Expedition Doctor Research Articles

Model Contract for Health Care on Trekking and Expeditions for Doctors – Recommendation of the Medical Commission of the Union Internationale des Associations d’Alpinisme (UIAA)

This suggested contract document attempts to clarify the rights and obligations of the tour operator (referred to herein as “organization”, OR), the ED and the EX to avoid trouble and misunderstandings during the trip.
 Being an Expedition or Trekking Doctor (referred to herein as “Expedition Doctor”, ED) is more than being merely a member which advises others in case of a health problem during the trip and who may get a discount on organized trips! An ED has specific responsibilities, has to provide special skills, and must always accept responsibility for any diagnosis made, whether right or wrong. Both, the tour operator and the participants of the Expedition (referred to herein as “Expedition”, EX) have their individual and often conflicting interests to which the ED’s own mountaineering interests must also be added. However, to minimize the possible multiple risks associated with these conflicts of interest, the rights, obligations and priorisation of medical and expedition scheduling should be made clear well in advance of the expedition. The following is a model text which may be adapted to an EX’s specific demands. In this text, EX includes the organizers of the trip, the expedition’s leaders and the participants.

Wilderness Medicine Simulation-Based Teaching Program for Medical Students in the UK

The UK undergraduate medicine curriculum provides insufficient opportunities for medical students to explore the field of wilderness medicine, despite interest in the area. The student-led Cambridge University Wilderness Medicine Society devised a low-cost wilderness medicine teaching weekend that can be replicated at other institutions. The weekend course consisted of small-group lessons introducing the roles of the expedition doctor and expedition leader and the assessment and management of acute conditions in remote environments. This was followed by a 3-station circuit to teach the principles of casualty triage, splinting, and construction of rope stretchers. These skills were then practiced in simulations in which participants rotated roles as care providers and patients. Participant confidence was compared before the course and immediately on course completion using the related-samples Wilcoxon signed-ranks test with significance accepted at P<0.05. Usefulness of course content and perceptions of learning were also assessed. Sixty-one medical students attended the wilderness teaching weekend and completed the structured feedback questionnaires. Participants rated the course highly in terms of usefulness of course content (mean±SD=18.3±1.9, range=12-20) and perceptions of learning (mean±SD=37.6±2.6, range=31-40), with 92% of participants "strongly agreeing" that the course was of high quality. There was an improvement in perceived confidence after course completion (P<0.001). We have demonstrated that a teaching program consisting of structured, low-cost "teaching weekends" is a potential solution to the lack of centralized national wilderness medicine teaching and can be integrated, with minimal disruption, into the undergraduate curriculum.

Last resting places of the Zambezi Expedition (1858-1864) doctors.

Last resting places of the Zambezi Expedition (1858-1864) doctors.

Practical Tips for Working as an Expedition Doctor on High-Altitude Expeditions.

Brants, Anne, and Tracee Metcalfe. Practical tips for working as an expedition doctor on high-altitude expeditions. High Alt Med Biol. 18:193-198, 2017.-With the explosion of adventure travel over the past decade, there has been a concurrent increase in mountaineering expeditions to extreme elevations, including many of the 8000-m peaks. This trend has created an increased demand for qualified expedition doctors to provide specialized medical advice and care to climbers and expedition staff. This review is intended to help physicians prepare for work on such expeditions. The authors rely heavily on their own experience and discuss the types of work available on high-altitude expeditions; how to identify a safe and reputable guiding company; personal and medical preparation; priorities in selecting or building an appropriate medical kit; and medical conditions commonly encountered on expeditions. The review concludes by considering ethical dilemmas and other difficult issues unique to this work.

Lower Respiratory Tract Infection: An Unrecognised Risk Factor for High Altitude Pulmonary Oedema?

The case of a 25-year-old expedition doctor who developed high altitude pulmonary oedema (HAPE) while climbing in the Swiss Alps is presented, with reference to the literature. The patient’s symptoms of HAPE were typical. Less typical was the fact that the doctor had previously been to similar altitudes uneventfully. The only differentiator is that on this expedition he developed a mild lower respiratory tract infection (LRTI) 2 days prior to travel. There has been limited, conflicting evidence regarding LRTI as a risk factor for HAPE and high quality research has not focused on this area. LRTI is not commonly recognised as being a risk in high altitude environments, which may be resulting in lethal consequences. This report aims to inform, provide a clinical question for future high altitude research expeditions, and encourage consideration by expedition and high altitude doctors.LEARNING POINTSLower respiratory tract infection (LRTI) may be a significant risk factor in the development of high altitude pulmonary oedema (HAPE).The diagnosis of HAPE is clinical as investigations have been shown to be unreliable.The Lake Louise HAPE criteria provide a reasonable identification framework but may miss the early stages.

Of Penguins, Pinnipeds, and Poisons: Anesthesia on Elephant Island.

Although Ernest Shackleton's Endurance Antarctic expedition of 1914 to 1916 is a famous epic of survival, the medical achievements of the two expedition doctors have received little formal examination. Marooned on Elephant Island after the expedition ship sank, Drs. Macklin and McIlroy administered a chloroform anesthetic to crew member Perce Blackborow to amputate his frostbitten toes. As the saturated vapor pressure of chloroform at 0°C is 71.5 mmHg and the minimum alveolar concentration is 0.5% of sea-level atmospheric pressure (3.8 mmHg), it would have been feasible to induce anesthesia at a low temperature. However, given the potentially lethal hazards of a light chloroform anesthetic, an adequate and constant depth of anesthesia was essential. The pharmacokinetics of the volatile anesthetic, administered via the open-drop technique in the frigid environment, would have been unfamiliar to the occasional anesthetist. To facilitate vaporization of the chloroform, the team burned penguin skins and seal blubber under overturned lifeboats to increase the ambient temperature from -0.5° to 26.6°C. Chloroform degrades with heat to chlorine and phosgene, but buildup of these poisonous gases did not occur due to venting of the confined space by the stove chimney. The anesthetic went well, and the patient-and all the ship's crew-survived to return home.

Exercise HIMALAYAN SERPENT: feedback article

Exercise HIMALAYAN SERPENT was open to junior doctors from the United Kingdom (UK) Armed Forces and aimed to educate potential expedition doctors on aspects of high altitude and wilderness medicine as well as conducting adventurous training (AT) and medical research. This was the first time such an exercise had been undertaken and this article explores the views of those junior doctors taking part to assess whether the exercise met the aims and objectives it set out.

Why expedition medicine is a valuable trek into the unknown

As an expedition doctor in Tanzania Katie Ovens gained useful clinical and managerial experience

An eye emergency at high altitude on the climber: things not to miss

Risk of eye emergencies at high altitude should be noted by Emergency Physicians or expedition doctors for high altitude missions. Early management and understanding the sequelae of the conditions will make a difference in management and decisions at high altitude. DOI: http://dx.doi.org/10.3329/bjms.v13i3.16099 Bangladesh Journal of Medical Science Vol.13(3) 2014 p.353-355

Viewpoint

Being an expedition doctor is a challenging yet rewarding field of medicine, allowing medics to combine their interest in remote and rural medicine with itchy feet and an adventurous spirit. The photo below was taken while I was waiting for my next patient to arrive at Barafu Camp, Kilimanjaro at 4673 metres. I had arranged an ‘open access’ clinic after lunch on our acclimatisation day to see the participants who had medical concerns or …

The Role of the Expedition Doctor: Lessons From 100 Years Ago

This paper explores the role of the doctor on the expeditions of the heroic age of Antarctic exploration. The medical role includes medical screening of prospective expedition members, choosing medical equipment so as to maintain a balance between being able to cope with any eventuality and the cost and weight of equipment and drugs, health screening during an expedition, first aid training for field parties without a doctor, and, obviously, treatment of any injury or disease that occurs. If injury or illness occurs, the presence of a doctor is of great psychological benefit to the expedition. Although medical experience is important, it is probably more important that the doctor is a "team member," playing a full part in the expedition's aims, whether these are scientific, exploration, or reaching some goal. Most of the lessons learned during these expeditions a hundred years ago are just as relevant today.

Sea-Level Assessment of Dynamic Cerebral Autoregulation Predicts Susceptibility to Acute Mountain Sickness at High Altitude

Dynamic cerebral autoregulation is impaired in subjects who develop acute mountain sickness (AMS), a neurological disorder characterized by headache. The present study examined if the normoxic sea-level measurement of dynamic cerebral autoregulation would predict subsequent susceptibility to AMS during rapid ascent to terrestrial high altitude. A dynamic cerebral autoregulation index was determined in 18 subjects at sea level from continuous recordings of middle cerebral artery blood flow velocity (Doppler ultrasonography) and arterial blood pressure (finger photoplethysmography) after recovery from transiently induced hypotension. Six hours after passive ascent to 3800 m (Mt Elbrus, Russia), the Lake Louise and Environmental Symptoms Cerebral Symptoms questionnaires were used to assess AMS. AMS scores increased markedly at high-altitude (Lake Louise: +3±2 points, P=0.001 and Environmental Symptoms Cerebral Symptoms: +0.6±0.9 points, P=0.0003 versus sea level). Inverse relationships were observed between the sea-level autoregulation index score and the high-altitude-induced increases in the Lake Louise (r=-0.62, P=0.007) and Environmental Symptoms Cerebral Symptoms (r=-0.78, P=0.01) scores. One subject with a history of high-altitude pulmonary and cerebral edema presented with the lowest sea-level autoregulation index score (3.7 versus group: 6.2±1.0 points) and later developed high-altitude cerebral edema at 4800 m during the summit bid. These findings suggest that a lower baseline autoregulation index may be considered a potential risk factor for AMS. This laboratory measurement may prove a useful screening tool for the expedition doctor when considering targeted pharmacological prophylaxis in individuals deemed "AMS-susceptible."

First footprints of an expedition doctor

First footprints of an expedition doctor

Exped 2010 – The Challenges of an Expedition Doctor

‘Exped 2010’, a climbing and trekking expedition to the Everest region of Nepal, marked the 150th anniversary of the Army Cadet Force, during October 2010. A team of 20 cadets...

Anaesthesia and high altitude: a history

During an expedition to climb Everest in 1933, expedition doctor Raymond Greene administered an open-drop chloroform anaesthetic to a Tibetan patient at an altitude of more than 14,000 feet. The patient's subsequent apparent cardiopulmonary arrest has long been attributed to the effects of altitude on anaesthetic delivery. However, anaesthetics can be safely administered at a wide variety of altitudes by adequately trained and experienced anaesthetists. The problems may have arisen from an inadequate depth of anaesthesia consequent to decreased chloroform vaporisation in a cold environment, Greene's concern about potential depression of ventilation and the contemporary lack of a precise approach to assessing depth of anaesthesia.

Wilderness Training for Medical Students— An Introduction

The growing popularity of wilderness medicine extends to medical students, many of whom have joined the Wilderness Medical Society. However, students in the United States have typically had to look outside their curriculum for training in this discipline and (even after becoming physicians) have received no recognition for the training other than continuing education units (CEUs). In Europe, by contrast, there are many courses leading to a diploma in mountain medicine, which qualifies physicians to lead mountain rescue teams or act as expedition doctors.1 As Dr Macias and his colleagues describe, there is now at least 1 thriving program in the United States that adds wilderness medicine to the medical school curriculum. If enough other schools follow this example, wilderness medicine will doubtless become a popular elective and will perhaps someday be recognized through a certification program that physicians can add to their qualifications. Certainly, the number of applications for the positions in the New Mexico program (which was not even advertised, except by word of mouth) and the very positive participant reviews should encourage medical schools to develop similar programs. Unlike European diploma courses, the New Mexico rotations in wilderness and travel medicine did not require participants to be experts in wilderness skills. Instead, they included wilderness survival and skills train-

The Gobi Desert medical kit

Matthew Lewin is an emergency physician at the University of California, San Francisco, and Brian Kuhn is a pharmacist at the University of Fresno. Matthew Lewin was the expedition doctor for the 2003 American Museum of Natural History-Mongolian Academy of Sciences joint expedition to the Gobi Desert, Mongolia. Together, they have arranged expedition medical kits for the past 3 years.

Rehearsing for Mountain Rescue— An Introduction

One theme of all wilderness emergency care training, from the first-aid to the medical level, is that in order to take care of other people in the wilderness, you must be able to take care of yourself. Most mountain medicine courses in Europe, therefore, include training in mountaineering skills. These courses, which Dr Peters has described in several previous articles (references 1 and 3 in his following article), are generally designed for physicians. Many of the courses lead to an International Diploma in Mountain Medicine, recognized by the Union Internationale des Associations Alpinistes. This diploma helps qualify physicians to be expedition or mountain rescue doctors. In Europe, unlike in the United States, mountain rescue is usually done by professionals, including physicians who have earned a Diploma in Mountain Medicine. There is a demand for professionally trained and certified rescue teams because climbers (and accidents) are far more concentrated in the Alps than in the mountains of the United States. There are more than enough incidents to keep professional rescue teams busy. In the United States, however, wilderness rescue is usually done by volunteers, and physicians are rarely involved. With rare exceptions, only the pilots and crew of aeromedical transport are paid professionals. Sheriffs’ deputies and park rangers with rescue responsibilities usually serve as coordinators. When physicians do volunteer for a mountain rescue or search-and-rescue team, their role in training other members of the team is usually at least as important as the medical skills they may bring to a rescue. Rescue team members in the United States are typically trained to the First Responder level, with some EMTs. But usually, each team sets its own training standards in emergency care as well as in wilderness skills. Although there are many programs in wilderness emergency care and wilderness medicine, such programs provide medical professionals with only continuing education units at most. They do not lead to a generally recognized certification to practice wilderness medicine. It will be interesting to see how much influence the European system of training for and professionalizing mountain rescue has on wilderness rescue in the United States. It would also be interesting to learn more about training for wilderness emergencies and rescue in other countries, such as Great Britain, Canada, Australia, New Zealand, the South American countries straddling the Andes, Russia, Turkey, and Japan. What kinds of courses are offered, who teaches them, whom are they for, and how do graduates use the training? Readers who have experience with wilderness training and rescue in these countries should consider sharing their knowledge by submitting articles for The Wilderness Instructor. By reading about other courses and other approaches to wilderness emergency training, we can get ideas for improving the training that we do. When we can compare training with the performance of course graduates in real situations, we will get an even better sense of what kind of training is effective. This will require surveys of people who have used their training to cope with wilderness emergencies as well as surveys of training programs like those of Dr Peters. There have been many attempts to reach a consensus and set standards for wilderness emergency care training in the United States.1.Wilderness Prehospital Emergency Care (WPHEC) curriculum. In: Forgey WW, ed. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. Merrillville, IN: ICS Books Inc; 1995:60–67.Google Scholar,2.Forgey W.W. Wilderness Medical Society Practice Guidelines for Wilderness Emergency Care. 2nd ed. The Globe Pequot Press, Guilford, CT2001Google Scholar Perhaps the diversity of wilderness environments and the dependence on volunteers make it unlikely that training and certification will ever be as standardized here as they are in Europe. But the more we know about what kinds of wilderness training have been tried and what results they have in rescue performance, the better job we can do as instructors.

New Zealand Himalayan Expedition

The Barun Valley lies on the west side of Makalu and the project of sending an expedition to it started in 1952, when Erie Shipton, Ed Hillary, George Lowe and I visited it, crossing to it for the first time from Solu Khumbu, and making a quick journey up and down it before returning to England at the end of the Cho Oyu Expedition. After that, Hillary, through the New Zealand Alpine Club, asked permission to take an expedition there in 1954. The view of Makalu from Everest led Hillary, particularly, to believe that there might be a way up Makalu from the west, and a reconnaissance of such a route was one of his ideas in launching this expedition. In the meantime, however, a Californian party had specific permission from the Nepalese to attack Makalu itself, and so our expedition was limited to making a survey of the Barun Valley and to climbing as many other mountains in the neighbourhood as we could. There were ten members of our Expedition: eight from New Zealand, namely Hillary, Harrow, Hardie, Beaven, Todd, Lowe, McFarlane, Wilkins; they very kindly asked two people from this country to join them?Michael Ball, the Expedition doctor, and myself. We are grateful to the New Zealand Alpine Club for this invitation, which kept up the association which we have had over the last four years in Himalayan exploration and climbing. Our Expedition started at Jogbani, a village of Bihar on the borders of India and Nepal, where we met towards the end of March when the ground is ankle deep in dust which rises all around you as you walk. Our first job at Jogbani was to get our loads away on coolies, most of whom were men, but we had women too and a few children. The largest loads always seemed to get on the smallest porters! When all the porters are gone and you have scoured the surrounding jungle for anyone who looks as if he might be able to carry anything, you find yourself as a rule still left with a few leaky tins of kerosene or rather uncomfortable loads of crampons, or else loads that are just heavier than all the rest, but in the end they all get away. On the first few days of our march in through the foothills we followed a wide mule track over the hills, in the general direction of the Arun river, following its left bank. We passed many Nepalese villages on the way, their houses straw-thatched and thickwalled, and remarkably cool inside. After Dhankuta we kept close to the river, only now and then climbing the ridges alongside it, from one of which we had our first view of the snows?Chamlang, a long, level mountain of about 24,000 feet. Brian Wilkins and I tried fishing on this part of the journey and concluded there were no fish in the Arun, but I am told that when Ed Hillary came down later in the season, the villagers were trying to sell lots of fish which had been left high and dry on the