Rachael Parker / 5th Year Medical Student, Cardiff University UK
In an attempt to eke Winter out for as long as possible, Rachael Parker recently retreated as far north as she could find, spending her final year medical elective taking in the enormous expanse of Swedish Lapland. Discovering cross-country skiing, the beauty of the midnight sun and the harsh reality of life as a medic in a freezing, isolated land along the way, she tells Adventure Medic why it’s one of the best decisions she ever made.
Why? Why Not?
Why go to a beach when a unique adventure awaits you in Swedish Lapland? In a land so vast, it is no wonder Sweden has its own unit of measurement: one Swedish mil is equivalent to 10km. Eight mils north of the Arctic Circle, Gällivare Hospital cares for 30,000 people across Norbottens county – a cool 98,000km2 equating to one quarter of Sweden, with approximately 0.5 inhabitants per square kilometer.
Flying north from Stockholm, the bright city lights rapidly disappeared and soon the only visible cartography was being magically created by moonlight reflecting off snow from lakes, mountains and forests. This is the awesome land of the Northern Lights and the Midnight Sun, and it most certainly did not disappoint.
I am a big enthusiast of all things adventurous and outdoors, and this extends to a passion for pre-hospital and wilderness medicine. Before I came on my elective I knew I wanted to combine all of these things (not to mention the appeal of gravlax, cinnamon buns, cross-country skiing and the top item on my bucket list, experiencing the Aurora Borealis) and so to me, Northern Sweden was simply perfect. I was based in the Emergency Klinik, which includes six Intensive Care beds and four Cardiac Care beds. I also spent a great deal of time with the ground ambulance crews and with the Scandinavian Air Ambulance. Despite being a fully capable hospital with 700 beds, the nearest tertiary centre and percutaneous coronary intervention (PCI) facility is 200km away in Luleå, which presents regular logistical and clinical challenges.
The indigenous Sami people divide the year into eight seasons; I came here on my elective in February and March, which in the Sami calendar is Spring Winter, and arguably the best time of year to come to Northern Sweden for snow and sunshine. Don’t be fooled by a clear blue sky though, temperatures at this time of year can range from -30° Celsius to a pleasant +4°. Combine this with unforgiving snowfall and wind-chill, extreme distances to reach patients and only one road to get there, this subarctic climate demands meticulous prior preparation from the emergency services, and for medical staff to maintain a very broad set of competencies.
Transfer of patients is often time-critical and in this environment, the fastest way to achieve this is by air. The Scandinavian Air Ambulance fleet consists of one fixed-wing airplane and one helicopter. Previously the Swedish and Norwegian RAF have augmented the Air Ambulance fleet, but this is no longer the case. The fixed-wing aircraft with one flight nurse makes three scheduled, non-urgent flights each week from Kiruna in the North. It stops at hospitals along the 600km trip south to Umeå (still technically in the North of Sweden), transporting patients to tertiary centres for treatment and back to regional hospitals like Gällivare for community rehabilitation. The fixed-wing aircraft can also transport unstable patients with a flight nurse and doctor on board when an emergency situation arises. There is one helicopter to serve the whole of Northern Sweden, based in Gällivare, with the ability to retrieve and transfer one acutely ill patient from remote locations to a place of definitive care. The structure of the Swedish healthcare system is largely similar to the NHS, although a significantly smaller population over an expansive geographical area enables and justifies the frequent use of medical aviation. Double crews, ensuring maximum flight hours and service provision, man both aircraft; however, bad weather is often the restricting factor in permitting flight operations. By sheer fluke and at the envy of every other junior doctor in the department, I was lucky enough to join the helicopter Air Ambulance crew to transfer a patient with a myocardial infarction from Gällivare to Luleå for coronary angiography and intervention. Flying over the snow-covered forests and lakes on a gloriously sunny day, moose-spotting along the way and arriving at Luleå hospital in time for lunch, was possibly the coolest day I have ever had on placement. It was also the day I found out I would be working in my first choice deanery as an F1 in August – Jättebra!
Aside from treating patients predominantly with cardiovascular disease and skiing-, snowmobile- or reindeer-induced injuries, I grabbed every opportunity to get out in the snow and wholly embrace the active lifestyle that unsurprisingly renders Sweden one of the healthiest countries in the world. During my second week it was ‘Sports Break’. Similar to half-term, this one week off school is specifically for skiing, exercising, venturing into the mountains, or relaxing if you really want to. I joined in for the final event on Friday evening: downhill skiing for free on Dundret Mountain until midnight, on floodlit pistes and off-piste through the trees guided only by head torches and the Northern Lights dancing in the sky above – a truly awesome experience, completed by having a beer in the sauna afterwards.
As well as learning a lot about Sweden and acute medicine I became educated in the secretive and scientific world of valla. When Sweden competes in snow sports, particularly against Norway, there are whole teams of people working on perfecting the skier’s valla, or wax on the skis – using the wrong valla for the temperature and snow conditions on the skis could lose you the gold medal. A very confident downhill skier, I admit that before coming to Gällivare I was totally unaware that there were even different types of cross-country skiing, and so I took it upon myself to progress from Bambi on ice, going out on sunny midweek evenings to learn to skate, ski in the classic style in the local tracks, and walk up mountains (with skis on) to ski, and eventually not fall, back down again. Swedish people seem to enjoy skiing off-piste a lot more than their European counterparts in the Alps, and the best place to experience serious off-piste is the legendary Riksgränsen resort on the Swedish-Norwegian border. Following the Torne River north to its source, the same river from which ice is harvested to build and rebuild the iconic Ice Hotel each year in Kiruna, the magnitude and sense of wilderness surrounding Riksgränsen is almost biblical.
Cold is Your Enemy, and Everyone is Cold
There are constant reminders of the power of nature. An elderly gentleman suffered severe head and limb injuries when he fell from the roof of his house clearing snow in a small village nine mils (90km) from Gällivare, and was treated on scene by a ground ambulance crew from a local base 30km away who brought him into the hospital. Having spent approximately 40 minutes lying on snow at -12° Celsius, hypothermia was certain; no attempt at obtaining venous access was made and the paramedic and ambulance nurse went straight for intraosseous access to administer fluids, analgesia and later blood on his arrival to the resuscitation room.
Clinically the patient was unconscious, had dark swollen eyelids, an airway obstructed by blood, broken ribs and a fractured wrist. CT scans revealed a temporal skull fracture and it transpired that the blood coming from the patient’s mouth was originating from the head injuries, tracking down through his sinuses. Unstable and in need of urgent neurosurgical intervention, the flying doctors’ fixed-wing flight crew from Umeå were called to package the patient and prepare for the two hour transfer time. This case highlighted the challenges presented by remote living in extreme environments, and that even with the most modern technology and competent teams, things take time. Even more so when factors like poor flying conditions and great distances to definitive care are taken into account, which can significantly influence a patient’s circumstances. This patient survived the transfer to Umeå hospital and at time of writing, his condition was being monitored in Intensive Care.
I will never forget my time in Sweden and am already planning to go back! I met so many kind and inspiring people, had countless new experiences and ticked things off my bucket list that I did not even know were on there… My thirst for pre-hospital and wilderness medicine has only grown and my exposure to clinical scenarios and extreme environments has taught me much about the importance of meticulous preparation in all operational aspects. This includes, importantly, making sure you are warmly and appropriately dressed for changing outside conditions, well-fed, and not in need of the toilet, to ensure you can perform at your highest level to provide the best care for the patient. There were moments almost every day when I felt outside my comfort zone, but the single most important thing this trip has taught me is to say yes to every opportunity presented to you, even if it scares you a little. Use this excited nervous energy not to get back into your box or comfort zone, but to make the box bigger and to experience all that you can.
Where / Gällivare hospital, Swedish Lapland, Northern Sweden.
When / February-March.
Weather / Temperatures can range from -30 to +4, often blue skies or snowing at this time of year. Hours of sunlight are similar to British winter, but increase rapidly so days will quickly get longer.
Travel / Fly to Stockholm Arlanda Airport, then take a 2 hour domestic flight up to Gällivare (flights often stop halfway at smaller airports).
Vaccinations / Standard UK childhood vaccinations.
Accommodation / Rachael stayed with a local doctor but accommodation is available very close to the hospital and more student/junior doctor apartments are currently being built in time for August 2015.
Essential Items / Very warm jacket (700-900 fill power), decent gloves and walking/insulated boots.
Contacts / Rachael suggests contacting Gällivare Hospital directly through the website, and passes the message on the phoning directly will get you a deal further than waiting for email replies…