Core Skills — 25 February 2022 at 12:58 pm

Life off the Beaten Track; Expedition Medicine for Paramedics

Chris Hewett / Paramedic Team Leader / South Western Ambulance

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

Practising tracking in the Gobi Desert

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

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

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

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

What level of supervision did I need?

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

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

Would my status be recognised internationally?

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

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

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

Annapurna Base Camp

What indemnity cover did I need?

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

What equipment would I require?

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

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

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

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

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

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

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

What about drugs?

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

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

Ultramarathon athlete footcare in Sierra Leone

Do I need any additional training or skills?

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

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

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

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

Would my boss approve the trip?

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

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

Preparation is key

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

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

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

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

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

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

The day job

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

You can follow him on Twitter and connect on LinkedIn.