News & Features — 31 July 2017 at 8:27 pm

Coming Down from On High

Sophie Wallace / Registrar in Emergency Medicine and Expedition Doctor

On 18 April 2014, 16 Sherpas were killed in an avalanche on Everest. Doctor Sophie Wallace was at Basecamp during the disaster and wrote movingly of the accident and of the days that followed. In this article, Sophie reflects on returning to Everest and on the psychological aspects of returning from the intensity of expedition life.

The arrival home after a long expedition is often thought about during the time away; the reunion with friends and family, the return to creature comforts, en-suite bathrooms, your old clothes.  How about the food you have been thinking about the whole time you were away?  Not to mention the fitness you’ve gained if you’ve been up mountains or trekking through jungles.  But what if coming home isn’t all you thought it would be?

The life of the expedition doctor while away on a long trip is fairly unique in many ways.  The patients are your friends and team mates.  The medical tent is right next to your sleeping tent.  You don’t get to go home and switch off and your patients are actually clients, with different expectations to your average hospital or medical practice clinical encounters.  They have invested huge amounts personally, physically and financially to be there.  Perhaps they have confided in you their hopes and dreams for their expedition?  What’s their motivation?  Maybe it is the child they lost, or the lifelong dream they have been aiming for if they could just get the planets to align so they can leave their life behind for a few months.  Maybe they have been saving every penny for a decade in order to come, and your job is to not only keep them healthy enough to realise that dream but to alleviate their fears as well as their ailments.

Returning from my second Everest expedition, and fifth Himalayan trip in June this year, I was having difficulty explaining the uneasy feeling I had returning home.  An expedition that was my first back in that environment after the 2014 disaster that killed 16 Sherpas.  I was looking forward to several meals out in Perth, to seeing my friends, to wearing clothes that didn’t come from an outdoor store and to sharing stories from the trip.  So why didn’t I feel ready to see everyone?

“Tell us everything!”

Deep down I knew that I wasn’t ready to meet the expectations of those who hadn’t been there.  The expectation that you can summarise all of the ups and downs of a ten week expedition into a few anecdotes over dinner and wine, so that your nearest and dearest can feel that they understand the world you have just been living in.  Faced with questions like “What was it like?  I want to hear everything, from start to finish!” seemed invasive and sometimes overwhelming.  Why I felt like this I can’t really explain, especially given the fact that 2017 was, comparatively, a hugely successful season.  Records were set, large numbers of people made successful summits and for the first time in many years not a single Sherpa was killed on the mountain.  After dealing with 16 deaths from the Sherpa teams in April 2014 (my last time on the mountain), some of whom were known to me, this fact alone was a particularly personal relief.

Despite the overall success of the season this year, inevitably deaths occurred on the mountain and needed to be dealt with. The tragic death of record-holding and highly respected climber Ueli Steck just one week after I was sitting next to him at dinner, and the frustratingly and seemingly avoidable deaths of climbers above the South Col were brutally real, close to home and, for our team, events some of them were personally involved in and needed debriefing from.  Discussing the emotions and answering questions of team members who have been involved in the same traumatic incidents as you can be an unexpected drain.  One needs to be able to be detached from one’s own emotions about the experience to be an impartial supporter and adviser to patients and clients, who will have had a very different experience of the same incident.  Everyone has their own black-box recording. In 2014 especially, making sure the team was okay required more of a mental disconnect that I had been capable of before or since.

Debriefing and Decompression

The military have thoroughly embraced the concept of debriefing-after-deployment, after a number of high-profile suicides and a high incidence of post-traumatic stress disorder (PTSD) in returning soldiers.  Strategies adopted include third location decompression, used by many of the NATO partners including Australia, Canada, the Netherlands and the UK, to prepare for the transition home.  Perhaps a similar approach can be recommended in expedition medicine, minimising risk for many of our climbers who choose to fly directly out of basecamp immediately after summiting Everest? The three-day walk out of basecamp can sometimes be an excellent decompression phase, speaking from first-hand experience.

All of the above partners used a preventative mental healthcare model throughout all stages of deployment in recent tours of Afghanistan, including the fact that for the frequently deployed, post-deployment debriefing often becomes pre-deployment debriefing before their next trip and therefore focus has shifted towards the complete chain of mental health support.  This includes: decompression (stage 4) and post-deployment mental health support at home (stage 5), as well as readiness training (stage 1), stress inoculation training (stage 2) and any necessary interventions immediately after a potentially traumatic incident (stage 3).  The third-location decompression stage for these organisations is a non-combat area and usually 1-3 days after finishing their tour, and post-deployment debriefing and screening occurs in the three-to-six month period after returning home.

There has been a shift away from an immediate single-session debriefing and towards an operational debrief session and a watchful waiting model, enabling the natural recovery process and accepting normal stress reactions to an abnormal event.  Ensuring the individual can be supported through their stress reaction, reassured that their reactions are expected responses to a traumatic event, and encouraged to seek help is vital.  Some partners even deploy a full mental health team routinely, and some sent out a full mental health team after major critical incidents.

Lessons for Expeditions

Extrapolating this to the expedition world, the expedition doctor would only usually be present during stages 3 and 4, with a responsibility to be aware of the need for stage 5, and may be asked to facilitate screening and referral for those deemed to be high risk.  With stages 1 and 2, we rely on the client to be responsible for their readiness prior to choosing to enter the potentially dangerous environment, and on the expedition organisations to have a responsible selection criteria for their clients before accepting them onto a potentially dangerous expedition, no matter how tempting their money is.

There has also recently been a lot of focus on the welfare of emergency services and medical staff, and rightly so.  In Australia currently the support of staff is being closely analysed after several suicides of young doctors, and every suicide of a paramedic (a depressingly frequent occurrence) also raises the same questions about self-care and how to look after oneself in a stressful job, but places the onus on the individual not the system.  And in the UK there will be a huge focus on critical incident stress debriefings for the staff involved in the Manchester and London terror attacks, and the Grenfell fire.  But it’s not just the military and emergency services who are affected by this.  The incidence of PTSD in mountaineers has also been reported at around 3%.  Perhaps this is lower than might be expected given the nature of accidents that they are likely to have witnessed over a climbing career, but still a significant number, with the potential for long term psychological morbidity and the associated impact on families and careers.

One of the responsibilities of the expedition doctor is to ensure the psychological wellbeing of your team during the expedition and anticipate problems on returning home.  The expedition leaders and guides are likely to be in an even higher-risk group given their responsibility for the overall running of the trip and their huge lack of personal time and space.  Time and space to deal with their own experience of events, in many of which they will have had a leadership and decision-making role.  Pre-departure you will have prepared your medical kit and brushed-up on your clinical knowledge, but honestly how many people just look at the physical aspects of their job and neglect the expedition psychology?  We don’t receive training in psychological screening, psychological education and “decompression” – tools used in the post-deployment phase.  So now you have a role in predicting the welfare of your team once they return, to mitigate risk for them in future in an area we are not usually trained in, and you need to try and look after yourself in the meantime.

Debriefing the Debriefer

So who debriefs the debriefer?  And how does one then leave an expedition and return immediately to the parallel universe we call “normal life” if there are still things left to process?  Returning home from time in a developing country can sometimes make familiar things feel alien, and previously important things feel incredibly trivial and superficial, albeit usually for a temporary period.   It’s easy to make the assumption that because we choose to go to these places, and most of the time it’s fun and “looks amazing!” that returning home is going to be easy. But it is more than just the “post holiday blues”.

The experiences that life as an expedition doctor bring are immeasurable in value, not only to you as a medical professional but also as an individual. The skills you develop out in the field, both clinical and non-clinical, will enhance your performance in hospital medicine or primary care undoubtedly. In order to maximise the benefits of your experience don’t underestimate the need for a psychological convalescence period after a long time immersed in a highly strung and emotive environment.  Especially when that environment is associated with personal trauma or the responsibility of you, as the doctor, to alleviate someone else’s.

So what are my tips for returning after an expedition like this?

Protect your own time and space / There will be a flurry of people wanting your time and your anecdotes.  You can say no.

Anticipate an adjustment reaction on returning home and prepare for it / Don’t expect to be able to return immediately into the same pace of life you were managing in before and don’t bury your head in the sand if you find it hard.

Write about your experiences / This can be for your own personal reflection, for your friends and family or for a much wider audience.  This can be a big help in processing the events of your expedition.

Don’t rush to get back into the next one / It can be very tempting to plan to leave for another trip as soon as possible because that world was so enjoyable.  Work out where your real life is and look after your relationship with those in it so you leave again for the right reasons.

Use your support team while you are away / They may not be physically present but a supportive email back can be a huge help when you may feel quite isolated and overwhelmed with the responsibility of looking after your team AND yourself.

Further Reading

Vermetten E, Greenberg N, Boeschoten MA, Delahaije R, Jetly R, Castro CA, McFarlane AC. Deployment-related mental health support: comparative analysis of NATO and allied ISAF partners. Eur J Psychotraumatol. 2014 Aug 14;5.

Qi W, Gevonden M, Shalev A. Prevention of Post-Traumatic Stress Disorder After Trauma: Current Evidence and Future Directions.Curr Psychiatry Rep. 2016 Feb;18(2):20.

Editor’s note: this article touches on aspects of life and medicine that are sometimes controversial and often very emotive. If you are feeling overwhelmed following an expedition, please seek help from a specialist or your doctor.