Hannah Evans / Adventure Medic Staff Writer
Kilimanjaro is a frequent destination for expedition doctors, especially early in their career. Yet despite its accessibility, it has the highest absolute number of deaths of any mountain. Kili is a great first expedition, but it is important to keep yourself right. Our own in-house Kilimanjaro expert, Hannah Evans, gives us her insights for a successful trip. (Photos: Matt Wilkes)
Kilimanjaro is the highest freestanding mountain in the world and the highest on the African continent, with its Kibo summit lying at 5895 metres above sea level. Summiting can be a tough physical and psychological undertaking and the trek’s popularity has been fuelled in recent years following the Comic Relief Celebrity Climb in 2009. Kilimanjaro has fast become one of the ultimate ‘charity challenges’.
For some event companies, the various routes up Kilimanjaro are the mainstay of their business, and so the demand for medics for these trips can be high. It can be climbed in seven days, or a more altitude sickness-prone four. Being the trip doctor is a commitment from pre-departure medical assessment forms to post-expedition advice and all that runs between.
This guide will hopefully serve as a useful preparatory aid for the trip medic.
Before you take any trip on – look broadly at the reputation of the company (TripAdvisor can be good here), the proposed group size and age-range and any arrangements already made for logistics. Most importantly, look at the altitude profile of the proposed route and make sure that you feel it is appropriate for the group.
Ask specifically about the the care of your porters. These guys often have a very hard time on Kilimanjaro – ascending ill-equipped and with heavy loads. Make sure the company is serious about porter wellbeing, and have a look at the IPPG Guidelines on Ethical Trekking if you need something to refer to. Think about treating porters as well as participants when putting together your medical kit.
I cannot stress strongly enough: gain as much knowledge about any health issues arising from the medical evaluation forms of the participants as possible. Trekkers may be evasive about medical problems as they often think that being truthful will preclude them from going on the trip. Reassure them that you are there to help them achieve their goals, but they need to be honest with you.
Pre-departure planning, including contingency planning, will prove invaluable on the mountain. Research at home will allow you to check drug interactions, take any extra medications for chronic conditions which crop up on the forms, as well as being able to talk to specialists in good time before departure if required. Remember that a lot of expedition companies employing doctors have little or no medical training and so their support pre-departure is imperative to a successful trip. They should be considerate of your pre-departure responsibility and willing to help out with any problems. Be prepared to walk away if the company will not let you do your job.
Ensure there is and you are familiar with a thorough evacuation plan with contact numbers and protocols in place before leaving for the mountain in country for each different point you are passing. Put numbers into your mobile and ideally bring a battery charging device for your phone. Evacuations can be delayed by weather, helicopter availability and terrain condition. In most areas, evacuation by road or Kili-taxi (a two-wheeled stretcher manned by porters) is feasible.
Lastly, it is easy in the thick of preparing others for the mountain, to forget about yourself. Ensure your vaccines are up-to-date and you have antimalarial prophylaxis, as well as a small medical kit for yourself separate from the general supplies.
The First Few Days
Once in country, my first piece of advice is still to look after yourself. You are not superhuman, despite what many will think! A successful trip is reliant on a healthy, rested doctor – you will need some downtime – remember to take it! Remember especially in the higher camps that being the doctor can be intense with constant requests for reviews and reassurance.
Having some basic local knowledge will help, as questions from the participants will start at the airport. Knowing a little about the flight, hotel, camp facilities and trek itinerary will come in handy. Having a UK contact, preferably with knowledge of altitude medicine and of a Consultant/GP grade is very useful, and often a condition of indemnity for some defense unions.
Most flights from the UK, approach Kilimanjaro Airport via a transit in Nairobi. A good tip is to try and sit on the left side of the plane from Nairobi to Kilimanjaro as the flight’s cruising altitude is usually around the same as Kibo summit providing brilliant views, weather permitting.
Before departing from the hotel to the mountain, you should unpack and repack your medical kit, especially if it is unfamiliar to you, to check you still have all the kit you need and that it is to hand when required. If travelling with a local company providing oxygen cylinders and IV fluids for example, you should ask to check these in good time before departure. Ensure that any camp managers/trek leaders know how to connect and administer the oxygen safely – I tend to watch them do this for extra piece of mind. Be sure that tanks are full, safety checked and that fluids are in date and the sterile packets unopened.
Giving the initial medical briefing can be daunting and covering everything is not always easy or necessary. Remember that as a general rule, people retain about 30% of the information they are told and so repetition and putting advice into context is useful during the trek.
I emphasise personal hygiene, especially when in a big group using the same toileting facilities. Alcohol hand gel is vital to avoiding the spread of disease, but I always state that it doesn’t replace thorough handwashing at camp or when available.
Diarrhoea can happen as a result of a change in diet, but could obviously be infective in origin and a concern. Replacing loses in a timely way can mean the difference between being able to continue and having to descend. Preventing spread is key with scrupulous hand hygiene and awareness about sharing around camp. Loperamide should be used sparingly where possible.
Constipation can occur on the mountain, as can increased flatus!
I mention briefly that alcohol on the mountain is not a wise idea, neither is the use of sleeping tablets.
I take time to try to normalise the physiological changes due to altitude in the minds of the participants. Tell them to expect an increased heart rate, respiratory rate and becoming a little more short of breath on exertion. Swelling of peripheries and face can also be normal at altitude, especially in the mornings.
If there is one piece of advice that seasoned local leaders will give is to maintain adequate hydration. There are many different figures suggested with regards to volume intake, but my advice is to drink as much as it takes to keep the urine clear. This usually equates to between 3-5 litres per day.
Aches and pains are inevitable especially to those not so used to physical exertion or with pre-existing bone or joint problems. Self-treating with simple analgesics is a good starting point, and I always encourage participants to bring an adequate supply. NSAID gels are also handy to have in personal medical kits.
Simple falls can mean the end of the trip. I always mention taking care when placing feet on unsteady ground. Despite being common sense, this may help prevent a fall. Many will not have used trekking poles before, and explaining how to size them up can be helpful.
It is surprising how many participants forget or don’t bring a sufficient supply of their normal medications so it’s useful to discuss this pre-departure and then again before you leave the vicinity of a pharmacy! Continuing antimalarials as prescribed is important despite the lack of mosquitoes on the mountain.
There tends to be reams of questions about Acetazolamide at this point, no matter how well it has been explained before. Some individuals may have been prescribed differing doses and preparations. I usually advise 125-250mg bd for prophylaxis, starting 48 hours before being exposed to altitudes over 2500m and taking a test dose before departure from the UK to check for adverse reactions to sulphur. I discuss the main side effects of diuresis, metallic tasting carbonated drinks and tingly fingers and toes. Two practical points to recommend are to avoid taking the evening dose late at night to minimise nocturia and to take acetazolamide with food to minimise GI side effects.
The strength of the sun can be deceptive and so I advise at least factor 30 sunscreen, even at higher altitudes where the ambient temperature is lower. Inform the trekkers not to forget more sensitive skin such as lips, noses and ears.
If you demonstrate how to self-treat blisters with zinc oxide tape or Compeed-type dressings at the briefing, then you can make sure everyone can do this effectively. I always stress that making sure ‘hot spots’ are dressed before they become blisters is crucial to staying comfortable whilst walking.
Lastly and by no means least, I broach the subject of emotional wellbeing during the trip. Often, sponsored trips are highly emotional. Normalise feeling tearful and overwhelmed and suggest taking time to reflect on their day. In large groups, establishing a buddy system can be very helpful.
Generally, trekkers will approach you as and when problems occur, however having a ‘clinic’ arrangement where individuals can come to a designated tent for a chat or to ask something can work well.
Dust-laden air can cause coughs and so protecting the nose and mouth in particularly dusty areas can help prevent this. Snoods and scarfs will help too.
I inform and show the participants where my tent is before retiring each night in case of any emergencies overnight.
During higher camp briefings, I stress the importance of maintaining good food and fluid intake. Most people will feel less inclined to eat with increasing altitude and so I encourage them to eat a lot of foods that appeal to them.
I make sure those who are on Acetazolamide continue to take it, and consider starting it in those who have very mild symptoms related to altitude. The weather will become cooler with increased altitude and layering clothes and protecting extremities becomes more important.
There is a fantastic Adventure Medic overview of this topic and further reading can be found in the Wilderness Medical Society’s Consensus Guidelines for the Prevention and Treatment of Acute Altitude Illness.
I tend to advise that AMS symptoms include headache plus lethargy, nausea, poor sleep and poor appetite. If they experience these symptoms, I advise them to rest, to drink at least 1000mls of fluid preferably with a sachet of oral rehydration salts, to take paracetamol and ibuprofen too if needed and to eat something. Keeping you informed of these symptoms should be firmly encouraged.
Extensive knowledge about AMS, HACE and HAPE is crucial for a successful trip. Giving the participants enough information without making them too fearful is important so I tend to leave this topic for the first or second night’s briefing.
The summit night is challenging, even for the medic. Depending on your route up, it involves a late night or early morning start with many hours spent trekking in the moonlight and often sub-zero temperatures.
A SLOW, steady pace here is crucial. Wearing plenty of layers at first is important, paying close attention to hands and feet – hand warmers are useful here. Leaders will often unknowingly increase the pace as they are in general more used to altitude and often fitter than the trekkers. Stay firm with keeping a slow pace – this undoubtedly reduces the chances of significant altitude related illness.
Generally the medic will be faced with hypothermia, nausea, headaches, exhaustion and waning motivation, and the participants will want advice and treatment regarding these too. Be mindful that hypothermia and hypoglycaemia can produce similar neurological symptoms to HACE. Encourage regular short breaks instead of longer ones. This allows everyone to drink, have a snack, readjust layers and keep you updated with any new symptoms.
Emphasise that it is your job to support people in reaching their own safest highest point. Be firm that you will make decisions based on your clinical judgment with regards to who should continue or go down and that this is non-negotiable.
Warn trekkers that fluid in hoser-type/Camelbak water devices can freeze, so they should blow the fluid back into the reservoir after every use to help avoid being stuck without water. Another top tip is to put flavouring/electrolyte tablets into the juice, which slightly reduces its freezing point.
Back down the mountain
Some participants will not disclose potentially serious symptoms in order to summit. There is no getting around this, no matter how good a rapport you develop with the group. Symptoms may be disclosed on the early descent and it is important to bare this in mind given that the altimeter reading is still high in the first few hours. Keep in close radio contact with other leaders and reaffirm the messages of good hydration and regular snacks at the summit for the journey down.
It is important to communicate any significant illnesses or injuries with the GP on return to the UK, including any follow up you would like them to have or advice you have provided.
Remind participants to keep taking their malaria prophylaxis as instructed on return and to have a low threshold for suspecting malaria with any significant febrile illnesses they have in the next 18 months. Any antibiotics started on trek should be continued and the course completed.
What should you tell them to bring? / Ibuprofen (gel and oral); Paracetamol; Own prescribed medicines; Compeed/zinc oxide tape ; Anti-itch/bite cream; Antimalarial tablets; Glucose sweets; Oral rehydration salts; Diamox (Acetezolamide); Muscle rub/deep heat; Alcohol gel; Suncream; Lip balm; Loperamide
What do I keep in my daypack? / Analgesia; Antiemetics; Tiger balm; Plasters; Bandage; Spare gloves; Anti itch / bite cream; Blister kit; Glucose sweets; Oral rehydration salts; SpO2 monitor; Stethoscope
What should you cover at the briefing? / Intro – who you are, day job, role on trek; Altitude physiology – brief intro; Symptoms of altitude; Honesty – with leader/medic and yourself; Periodic breathing; Buddy System – pair up and look out for one another; Fluid intake; No sleeping aids – alcohol/hypnotics on mountain; Hygiene – alcohol gel; D&V – what to do if this happens; Swelling; Aches and pains; Blisters and how to treat/prevent; Sunburn and how to avoid it; Diamox; Clinic system; Any changes since med forms?