Expedition Medicine

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Chapter 87 Expedition Medicine

Jon Dallimore, Nicholas P. Mason, James Moore

For online-only figures, please go to www.expertconsult.com

Historical Background

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:

• The jungle explorations of David Livingstone during his 6-year search for the origin of the Nile and the subsequent search for Livingstone by the journalist Henry Stanley ⁶² was sponsored by the New York Herald to further boost the newspaper’s circulation.

• The disputed claims of Robert Cook and of the celebrity-obsessed Robert Peary as to who, if either, may have reached the North Pole.³¹

• The ill-fated journey of Robert Falcon Scott to the South Pole, who discovered that he had been beaten by Roald Amundsen and then died with the rest of his team on the return journey only a few miles from the food cache that might have saved them.¹⁹

• Charles Darwin’s scientific voyages ¹⁴ to the southern hemisphere in The Beagle, which revolutionized our understanding of humans’ place on the planet.

• Sven Hedin’s expeditions ²⁹ to the deserts of Central Asia.

• Early British attempts on the north side of Mt Everest during the 1920s and 1930s ⁶⁶; Charles Houston’s expeditions to K2³⁶; the first ascent of an 8000-m (26,247-foot) peak by Maurice Herzog³²; and the ascent of Mt Everest by Sir Edmund Hillary and Tenzing Norgay.³⁸

Expedition Demographics

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. http://www.nepalmountaineering.org/.)

FIGURE 87-1 Climbing activity (members above base camp) for all 8000-m (26,247-foot) peaks between 1970 and 2006 with the Mt Everest and Mt Cho Oyu commercial routes shown separately.

(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.

Preexisting Medical Conditions

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.

The Expedition Medical Officer

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.

Expedition Phase

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:

Expedition Skills

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:

• Basic camp craft: erecting a tent or hammock efficiently, cooking on a stove, and living safely and comfortably in the expedition environment

• Navigation: a vital skill to enable the EMO to operate safely and independently, and essential for locating casualties and organizing evacuations

• Radio communication skills: proficiency in the use of radios and satellite telephones

• Rope work and mountaineering skills

• Jungle craft

Personal Skills

Desirable personal qualities of the EMO include self-awareness, communication skills, empathy and compassion, adaptability, a sense of humor, and skills of conflict resolution.

Self-Awareness

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.

Communication Skills

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.

In the event of a death or serious injury, it may fall to the EMO to deal with the media. This is dealt with in further detail later.

Empathy and Compassion

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.

Adaptability

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.

Sense of Humor

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.

Skills of Conflict Resolution

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 resolution ²⁷ 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:

• Decision making and hierarchy

• Expectations

• Purpose, morals, and ethics

Examine all areas that might cause a problem, and work through the issues. It is useful to consider the worst-case scenarios and examine strategies for resolving them.

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.

Decision Making and Hierarchy

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:

• Who is in overall charge of the expedition?

• What authority does the expedition medic have over factors that may influence the expedition timetable?

• If an issue arises between the medic and expedition leader that cannot be solved, who can act as a mediator?

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.

Expectations

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.

Conflict Stemming From Expedition Purpose, Ethics, and Morals

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:

• Commercial adventure/charity expeditions

• TV/film production work—often in exciting locations, but sometimes with potentially questionable ethics

• Impact of the expedition on local populations

• Disaster medicine—this may be motivated by good intentions, but with the potential to be carried out inappropriately

• Environmental issues associated with the expedition—is there an environmental cost/benefit issue?

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 behavior ⁶ that can be appropriately applied to the individuals and expedition as a whole² are the following:

• Autonomy—the rights of individuals to decide for themselves to accept or refuse treatment, ideally based on an informed decision-making process

• The doing of good—beneficence—making sure individuals are working for the benefit of others, through preparation, appropriate training, and delivery of care

• The avoidance of harm—nonmaleficence—choosing when and when not to intervene and having awareness of the consequences of one’s actions (physical, verbal, or emotional) on all parties, including the expedition, local communities, and the host country

• Justice, equity, and fairness

Who is Qualified to be the Expedition Medical Officer?

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

BOX 87-1

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:

08:20: Porter found to be semiconscious, vomiting, and to have frothy, blood-stained fluid around his mouth.

08:30: According to expedition medical protocols, given 8 mg of dexamethasone IM. He was unable to cooperate to swallow nifedipine. Shortly afterwards the porter fitted and lost consciousness. His breathing became labored, irregular, and noisy. He was placed in a hyperbaric bag and monitored.

08:45: Contacted Kathmandu office of expedition company and confirmed need for urgent helicopter evacuation.

09:00: Regained consciousness but became distressed and disorientated. He was removed from the hyperbaric bag but fitted again and once more rapidly lost consciousness.

09:10: The porter was placed back in the hyperbaric bag at 30° and monitored.

10:30: Intermittently regained consciousness but now appears unconscious. Unresponsive to sound. Respiratory rate 20 breaths/min.

11:15: Removed from hyperbaric bag. Had vomited and been incontinent of urine. Slurred speech and unable to stand. Still unable to take nifedipine. Rapidly deteriorated and put back in hyperbaric bag after it had been cleaned and his clothes changed.

14:00: Conscious and alert. Removed from hyperbaric bag. Complaining of headache. Began to become increasingly drowsy so placed back in hyperbaric bag.

14:30: Conscious and alert. Given further 4 mg dexamethasone IM. Able to take 20 mg nifedipine orally. Remained conscious and alert.

17:00: Remains out of hyperbaric bag, sleeping but rousable. Paracetamol 1 g.

20:30: Given further 4 mg dexamethasone IM and 20 mg oral nifedipine. Headache easing.

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.

HACE, High-altitude cerebral edema; HAPE, high-altitude pulmonary edema; IM, intramuscularly.

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.

TABLE 87-1 UIAA-Approved Basic Syllabus for the Diploma in Mountain Medicine

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.

Expedition Medical Planning

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

Advise and brief the team on medical issues (general and specific to expedition environment).

Undertake medical screening of all expedition members.

Encourage all participants to have a pre-expedition dental checkup.

Provide advice on immunizations and malaria prophylaxis.

Organize appropriate first-aid training for all expedition members.

Obtain, pack, and transport medical supplies and kits.

Undertake a risk assessment, and prepare associated documents.

Investigate local health services and medical facilities.

Anticipate and plan evacuation of a severely ill or injured person from each part of the expedition.

Consider the effects of weather and natural disasters such as tsunami, volcanic eruption, earthquake.

Prepare a communication network in case of evacuation.

Organize medical insurance with full emergency evacuation coverage.

Confirm that professional indemnity insurance will cover expedition medical officer role.

Medical Screening

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.

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.

Generic Pre-Expedition Advice for Persons with Preexisting Medical Conditions

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 A_1c, 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.

Vaccinations and Personal Medication

The EMO should ensure that all expedition participants have suitable travel vaccinations and are carrying appropriate antimalarials for the duration of the expedition.

Risk Management

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.

• A hazard is anything that may cause harm. Examples are fall from a height, rock fall, motor vehicle collision, and high environmental temperature.

• The risk is the chance that somebody could be harmed by a hazard—the chance may be very low, but there may be potentially very serious harm.

BOX 87-5 Briefing the Expedition Team

Topics to Cover for Hazard Control and Risk Reduction

The importance of clean water and hygienically prepared food

Dangers of the sun—sunburn, dehydration, and heat illnesses

The need for good personal hygiene to prevent skin and other infections

Promoting sexual health by avoiding risky sexual activity

Awareness of emotional problems such as isolation, homesickness, conflict within the group

Drug-taking behavior must be avoided, and alcohol should be used only in moderation

Avoiding bites and stings, the use of insect repellents, and dangers of walking barefoot

Special risks for some activities such as high-altitude mountaineering, scuba diving, kayaking, sailing

Appropriate pre-expedition immunizations and choice of suitable antimalarials

Pre-expedition fitness, including a dental checkup

Preparation of a suitable personal first-aid kit and first-aid training tailored to the environment and activities planned

Risk assessments should periodically be reviewed during the expedition because hazards change. For example, while ascending Mt Kilimanjaro in Tanzania (5895 m [19,341 feet]), the hazards change from those of a tropical environment to those of a high-altitude environment.

The most serious risks while traveling are falls and other injuries; drowning; road traffic collisions; altitude illness and heatstroke; serious infections (malaria, hepatitis, and human immunodeficiency virus [HIV]); and homicide.⁴ Although not exhaustive, the following list highlights the environment-specific hazards and risks that should be systematically evaluated during risk assessment:

Hazards Common to Most Expedition Environments

Solar radiation	Sunburn
High or low ambient temperatures	Heat and cold injuries
Hot, dry environments	Dehydration and heat exhaustion
Poor water and food quality	Gastrointestinal illnesses
Isolation	Unfavorable psychological reactions
Overcrowding	Upper respiratory and other infections
Attitudes and behavior	Sexually transmitted infections, injuries

Wildlife Hazards

Dogs	Infected bite wounds and rabies
Leeches	Wound infections
Snakes	Envenomation
Ticks	Typhus and other tick-borne diseases
Hippopotami	Animal attacks, capsizing of boats
Parasites	Infestations
Bears	Multiple injuries

Local Conditions

Lack of shelter	Hypothermia
Dangerous roads	Road traffic collisions
Open fires and stoves	Burns and scalds
Endemic diseases	Malaria, schistosomiasis, dengue fever, encephalitis
Human factors	Assault, kidnapping, terrorism, conflict

Environment-Specific Hazards

High Altitude

Altitude	Altitude-related illness (acute mountain sickness [AMS], high-altitude cerebral edema [HACE], high-altitude pulmonary edema [HAPE], altitude-related cough)
Solar radiation	Sunburn and ultraviolet (UV) keratitis (snowblindness)
Cold	Hypothermia and tissue cold injury
Avalanche and rockfall	Traumatic injury
Blizzard	Getting lost
Lightning	Lightning injuries
Climbing	Falls and traumatic injury
Snow holing	Carbon monoxide poisoning
	Asphyxiation

Desert

Solar radiation and extreme heat	Sunburn and heat illnesses
Lack of water	Collapse, dehydration
Snakes and scorpions	Envenomation

Jungle

Heat and high humidity	Heat exhaustion, syncope, prickly heat
River crossing	Drowning
Deadfall	Injuries
Plant life	Skin reactions, anaphylaxis
Animal and insect hazards	Snakebite, infected bites, and arbovirus infections

Maritime

Sun and wind	Sunburn/windburn and UV keratitis
Cold and heat	Thermal injuries
Saltwater	Saltwater boils
High waves	Seasickness, drowning
Ropes and pulleys	Hand trauma
High rigging	Falls and traumatic injury
Isolation	Interpersonal conflict, adverse psychological reactions

Country-Specific Risks

Detailed information about safety and security, local laws and customs, entry requirements, and health risks for all countries can be obtained via the following websites:

• Australia: http://www.dfat.gov.au

• Canada: http://www.voyage.gc.ca

• United Kingdom: http://www.fco.gov.uk

• UK Health Protection Agency: http://www.hpa.org.uk

• United States: http://www.travel.state.gov

• U.S. Centers for Disease Control and Prevention: http://www.cdc.gov/travel

• World Health Organization: http://www.who.int

Before departure, or shortly after arrival on location, the local medical facilities should be identified and, if possible, inspected: local and regional hospitals, clinics, and pharmacies. Embassies often provide useful information regarding good-quality medical services; some insurance companies list approved hospitals or local physicians. In some parts of the world emergency assistance may be obtained from the military. This includes search and rescue support using helicopters, inflatable rafts, or all-terrain vehicles. National parks staff and nongovernmental organizations may offer support in certain circumstances.

Expedition Medical Training

When operating in wilderness areas, it is common to provide medical care in remote hostile environmental conditions. The EMO will usually carry out his or her role independently with finite medical supplies, sometimes with limited communications and unreliable casualty evacuation facilities. Patient evacuation may be delayed for many reasons. When the EMO is required to look after more than one patient or casualty, his or her resources will be stretched to the limit. It is therefore important that expedition team members be trained to give first and second aid. The exact nature of the medical training for expeditions to wilderness areas should be tailored to suit the environment. For example, it may need to include training in tropical illnesses, malaria, cold injury, and high-altitude illness. Many of these subjects are not covered in “standard” first-aid courses. Advanced techniques that should be taught include the use of prescription medications, the use of specialized rescue equipment, and the reduction of fractures and dislocations.¹² All team members should have undergone basic first-aid training. Essential topics for all who operate in wilderness areas are the following:

• The safe approach to the injured casualty, including scene assessment

• Basic life support, including the management of cardiac arrest and choking

• Understanding the causes of shock and its field treatment, and in particular control of bleeding

• Care of the unconscious patient, including potential causes of loss of consciousness in the expedition’s environment

• Management of acute medical problems (e.g., asthma, hypoglycemia, and convulsions)

• Packaging and moving of patients—stretchers and logrolling

• Patient medical reports

There is no clear consensus in the United States regarding “industry standards” for wilderness first aid.⁶⁸ In the United Kingdom, British Standard 8848 was established in April 2007. This simply states: “The venture provider shall check the first aid qualifications of the leadership team and ensure that they are commensurate with the needs of the venture”⁹ Boxes 87-6 and 87-7 list common expedition complaints and recommended training courses for wilderness first aid.

BOX 87-6 Common Injuries and Illnesses During Wilderness Expeditions

Common Expedition Complaints

• Blisters

• Orthopedic injuries, including fractures and dislocations

• Splinters and other foreign bodies

Common Expedition Medical Conditions

• Infections, such as diarrhea, upper respiratory and urinary infections

Serious Medical Problems

• Anaphylaxis

• Chest pain

• Abdominal pain

• Cough and shortness of breath

Important Injuries

• Head and spinal injuries

• Chest injuries

• Abdominal trauma

• Pelvic injuries

Environmental Injuries

• Altitude-related illness

• Heat illnesses—heat exhaustion and heatstroke

• Cold injuries—frostbite, hypothermia

• Diving injuries

• Venomous bites and stings

Patient Handling

• Moving, lifting, and straightening of injured casualties

• Patient transportation, including improvised stretchers

BOX 87-7 Recommendations for Comprehensive Training Courses for Wilderness Medicine

Basic First Aid

• Cardiopulmonary resuscitation (CPR) and choking management

• Control of bleeding

• Wound and burn management

• Bone and joint medicine

• Treatment of the unconscious casualty

Expedition Medical Kit Preparation

Choosing, assembling, and packing an expedition medical kit takes a great deal of time and effort. Factors dictating the composition of medical kits are as follows:

• Number of expedition team members, including local staff

• Duration of the expedition

• Distance from medical help

• The presence of endemic diseases or other hazards, such as high altitude and extreme cold

• The type of activities—such as diving, rock climbing, vehicle-based travel, sailing, or caving

• Medical skills of the team

• Preexisting medical problems of the group members

• Cost, weight, and bulk

It is not possible to prepare for every possible eventuality and there is always a balance between being underprepared and having too much in a kit.³⁹ For detailed recommendations regarding medical kit contents, see Appendix A.

Diagnostic Equipment

This should include simple diagnostic apparatus such as stethoscope, sphygmomanometer, otoscope, urine testing strips, lightweight pulse oximeter, near-patient malaria testing kits, and low-reading thermometer.

Medical Kit Packaging

Containers should be lightweight, robust, and allow easy identification of the contents. Depending on the environment, the containers should protect from impact, crush, dust, moisture, and other contamination. Medications may need to be protected from extremes of hot and cold (see Appendix: Drug Storage and Stability).

In general, liquid medicines are best avoided because of weight and bulk. Tablets should be in blister packs to protect from damage during transport. Glass ampules are less robust than are plastic ampules; both need to be protected from extremes of cold and heat. For insulin, snakebite serum, and other medications that must be kept cold, specialized pouches are available, for example, those produced by Frio (http://www.friouk.com). Food vacuum flasks have been used to protect items from desert heat and Arctic cold.

When preparing the medical kit, related items should be packed together. For example, dressing materials should be in one box, tablets in another. This means that many different boxes do not have to be opened to deal with one clinical problem. It is helpful to mark clearly the contents on the lid of each box, which means that the boxes do not need to be opened to determine what is inside.

Problems of Transporting Controlled Drugs

Morphine and other controlled drugs should be taken on overseas expeditions only if done under strict supervision. Some countries impose stringent laws,²⁵ including the death penalty, for possession of opiates. In the United Kingdom, a Home Office license is required to export controlled drugs, but this does not protect the individual from applicable laws in other countries.²⁴ If controlled drugs are dispensed, this should be recorded in a controlled-drugs register.

A valuable source of information on the carriage of medications can be found through the International Narcotics Control Board.⁴¹ Information is heavily weighted toward narcotics control, and the website contains information only for countries willing to submit data. Nevertheless, it is a valuable resource for the EMO. The EMO should pay specific caution to any medications that affect the central nervous system, any that can be abused (such as steroids), injectables, and increased quantities of medication. The medical kit and medication should be accompanied by an official letter detailing its intended use, for whom it is intended, and the prescribing authority. This should be signed by the prescriber, with an official stamp, and, where possible, the needed language translations.

Treating Infections

Antibiotics and antimicrobials are commonly used on expeditions to treat or prevent gastrointestinal illness, wound and skin infections, respiratory infections, and important tropical illnesses such as malaria, typhus, and leptospirosis. A range of familiar antibiotics should be carried to cover common, important infections and should cater to those who may have antibiotic allergies.

Analgesia

Many injuries and illnesses are painful, so a comprehensive range of analgesics should be available. Analgesia should be offered regularly to control pain. Ketamine may be considered by experienced practitioners for its analgesic and anesthetic properties.

Other Essential Drugs

Regardless of whether there is an asthmatic team member, all expedition medical kits should include a salbutamol inhaler and medications to treat anaphylaxis—injectable chlorphenamine, epinephrine, and prednisone or hydrocortisone. Motion sickness and gastrointestinal illness can both cause incapacitating nausea and vomiting. Suitable antiemetics include ondanestron (Zofran), cyclizine (Marezine, Marzine, and Emoquil in the United States), and prochlorperazine (Compazine, Stemzine, Buccastem, Stemetil, and Phenotil). The latter may be given intramuscularly or via the buccal route. Other injectable drugs to consider include local anesthetic agents, parenteral antibiotics, polyvalent snakebite antivenom (controversial), and intravenous fluids.

Creams and Ointments

Antiseptic creams, antibiotic ointment for conjunctivitis, antifungal preparations, a mild steroid ointment, and antimicrobial cream for burns should be included in all kits.

Emergency Equipment

Depending on the expedition, the EMO may consider emergency airway management equipment, including the laryngeal mask airway, oxygen, and chest drainage apparatus. For persons operating in areas where they may encounter ballistic trauma, QuikClot and the combat application tourniquet (C-A-T) may be required for the treatment of torrential hemorrhage. It is important to base the decision to take such equipment on a realistic assessment of the likelihood of a safe and rapid evacuation of any casualty requiring such interventions. Many different emergency splints are available, but many orthopedic injuries can be immobilized with improvised splinting (see Chapter 27).

Obtaining Medical Supplies

Purchasing medical supplies for expedition medical kits is expensive. Some pharmaceutical companies may donate drugs, particularly if there is some recognition of sponsorship. Hospitals and pharmacists may provide drugs at cost price to save precious expedition funds. Many drugs can be purchased less expensively in destination countries, but there are very important concerns regarding potency and counterfeit drugs.

Base Camp and Satellite Medical Kits

A comprehensive medical kit should be kept at base camp.²⁴ Satellite camps should have smaller kits tailored to the size of the group, medical training of the team members, and likelihood of serious illness or injury. In addition, each team member should carry personal medication, with some spares (Box 87-8). For more prolonged expeditions or remote field stations, mechanisms must be in place to resupply the medical kits.

Medical Kits for Special Environments

The same basic medical kit can be used in many different theaters of operation; however, modifications will be required, depending upon the activities and environment:⁵⁹

• Tropical regions: The kit should include spare antimalarial drugs and near-patient testing kits, snakebite antivenom (controversial), and larger quantities of antibiotics for wound and skin infections. It is worth considering intravenous fluids for the treatment of dehydration and heat illnesses.

• Mountaineering expeditions: Trips above 4000 m (13,123 feet) must include acetazolamide, dexamethasone, and nifedipine. Larger groups may consider bringing a portable hyperbaric chamber.

• Maritime and diving trips: Seasickness medications, ear drops for otitis externa, and treatments for marine envenomation should all be considered.

Communications Technology

Expedition communication technology via two-way radios (AM, high-band FM, or UHF), mobile telephones, or satellite telephones is increasingly financially accessible to even small and lightweight expeditions. Many companies now offer ready-to-use expedition communication packages complete with web hosting. Communications operate at different levels:

• Internal communications between expedition members to facilitate expedition logistics, information exchange, and medical care. This may be over considerable distances for large expeditions with several sites. It is crucial that expedition members be familiar with radio procedures to facilitate accurate transmission of information in the event of illness or injury. Box 87-9 outlines the basic principles of good radio procedure.

• Communication with local agencies such as national park authorities, the military, embassies, or rescue services. It is important to ensure that you know before departure the correct telephone numbers or radio frequencies used by these agencies.

• Communication with the expedition home country for contact with the expedition head office, sponsors, or the media, and for expedition members to remain in touch with their families.

• Telemedicine is facilitation of health care delivery by exchange of health care information across distances. This can range from simple telephone advice to transmission of complex diagnostic images or data for remote analysis.⁷¹ Telemedicine clearly has significant potential to deliver diagnostic services and expert advice into remote areas. The French Institut de Formation et de Recherche en Medecine de Montagne (Ifremmont), based in Chamonix, now offers a subscription service for expedition trip leaders, guides, and EMOs that can help in expedition medical preparation and provides 24-hour telephone access to expert medical advice in French or English in the event of a medical problem.

BOX 87-9 Radio Procedure

Good radio procedure is marked by the following:

• Clarity: Always identify yourself and whom (you think!) you are addressing. Speak slowly and clearly.

• Accuracy: Use the NATO phonetic alphabet to spell difficult or unusual words.

• Brevity: Be brief! Think about what you are going to say before transmission. If in doubt, write it down.

End each message with “Over.”

Send message “Understood, over” or “Roger that, over” to acknowledge a received message.

Send message “Standing by” if you are continuing to monitor the frequency.

End message with your identity and “Out” if you have finished transmitting.

Use the mnemonic ETHANE to facilitate accurate transmission of casualty information:

• Number of casualties

• Emergency services on scene or required

NATO, North Atlantic Treaty Organization.

Box 87-10 outlines the story of a British climber who sustained frostbitten toes on Mt Aconcagua and avoided amputation through consultation with the UK Frostbite Advice Service. This service has been in existence since 2005 and has helped nearly 40 climbers with a combination of remote service advice, often using digital imaging, and rapid follow-up consultation on return to the United Kingdom. Contact details for both Ifremmont and the UK Frostbite Advice Service are given in the Resources section at the end of this chapter.

BOX 87-10 Telemedicine Saves Climber’s Frostbitten Toes

A 22-year-old climber developed frostbite of his toes while climbing Mt Aconcagua (6962 m [22,841 feet]) in Argentina. On descent to a local hospital, a surgeon advised amputation of the frostbitten toes. The climber contacted the British Mountaineering Council (BMC) in the United Kingdom, whose medical advisor put him in touch with Chris Imray, a British vascular surgeon specializing in local cold injury. Within 6 hours of the initial telephone call to the BMC, the vascular surgeon had reviewed digital images of the climber’s frostbitten toes that had been uploaded onto the climber’s website from Argentina. The surgeon advised against surgery and recommended that the climber return to Britain, where he made a full recovery. Follow-up was principally via review of photographs of the climber’s toes on his website. Three months after the injury, the climber completed the London Marathon.

Legal and Ethical Considerations of Expedition Medicine

Most people who venture into wilderness areas are willing to help sick or injured travelers in their own party or strangers whom they may encounter. In some countries, for example France, laws exist that make it an offense to not provide assistance to somebody in peril. These are sometimes referred to as Good Samaritan laws. In other parts of the world, offering assistance remains only an ethical and not a legal obligation.

Duty of Care

Each person has a duty of care to not injure others; however, this duty is different in certain circumstances. Leaders or members of a group have a clear duty of care to the other members of their group. Moral and ethical duties may exist to rescue another person but must be distinguished from legal duties. Common law does not impose a legal duty on an individual to rescue another person; however, a legal duty may be imposed on certain people in certain circumstances. A physician is under a legal duty to render emergency care to his or her own patient, although professional bodies such as the UK General Medical Council expect physicians to provide emergency assistance even when off duty: “In an emergency, wherever it may arise, you must offer anyone at risk the assistance you could reasonably be expected to provide.”²³ Whether a physician is treating a patient, advising a patient, or advising an expedition company, a clear duty of care exists in law. All who provide medical care or advice, be they physicians, nurses, paramedics, or laypersons, must do so reasonably and carefully.

A parent is under a legal duty to rescue his or her child. Police and fire service personnel are under a legal duty to rescue people in distress. Once a person undertakes the rescue, there is a legal duty to do everything possible to complete the rescue without causing personal injury. The law does not expect anyone to lose his or her own life, even when circumstances mean that there is a legal duty to rescue. In a court of law, assessment of whether an individual has met the duty of care expected of that individual would is judged according to the following principles:

Level of Control and Age/Experience of the Ill or Injured Person

Supervision of any wilderness activity must be appropriate to the age and experience of the participants. This is particularly important when working with children or youths, who cannot be expected to have the same degree of knowledge in wilderness situations as does an older, more experienced adult. For commercial groups with inexperienced adults, suitable guidance should be given by persons who are familiar with the environment and management of common problems. Appropriate staff-to-participant ratios should be determined to ensure adequate supervision.

Comparison with Peers

The courts will compare the provided standard of care with that expected from a person with similar experience and training acting in the same or similar circumstances. In effect from April 2007, British Standard 8848 describes recommended safety standards for expeditions and other adventure travel.⁶⁸

Likelihood of an Incident Occurring

In law, if an accident has happened before in similar circumstances, then it is considered that it could occur again and precautions should be put in place to prevent recurrence.

Maintenance of Equipment and Cost of Precautions

It is essential that medical, safety, and rescue equipment be appropriate for the wilderness area to be visited. Procedures must be in place to guarantee that equipment is fit for purpose and correctly stored and packaged to prevent damage when being transported into the theater of operation. Adequate funds must be invested in providing adequate medical kits and supplies, but a court might understand that cost of excessive precautions might preclude the activity in the first place.

Emergency Situations

In the case of an emergency, the court will take into account the specific circumstances, such as the need to act with speed in a hazardous situation, in determining whether a practitioner has acted with reasonable care. Courts recognize that medicine is practiced in remote areas and that medical resources are limited.

Standard of Care

In UK law, the case of Bolam v Friern Hospital Management Committee (1957) produced the following definition of what is reasonable: “The test is the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill at the risk of being found negligent. It is sufficient if he exercises the skill of an ordinary man exercising that particular art.” This definition is supported and clarified by the case of Bolitho v City and Hackney Health Authority (1993).⁸

Courts have indicated that they are not prepared to allow inexperience as a defense in actions of professional negligence. If a physician is unable to exercise reasonable care in carrying out a particular task, then he or she should not undertake that task. Should a practitioner hold himself or herself out to be an expedition physician (and as such, having a “specialist” skill), the physician’s actions are judged against what might reasonably be expected of a competent expedition physician, even if this is the first time he or she has ever taken on such a role.

Confidentiality

All persons who are ill or injured must be confident that sensitive medical information will be kept confidential. For example, such information will not be made known to the rest of the expedition team or other individuals who are not directly involved in medical treatment or nursing care. However, in the United Kingdom, the General Medical Council has made it clear that physicians also have a duty to the public at large. Rare circumstances can arise where confidentiality needs to be broken so that the health and safety of other expedition members are not jeopardized. The expedition leader may need to be informed that an individual is concealing an illness or refusing treatment. Box 87-11 gives an example of a situation where a patient’s withholding information about his past medical history engendered significant consequences for himself and the expedition.

BOX 87-11 Urinary Retention at Concordia

A 68-year-old man was taking part in a commercial trek to K2 Base Camp at Concordia in Pakistan and over the Ghondokoro La (5585 m [18,323 feet]). As part of the preparation for the trip, he had been required to complete a comprehensive medical questionnaire that was screened by the company medical officer, a physician with long-standing experience in mountain and wilderness medicine. The trekker declared no significant health problems.

Having arrived at Concordia, the group leader was woken at around midnight by one of the trekkers to say that his tent mate, the 68-year-old man, was unable to pass urine and was in considerable discomfort. He was well hydrated and had suffered no trauma. He again denied any significant past medical history. A satellite telephone call was made to the company’s medical officer, but the connection was poor and a detailed discussion of the case was not possible.

Simple measures including diazepam administration and sitting the man in a large bowl of warm water produced no result. The man was now in considerable pain. An inquiry was made of all the other groups camping at Concordia that night, but none had a urinary catheter. Eventually, an intravenous administration set was found, from which was improvised a urinary catheter. The man was successfully catheterized by the group leader, who had previously trained as a radiographer. This produced 1.5 L of heavily blood-stained urine.

After a considerable wait due to bad weather, the man was evacuated by helicopter to the District Headquarters Hospital at Skardu, where it became apparent that he had a history of prostatism and had been previously taking finasteride. Because of his failure to declare his history of prostatic problems, the man’s insurance was void and he was required to finance his evacuation and treatment in Pakistan.

Consent

Before starting treatment, the recipient must give consent. This means explaining what treatment is planned and ensuring that the patient is aware of the rescuer’s level of training and experience. There must also be agreement to continue treatment. Consent may be implied from the circumstances. Voluntary submission to treatment usually indicates consent. In the expedition or wilderness setting, verbal consent must often be sufficient. In situations where treatment carries considerable risk, or is controversial, informed consent should be obtained, documented, and ideally witnessed by an observer.

The concept of consent is governed by the law of battery. Without consent, treatment is assault. The law usually presumes consent in an emergency situation when immediate action is necessary for protection of the patient’s life. The law presumes that most reasonable persons under the same or similar circumstances would want their lives saved, if at all possible. Competent patients have the right to refuse treatment, even if, in the rescuer’s opinion, this will not be in their best interest.

Competence and Capacity

A competent person has the right to refuse treatment if the person understands the consequences of such a refusal; however, a competent adult may lack the capacity to consent as a result of a comatose state. Intoxicated adults, however, have been deemed by the courts to have the capacity to consent.

The only person who can give consent to treatment for someone over 16 years of age is that person himself or herself. Consent to treatment for a child under 16 years is given by a parent or guardian, although the child should be given information relevant to his or her age and understanding, and the child’s consent also should be sought. Children under 16 years can consent to medical treatment themselves if, in the opinion of the physician, they are capable of understanding the nature and consequences of that treatment. When taking children under the age of 16 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.

Negligence

To prove negligence and sue for damages, the plaintiff must establish a usual standard of care, then prove a breach of that standard of care and that as a result of that breach there is demonstrable injury. It must also be proved that the breach of duty was the logical and legal cause of the claimed injury (causation).

Contributory negligence is a factor that reduces liability. For example, a novice expedition member may forget to pack essential survival items, despite being informed that these items were required. Any settlement for negligence related to not having the items might then be reduced.

How Much Should Laypersons Be Taught About Medicine?

In the United Kingdom, the law does not prohibit any person from practicing medicine or dentistry; however, it is an offence for any person to pretend to be or imply that he or she is a physician. Thus the essence of what treatment should be provided by laypeople is largely a matter of patient consent and understanding.

Persons who participate in hazardous activities may, in many circumstances, be held to consent to the risks and rigors dictated by such a circumstance. In other words, if you become injured or ill, you have accepted that medical care may be of a less satisfactory nature than in a modern emergency department. It is very important that group members are involved in the risk assessment process and are aware of the level of medical care that can be expected.

Lay people should be taught sufficiently to enable any expedition to be safe insofar as that can be achieved. There exists a duty of care to exercise skills consistent with training, experience, and procedures. The duty of care will obviously vary. Care rendered by a completely untrained Good Samaritan providing urgent assistance in extreme or remote circumstances can easily be distinguished from the setting of a simple bony fracture by a trained first-aider acting at the direction of medical personnel providing advice by telephone or radio. The duty of care is defined in each individual circumstance.¹⁶

Legal Position of a Physician Advising Care to Be Administered by a Layperson

Persons accepting responsibility to provide medical, nursing, or paramedical help must be judged according to the state of their knowledge and experience and the extent to which they follow directions or advice given to them by more highly or appropriately qualified personnel removed from the accident scene. The higher the degree of training provided and the greater the detail of medical support in place, the greater the expectation of the patient to be properly treated and the rigor with which the duty of care is interpreted by lawyers.

Liability on Commercial Expeditions

Medical indemnity is discussed in detail later (see Professional Indemnity Insurance). Most medical indemnity organizations provide Good Samaritan coverage for physicians acting in any part of the world. The British Medical Defence Union (MDU) defines a Good Samaritan act as “The provision of clinical services related to a clinical emergency, accident or disaster when you are not present in your professional capacity but as a bystander,” and states that “MDU members who have a current Professional Indemnity Policy are covered for claims arising from Good Samaritan acts anywhere in the world.”⁵⁰ However, in an expedition setting, this would apply only where a team member just happens to be a physician. It would certainly not cover a physician receiving any form of inducement (for example, a discount in the trip fee or sponsorship in kind) that implies the physician has an official medical role on the expedition.

Expedition companies have a responsibility in common law to ensure that any EMO they choose to employ is suitably experienced. In the event of a claim for negligence, the claim would normally be made against the expedition company. A liability disclaimer signed by a patient before receiving treatment is unlikely to carry much weight before a court.

Expeditions Departing Without an EMO

Many smaller expeditions do not have the resources to be able to take an EMO into the field; however, the team will still be in need of medical advice and a suitable medical pack. In these cases, an EMO may do the following:

• Provide advice on travel medicine, such as the required vaccinations or recommended antimalarial chemoprophylaxis for an area.

• Supply private prescriptions for an expedition. It should be kept in mind that the drugs may be used for treatment of trip members previously unknown to the EMO. In these situations, the EMO (who retains a duty of care) should provide clear written guidelines, which should include indications, contraindications, doses, and side effects. It would also be prudent for the EMO to seek a written assurance from the person to whom prescriptions are supplied that the medication prescribed will be used only for the immediate treatment of expedition members in wilderness areas and not as a substitute for seeking professional medical advice when such is readily available.

• Delegate the responsibility for initiating treatment to a trip leader.

Medical Records

Brief, accurate, and contemporaneous medical records should be made for all clinical encounters. In serious illness or injury, this is essential so that detailed clinical information can be given to those who deliver definitive care to the patient. This principle applies to both medical and nonmedical expedition staff providing medical care—Box 87-1 is an example of excellent record keeping by a nonmedical expedition leader. Whenever a patient is evacuated or referred to a formal medical facility, he or she should be accompanied by clear notes outlining the history and treatment. If there are later concerns about the standards of care given in a wilderness setting, superb clinical notes will help to defend actions if legal activities occur. Examples of suitable medical records for use in the field can be found at http://medex.org.uk/diploma/resources.php.

Professional Indemnity Insurance

Professional indemnity insurance is an increasingly contentious issue and with considerable international variation. In the United Kingdom, professional indemnity insurance is provided by four national organizations: the Medical and Dental Defence Union of Scotland; the MDU, the Medical Protection Society, and the Royal College of Nursing. Each organization generally provides discretionary indemnity to its members for a period of volunteer or charity work such as accompanying an expedition or trek or being based in a mountain or wilderness clinic. Importantly, “This is dependent on the doctor confirming he or she is suitably trained and equipped to undertake that work,” (MDU personal communication).⁵⁰ There are, however, a number of countries in which indemnity insurance is not available. These include the United States and Canada and their dependent territories. Work for which the physician receives financial remuneration will be considered for indemnity cover but is likely to be charged on a pro rata basis of up to $6500 per year as of April 2010. In the United States, medical professional liability insurance is provided by private insurance companies at considerable cost. Any American EMO would need to discuss indemnity with his or her insurance company on an individual basis.

Canadian physicians obtain indemnity insurance through the Canadian Medical Protective Association (CMPA). Fees vary from province to province. The CMPA will indemnify its members only for treating Canadian citizens in the province in which they work. The CMPA does not provide indemnity insurance for overseas expedition work, so this must therefore be obtained privately. Private medical indemnity insurance can be very difficult to obtain and prohibitively expensive.

In Australia, the situation is more complex, particularly since the financial collapse in 2002 of one of the major providers of medical indemnity insurance. A variety of medical defense organizations provide cover, depending on whether the physician is self-employed or works in public hospitals. It would appear that the majority of organizations would consider providing indemnity cover for their members carrying out volunteer work in a similar manner, and with similar conditions, to the British organizations discussed earlier.

It is likely that many EMOs practice expedition medicine with inadequate indemnity insurance. The authors are unaware of any indemnity claim that has been brought against an EMO, but regrettably, in the current litigation climate and with the changing attitude and demographics of expedition members, it seems only a matter of time before such legal proceedings occur. It is crucial that anybody considering undertaking expedition medical work is competent to undertake the work and has a full discussion with his or her medical defense organization. With the risk for litigation and number of commercial expeditions offering medical professionals the chance to practice expedition medicine, it seems wise for anybody considering EMO activities to obtain a suitable and robust qualification, such as the Diploma in Mountain Medicine.

Nurses and paramedics acting as EMOs should inform their respective professional indemnity carriers about the potential extended scope of practice. The scope of professional indemnity insurance provided varies among national professional bodies. In the United Kingdom nurses are assumed to work within a skill set commensurate with their level of knowledge and training and in the event of a claim would be held accountable for straying from a suitable level of competency.⁶⁵

Ethical Considerations of Interacting with Local Populations

A frequent problem confronting an expedition is the extent to which treatment should be provided for a local population. When an expedition arrives in a new village, particularly if it is known that there is an EMO on the expedition, a queue of local people commonly forms to seek consultation and treatment. There are no absolute ethical guidelines for this situation. Each expedition must decide what policy it will adopt. The following factors should be taken into consideration:

Pre-expedition Planning

A decision should be made at the planning stage of the expedition as to the degree the expedition will offer medical care to the local population. This decision will be influenced by two major factors:

• Expedition resources and budget

• Preexisting medical facilities in the area being visited

The location of local health care facilities should be researched before the expedition. It is crucial that when local health care facilities exist, however basic, the expedition does not undermine them. Local clinics have to continue to provide care long after an expedition has departed and are not helped in their task if an expedition falsely raises the expectations of local communities. If an expedition intends to provide treatment for local people, for example in a region that lacks local health care facilities, it is important that this is anticipated and budgeted, and that extra resources are allocated for this.

During the Expedition

During the expedition walk-in, it is important to visit local health care facilities and to meet the staff. Such visits can provide encouragement for the local staff and inspiration for the visiting EMO, because the work carried out in such posts, often with minimal resources, is frequently impressive. It offers the opportunity to discuss with the local staff the best ways in which the expedition should interact with the community. It is also useful to discuss the existence of any indigenous healers in the area and to be guided by the local health staff as to the best way in which to interact with them (Box 87-12). The visit should also be used to determine the best ways to evacuate sick expedition members should direct air evacuation not be available.

BOX 87-12 Interacting With Local Healers

The left hand of a young Sherpa boy (Figure 87-4) who presented to the Community Action Nepal–International Porter Protection Group Rescue Post at Machermo in the Gokyo Valley of Nepal with a gangrenous accessory digit. His mother had been advised by a local shaman to tie a piece of the child’s hair around the accessory digit. The boy was referred to the Hillary Trust Hospital at Khunde, where he underwent amputation of the digit under ketamine anesthesia without complications.

FIGURE 87-4 The left hand of a young Sherpa boy with a gangrenous accessory digit.

If local people are treated, then only acute problems should be dealt with and anything requiring ongoing treatment, or follow-up, should be referred to the local health care facility with a formal letter of referral. On the walk out, it is courteous and helpful to leave any unused drugs and items of equipment that might be useful with the local health care facilities.

Treating Local Staff

Although the extent to which expeditions should treat members of local populations is open to debate, the manner in which local staff working for the expedition should be treated is not. They should receive the same medical care as do other members of the expedition. George Finch,²⁰ a member of the 1922 Mt Everest expedition wrote at the time:

There is only one form of transportation for this cumbersome, and at times dangerous, work: the native mountain people. The natives of the Himalayas, like all mountain people, are very tough and healthy as can be; they are resolute and brave, yet always of friendly and cheerful disposition, and are excellent porters if they are treated right. But they have to be cared for properly, that is, they must be clothed appropriately and supplied with ample provisions to keep them in peak performance.

Sadly, this self-evident sentiment is not the experience of many local staff who are regularly required to work without adequate clothing or shelter and too frequently abandoned and left to fend for themselves when they fall ill. This abuse of local staff, and in particular portering staff, is one of the most shameful features of modern expeditions.^48,⁴⁹ Box 87-13 tells the typical story of a sick porter abandoned by his expedition. Box 87-14 gives a Nepalese porter’s perspective of his work.

BOX 87-13 Another Nepalese Porter With HAPE and HACE

A 22-year-old Nepalese porter from the foothills of Nepal was portering for a commercial Swiss trek. Shortly after arrival at Gokyo (4750 m [15,584 feet]), which he had previously visited without problems, he began to feel unwell. As the evening progressed, he developed a headache and went to bed. He awoke in the night with severe dyspnea and orthopnea. By morning his condition had worsened. It is unlikely that the Swiss leader was aware that one of his porters was sick or that the group’s sirdar had paid him off at 250 Nepalese rupees (just over $3) per day and left him to descend alone.

The porter was found collapsed at the side of the trail, about an hour’s walk from Gokyo, semiconscious and vomiting, by Dutch and British trekkers. The British group’s Sherpa guide carried the porter 5 km (3.1 miles) to the Community Action Nepal–International Porter Protection Group Rescue Post at Machermo (4400 m [14,436 feet]), where he was diagnosed as having severe HAPE and HACE. This proved refractory to treatment with oxygen, nifedipine, dexamethasone, tadalafil, and inhaled β₂-agonists, and it was feared that the porter would die. Thanks to the generosity of trekkers staying in the village, who between them donated the $4500 cost of the rescue flight, the porter was flown by helicopter the following day to Khunde Hospital (3800 m [12,467 feet]), where he made a full recovery and was able to leave the hospital unaided 24 hours later.

HACE, High-altitude cerebral edema; HAPE, high-altitude pulmonary edema.

BOX 87-14

Porter Poetry

Life

by Gole Tamang

Today I am on the mountain.

I am carrying a heavy load.

Today the heavy snow has fallen.

My heart is reeling with agony as I see

The clothes and the shoes of foreigners and the guide

And those tattered ones of mine.

Does a porter feel cold less than others do?

Why don’t people treat the porter as a human being?

To whom and where shall I tell my pain?

But, I am helpless.

I follow them carrying load.

The next day as well.

From On a donkey’s back—poetry of the Nepalese mountain porters, Vineland, NJ, 2008, Yileen Press.

The International Porter Protection Group offers the following guidelines for the care of local staff:⁶⁴

1 Clothing appropriate to season and altitude must be provided to porters for protection from cold, rain and snow. This may mean: windproof jacket and trousers, fleece jacket, long johns, suitable footwear (boots in snow), socks, hat, gloves and sunglasses.

2 Above the tree line porters should have a dedicated shelter, either a room in a lodge or a tent (the trekkers’ mess tent is no good as it is not available till late evening), a sleeping mat and a decent blanket or sleeping bag. They should be provided with food and warm drinks, or cooking equipment and fuel.

3 Porters should be provided with life insurance and the same standard of medical care as you would expect for yourself.

4 Porters should not be paid off because of illness/injury without the leader or the trekkers assessing their condition carefully. The person in charge of the porters (sirdar) must let their trek leader or the trekkers know if a sick porter is about to be paid off. Failure to do this has resulted in many deaths. Sick/injured porters should never be sent down alone, but with someone who speaks their language and understands their problem, along with a letter describing their complaint. Sufficient funds should be provided to cover cost of rescue and treatment.

5 No porter should be asked to carry a load that is too heavy for their physical abilities (maximum: 20 kg (44.1 lb) on Kilimanjaro, 25 kg (55.1 lb) in Peru and Pakistan, 30 kg (66.1 lb) in Nepal). Weight limits may need to be adjusted for altitude, trail and weather conditions; experience is needed to make this decision. Child porters should not be employed.

Biomedical Research

There is a long-standing tradition of physiologic and medical research on expeditions, particularly at high altitude, where such work has made a major contribution to understanding cardiorespiratory physiology at sea level as well as at altitude.⁶⁹ It is crucial that any research on human subjects during an expedition meet the same ethical criteria as if it were carried out at home, namely:

• The project must have received ethics approval at the home institution and, wherever possible, from a comparable institution in the country in which the research is to be carried out. This is particularly important if the research involves local populations.

• Informed consent must be obtained from all subjects, who have the right to withdraw from the research at any point.

• The subjects’ rights to confidentiality must be respected and every step taken to ensure that data are collected and stored securely.

Dealing with the Media

Because of the inherent nature of expeditions, serious accidents, injury, and deaths can occur. On such occasions, it may fall to the EMO to talk to the media. This can be a very stressful experience. The manner in which such incidents are reported can have a significant effect on the public’s and the legal profession’s long-term interpretation of events. Box 87-15 gives guidelines on the best ways in which to interact with journalists and reporters.

BOX 87-15 The Media-Savvy Mountain Medic

Journalists want a good story—but this may conflict with your medical responsibilities and ethics. Your job is to lower the temperature, not to add fuel.

• Never speculate, embroider, or blame—your insurers won’t like it and the true cause of an accident or a death may be unexpected. Stick to the medical facts.

• Never name victims—this is a job for embassies and the police. Even if next-of-kin know, they need time to tell other family members and close friends. They should not learn of a serious accident or death via a TV or radio bulletin.

• Never say “no comment”—you’ll sound guilty. Just give a few simple facts to help a journalist. But if you say too little unscrupulous hacks will make it up anyway. Scrupulous reporters will just speculate.

• Always offer appropriate sympathy—it’s only human in the case of death or serious injury but it’s often forgotten. Try not to over-state the case—death is a “tragedy” but calling off an expedition because the entire team has diarrhea is merely “unfortunate” or “careless.”

• Always keep promises to journalists—it’s wise to keep them on-side. Broadcasters, in particular, work to very tight deadlines—so failing to deliver information on time may well attract negative coverage or speculation.

• Always tell the truth—even if you can’t tell the full story. A “quick bleed” is often a good policy if there’s been a mistake—but insurers don’t like it so don’t say too much.

You should always try to prevent a crisis turning into a media disaster and feeding frenzy. And remember, inquests and other court cases can turn on public perception rather than legal argument.

APPENDIX A Recommended Medical Kit

Quantities are for a group of 10 persons on a 6-week high-altitude mountaineering expedition. The list may be useful as a checklist when preparing kits for other types of expeditions.

ANTIMICROBIALS
Ceftriaxone powder for injection	4 g	5 ampules
Chloramphenicol 1% ointment	4 g	3 tubes
Clarithromycin	250 mg	40 tablets
Ciprofloxacin	500 mg	50 tablets
Amoxicillin/clavulanic acid	250/125 mg	84 tablets
Doxycycline	100 mg	80 tablets
Mebendazole	100 mg	20 tablets
Metronidazole	400 mg	100 tablets
Metronidazole suppositories	1 g	10 suppositories
Quinine sulfate	200 mg	50 tablets
Rabies vaccine	1 mL	5 vials
PAINKILLERS, LOCAL ANESTHETICS/SEDATIVES
Aspirin	325 mg	32 tablets
Bupivacaine 0.25% for injection	10 mL	5 vials
Acetaminophen/codeine	30/300 mg	80 tablets
Diclofenac	50 mg	100 tablets
Ibuprofen	400 mg	80 tablets
Ketamine solution for injection		2 vials
Ketorolac solution for injection	30 mg/mL	5 vials
Lidocaine 1% for injection	5 mL	10 ampules
Lidocaine 2% gel	30 mL	2 tubes
Lorazepam solution for injection	2 mg/mL	5 vials
Midazolam solution for injection	1 mg/mL	5 vials
Acetaminophen	500 mg	100 tablets
Tetracaine 0.5% eye drops	15 mL	6 bottles
Tramadol	50 mg	20 tablets
Eszopiclone	7.5 mg	20 tablets
GASTROINTESTINAL
Bisacodyl	5 mg	20 tablets
Antacid tablets		100 tablets
Oral rehydration solution sachets		100 sachets
Loperamide	2 mg	50 capsules
Prochlorperazine	5 mg	56 tablets
Ranitidine	150 mg	60 tablets
Prochlorperazine solution for injection	5 mg/mL	5 vials
Prochlorperazine suppositories	25 mg	10 suppositories
CARDIOVASCULAR
Bisoprolol	2.5 mg	20 tablets
Atropine solution for injection	1 mg/mL	5 vials
Enoxaparin	80 mg/0.8 mL	10 prefilled syringes
Nitroglycerin sublingual spray	400 mcg/spray	1 bottle
RESPIRATORY/ALLERGY
Epinephrine 1 : 1000 solution for injection	1 mL	10 ampules
Beclometasone for inhalation	80 mcg	2 canisters
Chlorphenamine	4 mg	60 tablets
Chlorphenamine solution for injection (UK)	10 mg/mL	5 vials
Diphenhydramine solution for injection (U.S.)	25-50 mg
Hydrocortisone powder for injection	100 mg/2 mL	5 vials
Prednisone	5 mg	100 tablets
Albuterol for inhalation	90 mcg	2 canisters
ALTITUDE
Acetazolamide	250 mg	250 tablets
Dexamethasone	2 mg	40 tablets
Nifedipine	20 mg	20 capsules
Portable altitude chamber		1
OTHER MEDICATIONs
Multivitamins with minerals		500 tablets
Dimenhydrinate	50 mg	40 tablets
CREAMS AND OINTMENTS
Acyclovir cream	2 g	6 tubes
Hemorrhoidal cream		1 tube
Mupirocin cream	15 g	6 tubes
Topical steroid/antibiotic ear drops	10 mL	4 bottles
Clotrimazole cream	20 g	6 tubes
Aqueous cream	50 g	1 tube
Fluconazole	150 mg	4 tablets
Hydrocortisone 1% cream	15 g	6 tubes
Sunblock SPF 25+		4 tubes
DRESSINGS
Adhesive plasters		50 assorted
Alcohol swabs	100	2 boxes
Cotton wool		4 packets
Crepe bandages	7.5 cm	4 units
Dressing No. 15		2 units
Eye dressing No. 16		4 units
Fluorescein eye test strips		10 strips
Gauze swabs	5 × 5 cm	100 swabs
Nonadherent dressing	10 cm²	5 dressings
Nonadherent dressing	5 × 5 cm²	5 dressings
Hypoallergenic tape	2.5 cm	2 rolls
Adhesive strips, assorted		4 packets
Triangular bandages		8 bandages
Petrolatum gauze	10 cm²	10 rolls
Zinc oxide roll plaster		2 rolls
INJECTION EQUIPMENT AND INTRAVENOUS (IV) FLUIDS
2-mL, 5-mL, 10-mL syringes		20 of each
Blue, green, orange needles		20 of each
IV cannulae, 14 gauge, 18 gauge		10 of each
Giving sets		5 units
Normal saline	1 L	6 bottles
Gelofusine	500 mL	8 bottles
Dextrose 5%	500 mL	4 bottles
AIRWAY CARE
Oropharyngeal airways (sizes 2, 3, 4)		2 of each
No. 6 nasopharyngeal airway		2 units
Bag-valve-mask device		1 unit
Minitracheostomy set		1 unit
Endotracheal tubes 7, 9 mm		2 of each
Laryngeal mask airway sizes 3,4		2 of each
Catheter mounts for above		2 units
Laryngoscope		1 unit
Oxygen tubing		1 unit
Oxygen cylinder		1 unit
Handheld suction unit		1 unit
MAJOR TRAUMA
Latex gloves (nonsterile)		100 pair
Tuff cut scissors		1 unit
Chest drain 32 Fr		2 units
Heimlich valve		2 units
Kendrick Traction Device		1 unit
SAM Splint		2 units
Adjustable cervical collar (Stifneck Select)		2 units
Urinary catheter 14 Fr		2 units
Catheter bag and tubing		2 units
Bladder syringe 50 mL		2 units
Nasogastric tube 12 Fr		2 units
Disposable scalpels		2 units
Gloves sterile (medium)		10 pair
Sutures:
2/0 silk straight		4 units
4/0 nonabsorbable suture		5 units
5/0 nonabsorbable suture		5 units
Staples and remover		1 unit
Needle holder		1 unit
Toothed forceps		1 unit
Scissors		1 unit
Spencer Wells forceps		2 units
Tissue glue		5 units
Dental first-aid kit		1 unit
Low-reading thermometer		1 unit
Thermometer (digital)		1 unit
EXAMINATION
Pen flashlight		3 units
Stethoscope		1 unit
Aneroid sphygmomanometer		1 unit
Ophthalmoscope/auriscope		1 unit