2 Preparations

The Royal Geographical Society (with IBG) estimates that >2500 overseas expeditions leave the UK annually. These will range from solo travellers or teams of two up to expeditions involving 100 or more participants. Expeditions typically last for as little as 1–2 weeks to many months, if not years in the case of continuing research programmes. The sheer volume of expedition traffic represents great scope for joining an expedition, assuming one is not inclined to organize a journey independently. Expeditions occur throughout the year but are usually timed for a variety of reasons; e.g. to coincide with a certain event (summer holidays, animal migration patterns), climatic conditions (avoiding monsoons or other ‘rains’), and the seasons (avoiding the Himalayan or north polar areas in the northern hemisphere winter).

Potentially there is a huge choice of where to go and what to do. Think first about your motivation:

Think second about your personal circumstances:

Unless you fully appreciate the demands of expedition travel, as opposed to independent travel, it is worth initially considering joining a short expedition before committing yourself to a prolonged and arduous journey in a very remote area, with little chance of repatriation if you find you cannot cope or hate the experience.

Expeditions are costly enterprises and normally each participant has to pay their way. At best you might get your costs covered by the expedition but it is unrealistic to expect a wage, unless you have a special skill and/or are vastly experienced. There is also the opportunity cost to consider while on an expedition when mortgages, pensions, and other bills have to be paid, and there is no corresponding income. In addition there are ‘hidden’ costs which might include upgrading clothing, camera equipment, special insurance, etc. It all adds up.

Universities, research groups, and public institutions (such as the Natural History Museum, Royal Botanic Gardens, Kew and Edinburgh, the Zoological Society of London, and the British Antarctic Survey) are examples in this class.

Commercial operators charge a fee to join their expeditions and aim to make a profit. They range from ‘one-off’ projects to ‘adventure travel’ companies who offer land-based expeditions and ocean sailing opportunities. Such businesses may be run by sole traders, as partnerships, or as limited companies and are subject to ‘Package Travel Regulations 1992’ (PTRs). Under these regulations a travel package is offered when at least two of the following three components are included: transport, accommodation, or other tourist service accounting for a significant proportion of the package. Anyone offering a ‘travel package’ is legally required to be ‘bonded’ so that any fees paid are protected if the organization folds prior to travel. Responsibility for implementation of the PTRs lies with the Department for Business, Innovation & Skills (BIS).

The Charity Commission is the regulator and registrar of charities in England and Wales. There is great variety in the expedition activities of such bodies. For example, they range from medical research expeditions, aid and relief work, youth expeditions, conservation and science projects to expeditions for medically disadvantaged people and ‘charity challenges’ (such as treks, cycle rides, and climbs) in aid of a specific cause. See  http://www.charity-commission.gov.uk for the register of organizations. Remember that companies that run ‘charity treks’ on behalf of registered charities are not charities and may be profit-driven businesses.

Anyone can set up an expedition and recruit team members to join it. This is not regulated and no qualifications are necessary to do so. A one-off expedition is outside the scope of the PTRs.

There is great public interest in the adventures and human dramas associated with expeditions. These adventures are made more accessible by low-cost filming and production techniques, and are another route by which aspiring medics might get an opportunity, sometimes paid, to join an expedition. The producers’ aim to capture the ‘drama’—both physical and emotional—of people in extreme circumstances may clash with a MO’s ethical and moral obligations to promote safe practices, so the nature of a film project and its participants should be considered wisely. See Working with the media, p. 126.

Polar races, jungle and desert marathons, ocean sailing races, and multi-sport adventure races are some examples of extreme challenges set in remote environments that are becoming popular. Whilst not necessarily true ‘expeditions’, these events do represent opportunities for medics. Managing the health of competitive athletes under extreme environmental conditions in remote environments can be a high-pressure, stressful responsibility.

While you may be grateful to any expedition that accepts you, you are about to invest a considerable amount of time, effort, and possibly money in the enterprise, so research the organization to satisfy yourself that it is likely to achieve its goals, and that the plans match your expectations.

The expedition MO is key to the success of an expedition. Success is achieved by preventing expedition members becoming ill and treating quickly and appropriately. This does not mean that, as MO, you must treat everything that is presented to you, but rather you must use your knowledge to advise on the best course of action. As MO you are unlikely to be busy with medical problems but, if someone is ill or injured, you may be the only person who can deal with the situation. These can be stressful times, with no advice available from seniors and no one to relieve you for a break. Good communication between you, your patient, and other expedition members is essential, as is strong decision-making, based on the knowledge and facilities available to you.

Medical screening of expedition members is essential to ensure tailored pre-travel advice and to expand the expedition first-aid kit. Ask each member to complete a personal medical questionnaire and emphasize the need for full disclosure to enable proper preparation and appropriate insurance cover. Make three copies of the questionnaire: leave one in the UK with a nominated contact and take two on the expedition, in case an emergency evacuation is needed.

As MO you are responsible for base camp health and hygiene—see ‘Caring for people in the field’ for full details (Chapter 3). Contribute to the design of the camp layout to ensure water supplies and waste disposal are correct. Undertake regular checks of latrine and kitchen hygiene, food storage, and rubbish disposal. If anything is substandard bring it to the attention of all expedition members and rectify. Strict adherence to the rules of camp and personal hygiene is essential to minimize gastroenteritis, the most common complaint on all expeditions.

A consultation service for non-urgent problems is one of the main roles of an MO; how you do this will depend on the size and structure of your expedition. Allocate a regular time each day when you are exclusively available for consultation; consider before or after meals. It is important to try to ensure complete privacy (not always easy). Briefly record consultations and any treatment given ( Documentation, p. 89).

Size, weight, and cost considerations mean that most expedition medical kits are fairly basic, and the number of diagnostic aids limited. MOs should ensure that they have medical supplies sufficient for treating minor illnesses and are able to provide emergency care for more serious conditions until a patient can be evacuated.

Most problems are straightforward and can be dealt with on the spot. The role of the MO is therefore uncomplicated: to make a diagnosis and treat. In urban settings, help is available to confirm intuitive feelings or doubts; however, in the field it is not, and as expedition MO you therefore have to assume the worst-case scenario. This may mean causing a lot of inconvenience and concern, e.g. by sending someone with stomach ache to hospital with possible appendicitis, or making someone with a headache descend 1000 m. You will provoke grumbling and hostility if the person recovers without intervention, but you really have no choice other than to take the safest course of action.

MOs are also there to offer reassurance. People come with genuine symptoms, whether major or minor, and the significance may not always be apparent to the sufferer. You will not know what the situation is until you have made a serious attempt at a diagnosis, so never fail to take this step. If you think nothing is wrong, friendly reassurance is very important. Remember that psychological or psychiatric problems, fears, and tensions may manifest themselves as physical symptoms. Expeditioners tend to be self-sufficient people, and the circumstances of an expedition often reinforce this. There is a tendency for MOs to overdo the self-sufficiency; this can lead them to try and solve all problems single-handedly. Always ask yourself whether extra advice is available and if it would be useful.

All patients rightly expect that medical information will be confidential. People also have a right to refuse treatment, even if, in the MO’s view, this will not be in their best interest. However, the General Medical Council (GMC) has made it clear that doctors also have a duty to the public at large. On expeditions circumstances can arise where confidentiality may need to be broken so that the health and safety of other expedition members is not jeopardized. The expedition leader may need to be informed that an individual is concealing an illness or refusing treatment.

Without consent, treatment is assault. Consent to emergency life-saving treatment is usually presumed by the law if the patient is unconscious or too ill to consent. The law presumes that a reasonable person would wish his/her life to be saved. In the case of a healthcare professional acting within his/her sphere of clinical competence, consent is usually implied, i.e. the patient does not resist the treatment and therefore is presumed to consent. In other situations where treatment carries considerable risk, or is controversial, informed expressed consent should be obtained. For consent to be informed the individual must understand the proposed treatment and the risks involved in accepting or refusing that treatment. This means that the patient should be made aware of material risks and common or serious side effects, as well as the likely consequences should treatment be withheld. Verbal consent, especially in an expedition setting, is usually adequate.

For an individual over 16 years of age, only that individual is able to give consent. Remember, patients have the right to refuse treatment. Children under 16 can consent to medical treatment themselves if, in the opinion of the doctor, they are capable of understanding the nature and consequences of that treatment (Gillick competence). The child should, however, be given information that is relevant to his/her age and understanding. When taking under-16s on an expedition it is wise to gain written permission from the parent or guardian that medical care can be given if it is thought to be in the child’s best interest.

Incidents may happen. One of the roles of the expedition MO is to write up an incident report if necessary. It is important that information collected is purely factual, and should include:

Medical health risk management should form part of overall risk assessment ( Risk management, p. 68). People who commonly encounter specific hazards, such as experienced climbers, cavers, or divers, should also contribute. In these activities, field leaders are usually well informed and often trained to advise less experienced individuals. Risks can be minimized by the use of sensible and simple precautions such as avoiding travelling at night, selecting appropriate equipment, wearing seat belts in vehicles and helmets while climbing. An emergency response plan should be prepared ( Emergency response plan, p. 136).

Once in the field, it is important to reassess the situation, particularly the hazards of local flora and fauna, the climate (e.g. both heat and humidity), and the physical environment. Situations may arise in the field where the MO will either have to give an opinion about a proposed activity, or give unsolicited warnings once activities have begun.

An essential role of the MO is the ability to make a decision on evacuation. Consider the following:

Plans should be prepared on communication and transportation methods in case an emergency or evacuation occurs (see Evacuation, p. 146 for further details on evacuation). If the evacuation is to be funded by an insurance company it will be critical to liaise with the insurance company’s medical assistance agent. This individual will hold the approval for financing evacuations. Failure to do this may result in the insurance company not paying for evacuation costs.

Expeditions may employ local workers and will encounter local communities. MOs may be asked to assist with the medical care of someone who is sick or injured. Chapter 4 discusses the ethical dilemmas associated with such situations.

If participants are fit and healthy at the end of an expedition, they probably don’t require any follow-up. For participants with symptoms, the MO should recommend urgent review by a doctor, to examine, investigate, and treat as appropriate. The most helpful post-expedition tests are:

Do not forget that tropical diseases such as malaria and schistosomiasis may present weeks, months, or even years after the expedition has ended. A single case in your expedition team should alert you to recommend the screening of other members, since they are likely to have shared the same risk of exposure. Usually the role of the expedition MO post-expedition will be to direct individuals to their best local health provider to investigate and treat the problem.

Expeditions create their own unique social atmosphere. There can be enormous strain on individuals and the team, brought about by the intensity of living in a group, which is amplified by physical hardship, deprivation of normal Western comforts, climatic and cultural demands, and the stress of striving to achieve the expedition’s objectives. This is one of the great attractions of expedition life: to put oneself to the test and willingly forego the relative safety and security of home in exchange for the deep satisfaction, elevated self-esteem, and close human bonds that can be one of the greatest benefits of the expedition experience.

To optimize the expedition experience for all participants, particular attention must be paid to appropriate team selection, team building, effective leadership, and an understanding of the dynamics of groups in the field.

There is great variation in how individuals come to join (or be selected for) an expedition. This is related to the myriad expedition styles, be they scientific, exploratory, adventure related, for personal and social development, other reasons, or some combination thereof, and whether the expedition is institutional, charitable, commercial, or private. At one end of the spectrum the only selection criteria may be an applicant’s ability to pay; in contrast, one can utilize a variety of tools to vet and select potential team members.

Any comprehensive, formal selection process involves:

Any selection process less than comprehensive relies on:

Arguably, it is simpler to de-select candidates, despite the negative connotations this has. Some de-selection criteria include:

The number of applicants can be reduced by providing sufficient information about the objectives of the expedition and the selection criteria to help applicants gauge their own suitability before applying.

If the selection criteria are public, clear, and unambiguous, and the selection process is fair and unbiased then it should be straightforward to inform failed applicants why they have not been selected. There is no legal requirement to provide reasons for not selecting someone but it is obviously polite to do so. Conversely, it is in the direct interests of the expedition to take the opportunity to inform successful applicants that they have been selected on certain merits but may have shortcomings that they should address.

Technical skills, experience, and physical fitness aside, expedition members should possess an abundance of the following personality traits and abilities:

In corporate recruitment circles it is accepted that ‘Past performance predicts future behaviour’. This is equally true when applied to expeditions. Finally, all other factors aside, consider whether the applicant would pass the ‘blizzard test’—that is, would you be happy to spend long periods of time with this person confined to a tent in a blizzard?

Time is well-invested prior to the expedition in building the expedition members into an effective team so that the team is ready to handle the demands of the expedition. The time devoted to this should be proportional to the size of the team and the complexity and longevity of the expedition. For large multi-national expeditions it is impracticable to get the team together before the expedition; in these circumstances a period of time should be devoted in-country to team building, skill development, and briefings, before the party is deployed to the field.

Team building is focused on developing:

Normal expedition preparation and planning activities are productive vehicles for team building and include:

Thought should be given to:

Leadership is a kind of behaviour that guides others to reach a desired objective or outcome. All teams require leadership. A small private expedition of friends may not have a formal leader and therefore be ‘leaderless’ but there is no such thing as a ‘leadershipless’ team. Leadership manifests itself in a number of ways. A leader may be formally appointed (or self-appointed). Otherwise leadership is transient and is exerted by individual team members from the position of an assigned role or responsibility, personal expertise, or personality. In some teams and circumstances, it may be useful to think more in terms of a ‘leadership team’—that group of people with more experience and responsibility who act in concert to manage the expedition, such as a school group with teachers, professional leaders, a medic, and a local ‘fixer’.

By definition, a leader would be deemed effective if the team achieves the expedition objectives, but in practice it is not so simple. Therefore consider two questions:

Leaders should do the following:

Leaders should be:

Leaders will engender discontent and will be criticized for:

A leader’s checklist:

Being a leader is a challenging role, for which most people are not trained. Individuals have unique needs and this is perhaps the greatest leadership challenge—to connect equally with all team members and steer their energy and efforts towards achieving the expedition’s goals. Often several individuals evolve to produce a leadership team to fulfil the diverse leadership roles.

A cohesive team is more likely to achieve the expedition aims than a fragmented group so it is desirable to promote this through pre-expedition team building and effective leadership. A cohesive team will be happier and more confident than a less cohesive group.

Morale and cohesion can be adversely affected under the following conditions:

The performance of individual team members can also be adversely affected by:

It is unrealistic to expect all team members to become great friends with each other. Team cohesion relies on trust, fairness, tolerance, and acceptance of different personalities, opinions, and habits within the framework of a workable team structure, an appropriate resource base, effective leadership, and a mutually agreed purpose that the team is motivated to achieve.

Vaccines offer safe, reliable protection against an increasing range of important disease hazards abroad, but it is important to note that medical preparation for going abroad is not just about immunization: careful attention to the other health precautions covered in this book are also of paramount importance, before, during, and after every successful expedition. An important benefit of going to be vaccinated is the opportunity to discuss a wider range of health concerns and precautions that may be even more beneficial than the vaccines themselves, an opportunity that should always be used to the full. It is important for those with an incomplete or absent vaccination history to understand that vaccinations are not only there to protect the individual, but also the indigenous population from imported disease.

Ideally, immunization should commence at least 6 weeks before departure, to allow time for vaccines requiring more than one dose and sufficient time for the vaccines to become effective (Table 2.1). Vaccine supply problems do occur from time to time, and this can be a further reason for seeking protection well in advance.

Everyone attending for immunization should bring with them any available records of previous vaccines received, to avoid unnecessary repeated doses.

Immunization schedules are becoming more complicated and especially where groups of young people are concerned, ‘catch-up’ protection may be necessary for any missed doses, notably MMR and diphtheria, tetanus, and polio (of note: significant outbreaks of mumps and measles have recently occurred in young people in whom MMR vaccine has been omitted).

Travel provides an important opportunity to ensure that the routine vaccination schedule is up to date. The UK childhood immunization schedule can be found at:  http://www.nhs.uk/Conditions/vaccinations/Pages/vaccination-schedule-age-checklist.aspx.

Where expedition participants are drawn from more than one country, it may be important to be aware of differences between national schedules.

HIV-positive and other immunosuppressed people require special advice about immunizations, for further details see:  http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-8-advising-travelers-with-specific-needs/immunocompromised-travelers.

Yellow fever is the only disease for which international, WHO-approved vaccination certificates still apply as a condition of entry to some countries. Travellers to Saudi Arabia during the Haj or Umrah pilgrimage may be required to show proof of vaccination against meningitis ACWY.

Most travel vaccines are not required formally as a condition of entry, but are ‘optional’—the choice is based on an assessment of the likely health risks such as locally prevalent diseases, the precise details of a trip or expedition, including its duration, conditions of accommodation, the likely level of contact with local people, and the environment.

In England, Wales, and Northern Ireland general guidelines are published by the National Travel Health Network and Centre (NaTHNaC) (  http://www.nathnac.org); in Scotland by Health Protection Scotland; the WHO also issues information, and it may also be helpful to consult resources from other countries, such as the United States. Many medical practices, travel clinics, companies and other organizations also formulate their own policies.

On an expedition, participants inevitably compare the vaccines and medication they have received; inconsistencies tend to be the rule rather than the exception, which can lead to unnecessary anxiety and can undermine confidence in the advice that has been given.

The best option is therefore for an expedition’s MO to draw up some general guidelines or a formal policy, seeking specialist advice if this is needed. The best care comes when one clinic or practice takes responsibility for the entire group. If this is not possible, the MO should circulate guidelines to all expedition members to give to the individual clinics or practices that will carry out immunization.

In the UK, only a small number of travel vaccines can be provided free of charge on the NHS, and escalating development costs mean that newer travel vaccines are costly—a factor that needs to be considered in the context of an expedition’s overall budget.

Individuals may have received either a full or partial vaccine courses in the past. It is important to note that vaccine courses rarely require restarting, irrespective of the time between doses. For example, if someone has received two hepatitis B vaccinations 3 years ago, they will only require a single hepatitis B vaccination to complete the primary course.

Most travel clinics are able to provide up-to-date information about areas of risk. Travellers who have had their spleen removed may be more vulnerable to this condition.

A new generation of ‘conjugated’ vaccines now offers robust protection against the A, C, W, and Y strains of the disease, currently without the need for a booster (booster recommendations may change in the future). A vaccine against the problematic B strain has now also been licensed, and hopefully a combination vaccine may soon be developed.

Vaccination is important for travellers at high risk (e.g. those who have had a splenectomy), and for travellers to high-risk destinations (see Fig. 2.1), especially if they will be in close contact with local populations (e.g. in schools, hospitals, or refugee camps). See also Meningitis, p. 473.

An oral vaccine is available that uses killed cholera bacteria and a modified form of the cholera toxin to generate localized antibody protection on the surface lining of the intestine. Other diarrhoea-causing organisms produce a very similar toxin, which is why this vaccine also has a 3-month protective effect against some types of traveller’s diarrhoea (notably enterotoxigenic Escherichia coli—ETEC—which accounts for as many as 40% of cases).

Cholera remains endemic in many parts of the world, but outbreaks tend now to be limited to settings with severe overcrowding, such as in refugee camps, or under conditions of extreme poverty. Improved ability to treat cholera with simple fluid replacement means that the consequences of infection are no longer as severe, though they can still sometimes be devastating. Cholera vaccine may be a sensible precaution for situations involving close contact with local communities in developing countries, though many people additionally use the vaccine for protection from ETEC.

Hepatitis A is common in hot countries and countries with poor hygiene (Fig. 2.2). A single hepatitis A vaccine lasts for ~1 year. A second vaccine provides reliable, long-lasting protection for up to 25 years, with growing experience suggesting that protection may in fact be life-long, in the same way that hepatitis A infection confers lasting immunity.

Hepatitis B is spread by sexual exposure, and by blood and blood products, including non-sterile medical instruments; it is a hazard in all developing countries (Fig. 2.3). It is a sensible precaution for anyone planning to spend a prolonged period abroad, particularly if they will be sexually active, in close contact with local communities, or at increased risk of needing medical treatment (see Viral hepatitis, p. 458).

In addition to the standard methods of giving the vaccine, accelerated schedules can be used when less time is available prior to departure (e.g. doses on days 0, 7, 21–28 with a booster dose at 1 year), which conveniently also matches the schedule for rabies vaccination.

Some people regard seasonal influenza (flu) as the world’s most highly prevalent vaccine-preventable disease; it is certainly a disease of travel. Although it occurs seasonally during the winter months in the northern and southern hemispheres, it is a year-round problem in the tropics.

Expeditions, by their very nature, tend to involve groups of people spending much time together. It would seem sensible to protect members against this common, potentially serious problem. A further benefit of vaccination is that it reduces the risk of developing a fever that might be confused with other, more serious febrile illnesses associated with travel. See also Fever, p. 262.

Japanese encephalitis is a viral disease transmitted by mosquito bites. It is rare in travellers (<1:1,000,000), but causes concern because it carries a high risk (around 30%) of serious neurological side effects. It occurs throughout Asia (Fig. 2.4), with an estimated 30,000–50,000 cases occurring each year, accounting for at least 10,000 deaths and 15,000 cases of neurological complications. It occurs mostly in rural areas—farm animals are the source of the infection (baby pigs and wading birds). The vaccine should certainly be considered by anyone likely to spend much time in rural and some urban parts of Asia.

Good quality vaccine may not be available in a high proportion of the countries where rabies is a problem ( Rabies, p. 461). Rabies immune globulin can be even more difficult to obtain, and can be extremely expensive (~£1000–2000 per person). Obtaining correct treatment may require a trip to be curtailed or abandoned.

Pre-exposure vaccination simplifies the treatment necessary after a bite: fewer vaccine doses, and no need for immune globulin injections. It is increasingly recommended for travellers likely to be exposed, particularly for travel to South East Asia, Africa, and South America (Fig. 2.5). Modern rabies vaccines are safe and cause little or no reaction

A safe vaccine is available, and medical experts in the affected regions strongly advise visitors to be vaccinated if they will be exposed to possible risk (Fig. 2.6). (In Austria, the entire population is vaccinated as a matter of routine!) The vaccine requires two, or preferably three, doses for protection, starting at least 4 weeks prior to travel and given on months 0, 1–3, with the final vaccine given 5 months after the second. The first two doses can be given 2 weeks apart.

Vaccination is strongly advised for people at risk, particularly those visiting forested areas in late spring, or those likely to drink unpasteurized milk from infected animals (e.g. Tibetan yaks). For short-term travellers, many advise tick avoidance measures only. See also Ticks, p. 288.

Immunization with bacillus Calmette–Guérin (BCG) is not routinely offered to children in the UK, though it is offered at birth to targeted risk groups. Expeditions involving travel to parts of the world that are highly endemic for tuberculosis (TB)—especially if there will also be a close degree of contact with local people—should consider the need for BCG protection or TB testing with a skin test or blood test. See also Tuberculosis, p. 475.

Typhoid remains common in all low-income countries, and in most hot countries with poor hygiene conditions ( Typhoid and paratyphoid (enteric fevers), p. 477). Vaccination is advisable for travel to Africa, Asia (especially the Indian subcontinent), and Latin America, and should also be considered for travel to Mexico and the Caribbean.

Two vaccines are available: an oral vaccine (Ty 21a), consisting of three capsules to be swallowed on alternate days, that provide full protection for up to 5 years; and an (Vi antigen) injected vaccine, that provides 3-year protection after a single dose.

Vaccination against yellow fever is necessary for travel to many parts of Africa and South America (Fig. 2.7), either as a certificate requirement or for personal protection ( Yellow fever, p. 464). It is also a certificate requirement in many countries outside the yellow fever endemic zones—notably in Asia, for travellers arriving from affected regions of Africa and South America. (Although yellow fever does not occur in Asia, it has the potential to cause serious outbreaks if inadvertently introduced by an infected traveller.)

In July 2016 the rules regarding Yellow Fever vaccination certificates were changed. New certificates will now state that they are valid ‘for the life of the person vaccinated’.

Older Yellow Fever certificates have a ‘valid to’ date 10 years after the most recent vaccination. This date can now be ignored, but do not cross it out or make any changes to your certificate as writing on the certificate can make it invalid. However, you can consider that it is now valid for life. Increasing awareness of vaccine side effects has coincided with efforts to define and map yellow fever risk more accurately, and to make sure that only people at genuine risk of exposure receive the vaccine. On the other hand, we now know that the vaccine offers long-lasting protection—both from yellow fever, and from vaccine risks in later life, and that many serious travellers do not know in advance where their travels will take them. There is an attractive case for vaccinating such people when they are younger, healthy, and immune-competent, regardless of their exact destination.

Chapter 28 contains information about the type of supplies and drugs that need to be included in an expedition medical kit. The exact requirements will depend upon:

Buying medical supplies from a retailer can be costly, and acquiring, packing, and labelling a medical kit can be time-consuming. UK drug companies may provide samples or donate medication, particularly if there is some formal recognition of the company’s sponsorship. Local pharmacists and NHS hospital trusts may be able to help by providing drugs at cost. Technically, GPs should not give NHS prescriptions for illnesses which may be acquired outside the UK, but many do.

In some parts of the world, prescription drugs are available over the counter but they may be counterfeit and the quality cannot be guaranteed.

Expeditions carrying reasonable quantities of drugs are unlikely to encounter problems at customs when entering a country. However, it may be useful to have a doctor’s letter stating that the drugs are for the personal use of the expedition team members and are not the subject of any commercial transaction.

Wherever possible, avoid taking ‘controlled’ drugs. A Home Office licence is required and must be returned within 28 days of return to the UK. For more details see:  http://www.gov.uk/controlled-drugs-licences-fees-and-returns. Any controlled drugs dispensed should be recorded in a controlled drugs register. Local controls over drugs, especially painkillers and sedatives, vary and it is important not to be found to be carrying inappropriate medications for that part of the world. The International Narcotics Control Board (  http://www.INCB.org) provides information on country regulations regarding the transfer of drugs across borders.

Managing sudden illness or injury on an expedition is very different from giving conventional first aid in a developed country where there is rapid recourse to definitive care. It may be necessary to render first aid in difficult environmental conditions—desert heat, Siberian cold, at high altitude, in darkness, rain, or snow. Evacuating a patient to definitive medical care may take days because of a remote location, poor weather conditions, or lack of communications and suitable transport. This means that expedition team members need to be prepared to give first and second aid while on an expedition. Some medical conditions encountered on expeditions will be very unusual in the UK and are not covered in standard first-aid texts, e.g. malaria, altitude illness, and venomous bites and stings. Learning advanced first-aid techniques such as straightening broken limbs or using antibiotics to treat infections will be essential and the use of any special medical equipment or drugs will require careful training.

Ideally, all expedition team members should have a basic first-aid qualification. Basic first-aid training should cover:

If it is not possible to train all team members, then a trained first-aider should be available at each expedition project site.

This is best learnt by attending one of the many standard courses run by the St John Ambulance or the British Red Cross. In addition, many other providers run courses aimed at those wanting to work in an outdoor environment. See  http://www.sja.org.uk and  http://www.redcrossfirstaidtraining.co.uk

The recognition of the increasing frequency of mental health problems on expedition clearly suggests a need for expedition medics to have the ability to provide basic mental health first-aid. Mental health first-aid courses should include areas such as:

The expedition MO (and as many of the expedition team as possible) should have basic first-aid skills, be able to measure vital signs, and be able to diagnose and treat important, common illnesses and injuries. For an expedition MO the bare minimum of skills needed are listed in Box 2.2.

More detailed information on how to diagnose and manage each of the conditions listed in Box 2.2 can be found within this book. To gain the necessary experience to deal with such conditions, it is advisable to attend a specialist course on expedition medicine.

Some potential expedition team members, including leaders, have pre-existing health problems or disabilities. The majority of these people can still enjoy safe, successful trips with careful planning.

There are several issues:

It is therefore essential to weigh up the possible risks against the potential benefits of travel for any individual who has significant pre-existing health problems. It would be nice to include all applicants, but for some the risk of serious illness, even death, may be unacceptable.

It is not uncommon for individuals to purposefully omit information from a medical declaration form, placing them and the team at greater risk, whilst potentially invalidating any insurance. Information omission occurs for a number of reasons, most commonly fear of not being allowed to go, or stigma associated with a particular condition. Expedition participants should be encouraged to divulge all information necessary for a safe expedition and this can be achieved through:

Ensure all participants complete a health questionnaire—preferably at least 6 months before planned departure (Box 2.3). It can be worthwhile interviewing expedition members face-to-face at the beginning of the expedition to check that their health questionnaire is accurate.

Request the past medical history of participants sensitively. Encourage disclosure of key information that may be both important to the expedition medic, and enable the traveller to enjoy their journey without medical problems. Follow up any significant issues with the patient and, if appropriate, request a report from a GP or specialist:

Sometimes acceptance on a trip is provisional, pending performance on training exercises or a full medical examination and review.

Occasionally, significant pre-existing illness is not declared until the expedition is in the field. This can be a very risky situation where there is inadequate information about the condition, additional medication is not available, and the expedition is very remote from expert medical help. If the applicant is uninsured because the insurers will not cover this particular condition, it may be necessary to repatriate that person before an incident occurs.

One in 12 adults has asthma (see Asthma, p. 380):

The management of acute asthma is discussed on Prevention of acute asthma attacks, p. 380.

Diabetes need not be a contraindication to travel; however, a person with type 1 diabetes needs to be confident monitoring their blood sugars and adjusting their diabetes control ( Diabetic emergencies, p. 256). Those who have recently been diagnosed with diabetes should consider deferring a trip to a very remote area until they are completely confident that they can manage the disease safely without outside support.

The main concerns regarding travel with diabetes are:

Antimalarials and immunizations should be advised as for other travellers. Consider how insulin will be stored on the expedition (see Box 2.4).

It is useful to have the following information from the GP, diabetes nurse, or specialist:

This information can be written in a letter and given to the patient. If appropriate, it can also usefully mention the need for carrying needles and syringes. Even if not eating, people with diabetes continue to need regular insulin, and frequent blood sugar testing becomes even more important. Intravenous fluids and injectable antiemetics may be needed if vomiting occurs, and the use of these items may need special training or the presence of a suitably qualified healthcare professional.

Other group members should be trained in recognizing the symptoms of hypoglycaemia and the treatment needed—GlucoGel^®, glucagon, or, rarely, intravenous glucose 10%.

It is important to consider:

 http://www.diabetes.org.uk

 http://www.diabetes-exercise.org

Isolated, well-controlled hypertension is not a problem for most people travelling to remote areas. However, if there is evidence of secondary organ damage due to hypertension (heart failure, renal failure) the risks of stroke or heart attack will be much higher ( Hypertension, p. 52). Consider:

A history of angina, previous MI, or claudication will be worrying. Similarly those with multiple risk factors for cardiovascular disease (hypertension, hypercholesterolaemia, smokers, and/or a strong family history of cardiovascular disease) need to consider carefully the risks of being remote from health care. Stresses of expedition life may provoke symptoms of chest pain ( Chest pain, p. 242) or breathlessness on exertion.

Six months after successful coronary artery bypass graft/angioplasty or stenting it is possible to undertake remote foreign travel provided there are no symptoms of chest pain or breathlessness while exercising to the level required on the expedition. The individual should be able to complete a full exercise electrocardiogram (EG) without symptoms or ECG changes.

There always remains the risk of recurrence and this must be accepted by the individual and team members. Ask the question: can the individual undertake vigorous activity at the same level as expected on the expedition (i.e. can they spend long days walking in the British hills)?

The consequences of a seizure during an expedition activity could be very serious; for instance, falling from the back of an open vehicle, being tossed overboard during white-water rafting, or collapsing on steep ground. Dehydration, alcohol, stress, and lack of sleep may all provoke convulsions. Gastroenteritis may affect antiepileptic levels and result in fitting.

Before the trip more information will be required regarding the frequency, severity, preventive medication, and treatment of convulsions. Other team members need to be aware and know what to do in the event of a fit ( Urgent treatment, p. 254). Those whose epilepsy is poorly controlled may not be suitable for expeditions. Antiepileptic medication may interact with other drugs, particularly antimalarials and quinolones such as ciprofloxacin. Chloroquine and mefloquine may provoke seizures and should not be used in those with epilepsy.

Treatment of status epilepticus (a seizure lasting longer than 30 min) is very difficult in a remote environment and the condition can be life-threatening. Those with epilepsy should follow guidance regarding swimming, driving, operating machinery, and dangerous activities such as diving and rock climbing as they would at home. Epilepsy is a significant pre-existing health problem and insurers must be aware of the diagnosis in the event of a claim. Consider taking rectal and IV diazepam or buccal midazolam together with an oropharyngeal airway and a hand-held suction device.

People with epilepsy are definitely travelling at increased risk but this can be minimized with preparation—some activities such as scuba diving may be unacceptably risky and this should be understood before departure.

Anaphylaxis is a severe form of allergic reaction ( Anaphylaxis and anaphylactic shock, p. 236; Fig. 8.8). It may be provoked by food, drugs, insect bites, or stings. Knowledge of the allergy is essential for cooks, expedition staff, and other group members.

All expedition members need to be aware of the symptoms and signs of severe allergic reactions and should know how to give adrenaline (epinephrine), if required. A MedicAlert^®/MediTag bracelet or similar should be worn at all times.

Adrenaline (epinephrine) auto-injectors in the form of an EpiPen^® or Jext^®, if recommended by the GP or specialist, needs to be carried at all times and must be kept in hand luggage during air travel. It is important that the person at risk knows how to use it in an emergency. Consider taking extra drugs for anaphylaxis—adrenaline (epinephrine), prednisolone, chlorphenamine, hydrocortisone, and a salbutamol inhaler.

In those with severe allergies, consider oral antihistamine for the duration of the trip. This should be discussed with the GP or specialist. Remember that severe allergy can be induced by aspirin in some people, and that aspirin and widely used non-steroidal anti-inflammatory agents, such as ibuprofen and diclofenac, can cause or aggravate urticaria and angioedema.

 http://allergyuk.org

 http://resus.org.uk

Inflammatory bowel disease such as Crohn’s disease or ulcerative colitis (UC) may predispose individuals to severe, possibly life-threatening diarrhoea and gastrointestinal (GI) haemorrhage. Other complications such as anaemia, dehydration, and generalized infection may also occur. The drugs used to treat inflammatory bowel disease may have an effect on the immune system so that infections may be easier to acquire. Some drugs, e.g. azathioprine, require periodic monitoring of blood tests. Infectious diarrhoea may trigger a flare up of the underlying condition. On expedition, it may be very difficult to differentiate between the two.

Individuals with inflammatory bowel disease should be fully aware of the potential risks. Severe, bloody diarrhoea, particularly if associated with a fever or abdominal pain, require prompt medical attention.

For those with inflammatory bowel disease:

Further information may be found at  http://www.crohns.org.uk and  http://www.crohnsandcolitis.org.uk/information-and-support

(See also Chapter 16.) Depression, anxiety, panic attacks, deliberate self-harm, and eating disorders are all common. Non-disclosure happens occasionally and will affect insurance cover. There is a wide variety in severity and risk of each illness. Those with a single episode of depression and subsequent recovery in response to a significant life event pose a lower level of risk than those with recurrent or chronic problems.

A carefully worded pre-expedition questionnaire is needed to ensure that psychiatric and psychological illness is not overlooked. Anyone with a history of psychiatric illness should be followed up with a more detailed discussion of the problem.

Some expedition companies will not accept those still taking antidepressant medication because of the difficulty of managing an exacerbation and for arranging regular supervision.

Dehydration predisposes to lithium toxicity which may be fatal.

Low body mass index (BMI) may mean that the individual has little physical reserve in the event of other illness. Binge eating or vomiting can be very disruptive for other group members to cope with.

Involve the GP and/or psychiatrist in making the decision regarding fitness to travel—an expedition is not the place to convalesce from a serious mental health problem.

If there is a history of psychotic illness most psychiatrists recommend that the individual should have been stable for 2 years, is off medication, and can show evidence of coping with stressful situations, including foreign travel.

Remarkable achievements on expeditions have been made by those with significant disabilities. Appropriate challenges can be identified which help to maintain independence and dignity by the use of special adaptations. A multidisciplinary team (occupational therapists, physiotherapists, nurses, rehabilitation physicians, and prosthetists) can all contribute to identifying these challenges and advising on safe travel.

The needs of those with disabilities may be considered under the following headings:

Expedition members who are HIV positive or immunosuppressed for other reasons need specialist advice about immunizations well in advance. Those who are immunosuppressed should be educated about the potential risks of infectious disease and there should be a low threshold for treatment as well as medical evacuation if needed ( Repatriation, p. 158). The individual risks of infectious disease in the location of the expedition need to be taken into account when deciding whether to accept a potential participant. Most of the immunosuppressed are unable to receive ‘live’ vaccines including yellow fever.

Those with HIV may need prophylaxis against opportunistic infections on the advice of their specialist. Those with a good CD4 count (>500) are considered to be without significant immune compromise. Consider whether any antiretroviral medication may need blood monitoring while away. Participants on immunosuppressive medications such as azathioprine may also require blood monitoring depending on the length of the expedition.

Splenectomized patients are at increased risk of bacterial infections caused by pneumococcus and meningococcus, as well as being more vulnerable to malaria. They should seek specialist pre-travel advice.

Those on prolonged courses of high-dose steroids (>20 mg prednisolone/day for >2 weeks) are at particularly high risk of infection.

Participants with a history of chronic or post-viral fatigue should be able to demonstrate full recovery and ability to participate in normal daily activities for a significant period of time prior to the expedition. Infectious diseases or overexertion may contribute towards relapse.

23% of adults in the UK are obese; some morbidly so (BMI >40). Obese travellers are at increased risk of heat acclimatization problems, dehydration, deep venous thrombosis (DVT), and musculoskeletal problems. In addition, there may be undiagnosed associated conditions such as hypertension and diabetes. Serious consideration should be given as to whether those with severe obesity are able to cope with the physical demands of an expedition. Encourage weight loss beforehand and consider assessment of physical capacity pre-expedition on training exercises.

Increasing numbers of older people are visiting remote and exotic places, or taking part in adventurous activities. Most travel without mishap. Advancing age, however, brings declining health and physical disability, which can increase health risk for the adventurous traveller. Pre-existing, chronic illness and medication increase overall health risk and older people are more likely to experience travel-related illness while abroad. The 65+ years age group differs from the young with potential adverse effects on global travel due to:

Adverse changes occur in:

A personalized pre-travel health review can identify potential problems and, with anticipation and precaution, overall risks to health can be reduced. In terms of health risk, the potential older traveller can be grouped in one of the following:

In addition to the regular pre-travel management plan, consider the following in relation to age, ability, and co-morbidities:

Whilst on expedition it is vitally important that both the individual traveller and expedition medic have a heightened awareness as to the age-related problems that might occur. Ensure:

As with any expeditioner, health problems can arise in the months following an expedition. Age-related physiological changes put the older traveller at greater potential risk for developing travel-related illness on return, the complications of which can be severe. Expedition members should be encouraged to seek medical advice on return if there are:

Awareness of risk, sensible pre-travel preparation, and a rapid response to problems whilst away will help ensure elderly travellers journey in good health.

Exploring with children and adolescents broadens everyone’s horizons and facilitates introductions to people who might otherwise have been passed by. It does, however, often mean adapting the style and pace of travel. Goal-driven trips where the targets have been set by adults without consulting younger members can be disastrous. Involve everyone in the planning and allow time for everyone to indulge their interests. The trip will be most successful if the adults are performing well within their levels of competence. Children are often more adaptable and resourceful than the adults with whom they travel.

Diagnosing illness in children, especially in the under-3s, is difficult—even for paediatricians—and so any adult travelling to remote places with small children must be well prepared, well read, and have a good back-out plan. The commonest causes of problems in travelling children are accidents, scrapes and bumps, swallowing things they shouldn’t have, traveller’s diarrhoea, skin sepsis, and common infections as at home: tonsillitis, ear, and chest infections. The responsible adult should either be carrying the wherewithal to treat these problems or should know someone who can.

Parents will need to ensure their child is up to date with the routine childhood vaccines (Table 2.1) because, in less well-resourced regions, levels of local immunization will be low and thus ‘herd’ immunity is poor. Travellers are therefore at increased risk of measles, pertussis, diphtheria, etc. For other immunizations the family should consult a travel health expert. Intrepid children are more likely to get bitten by dogs and monkeys; rabies immunization is therefore especially relevant for any mobile child.

Yellow fever immunization is not given to infants under the age of 9 months so this might preclude family travel to regions where yellow fever is common.

Parenteral typhoid immunization has poor efficacy in children under the age of 18 months and gives no cover at all against paratyphoid. Oral typhoid immunization offers some cover against paratyphoid but is only licensed for children over the age of 6. Parents must therefore be especially aware of the means of reducing the risk of these and other faecal-oral infections ( Diarrhoea and vomiting, p. 398).

Both mefloquine (Lariam^®) and atovaquone + proguanil (Malarone^®) can be given to small children. Mefloquine does not seem to cause the problems with mood that adults sometimes experience; the tablets crack easily into quarters for children’s doses. It should be noted, however, that travel into highly malarious regions with small children or when pregnant may be unwise, and expert advice should be sought before travel.

Odd and unexpected things can faze children and adolescents, including weird food, unfamiliar lavatorial arrangements (toddlers can’t squat over long drops), and issues surrounding personal space. Small children prefer to be down at a level where they too can explore; they get bored if carried all day, and it is sobering to realize that every year in the Alps children die from hypothermia while being carried in backpacks by skiing or mountaineering parents. A thermometer is not necessary to assess if a baby or toddler is chilling dangerously. Compare his skin temperature on the limbs with trunk temperature; if the limbs feel colder then the child needs to be warmed in a place of shelter.

Sunburn in childhood is associated with an increased risk of skin cancer in adulthood. It also makes the whole family miserable. Severe sunburn can lead to hypothermia, disastrous loss of fluids, and secondary infection. It is crucial, therefore, that children are protected with long clothes, hats, sun-protective swimsuits, umbrellas (if carried in a backpack), sunscreens, and avoidance of exposure at the very hottest times of the day. So-called sun-blocks reduce exposure to the wavelengths that cause sunburn without necessarily giving adequate protection to cancer-causing wavelengths. SPFs of 15–30 are therefore recommended; sunscreens need to be reapplied frequently (see also Solar skin damage, p. 266). Sunscreens need replacing each year.

A fine pimply, very itchy rash is probably prickly heat. Unlike many of the other causes of itching in children, this is not a histamine-mediated response and so it doesn’t respond to antihistamines. The treatment is getting the child cool—either by immersing or splashing with cold water, dabbing (not rubbing) with a damp cloth, and/or retreating to a room with a fan or air conditioning. Calamine lotion is soothing. Dressing the child in loose fitting, 100% cotton clothes will help avoid the problem, and so will a rest during the hottest part of the day.

It is wise to embrace precautions that avoid insect and tick bites, not least because an itching bitten child is miserable but, in hot climates, scratched bites often lead to skin infections. Hydrocortisone 1% or betametasone diproprionate 0.025% ointments are the best treatment for bites and stings, although could promote sepsis if the skin is broken. Skin infections ( Wound infections, p. 278) cause spreading redness, oozing, sometimes red tracking on the affected limb, and, later, fever.

Choosing the right clothes and footwear helps keep biters away, as does spraying these clothes with permethrin. At dusk, any remaining exposed skin can be covered in a repellent based on up to 30% DEET, or Merck 3535. Repellents that are based on citronella or lemon eucalyptus are less effective alternatives. If the child is small then he can be protected under a cot net (preferably also proofed with permethrin), and older children are partially protected by the fact that malaria mosquitoes tend to hunt at ankle level; thus applying repellent to the clothes usually discourages mosquitoes from searching up and biting the face. Further information on bite avoidance, bed nets, etc., is on Prevention of malaria, p. 483.

When children become unwell, they can become precipitously ill within hours, and diagnosis can very difficult, especially if the patient isn’t yet capable of explaining where it hurts. A toddler with tonsillitis, for example, will often point to his tummy when asked where the pain is. Many cautious paediatricians advise against intrepid travel with children who cannot yet talk because:

Once a child has reached the age of 4 years they become fun to travel with, they’ll enjoy sharing parental adventures and are better able to communicate symptoms of illness. Illness with fever can initially be treated with both paracetamol and ibuprofen. In a non-malarial region it is probably safe to delay consulting a doctor if the child perks up, although meningitis or typhoid are always possible. In areas where malaria is a risk, a child with a fever over 38°C should be evacuated to a clinic or hospital.

Diagnosis in an ill child is challenging whoever you are and travel makes this task even more difficult. The designated adult responsible for children would be well advised to travel with urine dipsticks, a thermometer and a child health book. The Baby Check scoring system is invaluable for grading the severity of illness in babies under 6 months (see Resources: children’s health abroad, p. 67). The responsible adult should also know the location of the nearest competent medical facility.

In diarrhoea, fluids are lost through increased bowel actions and from sweating (especially if there is also fever), yet the appetite will be wanting and often it is difficult to get the child to drink. Standard oral rehydration salts and even fruit-flavoured oral rehydration solutions taste unpleasant because of the potassium content, and many children—even if somewhat dehydrated—will refuse them. In most situations all that the child needs is water with some kind of solute in it. Sugars and/or salts enhance fluid transport into the body, so that water is absorbed more efficiently than if pure water is drunk.

Examples of rehydration solutions include: