Keith is an academic foundation doctor who is aiming to specialise in emergency medicine with a focus on pre-hospital critical care. For his final year elective, he spent four weeks in sunny South Australia split between pre-hospital critical care service, MedSTAR, and the Royal Flying Doctor Service (RFDS). Keith gives us the run-down of his elective: what to expect, the highlights, and how to plan your own.

MedSTAR Retrieval Service

MedSTAR is a part of the South Australian Ambulance Service and responds to adult, paediatric, and neonatal primary emergency retrievals as well as secondary inter-hospital transfers. The operational base located at Adelaide Airport includes a fleet of road ambulances, rapid response cars, and Bell 412 helicopters. Each retrieval team is formed of one retrieval doctor and either a nurse or a paramedic, all with a background in, and an ability to provide, critical care. Team activation and tasking are made by the decision of the medical retrieval consultant (MRC) supported by retrieval nurse consultants at the Emergency Operation Centre (EOC). MedSTAR also collaborates with RFDS to attend long-range or inter-state missions by fixed-wing aircraft when retrieval locations are out of coverage by helicopters.

Shift Pattern

Retrieval teams work in a 12-hour shift pattern, starting with equipment and vehicle checks, operational briefing with weather forecasts, and sometimes followed by teaching or simulation sessions. As an observer, I was expected to mirror the same working pattern as everyone else. Sometimes shifts run beyond 12 hours due to the  clinical complexity or unexpected weather conditions which increased the mission’s difficulty (and duration). Finish times in retrieval medicine are a target, not a certainty, so don’t be too ambitious with your post shift social plans!

Typical Day

The typical day consisted of attending base, completing the morning briefings and then awaiting tasking for a retrieval. Some days were slower than others so it’s worth have a good book or a podcast handy. Even better, getting the opportunity to learn from the retrieval team and hearing their stories was fascinating. There is a specific observer bleep which goes off when there’s a tasking and you can choose whether to observe the adult or the paediatric retrieval teams. Every observer must go through a safety briefing and an orientation in the operational base and with RFDS on their first day before attending any missions. The only limitations of observers were that we were not permitted to attend helicopter primaries due to space and weight restrictions, or any helicopter missions that will fly over water as this requires completion of the Helicopter Underwater Escape Training (HUET).

Case Mix

During my time with MedSTAR and RFDS, I was able to shadow a huge variety of retrieval missions and interesting cases, on both helicopters and fixed wing aircraft, and no day was the same. Cases ranged from neonates with cyanotic congenital heart disease, adults with status epilepticus, major trauma, cardiac emergencies such as complete heart block requiring transvenous pacing, cardiac arrest post myocardial infarction, or any patient requiring critical care support and transfer to a larger hospital.

Unforgettable missions

Who to retrieve?

One of the most unforgettable cases was when we received a task to retrieve a patient with worsening respiratory failure due to Covid infection. On arrival, when we walked past the small rural resuscitation room, the staff approached and asked us to review another 2 critically unwell patients who also needed retrieval. Now we have 3 patients: a child with small bowel obstruction, a young adult with severe asthma, and a middle-aged patient with COVID pneumonitis. The aircraft was designed to accommodate one stretcher only, and herein lies the challenge of retrieval medicine: being able to prioritise, and work in resource poor environments with complex logistics. I questioned myself, if I were the retrieval doctor, what decision would I make? Through discussions with the emergency operations centre, senior clinicians at the statewide telehealth service, and doctors back in Adelaide hospital – alongside challenging logistics – a plan was made. Multi-disciplinary teamwork at its finest! Ultimately, the patient with Covid was flown to Adelaide, the child had their initial surgery locally and underwent delayed retrieval whilst the asthma patient was stabilised and no longer required transfer. Our team ended up returning to base at midnight!

Taking critical care to the patient

Another notable case was a large-volume variceal bleed secondary to end-stage liver disease. The patient was extremely agitated, haemodynamically unstable, with profoundly deranged coagulation and metabolism. One of the challenges of retrieval medicine is the environment of flying – you often have limited access to your patient, you have limited equipment, supplies, and personnel, all the while it’s cramped, noisy and there’s multiple distractions. Ideally, patients need to be stabilised pre-flight and any procedures completed before take off. This patient required central venous access, an arterial line to monitor inotropic requirements, multicomponent blood product resuscitation and multiple intravenous infusions and was intubated and ventilated. The process took 4 hours on the ground – bringing critical care skills to the patient is one of the key aspects of retrieval work. However, the most difficult part of the retrieval was not managing the patient’s condition, it was the logistics of transfer. From resus to ambulance, ambulance to aircraft, aircraft back onto an ambulance, then ambulance to ICU, multiple times of bed-to-bed transfer, can you imagine how chaotic it is when you have to take care of a patient who might deteriorate anytime en route, while cautiously looking after all those tubes, lines and machines?

Rural Medicine

GP Anaesthetist

The sheer size of Australia means you can be a long way from a hospital and healthcare. Practitioners providing rural healthcare require a unique set of skills. While attending retrieval missions in the outback, I discovered several fascinating concepts that do not exist in the UK. According to the Australian Institute of Health and Welfare, about 28% of the Australian population, approximately 7 million people, live in rural areas [2]. Nevertheless, most rural hospitals are too small to maintain 24/7 specialist services onsite, for which I discovered the role of rural GP anaesthetist (RGA) [3]. The training programme itself was first launched in 2023, with the aim to provide rural generalists skills to deliver better care for remote communities to meet thedemand for anaesthesia in emergency and elective surgeries, maternity, resuscitative and post-resuscitative care.

Standardisation for emergencies

Standardisation of healthcare in the rural setting was evident when attending remote hospitals. Across all resuscitation rooms, there are “Can’t Intubate, Can’t Oxygenate” (CICO) kits. This equipment is standardised across hospitals in the entire SA region. Although CICO is an extremely rare airway emergency, it is time critical, and the presence of the standardised CICO kit allows a shared mental model and process for all staff involved in resuscitation. The kits are prepared for “grab and go” in such a situation and the procedure delivered rapidly by the team [4].

Enjoying Australia

Time at work was fantastic but I also made the most of my time outside of it. The weather was stereotypically Australian, being perfect every day with sunshine all round! I had chance to catch up with relatives in Sydney and got shown shown round the city taking in some of the iconic spots including the Opera House and Harbour Bridge. Australia is known for it’s brunch and coffee culture and it did not disappoint!  As a space enthusiast, I couldn’t resist visiting the Australian Space Discovery Centre the moment I landed in Adelaide. Most weekends were spent having a walk at the Botanic Garden, followed by wine tasting at the National Wine Centre of Australia or beer in the sunshine, and of course, who doesn’t like an ice cream on the beach?

Reflections

I thought retrieval medicine was attending incidents and performing dramatic procedures to save patients from life-threatening injuries. I soon realised this was not true when I shadowed my supervisor for a shift in the Emergency Operation Centre. Retrieval medicine presents many challenges beyond the clinical. Coordination, resource allocation, remote clinical advice is just as important. From the moment a retrieval referral has been made, the consultant provides clinical advice to the referrer, determines the urgency and complexity of the case, sends the most suitable team with the most appropriate mode of retrieval (by air or land), plans the landing site and receiving destination, as well as updating all involved parties. Not to mention, all decisions are limited by multiple factors, including weather conditions, destination terrain, crew/aircraft/bed availability. Now take a minute to put yourself in the retrieval consultant’s shoes (or crocs), imagine the challenges of bandwidth, cognitive overload, decision fatigue and need for continual communication. I really enjoyed the dynamism of retrieval work and it was a privilege to get an insight into this unique area of medicine.

Elective Opportunities

MedSTAR

The MedSTAR observership elective programme only takes two international students per year. Only one medical student observer can be accommodated at one period of time (usually between 4-6 weeks) to maximise learning opportunities and exposure. No elective fee is required and in return observers are expected to do an end-of-placement presentation and assist with any ongoing audits/research. Uniforms are provided but observers need to purchase a pair of safety footwear. I booked my accommodation in Adelaide city centre which is 15 minute commute to the operational base by car. Public transport takes 40 minutes by bus and cycling is an alternative option.

“Find a job you love, and you will never have to work a day in your life”. I loved every second of my time with MedSTAR, I have never felt so alive even though the job itself can be extremely demanding! I would like to thank my supervisor Dr. Perry, clinical director Dr. Pearce and admin Tricia for offering and organising such a fantastic opportunity for me to join this observership. It was my privilege to work with all those incredible human beings in SAAS, MedSTAR and RFDS.

Funding

I would like to thank The Royal College of Surgeons of Edinburgh, Binks Trust and the Turing Scheme. Their generosity allowed me to cover the majority my travel and accommodation costs. Further information can be found on their website. I’m also happy to provide advice for others who are thinking of applying for a retrieval medicine elective.

Twitter @keithleung102 / LinkedIn https://uk.linkedin.com/in/keith-s-k-leung

References

[1] Araiza, A., Duran, M., Surani, S. and Varon, J. (2021). Aeromedical transport of critically ill patients: A literature review. Cureus, [online] 13(5). https://pmc.ncbi.nlm.nih.gov/articles/PMC8180199/ DOI: https://doi.org/10.7759/cureus.14889

[2] Australian Institute of Health and Welfare (2024). Rural and remote health. [online] Rural and remote health. Available at: https://www.aihw.gov.au/reports/rural-remote-australians/rural-and-remote-health

[3] Australian College of Rural and Remote Medicine (2023). Rural Generalist Anaesthesia (RGA) [online] Available at: https://www.acrrm.org.au/fellowship/discover-fellowship/ast/rga

[4] Ti, J.S., Dwyer, S.P., McTernan, C.N., Dunlop, B.K. and Firth, M.J. (2020). Impact of ‘Can’t Intubate Can’t Oxygenate’ (CICO) kit ergonomic design on the timed responses of participants in simulated CICO crises: A randomised, crossover pilot study. Tasman Medical Journal, [online] 3(1), pp.45–51. Available at: https://tasmanmedicaljournal.com/2020/11/impact-of-cant-intubate-cant-oxygenate-cico-kit-ergonomic-design-on-the-timed-responses-of-participants-in-simulated-cico-crises-a-randomised-crossover-pilot-st/

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As a final-year medical student with a keen interest in Trauma surgery, applying for a medical elective in South Africa was an obvious choice for Rasa. In this elective report, he reflects on a five-week rotation with the Trauma unit at The Chris Hani Baragwanath Hospital in Johannesburg, between the months of April-May 2023, and what he’s taken forward to his foundation years.

Introduction

The Chris Hani Baragwanath Hospital, known simply as “Bara”, is the third largest hospital in the world, and the largest in the Southern Hemisphere.  The hospital is situated in Johannesburg, a city notorious for being one of the most dangerous on Earth due to its high rates of crime and violence.

Conveniently located on the border of Soweto, the largest township in South Africa, this government-funded institution provides free access healthcare for much of the local population. Approximately 70% of all admissions to the hospital are emergencies, including an estimated 160 gunshot wound victims per month¹. These patients are filtered through the ever-busy Trauma unit, where they are assessed, stabilised, and then await further treatment.

The Trauma unit

The Trauma unit is split into two sections: Resus and the assessment area, colloquially known as “The Pit”.

Both of these areas are covered at all times by a team of interns (equivalent to foundation doctors in the UK), registrars, an on-call consultant, and medical students from the University of the Witwatersrand. The team is supplemented by a revolving door of international medical students and doctors of differing grades, who have arranged placements ranging from one month to one year with the trauma team. During my time, there were several Italian emergency doctors, a group of medics from the Swedish military, and a handful of German and British medical students. This made for a engaging and multicultural environment.

Shift patterns for students fall into either day, night or 24-hour shifts. Full autonomy is given to shift decisions with the request that at least one student is on each night shift to support the interns. Throughout my time, I found that there were more trauma admissions at night and therefore more learning opportunities.

When choosing shifts, I would recommend doing at least one 24-hour shift, if anything just to get a sense of what the interns have to do twice a week as part of their contract (and to gain an appreciation of the FY1 rota). Also, try to get at least one shift covering pay-day weekend or one of the local football games, as this is when trauma rates rise to their highest and you get a chance to see the unit in full swing.

The Pit

“The Pit” is the entry point to the trauma unit . It is here that all new admissions are screened, before the decision is made as to where they will receive the remainder of their care. This is the medical students’ bread & butter; an endless supply of clerking of new admissions, blood gases, and the opportunity to do more cannulas than in your entire medical school training, in the space of one shift. As a result, I rapidly developed more confidence with practical procedures, suturing and the A-E assessment of patients. However, beware, as the interns will readily reward your eagerness by distributing their heavy workload to lessen their stress. This is understandable, but may put you in some difficult situations.

Nurses are primarily in charge of organising and distributing medical stock, and have little involvement in practical procedures on the shop floor. This can, initially, be a shock when compared to their more hands-on role in the UK. However, as in the UK, taking a little time to introduce yourself, learning their names, and making small talk, can have a hugely positive impact on your relationship. It might be the difference between getting your suture pack in one minute or one hour, as well as having someone to maintain motivation with on a slow night shift.

Resuscitation

Resus houses 12 beds which are reserved for more urgent and complex trauma cases. Common mechanisms of injury include: motor vehicle accidents, stabbings, gunshots and, tragically, a high number of paediatric and adult burns.These burns are an unfortunate consequence of poor health & safety standards around cooking appliances and roadside bonfires to dispose of household trash.

Unlike the steady nature of new admissions to “The Pit”, Resus is very stop-start. Often, 3-4 hours of a shift pass by with nothing to do, before a sudden influx of several seriously unwell patients all at the same time. The benefits of spending time in Resus included learning more about the assessment and management of the more niche trauma cases, and the opportunity to get involved and perform specialist procedures (under supervision), such as FAST scans, central lines and intercostal drains.

Trauma electives can offer a unique opportunity for eager medical students looking to practise more advanced medical procedures, such as intercostal drains, which may otherwise be reserved for more specialist trainees in hospitals back home.

There is a high level of competition between international medical students, international doctors and even domestic doctors to get a chance to place a drain. Doing a procedure really depends on who comes through the doors, who happens to be on-call (and therefore, how willing they are to let you get stuck in), and who is closest to the patient when the drain kit appears. My recommendation for anyone keen on doing these procedures would be to let it be known to the team early, build a good relationship with the Reg on-call, and be confident enough with the procedure so that you know what to do when the opportunity arises.

Overall, what I gained most from this elective was much greater confidence in approaching and starting the management of a sick trauma patient. By the end of the five weeks, I felt much more adept at completing full clerkings and carrying out procedures. I gained more confidence in seeking senior advice and better prepared in presenting a complete picture of the patient. At the end of the day, it was these skills which I have found most useful to develop, and which I will be taking with me into my first FY1 rotation.

Along the way, I developed my suturing skills considerably, having sutured countless wounds on all sorts of part of the body. I quickly learned from a plastics trainee everything from suturing lips, ears and eyelids. This was a consequence of several particularly busy night shifts in “The Pit”. Other notable experiences were developing my technique with the ultrasound machine, assisting in several intercostal drains, and observing a Lateral Canthotomy of the eye at close quarters on my last night shift. The latter was a procedure I never thought I would see in person, and a memory I will never forget.

I have strived to give a brief but useful idea of what is practically involved in this elective, however, I am sure there are a lot of things I have missed. I would urge anyone looking for more information to look at Nick Dai’s YouTube videos on his time at Chris Hani Baragwanath. Nick does a wonderful job of breaking down the placement, and I found his videos immensely useful in preparing for my own time there.

Life down south

South Africa is a beautiful country with incredibly friendly and warm people. No conversation starts without first greeting each other and asking, “How are you?”. I cannot stress this enough, especially given the fear culture built around violence and crime in South Africa. I found that a little common sense goes a long way, and I was able to relax and enjoy my time there in social spaces.

Johannesburg, though arguably not the most beautiful city in South Africa, has plenty of places to explore. In my downtime, I enjoyed evening drinks with the other students at the bars on Jan Smuts Avenue, explored the Sunday markets up in Rosebank, watched a rugby game at Ellis Stadium, and made the most of the insane exchange rate to enjoy fancy dinners at local restaurants. There were plenty of cultural activities available, such as a trip to the Apartheid Museum and Constitution Hill, or a guided cycle around Soweto, all of which give a much greater context for the communities you are treating and the society within which you are temporarily staying.

For nature lovers and hiking enthusiasts, there are a multitude of options if you want to venture out of town with several incredible areas of nature all within a day’s drive from the city centre. I would recommend Mountain Sanctuary Park and Thendele camp in the Drakensburg Park, both of which have mind blowing views and the option to stay overnight in a cabin.

If you have a little time before or after your rotation to travel, I’d highly recommend a visit to Cape Town. Cape Town made for a relaxing final destination, after a busy elective and week-long tour along the famous South-East coast, known as the Garden Route. Again, there is the opportunity for many nature escapes, wine tours, a trip to Robben Island, and lots of great bars and restaurants in the city centre.

Application process

Applications for this elective, as well as all other electives at the hospital, are done through the University of the Witwatersrand. Applications can take a very long time to be processed, with minimal contact from the university. For context, I applied via email in March 2022 and did not receive my confirmation until September, with no indication of any progress. I recommend applying as early on as possible and requesting regular updates from the administration team at the University of Witwatersrand.

Accommodation & Travel

When your elective is confirmed, Witwatersrand University will normally send an email with several recommended accommodation options. Most students, and doctors, stayed in one of two accommodations: Christine Loukakis’ house or Dr Alan Peter’s house. Both are great options and overall provide very similar experiences. Christine’s, where I stayed, had the added benefit of free laundry and a cleaning services as a part of your bill, whilst Alan’s seemed slightly more intimate and social, with the opportunity to accompany Alan (a doctor, ordained priest, and certified park ranger) on the occasional safari trip. Again, broadly, both offer the same experience for a very affordable price, and there is plenty of social contact between the houses.

The only two travel options are hiring a personal car or using Uber. As someone who doesn’t drive, I was lucky to be able to carpool with other students from Christine’s to commute to Bara, and used Uber on the days when I was heading out on my own. Uber is very similar to the UK, in that it is very readily available everywhere and generally safe. It was recommended to travel in groups, with the added benefit of being ridiculously cheap thanks to the exchange rate at the time (between £2-5 per trip).

Recommendations

Fairly early on in the elective, you’re going to have to decide whether you want to spend more of your time in the hospital on placement or outside exploring South Africa. I found myself being torn between the two early on, and opted to spend more time outside exploring, as that’s what mattered more to me. It’s very much a personal choice. The students who opted for more hospital experience tended to take on more regular shifts, meaning that they bonded a lot more with the team and had plenty of opportunities to carry out procedures. However, in my experience, they were a lot more tired and less inclined to spend their evenings exploring the city, and missed out on several of the hiking trips and safaris which ultimately ended up being the most memorable experiences for me.

I was particularly concerned about needlestick injuries and HIV transmission before coming on this elective. I was keen to get a post-exposure prophylaxis (PEP) pack to bring with me, but was put off by the hefty price in the UK. To give context, needlestick injuries were very common in the Trauma department, mainly thanks to sleepy suturing in the middle of a night shift. However, to reassure you, this hospital was responsive to needlestick injuries, with the Infectious Diseases department rapidly issuing PEP, and investigating infection risks.

It is essential to bring your own personal protective equipment (PPE) with you on this elective, along with medical equipment for yourself. My personal recommendations include: a decent sized bumbag, head torch, trauma shears, medical tape, Tegaderm, alcohol gel and a box of gloves.

Goggles are also an absolute must. I cannot begin to list the number of times they stopped a jet of Lidocaine or indeterminate bodily fluid from spraying me in the eyes, and sending me straight down the corridor to the Infectious Diseases department.

In addition, a hospital name badge or ID card holder is a great way to make yourself more recognisable to both staff and patients on the ward.

If you find time, try to arrange trips to other departments and with other services. Your time in South Africa is brief, after all, and there is much to see about how medicine is practised there. I was lucky enough to accompany Dr Peters on a medical post-take shift, seeing various pathologies diagnosed with expert clinical skill, and a variety of signs that we were never taught about in the UK. Christine is also able to arrange helicopter paramedic shifts for some of her students, another experience that I will never forget.

Finally, regular power outages (known as “load-shedding”) are part of the reality of living in South Africa. They can be unpredictable and last for a long time, so make sure to bring a decent book or a chess set.

Conclusion

I hope this report will serve as a useful resource for students considering a trip to Bara, if only to give a vague sense of what life and work in that busy Trauma unit can be like. For others, I hope it was an interesting read.

I deeply enjoyed my time at Chris Hani Baragwanath Hospitaland and in South Africa, and I am already planning to return later in my medical career. 

Links
¹https://www.chrishanibaragwanathhospital.co.za

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Dr Laura Appleton recently completed her medical degree at King’s College London and now works as a Foundation Year 1 Doctor in London. As a student, Laura developed interests in expedition and pre-hospital medicine and was involved with the university’s Wilderness Medicine Society. In this article, she shares with us stories and advice from her elective with the Royal Flying Doctors Service (RFDS) in Western Australia. Laura recounts in-flight intubations, lightning strikes and avoiding snakes during what sounds like the ultimate pre-hospital elective.

I was very fortunate to do an international elective following the pandemic. My key goals for elective were to have an experience unique to standard UK hospital placements and to experience different cultures. A retrieval medicine elective with the RFDS in remote Western Australia ticked every box.

Royal Flying Doctors Service

RFDS is a national retrieval and patient transfer service, which also operates remote GP clinics. I was in Port Hedland, a remote town in Western Australia. I joined a range of retrieval flights, both doctor-accompanied and flight nurse-only flights. Flight taskings are categorised as:

• Priority 1 (P1): Life-threatening emergency. Always doctor-accompanied, and the flight departs as soon as possible.
• Priority 2 (P2): Urgent medical transfer. The flight departs quickly and will be doctor-accompanied if there is the possibility of patient deterioration or complex management.
• Priority 3 (P3): Elective transfer for routine transfer of patients, with a target response of <48hrs. These are flight-nurse only, and can often be collected as add-ons after other patients.

Joining a number of P1s meant I had a truly unforgettable experience. P1s ranged from blunt force abdominal trauma from a mine site equipment injury to early labour. Most commonly, I joined P2s, with conditions such as appendicitis and pyelonephritis. During these flights, I assisted in basic A-E assessments, history-taking and documentation. In addition, owing to the size of Western Australia and most tertiary care being in Perth, RFDS receives funding to transport patients between hospitals. One particularly moving experience involved returning a patient with terminal cancer to her hometown and loved ones after a lengthy hospital admission in Perth.

The most memorable experience of my elective was a P1 for a suspected PR bleed in an elderly patient. Upon arrival at the airstrip, the patient was shocked (systolic BP <50mmHg). A rapid handover and assessment did not reveal signs of bleeding or an obvious cause for the patient’s condition, with the patient being drowsy but responsive. The patient rapidly deteriorated once in the aircraft, becoming extremely agitated and combative. The doctor, flight nurse and I tried to prevent the patient from thrashing around, which escalated to a safety issue. Consequently, an emergency in-flight rapid sequence induction was performed to intubate, which had been deemed a last resort given how haemodynamically unstable the patient was. For over three hours the doctor administered vasopressors and emergency drugs, set up the ventilator, and intubated the patient, before inserting an NG tube as we came into land. Meanwhile, the flight nurse was administering drugs and running blood gases. I was drawing up additional morphine and midazolam, and assisting with calming the patient. All of this in the back of a small aircraft was a truly eye-opening experience into retrieval medicine. I learnt valuable lessons in teamworking, communication, the importance of preparation and drawing up emergency drugs prior to flight.

Cultural Differences

My elective provided a fantastic insight into the differences between British and Australian healthcare, including respective healthcare systems and patient populations. Roughly 3% of WA’s population are Aboriginal or Torres Straight Islanders (ATSI), with this figure ranging from 18% in Port Hedland to 85% of the population further inland. I learnt about the beliefs that ATSI people hold about their land, society and relationships. For example, ‘dreamtime’ refers to the understanding of the deep connection to the land and their ancestors, which I often saw depicted in beautiful artwork. I also learnt about the differences in communication practices used to ensure respect. ATSI patients have higher rates of renal disease, diabetes and rheumatic heart disease. High alcohol intake among some members of the ATSI population can compound some of the deprivation and social determinants of health. In addition, people that move between communities can experience worse health outcomes due to lack of follow-up and regular care.

I joined two rural GP clinics at nursing posts out in the community, one of which involved flying into Australia’s hottest town. During these clinics, members of the community can see the RFDS GP or nurse for appointments and follow-ups. I learnt about different aboriginal terms for common healthcare terminology and saw patients that presented with MSK problems, mental health, rheumatic heart disease and dermatological conditions. In another rural GP clinic, I saw a patient who had received a nasty, wide facial laceration, but had not seen a healthcare professional for a month due to moving between communities, resulting in poor wound closure with likely significant scarring afterwards.

All RFDS nurses are dual-trained midwives. I joined flight tasks into remote outback areas, where aboriginal pregnant women may have limited antenatal care, either through lack of access or engagement. One young patient whose retrieval I joined was in early labour in an extremely remote area, whilst another pregnant patient had abdominal pain with a tragic history of three previous neonatal deaths during pregnancy or post-partum. Fortunately, both these women were flown to the regional hospital before subsequent transfer to Perth for the safe deliveries of their babies.

The Impact Of Weather

Whilst I avoided the tropical cyclones possible for that time of year, I certainly experienced the impact of the weather! Port Hedland’s base has two aircraft, which have a maximum altitude of 30,000ft. On some occasions, we were able to fly around storms or plan a delayed approach. However, on one return to Port Hedland with a patient, there was a very loud bang and a bright flash of white light – we had been struck by lightning! We came into land, with one very nervous patient and a worried flight nurse. After a full examination of the aircraft by the pilot, the aircraft was placed out of action, as the shockwave from the lightning strike to the propeller had travelled through the aircraft and damaged the engine. We had luckily avoided a possible nasty outcome. For those who do not like turbulence, I would reconsider an aeromedical retrieval elective, as I had my fair share of bad turbulence going through storms and in the hot, rockier descents, which produce more turbulence.

Another unforgettable experience was flying to a regional hospital to retrieve a patient having seizures after a prolonged collapse in a freezer. The storms that had been rolling in as we landed intensified whilst with the patient, causing a delayed transfer due to the risk of being exposed on the tarmac with the patient if further lightning was to occur. Once in the aircraft, the patient continued to have regular seizures, and with the storms not calming down, a ‘meet’ with another crew was organised. We landed in a remote base and handed the patient over to a crew in one of RFDS Western Australia’s two jet planes, which can fly at higher altitudes (therefore avoiding the storm).

The Area And Other Things To Be Aware Of

Port Hedland is a fairly isolated town that acts as a gateway to many of the Pilbara’s mine sites, and is one of the largest ports for iron ore export. It wasn’t quite the golden beach location I had had in mind, but there was a fantastic community spirit amongst the crew, and it was certainly a very different experience from London. RFDS staff welcomed me in every way, attending BBQs and pub nights regularly during my stay. I also joined a staff trip to Karijini National Park, walking through the gorges and desperately trying to avoid any snakes.

Due to the vast size of Western Australia and the remote nature of the Pilbara, there were limited opportunities to explore at weekends over my 4-week placement. The only flights out of Port Hedland are very expensive flights to Perth. Broome is an approximately eight-hour drive away (and Perth 18hrs). Luckily, I joined a group of Australian students doing a rural health placement year, exploring Pilbara spots, such as Cape Keraudren. You do have to be wary of crocodiles in some areas, and I was always on the lookout for snakes. I was glad not to have been present when one of Australia’s most venomous snakes (an Eastern Brown) made an appearance within the base, but I did brave putting an empty bin on a small snake (later confirmed as a legless lizard!) at the base. I did however get a bit of a surprise at a rural nursing station, where I found the toilet to be regularly inhabited by frogs!

I took one Friday off and had a mammoth weekend of driving down to Coral Bay. Driving 800km in a day through the outback alone, in 40+C weather and dodging kangaroos and cattle was quite the experience, but was more than worth it. I did a marine safari, where I was able to swim with manta rays, a leopard shark, baby reef sharks, several turtles and a vast array of coral and aquatic life. I did have a rather worrying experience driving the 800km back the following day when I nearly ran out of fuel alone in the outback in 44C, but fortunately made it to the next roadhouse just in time.

I had an incredible experience with the RFDS. Having said that, it was an intense 4 weeks, with very long (15hrs+) days not uncommon. I threw myself in for the experience, but it definitely isn’t sitting on a beach after clinic for a couple of hours. Different people will want different things out of their elective, so it is definitely something to consider. I had four weeks with RFDS, immediately followed by three weeks at the Royal Melbourne Hospital (doing anaesthetics) in an eight-week elective period. With hindsight, I wish I had organised a shorter second half to build in more time to travel/relax. I would recommend building time before/after an RFDS Port Hedland elective to explore the Kimberly and the beautiful regions of southwest Australia.

Electives can be a significant financial undertaking. I tutored a lot prior to and following elective in order to save/recoup as much as possible, and applied for grants and elective funds. I am thankful to the Association of Anaesthetists for their £300 contribution towards my elective. I claimed back costs for accommodation and car hire afterwards via the NHS travel bursary, but this can take a long time to be processed, and you have to front the money first. The remote nature of Port Hedland increases the cost of most things beyond what would be expected, so it is unfortunately not a cheap opportunity. A typical food shop could be nearly double that of the UK due to the costs of importing to such a remote area. Accommodation is very limited and very expensive, but fuel is cheaper than in the UK.

Final Thoughts

If you are fortunate enough to have the opportunity and means to go abroad and experience different cultures and healthcare systems, I would 100% encourage it. There will always be more time to experience a UK hospital environment. Being a student means you are afforded the opportunity to shadow and join unique experiences that become much harder once qualified as a doctor. I have found that on the whole, people are helpful and receptive to facilitating students if you put yourself out there and try. I am incredibly grateful to all patients I encountered but particularly to members of the local communities for allowing me to participate in their RFDS experiences. Gaining an insight into aboriginal culture and beliefs promoted both my healthcare knowledge and general personal development.

Further Information

When: January to March 2023

Costs: $1500 AUD elective fee for RFDS. £600 hire car (this was an absolute requirement due to the lack of public transport/size of the Hedland area). Free Australian tourist visa.

Accommodation: There is very limited accommodation in the area, and prices are inflated because of the costs the mining companies can pay for transiting workers. I booked the only available AirBnB for approximately £1800 for four weeks, which was significantly more than anticipated. The NHS travel bursary covers up to £55 per night for elective costs. The Western Australian Centre for Rural Health (WACRH) have a student house in Port Hedland, for which they offered a room for $110 AUD/week after I explained my situation. Unfortunately, I did not hear back for months, at which point I had paid for the non-refundable AirBnB.

Vaccinations: Pertussis booster (not common as a one-off in the UK – I had to go to a private clinic), rabies, hep B&C booster, BCG, and tetanus/diphtheria/polio booster. Three covid vaccinations. MRSA test between finishing placement pre-elective and departure for Australia.

Weather: Very hot and humid. Ranging from 35-42C daily in Port Hedland, reaching 46-48C in some mining site landing strips. January to March was tropical cyclone season. Luckily, I didn’t encounter any cyclones, but one did hit the Pilbara and the Kimberley not long after I left. I saw some fantastic thunder and lightning.

Essential Items: A wide-brimmed sunhat that covers your ears and neck is an absolute necessity. Sunglasses and sun cream (lots of it). Insulated water bottle to keep your water cool. Sturdy/durable shoes are advised (I wore my hiking boots).

Contact: Each state has its own RFDS branch, with contact addresses on each state’s subpage on the RFDS website. The RFDS Western Australia branch was the only one to get back to me. I contacted peopleandculture@rfdswa.com.au with my CV approximately 11 months prior to my elective, and received my offer in July 2022 for a January 2023 elective. I know of other medical students who have had equally fantastic experiences with RFDS in South Australia and in rural New South Wales.

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Wild Trials an annual UK university event hosted by a different medical school wilderness medicine society every year with the aim to promote wilderness medicine and meet like minded individuals.

ALRIGHT LISTEN UP, OUR GUY HAS STEPPED ON A LANDMINE. OUTSIDE OF THE SAFE ZONE IS LITTERED WITH LANDMINES, IF YOU STEP OUTSIDE YOU. WILL. DIE. YOU ARE THE MEDICAL TEAM, AND THE ONLY MEDICAL HELP WE WILL RECEIVE UNTIL THE EMERGENCY SERVICES ARRIVE. NOW DO YOUR JOB AND HELP OUR MAN.

*Gunshot sounds and loud music*

We approached the casualty, their legs had been blown off from an explosion.

Ok, treat the catastrophic haemorrhage first- put a tourniquet on both legs. Administer tranexamic acid. Now to perform an A-E assessment.  BANG! Another mine blows up. We’re deafened by the sound and can no longer hear each other. There’s another casualty outside the safe zone who needs immediate treatment. He can’t move. How do we get him into the safe zone? How do we communicate with each other…?

This was an example of one of the scenarios that we encountered during this year’s Wild Trials. 

Key facts

What // A competition between universities to manage a variety of different wilderness medicine scenarios. Teams of four compete to create a hands-on learning experience on how to manage patients in the wilderness.  Each year the event is hosted by a different university enabling it to travel around the UK. 

When // 22nd – 24th April 2022

Where // Chesterfield, Peak District

How much // £160 per team, for teams of four. This included two nights of camping and five meals. Transport to and from the event was not included in the cost.

Team prerequisites // Teams had to include a minimum of one preclinical (1st or 2nd year) or non-medic, and a maximum of one final year medic. Tickets were limited to one team per university at the start, and when there was more room for other teams to join ticket sales reopened. We sent two teams from Plymouth.

Who was involved // Twenty teams, all from different universities took part. Doctors were involved to judge the stations, providing feedback and teaching.

Wild trials 2022

The weekend was set on a fictional island: Merzonia, and we were given the role of F3 doctors. On the first day, we covered 12 scenarios. Each station lasted about half an hour, giving us enough time to assess the patient, make a management plan, and handover to the senior medical team in the field. My favourite stations included a snake bite, a fall from a cliff edge, and a landmine explosion.

On the second day, we worked in teams of eight (two teams from different universities) to run a rural walk-in clinic. My team started well organised, with designated jobs and good communication, however, the clinic quickly became overrun, making a more fast-paced and stressful scenario. My patient had gone into anaphylaxis after taking penicillin, and I was managing this by myself with basic medication and monitoring, whilst on the phone to the ambulance trying to get help (the ambulance could take up to six hours!) 

To end the weekend we managed a mass casualty scenario. The stations were very realistic, with actors, and makeup to represent injuries such as burns and bites. We had a kit bag containing all our medical equipment, and access to the BNF to work out drug doses. Everyone enjoyed the mass casualty scenario. It was not part of the competition, so it was just a bit of fun (both for actors and students!) and an opportunity to learn how to manage such a situation.

The evenings were spent socialising with other students and having a few drinks. The second night encompassed a group yoga session followed by a campfire. A big party was thrown in the hut with everyone dancing and joining in the games. The weekend was a great way to meet other medical students with similar interests, and connect with doctors.

The Verdict 

I loved it, and have come away with so much wilderness medicine knowledge and new friends. In addition to my passion for wilderness medicine, I am an outdoor junkie and love to make my own adventures, this was a great opportunity. For anyone who is considering a career in wilderness medicine, or just for anyone who wants to get involved in a fun weekend away with camping, making new friends, and a chance to learn some hands-on medicine, I would highly recommend getting involved.

Any university with a wilderness medicine society is welcome to get involved. You can get involved by being part of a team, or being a volunteer actor for the scenarios (which cost £20 this year). Wild Trials were advertised this year on the Facebook group ‘Student Wilderness Medicine UK’. I have not heard anything about Wild Trials 2023 yet, the dates and theme will likely be decided at the beginning of the next academic year. But keep an eye out for posts on this group.

Message from the organisers- Rosie Toms, Liverpool Wilderness Medicine Society President

‘Wild Trials was a culmination of many months of hard work, but it was so worth it when everything came together for a wonderful weekend of wilderness medicine in the sunny outskirts of the Peak District. My highlights from the weekend were having so many wilderness medicine enthusiasts together again after such a long time, and watching everyone get stuck in with all the challenges that came their way. We couldn’t have done it without everyone who gave up their weekend to assess and be patients – so thank you! We are so excited to see what Wild Trials 2023 has in store for next year.’

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Dr Marcus Stevens / GP / Bath, United Kingdom

Megan Roby is a medical student at the University of Exeter and the first student to complete Critical Care International’s e-internship. Dr Marcus Stevens is a GP based in Bath and CCI’s Head of Operations. In this article they share their experience of the first year of CCI’s pioneering medical student e-internship and their reflections on the model’s potential to enrich medical education.

The formation of a medical student’s professional identity extends beyond the acquisition of medical theory. Experience in a variety of diverse settings is needed to develop the communication skills essential for patient-centred care and to enhance a student’s ability to adapt to challenging circumstances. However, despite their importance it is often difficult to identify opportunities outside of university curricula that encourage a more holistic approach to healthcare. In the lockdown environment we saw a temporary shift in traditional medical education from hands-on learning to online delivery, highlighting opportunities to experience healthcare in places otherwise inaccessible. This article will explore the relatively novel concept of medical ‘e-internships’, exploring how they can advance medical education and improve the quality of learning students receive before entering the workforce.

Critical Care International (CCI) is a UK-based company specialising in medical consultancy, training and in-situ medical provision in resource-poor locations across the globe. Since its inception the CCI team has been remote, with doctors deployed around the world receiving operational and clinical support remotely on a weekly basis. Dr Marcus Stevens, currently Head of Operations at CCI, realised the weekly call structure could be extended to medical students, offering an opportunity for real-life learning and personal growth within the supportive, professional, but virtual environment of an ‘e-internship’. CCI understood that despite some inclusion of global health topics in medical school curricula, students are often naïve to issues faced by health systems outside of the UK, and to career opportunities available globally. Furthermore, topics such as healthcare economics, the operational delivery of healthcare and business management are not widely covered. The internship programme has been designed to run alongside a medical student’s degree and provide direct insight into how comprehensive medical care is delivered in resource-poor environments, including recruiting and managing deployed staff, advertising and pitching to new clients, and structures of medical and financial governance. Having seen the value of the experience, we believe such programs could be extended to a range of organisations and either organised alongside day-to-day study or in shorter, more condensed periods, which could be thought of as ‘e-electives.’

Megan Roby started as CCI’s first e-intern last year and has found it a steep but extremely rewarding and varied journey. Initially attending weekly governance calls she met the team and gained insight into the company structure. Having her own company email address meant Megan could independently take the lead on projects as well as seek clarification on topics when needed. As she became more familiar with CCI, Megan was able to take on greater responsibility and actively engage in team meetings. This has allowed her to experience many aspects of medicine that would normally be difficult to gain exposure to during medical school. She has also gained invaluable mentorship and advice, including on the huge range of professional opportunities available outside of a traditional medical career. For instance, she hadn’t considered a career in general practice as she wasn’t aware of the notion of a portfolio career, such as pursuing research or setting up clinics abroad alongside a traditional NHS role. By talking to CCI doctors from a range of countries and backgrounds, she’s been able to network and learn about specific steps others have taken in their careers, which will serve as a rich source of inspiration as she considers her own options. CCI’s Medical Director shared with Megan his reflections on what led him to pair an NHS career with working for CCI. “It’s vital to excel in the scientific elements of your degree but pursuing other passions alongside this activity will both enhance your performance as a doctor and your enjoyment of your career”, he explained. Indeed, the insights gained through the internship facilitate exploration of one’s own capabilities, interests and knowledge.

The primary aim of the internship program is educational. CCI is committed to supporting e-interns in pursuing the areas which are of interest to them and as such, there are no business functions which rely on interns for completion. Despite this, there is ample opportunity to have significant, long-lasting and varied impacts on the way the business operates. Megan’s biggest contribution has been leading CCI’s first national student essay competition. During weekly meetings she understood the company wanted to expand medical student engagement and she realised an essay competition would both raise awareness of CCI and their aims, whilst furthering discussion around topics of global significance. She was afforded independence to design the essay competition and following extensive research and collaboration with all members of the team she delivered a project to be proud of. Moreover, this was a fantastic opportunity to expand her knowledge on topics ranging from global health and climate change to medical technology as she evaluated the submissions. The winning essay is available here. She subsequently built on the success of the essay competition to organise and host a virtual panel event, inviting a select number of students to discuss their essay topics in front of a wider audience. She learned how to organise an online conference and reflected on the factors that make large events successful, such as having pre-set discussion points, encouraging audience interaction and incorporating visual aids. Such skills become vital as one progresses through medical training and are required to demonstrate involvement and proficiency in non-clinical areas such as teaching, research and service development.

The internship also offers exposure, remotely, to clinical situations one would rarely see in the UK. Discussions about managing snakebites, malaria, and other tropical diseases within a culture where patients often also seek help from traditional healers has been incredibly thought-provoking. Furthermore, helping to write clinical protocols and discussing cases presented in clinical governance meetings has provided exposure to the flexible approach and relevant considerations required when working in remote environments. For example, if a woman goes into preterm labour in a small remote clinic, how can she be managed in an ambulance on bumpy roads en route to a distant hospital? Being challenged to apply one’s medical knowledge and logistical imagination to such scenarios is a unique and invaluable opportunity that can be provided by e-internships.

At times both CCI and Megan have had to be flexible. When the stresses of medical school resulted in more time being set aside for study, Megan was supported within the team and learned to manage her time whilst also remaining transparent about her capabilities. CCI have constructed the programme so that the current intern is responsible for interviewing and selecting the next intern. In doing so, the current intern can adapt and improve the internship based on their experiences and any challenges they may have faced. The focus of Megan’s internship has been operational rather than clinical, however, future programmes could be developed to include stronger clinical components where students are involved with on-site doctors directly to learn about patient cases and their outcomes. We have found the internship model to be stimulating, supportive and flexible, allowing both CCI and Megan to benefit immensely.

We are hopeful our experiences will encourage others to establish similar programs; however, it is important for organisations to consider what opportunities they can offer and how much responsibility they are willing to delegate to interns. It is crucial that both the host organisation and the intern’s expectations are matched. For example, will the internship be focused on shadowing members of the team or will the intern be able to directly contribute to meetings and projects, ultimately increasing their self-confidence in the workplace and developing a broader set of skills? Will the focus be on understanding the structure and logistics of a company, or will it take on a more clinical focus? From our experience, we believe mentorship should be a foundational component of an e-internship, to ensure the intern is adequately supported to get the most possible value from the experience and to address challenges and boundaries to engagement as they arise. Exploring these questions and themes early in the process has allowed the CCI internship to develop into a role that encourages growth and learning, as well as the possibility for later employment in CCI or a similar organisation.

Despite their potential, medical e-internships are not currently widely available. Having seen their power to expose medical students to novel environments and cultivate skills beyond those developed within a traditional medical school curriculum, we are excited by the role they could play within medical education. The model can be applied at home and abroad, in both commercial and charitable settings. There are myriad organisations in which they could be offered, covering a range of geographical, clinical and political landscapes. Looking ahead, we envisage medical schools offering internships that run in parallel to the curriculum, allowing students to pursue individual interests, however distant or diverse. Although further research should be conducted into the opportunities and challenges e-internships present, in a world where the challenges facing medical students are rapidly changing, innovative methods should be explored. Medical student e-internships offer the chance to bridge the gap between theoretical learning and first-hand experience. They can support students to become ‘work ready’ through exposure to the non-clinical aspects of medical service provision, as well as expanding their vision of what is possible within a medical career. Given the potential thematic scope of e-internships and their adaptability to fit alongside the traditional medical curriculum, we believe they could prove to be an invaluable addition to the medical school experience and contribute to preparing cohorts of junior healthcare professionals who are better able to meet the evolving demands of their careers.

To learn more about CCI’s work, please visit their website here.

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Elective Competition 2017 Winner

Madeleine Thomas wins the Elective Competition 2015!

Electives in Developing Countries

We are pleased to share this elective opportunity run by our friends and colleagues in the New Zealand Society for Mountain Medicine. It’s an incredible programme for students interested in working in pre-hospital, mountainous and remote settings. While open to students all over the world we hope it also inspires those interested to consider setting up similar placements closer to home over dates or in environments better suited to them. This elective is being run at no profit to the organisers. Creating these opportunities in other countries may well be possible if you reach out to relevant organisations. There are also many commercial courses that could form part of an elective in remote environments across the globe. Participant reviews at the bottom of our Courses page may give you a feel for which may be best for you or what you are looking to create yourself. 

The New Zealand Society for Mountain Medicine is proud to announce their inaugural medical student elective taking place from 3 July – 11 August 2023. This 6 week elective will take place at a number of venues throughout the Southern Alps of New Zealand.

What will you gain?

• You will develop an improved understanding of the effects of austere environments on human physiology and psychology.
• You will learn to recognise and manage common issues found in mountain and wilderness locations, often with limited resources in dynamic and challenging environments .
• You will gain hands on exposure in a number of areas from pre-hospital trauma care and mountain medicine to winter snowcraft, avalanche rescue, mountain biking and skiing.
• You will learn and be expected to demonstrate skills in navigation, mountain weather forecasting, expedition trip planning, medical kit selection, basic snow-craft.
• You will develop your non technical skills such as teamwork, communication, self reliance and resilience.
• You will gain a direct understanding of the links in the chain of rescue and how they work together.

How is it delivered?

• Most of the learning will be delivered through hand-on workshops, tutorials and ​​​​simulated patient scenarios ‘in the field’ wherever possible.
• Faculty members delivering wilderness and prehospital aspect of the course have years of experience.
• Technical wilderness skills will be delivered by NZMGA guides.
• There will be visits to a number of organisations on the front line of wilderness, pre-hospital and rural ​​medicine in New Zealand.
• We will use mountain huts, educational centres and Holiday Parks to provide ​​​​accommodation for a substantial part of the elective. For other nights you will be based in ​​Christchurch and will need to organise accomodation yourself. You will have a number of ​​​weekends off so you can make the most of your time in New Zealand.
• You will get cold, wet, hungry and tired. The intention is to include mountain ​​biking, skiing, and mountaineering, with a high likelihood that this will all be achieved ​​​while covered in fake blood.
• By the end of the elective you will obtain qualifications in Outdoor Pre-Hospital Emergency Care, Pre Hospital Trauma Life Support with Austere Extended Care, and the NZSFMM Certificate in Mountain Medicine and Pre-Hospital Care.

If you would like to know more, please visit their website. Please note that no further electives are planned at this time (January 2026).

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Final year medical student Marcus had the privilege of experiencing the highs and lows on his medical elective in Zambia in 2019. Here he recounts his experience of working in a resource-poor setting; from obstetric emergencies; to daily life in Lusaka; to weekend tips to Victoria Falls and safari in Botswana.

Lusaka Hospital, Zambia

Starting my medical school elective placement in Obstetrics & Gynaecology (O&G) in Lusaka was both daunting and exciting in equal measure. Upon arriving at the hospital one of the most immediately obvious differences was the ubiquity of white coats. The white coat has been long banished from the wards of NHS hospitals; but worn universally amongst doctors and medical students in Zambia. Wearing this white cloak felt like assuming a mantle of responsibility – a physical manifestation of a professional identity. It did little for my Imposter Syndrome, however in tough situations it felt like a suit of armour; protecting me from mosquitoes, but not from the Zambian dust!

Despite my initial nerves I was quickly made to feel welcome and a valued part of the team. The medical staff at the women’s hospital are organised in a firm-based system and I was attached to one firm for the whole five-week placement. This structure enabled me to get to know the doctors I was with. They were keen to get me as involved as possible; clerking patients and presenting on rounds, brushing up on my obstetric examination skills in antenatal clinics, as well as assisting in theatre. I also had the pleasure of being surrounded by a supportive group of local medical students. They were more than happy to share their notes, skills, and (perhaps most importantly) the best places to grab lunch on campus!

Difficulties presented in a resource-poor setting

The hospital in which I was placed was government-run and they struggled with a lack of resources. Before my placement in Zambia, I took for granted the abundance of equipment we have at our fingertips in the UK. There was no running water on the labour ward; nor were there bottles of alcohol hand gel sitting proudly at the end of every bed. Women laboured in open wards separated by thin curtains, lying on plastic sheets and brightly coloured local fabrics they brought from home. There were times when the resource limitations did become very frustrating. A CTG machine would be wheeled out only to find there was no paper on which to record a trace. The tap to the scrub-room would cut out while you were soaped to your elbows. Running to the blood bank in temperatures over 30 degrees Celsius only to find they have no blood available. 

These were but a few of the problems we experienced in our short five weeks. However, our Zambian colleagues walked this scalpel edge every day. They strove hard to do the best for their patients in a setting that often worked against them. Sometimes women would queue for an emergency caesarean section due to the lack of fully trained anaesthetists for more than one theatre to be operating at a time. This often led to tragically poor outcomes for mother and baby. One day a young woman exsanguinated to death following a placental abruption simply because the blood bank was empty. Experiences like these were a haunting reminder of our privilege and how dangerous childbirth can be in resource-poor and lower-income countries.

Despite all the obvious difficulties, the greatest resource in the hospital remains the staff themselves. The doctors I worked with were highly knowledgeable and in turn, demanded high standards from their medical students. The vast majority of teaching is done on the job, informally on daily ward rounds, where students would routine be grilled at the bedside. As well as developing my clinical knowledge, I learned more practical skills such as the ability to think on my feet and problem solve with limited resources to hand.

A ward round in Lusaka can feel like the contents page of the O&G textbook at times, and I was exposed to many things I would never see on placement in the UK. Stage 4 cervical cancer, severe symptomatic anaemia of pregnancy, eclampsia, and mothers suffering from malaria, tuberculosis and HIV but to name a few. Unfortunately, like many other areas in Africa the severity of disease was often due to late presentation to a tertiary centre as well as either the lack of, or financial barriers to antenatal care.

Down-time

Away from the highs and lows of the clinical environment, the Work the World house in Lusaka feels like a sanctuary. After a hard day on placement we would share hospital stories by the pool, or relax out on the terrace with a cold drink and read or reflect on the day. Weekends offered opportunities for amazing travel experiences. From visiting the spectacular Victoria Falls in Livingstone to crossing the border to Botswana for a safari; with my highlight being getting up close to a family of swimming elephants. Closer to home, Lusaka itself is a fun city to spend time in at the weekend; often finding ourselves overindulging in the busy and vibrant local bar, restaurant and club scene!

Work the World’s Village Healthcare Week

Relocating from Lusaka to Chirundu; a bustling border town on the banks of the Zambezi; this week was the cherry on the top of my time in Zambia. Following a warm welcome into the home of a wonderful host family, we were able to gain a valuable insight into daily life for many Zambians living outside the capital city. If you ever visit Chirundu, remember to bring your dancing shoes; the local school kids will show you how to bust a few moves – or at least try to!

Daytimes were spent at the small district mission hospital which was a stark comparison to the government hospital in Lusaka. Facilitated and ran by the Catholic Church, this small-town hospital is better resourced and has greater facilities. As well as O&G, I was able to spend time in the paediatric department, giving me insight into conditions such as childhood malnutrition.

I would encourage any student or qualified healthcare professional alike to take the opportunity to travel to Zambia. My experience provided me with valuable experience in a low-resource setting with the support of friendly and highly skilled medical staff. Even when I felt a long way out of my comfort zone, Zambia was a home away from home.

Top Tips

• You don’t always need fancy kit to get the job done. If you don’t have a Rusch Balloon to hand to manage a post-partum haemorrhage, a latex glove filled with normal saline will do the trick just as well!
• Our over-reliance on technology can cause UK doctors to become de-skilled. In Zambia I learned how to listen to the fetal heart rate manually using a Pinard stethoscope, a skill not often not taught in the UK as there are usually Doppler ultrasound machines available!
• The healthcare service in the UK can be very wasteful. Reflecting on my time in Zambia, I started thinking about the ways in which the NHS could minimise waste production and still maintain a high standard of clinical care. 

Further Information

Where / Lusaka, Zambia

When / March – April 2019

How Much / Roughly £2500 (excluding flights) for a 5-week placement and Village Healthcare Experience

Flights & Visas / Flight to Kenneth Kaunda International Airport (Work the World can provide more information on flights and visas)

Contacts / To find out how the Work the World service works, head to worktheworld.co.uk

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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.

For my elective I wanted a placement that would offer new and challenging scenarios unlike any I had experienced in Scotland, but also enough support for me to learn and grow. I was in my second year of university when I first heard about Alice Springs from my supervising consultant who had spent their own elective there 30 years ago.

As I stepped off the plane, I couldn’t have felt further away from the dark Scottish exam hall I had sat in just a week before. Welcomed to Australian winter by 35⁰C  heat and an unrelenting sun, I was burnt just walking from the plane to the terminal. Alice Springs is a medium-sized town of small orange-roofed buildings and greenery surrounded by the golden yellows and oranges of the outback.  The Todd River ‘flows’ through the middle of the city, but for 11 months of the year it is just a dry river bed with thick ‘river red gums’ rising up and out of the sand.

Alice Springs Hospital is in a unique position in that it has all the facilities that you would expect to find in an economically developed country hospital, but it also serves a large indigenous population spread across 1.2 million square kilometers. The indigenous population has a much higher burden of ill-health than the rest of the population; the life expectancy of indigenous men is only 63 years, 16 years less than the rest of the male population of Australia. One of the most common presentations to the department, and the third most common reason for hospital admission, is missed dialysis. Another common presentation is trauma following assault.

Communication

Culture and tradition are very important to the indigenous Australians, and shape their health beliefs. The indigenous family groups are made up of their ‘skin names’, a method developed thousands of years ago to help avoid recessive mutations by ensuring that people married as distantly as possible within the tribe. Everyone with the same ‘skin name’ as your mother is called your ‘auntie’. Children would frequently be accompanied into hospital with their ‘auntie’, although this did not necessarily indicate the same degree of familiarity as it would in the UK. This, along with a language barrier and unfamiliar non-verbal communication, meant that you had to be very clear with the patient and their relatives to ensure that you were picking up the full story and not missing any details that might be important for the diagnosis.

Culture Shock

I had the opportunity to go out with both the St John’s Ambulance Service and the Royal Flying Doctors to experience health provision in an environment far removed from the hospital. Despite the excitement of being out on emergency calls, my visits to town camps with the teams were often saddening experiences.

Town camps are enclosed areas on the edge of town that are inhabited exclusively by members of the indigenous population. They are often areas of severe poverty in which the population do not have adequate housing. A building that on the other side of town would house a family of four, could be a home for up to 20 people in one of these camps. Every call out had its own challenges, whether it was the logistics of getting the patient out to the ambulance or trying to talk to and calm a crowd of people around you (who may be intoxicated).

Alcohol-related presentations were a major challenge faced by the emergency department, the ambulance crews and the communities themselves.  I was shocked by the scale of this problem given that Alice Springs is a relatively small town. I saw a number of patients presenting both due to acute intoxication and from injuries sustained while intoxicated. Two events in particular stand out in my mind. The first was a woman in her forties who presented with a 15cm scalp laceration from her forehead to the back of her skull. It had been inflicted by her sister using a ‘big stick’ (which, on taking a history turned out to be a crowbar) following a drunken argument. The second was when I was with the ambulance service and we were called out to a town camp where there were two women in their twenties being attacked by an intoxicated older man. We were unable to stop due to the potential risks to ourselves, but fortunately we were chased by the two women who were then able to climb into the ambulance.

Alcohol-related problems have additional consequences for the indigenous population. The houses are already massively overcrowded and the communities will cast out those displaying violent behaviour, forcing them to sleep rough (often in the Todd river bed) or present to the emergency department. The department does not turn these people away despite the fact they do not have a medical issue; instead they are allowed to sleep in the waiting room providing they do not cause any trouble.  Homelessness is the third most common reason for presenting to the emergency department in Alice Springs, with 653 presentations during the first three months of 2017 alone.

Out on the trails

Although Alice Springs does have its problems, it is one of the most amazing places that I have ever visited. In Edinburgh, I enjoy running around the hills and frequently take the bike down into Midlothian and the Borders. Alice Springs offers all the outdoor experiences you could ever want and even more. The weather was always beautiful, without a single drop of rain. There are hundreds of kilometers of mountain biking trails running along rocky ridge lines that are burnt orange under the sun, and through deep sandy river beds.  On arriving at the hospital, it quickly became public knowledge that I loved cycling and one of the consultants kindly lent me their mountain bike for my time there. I would be out two to three times a week with many of the mid-grade doctors and consultants, keen for a few hours blasting through the red dust of the outback.  It really was full of thrills and spills; you would be flying along the trail with a sharp turn into a shaded area of bush and suddenly a massive Red Kangaroo would shoot out and bounce only a meter or two ahead of you before disappearing again. Or you would ride straight through a giant spider’s web frantically trying to pull it off your face without ending up in the dust.  I quickly realised that everything in the bush was either spiky or very sharp as I came flying off my bike trying to take a rocky drop too fast and tore straight through my shoe! I also learned to be careful of the riverbeds after ending up eating a mouthful of sand. It was always important to remember my suncream and about three litres of water in order to make it back to town without turning into a lobster.

If cycling is not your thing, then the walking is also incredible and the views magical. Just at the south end of Alice Springs, the McDonnell Range runs for over 600km through central Australia. The highest point near Alice Springs is Mount Gillen and a very sweaty 45 minute walk up to the tops gives you a 360 degree view over all of Alice Springs and the endless outback.  It was also the perfect sunset spot which I found was best enjoyed with a few newly made friends and couple of cold beers. Many Thursday evenings were spent here before heading to Montes for the weekly pub quiz where you would find the majority of the hospital staff in attendance.

I also made several trips further afield. These would involve at least a two hour drive, something the locals think nothing of due to the vastness of the area.  On my third week, one of the intern doctors asked if I’d like to climb Mount Sonder. Of course I said yes. After a Saturday of mountain biking, I got a call to say I was being picked up and to remember my sleeping bag. It quickly became apparent that we were going for a Sunday sunrise. We arrived in the pitch black and set about making camp and a fire. Australians often sleep in ‘swags’ which are like a one-man tent with a blow-up mattress sewn in. I slept out in the open in my sleeping bag, hoping our fire would keep any unwanted visitors at bay. As the fire burnt out, the sky put on its own show with the Milky Way on clear display and frequent shooting stars. We were up at 3am to pack up and set off on the four hour plod up a mountain just higher than Ben Nevis. As we were climbing, we saw a lightning storm on the far horizon. On approaching the peak, we were treated to a dark red band of light climbing out of the horizon with a deep blue sky hanging over it and bright white stars throughout. The band became brighter and wider until the sun appeared over the horizon, turning the sky into a kaleidoscope of oranges and yellows with a scattering of light blue. The rock turned from a dull grey to bright orange.  After this incredible spectacle, it was time to head down before the hot morning sun could catch us.

I could go on and on about my time in Alice Springs  (I have not even mentioned going to Uluru, Kings Canyon or any of the bush walks I went on). It truly is a special area with wonderful people and I will always look back on my elective with the fondest memories of the places I visited and the friends I made. It has left a lasting impression on me both from professional and personal points of view; I have been able to learn so much about communication and I was truly humbled by the challenges faced by the indigenous Australians as well as the sheer size and beauty of Central Australia.  I will always carry a small amount of Alice with me – I still cannot get the red dust to wash out of the bottom of my trousers!

Top tips

• Make your interests known. I made it clear that I loved the outdoors and it resulted in offers of a loan for all the equipment I could ever need. Almost every day somebody would offer to take me out on an exciting trip – mountain biking, running outbush, 4x4ing to name a few.
• Don’t be afraid to go it alone. Travelling alone can open up many new opportunities. I was apprehensive at first, but it forced me to get out and meet new people.
• Try something new. An elective is an amazing opportunity to see a country you would never think of visiting on a holiday and to gain an insight into their potentially unique medical challenges.
• Listen to the the locals. They can tell you the best spots to see wild wallabies or to go for a swim. They can also advise you about dangers of the local area such as driving at dusk and dawn. Wild horses and kangaroos are frequently found on the roads at this time and if you are unaware of this risk then you could face trouble.
• Stay safe. Avoid getting into situations where you feel uncomfortable and ensure you know the local numbers for the emergency services.

Further Information

Where / Alice Springs, NT, Australia

When / April-June

Costs / I was not required to pay any fee for my elective.  However, Alice Springs is an expensive place to stay due to the difficulty in getting goods to the town.  Daily living costs (excluding accommodation) for 2 months was just shy of £1000 (including gifts to take home).

Weather / About 30 degrees during the day but could drop to as low as -5degrees at night.

Vaccinations / All standard UK vaccinations. Hepatitis A and Tetanus/Diphtheria/Polio booster advised before visiting. I was also recommended to get a pertussis booster due to frequent epidemics amongst the indigenous population.

Accommodation / Flinders University were able to provide self-catering accommodation. This cost about £100/week but all accommodation is expensive due to a limited amount of housing.

Essential items / Suncream, hat and sunglasses.  A comfortable pair of trainers to explore in.

Addition items / You will need an Ochre card (similar to a DBS or PVG) which can take several months to arrange so this should be organised well in advance as you cannot start without it.

Contact / Elective placements for visiting medical students

The post An Outback Elective appeared first on Adventure Medic.

Keen to experience the challenges of medicine in a resource-poor environment, Ben set his sights on sub-Saharan Africa for his medical elective. Many emails and several months later, he found himself in Ethiopia. From the intense heat and volcanic landscapes of the Danakil Depression, to the hustle of Addis Ababa, Ben recounts his experiences on and off the ward.

It’s 52 degrees Celcius outside the car as the midday sun glares out across the barren wasteland of the Danakil Desert either side of the road. As you drive around the corner you see a lorry on its side, windows smashed and cabin dented into the dry earth. To the left is a small figure lying in the sand beneath a jacket. What do you do?

This was the situation I found myself in, driving in a tourist convoy through the Danakil Depression in northern Ethiopia, after my elective in the capital city of Addis Ababa. Thankfully the driver of the lorry was not seriously injured, just in a state of shock and grazed. This situation did make me consider what we would have done had things been more serious. We really were in the middle of nowhere in a way I’d never experienced before. The nearest town was hours away, the nearest hospital even further and helicopter evacuation would not have been an option. Experiences like this are a reminder of how hard it really is for some people in the world to access appropriate emergency medical care, something in the UK we often take for granted.

Why an elective in Ethiopia?

It’s not on your list of common elective destinations and I was the first from Glasgow University to go, which caused the medical school some stress. When looking for my elective post I targeted my research around low-resource countries, particularly those in sub-Saharan Africa. Seeing first-hand the challenges of practising medicine in a low-resource environment would give me such a contrasting experience to that of an elective in a more developed country. I feel that’s what electives are all about: seeing medicine done differently. I had previously been to Ghana and this experience developed my intrigue in this area of the world. I emailed any contact I could get my hands on and applied in Uganda, Tanzania and many more. Most went without reply. Finally, I made an interested contact in Ethiopia which I sourced through a friend of a friend. From there on it was no plain sailing. Convincing my medical school that Ethiopia was not too dangerous, getting all the correct vaccinations, obtaining a visa and finding accommodation in-country were all challenging experiences.

The hospitals

I was based in CURE Children’s Hospital which is run by an American charity and specialises in paediatric orthopaedics. It is the only hospital of this specialty in the whole of Ethiopia! Because of this, all manner of weird and wonderful things could present in clinic. We saw children with extra toes, giant thumbs, some horrendous burn contractures and all sorts of odd fractures. The most common condition CURE deal with is clubfoot. This is common globally, but in places like the UK, it is usually treated before early childhood. In Ethiopia, however, cases often present much later and subsequently can require much more drastic surgery to give children functioning feet. We also saw a multitude of fractures which had healed in very odd positions. This happens as many people first visit their local bone setter or ‘Wedisha’ who wrap up the fracture tightly in Bamboo, often making the situation worse. Problems like this are just never encountered at hospital in the UK.

I also spent some time in the local government hospital, the ominously named ‘Black Lion’. This was the largest hospital in the country and the only teaching hospital. In orthopaedics, the commonest injuries were road traffic accidents and, believe it or not, being hit with a stick! I stayed well clear of any man carrying a stick after seeing some of those x-rays. As I expected, this hospital was much poorer in resources than those I am used to in the UK, however I was really surprised by the conditions for trainee doctors. On a surgical placement in Glasgow I might expect to walk into a theatre and find one consultant and one registrar. In Ethiopia there would be at least eight trainees each crowding round one operation, jostling for prime position to assist or even to see!

Time off the ward

Whilst in Ethiopia we didn’t only visit the hospital. Weekends were spent escaping Addis Ababa for nearby lakeside towns like Hawassa and Bishoftu where we relaxed and enjoyed some of the amazing scenery on offer. These trips were not always relaxing, however. Public transport in Ethiopia was an adventure in itself, best summed up by our return journey to Addis after a weekend in Bishoftu. We got to the bus station that was full of many calm, well organised queues. We found the one for Addis and waited patiently like the locals. Then suddenly there was a shout and all the queues dispersed and chaos ensued as everyone ran onto the street, crowding and cramming on to any minibus in sight. Apparently, the bus station was now closed! Thankfully, we had made a friend in the queue who helped us onto the right bus and got us home. In Hawassa we also had trouble. We arrived at the guesthouse we’d booked online to check in, the woman behind the desk gave us a quizzical look and asked, “online?”. They were fully booked and had to their knowledge had no website! To further the problem, that night was the graduation ceremony for Hawassa University, so every place in town was fully booked. After five hours of wandering from hotel to guesthouse to lodge we were about to give up and were seriously considering the logistics of sleeping rough for a night in Ethiopia! Our last option was the very extravagant international hotel, where the only remaining room was the honeymoon suite! It took a huge hit on our budget, but beat sleeping by a lake full of hippos!

After our time in Addis Ababa came to an end, we headed up north to the Danakil Depression, a mysterious and harsh land, with sulphur lakes, salt plains, scorching temperatures and a big Volcano: Erta Ale. We joined a group to explore these places and trekked to the top of the volcano to camp there one night. Just in case it wasn’t exciting enough already, we had to be escorted by the army in some areas for fear of attack. This final trip was a perfect way to round of what was an elective full of excitement, odd experiences, questionable food, mishaps, difficult situations, some seriously scary bits but most importantly an adventure.

What next?

This elective has furthered my love of travel and working in extreme environments. On return I have organised an SSC in trauma in our major A&E department and also attended the World Extreme Medicine conference, which I would highly recommend. Next summer for my senior elective I will be travelling to a major trauma centre in Baltimore to see the other side of the coin and the state of the art care.

Further Information

Where / Addis Ababa, Ethiopia

When / June – August

How Much / I managed to find return flights to Addis for under £400 (with a long lay over in Istanbul) however, with hindsight, flying with Ethiopian Air gives a huge discount on internal flights if you wanted to travel after an elective there. For safe accommodation a hotel/guest house would be recommended and ours cost roughly £500 for the four weeks in Addis Ababa. Any spending beyond that would really depend on the sort of travel activities you wanted to do. Food, drink and ground travel can be found very cheaply and easily.

Tips / Start planning your elective early! Particularly if you want to do one in a less commonly visited place. There are surprising amounts of admin to get through and it took a long time. This was stressful and time consuming for me as the deadline for travel approached. I would recommend trying to email and get hold of contacts as early as a year before you plan to go. This also helps build a rapport with the staff and hospital you are planning to visit before getting there. Internet connections in places such as Ethiopia can be troublesome and hence email correspondence can take a long time, however everything is much easier once you are in the country.

Contacts / Unfortunately I am unable to share contacts from this placement, however  speaking to other doctors who have made similar trips in the past is valuable. Speaking to consultants you like on placement and just asking can bring up some very interesting opportunities. Universities often have previous elective reports and contacts and if you have medical parents, use them!

The post A Truck Crash in a Volcanic Desert (and other stories from Ethiopia) appeared first on Adventure Medic.

Madoc transports us deep into the Peruvian Amazon as he recounts his experiences with Project Amazonas on his medical elective in 2017. This thrilling expedition began at the Orosa river clinic providing medical care to the remotest communities. From there, Madoc swapped the jungle for city life in the local town of Pevas, where he saw first-hand the inequalities in healthcare that result from widespread economic diversity. To round up his elective, he then embarked on a two-week river barge expedition up the Pintuyacu and Itaya rivers providing further medical clinics; interspersed with local herbology lessons, football tournaments and caiman-hunting!

We slowed as our canoe navigated the maze of small inlets on our way to our home for the next few weeks. Within seconds my skin was already craving the cool wind that comes with the wider rivers and faster movement of the boat. Luckily, five minutes later we were unloading our gear; our shirts already clinging to our skin, permeated with a heady mixture of DEET, river water and unavoidably, sweat. Here we were, Madre Selva (Mother jungle in Spanish): a biological station, and our home for the next three weeks. The fruition of eight months of planning, four months of work shifts squeezed between study, and near thirty hours of travel time to get here.

Madre Selva is a field research station 150km deep in the Peruvian Amazon, located off the Orosa river and run by Project Amazonas; a USA/Peruvian NGO providing medical care and environmental initiatives. It is directed by biologist Dr Devon Graham, a Canadian transplanted to Florida, and my main liaison whilst organising the elective.

Me and my fellow medical students, Louis and Matt, quickly dumped our scanty belongings in our basic wooden hut and headed out to kayak along the river and take in our surroundings until sunset. After which we had been warned by Julio (the boat captain, handyman and general good guy to have around) that ‘the caimans come out and the water gets dangerous’. We floated down the river along the muddy water, past the riverside huts built on stilts to protect from the dramatic seasonal river level changes, patched with up-cycled plastic adverts for Peruvian beers. After the bustle of the city, even the cacophony of animal sounds and flapping leaves felt almost deathly quiet.

This soon became our routine; a morning boat ride to Project Amazonas’ Orosa clinic, return for lunch, then kayaking, hiking or swimming ’til the sun came down. Our surroundings continually took my breath away, and combined with the lack of phone signal and electricity (bar a couple of noisy generator-fuelled hours) made it one of the most idyllic places I have ever been. We were also presented daily with a huge variety of exotic foods and juices prepared by the excellent local chef David; making our basic set-up very homely.

On placement, we had the privilege of gaining access to remote communities; talking to their inhabitants, playing football and sharing beers. However, from speaking to the locals I quickly realised that life in the Amazon is hard. The same remoteness that makes it so incredibly idyllic is also the reason for many of the difficulties the inhabitants’ face. As well as being a great distance from the nearest healthcare centre, their subsistence lifestyle means that it is often not financially possible to travel there (unless the whole village pools their cash towards the petrol). This means that many tribes rely on a tribe shaman or natural healer. However, since Project Amazonas started, remote villages now have access to western healthcare which is easily accessible.

The clinic was simple, with no means of protecting the medications from the 30-35 degree heat and near 100% humidity other than cool boxes. The range of medications was also limited, falling short of the WHO basic recommendations. The inaccessibility of basic investigations in the Amazon means that a good history and examination becomes even more important. Luckily our seasoned doctor Luiz was a great diagnostician and was able to differentiate between parasitic, bacterial and viral GI infections almost purely by the consistency and odour of patient’s diarrhoea!

Patient presentations were surprisingly similar to GP presentations back home, namely; fungal skin infections, GI infections and anaemia; as well as some tropical diseases not usually found in the UK (TB, Malaria, Dengue, Zika).  Consultations in the Amazon typically involve the whole family; a cultural difference I found a rather pragmatic option as infective illnesses were often passed around families. I found some patients were shy of foreign doctors, however our fractured Spanish managed to ease many consultations!

Inevitably the time talking, drinking and hanging out under the stars in Madre Selva had to end, we stuffed our clothes, by now quite musty, into our bags and headed out. However, a two-hour private speedboat back to Iquitos (the closest city) turned into a six-hour ordeal with numerous stops, near capsizing and an eventual boat rescue by one of the charities own speedboats – a classic example of running on ‘Peruvian time’! Iquitos, which is the base for Project Amazonas’ operations within Peru is the largest city in the world that is not accessible by road. It is an odd dichotomy of a place, with old colonial grandeur from the rubber boom (it boasts a house designed by Eiffel of Eiffel tower fame) clashing with the water slums of Belen. Internet cafés and electrical shops in abundance, alongside alleys selling shamanistic potions and illegal river meats.

Iquitos was simply meant to be a stop to resupply and wash our clothes in something other than river water before moving to our next clinic. Unfortunately Louis and I got the true jungle experience and ended up having to quarantine ourselves in our hotel with gastroenteritis. Given our swimming in the Amazon and eating every local food available to us, it was only going to be a matter of time. Thankfully in Peru all medications apart from opiates are available over the counter, so we sent Matt to forage the pharmacies and hunkered down. Once our all too personal experience of illness in Peru passed we headed off to our next clinic in Pevas.

Part 2: Pevas

The clinic in Pevas is a government clinic, 145km from Iquitos. The small town is known as ‘el terra de amor’ , the land of love, which is reflected in the warmth of its people. We were staying with a contact of Dr Graham’s, an internationally acclaimed artist Francisco Grippa, who helps the charity by housing volunteers in his sprawling wooden house and gallery, perched atop a hill overlooking Pevas.

Access to the government medical clinics and appropriate medication is free to any patients with public health conditions (TB, Zika, Malaria, HIV, pregnancy etc). Beyond these conditions, however, the issue of cost became a grey area, causing a lot of patients to avoid presenting for conditions that they anticipate to be costly. The clinic here was extremely busy, and much more of a challenge for us. However, it was a useful reminder to us of why NGO’s such as Project Amazonas are so vital in Peru. The government system has been battling hard to address the inequalities in healthcare that result from a widespread population with great economic diversity; one that is still hampered by the aftermath of frontier conflicts with neighbouring countries, as well as domestic social and political unrest. But, for the moment, NGO’s provide a valuable crutch to the national medical system.

Whilst there, we took advantage of being in a relatively populous area of the Amazon and used local contacts to organise a guide to take us around the local jungle and tribes. The next day a guy called Wellington turned up. Through the bulge of coca leaves in his mouth and a green-tinged grin we deciphered that he was to be our guide. Soon we were on board his dugout canoe heading to visit his tribe, the Bora Bora. Although western influence has certainly reached these remote regions there is still a strong tie to tradition. We were welcomed by a tribal dance in a traditional circular hut, built alongside more modern concrete counterparts. Dances represented the various deities and aspects of the peoples’ lives, complete with snakes, fish and jungle animals all being expressed through the pounding of staffs and guttural singing. Sadly, the financial strain of modern rural life has led to many tribes like the Bora Bora seeking money from tourists by selling cultural artefacts and crafts, which somewhat sullied the experience.

One of my motivating factors for going to Peru had been the indigenous communities’ deep understanding of medicinal plants and herbology. Whilst hiking we were stopped and shown the various fascinating uses of the plants around us. After a post-hike meal of fish wrapped in leaves and cooked in coals, we were onto the main event of the evening; caiman hunting. Although not something we personally agreed with on ethical grounds, in the Amazon it is a traditional part of the culture and the meat is regularly eaten by tribe members.

To spot a caiman you need three things: a boat, a torch and patience. By hour three we were starting to lack the third. As we entered the lagoon, we could see the torches of other boats out, blurred by the mist of the water. Yet despite all the other people there it was quiet except for the noise of the undergrowth. Wellington heard the distinctive call of the black caiman, halfway between a bark and the sound the water makes when you drop a large stone in it. Wellington replicated it as we drew nearer. Then we spotted them, two red lights reflecting back at us from our torch beams: the eyes of a caiman. As we drew closer Wellington inched his way to the front of the boat with his 3-pronged spear, lying on his belly as we closed in. In a moment that seemed both too quick and too slow he speared the caiman and shot out his arm to lift it by its tail and then swiftly clamp its jaw shut. “This is breakfast” he proudly proclaimed, binding the animal with rope so it wouldn’t get away. We sped back through the river, disturbing the calm reflection of the Milky Way upon the water.

Part 3: River clinics

After an emotional and rum-fuelled goodbye to the doctors and our host, Grippa, we took a boat to Iquitos for a quick pit-stop before heading out for the final leg of our adventure. We were about to launch on a two-week river barge expedition, following the tributaries to the most remote Amazonian communities. That evening we put on our least mildewy shirts and headed to meet our companions for the next section of our trip: a group of Florida international university students, a paediatrician, and Devon himself. The barge was equipped with a much better stocked pharmacy, had a full crew including translators and our friend Dr Luiz. I took a pharmacy internship to lower the costs of the trip and so was in charge of organising the medications.

The aim was to get as far up the Pintuyacu and Itaya rivers with the low dry season river levels and then work our way back along treating all the communities on the way. Clinics were held in the main communal house or school of the villages, with stations for registration, consultation, pharmacy and eye testing. When a patient came in they would be registered, height and weight taken, basic observations recorded, and prophylactic course of mebendazole administered (due to the high prevalence of parasitic illnesses within the populace). Vitamins would also be given to all children. We ran parallel clinics with the doctors and presented cases back to them to decide on management plans. Although we had an ample supply of medications, it was impossible to treat long term conditions effectively. Due to the high humidity we were not able to dispense stockpiles of medications as they would spoil before they could be used.

These remote communities only have access to healthcare twice a year from charities and outreach clinics, or must raise the money to make it to Iquitos to receive medical attention. Therefore, it was not surprising that saw a fair amount of drug seeking behaviour. Nearly every villager would present with symptoms they knew to be due to a medical condition. However, it was hard not to empathise with their predicament when they reside so far away from medical care.  One week before we arrived at one village a baby had died as the parents hadn’t been able to afford the cost of going to the doctors so had used a shaman to try and treat their baby’s malaria.

The conditions we saw in these communities were much more varied and developed. We saw Neurofibromatosis type 1, spinal cancer, malaria and TB, as well as a Cushing’s syndrome due to a patient self-medicating her arthritis with steroids her son had bought her. The other challenge we had here was that Dr Luiz unfortunately got ill and we had to ship a replacement doctor out. However, the practice of medicine in Peru is often less evidence-based than in the UK. Although our replacement doctor was a great diagnostician, he used many unorthodox treatment regimes and incorporated many of his own health beliefs into his practice, for example that IV/IM medications were more effective than oral preparations. We discussed the merits of different treatments, however as students, we ultimately had to respect our colleagues and the foreign practices in Peru.

Our clinic days generally ran from 8am until we had seen all the patients. We would then move on to the next community and moor up for the evening. Due to the increased number of clinicians we often managed to finish early in the afternoon and had enough time to socialise with the locals before moving on. No matter how far we travelled, there was one universal constant amongst all villages; a football pitch in the centre of the village, and the fact that we got beaten every…single…game. Although getting skinned by 8-year-old girls was humiliating, it was fantastic to get to know the locals as people rather than just as patients. This also made the goodbyes even harder. On board the barge, we had the opportunity to spot pink dolphins and sloths from our hammocks as we chugged along. And once all the medications had been prepped for the next clinic, we had time in the evenings to unwind by swimming or stargazing. It was the perfect end to our time with Project Amazonas.

All too soon we were back in Iquitos, parting with both colleagues we had spent seven weeks growing close to, and a place that had almost become home. Although we spent a few weeks afterwards hiking in the Andes, visiting Machu Picchu and all the other tourist destinations, the weeks spent working with Project Amazonas are my most treasured memories of that time. The warmth the people showed in inviting us into their communities and trusting us with their health was humbling. The fulfilment of working in a challenging environment where your presence really makes a difference to others is unparalleled, and I can’t recommend it enough to anyone. But you already knew that, why else would you be on this website…

Further Information

Where / Peru ( Iquitos, Madre Selva biological station, Pevas, Pintuyacu and Itaya rivers)

When / June – August 2017

How Much / Roughly £4000 including flights, insurance, living costs, donations to the charity and spending money. Biological station cost $100/week. Boat trips dependent on trip destination and length but can be subsidized by internships.

Contacts / If you would like to contact Project Amazonas or send a donation, simply head to their website. Dr Devon Graham, devon@projectamazonas.org (Project Amazonas charity director), Dr Madoc Flynn (Author and Elective Student) madocflynn@hotmail.com

Top Tips

• Think about how involved you want to be/how much medical work you actually want to do.
• Act early. Get in contact and show your interest early with organisations you are interested in.
• Think about what will progress your career in the future/skills you want to improve (e.g. Spanish in my case).
• Give yourself a generous budget so you know how much you need to raise, and the time scale.
• Remember to apply for bursaries and funding early.
• Most importantly try and go for your dream elective and find the way to make it happen, you only get to do it once so make the most of it.

About the author

Madoc is currently working as a Foundation Doctor in the north east of England, following his graduation from Newcastle University. He is an avid traveller: he was born whilst his parents were travelling and he hasn’t stopped since; 36 countries and counting. He loves rock climbing, hiking and any outdoor activity, and hopes one day to work as a medic on expedition or in a humanitarian setting.

The post Mother Jungle appeared first on Adventure Medic.

Having attended the World Extreme Medicine conference in Edinburgh, Saskia felt totally inspired by the people she met and the stories they told, so asked one of the speakers if she could join him for her senior undergraduate medical elective. Here, she reflects on her life-changing experience in South Africa, Botswana and Zimbabwe, where she embarked upon four weeks of wilderness and expedition medicine.

Until this trip, I had never slept under the stars in the Southern Hemisphere. The constellations are different; I can see the Southern Cross. I had never previously slept without a wall separating me from large wild animals. It’s the middle of the night, the moon illuminates the savannah around me and I am aware that I may be the only human awake for miles and miles.

I am in Pilanesberg National Park, just north of Johannesburg, South Africa. There are seven other students, a guide and a doctor all sleeping soundly behind me. I am on night watch for just a couple of hours, ensuring that we remain alive and well, until I wake the next person to come on duty. We have come out here for just a few days to gain skills in wilderness medicine and emergency first aid, as well as leadership, animal tracking, and connecting with our natural environment. Night watch is a time for reflection. As I recall today’s events, I stare into the dancing flames of the warm, orange, glowing fire in front of me.

Earlier tonight, we sat around the very same fire, discussing the nuances of cervical spine immobilisation in the bush and the reality that CPR doesn’t work out here (an uncomfortable and unfamiliar consideration in a normal medical setting), whilst consuming the spicy potjiekos we had cooked. Some time between the sun going down and the moon coming up, these after-dark musings were interrupted by our guide, Doric, telling us that Simon, our doctor, was missing. He looked nervous. One of the few expedition rules was that we always stick together and remain behind Doric, who has the rifle, as he is the only one who could safely protect us if we came across a large animal or poacher. We even defecated with someone on the lookout! And yet, here was Doric, complete with firearm, and Simon was out there in the black of night on his own.

Is this a drill? Please let this be a drill. Doric hurried us to action, and in that second, I forgot everything I had ever learned about medicine and first aid, but also how to walk. I immediately tripped over the log I had been sitting on. We grabbed our head torches and the medical kits and spread out, trekking up the mountain behind the camp where Simon had last been seen. When we found him, he told us he had fallen. There was blood visible on his head. After a short time, he became unrousable. Staged or otherwise, this night-time mountain rescue took me totally out of my comfort zone. Our teacher, the one person who would definitively know what to do right now, was unconscious.

What would you do? What are the right questions to ask? It’s not just a case of ‘to evacuate or not to evacuate,’ you must decide how and when. An ambulance wouldn’t be able to reach us, a helicopter wouldn’t fly at night, we didn’t have any phones on us and there was little chance of any network coverage anyway. The only viable option was to get Simon back to camp somehow and decide the next step afterwards. After a little panicking, and a lot of discussion about how to get him down the very steep hillside, we improvised a stretcher out of belts and a mattress. Then, with great difficulty, we attempted the descent.

Suddenly, the panting of an animal I hear but cannot see, pulls me back into the present moment. Is it close? Is it dangerous? I swing the torch across the horizon, to see if any pair of eyes reflect back at me. Nothing. I hear the same noise again, but it seems fairly distant. I hope it is fairly distant. I don’t recognise the sound. I can do sheep and cows, but animals out here? I learned the following morning from Doric that the sound had been a leopard!

Fortunately, Simon’s fall had been a drill. He stopped the simulation shortly after we started carrying him, and we had a debrief around the fire, discussing what went well and what we could have done better.  There are always so many lessons to learn – and there’s no better place to learn them.

Over the past few days, we have been practicing core survival skills in this remote environment. How to start a fire without matches and the basics of animal tracking. Suturing and inserting chest drains into animal carcasses. We are far from the city, hospitals, and our usual kit. We’ve learnt how to improvise when needed, such as creating stretchers, bandages, one-way chest seal valves, and tourniquets. There’s usually a solution to a problem you haven’t come across before, but I found that it can be hard to think ‘outside the box,’ having spent most of my medical life being told what equipment to use as well as how and when to use it. It’s been fun getting creative and inventing, looking at problems from a new perspective. We’ve trained in airway management, haemorrhage control, managing the unconscious patient, but with the added pressure of being in the territory of wild animals, short hours of daylight, and evacuation times of hours, if not days, rather than minutes.

Earlier during this elective, Simon took me to a park in Botswana where two people had been attacked by an elephant days before I arrived. He had assisted, with the aid of videocall, until the helivac arrived, telling those who were present what to do. There was no way of knowing with any certainty whether the victims would survive the six hours until help arrived, let alone beyond that. They had what appeared to be life-threatening injuries, with no doctors present except for the one on the little screen in neighbouring South Africa. When he returned, me in tow, he ran a training session for the safari guides, and discussed with the managers what equipment wasn’t available this time, but would be useful in future. Fortunately, the two victims made a good recovery.

One particular event that stood out for me as totally different to anything I’d ever done before, was entering a shoulder-deep (and very cold) watering hole to ventilate a ‘drowned’ patient whilst barefoot and blindfolded. But thanks to that, I now know that I could breath for someone in an emergency, with just one hand, in the darkness, in difficult conditions, if need be. Heck, I know that I could do it in a confined space, in the back of a bouncing 4X4 that has to drive for hours to the nearest hospital! I hope these skills practiced in difficult settings will now be automatic back in the comfort of a hospital, freeing up the brain to think about other things, such as what to do next.

A few weeks ago, I assisted on the medical team with various doctors and a trauma nurse, supporting several hundred cyclists as they toured Botswana, Zimbabwe and South Africa in the Tour de Tuli. We stayed in makeshift camps, moving from one to the next, and having to take all the medical equipment with us. Luckily for the cyclists, we mostly had to deal with small and easy-to-manage injuries, but I did have to chase a baboon out of the medical tent one morning, who was busy opening a box of bandages!

Tonight is our last night sleeping under the stars. Tomorrow we return to the city, where I will learn more about a wilderness doctor’s workload, about telemedicine consults and asking the right questions, like ‘what must I not miss?’ Calls have come in ranging from complaints of diarrhoea and vomiting to an incident in which a young child had been spat at in the face by a venomous cobra.

I’m going to miss the sunrises, the heat, the elephants and giraffe moving at their ponderous pace.  I’m going to miss the peace of the savannah. I’m going to miss the people I’ve met on my travels through Africa, the energy and kindness and, of course, the limitless flavours of rooibos tea. I’m already planning my return, working with rural people to provide emergency care in remote places. I wish (as my brother put it) to “give up all my worldly goods and go and join the leopards.”

Further information

When / July-August (Southern Hemisphere winter)

Weather / Hot in the day, very cold at night.

Vaccinations / Rabies is a good idea. I didn’t get my yellow fever vaccine as I wasn’t planning to visit any high-risk countries on my way to South Africa, but due to plane issues, ended up in Kenya for a night and they did want to see my yellow fever certificate on re-entry to Nairobi airport. Luckily, I managed to talk my way out of it. It’s safer to have had the vaccine and carry the card to prove it. Discuss the need for antimalarials with your travel clinic.

Travel / Flying between South Africa and London can be fairly cheap. However, it turns out it’s very expensive to fly direct from the north to South Africa. I left from Morocco but unfortunately experienced 20 hours of delayed flights, having to sleep next to two huge men in a locked office Lagos airport in Nigeria without my passport, and an impromptu trip to several Nairobi hotels before one would allow us to sleep for a few hours. Uber is cheap, reliable, and safe in Jo’berg.

Accommodation / Rent in Jo’berg is reasonably priced, tents (or just sleeping bags) for the bush, and you may stay in a luxury suite in one of the safari parks!

Essential items / Bring hats, gloves, lots of layers, hiking boots, tick spray, sun cream and sunglasses. And a buff for the dust! Everything you could need is available in shops in South Africa, so don’t worry if you’ve forgotten something.

Contact / You can follow Saskia on Instagram @thewildmedic 

Saskia may be able to provide further information for those interested in organising something similar. Please get in touch via Adventure Medic.

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With a keen interest in the global diversity of remote and pre-hospital medicine, Anna took the opportunity to explore a range of settings for her undergraduate medical elective in 2016. Travelling first to the Kathmandu valley in Nepal where she worked in a city hospital and remote health-camp, she then left the heat for the cold, flying to Tromsø in the Arctic Circle, to get a flavour of Norway’s world-class pre-hospital care system.

First stop: Nepal, where I began my elective with a week working in the Emergency Department of a busy urban hospital near the capital, Kathmandu. As I was curious about the reality of humanitarian medicine and keen to gain some experience of what working with an organisation such as Médecins Sans Frontières might be like, my urban placement was followed by an internship at a relatively resource-poor hospital in Manthali, where the local population was still dealing with the aftermath of a devastating earthquake.

In addition to helping with outpatient clinics at the hospital, at the weekends two other UK volunteer doctors and I helped the Medical Chief to run remote health-camps. We drove out to local villages by Jeep, stocked up with as much medication and kit as we could carry. We saw several hundred patients per day, most of whom rarely got the opportunity to see a healthcare worker. We did our best, despite rudimentary knowledge of the local dialect and very limited clinical and diagnostic resources.

My most memorable experiences at Manthali hospital were those from the maternity unit. One night, I was asked to assist with an emergency Caesarean section. Prior to this, I’d only ever seen deliveries in London hospitals, fully supported by midwives, obstetricians and anaesthetic and theatre teams. I felt somewhat out of my comfort zone, working in a team of only three to deliver the baby. Fortunately, the procedure went smoothly and both mother and newborn were well. I attended another vaginal delivery that night, which I am sure would been managed with a working epidural and plenty of analgesia in the UK. Watching a Nepali mother bite down on a piece of cloth and squeeze my hand for ‘pain relief’ during labour was a sobering experience.

After getting a flavour of the challenges of practising medicine in resource-poor and remote settings in Nepali, I set off back to Europe and into the midnight sun, to Norway’s northernmost hospital in Tromsø, 350 km north of the Arctic circle. I thought that a placement in Scandinavia, world renowned for its high standard of healthcare as well as its extraordinarily remote medical services, would be an interesting contrast to healthcare (and temperatures!) in rural Nepal.

Ever since I first heard about the Anna Bågenholm hypothermia case (‘Resuscitation from accidental hypothermia of 13·7°C with circulatory arrest’ ), I had dreamed of meeting the kind of anaesthetists who helped to achieve such a great recovery against all odds. After many emails and phone calls I managed to arrange an observership with Tromsø’s HEMS team via the Universitetssykehuset Nord-Norge’s (University Hospital of North Norway) Anaesthesiology and Critical Care Department

I was warmly welcomed and fully integrated into the medical team thanks to the friendly and multilingual staff and patients. I got daily practice in inserting IV lines, placing airway adjuncts, performing common airway manoeuvres (which I learned quickly look a lot easier than they really are), intubation and ventilation, as well rapid sequence induction.

The highlight of my elective was my final week spent with the Norwegian Air Ambulance HEMS team: I got to work and fly with the HEMS duty doctor, rescue man and pilot. During my time with the team, I got to see the base and dispatch centre, attend morning video-conferences with other remote bases, and (most excitingly) to join several missions across the vast fjord lands of Norway and Finland. During my placement, the team was called out for two search and rescue missions, two critical care inter-hospital transfers, two remote transfers of medically unwell patients and attended one homicide. I absolutely loved every minute of being part of this incredible medical team and watching how calmly they worked under pressure.

The opportunity to contrast emergency, critical care and remote medicine in a developing country with developed Western anaesthesia and pre-hospital care was a real insight and a great privilege. My placement in Norway allowed me to develop my knowledge and competencies in anaesthesia and my enthusiasm for pre-hospital care, while my time in Nepal enhanced my appreciation for the standards of care we take for granted in Europe. I would encourage any other medical student to get creative and to ‘pick-and mix’ when planning their elective.

Information

Manthali, Ramechapp, Nepal / Rural Assistance Nepal (RAN) organises electives here including at Tamekoshi Co-operative Hospital. Aim to stay for at least 3-4 weeks.

Dhulikel, Kathmandu, Nepal / Dhulikel is the teaching hospital for Kathmandu’s University and is the fanciest of Nepali hospitals. Placements are popular and they take a small fee. Contact them here.

Tromsø, Norway / Placement was organised via the University Hospital of North Norway. Make sure you have up to date (within the last 3 months) MRSA swabs via your Occupational Health department. They will not accept you unless you screen negative – Norway is MRSA free!

The post An Elective of Extremes: from Nepal to Norway appeared first on Adventure Medic.

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.

Aotearoa

Aotearoa, the Land of the Long White Cloud, had been in my sights as my elective destination from pretty much day one of medical school. As a self-confessed Lord of the Rings fan and outdoor enthusiast, the combination of New Zealand’s outstanding scenery and adventure, the opportunity to visit Hobbiton and climb Mount Doom, and a placement in Emergency Medicine created the elective recipe I had always wanted. The cherry on top was the opportunity to work with and learn from the Maori people, whose culture and history are vastly different from my own.

‘Hands on’ in Emergency Medicine

I had six weeks of clinical experience in emergency medicine, working in Rotorua’s ED, at the level of a Trainee Intern, New Zealand’s (paid!) final year medical students. This meant I managed my own patients under consultant supervision. It was a practical and educational placement, I soon learnt to suture a variety of wounds and apply casts to an assortment of broken limbs, thanks to the 130km of premier mountain bike trails running throughout the Redwood Forest right on our doorstep. I was taught how to do a FAST scan, lance abscesses and remove foreign bodies from eyes. I also assisted in three cardioversions, two resuscitation cases and an extensor tendon repair.

In New Zealand, people pay to see their GP but not for ED visits. Naturally, this results in many presentations to the ED that may better suited to primary care management. However, many of the ‘GP’ cases I saw whilst in ED were actually quite complicated, perhaps because patients delayed presenting due to the cost incurred. There were patients I saw who had never seen a GP because they simply could not afford to; a concept I found hard to deal with coming from the NHS. In the UK there is constant liaison and collaboration between primary and secondary care. In New Zealand, however, they are two separate entities which integrate care where possible, but within the limitations of their separate funding.

As Rotorua ED is the closest department to both the extremely popular Whakarewarewa Forest (miles of walking, but also mountain bike trails of varying complexity) and the Luge, a large majority of presentations were injury-related, especially FOOSH forearm fractures. Some were minor cuts and scrapes, others more complex trauma requiring specialist input and occasionally transfer to a larger hospital.

I think my most memorable case was a gentleman who had been triaged as a low-priority PR bleed. Going to assess him, I was running through the important questions I needed to ask in my head. However, I had barely stepped into the room when he dropped his trousers, anxiously asking me, ‘Is this normal?’ Frank, fresh, arterial blood was spurting from his perianal area. Whilst I assured him it was not normal, I grabbed the absorbent pad the triage nurse had given him and hastily applied pressure, explaining that I was calling for assistance, and the room was about to get very busy. Sure enough, within five minutes, he was round in Resus with two consultants managing the bleed, and the surgical registrar en-route. We subsequently found out he had had a surgical procedure for an abscess three weeks previously, and whilst on the toilet had felt something ‘pop’. He recovered really well, and after a couple of nights as an inpatient for monitoring, was discharged home. This case was a lesson that you can’t assume what is written on the front of the triage notes is always the full story!

Cultural Exchange

With one of the largest Maori populations in New Zealand, I was excited to gain an insight into this unique and fascinating people, their beliefs and culture during my placement in Rotorua. I was lucky enough to find myself in New Zealand for ANZAC day and attended the Dawn Parade: a march from the centre of town onto sacred Maori land for the culmination of the Remembrance service at sunrise. Serendipitously, the Lions (the UK Rugby team) were on tour in New Zealand during my placement and played against the Maori ‘All Black’ team in Rotorua.

Generally, there were no real clashes between the provision of ‘Western’ healthcare and Maori beliefs during my placement. If issues did arise, they were nearly always due to ignorance of Maori beliefs on the part of the healthcare providers. For example, tables are sacred to the Maori people, as they signify the bringing of family together with food. Indeed, if you are offered ‘kai’ (food), you are not just being fed, but are being welcomed into the family, regardless of your background. If you put an empty specimen pot on the hospital table, or lean on a table whilst talking (both seemingly innocuous actions in ‘Western’ culture) it is taken by many of the Maori people as a sign of disrespect, therefore making a good doctor-patient relationship much harder to establish.

Taking the time to learn a little about Maori customs was by far the best part of my elective. ‘Whanau’ (farn-o) means family, and it is all important. I was privileged enough to be asked to spend a weekend at a ‘marae’ (Maori meeting house), where I participated in ‘hongi’ (sharing of breath – gesture of respect), heard some of the Maori legends including the creation story of New Zealand, learnt some nursery rhymes in ‘Te Reo’ (Maori language) and the ‘Haka’, and was welcomed into the Whanau (family) with a ‘Hangi’ (feast). This is an experience I will always treasure.

Rotorua hospital is built on Maori land that has been donated to the town for the purpose of healthcare by the local ‘iwi’ (tribe). I find the Maori culture fascinating, and their beliefs, particularly about death and dying, are vastly different to those of the Western world. They believe that every person dies two deaths. Firstly a physical death and secondly when they are no longer remembered by those who are still living. I have come to realise that, regardless of cultural beliefs around death, the idea holds true universally – our own myths and legends prevent those who are long passed from being forgotten.

Extracurricular activities

I would highly recommend planning an elective in New Zealand: the scenery is stunning, the people are friendly and as an English-speaking country, you are only misunderstood if you forget to use Kiwi colloquialisms (flip flops = jandals, swimsuit = togs, bedding = manchester)! Driving is on the left, and whilst New Zealand’s main roads are more like our B roads than motorways, navigation is surprisingly straightforward. There really is something for everyone. Wellington’s ‘Te Papa’ museum and Hobbiton were fantastic experiences, and a trip to the Waitomo Glowworm Caves is a must-see.
I can definitely vouch for Rotorua if you like outdoor sports. Some of the best mountain bike trails in New Zealand run through the Redwoods, as well as miles of hiking trails (‘tramps’). The infamous Luge down the side of Mt Ngongataha (essentially a gravity-driven go-kart ride, down increasingly difficult tracks) is not for the fainthearted, but incredible fun. Rotorua also boasts some of New Zealand’s best geothermal activity, including the Pohutu geyser, and the extensive range of spas and hot springs. In addition, Rotorua is ideally located centrally, making weekend trips to most of the North Island easily accessible.

Top Tips

Trip Summary

Where / Rotorua, North Island, New Zealand

When / April-June, but they accept students February-November

Costs / 1000 NZD for 6 week placement

Weather / Varied! Despite approaching winter, there were still many days spent in shorts and t-shirt, granted, others required wearing as many layers as possible! Generally whilst the sun was out, it was hot, but following sunset, the temperature would plummet

Accommodation / There is hospital accommodation available, but you can also arrange to rent with hospital staff (cheaper, and gave me a more authentic Kiwi experience)

Contacts / I arranged my placement via the admin department of Rotorua Hospital.

The post There and Back Again: An Emergency Medicine Elective in New Zealand appeared first on Adventure Medic.

With the world’s population becoming increasingly interconnected, an understanding of global health is an important component of undergraduate medical education. In recognition of this, medical students in the UK are required to undertake an elective placement as part of their bachelor’s degree. Throughout my training to date, I have been excited about this opportunity to see how healthcare differs in a culture and setting of my choice. During the last six years, I have discovered a taste of remote, rural and expedition medicine and have become increasingly inspired by these fields. To try and get the most out of this elective period I began planning two years in advance.

Throughout my medical degree, I have been very involved in my university’s Wilderness Medicine Society. I have attended many educational and networking events, including the Extreme Medicine Conference held in Edinburgh. It was at this conference where I met the connections for my elective and I was fortunate enough to be accepted by World Extreme Medicine (WEM) to join one of their medical teams that provide healthcare in various global settings. I joined the WEM team in Fiji, who run a clinic on a remote island two hours from the mainland

Having never been to Fiji before I was excited to have the chance to learn about the culture and how the healthcare system works out there. The experience offered huge learning opportunities for me, in particular to see how the medical team worked in this remote environment and also to learn how the burden of disease differs between the Fijian and UK populations.

Another area of interest of mine is childhood obesity and declining physical activity levels amongst children. Knowing that Fiji has a particularly high prevalence of obesity, I was hopeful that I would be able to get involved in education and health promotion initiatives to combine both my medical interests.

The medical team I joined consisted of three doctors, two nurse practitioners and three paramedics. Having a medical student joining the team was a novel experience for them, but I couldn’t have felt more welcome. In addition to my team members, Fiji itself must be one of the friendliest countries I have visited, so any apprehension about spending time in an unfamiliar environment on my own quickly diminished.

We ran a daily clinic from 7am until 6pm. During these clinics we would see a great variety of primary care and tropical medicine presentations. I was able to consult individually and then discuss with the team to decide on the best management plan for each patient.  Outside of clinic hours, the team were fantastic in taking any opportunity to teach me about some of the medical equipment they use in remote environments. It was an invaluable chance to become familiar with pre-hospital care kit, and I am grateful for getting exposure to this at such an early stage in my medical career.

One particular clinical incident with which I was involved will stay with me as both an emotive personal experience and also as a memorable clinical learning experience. Whilst in clinic one day, I received a phone call reporting that a woman had collapsed in the local village. With two of the on-call doctors, we headed down fully equipped for any eventuality. We were unaware of the gravity of the situation until we arrived. A 47 year old local woman had collapsed and witnesses had commenced CPR. The next 40 minutes flew by. We were joined by our experienced paramedic and a very smooth and professional resuscitation effort proceeded. I wanted to be as helpful as possible without getting in the way.  I took control of getting an ECG and then controlled the oxygen bag-valve mask.  I felt comfortable in this role whilst others got on with their individual tasks. CPR is exhausting at the best of times, even more so in near 40 degree heat, so it was very important to rotate this role frequently. Unfortunately, despite the best efforts of the team, we were not able to recover the patient. This was distressing, especially so with the husband watching over us. The decision over when to stop CPR is a difficult one in any setting. Communicating this decision sensitively to relatives is also critically important. The woman’s husband was sensitively taken aside by the team. I sat with him for his last moments with his wife. This was very upsetting, but again a poignant experience which I will never forget.

All in all, this situation proved how teamwork and communication are essential for effective, professional and empathetic medical care. It emphasised to me the importance of a team leader and clearly delegated roles in such scenarios. I will take my learning from this experience on board as I start out in my medical career.

As well as being involved in the running of the clinic, I was given a fantastic opportunity to take part in some health promotion during my stay. I was keen to direct my teaching efforts towards healthy lifestyle advice and inspiring increased physical activity in children to help combat childhood obesity. I made links with the local primary school and planned an education session for the school assembly. I made leaflets with simple language (including the Fijian translation) and images for the school children aged 5-13. I also obtained posters with national guidelines for children about diet and exercise.  I gave a very interactive presentation to the children, allowing them to discuss their own thoughts on healthy living. The children seemed to really enjoy themselves and took the leaflets home to pass on information to their family and friends. I really relished the opportunity to be given an audience with these young children. I realise that I cannot combat this global epidemic through one teaching session, but hope that I instilled a positive change in thinking that the school teachers can continue to build upon in my absence.

I had some apprehensions before I travelled about where I, as the team’s first elective student, might fit into an already well established and efficient working team. I need not have worried; I felt extremely welcomed by the WEM medical team out in Fiji and settled in very quickly. I was a member of the daily rota and had a clear role, which instantly made me feel valued. During any downtime, we were all equally busy. I was relieved to be surrounded by others that also struggle with sitting still! Multiple watersports, tennis and fitness sessions were undertaken!

This experience taught me invaluable skills and provided memories that I will continue to draw upon both in a personal and professional context. It was a pleasure and an honour to work with the WEM medical team in Fiji and I hope I could be lucky enough to work in a healthcare team like this in the future.

Starting work as a doctor is an intimidating prospect, but I am confident that the skills and characteristics I have developed on this elective will help me in my future medical career. I am very grateful for this unforgettable opportunity and am very inspired to start working towards a future career in rural, remote and expedition medicine.

The World Extreme Medicine Conference, now in its seventh year, is being held from 23-25 November 2018 at Dynamic Earth in Edinburgh, UK. The three day event promises to be a festival of inspirational talks, workshops and networking opportunities and a bringing together of some of the best minds in humanitarian, pre-hospital, wilderness, expedition and extreme medicine. To register and secure your place, please visit their website.

The post Living my elective dream in Fiji appeared first on Adventure Medic.

Rebecca Trimble / University of Edinburgh Medical Student / Adventure Medic Student Rep & APEX 5 Volunteer

Altitude research is an amazing way to combine a love of the outdoors, travel, and education. Why not start getting involved as early as possible in your medical career? The APEX (Altitude Physiology EXpeditions) charity was founded in 2001 by Edinburgh medical students in order to explore the impact of altitude and low oxygen levels (hypoxia) on the human body. Many more students have followed in the footsteps of this first team, the most recent being APEX 5. They aimed to build on the work of those who had gone before, whilst enjoying the adventure and forging friendships along the way. Read about the team’s experience, and get in touch with Rebecca or APEX if you’re keen to be involved in the future or to learn more.

*The APEX 5 Organising Team: Christopher Graham, Rebecca Dru, Eleanor Lee, Gordon Paterson, Greig Torpey, Jason Young, Joe Wilson.

Last summer the APEX 5 expedition travelled to Bolivia, exploring hypoxia’s influence on the immune system, blood clotting, vision and cognitive function, as well as investigating the impact of personality traits on perceptions of altitude illness.

A team effort

Six University of Edinburgh medical students formed the APEX 5 organising team, and planning started in 2015. Chris Graham assumed the role of Expedition Leader, thanks to his leadership expertise and experience as an APEX 4 volunteer. Becky Dru was in charge of the books and finding willing backers for our inevitably costly expedition; Jason Young and Gordon Paterson took on the ethics applications and research logistics, in order to execute our ambitious research projects; Greig Torpey, with a wealth of experience with Scouts Scotland, was well suited to be Logistics Coordinator and organise our team-bonding weekend away; finally Ellie Lee, with her background as Yoga Society President, was in control of volunteer well-being. The organisers later welcomed Joseph Willson, Edinburgh PhD student, to assist with research.

Twenty-seven University of Edinburgh undergraduate students were then selected by interview to make up the team of research participants. Additionally, we recruited two experienced expedition doctors, Ailsa Stott and Nick Haslam.

A solid team.

The aim of the game

While expeditions make their names as life-changing experiences for all, the main aim of APEX 5 was high altitude research.

Jason led his neutrophil project, investigating the role of hypoxia in reprogramming immune response to bacterial infection. Gordon’s blood clotting research investigated how platelets are activated in hypoxia. Chris looked into the impact of hypoxia on the eye’s macula and fundus, and tested eye movements controlled by the brain to assess cognitive function. Finally Greig, with a helping hand from Becky and Ellie, undertook a psychology study investigating links between personality type and individual symptoms of acute mountain sickness.

Q&A Reflections

What was your main motivation to organise the APEX 5 expedition?

Inspired by the achievements of past expeditions, we formed APEX 5 to continue research into hypoxia and high altitude illness. Additionally, we all have a passion for the outdoors and expedition medicine, and were keen to get this exciting project off the ground and see it through.

What was your biggest challenge? How did you overcome this?

Aside from the steep learning curves for us all in areas such as logistics, ethical forms, financing an expedition, and the nitty gritty of scientific research abroad, we would say our biggest challenge was dealing with a last-minute change in location.

When the team arrived in La Paz, where we spent four days acclimatising, we met with our in-country logistician who had bad news. The road to Chacaltaya lodge (the destination for APEX 4, and our planned ‘laboratory’) was blocked off with snow and ice. This was uncharacteristic for the time of year. It was essential that we had safe road access for a rapid descent, in the event that a member of the team developed severe altitude illness. After some quick thinking and negotiation (and an attempt at digging/bulldozing our way to Chacaltaya) we secured an alternative lodge at the base camp of nearby Huayna Potosí Mountain (4,700m).

In what way did your research projects build on previous APEX expeditions?

Previous APEX expeditions have studied various aspects of both hypoxic physiology and high altitude illness, ranging from coagulation in hypoxia, to High Altitude Pulmonary Edema (HAPE). Our hypothesis for APEX 5 coagulation research evolved from the data gathered on these expeditions¹, aiming to uncover the physiological pathways up-regulated in platelets in hypoxia.

Will the results of your research have the potential to impact upon patient care?

The majority of our research projects investigated the effect of hypoxia on human physiology. By conducting our research in a healthy cohort at altitude, we were able to examine hypoxia in isolation, giving ‘clean’ data by removing confounding factors such as other diseases. We hope to relate these results to understand more about the impact and management of hypoxia in patients at sea level with ill-health, such as those with chronic lung disease and patients in the critical care setting.

For example, our neutrophil research may change our understanding of the immune system in patients with hypoxia and infection, such as patients with chronic obstructive pulmonary disease (COPD), which according to The British Lung Foundation affects an estimated 1.2 million in the UK. Laboratory experiments have shown that prolonged low oxygen levels in the presence of infection in mice can cause over activation of the immune system². However this does not happen if they were previously exposed to systemic hypoxia. This preconditioning of the neutrophil response thus seems to prevent a negative host immune response to hypoxia and infection. We hope to validate these findings in a human population with our results.

How did the volunteers fare at altitude?

We all came together and formed a fantastic team, able to look after each other when we had low points – we were pretty adept at making each other laugh when the going got tough.

We were lucky and extremely pleased that no volunteer had to be evacuated and that, despite the expected miserable symptoms of altitude sickness, everyone powered through and remained keen to stay involved in the research.

The team was also very thankful for our expert expedition doctors – Ailsa and Nick – who were crucial in keeping us all healthy and our morale high through good humour, many board games, and a few doses of painkillers throughout the expedition.

It was fantastic that our volunteers were keen to learn from our research. During research days, we offered half-day internships in the lab so that our volunteers could learn the science behind the research, improve their lab skills and ask any burning questions. This not only stands them in good stead for possible research-focussed careers, but also for the future of APEX.

What was the general atmosphere like at Huayna Potosí base camp?

Awesome! As said, our group got on amazingly well and the atmosphere was always very friendly. Our new place at Huayna Potosí was definitely cosier than Chacaltaya would have been, but it also allowed us the freedom to explore stunning surroundings. When not doing our research or out for a wander, there was always a card or board game being played, or a quiet space to read and reflect on the day’s events.

Can you describe a typical day at Huayna Potosí base camp?

After a tasty breakfast, it was questionnaire time, and on testing days this would be followed by blood tests, eye and vision testing, or helping out in the lab for the rest of the day. On research days there was a lot of work to be done with blood samples: preliminary analysis was undertaken on the mountain, and we prepared samples for transport back to the UK for comprehensive analysis – the laboratory team were kept busy!

After lunch, the afternoons were generally free, with some additional tests on research days. Many chose to chill out by the beautiful lake a stone’s throw from our lodge, play cards in the cosy dining room, or take a walk through the mountains. For days with less research it was necessary to become creative with your free time. The volunteers even wrote a parody (and recorded a music video) to Jordin Sparks’ “No Air”…

There was always time made to cuddle our two adopted expedition dogs – Nieve and Noche (Snow and Night – named for the colours of their coats) who lived full-time at base camp.

Following a traditional Bolivian dinner (always starting with soup), we often stayed together for a movie, a quiz, or even a spot of incredible stargazing. It would then be time to snuggle down in our sleeping bags looking forward to what tomorrow had in store.

What is your single best piece of advice for other students organising a similar expedition?

Find good mentors!

We would not have got the project off the ground without the help of Drs Kenneth Baillie and Roger Thompson, APEX founders, who provided us with so much support. Having their support and the support of other dedicated research supervisors was crucial in the planning and execution of such a unique trip.

What are you most proud of?

It is hard to sum up an expedition of this scale in just a few words. It took over two years of planning, many late nights and an awful lot of paperwork before we could even set foot in South America. From interviewing our volunteers and submitting complex ethical forms, to undertaking our ambitious multifaceted research in the Andes, we as a committee learned an unbelievable amount.

We are proud of everything that we achieved, of each other, of the volunteers, and of the fact that we organised an international medical expedition.

Keen to find out more?

For a taster of APEX 5 trip’s amazing surroundings, and their somewhat cheeky musical skills, see their YouTube music video.

If you’re interested in following up the results of their research, or are keen to contact the team who run APEX about future expeditions, visit their altitude.org website. Alternatively, drop Becky, our student rep and co-author of this article, an email on rebecca@theadventuremedic.com.

References

1. Thromboelastometry and Platelet Function during Acclimatization to High Altitude. Rocke et al. Thromb Haemost. 2018;118(1):63-71

2. Hypoxia determines survival outcomes of bacterial infection through HIF-1α–dependent reprogramming of leukocyte metabolism. Thompson et al. Sci Immunol. 2017;2(8): eaal286

The post APEX 5: Student Research at Altitude appeared first on Adventure Medic.

Tom wrote the winning entry for our 2017 Adventure Medic Elective Article competition. He penned this piece about his elective in the Himalayan mountains of northern India, where he travelled with the Himalayan Health Exhange. We hope you enjoy reading his lovely, reflective article as much as we did. If you’re considering this type of elective or trip yourself, enjoy his top tips at the end too. Thanks again to our competition sponsors who provided some superb kit as an incentive to write: Rab, Alpkit, Keela and Lifesystems.

The Himalayan Health Exchange

Last August, I was given the opportunity to join a month-long medical expedition in the Himalayan region of Kargiakh with the Himalayan Health Exchange (HHE). I joined them in their challenging mission to provide medical care to the underserved and often isolated peoples of the politically unstable Indian border state of Jammu and Kashmir. Each summer for over 20 years, by invitation of the local government, a team from HHE has visited the Zanskar region in order to deliver medical care to the local inhabitants, with primary and public healthcare objectives. Aside from direct medical care, the charity also uses proceeds from the trip to fund surgical procedures in the more southern city of Manali and also contributes to the training of Amchis: local providers of traditional holistic health care.

Our team included over 20 medical and physician-associate students from the UK, US and Canada as well as a core team of senior US doctors. We set out to visit villages far off the beaten track and our clinics were open to all, including local farmers, road workers, seasonal labourers from the valley, and even recreational trekkers. As access to many of the villages was only possible on foot, everything we needed for the trip was to be personally carried with the assistance of a small army of mules (47 of them to be exact).

Acclimatisation

To begin the expedition, we flew into New Delhi before connecting to the mountainous city of Leh to begin our acclimatisation period. Leh was largely comprised of traditional Buddhist architecture, with temples and palaces interspersed by winding alleyways, and strung together across the sky by colourful banners of prayer flags. This bustling tourist town provided a beautiful initial staging post for our team as we prepared for our weeks of trekking ahead. At our initial briefing we were reminded this would be the lowest point until the end of the trip, before which we would twice ascend to over 5,000m, breaching 5,400m at Phriste La Pass. Even in Leh at 3,505m elevation, a relatively modest height above sea level, the oxygen pressure in the air is around two thirds that at sea level. In practical terms this proved to cause one to become heavily short of breath on ascending the gentlest flight of stairs.

Physiological acclimatisation was an essential undertaking to reduce our risk of developing altitude related illnesses. These can be extremely debilitating and even fatal if not recognised and treated early. On previous trips, students had been evacuated due to illness after failing to follow acclimatisation instructions and exerting themselves too much early on; acclimatisation was viewed respectfully by everyone on the trip.

The best treatment for acute mountain sickness and its sequalae is descent, and the lead medics made it clear that their threshold for descent and evacuation was low. To help reduce the likelihood that we would develop altitude sickness, we were given strict orders. Rigorous hydration, rest, prophylactic acetazolamide (Diamox), and no alcohol. Remaining teetotal was to be no small feat for a group of medical students abroad (most post-finals) but given how far each of us had travelled, none was keen for an early and likely long and uncomfortable mule ride to the nearest road for evacuation.

To combat this real danger, we all submitted ourselves to the gruelling regimen and activities associated with acclimatisation. These included reading, drinking chai, regular naps and just lazily lounging about, trying not to exert ourselves. Surprisingly, even with added jet-lag, napping was perhaps the biggest challenge. Sleep at altitude is notoriously disturbed, with irregular and intermittent Cheyne-Stokes breaths causing sudden waking in the night, often to the alarm of an anxious tent-mate who may have just witnessed a very prolonged pause in breathing. In addition, we were all taking regular acetazolamide – a diuretic. As such, a night of undisturbed sleep was unheard of in the early part of the trip, as our bodies and kidneys took time to adapt physiologically to this new state of affairs.

Setting out

Setting out from Leh early in the morning, our fleet of 4x4s made light work of the initially well-constructed roads, ascending thousands of metres over the course of the day before we crossed the second highest road pass in the world, Taglang La (alt 5,328m), well before lunch. At this point members of the group were recording oxygen saturations of 69% and the first case of altitude-related sickness was spotted amongst our ranks. One of the senior medics who hadn’t spent much time in Leh due to a delayed flight hadn’t managed to acclimatise and was feeling very unwell. Fortunately, by the time he had become symptomatic our route ahead had begun to descend again. Camp was still hours away and so our driving speed increased significantly. He improved rapidly and completely following our sharp descent.

This gear shift seemed to coincide with a rapid deterioration in quality, or in some cases even presence, of the roads. This should have come as no surprise, we had overtaken the tarmac laying team earlier that morning and began to pass small teams of construction workers armed only with pick axes and shovels. Haste on these narrow and rudimentary roads felt like a recipe for disaster. Many of them were hand-cut from crumbling and landslide-prone Himalayan rock and barely allowed passage of a single 4×4, let alone the large oncoming trucks which often halted our progress and forced us to gingerly pass along the cliffs edges all too often. The multitude of poetically poignant anti-speeding/drink drive signs which punctuated the roadside did little to calm our nerves.

“Safety on the road means safe tea at home”

“Better to be ‘Mr late’ than ‘late Mr’”

“Don’t be risky, lay off the Whisky”

We eventually arrived safely on a windswept plateau just outside of Sarchu village, halting our thrilling and spectacular descent and providing a welcome respite from the motion sickness-inducing ride down. After setting up near to a local Indian army camp, we said goodbye to our vehicles and it became apparent that from there on, we were to be entirely self-sufficient and that all travel would be on foot or hoof. With that, we were also reminded we would be without phone signal, Wi-Fi, treated water, or a conventional toilet for the next three weeks, the latter of which would certainly take some getting used to. After pitching our tents for the first time, the early sunset and clear evening provided the first of a series of incredibly beautiful skies featuring the brightest of moons and clearest Milky Way that most of us had ever seen. The budding photographers amongst the group revelled in this, as the rest of the team turned in early before the first day of clinic.

Clinic days

Our first clinic days started soon after sunrise, with a huge pot of hot milky chai and an enormous breakfast spread to kick-start each session. Pancakes, French toast and fried eggs were a common treat.

Each clinic followed a similar format, with individuals rotated across all stations. A group provided initial triage, recording basic physiological observations and a main presenting complaint, before showing the patient to the relevant medical tent where they were seen by an assorted medical team. This team usually consisted of three students: a historian; a scribe; and an observer, with a supervising ‘resident’ and translator when possible. Patient evaluations were a team effort, which significantly helped as the process of taking a history via a translator (sometimes using three different languages at a time) was a challenge which was new to most of us. Each student would present the case to the supervising physicians and a shared plan was made, with the patients input. They were subsequently shown to the pharmacy station where appropriate medications and instructions were dispensed by our charming and cheeky resident monk – co-expedition leader and practical joker ‘Lama Ji’. He was a senior Buddhist monk, local teacher, and spoke a range of local dialects which proved invaluable throughout this often-convoluted process. In total we would see around 500 patients over 10 clinics throughout the trip, with nearly 90 seen on the busiest day.

After our first clinic in Sarchu, we continued through the valley and reached the Zanskar region, where we held clinics in Tangste, Khangsar, Testa, Kyng and Kargiakh villages. We were given a grand welcome at Phuktar Monastery, the site of one of our final clinics. Hundreds of years old, it was carved into the mountainside centuries ago and has since been home to around 70 monks and monklets (school-age monks in training).

Medical Experiences

Musculoskeletal, ophthalmological, gastrointestinal and dental problems were particularly common. The ‘HHE special’ was a common management option for many of the adult patients we saw. This consisted of sunglasses, eye drops, and ranitidine. Gastro-oesophageal reflux seemed to be almost universal in adults over 25, perhaps linked to the common habit of eating a single large meal, often very spice-heavy, at the end of the day just before bed. The presence of Pterygium, a fibrovascular growth of conjunctiva, was also particularly prevalent. Severe cases can lead to visual loss and its prevalence is greatest in dry climates with high UV exposure. Over 70 patients were seen with symptomatic and asymptomatic pterygium and those with conjunctivital symptoms were given a combination of sunglasses and eye drops. Asymptomatic patients and adults who worked outside were also given sunglasses as a prophylactic measure to help prevent direct UV damage.

After each clinic had packed up, we would debrief as a collective. This provided a forum to discuss specific challenges faced, scope for improvement, and particularly interesting cases. A memorable example includes the epidemic of ‘adolescent hypertension’ (aptly named Chai-pertension) in one village. It was thought this was due to the seven-a-day chai tea habit taken up by many of the children, some as young as four years old. We advised them to cut down but knew full well the hypocrisy of our advice. I was drinking a similar amount myself by this stage and didn’t consider holding back, it was delicious.

Survival in the Himalayas

Compared with the relative comfort of Leh, the effort and physicality needed to subsist in this region was evident. Twenty-year-olds looked forty, forty-year-olds looked seventy and I could count the number of overweight patients seen on one hand. The staggering scale and extreme nature of the physical environment clearly exerted a significant impact on the people living within it; severe osteoarthritis and other labour-related musculoskeletal problems were our most common presenting complaint.

Each path we trekked along lead us past mile upon mile of rock walls built to contain livestock, mainly yak and goats. These were interspersed with large religious shrines covered in thousands of engraved stones, some hundreds of years old. The time and effort invested into each of these structures was staggering.

Despite this, many of these people were not only surviving, but thriving, testament to their active lifestyle, their strong bond with the landscape and their ability to manipulate it to their benefit without desecrating or over-exploiting it. Each time we passed through settlements, we were able to see how entire local river tributaries were deliberately coaxed laterally across rock faces to supply local homes and crops. I was surprised to see valleys full of lush fields of barley and wheat, contrasting starkly with the arid brown rock in the higher climes. Yak patties (mud, yak manure, and straw) covered facades of buildings as they dried in the sun, ready to be used as an indoor stove fuel source. This practice is associated with myriad respiratory conditions but is by far the most widely accessible and cheap fuel option and as such, chronic cough was an all too common complaint.

The Inadequacy of overseas aid

However, in contrast to these established communities, the immigrant labourers and road workers we saw at the start and end of the trip were a heart-breaking sight at the road side, and later in clinic. These people were working long physical shifts, sleeping under tarpaulins and barely earning enough to feed themselves, let alone the families many had brought with them. Speaking with them in clinic, we realised many would never earn enough to escape their occupation, or this region. They were emaciated, malnourished and often desperate. Those that needed referrals to city clinics (about three days’ travel in good weather) were essentially hopeless cases. Despite being offered free care, we knew that few would be able to take time off work or have the money to pay for travel.

This provided me with my first appreciation that despite best efforts, sometimes overseas aid and charity work can be wholly inadequate in serving to address the specific health inequalities that are endemic in some areas. The health problems we glimpsed were symptomatic of a significant lack of infrastructure or a system to provide for the whole population. I took some solace knowing that proceeds from our contribution were going towards training new medical professionals elsewhere in the region.

Evenings and free time

Each clinic day we held 15-minute oral presentations which had been allocated and prepared prior to the trip. The topics included high altitude physiology, altitude related conditions, hypothermia, infectious diarrhoea, tuberculosis, HIV, local religious practises and alternative medicine, women’s health and women’s health rights in India, and a practical hyperbaric chamber demonstration. These sessions helped to supplement our clinical experiences and prepared us well for subsequent clinics.

On trekking days, we were free to use our evenings to recover. As well as excessive tea drinking, these time periods were revolved around competitive card games, diary writing, reading, listening to music and (attempting) yoga. We even adopted a curious local dog on the trip. ‘Trail Dog’, followed us for several days, snacking on leftover roti and providing much appreciated cuddles for the trekkers. Meals were freshly-prepared vegetarian dishes with Indochinese influence. They were of very high quality, and there was always plenty to go around, particularly important given that we were spending up to nine hours a day walking, ascending over 1000m on some.

One evening, we made use of an old cricket set the Sherpas who lead our trip had brought. It was an annual tradition that the Sherpas would play the students. As British students, there was certainly an expectation that we would field a reasonable team. Despite our questionable understanding of the specific rules we managed a decent result against a ruthless and clinical Sherpa side who showed no mercy. Fortunately, our US and Canadian counterparts made up for a lack of cricketing know-how with baseball style batting and fielding prowess, sending many a ball skyward for six with some spectacularly athletic diving one handed catches. This intro to cricket was a hilarious and invaluable bonding experience for the entire expedition team.

Why you should consider this (type of) elective

The Expedition to Kargiakh with HHE was filled with wonderful memories and was staffed by incredible people. We all treasured the bonds and friendships we developed whilst spending a whole month in the wilderness, and leaving everyone at the end was tough.

If you enjoy the outdoors, like a real physical challenge, have minimal personal hygiene needs, and an interest in expedition medicine or global health, this may well be the medical elective for you. I found an increased appreciation for the conditions, access to technology, global sanitation and medical care that we have in the UK, as well as deep respect for the people who call this harsh and beautiful area of the world their home.

Where / Kargiakh Valley, Ladakh, Jammu and Kashmir, India

When / August

How / All trip details and contacts and application forms can be found on the HHE website.

Price / The cost was £2,500 for the trip itself, which included all travel, meals and accommodation. Much of this money went towards the charity’s side project in the region (free surgery for those in need and training for local practitioners). An Indian Visa costs around £110. Return flights to New Delhi from the UK can be estimated at £500-£700 depending on when they are booked. Internal flights were about £40-60 each way to Leh.

Top tips

Final word

Writing this months later, I would honestly say the cultural, spiritual and environmental characteristics of this place are the most incredible I have been privileged enough to experience and it is strong wish of mine to return in the future. N.B The medicine was cool too.

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Having just finished medical school in Cambridge, Arav is due to begin working as FY1 doctor in Manchester at the end of the summer. Last year, he spent his medical elective roaming on the beautiful continent of South America, combining his placement with time in a boat, time on some skis, and time spent brushing up on a little altitude medicine. Here, Arav gives us a brief insight into his time abroad, and follows it up with some handy information on how you might organise something similar yourself. Look no further for elective inspiration… 

I ought to start this article with a confession, as it attempts to explain my choice of elective. Six years of medical school has done nothing to alleviate a condition that can only be described as a chronic case of FOMO*; my desire to be involved in a little bit of everything is somewhat of a class joke. I suppose it’s unsurprising that I see myself as a future generalist, albeit unclear on the specifics.

This, along with a taste for the outdoors and a (rusty) Spanish A Level, led me to that continent which is the feather in the cap of many a gap-yah traveller: South America. It’s easy to see why it’s so attractive; there are few places in the world where one can go from desert to jungle faster than Luis Suarez can latch onto an arm, or from metropolis to glacier faster quicker than it takes to order a cerveza in a Peruvian bar. I wasn’t in a thousand years going to miss out on the diversity of South America by spending my eleven weeks in one single location.

With that in mind I sought to organise a series of mini placements to experience some completely contrasting environments, while improving Spanish and travelling the gap year I never had. In the end, the two that excited me most were volunteering aboard the Amazon Hope in the Peruvian Amazon, and working at a ski clinic in the Chilean Andes. Both were completely different aspects of ‘wilderness’ medicine and neither disappointed.

Peru by boat

I found the well-advertised Amazon Hope Project on the Electives Network around the same time a friend mentioned his interest, and it seemed a great idea to go together.  The Vine Trust is a Scottish charity that is the brains behind this fantastic sustainable project. It recruits clinicians and students from the UK who spend a fortnight sailing up the Amazon’s wider tributaries on a fully kitted boat, to help provide basic healthcare to remote riverside communities far beyond where the tourist cruises reach. Alongside a core group of Peruvian physicians, nurses and midwives, we ran daily clinics for locals whose only contact with doctors was a visit from the Amazon Hope three times a year. Presentations were surprisingly like those one might see in a GP surgery in the UK: I saw many cases of uncontrolled diabetes, upper respiratory tract infections, and back pain. Where the difference lay was in the management. With limited resources on board, the British National Formulary was more a starting point for treatment than bible, and with specialist care days away, referrals had to be thought through twice. Whereas in the UK a referral to secondary care is just another rung in the NHS care ladder, in the remote environment, referring a local who takes your word as gospel could mean them putting weeks’ worth of wages towards a potentially fruitless trip to the nearest town. As well as the ‘bread and butter’ cases, there were several opportunities to treat patients with parasitosis, malaria, and one memorable 8-year-old who had been suffering with a nasty-sounding chest infection since the last visit.

Of course, the geography of the landscape meant a significant amount of time was spent travelling between villages, providing ample opportunity to read, watch the birds and practice my Spanish with crew mates, especially the translators who doubled up as language teachers. The early mornings treated us to dolphin sightings and the evenings gifted us stunning sunsets and some intense games of village football. As an amateur photographer, it really was paradise for a fortnight!

Chile by ski

Unlike the Amazon Hope Project, which has a great set-up for elective students (they take 2 medical students and 2 dental students per trip), my experience in Chile was a steeper learning curve. I’m a self-professed lover of mountains, and having intercalated in clinical physiology I was keen to learn more about altitude medicine. After gaining some personal experience by climbing a 6000-metre peak in Bolivia, I organised a 4-week split placement in Chile: 2 weeks with the mining communities to learn about the chronic effects of altitude on labourers, and 2 weeks at a ski clinic to brush up on my management of high-impact trauma. As was probably likely to happen at some point, my plans didn’t quite come to fruition and my ‘chronic’ fortnight fell through, leaving me with 2 weeks in a Santiago hospital in the occupational health department! The time was just about well-spent, with my head buried in a dusty book on altitude pathology, which I read so overtly that the department decided to gift it to me at the end of my time there. Opportunities also arose to discuss high-altitude research with local doctors, which proved very interesting indeed.

The fortnight in the Three Valleys ski resorts outside Santiago were exactly what I had hoped for and more. Upon arrival at the clinic I was immediately equipped with a radio and told to head out to the slopes! This set the tone for my days, which were spent hurtling down pistes and rushing over to the clinic whenever I got the call. On average, I would see 5 patients a day, giving me plenty of opportunity to practice my orthopaedic examinations and basic management. In contrast to the Amazon Hope, the clinics were private, catering to tourists from all over the world. Resources here were also limited because in a different sense, the ski clinic was also remote. However, the closest hospitals were just a 15-minute, £500 helicopter ride down to the capital (and I was very lucky to get my first HEMS experience on day two of this placement!). Perhaps surprisingly, the great infrastructure in Chile didn’t translate to easy organisation of this placement, which required a lot of pre-trip planning and the help of a God-send of a local surgeon who took me under his wing. Looking back on this particular placement, it didn’t feel like expedition or wilderness medicine per se, but it certainly ticked the ‘alternative’ box and provided me with an unforgettable and fun experience I would never have had through medical school.

Home again

In hindsight, I do think that that is what an elective should be all about. Not to decide on a place you like and find a medical placement there for the sake of it, but to push the boundaries a little and make sure that you experience something out the box in a place you’d love to immerse yourself in. For me, my elective certainly achieved that: at no point did work feel onerous – it really was a case of a working holiday. Returning to the UK after 11 weeks on the road was certainly a bump back to reality, but the plans for an FY3 are already bubbling away in the back (front) of my mind and show no signs of letting up! Within days of landing, I had signed up to the cauldron of inspiration that is the Student Wilderness Medicine UK Conference in Edinburgh, so here’s to the next adventure.

Further Information

Where / Peruvian Amazon & Farellones, in the Chilean Andes

When / June-August

How much / You’re looking at over £1000 for an Amazon trip, excluding flights but including all else. However, much of this (almost half) is a donation to the charity, so Crowdfunding the donation chunk is doable with foresight and cuts costs considerably. For the Chilean/ski segment, I had to find a cheap place to live while in the mountains – Club Andino Gastón Saavedra provided cheap and friendly lodging for extended periods of time. The owner Ricardo refused to charge me for any ski equipment hire when he found out I was a medic.

Tips / In general, for any elective, I would suggest to try to speak over the phone or on Skype with someone when organising, especially if doing it through a ‘friend of a friend’. Emails sometimes get lost and misinterpreted, so best to be sure ‘in person’.

Peruvian Amazon Hope trip – do it as part of a larger trip, as a two week trip only means 9/10 days on the boat, and there’s so much to do in that part of the world! Spanish isn’t needed as translators are used; a little, however, goes a long way. Incidentally, the Amazon Hope work also accepts dental students.

Chilean skiing clinic – from Farellones, the clinic ambulance will happily pick you up every morning and take you to the clinic. Of the three ski centres that Farellones serves, Valle Nevado offers the best skiing but is a good 25-30 minute drive from Farellones. El Colorado is great and very close by, as is La Parva, which is the smallest. June-August is the best time to go, and the last couple of years have had fantastic snowfall.

Finally in South America, pack for all weather! I struggled to think of a climate I didn’t encounter.

Contacts / Info on volunteering for medical expeditions on-board the Amazon Hope, or their other ventures, can be found on the Vine Trust website (their website was easy to use, and their office very helpful if you give them a call).

*For those of you not down with the kids, FOMO = ‘fear of missing out’ – editor.

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Last week, Sam Covins regaled us with the story of his research expedition to the Atlas Mountains. To follow this up, we asked Sam some questions about how he became involved in altitude research as an undergraduate, and what happened along the way.

Why altitude research?

For me, it all started at the 2014 Student Wilderness Medicine conference, during which Professor Chris Imray gave a captivating keynote talk on his involvement in the 2007 Caudwell Xtreme Everest research expedition. I’ve always had an ambition to climb mountains, and learning that it was possible to do so in combination with research was what really inspired me to organise an expedition of my own.

What kind of research were you conducting?

The study itself incorporated the protocols of six individual research projects that we independently designed and developed. Our research aims were as follows:

• To assess the impact of hypoxia on cardiac electrophysiology at high altitude, using continuous ECG monitoring.
• To investigate changes to the respiratory airways during ascent to high altitude, and their association with the onset and severity of acute mountain sickness (AMS).
• To perform a quantitative analysis of peripheral oedema at high altitude.
• To conduct a comprehensive assessment of visual function at high altitude.
• To analyse complex decision making and risk taking behaviors at high altitude.
• To explore the use of thermal imaging technologies for the assessment of peripheral perfusion at high altitude.

Our research was conducted in collaboration with academic staff from the University of Birmingham, the University of Warwick and local NHS trusts.

How did you go about setting up this study?

I established the Warwick Altitude Research Group back in February 2016. During our first meeting, we spent several hours discussing research ideas and debating locations for an expedition. Initially we decided upon an ascent of Mont Blanc, with the intention of recruiting local mountaineers as participants for our research. However, having spent some time liaising with various guide agencies in the Chamonix valley, we realised that Mont Blanc was way out of our budget. Back to the drawing board. But after much deliberation, we decided upon an expedition to the summit of Mount Jbel Toubkal. Having chosen a destination, we spent the next few months developing our research proposals, preparing ethics documents and drafting applications for funding. Rather than recruit mountaineers in Morocco, we decided that for research purposes it would be logistically easier to recruit participants in the UK and travel as one large expedition group. Our recruitment drive was short and simple with thirteen extra individuals jumping at the opportunity to take part in the study. The expedition was predominately advertised through word of mouth to our friends and colleagues. Each expedition member was provided with an information leaflet, providing them with all the necessary information about our research study. Everyone was given time to consider this information and decide whether or not to participate in the research, and participants were in no way coerced into taking part. Exclusion criteria varied between the different research projects.

Overall, the study was a success and we are currently in the process of preparing manuscripts for publication. In addition, myself and four other students were fortunate enough to be able to present our study findings at the 2016 Altitude Research conference, hosted by the Birmingham Medical Research Expeditionary Society (BMRES), and were awarded the prize for ‘best poster presentation’. Delighted!

What preparations did you have to make before you departed for Morocco?

We spent several months making plans to prepare for the expedition. Not only did we have to prepare for our ascent of Mt. Toubkal, but we also had to work out how to transport our research equipment and conduct our experimental protocols in the field. Although our expedition had been planned so that the majority of our research could be performed in the shelter and comfort of our overnight accommodation, we knew that our final round of experiments would have to be conducted on the summit which, in November, is covered in snow and very exposed to the elements. Therefore, in preparation for any unfavourable weather conditions, we packed and carried several tents and group shelters on our final day of ascent. Fortunately, our summit day was blessed with excellent weather and very little wind until the very end, which enabled us to conduct our research with little environmental disruption.

In order to maintain the consistency of our research, we made sure that all of the equipment used during the hypoxic chamber study back in the UK was transported with us to Morocco, and utilised for the same experimental purposes throughout the duration of the expedition. Unfortunately, due to our limited budget, we were unable to afford the purchase of any insurance for our research equipment. This was a significant source of anxiety for several members of the research team, particularly as most of our equipment had been acquired on a short-term loan basis for which we had to accept personal liability for any damage or loss. However, to ensure the safe transport and storage of our research equipment, we were very particular about the packaging and protection of each item in our luggage. We also decided to compile a list of all our equipment and allocate responsibility for individual items to different members of the research team to ensure that nothing was forgotten or lost.

Did everyone involved have previous experience of trekking at high altitude?

Around 500 people climb to the summit of Mt. Toubkal each year, and although the ascent does not require any technical mountaineering ability, a high level of physical fitness and stamina is needed. We were therefore quite selective during our phase of recruitment to ensure that only those with a reasonable chance of successfully reaching the summit were recruited. Despite our relatively limited knowledge of winter mountaineering techniques, we all had previous climbing and trekking experience from time spent in both the UK and abroad. In addition, several members of our group had previously travelled to high altitude at various locations around the world.

Did you arrange any training to ensure that the group were adequately prepared?

We did discuss the idea of organising some group training before our departure, but ultimately decided against it due to time constraints, and the difficulties associated with coordinating a pre-expedition meeting at suitable time and location. Although there was therefore no formal training for the volunteer participants, we advised each of them to prepare for the ascent with regular exercise to improve their cardiovascular fitness and stamina.

However, we did arrange a weekend of training for the expedition research team. Together we travelled to Great Malvern in Worcestershire and embarked on a walk along the length of the Malvern Hills. With us we carried all of our mountaineering and research equipment to simulate what it would be like during the expedition. Upon reaching the summit of the Worcestershire Beacon (the highest point along the route) we set up a temporary base camp and conducted a rehearsal of our research investigations in the field.

What was the biggest difficulty you faced, and how did you overcome it?

Funding for the study was our biggest limitation. As medical students, we were not only limited by the nature of our research (i.e. nothing invasive or interventional), but we were also forced to front most of the research costs from our own personal funds. We submitted several grant applications to various charities and organisations but securing financial support proved far more difficult than we’d ever anticipated. Fortunately, we were lucky enough to be awarded a small research grant from the JABBS Foundation – a Birmingham-based academic charity – to subsidise the costs of using the hypoxic chamber. More recently, we received a generous donation from the BMRES which was used to reimburse several members of our group and alleviate the financial burden of our research study.

What was your highlight of the expedition?

Although reaching the summit of Mount Toubkal was a great achievement, for me it was not the biggest highlight. I was unfortunately one of a minority of expedition members that did not acclimatise well to the altitude, and thus my time spent above 4,000m, with oxygen saturations of 75%, was an entirely unpleasant experience.

The highlight of the expedition for me was actually our evening meal in Marrakech on our last day in Morocco. With the research now complete, I found myself pausing for reflection as we sat and enjoyed our final meal. It was at this point that the sense of achievement really hit home for me. What had started out as a somewhat ambitious idea had become a reality, and after months of planning and preparation I felt relieved that it was over, but immensely proud of what we’d accomplished.

What advice would you give to other students wishing to plan their own research expedition?

Be organised and start the planning process as early as you can! Choose your group carefully – good teamwork and communication is essential for the success of an expedition. Seek financial help and apply for grants early. Find a good supervisor who will support and advise you. And finally, don’t be put off by the sceptics and the people that tell you “it can’t be done”.

“Challenges are what make life interesting, overcoming them is what makes life meaningful.”

– Joshua J. Marine

Looking back, would you consider doing something like this again?

Yes, absolutely! Although it was at times an incredibly stressful and time-consuming experience, I thoroughly enjoyed it, and I’m proud of what we’ve achieved as a group. So much so that we’re currently in the process of planning our next expedition to the Capanna Margherita on the Monte Rosa massif. Watch this space…

Any final words?

I’d just like to take this opportunity to thank both Dr Sam Lucas, from the University of Birmingham, and Professor Chris Imray for their advice and guidance throughout the duration of the study. Without them it would not have been possible and I’m sincerely grateful for their support. I’d also like to extend my gratitude to the BMRES and the JABBS Foundation for the financial support they have provided. And finally, here’s to the expedition research team: Gavin Miller, Kenneth Morrison, Daniel Jones, Alasdair Anderson, Sam Calcott & Alex Clark.

Want to know more? Read all about Sam’s Moroccan expedition here, and keep an eye out on Adventure Medic in case Sam is looking to recruit new students for his next expedition…

Photos credited to expedition photographers Alasdair Anderson and Lara Dooley, with thanks.

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This month Adventure Medic hears from Sam Covins, third year medical student at the University of Warwick, about a student-led research project to the Atlas Mountains. In the first of two articles, Sam, the group’s research coordinator, tells us of his experience conducting medical research at high altitude, and the enjoyment of Moroccan food and hospitality. We have followed this article up with a Q&A from Sam; handy for hints & tips on how to organise something similar for yourself.

In classical Greek mythology, Atlas was a Titan condemned by Zeus to hold up the sky for eternity as punishment for siding with his brother during the war against the Olympians. As the story goes, Atlas was later visited by the Greek hero, Perseus, who carried with him the severed head of the Gorgon, Medusa. When Atlas tried to drive Perseus away from the region, the hero held up the Gorgon’s head and turned the titan to stone, giving rise to the Atlas Mountains themselves.

At 4,167m, Mount Jbel Toubkal is the highest peak in the Atlas Mountains. We summited at 10:24am on Sunday the 13^th of November. In 2 days we’d ascended over 3,5000m to reach the highest point in North Africa.

With more and more people across the world sojourning to high places for work or recreation, it has become increasingly important to understand the effects of travelling to altitude. In November 2016, we, a group of post-graduate medical students from the University of Warwick, completed a two-part research study to investigate the effects of hypoxia on human physiology during a graded ascent to high altitude.

We were looking to compare the physiological adaptations and changes that take place in the human body during exposure to the normobaric conditions of high altitude simulation, and the true hypobaric conditions of genuine high altitude. Phase I of the study (normobaric hypoxia) was conducted in a specially designed hypoxifying chamber at the School of Sport, Exercise and Rehabilitation Science at the University of Birmingham, under the supervision of the facility director, Dr Sam Lucas. Phase II (hypobaric hypoxia) was conducted during a 6-day expedition to the Atlas Mountains, with the support and guidance of our UK-based supervisor, Professor Chris Imray – an internationally renowned expert in the field of altitude research. Here’s a bit about how, and what, we did when hiking up a mountain.

What were we actually doing?

To study the physiological changes that take place with increasing levels of hypoxia, we performed a series of investigations at several predetermined altitudes that corresponded with key locations along our route of ascent to the summit of Mt. Toubkal. We conducted the exact same experimental protocols at 466m (Marrakech), 1,740m (Imlil), 3,207m (Refuge Toubkal) and 4,167m (Summit of Mt. Toubkal) during both phases of the study. At each altitude, we established a research circuit consisting of several stations at which different experimental protocols were performed. Cognitive and behavioural changes were assessed at Station 1 using laptop-based tests, and it was at this station that participants were also asked to complete their Lake Louise questionnaires to report any signs or symptoms of acute mountain sickness (AMS). Physiological measurements (including heart rate, blood pressure, respiratory rate, oxygen saturations and end-tidal CO₂ values) were recorded at Station 2. Wrist and ankle circumference was measured to assess for any evidence of peripheral oedema, and thermal images were taken to analyse peripheral perfusion. Station 3 consisted of several visual function tests, including Snellen chart and Ischihara plate assessments, visual field testing and pupillary light reflex analysis. Respiratory function testing was performed at Station 4, both before and after a short exercise test, using a portable spirometer to analyse and record a variety of lung function parameters (including PEFR, FVC, FEV1). Continuous ECG monitoring was performed throughout the duration of the expedition using portable 3-lead ECG devices.

Day 1: Marrakech

We departed the UK on the morning of Thursday the 10^th of November, arriving safely in Marrakech with no unexpected flight delays and with all of our luggage accounted for. As we made our way from the airport to the hostel, we could just about make out the snow-covered tops of the distant Atlas Mountains through the hazy Moroccan scrubland. After arrival and check-in at our destination, we headed into the city for lunch. The streets of Marrakech were a hive of activity, full of street vendors, juice sellers and snake charmers. The rest of the day was spent sightseeing and exploring the local souks, and after an evening meal of tagine and couscous in the Jemaa el-Fna, we headed back to the hostel for a briefing from our Expedition Leader, Kenneth Morrison. Kenneth had previously summited Mt. Toubkal in 2008 and was chosen from amongst our group to plan and coordinate the expedition logistics. In his briefing, Kenneth gave a detailed overview of the expedition schedule and itinerary, highlighting important times and locations for transfers and other arrangements. He gave an instructional talk on health and safety and introduced a ‘buddy system’ to encourage the expedition members to monitor and care of one another.

Days 2 & 3: into the mountains

The next day, we spent the morning conducting our first round of research experiments on the roof terrace of our hostel, much to the fascination of the other guests. With the research complete, we bid farewell to Marrakech and set off on our journey to the Atlas Mountains, later arriving at the village of Imlil. Here, we were greeted by our guides from Pathfinder Treks, a local Moroccan mountain guide agency that Kenneth had worked with during his previous ascent of Mt. Toubkal. The guides led us to a nearby mountaineering outlet where we equipped ourselves with mountain boots, crampons and gaiters in preparation for our ascent. After a short scenic walk through the mountain woodlands we arrived at Hotel Atlas in the village of Aroumd, where we spent the night.

After breakfast, we packed our bags, loaded the mules and set off on our trek through the rocky foothills of the Atlas Mountains. We eventually arrived at the settlement of Chamharouch, where we stopped for a short refreshment break before continuing our ascent. Upon reaching the snowline, the porters decided to abandon the mules and carry our baggage on foot. It was here that we first caught sight of the smoke rising from the chimneys of the Refuge Toubkal in the distance, and after an hour of trudging through the snow we finally arrived at our destination. After check-in, we made an immediate start with our experiments so that we could all get a good night’s sleep in anticipation of our early start to attempt the summit the next day.

Day 4: summit day

For logistical purposes, we decided to split the expedition team into two groups. Group 1, which included all 7 researchers carrying the research equipment, began their ascent at 6am in the dark, and were rewarded with the most spectacular sunrise over the mountain tops. Progress was steady with regular rest breaks. As our altitude increased, many of the group started to experience some mild symptoms of AMS, but nothing too serious to warrant an early descent back to the refuge. We therefore continued our relentless ascent until we reached the 4,000m checkpoint where we were greeted by a breathtaking panoramic view of the Sahara. At this point we could make out the distant figures of our Group 2 companions, who had left the refuge two hours later to allow the the first group of researchers time to establish a research base on the summit. After pausing to take in the sights, we continued our ascent along a narrow exposed ridge that paved the way to the summit.

Our arrival at 4,167m was celebrated with an exchange of hugs and handshakes followed by a series of obligatory summit photos. The view from the top was simply outstanding with visibility for miles in every direction. I remember the huge sense of relief of having finally made it. After taking the time to take it all in, we then set to work establishing our research base and promptly began our fourth round of experiments. We were soon joined at the summit by the members of Group 2 who were quickly circulated around each of the research stations. As the clouds started to roll in, the guides grew anxious and eventually insisted that we descend to avoid the worst of the weather. Fortunately, we were able to complete the majority of our research investigations in the time available and our study was not hampered by our premature descent. Having once again successfully navigated across the exposed snowy ridge, we continued our descent back to the refuge. 

And home again.

In light of our successful summit attempt, and after a well-deserved lie in, the expedition team was in high spirits as they left the Refuge Toubkal and headed down towards Imlil. Tracing our footsteps along the route of ascent, we eventually arrived back in Aroumd where we were treated to lunch and Berber tea, courtesy of the guides. After lunch we continued our trek down to Imlil before boarding the minibus that was awaiting our arrival. A short car journey later and we were back in Marrakech where we spent the evening eating, drinking and recounting stories of our adventure. The next day we departed Morocco and returned home to the UK to begin the analysis and interpretation of our research results. Such an adventure.

What next?

We’re still in the process of analysing our data and preparing manuscripts for publication; I’ll keep you updated with the results of all of our hard work as soon as I can! Although it was a fairly stressful and time-consuming experience, I thoroughly enjoyed the entire experience, and I’m so proud of what we’ve achieved as a group. We loved it so much, we’re now in the very early stages of planning another expedition to the Monte Rosa massif already. So watch this space in case we’re looking or eager student participants soon…

Our follow-up Q&A article has now been published, showcasing how Sam organised his expedition and the ups & downs along the way: a great read, particularly if you’re considering doing something similar yourself. 

Photos credited to expedition photographers Alasdair Anderson and Lara Dooley, with thanks.

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The Faculty of Conflict & Catastrophe Medicine is offering three Student Elective Prizes of £750.00 each for Medical Student Electives in the fields of Conflict and Catastrophe Medicine.

Applicants must be in the clinical years of a medical degree at a UK Medical School embarking on an elective within 1 year of the prize being awarded.

Please submit an abstract of no more than 500 words outlining the planned elective and its relevance to Conflict and Catastrophe Medicine. You should include:

• Location, aims, plan of action.
• Nature of supervision and security precautions.
• Impact and relevance to Conflict & Catastrophe or Disaster Medicine
• How the money will be used in funding the elective.

The winners will be required to make a brief presentation to the Faculty after they have completed their electives.

Please contact: FacultyCC@apothecaries.org for an application form.

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Two years ago in a galaxy far, far away a final year medical student went on elective. Sophie Saul, runner up in our 2015 Elective Competition, describes her elective at NASA’s Johnson Space Center in Houston, Texas.

Pre-Launch

There is no environment more remote than space and the challenges of providing health care for astronauts who live and work there are numerous. However, space also offers great potential for medical advancement as the microgravity environment produces a unique setting for medical research and is continually providing new and interesting information. It is the ultimate in wilderness medicine.

Lift Off

I spent four weeks of my elective working with the company Barrios Technology, on site, at the Johnson Space Center in Houston, Texas. This is a small aerospace engineering services company who work with NASA to support the development of space exploration. I spent time working within MAPI (Mission and Program Integration contract) reviewing research papers of investigations carried out on board the International Space Station (ISS).

At any one time a staggering number of experiments are underway on board the ISS with data collected by the six crew members. The subjects of these experiments vary widely from deeply technical projects in biology, human biology and physics to the deeply optimistic: school children finding out if aliens exist by sending biscuits to the ISS and seeing if they return uneaten (they don’t). I was tasked with simplifying and condensing research papers into a few paragraphs that would be suitable for publication on the NASA website to give the public insight into the research being carried out.

I was also involved in writing a number of scripts to accompany educational videos explaining some of the health consequences faced by astronauts after a period living on board the ISS. I wrote scripts for bone disease and eye changes related to increased intracranial pressure.

This work really expanded my knowledge of the effects of microgravity on the skeletal, cardiac and immune systems as well as on bacterial and plant growth. It also enhanced my skills of critical thinking and problem solving as I had to ensure that the important information was conveyed succinctly, simplified to a level that could be understood by non-experts. Not only was the work hugely interesting, but so was the office in which it took place. I was co-located with the people responsible for finding space on board ISS for all of the experiments and necessary equipment, which included Robonaut’s legs!

Clinical Practice

Flight Surgeons

I was fortunate during my time in Houston to spend some time shadowing one of the Flight Surgeons. Flight Surgeons are typically from a military background and have the responsibility for providing care to the astronauts and their immediate families. They are assigned to astronauts who have been selected for a mission and work with them through the two years of preparation and training. They then sit in mission control during the period the astronauts are on the ISS and hold daily consultations with each crew member. When the astronauts return to Earth, the Flight Surgeons then work with them through rehabilitation and manage their recovery from any health issues developed through exposure to micro-gravity.

This was a fantastic opportunity to discover how people begin careers in flight medicine and also an insight into their main duties. I was able sit in on meetings to discuss the latest research to determine the causes of some of the health problems faced by astronauts living in space.

Astronaut Training

I also had the opportunity to observe two different types of astronaut training. All astronauts are taught how to carry out simple medical procedures, both for emergencies on board the ISS and also for recording measurements required by researchers. I was able to observe a refresher session for one astronaut who wanted to run through the procedure for checking intraocular pressure. This is an important skill as, when in space, there is a cephalic fluid shift which raises intracranial pressure and causes changes in the eye which can affect astronauts’ vision.

The second training session took place inside a full scale model of the ISS within the astronaut training facility. The model allows astronauts to participate in simulation-based training scenarios in an environment where everything is exactly as they will find it in space. The particular scenario I observed involved teaching the astronauts how to preserve their health when confronted with a situation involving loss of containment of hazardous materials. Definitely an example of teamwork and communication in a challenging situation!

Space Tourism

Mission Control

Whilst on site, I was given the opportunity to tour some of the many buildings at the Space Center. One of the employees took me to see the Mission Control Center (MCC) where the Flight Surgeons sit on console and communicate with the astronauts on board the ISS. My visit to the MCC coincided with a number of particularly interesting ISS activities. First, the crew were planning to conduct a spacewalk to fix a troublesome ammonia leak in the ISS cooling system and second, three crew members were preparing to make their return journey to Earth within the next few days. The team had astronauts in the Neutral Buoyancy Laboratory (a large indoor pool 12m deep containing modules of the ISS) working through different solutions to fix the suspected problem and were then relaying the developed methods to the astronauts in orbit.

Crew Change

Seeing ‘behind the scenes’ at the Johnson Space Center was both a unique and amazing opportunity to learn about the history of NASA and the challenges that they have faced to make space travel possible. It was also a good opportunity to observe the multidisciplinary nature of its work. In order for missions to be successful large numbers of teams specialising in different areas need to be able to communicate and work together to ensure the best outcome. This includes different Space Centers within the USA but also across the globe as the international space agencies work collaboratively to further space research.

I was fortunate to be at the Johnson Space Center during the time of a crew change on the ISS. The returning astronauts landed safely in their Soyuz capsule in Kazakhstan and were then flown back to the Johnson Space Center to begin the long process of debriefing and medical evaluation. I had the opportunity to meet two of the astronauts the day after they returned. It was very strange to be standing talking to two people who, just a few days before, I had been watching do weightless somersaults over the satellite link to Mission Control. They were equally curious to lean how a Scottish Medical Student had managed to end up in their Space Center!

Back on Earth

When considering a medical elective, remember that it is an amazing opportunity to go and explore the world of possibilities that a degree in medicine opens up. Electives offer an opportunity during our degree to think outside the world of hospital medicine and see what else is possible.

The Johnson Space Center elective was an incredible experience and one which I would not have changed for the world. However, if you wish to do something similar, be aware that arranging it may require a great deal of planning and perseverance. As you can imagine security at the Johnson Space Center is incredibly tight and the process to obtain security clearance as a ‘foreign alien’ is time consuming. I was required to make trips to the Center a year in advance of my elective to provide them with proof of identity, photographs and finger prints. There is also the matter of acquiring an American Visa appropriate for the work you will be doing. This can be expensive and require a trip to London for an interview at the American Embassy.

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Madeleine Thomas / Final Year Medical Student / University of Edinburgh

Immersion

I landed in Saint Vincent after dark, and was immediately embraced by the vibrant Saturday night that was in full swing. I couldn’t suppress a grin despite my travel fatigue at seeing the throngs of people on the streets, dotted every couple of hundred yards with barbecue spots and infectious calypso music. I felt a million miles from home, alone in this new and curious place. But this feeling wouldn’t last for long.

There’s nothing you can do but get stuck in. The tidal wave of life here sweeps you along without time for question. Over the next few weeks I found new friends everywhere I went. The locals were bursting to show-off their island; whenever they spoke about ‘Vincy’ it was hard to miss the pride between their words. I would frequently be identified from the other side of the street as a medical student. Saint Vincent does not receive many tourists save for a small handful of fancy resorts and those en route to the Grenadine islands.

Everywhere to be seen was blue, yellow and green

During my first week in Saint Vincent, thirty-six years of independence was being celebrated. Everything was adorned in the colours of the Vincentian flag. In Kingstown, the capital, bunting draped across the streets and along the buildings. They like an excuse for a good party, and they certainly know how to throw one. The island spirit is palpable at such gatherings, and being a relatively small community of around 100,000 people where it seems almost everyone knows each other, get-togethers are certainly not small affairs. I had missed ‘Carnival’ season (a month-long celebration of culture known as Vincy Mas) but a benefit concert was held for Dominica in the national football stadium during my stay. I was able to get hold of some tickets for myself and some of the other students in a good old-fashioned scrum around a ticketing booth with a window the size of an A4 sheet of paper. This in itself was a lively experience! Dominica is a neighbouring island nation recovering from one of the worst floods in its history, and the draw of the concert was that it was bringing together some of the biggest Caribbean artists all on one stage – it was a wonderful opportunity to hear a multitude of different Caribbean music styles, from Soca to Reggae, Calypso, R&B and dancehall. The teaming grounds were dynamic with dancing and chatter. The night air was heavy with the smell of popcorn and the local grass. You could feel the energy right down to your bones.

Making do with so much to do without

The main hospital on the island is the Milton Cato Memorial Hospital, named after the late Prime Minister who guided the country through independence in 1979. This hospital, where I was placed for a month, offers the highest level of care available on the island. Medical care is heavily subsidised by the government, but there is an absence of some specialist equipment, drugs and personnel on the island, meaning that in many cases patients need to go abroad for diagnostic tests or procedures. This has to be self-funded, meaning unfortunately there are often times when patients go without. The medical team face logistical struggles and the frustrations of waiting for investigations and treatments on a daily basis. It was painful professionally to know exactly what a patient needed to receive, but being unable to provide it. The height of the ceiling of care at times was enough to give you back pain from the constant stooping! I have not appreciated until now the number and variety of obstacles that can occur to hold up even the simplest patient care.

In the face of this, the camaraderie amongst the medical staff and their unrelenting ambition to do their utmost for their patients was impressive. The senior doctors also fostered an inexhaustible culture of continued education, and consequently I learnt much about the spectrum of diseases seen here and refreshed my memory of many a common ailment seen back home as well. It was also interesting to speak to local medical students and those from other countries about their studies and experiences. The similarities were often comforting but I found some of the disparities in opportunities and resources hard to believe at first. It threw into sharp perspective my own experience of medical school, making me feel incredibly lucky.

On the road

The pace of life in Saint Vincent is both fast and slow at the same time, it was impossible not to go along with the ebb and flow of things. The most efficient way of getting about the island was on the merchant fleet of motley minibuses, although does involve placing your life in the hands of the drivers. There really is no other cost-effective way to travel – the island is so mountainous, riddled with towering ridges and dramatic inland reliefs, all covered in a thick layer of rainforest and jungle. The minibuses are all customised for full eye and ear-catching effect. The colourful and blisteringly loud reggae music emanating from them gave you advanced warning there would be one passing your way shortly. A host of graffiti-style stickers and paint jobs made them impossible to miss. These wild rides proceed at helter-skelter pace, taking you up the eye-watering inclines, and then hurtling down into each new bay along the knuckle-whitening dips and twists on the other side. No second was wasted in unloading and loading passengers in and out of the sliding door, no inch of room inside spared for comfort. I had to admire the efficiency.

There was time off to explore the island, and daytrip across to several of the Grenadines. The tropical thunderstorms that spring on the Caribbean at the end of the rainy season were liable to interrupt even the most well planned excursions; flexibility was key in order to experience as much as possible. Taking advantage of the more spontaneous opportunities often led to the liveliest of adventures. A tour of the windward coast and an exhausting but rewarding hike up the volcano (La Soufrière – “the one that sulphurs”) with a taxi driver I met on my first day and just kept bumping into, were some of the highlights of my stay. He became a firm friend over the weeks and, for me, embodied the real soul of Saint Vincent. He was incredibly knowledgeable and passionate and had so much to say about each little village, plantation and view we passed, all the while making anecdotes about his reggae career and back-story. It would not have been the same experience without him.

Close encounters of a tropical kind

There was one other person I met during my first few days in Saint Vincent who really defined my time there. A patient admitted during my first week on the ward, who was on the brink of discharge as I left a month later. We were both new to the hospital and over the weeks I was able to share with her in many a difficult moment. Her case initially caught my attention due to my interest in infectious disease and tropical medicine. It was likely that she had adult T-cell lymphoma/leukaemia, which turned out to be HTLV-1 associated. The reading I did around this group of infectious diseases peaked my interest in her case, but what really struck a chord with me was what unfolded over the following few weeks. The day-to-day transformation and deterioration of her condition was astonishing, lurching from hope to despair and back again, but her quiet resolve throughout was incredibly resilient and humbling.

As I left she was almost ready to be discharged after her first cycle of chemotherapy, pending the recovery of her blood count to a safe level. It is remarkable how much a patient has to learn during their stay in hospital and how much they pick up on of that which we don’t consciously teach. As I learned more about the way of life on Saint Vincent, she was learning more and more about her condition. We were in each other’s worlds, both a little ‘deer-in-headlights’ at first, towards the end talking each other’s language. It made me realise that the hospital environment is a foreign place to our patients, full of uncertainty, different languages and routines, and often loneliness. As the locals had made me feel at ease with their warmth and kindness during my month in their country, I am drawn to recognize it is the responsibility of medical professionals to do the same for our patients.

The tempo of the island changed as my time in Saint Vincent drew to a close. With the general election taking place in a few weeks time, the political campaigning was ramping up. During my last few days the atmosphere was throbbing with heated debate, you could easily get caught in the sparks of crossfire created by the friction between the different sides. The walls and streets were now splashed with the party colours, symbols and mottos – divisive and impassioned as opposed to the unity and goodwill expressed during the independence celebrations. Even as a visitor I could not escape the campaigning machine, my local friends boiling over with facts and reasoning and purpose. This was a reflection of just how passionate they are about their country and its future. Saint Vincent has made a lasting impression on me both personally and professionally, the experience was a true adventure – the stunning landscapes, the smells from the market, the hearty taste of the street food to the swamping 100% humidity, the conversations shared and the memories made. I have been given perspective, and have been made a lifelong fan of the Vincy way of life.

Further information

Where / Milton Cato Memorial Hospital, Saint Vincent and the Grenidines, Caribbean

When / Oct – Nov, but students do go all year round

Costs / $25 USD application charge & $25 USD elective charge per week.

Weather / Around 28 degrees Celcius, often with 100% humidity. Hours of sunlight are from roughly 6am to 6pm all year round, and it is useful to know that it gets very dark very quickly with very little evening dusk. The rainy season, where daily showers are more likely, is supposed to end at the start of December.

Vaccinations / All standard UK vaccinations, Hepatitis A and Tetanus/Diphtheria/Polio booster advised before visiting. I also obtained HIV PEP to take with me.

Accommodation / The hospital has a list of recommended landlords and their contact details, which comes as part of the application documents. It is advisable to stay with one of these. Be warned that electricity may have to be paid on top of rental prices.

Essential items / Copious amounts of DEET repellent (mosquitoes are day-biting so I did not use the mosquito net I brought with me), suncream, cool loose clothing and a good pair of trainers

Contact / Dr Charles Woods, Medical Director. Tel: +1 (784) 456-1185 Ext 162/163 Fax: +1 (784) 457-1014. Email: kghsvg@vincysurf.com

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In 2011, Jamie rashly gave up a well-paid career in Telecoms, opting instead for the delights of Warwick Medical School. Now a Foundation Doctor in Edinburgh, Jamie is also a mountaineer, drawn to the high and untouched regions on the world. During his time at medical school he founded the Warwick Wilderness Medicine Society and became involved in altitude research. While undertaking his medical elective in Nepal, he read the late Dr Oliver Sacks’ ‘Awakenings’, a tale of extended case histories that had grated with the medical establishment upon its publication in 1973 on the grounds of being ‘not scientific’ enough. He found the humanisation of patients in these stories inspirational, and has written of a number of encounters he had in Nepal with this in mind, as a set of reflections and stories.

The backdrop is Tamakoshi Co-operative Hospital in Manthali, 8 hours’ bus journey from Kathmandu. The hospital was composed of 2 doctors, 3 medical assistants,10 nurses and midwives, 2 opticians, a dental assistant, an X-ray machine, an ultrasound machine, a tiny lab, an emergency room, a bed for minor procedures, dental and opticians’ facilities and a whole floor for surgery camps. There were 5-10 inpatients at any one time, relatives everywhere and the medics saw up to 90 outpatients daily with a least this number again visiting the other departments.

It Is Not Your Decision To Die

A nurse in a white flowing sari pushed past the people clustered outside the outpatient department and hailed Tara, in Nepali. Tara was the most experienced Medical Assistant at Tamakoshi hospital. He jumped up and followed her out. I had learnt that this procedure indicated that there was something going on, so followed. We processed 20m along a balcony lined with patients to the emergency room, arriving to see a semi-conscious 80-year-old lying on a green stained bed by the window. He was surrounded by nurses and, peripherally, by an entourage of slightly younger old men who were perched on stools, tables or whatever they could find. All were wearing the traditional Nepali multi-coloured topi (hats) and waistcoats.

The history from the family was vague, but we established the gentleman had been unresponsive for a time on the previous day also. After an A-E approach and administration of oxygen his GCS was 8.  His first bloods came back with a haemoglobin of 4, and the contention was that anaemia of unknown origin was the primary cause of his presentation. There is no blood available in Manthali for transfusion.

I walked into the ward a couple of hours later and the anaemic octogenarian was sitting up, alert, and talking at great speed with his family. He didn’t exactly look spritely, but he didn’t look too sick either. The ward-round commenced shortly after and having checked out the breast abscess, abdominal pains, COPDs, pneumonia and babies with fever, we came back to our pale patient. We were none-the-wiser as to the cause of his anaemia and the lead doctor began to take a history. The atmosphere become tenser and the old man raised his voice, followed by the doctor. This escalated into what seemed to be a row, with the family chipping in on the doctor’s side. Sadly I didn’t really know what was going on; it was all in Nepali, in which my understanding is limited to pleasantries and a motley collection of medical words. The drama continued for a couple of minutes, then stopped as the ward round dissipated.

Later, when I asked the doctor what it was all about, I was told that the gentleman had said that he wanted to die. That his parents were dead, his brothers were dead, his sisters were dead, some of his children were dead and he didn’t want to live anymore. This had prompted the argument and the doctor’s response, “It is not your decision to die”. He gave a little laugh and smile as he told me. He continued, “I told him, it is not in our religion to choose to die. Your children don’t want you to die, I don’t want you to die and it’s not in our culture for you to decide to die”. There followed another little laugh. “I told him these things”.

Like many of our patients, the gentleman discharged himself home, probably to die. Afterwards, I mused on the situation, and decided that in the context I was working, the old man’s decision seemed to me a reasonable one. The difference from that to which I was used in the UK was the doctor’s overtly paternalistic style, and not the patient’s autonomous decision.

Too Much Black

Every morning the x-ray machine at Tamakoshi was in almost constant use. Chests, arms, legs, hands, shoulders and a suspicious number of abdomens were x-rayed. This led to a constant stream of, all to often, low quality x-rays to interpret. Herein lay a problem. There was no radiologist, nor anyone nearly a radiologist at Tamakoshi. The two doctors who worked there were far removed from being so: it had been decades since they attended medical school, and they had rarely received teaching on, or confirmation of their interpretation of, x-rays or diagnoses. Everything was fine when there was a clear break of a bone or obviously pathology, but in the absence of this the doctors blustered knowingly, a technique which rubbed off on the medical assistants. There was of course nowhere to refer to for an opinion.  In addition, the patients often requested an x-ray of a particular area because of a colloquial understanding that the x-ray in itself was curative. The doctors generally acquiesced. In summary, there were x-rays being done with and without a good indication, often of poor quality, and with occasional questionable interpretation.

The biggest problem area was chests. An x-ray is a 2D image of multiple overlapping 3D structures, often with subtle signs. Tricky to interpret at the best of times, certainly for me, and many chest x-rays were done each day at Tamakoshi. They were almost inevitably under-penetrated and rotated, and were habitually interpreted using a dirty window rather than the one semi-functioning light box. With so many variables, I found chest x-rays particularly difficult to interpret (excluding barn door diagnoses), so decided to educate myself. I used an inspirational radiology presentation I had seen while rotating through a respiratory firm to try and embed theory, a system, tricks and tips*.

Despite my study I wasn’t making much headway at Tamakoshi. I was hunting down the plates (it was the first time I had seen an X-ray on anything other than a computer screen), taking them to the light box, playing with the plug until the loose connection sorted itself out, and being religiously systematic. Often scratching my head and wishing there was someone to tell me the answer, if only to corroborate my understanding. After a week of this it came to me that in the medical context of rural Nepal, x-rays were mostly an adjunct to diagnosis, building into an overall clinical picture, and it was ok not to know the answer, a fact I concluded could also be true at home. Perhaps initially some of the locals’ faith in the magical power of x-rays had rubbed off on me.

In my last week in Nepal, however, I was on a ward round when a new chest x-ray was delivered; about 10 people waved it around by the window for a minute, deciding pneumonia. A bit later I sought the plate and took it to the light box for a go at systematics. The bases looked a bit crowded, perhaps consolidated, particularly on the left. Going through my system there was definitely ‘too much black’ at the left apex extending down to about the 3^rd rib. It was asymmetrical and there were no lung markings. A pneumothorax had been missed and was compressing the rest of the lung, increasing the lung markings on the left.

Finding the pneumothorax was one of the first times that as a medical student I have been able to contribute anything meaningfully to care (a big problem in UK training), and was incredibly satisfying in its own little way.

Tea With An Itchy Lama

Mid way through my elective I unexpectedly and happily got the chance to work for a week in a health post in the town of Bamti. This was two days’ trek along the route to Everest base camp as walked by the successful British expedition in 1953. Nowadays this route gets relatively few visitors as most people fly into Lulkla, a week or so closer to Everest on foot. The health post’s hours were just 10am-2pm, which left the afternoons and evenings free for me to explore. I mainly climbed the surrounding hills, for the fun, the views and to help with acclimatisation for the trekking I was planning.

One day I climbed the 900 vertical metres from Bampti to Thodung Gompa (a Monastery), seated at 3000m. When I arrived it was quiet, with just four child monks (lamas) and a very old-looking lady lama wearing an orange jumper. She had no hair, an outdoor face with small eyes, a big smile and skin stretched tight over her cheeks as though she’d had a facelift some time in the distant past. I spent some time with these five, exchanging the usual pleasantries of those who don’t speak each other’s language. Namely, “Namaste” and “What is your name?”. The monastery’s Gompa was then unlocked and I was given a little tour of the lavish inside, which I photographed with great relish.

After my camera was replete, our little band was chilling out on the steps when the head lama at Thodung appeared. He was somewhere near forty and spoke a little English, learnt straight from a dictionary. He had lively eyes, a shaved head, and was incredibly friendly. Immediately on finding out that I was working at the health post he showed me his neck saying, “very itchy, very itchy”. I could see a raised lichenified skin lesion about 4 by 2 cm with a slightly smaller and less raised sister lesion beside it. He gave a two-year history of the problems, said he had tried creams from the health post without success, and asked could I help? I remember mumbling something noncommittal. We went to the monastery’s smoky kitchen and I drank prodigious amounts of sweet tea from a small china bowl that was refilled by a 10-year-old lama each time I got to its shallow bottom. I was told about a really important ‘Big Lama’, who was visiting later that week. It soon got late and I made my excuses, but promised to return to meet the Big Lama and to bring some medication for the skin problem, though I could not guarantee it would work.

I really didn’t know what to do for the lesion. Dermatology is not my strong point, particularly when various creams hadn’t worked. I needed help. Bamti doesn’t have a great deal of internet access, but there was a charity school nearby which had a connection to allow the orphaned children to communicate with their sponsors. I asked to use it and sent a photo of the lama’s neck to Tamakoshi hospital for advice. They had a look and diagnosed chronic tinea, and suggested a month’s course of antifungal and steroid.

So three days later I found myself again climbing the 900m to Thodung, my bag filled with medication, with the bonus of seeing the Big Lama (who was important enough to arrive by helicopter!). The itchy lama seemed pleasantly surprised to see me. I got the impression he didn’t think I would return. He was even more surprised with my presents of cream and pills; he was all smiles and blessed me.

The Many Things

I have many more medical and other stories to tell, if time and space allowed. There was the patient with status epilepticus caused by cysticercosis, nasty trauma, and the chants and throwing of rice by a traditional healer. I saw severe harm caused by excessive use of NSAIDs without gastric protection, put together a diabetes management card and worked at a remote Health Camp where we saw 350 patients in 4 hours. I spent much of my time inside a traditional clinical environment, but also saw a large amount of Ayurvedic and homeopathic medicine being practiced. In 5 weeks, I saw more fractures than I had seen in my orthopaedics and A&E rotations combined, and more patients than when on rotation in general practice. Last but not least, I spent 5 days trekking solo in the Himalayas, sleeping out in the open at 4000m, watching the snows billowing off Everest.

I did over 100 patient consultations whilst in Bamti and learnt a huge amount about low resource medicine and deep reflection. However no ‘consultation’ was more satisfying than that with the lama up the mountain, not least because of all the smiles and happiness than my medicine brought. It is difficult to put my finger on exactly why, but the combination of not knowing the diagnosis, using telemedicine, climbing almost 2000m and generally having to work hard made it very gratifying. Of course being blessed by a lama has got to be good for my Karma too…

Further Information

Where / Tamakoshi Co-operative Hospital, Manthali, Nepal. It regularly hosts volunteer doctors, nurses, midwives and dentists as well as medical students. It is an extremely welcoming, friendly place.

Accommodation / The hospital provides basic food and board in a block perched on the hill above the hospital. For this they ask in the region of £100/month.

Contacts / Elective & hospital placements are organised through Rural Assistance Nepal. The lead clinicial at the hospital is the dynamic Dr Suman, who is an inspiration, and the Tamakoshi Co-operative Hospital website has more information on the hospital itself.

*Thanks to Dr Natasha Jefferson, a radiologist at Warwick Hospital, for emailing me the chest x-ray presentation. It remains the best radiology teaching I have ever had!

The post Medicine in Manthali – Elective Stories from Nepal appeared first on Adventure Medic.

Donald Waters / FY2 Academic Paediatrics / Oxford University Hospitals NHS Trust

It is the start of a new medical year and, for many students nearing final year, time to start thinking about planning their electives. Foundation Doctors Jamie and Donald explain why they feel going to the developing world is a brilliant way to get the most out of your experience. They also guide us past some of the pitfalls of an overseas medical elective in a low-middle income country, coloured by their own experiences in Nepal, Vietnam and West Africa.

Organising your medical elective can be a stressful experience. For many students, it is the first major opportunity to shape your own medical training – the first chance to formally assert your individuality and take a step towards the sort of doctor that you want to be.

There are hundreds of overlapping factors that you have to take into account when choosing an elective, but of these one of the most important has to be location. Everything else will come from this decision, from the type of hospital you are working in to the specialties that are available to study under, from what you are able to do in your free time to what opportunities there are for undertaking extracurricular projects. We hope that a lot of you might be considering undertaking part or all of your elective in a low- or middle-income country. Indeed, we plan to argue through this article that doing so would be a brilliant and highly worthwhile decision which will benefit not only you, and your career, but also the place that you visit and the people that you meet there.

The Big Picture

We live in exciting and tumultuous times. In the richest nations of the world health continues to improve – with genetic technology and other advances promising further health gains; while in poorer nations life expectancy is stagnating or even going backwards. Poor people die young and avoidably. Of the 6.6 million children under 5 who die every year, 99% do so in low- or middle-income countries (LMICs), predominantly from preventable causes. Overall, most measures of global inequality are increasing: the rich are becoming richer whilst more than 30% of the world’s population continue to live on less than $2 a day.

Indeed, while some low-income countries may show signs of economic development, these are often driven by the gains of the already-rich and are offset by an increase in overall inequality, driving the majority of the global populace further into spirals of poverty and ill health. The healthcare needs of these countries are huge, but generally not reflected in the provision of healthcare workers: 25% of the global burden of disease is cared for by just 1.3% of the global health workforce. The poor people of our world desperately require medical assistance that, sadly, in many cases is not coming or not coming fast enough.

These data starkly highlight what many of us are already aware of and what we may see on the news each evening. Whilst shocking, we do not present them here to daunt you. Rather we want to highlight how important the healthcare needs of those in low-middle income countries are, and argue that in addition to the personal and career benefits outlined below, conducting your elective in a low-resource setting will enable you to get close to these issues, understand these individual human stories as more than just a set of numbers, and ultimately do something beneficial – either now or in the future.

“Nothing in life is to be feared, it is only to be understood. Now is the time to understand more, so that we may fear less”, Marie Curie.

Marie Curie’s famous quote encapsulates well how we can challenge feelings of distress and helplessness when confronted by the gigantic issues involved in global health. Maybe you aren’t going to be able to provide the assistance a qualified doctor could, maybe it will be a more difficult experience than an elective in a richer country. However, if you walk in to your elective with a smile, an open mind and good intentions then you will leave behind new seeds of possibility for improving the lives of patients where material and organisation resources may be scarce. Furthermore you will take away a deep personal understanding life and health in low-resource settings and hopefully be inspired to use this knowledge to tackle inequalities. And believe it or not, we promise you you’ll walk away with a lot more than just that.

So why should I?

Firstly, you will get direct involvement with a completely different type of medicine that you simply can’t appreciate without getting on a plane. Many of you are undoubtedly aware of the global issues outlined above and may plan to try to provide some assistance by working in a low-resource setting at some point in your career: any experience you can gain now will be invaluable.

You will all be familiar with the sense of discomfort that a first clinical placement causes, even at home. You must learn a whole new culture and interact with colleagues and patients in an unfamiliar manner. You become exposed to sicknesses and diseases, often masked or hidden from the public eye. This culture shock begets a steep but ultimately beneficial learning curve and is similar to what you will experience stepping into a wholly unfamiliar hospital environment overseas.

You may see unprecedented numbers of patients presenting with unusual diseases – or diseases progressed far beyond what we might expect to see in Europe and the US. An awareness of healthcare issues specific to the country gifts you the opportunity to start to address it: many excellent student-led charities and initiatives have sprung from elective experiences in developing countries and your potential to make a significant impact in this manner should not be underestimated. Students are able to take a step back from the clinical milieu and see how simple, achievable interventions can translate into patient benefit. Your contacts in your host country and access to a motivated student body will allow you to start effectively flying the flag for underrepresented issues back home.

Make an impact

There are other ways of making a real, immediate positive impact during your elective that you shouldn’t miss out on. Get in touch with your host unit and ask them if there is anything that you can help with. Perhaps there are specific surgical instruments that they are in dire need of, or medical textbooks or even expert advice on publishing their research in a high impact journal. Having found out their specific needs you can set about thinking how your elective can help: charities such as MedAID can help source old or unwanted equipment from the NHS to deliver overseas, perhaps you can organise a used textbook drive at your medical school, or meet up with a professor to discuss how to assist in their research? With a little initiative it is possible to make a valuable contribution to unit and people that you are visiting.

Teaching

The doctor:patient ratio may be much greater than you are used to (compare Africa’s startling 2.3 health workers per 1000 members of the population with America’s 24.8). Whilst, if you are unfortunate, this can result in less teaching, less supervision and subsequently fewer learning opportunities, it can also be to your advantage. Finding an enthusiastic teacher: the ability to smile, say hello to doctors and patients in their native tongue and to persevere until someone welcomes you are essential here. They will almost always be happy for the helping hand that a senior medical student can lend and, ensuring that you make clear the limits of your competence to them, you will gain a great chance to hone your practical and consultation skills.

You will also benefit from observing conditions being managed in a very different manner from our familiar evidence and guideline-based medicine, which is usually based on data derived from US or European populations only. The experience that you gain handling such unfamiliar cases will hugely benefit your work back home: your ability to listen to the patient and their family’s understanding of illness will be enhanced along with your ability to determine the best way for you to help the patient at hand. By gaining exposure to diseases, such as tuberculosis, AIDS and other infectious disease – as well as unusual presentations of more familiar conditions – you will widen your clinical acumen tremendously.  With the advent of cheaper air travel these diseases are no longer focused purely in any one area of the world, and you never know when a case of leishmaniasis or cysticercosis may present to the busy UK A&E department you are working in.

Research

Electives in low-middle income countries can also be rich in untapped opportunity to conduct research.  Having conducted (or attempted!) research in a low-middle income country demonstrates that you are a cut above the many other junior researchers and also provides you with an opportunity to give something back to the country that has hosted you. The key for students interested in this is to track down an effective supervisor – preferably one with experience in conducting research overseas – who will be able to support you in countless ways.  Of importance, they can assist you in selecting a project that is meaningful and manageable for the time you have available and help you in finding funding and ensuring that the research is conducted in a responsible and ethical manner. Whilst this might sound a daunting prospect, with sufficient time, planning and enthusiasm it is possible and highly rewarding.

Other skills

Moving onto those “generic professional skills” which we’re sure your medical education departments have been emphasising with all their hearts; conducting a successful elective in a low-middle income country demonstrates great initiative and organisational skills, important for any future job application and also future adventure planning! Choosing to do your elective in a low-middle income country is by no means easy and demonstrates that you are able to effectively organise things from a distance, working in an unfamiliar system, and then make it work on the ground once you are there, interacting with a wealth of new peoples and cultures. This experience should be of particular interest and value to all medics interested in working overseas but also any planning in collaborating in either a clinical or research capacity, an increasing part of any UK consultant role.

New friends

Lastly, as medicine is a social subject and medics usually social people, the one thing that you can guarantee on any placement overseas is that you will meet interesting people and make friends. This is brilliant, as not only will you make valuable contacts with whom you may be able to organise clinical and research overseas work in later years, but by having friends overseas you may gain a safe harbour in a storm – or a bed during a holiday – and you will begin to see your life and work as a part of a bigger picture. While this is also true of conducting an elective in Australia, you can easily go there on holiday next year with your wonderful Foundation wages and having friends in low-middle income countries gives you an invaluable new perspective on the world that could change your life in a way that Fosters on the beach just can’t quite match.

Pitfalls and naysayers

In this section we are going to try and anticipate some of the possible reasons that you may have, or may have heard of, for not travelling to a low-middle country for part of your elective. These are important to consider so that any potential problems can be identified and minimised or circumnavigated before you hit the ground! However, none of them are insurmountable and in many ways challenges can only add to the fun, here goes:

“What if I am thrown in too deep?”

This is a natural and important concern. Medical education may be less strictly regulated and there may be instances where you are expected to do something that you are not trained or competent to undertake. In these instances it is important to be able to politely and firmly explain that you cannot do it. People are usually understanding that the UK system requires that medical students are not pushed beyond their competence level whilst on elective.

You may see practices that you disagree with and again it is important not to feel pressured into participating. Take a step back, remember that visiting students should not be not be essential to service provision and be prepared to question practices, whilst keeping an open mind that best practice at home likely differs significantly from at your host country. When planning your trip it is advisable to seek out students that have visited there previously and listen to their experiences. In severely deprived countries where severe staffing or resource shortages are likely, you are at increased chance of being asked to provide care that you are not qualified to. There is also often an increased risk of crime and poor road safety. If you are worried that you are going to be overly pressured into providing care or that your own safety is at risk, then be ready at an early planning stage to reconsider and look for an alternative placement.

“I’m not interested in poverty tourism”

Good – and nor should you be. However, it is highly valuable to learn how medical services adapt when resources and funding are lacking or spent elsewhere. Observing and assisting the process of formulating a diagnosis and providing treatment without the wealth of technology available in your normal NHS setting will encourage you to think laterally about problems back in the UK. By seeing what we may consider to be best-practice at home being ignored in favour of procedures with less evidence you will learn how culturally rooted healthcare can be and how difficult it is to generalise the results of research conducted in the US or Europe to other countries with different population demographics. This will help you to see how fragile much of the dogma that you learn at medical school is and will improve your patient focus.

“Electives are difficult to organise in developing countries”

This is often the first stumbling block – finding a reliable contact to organise your elective with in your destination country can be difficult; especially when access to the internet, telephones and postal services may be limited. It is important to start trying to get in touch as far in advance as possible: 18 months would be ideal, although this is not always practical. Ask doctors working in your medical school or specialty of interest if they know of interesting places to go or have contacts, check the Adventure Medic Resources Section and be prepared to wait longer than usual for a response to your queries. It is important to state clearly from the outset what you need from your destination hospital in terms paperwork – will an email saying “you’re welcome to come” suffice, or do you need a letter on headed paper? Get it out of the way.

Another essential aspect to consider is whether the country you are looking at is safe to go to. Any medical school is unlikely to let a student travel to a country with a bad rep from the Foreign Office so their Travel Advisory page is a good place to start. You might also want to try to get in contact with doctors or other students who are already in the region as they will be able to provide you with an accurate local picture of what things are like on the ground.

“But would it look better on my CV to have visited a US/European centre of excellence?”

Having visited a prestigious institution can look very impressive, but this doesn’t always correlate with an excellent learning experience. Sure, it demonstrates that you beat the competition to secure a place there, but because of this popularity it is possible that learning opportunities will be diluted by a high number of students/junior doctors or institutional complacency. Furthermore, if you have already trained in a highly ‘Western’ hospital, it is likely that the differences between where you are visiting and what you have already experienced will be slight.

The cost of applying to well-known institutions can also be a significant problem, especially as many places will not refund you if they reject your application. Many low- and middle-income country placements will not charge you a placement fee and we would argue you are likely to have a more valuable learning opportunity travelling further afield. (Also do you want to be the guy/gal in the pub who has been to the same place on elective as everyone else?)

Medical employers recognise that what is important is not where you go, but what you learn, and often due to the wealth of new experiences on offer in low resource settings you will pick up skills and experience you simply couldn’t in a more traditional setting. Try to speak to someone who has visited where you are thinking of going before to ensure that there are ample learning opportunities, you could even consider attempting to organise a small research project that you could do on the ground.

What did we do?

James Loan / As a wannabe neurosurgeon, I travelled first to the small Annapurna Neurological Institute (ANI) in Kathmandu, Nepal before moving on to Cho Ray Hospital in Ho Chi Minh City, Vietnam – one of the worlds busiest neurosurgical centres.

Donald Waters / With a vague idea of a possible career in ophthalmology but a definite intention of working as a doctor in developing countries in the future I undertook my elective in Hôpital St. André de Tinré, Benin. This is the biggest specialist eye unit in West Africa but only has two consultants and to date only one elective student!

The pictures at the top of the article are from these expeditions.

Conclusions

We hope we have gone some way to convincing you that undertaking your elective in a low-middle income country would be a fantastic decision for many different reasons, both personal and professional. There is so much to gain and we wish you all the very best of luck in wherever your first medical adventure takes you. If you have any questions at all please get in touch with us (donaldwaters@hotmail.co.uk / jjloan90@gmail.com) and we will be more than happy to assist. Bon voyage!

Keen to start organising your elective? Have a look at the Adventure Medic Resources Section for some ideas.

The post Electives in Developing Countries appeared first on Adventure Medic.

In an attempt to eke Winter out for as long as possible, Rachael Parker recently retreated as far north as she could find, spending her final year medical elective taking in the enormous expanse of Swedish Lapland. Discovering cross-country skiing, the beauty of the midnight sun and the harsh reality of life as a medic in a freezing, isolated land along the way, she tells Adventure Medic why it’s one of the best decisions she ever made.

Why? Why Not?

Why go to a beach when a unique adventure awaits you in Swedish Lapland? In a land so vast, it is no wonder Sweden has its own unit of measurement: one Swedish mil is equivalent to 10km. Eight mils north of the Arctic Circle, Gällivare Hospital cares for 30,000 people across Norbottens county – a cool 98,000km2 equating to one quarter of Sweden, with approximately 0.5 inhabitants per square kilometer.

Flying north from Stockholm, the bright city lights rapidly disappeared and soon the only visible cartography was being magically created by moonlight reflecting off snow from lakes, mountains and forests. This is the awesome land of the Northern Lights and the Midnight Sun, and it most certainly did not disappoint.

I am a big enthusiast of all things adventurous and outdoors, and this extends to a passion for pre-hospital and wilderness medicine. Before I came on my elective I knew I wanted to combine all of these things (not to mention the appeal of gravlax, cinnamon buns, cross-country skiing and the top item on my bucket list, experiencing the Aurora Borealis) and so to me, Northern Sweden was simply perfect. I was based in the Emergency Klinik, which includes six Intensive Care beds and four Cardiac Care beds. I also spent a great deal of time with the ground ambulance crews and with the Scandinavian Air Ambulance. Despite being a fully capable hospital with 700 beds, the nearest tertiary centre and percutaneous coronary intervention (PCI) facility is 200km away in Luleå, which presents regular logistical and clinical challenges.

The indigenous Sami people divide the year into eight seasons; I came here on my elective in February and March, which in the Sami calendar is Spring Winter, and arguably the best time of year to come to Northern Sweden for snow and sunshine. Don’t be fooled by a clear blue sky though, temperatures at this time of year can range from -30° Celsius to a pleasant +4°. Combine this with unforgiving snowfall and wind-chill, extreme distances to reach patients and only one road to get there, this subarctic climate demands meticulous prior preparation from the emergency services, and for medical staff to maintain a very broad set of competencies.

Airtime

Transfer of patients is often time-critical and in this environment, the fastest way to achieve this is by air. The Scandinavian Air Ambulance fleet consists of one fixed-wing airplane and one helicopter. Previously the Swedish and Norwegian RAF have augmented the Air Ambulance fleet, but this is no longer the case. The fixed-wing aircraft with one flight nurse makes three scheduled, non-urgent flights each week from Kiruna in the North. It stops at hospitals along the 600km trip south to Umeå (still technically in the North of Sweden), transporting patients to tertiary centres for treatment and back to regional hospitals like Gällivare for community rehabilitation. The fixed-wing aircraft can also transport unstable patients with a flight nurse and doctor on board when an emergency situation arises. There is one helicopter to serve the whole of Northern Sweden, based in Gällivare, with the ability to retrieve and transfer one acutely ill patient from remote locations to a place of definitive care. The structure of the Swedish healthcare system is largely similar to the NHS, although a significantly smaller population over an expansive geographical area enables and justifies the frequent use of medical aviation. Double crews, ensuring maximum flight hours and service provision, man both aircraft; however, bad weather is often the restricting factor in permitting flight operations. By sheer fluke and at the envy of every other junior doctor in the department, I was lucky enough to join the helicopter Air Ambulance crew to transfer a patient with a myocardial infarction from Gällivare to Luleå for coronary angiography and intervention. Flying over the snow-covered forests and lakes on a gloriously sunny day, moose-spotting along the way and arriving at Luleå hospital in time for lunch, was possibly the coolest day I have ever had on placement. It was also the day I found out I would be working in my first choice deanery as an F1 in August – Jättebra!

Downtime

Aside from treating patients predominantly with cardiovascular disease and skiing-, snowmobile- or reindeer-induced injuries, I grabbed every opportunity to get out in the snow and wholly embrace the active lifestyle that unsurprisingly renders Sweden one of the healthiest countries in the world. During my second week it was ‘Sports Break’. Similar to half-term, this one week off school is specifically for skiing, exercising, venturing into the mountains, or relaxing if you really want to. I joined in for the final event on Friday evening: downhill skiing for free on Dundret Mountain until midnight, on floodlit pistes and off-piste through the trees guided only by head torches and the Northern Lights dancing in the sky above – a truly awesome experience, completed by having a beer in the sauna afterwards.

As well as learning a lot about Sweden and acute medicine I became educated in the secretive and scientific world of valla. When Sweden competes in snow sports, particularly against Norway, there are whole teams of people working on perfecting the skier’s valla, or wax on the skis – using the wrong valla for the temperature and snow conditions on the skis could lose you the gold medal. A very confident downhill skier, I admit that before coming to Gällivare I was totally unaware that there were even different types of cross-country skiing, and so I took it upon myself to progress from Bambi on ice, going out on sunny midweek evenings to learn to skate, ski in the classic style in the local tracks, and walk up mountains (with skis on) to ski, and eventually not fall, back down again. Swedish people seem to enjoy skiing off-piste a lot more than their European counterparts in the Alps, and the best place to experience serious off-piste is the legendary Riksgränsen resort on the Swedish-Norwegian border. Following the Torne River north to its source, the same river from which ice is harvested to build and rebuild the iconic Ice Hotel each year in Kiruna, the magnitude and sense of wilderness surrounding Riksgränsen is almost biblical.

Cold is Your Enemy, and Everyone is Cold

There are constant reminders of the power of nature. An elderly gentleman suffered severe head and limb injuries when he fell from the roof of his house clearing snow in a small village nine mils (90km) from Gällivare, and was treated on scene by a ground ambulance crew from a local base 30km away who brought him into the hospital. Having spent approximately 40 minutes lying on snow at -12° Celsius, hypothermia was certain; no attempt at obtaining venous access was made and the paramedic and ambulance nurse went straight for intraosseous access to administer fluids, analgesia and later blood on his arrival to the resuscitation room.

Clinically the patient was unconscious, had dark swollen eyelids, an airway obstructed by blood, broken ribs and a fractured wrist. CT scans revealed a temporal skull fracture and it transpired that the blood coming from the patient’s mouth was originating from the head injuries, tracking down through his sinuses. Unstable and in need of urgent neurosurgical intervention, the flying doctors’ fixed-wing flight crew from Umeå were called to package the patient and prepare for the two hour transfer time. This case highlighted the challenges presented by remote living in extreme environments, and that even with the most modern technology and competent teams, things take time. Even more so when factors like poor flying conditions and great distances to definitive care are taken into account, which can significantly influence a patient’s circumstances. This patient survived the transfer to Umeå hospital and at time of writing, his condition was being monitored in Intensive Care.

Lessons Learnt

I will never forget my time in Sweden and am already planning to go back! I met so many kind and inspiring people, had countless new experiences and ticked things off my bucket list that I did not even know were on there… My thirst for pre-hospital and wilderness medicine has only grown and my exposure to clinical scenarios and extreme environments has taught me much about the importance of meticulous preparation in all operational aspects. This includes, importantly, making sure you are warmly and appropriately dressed for changing outside conditions, well-fed, and not in need of the toilet, to ensure you can perform at your highest level to provide the best care for the patient. There were moments almost every day when I felt outside my comfort zone, but the single most important thing this trip has taught me is to say yes to every opportunity presented to you, even if it scares you a little. Use this excited nervous energy not to get back into your box or comfort zone, but to make the box bigger and to experience all that you can.

Further Information

Where / Gällivare hospital, Swedish Lapland, Northern Sweden.

When / February-March.

Weather / Temperatures can range from -30 to +4, often blue skies or snowing at this time of year. Hours of sunlight are similar to British winter, but increase rapidly so days will quickly get longer.

Travel / Fly to Stockholm Arlanda Airport, then take a 2 hour domestic flight up to Gällivare (flights often stop halfway at smaller airports).

Vaccinations / Standard UK childhood vaccinations.

Accommodation / Rachael stayed with a local doctor but accommodation is available very close to the hospital and more student/junior doctor apartments are currently being built in time for August 2015.

Essential Items / Very warm jacket (700-900 fill power), decent gloves and walking/insulated boots.

Contacts / Rachael suggests contacting Gällivare Hospital directly through the website, and passes the message on the phoning directly will get you a deal further than waiting for email replies…

The post Northern Lights: An Elective in Lapland appeared first on Adventure Medic.

Emily jumped at the chance to spend her elective promoting porter welfare with the International Porter Protection Group in Nepal. She has now (reluctantly) settled back into life in the UK and wants to share her experiences and spread the IPPG word.

Where did I go?

My ten-week medical elective was spent with the International Porter Protection Group (IPPG) at their Rescue Post and Porter Shelter at 4450m in the village of Machermo. This village lies in the picturesque Gokyo Valley in the Khumbu (Everest) region of the Nepalese Himalaya. It is reached by a light aircraft flight from Kathmandu to the mountain airport at Lukla (not for the faint-hearted!) and from there it’s roughly a week’s trek. A couple of days after leaving Lukla, the trail branches off from the main Everest base camp route and the valley becomes less visited by tourists, quieter and arguable even more beautiful.

Although the Gokyo valley is a less busy trekking route than the Everest valley, it is becoming increasingly popular. It is a particularly dangerous valley in terms of altitude illness because it is difficult to descend quickly – the crucial step in saving the lives of those unwell with altitude illness. This makes IPPG’s presence there all the more important.

IPPG

The IPPG is run entirely by volunteers and works for the safety of mountain porters around the world but with particular focus in Nepal.

“In 1997, a young Nepali porter employed by a trekking company became severely ill with altitude illness. He was paid off and sent down alone. It took just another 30 hours for him to die. He was 20 years old and left behind a wife and two small children… IPPG was formed to prevent these recurring tragedies.”

Mountain porters face many occupational health and environmental hazards. IPPG recognises this and the poor treatment of this vulnerable group – they work to improve the conditions of mountain porters worldwide. IPPG’s mission is for every porter to have: “access to adequate clothing, boots, shelter and food (appropriate to the altitude and weather); medical care when ill or injured; and insurance”.

IPPG also works with a number of other organisations to promote the welfare of porters, including Community Action Nepal, Himalayan Rescue Association and Kathmandu Environment and Education Project.

The Porter Shelter and Rescue Post, Machermo

The Porter Shelter and Rescue Post at Machermo is a joint project between IPPG, Community Action Nepal, The Sagamartha National Park and local villagers who make up the Local Management Committee. The Rescue Post is staffed by IPPG volunteers during the trekking seasons (March-May and September-November) and the running of the post is overseen by Chhewang (manager) and Kanchha (cook). The post offers shelter (dormitory style accommodation and a kitchen) and free medical care to porters. Trekkers are also treated at the post for a fee and it is these fees, together with donations, that allow the charity to function. The volunteers at the post give an educational talk each day about porter welfare and altitude illness to trekkers currently staying in the village with the aim of increasing awareness and understanding of these issues. As of the 2014 season, there is also a second Porter Shelter and Rescue Post at the village of Gokyo (a day’s walk up the valley).

So what did I do?

I arrived at Machermo after a beautiful (and breathless!) seven day trek in from the Tenzing-Hillary airport, which perches on the mountainside at Lukla. My roles at the Rescue Post included carrying out consultations with sick porters and trekkers and helping to give the daily talk to trekkers about altitude illness and porter welfare. I was also involved in collecting data regarding altitude illness and helping with the seasonal maintenance of the Rescue Post.

Daily life was very enjoyable and was spent tending to patients whenever they arrived, along with completing chores around the post, heating water in the solar concentrator for a bucket shower, going out for walks and playing a lot of cards and backgammon! We were extremely well fuelled by all the fantastic and varied food that Kancha produced for us – momos were a firm favourite! It was pretty chilly at times, especially earlier on in the season and we always eagerly awaited 5pm when the yak dug stove was lit! In terms of communication with home, this was understandably limited but it was possible now and again. There was internet about one and a half hours walk away and the Rescue Post has a satellite phone connection, which people can ring in on. And then, there’s always the option of sending a post card – although, 6 months down the line, the ones I sent still haven’t arrived home. I’m remaining optimistic that they’ll turn up eventually though!

In terms of medical treatment, we saw 129 patients during the season – half of these were trekkers and half were Nepali locals and porters (Chhewang or Kanchha translated when needed). The pre-monsoon season is typically quieter than the post-monsoon season, with the latter usually seeing 250-300 patients. Patients could turn up at any time, day or night, and we were occasionally called out to seeing unwell trekkers in their lodges or to meet people on the trail.

Half of our patients had altitude-related illness – one or more of acute mountain sickness, high altitude cerebral oedema (HACE) and high altitude pulmonary oedema (HAPE). The other half had a range of problems including gastritis, gastroenteritis, minor trauma, respiratory infections and various ophthalmology and dental problems.

During the season, seven patients (all of whom were trekkers) were evacuated by helicopter. These evacuations were for high altitude cerebral oedema and/or high altitude pulmonary oedema. It is worth bearing in mind that helicopter evacuation is very weather dependent – it can only happen during the day in clear visibly. In reality this means that helicopter evacuations rarely happened after lunch when the cloud tends to come in. This can present some problems as most people become unwell with altitude illness later in the afternoon once they start to feel the effects of the new altitude that they have reached that day. This meant that most of our seriously unwell patients spent the night at the Rescue Post receiving treatment and were evacuated out the next morning.

A typical case

A typical case of altitude illness was a 69 year old trekker who presented at around 6pm one evening. She had been feeling unwell for the past 5 days. Initially, she had a headache, she hadn’t been sleeping well and she had a cough. This progressed to feeling short of breath, particularly on lying down. Her trekking partner reported that she had been unsteady on her feet for the last few days and had appeared confused at times forgetting where she had put things, which was unusual for her. On examination, her oxygen sats were 78% (which is low even for 4450m), heart rate 90 bpm, respiratory rate 35, BP 128/62 and temperature 37.6ºC. On auscultation of her chest, she had crackles in the left mid zone. She demonstrated moderate ataxia on assessment of heel-toe walking. Our impression was that she had both HAPE and HACE – her low oxygen saturations, high respiratory rate and chest crackles suggested HAPE and her confusion and ataxia suggested HACE. We treated her accordingly with acetazolamide, dexamethasone and nifedipine. It was too late in the day for a helicopter evacuation and the patient opted to return to her lodge for the night with her friend. We advised helicopter evacuation the following morning, particularly as the trail down from Machermo is slow to lose height and even in full health it is still 2-3 day walk back to the airport at Lukla. In addition, HAPE is known to worsen on exercise. However, the patient was insistent that she wanted to walk out. There was little we could do other than ensure she had enough medication to take with her.

This case illustrates some of the ethical and moral problems that we faced during the season. Often trekkers did not want to accept that they were potentially seriously unwell and they did not follow our advice to be evacuated. In addition, we faced some problems with language barriers – we tended to some patients with severe HACE and HAPE with no way of communicating with them in a language they understood.

As a medical elective, the season at Machermo gave me fantastic experience of working in a remote high altitude wilderness environment and I gained a lot of knowledge about the recognition and treatment altitude illness. We had limited treatment options and very black and white decisions needed to be made – ‘does this patient need a helicopter or not?’. This is in many ways far from relevant to medical finals and everyday UK practice but nevertheless, very applicable to places that I would like to work in the future.

Occupational health of mountain porters

Due to the nature of the work at the post, a key focus of mine during the season was the occupational welfare of porters. To fully consider this and the surrounding issues, it is important to understand that there are a number of different types of mountain porter:

• Trekking porters – carry trekkers’ kit, food, tents. They are either employed by trekking companies or they are employed directly by independent trekkers who are not using a trekking company.
• Supply porters – transport supplies for the region. These supplies include food for locals and tourists and building materials for new lodges. Although these porters are paid by locals to transport the goods, the majority of what is being transported can be directly linked back to the tourist industry.
• High altitude porters – working at high altitude on mountains such as Everest.

All mountain porters face many hazards during their daily work. Indeed, IPPG state that porters suffer from more illness and accidents than Western trekkers. They are exposed to a number of environmental hazards, including high altitude and the cold, which puts them at risk of altitude illness, hypothermia and frostbite. The risk of these problems arising is accentuated by their lack of adequate clothing and footwear, lack of shelter, lack of sufficient food and lack of appropriate medical care. In terms of accommodation, sometimes porter may be able to stay at the lodge with their western trekking group but only if the lodges are not full with trekkers and they will have to pay a large proportion of their wage for this shelter. The reality is that lodges are often full and porters have no choice but to sleep out in caves; which are regularly passed along the main trekking trails. Life in the Everest region is expensive compared to other areas of Nepal, so a large proportion, if not the entirety, of a porter’s wage is spent on living costs and trying to get an adequate calorie intake – this means they are very reliant on tips from trekkers to make any profit at all. Thankfully, in some villages there are now dedicated porter shelters, such as the IPPG porter shelters at Machermo and Gokyo.

Loads

Regarding porter injury and illness, the risk of this is increased by the unbelievably large and heavy loads that many porters carry on a daily basis. It is unfortunately not uncommon for a porter to carry far beyond the 30kg limit that IPPG recommends; and, if this were not arduous enough, they will be walking perhaps 30km in a day, at high altitude, wearing a pair of flip flops for footwear – a task that most of us couldn’t even consider doing at sea level with all the latest outdoor kit. Indeed, throughout the season we saw many examples of porters with inadequate clothing and footwear – watching porters carrying loads many times their size wearing a pair of flip flops was an almost daily occurrence. Often the porters carrying the largest loads are supply porters as they are paid by weight and so there is a huge incentive to carry heavier loads. However, load size issues are present with both trekking and supply porters.

Altitude Illness

In terms of altitude illness, it is often not appreciated that most trekking and supply porters are not Sherpa (the indigenous people of the highlands who have some genetic protection against altitude illness). Whilst most of the high altitude porters working on Everest itself are indeed Sherpa, in fact most trekking and supply porters come from the lowlands and ascend to work during the trekking seasons. This means that they are just as susceptible to altitude illness as you or I, particularly at the start of the trekking season when they are not yet acclimatised.

Insurance

An additional problem for porters is that a large number of them do not have insurance, particularly supply porters or those trekking porters who work independently rather than for a trekking company. This leads to problems if they fall ill – a western trekker who presents to the Rescue Post with severe altitude illness would likely be evacuated by helicopter; however, this quick and effective treatment is not an option for a porter who is not afforded the luxury of insurance. Instead, often the only option is to make the multi-day journey to lower altitudes on a yak or on the back of a fellow porter. In addition to the above, there is no social security in Nepal. This means that if a porter is unable to work or, in the worse case dies, their family and dependents are left in a very difficult position. In relation to this, during my season at the Rescue Post, on 18th April a fatal avalanche happened on Mount Everest. This was the most deadly disaster in Mount Everest’s history with 16 porters losing their lives. Many articles have been written about this disaster with many points of view expressed and it is not possible to discuss it in detail here. However, a key issue raised is that of insurance – the desperate need for wide spread, comprehensive insurance amongst porters. It is hoped by many that in the wake of the 2014 disaster this may become a reality, but it waits to be seen whether this will be the case.

Medical treatment of porters at the Rescue Post

During the season we treated roughly 20 porters at the Rescue Post. A variety of illnesses were seen including altitude illness, respiratory infections, gastroenteritis, wound infections, back/neck pain and snow blindness. Conditions that were particularly poignant, especially in terms of occupational involvement, were: infected scalp wounds from abrasion by the head strap that porters use to carry their loads; severe (and sometimes infected) blisters resulting from inadequate footwear, excessive loads and poor access to washing facilities; and finally snow blindness because of a lack of sunglasses. In addition, we saw many cases of altitude illness in porters who had ascended too fast and who had been placed at additional risk due to the exertion of carrying excessively heavy loads. Furthermore, some porters were significantly unwell (for example, with altitude illness and respiratory infections) but they were unable to rest and take time off work to recover because if they didn’t work they wouldn’t get paid and their trekking companies had strict itineraries to stick to and would carry on without them. This illustrates a key problem within the industry and the lack of regulation surrounding porter welfare.

Summary

It is clear that Nepalese porters face many occupational health problems. There is currently a lack of centralised national systems in place to protect porters and promote their welfare. The main independent forces acting to improve porter welfare are charities working in the region, such as IPPG. In terms of occupational health medicine in Nepal as a whole, there is evidence of the emergence of this field within Nepal; however the health of porters is rarely discussed despite their vital role in Nepal’s tourism industry. Looking to the future it is important to continue to increase trekkers’ awareness of porter welfare, which will hopefully result in trekking companies giving their porters better working conditions such as adequate clothing, footwear, accommodation, medical care, insurance and pay. Porters are the backbone of the trekking industry, which is a vital part of the Nepalese economy – we can but hope that the government will truly acknowledge this and that their involvement and regulation may also act to improve porters’ working conditions in the future.

I thoroughly enjoyed being part of the fantastic work that IPPG do and I feel extremely lucky to have been able to spend my elective in the Himalayas with the wonderful Nepali people. I have learnt a great deal, in particular about the occupational health problems of mountain porters and about altitude illness.

For more information on porter welfare and the work of IPPG please visit their website.

Key elective information

Where / with the International Porter Protection Group (IPPG) at their Rescue Post and Porter Shelter at 4450m in the village of Machermo, Nepal.
When / March – May 2014 (seasons run March – May and September – November each year).
Accommodation / at the rescue post with the other volunteers – you don’t have to pay for accommodation or food at the Rescue Post.
Supervision / the doctors volunteering that season. IPPG will ensure they are happy to supervise/teach a medical student.
Travel / Fly to Kathmandu. Internal flight from Kathmandu to the small mountain airport at Lukla. 6-7 day trek from Lukla to Machermo.
Costs: approximately £2000-3000 for 10 weeks depending on flights, vaccinations needed, how much independent trekking you do and how much kit you need to buy. You don’t have to pay IPPG to volunteer for the season but you need to cover all costs of getting to the Rescue Post (international and internal flight, porter and living costs on the trek to/from the Rescue Post).
Contact / http://www.ippg.net/ There is a section about medical electives on the website, including the application form. Deadlines for application are detailed on the website. There are also lots of reports from previous seasons on the website which have further helpful and interesting information.

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Last year, Naomi Dodds headed to Tromsø in northern Norway for her final year elective. In an enviable couple of months, she experienced a mix of anaesthetics and pre-hospital care in a truly unique environment. Read on for how you can do it too, and why being a ‘HEMS Rescue Man’ might just be the most kickass gig in the Arctic.

Healthcare in Arctic Norway

Tromsø is a remote city located 350 kilometres north of the Arctic Circle in Northern Norway, famous for its midnight sun and magical northern lights. The University Hospital of Northern Norway in Tromsø is the regional hospital for 475,000 inhabitants from a vast land area of 110 square kilometers across Finnmark, Nordland and Troms. Additionally, the hospital provides care to the thousands of visitors travelling to Northern Norway for work and pleasure.

Comparable to the NHS, the national Norwegian health care system is run by the government with funding from the national budget, meaning that health care is free of charge for all citizens. However, the hospitals are not open access via the Emergency Department. To receive specialist care patients must be referred by their GP or if they are critically unwell they are brought into hospital via the one of the pre-hospital emergency medical services. 

Anaesthetics

My elective was organised through the Anaesthetics Department, with my time split between managing airways in theatre and learning about the pre-hospital emergency care system.

In Norway the specialty of ‘Anaesthesiology’ or Anaesthetics currently encompasses Intensive Care Medicine, Emergency Medicine and Pre-hospital Care as there is currently no formal pathways for these specialties, although rumours suggest that there may be in the near future.

Similarly to America and other parts of Scandinavia, anaesthetic nurses in Norway are extremely skilled and take on much of the role of the UK anaesthetist. The ‘Lege’ or doctor oversees a number of different operating theatres and is required during difficult or complicated intubation. This means there was ample opportunity for medical students to gain hands-on airway experience under close supervision in a variety of settings.

Language was never an issue, despite always initially apologising for their poor English, the Scandinavians actually spoke it perfectly and were keen to practice by conversing with me.

Pre-hospital Care

Pre-hospital care is an integral part of the national health care system in Norway due to the remote landscape. To put things into perspective, Northern Norway encompasses an area of similar size to the whole of England with only one major hospital, therefore access to specialist care can be geographically challenging.

To meet the challenge, the pre-hospital emergency care service in Northern Norway consists of ground ambulances, fixed-wing ambulances, Helicopter Emergency Medical Service (HEMS), and the Royal Norwegian Air Force 330 Squadron Civilian Search and Rescue (SAR) service. These services are available 24 hours a day and are coordinated through the regional 113 Emergency Medical Dispatch Centre in Tromsø.  I was lucky enough to join each of these in turn to gain a greater insight into the service they provide.

The ground ambulances form the backbone of the pre-hospital emergency care service. These were staffed predominantly by paramedics, with a local GP often present at the scene. Interestingly, final year medical students are also permitted to work as part of the crew, which provides them with some fantastic pre-hospital emergency care experience and pocket money!

The fixed-wing air ambulances are predominantly used for retrieval and inter-hospital transport, and travel as far as Longyearbyen, the world’s northernmost city on the Norwegian archipelago of Svalbard. They collect patients from smaller rural hospitals and bring them to Tromsø for more specialist treatment. They are staffed with two pilots and a specialist anaesthetic or critical care nurse, and an anaesthetist if the patient is critically unwell or requires airway support.

HEMS and SAR

Tromsø is one of the twelve national Norwegian HEMS Air Ambulance bases, providing a 24 hour service 365 days a year. It is tasked to life threatening incidents such as cardiac arrest, stroke and trauma. The HEMS crew consists of a highly trained pilot, an anaesthetist and a HEMS Rescue Man. The Rescue Man is typically a paramedic or nurse with significant pre-hospital experience capable of radio communication, winching, navigating and even flying the plane!

The aircraft was spacious, allowing the team to actively treat two patients during flight. The equipment on board the aircraft was innovative with mechanical compression devices, diagnostic ultrasound and even the capacity for extracorporeal membrane oxygenation. The crew work roughly one in four weeks and work 24 hours a day during those seven days on call, with compulsory breaks in flying to allow the pilot to rest. The HEMS pilots are the most experienced in Norway and the highlight of my time with them was certainly the incredible scenic flights over the fjords, glaciers and mesmerising Norwegian mountains.

The Royal Norwegian Air Force 330 Squadron provides a civilian service in the form of white and orange Sea King SAR helicopters located at five bases across Norway, including Banak in Finnmark, Northern Norway. They can reach anywhere in Norway within 90 minutes flying time from one of these bases, and each aircraft has the capacity to rescue up to nineteen casualties. The Sea King flies with a crew of six; two pilots, one navigator, one engineer/winch operator, one rescue man/swimmer, and one rescue trained civilian anaesthetist.

As with HEMS, the rescue man is a paramedic or nurse with phenomenal sea and mountain rescue expertise who is winched down to the scene. It is probably one of coolest jobs in the world! Also similarly to HEMS, the crew work long shifts of 24 hours for seven days. They live at base during this week, which means that the base is exceptional with a gym, badminton court, café/restaurant and even a Sea King BBQ!

My most memorable scramble was to a remote area inaccessible by road on the Northern coast of Finnmark. Unable to safely land near the injured patient due to the sea fog the pilot brought us down on an isolated beach. The doctor and rescue man managed to find a local Sami reindeer farmer and convinced him to give them a lift over the mountains in a trailer on the back of his quad bike. The rest of us sat in the sunshine picking blueberries and swimming in the Arctic Ocean until the sea mist cleared and we could fly in to pick up the crew and take the injured patient who had sustained a fractured humerus during a fall safely to hospital.

Pre-hospital care in Norway isn’t all glamorous though. We spent rather a large amount of time hanging out at base lounging in jumpsuits, drinking coffee and watching really awful Norwegian films!

Free-time adventures

Born on skis, the Norwegians have an innate passion for adventure. Therefore, recruiting companions was no issue and with 24 hours of daylight the fun never stopped! There can only be a few places in the world where it is common to receive texts at 10pm inviting you on a remote mountaineering venture.

Norway is an adventurer’s paradise with endless fjords to paddle, isolated rock to climb and beautiful mountains to explore. Norway also has a unique network of mountain huts belonging to the Norwegian Trekking Association providing a base for multiday expeditions into the wilderness. My favourite Norwegian adventure was a weekend alpine mountaineering in the Lyngen Alps, climbing the famous dome-shaped glaciated peak of Jiehkkevárri 1834m.

Doing it youself

Logistics / Choosing where to go on elective is one of the biggest decisions faced as a medical student. Do I want to learn about medicine, develop my clinical skills or just go on an incredible adventure? For me, Norway ticked all the boxes. Norway is renowned for it’s expensive living, though with some additional planning and preparation this was easily overcome. Norwegian Air charge a small fee for additional baggage and customs allow a generous amount of goods to be imported, therefore I took the vast majority of my food with me and went fishing for fresh mackerel to boost supplies.

Positives / I met some fantastic people and gained more remote pre-hospital experience than I could have ever hoped for. I have certainly been inspired to learn Norwegian so I can travel back and work in this picturesque remote arctic landscape in the future.

Negatives / There is no formal elective programme and therefore no guarantee this experience can be repeated.  It was challenging to confirm any pre-hospital opportunities until I arrived in Tromsø and I was extremely lucky that they valued my previous pre-hospital experience and invited me to join them.

Details

Destination / Tromsø, Northern Norway

Time of Year / June and July but possible anytime of year.

Weather / Similar climate to the Scottish Highlands – sunshine, cloud and rain during the summer and arctic conditions during the winter.

Budget / Administration fees £0, Flights £300, Accommodation £100 per week, Food £50 per week.

Vaccinations / Usual British vaccinations

Essential Item / Hiking boots, a fishing rod and cheap imported alcohol to make Norwegian friends!

Do you have an exciting elective adventure to share? Adventure Medic are keen to publish more student elective articles, if your interested get in touch.

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Olaoluwakitan “Ollie” Osunkunle is a Foundation Trainee from Cambridge University. Here he looks back at his elective experience in Lesotho and Cape Town, South Africa.

The landscape in Lesotho is simply breathtaking – beyond words. Rather it is an experience. One that I am very fortunate to have enjoyed. Snow capped mountains frame the landscape, with stony sculptures beautifully carved from mother nature carpeting the terrain between.

Unfortunately, this picturesque view is made harsh by the bitter cold that bites sharply into one’s bones. Perhaps I should have made a wiser choice than to visit Lesotho in the winter. Fortunately, the hospital accommodation includes an abundant supply of woolly blankets, which I buried myself beneath every night to protect from Lesotho’s frigidity.

Contrasts

During my ten week elective period, I spent five weeks in the Orthopaedic department of the King Edward VIII hospital in Durban, South Africa and five weeks in the Maluti Adventist hospital in Mapoteng, Lesotho. I chose this combination so I could contrast the standard of medical care in the developed country of South Africa, against that of a developing country in Lesotho. One of my aims in organizing my elective was to learn more about the major health problems afflicting African countries. HIV and tuberculosis (TB) infection are two such notable issues, and Lesotho and South Africa have high rates of both. The HIV prevalence in Lesotho is the third highest in the world at 24% amongst those aged 15-49, while that of South Africa lags not far behind at the fourth highest: 17.8%. In addition, there is a prevalence of TB of 795/100 000 people in South Africa and 402/100 000 in Lesotho. A popular medical South African idiom goes, “Here in southern Africa, we are number one in HIV, TB and trauma.” What an accolade.

Lesotho

In Lesotho, the hospital is a 150 bed mission hospital run by the 7th Day Adventist Church but funded by the government. It serves a local population of about 100,000. As the Maluti Adventist Hospital is situated in a rural setting, the spectrum of disease varies markedly from that which one would experience in the UK. Amongst the paediatric population, malnutrition and infectious diarrhoea remain the major problems. In the hospital I performed the duties of a junior doctor, assisting in the outpatient department, the wards and the operating theatre. I was not confined to any particular specialty but spent the majority of my time in the outpatient department of the hospital, attending to a portion of the three hundred or so patients that attend each day. This offered me an excellent opportunity to improve my diagnostic and clinical reasoning skills. I also had the opportunity to improve my clinical skills. Suturing was frequently required, as wounds following episodes of violence were a common reason for presentation to the hospital. In addition, I was involved in the management of emergency cases, usually of shocked patients following trauma or obstetric complications. Unfortunately, language was a barrier here, as the local population were fluent only in their native language of Sesotho. However, student nurses were assigned to help translate for the doctors; none of the doctors were originally from Lesotho. The chief medical officer was originally from Argentina and there was a volunteer middle grade doctor from Amsterdam who was planning to stay for two years. The remainder of the doctors were from African countries, including the Democratic Republic of Congo and Zimbabwe.

Outreach

The hospital was involved with outreach clinics, and I was able to assist in one such trip. This was to a rural village to provide free assessment and medication to those who could not afford to attend the hospital. The outreach clinic was set up at a school in the village. Here make-shift stations were set up in outdoor tents, with a volunteer healthcare professional at each station. Food was also cooked outdoors in large pots, and supplied to the patients as they waited.
The day was primarily focused on child health, with stations for mass immunization, growth monitoring, nutritional assessment and advice and dental reviews. There were also HIV DNA PCR test stations. A crew of four doctors were available to assess the multitudes and put into effect whatever treatments they felt were appropriate from the available list of ten or so medications… I joined the team in assessing patients and either prescribing medication or referring them to the hospital when I felt that the level of care they required was simply not possible at the outreach clinic.

Expectations

Although I began the trip expecting to largely reassure the worried well, I was surprised by the sheer number of serious pathologies that I witnessed. The time I had spent in hospitals and general practice clinics in the UK had caused me to forget that elsewhere in the world, healthcare is not so easily available. From patients grappling with the devastating complications of HIV to babies scarred by severe burns. Unfortunately for some the cost of visiting the hospital (50 Rand, or the equivalent of £4 in the UK) was the limiting factor preventing patients from seeking treatment. When I think back to the abundance of investigations and treatment and available in the UK the plight of these patients is truly distressing.

Top Tips

Positives

Negatives

Summary

Destination / Maluti Adventist Hospital, Mapoteng, Lesotho.
Time of Year / July/August (Winter in Lesotho!)
Weather / Winter
Religion / Hospital is a 7th Day Adventist Campus.
Hospital contact / jrrodriguez57@yahoo.com.ar (Chief Medical Officer)

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Hannah Newcombe is a Foundation Trainee from South London who studied at the University of Manchester. With winter approaching she recounts her ski medicine elective experience in the French Alps last season – a good mix of acute wilderness medicine and corduroy-shredding ski goodness.

I am an outdoor enthusiast and get the most out of a weekend by keeping busy, active and outdoors. So, I chose an elective to compliment my interests. I travelled to the frosty snow and beautiful sunshine of Avoriaz Medical Centre, Portes du Soleil ski area in France. I had switched a slow drive around the M60 motorway for a gentle ride up the gondola ski lift and a ski down the piste. It was a trip to remember!

Medical Centre

The medical centre is cosy and compact, found at the base of main chair lifts, in the middle of the traditional ski resort of Avoriaz. There are no roads in Avoriaz so in the winter, locals get about on foot, snow-mobile or with horse and sledge which all adds to the charm and reminds you of the seclusion of the village. The experienced and close knit team is made up of four doctors, two nurses and radiographers and one physiotherapist. They all lived nearby for the winter season and were keen to involve me in the team, teach, and encourage me to make the most of the mountains.

French healthcare

French healthcare system is similar to the UK; there is good access to resources, and similar medications and treatment options which made it easy to transfer my knowledge from UK to the consultations in France.

I observed differences in primary care, for instance one would take their child directly to a paediatrician rather than the GP, and for every different medical condition an adult would go to a separate medical specialist. The GP is the co-ordinator of referrals and triage patients initially. Also, it is a social insurance system where employers pay a compulsory fee for healthcare and private insurance schemes top up the surplus. I observed easy access to X-rays and ultrasound to confirm diagnoses quickly, and more technical splints and supports for immobilising dislocated joints or fractured bones.

Comparison to UK

The medical centre went beyond the initial management that I was used to in a central Manchester GP practice as there could be a delay in getting to the local hospital due to the distance, the mountain road, and the challenging weather. For example one patient presented with collapse and was clinically dehydrated. They were promptly treated with intravenous fluids, discharged home and then followed up the next day, once blood test results were back. Another patient was systemically unwell from pneumonia and required intravenous antibiotics. These were started immediately whilst the patient was awaited transfer to the hospital.

Daily routine

I would describe a typical day, however there as so much variety and different opportunities available that it is a little tricky! My days were pieced together by either GP clinics or acute trauma walk-ins. I would find myself taking a history or undertaking an examination following a patient through to X-ray or ultrasound, reviewing them with the doctors where I would be quizzed on my differential, and finally assist with fixing/strapping/suturing/immobilisation. As my placement progressed I was able to see patients in each of these stages on my own, depending on language and severity of illness or injury. I became neater at suturing, quicker at spotting a dislocation, and handier at helping apply a cast to a fracture.

There were often times of gazing out the window at the slopes, or critiquing skiers techniques from the sun loungers on the terrace in the quiet moments. But they were often interrupted by the siren of the piste patrol bringing in an injured patient. Everyone snapped into action transporting the patient into the medical centre and through the slick consultation and treatment cycle.

I was lucky enough to join one of the doctors in the helicopter when the piste patrol requested the doctors support. It involved a stunning if brief trip over the high peaks to reach the patients. Stabilising them, giving analgesia or even a nerve block before transport back to the medical centre or local hospital. It was a challenge to keep the patient warm, fully informed and as comfortable as possible to insert a cannula whilst I was knee deep in snow myself and gradually loosing feeling to my own fingers.

One particular case that has stayed in my memory was of an English lady who came to the centre after a fall onto her right arm in the last week of my placement. She was a GP herself and I tentatively took a history and examination before sending her for an X-ray of the shoulder. I was feeling quietly confident of the expected diagnosis and was already lining up which sling to use. However I studied the X-ray and it looked normal. In fact the GP/patient had a look herself and was relieved that there was no obvious abnormality. So we trundled back to the consultant who after hearing the history alone and a glance of the film got out his ultrasound machine, revealing what was my initial diagnosis; fractured head humerus. A shocked GP accepted her sling, analgesia and physio advice, and I accepted a good lesson from my consultant: he explained that from the description of her fall, the fact she was skiing (rather than snowboarding) and her description of the sound and of the pain, it had to be a fracture. He gave me confidence to utilise the depth and preciseness of history taking to get the diagnosis whilst using images to merely confirm this… and to keep looking!

Après work

My accommodation was down the valley in Morzine which is an adjoining ski resort. Here I lived with Seasonaire’s who were balancing their jobs of cleaning, waitressing and instructing whilst managing to cram in as much skiing and boarding as they could. I was able to socialise with young people of varying ages and could make plans to ski different areas, trek up to incredible views and off-piste ski, and of course have some company for the ice-hockey matches, film nights, fancy-dress, quiz nights, wine bars, local cuisine, mountain view swimming pool. This complimented the busy shifts at the medical centre with a chance to enjoy life in the resort.

Top Tips

Pros

Cons

Summary

Where / Avoriaz Medical Centre, Portes du Soleil ski area, France (bordering Switzerland)

When / Jan – Mar (available December-April)

Travel / Fly to Geneva from most UK airports. There are many transfer companies to choose from to take you to resort

Work schedule / Alternating early or late shifts (0800-1400/1300-1900) and then long-day or off for Saturday & Sunday.

Weather / Alpine sunshine but cool temperatures -30 to +12 in resort

Costs / Approximately £600 a month (accommodation, ski pass, ski hire, and food) dependent on preference of standard of accommodation

Necessaries / French language skills of A-level or equivalent and the will to learn and improve

For more information, or to arrange your own elective in Avoriaz, please follow this link.

The post Alps Ski Medicine Elective appeared first on Adventure Medic.

Thomas Eriksen is a final year medical student at the University of Glasgow. He has had a life long fascination with the marine world and achieved his PADI Open Water Diver certification aged 15. He has worked as a Divemaster in Honduras and has dived in numerous locations throughout the world. Here, he tells Adventure Medic about the ups and downs of a dive medicine elective at the Townsville Hyperbaric Unit.

Why Townsville?

For me, it was a no brainer that one of my elective placements would be in Hyperbaric Medicine. I chose to go to Townsville Hyperbaric Unit in Queensland, Australia as it had the largest hyperbaric chamber in the Southern Hemisphere and is the main referral centre for the whole of the South Pacific. My interest lies in dive medicine, but specifically recreational dive medicine rather than occupational dive medicine. Townsville offered the best chance to gain exposure to recreational divers with dive injuries due to the proximity of the Great Barrier Reef.

Who do they treat?

Before arriving in Townsville, I had learned that dive accidents were becoming less common and that hyperbaric units were treating fewer and fewer divers. So, I was prepared to only see a few cases during my stay. The unit treats around 10 patients a day of which >90% are non divers with radiation necrosis or hypoxic wounds. I learnt a great deal about the use of hyperbaric oxygen to treat these conditions.

What did you get up to?

The first week was spent familiarising myself with the unit and learning about the many other conditions that are treated with hyperbaric oxygen therapy. I also came up with a research project to keep myself busy while awaiting an incident. I conducted a 10 year patient review to see how the patient groups had changed over the last decade. As expected, the numbers of divers being treated fell steadily over the decade from around one diver a week to around one diver a month. I then reviewed the factors that may have played a role in this apparent increase in the safety of scuba diving. The most likely to have had the biggest impact is the now widespread use of dive computers. They calculate a diver’s nitrogen load taking into account previous dives and surface intervals to give a real time no decompression limit. Other important factors involved are diver and crew education, tougher dive industry regulation and fewer dives being completed due to the global recession

During my stay I observed the treatment of two divers. They both had different diving histories, symptoms and diagnoses. One was treated for decompression sickness and the other for arterial gas embolism to the spinal cord. It was fascinating seeing the coordination of team members, including those on the dive boat, rescue helicopter, emergency department and hyperbaric unit. I followed the divers’ journey from admission to discharge, after successful treatment with hyperbaric oxygen. It was an invaluable learning experience to see the course of conditions I had studied so much, and was very pleasing to observe the successful treatment of their conditions.

As well as the hospital itself, I was able to spend time in the Townsville municipal airport, seeing the rescue helicopter and medical evacuation planes with an A&E consultant and paramedics. Although unable to join a flight, despite my best efforts, I did learn a huge amount about the considerations and logistics involved in getting critically ill patients from remote areas to the relative safety of the hospital. This is an aspect of medicine that is very important for rural Australians since the country is so vast. On my first day I learned that Townsville Hospital serves an area the size of France, which really put things in perspective.

On top of all this, I organised some anaesthetics experience for a few days too. It was during my time in theatres that I realised that Australia is plagued by most of the same health problems that are prevalent in the population of the West of Scotland. There are significant problems associated with deprivation, particularly in the Aboriginal population and remarkably obesity is actually more of a problem than in the U.K.

Sum it up for us

I very much enjoyed my elective at the Townsville Hyperbaric Unit. If I had not been able to relate all I learned to real cases, I think I would have felt differently. My learning experience was greatly enhanced by the misfortune of two divers who fortunately and thanks to the services provided in Townsville made full recoveries. The elective even changed the way I dive. I have deepened (apologies for the pun) my knowledge about the dangers of diving and how they strike both the reckless and the unfortunate. I have since altered my underwater behaviour to be even safer than before. I have also taken reassurance from my project that scuba diving, though viewed as an extreme sport by many, is safer than ever. If only insurance companies would see it the same way and reduce dive insurance premiums!

Positives

• Great to learn about a specialty that some final year students have never even heard of.
• I was welcomed by the whole team and was part of the action when the divers came in.
• I got to spend time at the airport with Emergency Management Queensland and Careflight, and also in theatres.
• I learned about the Australian medical training and what it is like working as a doctor there. Very useful since it is a real career option for British doctors.
• Travel opportunities in Australia and around Australia are fantastic. I went diving on the Barrier Reef and on the incredible Yongala Wreck. After my elective I went travelling in Indonesia, where I spent the majority of my time underwater.

Negatives

• Australia is very expensive to live in.
• There are a very small number of divers treated per year, even in Townsville. So if you have very little interest in the other conditions treated with hyperbaric O₂ it may be boring at times.
• Less hands-on practical experience than other specialties can offer. Which may be a positive for some, but I went seeking practical experience up in theatres.
• Townsville is less exciting than other Australian destinations.

Do it yourself

Destination / Townsville Hyperbaric Unit, Townsville, Queensland, Australia

Time of Year / July and August

Weather / 22-25°C mostly cloudless, cooler at night.

Money Spent / Too much! Australia is expensive to live in! Approx £250 per week

Vaccinations / I required none

First Aid Essentials / Nothing special, plasters for fin blisters!

Risks / For much of the year there are jellyfish in the sea which can be dangerous. There are stinger nets and the sea water pool is filtered but you swim at your own risk. July and August are outside of stinger season so I swam carefree.

Tips

• Understand that decompression sickness and arterial gas embolism are rare conditions before committing yourself
• Liaise with the unit director about a possible project to keep yourself occupied while you are waiting for unlucky divers
• The hospital offers no accommodation and the University charges extortionate rates. Organising an apartment with others would be the most economical. I got a monthly rate with a hostel.

The post Dive Medicine Elective appeared first on Adventure Medic.

Flic, originally from the Island of Arran, is a recently graduated doctor from the University of Glasgow. Here is an account of her experience of spending a month with the Royal Flying Doctors Service of Australia.

Logistics

For my junior elective I travelled to Port Augusta a small town in South Australia approximately 3 hours drive north of Adelaide. It is home to the Royal Flying Doctor Service (RFDS) base for South Australia. This base controls three separate airbases, Port Augusta itself, Adelaide to the South and Alice Springs to the North. Within the town there are three RFDS doctors, all of whom fly with the RFDS on clinic one day a week, cover an on call rota and fill the rest of their time with local GP clinics and hospital work.

I spent my elective attached to one such RFDS doctor who acts as a first port of call for patients and as a gateway to medical services. He is also first on scene in the event of accident or acute illness is available for telephone consultations 24 hours a day 7 days a week. Most of all though, he is their one security in living hundreds of kilometres from the nearest medical care.

As well as the small towns, the area covered by the Port Augusta base comprises many aboriginal communities dotted throughout the outback, arisen from the Aboriginal populations’ attachment to the land. It also includes several mines, each with its own population of miners, as well as families who work on both sheep and cattle stations. These communities, mines and stations are very much remote populations.

In the aboriginal communities the only contact with a doctor is on clinic days which are conducted between once a week or once a month, depending on the location. The RFDS fly for up to 2 hours, 800 kilometres from Port Augusta, with a freight consisting of a doctor, a flight nurse, a pilot, and supplies such as drugs, vaccinations, equipment for investigations such as urine samples and blood tests, minor surgical procedure equipment and a defibrillator. On arrival the plane is unpacked and “set up” in a clinic within the community, which is managed by a nurse within the community. From here the doctor conducts a routine GP clinic.

If the condition of any patients is serious enough to warrant hospital treatment then an emergency evacuation flight is requested by the doctor. Mines and stations necessitate a young working population. Because of this and because of the nature of the work, many of the health problems encountered are trauma related as opposed to chronic health problems. For example motorbike accidents incurred whilst droving cattle are not uncommon. This is the type of medical problem that in Scotland would be dealt with by hospital accident and emergency departments but which the RFDS GP needs to be experienced and competent in dealing with, especially over the phone, both to deliver initial treatment and to assess the necessity for an immediate evacuation. As there are only 2 planes at each station, resources are limited and so flying out to one casualty can put a potential more serious patient at risk. Being from a Scottish island I am used to being fairly out the way. However, I could not imagine living so far out from access to health care, especially when surrounded for so many hundreds of kilometres by nothing but the unforgiving outback.

Aboriginal populations

In the Aboriginal communities the main health problems are those of chronic disease attributed to the introduction of a western lifestyle in an unaccustomed population. For example hypertension, type II diabetes, obesity, heart disease and chronic kidney disease are common place and are the main target for education, prevention and health interventions.

Health issues resulting from customs of Aboriginal culture and tradition are an interesting aspect of the job which I was not expecting. Death is an event which comprises a great many of these customs. When someone in the community dies, a “sorry camp” is held where family and friends within the community, and those from farther afield who travel especially for the event, set up camp and grieve for the deceased for weeks at a time. The funeral will take place at some time during the camp’s duration. During this period even children and the elderly will live in tents with the only heat in winter provided by camp fires. Burns, hypothermia and joint pains in elderly people sleeping on the ground are all common occurences at these camps. Self harming – cutting the skin of the arms or chest – is performed as a ritual in order to leave a scar as a reminder of the deceased. These “sorry cuts” can become dangerous if large blood loss or infection occurs.

One specific example of health care issues related to Aboriginal customs was evident in the case of one patient seen in a remote community. In this case an elderly woman presented to the GP clinic complaining of stress and not sleeping as a result of her home situation. Aboriginal people are obliged to take in any family member who requests a place to stay. In this case the patient, who had a medical history of chronic lung disease and who was already quite frail, had taken in her cousin who was an un-medicated schizophrenic. The cousin was keeping the patient up all night and was causing disturbance in the household. However, the patient was not permitted, by custom, to ask her to leave. The GP in this instance is ill supported by social work bodies or metal health workers who may be able to arrange alternative accommodation, section the patient in order to medicate them etc, unlike the Scottish GP. They must respect that the patient is obliged to look after their family member and must try to accommodate this in their care of the patient.

Poor hygiene is of major significance in Aboriginal communities both in adults and children. One 5 year old girl evacuated during my stay with the complaint of tape worm was on investigation found also to have chronic otitis media in both ears and a Giardia infection in her bowel. Health care campaigns in these regions start as simply as posters in the clinic stating “Have a bath, you might enjoy it”. This seemingly condescending message highlights the basic level at which healthcare could be improved in these communities.

I was particularly struck by how different not only these communities were in terms of their culture and rituals but also by the health conditions faced by them. I saw one 9 year old girl in an aboriginal community who had rheumatic fever. It was quite shocking to learn that a now essentially 3rd world disease was presenting in a westernised country. Over my time in Australia, outwith medical practice, I was frequently affronted by the negative attitude towards aboriginals by Western Australians. This was an attitude I had not foreseen and it was unsettling. Many projects are now in place to “close the gap” of health inequalities between the two populations and many of the doctors, nurses and midwives were working very hard to achieve this. It seems however that this may be a bigger problem than individual projects can manage alone.

Despite what I have said, the doctors and nurses in the RFDS working with the aboriginal population held a very different opinion of their patients. They worked alongside communities appreciating their beliefs and cultures and did everything they could to treat them as best they could whilst respecting their wishes.

This proved difficult for one male GP who performed antenatal checks on a pregnant aboriginal woman 800k north of Port Augusta. The patient had gestational diabetes and the doctor therefore wished to deliver her by Caesarian section in the hospital in Port Augusta before her due date. Aboriginal women are very modest and will often not speak unless prompted. It is not unusual for them to keep their eyes lowered and not look males in the eye. Additionally, childbirth is considered “woman’s business” and traditionally they will leave the community to a sacred birthing site and return only when the baby is born. I was fascinated to witness the doctors ability to communicate effectively with the patient despite these barriers, to explain to her the issues in her pregnancy and to sensitively encourage her to deliver her baby in the hospital despite it being so far from her community. I was very honoured to be able to assist in the delivery of her baby on the last day of my placement.

Conclusion

The vast and varied aspects of life as an RFDS doctor mean a broad knowledge of medicine is essential, as well as a sound basis in emergency medicine. Furthermore, the social aspects of working with Aboriginal communities, with their differing customs and beliefs is an important part of the job. The trust the patient’s have for their RFDS doctor makes his job not only easier but worthwhile. The RFDS is an organisation which gains a huge amount of respect from not only its patient’s but also the media and the Australian population. It is a symbol of national pride, certainly not an accolade afforded to the average Scottish GP.!

Pros

• Witnessing a very different way of life
• Flying over the australian outback and seeing the scenery on a daily basis
• Having the privileged opportunity to be a trusted person in aboriginal communities
• Working alongside a close knit team of doctors, nurses and pilots

Cons

• Frustration at not having simple tests on hand in aboriginal communities
• Unpredictable hours
• Australia is not cheap anymore!

Details

Where / Port Augusta, Western Australia.

When / June-July

Weather / A wintry 20 degrees

Costs / Around £2000 all in for a months elective plus travel time

Necessaries / Walking boots and a good book for long flights back to clinic

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This summer I heard the tragic news that fourteen climbers were killed in an avalanche on July 12th on Mont Blanc. Roger Payne, amongst them, was a widely respected mountain guide and accomplished climber whose death shook the mountaineering community. Whilst working in Switzerland in the summer of 2009, I was lucky enough to learn from Roger first hand on a climbing trip that he guided. Of his many stories and anecdotes, his sagacious advice to ‘live life like a thrown knife,’ remains my favourite. His thirst for life and adventure was truly contagious.

Mountain Medicine Society of Nepal

Returning to the UK feeling inspired by Roger’s stories, I made contact with the Mountain Medicine Society of Nepal (MMSN) and had my first experience of Nepali friendliness. It came as a warm reply to my e-mail, from the secretary, offering assistance with my research project. Instead of politely explaining to them that I hadn’t really intended to do any research, the seed had been sown and idea for a project soon began to develop into a reality.

Following a series of emails and internet searches, I discovered that the burden of altitude-illness in the Himalayas is substantial, despite recent improvements in safety and knowledge in ‘Western trekkers.’ Every year around half a million religious pilgrims from Nepal, India and China also ascend to altitude sites scattered throughout the Himalayas. Unlike trekkers, awareness of altitude sickness is low, adversity is often favoured and turning back is not even considered! Pilgrims, seeking enlightenment, forgiveness or cure, are at great risk of suffering the progressive and life threatening forms of altitude illness.  In August, during the annual Hindu festival of Janaipurnima, around 20,000 determined pilgrims ascend to a high altitude ‘holy’ lake in the Langtang region of the Nepalese Himalaya.  This pilgrimage and its pilgrims would form the basis for my research. I set out to study the unique risk factors for altitude-illness in this highly susceptible population.

Kathmandu

After months of planning I arrived in Kathmandu, Nepal’s capital city. The taxi ride from the airport was a wholly disorientating experience. The smells and choking fumes, the deafening Suzuki’s car horns and the cows lying in the middle of the frantic, potholed road took me by surprise. For some reason, despite all my planning, I hadn’t prepared myself for any of this.

With ten weeks before the festival began, I had some time to explore. I got my first glimpse of the mountains on a trek in the Annapurna mountain-range. With eight out of the ten largest mountains in the world tucked within its borders, Nepal has some of the most beautiful and dramatic scenery imaginable.  Unwilling to leave the hills, I spent a fortnight in a community hospital, where I got my first experience of obstetrics and surgery . Soon after, on a kayaking trip on the monsoon flooded Trisuli  river, I found myself hitching back over the mountain pass to Kathmandu with my guide, sat in our kayaks on the roof a lorry. It wasn’t your average journey! Once back in the capital I began work in the Kathmandu Model hospital. The department I worked with travelled to remote areas in Nepal to run fortnightly surgical camps, setting up temporary operating theatres.

Village Life

After a month, I escaped from the city to a small village north of the Kathmandu valley. I stayed with a very hospitable Nepali family and I helped out at the local Health Point having a more authentic Nepali experience.  Without any trained medical staff present there I tried my best to help, but often struggled with my limited knowledge of the Nepali language.  In the afternoons, I visited the local secondary school where amongst other topics I was asked by an embarrassed head-teacher to teach sex education. One of the classes ended in a disaster, when a student drew the male sex-organs on the white-board unwittingly with a permanent marker pen. As amusing as his drawing was, it was a little awkward explaining this to the head-teacher.  After a few weeks I was incredibly reluctant to leave this village where I had been so welcomed, but departed with two Nepali medical-students  to the north of Nepal to begin my research.

The Research

The dirt road that winds its way along precarious cliff edges towards the start of the trail was a little unnerving. The abundance of abandoned, dilapidated buses at the valley bottom served as a reminder of the hazards of this journey. Sat on the roof of the overcrowded bus as it rocked from side to side, I managed to convince myself I was in the ideal position to jump off should I need to. The relentless monsoon rain that falls on Nepal during the summer months means a number of landslides annually dissect this road and require a crossing by foot.

After just ten days at altitude we were able to complete the study successfully and collated data obtained from 170 of the pilgrims. This data nearly perished as a co-investigator accidently knocked his rucksack off the edge of the path- which then tumbled down the hillside. Covered nearly head to toe in leeches, we eventually recovered the rucksack with the kind help of the locals. The subsequent bus journey back towards the capital city continued late into the night. The road had disintegrated under the tracks of the countless buses during the festival period, but fortunately the darkness concealed the exposure and helped ease the sense of impending doom.

The return flight to the UK was a memorable one; not least because of the awesome views of the Himalayan peaks finally offered as we climbed above the monsoon clouds. For the past few months, I had become totally absorbed in the life I had in Nepal; I was returning to what seemed like a strangely ‘foreign’ home. I found myself reluctant to be leaving behind all the negotiating, the laughter and the daily adventures Nepal had provided.

There and back again

As I settled back into my medical rotations it didn’t take long before I began to feel restless and start to think what I could do next. I knew a team based at University of British Columbia, Vancouver, who had also worked at this festival previously. After making contact, we began working to develop a protocol for a large-scale longitudinal study. We sought to collect enough genetic data for a Genome Wide Association Scan for altitude sickness. I also considered the use of ultrasound to detect cerebral oedema and so liaised with an Emergency Ultrasound Department in Boston, Massachusetts to include an ultrasound study as part of the project.

Before I knew it I was leaving the UK again for my senior elective. First in Boston, I collected the ultrasound probe and received training on its use from the A&E department at Massachusetts  General Hospital. To my dismay the device began malfunctioning. With little time before the festival I eventually managed to fix the problem with a tenuous DIY ultrasound repair.

Arriving in Kathmandu, we discovered that ethical approval had somehow still not been processed. To complicate matters the entire team were, for some reason, unable to withdraw money and the local Health Board was now refusing permission for us to continue with the research plans. After three days of countless taxi-rides, official meetings and cups of dubious sugary-tea, we were fortunately given the official stamp-of-approval. We met with the two Nepali doctors and two medical students from the Mountain Medicine Society of Nepal (MMSN) who would be helping us with the study and we were finally ready to begin our research.

We had organised jeep transport this time, but still found ourselves crossing a worrying  landslide by foot. After a series of near misses with the constant rock fall, we were relieved to make it across in one piece.  Four members of the team were based at the start of the trail and five of us based at the lake at 4380m. We provided roti and other snacks to entice volunteers and a large poster made by locals drew more attention to our base. The poster needed some prompt alteration as it initially read “free poison”! The days were long, starting at 04:30 and busy usually until 23:00. We collected demographic information, buccal genetic samples, baseline balance information, heart-rate, blood haemoglobin and oxygen saturation and finally exhaled carbon monoxide and nitrous oxide.  At high camp we worked along-side the Himalayan-Rescue-Association who run a temporary health camp during the festival. We collected altitude illness information, saliva genetic samples, ultrasound scans, balance (ataxia data), heart-rate and oxygen saturations.

A further translation error nearly landed me in bother when I was advised by an amused porter that my pronunciation of the Nepali word for bracelet was in actual fact the word for vagina! My attempts to find our identifying red bracelets for follow ups were soon halted and he kindly offered to take over from there on.

Additional members of our research team joined us at the lake for the busiest night of the festival to provide extra help in all the chaos. Amongst the pandemonium of sick pilgrims who arrive in their masses, there are very scant toilet facilities, limited accommodation, monsoon rain and of course a festival of music, alcohol and dance. Eight of us shared a double-bed sized room and on the busiest day I spent the night in the health camp hoping to examine sick pilgrims with the ultrasound. Once again the research was a great success. In all, we managed to collect longitudinal data on 567 pilgrims (95% of those recruited by the low altitude team!) and a further 96 sick pilgrims at the lake.

During the festival period I also gained great experience of wilderness medicine, where resources were minimal. I remember my alarm as a lady sat conscious with an oxygen saturation of 29%; the lady lying next to her with severe pneumonia was in greater need of the oxygen at that time! Patients sometimes required urgent evacuation down the mountain; which would involve being carried on the back of a porter, along with an oxygen cylinder, often in the middle of the night. It was a horrible reminder that unlike trekkers, these pilgrims could not afford the insurance needed for helicopter rescue and as such death was a distinct possibility.

Final words

Shortly after returning home to the UK I was admitted to hospital and treated for Typhoid fever. Nepal has made its mark on me; I have also had Giardia, food poisoning and a lot of diarrhoea; but aside from all that, I have experienced some of challenges of field research, I’ve been awed by the mountains and humbled by the generosity and kindness of the people. In many ways this has been pilgrimage of my own during my medical school years. In the niche world of altitude illness research and expedition medicine, I have experienced a sense of responsibility, purpose and adventure that has shaped my future ambitions. It is strange now, to think, how much resulted from the kindness and slight misunderstanding of that first email. There is a famous Nepali saying ‘khe garne?’ which translates as ‘what is there to do?’ Well in my opinion Roger saying covered it pretty well in his words ‘live life like a thrown knife’.

Details

Destination / Nepal
Time of Year / June- August
Weather / Monsoon season, plenty of rain and clouds, but mountain tops can still be seen early in the mornings!
Religion / Hinduism and Buddhism
Money Spent / Flights roughly £500. Daily living costs will vary (approx. £5-10)
Vaccinations / Hep A, Hep B, TB, Rabies, Typhoid, Japanese Encephalitis (optional)
First Aid Kit / Alcohol gel, Rehydration Sachets, Antibiotics, Paracetamol

Positives / Diversity of scenery and landscape; Potential for adventure with outdoor pursuits; Cheap living costs

Negatives / Things often don’t go to plan- be prepared to be flexible; The clouds, leeches and landslides might worry some, but remember the monsoon scares away most tourists and makes for a more authentic experience of Nepal

Placements can be arranged very easily once you have arrived in Nepal if things don’t work out as originally planned. Bear in mind that as you move to a smaller and more rural setting less English is spoken, but there is often more scope to get hands on experience. It is a great experience to spend some time living with a Nepali family but it can feel a little restrictive if for a long time. A water filter is a great alternative to chemical treatment. Finally make sure to google ‘Himalayan Hash Harriers’ before you leave- this is a must do for anyone – runner or not!

I am hugely grateful for the support and help I have received during these projects both in Glasgow, Boston, Vancouver and Nepal and to the organisations that provided me with essential funding and research equipment.

The post Altitude Elective in Nepal appeared first on Adventure Medic.

Malawi is frequently referred to as the ‘warm heart of Africa’ and with good reason. The local people are friendly, open and very welcoming to all who visit. ‘From Mzungo to Rafiki’ means ‘From Foreigner to Friend’ and that was absolutely how it felt. In addition to being a great place for the novice African traveller, it also has many draws for the medical student.

I spent my elective at Kamuzu Hospital in Lilongwe. The hospital was split into four main departments: adult female, adult male, paediatrics and obstetrics & gynaecology.

Healthcare in Malawi

The healthcare system in Malawi is completely different to the UK. Resources are limited, funds are lacking and the staff members are stretched. There are approximately two physicians per 100,000 population and so the hospitals can be a little overwhelming.

My first day was spent in awe of the queues of hundreds of people all over the hospital. Once over this initial shock however, the big numbers became a positive learning experience, as I honed my skills in a more highly-pressured environment than anything I will be likely to experience in the UK. This is an exceptionally valuable and transferable skill for my future career.

Over half of Malawi’s 13 million inhabitants are under the age of fifteen. This was a great incentive to an aspiring paediatrician. I was able to gain plenty of experience and practice my clinical skills in a very busy department, including many resuscitations, which are thankfully rare in the UK. These experiences were fraught, scary and often frustrating, but also incredibly useful to develop my confidence and abilities in such life-threatening scenarios.

The acceptance of death, especially of children, felt quite shocking to me and in addition, many of the deaths felt preventable. My eyes were openned to the alarming poverty and illness in Malawi and we from the UK felt lucky in comparison.

The experience

Despite these harsh realities, the positive experiences far outweighed any negatives. There was the chance to gain a wealth of knowledge of tropical diseases, as well as improved confidence in my own abilities and decision-making skills. Teaching opportunities were plentiful, as many of the Malawian medical students were keen to learn from us. We worked in hugely diverse teams, made friends along the way and learnt how to cope when the chips were down.

I loved my elective and have since found even the moments of frustration to be of use, as I practice to be a doctor. Malawi was a great place to explore, with stunning scenery, super-friendly locals and a unique vibrant atmosphere. I would thoroughly recommend it to any medical student embarking on their own elective journey.

The details

Destination / Kamuzu Central Hospital, Lilongwe

Time of Year / January – March

Weather / Warm but rainy (a mixture of waterproofs and shorts recommended)

Religion / 80% Christian. 15% Muslim Shoulders and knees should be covered

Money Spent / Approximately £100 per week

Vaccinations / Hepatitis A, Typhoid, Tetanus, Hepatitis B. Consider Rabies, Cholera, Yellow fever.

First Aid Essentials / Malaria prophylaxis, PEP, mosquito net, anti-bug spray (Avon Skin So Soft)

Tips

Kamuzu is a general hospital. More specialised experience can be found at the tertiary-level Blantyre hospital in the south.

Contact staff before you visit to find out about any resources you may be able to bring over for them from the UK. Things like a box of gloves, alcohol gel and NG tubes can go a long way.

Travelling in a group can be beneficial, as on the wards it can be a little overwhelming. Having the support of another student greatly impacts upon your experience and helps you to be more involved.

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