Marika Davies / Medicolegal Adviser at the Medical Protection Society
The offer of a free place on an expedition to an exotic location is a great opportunity to use your medical skills in a new and challenging environment. But working in a remote and unfamiliar location without the diagnostic tools or support systems you usually take for granted means you have to ensure you are the right person for the job and are adequately prepared.
At Adventure Medic, we are often asked about indemnity and the legal aspects of expedition medicine. Ever at your service, we put some of your questions to Marika Davies, Medicolegal Adviser at the Medical Protection Society, to try to set your minds at ease.
Dr A was employed by an adventure travel company as expedition medic for a team of British climbers attempting to ascend Mount Everest. As part of her preparations she advised her defence organisation (MPS) of her plans prior to her departure.
On the ascent the team came across a climber in another team, experiencing difficulty. He was complaining of a 24 hour history of headache, nausea and dizziness. Since there was no other medic present Dr A assessed the climber, diagnosed altitude sickness and advised him to descend. The climber and his team did not take this advice. The next morning the climber was unable to be roused from sleep and was evacuated by helicopter. He died several days later.
Back home in the UK, Dr A was asked by the Coroner to provide a report for the purposes of an inquest into the death of the climber. She contacted her defence organisation and was assisted in preparing a full and factual account of her involvement.
Some time later Dr A was surprised to be contacted by solicitors acting for the family of the deceased, who advised her that a claim was to be brought against her and the climber’s travel company. Although Dr A had thought she was indemnified by the adventure travel company who had employed her, they declined to assist as the claim arose from the treatment of an individual who was not on the expedition team. Dr A contacted her defence organisation again and was provided with all necessary legal assistance, and the claim against her was discontinued.
Before you go
Before accepting an appointment, agree with the expedition organisers what will be expected of you and ensure you have the appropriate skills and experience to take on the role of medic to this particular expedition.
A medical officer’s usual responsibilities include the clinical care of the expedition team, risk assessments, preparing medical kits and equipment, prescribing medicine and arranging evacuation where necessary. What makes expedition medicine so challenging is the extreme autonomy you have as the only available medical opinion, with no support, second opinion or specialist to easily call upon. Essential qualities of the team medic include good decision-making skills, communication skills and self-reliance.
Pre-expedition planning is carried out in order to avoid – or to be ready for – adverse events. This includes assessing the team and the environment in which you will be working.
Asking team members to complete a health questionnaire and a consultation with you before you leave should uncover pre-existing medical conditions and allow you to record drug histories, allergies, immunisations, anti-malarials and personal medical kits. The absence of crucial medical information can hamper the correct diagnosis and management in already difficult circumstances. If necessary you should seek fuller details from the GP, with consent. It is helpful to ensure team members are aware of the limitations to the care that can be provided. Consider also giving members of the team basic training in first aid.
It is essential to understand the environment in which you will be working, as different locations present their own unique risks and challenges. Ensure you know how to manage the particular medical conditions you may encounter in the environment. Be aware of what medical facilities will be available should they be needed, what support there will be, and how you will make contact with that support in an emergency. Consider medical evacuation services, changing weather conditions, and language difficulties. Where appropriate liaise with local emergency medical services in advance, and make sure you are satisfied with the expedition company’s risk assessment.
Most importantly, speak to your professional indemnity organisation in order to establish you have adequate and appropriate indemnity in place. As an expedition medic you are responsible for the care you provide and potentially liable if it is found to be inadequate or incorrect, causing harm. It is not enough for the team members to have personal injury insurance – their insurer can pursue a claim against you if it can be shown that you failed in your duty of care.
The legal position of an expedition doctor may change depending on whether he or she is contracted or directly employed by the organisers, but whatever the contractual situation you should always have your own professional indemnity cover. Check the jurisdiction clause of your contract to ensure that it will be interpreted in accordance with the laws of the UK, and if unsure speak to your professional defence organisation.
You should also be registered as a medical practitioner in the country in which you will be working. Details of relevant regulatory bodies can be found on the GMC’s website.
Good Samaritan Acts
In common with other defence unions, all MPS members can apply for an indemnity for Good Samaritan acts worldwide. However, if you have agreed to take part in an expedition as the medical officer, even if you are not being paid for your services, this would not constitute a ‘Good Samaritan act’ should an incident arise. Indemnity for Good Samaritan acts would only apply if you were on an expedition as a lay person and a genuine and unexpected emergency arose which required you to exercise your medical skills.
Claims under US and Canadian law
Due to the very high cost of litigation and the level of awards, indemnity does not extend to negligence claims arising in the USA or Canada. If there are American or Canadian nationals in your party then appropriate indemnity must be provided by the expedition organisers. If proceedings are brought in the US or Canada it is unlikely that your defence organisation will provide indemnity, unless it is for a Good Samaritan act. Likewise, MPS does not normally provide indemnity for expeditions in the US, Canada or Australia, but MPS members may apply for an extension of benefits if travelling with a UK party to these countries and treating only British expedition members.
A doctor cannot rely upon a disclaimer to avoid liability. Even if the expedition company uses such disclaimers the doctor should still ensure they have adequate and appropriate indemnity cover.
A small amount of medication may be taken into most countries for personal use, but those not part of a personal allowance must be declared and import duty may be payable. Controlled drugs may require special clearance. Check with the Medicines and Healthcare Products Regulatory Agency (MHRA) and relevant regulatory bodies in your destination country. Ensure drug inventories are up-to-date and establish whether you need to maintain a drug register . In the UK you must be a registered healthcare professional in order to prescribe, administer or supply prescription-only medicines and it is likely that other countries will have similar rules.
While you are there
Clinical decisions are made taking into account the particular setting you are in, the equipment and resources available, your own of level of competence and experience and, of course, the best interests of the patient. On an expedition you also have a responsibility for the safety of the team as a whole, and working closely with the expedition leader to make good decisions is essential.
Standard of care
Should a claim in clinical negligence be brought against you, the claimant must establish that:
- You owed them a duty of care (easily done when you are the expedition doctor treating a member of the expedition team)
- Your care fell below a standard that could reasonably be expected (ie. a breach of duty)
- That breach of duty caused them to suffer an injury or loss that they otherwise would not have sustained (causation).
In the UK, the standard of care expected is that of an ordinary, competent doctor in similar circumstances. The particular situation in which the incident occurred will be taken into account: a court considering standard of care would not expect a doctor to provide the same standard in a remote wilderness as in a well-equipped emergency room, but would expect that doctor to provide a similar standard to a competent doctor in a similar situation.
Inexperience is not a defence. A doctor who holds him or herself out as an expedition doctor is held to the standards of a reasonably competent expedition doctor, even if it is the first time they have acted in this capacity. Ensuring you have undergone sufficient training and have appropriate qualifications for the role is therefore essential.
The same good medical practice considerations apply no matter how remote your location and you must abide by the professional and ethical codes of conduct in the country in which you work.
Looking after the team
Try to set time aside to give privacy to individual team members who may wish to discuss medical concerns. Remember you are a professional as well as a member of the team: this boundary may be easily blurred but you must try to ensure it is respected. Maintaining your objectivity and respecting confidentiality is essential. Ensure you have patient consent for any treatment, and before discussing medical information with others.
Keep a record of any consultations or drugs prescribed; this is helpful for your own continuing care of the patient during the expedition, if handover to a local medical facility is required, or if a complaint or claim arises some time after the trip.
Responsibilities to locals
You may come across a situation where someone who is not a member of your expedition team requires medical assistance. GMC guidance says ‘In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence, and the availability of others for care.’ The situation may be different in other countries, for example in France there is a legal obligation to assist in an emergency. Guides or porters should receive the same medical treatment as any other expedition member.
If asked to treat local people it is important to be sensitive to local customs, and recognise that there may not be much you can do with the limited resources you have available.
In the unlikely event that a complaint or claim is brought against you, contact your professional defence organisation immediately for advice. If legal proceedings are brought, they are usually commenced in the country in which the alleged negligence took place. The GMC will consider complaints from anywhere in the world against a UK-registered medical practitioner. If you are found guilty of misconduct by a regulator in another jurisdiction, the GMC can use this as evidence to act on your UK registration.
Despite everything that has been said, be reassured that very few cases are brought against expedition doctors, perhaps due to the fact that expedition members accept they have taken on a risk and are grateful for the help they have been given in difficult circumstances.
If you liked this article you may also be interested in Never Off Duty?, a look at the responsibilities of a medic on holiday, by Dr Katie Hawkins.
(Photo: Nell Anderson, Nepal)