Chapter 87 Expedition Medicine
The desire for exploration runs deep in the human spirit. “The Journey” appears as a recurring theme in historical, religious, and literary records of numerous societies. It is used as a vehicle to describe and understand the mystery of human existence: the Exodus of the Israelites from Egypt and their wandering in the wilderness for 40 years, recorded in the Pentateuch books of the Old Testament; Homer’s Odyssey, describing the journey of Odysseus home from the Trojan Wars; and the voyage of Marlow along an African river in Conrad’s Heart of Darkness. The Oxford English Dictionary defines an expedition as “a journey undertaken by a group of people with a particular purpose, especially that of exploration, research or war.”54
A history of expeditions is beyond the scope of this chapter. Readers are referred to excellent works published on this topic.1,18 The first clearly documented expeditions are those of Harkhuf, who was the governor of Upper Egypt during the 23rd century BC and whose three explorations along the Nile are recorded on his tomb at Aswan. In modern times, the golden age of expeditions and exploration stretches from the middle of the 19th century to the middle of the 20th century, although it has been mentioned that many of those who occupy a prominent place in the Western imagination were merely recorders of preexisting civilizations, rather than genuine explorers of untrodden ground.1 Despite this observation, many expeditions that took place during this period illustrate both the varied environments and eternal controversies that surrounded expeditions then and continue to do so today:
In the six decades since Hillary and Tenzing stood on the summit of Mt Everest, the demographics of expeditions, and mountaineering expeditions to the Great Ranges in particular, have changed dramatically. Although audacious, groundbreaking ascents continue to be made,11,22 mountains that were once the domain of only an elite group of climbers, who served long apprenticeships to gain the skills necessary to survive in hostile surroundings, are today frequently attempted by less experienced mountaineers. Where once expedition members were chosen for their experience and ability to function autonomously, many now buy into the infrastructure of a commercial expedition and purchase the services of highly experienced guides to fulfill their summit dreams. There has also been an explosion in charity treks over the last 15 years, which has contributed to large numbers of unfit wilderness- and altitude-naive individuals being led into an environment for which they are totally unprepared.
Many accounts from leaders, guides, physicians, and a growing number of books recount expeditions in the commercial era in an unfavorable light.* Figure 87-1, online, from the Himalayan Database, shows climbing activity on all of the 8000-m (26,247-foot) peaks between the years 1970 and 2006, with the commercial routes on Mt Everest and Mt Cho Oyu separated out. This demonstrates the large increase in the number of people attempting these routes. The increased popularity of the highest peaks has been mirrored on lower peaks and by nonclimbing trekkers. Figure 87-2 illustrates the numbers of climbers with permits issued for the 18 Nepalese group B climbing peaks, which includes the most popular peaks below 7000 m (22,966 feet), formerly known as trekking peaks, between 1996 and 2009. The number of visitors to Sagarmatha National Park of Nepal has increased massively over the last 35 years. Between 1972 and 1973 there were approximately 1400 visitors; 7492 persons visited in 1989 and 25,925 in 2001. Visitor numbers fell during the recent civil unrest but were reported at over 20,000 in 2004.57
FIGURE 87-2 Permits issued by the Nepal Mountaineering Association for the 18 Nepalese group B climbing peaks, formerly known as trekking peaks, between 1996 and 2009. The five most popular peaks—Mera, Island Peak (Imja Tse), Pharchamo, Lobuche, and Pokhalde—are grouped separately.
(From Nepal Mountaineering Association. www.nepalmountaineering.org/.)
(Data from Salisbury R, Hawley E: The Himalaya by the Numbers, Golden, Colo, 2007, The American Alpine Club.)
This increase in popularity has in all likelihood been accompanied by a decrease in the experience and wilderness skills of expedition participants. There is certainly a need for data to substantiate anecdotal accounts of guides and of medical professionals who provide medical cover for these trips or who work at high-altitude rescue posts in Nepal. Increasing familiarity of the general public with wilderness environments and “extreme sports” via the media has resulted in exponential growth in adventure tourism. The most thoughtful commercial companies vet participants for appropriate experience. However, many do not. Strangers, whose primary motivation is completing a trek or climb, are often grouped together. Individuals physiologically acclimatize to their environments at differing rates, which presents significant challenges for group leaders adhering to tight schedules. Members are frequently unaccustomed to adapting goals to weather, terrain, or the needs of other team members.
Recently many countries have seen development of the charity trek business, in which supporters of charities attempt endurance events such as treks, long-distance cycle rides, or summit climbs to raise money through individual sponsorship of these efforts. These have been further popularized by widely publicized “celebrity” treks” that make light of the risks.42,40 Inexperienced participants entirely depend for their safety on the advice, guidance, and care provided by the trek organizers.
Three very popular destinations are Mt Kilimanjaro in Tanzania, Mt Everest Base Camp in Nepal, and Mt Aconcagua in South America. Mt Kilimanjaro at 5895 m (19,341 feet) attracts more than 20,000 climbers per year, of which fewer than 70% reach the summit. Between 1996 and 2003, 25 tourists died attempting to reach the summit.28 Sensible ascent profiles of Mt Kilimanjaro would suggest that trekkers require 7 to 9 days above 2500 m (8202 feet) to ascend safely and maximize their chances of summit success. In one comparative study of commercial charity treks, it was found that 15 out of 20 treks planned only 4 nights above 2500 m (8202 feet).52,37 There are many reasons for this. The Tanzanian government levies a charge in excess of $100 per day for each day tourists spend in the national park, and as a result, in an attempt to maximize profits, trekkers are encouraged to climb the mountain as quickly as possible, thereby putting lives at risk. None of the charity groups surveyed offered the option of an acclimatization ascent of Mt Meru (4566 m [14,980 feet]) before attempting Kilimanjaro.
Tourists may choose to ignore sensible ascent profiles, but this is not the case for their employed porters, without whom they would be unable to make an attempt on the mountain. No formal statistics are available, but porters die as a result of altitude illness or when guides push on in bad weather.43 The difficulties faced by mountain porters are discussed in more detail later.
More participants with complex medical problems are attempting expeditions. There is once again need for international data. The medical advisor to a major British commercial expedition company has described his experience of clients who successfully completed mountaineering trips with Hodgkin’s lymphoma; epilepsy; insulin-dependent diabetes; a cardiac pacemaker; postcoronary angioplasty, or postrenal transplant.34 It is increasingly common for prospective clients to have a history of depression, anxiety, hypertension, asthma, or diabetes.35 Comparatively little is known about the effects of altitude on the majority of common medical problems.26 Most published recommendations deal with cardiopulmonary pathologic conditions at altitude but are frequently based on theoretic considerations rather than documented experience.10,33,46,51,55 The result of this lack of documented experience with preexisting medical conditions is that advice given to potential expedition participants may be unduly conservative and prohibitive. It is apparent that, with appropriate motivation, care, and planning, it is possible for people with significant comorbidities to successfully and safely trek and climb in remote, hostile wilderness environments.34 The approach to pre-expedition screening is discussed later.
It is not the intention of the authors to criticize those who take part in commercial expeditions and treks. Many experienced mountaineers and travelers use commercial organizations to facilitate trips. However, the days of the ad hoc expedition physician, who often learned his or her trade extemporaneously while caring for his or her friends while climbing, are receding. It is in the context of these demographic changes that the 21st-century expedition medical officer (EMO) is expected to operate.
Providing health care in an expedition setting is a specialist area of practice, requiring not only medical skills, but also the ability to live and work in a potentially austere or hostile environment. This distinctive area of practice demands a set of skills and qualities seldom found in other disciplines. The attributes of an experienced EMO may be divided into three main categories that will be required simultaneously during an expedition, but not necessarily in equal measure. These categories are clinical skills, expedition skills, and personal skills.
The EMO needs to have broad-based clinical skills. As in nonexpedition clinical practice, it is usual for the EMO to have a specialist interest, such as tropical medicine, envenomation, or high-altitude medicine. However, other than for the situation of the high-altitude environment, this is unlikely to provide the majority of the expedition medical caseload, which will generally consist of common, usually minor, ailments, of which the most frequent will be gastrointestinal illnesses, followed by minor orthopedic and trauma problems, respiratory conditions, and other minor medical and surgical problems.3,13,56 The required clinical skills of the EMO will also be influenced by the following:
Remoteness of the expedition location will determine the level of clinical autonomy required. An EMO working in an isolated environment where evacuation is likely to take days or weeks, or with poor communications, would be expected to manage complex and difficult cases that elsewhere would be evacuated. In contrast, a team equipped with good communications and reliable and rapid access to definitive care might be confident working with a much lower level of medical support.
The expedition environment also influences the medical skills that are required of the EMO. A medic operating above 3000 m (9843 feet) requires familiarity with high-altitude pathologic conditions and frequently with cold injuries. This skill set is quite different from that required when operating in a jungle environment, where the likely injuries and illnesses include those resulting from local flora and fauna. Dive, caving, and maritime expeditions each require familiarity with the environment and activity-specific medical problems.
There is a long tradition within medical and scientific expeditions for the EMO also to be part of the research team to offer specific scientific skills in addition to providing medical care. More commonly, the EMO may provide medical support for a building project in a developing country, where traumatic injuries are likely to form a significant part of the EMO’s workload. Personal development expeditions commonly include a mixture of local project work with adventurous activities. Program participants, particularly on youth expeditions, may have psychological problems, so superb personal communication and counseling skills may be advantageous for the EMO.
As discussed above, increasing numbers of people with complex medical problems are successfully taking part in expeditions. The EMO should be fully familiar and able to deal with many conditions that lie outside of his or her normal area of practice.
The EMO will often be required to possess nursing skills not normally required in the EMO’s routine practice. It is common to need to record regular vital signs, dress wounds, clean and change soiled patients, and reposition victims to prevent pressure areas (sores) while awaiting rescue or evacuation. These skills are crucial to delivery of good remote-environment medical care.
Expedition medicine is frequently practiced in challenging and hostile environments. A successful EMO must be capable of functioning autonomously and confidently in such environments and must possess appropriate expedition skills to permit the EMO to work effectively, without jeopardizing the safety of the expedition members. Such skills should be commensurate with the environment in which the EMO is required to practice and might include the following:
An EMO should have a realistic understanding of his or her strengths and weaknesses and how the EMO interacts with the expedition team. The close proximity of expedition living heightens even minor tensions. The EMO may be required to care for any team member, irrespective of his or her own feelings toward that individual.
Good communication skills are crucial to effectively eliciting a patient’s problems and concerns. This includes communicating information and discussing treatment options and providing psychological and emotional support.47 These communication skills are not only useful while practicing medicine, but also when working as an arbitrator in times of team conflict. This is discussed in greater detail later.
The emotional support of expedition members forms an important part of the EMO’s responsibility. It is not unusual for individuals to place considerable emotional significance on their participation in an expedition. It may be the holiday of a lifetime or may be undertaken as affirmation after bereavement, divorce, or illness. With such psychological weight placed on the expedition, an injury or illness in an alien and threatening environment can result in an emotional response that is far greater than would have occurred for a comparable problem at home. Increased availability of satellite telephones can worsen the situation. When things go wrong, the first reaction of a person is often to want to speak to family or friends. This can heighten their natural feeling of homesickness and further compound the emotional response.
A key quality of any EMO is the ability to adapt practice to the surrounding environment or conditions. Having an expectation that things may not go as planned is the first step in making allowances for these eventualities and preparing accordingly. One practical expression of this is planning a medical kit so that drugs and equipment can be used for more than one problem. The ability to think dynamically in changing circumstances is a crucial attribute of any EMO.
Arguably one of the greatest assets of any team member is a good sense of humor, and this is especially true of the EMO. Self-deprecating humor aids humility, promotes courage, and can diffuse tense and difficult situations. A strong sense of humor must be combined with sensitivity, patience, and compassion.
There will be times of increased stress or pressure. The pressure has the potential to spill into professional conflict. Much that has been written on the art of conflict resolution27 can probably be summarized in one word—communication. The EMO might be in the position of arbitrator during times of expedition conflict. The key to avoiding nearly all issues of conflict is to first examine and resolve them during the expedition planning stage and second, not to shy away from discussing them. Clear dialogue should highlight and resolve any issues in the following three categories:
Honesty and integrity are two key aspects of this process. There is often the temptation to skip uncomfortable issues, with the assumption that they can be sorted out during a time of need in the expedition. All expedition team members should be encouraged to discuss uncomfortable issues ahead of time.
Expedition medics are part of the expedition leadership team. Decisions made by them will inevitably affect members of the team, and occasionally the entire group. Therefore it is important that persons making the decisions do so with good judgment and authority. During the planning stages, typical questions that should be asked are the following:
If there is an expedition medical team, establishing clarity of roles, responsibilities, and command hierarchy within this team is vitally important. By having a clear understanding of the skills, knowledge, and background of the medical team members, the lead medical officer will be able to make more informed decisions and avoid professional disagreements. This exercise should be completed at an early stage of the expedition (preferably in the planning stages) to avoid later difficulties.
Team members will have differing expectations of the role of the expedition medic. This will depend on their individual knowledge and experience and the confidence they have in caring for themselves. Expedition medics will also vary in how much they expect individuals to look after themselves. Initially running daily clinics, where medical issues can be addressed in a more controlled environment, will enable the medical officer to decide on appropriate levels of input.
It is unlikely that the expedition medic will practice at the same intensity as in the normal hospital environment, which some individuals might find frustrating. However, periods of intense activity may be required at any stage of the expedition with little or no warning. For many clinicians, this “rapid response” may be unfamiliar unless they are specialists in prehospital or emergency care.
There may be expectations surrounding the level of involvement the medic is expected to have in nonmedical expedition activities. Medical officers who opt out of expedition work are likely to cause resentment amongst other hard-working team members. There must be a balance so that medic involvement in expedition activities and ensuing tiredness does not affect the ability to function medically in the event of an emergency.
Medics may find themselves in the position of having to provide medical care for indigenous populations, which is sometimes a very contentious subject. There is a requirement to balance help for persons in distress, consumption of medical supplies, putting the expedition team at risk, and the potential to undermine local health care systems. There is no easy solution. Medical officers working on expeditions in or near poor communities will be surrounded by health care problems that, in their normal practice, could be solved with simple interventions. All team members are likely to find it difficult not to intervene at varying levels.
Another area of expectation to consider is health care and communication equipment. There should be a clear understanding surrounding access to medical and communication equipment while on expedition.
All team members must have a clear understanding of the purpose of the expedition. This is equally important for the EMO. It can be very easy to agree to take part in an expedition based on the location and the work, without necessarily taking into consideration some of the ethical or moral issues behind the trip, as in the following examples:
Ethical considerations transcend every part of an expedition, from the expedition purpose or goal, through delivery of care to expedition members and affiliates, to the impact on host cultures and countries. The four principles of ethical debate and behavior6 that can be appropriately applied to the individuals and expedition as a whole2 are the following:
The first EMOs were physicians who frequently combined providing medical care with their role as climbers or with physiologic or other scientific research.* Skills and knowledge were generally passed on to aspiring EMOs in an informal manner. With the growth of commercial expeditions, many physicians with little or no experience or understanding of expedition medicine accepted the offer of a reduced-price place on an expedition. This provided the pretense of medical cover to the group, sometimes with disastrous consequences. There is no doubt that the EMO does not necessarily need to be a physician. Emergency medical care on expeditions has been provided safely by registered nurses or paramedics with appropriate training and experience similar to civilian and military prehospital care. There is no information as to how care provided by a nonphysician EMO compares with that provided by a physician; however, UK emergency nurse practitioners have demonstrated equally competent levels of skill and knowledge when compared with their traditionally trained medical colleagues.5,58 No established medical specialty encompasses all of the skills and knowledge required for the safe practice of expedition medicine.
Increasingly, expeditions do not have a formal EMO, so the pre-expedition and postexpedition and expedition phases are performed by different people. The pre-expedition medical screening and planning and the provision of training and medical kits may be provided by a corporate (company) EMO, whereas care in the field is delivered by the expedition leader or guide. Nonmedical veterans of many expeditions may be more experienced than the EMO, so, along with appropriately trained expedition leaders, they can provide a high standard of emergency care to expedition members. Box 87-1 gives an example of the lifesaving care provided by an expedition leader to a Nepalese porter during an expedition to Baruntse. The role of telemedicine in providing expert medical support to expeditions without an EMO and the legal responsibility of non–medically qualified leaders providing medical care to members of their group are discussed later. One unique model of care is the Everest Base Camp Medical Clinic (Everest ER), founded in 2003 by Dr. Luanne Freer to address the problems of expeditions on Mt Everest. The temporary clinic offers medical care to all expeditions on the Nepalese side of Mt Everest during the spring climbing season.17,21
A Nepali Porter With Severe HACE and HAPE
A 50-year-old Nepali porter working for a commercial expedition that did not have a medical officer was taken ill at Makalu Base Camp (5450 m [17,881 feet]) in Nepal. The following is a summary of the excellent contemporaneous notes made by the expedition leader outlining the lifesaving treatment he gave to the porter:
The porter was monitored overnight by his brother making observations every hour. He continued to receive regular dexamethasone and nifedipine. The following morning when he was evacuated by helicopter to Kathmandu, his condition was much improved although he remained very ataxic. He was cared for at the Kathmandu offices of the expedition company, where he was also reviewed by a Western physician, and made a complete recovery.
From Paul Donovan, expedition leader with Jagged Globe.
Paralleling the explosion in commercial expeditions and increased formalization of all aspects of medical training are the many courses around the world offering wilderness, expedition, or mountain medical training in one form or other. In August 1997, the medical commissions of the International Mountaineering and Climbing Federation (UIAA), International Committee on Alpine Rescue (ICAR), and International Society for Mountain Medicine (ISMM) established minimal requirements for courses in mountain medicine. These standards, last updated in 2007, have been adopted across many countries. There are currently six UIAA-ICAR-ISMM approved diplomas in mountain medicine in France, Germany, Italy, Spain, Switzerland, and the United Kingdom.53 With the growing concern about possible litigation from expedition clients (see Legal and Ethical Considerations of Expedition Medicine, later), it seems advisable that there be consensus among expedition medical providers about the core knowledge and clinical competencies required to practice expedition medicine in each of its major environments. Details of the UIAA-ICAR-ISMM syllabus for the Diploma in Mountain Medicine are given in Table 87-1.
Satellite expeditions medically coordinated from a single central base camp allow utilization of broader skill sets and abilities, with the most qualified or experienced medic able to provide advice or support from a central location (Figure 87-3, online). There are numerous variations based on this theme. These might include having the senior EMO based with the group deemed at highest medical risk, with outpost medical support provided from that location.
FIGURE 87-3 Allocation of medical staff according to level of risk and skills required at each expedition site. In Example 1, the expedition medical officer (EMO) with the highest levels of skills and competency is based centrally with equal access to each expedition site. In Example 2, the EMO with the highest skill base and competence has been allocated to the expedition site with the highest risk.
The EMO should aim to prevent illness and injury and to treat those who sustain injuries or become unwell as quickly and appropriately as possible. The chance of successfully achieving these aims is greatly increased by careful pre-expedition planning, which should include medical screening of all expedition members and risk assessment and management. Any serious illness or injury will fully occupy the EMO and his or her work will be greatly facilitated if other team members have received pre-expedition medical training. An expedition medical planning checklist is given in Box 87-2.
BOX 87-2 Expedition Medical Planning Checklist
Persons with special health care needs should be involved with risk management and careful pre-expedition planning to aim for a safe and successful trip. Certain chronic illnesses and disabilities mean that certain individuals will be unable to participate fully, but with forethought, they can still enjoy a worthwhile challenge or experience. The stresses and strains of expedition life may exacerbate underlying joint problems, inflammatory bowel disease, respiratory illnesses, angina, and other long-standing health issues. The main concerns are that if conditions worsen, definitive medical care may be very remote and evacuation times prolonged.
Before a decision can be made regarding an expedition team member’s suitability for the proposed trip, it is essential to consider all the risks that may lead to serious illness, or even death. For some persons, an alternative trip with less-demanding objectives may be more suitable.
All participants should complete a detailed health questionnaire (Box 87-3). The information may prompt a request for further details from the patient, the family physician, or specialist. It is important to determine the severity of the condition and whether the disease is stable, worsening, or improving. One useful predictor of future performance is the individual’s prior ability to cope with wilderness travel in other isolated or remote areas. The individual may need to be involved in the final decision and take into consideration expedition duration and environment, presence of medical support, field communications, and remoteness of the location and evacuation options.
BOX 87-3 Health Questionnaire for Preexisting Medical Conditions
It is essential to check that all team members are fully financially insured. Incomplete medical disclosure may invalidate insurance coverage. Undeclared medical conditions may mean that the EMO is not prepared to give appropriate medical care because of inadequate knowledge or lack of appropriate medications.
Any illness should be stable and well controlled before departure, and a self-management plan must be agreed on between the individual, family physician or specialist, and the EMO. For instance, in the case of a person with diabetes, a summary of the condition and recent test results, such as electrocardiogram, blood glucose level, hemoglobin A1c, and medications, are important for anyone who assumes care of the individual. Additional items of medical equipment may be required, so the EMO may need to acquire familiarity with specialty medications and new equipment. During the expedition, support and advice will be readily available from the EMO. Where sufficient communications exist, it may be possible to get advice from an individual’s physicians at home, but this should not be relied upon. Potential risks and possible difficulties obtaining further medical help should be discussed openly beforehand.
Where appropriate, with conditions such as diabetes or epilepsy, other team members should have an understanding of the individual’s condition and be able to give emergency treatment if required, such as for management of hypoglycemia or convulsions. Explicit guidelines about actions to be taken with any warning signs of a worsening condition should be documented in advance.
It is important that, where appropriate, all participants are aware of and prepared to accept the risks that an individual’s preexisting medical condition can bring to an expedition, such as the need for evacuation. The individual must be physically and psychologically prepared for the planned expedition. Training in a similar environment will enable an assessment to be made of how an individual will cope during the expedition.
If there have been problems during a trip, prompt reassessment should be advised on return to the home country. It may be appropriate to send a report of any significant problems to the patient’s physician.
Potential risks to expedition members should be systematically identified and control measures instituted to reduce these risks.4 This easily neglected exercise is an important part of expedition planning. The EMO should work closely with the expedition leader to formulate a formal risk assessment (Box 87-4). All team members must be fully informed before departure of the risks to which they are likely to be exposed and the means of hazard control and must understand that it is not possible to eliminate all risk completely (Box 87-5). With this information, they can make an informed decision about their participation in the expedition.