Medical Expedition Advice
By Dr David Hillebrandt
Medical preparation for any expedition is a form of insurance. Like insurance it should be of high quality but hopefully never needed. These notes are designed to steer a traditional UK expedition of experienced climbing partners to the best sources of advice. They are not intended for commercially run “expeditions” which may be introducing relative novices to personally challenging objectives where there is a commercial duty of care and a designated leader and support team.
Doctors with mountaineering experience can be useful on an expedition. Doctors with no mountain experience can be a hindrance. For a real bonus try for a medically qualified friend who fits in with the team, has mountain skills and experience and a specific interest, and possibly training, in mountain medicine.
If you do not have a suitable tame doctor with you at least try to find one to help train and equip your team prior to departure. Whatever you do ensure at least one team member has some remote area first aid training and is willing to take responsibility for this aspect of planning. A search via the Alpine Club membership list may reveal a suitable medical advisor. Several members of the AC hold the UK UIAA/IKAR/ ISMM Diploma of Mountain Medicine and the Medex website has a list of all diploma holders (http://medex.org.uk/diploma/diploma_holders.php) with their specific areas of expertise. Additionally the Royal Geographic Society has a medical cell ( http://www.rgs.org/OurWork/Fieldwork+and+Expeditions/Specialist+Advice/M... ) which is a good source of advice.
PRE TRIP ADVICE
General Medical Advice
If you do not have an expedition doctor or medic you will need to do research to know what questions to ask any advisor you can contact. A good initial place to look is the reports of previous expeditions (AC, BMC and RGS libraries) that have been to the same or similar areas to see if they have encountered any specific problems. Many reports will have a medical section. An excellent lay mans guide to staying healthy at altitude is produced by Medex as a free downloadable internet publication in 13 languages (http://medex.org.uk//medex_book/about_book.php ) . Alpine Club member Dr Mark Hallam has recently (Dec 2012) produced an excellent layman’s online guide to expedition medicine which will merit a read early in the preparation process ( http://www.summitpost.org/expedition-medicine/675753 )
Immunisations and Malaria
Immunisation and Malaria prevention advice can be obtained from commercial travel clinics such as MASTA (http://www.masta-travel-health.com) or your own GP. In an ideal world clients would seek advice three months prior to departure. MASTA also offers free online advice sheets. The public can access advice from the Scottish NHS Fit for Travel website which is used by many doctors (http://www.fitfortravel.scot.nhs. uk/home.aspx) .
Many professionals also use the American government site from the Atlanta Centre for Disease Control and Prevention (http://www.cdc.gov ).
Specific Malaria prevention advice for climber is available in the medical section of the mountaineering part of the BMC website (http://www.thebmc.co.uk ).
All immunisations are a risk/benefit decision and more experienced practitioners are used to making individual assessments based on the nature of the trip, remoteness of the area, seasonal risks and flight stopover risks. Patients have to pay for most travel immunisations but what appears expensive in the UK may seem like very good value when far from help in a remote area. GP surgeries tend to offer cheaper immunisation charges than commercial clinics.
Ever had toothache on an expedition? The cost of a pre trip check up can be money well spent.
Pre existing Medical conditions
Inevitably with an increasingly fit older population more active AC members will have pre existing medical conditions. Very few conditions preclude enjoyment of any form of expedition climbing but sometimes an altitude ceiling may be sensible or other modification of expectations. It is best to take advice from experienced expedition doctors who may want to work with your own GP and hospital consultant.
If you are on regular medication do carry spares in case of loss or theft. Do inform team members of any condition that may also put them at risk. A team doctor or medic should make confidential enquiries of team member about previous problems on trips, chronic conditions r anything needing a regular supply of medication. Pre expedition planning is essential and may involve carrying specialised drugs or equipment in the medical kit to protect a member with specific problems. Advice sheets on an increasing number of specific pre existing conditions are available from the medical section of the UIAA website (http:// www.theuiaa.org/medical_advice.html ).
The fact that you are reading this section of the AC website is a form of insurance. It is the nature of a true expedition that you will almost certainly have to initiate any rescue yourself but if the shit really hits the fan, once you get out of immediate danger, good rescue, medical and repatriation insurance will be invaluable. See above.
We should all be aware of the risks of our sport. Prior to a trip it is the medic’s responsibility to prepare for any emergency. In the event of a team member’s death all the team will be shocked and it makes formalities easier if members are aware of each others insurance provision, next of kin details and possible wishes regarding body disposal. I recommend lodging these details with the British Consul in the country being visited. These officials can be extremely helpful in a genuine emergency.
Medical/First Aid training
On any expedition it is worth having at least one member with some first aid experience. It is better to have two trained members as an insurance policy for the main medic. A basic Red Cross or St John first aid qualification is designed for city or roadside care and is virtually useless in a remote area. The Rescue Emergency Care Mountain First Aid course is a respected outdoor first aid qualification (http://www.recfirstaid.net) run by several outdoor centres including Plas Y Brenin and by various independent instructors.
The market is now swamped by remote and expedition courses and although many are excellent beware of ones based on Rambo type drama and backed with little real clinical experience. Two respected companies running courses with truly experienced instructors are Jon Dallimore’s Wilderness Medical Training ( http://wildernessmedicaltraining.co.uk ) or the commercially slicker Expedition Medicine Company (http://www.expeditionmedicine.co.uk) .
The internationally based Diploma of Mountain Medicine in the UK is a formal postgraduate medical qualification. It is a demanding four module course open to doctors, nurses and paramedics and the syllabus is divided equally between medical and mountaineering skills using UAIGM guides for teaching and assessment of mountain skills. Details from Medex (http://medex.org. uk/diploma/about_diploma.php) .
Beware any book, website or course which tells you what you need in an expedition medical kit. The only medical kit worth having is the one that you have with you when in trouble. In other words it must be small, compact, robust and geared to your objective and your medical skill. On a multiday new extreme route in Alaska spare abseil tat and gloves may be more use than any first aid kit in terms of getting you out of the shit in one piece. On a 7000m peak an ampoule of dexamethasone and the knowledge of how and when to use it may be all that is needed for an emergency on summit day.
A base camp kit has to be tuned to your skill level but I believe anybody can be trained to use emergency altitude drugs such as dexamethasone and nifedipine, strong analgesics and antibiotics. Drugs can often be purchased in pharmacies abroad but quality can be questionable so it may be preferable to get them from a UK pharmacy via an experienced doctor who can also offer training and advice on their use. Medico legally the drugs use will remain the responsibility of the prescribing doctor so he or she will have to have insight into the problems of expedition medicine and also insist on training and a written protocol for their use. But making up your own medical kit, with guidance, you will have already thought through potential problems and thereby be one step ahead of any emergency. Commercial expeditions will almost certainly employ a medical advisor and have their own monitored system for drug supply.
Don’t forget the most dangerous part of any expedition is usually driving to the objective. Don’t forget that the most common medical problem is traveller’s shits. Personal care can minimise but not stop these risks. Having read the preparation section hopefully you will have little use for this section.
Know the location and facilities available close to your objective and for any evacuation route home. A visit on the route into base camp can pay dividends in the event of a problem. It will also mean you know the limitations of any local services. Local Rescue facilities (or lack of) As for local medical facilities.
Advice in the field
No doctor on the trip. Do you have a sat phone? Communications are the key to good medical care anywhere in the world. Now you know why prior liaison with an experienced medical advisor is useful. “Phone a friend”. If you did not organise anything prior to departure a phone call to the BMC may put you in touch with one of their medical advisors. If you do have a doctor on your expedition he or she may want a second opinion and should have arranged UK contacts prior to the trip.
The UK has a frostbite advice service run in cooperation with the BMC (http://www.thebmc.co.uk/how-to-get-expert-frostbite-advice?s=4 ) or go direct to the service at http://www.christopherimray.co.uk/highaltitudemedicine/frostbite.htm . If you have a satellite phone and can take digital images from the moment you are aware of a cold injury until you are able to transmit them to the UK, advice can be started in the field and assessment arranged after emergency repatriation to the UK.
The team medic (doctor or otherwise) has an ongoing obligation to the team members. Any with outstanding problems on return should be referred to experts in the UK for further care. This may also apply to the family of team members. Give feedback to any expedition advisors. It may help future trips.
The Oxford handbook of Expedition and Wilderness Medicine published 2008 by Oxford University Press. ISBN: 978-0-19-929661-3 is the book to read before departure. A new edition is in preparation for 2013.
Pocket first Aid and Wilderness Medicine by Jim Duff and Peter Gormly published by Cicerone. ISBM: 13: 978 1 85284 500 1. Tenth edition published 2007 and reprinted with amendments 2010. This is the book to have with you in your medical kit.
TOP TEN TIPS!
- Never travel to a county unless you are prepared to receive initial treatment in a local hospital.
- Communication is the key to any medical emergency. You won’t argue about the cost of calls when an emergency occurs.
- Never be afraid to phone a friend
- Medical equipment can be improvised, knowledge cannot.
- If you choose to treat locals or members of other expeditions always keep some strong painkillers and antibiotics in reserve for your own use.
- An expedition doctor is only as good as his/her mountain ability and knowledge.
- A large medical kit may look impressive but it will never be where you want it when you want it.
- The best medical kit is the one that is never opened
- By choosing to go to a remote area we choose to be away from high tec medical facilities. We have to accept the consequences.
- Stop reading this and get out climbing!