1 Expedition medicine

‘Because it is there.’

George Mallory (1923)

This book is about the healthcare of travellers to remote areas. Remote areas are defined as places where access to sophisticated medical services is difficult or impossible, and the responsibility for dealing with medical problems falls on expedition members. In Europe this branch of medicine is usually called ‘expedition medicine’, while in North America it is called ‘wilderness medicine’.

An expedition is an organized journey with a purpose. Early expeditions sought new lands to claim, develop, and exploit. In the twentieth century, as gaps on maps shrank, geologists, naturalists, and ecologists added detail to the knowledge, while physiologists explored human responses to extreme environments. Today, new scientific knowledge often requires a highly technological approach and considerable funding, so personal development, cultural exchange, and fund-raising have become increasingly important justifications for travel.

Adventure travel organizations send tens of thousands of people overseas each year to areas that 20 years ago could only be reached by a well-equipped expedition. Given a (very) thick wallet, trips to both Poles, the summit of Everest, and even outer space can be purchased. Age is no longer considered a bar to travel, with both healthy and less fit elderly clients expecting to reach remote and often physically demanding destinations—an octogenarian has reached the top of Everest. Attitudes to physical and mental disabilities have also changed enormously. A blind climber has summited Everest and limbless military veterans walked to the South Pole. The distinction between an expedition and a recreational journey is no longer obvious, but the challenges of caring for people far from a base hospital remain.

Technology has shrunk the world, potentially making even the remotest locations accessible from any Internet link. Superjeeps, helicopters, and satellite communications enable ready access to previously isolated parts of the globe. Increasingly, the wilderness is used as a playground for sporting endeavours that push the limits of human physiology.

Despite the improvements in communications and technology, the physical, environmental, and health risks of remote areas remain. This book is about helping travellers understand and prepare for the hazards of remote environments. It is designed to assist doctors, nurses and paramedics who support groups far from formal medical facilities.

Increasingly during the past decade, military and disaster-relief organizations have developed the capability to provide portable but remarkably sophisticated healthcare in remote locations. This has been a response both to war in difficult environments such as the Middle East, and to better assist countries following major natural disasters such as tsunami and earthquakes. These capabilities rely on skilled manpower and costly logistic support, and this book does not deal with this type of healthcare.

Expedition medicine is about:

Organizing the medical care of an expedition takes time and includes tasks such as:

Each of these aspects will be covered later in this book.

Expedition medicine is not just about the treatment of disease or coping with injuries; it should permeate all facets of the expedition. Health criteria must be considered when the location of the base camp is decided and the activities of the trip planned. Food, sanitation, and psychology are part of the expedition medic’s work. The medic will fulfil many roles and will certainly be expected to be nurse as well as doctor. Sometimes the work will involve listening to and encouraging those who are finding the expedition stressful. The obligation to care for the sick or accompany a casualty during evacuation may mean that certain personal goals are not attained.

Not all expeditions will have a trained doctor, nurse, or paramedic attached to them, but all expeditions must consider how they can prevent disease, and cope with illness or trauma should it develop. Correctly practised, expedition medicine should not constrain the enthusiasms and ambitions of an expedition but, by anticipating preventable medical problems, facilitate the achievements and enjoyment of all participants.

When planning an adventure, people often seek novel experiences. Expedition medicine requires an understanding of how humans can physiologically acclimatize and technologically adapt to extreme environments. Contemporary travel is able to take someone within a few hours from a relatively benign to a potentially life-threatening environment. Newcomers may have no idea of the hazards they face and inadvertently place themselves in danger. Within an organized group it is the role of the leader, local guides, and medic to ensure that participants know how to behave to maintain safety, and that expedition plans match the physical and physiological capabilities of the weakest member of the group.

Between 1995 and 1997 the Royal Geographical Society and Institute of British Geographers (RGS-IBG) surveyed a large number of expeditions and at that time mountain ranges and tropical jungles were the most popular expedition destinations (Fig. 1.1).

Other destinations have increased in popularity and accessibility. During the 1970s, only a handful of tourists visited Antarctica. In the 1980s, numbers increased to around 2000 a year, and this expansion has continued to the current level (2013/14) of around 40,000 visitors a year. Iceland has become a very popular adventure destination and in 2013 attracted over 700,000 visitors, of which 90,000 came from the UK, more than half during the winter months. Mountain trekking in the great ranges has seen similar increases in popularity. In 2013, about 400,000 ‘adventure holiday’ packages were sold in the UK, so it is increasingly likely that a family practitioner will be consulted about the preparations required for travel in remote areas. Chapters 20–27 of this book provide information about human health and physiology in extreme environments.

The explorer’s worst nightmare may be to catch a dreadful tropical disease or to be attacked by a ferocious wild animal, but for most expeditions the reality is more mundane. Stomach upsets, sprains, bruises, and insomnia are the common problems. The risks of catching insect-borne diseases such as malaria or dengue, or being involved in a vehicle collision on the way to the expedition area are usually far greater than the more exotic risks of the wilderness.

Death during an expedition is rare and tragic but should be kept in perspective (Tables 1.1 and 1.2). The media love dramatic stories but ignore the hazards of daily life. With the exception of extreme sporting activities, the risk for participants in a well-planned expedition is not that different from the risks faced during an active life at home.¹ Fatal road accidents, drowning, or falls can occur anywhere; effective advanced planning can reduce their incidence. Proper briefing of travellers, together with good risk management, can reduce harm. Sadly, the risk of violent death overseas from crime or terrorism has climbed from a low point in the mid twentieth century.

Expeditions are becoming safer. In the eighteenth and nineteenth centuries, complete expeditions such as Sir John Franklin’s ill-fated Arctic Voyage, would disappear into the wilderness and never be heard from again. Between 1943 and 1983, 26 staff of the British Antarctic Survey died (1% of those who overwintered); in the 30 years since 1983 there has been only one death. In 2012, over 35,000 tourists visited Antarctica, most of them on cruise ships. The rate of those dying of natural causes on the ships is not recorded, but there were five recorded deaths on the continent, two as a result of a base fire, and three associated with a shipwreck.

In the twentieth century, the ratio of successful summit attempts to deaths on Mount Everest was 1:7; by 2007 the ratio had improved to six deaths for 500 successful summits² (Table 1.3). However, this reduction in relative risk has been associated with much greater numbers of people tackling the challenge, not a reduction in the absolute numbers of deaths—with nine climbers dying on the mountain in 2012 and ten in 2013. Overall around 6000 UK Nationals die abroad each year, but most of these are expatriate residents. The Foreign and Commonwealth office produces an annual report³ summarizing the needs for consulate assistance overseas.

Judged by the numbers of people dying, the much lower Kilimanjaro⁴ is more hazardous than Everest with estimates of fatalities of between 10 and 30 deaths per year. But this reflects the ease of access—over 30,000 people attempt to climb the mountain each year, and the wide age profile of trekkers, some of whom may have a high underlying risk of cardiovascular problems before departure. But over 50% of the trekkers turn back below the summit due to cold, dehydration, and altitude sickness and this reflects the common use of inappropriate ascent profiles.

Fatalities amongst young people are always tragic and the dramatic circumstances in which they occur means that they are often highly publicized, giving the impression that such travel is more hazardous than it really is. Recent well-publicized deaths of UK nationals during youth expeditions include cases of hyperthermia, wild animal attack, electrocution, and inappropriate fluid ingestion.

Better weather forecasting, equipment, communications, training, and rescue services have all contributed to reducing the risk of travel in remote areas, but safety should not be taken for granted, and travellers to remote areas must strive to minimize risk and be self-sufficient.

Gathering and collating information about health on expeditions is very difficult owing to concerns about confidentiality and data protection. The RGS study,⁵ published in 2000, analysed health issues from 246 expeditions. Fig. 1.2 shows a summary of the key findings.

Diarrhoea and vomiting are an inevitable hazard of travel and are usually self-limiting. However, serious cases lead to dehydration and hospitalization. Dysentery, cholera, and giardiasis can infect the unwary. Simple hygiene measures can reduce the incidence of problems, but all travellers need to carry basic remedies for days when travel is unavoidable, and larger expeditions ought to have the facilities to rehydrate a seriously affected member.

Simple medical problems such as respiratory infections and headache are very common, and are usually easily treated. Insect-borne diseases such as malaria and dengue fever can be incapacitating and sometimes fatal. Appropriate precautions should be taken.

Sprains and back strain are common; rest and simple painkillers help. Fractures and serious trauma will require evacuation.

Environmental extremes may cause problems for the unprepared. Altitude sickness affects many travellers ascending rapidly to altitude; heat exhaustion and heatstroke can be a serious problem, while at the other extreme frostbite and non-freezing cold injury can cause long-term disability. When environmental problems occur they can be serious, and require urgent treatment and evacuation, often in difficult circumstances.

Unfamiliarity with local animal life can lead to injury. Scorpions and sea urchins commonly cause problems. Wherever rabies is endemic, dogs should be treated with caution. Although attacks are rare, large animals throughout the world present a hazard both directly and as a cause of road collision

Good foot care is always essential. Blisters cause misery and can become infected on a long expedition. Regular cleansing and use of foot powder reduces fungal infections and sores.

Acute abdominal crises, severe gynaecological pain, and renal stones are very alarming and often require evacuation of the patient, but fortunately are rare.

In this study of 250 expeditions, 25 participants required temporary or permanent evacuation, and eight had to be repatriated. Eleven of these evacuations were caused by acute mountain sickness and were taken to a lower altitude, while 13 participants had to be admitted to hospital for malaria, dysentery, appendicitis, or renal stones.

Fortunately, death and serious injury are nowadays very rare on expeditions, so epidemiological studies must study large numbers of people. Few results of these have been published, but data from the UK gives an idea of the type of issues arising in a frequently visited mountainous area. The Ysbyty Gwynedd hospital in Bangor, North Wales receives almost all the casualties from the mountains of the nearby Snowdonia National Park. The Park is a very popular destination for walkers, climbers, and tourists with 4.25 million visitors spending around 10.4 million days in the area during 2012. Military and civilian mountain rescue teams and helicopters provide search and rescue (SAR) cover to evacuate casualties beyond the reach of conventional ambulances.

The hospital receives over 100 casualties a year who require rescue and urgent hospital treatment as a result of events taking place within the mountains, and their mountain medicine database⁶ has logged over 1000 incidents. Eleven per cent of patients were children, a third were in the 18–28 age group, a third were aged 29–49, with the remainder over 50. Two-thirds became injured or ill while hill-walking, 7% were scrambling, and 11% were rock climbing.

Only 19% of the patients presented with medical conditions although the incidence of medical problems increases with age—in those aged >60 medical problems were the cause of more than a third of the admissions. Overall, 63% of all the casualties were male, and 55% of the patients presented with lower limb injuries.

Between 2004 and 2011 there were 70 fatalities in the mountains of the National Park, 93% of whom were male. This sex ratio reflects the predominance of male casualties in most other trauma registries. Owing to the remote locations of many accidents, skilled assistance takes time to arrive—typically between 45 minutes and an hour—and this delay has a triage effect: the most seriously injured do not survive. The majority of trauma victims who die within this initial period have non-survivable head or spinal cord injuries. Of those with serious spinal fractures, 73% had spinal cord disruption at post-mortem.

The pattern of survivors is quite different. Half of Snowdonia mountain trauma casualties complain of back pain, or have a mechanism of injury that would mandate ‘spinal packaging’ in conventional pre-hospital practice. However, in the mountains providing such care may delay evacuation and create additional hazard to both rescuers and casualty. Analysis suggests that while 14% of this group of casualties prove to have some form of spinal fracture, most are stable transverse process fractures that are painful, but clinically insignificant. Less than 2% of mountain casualties found alive after a serious accident have an unstable spinal fracture—a comparable rate to most major trauma series in urban populations.

Pelvic fractures also cause concern to rescuers, because pelvic splints are difficult to apply in precarious locations. However, only 2% of the mountain trauma casualties had a pelvic fracture and severe pelvic disruption was only seen in those who died before help arrived.

People enjoy the excitement and challenges of the great outdoors. Travels in remote areas will always carry risk, and if things go wrong help may be far away. Expedition medicine involves many aspects of care unfamiliar to clinicians used to working in conventional hospital or family practice. Good planning and logistics, effective risk management, communications, hygiene, and sanitation, together with an understanding of human health and physiology in extreme environmental conditions, form the core of the specialist knowledge necessary to work effectively.

Many people attracted to remote areas are risk-takers. Effective planning and risk management is about ensuring that the risks encountered are controlled and mitigated to the greatest possible degree. This is especially important when young or naïve clients join a group travelling to a remote area. Those with greater skills and knowledge have a ‘duty of care’ to the novices.

Many doctors, nurses, and paramedics seek to participate in expeditions, and the authors hope that this Handbook will provide a useful guide to the knowledge and skills that these clinicians will require as they head to distant parts.