In this interview, Dr Ben Alba explains how the Ubuntu Network came to be, what it is, and how you can get involved. An emergency medicine middle-grade with an interest in high-altitude medicine, Ben formed the Ubuntu Network following a challenging case whilst working at Everest Base Camp. As the medic, he was closely involved in remotely managing a cardiac arrest of a participant for another tour operator, who unfortunately died. After returning home, Ben sought support from the expedition medicine community, but found that practitioners often operated independently without coming together to share experiences or lessons learned. This led to the birth of the Ubuntu Network, a community and collective where cases are shared and discussed amongst like-minded medics, with a focus on the human factors, leadership and decision-making challenges that are uniquely faced in remote medicine. Ubuntu is a southern African word meaning ‘humanity’ or ‘I am because you are’, and the network holds online events regularly throughout the year where a presenter speaks about an experience they’ve had while practising remotely alongside a facilitator who brings in the audience for constructive discussion.

Imara: Thank you, Ben, for taking the time to tell us all about the Ubuntu Network! I’ve been a big supporter from the beginning and feel that the community you’ve created is supportive, informative, and certainly needed in the expedition medicine world. It sounds like the experience you had at Everest Base Camp was particularly challenging, and it’s inspiring to see how that has spurred you to create Ubuntu in the aftermath. It must have been difficult speaking about the case in an open forum. Could you tell us a bit about how Ubuntu works and what people joining an event can expect?

Ben: Thanks, Imara, and as you are a key part of the team at Ubuntu, it wouldn’t be where it is now without your support! And yeah, it is hard to talk about these things, which I guess is part of what makes Ubuntu such a special space. That being said, we aren’t looking for presenters to be in the emotive and emotional stage of dealing with the issue. I think if I’d spoken on the Ubuntu the week after I got back from Everest, I probably would have cried, but the fact that I could take some time to process the experience before presenting was an important step in coming to terms with what had happened to me and getting my own support network going as well. But I agree with you, I think Ubuntu offers a really valuable resource as a place where people can come together and talk about difficult things and feel supported in a non-judgmental space. I think the way we run an event is very involved and discussion-based and not focused on people’s mistakes or decisions, but actually just listening to and engaging in a really interesting perspective from someone who’s had a lived experience.

An important part of that is that it’s not necessarily something drastic, you know? It doesn’t have to be a man getting mauled by a bear in the Grand Teton National Park. It can be 15 people who get diarrhoea and vomiting, and that’s the whole expedition over, and trying to deal with that. It’s those real things that we see in expedition medicine, and their unique logistical challenges. I’ve always said that expedition medicine boils down to coughs and colds, diarrhoea and vomiting and some minor trauma. I still stand by that, really, most of the stuff you see is that, and it’s not very exciting. But you’ve got to get through the often boring times or the often easy days to get to those hard bits when someone does have frostbite, and there is a really difficult management decision to make about whether we get them out and how quickly we do it.

These are all equally important to discuss, and I think the more we can talk about them and support people’s decision-making, the more we learn. Because there’s not much research out there really for expedition or wilderness work, a lot of it is derived from in-hospital research, and sometimes it’s very difficult to translate it to the remote setting.

In terms of how the network runs, we currently have a highly active WhatsApp group, where we advertise our events and disseminate other information, as well as advertise through our social media on Instagram. In the background, the Ubuntu team work to get a case presenter and a facilitator prepared. Essentially, on the night, the case presenter presents a case of something that’s been difficult in a remote environment. We’ve had snake bites in the desert, altitude cases, rabies in the Indonesian rainforest, and a case where the medic has become unwell and had to consider their position in the group. Some really varied cases. And again, as I stressed before, this isn’t about medical management and making the right medical decision. A lot of these cases essentially have human factors and logistical challenges at their core, because in reality, these are what you have to manage in remote care. How are you going to maintain their airway? How are you going to move them somewhere else? Are you going to deplete your stock of drugs by treating this one person when you have 30 other people to look after for the next two months? Are you going to use up the resources of the local community? What security risks do you have to consider?

Everyone can read an algorithm on how to manage the stages of septic shock, for example, things like that you can review in your own time, but actually what we’re trying to get at here is the real-time experience from someone who’s been in this place and had this experience and understand what their thought processes were; a virtual simulation so to speak.

The way we initially ran sessions was one person discusses a case and goes through it with a facilitator, asking prompting questions and bringing in a collaborative discussion at the end, and it’s worked really well. At the WEM conference last year, we decided before that we would pause halfway through and open it up to the audience to see where their thoughts were at. So, we’re aiming for a hybrid mix now, depending on the case. The main thing we are trying to get is engagement, and the best way to manage this has been through getting the audience to ask questions about what their thought processes are, as if they were themselves in the situation posed to them. We want it really to be a discussion and not a lecture, and invite people to bring in their own experiences too. There is no right or wrong answer in these situations; these are just discussions and a place for people to connect.

Imara: I think the exciting thing about wilderness and expedition medicine is that it’s the things that people might consider simple, like your diarrhoea and vomiting, that in certain contexts can actually be quite devastating. Depending on the situation, each scenario will play out so differently, and as you say, there are no right or wrong answers when it comes to the management of complex cases in the field. And reiterating that there is so much we can learn from each other.

What kind of direction do you see Ubuntu going, and what would you like it to look like in the future? Have you got any new exciting cases coming up?

Ben: I suppose initially the plan was to simply gather interest, but now we are in a period of moving to WhatsApp as our main hub of activity to increase that sense of community and engagement. We want to focus back on our key model of gathering not only the expedition but humanitarian, wilderness, and rural medical communities, in the UK and beyond.

The WhatsApp group is where event updates are posted with links to the sessions on Teams. Jonny Milton has also come on board to run an interactive journal club through the WhatsApp group to further the general discussion. We have already seen an influx into the group of medics from all backgrounds, from medical students to paramedics to mountain guides, all the way through to consultants and bona fide experts in their field. Having that spectrum really brings people together, and we hope it can become a space where people can get advice, ask for support and just generally network with their peers.

We had our first in-person independent Ubuntu event in Bristol in late February, and with online cases already lined up for April, June, and September, the year is looking full to the brim with great speakers and discussions. We will be at WEM again in November, and it looks like this will be a yearly date for us, which we are delighted about. We are even having people come to us now to ask to share information, be that presenting a case, or, for example, in April, Hannah Lock is doing a frostbite update through Ubuntu, which again is a testament to the ripples we are making through the community.

So you know, we’re slowly growing, and I think hopefully in the coming year we will see a kind of explosion through different methods of reaching out to people. You can’t force engagement, but we can make it easier for people to get involved, and so fingers crossed our move into WhatsApp will encourage that.

Imara: Amazing, it sounds like the future is very bright for Ubuntu, there’s a lot going on and different ways that people can engage and get involved, be it on your WhatsApp group, Instagram, conferences or events. It’s a really exciting time! Thanks, Ben, for taking the time to chat about Ubuntu and what you’ve created, and it’s certainly a space to watch…

Access the Ubuntu Network WhatsApp here

Access the Ubuntu Network Instagram here

The post Ubuntu Network appeared first on Adventure Medic.

Dr Khan is a dedicated expedition medic who served 31 years as a General Practitioner in the British Army. He specialised in providing Primary Healthcare and Prehospital Emergency Care in some of the world’s most remote and challenging environments. His operational and expedition experience spans six continents, with plans underway to complete the seventh in Antarctica. A recognised authority in wilderness and expedition medicine, Dr Khan founded and chaired the special interest group in this field and contributed significantly to the Joint Service Expedition Medical Advisory Group. His expertise is formally recognised by the Fellowship of the Royal Geographical Society (2016) and the Fellowship of the Academy of Wilderness Medicine (2021). He also serves as a trustee for Equal Adventure and supports veterans through The Not Forgotten and the Royal British Legion. Dr Khan maintains a strong affinity for the wilderness, particularly high altitude trekking and diving.

A diver surfaces, breaking the water’s calm. She is streamlined, powerful, and completes her surface protocol with practiced efficiency. Moments later, another diver emerges from a deeper, more demanding dive. He removes his mask, takes his first recovery breaths, but something is not quite right. His head begins to roll, and his arms exhibit uncoordinated, jerky movements. Within seconds, his safety diver is there, securing his airway and offering support. The episode passes as quickly as it began; colour returns to the diver’s face, and lucidity is restored.

As the medic observing from the boat, you have just witnessed a classic, well-managed loss of motor control. What physiological cascade has just reached its critical point? And what is your immediate concern?

More Than Just Holding Your Breath

Freediving, the discipline of underwater diving on a single breath, is often misrepresented in popular media as a daredevil pursuit. In reality, it is a sport of immense skill, equanimity, and profound physiological adaptation. For remote medicine practitioners, whose work often places them in environments where such activities occur, moving beyond the sensationalism is crucial. This article aims to equip you with a foundational, clinically relevant understanding of freediving physiology and the key medical considerations you might encounter, enabling a more informed medical practice.

The Body’s Aquatic Blueprint: Understanding the Mammalian Dive Reflex

At the core of a freediver’s ability to explore depth is a remarkable set of innate adaptations known as the Mammalian Dive Reflex (MDR). Far from being an anomaly, this is a conserved physiological response hardwired into our genetics, which is voluntarily honed by freedivers to a remarkable degree. The primary components include:

• Bradycardia: Upon facial immersion in water (particularly cold water), the heart rate slows profoundly, in some elite divers dropping to below 30 beats per minute. This powerful vagal response dramatically reduces myocardial oxygen demand, conserving precious reserves for the dive.
• Peripheral Vasoconstriction: The MDR initiates a powerful, systemic shunting of blood away from the peripheries—the muscles of the limbs and skin—towards the vital organs of the central circulation, namely the brain and the heart. This intelligent redistribution ensures that oxygenated blood is directed where it is most critically needed.
• The Spleen Effect: One of the most fascinating components is the contraction of the spleen. Acting as a biological scuba tank, the spleen stores a reserve of concentrated red blood cells. During a dive, it contracts, releasing this oxygen-rich blood into circulation and significantly boosting the body’s oxygen-carrying capacity.

The Pressure Gradient: Key Pathophysiology for the Expedition Medic

While the MDR is protective, the rapid changes in ambient pressure create the primary pathological risks. A sound understanding of these mechanisms is essential for any medic providing cover.

Barotrauma: The Physics of Squeeze

Barotrauma results from the failure to equalise pressure in the body’s air-filled spaces with the surrounding hydrostatic pressure.

• Middle-Ear and Sinus Barotrauma: This is the most common malady affecting novice and experienced divers alike. Failure to introduce high-pressure air into the middle ear via the Eustachian tubes during descent creates a negative pressure gradient, leading to pain, tympanic membrane oedema, haemotympanum, and potential perforation. Sinus squeeze presents similarly with sharp, localised facial pain.
• Thoracic Barotrauma: A far more serious concern, lung squeeze occurs when a diver descends to a depth where the ambient pressure compresses the thoracic cavity to a volume below the lungs’ residual volume. This can cause transudation of fluid and blood into the alveolar spaces. The primary clinical sign is post-dive haemoptysis, which can range from blood-streaked sputum to more significant bleeding and requires immediate cessation of diving.

Hypoxia and Its Manifestations

The entire discipline is a dance with hypoxia. Understanding its presentation is critical.

• Hypoxic Blackout (BO): Often termed ‘shallow water blackout’, this loss of consciousness is typically not a result of running out of oxygen at depth. Instead, it occurs during the final 10-15 metres of ascent. Due to Boyle’s Law, as the diver ascends and ambient pressure rapidly decreases, the partial pressure of oxygen (PO2​​) in the lungs drops precipitously. If this PO2​​ falls below the level required to maintain consciousness (~30 mmHg), a blackout will occur, usually without any warning sensation.
• Loss of Motor Control (LMC / “Samba”): As witnessed in our opening vignette, an LMC is a visible sign of significant, near-critical hypoxia. It represents a point on the hypoxic continuum just prior to a full blackout. The uncoordinated movements are a sign that the motor centres of the brain are failing, and it is a critical moment for intervention by a safety diver. Rapid recovery is typical once breathing is restored, but it is a clear indicator that the diver has reached their absolute limit for that dive.

Gas-Related Issues

While more commonly associated with scuba, certain gas-related problems are relevant to freediving.

• Nitrogen Narcosis: At depths typically beyond 30-40 metres, the increased partial pressure of nitrogen can exert an anaesthetic effect on the central nervous system, leading to euphoria, impaired judgement, and reduced coordination. This can compromise a diver’s ability to execute their dive plan and recognise warning signs.
• Decompression Sickness (DCS): Though uncommon in most recreational freediving profiles, DCS is a recognised risk, particularly for professionals engaged in repetitive deep dives with short surface intervals or prolonged ‘hang-out’ dives for photography or work. The pathophysiology is familiar: inert nitrogen absorbed into tissues under pressure comes out of solution as bubbles upon ascent if the ascent is too rapid or the cumulative bottom time is too great. The presentation can range from joint pain and skin mottling to serious neurological or cardiopulmonary symptoms.

An Informed Perspective on a Profound Sport

Freediving is a sport defined not by recklessness, but by incredible physiological control, rigorous training, and an intimate understanding of one’s own body. For the expedition medic, the key is to appreciate the unique physiological stresses and recognise their specific clinical manifestations.

The risks, while real, are largely manageable through education and strict adherence to safety protocols. The most important of these is the cardinal rule of the sport: never dive alone. The presence of a qualified and attentive safety diver is the single most critical factor in preventing a hypoxic incident from becoming a fatality. As a medical professional, your role is enhanced by viewing this remarkable activity not just through a lens of pathology, but as a masterclass in human potential and applied physiology.

The post From Bradycardia to Barotrauma: An Expedition Medic’s Guide to the Physiology of Freediving appeared first on Adventure Medic.

Jonathan is an Aeromedical Transfer and Critical Care Consultant at University Hospitals Birmingham, UK. He completed his undergraduate degree in the UK and postgraduate training in New Zealand. He has worked as the doctor on a dozen expeditions across six continents, avoiding North America for a growing number of reasons. He has the International Diploma in Mountain Medicine. The most common question he is asked is “Why Birmingham?” Other questions can be asked if you find him on Instagram @jonadventuremedic

Continuous dynamic risk assessment and management

Rolling around some cross-country trails on touring bicycles, I heard “ROCK!” up ahead, before a hollow thud. I approached, and found the rider had hit that very rock he was warning about, careened off the track and embraced a tree. This is an example of (admittedly poor) dynamic risk assessment and management.

Risk is inherent in everything we do in adventure medicine and is the main rationale for our employment. If there is no risk, it is hard to justify the cost of an expedition medic. Our job is to work with the expedition leader to assess and minimise the risks associated with the expedition, and to be prepared for their eventuality. Knowing the risks informs the packing of a medical kit and the establishment of escalation and evacuation plans.

I went to help the unfortunate cyclist, now half covered in foliage and half covered in bicycle, with a very bruised bottom and a tender anatomical snuffbox. Fortunately, I had anticipated the possibility of trauma on a cycle tour in pre-departure planning and carried some splints and bandages. I had also acknowledged the ready availability of NHS hospitals along the length of our Lands End to John O’Groats route and hadn’t packed Plaster of Paris. Together with the patient, we weighed up a number of risks and options and decided to continue the ride, albeit on a relaxed detour, with a splint available for comfort if the pain persisted, and a visit to a local A&E if worse still.

Opportunity cost

One of the risks often not discussed is that of missed opportunity. It is simple to choose the most medicolegally defensible option to cancel someone’s trip because of a risk, but if you set your acceptance of risk very low, you defeat the purpose of an expedition medic. We are there to support clients on their adventures as best we can. In an ideal world, I would sit down with each client beforehand and discuss their specifics in terms of appetite for risk, past medical history, and fitness, and tie this in with the itinerary to make an advanced care plan, much like I would hope happens for my NHS patients.

Unfortunately, we do not live in an ideal world, and much like my clients in intensive care, manifests arrive with incomplete medical histories and missing contact details. We meet our potential patients for the first time at the departure airport, or as the ship pulls out of the port, and these discussions are deferred to the moment of crisis. I suspect my plans for developing a national Risk Summary Plan for Expedition Care and Treatments (RiSPECT) form will not catch on.

A balancing act

A client had the foresight to message me prior to departure on a hike around the Annapurna Circuit about some recent blood tests and we were able to have this conversation. She had moderately deranged liver function tests after a routine private health check-up, and her specialist had said it was likely gallstones. She was told not to worry until her booked ultrasound scan in six weeks. While this was an appropriate stance while working in an office in Bristol, the balance of risks changes substantially while trekking through Nepal. She was keen to continue, so I discussed with her the small risk of it not being gallstones, or indeed it being gallstones that proceed to obstruct, or her liver function worsening by contracting hepatitis A, all while being relatively remote from healthcare, which was itself delivered at a different resource level than in the UK.

With this discussion, we can hit the somewhat clichéd buzzwords of “shared decision making” and “patient centred care” to support the client/patient into making a decision they will be happy with. Hypothetically, I would have been happy to travel with her should she have accepted the serious risks, and should we have been able to demonstrate that her developing an illness would not significantly interrupt the itinerary of her fellow travellers, but this would require very careful documentation, and probably some intimidating consent forms with “death” and “financial ruin” in bold and capitals for my own medicolegal protection. It is our right as people with capacity to make our own decisions after all, even if they appear to be foolish, but this should not be to the detriment of other travellers or the communities and environments to which we travel. Ultimately, she was unable to travel as her insurer would not cover her for biliary related issues, and she fairly sensibly determined the risk was too high.

Time for introspection

When having these discussions about risk, it’s exceptionally important to consider one’s own limitations. None of us are perfect expedition medics. I come from an intensive care background, so feel comfortable discussing the various potentially life-threatening conditions, but am more unfamiliar with broken wrists. General practitioners on the other hand might feel very comfortable with rashes, but less with acute life-threatening asthma, and physiotherapists might be excellent at strapping knees but less comfortable with the risks of antibiotics for traveller’s diarrhoea. When discussing risk with clients, be up front about your own limitations and uncertainties.

Balancing with the day job

I am often asked how I manage to undertake expeditions around my day job, as if the day job is a barrier to employment on expeditions. While it does cut down on the time available, I wouldn’t be able to safely undertake my expedition work without it. There are clinicians who frame themselves primarily as expedition medics, but expeditions alone do not allow one to keep up to date with the rare but serious conditions that are used to justify our employment. Parallel acute clinical work is mandatory to ensure this exposure.

As a resident doctor in New Zealand, I used about half of my annual leave to do expeditions, with the other half reserved to recuperate. As a critical care consultant in the United Kingdom, due to an annualised hours contract, I am able to front load a lot of my work and ensure good periods of time off where I can either recuperate or work on expeditions. In this way, I can maintain a full-time domestic job which helps build clinical experience, and still complete expeditions, which mostly develop team working and interpersonal skills. I suggest we build our experience in both expedition and domestic work to balance our own professional risk.

The riskiest trip

I travelled to Antarctica on a tall ship in January as the sole medical cover, and on paper this was the riskiest trip I have undertaken. Some of the clients were anticoagulated, others on immunotherapy for metastatic cancer, and everyone was climbing up the rigging untethered some twenty metres above the deck – or above the deep dark ocean when there was a more aggressive heel to the boat. We were at our farthest approximately three days’ continuous motor cruising from the nearest hospital, with no realistic prospect of an airborne rescue.

The Faculty of Pre-Hospital Care of the Royal College of Surgeons of Edinburgh publish guidelines for the degree of experience suggested for expedition medics, and quite rightly this trip featured in the highest risk and highest consequence categories of their risk matrix. For this expedition, the faculty suggest experience working in the leadership of expeditions, with specific environmental experience, advanced experience in any undertaken activity, and the title of a consultant doctor, highly experienced in expedition medicine. Acknowledging this, I signed up for a trip as expedition and ships doctor on a more resourced trip around the Arctic in the previous year to build the specific experience suggested. This helped me to manage my own risk by building my exposure gradually.

Top tips

Dom Hall wrote about risk management over a decade ago for Adventure Medic as a non-clinician. He provides four top tips; I’ll add my own to take it to eight:

1. Consider the interplay of your patient’s medical history, the environment, the activity, and your own experience when determining risks; both for you and your clients
2. Work with the expedition leader and the clients to negotiate an acceptable level of risk
3. Pack a medical kit that covers the likely eventualities
4. Finally, consider how it would look if it went to court. Would you expect others in the field to stand behind you and agree they would have done similar, or do you need to build your own experience first?

For me, I’ll continue to work in my day job, pick up expeditions where I can, and pop down to the Emergency Department from time to time to remind myself where the scaphoid is.

Afternote

Details have been changed about the patients and expeditions to maintain anonymity.

The post Risk Management and the Expedition Medic appeared first on Adventure Medic.

One of the most enjoyable aspects of adventure medicine is keeping up with new developments in sport or exploration and figuring out how to best support our clients in pushing their boundaries. In this article, Matt Wilkes and Jake Holland review the adventure medicine considerations for paralpinism, considering each phase of the activity in turn.

Matt is one of the founders of Adventure Medic, and a visiting senior lecturer at the Extreme Environments Laboratory in Portsmouth. He loves flying paragliders in the high mountains, especially the Alps and the Himalayas. Jake Holland is a filmmaker and multisport athlete based in Chamonix, France. Jake is one of the athletes pushing paralpinism in the Alps, and all over the world. Check out his Instagram, and his latest film, The Magic of Freedom.

Paragliding is born

In June 1978, skydiver Jean-Claude Bétemps stood with his friend André Bohn on Mont Pertuiset, overlooking Mieussy in France. He took the risers of his parachute in his hands and ran headlong down the slope. The canopy filled with air, and Bétemps lifted off, flying to the valley floor. Bohn soon joined him, and paragliding was born.

Since that day, paragliding has evolved to become the dominant form of free flight. Free flight is flying without an engine, and includes sailplane gliding, hang gliding and wingsuit flying. The introduction of new materials, such as lightweight and durable fabrics and lines, as well as improved aerodynamic understanding, has revolutionised glider construction. The paragliding cross-country distance record is now 612 km in a single unpowered flight, and the (voluntary) altitude record is 8,407 m without oxygen.

Paragliding meets alpinism

Forty-four years after Jean-Claude and André, on 26 June 2022, paraglider pilots and alpinists Jake Holland, Will Sim, and Fabi Buhl took off on paragliders from the hot, dusty slope above the village of Karimabad in Pakistan (2,900 m). They used rising air to climb to over 6,000 m and flew 20 km along the south side of Ultar Sar. Putting on skis in midair, they landed on the glacier at the base of the Gulmit Tower (5,801 m). At 2 am the following day, Will and Fabi made the first ascent of the 900 m west face. The team flew back to Karimabad later that same day, although Fabi initially struggled to take off in the changing conditions. By flying in, they avoided the four-day, steep, avalanche-prone trek in and out that had hampered previous expeditions. The story is told in Jake Holland’s fantastic movie, A New Way Up.

Manufacturers are now releasing ultralight paragliding wings and harnesses specifically designed to support other mountain activities, like climbing or running, including single-surface descent wings weighing less than 1.5 kg. These advances have made paralpinism, a combination of paragliding and other mountain activities (sometimes called “combos” for short), a viable approach for alpine exploration. Athletes are using paragliders to access new lines, as well as routes which have become less accessible as the snowline recedes with climate change (for example, the Pas de Chèvre in Chamonix). This year, mountain guide Benjamin Védrines climbed K2 without supplementary oxygen in just 10 hours 59 minutes and 59 seconds – a new record – then flew down on a specially designed wing weighing just a kilogram. Some athletes, like Benjamin, use paragliders primarily for descent at the end of a route. Others, like Jake, Will and Fabi, use them to ascend, fly cross-country to access the route, and then to return home.

Training and preparation

Paragliding is a highly technical sport, as is alpinism. To combine them, athletes must acquire the necessary portfolio of technical skills, both in the air and on the ground, as well as physical fitness and suitable equipment. Sadly, there have been accidents precipitated by athletes without paragliding backgrounds not taking the time to learn the skills and the meteorology necessary to fly safely in the mountains. Athletes who only fly paragliders for descent in still air are sometimes caught out if they launch early or late, finding themselves in thermic conditions, strong winds or turbulent lee sides. Equally, paraglider pilots can find themselves ill-equipped if they land on a high, crevassed slope. On 26 June 2019, over 150 paraglider pilots took advantage of a high cloud base to land atop Mont Blanc (4,810 m), most without mountaineering equipment. Some struggled to launch again, becoming quickly exhausted due to the altitude. One pilot slid down the face of the mountain to his death. No matter their background, once in the air an athlete is a pilot, and once on the ground they are an alpinist, and therefore must ensure they are sufficiently skilled in both.

Take off and outbound flight

The first hurdle of paragliding is getting airborne. The pilot faces into the wind and lifts the glider above their head. The pilot then walks or runs forwards until the ground falls away beneath them and they take flight, supported by the glider. Strong winds or thermals, steep or uneven ground, or being heavily laden with equipment can make take-off a challenge. In the outbound flight, paralpinists may be flying with skis, climbing gear and camping equipment. The added weight increases airspeed, while lightweight mountaineering harnesses have limited (or absent) back and pelvis protection, compared to regular paragliding harnesses. Collectively, these increase the likelihood and potential severity of injury from a fall, or from being dragged along the ground following a failed take-off.

Once airborne, the paralpinist sets course for their objective. Flying paragliders in the high mountains is challenging, navigating strong thermals and equally strong areas of turbulence through complex terrain to the objective. The need to search for lift means success isn’t guaranteed; often a circuitous route is required, and athletes flying together can become separated. Paralpinists have the potential to gain over 5,000 m in altitude in flight, limited only by the height of the clouds and the strength of the winds aloft. In flight they can face hypobaric hypoxia, acceleration (G) forces, wind, cold, and UV radiation. There is even the (theoretical) potential for decompression illness, the bends, though there have been no documented cases.

Landing high

Landing at high altitude is technically demanding. Thermals coalescing at the top of the terrain can make it hard to touch down, with risks of overshooting or falling back into the lee side of the ridge, precipitating a wing collapse close to the ground. It is also possible to tumble on landing, especially if the ground is snowy or uneven. Landing on skis helps dissipate speed and maintain balance, but requires the paralpinist to put their skis on in the air before landing, removing their hands from the controls for several minutes to do so.

Once on the ground, the hazards depend on the planned activities, which are typically climbing or skiing on glaciated terrain. The final consideration is the return flight. If the wind drops to nothing, it can require considerable effort to take off at high altitude, as the wing requires a higher airspeed to generate lift. If the winds are too strong, become katabatic (a strong, cold, backwind) or the mountain becomes covered in cloud, then launching can be impossible. In either case, the paralpinist risks becoming stranded until the weather improves.

Antoine Girard’s ascent of Diran (7,266 m) on 3 July 2023, two years after his ascent of Spantik (7,022 m), typified these risks. Antoine took off at 2,900 m carrying 30 kg of equipment. He flew 23 km, landing at 2.35 pm at 6,750 m on Diran’s West Ridge. He cached gear and reached the summit at around 8 pm, first with skis, then with crampons. Antoine was insufficiently acclimatised to spend the night at the summit and so he descended in the dark to 6,450 m. Fighting exhaustion, he waited out the night in a tent, developing vomiting, mild confusion and loss of coordination, all signs of cerebral oedema. He had acetazolamide and dexamethasone but could not take either due to vomiting. He hoped to fly down at first light, but the winds were too strong at his altitude. A storm was coming, and he needed to get lower to have any hope of taking off. Antoine descended on foot, exhausted and ataxic, through heavily crevassed terrain. A snowbridge gave way beneath him, and he fell 2 m into a crevasse. He was able to self-rescue and continue down to a suitable take-off, launching from 6,150 m at 11:20 am, moments before the storm, and landing safely but exhausted in Karimabad 40 minutes later.

Adventure medicine considerations

Hypobaric hypoxia

In our experience, the relative ease of climbing to extreme altitudes in a paraglider, and the (mis)perception of being relatively unimpaired while in flight, can lead athletes to overestimate their degree of acclimatisation and underestimate the risks of hypoxia, and the challenges of a prolonged period of physical activity at altitude.

As medics, we should help athletes understand the insidious nature of hypoxia, and how symptoms and susceptibility can vary within and between individuals. This includes the potential “hangover effect” of hypoxia once back at lower altitudes. Athletes are often reluctant to use oxygen, as even systems designed for mountaineering are relatively complex, heavy and bulky. This places a premium on an effective acclimatisation strategy. In many ways, paragliding is actually quite enabling for acclimatisation. Repeated flights have the potential to be mildly acclimatising in themselves, as they often add up to several hours in hypobaric hypoxia. However, it is the opportunity to land at progressively higher altitudes, exercise, sleep, and then rapidly return to lower altitudes for further training and recovery that offers more flexibility than traditional alpinism. In effect, paralpinists can both live high and low, while training high and low. Anecdotally, we have found that ‘one night high, two nights low’ appears to balance acclimatisation alongside rest and recovery, optimising performance in paralpinists. Clearly, this strategy is dependent on finding suitable landing sites at progressively higher altitudes. Care should be taken to choose sites where walking down is a possibility if symptoms of altitude illness develop.

Environmental protection

Athletes need to manage both heat and cold. On takeoff, dressed for higher altitudes, athletes will rapidly start to sweat in the heat of a low, sunny takeoff. Once in flight, they will experience falling temperatures and increasing wind chill as they climb higher. Paraglider pilots fly with their hands above their heads, armpits and wrists exposed to the apparent wind and fingers looped around the control handles, so they are particularly vulnerable to cold hands. We need to strike a compromise between preventing cold injury while maintaining sufficient dexterity to control the paraglider and deploy a reserve parachute in an emergency. We have found a down layering system with a wind-impermeable outer shell, an insulated helmet and electrically heated gloves to be most adaptable to conditions. A harness with a leg cocoon effectively shields the lower limbs. A plastic bag, placed between the socks and boots, can prevent sweat soaking into the boots on takeoff and can be removed once landed at high altitude. Ski goggles suitable for bright light and a buff/balaclava offer UV protection. Paraglider pilots tend to produce an excess of dilute urine, likely due to cold, hypoxia, and semi-recumbent positioning in the harness. As in alpinism, we should encourage paralpinists to eat and drink to maintain performance. Nutritional requirements will depend on the planned activities, but in general, we would suggest a diet prominent in complex carbohydrates and hydration with an electrolyte-rich solution, both whilst in the air and on the ground.

Preparation for stranding

As with Fabi and Antoine, we need to make sure that paralpinists are adequately prepared for being unable to fly down. This might be due to adverse weather, terrain, damage to equipment, physical incapacitation or injury. In addition to progressive acclimatisation, it’s worth considering offering education and rescue medication in case of altitude illness (acetazolamide, nifedipine and dexamethasone). Ensure there is sufficient food, water and shelter. If equipment must be divided between several paralpinists, leave the last person to fly home in possession of the stove, shelter and rescue medication in case they become stranded.

Trauma and first aid

We suggest a minimalist first aid kit, suitable for treating bleeding and isolated limb injuries: typically, a trauma bandage, gloves, two flexible aluminium splints (SAM splints), gauze and zinc oxide tape. We have offered selected paralpinists training and access to methoxyflurane as a strong analgesic, given its light weight and ease of administration by non-medical personnel, particularly in facilitating splinting. There may even be an argument for tranexamic acid if an autoinjector becomes readily available.

Casualty evacuation and communication

The range of modern paragliders, alongside the possibilities of stranding, altitude illness and trauma, makes casualty evacuation planning complex. If the paralpinist cannot find lift during the outbound flight stage, they may land anywhere en route. At their objective, they may need to divert to another landing if the conditions are unsuitable. They may land somewhere inaccessible by foot, preventing the paralpinist from descending or a rescue party from reaching them. In many parts of the world, helicopter coverage is inconsistent, and the insurance situation is fluid. While the specifics of a casualty evacuation plan will vary by location, we stress the importance of detailed route discussion, including alternative landing sites, during the planning phase, then multiple channels of communication while underway.

Pilots typically fly with a variometer/GPS instrument to assist with thermal optimisation and navigation. We use Very High Frequency (VHF) radio for conversation in flight, and high-resolution 4G live tracking via mobile phone, backed up by a satellite tracker/messenger to transmit position (for example, Garmin InReach). Then, when the paralpinist is on the ground, a combination of local mobile phone, VHF radio and satellite tracker/messenger. Paraglider pilots often fly near one another, and alongside other soaring aircraft such as sailplanes. Flying paragliders into clouds is a breach of aviation law and risks collision with terrain or other aircraft. However, on occasion, pilots misjudge the strength of lift and can be sucked into clouds. This is highly disorientating. A ball compass can help maintain heading, and FLARM, an automated radio-based collision avoidance system, is being encouraged by aviation authorities to make paragliders electronically conspicuous to other aircraft nearby.

Paralpinism is an attractive new approach for mountain athletes seeking rapid access to new or otherwise inaccessible routes. Its popularity will likely increase as the equipment continues to improve and climate change pushes the snowline ever higher. It also makes for engaging social media content. There is rich potential for research, particularly into optimum acclimatisation and performance strategies, given athletes have the freedom to climb, camp and descend via paraglider. Paralpinism is also endlessly exciting to support from an adventure medicine perspective, combining the challenges of several sports at once, multiple environmental stressors, nuanced human factors and complex logistics.

The post Paralpinism appeared first on Adventure Medic.

Grace is a clinical teaching fellow working in Birmingham with an interest in humanitarian medicine. They spent three months volunteering as the field co-ordinator for First Aid Support Team (FAST), a non-governmental organisation providing first aid to displaced people in Calais and Dunkirk. Grace shares their experience in the role for those interested in gaining humanitarian medicine experience early in their careers. 

The context

Migration of those seeking asylum in Europe from regions affected by war, famine, or economic difficulties presents a complex array of challenges, one of which is providing adequate humanitarian assistance. In 2024, approximately 37,000 people entered the UK by undertaking perilous journeys across the English Channel on small boats. This accounts for approximately half of the 84,000 asylum applications in 2024 and represents only five percent of net migration to the UK in the year ending June 2024. The UK-France border only sees 5% of the total displaced people entering Europe. They arrive looking to seek asylum, a right enshrined by international law, with most of those aiming to come to the UK due to familial or language connections. A disparate group of people at various stages of asylum, whether to the UK or France, wait at the border, living in tents and relying mostly on non-government organisations (NGOs) for food, water, shelter, and healthcare.

The number of people in Calais attempting to cross at any one time is difficult to estimate; however, for the three months I was field co-ordinator for FAST, we saw on average nearly 200 individuals per day. The numbers are seasonal: lower during winter and peaking in the summer months when conditions are more favourable for crossing the Channel. The majority of the people waiting to cross at the border in Calais are Sudanese, fleeing a devastating humanitarian crisis, with a third of the population displaced. There are also significant numbers of people from Syria, Afghanistan, Iraq, Türkiye, Kurdistan, Eritrea, Ethiopia, Somalia, and Libya. While the majority of displaced people are young men and boys, there are also many women, girls, and young children.

The set-up

The needs of the displaced population are vast and often mismatched by the services provided. FAST, for example, is operated out of a single shipping container, which provides space for running clinics, storing stock and equipment, as well as an office for the team. The day-to-day involves mornings at the container preparing for the clinic, completing stock checks, cleaning equipment, printing advice leaflets and referral letters in varying languages, in addition to loading the vehicle for outreach services. Other days, sourcing stock is required, often involving some confused locals as you order hundreds of toothbrushes. The afternoons involved running a mobile clinic out of the back of the car, either directly at the camps or at distribution points/day centres with other NGOs. As co-ordinator, my week also involved board meetings, coordinating with other NGOs operating in Calais, and teaching first aid to other volunteers and humanitarian workers. FAST operates six days per week, with Friday always kept clear for a much-needed decompression time.

The needs

Many individuals came simply for requests of hygiene items, such as tissue, toothbrushes, and soap. Consultations for conditions created or worsened by living in crowded, damp conditions and walking long distances were incredibly common; mostly, we saw respiratory, musculoskeletal, and dermatological conditions. Wound and foot care were also a key part of our practice. In between the fungal skin infections, common colds, and scabies, some patients presented with more serious (and for a UK clinician more unusual) conditions such as cutaneous diphtheria and non-freezing cold injury i.e. trench foot.

It was fairly rare to have chronic disease consultations, likely due to the arduous journey required to get to France, and the fact that people do not focus on their health conditions while they are actively attempting to cross a border. However, requests for long-term medications were reasonably common, as were pregnant women seeking antenatal care, most of whom had received none despite their advanced pregnancies.

To meet these needs, we came well-stocked with simple hygiene items, creams and dressings for wound and foot care, cold remedies, joint supports, and toys for the children. We worked in concert with the other NGOs and, to a limited extent, the French healthcare system. Conditions FAST we were unable to deal with were sent to La Pass (Permanence d’accèss aux soins de santé); a clinic run by the French healthcare system that does not require documents or money to access. While I was in Calais, they were open weekdays; otherwise, patients would have to attend the emergency department for more urgent medical issues. La Pass also had dentist appointments around two days per week, although there were only ten appointments per clinic, which is woefully inadequate when compared with the need for dental services. MSF and the Red Cross also conducted one mobile clinic each week in Calais, although the majority of their work was in neighbouring Dunkirk. The impressive MSF psychology team worked with the displaced population alongside the Refugee Women’s Centre for women and children, and ECPAT for unaccompanied minors. The network of NGOs working in Calais did their utmost our best to provide holistic, joined-up care, in a challenging, often difficult environment. This was underpinned by the incredible work of the Channel Information Project, providing up-to-date guides for both displaced people and aid workers in Calais, and ‘Utopia 56’ providing transport to medical facilities and immediate aid after failed crossing attempts.

Challenges

With such a diverse group of patients, translation was a key difficulty. The majority were Arabic speakers, but there were also many Tigrinya, Amharic, Somali, Kurdish, Farsi, Dari, and Pashto speakers. We unfortunately did not have professional translators, so we relied on the language skills of the team and improvising with translation apps. Often, a displaced person with language skills would assist with translation, which was an immense help! The constraints and ethical challenges of these forms of communication are obvious, but the alternative is further restricting access to already limited healthcare.

Regrettably, very few displaced people in Calais had heard of La Pass or knew how to access it, and many were unwilling to go even when it was an option, often due to fear of French authorities or difficulty with transport and timing around traveling for food, water, administrative appointments, and attempting to cross.

Provision of humanitarian healthcare doesn’t occur in a vacuum; addressing the health needs of a displaced population is also impacted by the geopolitical environment. The Compagnies Républicaines de Sécurité (CRS) or Police Nationale regularly evicts camps, removing tents and belongings of displaced people. This disruption to a vulnerable population has consequences. On one occasion, I met a very distressed man who told us he had his tent and belongings taken by the CRS, which sadly included his insulin for his diabetes as well as and his reading glasses. On another occasion, we encountered a 15-year-old unaccompanied boy with a severely infected wound on his leg. He had no access to transport, did not speak French, and had no method of communication. We attempted to transport him to hospital, but on passing one of the camps with a heavy police presence, the car was stopped, the injured boy forced to get out, and my colleague was questioned for around an hour before being allowed to leave. The lack of reliable, safe options to get medical aid for an unwell child was astounding and left the team shaken. 

A further challenge was the resource limitations of all the NGOs in Calais, borne from the crisis on the border, the lack of safe passage to claim asylum, and the reduction in donations across Europe. The impact of this situation on displaced populations is profound – I remember when I encountered a crying boy of around eight and his mother. I asked if they had any medical needs, and his mother told me that he was scared of going back to the sea and the boats. I offered a referral to the MSF psychology team, which they refused, and I then had nothing else to offer them. I gave him a toy and left, leaving him to go on a journey that has killed many children his age. I have never felt more impotent.

My experience

Despite the long hours and tears shed, I would undoubtedly say that co-ordinating for FAST Calais is the best job I’ve ever had, which is saying a lot as it was unpaid! Initially, the complexities and ever-changing demands of coordinating were overwhelming, and it was intimidating to often be the most senior clinician in the field this early in my medical career. However, through the support of previous co-ordinators and the wider FAST organisation, I can say the experience was overwhelmingly positive. Day-to-day interactions with patients were incredibly fulfilling and usually filled with respect and generosity; if I encountered people cooking or eating outside their tents in the camps, I was almost always offered food.

One day, in torrential rains in a car park (our usual distribution point), volunteers and displaced people alike all joined in dancing. After a valiant attempt at teaching us a dabke (a traditional Levantine dance), the British volunteers expertly demonstrated our lack of rhythm performing the ‘Macarena’ (a British dancefloor classic). The whole afternoon overall is one of my favourite memories of my time as co-ordinator, and most clinics contained overwhelming feelings of community, joy, and generosity, even in the background of desperation and injustice. 

How to get involved

FAST will always be in need of donations and volunteers! The co-ordinator position must be a nurse, doctor, or paramedic, but medical and nursing students in clinical years and other professions (such as podiatrists) can be a vital addition to the team as volunteers. One week is the minimum volunteering time if you’ve never volunteered with FAST before, and then there’s no minimum time for returning volunteers. The co-ordinator position is usually for 3 months. You can apply to volunteer and donate directly through the website.

You can also volunteer as a medical professional with a similar organisation operating in Dunkirk called No Border Medics, and with the Boat Refugee Foundation operating in the Greek Islands. Medical Volunteers International is another similar organisation operating in multiple European countries, both on borders and with more settled populations in camps. 

There are also loads of opportunities to volunteer with non-medical organisations, such as Care4Calais, Refugee Community Kitchen, and Calais Food Collective.

The post Humanitarian Healthcare in Calais appeared first on Adventure Medic.

After completing their foundation training in the UK, Calum and Ellen moved out to New Zealand in 2022. They chose to swap life on the wards to explore the world of Urgent Care. Alongside varied case loads and improved work-life balance, they’ve also had the opportunity to adventure through the wilds of Aoteoroa.

What is Urgent Care? / Our Journey with a Move to New Zealand

We moved to Aotearoa in August 2022 after finishing Foundation Training in the UK. We had always wanted to relocate to New Zealand and started looking for jobs in late 2021. Whangārei, in the Northland region, caught our attention with its stunning beaches, surf breaks, and mild winters. So, we began making inquiries. Initially, we reached out to the local hospital and some locum agencies, but things were moving slowly, so we broadened our search. That’s when we discovered Whitecross Whangārei, an Urgent Care clinic, and decided to get in touch.

At that point, we didn’t know much about urgent care, so we had to do some research. Urgent care is a unique medical specialty in Aotearoa, New Zealand, sitting between General Practice (GP) and Emergency Departments (ED). It provides walk-in services for a broad range of conditions—from something as simple as paronychia to more serious concerns like chest pain, and everything in between. It’s a fast-paced and exciting field with excellent support and great working hours.

Things moved quickly once we contacted Whitecross Whangārei. We were connected with the recruitment team in Auckland, and after an interview, they helped us with the visa application process, indemnity insurance, clinic placements, and scheduling. We arrived in New Zealand in August 2022 and spent a couple of weeks in Auckland orientating ourselves. This time involved shadowing Urgent Care College fellows, getting familiar with clinic systems, and learning about the common cases seen in urgent care. We were surprised to find that many other Brits had also ended up in urgent care! In September 2022, we moved to Whangārei to begin our roles. The initial supernumerary roster provided a soft landing while we got used to a new healthcare system and a new country.

Since arriving in New Zealand, we’ve worked for Tamaki Health, one of the country’s largest primary care providers. They were incredibly supportive throughout our relocation and reimbursed our moving expenses. We typically work around 35 hours a week, with flexible shifts that offers the option to pick up extra hours if desired. After working long shifts and nights in the UK during the COVID-19 pandemic, the reduced hours and extra free time have been a welcome change. With three days off each week, we’ve had the chance to explore both the North and South Islands, especially the Northland region, including the Far North and Bay of Islands. The hiking, bikepacking routes, and beaches here are some of the most beautiful we’ve seen.

Varied Caseload

Urgent Care is the realm of the generalist and the caseload was very varied. Despite White Cross being only a 5 minute drive from the hospital, we would often see acute life threatening emergencies amongst the day to day minor ailments and GP overflow – one particular patient was adamant their chest pain was related to too much bodyboarding the day before, yet they were clearly in Rapid Atrial Flutter with a HR 220! Multiple health and inequality factors influence the acuity and presentations we have seen in Urgent Care in Whangārei. We have both seen presentations of Acute Rheumatic Fever, exposure to which we would not have had if we had continued working in Scotland. We have both managed patients presenting acutely with Meningitis, Subarachnoid Haemorrhage, Kawasaki Disease and Septic Arthritis. Working in a rural part of Aotearoa has also given us new skills which we hadn’t anticipated, such as, removing Kina spikes (sea urchin), suturing surfboard fin injuries and metal from corneas from backyard welding. Also dealing with unexpected results, such as a patient who had just walked a few kilometers into town after machinery fell onto him in his own garage two days prior, whose chest xray showed a ruptured diaphragm – never trust a farmer! However, in all of these cases we dealt with – we worked as a team, had support, excellent experienced staff on site and very helpful colleagues in the hospital for advice.

Careers in Urgent Care

Every day is different, and the saying “you never know what’s going to walk through the door” couldn’t be more accurate. The shift from hospital medicine to community care was a challenge at first, but we received excellent support from senior doctors at the clinic—many of whom are fellows of the Urgent Care College—as well as local GPs. The relationship between clinics and secondary care services is strong, ensuring that patients needing hospital care are referred appropriately.

New Zealand has its own dedicated training programme for Urgent Care, typically taken after foundation training. This pathway offers a chance to explore options beyond hospital medicine and can sometimes act as a stepping stone to a career in General Practice. You can secure a position in an Urgent Care Centre where you’ll start with supervision before working independently, however, senior staff are always available for advice if you face any tricky cases. Unsurprisingly, several colleagues who also relocated from the UK have since pursued the Urgent Care training programme, a four-year course that combines clinical work in Urgent Care clinics with experience as registrars in emergency departments. This provides a well-rounded experience across a wide range of medical cases.

Adventures

We were very fortunate that our amazing practice manager (Dan) organised our rota so we could work the same days and was very flexible with leave requests. This allowed us time to explore the North Island extensively when we first moved out, equally being the ‘Winterless North’ and coming from Scotland, we were able to comfortably continue our adventures late into winter. Highlights besides some new hobbies of fishing, golf, flying lessons and surfing, were our day hikes out to ‘huts’ aka ‘bothies’.

We recently completed an overnight hike on the Cape Brett Track. It’s a 16km track through native bush in Northland, through rough and steep terrain with amazing coastal and cliff views along the way. Bringing all of our gear was hard work, but worth the effort when we made it to the ‘hut’ which was an old lighthouse keepers house. From there you can fish, kayak and swim at the remote headland and folk often get the water taxi back to the nearest pier, however, with the wind and waves picking up that evening there was no way back apart from the track back to the start in the morning. The reward: we were treated to an amazing sunrise on our return and a hearty soup and a sandwich when we got back to Russell later that afternoon.

We also recently completed an overnight hike in Fowlers Pass staying at Stanley Vale Hut. We chose this primarily as we were able to bring our dog along with us too! This was another 16km track in Northern Canterbury in the South Island, the terrain/fauna/climate is completely different. Impassable in the winter due to risk of avalanche, we waited until Spring to complete this which made the multiple river crossings particularly chilly! However, despite wet feet we had glorious sun all the way and our dog Indie had such a blast. We camped outside the hut with Indie and her own sleeping bag (of course) and slept under the stars. We will definitely do this route again as it links up with other trails in the area for an extended multi-day hike and stay at the other huts in the area along the way.

Onwards to Primary Care

After two years in Whangārei, we decided to explore new opportunities for our GP training, and so, we’ve relocated to Ōtautahi (Christchurch). Working in Urgent Care has been a great foundation for moving into primary care. The variety of conditions seen—everything from infants to the elderly, and everything from orthopaedics to obstetrics, gynaecology, and ENT—has greatly expanded our skills. The day-to-day challenges are similar to what we encountered in the UK, though one key difference in New Zealand is the partial patient funding for healthcare, which can complicate decision-making when patients are unable to afford certain treatments or tests. Despite this, the skills and knowledge required are transferable between both countries.

UK vs NZ

We were eager to pursue GP training in New Zealand rather than the UK. Both countries offer three-year training programs, and UK graduates are welcomed into New Zealand’s programme. One of the key advantages of training in New Zealand is that no entry exams (such as the MSRA) are required after completing foundation training. The program is community-based, with no mandatory hospital rotations. The first year typically involves two six-month rotations, while the final two years are spent working within a practice arranged by the trainee.

Applications

The application process is straightforward: contact the Royal New Zealand College of General Practitioners, submit your application along with your CV and references, and if your qualifications align with the program’s requirements, you may be invited for an interview or directly offered a position.

Trainees can choose to be College-employed or Practice-employed for their first year. College employment is the standard route, offering a salary and covering costs for exams, registration, and access to the annual conference. Practice employment requires negotiations with a GP practice, which can be more difficult outside of New Zealand, but it offers the benefit of choosing the specific practice for training. In terms of teaching, New Zealand’s GP programme includes weekly in-person teaching days and 1.5 hours of in-house teaching each week with a GP supervisor.

Options to Explore

If you’re thinking about making the move to Aotearoa, Urgent Care could be a great option to explore!

Tamaki Health, one of the largest primary care providers in New Zealand, runs numerous clinics across both the North and South Islands. They list job openings on their website but you can also contact Carlos Jimenez directly with your CV, experience, and preferred location. While experience in both Emergency Departments and General Practice is usually expected, there’s flexibility depending on your previous experience and roles.

Throughout our journey, we’ve felt incredibly supported. Tamaki Health has been a fantastic employer, genuinely valuing its staff and their well-being. Living and working in such an incredible country has been a privilege, and if you have any questions or would like to know more, we’d be happy to help.

The post Urgent Care and Adventures in New Zealand appeared first on Adventure Medic.

Living in Emergency – Stories of Doctors Without Borders

Where: Vimeo

About: It’s a documentary that portrays the experiences of healthcare professionals working with Doctors Without Borders (Médecins Sans Frontières) in conflict and crisis regions. It sheds light on the difficulties, moral challenges, and emotional strain they encounter while providing critical medical services in hostile and extreme environments. The film highlights the dedication and strength of these medical workers as they work tirelessly to save lives amid chaos, violence, and scarce resources, revealing both their unwavering humanitarian commitment and the tough conditions they face while delivering aid in emergency situations.

Why: It is inspiring to see what motivates these doctors to give up their more comfortable lives to live remote in these extreme environments treating patients who need it most. Doctors who are depicted in the documentary give their honest opinions about what it’s like to work for MSF which gives you a real insight: ‘I could never have imagined what it’s like being the doctor. For some patients I am the first doctor they have seen in 27 years.’ ‘Everything is supersized in perspective to severity.’ ‘The huge responsibility you have suddenly, where you would normally share this with 5 other doctors who know something about their own small area of medicine.’ ‘It’s tremendously frustrating, we have to compensate how we practise medicine. The things that we do, are not as good as they could be.’ If you are paralysed by indecision, you can’t do this job. So you have to be able to live with wrong decisions, and that is really hard to do.’ I’m really convinced that one the reasons why people need to have so much sex when they are on a mission is because they are facing very difficult situations that they are not used to. 5-10 patients are dying every day.

In summary, it’s a must-watch to get a glimpse of what it really means to work for an NGO like MSF.

Book:

Hope in Hell: Inside the World of Doctors Without Borders

About: ‘Hope in Hell’ offers an inside look at the work of Médecins Sans Frontières (MSF), or Doctors Without Borders, a global organisation providing medical aid in crisis zones. Dan Bortolotti traces MSF’s founding in 1971 and highlights its mission to deliver urgent care while speaking out against human rights abuses. Rather than portraying MSF volunteers as heroes, the author presents MSF workers as ordinary people driven by compassion and determination. Overall, Hope in Hell provides a powerful and honest portrait of humanitarian work and the courage it takes to bring help and hope to those in desperate need.

Why: The book highlights the challenges of delivering care in war zones, refugee camps, and disaster areas while showing the resilience and compassion required to save lives. It provides valuable insight into global health, medical ethics, and the emotional demands of humanitarian work. In the first chapter, we immediately learn about the important role of MSF. It is about Maternité Solidarité in Port-au-Prince, Haiti, and shows you how they were able to move a complete hospital. When the tsunami hit in 2010 they were able to build a 9000-square foot inflatable hospital in only 48 hours. On the other hand, the book openly addresses the possible drawbacks of working for MSF. In one of the last chapters, they highlight the possible dangers: ‘Aid workers are also at risk for malaria, typhoid, even HIV. But these illnesses, along with landmines, plane crashers and stray bullets, are occupational hazards that MSF field workers are prepared to confront. ‘Most MSF field workers are never abducted or physically assaulted, but they all know someone who has been. Many have their own stories about close calls: moments when they thought their number was up.

Returning from a mission to Western society can be highly challenging, as one MSF worker explains, describing the difficulty of dealing with patients who display entitlement and selfishness: ‘You know, your health care is some of the best in the world, and it’s free. So shut up’. These honest accounts from MSF workers are what truly make this book a must-read!

Podcast:

Working for Doctors Without Borders (MSF) with Dr Michael Malley

Where: Spotify & Geeky Medics

About: Dr. Micheal Malley, UK paediatrician, discusses how he became involved with MSF. He did five projects and four missions, starting in Iraq in 2018. He talks about his latest mission in South Sudan, where he spent four months in a rural area dealing with, amongst others, malaria and malnutrition.

Why: The podcast delves into what it’s really like to practise medicine in settings where patients are far sicker and resources are scarce. Through firsthand accounts, you’ll hear about working side by side with experienced local healthcare professionals and the invaluable skills that come from those collaborations. Dr. Malley also shares the emotional adjustment of returning home, moving from the relief of reuniting with loved ones to the shock of an over-abundant society where even butter comes in twenty varieties. Along the way, listeners gain practical insight into the limits of medicine and the complex ethical challenges, including “white saviorism.”

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘Hope in Hell: Inside the World of Doctors Without Borders’.

The post AM Team Recommendations October 2025 appeared first on Adventure Medic.

Since graduating five years ago, Dr Munro Moffat has spent time working in Zambia, Gambia, and now Japan. He has a special interest in global health and expedition medicine and has been an expedition medic in Morocco and recently completed the Diploma in Tropical Medicine and Hygiene. Outside of work he is usually found rock climbing or scrambling around the north of Scotland. After stumbling across an Adventure Medic facebook post advertising the job, he found himself working at a ski clinic in rural northern Japan for the winter.

This winter I spent my weekends cruising down fresh powder snow and my weekdays reducing shoulders and assessing knee injuries. This was through the incredible sports medicine and general practice training programme at Niseko International Clinic, Japan. Niseko, situated in northern Japan, famed for fresh powder snow, is a world class destination for snow sports. During the busy winter months, Niseko transforms as seasonal workers and tourists descend on the area for their chance to ride on the slopes by day and enjoy the culinary delights of Japan by night.

What is the Niseko International Clinic?

Niseko International Clinic is a private medical facility providing medical care to tourists and residents during this busy time. With English speaking staff and a focus on snow sport related injuries, the clinic itself is one of a kind in Japan. For the past two years the clinic has taken on international doctors for a sports medicine and general practice training program, and I was lucky enough to be offered one of these roles for the 2024/2025 winter season.

What was working at the clinic like?

In the busy months there was an endless supply of snow sport related injuries. As a novice skier, this definitely forced a moments pause before venturing onto the slopes to learn to ski myself. The clinic could see over 150 patients a day, with somewhere between three to five doctors on duty. Although I have worked in emergency departments in the UK for over a year, I had never had the opportunity to reduce fractures or dislocations. Becoming proficient in these skills was perhaps the best aspect of my time here. With no radiographers at the clinic I was also expected to perform my own x-rays. Having immediate access to the x-ray machine and being able to easily gain extra views proved very useful at picking up more subtle fractures.

Beyond the trauma, the clinic also runs a fever clinic. This aims to funnel the coughing and febrile patients away from the main clinic. I was initially sceptical of the positive pressure trailer used to replenish air within it every 15 minutes and maintain airflow away from the staff. However, after seeing respiratory tract infections multiple times a day and remaining well throughout the season I have become more trusting of it. There was a daily barrage of influenza patients and being able to confirm the diagnosis with point of care testing made the inevitable conversation around antibiotics far easier. Japan is incredibly liberal at prescribing antiviral medications for viral infections such as influenza, including a single dose inhaled medication called Inavir; not licensed in the UK. People fly from all over the world to Niseko, bringing with them infections that would not otherwise be seen here. I saw three confirmed cases of Dengue fever during my time here, a disease which is not endemic to Japan.

Management of typical injuries

There are significant differences in the presentations from snowboarding and skiing related injuries. Common to both were rib fractures, head injuries, shoulder injuries, and lacerations from ski or snowboard edges. In my experience, concussion patients receive a relatively poor standard of care in the UK. This usually consists of telling the patient there is no specific treatment and warning them of red flags to look out for. One great aspect of the clinic was working closely with the sports physiotherapy team. They are much more proficient at managing concussion;  with their support we were able to offer our patients a more structured approach to both returning to daily life and returning to sport. We recorded their symptoms on the Sport Concussion Assessment Tool 6 (SCAT6), and provided them with a six step approach to returning to sport. The SCAT6 allows a more objective measure of their symptoms, helping any progress, or lack of, to be more easily identified.

Snowboarders commonly injure their wrists and ankles, while skiers commonly injure their knees or Achilles (one particularly unfortunate patient suffering from bilateral Achilles tendon rupture). Amongst the paediatric skiing population we saw a high number of mid-shaft tibial fractures. For wrist injuries we saw daily distal radial fractures, providing the opportunity to learn how to perform haematoma blocks to reduce these.

Japan has more MRI machines per head of population than any other country in the world making access to MRI as easy as you would expect. With this “on the day” or next day MRI service we were able to guide holiday makers through their choices concerning their injuries and ongoing travel.

The patients themselves presenting to the clinic vary in their financial means and background. The seasonal workers tend to have limited means and live in overcrowded accommodation. As a result, scabies was a constant battle throughout the season. Perhaps another consequence of the cramped living conditions was the ever increasing burden of STI’s as the season progressed. In stark contrast to this, the holiday makers tended to come from very affluent backgrounds, with celebrity and royalty passing through the clinic. 

How was it working in private practice?

Japanese health care runs on a government sponsored health insurance programme. You pay a monthly premium for your health insurance entitling you to 70% off your, already heavily regulated, medical bill. Tourists are not eligible for this and so for the non-resident patients the clinic runs as a private medical practice. Like most doctors practising in the UK, this was my first experience of working in private practice. Adding a list of billable items at the end of my notes was certainly a novel experience, but there were benefits. It facilitated more of a conversation with patients about their treatment. Offering them a range of services and explaining what they needed and then the available optional extras became part of my practice. An example of this would be getting an MRI. Even if an MRI was needed, there was often not a clinical need for it to be done in Japan and it could wait until that individual went home. However, patient preference may be to get some answers sooner in order to give them some diagnostic certainty to aid their ongoing holiday plans. 

Being in a position to advocate for physiotherapy was great. In the UK physiotherapy on the National Health Service is limited, and often reserved for those we feel really need it. On the other hand, it became very uncomfortable when you felt like a Japanese government health insurance holder would benefit from something such as physiotherapy or STI screening, only to inform them that this would not be covered and thus an additional cost.

What are the challenges of working at the clinic?

Given how well set up the clinic is (with x-ray facilities, ultrasound, and in-house blood testing), it is easy to forget how remote Niseko is. This sometimes means rationalising medical decisions to adapt to the limitations of the local health service; a daunting experience. With no official emergency department, the out of hours service at the local hospital could be run by anyone from a dermatologist to a general surgeon. On top of this, hospitals can, and do, refuse to take patients if they feel they do not have the capacity. Depending on the ailment of your patient, you need to have a much higher threshold for referring them for inpatient management out of hours. One patient attended with abdominal pain and with the onsite blood testing was diagnosed with pancreatitis requiring hospitalisation. At this stage we started calling local hospitals but the referral was repeatedly declined. The clinic has no inpatient facilities or out of hours service, but with no safe place for the patient to go, staff stayed until eventually a hospital over two hours away agreed to accept the patient.

One rather unexpected challenge of my time at the clinic was managing the regular medication supply issues that occur across Japan. Whilst I was there the country experienced shortages of antibiotics and the highly used lidocaine. Penthrox is not licensed for use in Japan and the standard management at the clinic was intra-articular lidocaine for reducing anterior shoulder dislocations. The shortages forced us to do reductions without supporting analgesia.

What do you do in your downtime?

Putting shoulders back in and reducing distal radial fractures is definitely satisfying, but it is the snow that draws people here. I came here as a total novice on the slopes, but spent most weekends skiing. If you are experienced then there is an incredible world of backcountry skiing to explore. Strapping on your skis and flying down the local volcano (Mt Yotei) is a rite of passage for travellers to the area, but well beyond my skillset! When I could pull myself away from the powder there were many other treasures to explore in this often overlooked part of Japan. I experienced various snow festivals in nearby towns (think building sized snow sculptures) and tried ice fishing on a nearby frozen lake. Many of my evenings were spent in onsens (Japanese hot springs) and delving into the incredible culinary world of Japan. One of the greatest delights of Japan is going to the toilet. Never again do I want to suffer through an unheated toilet seat!

How to get involved

At the time of writing, applications for the 2025/2026 winter season were open. The position is not salaried, but my flights and accommodation were covered and I was given a stipend which was enough money to live off and enjoy life here. Medical Indemnity is also provided through the clinic. The medical director, Dr Moroi, is very supportive and takes the training aspect of your time here seriously. Any qualified doctor with at least 3 years of practice behind them can apply. I came out here with my wife and son and we have had an incredible experience as a family. Other doctors have come out on their own. A background in general practice, emergency medicine, or orthopaedics would suit the position best.

If this sounds like your dream job and you are willing to move to Japan for the winter, then reach out to Niseko International Clinic through their website or facebook page.

The post Life as a Doctor at The World’s Best Ski Resort appeared first on Adventure Medic.

From hammocks, mosquitoes, and beaches in paradise, to health care and humanitarian work in the jungles of Panama. Noemi is a physician specialising in gynaecology and obstetrics. She has an interest in mountain and expedition medicine following successful completion of both Diploma in Mountain Medicine and Masters in Extreme Medicine. Her passion lies in providing humanitarian care in remote and rural environments. Noemi is especially keen to advocate for women’s health, and in this article describes her work with Floating Doctors in August 2023.

Why Humanitarian Work? And Why Floating Doctors?

Choosing to engage in humanitarian work is not a decision to be taken lightly; it is a deeply personal choice that requires careful consideration. You must recognise the responsibility it entails, as well as your own abilities and the potential challenges you may face.

Finding the right organisation that aligns with your values can be a complex task and demands thorough research. Ultimately, I chose to work with Floating Doctors. This organisation provides community-based healthcare to rural, indigenous communities, where issues such as women’s and maternal health are particularly significant.

About Floating Doctors

The foundation for Floating Doctors’ mission was laid in 2010 during the massive earthquake in Haiti. Floating Doctors travelled there in the converted aid ship Southern Wind with 20,000 pounds of medical relief supplies.

Since 2011, Floating Doctors in Panama has been working to build and establish a permanent, sustainable programme for rural health services and community development aid in Panama. The programme covers a large part of the many small islands of Bocas del Toro, some of the more remote rural areas and is often the only medical, veterinary, or dental help within a radius of several kilometres. The Floating Doctors mission is “To reduce the present and future burden of disease in the developing world, and to improve healthcare delivery worldwide.”

For more information about Floating Doctors, see here.

What to expect upon arriving in Bocas del Toro and at the Floating Doctors Base

From Bocas del Toro, a boat transports all the volunteers to the Floating Doctors Base on Cristóbal Island. I arrived on a Sunday accompanied by six other volunteers. After settling into our rooms and receiving a brief introduction we gathered for dinner. During the meal everyone introduced themselves, both volunteers and permanent staff. The atmosphere at the Base was warm and welcoming, which immediately created a positive vibe. The volunteers came from diverse backgrounds, including doctors, dentists, veterinarians, physiotherapists, and nurses, as well as non-medical volunteers who assist with logistics and the general upkeep of the Base. People had travelled from all over the world.

Life on the Floating Doctors Base

The Base is powered by solar energy. There is a volunteer house where all the volunteers sleep, usually in bunk beds, with rooms accommodating up to four people. During my stay however, each volunteer had their own room. The number of volunteers fluctuates regularly. Mosquito nets and fans are provided for comfort. There is also a large washhouse with showers and toilets, as well as smaller cabins by the seaside for the permanent staff. The central communal building houses the kitchen, dining area, pharmacy and there is also a small meeting room available for general use. Three meals are served each day on weekdays and the food is always delicious. In your free time you can play volleyball, enjoy the surrounding sea, go snorkeling or try fishing. You can also experience the stunning bioluminescence in the water and gaze at the breathtaking stars in the sky.

Days at Clinics

Every day after breakfast, the cayuco (a traditional boat) is loaded with all the necessary equipment for the clinics. Everyone pitches in to help carry everything. Clinic weeks are organised into single-day and multi-day clinics.

Single-day clinic from Tuesday to Thursday

Monday serves as an introduction day, providing time to prepare for the clinic days ahead. From Tuesday to Thursday, we load the boat in the mornings and travel to the community. Once there, we set up the clinic and treat patients throughout the day. Around 4:00-4:30 p.m., everything is packed up, the cayuco is loaded, and we return to the Floating Doctors Base where we primarily sleep.

Multi-day clinic from Monday to Thursday

For communities that are further away, where a return trip within a day isn’t possible, a multi-day clinic is organised and we stay on-site overnight. These communities are typically large, with the number of patients exceeding the capacity of a single day, so treatment is spread over several days. During a multi-day clinic, volunteers sleep in hammocks within the community, and local residents cook for us.

Depending on your proficiency in Spanish, you will be assigned a translator from the Floating Doctors team. The team makeup changes daily, which allows you to get to know a broad range of colleagues quickly. An additional table is set up for nurses during clinics to record the vital signs of all patients, which may also include tests such as pregnancy or blood sugar measurements if necessary. Dentists, veterinarians, and physiotherapists usually work in separate areas with their patients when possible. Each community is generally visited by the Floating Doctors team approximately every three months.

Common illnesses and presentations

The most common conditions we encountered included fever, worms, scabies, various rashes, coughs, hypertension, diabetes, cataracts, musculoskeletal pain, headaches, dehydration and contraceptive injections. We also saw rarer conditions, such as leishmaniasis and a cheek abscess.

In general all doctors work as general practitioners, though they also treat patients related to their specialties. Given my training in obstetrics and gynaecology, I primarily cared for pregnant women and women with gynaecological concerns. Whenever questions arose regarding unclear or complex medical cases during the clinic, we could always refer to the treatment guidelines to determine the best course of action according to Floating Doctors’ standards. If needed, we could also seek advice from the Lead Medical Provider.

Special Cases

Case 1:

A little girl, around 10 years old, came to us saying that something was stuck in her ear and moving. She was so frightened that she could barely allow us to examine her. After gathering her courage, we used an otoscope and discovered a cockroach in her ear canal, which was moving but stuck. We couldn’t reach it with forceps, and the girl was too afraid to let us use them, so our Plan B was to apply coconut oil overnight to help the cockroach “slip out.”

We offered the family the option to return the following day if the condition hadn’t improved. Since the family didn’t return, we assumed the cockroach had eventually made its way out of the ear.

Case 2:

A 19-year-old pregnant woman came to our clinic. It was her first pregnancy, and she had never had a prenatal check-up. She planned to give birth at home, as is common in these communities. She reported that she could barely feel the baby moving. Given the size of her abdomen, it was clear the pregnancy was quite advanced. At that moment, the ultrasound machine was broken, and we had no ear trumpet with us, so we couldn’t check the baby’s heartbeat. After further examination and calculating her due date, we realised she was already 21 days overdue.

From a medical standpoint, it was evident that she needed to be hospitalised immediately. However, as is common in these communities, the inhabitants were very poor, and the boat ride to the mainland was prohibitively expensive. As a result, the young woman initially refused to go to a hospital. After lengthy discussions and a lot of persuasion, we were finally able to convince her to take a boat to the mainland and seek medical care at a clinic as soon as possible.

The uncertainty about whether the birth went well or whether complications arose—potentially with serious consequences—is one of the most challenging aspects of humanitarian work. It is a concern for every medical professional dedicated to helping those in need.

In a humanitarian setting diagnostic and treatment options, as well as available equipment, are often very limited. You can only provide the best advice and care possible with the resources at hand. Ultimately, it is up to the patients whether they follow the recommendations or not. Since we only visit the same community every few months, we must wait to find out if the patients followed our advice or treatment plans.

Fridays and Weekends

On Fridays, the pharmacy is thoroughly checked, and medicines are restocked, including all long term medications for patients with long-term conditions who will be seen the following week. Every Friday at 2:30 p.m., the boat to Bocas del Toro departs, allowing all volunteers to enjoy a well-deserved weekend in and around Bocas Town.

There is much to explore in and around Bocas del Toro. While Bocas itself is known as one of the most famous party destinations in Central America, the natural beauty of the islands and the surrounding smaller islands is equally stunning. Whether you’re looking to surf, snorkel, dive, or simply relax on a Caribbean beach, there’s something for everyone to enjoy.

When is the best time in your training or career to work with Floating Doctors?

While there are no minimum requirements, it is recommended to have at least two years of experience working in a hospital. I also found it very helpful to have completed a humanitarian aid course from World Extreme Medicine, which provided valuable insights and preparation for the challenges of working in a humanitarian setting.

What preparation is necessary?

The organisation provides excellent preparation. You will receive online access to all treatment guidelines and standards, as well as tips on how to reach the remote base and a list of essentials for both the base and the clinic.

Tips and tricks on what you should definitely bring with you:

• Crocs
• Coconut oil for the sandflies (‘chitras’)
• Mosquito repellent
• Anti-itch cream
• Snorkelling equipment
• Water bottle and lunchbox
• Power bank
• Hat, sunglasses
• Sun cream
• Raincoat
• Drysack for boat rides to the communities

Is it possible to work with Floating Doctors in the long term or to help as a non-medical practitioner?

Yes. It is possible to take on a long-term position of 6 months or more, either as part of a fellowship or in a non-medical role at the base. There are several positions you can apply for, including:

• Volunteer Coordinator
• Facilities Manager
• Medical Director
• Lead Allied Healthcare Provider
• Lead Medical Provider
• Operations Manager
• Lead Veterinary Provider
• Health Education Coordinator
• Communications Coordinator
• Lead Dental Provider
• Pharmacy Manager
• Dental Coordinator
• Clinic Manager
• Base Supervisor
• Executive Director

Further details and requirements can be found here.

What is the application process for volunteering with Floating Doctors?

The application process was straightforward and completed directly on their website here. Within a few hours, I received a welcoming response from the organisation confirming my acceptance.

For physician applications, the following documents were required:

• A copy of the licence to practise medicine
• A copy of the certificate of graduation
• A background check with information on criminal history or child protective investigations
• A coloured passport photo
• A copy of a curriculum vitae
• Proof of vaccination against COVID-19
• Distribution Fee for Volunteers depending on the term of the stay

Is there any way to help without volunteering?

Yes! There is always the possibility to donate here.

My experience – would I recommend it?

Working with Floating Doctors was an unforgettable experience. The combination of beautiful Caribbean islands, incredible people, and the chance to provide medical care and support to local communities made it a truly enriching journey. While there were challenging emotional moments and encounters with patients facing serious health issues, there were also many rewarding treatments and individuals who left the clinic in better health. It was deeply moving to experience life alongside the locals, who welcomed me with open arms and warmth. This experience has been invaluable, and I would gladly work with Floating Doctors again in the future.

The post Volunteering with Floating Doctors in Bocas del Toro appeared first on Adventure Medic.

Dr Zoe Carter Tai / ED Global Health Clinical Fellow / Bristol

Dr Constance Osborne / Evidence Explorer Lead / London

Contents

• Introduction and Collaborators
• Expedition and Wilderness Medicine Section
• Global Health and Humanitarian Medicine Section
• Want to get involved?

We are changing the publication schedule of the Evidence Explorer from now on. Instead of quarterly, we will be producing an article biannually, with all the best research the wilderness and global health medicine.

Thank you to our contributors and a particular shout out to Dr Murdoch for providing the accompanying images.

Dr Katherine Murdoch is an ED expedition clinical fellow in Bristol. In the past year, she has beens a medic on an ultra-marathon in the Jordanian desert, a camp medic in the Mexico Jungle, and worked as a festival first responder. More recently, she has been part of the paediatric blast injury partnership, assisting on the prehospital paediatric trauma course abroad. In her spare time she enjoys cycling, and last year she cycled unsupported across Japan and Korea.

Wilderness and Expedition Medicine

In this evidence explorer, we start by reviewing the role of tranexamic acid, and note that women and the elderly were less likely to be given the drug compared to men in the study. Tranexamic acid is often used in pre-hospital settings, yet it is less likely to be present in most expedition doctors kit bags. Time and more evidence may change that. Next up is a systematic review looking at the efficacy of expired anti-venom, which was largely positive, however, more evidence is needed. An article looking at the role of rashes in decompression sickness shows that any rash should be taken seriously and may indicate concurrent neurological effects. Ever wondered what a plane medical kit bag may contain? An American article outlines the kit list which has not been updated since 2006 and argues that there should be some important additions. Finally, a systematic review outlines a likely positive predictive relationship between pulse oximetry and acute mountain sickness. 

Evaluation of the prehospital administration of tranexamic acid for injured patients: a state-wide observational study with sex and age-disaggregated analysis

Girardello C, Carron P, Dami F, et al. EMJ. August 2024

Tranexamic acid is an antifibrinolytic which has been shown to reduce mortality in trauma patients. It is not routinely available in expedition medicine kit bags but this may change in the future. This study was a retrospective observational study in Switzerland between 2018 and 2021. The study looked at all patients who had an ambulance/helicopter dispatched who should have received tranexamic acid according to their BATT score – Bleeding Audit for Trauma and Triage. A total of 2401 patients were identified to be at risk of death from bleeding, however, only 11% received tranexamic acid. It was more likely to be given with higher BATT scores. However, women and elderly were significantly less likely to be given tranexamic acid.

The study had a large sample size, although it was carried out in Switzerland rather than the United Kingdom so it is unclear if the research is applicable to our population. Statistical analysis was clear and the confidence intervals were statistically significant. The study calls for qualitative research to understand why there was a difference in tranexamic acid administration between women and men.

Preclinical testing of expired antivenoms and its uses in real-world experience: a systematic review

Sutinee Soopairin, Chanthawat Patikorn, Suthira Taychakhoonavudh. EMJ. September 2024

Managing a patient with a suspected venomous snake bite relies upon prompt availability of anti-venom. This paper wished to assess whether the quality, efficacy and safety was degraded with expired anti-venom. They approached the study question by undertaking a systematic review in 2023 using four databases (PubMed, Scopus, Web of Science and Embase). A total of 15 studies were included, which was made up from 10 pre-clinical studies and five articles which described their use in the real world. The storage time ranged from two months to twenty years.

One of the studies assessed the quality of expired anti-venom and found it comparable to unexpired anti-venom. Five of the studies looked at the venom binding capacity and found this was comparable, with the caveat that efficacy declines with time from expiration.  The evidence for the systematic review was poor with small sample sizes and anecdotal evidence. The authors concluded that their findings are ‘inconclusive’ and more research is required in the future.

Potet responded to the article succinctly commenting that the ‘data, although incomplete, could also be helpful for national regulatory drug authorities to conduct a benefit-risk analysis and make informed decisions on a case-by-case basis about exceptional off-label use of expired vials, when non-expired antivenoms are unavailable. Obviously, use of expired antivenoms should be ‘the exception, not the rule’.

Clinical Significance of Mottling Rashes in Diving Decompression Sickness

Breen, Ilana D.; Stepanek, Jan; Marks, Lisa; Yale, Katerina; Mesinkovska, Natasha; Swanson, David. Aerospace Medicine and Human Performance. September 2024

Decompression sickness in divers occurs during ascent when the inert gas nitrogen enters tissues. The mechanism is poorly understood with the thought that the primary effect of nitrogen damages tissues by occlusion and the secondary effect is an inflammatory response causing further damage. Symptoms can include joint pain, chest pain, neurological deficit, headache, fatigue and a rash. (Decompression illness, RCEM learning)

This article carried out a systematic review to understand the relationship of the rash in decompression sickness and two outcomes – (1) paradoxical embolism across a right to left shunt (RLS) and (2) neurological effects. Four databases were searched over a sixty year period with a total of 31 articles meeting the inclusion criteria. Of the 128 pooled patients, 63 had neurological deficits and 76 had RLS. The majority recovered with hyperbaric oxygen treatment (84%) and there were four deaths.

Positively, the systematic review looked at a range of databases over a long period of time. However, there is a small sample size and the included studies were of varying quality. There was no mention of the limitations of the study or statistical analysis.

Clinicians should be aware that a rash in the context of suspected decompression sickness should be taken seriously and it should be a trigger for investigating for any other signs and symptoms.

Recommendations for Updates to Emergency Medical Kits for Commercial Aviation

Alaina Brinley Rajagopal, Adam Pissaris, Katharine Clark, Andrea Merrill, Robert Glatter, Amy Ho, Daryn C Towle, Justin Yanuck, Sari Lahham, Lindsey Ulin, Chanel Fischetti, Luke Apisa. Aerospace Medicine and Human Performance. October 2024

Have you ever been concerned when boarding a plane that they will call for a doctor to assist with a medical emergency? You’ve left your seat and wandered down the aisle apprehensively. You are given the on board medical bag and expected to assess the passenger.

There is a lot of planning involved in deciding what equipment and medications you will take on an expedition. You would expect the same level of planning for medical kits on commercial flights. This American article comments that the medical kits, although standardised by the Federal Aviation Administration, have not updated the contents list since 2006. You may notice that an automated blood pressure cuff, pulse oximeter, glucose meter and epipen are not included. The authors advocate for their inclusion in the article and for the introduction of a centralised data collection of all medical emergencies on commercial flights.

Next time you board a flight, you may need to remember how to draw up the correct dose of adrenaline and dig out the manual blood pressure skills from medical school.

Pulse oximetry for the prediction of acute mountain sickness: A systematic review

Johnathan S. L. Goves, Kelsey E. Joyce, Sophie Broughton, Julian Greig, Kimberly Ashdown, Arthur R. Bradwell, Samuel J. E. Lucas. Experimental Physiology. September 2024

Any individual at high altitudes is at risk of acute mountain sickness. The diagnosis is mainly a clinical one using a scoring system. This article carried out a systematic review using 7 databases to include any studies which involved human participants from lowland locations and monitored oxygen saturations to high altitude. The primary research question was ‘Is there a predictive relationship between oxygen saturation and subsequent development of AMS?’.

The study found ‘a predictive relationship between decreased resting 𝑆p⁢O2 measured around 3500 to 4000 m and the risk of developing AMS at higher camps’. Therefore, measuring oxygen saturations may be a useful tool with your clinical assessment when deciding if a participant should continue on a high altitude expedition.

There was an assessment for bias (low for six and moderate for one study), heterogeneity and there were transparent research methods outlined. It is noted that the times for when the measurement was taken varied between all the studies and this was raised as a limiting factor.

Heat Alert! These Medications May Influence the Risk of Heat Illness

Ashley Hedges, PharmD, BCPS, BCCCP. Wilderness Medicine Magazine. July 2024.

Finally, we came across this handy table to remind expedition doctors of medications which may affect heat illness. Further details available in the full article above.

Global Health Section

This section looked at six papers in total. The first explores perceptions of cancer in Ethiopia. We assessed the role of strong caregiver relationships in reducing post-conflict trauma in Congolese Youth. We reviewed two papers which used predictive technologies to identify patterns of disease. We reviewed strategies used to decrease sex-workers’ risk of HIV/AIDS in Zimbabwe. Finally we discuss how up-skilling medical workers in rural areas in Nepal can improve obstetric care.

Perceived causes of cancer in a rural community of Ethiopia: a qualitative study

A.Wondimagegnehu, M.Gizaw, L.Abebe, et al. Global Health Action. September 2024.

Cancer incidence is increasing worldwide and is projected to reach 30.2 million cases over the next two decades, with two-thirds occurring in low- and middle-income countries. In 2020, Ethiopia was estimated to have over 77,000 new cancer cases and more than 50,000 cancer-related deaths, with breast and cervical cancers being the most common. Community-based studies in southern Ethiopia have shown that cancer knowledge is approximately 11%, with rural residents displaying lower overall awareness—likely due to limited education and access to basic healthcare services. This is reflected in the frequent late presentations of cancer and the continued reliance on traditional healers and religious leaders.

This study aimed to fill a gap in qualitative data regarding perceptions of cancer, with the goal of improving early identification and treatment. Researchers surveyed 58 participants from four remote villages located 135 km from the capital. The participants included a diverse group, ranging from health professionals to community members. Each participant took part in two semi-structured interviews exploring their perceptions of cancer, including its causes, signs and symptoms, transmission, treatment, and prognosis.

Data were collected through focus group discussions and in-depth interviews conducted in various configurations to ensure participants could freely express their views—for example, within maternal and child health groups, and in gender-specific sessions. Data collection continued until saturation was reached, meaning no new themes emerged. The findings were categorized into four areas within each broad theme: (1) desirable and beneficial, (2) undesirable and harmful, (3) non-existent or incomplete, and (4) benign perceptions.

Many participants described cancer as a very dangerous disease that is difficult to treat, often referring to it by the local term “Nekersa.” Most recognized weight loss as a significant symptom of cancer. While there was general awareness of breast and uterine cancers, few participants mentioned cancers of the brain, neck, lungs, abdominal organs, bones, or legs. Participants believed cancer could be caused by “bad air,” but also expressed several other misconceptions, categorized as undesirable and harmful—for example, exposure to sunlight during breastfeeding, and transmission through sharp objects or breastfeeding.

Benign perceptions included beliefs such as cancer being caused by exposure to bad air, sunlight after preparing traditional alcohol, storing coins under the bra, or urinating in the direction of the sun or moon, or on dirty ground. A recurring belief was that urinating on contaminated soil would allow dust or ash to enter the uterus, causing cancer. Cancer was most often associated with the appearance of a visible wound as the first sign of disease. Additionally, there was confusion between cervical cancer and other conditions such as menstrual bleeding, hemorrhoids, fistulas, and sexually transmitted infections, due to overlapping symptoms.

This study will contribute to the design of more effective public health campaigns by addressing and correcting community misconceptions about cancer.

Close relationships with caregivers as protective factor for the mental health and functioning of war-affected Congolese youth

F.Scharpf, R.Haer, T.Hecker. Conflict and Health. October 2024.

Conflict-affected youth face significant risks to their well-being due to high levels of trauma exposure and, in many cases, involvement in violent acts as members of armed groups. This regression study examined the association between the quality of caregiver relationships and the protective effect these may have on the link between traumatic experiences and various indicators of adjustment—specifically, post-traumatic stress symptoms (PTSS), emotional problems, behavioural issues, and criminal behaviour.

As of 2022, over one in six children globally were estimated to live in conflict-affected areas, alongside a rise in child soldier recruitment. War-related trauma is a well-known risk factor for poor mental health, with greater exposure correlating with a higher likelihood of aggressive and violent behaviour.

The study assessed 268 war-affected youth in the Democratic Republic of Congo, around half of whom were former members of armed groups. Participants were recruited through local child protection organisations using convenience sampling. Data were gathered via individual, structured quantitative interviews, and participants received $5 compensation. Mental health referrals were provided as needed. The questionnaire evaluated socioeconomic characteristics, war-related trauma exposure and violence perpetration, perceived caregiver relationship quality, PTSS, emotional and behavioural problems, and criminal behaviour.

As expected, higher trauma exposure was significantly associated with increased PTSS and emotional problems. Greater perpetration of violence was linked to higher rates of PTSS, behavioural issues, and criminal behaviour.

A better-quality caregiver relationship was associated with lower levels of these problems, especially in cases of high exposure. The findings show that perceived caregiver relationship quality moderates the link between war-related trauma and youth adjustment. This reinforces the importance of a supportive home environment as a key protective factor for mental health and functional recovery.

Youth rated caregiver relationships highly when they were emotionally warm and supportive, helping them process and cope with trauma. Maladjustment was partly linked to community and family stigma. Caregivers who showed forgiveness and acted as mediators in their communities helped reduce stigma and support reintegration, aiding the healing process.

Use of Open-Source Epidemic Intelligence for Infectious Disease Outbreaks, Ukraine, 2022

A.Kannan, R.Chen, Z.Akhtar, et al. Emerging Infectious Diseases. September 2024.

During conflict, public health surveillance is often disrupted, hindering epidemic tracking and increasing outbreak risks. Even before Russia’s invasion in early 2022, Ukraine had some of the world’s lowest vaccination rates (for COVID-19, polio, and measles) and high rates of TB and HIV/AIDS—partly due to ongoing conflict since 2014. The invasion worsened these issues by disrupting vaccination programs, limiting testing, and causing displacement and overcrowding.

The conflict also damaged access to clean water, housing, nutrition, hygiene, and sanitation. Formal disease surveillance largely ceased post-invasion. This study explored the use of open-source data—including news, social media, and medical reports—combined with AI to generate early warning signals and provide epidemiological data over two years, spanning before and after the invasion.

Researchers used EPIWATCH, a system that scans 200 disease-related terms in 46 languages; 70% of data came from non-English sources within Ukraine. Reports were included only if they involved confirmed, probable, or suspected infectious or zoonotic diseases. The top eight most reported diseases were compared to official surveillance data from the same period.

Between February–July in 2021 and 2022, outbreak reports increased by 447%. Gastroenteritis cases, including cholera and dysentery, rose notably. A meningitis report from July 31, 2021, indicated a rise in viral and bacterial meningitis cases since pre-invasion.

The disease profile shifted post-invasion—from COVID-19, influenza, and polio, to COVID-19, cholera, botulism, TB, HIV/AIDS, salmonellosis, and diphtheria. Cholera had not been reported before the conflict. Most diseases were not formally reported during the invasion, except for botulism, TB, and diphtheria. Botulism was more prevalent in formal reports than EPIWATCH, while TB was vastly underreported (5,647 cases in EPIWATCH vs. 113 officially reported). Both sources recorded two diphtheria cases.

The study also underscored how worsening hygiene and sanitation contributed to outbreaks like cholera and gastroenteritis. Ultimately, this study demonstrated the utility of combining AI with open-source intelligence to detect and monitor disease outbreaks during conflict, especially when formal surveillance is compromised.

Cost-effectiveness and health impact of screening and treatment of Mycobacterium tuberculosisinfection among formerly incarcerated individuals in Brazil: a Markov modelling study

A.Titan, F.Klaassen, D.Pelissari et al. The Lancet Global Health. September 2024.

This study modelled the health impact and cost-effectiveness of TB screening and treatment among previously incarcerated individuals in Brazil—a group currently ineligible for TB prevention despite their high incidence rates. The aim was to evaluate whether implementing a TB screening and preventive treatment (TPT) program in this population could reduce disease burden and be cost-effective.

Prisons act as TB amplifiers due to overcrowding, poor ventilation, and higher baseline disease prevalence. Incarcerated individuals also face increased TB risk due to malnutrition, untreated comorbidities, smoking, and drug use. In Brazil, TB notification rates are 40 times higher among incarcerated individuals. Brazil has committed to the WHO’s End TB Strategy, aiming to eliminate TB by 2030.

Using a Markov state-transition model, the study simulated TB-related health outcomes and costs in the previously incarcerated population. It compared several infection tests and TPT regimens against a no-screening scenario. Outcomes included reductions in TB cases, deaths, and disability-adjusted life years (DALYs) per 1,000 people. Costs (in USD) were estimated by comparing intervention and baseline scenarios, and results were expressed as the incremental cost per DALY averted. The model population had a mean age of 30, had been incarcerated for at least two years, and had been released three months before the intervention.

All TPT strategies were found to be cost-effective compared to no intervention. TB incidence dropped from 225 to 184 per 100,000 with intervention. DALYs averted were greatest among younger individuals and those tested soon after release, particularly if incarcerated for two years or less. Any combination of testing and treatment was more beneficial than no screening. IGRA testing offered greater health benefits than TST, and shorter TPT regimens were more effective than longer ones.

Limitations included not accounting for reincarceration, a wide range of uncertainty due to limited data, and omission of TB drug resistance. However, these did not significantly affect the cost-effectiveness estimates. The study concluded that resources should be directed toward TB screening and treatment in formerly incarcerated populations.

A risk-differentiated, community-led intervention to strengthen uptake and engagement with HIV prevention and care cascades among female sex workers in Zimbabwe (AMETHIST): a cluster randomised trial

Prof F.Cowan, F.Machingura, M.Ali et al. The Lancent Global Health. September 2024.

Female sex workers are disproportionately affected by HIV. This study assessed the effectiveness of peer support for female sex workers in Zimbabwe in reducing their risk of acquiring or transmitting HIV over just over two years (May 2019 to December 2021). It was a cluster-randomised, open-label, controlled trial involving 22 clinics dedicated to female sex workers, each within a government health facility, randomized to either standard care or the AMETHIST intervention.

Standard care included HIV testing, pre-exposure prophylaxis (PrEP), referral to government antiretroviral therapy (ART) services, contraception, condoms, syndromic management of sexually transmitted infections, health education, legal advice, and peer support. The AMETHIST intervention added peer-led microplanning tailored to individual risk and self-help groups. Data reviewers were blinded to intervention status, although program implementers were aware.

Participants were followed up after 28 months via survey to assess the primary outcome: the proportion of sex workers at risk of acquiring or transmitting HIV. Risk of transmission was defined as HIV-positive individuals who were not virally suppressed and inconsistently used condoms. Risk of acquisition was defined as HIV-negative individuals who inconsistently used condoms or PrEP.

The study found no overall reduction in combined risk of transmission or acquisition from the intervention. However, viral load suppression improved in the AMETHIST group, suggesting better ART adherence.

Successful task shifting: a mixed-methods cross-sectional evaluation of an emergency obstetric care program to increase access to caesarean sections in rural Nepal

R.Budhathoki, A.Knoble, S.Tamang, Et Al. Global Health Action. December 2024.

In 2020, an estimated 800 women died daily worldwide from preventable childbirth-related causes, mostly in low- and middle-income countries (LMICs). Approximately 86% of these deaths were due to obstetric complications. Nepal’s maternal mortality ratio (MMR) remains high, with 12% of deaths among women of reproductive age attributed to preventable obstetric causes and a shortage of doctors. Improved access to medical interventions like cesarean sections (CS) could reduce MMR by 63% in low-income countries. The WHO recommends CS rates of 10–15%, but Nepal’s rate was only 5.9% in 2020, partly due to uneven distribution of skilled healthcare workers.

To address this, a Nepalese NGO and the National Health Training Centre developed a 70-day Advanced Skilled Birth Attendant (ASBA) program in 2013 to train non-specialist medical officers (MOs) to perform safe CS and manage obstetric emergencies. Graduates were placed in facilities with emergency obstetric care and operating theaters. This mixed-methods study used surveys, interviews, and focus groups to assess the program’s effectiveness and barriers to CS availability.

Of 234 ASBA graduates surveyed, 93 responses were analyzed. Over 90% performed CS after training, 75% did so unsupervised, and 65% continued performing CS up to 10 years later. Factors supporting ongoing CS practice included temporary contracts, presence of another ASBA, and longer facility tenure. Where CS was not performed, over half cited the lack of a functional operating theater. The presence of ASBAs increased patient presentations and reduced referrals, especially in rural areas and where multiple ASBAs worked.

Barriers included presence of specialist teams, hospital level, and lack of infrastructure such as blood banks. Participants suggested adding abortion care and emergency hysterectomy training to the curriculum, along with follow-up and refresher courses.

This study supports training MOs through ASBA-style programs to fill human resource gaps, improve safe obstetric care, and enhance rural hospital conditions in LMICs.

That’s all folks! We will be coming back at you better than ever in the next few months with a new edition of the Evidence Explorer.

The post Evidence Explorer: Updates and news from the academic community, Winter 2024 appeared first on Adventure Medic.

Loved By All: The Story of Apa Sherpa

Where: Vimeo

About: The film traces the journey of Apa Sherpa, a Nepalese mountaineer who holds the world record for climbing Mount Everest 21 times. Yet behind this extraordinary accomplishment lies a story of hardship; Apa was forced to leave school at the age of 12 and work as a high-altitude porter after his father passed away.

Why: While many mountaineering films focus on the triumphant climber who conquers the summit after overcoming great odds, this documentary takes a different path. It’s a human tale of resilience, sacrifice, and the unsung heroes behind those iconic ascents. By shifting the spotlight to the Sherpa community, the film highlights the harsh economic realities and social pressures, particularly the difficult trade-offs between pursuing education and taking on risky, high-altitude work.

Book:

The Modern Explorers

About:  The book is about forty contemporary adventurers who continue to push the boundaries of exploration in the modern world and challenge the notion that the world has no frontiers left to explore. The book is organised into nine themed sections, such as Polar, Desert, Ocean, Rainforest, highlighting expeditions in extreme and remote environments. Each explorer shares first-hand accounts of their journeys, offering insights into both physical challenges and personal motivations.

Why: Because most of the stories are told by the explorers themselves, they come across as vivid and deeply authentic. For anyone fascinated by modern-day adventurers embarking on remarkable journeys to the world’s most remote places, this book offers powerful inspiration. As seasoned explorer John Blashford-Snell aptly says: ‘In these dark days of world tension, this expedition showed that people of many nations, inspired by a sense of adventure and with a healthy contempt for difficulties and dangers, can come together and perform a worthwhile task.’

Podcast:

CoROM Podcast – Expedition Dentistry with Burjor Langdana

Where: Spotify

About: Aebrhric O’Kelly, a critical care paramedic and former Green Berett talks to Burjor Langdana about Wilderness and Expedition Dentistry. Burjor trained in maxillofacial surgery in India and later worked in Oman, the UK, New Zealand, and Malawi, gaining extensive experience in well-resourced and extremely limited settings. He shares his passion for providing dental care in an austere setting, teaching others how to do so and is an Adventure Medic patron. He also created the Wilderness Dentistry website, offering free videos, articles, and downloadable materials for remote dentistry.

Why: Most medics and paramedics receive little or no formal training in dental emergencies, despite the fact that dental problems are common and can become serious in the field. In this podcast Burjor Langdana shares practical lessons from years of delivering dental and facial trauma care in some of the world’s most challenging environments like Antarctica.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘Modern Explorers’.

The post AM Team recommendations June 2025 appeared first on Adventure Medic.

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/

The post From Land to Sky – A Retrieval Medicine Elective appeared first on Adventure Medic.

Kacylia Roy Proulx is a third year medical student at McGill University with an interest in expedition medicine. She took on the challenge of climbing Mount Kilimanjaro as both a personal endeavour and an opportunity to see physiology and mountain medicine in action. Here she shares what she learned preparing for and executing the climb. 

In July 2024, I embarked on one of the most transformative experiences of my life – climbing Mount Kilimanjaro. Standing at 5,895 meters, Africa’s highest peak is a challenge that demands both physical and mental resilience. As a third year medical student with an interest in wilderness, expedition and trauma medicine, this climb was more than just a personal goal. It was a unique opportunity to observe first hand the effects of altitude on the human body and connect these experiences to the research and lectures I had studied before the ascent. What I didn’t anticipate was how much the mountain would teach me – not only about medicine but also about perseverance and personal growth.

Understanding High-Altitude Physiology

Kilimanjaro is often described as one of the most accessible high-altitude climbs. It doesn’t require technical climbing skills, making it a popular destination for trekkers of all backgrounds, with approximately 35,000 to 50,000 climbers attempting the summit each year. However, while the trek itself may be non-technical, the altitude poses significant physiological challenges, reducing its success rate to about 65%.

With every 1,000-meter increase in elevation, oxygen levels decrease by around 3.5%, forcing the body to work harder to meet its oxygen demands and significantly increasing the risk of altitude sickness. To understand why, it is important to examine what happens during ascent. The percentage of oxygen in the air remains constant at 21% regardless of altitude. What changes is atmospheric pressure, which decreases with elevation. This reduction in atmospheric pressure lowers the partial pressure of oxygen – the driving force that moves oxygen into the bloodstream. At sea level, the partial pressure of oxygen is approximately 159 mmHg, but at 5,000 meters, atmospheric pressure is roughly halved, reducing the partial pressure of oxygen’s to around 80 mmHg. This explains the cascade of symptoms and physiological changes climbers experience at high altitudes.

Here’s how it works: the lungs rely on a pressure gradient to move oxygen from the inhaled air in the alveoli into the blood. When the partial pressure drops, less oxygen diffuses into the bloodstream, leading to hypoxaemia (low blood oxygen levels) and, consequently, hypoxia (low oxygen availability in the tissues).

The body has a host of physiological responses that enable it to adapt, or acclimatise, to these conditions. Within hours, heart rate rises to increase cardiac output and support oxygen delivery. The respiratory rate also increases. This hyperventilation increases both oxygen intake and carbon dioxide removal, leading to hypocapnia, which increases blood pH and induces a state of respiratory alkalosis. Whilst an alkalotic state actually shifts the oxygen-haemoglobin dissociation curve to the left, making it more difficult to unload oxygen to the tissues, the decrease in hydrogen ions that causes the alkalosis stimulates a compensatory mechanism in which 2,3-diphosphoglycerate (DPG – a compound found in red blood cells) levels are increased. This increase in DPG shifts the curve back to the right, facilitating enhanced oxygen delivery to the tissues.

Within weeks red blood cell production (erythropoiesis) accelerates and angiogenesis occurs, providing new capillaries to improve oxygen delivery to the tissues.

In the lead up to the climb, I immersed myself in medical literature on high-altitude physiology. I was fascinated by the body’s ability to adapt to extreme environments and determined to understand the mechanisms behind conditions like Acute Mountain Sickness (AMS). AMS, which can occur at elevations as low as 2,500 meters, arises when the body struggles to acclimatise quickly enough to reduced oxygen levels. Symptoms like dizziness, nausea, headaches, and difficulty sleeping are hallmark signs of AMS.

However, AMS isn’t the end of the story. If left unchecked, it can progress to severe and potentially life-threatening complications, such as High-Altitude Cerebral Edema (HACE) and High-Altitude Pulmonary Edema (HAPE), however not all who develop HACE or HAPE experience AMS symptoms. Although the pathophysiological mechanism of HACE is not fully understood, in simple terms it is thought to occur due to hypoxia-driven neurohormonal and haemodynamic changes which cause cerebral vasodilation and increased permeability of the cerebral vasculature, leading to cerebral oedema and a rise in intracranial pressure. This can present as confusion, ataxia, severe headaches, and, in extreme cases, coma and death.

HAPE, on the other hand, is caused by uneven vasoconstriction in the pulmonary arteries, a response to low oxygen levels. Hypoxia triggers pulmonary blood vessels to constrict, redirecting blood flow to better-oxygenated areas of the lungs. However, this process can occur unevenly, creating localised areas of high pressure. This increased pressure forces fluid out of the capillaries and into the alveoli thus impairing gas exchange. Symptoms of HAPE include shortness of breath, a persistent cough (classically producing frothy or blood-streaked sputum), and cyanosis. If untreated, the strain on the pulmonary circulation can lead to right heart failure, compounding the risk of fatal outcomes. Both HACE and HAPE require immediate descent and, if available, medical intervention to prevent further deterioration.

Understanding these risks heightened my vigilance during the climb as I closely monitored myself and my fellow climbers for any early warning signs. One climber in my group began experiencing altitude sickness as early as the third day of our trek, with severe vomiting, dizziness, and headaches. We immediately slowed the pace, increased her water intake, and ensured she was eating enough, as proper hydration and nutrition are essential for managing and preventing altitude sickness. While her symptoms were relatively mild, they were a stark reminder of how fragile the human body can be in extreme conditions. With rest and care she improved but remained vulnerable over the following days, requiring close monitoring for any further warning signs.

In addition to our personal vigilance, our guide implemented an important safety measure: taking the oxygen saturation levels of everyone in the group every evening. This provided an objective way to monitor how our bodies were coping with the increasing altitude. At sea level, healthy individuals typically maintain oxygen saturation levels between 95% and 100%. However, as we ascended, the reduced atmospheric pressure caused oxygen saturation levels to drop significantly. By tracking these levels daily, the guide could identify early signs of hypoxemia, which could signal an increased risk of severe altitude sickness. This allowed for timely interventions, such as slowing the pace, administering supplemental oxygen, or even descending to a lower altitude if necessary. It was fascinating to observe how individual responses varied, with some climbers maintaining relatively stable readings while others saw more dramatic declines. These small but critical measures underscored the importance of preparation, monitoring, and teamwork in tackling the challenges of high-altitude trekking.

The Role of Preparation

Preparation is the key to a successful and safe climb. For me, it became clear that understanding the medical principles behind these strategies, combined with careful personal preparation, made all the difference during my Kilimanjaro climb.

Physical fitness plays a crucial role in tackling the demands of high-altitude climbs. A higher level of cardiovascular fitness can be an advantage, particularly when adjusting to lower oxygen levels. Fitness improves circulation, endurance, and the body’s ability to handle increased strain. A prospective observational study at extreme altitudes conducted in 2023 found that climbers with higher maximal oxygen uptake (VO2 max) at sea level and moderate altitudes had a better chance of reaching the summit and a lower risk of experiencing severe altitude sickness.

Before the climb, I made sure to train specifically for the challenge. Although I maintain a baseline level of fitness, I knew that high-altitude trekking required some additional preparation. In the months leading up to the climb, I focused on hiking in the mountains near my home, particularly in the Adirondack Mountain Chain. This allowed me to simulate the conditions I would face on Kilimanjaro, testing not only my fitness but also my gear. On weekends, I would set off on longer hikes, carrying a loaded pack to get used to the strain of altitude while refining my pacing. During the week, I maintained my cardio fitness with activities like running and cycling, focusing on building endurance and strengthening my legs. Combining these different types of training helped me feel confident that I was physically prepared for the demands of the climb.

However, physical fitness alone isn’t enough to protect against altitude sickness. Even the fittest climbers are at risk, and that’s where pharmacological interventions like acetazolamide can be considered. Acetazolamide, a carbonic anhydrase inhibitor, is sometimes recommended to help prevent altitude sickness by stimulating the kidneys to excrete bicarbonate, leading to mild metabolic acidosis. As a prophylactic measure, this facilitates acclimatisation by stimulating ventilation and therefore increasing alveolar and arterial oxygen levels. Taken at altitude, this acidosis compensates for the respiratory alkalosis caused by hyperventilation, favouring increased oxygen delivery to the tissues which can help prevent and treat symptoms of AMS.

The Importance of Acclimatisation

With all aspects of preparation in place, acclimatisation became the final, essential piece of the puzzle for avoiding altitude sickness and reaching the summit. Initially, the body responds by increasing alveolar ventilation, helping improve oxygenation in the blood. As you climb higher, plasma volume decreases, which raises the concentration of haemoglobin, enhancing oxygen carrying capacity. Over time, this process stimulates the production of red blood cells, which further increases oxygen transport to tissues and organs.

Kilimanjaro’s Lemosho route, which we followed over 8 days, is renowned for its gradual ascent, allowing for improved acclimatisation. This slower pace is why the Lemosho route boasts a high success rate, ranging from 80-90%. On several occasions, we hiked to higher elevations during the day and returned to a lower altitude to sleep. This practice, called “climb high, sleep low,” is a key strategy to help your body adjust without overburdening it.

The Mental Health Component of Climbing

While physical endurance is essential for climbing a mountain like Kilimanjaro, the mental component is just as crucial – if not more so. The psychological toll of high-altitude trekking is something I hadn’t fully anticipated until I was deep into the climb. After several days of trekking, I began to notice the psychological effects of the altitude: sleep disturbance, irritability, and a constant, underlying sense of exhaustion that weighed on me more than I expected.

It wasn’t just the physical fatigue that affected me – it was the mental fatigue that came with it. The body’s struggle to get proper rest at high altitudes plays a big role. Research backs this up, showing that sleep quality significantly declines as you ascend. The lower oxygen levels make it more difficult for the body to enter the deep stages of sleep, which are essential for muscle recovery. I noticed that even when I did manage to fall asleep, I would wake up multiple times throughout the night, feeling restless and unrefreshed. This sleep deprivation, combined with the physical exhaustion, led to moments of mental struggle – times when my patience was tested, and my mood would fluctuate, making the climb feel even more challenging.

The cognitive effects at high altitude also became more evident as the days passed. It wasn’t just physical performance that I had to focus on, but mental sharpness too. Simple tasks, like remembering small details or keeping my attention on the path ahead, started to feel more challenging. Research has shown that cognitive function at high altitudes can suffer. Short-term memory, decision-making, and attention span can decline as the body adjusts to the reduced oxygen levels.

Despite these mental challenges, I found ways to cope. The climb itself, with its pole – pole, slow and steady rhythm, helped me focus on smaller, manageable goals rather than the overwhelming task of reaching the summit. I would focus on the next step, the next bend in the trail, or making it to the next camp. It was these small victories that kept me going.

The Risk of Hypothermia

As the mental and physical challenges of the climb continued to weigh on me, I was reminded that in high-altitude environments, the threat of hypothermia is ever-present. On the seventh day of our climb, we woke up at 1am, ready to start our summit push – a 7-hour climb in the dark and freezing temperatures to reach Uhuru Peak at 5,895 meters for sunrise. Despite the exhilaration of the summit, the biting cold was unrelenting. My gloves barely seemed to keep the cold at bay, and my fingers began to tingle ominously – a subtle but significant warning sign of frostnip, the precursor to frostbite.

Hypothermia becomes a real risk when heat loss exceeds heat production, especially as the body burns through energy reserves at an accelerated rate just to maintain basic functions. The body’s natural response to the cold is peripheral vasoconstriction, which diverts blood flow away from extremities to preserve core temperature. However, this process also sets the stage for frostbite in unprotected tissues.

As I stood there, I felt the conflicting pull between the desire to take in the breathtaking view and the urgent need to retreat from the unforgiving conditions. I could sense how exhaustion, combined with the freezing cold, could make it easy to overlook the early signs of hypothermia – shivering, clumsiness, and slowed thought processes. I tried to keep moving to generate heat, wiggling my toes inside my boots and flexing my fingers inside my gloves. Taking my gloves off for a quick photo was a painful reminder of how quickly the cold can penetrate; within seconds, my fingers felt as if they were being stabbed by needles, a stark indication of just how little time it takes for exposed skin to begin freezing. As I checked my hands for any signs of white or waxy skin, I was struck by how textbook symptoms suddenly felt very real.

Reaching the summit was euphoric, but the risks were impossible to ignore. The thin air and intense cold meant we couldn’t linger long. Descending felt like a race against time to escape the cold, and as I moved lower, the tingling in my fingers and toes slowly subsided, a reassuring sign that circulation was improving. This experience underscored the delicate balance between adventure and safety, between pushing limits and respecting the body’s fragility in the face of nature’s extremes.

A Summit of More Than Just Altitude

Reaching the summit of Mount Kilimanjaro was more than a personal achievement; it was a powerful first-hand lesson in the balance between human resilience, preparation, and the unpredictability of nature. The climb not only tested my physical and mental limits but also offered valuable insights that I continue to apply to my medical career. Understanding how the human body reacts under extreme conditions – whether due to altitude, trauma, or other stressors – will shape my approach to patient care.

But most importantly, Kilimanjaro, for all its beauty and challenge, has shown me that the journey to the summit is never just about reaching the top – it’s about the lessons learned along the way.

The post Where Medicine Meets the Mountain appeared first on Adventure Medic.

Dr Abigail Wrathall / EM Registrar / North of Scotland

Original Article:

Chris Imray / Consultant Vascular Surgeon, Coventry and Warwickshire NHS Trust

Andy Grieve / Deputy Senior Medical Officer, RAF Valley, Anglesey

Charles Handford / RAMC, Medical Student, University of Birmingham

Ben Cooper / Charge Nurse, A&E, Northern General Hospital, Sheffield

Sean Hudson / General Practitioner, Maryport

In 2013, Adventure Medic published this review of frostbite, with a detailed breakdown of the condition and the evidence for its identification and management. This is an update to that article, with thanks to the original authors.

Frostbite is a vascular injury, as a result of exposure to cold temperatures. Risk increases with reductions in temperature, and so as expedition and extreme medicine providers we must be aware of the condition, especially the avoidance, recognition and early management whilst out in the field. As humans push further into wild environments and sadly as large numbers of people become unhoused due to socio-economic circumstances, politics, and war; frostbite is set to become an increasingly frequent presentation, and has significant long term effects on quality of life and function.

How, why and where?

Frostbite most commonly affects the feet and hands, however can be identified in many other places across the body: nose, ears, chin, buttocks, and the penis. These reflect the activities undertaken in cold environments: mountaineers and adventurers exercising in extreme cold and high altitude; and sitting on cold surfaces, especially in people experiencing homelessness.

There are four phases to frostbite:

Pre-freeze: where the tissues cool, vessels vasoconstrict and blood flow is reduced leading to ischaemia. There may be paraesthesia at this stage.
Freeze-thaw: ice crystals form during the freeze, causing deranged proteins, lipids and electrolytes, disruption of cell membranes and eventually cell death. During thaw, there is further ischaemia with reperfusion injury & massive inflammatory response.
Vascular stasis: blood vessels cycle between vasodilation and -constriction, with fluid & protein leaking due to vessel wall damage and intravascular coagulation.
Late ischaemic: inflammatory cascade leads to progressive tissue ischaemia and infarction, intermittent vasoconstriction and vasodilation results in continued reperfusion injury, and emboli & coagulation in downstream vessels.

The inflammatory cascade is responsible for much of the damage caused by frostbite. This is mediated by a number of factors, including histamine, bradykinin, thromboxane A2 and prostaglandin F2alpha. The disruption of vascular function and destruction of microcirculation results in cell death. If repeated exposure to freezing is experienced, the damage is compounded.

Prevention and avoidance

Before discussing identification and treatments, it is important to note that there are several things that can be done to avoid frostbite all together. As ever, prevention is the best cure. The core of prevention is a combination of maintaining perfusion and reducing heat loss. The use of exercise to avoid frostbite is a recommendation to be applied with caution. There is ongoing research into chemoprophylaxis for frostbite.

Perfusion

There are several ways to maintain perfusion. Ensuring adequate core temperature; good hydration and nutrition; reducing exposure by covering all skin and avoiding restrictive clothing, including too-tight footwear and tight cuffs on jackets. There is also some evidence for using supplemental oxygen in high altitude environments to improve perfusion & oxygenation of peripheral tissues – this appears to be predominantly due to an inability with hypoxia to maintain a sufficient core temperature. In addition, mountaineers not using supplemental oxygen for summit attempts are breathing more rapidly and deeper, leading to increased volume of cold air exposure.

Reducing heat loss

Simple tactics can make the biggest difference in terms of safety in extreme cold. Ensuring appropriate clothing is being used by individuals; replacing clothing – especially gloves – which become wet (including with perspiration); avoiding sweating by using appropriate layering for the environment; encouraging individuals to avoid the use of alcohol and drugs; recognising signs of hypoxaemia that may alter behaviours; use of electrical and chemical warming devices, including heated socks/gloves, and hand/foot warmers (with caution to avoid direct skin exposure and reduced blood flow due to tight footwear). Recognition of early signs of frostnip/frostbite is also key to avoiding further damage.

Exercise

There is no doubt that exercise raises core body temperature, and therefore can increase blood flow and perfusion of extremities. However, exercise often causes perspiration, leading to increased heat loss as detailed above. It also increases energy use and in extremes can lead to exhaustion, exacerbating rapid heat loss. It can be a helpful method to avoid cold injury in moderation.

Chemoprophylaxis

The use of prophylactic medication is not commonplace, and is still an area lacking in research. There have been mouse studies into ‘antifreeze’ proteins, however as it stands there are no available or recommended medications for preventing frostbite in humans.

Classification and recognition

Frostnip

This is a superficial cold injury, with vasoconstriction in areas of skin exposed to the cold air, usually on the face. There may be frost visible on the skin surface. Rewarming leads to recovery of blood flow and therefore resolution of the symptoms of numbness and skin pallor. It can precede frostbite, and when frostnip is identified indicates that there is high risk of developing frostbite.

Frostbite

The longstanding 4-tiered classification system for frostbite is based on both clinical and radiological findings. There is a more recent 2-tiered classification, more appropriate for use in the field. This describes the prognosis following rewarming, but prior to imaging, which represents a more common realistic scenario in the world of extreme & expedition medicine.

• Superficial: represents no or minimal tissue loss
• Deep: anticipated tissue loss (corresponding to 3rd- and 4th- degree injury)

The Cauchy classification system can be used at day 2 post-injury to predict prognosis and therefore plan for evacuation, if required. The full details of this can be read here. However in brief, the more proximal the lesion is and/or the presence of haemorrhagic blisters, are both negative prognostic indicators and increase the risk of amputation, systemic involvement and sepsis. The use of bone scanning in these patients is beneficial, but obviously unavailable in a remote context.

Signs & Symptoms

Initially, the individual will experience sensory loss of the affected extremity or digit. Often described is the feeling of clumsiness, as a result of a loss of proprioception. There can be severe pain, especially during the thaw cycle and the resulting reperfusion. Some experience paraesthesia in the days following the injury.

Clinically, skin is often pale but otherwise can appear relatively normal during the freeze stage however following this, blisters can appear, which are haemorrhagic in severe cases. On re-warming, tissues can appear blue, yellow-white, or waxy. If the extremity undergoes rapid rewarming, then erythema can occur.

Management

This will be divided into treatment options in the field (with the caveat that ability to provide these interventions may be variable based on resources), followed by hospital-based management. The Gold Standard for treating cold injuries remains the State of Alaska cold injuries guidelines.

Field management

Thawing: The first decision to be made is whether to thaw the tissues. While it may seem like the obvious start, if the extremity cannot be adequately protected from the risk of refreezing occurring, then it is not recommended to commence thawing. Instead, protect from physical injury by avoiding use, and remove restrictive jewellery and constrictive clothing. The extremity should not be placed in ice or snow, and there is no evidence that dressings have any therapeutic benefit. Any dressings which are applied should not be restrictive or damaging to the skin.

The following treatments can be applied whether the intention is to thaw the tissue or not. Most frostbite will spontaneously thaw. Do not rub the extremity or directly expose to heat.

Treat hypothermia: Moderate to severe hypothermia should be managed prior to treating a cold based injury; mild hypothermia can be treated concurrently. See our hypothermia article for more details on this.

Rehydration: Good hydration status reduces the risk of developing frostbite, however there is little evidence of treatment once the injury occurs. Maintain fluid intake orally, or if unable to drink then with (ideally prewarmed) boluses of IV fluids targeted based on urine output.

Ibuprofen/Aspirin: There is poor quality evidence to recommend these therapies, which in theory may improve circulation, however aspirin can inhibit prostaglandins necessary for wound healing. Commencing ibuprofen at 12mg/kg/day (max 2400mg/24hr) is the current recommendation.

Low Molecular Weight Dextran: No longer recommended.

If the intention is to rewarm/thaw, then the following treatments can also be applied in the field. If rapid rewarming is not available, then spontaneous thawing & rewarming should be allowed.

Rapid rewarming: The ideal way to do this is by warm bath immersion; other methods have increased risk of heat injuries. The water should be heated to ~37 to 39 degrees centigrade, ideally using a thermometer to maintain this range. This can be checked without a thermometer by immersing the hand of someone other than the casualty for 30 seconds to ensure the temperature is tolerable. Water should be stirred and regularly reheated to maintain the adequate temperature, although reheating water should be avoided while the extremity is immersed. Alternating between two containers is one way to avoid this. The rewarming process is normally completed within 30 minutes, and the extremity will appear red or purple with tissues being palpably soft. Following this, gentle drying should take place, taking care not to cause damage to the skin.

Antiseptics: If available, addition of an antiseptic solution to the rewarming water may reduce the risk of developing cellulitis, however there is no evidence for its use in frostbite.

Topical Aloe Vera: May theoretically be beneficial, and if being used should be applied prior to any dressings.

Analgesia: Based on the WHO pain ladder and the patient’s symptoms.

Debridement of blisters: This is not recommended in the field due to risk of infection. If there is a tense blister at risk of rupture, then aseptic aspiration can be performed, however deroofing should not be carried out. Haemorrhagic blisters should not be aspirated or debrided.

Dressings: Dry gauze dressings should be applied to the affected areas, with care not to wrap circumferential dressings tightly due to progressive oedema. Any such dressings should be checked regularly to ensure they are not restrictive.

Elevation: Raising the affected area above the level of the heart to reduce tissue oedema is recommended.

Ambulation: Use of the affected extremity should be avoided unless absolutely necessary for safe evacuation, as it can worsen tissue damage and increase the risk of amputation.

Oxygen: As discussed in the prevention section, hypoxia worsens tissue perfusion. However, it can also cause vasoconstriction. The recommendation is to apply supplemental oxygen in cases of hypoxia or at high altitude, but to avoid otherwise, however the evidence for this is weak.

Additional field management options are currently under research, including peripheral nerve blocks. There is currently no evidence for their use in frostbite.

Hospital management

Some treatments remain the same once hospital is reached: treatment of hypothermia, hydration, low molecular weight dextran, ibuprofen, aloe vera, and rapid rewarming. If thaw has been achieved, further rewarming is not of benefit.

The Helsinki Frostbite management protocol can be useful if in a centre with access to angiography, as a stepwise approach to management in tertiary care.

Blisters: As in the field, haemorrhagic blisters should not be aspirated or deroofed. Clear or cloudy blisters can be reduced by needle aspiration once in hospital, however there is limited evidence of benefit to carrying this out. Application of sterile dressings to open blisters reduces the risk of secondary infection.

Antibiotics: Prophylaxis is not routinely recommended; initiate if major trauma, high risk of infection due to other causes, or evidence of cellulitis or sepsis.

Tetanus prophylaxis: Should be administered, see Green Book guidelines for use of booster vaccine vs immunoglobulin depending on patient’s vaccination history.

Iloprost: This is the mainstay of drug treatment for frostbite, and its use is now widespread across the world. It is a vasodilator that reduces inflammation and platelet aggregation. There is a randomised controlled trial that demonstrated it was more effective than combination therapy with tPA, or alpha blocker monotherapy, at reducing amputation rate. Its use is also supported by case series in Canada, Finland and the Himalaya. It should be considered the first line treatment where available; where it is not then thrombolysis with tPA is second line.

Thrombolysis therapy: Tissue plasminogen activator (tPA) administered IV or intra-arterial may be of some benefit in the first 24 hours following tissue thawing. The standard risks of thrombolysis accompany the treatment, with the addition of increased risk of compartment syndrome. There is no high level evidence for its use, however the available evidence suggests a reduction in amputation rates.

Vasodilators: The use of vasodilators is restricted to adjuvant therapy, rather than first or second line monotherapy.

Long term management

There are various longer term treatments that have variable evidence supporting their use in reducing the morbidity and sequelae of frostbite. These include:

• Hydrotherapy
• Hyperbaric oxygen therapy
• Imaging (for prognostication and surgical planning)
• Sympathectomy
• Fasciotomy (to treat compartment syndrome)
• Surgical debridement or amputation (should be delayed until definitive demarcation of necrotic tissue, unless sepsis requires more urgent intervention)

These interventions should only be undertaken in specialist centres with expert advice taken.

Telemedicine

There is advice available via phonecall/email from anywhere in the world via three UK experts in frostbite. See here for details. Any decisions for surgery or repatriation should ideally be discussed with one of the experts here prior to action undertaken.

Conclusions

Frostbite is a predominantly avoidable condition with significant sequelae affecting morbidity and quality of life. Early recognition, prompt effective field management, and appropriate hospital transfer and treatments can all reduce the individual’s risk of amputation, and improve their level of function following the injury. Whilst there is gradually increasing research into novel treatments, by knowing the basics and getting them right, as a medic providing care in extreme environments, we can make a difference.

Useful Resources

Canadian Frostbite Care Network (CFCN)

“Frostbite injury can have significant functional impacts on affected individuals, including the possibility of amputation, increased risk of future cold injuries, chronic pain, and challenges in wound healing in severe cases. Our research has identified a pressing need for easily accessible, evidence-based information on frostbite treatments and protocols. Community hospitals see the majority of frostbite cases, which frequently includes marginalised and homeless populations, who stand to benefit the most from improved awareness and treatment protocols. To address this need, the Canadian Frostbite Care Network launched in October 2024, providing an information and collaboration hub for the public and healthcare professionals to enable timely access to high-quality frostbite care. The Canadian Frostbite Care Network is dedicated to improving frostbite treatment across Canada by promoting best practices, fostering expert collaboration, and supporting ongoing research and education.”

Adventure Medic would like to thank the CFCN for the use of their photographs in this article. The CFCN resources can be accessed here: https://frostbitecare.ca

Dr Chris Imray in The Alpine Journal

“In the UK, the British Mountaineering Council Frostbite Service has been operating for 20 years. This service, which is run by Dave Hillebrand, Paul Richards and myself, offers expert advice over satellite phone or by email to those dealing with frostbite. All three of us hold the UIAA Diploma in Moun- tain Medicine and have practical expedition experience. We provide remote advice for affected individuals both locally in the UK and on expeditions abroad. The aim is to support and advise local providers or offer to take over care where appropriate. Contact details for all three of us are available via the BMC website.

However, even the best advice will be of little use if you can’t access the right treatments. Throughout this article, I’ve repeatedly mentioned the frostbite drugs iloprost and rTPA. In recent years, these drugs have revolutionised the care of those with more serious frostbite. Time is crucial and treatment with them should ideally be started within 24 hours of injury. The longer the delay, the less effective the treatment becomes as the frostbitten extremities die without a blood supply. Doctors use the phrase ‘time is tissue’ to indicate that the longer something is left untreated, the more tissue will be lost.

Speed is not the only consideration. It is also very important to go to a unit familiar with these modern treatments. Sadly, there have been a number of cases recently where climbers have been taken to units that do not offer iloprost, despite the presence of units offering the treatment within the same city. Because this information was not volunteered, digits were lost when they needn’t have been.

To try and get around this issue, the recently set up International Freezing Cold Injury Working Group is establishing a worldwide database listing the units that offer iloprost and other complex frostbite treatments as well as a second database of clinicians who regularly advise on cold injuries.

Until recently, this first database would not have included sites in the USA as iloprost was not approved for use there. This changed in February 2024, when the US Food and Drug Administration (FDA) approved the use of iloprost for the treatment of severe frostbite. You can now visit Alaska safe in the knowledge that, should you face a case of severe frostbite, regulation will not prevent you from receiving the best treatment currently known to science.

Dr Imray’s article can be found here,

UK Frostbite Care

“At UK Frostbite, we are a dedicated team of medical doctors and researchers focused on providing accurate and comprehensive information about frostbite prevention and treatment. Our expertise ensures that you receive reliable guidance to protect yourself and others from frostbite-related issues.”

The UK Frostbite Care site can be accessed here.

References

1. McIntosh SE, Freer L, Grissom CK, et al. Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update. Wilderness & Environmental Medicine. 2024;35(2):183-197.
2. Gross EA, Moore JC: Using thrombolytics in frostbite injury. J Emerg Trauma Shock. 2012, 5 (3): 267-271.
   Handford, C., Buxton, P., Russell, K. et al. Frostbite: a practical approach to hospital management. Extrem Physiol Med 3, 7 (2014).
3. Imray C, Grieve A, Dhillon S, Caudwell Xtreme Everest Research Group: Cold damage to the extremities: frostbite and non-freezing cold injuries. Postgrad Med J. 2009, 85 (1007): 481-488.
4. Murphy JV, Banwell PE, Roberts AH, McGrouther DA. Frostbite: pathogenesis and treatment. Journal of Trauma and Acute Care Surgery. 2000 Jan 1;48(1):171.
5. Gupta A, Soni R, Ganguli M. Frostbite–manifestation and mitigation. Burns Open. 2021 Jul 1;5(3):96-103.
   McLeron K. State of Alaska Cold Injury Guidelines. 7 ed. Department of Health and Social Services Division of Public Health Section of Community Health and EMS; 2003.
6. Joshi K, Goyary D, Mazumder B, Chattopadhyay P, Chakraborty R, Bhutia YD, Karmakar S, Dwivedi SK. Frostbite: Current status and advancements in therapeutics. Journal of Thermal Biology. 2020 Oct 1;93:102716.
   Sheridan RL, Goverman JM, Walker TG. Diagnosis and treatment of frostbite. New England Journal of Medicine. 2022 Jun 9;386(23):2213-20.
7. Zaramo, Taborah Z. BS; Green, Japjit K. MD; Janis, Jeffrey E. MD, FACS. Practical Review of the Current Management of Frostbite Injuries. Plastic and Reconstructive Surgery – Global Open 10(10):p e4618, October 2022. | DOI: 10.1097/GOX.0000000000004618
8. Lindford A, Valtonen J, Hult M, Kavola H, Lappalainen K, Lassila R, Aho P, Vuola J. The evolution of the Helsinki frostbite management protocol. Burns. 2017 Nov 1;43(7):1455-63.
9. Cauchy E, Davis CB, Pasquier M, Meyer EF, Hackett PH. A new proposal for management of severe frostbite in the austere environment. Wilderness & environmental medicine. 2016 Mar;27(1):92-9.

The post Clinical Update: Frostbite Prevention and Management 2025 appeared first on Adventure Medic.

Theresa Menders is a documentary photographer, independent humanitarian advocate, and senior director at a global pharmaceutical company. She is earning her Doctorate of Public Health (DrPH) from the University of Illinois at Chicago and is co-author of “Psychological First Aid: Pocket Field Guide.”

When disaster strikes, whether it’s a natural calamity, forced displacement, conflict, or an individual emergency like a house fire or car accident, the immediate focus is often on addressing physical injuries and securing safety. However, the psychological wounds inflicted by such events can be just as debilitating as physical trauma. Psychological First Aid (PFA) offers a structured yet flexible framework for providing emotional support that anyone can learn. This vital skill enables individuals to assist people in distress, helping them to cope and begin their journey toward recovery.

What is Psychological First Aid?

PFA, as outlined by the World Health Organization (WHO), is a humane and evidence-informed approach designed to reduce initial distress and foster longer-term resilience. Rooted in principles of care, comfort, and communication, PFA is not a one-size-fits-all solution but rather a set of adaptable actions that can be applied across diverse contexts, from large-scale disasters to personal tragedies. Importantly, it is not therapy or professional counseling, but instead a practical, supportive response that anyone can provide.

How does it work?

PFA is based on the understanding that people affected by crises will have a wide range of reactions. Some may appear calm, others deeply distressed. Importantly, PFA does not assume all individuals are traumatized or require professional mental health interventions. Instead, it emphasizes providing immediate, compassionate support that respects the individual’s dignity, autonomy, and cultural context. Through my experience as a trained PFA provider and trainer, as well as in documenting humanitarian crises globally, I’ve witnessed firsthand the transformative impact of this approach. In refugee camps, for instance, displaced families often grapple with the compounded stresses of losing loved ones, homes, and livelihoods while navigating uncertainty about the future. In these settings, offering a listening ear, ensuring basic needs are met, and connecting people to further resources can significantly reduce feelings of helplessness and despair. Similarly, PFA is valuable in more localized emergencies. Consider a house fire where a family loses all their possessions or a car accident that leaves individuals shaken and fearful. Though less far-reaching than large-scale disasters, these situations still create immense stress for those involved. By addressing emotional needs alongside physical ones, anyone trained in PFA can provide holistic care that fosters senses of safety and stability.

Preparation for delivering PFA

Before helping individuals in distress, it is essential to prepare mentally and logistically. This includes learning about the specific context of the crisis, whether it’s a natural disaster, conflict, or an individual emergency. Preparation involves knowing your role and limitations, being aware of available resources, and ensuring your own safety and well-being. For anyone providing PFA, preparation may also mean understanding the cultural background of those affected and reflecting on personal biases to provide respectful and culturally sensitive care.
The WHO’s primary action principles of PFA can be summarized as “Look, Listen, and Link”. This approach helps guide practitioners on how they should assess and then safely enter a situation, engage with affected people, understand their immediate needs, and then connect them with the appropriate resources. These principles are designed to guide anyone, not just emergency personnel, in providing effective support.

Look, Listen, and Link

LOOK

The “Look” component involves assessing the situation and identifying who may need help. This includes: ensuring physical safety by checking the immediate environment is secure; observing for people in obvious distress, such as crying, agitation, withdrawal, or confusion; and identifying basic needs like food, water, or medical attention. Even in a local emergency like a car accident, scanning the scene and prioritizing who might need immediate support is a key first step.

LISTEN

Active listening is at the heart of PFA. This means approaching individuals respectfully, asking about their needs and concerns in a non-intrusive manner, and allowing them to share their experiences without pressure. Empathy and validation are key. Listening goes beyond just hearing words. It requires observing body language and tone, recognizing unspoken fears, and validating emotions. Simply by being present and attentive, anyone can provide reassurance and reduce feelings of isolation.

LINK

The final component, “Link,” involves helping individuals access additional resources and support. This might include providing information about available services, reconnecting people with family or community members, or referring those with severe distress to professional mental health services. Linking people to resources bridges the gap between immediate support and long-term recovery.

What PFA can offer

The benefits of PFA extend beyond the immediate aftermath of a crisis. For those receiving support, PFA can help restore a sense of control and normalcy. By addressing emotional and psychological needs early on, it reduces the risk of long-term mental health issues such as post-traumatic stress disorder (PTSD). Research shows that individuals who receive compassionate, practical support are better prepared to recover psychologically and reintegrate into their communities.

For those providing PFA, the experience can be deeply rewarding. Knowing how to offer effective emotional support fosters confidence and reduces feelings of helplessness in crisis situations. Moreover, learning PFA equips individuals with skills that can be applied in everyday life, such as active listening and empathy, which strengthen personal and professional relationships.

One of the strengths of PFA is its versatility. While the principles remain consistent, the approach can be adapted to different settings and populations. In the aftermath of hurricanes, earthquakes, or floods, PFA providers may focus on creating safe spaces, reuniting families, and addressing immediate concerns such as food and shelter. In refugee camps or conflict zones, the emphasis might shift to restoring a sense of stability and providing information about available resources. Even in individual emergencies, such as car accidents or house fires, PFA can help individuals process their emotions and connect with loved ones or local support systems. For example, during a massive power outage in an urban area, individuals trained in PFA might prioritize calming people who are panicking in elevators, assisting elderly residents who are stuck in high-rise apartments, or ensuring children feel safe in darkened spaces. Each scenario requires flexibility and sensitivity to the unique needs of those affected.

Practicing self-care as a PFA provider

While offering PFA can be incredibly fulfilling, it is not without its challenges. Providers often find themselves in emotionally charged and high-stress situations, which can take a toll on their own mental health. Recognizing and addressing this impact is critical to ensuring they can continue to serve others effectively. Practicing self-care is not a luxury, it is a necessity. Self-care begins with acknowledging your limits. Even the most compassionate helper cannot solve every problem, and accepting this reality can prevent feelings of guilt or inadequacy. Taking time to rest, reflect, and recharge after offering support allows providers to process their emotions and maintain their mental well-being. Simple practices such as mindfulness, adequate sleep, and regular meals can make a significant difference in resilience.

It is also important for PFA providers to build a support network. Sharing experiences with colleagues or trusted friends can offer relief and provide perspective. Many organizations emphasize peer support systems for debriefing after challenging situations. These conversations can help normalize emotional reactions and provide strategies for coping with future stressors. While it’s natural to want to help as much as possible, overextending oneself can lead to burnout so creating boundaries is essential. Setting clear limits on the time and energy devoted to crisis response ensures that helpers remain effective and can return to their personal lives back at home in a healthy state of mind. By prioritizing self-care, PFA providers not only safeguard their own well-being but also enhance their ability to support others in times of need.

Finding PFA training

PFA is not just for emergency personnel. It’s a skill that anyone can learn and use to make a meaningful difference in the lives of others. By integrating PFA into their communities, individuals can provide compassionate and practical support during times of crisis, helping people regain strength and hope in the face of adversity.

One of the most important aspects of PFA is its accessibility. Anyone can learn the skills needed to provide psychological first aid. The WHO’s PFA Guide for Field Workers is a comprehensive resource that outlines practical steps and strategies for offering effective support. The guide emphasizes that PFA is not therapy. It does not involve diagnosing or treating mental health conditions; instead, it focuses on humane and practical actions that anyone can take to help others in distress.

There are a number of online PFA courses available through different agencies and organizations. The UK Health Security Agency (UKHSA) offers both a general PFA course as well as a course focused on providing PFA to children and young adults in a crisis. U.S.-based Johns Hopkins University also offers a PFA course. The U.S. Center for Disease Control offers a PFA course geared toward radiation disasters, however, many of the same principles can be applied to general crisis situations.

Training in PFA typically covers scenarios ranging from natural disasters to individual emergencies. Participants learn how to use the “Look, Listen, Link” framework or similarly effective approaches, understand common reactions to crisis events, and practice communication techniques that foster trust and calm. Many organizations and communities offer free or low-cost PFA training programs, making it an accessible option for those who wish to contribute during times of need.

In a world where crises are increasingly frequent and complex, learning PFA is not just valuable, it’s essential. By equipping yourself with these skills, you can be a source of stability and resilience for those around you, transforming moments of chaos into opportunities for recovery and connection.

Links:

WHO PFA Guide for Field Workers
UKHSA general PFA course
UKHSA children and young adult PFA course
Johns Hopkins PFA course
Center for Disease Control

The post Psychological First Aid: a Valuable Skill for Everyone appeared first on Adventure Medic.

Last Breath

Where: Netflix

About: The documentary is about a near-death experience in commercial diving, focusing on the incredible story of saturation diver Chris Lemons. While performing underwater maintenance work at a depth of over 100 meters (328 feet) on the seafloor of the North Sea, his diving umbilical, which supplies him with breathing gas, warmth, and communication with the diving bell, is accidentally severed. This leaves him with only five minutes of breathable gas in his backup tank and he has no chance of being rescued by his crewmates for more than 30 minutes.

Why: Saturation diving is not for everyone and can be a stressful profession with significant risks. You live in pressurised chambers for weeks, descending to incredible depths to repair oil rigs and pipelines. It’s hard to imagine what saturation diving entails, but through ‘last breath’ you get a feeling of what it’s like and what could go wrong.  With a blend of real footage, reenactments, and interviews with Chris Lemons and his colleagues, it feels incredibly authentic and keeps you on the edge of your seat.

Book:

Adventure Mind

About: The book delves into how adventure can profoundly enhance mental health and well-being. Drawing on over twenty years of experience leading expeditions across the globe, Kirk demonstrates how participating in adventurous pursuits can alleviate anxiety, conquer fear, boost self-esteem, and strengthen relationships. It covers a well-being theory called the PERMA model, which identifies five independent components: Positive emotions, Engagement, Relationships, Meaning, and Accomplishments. Adventure, she poses, supports every single one of them. By actively seeking challenges, choosing to face fear and uncertainty, engaging in adversity and risk, we get to feel really, truly alive.

Why: It’s inspiring that the book’s author is the perfect example of how adventure can change a fixed mindset to a growth mindset and change your life for the better. She explains how adventure changed her from feeling like a victim with low self-esteem to becoming an  empowered and confident woman. As a teenager, she felt she wasn’t good enough having suffered physical abuse. The turning point was a hiking and camping school trip when she was sixteen. This made her leave her comfort zone and enter the ‘stretch zone’ where personal growth happens. At eighteen, she went on her first big adventure and joined a yearlong expedition to Tanzania to study wild monkeys. It was at that moment that she learned that putting yourself out there, outside of your comfort zone, is how you get to experience magic.

She claims that predictability and boredom have nowadays replaced uncertainty, so much that we have become unaccustomed to the unknown or unplanned, even fearful of it. Also, rather than protecting us, becoming unaccustomed to dealing with risk makes us less equipped to cope with the inevitable challenges of life.

In summary, this book offers invaluable insights and motivation to embrace adventure as a transformative force and shows us why we should implement it into our own lives. So the question is, how are you going to add more adventure to your life?

To end with a quote from the book: ‘If you think adventure is dangerous, try routine, it’s lethal’.

Podcast:

Fitness in Diving Podcast

Where: Spotify

About: This episode of ‘Fitness in Diving’ features Dr. Kelly Johnson-Arbor. She is a physician board-certified in Emergency Medicine and Undersea and Hyperbaric Medicine. She serves as the Medical Director of the Hyperbaric Medicine program at MedStar Health in Washington, D.C. In this episode, she will share her expertise in treating injured divers in a hyperbaric chamber. The discussion will cover the effects of decompression sickness on divers and the role of hyperbaric oxygen therapy in their recovery.

Why: The overall risk of decompression sickness in recreational diving is estimated to be 1-3 cases per 10,000 dives (0.01–0.03%). The risk increases in technical diving to an estimated 1–10 cases per 1,000 dives (0.1–1%).

Do you know the difference between type I, type II and type III decompression sickness? When you experience symptoms after diving, do you call DAN (Divers Alert Network) or is it better to call the emergency department? What is the benefit of a multiplace hyperbaric chamber when treating decompression sickness? If you do not know the answers to these questions this podcast is worth checking out. Diving is still increasingly popular and your next patient might be a diver. And we all know that proper preparation prevents poor performance.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘Adventure Mind’.

The post AM Team recommendations February 2025 appeared first on Adventure Medic.

As a matter of tradition, everybody with an adventurous mind has been looking forward to this weekend since the beginning of the year. The World Extreme Medicine (WEM) conference is a three-day conference where medical professionals from diverse backgrounds explore the practice of medicine in challenging and resource-limited environments. Hosted annually at Dynamic Earth in Edinburgh, the conference offers a unique blend of hands-on experience and cutting-edge education across multiple streams, including expedition and wilderness medicine, humanitarian and disaster medicine, and more.

The World Extreme Medicine Conference stands out as a unique medical event. Its dynamic program, featuring workshops, keynote speeches and panel discussions, keeps you informed on the latest research in the field. What truly sets it apart, however, is the welcoming, informal atmosphere and the ease of connecting with others. It’s not just any crowd, you’ll find some of the most fascinating and adventurous individuals from around the world gathered here.

Whether you’re completely new to the concept of ‘extreme medicine’ or a seasoned expedition medic, there is something to boost everyone’s knowledge here. It was emphasised  to become self-reliant and dependable in your desired environment. You need the physical and mental stamina to be reliable and have the capacity at the end of the day to look after your team.  Firstly consider yourself a ‘rescue personnel’, and the medic as a bonus. Particularly for those hoping to enter into this world, it will make you desirable to employers. Being a generalist and simply being a nice person might seem like stating the obvious, but is easy to forget! After all, who would want to spend weeks on a mountain or aboard a ship with someone they don’t enjoy being around?

As has been the case for many years now, some of the Adventure Medic team were in attendance over the weekend. Thank you to all who came to say hello to us on our stand and around the venue.  What an inspiration to meet so many different types of people with the same passion. We spoke to doctors, nurses, medical students, paramedics, first responders, scientists, astronauts, psychologists, journalists and many more. Not only did we get a chance to hear the stories of their latest expeditions and adventures, but some of them also agreed to write an article for our website in the future. When we weren’t manning the stand, we thoroughly enjoyed immersing ourselves in the conference. With so many excellent presentations, it’s difficult to pick just a few highlights from the conference – but we’ve given it a go!.

Conference highlights

The Big Debate: What are YOU Worth as an Expedition Medic? At the moment, there is no standard for expedition medical pay. There is a concern about the potential exploitation of medics who are eager to gain experience and grateful for the opportunity to get a foothold in the field. Although guiding standards, professionalization and pay have increased in the past decade, medic pay has lagged far behind. If you want to dive deeper into this topic, check out this recently published first part of our Masterclass series on Pay in the Expedition Medicine Community.

Shawna Pandya is an inspirational Canadian physician, who became Canada’s first named female commercial astronaut and is scheduled to fly with Virgin Galactic to advance space-based biomedical and physiological research. She shared her journey as a doctor and astronaut, and the 10 key lessons from operational environments she learned in the process. For example, during underwater spacewalk training, being suspended upside down underwater, with a leaking facemask, juggling a task and communicating with colleagues taught her how to be comfortably uncomfortable.

IED (Improvised Explosive Devices) was a scenario-based training where participants were divided into two groups. One group, acted as the field’s first responders. Armed with medical kits, they focused on addressing the most life-threatening conditions first. The chaos of the screaming sounds of the casualties and blaring sirens from the speakers and thick smoke heightened everyone’s adrenaline and added to the realism of the scenario. After performing critical life-saving measures, such as applying tourniquets, the team collaborated to transport the injured to medical tents, where the other group took over care as a field hospital of sorts.  This was followed by a debrief and a discussion, with some excellent feedback and lessons learned.

The WEM Ceilidh is optional when booking the conference, but highly recommended. It is a traditional Scottish social gathering that features lively folk music and a lot of dancing. Don’t worry if you think you can’t dance, a “caller” guides participants through the steps. It’s always very enjoyable, and much more fun when everyone gets stuck in.

Get Involved

If you came up and spoke to us at our stand and would like to get involved, please contact us at contact@theadventuremedic.com.

If you want to get involved in expedition and wilderness medicine or humanitarian and disaster medicine this is your next best step. The WEM conference gives you the chance to connect with hundreds of ambitious like-minded medics and ignite ideas for your next expedition!

Don’t want to miss out on next year’s opportunity to attend the conference in person? The WEM conference will be in Edinburgh once again from the 15th-17th of November 2025. Secure your tickets here.

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The year of 2022-23 was the first year Endeavour Medical opened up their Expedition and Remote Medicine Fellowships for aspirational colleagues to join their team. In this article, two previous fellows, Claire and Lucy, discuss what the fellowship involves, the diverse range of opportunities available, what they did, and how to get involved.

In 2022, Endeavour Medical opened up fellowship opportunities for keen colleagues to join their team and we, Claire (IMT trainee) and Lucy (F1 at time of fellowship), were lucky enough to be their first two fellows.

What does the fellowship involve?

Time frame

12-month post

Location

Remote! But the opportunities available to you extend across the globe…

Commitment required of us / you

Two hours per week for Endeavour Medical Project Work – for us this involved teaching, critical appraisal, administration, and/or social media. The time you commit is very flexible and can easily be adapted to suit your personal projects, interests, and commitments within the company.

Opportunities provided by Endeavour

• Mentorship from leads in the fields of Expedition & Wilderness Medicine and Global Health.
• Teaching opportunities on courses in a variety of environments.
• Opportunities to engage in academic projects in global health and remote medicine.
• Access to a large faculty network with extensive medical experience across global health and remote polar, mountain, marine and jungle regions.
• Engagement in development of online teaching tools providing evidence based up to date education in remote and global health medicine.

Fellowship pre-requisites

• Has capacity and time to dedicate 2 hours per week.
• Organised with a keen interest to learn more about remote/expedition medicine and global health.
• Lots of enthusiasm for the outdoors!

  

What we did during our fellowship year

Over the year 2022-23 with Endeavour Medical, we have both been offered many opportunities to improve and broaden our skills and knowledge in expedition medicine and global health, as well as building on many transferable skills such as leadership and presenting. Opportunities have been both in the classroom and out in the field, through teaching and research. Along the way, we have met some truly inspirational colleagues who have given us invaluable advice and plenty of inspiration for our future plans!

Our highlights

Remote and Restorative Courses

We have both taught on Remote and Restorative courses that took place on Dartmoor and in Coverack, Cornwall. These are two day courses that offer junior doctors and allied health professionals an opportunity to enhance existing clinical and professional skills whilst restoring enthusiasm for the profession. The courses are delivered outdoors through simulation, workshops, lectures and open discussions, and not only provide remote medicine simulation training, but have a focus on crew resource management, teamwork and leadership, and structured mental health and resilience workshops. We had plenty of opportunities to broaden our teaching experience and develop a wider skillset with human factors at the centre.

Marine Medicine Courses

Lucy has a background in marine rescue services and has used this experience to facilitate and teach on Endeavour’s Marine Medicine courses throughout this year in both Sardinia and Cornwall. In Sardinia, Lucy was lucky enough to teach alongside Endeavour’s Medical Director, Dr Anna Shekhdar, to provide international sea kayak guides (members of the ISKGA) with the medical knowledge they need when out on remote marine expeditions across the globe. We taught marine medicine through kayaking associated simulations both in and off the water, as well as workshops and open discussions. Lucy thoroughly enjoyed this teaching experience especially as the common language of delegates was Swedish rather than English, which allowed for not only good discussion points regarding communication during rescues in an international team, but also some interesting scenario analysis as a facilitator!

Building on the success of this course, Lucy took up the opportunity to teach alongside Dr Lucy Obolensky, Endeavour’s Founder, and Dr Anna Shekhdar on the Endeavour Marine Medicine Course in Polzeath, Cornwall. The course provided doctors from across the UK with the knowledge and experience to fulfill the role of an expedition doctor on marine expeditions. Despite being junior to the delegates in the NHS clinical environment, Lucy enjoyed sharing her skill-set and knowledge with those who had previously seldom worked in a marine environment.

Global Health experiences in Kenya

Claire was keen to broaden her experience in medicine outside of the NHS, which led her to join a team of three global health doctors on a health scoping project in Northern Kenya alongside the Northern Rangelands Trust (NRT). This part of Kenya is extremely remote with limited access, and healthcare provision is often basic and underfunded. The region is prone to intense droughts that hamper water provision and intensify existing health needs. The trip was very eye-opening and successful; they visited multiple clinics across the region and met a number of inspiring nurses, healthcare professionals, and local community leaders. After collating their findings, they presented them and their recommendations to the local government.

The team have since gone on to write up their research for publication. Claire was very inspired by this project and wants to continue working within global health alongside her career in the NHS. In addition, she gained exposure to the logistical challenges of research in a remote healthcare environment, compared to the controlled laboratory setting from which she was previously more familiar with.

How were we supported / appraised?

Our fellowship mentor was Dr Lucy Obolensky, who we met with every 3 months via an online group meeting to discuss our progress and educational opportunities, as well as clarifying personal and team goals throughout the year. Further to this, we were in regular contact with each other and other Endeavour colleagues via WhatsApp platforms when working on individual projects within the organisation. Feedback from colleagues, such as those we worked with on courses, or those we collaborated with to provide online educational content, was relayed to us by Lucy Obolensky at our regular meetings.

What are we up to next?

Lucy will continue to enjoy the Cornish work-life balance whilst completing her FY3 year at the Royal Cornwall Hospital in Truro. She plans to travel and gain some experience as an expedition medic in marine and mountain environments, including a trip to Kilimanjaro as the trip medic before applying for ED training hopefully in the SW!

Claire meanwhile, has started Internal Medicine Training in Wessex and in her spare time wishes to remain active in research and to embark on remote expeditions as and when training allows. Her interests are mainly in mountain and polar medicine, as well as in global health and promoting equality in healthcare.

Would we recommend the fellowship?

100%! This fellowship has provided us with a wealth of experience and professional development as teachers and educators in a variety of settings, whilst enabling us to develop our clinical and non-technical skills in remote outdoor environments. We have been able to bring back these skills to our clinical work in the NHS, whilst also seeking opportunities in expedition medicine and global health in both research and work out in the field. This fellowship has opened the door for further opportunities for which we are both very grateful. Furthermore, we have been lucky to meet and work alongside an amazing network of hugely experienced Endeavour faculty members who have inspired and supported us to take our medical careers in new and exciting directions. Thank you to all of you!

Recruitment process

If you would like to get involved, please contact the Endeavour Medical team at: hello@endeavourmedical.co.uk.

There is a twice-yearly intake for fellowships, in January and August. Applicants can email their CV and cover letter at any time, and will be contacted prior to the recruitment rounds for interview.

The post Endeavour Medical Fellowship Review appeared first on Adventure Medic.

This is the first article in a series on pay and considerations when employing a medic. They have been written for both medics and employing companies to improve on the understanding of the profession in the expedition field. The next article, ‘Employing an Expedition Medic’, will be published soon.

Introduction

Adventure Medic has long been aware of the battle for remuneration for expedition medicine work and the challenges of securing fair pay.

There are an ever-increasing number of commercial providers organising trips to exotic destinations and requesting an accompanying medic. This is in part due to changing societal expectations and insurance requirements, alongside the general growth of adventure tourism.

We are healthcare professionals with extensive training and experience, taking professional risk. However, remuneration for expedition medics varies greatly with no guidance or standard set by a professional body. It is important that both medics and expedition providers understand each other’s perspectives as we carve a way towards fair remuneration.

This article will set out why pay is a complex issue, and how to advocate and negotiate for remuneration for our work. This is the first in our Masterclass series on ‘Pay in the Expedition Medicine Community’.

Current Factors Affecting Expedition Pay

At present, there is no standard for expedition medic pay. Financial arrangements can range from voluntary to a competitive salary. Most companies will offer reimbursement for expenses, although sometimes with exceptions (e.g. indemnity or flights) leaving a medical professional at a financial loss. A daily wage in addition to expenses is, however, becoming increasingly common amongst more professional and ethical companies. Below is a diagram demonstrating the range of pay:

Sometimes financial arrangements are unclear from the outset. If pay is available, it may be hourly, daily or a flat rate. In addition, significant pre-expedition tasks such as screening or building a medical kit may or may not be included in paid time.

Recommendations for specific pay come with difficulties. They must be viewed as fair and also fit within the culture and context of the expedition community. Where a cheaper medic is available, providers may choose them without factoring in aspects such as experience or trip remoteness, both key factors highlighted in the Faculty of Prehospital Care framework. Often, this is simply because, to those outside healthcare, a medic is a medic. We need to play our part as a community in educating providers, an standing together for fair pay.

Cultural Attitudes to Pay Amongst Medics

It is important to consider the ecosystem in which we operate. It encompasses everything from aspiring medics to experienced expedition sages on one side, and new and established commercial companies on the other. The narratives, relationships and economic contexts in which these providers and medics sit will affect any drive for changes to pay.

Some medics may feel that the opportunity to travel is a sufficient price for their services. Others may believe they will lose a ‘foot in the door’ to the expedition world if they advocate for pay. Many believe that due to the desirable nature of expedition work, companies often have no shortage of interested parties to fill roles, and so hold the court on pay. Few consider the risks to their future livelihood, should a legal claim be brought against them.

There is a risk that in not offering remuneration, providers attract only the most junior or inexperienced medics who are looking for their first opportunity to start their expedition medicine careers.

Even with experience, we may still be tempted into unpaid roles for scarce opportunities, or in support of research data collection or charity fundraising. In such situations sometimes all staff are voluntary. However, if there is an intermediary company hiring the medic and supporting a separate charity with expedition logistics, then this company is often commercial. We should not assume that because we are unpaid, everyone else is unpaid: “what is the day rate for the expedition leader?” is often a very revealing question.

Cultural Attitudes to Pay Amongst Providers and Companies

Many expedition companies have narrow margins, and an anxiety that paying the medic will drive costs up, raising prices, and putting off clients. The pandemic and economic instability have amplified this concern.

It would be unfair to tar all providers with the same brush. Some will pay their medics in line with the pay of other leaders, acknowledging the hard work, legal risk and responsibility. However, others will use the financial argument above to justify leaving the medic out of pocket (indemnity or insurance, flights or food and accommodation). Still others will extol their desire to pay medics but call it unaffordable. Some assume that the medic is being paid for a day job elsewhere to fund their costs of living.

What is Fair Pay?

In the last year, this discussion has gained momentum and provoked a range of opinions in the expedition community. We all appreciate that commercial expedition companies must break even and have struggled with losses during the pandemic. Equally, a skilled medic working on the trip should be fairly compensated for their work commitments, and professional risk.

Comparisons are sometimes drawn between pay for medics and other leaders, such as guides, in the same expedition team. This is a starting point, and a reference point as to what may be ‘fair’ in that particular context. Pay will vary between expedition leaders, assistant leaders, local ground handlers and others. Nonetheless, we believe the approach to remuneration for skill and experience, work and risks, should be transparent and fair across all staff involved in making an expedition a success. For example, if the medic is covering two roles (leader and medic), we believe they should be fairly remunerated for carrying the extra burden of responsibility.

By example, we have put together the table below, based on trips that the Adventure Medic team and others have worked on:

*Expenses should be all expenses including indemnity. Travel days should also receive 50-100% of the day rate.

Legalities of Paid Work

Medics may receive payment for expedition work alongside a wage for another job provided the trip was conducted during off and annual leave days. If using contracted study leave or educational development time, they cannot be paid for the same day of work by both their regular employer and an expedition company. The situation is more complex where a mixture of day “types” is used, in this case the medic can be paid for only those that are off or annual leave days. In other words, we can’t “double dip”.

Negotiating Pay

Negotiating for fair pay is complex and nuanced. This should not put us off asking the question however. Steps and tips for negotiating:

1. Begin by discussing the trip, including the clients, leaders, itinerary, risks and goals.
2. Be explicit in your experience, and the services you will provide, pre-, during and post-expedition to support these clients in their goals. This is a good opportunity to discuss other potentially contentious issues, including the care of local staff.
3. Clarify the current offer. Does it match the table above? Is indemnity covered? Is the kit provided? Are food and accommodation included including on travel days? Is travel covered from your front door to the destination? Are there any hidden expenses? Be explicit in your questioning.
4. Ask whether other team members are remunerated in the same way – if not, gently ask the provider to explain the differences in their approach.
5. Take a step back, and think whether the remuneration is right for you – are you happy to do this trip? In your annual leave, and on the terms given? You can always walk away, and there will always be other trips – no matter how it seems. Further information on Assessing an Expedition Opportunity is available here.

Below is a written example of how you might advocate for your work:

“I am grateful for the opportunity to join your expedition and to work with your clients. I would like to clarify remuneration, and the reimbursement of costs.

In the [X] years I have worked in healthcare, I have gained additional skills including [X] and achieved formal qualifications in [X]. This puts me in a strong position to offer medical support to your team and I’m looking forward to doing so.

Having an experienced medic is reassuring to clients and attracts bookings. It reduces cognitive bandwidth for the expedition leader, and clients appreciate the additional moral, as well as medical, support from a medic. Some companies find that having a medic reduces their insurance costs. Please also bear in mind that, in acting as medic, we take on significant medico-legal risk. If issues occur, they have the potential to impact our entire career.

I will of course do my utmost to safeguard against this and to protect your company and your clients. I will assist with pre-expedition screening and medical kit prep. I will be on-call throughout the trip for clients’ medical and psychological needs. Post-expedition I will produce a report, and arrange handover to clients’ regular medical practitioners, where necessary.

In return for the skills and experience I bring, and for giving up my annual leave to work on your expedition, I hope your company will reimburse my costs and consider remuneration for this work. For a similar expedition, I would typically look for a day rate of x / day, plus expenses.

I look forward to hearing from you so we can agree on a contract for this work, and I can begin supporting your expedition.”

Protecting Ourselves

We must protect ourselves from expeditions that exploit us. If the enjoyment, remuneration and energy required do not outweigh the cost and sacrifices, is the trip worth it? If a provider does not value our time, energy and skills then we should see this as a red flag and strive to protect ourselves. This holds particularly true for those under significant strain in their “day jobs”, where the additional stresses of a challenging expedition may increase burnout risk and pressures at home.

Some situations develop insidiously, with hidden costs gradually revealed through the trip. We should not shy away from advocating for ourselves and feeding back to the provider about our treatment and our worth. Always do so with an open and empathetic mind – the provider may simply need the opportunity to adapt and adjust.

Sadly, there is no formal governing body to report mistreatment. However, the expedition community is small and news travels fast. Opportunities with providers who support and remunerate their medics fairly will become highly sought after. Equally, there will always be other opportunities. By turning a blind eye to exploitation, we help neither ourselves nor those who follow in our footsteps.

Caveats

This article features information gathered from the experiences and opinions of medics within the expedition community. Adventure Medic acknowledges that the situation is dynamic and expedition medics and providers are striving to improve standards across the industry. This includes pay for medics.

Reference:

1. Updated Guidance for Medical Provision for Wilderness Medicine. Faculty of Pre-Hospital Care. Royal College of Physicians and Surgeons of Edinburgh. 2nd Edition. 2023.

The post Pay in the Expedition Medicine Community appeared first on Adventure Medic.

Vivienne Mathews / Scotland / Medical Student

Dr Constance Osborne / London / Evidence Explorer Lead

Contents

• Introduction and Collaborators
• Expedition and Wilderness Medicine Section
• Global Health and Humanitarian Medicine Section
• Want to get involved?

Thank you for joining us once again at the Evidence Explorer. As an academic amuse-bouche, we’re opening this edition with an FAQ page on ‘Women at Altitude’. This piece was written by members of the UIAA Medcom, who undertook a large scale evaluation of medical evidence on women’s health at altitude. They presented their work earlier this year at the International Society of Mountain Medicine Congress held in Utah. If you would like to peruse a more detailed review of the topic, it can be found in the journal of ‘High Altitude Medicine and Biology’.

Now, onto the main course! The articles in this edition were selected and appraised by our wonderful collaborators over the course of the summer.

Dr Jake Warrington is a FAWM certified doctor currently living and working in Sheffield, where he is completing an emergency medicine fellowship. When not at work, he can be found in the Peak District with his young family. His interests include trad climbing, cycling, surfing, paddleboarding and woodworking. He spends winter weekends attempting to tick off different icy routes up Ben Nevis.

Vivienne Mathews is a medical student in Scotland and a biomedical scientist. She has an interest in adventure medicine, which was ignited through the KCL Wilderness Medicine Society during her undergraduate degree. She loves combining medicine with travel and adventure! Viv likes to explore the Scottish outdoors, ski, surf and climb. She has also volunteered across several African countries including Zambia, Zimbabwe, Uganda and most recently Madagascar.

Wilderness and Expedition Medicine

In this quarter, we will be exploring both ends of the spectrum of temperature illness. We will take you from a case series looking at rescue techniques in hypothermic hill walkers, to sweaty Sicilian runners and the physiological stresses experienced by a healthy volunteer exercising in a heat wave. Sticking with the temperature theme, we will be presenting the 2024 update to evidence-based guidance on the management of cold injury. In fact, it’s been a summer for new evidence based guidelines, which means we will also be presenting the updated WMS guidelines on acute altitude illness. To finish off, we will investigate the effect of alcohol and smoking on the incidence of Acute Mountain Sickness on Mount Fuji.

The Outcome of Walking Cold Patients with Potential Mild Hypothermia to Safety: A Mountain Rescue Case Series

Greene M, Dodds N, Gordon L et al. Wilderness and Environmental Medicine. 14 June 2024.

Laboratory experiments into hypothermia have previously suggested that mobilising patients with even mild hypothermia could potentially be dangerous due to the risk of afterdrop and cardiac arrhythmias. However, these experiments have often utilised immersion cooling in well rested volunteers, which doesn’t quite match up to the slowly cooled, exhausted walkers that find themselves requiring rescue in the British hills. It is thought that a delay in extraction in these people may lead to greater exposure time and more cooling. Greene et al. collected data on all rescues where casualties were exhibiting signs of hypothermia (as defined by the Swiss staging system for accidental hypothermia) and compared the outcomes of those that were walked out immediately versus those that received an element of warming or delayed extraction. Data was collected from various Mountain Rescue teams and the authors admit that there were differences in the completeness of the data and that the core temperatures of the casualties involved may have been different. Despite this, the patients included all displayed clinical features of hypothermia and were in an environment where this was possible. This case series showed no difference in the outcome of patients that were mobilised immediately or received delayed transfer and whilst further study is needed, it provides an interesting perspective on the practicalities of rescue in this scenario.

Wilderness Medical Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite: 2024 Update

McIntosh S, Freer L, Grissom C et al. Wilderness & Environmental Medicine. April 5 2024

The Wilderness Medicine Society has reconvened its panel of experts for a number of evidence reviews and updates this summer and we will present you with two of them in this edition of the Evidence Explorer. The first drops the mercury level into frostbite territory and addresses the prevention, diagnosis and management of cold injury. This guideline represents an update on the 2019 edition and is accompanied by strength of recommendation and evidence base for the points put forward. It is comprehensive and a summary that does it justice would not be possible in this piece. Instead, we will simply outline its scope and depth for those of you who’d like to dip your toes into the freezing waters before taking the plunge!

The review covers the pathophysiology of the stages of freezing injury and their classification in the early stages. Formal classification can be difficult in the field and the authors have therefore recommended a two-tier field classification system which can be completed after rewarming but without need for imaging. Preventing frostbite is clearly better than trying to treat it.The various methods for prevention and their effectiveness are discussed in the next section of the review with the options for treatment depending on whether the frozen part has the potential to refreeze or not. Naturally, the early treatment options expand once a person has reached a hospital or high level field clinic. This review covers the management of hypothermia, hydration, rewarming and blisters as well as the use of low molecular weight dextran, aloe vera, antibiotics, tetanus, ibuprofen, thrombolysis, iloprost, heparin and other vasodilators in this setting. Post-thaw therapies are outlined in the final section of the review.

The need for further research into peri-thawing procedures and post-thaw therapies to improve outcome is identified in the review. Overall, it provides a thorough evaluation of the current treatment options available today and is well worth a read to those with an interest in taking people to cold places.

A case report on the physiological responses to extreme heat during Sicily’s July 2023 heatwave

Filingeri D, Valenza A, Ficarra S et al. Physiological Reports. 7 June 2024

You’ll be pleased to hear that things are starting to warm up a bit in this case study, which looks at the physiological response to heat in a healthy volunteer during the July 2023 heatwave in Sicily, where temperatures reached highs of 47 degrees celsius. The reports aimed to look at the effects of physical work or exercise when environmental factors such as solar radiation and airflow are taken into account; all difficult to replicate in laboratory experiments into heat tolerance. The participant was tested on two separate days, one with the highest level of heat warning possible issued by the Sicilian authorities and another where no warnings were in place. As you would expect, they found that exercise in the hotter temperature caused greater physiological stress. However, even on the cooler day, with no health warning, the volunteer still experienced a significant level of physiological stress. Filingeri et al. argue that the current advice regarding heat warnings may underestimate the thermal stress placed on even healthy people during exercise. Whilst this is a case study and represents data from a single participant, it provides good food for thought when planning a trip to warmer climates and considering the effects of rising world temperatures on sporting events.

Summary of Wilderness Medical Society Practice Guidelines for the Prevention, Diagnosis and Treatment of Acute Altitude Illness: 2024 Update

Rodway G, and Luks A. Wilderness Medicine Magazine. 8 July 2024.

We’re heading back to the updated WMS guidelines for this next article with a review of acute altitude illness. Once again the available evidence has been analysed and is presented by a panel of experts to help with prevention, diagnosis and management of Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE). Naturally there is a fair amount to work through here but the review is divided into clear sections looking at the different presentations. AMS and HACE are discussed together in the first half of the review due to the latter representing a rather extreme progression of the former. HAPE, and concurrent HAPE and HACE are covered in the later sections of the review. The treatment of these conditions depends on the severity of symptoms and whilst it is acknowledged that gradual ascent or even descent are usually the best options, the merits and indications for the various pharmacological approaches are also discussed in detail. This is once again a thorough and detailed review of altitude illness and a highly recommended read for any medic accompanying an expedition in the mountains.

Influence of Smoking and Alcohol Habits on Symptoms of Acute Mountain Sickness on Mount Fuji: A Questionnaire Survey-Based Pilot Study

Horiuchi M, Mitsui S & Uno T. High Altitude Medicine & Biology. 14 June 2024

The possible effects of different comorbidities on an expedition group is something that any medic needs to consider when planning a trip. However, Horiuchi et al make it clear that an individual’s recreational behaviour should also be taken into consideration. This paper looked at how smoking and alcohol consumption affect the incidence of AMS in hikers climbing Mount Fuji. The climbers were given questionnaires to collect data on smoking and alcohol use as well as general demographic data. Results from 887 hikers were analysed.

Symptoms of AMS were present in 45% of participants surveyed. Younger climbers (aged 20-29) were statistically significantly more likely to develop AMS. All ages of climbers were more likely to develop AMS if they had also been smoking during the ascent. The effects of alcohol consumption varied depending on age group. Younger climbers were no more likely to develop AMS with alcohol consumption (though they are already at increased risk in their own right). Middle-aged (50-59) climbers’ risk of AMS did increase with alcohol consumption.

Whilst the results of this study relies on self-reported behaviours, which leaves it vulnerable to bias, it does provide a useful insight into the possible effects behaviour and habits can have on the incidence of AMS within a group.

Global Health and Humanitarian Medicine

This section discusses two neglected tropical diseases, Rift Valley Fever and onchocerciasis. We investigate trends in opiod consumption across Africa and delve into the human factors behind mosquito net adherence. Finally, we explore the relationship between internet use and frailty.

Widening geographic range of Rift Valley fever disease clusters associated with climate change in East Africa

Situma S, Nyakarahuka L, Omondi E, et al. BMJ Global Health. June 2024

Rift Valley Fever (RVF) virus can cause haemorrhagic syndrome, jaundice and encephalitis. It is transmitted by mosquitoes and is found in humid areas. As this climatological profile is met by much of East Africa, the study focused on Kenya, Uganda and Tanzania to assess the relation of weather and RVF prevalence in humans and livestock. Previous studies established that extreme weather which enhances humidity (e.g. flooding) increases vector populations and can trigger epidemics in these regions. There is growing concern that climate change in East Africa will lead to an expanded geographic disease range. This study evaluated 100 disease events from 2008 to 2022. It found that 35% of identified RVF clusters were reported in areas that previously had no RVF history. The results of the study suggest that the combination of increasing temperature, increasing rainfall trends and a decrease in the annual number of dry days is a driving factor behind the escalating public health risk of RVF disease in Uganda. Similar patterns were observed in Kenya. A limitation is that many clusters represent as few as 1-3 human cases, drawing grand conclusions from a small sample size. In addition, the relationship between weather and prevalence is correlative and needs further research to establish if it is truly causal. Finally, due to lack of healthcare infrastructure, it is also necessary to acknowledge that case-reporting may not always reflect true prevalence, and that perhaps by comparing past to current datasets, the study is simply reporting an increase in monitoring.

Elimination of transmission of onchocerciasis (river blindness) with long-term ivermectin mass drug administration with or without vector control in sub-Saharan Africa: a systematic review and meta-analysis

Mutono, N., Basáñez*, M.G., James, A., et al. The Lancet Global Health. May 2024

Onchocerciasis or ‘River blindness’ persists in many countries despite half a century of programmes to decrease disease burden. More than 99% of onchocerciasis cases are found in sub-Saharan Africa. WHO has set an elimination goal by 2030. This systematic review collated data published on sub-Saharan Africa, in which a decade or more of ivermectin mass drug administration had been established (with or without vector control). Of 1525 articles screened after the removal of duplicates, 75 provided 282 records from 238 distinct foci in 19 (70%) of the 27 onchocerciasis-endemic countries in sub-Saharan Africa. It aimed to identify factors which contribute to successful elimination of transmission. The factors contributing to ongoing transmission included lack of vector elimination and holoendemicity. This suggests that long-term larviciding of blackfly-species breeding sites can significantly affect transmission of onchocerciasis. Furthermore, the areas in which continuous treatment with effective therapeutic coverage was established in 80% or more of the eligible population, improved the likelihood of achieving the elimination. Perhaps unsurprisingly, the results of the study indicate that  drug administration and blackfly vector control are key.

A proportion of these findings based on self-reported cases, the accuracy of which is difficult to ascertain. Additionally, due to the inclusion criteria, grey literature sources were not included (instead focussing on peer-reviewed articles), which is thought to explain the lack of data on eight onchocerciasis-endemic countries in sub-Saharan Africa. Nevertheless, the results are useful in providing guidance for the implementation of effective measures and can provide data for future transmission modelling studies on onchocerciasis.

Analysis of opioid analgesics consumption in Africa: a longitudinal study from a 20-year continental perspective

Hadjiat, Y., Toufiq, J., Ntizimira, C., et al. The Lancet Global Health. July 2024

Opioid analgesics have been listed as an essential medicine for palliative care and pain relief by the WHO. However, only 8% of available opiates are consumed by those in low/middle-income countries, compared with the remaining 92% being consumed by the high-income countries (who make up 17% of the world’s population). Several factors may contribute to this, though opioid expense underlies many of them. Healthcare professionals across many African countries seem reluctant to prescribe opioids (perhaps also due to cost), favouring non-steroidal anti-inflammatories (NSAIDs), even in cases where opioids would be indicated as first-line treatment. Individuals, aside from cost, may also reject opioids due to the stigma of pain endurance, palliative care and fear. Although cancer incidence and mortality in Africa has consistently risen during the last 20 years, the consumption of opioids remains almost unchanged.

The worldwide use of opioids has doubled each decade, mainly driven by high-income countries. This paper is the first to evidence the low and stagnant use of opioids in African countries between 1999 and 2021, and although it struggles to distinguish between the indications for opioid use, the increase of cancer and mortality strongly imply an increased need for opioids. Quality of data appears to be the study’s most significant drawback. For example, as tramadol is not under international control, it is not reported by the International Narcotics Control Board (INCB), meaning that no conclusions regarding this opioid could be made, and was therefore excluded. In addition, there is uncertainty in the consumption estimates due to imprecise population estimates and the number of stockpiled or unused opioid medications. Nonetheless, given the data and resources this research group did possess, it produced a compelling paper which suggests underconsumption of opioids in many African countries.

Reasons for mosquito net non-use in malaria-endemic countries: A review of qualitative research published between 2011 and 2021

Ladu, H.I., Shuaibu, U., and Pulford, J. Tropical Medicine and International Health. July 2024

Mosquito nets are the recommended method of vector control, yet they are not always used as advised and access to insecticide-treated nets is lacking. In this review, the lack of use of all forms of mosquito nets was analysed, using the qualitative data collated from literature between 2011 and 2021. It seems that the most common reasons for the non-use of mosquito nets were: lack of comfort (from heat and/or sharing one net between whole families), as well as perception of low mosquito levels. Furthermore, insecticide-treated mosquito nets were also underused due to the perception that malaria-risk was low or, conversely, that they needed to be saved for future use. However, the study only included English language publications and focused mainly on rural populations. When evaluating a qualitative study, it is important to remember that the quotes included are also subject to translation and potential bias. Nonetheless, this is an in-depth and analytical review presenting an insight into the under-use of mosquito nets and is unique for its focus on qualitative data, allowing greater insight into human drivers behind non-adherence. This research can guide future interventions to improve mosquito-net use.

Internet use and frailty in middle-aged and older adults: findings from developed and developing countries

Li, L. Globalisation and Health. July 2024

The term ‘frailty’ encompasses the decline in multiple physiological functions of the body, often leading to complicated care plans and burden on healthcare systems. In this unique multi-cohort study, Li investigated the longitudinal correlation between internet use and frailty across 32 countries. These cohorts encompassed a range of digitalisation, with the rates of internet use starting from 5.56% in China to 83.46% in Denmark. The results demonstrated that a country’s degree of development is also reflected in their rates of internet usage, but perhaps unexpectedly, also showed an inverse correlation between internet usage and frailty in middle aged and older adults. I say unexpectedly, as in younger generations, increased internet usage is often an indicator of poorer health (associated with lack of physical activity for example), yet there are many factors that can attempt to explain why in middle-aged/older adults this has the opposite effect in terms of frailty.

The finding that internet use correlated negatively with frailty is up for interpretation and further investigation. Li suggests that internet use mitigates social isolation (which accelerates frailty) and is a convenient source of information on healthy eating, exercise and medical information, which is what this demographic of adults tended to search. The correlation itself is robust, with the extensive sample size and data from 32 countries. Nonetheless, it is difficult to avoid some recall biases in this study, as the data was largely gathered from self-reports. Additionally, some datasets had presented internet use as a household rather than individual, meaning that the higher internet use of younger generations in the household may have skewed the outcome. Finally, this paper does not delve into whether increased internet use amongst the older demographic is in fact, preventing risk of falls or hospitalisation (which also define frailty), due to inactivity. It does however acknowledge the potential limitations and perhaps even negative implications of internet use and urges these to be taken into consideration in future research. Overall, the paper does provide a unique insight into the new and developing relationship between middle-aged/older adults and the internet era, furthering questions about how the two may work together to increase quality of life for this demographic.

The post Evidence Explorer: Updates and news from the academic community, Summer 2024 appeared first on Adventure Medic.

Dr Kalpanee Wijendra is working as an anaesthetics registrar in England but after the Covid pandemic and a long time working in UK ICUs she was looking to challenge her horizons. Her research and job applications took her to rural South Africa with the Tshemba Foundation where she worked alongside our very own Dr Alex Taylor. Here she explains the incredible work she was involved with, the challenges she faced and how these contributed to the truly bidirectional nature of the development and learning from such a job. 

Stepping Into The Unknown

In my experience, to go against the grain in a medical career requires bravery, determination and a sprinkle of imagination. The emphasis on trainees to meet portfolio requirements and pass exams is often at the expense of personal career goals. Although specialty training has its own challenges, demanding vast commitment and dedication, during the COVID-19 pandemic, I found myself completely exhausted from looping through the same day on ITU. I wanted a change. I was fortunate enough to stumble upon an email calling for Global Health Fellows to volunteer in low-resource settings. I sent off my application, received a place, and took a step into the unknown.

The fellowship offered multiple placements to choose from. I settled on South Africa, as I hoped it would ease my transition as an English speaker. Then I had to choose between working in a well-supported, busy hospital where my anaesthetic logbook would flourish or working in a remote rural setting, where I would be out of my comfort zone. Both scenarios were tempting for different reasons.  I chose the latter and embarked on my global health adventure. 

Tshemba Foundation

The Tshemba Foundation is a wonderful charity which provides volunteering opportunities for healthcare professionals to work in a rural hospital in Mpumalanga (Northeast South Africa). Volunteers work clinically whilst also contributing to health education and engagement in long-term local health projects. The ethos of the charity centres around sustainable change within the local community. Tshemba is unique because of its setting. The volunteers from around the world live together on a private game reserve alongside the ‘Big 5’: lions, leopards, rhinoceros, elephants and African buffalos.

For nearly 5 months I lived and worked with clinicians who had led unconventional yet fascinating lives. I was particularly inspired by a few clinicians whom I got to know very well and now regard as my mentors. A South African GP and author who has travelled the world and practiced medicine on every continent. She is a force of nature, who taught me to embrace the wilder life. Also a Dutch trauma surgeon shared his inspirational stories of treading the path less trodden and his career in the International Committee of the Red Cross (ICRC). Meeting and working alongside international volunteers were one of the many highlights of the Tshemba Foundation. They encouraged me to be fearless in taking the scenic career route, combining Anaesthesia with Global Health.

Tintswalo Hospital

Tintswalo, located in Acornhoek is a 423-bed District General Hospital in the beautiful province of Mpumalanga. Unlike hospitals in the UK, there was no consistent consultant supervising or on-call; instead, the hospital was run by medical officers of varying experience. From my observation, South African junior doctors are more generalist than their British counterparts. I was impressed to find that after only two years of postgraduate medical training, these doctors were independent in most procedures from giving a general anaesthetic to performing a caesarean section.

Challenges

The working conditions in rural hospitals are challenging for many doctors in South Africa. From my own experience and observation, South African doctors in low-resource environments, often work without basic medication and equipment. Overwhelmingly notable is the huge health inequality that exists between black and white people, even 30 years after the apartheid. These inequalities are far too complex to unpick in one article, however, I will explore a few examples that I encountered during my time in Tintswalo.

One of the biggest challenges is the long-standing water shortages which are the result of insufficient infrastructure to support the growing population. When these water shortages occur, no water is supplied to the entire Acornhoek area, unavoidably affecting the hospital. As a result, only emergency surgery such as caesarean sections can go ahead. These shortages can go on for weeks and often come without warning. The lack of water for drinking, cleaning and sterilising has a devastating impact on the local community. During my time at Tintswalo, the people of Acornhoek became so enraged that they protested outside of the hospital. This protest resulted in funds being mobilised to supply water containers for emergencies.

At the Tshemba Foundation, we were fortunate to not have water shortages, as the foundation was located half an hour away from Tinswalo Hospital in a small town called Hoedspruit. However, we regularly experienced power cuts or ‘load shedding’. The biggest personal challenge I found during load shedding was the disruption of communication with friends, family and colleagues due to cuts in the local and national power supply. Despite at times feeling isolated, the scheduled power cuts lasted only a few hours and I found the forced disconnection from the world rather peaceful, especially after the intensity of my clinical duties.

I had to alter my clinical practice based on these limitations. For example, due to a lack of availability of large-sized syringes, I had to use only 5ml and 2ml syringes when giving countless general anaesthetics and during the resuscitation of a patient in a makeshift ITU. At any given time, the hospital only had 3 units of O-negative blood available for resuscitation, therefore during surgery, I had to ensure high-risk patients were transferred to specialist hospitals and be very proactive in minimising blood loss by working closely in collaboration with the surgeons and utilising alternative products such as plasma expanders. 

I also had to adjust to working with limited medication available. For example, at the beginning of my time in Tintswalo the only available muscle relaxant was Suxamethonium, which is a short-acting muscle relaxant and unsuitable for long procedures which require prolonged intubation. I had to use muscle relaxant-sparing strategies to continue to safely anaesthetise patients. Another big adjustment was the limited analgesic options available in both the theatre and the wards. Where possible I used local anaesthetic, which was often available due to its limited use and encouraged the surgeons to do a local infiltration, which previously was not common practice in Tintswalo.

The limitations of equipment and medication, despite being inconvenient and challenging, were easier to adjust to than the emotional toll of systemic failures. These I found much more difficult to bounce back from. A particular case I found most upsetting was waiting 3 hours for an ambulance to pick up a pregnant patient whose unborn child was exhibiting signs fetal distress. Unfortunately by the time this patient presented to the hospital, we found no fetal heartbeat. Something potentially avoidable with more resource for pre hospital services.

Working Together

We often worked with the local doctors to overcome these challenges through shared decision-making. In these circumstances, it is common to feel alone and helpless, but I felt we had a lot of support from both the local doctors and the Tshemba Foundation. For example, when there is a critically unwell patient in the hospital, colleagues would rally together to help each other as there are no formal pre-allocated medical emergency teams. When the power failed and we had to stop the theatre after a spinal anaesthetic, the entire theatre team made the decision together to not operate in the dark, prioritising the safety of the patient and her unborn child. When I needed to transport a mother with fetal distress in a private vehicle, which belonged to the Tshemba Foundation, I had the full support of the group.

As a Foundation we had fortnightly debriefing sessions to jointly discuss all the challenges and barriers we were facing, and then we would work together to form solutions. This was an effective space to problem-solve and it was inspiring to see how the volunteers used their initiative and creativity to overcome challenges. For example, I wanted to encourage the identification of surgical patients earlier in the week to allow for optimisation and possible transfer to higher-level hospitals if they were not suitable for Tintsawlo. This had been historically challenging. One of the surgical volunteers after a debrief session initiated a grand round within the surgical team to identify potential patients for the semi-elective list later in the week. This changing of working culture by initiating MDT ward rounds was one of the biggest improvements within the surgical department during my time in Tintswalo, and it arose as a collaboration between the volunteers and resident doctors. 

Health Education Opportunities

During my placement, I noticed that there were gaps in nursing care in some of the medical and surgical wards. Unlike doctors, once graduated in South Africa, nursing staff are not obliged to complete further training, annual CPD courses or events. Educational activities are often not available due to a lack of funding and resources. As a result, some nursing practices are outdated and, in some cases, unsafe.

This fuelled me to devise a nurse training curriculum and deliver teaching alongside my Tshemba colleagues. We involved the senior nursing staff in the hospital and pitched the idea of a rolling teaching curriculum which covered basic observations and points of escalation. The curriculum consisted of 10 nursing topics which covered theory elements, demonstrations and opportunities to practice with each other. The sessions would last around 45 – 60 minutes, with each topic being covered a few times to enable staff from day and night shifts to attend. We set up a pilot session covering blood pressure measurement, which was observed by the head of nursing in the hospital. The pilot had a positive reception and the curriculum in its entirety was rolled out. Even after my time with Tshemba ended, the training programme has continued to be a successful initiative.

I was also able to support my junior colleagues who were thrown into complex anaesthetic cases with little experience and provided a safety net that they were not used to having. Unfortunately, I did not have any senior anaesthetic colleagues to support me, therefore the cases that I felt were beyond my capacity to resolve were highlighted to the clinical manager (the equivalent of the clinical director of a hospital), who then authorised the transfer of the patients to a higher-level hospital with consultant cover. I did find working without the direct supervision of consultants rather uncomfortable, so I ensured boundaries were established with the clinical manager about which cases I would not be able to lead on. 

The extensive knowledge of equipment needed for primary FRCA exams came in handy when I saw a donated French syringe driver lying about. I used my knowledge of equipment alongside translating apps to source consumables and write a working manual to get the syringe driver to work. This syringe driver and the manual have now been approved by the province to be used in the Tintswalo, offering the team a safe way of infusing medications.

Reflecting On My Experience At Tshemba

Upon arrival at Tinswalo Hospital, I became quickly aware that I was the most senior anaesthetist in the hospital. I realised that there were no consultants to ask for help or discuss my plans with. I felt well out of my comfort zone. The biggest adjustment for me was an awareness of the lack of safety netting which I had been used to in the way of having multilevel systems in place to prevent harm and consequently the weight of my independent decision-making. The circumstances required me to step up and take on a leadership role. There was no time to allow for self-doubt. I felt immense pressure in decision-making, especially trying to ensure I was making safe decisions in challenging circumstances.

During my time in Tintswalo and following my return to medicine in the UK, I did consider how the charity Tshemba fits into the wider picture of Tintswalo (a low-resourced district general hospital). I wondered if by volunteering we were helping bridge a service gap which potentially disincentivizes the health authorities to allocate funds to more doctors and services to help the local population. Once I understood the system more, I recognised that these systemic failures and lack of resources were present and unresolved years before the Tshemba Foundation. Also, sadly many of the local doctors are burnt out and demotivated, which means that processes such as quality improvement and education had fallen by the wayside and this is where I saw a real place for Tshemba. The projects I engaged in I felt were sustainable and hopefully contributed to ongoing patient safety. My contribution was a drop in the ocean, but I hope that it ultimately contributes to a wave of positive change.

This was the hardest anaesthetic placement of my career so far but equally the most rewarding. I felt that my presence really made a difference to the patients I looked after and the colleagues I worked with. I learnt how to adjust to an incredibly challenging environment and how to advocate for my patients and colleagues. In South Africa, I learnt to trust my anaesthetic skills and my instincts – perhaps my greatest lesson and what I treasure the most from my Global Health Fellowship.

Living and working for the foundation along with other international volunteer doctors was one of the greatest privileges of my career so far.  The Tshemba Foundation for me was a place of inspiration. My advice to anyone who is considering pursuing similar fellowships that are on offer is to go for it! Take the leap! It certainly will be the biggest challenge of your career but the best thing you will ever do.

Highlights:

• Living amongst the Big 5 in spectacular surroundings.
• Working in a low resource but highly rewarding environment.
• Travelling and making lifelong friends.
• Being part of a cause and collectively working towards supporting a community.
• Being able to do the job you love, somewhere else in the world. 

The post The Adventures of a Global Health Fellow in Tshemba appeared first on Adventure Medic.

The man who wanted to see it all

Where: Netflix

About: On August 22, 1962, Heinz Stücke left Hövelhoff in Germany with his bicycle and a tent. Driven by an insatiable desire for adventure, he navigates diverse cultures and landscapes, forming connections with locals and confronting personal challenges along the way. Now, he returns home for the first time after more than 50 years of nomadic life without ever established in any one place. The film is a trip through his memories, and an introduction to the people he met during his lifetime, who have become his global family.

Why: The film beautifully captures the essence of adventurous trips, emphasizing the richness of diverse cultures and the connections we make along the way. It’s not just about the destinations; it delves into the personal growth and transformative experiences that come from stepping outside your comfort zone. It’s a reminder that sometimes the journey matters more than the destination!

Book:

The Art Of Risk

About: Dr. Richard Harris, an anesthesiologist and cave diver who played a crucial role in the Tham Luang cave rescue in northern Thailand, takes us into the lives of other ‘risk-takers’ to find out why they do what they do. Through five chapters, named Metal, Earth, Water, Air and Fire. All of these people are associated with a high level of risk involved in their professional, or recreational life, such as the free solo climber Alex Honnold.

The author frequently shares stories about his own passion for cave diving and how difficult it is for others to fully grasp: ‘Now and then, when learning about my sport and what it entails, people tell me I must be crazy. It turns out there are many people – who are otherwise perfectly polite – who aren’t shy of making this assessment. To the best of my knowledge, none of them were practising psychiatrists, but that doesn’t stop them from editorialising about my mental health.’

In this book he tests his scientific hypothesis that people who take seemingly huge risks are just like him:  not reckless adrenaline junkies, but careful, measured risk takers.

Why: This book brings valuable insights in the minds of the world’s leading risk-takers like big-wave surfers, free solo climbers, base-jumpers and many more. Like free solo climber Alex, who draws a distinction between risk and danger. ‘He thinks of risk as having two components – the likelihood of a dangerous event occurring and consequences of that event. For example, it’s highly unlikely that your commercial aeroplane will crash, but if it does, the consequences will be devastating. Because the risk-to-consequence ratio is extremely low, people continue to jet all over the world. According to Alex, a lot of his free-solo climbing isn’t particularly risky, because he knows, based on his record of previous successful climbs, that he has an incredibly low likelihood of falling.’

If you want to know more about how these people perform near-superhuman physical feats, mitigate risks and step out of their comfort zone into their ‘stretch zone’, then this is a must-read!

Podcast:

The Flying Doctor #77

Where: Spotify

About: Dr. Katrina Starmer tells the story of how she was inspired to become a Flying Doctor with the Royal Flying Doctor Service (RFDS) in Queensland, Australia. Her journey began as a teenager during a personal medical emergency, when she first encountered the RFDS. This experience motivated her to pursue a career as a flying doctor herself. Besides talking about her day-to-day work, she also mentions Survive25, a program designed to help teenagers make informed choices and avoid situations that could lead them to require the Flying Doctors’ assistance.

Why: The work at RFDS captures the imagination, yet it can be unclear what it fully involves. Listening to a doctor recount her journey into this field provides valuable insight. It is inspiring to hear how passionate she is about the RFDS and how she found her ‘Ikigai’.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘The Art of Risk’.

The post AM Team recommendations October 2024 appeared first on Adventure Medic.

The initial guide to marine envenomation was published in May 2016. With summer around the corner for the southern hemisphere, we thought it was time this important but rarely encountered condition was brought to the forefront again. Here is Dr Edi Albert’s original article again for your education, with an update on the most recent evidence to keep us current.

When I was eight years old we went on a family holiday to Majorca. As a lad growing up in Liverpool where the local waters looked like they had flowed straight out of Mordor, it was an amazing experience to splash around in the warm blue sea of the Mediterranean: until something slippery slithered past my leg and I screamed so loudly that even my usually hydrophobic mother rushed in to help. No doubt I was being overly dramatic. It probably wasn’t a sea snake that had relocated to cooler climes, nor a sea jelly (the taxonomists tell us not call them jellyfish – because they are Cnidarians and not fish at all), but probably just a bit of seaweed suspended in the water column and moving at the whim of the currents. The story has a happy ending: there were no marks on my legs, I did not suffer a cardiac arrest, and fortunately have become rather tougher and more stoic as an adult.

The point of the story is that more often than not, when somebody suffers an insult in the water we do not know what caused the problem. Sometimes we can make a pretty good guess based on geographical location and the context of the injury. Of course, it is sometimes evident what caused the injury: a sea snake caught in a fishing net, a cone shell picked up by someone unaware as to its potential, or an accidental brush with the spines of a sea urchin. But, given that this topic is not well covered at medical school, even knowing what did it might not help much.

It is quite possible to provide first aid care without knowing what creature caused the insult. Let’s face it, most of us aren’t marine biologists. If you want to provide care beyond first aid though, you will need to be reasonably certain about what type of animal did the dirty. With some prior preparation before your trip and our downloadable Marine Envenomation Flowchart, you can have a pretty good stab at that too.

Back to Basics

Before we dive headlong into the nitty gritty, let’s define the scope of this article and go back to basics to re-visit some toxinological concepts and definitions.

This article is about marine envenomations that may be experienced in an expedition context or may be seen in GP / ED settings in regions where these animals are endemic. It does not cover common nuisances such as swimmers itch, surfer’s ear or skin infections occurring in a marine context. Nor does it cover ciguatera and scromboid poisoning; though you will need to think about all of these before heading off on your dream trip to paradise. Oh, and then there are the sharks – just make sure you’re not the slowest swimmer in the group, or wear a pink and green wetsuit so you don’t look like a seal. Always works for me, although I get funny looks putting my wetsuit on at the beach.

What is the difference between poisoning and envenomation? Or between a toxin and a poison?

Toxinology is the study of toxins, in a restricted sense, with reference to the relatively unstable proteinaceous substances of microbial, plant, or animal origins.

Poisons are substances that disrupt the body’s normal functioning. Toxins are naturally occurring poisons. Venom is a toxin that is deliberately injected into by one animal into another. Venom is a cocktail of proteins, predominantly enzymes, which cause havoc by multiple means. The contents of the venom vary between species. Havoc is usually wreaked on one or more of the nervous system, coagulation, muscle, and the heart. Anti-venom can be used to combat envenomation, however, it doesn’t always help and serum sickness (the body’s immunological response to a foreign protein) can be a real problem.

Remember it is the patient that we are treating, not the venom or the animal. A thorough initial assessment of the patient, with regular reviews, to determine whether the patient is systemically well or not, and whether the patient has specific signs of envenomation or not, is essential.

It may also help to understand that venom potency is related to the temperature of the environment. Thus, marine envenomations outside of tropical waters are rarely significant. For example, whilst a Bluebottle sting in southern Queensland may be very unpleasant indeed, the same animal down in Tasmanian waters is unlikely to disrupt your activities too much.

Planning

Before you go, try to consider the following:

Pre-trip planning / What lives where you are going? How do they behave? What might they do to you?

Contacts / In the event of an incident, and where you will be providing ongoing care, make sure you already have the phone number of a toxinologist who is familiar with the region in which you are travelling. In Australasia the Poisons Information Centre Australia (13 11 26) is your one-stop shop.

Now let’s consider what to do when an envenomation occurs.

From First Aid to Advanced Care

How do we provide first aid treatment if we don’t know what did it?

When you look at the conventional medical texts and first aid books, the content is arranged by the animal implicated with specific treatments described accordingly. This isn’t particularly helpful when you don’t deal with this stuff very often. Especially when you don’t have an encyclopaedic knowledge of marine species and little idea as to what might have caused the problem. A different approach is needed.

Some years ago I stumbled upon Peter Fenner’s Marine Medic website. Peter is a doctor in Mackay, Queensland, and although now retired, he has an international reputation in this field of marine envenomation and co-authored the wonderfully worthwhile and amazingly illustrated Venomous and Poisonous Marine Animals: a Medical and Biological Handbook. His website contains a lot of interesting information, but the icing on the cake is a simple flow diagram that guides management based on a few simple clinical criteria.

I have adapted and extended his flow chart to include advanced care. Download it as a free PDF, then laminate it and put it up on your yacht or in with your dive gear.

Pain

The first thing is to determine whether the original injury was painful or painless. Perhaps surprisingly, some of the deadliest things are painless.

The Painless Puncture Wound

A painless puncture wound can be caused by cone shells, sea snakes and blue ringed octopus, and whilst the circumstances of the injury may point to the culprit, all you need to know to start with is that the patient has painless puncture wound, and if in an endemic area for these creatures, then pressure immobilisation bandages (elastic NOT crepe) should be applied in the same way that you would for a snake bite. It is important to immobilise the limb, not just wrap it up. This is most certainly a patient you will keep a very close eye on and attempt to evacuate. It is also one of the few pre-hospital presentations in which prolonged CPR in the event of an arrest is worthwhile.

The painful wound

The first thing to figure out here is whether there are any tentacles adherent to the skin that would suggest a jellyfish sting. The painful wound without tentacles adherent will be likely to have a barb in it – which may be broken off inside the wound. The context of the injury will help you figure out the culprit, but irrespective of that, hot water or heat packs are indicated to neutralise the toxin and relieve pain.

When it comes to jellyfish, Chironex (Chironex fleckeri or commonly known as the “box jelly”) and Irukandji (Carukia barnsi) are the two nasties that always get the attention as they can be deadly, but there are other species capable inflicting misery. First aid and ongoing management is species dependent and is covered in the flow chart.

A Case

Let’s test out this approach using the flowchart with a clinical case.

You are on a dive trip somewhere nice and warm, and heading back to camp located at the back of a shallow bay. Ahead of you is another dive boat. There is a lot of commotion going on and a man is hopping on one leg, yelling and hanging on to the boat for balance.

By the time you get there five minutes later he is sitting on the beach. His foot is very painful and looks like the one in the picture below.

What is your immediate management? / This is a painful puncture wound and should be treated with hot water to denature the toxin.

You help him hobble back to the campsite. However, there is no electricity and only a modest first aid kit.

How might you practically administer his treatment? / Heat water on the camping stoves, mix it with cold water, do the “elbow test” and partly fill a dry bag in which to place the foot. The hot water can be topped up at regular intervals.

When we looked after this case for real, we also administered liberal quantities of fine tawny port to the whole group to maintain morale. His pain subsided quite quickly and the foot was left bathed in hot water for a couple of hours. No symptoms or signs of systemic envenomation occurred. The patient continued with his dive trip and the swelling settled over the next few days.

Given the location and circumstances of the injury, can we hypothesise what animal caused it? / This injury occurred in warm waters to a man wading in a shallow, sandy bottomed bay. This suggests a stingray injury, as stingrays often settle half hidden under the sand in shallow water. A stonefish injury is less likely, but if in the right region within the realms of possibility. However, one might expect that the pain would not be well controlled with just hot water and that the patient would show systemic signs of envenomation and require evacuation.

Keep Swimming

Remember, all articles on this subject, including this one, tend to focus on the nasty stuff. The reality is that most bites and stings cause only self-limiting inconvenience and can be treated quite simply. So keep playing in the sea!

Most recent updates

Since this article was first written 6 years ago there have been ongoing questions about which jellyfish species are best treated with ice and which with heat, and which is better (1). I think this shows two important things. Firstly, doing research on envenomation is technically difficult and getting high powered good quality studies in vivo is very difficult if not impossible. Secondly, when we are talking merely about symptomatic treatment (as opposed to life saving treatment) the fact that the debate continues probably suggests it doesn’t matter that much. If it makes the patient feel better, it makes the patient feel better. The flow chart remains up to date according to the best evidence we have.

There is an ongoing myth, that started as a controversy, when it comes to the use of vinegar in tropical jellyfish. The research unequivocally proves that vinegar prevents nematocyst discharge. (nematocysts are the barbed stingers that when released inject venom). An in vitro study was published in 2014 that demonstrated that vinegar increased the venom load in already discharged nematocysts (2). This was quickly promulgated in the press – without the full story. Firstly, there is a question as to whether this in vitro study in fact translates into an in vivo situation, but the biggest catch is that although the effect seen in the study is undoubtedly true, approximately 80% of nematocysts on a patient after a sting are still undischarged. So, the overall effect with vinegar is to reduce the amount of venom available. Vinegar remains as a first aid treatment that has genuine merit.

Irukandji treatment has seen a positive breakthrough. Evidence of Magnesium remains unproven and expert consensus in Australia suggests its use only as a second- or third-line agent in those with severe sympathomimetic symptoms. For those of you who, like me, don’t see this injury every day the key issue with Irukandji Syndrome is the massive sympathomimetic response resulting in tachycardia, uncontrolled hypertension and severe pain that is often opioid refractory. A 2022 retrospective study demonstrated that clonidine given iv in a dose 1mcg/ kg had a marked reduction in their opioid requirements post administration (3). The authors of the study recommend that is be given early.

Useful resources

Apps

Australian Bites and Stings App (Android / Apple: Free on App Store)

FOAMEd

Clinical Toxinology Resources from the University of Adelaide

Berling I, Ibister G. Marine Envenomations. Australian Family Physician, 2015. 44(1); 28-32

Perkins RA, Morgan SS.Poisoning, Envenomation, and Trauma from Marine Creatures. Am Fam Physician. 2004 Feb 15;69(4):885-890. This article provides a good overview with an American focus.

Lionfish and Stonefish Envenomation

Books

Warrell DA. Risks from animals. Ch17 in Johnson C et al (eds) Oxford Handbook of Expedition Medicine. Oxford: OUP; 2015.

White J. A Clinician’s Guide to Australian Venomous Bites and Stings. Parkeville: CSL Laboratories; 2013.

Williamson JA, Fenner PJ, Burnett JW, Rifkin JF (eds). Venomous & Poisonous Marine Animals. Sydney: UNSW Press; 1996.

A big thanks to Dr Bill Nimorakiotakis, Emergency & Retrieval Physician, and Clinical Toxinologist for reviewing this article. Cover image: Blue Ringed Octopus (Zain Fimmel)

References

1. Seymour J. Are we using the correct first aid for jellyfish? Med J Aust 2017; 206 (6): 249-250. || doi: 10.5694/mja17.00053
2. Welfare P, Little M, Pereira P, Seymour J. An in-vitro examination of the effect of vinegar on discharged nematocysts of Chironex fleckeri. Diving Hyperb Med. 2014 Mar;44(1):30-4. PMID: 24687483.
3. Isman A, Seymour J, Little M. Use of clonidine in the treatment of Irukandji syndrome: A 4-year retrospective cohort study on safety, efficacy and clinical utility. Emerg Med Australas. 2022 Aug;34(4):504-508. doi: 10.1111/1742-6723.14017. Epub 2022 May 31. PMID: 35638940.

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Diving and Hyperbaric Medicine is a unique subspecialty of medicine that many trainees never get exposed to throughout their entire careers. For aspiring adventurous medics, a new opportunity to work as a Foundation Doctor at the DDRC is a great way to gain experience in this field in a supportive setting. Dr Ayesha Sithirapathy describes her experience of working as the first-ever F2 doctor in Diving and Hyperbaric Medicine at the DDRC Hyperbaric Chamber.

What is the DDRC?

DDRC Healthcare (formerly the Diving Diseases Research Centre) is a hyperbaric medical facility in Plymouth. It is one of only 10 chambers in the UK providing emergency hyperbaric oxygen therapy (HBOT) as British Hyperbaric Association (BHA) members. DDRC is a registered not-for-profit organisation and has three key aims: research into hyperbaric illnesses and treatments; education to improve diver safety and accident management; and HBOT for both emergency and non-emergency conditions.

Whilst the centre is best known for treating diving decompression illness or ‘the bends,’ divers only account for one-third of their patients. They also offer HBOT for a variety of non-diving-related conditions. These conditions include iatrogenic gas embolisms, radiation proctitis, sudden sensorineural hearing loss, non-healing wounds, and many more.

DDRC delivers 24/7 diving and hyperbaric medical emergency services, operating the national BHA Emergency Helpline. As well as this it produces diver safety materials, presentations, courses, and events.

My Journey to DDRC

The Foundation Year Two role was created in 2023, making me the first person to rotate to DDRC in this capacity. The application process for this job has since changed, and now uses the national allocation process on Oriel. Having been an active member of the University Wilderness Medicine Society I had a small amount of academic exposure to dive medicine and medicine in controlled environments. However, no prior knowledge or experience in this field is required with excellent on-the-job teaching and close supervision to guide you through. It was a steep learning curve initially, but rewarding to see the progress of assessing and treating patients with both emergency and non-acute presentations.

What cases do you see?

The DDRC’s clinical work is roughly divided into emergencies (e.g. ‘the bends’ and gas embolisms) and elective therapies. The DDRC is also involved with outpatient clinics and reviews inpatient referrals from Derriford Hospital.

As the F2 Doctor, you occasionally hold the on-call doctor bleep in hours as the ‘duty doctor’ and can take calls through the BHA Emergency Helpline. You will always be supervised and have people to ask for advice if you are unsure about anything.

For example, when I was the duty doctor, I took a call regarding a diver in Dorset who developed neurological symptoms after surfacing; unilateral arm paresthesia and weakness. Working through a proforma of questions the patient’s history suggested a likelihood of having the bends (inert gas bubbles evolving within body tissues). For this condition, the patient required an in-patient assessment at our chamber. I provided advice on how to stabilise the patient and arranged for a transfer to the chamber.

On arrival of the patient, I led the initial assessment, including a full history, neurological exam, and hyperbaric chamber safety checklist. As an F2, all of this is done under supervision from a senior doctor highly experienced in hyperbaric medicine.

This patient responded brilliantly to treatment in the chamber. The treatments have set times but can be extended until the patient’s symptoms resolve, sometimes lasting several hours. If, despite this, there is not a satisfactory resolution of symptoms, the patient would be reassessed to decipher whether there may be another cause for the symptoms.

Outcomes are significantly improved the faster treatment is commenced thus helicopter versus ambulance transfer is often a decision we need to make. The DDRC is technically a remote medical site, so patients must be stable before arriving here. If they are unwell, we recommend they attend the Emergency Department first as a clinical priority – we are then only five minutes away from Derriford Hospital, a major tertiary centre.

How does this role fit into Foundation Training?

This job is located within the Peninsula Deanery (covering Devon and Cornwall) and accounts for your community F2 job if working at Derriford Hospital in Plymouth. Although the hours are Monday to Friday, 08.30 am to 5 pm, you are welcome to attend any out-of-hours emergency calls for excellent learning. It is a standard-length 4 monthly rotation with only one F2 doctor at a time thus providing a wealth of supervised learning opportunities.

As a community placement, I found it to be a well-needed break from the acute hospital rush. If you are an outdoorsy person then living in the South West is fantastic. Having Dartmoor and the South Coast on the doorstep is a huge perk and a complimentary bonus of training in Devon.

Other opportunities

Aside from the clinical work mentioned above, the role has plenty of non-clinical opportunities. You can get involved with teaching on the various courses offered by the DDRC, delivered to both medical and non-medical personnel. With this teaching experience, and more head space, I  designed and implemented a new part of the Peninsula Deanery Foundation Doctor’s regional teaching programme.

Engaging in research and audit opportunities has also been an excellent benefit of the job. Having protected project time allowed me to complete an audit of the BHA helpline calls from last year; presenting these results at the national 2023 BHA/UKDMC in London.

There is an opportunity to attend teaching, including the Diving Medical Advisory Course (which is the qualification required to become an Approved Medical Examiner of Divers) around your work commitments.

As well as being a great start for anyone wanting to pursue a future career in Diving Medicine this role supports doctors looking to do any remote or expedition work near the coast or sea.  Aside from this F2 position, there are junior clinical fellowship positions available at DDRC which I am fortunate enough to be starting now.

The Verdict

My experience at DDRC was overwhelmingly positive. The staff are all extremely friendly, supportive and keen to teach. I found it intellectually stimulating covering new and exciting content whilst being very practical. The only downside is that it is slightly less clinical when compared to other Foundation rotations but the other opportunities more than make up for this.

Overall, I would wholeheartedly recommend applying for this F2 role if you can. DDRC is one of the only places in the UK where junior doctors can train and work in diving and hyperbaric medicine, so whether you are specifically interested in pursuing a career in these fields or simply want to learn something new, it is a fantastically unique opportunity!

Photos Courtesy of Dr Ash Sithirapathy

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Ben is currently working in remote primary and emergency healthcare in Papua New Guinea. The location is popular with adventurous surfers, divers, and billionaires arriving on superyachts. On occasion, they become unstuck and require emergency healthcare. Ben describes a recent case of acute febrile illness.

Abstract

This case review examines the diagnosis and management of a traveller experiencing an acute febrile illness in tropical Papua New Guinea. The case underscores the critical role of thorough pre-departure evaluation and adept management of febrile conditions in tropical environments.

The case describes a patient experiencing severe headaches, fever, and rigours on a luxury yacht cruise without appropriate malaria prophylaxis or knowledge of the risks associated with mosquito-borne diseases. The detection of malaria through a positive rapid diagnostic test (RDT) led to a treatment plan incorporating intramuscular artemether in addition to empirical antibiotics before private jet transfer to an overseas healthcare facility.

The review examines the literature on the diagnostic challenges of tropical medicine. It highlights the greater prevalence of non-tropical diseases in travellers compared to tropical diseases, while emphasising the significant burden of malaria to febrile illness and mortality in these situations. Furthermore, the review evaluates the accuracy of rapid diagnostic tests (RDTs) for diagnosing tropical diseases such as malaria, dengue, and typhoid in areas with limited resources. It outlines a management strategy for undifferentiated acute febrile illness in tropical locations.

Introduction

As the world’s population grows and the collective desire for adventure increases, more holidaymakers are exploring destinations worldwide. Many of these destinations are idyllic tropical settings, which offer an escape from the bitter cold of winter and the monotony of urban life. However, travel to these areas presents unique challenges. These include the risk of tropical infectious diseases, extreme environmental conditions that stress unacclimatised bodies, and often remote locations with limited access to medical care. As a result it is now essential for all healthcare professionals to understand the common causes and management strategies for acute febrile illnesses in tropical environments. Those working in non-tropical regions must be equipped to conduct pre-departure assessments as well as evaluate and manage febrile patients returning from travel. Similarly, health professionals in tropical areas must be adept at caring for febrile travellers, particularly in isolated and resource-limited settings.

Case Presentation

Patient Information

This case concerns a male in his late sixties of European descent, with a medical history including obesity, dyslipidaemia, hypertension, mild fatty liver disease, and benign prostatic hypertrophy. His medications comprised of antihypertensives, a statin, and tamsulosin-dutasteride for prostate management. He had no reported allergies.

Situation

The patient had embarked on a 14-day luxury superyacht cruise around Papua New Guinea’s remote islands. The 168-foot vessel hosted approximately eight guests and twelve crew members. The vessel was equipped with a comprehensive medical kit, which did not meet all of the requirements for Category A vessels as outlined by the UK Maritime and Coastguard Agency (MCA).¹  This discrepancy was likely due to a provision which permits adjustments based on the recommendations of a qualified health professional to suit the crew’s needs and the voyage’s specifics. The captain was responsible for medical care and had access to international maritime medical support. A private plane was utilised to transport guests to the yacht and was stationed on standby in Northern Australia for the duration of the cruise.

The cruise offered guests yacht-based activities such as snorkelling, diving, jet skiing, and occasional land-based adventures such as jungle hikes and white-water rafting. Throughout the journey, the health of all staff and the other guests remained stable, and no acute illnesses were reported. However, despite the voyage’s location and occasional land excursions into dense jungle, no malaria prophylaxis was provided to guests or crew, underestimating the mosquito exposure risk during onshore activities in Papua New Guinea. Furthermore, preventative measures against insect bites were not taken for land excursions, and guests were not informed about the risks of mosquito-borne diseases prevalent in this tropical region.

Clinical Assessment

The focus of this case, a male in his late sixties, started experiencing a mild headache and lethargy the evening before seeking medical care. Upon return from a remote health patrol, an Australian doctor volunteering in the province received a phone call informing them that the vessel was en route to port for medical care due to the patient’s worsening condition. Over the day, the patient’s headache intensified, becoming severe, accompanied by high fevers peaking at 39.8°C, rigours, and sinus tachycardia with heart rates ranging from 100-120 beats per minute. He remained normotensive. The patient reported no other symptoms in the previous three days, and neither the guests nor the crew had observed any further symptoms before this deterioration.

Upon boarding the yacht, a thorough examination and history revealed numerous mosquito bites within the past 14 days. The individual reported no respiratory, urogenital, cutaneous or gastrointestinal symptoms. They had not recently started any new medications. There was no reported recreational drug use or high risk sexual activity. The examination confirmed the patient’s account, noting only subtle suprapubic tenderness and persistence of the tachycardic but normotensive state, with fevers slightly reduced to the 38°C range after paracetamol.

Diagnostic Assessment

Before boarding the yacht, the doctor prepared a list of differential diagnoses, aiming to refine them through clinical evaluation and bedside testing. The primary considerations for fever in a visitor to Papua New Guinea included acute tropical and non-tropical infectious diseases and rare non-infectious causes such as medication side effects, hypermetabolic states like thyroid storm, or inflammatory conditions such as vasculitis.

The doctor requested and reviewed the yacht’s medical supplies list, noting an absence of malaria rapid diagnostic tests (RDTs) and antimalarial medications. This review enabled them to gather these crucial supplies, an intravenous cannula, and fluids before heading to the yacht. This ensured preparedness for as many potential diagnoses as possible. The doctor directed the crew to give the patient paracetamol and promote oral hydration to control fever and maintain fluid balance while they made it to the yacht.

In this remote part of Papua New Guinea, diagnostic options were limited. The absence of urine analysis, dengue and typhoid RDTs, and non-operational x-ray equipment at the local hospital further constrained diagnostic capabilities. The primary differential diagnosis in a man in his late sixties, presenting with severe headache, fever, and rigours after a 14-day trip to Papua New Guinea, was malaria. This was supported by a weakly positive RDT. Differential diagnoses included urinary tract infection, dengue, typhoid, and rickettsial infection. However, the lack of specific tests for these conditions required reliance on clinical judgment and the patient’s response to empirical treatment.

Management

Initial management involved administering paracetamol for fever and promoting oral hydration. Following assessment, targeted interventions began, including 3.2mg/kg of intramuscular artemether for suspected malaria. This was chosen for its once-daily dosing effectiveness and the practicalities of administration in a human resource-limited setting.²  Concurrently, to cover potential bacterial infections, 2g of ceftriaxone was given intramuscularly, empirically addressing alternative causes of fever, including urinary and respiratory infections, typhoid, rickettsial diseases, and meningococcal infections.^3-6 Oral artemether/lumefantrine was also supplied to allow continued treatment once a higher-level medical facility was reached, in anticipation of potential delays in accessing malaria treatment in non-endemic regions.

In the absence of glucose monitoring, the patient was advised to consume one glass of sugar-added fluids for every two of water to prevent hypoglycemia. The yacht crew monitored the patient every six hours for signs of deterioration, with thresholds set for seeking further medical assistance. Arrangements were made for expedited transfer the following morning to an overseas tertiary healthcare facility using the patient’s private plane, ensuring timely and safe transportation.

Follow-up and Outcomes

The patient showed improvement overnight, with reduced fever and tachycardia, but remained in a suboptimal location for ongoing management. Given the patient would arrive at the tertiary hospital within 24 hours and the continued effect of the administered artemether and ceftriaxone, no further doses were given pre-transfer. Stable and afebrile, he was deemed fit for travel without medical escort on his private plane from Papua New Guinea. He remained stable during the flight and recovered sufficiently at the tertiary facility. Unfortunately the precise cause of his fever, with its wide differential, was never communicated back to Papua New Guinea.

Discussion

This case required the doctor to navigate various diagnostic and therapeutic decisions with limited support and access to resources. Reflecting on this experience, a thorough review of the diagnostic and management processes has shed light on potential improvements and modifications to this doctors clinical practice while working in remote tropical locations. These insights aim to improve patient outcomes in similar situations encountered in the future. The details in the subsequent sections aim to share this knowledge with other healthcare professionals working in or aspiring to work in similar tropical environments.

Febrile Illness in Tropical Environments

This case underscores the difficulties in diagnosing and treating acute febrile illnesses in remote tropical settings like Papua New Guinea, highlighting the need for a comprehensive list of differential diagnoses for travellers with fever and nonspecific symptoms. In such cases, non-tropical infectious diseases, including respiratory and urinary tract infections, are the most prevalent cause, accounting for 39% of cases.⁷ Tropical infectious diseases follow closely at 33%, whereas non-infectious causes of fever represent a mere 0.5% of febrile illnesses in travellers to tropical regions.⁷ Malaria stands out as the predominant organism to cause fever in travellers to tropical regions (22%). It has a mortality rate of 0.2-0.5%, causing 25-55% of infectious disease related deaths among travellers, hence testing for and treating malaria is essential.^6-10

Dengue fever is the second most common organism to cause fever among travellers to tropical areas, constituting 5.2% of cases. However it does presents a significantly lower mortality and complication rate compared to malaria.^6-9  Other significant tropical diseases include enteric fever (typhoid and paratyphoid) and rickettsial infections.^6,7,9  Less common causes, accounting for under 2% of cases, include schistosomiasis, helminthic infections, amebiasis, viral haemorrhagic fevers, brucellosis, melioidosis, and borreliosis.⁷

To summarise, the primary causes of a fever in a traveller on a short, less than two week, tropical holiday include; ^6-17

• 39% non-tropical infectious diseases, such as respiratory and urinary tract infections
• 33% tropical infectious diseases
• 0.5% non-infectious diseases, such as vasculitides

The five most common tropical infectious diseases are listed in the table below.^6-17

Field Diagnosis of Tropical Infectious Diseases

Rapid Diagnostic Tests (RDTs) have revolutionised the diagnosis of acute febrile illnesses in resource-limited tropical settings. They provide accurate in-field confirmation of major causes like malaria, dengue, and typhoid. For malaria, RDTs show remarkable sensitivity and specificity, particularly for Plasmodium falciparum, with rates exceeding 95%. This helps facilitate immediate and targeted treatment, which significantly improves patient outcomes in remote areas.^6,13,18  Dengue RDTs demonstrate a sensitivity range of 76-93% and impressive specificity over 98%. Furthermore, Typhoid RDTs, such as Typhidot, achieve sensitivity of 95-97% and specificity above 89%.¹³ By minimising the necessity for complex laboratory tests and streamlining the diagnostic workflow, RDTs have expedited the delivery of disease-specific treatments, significantly reducing the morbidity and mortality linked to these infectious diseases.

Field Management of Acute Febrile Illness in a Tropical Environment

Managing undifferentiated fever in travellers to tropical regions involves a systematic evaluation for various potential diagnoses, emphasising identifying localising symptoms to quickly narrow down the differential.⁹ The Quick Sepsis-related Organ Failure Assessment (qSOFA) and similar tools are crucial for identifying patients at risk of severe sepsis and rapid deterioration, who need urgent care and empirical antibiotics.⁹

Malaria testing using RDTs or blood smears is mandatory for all travellers to endemic areas, with positive cases treated immediately with artemisinin-based therapies.⁹  If malaria is ruled out, available dengue and typhoid RDTs should be performed, and positive results should be treated accordingly.

After ruling out malaria, dengue, and typhoid fever, if possible, consider commencing empirical antibiotic therapy with ceftriaxone (100mg/kg/day IV or IM) and doxycycline (5mg/kg/day), with the option to add azithromycin (10mg/kg/day), pending transfer for further assessment and management.¹³  Upon reaching a suitable healthcare facility, repeat malaria testing is essential to ensure no missed diagnosis. If the patient’s condition worsens in the field, empirical malaria treatment should be started with parenteral artemisinin-based therapy and empiric antibiotics, including azithromycin, until transfer to a well-equipped healthcare facility.

Learning Points

1. Seek pre-departure health assessments, vaccinations, and travel advice from a tropical medicine specialist.
2. Non-tropical infections are the leading cause of fever in travellers to tropical areas.
3. Malaria is the most common tropical disease that causes fever in travellers.
4. Dengue, Typhoid, and Rickettsial infections are other significant causes of fever in these travellers.
5. Tropical diseases often initially present with non-specific symptoms, including headache, fever, rigours, and malaise.
6. Use rapid diagnostic tests for malaria, dengue, and typhoid when available. Plan to secure a supply in advance.
7. Diagnosing illnesses in tropical environments can be challenging. When faced with uncertainty, severely ill, or deteriorating patient, opt for broad treatment. This should include artemisinin-based therapy for malaria and antibiotics, including ceftriaxone and doxycycline, with azithromycin as an optional addition to the regimen if necessary.
8. Initiate early communication with transportation, retrieval services, referral hospitals, and global health agencies. The optimal care location is typically elsewhere for unwell travellers in tropical areas. Prompt transfer of the patient to a suitable medical facility is crucial for improving outcomes.

Conclusion

This case highlights the challenges of delivering medical care in remote tropical locations, where the range of possible illnesses expands but access to diagnostic testing diminishes, complicating accurate diagnosis. A broad understanding of potential causative agents enables the implementation of wide-ranging treatment protocols to optimise patient outcomes. The key to improving patient outcomes in this setting is the early identification and treatment of malaria, coupled with swift transfer. However, clinicians must remember that most acute febrile illnesses in these regions are caused by infections common to non-tropical areas.

Optimising care for acutely febrile travellers in remote tropical settings requires a broad knowledge base and skill set, foresight in planning and anticipatory decision-making, effectively utilising limited resources and evacuation coordination for at-risk or deteriorating patients.

References

1. Maritime and Coastguard Agency (MCA). Merchant shipping notice: MSN 1905 (M+F) Amendment 1 – Ships’ medical stores. Southampton, United Kingdom: Maritime and Coastguard Agency; 2012 [cited 2024 Mar 11]. Available from: https://assets.publishing.service.gov.uk/media/60ae23d48fa8f520c949b676/MSN_1905__M+F__Amendment_1_ships__medical_stores.pdf
2. Medicins San Frontieres. Essential drugs: Drugs potentially dangerous or obsolete or ineffective – Artemether injectable. Medicins San Frontieres; n.d. [cited 2024 Mar 11]. Available from: https://medicalguidelines.msf.org/en/viewport/EssDr/english/artemether-injectable-16682453.html
3. Dryden M, Miller A, Morgan C, Warrell DA. Treatment: infectious diseases. In: Johnson C, Anderson S, Dallimore J, Imray C, Winser S, Moore J et al. Oxford handbook of expedition and wilderness medicine. 2nd edition. Oxford (United Kingdom): Oxford University Press; 2015. P 455-514.
4. Therapeutic Guidelines. Early intervention for sepsis and septic shock: prehospital management. Melbourne: Therapeutic Guidelines; 2020.
5. Lokida D, Hadi U, Lau CY, Kosasih H, Liang CJ, Rusli M et al. Underdiagnoses of rickettsia in patients hospitalized with acute fever in Indonesia: observational study results. BMC Infect Dis [Internet]. 2020 Dec [cited 2024 Mar 11];20:1-2. DOI: 10.1186/s12879-020-05057-9
6. Fink D, Wani RS, Johnston V. Fever in the returning traveller. BMJ [Internet]. 2018 Jan [cited 11 Mar 2024];25;360-369. DOI: 10.1136/bmj.j5773
7. Buss I, Genton B, D’Acremont V. Aetiology of fever in returning travellers and migrants: a systematic review and meta-analysis. J Travel Med [Internet]. 2020 Dec [cited 2024 Mar 12];27(8),1-12. DOI: 10.1093/jtm/taaa207
8. Leggat PA. Assessment of febrile illness in the returned traveller. Aust Fam Physician [Internet]. 2007 May [cited 2024 Mar 12];36(5):328-333. Available from: https://researchonline.jcu.edu.au/2795/1/2795_Leggat_2007.pdf
9. Thwaites GE, Day NP. Approach to fever in the returning traveller. NEJM [Internet]. 2017 Feb [cited 2024 Mar 12];376(6):548-60. DOI: 10.1056/NEJMra1508435
10. Wilson, M. Fever in the returned traveller, CDC yellow book 2024: post travel evaluation. Centers for Disease Control and Prevention [Internet]; 2023 [cited 2024 Mar 12] . Available from: https://wwwnc.cdc.gov/travel/yellowbook/2024/posttravel-evaluation/fever-in-the-returned-traveler
11. NSW Agency for Clinical Innovation. Emergency care institute, New South Wales: returned traveller. NSW Agency for Clinical Innovation; 2024 [cited 2024 Mar 12]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/infectious-diseases/returned-traveller#:~:text=Severe%20respiratory%20symptoms%20associated%20with,%2C%20such%20as%20Legionnaires’%20disease
12. NSW Agency for Clinical Innovation. Incubation periods of common travel-related infections [Internet]. NSW Agency for Clinical Innovation; 2024 [cited 2024 Mar 12]. Available from: https://aci.health.nsw.gov.au/__data/assets/pdf_file/0007/286837/Incubation_periods_of_common_infections.pdf
13. Singhi S, Chaudhary D, Varghese GM, Bhalla A, Karthi N, Kalantri S et al. Tropical fevers: management guidelines. IJCCM [Internet]; 2014 Feb [cited 2024 Mar 12];18(2):62-69. DOI: 10.4103/0972-5229.126074
14. Wilson M. Evaluation of fever in the returning traveller. UptoDate [Internet]; 2023 [cited 2024 Mar 12]. Available from: https://www-uptodate-com.
15. Rathi N, Rathi A. Rickettsial infections: indian perspective. Indian pediatr [Internet]. 2010 Feb [cited 2024 Mar 12];47:157-64. DOI: 10.1007/s13312-010-0024-3
16. Mahajan SK. Rickettsial diseases. J Assoc Physicians India [Internet]. 2012 Jul [cited 2024 Mar 12];60(7):37-44. Available from: https://www.researchgate.net/profile/Sanjay-Mahajan-2/publication/235618717_Ricketsial_diseases/links/58f619554585158514b54ef9/Ricketsial-diseases.pdf
17. Haake DA, Levett PN. Leptospirosis in humans. Curr Top Microbiol Immunol.[Internet]. 2015 [cited 2014 Mar 12];387;65-97. DOI: 10.1007/978-3-662-45059-8_5
18. Mukkala AN, Kwan J, Lau R, Harris D, Kain D, Boggild AK. An update on malaria rapid diagnostic tests. Curr Infect Dis Rep [Internet]. 2018 Dec [cited 2024 Mar 12];20:1-8. DOI: 10.1007/s11908-018-0655-4

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Dr Emily Watts is working as a registrar in Emergency Medicine with special interest in Pre-Hospital Emergency Medicine based in Cumbria. She is developing her expedition and wilderness portfolio with a post graduate diploma, and has been involved with medical cover for ultramarathons in the UK and Europe. Outside of work, she can be found up a fell, on or in the water, or cycling the gravel tracks that make living in the Lake District so fantastic for any outdoorsman.

Clinical fellowship title, specialty and grade 

Title: Clinical Fellow in Emergency Medicine with Specialist Interest

During my fellowship, the role was advertised for those with a special interest in Pre-Hospital Emergency Medicine. This has now been broadened to include special interests in Pre-Hospital Medicine, Mountain Medicine, Simulation Medicine, Academic Medicine, Paediatrics, and Intensive Care Medicine.

Base Specialty: Emergency Medicine 

Grade: Post-FY2 – commonly as stand-alone FY3 or as an ‘out of programme experience’ for EM trainees.

Structure of the role

This role is a fixed-term contract for 12 months. My time was split as 70% Emergency Medicine and 30% special interest, which has changed to an 80% / 20% split since. My PHEM special interest time included experience with North West Ambulance Service and Mountain Rescue Teams. The opportunity to work with Great North Air Ambulance Service was unfortunately limited by the onset of the Covid-19 pandemic. This has since been re-established for more recent fellows.

The trust supports less than full-time working – ask on application if interested. 

Prerequisites for application  

This fellowship prerequisites are straightforward:

• 4 months experience in Emergency Medicine
• Completion of the foundation training programme
• Advanced Life Support (ALS) provider

This post is targeted at the post-FY2 / pre-specialty application doctor, and represents the majority of the applicants, but they are open to applications with higher levels of experience.

Location of fellowship

Clinical Fellows are based in Cumbria, in the North-West of England. The hospitals are in Carlisle (North East Cumbria) and Whitehaven (North West Cumbria), with the fellowship base hospital usually set as Carlisle. This is discussed on an individual basis and decided based on special interest preferences. As my interests included mountain medicine, my base was set as Whitehaven for my fellowship year.

Pre-hospital experience will be largely dependent on where you are based owing to the geography of the Lake District and Cumbria in general. I joined ambulance crews from bases local to the Whitehaven area and worked alongside the Wasdale mountain rescue team. The Great North Air Ambulance Service has bases in Langwathby and Eaglescliffe.

Brief description of the job role.

Emergency Medicine:

You will join the SHO rota, working alongside the clinical team and wider MDT to provide emergency care to the local and visitor populations. This roster includes working a range of shifts, including late and night shifts, as well as weekend working – this is unlikely to be surprising to applicants, given the prerequisite for ED experience. Both hospitals have mixed Emergency Departments, meaning there is an opportunity to work with the paediatric and adult patients. Owing to the rural location and nature of a district general hospital, there are limited specialty services on-site, especially at Whitehaven. Consequently, there is a greater emphasis on procedures and skills being taught and performed within the Emergency Department. The tertiary centre for many specialties will be in Newcastle, approximately 2 hours away by road from Whitehaven. 

Special Interest:

The fellowship was a new role when I joined, without any set format or criteria. This meant that there was a lot of work on my part initially to set up opportunities by email and phone calls. This is now a well-established role so there is more structure to facilitate the ease of taking up local opportunities. For applicants considering this role, I suggest you reach out to the recruiting team to see if they can cater to your area of interest and particular opportunities you would like to experience (I expect the answer will be yes!).

Within the rota, I was allocated a week at a time (roughly every 3 weeks) as my pre-hospital time. However, as long as I ensured I could account for my hours at the end of the year, the senior leadership team was happy for me to self-manage this time. I relished that I was given the freedom to do so, and it meant I got far more done. For example, attending a weekly training session with the mountain rescue team. Some weeks I ended up mixing clinical and pre-hospital elements, whilst others were almost rest weeks to compensate. The senior leadership team was incredibly supportive – making suggestions and options for ways to use my time, they were also able to help nudge opportunities along if I wasn’t getting responses.

Unfortunately, by the time I had arranged observer shifts with GNAAS, the COVID-19 pandemic had hit, so these and my observer shifts with the ambulance crews were put on hold. However, my pre-hospital time was protected despite the circumstances, and I was able to develop other areas of my portfolio: teaching, quality improvement projects, etc.

Academic accreditation

I did not receive accreditation for training for my fellowship year. I used this time to complete an appraisal, maintain my portfolio and prepare for specialty application. Contact the department for further discussion and information.  

Overall impression 

I was excited by this ‘sideways’ career move, as it offered a chance to develop on my career interests throughout my working week rather than cramming it into my rest days. After the usual challenges of relocation and settling into a new trust and department, it quickly became apparent that it was the best decision I could have made.

In my pre-hospital weeks, I had the chance to go on courses (yes, there was a study budget too!) and be an observer with the local ambulance crew. I also linked in with one of the local mountain rescue teams – helping with medical training, but also being accepted as a probationary member for callouts. I covered an ultramarathon in Belgium, with further events lined up for later in the year, and I liaised with the Great North Air Ambulance Service, to arrange exposure to the world of Helimed. 

When COVID-19 hit, it threw a spanner in the works and life as we all knew it ended, which included many of my pre-hospital opportunities. Due to lockdown, the lakes were quieter resulting in less footfall and, therefore, fewer injuries and accidents.

Outcomes of the fellowship

As well as confirming that the ED is where I want to be long-term, it demonstrated how beneficial it is to have allocated time to pursue courses and self-development opportunities is. It reignited my passion for medicine and allowed me to focus on optimising my application for specialty training, without sacrificing rest and recovery.

Ultimately, taking this job helped me to realise that I don’t want to rush through training and that I am happy to take a path less travelled. Whilst I returned to training the following year, this was largely due to the uncertainty around the Covid-19 pandemic. I had initially planned an ‘FY4’ to travel and pursue expedition and remote medicine opportunities. With world travel and a return to normality appearing uncertain, I decided that re-entering training instead would allow me to enhance my skill-set in preparation for future out-of-training options. As a result, I uncoupled training – making a natural break between core and higher training. With the completion of my core years now imminent, this is a decision that I am so glad I took. It allows me further time out to pursue a wide breadth of opportunities, without prohibiting return to higher training in due course.

Costs and potential funding

Travel: Cumbria is rural, with limited public transport options. Whilst it is possible to get around without a car, in my opinion, driving is fundamental to maximise the opportunities this fellowship offers.

Accommodation: Hospital accommodation is available. The human resources team and ED secretaries also have a list of local landlords with available properties for a variety of timespans and needs.

Courses: Applicants are encouraged to pursue areas of interest that can benefit their career. I completed APLS and would have also done ATLS (COVID-19 meant this was postponed to the following year). There is a study budget, but it is not unlimited. If an applicant has a particular course or degree in mind, I suggest discussing this before or during the application process.

Anything else you wish you’d known beforehand?

Bear in mind that Cumbria is rural. For many (myself included) this is a perk. However, this does mean that it’s not got everything at its fingertips. Deliveroo does not exist and there is no large shopping centre! Public transport can be unreliable, and is not as frequent as in cities.

Job application:

Advertised via NHS Jobs. Jobs can open as early as March, for an August recruitment. This last year (2024), applications opened in June.
Application found by searching here: https://www.jobs.nhs.uk/candidate  

The post Clinical Fellowship Review: Emergency Medicine with Special Interest in Pre-Hospital Emergency Medicine appeared first on Adventure Medic.

Public Health England (PHE) have published updated guidance on malaria prevention for travellers from the UK. You can read the full guidance via this link.

Here are some take home messages:

A  Avoidance of travel to malarious areas if the person is at high risk of severe or fatal malaria. For example pregnant women, children, the elderly, people without a spleen and those with complex comorbidities or immunosuppression.

B  Bite prevention. Reducing the number of bites you receive reduces your chance of developing Malaria.

• Full-length, loose-fitting clothing and socks.
• Particular caution at dusk and dawn.
• Screening of doors and windows.
• 50% DEET (N,N-Diethyl-meta-toluamide) based insect repellent is first line on exposed areas of skin. This should be applied after sunscreen. Alternatives to DEET are available including Icaridin and IR3535.
• Bed nets. The World Health Organisation (WHO) have made strong recommendation that pyrethroid-only long-lasting insecticidal nets (LLINs) should be deployed for the prevention and control of malaria in children and adults living in areas with ongoing malaria transmission. Pyrethroid-chlorfenapyr insecticide treated nets (ITNs) should be deployed instead of pyrethroid-only LLINs for prevention of malaria in adults and children in areas with pyrethroid resistance.
• Indoor residual spraying (IRS). The WHO also makes recommendation for IRS where certain listed requirements are met, including that people mainly sleep indoors at night.
• If electricity is available, an electric pyrethroid vapouriser or coils can be used.

C Chemoprophylaxis should be prescribed based on an individual risk assessment. Consider the need for standby emergency medication if a person will be in a remote area. This is not a replacement for chemoprophylaxis, it is an adjunct.

D Diagnose promptly and treat without delay. The WHO Global Malaria Programme will be the focus for malaria control and elimination. The key message is Test, Track and Trace.

Vaccination

Despite research since the 1960s, the international community has struggled to produce a malaria vaccine. This was partly due to the complexity of the life cycle of Plasmodium and its high mutation rate, but more importantly the long-standing lack of urgency and funding behind malaria research in general. In 2015 the final results from breakthrough Phase III trials were published in the Lancet; they showed that children from 5 to 17 months old who received three doses of the RTS,S/AS01 (RTS,S) vaccine plus a booster, would have a 29% reduced risk of severe malaria.

In 2019, the WHO introduced a pilot implementation of malaria RTS,S vaccine in Malawi, Ghana and Kenya. Four years on, over 6 million doses of vaccine have been administered through the Malaria Vaccine Implementation Programme (MVIP), coordinated by WHO and funded by Gavi, the Vaccine Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and Unitaid.

Demand is very high for the first malaria vaccine, RTS,S, recommended by WHO for the prevention of Plasmodium falciparum malaria in children living in regions with moderate to high malaria transmission. It is the first licensed vaccine against human parasitic disease. Also known as Mosquirix, the vaccine is given to children aged 6 weeks to 17 months to protect against malaria caused by Plasmodium falciparum.

It consists of two parts. The first is a recombinant protein which is normally secreted by the Plasmodium parasite during its sporozoite phase; this is the phase in which the parasite enters the human body from the mosquito. This protein is combined with the surface antigen of the hepatitis B virus (HBsAg) to form a soluble, virus-like particle. The second part of the vaccine is an adjuvant chemical which helps to boost the immune response.

Impact and evidence supporting RTS,S malaria vaccine

• Pilot introductions resulted in a 13% drop in mortality among children age-eligible for vaccination and substantial reduction in severe malaria.
• Estimated 1 life saved for every 200 children vaccinated.
• Phase 3 trial (2009-2014) of vaccine showed malaria cases dropped by over half in the first year after vaccination and a 40% reduction in malaria episodes over 4 years of follow up.
• Phase 3 trial (2017-2020) of vaccine provided just prior to peak malaria season in areas with highly seasonal malaria found vaccine efficacy similar to efficacy of Seasonal Malaria Chemoprevention (SMC), shown to prevent around 75% of malaria cases.
• Safety demonstrated after nearly 4 million vaccine doses given to more than 1.2 million children

The RTS,S vaccine is prequalified by WHO. Gavi is investing an initial nearly $USD 160 million for broader vaccine roll-out in endemic countries (2022-2025). Click this link to explore the Framework by which vaccine doses are being allocated.

Further Vaccination

In July 2022, Gavi, the Vaccine Alliance, opened a funding window to support Gavi-eligible countries in rolling out this vaccine and other malaria vaccines as they become available. Since then, over 28 countries expressed interest. Fourteen applications, submitted to Gavi by countries in the first two application opportunities, were recommended for approval by Gavi’s Independent Review Committee (IRC) following the standard Gavi processes. The available vaccine supply for the period 2023-2025 is currently limited to 18 million doses.

WHO has added the R21/Matrix-M malaria vaccine to its list of prequalified vaccines, recommending it’s use in October 2023. This prequalification allows vaccine procurement by UNICEF and funding support for deployment by Gavi, the Vaccine Alliance. This second malaria vaccine is approved by WHO for widespread use for the prevention of malaria in children following the advice of the WHO Strategic Advisory Group of Experts (SAGE) on Immunization and the Malaria Policy Advisory Group. It has been shown to have high efficacy when given before the high transmission season and in an age-based schedule. This new malaria vaccine, R21/Matrix-M, had over 75% efficacy against clinical malaria with seasonal administration in a phase 2b trial in Burkina Faso. Further reporting on safety and efficacy of the vaccine in a phase 3 trial enrolled over 4800 children across four countries followed for up to 18 months at seasonal sites and 12 months at standard sites.

WHO currently recommends the programmatic use of malaria vaccines for the prevention of P. falciparum malaria in children living in malaria endemic areas, prioritizing areas of moderate and high transmission. This now applies to both RTS,S/AS01 and R21/Matrix-M vaccines.

There has not yet been a trial that directly compares the RTS,S and R21 vaccinations, yet both have demonstrated good efficacy and will tackle the fact that demand outweighs supply for these life-saving vaccines. Both vaccines are shown to be safe and effective in clinical trials, for preventing malaria in children. When implemented broadly, along with other recommended malaria control interventions, they are expected to have a high public health impact.

Climate

Each year, WHO’s World malaria report provides a comprehensive and up-to-date assessment of trends in malaria control and elimination across the globe. This year’s report includes, for the first time, a dedicated chapter focused on the intersection between climate change and malaria. Malaria places a particularly high burden on children in the African Region, where nearly half a million children die from the disease each year. Globally, in 2022, there were an estimated 249 million malaria cases and 608 000 malaria deaths across 85 countries.

Climate variability, such as changes in temperature and rainfall, can impact the behaviour and survival of the malaria-carrying Anopheles mosquito. Extreme weather events such as heatwaves and flooding may lead to increases in the transmission and burden of the disease.

A changing climate has indirect effects on malaria, too. As an example, population displacement may lead to more malaria as people without immunity migrate to endemic areas. Climate variability has also led to malnutrition in many places, a risk factor for severe malaria among young children and pregnant women.

WHO World malaria report conclusions

Last year, 49 million children were reached with seasonal malaria chemoprevention in 17 African countries, up from just 170,000 in 2012. Additionally, a new generation of dual-ingredient insecticide-treated bed nets, recommended earlier this year by WHO, has been shown to have greater impact against pyrethroid-resistant mosquitoes compared to standard pyrethroid-only nets.

Meanwhile, the goal of malaria elimination has been achieved in a widening circle of countries. This year alone, three more countries were certified by WHO as malaria-free: Azerbaijan, Belize, and Tajikistan. Several others are on track to eliminate the disease in the coming year.

These and other advances are a testament to both national commitment and global resolve to control and eliminate the disease. However, amid extreme weather events, scarce resources and a growing number of biological threats, there is still a long way to go to achieve our vision of a world free from malaria.

A substantial pivot with much greater resourcing, data-driven strategies and new tools is needed to rebuild momentum in the fight against malaria. With the added threat of climate change, sustainable and resilient malaria responses are needed now more than ever.

References

• https://cks.nice.org.uk/topics/malaria/
• https://www.fitfortravel.nhs.uk/advice/malaria
• https://www.nathnac.net/
• https://www.bug-off.org/
• https://www.who.int/news-room/fact-sheets/detail/malaria
• https://cks.nice.org.uk/topics/malaria-prophylaxis/diagnosis/assessment/
• https://www.ema.europa.eu/en/opinion-medicine-use-outside-EU/human/mosquirix
• https://www.smithsonianmag.com/science-nature/why-did-it-take-35-years-to-get-a-malaria-vaccine-180980151/
• https://www.newscientist.com/lastword/mg25233643-900-if-mosquitoes-were-eradicated-what-would-be-the-consequences/
• https://cdn.who.int/media/docs/default-source/immunization/mvip/infographic_rtss-malaria-vaccine_english_april-2023.pdf?sfvrsn=b9a755ae_14
• https://www.who.int/teams/global-malaria-programme/reports/world-malaria-report-2023
• Efficacy and safety of RTS,S/AS01 malaria vaccine with or without a booster dose in infants and children in Africa: final results of a phase 3, individually randomised, controlled trial. The Lancet. 2015; 386(9988), 31-45
• Datoo, M. S., Natama, M. H., Somé, A., Traoré, O., Rouamba, T., Bellamy, D., … Tinto, H. Efficacy of a low-dose candidate malaria vaccine, r21 in adjuvant matrix-M, with seasonal administration to children in Burkina Faso: A randomised controlled trial. The Lancet. 2021; 397(10287), 1809–1818
• Chandramohan, D., Zongo, I., Sagara, I., Cairns, M., Yerbanga, R.-S., Diarra, M., … Greenwood, B. Seasonal malaria vaccination with or without seasonal malaria chemoprevention. New England Journal of Medicine. 2021; 385(11), 1005–1017
• Datoo, M., Dicko, A., Tinto, H., Ouedraogo, J-B., Hamaluba, M., … Olotu, A. Safety and efficacy of malaria vaccine candidate R21/Matrix-M in African children: a multicentre, doubleblind, randomised, phase 3 trial. The Lancet. 2024; 403: 533-44

The post Clinical Update: Malaria Prevention and Vaccination 2024 appeared first on Adventure Medic.

In this article, Juan reflects on his time volunteering as a medic for Floating Doctors in Panama. As well as tackling life in a new environment and challenging presentations, Juan speaks freely about his changing beliefs on what healthcare truly means.

Introduction

As far back as I can remember I’ve wanted to work in humanitarian aid. Born in Argentina and raised in Canada, I went to medical school in Ireland, before landing in Philadelphia where I currently train.

Amidst the COVID-19 pandemic in 2020, I flew across the pond from Ireland as a final-year medical student to work with Floating Doctors, a medical group treating native communities from boats off the Caribbean coast of Panama.

Floating Doctors is a volunteer-funded humanitarian medicine group that operates from the island of San Cristobal in the Bocas del Toro Archipelago. They provide care to the Ngabe-Buble indigenous groups living in hard-to-reach islands throughout the region. This population are so isolated that, over ten years ago, the Panamanian government reached out to Floating Doctors for help providing their medical care. Over time Floating Doctors have woven themselves into the fabric of the Ngabe communities, sailing from village to village and providing outpatient healthcare, as well as health education in their schools, midwifery training with local parteras, dental care, and physiotherapy. They are always receptive to new volunteers, although their economic model is built on donations and a pay-to-volunteer system.

I spent ten weeks travelling between the islands working with a population deprived of healthcare during the pandemic, and conditions were extremely difficult. As I saw more patients, I learned about the people and their environment, grew closer to their culture, and began to understand their day-to-day challenges. Throughout this, I waged perennial battles against the sandflies, jellyfish, cacao-crazed violent primates, and my own temperamental gastrointestinal tract. What I learned about myself, this job, life, and everything in between, was worth more than the entire eight years of training that had come before it. I was hooked and knew life would bring me back in due course.

Shaping a career around humanitarian work

With those lessons learned, I spent the first two years of my internal medicine residency in Philadelphia (think of residency like an accelerated training scheme that takes you from intern year to consultant in three or four years), focused on expanding a skill set for humanitarian work. I got involved with the state department delivering care to refugees, worked in clinics for the uninsured, and advocated heavily for people entrenched in the struggle with opioids.

About halfway through my second year, I felt that I was finally hitting my stride. With my eyes still set on the communities I had worked with in Latin America, I geared up to bring my newfound skills back to Panama. Like any physician, I was hyper-focused on exploring the nature of healthcare inequality through the tools I knew: my stethoscope and my medicines. Of course, I was still a trainee with a lot to learn, but despite not knowing everything, I felt I knew what was most important. I knew how to think clinically, I understood the basic essence of medicine.

Or so I thought.

Returning to Panama, with an emphasis on community

Arriving in Panama for a second time, I slotted right back into clinical work. Immediately it came back to me, the daily presentations with pelvic inflammatory disease, the traumas, the worms and their parasitic cousins, the infections, snakebites, arthritis, epilepsy, and all things in between. I was also met with new and surprising challenges, clinical and non-clinical. Notably, there were several more physicians this time around (now post-pandemic), and also a new division entirely: the veterinary group.

Initially, I had mixed feelings about the vet program as I struggled to understand its benefit to a medical group operating on a tight budget. This, however, gradually shifted when I saw how invested the community was in the wellbeing of their animals, garnering a far greater emotional response than with any tablet I could prescribe. I reflected on how healthcare doesn’t always give people meaning in their lives. People find real meaning through things like community, affection, and compassion. If anything, I might argue that the veterinary group was contributing more meaningfully to people enjoying life than the medical arms were.

These ruminations were accelerated the very next week, following one of our clinics in the village of Norteño. In the evening, the whole community came out after dark to celebrate the lighting of a community Christmas tree. People young and old lined the paths. They shared words and prayers, followed by a ceremonial lighting of candles. We were tremendously honoured as a group when they asked us to light the stocks as a sign of their appreciation for our work. When the tree was lit, it was quite a spectacle. Children, parents, church organisers, and the rest all blended into one living, breathing collective, enjoying the camaraderie of creating something beautiful together. The more I thought about it, the more this togetherness made sense. The houses that line the community are just metres apart. Voices carry from home to home all day long. Even if you wanted to, you couldn’t get away from your neighbours if you tried. This, combined with their shared tribulations, forms a tight-knit community of people who depend upon one another.

I thought about how ceremonies like these were few and far between where I grew up. I got to know just a few of my neighbours in the suburbs outside Toronto. Everyone gets into their own car, drives to work, takes their kids to school, and tries to live as un-influenced by those around them as they can. Why is that? Is it because technology makes it easier for us to do things without leaving the home? Is it because we no longer need support from our neighbours to live fruitfully? I don’t know. What I do know is that at that moment I thought about Philadelphia, a city that is hurting in so many ways. Where, despite so much wealth, so many are neglected and fall through the cracks. I thought about how despite endless attempts to build relationships with the people that live in my own building, I feel like everyone is just trying to mind their own business.

For all our advances, we have much to learn from communities like Norteño. Despite their seemingly worse metrics for healthcare inequality, I’d wager many of them are living more enriched and meaningful lives there than in the West. I asked myself what this meant about the nature of inequality as I understood it. What is inequality really? Financial inequality is easy to measure, to understand, but what about inequality of community, or inequality of meaningful connection? As I think about what it means to build health, I realise that maybe I have been looking at health the wrong way.

A Paradigm Shift

I had spent my career trying to fix people’s health on the promise that I was doing a fundamental good. In search of that, I had invested uncompromisingly in the metrics of classical medicine: blood pressure, blood sugar, chronic disease, and functional optimisation. I worked on the principle that health is important because people should have good health—yes, sure, but despite training for eight years and practising for two, I had never taken the time to really ask myself why is health important?

So, with a newfound sense of community, I sat and contemplated these things. This is it, I thought. This is what I am trying to capture in a bottle and bring to people in need. Health is not the end goal, meaning is. Our goal should not be to put health on a pedestal, but to build health as a means to augment people’s ability to live meaningfully through community. That is the essence of medicine. At that moment something clicked; I will never see or approach my work the same way again. If I had to choose between building community or building health, I’d reply that they’re too intertwined to have one without the other. Community is our reason for living; without it, health becomes seemingly less paramount. If we lose sight of that and obsess over healthcare metrics, we’ve missed the mark entirely. Of all of the things that Panama has taught me, this was the most powerful lesson of all.

Reflections

What exactly to do with this realisation, I am not sure. I know it will be hard to take these conclusions back to my place of work in America, to a system that pigeon-holes the best of us into electronic chart box-tickers. Maybe, for the right patients, I can worry less about healthcare metrics and invest my time in building meaning through personal connection, enjoying their presence to brighten their day, and inspire a spark that reminds them to enjoy life. Maybe in the future when I approach medicine at a population level, I will think harder about community building and education as the real goal before losing myself in ‘measurable healthcare outcomes’. In truth, this new understanding leaves me in some ways unsure how to proceed, like the systems that I work in leave little room for me to help people actually find meaning.

That’s the fun in this career though isn’t it, we get to take agency in enacting change. I may not see the path forward clearly, but I know which direction it’s going. Stethoscope in hand, not always plugging my ears, the quest for meaning carries on.

How to volunteer

Find out more about volunteering with them here.

The post Floating Doctors in Panama appeared first on Adventure Medic.

Soo Jeong Han / Medical Student / King’s College London

Dr Constance Osborne / Evidence Explorer Lead / Bristol

Contents

• Introduction and Collaborators
• Expedition and Wilderness Medicine Section
• Global Health and Humanitarian Medicine Section
• Want to get involved?

‘April showers bring May flowers…’

This old adage feels appropriate for the wet spring that we’ve experienced this year. After all the rain, the sun is finally shining through and the countryside is bursting with colour. You might see golden gorse, scarlet poppies or violet bluebells. This season, we have gathered together a collection of summaries as striking as a field of wildflowers. We hope you enjoy this edition of the Evidence Explorer. 

Abbie Oster is a medical student at the University of Leeds, who has just finished her intercalated year in Physiology at King’s College London. In her free time, she enjoys powerlifting, running and the occasional ski trip. Her dream job is to be a ski doctor in the Alps, once she has perfected her French! She is looking forward to returning to Leeds and the moors to do some hiking.

Soo Jeong Han is a medical student at King’s College London. She is interested in expedition and humanitarian medicine. Reviewing articles for the Evidence Explorer has allowed her to delve into the research side of global health and health inequalities. She enjoys travelling the world and experiencing many different cultures, as she herself has lived in six different countries growing up!

Wilderness and Expedition Medicine

This edition is especially adventurous, with articles linked to every sort of environment. We discuss the energy required for ocean crossings, nutrition at altitude and vital signs monitoring in space. We summarise the effect of delayed suspension syndrome on aerial activities and musculoskeletal injury trends in trail runners.

Maximal Sustainable Energy Intake During Transatlantic Ocean Rowing Is Insufficient For Total Energy Expenditure And Skeletal Muscle Mass Maintenance

Holsgrove-West R, Iniesta R, Abdelrahman D et al. The Physiology Society: Experimental Physiology. February 2024

This article explores the physiological limits of energy intake (EI) during extreme endurance activities, particularly focusing on a transatlantic rowing race. The study involved 49 participants, both male and female, aged 24 to 67, who rowed for approximately 46 days, covering 3000 miles. Researchers measured EI, total energy expenditure (TEE), body mass, and muscle mass before and after the race.

They found no significant differences between sexes or age groups in EI, TEE, or body mass loss. Despite participants consuming EI at about 2.5 times their resting metabolic rate (RMR), it was insufficient to match the total TEE, indicating a physiological limit to EI. The study highlights that even with a maximal sustainable EI, individuals experienced significant body mass loss, suggesting a limit to the body’s ability to intake energy during prolonged ultra-endurance activities. With the increasing popularity of ultra-endurance sports it’s important to consider adequate nutritional intake when supporting the endeavours of those undertaking these feats.

Beyond the realm of sports, this study’s implications are important in crucial areas like managing critical illness, navigating space travel challenges, and addressing ageing-related concerns, underscoring human energy dynamics across diverse scenarios. The article also demonstrates the importance of good nutritional planning for extended expeditions, revealing the challenge of sustaining optimal nutritional equilibrium in such demanding circumstances.

Nutrition In Women At High Altitude: A Scoping Review—UIAA Medical Commission Recommendations

Andjelkovic M, Paal P, Kriemler S et al. High Altitude Medicine & Biology. March 2024

This review article looks at the role of nutrition for women during short-term, high-altitude activities. High-altitude affects the body in many ways and therefore optimising nutrition is vital. The researchers found that high-altitude exposure induces metabolic changes, impacting carbohydrate and fat utilization. While menstrual cycle phases may influence metabolic responses, it was found to be more important to ensure sufficient carbohydrate intake to support overall health and performance. Protein consumption, particularly in relation to muscle anabolism and catabolism, warrants further investigation.

Hydration is important, considering increased respiratory and urinary water losses at altitude. Weight loss patterns differ between sexes, with appetite suppression and increased energy expenditure contributing to this. Iron metabolism is pivotal, as iron deficiency is more common in women and can impact erythropoiesis, which is crucial for acclimatization. However, evidence on iron supplementation remains inconclusive.

Regarding supplementation, few studies address women specifically, highlighting the need for further research. While carbohydrate drinks and beet juice may aid performance and acclimatization, zinc and leucine supplementation show limited benefits. Overall, maintaining energy balance and hydration is key for high-altitude performance, with consideration for individualized nutritional needs and supplementation strategies. The review demonstrates the need for more comprehensive research to elucidate women-specific nutritional requirements in high-altitude environments. It is interesting to know more about nutritional requirements specifically for women, considering the significant influence hormones play over systemic functions in the body. This understanding suggests an opportunity to tailor nutrition to better support women’s health and well-being.

Delayed Suspension Syndrome Onset In Aerially Suspended Victims Through Leg Raising

Willihnganz S, Ahmed Z, Lee J. Wilderness and Environmental Medicine Journal. March 2024

Suspension syndrome (SS) is due to venous blood pooling in the extremities during passive suspension, occurring in activities like mountaineering or industrial work at heights. Venous blood pooling leads to functional hypovolemia, inducing pre-syncopal symptoms and can cause loss of consciousness or death. This study aimed to explore leg raising as a prevention strategy for SS, hypothesizing it could delay symptom onset.

University of Birmingham students participated in the study, randomly assigned to control or intervention groups. Participants were suspended in neutral or legs-raised positions, with measurements collected pre, mid, and post-suspension. Leg-raised participants demonstrated significantly longer suspension times and lower pain ratings, suggesting delayed symptom onset. The study highlighted the potential of leg raising to delay SS symptoms in passively suspended individuals, offering insights for emergency workers. Notably, leg raising reduced lower extremity mottling, an indicator for early SS symptoms. These findings could inform standard operating procedures for aerial rescue, enhancing emergency response protocols and provide better advice for paramedics and pre-hospital medics working in the field.

Further research with larger sample sizes and continuous data collection methodology is needed to ensure the findings of this research is valid. Using advanced techniques like ultrasound or near-infrared spectrometry could provide more information about onset of SS. The simulation nature of this study, small sample size and young participants may affect generalizability. Therefore, future investigations are needed and should explore additional interventions to prevent or delay SS onset.

Musculoskeletal Injuries During Trail Sports: Sex And Age Specific Analyses Over 20 years From A National Injury Database

Owen M, Workman C, Angileri H et al. Wilderness and Environmental Medicine Journal. March 2024

In this study, the incidence of MSK injuries was investigated in relation to the rising popularity of trail sports in the past two decades. From analysis of US emergency department patients (2002-2021 inclusive), there was a significant rise in injuries seen during the period. Interestingly, while males constituted a larger proportion of injuries in the early 2000s, females surpassed them in injury rates from 2010 onward. The increase in female injury rates aligns with the growing participation of females in outdoor activities, underscoring the need to understand and address gender-specific injury patterns. Looking at the differences between age groups, those under 18 exhibited higher rates of head injuries and concussions, indicating a potential area of concern for youth participating in trail sports. On the other hand, individuals over 65 showed higher rates of fractures, emphasizing the importance of tailored interventions to mitigate injury risks in older populations, such as monitoring for reduced bone strength in osteoporosis.

Further analysis revealed distinct injury patterns between sexes, with males more prone to shoulder, upper trunk, and hand injuries, while females experience more elbow, wrist, knee, lower leg, or ankle injuries. Moreover, females were more likely to sustain strains/sprains and fractures, highlighting potential anatomical and physiological differences contributing to injury susceptibility. The study also identifies discrepancies in injury rates compared to expected values for specific activities and age groups. For instance, mountain biking participation among those under 18, had higher injury rates than predicted, signalling a need for targeted interventions such as concussion prevention education and helmet promotion.

Despite limitations in data representation and analysis, the findings underscore the importance of injury prevention strategies in trail sports. This is particularly important to address sex-specific and age-related injury patterns, in order to promote safe and enjoyable outdoor recreational activities.

A Built-In Guidance System To Monitor Vital Signs In Space And On Earth

Huerta R, Kaduk S, Fatai L et al. Aerospace Medicine and Human Performance. March 2024

This article addresses the challenge of providing timely and effective medical support during remote operations and exploration missions, both on Earth and in space. With longer evacuation times and limited access to medical facilities, future deep-space exploration missions require enhanced medical care for crew members. Technological advancements, particularly in telemedicine, have significantly improved medical support from the ground, increasing the crew’s ability to handle medical emergencies independently.

The study compared the use of a ‘Tempus Pro’ (a tool to measure a range of vital signs) in medically trained and medically untrained subjects, comparing the usability and ratings of ease. The results found that both groups were able to obtain stable and valid vital signs within a clinically acceptable time frame. While medically experienced individuals performed faster, the inexperienced group demonstrated significant improvement after one simulation, suggesting the device’s effectiveness in training individuals with limited medical background. This has potential benefits for future space missions.

Despite limitations such as a small sample size and the absence of female subjects, the study demonstrates the potential of automated medical devices equipped with guidance systems to provide lifesaving support during remote missions.

Global Health and Humanitarian Medicine

This section summarises a range of topics including communication about herbal medicine during pregnancy, a potential solution to anti-venom shortages, the long term efficacy of the dengue vaccine and the feasibility of psychological therapy being delivered remotely in a humanitarian setting. 

Patient Physician Communication On Herbal Medicine Use During Pregnancy: A Systematic Review And Meta-Analysis

Hyea Bin Im, Jung Hye Hwang, Dain Choi et al. BMJ Global Health March 2024.

This systematic review of 111 studies across 51 countries has revealed that 34% of pregnant women use herbal remedies during pregnancy, believing these to be more natural and mild compared to pharmaceutical medications due to the potential risk of teratogenicity.  For example, ginger, peppermint, and chamomile have proven effective in relieving nausea and vomiting, while cranberry consumption has demonstrated efficacy in preventing urinary tract infections. However, only 28% of these women disclosed their use of herbal remedies to their healthcare providers, often due to perceived safety (sometimes from unreliable internet sources) and a lack of inquiry by doctors. This could lead to inappropriate use of remedies, for example, inappropriate use of ginger can lead to stomach irritation, heartburn, and even cardiac arrhythmias. Prolonged use of chamomile has been associated with a higher risk of preterm delivery and low birth weight.

It was found that disclosure about herbal remedy use to healthcare providers resulted in significantly better health outcomes for pregnant women, while non-disclosure was correlated with higher maternal and neonatal mortality rates. This highlighted the importance of more effective communication and proactive inquiry into the use of herbal remedies to improve antenatal care and, in turn, reduce mortality rates in both mother and baby.

African Polyvalent Antivenom Can Maintain Pharmacological Stability And Ability To Neutralise Murine Venom Lethality For Decades Post-expiry: Evidence For Increasing Antivenom Shelf Life To Aid In Alleviating Chronic Shortages

Gabriela Solano, Sinead Cunningham, Rebecca J Edge et al. BMJ Global Health. March 2024.

Antivenom is a polyclonal mixture of antitoxin antibodies refined from hyperimmunised horses or sheep. It is currently the only established treatment for snake envenomation, which is thought to cause approximately 81,000 – 138,000 deaths each year and permanently disables a further 400,000 people worldwide. It would be helpful if the stocks of these antivenoms lasted a long time, but antivenom stocks are known to last only 2-5 years (depending on the antivenom), after which time these are discarded. Even in places where antivenom distribution and storage is limited, substantial quantities of antivenom are still discarded. The most notable example of this is Sub-Saharan Africa, where suboptimal inventory management and lack of research around national antivenom distribution requirements contributes to a waste of up to 50% of stocks despite the extremely limited supply.

This study, using in vitro and murine in vivo methods, provided evidence that the South African Institute for Medical Research (SAIMR) polyvalent antivenom can retain preclinical efficacy and maintain acceptable stability for up to 25 years after its stated expiry date. This provides promising evidence that supports the use of expired antivenoms in emergency scenarios where in-date antivenoms are not available. There is precedent for this, as the US Food and Drug Administration (FDA) approved the use of expired North American coral snake antivenom.

Feasibility And Acceptability Of Phone Delivered Psychological Therapy For Refugee Children And Adolescents In A Humanitarian Setting

Fiona S. McEwen, Hania El Khatib, Kristin Hadfield et al. Conflict and Health Jan 2024

This is the first study to explore feasibility and acceptability of telephone-delivered therapy with refugee children in a humanitarian setting. Accessibility of psychological therapy is a huge barrier for refugee children, not only because of the shortage of mental health professionals, but also the cultural stigma of receiving therapy, especially in conflict zones. This study used telephone delivered therapy (the Common Elements Treatment Approach – CETA) by lay counsellors (n=3) to try to bridge this accessibility gap. The children (n=11) that were contacted lived in informal tented settlements in the Beqaa region of Lebanon. The counsellors, family members and children themselves were interviewed after the session, and the results thematically analysed.

The results showed that telephone-delivered CETA was effective in reducing symptoms for many of the Syrian refugee children. It also showed that various factors (such as the family’s preconceived attitude to mental health) and the relationship with the counsellor and the family affected the efficacy of the therapy delivered. Challenges in logistics, such as poor network coverage and communication difficulties over the phone were also highlighted.

Post Discharge Malaria Chemoprevention In Children Admitted With Severe Anaemia In Malaria Endemic Settings In Africa: A Systematic Review And Individual Patient Data Meta Analysis Of Randomised Controlled Trials

Kamija S Phiri, Carole Khairallah, Titus K Kwambai et al. The Lancet Global Health Jan 2024.

Severe anaemia poses a significant risk of death for young children, especially in malaria-prone regions. Surviving children often face further risks of death or hospital readmission after discharge. Researchers have conducted a comprehensive review and meta-analysis to evaluate the effectiveness of monthly malaria chemoprevention in children recovering from severe anaemia.

Numerous databases were reviewed for relevant studies, ultimately including three double-blind, placebo-controlled trials from The Gambia, Malawi, Uganda, and Kenya. These trials involved 3,663 children and tested different malaria prevention drugs administered monthly post-discharge. Children who received malaria chemoprevention showed a 77% reduction in mortality and a 55% reduction in readmissions during the intervention period compared to those given a placebo. However, the protective effects did not last beyond the treatment period, highlighting the need for continued research into extending these benefits. One major limitation is the small number of trials analysed, which made it difficult to assess heterogeneity and publication bias.

Long Term Efficacy And Safety Of A Tetravalent Dengue Vaccine (TAK-003): 4·5 Year Results From A Phase 3, Randomised, Double Blind, Placebo Controlled Trial

Vianney Tricou et al. The Lancet Global Health Feb 2024

Dengue fever threatens nearly half of the global population, particularly in endemic regions. To address this, researchers evaluated the long-term efficacy and safety of the tetravalent dengue vaccine, TAK-003, in children and adolescents. This is an ongoing RCT across 26 medical centres in 8 dengue-endemic countries.

The vaccine was effective against all four dengue virus serotypes in previously exposed participants, while it showed efficacy against DENV-1 and DENV-2 in those without prior exposure. Of note, it is difficult to predict the transmission dynamics of the different DENV stereotypes. Serious adverse events were similar between the TAK-003 and placebo groups over the 4.5 years, with no deaths attributed to the vaccine. This study highlights TAK-003 as a promising long-term solution for dengue prevention in endemic regions, with further research required to explore its efficacy across different populations and serotypes.

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Pat McAllister travels to the beautiful Blue Mountains, New South Wales, to give us a rundown of the latest Australasian Wilderness and Expedition Medicine Society (AWEMS) conference. This year’s theme, ‘Discover New Heights,’ brought a diverse and inspiring range of speakers who covered everything from space medicine to disaster management. 

What is AWEMS?

AWEMS is a not-for-profit organisation that supports the field of wilderness and expedition medicine. They organised a fantastic programme for their 2023 conference, with local and international speakers bringing a varied and exciting line-up to the weekend. This year, the conference was hosted by the Fairmont Hotel in the beautiful Blue Mountains (Ngurra), a luxurious location and the perfect contrast for a prize-giving ceremony that rewarded accolades such as ‘longest time without a shower’ – an honourable yet odorous, 80 days.

Programme Highlights

The weekend kicked off with paramedic and former Royal Marines Commando Andy Hughes describing the daily realities of work as an expedition medic. He spoke of dealing with wounds, dysentery, and extreme humidity from the confines of a jungle hammock.

Dr Rowena Christianson brought an interesting perspective to aerospace medicine, where the risks and rewards of commercial space travel were debated. Human space travel may sound like a galaxy far away, but we were given a snapshot into the extensive ongoing research surrounding travel to the ‘final frontier’.

From a slightly lower altitude, Dr Brent Systermans recounted his experiences from a career that has seen him working at Everest Base Camp, as an expedition medical officer in Antarctica, and at the renowned Perisher Ski resort.

Scott McNamara delivered a harrowing and memorable talk on his deployment with Australia’s Disaster Response Team to assist following the earthquake in Southern Turkey. He included drone footage of the devastation and sombrely explained his role in providing medical aid while conducting search and rescue missions through the rubble.

The keynote speaker, anaesthetist Dr Richard Harris, needed little introduction. He played a huge role in the 2018 Tham Luang cave rescue in Thailand, where 13 children were saved. Dr Harris was an extraordinarily humble speaker who spoke of maintaining calmness and internal control in high-pressure situations.

Dr Kate Baecher continued this theme in her talk, which explored the psychology behind how to perform risky, high-precision activities in dangerous and complex environments. She also spoke about ‘post-expedition blues’ and how the study of ‘salutogenesis’ can provide a framework for an adventurer’s ‘new normal’ after they return home.

Conference Events and Workshops

The opening Friday night event was a casual meet-and-greet, with the addition of an ice skating rink where attendees could cut some turns before heading to the bar. On Saturday night, hiking boots were exchanged for heels with a cocktail party at the famous Echo Point lookout. The breathtaking backdrop of ‘The Blueys’ made the perfect venue for meeting new colleagues and discussing the day’s talks.

Sunday allowed delegates to get hands-on with outside workshops and an optional canyoning trip. Workshops included water purification with Adam Kershaw, who, confident in his equipment, turned brown, muddy water into a steaming cup of tea. Brett Eichorn and Gavin Oliver shared their extensive outdoor experience, delivering a practical course on ropes, knots, and shelter building. Andrew Bennet and Andy Hughes kept things realistic with fake blood and traumatic amputations, teaching pre-hospital techniques with limited equipment.

AWEMS president Kerryn Wratt wrangled the ‘mule’, a mono-wheel stretcher designed for tough patient extrication, and we witnessed SALAD (Suction-Assisted Laryngoscopy Airway Decontamination) turned into a true bush-style airway management. We were also lucky enough to meet the NSW special operations paramedics and police service, who were keen to show off their rescue equipment.

Final Thoughts

AWEMS’ Discover New Heights conference was a fantastic weekend in the mountains and an opportunity to meet colleagues from various disciplines. It delivered inspirational talks, a sense of community, and practical workshops in person and online.

The next AWEMS conference will be held in October 2024. Further information can be found on their website.

Photo credits: Dr Molly Cargill, Tristan Reid, Kelsie Herbert.

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The importance of note-keeping is well documented (pardon the pun). Maintaining good clinical records is the cornerstone of exemplary patient care and should not be overlooked, especially on expedition. This article, the second in our masterclass series, provides an overview of the approach to clinical records and documentation on expeditions.

The context

The General Medical Council (GMC) stipulates that maintaining clear and accurate records is a key responsibility of any doctor providing medical care. These requirements are outlined in ‘Good Medical Practice’, succinctly and clearly.¹ In brief, clinical records should include the following:

• Relevant clinical findings
• The decisions made and actions agreed
• Who is making the decisions and agreeing the actions
• The information given to patients
• Any drugs prescribed, other investigations, and treatment
• Who is making the record and when
• Clear, accurate, and legible information
• A record of the time of events

If your practice is under the governance of the Nursing and Midwifery Council (NMC) or the Health and Care Professions Council (HCPC), both organisations also produce guidance regarding clinical record keeping. This can be found in either the NMC’s ‘The Code’ or HCPC’s ‘Standards documents’.^2,3 These standards can, and should, be applied in the context of wilderness medicine, and should constitute fundamental considerations before and after an expedition.

Prior to the Expedition

Expedition medical planning should take place significantly in advance of departure. Usually this means at least three to six months prior to the departure date. Designing, and deciding how to manage, medical documentation should take place in this planning phase. The discovery of poor medical documentation policies, and an unwillingness to address them, should cause a medic to question their participation in the planned expedition.

During the planning phase there are several considerations with regards to medical documentation:

1. Determine whether the expedition intends to use paper or electronic notes (or both)
   Each note keeping method has its advantages and disadvantages, so consider the expedition setting. Larger expeditions, with a base camp, may favour electronic notes, as they will have the required resources, power and hardware. Smaller, roaming expeditions may be better suited to old fashioned paper notes.
2. Consider protection of your notes from the environment
   Remember water and paper mix poorly. Medical notes are legal documents and should be kept in the best possible condition. Your medicolegal defence is only as good as your notes. Similarly, batteries are rapidly depleted with cold exposure.
3. Consider the documents that will assist your note-keeping whilst on expedition.
   Observation and drug charts, patient assessment proformas, and transfer of care documents improve the quality of documentation within the hospital setting. Consider producing pre-made forms for the expedition. These are extremely useful in austere or challenging environments, or during time-critical incidents to ,ensure all required information is captured.
4. Consider the security of medical information before, during and after the expedition.
   Pre-expedition medical screening creates the first medical notes for an expedition, and these are often electronic. Determine how you intend to store these medical notes securely before, during and after the expedition. Participant’s medical screening should include past medical and surgical history, drug history, allergies, immunisations, and emergency information such as passport/ insurance/ next of kin. This needs to be kept securely, but be readily accessible to the expedition medic. There’s little value in taking this information on expedition if you are unable to locate it in an emergency. Similarly, be wary of accessing this information via the organisation’s headquarters, as this relies on an individual picking up the phone, or answering an email, often out-of-hours or in a different time zone. Patient confidentiality and a difficulty with security clearance over the phone will often limit what information can be given.
5. (Note storage after the expedition is discussed later.)

Clear clinical note management is complemented by other aspects of the expedition preparation. These include documentation focusing on the expedition medical kit and medicine storage, specific expedition guidelines, risk assessments, and a comprehensive emergency response plan.

The British Standard 8848 (BS8848) is the gold standard for expedition planning for UK based organisations.⁴ It’s a huge document but thankfully the Faculty of Pre-Hospital Care have produced an easily digestible review, and this should be read alongside FPHC’s own Updated Guidance for Medical Provision for Wilderness Medicine. ^5,6

During the Expedition

This may be the easiest aspect of expedition medical note management, provided there is commitment to good clinical note keeping. Here are some important considerations:

• Ensure patient details (name and DOB) are present on your documentation, alongside time and date.
• It may be relevant to include specific environmental information: location, altitude, temperature/weather.
• Remember to sign off your documentation with signature, name, and professional registration number.
• If you’re an expedition doctor, don’t forget what our incredible nursing and allied colleagues do every day. Documentation of observations, medicines administered, and personal care should all be recorded.
• You may be the only clinician present, so it is important to document uncertainty in diagnosis and the rationale for decisions around treatment or evacuation.
• If you can’t keep contemporaneous notes, consider asking an appropriate member of the expedition to scribe. Alternatively, use your phone for voice or written notes which you can transcribe later.
• Document discussions with the expedition leadership team, medical supervisors and patients . This is of paramount importance when there are areas of conflict. For example, sending a participant down from a seven summits attempt due to altitude illness, or when health takes precedence over other agendas.
• Adverse or serious incidents require additional documentation and should include a factual history of what happened and when, what actions were taken, and the resultant outcome.
• Detailed notes may be necessary for insurance claims for the patient, and will benefit you if you are asked to write a report to support their claim.
• Remember photos and videos can be helpful adjuncts to your written clinical notes. For example, ongoing care of a wound. These must be securely stored and can only be taken with patient consent.
• Additionally, photography at the scene of a major trauma scenario may seem like a breach of confidentiality, but if sensitively conducted may later help the patient to process and recover from the event.

Some expedition companies provide a template for assessments, or you can make your own to take with you.

After the Expedition

Upon returning home from a (hopefully!) successful expedition, your responsibilities as a wilderness medic aren’t over yet. Depending on the events of the expedition, you may be required to contact a participant’s GP if there have been any clinically significant illnesses that require onward care or further investigation. Furthermore, it is also important to write a letter to a participant’s GP regarding significant although resolved episodes, so they are able to update their permanent medical records. For example, a dislocated shoulder which has been relocated on expedition.

Additionally, the post-expedition report may require a breakdown of illnesses and injury diagnoses that occurred. This helps the organisation to tailor their medical kit and tweak risk assessments for future, similar expeditions. Once you’ve completed any necessary GP letters, and finalised the post-expedition medical report, consider the storage of expedition medical notes. Unsurprisingly, the GMC has advice on this;⁷

“You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection law requirements.”

There are several pieces of guidance and legislation to be aware of when considering medical documentation storage. These include:

• The GMC’s ‘Good Medical Practice’ and ‘Confidentiality: good practice in handling patient information’ ^1,7
• General Data Protection Regulation (GDPR)⁸
• Health and Social Care Act (2012)⁹
• NHS Records Management Code of Practice (2021)¹⁰
• The Private and Voluntary Health Care (England) Regulations (2001)¹¹

As discussed, the GMC determines the professional standards with regards to medical documentation. The other pieces of legislation or guidance refer to the legal requirements of clinical note storage both within the NHS and private practice. This legislation and guidance is limited to UK jurisdiction, and most expeditions occur outside of these areas. However, it can be reasonably assumed that these documents would be the standard for practice in expedition settings. For example, for a UK doctor the GMC’s guidance holds true for other aspects of expedition medical work, even if outside the UK.

This is a complex area, but the bottom line is that medical documentation should be stored, post-expedition, for a minimum of 8 years. In addition, there are also conditions under which the notes should be held. Correct and proper storage of medical notes is the primary responsibility of the ‘data controller’, which is the individual or organisation who is tasked with storing the notes. The clinician should be content that their notes will be held appropriately by the organisation’s ‘data controller’. Importantly, GDPR determines that medical documentation should be:⁸

“processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organisational measures.”

As such, it is important to determine, when accepting an expedition medic position, who will be responsible for medical note storage post-expedition. This may be straightforward if travelling with a large organisation, as they should have a suitable system and policy in place, but don’t assume and do check. If it is a smaller expedition, be aware that you may be required to be the ‘data controller’, which comes with significant responsibility and commitment. For more information and advice, speak to your defence union.

The Medical Protection Society (MPS) were approached for comment and provided information relevant to storage of medical notes which aligns with the above information. The Medical Defence Union (MDU) also produces guidance on record keeping.¹² Both are happy to be approached for assistance.

Take home messages

• Remind yourself of your professional body’s expectations for good note keeping.
• Decide how you intend to create and store notes for the expedition, and tailor this to your environment.
• Medical notes require storage for 8 years post expedition.
• Consider who is the ‘data controller’ when planning the expedition, as this determines who is responsible for storage of all medical notes from the expedition.
• Contact your medical defence provider to clarify any legal elements of clinical note storage.

References

1. General Medical Council (2013). Good Medical Practice. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice (Accessed August 2023)
2. Nursing and Midwifery Council (2015). The Code. Available at: https://www.nmc.org.uk/standards/code/ (Accessed August 2023)
3. The Health and Care Professions Council (2023). Standards: Record Keeping. Available at: https://www.hcpc-uk.org/standards/ (Accessed August 2023)
4. British Standards Institution (2014) BS8848: Safer adventures: Managing the risks of adventure travel. Available from: https://www.bsigroup.com/localfiles/en-gb/consumer-guides/resources/bsi-consumer-brochure-adventurous-activities-uk-en.pdf (Accessed August 2023)
5. Royal College of Surgeons of Edinburgh (RCSEd): Faculty of Pre-Hospital Care (2020). A brief review on BS8848: 2014 and its relevance to new or inexperienced expedition ‘medics’. Available at: https://fphc.rcsed.ac.uk/media/2966/bs8848.pdf (Accessed August 2023)
6. Royal College of Surgeons of Edinburgh (RCSEd): Faculty of Pre-Hospital Care (2020). Updated guidance on medical provision for wilderness medicine. Available at: https://fphc.rcsed.ac.uk/media/2781/updated-guidance-on-medical-provision-for-wilderness-medicine.pdf (Accessed August 2023)
7. General Medical Council (2017). Confidentiality: good practice in handling patient information. Available at: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/ (Accessed August 2023)
8. General Data Protection Regulation (GDPR). Available at: https://ico.org.uk/for-organisations/uk-gdpr-guidance-and-resources/ (Accessed July 2023)
9. Health and Social Care Act (2012). Available at: https://www.legislation.gov.uk/ukpga/2012/7/contents/enacted (Accessed July 2023)
10. NHS Records Management Code of Practice (2021). Available at: https://transform.england.nhs.uk/information-governance/guidance/records-management-code/ (Accessed July 2023)
11. The Private and Voluntary Health Care (England) Regulations (2001). Available at: http://www.legislation.gov.uk/uksi/2001/3968/contents/made (Accessed August 2023)
12. Medical Defence Union (2013). Good record keeping. Available at: https://www.themdu.com/~/media/Files/MDU/Publications/Guides/UPDATED%20Consultant%20pack/B4%20Good%20record%20keeping.pdf (Accessed July 2023)

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Aftershock, Everest and the Nepal Earthquake

Where: Netflix

About: A three-part series from Netflix looking at the calm before, the terror during, and the aftermath of the Nepal earthquake in 2015. The earthquake killed nearly 9000 people and made hundreds of thousands of people homeless in an instant.

Why: There is a sense of dread in the first instalment, knowing what is to come. Certainly, when it hits, the handheld footage brings home the impending devastation and a snapshot of the fear felt watching death charge towards you. The series manages to balance both the personal tragedies and the scale of the disaster. It also takes care to focus on the devastated communities, and not just the expedition teams. Indeed, they reflect on the ethics of asking to be saved when others are worse off than you.
There is a terrifying insight into instigating a mass casualty triage at base camp, with real time decisions being made on screen. Left with nowhere to see people, and no equipment to help them with, the medical team resort to supportive care. Despite all the devastation and suffering around, some still want to summit the mountain, providing an interesting glimpse into the power of “summit-fever.”
We don’t know how we will react in a never-event. We train and practice and hope we will act well, but we won’t know until then. We glimpse the good and bad of humanity, with a chilling reflection that we are as dangerous as nature.

If you want to find out more about the medical side, there is a write up of the mass casualty event: Zafren K, Brants A, Tabner K, et al. Wilderness Mass Casualty Incident (MCI): Rescue Chain After Avalanche at Everest Base Camp (EBC) In 2015. Wilderness & Environmental Medicine. 2018;29(3):401-410.

Book:

Holiday SOS

About: Did you know that Monday the 27th is statistically the worst day for an accident? Or that most problems arise in the first 48 hours of a holiday?

‘Holiday SOS: Lifesaving Adventures of a Travelling Doctor’ by Dr Ben MacFarlane offers an insightful and often humorous look into the life of a repatriation doctor. The book chronicles Dr MacFarlane’s experiences as he travels around the world, assisting holidaymakers who fall ill or suffer accidents while abroad. Dr MacFarlane provides a behind-the-scenes look at the challenges and rewards of his unique profession, by sharing his most memorable stories during his year working as a flying doctor.

Why: When sitting down on the plane, having already successfully navigated traffic, security, finding the gate, and the ever-changing baggage restrictions, there is just one phrase left that could crash the holiday spirit. The phrase is one that many medics dread hearing on the tannoy, namely, “is there a doctor on board?”
Fortunately, most doctors never have to help during a flight to their holiday destination.
From the comfort of your sofa, this book allows you to discover what kind of medical problems a repatriating doctor can encounter, from a few broken bones to life-threatening situations, such as ventricular fibrillation or a malfunctioning chest drain. Dr MacFarlane demonstrates just how creative you have to be as a flying doctor, like, for instance, using a urinary catheter to stop a severe nosebleed.
Besides these dramatic and sometimes hilarious situations, he is also able to vividly describe the flamboyant characters he meets during his repatriating duties. He shares the stories of the elderly lady who refused to go back home, and the cardiologist who knew better than him at every step.
All in all, it gives the reader a great insight into a not-everyday profession.
…Are you prepared for your next holiday?

Podcast:

World Extreme Medicine podcast: “It’s never too late to dive in and it’s kind of amazing what the opportunities will turn out to be.”

Where: Spotify

About: A diverse panel of medical professionals share their unique journeys into expedition medicine. The speakers include eye surgeons, dentists, GPs, emergency doctors, humanitarian doctors, and the director of space medicine group.

Why: It can be hard and confusing sometimes to find out how to get into expedition medicine. In this podcast the panel discuss how they expanded their traditional medical career to expeditions and beyond, and the importance of saying yes to an opportunity. The skills they have learned in austere environments appear to apply to their daily job too. It is inspiring to hear how their change of career path changed their lives drastically, and gave them a sense of fulfilment and happiness.
Despite their passion for expedition medicine, it is an honest conversation. They also discuss the negatives, such as the financial compromise, because it does not pay as well as working in a hospital, and the fact that it interferes with your family time. One of their recommendations is to find a mentor figure in the expedition medicine world. This podcast features six of them, so that’s a great start.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

Follow us on instagram @theadventuremedic and have a chance to win this AM Team recommendations book ‘Holiday SOS’.

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Another beautiful autumnal weekend in Edinburgh draws to a close, and with it another World Extreme Medicine (WEM) conference. The Adventure Medic team was there all weekend, chatting to attendees and WEM staff alike, spreading the word about our website, and widening our network. In this piece, we will give you a rundown of our favourite sessions and our take-home messages from the conference. 

What is it?

A three day conference open to people from all career backgrounds and experience in extreme medicine. The event takes place at Dynamic Earth, a stunning venue found at the foot of Edinburgh’s Salisbury Crags. It is an event to learn new skills, hear about novel research, discuss topics with the best in the field, and of course to have a jig at Saturday’s ceilidh. The conference is organised by experienced clinicians and instructors, who are specialists in delivering training for medical work in extreme environments worldwide.

Conference highlights

Mr Ken Hutt – he is setting out to be the oldest person to paraglide from the summit of Everest, whilst raising awareness and money for Rotary International’s End Polio Now campaign.

Mr Alex Lewis and Dr Geoff Watson – a presentation about the relationship between Alex, who contracted life-threatening Toxic Shock Syndrome, and the doctor that saved his life. Alex has gone on to travel in extreme environments and become a motivational speaker.

Mr Benjamin Black – he led multiple sessions over the weekend, the most memorable being an exploration of how to deliver safe sexual and reproductive healthcare in environments where this is not always welcomed.

Dr Saleyha Ahsan – an eye-opening session on ‘Healthcare as a Weapon of War’, the subtle (and not so subtle) ways that medical care can be used to achieve battlefield objectives, and how we as clinicians can avoid being complicit in this.

Mr Jamie Pattison – a member of UKISAR, paramedic and winchman Jamie was an impressive yet relatable speaker. One of his sessions on how to carve a niche for yourself in the field of extreme medicine was particularly inspiring.

A sense of community

The WEM conference is accessible to a variety of disciplines. We were delighted by the range of people who came and spoke to us at the Adventure Medic stand: nurses, paramedics, dieticians, physiotherapists, police officers, first responders, and journalists. It was a refreshing group to move amongst and felt representative of the multi-faceted world of extreme medicine.

From humanitarian speakers to practical sessions on wilderness dentistry (from our own patron dentist Dr Burjor Langdana) and improvised medicine, everyone in attendance was keen to share their experience, and answered questions openly and honestly.

Dr Klara Weaver, Dr Alex Taylor and Dr Erin Kilborn were three speakers that exemplified this nicely, by not only highlighting the positives of working in a remote environments, but also the stark, sometimes lonely reality of practising medicine in these places. There was no omission of difficulties, but instead a balanced account of their experiences and the outcomes.

Research Presentations 

There were several sessions over the weekend that involved the presentation of original research. Two projects in particular caught our attention, not only because of the nature of the research, but because of the exciting ways in which they collected their data in remote environments.

Project NEPTUNE 100 (https://www.mrdf.org/project-neptune) took place in Key Largo, Florida and involved Dr Joseph Dituri living underwater for 100 days. During his time subaquatic, he conducted extensive physiological, psychological, and biochemical testing, measuring the body’s response to the stresses of living underwater.

Our very own Adventure Medic patron, Professor Chris Imray, along with the Inspire22 team, presented their experience of collecting data during a ski expedition to the South Pole. There were useful discussions on how to gain sponsorship for big trips and the necessity of exploring non-traditional financial avenues. The comradery amongst the team was evident in their panel talk and Q&A session, which emphasised that the experiences and friendships you make on an expedition are often the biggest takeaway.

Final thoughts

Without a doubt, there are two speakers that have stayed with us on our journeys home this year. The first, Dr Romain Pizzi, a wildlife veterinarian, who spoke about the ethical question of treating individual animals in the context of their habitat being destroyed. Secondly, Mr Martin Penmar, a trauma surgeon, who asked us to question whether all boundaries should be pushed, and reminded us that there are some lines that should not be crossed. This is a topic that is relevant to all of us, and encourages us to question the moral and ethical issues that lie behind practising medicine outside of the hospital environment.

Get Involved

If you came up and spoke to us at our stand and would like to get involved, please contact us at contact@theadventuremedic.com.

The World Extreme Medicine Conference will once again return to Dynamic Earth in Edinburgh on the 16^th – 18^th November 2024. To find out more and book your ticket, click here.

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Dr Klara Weaver / Locum Acute and Emergency Medicine Doctor / Inverness

Dr Constance Osborne / Locum Emergency Medicine Doctor / Bristol

Contents

• Introduction and Collaborators
• Global Health and Humanitarian Medicine Section
• Expedition and Wilderness Medicine Section
• Want to get involved?

At last, the crocuses are out and the sun is shining. Here at Adventure Medic we can’t wait for the spring to arrive, but let’s take a moment to back over all the wonderful research that came out this winter. Once again, thank you to our fabulous collaborators who have taken the time to comb through over twenty journals to find some of the best articles out there.

Dr Lydia Potter is an F3 doctor living in Conwy, Snowdonia. She is currently doing a less-than-full-time Junior Clinical Fellow job in Emergency Medicine and Paediatrics in Ysbyty Gwynedd, Bangor. In her spare time, she is part of the RNLI boat crew in Conwy and teaches on Unique Expeditions’ UK courses. She has experience providing medical cover for expeditions, ultra-endurance races, sports matches and festivals in the UK and abroad. She is working towards her Mountain Leader qualification. When not at work, you can find her open-water swimming, hiking, climbing or bouldering in Eryri National Park. After her F3 year, she is hoping to enter EM ACCS, continue doing expedition medicine work, and eventually sub-specialise in PHEM.

Dr Klara Weaver is an acute medical and emergency medicine doctor currently practicing in the highlands. She has been involved in expedition medicine for the past five years from Antarctica to Mongolia and everywhere in-between. She is looking forward to starting GP training in the Highlands and in her spare time is a passionate mountaineer and lover of cold places.

Global Health and Humanitarian Medicine

In global health and humanitarian medicine we present eight papers from across the world. We begin with an evidence-based call for the climate crisis to be treated as a global health emergency, an unflinching statement piece published by an authorship group of 200 health journals. From there, we journey to the Philippines to discuss a randomised controlled trial from Reñosa et al., testing a novel initiative to improve vaccination compliance.

We then dive into an exploratory analysis by Koua et al., regarding the trends of public health emergencies over the last 22 years in the World Health Organisation (WHO) African region. From Bangladesh we look at a Lancet article by Levine et al., comparing tools for assessing dehydration status in patients with acute diarrhoea. All health systems must be financed securely, and Nabyonha-Orem et al. have carried out a scoping review of innovative health financing mechanisms in the WHO African region to assess methods to address underfunding. Bartlett et al. carried out a systematic review to determine the level of critical care delivery available in low- and low-middle-income countries according to the literature.

Menstrual health is vital and Plesons et al. developed a fantastic set of research priorities from consultative processes with relevant stakeholders in the context of global health. Our final stop is the conflicts in Syria where a qualitative analysis from Abbara et al. looks at the impact of attacks on the personal and professional lives of health workers.

Time to treat the climate and nature crisis as one indivisible global health emergency

Zielinksi C (on behalf of authorship group of 200 health journals). BMJ Global Health (published simultaneously in multiple journals). Date of issue: 25th October 2023

The article’s title says it all. The time has come to recognise the global health emergency that is rapidly developing as a result of the climate crisis. This statement piece, authored by over 200 health journals, has been published simultaneously in multiple periodicals. It urges political leaders, the United Nations and health professionals worldwide to recognise the severity of the environmental crisis in terms of global health. Additionally, the paper calls on the World Health Organisation to declare the climate and nature crisis a global health emergency by their assembly in May 2024.

A key point in this piece is that climate change and biodiversity loss should be treated as part of the same complex problem and not separate challenges. There is no doubt of the catastrophic harm to health that is arising from the loss of nature: shortages of food, water, increased poverty, air pollution, increased spread of infectious diseases, and millions of climate refugees due to extreme weather events and lack of shelter. This short but powerful article is definitely worth a read to fully appreciate the true impact on health from the climate and nature crisis, and will fire up you up to become the advocates that our planet and patients need.

Human-centred design bolsters vaccine confidence in the Philippines: results of a randomised controlled trial

Reñosa M, Wachinger J, Guevarra J et al. BMJ Global Health. Date of issue: 21st October 2023. 

Vaccination non-compliance is a  threat to public health, leading to outbreaks of preventable diseases that can tear through populations. In the Calabarzon region of the Phillipines, Reñosa et al. used a human-centred design to create a story-based video intervention to address vaccine hesitancy within Filipino families and community leaders. This was authorised by the Department of Health. The intervention was a 5-minute cartoon with narrated stories of Filipino families, with concerns about vaccinations, learning the benefits of vaccinations, subsequently vaccinating their children and creating a strong community with immunisation against measles. The design process was 12-15 months, and the video was created with Filipino cartoonists, local voice actors, and community experts. It was named ‘Salubong: Building Vaccine Confidence’. ‘Salubong’ is a Filipino term meaning the welcoming of someone into one’s life. The phrase in this context referred to welcoming of vaccines into the community.

Once the video was created, a randomised controlled trial was carried out with 719 caregivers of children to test the video against a control video (a ‘How to fight COVID-19’ video produced by the Phillipines Department of Health). The cohort included both urban and rural residents. The participants were asked questions about vaccine attitudes before and after the videos. The results were encouraging, with 62% of the intervention group improving their vaccine attitude scores versus 37% of the control group (p<0.001). This study shows the potential of realistic narratives to improve vaccination confidence in areas with vaccine hesitancy to improve public health. The intervention video is available for viewing at https://www.youtube.com/watch?v=M8nEj5G9Iuc.

Trends in public health emergencies in the WHO African Region: an analysis of the past two decades public health events from 2001 to 2022

Koua EL, Njingang JR, Kimeyi JP et al. BMJ Global Health. Date of issue: 9th October 2023

Africa has the highest burden of public health emergencies globally. This paper from the WHO Regional Office for Africa is an exploratory analysis of the public health data over the past 22 years in this region. The aim was to explore the trends to inform public health strategies and develop tools to improve the response to these events. The WHO divides the world into six regions for the purposes of reporting, analysis, and administration. The WHO Africa region includes 47 member states, covering the majority of the continent, but excluding Western Sahara, Morocco, Tunisia, Libya, Egypt, Sudan, Djibouti and Somalia (all of which are part of the Eastern Mediterranean Region).

The results of the analysis show that between 2001 and 2022, there were 2234 public health events, with an average of 102 annually during the 22-year period. 92% of the events classed as ‘substantiated’ were infectious diseases (n=1730) and 5% (n=92) were humanitarian crises (e.g. natural disasters or conflict). The number of zoonotic disease outbreaks was found to have significantly increased (87% increase) over the past two decades. The average annual outbreak was 26; however, the highest number of outbreaks was recorded in 2022 (n=55). Recent studies suggest climate change is exacerbating the infectious diseases burden by bringing people and disease-causing organisms closer together. This paper comments on this suggestion, agreeing that there is a possibility of this increase being an indirect reflection of climate change. For the clinician with an interest in African public health, we would advise reading this paper in full to appreciate the geographic patterns and changes over time of each zoonotic disease. 

A comparison of the NIRUDAK models and WHO algorithm for dehydration assessment in older children and adults with acute diarrhoea: a prospective observational study

Levine AC, Gainey M, Qu K et al. The Lancet Global Health. Date of issue: November 2023.

Diarrhoea is the eighth leading cause of mortality worldwide and the fifth within low-income countries. Death occurs due to severe dehydration, therefore rehydration is the most vital step in improving morbidity and mortality. Despite the clear importance of being able to accurately assess one’s hydration status, no validated tools exist to assist clinicians in assessing the severity of dehydration in older children and adults. This study by Levine et al. aimed to validate the clinical decision support tool and scoring system NIRUDAK (Novel, Innovative Research for Understanding Dehydration in Adults and Kids).

This scoring system is a 14-point system to assess the severity of dehydration in older children and adults with acute diarrhoea. Points are scored for skin pinch (rapid, slow, very slow), eye level (normal, sunken), respiration depth (normal, deep), urine output (normal, decreased, minimal/none) and radial pulse (strong, decreased, absent). This prospective cohort study took place in Bangladesh over one year and included 1580 patients over 5 years old with acute diarrhoea. All patients were scored using NIRUDAK and the WHO IMIA algorithm (current WHO guidelines) and were weighed every 4 hours to determine their percentage weight change with rehydration. Accuracy and reliability were then assessed using the ordinal c-index and the intraclass correlation coefficient. This study has validated the NIRUDAK model and demonstrates the tool predicts a patient’s dehydration status with greater accuracy and reliability than the current WHO IMAI algorithm. This tool is therefore a useful addition to the global health clinician’s toolbox when assessing the hydration status of a patient with acute diarrhoea. 

The nature and contribution of innovative health financing mechanisms in the World Health Organisation African region: a scoping review

Nabyonha-Orem J, Christmals CD, Addai KF et al. Journal of Global Health. Date of issue: 15th November 2023.

Medical provision is often only available with substantial funding. A second paper this quarter out of the WHO Regional Office for Africa is this scoping review by Nabyonha-Orem et al. analysing the nature, type, and factors that affect the implementation of novel financing mechanisms within the WHO Africa region. This scoping review searched the literature from 2010 to 2022, including government policy documents, reports, and published studies regarding health financing for all population groups in the WHO African region. 41 documents were included in total, describing 10 innovative financing mechanisms (tobacco tax, alcohol tax, sugar tax, airline levy, oil/gas/minerals, HIV/AIDS trust fund, social impact bond, financial transactions tax, mobile phone tax, and equity funds) within 43 of the 47 WHO African region countries. A summary table is available within the paper showing which method/s each country utilises. Whilst this paper is not medical, for any clinicians with global health aspirations, it is an interesting read to appreciate the complexities of health financing. 

Critical care delivery across healthcare systems in low-income and low-middle-income country settings: A systematic review

Bartlett ES, Lim A, Kivlehan S et al. Journal of Global Health. Date of issue: 1st December 2023

Provision of good quality critical care services is a vital part of any healthcare system. In addition to resource limitations, low- and low-middle-income countries have a greater burden of critical illness and therefore a higher morbidity and mortality rate from these. This systematic review by Bartlett et al aimed to identify the range of critical care interventions and services provided within low- and low-middle-income countries. The literature search was from 2008 – 2020 and identified 1620 studies in total from relevant countries (low- and low-middle-income countries as defined by the World Bank classification). This has allowed a comprehensive systematic review to be produced detailing the critical care interventions available within these countries according to the literature. 

Research priorities for improving menstrual health across the life-course in low- and middle- income countries

Plesons M, Torondel B, Caruso BA et al. Global Health Action. Date of issue: 27th November 2023.

This study from the Global Menstrual Collective’s Research and Evidence Group by Plesons et al. aimed to identify research priorities for menstrual health in low- and middle-income countries. 82 individuals from stakeholder groups with expertise in menstrual health were asked to identify research priorities to guide improvements in menstrual health. The results showed that top research priorities were not limited to one area of expertise, but were distributed across a variety of topics, including menstrual pain, socio-cultural factors, menstrual products, and participation in school/work. This indicates research gaps exist throughout a number of domains related to menstrual health. A large number of research questions were also identified regarding ‘understanding the problem’, showing us that knowledge gaps remain regarding the menstrual experience, limiting our understanding of how to assess and meet the requirements of those menstruating in these countries. It is clear significant work is required to improve menstrual health in low- and middle-income countries, but we hope that the identification of these research priorities can be utilised by policy makers, researchers and funders to guide studies in this area.

“Actually, the psychological wounds are more difficult than physical injuries”: a qualitative analysis of the impacts of attacks on health on the personal and professional lives of health workers in the Syrian conflict

Abbara A, Rayes D, Tappis H et al. Conflict and Health. Date of issue: 9th October 2023.

Healthcare staff working in regions of conflict face substantial risks to their personal and professional lives, including risk of death. In Syria, violence against healthcare facilities has been frequent, with the Syrian American Medical Society facing over 222 attacks on their programmes since 2015. This qualitative analysis recruited Syrian health workers (in clinical and administrative roles) who had experienced attacks against their facility between 2013 and 2020. Open-ended, semi-structured interviews were conducted to explore their experiences and views.

From this study, it is clear that attacks on Syrian healthcare workers have left significant, complex and long-lasting impacts. Coping mechanisms discussed were behavioural, cognitive, emotional and religious, the latter often being very important for participants. Interviewees also discussed the solidarity with their colleagues and a responsibility they feel towards their community. Mitigating attacks on healthcare workers is an important, but deeply complex, issue. Organisations should consider their support mechanisms to help staff cope with the danger, stress and moral injury of working in these settings. For the interested reader, the full text article contains quotes from interview transcripts. We recommend reading these to fully appreciate the themes discussed in the paper. 

Expedition and Wilderness Medicine

There is plenty in this quarterly evidence explorer to evoke your interest. From the mountainside to outer space, there is no place that humans and medicine will not go. We evaluate termination of CPR during mountain rescue efforts, the use of drones in search and rescue, Selective Serotonin Reuptake Inhibitors (SSRIs) in space, and ultrasound scanning in austere environments. We hope you enjoy this selection of articles. 

Notable mention – High Altitude Medicine and Biology ran a special edition on ‘Women at Altitude’, however the results of the majority of the papers (n=4) simply showed a massive data gap for women at altitude in a variety of clinical settings. 

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

Viktor Lugnet, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, Peter Paal. High Altitude Medicine & Biology. Date of Issue: December 2023.

It is a situation no expedition medic wants to find themselves in, but in remote environments and extreme conditions cardiac arrest is an important scenario to consider when planning a trip. Building on the 2012 recommendations, Lugnet et al add new, evidence-based advisories around the use of mechanical chest compression devices, point of care ultrasound (POCUS), relevance of water temperature to resuscitation in drowning, and criteria for burial time in avalanche rescue. 

Lugnet et al, in line with the UK Resusitation Council, cautions against routine use of mechanical chest compression devices, but acknowledges the benefit of their use in prolonged or strenuous rescues, where manual compressions are less likely to remain consistent and effective. POCUS is to be used, where available, to aid decision making in termination of resuscitation. Regarding drowning, the authors recommend withholding CPR in a drowning victim with a submersion time >30 minutes in water >6°C or >90 minutes in water <6°C. Finally, regarding avalanches, the advice is to provide full resuscitative efforts for an avalanche victim with a core temperature <30°C with a patent airway and without lethal injuries, and transport to an extracorporeal life support capable centre. CPR should not be commenced in those in asystole and obstructed airway, with a burial time of >60 minutes.  

Use of Unmanned Aerial Vehicles (UAVs) in Wilderness Search and Rescue (WSAR) Operations: A Scoping Review

Craig Vincent-Lambert, , Anje Pretorius, BHS EMC, and Bernard Van Tonder, M EMC. Wilderness & Environmental Medicine, Volume 34, Issue 4. Date of Issue: December 2023

Love them or hate them, drones are everywhere. But with an increasing pressure on WSAR services, and an improvement in drone technology, graphics and durability, could they become a valuable tool in the SAR toolkit? 

Vincent-Lampbert et al conduced a scoping review of the literature, finding 21 sources that focused on UAVs in WSAR operations. Benefits described included the ability for UAVs to perform pre-programmed search patterns, thermal imaging, reduction in time to locate, and the ability of UAVs to tackle terrain deemed too risky for humans. It was recognised by the authors that limitations include drone-specific software, user fatigue, obscured view, weather conditions, and also the vast differences in average flight times between models. The conclusion drawn by the author is that UAVs are a useful tool that can aid but not replace human search efforts. They called for more specific language to differentiate “drones” from UAVs in the SAR environment as a marker of WSAR capability.  

Selective Serotonin Reuptake Inhibitors and Other Treatment Modalities for Deep Space Missions

El-Khoury, Bashir B.; Ray, Kristi L.; Altchuler, Steven I.; Reichard, John F.; Dukes, Charles H. Aerospace Medicine and Human Performance, Volume 94, Number 11. Date of Issue: November 2023

Modern humans are more stressed and anxious than ever, despite improved mental health awareness and de-stigmatisation encouraging more people to act positively for their mental health. Serotonin reuptake inhibitors (SSRIs) are useful treatment for depression and anxiety. However, with space tourism on the 25-50 year horizon, and gathering data on humans in space, it may be time to call it quits on SSRIs when out of Earth’s atmosphere. 

SSRIs have well documented side effects with longer term use, including weight gain, sleep disturbance and a moderate increase in bleeding risk (especially in conjunction with NSAIDS). However, as highlighted by this meta-analysis by El-Khoury et al, the literature shows a troubling link between long term SSRI use and decrease in bone mass. Bone loss in spaceflight is already a known phenomena, attributed mostly to microgravity, high sodium and protein intake, increased ambient CO2 levels and reduced sun exposure. El-Khoury et all raise the question whether SSRI’s should be allowed in the spaceflight population, and suggest potential alternative therapies such as Transcranial magnetic stimulation, cranial electrotherapy stimulation, and off-label ketamine prescription, along with managing the initial risk of the selected population. 

Ultrasound (US) Gel Alternatives in an Austere Environment

Julia DeLuca, BS, Daniel Doynow, DO, MPH, Jacob Grondin, BS, Ellen Lockhart, MS, and Stephanie Lareau, MD. Wilderness & Environmental Medicine, Volume 34, Issue 4. Date of Issue: December 2023

Point of care ultrasound is breaking into the prehospital and wilderness medicine scene in an increasing variety of ways. With advances in probe portability, interface with existing smart phones, and telemedicine technology, they seem an inevitable part of the wilderness medic’s toolkit. However, on expeditions, pack space and weight can be limited. DeLuca et al, used survey based data to rate commonly found mediums that could substitute for ultrasound gel, and to evaluate whether control picture quality was good enough for clinical diagnosis. They found that alternatives, including vegetable oil (88.5%), aloe vera (80.9%), and shampoo (69.2%), were rated equal or better quality US mediums when compared to traditional gel, and were sufficient for diagnosing acute pathologies. Whilst this may not change the face of expedition medicine as we know it, knowing MacGyver workarounds for POCUS could save you space and stress in remote field care. 

The post Evidence Explorer: Updates and news from the academic community, Winter 2023-24 appeared first on Adventure Medic.

Dr Katharine Ganly worked as a medical officer with the British Antarctic Survey Medical Unit (BASMU) from 2019 to 2021. She experienced both summer and winter in Antarctica, and also spent time working as the ship’s doctor on the RRS James Clark Ross. In this article, Dr Ganly describes what it’s like to be a doctor with BASMU, sharing her advice and experiences of working in one of the wildest places on Earth.

Ever wondered what it is like to live and work at the very edge of the world? The British Antarctic Survey Medical Unit appoints doctors annually to deploy to Antarctica, working on remote research stations and polar vessels. This is a dream job for adventurous medics with a love of cold, remote places.

What is the British Antarctic Survey?

The British Antarctic Survey (BAS) is the UK’s national Antarctic program. It is part of the National Environment Research Council and is the responsible body for the UK’s scientific research in Antarctica. BAS is headquartered in Cambridge and conducts scientific research in several areas of polar science, including marine biology, oceanography, meteorology, and atmospheric science. BAS scientists are credited with the discovery of the ozone hole in the 1970s, drawing attention to the impact of human activity on the global environment. BAS continues to undertake several long-term data collection projects relating to the polar regions and climate change.

There exist five permanent BAS research stations: Rothera and Halley on the Antarctic peninsula and Brunt Ice Shelf respectively, and the island stations of Signy in the South Orkneys, King Edward Point (KEP) at South Georgia, and Bird Island (BI) research station. The three stations of Rothera, KEP, and BI are staffed year-round, whilst Signy and Halley are operational throughout the austral summer alone. In addition to these stations, there is ongoing scientific research conducted from temporary field-based summer camps and outposts. The UK’s new polar research vessel The Sir David Attenborough (yes, the one that narrowly escaped being called ‘Boaty Mc Boatface’, thanks to the humour of the British public) heads south annually in the autumn to arrive in Antarctic waters for the period of the Antarctic summer (typically November-May) and has the dual role of conducting polar research and providing the annual resupply of equipment and staff.

BAS deploys up to 600 scientists and staff to the polar south annually. Personnel are not limited to scientists and include everyone essential to keeping life running and research going at the remote extremes of the world: chefs, field guides, mechanics, electricians, diving and boating officers, management personnel, engineers, and (thankfully for those reading this) polar-loving doctors.

What is daily life like in the Antarctic?

The UK working week is impractical in the Antarctic and as such, work fluctuates according to the weather and season. Exact details of routine are specific to each station, but the Antarctic has a steady overall rhythm splitting summer and winter. Summer is busy: this is the time of maximal activity. At Rothera, this means there are over 200 people on station, with many more transiting through this Antarctic hub. Personnel arrive on station via Dash-7 plane from Punta Arenas, Chile (around 4.5 hours flying time), or from the UK on the RRS Sir David Attenborough (a voyage of many weeks) with the annual resupply. Onward travel to the field is via a Twin Otter plane. At KEP the population is smaller, with approximately 30 on station during summer. South Georgia is solely accessible by sea, and personnel arrive via ship from the Falklands (around four to five days if the sea conditions are good).

All stations eat meals in a central dining area, with a chef at the larger stations and a cooking rota for personnel on the smaller sites. There is ample access to recreation on all sites including gym equipment, the opportunity to ski, and access to books, movies, and other media. Station life is dependent on everyone helping to keep things running. As a doctor in the Antarctic, you will find yourself cleaning, cooking, and taking inventory as well as running clinics. If you are lucky, this is made up for by the opportunity to fly in a Twin Otter at Rothera or pilot a rigid-hulled inflatable boat (RHIB) around unchartered waters at KEP (yes, really). You’ll also get the privilege of seeing some of the most remarkable wildlife in the world: Antarctic marine mammals and birds are the most incredible you’ll ever see.

Winter is a quieter time, with core personnel of around 25 at Rothera and eight at KEP. Work continues, but the pace is slowed. Personnel finally get their own room after a summer of sharing space with another. It gets colder and darker, and often tempers shorten along with the daylight. Navigating this as a doctor whilst living amongst your patients does pose its challenges. It’s a unique, special experience. The winter solstice is a time of midwinter celebration amongst your small team, as you look forward to longer days and dream of the fresh food you haven’t seen for months.

What does the role of a BASMU medical officer entail?

Recruitment

The BAS Medical Unit is based at University Hospitals Plymouth NHS Trust. BASMU recruits Antarctic medical staff annually in the late summer, and three doctors get selected to become the season’s doctors for Rothera, KEP, and the RRS Sir David Attenborough. Station doctors spend between 12 and 18 months in the Antarctic, and the ship doctor deploys for around eight months.

Pre-deployment and training

All BASMU medical officers have six months of pre-deployment training in Plymouth, which takes place predominantly at Derriford Hospital. Though there are certain skills all doctors must learn, during these months of gearing up for departure, you are largely responsible for taking charge of your training. Your role is predominantly spent in the emergency department (ED) but you are in the privileged position of being entirely supernumerary. This means you get the opportunity to place yourself wherever you have a training need, be it dealing with minor injuries, joint manipulations and plastering, or getting stuck into resus. You can tailor sessions outside the ED with other specialties to gain exposure to any areas required, be it a week or two with ENT, learning basic hand surgery from plastics, or taking swabs and gram-staining in the sexual health clinic. All doctors undergo an intensive dental course where you gain the essentials in dental examination, hygiene, fillings, and dental emergencies including extractions. Equally, all doctors rotate through basic training in radiography and physiotherapy. You will also be taught how to operate a hyperbaric recompression chamber at the Diving Diseases Research Centre (DDRC), as diving for both science and construction takes place at the main wintering stations. In addition to all this, you get a modest study budget and study leave that you can use for any further courses or skills required for departure. Historically, some doctors have used this for associated ‘extracurricular’ skills such as baking (if you winter at KEP, you are expected to bake bread regularly!).

As if this wasn’t enough to get stuck into, you also go through BAS winter pre-deployment training, which involves generic skills for all personnel deploying to Antarctic stations. Depending on which position you are heading to, you may undergo other station-specific training such as sea survival certifications, powerboating qualifications, or crevasse rescue.

Other UK responsibilities include pre-departure medical screening for BAS personnel. This takes place at BAS Cambridge and usually works out as spending between one and two weeks a month in Cambridge in the months leading up to departure. Accommodation is provided and travel costs are reimbursed. There is a BASMU car that can be used for work travel, or mileage is reimbursed if your own vehicle is used. This allows you to meet some of the BAS personnel and identify any extra medical investigations or precautions that are needed before departure.

Working in Antarctica

Once deployed, your role as medical officer in the Antarctic is unlike any other you will have filled. For the vast majority of your deployed time, you will be the sole medic within hundreds of miles. My deployment to South Georgia meant I was the only doctor in the entire territory, with the nearest other physician being over 800km away on the Falkland Islands, at best a 4-day ship’s passage away over the roughest seas in the world.

Day-to-day medical work is light compared to jobs in the UK, and the bulk of your ‘office’ time is much more likely being spent taking stock of pharmacy, reviewing major incident protocols and equipment, and training your winter team in advanced first aid (you need to have someone who can give you a hand if an emergency occurs, or even to look after you should you break something). Your population in the Antarctic is small, medically screened, and largely risk-averse. Most consultations fall under the realms of general practice: GI upsets, sleep disturbance, dermatology, and some minor injuries. Dental complaints are relatively common occurrences and are rewarding to treat thanks to excellent pre-departure dental training. Other common consultations include psychological issues, sexual health, and support around general well-being for a population living in very unusual circumstances. Everything in the Antarctic is complicated by its remoteness. What would be considered a seemingly minor complaint in the UK requires more careful consideration on the ice. The potential for things to develop into something more concerning needs to be carefully evaluated when you know any definitive treatment may involve a medevac that could span weeks. Away from the hospital and the majority of diagnostic tools that we are accustomed to, reliance on good clinical skills becomes paramount.

Managing medical emergencies

Though infrequent, acute illness and major injury do occur. Recent seasons have faced major GI haemorrhage, respiratory emergencies, sepsis, and major lower limb trauma requiring evacuation. I was faced with a case of cold-induced angioedema: an unusual anaphylactoid reaction to extreme cold, and not something you want when the temperature rarely gets above freezing. Generally due to good training and PPE, other cold-related emergencies are uncommon, and hypothermia and frostbite are rarely seen amongst BAS personnel. Whatever situation arises, you need to be able to manage as a solo medic with limited resources. There are no CT scanners or biochemistry labs in your clinic. You will have plain-film X-rays (which you will learn how to take and develop yourself) and basic point-of-care testing. Most sophisticated medical equipment is not designed for the extreme remoteness of the far south, and some kit that works at the start of your deployment may no longer do so come winter. You will nonetheless have a pharmacy that is well-stocked with both emergency drugs and supplies for more common ailments. You will also have access to a team of enthusiastic first aiders, should you choose to train them.

Thanks to modern telecommunications, you have several experienced BASMU clinicians as well as specialists at your fingertips. Responses to clinical queries are normally within a few days. Telephone can always be used for more urgent concerns, with 24/7 top-cover support in an emergency. Video consultations have been used when the satellites are well aligned.

The role of a BAS medical officer requires a large degree of robustness and adaptability. Challenges include isolation, skill fade, unconventional patient-doctor relationships, and the unpredictability of Antarctic deployment. You have to be able to respond to anything, including the emergence of a global pandemic whilst deployed – not something any of the doctors had envisaged when travelling south in 2019. The benefits of learning a range of diverse skills, and the privilege of living in a truly awe-inducing location far outweigh any difficulties faced. The opportunity to work with a team of dedicated scientists and support staff, and to play a part in keeping vital research ongoing in such a special place makes this job truly one of a kind.

Practical Information

Candidate information: to meet the requirements, you’ll need to be a fully registered medical practitioner and have a minimum of 3 years post-qualification. Doctors from a wide variety of specialties and backgrounds are considered by BASMU for the posts. Acute specialty experience is probably useful, as you need to be able to keep calm under pressure, but not essential. Key useful traits are resourcefulness and flexibility.

Timelines: BASMU advertises at the end of summer in the BMJ, with interviews in the autumn. Jobs will then usually start on the 1st of May, with pre-deployment training running from May through to October. Deployment begins in November or December and is for 12-18 months. There is a huge amount of organisational development and expansion at BAS at present and the medical unit is required to be reactive and flexible to this. As such, the exact deployment duration and details are always subject to change.

Doctors in training: some deaneries will approve an OOPE (Out of Programme Experience) for BASMU employment, so it is worth applying even if you are in training. This allows you to keep your training number and return to your role when you are home. A benefit of this option is that you can usually access ‘supported return to training’ once you return to the UK, easing the transition back into hospital practice. I would recommend this.

Administrative info: as a BASMU doctor, your employer is Plymouth Hospitals NHS Trust. This means you retain your continuous NHS employment for the duration of this position. If you are deployed for over 12 months, you do not need to pay UK tax, although you will need to pay ‘BAT tax’ (British Antarctic Territory Tax) of 7% instead. You will have essentially no expenses when you are away.

Academic: the complete program of training, clinical responsibility and research is designed to enable doctors to obtain a certificate, diploma, or master of science degree in remote and global healthcare, awarded by the Peninsula Graduate School for Antarctic Deployments. Alternatively, you can use these funds to undertake another distance learning program of your choice. There is the opportunity to get involved with BASMU research, which recently has focused on cold injury, drug tolerance, and respiratory virus transmission.

Author Information

Dr Katharine Ganly worked as a medical officer for The British Antarctic Survey between 2019-2021. She overwintered at King Edward Point and was the first station doctor on Bird Island, where she spent her second Antarctic summer. Doc Kat was the ship’s doctor on the RRS James Clark Ross on her exit from Antarctica. She completed her MSc in Global and Remote Health whilst working for BASMU, alongside conducting research into drug stability in remote environments and respiratory viral transmission amongst an isolated population during the COVID-19 pandemic. She has now returned to work as an anaesthetics registrar in the west of Scotland.

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Dr Hannah Lock is a Senior Clinical Fellow in Emergency Medicine at Ysbyty Gwynedd, Bangor. Since 2018 she has also worked as an Expedition Doctor, specialising in high-altitude environments, and has been involved in medical research on three high-altitude research expeditions. Hannah is part of the teaching faculty for UCLan’s Diploma in Mountain Medicine and World Extreme Medicine. In 2023 she launched an online learning platform called Humans At High Altitude, sharing knowledge about high-altitude medicine with both medics and lay adventurers. 

Introduction

Whether you’re planning a personal high-altitude adventure or taking a job as a medic on a high-altitude expedition, a thorough understanding of how this environment affects us is key to preventing, assessing, and managing medical issues. This article aims to summarise the basics of high-altitude medicine to get you started.

In 2018 I was trekking in the Khumbu region of Nepal with a friend and one porter. We had been walking for seven days to reach the little village of Chukhung (4730 m) and I was tucking into my evening meal in the cosy tea house when our porter, Bishal, came over looking concerned. He had been chatting to the owner of the tea house who was worried about one of the other guests and knowing I was a doctor, Bishal came to ask if I would help. 

The normally fit and well 21-year-old man was lying on his bed, looking pale and unwell. He told me he had vomited, had a severe headache, and felt very tired. He and his two friends had walked from Lukla (2800 m) to Chukhung (4739 m) in three days and none of them felt great but he was the worst. They had no prior experience at high altitudes and minimal knowledge of altitude illness. They planned to trek over the Kongma La, a pass at 5555 m, and walk down to Lobuche (4910 m) the following day. 

After a more detailed history and brief examination, I concluded that the man was suffering from moderate-severe Acute Mountain Sickness and explained to him what this meant. I gave him some of my own Acetazolamide, Ondansetron, and Paracetamol. I made him a litre of fluid with electrolyte mix and told him to drink this over the next couple of hours.… Read on to find out what happened to him at the end of the article… 

Basic Altitude Physics

Figure 1: Widely accepted definitions of altitude zones

Simply put, as altitude increases, the barometric pressure decreases. At lower pressures, gas molecules are more spread out in any given space. This results in there being fewer gas molecules in each breath we take in at high altitudes, which includes lower amounts of our favourite gas, oxygen. Oxygen still makes up 21% of the total molecules in that breath of air, but compared to at sea level the actual quantity gets lower as we ascend. Make sense?

To give us some relatable numbers, compared to at sea level there is effectively only two-thirds as much oxygen available by the time you reach 3000 m, only half by the time you reach 5500 m, and only one-third at the summit of Everest! So how do humans cope with this huge reduction in available oxygen? The answer lies in adequate acclimatisation. 

Acclimatisation To High Altitude 

Some Indigenous populations have lived at over 2500 m for thousands of years and have evolved genetic adaptations to cope with high altitudes. Lowland populations do not have these adaptations and are not automatically physically prepared for high-altitude living.

Acclimatisation to high altitude describes the physiological processes of adaptation to low oxygen levels. The body is forced to adapt and work hard to cope with worsening hypoxia. Acclimatisation is a gradual process that takes days to weeks and the rate of acclimatisation differs between individuals. A well-acclimatised person can tolerate altitudes that would kill a person that has just arrived. Poorly acclimatised people are most at risk of altitude illness. 

Within hours of being at high altitude, our hypoxic ventilatory response reacts to the decreased partial pressure of oxygen in the arterial blood, and the result is an increased respiratory rate and depth of breathing. Our heart rate and stroke volume also increases. More fluid is excreted from the renal system to increase the concentration of haemoglobin in the blood. 

In the following days, oxygen is released more readily from red blood cells to be utilised in the tissues, we increase blood flow to vital organs such as the brain, and we start to produce more erythropoietin to stimulate the production of more red blood cells to increase our oxygen carrying capacity. 

Altitude Illness Overview

Acute Mountain Sickness (AMS)

AMS is a collection of symptoms generally starting 6-12 hours after arriving at an altitude greater than 2000 m. The diagnosis of AMS is a Headache + 1 more of the following symptoms:

• Nausea and/or vomiting
• Reduced appetite
• Fatigue
• Dizziness

The headache tends to be throbbing in nature, worse on exertion and at night. AMS is common when ascending > 2500 m rapidly and gets more common at higher altitudes. 

Risk factors for AMS include rapid ascent, altitude > 4500 m, previous altitude illness, physical exertion at high altitude, pre-existing lung condition, young age, and limited knowledge of the condition. 

The treatment for AMS tends to be relatively simple – stop ascending, rest, simple analgesia, antiemetic if required, and rehydration. Descent should always be considered, especially in severe cases. If the casualty shows no improvement overnight then descent should be arranged. Additional management strategies for moderate to severe cases include Acetazolamide (Diamox) 250 mg BD PO, Dexamethasone 4 mg QDS PO, supplemental oxygen, and portable hyperbaric chamber use. None of these replace the need for descent in severe cases. Descent is the gold standard treatment for all severe altitude illnesses. 

High Altitude Cerebral Oedema (HACE)

HACE is a rare but life-threatening high-altitude illness that must be recognised and acted on urgently. HACE is most commonly seen at altitudes over 5000 m, however, there have been rare cases seen at altitudes as low as around 2500 m. As with AMS, the pathophysiology is not completely understood but HACE is thought to be a continuation of AMS with both vasogenic and cytotoxic mechanisms hypothesised. 

HACE is diagnosed by the presence of current or recent symptoms of AMS plus any new neurological signs. Often the sufferer may not be aware of their condition and it may be team members who first notice the signs. The most commonly recognised neurological signs are:

•  Ataxia 
•  Confusion or disorientation
•  Speech disturbance
•  Behaviour changes e.g. withdrawn, violent, euphoric
•  Urinary incontinence or retention
•  Seizures (late sign)
•  Reduced consciousness

Unless there is an obvious, reversible alternative diagnosis (e.g. hypoglycemia in a known diabetic and the casualty improves fully with glucose administration), any of these signs at an altitude greater than 2000 m should be managed urgently as HACE. 

Risk factors are very similar to those of AMS, with a rapid ascent to high altitude being the most important. 

Managing HACE always involves organising urgent descent to an altitude of at least 500 m lower than the point at which symptoms or signs of HACE occurred. Preferably the casualty should be carried rather than walked down, or a helicopter called if available in the region. In addition, Dexamethasone 8 mg PO initially (followed by 4 mg QDS) should be started and supplemental oxygen administered if available. They should not be left alone and good supportive care is essential. If descent cannot happen immediately e.g. too dangerous to move the to group due to weather conditions, a portable hyperbaric chamber can be used if available. 

A portable hyperbaric chamber (see picture below) is a sealed bag in which a conscious casualty can be placed for several hours at a time. By pumping air into the bag, the pressure inside increases, and this simulates a lower altitude than the true elevation of the environment, hence increasing the available oxygen inside the bag. Most bags or chambers can simulate altitudes significantly lower than the true altitude, enough to improve someone’s symptoms significantly in many cases. This is only a holding method, however, because as soon as the person leaves the bag, their hypoxia and symptoms can return rapidly. Note that this is not appropriate management for unconscious patients.

High Altitude Pulmonary Oedema (HAPE)

HAPE is another potentially life-threatening high-altitude illness that must be managed with urgency. It generally occurs a few days after the ascent to >2500 m, with the incidence increasing with altitude. Some data suggests the incidence is about 15% at 5500 m. This is a non-cardiogenic pulmonary oedema thought to be caused by a patchy distribution of vasoconstriction across the lungs in response to hypoxia. The uneven spread of vessels contracting leads to stress failure of the membranes and fluid leaking from the capillaries into the alveoli.

Symptoms may start mildly but can rapidly progress to severe: 

• Significant fatigue
• Shortness of breath, which does not recover with rest
• Cough, which is initially dry but can become productive
• Haemoptysis 
• Chest pain
• Low oxygen saturations and increased respiratory rate (often useful to compare to those of people feeling well who have had a similar ascent rate)
• Crackles on auscultation, often mid-zones worse
• AMS symptoms commonly occur

Risk factors for HAPE are the same as for AMS plus altitude > 4500 m, recent or current inflammatory or infectious lung condition, male sex, cold, previous HAPE, small lung volumes, conditions predisposing to pulmonary hypertension e.g. structural heart defects, COPD, pulmonary fibrosis.

As with HACE, managing HAPE always involves organising urgent descent. Consider differential diagnoses but when in doubt, treat them as HAPE. The casualty must not be left alone, keep them sat up and avoid any further exertion. Supplemental oxygen should be administered if available and Nifedipine 30 mg given. There is no role for diuretics in the treatment of HAPE as this is not a cardiogenic fluid overload and often the casualty will have intravascular volume depletion. If descent cannot happen immediately (e.g. too dangerous to move the to group due to weather conditions), a portable hyperbaric chamber can be used if available. A chamber can also be used to stabilise a casualty whilst descent is organised but its use must not delay the evacuation.

Preventing Altitude Illness

As with any medical condition, prevention is better than cure. There are several ways in which to prevent high altitude illness but the most important is to allow adequate acclimatisation by gradual ascent. 

The consensus from most medics including the Wilderness Medicine Society panel of experts is that above 3000 m, you should not not increase sleeping elevation by more than 500 m per day. This doesn’t mean you can’t ascend more than this during the daytime (e.g. walk up and over a pass gaining 800 m height), but that you must descend again to sleep no higher than about 500 m from the altitude of the previous night (e.g. descend 300 m vertical height down the other side of the pass you just climbed in the above example). 

It is also advised to include a rest day every 3 – 4 days to aid acclimatisation. During this rest day, gaining altitude on a day trip is fine, so long as there is no increase in the sleeping altitude. Vigorous exercise is not recommended for a day or two after arriving at a modest altitude. 

Managing risk factors is also important e.g. maintaining adequate hydration and ensuring good food and hand hygiene to reduce the risk of any concurrent illness. 

Medical Prophylaxis

The only drug that aids acclimatisation to reduce the risk of altitude illness is Acetazolamide (mentioned earlier in the treatment of AMS). Other drugs can reduce the risk of HACE and HAPE but do not work by speeding up acclimatisation. Acetazolamide increases the hypoxic ventilatory response by inducing metabolic acidosis, leading to oxygen availability. 

One of the most common questions I get asked is whether someone should take Acetazolamide to aid them on their high-altitude adventure. Of course, this must be answered on a case-by-case basis taking into account medical history, medication list, etc. The WMS approach to answering this question recommends a risk stratification approach. The assessment must include their planned ascent profile and previous history at altitude to conclude their risk level. See Figure 2 for the WMS risk categories for AMS.

Figure 2: Copied from the Wilderness Medicine Society Clinical Practice Guidelines for the Prevention and Treatment of Acute Altitude Illness: 2019 Update.

Summary

Prior knowledge of altitude illness and gradual ascent to high altitude remain the best ways to prevent all altitude illnesses. Acetazolamide aids acclimatisation but is not a magic bullet and does not replace the need for safe ascent profiles. Any new neurological signs at high altitude should be treated as HACE until proven otherwise. HACE and HAPE are life-threatening conditions and someone displaying signs of either (or both) of these requires urgent support and evacuation to lower altitudes. Descend. Descend. Descend!

What Happened To The Man in Chukhung?

I had formulated some evacuation plans in case my unexpected patient had not improved or had deteriorated, but when I went back to see the young man I was relieved to find him looking a bit better. He had managed to keep down the fluids with no further vomiting and his headache had reduced from severe to moderate.

The following morning I checked on him before setting off for my own trek and was pleased to find he was feeling much better but still very tired. I advised him not to trek that day, but to rest, hydrate and acclimatise to the current altitude. I gave him another dose of my own Acetazolamide and advised him that only if he felt well the following morning should he attempt to continue the trek and that if he started to feel worse again to descend. I spent some time with him and his friends explaining some basic altitude physiology and medicine. I didn’t see them again after this so I don’t know what happened later but I do know that this illness could have been prevented with a little bit of knowledge and a slower ascent rate. 

Where To Learn More…

To gain a deeper understanding of altitude medicine and gain confidence and knowledge before working as a medic at high altitude, my online course An Introduction To Humans At High Altitude is ideal. This is the resource I was looking for when I started my expedition medicine journey. It’s a self-directed course/e-learning package with over five hours of pre-recorded videos, practical activities, and case studies broken down into bite-sized chunks. It covers everything from altitude physiology, illnesses (beyond those in this article), route planning, sleep, and nutrition, how to prepare for the high altitude environment, medical kits, equipment, and managing emergencies. Once you sign up, you have lifelong access. 

Students get a 50% discount off my online courses! Get in touch with me via my website to ask for a student discount code.  

I’m currently creating a second online course, Women’s Health On Mountain Adventures And At High Altitude which will be launched in Spring 2024. 

Website: drhannahlock.co.uk

Instagram: hannah_lock_exped_doc

LinkedIn: Dr Hannah Lock

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The Emergency Department of Ysbyty Gwynedd, Bangor, provides the opportunity for middle grade doctors to further develop their Emergency Medicine skills in a rural ED that sees everything from trauma to snake bites. Their fellowship also provides protected time to undertake Pre-Hospital Emergency Medicine work across several services. Dr Katharine Ganly shares her experience of this unique role.

Clinical fellowship title, specialty and grade

Senior Clinical Fellow in Emergency Medicine (EM) and Pre-Hospital Emergency Medicine (PHEM)

Structure of the role

The PHEM clinical fellow jobs are offered as 12 months fixed-term contracts. 80% of your time is spent in the Emergency Department (ED) at Bangor Hospital and 20% of your time is spent in pre-hospital activities, split between HEMS (Helicopter Emergency Medical Service) shifts with the Welsh Air Ambulance, EMRTS Cymru (Emergency Medical Retrieval and Transfer Service, Wales) and the Welsh Ambulance Service. There is the option for less-than-full-time working.

Prerequisites for application

Prerequisites are that applicants should have completed UK ACCS training (or be able to demonstrate equivalent competencies in Emergency Medicine, Acute Medicine, Intensive Care Medicine and Anaesthetics).

The majority of PHEM clinical fellows are EM trainees, however Anaesthetic or Acute Medicine Trainees would also be eligible to apply provided they have at least 6 months of EM experience. For interested applicants who don’t quite meet the level of experience required, there are options for 6-month SHO-tier EM posts in order to become eligible, on discussion with the department.

Whilst the positions are generally offered as 12-month posts, MRCEM/FRCEM Intermediate holders with 12 months EM experience can apply for posts of 6-month duration.

As a post ACCS (Anaesthetics) doctor, albeit with some additional EM experience, I started the job with a degree of trepidation regarding being the EM senior on-site overnight. However, the consultant body and senior nursing staff are extremely friendly and are available for support and advice through your solo shifts. You learn the ropes quickly, and I would not let being from a non-EM base specialty put anyone off the role.

Location of fellowship

Fellows are based in the ED in Ysbyty Gwynedd, Bangor. The PHEM portion of the role is primarily based out of the EMRTS base at Caernarfon airport. There is scope to have shifts out of the sister EMRTS site at Welshpool. The remaining PHEM time can be spent with the Welsh Ambulance Services Trust (WAST) on RRVs (Rapid Response Vehicles), ambulances, or in the Ambulance Control Centre. There are also a range of observer shifts available with the North West and North Wales Paediatric Transport Service.

Academic accreditation

The fellowship does not provide academic training or accreditation.

Brief description of the job role

On EM shifts, the role is of an EM middle tier doctor on the registrar rota. Ysbyty Gwynedd is a rural emergency department that sees a wide range of presentations. There is a fair amount of trauma. Given the unit’s proximity to the mountains, fallen walkers and climbers are not infrequently brought in, especially during the summer months. Farm, water, and motorbike-related trauma are equally not uncommon. The rural location means snakebites are also seen, a rare presentation in an urban ED. Overnight you are the senior clinician in the ED, with easy access to Consultant support by telephone if needed. During daylight hours there is a Consultant on the shop floor who holds the supervisory role.

The PHEM portion of the role (which equates to approximately four days per month) comprises two monthly EMRTS air-ambulance shifts and two slots for other PHEM activities. The EMRTS shifts are as a third person on the Clinical Air Ambulance team. Depending on the day, the fellow will either be joined by a Consultant and Critical Care Paramedic (CCP) duo or a double-CCP team. The variation in team makeup allows you to see a different range of presentations. You are a functional member of the clinical team, not a passive ‘observer’, and are able to fully participate in the initial assessment, management and transfer of patients as your skill set allows.

There is flexibility with the remaining two PHEM sessions, and they can be used with WAST, in Ambulance Control, or on PHEM-related courses and activities.

You are expected to participate in Clinical Governance in both your EM and PHEM roles, for example in the form of M&M meeting attendance, chairing, or minute-taking.

Overall impression

The workplace environment in both the ED and the Air Ambulance is exceptionally welcoming and supportive, and I was unsurprised when Ysbyty Gwynedd (Bangor) ED came out top in the UK for EM training in the GMC 2023 survey. For those used to large urban hospitals, it will be a change, as a lot of staff know each other socially as well and professionally, and most know at least some of the patients in the department as well. The working atmosphere is friendly across the MDT, despite the pressures on emergency departments in 2024. The ED promotes a good work-life balance, and less-than-full-time working is quite normal for fellows in this role.

There is good senior support, and as a PHEM fellow you get a named Educational Supervisor who is a PHEM consultant and can help identify PHEM-specific areas for development and progression. The exposure to pre-hospital medicine during this post will help those who are considering applying for PHEM subspecialty training, or those who just want to know what it is all about.

Highlights of the job are a fully-funded place on the National PHEM course, which is excellent high-fidelity training held annually in August. The opportunity to fly over the hills of North Wales and make a real difference to outcomes through immediate management of trauma and illness is an additional high point, and immensely rewarding.

It would be remiss not to mention the location as a benefit. North Wales is a wonderful place to live for those that love the outdoors, with access to sea and mountains in equal proximity, and plenty of friendly outdoors folk to enjoy them with.

Outcomes of the fellowship

The opportunity to start building a PHEM portfolio will put fellows in good standing if they decide to pursue formal PHEM training pathways. The posts equip fellows with many of both the ‘essential’’ and ‘desirable’ attributes required by the PHEM sub-specialty person specification, and you get a good overview of both HEMS and the wider Ambulance service.

There are opportunities to present at M&M’s, Trauma Meetings and Clinical Governance Meetings, all of which are CV-building. You are enrolled in the national PHEM course in August as part of your clinical fellow post, which is an excellent immersion into PHEM. Other PHEM-related courses can be attended during PHEM-allocated time, and there is a study budget available. There is access to the Mountain Medicine database for those interested, and this can be used for research projects and publications. There is an excellent network of wilderness-minded medics for those wanting to make contacts and pursue activities in the fields of outdoor and wilderness medicine.

Costs and potential funding

There are no extra costs associated with this post. There is an NHS relocation budget accessible to post holders. PPE and training is provided.

The geographical location of this post is favourable financially. North Wales has a relatively low cost of living compared to elsewhere in the UK.

The study budget for these posts is a very generous £5000. A portion of this goes towards funding the IBTPHEM course which is run in August. This comprises approximately half of the budget, and the remainder can be used to fund other PHEM and CPD courses.

Anything you wish you’d known beforehand?

Accommodation in North Wales can be tricky to find from afar, but you can be put in touch with people locally if you ask to be plugged into the local WhatsApp group upon appointment. Once you are here it is a lot easier and places to live can be found easily.

The flexible annualised rota means you can plan for an adventure or time off and work your shifts around it. If you have something in mind, start thinking about it before you get here. I arranged a few weeks off in early springtime in order to undertake a winter Arctic expedition and it was not difficult to plan my shifts around this. Offering to work the Christmas shifts gave me a bit of goodwill ‘in the bank’ with my fellow mid-tier colleagues, and meant I could organise a decent block of time away from work later in the year. You don’t necessarily need to bargain by offering to do the unpopular shifts, the rota is set in 6-month blocks and if you can alert colleagues early to the dates you would like off, the team can usually support everyone’s requests.

It is worth learning a little Welsh before you get here. The DuoLingo course is not bad, and being able to say ‘hello’ and ‘thank you’ goes a long way. There are Welsh courses available locally with substantial discounts for NHS staff, and I would highly recommend attending one of these when you arrive if you are able to. The language is wonderful.

Links

The best place to check for jobs is the YGED website at: https://www.mountainmedicineyg.co.uk/jobs

Here you can see job specifications and current vacancies. If you are interested in working at YGED you can also contact the Consultants through the details available on the above page.

In addition to the PHEM Clinical Fellow posts, posts are also offered with Medical Education, Quality Improvement and Global EM as alternative options to the PHEM interest. There is the option to work less than full-time if desired.

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Having worked in a private sector emergency department for three years, Dr Amy Collyer (@dr.amylouise) wanted a change. She packed up and moved to Limpopo, volunteering for an NGO called the Tshemba Foundation. Whilst working there she got a call to move to Zululand and work in a public hospital. A week later she packed her life into her car and made the ten-hour drive, arriving ready to start a new challenge. 

An Introduction to Healthcare in Zululand, South Africa

Zululand is in the north of KwaZulu-Natal, one of South Africa’s nine provinces. It extends inland from the coast, and is home to almost one million people dispersed into cities, small towns and rural homesteads. Despite its’ middle-income status, there are significant inequities between South Africa’s public and private health services. Public healthcare tends to be poorly resourced, along with staff shortages and long ambulance delays. This is keenly felt in emergency medicine where a deep passion for the work is needed to survive. Here, we do early, late, and 19 hour-long “call” shifts. The latter is a misnomer, as they are long, busy on-site shifts that are made more tiring by the struggle for resources, including imaging and working technology, the language barriers and limited breaks. Despite these pressures, there is an unshakeable drive to do the best we can for each person who comes in through the doors.

A 19-hour emergency shift

Please note, this is a descriptive piece representing an accumulation of compiled memories and experiences that would reflect a typical 19-hour shift. It is not a true account of an actual shift. 

It’s 13:55 pm on a Friday, and I’m walking along the corridor towards the emergency unit to start my 19-hour shift, with coffee in hand, feet a little sore from the late shift yesterday, and eyes heavy. From the corridor I can’t hear any chaos, so I stop at the bathroom to use the toilet. There are few things as excruciating as doing handover with a full bladder, and who knows when the next opportunity will arise. On entering the ‘majors’ section I see that all fourteen beds are occupied, with two patients ventilated. As we only have two ventilators, this is not a good start to the weekend. All of a sudden I can hear shouting and see all the doctors and nurses moving frantically around the first resuscitation bed in the trauma bay. I can feel my heart beating faster. One of the doctors catches my eye and I see a glimpse of relief in theirs, “Amy, quick, put on gloves, take over CPR!”.

I fling my bags to one side and grab the closest box of gloves I can find. I fumble to put the unfortunately over-sized pair on, while climbing onto the step next to the patient. The monitors are alarming noisily. Words are flying across me, “1 amp of adrenaline given!”, “What is the glucose?”, “Keep the C-spine stabilised”, “Get ready for bilateral finger thoracostomies!”, “Someone fetch the bear-hugger!”, “Let’s get a second line!”.

Right hand over left, arms straight, positioned above the chest, I begin chest compressions, “One, two, three, four… what is the story here?” I pant while compressing. The short reply of “Motor vehicle accident!” is all I get from somewhere at the end of the bed, where doctors are applying a plaster cast for a seemingly mangled limb. “… Twenty-eight, twenty-nine, thirty, breathe”, I lift my hands from the chest so some air can enter the lungs as another doctor gives two squeezes of the bag valve mask. As I continue chest compressions, I look across to see a doctor performing a thoracostomy, in an attempt to relieve any underlying blood or air that could be compressing the lung and accounting for the patient being in cardiac arrest. From behind me someone says, “Amy, don’t mind me, I’m going to do the same thing this side, just move over slightly so I can access the chest wall.”

All I can think about is doing my compressions well while everyone else focuses on their tasks. We are like one dynamic organism, all working together to try to save this life. The doctor repeats the procedure on my side of the patient, and sticks their finger in to access the pleural space. Within seconds a large gush of blood, probably two litres, escapes from the patient and hits the floor. As I continue CPR, more blood leaves the patient with each compression. The doctor behind inserts a tube into the patient’s chest and and connects a Sinapi chest drain. Within seconds the drain is filled to the brim. Shortly afterwards I am relieved when a colleague takes over chest compressions.

Despite the drains, CPR, oxygen, fluids, straightening of broken limbs, provision of warmth, and more, the patient does not improve. As time goes on, it becomes obvious to everyone that there is nothing else left to try. Eventually, the team leader calls an end to the resuscitation effort. There are no signs of life. Gloves come off, and most of the team disperse to see other patients. One doctor remains to document the events and break the bad news to the family. A nurse stays behind to organise a mortuary transfer. As I take moment to change scrubs, I feel a wave of sadness for the loss of this life. But I am consoled by how much the team did to try to save them. Sadly, we can’t help everyone.

On returning to the minors unit, I wade past stretchers, wheelchairs, relatives and nurses to survey the two most important boxes in the departments: waiting to be seen and needing review. There are two unseen patients and six needing a review. But I can’t start with any of this because we still have to do the ward round and participate in teaching. The ward round is quick as everyone is tired, and afterwards we pull up chairs in a circle for our “five-minute teaching”. Today it’s my turn and I discuss the diagnosis and management of septic arthritis. After feedback, everyone except the late and call teams go home, but one consultant remains available after hours for advice.

After some hard graft in minors, it is time for a dinner break. The call room is a bubble of peace in the chaos. From here I can see the exquisite orangey-pink sunset descending over the community and distant rolling hills. Nearby taverns have already started to pump out very loud amapiano (a type of South African music), and taxis are whizzing along the main road that the hospital entrance gate leads onto. After eating, I try and put my head down for a short nap, but I struggle against the noise of the people and buses in the parking lot below. There are limited transport options in Zululand, and some patients live up to five hours away from the hospital. To help with this, intermittent hospital buses take patients who have been at the specialist clinics back to their base facility. It feels like I’ve just closed my eyes when my alarm sounds, signalling my return to the emergency department.

I survey the emergency department. Fortunately, most of the patients in majors unit are stable, so I head back to minors. Despite our hard work earlier, the boxes are full. I take one of the unseen files, a paracetamol overdose. This is, heartbreakingly, one of our “bread-and-butter” cases. The typical patient profile is a young adolescent who has engaged in deliberate self-harm. It is usually triggered by a fight with a lover, or after receiving subpar results in school. It can be serious, even life-threatening. But we see this presentation so often that the management is automated for me: consult, examine, counsel, evaluate suicide risk, take blood tests, start fluids, offer symptomatic treatment for any dehydration and vomiting, and decide on whether the antidote is required. These patients are either referred for hospital admission and ongoing management, or are sent to see a social worker before discharge home.

After this, I pick up the review files. Two can be referred onwards to surgery and internal medicine. The rest are still waiting on blood results. Time has flown by, and it is time for an evening telephone round with the consultant. They listen to the patient list and give advice on management, and on overcoming barriers to flow on the floor. After the late team leaves, a team of three to four is left to cover the next twelve hours until the morning. We head back to the minors unit and see that two patients from a motor vehicle accident have arrived with the paramedics on scoop stretchers due to concerns about spinal injury. My colleagues attends to them, so I continue with other unseen patients and answer calls from the clinic phone. The rural outlying clinics, some up to 50km away, often call for advice or to refer patients that are too unwell for them to manage. I accept a patient who has been stabbed in the chest with a broken beer bottle, giving the nurse on the other end some advice to make sure the patient is stabilised prior to being transferred.

In between my next few patients I make sure to rehydrate and refuel. It is easy to get bogged down by tasks and forget to look after ourselves. But I’ve no sooner closed my lunch bag when a concerned looking nurse approaches me. “Dokotela, (doctor in isiZulu) the patient in bed thirteen is becoming restless”.

It is a patient with head injury secondary to assault. Unfortunately, this is also a common presentation. This patient’s head injury is severe and they have been intubated and placed on a ventilator for prevention of secondary brain injury. I begin troubleshooting and looking for causes for restlessness in a head-injured patient. It could be pain, hypoxia, hypoglycaemia, low blood pressure, even seizures. Ruling these issues out, I decide to increase their sedation so that the patient will tolerate the ventilator better.

While I’m in the majors unit I decide to check on a patient with diabetic ketoacidosis (DKA). They came in really sick with a pH of 6.9 and are surrounded by drips and pumps. They need close monitoring of their sugars, electrolytes and acid-base status, while insulin and fluids brings down their high blood glucose, and we look for an underlying cause.

The rest of the night is a constant flow of sick and injured patients to sort out. The team is kept busy. Patients keep arriving. These include a patient with a snake bite for blood tests and limb elevation, a breathless, immune-compromised patient for oxygen and antibiotics, one with heavy chest pain for four hours management of a likely myocardial infarction, a patient with a dislocated knee for reduction, and a patient with an angle-grinder injury for tying off an arterial bleed and admission for amputation of two of their fingers. Eventually, the patient who was stabbed in the chest with a beer bottle arrives. They are drunk and frustrating to work with, but fortunately I can see on X-ray and bedside ultrasound that none of their vital organs are affected. I clean their wound, suture it closed, apply dressings, and give them fluids and a thiamine drip owing to their intoxication and chronic alcohol use. Later I send the patient home on pain medicine.

As the night wears on I can feel my concentration dipping and thought processes slowing. Caffeine helps but I’m willing time to speed up. Eventually, there is a lull. There aren’t many more expectant cases, especially no more red codes requiring laborious and heart-wrenching resuscitation efforts. Some of us sit, chat and laugh together, others put their heads down on the desk to rest their tired eyes.

6am rolls around. It is still two hours before the handover round but I can see through the glass windows that first light has emerged. This is my signal to make instant oats, and head outside to devour them while watching the sun rise over the community from the helipad. The air is fresh and I feel a renewed sense of hope. The night is almost over, and I’ll be home in my bed soon. Only to do it all again later that evening.

Interested?

You can apply for a job at Zululand hospitals through this website. Doctors will require a right to work in South Africa (see this page for advice), and registration with the HPCSA.

International medical students and doctors interested in emergency medicine experience in KwaZulu-Natal, either for university requirements or personal interest, can email mbanjwaa@ukzn.ac.za or go to this website to read more.

The post A 19-hour emergency shift in Zululand appeared first on Adventure Medic.

Bear Island

Where: Netflix

About: Three brothers follow their dreams, and journey to the remote island of Bjørnøya (Bear Island) in the Barents Sea. Travelling with surfboards, snowboards, and a paraglider, and supplied with food foraged from supermarket bins, they search for the perfect wave.

Why: The movie really embraces the outdoor spirit. It’s interesting to watch these three brothers conjure, plan and then pursue their dreams of spending two months on a remote island. How do you survive in, let alone surf through, the harsh conditions of the Arctic? With freezing temperatures, strong winds, and, of course, the ever present risk of an encounter with a polar bear? You can tell why it took them one and half years of preparation. One of the brothers says, ‘I am not brave. I like doing objectively dangerous things in a safe way.’

In the end it’s an easy to watch, feel-good movie, but it also addresses more serious subjects like plastic pollution and the importance of family.

Book:

Mountain Recue Doctor

About: Christopher Van Tilburg, M.D., is an American doctor with a varied work schedule. His career has taken him out of the Emergency Room to ski patrol, mountain rescue, cruise ships, and as an expedition medic on six continents. Dr. Van Tilburg’s work requires a unique combination of emergency medicine, survival skills, agility, and extreme sports. In ‘Mountain Rescue Doctor’, Van Tilburg shares personal stories of harrowing rescues and recoveries full of nail-biting suspense.

Why: The author describes some of their mountain rescue cases in great detail. In doing so, he makes clear just how complicated any extraction off the mountain can be. He explores how different factors influence a rescue, and how effective teamwork is of the utmost importance. In addition, he shares some personal insights to life, such as how his passion for wilderness medicine began. “As a young medical student, I didn’t bother to think, can I make a living at wilderness medicine? All I could focus on was that I was to begin the journey to specialising in wilderness medicine. I would forge a career that would take me far beyond medicine, and perhaps one day, merge my two lives.” This is probably something our readers can relate to.

Podcast:

The Wilderness Medic Podcast (S3E7) Medic SOS

Where: Spotify

About: Dr. Daniel Grace is joined by David Tamale-Sali to talk about the big taboo in medicine: quitting. He discusses the shame he felt after being kicked out of Medical School, and the road to recovery and acceptance. Later in life, he helped a Doctor in distress on social media, and this inspired him to put together a book with the help of hundreds of doctors, gathering words of wisdom, encouragement, and strategies for overcoming burnout.

Why: David talks about the pressure he felt from his family to study medicine. He explains this by telling a joke that runs in African families; ‘There are four jobs you are allowed to have: doctor, engineer, lawyer and a disgrace to the family.’ It is still difficult for doctors to openly, and privately, have second doubts about their medical career. Therefore we need to open up the conversation, and show young medical students and doctors that these aren’t blasphemous or even uncommon thoughts. It is vital that we destigmatise the subject and discuss it in the open, and David is making good steps towards that.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

The post AM Team Recommendations February 2024 appeared first on Adventure Medic.

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

The post Trauma Elective in Johannesburg, South Africa appeared first on Adventure Medic.

Founded in 2021, Endeavour Medical is a new provider of global health and expedition medical training. Their large faculty can boast decades of experience in multiple extreme environments, including mountain, jungle, polar, and desert, and countless teaching and academic accolades. Endeavour Medical delivers an array of courses, including global health, sports medicine, wilderness, expedition, and leadership. The Marine Medicine course, based in North Cornwall, aims to give you the knowledge, skills, and confidence to work as a medic in maritime expeditions and events. The three facilitators on this year’s course were junior doctor Lucy Longbottom, A and E Consultant Anna Shekdar, and Lucy Obolensky (founder of Endeavour and Associate Professor of Global Health). They teamed up with Era Adventures, an outdoor activity organiser boasting internationally recognised surf coaching, first aid, and emergency medical courses. Other faculty included RNLI doctors, surf lifesaving medics, and water safety experts, who covered the London Olympics and big wave surfing events. 

Key Facts

Duration: Five nights in total with four full days of water and land-based learning.

Dates: Next course May 2024 (check the Endeavour website for updated details).

Location: North Cornwall. In 2024 it will be based in Tintagel YHA with various beautiful North Cornwall beaches visited during the days.

Cost: £1395. Price includes accommodation, meals, equipment rental, transport on the course, and water safety cover.   Not included in the cost: personal insurance, travel to and from the course, personal equipment, snacks, and alcohol. 

Delegates: Five delegates (medics and non-medics welcome).

Prerequisites: One day of pre-course e-learning (digital content sent out six weeks before the course date). 

Qualification/Accreditation: This course contributes to 25 hours of self-certified CPD points, plus the option to discuss clinical matters for portfolio and complete case-based discussions.

Example Course Contents

Pre-course Lectures Include:

• Preparing for Expedition
• Medico-legal and Public Health aspects of Expedition Medicine
• Medical Kits
• Leadership in Expedition
• Environmental factors such as Altitude, Cold, Heat, Tropical Medicine, and Drowning

Practical Content:

• Sea Kayak Tour with Paddle Skills
• Kayak Rescue Training Techniques
• Trauma, Spinal Injuries, Fractures and Dislocations in Marine Environments
• Marine Wildlife Bites/ Stings Management
• Coasteering and SUP techniques
• Surf Life-Saving Training

The Course

Endeavour’s organisation and communication were brilliant throughout. Prompt emails were sent out with joining instructions, links to pre-course learning, and plentiful information regarding the course itinerary, kit, and accommodation. The course faculty created a WhatsApp group which allowed us to introduce ourselves, plan our journeys, and open up possible car share opportunities.

Delegates arrived on the Sunday afternoon/evening and settled into the accommodation ready to start the following morning.

Day One started with optional 7 am circuits on the beautiful beach in Polzeath, accompanied by a friendly dog and some drum and bass. Some of the candidates opted for a long early morning run around the coast instead. We then reconvened and headed to Era Adventures to meet our instructor Llyr – a previous GB life-saving representative. His patience and calm nature proved to be invaluable for the upcoming week’s activities. Once sized up with wetsuits, boots, and life jackets we were ready for the activities to commence.

Quite literally ‘thrown into the deep end’ we started the day with some surf rescue skills. Having never touched a surfboard before, and being rather accustomed to calm tropical waters, I found this rather difficult. I successfully lost my casualty once and gave myself multiple saline nasal irrigations. But, with brilliant instruction, I got used to the cold choppy waters and developed new-found paddling techniques. The water activities presented plentiful opportunities to manage drownings and spinal trauma scenarios, and I became proficient at pulling casualties onto my surfboard.

After a much-appreciated hot shower and delicious lunch, we returned to the sea to practice some coasteering and further key rescue skills. We bobbed around some beautiful caves, jumped off cliffs, practiced delivering rescue breaths to drowning casualties, and towed each other to safety. After a few hours of this I was quite tired, but also concerned that this was just the warm up.  Fortunately I was reassured by the team that the conditions had been rather testing that day! We enjoyed a glass of wine in the evening over another delicious meal and discussed the legal aspects of working in marine environments. The day finished with a brilliant talk from a cruise ship doctor who video called us directly from her office at sea. 

The week became physically easier as the sun came out and the sea calmed down, creating visually tropical, crystal-clear waters. We enjoyed a hike to Port Quin where Anna scared us repetitively by developing symptoms for us to manage. As a team we learnt how to splint fractures, manage dislocations, then package and evacuate our casualties. We became accustomed to using the contents of the small and portable medical bag, including what analgesia to use and when. All of this required close communication among our team, as well as other services on land, which helped the team to become more proficient at using the walkie-talkies and radios.

Over the following days, we planned expeditions factoring in routes, weather conditions, and medical equipment. We set off on a mini “expedition”, camping in a field and enjoying a refreshing but beautiful evening swim. This led seamlessly to a scenario of a hypothermic patient. As a team, we learnt how to get the patient into a “burrito roll” to prevent dangerous hypothermia from developing. To stay nice and warm ourselves we set up a lovely fire that became perfect for toasting marshmallows on.

Some of the less clinical activities included a relaxing paddleboard and prosecco, surf lessons (which I found highly addictive), and a rather hilarious game of ‘Beach Flag Bingo’, a novel way of testing our beach sign knowledge.

The Verdict

I could not recommend this course enough. I came back from the course motivated, inspired, achy (in a good way), excited to read more, and feeling like I had challenged myself to a new level. Beyond acquisition of new knowledge and clinical skills, this course facilitated fascinating conversations with the faculty and other delegates, whilst providing nutritious meals throughout the day. There are many skills I hope to take with me to aid my career in expedition medicine such as completing a thorough pre-travel medical screening, and familiarising myself with all the equipment in advance to name a few. 

I am grateful to the team and to the other participants for making this such an educational and enjoyable week. It has provided me with a wonderful introduction to the knowledge and skills as I develop my career in humanitarian and conservation medicine in remote environments. Thank you so much Endeavour.

Top Tip

I found having a background in Emergency Medicine to be very useful when dealing with emergency scenarios during this course, but this is not a pre-requisite. No matter what your previous level of experience is, you will learn how to manage the same scenarios with brilliant instruction and supervision. This course would be suitable for paramedics, advanced first aid practitioners, and emergency and expedition nurses or professionals. 

To find out more about Endeavour’s Marine Medicine Course in North Cornwall, see Endeavour’s website

Photos courtesy of the Endeavour Faculty

The post Endeavour Medical Marine Medicine Course- Review appeared first on Adventure Medic.

How do you become a team physician?

The most common route to become a team physician is to specialise in sports and exercise medicine first. Since 2014 sports medicine is an acknowledged specialisation in the Netherlands. It takes 4 years of specialty training and there are only 7 places available each year to start. In the UK it is a bit different. After foundation programme completion, you become eligible to apply to specialty training in sports and exercise medicine. There are 11 specialty training places available in the UK and completion will take a minimum of six or seven years. Although most team physicians finish sport and exercise medicine training, luckily it is also a possibility when you are a general practitioner like myself.

For me, it all started during a visit to the first Action Sports and Exercise Medicine Congress in Italy. After an interesting talk from the World Skate team I asked if I could get involved. A few months later I was accepted as a volunteer for the World Skate medical commission. Two years after my start in the medical commission I was able to join the International Olympic Committee (IOC) World Conference on Prevention of Injury and Illness in Sports in Monaco. This meeting is organised every four years. Here I got the chance to meet different team physicians and show my interest in this field of medicine. Thereafter, I stayed in touch and meanwhile I enrolled in a basic sports medicine course. Fast-forwards and I received a phone call with a great opportunity to apply for the role of team physician for the elite swimmers at the High Performance Centre in Eindhoven, the Netherlands.

Why become a team physician?

First of all, I find it a privilege to work with these highly motivated individuals who perform at the highest levels. It is inspiring to see how they can push their physical and mental boundaries to strive for excellence every single day.

Secondly, being a team physician means immersing yourself in a dynamic and fast-paced environment. Sports teams operate on tight schedules and face unexpected health issues, requiring you to be adaptable and quick-thinking. This constant dynamism keeps the role interesting and ensures that no two days are alike. On top of that, you get the opportunity to travel with the team for competitions and events, allowing you to experience different locations and cultures.

Lastly, being part of a team where all members have the same goal is very encouraging. As a team physician, you work in the same team composition for a longer period, which creates long-term relationships with athletes, coaches, and support staff. This continuity allows you to understand the individual health needs and challenges of each athlete, contributing to more personalised and effective medical care than you might normally be able to provide.

Teamwork

While as a doctor you might be used to working in a team, it can still be a different way of working as a doctor within an elite sports team. As a general practitioner, I am quite used to being the one on the receiving end of all the information from the other players in the medical field (doctors assistants, specialists, psychologists, nurse practitioners, dieticians, etc.). In elite sports, it is the coach that fulfils the central role. It makes it even more important to get to know everyone involved so you don’t get behind in what is going on. Besides the coach, the team consists of, but is not limited to: physiotherapists, strength and condition coach, sport psychologist, nutritionists, lifestyle coach, embedded scientists and different managers. Everyone has their own role in the team, but there are overlapping roles. For example, it is important to know the diet and supplements an athlete uses before deciding which blood tests to order.

Swimmer illness

As a team doctor, you will most likely encounter ordinary diseases like every other person who is not an elite athlete would. This is one of the main reasons why a general practitioner is suitable for this job. On the other hand, there are also sport-specific diseases in swimming. Otitis externa is really common in competitive swimmers for example. The mildly acidic cerumen normally provides a waxy coating that protects the auditory canal from bacterial and fungal infections. Prolonged water exposure and physical cleaning of the ear canals may cause a swimmer to scratch the pruritic ear canals, leading to superficial lacerations that become the portal for skin infections.

Exercise-induced bronchoconstriction is also more prevalent in elite swimmers. Swimming in indoor chlorinated pools can lead to airway chlorine allergen exposure and it is suggested that this generates airway epithelial damage, inflammation, and bronchoconstriction.

Swimmers injuries

Competitive swimming is unique because it is non-weight bearing and has a large dependence on upper extremity strength for propulsion (legs only count for 10-20%). This predominance of the upper extremities combined with high volumes of swimming training explains why shoulder pain is the most common musculoskeletal complaint in competitive swimmers.

The second most common musculoskeletal injury is breaststroker’s knee. It typically causes medial and/or anterior knee pain and results from the repetitive valgus load, which causes medial distraction and lateral compression of the knee compartments. A proper breaststroke kick technique, with optimal hip abduction angle range from 37 – 42 degrees, can prevent this. Groin pain is another injury risk and is caused by repetitive hip adduction. This movement puts significant stress on the adductor longus, brevis and magnus, pectineus and gracilis that can lead to overuse injury.

Prevention and Performance

In addition to illness and injury management, the team physician plays an important role in prevention and in optimizing the performance of elite swimmers. The main goal is to have as many healthy training hours as possible. It is crucial to recognise if performance is declining to reduce the risk of injury. Different tools are used to get a global idea of the performance of these athletes. Every week different strength measurements are done and compared to their personal mean. Another tool is an athlete self-reported daily questionnaire about subjects like their sleep, stress and mood to signal early signs of non-functional overreaching. The coach can also have a look at the acute to chronic workload ratio (ACWR). ACWRs are calculated by dividing the acute workload (total load over the last week) by the chronic workload (average of the last 6 weeks). The higher the outcome the higher the risk for an injury.

Mental Health

The pressure to perform at peak levels in combination with rigorous training regimens can have an impact on the mental health of elite athletes. The expectations placed on these athletes, both internally and externally, can lead to a range of mental health challenges. Anxiety, depression, eating disorders, injury related stress, social isolation and burnout are some examples. The pressure to continually perform better, coupled with the fear of failure, can have a big impact on the mental well-being of athletes.

As a team physician it is important to be extra aware during certain periods, because the athletes are more prone to mental health challenges. These include, yet are not limited to:

• When they are away from home for extended periods due to training abroad homesickness and loneliness can be a challenge.
• During major events like the Olympic Games or World Championships. These events can add extra pressure to perform and create a fear of failure.
• After a major competition or achievement, some athletes may experience a sense of emptiness also known as post-competition blues.
• Dealing with injuries and rehabilitation can lead to fear of not fully recovering and anxiety about returning to competition at the same level.

It is crucial to have a good relationship with the athletes and know their personal background. This will facilitate the identification of any out of the ordinary behaviour and also lower the threshold for them opening up to a conversation about mental health challenges. As a physician in elite sports, it is fundamental to be aware of signs of mental health challenges, open up the conversation and, if necessary, refer to a sports psychologist.

Antidoping

As a doctor, you are also responsible to promote a clean and fair environment in elite sports. Each year the World Anti-Doping Agency (WADA) publishes an updated version of the List of Prohibited Substances and Methods. This list contains all the substances that are prohibited at all times, in competition and specific sports. A substance can be added to the list if it satisfies two of the following three criteria:

1.     It has the potential to enhance or enhances sport performance

2.     It represents an actual or potential health risk to the athlete

3.     It violates the spirit of sport

Anabolic agents, oral corticosteroids, stimulants and diuretics are obvious examples. Beta-blockers are probably not the first to come to mind when thinking of prohibited substances. Though, when you think about it, it makes sense that this substance is prohibited in particular sports like archery, darts and shooting. Certain athletes may have an illness or a medical condition that requires particular medication. If this medication contains a substance that is on the List of Prohibited Substances and Methods, you can apply for a Therapeutic Use Exemption (TUE). A TUE allows the athlete to use the medication as it will not afford a competitive advantage but rather ensures the athlete to compete in a proper state of health.

Elite athletes often use several supplements and as the team physician, you should be aware of this. Supplements can be contaminated and cause a positive test. This is why there are several systems developed to check for a guaranteed clean supplement, such as: ‘Informed Sport’, ‘Banned Substances Control Group (BSCG)’, ‘National Sanitation Foundation (NSF) International’ and ‘Informed choice’.

Top tips to work as a team physician

• Get to know the sport. I listened to podcasts about swimming and read different biographies of famous swimmers to better understand the sport. Furthermore, I took lessons to learn freestyle swimming myself. Swimming is a technical sport. If you understand the technique you can also explain why certain injuries happen to certain athletes and make adjustments to prevent this.
• Get to know the supporting team. As mentioned before, there is a big group of supporting personnel and it is really important that you know the role of each person in this group. If an illness or injury is present you want to make sure you can tackle this as fast as possible so it helps to know who to consult in every situation. In elite sports, every missed training day is one too many.

Get started

In my opinion, the best way of learning is to learn on the job. Luckily for me there are many experienced professionals in the team who I can ask for advice. However, if you want to follow a course, the IOC Advanced Team Physician Course may be a good start.

The post Behind the Scenes of a Team Physician appeared first on Adventure Medic.

Dr Jade Hanley / FY2 Doctor / University Hospitals Birmingham, UK

GECCo (Global Emergency Care Collaborative) have been hosting conferences for the last three years and they get more impressive each time. GECCo describe themselves as neither a who nor a what, but rather as a way of connecting those involved in emergency care with an interest in global health.

Who are GECCo?

GECCo is a network of emergency clinicians (doctors, nurses, ACPs and others) from the UK and beyond, who are actively pursuing global health projects and seeking ways to advance the quality of this work. They believe that striving to deliver excellent emergency care in the UK, and our projects to achieve the same on a global scale, needn’t be in competition, that, in fact, there are many synergies to be found and capitalised on. This is what makes GECCo so exciting. They represent a forward-thinking, problem-solving mentality, combined with an ethos of equity in global emergency care. Who wouldn’t want to join that party? I certainly did, so off I went to Edinburgh, for a dose of fresh ideas, inspiration and, I hoped, new connections. The theme of this event was UK global health projects, the who’s who and what’s what of an environment that can be difficult to navigate given the tangle of government bodies, international organisations, NGOs and others who operate in this space.

Conference Review

The day kicked off with an introduction by Dr Anisa Jaffar, a founding member of GECCo, Higher Emergency Medicine trainee, and NIHR Clinical Lecturer at the University of Manchester’s Humanitarian and Conflict Response Institute. I’ve met Anisa at previous GECCo events and her energy and presence encapsulate GECCo’s ‘ask-good-questions-and-get-stuff-done’ vibe. She’s sharp, practical, great with a crowd, and set the tone for a day packed full of fascinating people doing exciting and important things.

Dr Ram Vadi, Health Director of UK-Med, gave a brilliant talk on UK-Med’s response to the devastating earthquake affecting Turkey and Syria in February 2023. He shared UK-Med’s approach to mobilising a team, as well as some of the challenges presented by the (very necessary but at times cumbersome) legal structures which surround deploying an emergency medical team (EMT). Countries wishing to welcome the support of international EMTs are required to put out a formal invitation, to which interested EMTs respond with an offer of support which must be formally accepted by the host country before the EMT deploys. Following the Turkey-Syria earthquake, UK-Med felt that, based on their experience, provision for primary care, obstetrics and paediatrics would be a critical part of any response, due to the disruption to normal services and the evacuation of many local doctors from the area. However, the government officials who were coordinating the response were focused almost exclusively on emergency care. Working through this difference of opinion took time, and required clear and efficient communication to mount a timely and effective emergency response.

Next was an update on the Royal College of Emergency Medicine’s (RCEM) current global emergency medicine activity from Victoria De Witt, Senior International Officer at RCEM. Victoria introduced RCEM’s new Visiting Observer Fellowships, in which emergency medicine clinicians from low- and middle-income countries (LMICs) visit UK clinical centres with the aim of exchanging good practice and developing knowledge. RCEM are now also offering Global Health placement grants to RCEM members and fellows based in the UK. These grants provide the opportunity to spend time in LMICs to support the development of Emergency Medicine as a specialty in the host country. RCEM encourages applications from Emergency Medicine clinicians at all levels of experience, whether trainees or consultants. Projects or placements that are working towards sustainable goals are preferred. This year’s application round has closed but application forms for next year can be found on RCEM’s website.

Following a quick coffee break, GECCo introduced their new idea in conference organisation, the ‘concept carousel’. Think poster presentation meets speed dating. Eight presenters with their posters had two minutes each to share a headline summary of their research, followed by a further few minutes for questions. Given the varied and collectively vast global EM experience in the room, this made for some excellent discussions. Adventure Medic’s very own Dr Alex Taylor presented her recent work with the Tshemba Foundation in Mpumalanga, South Africa, where she worked with the local emergency department to further develop their systems. Another highlight was the work of Dr Eleanor Broad, Global Emergency Medicine Fellow based in Manchester, on what we can learn in the UK from international approaches to tackling inequality in child health services.

Next, attendees were treated to a keynote speech full of compassion and the insights of a long career, by Professor Tony Redmond, Professor Emeritus of International Emergency Medicine and founder of UK-Med. Professor Redmond shared what he has learnt from a career that has played a significant role in how International Emergency Medicine is practiced today. He stressed the importance of humility and the pursuit of true equity. International crises are not a time for honing skills or taking professional leaps, he reminded us. They are a time for expertise and the utmost professionalism. He also addressed one of the sticky areas of International Emergency Medicine, why do we do it? Is it because we are motivated by social justice? Or is it because it feels exciting? Probably a combination, he reflected. He encouraged us all to be honest with ourselves about our motivations. It is only in doing so that you can keep these motivations in check, and aligned to what must be the ultimate goal, providing the best possible medical care to those in need. It’s okay to find this work exciting, he said. But excitement must never be the goal. This was an important reminder and grounding principle for the day.

A second fantastic keynote was delivered by Dr Ellen Weber, San Francisco-based Emergency Medicine Consultant and EMJ Editor. Dr Weber focused on approaches to performing high-impact, low-cost research in resource-limited settings. She emphasised the need for pragmatic approaches. She gave the example of randomised controlled trials, which are often not possible due to limited funding and available resources. However, the need for an evidence base is still absolute, so how can we go about it? Dr Weber has a longstanding relationship with a number of emergency departments in Tanzania and has supported many clinicians in conducting valuable research. Methods such as prospective cohort stories, and descriptive cohort studies, that are relatively time and cost effective can be incredibly useful, and highlight areas that warrant further investigation. Such studies addressing the aetiologies and outcomes of patients presenting with abdominal pain, and the utility of point-of-care serum lactate in predicting serious adverse outcomes, have produced knowledge that can guide practice and the allocation of resources.

The rest of the afternoon was spent in interactive workshops, including ‘Urgent care of poisoning & envenomation in West Africa’ by Professor Michael Eddleston and ‘The cHALO programme for emergency care training in Pakistan’ led by Dr Taj Hassan. These small group workshops gave participants the opportunity to take a deep dive into these specific areas, as well as ask questions and exchange ideas with the projects’ leaders.

To round out the day, Kevin Miles, Senior Lead for Global Fellowships in NHS England, introduced the audience to the NHS Global Fellowship Volunteer Programme. The programme is open to all doctors in speciality training for General Practice, Paediatrics, and ACCS in English deaneries, and aims to make a contribution to the improvement of health outcomes in rural and resource-poor communities. The programme supports fellows to use their skills during a 4-6 month deployment to a low-resource medical facility in one of several African countries, including Kenya, Malawi and South Africa. As well as aiming to support teams in the host country, the programme aims to bring benefit to the NHS as fellows return with enhanced clinical, leadership and decision-making skills. More information on the programme is available here.

The last speaker of the day was Professor Justine Davies, Institute for Global Innovation at the University of Birmingham, who presented her team’s work on access to quality care for injuries in LMICs. She stressed the importance of seeking to identify the ‘unknown unknowns’ with respect to the causes of delay in accessing medical care following injury. Using the ‘process mapping method’ and ‘three delays framework’, the team identified the critical actions and decisions required to access emergency care in Northern Malawi, as well as the barriers to doing so. Barriers included logistical challenges such as long journey times, compounded in some cases by poor road conditions, but also included individuals personal choices, such as preferentially visiting traditional healers. It was fascinating to see the potential of creative approaches to research methods and data presentation to illuminate barriers that once known can be addressed.

Thoughts over a drink…

After a long day full of interesting people and exciting projects, many attendees headed out into Edinburgh to continue the conversation over a drink. I personally came away reinvigorated and reminded of the privilege that it is to do this work, as well as a couple of new projects busier. If you love emergency medicine but the idea of limiting the scope of your practice to the UK makes you want to run for the nearest exit, check out GECCo, you might find it is exactly what you’ve been looking for.

The post GECCo 2023 Conference Review appeared first on Adventure Medic.

Dr Craig Miller / Emergency Medicine Registrar / Peninsula

Dr Constance Osborne / SHO / Evidence Explorer Lead / London

Contents

• Introduction and Collaborators
• Expedition and Wilderness Medicine Section
• Global Health and Humanitarian Medicine Section
• Want to get involved?

The clocks have gone back and the nights are drawing in, so what better time to settle into an armchair with a cup of tea and catch up on the latest in academia.We are excited to announce the publication of the Third Edition of the Oxford Handbook of Wilderness Medicine. It contains updated national and international treatment guidance, and revised chapters on caving medicine, analgesia and anaesthesia. This is the perfect handy guide for any expedition medic’s kit bag.

We would also like to flag The Lancet commission on peaceful societies through health equity and gender equality. It is a long document requiring a particularly large mug of tea, but it is an important read because it presents a pragmatic policy, and learning agenda, for global players at every level.

‘The world is experiencing a polycrisis—ie, an interaction of multiple crises that dramatically intensifies suffering, harm, and turmoil, and overwhelms societies’ ability to develop effective policy responses. Bold approaches are needed to enable communities and countries to transition out of harmful cycles of inequity and violence into beneficial cycles of equity and peace… The Commission, which had its inaugural meeting in May 2019, examines the interlinkages between Sustainable Development Goal 3 (SDG3) on health; SDG5 on gender equality; and SDG16 on peace, justice, and strong institutions. Our research suggests that improvements to health equity and gender equality are transformative, placing societies on pathways towards peace and wellbeing.’

The Lancet Commission on peaceful societies through health equity and gender equality 2023

After scrutinising twenty-five journals, Dr Miller and Dr Roberts have curated a fascinating selection of articles for you. From altitude physiology and the efficacy of avalanche airbags, to antenatal healthcare in armed conflict and the impact of nutrition on tuberculosis, there is something for everyone.

Dr Craig Miller is an Emergency Medicine Registrar, based in Peninsula, who currently works at the Royal Cornwall Hospital. Throughout his career, he has worked as an expedition doctor in most environments, from high altitude to the desert. He has a passion for tropical marine environments and diving medicine, and is a qualified Diving Physician. He has completed expeditions to West Papua and the British Indian Ocean Territory. Alongside his field experience, he has worked as an expedition medical advisor and is a course director for Wilderness Medical Training. He is currently focusing on completing a Masters in Global Health, alongside his UK work.

Dr Hugh Roberts is a Critical Care and Retrieval Medicine Registrar in New Zealand, having completed UK core anaesthetic training in August 2023. He is an Adventure Medic Editor, and has worked as an expedition medic in Tanzania, India, Indonesia and at sea. Hugh authored the Adventure Medic guide on how to balance expedition medicine with UK specialty training. Outside of work, Hugh enjoys SCUBA diving and climbing.

Expedition and Wilderness Medicine

In the autumn edition of Evidence Explorer, we’re already looking ahead to winter. We appraise a pilot study about mechanical CPR on ski slopes, an article on the effectiveness of avalanche airbags, and a review on the performance of chemical heat blankets in wet conditions. We then turn our attention to some of the most potent analgesics in our expedition medicine kits. We review a study that compares sufentanil to other opiates in acute traumatic pain, and a paper on the environmental impact of Penthrox. We round off this section with a paper on physiology at high altitude and a review of the limitations of pulse-oximetry for darker-skinned patients.

Manual vs Mechanical Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest on a Ski Slope: A Pilot Study

Rupp S, Overberger R. Wilderness & Environmental Medicine Journal. Sep 2023.

This study, conducted in the Pocono Mountain region of Pennsylvania, examined mechanical vs manual CPR on a mannequin during extrication from a ski slope. Three-person ski rescue teams performed eight trials, four with a LUCAS 3 device to provide chest compressions, and four with a rescuer providing manual chest compressions. The same ski slope was used for each extrication (which was described as ‘moderately pitched’ at 610m altitude) and different manual chest compression providers were used for each extrication to limit tiring. CPR quality was measured using a CPR quality monitor attached to the mannequin, which measures both rate and depth to determine compression quality.

The study found an increased percentage of time spent performing high-quality chest compressions in the mechanical group (58.5%; 95% CI) vs the manual (25.6%; 95% CI). There was a statistically significant increase in extrication time in the mechanical group (8.6 +/- 0.4min) vs the manual group (7.6 +/- 0.5min) but the authors suggest that the impact of a 1 minute delay would be negligible in real-world scenarios.

This pilot study neatly demonstrates the potential of mechanical CPR for ski patrols; not only does it free up a rescuer for other duties, but it should provide high-quality, continuous CPR on challenging terrain or in adverse weather conditions at altitude. The effect of the cold environment on battery life is an important consideration mentioned by the authors, but was not examined in this study.

The dependence of maximum oxygen uptake and utilization (V̇O2max) on hemoglobin-oxygen affinity and altitude

Webb K, Joyner M, Wiggins C et al. Physiological Reports. Aug 2023.

This is not a paper for light reading post on-call. Brace yourself for some physiology.

Higher haemoglobin-oxygen affinity (Hb-O2 affinity) results in increased oxygen uptake in the lungs, but less off-loading of oxygen to the tissues. These two changes have competing effects on VO2max, which is the maximum attainable rate of oxygen consumption. So does that mean that VO2max will increase or decrease? Naturally, an expedition medic may also ask, how does this effect change at altitude? This study addresses these questions using mathematical models to predict how VO2max will be affected by low, normal or high Hb-O2 affinities at altitudes of 0-10 km.

The results demonstrated that until approximately 4500m, low-normal Hb-O2 affinities result in an increased VO2max compared to high Hb-O2 affinity. However, this effect reverses above 4500m (see Figures available in the original article). This is of interest as it suggests a potential mechanism for the prophylaxis and/or treatment of high-altitude illness by using drugs which may increase Hb-O2 affinity. In fact, these drugs have already been developed and investigated for the treatment of sickle cell disease. This paper is entirely based on mathematical models and further studies are required to verify these findings.

Environmental impact of low-dose methoxyflurane versus nitrous oxide for analgesia: how green is the ‘green whistle’?

Martindale A, Morris D, Cromarty T et al. Emergency Medicine Journal. Sep 2023.

Penthrox has become increasingly popular in pre-hospital and expedition medicine as a lightweight, potent analgesic with a short duration of action. It is also a non-opioid and non-controlled drug, making it suitable for international expeditions. This paper investigates the environmental impact of Penthrox, and compares it to Entonox and intravenous morphine.

The authors thoroughly examined the Penthrox lifecycle in five distinct areas: raw materials, methoxyflurane manufacture, production processes, transport and disposal. Carbon dioxide equivalent (CO2e) was used as the primary measure of environmental impact. Existing data on Entonox and morphine were used from papers published in Anaesthesia and BMJ Open, respectively. The analysis compares one unit of Penthrox containing 3ml methoxyflurane (equivalent to 30 minutes use) with 30 minutes of continuous Entonox at 14L/min and 7mg of morphine. The results showed that Penthrox (0.84kg CO2e) has a CO2e 117x less than Entonox (98.89kg CO2e), whilst the CO2e of morphine was negligible (0.01kg CO2e).

The comparative analysis used in this study seems unfairly weighted against Entonox, assuming very high flow rates by not taking into account the presence of a demand valve (as used in ED or maternity to ensure Entonox is only delivered when the patient breathes through the mouthpiece). Even so, this study suggests that Penthrox is a ‘greener’ choice than Entonox, so we can all feel a little less guilty about including a whistle or two in our expedition med kits.

Effect of intranasal sufentanil on acute post-traumatic pain in the emergency department: a randomised controlled trial

Malinverni S, Kreps B, Lucaccioni T et al. Emergency Medicine Journal. Sep 2023.

Onto another up-and-coming drug of the pre-hospital med kit, intranasal sufentanil. Sufentanil is an opioid with 10x more potency than fentanyl. It is highly lipophilic, which means it can be absorbed through the nasal mucosa to provide rapid analgesia without the need for an IV cannula. In this randomised controlled trial from Belgium, intranasal sufentanil 0.5μg/kg was compared with a control of either oral oxycodone 5mg or IV morphine 0.1mg/kg (based on clinician’s judgement). The study included 170 adult patients that presented to the ED with acute post-traumatic pain in the extremities, spine or thorax, scoring greater than 7/10 on the visual analogue scale (VAS). Pain scores were assessed at 0, 15 and 60 minutes, and smaller supplementary doses of opiates were allowed at these times.

The results showed that baseline pain scores were similar between groups, and intranasal sufentanil resulted in a greater reduction in VAS pain scores than the control group at both 15 minutes (3.0 vs 1.5; p<0.001) and 60 minutes (5.0 vs 6.6; p<0.001). There was a significantly greater number of patients who experienced minor adverse effects in the intranasal sufentanil groups, particularly dizziness, vomiting and sweating (59 [71%] vs 20 [23%]; p<0.001). Supplementary analgesia was used similarly by both groups. This is an intention-to-treat study and therefore the high rates of adverse effects in the intranasal sufentanil group are taken into account.

This paper is well worth a read. It serves as an excellent introduction for clinicians unacquainted with intranasal sufentanil, whilst also producing some interesting data for those more familiar with it.

Improving pulse oximetry accuracy in dark-skinned patients: technical aspects and current regulations

Cabanas A, Martín-Escudero P, Shelley K. British Journal of Anaesthesia. Aug 2023.

It has been well-documented that patients with darker-pigmented skin are at higher risk of occult hypoxaemia (peripheral oxygen saturations [SpO2] >92% despite true arterial oxygen saturations being [SaO2] <88%). The two wavelengths used as standard in pulse oximeters are 660nm (red light) and 940nm (infrared light). Deoxyhaemoglobin absorbs more light at 660nm, while oxyhaemoglobin absorbs more light at 940nm. As melanin absorbs more light at 660nm compared to 940nm, patients with darker-pigmented skin may therefore have a falsely high SpO2 reading. The reason these wavelengths are used is because the majority of the data used to calibrate pulse oximeters has been collected from studies of patients with lighter-pigmented skin. Of the relatively few studies that have examined darker-skinned patients, most have used questionable methodology. Poor-quality polychromatic LEDs (which are often found in pulse oximeters bought on the high street or online) further increase the risk of occult hypoxaemia, as they are affected by the spectral absorption of melatonin to a greater degree than monochromatic LEDs (which are found in FDA 510[k] authorised pulse oximeters used in professional healthcare settings).

Until there is an improved availability of pulse oximeters calibrated for patients with darker-pigmented skin, what can we do as expedition medics to tackle this issue? Raising awareness is important. We should also ensure our pulse oximeters are FDA 510(k) authorised, and maintain a degree of clinical suspicion when we have patients with darker-pigmented skin and a reassuring SpO2.

Effectiveness and use of avalanche airbags in mortality reduction among winter-recreationists

Lucia Laura Di Stefano, MD1,*, Bianca Della Libera, MS2 and Paolo Rodi, MD3. Journal of Travel Medicine. October 2022

My friends that regularly ski will often talk about the appeal of heading off-piste for fresh powder, leaving novice skiers like me to flounder on the blue slopes. However, skiing off the bashed track is not without risk. The overall mortality of individuals caught in an avalanche is 13-23%. During the 2020-21 winter season in the Alps, there were 130 avalanche-related deaths. Equipment commonly carried by winter recreationists includes a transceiver/shovel/probe combination and an avalanche airbag.

This paper is a narrative review of the available data on avalanche airbags. The authors identified six articles with data on mortality reduction, of which one was a survey and five were retrospective experimental studies on real-life accidents. They concluded that airbags reduce the risk of both critical burial (defined as burial of the head and impaired breathing) and mortality. Non-deployment of airbags is a major issue, occurring at a rate of around 20%. It may be caused by user error (60%), device failure (17%), maintenance error (12%) (such as the canister not being attached properly), or destruction of the airbag during the avalanche (12%).

Whilst it’s reassuring to know that deploying an airbag does reduce the risk of death if you find yourself caught in an avalanche, there still remains a significant risk. There is no substitute for appropriate education and training on avalanche avoidance. Always take time to make sure you know how to use your device properly, and keep it maintained to significantly reduce the risk of non-deployment.

Performance of a Chemical Heat Blanket in Dry, Damp, and Wet Conditions Inside a Mountain Rescue Hypothermia Wrap

Greene M, Long G, Greene K et al. Wilderness and Environmental Medicine. September 2023.

This research was conducted by authors Mike Greene and Karen Greene (both highly experienced mountain rescue doctors and founders of Mountain and Expedition Emergency Medicine), Geoff Long and Matt Wilkes (both affiliates of the School of Sport, Health and Exercise Science at the University of Plymouth, and you may also recognise Matt as the founder of Adventure Medic).

This study examined the performance of chemical heat blankets (CHB) in three experiments. The first experiment measured whether a CHB heats up quicker when packed loosely in a rucksack or when exposed to the open air. The second experiment measured temperature and heat flux (the rate at which heat is transferred) from a CHB through dry, damp and saturated wet fleeces. The third experiment compared the temperatures of mannequins dressed in dry, damp or saturated wet fleeces and wrapped in a “hypothermic wrap”. The hypothermic wrap, as used by Mountain Rescue England and Wales, consists of a CHB, then a vapour barrier, surrounded by an insulating fibre pile bag with a wind and waterproof outer layer. Finally, the wrapped casualty is supported in a vacuum mattress, which provides additional insulation. A temperature probes was placed next to the base layer on the mannequin and then the mannequin was left for 7 hours to see if steady-state temperatures were maintained.

There are several useful takeaways from this study, and I would highly recommend reading this paper yourself to better understand the findings. The first experiment showed that a CHB packed loosely in a rucksack heated up quicker than a CHB in the open air (43oC vs 32oC at 30 min), demonstrating that it is not necessary to open the CHB to allow in more oxygen. Readying a CHB in your rucksack in advance of reaching your casualty may be beneficial, to allow it to warm up. However, the application of a CHB should not be delayed, as it starts to provide heat to a patient from the moment it is applied. The second experiment showed that the performance of a CHB is similar in dry or damp conditions, but impaired in wet conditions. The explanation provided by the authors for this is that the water surrounded the panels, preventing oxygen reaching the CHB and thereby impairing heat production. Therefore, consider cutting off saturated clothing before wrapping a casualty as it may impair the efficiency of a CHB. The third experiment showed that hypothermic wraps will maintain the median steady-state temperatures for 7 hours with dry, damp or saturated wet fleece, so there is really no need to check or change them before this time. The highest temperature recorded against the CHB (with the dry fleece) was 67oC. This is more than sufficient to cause burns, so we should always have a protective layer of clothing between the CHB and the casualty’s skin.

Global Health and Humanitarian Medicine

As we enter the final months of 2023, it’s time to introduce you to the final Global Health Evidence Explorer for the year. Get yourself a cup of tea and we’ll take you through six key papers published in the past few months. 

Inequality across the globe has a huge impact on human health and this edition explores different aspects of this issue, and its impact on different populations. Ataguba et al publish an expansive global assessment of income inequality and its impact during pandemics. Displaced populations are particularly vulnerable to inequality. Okumu studies the interplay between gender inequality and condom use in displaced populations with a high prevalence of HIV. Zhang et al examines access to antenatal healthcare during armed conflict, which is a particularly powerful study given the current conflicts in Europe and the Middle-east. There are two randomised controlled studies in this quarter’s edition: one looking at wider nutritional supplementation for households with known TB, and another determining the effectiveness of intermittent preventive treatment of malaria.

Income inequality and pandemics: insights from HIV/AIDS and COVID-19 — a multicountry observational study

J Ataguba, C Birungi, S Cunial et al. BMJ Global Health, September 2023

Inequality is a key determinant of poor health outcomes. This global retrospective observational study illustrates this point clearly by utilising national data from two global pandemics: HIV/AIDs (217 countries) and Covid-19 (151 countries). Countries and regions with greater inequality, as assessed by the Gini index*, show a statistically significant (p<0.01) increase in prevalence of HIV, AIDs mortality rate, and excess deaths owing to Covid-19. The consequences of this are two-fold: the poorest populations are the most vulnerable during pandemics, in part owing to limited access to healthcare, and greater inequality perpetuates and exacerbates pandemics thorough increased case numbers. Articles such as this one helps to focus international attention and drive agendas such as the Sustainable Development Goals.

*The Gini index (or coefficient) is an internationally recognised measure of inequality. It specifically examines the distribution of household income and how this deviates from perfect distribution, with 1 being complete inequality and 0 being complete equality. One limitation is that it is a relative, not absolute measure, meaning the Gini index can rise for a developing country i.e. become more unequal whilst the absolute number of those living in poverty reduces. Similarly, two countries may have similar levels of equality, i.e. the same Gini index, yet the absolute wealth between the two countries may be vastly different. Want to read more? https://ourworldindata.org/what-is-the-gini-coefficient 

Does armed conflict lead to lower prevalence of maternal health-seeking behaviours: theoretical and empirical research based on 55 683 women in armed conflict settings

T Zhang, Q He, S Richardson et al. BMJ Global Healt, August 2023

Women and children are amongst the most vulnerable in conflict zones, and access to antenatal healthcare is challenging. This study aims to quantify the effect of conflict on maternal health seeking behaviours using maternal and child health (MCH) data from UNICEF. The paper suggested that where humanitarian assistance was provided, improvements in maternal care can be achieved, particularly tetanus vaccination and single visit antenatal care (ANC). This is likely because it is more feasible to deliver a vaccination programme and single visit ANC than the WHO recommended 8+ ANC contacts*. Caution should be exercised however, as no clear trends were identified across the countries studied (CAR, Chad, DRC, Afghanistan), many of the results were not statistically significant, and MCH improvements are presumed. Overall, this paper highlights the variability in delivery of MCH humanitarian assistance in conflict zones. Whilst it does develop a ‘theoretical model of utility to explain the effects of armed conflict on maternal health-seeking behaviours’, it remains to be seen how applicable this model is to real world interventions.

*The World Health Organisation publishes recommendations on ANC for a positive pregnancy. They recommend a model with a minimum of 8 ANC contacts, as evidence shows a reduction in perinatal deaths. Furthermore, the ANC 8+ contact model supports improved safety, earlier detection of complications, and better health engagement and communication.

[WHO recommendations on antenatal care for a positive pregnancy experience. 2016. Available at: https://www.who.int/publications/i/item/9789241549912 ]

Nutritional supplementation to prevent tuberculosis incidence in household contacts of patients with pulmonary tuberculosis in India (RATIONS): a field-based, open-label, cluster-randomised, controlled trial

A Bhargava, M Bhargava, A Meher et al. Lancet Global Health, August 2023

Social determinants of health are increasingly recognised as a key determinant of the burden of tuberculosis (TB). The WHO strategy to end tuberculosis addresses both the biological and social aspect of the disease. The national ‘Eliminate TB Strategy’ in India aims to address the syndemic of malnutrition and TB through provision of direct nutritional support to patients. This study is the first of its kind to examine the role of malnutrition support, not only for pulmonary TB patients, but also their household contacts.

The study was undertaken in eastern India, with over 10,000 household contacts recruited from the predominantly indigenous and rural population. After randomisation, the household contacts of confirmed pulmonary TB patients received nutritional support (750 Kcal/day) in the intervention group, whilst in the control group only the TB patients received nutritional support. The intervention resulted in a 39% reduction in TB incidence, but it is important to be inquisitive when impressive numbers are stated. The figure was calculated by comparing the incidence rate per 100 person-years in the control (1.27 per 100 person-years (95% CI 1·00–1·61)) and intervention arms (0.78 per 100 person-years (0·64–0·96)), which resulted in an absolute difference in the incidence rate of 0.49, a more modest reduction. Another curious aspect of the results was the intervention had no impact on hospitalisations or deaths from other illnesses, although unfortunately that data is not provided for interrogation.

The generalisability of the study is limited. It is a single-country study focused on a predominantly rural population, with a disproportionately high representation from the indigenous population.  Nevertheless, its implications are clear, to reduce the burden of disease in impoverished populations, global health leaders and policy makers must recognise that healthcare needs to be holistic, and address the social determinants of health, to be truly effective.

A syndemic of inequitable gender norms and intersecting stigmas on condom self-efficacy and practices among displaced youth living in urban slums in Uganda: a community-based cross-sectional study

M Okumu, C Logie, A Chitwanga. Conflict and Health, August 2023

A lack of research examining sexual and reproductive health (SRH) exists in humanitarian settings, yet the globally displaced population is nearly 30 million, of which nearly 50% are under the age of 18. Displaced youth are particularly vulnerable to HIV and other STIs due to limited provision of SRH, higher rates of sexual violence and transactional sex. Condoms remain the most effective method to prevent HIV, however use is limited amongst 15-24 year olds. Lack of education is rarely identified as a contributor to low use. This cross-sectional study investigates the relationship between adverse sociocultural factors and condom use in displaced youth populations living in informal settlements in Kampala. Uganda was chosen for the study, as it hosts the greatest number of displaced persons (1.5 million) in sub-Saharan Africa, and high rates of HIV are reported. Data collection took the form of a questionnaire, with researchers identified and trained from within the displaced population and supported by the lead author. It suggests that inequitable gender norms, HIV and SRH stigma interact to reduce condom self-efficacy, which is a measure of an individual’s ability to consistently use condoms. This concurs with the researchers’ presented hypothesis and champions the use of multi-faceted HIV prevention programmes, not only providing SRH and HIV services, but tackling underlying gender inequality and stigma.

Methodology is clearly described alongside the data and regression analyses, but there remains significant limitations. Purposive sampling, used in this study, is pragmatic when attempting to capture data from a specific population, but introduces researcher bias. Snowball sampling and payment of participants compounds researcher bias with sampling bias. This paper is focused on displaced youth in Uganda based in informal urban settlements, it is not generalisable to the entire displaced population, which would require random sampling across multiple sites and groups.

Quick diversion: when reviewing studies that utilise surveys or questionnaires it is important to identify the ‘Cronbach’s alpha number’ for each. This is a statistical measure of the internal reliability of the questions. Below 0.5 is considered unreliable and the questions should be revised, above 0.7 is considered reliable. All surveys used in this study had a Cronbach’s alpha of >0.7.

Association between the quality of care and continuous maternal and child health service utilisation in Angola: Longitudinal data analysis

A Aoki, K Mochida, M Kuramata. Journal of Global Health, August 2023

Reducing maternal and child mortality is a key priority of the United Nations and World Health Organisation as set out in the UN Sustainable Development Goals (SDG number 3). Sub-saharan Africa remains particularly burdened with high maternal and child mortality. To address this challenge, Angola introduced the Maternal and Child Health (MCH) Handbook. This is a physical home-based integrated care record which documents maternal care, child development and immunisations. This was introduced alongside healthcare workforce education, implementation of protocols and increasing service utilisation. A randomised controlled trial assessed the MCH impact on care for pregnant women and mothers. The study presented here is a longitudinal analysis of data from both the original RCT, as well as data from the subsequent implementation study, covering a combined period of 16 months.

WHO defines quality of care as ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes’. Quality of care and its impact on service utilisation is poorly studied. This is the first study to examine quality as a facilitator to improve ANC patient engagement. The analysis examines differences between optimal and sub-optimal care with the hypothesis that optimal care should increase service utilisation. Optimal care was defined as 4+ ANC contacts, facility delivery, and optimal vaccinations for children at 6 months. Sub-optimal care was defined as any level below optimal care. As discussed earlier, the WHO now recommends 8+ ANC contacts, therefore what is presented as optimal care would actually be suboptimal according to WHO’s updated recommendation. It is important to note however that the updated guidance was released during the study period. The study included over 3000 pregnant women of whom over 70% received optimal care. Positive service user perception was statistically significantly higher when optimal care was delivered. Those populations who received suboptimal care were likely to be younger, from rural populations or ethnic minorities, and have limited education.

The major flaw in this study is that ‘optimal care provision’ was used as a proxy for good quality of care. This is a significant presumption. Quality of care should be patient-centred and the paper does little to explore how or why marginalised populations were more likely to receive suboptimal care. Moreover, it is a country specific study and different cultural and demographic factors would need to be considered if attempting to apply this study to other populations.

Effectiveness and safety of intermittent preventive treatment with dihydroartemisinin–piperaquine or artesunate–amodiaquine for reducing malaria and related morbidities in schoolchildren in Tanzania: a randomised controlled trial

G Makenga, V Baraka, F Francis et al. Lancet Global Health, August 2023

Prevention of malaria is multi-faceted, including chemoprophylaxis, personal protection measures against mosquitoes and mosquito control. Additionally, two malaria vaccines have recently been approved and are beginning to be delivered in certain regions across sub-Saharan Africa. The aim of this study was to assess the effectiveness of intermittent preventive treatment of malaria in school children (IPTsc) in reducing the burden of anaemia associated with malarial infection. Conducted in Northeast Tanzania, over 1500 children across seven primary schools were randomised in this open label study. Two intervention groups received either dihydroartemisinin–piperaquine or artesunate–amodiaquine four monthly for one year versus a control group which did not receive anti-malarials. Primary end-points were (at 12 and 20 months) change in baseline haemoglobin and incidence and prevalence of malaria.

Secondary end-points were anaemia prevalence at each 4 month visit and change in psychomotor and cognitive scores at 12 and 20 months. The study controlled for the potential effect of soil-transmitted helminths and schistosomiasis as a cause of anaemia through preventive treatment with albendazole and praziquantel according to national guidance. Stool samples were tested to ensure effectiveness of treatment.

ITPsc demonstrated a positive, albeit small, effect on mean haemoglobin levels. Both intervention groups demonstrated an increase of 0.5g/dL compared with the control, the clinical significance of this is unclear. Arguably, the more important finding was the reduction in prevalence of malarial parasitemia and the reported 20% protective effect of ITPsc against clinical malaria at 12 months. No effect of ITPsc on cognitive or psychomotor scores was demonstrated. Whilst robust, this study has one significant flaw, due to the Covid-19 pandemic nearly 1200 children missed visit four, which was crucial as visit four was conducted at 12 months and was one of the primary end-points. They state the analysis was still statistically powered, however missing nearly 80% of data at the primary endpoint of the interventional period is clearly problematic. Overall, the study demonstrates a pragmatic, community centred approach to reducing the burden of malaria. As such, WHO’s 2023 malaria guidelines advocate the use of intermittent preventive treatment for malaria in school aged children (ITPsc) in areas with high endemicity of disease to run alongside current school based health programmes such as mass treatment for soil-based helminths and schistosomiasis.

The post Evidence Explorer: Updates and news from the academic community, Autumn 2023 appeared first on Adventure Medic.

Jenny Bradshaw / FY2 Doctor / Newcastle

Founded in 2021, Endeavour Medical is a new provider of global health and expedition medical training. Their large faculty can boast of decades of experience in multiple extreme environments, including mountain, jungle, polar, and desert, and countless teaching and academic accolades. Endeavour Medical delivers an array of courses, including global health, sports medicine, wilderness, expedition, and leadership. The Altitude Medicine in Practice course, designed by Lucy Obolensky and Anna Shekhdar, runs once a year in March, and is based in St Jean d’Aulps in the French Alps. This year it was led by Dr Nathan Hudson-Peacock, an ED doctor with experience leading multiple high-altitude expeditions, and supported by Dr Francis Screech, a previous endeavour fellow and now an expedition medic.

Key Facts:

Duration: Seven days in total: one to two days of resort-based skiing, three to four days spent ski touring to and from a high mountain hut (conditions dependent). Arrival and departure days either side. Teaching interspersed throughout. 

Dates: Next course March 2024 (check website for dates)

Location: Base: an apartment in St Jean d’Aulps. High mountain huts: best available given the conditions.

Cost: Early Bird Price £1895 (before 1st December 2023) then £1995. Price includes course tuition, a ski guide, ski pass, all ski and safety equipment, accommodation in Morzine, accommodation and meals in mountain refuge.

Qualification/Accreditation: Course attendance certificate, worth 40 CPD points, and the opportunity to complete Supervised Learning Events (including case-based discussions and clinical evaluation exercises).

Delegates: Five Delegates (medics and non-medics welcome).

Prerequisites: A moderate level of fitness. Enthusiasm to learn about expedition medicine and global health. Beginner and intermediate courses available dependent on previous level of skiing/touring experience.

The Course

St Jean d’Aulps is easily accessible from the UK, with regular flights to Geneva followed by a less than two hour transfer to the town. The rest of the Portes du Soleil ski area, including the resorts of Avoriaz and Morzine, are all close by, and there are a multitude ski touring routes and mountain huts to stay in. Your guide for the week decides the best route and itinerary based on the mountain conditions at the time. Each day one of us was allocated as ‘medic of the day’ to get an idea of how it felt to be the expedition medic.

Example Course Contents

Lectures Include:

• Altitude sickness, HAPE, HACE
• Avalanche safety
• Hypothermia and cold injuries
• Expedition preparation and mental health
• Medical Kits
• Expedition Sustainability

Practical Content:

• Ski touring skills and ski technique optimisation
• Trauma and Primary surveys
• Packaging casualties
• Avalanche rescue
• Rope skills and crevasse rescue
• Use of crampons and ice axe

Delegates arrived on the Sunday and settled into the apartment, with dinner made for us by the Endeavour faculty. We were met on the Monday morning by our guide for the week, Guillaume, who is president of the high mountain guides of Portes du Soleil and is accredited by the International Federation of Mountain Guides Associations (IFMGA). After picking up our ski touring gear we headed off for a day on the slopes of Avoriaz. This not only allowed us to get our ski legs back, but also to become accustomed to the touring gear for those not familiar, with and get personalised tips on how to improve our skiing technique from Guillaume. A highlight of the day was Guillaume talking us through the seven different types of snow, and which ones carry the highest avalanche risk. We enjoyed a picnic lunch in the sunshine, chatting about what to include in the daily medic brief expected during expeditions. In the evening, informative and hands-on teaching sessions were led by Nathan and Francis, covering airway management, major trauma, and splinting limbs. We learnt how to expertly package a casualty in a “burrito” to ensure they are kept warm and dry, before perfecting this technique on each other.

Ski Tour to Le Refuge des Prés

Tuesday saw us setting out for the start of our ski touring expedition. Unfortunately, the weather conditions are not controllable, and the plan for a hut to hut trip had to be adjusted owing to forecasted snow and rain storms leading to a dangerously high avalanche risk. This was no trouble for our faculty who took it in their stride and found an excellent hut that would remain safe, Le Refuge des Prés. We set off from the valley and, after touring somewhat unconventionally over, at times, a mixture of ice and mud, made it to the hut in time for a beer and cake as the forecasted snow started to fall. We had a practical session on the use of avalanche safety equipment before our evening finished with more lectures about altitude medicine over a delicious, hut-cooked dinner.

On Wednesday morning we awoke to snowy scenes. Guillaume led us out on a morning ski tour to a nearby col, from which we skied through powder back to the hut for lunch. In the afternoon we headed out for an afternoon tour. On our return we were surprised with a scenario. Francis had been caught in an imagined avalanche and we needed to find him using our transceivers, assess him with an ABCDE framework, and carry him back to the hut to avoid him becoming more hypothermic. This was a great way to put into practice the skills we had learned so far, and the teaching continued with a debrief and discussion. Due to Friday’s forecast being suboptimal, we made plans to leave the hut a day early, and tucked into well-earned cheese fondue to celebrate our final night in the hut.

On Thursday the sun was unexpectedly shining, but we could see evidence of avalanches that had happened overnight. This experience helped to put into perspective the importance of all that we had learned so far. We headed out for a tour with low avalanche risk which would take us back to the bottom of the valley, stopping on route for an excellent practical session on rope skills and crevasse rescue, led by Guillaume. As we were approaching the van, another surprise scenario saw us assessing and treating Francis for high altitude cerebral oedema (HACE). We had dinner out at a local pizzeria in St Jean d’Aulps, and reminisced over our incredible experience in the mountains.

On our final day, we were glad to be off the mountain as we woke up to a thunderstorm. Luckily this cleared quickly, and we discovered that at the slightly higher altitude in Avoriaz, the rain had fallen as snow. We were treated to a resort powder day. Guillaume showed us all the best places to go ‘off-piste’, and we practiced our deep powder technique. This was, of course, interspersed with a final scenario: we discovered a trauma casualty (Nathan) who had sustained a crampon inflicted arterial injury and a femoral fracture. We worked together as a team to assess and manage this scenario and felt much more confident after the previous scenarios and debriefs. We finished the week with a final dinner in Morzine, before setting off in different directions of onward travel. We all felt exhausted but inspired, and glad to have met a group of such intrepid, like-minded people.

The Verdict

We would highly recommend this course to all those interested in altitude medicine, who enjoy ski touring or have a strong desire to learn. The course material was interesting and focused, and the ability to apply it immersively, in a practical setting, was fantastic for consolidating our learning. The faculty were all incredibly knowledgeable. We felt safe in their hands at all times whilst they ensured that we all had an excellent time in what were challenging weather and snow conditions.

Top tips:

• Having an intermediate level of ski ability and a moderate level of physical fitness prior to the course will enable you to get the most out of the skiing side of the trip.
• Watch the pre-course lectures online prior to attending, as this means that you can have more in-depth discussions surrounding the topics during the course.
• Pack light. Ski touring is heavy work.
• Remember to log the teaching and CPD points in your portfolio.

To find out more about Endeavour’s winter Altitude in Practice course in Morzine, see Endeavour’s website

Photos courtesy of Dr Persia Bowater

The post Endeavour Medical Hut to Hut Ski Touring and Altitude Medicine in Practice Course, St Jean d’Aulps, France – Review appeared first on Adventure Medic.

Emergency medicine trainee, Adventure Medic editor, and taking-time-out enthusiast Dr Jake Adams takes us through his experience of stepping off the treadmill. From ad-hoc locuming to unusual clinical fellowships, he provides a comprehensive guide for anyone considering taking an ‘FY3’ year in the UK.

After five or six years of university and two years of foundation training, it is unsurprising that many junior doctors take time out of training. A break from the hoop-jumping, the relentless rota, or a voyage of self-discovery: there are countless reasons why people choose this route. Whatever the reason, taking a break is a fantastic way to regain autonomy and headspace, and capitalise on the ever-growing opportunities available both inside and outside of medicine.

The number of doctors taking an ‘FY3’ year has risen steadily from 17% in 2010 to 65% in 2019. Few seem to regret their time out and 93% return to training within five years, hopefully refreshed, recharged, and re-enthused. My own time out was not only fun but also allowed me to return to a career that I had chosen, rather than one that I had fallen into at 17 years old.

It is very easy to take time out, simply don’t apply for a training programme. The more difficult task is planning your time. When thinking about beginning something, it is often helpful to start at the end. As the British Medical Association puts it, ‘Will you be better equipped at the end of your time out than at the beginning?’. It is not difficult to answer this with a resounding yes: many doctors return to training with more experience, better qualified, and, hopefully, reinvigorated. This article provides a starting point for those planning their time out, from exciting opportunities to much less exciting practicalities.

The Case for Remaining in the UK

If the yearly GMC survey is to be believed, many FY2s will spend their year applying for visas, planning either temporary or permanent ventures into the Southern Hemisphere. For more information on packing up your stethoscope and your sun cream, Adventure Medic has guides on moving to Australia and New Zealand. The benefits of remaining in the UK, however, are plentiful. For most, it will mean no immigration bureaucracy or complicated medical council paperwork, a process that is not just painstaking but also extremely expensive. Working in the UK will also appeal to the climate-conscious, and allows many to remain close to their support networks. In addition to this, there are now a huge number of more ‘unconventional’ work options within the UK, with many NHS trusts recognising the value of specialised junior fellow years. Trusts are also increasingly keen to sweeten these deals: many employers now offer adventure-friendly options such as funded qualifications, out-of-hospital experience, and annualised contracts.

Logistics

• Indemnity – Doctors must always have legal cover that is appropriate to their stage and responsibilities. Make sure you update your provider regarding any changes to your address or job. See our guide to expedition indemnity here.
• NHS Pension, National Insurance, and Student Loan – for those working for staff bank or in a contracted post, these will continue to be automatically debited from your pay cheque. Otherwise, it is the employee’s responsibility to ensure that these are paid (if applicable) and you may need to submit your own tax returns. With student loan repayments in particular, you must arrange to continue your repayments if you are working abroad. Remember also, that all doctors are eligible to claim tax back on employment expenses, including college fees, GMC fees, and exam fees.
• CV – It is a good idea to have an up-to-date CV ready to go and this can make all the difference when opportunities pop up unexpectedly. CV writing is a difficult skill and it is worth spending some time ensuring that yours is concise, error-free, and tailored to the opportunities you are applying for.

UK Employment Options

It is remarkably easy to forget that there is a whole world of work outside of clinical medicine. Those deciding to venture into a different field undoubtedly bring back a wide range of skills and experience. Doctors choosing this path should plan carefully regarding their GMC status (details below). The other option is to continue to work within medicine. In this case, there are two main choices. The first choice is whether to work abroad or in the UK. The second choice is whether to take a contracted post or to work as a locum, be that via an internal bank or an agency.

Loving that Locum Life – Staff Banks v.s. Locum Agencies

For those wanting to maximise their earnings, locuming is very attractive. Pay varies in a supply-demand fashion across different trusts. The BMA suggests £70-80 per hour as a standard rate, but as a rough guide £40 per hour is common. Working as a locum usually pays more and offers autonomy over shifts, ensuring maximal flexibility. That said, extra pay comes with extra risks. Locum doctors are not entitled to annual leave, sick leave, study leave, or a study budget. There is also no guarantee of work, and work that is advertised may be last-minute cover for unsociable shifts.

For some, the familiarity of colleagues and systems makes working via their hospital staff bank an attractive option. Employers will usually give priority to doctors on their staff bank as it costs them less than agency fees. The other, potentially more lucrative, option is to use an agency. This can result in quicker turnarounds for payment, and sometimes a higher wage. Agency work usually requires more movement between trusts and departments, so for those with a dread of changeovers it may not be ideal. With both options, it is important to keep track of hours worked, agreed rates, and what has, or has not, been paid. Mistakes happen and if you, the employee, do not spot them, then in all likelihood, no one will. It is also worth remembering that after 12 weeks of work with the same employer, locum workers are entitled to the same benefits as other employees, including receiving ‘rolled-up holiday pay’.

For She’s a Clinical Fellow

Clinical fellow roles have exploded in both availability and popularity over the last few years. They are a great choice for hospitals, as they are cheaper than paying locums, but also for doctors as they often come with extra opportunities. Clinical fellow jobs have many advantages; they offer the stability of rostered shifts, a guaranteed and predictable pay cheque, annual and sick leave, and the consistency of working within a set team or specialty. Typically, fellow jobs are six or twelve months long, allowing flexibility to combine work and travel. They offer valuable opportunities to try out specialties and gain experience that will pay dividends come interview. There are also many themed fellow jobs, with opportunities including expedition medicine, global health, trauma, and pre-hospital medicine. A common model is for employers to offer 80% clinical time with 20% time allocated to a specialist interest, decided by the trainee. These are ever-evolving and will only become more plentiful as trusts face more competition for employees.

Apply and Defer

Depending on the specialty, and who is leading recruitment, it can be possible to defer the start date of a training programme by six months. This could be the perfect option for doctors who know what training job they want to do but want a short break before starting.

LAT but not Least

An alternative to clinical fellow posts is taking a Locum Appointment for Training (LAT) job. While seemingly very similar to a clinical fellow role, they are recognised for training so the time in these posts can ‘count’ towards training if you want it to. These posts are an excellent option for doctors who know what their final specialty will be, but don’t want a training number yet. LAT jobs allow more choice in location, and offer a degree of ‘try-before-you-buy’ for training programmes.

Expedition Medicine from the UK

The world of expedition medicine can seem like a difficult area to break into. However, there are many ways to gain experience and get your foot in the door. Taking time out after FY2 offers a great platform to branch out into the expedition world. What’s more, these experiences will all count towards appraisals and offer something different to showcase at interviews. The UK makes for an excellent base for this. A useful place to start is by looking into courses and qualifications that align with your areas of interest. A list of courses including diplomas, masters, and short-course options can be found here.

Courses

There are many courses on offer from a variety of different providers. Adventure Medic is full of course reviews to help guide future participants and has a helpful calendar too. Courses can be expensive, but provide a good grounding in expedition medicine, usually with training in the field. Expect to have a tiring but fun experience, make some great new contacts, and become more credible as a prospective expedition doctor.

Diplomas

Diplomas are a highly useful way to spend all the new free time that time out of training provides. There are many options, with courses in expedition medicine, disaster medicine, and global health medicine proving very popular. It is worth noting that some clinical fellow jobs will contribute to diploma costs. As the expedition medicine field gets more competitive, formal qualifications will be increasingly important to make applicants stand out.

Charity Expeditions, Sports and Event Medicine

Charities offer a worthwhile and interesting introduction to expedition medicine. The general advice is to email organisations and see if they are hiring – another reason to have an updated CV. There are a wide range of options, many of which require a financial contribution.

Event medicine and sports medicine also offer an excellent way to build out-of-hospital experience. As well as networking opportunities, these jobs offer exposure to challenges such as pre-planning, resource management, and real-time medical problems – experience that is very transferable to expedition work. Again, there are many different companies, both local and national, that offer event medical cover. The best way to get involved is to contact sports teams directly or find a doctor who is already involved and ask them.

Humanitarian Work

Volunteering for NGOs and humanitarian causes is a meaningful way of gaining out-of-hospital experience. Though most placements will not be in the UK, many doctors both in and out of training find these placements eye-opening and purposeful. There are a plethora of charities and organisations that will be keen for new enthusiasm and energy. Prospective volunteers should ensure they know what their duties will be, what support, both personally and clinically, will be available, and check that their indemnity is valid. The BMA has a very useful guide here.

Returning to Training

General Considerations

1. It’s worth noting that the proudly earned certificate awarded for passing foundation training, the FACD 5.2, is only valid for three years. If foundation graduates are out of training for longer than this, a consultant who has supervised them for at least three months must fill in a Certificate of Readiness to Enter Specialty Training(CREST) form found here.
2. Keep up to date with your intended specialty’s application matrix. Some programmes mark candidates down if they have too much out-of-training experience in certain fields.
3. Be prepared to justify any gaps in training and employment. Most employers and interviewers will look favourably on career breaks; they are something different to talk about and can make candidates stand out. Whether it be for courses, qualifications, personal development, or looking after your mental health, the reason will rarely matter as long as you are prepared for these questions.
4. Many specialties can offer a return to work period, although it might not be offered automatically. This provides greater support and supervision to help trainees return to clinical work if they’ve been away for more than three months.

GMC Licence

There are three options to choose from with more detailed information available here:

1. Continue to hold a full licence to practise. Doctors must continue to pay their GMC fees and are advised to organise a yearly appraisal. For those who will work in the UK, this is the right option.
2. Give up your licence to practise but continue to be registered with the GMC. This allows doctors to continue to practise medicine abroad, but not work within the UK. This is a good option for those working abroad for an extended period, or those choosing to take a complete career break. Doctors continue to pay a reduced annual fee to the GMC, and the GMC will issue a certificate of good standing to other medical regulators. It can take some time to regain your licence to practise and doctors should anticipate this when returning to UK medical practice.
3. Give up GMC registration. This is also known as voluntary erasure. Think carefully about this as it is intended for those who don’t ever want to practise medicine in the UK again.

Appraisal

The GMC recommends an annual appraisal for every doctor with a licence to practise. This is an annual meeting between a doctor and a colleague who has been trained as an appraiser. Those working within a hospital should be allocated an appraiser by their department. Locum agencies usually organise appraisals internally as part of their service, but it is worth clarifying this.

Appraisals are a process of facilitated self-review supported by information gathered from the doctor’s full scope of work. Aprasiees are expected to reflect on their practice, identify learning needs, and demonstrate that they are fit to practise. In reality, following the requirements of FY2 should be a reasonable blueprint to pass an appraisal. Some trusts will share access to an e-portfolio, otherwise it might mean a return to paper forms. All of the information is available here but it is useful to consider the following areas when preparing for an appraisal:

• Personal Development Plan (PDP) – setting up a PDP with a couple of achievable points makes the appraiser’s job easy.
• Continued Professional Development (CPD) – RCEM for example, suggests getting 50 CPD points per year which equates to an hour a week of podcast listening or journal reading. Exams, courses, and conferences all count too. Different specialties will offer different advice, but the important thing is to keep a record of your learning.
• Logbook – In some specialties, keeping a logbook is essential. There are a variety of ways to facilitate this with many choosing apps or online platforms for ease of use. 
• Reflections – It is important to show evidence of your reflective practice, particularly with regards to any significant adverse events, complaints, or near-misses that may have occurred.

Your Own Adventures

Sometimes the best expedition experience is an independently organised personal adventure. Planning a big trip offers plenty of life lessons, and just because it was technically a holiday doesn’t make it any less valuable to talk about at interviews. The UK can be easy to overlook when searching for adventure but offers a plethora of outdoor opportunities in an amazingly varied landscape. Whichever path you choose, taking time out is a great chance to reconnect with friends, hobbies, and general life. It emphasises the perks of working as a medic, demonstrating just how flexible, varied, and rewarding medicine can be. However you decide to spend your time out, have a wonderful time.

Useful Resources

https://www.bmj.com/careers/article/bmj-s-guide-to-planning-your-f3-year

https://www.holtdoctors.co.uk/blog/the-ultimate-guide-to-planning-your-f3-year

https://www.mindthebleep.com/how-to-plan-your-fy3/

The post Taking Time Out After Foundation Training: UK-Based Options for Adventurous Medics appeared first on Adventure Medic.

The Deepest Breath

Where: Netflix

About: This documentary takes a deep dive into the freediving community. As well as introducing the sport, it follows the relationship between record-breaking freediver Alessia Zechhini and her safety diver partner, Stephen Keenan.

Why: The intense filming really brings home the scale of what these athletes are achieving, and the deadly risks they take with every dive. I caught myself several times literally holding my own breath! Whether or not you like freediving, it’s hard not to be infected by their passion for their sport. There is an almost gladiatorial intrigue, bordering on the macabre, as you watch them push their physical and mental limits. During the documentary, you also witness the development of an extraordinary relationship between two people who are both passionate about taking freediving to the next level. Through Stephen, a renowned safety diver, you also gain some insight into the medical team and how they attempt to keep people safe during freediving competitions.

Book:

A Wilder Life

About: Dr Joan Louwrens is an African medical doctor with additional qualifications in family medicine, anaesthesia and tropical medicine. She swerved onto an unconventional medical path that led to her working across all seven continents, as well as some oceans in between.

Why: This book is a must-read for anyone who is interested in practising medicine outside of the safe environment of their hospital or GP practice. Dr Louwrens writes about her adventures practising medicine in places ranging from remote islands you have never heard of, to the polar regions of the Arctic and Antarctica. She has the ability to write in a vulnerable fashion, reflecting on her decision-making in difficult situations, and the burden of responsibility when you are the only doctor on-site. You can really feel her passion for adventure medicine through her compelling stories. In fact, it’s hard not to get inspired to plan your next trip and get out there!

Podcast:

Medicine on the Frontier (S1E1)

Where: Spotify

About: Luc Woodall Gillard and Mat Howes speak with Dr Rebecca Boys, freshly returned from working in Antarctica for 18 months with the British Antarctic Survey Medical Unit.

Why: Dr Boys talks about how she got into pre-hospital and expedition medicine. During the conversation, she explains the application process, and also how she prepared for her role as an expedition doctor. They discuss what outdoor skills are essential, as well as less obvious questions, such as how do you prepare to take on the role of nurse, radiographer or dentist?

It’s hard not to get swept away as she tells stories about her incredibly varied work, including in South Georgia, on the ship RRS Sir David Attenborough, the British Antarctic Survey station and being the co-pilot of a Twin-Otter aircraft. However it’s not all adventure and excitement. She takes care to underline the less pleasant aspects of the job during the podcast. From working during the COVID pandemic, to living through six weeks of darkness, Dr Boys talks about how she coped with the responsibility of taking care of her group in a remote and inhospitable area.

In summary, listen for a reflective and informative insight into what it’s like to be an expedition doctor in a remote area.

Watch this space to get your quarterly AM Team recommendations. We would also love to hear your suggestions!

Please send them to: rogier@theadventuremedic.com

The post AM Team recommendations October 2023 appeared first on Adventure Medic.

The process of acquiring indemnity or insurance for expeditions has become increasingly opaque. Whilst medics are still gaining indemnity or insurance without issue, anecdotally the pandemic brought expedition work under scrutiny and refusals are occurring. As individuals who are passionate about adventure medicine in all its forms; Adventure Medic has produced this guide to help with the indemnity process. This is the second in our ‘Masterclass’ series designed to help practicing expedition medics navigate some of the roadblocks we all encounter.

Whilst this is UK-focused, it highlights considerations relevant to those worldwide. Be mindful that this guidance is dynamic and specific advice will likely change. Please continue to enquire with indemnity organisations and let us know if updates are required.

What is indemnity?

Indemnity is designed to provide financial protection to medics against legal and compensation costs that may arise out of claims due to negligence, mistakes, or malpractice. In practice, on expedition, if you make a clinical call and that patient comes to harm because of this, they can claim against you. An extreme example would be allowing a patient with overt signs of heat illness to continue to run a jungle marathon, who later collapses and has a seizure.¹

In the NHS, doctors’ indemnity is provided through clinical negligence schemes.²

“Under the law, a doctor must have cover against liabilities that may be incurred in practicing medicine having regard to the nature and extent of the risks. The type and level of insurance or indemnity a doctor requires depends on factors including where a doctor works, whether they are employed (and, if so by whom and for what services) or self-employed, and the nature of work they do.”

Often this indemnity is extended through an additional policy with a medical defence organisation. The defence organisation can assist with a wider range of legal and ethical issues relating to professional practice. The scope of this is more extensive, for instance, the Medical Protection Society states members can request assistance with;

“clinical negligence claims, complaints, medical and dental council inquiries, legal and ethical dilemmas, disciplinary procedures, inquests and fatal accident inquiries.” ³

For GPs state-backed indemnity provides indemnity for clinical negligence claims arising from primary care within the NHS in England or Wales. The scope of this is, again, specific and does not extend to other areas such as guidance with coroners’ inquests.⁴

How does indemnity compare to insurance?

Medical malpractice insurance is usually provided as a stand-alone policy and is tailored and specific to the job (e.g. an expedition medic role).⁵ It usually comes from a commercial insurance company unlike indemnity which is provided by membership-based not-for-profit medical defence organisations. Further information can be found at this link.

Why do I need indemnity or insurance on expeditions?

Expedition medicine and voluntary work often cover areas of practice extending beyond those specified in day-to-day indemnity protection. As such, expedition medicine and voluntary work fall under the remit of private practice. They therefore require additional indemnity or an extension to existing protection. This is true regardless of whether the work is in the UK or not, as for many hospital doctors their indemnity confines their work to within their state (e.g. NHS) hospital in alignment with their job specification.

Failure to acquire indemnity or insurance could lead to claims that may not be covered. This could impact practitioner finances, security, and medical registration significantly. This is often cited as one of the arguments that supports fair remuneration for doctors on expeditions.

Adventure Medic provides further information on the remit of an expedition medic and why this is pertinent here. Adventure Medic is also currently producing an article on pay for expedition medics – please look out for this publication shortly.

How do I acquire indemnity or insurance?

Acquiring indemnity or insurance can be a complex process and it is advisable to start early. This ensures there are no surprises and it allows you to confirm with the expedition company that you can cover the trip. Quotes acquired can be held on file by some companies for purchase at a later date.

Doctors

Defence unions
Indemnity covering expedition work can be an extension of indemnity protection you already hold or obtained through a new provider. This is achievable with the following not-for-profit medical defence organisations:
– Medical Protection Society – MPS
– Medical Defence Union – MDU
– Medical and Dental Defence Union of Scotland – MDDUS
The MDU has advised that all applications will be considered individually. They will endeavor to cover expedition medics where possible. They have offered this article to any seeking MDU indemnity.

Expedition company
Alternatively, the expedition company or other companies supplying healthcare practitioners may be able to subcontract the practitioner covering them under their own insurance.

Insurance providers
Insurance for expedition cover and approaching insurance companies directly is an option where other avenues have failed. Two companies which can provide this are:
– Saepio
– Beazley – contactable directly or through ADF insurance

Societies
Additionally, gold members of the British Mountain Medicine Society can access indemnity or insurance as part of their membership provided they:
–  Have paid for ‘gold membership’
–  Hold the Diploma in Mountain Medicine (DiMM)
–  Cover has been confirmed with the society
–  Are not undertaking an expedition in the USA

Gold members must complete a short declaration form which is sent to the insurers to confirm their eligibility and to grant indemnity insurance. Silver members can also access indemnity insurance, but the applications must be individually vetted to ensure their experience is adequate. Prices can currently be found here.

There is some consideration of equivalent qualifications to the DiMM. Recently the Diploma in Expedition and Wilderness Medicine has been authorized as holding equivalence to the DiMM by the Society and therefore is eligible with gold membership for indemnity insurance. For other qualifications, the final decision lies with the BMMS underwriters.

Paramedics

For paramedics we have been told cover is often automatic because the remit of their work allows them to work in pre-hospital environments. This is mostly provided by the College of Paramedics. Further information for expedition paramedics can be found here. It is worth being mindful that a pre-hospital environment in the UK streets may not hold equivalence with that in a jungle or polar environment (for example). Aim to clarify with the college your cover and disclose trip details before departing.

Nurses and allied healthcare practitioners

Our insight into indemnity for nurses and physiotherapists is currently lacking. If you’d like to share this information and support Adventure Medic in supporting your fellow practitioners, do get in touch.

How do I ensure the policy covers what I need?

It is essential to thoroughly read and confirm the protection offered will cover the remit of your work. For example; some may state that protection ends on the last day of your expedition and therefore claims falling after this are not covered! Clarify this fully with the company to ensure there are no exceptions. Check if the cover includes your pre-screening – which will fall prior to the start date of the expedition.

How do indemnity or insurance providers assess if they can provide cover?

After providers have collected details from you they make an assessment called the ‘rating factor’ based on the activities and details given. This is dynamic and can change throughout the year. For instance, since COVID-19, medical cover on seafaring vessels that cross oceans and are not within easy reach of land has increased in risk. The new rating factor means many indemnity organisations or insurers will not provide indemnity or insurance. However, where your application has been made to an insurer, rather than an indemnity organisation, these are businesses. They may adjust rating factors and risk assessments if they see demand and that there is money to be made. Never be shy about asking for quotes as requests can alter the market for the good of all.

If your case is being deliberated or is complex, which, often expedition requests are, then it may be sent to the underwriters for the organisation. They will make a case-by-case assessment of whether they feel they can offer protection for the role. They may request additional information to ensure they have a full understanding of the role you are undertaking. In some organisations they are not directly contactable over the phone and prefer to come back to you via email. They will often offer the final say on whether indemnity is provided.

Beware; this process can take 2-3 weeks so it is strongly advisable to try and acquire a quote for indemnity or insurance well in advance of your trip. This can be held on file and paid for later. It also allows time to approach other organisations if adequate protection cannot be provided.

What things will the indemnity providers or insurers need to know to assess me?

Short list

The information which indemnity providers or insurers will require to assess eligibility:

• Destination
• Dates of trip
• Organisation you are working with – charity, institution, company, hospital, etc
• Details of your seniority, experience, training, or relevant qualifications
• Whether you have shared or overall clinical responsibility
• Will there be any supervision of the role?
• Is this supervision remote or on-site?
• A brief description of your work and role on the expedition
• Whether the role is paid (and if paid how much)
• A brief description of those you will care for (nationalities, ages, celebrities, pregnancies)
• Any indemnity or other insurance you already hold, or if any indemnity or insurance is provided by the event organiser/company

Destination

The legalities of what cover can be provided and in what locations are nuanced. By and large a license to practice in the UK is accepted by indemnity organisations and insurers as a sufficient qualification to allow you to cover your own group on expedition. However, different countries have different legal, insurance, regulatory, or licensing requirements to practice in their countries. Ideally, these should be known. It is essential to explore this where your work includes any of the following:

• Involves caring for the local population
• Is humanitarian work
• Is officially paid (as opposed to voluntary)

This is illustrated by the arrest of Sarah Kemp,⁶ an Australian doctor who was working in a travel clinic in Nepal attending to foreign diplomats, tourists, and aid workers. Allegedly she was arrested along with 17 other foreign doctors as she did not hold a license to practise medicine within Nepal. Following this one charity operating in Nepal, the International Porter Protection Group (IPPG), began registering its volunteer doctors in Nepal. A process that initially took 35 days. This is a lengthy time to build into a trip if required to safeguard your work and is on the shorter end of the spectrum with some registrations taking 3-6 months.

Different countries may have different legal, regulatory or licensing requirements that need to be met to allow a doctor to practice medicine in that country. It remains the medic’s responsibility to ensure that they meet any such requirements. For example, if insurance is a legal requirement in the country you are travelling to (rather than discretionary indemnity), you may be advised to seek an alternative provider.

Provider specifics
At the time of writing  MDDUS specializes in the separate legal jurisdictions that exist within England, Scotland, Wales, Northern Ireland, the Channel Islands, and the Isle of Man, and does not offer membership benefits outside of these jurisdictions, other than in respect of GoodSamaritan acts, humanitarian work and limited voluntary or expedition medicine. Upon request and subject to underwriting review, membership can be extended to provide access to indemnity for bona fide humanitarian work. This work can take place globally but access to indemnity is provided on the basis that claims must be brought in a court within the UK, Channel Islands, or Isle of Man.

Saepio requires a pre-agreement to provide cover in the USA and Canada.

There may be some flexibility in registration requirements where you work in a supervised or ‘fellowship’ position under the guidance of a senior in-country doctor who can sign off your practice. This must be clarified with the provider of the indemnity cover.

Duration of trip and cover

For some indemnity providers indemnity costs will vary based on whether the medic has overall clinical expedition responsibility or shared clinical responsibility. The former is considered higher responsibility and risk. Cost is mostly decided on a case-by-case basis, and due to fluctuations organisations could not offer further insights with long-term accuracy.  

It is important to clarify the duration of protection required for the indemnity or insurance, as different companies may have different limits. Most indemnity organisations offer occurrence-based protection. MPS members for example:

“remain entitled to request advice and assistance for any matters arising from their expedition work at any time, even if they have since left MPS membership or ceased practicing.”

Saepio covers a year post-expedition by default but can extend this on asking.

This is not true of all providers and the utility of a policy that ends on the day your trip finishes is debatable!

Experience and responsibility

These are both extremely nuanced. Some indemnity or insurance companies more readily understand seniority in terms of career progression or profession. For example; a registrar doctor may be treated as more independent and experienced in seniority even if working with a senior prescribing nurse who has done multiple expeditions and has multiple expedition-related qualifications. This is because these qualifications are not always considered by indemnity providers.

Some organisations prefer to consider cover based on the number of years post-graduation and will set a threshold before you can be considered for more senior roles such as overall clinical responsibility.

Provider specifics
MPS advises that it reviews each application for indemnity for expeditions on a case-by-case basis and takes into account multiple factors, including clinical experience, relevant training and qualifications, and level of responsibility/supervision.

One organization, the MDDUS, advises that for UK-based expeditions it would consider work on a case-by-case basis looking at the trip, and the practitioner’s qualifications and experience. This usually requires referral to the underwriters – the process for which is detailed below.

Lastly, Saepio will utilise your CV to make a personal assessment of your request.

Supervision

For some practitioners, supervision may be required to obtain indemnity or insurance. This varies on a case-by-case basis and may require a supervisor to be sourced of a certain seniority. This person often needs to be sourced by the practitioner if one is not immediately linked to the role. The supervisor may be remote or on-site depending both upon what the indemnity or insurance provider requires, and what the employing company can subsidize. Ensure, if you are sourcing your own supervisor, that they have full awareness of what you are doing, are happy to be on-call to advise at all hours, and feel comfortable advising within the remit of your expedition. For instance, an altitude expedition will benefit from a supervisor who has altitude illness experience.

Nationalities

Some indemnity or insurance companies will not indemnify care provided to attendees of certain nationalities. Usually, this pertains to citizens of countries where legal cases against practitioners are common and expensive, for example, the USA and Canada. This often requires clarification with the provider but can be an expensive minefield.

Most policies contain a clause that navigates this by stating that indemnity or insurance will be provided only if claims are made in the country of “ membership.” This refers to the country in which a member holds membership for the purpose of their regular medical/clinical practice.

The nationality of the expedition company should not affect the support indemnity providers can deliver, so long as the claim is made in the practitioner’s home jurisdiction/country of core membership.

If a claim is made out of the practitioner’s home jurisdiction then some indemnity providers will assist in moving it to the home jurisdiction. Not all will do this.

Special populations

MDDUS and BMMS memberships advise that they can indemnify for the care of participants of any age. Saepio will make an assessment based on ratios – if your trip is predominantly children, it is unlikely to be covered, but if the trip is predominantly adults (60:40) it may be covered. 

Pregnant women and high-profile participants may not be covered by policies or will incur vastly increased costs.

Dual insurance

If the expedition company or your own insurer is already providing insurance then this may invalidate further policies which are taken.

Subcontracting

If you are working for another company, for instance, a production company that has subcontracted you on behalf of another provider, then you need to ask your indemnifiers if they offer ‘company indemnity to principle’. This determines if your insurance for negligence will extend to the company subcontracting you. If it will not, then technically the company you are working for could also sue you for negligence if you leave them exposed.

Additional questions may be asked:

• Will the work involve any new or experimental treatment?
• Will the work involve prescribing any drugs off-license?
  – For instance penthrox in under 18s – widely used on expeditions but not officially licensed
• Confirming if you will be undertaking any of the following:
  – An expert demonstrating a procedure for the benefit of local practitioners
  – An expert providing treatment to a patient or patients that would not otherwise be available in that country
  – Cosmetic medicine/surgery
  – Highly paid work in a developed country
  – Neurosurgery
  – Obstetrics
  – Orthopaedics
  – Teaching/educational work
• Confirming that local indemnity cannot be sourced in the destination country
• Providing a CV
• Are any of your patients or clients elite or professional athletes?
• Are any of your clients high profile? – these participants can be especially hard to cover

Are there limits and excesses to this insurance?

Often excesses are not a feature of indemnity, but do ask as one insurance provider has an excess of £1000 per claim. 

Limitations should be specified by the provider. For instance, an example would be: :
– Indemnity covers only members of the organised group you are accompanying
– Assistance is provided only with claims brought against you in your home jurisdiction
– You must act within your competency. For assessing this and an expedition opportunity please see here. (hyperlink article for assessing an expedition opportunity)
– You need to meet legal, regulatory, or licensing requirements to practice in the country you are travelling to
– You are not managing any declared pregnancies

Can medical directors be covered?

Some companies (e.g. Saepio) will grade cover for medical directors based on the trip and rating factor and can supply it on a case-by-case basis. Other organisations should be contacted directly with inquiries. 

Are local guides and people employed by the expedition company covered?

The assumption is that anyone who is present solely for the purpose of the expedition should be counted as part of the team and therefore covered under indemnity.⁷ Saepio and MPS confirmed this is their policy.

What if I have been refused indemnity insurance?

Previous refusal for trips should not stop you from being granted expedition indemnity insurance from the same company in the future. Nor should it prevent you from approaching other companies for quotes.

Provider specifics
However, some companies, such as MPS, require you to have held core membership with them for 6 months prior to acquiring expedition protection. MDU, MDDUS, and BMMS also require membership (BMMs members must be gold). Some organisations will also require disclosure if you have had previous refusals. Saepio does not require membership and is happy to consider all requests.

Where these usual avenues have been exhausted, exploring subcontracting or private quotes for insurance through Beazley or ADF insurance can reap rewards.

Summary

The world of indemnity and insurance can be complex and a headache for many expedition medics. We hope this guide will help you navigate indemnity and insurance in the future to safeguard your own practice in adventurous medicine. Please utilise it and share it widely with others who could benefit. Above all, don’t be afraid to approach indemnity organisations and private insurers and ask. Assessments for indemnity are ever changing, and requests are often considered on a case-by-case basis. Your request may open doors for others in the future. 

We are acutely aware that information regarding indemnity and insurance for humanitarian work, dentists, nurses, and physiotherapists is lacking, although, many indemnity organisations are willing to provide protection for these roles.  As people who are passionate about protecting our future in this field, if you have found any information you feel would be useful to the community, please do get in touch.

References

1) Insurance, indemnity and medico-legal support. General Medical Council.
Available from: https://www.gmc-uk.org/registration-and-licensing/managing-your-registration/information-for-doctors-on-the-register/insurance-indemnity-and-medico-legal-support
Accessed [26/03/2023]

2) What is indemnity insurance? Securenow_insuropedia
Available from: https://securenow.in/insuropedia/what-is-medical-indemnity-insurance/
Accessed [26/03/2023]
Updated 28/11/2022

3) About us. Medical Protection Society. Available from:
https://www.medicalprotection.org/uk/about
Accessed [ 26/03/2023]

4) State-backed indemnity. The Medical Defence Union
Available from: https://www.themdu.com/mindthegap#:~:text=What%20does%20the%20state%2Dbacked,duties%20in%20England%20and%20Wales.
Accessed [26/03/2023]

5) Medical Defence Organisations vs. Insurance Companies for Medical indemnity – Which is right for you? Medicas
Available from: https://www.medicas.co.uk/resources-guides/medical-defence-organisations-vs-insurance-companies-for-medical-indemnity-which-is-right-for-you#:~:text=One%20of%20the%20main%20disadvantages%20of%20medical%20malpractice%20insurance%20is,need%20to%20make%20a%20profit.
Accessed [26/03/2023]
Last updated 1/3/23

6) Australian doctor Sarah Kemp arrested in Nepal for practising without proper accreditation. Heanue S,
Available from https://www.abc.net.au/news/2018-02-01/australian-doctor-sarah-kemp-arrested-in-nepal/9381862
Accessed [26/03/2023]
Updated: 1/2/2018

7) Moore J and Winser S. Caring for people in the field. In: Johnson C, Anderson S, Dallimore j, Imray C, Winser S, Moore J, Warrell D. (eds) Oxford Handbook of Expedition and Wilderness Medicine. 2nd Ed. Oxford University Press; 2016. p.81-110

The post Indemnity or Insurance on Expeditions appeared first on Adventure Medic.

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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If you would be interested in sharing your opinions and participating in the study then follow this link and fill out the form. It should only take about 5 minutes and you will be helping to inform this interesting discussion. We at The Adventure Medic are really looking forward to reading the findings!

If you have thoughts on this topic, feel free to get in touch with us on social media, we would be really interested to hear a variety of thoughts on this topic.

URL for the online form: https://forms.office.com/pages/responsepage.aspx?id=DQSIkWdsW0yxEjajBLZtrQAAAAAAAAAAAANAAR5V-IJUQzVCRTdYNDQ2NFFZMFVXUjNXQU5JWEw1VC4u

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Dr Lydia Potter / Junior Clinical Fellow / North Wales

Dr Holly Andrews / Anaesthetics Registrar / Evidence Explorer Lead / West of Scotland

• Introduction to Papers of the Quarter and Our New Collaborators
• Expedition and Wilderness Medicine
• Global Health and Humanitarian Medicine

Whilst we’ve all sucessfully navigated another ‘first Wednesday of August’ and learnt that this summer is one for always co-packing GoreTex and factor 50 whilst out on adventure, the global health and expedition medicine academic publications have been flowing out.
It’s been a busy time for our team at Adventure Medic with many of us jetting off to global expeditions, supporting wilderness training and heading up global health endeavours and so we’ve drafted in two brilliant adventurous Doctors from North Wales. Drs Clapham and Potter have been scouring the academic community for interesting publications from their offices overlooking the impressive mountains of Snowdonia. Here they present a wide range of publications, from essential guideline updates from the UIAA on managing diabetes in the wilderness, to thought provoking prose on decolonising healthcare and our role in healthcare in the battle against plastic pollution.
We really have got something for everyone this issue – happy reading!

Dr Laura Clapham

Laura is in her third year of Emergency Medicine training in North Wales. She has a keen interest in Global Health and medicine in low-resource settings. During her time out of training, she has worked in rural Zambia, on board Mercy Ships in Guinea and Senegal, in Lesvos with Boat Refugee Foundation, been on expeditions to Madagascar and Honduras, worked at a ski field in New Zealand and in Darwin ED. In her spare time, she enjoys being immersed in cold water swimming or diving, and is trying to learn to some climbing skills to keep up with the North Wales crew!

Dr Lydia Potter

Lydia is a FY3 doctor living and working in Conwy, Snowdonia. She is currently doing a less than full time junior fellow job in Emergency Medicine and Paediatrics in Ysbyty Gwynedd, Bangor. In her spare time, she is part of the RNLI boat crew in Conwy and teaches on the Unique Expeditions UK courses. She has experience providing medical cover for ultra-endurance races, sports matches and festivals in the UK and abroad. She is working towards her Mountain Leader qualification in the hills of Snowdonia. When not at work, you can find her open-water swimming, hiking, climbing or bouldering in Eryri.
After her ‘F-free year’ she is hoping to enter EM ACCS, continue doing expedition medicine work and eventually sub-specialise in PHEM.

Expedition and Wilderness Medicine

This quarter in wilderness and expedition medicine, we present six fascinating publications. These papers take us from Kilimanjaro, discussing the effect of menstruating on incidence of Acute Mountain Sickness (AMS) to California, looking at the dangers of endurance sports, analysing a case series that presents four runners requiring dialysis following an ultra-marathon. Detailed and practical guidelines have been produced by the UIAA (International Climbing and Mountaineering Federation) medical commission for managing diabetes in the mountain – fantastic news for any expedition medic taking a diabetic client into the wilderness. Equally, for those of us who feel rising stress when dealing with a pregnant client on expedition, Coffet et al have done our research for us, and produced a literature review detailing considerations for wilderness and remote travel for those in the first trimester. For the scientists in us, altitude physiology has been explored further, with Kammerer et al looking at the effects of hypobaric hypoxia on coagulation in healthy patients. Finally, we have been treated to more evidence-based guidelines, with an expert panel grouping together to supplement WMS clinical practice guidelines on the treatment, management and prevention of non-freezing cold injury and warm water immersion. There is plenty this quarter to inform and inspire and we hope these articles can improve your practice when you are out in the wilderness, wherever that may be.

A Preliminary Study of the Effect of Menstruation on the Incidence of Acute Mountain Sickness
Paul M, Wagner T, Tukel C et al. Emergency Medicine Journal. April 2023

Menstruating whilst on expedition…it’s a faff at best and can be a major issue at worst, but does it have any effect on physiological adjustment to altitude? For many years, women were excluded from high altitude activities and neglected from scientific studies based in such environments. Thankfully, this is now changing, with 50% of those engaging in high altitude expeditions being women⁽¹⁾. This study by Paul et al aimed to compare the incidence of acute mountain sickness (AMS) between women who were menstruating and those were not menstruating during an ascent of Kilimanjaro (5895m). A secondary outcome was the use of AMS prophylaxis on this relationship. AMS was defined by the Lake Louise Consensus Scale and the expedition doctor’s clinical judgement. 46 women were included in the study, all from the same expedition, with 17 women menstruating. No significant difference in AMS incidence was found between women who were and were not menstruating or any effect of prophylaxis use on this relationship. The main limitation of this study was its size and lack of rigorous controls. However, the results certainly provide the start of a more solid evidence base to use when advising female participants on expedition. Larger-scale studies are still needed to fully define the relationship between hormonal influences on AMS incidence, but the findings of this work do go some way to help address the discrimination and misinformation about female athletes operating in extreme conditions. The findings may also act to reassure those having that heart-sink feeling when they realise their cycle lines up with their high-altitude expedition!

UIAA Medical Commission Recommendations for Mountaineers, Hillwalkers, Trekkers and Rock and Ice Climbers with Diabetes
Hillebrandt D, Gurtoo A, Kupper T et al. High Altitude Medicine and Biology. June 2023

Diabetes is a huge topic with a large prevalence, so it is unsurprising the UIAA Medical Commission’s advice article is a sizeable read. Whilst diabetic emergencies in remote locations can be fatal, there is no reason a knowledgeable diabetic who is skilled in self-care cannot function well in an extreme environment. It is clear the UIAA community wishes to support diabetics to safely enjoy all aspects of mountaineering and this recommendation document is an informative read for those wishing to support mountain expeditions with diabetic participants.
The UIAA (International Climbing and Mountaineering Federation), abbreviated by its French name, Union Internationale des Associations d’Alpinisme, is the international governing body for climbing and mountaineering, advising on issues such as mountain safety, sustainability and competitive sport. This recommendation article is split into seven numbered sections. The first four sections (introduction to the guideline document, introduction to diabetes, managing diabetic emergencies and caring for diabetic competitive climbers in non-remote settings) are written in non-technical terms, for the reading of the lay person. Sections five and six are written for clinicians, with section five focusing on insulin-dependent diabetes mellitus and section six on mountaineers taking oral hypoglycaemic medication. These two sections are fantastic, laying out the evidence clearly and advising on practical aspects of diabetic care at altitude; from the effects of temperature on insulin storage to how Acetazolamide prophylaxis affects glucose regulation. Section seven discusses recent technology developments in diabetic care, including insulin pumps and continued glucose monitors; setting out the pros and cons of modern diabetic technology use in a remote area. Given the prevalence and popularity of such devices, this final section is highly topical and enlightening. Whilst lengthy, this recommendation document contains all the information one could need when supporting diabetic patients in the mountains and is a vital read for any medic accompanying such a patient on expedition.

Effects of Hypobaric Hypoxia on Coagulation in Health Subjects Exposed to 3,500m Altitude
Kammerer T, Walzl A, Müller T et al. High Altitude Medicine and Biology. June 2023

Trauma at altitude is thankfully rare, but in an environment of rock faces, crevasses and seracs, when trauma does occur it can be significant. Whilst major trauma ultimately requires extrication and evacuation to in-hospital care, knowledge of the effects of altitude on coagulation and trauma-induced coagulopathy can be useful for the expedition medic practicing at altitude. Hypoxia is thought to be a trigger for pro-thrombotic changes, both in critically unwell patients and in healthy people at altitude, but do patients really bleed more at altitude? This small-scale study used twelve healthy females controlled for their variables and studied their functional coagulation and blood lysis at both a hypobaric hypoxia equivalent to 3,500m and at normoxia. Plasma-based coagulation tests were also done. There were no significant changes found, with no difference between lysis ability, clotting time, clot formation, clot amplitude or clot firmness. Kammerer et al concluded that moderate hypobaric hypoxia has no influence on blood coagulation in healthy females. This is a small-scale, but highly controlled study with interesting results that dispel some commonly accepted beliefs. Whilst this study should not change extrication plans for the trauma patient at altitude, it may have implications for risk stratification and certainly for future research.

Prevention and Treatment of Non freezing Cold Injuries and Warm Water Immersion Tissue Injuries: Supplement to Wilderness Medicine Society Clinical Practice Guidelines for the Prevention and Treatment of Frostbite
Zafren K, Hollis S, Weiss E et al. Wilderness and Environmental Medicine Journal. June 2023

In our Spring Evidence Explorer, we discussed Tipton & Eglin’s article ‘Non-Freezing Cold Injury [NFCI]: A Little-Known Big Problem’, which highlighted the difficulties in assessing, preventing and treating this condition due to its unclear mechanisms. Immersion injuries including NFCI and warm water immersion injuries often affect the feet, mostly of those operating in cold and/or wet regions for prolonged periods of time. These injuries are debilitating, painful and can be expedition-ending when affecting those required to walk long distances. To supplement the current Wilderness Medical Society guidelines, a panel of experts have gathered to develop evidence-based clinical guidelines for the evaluation, differential diagnoses, treatment and prevention of NFCIs and warm water immersion injuries. This article presents the available evidence alongside clear recommendations from the expert panel. It is well worth a read for anyone likely to encounter patients with immersion injuries – anyone working in environments where feet are soggy for prolonged periods of time.

First-Trimester Pregnancy: Considerations for Wilderness and Remote Travel
Coffet CH, Casper LM, Reno EM et al. Wilderness and Environmental Medicine Journal. June 2023

Whilst heavily pregnant women are unlikely to be involved in expeditions in extreme environments, those in their first-trimester may partake in many outdoor activities with ease. Additionally, a person may discover their pregnancy during an expedition or even travel unknowingly during this period. This literature review addresses diagnostic and management considerations in multi-day expeditions during the first trimester of pregnancy. The article covers both gynaecological considerations, including vaginal bleeding, suspected ectopic pregnancy and threatened pregnancy as well as non-gynaecological considerations, including treating infections, dealing with nausea and vomiting and vaccinations recommendations. Clinicians working in extreme environments should be prepared to answer queries about travelling during first-trimester pregnancy and be comfortable prescribing, treating and determining the need for evacuation. Even if an expedition medic believes there are no pregnant participants on their trip, it may be a possibility and one should be prepared for any eventuality. This article addresses commonly encountered questions and presents available research, helping us all to advise with a solid evidence base.

Four Cases of Acute Kidney Injury Requiring Dialysis in Ultramarathoners
Pasternak AV, Newkirk-Thompson C, Howard  JH. Wilderness and Environmental Medicine Journal. June 2023

The popularity of ultra-endurance events are on the rise and it’s easy to see why. Participants can race through stunning landscapes with a ‘run when you can, walk when you want’ attitude, focusing on the journey, not the completion time. With a huge range of ultra-endurance race providers operating in almost every environment possible, there is a magnitude of events to choose from. Clinicians working in event medicine, particularly in ultra-marathons, will be used to advising athletes to keep hydrated and avoid non-steroidal anti-inflammatories (NSAIDs) such as ibuprofen. This advice comes from a desire to avoid a pre-renal acute kidney injury (AKI) and exertional rhabdomyolysis, but are we and our clients truly aware of how serious this can become? This interesting case series by Pasternak et al presents four cases of AKI requiring haemodialysis following ultra-endurance footraces. The four runners discussed had all run the Western States 100-mile Endurance Race (WS100) in sunny California over a three year span. Importantly, the race day temperatures were high, ranging from 36.6-38.3 degrees Celsius. All four runners presented to secondary care 17-32 hours following their race with biochemical findings of rhabdomyolysis, hyponatraemia and AKI. All four had symptoms of nausea, vomiting, dark urine and muscle cramping during their race and their presenting symptoms on arrival at hospital were ongoing fatigue, myalgia, nausea and vomiting, with one runner experiencing haematemesis. One participant had taken 200mg Ibuprofen, but all others had avoided any medications. Typically, AKI and exertional rhabdomyolysis is transient and does not require dialysis; however, all four of these runners required haemodialysis for between 10 days to 6 weeks. Despite the seriousness of their presentations, all four patients did recover fully and returned to endurance running with no chronic kidney disease. This case series is a really interesting read and provides some great evidence to take renal issues in endurance sport seriously. For budding wilderness medics, endurance races may be the first exposure to expedition medicine and this study highlights how vital it is to advise athletes on hydration, electrolyte intake and the avoidance of NSAIDs.

Global Health and Humanitarian Medicine

This quarter’s global health publications present many thought provoking topics that provide an evidence base for instigating essential discussions within our communities and give inspiration for meaningful action and change.
The first two articles discuss the inter-relationships between artificial intelligence and plastic pollution to our healthcare systems and not only explain the problem but also provide helpful ways in which we might take steps to improving both. Decolonisation throughout the world has been a hot topic over the past year and its importance within health systems is incredibly important in the drive to promote heath equity. Laura presents two excellent articles below related to this giving advice on how we as individuals can take steps to helping improve global health equality.
Over the past decades we’ve seen an ever increasing flow of UK doctors drawn to Australia to work. Such an opportunity is exciting but it is important to pause amidst drowning in visa admin to consider our potential impact on the native communities there prior to arrival. Crocetti et al describe the problems with alcoholism within Aboriginal communities and highlights the potentially disastrous impact that global companies can have on this.
And finally, in a previous evidence explorer edition we talked about the bi-directional benefit of working in LMICs highlighting the article by Walpole et al and here we present another providing evidence of the skills gained during global health placements.
Enjoy!

Threats by artificial intelligence to human health and human existence
Federspiel F, Mitchell R, Asokan A et al. BMJ Global Health. May 2023

Artificial intelligence (AI) has enormous potential to benefit healthcare. Yet most of us are immediately drawn to horror films where AI destroys the planet and the human race forever. This paper takes a more logical approach and examines the potential threat to human health and wellbeing through social, political, economic and security-related factors. If “narrow AI” (a learning algorithm designed to perform a single task) is misused, it could threaten human health by controlling and manipulating people, enhancing lethal weapon capacity and rendering human labour obsolete. And maybe those movies weren’t fantastical after all; the development of self-improving artificial general intelligence (AGI) could pose an existential threat to humanity. The authors call for effective regulation and the prohibition of certain AI types and applications, and even suggest a moratorium on self-improving AGI development. It is a rapidly evolving technology and perhaps the medical community should be advocating for social and economic policies which advocate for safe AI to protect future generations?

Supplement: Plastic pollution: how can the global health community fight the growing problem?
Bidashimwa D, Hoke T, Ba Huynh T et al. BMJ Global Health. June 2023

From AI to plastics, the threat to human health is real. The UN defines the principle of “One Health” as “an integrated, unifying approach… to sustainably balance and optimise the health of people, animals and ecosystems.” ⁽²⁾ This paper details how plastic pollution negatively impacts all three. It goes on to argue that the global health community has not been very vocal on the issue. Despite the global crisis and the burden it poses, the authors’ literature search found only 65 articles on plastic pollution in 15 out of the top 50 global health journals in the past 5 years. They include a call to action and suggest: 1) filling the evidence gap, 2) employing a multi-disciplinary approach with environmentalists and animal health specialists, 3) using a circular economy for medical plastic waste, and 4) engaging with global, national and local health leaders to advocate for effective interventions. Perhaps next time we throw away the waste from a cannula, we can pause and ponder what part we can play in the big picture?

Global health has deep roots in colonialism and these structures still persist today. These two papers provide insight into the problem and consider the future of deconstruction.

Colonization and decolonization of global health: which way forward?
Hussain M, Sadigh M, Sadigh M et al. Global Health Action. Nov 2022

This article is a sobering reminder how ingrained colonialist ideas have birthed and molded global health as we know it today. It highlights historical examples of the negative health impacts these structures have had and challenges whether we can begin to change them while operating within them. It demonstrates how medical progress has benefited people of the colonial powers and exploited vulnerable groups. Still today, global health partnerships “that aim to help often mirror colonial relationships with members of high-income countries being given greater opportunities (mentorship, employment opportunities, leadership positions, compensation) in low income countries than the other way around”. The “Next Steps” section will leave you with much food for thought as the authors present some tough questions on the future of decolonising global health.

Drivers of health workers’ migration, intention to migrate and non-migration from low/middle-income countries, 1970–2022: a systematic review
Toyin-Thomas P, Ikhurionan P, Omoyibo EE et al. BMJ Global Health. May 2023

Following on from decolonising global health, this study aimed to understand the factors driving healthcare workers’ migration from low/middle-income countries (LMICs). They analysed 107 studies published between 1970 and 2022, focusing on doctors and nurses from 26 countries. The key drivers were found to be remuneration, security problems, career prospects, working environment and job satisfaction. These factors remained consistent over the last five decades and were similar across geographical regions in LMICs. With evidence now to guide action we hope that better progress can be made to support LMICs in retaining their health worker populations. 

Surgery: a crucial ally for universal palliative care access
Rosa WE, Lumati JS, Alatise OI et al. The Lancet Global Health. May 2023

Surgery is all about cutting, right? But what happens when cutting can no longer cut it? Pun absolutely intended. This paper reminds us of the inequalities in access to palliative care globally, and argues that collaboration between surgical and palliative care teams could help bridge health gaps. Globally, 5 billion people lack surgical care while 61 million suffer for want of palliative care. 64% of countries lack palliative care access, mainly low-income ones. A multidisciplinary approach involving surgeons is crucial, particularly in low-income countries, to address unmet needs. If you are thinking of working or have worked in surgery in a low-income country, integrated palliative care is perhaps something to consider when planning your resource allocation. 

‘A recipe for cultural disaster!’– a case study of Woolworths Group’s proposal to build an alcohol megastore in Darwin, Northern Territory
Crocetti A, Cubillo B, Walker T et al. Globalization and Health. June 2023

If you have spent time in the Northern Territory (NT) of Australia, you will know what a beautiful and culturally important place it is. Aboriginal culture is one of the oldest on the planet and yet they have been treated appalling in recent history. [I recommend reading Dark Emu for more on this]. In order to alleviate some of the problems caused by alcohol, so-called ‘dry’ communities have banned alcohol. This study delves into the impact of commercial activity on Indigenous populations, focusing on the effects of the alcohol industry in Australia. The supermarket chain Woolworths aimed to build a large alcohol store near ‘dry’ Aboriginal communities in the NT. Through interviews and data analysis, the study reveals Woolworths’ tactics, including lobbying and divisive rhetoric, disregarding existing evidence of harm. Advocacy efforts, emphasising unity and Aboriginal leadership, countered these tactics. It is inspiring to read how these strategies can protect Indigenous health against powerful commercial interests.

Applicability of working abroad for physicians with a specialization in Global Health and Tropical Medicine
Ozcan H, Overeem L, Bakker M et al. Globalisation and Health. April 2023

“So please tell us how your experience overseas has helped you in your work in the NHS…” This may be a familiar question in interviews or even in casual conversation at work. Sometimes it is hard to put it into words. Well, this study may provide a useful talking point. In the Netherlands, the Global Health and Tropical Medicine training programme involves 27 months of training in Obs & Gynae, Surgery and/or Paediatrics followed by a six month internship in a low-middle income country (LMIC). The study explores the competencies developed by physicians specialising in Global Health and Tropical Medicine during their work in low-resource settings (LRS) and their applicability in high-resource settings (HRS). Using qualitative methods, the study identifies 15 themes including cultural awareness, communication skills, public health, teamwork, and many others. These competencies enhance physicians’ professional, personal and cultural perspectives, potentially improving healthcare delivery in both LRS and HRS. A really useful read whilst reflecting on your own experiences working in low resource settings. 

Thank to our collaborators this quarter, we’ve really enjoyed having you on board.
As always, do get in contact if you’d like to be involved with contributing to future releases of this feature – we always look forward to hearing from you.

Bibliography

1. Twombly  SE, Schussman  LC. Gender differences in injury and illness rates on wilderness backpacking TRIPS. Wilderness Environ Med 1995;6:363–76.
2. https://www.who.int/europe/initiatives/one-health#:~:text=One%20Health%20is%20an%20approach,animal%2Dhuman%2Denvironment%20interface.

The post Evidence Explorer: Updates and news from the academic community, Summer 2023 appeared first on Adventure Medic.

Dr Liv Grover-Johnson reviews the the Medical Care on Offshore and Inland Waters (MCOIW) course. This course is one of the newest offerings by the Healthcare in Remote and Extreme Environments (HREE) program at the University of Tasmania (UTAS). Candidates learn about search and rescue, medical care at sea, basic navigation and more. MCOIW is a supercharged version of HREE’s highly engaging Expedition Medicine course. It is currently the only maritime medicine for healthcare professionals available in Australia. And it’s on a boat.

Key Facts

What: An eight day intensive medical course, including three nights aboard a wooden tall ship, “The Lady Nelson”.

When: Typically the course runs once per year, in November. This is an eight day course.

Where: Hobart, Tasmania.

The first four days are at the UTAS Medical Precinct in Hobart. For the rest of the course you are aboard the “The Lady Nelson”, in the coastal waters and harbours in Southern Tasmania, .

Cost: Health Professionals: AU$5,990. (Reduced to AU$5,434 if completing it as part of the Graduation Certificate or Diploma in Healthcare in Remote and Extreme Environment). There is one free place per course for UTAS medical elective students. UTAS students should contact the elective director or the head of their clinical school for further advice.

Costs include a course manual, pre-course education, morning coffee and lunch during the course days, and all meals and accommodation whilst aboard “The Lady Nelson” (three nights).

Costs do not include travel to and from Hobart, accommodation whilst in Hobart, or mandatory equipment. It is possible to borrow or hire some gear for the duration of the course if you do not have them.

For Australian citizens or permanent residents, you can apply for fees support.

End Qualification:

• Certificate of completion (Note that this is the only maritime medicine course for health professionals in Australasia).
• Credit towards the HREE Graduate Certificate/Diploma/Masters. There is an additional 3000 word assignment to submit if you want to complete the unit and not just the short course.
• CPD points accredited by the Australian College of Rural and Remote Medicine, and also by the Royal Australian College of General Practitioners.

Delegates: Maximum 20

All health care professionals are welcome including nurses, paramedics and doctors. Outdoor educators guides and enthusiasts are also welcome to join the short course and often do.

Prerequisite Specific Skills:

• 10 to 15 hours of pre-reading and coursework, accessed online at no additional cost (https://hree.tsom.utas.edu.au/) 
• Swimming: must be able to safely swim 200m fully-clothed
• Preparation and purchase or sourcing of essential gear and equipment

The Course

MCOIW is one of the newest offerings by the Healthcare in Remote and Extreme Environments (HREE) program at the University of Tasmania (UTAS). It is a supercharged version of their highly engaging Expedition Medicine course. On a boat. 

MCOIW is the only course of its kind in Australasia. It teaches medical skills and an array of practical skills relevant to medical care at sea or on the water. It can be completed as a stand-alone course or as part of one of HREE’s certificate or diploma programs. 

The course covers:

• Approaches to the provision of emergency and primary medical care on board a vessel
• Designing medical kits, risk assessments and disaster and evacuation plans 
• Provision of topside support appropriate to a wide range of maritime and inland water settings 
• Basic navigation and meteorology
• Emergency and survival procedures at sea, including practical search and rescue (SAR), patient assessment and extrication exercises, and swift water safety and rescue
• International and Australian regulations covering the maritime industry
• Short range radio operators course & licence

The Instructors

Instruction is provided by doctors, nurses and paramedics with significant experience in expedition and wilderness medicine. They have worked across a variety of settings including polar expedition yachts, ocean racing, cruise ships and maritime refugee assistance missions. 

The course draws on the incredibly valuable knowledge and skills of non-healthcare professionals. They have extensive experience with remote expeditions, maritime search and rescue, nautical navigation and communications, ocean sailing and racing.

General Review

This is the most fun I have had on a medical course.

Hobart feels like the last city at the edge of the world. It squeezes itself into a spectacular location beneath Kunanyi (1,271m), and the shores of the Derwent River and Storm Bay. To the west of Kunanyi is the vast protected wilderness of the Franklin-Gordon Wild Rivers National Park. Being one of the Antarctic Gateway cities, you may be lucky enough to see some of the Antarctic-bound research vessels docked at the wharfs in town. You might even see one heading out on a journey into the Southern Ocean and down to the ice.

“The Lady Nelson”, a wooden tall-ship, becomes the class-room for four days of the course, exploring the coastline, islands and harbours around Hobart and to the South. Whilst on-board you share all accommodation and meals with other delegates and faculty, just as on a real expedition. During the course your mandatory clothing, equipment and safety kit are assessed. These are things you actually need during your time at sea – so it is a good chance to test and refine your gear.

The opportunity to sail aboard “The Lady Nelson” enables the MCOIW course to get us outside of the four-walls of our normal healthcare settings, and open our minds to the  creativity, resourcefulness and innovation required in the expedition setting – especially at sea. Many aspects of this course are integrated into practical scenarios that resemble the complexities of real life. They demand real teamwork, real radio communication, real planning… you don’t get this opportunity anywhere else.

Extra benefits

• Networking – the people who choose to do a course like this one are invariably wonderful, interesting, bold and adventurous types. You will find a great network of friends and colleagues who think just like you do. It may well lead to opportunities in other weird and wonderful corners of the world.
• VHF Radio Licence: Short Range Operators Certificate of Proficiency (SROCP) 

Overall Verdict

If you are looking to take your healthcare skills outside the four walls of the hospital and onto the lakes, rivers and oceans, then this course is one you want to do.

Definitely pay attention to the assessed items on the mandatory “gear and equipment list”. Indeed I would strongly recommend aiming for top marks. If you neglect this you will still learn the lesson, but it will be the hard way and you will regret your half-hearted job!

Useful Links

Course flyer: https://www.utas.edu.au/__data/assets/pdf_file/0009/1605663/MCOIW_Flyer.pdf

Course Website: https://www.utas.edu.au/health/study/cpdu/medical-care-for-offshore-and-inland-waters 

The post Medical Care on Offshore and Inland Waters Course (MCOIW), University of Tasmania: Course review. appeared first on Adventure Medic.

If polar adventures as a medic are on the cards, this open access article on legal considerations is for you. It highlights several controversies touching on telemedicine, medical kits and suggested qualifications. It showcases the need for internationally recognised standards to ensure appropriately trained and experienced clinicians are recruited to provide quality medical care to those travelling in these remote regions. It could arguably be extrapolated to expedition and remote medical work in other environments where governance is also currently lacking with significant variability in the provision of care. We hope this helps spur on conversations and the creation of standards in the field. 

The article is by paramedic and polar guide/medic, Kai Müller. It is part of his Diploma in Remote and Offshore Medicine with the Royal College of Surgeons of Edinburgh.

The post Legal Considerations for Medical Care in Polar Waters appeared first on Adventure Medic.

The field of expedition medicine is vast. Expeditions encompass a variety of remote locations, climates, agendas, and participants. They may differ hugely in the range of skills the medic requires. We’ve put together guidance on assessing expedition opportunities in order to decide on the right expedition for you.

Contents

1. You

Your first responsibility and obligation under Good Medical Practice¹ is to ensure you are acting within your competency. You should have the necessary skills, knowledge, and experience for the environment and expedition. If in doubt the Faculty of Pre-hospital Care, Royal College of Surgeons Edinburgh guidance for medical provision for wilderness medicine² can guide your choices. These guidelines give an idea of what competencies will be expected of you and can identify areas in your knowledge and skill base that need some buffing.² The below list can help target areas to improve your proficiency and confidence as the medic.

1.1 Education

An expedition medicine course is extremely useful if you think your knowledge and skills could be improved. Remember that being an expedition medic is often more about logistics – casualty evacuation, communications, supplies – than injuries and medical conditions. Courses should cover these aspects.

There are a variety of expedition and wilderness medicine courses and diplomas on offer, and choosing one is almost an article in itself. Adventure Medic has published a number of recent and informative reviews which are all written by previous course delegates. As a minimum, most expedition companies look for a week-long course. A list of courses can be found here on our resources page.

Although going on an expedition/wilderness medicine course will provide you with the basics it is unlikely to be tailored to your specific expedition and environment. In addition, these courses can be expensive, and if expeditions are your only income you will be unlikely to earn this money back. Scrutinise course contents before selecting to make sure it meets your own learning objectives.

1.2 Expectations vs Proficiency

Get a thorough understanding of the nature of the trip and the participant demographics before accepting. Be honest about your own experience in relation to this. You should be clear on the company’s expectations of the expedition doctor. Ensure these are reasonable and that you have capacity to meet them. If you claim to be a ‘mountain medicine expert’ then you may be expected to take on roles and responsibilities which are outside of your competence.

You should be familiar with all the medical kit you carry. For example, if based remotely for many months with a dental kit then having some experience of removing teeth is important.  A caveat to this is telemedical support which is an ever-expanding area in expedition and wilderness medicine.

Experience also covers your own comfort and capability in the environment or activity. It is easier to look after others if you are able to look after yourself, you should be at least as proficient, if not better than the clients you are looking after in any expedition activities. Your workload will likely involve caring for others between your own personal admin. Famniliarity and experience allow you to keep some head-space free for the medical aspects of the trip, and any other problems you might encounter along the way. Taking a job as a ship medic only to find out you are susceptible to seasickness is one example of a less-than-ideal situation.

However, experience expands beyond medical and environmental skills. Generally, the bread and butter of being an expedition medic involves:

• Dynamic risk assessments –  hazard awareness and safely managing scenes
• Prompt decision-making in the management of patients
• Evacuation planning
• Situational awareness including human factors
• Screening and briefing
• Liaison and communications skills with all team members

These are probably the most important skills of a successful expedition doctor.

1.3 Personal Health

Ensure you are healthy enough to support the expedition. A good baseline level of physical fitness is mandatory. If you think your physical fitness could use some work, start early – you may need to push yourself to get to casualties on expedition. In the time leading up to your medical expedition career, get outside and put your outdoor skills to practice in activities you hope to work as medic in; for example tyre hauling as a surrogate for pulk pulling.
Finally, remember to pack your own personal medications if you have any medical conditions.

Mental health is often an overlooked aspect of self-care on expeditions. Remember, you are often out with your own comfort zone; environmentally but also geographically, and emotionally distanced from loved ones. Expeditions are exhausting; the physical strain of the activities combined with sub-optimal sleep and the daily mental responsibility of looking after the health and safety of the group can be extremely energy-demanding. Acknowledge this and look after yourself. A top tip is to find some quiet time in and amongst the hectic expedition day to reflect on how you are feeling and the events of the day. Keeping a journal is a good way to decompress  – and also provides a record of memories and funny stories to recount later.

2. The Expedition

2.1 The Expedition Company

Make yourself familiar with the expedition company. Explore their website to assess what their company experience is and what they are advertising. Speak with colleagues who have been on expeditions with them – this provides invaluable insights and tips for approaching practicalities.

Set up a phone call to discuss the expedition in detail with a member of the expedition company. List questions to ask them in preparation. The level of understanding and response to your questions can be very revealing. Participant welfare, health, and safety are your priority, however, this may not always be the expedition company’s top goal. Ensure your company has clear risk assessments and evacuation plans. These should cover emergency medical evacuation protocol, relevant natural disasters (floods/tsunamis/storms/hurricanes), civil unrest, missing participants, lost passports, and missing flights to name a few possibilities. Clarify when you will expect to receive documents such as; participant health declarations, evacuation plans, and flight information. It is imperative to know about the logistics of all evacuation plans, and which personnel from your expedition company will be involved. Poor risk assessments and evacuation plans are the most likely aspects of expeditions to let you down.

Ensure that their protocols meet with your own ethical and moral standards – for example; their policy on treating local staff. At Adventure Medic, we strongly believe that you are responsible for the well-being of everyone on your trip, including porters. The International Porter Protection Group made recommendations for trekkers and porters on their trip. Although this organization is no longer operating Adventure Medic stands by the principles which can and should be referred to here.

It might also be helpful to make yourself aware of the Specification for the Provision of Visits, Fieldwork, Expeditions and Adventurous Activities Outside the United Kingdom (BS8848, 2014).³ This is the national standard for managing risks on expeditions out with the UK and draws up specifications to ensure effective operational systems are in place to assess and manage the risks associated with overseas adventures.

2.2 Medical Director

Many expedition companies will have a ‘medical director’. However, this title does not indicate a standardised job specification and this role varies hugely between different companies. Larger or longer-standing companies are likely to have one, and clarifying their role is essential so that you know when to call on their assistance. Some will be involved with medical kit building and guidance, some with screening, and some on-call for remote advice, evacuation guidance, and logistics. If there is no on-call medical director you will need to establish if you require a supervisor on-call (which you may need to source yourself if you are more junior, in order to facilitate your indemnity insurance). Consider exploring if there is a remote telemedical service provided for support and guidance.

2.2 The Environment

The expedition environment will have a significant impact on the medical conditions you may encounter, and the contents of your medical and personal kit bag. An awareness of how remote and exposed you will be and for how long will influence what you wish to carry. Ensure again that you are comfortable with this and the evacuation times before taking on the expedition.

2.3 The Expedition Guides and Leadership

Thankfully, on almost all commercial or charity expeditions guides are employed. Guides may be in-country, out-of-country or you may have both. The expertise they bring to trips is often invaluable. They usually take the reigns of leading the group which allows you to prioritise medical decisions. It is worth establishing the background of the guide you are working with and what their qualifications allow. Contact them in the run-up to the trip as you will be working closely together. Avoid taking the chief leadership role on the expedition unless you have been specifically employed to lead the group, you feel the leader is compromised or you need to assert leadership due to health and safety. If this is an area you wish to expand on to build your own confidence prior to the expedition then the Summer Mountain Leader (and similar qualifications) are fun and viewed favourably by expedition companies. Some will use this as a benchmark to employ you as a joint group leader and medic which may increase your pay. Be wary of this role as it should be reserved for small groups only and where the medic feels they have the capacity to deliver both aspects. Regardless of additional leadership qualifications a broad outdoor skills base and common sense will stand you in good stead as the medic on any expedition.

3. The Participants

Make sure you know exactly how many participants you are responsible for and their ages. The ratio of participants to guides and participants to medics on the trip should not be excessive, and the ratios you’re comfortable with will vary depending on the trip. This information will help you anticipate their likely fitness levels, the medical input they will need, and the expected supervision level from guides. Knowledge of when and how you will receive their pre-expedition health questionnaires (or if you need to write one of these) is important as it will likely influence your risk assessments, medical kit preparation, and optimisation of the participants.

4. Health, Safety, and Logistics

4.1 Medical Kit

As medics, we are used to having access to kit in hospitals but we have to economise on expeditions. A fair bit of questioning is required to ensure the kit is correctly provided and is tailored to your trip and participants. The expedition company should be able to comprehensively answer the following:

• Does the expedition company provide you with a medical kit, or are you required to provide or assemble this yourself? If so, will they cover the costs of you supplying all the kit and also your time for putting it all together?
• When was the medical kit made? When was the kit last updated? How often does the medical kit get thoroughly checked for inventory and expiry dates? And by whom?
• Is the medical kit bag designed specifically for the location you are going to, and at that time of year? A medical kit bag for a trip to the saharan desert is vastly different from that for an expedition to altitude.
• What level of care does the medical kit provide? A full inventory is required for all items and if the company has a pre-assembled kit they should be able to send this to you.
• How big a group is the medical kit designed for? Are participants also advised to bring their own personal medical kits and spares of their own medications?

5. Financial

5.1 Indemnity

Indemnity insurance covers you legally for your medical work on an expedition and safeguards you and your career. Enquire about suitable indemnity cover early. If you are unable to access indemnity insurance it will prohibit you from acting as a medic. The insurers want to know if you are the sole or lead medic, the number of participants, your ‘grade’ or experience, the duration and destination, and the number and nationalities of the participants. You can find out a lot more information about this in our Guide to the Legal Aspects of Expedition Medicine and upcoming indemnity article.

Ask your expedition company if they will reimburse you for indemnity, as it can be a considerable cost. Expedition companies can often forget that this is a necessary part of being a doctor and that it safeguards the medic in a way travel insurance doesn’t.

5.2 Payment / Non-payment

Be clear about the deal you are being offered as expedition companies vary wildly in their willingness to cover costs. Get in writing a record of costs that will be covered, this should include:

• All flights
• Accommodation in-country
• Airport hotel stay / meals
• Transport fees in-country
• Medical indemnity insurance
• In-country expenses
• VISA costs
• The medical kit you have ordered

Often, the cost of personal kit, indemnity, and preparation time will be considerably more than the company thinks and may detract from your enjoyment of the expedition or leave you out of pocket. The latter should not happen.

Look out for our upcoming article on pay for expedition medics. To briefly summarise: our position at Adventure Medic is that being an expedition medic is a job, with professional risks and responsibilities. Ideally, it should include a daily pay rate, in addition to reimbursement for necessary kit purchases and indemnity costs. Fundamentally, expedition companies are paying for your time (both in the planning stages and in-country) as well as your knowledge, skills, and expertise. It is in the best interests of the expedition company to hire a reputable, professional, and thorough doctor with sound-decision making skills for their expedition.

As doctors, we have a professional responsibility and are influential in the field of expedition and wilderness medicine. We need to be advocates for each other and ensure that we are well respected, represented, and supported in the field. And thus, we should not be hesitant to expect payment for expeditions. It may also be appropriate to ethically question the payment of the expedition guides and how this compares to the payment of the expedition doctors.

Whatever expedition you choose though, and whatever costs your expedition company covers please make sure that you feel protected, and adequately compensated for your work. As a minimum, charity work / expeditions should cover expenses and personal time in the planning / preparation stages. Expeditions with charities often have limited budgets and as such these situations may be those in which it would be acceptable to not be paid a wage. However, you should never lose money on any expedition.

6. Summary

• Ensure that you have the right knowledge, skill set, and environmental expertise to fulfil the required competencies on the expedition – the faculty of prehospital care guidance can assist.
• Discuss with the expedition company their expedition, risk assessments. Evacuation protocols will often give insights into their proficiency.
• Establish the roles of the guides and medical director as you will rely on them for support during your expedition.
• Keep in mind the priorities of the expedition company and directors, as these will not always match with your own ethics and prioritisation of health and safety.
• Clarify the headlines regarding patient demographics and the medical kit so you tailor and prime each as needed.
• Open conversations early to ensure you are financially reimbursed and safeguarded with indemnity insurance.
• Early research and preparation when choosing an expedition will reduce stress and increase enjoyment in-country.

For your convenience, Adventure Medic has compiled a list of specific jobs and volunteering positions which is updated regularly.  A list of some expedition medicine providers is also a good place to start looking for your first expedition job. (Please note, however, we do not endorse organisations, or the contents of external websites or offer any adventure medicine work ourselves.) If you don’t find what you are looking for here, then try contacting some of these organisations directly, or alternatively peruse through the various expedition articles we have published on Adventure Medic’s Adventures page to see what others have done before and get some inspiration. Please mention us if you find your job through Adventure Medic. It keeps the wheels turning. Happy expeditioning.

References

1. Good Medical Practise, Domain 1: Knowledge skills and performance, General Medical Council
   https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-1—knowledge-skills-and-performance [Accessed 5/6/23]
2. Updated Guidance for Medical Provision for Wilderness Medicine, Faculty of Pre-hospital Care, Published 2019, pp 7
   https://fphc.rcsed.ac.uk/media/2780/updated-guidance-for-medical-provision-for-wilderness-medicine.pdf [Accessed 5/6/23]
3. BS 8848:2014, Specification for the provision of visits, fieldwork, expeditions and adventurous activities outside the United Kingdom. Published March 2014, BSI, https://knowledge.bsigroup.com/products/specification-for-the-provision-of-visits-fieldwork-expeditions-and-adventurous-activities-outside-the-united-kingdom-1/standard, [Accessed 5/6/23]

The post Adventure Medic’s Guide to Choosing an Expedition Medicine Job appeared first on Adventure Medic.

Founded in 2021, Endeavour Medical is a new provider of wilderness and expedition medical training. Their large team of faculty boasts decades of experience in multiple extreme environments including mountain, jungle, polar, and desert with countless teaching and academic accolades to their name. Endeavour Medical delivers an array of courses, including global health and sports medicine courses as well as wilderness, expedition, and leadership offerings. Based in Morzine it provided the perfect location for easy access to the French, Swiss, and Italian Alps and is just 1 hour drive from Geneva airport. The course was run by Dr Lucy Sykes (Stroke consultant in Dorset and consultant for the Wessex Ghana Stroke Partnership), Dr Alex Taylor (ST3 Emergency Medicine trainee) and Dr Jon Dallimore (GP and co-editor of the Oxford Handbook of Expedition Medicine) who, between them, have a huge range of experience in global health and expedition medicine and are passionate about sharing their knowledge.

Key Facts

Duration: Five days. One day of lecture-based online learning and four practical days in Morzine comprising of scenarios, workshops, and discussions.

Dates: January

Location: Morzine, French Alps

Cost: £995. Inclusive of luxury chalet accommodation, breakfast, afternoon tea and cake and dinner. Travel to course not included. Discount available to students.

Number of delegates: 12 participants (doctors and medical students).

Prerequisites: None, morning skiing is a course component but not essential.

End qualification: Course attendance certificate (worth 40 CPD points). Opportunities to complete Supervised Learning Events (including case-based discussions and clinical evaluation exercises).

Course website: https://endeavourmedical.co.uk/remote-medical-course-winter/

Course Content

Lectures include:

• Hypothermia and hyperthermia
• Altitude medicine
• Mental health in the remote setting
• Medical kit and pain management
• Global health and sustainability
• Tropical and dive medicine

Practical sessions include:

• Patient assessment in remote environments
• Injury taping and splinting
• Scenarios involving leadership and medical management, often using real-life examples experienced by the instructors
• Confidence roping and movement in the snow
• Nutrition

The Course

Delegates arrived the night before the course began at the chalet in Morzine. The fire was roaring; we got to know each other and discussed our aims for the week over cups of tea.

The course began with an introductory talk from one of the leaders on keeping yourself safe in the mountains. Endeavour’s founder, Lucy, had done a snow dance and it certainly paid off; a large dump the week before meant there was plenty of snow, so we hit the slopes. Each morning we explored the pistes, with Jon helping the less confident skiers fuelled by hot chocolates. Morning skiing was not essential and there was plenty to do in beautiful surroundings, or just relax and enjoy the hot tub at the chalet. We were blessed with ‘bluebird’ days, giving us beautiful views over the Alps, across Chamonix and the summit of Mont Blanc. Morning skiing was followed by tea and cake at the chalet before the afternoon teaching.

Teaching was delivered as a mix of small group scenario work (building on the pre-course lecture series), practical sessions and discussions around key focus areas. The scenarios involved altitude medicine and human factors allowing delegates to put their newly learnt knowledge to the test. Discussions varied from sustainability and ethics to mental health on expedition. Over the week, everyone shared their experiences and feelings towards these topics. A personal highlight included listening to personal methods of coping with mental health on expedition. It was great to hear everyone’s tips and learn from each other.

Practical sessions included trauma care; practising with splints and traction, and a local physiotherapist showed us how to use tape to protect joints in soft tissue injuries. There were no achy limbs on the mountain after that! The chalet garden was used for practical scenarios. One example was running up the hill practising stepping in deep snow before some work with confidence roping and rescuing Alex where she had fallen down a slope close to the river and broken her wrist.

On the final evening, we consolidated our learning to rescue the facilitators, Jon and Alex who had fallen sustaining multiple injuries. Caring for and moving patients in the snow added a whole extra dimension, forcing us to move quickly to stop the patient from getting cold.

Evenings were filled with talks from each of the faculty members about their careers. It was great to hear their individual stories and experiences; Jon and Alex have so much experience in expedition medicine and Lucy has helped to develop stroke care in Ghana and the Gambia – between them, they had a lot of advice and made us feel like anything was possible. These were followed by a 3-course dinner and plenty of wine. One night we went into Morzine for local mountain dishes.

The Verdict

Overall, it was a great course. The pre-course lectures allowed the afternoon teaching to be interactive and practical. Morzine was such a perfect base with excellent skiing for all abilities. The chalet was in a beautiful setting; there are not many places better to practice traction splints than in front of a log fire whilst there’s knee-deep snow outside and the stars are shining. Unlimited wine and a hot tub aren’t bad either.

As well as the formal teaching sessions there was plenty of time to chat with the faculty and to learn from each other’s experiences. It’s hard not to be inspired when surrounded by a group of such like-minded people. By the end of the week, there were lots of plans afoot for expeditions and future meet-ups in Scotland and beyond.

Top Tips

• Make time to watch the online videos before the course
• Arrive early to make the most of the skiing
• Bring your swimming kit for the hot tub at the chalet
• Make the most of your downtime with like-minded people and experienced expedition medics to get ideas and inspiration for the future
• Log your CPD time and reflect on what you took away from the course

Photos courtesy of Dr Jenny Baker

The post Winter Expedition Medicine and Leadership Course, Endeavour Medical: A Review appeared first on Adventure Medic.

Rogier shares his journey from skateparks in Utrecht to surf medicine in Indonesia. He puts his qualifications to the test staffing one of the most remote surf clinics in the world, renowned for its formidable waves and furtive monkeys.

G-land, situated on the Eastern side of the Bay of Grajagan in Java, Indonesia, is home to internationally renowned left-handers and some of the biggest surf competitions in the world. But, G-land’s surfing credentials come at a cost: waves ranging from 2-20+ feet, shallow coral reefs and its remote location also produce some of the most dangerous surfing conditions in the world. Working as a surf doctor is not something that is taught at medical school, but for those that are interested, there are definitely ways to get started.

Why Surfing?

As a young kid, I was really passionate about skateboarding. I was addicted to the physical rush it gave me to land a new trick. I would literally eat, sleep, go to school, skateboard and repeat. Five years later, I was starting medical school and saying goodbye to the passion that had brought me so much joy. Thankfully, this would not turn out to be a definitive farewell from board sports.

During my time at university, I joined the board sports student association and tried snow-kiting, surfing and wakeboarding. I realised that I loved surfing. It was not just the physical rush of catching a great wave, but also the serenity of being out in the water that I fell in love with.

Training as a Surf Medic

I came across a group, back then called the European Association of Surfing Doctors (EASD), which spiked my interest immediately. EASD, now known as Surfing Medicine International (SMI), was founded as a non-profit organisation to connect doctors with a passion for surfing. SMI aims to contribute to the health of the surfer by developing surf medicine.

I joined SMI’s Advanced Surfing Life Support (ASLS) course in Ericeira, Portugal. It was great to meet like-minded doctors with an interest in practising medicine outside of the clinical environment. Our days were filled with lectures about topics from drowning to dive medicine, to infectious diseases and heat stroke. The workshops focussed on hands-on scenarios such as CPR, evacuating an injured patient and C-spine immobilisation. Following the acronym DR. MARCH (Danger, Response, Massive haemorrhage, Respiration, Circulation, Hike vs Helicopter/Hypothermia vs Hyperthermia) we had to assess and treat the simulated patient. This might seem similar to an Advanced Wilderness Life Support (AWLS) course but there was one big difference; lifeguarding is also an integral part of the course.  How would you get an unconscious surfer on to your board and out of the water as fast as possible?

G-Land

It took me a while to put my training to full use. After graduation, I worked in Emergency medicine and then in surgery, before finishing my training to become a general practitioner. The first thing I did as a fully qualified GP was start my journey to G-Land.

I contacted Surfing Doctors, a non-profit organisation that aims to provide medical care in dangerous and remote surf locations. G-land surf camp is located within the Plengkung Nature Reserve at the edge of Grajagan Bay in Java, Indonesia. Practically, it is a 3-hour fast boat from Kuta, Bali. G-land was discovered by an elite group of surfers in the mid-1970s and is considered one of the best lefts in the world. It produces dangerous surfing conditions that mean reef cuts, infections and trauma can happen in the blink of an eye.

Surfing Doctors has a roster to make sure a doctor is always on-site to provide the necessary medical care. There are three clinics each with basic medical facilities. For more serious injuries, patients are usually evacuated to Bali International Medical Centre (BIMC). BIMC can be reached in seven to ten hours overland, three hours by fast boat, or in more urgent situations, a short helicopter flight.

The Medical Clinic

When I was in G-land, I was the only doctor on site. My first priority on arrival was to visit the clinic and familiarise myself with the medical equipment. The clinic is funded by donations, often from injured surfers who after treatment, can donate to replace the medical equipment that has been used. The most common injuries seen in G-land are reef cuts, sprains and strains. These might seem like minor problems, but even the smallest, most harmless-looking reef cut has a high chance of developing into a serious infection if not treated correctly. This is why antiseptic cream and antibiotics are your best friends in G-land.

Marine life injuries are also common, especially from sea urchins which can leave their mark on a surfer’s foot. The needles are very fragile and can easily break or crush when you’re trying to remove them. On the contrary, shark attacks are really rare; you have a 1 in 63 chance of dying from the flu compared to a 1 in 3.7 million chance of being killed by a shark. Approximately 80 attacks occur worldwide each year, only 5 of which are fatal. To put this in stark perspective, humans kill an astonishing 100 million sharks every year.

Besides marine life, it is also important to be aware of the monkeys that inhabit the surrounding area and jungle. They are accustomed to humans and can transmit rabies through their bite. They are not to be fooled around with, especially the dominant males. At one point they came really close during a yoga session and stole my wallet. Thankfully for me, the only thing bitten was my driver’s licence.

Other common medical problems in G-land include sunstroke, sunburn, malaria, dengue fever and traveller’s diarrhoea. The Indian ocean at G-land can be extremely hostile: major traumatic injuries happen as a result of the enormous power of the waves, with surfers known to have suffered serious pelvic fractures in previous years. Luckily no major incident requiring evacuation occurred during my stay.

The Surf

During my stay, I had enough time to explore the surrounding jungle and catch some waves myself. When surfing anywhere, it is really important to understand and stick to surfing etiquette. It’s also important to respect surf culture and be aware of more unpleasant tendencies like ‘localism’. Surf localism, which I’ve only rarely encountered, is more common in crowded surf spots where locals object to ‘strangers’ catching ‘their’ waves. This mostly consists of verbal assault but has been known to escalate to intimidating signs, physical violence and vandalised equipment. Fortunately, G-land is not a crowded place and the locals were extremely accommodating. A big advantage of being the surf doctor was that a lot of the surfers were happy to see me in the line-up and would often ‘give’ me one of ‘their’ waves.

Surfing terms and etiquette

Doctor Becomes Patient

Unfortunately, on my last day in G-land I felt really sick. At first, I thought it was just seasickness from the ride on the fast boat back to Bali. Arriving at my hotel, I continued to feel nauseous, developed painful joints and felt feverish. A few hours later, I was vomiting and beginning to get dehydrated. I used some salt and sugar to make my own oral rehydration solution (8 teaspoons of sugar and 1 teaspoon of salt, dissolved in 1 litre of water usually does the trick). As time passed, I began feeling more and more drowsy and decided to head to hospital. I was so weak by this point that I remember struggling not to collapse whilst walking to the taxi. I was afraid I might have malaria or dengue fever but luckily, after a battery of negative tests, we presumed it was just ‘Bali belly’. Thankfully, I made a quick recovery and was able to enjoy the rest of the time I had left in Indonesia.

Top Tips for Working as a Surf Medic:

• Put your own safety first. Don’t go out there and surf in conditions that you are not capable of. Never forget that you are (most likely) the only medical doctor in an incredibly isolated spot and that you need to be in good condition to be able to help others.
• Prepare for the worst. Make sure you know your medical equipment inside out. Get acquainted with the equipment, environment and evacuation procedures as soon as you arrive, so that you don’t lose time when there is a medical emergency.
• Get to know the surfers and get out there. The more you get involved and earn their respect, the sooner they will come to you with a medical problem. It is always easier to treat a medical problem/wound (reef cut) at an earlier stage to prevent the need for evacuation.

More Information and Getting Involved:

• For specific enquiries, Surfing Doctors (glandsurfdocs@gmail.com) have information on current vacancies and opportunities in G-Land.
•  The World Conference on Surfing Medicine is a yearly event run by Surfing Medicine International – this year it was in April in Valdovino, Spain. 2024 venue TBA – more information can be found at https://www.surfingmed.com/world-conference-2023/
• Advanced Surfing LIfe Support courses are also run by Surfing Medicine International. Information can be found here https://www.surfingmed.com/smi-live-events/#2

The post From GP to G-land: Surf Medicine in Remote Indonesia appeared first on Adventure Medic.

University Hospitals Dorset provides a unique opportunity for junior doctors to combine an emergency medicine post with a fully funded qualification in the world’s first postgraduate course in Extreme Medicine. Dr Johnston and Dr Pearson have melded a passion for adventure with academia and clinical experience. They discuss the realities of the role and the exciting places it has led them.

Structure of the Role

The post is an 80:20 split of clinical emergency medicine to non-clinical time development time. From a clinical perspective, a fellow will work a normal SHO or middle grade rota in the Poole Emergency Department. The remaining part of the year involves the completion of course modules culminating in a Postgraduate Certificate (PGCert), Diploma (PGDip) or Masters (MSc) in Extreme Medicine from the University of Exeter.

The job is for twelve months with an optional extension of up to three years for the completion of the MSc. If a fellow’s academic requirements are completed early, the remaining non-clinical time can be used to work as a doctor on an expedition or event. Such positions are arranged by the individual, not by the department.

Prerequisites for application

For the SHO role, a candidate must have completed foundation training or the equivalent if applying from overseas and should have at least six months experience in Emergency Medicine.

For the Specialty Registrar role at least three months experience in anaesthetics and/or ICU is required. If a candidate has prior experience working in remote environments or evidence of an interest in expedition or humanitarian medicine this will be looked upon favourably, but is not a requirement.

Location of the fellowship

Fellows are primarily based in Poole Hospital, with the option of a secondment to Royal Bournemouth Hospital for more varied clinical exposure. The rest of the post involves course modules which are based in the UK and abroad. Examples of the MSc course locations include: Oman (Desert Medicine), Norway (Polar Medicine), Costa Rica (Jungle Medicine), Nepal (Mountain Medicine), Florida (Dive Medicine) and Slovenia (Alpine Medicine).

Accreditation

The trust provides a funded place on the MSc in Extreme Medicine from the University of Exeter. A MSc will be obtained, assuming academic satisfaction, after 3 years working for the trust. For those in the fellowship for a shorter duration, such as one or two years, there is the option of completing a PGCert or PGDip in Extreme Medicine respectively.

Our Overall Impression

The opportunity to learn to provide medical care at a high level in extreme environments is what distinguishes this job from other emergency medicine fellowships. For each module, the multi-disciplinary student cohort is different and therefore peer-to-peer learning and networking is exceptionally varied.

The modules generally consist of a residential component, with opportunities to learn both expedition skills and the medical considerations relating to a specific environment. The academic component required after each course is linked to the theme of the module. For example, a fellow may be asked to write a critical appraisal of the evidence surrounding the prevention and treatment of heat-related illness following the desert medicine module.

The Poole Emergency Department is a friendly and supportive workplace. The clinical work is diverse, team-based and enjoyable. As the fellowship is a full-time post in the same department, the rota will often be made available up to six months in advance. The town of Poole is a fantastic place to live. There is easy access to the Jurassic coast and the harbour is great for water sports, including kitesurfing.

Outcomes of the fellowship

An Extreme Medicine qualification does not automatically lead to pre-hospital work, however partaking in the modules provide ample opportunity for networking with expedition clinicians and inspirational colleagues. The MSc modules cover the logistics, practicalities and the medico-legal considerations of working in an expedition environment, which prepare fellows to work outside of the hospital environment.

In terms of career progression, fellows are encouraged to undertake quality improvement projects within the emergency department and maintenance of a clinical portfolio is facilitated by the senior team.

Funding

The cost of the PGCert/PGDip/MSc is funded by the trust, however personal kit, transport (including flights) and certain course supplements need to be self-funded. While attending a course module a fellow will continue to receive their usual daily wage.

There is an additional study budget provided by the department for related courses and conferences. Study leave will be incorporated into the time required to complete the relevant Extreme Medicine modules.

Further considerations

It is worth bearing in mind that although this is a largely clinical role, when there is personal development time, it is taken in blocks throughout the year. A fellow will be expected to work a full-time rota for the remainder of the post. This inevitably leads to a greater proportion of lates, nights and weekend shifts.

Currently, the Poole and Bournemouth Emergency Departments are split-site resulting in a lack of exposure to certain clinical presentations. Bournemouth is the acute stroke and cardiology centre, so fellows placed in Poole will see fever stroke and acute cardiology presentations. On the other hand, Poole is the local trauma unit, so a fellow will see more trauma presentations. A new acute service is being built and the departments will be merged into a single-site in 2025.

Final Thoughts

This job is ideal for an adventurous medic who wants to combine clinical experience with expedition academia. It is a unique role, which allows for development as a clinician and exploration of opportunities outside the typical hospital environment.

Links

For those considering this post, recruitment for August 2024 will begin in October and will be advertised on NHS Jobs and World Extreme Medicine’s social media platforms.

Information about the MSc in Extreme Medicine can be found on the University of Exeter webpage: Extreme Medicine MSc (Distance) | Postgraduate taught | University of Exeter.

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Third year medical student, Georgina takes us through a review of the literature regarding the aetiology, diagnosis and management of the most common otological conditions; barotrauma and decompression sickness.

Over recent years, the number of people recorded to have taken part in scuba diving has decreased with an estimated 2,717,000 divers in the United States in 2019 showing a 4.63% decrease from 2018. ⁽¹⁾ However, according to a 2021 Sports and Fitness Industry Report, although the number of casual divers (one to seven dives per year) decreased by 6.7% from 2019 to 2020, the number of more serious divers (eight or more dives per year) increased by 1.3% among the American population. ⁽²⁾

Dive injuries occur primarily due to the effects of pressure when moving through the water. There is an extensive medical questionnaire which divers are required to fill in before in order to go some way to mitigating these injuries.

When done correctly with experienced guides, diving is usually not an unsafe activity. Nevertheless, incidents do occur, even with professionals. In a report by Divers Alert Network (DAN) between 2010 and 2013, 43.75% of injuries were head and neck related and of these, 72.53% were injuries to the ear. ⁽³⁾

Injuries relating to the ear such as barotrauma (injury due to pressure change) and decompression sickness (DCS) are more common dive issues.

This review discusses the aetiology, diagnosis, and management of common otological consequences of diving with a specific focus on inner ear decompression sickness (IEDCS), inner ear barotrauma (IEBt) and middle ear barotrauma (MEBt).

Incidence

Dive injury incidence is low. In a study by the DAN, who looked at 9,000 divers who did 135,000 dives, decompression illness occurred at a rate of 0.03%. ⁽⁴⁾ The study was conducted following safe and accepted dive procedures. When an injury occurs though, rapid diagnosis is beneficial. This can be a challenge due to the diverse range of symptoms and severity. Decompressing after a dive is important but one should also pay close attention to symptoms that may arise afterwards.

Figure 1 shows the anatomy of the middle and inner ear for reference.

Physics

Decompression Illness

Decompression illness is an umbrella term for two distinct aetiologies: decompression sickness and arterial gas embolus.

Decompression sickness is more relevant to otology and is largely impacted by Henry’s Law.

Henry’s Law states, ‘as the partial pressure of a gas above a liquid increases, that gas becomes proportionally likely to dissolve in that liquid’.

Due to the increased pressure that divers are under, the gas they inspire has a higher pressure. This can cause supersaturation of tissues meaning that they are at their capacity for the amount of inert gas they can hold. ⁽⁴⁾

Decompression sickness most commonly occurs when divers surface too quickly as the gas in tissues isn’t given enough time to be released slowly leading to supersaturation and bubble formation. These bubbles of evolved gas can cause a direct or indirect effect. The direct effect results in damage as the bubbles can occlude vessels, leading to ischaemia. The indirect effect is caused by an inflammatory response which activates the clotting cascade. Decompression sickness can occur at different levels of severity, but at worst can cause serious damage to the central nervous system and the cardiorespiratory system. ⁽⁵⁾ Arterial gas embolus can occur as a consequence of DCS. It is when the alveoli become over inflated and nitrogen bubbles enter the bloodstream and travel to the brain, for example, potentially blocking major vessels. This is usually less relevant to otology.

Barotrauma

Barotrauma, the damage to tissues caused by the direct effects of pressure, follows Boyle’s Law.

Boyle’s Law explains that, ‘as you descend deeper into water, the volume of a gas decreases but the pressure increases substantially’.

All enclosed spaces in the body such as the paranasal sinuses and the inner and middle ear can be affected by this increase in pressure. If this pressure build up is left, it can lead to pain, haemorrhage and perforation of anatomical structures.⁽⁵⁾

Divers are taught to equalise early and often as they descend, using the Valsalva manoeuvre, to avoid barotrauma.⁽⁶⁾ This manoeuvre equalises pressure across the tympanic membrane. When equalising, the air is forced through the eustachian tubes into your middle ear. This increases the volume of gas in your middle ear and decreases the pressure. This happens because as the diver ascends the trapped air expands by three to five times in volume, dependent on dive depth. ⁽⁷⁾

Middle Ear Barotrauma

Aetiology

The most common difficulties experienced by divers are middle ear barotrauma (MEBt) and eustachian tube dysfunction. ⁽⁸⁾ Eustachian tubes connect the middle ear space to the throat. This connection allows the pressure in the middle ear space and the external auditory canal to remain balanced or equalised. On the descent, pressure release is an active process. On the ascent, however, it happens passively. Disruption to the release of pressure can cause issues.

As divers descend, ambient pressure increases meaning that the volume of the gas in the middle ear decreases. This creates a vacuum. If equalisation cannot sufficiently compensate for this, MEBt occurs. The vacuum created causes blood flow to local vessels to increase in turn causing inflammation. ⁽⁸⁾ Blood vessels can then rupture and with the subsequent pressure increase, perforation of the tympanic membrane occurs.

Diagnosis

MEBt can present with difficulty equalising, discomfort and a stuffy sensation in the ear. ⁽⁹⁾ Diagnosis is difficult as often requires symptom reports from the patient which can be subjective. If suspected, an otoscopic examination is required to determine the grade of the injury.

There are three grading systems for MEBt: the Teed, the modified Teed and the O’Neill. The Teed Classification (1944) has been modified over the years but the current and most relevant is the O’Neill Classification. ⁽¹⁰⁾ The O’Neill consists of three grades as shown in Table 1.

Table 1 – The O’Neill Classification (8)

Management

Most cases of MEBt are transient and may only require rest, a course of steroids or antibiotics. Grades 0-1 are mostly treated conservatively. In more severe cases, such as tympanic membrane perforations surgery might be considered. Diving should not be considered until injury and symptoms are fully resolved and in the case of perforation, the tear is fully closed. ⁽¹¹⁾

Inner Ear Barotrauma (IEBt) and Inner Ear Decompression Sickness  (IEDCS)

Aetiology

As the external pressure increases during descent, the tympanic membrane is pushed inwards. This increases the pressure in the cochlea. When the pressure differential rises above 90mmHg the ET tubes are no longer functional meaning the equalising of pressure can no longer take place. ⁽¹²⁾ IEBt can be termed implosive or explosive. The perilymphatic duct connects the cochlea to the subdural space in the superior cranial fossa. Subsequent failed Valsalva manoeuvres can therefore increase the intracranial pressure and the pressure in the cochlea. An increase in perilymphatic fluid pressure causes an explosive rupture whereas a decrease leads to an implosive rupture. Implosive rupture especially can have many subsequent effects such as tearing the internal cochlear membrane or basilar membrane.

A study by Nachum et. al. revealed that of divers diagnosed with IEDCS, 48% of them were suffering from other decompression illness symptoms. ⁽¹³⁾ Although not fully understood, IEDCS is believed to occur due to the formation of a bubble of compressed gas in the endolymphatic and perilymphatic spaces due to the supersaturation of local tissues. ⁽¹⁴⁾ A correlation between persistent foramen ovale (PFO) (a right-to-left shunt) and IEDCS has been seen suggesting that gas bubbles can enter the arterial circulation from the venous circulation rather than being exhaled from the lungs. This can cause ischaemic events due to gas emboli. In a study by Mitchell et. al., in cases where IEDCS was detected, 77% were also found to have a large right-to-left shunt. ⁽¹⁵⁾

Diagnosis

IEBt can present with problems with balance and coordination as well as tinnitus, sensorineural hearing loss and vertigo. ⁽¹⁶⁾ Surgery may be required if the symptoms do not improve over an observational period, usually of about ten days. Some injuries relating to IEBt have been seen to spontaneously resolve over several days, although instances of this are thought to be underreported due to less severe symptom presentation. ⁽¹⁷⁾

The overlap in symptoms between IEBt and IEDCS leads to misdiagnosis. Divers are often divided into risk groups considering various factors:

• Previous dive incidents
• Use of decompression stops with a controlled ascent
• The time of onset of symptoms after the dive
• Diving with mixed gas

The presence of these factors makes a diagnosis of IEDCS more likely. There is a criterion known as HOOYAH, as seen in Table 2, which is used to understand the aetiology of a presenting patient and differentiate between the diagnoses of IECDS and IEBt.⁽¹⁹⁾

Table 2 – HOOYAH criteria used to differentiate between IEBCS and IEBt ⁽¹⁹⁾

Important differences which aid in distinguishing between Inner Ear Decompression Sickness (IEDCS) and Inner Ear Barotrauma (IEB) are as follows:

Management

The importance of differentiating between the two becomes apparent when looking at their treatment methods. ⁽⁸⁾ The gold standard treatment for IECDS is urgent recompression using hypobaric oxygen treatment.

This works by increasing the pressure of the environment and consequently decreasing the size of the gas bubble (usually nitrogen) allowing more oxygen to be delivered to tissues and aiding dissolved gas offloading. ⁽¹⁴⁾ Until this can be administered, 100% oxygen must be given. ⁽²⁰⁾ Steroids to reduce inflammation can be given as an adjunctive treatment option. 

The incidence of PFO is higher in a patient with IECDS compared with the general population. This is a good indication for screening using Doppler sonography. However, a diagnosis of PFO would not necessarily restrict further diving as it is possible for people with PFO to dive following the ‘low bubble diving’ guidance. ⁽²¹⁾

For acute IEBt, bed rest and avoidance of actions that induce pressure transmission are advised. Suggested treatment for IEBt is usually a course of steroids at a high dose, for example, 250mg prednisolone for three days, followed by a steroid taper course. ⁽²²⁾ In circumstances where the patient’s hearing continues to deteriorate, further investigation is required, often by surgery. This is also the case if there is thought to be a perilymphatic fistula. For any patient experiencing IEBt, a high-resolution CT scan of the temporal bone is required to rule out further complications. ⁽²³⁾

After treatment patients are to be counselled on the further risks of diving and really that they should try to avoid it all together. However, a paper by Parell et. al, suggested that this advice might be ‘unnecessarily restrictive’. ⁽²⁴⁾ This study looked at twenty-one patients who, after receiving counselling, still decided to continue diving despite their IEBt diagnosis. They were taught effective middle ear equalisation techniques. After yearly follow-ups no further damage was seen in the inner ear of any of these patients posing a potential challenge to the conventional teaching advice on this. 

Conclusion

Diving carries a relatively high incidence of otological consequences. It is not only important that clinicians and instructors are aware of these but also divers themselves. More research into how we can improve patient management and what can be done to decrease the incidence of these pathologies needs to be conducted and published. It is also critical that these findings are presented to divers in a clear and timely fashion.

Patients should be appropriately counselled on prevention such as correct equalisation techniques and the importance of following guidance. The effects of diving irresponsibly can be devastating. Even in situations where otological injury is not severe, it can cause panic and the cascade of much more dangerous consequences.

Bibliography

1. 2020 Outdoor Participation Report Outdoor Industry Association; 2020 [Available from: https://outdoorindustry.org/resource/2020-outdoor-participation-report/.
2. 2021 Sports, Fitness, and Leisure Activities Topline Participation Report Sfia.org;  [Available from: https://www.sfia.org/reports/900_2021-Sports%2C-Fitness%2C-and-Leisure-Activities-Topline-Participation-Report.
3. Buzzacott P, Trout B, Caruso J, Nelson C, Denoble P, Nord D, et al. Annual Diving Report  2012-2015 Edition. Divers Alert Network; 2015.  Contract No.: 31 January.
4. Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression illness. Lancet. 2011;377(9760):153-64.
5. Livingstone DM, Smith KA, Lange B. Scuba diving and otology: a systematic review with recommendations on diagnosis, treatment and post-operative care. Diving Hyperb Med. 2017;47(2):97-109.
6. Seddon F, Thacker J, Jurd K, Loveman G. Effects of Valsalva manoeuvres and the ‘CO₂-off’ effect on cerebral blood flow. Diving Hyperb Med. 2014;44(4):187-92.
7. Becker GD, Parell GJ. Barotrauma of the ears and sinuses after scuba diving. Eur Arch Otorhinolaryngol. 2001;258(4):159-63.
8. O’Neill OJ, Kaighley B, Anthony FJ. Middle Ear Barotrauma. Treasure Island (FL): StatPearls Publishing: StatPearls 2021.
9. Chen JM, Lu ZN, Wu RW, Bi KW, Liu CT. Effect of self-acupressure on middle ear barotrauma associated with hyperbaric oxygen therapy: A nonrandomized clinical trial. Medicine (Baltimore). 2021;100(17):e25674.
10. O’Neill OJ, Weitzner ED. The O’Neill grading system for evaluation of the tympanic membrane: A practical approach for clinical hyperbaric patients. Undersea Hyperb Med. 2015;42(3):265-71.
11. Nofz L, Porrett J, Yii N, De Alwis N. Diving-related otological injuries: Initial assessment and management. Aust J Gen Pract. 2020;49(8):500-4.
12. Shupak A, Doweck I, Greenberg E, Gordon CR, Spitzer O, Melamed Y, et al. Diving-related inner ear injuries. Laryngoscope. 1991;101(2):173-9.
13. Nachum Z, Shupak A, Spitzer O, Sharoni Z, Doweck I, Gordon CR. Inner ear decompression sickness in sport compressed-air diving. Laryngoscope. 2001;111(5):851-6.
14. Boyd KL, Wray AA. Inner Ear Decompression Sickness. Treasure Island (FL): StatPearls Publishing: StatPearls Publishing; 2021.
15. Mitchell SJ, Doolette DJ. Pathophysiology of inner ear decompression sickness: potential role of the persistent foramen ovale. Diving Hyperb Med. 2015;45(2):105-10.
16. Clayton S, Walklett C. Decompression Illness. RCEM Learning2019.
17. Love JT, Waguespack RW. Perilymphatic fistulas. Laryngoscope. 1981;91(7):1118-28.
18. Elliott EJ, Smart DR. The assessment and management of inner ear barotrauma in divers and recommendations for returning to diving. Diving Hyperb Med. 2014;44(4):208-22.
19. Rozycki SW, Brown MJ, Camacho M. Inner ear barotrauma in divers: an evidence-based tool for evaluation and treatment. Diving Hyperb Med. 2018;48(3):186-93.
20. Talmi YP, Finkelstein Y, Zohar Y. Decompression sickness induced hearing loss. A review. Scand Audiol. 1991;20(1):25-8.
21. Torti SD, Kraus MD, Völlm E. Swiss Underwater and Hyperbaric Medical Society (SUHMS) Patent Foramen Ovale 2019 [Available from: https://suhms.org/wordpress/wp-content/uploads/2019/02/K_PFO_E_19_02_CMYK.pdf.
22. Klingmann C, Praetorius M, Baumann I, Plinkert PK. Barotrauma and decompression illness of the inner ear: 46 cases during treatment and follow-up. Otol Neurotol. 2007;28(4):447-54.
23. Shupak A. Recurrent diving-related inner ear barotrauma. Otol Neurotol. 2006;27(8):1193-6.
24. Parell GJ, Becker GD. Inner ear barotrauma in scuba divers. A long-term follow-up after continued diving. Arch Otolaryngol Head Neck Surg. 1993;119(4):455-7.

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Post-covid, we as healthcare professionals are acutely aware of burn-out and the need for reconnecting with ourselves and our peers. The Remote and Restorative course, delivered by Endeavour Medical, offers training on pre-hospital and expedition medicine in the context of building resilience, learning from shared experiences, and getting back in touch with our environment. Here, Dr Beth Payne reviews her time on the course delivered in Coverack, Cornwall, highlighting the therapeutic effect of being by the sea.

Endeavour Medical Company Synopsis

Established in 2021, Endeavour Medical delivers training in expedition medicine and global health. Their faculty boasts decades of experience with a number of impressive accolades. Courses are available to healthcare professionals and non-medics, and cover an array of topics in differing locations. Their underlying ethos of equitable healthcare globally means that funds generated from courses help initiatives in Northern Kenya.

Key Facts

Rough Annual Dates and Duration / I did the course in June 2022, but there are multiple dates from April to September. Course duration is two days.

Location / Coverack Youth Hostel, Cornwall. The company also offer courses in other areas of Cornwall and Devon.

Cost / £420, inclusive of two nights accommodation, tuition and meals.

Delegates / Around 20 doctors and physician associates from Derriford Hospital.

Prerequisites / No previous experience required. The course is open to doctors, medical students and other allied healthcare professionals such as paramedics or physician associates.

End Qualification / Certificate of attendance.

Faculty / The course was run by a range of enthusiastic and professional faculty members. This included doctors with significant experience in expedition and emergency medicine and  an advanced critical care paramedic practitioner.

Link to Course Website / Endeavour Medical

Course Setting and Delivery

This was a two-day course set in the idyllic Cornish coastal village of Coverack, on the Lizard Peninsula.

The sun shone for two glorious days spent delving into the world of remote and restorative medicine. Based at the Coverack Youth Hostel, we were treated to stunning sea views, cozy shared dormitories, and delicious home-cooked meals from the Youth Hostel staff. A stone’s throw from the village of Coverack itself, we could easily explore the traditional fishing harbour and sample local ciders on offer during the available down-time. On the morning of day two, we loosened up with a joyous beach yoga class.

The other delegates were a mixture of grades and specialties, all based in the South West. This presented a unique opportunity to work and learn from each other, in a completely different setting to which we would usually interact.

The delivery of the course was fantastic – the course faculty were experienced, knowledgeable and skilled in imparting their expertise and you could tell they had a genuine passion for both expedition medicine and education. Additionally, they were open and honest with their experiences, careers and routes into this novel and exciting specialty; providing pragmatic and invaluable advice.

Course Content

Broadly, the course was split into two main elements; remote and wilderness medicine, and restorative medicine.

The remote medicine aspect involved a wide range of outdoor based tutorials, workshops and practicals. Topics included an outdoor trauma scenario, hyperthermia management, shelter building, packaging and transfer of patients, c-spine injuries and the use of radios for communication in remote environments. A particularly memorable workshop on heuristics enabled us to consider what our natural leadership style is, and introduced us to alternative methods that we could trial throughout the course. At the end of each scenario, we were encouraged to reflect on how we worked as a team, what our individual roles were, and whether we had tried a different style of leadership/teamwork. The setting offered the perfect environment to do so; in a fun and collaborative way, in the beautiful Cornish weather, and all whilst learning new skills.

The coastal location allowed us to experience two unique practical elements of the course. Firstly, the hypothermia workshop, which involved a volunteer (myself) immersing themselves in the ‘cold’ harbour water for 10 minutes before being warmed by the rest of the team. And secondly, a demonstration ‘rescue at sea’, when a casualty-at-sea scenario unfolded whilst we kayaked around a sunny sheltered harbour. In this workshop we were invited to board a working lifeboat to witness a RNLI crew response.

The restorative aspect of the course was a tonic to the challenging experiences all of us have had over the past two years, and the team created a safe and remedial space to open up and share. Highlights included workshops on an approach to mental health in remote environments and a wellbeing and resilience workshop.

Additional Benefits

The main skills I took away from this course were a mixture of leadership and team working skills, and some practical skills.

Utilising the leadership heuristics workshop and the reflections at the end of each scenario, we were able to become more self-aware of our own natural tendencies and roles within teams. This enabled us to take turns trying out new ways of leadership or collaboration, and I am sure all of us will use these transferable skills in the clinical environment.

The trauma, shelter building, radio and practical scenarios were invaluable, as they are not commonplace in traditional medical education.

Overall Verdict

This was an absolutely excellent course – one which I would highly recommend to anybody interested in either an introduction to remote medicine, or wanting a unique opportunity to gain knowledge and experience outside of a hospital setting.

The practical skills I gained were invaluable; I feel more confident and have created a solid basis to build further knowledge and experience in expedition medicine.

Being able to learn together and socialise away from the pressures of our working lives, made for a relaxed atmosphere. We were able to challenge ourselves to trial leadership/followership styles which may not have felt entirely natural, but the scenarios enabled us to do so in a fun and stress-free environment.

The resilience aspect of the course was a highlight for me. I felt very refreshed and restored following the course and this was reiterated by many colleagues I spoke to.

Another highlight for me was the evening talk from Dave Dungay, a critical care paramedic who shared some interesting highlights and key points that have defined his career. This open and honest talk was really inspiring, and opened up the floor  to discuss and reflect on the collective experiences of varying healthcare professionals present.

All in all, this was an excellent, well-organised course that I would thoroughly recommend to anybody.

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It is in human nature to constantly strive for tougher challenges, push further, to increasingly extreme environments. Any running race longer than a traditional marathon (26miles or 42.2km) is classified as an ultramarathon. There are over 5000 ultramarathon races every year worldwide. Many of these are located in remote and inaccessible locations, and some take place over multiple days. With the complexity, duration and rural location of these events, medical cover is required to reduce risks to participants. This falls under the remit of both wilderness and sports medicine. 

The Highland Ultra Background

‘Beyond the Ultimate’ (BTU) hosts a 125 km ultramarathon in Knoydart, in the Scottish Highlands. The race is run over three days in particularly challenging terrain, with over 5500m of ascent.

The event is split into three stages. 54km, 42km and 29km. Basecamp, where runners sleep on the first and last nights, is located at Inverie, only accessible by ferry from Mallaig. At the end of the first and second stage runners camp at Kinloch Hourn. Aside from tents and drinking water provided at each camp, runners have to be self-reliant, and able to deal with any issues that arise on the trail. Clothes, sleeping bags, food and personal med kits must be carried by each runner.

Beyond the Ultimate specialises in arranging unique ultra-marathons across the world. The inaugural Highland Ultra took place in October 2021, and we attended during its second year. On this occasion, medical cover was provided by a team of 6 with a range of experience and backgrounds. This included a consultant team leader, three doctors, one physio, and one advanced nurse practitioner, however the composition of event teams can vary considerably.

Why Choose the Highland Ultramarathon as a Medic?

Working on the Highland Ultramarathon would be appealing to anyone who enjoys spending time in remote and beautiful places. There is no requirement to be any kind of runner; simply an appreciation of the Scottish highlands and a desire to combine professional skills and a passion for the outdoors.

Having worked for BTU in the past we understood its core ethos and values. They are a great team that take time to invest and support the local communities. For the Highland Ultra, event organisers source all food and beer locally from Inverie, plant one tree per entrant and reduce unnecessary waste by providing a water filter bottle to each runner.  There is an expectation that volunteer medics are self-sufficient; it goes without saying that medics must be able to look after themselves first and foremost. Much of your personal equipment you have to provide yourself, including basic camping and hiking equipment and food.

Role of the Clinician

So what does working at this event actually look like? There is no clear answer to this – the joys of a pre-hospital environment come from a varied and unpredictable workload. It is common to find yourself in a very remote environment with limited kit and communications and as a result the planning stage is a vital part of the work. Establishing each member’s skillset, experience and areas of practice is essential in planning your medical response.

Each stage of this event presented its own challenges, and therefore each evening the medical team would liaise with the event coordinators to plan activities for the next day. This included highlighting challenging terrain, where specific risks would be encountered by runners and deciding where medical bags would be strategically placed along the route.

There were three types of kit bag: trauma bags, checkpoint bags and resus bags. Trauma bags were based at the start and finish of each day, being too cumbersome to be carried on foot across challenging terrain. Checkpoint bags accompanied a medic at each checkpoint. Resus bags could be carried more easily and were used in responding to emergencies. At basecamp, a wider range of kit was available.

Minor ailments can wait until the checkpoints or the base camp but anything more serious may require a swift action response. Due to dead zones in the phone signal we relied on trackers that identify runners’ locations  and allow some basic messages to be sent. One potential emergency was encountered during the race and we received a message with no details at the time. We had to respond immediately to reach the runner, taking the resus bag. On arrival it was apparent it was a flare up of a pre-existing medical condition, and not in fact an emergency. The runner needed some supportive care and escorting off the route. No further intervention was required for this patient. However, this reinforced the necessity to be available and adapt to dynamically occurring incidents, sometimes with minimal information.

Tick Awareness

Working in any wilderness environment there always has to be consideration of the wildlife. Whilst there aren’t any exotic spiders in Scotland, there are ticks. Lots of ticks. The issue is that tick bites may lead to Lyme disease, with the iconic bulls-eye lesion (erythema migrans). Whilst ticks in themselves are not necessarily medical, the medical team has a role to play. The medical team can brief the runners about ticks, including some of the tips below. It is ultimately up to the runners to search for ticks themselves. We encouraged runners to correctly remove their own ticks where possible, some however felt uncomfortable and asked the medical team to assist. As a clinician some of the key points to remember are below.

Top ticks:

1. Always carry tick tweezers
2. Check for ticks in places where the sun doesn’t shine
3. Buddy up (might need this for tick 2)
4. Long. Trousers. Always.
5. Remind yourself about target lesions

Foot Care

Foot care and foot management was a common reason for presenting to the medics at the checkpoints and basecamps. Hot spots, blisters or toenails coming loose were experienced by most of the runners and had the potential to be race-ending issues if not managed appropriately. Having only had experience in secondary care, foot issues from running were not clinical presentations that we had come across previously.

Runners were encouraged to self manage their foot problems, given that they had the greatest experience with their own body. The medical team would only step in when they were unable to do so. There is little evidence available to guide foot care in long distance running; the only protective factor appears to be previous race experience¹. Cumulative experience of these types of events is in itself preventative, which emphasises the importance of self-management.

The general guidance that we were advised to implement was three-fold; Prevention, Hot spots, Blisters.

• Participants were advised to bring their own blister prevention or management kit (such as tape) so that if they became aware of their own foot hot spots, they could manage it themselves before seeking medical attention.
• If a participant presented with a hot spot, defined as an area where friction is evident, but no separation of the skin layers has yet occurred (normally red and painful), advice about reducing friction was provided². This included straightening out socks and/or the application of tape which would reduce further friction and hopefully prevent development to a blister.
• If the participant presented with a blister, advice was normally to avoid bursting/deroofing due to the risk of infection. If the blister was too big or too painful to allow the participant to continue, reducing the pressure by using a sterile needle and thorough cleaning was considered with close monitoring for infection. Thankfully very few blisters were encountered during the event that required this management.

For the future, and due to the lack of current research in the area, the medical team was keen to get a better idea on how to best advise and provide care to participants presenting with foot issues. Following this event, runners were asked to fill a research questionnaire to find out their experience of foot related issues and what steps they took to manage it, including self management as well as any intervention by the medical team. This research was carried out by a member of the BTU medical team with the intention of repeating the questionnaire after multiple BTU ultra events. This would provide a large patient sample size with demographics, variety of experience and interventions, to further understand what is the best method of preventing and managing these issues.

The Finish Line

Overall, the event progressed very smoothly, with nearly every runner crossing the finish line. For the medics there are long days with early starts and limited sleep. Unfortunately, one’s duty doesn’t quite end at the finish line. This is always the area where we needed to be the most vigilant. Runners’ mental resilience is put to the test as they fight to the end, but the pain they have been desperately trying to ignore may be a matter for concern. It is not uncommon to see runners fainting due to a mixture of sheer exhaustion, dehydration, low blood sugars, etc.

The icing on the cake is of course the well-earned rewards at the finish line. With the mood and spirits high it is very easy for medics to get caught up in the celebrations, but it is important to keep an eye out in case anything goes wrong. Luckily there were no complications, and everyone thoroughly enjoyed the evening with food and entertainment provided by the local community including pizzas and a folk band.

Interested?

This event ticked all the boxes for us. It was great fun with a competent group of medical and non-medical staff. The weather was marvellous (very fortunately) as was the scenery.  Beyond the Ultimate are a great organisation to work for. They are very supportive of the medical team, understand their limitations, and make the team feel valued by really incorporating the medics into the race team. They welcome medics to get involved with some of the wider race support during quieter times and foster a feeling of inclusion and teamwork. Any appropriately qualified individual with an interest in expedition medicine who wants to participate in exciting events within the U.K. should be reassured that there are many opportunities. The Highland Ultra is just one and we hope that this article and the pictures will inspire you to reach out and get involved.

For those new to expedition medicine, it is worth noting that most roles are on a voluntary basis. BTU provides a contribution to expenses, but it is always advisable to check what is and isn’t covered before signing up to these sorts of events.

Indemnity was free for both of us, but this is not always the case. As it was a voluntary role, with senior supervision, there was no issue in obtaining this from the MDU. It is worth arranging this well in advance of the event as the paperwork can take some time to be processed.

The main ways of hearing about these sorts of events are by word of mouth, by messaging companies directly, or by the adventure medic website. There are so many opportunities and events out there, the best thing you can do is express your interest early on and get involved in whatever you can.

Key Details

Timings

The event occurred over three days (Thursday-Saturday), however, the BTU staff were already setting up the event a few days beforehand. The medical and runners were expected to arrive the prior (Wednesday) in good time to run though briefings and kit checks. We all left on Sunday. Some staff and runners did stay within the area to do some more exploring of Scotland, unfortunately, limited annual leave and primary job responsibilities meant that we had to return home.

Logistics

Multiple methods of getting to the location were available. We opted to drive from Edinburgh due to time constraints. Our colleagues flew to Glasgow where we picked them up to drive to Mallaig. Some participants took the train to Mallaig (direct train from Glasgow) where the ferry left for Inverie (start location of the race).

Cost Breakdown

It is likely that your travel costs will be covered by BTU. It is best to check prior to committing how much BTU will reimburse for travel. This is the same for their overseas events as well.

Other costs include:

• Any camping/hiking equipment that you may need (see list below)
• Your own food and snacks. Food and drink was provided on the final evening
• Any drinks at the local pub after the event

Kit and Equipment Not Provided by BTU

Essentials:

• Sleeping bag
• Sleeping mat
• Water bottles (ideally ability to hold at least 2 litres of water)
• Hiking trousers and shirts
• Socks and underwear (and spares. It is best to have as little cotton made clothing as possible due to difficulty drying wet clothing)
• Warm clothing (base layer, mid-layer, hat, gloves)
• Wet weather clothing (jacket and trousers)
• Food (ration packs/dry foods best, lots of snacks)
• Bowl + cutlery
• Head torch (and spare batteries)
• Compass
• Notepad and pen
• Good pair of hiking boots
• Personal toiletries and sun cream
• Travel towel
• Dry bags
• Phone and power bank (+ cable)

Desirables:

• Blow up pillow
• Gaiters
• Small stove (for having a brew at the checkpoints; hot water was provided at the campsites)
• Swimming trunks/swimsuits
• Thermos
• Camera

Useful links

This list is by no means exhaustive and it is purely for interest and to guide further reading.

Guidance for Medical Provision for Wilderness Medicine is useful for those with limited previous experience, and describes logistics, communications, and most crucially the level of support that should be provided, including capabilities of lead medics.

BMJ Best Practice: Heat Illness. The participants in these races are often extremely motivated and will push themselves to the limit when taking part. Heat illness is potentially life threatening and high risk at these events.

DermNet: tick bites and Lyme disease. These were very common and anyone coming away from the event without a tick bite (whether racing or support staff) were by far in the minority. Dealing with ticks and their potential consequences are important to understand.

Oxford Handbook of Expedition and Wilderness Medicine: A very handy guide to emergencies and treatments in the outdoor environment.

References

1.Scheer, B.V. et al. (2014) “The enemy of the feet,” Journal of the American Podiatric Medical Association, 104(5), pp. 473–478. Available at: https://doi.org/10.7547/0003-0538-104.5.473.

2.Dack, D. (2022) Hotspots while running – how to avoid hot feet when running -, Runner’s Blueprint. Available at: https://www.runnersblueprint.com/hotspots-running/ (Accessed: December 16, 2022).

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EXPLORE weekend offers something for everyone with an adventurous spirit. This event, hosted annually by the Royal Geographical Society (RGS), aims to educate, inspire and empower you to transform your expedition and fieldwork dreams into reality. Drawing on the expertise of explorers, geographers and field researchers, EXPLORE covers a broad range of topics and is sure to appeal to anyone with an interest in exploration.

EXPLORE’s two-day programme is curated to both ‘inform and inspire’. Shared experience of over 100 leading scientists and explorers is presented through a series of talks and specialist workshops. The workshops allow discussion and give practical advice on project planning and execution and ample time is provided between sessions to network in the historical map room.

Programme Structure

EXPLORE is held at the RGS in South Kensington, London. This beautiful building has the feeling of a country house nestled amongst the city, packed with curiosities from historical expeditions. Alongside the Natural History and Science museums and Imperial College of Science, Technology and Medicine the location alone is enough to inspire the mind.

A range of tickets are available to cater for single day, weekend and virtual attendance. Prices then reflect duration, level of interaction, members and non-members, students and early bird tickets.

Weekend Highlights

This year heralded EXPLORE’s first in-person event since pre-pandemic times, and what a magnificent debut it was! Over twenty talks allowed for a huge diversity of topics to be covered. With such an impressive line-up, it was difficult to select those that stood out the most. Professional explorer Lucy Shepherd inspired us with tales of adventure, followed by practical expedition planning advice. Chris Woodfield delivered a harrowing but necessary reminder of the climate and ecological emergency, discussing how our actions today can help the planet tomorrow. In an alternative twist, Myles Harris’s research enacted possible healthcare scenarios in the exploration of alien planets. This was complemented by Elly Trobe and Jason Gibbs, who walked us through the numerous medical preparations required to safely explore our planet Earth. The afternoon ended with the first round of specialist workshops: Expedition Logistics. Led by a panel of experts, delegates could choose from a number of different environments including ocean, mountain and polar.

The Explorer’s bar, open after the conclusion of Saturday’s proceedings, provided the perfect venue to continue the day’s discussions over a well-earned pint!

Sunday’s follow-up did not disappoint. The morning opened with Niall McCann’s ‘Why Fieldwork Matters’. His authenticity and undiminished enthusiasm for conservation and the natural world was infectious. He instantly captured the room. Niall left us with a powerful take-home message that “human health, animal health and planetary health are all one health”. It is all of our responsibilities to ensure we conserve it for future generations. Morning talks were concluded with Anthroposea, a short but powerful film by Michelle Sanders on human interconnectivity to our oceans shot aboard Sail Britain. A second round of workshops covered field research in a number of social, biological and medical disciplines.

A huge variety of talks were crammed into the final afternoon. Jamie Buchanan-Dunlop’s profound and heartfelt talk covering communication in the field, international collaboration and humanity had us all reaching for the tissues. Artist Sarah Fortais provided an alternative perspective on human endeavour. Bridging the gap between science and art her displays included space suits for giraffes and genuine NASA moon rocks!

Exhibitors

Numerous exhibitors across a range of specialist areas provided delegates with further opportunity for expert advice and networking. These included Nomad Travel, who provide expeditions with bespoke medical equipment and Silk Road, who deliver environmentally sustainable first aid training to those exploring challenging environments. A full descriptive list of exhibitors may be viewed here.

Reviews

I asked a number of delegates and exhibitors about their experiences of EXPLORE weekend:

“Inspiration from a range of experts and people who have gone and done the extra-ordinary”

“Very cool to meet people who are doing this differently… this makes it feel possible”

“The talks have been inspired and varied… having snippets of people coming in talking about their experiences is lovely”

“Some of us are planning to organise expeditions and get funding… the practical side of things, the talks were really good”

“I have been able to see people that when they have a strong enough idea, there will be others willing to fund it!”

“Having come in with an expedition plan, it’s been pretty helpful to think about areas that we haven’t considered… evacuation plans, yes!”

“It’s been really nice to meet new people… gaining contacts”

Personal thoughts

This was my first EXPLORE weekend. My dad, often knowing me better than I know myself, had twisted my arm slightly and bought me a ticket as an ‘early Christmas present’. I therefore felt rather obliged, on that rainy morning in November, to make my way over to the RGS. However, as I squelched through the doors, I was immediately drawn in by the buzz and excitement that greeted me. The staff, delegates and exhibitors were incredibly friendly and welcoming. I soon got chatting during the morning coffee break. Living in London, it is a rare occurrence to find like-minded individuals who have managed to incorporate their love for the outdoors with a career in medicine. What inspired me so much was meeting others who were in the place I aspired to be. I was so encouraged to believe that it is actually possible.

EXPLORE weekend is not just for medics. It offers a huge variety of content on the essential aspects of expeditions and planning. You may, therefore, share my early scepticism about the relevance of certain areas of this event to your future career as an expedition medic. Why would a medic need to learn about applying for expedition grants, or the creative sharing of experiences through music and art? Well, I’m afraid I can’t provide you with a clear or correct answer. After all, I’m not even a medic yet…

I reflect that as medics we can be caught up in what we do, perhaps missing the bigger picture. EXPLORE was a refreshing ‘zoom-out’ and a reminder of the part we can play. An appreciation of the work that goes into getting you to that polar ice cap, jungle or atop that mountain. We can learn to be a much more effective small cog in that bigger machine. We can enable exploration, positive change and a greater breadth of understanding of the world around us.

Thank you RGS for hosting such an inspiring and successful weekend.

Make sure you keep your diary clear for next year’s event. To find out more about EXPLORE 2023 click here.

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Dr Georgina East / General Practitioner and Expedition Medic / Queenstown, New Zealand

Dr Daniel Lack / General Practitioner and Technical Rescue Specialist / Tasmania

Dr Robert Dickson / General Practitioner /  Australian Antarctic Division, Tasmania

The Healthcare in Remote and Extreme Environments (HREE) programme at the University of Tasmania (UTAS) has been developed by organisations collaborating through the Centre for Antarctic Remote and Maritime Medicine (CARMM). Nurses, paramedics, and doctors can complete a range of postgraduate short-courses and full-credit university subjects which contribute to a Graduate Certificate, Graduate Diploma, or Master’s Degree in Healthcare in Remote and Extreme Environments. Courses and subjects can also be completed as standalone units. The coursework mixes online distance learning with in-person residential courses and camps. The residential components are also open to outdoor professionals, outdoor enthusiasts, and others looking to develop their skillset. You meet like-minded individuals, share some incredible experiences in the glorious outdoor playground of Tasmania, and, importantly, have the opportunity to formalise your learning in the burgeoning sector of outdoor/wilderness/remote/extreme medicine.

Key Facts

What:  An eight-day immersive residential expedition medicine course

When: It runs three times a year in April, July, and December (see website link for specific dates)

Where: Two days at UTAS campus Launceston and six days at Mount Cameron Regional Reserve, North East Tasmania

How much:

• Health professionals: $5,990 AUD
• Non-health professionals: $2,995 AUD
• Students undertaking the Graduate Certificate in Healthcare in Remote and Extreme Environments: $5,175 AUD

Price includes course manual and pre-course education as well as all meals and accommodation while at the Mount Cameron Field Study Centre.

Course link:

Link to the pre-course reading (free registration):

Photos courtesy of: Dr Georgina East, Dr Daniel Lack, and Dr Robert Dickson

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Links for Further Information

The post Healthcare in Remote and Extreme Environments MSc, University of Tasmania: An Overview appeared first on Adventure Medic.

Dr Ruth Warren / Foundation Year 1 / South Yorkshire

Dr Holly Andrews / Anaesthetics CT3 / Evidence Explorer Lead / Peninsula

• Introduction to Papers of the Quarter and Our New Collaborators
• Expedition and Wilderness Medicine
• Global Health and Humanitarian Medicine

The spring snow has transformed, the bluebells have bloomed and here at Adventure Medic we are packing away the ice tools and cautiously dusting off the summer wetsuit. Whilst the team have been busy across the globe supporting expedition endeavours clinically, the academic community have had an equally as productive transition into summer. We’ve once again seen some really interesting publications both in novel research and case studies and as always there’s been some hard hitting expert commentary on emerging Global Health issues.
This quarter we’ve had collaboration from two budding adventurists – Drs Warren and Dugmore who have been invaluable in the critical appraisal of what is a large body of work from our academic colleagues across the world. Here they present what we think are some of the most pertinent pieces to our practice and interest. From health care reports under a Taliban regime to solar water disinfection advice and evidence based guidance on how to avoid misdiagnosing stroke at high altitude.
We’ve got something for everyone this issue – happy reading!

Dr Phoebe Dugmore

Phoebe is passionate about pre-hospital and emergency medicine. She thrives on challenges and inspires others to push their own boundaries; be that by running ultramarathons or travelling for 3 months around Europe in a van with her partner, 4 month old and a dog! Evidence explorer is her latest challenge and has allowed her to marry her outdoor and pre-hospital interests with cutting edge research.

Dr Ruth Warren

Ruth is a Foundation Year 1 Doctor working in South Yorkshire.  She has travelled extensively whilst visiting family abroad, which exposed her to inequalities across the world from a young age. Her interest in Global Health was sparked during medical school and she decided to study this further through an intercalated Masters in International Development and Public Health. Through this, she was able to conduct research during the COVID-19 pandemic, working with small community in Tanzania, and in partnership with an NGO protecting children living in the slums of Kampala, Uganda. Her ongoing interest in Global Health has led to her involvement in this edition of Evidence Explorer.

Expedition and Wilderness Medicine

Every expedition medic will be well versed in the nuances of AMS, HACE and HAPE but what about the conditions that we see more commonly in our daily practice across Emergency Departments in the UK that mimic these high altitude conditions? Common things are common is a rule that of course we adapt to our environment but it’s also essential that we don’t miss potentially life threatening diagnoses by focusing on the red herring. Read on to understand more about stroke at high altitude.
Alongside this important article we present WEM’s approach to rebalancing gender equity and their evaluation of solar water disinfection methods alongside an interesting read on the medical implications of TASER devices and a comprehensive teaching paper on non-freezing cold injury.

Stroke at Moderate and High Altitude.
Syed M, Khatri I, Alamgir W, et al. High altitude medicine and Biology. March 2023.

With an improvement in road infrastructure, we’ve seen a rise in the access to high altitude for both recreation and living purposes in recent years. There are a lot more people entering these environments who, due to co-morbidities may not have done in times gone by. This together with normal physiological changes that occur at high altitude means that the incidence of stroke in our expedition population is likely to increase. This article reviews the available literature on the topic and is helpful for those medics working at high altitude to think about stroke as well as HACE. One of the most interesting take-homes from this article is that it highlights that venous sinus thrombosis is actually more common than arterial stroke so keep it in your differentials. Furthermore they discuss that conventional risk factors that must not be forgotten.
Further studies are needed on this topic but it makes for a useful read.

Changing Times and Shifting Priorities: Promoting Gender Equity at Wilderness & Environmental Medicine, Editors note
Binder W, Kenefick R, Rodway G, et al. Wilderness and Environmental Medicine. March 2023.

Most females are aware of the ongoing gender inequities in the medical profession but this editorial gives a real stark picture of the magnitude of the problem. Despite the majority of medical students in the UK in 2022-23 being women there is still a huge gender imbalance, particularly in academic medicine. It is significantly harder for women to get publications which we all know is an important part of many specialty application tick boxes. Women were found to be first authors in less than 25% of WEM articles – this is not ok.
WEM have recognised these frankly shameful gender inequities, releasing a statement with clear steps they are going to take to improve diversity in their editorial board and reviewer pool. So let’s watch this space!

Evaluation of Escherichia coli Inactivation at High Altitudes Using Solar Water Disinfection
Van Hoesen K, Mundo W, Mierau S, et al. Wilderness and Environmental Medicine. March 2023.

Many of our readership who have been on expeditions are familiar with Solar Water Disinfection (SODIS) devices. SODIS is established at lower altitudes (LA) to inactivate most pathogens and is dependent on UV-A and UV-B radiation. This study, conducted in Colorado, focused on trying to determine whether SODIS is also effective at high altitudes (HA). With less atmospheric density at HA, there are greater amounts of UV radiation so they hypothesised that it should be effective. They used E-coli as the model bacterial contaminant and added it to sterile water in 3 different types of container placed at 3 different altitudes with the attempted same weather conditions. After 6 hours they then tested samples from each. Interestingly they found different results to existing literature including time most bacterial inactivation occurs being in the first 2 hours and temperature of the water playing less of a role than previously thought. Plastic bottles were also found to be the best container.
From this study its clear further research is needed but it’s a promising start in informing guidelines and recommendations for safer water drinking policies at HA.

Non-freezing cold injury: A little-known big problem
Tipton M, Eglin C. The Physiology Society. March 2023

This is a really interesting article not only for the expedition medic but also the EM and GP guys amongst us. Most medics and lay people alike have heard of Frostbite but non-freezing cold injury (NFCI) is a bit of an unknown to us all. However it is a lot more common, being a hazard for rough sleepers and the ever increasing cold-water swimmer population, and can cause significant long-term complications for patients.
The editorial aims to give a bit of background on the condition and also highlight the lack of understanding there appears to be surrounding its pathogenesis and pathology. The mechanisms remain unclear – is it primarily vascular, neural or a combination of both? Combine that with the large number of environmental and patient-specific variables to consider and it makes screening, assessment, prevention and treatment of this illness very difficult.
Experimental physiology have released 3 back to back papers examining the condition from both the neural and vascular perspectives which are worth a read to increase our understanding but the clear take-home is that there is very little reliable literature on the topic and a longitudinal study is what is needed.

Annalise Wille from Arizona also presents a succinct presentation of this condition – the ‘screaming barfies’ – in the February edition of Wilderness Medicine Magazine.

The use of TASER devices in UK policing: an update for clinicians following the recent introduction of the TASER 7.
Bleetman A,  Hepper A, Sheridan R. Emergency Medicine Journal. February 2023.

Conducted energy devices (CED) or tasers as they are more colloquially known have been utilised by the UK police force for some time. In order to help control serious and violent situations they are intended to bridge the gap between close quarter options such as batons and irritant sprays and the much more significant lethal firearms. When used correctly, the CED is designed to deliver an electric shock to the individual it’s directed at which will cause pain and ‘neuro-muscular incapacitation’ whereby they fall to the ground. TASER 7 devices are those used most commonly by UK forces now and although highly effective, they do some with some medical consequence.
Thankfully, despite the electrical nature of discharge, arrhythmias are rare but the manufacturers do advise a period of cardiovascular monitoring and an ECG with particular relevance to the pregnant individual. The discharged CED ‘barbs’ invariably cause burns around the skin contact sites and require a specialist technique in order to remove. Injuries from the fall that ensues are also very common and it is essential that all patients receive a thorough primary and secondary survey.
As an event medic or for anyone working in pre-hospital teams alongside the police force this article is a must read. The authors explain great detail about the specific extraction methods to remove the barbs and advice on the monitoring and investigations required for individuals who have been ‘hit’ by a TASER 7 device.

Global Health and Humanitarian Medicine

Health inequalities are often the driving force for global health research and initiatives. In this quarter’s selection of articles, health inequalities amongst marginalised groups are highlighted and analysed.
The first two articles focus on those faced by poorer groups and of ethnic minorities, highlighting that even in high-income countries, these groups may not even have adequate access to water and sanitation, cascading to a higher risk of non-communicable diseases and poor population health. 
Belizzi et al in our third article advocate for the recognition of another group of vulnerable people – those displaced from their homes and countries by extreme weather due to climate change.
The last three articles are predominantly focussed on conflict, but all individually highlight the detrimental effects of conflict on women’s health.  Whilst the restriction of women is evident in conflict, the empowerment of women emerges through the last two articles as a solution to women’s adverse health outcomes and as a tool for conflict resolution.
Some tough but inspirational reading from acclaimed authors in the field. Read on to find out more.

The effects of racism, social exclusion, and discrimination on achieving universal safe water and sanitation in high-income countries
Brown J, Acey CS, Anthonj C, et al. The Lancet Global Health. April 2023

This article brings to the fore the ongoing inequalities and insecurity surrounding water, sanitation and hygiene (WASH) in high-income countries (HICs). It uses 5 contexts within USA, Europe and Australia where ethnic minority groups have significantly reduced access to water and sanitation. In these regions where lack of resources is not a contributing factor, the article argues that the driving factors for this inequality are racism, social exclusion and discrimination.  The proposed mechanisms of this include segregation; inadequate housing; property ownership rates; and lack of funding in areas heavily populated by marginalised groups compared to other regions. This has also been worsened by privatisation which brings the expectation that access to WASH is based upon individual effort and income rather than a responsibility of society to provide it as a human right for all.
This article stands out from other literature surrounding WASH where the focus is usually on low-income countries. One could argue that it is often assumed that HICs have met international WASH standards on a whole population level. This article highlights that although national statistics can achieve these standards, the disaggregated data for marginalised communities may not. These communities are often a small group and more likely to be excluded from data. Further disaggregation of national data could allow for recognition of these inequalities and therefore improve allocation of resources. The article also calls for a collective responsibility to change the wider social issues of racism and discrimination in order to tackle the WASH inequalities in HICs.
It seems that WASH inequalities may be closer to home than we realise and there is certainly a need to investigate this issue within the UK.

Risk, lifestyle and non-communicable diseases of poverty
Manderson L, Jewett S. Globalization and Health. 02 March 2023

The theme of inequalities being masked by national data continues with this commentary, which discusses how non-communicable diseases (NCDs) are most prevalent in the poorest communities. Although national data suggests that NCDs are less prevalent in the lowest-income countries compared to middle and higher income countries, it is consistently the poorest communities within these countries that have the highest rates of NCDs. In countries with high rates of wealth inequality e.g. South Africa national statistics often do not reflect the NCD prevalence in these poorer groups.  The commentary also highlights the discrepancy between genders in NCD prevalence which varies across cultural contexts and suggests an element of cultural influence rather than purely biological causes.
Similar to the previous article, there is a call for the discourse focus to shift from individual efforts to wider societal efforts in reducing NCD prevalence. As poverty is so closely linked to NCD prevalence, it suggests that wider determinants of health play a crucial role in this. However, NCD prevention campaigns and policies tend to focus on individual “lifestyle choices” rather than recognising the external factors which contribute to obesogenic environments that impact poorest groups most. It argues that those in poverty lack choice and agency in their health behaviours due to financial constraints and lack of local security. Furthermore, those in poverty are more likely to suffer from infectious disease, injury/trauma and worse maternal/child health outcomes. With the addition of higher NCD prevalence and morbidity, poorer communities face the “quadruple burden of disease”.
This article suggests the use of the term “non-communicable diseases of poverty” (NCDP) when addressing NCDs to highlight the importance that societal factors play and to shift attention away from individual efforts. It also calls for a wider systems approach with disaggregated data to recognise and tackle NCD prevalence effectively.

Global health, climate change and migration: The need for recognition of “climate refugees”
Bellizzi S, Popescu C, Napodano CMP, et al. Journal of Global Health. March 2023

This is a quick and interesting viewpoint. It addresses the rising issue of displacement of people from their countries due to extreme weather attributed to climate change. The majority of affected people are from regions within lower-income countries who must migrate elsewhere for safety. However, the main contributors to climate change are within high-income countries, further widening inequalities between different economically developed countries. These displaced groups do not always fall under definitions of “refugee” or “asylum seeker” which require a person to be fleeing from persecution. They are therefore not always entitled to the same benefits and legal protection as other refugees, despite facing mental and physical health needs directly linked to their environmental exposure and migration.
The United Nations Environment Programme (UNEP) has been using the term “climate refugees” since 1985 and the United Nations Human Rights Council (UNHRC) has broadened its protection to account for these groups as well. The article gives encouraging examples of various countries such as Argentina, Finland and Australia who have taken proactive approaches to protect climate refugees.
However, the article stresses that further recognition of climate refugees as a group of vulnerable people is required, especially as increasing numbers of people will be displaced due to weather-related disasters over time. Inclusion of this group within policies should be done to give adequate legal protection. Furthermore, projects working to mitigate the risks of extreme weather and displacement are becoming increasingly important in helping these vulnerable populations and reducing their health burden.
This article reminds us of the importance of environmentally sustainable practice and its knock-on effects on global health inequalities. It also emphasises the responsibility upon the Global North to protect these victims of weather-related disasters given its large contribution to climate change.  

Afghanistan’s healthcare under Taliban: what are the challenges?
Arif S, Rezaie KF, Madadi S, et al. Medicine, Conflict and Survival. February 2023

Afghanistan was at the forefront of news media in Summer 2021 due to the takeover by the Taliban.  This article discusses the key impacts on health that the rise of the Taliban has had and the need for international aid and funding to combat these severe issues.
Afghanistan has had high poverty and child mortality rates noted since 2002, and these have worsened in some areas since then.  It had become dependent upon international funding for various projects to strengthen the health system such as the Sehatmandi Project.  However, since 2021, much of Afghanistan’s international funding has been withdrawn. Alongside this, a lack of equipment, staffing and resources due to border controls and insecurity has compounded the failure of health services. This has led to the near collapse of the healthcare system with more than 90% of health facilities closing down and many having to travel more than 10km to access healthcare.
Women and children are depicted as particularly vulnerable during this conflict. Under the new authorities, women’s movement is more restricted and they require male chaperones which can inhibit their access to healthcare. Furthermore, more women are being forced into early marriages due to financial desperation within their families, leading to poorer maternal and child health outcomes as a result of early pregnancy.  Malnutrition is highly prevalent, affecting children the worst and making them more vulnerable to other diseases. COVID-19 has been an additional burden with inadequate resources to test and treat this disease.
This article makes the case for increased international aid to Afghanistan given the drastic health consequences of the current conflict and the withdrawal of major international donor funding of the healthcare system. It also links with the following articles regarding women in conflict and demonstrates how conflict can disproportionately affect women and act as a barrier to their engagement with health services and leadership.

FAWM accredited EM physician, Dr Terri Davis describes her role in Camp Buehring in Kuwait where she oversaw the treatment and care for Afghan refugees fleeing their country after the fall of Kabul.
Wilderness Medicine Magazine Sept 2022.

Strengthening health systems and peace building through women’s leadership: a qualitative study
Meagher K, Khaity M, Hafez S, et al. Globalization and Health. March 2023

This is interesting research that discusses the links between women’s empowerment, health systems and resolving conflict. Healthcare has been a powerful tool for peace-building, as it is valued and a common goal regardless of political stance.  Furthermore, there is a need for humanitarian projects within conflict to have a longer-term focus so that they align better with developmental goals.  This is increasingly important as conflicts become more protracted and complex, with Afghanistan as an example. A systems approach has therefore been suggested to improve long-term outcomes within conflict settings with leadership being a core element of this.  In addition, women are often worse affected by conflict due to gender-based violence and political agendas that restrict women’s freedom.
This study involved key informant interviews and 2 focus group discussions involving participants from a range of contexts affected by conflict. From the themes and codes generated, it became evident that women can be influential in peace-building initiatives with longer-lasting effects and higher rates of implementation.  As women are often viewed as non-threatening, they can be used to move more freely amongst different groups and are more likely to be trusted. As health system improvement can be a useful peace-building tool, this article suggests that the involvement of women in leadership within healthcare systems may combine the powerful effects of both approaches to resolve conflict. However, it also emerged that conflict can be a significant barrier to women’s empowerment and engagement in leadership, making this difficult to implement.  It suggests a feminist approach may be required to tackle the double burden of conflict and patriarchal oppression many women face in conflict.
Although it is not clear how to overcome the barriers that conflict brings in empowering women, this article does provide some practical points for peace-building projects.  Lederach’s framework of leadership (proposed by a professor of international peacekeeping) was used and adjusted to include specific areas at each level where women could be encouraged to participate within health systems.  This framework may be a useful reference point for peace-building frameworks and participation of women in leadership going forward.

Women’s sexual and reproductive health in war and conflict: are we seeing the full picture?
Hedström J, Herder T. Global Health Action. March 2023

This final article again highlights the vulnerability of women within conflict. Women’s sexual and reproductive health (SHRH) is significantly worse during conflict. However, much of the literature surrounding this issue focuses on structural factors such as poverty, malnutrition, lack of infrastructure, and poor water and sanitation facilities as the drivers of this issue.  This article suggests that insufficient attention has been paid to the cultural factors which harm women’s SHRH. Examples of this include forced marriage, forced retirement, control over contraception and gender-based violence.  In some conflicts, these factors are intentionally used as part of military tactics.
These factors also vary significantly across different contexts and over time.  Therefore, this article argues that approaches to women’s SHRH must be flexible and dynamic over time instead of using blanket approaches. A feminist approach is proposed to fully understand the root causes and extent of poor SHRH for women. To implement this approach, it suggests enhanced engagement of women from conflict and post-conflict zones in interviews and discussions on the impact of conflict on their SHRH.  However, it also mentions that poor reproductive health can impede women’s participation in decision-making and peace-building.
Despite this, the need for engagement of women in projects working to improve SHRH and peace-building in conflict zones has again been emphasised and future projects should consider the importance of engaging women throughout the process wherever possible..  Through this, there may be a solution to overcoming the cycle of poor health outcomes and disempowerment of women often seen in conflict.

As always, do get in contact if you’d like to be involved with contributing to future releases of this feature – we always look forward to hearing from you.

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The Mountain Leader (ML) award is the qualification for leading groups of people walking in the UK hills. It is run by the Mountain Training Association, and requires a detailed logbook, attending a training course and passing a multi-day assessment. Here Abbey shares the benefits the qualification has had for her as a medical professional.

Why Mountain Leader?

Like many others, as I progressed through university, I began to look for inspiration on how to personalise my medical career. Many of the options I found involved either being highly qualified in post-graduate medical training, or paying vast amounts of money to travel to far flung places in the world. Both of these were prohibitive to me as a student, and did not fit into how I saw myself working in the future.

I got involved with my University’s Duke of Edinburgh centre, first by finishing the Gold Award, and then by running the award for participants for several years. It was there where I heard about the ‘Mountain Leader’ – the people that kept our groups safe whilst completing the expedition aspect of the award in the Scottish hills and mountains.

The Training Process

Fast forward to my Foundation Years. I became captivated by ‘Munro Bagging’ – trying to reach all the summits over 3000 feet in Scotland. A list that is updated every few years but with a current total of 282 peaks. Whilst looking for ways to spend my annual leave, and the impossibility of coordinating time off with friends, I decided to book onto Mountain Leader training in North Wales.

What followed was one of the most fulfilling and well rounded training courses I have been on both within and outside of medicine. The focus was on leading a team whilst maintaining oversight and an awareness of each individual’s competency and capacity to deal with the task at hand. Doing all this while exercising, carrying a heavy pack, with wet feet, and the wind and rain in your face but still having fun!

The following summer, I moved further North to take up a Clinical Fellow ‘FY3’ post in the Scottish Highlands. There I completed my consolidation period, and passed the five day assessment in the Cairngorms, finishing my ‘Munro Bagging’ goal in the process.

Transferable Skills

Part of the consolidation period between training and assessment requires pushing yourself to head out into the mountains in bad weather and confidently manage and maintain safety often for groups of inexperienced people. I regularly took friends and colleagues from work out into the hills to show them how wonderful it could be for physical and mental health.

Without noticing, over time these skills spread into my working life. I found myself naturally gravitating towards leadership roles, and felt more comfortable doing so. The skills and theory I had learnt during the training week and honed out in the hills had undeniably given me a greater understanding of effective leadership and team working and the confidence to put these skills into practice in all aspects of my life.

What Comes Next?

The opportunities that arise from the qualification are wide ranging and very individual. Having expertise in both medicine and in enabling people to enjoy the outdoors safely is desirable for many branches of work. Proving that you can look after yourself in physically and mentally challenging conditions is invaluable, and the Mountain Leader scheme is one way of evidencing this. It also does so without shelling out thousands of pounds to big companies, having to be away for weeks at a time, or needing any amount of post graduate experience.

The opportunities for further development are extensive. Mountain Training provides a wide array of complimentary qualifications and skill sets, including rock climbing and winter hillwalking. As with the summer ML these qualifications are wonderfully flexible and are often looked for by expedition companies looking for leadership staff. Outside of the training and assessment weeks, the logbook requirements can be obtained in your own free time.

The practicalities

Requirements for training:

• Minimum one year experience of UK hillwalking
• Membership of the British Mountaineering Council, Mountaineering Scotland or Ireland
• A logbook of minimum 20 ‘Quality Mountain Days’ (QMDs) defined by Mountain Training, QMDs include (but not limited to) the use of map & compass, navigating in poor visibility/weather and full involvement in planning of the route.

Requirements for assessment:

• Completion of a recognised Mountain Leader Training course
• Completion of an in-person 16 hour First Aid course (special exemptions can apply on an individual basis for doctors)
• An additional 20 QMDs after training, logged in multiple different mountainous areas of the UK.
• A logbook of 8 nights camping, with a minimum of 4 nights wild camping

Time commitment:

• Six days for training
• Five days for assessment
• Minimum 40 days of hillwalking (can be logged over many years)
• Additional time consolidating navigation and rope work skills

Costs:

• Training course, from £375
• Assessment, from £375
• Costs of fuel & accommodation in achieving logbook requirements
• Gear/kit costs

Resources

Mountain Training

British Mountaineering Council

Mountaineering Scotland

Mountaineering Ireland

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In this article Dr Constance Osborne and Dr Rebecca Webb share their experiences of working as race medics at Montane’s Summer Spine ultramarathon. From extreme foot care to asthma and hypoglycaemia, the race medic needs to be prepared to support runners with minimal resources at their disposal. Here, Constance and Rebecca share some of their highlights and insights from a challenging but rewarding race.

Introduction

The runner came through the door of our medical room in the small hours of the morning, guided by a concerned volunteer. She had been picked up on the side of the trail, battling nausea and exhaustion. A warm blanket placed around her shoulders, mug of tea in hand, the limited medical assessment could begin.

The history was unremarkable aside from several vomiting episodes. No trauma or predisposing medical conditions. Pulse and blood pressure within an acceptable range, temperature and blood sugar equally normal. What could be causing this overwhelming nausea? We made a makeshift bed out of a roll mat and continued to question her.

“I don’t know why I feel so awful,” she said, “I’ve drunk at least 10 litres of water today.”

Our new differential diagnosis: hyponatraemia secondary to overzealous adherence to the pre-race medical briefing warning against dehydration. After giving an anti-emetic, we observed her for half an hour and advised some rest after dinner. She emerged from the camp bunk bed three hours later feeling much better. We safety-netted her and then she was on her way again. Off running into the night.

The Montane Summer Spine Race

The Montane Summer Spine is a legendary course amongst trail runners. Starting in the bucolic town of Edale, athletes will navigate the full length of the Pennine way over six and a half days. From the Peak District to the Yorkshire Dales, across Northumberland National Park to the finish line at Kirk Yeltholm in the Scottish Borders, they will encounter some of the most difficult terrain in the UK. No section of this race is forgiving, but each is breath-taking. The full course is 268 miles and inevitably not everyone crosses the finish line. There are shorter, though no less arduous, iterations of the route that occur alongside the main event: the ‘Sprint’ and ‘Challenger’ races.

Participants range from first timers to seasoned trail runners. Each determined to test their mettle against the unforgiving elements. But even the most experienced runner may need some help along the way. This is where local volunteers and the medical team from Beyond the Ultimate (BTU) step in. BTU organises a growing repertoire of multi-stage foot-races and it is through them that we applied for medical volunteer roles in late June 2022.

Day to Day

The job of an ultramarathon medic is to ensure that runners are safe to continue racing. We are there to treat emergencies, which fortunately are rare. Occasionally a medic has the unenviable role of balancing a participant’s determination to finish the race with their health needs and the risks inherent to an endurance event. Prior to the event all medical personnel were briefed comprehensively on the contents of the kit bags and emergency protocols. These requirements were reiterated at each check-point to the runners. We had a clear chain of command and access to senior support at all hours.

Common things are common

The bread and butter of a race medic’s day is foot care. We became quickly acquainted with the nuances of K-Tape (a multi-purpose flexible tape used in high-performance sport). Musculoskeletal issues were frequent, ranging from twisted ankles to tendonitis. When assessing runners, we looked for features of stress fractures or signs that indicated the need for an x-ray. Anything that warranted further investigation meant withdrawal from the race. Inexplicable nausea and vomiting was also a routine complaint, something which often resolved with half an hour’s rest. Hypoglycaemia, asthma exacerbations, insect bites, lacerations and chafing all made their way to the medical team. However, where safe, athletes were encouraged to self-manage their issues. Occasionally this in itself led to difficulties with a few runners deciding to ignore the pre-race brief to avoid NSAIDs during the event due to recognised complications such as renal impairment and hyponatraemia.

The Race Environment

The effective management of an ultramarathon runner must incorporate a consideration of their surroundings. The continuous slog through a variety of weathers and landscapes leads to an equally varied range of pathologies. Uneven, rocky surfaces lead to falls and head injuries. Wet weather can lead to foot maceration. The Summer Spine is not always sunny despite its name and wind chill, rain and running through the night meant that hypothermia and its sequelae were important differentials. This year’s race featured some exceptionally hot days, with runners having to traverse exposed moors and trails for hours. The sustained nature of the exertion combined with high ambient temperatures can affect the thermoregulatory mechanisms of even the most experienced athlete. That said, we only saw a couple of cases of heat exhaustion towards the end of the race and thankfully none of heat stroke.

Weird and Wonderful

In the final days, we saw a couple of cases of ‘the ultramarathon lean’. This is when a runner leans anywhere up to 90 degrees to one side, leading to a banana-like posture. Another runner had such bad neck fatigue that he could not lift his head for the last 14 hours of the race. These issues were treated with an hour’s sleep where possible and an encouraging word or two as they continued onwards. Towards the end of the race, the cocktail of exhaustion and continuous stimulation sometimes led to hallucinations. Tree trunks, roots and rocks can take on a life of their own for an ultramarathon runner in these conditions.

How to get involved

Our experience as medic volunteers was unforgettable, not just the impressive blisters, but because of the athletes themselves. Being a medic allows a unique insight into the highs and lows of each person’s race experience, along with the chance to become a unique part of their story. The jubilation felt watching a runner that you have patched together cross the finish line is hard to describe. However this is not a volunteering role to take lightly. It is a tiring event with long and unpredictable hours. Most of the volunteers were there during their annual leave and returned to work more tired than when they left.

As junior doctors seeking experience in expedition medicine, this was the perfect opportunity for us to develop some prehospital skills. That said, anyone seeking to volunteer at this event below ST3 level may run into indemnity issues. The BTU medical team will assist you in arranging indemnity through a private broker, but this can take weeks, so please keep that in mind when applying.

Food and accommodation are provided throughout the event. Each volunteer is issued with a certificate of attendance. As it is a Montane race, opportunities for merchandise and a personal discount code are available. Fuel expenses are reimbursed and a further £100 contribution made for additional costs such as indemnity (rising to £350 if you do four or more days).

You can read more about the variety of events organised by Beyond the Ultimate here.

If you would like to inquire about volunteer opportunities, contact the team via email: info@thespinerace.com. Please have a CV prepared.

All photos included in this article were used with the owner’s permission. All medical photography has been included with the featured patient’s permission.

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Dr Hugh Roberts is an anaesthetic trainee currently working in the North East. He has worked as an expedition medic for the last 5 years. This started whilst taking time out of training to work as an emergency medicine and expedition medicine clinical fellow in Bristol. Now that he is back in training he has successfully continued to integrate his expedition work into his life as an anaesthetic trainee. In this article he uses his experience to explore the issues and options surrounding combining work as an expedition medic and specialty trainee. 

Years out of training after the Foundation Programme are often some of the most enjoyable of a doctor’s career, and stepping back into training can feel like the end of the adventurous lifestyle of those F3+ years. However, being a specialty trainee does not have to mean your expedition medicine career is put on hold. This article describes how you can balance a career in expedition medicine with specialty training, with specific focus on anaesthetics, emergency medicine and general practice.

We will begin by reviewing the current state of UK specialty training and examining the benefits that expedition medicine can bring to both trainees and training schemes. We will then consider the options available for taking leave from training, and finish with some case examples of doctors who have managed to successfully balance expedition medicine with their specialty training.

The State of UK Specialty Training

There is a retention crisis across UK specialty training. In 2020, the Royal College of Emergency Medicine (RCEM) published the document Retain, Recruit, Recover – our call to action to improve the urgent & emergency care system.¹ It reported that 36% of emergency medicine doctors in training were considering working abroad and 25% were considering changing specialty. In the same vein, in 2021 the Royal College of Anaesthetists (RCoA) released the document Respected, Valued, Retained – working together to improve retention in anaesthesia.² It reported that 25% of  anaesthetists in training were planning to leave the NHS within five years. It is a similar picture in general practice, with the Royal College of General Practice (RCGP) reporting that 22,000 GPs and GP trainees plan to leave the specialty in the next five years, citing exhaustion and burnout as key causes.³

These figures are stark and it is clear that training schemes need to make changes to improve retention. Although it is early days, it is encouraging that the Royal Colleges are acknowledging these problems and recognise that change is required. RCoA responded to the findings of its report by committing itself to improving work-life balance for trainees, increasing flexibility and supporting portfolio careers.² These changes would certainly make it easier to balance expedition medicine with specialty training, but exactly how these will be implemented remains to be seen.

The Benefits that Expedition Medicine can Bring to Training

The benefits to training schemes of making it easier to balance expedition medicine with training go beyond improved retention. Expedition medicine training and experiences can also bring many other benefits that increase a trainee’s value to the NHS:

• Working without access to investigations can enhance a doctors’ clinical acumen and problem solving.
• Working independently in remote settings can increase self-reliance and clinical confidence.
• Experience of medical screening and working in challenging environments can enhance understanding of risk and ability to conduct dynamic risk assessments.
• Exposure to other healthcare systems and pre-hospital practice can inspire quality improvement projects and research on return to the NHS.

RCEM considers expedition and wilderness medicine to be a branch of pre-hospital emergency medicine (PHEM), and in this article they describe many benefits that training emergency medicine doctors in PHEM can bring.⁴

How to Take Leave from Training for Expedition Medicine

General Principles for Taking Leave

There are some general principles that are important to be mindful of when taking leave during your training. You should be up to date or ahead with your competencies and portfolio, otherwise you stand little chance of having leave approved. Make sure you give plenty of notice for leave requests;  in most cases, several months advanced notice is required to facilitate the approval processes and prevent clashes with on-call commitments. When you do make it away on expedition, always keep your General Medical Council (GMC) registration, or you will lose your training number.

Options Available for Taking Leave

Option 1: Out of Programme (OOP)

The Gold Guide (also known as The Reference Guide for Postgraduate Specialty Training) details how to take time Out Of Programme.⁵ The GMC also has a useful guide on OOP.⁶ There are several types:

• OOPE (Experience)
• OOPC (Career break)
• OOPT (Training)
• OOPR (Research)

Information on OOP from RCoA can be found here, and from RCEM here. There should also be guidance available from your local deanery. There is no specific guide from RCGP, so you should refer to the GMC guide and your local deanery guidance.

OOPE

The purpose of OOPE is to gain professional skills that would enhance your future practice. It may benefit you (e.g. working in a different health environment/country) or may help support the health needs of other countries (e.g. with Médecins Sans Frontières, Voluntary Service Overseas, global health partnerships). GP training deaneries are offering opportunities for international OOPEs to locations such as South Africa, Zambia and India. There is also the National Global Health Fellowships Volunteer Programme, open to GP, paediatrics and ACCS trainees, offering posts in a number of African countries.

OOPC

OOPC allows you to step out of the training programme for a designated and agreed period of time to pursue other interests (e.g. domestic responsibilities, work in industry, developing talents in other areas or entrepreneurship). Dr Tamal Ray, a finalist from the sixth series of The Great British Bake Off, used an OOPC to join the show from anaesthetics training. An OOPC could also be used to pursue expedition interests.

OOPT

OOPT is clinical training, taken out of programme, that can count as time towards CCT provided certain conditions are met. For anaesthetics trainees, you need to be a higher or advanced level trainee to take an OOPT, which can count for up to one year towards CCT.⁷ RCEM do not specify at what stage of training you can take an OOPT.⁸ Specifically to support trainees wanting to undertake OOPT in a low-middle income country, RCoA has developed a unit of training Annex D – anaesthesia in developing countries to enable this to count for up to six months towards your general duties requirements. The criteria for this are quite rigorous, so you are probably better off joining an established project, such as those advertised here. 

OOPR

OOPR is research taken out of programme. If an expedition involves research, this may be an opportunity to take OOPR. Both RCoA and RCEM state that some OOPR time may count towards CCT, provided certain criteria are met.^7,8

How to Apply for OOP

You should refer to the relevant guidance described above. Unlike OOPT and OOPR, OOPE and OOPC cannot count towards your CCT and are approved at the level of the Local Education and Training Board (LETB), meaning you do not need Royal College or GMC approval.⁶ Your LETB will have its own OOP application process that you will need to follow. It is recommended that you discuss your OOP with your Educational Supervisor (ES) and Training Programme Director (TPD) at least six months in advance, so it is unlikely that these are going to be useful for last minute expeditions. Ultimately, approval for OOPE or OOPC is at the discretion of your TPD and Postgraduate Dean. This can work for or against you, depending on where you are training. Although it may seem unfair, that is the current system. It is important to note that for anaesthetics trainees, you are allowed up to a maximum of two years total in any mixture of Out Of Programmes.

Option 2: Study Leave

This is another option that requires a sympathetic ES, although it is easy to justify why study leave for expeditions or expedition medicine courses/certificates/diplomas/MSc programmes is reasonable:

• Expedition medicine teaches lots of ‘soft skills’ that are often specific learning outcomes for specialty training, such as: communication, leadership, teamwork, organisation/planning and situational awareness.
• Research and critical appraisal are usually components of specialty training curriculums and may be components of expedition medicine postgraduate certificates, diplomas or MSc programmes.
• Expedition medicine experience is useful for higher specialty training applications. ST4 anaesthetics self-assessment criteria include Domain 10: activities demonstrating leadership and/ or management inside or outside of work, with high scores for ‘commitment to leadership or management inside or outside of medicine such as expedition leadership’. A postgraduate certificate, diploma or MSc will also score points, and expedition medicine is a great topic to talk about at an interview!

Set expectations early by discussing your interest in expedition medicine with your ES at your initial meeting. Having a Personal Development Plan (PDP) that links your interests in expedition medicine with your chosen specialty is likely to help too. It is generally easier to get study leave for courses, diplomas or MSc programmes than it is for expeditions, although study leave for expeditions is not unheard of and so it is always worth asking. You should not expect to get any study leave funding, and shorter periods of study leave are more likely to be approved.

Option 3: Less than Full Time (LTFT)

73% of UK anaesthetists in training state that being able to work flexibly or work LTFT is important to encourage them to stay in the NHS, and 57% of emergency medicine doctors in training are considering reducing their working hours.^1,2 All doctors in training can apply for LTFT, either at the point of application for entry into training or at any point during training. It is important to note that when applying for LTFT at the point of application, it will not affect your chances of being appointed. Although you have to give a ‘well-founded individual reason’ to apply for LTFT, expedition medicine should certainly fall within this scope.⁵ LTFT is a great option if you want to complete a postgraduate certificate, diploma or MSc, or need time to be involved with a regular commitment such as mountain rescue. Information about LTFT can also be found in The Gold Guide.

Option 4: Weekends

We now move onto the first of two options that require you to give up your free time. The disadvantages of using weekends are obvious: you risk burnout, and lose time that you could be spending with friends and family, or pursuing your own adventurous interests! However, there are some advantages: it will not extend the duration of your training and you are not required to justify your weekend activities to your training programme. Charity challenge companies are always looking for volunteer medics for their weekend UK events, and these are a great way to foster your relationship with companies whilst continuing to gain expedition medicine experience and bolster your CV.

Option 5: Annual Leave

This is arguably the least attractive option. As specialty trainees, we deserve our time off; we work long and unsociable hours whilst balancing many other work commitments, such as audits, exams revision and portfolio management. RCoA agrees with this sentiment, advising that individuals should ‘take annual leave and time they need to look after themselves and recuperate’.² The advantage of this option is that your annual leave is yours to do with what you will, so there is no need for justification and approval from your training programme. Where possible, give your rota coordinator plenty of advanced notice to avoid clashes with on-call commitments. Make sure you include time for recharging on a sunny beach or ski slope as well!

Examples of Doctors Who Have Made It Work

In case you need proof of what you have read so far, here are some examples of doctors who have managed to strike the balance with specialty training and expedition medicine. Hopefully their stories will provide you with encouragement and inspiration, as well as some tips on how to make it work for you.

Dr Nikki Cox / Consultant Anaesthetist / Queen Alexandra Hospital, Portsmouth

What have you done during training?

I finally CCT’d in summer 2021, but I had plenty of gaps in my training! After completing core training, I took some time out and worked with a charity challenge company on UK events, an Everest Base Camp expedition and a London to Paris cycle ride. I also volunteered with Mercy Ships in the Congo and Madagascar. Once I started specialty training, I managed to continue with both of these companies, using annual leave for charity challenge events and taking a combination of study leave and an OOPE to teach in Senegal with Mercy Ships. I also took an OOPC to spend 6 months in Provence and improve my French language skills, ready for Senegal.

What was your experience of getting leave?

My TPD was very supportive. I think in anaesthetics, you tend to be recognised as a whole person rather than just as an anaesthetist. They are not trying to make us all into identical doctors. 

Any advice?

Once you have got your final exams, the training programme is very keen to keep you and that can help. On expeditions, you are pushed out of your comfort zone and often have to deal with the unexpected, so there is a lot you can learn that is relevant to work as an anaesthetist. Whilst you are in-programme, it helps to save money so you then have the flexibility to take six months off and be free to do what you want, rather than having to locum.

Do you think anaesthetics and expedition medicine complement each other well, and why?

Anaesthetics is a sessional specialty, and that makes it easier to take time off. Since CCT, I have been away again for a month to teach in Senegal. Just do not expect to get leave during the school holidays when everyone else wants time off!

Dr Ellie Debenham / CT2 Anaesthetics / Cumberland Infirmary, Carlisle

What have you done during training?

I went LTFT when I began ACCS. My reason for going LTFT was to do the Diploma in Mountain Medicine (DiMM) and to have more time to get out in the mountains. I have done the first three DiMM modules now and just have the alpine module left. I also planned to get involved with mountain rescue, but I am yet to join as I am enjoying my climbing too much! 

What was your experience of getting leave?

When I started ACCS, work-life balance was not considered a valid reason for going LTFT, so I had to sell it as doing the DiMM. That is definitely not the case anymore. Some people are very supportive and might say: “I am slightly jealous of your lifestyle, I wish I had made different decisions!”; others might say: “you are not committed, why are you even a trainee, why are you even a doctor?”. You have to stay true to what is giving you the lifestyle you want. Sometimes I have been able to get study leave for the DiMM modules, and sometimes I have had to take annual leave, it is variable.

Any advice?

One of the nice things about doing a postgraduate qualification like the DiMM is that suddenly, you have a network of channels that you can contact as you are in a room of like-minded people who want to have a career but also want to go on adventures! Once you have got the diploma, you have got it, and you do not know what opportunities it might open up in the future. I would like to go work at the Sherpa outpost hospitals. It is also helpful for higher specialty training applications – a diploma is another tick in the box, so why not do it in something really fun rather than something dull?

Do you think anaesthetics and expedition medicine complement each other well, and why?

I think that anaesthetics is the best career you can do in medicine, why would you want to do anything else?! It is the most fun and practical. With anaesthetics, you learn the ability to deal with horrendous situations and look after critically ill people. I also think having A&E experience is useful, for example for trauma management, and GP is useful for managing comorbidities or problems that might present to primary care.

Dr Alex Taylor / ST3 ACCS Emergency Medicine / Bristol Royal Infirmary, Bristol

What have you done during training?

During ST1, I worked on an event with Children in Need. Covid had cancelled another trip I was supposed to be on to Nepal and luckily the leave I had taken lined up with this UK challenge! In ST2, I spent two and a half weeks on a polar expedition in Greenland with a youth development charity. Most recently I worked in a rural hospital in South Africa for four months as part of a six month OOPE offered by Health Education England. I have also taken leave to teach on a variety of expedition and wilderness medicine courses.

What was your experience of getting leave?

The Children in Need event was annual leave. Greenland was a mix of annual leave, study leave and Educational Development Time (EDT). South Africa was an OOPE, and the role included reimbursed costs (up to a limit per month), funded accommodation and annual leave. For teaching on courses, I was granted study leave. In my experience, I have found it is definitely easier to get study leave for teaching than it is for going on expeditions.

Any advice?

Be prepared! Tell your ES about your interest in expedition medicine from the outset. It helps to write a PDP before your initial meeting which demonstrates a long-term interest, and support it with evidence. Your ES may not have any personal experience of expedition medicine, so having a discussion about what is involved (screening participants, preparing medical kits, leadership and teamworking, risk assessments, working in a resource poor environment) helps them understand that you are not asking for extra holiday leave! I also like to use Workplace Based Assessments (WBAs) as evidence of my clinical work on expeditions. You could arrange a Case Based Discussion (CBD) with your ES after your expedition, or with a senior medic on your expedition if there is one – it is all helpful for your portfolio.

Do you think emergency medicine and expedition medicine complement each other well, and why?

The cases you are likely to encounter on expedition are either problems that might present to GP, or emergencies, and the emergencies are the ones that people tend to worry about. Emergency medicine also teaches you a lot of ‘soft’ skills that are useful on expedition, like dynamic risk assessment, resource management, flexibility and leadership. Looking after an unwell patient on expedition usually requires the whole expedition team, so it is a lot like managing a busy emergency department!

Dr Jack Watson / GP / Cheltenham / @outdoormedics

What have you done during training?

I was interested in expedition medicine during foundation training, but did not feel I was cut out for it – looking after sick patients alone in a remote setting seemed like a lot of responsibility, and I was never the one fighting to the front at crash calls! I started GP training and after ST2, took a global health fellowship to rural South Africa. This was a huge change for me – I was caring for really sick patients and the buck stopped with me, so it gave me the confidence to manage prehospital cases on my own. When I returned to finish GP training, I felt inspired to gear everything towards expedition medicine. I started working events with a charity challenge company and built on my prehospital experience, including a case that summer when a spectator fell and broke her arm. I also enrolled on a BASICS course near the end of ST3. The events were a ‘foot in the door’ for me to get on my first international expedition to Kili in January 2019, a few months after I finished GP training. I have also spent time working as a rural GP in Shetland and the Outer Hebrides. There was lots of overlap with expedition medicine in that role, and having BASICS was really useful.

What was your experience of getting leave?

The South Africa global health fellowships are run by Health Education England, so it was easy to get study leave for the preparatory courses for that. The fellowship itself was an OOPE. There was no pay progression during the fellowship year, which was quite frustrating. I got study leave for the BASICS course and received funding of about £1500 to cover the course fees. My ES was very supportive, but was surprised that I got the funding approved! I sold it mainly as being useful for rural GP rather than expedition work, and I think that it also helped that by that time I had completed my Clinical Skills Assessment (CSA) and Applied Knowledge Test (AKT). I also did ALS during ST3, as I wanted to do some work in A&E, but the training programme would not fund that as GP training only requires ILS.

Any advice?

You have to fight your corner and be savvy. Show that what you are doing brings transferable skills and relate it to the GP training curriculum. Unfortunately there is big variability geographically, and what you get approval for depends on what region you train in.

Do you think GP and expedition medicine complement each other well, and why?

I am a big believer that GP is the best specialty to balance with expedition medicine as it is a short training scheme and then you can be your own boss. There is a big overlap in skills and 90% of problems you encounter on expedition are GP presentations.

Conclusion

There is no doubt that finding time for expedition medicine is harder as a trainee on a rota than it is with the complete freedom of working as a locum. However, hopefully this article has helped to show that there are ways that you can make it work. The Royal Colleges recognise the need to prevent trainee burnout and drop out, and want to work with trainees to fit their goals around their training and keep them in the programme. Use the options that are available to you, plan well in advance, engage with your ES and TPD, and expect that shorter expeditions, weekend events and postgraduate qualifications will be easier to fit in around your training than longer expeditions. Do these things, and the adventure does not have to end at CT1/ST1!

References

1. The Royal College of Emergency Medicine. Retain, Recruit, Recover – A Call for Action [Internet]. 2021 [cited 2023 Mar 1]. Available from: https://rcem.ac.uk/retain-recruit-recover-a-call-for-action/
2. The Royal College of Anaesthetists. Improving retention in anaesthesia [Internet]. [cited 2023 Jan 25]. Available from: https://www.rcoa.ac.uk/policy-communications/policy-public-affairs/anaesthesia-fit-future/improving-retention-anaesthesia
3. The Royal College of General Practice. Retention as vital as recruitment in addressing GP workforce crisis – College calls for urgent action to keep GPs in the profession [Internet]. [cited 2023 Mar 4]. Available from: https://www.rcgp.org.uk/News/Workforce-Retention-Statement
4. The Royal College of Emergency Medicine. What do RCEM committees do? Introducing the RCEM PHEM Professional Advisory Group [Internet]. 2021 [cited 2023 Mar 4]. Available from: http://president.rcem.ac.uk/index.php/2021/01/18/what-do-rcem-committees-do-introducing-the-rcem-phem-professional-advisory-group/
5. Conference of Postgraduate Medical Deans of the United Kingdom. A Reference Guide for Postgraduate Specialty Training in the UK – The Gold Guide 9th Edition [Internet]. 2022 [cited 2023 Jan 11]. Available from: https://www.copmed.org.uk/gold-guide/
6. General Medical Council. Out of programme guidance for doctors in training [Internet]. [cited 2023 Jan 11]. Available from: https://www.gmc-uk.org/education/standards-guidance-and-curricula/guidance/out-of-programme/out-of-programme-guidance-for-doctors-in-training
7. The Royal College of Anaesthetists. Out of programme [Internet]. [cited 2023 Jan 11]. Available from: https://www.rcoa.ac.uk/documents/12-out-programme
8. The Royal College of Emergency Medicine. All UK Training Programmes [Internet]. [cited 2023 Mar 4]. Available from: https://rcem.ac.uk/emergency-medicine-training-programmes/

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Dr Tom Everett / GP / Highlands, Scotland

It has been a pleasure and privilege to attend WEM 2022 representing The Adventure Medic. We are so grateful to WEM for inviting us back to cover what is undoubtedly the highlight of the conference calendar for those with an adventurous streak.

Just like that, in a blur of buzz, ropes, explosions and explorers, the World Extreme Medicine (WEM) Conference has concluded for the year. 19th – 21st November 2022 saw the most eminent explorers, adventurers, astronauts, scientists, rescuers and healthcare workers descend on Dynamic Earth in Holyrood, Edinburgh for the world’s biggest extreme medicine conference. The breadth of experience and achievement present in one place is unsurpassed; the excitement among delegates was palpable.

WEM have been organising this conference for over 10 years. It is evident in the delivery of this slick, efficient and industry-leading event. As well as optimising their face-to-face product, there is the opportunity to join the conference online from anywhere on the planet for a lower price, thus maximising the exposure and impact of content. This feature was facilitated by a small army of technicians ensuring that the live stream of lectures and workshops was high quality worldwide. Equally, a slick app provided a dynamic agenda, profiles for delegates and messaging capabilities for networking. Amid the impressive academic and humanitarian representation there were pioneering companies providing demonstrations of cutting-edge kit.

Arguably more important and impressive than the logistical side of the event was the approachable atmosphere that permeated throughout. WEM 2022 provided a truly international network of impassioned medics and adventure enthusiasts. Too many speakers to mention drifted by the Adventure Medic stand bestowing mind-blowing tales of mountain, jungle, ocean and polar environments with complete modesty; some of these we hope you will see here soon as the authors of future articles! The evidence of global networking and multidisciplinary learning from so many countries, cultures and professions was humbling.

Highlights of the Saturday took us everywhere from the International Space Station to icy Svalbard, Myanmar to rowing oceans. Mark Hannaford warmly welcomed everyone, kicking the conference off to a great start – did we really witness bagpipes played in outer space? Klara Weaver covered the challenges, complex and bizarre, that she faced as a medic returning from 20 months overwintering in Antarctica with her unique perspective on the global Covid-19 pandemic. Martin Bromiley, founder of the Clinical Human Factors Group and an airline training captain, provided an invaluable session on the importance of and barriers to integrating human factors training into healthcare. Pushing yet more boundaries was Lucille Chauveau who described the unique complexities of providing Medevac services to the one hundred and eighteen diverse and remote islands that make up the French Polynesian archipelago.

Delegates and speakers came from a wide range of backgrounds, from paramedicine, nursing and film-making through to mountain rescue, humanitarian and dive medicine. Hands-on breakout sessions allowed attendees to get stuck into everything from expedition vehicle maintenance, splinting, wound care and rope skills. We could not turn down the opportunity to attend an expedition dentistry workshop with the Adventure Medic’s own Burj Langdana; the energy and passion that Burj brings to his teaching is a sight to behold and certainly worthwhile.

Buoyed up with inspiration from Saturday, Sunday arrived with a further jam-packed day of industry legends. Andy Kent from UK-MED reflected on how it felt delivering trauma care teaching to Ukrainian paramedics and then seeing the same group, four days later, responding to a mass casualty event. His presentation included a video showing the erection of a UK-MED bespoke, fully equipped temporary hospital in 12 days, following the intentional destruction of a hospital. His powerful talk really demonstrated the great capabilities and importance of this organisation.

Hopeful pre-hospital medics of the future listened intently to Ffyon Davies and Patrick Wenger, from Air Zermatt, in the HEMS workshop and career panel. They discussed the use of standard equipment in novel ways, demonstrating the creative thought processes required by pre-hospital clinicians managing extreme injuries with limited kit.

Lucy Shepherd, the first keynote speaker of Sunday, embodied adventure. She challenged the misconception that “we are past the glory days of exploration”, wowing the audience with her experience of crossing the snake-ridden Kanuku mountains, an uncharted region of the Amazon. Maritime legend Mensun Bound closed Sunday by telling his story of the successful voyage to locate Shackleton’s vessel, ‘Endurance’ beneath Antarctic sea ice. Given the loss of this ship led to one of the greatest stories of human survival, it is amazing to see footage of the name clearly preserved upon the stern of a ship now found again deep in the ocean.

Monday started slowly with bleary-eyed delegates comparing tales of cocktails and dancing; what a night the WEM ceilidh was! Sarah Spelsberg’s talk was a perfect antidote to the excesses of the night before, detailing how breaking-down boundaries creates opportunity and fulfilment. She attended medical school late and pushed herself to the extremes by working as a medical intern in the remote Aleutian Islands. She described having an “anti-resume” and being “anti-fragile”, making the point that sometimes resilience is unachievable and undesirable. Her talk was incredibly inspiring, concluding that to secure joy, we should “contemplate, innovate, adapt and evolve”.

GoodSAM updated delegates on how their impressive app is improving cardiac arrest outcomes worldwide by connecting casualties to a volunteer first responder network. The Arclight Project provided valuable ophthalmology teaching using their novel and effective ophthalmoscope. It’s ability aiding the diagnosis and management of eye and ear pathology in low and middle-income countries. There were also updates on artificial intelligence and telemedicine projects and their ethical dilemmas and multiple in-depth discussions on how best to look after our own and our clients’ mental health in relation to conflict, expedition and relief work.

Reflecting on the take-home messages from the World Extreme Medicine conference 2022 we have lots to be thankful for. Inclusive, exciting and collaborative are words that immediately spring to mind. The WEM team, speakers and attendees created this inspirational, supportive event for adventurous medicine. This conference is progressive, full of high-calibre content and provides an approachable and truly multidisciplinary atmosphere. It is this that made 2022 such a special WEM conference as attendees from all over the globe, in person and online, could interact in such positive ways. The Adventure Medic is already excited to hear of the projects that will prosper and launch from this conference.

If you missed this year’s event, online tickets are still available by contacting WEM directly and provide access to up to 70 hours of extreme medicine content. You can catch session recordings on-demand for up to 12 months post-conference. For those interested in attending WEM 2023, details can be found here, with speaker submissions now open.

Photo credits: Tom Everett 

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A good expedition medic is so much more than just being a good clinician. We need to have a mix of clinical, interpersonal, leadership and expedition skills relevant to that environment. This article will focus on these ‘expedition’ skills; explaining what they are, understanding why they are important and giving you a few ideas of how you can gain them and demonstrate your competence.

What are ‘expedition’ skills?

Expedition skills allow us to comfortably work within and travel safely through the environment we are in. For example, on a canoeing expedition down the Amazon, to have the ability to be able to manoeuvre a canoe and assist the leader with rescuing other members of the team if they got into difficulty. We would also need to be comfortable living in a jungle environment, with an awareness of how to keep ourselves and others safe, knowledge of the fauna and flora and how to use required tools safely, e.g. a machete.  We want to know we can always be ready ahead of the team, so we can support them each morning with any medical queries.

Why are they important?

The Faculty of Pre-Hospital Care (FPHC) gives guidance on the skills and competencies an expedition medic should possess depending on the expeditions’ remoteness and risk. It is essential reading for anyone considering work in the field.

The FPHC cites examples of the expedition medic not having all these skills. For example, the medic on a high-altitude expedition having no prior altitude experience, then struggling and becoming unwell before being evacuated off the mountain, so leaving the team without a medic. Other examples include the medic not having the technical skills such as being able to get through rocky scrambling terrain to reach a casualty.

Finally, we know as medics that prevention is better than a cure. If you understand the activity and environment, you can work with the team to prevent injury and illness far more effectively. Basic camp skills like knowing how to purify water, safely prepare food, manage fires and stoves and waste disposal are absolutely necessary if you plan to work anywhere that these may be required.

Gaining skills and demonstrating competence

Outdoor qualifications, a logbook of experience, courses and formal postgraduate diplomas and masters programmes all have their place.

Qualifications are often required for client-to-staff ratios and quickly demonstrate your interest and base ability to a company. Some companies only take medics who already have certain industry-standard qualifications. For example, British Canoeing 3* would show your ability to paddle on moving water in a canoe or a Mountain Training summer Mountain Leader qualification would show your ability to safely lead groups in the UK mountains in non-winter conditions.

A logbook would be another way to show someone your experience when applying to be the medic on an expedition. If you can present them with details of the types of vessels you’ve sailed alongside the locations and weather or scuba dive types, profiles and conditions this may be more valuable than a qualification as it shows your ongoing currency and development. However, it doesn’t necessarily show you have learnt the ‘correct’ way to do things in the same way an industry standard course may. A course with a certificate of attendance, again, would show that you have attended formal training. For example, if you were to book a jungle survival course, you could also ask the instructor leading the course to write a reference or letter of recommendation.

Diplomas and Masters programmes can demonstrate competency, such as the Diploma in Expedition and Wilderness Medicine or the Diploma in Mountain Medicine. They show an employer that you have invested significant time and interest into the field, are up-to-date with academic findings and guidance and have been assessed and met certain criteria for work in a particular environment.

Next steps

• Start a logbook
• Consider which activities you would like to try or develop
• Check out the Adventure Medic resources with recognised industry-standard outdoor qualifications to work towards
• See our course reviews section on our events page to help you decide which courses may be for you
• Visit our resources section on the plethora of formal post-graduate diploma and masters programmes now available

Whether you join a mountaineering club, find a kayaking course or join an expedition medicine course based on the slopes, we wish you happy adventures. If you have been on a course or completed a diploma that you’d like to review, please get in touch and we’ll send you our proforma for these. We have all benefited from the gems on Adventure Medic and are keen to keep sharing opportunities and your insights. We look forward to hearing your suggestions and what you get up to next.

The post Outdoor Skills for the Expedition Medic appeared first on Adventure Medic.

Dr Sonia Henry is a General Practitioner who had been working in Sydney until a combination of personal events and the Covid-19 pandemic came crashing into her life. She found herself on an unexpected and completely off-the-beaten-track adventure into rural and remote Australian communities, where she was frequently the only doctor for hundreds of kilometres. Sonia has shared with us an extract from her book “Put your feet in the dirt, Girl” – an account of her time living and working in these communities (so far!). Here, she also reflects on the opportunities that a medical degree can provide to shape a life and career of your own, if you are brave enough to step out the door of the hospital systems and “put your feet in the dirt”.

Use your stethoscope as a passport

I read somewhere that the great thing about being a doctor is that you can use your stethoscope as a passport to travel the world. I think I was a medical student at the time, and looking for any sliver of hope that after the hard years of slogging my way through there was something to look forward to at the end of it all. I found this article with the line about the stethoscopes and passports, and I never forgot it.

My pathway to medicine was slightly unconventional. After working for a few years as a physio I decided I wanted a different challenge so applied for medicine. After ten weeks of my first year of medical school I wasn’t too sure about it and deferred. I got a job working for an offshoot of the London ballet company as a physio but two days before I left I broke my arm on a ski trip in Australia. That rendered my ability to work pretty useless (a sports physio without a functioning arm is like a surgeon without functioning hands), and a few months later I was running out of money. Had I not broken my arm I might have ended up loving the work so much I may never have returned to Australia, or medicine, – who knows?

The moment that sealed the deal was when my arm had healed, and I decided to head to Zermatt to ski the famous Matterhorn glacier, the only place really that had any snow left to ski as it was autumn. Despite the stress of the self serve T-bar ski tows, I also found myself sharing a room at the backpackers with a Spanish doctor called Sara. She’d driven her van from Spain to Switzerland and was doing a mountain rescue course. She enlisted my help in editing a PowerPoint presentation to make sure any English words she wasn’t as sure of were ok, and invited me out with the course attendees for drinks. Hearing the story of her life as a doctor, working in mountains, remote Europe and Spain really captured my imagination. She was also extremely humble and very kind. For the first time- I had met a doctor who had the kind of life and personality that I genuinely liked and saw myself emulating. So, with a healed arm, an empty bank balance, and this renewed enthusiasm for medicine, I returned to Australia and the rest, as they say, is history.

Feel free to live the life you want to

Some of us in this world have a wandering spirit, and I’ve learnt it is actually ok to be the person that you want to be and live the life you choose to live. Sure, there have been times I’ve definitely run away from my life, but when the dust has settled I have realised that I genuinely enjoy my ‘peripatetic’ existence. As a GP, I can work anywhere and settle anywhere, which allows me great freedom.

I have been lucky that as well as being a GP I have also been able to pursue my childhood dream of becoming a published author. I have published two books, one a novel loosely based upon my intern year, and the other a memoir about living and working as a GP around very remote parts of Australia.

I think there is much to be said for working in new environments. It doesn’t only make you a better doctor, I think it makes you a better person. I have always been a strong believer in the adage that change is as good as a holiday, because it is only by immersing ourselves in different places and with different people that we learn not just the art of medicine but also humility and humanity. It is unbelievable to me that when I lived in Sydney I could not even conceptualise places like those that I have worked and lived in now. Humanity is, by virtue, a tapestry of differing experiences. To truly understand or at least try to understand other people, to walk in their shoes, develops great empathy and also in turn your own self development.

How do you ‘put your feet in the dirt’?

After qualifying as a GP, I found that there were many, many job options with a wide variety of locations and experiences. For other GPs or doctors looking to do something a little different, I’d recommend finding a good locum agency, and researching some areas you are interested in working within. Often that will involve a bit of up-skilling, but there are plenty of courses available depending upon your interests. There is a shortage of GPs in rural and remote Australia, so there is a surplus of opportunities. I would particularly recommend the Kimberley region of Western Australia, known for its beauty and incredible scenery. Here the work you can do in First Nations communities is not only incredibly interesting, but also opens your mind both medically and personally to how difficult life can be in remote Australia. It also illustrates great discrepancies between metropolitan and remote health access, and the gap in health outcomes for First Nations Australians. For me, after having lived and worked in the places I have, remote medicine and First Nations health is no longer a concept or a chapter in a textbook, but very much a reality. It is only by spending time living within these communities that you can become a genuine advocate for equitable access to healthcare in these remote areas of Australia.

To any doctors reading this who want to try something new, go off the beaten track, have an adventure- I can only encourage you. Who knows- one day you might even write a book about it.

An extract from “Put your feet in the dirt, Girl”

My routine of swimming at Cable Beach is becoming slightly more stressful every morning. It seems that every day I see a another patient, usually a pearl diver, who has been stung by Irukandji, or wrestled sharks or spotted crocodiles – the big, scary ones, saltwater crocs.

‘I don’t think Irukandji really kill people,’ my pearl-diving patient tells me, ‘But (…) you want to want to avoid it if you can. I’ll never forget being stung by one of them. Got me on my finger. You can still see what it looks like.’

He shows me his thumb, which is deformed and permanently swollen.

‘I think it got infected or something,’ he says casually. ‘Anyway, that one was a few years ago. But it wasn’t really my thumb (…) that was so bad: it was the doom.’

I’ve read about this so have some idea of what he’s talking about. The toxin released by Irukandji jellyfish, creatures tinier than fingernails, has some neurotoxic effect that causes symptoms so severe and so bizarre there’s a name for it: ‘Irukandji syndrome’. The worst thing, my patient confirms, is the horrendous sense of impending doom. Apparently no one’s quite sure what causes this feeling, but it’s been suggested that the venom results in an uptake in adrenaline and noradrenaline, which are connected to anxiety.

‘That sounds absolutely horrendous,’ I say, feeling a little sick.

He nods at me. ‘I was crying on the phone to my Mum,’ he says. ‘It was so awful. I couldn’t stop crying. When they got me onto the beach they thought I was crawled up because of the pain, but it wasn’t that. It was just this sense that my whole world was collapsing.’

A few mornings later I come out of the water with a small, painful red lump on my leg. The water is warm, probably over 26 degrees, so I knew the Irukandji would be about and swam anyway. I’ve heard it takes about twenty minutes to determine whether it’s an Irukandji sting, so I head to the vinegar station, which is essentially just a seedy old bottle of vinegar near the surf club’s steps.

I don’t have a towel, so I use an old leaf I find on the sand to ineffectually rub vinegar onto my leg.

A man comes past, heading down the steps, and stops.

‘You right, mate?’

A typical Broome understatement, as we both know what it can mean if a person is throwing vinegar on themselves in a place like Cable Beach.

‘Guess I’ll know in about fifteen minutes,’ I tell him. ‘I’m ok now.’

Fifteen minutes later I’m still alive and haven’t started crying, so I put it down to sea lice and get ready for work. Another near-death experience narrowly avoided. If I were a cat, I’d be coming very close to nine up here.

From: put your feet in the dirt, girl by Dr Sonia Henry, published by Allen & Unwin in May 2023

Links

www.soniahenry.com.au
Instagram: @sonnie_h
You can buy Sonia’s book here

The post Put your feet in the dirt, Girl appeared first on Adventure Medic.

How much thought have you ever put into your sunglasses choice, beyond the shape of the frame? In an aging population, protecting our future eye health is more important than ever, especially in a world with a depleting ozone layer, ever-changing climates, and infinite opportunities to travel. Dr Josie Hollywood helps to unravel the crucial points when it comes to choosing your perfect pair of sunglasses.

Eye Health

As well as ensuring a comfortable viewing experience in the sun, sunglasses also offer vital protection against ultraviolet radiation (UVR) reaching the eyes. This is important for preventing an array of eye problems that have all been shown to be associated with ocular exposure to UVR.^1,2

Short-Term Problems:

Photokeratitis: essentially sunburn of the cornea, also known as “snow-blindness”

Long-Term Problems:

Pterygium: part of white conjunctiva growing over into the cornea
Cataracts: clouding of the lens- the leading cause of blindness worldwide
Macular degeneration: degeneration of the central portion of the retina
Eyelid malignancies: melanoma, basal cell carcinoma, squamous cell carcinoma

So What Is UVR?

Sunlight is the only naturally occurring form of UVR. UVR contains more energy than visible light rays but plays a minimal, if any, role in vision. It sits between visible light rays and X-rays on the electromagnetic spectrum in terms of the amount of energy involved. UVR is typically classified into bands according to wavelengths, with shorter wavelengths containing more energy and therefore being more dangerous.

The three bands of UVR are:

UV-A (315-400nm): least energy
UV-B (280-315nm)
UV-C (100-280nm): most energy

The ozone layer currently absorbs almost all UV-C wavelengths, preventing this from reaching Earth’s surface. Because of this, the UVR wavelengths that reach us, are made up of 95% UV-A and 5% UV-B. Even just these small proportions of UV-B can have significant adverse heatlh effects. With the amount of UV-B absorbed being dependent on the ozone, the depleting ozone layer becomes a prominent issue for our eyes too.³

What Affects How Much UVR Reaches Our Eyes?

The amount of sunlight, and therefore UVR, reaching our unprotected eyes varies according to the ease of the path of the sun’s rays. This means the degree to which our eyes are exposed to UVR varies according to a few important factors, largely relating to the elevation of the sun.⁴

Time of Day:
Somewhat counter-intuitively, the highest elevation of the sun around midday doesn’t equal the highest level of exposure. This is because your eyebrows and eyelashes do an excellent job of protecting your eyes from the sun directly above. The sunlight has a more direct path to your eyes when solar elevation is low, bypassing more of the eyebrows and lashes, with morning and late afternoon delivering the highest amount of exposure.
Altitude:
This one does make sense: the higher the altitude, the closer you are to the sun, therefore the shorter the path of UVR rays to your eyes.
Season:
There is around 3.5% more exposure to UVR in summer compared to winter, likely due to daylight hours and cloud cover. Conversely, 3.5% is a relatively small difference, highlighting the importance of ensuring adequate eye protection even in the winter months.
Ground reflection:
This is an important one. The two biggest culprits are snow and sand, both of which reflect significantly more UVR than typical day-to-day materials such as pavement or grass. Especially important because people tend to spend more time at the beach in sunny weather or climates, and are usually sat on the sand, thus closer to the point of reflection. In snow, this highlights the importance of always wearing snow goggles during winter sports, even when the sun isn’t out. Especially as these activities are often performed in mountainous areas: at higher altitudes.

So, What To Look For When Buying Sunglasses?

The single biggest controllable factor affecting your eye’s UVR exposure is adequate eye protection – usually in the form of sunglasses. However, caps and wide-brimmed hats also offer enhanced protection, ideally in combination with a proper pair of sunglasses.

UV Protection

Protection from UVR is now usually embedded into the lens of the glasses, rather than a protective film. Most well-known sunglasses brands will offer 100% UV protection as standard, but there is a huge amount of variation, especially amongst cheaper non-branded sunglasses, so it is always important to check.

The keywords to look for are:

• 100% protection against UV 400 (All wavelengths up to 400nm, which includes UV-A and UV-B)

• 100% UVA & UVB

Categories

When browsing, you may see a category provided alongside each pair of sunglasses, which can be a little confusing. This doesn’t actually have any relation to the amount of UV protection. It instead refers to the amount of light that is transmitted through the lenses; the tint of the lenses. You may also see the acronym VLT, meaning Visible Light Transmission, which determines the percentage of light allowed through by the lens. The category, or degree of tint in the lenses, therefore simply affects the comfort of the eye in bright conditions.⁵

Category 0
80-100%
Clear/very light
Safety goggle

Category 1
43-80%
Light
Casual or fashion use

Category 2
18-43%
Medium
General or sport – most common