Life Saver
To some extent, this scenario can be mitigated by having a well-planned expedition medical kit backed up with experienced remote-area first-aiders or formally qualified health professionals.
The wisdom of this advice was first brought home to me during a mountaineering expedition to the Altai range of Mongolia in 1992. This was long before the area became available to commercial expedition companies: one still travelled with the local nomads, shared vodka, and internal flights were plagued by a lack of fuel and tyres bursting on landing. At base camp, we were visited by an elderly Japanese trekker and his wife. During the night,he fell unconscious from presumed altitude sickness. We had to make the difficult decision to evacuate him, using drugs to buy time, sitting him upright on a stretcher with a rapid ascent of about 150 metres before we could take the only feasible route to a lower altitude, using a commandeered truck to get him to a local hospital.
The ‘hospital’ consisted of a mud building with a central ‘intensive care unit’ and a four-bed surgical and medical ward in each wing. It looked more like a Scottish bothy but one couldn’t fault the care of the local Russian-trained doctor. Needless to say, our Tupperware box of expedition medical supplies was invaluable. The trekker survived.
Take your brain
So what does one take in one’s medical kit? The single most important thing is one’s brain, supplemented with careful preparation, experience and the ability to rationalise difficult decisions, as well as an element of training. In a perfect world,you will return with an unopened medical kit, but in the event of an accident or serious illness, whatever you pack will almost certainly be found wanting.The contents will be totally dependent on the area visited, the size of the party, the medical expertise within the team, allowable weight, acceptable bulk, monetary funds, the ability to improvise, local facilities, evacuation plans, obligations to local employees, regional disease patterns and any pre-existing medical problems within the team.
Most of my expeditons have consisted of three or four friends attempting first ascents in remote areas. Being a slow acclimatiser, I’ve learnt that I prefer the peaks of Chilean Patagonia to the high peaks of the Himalaya. Since we need no altitude drugs, our main expedition medical kit will often fit in a four-litre plastic container, although with increasing age and potential prostate problems, we’ve now added a urinary catheter.
In addition to the main kit, each team member carries a small first-aid kit with strong analgesics, syringe and needle (which can be reused on the same patient), a small quantity
of antibiotics, basic dressings and an airway. In an emergency,these small kits complement each other and can be used for a couple of days until the main team kit can be collected from our base. This is a good principle for all expeditions to every geographic area. If one relies on a single heavy kit, it will never be in the right place at the right time.In addition, I always insist on each member having a small personal base camp medical kit for minor problems. This will include their favourite simple home remedies, as well as creams for athletes’ foot/crotch, analgesia for headaches and muscle strains, and (if relevent) malaria prophylactic medication. This encourges members to take responsibility for their own health and stops me being pestered about minor ailments.
These basic principles for medical kits apply to all expeditions but they may need to be modified for larger trips or more specialised trips. A good example would be the recent Caudwell Xtreme Everest Medical research expedition. Although very determined to reach the summit, they also carried out a huge programme of research involving numerous trekkers. In order to obtain ethical approval for some of these quite invasive medical procedures,the expedition had to be able to provide full Intensive Therapy Unit resuscitation facilities at base camp. The medical expertise within the research and climbing teams was impressive, with several anaesthetic intensivists,a vascular surgeon with interest in frostbite, casualty consultants and general practitioners. Each person had good reason to request the inclusion of the drugs and equipment for their speciality.
By contrast, I was invited to join a proposed trip to Mount Everest in 2003 as trip doctor to a team that had planned to climb the mountain using equipment based entirely on the original first ascent in 1953. When I suggested that I take a medical kit using only drugs from the 1950s the reply was a unanimous, “No!”A further contrast would be when I act as a medical advisor to some of the modern and very lightweight, fast-moving two-person teams attempting extreme lines on remote Alaskan peaks. These super-fit and experienced climbers will climb for several days with minimal food and shelter,relying on speed and a sustained break in the weather. In these situations, carrying any medical kit above base camp is pointless. In the event of an accident, a spare pair of gloves or one or two extra abseil slings would be far more useful.
What to take?
The astute reader will have already realised that I’m reluctant to list the specific contents of a medical kit. It’s for the expedition’s medical officer or advisor to determine precisely what is required for your specific project. This is best done by considering worst-case scenarios and then thinking through the best way of coping with the minimum amount of equipment. Always consider making use of a drug’s side effects. For example, codeine phosphate is a good painkiller but also useful if it’s necessary to constipate a patient. The thought put into this preparation is important training for the whole group.
The next stage of preparation is to ponder potential minor problems that can make life miserable and work out how one would deal with them. Improvised treatments – such as steam inhalations for coughs – can allow one to minimise the number of drugs carried. A formal pre-trip medical questionaire for all members is a valuable preventative tool; for commercial trips, where the team may not know each other, it’s vital. It should ask if any regular medication is taken, including the oral contraceptive (which is often overlooked). Has the member ever been in hospital,or visited an outpatient department or GP regularly for any recurrent problem (including any psychiatric problems, which are also often forgotten)? Are there any known allergies – such as to penicillin – which could result in a complete change in the drugs carried in the medical kit? Or to insect bites, in which case the potential patient should carry their own easily accessible Epinephrine (Adrenaline) autoinjector (Epipen). Specifically, does the expedition member have any potential problems or medical worries that they wish to discuss prior to the trip?
This is also a good time to suggest that all members are up to date with relevant immunisations and have a pre-expedition dental check. I find they all become much more keen on this last idea when I explain that I have had some limited specific expedition dental training and am quite good at extractions, but it’s the local anaesthetic that I find difficult to get to work well. Every medical kit should include material for temporary dental fillings, which, if applied to a dry socket, will normally last until the patient has returned home.Some geographical areas mean that certain items become obligatory. I believe that any doctor going much above 4,000 metres should carry drugs to buy time for descent in the event of a companion developing high-altitude cerebral or pulmonary oedema. The current recommendations are for injectable dexamethasone,oral slow-release nifedipine and acetazolamide.
Polar and very-high-altitude trips should have Super Glue available for smearing into the painful cuts of chapped hands. Not only does this give instant relief from pain but also facilitates healing, and it can also be used to mend damaged equipment. Anybody visiting or passing through a malarial region should take precautions against being bitten and be on prophylactic medication, which may have to be taken for up to a month after leaving the area. No preventative drug regime is totally effective, so an expediton should consider carrying some rapid-diagnostic testing kits and a treatment course of Quinine, Malarone or Riamet as outlined in the British National Formulary.
Whistle while you wait
Different areas will require different drugs and equipment matched by the skill and experience of the team medic, but what items have I found to be particularly useful over the years?As they say in the military, the key to dealing with an adverse situation is command, control and communications. From the point of view of communications, I include a whistle in all first-aid kits. Not only are they cheap and robust, they keep working until you stop breathing. For communication about the patient, I include a pre-prepared casualty report form. This acts as an aide memoire for a stressed first aider and reflects any changes in the patient’s condition. By basing it on a pictorial representation of the human body that can be annotated with the small pencil supplied, it’s automatically multilingual. Working on the principle that it’s vital to protect oneself – and best to assume all patients are HIV- or hepatitis-positive – I ensure the kit contains a few pairs of disposable gloves.
Most patients self-triage before you reach them in remote-area first-aid situations. That said, I do carry an airway in case I ever have to leave an unconscious patient. Recently, I’ve discarded the ubiquitous Güdel airway in favour of a nasopharangeal airway. It’s accepted by a patient at a higher level of consciousness and has the advantage of being versatile enough to also be used as a drinking straw when trying to reach that teasing trickle of water just out of reach in a boulder-choked stream or on a dry glacier.
This type of airway should be lubricated before use; I’ve used the patient’s saliva or even my own. In a remote area, almost all wounds will be contaminated, so a small excess infection risk isn’t important.I carry the same philosophy to sterile wound dressings and prefer the much cheaper and more versatile alternative of a non-stick Melolin pad next to the wound backed by a sanitary towel. These are often in individual plastic pouches, manufactured to a high degree of cleanliness, highly absorbent and cheap. They can be held in place by a cut strip of Elastoplast strapping.At all times, improvisation is key. On one occasion, while skiing, I visited a French doctor for an eye problem and arrived with a sanitary towel stuck over my injury. He treated me rapidly and didn’t charge me. I suspect he wanted me out of his waiting room as quickly as possible.
For doctors only
Doctors who are keen to extend their mountain-medicine skills are encouraged to consider enrolling for the Diploma in Mountain Medicine. This internationally recognised qualification has certificate recognition from the University of Leicester. The course is taught by an experienced team of doctors and qualified mountain guides.For more information, visit www.medex.org.uk. A list of doctors who hold this qualification is maintained on the same website.
July 2007
The wisdom of this advice was first brought home to me during a mountaineering expedition to the Altai range of Mongolia in 1992. This was long before the area became available to commercial expedition companies: one still travelled with the local nomads, shared vodka, and internal flights were plagued by a lack of fuel and tyres bursting on landing. At base camp, we were visited by an elderly Japanese trekker and his wife. During the night,he fell unconscious from presumed altitude sickness. We had to make the difficult decision to evacuate him, using drugs to buy time, sitting him upright on a stretcher with a rapid ascent of about 150 metres before we could take the only feasible route to a lower altitude, using a commandeered truck to get him to a local hospital.
The ‘hospital’ consisted of a mud building with a central ‘intensive care unit’ and a four-bed surgical and medical ward in each wing. It looked more like a Scottish bothy but one couldn’t fault the care of the local Russian-trained doctor. Needless to say, our Tupperware box of expedition medical supplies was invaluable. The trekker survived.
Take your brain
So what does one take in one’s medical kit? The single most important thing is one’s brain, supplemented with careful preparation, experience and the ability to rationalise difficult decisions, as well as an element of training. In a perfect world,you will return with an unopened medical kit, but in the event of an accident or serious illness, whatever you pack will almost certainly be found wanting.The contents will be totally dependent on the area visited, the size of the party, the medical expertise within the team, allowable weight, acceptable bulk, monetary funds, the ability to improvise, local facilities, evacuation plans, obligations to local employees, regional disease patterns and any pre-existing medical problems within the team.
Most of my expeditons have consisted of three or four friends attempting first ascents in remote areas. Being a slow acclimatiser, I’ve learnt that I prefer the peaks of Chilean Patagonia to the high peaks of the Himalaya. Since we need no altitude drugs, our main expedition medical kit will often fit in a four-litre plastic container, although with increasing age and potential prostate problems, we’ve now added a urinary catheter.
In addition to the main kit, each team member carries a small first-aid kit with strong analgesics, syringe and needle (which can be reused on the same patient), a small quantity
of antibiotics, basic dressings and an airway. In an emergency,these small kits complement each other and can be used for a couple of days until the main team kit can be collected from our base. This is a good principle for all expeditions to every geographic area. If one relies on a single heavy kit, it will never be in the right place at the right time.In addition, I always insist on each member having a small personal base camp medical kit for minor problems. This will include their favourite simple home remedies, as well as creams for athletes’ foot/crotch, analgesia for headaches and muscle strains, and (if relevent) malaria prophylactic medication. This encourges members to take responsibility for their own health and stops me being pestered about minor ailments.
These basic principles for medical kits apply to all expeditions but they may need to be modified for larger trips or more specialised trips. A good example would be the recent Caudwell Xtreme Everest Medical research expedition. Although very determined to reach the summit, they also carried out a huge programme of research involving numerous trekkers. In order to obtain ethical approval for some of these quite invasive medical procedures,the expedition had to be able to provide full Intensive Therapy Unit resuscitation facilities at base camp. The medical expertise within the research and climbing teams was impressive, with several anaesthetic intensivists,a vascular surgeon with interest in frostbite, casualty consultants and general practitioners. Each person had good reason to request the inclusion of the drugs and equipment for their speciality.
By contrast, I was invited to join a proposed trip to Mount Everest in 2003 as trip doctor to a team that had planned to climb the mountain using equipment based entirely on the original first ascent in 1953. When I suggested that I take a medical kit using only drugs from the 1950s the reply was a unanimous, “No!”A further contrast would be when I act as a medical advisor to some of the modern and very lightweight, fast-moving two-person teams attempting extreme lines on remote Alaskan peaks. These super-fit and experienced climbers will climb for several days with minimal food and shelter,relying on speed and a sustained break in the weather. In these situations, carrying any medical kit above base camp is pointless. In the event of an accident, a spare pair of gloves or one or two extra abseil slings would be far more useful.
What to take?
The astute reader will have already realised that I’m reluctant to list the specific contents of a medical kit. It’s for the expedition’s medical officer or advisor to determine precisely what is required for your specific project. This is best done by considering worst-case scenarios and then thinking through the best way of coping with the minimum amount of equipment. Always consider making use of a drug’s side effects. For example, codeine phosphate is a good painkiller but also useful if it’s necessary to constipate a patient. The thought put into this preparation is important training for the whole group.
The next stage of preparation is to ponder potential minor problems that can make life miserable and work out how one would deal with them. Improvised treatments – such as steam inhalations for coughs – can allow one to minimise the number of drugs carried. A formal pre-trip medical questionaire for all members is a valuable preventative tool; for commercial trips, where the team may not know each other, it’s vital. It should ask if any regular medication is taken, including the oral contraceptive (which is often overlooked). Has the member ever been in hospital,or visited an outpatient department or GP regularly for any recurrent problem (including any psychiatric problems, which are also often forgotten)? Are there any known allergies – such as to penicillin – which could result in a complete change in the drugs carried in the medical kit? Or to insect bites, in which case the potential patient should carry their own easily accessible Epinephrine (Adrenaline) autoinjector (Epipen). Specifically, does the expedition member have any potential problems or medical worries that they wish to discuss prior to the trip?
This is also a good time to suggest that all members are up to date with relevant immunisations and have a pre-expedition dental check. I find they all become much more keen on this last idea when I explain that I have had some limited specific expedition dental training and am quite good at extractions, but it’s the local anaesthetic that I find difficult to get to work well. Every medical kit should include material for temporary dental fillings, which, if applied to a dry socket, will normally last until the patient has returned home.Some geographical areas mean that certain items become obligatory. I believe that any doctor going much above 4,000 metres should carry drugs to buy time for descent in the event of a companion developing high-altitude cerebral or pulmonary oedema. The current recommendations are for injectable dexamethasone,oral slow-release nifedipine and acetazolamide.
Polar and very-high-altitude trips should have Super Glue available for smearing into the painful cuts of chapped hands. Not only does this give instant relief from pain but also facilitates healing, and it can also be used to mend damaged equipment. Anybody visiting or passing through a malarial region should take precautions against being bitten and be on prophylactic medication, which may have to be taken for up to a month after leaving the area. No preventative drug regime is totally effective, so an expediton should consider carrying some rapid-diagnostic testing kits and a treatment course of Quinine, Malarone or Riamet as outlined in the British National Formulary.
Whistle while you wait
Different areas will require different drugs and equipment matched by the skill and experience of the team medic, but what items have I found to be particularly useful over the years?As they say in the military, the key to dealing with an adverse situation is command, control and communications. From the point of view of communications, I include a whistle in all first-aid kits. Not only are they cheap and robust, they keep working until you stop breathing. For communication about the patient, I include a pre-prepared casualty report form. This acts as an aide memoire for a stressed first aider and reflects any changes in the patient’s condition. By basing it on a pictorial representation of the human body that can be annotated with the small pencil supplied, it’s automatically multilingual. Working on the principle that it’s vital to protect oneself – and best to assume all patients are HIV- or hepatitis-positive – I ensure the kit contains a few pairs of disposable gloves.
Most patients self-triage before you reach them in remote-area first-aid situations. That said, I do carry an airway in case I ever have to leave an unconscious patient. Recently, I’ve discarded the ubiquitous Güdel airway in favour of a nasopharangeal airway. It’s accepted by a patient at a higher level of consciousness and has the advantage of being versatile enough to also be used as a drinking straw when trying to reach that teasing trickle of water just out of reach in a boulder-choked stream or on a dry glacier.
This type of airway should be lubricated before use; I’ve used the patient’s saliva or even my own. In a remote area, almost all wounds will be contaminated, so a small excess infection risk isn’t important.I carry the same philosophy to sterile wound dressings and prefer the much cheaper and more versatile alternative of a non-stick Melolin pad next to the wound backed by a sanitary towel. These are often in individual plastic pouches, manufactured to a high degree of cleanliness, highly absorbent and cheap. They can be held in place by a cut strip of Elastoplast strapping.At all times, improvisation is key. On one occasion, while skiing, I visited a French doctor for an eye problem and arrived with a sanitary towel stuck over my injury. He treated me rapidly and didn’t charge me. I suspect he wanted me out of his waiting room as quickly as possible.
For doctors only
Doctors who are keen to extend their mountain-medicine skills are encouraged to consider enrolling for the Diploma in Mountain Medicine. This internationally recognised qualification has certificate recognition from the University of Leicester. The course is taught by an experienced team of doctors and qualified mountain guides.For more information, visit www.medex.org.uk. A list of doctors who hold this qualification is maintained on the same website.
July 2007
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