her to pursue a career as a flying doctor herself. Besides talking about her day-to-day work, she also mentions Survive25, a program designed to help teenagers make informed choices and avoid situations that could lead them to require the Flying Doctors’ assistance.

Why: The work at RFDS captures the imagination, yet it can be unclear what it fully involves. Listening to a doctor recount her journey into this field provides valuable insight. It is inspiring to hear how passionate she is about the RFDS and how she found her ‘Ikigai’.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘The Art of Risk’.

The post AM Team recommendations October 2024 appeared first on Adventure Medic.

The initial guide to marine envenomation was published in May 2016. With summer around the corner for the southern hemisphere, we thought it was time this important but rarely encountered condition was brought to the forefront again. Here is Dr Edi Albert’s original article again for your education, with an update on the most recent evidence to keep us current.

When I was eight years old we went on a family holiday to Majorca. As a lad growing up in Liverpool where the local waters looked like they had flowed straight out of Mordor, it was an amazing experience to splash around in the warm blue sea of the Mediterranean: until something slippery slithered past my leg and I screamed so loudly that even my usually hydrophobic mother rushed in to help. No doubt I was being overly dramatic. It probably wasn’t a sea snake that had relocated to cooler climes, nor a sea jelly (the taxonomists tell us not call them jellyfish – because they are Cnidarians and not fish at all), but probably just a bit of seaweed suspended in the water column and moving at the whim of the currents. The story has a happy ending: there were no marks on my legs, I did not suffer a cardiac arrest, and fortunately have become rather tougher and more stoic as an adult.

The point of the story is that more often than not, when somebody suffers an insult in the water we do not know what caused the problem. Sometimes we can make a pretty good guess based on geographical location and the context of the injury. Of course, it is sometimes evident what caused the injury: a sea snake caught in a fishing net, a cone shell picked up by someone unaware as to its potential, or an accidental brush with the spines of a sea urchin. But, given that this topic is not well covered at medical school, even knowing what did it might not help much.

It is quite possible to provide first aid care without knowing what creature caused the insult. Let’s face it, most of us aren’t marine biologists. If you want to provide care beyond first aid though, you will need to be reasonably certain about what type of animal did the dirty. With some prior preparation before your trip and our downloadable Marine Envenomation Flowchart, you can have a pretty good stab at that too.

Back to Basics

Before we dive headlong into the nitty gritty, let’s define the scope of this article and go back to basics to re-visit some toxinological concepts and definitions.

This article is about marine envenomations that may be experienced in an expedition context or may be seen in GP / ED settings in regions where these animals are endemic. It does not cover common nuisances such as swimmers itch, surfer’s ear or skin infections occurring in a marine context. Nor does it cover ciguatera and scromboid poisoning; though you will need to think about all of these before heading off on your dream trip to paradise. Oh, and then there are the sharks – just make sure you’re not the slowest swimmer in the group, or wear a pink and green wetsuit so you don’t look like a seal. Always works for me, although I get funny looks putting my wetsuit on at the beach.

What is the difference between poisoning and envenomation? Or between a toxin and a poison?

Toxinology is the study of toxins, in a restricted sense, with reference to the relatively unstable proteinaceous substances of microbial, plant, or animal origins.

Poisons are substances that disrupt the body’s normal functioning. Toxins are naturally occurring poisons. Venom is a toxin that is deliberately injected into by one animal into another. Venom is a cocktail of proteins, predominantly enzymes, which cause havoc by multiple means. The contents of the venom vary between species. Havoc is usually wreaked on one or more of the nervous system, coagulation, muscle, and the heart. Anti-venom can be used to combat envenomation, however, it doesn’t always help and serum sickness (the body’s immunological response to a foreign protein) can be a real problem.

Remember it is the patient that we are treating, not the venom or the animal. A thorough initial assessment of the patient, with regular reviews, to determine whether the patient is systemically well or not, and whether the patient has specific signs of envenomation or not, is essential.

It may also help to understand that venom potency is related to the temperature of the environment. Thus, marine envenomations outside of tropical waters are rarely significant. For example, whilst a Bluebottle sting in southern Queensland may be very unpleasant indeed, the same animal down in Tasmanian waters is unlikely to disrupt your activities too much.

Planning

Before you go, try to consider the following:

Pre-trip planning / What lives where you are going? How do they behave? What might they do to you?

Contacts / In the event of an incident, and where you will be providing ongoing care, make sure you already have the phone number of a toxinologist who is familiar with the region in which you are travelling. In Australasia the Poisons Information Centre Australia (13 11 26) is your one-stop shop.

Now let’s consider what to do when an envenomation occurs.

From First Aid to Advanced Care

How do we provide first aid treatment if we don’t know what did it?

When you look at the conventional medical texts and first aid books, the content is arranged by the animal implicated with specific treatments described accordingly. This isn’t particularly helpful when you don’t deal with this stuff very often. Especially when you don’t have an encyclopaedic knowledge of marine species and little idea as to what might have caused the problem. A different approach is needed.

Some years ago I stumbled upon Peter Fenner’s Marine Medic website. Peter is a doctor in Mackay, Queensland, and although now retired, he has an international reputation in this field of marine envenomation and co-authored the wonderfully worthwhile and amazingly illustrated Venomous and Poisonous Marine Animals: a Medical and Biological Handbook. His website contains a lot of interesting information, but the icing on the cake is a simple flow diagram that guides management based on a few simple clinical criteria.

I have adapted and extended his flow chart to include advanced care. Download it as a free PDF, then laminate it and put it up on your yacht or in with your dive gear.

Pain

The first thing is to determine whether the original injury was painful or painless. Perhaps surprisingly, some of the deadliest things are painless.

The Painless Puncture Wound

A painless puncture wound can be caused by cone shells, sea snakes and blue ringed octopus, and whilst the circumstances of the injury may point to the culprit, all you need to know to start with is that the patient has painless puncture wound, and if in an endemic area for these creatures, then pressure immobilisation bandages (elastic NOT crepe) should be applied in the same way that you would for a snake bite. It is important to immobilise the limb, not just wrap it up. This is most certainly a patient you will keep a very close eye on and attempt to evacuate. It is also one of the few pre-hospital presentations in which prolonged CPR in the event of an arrest is worthwhile.

The painful wound

The first thing to figure out here is whether there are any tentacles adherent to the skin that would suggest a jellyfish sting. The painful wound without tentacles adherent will be likely to have a barb in it – which may be broken off inside the wound. The context of the injury will help you figure out the culprit, but irrespective of that, hot water or heat packs are indicated to neutralise the toxin and relieve pain.

When it comes to jellyfish, Chironex (Chironex fleckeri or commonly known as the “box jelly”) and Irukandji (Carukia barnsi) are the two nasties that always get the attention as they can be deadly, but there are other species capable inflicting misery. First aid and ongoing management is species dependent and is covered in the flow chart.

A Case

Let’s test out this approach using the flowchart with a clinical case.

You are on a dive trip somewhere nice and warm, and heading back to camp located at the back of a shallow bay. Ahead of you is another dive boat. There is a lot of commotion going on and a man is hopping on one leg, yelling and hanging on to the boat for balance.

By the time you get there five minutes later he is sitting on the beach. His foot is very painful and looks like the one in the picture below.

What is your immediate management? / This is a painful puncture wound and should be treated with hot water to denature the toxin.

You help him hobble back to the campsite. However, there is no electricity and only a modest first aid kit.

How might you practically administer his treatment? / Heat water on the camping stoves, mix it with cold water, do the “elbow test” and partly fill a dry bag in which to place the foot. The hot water can be topped up at regular intervals.

When we looked after this case for real, we also administered liberal quantities of fine tawny port to the whole group to maintain morale. His pain subsided quite quickly and the foot was left bathed in hot water for a couple of hours. No symptoms or signs of systemic envenomation occurred. The patient continued with his dive trip and the swelling settled over the next few days.

Given the location and circumstances of the injury, can we hypothesise what animal caused it? / This injury occurred in warm waters to a man wading in a shallow, sandy bottomed bay. This suggests a stingray injury, as stingrays often settle half hidden under the sand in shallow water. A stonefish injury is less likely, but if in the right region within the realms of possibility. However, one might expect that the pain would not be well controlled with just hot water and that the patient would show systemic signs of envenomation and require evacuation.

Keep Swimming

Remember, all articles on this subject, including this one, tend to focus on the nasty stuff. The reality is that most bites and stings cause only self-limiting inconvenience and can be treated quite simply. So keep playing in the sea!

Most recent updates

Since this article was first written 6 years ago there have been ongoing questions about which jellyfish species are best treated with ice and which with heat, and which is better (1). I think this shows two important things. Firstly, doing research on envenomation is technically difficult and getting high powered good quality studies in vivo is very difficult if not impossible. Secondly, when we are talking merely about symptomatic treatment (as opposed to life saving treatment) the fact that the debate continues probably suggests it doesn’t matter that much. If it makes the patient feel better, it makes the patient feel better. The flow chart remains up to date according to the best evidence we have.

There is an ongoing myth, that started as a controversy, when it comes to the use of vinegar in tropical jellyfish. The research unequivocally proves that vinegar prevents nematocyst discharge. (nematocysts are the barbed stingers that when released inject venom). An in vitro study was published in 2014 that demonstrated that vinegar increased the venom load in already discharged nematocysts (2). This was quickly promulgated in the press – without the full story. Firstly, there is a question as to whether this in vitro study in fact translates into an in vivo situation, but the biggest catch is that although the effect seen in the study is undoubtedly true, approximately 80% of nematocysts on a patient after a sting are still undischarged. So, the overall effect with vinegar is to reduce the amount of venom available. Vinegar remains as a first aid treatment that has genuine merit.

Irukandji treatment has seen a positive breakthrough. Evidence of Magnesium remains unproven and expert consensus in Australia suggests its use only as a second- or third-line agent in those with severe sympathomimetic symptoms. For those of you who, like me, don’t see this injury every day the key issue with Irukandji Syndrome is the massive sympathomimetic response resulting in tachycardia, uncontrolled hypertension and severe pain that is often opioid refractory. A 2022 retrospective study demonstrated that clonidine given iv in a dose 1mcg/ kg had a marked reduction in their opioid requirements post administration (3). The authors of the study recommend that is be given early.

Useful resources

Apps

Australian Bites and Stings App (Android / Apple: Free on App Store)

FOAMEd

Clinical Toxinology Resources from the University of Adelaide

Berling I, Ibister G. Marine Envenomations. Australian Family Physician, 2015. 44(1); 28-32

Perkins RA, Morgan SS.Poisoning, Envenomation, and Trauma from Marine Creatures. Am Fam Physician. 2004 Feb 15;69(4):885-890. This article provides a good overview with an American focus.

Lionfish and Stonefish Envenomation

Books

Warrell DA. Risks from animals. Ch17 in Johnson C et al (eds) Oxford Handbook of Expedition Medicine. Oxford: OUP; 2015.

White J. A Clinician’s Guide to Australian Venomous Bites and Stings. Parkeville: CSL Laboratories; 2013.

Williamson JA, Fenner PJ, Burnett JW, Rifkin JF (eds). Venomous & Poisonous Marine Animals. Sydney: UNSW Press; 1996.

A big thanks to Dr Bill Nimorakiotakis, Emergency & Retrieval Physician, and Clinical Toxinologist for reviewing this article. Cover image: Blue Ringed Octopus (Zain Fimmel)

References

1. Seymour J. Are we using the correct first aid for jellyfish? Med J Aust 2017; 206 (6): 249-250. || doi: 10.5694/mja17.00053
2. Welfare P, Little M, Pereira P, Seymour J. An in-vitro examination of the effect of vinegar on discharged nematocysts of Chironex fleckeri. Diving Hyperb Med. 2014 Mar;44(1):30-4. PMID: 24687483.
3. Isman A, Seymour J, Little M. Use of clonidine in the treatment of Irukandji syndrome: A 4-year retrospective cohort study on safety, efficacy and clinical utility. Emerg Med Australas. 2022 Aug;34(4):504-508. doi: 10.1111/1742-6723.14017. Epub 2022 May 31. PMID: 35638940.

The post AM Guide to Marine Envenomation – an update appeared first on Adventure Medic.

Diving and Hyperbaric Medicine is a unique subspecialty of medicine that many trainees never get exposed to throughout their entire careers. For aspiring adventurous medics, a new opportunity to work as a Foundation Doctor at the DDRC is a great way to gain experience in this field in a supportive setting. Dr Ayesha Sithirapathy describes her experience of working as the first-ever F2 doctor in Diving and Hyperbaric Medicine at the DDRC Hyperbaric Chamber.

What is the DDRC?

DDRC Healthcare (formerly the Diving Diseases Research Centre) is a hyperbaric medical facility in Plymouth. It is one of only 10 chambers in the UK providing emergency hyperbaric oxygen therapy (HBOT) as British Hyperbaric Association (BHA) members. DDRC is a registered not-for-profit organisation and has three key aims: research into hyperbaric illnesses and treatments; education to improve diver safety and accident management; and HBOT for both emergency and non-emergency conditions.

Whilst the centre is best known for treating diving decompression illness or ‘the bends,’ divers only account for one-third of their patients. They also offer HBOT for a variety of non-diving-related conditions. These conditions include iatrogenic gas embolisms, radiation proctitis, sudden sensorineural hearing loss, non-healing wounds, and many more.

DDRC delivers 24/7 diving and hyperbaric medical emergency services, operating the national BHA Emergency Helpline. As well as this it produces diver safety materials, presentations, courses, and events.

My Journey to DDRC

The Foundation Year Two role was created in 2023, making me the first person to rotate to DDRC in this capacity. The application process for this job has since changed, and now uses the national allocation process on Oriel. Having been an active member of the University Wilderness Medicine Society I had a small amount of academic exposure to dive medicine and medicine in controlled environments. However, no prior knowledge or experience in this field is required with excellent on-the-job teaching and close supervision to guide you through. It was a steep learning curve initially, but rewarding to see the progress of assessing and treating patients with both emergency and non-acute presentations.

What cases do you see?

The DDRC’s clinical work is roughly divided into emergencies (e.g. ‘the bends’ and gas embolisms) and elective therapies. The DDRC is also involved with outpatient clinics and reviews inpatient referrals from Derriford Hospital.

As the F2 Doctor, you occasionally hold the on-call doctor bleep in hours as the ‘duty doctor’ and can take calls through the BHA Emergency Helpline. You will always be supervised and have people to ask for advice if you are unsure about anything.

For example, when I was the duty doctor, I took a call regarding a diver in Dorset who developed neurological symptoms after surfacing; unilateral arm paresthesia and weakness. Working through a proforma of questions the patient’s history suggested a likelihood of having the bends (inert gas bubbles evolving within body tissues). For this condition, the patient required an in-patient assessment at our chamber. I provided advice on how to stabilise the patient and arranged for a transfer to the chamber.

On arrival of the patient, I led the initial assessment, including a full history, neurological exam, and hyperbaric chamber safety checklist. As an F2, all of this is done under supervision from a senior doctor highly experienced in hyperbaric medicine.

This patient responded brilliantly to treatment in the chamber. The treatments have set times but can be extended until the patient’s symptoms resolve, sometimes lasting several hours. If, despite this, there is not a satisfactory resolution of symptoms, the patient would be reassessed to decipher whether there may be another cause for the symptoms.

Outcomes are significantly improved the faster treatment is commenced thus helicopter versus ambulance transfer is often a decision we need to make. The DDRC is technically a remote medical site, so patients must be stable before arriving here. If they are unwell, we recommend they attend the Emergency Department first as a clinical priority – we are then only five minutes away from Derriford Hospital, a major tertiary centre.

How does this role fit into Foundation Training?

This job is located within the Peninsula Deanery (covering Devon and Cornwall) and accounts for your community F2 job if working at Derriford Hospital in Plymouth. Although the hours are Monday to Friday, 08.30 am to 5 pm, you are welcome to attend any out-of-hours emergency calls for excellent learning. It is a standard-length 4 monthly rotation with only one F2 doctor at a time thus providing a wealth of supervised learning opportunities.

As a community placement, I found it to be a well-needed break from the acute hospital rush. If you are an outdoorsy person then living in the South West is fantastic. Having Dartmoor and the South Coast on the doorstep is a huge perk and a complimentary bonus of training in Devon.

Other opportunities

Aside from the clinical work mentioned above, the role has plenty of non-clinical opportunities. You can get involved with teaching on the various courses offered by the DDRC, delivered to both medical and non-medical personnel. With this teaching experience, and more head space, I  designed and implemented a new part of the Peninsula Deanery Foundation Doctor’s regional teaching programme.

Engaging in research and audit opportunities has also been an excellent benefit of the job. Having protected project time allowed me to complete an audit of the BHA helpline calls from last year; presenting these results at the national 2023 BHA/UKDMC in London.

There is an opportunity to attend teaching, including the Diving Medical Advisory Course (which is the qualification required to become an Approved Medical Examiner of Divers) around your work commitments.

As well as being a great start for anyone wanting to pursue a future career in Diving Medicine this role supports doctors looking to do any remote or expedition work near the coast or sea.  Aside from this F2 position, there are junior clinical fellowship positions available at DDRC which I am fortunate enough to be starting now.

The Verdict

My experience at DDRC was overwhelmingly positive. The staff are all extremely friendly, supportive and keen to teach. I found it intellectually stimulating covering new and exciting content whilst being very practical. The only downside is that it is slightly less clinical when compared to other Foundation rotations but the other opportunities more than make up for this.

Overall, I would wholeheartedly recommend applying for this F2 role if you can. DDRC is one of the only places in the UK where junior doctors can train and work in diving and hyperbaric medicine, so whether you are specifically interested in pursuing a career in these fields or simply want to learn something new, it is a fantastically unique opportunity!

Photos Courtesy of Dr Ash Sithirapathy

The post A New Foundation Doctor Role in Diving and Hyperbaric Medicine appeared first on Adventure Medic.

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

Clinical fellowship title, specialty and grade 

Title: Clinical Fellow in Emergency Medicine with Specialist Interest

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

Base Specialty: Emergency Medicine 

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

Structure of the role

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

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

Prerequisites for application  

This fellowship prerequisites are straightforward:

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

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

Location of fellowship

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

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

Brief description of the job role.

Emergency Medicine:

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

Special Interest:

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

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

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

Academic accreditation

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

Overall impression 

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

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

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

Outcomes of the fellowship

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

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

Costs and potential funding

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

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

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

Anything else you wish you’d known beforehand?

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

Job application:

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

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

Soo Jeong Han / Medical Student / King’s College London

Dr Constance Osborne / Evidence Explorer Lead / Bristol

Contents

• Introduction and Collaborators
• Expedition and Wilderness Medicine Section
• Global Health and Humanitarian Medicine Section
• Want to get involved?

‘April showers bring May flowers…’

This old adage feels appropriate for the wet spring that we’ve experienced this year. After all the rain, the sun is finally shining through and the countryside is bursting with colour. You might see golden gorse, scarlet poppies or violet bluebells. This season, we have gathered together a collection of summaries as striking as a field of wildflowers. We hope you enjoy this edition of the Evidence Explorer. 

Abbie Oster is a medical student at the University of Leeds, who has just finished her intercalated year in Physiology at King’s College London. In her free time, she enjoys powerlifting, running and the occasional ski trip. Her dream job is to be a ski doctor in the Alps, once she has perfected her French! She is looking forward to returning to Leeds and the moors to do some hiking.

Soo Jeong Han is a medical student at King’s College London. She is interested in expedition and humanitarian medicine. Reviewing articles for the Evidence Explorer has allowed her to delve into the research side of global health and health inequalities. She enjoys travelling the world and experiencing many different cultures, as she herself has lived in six different countries growing up!

Wilderness and Expedition Medicine

This edition is especially adventurous, with articles linked to every sort of environment. We discuss the energy required for ocean crossings, nutrition at altitude and vital signs monitoring in space. We summarise the effect of delayed suspension syndrome on aerial activities and musculoskeletal injury trends in trail runners.

Maximal Sustainable Energy Intake During Transatlantic Ocean Rowing Is Insufficient For Total Energy Expenditure And Skeletal Muscle Mass Maintenance

Holsgrove-West R, Iniesta R, Abdelrahman D et al. The Physiology Society: Experimental Physiology. February 2024

This article explores the physiological limits of energy intake (EI) during extreme endurance activities, particularly focusing on a transatlantic rowing race. The study involved 49 participants, both male and female, aged 24 to 67, who rowed for approximately 46 days, covering 3000 miles. Researchers measured EI, total energy expenditure (TEE), body mass, and muscle mass before and after the race.

They found no significant differences between sexes or age groups in EI, TEE, or body mass loss. Despite participants consuming EI at about 2.5 times their resting metabolic rate (RMR), it was insufficient to match the total TEE, indicating a physiological limit to EI. The study highlights that even with a maximal sustainable EI, individuals experienced significant body mass loss, suggesting a limit to the body’s ability to intake energy during prolonged ultra-endurance activities. With the increasing popularity of ultra-endurance sports it’s important to consider adequate nutritional intake when supporting the endeavours of those undertaking these feats.

Beyond the realm of sports, this study’s implications are important in crucial areas like managing critical illness, navigating space travel challenges, and addressing ageing-related concerns, underscoring human energy dynamics across diverse scenarios. The article also demonstrates the importance of good nutritional planning for extended expeditions, revealing the challenge of sustaining optimal nutritional equilibrium in such demanding circumstances.

Nutrition In Women At High Altitude: A Scoping Review—UIAA Medical Commission Recommendations

Andjelkovic M, Paal P, Kriemler S et al. High Altitude Medicine & Biology. March 2024

This review article looks at the role of nutrition for women during short-term, high-altitude activities. High-altitude affects the body in many ways and therefore optimising nutrition is vital. The researchers found that high-altitude exposure induces metabolic changes, impacting carbohydrate and fat utilization. While menstrual cycle phases may influence metabolic responses, it was found to be more important to ensure sufficient carbohydrate intake to support overall health and performance. Protein consumption, particularly in relation to muscle anabolism and catabolism, warrants further investigation.

Hydration is important, considering increased respiratory and urinary water losses at altitude. Weight loss patterns differ between sexes, with appetite suppression and increased energy expenditure contributing to this. Iron metabolism is pivotal, as iron deficiency is more common in women and can impact erythropoiesis, which is crucial for acclimatization. However, evidence on iron supplementation remains inconclusive.

Regarding supplementation, few studies address women specifically, highlighting the need for further research. While carbohydrate drinks and beet juice may aid performance and acclimatization, zinc and leucine supplementation show limited benefits. Overall, maintaining energy balance and hydration is key for high-altitude performance, with consideration for individualized nutritional needs and supplementation strategies. The review demonstrates the need for more comprehensive research to elucidate women-specific nutritional requirements in high-altitude environments. It is interesting to know more about nutritional requirements specifically for women, considering the significant influence hormones play over systemic functions in the body. This understanding suggests an opportunity to tailor nutrition to better support women’s health and well-being.

Delayed Suspension Syndrome Onset In Aerially Suspended Victims Through Leg Raising

Willihnganz S, Ahmed Z, Lee J. Wilderness and Environmental Medicine Journal. March 2024

Suspension syndrome (SS) is due to venous blood pooling in the extremities during passive suspension, occurring in activities like mountaineering or industrial work at heights. Venous blood pooling leads to functional hypovolemia, inducing pre-syncopal symptoms and can cause loss of consciousness or death. This study aimed to explore leg raising as a prevention strategy for SS, hypothesizing it could delay symptom onset.

University of Birmingham students participated in the study, randomly assigned to control or intervention groups. Participants were suspended in neutral or legs-raised positions, with measurements collected pre, mid, and post-suspension. Leg-raised participants demonstrated significantly longer suspension times and lower pain ratings, suggesting delayed symptom onset. The study highlighted the potential of leg raising to delay SS symptoms in passively suspended individuals, offering insights for emergency workers. Notably, leg raising reduced lower extremity mottling, an indicator for early SS symptoms. These findings could inform standard operating procedures for aerial rescue, enhancing emergency response protocols and provide better advice for paramedics and pre-hospital medics working in the field.

Further research with larger sample sizes and continuous data collection methodology is needed to ensure the findings of this research is valid. Using advanced techniques like ultrasound or near-infrared spectrometry could provide more information about onset of SS. The simulation nature of this study, small sample size and young participants may affect generalizability. Therefore, future investigations are needed and should explore additional interventions to prevent or delay SS onset.

Musculoskeletal Injuries During Trail Sports: Sex And Age Specific Analyses Over 20 years From A National Injury Database

Owen M, Workman C, Angileri H et al. Wilderness and Environmental Medicine Journal. March 2024

In this study, the incidence of MSK injuries was investigated in relation to the rising popularity of trail sports in the past two decades. From analysis of US emergency department patients (2002-2021 inclusive), there was a significant rise in injuries seen during the period. Interestingly, while males constituted a larger proportion of injuries in the early 2000s, females surpassed them in injury rates from 2010 onward. The increase in female injury rates aligns with the growing participation of females in outdoor activities, underscoring the need to understand and address gender-specific injury patterns. Looking at the differences between age groups, those under 18 exhibited higher rates of head injuries and concussions, indicating a potential area of concern for youth participating in trail sports. On the other hand, individuals over 65 showed higher rates of fractures, emphasizing the importance of tailored interventions to mitigate injury risks in older populations, such as monitoring for reduced bone strength in osteoporosis.

Further analysis revealed distinct injury patterns between sexes, with males more prone to shoulder, upper trunk, and hand injuries, while females experience more elbow, wrist, knee, lower leg, or ankle injuries. Moreover, females were more likely to sustain strains/sprains and fractures, highlighting potential anatomical and physiological differences contributing to injury susceptibility. The study also identifies discrepancies in injury rates compared to expected values for specific activities and age groups. For instance, mountain biking participation among those under 18, had higher injury rates than predicted, signalling a need for targeted interventions such as concussion prevention education and helmet promotion.

Despite limitations in data representation and analysis, the findings underscore the importance of injury prevention strategies in trail sports. This is particularly important to address sex-specific and age-related injury patterns, in order to promote safe and enjoyable outdoor recreational activities.

A Built-In Guidance System To Monitor Vital Signs In Space And On Earth

Huerta R, Kaduk S, Fatai L et al. Aerospace Medicine and Human Performance. March 2024

This article addresses the challenge of providing timely and effective medical support during remote operations and exploration missions, both on Earth and in space. With longer evacuation times and limited access to medical facilities, future deep-space exploration missions require enhanced medical care for crew members. Technological advancements, particularly in telemedicine, have significantly improved medical support from the ground, increasing the crew’s ability to handle medical emergencies independently.

The study compared the use of a ‘Tempus Pro’ (a tool to measure a range of vital signs) in medically trained and medically untrained subjects, comparing the usability and ratings of ease. The results found that both groups were able to obtain stable and valid vital signs within a clinically acceptable time frame. While medically experienced individuals performed faster, the inexperienced group demonstrated significant improvement after one simulation, suggesting the device’s effectiveness in training individuals with limited medical background. This has potential benefits for future space missions.

Despite limitations such as a small sample size and the absence of female subjects, the study demonstrates the potential of automated medical devices equipped with guidance systems to provide lifesaving support during remote missions.

Global Health and Humanitarian Medicine

This section summarises a range of topics including communication about herbal medicine during pregnancy, a potential solution to anti-venom shortages, the long term efficacy of the dengue vaccine and the feasibility of psychological therapy being delivered remotely in a humanitarian setting. 

Patient Physician Communication On Herbal Medicine Use During Pregnancy: A Systematic Review And Meta-Analysis

Hyea Bin Im, Jung Hye Hwang, Dain Choi et al. BMJ Global Health March 2024.

This systematic review of 111 studies across 51 countries has revealed that 34% of pregnant women use herbal remedies during pregnancy, believing these to be more natural and mild compared to pharmaceutical medications due to the potential risk of teratogenicity.  For example, ginger, peppermint, and chamomile have proven effective in relieving nausea and vomiting, while cranberry consumption has demonstrated efficacy in preventing urinary tract infections. However, only 28% of these women disclosed their use of herbal remedies to their healthcare providers, often due to perceived safety (sometimes from unreliable internet sources) and a lack of inquiry by doctors. This could lead to inappropriate use of remedies, for example, inappropriate use of ginger can lead to stomach irritation, heartburn, and even cardiac arrhythmias. Prolonged use of chamomile has been associated with a higher risk of preterm delivery and low birth weight.

It was found that disclosure about herbal remedy use to healthcare providers resulted in significantly better health outcomes for pregnant women, while non-disclosure was correlated with higher maternal and neonatal mortality rates. This highlighted the importance of more effective communication and proactive inquiry into the use of herbal remedies to improve antenatal care and, in turn, reduce mortality rates in both mother and baby.

African Polyvalent Antivenom Can Maintain Pharmacological Stability And Ability To Neutralise Murine Venom Lethality For Decades Post-expiry: Evidence For Increasing Antivenom Shelf Life To Aid In Alleviating Chronic Shortages

Gabriela Solano, Sinead Cunningham, Rebecca J Edge et al. BMJ Global Health. March 2024.

Antivenom is a polyclonal mixture of antitoxin antibodies refined from hyperimmunised horses or sheep. It is currently the only established treatment for snake envenomation, which is thought to cause approximately 81,000 – 138,000 deaths each year and permanently disables a further 400,000 people worldwide. It would be helpful if the stocks of these antivenoms lasted a long time, but antivenom stocks are known to last only 2-5 years (depending on the antivenom), after which time these are discarded. Even in places where antivenom distribution and storage is limited, substantial quantities of antivenom are still discarded. The most notable example of this is Sub-Saharan Africa, where suboptimal inventory management and lack of research around national antivenom distribution requirements contributes to a waste of up to 50% of stocks despite the extremely limited supply.

This study, using in vitro and murine in vivo methods, provided evidence that the South African Institute for Medical Research (SAIMR) polyvalent antivenom can retain preclinical efficacy and maintain acceptable stability for up to 25 years after its stated expiry date. This provides promising evidence that supports the use of expired antivenoms in emergency scenarios where in-date antivenoms are not available. There is precedent for this, as the US Food and Drug Administration (FDA) approved the use of expired North American coral snake antivenom.

Feasibility And Acceptability Of Phone Delivered Psychological Therapy For Refugee Children And Adolescents In A Humanitarian Setting

Fiona S. McEwen, Hania El Khatib, Kristin Hadfield et al. Conflict and Health Jan 2024

This is the first study to explore feasibility and acceptability of telephone-delivered therapy with refugee children in a humanitarian setting. Accessibility of psychological therapy is a huge barrier for refugee children, not only because of the shortage of mental health professionals, but also the cultural stigma of receiving therapy, especially in conflict zones. This study used telephone delivered therapy (the Common Elements Treatment Approach – CETA) by lay counsellors (n=3) to try to bridge this accessibility gap. The children (n=11) that were contacted lived in informal tented settlements in the Beqaa region of Lebanon. The counsellors, family members and children themselves were interviewed after the session, and the results thematically analysed.

The results showed that telephone-delivered CETA was effective in reducing symptoms for many of the Syrian refugee children. It also showed that various factors (such as the family’s preconceived attitude to mental health) and the relationship with the counsellor and the family affected the efficacy of the therapy delivered. Challenges in logistics, such as poor network coverage and communication difficulties over the phone were also highlighted.

Post Discharge Malaria Chemoprevention In Children Admitted With Severe Anaemia In Malaria Endemic Settings In Africa: A Systematic Review And Individual Patient Data Meta Analysis Of Randomised Controlled Trials

Kamija S Phiri, Carole Khairallah, Titus K Kwambai et al. The Lancet Global Health Jan 2024.

Severe anaemia poses a significant risk of death for young children, especially in malaria-prone regions. Surviving children often face further risks of death or hospital readmission after discharge. Researchers have conducted a comprehensive review and meta-analysis to evaluate the effectiveness of monthly malaria chemoprevention in children recovering from severe anaemia.

Numerous databases were reviewed for relevant studies, ultimately including three double-blind, placebo-controlled trials from The Gambia, Malawi, Uganda, and Kenya. These trials involved 3,663 children and tested different malaria prevention drugs administered monthly post-discharge. Children who received malaria chemoprevention showed a 77% reduction in mortality and a 55% reduction in readmissions during the intervention period compared to those given a placebo. However, the protective effects did not last beyond the treatment period, highlighting the need for continued research into extending these benefits. One major limitation is the small number of trials analysed, which made it difficult to assess heterogeneity and publication bias.

Long Term Efficacy And Safety Of A Tetravalent Dengue Vaccine (TAK-003): 4·5 Year Results From A Phase 3, Randomised, Double Blind, Placebo Controlled Trial

Vianney Tricou et al. The Lancet Global Health Feb 2024

Dengue fever threatens nearly half of the global population, particularly in endemic regions. To address this, researchers evaluated the long-term efficacy and safety of the tetravalent dengue vaccine, TAK-003, in children and adolescents. This is an ongoing RCT across 26 medical centres in 8 dengue-endemic countries.

The vaccine was effective against all four dengue virus serotypes in previously exposed participants, while it showed efficacy against DENV-1 and DENV-2 in those without prior exposure. Of note, it is difficult to predict the transmission dynamics of the different DENV stereotypes. Serious adverse events were similar between the TAK-003 and placebo groups over the 4.5 years, with no deaths attributed to the vaccine. This study highlights TAK-003 as a promising long-term solution for dengue prevention in endemic regions, with further research required to explore its efficacy across different populations and serotypes.

The post Evidence Explorer: Updates and news from the academic community, Spring 2024 appeared first on Adventure Medic.

Aftershock, Everest and the Nepal Earthquake

Where: Netflix

About: A three-part series from Netflix looking at the calm before, the terror during, and the aftermath of the Nepal earthquake in 2015. The earthquake killed nearly 9000 people and made hundreds of thousands of people homeless in an instant.

Why: There is a sense of dread in the first instalment, knowing what is to come. Certainly, when it hits, the handheld footage brings home the impending devastation and a snapshot of the fear felt watching death charge towards you. The series manages to balance both the personal tragedies and the scale of the disaster. It also takes care to focus on the devastated communities, and not just the expedition teams. Indeed, they reflect on the ethics of asking to be saved when others are worse off than you.
There is a terrifying insight into instigating a mass casualty triage at base camp, with real time decisions being made on screen. Left with nowhere to see people, and no equipment to help them with, the medical team resort to supportive care. Despite all the devastation and suffering around, some still want to summit the mountain, providing an interesting glimpse into the power of “summit-fever.”
We don’t know how we will react in a never-event. We train and practice and hope we will act well, but we won’t know until then. We glimpse the good and bad of humanity, with a chilling reflection that we are as dangerous as nature.

If you want to find out more about the medical side, there is a write up of the mass casualty event: Zafren K, Brants A, Tabner K, et al. Wilderness Mass Casualty Incident (MCI): Rescue Chain After Avalanche at Everest Base Camp (EBC) In 2015. Wilderness & Environmental Medicine. 2018;29(3):401-410.

Book:

Holiday SOS

About: Did you know that Monday the 27th is statistically the worst day for an accident? Or that most problems arise in the first 48 hours of a holiday?

‘Holiday SOS: Lifesaving Adventures of a Travelling Doctor’ by Dr Ben MacFarlane offers an insightful and often humorous look into the life of a repatriation doctor. The book chronicles Dr MacFarlane’s experiences as he travels around the world, assisting holidaymakers who fall ill or suffer accidents while abroad. Dr MacFarlane provides a behind-the-scenes look at the challenges and rewards of his unique profession, by sharing his most memorable stories during his year working as a flying doctor.

Why: When sitting down on the plane, having already successfully navigated traffic, security, finding the gate, and the ever-changing baggage restrictions, there is just one phrase left that could crash the holiday spirit. The phrase is one that many medics dread hearing on the tannoy, namely, “is there a doctor on board?”
Fortunately, most doctors never have to help during a flight to their holiday destination.
From the comfort of your sofa, this book allows you to discover what kind of medical problems a repatriating doctor can encounter, from a few broken bones to life-threatening situations, such as ventricular fibrillation or a malfunctioning chest drain. Dr MacFarlane demonstrates just how creative you have to be as a flying doctor, like, for instance, using a urinary catheter to stop a severe nosebleed.
Besides these dramatic and sometimes hilarious situations, he is also able to vividly describe the flamboyant characters he meets during his repatriating duties. He shares the stories of the elderly lady who refused to go back home, and the cardiologist who knew better than him at every step.
All in all, it gives the reader a great insight into a not-everyday profession.
…Are you prepared for your next holiday?

Podcast:

World Extreme Medicine podcast: “It’s never too late to dive in and it’s kind of amazing what the opportunities will turn out to be.”

Where: Spotify

About: A diverse panel of medical professionals share their unique journeys into expedition medicine. The speakers include eye surgeons, dentists, GPs, emergency doctors, humanitarian doctors, and the director of space medicine group.

Why: It can be hard and confusing sometimes to find out how to get into expedition medicine. In this podcast the panel discuss how they expanded their traditional medical career to expeditions and beyond, and the importance of saying yes to an opportunity. The skills they have learned in austere environments appear to apply to their daily job too. It is inspiring to hear how their change of career path changed their lives drastically, and gave them a sense of fulfilment and happiness.
Despite their passion for expedition medicine, it is an honest conversation. They also discuss the negatives, such as the financial compromise, because it does not pay as well as working in a hospital, and the fact that it interferes with your family time. One of their recommendations is to find a mentor figure in the expedition medicine world. This podcast features six of them, so that’s a great start.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘Holiday SOS’.

The post AM Team recommendations July 2024 appeared first on Adventure Medic.

Another beautiful autumnal weekend in Edinburgh draws to a close, and with it another World Extreme Medicine (WEM) conference. The Adventure Medic team was there all weekend, chatting to attendees and WEM staff alike, spreading the word about our website, and widening our network. In this piece, we will give you a rundown of our favourite sessions and our take-home messages from the conference. 

What is it?

A three day conference open to people from all career backgrounds and experience in extreme medicine. The event takes place at Dynamic Earth, a stunning venue found at the foot of Edinburgh’s Salisbury Crags. It is an event to learn new skills, hear about novel research, discuss topics with the best in the field, and of course to have a jig at Saturday’s ceilidh. The conference is organised by experienced clinicians and instructors, who are specialists in delivering training for medical work in extreme environments worldwide.

Conference highlights

Mr Ken Hutt – he is setting out to be the oldest person to paraglide from the summit of Everest, whilst raising awareness and money for Rotary International’s End Polio Now campaign.

Mr Alex Lewis and Dr Geoff Watson – a presentation about the relationship between Alex, who contracted life-threatening Toxic Shock Syndrome, and the doctor that saved his life. Alex has gone on to travel in extreme environments and become a motivational speaker.

Mr Benjamin Black – he led multiple sessions over the weekend, the most memorable being an exploration of how to deliver safe sexual and reproductive healthcare in environments where this is not always welcomed.

Dr Saleyha Ahsan – an eye-opening session on ‘Healthcare as a Weapon of War’, the subtle (and not so subtle) ways that medical care can be used to achieve battlefield objectives, and how we as clinicians can avoid being complicit in this.

Mr Jamie Pattison – a member of UKISAR, paramedic and winchman Jamie was an impressive yet relatable speaker. One of his sessions on how to carve a niche for yourself in the field of extreme medicine was particularly inspiring.

A sense of community

The WEM conference is accessible to a variety of disciplines. We were delighted by the range of people who came and spoke to us at the Adventure Medic stand: nurses, paramedics, dieticians, physiotherapists, police officers, first responders, and journalists. It was a refreshing group to move amongst and felt representative of the multi-faceted world of extreme medicine.

From humanitarian speakers to practical sessions on wilderness dentistry (from our own patron dentist Dr Burjor Langdana) and improvised medicine, everyone in attendance was keen to share their experience, and answered questions openly and honestly.

Dr Klara Weaver, Dr Alex Taylor and Dr Erin Kilborn were three speakers that exemplified this nicely, by not only highlighting the positives of working in a remote environments, but also the stark, sometimes lonely reality of practising medicine in these places. There was no omission of difficulties, but instead a balanced account of their experiences and the outcomes.

Research Presentations 

There were several sessions over the weekend that involved the presentation of original research. Two projects in particular caught our attention, not only because of the nature of the research, but because of the exciting ways in which they collected their data in remote environments.

Project NEPTUNE 100 (https://www.mrdf.org/project-neptune) took place in Key Largo, Florida and involved Dr Joseph Dituri living underwater for 100 days. During his time subaquatic, he conducted extensive physiological, psychological, and biochemical testing, measuring the body’s response to the stresses of living underwater.

Our very own Adventure Medic patron, Professor Chris Imray, along with the Inspire22 team, presented their experience of collecting data during a ski expedition to the South Pole. There were useful discussions on how to gain sponsorship for big trips and the necessity of exploring non-traditional financial avenues. The comradery amongst the team was evident in their panel talk and Q&A session, which emphasised that the experiences and friendships you make on an expedition are often the biggest takeaway.

Final thoughts

Without a doubt, there are two speakers that have stayed with us on our journeys home this year. The first, Dr Romain Pizzi, a wildlife veterinarian, who spoke about the ethical question of treating individual animals in the context of their habitat being destroyed. Secondly, Mr Martin Penmar, a trauma surgeon, who asked us to question whether all boundaries should be pushed, and reminded us that there are some lines that should not be crossed. This is a topic that is relevant to all of us, and encourages us to question the moral and ethical issues that lie behind practising medicine outside of the hospital environment.

Get Involved

If you came up and spoke to us at our stand and would like to get involved, please contact us at contact@theadventuremedic.com.

The World Extreme Medicine Conference will once again return to Dynamic Earth in Edinburgh on the 16^th – 18^th November 2024. To find out more and book your ticket, click here.

The post World Extreme Medicine (WEM) Conference 2023: pushing boundaries and considering our own appeared first on Adventure Medic.

Dr Klara Weaver / Locum Acute and Emergency Medicine Doctor / Inverness

Dr Constance Osborne / Locum Emergency Medicine Doctor / Bristol

Contents

• Introduction and Collaborators
• Global Health and Humanitarian Medicine Section
• Expedition and Wilderness Medicine Section
• Want to get involved?

At last, the crocuses are out and the sun is shining. Here at Adventure Medic we can’t wait for the spring to arrive, but let’s take a moment to back over all the wonderful research that came out this winter. Once again, thank you to our fabulous collaborators who have taken the time to comb through over twenty journals to find some of the best articles out there.

Dr Lydia Potter is an F3 doctor living in Conwy, Snowdonia. She is currently doing a less-than-full-time Junior Clinical Fellow job in Emergency Medicine and Paediatrics in Ysbyty Gwynedd, Bangor. In her spare time, she is part of the RNLI boat crew in Conwy and teaches on Unique Expeditions’ UK courses. She has experience providing medical cover for expeditions, ultra-endurance races, sports matches and festivals in the UK and abroad. She is working towards her Mountain Leader qualification. When not at work, you can find her open-water swimming, hiking, climbing or bouldering in Eryri National Park. After her F3 year, she is hoping to enter EM ACCS, continue doing expedition medicine work, and eventually sub-specialise in PHEM.

Dr Klara Weaver is an acute medical and emergency medicine doctor currently practicing in the highlands. She has been involved in expedition medicine for the past five years from Antarctica to Mongolia and everywhere in-between. She is looking forward to starting GP training in the Highlands and in her spare time is a passionate mountaineer and lover of cold places.

Global Health and Humanitarian Medicine

In global health and humanitarian medicine we present eight papers from across the world. We begin with an evidence-based call for the climate crisis to be treated as a global health emergency, an unflinching statement piece published by an authorship group of 200 health journals. From there, we journey to the Philippines to discuss a randomised controlled trial from Reñosa et al., testing a novel initiative to improve vaccination compliance.

We then dive into an exploratory analysis by Koua et al., regarding the trends of public health emergencies over the last 22 years in the World Health Organisation (WHO) African region. From Bangladesh we look at a Lancet article by Levine et al., comparing tools for assessing dehydration status in patients with acute diarrhoea. All health systems must be financed securely, and Nabyonha-Orem et al. have carried out a scoping review of innovative health financing mechanisms in the WHO African region to assess methods to address underfunding. Bartlett et al. carried out a systematic review to determine the level of critical care delivery available in low- and low-middle-income countries according to the literature.

Menstrual health is vital and Plesons et al. developed a fantastic set of research priorities from consultative processes with relevant stakeholders in the context of global health. Our final stop is the conflicts in Syria where a qualitative analysis from Abbara et al. looks at the impact of attacks on the personal and professional lives of health workers.

Time to treat the climate and nature crisis as one indivisible global health emergency

Zielinksi C (on behalf of authorship group of 200 health journals). BMJ Global Health (published simultaneously in multiple journals). Date of issue: 25th October 2023

The article’s title says it all. The time has come to recognise the global health emergency that is rapidly developing as a result of the climate crisis. This statement piece, authored by over 200 health journals, has been published simultaneously in multiple periodicals. It urges political leaders, the United Nations and health professionals worldwide to recognise the severity of the environmental crisis in terms of global health. Additionally, the paper calls on the World Health Organisation to declare the climate and nature crisis a global health emergency by their assembly in May 2024.

A key point in this piece is that climate change and biodiversity loss should be treated as part of the same complex problem and not separate challenges. There is no doubt of the catastrophic harm to health that is arising from the loss of nature: shortages of food, water, increased poverty, air pollution, increased spread of infectious diseases, and millions of climate refugees due to extreme weather events and lack of shelter. This short but powerful article is definitely worth a read to fully appreciate the true impact on health from the climate and nature crisis, and will fire up you up to become the advocates that our planet and patients need.

Human-centred design bolsters vaccine confidence in the Philippines: results of a randomised controlled trial

Reñosa M, Wachinger J, Guevarra J et al. BMJ Global Health. Date of issue: 21st October 2023. 

Vaccination non-compliance is a  threat to public health, leading to outbreaks of preventable diseases that can tear through populations. In the Calabarzon region of the Phillipines, Reñosa et al. used a human-centred design to create a story-based video intervention to address vaccine hesitancy within Filipino families and community leaders. This was authorised by the Department of Health. The intervention was a 5-minute cartoon with narrated stories of Filipino families, with concerns about vaccinations, learning the benefits of vaccinations, subsequently vaccinating their children and creating a strong community with immunisation against measles. The design process was 12-15 months, and the video was created with Filipino cartoonists, local voice actors, and community experts. It was named ‘Salubong: Building Vaccine Confidence’. ‘Salubong’ is a Filipino term meaning the welcoming of someone into one’s life. The phrase in this context referred to welcoming of vaccines into the community.

Once the video was created, a randomised controlled trial was carried out with 719 caregivers of children to test the video against a control video (a ‘How to fight COVID-19’ video produced by the Phillipines Department of Health). The cohort included both urban and rural residents. The participants were asked questions about vaccine attitudes before and after the videos. The results were encouraging, with 62% of the intervention group improving their vaccine attitude scores versus 37% of the control group (p<0.001). This study shows the potential of realistic narratives to improve vaccination confidence in areas with vaccine hesitancy to improve public health. The intervention video is available for viewing at https://www.youtube.com/watch?v=M8nEj5G9Iuc.

Trends in public health emergencies in the WHO African Region: an analysis of the past two decades public health events from 2001 to 2022

Koua EL, Njingang JR, Kimeyi JP et al. BMJ Global Health. Date of issue: 9th October 2023

Africa has the highest burden of public health emergencies globally. This paper from the WHO Regional Office for Africa is an exploratory analysis of the public health data over the past 22 years in this region. The aim was to explore the trends to inform public health strategies and develop tools to improve the response to these events. The WHO divides the world into six regions for the purposes of reporting, analysis, and administration. The WHO Africa region includes 47 member states, covering the majority of the continent, but excluding Western Sahara, Morocco, Tunisia, Libya, Egypt, Sudan, Djibouti and Somalia (all of which are part of the Eastern Mediterranean Region).

The results of the analysis show that between 2001 and 2022, there were 2234 public health events, with an average of 102 annually during the 22-year period. 92% of the events classed as ‘substantiated’ were infectious diseases (n=1730) and 5% (n=92) were humanitarian crises (e.g. natural disasters or conflict). The number of zoonotic disease outbreaks was found to have significantly increased (87% increase) over the past two decades. The average annual outbreak was 26; however, the highest number of outbreaks was recorded in 2022 (n=55). Recent studies suggest climate change is exacerbating the infectious diseases burden by bringing people and disease-causing organisms closer together. This paper comments on this suggestion, agreeing that there is a possibility of this increase being an indirect reflection of climate change. For the clinician with an interest in African public health, we would advise reading this paper in full to appreciate the geographic patterns and changes over time of each zoonotic disease. 

A comparison of the NIRUDAK models and WHO algorithm for dehydration assessment in older children and adults with acute diarrhoea: a prospective observational study

Levine AC, Gainey M, Qu K et al. The Lancet Global Health. Date of issue: November 2023.

Diarrhoea is the eighth leading cause of mortality worldwide and the fifth within low-income countries. Death occurs due to severe dehydration, therefore rehydration is the most vital step in improving morbidity and mortality. Despite the clear importance of being able to accurately assess one’s hydration status, no validated tools exist to assist clinicians in assessing the severity of dehydration in older children and adults. This study by Levine et al. aimed to validate the clinical decision support tool and scoring system NIRUDAK (Novel, Innovative Research for Understanding Dehydration in Adults and Kids).

This scoring system is a 14-point system to assess the severity of dehydration in older children and adults with acute diarrhoea. Points are scored for skin pinch (rapid, slow, very slow), eye level (normal, sunken), respiration depth (normal, deep), urine output (normal, decreased, minimal/none) and radial pulse (strong, decreased, absent). This prospective cohort study took place in Bangladesh over one year and included 1580 patients over 5 years old with acute diarrhoea. All patients were scored using NIRUDAK and the WHO IMIA algorithm (current WHO guidelines) and were weighed every 4 hours to determine their percentage weight change with rehydration. Accuracy and reliability were then assessed using the ordinal c-index and the intraclass correlation coefficient. This study has validated the NIRUDAK model and demonstrates the tool predicts a patient’s dehydration status with greater accuracy and reliability than the current WHO IMAI algorithm. This tool is therefore a useful addition to the global health clinician’s toolbox when assessing the hydration status of a patient with acute diarrhoea. 

The nature and contribution of innovative health financing mechanisms in the World Health Organisation African region: a scoping review

Nabyonha-Orem J, Christmals CD, Addai KF et al. Journal of Global Health. Date of issue: 15th November 2023.

Medical provision is often only available with substantial funding. A second paper this quarter out of the WHO Regional Office for Africa is this scoping review by Nabyonha-Orem et al. analysing the nature, type, and factors that affect the implementation of novel financing mechanisms within the WHO Africa region. This scoping review searched the literature from 2010 to 2022, including government policy documents, reports, and published studies regarding health financing for all population groups in the WHO African region. 41 documents were included in total, describing 10 innovative financing mechanisms (tobacco tax, alcohol tax, sugar tax, airline levy, oil/gas/minerals, HIV/AIDS trust fund, social impact bond, financial transactions tax, mobile phone tax, and equity funds) within 43 of the 47 WHO African region countries. A summary table is available within the paper showing which method/s each country utilises. Whilst this paper is not medical, for any clinicians with global health aspirations, it is an interesting read to appreciate the complexities of health financing. 

Critical care delivery across healthcare systems in low-income and low-middle-income country settings: A systematic review

Bartlett ES, Lim A, Kivlehan S et al. Journal of Global Health. Date of issue: 1st December 2023

Provision of good quality critical care services is a vital part of any healthcare system. In addition to resource limitations, low- and low-middle-income countries have a greater burden of critical illness and therefore a higher morbidity and mortality rate from these. This systematic review by Bartlett et al aimed to identify the range of critical care interventions and services provided within low- and low-middle-income countries. The literature search was from 2008 – 2020 and identified 1620 studies in total from relevant countries (low- and low-middle-income countries as defined by the World Bank classification). This has allowed a comprehensive systematic review to be produced detailing the critical care interventions available within these countries according to the literature. 

Research priorities for improving menstrual health across the life-course in low- and middle- income countries

Plesons M, Torondel B, Caruso BA et al. Global Health Action. Date of issue: 27th November 2023.

This study from the Global Menstrual Collective’s Research and Evidence Group by Plesons et al. aimed to identify research priorities for menstrual health in low- and middle-income countries. 82 individuals from stakeholder groups with expertise in menstrual health were asked to identify research priorities to guide improvements in menstrual health. The results showed that top research priorities were not limited to one area of expertise, but were distributed across a variety of topics, including menstrual pain, socio-cultural factors, menstrual products, and participation in school/work. This indicates research gaps exist throughout a number of domains related to menstrual health. A large number of research questions were also identified regarding ‘understanding the problem’, showing us that knowledge gaps remain regarding the menstrual experience, limiting our understanding of how to assess and meet the requirements of those menstruating in these countries. It is clear significant work is required to improve menstrual health in low- and middle-income countries, but we hope that the identification of these research priorities can be utilised by policy makers, researchers and funders to guide studies in this area.

“Actually, the psychological wounds are more difficult than physical injuries”: a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict

Abbara A, Rayes D, Tappis H et al. Conflict and Health. Date of issue: 9th October 2023.

Healthcare staff working in regions of conflict face substantial risks to their personal and professional lives, including risk of death. In Syria, violence against healthcare facilities has been frequent, with the Syrian American Medical Society facing over 222 attacks on their programmes since 2015. This qualitative analysis recruited Syrian health workers (in clinical and administrative roles) who had experienced attacks against their facility between 2013 and 2020. Open-ended, semi-structured interviews were conducted to explore their experiences and views.

From this study, it is clear that attacks on Syrian healthcare workers have left significant, complex and long-lasting impacts. Coping mechanisms discussed were behavioural, cognitive, emotional and religious, the latter often being very important for participants. Interviewees also discussed the solidarity with their colleagues and a responsibility they feel towards their community. Mitigating attacks on healthcare workers is an important, but deeply complex, issue. Organisations should consider their support mechanisms to help staff cope with the danger, stress and moral injury of working in these settings. For the interested reader, the full text article contains quotes from interview transcripts. We recommend reading these to fully appreciate the themes discussed in the paper. 

Expedition and Wilderness Medicine

There is plenty in this quarterly evidence explorer to evoke your interest. From the mountainside to outer space, there is no place that humans and medicine will not go. We evaluate termination of CPR during mountain rescue efforts, the use of drones in search and rescue, Selective Serotonin Reuptake Inhibitors (SSRIs) in space, and ultrasound scanning in austere environments. We hope you enjoy this selection of articles. 

Notable mention – High Altitude Medicine and Biology ran a special edition on ‘Women at Altitude’, however the results of the majority of the papers (n=4) simply showed a massive data gap for women at altitude in a variety of clinical settings. 

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

Viktor Lugnet, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, Peter Paal. High Altitude Medicine & Biology. Date of Issue: December 2023.

It is a situation no expedition medic wants to find themselves in, but in remote environments and extreme conditions cardiac arrest is an important scenario to consider when planning a trip. Building on the 2012 recommendations, Lugnet et al add new, evidence-based advisories around the use of mechanical chest compression devices, point of care ultrasound (POCUS), relevance of water temperature to resuscitation in drowning, and criteria for burial time in avalanche rescue. 

Lugnet et al, in line with the UK Resusitation Council, cautions against routine use of mechanical chest compression devices, but acknowledges the benefit of their use in prolonged or strenuous rescues, where manual compressions are less likely to remain consistent and effective. POCUS is to be used, where available, to aid decision making in termination of resuscitation. Regarding drowning, the authors recommend withholding CPR in a drowning victim with a submersion time >30 minutes in water >6°C or >90 minutes in water <6°C. Finally, regarding avalanches, the advice is to provide full resuscitative efforts for an avalanche victim with a core temperature <30°C with a patent airway and without lethal injuries, and transport to an extracorporeal life support capable centre. CPR should not be commenced in those in asystole and obstructed airway, with a burial time of >60 minutes.  

Use of Unmanned Aerial Vehicles (UAVs) in Wilderness Search and Rescue (WSAR) Operations: A Scoping Review

Craig Vincent-Lambert, , Anje Pretorius, BHS EMC, and Bernard Van Tonder, M EMC. Wilderness & Environmental Medicine, Volume 34, Issue 4. Date of Issue: December 2023

Love them or hate them, drones are everywhere. But with an increasing pressure on WSAR services, and an improvement in drone technology, graphics and durability, could they become a valuable tool in the SAR toolkit? 

Vincent-Lampbert et al conduced a scoping review of the literature, finding 21 sources that focused on UAVs in WSAR operations. Benefits described included the ability for UAVs to perform pre-programmed search patterns, thermal imaging, reduction in time to locate, and the ability of UAVs to tackle terrain deemed too risky for humans. It was recognised by the authors that limitations include drone-specific software, user fatigue, obscured view, weather conditions, and also the vast differences in average flight times between models. The conclusion drawn by the author is that UAVs are a useful tool that can aid but not replace human search efforts. They called for more specific language to differentiate “drones” from UAVs in the SAR environment as a marker of WSAR capability.  

Selective Serotonin Reuptake Inhibitors and Other Treatment Modalities for Deep Space Missions

El-Khoury, Bashir B.; Ray, Kristi L.; Altchuler, Steven I.; Reichard, John F.; Dukes, Charles H. Aerospace Medicine and Human Performance, Volume 94, Number 11. Date of Issue: November 2023

Modern humans are more stressed and anxious than ever, despite improved mental health awareness and de-stigmatisation encouraging more people to act positively for their mental health. Serotonin reuptake inhibitors (SSRIs) are useful treatment for depression and anxiety. However, with space tourism on the 25-50 year horizon, and gathering data on humans in space, it may be time to call it quits on SSRIs when out of Earth’s atmosphere. 

SSRIs have well documented side effects with longer term use, including weight gain, sleep disturbance and a moderate increase in bleeding risk (especially in conjunction with NSAIDS). However, as highlighted by this meta-analysis by El-Khoury et al, the literature shows a troubling link between long term SSRI use and decrease in bone mass. Bone loss in spaceflight is already a known phenomena, attributed mostly to microgravity, high sodium and protein intake, increased ambient CO2 levels and reduced sun exposure. El-Khoury et all raise the question whether SSRI’s should be allowed in the spaceflight population, and suggest potential alternative therapies such as Transcranial magnetic stimulation, cranial electrotherapy stimulation, and off-label ketamine prescription, along with managing the initial risk of the selected population. 

Ultrasound (US) Gel Alternatives in an Austere Environment

Julia DeLuca, BS, Daniel Doynow, DO, MPH, Jacob Grondin, BS, Ellen Lockhart, MS, and Stephanie Lareau, MD. Wilderness & Environmental Medicine, Volume 34, Issue 4. Date of Issue: December 2023

Point of care ultrasound is breaking into the prehospital and wilderness medicine scene in an increasing variety of ways. With advances in probe portability, interface with existing smart phones, and telemedicine technology, they seem an inevitable part of the wilderness medic’s toolkit. However, on expeditions, pack space and weight can be limited. DeLuca et al, used survey based data to rate commonly found mediums that could substitute for ultrasound gel, and to evaluate whether control picture quality was good enough for clinical diagnosis. They found that alternatives, including vegetable oil (88.5%), aloe vera (80.9%), and shampoo (69.2%), were rated equal or better quality US mediums when compared to traditional gel, and were sufficient for diagnosing acute pathologies. Whilst this may not change the face of expedition medicine as we know it, knowing MacGyver workarounds for POCUS could save you space and stress in remote field care. 

The post Evidence Explorer: Updates and news from the academic community, Winter 2023-24 appeared first on Adventure Medic.

The Emergency Department of Ysbyty Gwynedd, Bangor, provides the opportunity for middle grade doctors to further develop their Emergency Medicine skills in a rural ED that sees everything from trauma to snake bites. Their fellowship also provides protected time to undertake Pre-Hospital Emergency Medicine work across several services. Dr Katharine Ganly shares her experience of this unique role.

Clinical fellowship title, specialty and grade

Senior Clinical Fellow in Emergency Medicine (EM) and Pre-Hospital Emergency Medicine (PHEM)

Structure of the role

The PHEM clinical fellow jobs are offered as 12 months fixed-term contracts. 80% of your time is spent in the Emergency Department (ED) at Bangor Hospital and 20% of your time is spent in pre-hospital activities, split between HEMS (Helicopter Emergency Medical Service) shifts with the Welsh Air Ambulance, EMRTS Cymru (Emergency Medical Retrieval and Transfer Service, Wales) and the Welsh Ambulance Service. There is the option for less-than-full-time working.

Prerequisites for application

Prerequisites are that applicants should have completed UK ACCS training (or be able to demonstrate equivalent competencies in Emergency Medicine, Acute Medicine, Intensive Care Medicine and Anaesthetics).

The majority of PHEM clinical fellows are EM trainees, however Anaesthetic or Acute Medicine Trainees would also be eligible to apply provided they have at least 6 months of EM experience. For interested applicants who don’t quite meet the level of experience required, there are options for 6-month SHO-tier EM posts in order to become eligible, on discussion with the department.

Whilst the positions are generally offered as 12-month posts, MRCEM/FRCEM Intermediate holders with 12 months EM experience can apply for posts of 6-month duration.

As a post ACCS (Anaesthetics) doctor, albeit with some additional EM experience, I started the job with a degree of trepidation regarding being the EM senior on-site overnight. However, the consultant body and senior nursing staff are extremely friendly and are available for support and advice through your solo shifts. You learn the ropes quickly, and I would not let being from a non-EM base specialty put anyone off the role.

Location of fellowship

Fellows are based in the ED in Ysbyty Gwynedd, Bangor. The PHEM portion of the role is primarily based out of the EMRTS base at Caernarfon airport. There is scope to have shifts out of the sister EMRTS site at Welshpool. The remaining PHEM time can be spent with the Welsh Ambulance Services Trust (WAST) on RRVs (Rapid Response Vehicles), ambulances, or in the Ambulance Control Centre. There are also a range of observer shifts available with the North West and North Wales Paediatric Transport Service.

Academic accreditation

The fellowship does not provide academic training or accreditation.

Brief description of the job role

On EM shifts, the role is of an EM middle tier doctor on the registrar rota. Ysbyty Gwynedd is a rural emergency department that sees a wide range of presentations. There is a fair amount of trauma. Given the unit’s proximity to the mountains, fallen walkers and climbers are not infrequently brought in, especially during the summer months. Farm, water, and motorbike-related trauma are equally not uncommon. The rural location means snakebites are also seen, a rare presentation in an urban ED. Overnight you are the senior clinician in the ED, with easy access to Consultant support by telephone if needed. During daylight hours there is a Consultant on the shop floor who holds the supervisory role.

The PHEM portion of the role (which equates to approximately four days per month) comprises two monthly EMRTS air-ambulance shifts and two slots for other PHEM activities. The EMRTS shifts are as a third person on the Clinical Air Ambulance team. Depending on the day, the fellow will either be joined by a Consultant and Critical Care Paramedic (CCP) duo or a double-CCP team. The variation in team makeup allows you to see a different range of presentations. You are a functional member of the clinical team, not a passive ‘observer’, and are able to fully participate in the initial assessment, management and transfer of patients as your skill set allows.

There is flexibility with the remaining two PHEM sessions, and they can be used with WAST, in Ambulance Control, or on PHEM-related courses and activities.

You are expected to participate in Clinical Governance in both your EM and PHEM roles, for example in the form of M&M meeting attendance, chairing, or minute-taking.

Overall impression

The workplace environment in both the ED and the Air Ambulance is exceptionally welcoming and supportive, and I was unsurprised when Ysbyty Gwynedd (Bangor) ED came out top in the UK for EM training in the GMC 2023 survey. For those used to large urban hospitals, it will be a change, as a lot of staff know each other socially as well and professionally, and most know at least some of the patients in the department as well. The working atmosphere is friendly across the MDT, despite the pressures on emergency departments in 2024. The ED promotes a good work-life balance, and less-than-full-time working is quite normal for fellows in this role.

There is good senior support, and as a PHEM fellow you get a named Educational Supervisor who is a PHEM consultant and can help identify PHEM-specific areas for development and progression. The exposure to pre-hospital medicine during this post will help those who are considering applying for PHEM subspecialty training, or those who just want to know what it is all about.

Highlights of the job are a fully-funded place on the National PHEM course, which is excellent high-fidelity training held annually in August. The opportunity to fly over the hills of North Wales and make a real difference to outcomes through immediate management of trauma and illness is an additional high point, and immensely rewarding.

It would be remiss not to mention the location as a benefit. North Wales is a wonderful place to live for those that love the outdoors, with access to sea and mountains in equal proximity, and plenty of friendly outdoors folk to enjoy them with.

Outcomes of the fellowship

The opportunity to start building a PHEM portfolio will put fellows in good standing if they decide to pursue formal PHEM training pathways. The posts equip fellows with many of both the ‘essential’’ and ‘desirable’ attributes required by the PHEM sub-specialty person specification, and you get a good overview of both HEMS and the wider Ambulance service.

There are opportunities to present at M&M’s, Trauma Meetings and Clinical Governance Meetings, all of which are CV-building. You are enrolled in the national PHEM course in August as part of your clinical fellow post, which is an excellent immersion into PHEM. Other PHEM-related courses can be attended during PHEM-allocated time, and there is a study budget available. There is access to the Mountain Medicine database for those interested, and this can be used for research projects and publications. There is an excellent network of wilderness-minded medics for those wanting to make contacts and pursue activities in the fields of outdoor and wilderness medicine.

Costs and potential funding

There are no extra costs associated with this post. There is an NHS relocation budget accessible to post holders. PPE and training is provided.

The geographical location of this post is favourable financially. North Wales has a relatively low cost of living compared to elsewhere in the UK.

The study budget for these posts is a very generous £5000. A portion of this goes towards funding the IBTPHEM course which is run in August. This comprises approximately half of the budget, and the remainder can be used to fund other PHEM and CPD courses.

Anything you wish you’d known beforehand?

Accommodation in North Wales can be tricky to find from afar, but you can be put in touch with people locally if you ask to be plugged into the local WhatsApp group upon appointment. Once you are here it is a lot easier and places to live can be found easily.

The flexible annualised rota means you can plan for an adventure or time off and work your shifts around it. If you have something in mind, start thinking about it before you get here. I arranged a few weeks off in early springtime in order to undertake a winter Arctic expedition and it was not difficult to plan my shifts around this. Offering to work the Christmas shifts gave me a bit of goodwill ‘in the bank’ with my fellow mid-tier colleagues, and meant I could organise a decent block of time away from work later in the year. You don’t necessarily need to bargain by offering to do the unpopular shifts, the rota is set in 6-month blocks and if you can alert colleagues early to the dates you would like off, the team can usually support everyone’s requests.

It is worth learning a little Welsh before you get here. The DuoLingo course is not bad, and being able to say ‘hello’ and ‘thank you’ goes a long way. There are Welsh courses available locally with substantial discounts for NHS staff, and I would highly recommend attending one of these when you arrive if you are able to. The language is wonderful.

Links

The best place to check for jobs is the YGED website at: https://www.mountainmedicineyg.co.uk/jobs

Here you can see job specifications and current vacancies. If you are interested in working at YGED you can also contact the Consultants through the details available on the above page.

In addition to the PHEM Clinical Fellow posts, posts are also offered with Medical Education, Quality Improvement and Global EM as alternative options to the PHEM interest. There is the option to work less than full-time if desired.

The post Senior Clinical Fellowship Review: Pre-Hospital Emergency Medicine, Bangor appeared first on Adventure Medic.

Bear Island

Where: Netflix

About: Three brothers follow their dreams, and journey to the remote island of Bjørnøya (Bear Island) in the Barents Sea. Travelling with surfboards, snowboards, and a paraglider, and supplied with food foraged from supermarket bins, they search for the perfect wave.

Why: The movie really embraces the outdoor spirit. It’s interesting to watch these three brothers conjure, plan and then pursue their dreams of spending two months on a remote island. How do you survive in, let alone surf through, the harsh conditions of the Arctic? With freezing temperatures, strong winds, and, of course, the ever present risk of an encounter with a polar bear? You can tell why it took them one and half years of preparation. One of the brothers says, ‘I am not brave. I like doing objectively dangerous things in a safe way.’

In the end it’s an easy to watch, feel-good movie, but it also addresses more serious subjects like plastic pollution and the importance of family.

Book:

Mountain Recue Doctor

About: Christopher Van Tilburg, M.D., is an American doctor with a varied work schedule. His career has taken him out of the Emergency Room to ski patrol, mountain rescue, cruise ships, and as an expedition medic on six continents. Dr. Van Tilburg’s work requires a unique combination of emergency medicine, survival skills, agility, and extreme sports. In ‘Mountain Rescue Doctor’, Van Tilburg shares personal stories of harrowing rescues and recoveries full of nail-biting suspense.

Why: The author describes some of their mountain rescue cases in great detail. In doing so, he makes clear just how complicated any extraction off the mountain can be. He explores how different factors influence a rescue, and how effective teamwork is of the utmost importance. In addition, he shares some personal insights to life, such as how his passion for wilderness medicine began. “As a young medical student, I didn’t bother to think, can I make a living at wilderness medicine? All I could focus on was that I was to begin the journey to specialising in wilderness medicine. I would forge a career that would take me far beyond medicine, and perhaps one day, merge my two lives.” This is probably something our readers can relate to.

Podcast:

The Wilderness Medic Podcast (S3E7) Medic SOS

Where: Spotify

About: Dr. Daniel Grace is joined by David Tamale-Sali to talk about the big taboo in medicine: quitting. He discusses the shame he felt after being kicked out of Medical School, and the road to recovery and acceptance. Later in life, he helped a Doctor in distress on social media, and this inspired him to put together a book with the help of hundreds of doctors, gathering words of wisdom, encouragement, and strategies for overcoming burnout.

Why: David talks about the pressure he felt from his family to study medicine. He explains this by telling a joke that runs in African families; ‘There are four jobs you are allowed to have: doctor, engineer, lawyer and a disgrace to the family.’ It is still difficult for doctors to openly, and privately, have second doubts about their medical career. Therefore we need to open up the conversation, and show young medical students and doctors that these aren’t blasphemous or even uncommon thoughts. It is vital that we destigmatise the subject and discuss it in the open, and David is making good steps towards that.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

The post AM Team Recommendations February 2024 appeared first on Adventure Medic.

Dr Craig Miller / Emergency Medicine Registrar / Peninsula

Dr Constance Osborne / SHO / Evidence Explorer Lead / London

Contents

• Introduction and Collaborators
• Expedition and Wilderness Medicine Section
• Global Health and Humanitarian Medicine Section
• Want to get involved?

The clocks have gone back and the nights are drawing in, so what better time to settle into an armchair with a cup of tea and catch up on the latest in academia.We are excited to announce the publication of the Third Edition of the Oxford Handbook of Wilderness Medicine. It contains updated national and international treatment guidance, and revised chapters on caving medicine, analgesia and anaesthesia. This is the perfect handy guide for any expedition medic’s kit bag.

We would also like to flag The Lancet commission on peaceful societies through health equity and gender equality. It is a long document requiring a particularly large mug of tea, but it is an important read because it presents a pragmatic policy, and learning agenda, for global players at every level.

‘The world is experiencing a polycrisis—ie, an interaction of multiple crises that dramatically intensifies suffering, harm, and turmoil, and overwhelms societies’ ability to develop effective policy responses. Bold approaches are needed to enable communities and countries to transition out of harmful cycles of inequity and violence into beneficial cycles of equity and peace… The Commission, which had its inaugural meeting in May 2019, examines the interlinkages between Sustainable Development Goal 3 (SDG3) on health; SDG5 on gender equality; and SDG16 on peace, justice, and strong institutions. Our research suggests that improvements to health equity and gender equality are transformative, placing societies on pathways towards peace and wellbeing.’

The Lancet Commission on peaceful societies through health equity and gender equality 2023

After scrutinising twenty-five journals, Dr Miller and Dr Roberts have curated a fascinating selection of articles for you. From altitude physiology and the efficacy of avalanche airbags, to antenatal healthcare in armed conflict and the impact of nutrition on tuberculosis, there is something for everyone.

Dr Craig Miller is an Emergency Medicine Registrar, based in Peninsula, who currently works at the Royal Cornwall Hospital. Throughout his career, he has worked as an expedition doctor in most environments, from high altitude to the desert. He has a passion for tropical marine environments and diving medicine, and is a qualified Diving Physician. He has completed expeditions to West Papua and the British Indian Ocean Territory. Alongside his field experience, he has worked as an expedition medical advisor and is a course director for Wilderness Medical Training. He is currently focusing on completing a Masters in Global Health, alongside his UK work.

Dr Hugh Roberts is a Critical Care and Retrieval Medicine Registrar in New Zealand, having completed UK core anaesthetic training in August 2023. He is an Adventure Medic Editor, and has worked as an expedition medic in Tanzania, India, Indonesia and at sea. Hugh authored the Adventure Medic guide on how to balance expedition medicine with UK specialty training. Outside of work, Hugh enjoys SCUBA diving and climbing.

Expedition and Wilderness Medicine

In the autumn edition of Evidence Explorer, we’re already looking ahead to winter. We appraise a pilot study about mechanical CPR on ski slopes, an article on the effectiveness of avalanche airbags, and a review on the performance of chemical heat blankets in wet conditions. We then turn our attention to some of the most potent analgesics in our expedition medicine kits. We review a study that compares sufentanil to other opiates in acute traumatic pain, and a paper on the environmental impact of Penthrox. We round off this section with a paper on physiology at high altitude and a review of the limitations of pulse-oximetry for darker-skinned patients.

Manual vs Mechanical Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest on a Ski Slope: A Pilot Study

Rupp S, Overberger R. Wilderness & Environmental Medicine Journal. Sep 2023.

This study, conducted in the Pocono Mountain region of Pennsylvania, examined mechanical vs manual CPR on a mannequin during extrication from a ski slope. Three-person ski rescue teams performed eight trials, four with a LUCAS 3 device to provide chest compressions, and four with a rescuer providing manual chest compressions. The same ski slope was used for each extrication (which was described as ‘moderately pitched’ at 610m altitude) and different manual chest compression providers were used for each extrication to limit tiring. CPR quality was measured using a CPR quality monitor attached to the mannequin, which measures both rate and depth to determine compression quality.

The study found an increased percentage of time spent performing high-quality chest compressions in the mechanical group (58.5%; 95% CI) vs the manual (25.6%; 95% CI). There was a statistically significant increase in extrication time in the mechanical group (8.6 +/- 0.4min) vs the manual group (7.6 +/- 0.5min) but the authors suggest that the impact of a 1 minute delay would be negligible in real-world scenarios.

This pilot study neatly demonstrates the potential of mechanical CPR for ski patrols; not only does it free up a rescuer for other duties, but it should provide high-quality, continuous CPR on challenging terrain or in adverse weather conditions at altitude. The effect of the cold environment on battery life is an important consideration mentioned by the authors, but was not examined in this study.

The dependence of maximum oxygen uptake and utilization (V̇O2max) on hemoglobin-oxygen affinity and altitude

Webb K, Joyner M, Wiggins C et al. Physiological Reports. Aug 2023.

This is not a paper for light reading post on-call. Brace yourself for some physiology.

Higher haemoglobin-oxygen affinity (Hb-O2 affinity) results in increased oxygen uptake in the lungs, but less off-loading of oxygen to the tissues. These two changes have competing effects on VO2max, which is the maximum attainable rate of oxygen consumption. So does that mean that VO2max will increase or decrease? Naturally, an expedition medic may also ask, how does this effect change at altitude? This study addresses these questions using mathematical models to predict how VO2max will be affected by low, normal or high Hb-O2 affinities at altitudes of 0-10 km.

The results demonstrated that until approximately 4500m, low-normal Hb-O2 affinities result in an increased VO2max compared to high Hb-O2 affinity. However, this effect reverses above 4500m (see Figures available in the original article). This is of interest as it suggests a potential mechanism for the prophylaxis and/or treatment of high-altitude illness by using drugs which may increase Hb-O2 affinity. In fact, these drugs have already been developed and investigated for the treatment of sickle cell disease. This paper is entirely based on mathematical models and further studies are required to verify these findings.

Environmental impact of low-dose methoxyflurane versus nitrous oxide for analgesia: how green is the ‘green whistle’?

Martindale A, Morris D, Cromarty T et al. Emergency Medicine Journal. Sep 2023.

Penthrox has become increasingly popular in pre-hospital and expedition medicine as a lightweight, potent analgesic with a short duration of action. It is also a non-opioid and non-controlled drug, making it suitable for international expeditions. This paper investigates the environmental impact of Penthrox, and compares it to Entonox and intravenous morphine.

The authors thoroughly examined the Penthrox lifecycle in five distinct areas: raw materials, methoxyflurane manufacture, production processes, transport and disposal. Carbon dioxide equivalent (CO2e) was used as the primary measure of environmental impact. Existing data on Entonox and morphine were used from papers published in Anaesthesia and BMJ Open, respectively. The analysis compares one unit of Penthrox containing 3ml methoxyflurane (equivalent to 30 minutes use) with 30 minutes of continuous Entonox at 14L/min and 7mg of morphine. The results showed that Penthrox (0.84kg CO2e) has a CO2e 117x less than Entonox (98.89kg CO2e), whilst the CO2e of morphine was negligible (0.01kg CO2e).

The comparative analysis used in this study seems unfairly weighted against Entonox, assuming very high flow rates by not taking into account the presence of a demand valve (as used in ED or maternity to ensure Entonox is only delivered when the patient breathes through the mouthpiece). Even so, this study suggests that Penthrox is a ‘greener’ choice than Entonox, so we can all feel a little less guilty about including a whistle or two in our expedition med kits.

Effect of intranasal sufentanil on acute post-traumatic pain in the emergency department: a randomised controlled trial

Malinverni S, Kreps B, Lucaccioni T et al. Emergency Medicine Journal. Sep 2023.

Onto another up-and-coming drug of the pre-hospital med kit, intranasal sufentanil. Sufentanil is an opioid with 10x more potency than fentanyl. It is highly lipophilic, which means it can be absorbed through the nasal mucosa to provide rapid analgesia without the need for an IV cannula. In this randomised controlled trial from Belgium, intranasal sufentanil 0.5μg/kg was compared with a control of either oral oxycodone 5mg or IV morphine 0.1mg/kg (based on clinician’s judgement). The study included 170 adult patients that presented to the ED with acute post-traumatic pain in the extremities, spine or thorax, scoring greater than 7/10 on the visual analogue scale (VAS). Pain scores were assessed at 0, 15 and 60 minutes, and smaller supplementary doses of opiates were allowed at these times.

The results showed that baseline pain scores were similar between groups, and intranasal sufentanil resulted in a greater reduction in VAS pain scores than the control group at both 15 minutes (3.0 vs 1.5; p<0.001) and 60 minutes (5.0 vs 6.6; p<0.001). There was a significantly greater number of patients who experienced minor adverse effects in the intranasal sufentanil groups, particularly dizziness, vomiting and sweating (59 [71%] vs 20 [23%]; p<0.001). Supplementary analgesia was used similarly by both groups. This is an intention-to-treat study and therefore the high rates of adverse effects in the intranasal sufentanil group are taken into account.

This paper is well worth a read. It serves as an excellent introduction for clinicians unacquainted with intranasal sufentanil, whilst also producing some interesting data for those more familiar with it.

Improving pulse oximetry accuracy in dark-skinned patients: technical aspects and current regulations

Cabanas A, Martín-Escudero P, Shelley K. British Journal of Anaesthesia. Aug 2023.

It has been well-documented that patients with darker-pigmented skin are at higher risk of occult hypoxaemia (peripheral oxygen saturations [SpO2] >92% despite true arterial oxygen saturations being [SaO2] <88%). The two wavelengths used as standard in pulse oximeters are 660nm (red light) and 940nm (infrared light). Deoxyhaemoglobin absorbs more light at 660nm, while oxyhaemoglobin absorbs more light at 940nm. As melanin absorbs more light at 660nm compared to 940nm, patients with darker-pigmented skin may therefore have a falsely high SpO2 reading. The reason these wavelengths are used is because the majority of the data used to calibrate pulse oximeters has been collected from studies of patients with lighter-pigmented skin. Of the relatively few studies that have examined darker-skinned patients, most have used questionable methodology. Poor-quality polychromatic LEDs (which are often found in pulse oximeters bought on the high street or online) further increase the risk of occult hypoxaemia, as they are affected by the spectral absorption of melatonin to a greater degree than monochromatic LEDs (which are found in FDA 510[k] authorised pulse oximeters used in professional healthcare settings).

Until there is an improved availability of pulse oximeters calibrated for patients with darker-pigmented skin, what can we do as expedition medics to tackle this issue? Raising awareness is important. We should also ensure our pulse oximeters are FDA 510(k) authorised, and maintain a degree of clinical suspicion when we have patients with darker-pigmented skin and a reassuring SpO2.

Effectiveness and use of avalanche airbags in mortality reduction among winter-recreationists

Lucia Laura Di Stefano, MD1,*, Bianca Della Libera, MS2 and Paolo Rodi, MD3. Journal of Travel Medicine. October 2022

My friends that regularly ski will often talk about the appeal of heading off-piste for fresh powder, leaving novice skiers like me to flounder on the blue slopes. However, skiing off the bashed track is not without risk. The overall mortality of individuals caught in an avalanche is 13-23%. During the 2020-21 winter season in the Alps, there were 130 avalanche-related deaths. Equipment commonly carried by winter recreationists includes a transceiver/shovel/probe combination and an avalanche airbag.

This paper is a narrative review of the available data on avalanche airbags. The authors identified six articles with data on mortality reduction, of which one was a survey and five were retrospective experimental studies on real-life accidents. They concluded that airbags reduce the risk of both critical burial (defined as burial of the head and impaired breathing) and mortality. Non-deployment of airbags is a major issue, occurring at a rate of around 20%. It may be caused by user error (60%), device failure (17%), maintenance error (12%) (such as the canister not being attached properly), or destruction of the airbag during the avalanche (12%).

Whilst it’s reassuring to know that deploying an airbag does reduce the risk of death if you find yourself caught in an avalanche, there still remains a significant risk. There is no substitute for appropriate education and training on avalanche avoidance. Always take time to make sure you know how to use your device properly, and keep it maintained to significantly reduce the risk of non-deployment.

Performance of a Chemical Heat Blanket in Dry, Damp, and Wet Conditions Inside a Mountain Rescue Hypothermia Wrap

Greene M, Long G, Greene K et al. Wilderness and Environmental Medicine. September 2023.

This research was conducted by authors Mike Greene and Karen Greene (both highly experienced mountain rescue doctors and founders of Mountain and Expedition Emergency Medicine), Geoff Long and Matt Wilkes (both affiliates of the School of Sport, Health and Exercise Science at the University of Plymouth, and you may also recognise Matt as the founder of Adventure Medic).

This study examined the performance of chemical heat blankets (CHB) in three experiments. The first experiment measured whether a CHB heats up quicker when packed loosely in a rucksack or when exposed to the open air. The second experiment measured temperature and heat flux (the rate at which heat is transferred) from a CHB through dry, damp and saturated wet fleeces. The third experiment compared the temperatures of mannequins dressed in dry, damp or saturated wet fleeces and wrapped in a “hypothermic wrap”. The hypothermic wrap, as used by Mountain Rescue England and Wales, consists of a CHB, then a vapour barrier, surrounded by an insulating fibre pile bag with a wind and waterproof outer layer. Finally, the wrapped casualty is supported in a vacuum mattress, which provides additional insulation. A temperature probes was placed next to the base layer on the mannequin and then the mannequin was left for 7 hours to see if steady-state temperatures were maintained.

There are several useful takeaways from this study, and I would highly recommend reading this paper yourself to better understand the findings. The first experiment showed that a CHB packed loosely in a rucksack heated up quicker than a CHB in the open air (43oC vs 32oC at 30 min), demonstrating that it is not necessary to open the CHB to allow in more oxygen. Readying a CHB in your rucksack in advance of reaching your casualty may be beneficial, to allow it to warm up. However, the application of a CHB should not be delayed, as it starts to provide heat to a patient from the moment it is applied. The second experiment showed that the performance of a CHB is similar in dry or damp conditions, but impaired in wet conditions. The explanation provided by the authors for this is that the water surrounded the panels, preventing oxygen reaching the CHB and thereby impairing heat production. Therefore, consider cutting off saturated clothing before wrapping a casualty as it may impair the efficiency of a CHB. The third experiment showed that hypothermic wraps will maintain the median steady-state temperatures for 7 hours with dry, damp or saturated wet fleece, so there is really no need to check or change them before this time. The highest temperature recorded against the CHB (with the dry fleece) was 67oC. This is more than sufficient to cause burns, so we should always have a protective layer of clothing between the CHB and the casualty’s skin.

Global Health and Humanitarian Medicine

As we enter the final months of 2023, it’s time to introduce you to the final Global Health Evidence Explorer for the year. Get yourself a cup of tea and we’ll take you through six key papers published in the past few months. 

Inequality across the globe has a huge impact on human health and this edition explores different aspects of this issue, and its impact on different populations. Ataguba et al publish an expansive global assessment of income inequality and its impact during pandemics. Displaced populations are particularly vulnerable to inequality. Okumu studies the interplay between gender inequality and condom use in displaced populations with a high prevalence of HIV. Zhang et al examines access to antenatal healthcare during armed conflict, which is a particularly powerful study given the current conflicts in Europe and the Middle-east. There are two randomised controlled studies in this quarter’s edition: one looking at wider nutritional supplementation for households with known TB, and another determining the effectiveness of intermittent preventive treatment of malaria.

Income inequality and pandemics: insights from HIV/AIDS and COVID-19 — a multicountry observational study

J Ataguba, C Birungi, S Cunial et al. BMJ Global Health, September 2023

Inequality is a key determinant of poor health outcomes. This global retrospective observational study illustrates this point clearly by utilising national data from two global pandemics: HIV/AIDs (217 countries) and Covid-19 (151 countries). Countries and regions with greater inequality, as assessed by the Gini index*, show a statistically significant (p<0.01) increase in prevalence of HIV, AIDs mortality rate, and excess deaths owing to Covid-19. The consequences of this are two-fold: the poorest populations are the most vulnerable during pandemics, in part owing to limited access to healthcare, and greater inequality perpetuates and exacerbates pandemics thorough increased case numbers. Articles such as this one helps to focus international attention and drive agendas such as the Sustainable Development Goals.

*The Gini index (or coefficient) is an internationally recognised measure of inequality. It specifically examines the distribution of household income and how this deviates from perfect distribution, with 1 being complete inequality and 0 being complete equality. One limitation is that it is a relative, not absolute measure, meaning the Gini index can rise for a developing country i.e. become more unequal whilst the absolute number of those living in poverty reduces. Similarly, two countries may have similar levels of equality, i.e. the same Gini index, yet the absolute wealth between the two countries may be vastly different. Want to read more? https://ourworldindata.org/what-is-the-gini-coefficient 

Does armed conflict lead to lower prevalence of maternal health-seeking behaviours: theoretical and empirical research based on 55 683 women in armed conflict settings

T Zhang, Q He, S Richardson et al. BMJ Global Healt, August 2023

Women and children are amongst the most vulnerable in conflict zones, and access to antenatal healthcare is challenging. This study aims to quantify the effect of conflict on maternal health seeking behaviours using maternal and child health (MCH) data from UNICEF. The paper suggested that where humanitarian assistance was provided, improvements in maternal care can be achieved, particularly tetanus vaccination and single visit antenatal care (ANC). This is likely because it is more feasible to deliver a vaccination programme and single visit ANC than the WHO recommended 8+ ANC contacts*. Caution should be exercised however, as no clear trends were identified across the countries studied (CAR, Chad, DRC, Afghanistan), many of the results were not statistically significant, and MCH improvements are presumed. Overall, this paper highlights the variability in delivery of MCH humanitarian assistance in conflict zones. Whilst it does develop a ‘theoretical model of utility to explain the effects of armed conflict on maternal health-seeking behaviours’, it remains to be seen how applicable this model is to real world interventions.

*The World Health Organisation publishes recommendations on ANC for a positive pregnancy. They recommend a model with a minimum of 8 ANC contacts, as evidence shows a reduction in perinatal deaths. Furthermore, the ANC 8+ contact model supports improved safety, earlier detection of complications, and better health engagement and communication.

[WHO recommendations on antenatal care for a positive pregnancy experience. 2016. Available at: https://www.who.int/publications/i/item/9789241549912 ]

Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based, open-label, cluster-randomised, controlled trial

A Bhargava, M Bhargava, A Meher et al. Lancet Global Health, August 2023

Social determinants of health are increasingly recognised as a key determinant of the burden of tuberculosis (TB). The WHO strategy to end tuberculosis addresses both the biological and social aspect of the disease. The national ‘Eliminate TB Strategy’ in India aims to address the syndemic of malnutrition and TB through provision of direct nutritional support to patients. This study is the first of its kind to examine the role of malnutrition support, not only for pulmonary TB patients, but also their household contacts.

The study was undertaken in eastern India, with over 10,000 household contacts recruited from the predominantly indigenous and rural population. After randomisation, the household contacts of confirmed pulmonary TB patients received nutritional support (750 Kcal/day) in the intervention group, whilst in the control group only the TB patients received nutritional support. The intervention resulted in a 39% reduction in TB incidence, but it is important to be inquisitive when impressive numbers are stated. The figure was calculated by comparing the incidence rate per 100 person-years in the control (1.27 per 100 person-years (95% CI 1·00–1·61)) and intervention arms (0.78 per 100 person-years (0·64–0·96)), which resulted in an absolute difference in the incidence rate of 0.49, a more modest reduction. Another curious aspect of the results was the intervention had no impact on hospitalisations or deaths from other illnesses, although unfortunately that data is not provided for interrogation.

The generalisability of the study is limited. It is a single-country study focused on a predominantly rural population, with a disproportionately high representation from the indigenous population.  Nevertheless, its implications are clear, to reduce the burden of disease in impoverished populations, global health leaders and policy makers must recognise that healthcare needs to be holistic, and address the social determinants of health, to be truly effective.

A syndemic of inequitable gender norms and intersecting stigmas on condom self-efficacy and practices among displaced youth living in urban slums in Uganda: a community-based cross-sectional study

M Okumu, C Logie, A Chitwanga. Conflict and Health, August 2023

A lack of research examining sexual and reproductive health (SRH) exists in humanitarian settings, yet the globally displaced population is nearly 30 million, of which nearly 50% are under the age of 18. Displaced youth are particularly vulnerable to HIV and other STIs due to limited provision of SRH, higher rates of sexual violence and transactional sex. Condoms remain the most effective method to prevent HIV, however use is limited amongst 15-24 year olds. Lack of education is rarely identified as a contributor to low use. This cross-sectional study investigates the relationship between adverse sociocultural factors and condom use in displaced youth populations living in informal settlements in Kampala. Uganda was chosen for the study, as it hosts the greatest number of displaced persons (1.5 million) in sub-Saharan Africa, and high rates of HIV are reported. Data collection took the form of a questionnaire, with researchers identified and trained from within the displaced population and supported by the lead author. It suggests that inequitable gender norms, HIV and SRH stigma interact to reduce condom self-efficacy, which is a measure of an individual’s ability to consistently use condoms. This concurs with the researchers’ presented hypothesis and champions the use of multi-faceted HIV prevention programmes, not only providing SRH and HIV services, but tackling underlying gender inequality and stigma.

Methodology is clearly described alongside the data and regression analyses, but there remains significant limitations. Purposive sampling, used in this study, is pragmatic when attempting to capture data from a specific population, but introduces researcher bias. Snowball sampling and payment of participants compounds researcher bias with sampling bias. This paper is focused on displaced youth in Uganda based in informal urban settlements, it is not generalisable to the entire displaced population, which would require random sampling across multiple sites and groups.

Quick diversion: when reviewing studies that utilise surveys or questionnaires it is important to identify the ‘Cronbach’s alpha number’ for each. This is a statistical measure of the internal reliability of the questions. Below 0.5 is considered unreliable and the questions should be revised, above 0.7 is considered reliable. All surveys used in this study had a Cronbach’s alpha of >0.7.

Association between the quality of care and continuous maternal and child health service utilisation in Angola: Longitudinal data analysis

A Aoki, K Mochida, M Kuramata. Journal of Global Health, August 2023

Reducing maternal and child mortality is a key priority of the United Nations and World Health Organisation as set out in the UN Sustainable Development Goals (SDG number 3). Sub-saharan Africa remains particularly burdened with high maternal and child mortality. To address this challenge, Angola introduced the Maternal and Child Health (MCH) Handbook. This is a physical home-based integrated care record which documents maternal care, child development and immunisations. This was introduced alongside healthcare workforce education, implementation of protocols and increasing service utilisation. A randomised controlled trial assessed the MCH impact on care for pregnant women and mothers. The study presented here is a longitudinal analysis of data from both the original RCT, as well as data from the subsequent implementation study, covering a combined period of 16 months.

WHO defines quality of care as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes’. Quality of care and its impact on service utilisation is poorly studied. This is the first study to examine quality as a facilitator to improve ANC patient engagement. The analysis examines differences between optimal and sub-optimal care with the hypothesis that optimal care should increase service utilisation. Optimal care was defined as 4+ ANC contacts, facility delivery, and optimal vaccinations for children at 6 months. Sub-optimal care was defined as any level below optimal care. As discussed earlier, the WHO now recommends 8+ ANC contacts, therefore what is presented as optimal care would actually be suboptimal according to WHO’s updated recommendation. It is important to note however that the updated guidance was released during the study period. The study included over 3000 pregnant women of whom over 70% received optimal care. Positive service user perception was statistically significantly higher when optimal care was delivered. Those populations who received suboptimal care were likely to be younger, from rural populations or ethnic minorities, and have limited education.

The major flaw in this study is that ‘optimal care provision’ was used as a proxy for good quality of care. This is a significant presumption. Quality of care should be patient-centred and the paper does little to explore how or why marginalised populations were more likely to receive suboptimal care. Moreover, it is a country specific study and different cultural and demographic factors would need to be considered if attempting to apply this study to other populations.

Effectiveness and safety of intermittent preventive treatment with dihydroartemisinin–piperaquine or artesunate–amodiaquine for reducing malaria and related morbidities in schoolchildren in Tanzania: a randomised controlled trial

G Makenga, V Baraka, F Francis et al. Lancet Global Health, August 2023

Prevention of malaria is multi-faceted, including chemoprophylaxis, personal protection measures against mosquitoes and mosquito control. Additionally, two malaria vaccines have recently been approved and are beginning to be delivered in certain regions across sub-Saharan Africa. The aim of this study was to assess the effectiveness of intermittent preventive treatment of malaria in school children (IPTsc) in reducing the burden of anaemia associated with malarial infection. Conducted in Northeast Tanzania, over 1500 children across seven primary schools were randomised in this open label study. Two intervention groups received either dihydroartemisinin–piperaquine or artesunate–amodiaquine four monthly for one year versus a control group which did not receive anti-malarials. Primary end-points were (at 12 and 20 months) change in baseline haemoglobin and incidence and prevalence of malaria.

Secondary end-points were anaemia prevalence at each 4 month visit and change in psychomotor and cognitive scores at 12 and 20 months. The study controlled for the potential effect of soil-transmitted helminths and schistosomiasis as a cause of anaemia through preventive treatment with albendazole and praziquantel according to national guidance. Stool samples were tested to ensure effectiveness of treatment.

ITPsc demonstrated a positive, albeit small, effect on mean haemoglobin levels. Both intervention groups demonstrated an increase of 0.5g/dL compared with the control, the clinical significance of this is unclear. Arguably, the more important finding was the reduction in prevalence of malarial parasitemia and the reported 20% protective effect of ITPsc against clinical malaria at 12 months. No effect of ITPsc on cognitive or psychomotor scores was demonstrated. Whilst robust, this study has one significant flaw, due to the Covid-19 pandemic nearly 1200 children missed visit four, which was crucial as visit four was conducted at 12 months and was one of the primary end-points. They state the analysis was still statistically powered, however missing nearly 80% of data at the primary endpoint of the interventional period is clearly problematic. Overall, the study demonstrates a pragmatic, community centred approach to reducing the burden of malaria. As such, WHO’s 2023 malaria guidelines advocate the use of intermittent preventive treatment for malaria in school aged children (ITPsc) in areas with high endemicity of disease to run alongside current school based health programmes such as mass treatment for soil-based helminths and schistosomiasis.

The post Evidence Explorer: Updates and news from the academic community, Autumn 2023 appeared first on Adventure Medic.

Emergency medicine trainee, Adventure Medic editor, and taking-time-out enthusiast Dr Jake Adams takes us through his experience of stepping off the treadmill. From ad-hoc locuming to unusual clinical fellowships, he provides a comprehensive guide for anyone considering taking an ‘FY3’ year in the UK.

After five or six years of university and two years of foundation training, it is unsurprising that many junior doctors take time out of training. A break from the hoop-jumping, the relentless rota, or a voyage of self-discovery: there are countless reasons why people choose this route. Whatever the reason, taking a break is a fantastic way to regain autonomy and headspace, and capitalise on the ever-growing opportunities available both inside and outside of medicine.

The number of doctors taking an ‘FY3’ year has risen steadily from 17% in 2010 to 65% in 2019. Few seem to regret their time out and 93% return to training within five years, hopefully refreshed, recharged, and re-enthused. My own time out was not only fun but also allowed me to return to a career that I had chosen, rather than one that I had fallen into at 17 years old.

It is very easy to take time out, simply don’t apply for a training programme. The more difficult task is planning your time. When thinking about beginning something, it is often helpful to start at the end. As the British Medical Association puts it, ‘Will you be better equipped at the end of your time out than at the beginning?’. It is not difficult to answer this with a resounding yes: many doctors return to training with more experience, better qualified, and, hopefully, reinvigorated. This article provides a starting point for those planning their time out, from exciting opportunities to much less exciting practicalities.

The Case for Remaining in the UK

If the yearly GMC survey is to be believed, many FY2s will spend their year applying for visas, planning either temporary or permanent ventures into the Southern Hemisphere. For more information on packing up your stethoscope and your sun cream, Adventure Medic has guides on moving to Australia and New Zealand. The benefits of remaining in the UK, however, are plentiful. For most, it will mean no immigration bureaucracy or complicated medical council paperwork, a process that is not just painstaking but also extremely expensive. Working in the UK will also appeal to the climate-conscious, and allows many to remain close to their support networks. In addition to this, there are now a huge number of more ‘unconventional’ work options within the UK, with many NHS trusts recognising the value of specialised junior fellow years. Trusts are also increasingly keen to sweeten these deals: many employers now offer adventure-friendly options such as funded qualifications, out-of-hospital experience, and annualised contracts.

Logistics

• Indemnity – Doctors must always have legal cover that is appropriate to their stage and responsibilities. Make sure you update your provider regarding any changes to your address or job. See our guide to expedition indemnity here.
• NHS Pension, National Insurance, and Student Loan – for those working for staff bank or in a contracted post, these will continue to be automatically debited from your pay cheque. Otherwise, it is the employee’s responsibility to ensure that these are paid (if applicable) and you may need to submit your own tax returns. With student loan repayments in particular, you must arrange to continue your repayments if you are working abroad. Remember also, that all doctors are eligible to claim tax back on employment expenses, including college fees, GMC fees, and exam fees.
• CV – It is a good idea to have an up-to-date CV ready to go and this can make all the difference when opportunities pop up unexpectedly. CV writing is a difficult skill and it is worth spending some time ensuring that yours is concise, error-free, and tailored to the opportunities you are applying for.

UK Employment Options

It is remarkably easy to forget that there is a whole world of work outside of clinical medicine. Those deciding to venture into a different field undoubtedly bring back a wide range of skills and experience. Doctors choosing this path should plan carefully regarding their GMC status (details below). The other option is to continue to work within medicine. In this case, there are two main choices. The first choice is whether to work abroad or in the UK. The second choice is whether to take a contracted post or to work as a locum, be that via an internal bank or an agency.

Loving that Locum Life – Staff Banks v.s. Locum Agencies

For those wanting to maximise their earnings, locuming is very attractive. Pay varies in a supply-demand fashion across different trusts. The BMA suggests £70-80 per hour as a standard rate, but as a rough guide £40 per hour is common. Working as a locum usually pays more and offers autonomy over shifts, ensuring maximal flexibility. That said, extra pay comes with extra risks. Locum doctors are not entitled to annual leave, sick leave, study leave, or a study budget. There is also no guarantee of work, and work that is advertised may be last-minute cover for unsociable shifts.

For some, the familiarity of colleagues and systems makes working via their hospital staff bank an attractive option. Employers will usually give priority to doctors on their staff bank as it costs them less than agency fees. The other, potentially more lucrative, option is to use an agency. This can result in quicker turnarounds for payment, and sometimes a higher wage. Agency work usually requires more movement between trusts and departments, so for those with a dread of changeovers it may not be ideal. With both options, it is important to keep track of hours worked, agreed rates, and what has, or has not, been paid. Mistakes happen and if you, the employee, do not spot them, then in all likelihood, no one will. It is also worth remembering that after 12 weeks of work with the same employer, locum workers are entitled to the same benefits as other employees, including receiving ‘rolled-up holiday pay’.

For She’s a Clinical Fellow

Clinical fellow roles have exploded in both availability and popularity over the last few years. They are a great choice for hospitals, as they are cheaper than paying locums, but also for doctors as they often come with extra opportunities. Clinical fellow jobs have many advantages; they offer the stability of rostered shifts, a guaranteed and predictable pay cheque, annual and sick leave, and the consistency of working within a set team or specialty. Typically, fellow jobs are six or twelve months long, allowing flexibility to combine work and travel. They offer valuable opportunities to try out specialties and gain experience that will pay dividends come interview. There are also many themed fellow jobs, with opportunities including expedition medicine, global health, trauma, and pre-hospital medicine. A common model is for employers to offer 80% clinical time with 20% time allocated to a specialist interest, decided by the trainee. These are ever-evolving and will only become more plentiful as trusts face more competition for employees.

Apply and Defer

Depending on the specialty, and who is leading recruitment, it can be possible to defer the start date of a training programme by six months. This could be the perfect option for doctors who know what training job they want to do but want a short break before starting.

LAT but not Least

An alternative to clinical fellow posts is taking a Locum Appointment for Training (LAT) job. While seemingly very similar to a clinical fellow role, they are recognised for training so the time in these posts can ‘count’ towards training if you want it to. These posts are an excellent option for doctors who know what their final specialty will be, but don’t want a training number yet. LAT jobs allow more choice in location, and offer a degree of ‘try-before-you-buy’ for training programmes.

Expedition Medicine from the UK

The world of expedition medicine can seem like a difficult area to break into. However, there are many ways to gain experience and get your foot in the door. Taking time out after FY2 offers a great platform to branch out into the expedition world. What’s more, these experiences will all count towards appraisals and offer something different to showcase at interviews. The UK makes for an excellent base for this. A useful place to start is by looking into courses and qualifications that align with your areas of interest. A list of courses including diplomas, masters, and short-course options can be found here.

Courses

There are many courses on offer from a variety of different providers. Adventure Medic is full of course reviews to help guide future participants and has a helpful calendar too. Courses can be expensive, but provide a good grounding in expedition medicine, usually with training in the field. Expect to have a tiring but fun experience, make some great new contacts, and become more credible as a prospective expedition doctor.

Diplomas

Diplomas are a highly useful way to spend all the new free time that time out of training provides. There are many options, with courses in expedition medicine, disaster medicine, and global health medicine proving very popular. It is worth noting that some clinical fellow jobs will contribute to diploma costs. As the expedition medicine field gets more competitive, formal qualifications will be increasingly important to make applicants stand out.

Charity Expeditions, Sports and Event Medicine

Charities offer a worthwhile and interesting introduction to expedition medicine. The general advice is to email organisations and see if they are hiring – another reason to have an updated CV. There are a wide range of options, many of which require a financial contribution.

Event medicine and sports medicine also offer an excellent way to build out-of-hospital experience. As well as networking opportunities, these jobs offer exposure to challenges such as pre-planning, resource management, and real-time medical problems – experience that is very transferable to expedition work. Again, there are many different companies, both local and national, that offer event medical cover. The best way to get involved is to contact sports teams directly or find a doctor who is already involved and ask them.

Humanitarian Work

Volunteering for NGOs and humanitarian causes is a meaningful way of gaining out-of-hospital experience. Though most placements will not be in the UK, many doctors both in and out of training find these placements eye-opening and purposeful. There are a plethora of charities and organisations that will be keen for new enthusiasm and energy. Prospective volunteers should ensure they know what their duties will be, what support, both personally and clinically, will be available, and check that their indemnity is valid. The BMA has a very useful guide here.

Returning to Training

General Considerations

1. It’s worth noting that the proudly earned certificate awarded for passing foundation training, the FACD 5.2, is only valid for three years. If foundation graduates are out of training for longer than this, a consultant who has supervised them for at least three months must fill in a Certificate of Readiness to Enter Specialty Training(CREST) form found here.
2. Keep up to date with your intended specialty’s application matrix. Some programmes mark candidates down if they have too much out-of-training experience in certain fields.
3. Be prepared to justify any gaps in training and employment. Most employers and interviewers will look favourably on career breaks; they are something different to talk about and can make candidates stand out. Whether it be for courses, qualifications, personal development, or looking after your mental health, the reason will rarely matter as long as you are prepared for these questions.
4. Many specialties can offer a return to work period, although it might not be offered automatically. This provides greater support and supervision to help trainees return to clinical work if they’ve been away for more than three months.

GMC Licence

There are three options to choose from with more detailed information available here:

1. Continue to hold a full licence to practise. Doctors must continue to pay their GMC fees and are advised to organise a yearly appraisal. For those who will work in the UK, this is the right option.
2. Give up your licence to practise but continue to be registered with the GMC. This allows doctors to continue to practise medicine abroad, but not work within the UK. This is a good option for those working abroad for an extended period, or those choosing to take a complete career break. Doctors continue to pay a reduced annual fee to the GMC, and the GMC will issue a certificate of good standing to other medical regulators. It can take some time to regain your licence to practise and doctors should anticipate this when returning to UK medical practice.
3. Give up GMC registration. This is also known as voluntary erasure. Think carefully about this as it is intended for those who don’t ever want to practise medicine in the UK again.

Appraisal

The GMC recommends an annual appraisal for every doctor with a licence to practise. This is an annual meeting between a doctor and a colleague who has been trained as an appraiser. Those working within a hospital should be allocated an appraiser by their department. Locum agencies usually organise appraisals internally as part of their service, but it is worth clarifying this.

Appraisals are a process of facilitated self-review supported by information gathered from the doctor’s full scope of work. Aprasiees are expected to reflect on their practice, identify learning needs, and demonstrate that they are fit to practise. In reality, following the requirements of FY2 should be a reasonable blueprint to pass an appraisal. Some trusts will share access to an e-portfolio, otherwise it might mean a return to paper forms. All of the information is available here but it is useful to consider the following areas when preparing for an appraisal:

• Personal Development Plan (PDP) – setting up a PDP with a couple of achievable points makes the appraiser’s job easy.
• Continued Professional Development (CPD) – RCEM for example, suggests getting 50 CPD points per year which equates to an hour a week of podcast listening or journal reading. Exams, courses, and conferences all count too. Different specialties will offer different advice, but the important thing is to keep a record of your learning.
• Logbook – In some specialties, keeping a logbook is essential. There are a variety of ways to facilitate this with many choosing apps or online platforms for ease of use. 
• Reflections – It is important to show evidence of your reflective practice, particularly with regards to any significant adverse events, complaints, or near-misses that may have occurred.

Your Own Adventures

Sometimes the best expedition experience is an independently organised personal adventure. Planning a big trip offers plenty of life lessons, and just because it was technically a holiday doesn’t make it any less valuable to talk about at interviews. The UK can be easy to overlook when searching for adventure but offers a plethora of outdoor opportunities in an amazingly varied landscape. Whichever path you choose, taking time out is a great chance to reconnect with friends, hobbies, and general life. It emphasises the perks of working as a medic, demonstrating just how flexible, varied, and rewarding medicine can be. However you decide to spend your time out, have a wonderful time.

Useful Resources

https://www.bmj.com/careers/article/bmj-s-guide-to-planning-your-f3-year

https://www.holtdoctors.co.uk/blog/the-ultimate-guide-to-planning-your-f3-year

https://www.mindthebleep.com/how-to-plan-your-fy3/

The post Taking Time Out After Foundation Training: UK-Based Options for Adventurous Medics appeared first on Adventure Medic.

The Deepest Breath

Where: Netflix

About: This documentary takes a deep dive into the freediving community. As well as introducing the sport, it follows the relationship between record-breaking freediver Alessia Zechhini and her safety diver partner, Stephen Keenan.

Why: The intense filming really brings home the scale of what these athletes are achieving, and the deadly risks they take with every dive. I caught myself several times literally holding my own breath! Whether or not you like freediving, it’s hard not to be infected by their passion for their sport. There is an almost gladiatorial intrigue, bordering on the macabre, as you watch them push their physical and mental limits. During the documentary, you also witness the development of an extraordinary relationship between two people who are both passionate about taking freediving to the next level. Through Stephen, a renowned safety diver, you also gain some insight into the medical team and how they attempt to keep people safe during freediving competitions.

Book:

A Wilder Life

About: Dr Joan Louwrens is an African medical doctor with additional qualifications in family medicine, anaesthesia and tropical medicine. She swerved onto an unconventional medical path that led to her working across all seven continents, as well as some oceans in between.

Why: This book is a must-read for anyone who is interested in practising medicine outside of the safe environment of their hospital or GP practice. Dr Louwrens writes about her adventures practising medicine in places ranging from remote islands you have never heard of, to the polar regions of the Arctic and Antarctica. She has the ability to write in a vulnerable fashion, reflecting on her decision-making in difficult situations, and the burden of responsibility when you are the only doctor on-site. You can really feel her passion for adventure medicine through her compelling stories. In fact, it’s hard not to get inspired to plan your next trip and get out there!

Podcast:

Medicine on the Frontier (S1E1)

Where: Spotify

About: Luc Woodall Gillard and Mat Howes speak with Dr Rebecca Boys, freshly returned from working in Antarctica for 18 months with the British Antarctic Survey Medical Unit.

Why: Dr Boys talks about how she got into pre-hospital and expedition medicine. During the conversation, she explains the application process, and also how she prepared for her role as an expedition doctor. They discuss what outdoor skills are essential, as well as less obvious questions, such as how do you prepare to take on the role of nurse, radiographer or dentist?

It’s hard not to get swept away as she tells stories about her incredibly varied work, including in South Georgia, on the ship RRS Sir David Attenborough, the British Antarctic Survey station and being the co-pilot of a Twin-Otter aircraft. However it’s not all adventure and excitement. She takes care to underline the less pleasant aspects of the job during the podcast. From working during the COVID pandemic, to living through six weeks of darkness, Dr Boys talks about how she coped with the responsibility of taking care of her group in a remote and inhospitable area.

In summary, listen for a reflective and informative insight into what it’s like to be an expedition doctor in a remote area.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

The post AM Team recommendations October 2023 appeared first on Adventure Medic.

Dr Lydia Potter / Junior Clinical Fellow / North Wales

Dr Holly Andrews / Anaesthetics Registrar / Evidence Explorer Lead / West of Scotland

• Introduction to Papers of the Quarter and Our New Collaborators
• Expedition and Wilderness Medicine
• Global Health and Humanitarian Medicine

Whilst we’ve all sucessfully navigated another ‘first Wednesday of August’ and learnt that this summer is one for always co-packing GoreTex and factor 50 whilst out on adventure, the global health and expedition medicine academic publications have been flowing out.
It’s been a busy time for our team at Adventure Medic with many of us jetting off to global expeditions, supporting wilderness training and heading up global health endeavours and so we’ve drafted in two brilliant adventurous Doctors from North Wales. Drs Clapham and Potter have been scouring the academic community for interesting publications from their offices overlooking the impressive mountains of Snowdonia. Here they present a wide range of publications, from essential guideline updates from the UIAA on managing diabetes in the wilderness, to thought provoking prose on decolonising healthcare and our role in healthcare in the battle against plastic pollution.
We really have got something for everyone this issue – happy reading!

Dr Laura Clapham

Laura is in her third year of Emergency Medicine training in North Wales. She has a keen interest in Global Health and medicine in low-resource settings. During her time out of training, she has worked in rural Zambia, on board Mercy Ships in Guinea and Senegal, in Lesvos with Boat Refugee Foundation, been on expeditions to Madagascar and Honduras, worked at a ski field in New Zealand and in Darwin ED. In her spare time, she enjoys being immersed in cold water swimming or diving, and is trying to learn to some climbing skills to keep up with the North Wales crew!

Dr Lydia Potter

Lydia is a FY3 doctor living and working in Conwy, Snowdonia. She is currently doing a less than full time junior fellow job in Emergency Medicine and Paediatrics in Ysbyty Gwynedd, Bangor. In her spare time, she is part of the RNLI boat crew in Conwy and teaches on the Unique Expeditions UK courses. She has experience providing medical cover for ultra-endurance races, sports matches and festivals in the UK and abroad. She is working towards her Mountain Leader qualification in the hills of Snowdonia. When not at work, you can find her open-water swimming, hiking, climbing or bouldering in Eryri.
After her ‘F-free year’ she is hoping to enter EM ACCS, continue doing expedition medicine work and eventually sub-specialise in PHEM.

Expedition and Wilderness Medicine

This quarter in wilderness and expedition medicine, we present six fascinating publications. These papers take us from Kilimanjaro, discussing the effect of menstruating on incidence of Acute Mountain Sickness (AMS) to California, looking at the dangers of endurance sports, analysing a case series that presents four runners requiring dialysis following an ultra-marathon. Detailed and practical guidelines have been produced by the UIAA (International Climbing and Mountaineering Federation) medical commission for managing diabetes in the mountain – fantastic news for any expedition medic taking a diabetic client into the wilderness. Equally, for those of us who feel rising stress when dealing with a pregnant client on expedition, Coffet et al have done our research for us, and produced a literature review detailing considerations for wilderness and remote travel for those in the first trimester. For the scientists in us, altitude physiology has been explored further, with Kammerer et al looking at the effects of hypobaric hypoxia on coagulation in healthy patients. Finally, we have been treated to more evidence-based guidelines, with an expert panel grouping together to supplement WMS clinical practice guidelines on the treatment, management and prevention of non-freezing cold injury and warm water immersion. There is plenty this quarter to inform and inspire and we hope these articles can improve your practice when you are out in the wilderness, wherever that may be.

A Preliminary Study of the Effect of Menstruation on the Incidence of Acute Mountain Sickness
Paul M, Wagner T, Tukel C et al. Emergency Medicine Journal. April 2023

Menstruating whilst on expedition…it’s a faff at best and can be a major issue at worst, but does it have any effect on physiological adjustment to altitude? For many years, women were excluded from high altitude activities and neglected from scientific studies based in such environments. Thankfully, this is now changing, with 50% of those engaging in high altitude expeditions being women⁽¹⁾. This study by Paul et al aimed to compare the incidence of acute mountain sickness (AMS) between women who were menstruating and those were not menstruating during an ascent of Kilimanjaro (5895m). A secondary outcome was the use of AMS prophylaxis on this relationship. AMS was defined by the Lake Louise Consensus Scale and the expedition doctor’s clinical judgement. 46 women were included in the study, all from the same expedition, with 17 women menstruating. No significant difference in AMS incidence was found between women who were and were not menstruating or any effect of prophylaxis use on this relationship. The main limitation of this study was its size and lack of rigorous controls. However, the results certainly provide the start of a more solid evidence base to use when advising female participants on expedition. Larger-scale studies are still needed to fully define the relationship between hormonal influences on AMS incidence, but the findings of this work do go some way to help address the discrimination and misinformation about female athletes operating in extreme conditions. The findings may also act to reassure those having that heart-sink feeling when they realise their cycle lines up with their high-altitude expedition!

UIAA Medical Commission Recommendations for Mountaineers, Hillwalkers, Trekkers and Rock and Ice Climbers with Diabetes
Hillebrandt D, Gurtoo A, Kupper T et al. High Altitude Medicine and Biology. June 2023

Diabetes is a huge topic with a large prevalence, so it is unsurprising the UIAA Medical Commission’s advice article is a sizeable read. Whilst diabetic emergencies in remote locations can be fatal, there is no reason a knowledgeable diabetic who is skilled in self-care cannot function well in an extreme environment. It is clear the UIAA community wishes to support diabetics to safely enjoy all aspects of mountaineering and this recommendation document is an informative read for those wishing to support mountain expeditions with diabetic participants.
The UIAA (International Climbing and Mountaineering Federation), abbreviated by its French name, Union Internationale des Associations d’Alpinisme, is the international governing body for climbing and mountaineering, advising on issues such as mountain safety, sustainability and competitive sport. This recommendation article is split into seven numbered sections. The first four sections (introduction to the guideline document, introduction to diabetes, managing diabetic emergencies and caring for diabetic competitive climbers in non-remote settings) are written in non-technical terms, for the reading of the lay person. Sections five and six are written for clinicians, with section five focusing on insulin-dependent diabetes mellitus and section six on mountaineers taking oral hypoglycaemic medication. These two sections are fantastic, laying out the evidence clearly and advising on practical aspects of diabetic care at altitude; from the effects of temperature on insulin storage to how Acetazolamide prophylaxis affects glucose regulation. Section seven discusses recent technology developments in diabetic care, including insulin pumps and continued glucose monitors; setting out the pros and cons of modern diabetic technology use in a remote area. Given the prevalence and popularity of such devices, this final section is highly topical and enlightening. Whilst lengthy, this recommendation document contains all the information one could need when supporting diabetic patients in the mountains and is a vital read for any medic accompanying such a patient on expedition.

Effects of Hypobaric Hypoxia on Coagulation in Health Subjects Exposed to 3,500m Altitude
Kammerer T, Walzl A, Müller T et al. High Altitude Medicine and Biology. June 2023

Trauma at altitude is thankfully rare, but in an environment of rock faces, crevasses and seracs, when trauma does occur it can be significant. Whilst major trauma ultimately requires extrication and evacuation to in-hospital care, knowledge of the effects of altitude on coagulation and trauma-induced coagulopathy can be useful for the expedition medic practicing at altitude. Hypoxia is thought to be a trigger for pro-thrombotic changes, both in critically unwell patients and in healthy people at altitude, but do patients really bleed more at altitude? This small-scale study used twelve healthy females controlled for their variables and studied their functional coagulation and blood lysis at both a hypobaric hypoxia equivalent to 3,500m and at normoxia. Plasma-based coagulation tests were also done. There were no significant changes found, with no difference between lysis ability, clotting time, clot formation, clot amplitude or clot firmness. Kammerer et al concluded that moderate hypobaric hypoxia has no influence on blood coagulation in healthy females. This is a small-scale, but highly controlled study with interesting results that dispel some commonly accepted beliefs. Whilst this study should not change extrication plans for the trauma patient at altitude, it may have implications for risk stratification and certainly for future research.

Prevention and Treatment of Non freezing Cold Injuries and Warm Water Immersion Tissue Injuries: Supplement to Wilderness Medicine Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite
Zafren K, Hollis S, Weiss E et al. Wilderness and Environmental Medicine Journal. June 2023

In our Spring Evidence Explorer, we discussed Tipton & Eglin’s article ‘Non-Freezing Cold Injury [NFCI]: A Little-Known Big Problem’, which highlighted the difficulties in assessing, preventing and treating this condition due to its unclear mechanisms. Immersion injuries including NFCI and warm water immersion injuries often affect the feet, mostly of those operating in cold and/or wet regions for prolonged periods of time. These injuries are debilitating, painful and can be expedition-ending when affecting those required to walk long distances. To supplement the current Wilderness Medical Society guidelines, a panel of experts have gathered to develop evidence-based clinical guidelines for the evaluation, differential diagnoses, treatment and prevention of NFCIs and warm water immersion injuries. This article presents the available evidence alongside clear recommendations from the expert panel. It is well worth a read for anyone likely to encounter patients with immersion injuries – anyone working in environments where feet are soggy for prolonged periods of time.

First-Trimester Pregnancy: Considerations for Wilderness and Remote Travel
Coffet CH, Casper LM, Reno EM et al. Wilderness and Environmental Medicine Journal. June 2023

Whilst heavily pregnant women are unlikely to be involved in expeditions in extreme environments, those in their first-trimester may partake in many outdoor activities with ease. Additionally, a person may discover their pregnancy during an expedition or even travel unknowingly during this period. This literature review addresses diagnostic and management considerations in multi-day expeditions during the first trimester of pregnancy. The article covers both gynaecological considerations, including vaginal bleeding, suspected ectopic pregnancy and threatened pregnancy as well as non-gynaecological considerations, including treating infections, dealing with nausea and vomiting and vaccinations recommendations. Clinicians working in extreme environments should be prepared to answer queries about travelling during first-trimester pregnancy and be comfortable prescribing, treating and determining the need for evacuation. Even if an expedition medic believes there are no pregnant participants on their trip, it may be a possibility and one should be prepared for any eventuality. This article addresses commonly encountered questions and presents available research, helping us all to advise with a solid evidence base.

Four Cases of Acute Kidney Injury Requiring Dialysis in Ultramarathoners
Pasternak AV, Newkirk-Thompson C, Howard  JH. Wilderness and Environmental Medicine Journal. June 2023

The popularity of ultra-endurance events are on the rise and it’s easy to see why. Participants can race through stunning landscapes with a ‘run when you can, walk when you want’ attitude, focusing on the journey, not the completion time. With a huge range of ultra-endurance race providers operating in almost every environment possible, there is a magnitude of events to choose from. Clinicians working in event medicine, particularly in ultra-marathons, will be used to advising athletes to keep hydrated and avoid non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen. This advice comes from a desire to avoid a pre-renal acute kidney injury (AKI) and exertional rhabdomyolysis, but are we and our clients truly aware of how serious this can become? This interesting case series by Pasternak et al presents four cases of AKI requiring haemodialysis following ultra-endurance footraces. The four runners discussed had all run the Western States 100-mile Endurance Race (WS100) in sunny California over a three year span. Importantly, the race day temperatures were high, ranging from 36.6-38.3 degrees Celsius. All four runners presented to secondary care 17-32 hours following their race with biochemical findings of rhabdomyolysis, hyponatraemia and AKI. All four had symptoms of nausea, vomiting, dark urine and muscle cramping during their race and their presenting symptoms on arrival at hospital were ongoing fatigue, myalgia, nausea and vomiting, with one runner experiencing haematemesis. One participant had taken 200mg Ibuprofen, but all others had avoided any medications. Typically, AKI and exertional rhabdomyolysis is transient and does not require dialysis; however, all four of these runners required haemodialysis for between 10 days to 6 weeks. Despite the seriousness of their presentations, all four patients did recover fully and returned to endurance running with no chronic kidney disease. This case series is a really interesting read and provides some great evidence to take renal issues in endurance sport seriously. For budding wilderness medics, endurance races may be the first exposure to expedition medicine and this study highlights how vital it is to advise athletes on hydration, electrolyte intake and the avoidance of NSAIDs.

Global Health and Humanitarian Medicine

This quarter’s global health publications present many thought provoking topics that provide an evidence base for instigating essential discussions within our communities and give inspiration for meaningful action and change.
The first two articles discuss the inter-relationships between artificial intelligence and plastic pollution to our healthcare systems and not only explain the problem but also provide helpful ways in which we might take steps to improving both. Decolonisation throughout the world has been a hot topic over the past year and its importance within health systems is incredibly important in the drive to promote heath equity. Laura presents two excellent articles below related to this giving advice on how we as individuals can take steps to helping improve global health equality.
Over the past decades we’ve seen an ever increasing flow of UK doctors drawn to Australia to work. Such an opportunity is exciting but it is important to pause amidst drowning in visa admin to consider our potential impact on the native communities there prior to arrival. Crocetti et al describe the problems with alcoholism within Aboriginal communities and highlights the potentially disastrous impact that global companies can have on this.
And finally, in a previous evidence explorer edition we talked about the bi-directional benefit of working in LMICs highlighting the article by Walpole et al and here we present another providing evidence of the skills gained during global health placements.
Enjoy!

Threats by artificial intelligence to human health and human existence
Federspiel F, Mitchell R, Asokan A et al. BMJ Global Health. May 2023

Artificial intelligence (AI) has enormous potential to benefit healthcare. Yet most of us are immediately drawn to horror films where AI destroys the planet and the human race forever. This paper takes a more logical approach and examines the potential threat to human health and wellbeing through social, political, economic and security-related factors. If “narrow AI” (a learning algorithm designed to perform a single task) is misused, it could threaten human health by controlling and manipulating people, enhancing lethal weapon capacity and rendering human labour obsolete. And maybe those movies weren’t fantastical after all; the development of self-improving artificial general intelligence (AGI) could pose an existential threat to humanity. The authors call for effective regulation and the prohibition of certain AI types and applications, and even suggest a moratorium on self-improving AGI development. It is a rapidly evolving technology and perhaps the medical community should be advocating for social and economic policies which advocate for safe AI to protect future generations?

Supplement: Plastic pollution: how can the global health community fight the growing problem?
Bidashimwa D, Hoke T, Ba Huynh T et al. BMJ Global Health. June 2023

From AI to plastics, the threat to human health is real. The UN defines the principle of “One Health” as “an integrated, unifying approach… to sustainably balance and optimise the health of people, animals and ecosystems.” ⁽²⁾ This paper details how plastic pollution negatively impacts all three. It goes on to argue that the global health community has not been very vocal on the issue. Despite the global crisis and the burden it poses, the authors’ literature search found only 65 articles on plastic pollution in 15 out of the top 50 global health journals in the past 5 years. They include a call to action and suggest: 1) filling the evidence gap, 2) employing a multi-disciplinary approach with environmentalists and animal health specialists, 3) using a circular economy for medical plastic waste, and 4) engaging with global, national and local health leaders to advocate for effective interventions. Perhaps next time we throw away the waste from a cannula, we can pause and ponder what part we can play in the big picture?

Global health has deep roots in colonialism and these structures still persist today. These two papers provide insight into the problem and consider the future of deconstruction.

Colonization and decolonization of global health: which way forward?
Hussain M, Sadigh M, Sadigh M et al. Global Health Action. Nov 2022

This article is a sobering reminder how ingrained colonialist ideas have birthed and molded global health as we know it today. It highlights historical examples of the negative health impacts these structures have had and challenges whether we can begin to change them while operating within them. It demonstrates how medical progress has benefited people of the colonial powers and exploited vulnerable groups. Still today, global health partnerships “that aim to help often mirror colonial relationships with members of high-income countries being given greater opportunities (mentorship, employment opportunities, leadership positions, compensation) in low income countries than the other way around”. The “Next Steps” section will leave you with much food for thought as the authors present some tough questions on the future of decolonising global health.

Drivers of health workers’ migration, intention to migrate and non-migration from low/middle-income countries, 1970–2022: a systematic review
Toyin-Thomas P, Ikhurionan P, Omoyibo EE et al. BMJ Global Health. May 2023

Following on from decolonising global health, this study aimed to understand the factors driving healthcare workers’ migration from low/middle-income countries (LMICs). They analysed 107 studies published between 1970 and 2022, focusing on doctors and nurses from 26 countries. The key drivers were found to be remuneration, security problems, career prospects, working environment and job satisfaction. These factors remained consistent over the last five decades and were similar across geographical regions in LMICs. With evidence now to guide action we hope that better progress can be made to support LMICs in retaining their health worker populations. 

Surgery: a crucial ally for universal palliative care access
Rosa WE, Lumati JS, Alatise OI et al. The Lancet Global Health. May 2023

Surgery is all about cutting, right? But what happens when cutting can no longer cut it? Pun absolutely intended. This paper reminds us of the inequalities in access to palliative care globally, and argues that collaboration between surgical and palliative care teams could help bridge health gaps. Globally, 5 billion people lack surgical care while 61 million suffer for want of palliative care. 64% of countries lack palliative care access, mainly low-income ones. A multidisciplinary approach involving surgeons is crucial, particularly in low-income countries, to address unmet needs. If you are thinking of working or have worked in surgery in a low-income country, integrated palliative care is perhaps something to consider when planning your resource allocation. 

‘A recipe for cultural disaster!’– a case study of Woolworths Group’s proposal to build an alcohol megastore in Darwin, Northern Territory
Crocetti A, Cubillo B, Walker T et al. Globalization and Health. June 2023

If you have spent time in the Northern Territory (NT) of Australia, you will know what a beautiful and culturally important place it is. Aboriginal culture is one of the oldest on the planet and yet they have been treated appalling in recent history. [I recommend reading Dark Emu for more on this]. In order to alleviate some of the problems caused by alcohol, so-called ‘dry’ communities have banned alcohol. This study delves into the impact of commercial activity on Indigenous populations, focusing on the effects of the alcohol industry in Australia. The supermarket chain Woolworths aimed to build a large alcohol store near ‘dry’ Aboriginal communities in the NT. Through interviews and data analysis, the study reveals Woolworths’ tactics, including lobbying and divisive rhetoric, disregarding existing evidence of harm. Advocacy efforts, emphasising unity and Aboriginal leadership, countered these tactics. It is inspiring to read how these strategies can protect Indigenous health against powerful commercial interests.

Applicability of working abroad for physicians with a specialization in Global Health and Tropical Medicine
Ozcan H, Overeem L, Bakker M et al. Globalisation and Health. April 2023

“So please tell us how your experience overseas has helped you in your work in the NHS…” This may be a familiar question in interviews or even in casual conversation at work. Sometimes it is hard to put it into words. Well, this study may provide a useful talking point. In the Netherlands, the Global Health and Tropical Medicine training programme involves 27 months of training in Obs & Gynae, Surgery and/or Paediatrics followed by a six month internship in a low-middle income country (LMIC). The study explores the competencies developed by physicians specialising in Global Health and Tropical Medicine during their work in low-resource settings (LRS) and their applicability in high-resource settings (HRS). Using qualitative methods, the study identifies 15 themes including cultural awareness, communication skills, public health, teamwork, and many others. These competencies enhance physicians’ professional, personal and cultural perspectives, potentially improving healthcare delivery in both LRS and HRS. A really useful read whilst reflecting on your own experiences working in low resource settings. 

Thank to our collaborators this quarter, we’ve really enjoyed having you on board.
As always, do get in contact if you’d like to be involved with contributing to future releases of this feature – we always look forward to hearing from you.

Bibliography

1. Twombly  SE, Schussman  LC. Gender differences in injury and illness rates on wilderness backpacking TRIPS. Wilderness Environ Med 1995;6:363–76.
2. https://www.who.int/europe/initiatives/one-health#:~:text=One%20Health%20is%20an%20approach,animal%2Dhuman%2Denvironment%20interface.

The post Evidence Explorer: Updates and news from the academic community, Summer 2023 appeared first on Adventure Medic.

If polar adventures as a medic are on the cards, this open access article on legal considerations is for you. It highlights several controversies touching on telemedicine, medical kits and suggested qualifications. It showcases the need for internationally recognised standards to ensure appropriately trained and experienced clinicians are recruited to provide quality medical care to those travelling in these remote regions. It could arguably be extrapolated to expedition and remote medical work in other environments where governance is also currently lacking with significant variability in the provision of care. We hope this helps spur on conversations and the creation of standards in the field. 

The article is by paramedic and polar guide/medic, Kai Müller. It is part of his Diploma in Remote and Offshore Medicine with the Royal College of Surgeons of Edinburgh.

The post Legal Considerations for Medical Care in Polar Waters appeared first on Adventure Medic.

University Hospitals Dorset provides a unique opportunity for junior doctors to combine an emergency medicine post with a fully funded qualification in the world’s first postgraduate course in Extreme Medicine. Dr Johnston and Dr Pearson have melded a passion for adventure with academia and clinical experience. They discuss the realities of the role and the exciting places it has led them.

Structure of the Role

The post is an 80:20 split of clinical emergency medicine to non-clinical time development time. From a clinical perspective, a fellow will work a normal SHO or middle grade rota in the Poole Emergency Department. The remaining part of the year involves the completion of course modules culminating in a Postgraduate Certificate (PGCert), Diploma (PGDip) or Masters (MSc) in Extreme Medicine from the University of Exeter.

The job is for twelve months with an optional extension of up to three years for the completion of the MSc. If a fellow’s academic requirements are completed early, the remaining non-clinical time can be used to work as a doctor on an expedition or event. Such positions are arranged by the individual, not by the department.

Prerequisites for application

For the SHO role, a candidate must have completed foundation training or the equivalent if applying from overseas and should have at least six months experience in Emergency Medicine.

For the Specialty Registrar role at least three months experience in anaesthetics and/or ICU is required. If a candidate has prior experience working in remote environments or evidence of an interest in expedition or humanitarian medicine this will be looked upon favourably, but is not a requirement.

Location of the fellowship

Fellows are primarily based in Poole Hospital, with the option of a secondment to Royal Bournemouth Hospital for more varied clinical exposure. The rest of the post involves course modules which are based in the UK and abroad. Examples of the MSc course locations include: Oman (Desert Medicine), Norway (Polar Medicine), Costa Rica (Jungle Medicine), Nepal (Mountain Medicine), Florida (Dive Medicine) and Slovenia (Alpine Medicine).

Accreditation

The trust provides a funded place on the MSc in Extreme Medicine from the University of Exeter. A MSc will be obtained, assuming academic satisfaction, after 3 years working for the trust. For those in the fellowship for a shorter duration, such as one or two years, there is the option of completing a PGCert or PGDip in Extreme Medicine respectively.

Our Overall Impression

The opportunity to learn to provide medical care at a high level in extreme environments is what distinguishes this job from other emergency medicine fellowships. For each module, the multi-disciplinary student cohort is different and therefore peer-to-peer learning and networking is exceptionally varied.

The modules generally consist of a residential component, with opportunities to learn both expedition skills and the medical considerations relating to a specific environment. The academic component required after each course is linked to the theme of the module. For example, a fellow may be asked to write a critical appraisal of the evidence surrounding the prevention and treatment of heat-related illness following the desert medicine module.

The Poole Emergency Department is a friendly and supportive workplace. The clinical work is diverse, team-based and enjoyable. As the fellowship is a full-time post in the same department, the rota will often be made available up to six months in advance. The town of Poole is a fantastic place to live. There is easy access to the Jurassic coast and the harbour is great for water sports, including kitesurfing.

Outcomes of the fellowship

An Extreme Medicine qualification does not automatically lead to pre-hospital work, however partaking in the modules provide ample opportunity for networking with expedition clinicians and inspirational colleagues. The MSc modules cover the logistics, practicalities and the medico-legal considerations of working in an expedition environment, which prepare fellows to work outside of the hospital environment.

In terms of career progression, fellows are encouraged to undertake quality improvement projects within the emergency department and maintenance of a clinical portfolio is facilitated by the senior team.

Funding

The cost of the PGCert/PGDip/MSc is funded by the trust, however personal kit, transport (including flights) and certain course supplements need to be self-funded. While attending a course module a fellow will continue to receive their usual daily wage.

There is an additional study budget provided by the department for related courses and conferences. Study leave will be incorporated into the time required to complete the relevant Extreme Medicine modules.

Further considerations

It is worth bearing in mind that although this is a largely clinical role, when there is personal development time, it is taken in blocks throughout the year. A fellow will be expected to work a full-time rota for the remainder of the post. This inevitably leads to a greater proportion of lates, nights and weekend shifts.

Currently, the Poole and Bournemouth Emergency Departments are split-site resulting in a lack of exposure to certain clinical presentations. Bournemouth is the acute stroke and cardiology centre, so fellows placed in Poole will see fever stroke and acute cardiology presentations. On the other hand, Poole is the local trauma unit, so a fellow will see more trauma presentations. A new acute service is being built and the departments will be merged into a single-site in 2025.

Final Thoughts

This job is ideal for an adventurous medic who wants to combine clinical experience with expedition academia. It is a unique role, which allows for development as a clinician and exploration of opportunities outside the typical hospital environment.

Links

For those considering this post, recruitment for August 2024 will begin in October and will be advertised on NHS Jobs and World Extreme Medicine’s social media platforms.

Information about the MSc in Extreme Medicine can be found on the University of Exeter webpage: Extreme Medicine MSc (Distance) | Postgraduate taught | University of Exeter.

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EXPLORE weekend offers something for everyone with an adventurous spirit. This event, hosted annually by the Royal Geographical Society (RGS), aims to educate, inspire and empower you to transform your expedition and fieldwork dreams into reality. Drawing on the expertise of explorers, geographers and field researchers, EXPLORE covers a broad range of topics and is sure to appeal to anyone with an interest in exploration.

EXPLORE’s two-day programme is curated to both ‘inform and inspire’. Shared experience of over 100 leading scientists and explorers is presented through a series of talks and specialist workshops. The workshops allow discussion and give practical advice on project planning and execution and ample time is provided between sessions to network in the historical map room.

Programme Structure

EXPLORE is held at the RGS in South Kensington, London. This beautiful building has the feeling of a country house nestled amongst the city, packed with curiosities from historical expeditions. Alongside the Natural History and Science museums and Imperial College of Science, Technology and Medicine the location alone is enough to inspire the mind.

A range of tickets are available to cater for single day, weekend and virtual attendance. Prices then reflect duration, level of interaction, members and non-members, students and early bird tickets.

Weekend Highlights

This year heralded EXPLORE’s first in-person event since pre-pandemic times, and what a magnificent debut it was! Over twenty talks allowed for a huge diversity of topics to be covered. With such an impressive line-up, it was difficult to select those that stood out the most. Professional explorer Lucy Shepherd inspired us with tales of adventure, followed by practical expedition planning advice. Chris Woodfield delivered a harrowing but necessary reminder of the climate and ecological emergency, discussing how our actions today can help the planet tomorrow. In an alternative twist, Myles Harris’s research enacted possible healthcare scenarios in the exploration of alien planets. This was complemented by Elly Trobe and Jason Gibbs, who walked us through the numerous medical preparations required to safely explore our planet Earth. The afternoon ended with the first round of specialist workshops: Expedition Logistics. Led by a panel of experts, delegates could choose from a number of different environments including ocean, mountain and polar.

The Explorer’s bar, open after the conclusion of Saturday’s proceedings, provided the perfect venue to continue the day’s discussions over a well-earned pint!

Sunday’s follow-up did not disappoint. The morning opened with Niall McCann’s ‘Why Fieldwork Matters’. His authenticity and undiminished enthusiasm for conservation and the natural world was infectious. He instantly captured the room. Niall left us with a powerful take-home message that “human health, animal health and planetary health are all one health”. It is all of our responsibilities to ensure we conserve it for future generations. Morning talks were concluded with Anthroposea, a short but powerful film by Michelle Sanders on human interconnectivity to our oceans shot aboard Sail Britain. A second round of workshops covered field research in a number of social, biological and medical disciplines.

A huge variety of talks were crammed into the final afternoon. Jamie Buchanan-Dunlop’s profound and heartfelt talk covering communication in the field, international collaboration and humanity had us all reaching for the tissues. Artist Sarah Fortais provided an alternative perspective on human endeavour. Bridging the gap between science and art her displays included space suits for giraffes and genuine NASA moon rocks!

Exhibitors

Numerous exhibitors across a range of specialist areas provided delegates with further opportunity for expert advice and networking. These included Nomad Travel, who provide expeditions with bespoke medical equipment and Silk Road, who deliver environmentally sustainable first aid training to those exploring challenging environments. A full descriptive list of exhibitors may be viewed here.

Reviews

I asked a number of delegates and exhibitors about their experiences of EXPLORE weekend:

“Inspiration from a range of experts and people who have gone and done the extra-ordinary”

“Very cool to meet people who are doing this differently… this makes it feel possible”

“The talks have been inspired and varied… having snippets of people coming in talking about their experiences is lovely”

“Some of us are planning to organise expeditions and get funding… the practical side of things, the talks were really good”

“I have been able to see people that when they have a strong enough idea, there will be others willing to fund it!”

“Having come in with an expedition plan, it’s been pretty helpful to think about areas that we haven’t considered… evacuation plans, yes!”

“It’s been really nice to meet new people… gaining contacts”

Personal thoughts

This was my first EXPLORE weekend. My dad, often knowing me better than I know myself, had twisted my arm slightly and bought me a ticket as an ‘early Christmas present’. I therefore felt rather obliged, on that rainy morning in November, to make my way over to the RGS. However, as I squelched through the doors, I was immediately drawn in by the buzz and excitement that greeted me. The staff, delegates and exhibitors were incredibly friendly and welcoming. I soon got chatting during the morning coffee break. Living in London, it is a rare occurrence to find like-minded individuals who have managed to incorporate their love for the outdoors with a career in medicine. What inspired me so much was meeting others who were in the place I aspired to be. I was so encouraged to believe that it is actually possible.

EXPLORE weekend is not just for medics. It offers a huge variety of content on the essential aspects of expeditions and planning. You may, therefore, share my early scepticism about the relevance of certain areas of this event to your future career as an expedition medic. Why would a medic need to learn about applying for expedition grants, or the creative sharing of experiences through music and art? Well, I’m afraid I can’t provide you with a clear or correct answer. After all, I’m not even a medic yet…

I reflect that as medics we can be caught up in what we do, perhaps missing the bigger picture. EXPLORE was a refreshing ‘zoom-out’ and a reminder of the part we can play. An appreciation of the work that goes into getting you to that polar ice cap, jungle or atop that mountain. We can learn to be a much more effective small cog in that bigger machine. We can enable exploration, positive change and a greater breadth of understanding of the world around us.

Thank you RGS for hosting such an inspiring and successful weekend.

Make sure you keep your diary clear for next year’s event. To find out more about EXPLORE 2023 click here.

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Links for Further Information

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Dr Ruth Warren / Foundation Year 1 / South Yorkshire

Dr Holly Andrews / Anaesthetics CT3 / Evidence Explorer Lead / Peninsula

• Introduction to Papers of the Quarter and Our New Collaborators
• Expedition and Wilderness Medicine
• Global Health and Humanitarian Medicine

The spring snow has transformed, the bluebells have bloomed and here at Adventure Medic we are packing away the ice tools and cautiously dusting off the summer wetsuit. Whilst the team have been busy across the globe supporting expedition endeavours clinically, the academic community have had an equally as productive transition into summer. We’ve once again seen some really interesting publications both in novel research and case studies and as always there’s been some hard hitting expert commentary on emerging Global Health issues.
This quarter we’ve had collaboration from two budding adventurists – Drs Warren and Dugmore who have been invaluable in the critical appraisal of what is a large body of work from our academic colleagues across the world. Here they present what we think are some of the most pertinent pieces to our practice and interest. From health care reports under a Taliban regime to solar water disinfection advice and evidence based guidance on how to avoid misdiagnosing stroke at high altitude.
We’ve got something for everyone this issue – happy reading!

Dr Phoebe Dugmore

Phoebe is passionate about pre-hospital and emergency medicine. She thrives on challenges and inspires others to push their own boundaries; be that by running ultramarathons or travelling for 3 months around Europe in a van with her partner, 4 month old and a dog! Evidence explorer is her latest challenge and has allowed her to marry her outdoor and pre-hospital interests with cutting edge research.

Dr Ruth Warren

Ruth is a Foundation Year 1 Doctor working in South Yorkshire.  She has travelled extensively whilst visiting family abroad, which exposed her to inequalities across the world from a young age. Her interest in Global Health was sparked during medical school and she decided to study this further through an intercalated Masters in International Development and Public Health. Through this, she was able to conduct research during the COVID-19 pandemic, working with small community in Tanzania, and in partnership with an NGO protecting children living in the slums of Kampala, Uganda. Her ongoing interest in Global Health has led to her involvement in this edition of Evidence Explorer.

Expedition and Wilderness Medicine

Every expedition medic will be well versed in the nuances of AMS, HACE and HAPE but what about the conditions that we see more commonly in our daily practice across Emergency Departments in the UK that mimic these high altitude conditions? Common things are common is a rule that of course we adapt to our environment but it’s also essential that we don’t miss potentially life threatening diagnoses by focusing on the red herring. Read on to understand more about stroke at high altitude.
Alongside this important article we present WEM’s approach to rebalancing gender equity and their evaluation of solar water disinfection methods alongside an interesting read on the medical implications of TASER devices and a comprehensive teaching paper on non-freezing cold injury.

Stroke at Moderate and High Altitude.
Syed M, Khatri I, Alamgir W, et al. High altitude medicine and Biology. March 2023.

With an improvement in road infrastructure, we’ve seen a rise in the access to high altitude for both recreation and living purposes in recent years. There are a lot more people entering these environments who, due to co-morbidities may not have done in times gone by. This together with normal physiological changes that occur at high altitude means that the incidence of stroke in our expedition population is likely to increase. This article reviews the available literature on the topic and is helpful for those medics working at high altitude to think about stroke as well as HACE. One of the most interesting take-homes from this article is that it highlights that venous sinus thrombosis is actually more common than arterial stroke so keep it in your differentials. Furthermore they discuss that conventional risk factors that must not be forgotten.
Further studies are needed on this topic but it makes for a useful read.

Changing Times and Shifting Priorities: Promoting Gender Equity at Wilderness & Environmental Medicine, Editors note
Binder W, Kenefick R, Rodway G, et al. Wilderness and Environmental Medicine. March 2023.

Most females are aware of the ongoing gender inequities in the medical profession but this editorial gives a real stark picture of the magnitude of the problem. Despite the majority of medical students in the UK in 2022-23 being women there is still a huge gender imbalance, particularly in academic medicine. It is significantly harder for women to get publications which we all know is an important part of many specialty application tick boxes. Women were found to be first authors in less than 25% of WEM articles – this is not ok.
WEM have recognised these frankly shameful gender inequities, releasing a statement with clear steps they are going to take to improve diversity in their editorial board and reviewer pool. So let’s watch this space!

Evaluation of Escherichia coli Inactivation at High Altitudes Using Solar Water Disinfection
Van Hoesen K, Mundo W, Mierau S, et al. Wilderness and Environmental Medicine. March 2023.

Many of our readership who have been on expeditions are familiar with Solar Water Disinfection (SODIS) devices. SODIS is established at lower altitudes (LA) to inactivate most pathogens and is dependent on UV-A and UV-B radiation. This study, conducted in Colorado, focused on trying to determine whether SODIS is also effective at high altitudes (HA). With less atmospheric density at HA, there are greater amounts of UV radiation so they hypothesised that it should be effective. They used E-coli as the model bacterial contaminant and added it to sterile water in 3 different types of container placed at 3 different altitudes with the attempted same weather conditions. After 6 hours they then tested samples from each. Interestingly they found different results to existing literature including time most bacterial inactivation occurs being in the first 2 hours and temperature of the water playing less of a role than previously thought. Plastic bottles were also found to be the best container.
From this study its clear further research is needed but it’s a promising start in informing guidelines and recommendations for safer water drinking policies at HA.

Non-freezing cold injury: A little-known big problem
Tipton M, Eglin C. The Physiology Society. March 2023

This is a really interesting article not only for the expedition medic but also the EM and GP guys amongst us. Most medics and lay people alike have heard of Frostbite but non-freezing cold injury (NFCI) is a bit of an unknown to us all. However it is a lot more common, being a hazard for rough sleepers and the ever increasing cold-water swimmer population, and can cause significant long-term complications for patients.
The editorial aims to give a bit of background on the condition and also highlight the lack of understanding there appears to be surrounding its pathogenesis and pathology. The mechanisms remain unclear – is it primarily vascular, neural or a combination of both? Combine that with the large number of environmental and patient-specific variables to consider and it makes screening, assessment, prevention and treatment of this illness very difficult.
Experimental physiology have released 3 back to back papers examining the condition from both the neural and vascular perspectives which are worth a read to increase our understanding but the clear take-home is that there is very little reliable literature on the topic and a longitudinal study is what is needed.

Annalise Wille from Arizona also presents a succinct presentation of this condition – the ‘screaming barfies’ – in the February edition of Wilderness Medicine Magazine.

The use of TASER devices in UK policing: an update for clinicians following the recent introduction of the TASER 7.
Bleetman A,  Hepper A, Sheridan R. Emergency Medicine Journal. February 2023.

Conducted energy devices (CED) or tasers as they are more colloquially known have been utilised by the UK police force for some time. In order to help control serious and violent situations they are intended to bridge the gap between close quarter options such as batons and irritant sprays and the much more significant lethal firearms. When used correctly, the CED is designed to deliver an electric shock to the individual it’s directed at which will cause pain and ‘neuro-muscular incapacitation’ whereby they fall to the ground. TASER 7 devices are those used most commonly by UK forces now and although highly effective, they do some with some medical consequence.
Thankfully, despite the electrical nature of discharge, arrhythmias are rare but the manufacturers do advise a period of cardiovascular monitoring and an ECG with particular relevance to the pregnant individual. The discharged CED ‘barbs’ invariably cause burns around the skin contact sites and require a specialist technique in order to remove. Injuries from the fall that ensues are also very common and it is essential that all patients receive a thorough primary and secondary survey.
As an event medic or for anyone working in pre-hospital teams alongside the police force this article is a must read. The authors explain great detail about the specific extraction methods to remove the barbs and advice on the monitoring and investigations required for individuals who have been ‘hit’ by a TASER 7 device.

Global Health and Humanitarian Medicine

Health inequalities are often the driving force for global health research and initiatives. In this quarter’s selection of articles, health inequalities amongst marginalised groups are highlighted and analysed.
The first two articles focus on those faced by poorer groups and of ethnic minorities, highlighting that even in high-income countries, these groups may not even have adequate access to water and sanitation, cascading to a higher risk of non-communicable diseases and poor population health. 
Belizzi et al in our third article advocate for the recognition of another group of vulnerable people – those displaced from their homes and countries by extreme weather due to climate change.
The last three articles are predominantly focussed on conflict, but all individually highlight the detrimental effects of conflict on women’s health.  Whilst the restriction of women is evident in conflict, the empowerment of women emerges through the last two articles as a solution to women’s adverse health outcomes and as a tool for conflict resolution.
Some tough but inspirational reading from acclaimed authors in the field. Read on to find out more.

The effects of racism, social exclusion, and discrimination on achieving universal safe water and sanitation in high-income countries
Brown J, Acey CS, Anthonj C, et al. The Lancet Global Health. April 2023

This article brings to the fore the ongoing inequalities and insecurity surrounding water, sanitation and hygiene (WASH) in high-income countries (HICs). It uses 5 contexts within USA, Europe and Australia where ethnic minority groups have significantly reduced access to water and sanitation. In these regions where lack of resources is not a contributing factor, the article argues that the driving factors for this inequality are racism, social exclusion and discrimination.  The proposed mechanisms of this include segregation; inadequate housing; property ownership rates; and lack of funding in areas heavily populated by marginalised groups compared to other regions. This has also been worsened by privatisation which brings the expectation that access to WASH is based upon individual effort and income rather than a responsibility of society to provide it as a human right for all.
This article stands out from other literature surrounding WASH where the focus is usually on low-income countries. One could argue that it is often assumed that HICs have met international WASH standards on a whole population level. This article highlights that although national statistics can achieve these standards, the disaggregated data for marginalised communities may not. These communities are often a small group and more likely to be excluded from data. Further disaggregation of national data could allow for recognition of these inequalities and therefore improve allocation of resources. The article also calls for a collective responsibility to change the wider social issues of racism and discrimination in order to tackle the WASH inequalities in HICs.
It seems that WASH inequalities may be closer to home than we realise and there is certainly a need to investigate this issue within the UK.

Risk, lifestyle and non-communicable diseases of poverty
Manderson L, Jewett S. Globalization and Health. 02 March 2023

The theme of inequalities being masked by national data continues with this commentary, which discusses how non-communicable diseases (NCDs) are most prevalent in the poorest communities. Although national data suggests that NCDs are less prevalent in the lowest-income countries compared to middle and higher income countries, it is consistently the poorest communities within these countries that have the highest rates of NCDs. In countries with high rates of wealth inequality e.g. South Africa national statistics often do not reflect the NCD prevalence in these poorer groups.  The commentary also highlights the discrepancy between genders in NCD prevalence which varies across cultural contexts and suggests an element of cultural influence rather than purely biological causes.
Similar to the previous article, there is a call for the discourse focus to shift from individual efforts to wider societal efforts in reducing NCD prevalence. As poverty is so closely linked to NCD prevalence, it suggests that wider determinants of health play a crucial role in this. However, NCD prevention campaigns and policies tend to focus on individual “lifestyle choices” rather than recognising the external factors which contribute to obesogenic environments that impact poorest groups most. It argues that those in poverty lack choice and agency in their health behaviours due to financial constraints and lack of local security. Furthermore, those in poverty are more likely to suffer from infectious disease, injury/trauma and worse maternal/child health outcomes. With the addition of higher NCD prevalence and morbidity, poorer communities face the “quadruple burden of disease”.
This article suggests the use of the term “non-communicable diseases of poverty” (NCDP) when addressing NCDs to highlight the importance that societal factors play and to shift attention away from individual efforts. It also calls for a wider systems approach with disaggregated data to recognise and tackle NCD prevalence effectively.

Global health, climate change and migration: The need for recognition of “climate refugees”
Bellizzi S, Popescu C, Napodano CMP, et al. Journal of Global Health. March 2023

This is a quick and interesting viewpoint. It addresses the rising issue of displacement of people from their countries due to extreme weather attributed to climate change. The majority of affected people are from regions within lower-income countries who must migrate elsewhere for safety. However, the main contributors to climate change are within high-income countries, further widening inequalities between different economically developed countries. These displaced groups do not always fall under definitions of “refugee” or “asylum seeker” which require a person to be fleeing from persecution. They are therefore not always entitled to the same benefits and legal protection as other refugees, despite facing mental and physical health needs directly linked to their environmental exposure and migration.
The United Nations Environment Programme (UNEP) has been using the term “climate refugees” since 1985 and the United Nations Human Rights Council (UNHRC) has broadened its protection to account for these groups as well. The article gives encouraging examples of various countries such as Argentina, Finland and Australia who have taken proactive approaches to protect climate refugees.
However, the article stresses that further recognition of climate refugees as a group of vulnerable people is required, especially as increasing numbers of people will be displaced due to weather-related disasters over time. Inclusion of this group within policies should be done to give adequate legal protection. Furthermore, projects working to mitigate the risks of extreme weather and displacement are becoming increasingly important in helping these vulnerable populations and reducing their health burden.
This article reminds us of the importance of environmentally sustainable practice and its knock-on effects on global health inequalities. It also emphasises the responsibility upon the Global North to protect these victims of weather-related disasters given its large contribution to climate change.  

Afghanistan’s healthcare under Taliban: what are the challenges?
Arif S, Rezaie KF, Madadi S, et al. Medicine, Conflict and Survival. February 2023

Afghanistan was at the forefront of news media in Summer 2021 due to the takeover by the Taliban.  This article discusses the key impacts on health that the rise of the Taliban has had and the need for international aid and funding to combat these severe issues.
Afghanistan has had high poverty and child mortality rates noted since 2002, and these have worsened in some areas since then.  It had become dependent upon international funding for various projects to strengthen the health system such as the Sehatmandi Project.  However, since 2021, much of Afghanistan’s international funding has been withdrawn. Alongside this, a lack of equipment, staffing and resources due to border controls and insecurity has compounded the failure of health services. This has led to the near collapse of the healthcare system with more than 90% of health facilities closing down and many having to travel more than 10km to access healthcare.
Women and children are depicted as particularly vulnerable during this conflict. Under the new authorities, women’s movement is more restricted and they require male chaperones which can inhibit their access to healthcare. Furthermore, more women are being forced into early marriages due to financial desperation within their families, leading to poorer maternal and child health outcomes as a result of early pregnancy.  Malnutrition is highly prevalent, affecting children the worst and making them more vulnerable to other diseases. COVID-19 has been an additional burden with inadequate resources to test and treat this disease.
This article makes the case for increased international aid to Afghanistan given the drastic health consequences of the current conflict and the withdrawal of major international donor funding of the healthcare system. It also links with the following articles regarding women in conflict and demonstrates how conflict can disproportionately affect women and act as a barrier to their engagement with health services and leadership.

FAWM accredited EM physician, Dr Terri Davis describes her role in Camp Buehring in Kuwait where she oversaw the treatment and care for Afghan refugees fleeing their country after the fall of Kabul.
Wilderness Medicine Magazine Sept 2022.

Strengthening health systems and peace building through women’s leadership: a qualitative study
Meagher K, Khaity M, Hafez S, et al. Globalization and Health. March 2023

This is interesting research that discusses the links between women’s empowerment, health systems and resolving conflict. Healthcare has been a powerful tool for peace-building, as it is valued and a common goal regardless of political stance.  Furthermore, there is a need for humanitarian projects within conflict to have a longer-term focus so that they align better with developmental goals.  This is increasingly important as conflicts become more protracted and complex, with Afghanistan as an example. A systems approach has therefore been suggested to improve long-term outcomes within conflict settings with leadership being a core element of this.  In addition, women are often worse affected by conflict due to gender-based violence and political agendas that restrict women’s freedom.
This study involved key informant interviews and 2 focus group discussions involving participants from a range of contexts affected by conflict. From the themes and codes generated, it became evident that women can be influential in peace-building initiatives with longer-lasting effects and higher rates of implementation.  As women are often viewed as non-threatening, they can be used to move more freely amongst different groups and are more likely to be trusted. As health system improvement can be a useful peace-building tool, this article suggests that the involvement of women in leadership within healthcare systems may combine the powerful effects of both approaches to resolve conflict. However, it also emerged that conflict can be a significant barrier to women’s empowerment and engagement in leadership, making this difficult to implement.  It suggests a feminist approach may be required to tackle the double burden of conflict and patriarchal oppression many women face in conflict.
Although it is not clear how to overcome the barriers that conflict brings in empowering women, this article does provide some practical points for peace-building projects.  Lederach’s framework of leadership (proposed by a professor of international peacekeeping) was used and adjusted to include specific areas at each level where women could be encouraged to participate within health systems.  This framework may be a useful reference point for peace-building frameworks and participation of women in leadership going forward.

Women’s sexual and reproductive health in war and conflict: are we seeing the full picture?
Hedström J, Herder T. Global Health Action. March 2023

This final article again highlights the vulnerability of women within conflict. Women’s sexual and reproductive health (SHRH) is significantly worse during conflict. However, much of the literature surrounding this issue focuses on structural factors such as poverty, malnutrition, lack of infrastructure, and poor water and sanitation facilities as the drivers of this issue.  This article suggests that insufficient attention has been paid to the cultural factors which harm women’s SHRH. Examples of this include forced marriage, forced retirement, control over contraception and gender-based violence.  In some conflicts, these factors are intentionally used as part of military tactics.
These factors also vary significantly across different contexts and over time.  Therefore, this article argues that approaches to women’s SHRH must be flexible and dynamic over time instead of using blanket approaches. A feminist approach is proposed to fully understand the root causes and extent of poor SHRH for women. To implement this approach, it suggests enhanced engagement of women from conflict and post-conflict zones in interviews and discussions on the impact of conflict on their SHRH.  However, it also mentions that poor reproductive health can impede women’s participation in decision-making and peace-building.
Despite this, the need for engagement of women in projects working to improve SHRH and peace-building in conflict zones has again been emphasised and future projects should consider the importance of engaging women throughout the process wherever possible..  Through this, there may be a solution to overcoming the cycle of poor health outcomes and disempowerment of women often seen in conflict.

As always, do get in contact if you’d like to be involved with contributing to future releases of this feature – we always look forward to hearing from you.

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Dr Tom Everett / GP / Highlands, Scotland

It has been a pleasure and privilege to attend WEM 2022 representing The Adventure Medic. We are so grateful to WEM for inviting us back to cover what is undoubtedly the highlight of the conference calendar for those with an adventurous streak.

Just like that, in a blur of buzz, ropes, explosions and explorers, the World Extreme Medicine (WEM) Conference has concluded for the year. 19th – 21st November 2022 saw the most eminent explorers, adventurers, astronauts, scientists, rescuers and healthcare workers descend on Dynamic Earth in Holyrood, Edinburgh for the world’s biggest extreme medicine conference. The breadth of experience and achievement present in one place is unsurpassed; the excitement among delegates was palpable.

WEM have been organising this conference for over 10 years. It is evident in the delivery of this slick, efficient and industry-leading event. As well as optimising their face-to-face product, there is the opportunity to join the conference online from anywhere on the planet for a lower price, thus maximising the exposure and impact of content. This feature was facilitated by a small army of technicians ensuring that the live stream of lectures and workshops was high quality worldwide. Equally, a slick app provided a dynamic agenda, profiles for delegates and messaging capabilities for networking. Amid the impressive academic and humanitarian representation there were pioneering companies providing demonstrations of cutting-edge kit.

Arguably more important and impressive than the logistical side of the event was the approachable atmosphere that permeated throughout. WEM 2022 provided a truly international network of impassioned medics and adventure enthusiasts. Too many speakers to mention drifted by the Adventure Medic stand bestowing mind-blowing tales of mountain, jungle, ocean and polar environments with complete modesty; some of these we hope you will see here soon as the authors of future articles! The evidence of global networking and multidisciplinary learning from so many countries, cultures and professions was humbling.

Highlights of the Saturday took us everywhere from the International Space Station to icy Svalbard, Myanmar to rowing oceans. Mark Hannaford warmly welcomed everyone, kicking the conference off to a great start – did we really witness bagpipes played in outer space? Klara Weaver covered the challenges, complex and bizarre, that she faced as a medic returning from 20 months overwintering in Antarctica with her unique perspective on the global Covid-19 pandemic. Martin Bromiley, founder of the Clinical Human Factors Group and an airline training captain, provided an invaluable session on the importance of and barriers to integrating human factors training into healthcare. Pushing yet more boundaries was Lucille Chauveau who described the unique complexities of providing Medevac services to the one hundred and eighteen diverse and remote islands that make up the French Polynesian archipelago.

Delegates and speakers came from a wide range of backgrounds, from paramedicine, nursing and film-making through to mountain rescue, humanitarian and dive medicine. Hands-on breakout sessions allowed attendees to get stuck into everything from expedition vehicle maintenance, splinting, wound care and rope skills. We could not turn down the opportunity to attend an expedition dentistry workshop with the Adventure Medic’s own Burj Langdana; the energy and passion that Burj brings to his teaching is a sight to behold and certainly worthwhile.

Buoyed up with inspiration from Saturday, Sunday arrived with a further jam-packed day of industry legends. Andy Kent from UK-MED reflected on how it felt delivering trauma care teaching to Ukrainian paramedics and then seeing the same group, four days later, responding to a mass casualty event. His presentation included a video showing the erection of a UK-MED bespoke, fully equipped temporary hospital in 12 days, following the intentional destruction of a hospital. His powerful talk really demonstrated the great capabilities and importance of this organisation.

Hopeful pre-hospital medics of the future listened intently to Ffyon Davies and Patrick Wenger, from Air Zermatt, in the HEMS workshop and career panel. They discussed the use of standard equipment in novel ways, demonstrating the creative thought processes required by pre-hospital clinicians managing extreme injuries with limited kit.

Lucy Shepherd, the first keynote speaker of Sunday, embodied adventure. She challenged the misconception that “we are past the glory days of exploration”, wowing the audience with her experience of crossing the snake-ridden Kanuku mountains, an uncharted region of the Amazon. Maritime legend Mensun Bound closed Sunday by telling his story of the successful voyage to locate Shackleton’s vessel, ‘Endurance’ beneath Antarctic sea ice. Given the loss of this ship led to one of the greatest stories of human survival, it is amazing to see footage of the name clearly preserved upon the stern of a ship now found again deep in the ocean.

Monday started slowly with bleary-eyed delegates comparing tales of cocktails and dancing; what a night the WEM ceilidh was! Sarah Spelsberg’s talk was a perfect antidote to the excesses of the night before, detailing how breaking-down boundaries creates opportunity and fulfilment. She attended medical school late and pushed herself to the extremes by working as a medical intern in the remote Aleutian Islands. She described having an “anti-resume” and being “anti-fragile”, making the point that sometimes resilience is unachievable and undesirable. Her talk was incredibly inspiring, concluding that to secure joy, we should “contemplate, innovate, adapt and evolve”.

GoodSAM updated delegates on how their impressive app is improving cardiac arrest outcomes worldwide by connecting casualties to a volunteer first responder network. The Arclight Project provided valuable ophthalmology teaching using their novel and effective ophthalmoscope. It’s ability aiding the diagnosis and management of eye and ear pathology in low and middle-income countries. There were also updates on artificial intelligence and telemedicine projects and their ethical dilemmas and multiple in-depth discussions on how best to look after our own and our clients’ mental health in relation to conflict, expedition and relief work.

Reflecting on the take-home messages from the World Extreme Medicine conference 2022 we have lots to be thankful for. Inclusive, exciting and collaborative are words that immediately spring to mind. The WEM team, speakers and attendees created this inspirational, supportive event for adventurous medicine. This conference is progressive, full of high-calibre content and provides an approachable and truly multidisciplinary atmosphere. It is this that made 2022 such a special WEM conference as attendees from all over the globe, in person and online, could interact in such positive ways. The Adventure Medic is already excited to hear of the projects that will prosper and launch from this conference.

If you missed this year’s event, online tickets are still available by contacting WEM directly and provide access to up to 70 hours of extreme medicine content. You can catch session recordings on-demand for up to 12 months post-conference. For those interested in attending WEM 2023, details can be found here, with speaker submissions now open.

Photo credits: Tom Everett 

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Dr James Spittle / Foundation Doctor / South Yorkshire

Dr James Spittle BSc (Hons) BMBS.
When not working as a Foundation Doctor in South Yorkshire, James spends most of his time cycling and climbing. Whilst studying in Exeter he helped set up and run the wilderness medicine and anaesthetic societies as well as providing medical cover for a number of events including Glastonbury festival. He has a keen interest in pre-hospital, mountain and sports medicine/physiology and has been invaluable in the production of the expedition section of this winter edition of Evidence Explorer.

• Introduction to Papers of the Quarter
• Expedition and Wilderness Medicine
• Global Health and Humanitarian Medicine
• The long-list extras

Welcome to the Winter edition of Evidence Explorer. This quarter we’ve had Dr James Spittle on board scouring journals in the expedition and wilderness sector. He’s picked out some interesting reads with thought-provoking ideas that may just spark changes in your own practice, or build ideas for study and research. The global health journals were packed with hard-hitting articles both before and after COP-27 in the latter part of 2022, and we’ve picked a few of these for summary alongside some other important reads. This latter section has been particularly fruitful over the past months and so we’ve included the long-list footer again which is worth a scan.

As always, do get in contact if you’d like to be involved with contributing to future releases of this feature – we always look forward to hearing from you.

Happy Reading!

Expedition and Wilderness Medicine

We have a broad range of topics summarised in the expedition section this quarter; from trying to answer questions on how best to clean wounds, to discussing the benefits and development of using whole blood transfusions in pre-hospital resuscitation and stabilisation. The esteemed Dr Basnyat and his team have produced evidence-based statements on teaching and expanding knowledge for the layperson on illness at altitude which James has summarised below, along with an interesting letter about new, lightweight kit in a mountain clinic.

Strengthening Altitude Knowledge: A Delphi Study to Define Minimum Knowledge of Altitude Illness for Laypersons Traveling to High Altitude
Remco R. Berendsen, Peter Bärtsch, Buddha Basnyat, et al. High Altitude Medicine & Biology. Dec 2022

Poor knowledge of altitude illness is known to accompany an increased risk of the spectrum of acute mountain sickness, however, few if any guidelines target the layperson. This paper aimed to fill that void, seeking expert consensus on the essential knowledge required for people planning to travel to high altitudes. Utilising a Delphi method, involving three rounds and two expert groups, it creates 28 essential knowledge statements in five categories (altitude physiology, sleeping at altitude, AMS, HACE, and HAPE). These statements can be incorporated into our teaching and practice, empowering our teams/clients to look after themselves, or indeed filling in gaps in our own knowledge. A worthwhile read.

A survey to define the pre-hospital blood resuscitation practices of UK Air Ambulances
Ed Barnard, Laura Green, Tom Woolley, et al. Emergency Medicine Journal. December 2022

Prehospital use of whole blood for ill and injured patients during critical care transport
Philip S. Nawrocki,Brendan Mulcahy,Michael Shukis, et al. Air medical journal. September-October 2022.

Those of us working in the UK pre-hospital setting will know crystalloids and/or packed red blood cells (PRBCs) have been used for a while now. This first paper shows UK Air Ambulances (AAs) carry a mean of 2.6 (±0.9) red cells and 3.0 (±1.1) plasma units. Also of note, they found the mean prehospital time (999-call to hospital arrival) to be 92.2 (±18.6) minutes. 

There is a growing argument for the use of whole blood (WB) in the pre-hospital setting. This would provide patients with platelets (which WB contains), which given their difficulty to store (5-day shelf life, 20-24 degree storage, agitation requirement) are not carried as a separated component by AAs. It could also be seen as more efficient with only one blood product being transfused, making things simpler and notably lighter. 

Our second paper comes from the United States and shows that WB can be used in the prehospital setting, as well as being associated with low incidences of adverse events such as transfusion reactions. 

This leads to us highlighting a new clinical trial which commenced in December 2022 and will be running over a two-year period. The Study of Whole blood In Frontline Trauma (SWIFT) trial will involve 10 UK air ambulance trusts. It will compare outcomes such as survival and amount of blood needed 24 hours after injury between patient groups receiving PRBC with those receiving WB. One to watch out for in a future evidence explorer…

Letter to the Editor: A Compact and Lightweight X-Ray Unit in a Mountain Clinic
Rikiya Kameno, Yutaka Igarashi, Kunio Hirai et al. High Altitude Medicine & Biology. December 2022.

Those of us who have worked in mountain clinics may be more familiar with the equipment (or lack thereof) available in such an environment. This intriguing letter is the first to detail the availability of compact and lightweight x-ray units at high altitude using a rechargeable machine weighing roughly three and a half kilograms. Could a portable machine overcome the previous barriers to imaging such an environment creates, or does it just add to our ever-growing kit list? This machine was used to image a number of anatomical areas including the chest, abdomen, joints (shoulder, wrist, knee), clavicle, and lumbar spine. With trauma and respiratory diseases being common to mountain clinics this tool could be a significant addition to the arsenal; could it help identify those in need of a hastier extraction or simply add time to doing so?

Water for wound cleansing
Fernandez R, Green H, Griffiths R et al. Cochrane database systems review. September 2022

Normal saline is often used for cleaning wounds as it is a sterile, isotonic solution and therefore not thought to interfere with the normal healing process. Unfortunately saline is relatively expensive, difficult to transport and at times hard to come by, therefore not ideal for the prehospital setting. Yet it is unclear whether there is any significant benefit over using tap water or indeed any other more available fluids, this Cochrane review tried to answer this question.
It looks at 13 trials with a total of 2504 participants (the majority, 2204, being in the tap water versus normal saline comparison), aged between 2 and 95 years, suffering from open fractures, surgical wounds, traumatic wounds, anal fissures and chronic wounds. Comparisons included care with no cleaning, normal saline (0.9%), tap water, cooled boiled water and distilled water. Outcomes assessed included patient satisfaction, pain, wound healing, and infection rates.
Unfortunately, the authors were unable to come to firm conclusions as across all outcomes the evidence identified was mostly of low or very low certainty. Of interest there was no strong signal of harm from using tap water in place of saline, paving the way for further large, well-designed, randomised controlled trials in order to answer this question once and for all.

Global Health and Humanitarian Medicine

Three major topics sprung out to us this quarter in the global health sector with multiple publications on each.
Firstly we present two distinct articles discussing the relationship between colonialism and health, how historical rhetoric is shaping today’s practice, and more importantly giving helpful advice on how we can begin to undo the destructive health structures of a colonial past.
We then shift focus to the interaction of planetary health and human health and summarise two articles released around the period of the COP27 climate conference.
Finally, we have two excellent publications on the subject of antimicrobial resistance, the presentation of an interesting large-scale study on the interaction of poverty and antibiotics, and another detailing how IT systems are paving the way to a brighter future for use of antibiotics in LMICs.

Dismantling and reimagining global health education
Gichane W, Wallace D. Global Health Action. Oct 2022

Many of us interested in a career in global health will pursue higher education on the subject but with over 95% of master’s programmes located in high-income countries, does that education accurately and fairly represent global health in its truest and most equal standing? In this thought-provoking article, assistant professors Margaret Gichane and Deshira Wallace discuss the biased admissions criteria and curriculum and the potential immense harms of the student placements that occur as part of global health masters programmes in place today. They go on to say that worryingly, the current education set-up is contributing to the legacy of the colonial tropical medicine that stood before. They present their recommendations as succinct bullet points at the end of their piece. Perhaps an idea to cross reference these points to any global health programme you are involved with or due to start. Speak up and ask these difficult questions to those who head up the courses and together we can continue to strive to improve global health education for the globe.

Shifting paradigm from biomedical to decolonised methods in Inuit public health research in Canada: a scoping review
Belaid L, Budgell R, Sauve C.   BMJ Global Health. Nov 2022

This large scoping review expanded on the decolonisation topic focusing particularly on the Inuit communities in Canada. The National Inuit Strategy on Research (NISR) advocates for self-determination in research and has been doing so for some time but sadly found poor results. Only 76 out of 356 studies involving Inuit communities showed any community engagement in their methodologies, and worse still there was limited evidence across all studies that their results were translated into culturally appropriate and beneficial public health interventions. The article goes on to give disappointing statistics from across a vast array of studies undertaken with the Inuit population showing poor compliance with standards set by the NISR. If you have time for nothing else – the introduction of this article is well worth a read. It explores evidence and explains the term ‘cultural safety’ and how in fact, research can and does have deleterious effects on local indigenous communities when undertaken without full consideration and thorough involvement with those it affects.

COP27 climate change conference: urgent action needed for Africa and the world
Chris Zielinski et al. BMJ Global Health. Oct 2022

Glance at any journal related to Global Health in the run-up to COP27 last year and you will see this article published. The BMJ, The Lancet Global Health, and Journal of Global Health are among the giants in the publishing world to share this article, and in fact, it comes as a consensus statement from 231 health journals and their editors. Clearly an incredibly important topic, the news of which needs to be disseminated. The authors open by reminding us that pledges made in the 2015 Paris agreement to provide climate finance to LMICs are yet to materialise and call for urgent action from COP to deliver climate justice to vulnerable countries. They go on to state the shocking stats related to CO2 emissions. Since the industrial revolution, North America and Europe have produced 62% of global emissions and Africa only 3%. Yet arguably Africa is feeling some of the most intense pressures from the climatic consequences. Drought, severe cyclones and flooding seen from extremes of weather are forcing migration, loss of shelter, hunger and malnutrition. Changes in vector ecology and damage to environmental hygiene are seeing a surge in diseases such as malaria and dengue fever, and water-borne diseases and diarrhoeal illnesses are on the rise from reducing water quality. This is a succinct, emotive and highly impactful statement – a must-read for anyone looking for an introduction to the inequalities in health and the environment.
The outcome of COP27 thankfully was positive in this regard with the development of the ‘COP27 loss and damage fund’. Head here for a summary from the UN on how they hope this will be instituted. 

Sustaining planetary health in the anthropocene
Shilu Tong, Hilary Bambrick. Journal Of Global Health. Nov 2022

The World Health Organization (WHO) recently estimated that more than 13 million deaths occur annually due to avoidable environmental causes including climate change, air pollution, and other exposures. This article expands on the cause of these arguably unavoidable deaths and talks of the ‘anthropocene epoch’ – the era that we find ourselves living in where the presence of human life is having a significant impact on planetary health ecosystems. The authors call for urgent action to improve planetary health and propose 4 main strategies. Understanding the major drivers of global change and implementing intervention policies to slow down or halt these changes is their first point. They name consumeristic behaviours and inappropriate use of technology as two priorities to tackle. As the fallout of COP27 has highlighted, the authors of this paper also agree that planetary health can only be sustained if socioeconomic inequities and environmental injustice are lessened. They also mention indigenous cultures and how we must see ourselves as part of a global village to learn planetary stewardship from all. They conclude with a powerful final paragraph stating that collective action must be built across generations as planetary health will not be solved within one generation, and we must build sustainable action that continues, is handed over and built upon.

The role of multidimensional poverty in antibiotic misuse: a mixed-methods study of self-medication and non-adherence in Kenya, Tanzania, and Uganda
Green D, Keenan K, Fredricks K et al. The Lancet Global Health. Jan 2023

Antimicrobial resistance is a growing threat to global public health and it is widely accepted that antibiotic misuse and overuse are the greatest drivers. This includes behaviours such as incomplete adherence, use without a prescription and the indiscriminate use of broad-spectrum preparations. It has been proposed that poverty in its multiple dimensions has an important role to play in this resistance acceleration, but evidence of this relationship was sparse. This unique study aimed to plug that gap and produced some interesting results. The authors here measured poverty in a more representative, multi-dimensional and holistic manner than previous studies have. Contrary to both previous studies and public discourse they found that antibiotic non-adherence and self-medication were least common in those living in the most deprived settings. They go on to discuss the likely reasons for this and unpick how socioeconomic hierarchy and education impact antibiotic use behaviours.  They provide evidence that it is the structural barriers of poorly resourced and inaccessible healthcare provision that is the driving force behind misuse rather than individual education or health beliefs. A really interesting read. Skip to the discussion if you are time-poor, the authors present their findings in a thought-provoking and digestible manner useful to all.

An additional editorial on the same topic:
Poverty and antibiotic misuse: a complex association
Obua C, Talib Z, Haberer J. The Lancet Global Health. Jan 2023

Strengthening digital monitoring of antibiotic resistance in low-resource settings
Yogita Thakral, Sundeep Sahay, Arunima Mukherjee. Journal Of Global Health. Oct 2022

More on antibiotic resistance here with the presentation of a novel solution to the growing public health concern. The authors open with a powerful quote from the former secretary-general of the World Health Organization, M Chan, who describes antibiotic resistance as a “slow-moving tsunami” threatening “the end of modern medicine as we know it”. They then go on to discuss the details of how they designed and implemented an antibiotic resistance monitoring programme in India where the scale of the problem is particularly acute. They conclude by detailing how their systems can and will be adapted for multiple settings. An interesting and succinct read relevant for those who are interested in technology and how it can be used simply for major public health benefits globally.

The long-list

Here we present the articles that are definitely worth a read for those with a little more time on their hands:

Expedition and Wilderness Medicine

Importance of Trail Safety Education for All Fitness Levels
Ryan G. Wilderness Medicine Magazine. December 2022.

Trends in SOS Incidents from Satellite Communication Devices
Thurman J. Wilderness Medicine Magazine. December 2022.

Temperature measurement of babies born in the pre-hospital setting: analysis of ambulance service data and qualitative interviews with paramedics
GoodwinL, Voss S, McClelland G, et al. Emergency Medicine Journal. November 2022

Differences in the thermal properties and surface temperature of prehospital antihypothermia devices: an in vitro study
Dvir E, Epstein D, Berzon B. Emergency Medicine Journal. November 2022

Perceptions Among Backcountry Skiers During the COVID-19 Pandemic: Avalanche Safety and Backcountry Habits of New and Established Skiers
Valle E, Cobourn AP, Spencer JH et al. Wilderness and Environmental Medicine Journal. December 2022

Wilderness-Telemedicine, a New Training Paradigm
Lafleur J,Sikka N, Hood C. Wilderness and Environmental Medicine Journal. December 2022.

Global Health and Humanitarian Medicine

Understanding resilience, self-reliance and increasing country voice: a clash of ideologies in global health
Shawar Y, Neill R, Kunnuji M et al. BMJ Global Health. Jan 2023

Investing in preparedness for rapid detection and control of epidemics: analysis of health system reforms and their effect on 2021 Ebola virus disease epidemic response in Guinea
Keita M, Talisuna A, Chamla D et al. BMJ Global Health. Jan 2023

Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: experience from six countries
Alwan A, Majdzadeh R, Yamey G, et al.BMJ Global Health. Jan 2023

Essential packages of health services in low-income and lower-middle-income countries: what have we learnt?
Alwan A, Yamey G, Soucat A. BMJ Global Health. Jan 2023

Transitioning the COVID-19 response in the WHO African region: a proposed framework for rethinking and rebuilding health systems
Balde T, Oyugi B, Byakika-Tusiime J et al. BMJ Global Health. Dec 2022

Pandemic preparedness and response: exploring the role of universal health coverage within the global health security architecture
Lal A, Abdalla S,  Kumar V et al. The Lancet Global Health. Nov 2022

Effectiveness of a community-based education and peer support led by women’s self-help groups in improving the control of hypertension in urban slums of Kerala, India: a cluster randomised controlled pragmatic trial
Suseela R, Ambika RB, Mohandas S et al.  BMJ Global Health. Nov 2022 

Creating health by building peace
Ghebreyesus T. BMJ Global Health. Oct 2022

Worldwide physical activity trends since COVID-19 onset
Tison GH, Barriosa J, Avram R et al. The Lancet Global Health. Oct 2022

Decision making in global health: is everyone on board?
The Lancet Global Health. Nov 2022

The HIV and sexually transmitted infection syndemic following mass scale-up of combination HIV interventions in two communities in southern Uganda: a population-based cross-sectional study
Grabowski K, Mpagaz J, Kiboneka S et al. The Lancet Global Health. Dec 2022

The cost of inaction on physical inactivity to public health-care systems: a population-attributable fraction analysis
Santos A, Willumsen J, Meheus F et al. The Lancet Global Health. Jan 2023

The effects of a peripartum strategy to prevent and treat primary postpartum haemorrhage at health facilities in Niger: a longitudinal, 72-month study
Seim A, Alassoum Z, Souley I et al. The Lancet Global Health. Feb 2023.

The post Evidence Explorer: Updates and news from the academic community, Winter 2022/23 appeared first on Adventure Medic.

Wishing all of our readers across the globe a wonderful holiday season with family, friends and colleagues. Wherever you are we hope you have some time away from the hospital/practice for adventures large or small.

It’s been a brilliant year here at Adventure Medic. We have published expedition course, elective and fellow job reviews and brought you the latest from conferences on three continents. The launch of the quarterly Evidence Explorer has received fantastic feedback from clinicians worldwide. There has been a focus on humanitarian and global health opportunities alongside related telemedicine, One Health and artificial intelligence updates. Following our previous top tips on altitude and jungle environments we have a recent polar article. For those wishing to hone their decision making we have published more dive cases, dirty adrenaline and further dental tips and tricks. We are also very happy to have shared a number of articles by and for paramedics including a comprehensive guide for the ever growing world of expedition work.

This is all thanks to you, the wider community of passionate, adventurous and insightful colleagues who share your thoughts, articles and images. It is an absolute privilege working with you all. Your photo submissions for our Sustainability Photography Competition with Eco Medics were a real highlight. 

Happy holidays and we’re excited to hear more of your tales in 2023!

Photo: A gentoo penguin trumpeting (Shona Main)

The post Happy Holidays appeared first on Adventure Medic.

Jonathan Knight / Final year medical student / UCL //

A final year medical student at UCL, Jonathan has interests in public and global health, and is currently planning his elective to Argentina. He joined the team for this quarter’s global health edit and was invaluable utilising skills in literature review and his linguistics degree to contribute to the release. 

• Introduction to Papers of the Quarter
• Expedition and Wilderness Medicine
• Global Health and Humanitarian Medicine
• The long-list extras

It’s been an incredibly fruitful Autumn in the academic community and here at Adventure Medic we’ve had a hard time choosing which releases to include in our quarterly highlight. As such, this time, we’ve included our extended ‘long-list’ at the foot of the page to include all articles and publications in both expedition medicine and global health that have peaked our interest over the past few months. Before that, we present a handful of what we believe are some of the most relevant and interesting publications along with a summary paragraph for those reading in a rush.

As always, do get in contact if you’d like to get involved with contributing to future releases of this feature – we always look forward to hearing from you.

Happy Reading!

Expedition and Wilderness Medicine

This quarter we present a few papers highlighting women as a focus, not only for their involvement in and contribution to expedition medicine but we also begin to delve into the evidence that is emerging behind some of the gender inequalities in the receipt of emergency healthcare. We present not only the original research but some interesting commentary in the form of an editorial piece on the gender differences in the administration of Tranexamic Acid in major trauma. Some interesting research on the management of shoulder dislocation follows and a helpful article on the use of different types of analgesia for headache that is very translatable from the Emergency Department to the field. An article on pulmonary vascular disease at altitude is arguably the most academic paper presented this quarter but written in a manner digestible for all from the respiratory physician through to the novice doctor on their first expedition. Finally, the UIAA’s recent conference ‘Women going to altitude’ has kindly been recorded and made available to all – a must watch.

Use of tranexamic acid in major trauma: a sex-disaggregated analysis of the Clinical Randomisation of an Antifibrinolytic in significant haemorrhage (CRASH-2 and 3 trials) and UK trauma registry (trauma and audit research network) data
Nutbeam T, Roberts I, Weeked L et al. British Journal of Anaesthesia. August 2022. 

Inequalities in healthcare exist in many forms both nationally and globally. Not only are they the product of large-scale political and financial difficulties but often many can be attributed to the complex interactions of our own everyday unconscious bias. This analysis article uses the well-known CRASH-2 and 3 data along with the huge database of the Trauma and Audit Research Network to investigate and present how the use of Tranexamic Acid (TXA) in the trauma patient varies due to sex.
Firstly they provided evidence that the use of TXA in polytrauma and traumatic brain injury serves the same reduction in mortality benefit for males and females. They then move on to analyse data from over 216 000 patients with a trauma severity score of >9 and present surprising findings…
TXA was received by 7.3% of the females and 16.8% of the males. Women are treated less frequently than men regardless of their risk of bleeding or severity of injuries. The authors go on to reference many other studies of similar nature and magnitude stating that in fact, women are less likely to receive certain treatments over men in a multitude of settings.
The discussion talks a little about the authors’ postulations for this disparity. They name strict prehospital SOPs to be one possible cause but otherwise speculate it to be the product of clinicians’ unconscious bias compounded by education and the stereotypes laid out in simulation. Certainly an interesting read and a reminder to us all to be aware of all types of unconscious bias in our working world. 

Our friends and colleagues over at Endeavour Medical have just released a full critical appraisal of this paper, head to their website here to read more. 

Sex discrimination after injury: is inequity in TXA administration just the tip of the iceberg?
Cole E, Curry N, Davenport R. British Journal of Anaesthesia. August 2022

This editorial summaries Nutbeam et al’s study well, presenting the key statistics and outcomes, discussing the limitations and strengths and presenting additional data on the sex-related differences in coagulation and immunology that could play a part in the wider picture of this discussion.
The authors reference further studies stating that women also receive lower emergency health prioritisation than their male counterparts, are less likely to be triaged to a major trauma centre, and are less commonly admitted to critical care.
Although unproven, these findings may present a significant decision to treat bias. Globally there is strong evidence that gender equality, in general, has been improving over the years and we in healthcare must not fall behind.

Risk factors for the presence of important fractures in ED patients with shoulder dislocation: a retrospective cohort study
Henri Houze-Cerfon C, Le Gourrierec T, Charpentier S et al. Emergency Medicine Journal. August 2022

Whether you are the medic supporting a long-distance cycle tour, manning a mountain rescue hut for the winter climbing season, or taking a group of school children on a tall ship for a few weeks, as an expedition medic you are more than likely to encounter a dislocated shoulder in the field at some point. There are a whole host of eponymously named manoeuvres for popping them back in but what about the risk of a fracture dislocation? Something that is always on our minds when dangling arms strapped to tins of beans over a bed frame miles from the nearest possibility of an X-Ray.
This digestible, retrospective cohort study looked at around 600 patients presenting to the ED with shoulder dislocation. They screened for the presence of a clinically important associated fracture and then analysed the patient demographics of those patients to present these 3 independent risk factors for fracture-dislocation:

1) Age >40years
2) Traumatic mechanism of dislocation
3) First incident

They go on to say that in the absence of these risk factors ‘pre-reduction radiography may be safely avoided’. Timely relocation is essential for patient comfort and minimising risk of long-standing musculoskeletal damage. This study adds some evidence to help us in the assessment of these patients and in making decisions to relocate in the field or facilitate evacuation and transfer to hospital. 

Paracetamol, ketorolac, and morphine in post-trauma headache in emergency department: a double blind randomized clinical trial 
Azimi Far A, Abdoli A, Poorolajal J, Salimi R. Emergency Medicine Journal. July 2022

The ‘Global Emergency Highlights’ from the EMJ is always an interesting feature, summarised in digestible abstracts to gain some insight into emergency medicine research across the world. This randomised clinical trial (RCT) comes from Hong Kong and provides some interesting evidence on how best to treat headache after traumatic head injury. Despite relatively small numbers (n=105), they found that IV paracetamol and ketorolac provided better analgesia (measured with a patient-reported headache severity score) than IV morphine. These results were statistically significant when measured at both 15 and 30mins post-administration. They measured secondary outcomes as side effects of the analgesia and as expected, the incidence of adverse effects in the morphine group was significantly higher. Useful data for when managing headache after trauma in the field where we are often devoid of strong opiates. 

Clinician’s corner: counseling patients with pulmonary vascular disease travelling to high altitude
Ulrich S, Lichtblau M, Schneider S et al. High Altitude Medicine and Biology. Sept 2022

With the increasing popularity of travel to previously inaccessible environments, we are seeing that it’s not just the fittest and athletic types that embark on an adventurous expedition. More and more we, as the expedition medic, are seeing clients with a multitude of chronic disease and our job includes counselling and keeping them safe in austere environments.
Managing patients with pulmonary vascular disease (PVD) poses a challenge to any clinician regardless of speciality and the thought of taking someone who has a predisposition to hypoxemia to altitude would certainly pose some serious consideration. This article is incredibly helpful in quantifying the risk to patients with PVD in short trips to medium to high altitude and in fact stating that the vast majority of patients with PVD can tolerate short-term exposure to moderate altitudes up to 2,500 m. Equally, for the roughly 10% of patients with stable disease who do develop severe hypoxemia when ascending to 2,500 m, they respond well to low-level supplemental oxygen support. The authors also present a good revision of the physiology of PVD and a detailed yet digestible explanation of the effects of hypoxia on pulmonary physiology. They include a helpful table written by a GP in conjunction with a pulmonary hypertension unit on what to include in a pre-trip counselling consultation for patients with PVD. 

International Climbing and Mountaineering Federation: UIAA Medcom.
Video of ‘Women Going to Altitude’ conference:

Held in the Swiss mountains in September this inspiring conference has been made available to watch by the UIAA with the suggestion that you might donate to the federation should you enjoy what is over 5 hours of quality and inspirational talks and discussion.
In 2008 the UIAA Medcom released a consensus document entitled ‘Women Going To Altitude’ which covers considerations such as contraception, menopause and pregnancy at altitude. The conference aimed to follow on and expand upon this release and brings together some truly inspiring women from across the world.
The conference centre was accessed by either cable car or a 2.5hr hike and booking fees included a glacier walk … definitely one to keep in the diary for the future.
Watch here

Global Health and Humanitarian Medicine

Some important and eye opening publications in the Global Health sector this quarter with presentation of health data from the Russia-Ukraine war to some shocking statistics about the global burden of neglected tropical diseases. We also highlight a paper detailing the use of the ‘WHO non communicable disease kit’ which certainly sparks some thought to the less well advertised aspects of humanitarian care. Read on to learn more on the fight to eliminate measles and rubella worldwide and digestible synopses on some of the most current issues in global health.

The human toll and humanitarian crisis of the Russia-Ukraine war: the first 162 days
Haque U, Naeem A, Wang S et al. British Medical Journal: Global Health. Sept 2022

This review of data is a thoughtful and comprehensive witness to the disruption and destruction of the healthcare infrastructure in Ukraine as a result of the 2022 war. The data measures the toll on healthcare during this ongoing conflict. The author’s systematic approach attempts to collate data from several sources to sum up casualties and infrastructure destruction from every single day in the period studied. Naturally, the true scale of the human cost of the war and the long-term effects on the healthcare system will take more time to characterise. The article underlines the importance of continued surveillance on the impact that conflict and war have on healthcare – a difficult yet necessary testimony. 

Assessment of the non-communicable diseases kit for humanitarian emergencies in Yemen and Libya
Kiapi L, Hecham Alani A, Ahmed I et al. British Medical Journal: Global Health. July 2022

This article gives an assessment of the ‘WHO non-communicable diseases (NCD) kit’ that was provided to health clinics in Libya and Yemen during acute humanitarian emergencies. It is a relatively new development, having only existed for 5 years and was developed to cover the emerging gap in humanitarian response to treating chronic disease in emergency settings. The kit is useful for maintaining continuity of care for common NCD conditions such as asthma, diabetes and hypertension, but was not designed for long-term use or to weather supply chain collapse. This practice paper provides a good insight into an often-overlooked part of humanitarian work – helping to manage NCDs with continuity of care as well as treating exacerbations. It is useful to know the level of awareness of the kit, how it fits into use in complex humanitarian situations, limitations of the kit and potential ideas for better practice to improve use. This is a good paper to read for anyone considering humanitarian work or looking to evaluate these or similar systems in other countries. 

Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders
Gustavsson M, Juth N, Arnberg F et al. Conflict and Health. May 2022

Working in a disaster environment as a healthcare worker presents a number of moral challenges and stressors. These challenges can be relevant both to our practice in our home countries (for example, during the COVID-19 pandemic) as well as overseas humanitarian work. This detailed qualitative analysis provides a framework that might be useful in understanding the way that we as individuals respond to these challenges. While it is a qualitative analysis of a relatively small group (n=12) of workers from one country, Sweden, the themes that are touched on are likely to be relevant for anyone who wants to understand not only how to support responders on an organisation level but also how they might react to similar situations themselves. The authors conclude that the most useful support was that from other colleagues in the same situation, followed by psychosocial support from someone with similar experiences. The introduction to the concept of ‘moral distress’ at the start of this research publication is particularly interesting and a good insight for anyone involved in humanitarian healthcare.

Neglected tropical disease elimination is a relay race – let’s not drop the baton
Downs P, Bush S, Bannerman R et al. International Health. Sept 2022

This is a retrospective analysis of the achievements and methods of ‘Ascend’, a major UK aid-funded project in west African countries that aimed to treat 5 neglected tropical diseases (NTDs). It demonstrates the impact that such a targeted project can have. It carries a focus on the handover to local partners after a flagship project in order to achieve long-term improvements in care and provision. The project was prematurely closed due to UK Foreign, Commonwealth and Development Office’s funding cuts; the authors note their view of these cuts as unwise. It shows, to some degree, how vulnerable government aid projects are to political changes. Reading the author’s summary of how the project was planned and executed is a good insight into how humanitarian projects work at a broader organisational level. It’s useful to learn the context around a major foreign aid project that has been working for the last few years. The authors highlight and expand upon the need to ‘not drop the baton and maintain the momentum of NTD elimination during times of global disruption. A powerful analogy and one which leaves readers with a greater understanding of just how powerful UK aid investment can be in strengthening health systems to fight public health problems.

Investing in global measles and rubella elimination is needed to avert deaths and advance health equity
Raghunathan P, Orenstein W. The Lancet Global Health. October 2022.

This Lancet comment article is a succinct summary of the modelling and work surrounding rubella and measles eradication. After polio and guinea worm disease, rubella and measles will hopefully be the next two infectious diseases targeted to be totally eradicated in a global program. The paper examines the tailored approach that will be needed in the program to eliminate these conditions. Rubella eradication is thought to be more feasible than measles due to the lower transmission rate but with a particular focus on geographical areas where ‘zero dose’ children exist the chance of eradication markedly increases. Equity in healthcare access and targeting these low-coverage areas have been highlighted as particularly important methods in measles to reduce the risk of its reintroduction from endemic areas.
A good preview of some of the groundwork for what are likely to be major global health projects in the rest of the 2020s and 2030s.

The long-list

Here we present the articles that didn’t quite make the cut but are definitely worth a read for those with a little more time on their hands:

Intranasal topical application of tranexamic acid in atraumatic anterior epistaxis: A double – blind randomised clinical trial
Hosseinialhashemi M, Jahangiri R, Faramarzi A, et al. Emergency Medicine Journal. September 2022

The ethical considerations for emergency care research in low and middle income countries: A scoping review of the published literature
Hirner S, Saunders C, Stassen W. African journal of Emergency Medicine (EMJ, Global Emergency Highlights). March 2022. September 2022

Influence of prehospital management on the outcome of spinal cord decompression sickness in scuba divers
Andre S, Lehot H, Morin J, et al. Emergency Medicine Journal. October 2022

Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial
Zwaans J,  Raven W,  Rosendaal A et al. Emergency Medicine Journal. September 2022

A randomized non-inferiority pilot study on the use of methoxyflurane (Penthrox) for pain control in the emergency department
Wong K, Lau J, Siu A et al.  Emergency Medicine Journal. July 2022

Gender equity in membership, leadership and award recognition in the Wilderness Medical Society
Shlein S, Pollock N, Polukoff N et al. Wilderness and Environmental Medicine Journal. Sept 2022

Gender distribution within the journal Wilderness and Environmental Medicine
Keyes L, Schlein S, Brown A et al. Wilderness and Environmental Medicine Journal. Sept 2022

Pulmonary embolism at extreme high altitude: a study of seven cases
Wu J, Haiwen X, Wang L et al. HIgh Altitude Medicine and Biology. Sept 2022

Reimagining human rights in global health: what will it take?
Khosla R, Allotey P, Gruskin S. British Medical Journal: Global Health. August 2022

Medical educators’ perspectives on the barriers and enablers of teaching public health in the undergraduate medical schools: a systematic review
Kadir N, Schutze H. Global Health Action. Sept 2022

Culturally relevant COVID-19 vaccine acceptance strategies in sub-Saharan Africa
Ajeigbe O, Arage G, Besong M et al. The Lancet Global Health. June 2022

Keeping an eye on pink eye; global conjunctivitis outbreak expert survey
Kaur G, Seitzman G, Lietman T et al. International Health. Sept 2022

Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan
Latif Daebes H, Latifa Tounsi L, Nerlander M et al. Emergency Medicine Journal. August 2022

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries
The Global Retinoblastoma Study Group. August 2022. The Lancet Global Health

“See one, do one, teach one”: Balancing patient care and surgical training in an emergency trauma department
Ayub S. Journal of Global Health. July 2022

Primary Healthcare Quality in Conflict and Fragility: a subnational analysis of disparities using Population Health surveys
Ramadan M, Tappis H, Brieger W. Conflict and Health. June 2022

Monkeypox outbreak: Preventing another episode of stigmatization
Chang C, Thum C, Jie Lim X et al. Tropical medicine and international health. July 2022

The post Evidence explorer: Updates and news from the academic community, Autumn 2023 appeared first on Adventure Medic.

As well as being a talented musician, Daniel works in the field of renewable and sustainable technologies. In 2020, his ever-growing awareness of, and anxiety about, the current planetary crisis, as well as a desire to improve the safety of cycling on the streets of Edinburgh, galvanised him into action. By working together with a like-minded group of people, from a great variety of backgrounds, the Edinburgh version of a global cycle movement has been founded. This group has gone from strength to strength, bringing an increasing number of people forward to join the cause. They have been involved in advocacy work and, in the Spring of 2022, have even released a single, called ‘our streets’ – (see the link below). Access to safe cycling is not only important for the environment but also for our health and wellbeing. At a time when lifestyle medicine and green prescribing are climbing in popularity, cycling surely fits the bill, as well as being a robust way to take action towards saving our beautiful life-giving planet.

Reducing greenhouse gas emissions, reducing particulate pollution, tackling obesity, improving people’s mental health, improving road safety, supporting local businesses, reducing noise pollution…these are just the start of a long list detailing what cycling can do for us and our environment. This list is so lengthy that I wonder if it wouldn’t be quicker to just note down the things that it can’t do. Either way, these lists are fairly non-controversial. We could pull apart the evidence, the reasoning, the facts and figures, but surely common sense tells us that increased cycling in our cities and towns would make the world a better place in a lot of ways.

The more challenging question is: how do we achieve a major increase in cycling? Again the answer seems deceptively simple: better bike infrastructure and fewer cars to make people feel safer when cycling on the roads. After all, when Jaguar Land Rover is over 200 times heavier than a bike, no wonder people are scared. In 2019, a survey conducted in Edinburgh showed that 51% of residents didn’t cycle due to safety concerns. We all observed how during the first lockdown, the lack of cars on the road suddenly made our streets surprisingly peaceful and quiet, encouraging more people to use their bikes and many others to purchase one. 

But there is a better example just across the North Sea. The Netherlands – or, as I like to call it, Cycling Paradise. In the Netherlands, 25% of all roads have bike lanes that are physically segregated from other vehicles. The remaining 75% of roads have other measures in place to provide safe cycling routes. The result of this is that 27% of trips are made by bicycle, rising to an incredible 60% in some cities such as Groningen. The popularity of cycling in the Netherlands is reported to have reduced deaths by 11,000 per year, and yields economic health benefits of €19 billion per year. And all this has happened despite the government only spending €0.5 billion on cycling infrastructure.

So, how do we go about turning the UK into a cycling paradise? Local authorities decide whether to install bike lanes, and it’s our taxes that pay for them. But aside from voting for the most bike-friendly politicians, how do we convince them of the urgent need for better bike infrastructure? And how can we show our fellow citizens how much support there is for cyclists? The answer from Critical Mass is advocacy in the form of protest, activism, and campaigning.

Sadly, the aforementioned ‘bicycle boom’ during the first lockdown seems to have faded from view before it had a chance to build any momentum. However, in the summer of 2020 a few folk in Edinburgh, inspired by the brief glimpse of a car-reduced city that the pandemic had provided, decided to take action. We founded the Edinburgh version of a movement which exists right around the world, called Critical Mass.

At its heart, Critical Mass is a monthly event where cyclists ride slowly around a city, taking up as much space as is needed to keep everybody safe. It takes its name from the idea that you need a certain number of riders, cycling together as one unit, to reach the ‘critical mass’ around which cars, and other motor vehicles, can no longer safely overtake. The name also refers to the future vision where a ‘critical mass’ of cyclists on our streets would change the way drivers behave. With a critical mass of cyclists, drivers could never assume that there wouldn’t be a cyclist just around every corner, and the government could not ignore the need for better cycling infrastructure.

Critical Mass movements around the world each have their own character, some of which have been criticised for being aggressive to cars or dominated by confident male riders. In Edinburgh, we have tried to maintain a focus on accessibility, diversity, avoidance of aggression to drivers, and having fun (we even have a trailer which has a loudspeaker pumping out music to create a ‘street-party’ atmosphere). We aren’t too prescriptive about the motivations for the rides and everyone who joins us has slightly different reasons, but our experience from talking to participants suggests that the vast majority see it as a protest for better bike infrastructure. It’s also very joyful and liberating to ‘take back the streets’ from cars, even if it is only for a short amount of time. You could say it’s ‘pre-figurative’ – creating the world you want to live in, just for a few hours, and showing people what that world looks like.

The Edinburgh rides have been successful, growing from 20 people to 300 in just a few months, and generating significant media coverage. The reaction we get on rides is very positive, both from pedestrians and (most) car drivers. After all, we are only slowing them down for a few minutes at most.

It is important to say that there are many great cycle campaigning groups in Edinburgh, Scotland, and the UK. We hope that Critical Mass fills the need for a regular, on-the-street, presence to be noticed, as well as a chance to bring cyclists together and reach people in person, not just those that exist on social media or the politicians who send a stock reply when you write to them.

Many people, including myself, are suffering from climate anxiety. This is a rational response to the scary state of our natural world, but one of the most effective ways I have found to deal with this anxiety is to take action and protest. Buying an “eco” product might give you the short-term feeling that you are doing your bit, but what we need are urgent systematic changes. These changes will only come about through people taking a stand within their communities, out on their streets – which, by the way, is much more fun than simply changing which products you buy! A huge number of people are already aware, and afraid, of climate change. We now need to shift our focus to the many positive changes that will not only fix the climate but also make our urban landscapes more pleasant to live in. 

Here’s a thought: better bike infrastructure can improve your health on three different timescales:

Today: don’t get hit by a car.

This year: get your body and mind healthy by cycling regularly.

Your lifetime: help to fix the climate and natural world so that it is habitable for us all.

So should healthcare workers be prescribing Critical Mass for every patient? I’d say so. In Edinburgh, Critical Mass rides out together on every last Saturday of the month, meeting at 2 pm on Middle Meadow Walk (or you search online for a Critical Mass near you). At Critical Mass Edinburgh, we plan to continue growing bigger and bigger throughout 2022 and beyond, bringing thousands of people onto the street with their bikes to call for the changes that are urgently needed to provide safe cycling infrastructure for all. Come and join the movement. 

In the summer of 2022, Daniel released a single, ‘our streets’, a protest song about cycling. You can watch it here, and download the track for free here.

The post Critical Mass: The Cycling Revolution appeared first on Adventure Medic.

In Manchester the sense of excitement was palpable as attendees, or potential collaborators as the GECCo team would stress, chatted and made their way into the venue. Dr Anisa Jafar, Higher Emergency Medicine Trainee, NIHR Academic Clinical Lecturer and GECCo collaborator, kicked off proceedings with an introduction to the work and goals of GECCo. She explained that GECCo is not ‘a who’ or ‘a what’ but rather a resource for connecting those involved in emergency care with an interest in global health. Indeed, anybody with the time and interest to grow the collaborative is welcome and this thread of open invitation was woven throughout the afternoon. GECCo emerged out of an ongoing exchange of ideas between a group of clinicians who found themselves coalescing around related subjects in global emergency care and saw the need for a platform through which UK emergency care and global health could coexist. GECCo aims to provide this platform with a particular emphasis on sustainable and responsible practice. Dr Jafar emphasised that GECCo is its participants and encouraged us to share our ideas, make connections and identify areas for collaboration throughout the day.

The first session was delivered by a panel of current and past Emergency Medicine Global Health Fellows. If your attention is immediately hooked by this fantastical job title, you are not alone! The audience listened attentively to the experiences of Doctors Molly Howarth-Maddison, Imara Gluning and Bethany Fenby-Hodgson from the North Manchester, Bristol and Leeds programmes respectively. Whilst the fellowship offered by each institution differs in the details of its makeup, they all aim to provide post-F2 doctors with an opportunity to combine experience in the ED with experience working in a global health setting, as well as the time and funding to undertake relevant courses and gain experience in related specialities. For example, Molly shared her experience of undertaking the Diploma in Tropical Medicine and Hygiene, spending three months within North Manchester’s infectious diseases team alongside her ED work. As part of Imara’s fellowship based in Bristol, she spent two months working in Nanyuki Kenya, with a focus on quality improvement projects. It was encouraging to hear how these fellowships have taken the journey from idea to reality and that they are also increasing in number across the UK, creating more formal opportunities for early career doctors to integrate these interests into NHS posts.

This session was followed by a complementary panel discussion that explored how programmes such as the Emergency Global Health Fellowships can be crafted to meet the needs of NHS trusts and teams. Doctors Caroline Heggie and Katherine Potier, Emergency Medicine Consultants, and senior staff nurse Sara Visus-Marco shared their experiences of the ‘back end’ machinations of integrated global health work and NHS careers. Dr Katherine Potier, North Manchester, described the process of creating the North Manchester Global Emergency Medicine Fellowship and building support for it within the wider team and trust. Drawing on the hospital’s local context in which there is a relatively high burden of infectious disease, she saw the opportunity to create an attractive F3-type post which would provide invaluable experience for the fellow in both the ED and the infectious diseases department, as well as the opportunity for funded further study or international working. At the same time, the fellow would provide reliable service provision within the busy emergency department, facilitate more effective working across the ED and ID teams and be well placed to lead audits and quality improvement projects. This was an inspiring example of how creative solutions that support all involved can enable trusts to see such projects as being of direct benefit, rather than as luxuries that they cannot afford. Dr Caroline Heggie then shared with us her experience of her unique consultant post working on Shetland.  This enables her to work clinically both on and off Shetland and provides protected global health time annually, during which she can undertake international projects. She explained how currently there are similar contracts available within General Practice, Obstetrics and Gynaecology and General Surgery, with posts in Psychiatry and Anaesthetics in the works.

Sara Visus-Marco, Senior Staff Nurse at Bristol Royal Infirmary, provided an invaluable perspective on the landscape of global emergency healthcare for nurses, which sadly at present reflects the asymmetry in access between doctors and other clinicians elsewhere in global health. Sara shared her experience of taking up a global health emergency medicine fellowship run through the BRI. As part of the fellowship, she spent 10 weeks working in Nanyuki, Kenya, with a particular focus on sustainable quality improvement projects in collaboration with local colleagues. Sara reflected on the opportunities presented by such an experience including increased exposure to paediatric, obstetric and gynaecological presentations, as well as the development of her research and teaching skills. However, she also shared some of the challenges including having to take unpaid leave to complete the fellowship. In the discussion that followed it was clear that the consensus in the room was that we must all take on the challenge to support the integration of the MDT into global emergency care. The benefits in terms of the invaluable contributions that the MDT can make to global health projects, as well as the gains in staff morale, professional development, and retention, more than justify an urgent review of the current situation, particularly with respect to funding.

Attendees were then introduced to the event partners including the Humanitarian and Conflict Response Institute, Doctors Worldwide and the Faculty of Remote, Rural and Humanitarian Healthcare of the Royal College of Surgeons of Edinburgh. Please do explore the range of resources and global opportunities they offer.

Next up, fuelled by some fantastic cake (gluten-free and vegan – thank you very much GECCo!) and tea, we pooled our collective experience and insights through a workshop steered by Bristol-based Emergency Medicine Consultant Andy Lockyer. In groups representing different stakeholders in the global emergency healthcare ecosystem, of which we drew up a list at the start of the workshop, we brainstormed how each party would define a successful intervention and how we can measure this effectively. The workshop generated much discussion and lively debate and Andy invited all involved to continue the conversation beyond the session – watch this space for new approaches emerging from the fertile ground GECCo has created.

Andrew Fryer, of the Royal College of Emergency Medicine’s Global Emergency Medicine Committee, then joined us remotely with an update on the committee’s current work. The goal of the committee is to contribute to developing emergency care systems globally and it currently runs partnership programmes in Egypt, Uganda, Ghana, India and Pakistan. It also provides a range of resources to interested international partners, as well as awards and grants, for example, the William Rutherford Award.

Last and certainly not least, we got out of our seats for several rounds of speed networking. This was a professional musical-chairs of sorts where attendees rotated through several pairings, each providing the opportunity to connect with and learn about each other’s projects and professional journeys.

All in all, GECCo succeeded in bringing people together whose interests and experiences run the spectrum of emergency care and global health. Conversations were initiated, people connected and everyone from FY1s to consultants were given an open invitation to get involved. The sessions were both enlightening and inspiring but perhaps most importantly, they were pragmatic with a focus on action. My take-home message from the day is that global emergency care must be a priority as we consider global health equities and it is us, the interested and the motivated who must carry these projects forward into real action. With the network of expertise and resources that GECCo has created, we are all far better placed to do so.

For more about GECCo and the fantastic resources they have available, please check out their website.

All photos credited to Dr Anisa Jafar.

The post GECCo Conference 2022 – Weaving Global Health into the ED: Partners, mentors and fellowships appeared first on Adventure Medic.

• Introduction to Papers of the Quarter
• Expedition and Wilderness Medicine
• Global Health and Humanitarian Medicine
• The Adventure Medic reading list

Introduction to Papers of the Quarter

We practice in a culture of evidence based medicine and regularly share novel research, case based learning, clinical updates, guidelines and editorial discussions. The pandemic spawned a whole new level of information sharing that it seems to us should, and we hope will, continue into ‘non-pandemic’ times.  

Leading busy lives seeking adventure around our medical work and with so many excellent peer-reviewed journals in the field, it can be a daunting task to keep up to date with so many new relevant publications.

Here at Adventure Medic we have been studying the top journals publishing in wilderness, expedition, adventure and humanitarian medicine and scanning the global health network for stand out articles to bring to your attention.

Perhaps you need some inspiration for a journal club? Not sure which journals in expedition medicine have the highest impact factor? Fancy some interesting reading other than the back of the cereal packet over breakfast? Then look no further for a quick, one-stop resource to tap into to what we think have been some of the most relevant articles published over the last quarter.

Being a new feature for us, we have, just this once, included some older articles and editorials that have been important in shaping the global health community over the past few years. However, we have mostly focused on the past quarter and will be doing so in future. It’s been a hard job cutting down to highlight just the select few – there’s a lot of quality reading out there, so we’ve included a list of the top journals and online resources that we use if you’re interested in catching up on their latest issue in a little more detail. As always, our text is hyperlinked for further reading and wonderfully almost all the journals are open access.

Please do get in contact if you think a particular publication should be added for the next quarter or indeed, if you’d like to get involved with contributing to this feature – we always look forward to hearing from you.

Happy reading!

Expedition and Wilderness Medicine

This quarter we highlight recent papers looking at multiple aspects of hypothermia management and published work on some commonly used treatment tools. We head up the mountain on terra firma analysing recent avalanche mortality data and launch off the top into an interesting report on paragliding accidents. An article on telemedicine and its role in the expedition community piqued our interest and we summarise it below, along with a piece from the EMJ summarising the evidence for immobilising distal radius fractures.

Clinical staging of accidental hypothermia: The Revised Swiss System
Musi M, Sheets A, Zafren K et al. Resuscitation. March 2021

Clinical staging of hypothermia is essential in guiding out-of-hospital treatment and evacuation decisions. The measurement of core temperature in the field is impractical and can cause further core temperature drop. The International Commission for Mountain Emergency Medicine (ICAR MedCom) have published an update to the classically used ‘Swiss Field Staging System’. They highlight the evidence base behind using conscious level as a sole determinant of staging, suggesting that all other physiological signs of hypothermia are too variable to be a reliable indicator of severity. They conclude by publishing their ‘Revised Swiss System’ which uses the AVPU scale and the absence or presence of vital signs to more accurately stage hypothermia in the field. Yet to be formally tested however, there is a research opportunity to pit their system against previous standards.

Thermodynamics of the Oral Treatment of Mild Hypothermia
Billin A. Wilderness Medical Society Magazine. June 2022

We often see groups of sea swimmers sitting cuddling a hot cup of tea on the shore in their dry robes but is it actually a useful clinical treatment option for hypothermic patients in the wilderness? Dr Aaron Billin, a master fellow of the Academy of Wilderness Medicine walks us through the calculations required to dose the amount of hot water drink to raise core body temperature. It turns out it’s rather a lot. His bottom line advises that hot drinks are unlikely to significantly raise core body temperature and that we should focus our management on the other core aims of treating hypothermia.

Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update
Dow G, Giesbrecht G, Danzl D et al. Wilderness and Environmental Medicine Journal. Dec 2019

The WMS and their expert panel from across the world have provided comprehensive, fully evidence based practical guidelines for the management of many commonly encountered conditions on expedition. Here they present an update on the evaluation and management of accidental hypothermia in a pre hospital environment. Not only are their guidelines easy to read and digest, they present their information alongside a grading system based on the quality of supporting evidence. Hypothermia can be a real risk on any expedition, in any environment and this guideline gives you the tools as a medic to mitigate the risks associated with it.

Quantifying risk in air sports: Flying activity and incident rates in paragliding
Wilkes M, Long G, Massey H et al. Wilderness and Environmental Medicine Journal. March 2022

Interesting results from a large scale survey on the risks of paragliding. Though some view it as high risk activity, the risks of paragliding  have not been well-quantified until now. Results show that paragliding is approximately twice as risky as skydiving or flying a light aircraft and the majority of incidents result from pilot error rather than equipment failure. The authors advise that future safety interventions should focus on improving glider control skills and encouraging prompt reserve parachute deployment in emergencies. Food for thought for the paragliding community, those that run teaching and training and definitely a foundation for future research.

Prehospital use of ultrathin reflective foils
Kosinski S, Podsiadlo P, Darocha T et al. Wilderness and Expedition Medicine Journal. March 2022

Ultrathin reflective foils are marketed to protect patients against heat loss. Certainly they have become a ubiquitous image as a drape over athletes at the finishing line or around a casualty huddled on expedition. This paper reviews the physics of thermal insulation, debunks many of their uses and gives some clear guidance on the situations where they may or may not be a useful tool in managing hypothermia. The authors conclude that the heat reflecting property of the foil is relatively clinically insignificant and may in fact be detrimental if conditions allow condensation and freezing on the inner layer. They state that they may still play a role in hypothermia management when used in combination with other materials, particularly as a windproof layer but alone, they have much less benefit than we have been led to believe.

Avalanche preparedness and accident analysis among backcountry skier, sidecountry, and snowmobile fatalities in the United States: 2009 to 2019
Niemann D, Subrata P, Humairat R. Wilderness and Expedition Medicine Journal. April 2022

For those of us adventuring on skis in the backcountry avalanche forecasting and preparedness is ingrained into every trip but what about other risky activities on the snow? Analysis from over 200 avalanche fatalities in the US looked at different groups of backcountry users in the winter and what specific factors contributed to their fatalities. The results showed that those riding snowmobiles or those hiking or snowshoeing in the ‘side – country’ were less well prepared but equally as likely to be involved in an avalanche. A lesson for us all to be alert to the real possibility of avalanche as soon as we step into the back country regardless of the activity.

The intersection of telemedicine and wilderness care: past present and future
Davis C, Lorentzen A, Patel H et al. Wilderness and Expedition Medicine Journal. April 2022

As the telemedicine market begins to boom we often are left wondering how it will affect our working lives. Initial reactions are often of trepidation and anxiety at the unknown but this article explains how technological advances can be truly beneficial to the expedition medicine community. From the use of drones to access the previously inaccessible, to the application of remote consultations and patient monitoring we learn how telemedicine can add positively to care in austere environments.
Read more here from a fascinating recent article we published from Dr Isabel Straw on AI and its role in medicine.

BET 1: should Colles’ fractures be splinted in a long or short arm cast?
Ramsden S, Beals L. Emergency Medicine Journal. February 2022

A review by the emergency physicians of available evidence on the effectiveness of types of splint following distal radius fracture. Following reduction of a closed distal radius fracture the authors found that there is no benefit to splinting above the elbow. With a potential improvement in comfort and no negative impact to maintenance of reduction, below elbow splinting is advised. When resources may be limited in the wilderness and with comfort for evacuation always on our minds we think this could be really useful, translatable evidence from the ED community. Worth thinking of this when reaching for the SAM Splint.

Global Health and Humanitarian Medicine

High quality health systems in the SDG era: time for a revolution
Kruk M, Gage A, Arsenault C et al. The Lancet Global Health. Sept 2018

‘The human right to health is meaningless without good quality care’ – a quote from the introduction of this report from the Lancet Global Health commission. They examined wide reaching national and cross-national data to evaluate the quality of care received by those living in LMICs. Presenting their conclusions as five concise points they highlight the extent to which the most vulnerable populations globally receive the poorest quality care. They focus on the goal of maximising health outcomes rather than merely geographical access. Moving forwards they propose new ways in which to define and evaluate the quality of health systems, suggest ways in which to ensure those in need benefit from improvements and recommend new structural solutions to health inequality in line with the UN’s sustainable development goals.
A must read for those interested in global health or summarised here in audio visual.

Introducing the Lancet Global Health commission on financing primary health care: putting people at the centre
Hansen K, Brikci N, Erlangga D et al. The Lancet Global Health. April 2022

‘Putting the rights and needs of the poorest and most vulnerable segments of a population first should drive every aspect of primary health care’ – the ethos of this latest Lancet Global Health commision. In their report the team focus on primary care funding and how through ‘people-centered financing arrangements’ we can build global primary care systems that respond quickly and effectively to changing population health needs. They present four key attributes of ‘people centred financing’ as a guide to achieve public health equity. An easy to digest summary of a huge body of work and essential reading for anyone looking to be involved in primary care global health partnerships.

The price of primary: from evidence to action
The Lancet Global Health. April 2022

An editorial on the above publication neatly summarising or providing a good introduction to the topic. The author describes the commission report as ‘comprehensive, yet comprehensible’, and we agree. Global health economics can, to some of us, seem full of new and baffling jargon but this report really strikes a good balance and is a great introduction to how systems need to be changed from the top down.

Global surgery 2030: evidence and solutions for achieving health, welfare and economic development
Meara J, Leather A, Hagander L et al. The Lancet Global Health. April 2015

In line with the release of the new sustainable development goals in 2015, the lancet commissioned a large scale multi disciplinary team to focus particularly on improving access to and provision of safe and effective surgical and anaesthesia care in LMICs. Previously surgical care had been relatively absent from the global health discourse with much more of an emphasis on disease focused goals. They state that the aim of universal health coverage set out in the SDGs will be impossible without more work to deliver quality and sustainable surgery particularly in LMICs. As is the norm with these quality reports from the Lancet, their findings and recommendations are laid out in an easy to digest format.

Time to go global: a consultation on global health competencies for postgraduate doctors
Walpole S, Shortall C, Schalkwyk et al. International Health. Sept 2016

The bidirectional benefits of being involved with global health partnerships have long been recognised and whilst we work in an increasingly interdependent world it makes sense that we train our healthcare workforce to understand the global arena to which they work within. That said, the UK Royal Colleges are yet to all incorporate global health competencies into their curricula. This study put forward seven global health ‘core competencies’ for consultation and collated the views of over 250 stakeholders from a vast array of medical specialities, healthcare professions, policy makers and the general public. From the feedback they developed five goals that aim to achieve a core level of global health competency for postgraduate doctors. The authors acknowledge the importance of not overburdening trainees but instead suggest a tailored approach by each speciality to integration and delivery of their recommendations.

The use, misuse and overuse of the ‘low-income and middle-income countries’ category
Lencucha R, Neupane S. BMJ Global Health. March 2022

This article introduces a quote from Memmi in their opening paragraphs: ‘The colonialist stresses those things which keep him separate, rather than emphasizing that which might contribute to the foundation of a joint community’. They then go on to pick apart the term with which we use so ubiquitously yet so rarely question. The broad classification based on gross national income puts 63% of countries in the world into the category of ‘lower middle income country’ (LMIC). The authors argue that the unreflexive use of the term can obscure and divide particularly in global health. They suggest that we use a more targeted classification or at least justify our terms in order to avoid mis or overuse.

Ethical and cultural considerations for improving short term experiences in global health
Woods B, Woods J. Wilderness and Expedition Magazine March 2022

With many of us squeezing work abroad in amongst a jam packed NHS rota we are often constrained as to the amount of time we can give to volunteer work. Whilst there are clear and well documented benefits to not only the host community but ourselves as volunteers, the ethics and sustainability of short trips has often been called into question. This short but effective piece goes a long way to untangling these pitfalls and more importantly presents a helpful guideline to anyone considering a short term volunteer placement in a LMIC.

For further reading on this subject…

Guidelines for responsible short-term global health activities: developing common principles
Lasker J, Aldrink M, Balasubramaniam R et al. Globalization and health journal. Feb 2018

Following a scoping review of the available literature the authors of this paper present six core principles for effective and ethical short term medical missions. They aim to mitigate the potential harms and maximise benefits of such short term volunteering in healthcare and provide a guideline for those wishing to do so.

Improving Short-Term Medical Engagements with Low-to-Middle-Income Countries
Compton B, Colatrella B, Hamilton L et al. National Academy of Medicine Health Perspectives. March 2021

This paper uses Lasker and colleagues’ six core aims of mitigating the harm of short term health volunteering as a framework to present the challenges and opportunities associated with each. They suggest ways in which through co-ordinated action we can all help to establish best practice in this field. An in depth and really useful follow on from the previous two articles for those wanting to know more.

The Adventure Medic reading list:

Impact factors (IF) presented correct at time of writing.

Expedition and wilderness medicine

High Altitude Medicine & Biology IF 1.981
Wilderness and Environmental Medicine Journal IF 1.426 
The Physiology Society:
Experimental Physiology IF 2.969
Physiological Reports IF 2.261
Aerospace Medicine and Human Performance IF 1.053
Emergency Medicine Journal IF 2.794
BJA IF 9.166
AIrMed and Rescue Magazine
Wilderness Medicine Magazine
International Climbing and Mountaineering Federation – UIAA – (Medical Commission)
International Commission for Alpine Rescue – ICAR – (Medical Commission)

Global health and humanitarian medicine

BMJ Global Health IF 6.14
The Lancet Global Health IF 26.76
International Journal of Health from RSTMH IF 2.473
Journal of Global Health IF 4.413
Global Health Action IF 1.817
Conflict and Health IF 3.75
Emerging Infectious Diseases IF 6.883
Medicine, Conflict and Survival IF 0.51
Tropical Medicine and International Health IF 2.622
Journal of Infectious Diseases IF 5.226
Globalisation and Health Journal IF 3.031
ReliefWeb
International Anaesthetist
World Anaesthesia News

Watch this space for the next quarterly review – please do get in contact if you’d like to contribute or have any comments. We always look forward to hearing from you.

The post Evidence explorer: Updates and news from the academic community appeared first on Adventure Medic.

Think: expeditions, years abroad, pioneering courses, global health ventures, professional degrees and research, private sector opportunities and ideas for how to make the most of your career.

As ever, happy adventuring!

Photo: Paraglider over Verbier (Matt Wilkes)

The post Inspiring team members on podcasts appeared first on Adventure Medic.

We are proud to present the winners of our International Photography Competition with Eco Medics. We have loved looking through all of the entries. Thank you to everyone who shared their images and insights. As the climate crisis continues, we hope they lead to further discussion and consideration on the ways we choose to adventure and the examples we all set. We hope you enjoy the shortlist.

Thank you to the great Robbie Shone for judging the competition. A National Geographic Photographer, cave explorer and visual storyteller who is helping highlight the climate crisis through his images alongside the scientists collecting samples from these caves. If you’d like to see more of his work his book ‘Hidden Worlds’ is now available to pre-order. 

With thanks too to Patagonia, Bower and Grüum for their activism and focus on providing products in a more sustainable manner. We hope the winners enjoy their prizes from them.

Happy man-powered adventuring and repurposing and sharing of your gear from us all at Adventure Medic and Eco Medics.

The post Winners of the Sustainable Adventure International Photography Award 2022 appeared first on Adventure Medic.

We are proud to present our shortlist of finalists from our International Photography Competition with Eco Medics. The shortlist represents the best entries that we felt were both high quality images and encapsulated the theme of “Sustainable Adventure”.

Voting for the People’s Choice Award is now closed and the winners have now been announced.

We have loved looking through all of your entries. Thank you to everyone who entered for taking the time to share your images and thoughts. As the climate crisis continues, we hope they lead to further discussion and consideration on the ways we choose to adventure and the examples we all set.

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While most articles for Adventure Medic come from far away places, this one concerns another frontier altogether – Artificial Intelligence in medicine and its implications for the patients we care for, at home and overseas. Isabel Straw is an Emergency Medicine doctor, studying for a PhD at University College London on the ‘Artificial Intelligence and Healthcare’ programme. Previously, she worked for the United Nations, and in Syria, with the Syrian American Medical Society. In this fascinating essay, Isabel gives us an insight into the world of medical AI, including some of its ethical dilemmas, as well as her incredible career so far.

The year is 2030 and you are the Intensive Care Registrar on call. Having received your third referral for a patient requiring high-level support on ITU, you look nervously at your patient list. In recent years, the hospital you work at has integrated an algorithmic system for predicting the likely mortality of patients, ascribing a survival likelihood score to each patient depending on their pathway of care. The three patients that have been referred to you differ very little in their physiological and clinical background, yet the machine learning model has identified Patient Three as the most likely survivor if offered the only remaining ITU bed. Over the past decade, Artificial Intelligence (AI) has proliferated across social sectors, and it is common knowledge that it often supersedes human ability to evaluate and predict events. You are also aware of the complex history of AI bias and the recent news reports regarding the various discrimination cases against certain demographic groups by AI algorithms (see glossary). If you challenge the AI decision you must be able to justify this to your senior. If you act on the AI’s decision you must be able to explain your reasoning to the families of the patients who will not receive an ITU bed.

In my current role, which sits at the intersection of Artificial Intelligence, healthcare inequalities and clinical medicine, my work is concerned with the ethics of these evolving systems. AI is rapidly disseminating throughout society, often with little public awareness, despite its increasing impact on our daily lives. In this article, I intend to give you an insight into the world of medical AI and highlight why medical AI ethics matters. I will share with you how I ended up in my role, through the prism of books, experiences, and the role models that led me here.

Stuart Maconie describes himself as a ‘Child of the Welfare state’, a term which rang true for me having grown up with the welfare state playing a central role in my life.¹  For those who have been shaped by the state, the political is always personal. Both my medical career and subsequent journey into medical AI have been shaped by my passion for social justice. My interest in politics, economics, and philosophy has been driven by the same sentiments which drew me to medicine – to reduce suffering and address harm. The political philosophy of the incumbent government and their subsequent decisions on public policy shape the distribution of diseases within the population. Throughout medical history, doctors have played a role in socio-political discourse, and it was Rudolf Virchow who said – ‘Medicine is a social science and politics is nothing else but medicine on a large scale’. ^2,3  Whilst we may learn of Virchow’s notable contributions to pathophysiology at medical school, he was also a political advocate for his patients and promoted the role of doctors in the wider social context.²

At first glance, the A&E (Accident and Emergency) department seems to be a setting of social levelling; for, no matter the patient’s background, income, privilege, or status, everyone is equal in the NHS. This notion, combined with the A&E’s flattened professional hierarchy, drew me to choose it as a discipline. However, you cannot be an A&E doctor without noticing the impact of poverty, environment, family and demographic factors on health trajectories. Michael Marmot’s infamous writings (‘The Health Gap’, ‘Status Syndrome’) formed part of my early education regarding the social determinants of health. I learned how life expectancy depended on postcode, how education level influenced disease mortality and how the steepness of the social ladder negatively affects the health of all.^4,5  Moreover, it was through the works of Angela Saini and Emily Cleghorn that I discovered that healthcare inequalities can’t only be ascribed to socioeconomic factors, but that the practice of medicine itself perpetuates historic harms that maintain social inequities.^6,7  The books ‘Superior’, ‘Inferior’, and ‘Unwell Women’ describe the scientific sexism, racism and classism that are rooted in medical history and continue to harm patients from different demographic backgrounds.^6,7,8

Thanks to funding from the Fulbright and Thouron scholarship programmes, I was able to gain a better understanding of healthcare inequalities and the history of medicine, by pursuing a Master’s in Public Health (MPH) in the USA. During this time, I was exposed to multidisciplinary scholars and topics that are less commonly covered in UK medical schools – critical race theory, the politics of women’s health, the role of geopolitical power structures in healthcare, and health and human rights. The anthropological lens through which I learned to view medicine increased my awareness of the role that medicine plays in exacerbating social divides, as opposed to providing equitable care as I once thought. To gain further experience in international policy and global health inequalities, I pursued clinical experience in humanitarian settings in Europe and the Middle East. Here, I observed the role of international organisations in providing the necessities for health and life when nation-states had failed. Following this, I had the opportunity to work at the United Nations and it was here that I first encountered the field of AI.

I arrived at the UN in 2019 when they were developing the first Recommendation on the Ethics of Artificial Intelligence.⁹  Philosophers from around the world were drafting the first document that detailed the dangers that AI posed for different population groups due to bias, discrimination, and exclusion. My role was to examine AI through the lens of medicine and contextualise issues from other social sectors into a biomedical setting. For example, various AI policing systems with high false-positive rates overly profile innocent citizens who tend to be black, resulting in the further criminalization of the black community. Recently, a similar case was reported in medicine, in which a healthcare algorithm had a high error rate for black patients and under-referred them for hospital care. My MPH studies had taught me that clinical medicine was already a conduit for historic power imbalances, and at the UN, it became apparent that without effective research and regulation, medical AI would further embed these harms into impenetrable digital systems.

After the UN, I returned to the USA and completed the last year of my MPH in the computer science school. I learned to code and published papers that demonstrated biases in psychiatric AI algorithms.¹⁰  Our research revealed discriminatory assumptions that existed within machine learning datasets and model architecture used to identify risks of suicide, self-harm, and homicide in people of concern.⁹  From emotion mining that disrupts our concepts of confidentiality, to the impact of neurotechnology on autonomy, and the implications of governmental AI systems on population inequalities, the ethical issues with medical AI were becoming rapidly more apparent, For more information on these topics, our team published a series of papers on bias in medical AI algorithms and the evolving use of AI in psychiatry which are available in the bibliography.^10,11,12

The danger of digital algorithms is that they embed an existing belief system into an invisible decision-making process.^13,14  As Cathy O’Neil explains in her book ‘Weapons of Math Destructions’, ‘algorithms are opinions embedded in maths’.¹³  Throughout history, the biomedical sciences have been shaped by the social context, so much so that the remnants of power structures are built into the foundations of our institutions. The scientific racism that underlies different respiratory criteria for black and white children is rooted in fallacies created by plantation owners centuries ago.^15,7  The medical sexism that excluded female bodies from medical education continues to result in delayed referrals, misdiagnosis, and increased mortality for women across a range of conditions.^6,12,16,17  Further, the history of medical eugenics, scientific classism, the pathologizing of the queer community, and Eurocentric medical culture all disadvantage patients who have historically been excluded from social power.^{18,19,17,15,12,6,20,21,8,7,22}  Algorithms developed in the present are built from our cultural history, and without intervention, these systems weave harms from the past into the fabric of our future.

The field of medical AI is a rapidly evolving space that requires diverse perspectives, especially those with an understanding of medical history and anthropology. At present, I am continuing my research into medical algorithmic bias at University College London (UCL) on the ‘Artificial Intelligence and Healthcare’ PhD programme. My PhD research focuses on the use of supervised and unsupervised machine learning methods for evaluating and mitigating biases in automated medical systems. Over the summer I returned to the United Nations to continue working on the Recommendation on the Ethics of AI, and as of November 2021, this document has been released as the first international instrument adopted by member states for the ethical regulation of AI.²³  In addition to my AI research, I continue to work part-time as a clinician in A&E, where our safeguarding team are investigating the role of technology in cases of domestic violence in the hospital.  The intersection of technology and violence is a separate topic to this essay, but for those interested check out the ‘Gender and IoT’ team at UCL STEaPP, who investigates the impact of spyware, electronic surveillance, and smart home devices on victims of violence.

This article began by discussing an AI-based dilemma for an ITU junior doctor. The case is one of a series of scenarios included in a medical AI curriculum currently being developed into a training programme for junior doctors in North London. Other scenarios include a machine learning algorithm that can predict the likelihood (and likely date) of a miscarriage for pregnant mothers from the day of conception. Another example discusses the implications of bias in a child abuse prediction algorithm implemented in a local GP practice – based on an existing model described by Eubanks in his book ‘Automating Inequality’. Through these new educational programmes, we aim to equip healthcare practitioners with the tools to critique these models and advocate for their patients. At present, these systems are growing in power and scope, and few professionals outside of the data science community understand their constituents enough to challenge them.

A career in medicine offers a rich diversity of possible career pathways and AI ethics will apply to all these routes. The field of global health must address the challenges of drone-delivered aid, humanitarian aid forecasting, and AI predictive systems that regulate the international journeys taken by refugees.^24,25,26,27  Further, the ‘Decolonise AI’ movement seeks to address the power imbalances that digital tech introduces between high- and low-income countries, with the Global South being largely underrepresented in the development of these consequential systems.³⁶  Paediatric specialists will witness the impact of augmented realities, the metaverse and digital relationships on children, in addition to seeing new ethical issues associated with the digitisation of children’s bodies.²⁸  Women’s health specialists will need to understand the rise of technology-facilitated abuse, community practitioners will need to get comfortable with medical smart home surveillance, and hospital specialists will need to understand the proliferating machine learning algorithms that create patient predictions from masses of clinical data.^11,29,30,31  Beyond being medics, we will all have to reckon with the social shifts and personal challenges arising from the growth of neurotechnology, automated governmental systems and algorithms that can supposedly predict your character, potential and life trajectory.^9,13

In medicine, all patients suffer a degree of error that is proportional to their distance from the defined medical average; the physiological average that underpins prognostic tools, the biochemical average that determines diagnostic thresholds, and the anatomical average which populates our textbooks. This medical average evolved from historical and social power constructs and the legacy of these political dynamics materialises in all aspects of medicine. For doctors who wish to address AI harms, but are less technologically inclined, the most powerful work begins by challenging the ground truth of medicine. Data scientists use current practice as the foundation of any healthcare algorithm. By evaluating biases and discrimination within the foundations of existing clinical care, we can all contribute to mitigating the harms of digital systems. For example, is it acceptable that we use unisex thresholds for cardiac biomarkers in managing heart disease? PubMed has some answers.³²  Do our existing screening tools contribute to racist, sexist or classist healthcare disparities, for example when diagnosing autism? ³³  Research into medical bias is an opportunity to be curious, to challenge our assumptions and to reflect on the limitations of our own education. Medical training offers very little time for the extra-curricular, but research such as this can form a part of continuing professional development and fits well within the quality improvement projects that we are expected to undertake. Beyond this, educating others and having an awareness of the history of our discipline will allow us to see how biases emerge in our own practice and how we can avoid integrating such harms into digital medicine.

Individuals who are interested in the more technical side have a wealth of resources at their disposal. To develop the coding skills that will equip you to evaluate medical algorithms, short courses, University Masters degrees and online platforms such as Codeacademy can provide an introduction. At UCL we are developing a curriculum on medical AI for undergraduates. Students could advocate for this at their own Universities. There is a mass of data ethics podcasts on Spotify, evolving academic platforms such as The Lancet Digital Health and the Artificial Intelligence in Medicine journals, and documentaries such as ‘Coded Bias’ and ‘The Great Hack’ which highlight the wider social issues of AI. In medicine, the patient-doctor relationship has always been based on trust. If AI is to be beneficent in healthcare the doctor-AI relationship must share this foundational principle. Through education and awareness, self-reflection, skill-building, research, and knowledge sharing, we can all play a role in creating digital medicine that works for everyone.

Glossary of Terms

Artificial Intelligence

Artificial intelligence stands for computer systems that behave intelligently, which means here: They solve tasks that normally require intelligence, such as understanding and expressing language, image recognition, decision-making or translations.³⁴

Machine Learning

Machine learning creates computer systems that use data to learn how to perform tasks. Instead of a developer who specifies instructions line by line in the form of programming code, the software independently updates its code after the first trigger and optimizes it for a better result.³⁴

Algorithm

An unambiguous specification of a process describing how to solve a class of problems that can perform calculations, process data and automate reasoning.³⁵  An algorithm can be thought of like a cooking recipe, it is a series of instructions/steps that tell a computer what to do with data.

References

1. Maconie, S., The Nanny State Made Me: A Story of Britain and How to Save it. 2020: Ebury Publishing.
2. Anis, J.w.a.t.S., Virchow misquoted, part-quoted, and the real McCoy. Journal of Epidemiology Community Health, 2006. 60: p. 671.
3. Dunn, L., Rudolf Virchow – Now You Know His Name. 2012: Createspace Independent Publishing Platform.
4. Marmot, M., Status Syndrome: How Your Social Standing Directly Affects Your Health. 2004, London: Bloomsbury Publishing.
5. Marmot, M., The Health Gap. 2015, USA: Bloomsbury Publishing.
6. Cleghorn, E., Unwell Women: Misdiagnosis and Myth in a Man-Made World. 2021: Dutton.
7. Saini, A., Superior: The Return of Race Science. 2020: Harper Collins Publishers.
8. Saini, A., Inferior: How Science Got Women Wrong-and the New Research That’s Rewriting the Story. 2017, Boston: Beacon Press.
9. UNESCO, U.N. Artificial Intelligence: Recommendation on the ethics of artificial intelligence. 2020 [cited 2021; Available from: https://en.unesco.org/artificial-intelligence/ethics.
10. Isabel Straw, C.C.-B., Artificial Intelligence in mental health and the biases of language based models. PLoS ONE, 2020. 15(12).
11. Straw, I., The automation of bias in medical Artificial Intelligence (AI): Decoding the past to create a better future. (1873-2860 (Electronic)).
12. Straw, I., The automation of bias in medical Artificial Intelligence (AI): Decoding the past to create a better future. Artificial Intelligence in Medicine, 2020. 110.
13. O’Neil, C., Weapons of math destruction. 2017, Harlow, England: Penguin Books.
14. Noble, S.U., Algorithms of oppression. 2018, New York: NYU Press.
15. Braun, L., Race Correction and Spirometry: Why History Matters. Chest, 2021. 159(4): p. 1670-1675.
16. Curry, S., Inferior by Angela Saini – a powerful exploration of women’s ‘inferiority’, in The Guardian. 2017, Ocamm’s corner.
17. Hamberg, K., Gender bias in medicine. (1745-5065 (Electronic)).
18. Dahal, P.A.-O.X., et al., Gender disparity in cases enrolled in clinical trials of visceral leishmaniasis: A systematic review and meta-analysis. (1935-2735 (Electronic)).
19. (BHF), B.H.F., Misdiagnosis of heart attacks in women. Heart Matters Magazine: Women and Heart Disease, 2021.
20. Lock, M.N.V., The Normal Body, in An Anthropology of Biomedicine. 2018, Wiley & Sons, Inc.: Oxford, UK. p. 29 – 49.
21. Inserro, A., Flawed Racial Assumptions in EGFR Have Care Implications in CKD. 2021.
22. Nancy Krieger, E.F., Man-made medicine and women’s health: the biopolitics of Sex/Gender and Race/Ethnicity. Int J Health Serv, 1994: p. 265-283.
23. UNESCO, U.N., UNESCO member states adopt the first ever global agreement on the Ethics of Artificial Intelligence, U.N. UNESCO, Editor. 2021: Online.
24. Petra Molnar, L.G., Bots at the gate: A Human Rights Analysis of Automated Decision-Making in Canada’s Immigration and Refugee System. 2018, The Citizen Lab and University of Toronto: Online.
25. Andres, J., Wolf, C. T., Barros, S. C., Oduor, E., Nair, R., Kjærum, A., Tharsgaard, A. B. & Madsen, B. S. , Scenario-based XAI for Humanitarian Aid Forecasting. ACM: CHI Extended Abstracts 2020: p. 1-8.
26. Foundation, U.T.R., Artificial intelligence in global health: defining a collective path forward. 2019: Online.
27. Microsoft. AI for Humanitarian Action. 2021; Available from: https://www.microsoft.com/en-us/ai/ai-for-humanitarian-action.
28. Sandvik, K.B., Wearables for something good: aid, dataveillance and the production of children’s digital bodies. Information, Communication & Society, 2020. 23(14): p. 2014-2029.
29. Thiébaut, R., and Sébastien Cossin Artificial Intelligence for Surveillance in Public Health. Yearbook of Medical Informatics, 2019. 28: p. 232-34.
30. Tanczer, L.M., López-Neira, I., & Parkin, S. , I Feel Like We’Re Really Behind the Game’: Perspectives of the United Kingdom’s Intimate Partner Violence Support Sector on the Rise of Technology-Facilitated Abuse. Journal of Gender-Based Violence, 2021. 5: p. 431-450.
31. Tanczer, L.M., et al. Emerging risks in the IoT ecosystem: Who’s afraid of the big bad smart fridge? in Living in the Internet of Things: Cybersecurity of the IoT – 2018. 2018.
32. Sobhani, Kimia, et al. ‘Sex Differences in Ischemic Heart Disease and Heart Failure Biomarkers’. Biology of Sex Differences, vol. 9, no. 1, Sept. 2018, p. 43. PubMed, https://doi.org/10.1186/s13293-018-0201-y.
33. Navarro-Pardo, Esperanza, et al. ‘Diagnostic Tools for Autism Spectrum Disorders by Gender: Analysis of Current Status and Future Lines’. Children, vol. 8, no. 4, Mar. 2021, p. 262. PubMed Central, https://doi.org/10.3390/children8040262.
34. Olckers, Ayran. ‘Artificial Intelligence: AI Terms Simply Explained’. Medium, 15 Mar. 2020, https://towardsdatascience.com/artificial-intelligence-ai-terms-simply-explained-745c4734dc6c.
35. ‘AI Glossary’. Appen, Available online at https://appen.com/ai-glossary/. Accessed 24 Feb. 2022.
36. Roche, Cathy, et al. ‘Artificial Intelligence Ethics: An Inclusive Global Discourse?’ ArXiv:2108.09959 [Cs], 1, Aug. 2021. arXiv.org, http://arxiv.org/abs/2108.09959.

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Cameras at the ready – it’s competition time!

The Adventure Medic and Eco Medics have teamed up to bring you this exciting contest. Photographs have the power to tell a story, to start a conversation and to create change. With our planet suffering and nature fighting for survival, change is needed now.

The Adventure Medic magazine shares inspiring tales of travel and exploration for healthcare professionals interested in the path less travelled. Taking a year out in Australia, heading off with MSF, overwintering in Antarctica – we have you covered. Eco Medics puts healthcare professionals at the forefront of the response to the climate crisis with free educational events, an annual sustainable healthcare conference, ecoQIP templates and more. With that in mind, the theme of this competition is sustainable adventure.

Adventure in the outdoors is hugely beneficial to both our physical and mental health. However, with biodiversity loss increasing at an alarming rate, air pollution from long haul flights on the rise, and a rapidly warming planet, we can’t ignore the environmental and therefore wider health consequences of our actions.

We want you to capture the essence of this exact problem from behind the lens. You may choose to tell the tragic tale of a remote island ruined by plastic waste, to portray the hidden beauty of a micro-adventure in your back garden, or to inspire others with your human-powered experiences using shared, swapped and reused gear. Once you are behind the lens, you become the storyteller; we can’t wait to see what you have to offer.

We are also delighted to introduce our competition judge, Robbie Shone. As a National Geographic photographer who has been on some incredible climate research trips, including the Northeast Greenland Caves expedition in 2019, we can’t think of anyone better placed to help us select a winner.

Details

Entry: This competition is now closed to further submissions.

Deadline: Friday 6th May

Prizes: Winning prize of a Patagonia bag with runner-up and people’s vote prizes of Bower and Grüum products along with Eco Medics’ cups and masks.

Judging Criteria: Photos will be judged alongside their title and description based on originality, creativity, relevance to the theme, technical execution and ‘wow’ factor. Photos will be shortlisted by the Eco Medics and The Adventure Medic teams. The winning photo and runner-up will be decided by Robbie Shone, and there will also be a third winner, decided by a people’s vote from attendees at the upcoming Eco Medics conference.

Winner announcement: Winners will be announced on 22nd May at the Eco Medics conference – Eco Medics 2022: A Prescription for Climate Action. The conference is free to attend, both online and in-person – for details, abstracts and registration, head to www.EcoMedics.co.uk/2022.

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The World Extreme Medicine Conference has it all. It boasts an impressive array of speakers, a schedule packed full of talks to inspire, and diverse workshops that’ll equip you with new skills. It’s sure to appeal to anybody with an interest in practising adventurous medicine, be that expedition work, humanitarian medicine, military or disaster relief. Here’s our review of the 2021 event.

Adventure Medic’s invite

At Adventure Medic we are always thrilled to read, hear, or discuss all things adventurous. As an online magazine, we strive to represent the breadth of opportunities available, covering humanitarian, global health, and expedition work alongside tales of travel and local escapades. We act as a resource for interested healthcare professionals to share their articles and top up their knowledge. As a community, we advocate for alternative opportunities outside of the hospital setting, and the benefits these offer to both the professional and their employer. The WEM conference showcases all this and more, providing inspiring talks from adventurous individuals and organisations, and the opportunity to network with fascinating experts in their field. We were delighted to be invited to cover the event on WEM’s 10th anniversary.

Theme and structure

The theme for this year’s event, “A New World Awaits” is representative of WEM’s ambition to deliver a diverse conference encompassing everything from space medicine to climate change. With this breadth, WEM has departed from previous efforts to categorise days into topics. This suits the attendee who can expect to be overwhelmed by the inspiring and influential speakers on offer regardless of the day!

A range of tickets and prices are offered to suit different professions, availabilities (single day or whole conference options) and locations. Particular attention had been paid to delivering a virtual experience without loss of networking and interaction. Read on to hear virtual attendee Jade’s review of the digital conference experience.

For those attending in person, Edinburgh’s Dynamic Earth offers an impressive venue at the foothills of Arthur’s seat. Scenic runs, sea swims and the city itself make for an incredible weekend. Attendees breezed through registration and straight into refreshments where the buzz of excited chatter filled the auditorium. In a venue packed with adventurous medics, explorers and outdoor enthusiasts, it was inevitable that collaborations and friendships were being struck up in all directions.

Exhibitors

In addition to the full timetable of speakers, delegates have the opportunity to explore opportunities and connect with exhibitors. Organisations included Mountain Rescue England & Wales, Raleigh International, The Faculty of Conflict & Catastrophe Medicine, and the Royal Navy to name just a few. At the Adventure Medic stand we thoroughly enjoyed meeting you all to hear about your dilemmas, career challenges, interests and adventures across the globe. We look forward to exploring these further and providing articles that answer your queries.

Highlights

With such a diverse and impressive line-up there’s a number to choose from. Jeremy Windsor captured the room with his “Deaths on Everest”, whilst James Bloor-Griffiths educated us about Africa’s dangerous flora and fauna. Meanwhile, Erin Kilborn shared her dedicated work with MSF in Gaza; stepping us through her experiences with the burns unit. We also found ourselves dwelling on two speakers from the main stage. Firstly, Hugh Montgomery offered his facts on climate change and how this is the greatest health crisis of our time. It was simultaneously terrifying and a powerful call to action. When we felt there could be no follow up act, astronaut Mike Barratt arrived on screen to introduce environmentalist and ethologist Jane Goodall in a heartwarming interaction. Jane captivated the audience with stories of her life, work and positivity. “Each person makes an impact and you can choose the impact you make”, she advised before bidding farewell to us all in chimpanzee. On Monday, Roger Alcock discussed his work with the International Committee of the Red Cross. The weekend offered many valuable take-home messages, but Roger’s suggestions to “leave your ego at the door”, and “go in with the attitude you’re going to learn more than you’re going to teach” were particularly memorable.

Alongside the variety of talks, delegates had the opportunity to attend numerous workshops, including careers panels, facial trauma workshops, and Burjor Langdana’s engaging and dynamic emergency dentistry workshop. Meanwhile, those attending the ropes workshop were treated to an unrivalled view of the main stage as they abseiled down past the biosphere windows.

For those in town, the Caves provided an excellent venue to enjoy this year’s infamous ceilidh. Live music, dancing, and further opportunity to meet like-minded adventurers over a drink or two.

World Extreme Medicine Conference 2021 – The digital experience

Jade Hanley / Medical Student / Nottingham

What a weekend. At 8am on Saturday 13th Nov, I quickly brewed some coffee as I prepared to join the 10th World Extreme Medicine conference, ‘A New World Awaits’. Famous for bringing together some of the biggest and baddest names in extreme medicine, the WEM conference is a totemic event in the calendar of anybody with an interest in the industry. The line-up of speakers spanned pioneers in space medicine, polar explorers, humanitarian response teams and jungle experts. In short, for a gal with expedition medicine ambitions, this felt like Christmas. Tinged with a hint of the trepidation of meeting your heroes.

As delegates made their way into Dynamic Earth venue in Edinburgh, I loaded up my computer and got comfortable at my desk. For the first time, the conference was open to both in-person and online attendees. I had opted for the digital conference ticket for a couple of reasons. Firstly, as a medical student, I am not exactly flush with cash so the significant saving on the ticket itself, as well as the savings made on transport and accommodation in Edinburgh appealed. Also, I often have very little notice about where I need to be for my clinical placements and so couldn’t be sure that I’d be able to attend on the third day of the conference, being a Monday. At least if I went for the digital option, I could log on at lunch!

I booked my digital ticket with some hesitation, worried that the experience might be limited by technical difficulties, reduced networking opportunities and fewer available sessions but I am happy to say that I couldn’t have been more wrong. The digital platform was fantastic. A purpose-built WEM app allowed attendees to build their own itinerary from the range of sessions available and to navigate easily between sessions, providing a slick and user-friendly experience. The platform held up for all except one session for me and when this glitch did occur, the WEM team were quick to acknowledge this and find a solution. During sessions, digital attendees were able to see both the presenter and their slides and to join in live with Q&As via the chat function.

With the digital platform providing such a smooth experience, I was free to think about connecting with other attendees. The app facilitated networking better than any I’ve experienced before. Attendees were able to create a profile, allowing others to identify potential collaborators in adventure and research. I could ‘connect’ with other attendees via an instant messaging feature and connect I did! My nervousness about networking with so many inspiring medics was soon alleviated by the positive, relaxed responses I received, and I’m delighted to say I’ve made many connections that I’m excited to follow up.

In terms of content, the conference did not disappoint. I attended sessions focused on practical skills for expedition medicine, including Raleigh International’s Katya Alldis on the pre-departure screening of expedition participants and Antarctic veteran Steve Jones’ expert take on expedition safety planning. I also had my eyes opened by courageous and poignant talks by Dr Hamza Al-Kateab, former Director of Al-Qudes hospital in Eastern Aleppo, Syria and MSF’s Dr Erin Kilborn, on working in Gaza during the Great March of Return. I had my (already ambitious) ideas about where I can take medicine stretched by fantastic talks by WEM co-founder Dr Sean Hudson and NASA astronaut and physician Mike Barratt. The only aspect of the event that couldn’t be accessed by digital attendees was, understandably, the host of practical workshops ranging from managing extreme blisters to prepping your vehicle for expeditions. Whilst I longingly scrolled past these sessions on the agenda, there was plenty to fill my schedule and I felt that every effort had been made to bring digital attendees as close to the in-person experience as possible.

In conclusion, whilst I hope that next year I will be able to attend in person, I would recommend the WEM digital conference experience to anyone. The digital experience allows you to enjoy almost all the exceptional content and networking opportunities of the in-person event whilst perhaps better facilitating your budget, access requirements and schedule. Furthermore, given the unpredictable situation we currently face with Covid, knowing that an event of this scale can be pulled off so successfully via a digital platform is great news. The WEM team has clearly invested significantly in their digital platform and the result was an interactive and thoroughly enjoyable experience.

Take home thoughts

WEM’s “A New World Awaits” conference delivered a weekend packed full of inspirational speakers, dynamic workshops and plentiful networking opportunities. The virtual element of the conference was excellently delivered, enabling candidates to attend globally without the need to travel. The focus continues to shift towards how we can adventure sustainably, whilst protecting our fragile planet, and we look forward to hearing more about this at WEM’s 2022 conference. Once again, thank you to WEM for inviting us along.

If you weren’t part of the World Extreme Medicine 10th Anniversary Conference but want to catch up on the content, tickets (£149) can now be purchased by contacting the WEM team directly at operations@extreme-medicine.com.

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Dear readers, thank you for your continued enthusiasm, contributions and support. You have helped the magazine grow into the leading adventure resource for healthcare professionals across the globe. We are proud that Adventure Medic remains freely accessible and non-commercialised, and will continue to work hard to sustain this. It’s a delight to inspire and enable fellow medics to pursue interesting, charitable and unusual avenues through their careers. From remote projects to wild adventures, reading about your exploits has truly been a source of great pleasure.

To new ideas, opportunities and the road less travelled! Happy Adventuring for 2022!

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In light of the recent COP-26 meeting, The Physiological Society has produced a virtual COP-26 Hub to raise awareness, educate and promote debate around climate change and how it affects both the planet and human physiology.

This platform is entirely free and provides many easy-to-follow and useful resources including; the ‘Physiology and Climate Change Booklet‘, online recorded lectures, news articles and many more. Suitable for school students, interested patients and professionals alike. Check it out!

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There comes a point where we need to stop just pulling people out of the river. We need to go upstream and find out why they’re falling in.

Archbishop Desmond Tutu (7th December 1931 – 26th December 2021)

In 2017 it was estimated that 37% of the estimated 11 million people living in KwaZulu-Natal have HIV, one of the highest prevalence areas worldwide. In what is known as ‘the garden province’ of South Africa, a grassroots organisation has taken this sage advice from Archbishop Tutu on board. With minimal funding or publicity, but an awful lot of drive and determination, they have looked upstream and asked why a group of young people keep falling into dangerous waters. 

In 2016 Phindile Khumalo, a social worker, and Mom Ntshosho, an HIV counsellor, in the busy market town of Nongoma, founded ‘Amaqhawe – Achievers of the future’. This is a support group for children and adolescents who have contracted HIV. It is well known that for mothers whose viral loads are not adequately surpressed, vaginal delivery and breastfeeding pose a risk of transmission, however there are complex social, cultural and personal reasons why accessing and continuing ARV treatment is diffiuclt for many. Since 2016, despite the additional challenges posed by Covid-19, Phindile and her colleagues have provided a stable support system for children and adolescents living with HIV in Nongoma, and the results speak for themselves.

This article is about a support group for adolescents infected with HIV in the perinatal period. The group is based in Nongoma, South Africa. Nongoma is a small town in rural KwaZulu-Natal that is rich in heritage but characterized by poverty, unemployment and staggering rates of HIV. The support group was founded in July of 2016 in an attempt to mitigate the challenges faced by these adolescents.

In 2016 I was working in the HIV clinic of Benedictine Hospital, Nongoma. While there I observed what seemed to be a steady incline in the number of deaths of adolescents born with HIV. This was confusing to various health care workers because the rollout of antiretroviral drugs (ARVs) was at its peak, and life expectancy was predicted to be much higher than in previous years. The adolescents were collecting their medication from the hospital, but they were not taking it. Without these ARVs, their viral loads of HIV were not being suppressed. Discovering the reasons for this non-compliance posed a great challenge to clinicians.

It became clear that although the medical community had taken great strides in providing medical treatment that increased the life expectancy of these adolescents, it was ill-equipped to provide the psychosocial support required by patients. To address the non-compliance observed, adolescents whose viral loads were not suppressed were referred to medical social workers for counselling and health education. Within a group of 31 adolescents who were referred, 23 had viral loads in the thousands to tens of thousands per millilitre. High viral loads would sentence these adolescents to a reduced life expectancy, give them a high likelihood of developing AIDS and put them at risk of transmitting the virus to others.

In the numerous sessions with the adolescents, we started noticing trends in their responses as to why they didn’t take their medication. Some of the emerging themes were lack of a support system, internalized stigma, anger and pill fatigue, to name but a few. During one-on-one therapy with the adolescents, they expressed that they felt alone and that no one truly understood the challenges that they faced. It was decided that it would be a good idea to bring them together as a group. It was felt that they would be able to create a support network where they would not feel alone and could draw strength from each other that would help them navigate through life’s challenges.

In July of 2016 we started the support group. The purpose of the group was to provide support and create a safe environment for the adolescents to express their feelings. We wanted to instil a belief in these young people that, although HIV is life-changing in some respects, it does not need to be life-limiting. Their common attributes also gave the adolescents a sense of belonging.

When we started the group, our vision was to enhance the lives of the adolescents in every way. We wanted to make sure that we did our best to help them thrive socially, academically and psychologically, as well as improve their health. Each child has an individual plan which helps us identify the areas in which they need more attention and support. We also have motivating programs that challenge and stimulate the children to reach for new heights. The results have been absolutely amazing: we have been keeping track of the viral loads of the children over the years and we are in awe of the changes that we have observed. Out of the group of 31 adolescents, 22 have suppressed viral loads, 13 of whom have undetectable levels. These adolescents, with the help of the support group, can hope to live long lives, avoid developing AIDS and avoid transmitting HIV to their partners and future children.

Working with this group does not come without its challenges. In the years that the group has been running, the main challenge faced is pill fatigue. Most adolescents in the group go through stages where they get tired of taking their medication. They know the risks involved with not taking their medication properly, but they just get tired. In one of the group sessions, one adolescent asked if it would be such a bad thing if ‘[they] took a break from [their] pills, just one year, saying that it’s not fair that [they] have to take medication from the day [they] are born until the day [they] die’. Pill fatigue remains our biggest challenge and we continue to try to find innovative ways to deal with the problem.

The adolescents are in a stage of identity versus role confusion, they are conflicted with dozens of values and ideas of who they should be and what they should think. Having to navigate this stage of life while being HIV positive is quite daunting for them, and it results in psychological and emotional distress. Some of them have started dating and they are scared to disclose to their partners, or even to their friends, their HIV status because they fear rejection and discrimination. One of them had to change schools because of the discrimination she faced after disclosing her diagnosis to her friends. Other challenges include internalized stigma, discrimination, anxiety, depression, grief, and anger. The road to sound mental and physical health is a lifelong one but we are walking it with them, every step of the way.

When we first started the group, the biggest challenge we had was that of finances. We wanted to ensure that we served the adolescents breakfast and lunch at every session. Some of the adolescents would travel very long distances, starting very early in the morning, to get to the hospital for the sessions. Most of them also face food insecurity at home. Fundraising for the meals was difficult and we often used our own money to meet the needs of the group.

We had a major breakthrough when a doctor from the UK, who was working at our hospital at the time, came across our group work proposal, she shared it with her friends and family in the UK and the support we have received since has been overwhelming. We have managed to do more than we could have ever imagined. We have managed to buy school uniforms for those that come from poor households. We are also able to assist some adolescents with travel costs when they come to group sessions and others that are in urgent need of food or school registration fees. We are still hoping to expand our project and reach more children and adolescents living with HIV, but that is not currently possible due to financial and human resource constraints.

When we started this group, we wanted to make a difference to the lives of adolescents living with HIV. Little did we know how much they would change our lives. Watching them grow and evolve has truly been the greatest privilege of all. The lifelong connections we have made with colleagues and friends from the UK have also been such a blessing. Our support group is now a part of a global community, and we are eternally grateful.

If you would like to get in contact with Phindile, to find out more about the project, to offer financial support, to help design and make a website or to provide legal advice, please email her at khumalophindy26@gmail.com

The post Living Positively with HIV appeared first on Adventure Medic.

Dr Burjor Langdana takes us through the problems with dental hygiene during endurance sports and expeditions. The Colgate Duraphat 5000 toothpaste’s high fluoride content helps to mitigate these risks and can help prevent both dental cavities and gum disease.

But I’m not an endurance athlete

If you are reading Adventure Medic you are likely to be involved in many outdoor pursuits already. Perhaps cycling to work, on your feet walking around the hospital (or other healthcare setting) all day and then any post-work sporting pursuits. At the weekend, a run, hill-walk or climb perhaps. In other words, you are directly or indirectly involved in endurance activities. Thus, you are sharing the oral insults these activities entail.

Do protractive frequent endurance activities affect my oral health?

Unfortunately yes, this is true. Oral health gets a right beating before, during and after exercise. This is how it happens:

Saliva

a) Viscosity – Sympathetic activity during strenuous exercise increases the mucinous, sticky saliva secretion.¹

b) Volume – is decreased due to dehydration and mouth breathing.

c) Composition – IgA concentration is decreased, reducing mucosal and upper respiratory tract immunity.¹

Diet

A change in regular diet, increased snacking or energy supplements can result in:

a) Increased quantity and frequency of carbohydrate intake.

b) Increase in acid exposure, which causes increased dental corrosion due to the chelating action of the acids present in saliva.¹

Immunosuppression

Studies show that after intense frequent physical activity for 3-24 hours, immune function is affected in the following ways:²

a) Neutrophil respiratory burst.

b) Lymphocyte proliferation.

c) Monocyte antigen presentation.

This results in increased soreness of the throat and mouth.

So, what does all this mean?

This means that your active fun-filled lifestyle puts you in a high-risk group of individuals predisposed to dental decay and gum disease.

Duraphat 5000 Toothpaste

But I go for regular dental check-ups and brush twice a day. What else can I do? A simple addition to your regime is Duraphat 5000 Toothpaste.

What is it? – Colgate Duraphat 5000 ppm toothpaste contains four times the amount of fluoride found in regular toothpaste.

What does it do? – Over-the-counter fluoride toothpaste (1000 ppm) reduces cavities by approximately 23% while a toothpaste in the range of 2400-2800 ppm reduces cavities by about 36%. A 5000 ppm high fluoride toothpaste reduces the cavity risk even more – estimated to be about a 42% reduction.³

How does it work? – The active ingredient sodium fluoride prevents the build-up of plaque that can cause tooth decay and cavities (dental caries). It works by strengthening and remineralising enamel to help resist acid erosion.³

a) Decreases the formation of new cavities.

b) Slows down the progress of any existing dental decay to a certain extent.

c) Helps to decrease dental sensitivity.

d) Decreases the progression of gum disease to a certain extent.

How do I use it? – Ideally, brush for three minutes three times a day and then do not rinse. Try not eating or drinking or rinsing for 30 minutes after that.

Where can I get it? – For those in the UK, if your dentist agrees that you are in the high-risk category for dental decay then you can get up to four tubes on a single NHS prescription.

Practical advantages for the outdoors

• Colgate Duraphat 5000 comes in a small tube and you only need a pea-sized quantity on your toothbrush; saving both weight and space in your pack.
• Its minimal foaming action helps to keep your kit clean and tidy when brushing teeth in a tent.
• Due to its high fluoride content, Colgate Duraphat 5000 can also be used for sensitive teeth – by rubbing and leaving it on sensitive teeth.
• Bottom line: By making Colgate Duraphat 5000 your regular toothpaste, its beneficial effects will make up for the inevitable temporary lapses in oral hygiene maintenance when out in the field.

References

1. Influence of intensive training on salivary flow, on salivary pH and on salivary lactate concentration: consequences for oral health. Reis N, et al. 2015. International Congress of CiiEM.
2. Immune function in sport and exercise. Gleeson M. 2007. Journal of Applied Physiology.
3. The Anticariogenic Efficacy of 5000 ppm Fluoridated Toothpaste: A Systematic Review. Chaudhary D, et al. Journal of Clinical and Diagnostic Research. 2018 Jan, Vol-12(1): ZE04-ZE10.

The post Duraphat 5000 – The Secret Dental Elixir For Endurance Athletes 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.

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Access to the module can be found on the BMMS mountain medicine blog.

If you would like to be involved in writing the next set of questions please get in touch with the team at BMMS.

Photo: Tom Beddis

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The full standards can be accessed here.

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Dr Burjor Langdana explains why routine use of antibacterial mouthwash, such as 0.2% chlorhexidine may reduce the beneficial effects of training; especially in the recovery phase.

Newsflash – Routine use of antibacterial mouthwash like 0.2% chlorhexidine may reduce the beneficial effects of training especially is the post-training phase ¹.

Mechanism – Oral bacteria play a key role in the cardiovascular effects of exercise, specifically the vasodilation and low blood pressure seen after exercise. When you exercise, cells in your blood vessels and muscles produce nitric oxide, which widens blood vessels and increases blood flow to working muscles. The nitrate formed during exercise is then absorbed by the salivary glands and secreted in the mouth during the recovery period after exercise ¹. After nitrate is secreted into the mouth, oral bacteria reduce this to nitrite which is then swallowed. After swallowing, a small portion of nitrite is rapidly absorbed into the bloodstream and forms new nitric oxide; helping to sustain optimal blood supply to active tissues. This causes a blood pressure lowering response termed ‘post-exercise hypotension’.

Bottom Line – Antibacterial mouthwashes such as Corsodyl (active ingredient: chlorhexidine) may be detrimental to recovery. By killing the ‘good’ oral bacteria, less nitrates are converted into nitrites and thus less nitric oxide is available to widen the diameter of blood vessels after exercise. Therefore, tissue perfusion is reduced as well as post-exercise hypotension.

References

1. Post-exercise hypotension and skeletal muscle oxygenation is regulated by nitrate-reducing activity of oral bacteria. C Cutler et al. Free Radical and Biology Medicine. 2019. 1;143:252-259. Accessed at: https://pubmed.ncbi.nlm.nih.gov/31369841

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A post shared by Nirmal Purja MBE - Nimsdai (@nimsdai)

At 17:00 on the 16th of January, the first winter ascent was claimed by an all-Nepali team; lead by Mingma Gyalje Sherpa and Nirmal Purja Pun Magar. Mingma Sherpa is an IFMGA guide who has previously ascended 22 8000m peaks. Purja, known as Nims, holds the record for ascending all 14 8000m peaks in six months and six days, smashing the previous 1987 record of seven years 11 months and six days. In total their ten-person team have ascended 100 8000m peaks between them – which made for a highly experienced, dedicated and formidable team. This, combined with fortunate weather windows and forgivable ground conditions built the foundations for their success.

K2 stands at 8611m on the China-Pakistan Border. In 1953 George Bell described it as a “savage mountain that tries to kill you”.¹ The Himalayan Database indicates a staggering 9159 people have summited Everest successfully and 295 have tragically died attempting it. Odds on K2 are even more stark however; of the 367 people who have successfully stood on its summit, 86 did not return home. Considering that K2 is the last 8000m peak to be climbed in winter, you are right to be in awe of the team’s achievement. There are many reasons for this; temperatures can reach -65 degrees Celsius, strong winds increase risk of frostbite and remove snow from the mountain leaving exposed rock which necessitates technical ascents. In light of the terrifying death statistics on K2 attempts to date, it is clear that both the team’s pre-expedition and on-mountain preparation of fixed lines, robust camps, efficient use of oxygen; as well as teamwork and camaraderie led them to summit and ensured their safe return to basecamp.

Despite these obvious unpredictable dangers, over 60 hopeful mountaineers have descended on K2 already this year, with four teams each seeking a winter summit.¹ Sadly, the mountain has continued to live up to its deadly reputation; experienced Spanish mountaineer Sergio Mingote fell 600m on return to base camp from an acclimation trek in early January 2021. Rescue teams were mobilised but he did not recover from his injuries. Fellow K2 climber Tamara Lunger has paid tribute to him stating, “Not only have all of us lost a great and strong mountaineer, but I had found and so soon lost a wonderful friend, with a big heart so positive, happy and full of love for the mountains, others, and life.”

Many expedition medics are acutely aware of these risks of high altitude mountaineering and the medical support needed for such endeavours. However, we also know of the strength, experience and invaluable support local porters and guides provide on any expedition. Crucially; this isn’t just a victory for the first winter ascent of an >8000m mountain, but a success for representatives of a strong, proud and unified Nepalese nation who have supported generations of International climbers on their own ascents. It is now the time for this community to claim a summit of their own and step firmly into the spotlight.

References

1. Arnette Alan, A Nepali Team Just Made the First Winter Ascent on K2. Outside
   Accessed at https://www.outsideonline.com/2420319/k2-first-winter-ascent
   Published 16/1/21. [Accessed on 17/1/21].
2. Nepali climbers make history with winter summit of K2 mountain – BBC. Accessed at https://www.bbc.co.uk/news/world-asia-55684149. Published 16/1/21. [Accessed on 17/1/21].
3. Wilkinson Freddie, Climbing Mount Everest, explained. National Geographic
   Accessed at https://www.nationalgeographic.co.uk/2019/02/climbing-mount-everest-explained
   Published 9/4/19. Updated 5/11/20. [Accessed on 17/1/21].
4. Bisharat Adrian, Climbers Attempt ‘Impossible’ K2 Winter Ascent. National Geographic
   Accessed at https://www.nationalgeographic.co.uk/travel-and-adventure/2019/02/climbers-attempt-impossible-k2-winter-ascent Published 1/2/19. Updated 5/11/20. [Accessed on 17/1/21].
5. Benavides Angela, Saddest News from K2: Sergi Mingote Dies in Fall. Published 16/1/21
   Accessed at https://explorersweb.com/2021/01/16/saddest-news-from-k2-sergi-mingote-dies-in-fall/ [Accessed 17/1/21]

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The first issue of Adventure Medic, conceived in December 2011, released in Summer 2012, alongside the magazine today.

We are delighted to announce that from 2021, Adventure Medic will be in the capable hands of the next generation of adventurous medics, led by Shona Main, Rebecca Trimble and Tom Beddis.

We’ve come a long way together. My first taste of expedition medicine was on the APEX2 Altitude Expedition to Bolivia as a medical student in 2003. Eleven years later, fellow Adventure Medic founder Ellie Heath and I were the expedition doctors on the APEX4 expedition. There, we met Shona, Rebecca and Tom, then students themselves. It was clear that they were stars in the making, and they soon joined our Adventure Medic team. Now, they are qualified, adventuring and taking over the reins.

Adventure Medic is nearly ten years old. We started it as a group of friends, to support our fellow medics in pursuing interesting, charitable or unusual paths through life. We are delighted that this group of friends has become a worldwide community. We have tried to stay true to our values as the magazine has grown, and serving our community has been a privilege and a source of joy. Reading about all your adventures over the years has been inspirational.

We want to thank everyone who has contributed to the magazine since it began. It has truly been a team effort and will always be so. We are excited to leave Adventure Medic in such capable hands. We know that the new team will continue our mission with enthusiasm. We remain as passionate about adventure as ever.

Keep reading and best wishes. Here’s to the next ten years!

Matt

On behalf of the Adventure Medic team past, present and future.

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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.

The post Taking Time Out of UK Training appeared first on Adventure Medic.

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.

The post FPHC Guidance for Medical Provision for Wilderness Medicine 2019 appeared first on Adventure Medic.

What do the rescue posts do?

Being a porter in the Khumbu is a tough proposition, but pays well enough to attract even those without experience of the mountains or altitude. Before the clinics, shelters and clothing banks were built, many porters were ill-prepared for the elements. Some slept in caves and occasionally, one succumbed to the effects of altitude and lost their life. The International Porter Protection Group (IPPG) and Community Action Nepal (CAN) built two rescue posts and porter shelters, offering food, a roof over the head and medical care for these deeply hardworking people. The model was sustainable, subsidised by treating Western trekkers at the clinics for a fair price. IPPG also offered free altitude education to those passing through the villages, a simple but effective public health intervention that likely saved many lives. Adventure Medic’s own Ellie Health and Matt Wilkes spent the autumn 2017 season working at the rescue posts and witnessed first-hand the immeasurable good that they do for the local population. The closure of the posts is a desperate loss, to the porters of the Khumbu, to the local staff employed by IPPG, to the mountain medicine community and to all those visiting this special part of the world.

Why are the rescue posts closing?

Dr Nick Mason, along with his wife Emma and many dedicated volunteers, have worked tirelessly to keep the rescue posts running over the years. Nick has written the following open letter regarding their closure.

Dear friends

It is with great sadness that I have to report the forced closure, with immediate effect, of the rescue posts in the villages of Machermo and Gokyo, Nepal.

For the last 17 years the International Porter Protection Group (IPPG) and Community Action Nepal (CAN), and in recent years with the support of the Mountain Medicine Society of Nepal (MMSN), have quietly and efficiently been operating a porter shelter and rescue post in the village of Machermo at 4450m above sea level. During the last decade they have been operating a similar facility in the neighbouring village of Gokyo at 4900m. Some of you will know the area well having worked for IPPG as volunteers.

In October of last year, without warning, a small private clinic in Kathmandu opened a satellite clinic in one of the lodges in the centre of Gokyo. Last season the clinic was staffed by a doctor qualified for less than one year and with no experience of altitude or travel medicine. He attended IPPG’s altitude talk for lay people and said that he learned a great deal! The business model for the new clinic would appear to be to evacuate as many trekkers as possible to Kathmandu where it is alleged they are often subjected to excessive or fictitious investigations and treatment. Those trekkers not evacuated are frequently subjected to excessive and sometimes dangerous over treatment and polypharmacy. Last season’s volunteer doctors for IPPG had the impression that up to 50% of patients seen at the new clinic were evacuated by helicopter compared to IPPG’s rate of around 5% and then only the most seriously ill. The helicopter company used for the majority of the evacuations from the new clinic is owned by a major shareholder in the Kathmandu clinic.

Many of you will be aware that IPPG’s funding for the free care of porters and local people comes from treating trekkers and charging them for this care. This just about covers the operating costs of the 2 rescue posts. With the new clinic opening in the centre of Gokyo and, for the first time since IPPG began working in Gokyo, hostility and abuse towards IPPG’s doctors from those lodge owners associated with the new clinic, trekkers attending the IPPG-CAN rescue post have already begun to fall. This would obviously have an impact on our ability to fund our work and so we had begun to look at the possibility of alternative funding arrangements. but unfortunately the Khumbu Pasang Lhamu Rural Municipality (local government for the Khumbu) have refused IPPG permission to operate in the Gokyo Valley for spring 2020 and subsequent seasons. Without this permission it is impossible for IPPG’s doctors to obtain a work permit and without that registration with the Nepalese Medical Council. The Khumbu Pasang Lhamu Rural Municipality has been in existence since 2017 and it seems more than a coincidence that it is only with the opening of the new private clinic that permission for IPPG to work in the valley has now been refused. It has proved impossible to engage in any discussion with the Rural Municipality.

In the 17 years that the posts have been open, thousands of patients have been treated; hundreds of lives have been saved and in excess of 30,000 people have attended the daily Altitude Talk and been educated on altitude illness and, even more importantly, how better to take care of porters. Tragically it is highly likely that with the loss of the medical and educational roles of the rescue posts, as a direct consequence of the decision of the Rural Municipality, deaths from avoidable altitude illness will increase in the Gokyo Valley.

We hope that the much needed porter shelter in Gokyo will continue to function. The shelter in Machermo has been a victim of its own success and a number of tea shops have subsequently opened in the village specifically to provide porters with cheap food and accommodation. It is now rarely used by porters. Prior to the opening of the shelters, porters slept in the open, under tarpaulins or in caves while the trekkers whose kit bags they had carried all day slept in warmth and comfort.

We have always viewed ourselves as guests of the Sherpas of the Gokyo Valley, having been originally invited into the valley by the local community and the Sagamartha National Park, and it has been a privilege to serve them. We looked forward to the day when we would be able to hand over the rescue posts and porter shelters fully to the Nepalese. Despite increasing difficulties over the last few years we did not envisage that we would be forced to stop caring for the porters and trekkers visiting the Gokyo Valley in such an abrupt manner. Nepal has undergone huge socio-political changes during the past decade and it is clear that for some influential people in Nepal our help is no longer welcome. It will be for the talented and inspirational young doctors of the MMSN to choose how to face these new challenges. It is to be hoped that they will strive to uphold the highest standards of medical practice in mountain medicine in Nepal and that they will be ably and robustly supported in this task by the international mountain medicine community.

Best wishes,

Nick

Dr. Nick Mason PhD, FRCA, FFICM, FRGS, Dip Mtn Med

Chair of Trustees, IPPG(UK)
Registered Charity Number: 1143221

(Photos: Matt Wilkes)

The post IPPG Nepal Rescue Posts Forced to Close appeared first on Adventure Medic.

Another year draws near to a close and for the medical adventure and expedition enthusiasts, that means the annual World Extreme Medicine (WEM) Conference at Dynamic Earth, Edinburgh. The culmination of all things wilderness, expedition and humanitarian medicine all rolled into a well-run, exciting and inspiring weekend to remember.

As an editor for Adventure Medic, my colleagues and I were kindly invited to attend the WEM conference for another year. We are an online magazine showcasing all things adventurous within medicine, and advocate for the alternative opportunities available outside the regular NHS hospital job. We publish articles written by doctors, nurses and paramedics who have a story to tell; from high-altitude expeditions, to jungle medicine; and from polar research to humanitarian aid work. The WEM conference is the perfect opportunity for networking and hearing all about all the latest adventurous trips our colleagues have taken or are planning.

This year the WEM conference theme was ‘Thriving in Adversity’. The line-up certainly did not disappoint; with Dr. Kevin Fong, Dr. Serena Auñón-Chancellor, and Dr. Chris Imray to name but a few; attending to share exhilarating stories and ground-breaking research on topics from polar medicine to space exploration to conflict zone management.

As well as the many inspirational talks and workshops on offer, a particular attraction of the WEM conference is the opportunity for delegates to network with a wide variety of other like-minded folk, organisations, and industries. During the breaks each day the air was alive with the chatter and hustle and bustle over coffee in the atmospheric dome of Dynamic Earth. It was such a privilege to be in the company of some of the most remarkable medics, scientists, explorers and adventurers who are pushing the boundaries of exploration and understanding of the human body in extremes. It was clear from this year’s conference that the world of expedition medicine is not confined by the boundaries of planet earth; but that the many technological and engineering advances have allowed astronauts to push medical research into space. This year certainly, the WEM tagline, ‘where mankind goes, medicine must follow’ resonated particularly.

In between manning the Adventure Medic stand and chatting to delegates about their extraordinary stories, we had the privilege of being able to listen to the many inspiring talks in the ‘Biosphere’ (main conference hall). Instantly upon walking into this inspiring space, you could feel the waves of energy from a hundred or so aspiring or established expedition and remote doctors, nurses, and paramedics. It was impossible not to be enthralled by the many world-class speakers on the program, and even if you found yourself in a talk that hadn’t initially made it onto your ‘must-see’ list on the excellent WEM mobile app, it was hard to not be hooked within the first minute.

I was particularly keen to hear the lecture about the Grenfell Tower fire, and dealing with the aftermath of a major disaster. The senior investigating police officer Det. Supt. Matt Bonner, gave a humbling and heartfelt talk about how the tragic events of the night unfolded, the scene search and rescue and the complex and lengthy process of victim identification. Also an interesting point of discussion was the occupational health considerations of the officers involved, who were on site for five months, and many of whom volunteered their time in addition to their usual duties. This was a moving talk and resonated with many on a personal as well as an academic level.

Another highlight was hearing Dr. Kevin Fong, consultant anaesthetist at University College London Hospitals and flying doctor with Kent, Surrey and Sussex Air Ambulance, speak about managing risk in complex environments; challenging the limits of the human body; and the technological advantages that have allowed further space exploration and research to take place.

A salient theme running throughout the conference was mental health on expedition. There were a couple of fascinating lectures from clinical psychologist Dr. Kate Baecher; who has worked with many groups including the special forces and elite sporting teams. She shared her advice on how to maintain sanity, humour and humanity in remote environments; and how to avoid burnout and protect your mental health in extreme environments.

By the end of each day, it was hard to not feel inadequate in the company of such ‘maverick medics’. But at the same time, revved up with a new-found appreciation for our planet, our people, and the incredible achievements that are possible when you put the two together; with a little imagination, hard work and determination. As proceedings drew to a close, I strolled out of Dynamic Earth and onto the historic streets of the Edinburgh old town on a cold, clear November night. Walking home along the same streets I have walked countless times, but this time with a newfound appreciation for the possibilities that lie before each of us in life; if we are not reticent in grasping the opportunities presented to us.

The World Extreme Medicine Conference is returning to Edinburgh from 17-19^th October 2020. Click here to book your ticket now!

The post Adventure Medic at the World Extreme Medicine Conference 2019 appeared first on Adventure Medic.

This article was originally published on 7 Mar 2018, and has since been updated ready for the 2023 application window.

Dr Shona Main / ST4 Emergency Medicine / Wessex

Dr Will Denehan / ST4 Anaesthetics / Wessex

Dr James Truell / F4 / Wellington

For many years now, New Zealand has been an incredibly popular destination for doctors at all stages of their training looking to expand their horizons and experience life and work in another culture and healthcare system. With it’s stunning landscapes, sunny climate, unlimited opportunities to explore the great outdoors, countless wineries (need we go on?!) not to mention the favourable working conditions and pay, it’s easy to see why so many are tempted down under.

Adventure Medic initially teamed up with UK junior doctors Shona Main and Will Denehan in 2018 to bring you their ‘Definitive Junior Doctors’ Guide to Working and Living in New Zealand’, which has since been updated by Jamie Truell in 2023. 

Drawing on their invaluable recent first hand experience and research, Shona, Will and Jamie will guide you through the process of job applications and relocation from start to finish, demystifying the bureaucracy and simply informing you what you need to do and how you need to do it.

Now you’ve no excuse..!

If you are interested in this piece, you may be interested in these others relating to work in Australasia:

There and Back Again: An Emergency Medicine Elective in New Zealand

Emily is an FY1 doctor in Chesterfield, after graduating from Nottingham Medical School in 2017. She spent her final weeks of medical school on elective in Rotorua, working in their Emergency Department (ED) and taking advantage of New Zealand's rich culture and great outdoors.

An Outback Elective

Bobby Greig is a runner, climber and mountaineer who is currently working in South Scotland. He spent his elective in Alice Springs, Australia during spring 2017. In his article, Bobby tells us about work and play in The Outback.

Thinking of straying to Straya? The Definitive Junior Doctors’ Guide to Living and Working in Australia

Junior doctors Ella Bennett and Jack Leach have demystified and condensed all you need to know to make the move to live and work as a doctor in Australia. What are you waiting for?

Contents

1. Checklists
2. The NZ system
3. The Application
   1. How to apply
   2. What to apply for
   3. Where to apply
   4. Important dates
   5. Documents required for your applications
4. Things you’ll need to start work
   1. MCNZ
   2. GMC
   3. Certificate of good standing
   4. Visas
   5. Occupational Health
   6. Indemnity
5. Things you’ll need to live
   1. Accomodation
   2. Bank accounts
   3. Tax numbers
   4. Health insurance
   5. Car
   6. Phone
   7. Student Loans
6. Things to know about work
   1. Annual leave
   2. Study leave and courses
   3. Portfolio
   4. Swapping jobs
   5. Bonuses
   6. Pay
7. Fees and finance
8. Useful websites
9. About the authors

1. Checklists

Documents for your applications

Once you’ve got a job offer

Once you’ve landed in NZ

2. The NZ system

The academic year in NZ starts in January/February (rather than August as in the UK). It is possible to start work in August i.e. as soon as you finish F2, although a many people start in January/February. This means you can work in NZ within F3 – work for 6 months (January/February to July/August) or 12 months (August to August); returning to the UK for interviews and then again to start training. Others take an F3 and F4; working January/February to January/February and return to the UK for interview season in their F4 year (or for February starts).

The grade scale is slightly different in NZ, see below:

3. The Application

(a) How To Apply

There are two main routes to getting work in NZ.

• Kiwi Health Jobs
• Via a locum agency

Other routes include applying directly to hospitals, though at a junior level you’re often re-directed back to the national applications.

1. Kiwi Health Jobs

Individual hospitals or deaneries (called district health boards, or DHBs) will publish available jobs on Kiwi Health Jobs. You can often still get ahead of the game by looking at the DHB’s own website too or contacting them directly. Click here for a list of DHB websites. It varies between the DHBs, but they usually list either:

• A specific job at a specific grade in a specific DHB e.g. House Officer in Emergency Medicine in Waikato DHB, or
• General jobs at a specific grade in a specific DHB e.g. All House Officer jobs in Lakes DHB

The Kiwi Health Jobs application system auto-populates your answers if you’ve answered the same question in another application. This is handy, though there are still small differences that can catch you out. For example, Northlands DHB have a separate application form entirely. Similarly the Auckland DHB (a large area covering Waitemata, Auckland and Counties Manukau DHB’s) has a separate CV form that you must use; failure to do so can void your application.

2. Locum Agencies

There are a few locum agencies with whom you can register in order to get a job in NZ. Jamie’s experience was with Triple0, though others do exist. They are free for the user and receive a “finder’s fee” from the health board.

The upside is that they facilitate a lot of the paperwork that you will otherwise need to do yourself. They are more likely to have job availability during periods when national applications aren’t open (e.g. in August when you finish F2) and can look for quite specific jobs for you e.g. House Officer in O&G in Auckland starting in October, rather than having to apply to many different jobs.

Their downside is their popularity – you have to register early in order to get ahead of the masses! They may also not find you a job, or find you one very last minute. If you want a set plan and structure to your time out, relying on the locum agencies to find you a job at a specific time isn’t the most sensible. It is always worth regularly staying in contact to ensure you stay on their radar.

The best thing to do is to try to tailor your approach; decide where you want to work and what in. Even if you decide on just North or South island, it will save you an incredible amount of time in application form filling!

(b) What To Apply For

After finishing F2 in the UK, you are eligible for either House Officer or Junior Registrar posts in NZ [see table above].

House Officer jobs are essentially like F1 and F2 all over again. They are a good option if you don’t know what you want to do long term and just want a job full stop. They can be useful to gain experience in specialties you haven’t done during F1/2, for example more time in surgical specialties, ED etc. If you do know what you’ll train in, they can be useful to build points for an application (e.g. Anaesthesia applications give points for 12+ months post-F2 in “complementary specialties”). Their downfall is that you’re not really progressing; it’s like doing more time in an F1 or F2 role.

Due to changes in junior doctor contracts, there are more House Officer jobs available than previously. This should make it easy to get one somewhere. That said, priority is given to NZ nationals (and in particular NZ nationals of Maori descent), so you are unlikely to get all your first choices in terms of location or specific specialty.

Junior Registrar jobs are more like core training jobs in the UK. They are good if you know what you want to specialise in, or want experience in a specific field to see whether it’s for you. The application process is the same, but there is greater competition for places. Some of them require a certain length of time in the specialty before applying e.g. 6 months Emergency Medicine before applying to be an ED Registrar, 9 months Surgery before applying to be a Surgical Registrar. In most centres it is easy to transition to a Junior Registrar from a SHO after 6 months. Of note, Registrar posts tend to run February to February, rather than January to January.

(c) Where To Apply

There are 20 DHBs in NZ, now all under the umbrella of Te Whatu Ora (Health New Zealand). Most tend to have 1 or 2 big hospitals, with a larger number of smaller DGH-type hospitals. It’s best to do some thinking about what you want hospital-wise (big city vs. small rural) as well as where you want to work (small town by the beach, major city etc). The government’s website with a list of individual DHB websites is a good place to start and there’s a helpful map here.

(d) Important Dates (approximate)

These are provided as a guide, but please check up to date application dates directly with where you intend to apply.  For example Christchurch, or Auckland.

(e) Documents required for your Applications

Passport

Regardless of what visa type you apply for (see ‘Visas’ below), you will need a minimum of 15 months left on your passport from the time your visa starts (usually the first day you enter the country). If you planned on starting work in NZ in August 2023, your passport should expire no earlier than November 2024. Worth looking at early on, as last-minute new passports are pricey!

CV

All applications require a CV. As mentioned above, the Auckland Region has its own CV template. Otherwise it’s an as-you-like-it CV. Worth getting in order early, especially as you’ll need one for UK applications anyway.

References

A mandatory requirement for applications are three references. These must be from the three rotations/jobs you did immediately prior to starting in NZ. There is a generic RP6: Referee Form, used by the DHBs and the MCNZ.

If you are planning to start in NZ in August, the references will be from your Clinical Supervisors for your three F2 rotations.

If you are planning to start in NZ in January/February, and have done one locum or trust grade job between August and then, the references will be from your locum supervisor and the Clinical Supervisors from your last two F2 rotations.

It can seem annoying to have to get the form filled out; our best suggestion is to print off a number of copies and bring one to end-of-rotation meetings, getting the supervisor to fill it out then and there. You’ll then have to scan it yourself and upload it to your application later. Some regions now do these electronically, so give your supervisor a copy in case they need to fill it out online again at a later date.

DBS/Police Checks

You will need to have checks from any country you are a citizen of, in addition to NZ police forces, during the process of getting a job in NZ. The international police certificate(s) are for immigration purposes. UK certificates cost £55 (or £95 if you leave it last minute) and can be requested here.

The NZ police certificates is for work purposes. It is free. Once you receive your job offer, your employer will email you a Police Vetting Form to fill out.

Other Documents

Both National and Locum application processes will require copies of a wide array of documents. These include personal ID (passport, driver’s licence) and medical documents (ALS certificate, F2 completion certificate etc.). Please see the checklists above for a full list of the documents you’ll require.

Verification of Documents and Statutory Declaration

Some documents you will need to have verified as being yours through the US based Electronic Portfolio of International Credentials (EPIC) Physicians Portal. The whole process takes a few weeks, includes an identity check over zoom and costs 230 USD. Your EPIC Identification Form (EIF) must be certified by an authorised official. The Post Office offers this service – you’ll need to bring the original document, a photocopy and the £12.75 fee. See here for more details. If your name differs between any of your official documents, you will need to have a statutory declaration signed to verify they’re all yours. Examples might be lacking middle names, or maiden and married names on different documents. This has to be done by a notary. If you don’t happen to have a family friend or colleague who’s a notary, you may have to pay for this to be done, in the region of £75. You can find your nearest one here.

4. Things You’ll Need To Start Work

(a) MCNZ Licence

The MCNZ is New Zealand’s GMC equivalent. You’ll need a licence to practise before you start work. As a UK graduate, you’ll be given a 6 month provisional license to practice which, assuming you get ‘signed off’ at the end of the period, will be converted to a full licence to practise after that time. The MCNZ also require references – you can use the same ones as for your job applications.

The application can be pricey. Most people pay an initial fee of approximately $600, followed by the actual licence fee. The license fee cost changes depending on your birthday (yeah, we know it’s weird), but is going to be in the region of $700-$1000. The good news is that you can claim that fee back once you start work; the bad news is you have to have the money in the first place to afford it! See Fees and Finances below.

Once you have applied for a licence, the next step is being “invited for a zoom interview”. This is merely a document-checking and form-filling exercise, but has to be done in NZ by an MCNZ-approved notary. It is free. Once this has been done and paperwork approved you will receive a practising certificate.

On finishing work in NZ, contact the MCNZ to let them know. If you are even considering returning to work in NZ again, they recommend remaining on their register as a non-practicing clinician (equivalent to relinquishing your license to practice but staying on the GMC register). This is currently free.

(b) GMC Licence

As an aside, it is worth considering what to do with your GMC licence. There are three options:

• Keep your licence: you’ll pay full fees, but be eligible to work in the UK (including as a locum). You’ll also have to revalidate annually i.e. complete an annual return. This either means getting your current designated body to agree to keep you on their books and doing your revalidation meeting OR paying a fee to the GMC to do it.
• Relinquish your licence: you won’t have a license to practise medicine in the UK, though you’ll keep your registration with the GMC. You’ll pay less in fees. It costs £10 to relinquish your license and £10 to reinstate it. You won’t need a designated body nor have to complete an annual return. To reinstate your licence to practise you will need to provide statements from employers since relinquishing your licence and a certificate of good standing/professional status from the medical council(s) you have worked under (e.g. COPS from MCNZ currently costs 220.43 NZD [March ’23]). You will also need a completed UD8 form.
• Relinquish your registration: you won’t have a licence to practise and you’ll be removed from the GMC list of registered medical practitioners. Not really the done thing unless you’re leaving medicine entirely or plan to never return to the UK to practice medicine. You can re-register, but we wouldn’t really recommend this option.

More information can be found on the GMC website under Revalidation.

(c) Certificate of Good Standing

You will be asked to provide a Certificate of Good Standing (a.k.a. Certificate of Current Professional Status; CCPS) from the GMC. This is for the MCNZ to verify you haven’t been struck off etc. The certificate sent must be within 3 months of your start-date for work. If you apply too early, you’ll have to re-apply to get one within that 3 month time frame. It is free. It is an electronic certificate that is sent directly to the MCNZ. You do not have to carry, print or hand it in. Simply request it and the rest happens automatically.

To request one, log into your GMC Online account. Then follow: My Registration ⇒ My CCPS Request ⇒ Request a CCPS.

(d) Visas

There are three main visas on which you can work: Working Holiday Visa, Straight to Residency Visa and Accredited Employer Worker Visa.

For those not looking for a permanent move, the oxymoronic Working Holiday Visa is your best bet. You must apply for one before you get a permanent job offer. You can apply for 12 months (455 NZD) or 23 months (910 NZD). For the 12-month visa, you may need a CXR depending on time spent in TB-endemic countries. For the 23-month visa, you will need a CXR and medical as above. Our understanding is that once 23 months has elapsed, you will not be eligible for a further Working Holiday Visa again in the future. Getting a Working Holiday Visa is quick; can be within 2 weeks. Time on a Working Holiday Visa does not count towards residency and citizenship requirements.

From July 2023, Working Holiday Visas are open to UK citizens aged up to 35 and can last up to three years.

For those planning to be in NZ longer term, the Straight to Residency Visa is an expensive but efficient choice. Doctors are “Tier 1” roles that New Zealand wants. As such, they have introduced a 2-year fast track to permanent residency. It costs 4890 NZD to apply for from the UK and will take at least a couple of months to be approved. You will require a full medical and CXR. After your two years, you can apply for permanent residency. This beats the six years for most other professions.

The middle ground between these two is the Accredited Employer Worker Visa. This is a three-year work visa linking you to a specific job. Due to the changes to Working Holiday and introduction of Straight to Residency, this is unlikely to be your best option for short or long term.

Some of you will have partners who aren’t doctors but are coming with you to New Zealand. We recommend visiting the New Zealand immigration website which has all of the above information and more.

(e) Occupational Health (OH)

You will fulfil most OH requirements just by having the required immunisations for F1/2 in the UK. There are, however, some differences which require you to have extra tests and possibly vaccines. These are free from the OH department at your employing trust, so don’t shell out for them at home privately! TB – Unlike the UK, BCG scar is not evidence of adequate immunity against TB. OH will want you to have a Quantiferon Gold test. If this is negative, no dramas. If it is positive, they will want you to have a CXR as evidence you don’t have pulmonary TB. If you have had a CXR for visa purposes, you can send them the [normal] report from this; you won’t have to have a 2nd CXR.

VZV – A positive history of chicken pox is likewise not considered adequate immunity, so you will have to have a VZV antibody titre. Presumably if this is low, you will be offered a booster.

(f) Indemnity

You will need professional indemnity cover to work in NZ. Have a look at the indemnity insurance page on the NZRDA website. The NZRDA are the Kiwi equivalent of the BMA.

There are a few companies that provide indemnity; it’s best to check out which is right for you. Options include MPS-NZ, NZMII and Medicus.

We went with MPS-NZ. If you are already an MPS member in the UK – you can transfer your membership across to NZ. You won’t have to pay any new fees if you’ve already paid for the year. There are certain criteria you have to fulfil for this to work – one of which is retaining your GMC registration (but not license). If you aren’t already an MPS member in the UK, you’ll have to create a membership and pay the subscription fee for your cover (this can also be claimed back once you start work).

5. Things You’ll Need To Live

(a) Accommodation

Accommodation can be tricky to sort as you arrive in a new country. It’s best to arrive early and get stuck in to finding somewhere to live as soon as possible. TradeMe is a good bet for both rental property (via ‘Estate Agents) or ‘Flatmates Wanted’ i.e. renting a room in a pre-existing household. There are also Facebook groups e.g. ‘Auckland Flatmates Wanted’. The other option is renting via an estate agent directly; the big ones (in Auckland) are Barfoot & Thompson, Ray White and Harcourts.

In the interim, staying with friends, friends-of-friends or Airbnb are good options. You will need an NZ address for many of the things below, including bank accounts, IRD numbers and car purchase/insurance. Best to ask someone you know (well) if you can use their address for official things – others have had success using Airbnb addresses.

Be aware that many properties come unfurnished and may not have white goods. Everything can be purchased through TradeMe at reasonable rates.

(b) Bank Account

You’ll need an active NZ bank account for your wages (these cannot be put into international accounts), as well as for your IRD number and day-to-day living. There are a number of different banks you can choose to bank with (see ‘Banks’ under Useful Websites). The banks all seem much-of-a-muchness; we personally went with Westpac as we had them recommended to us and it was extremely smooth.

We recommend you apply for your bank account in advance of your arrival in NZ. You can then arrange to have it activated (requires a meeting at the bank in person) on one of the days soon after your arrival, meaning you’ll avoid having to use UK cards etc.. You are also able to transfer money into your account in advance of it being active. This means that on the day you activate it, you’ll have money ready to go! For international transfers, we recommend Transferwise.

All bank accounts come with an EFTPOS card – this is a non-personalised, non-contactless transaction card. It is linked to your account, can be used in most shops, petrol stations etc and to withdraw cash from ATMs. It does not work for online purchases – you will need to apply a debit or credit card for these. Our recommendation is applying for a debit (+/- credit) card during your initial activation meeting at the bank. You can also have it sent to the bank branch to collect if you don’t have a permanent address yet.

(c) IRD Number

The NZ IRD Number is the equivalent of a UK National Insurance Number. In theory it’s not a mandatory requirement to work, although without it all your earnings are taxed at 45% (and not retrospectively reclaimable if you get an IRD number later). You need to already be in New Zealand before you can apply; applying online gets you your number quickly (<1 week) versus the paper application (2-3 weeks). The IRD website has the details for applying, but you’ll need an active bank account to apply, so sort that out first!

(d) Health Insurance

Emergency healthcare is free at the point of contact. GP appointments are not, and you will have to pay for an appointment +/- extra depending on what they do. It is unlikely you will find a health insurance policy that covers you for the whole year. Most annual policies seem to last for just the first 90 days of any one trip. If you return to the UK within the first 3 months of your time in NZ, then fly back, it will reboot it – this is an expensive option however!

(e) Car

The public transport systems in NZ are pretty woeful compared to most of the UK, certainly compared to major UK cities. Inter-city trains are virtually non-existent. Within cities and towns, there will be variable bus and train networking. Auckland has the best train network, though it is still relatively poor.

If you plan on doing any sort of travelling in-country, you will need a car. The car market in NZ is slightly odd – the bulk of it consists of Japanese cars that have been imported (seemingly because Japan has an extremely strict M.O.T after a few years, which is so expensive most people just sell their cars to exporters rather than have it done). The bonus of getting a second hand car of Japanese make is that they tend to be cheaper (as there’s a big supply) and if they do break, spare parts are plentiful. By comparison, European makes such as Volkswagen are less plentiful, tend to be a bit pricier and are more expensive to fix. If you don’t require one day-to-day, it may be worth just renting a car or camper van for when you do want one! If you need one day-to-day, there are a few places to get one from:

• Car Fairs: These are pre-organised days where people bring their car and try to sell it. The upsides are that you can see loads of cars at once and can negotiate a price individually. The downsides are the quality is very much dependent on who pitches up to sell on the day, as well as the usual downsides of buying privately rather than through a dealer. You’ll have to find the nearest car fair to where you’ll be working/staying, but as an example in Auckland they have them every Saturday (Auckland Central – www.aucklandcitycarfair.co.nz) and Sunday (Ellerslie).
• TradeMe: TradeMe is the hub of most internet buying/selling in NZ. It is sort of a lovechild of Gumtree, Ebay, Freecycle and Amazon. With respect to cars, both private dealers and car dealerships will put cars up for sale on TradeMe. The same pros and cons apply as above; it can be good for seeing rough pricing estimates etc.
• Car Dealerships: There are loads out there, from make-specific new car dealerships to generic second hand dealers. The bonus of a dealership is that they’ve got their reputation on the line, so are less likely to try and rip you off. There are also some consumer rights that mean if your car implodes within a “reasonable time frame”, the dealer is culpable.

Car Insurance is not actually mandatory in NZ! Although it is obviously recommended. It tends to be cheaper than back home (approximately half the price of UK insurance). If you have car insurance, anyone over the age of 25 with a licence can drive your car for free without being named on the insurance policy. The excess tends to be greater if you have had an NZ licence for less than 2 years (or don’t have one at all). There are lots of insurance companies available; the AA is a popular choice.

In NZ the MOT is called a “WOF” (Warrant of Fitness). It is done annually, is cheaper than an MOT ($50-80), and can be done in most garages. If you’re buying a car, make sure its WOF is up to date. If not, take this into account for pricing.

Road Tax is called Registration (or “Rego”). It’s more expensive than the UK, though still not loads. As with the WOF, make sure the car you buy has an up-to-date registration.

Pre-purchase inspection. The AA do two levels of car inspection. Most dealers will say their car has “passed AA inspection”, which basically means it has 4 wheels and a chassis. There is a more detailed inspection called a Pre-Purchase Inspection. It costs $209, but gives a thorough run through of the mechanics etc. of the car. Worth the dollar if you’re set on a car but want an eye cast over it.

(f) Phone

There are fewer available phone networks in NZ. The big brands are all much-of-a-muchness, though it’s worth scouting which one will be best for you. Vodafone, Spark and 2Degrees are the three main brands; anecdotally Vodafone and Spark have the best network coverage.

(g) Student Loans

If you have a student loan there is unfortunately, no escaping paying it off. It is worth contacting the student loans company before you go to organise this as friends that didn’t got hit with a large bill on their return.

6. Things To Know About Work

(a) Annual Leave

For House Officer roles, leave is:

• 30 days annual leave; max 2 weeks in a row, can split however you like between rotations.
• Leave can be taken on any shift, although they can turn down normal leave requests for out of hours shifts if needed for staffing
• STILL/STAT days; the NZ equivalent of ‘days in lieu’, these are earned by working public holidays. You can take them at any time and, if 2 weeks notice is given, they cannot reject your request.
• If you would like a long weekend, request the Friday off before you get your rota. This guarantees your weekend off.

If you don’t take all your leave, you get paid for the leave you don’t take. For example, if you only took 28 days leave in the year, you will be paid 2 days worth of salary (at the rate of your most recent job). If you use up all 30 days, you are allowed to take more leave, though it is unpaid and still has to be approved in the same way. If you move jobs within a DHB, or to a different DHB, your remaining leave can be transferred. This process takes some time, however, so you may not be able to take it straight away.

(b) Study Leave and Courses

At house officer level you have 5 days study leave during an academic year. It has to be approved in the same way as annual leave.

You will be reimbursed for courses you go on if they are deemed relevant to your job or your training. This isn’t clearly defined – best option is to find a course you want to do, ask your employer in advance whether they’ll refund it, then book on if they say yes. You can do many of the courses that are recognised internationally e.g. ATLS, APLS – if you want to do these and/or need them for applications, may be sensible to get them done in NZ for free!

(c) Portfolio

No portfolio is required until you have your general registration (which will be after six months of work with completed sign offs submitted to the MCNZ). You will, however, have to have a completed RP3/5 form for each run within this time period (usually two runs if a house officer, one if a registrar). These forms must be signed by the supervisor named on your MCNZ provisional license certificate; if this supervisor hasn’t directly worked with you on the run, their countersignature will do.

At six months you will complete a change of scope form, to apply to switch from provisional to general registration. Your named supervisor will also need to sign this change of scope form in the same fashion as above. Ensure that they are happy to provide future references, as many UK jobs you return to will require references for all jobs you have done in the last five years.

Once you are eligible for general registration, the MCNZ will contact you and explain how to set up ‘Inpractice’. This is their eportfolio equivalent; a less time consuming version of the UK ones.

(d) Swapping Jobs

In theory you are able to swap any of your rotations. To do so you need to fill out a swap form stating which rotation you have and which rotation you want to have. You are most likely to get a swap approved if you can find a reciprocal swapper. You can, however, submit a form without a pre-organised match and hope they’ll pair you to an anonymous swapper. Ask your recruiting DHB who to email and for a swap form if you get dealt a rough hand.

If you begin as a House Officer and want to upgrade to a Registrar this can be done; you’ll have to have an offer of a Registrar job and also give 3 months notice on your House Officer contract.

(e) Bonuses

There are loads of other bonuses you can claim once you begin work. Examples include claiming 1.5x pay for working public holidays (on top of your existing salary and banding) and claiming ‘additional hours’ if your co-worker calls in sick (on top of your existing salary!). You are also guaranteed at least one free hot meal per shift. In some hospitals this translates to a totally free canteen; just swipe your ID to “pay”.

(f) Pay

You are paid fortnightly! Your income tax is deducted at source; there is no tax-free allowance in NZ. You do pay pension contributions though can claim these back when you exit the country. As in the UK, each rotation has a different banding (called Category).

See below for the current annual House Officer, non-urban, non-shift work pay scales (in NZ Dollars). In our experience, F3’s are paid at Year 3 rates with urban and shift work scales being higher. Registrar rates will differ but can also be found in the MECA agreement.

Non-urban scales apply at Northland, Lakes, Taranaki, Tairawhiti, Hawkes Bay, Bay of Plenty, Whanganui, MidCentral, Wairarapa, Nelson Malborough, South Canterbury, West Coast, and Invercargill Hospital-based runs at Southern DHB.

If you start or finish work any time except the start/end of the NZ tax year (April to April), you may be eligible for a tax rebate. This can be done online via Inland Revenue at the start of the following tax year.

7. Fees and Finances

The process of setting yourself up for work and life in NZ is not cheap; you will need a chunk of money to cover the initial costs. A rough estimate is below – we have erred on the side of expense but in reality may be cheaper. (All prices are converted into £ at a rate of $1.95 NZD = £1).

In order to start work, assuming you opt for a 12 month working holiday visa, with CXR required and paying a notary, and get a phone sim on arrival, minimum costs are:

In addition to this you will need to consider the cost of a car (in the region of £3000 if you buy it outright) and permanent accommodation (typically in the region of £400-650/month, estate agents usually require 1 week’s rent in advance, 3 weeks deposit and a letting fee, which is usually 1 weeks rent plus tax).

8. Useful websites

Locum / Recruitment Agencies

locums.co.nz – Gold Standard Locums

www.apac.medacs.com – MedAcs

www.triple0.com – Triple0.

www.medrecruit.com – MedRecruit

www.headmedical.com – Head Medical

Banks

www.westpac.co.nz – WestPac

www.bnz.co.nz – BNZ

www.anz.co.nz/personal/ – ANZ

www.asb.co.nz – ASB

Miscellaneous

Auckland Doctors – Information on childcare, education, moving your pets, relocation companies, tax, transport etc. Courtesy of the Auckland Doctors website.

Trade Me – Listings for properties, cars and all general items

Triple0 – Guides to relocating as a junior/specialist/GP, locuming, living and working in NZ and more.

9. About the authors

Shona and Will were F3/4s in Auckland when they originally wrote this article. Before their Antipodean adventure began they mixed locum work in A&E with cycle touring, traveling and simulation/emergency teaching in Uganda with the Poole Africa Link.

Jamie is an F4 working as a paediatric SHO in Wellington having worked in Southampton Children’s Emergency Department during his F3 year. He plans to stay in New Zealand for now.

The post The Definitive Junior Doctors’ Guide to Working and Living in New Zealand appeared first on Adventure Medic.

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

The post Diving: Managing Decompression Illness in Remote Locations appeared first on Adventure Medic.

Working away from the hospital is often a source of inspiration. We get the chance to see the world from a new angle and that can spawn all sorts of interesting ideas. However, it is a rare individual that can turn a moment of inspiration into a real object that makes a difference to people’s lives. Tim Jeffrey was one of the founding members of i-am associates, an international branding consultancy based in London. In 2013, he was inspired by news reports of suffering around the world to create the Bottleshower, which is helping the victims of acid attacks, burns and even chemical weapons around the world. This is how it happened.

By November 2013, life in the war zones of the Middle East continued to go from bad to worse. British and American troops were trying to extract themselves from the dust bowls of Helmand Province Afghanistan, the Syrian Government had just bombed the city of Aleppo and to cap it all a typhoon devastated the Philippines leaving people homeless and knee deep in debris.

I was watching the news one day, and was left with an indelible image, starting a mission that would pretty much consume me for the following five years.

The programme had included a report from a hospital somewhere in Aleppo showing a mother with
her young son in her arms who stood like ghostly figures covered in powdery grey rubble dust. He had suffered terrible blast burns. As she screamed for help for her boy amid the turmoil, she took a bottle of water from a trolley and poured it over her son’s arms and legs in an attempt to ease his suffering. She was desperately trying to clean his wounds, but the pressure of water made him literally jump out of her arms. His look of pain and desperation moved me deeply.

The bulletins came thick and fast, the next showed British troops on the frontline dealing with extreme temperatures pouring bottles of water over their heads as momentary relief to ease their discomfort. The one valuable asset in both these clips other than life itself was water and at some point in all of this I started to wonder if there was a better more effective way to use this bottled asset to help those I had witnessed in these and other disaster zones. Could I make a difference? Could I actually give something back? If I could, it would have to be my time and money with no one to blame if I fell short.

So that’s how my quest to find a better way to use bottled water when washing started. The picture I had stuck in my head was of a shower flow from a bottle. It looked to me like a good idea. So good in fact that it must have been done already.

The potential market I envisaged would be the Red Cross and similar relief organisations that needed to distribute bottles of water as a primary solution for personal washing and preparation of food. Having such a strong feeling about the potential I spent the following weeks researching the idea and looking for products that fulfilled my brief which was simple: a showering device that would work with any plastic drinking water bottle, provide a proper shower stream and extend the flow time, while being compact, light and affordable.

To my surprise all I found fell short of the target. So, the question was how to develop the idea into a solution that would be so good it would be unthinkable not to use one when faced with extreme circumstances. However, before I sank my time and money into this project it had to have a reality check. I took the idea to my Patent Attorney in London, explained the idea with a couple of sketches showed him my research, then sat back and watched his reaction. His conclusion was a good, simple, idea, defendable with patents if I could make it work, makeable and marketable.

Simple does not mean easy

I read somewhere that simple doesn’t mean easy. How right the author was. Six months later I had a solution that fitted every commercial narrow neck bottle available, created two calibrated shower flows multiplying the flow time up to ten times, a working model of both and found UK manufacturers and suppliers for all of the components at the right price. The trail of discarded handmade prototypes was long and painful. I had made so many that failed miserably that at times I had wondered about giving up on the idea.

After further Patent Attorney meetings and having filed all of the necessary patent applications, copyrights and trademarks, I proceeded to hawk 3D samples of the Bottleshower (now, Bottleshower TM!) heads around to a long list of targets. I did the full marketing card of mail shots, sampling and meetings. Looking back, there is no other way to describe this period other than to say it was a long road with lots of dark tunnels and very little light. I was asked recently if I had any moments of doubt about the project to which I replied only once, “2014”.

Gathering momentum

By the beginning of 2015, I had secured orders with one of the largest travel accessory companies in the UK with agents throughout Europe. They had seen the potential for a solution to showering using limited supply of water, even a shower with just one litre in extreme circumstances. Very positive press coverage in the nationals and travel journals in 2016 saw further interest and subsequent orders from other agents and retailers. However, despite my determined efforts to get a major relief agency on board, success in this sector still eluded me. The lack of traction was only partially eased by the positive feedback from agencies that had sampled it in the field, including trials in a Syrian refugee camp and by aid teams in Africa. By the summer of 2017, I had an awful lot of carrots but very little meat.

The year 2017 saw a terrible upsurge in in gangs using acid as an attack weapon in the act of robbery on the streets of our capital city. The effects were terrifying for the victims, as acid was usually sprayed in the face, leaving horrendous scar tissue if not diluted quickly. The evening news reports showed the Metropolitan police having to deal with the situation as best they could by pouring water over victims from large five litre bottles, before the fire brigade took over using their hoses set to trickle. It was painful to watch, the victim in sheer panic with the police doing the best they could. Nevertheless, the Met adapted quickly, gloves and goggles were issued to protect themselves from the splashing effect of the corrosive substances.

As I read and watched these attack reports, I felt very frustrated by the way they were attempting to pour water over victims and potentially doing more damage, I knew the Bottleshower could do a much better job but how could I get the opportunity to convince them? Travelling home one evening from London on the train, I picked up a copy of the London Evening Standard and read yet another report on the devastating acid attacks plaguing the city. The Met now had an officer in charge of corrosive crime, Detective Superintendent Mike West, whose responsibility it was to take control of deterrent, protection and treatment. I now had a name.

Calling the Police

After several days of trying to contact Mike West I was getting nowhere. I was desperate to help prove I had a better way to help dilute, cool and remove the corrosive substances being used but I needed another way in. I contacted the London Evening Standard and told them I had a product that would help the Police and victims of acid attacks but couldn’t get through to the right people at the Met.

The reporter I spoke to said he was interested in pursuing the story and if he thought it was as good as I said from information I sent him, he would contact the Met to see what they thought. A week passed by, very conscious that even though I thought I was the most important thing in his world, I was probably some way down the list. I kept on bugging the reporter for an update but nothing came back. This is the world of reporting, I thought: get the story, get it on the page, move on. What more could I do?

On the evening of Tuesday1 August 2017, I picked up my copy of the Evening Standard and found a seat on the train. Page two of the paper ran yet another headline ‘Acid attack horror outside Harrods’. The picture said it all, I thought as I read the article then the sub story, ‘MET to test bottle shower for burns as it issues kits’. It went on to say that the head of the Metropolitan Police’s Corrosive-based crime unit was to meet me to arrange the trial. I was pleasantly shocked, surprised and confused. It was the first I’d heard of it, but I could hear the creak of a door opening.

Over the next month I was eventually able to talk to Mike West, who passed me on to the Threat Mitigation Technologies Team for assessment. It transpired was that the Met used the large five litre bottles and had decided this volume of water was the way forward. The Bottleshower didn’t fit five litre containers, as I had designed it for narrow neck bottles. It could have been the end of the road but they were sufficiently won over to ask me to go away and make it work to their specification.

The turning point

Two weeks later, I went back with a solution that passed the test. They were decisive and within two months, all of the Met’s response vehicles and static security posts were equipped with Corrosive Attack Kits featuring the five litre Bottleshower. Subsequent operational feedback was positive, the Bottleshowers were making a difference when washing victims, as the shower stream was directable. Rather than water all over the floor, an uncontrollable burst or a dribble of water, there was a four-minute constant strong shower stream. This was a turning point in my journey.

In 2018, I was approached by Scott Howard, Head of CBRN Resilience for West Midlands Police, who was putting together a Decontamination Kit with SP Services. He wanted to include the Bottleshowers based on feedback from the Met. Following this and other police requests, the Bottleshower is now recognised by Police forces and both the National CBRN Centre and British Burn Association, as the best way to deliver water from a bottle when used to irrigate burns and wounds.

The challenge is, of course, by no means over but my mantra is clear. If you use a bottle of water to wash with, you need a Bottleshower. My focus is now on medics and the military, with versions that fit the Pattern 58 Osprey MOD/NATO water bottle, as well a range of specialised sterile water bottles used by medical teams. In fact, anyone that uses bottled water to shower, wash or irrigate. It’s a long list that just gets longer, but relief agencies are still up at the top.

When I reflect back, it’s ironic that a devastating crime provided the springboard for getting the Bottleshower into the spotlight. However, if it has helped to make a difference, it’s fulfilled the purpose I set out for at the very beginning. For that, I am truly grateful.

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The Wilderness Medical Society have published a free ‘cut out and keep’-style double sided card, summarising the key elements of hypothermia evaluation and field care for laypersons, trained rescuers and first responders. The full text paper explains its design and evolution, alongside high-resolution printable images of the card. We thought the card might be usefully distributed to participants on our next winter expedition.

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Katie Beck is a Registered Nurse with a specialist interest in Emergency, Expedition and Travel Medicine. She has worked on a number of overseas expeditions and in remote environments, and is currently Medical Co-ordination Manager and Deputy for Safeguarding at Raleigh. In the second of our articles on safeguarding, Katie builds on Jono Oldershaw’s article on safeguarding vulnerable adults and younger people, exploring the role of the medic in protecting everyone involved with expeditions from maltreatment.

Safeguarding: A Broader Definition

Safeguarding has traditionally been the term used to describe ‘the action that is taken to promote the welfare of children and vulnerable adults, and to protect them from harm’ (NSPCC). However, increasingly the term ‘safeguarding’ is no longer only used in the context of protecting children and adults who meet a pre-defined criterion of ‘vulnerable’. Ever broader definitions are being adopted that recognise vulnerability is relative and aim to protect everyone from harm, whether perceived as vulnerable or not. In practice, safeguarding now refers to all incidents of harm that occur as a result of maltreatment or abuses of power. For example, sexual assault or harassment, exploitation or domestic violence.

Recently, The Charity Commission released a new definition of safeguarding as ‘the range of measures in place to protect people in a charity, or those it comes into contact with, from abuse and maltreatment of any kind.’ Protecting Children and Vulnerable Adults remains a fundamental part of this and for more advice on how to do this, see Jono Oldershaw’s excellent article here. However, this particular article will focus on how medics can ensure necessary steps are being taken to protect everyone involved with expeditions (both directly and indirectly) from maltreatment.

An Organisational Approach

Whoever you work with or volunteer for, big or small, safeguarding should be at the centre of expedition planning and ingrained at every level of the organisation. Responsibility for safeguarding should be shared by the safety team as a whole, and everyone taking part in the expedition should know how to raise concerns. However, expedition medics should pay particular attention to safeguarding, because although these issues are not purely medical, there are often medical elements to them (both in terms of mental and physical health). While in an expedition setting, people often approach the medic first following a safeguarding incident. If organisers fail to consider safeguarding at the planning stage of the expedition, there is a danger that issues may be left for the medic to deal with alone. It is therefore in a medic’s interest to ensure that adequate procedures, time, support and training are available to ensure the correct handling of the situation.

There will always be a risk of harm occurring during an expedition, but there are several questions you can ask to ensure the organisation is doing everything they can possible to safeguard participants, staff, and locals alike:

Is the risk of harm recognised?

People participating in expeditions or overseas projects may be particularly vulnerable to sexual harassment and assault. Groups are tight-knit, often away from infrastructure and law enforcement, outside their usual safety and support networks, in a country with different culture and laws, and they are often reliant on one or two individuals for their safety. Certain demographics might also be more at risk, for example women and those from marginalised communities such as LGBTQI+ and ethnic minorities. This is particularly true in countries and communities with significant cultural differences. It is important to realise that the group are not the only people at risk, expedition organisers should also take seriously their ethical duty to protect those the expedition will come into contact with. Disparities in wealth and attitudes between locals and expedition members may leave local communities vulnerable to harm and exploitation too, as highlighted in a number of high-profile cases recently.

Organisations routinely risk assess physical dangers, and increasingly psychological ones too. However, there is often a blind spot when it comes to the risk of safeguarding issues, perhaps because risks are not obvious, are often human, and can be taboo. When creating a risk assessment, careful thought should be given to the potential for individuals to perpetrate sexual, financial, physical and emotional abuse. Remember that leaders, members, locals and anyone else that comes into contact with the expedition have the potential to be both to be victims and perpetrators of harm.

Thought must also be given to the types of projects undertaken and the potential for contributing to wider institutional abuse. For example, visiting or volunteering in orphanages should be completely avoided: see here for why.

It is impossible to mitigate against all risk of abuse, but there are some steps that can be taken reduce the risk, which we explore below.

Is there a Safeguarding Policy?

Policies will be tailored to the specific context of expeditions, but every expedition should have something. It might not be called a ‘safeguarding policy’ (although increased awareness of safeguarding would make this an example of good practice) but, there should be something that outlines the steps that are taken to protect children, vulnerable adults, and the wider population from harm and maltreatment. ‘We don’t need a safeguarding policy because we don’t work with children’ doesn’t wash anymore.

Is there a Code of Conduct?

Safeguarding aside, a code of conduct is a medic’s best friend, as so many medical incidents on expeditions can be avoided by people behaving well! It may feel patronising, but by establishing boundaries early you help to foster a culture of respect and leave no excuse for poor behaviour in the future. It should outline the expected standard of behaviour during the expedition and could include reference to:

• The consumption of alcohol and other drugs
• Adherence to safety protocol
• Respect for others
• Equal opportunities
• Acts of violence
• Respect of local traditions and customs
• Working with children
• Illegal activities
• Relationships between leaders and participants

Codes of conduct should apply to all members and be available for reference throughout the expedition. It can be a useful tool for nipping any inappropriate behaviours in the bud before they escalate. The code of conduct should also clearly state the consequences of infractions.

Are the staff and participants suitably background or reference checked?

Knowing to what level this has been done may help reassure you that safeguarding is being taken seriously. The level of background check that is suitable will depend on the context. If you are on commercial expeditions or expeditions that are not working with children or vulnerable adults, Disclosure and Barring Service (DBS) checks for participants may not be appropriate or possible. Similarly, if staff or participants are from outside the UK, background checks may be difficult to obtain. However, some considerations should be given to ensuring staff, and wherever and whenever possible participants, are of good character and unlikely to present a risk to others.

Are staff and participants trained in safeguarding?

Ideally organisations would incorporate safeguarding into Health and Safety briefings for an expedition. This would ensure consistent and mutually understood routines and procedures. Topics that should be covered include:

• The concept of safeguarding
• Responding to and reporting a disclosure
• Recognising and reporting safeguarding concerns
• Consent
• Code of Conduct
• Diversity and inclusion

Are there any specific risks that should be mitigated in particular ways?

Every group and environment are different, but examples of things that should be considered are:

• Suitability of accommodation and gender mix
• Minimising interaction with children or vulnerable adults, or ensuring boundaries are established prior to interaction
• Privacy and security, especially at night or around washing facilities and toilets
• Local laws or practices that may pose a risk to some members of the expedition e.g. anti-homosexuality laws or attitudes to women

Is there clear documentation and are reporting processes for safeguarding concerns explicit?

You should be clear about how to document concerns and if, when, and to whom they should be referred. Consideration should be given to:

• Confidentiality and consent for information sharing
• Statutory obligations (for children and vulnerable adults)
• Routes of communication with the outside world
• Alternative means of communication

If an expedition leader is the only means of communication with the outside world and they are the perpetrator of harm, then the organisation has created an unsafe situation.

Only when you give someone a voice will they use it. Reporting of incidents is rising, probably not because incidents are more common, but because people feel more able to report, and feel that expedition providers/employers have more responsibility to support them.

How are safeguarding concerns responded to?

This is a particularly important question for medics to ask as often they will play a critical role in the response to more serious safeguarding incidents. Some things to consider are:

• Mental health support plan: What resources do you have for supporting mental health? This is everything from mental health first aid to local services, and specialist over the phone psychological support.
• Plan for the reporting of safeguarding concerns about children or vulnerable adults: more here.
• Plan for referring or signposting adults to services.
• Plan for reporting to local police and services
• Serious sexual assault response plan. Serious sexual assaults can be incredibly difficult to deal with whilst on an expedition. This is exacerbated without a good pre-existing plan in place. You are likely to have limited access to specialist medical and psychological resources and could be working in a country with a radically different legal infrastructure and attitude to sexual assault.

A Sector-Wide Responsibility

The world is waking up to the fact that abuse, especially sexual abuse can happen anywhere and to anyone. Most recently, the Oxfam Scandal and the #metoo movement have shown that no sector is immune. Expedition organisers need to learn from this, recognise their responsibility, and be prepared and equipped to protect not just their participants, but all of the people their programmes come into contact with.

Further Reading

Whether the expedition provider is a charity or not, this guidance published by The Charity Commission gives clear and practical advice which is relevant across many sectors.

Photo: Katie Beck.

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What about a career in the sky? The Helicopter Medical Careers Conference promises to answer any questions you may have about a job in aeromedicine. This event is for students, paramedics nurses and doctors interested in helicopter retrieval. It will be held at Glasgow University on 23 March 2019, organised by Dr Stephen Hearns, an internationally renowned as an expert in the field and lead clinician for Scotland’s Emergency Medical Retrieval Service.

Doctors, paramedics and nurses will share their experiences of practicing in this exciting and rapidly expanding medical speciality. They will let you know how they trained for the role, how they made helicopter medicine into a career and how it feels to work with the world’s leading helicopter services. The day aims to inspire those with a passion for helicopter medicine and guide them towards a career in the speciality.

More information on the programme and speakers can be found here.

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We all know that teamwork and communication can make or break an expedition. So what affects how your group gels together in the field? Dr Nathan Smith is founder of the online School for Psychology in Extremes, In Extremis. A Fellow of the Royal Geographical Society, Honorary Lecturer at the University of Exeter Medical School and a former research scientist at the UK MOD Science and Technology Laboratory (DSTL), Nathan is ideally placed to give us an overview of the factors at play.

Medics work in some of the world’s most demanding environments. Think of those providing humanitarian support in low-resource camps in Syria and the Yemen, those offering their services to high-altitude expeditions in the Himalaya, tactical medics operating as part of a Medical Emergency Response Teams (MERT), or the solo medic relied upon for keeping a small team healthy during prolonged endurance endeavours through desert, jungle and polar environments.

In these examples, the medic will invariably have to work as part of a team often operating under intense physical, psychological and interpersonal stressors. It is likely that the team will be made up of people with different characteristics, including varying degrees of experience and a range of specialties, as well as diversity with regards to age, gender, culture and background. Inevitably, in such diverse groups, there will also be individual differences to consider, including the personality, motivation, goals and needs of the team members.

These different team composition factors may impact on your own performance and on that of your team. Understanding them can help during pre-departure preparation and feed into your own group risk assessments (whether they be formal or informal). This type of pre-planning may then help mitigate or manage interpersonal difficulties that arise as individuals become tired and fatigued, when social tensions start to emerge in demanding, challenging or hostile environments.

“When effective teamwork exists, people speak of uplifting experiences and of achievements beyond their expectations. They speak of a synergy that occurs in well-functioning teams that allows them to achieve more than the individuals themselves could have achieved. They speak of the experience as being life-changing and rejuvenating.”

Pamela Lupton-Bowers, Teamwork in Humanitarian Missions, 2003.

When considering team composition issues, it is useful to break these areas down into what are termed surface- and deep-level characteristics. Surface-level characteristics are those attributes or demographic criteria that can typically be observed (think age, gender or race). In contrast, deep-level characteristics are those that are more internal to an individual and are likely to have a more enduring impact on team and group function. Examples of deep-level factors include personality, personal values and motives. Consistent with the complexity of studying teams and groups, there are also a variety of other-related characteristics, including group size, leadership and issues related to cohesion that can impact upon individual performance and health.

Surface-level characteristics

Age / A large age-range between members of a group can be a source of tension, likely related to differing levels of experience. Younger or less experienced group members are likely to be learning how cope with the demands of the environment, whilst older and more experienced members may find the situation routine, or even mundane.

Gender / Mixed-gender teams tend to function harmoniously in extreme environment settings. However, it is worth noting that unconscious biases have been linked to the assignment of gender-stereotyped roles, which can be a source of stress. Single-gender teams tend to have their own challenges. In the past, all-female teams have been observed to be generally emotionally-supportive, however acknowledged that this concern for teammates can be a source of stress. All-male teams have been found to be competitive, sometimes to their detriment, but generally cooperative and functional.

Culture / Understanding culture in teamwork has been the focus of many extreme environment studies. This is particularly relevant to international space crews, which often include members from various nationalities. Issues related to culture can be a source of tension, especially when those differences are more readily observed, such as with language. Culture is often associated with the desire for different types of leadership, adherence to and acceptance of rules, and styles of communication, which can all impact upon group function.     

Deep-level characteristics

Personality / Personality tells us what people are typically like and is linked to how they think, feel and behave. In extreme environments, the personality characteristics of agreeableness (having good interpersonal capacity), openness to experience (staying open-minded) and low neuroticism (emotionally-stable) are thought to be important for good group function over a long-period. Whilst it is not always possible to choose who you work with, trying to find out and understand what a person is like can help figure out how to get the best out of them and what impact they will have upon the larger group. In general, closeness on personality is a good thing but it can also be helpful to have a mix of characters. Encouraging tolerance of individual differences is critical for minimising conflict between members of the group.

Personal values / Whilst personality tells us what people are like, values indicate what they are interested in. Individuals are likely to endorse a variety of different values. In diverse groups, you might have one person that really enjoys new experiences, taking the initiative and going into the unknown. On the other hand you may have someone in the group who appreciates safety and security, is concerned with the welfare of other group members, and likes consistency and routine. Differences in values can be a source of interpersonal tension, especially during prolonged work with the same people, but can also be harnessed and used to celebrate the diversity of the group.

Needs / A person’s needs can be thought of as being complementary or supplementary. Complimentary-fit refers to needs that are different but well-suited. For example, you might have one group member who likes to lead and another that is happy occupying a follower role. Supplementary-fit refers to when you have consistency in group member needs. For example, all group members like to make the most of new experiences, are comfortable with uncertainly and happy operating with flexibility. Understanding a person’s needs can help inform the type of roles they occupy, who they might be asked to work with, and why they might act and behave in a certain way.       

Other-related characteristics

Group size / The larger the group the more productive it is likely to be. However, size also places a strain on resources, particularly if operating in an isolated and remote environment without the possibility of resupply. It may also be relevant to consider how working as part of an even and odd-numbered group might impact upon decision-making. In an even numbered group, there is possibility for decision-making deadlock if you are basing decisions on a group member consensus, and therefore an odd number may be desirable. It is accepted that larger groups (> 6 people) experience fewer problems than small groups. However, in expedition settings it is common to have smaller groups. In these settings, three-person crews tend to work better than two, but there is the possibility for one-person to become truly isolated and alone in the event of disagreements.

Leadership / It is typical for the role of the leader to change during activities in extremes. This is linked to the group adapting and being more comfortable in the environment. Early on, expect the leader to be task-focused and interested in ensuring everyone knows their roles and is completing tasks safely and successfully. Over time, the leader may move into a more social-focused role with the aim of maintaining connection between group members. The ability to both lead and follow is important in small interdependent teams, particularly when made up of a range of highly skilled people. This shifting of roles is a fluid process that can be encouraged during training activities.

Groupthink / A risk to groups that have been through intense shared experiences is groupthink. Groupthink occurs in highly cohesive groups and is reflected by members losing the ability to think critically and not questioning decisions in order to maintain the status quo. Groupthink is linked to poorer team performance and has implications for group safety. Individuals that do question the group can sometimes be ostracised and viewed as trying to break the group down. Trying to maintain objectivity, questioning assumptions and proposing alternative group-based decisions is healthy, when done at the right time in the right way.

How to use this information

Above, we have discussed a few of the issues related to understanding team and group composition in small interdependent teams operating in extreme contexts, such as those faced by expedition and extreme environment medics. The psychology of groups is endlessly complex, but you can use these factors in your medical preparation to raise awareness, engender a sense of tolerance and provide a starting point for diagnosing, discussing and appreciating why people might think, feel and behave in the way that they do. Of course, there are many other strategies that can be applied to enhance group cohesion, resolve conflict and improve task effectiveness. These will all be more effective with an understanding of the roles of surface- and deep-level team composition factors.

If you are interested in learning more about psychology in extreme environments, including identifying stressors, understanding personality, selection and training, monitoring performance and health in extremes, group dynamics, and post-expedition transition, reintegration and readiness then join Nathan at the online school, In Extremis.

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As an expedition medic, you may find yourself looking after vulnerable adults or young people. Safeguarding is an important topic on any expedition, but particularly so when your participants have additional support needs. Jono Oldershaw is a registered Social Worker with a specialist interest in international Child Protection, Mental Health and Offending. He has worked in a range of medical and institutional settings including prisons, youth offending institutions and refugee camps as a Social Worker, Healthcare Assistant and Healthcare Consultant. Here, he gives us some advice.

A brief mention of the words ‘child protection’, ‘vulnerable persons’ or ‘safeguarding’ can often be enough to stop any adventurous plan in its tracks. Caught in a spider’s web of red tape, the innovator concedes on all unknown aspects of their venture, culminating in a plan so moderated that it would hardly seem worth getting out of bed for.

However, you do not need to be an expert in safeguarding to make safe decisions on your next expedition. As a Social Worker who has worked nationally and internationally to protect vulnerable individuals, and informed UK safeguarding guidelines, here are a few tips on what to consider and how to keep both you and your expedition participants safe. So, before you become lost in risk assessments and paper work, think through the following practical steps, combined with a healthy dose of common sense.

Safeguarding is the action that is taken to promote the welfare of children and vulnerable adults, and to protect them from harm.

It means protecting children and vulnerable adults from abuse and maltreatment; preventing harm to health or development; ensuring the provision of safe and effective care and enabling all children and vulnerable adults to have the best outcomes.

(Adapted from NSPCC)

Pre-Expedition Preparation

Know your team

Before you can start thinking about safeguarding you must ask two simple questions: who is on the expedition and what unique needs might these individuals have? No one expects you to be an expert and fortunately there are loads of great resources to help you think about safeguarding your team. There isn’t room here to list them all but for children, the NSPCC and CEOP are great places to start; for adults, try SCIE and MIND.

Once you have characterised the likely needs of your participants, think about identifying any local resources you could draw on in case of any concerns during the expedition. For example, if your participants are from the UK and all reside in a particular area, it would be worthwhile arming yourself with the local authority’s adult and children services referral and assessment team contact details, including the out-of-office team. Take time to understand the local support structures present in your destination, and be mindful of cultural context and its impact on safeguarding thresholds.

Hopefully you will not be alone. There will likely be an expedition leader, other staff and volunteers involved in your trip, so it is best to ensure these individuals have also undertaken a Disclosure and Barring Service (DBS) check and are appropriately trained.

Screen your team

If there are particular aspects of your expedition you feel might present safeguarding concerns (think conversation topics that could uncover difficult memories or imperfect sleeping conditions) then try to find out a little bit more about your participants before you go. A relevant and simple questionnaire in advance of departure is an effective way of doing some light checking on how comfortable your team is with the arrangements and whether they might wish to disclose any concerns.

Adapt your approach to reflect new information

Speak with peers, expedition leaders and support staff from the institutions your participants attend to gather as much information as possible. Understandably, some may be wary of saying too much under data protection legislation but most should be willing to provide some guidance, particularly if the information provided is not person-specific and cannot be used to identify any one individual. This information may be critical in assessing risk and safeguarding against any concerns, but will also likely prove useful for informing your approach to the expedition as a whole. If you can’t find an adaptation which helps to manage the known concerns, then it might be best to seek further advice from the team or review, in light of your internal safeguarding policy. If you don’t have such protocols in place: the NSPCC provides a very useful snapshot on what to include here, along with some examples.

Incorporate safeguarding concerns into your risk assessment

This way you have them embedded into everything you do rather than tacked on as an afterthought. Dom Hall has written a really useful article on risk assessments so I will say no more.

Share risk with your peers, don’t juggle it alone

Before you set off, be sure to discuss any concerns with the team. It may be that the buck stops with you or the expedition leader when it comes to owning risk, but sharing knowledge and understanding with the team will prove a critical tool in helping you to manage any issues over the course of the expedition. Remind everyone of their confidentiality duties and your expectations for reporting and recording incidents.

In-expedition activity

As a general rule, safeguarding trumps confidentiality.

Observe staff and participants

This one speaks for itself. You should keep an observant eye on both staff and participant activity throughout your expedition. Speak to the participants and set out clearly at the start how you will manage confidential matters and when information will be shared. If you do have concerns, you need to gauge the level of risk presented and decide what an appropriate and reasonable safeguarding response might be. If in doubt, it is best to choose the more severe response in order to be sure. As a general rule, safeguarding trumps confidentiality. Remember, if you can justify your decision at the time with the information presented to you then your response is most likely both measured and appropriate. Unfortunately, hindsight is a wonderful thing and sometimes you will be challenged.

Record niggling incidents

It often takes times for a full picture to evolve and you will be thankful for having recorded the details whilst your memory is fresh. Record any incidents, actions or words that are of note throughout the expedition. Often these events will be nothing to worry about but sometimes they can be helpful in piecing together a bigger picture when concerns evolve at a later point. If you are in a region with internet access and it was appropriate to the expedition, you could even identify a suitable incident form online and encourage all of the leadership team to use this format when noting down their observations.

Keep safeguarding on the agenda

Whilst safeguarding may be high on your list of priorities, it won’t be for everyone involved. It might not be until you ask the question that you come to hear about some relevant information. Incorporate a specified time for safeguarding conversations with the team both as part of your preparations and during your morning/ evening debrief on the expedition. This will help with recording concerns and ensuring your team are attentive to the needs of the participants.

Post-expedition follow up

Referrals

If you have information that you feel warrants a referral into social services, or perhaps is below the threshold but you still think should be shared, write it up as a concern and share with the relevant professional(s). Initially you should only share this information with a suitable professional on a need to know basis: this might be a school, GP, community support worker, social worker or the police. If you believe an individual is in, or at risk of, immediate danger then call the police, and follow up with a referral to the local authority safeguarding assessment team. Avoid sharing the information widely as the statutory professional will know how best to proceed. Where appropriate, speak to the individual or their family network first; the individual involved is the expert on their own needs and both children and adults are often very resourceful in meeting these needs.

Endings

Avoid on-going contact with participants unless appropriate to do so for your particular expedition. On occasion, individuals will struggle to understand professional boundaries and seek to connect via social media or extend the relationship unnecessarily beyond the expedition. Endings can be difficult but need to be managed in a clear and sensitive manner.

Reflection

Critical reflection is a great way to learn from your experiences and think more about your safeguarding practice. You might want to run a reflection session with the team to explore what went well and areas for improvement. This can be done just as effectively on your own. If you need some more guidance have a look at Gibbs’ Reflective Cycle, widely used by practitioners and easy to digest.

Further Training

The above should be more than enough to keep you and your participants safe on most expeditions. If you are looking to build your knowledge base further due to the nature of your expeditions or the heightened needs and vulnerabilities of your participants there are a number of training opportunities available to you. Again, SCIE and NSPCC will be well placed to advise on this. In the meantime, just remember: plan, record and reflect.

(Photos: Jono Oldershaw)

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The evening will also recognise the incredible achievements of Emily Penn, Oceans Advocate, Skipper and Artist; Vanessa O’Brien, Mountain Climber, Explorer and Speaker; and Mark Beaumont, Athlete, Broadcaster and Ambassador. All three will be presented with Honorary SES Awards. Now if those triads of achievements aren’t enough to impress you, try a quick internet search of these Goliaths of discovery, and you shall be rewarded with a lifetime’s worth of inspiration.

Tickets can be bought here and direct any queries to sally@ses-explore.org

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Dr Samantha Roper is a British doctor with a passion for humanitarian work, who deployed to West Africa during the 2014 Ebola outbreak. She was one of the doctors in charge of Save The Children’s Ebola Treatment Centre in Kerry Town, and subsequently returned to set up ebola survivor clinics for Médecins Sans Frontières. Sam describes her personal experience working with the local Sierra Leonean teams at the survivor clinics, and explores what lessons can be learnt from them about building resilience in preparation for future global health threats.

West Africa is just emerging from the most deadly outbreak of Ebola the world has ever witnessed. This will remain a tragedy of unknown proportions as many deaths will remain unaccounted for and many survivors will continue to suffer in remote communities where medical aid cannot reach. The epidemic has been particularly devastating for the people of Sierra Leone who have a long history of suffering, including the most recent flooding and landslide in Freetown which took another five hundred lives and displaced six thousand people from their homes. The effects of repeated disease outbreaks and a brutal civil armed war have left prominent scars that are still visible throughout the country today.

Despite this, and with ongoing political and economic threats to their daily struggle for survival, the people of Sierra Leone have demonstrated to the world what incredible strength and resilience is possible. During the height of the outbreak, Sierra Leonean healthcare workers continued to fight on the front line despite being at a disproportionately higher risk of dying from the disease. They often worked with no protective equipment to safeguard themselves, witnessing their patients and colleagues dying around them on a daily basis.

Stories from Sierra Leone

National Community Health Officers like Amara Sesay fought tirelessly alongside international and national health organisations to protect communities in some of the worst hit areas such as Kenema, where British nurse Will Pooley and American doctor Ian Crozier became infected. Amara described his experiences caring for his tutor Dr Khan, Sierra Leone’s lead expert in viral haemorrhagic fever who tragically contracted the disease from one of his patients at the beginning of the outbreak.

“I was terrified of going back to work after watching him die from the disease but my mother reminded me of the duty I had to care for my community and the people of my country”

All over West Africa we saw Ebola survivors return to work in treatment centres to help care for the sickest patients inside the Red Zone, even though this triggered traumatic memories of their own suffering. In view of what little knowledge there is about immunity and therefore the risk of re-infection, this was a powerful demonstration of the level of compassion and commitment the Sierra Leonean people have to each another.

Ebola survivors suffer debilitating fatigue and body pains, frequently associated with loss of both vision and hearing. Despite this they formed their own support groups and survivor networks in remote parts of the country where national and international aid could not reach. Aminata was deaf from birth and was admitted to Medecins Sans Frontiere’s Ebola Management Centre in Magburaka with two small children. She had already lost her husband and another child to Ebola and could only watch helplessly as two further children succumbed to the disease.  In her village more than fifty people had been infected and only nine survived. She was terrified of returning home as she had no way of supporting herself, but her village donated a plot of land for the survivors, who pooled their resources to buy seeds and contributed labour with the hope to split the produce.

We also witnessed distant family members and altruistic neighbours coming forward to adopt Ebola orphans. Twelve year old Edward became sick when both his parents contracted the disease; he was the only one who survived. He returned home to help care for his six siblings, who are also now Ebola orphans. The people in his village helped support the funding needed for the children to return to school, so that Edward would not miss out on his education.

Reflections

The people of Sierra Leone continued to demonstrate a profound tolerance throughout the outbreak, collaborating with foreign partners who have largely dominated the response to Ebola in their country. This tolerance, and the altruism they showed towards strangers from both inside and outside their communities, provided essential support for victims of the disease – especially in remote areas of the country where it was extremely difficult to access help.

Now that the fight against Ebola has quietened, we have an opportunity to reflect on what can be learnt from the way that the people of West Africa have responded to this deadly disease. In the Western world, where the focus is often on the individual and rather than the community, I wondered how would we respond to this epidemic in our homes, villages and hospitals? Recent tragic events in the UK such as the Manchester bombing and the stabbings in London have demonstrated our ability to unite in the face of tragedy, and the power of this to help people overcome adversity. We can and should look to use these experiences in building our own resilience and sense of community for future threats to humanity, both in the UK and overseas.

Interested in working in Sierra Leone?

The King’s Sierra Leone Partnership / There are a range of funded volunteer opportunities that can be found on the KSLP website.

Global Links RCPCH / Looking for paediatric experience? There are volunteer placements available in Myanmar, Rwanda and Sierra Leone on the UK Royal College of Paediatrics & Child Health site.

Cap Anamur German Emergency Doctors / A German-based non-profit organisation focussing on medical care and access to education. Send them an application and CV if interested in working with them.

Welbodi Partnership / An organisation that works in tertiary hospitals & primary care in Sierra Leone, aiming to improve access to good community healthcare, in particular for women and children. Voluntary and staff postions can be found advertised online and via their mailing lists.

All photos are used with the permission of those photographed. All names/stories are used with permission, are published already in mainstream media, or have been altered to retain patient anonymity.

The post The fight against ebola & the power of resilience appeared first on Adventure Medic.

Hannah Phelan, an anaesthetic trainee and member of Adventure Medic’s editorial team, is currently working on an anaesthetic project in Zambia. A passionate advocate for uniting UK medical training and global, humanitarian medicine, Hannah talks us through an incredibly important document that supports, and helps justify at a governmental level, international volunteering. If you’re looking to take time out, whether for a few days’ study leave or for a full-blown career break, there is a treasure trove of information in here for you. Well worth a read.

In May The Royal College of Physicians and Surgeons of Glasgow (RCPSG) published Global Citizenship in the Scottish Health Service – The value of international volunteering. Commissioned by the Scottish Global Health Collaborative and authored by Stuart Fergusson and Michael McKirdy of the RCPSG, it set out to determine the extent of international volunteering by Scottish health care workers. It looked to explore the benefits to all involved, including NHS Scotland, and make recommendations for how Scotland can support such work in order to uphold its commitment to the Sustainable Development Goals (SDGs) and Global Citizenship.

So let’s break it down.

The Background

As long as poverty, injustice and gross inequality persist in our world, none of us can truly rest… overcoming poverty is not a gesture of charity. It is an act of justice.

Nelson Mandela 03.02.05 and the opening sentence of the RCPSG report.

In 2005 Scottish Government produced its first International Development policy, which provided a focus for Scottish involvement in tackling global inequality. In 2016, a year after the creation of the SDGs, Scottish Government refreshed their strategy and made a commitment to the concept of Global Citizenship. In their executive summary, Scottish Government named utilisation of Scottish expertise as one way in which they intend to:

Fight against global poverty, inequality, injustice, and promotes sustainable development via the mechanism of the UN Global Goals.

The Scottish Global Health Collaborative (SGHC), founded in 2015 and chaired by Scotland’s Chief Medical Officer Catherine Calderwood, aims to help steer the Scottish health service towards a coordinated, effective and supportive contribution to the national commitment to Global Citizenship. With this mandate in mind they asked the RCPSG to produce a report outlining current involvement of Scottish health care workers in international development, determine the benefits of such work and assess the support given to such activities by NHS Scotland in order to formulate recommendations to help realise their goals.

The Report

The report involved extensive research carried out over 18 months, including the collection and collation of quantitative and qualitative data from a head-spinning number of sources.

The authors consulted with the senior management teams of all 22 Scottish health boards, while the SGHC provided online questionnaires answered by over 400 health service workers, to build a picture of the current level of involvement in overseas volunteering and its perceived benefits. The research also encompassed a review of reports, policies, published and non-published literature, and other governmental and academic experts, charitable and professional organisations and individuals were consulted.

From this data the report provides a definition of international volunteering, including the various ways in which it can be undertaken, the history of political involvement, and current NHS Scotland policy for Scottish health care workers wanting to formally train in, or time out of work to engage in, international volunteering. The report goes on to compare NHS Scotland with the rest of the UK and other select European countries.

The Findings

This is roughly divided into general considerations, benefits to the individual volunteer and benefits to NHS Scotland.

General Considerations

There is no doubt that participation in international volunteering is a moral undertaking. However, it is important to point out that this is not just for the benefit of the country visited, but also for the benefit of the health inequalities in all of our home nations. As highlighted by the RCPSG report, there are ever-increasing similarities between the challenges faced by health systems worldwide. Four key challenges discussed in the report are:

1. Infectious disease: Multi drug-resistant organisms are a global problem and epidemics of infectious disease do not respect international borders.
2. Prevention and management of non-communicable diseases: Conditions such as diabetes and cardiovascular disease are on the rise worldwide, and place a significant burden on health care systems.
3. Increasing demands on available resources: The costs of providing health care for ageing populations, combined with improvement in, but rising costs of, technology and limited human resources.
4. Rural populations: The difficulties posed by being required to provide equitable health services for remote and rural populations, including the problems encountered in recruiting staff to such settings.

International volunteering helps to provide a communication network through which the world can unit together to address these challenges and improve healthcare for all.

Before this potential can be realised, it is of great importance to ensure that the project undertaken benefits the country visited. This benefit can be difficult to quantify as the interactions within such a setting are complex. However, encouraging improvements in morbidity and mortality,  knowledge, skills and confidence, quality of care provided, development of new services, training and education capacity, institutional governance, policy development and system enhancement, have all been observed by studies such as that carried out by The Tropical Health Education Trust (THET). Following on from their study, THET went on to review their own data, and interviewed several of their partners in low and middle income countries (LMICs) in order to identify crucial themes required for the success of a project:

1. Addressing country need: UK partners need to understand local contexts- both institutional and national, and not impose their own priorities.
2. Transparency: If lacking, can result in resentment and confusion.
3. Ownership: LMIC partners need to be co-producers of all aspects of strategy as well as delivery.
4. Sensitivity: Careful respect of cultural values and clearer alignment with national plans. (THET 2016 summarised in RCPSG report)

Benefits to the individual volunteer and NHS Scotland

The report has produced two helpful infographics to display the benefits of international volunteering to the individual and NHS Scotland. For those who already engage in international volunteering, or who support international projects, the findings may seem obvious. This report, however, has really got down to the nitty gritty of the matter, and, what is more, has provided evidence.

The benefits to the individual read like a hit list of the essential and desired attributes seen on most person specifications for health care positions in the NHS; we dedicate training time to improving our clinical skills, policy awareness, and leadership and management skills, to mention just 3 of the 7 benefits identified in the report. The collective evidence shows that these attributes can be developed within the global health setting while undertaking international volunteering, and that this setting provides a breadth of experience which may not always be attainable within the NHS.

In many NHS settings, health care workers can struggle to gain sufficient experience in taking on leadership and management roles. This is not the case when volunteering. Often these are the roles which are most required, the roles which overstretched clinicians on the ground need help with and the roles through which visiting clinicians can really test their resilience. Quite apart from improving their skills, volunteers often return with a higher appreciation of the difficulties faced in these roles within their own healthcare setting, and return better able to face challenges having taken on more challenging roles overseas.

There is no end to the ways in which an individual can boost their powers of communication and teamwork. Placed in an unfamiliar environment, often for a relatively short placement, and faced with numerous new colleagues with different clinical experience, multi-layered language barriers (Zambia, for example, has 8 official languages and up to 72 dialects), the demands of absorbing daily cultural norms and occasionally complex political situations… requires volunteers to sprint up a vertiginous learning curve of communication and camaraderie. In addition, many throw themselves into compiling written or video blogs, and return to give presentations, or hand in descriptive reports, to colleagues, departments or funders. They have been found to return with a new and improved take on how to conduct themselves within a team and, the a-word once again, an ‘increased appreciation’ of the importance of communication and good working relationships.

What else? Experience education, training and research outside your home zone; involvement in global health partnerships provides an international platform for academic collaboration that you may have not tapped into before. Work with policies that are unfamiliar, and your ability to remain flexible and problem-solve will help see you through many a challenge within the NHS or elsewhere. Gain different clinical abilities, skill-share with wildly varied resources, and experience a better understanding of other cultures and infrastructure: it can be invaluable. You gain perspective, reach a greater personal capacity for resilience and innovation, and return with an enthused engagement with basic skills and awareness of opportunities in your own health system.

Essentially, ‘enhancing recruitment and retention’ in an ‘exactly-what-it-says-on-the-tin’ benefit. By providing the enticement of opportunities to engage in the ever-more popular field of Global Health, NHS Scotland can hope to stem the flow of health professionals out of the NHS. Although this does not apply exclusively to doctors, a ‘Career Destination Report’ from the UK Foundation Programme Office showed a distinct decline in trainees choosing to continue straight into speciality training. In 2015 only 52% of doctors did so, compared with 71% in 2011. They also found an increase in doctors of all grades taking career breaks, from 4.6% in 2011 to 13.1% in 2015. Supporting engagement in Global Health, thus providing a more enticing career opportunity, will undoubtedly prove more cost effective than current reliance on locum agencies. It will also improve the work-life balance of those health care workers who often find themselves filling in empty shifts out of good will.

A current key objective for NHS Scotland, instigated by Chief Medical Officer Dr Catherine Calderwood and described in her annual report ‘Realising Realistic Medicine’, is the rationalisation of the provision of healthcare in Scotland. It has been described, by the WHO no less, as a public health revolution. Apart from championing a more patient-centred approach, Dr Calderwood is attempting to steer NHS Scotland away from wasteful practices, and waste of both time and resources. Through international volunteering in low-resource settings, much can be learnt about the ways in which this can be achieved. We can also learn how to provide and maintain health service coverage to remote areas of a country, such as the highlands and islands of Scotland. And how, in an increasingly specialised world, to retain high quality, generalist skills in these settings.

The Challenges

The authors do not claim that taking part in international volunteering comes without its challenges. It has already been mentioned that projects can fail to meet the needs of the country visited and the report groups other potential challenges together into six main ‘domains’: Service delivery, financial costs, personal safety, opportunity costs, regulatory issues and reputational risks.

The first is by far the most commonly talked about challenge at global health conferences and the authors state that:

At an institutional level, the most frequently cited challenge to international volunteering was the resultant temporary loss of staff from Scottish health boards.

A recent demonstration of this was seen following the call for UK health care workers to provide personnel during the Ebola crises. Not all who volunteered were released for deployment by their NHS health board. Although this may seem frustrating, concerns about maintaining sufficient staffing levels at home must be taken seriously. Global Health does include our base countries too. Saying this, there are some solutions to this challenge, such as UK-Med whose financial support extends to cover the NHS for costs incurred ‘back-filling’ the rota. Other possible methods include various permutations of annual hours, or less than full time contracts. It should also be reiterated that supporting engagement in international volunteering has the potential to boost recruitment to an NHS health board, and thus stem the flow of health care workers leaving in search of the greater contract flexibility offered elsewhere.

The personal financial impact of international volunteering is of concern, and sometimes prohibitive, to health care workers. This does not only relate to a drop in, or lack of, salary whilst away, but also the reduction in pension owing to time spent outside of paid employment. There are, of course, ways around this. Some NHS boards provide honorary contracts to maintain years contributed to a pension, while others provide funding for medical equipment or necessary vaccinations. Outside of this there is also the option to boost your pension by buying extra years’ worth of contributions, and occasionally charitable organisations will offer to help with contributions for posts over a certain duration. Some voluntary posts come with a basic salary to cover expenses such as living costs, travel to work, resources for teaching, internet, and necessary costs including return flights, visas and medical registration. Other organisations will have inbuilt insurance and indemnity which covers their volunteers. Much of this comes from governmental or external funders so can be intermittent. Many health care workers also apply for personal funding from their colleges or associations, as well as charitable or private companies.

Personal health and safety risks are easy to recognise when we discuss situations like the Ebola Crisis, or numerous other humanitarian disasters currently occurring throughout the world. The threat of contracting a fatal infection, regional violence or being the target of an extremist fraction, is hard to ignore. However, many organisations who operate in these settings take this into consideration, for example the thorough briefing and debriefing that occurs throughout UK-Med deployments.

This fulsome approach remains aspirational for many volunteering initiatives.

(RCPSG report)

What gains less attention are opportunity costs, regulatory issues and repetitional risks.

Opportunity costs relate to the encroachment of time which would have been used to engage in training, spend time with family and friends or simply enjoy a holiday. The report recognises that there is an increase in short-term ‘more focussed placements’ within international health, and an increase in the use of study leave to participate in such deployments. One could also add that engagement in international volunteering is a form of training in itself but that many in the field of global health would recognise the importance of rest, relaxation and time spent with their personal support networks.

Regulatory issues have been raised in previous adventuremedic.com articles. For UK doctors, the GMC now requires a process of annual appraisal to achieve revalidation every five years. This can affect both duration of placements and engagement in international volunteering after retirement. There are loop holes, but these can be time-consuming and costly.

Reputational risks allude to the detrimental effects, specifically for the donor country, of a poorly organised project or health partnership. One hopes that the now widespread focus on accountability, transparency and professionalism of international volunteering, with the institution of lists of reputable organisations, will help to improve the delivery of global health and reduce the instances of ‘inappropriate, unskilled and culturally insensitive volunteers’ giving their home nations, and fellow volunteers, bad press.

The Recommendations

From their extensive research, the authors came to the conclusion that the best way to harness the unquestionably bidirectional benefit of international volunteering is to aim for a coordinated and supportive approach to global health partnerships. The authors have made eight key recommendations.

In simple English, the eight recommendations read as:

1. Development of a strategic approach: Coordinate the advice given to Scottish NHS health boards, in the form of guidance and policy documents, and develop a strategic approach to Scottish involvement in international volunteering. Currently Scotland has established links in Zambia, Rwanda, Pakistan and Malawi: this recommendation would see these becoming a Scottish-wide special focus, and a springboard for health care workers wanting to be involved in the field of Global Health. However, the report makes it clear that voluntary posts which fall outside this ‘special focus’ should still be supported, as even an individual-to-individual partnership has the potential to be an established institutional relationship of the future.
2. Professionalising support and coordination: Create a central body which can provide a panel to create guidance and policy documents, help with all organisational aspects of international volunteering, including holding a directory of volunteering posts, and act as a point of contact for employers and interested health care workers.
3. Maximising the benefit: This recognises the potential for boosting morale in the health service. A health worker who can engage in work outside of their normal environment not only learns a plethora of new skills, but returns feeling motivated and empowered. A health board who is seen to encourage and support such experiences, can expect to see increased recruitment to their institutions.
4. Ensuring effectiveness: There is a growing understanding that the focus of international volunteering requires a change from the provision of aid to a need-led partnership. This recommendation would aim to prevent unwanted interventions and instead promote sustainable projects. Continual evaluation would be encouraged at an institutional body and individual practitioner level.
5. Valuing collaboration: Collaboration is an important way to overcome the barriers and challenges which stand in the way of global health equality; it also helps garner funding and avoid overlapping projects. There is already a wealth of Scottish expertise in the field of global health. This should be shared throughout the UK and globally with other institutions and individuals, and the knowledge and expertise of these groups harnessed, in order to further improve the impact of international volunteering.
6. Expressing local commitment: In order to encourage local health boards to support international volunteering, attention should be paid to the way in which other NHS health boards, who have established international health links, have improved the quality of service delivery in their institutions.
7. Defining support mechanisms: The majority of health workers embark on international volunteering during annual leave or between training jobs. Some health boards allow the use of study leave, which shows an understanding of the personal development gained by such work. This recommendation asks that study leave, unpaid leave, sabbaticals and career breaks are all considered as options for involvement in international volunteering, and points to Dutch and Norwegian global health training or sabbatical models that could be considered.
8. Setting expectations: The focus of this recommendation is the individual Scottish health care worker planning to carry out international volunteering. It is in keeping with the international move towards best practice, accountability and professionalism in humanitarian work. For NHS Scotland it would be a way to inform the individual of their responsibilities and avoid the serious repercussions of poorly conducted programmes for all involved.

Further Reading – a selection

Photos courtesy of Hannah Phelan: a selection from those employed in international volunteering.

The post Mutual Benefits of International Volunteering: The Evidence appeared first on Adventure Medic.

On 18 April 2014, 16 Sherpas were killed in an avalanche on Everest. Doctor Sophie Wallace was at Basecamp during the disaster and wrote movingly of the accident and of the days that followed. In this article, Sophie reflects on returning to Everest and on the psychological aspects of returning from the intensity of expedition life.

The arrival home after a long expedition is often thought about during the time away; the reunion with friends and family, the return to creature comforts, en-suite bathrooms, your old clothes.  How about the food you have been thinking about the whole time you were away?  Not to mention the fitness you’ve gained if you’ve been up mountains or trekking through jungles.  But what if coming home isn’t all you thought it would be?

The life of the expedition doctor while away on a long trip is fairly unique in many ways.  The patients are your friends and team mates.  The medical tent is right next to your sleeping tent.  You don’t get to go home and switch off and your patients are actually clients, with different expectations to your average hospital or medical practice clinical encounters.  They have invested huge amounts personally, physically and financially to be there.  Perhaps they have confided in you their hopes and dreams for their expedition?  What’s their motivation?  Maybe it is the child they lost, or the lifelong dream they have been aiming for if they could just get the planets to align so they can leave their life behind for a few months.  Maybe they have been saving every penny for a decade in order to come, and your job is to not only keep them healthy enough to realise that dream but to alleviate their fears as well as their ailments.

Returning from my second Everest expedition, and fifth Himalayan trip in June this year, I was having difficulty explaining the uneasy feeling I had returning home.  An expedition that was my first back in that environment after the 2014 disaster that killed 16 Sherpas.  I was looking forward to several meals out in Perth, to seeing my friends, to wearing clothes that didn’t come from an outdoor store and to sharing stories from the trip.  So why didn’t I feel ready to see everyone?

“Tell us everything!”

Deep down I knew that I wasn’t ready to meet the expectations of those who hadn’t been there.  The expectation that you can summarise all of the ups and downs of a ten week expedition into a few anecdotes over dinner and wine, so that your nearest and dearest can feel that they understand the world you have just been living in.  Faced with questions like “What was it like?  I want to hear everything, from start to finish!” seemed invasive and sometimes overwhelming.  Why I felt like this I can’t really explain, especially given the fact that 2017 was, comparatively, a hugely successful season.  Records were set, large numbers of people made successful summits and for the first time in many years not a single Sherpa was killed on the mountain.  After dealing with 16 deaths from the Sherpa teams in April 2014 (my last time on the mountain), some of whom were known to me, this fact alone was a particularly personal relief.

Despite the overall success of the season this year, inevitably deaths occurred on the mountain and needed to be dealt with. The tragic death of record-holding and highly respected climber Ueli Steck just one week after I was sitting next to him at dinner, and the frustratingly and seemingly avoidable deaths of climbers above the South Col were brutally real, close to home and, for our team, events some of them were personally involved in and needed debriefing from.  Discussing the emotions and answering questions of team members who have been involved in the same traumatic incidents as you can be an unexpected drain.  One needs to be able to be detached from one’s own emotions about the experience to be an impartial supporter and adviser to patients and clients, who will have had a very different experience of the same incident.  Everyone has their own black-box recording. In 2014 especially, making sure the team was okay required more of a mental disconnect that I had been capable of before or since.

Debriefing and Decompression

The military have thoroughly embraced the concept of debriefing-after-deployment, after a number of high-profile suicides and a high incidence of post-traumatic stress disorder (PTSD) in returning soldiers.  Strategies adopted include third location decompression, used by many of the NATO partners including Australia, Canada, the Netherlands and the UK, to prepare for the transition home.  Perhaps a similar approach can be recommended in expedition medicine, minimising risk for many of our climbers who choose to fly directly out of basecamp immediately after summiting Everest? The three-day walk out of basecamp can sometimes be an excellent decompression phase, speaking from first-hand experience.

All of the above partners used a preventative mental healthcare model throughout all stages of deployment in recent tours of Afghanistan, including the fact that for the frequently deployed, post-deployment debriefing often becomes pre-deployment debriefing before their next trip and therefore focus has shifted towards the complete chain of mental health support.  This includes: decompression (stage 4) and post-deployment mental health support at home (stage 5), as well as readiness training (stage 1), stress inoculation training (stage 2) and any necessary interventions immediately after a potentially traumatic incident (stage 3).  The third-location decompression stage for these organisations is a non-combat area and usually 1-3 days after finishing their tour, and post-deployment debriefing and screening occurs in the three-to-six month period after returning home.

There has been a shift away from an immediate single-session debriefing and towards an operational debrief session and a watchful waiting model, enabling the natural recovery process and accepting normal stress reactions to an abnormal event.  Ensuring the individual can be supported through their stress reaction, reassured that their reactions are expected responses to a traumatic event, and encouraged to seek help is vital.  Some partners even deploy a full mental health team routinely, and some sent out a full mental health team after major critical incidents.

Lessons for Expeditions

Extrapolating this to the expedition world, the expedition doctor would only usually be present during stages 3 and 4, with a responsibility to be aware of the need for stage 5, and may be asked to facilitate screening and referral for those deemed to be high risk.  With stages 1 and 2, we rely on the client to be responsible for their readiness prior to choosing to enter the potentially dangerous environment, and on the expedition organisations to have a responsible selection criteria for their clients before accepting them onto a potentially dangerous expedition, no matter how tempting their money is.

There has also recently been a lot of focus on the welfare of emergency services and medical staff, and rightly so.  In Australia currently the support of staff is being closely analysed after several suicides of young doctors, and every suicide of a paramedic (a depressingly frequent occurrence) also raises the same questions about self-care and how to look after oneself in a stressful job, but places the onus on the individual not the system.  And in the UK there will be a huge focus on critical incident stress debriefings for the staff involved in the Manchester and London terror attacks, and the Grenfell fire.  But it’s not just the military and emergency services who are affected by this.  The incidence of PTSD in mountaineers has also been reported at around 3%.  Perhaps this is lower than might be expected given the nature of accidents that they are likely to have witnessed over a climbing career, but still a significant number, with the potential for long term psychological morbidity and the associated impact on families and careers.

One of the responsibilities of the expedition doctor is to ensure the psychological wellbeing of your team during the expedition and anticipate problems on returning home.  The expedition leaders and guides are likely to be in an even higher-risk group given their responsibility for the overall running of the trip and their huge lack of personal time and space.  Time and space to deal with their own experience of events, in many of which they will have had a leadership and decision-making role.  Pre-departure you will have prepared your medical kit and brushed-up on your clinical knowledge, but honestly how many people just look at the physical aspects of their job and neglect the expedition psychology?  We don’t receive training in psychological screening, psychological education and “decompression” – tools used in the post-deployment phase.  So now you have a role in predicting the welfare of your team once they return, to mitigate risk for them in future in an area we are not usually trained in, and you need to try and look after yourself in the meantime.

Debriefing the Debriefer

So who debriefs the debriefer?  And how does one then leave an expedition and return immediately to the parallel universe we call “normal life” if there are still things left to process?  Returning home from time in a developing country can sometimes make familiar things feel alien, and previously important things feel incredibly trivial and superficial, albeit usually for a temporary period.   It’s easy to make the assumption that because we choose to go to these places, and most of the time it’s fun and “looks amazing!” that returning home is going to be easy. But it is more than just the “post holiday blues”.

The experiences that life as an expedition doctor bring are immeasurable in value, not only to you as a medical professional but also as an individual. The skills you develop out in the field, both clinical and non-clinical, will enhance your performance in hospital medicine or primary care undoubtedly. In order to maximise the benefits of your experience don’t underestimate the need for a psychological convalescence period after a long time immersed in a highly strung and emotive environment.  Especially when that environment is associated with personal trauma or the responsibility of you, as the doctor, to alleviate someone else’s.

So what are my tips for returning after an expedition like this?

Protect your own time and space / There will be a flurry of people wanting your time and your anecdotes.  You can say no.

Anticipate an adjustment reaction on returning home and prepare for it / Don’t expect to be able to return immediately into the same pace of life you were managing in before and don’t bury your head in the sand if you find it hard.

Write about your experiences / This can be for your own personal reflection, for your friends and family or for a much wider audience.  This can be a big help in processing the events of your expedition.

Don’t rush to get back into the next one / It can be very tempting to plan to leave for another trip as soon as possible because that world was so enjoyable.  Work out where your real life is and look after your relationship with those in it so you leave again for the right reasons.

Use your support team while you are away / They may not be physically present but a supportive email back can be a huge help when you may feel quite isolated and overwhelmed with the responsibility of looking after your team AND yourself.

Further Reading

Vermetten E, Greenberg N, Boeschoten MA, Delahaije R, Jetly R, Castro CA, McFarlane AC. Deployment-related mental health support: comparative analysis of NATO and allied ISAF partners. Eur J Psychotraumatol. 2014 Aug 14;5.

Qi W, Gevonden M, Shalev A. Prevention of Post-Traumatic Stress Disorder After Trauma: Current Evidence and Future Directions.Curr Psychiatry Rep. 2016 Feb;18(2):20.

Editor’s note: this article touches on aspects of life and medicine that are sometimes controversial and often very emotive. If you are feeling overwhelmed following an expedition, please seek help from a specialist or your doctor.

The post Coming Down from On High appeared first on Adventure Medic.

Moore JK, Ladbrook M, Goodyer L, Dallimore J. The Provision of Prescription-Only Medicines for Use on UK-based Overseas Expeditions. Wilderness Environ Med. 2017 Jun 16.

The post Prescription Medications for Expeditions appeared first on Adventure Medic.

How did Xtreme Everest start?

Xtreme Everest was developed by a group of healthcare workers including anaesthetists, intensivists, trainees, a physician, a nurse, and a GP. As well as working with sick people, they also had a love of the outdoors, and in particular, mountains. Xtreme Everest was set up to carry out research into improving outcomes for critically ill patients. Low oxygen levels are a critical factor for this group of patients, whether in intensive care, accident and emergency, or undergoing major surgery. Similarly low oxygen levels are experienced by individuals visiting extreme environments, such as those found at altitude. Research results from critically ill patients can be difficult to interpret because of the multitude of underlying issues that cause someone to become critically ill in the first place. These issues are not likely to be present in healthy volunteers. Although it has been possible to simulate low oxygen environments in chambers, the studies are expensive to run, and can only accommodate small numbers at a time. Therefore, Xtreme Everest has used the exposure of healthy volunteers to environmental hypoxia as a model for the majority of its critical care research to date.

The Xtreme Everest Oxygen Research Consortium grew out of a research project conceived by members of CASE Medicine. The first official meeting of Xtreme Everest took place in March 2004. The number of people involved has grown to include investigators from a variety of health related disciplines; sponsors from commercial companies, third sector grant giving bodies, and governmental organisations, as well as individuals; members of the media; and our healthy volunteer subjects.

The work has been funded from a number of sources including individuals, companies, charities, and public institutions. It has resulted a large number of scientific publications, with additional related articles, and countless ‘opportunities to view’ via television, radio, print and electronic media coverage, as well as a growing exposure via other modems of social media.

Can you tell us more about the resarch?

Xtreme Everest has carried out nine research expeditions at altitude in environmental hypoxia, involving highland and lowland adults, and lowland children, and 2 research studies in chambers. Caudwell Xtreme Everest, our largest expedition to date in 2007, involved 222 lowland subjects trekking to Everest Base Camp (EBC), with a subgroup of 14 investigators studied at altitudes of up to 8400m. Baseline studies were carried out at sea level (75m) on all subjects, and then repeated in dedicated field laboratories in Kathmandu (1300m), Namche Bazaar (3500m), Pheriche (4250m), and EBC (5300m). Members of the subgroup underwent additional testing in the Western Cwm (6400m), the South Col (7950m), and the Balcony (8400m).

Repeated measurements included core physiological data such as daily blood pressure, heart rate, respiratory rate, and the Lake Louise score. Researchers also investigated maximum exercise capacity, how efficiently the body uses oxygen and fuel, brain function, lung function tests, and blood and body oxygen levels. All protocols and equipment were tested by members of the investigator team in chambers, laboratories and/or the field prior to the start of the expedition to ensure they would produce reliable data.

Three further research expeditions, including Xtreme Everest 2, have followed an identical ascent profile, with data collected up to EBC. One of the chamber studies replicated this same ascent profile up to the equivalent of Namche Bazaar (3500m). Xtreme Everest 2 included a mixture of highland and lowland subjects, including identical twins and ‘repeaters’ – healthy volunteers that had participated in at least one of our previous research expeditions in Nepal.

Whilst some of the research themes investigated over the various expeditions have been identical, some have changed as earlier results have directed the research team in new directions, for example related to epigenetic markers. Some members of the team have returned from Nepal within the last two weeks after completing a tenth anniversary trek with a similar ascent profile. It included an extra day at Namche Bazaar to enable the team to hold an event for the Sherpa community, organised with the assistance of the Namche Youth Group and the Namche Women’s group. This included presentations of research findings and demonstrations of Xtreme Everest’s gratitude for the support this community has given the team over the previous decade.

And what did you find?

Perhaps the most well-known results so far have been the arterial blood oxygen levels obtained from our climbing investigators close to the summit of Everest. The lowest arterial oxygen level recorded was 2.55 kPa. This was from one of four subjects who had just summited Everest. The subjects took the samples from each others’ femoral arteries, (average PaO2 was 3.28 kPa), and each sample was obtained at the first attempt, demonstrating the investigators’ fine motor skills despite profound low oxygen levels. These results have driven the team to investigate whether patients need to be treated so aggressively when their oxygen levels drop when critically ill. This is being done through the development of clinical feasibility studies. Some of these aggressive treatments, currently used on patients, can in themselves be harmful.

Highlights from the brain research group have included a better understanding of blood flow to the brain, and its contribution to raised pressures in the brain and high altitude headache in the presence of extremely low oxygen levels. Investigators interested in oxygen delivery have presented data related to changes at the cellular level and blood flow and muscle oxygenation in the presence of low oxygen levels, and the role of nitrogen oxide. Studies investigating the body’s use of oxygen have highlighted changes in muscle energetics, mitochondria (cell batteries) in skeletal muscle, heart function and energy metabolism. Work is on-going to publish a wealth of additional data related to these and other topics including exercise capacity, metabolic function, genetics, and epigenetics.

What are the next steps for Xtreme Everest?

The research has generated a comprehensive data set related to more than 300 adults undertaking the same ascent profile to Everest Base Camp, generating exposure at the same rate of reduction in environmental oxygen levels. The results from the analysis of some of this data are still awaiting publication, and this is expected in coming months. Work is also on-going to future proof the data as developments in software and hardware since Xtreme Everest started collecting data have been significant, and it is important that the raw data remains in a format that can be interrogated down the line. This will also enable the team to use developing data handling and management techniques to ensure that complex patterns are identified that are associated with good and poor adaptation to low oxygen levels. The long-term intention of the team is to make this fully anonymised data set available for interrogation by other research teams, once we have exhausted our own research questions.

Finally, we aim to develop a cohort study from our subjects, approaching them at ten year intervals to secure repeat measurements of some research data sets, and to catalogue significant health related events amongst this group. This will give us information regarding the impact exposure to a profoundly hypoxic environment has had on individuals’ health long term.

As the tenth anniversary of the Caudwell Xtreme Everest expedition approaches next year, the Xtreme Everest Executive team are putting on two events. The first, Knowledge 10: Oxygen, will be on 23-24 May 2017 at the Royal Society of Medicine (RSM) in conjunction with the RSM Critical Care section. Day 1 focuses on the history of research related to oxygen and altitude, and Day 2 on research results from Xtreme Everest to date. The second event will be a lecture at the Royal Geographical Society on the evening of 23 May 2017, the tenth anniversary of Xtreme Everest’s successful summit which culminated in the arterial blood sampling on Everest’s Balcony, highlighted above.

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A couple of weeks ago, the six members of the British Trans-Americas Expedition set forth on their epic 20,000 mile journey from south to north along the pan-American highway by motorbike. Apart from the small matter of the distance, they are hoping to raise £10,000 for veterans mental health charity Combat Stress.

The team are aiming to set a new world record for being the first motorcycle team to ride the entire length of the world’s longest road, from Cape Horn on the southern tip of Chile to Prudhoe Bay on the Northern coast of Alaska. Along the way they will face a multitude of challenges including fierce winds of patagonia, two continents worth of weather and the infamous Darien Gap.

We wish them well with their adventure.

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Why Namibia and the San?

Namibia has one of the highest incidence rates of TB in the world. Within the country, the indigenous San people in particular have one of the highest rates of multidrug resistant TB. Whilst Namibia’s German-speaking population has a life expectancy of 79 years, the San people rarely live beyond 50. The San are an indigenous, largely nomadic group of people living across parts of Southern Africa. Known for their clicking languages, their unique culture has sometimes resulted in unfair discrimination against them. The San, and other ethnic groups in the area, often report ill-treatment from local health workers and are less confident when attempting to access health care services. These cultural barriers, when combined with a lack of nutritious food, and the nomadic lifestyle of the San, contribute to the spread of multi drug resistant TB.

How do we overcome the barriers identified by the WHO?

It is important to work closely in partnership with communities to understand what their barriers are to accessing healthcare, and to educate them about their health rights. We try to give communities the practical knowledge they need to take charge of their own health, whilst also strengthening existing health systems to ensure they receive good quality, culturally appropriate care. I’ll give you an example: when ≠ioma N!ania began having chest pains and sweating in the night, he didn’t know what his symptoms meant. It wasn’t until a community representative from his local area attended some health training from us that he learnt he had TB.

“When he returned from his training, he started to teach us in the village that chest pain and night sweats can be signs of TB. He encouraged me to go for a test.”

≠ioma N!ania

After he was diagnosed ≠ioma was given both treatment and training to teach him how to prevent the spread of his TB. He was also provided with temporary accommodation near the Tsumkwe clinic, as well as meals to support his recovery. But not everyone can come to stay near the clinic throughout their treatment. Many San people live a nomadic lifestyle which makes moving to a big town for months of treatment very difficult, both socially and financially. We need to prioritise early diagnosis and treatment to prevent hospitalisation to ensure that those infected with TB can remain in their communities whilst completing their treatment.

We train treatment supervisors to visit families, take samples for diagnosis, and visit them again to deliver their medicines. To prevent the further spread of multidrug resistant TB it is essential patients complete their course of medicine- even if this takes months or years. Treatment supervisors visit patients regularly to ensure they don’t stop their treatment for any reason.

We have also been working in partnership with the San people to set up Clinic Health Committees. These committees bring together community representatives to meet with local health officials, providing a space for the San people’s voices to be heard, so that local services can be adapted and made accessible to their cultural and local needs. Feedback about health services is collected by the committees, and then passed on to government officials at regional and even national level.

Has this approach been successful?

Although the process has often been challenging and slow, the voices of the San are finally being heard. As a result, the national government has recognised the need for greater support to stop the spread of drug-resistant TB in Tsumkwe. As the world continues to tackle TB, it will be crucial to take on not just the medical causes of TB, but also the cultural and social barriers preventing different groups from accessing treatment. In Tsumkwe this means healthcare needs to keep adapting to suit the culture and nomadic lifestyle of the San people, and make it easier for them to access healthcare and treatment without drastically altering their day to day lives. Despite these challenges, the healthcare professionals we work alongside in Namibia, but also all over the world are determined to deliver the best possible care to their patients.

Last year, Health Poverty Action trained 2,520 doctors, midwives, nurses and healthcare workers to improve the quality of care in the poorest communities and worked with 9,792 local health workers, community health volunteers and leaders to improve the health of their communities. To support them, please consider donating to their As One campaign.

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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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Building-Antenna-Span-Earth: All About That BASE

An El Cap Education

Glide!

Dr Francesco Feletti is a consultant at the Hospital of Ravenna, Italy. He’s Board Certified in Medical Imaging and mainly engaged in emergency and interventional radiology, musculoskeletal diseases and sports pathology. Together with the Politecnico di Milano, the largest Technical University in Italy, he is undertaking some groundbreaking research into healthcare in extreme sports. We interviewed him about his passion for adventure, his new book Extreme Sports Medicine and posed him the question – what is an extreme sport?

So Francesco, how did you get into extreme sports medicine?

Ever since I was a child I have practiced – and still do – various sports, competitively and at international level. They have included athletics, sailing and windsurfing. Enthusiasm and curiosity have also led me to various other adventure pursuits including kite-buggying, snow-kiting, downhill mountain biking, paragliding and skydiving. I’m also attracted to BASE jumping and wingsuit proximity-flying and as soon as I have enough time, I’d love to have a crack at them too.

However, my main focus since 1999 has been kitesurfing. When I began, there were no modern safety systems. So, more than once I found myself having to rescue a kiter who had sustained serious injuries after losing control of their kite. That’s when the desire to put medicine at the service of these sports came into being.

It’s interesting that you mention BASE jumping. Its dangers have always led to a certain amount of controversy, but the debate has become more heated after a difficult last summer for the sport. What are your thoughts?

In writing the chapter of my book that deals with BASE jumping I spent a lot of time with the jumpers themselves. I found them to be remarkable, capable of working for months on a single jump, meticulously attentive to every detail, dedicated and precise. It’s a reality that contrasts sharply with the ‘adrenaline junkie’ label the media has given these athletes.

There is no exact figure for the number of BASE jumpers, so accurately quantifying the risks of the sport through epidemiological studies is difficult. It is true that some authors have estimated injury rates and found them to be significantly higher than those seen in skydiving but the fact that this is a young, fast-growing sport needs to be taken into account.

Are you saying that BASE jumping might, in the future, be seen as a safe sport?

A look back at motorsport shows us that racing drivers and motorcycle riders used to risk their lives every time they took to the track. Later on, safety improved to the point where these sports were universally accepted and appreciated. Moreover, the use of motorsport-proven safety systems was extended to production vehicles, making a considerable contribution to road safety.

I believe the same could happen in BASE jumping, that the safety systems developed for it could later be used in other areas such as ultra-light flight, paragliding or even in the airline industry.

Your new book begins by questioning the definition of ‘extreme sports’. How do you define them? What makes them stand apart from others?

In the opening pages of my book I attempt to provide a definition, but it is difficult: ‘extreme sports’ covers such a broad range of activities and they are evolving constantly.

The word ‘extreme’ immediately evokes the concept of risk. Yet extreme does not necessarily mean dangerous. In truth, while epidemiological data exists only for certain disciplines such as surfing and climbing, it nevertheless shows that, in some extreme sports, both the incident rates and the severity of injuries are lower than in many traditional sports. In many cases the risk is more perceived than real, a perception shaped by the spectacular nature of such disciplines.

And that, I think, is the first key aspect that characterises extreme sports: they are, indeed, ‘spectacular’, a quality that makes them extremely media-friendly and excellent vehicles for advertising and fashion. Their sheer visceral appeal and “watchability” is undoubtedly why the International Olympic Committee is gradually beginning to slip extreme sports into the Olympic programme.

The second key characteristic is the role played by the natural environment, the unpredictable arena in which these sports play out, in contrast with the controlled surroundings of traditional sports.

A third element concerns performance evaluation. In traditional sports, these are typically quantitative: who came in first? who scored the highest? However, in many extreme sports there are no competitions, just events.

There are many more, but I shall limit myself to stating just a fourth, which I think is crucial: the technological aspect. Many extreme sports would be very different or, perhaps, not even exist without the advancement of materials and equipment.

Along with other key authors, I delved deeper into the question of what actually characterises these sports in the paper “Understanding action and adventure sports participation – An ecological dynamics perspective”, currently pending publication.

What are the biggest challenges facing extreme sports medicine as a developing speciality?

There are plenty! First, many disciplines are practiced in remote, austere locations where it’s hard to find transport, equipment or the researchers to travel to such places.

Second, creating controlled, reproducible conditions for studies is tricky; this is because we are managing so many more variables including the weather, and a complex web of reciprocal interactions.

Perhaps the biggest problem is posed by the participants’ own cultural attitudes. As I argued during the 2nd international Extreme Sports Medicine Congress, held in Boulder, Colorado in 2016, many extreme sports participants simply prefer not to talk about their injuries. The reasons behind their reluctance are multiple including, for example, the fear that drawing the attention of science to the risks might lead to new legal restrictions on their sports. That said, we should make distinctions: aerial sports, for example, are influenced by aviation safety culture and are perhaps more likely to engage in research programs.

In any case, extreme sports need to be studied from the inside. Researchers must have practiced the sports or have been embedded in these ‘communities’ for some time both to gain an in-depth appreciation of the topic and to win the athletes’ trust and cooperation.

What areas within extreme sports research excites you the most?

I believe technology will play a decisive role in the future of extreme sports medicine. Not just in terms of helmets and ergonomic protection systems, but in keeping pace with the technology of the sports themselves: for instance, in kitesurfing the introduction of hydrofoils requires the development of rescue craft that are at least as fast. Vehicles that are, in fact, likely to be equipped with the same technology.

It is rehabilitation that interests me the most: injured participants are always keen to get back into their sports quickly, and full physical and psychological recovery is vital before returning to extreme sports.

Rehabilitation programs require specific sports simulation systems and the role of bioengineering may prove to be decisive in this area too.

Our audience are mostly expedition and wilderness medics. Is there anything they should be particularly aware of when dealing with extreme sports injuries?

I’m sure your readers are experts on dealing with injuries and other medical problems in hostile environments. They’re probably well informed on extreme sports too.
So I’ll limit myself to two considerations both of which, while pretty obvious, are crucial.

1 / In approaching these sports, please bear in mind the huge differences that exist between the myriad of styles and sub-disciplines needs. Don’t just lump them all together.

2 / Remember that extreme sports don’t just involve serious injury. Indeed, speed-induced vibration might be a key factor in chronic degenerative joint diseases. Since technique is often more important than pure physical performance, many extreme sports can be practiced – at quite a high level – by people who are older than “traditional sportspersons”. This is a tremendous advantage, but also means that “overuse” pathologies take on greater relevance.

Where should we begin if we want to get involved in extreme sports medicine?

Extreme sports have never been so popular, so I think the time is ripe for medicine to become more involved. It is important to consider that extreme sports are complex activities and require a multidisciplinary approach.

In addition, these sports evolve at a breakneck pace, so their study and support demand new models of professional and scientific interaction. In 2013, I co-founded the international ExtremeSportMed association. Our goal is to organise a PhD-level summer school (Extreme Sports Medicine & Engineering). The first edition is expected to be held in 2017, on the shores of Lake Como in the foothills of the Italian Alps, a natural setting for several extreme sports. An international conference is also being planned for 2018. So if anyone feels like getting involved they’re warmly invited to join us by filling out the form at https://www.extremesportmed.org/join-us/ and by joining our Facebook group.

Dr Feletti’s book is available in hard copy and electronic formats from Springer International Publishing, 2017. DOI 10.1007/978-3-319-28265-7. We’ve got it, it’s great!

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Drugs in the Mountains

Hypoxia and Cold – From Science to Treatment

Hydration Strategies at Altitude

This is an interesting follow up to the groundbreaking Outside Magazine article ‘Climbing’s Little Helper’ and the recent comprehensive UIAA advice on drugs in the mountains. What are people taking on Everest? And do you know what your group are taking on your expedition?

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Building-Antenna-Span-Earth: All About That BASE

Francesco Feletti: Extreme Sports Medicine

An El Cap Education

Access to the outdoors is at the heart of adventure medicine and this inspiring and joyful short film illustrates that to perfection. Glide! is the story of four American wheelchair users’ quest to fly paragliders. We liked it so much that we had a chat to the director and producer, Niels Dachler, for the background to the tale.

How did it all start?

I first met them at Point of the Mountain in Utah. The site is one of the more majestic sights in America. Paragliders, hang gliders, hawks and model airplanes play here with incredible density and delight that the sky often resembles some kind of flying circus. I was a film producer and paraglider pilot, hoping to help tell their story.

At the time, Sarah was a dancer, a ‘pizza delivery professional’ and a knitter of stuffed aliens. Ernie was a retired Air Force rescue jumper, Darol, a day trader and Muffy, a mother and seven times Olympic medalist. We all gathered with Rob Sporrer and Nick Greece, two of the best paragliding instructors in the US, to take to the skies.

As a paraglider pilot yourself, how did it feel to fly with the four of them?

Witnessing their first solo flights were some of the most memorable days of my life. For Sarah it was in Salt Lake City. For Ernie and Darrel it was a high peak in San Bernadino, California. As Sarah says so memorably in the film, ‘when you are a in a wheelchair, you feel like you are in a wheelchair. In this, you feel like all the other pilots’. And that is how it was once we were up flying, it was just like sharing the sky with four other pilots.

Were there any particular technical challenges faced by the pilots once airborne?

Paraglider pilots exert much of their control over the wing by weight-shifting the body from one side to another. This is more difficult if you lack full control of the hips. However, the design of the chair was great here, as the paragliding harness was designed to ‘float’ above the wheelchair in flight, providing a freedom that maximised weight shift. Also, the wing’s angle of attack (and so its speed) is conventionally adjusted using a bar operated by the pilot’s feet. We are still trying to come up with a good design to give our pilots that added control.

Have there been challenges since?

The enthusiasm never dies, but the support for the program comes in spells. There are a lot more inquiries than the program can currently handle – we need to formalise the program to be able to serve that demand. The health of paraplegics can often be more precarious than the average pilot, so that gives us a sense of added urgency.

We are not the only people doing this, there are lots of innovators around the world designing paragliding equipment for paraplegics. This leads to lots of one-off, experimental prototypes that have provided us with a lot of insight and experience. However, as it becomes a broader effort it would be great if they could cooperate on a more universal, standardised design. This would help pilots fit more seamlessly into a club environment when they leave the program.

You can find out more about the Wheels Up program on their website. In the UK, check out Flyability, the British Hang Gliding and Paragliding Association’s access programme for those with disabilities, and specialist centres such as Escape Paragliding in Cumbria.

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Medication Use Among Mount Everest Climbers

An Unusual Case of HACE?

Hypoxia and Cold – From Science to Treatment

A team from the International Climbing and Mountaineering Federation (UIAA), led by the UK’s Dr Dave Hllebrandt, has just published an evidence-based guide to drug use in the mountain environment. The report was ten years in the making and includes the medicinal, the performance enhancing, the recreational and the simply baffling (mescaline at 8000m anyone?). It’s comprehensive, a very handy reference for anyone working in the mountains and available free on the High Altitude Medicine and Biology site.

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It’s job application time again. As you know we at Adventure Medic love anyone who has taken the road less traveled, except in this instance she took the runway: we speak to Bonnie Posselt, the UK’s new Aviation and Space Medicine Trainee about the specialty.

Congratulations on becoming ‘the trainee’ in Aviation and Space Medicine! Tell us how you got here.

I’ve always been fascinated with flying and very much enjoyed flying in a small propeller aircraft with the University Air Squadron. I took an extra year out for an intercalated degree in Aerospace Physiology, run at King’s College London and this really opened to my eyes to the specialty. I presented my dissertation research in the form of a poster at the Aerospace Medical Association annual conference, in Alaska, winning the Young Person Investigator prize.

On graduating, I did my Foundation Training in Birmingham with the RAF and went on to complete my Military Officer training at RAF Cranwell. I decided on the three-year ACCS programme, always with the aim of carrying on with Aviation Medicine. I was extremely lucky that by the time I had finished physician training, the specialty had just been recognised and the RAF were willing to support my training.

Aviation medicine has always existed, but specialty recognition now means a formalised training programme in line with all the other traditional specialties.

Please tell us more about the programme.

“Aviation and Space Medicine is the study of all factors affecting the human body in flight, in health as well as sickness and the means by which those flying may be protected against the potentially harmful effects of their abnormal environment. Consultants in the speciality will act as an expert on the medical aspects of aviation.”

Aviation and Space Medicine Curriculum

There is a set curriculum and like all other specialties I will need to provide evidence that I have achieved those competencies. Areas covered include understanding the unique aviation and space working environments and how it affects human physiology, as well as the equipment that can be used to protect against certain hazards. I will undertake training in the hypobaric chambers, the centrifuge and the disorientation simulator. Placements will be split between the Centre of Aviation Medicine at RAF Henlow, aeromedical centres, regulation authorities and the European Space Agency. Other areas include protective equipment integration and accident investigation. I love how it covers all aspects of medicine, but in an extreme environment.

How long is the training?

The curriculum is competency based, so time in training can be slightly flexible. However, a four year training programme will be considered the average length, with additional research (MD or PhD) being highly desirable.

Are there exams?

The Diploma of Aviation Medicine (DAvMed) will be incorporated into the training. This is a six-month course run by King’s College London, with a series of exams at the end administered by the Faculty of Occupational Medicine. The Diploma gives the trainee a sound grounding in basic science with an emphasis on human physiology. Currently these are also considered the ‘exit exams’, but I think there will be a move towards additional exams at the end of training.

What are the entry requirements?

Completion of Foundation Training followed by either Core Medical Training (CMT) or Acute Care Common Stem (ACCS) in Acute Medicine and the Membership of the Royal of Physicians (MRCP) exam. Doctors who have taken alternative pathway such as General Practice or Core Anaesthetics will also be eligible to apply but will need to undertake a ’Training Needs Analysis’ to ensure that their competencies will be of an equivalent level.
Doctors will then undergo selection into the specialty using a nationally-agreed Person Specification.

Do you have any advice for those wanting to apply?

Aviation Medicine is a small specialty, but a fantastic and supportive community. It is different from other specialties in that it is not NHS funded, so you need to have a sponsor to support you through your training. This can be the military, or any company that would require a consultant, such as the airlines or regulatory authorities.

As such there will only be a small cadre of personnel and recruitment into higher training every few years. However, this may increase with the recognition of the new specialty and I know that the CAA have been recently advertising in the BMJ for applicants. It would be a question of talking to the people within the specialty, making connections, promoting your interest and keeping your ear to the ground about applications.

For anybody interested, I would also advise coming to the Royal Aeronautical Society Evening Lectures, many of which are free and great opportunities to meet people from the industry. In particular, the Annual Aeromedical Conference, held in their London headquarters at the beginning of March.

If you would like to contact Bonnie, please do so using her Twitter handle @bonposselt. She will also be speaking about the speciality at an upcoming Space Medicine conference, run by Kevin Fong at the Institute of Sport, Exercise and Health on 19 November 2016.

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Sarah Kessler / Director of Communications & Strategic Partnership / Lifebox Foundation

Sarah and Sibonile work at Lifebox Foundation, the only NGO devoted to promoting and maintaining safer surgery in low-resource countries around the world. The charity aims to provide sustainable equipment, safety check-lists and education to vastly improve surgical outcomes. As those who work at the healthcare end of the spectrum, we rarely hear the perspective from non-medical charity staff. Here, Sarah and Sibonile give us some insight into working for a medical charity, and put Lifebox into context by highlighting the work they have recently seen the charity undertake in Guatemala and Zambia.

Sarah / Safer surgery in Guatemala

Surgery in low-resource settings isn’t cosmetic or elective; emergency demand is often barely covered and palliation is rare.  The surgery is life and livelihood saving – but because of a chronic lack of essential resources and training, can be extremely dangerous. Lifebox is an international NGO making surgery and anaesthesia safer in resource-poor settings. We work in partnership with local communities to deliver essential monitoring equipment and training in 100 countries around the world.

When we talk about the value of surgery as compared to other healthcare interventions, consider Guatemala. Almost half of the population is under 19 years old, making it the youngest in Latin America. And the most common health risks they’ll face – road traffic accidents, complications of childbirth – have a mortality point of no return that only surgery can cross.

“The patients we’re saving are actually very young and have the potential for many, many years ahead – their whole lives, really,” explains Professor Alan Merry, Lifebox Foundation trustee.  “They’re people having highly correctable, life-saving surgery – a C-section for example – and if they get through it they’ll live another 30, 40 years.”

In 2013 we joined Dr Sandra de Izquierdo, an anaesthesiologist at the Herrara Llerandi Hospital in Guatemala, and the Guatemalan Association of Anesthesiology and Pain Treatment (AGARTD) to learn more about the challenges hospitals face in providing safe surgical care. Some of the stories will feature in an upcoming documentary about the state of safety in surgery, globally, and some of the photos you see above are debuting here.

Global surgery sits at an incredibly busy intersection: science, politics, philanthropy, research, technology – but most importantly, community. So working for Lifebox isn’t just a chance to understand these worlds better, it’s an extraordinary opportunity to be part of a global movement with an undeniable goal: make surgery safer for the millions who need it now. It’s been fascinating to grow with the organization, humbling to see my personal experiences of life-saving surgery in a bigger context, and a privilege to work with so many people around the world, from ministries of health to the frontline of the global surgical safety crisis, who are committed to making a difference.

Sibonile / My safer surgery journey

What is ‘safer surgery’? If someone had asked me this question two years ago they would have been met with silence. At that time I was studying for my masters degree in international development at the University of Birmingham. I was completely immersed in my studies, exploring the field I love. My course focused on poverty and equality. We learned about the multidimensional nature of poverty – how the world’s poorest people don’t face just one but a myriad obstacles that make and keep them poor – and what initiatives are and have been implemented to help people lift themselves out of poverty.

One such barrier is lack of access to adequate healthcare. For many people around the world even the most basic healthcare services are simply out of reach. Global health is a field which seeks to address such disparities through education, research, funding and implementation of projects to enable communities to live healthier lives. We have rightfully rejected the idea that where you’re born should dictate your well-being and your future. We recognise the importance of vaccinating children against deadly diseases and we support HIV prevention initiatives – yet startlingly in this day and age you’re more likely to be killed by a surgically treatable condition than a communicable disease. So why is surgery not visible in many healthcare systems worldwide?

Joining Lifebox

In January 2015 I was formally introduced to the field of global surgery, often referred to as ‘the neglected step child of global health.’ Prior to joining Lifebox I had never really thought of surgery in the context of global health. I was lucky to start my work at a time when there was a real international shift in the understanding of the important role that surgery and anaesthesia play in a functioning healthcare system.

In this landmark year the World Health Assembly passed an historic resolution – strengthening emergency and essential surgical and anaesthesia care as a component of universal health coverage – putting the often overlooked and under-resourced area of global surgery on the international health agenda for the first time. In the same year, the Lancet Commission on Global Surgery published a report that showed that 5 billion people around the world do not have access to safe surgery when they need it. This data was invaluable in grounding my understanding of the often dire realities of accessing safe surgical care around the world, and Lifebox’s work in supporting front-line healthcare workers in low-income countries to provide the best care.

Pulse oximetry is a proxy for safety, and deemed to be one of the essential components of surgical access. Through its Safe Anaesthesia work, Lifebox distributes this vital piece of monitoring equipment – the pulse oximeter – used to monitor a patient’s oxygen levels when they’re under anaesthesia. Sadly this lifesaving device is missing from over 70,000 operating theatres in the developing world, which often means that routine surgical procedures can become life-threatening. Distribution of pulse oximeters goes hand-in-hand with our education programme to help build the capacity of anaesthesia providers in low-resource settings. This sustainable approach to training means that medical teams gain essential anaesthesia knowledge and the skills to pass this on to their colleagues.

Safe surgery in action!

Since Lifebox was founded in 2011 we’ve distributed over 13,000 pulse oximeters to 100 countries across Africa, Asia, Eastern Europe and Latin America, and trained over 5,000 anaesthesia providers in basic safety checks making surgery safer for 10 million people around the world.

As part of my communications role at Lifebox I spend a lot of my time promoting and sharing these powerful stats with our donors, friends, partners and supporters around the world: they not only demonstrate the impact of our work, but the collaborative effort required to help make surgery safer. I was delighted to have the opportunity to travel to Zambia last November to see our work on the ground, and was keen to meet the team working to support anaesthesia practice across the country.

In preparation for my trip l learned about Lifebox’s long history in Zambia: from supporting the MMed programme (training of the first medically qualified anaesthesiologists in the country) with equipment and education materials, to conducting follow-up research on the impact of our pulse oximeter donations. I was off to take part in Lifebox’s fourth training workshop in collaboration with our co-founder the Association of Anaesthetists of Great Britain and Ireland (the AAGBI). This four day refresher course focused on safe anaesthesia and introduction of the WHO Surgical Safety Checklist, as well as the delivery of the AAGBI’s SAFE obstetric anaesthesia training.

Meeting the dream team

Zambia is a large country with a population of over 16 million and, as with many low-resource countries, medically trained and qualified anaesthetists are scarce. Most anaesthetics are provided by clinical officer anaesthetists (COAs) who by and large have some medical training, but not the up-to-date knowledge required to provide a safe anaesthetic. This disparity, coupled with a lack of adequate monitoring equipment, means that anaesthesia mortality is 100 to 1000 times more dangerous in these settings compared to high-income countries.

Many people live in the country’s historically and commercially significant Copperbelt region. This mining area includes Ndola: Zambia’s third largest city, a gateway to the mineral-producing region of the country, and my base for the week.

I arrived in Ndola on a hot Monday afternoon, and as the plane touched down I went back to this idea of impact. I thought about our small team of fewer than 10 colleagues based in London and Boston, and the amazing global reach we’ve had over the last five years. It really struck me that I was about to witness first-hand the collaborative effort stretching across the world, from idea to action, to make safer surgery happen. So I was thrilled to meet two of our workshop coordinators when they picked me up from the airport: Wisdom Chelu (Zambia’s national anaesthesia lead) and Dr Phil Bonnett (a consultant anaesthetist in the UK) . After a quick stop to drop off my luggage we made our way to Ndola Central Hospital where set-up for the course began.

We were based at the hospital’s School of Nursing, a block of four classrooms (perfect for group sessions) with a larger room used as the main lecture area. I was introduced to the course faculty, a group of 11 UK and Zambian anaesthetists including two MMeds, Masuzyo Zyambo and Ushmaben Patel, based at the University Teaching Hospital in Lusaka. Over the week I came to know this dynamic group better – learning more about their backgrounds, what drew them to this specialty and their motivations for supporting Lifebox’s work. Consultant anaesthetist Papari Deka, who had been working in Zambia for a year, summarised: she was, simply, “keen to impart my knowledge to train anaesthetic providers to go out into Zambia and practice safe anaesthesia.”

Over 20 COAs attended our Ndola workshop, travelling from across the Copperbelt region and beyond. For many of them this was a rare opportunity to receive refresher training and a pulse oximeter.

“This would actually make a difference, and would help save many lives.”

Chilala Hakayobe, Namwala Hospital. Delegate at the Ndola workshop.

Throughout the week I attended various sessions led by the faculty and witnessed practical demonstrations of pulse oximeter use, checklist discussions and role-play focused on supporting expectant mothers. This was particularly significant as the majority of the surgeries that these anaesthesia providers attend are obstetric. Keguin Chifunda, a delegate from Arthur Davidson Children’s Hospital stressed the importance of receiving refresher training as it provides, “the latest information on the management of obstetric cases and neonatal resuscitation.”

Although my time in Zambia was brief it really informed my understanding of what it means to support colleagues on the front line of surgical care in their communities. This workshop was a collaborative effort supported by different groups and individuals all with the goal to help improve surgical safety in Zambia. Thanks to funding from the Ministry of Health and support from the AAGBI, Lifebox distributed 33 pulse oximeters and equipped 21 anaesthesia providers with the skills and knowledge to provide better anaesthesia care to their patients.

So what have I learnt over the last 18 months in my role at Lifebox? It was and is clear to me that partnerships are crucial to making safe surgery and anaesthesia a global reality. From our Ndola dream team who use the very oximeters we distribute, to our group here at Lifebox, chaired by renowned surgeon Atul Gawande. Surgery and anaesthesia are vital to global health, and ensuring access to safe, affordable care for those in need takes team work.

Want to help? / Click here to donate to Lifebox, or help the AAGBI to reach their target of £96,000 in their Lifeboxes for Rio fundraising campaign.

Photos: Kristopher Anderson, Lauren Anders Brown, Luca Koritsanszky, Sandra Leal & Sandra de Izquierdo. Patient images taken with consent.

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If you spend enough time in remote places, or doing the kind of activities that (we feel) make life worth living, then it is inevitable you will come across death at some stage. It might even be you who dies. We all will die at some point after all, but what happens if you die in the wilderness, or on expedition? How do you get home? What happens to your property? As medics, we are often pretty ignorant of legal matters, and we are notably bad at planning for our future. We asked climber and skier Thomas Taylor, Director of Net Lawman about preparing for the worst.

It is human nature not to want to consider in too much depth what would happen in the case of our own death. Yet, just as vaccinations are a standard part of preparing for a trip abroad, making sure that your money, possessions and life assurance payouts go to the people you want should be as well.

Your body

When you die, you no longer own your body. That means that in theory, you have no say in what happens to it after your death. In practice, however, most people leave their wishes in their will, which their family follows. If you’re on expedition, following your wishes may be much more difficult.

Your body may be held by legally recognised authorities (such as the police) in the country in which you die so that they can carry out investigations into the cause of your death. That can take time, and may limit what happens to your body. Your family will also need to register your death in the country where you die in order to obtain a death certificate.

So if you’re abroad for any reason, holiday or work, it’s a good idea to have an insurance policy that covers repatriation of your body (that is embalming it, buying a coffin and transporting it back to the UK). The cost of this if you die in a remote place, can be really high and would otherwise be borne by your family or by you.

Your will

Every adult should make a last will and testament. Doing so is the only way you can control who inherits your money and possessions.

If you haven’t made a will (in legal terms if you die intestate), then the law sets out the order in which people inherit your estate – that is what you own after any debts have been repaid. Despite you no longer being alive, your estate can still be sued for your negligence while you were alive on the expedition. If the claim is successful, then it might create further liabilities to be paid from your estate alongside any other debts, depending on the terms of your professional indemnity policy.

It is important to be aware that some of the people you would assume the law would recognise as having an interest in your estate, do not by default. That is one reason why making a will is so important in looking after those you leave behind.

What makes up your estate?

Anything you own by yourself, such as jewellery belongs to you. Things that you own with someone else can be owned in two ways: either jointly or in specific proportions. Unless you have made an agreement that sets out the split of ownership, you own the things jointly.

The type of things that you might own with someone else, such as an unmarried partner, include real property, such as your home, and joint bank accounts or investments.

When you die, any jointly owned assets immediately pass automatically to the other owners. Your ‘share’ does not form part of your estate (except for tax purposes). The implication is that because it is not part of your estate, you cannot nominate who receives it in your will.

If you want to leave your share of a co-owned asset to someone who isn’t the other owner, you need to sever the joint tenancy and become tenants-in-common. Despite the legal jargon, the process is as simple as the joint owners stating in writing that they agree to do so, and recording the ownership shares.

Who has an interest in your estate?

Rules regarding intestacy set out who receives your estate if you haven’t made a will. There are two things of particular note.

Despite the law of intestacy being updated in 2014, unmarried partners are still not entitled to a share of your estate by default. There is no such thing as a common-law partner (including in Scotland, where before the Family Law (Scotland) Act 2006 was passed, cohabiting partners used to have some of the rights of married couples in certain circumstances).

So if you live with someone (regardless of the length of your relationship) but you are not married, the only way of making sure he or she inherits what you want them to is to make a will.

The other consideration is the default position if you are married and have children from earlier relationships. If you are married and have no children, then your wife or husband inherits all your estate. If you are married and have children, then your wife or husband is entitled to the first £250,000 of value in the estate, and half of the remainder. The other half of the remainder is split between your children, and they inherit it when they reach 18 years of age.

If you have children from earlier relationships, then this may not be what you want. Firstly, you may want a greater proportion of your estate to pass to them. Secondly, you cannot guarantee that your current spouse will leave any of his or her share of your estate to them. Particularly if he or she remarries, then your estate may be passed on to people you don’t know (his or her future spouse and their extended family), and not your own children. The only way you can be sure that your children benefit from your estate is to name them in your will.

Property ownership where the deeds are in one person’s name only

In unmarried relationships, one person might have bought a house using his or her savings as a deposit and taking a mortgage out in his or her name. The other person might, however, contribute to the mortgage and running costs.

In law, contributing to the mortgage does not give someone an automatic right to a share of ownership. The default position is that you are paying rent under a lodger arrangement.

To be entitled to a share of the property, you need to have an agreement in place (usually within a document called a cohabitation agreement) that states how your payments affect your relative ownership. It is not practical to update the deeds regularly to reflect this share (and in any case, the mortgage provider may not allow it), but an agreement will support your claim that you are entitled to the proceeds from a sale.

Life assurance payouts

The NHS Pension Scheme gives life assurance cover for death in membership, but to be eligible, you must be contributing to it at the time you die. It is likely that you will continue to do so if you are taking holiday, unpaid leave or authorised leave, but you should double check if you are out of contract or training or away for a long period.

The Scheme pays a lump sum (called a Death Gratuity) on your death. The amount depends on which Section of the Scheme you joined, but roughly equates to two years of pensionable pay.

You can nominate who receives this and no inheritance tax is payable on the amount.

It also pays a “short term” pension to your wife, husband or civil partner for six months. If you are unmarried, but have lived with someone for more than two years, you are usually able to nominate your unmarried partner to receive this pension.

If you have contributed to the pension scheme for more than two years, then a “long term” pension may also be payable after the six months. The amount depends on how much you have paid into the Scheme.

Additionally, an allowance might be paid to your children under 23 years of age if they are financially dependent on you.

Planning for the death is not difficult

Expeditions aside, all adults should ensure that what happens if they were to die unexpectedly is what they want to happen, whether or not they’re going to a remote place or staying at home. It is not difficult, nor expensive – just a little more personal administration.

An upcoming trip is as good a prompt as any to consider whether those you love would be looked after and possessions distributed as you would like should you die.

Making a will

A will is one of the only legal documents that is recognised across all the jurisdictions of the UK. A will written under English and Welsh law is just as valid in Scotland as if it were made under Scottish law. So if you are a Scottish or Northern Irish resident, you can use a (usually cheaper) English will writing service.

Be aware that to be legally valid, a will needs to be signed and witnessed in a particular way. If you just leave a signed letter setting out what you want to happen, it will not be legally valid and your wishes will not be followed. But making a will doesn’t have to be expensive. You don’t need to use a solicitor. If your situation is uncomplicated (an estate worth less than £325,000 and no assets abroad) then there are a number of suitable templates that you can download online. For example, our company, Net Lawman, offers free templates and online will writing software. We also offer an optional low-cost review service if you would then like to have your will checked by a qualified will writer.

Further reading

You can find out more about the two types of joint ownership: “joint tenancy” and “tenants in common” in this article.

You can also read more about the rights of cohabiting couples and using a cohabitation agreement.

The BMA provides a summary of NHS pensions and death in service that is easier to read around than the guidance provided directly by the NHS.

Photo: Captain Robert Falcon Scott’s Party at the South Pole, 17 January 1912 (WikiMedia Commons)

The post Preparing for the Worst appeared first on Adventure Medic.

Colin Henderson is a mountain and adventure sports photographer from Edinburgh. A digital project manager by trade, he took up photography fairly late in life, at first teaching himself the basics then perfecting his craft shooting friends and athletes at play in the mountains. His website is inspiring to anyone who loves the outdoors. We caught up with Colin to ask about his work, and to get some tips on improving our own adventure photography. We covered location, lighting, shooting angles, equipment, editing and resources – all you could need to shoot your next expedition in style.

Being an Adventure Sports Photographer sounds pretty good! What are the best parts of your job?

The best parts? I love being outside, especially at the start and end of the day when the light can be so magical. Visiting new places is always exciting (although I’ve realised you don’t have to go far to document adventure – there’s plenty gems in Scotland that I’m still discovering, despite travelling extensively over the country for years).

I do like seeing athletes perform well in their chosen environment, be it a runner in the mountains or a kayaker going down white water. There’s something very pleasing about seeing people who are really good at things do them really well. Being there to capture it on camera is a privilege.

Before I even get to a shoot, I enjoy the preparation that’s required. I love the process of marketing myself, pitching for work, researching ideas, scouting out locations and considering what equipment I’ll need to meet a brief (though see below). I also enjoy creating or reviewing production sheets, agreeing shot lists with the client, thinking about the digital tech, etc. Very often I’ll do all this myself but I will employ people to do parts of the process – I really like working with other creatives.

How about the worst?

The worst parts? I don’t like travelling. I’m slightly OCD and packing for a trip is stressful for me as I’ll pack and re-pack things in the run up to leaving, for no real reason. Taking off and landing in a plane are also necessary evils I could do without. Photography equipment is heavy and carrying equipment, especially up and down hills is hard work. There are days when I long to go out with just a waterproof in my rucksack. I always regret though not having the ability to capture things in one way or another – I’ll need to buy a Go Pro.

What has been your favourite shoot so far?

I was invited to Southern Chilean Patagonia to photograph the Patagonian Expedition Race, a 700km mountain biking, kayaking, trekking and mountaineering challenge for teams of four. The media team was a mix of video and still photographers from around the world and I still keep in touch with many of them. Our brief was to follow the racers and document the arduous nature of the race. It was epic. The landscape in Chile is wild, like Scotland I’d imagine thousands of years ago, and it made for a huge adventure.

I’d been to Patagonia before – I’m the author of a trekking and travel Guidebook to Patagonia’s Los Glaciares National Park, which is home to peaks such as Cerro Torre and Monte Fitz Roy – but not to Chile.

I’d love to shoot, Iceland, Norway, the Lofoten Islands and Pakistan.

What makes a great adventure sports photo?

What someone defines as a “great” photograph is generally a very personal thing but when I see an image that really captures my attention, it’s usually because two or more of the following have taken place:

People / Someone’s captured a dynamic moment in a really creative way;

Place / They’ve used an inspiring location (either one I’ve not seen before or, if I have, it’s photographed in a unique way) that really connects me with the scene and helps me understand what’s going on;

Lighting / They’ve made great use of natural or artificial light to bring the image to life.

There’s lots of good photographers out there ticking these boxes. But if you can do all three, consistently, on trip after trip. shoot after shoot, or for client after client, then you’ll start to stand out from the crowd.

What should we focus on to improve our pics?

Take shots when it’s wet and stormy. Take shots when other expedition members are tired. Take shots when you’re tired. Get up before folk and go to bed after them.

The best advice I received when I was starting out was to always have my camera readily accessible (I use a Lowepro Toploader pack and carry it over my chest) and take lots of shots. The former was great advice because it’s difficult to take lots of shots when your camera is in your backpack and the latter was because it set me up to give myself the best chance of capturing the right postures and the most dynamic movements when shooting athletes. I quickly realised that the more shots I took, the easier it was to understand what worked in different scenarios and what didn’t. It greatly increased my learning curve.

If you’ve plans to document an expedition you’re on, I’d recommend thinking of the story you’d like tell with your photos and then build up your ideas from there. Consider wide angle shots showing the environment of the adventure, then look for details in the landscape that brings a viewer closer into the action. Don’t forget the detail shots – the packing and approach, the taped, bloodied hand of a rock climber, the portrait of a weathered face that portrays the impact of a life spent outdoors or the close-up view of a wrinkled, callused hand of a whitewater paddler.

Take shots when it’s wet and stormy (especially take shots when it’s stormy – the light can often be amazing). Take shots when other expedition members are tired. Take shots when you’re tired. Get up before folk and go to bed after them. Do everything you can to create images you’re proud of and want to share. Then share them as wide as you can – on a website or just on social media, it doesn’t matter. Think of ways you can solicit feedback and then see what you can do to improve. It’s a constant learning curve. One which can be hugely rewarding when you get home and realise you’ve got something you really can’t wait to share, both with those on the trip and the wider world.

How do we make the most of the place in our shots?

Backdrop / I’ll almost always start by thinking about the landscape first and then framing my images based on what I see in front of me. If I want the landscape to be a key element in a shot, say on a trekking or a mountain biking shoot, I’ll look for things that help bring depth to a scene (e.g. something in the front, middle and back of the image) and I like to have a strong horizon, e.g a jagged mountain ridge, that will help me offset an athlete in the frame). On a surfing shoot, where the landscape may be less of a priority, I may look instead to where the waves will break in a frame, so I can position the surfer accordingly, Whereas on a shoot with lots of graceful movement, say for a capoeira shoot, I may choose to ignore the landscape altogether and focus completely on the athlete.

Position / Once I’m happy with how I’ve framed the backdrop, I’ll consider how best to position a person or persons within it. When composing an image, I like simple backdrops, with no distractions around the athlete and really clean edges to the frame (which I think is super important – having things sticking into or out of your image can be very distracting when you’re trying to focus your viewer’s attention solely on a key element). To help you picture where I add people into my shots, think of an imaginary grid. My aim usually is to position folk on the horizontal and vertical intersections, either entering or exiting the frame. But I’m not averse to placing athletes right into the middle of a scene, if I feel it looks good.

Angle / There’s no specific position I’ll put myself in when taking a shot. I do though like being above a person so I will often look out e.g. rocky outcrops that I can climb upon and take in more of the scene. If there’s nothing suitable I’m not averse to bringing a step ladder with me, if the location accommodates it. Or standing on the roof of a Land Rover. One tip I’d share would be to try and get yourself into a position that someone taking a snapshot of the scene wouldn’t think of. Get up high or lie on the ground. Do both. And then try something else. Move around and concentrate your efforts on maximising the shot potential in every scene.

And how about light?

Very simply, get up early and stay out late. Then get up early again the next day. Maximise the time you’re out shooting when the light is good. Don’t discount days when it’s really cloudy, as the sun can break through and shine magical light onto your scene in seconds. Consider adding your own light if the weather, or your vision, warrants it: for example, using a reflector or a flash to call attention to a certain part of the image, such as an athlete’s face or clothing.

Technology-wise, mobile apps such as Sunseeker are indispensable. They show the trajectory of the sun through the day, and more. When you’re researching a location, or you’re on site, think about where the sun currently is and where it’s headed. At dawn and dusk, an obvious position to place yourself would be facing east or west. If you’re shooting then, or through the day, consider positioning yourself at right angles to the sun or even shooting right into it, and see what drama it adds. Do your shots look better? There’s no right or wrong. Try things and see what happens. And endeavour to learn from them.

How do you edit down your pictures to the best images?

I have what I find to be a very efficient workflow to go from 1000s of images down to the select few I’ll deliver to a client.

Downloading / It starts as soon as I return from a shoot, when I’ll download all the images from my memory cards onto my desktop computer (though I may possibly have already backed the images up on location to my laptop computer too – I like to have redundant copies as quickly as possible). Once the images are transferred to my main working drive, I have two copies. I don’t remove the images from the memory cards until I have at least three copies elsewhere. Then I can reformat the cards and they’re ready for me to start shooting again.

Editing / To start my editing process, I’ll copy all the images from a shoot into a folder on my computer. I’ll then import the images into Lightroom and use Lightroom’s filter capability to rate them 1, 2 or 3. Once I have highlighted the 1 star images (which I’ll reject because, e.g. an athlete’s eyes are shut or I’ve captured the wrong body posture and it doesn’t make for a very dynamic image, or the image isn’t perfectly in focus), I’ll remove these both from Lightroom and my hard drive and they’re gone for good. I do this very quickly – an image either stays or goes on first glance and I don’t tend to revisit my choices.

Processing / Once I have a library of rated images, I can go through these in more detail and identify which images most meet the brief. I’ll repeat the rating process, marking on-brief images as 3 star until I have a selection of images I am happy to do some basic processing on and share with the client. Once I have a client’s selects, I’ll rate these as 4 star, complete the processing of them to suit their requirements, keyword and caption them and share them to finish the job. (5 star images are rare – I’m very picky – and usually will make their way into my website portfolio).

I’ve written a blog post about my photo workflow process and shared it on my website – I’m happy to answer any questions about it.

Printing / For a long time, I’ve used a professional print shop in England, a small business I scouted out first online then used to print lots of test images to see the quality they provided. Recently, I’ve re-branded my portfolio book and used a printer in Edinburgh. I like the idea of being able to visit a supplier to see the print process and I think it’s valuable to support local businesses.

What equipment do you typically carry?

The camera gear I carry depends on the shoot but my basic kit (say for a trekking shoot when we’ll be travelling hut to hut) would look like this: professional camera body and lenses (wide angle / telephoto), memory cards (at least x100Gb), spare batteries, Sunseeker app, dry bag, lens cloths, lens blower and chamois leather.

To this, I’ll add additional or redundant gear, e.g. an extra camera body, extra lenses, speedlights or a strobe, pocket wizard transceivers, light modifiers (e.g. a reflector or a softbox), plus anything else I think I will need, as appropriate.

I shoot with Nikon equipment (for no reason other than I like the ergonomics). I find I use the 17-35mm f2.8, the 85mm f1.8 and the 70-200mm f2.8 lenses most often. If I want to travel lighter, I’ll take a 24mm f2.8 prime lens for wide angle shots and the 85mm f1.8 for close ups. I always miss not having the 70-200m lens with me though. I love that lens.

Other items of camera equipment I might take on a shoot include a Gorillapod Focus (if I don’t want to carry a full tripod) or a monopod (which is usually instead of a light stand but I’ll need an assistant to hold it), an underwater DSLR case if we’re swimming and a Macbook or iPad, so I can tether the camera and share shots immediately with the client. In short, I’ll bring anything I think I need to meet the requirements of the brief, and beyond.

I don’t mind carrying extra gear (I can always hire someone to carry it if need be) but if the job involves me moving with the athletes, e.g. along the Black Cuillin ridge on the Isle of Skye or on a trekking stage of the Patagonian Expedition Race, I’ll definitely pair my kit down to the minimum possible. It’s very hard to keep up with folk if I don’t.

What equipment would you recommend to those starting out?

I’d recommend investing in lenses over your camera body. I started out with a consumer camera and a kit lens. When I added my 17-35mm f2.8 lens I was blown away by the improvement in quality. What to buy depends really on what you want to shoot and where you think your images will end up. A GoPro or mobile phone can give you awesome pictures these days if you’re just posting them on social media. If however you’re committed to your photography, and want to print and perhaps sell your images, I’d recommend buying the best equipment you can afford, learn its limitations and shoot as much as possible.

Second hand / Don’t discount second-hand. Nikon’s D700 is an awesome camera for adventure photography and can be found fairly cheap online. (Cheap I appreciate being a relative term in an industry where the tiniest bit of plastic can cost you twenty quid). Add a ‘fast’ prime lens (e.g. a 24mm f2.8) and you have a great, fairly lightweight (again, relatively speaking) combination for documenting the action whilst you’re on an expedition. Consider adding another small prime lens, e.g an 85mm f1.8, to give a bit of variety to the look of your shots and for portraits (especially head-shots) and to help you capture a lot of the details.

Finally, any recommended resources for budding adventure photographers?

Competition-wise, Red Bull Illume is the most famous adventure photography competition at the moment. I love viewing the selects from the Maria Luisa Memorial. They are usually very inspiring.

Away from awards, US photographers Michael Clark, Tom Bol and Dan Bailey have all written books on adventure sports photography. Corey Rich freely shares his knowledge on his website or other channels, e.g. Adorama’s YouTube page and Seattle-based Chase Jarvis is renowned for sharing his and others’ thoughts on being creative and staying competitive in business. Chase is also responsible for Creative Live, an online educational resource. A quick search shows that Lucas Gilman and Corey Rich both have courses on Creative Live where they’ll teach you about adventure photography. More generally, there’s lots of information on the internet so I’d suggest you focus your education on the areas you want to improve most and keep putting things into practice.

I wish you the best of luck. I’d love to see what you shoot!

Thanks so much! To see more of Colin’s work, please visit his website. You could also sign up for his email newsletter or follow him on Facebook or Instagram.

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So, what has the Principia Mission done for science? Has it been worth the £80 million that ministers had to cough up to secure Peake’s place on the mission?

Well the BBC certainly think so:

You can assess the research he has carried out in orbit or the profile he has given to the UK’s space industry or the inspiration he’s provided to a new generation.

Tim Peake has helped to engage over 1 million school children in over 30 projects, which promises to increase numbers enrolling in STEM subjects. He has been involved with a number of ongoing experiments; inflammatory change relevant to asthma suffers, how endothelial cells age and preparatory experiments to prepare for future extended space exploration to name but a few. Lastly he has turned public, media and government attention towards Britain’s previously poorly funded space industry.

We’ve genuinely enjoyed looking into what he actually got up to, please click on the picture below to explore for yourself.

The post What Has British Astronaut Tim Peake Done For Science? appeared first on Adventure Medic.

Desperate to explore but worried about the long-term consequences of stepping off the training ladder? We’ve all been there. So far though, we’ve always found these fears to be happily unfounded. For the Adventure Medic team, our time out of training has been personally enriching, as well as helping us get on professionally.

However, we’ve all been asked to justify our decisions at one point or another, to ourselves or to to others. Louise Tossell is due to start GP training in August, has worked on several expeditions in Central America and has been involved in remote jungle medicine between her training posts. In this article, Louise pulls out some buzzwords to make your expedition shine on your job application or annual review. Specialty Training Gold!

In these uncertain times, many doctors are looking for alternatives to the traditional training pathways and are considering a break from full-time work in the NHS. Expedition medicine is an attractive proposition, providing opportunities for travel and adventure around the globe. But how can working on expedition help you progress? The General Medical Council’s Good Medical Practice requires a doctor to demonstrate many professional qualities and to continue to develop them throughout their career, and gaining some experience in this out-of-the-ordinary speciality can do just that.

In August 2013, when I had completed my second year of Foundation Training, I decided to step off the training ladder and try something different. After attending an Expedition Medicine course, I applied for a post with Raleigh International and in 2014 I set off to Costa Rica as a medic on their summer expedition. As a multidisciplinary team of eight UK medics, we provided training, support and medical care for approximately one hundred and forty staff and volunteers across two countries. We treated a wide range of conditions requiring knowledge of occupational health, acute medicine, trauma care and ENT, to name but a few.

What exactly is an expedition medic?

The role of an expedition medic is exciting and varied, and may involve: pre-expedition planning; the provision of training and medical support at the in-country headquarters; being the on-site medic at static projects; or acting as the mobile medic on trek. The reality of the job, however, is that you will often not do much medicine at all… Medics will usually be expected to fulfil additional roles on a trip, stepping sideways into the clinical role as and when required. For example, on a Raleigh expedition the medics are as much project managers as the non-medical volunteer leaders; you are required to organise and lead a sustainable development project or to head up a trek, alongside a team of young volunteers whose personal development you need to guide and nurture along the way.

The definition of ‘medicine’ itself is different from that which you might expect. I recently returned from a trip with the British Exploring Society, as one of three medics on the expedition in the Peruvian Amazon. During my time there I was involved in CASEVAC planning and reconnoitring the local hospitals and clinics before the main party arrived. One memorable day involved rising before dawn to travel upriver and visit the nearest town, where a group was scheduled to take part in a community project. My job as part of the recce team was to visit the medical centre, view the facilities, and speak to the staff about the extent of treatment they could provide to ensure that it was appropriate for use by the expedition. We also needed to identify a safe campsite with adequate access to water and a clear evacuation route in case of medical emergency, and to visit and risk-assess the intended worksite. Not a typical set of tasks for the average NHS doctor.

On our return to camp, I was greeted by the request “stitch me up, Doc”. One of the leaders had sustained a head injury while clearing an area of ground with a mattock. Suturing a scalp laceration in the dark and the rain, by the light of a head torch, in the middle of the Amazon? Only on expedition.

So how do you tick that CPD box?

The worry for anyone taking time out, not infrequently bolstered by the scare stories of those who have not, is that it might be difficult to justify the decision at interview, on application forms, or at any medical review panel. Here are just a few of the many reasons that this argument holds no water. After all, everyone loves a CPD buzzword:

The demands and scope of expeditions provide ample opportunities to apply both practical and managerial skills; from dressing wounds and splinting, to record-keeping and accounting. Arguably though, the most important skill for an expedition medic is that of effective communication. Working internationally brings with it a wide demographic and a variety of languages and cultures, and – in addition to interacting with the people on expedition – you may come into contact with local communities and medical services, or have to liaise with medics and relatives at home. Telephone triage is a big challenge, especially with a language barrier, and requires a cool head and logical thinking to decide whether to treat in the field or evacuate the patient to a secondary medical facility. It is tricky, too, to advise a non-medic over the phone to perform an examination and then to gain a clear description of their findings, in order to form a management plan. All these situations require clear, concise communication. I distinctly recall a series of conversations with the non-medic leader of a group isolated on a mountain, for whom English was their second language, using a poor phone line which often cut out – trying to explain how to assess a participant’s neurological symptoms before darkness cut off their evacuation route was more than a little challenging.

I have been fortunate during expeditions and events to work alongside paramedics, nurses and first-aiders, as well as doctors from various specialties. The opportunity to work with such a team on expedition is invaluable, as the sharing of knowledge and experience helps everyone to pick up amazing tips, and enables you all to provide great all-round care for participants. It also fosters a true appreciation of each healthcare professional’s role, both within the event team and in the UK health service. You may be required to deliver first-aid training to expedition participants; a useful exercise in itself, but doubly valuable from an educational perspective when delivered by a multidisciplinary team. Doctors in training are expected to provide evidence of teaching experience, and the opportunity to teach groups of non-medics is an interesting and rewarding one: harder to find, perhaps, in a hospital environment.

Expedition medicine often calls for strong leadership skills, especially during casualty evacuations. A group may instinctively look to the medic in an acute incident; not just to deal with the casualty, but for general and logistical guidance. In such circumstances, you will have to communicate with headquarters, delegate roles to other group members and facilitate the evacuation procedure, as well as treating the patient. These are excellent learning opportunities from both a clinical and personal point of view, particularly when married up with good reflective practice – and you will definitely have plenty of fodder for that. At the expedition headquarters in-country, the medic may be involved in the planning of a MEDEVAC (non-urgent medical evacuation of a casualty) or CASEVAC (urgent evacuation for treatment), alongside non-medical staff members. This can be a fascinating insight into the crisis management procedures of an organisation, and provides rare experience of the organisation and logistics required to successfully carry out such an operation. Teamwork, communication, time management and task prioritisation all come into play, while at the same time you need to provide medical advice to those in the field with the casualty. There is much to be learned from being part of a practised and efficient multidisciplinary team working behind the scenes in an emergency, and these skills are just as important and applicable when participating in an A&E trauma call as they are on expedition.

Another of the appeals of this speciality is to develop the ability to work with limited kit and resources, in environments far from the cleanliness and order of an NHS hospital. Washing an eye out with an IV giving set in the middle of the jungle, for example, will later make you truly grateful for the comparative luxury of an A&E Minors department! Problem-solving, lateral thinking and the ability to make-do and improvise promote self-sufficiency and a diagnostic mind, essential for every clinician. In our current world of cut-backs and budget restrictions, a medic who has learned to appreciate the resources available and to use only what is needed, without waste, is a very useful one indeed.

Tempted to give it a go?

There are several UK-based organisations which recruit medics at various levels of training to provide support on expeditions. If you have some A&E experience, are at least post-FY2 level and have an Expedition Medicine course under your belt, you’re often eligible to apply.

Communication, teamwork, organisation and resourcefulness are just a few of the characteristics thought by the GMC to be vital for every doctor. I am not advocating that a life practising medicine in the wild is the only way to gain these skills; rather that seeking some experience in expedition and wilderness medicine, alongside a career in the NHS, can provide novel and exciting opportunities for continued professional development.

Editor’s Note

Adventure Medic Director Matt Wilkes is a seasoned time-outer and has always been able to sneak back into training. He has the following advice for anyone concerned about the UK application implications of taking time out:

Applications shouldn’t be the first thing on your mind when you step out of training. Instead, your thoughts should be about how your decision will enrich your life: what you’ll learn as a person and a doctor and the incredible opportunities and experiences now open to you. Many of your future colleagues and employers will be sympathetic and see that as ‘justification’ enough. When talking to those who are still sceptical: own your choices, be enthusiastic about the path you have taken and what you have learnt as a result. They may not agree with your decisions, but they will respect them.

However, I do know that the decision not to apply to the next stage can be daunting. In UK training, there is always another rung on the ladder in easy reach and the pressure from colleagues to grab it immediately can be quite intense. So, please remember you lose no points on UK specialty training applications for taking time out. Yes, there are time limits for how much extra specialty experience you can gain, but expeditions and other adventures do not count there. There is also a section on most forms asking you to list any breaks in employment but this is for occupational health reasons – they want to know if you were in bed with back pain or locked up in jail – not to punish you for going on safari.

In fact, you can only gain application points (and experience) from going away: use a small fraction of your time to do an audit, a presentation, an interesting course, write a letter or an article and you’ll be swimming in points that you would have missed out on if you had applied straight away. Look at person specs for the job you want and fill in some of your blanks in between travels. Each job and specialty is unique and frequently updated, but see the NHS Speciality Training 2015 Person Specifications for guidance. You’ll be at the top of the pile in no time.

Finally, think about who is giving you advice. We all like to feel we have made good decisions in life, so a doctor who has taken no time out of training might be more likely to recommend that you don’t either, as that helps validates their own decisions. The same applies equally to us, we want you to take time out to explore because we have too. So, take advice widely from all camps – it is sometimes good for people to tell you what you don’t want to hear – but take it all with a pinch of salt. You only have one life, think about what you actually want to do with it and then get on and enjoy it. Then, write in and tell us all about what you got up to.

Further Reading

For more information on CPD and what’s important according to the UK’s General Medical Council (GMC), see their Good Medical Practice and Tomorrow’s Doctors guidance.

Looking for some bed-time reading before a trip away? Try Expedition Medicine by the Royal Geographical Society. Warrell, DA and Anderson, SR. Expedition Medicine. London: Profile Books Ltd, 2002. Print.

Visit the British Exploring Society, Raleigh International and our own Resources pages for up to date information on expedition links both in the UK and elsewhere.

Click here for our article on Breaking into Expedition Medicine and consider reading our piece on the Top Ten Skills To Master for the Expedition Medic by Harvey Pynn, Medical Director of Wilderness Medical Training.

Photos: Louise Tossell

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