Elephants and Expeditions: Medicine in the Wilderness

Dr Saskia Loysen / Foundation Doctor / Bristol

Having attended the World Extreme Medicine conference in Edinburgh, Saskia felt totally inspired by the people she met and the stories they told, so asked one of the speakers if she could join him for her senior undergraduate medical elective. Here, she reflects on her life-changing experience in South Africa, Botswana and Zimbabwe, where she embarked upon four weeks of wilderness and expedition medicine.

Until this trip, I had never slept under the stars in the Southern Hemisphere. The constellations are different; I can see the Southern Cross. I had never previously slept without a wall separating me from large wild animals. It’s the middle of the night, the moon illuminates the savannah around me and I am aware that I may be the only human awake for miles and miles.

I am in Pilanesberg National Park, just north of Johannesburg, South Africa. There are seven other students, a guide and a doctor all sleeping soundly behind me. I am on night watch for just a couple of hours, ensuring that we remain alive and well, until I wake the next person to come on duty. We have come out here for just a few days to gain skills in wilderness medicine and emergency first aid, as well as leadership, animal tracking, and connecting with our natural environment. Night watch is a time for reflection. As I recall today’s events, I stare into the dancing flames of the warm, orange, glowing fire in front of me.

Earlier tonight, we sat around the very same fire, discussing the nuances of cervical spine immobilisation in the bush and the reality that CPR doesn’t work out here (an uncomfortable and unfamiliar consideration in a normal medical setting), whilst consuming the spicy potjiekos we had cooked. Some time between the sun going down and the moon coming up, these after-dark musings were interrupted by our guide, Doric, telling us that Simon, our doctor, was missing. He looked nervous. One of the few expedition rules was that we always stick together and remain behind Doric, who has the rifle, as he is the only one who could safely protect us if we came across a large animal or poacher. We even defecated with someone on the lookout! And yet, here was Doric, complete with firearm, and Simon was out there in the black of night on his own.

Is this a drill? Please let this be a drill. Doric hurried us to action, and in that second, I forgot everything I had ever learned about medicine and first aid, but also how to walk. I immediately tripped over the log I had been sitting on. We grabbed our head torches and the medical kits and spread out, trekking up the mountain behind the camp where Simon had last been seen. When we found him, he told us he had fallen. There was blood visible on his head. After a short time, he became unrousable. Staged or otherwise, this night-time mountain rescue took me totally out of my comfort zone. Our teacher, the one person who would definitively know what to do right now, was unconscious.

What would you do? What are the right questions to ask? It’s not just a case of ‘to evacuate or not to evacuate,’ you must decide how and when. An ambulance wouldn’t be able to reach us, a helicopter wouldn’t fly at night, we didn’t have any phones on us and there was little chance of any network coverage anyway. The only viable option was to get Simon back to camp somehow and decide the next step afterwards. After a little panicking, and a lot of discussion about how to get him down the very steep hillside, we improvised a stretcher out of belts and a mattress. Then, with great difficulty, we attempted the descent.

Suddenly, the panting of an animal I hear but cannot see, pulls me back into the present moment. Is it close? Is it dangerous? I swing the torch across the horizon, to see if any pair of eyes reflect back at me. Nothing. I hear the same noise again, but it seems fairly distant. I hope it is fairly distant. I don’t recognise the sound. I can do sheep and cows, but animals out here? I learned the following morning from Doric that the sound had been a leopard!

Fortunately, Simon’s fall had been a drill. He stopped the simulation shortly after we started carrying him, and we had a debrief around the fire, discussing what went well and what we could have done better.  There are always so many lessons to learn – and there’s no better place to learn them.

Over the past few days, we have been practicing core survival skills in this remote environment. How to start a fire without matches and the basics of animal tracking. Suturing and inserting chest drains into animal carcasses. We are far from the city, hospitals, and our usual kit. We’ve learnt how to improvise when needed, such as creating stretchers, bandages, one-way chest seal valves, and tourniquets. There’s usually a solution to a problem you haven’t come across before, but I found that it can be hard to think ‘outside the box,’ having spent most of my medical life being told what equipment to use as well as how and when to use it. It’s been fun getting creative and inventing, looking at problems from a new perspective. We’ve trained in airway management, haemorrhage control, managing the unconscious patient, but with the added pressure of being in the territory of wild animals, short hours of daylight, and evacuation times of hours, if not days, rather than minutes.

Earlier during this elective, Simon took me to a park in Botswana where two people had been attacked by an elephant days before I arrived. He had assisted, with the aid of videocall, until the helivac arrived, telling those who were present what to do. There was no way of knowing with any certainty whether the victims would survive the six hours until help arrived, let alone beyond that. They had what appeared to be life-threatening injuries, with no doctors present except for the one on the little screen in neighbouring South Africa. When he returned, me in tow, he ran a training session for the safari guides, and discussed with the managers what equipment wasn’t available this time, but would be useful in future. Fortunately, the two victims made a good recovery.

One particular event that stood out for me as totally different to anything I’d ever done before, was entering a shoulder-deep (and very cold) watering hole to ventilate a ‘drowned’ patient whilst barefoot and blindfolded. But thanks to that, I now know that I could breath for someone in an emergency, with just one hand, in the darkness, in difficult conditions, if need be. Heck, I know that I could do it in a confined space, in the back of a bouncing 4X4 that has to drive for hours to the nearest hospital! I hope these skills practiced in difficult settings will now be automatic back in the comfort of a hospital, freeing up the brain to think about other things, such as what to do next.

A few weeks ago, I assisted on the medical team with various doctors and a trauma nurse, supporting several hundred cyclists as they toured Botswana, Zimbabwe and South Africa in the Tour de Tuli. We stayed in makeshift camps, moving from one to the next, and having to take all the medical equipment with us. Luckily for the cyclists, we mostly had to deal with small and easy-to-manage injuries, but I did have to chase a baboon out of the medical tent one morning, who was busy opening a box of bandages!

Tonight is our last night sleeping under the stars. Tomorrow we return to the city, where I will learn more about a wilderness doctor’s workload, about telemedicine consults and asking the right questions, like ‘what must I not miss?’ Calls have come in ranging from complaints of diarrhoea and vomiting to an incident in which a young child had been spat at in the face by a venomous cobra.

I’m going to miss the sunrises, the heat, the elephants and giraffe moving at their ponderous pace.  I’m going to miss the peace of the savannah. I’m going to miss the people I’ve met on my travels through Africa, the energy and kindness and, of course, the limitless flavours of rooibos tea. I’m already planning my return, working with rural people to provide emergency care in remote places. I wish (as my brother put it) to “give up all my worldly goods and go and join the leopards.”

Further information

When / July-August (Southern Hemisphere winter)

Weather / Hot in the day, very cold at night.

Vaccinations / Rabies is a good idea. I didn’t get my yellow fever vaccine as I wasn’t planning to visit any high-risk countries on my way to South Africa, but due to plane issues, ended up in Kenya for a night and they did want to see my yellow fever certificate on re-entry to Nairobi airport. Luckily, I managed to talk my way out of it. It’s safer to have had the vaccine and carry the card to prove it. Discuss the need for antimalarials with your travel clinic.

Travel / Flying between South Africa and London can be fairly cheap. However, it turns out it’s very expensive to fly direct from the north to South Africa. I left from Morocco but unfortunately experienced 20 hours of delayed flights, having to sleep next to two huge men in a locked office Lagos airport in Nigeria without my passport, and an impromptu trip to several Nairobi hotels before one would allow us to sleep for a few hours. Uber is cheap, reliable, and safe in Jo’berg.

Accommodation / Rent in Jo’berg is reasonably priced, tents (or just sleeping bags) for the bush, and you may stay in a luxury suite in one of the safari parks!

Essential items / Bring hats, gloves, lots of layers, hiking boots, tick spray, sun cream and sunglasses. And a buff for the dust! Everything you could need is available in shops in South Africa, so don’t worry if you’ve forgotten something.

Contact / You can follow Saskia on Instagram @thewildmedic 

Saskia may be able to provide further information for those interested in organising something similar. Please get in touch via Adventure Medic.