Polar Medicine

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Chapter 9 Polar Medicine

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Like much of wilderness medicine, polar medicine’s identity derives to a large extent from its setting. Polar, however, can be defined in several different ways. Geographically, the Arctic and Antarctic circles, at latitudes 66 degrees, 33 minutes north and south, delimit areas in which the sun does not rise or set on at least 1 day of the year. A more functional definition is the 10° isotherm, which joins those areas in which the average temperature in the warmest month of the year is 10° C (50° F); this correlates roughly with the tree line.

For medical purposes, the definition of polar is more complex. Although climate and geography are clearly important, the salient features of polar medicine are logistic and experiential. Unlike high-altitude medicine or hyperbaric medicine, for example, polar medicine is not unified by an underlying pathophysiology. High-altitude medicine is a medical field because of the environment’s effect on the human organism, but polar medicine is largely medical practice within this setting.

Medical practice in isolated settings is paradigmatic of wilderness medicine: the patient population is essentially, if not literally, a small demographic island. A provisional definition of polar medicine, then, could be “the practice of medicine in isolated settings within an extreme cold environment.” It is the cold, remoteness, hostility, and unforgiving nature of the environment in which humans struggle to survive, let alone work, that make medicine in polar areas, and in particular Antarctica, so challenging.66

The Distinction Between Arctic and Antarctic Medicine

Although the polar regions share the predominant attributes of cold, dark, isolation, and severe weather, they display many important contrasts. The Arctic has been described as a frozen sea nearly surrounded by land, whereas Antarctica is a land and ice mass circumscribed by ocean. The moderating effect of the North Polar waters compared with the elevation (2835 m [9301 feet]) of the South Polar plateau accounts for the roughly 40° C (72° F) differences in wintertime low temperatures. On a plot of temperature versus humidity, the polar plateau is more similar to Mars than to the rest of the earth. The flora and fauna are unique to each area. The Arctic has an abundance of land- and sea-based animals as well as migratory birds and plant life. On the other hand, the Antarctic has no permanent land-based animals, although there are migratory birds, as well as a rich marine life and limited plant life.

The differences in population patterns mark an important north–south disjunction in polar studies in general and in polar medicine in particular. The northern polar or frigid areas above 66° latitude comprise a frozen sea that is surrounded by eight countries, each with its unique set of populations and medical care services. The countries of the Arctic are Canada, Finland, Greenland (Denmark), Iceland, Norway, Russia, Sweden, and the United States. Together, they make up approximately 8% of the earth’s surface. Human population is scattered throughout the Arctic, with several relatively large urban areas, but for the most part the Arctic is sparsely populated, totaling less than 1% of the world’s population.124 The overall estimated population of the Arctic as defined by the Antarctic Monitoring and Assessment Programme (AMAP) is approximately 4 million; indigenous peoples make up 10% of that population, and constitute the majority of the total population in Greenland and in sparsely settled areas of northern Alaska and Canada.62,123 Within the Arctic, there are 8 major indigenous peoples and more than 30 minority groups. Some of these peoples have separate governments, languages, and socioeconomic possibilities.

There are no indigenous peoples in Antarctica, which is regulated by the Antarctic Treaty, with 12 original and currently a total of 47 signatory countries.4 This complex treaty helps delineate the relationships of the countries that are active in Antarctica and how the continent is to be best preserved and used for peaceful purposes. Seven countries claim territorial rights.4 Of the 79 stations in Antarctica, 39 are operated year-round.22 The total population living in Antarctica, all seasonal, now exceeds 4400 persons in the summer and well over 1100 in the winter.18

In the Arctic, there are two overlapping but distinct spectra of medical problems—those of indigenous Arctic people and those of visitors and immigrants to the polar region. Many of the medical problems among the Inuit, Sami, Chukchi, Nenet, and other northern groups are those of populations making the often Faustian demographic and cultural transition to a Western industrialized society. Thus medical practice among these groups is similar to that among many other displaced indigenous populations. In a sense, the current illnesses and health risks of the indigenous Arctic populations are the results of contamination from distant sources and too much contact with other cultures.14 In contrast, medical problems in Antarctica among the usually young and fit scientific, commercial, tourist, and expedition support personnel are often related to trauma and the environment and thus fall more appropriately under the purview of travel or expedition medicine. Furthermore, tourist cruise ships often bring older adults, whose complex medical problems can create logistic dilemmas. It makes sense to focus not only on the health of elite visitors to these remote areas but also on the health of the local population and the effects caused by visitors.

Importance of Polar Medicine

Increases in Tourism and Expeditions

The combined geographic polar regions cover about one-sixth of the earth’s surface, and their territory in the imagination has been enlarged by several remarkable expeditions and recent popular magazine articles and books on polar tourism. In the past decade, there has been a veritable explosion of tourist activities in both the Arctic and the Antarctic. Despite or because of the forbidding environment, tourism of various sorts is increasing.77 The Arctic is a trendy destination. An estimated 1.5 million tourists visit the Arctic each year, up from 1 million in the prior decade.122 In 1980, it was estimated that a total of 31,000 paying tourists, adventurers, or guests of national scientific expeditions had ever visited Antarctica, but its increasing lure has led to explosive growth. According to International Association of Antarctica Tour Operators (IAATO) statistics, more than 62,000 tourist, staff, and crew visited Antarctica by air or ship in 2009. Since 1989, tourists have visited approximately 200 sites, including 20 research stations in the Antarctic Peninsula region, the most common site for tourists. About 50 of these sites have received more than 100 visitors in any one season, and about the same number have been visited only once. Most visits are to one of 35 sites. Fewer than 10 sites receive around 10,000 visitors each season. The British Antarctic Survey (BAS) monitors Port Lockroy and maintains an ongoing program on the effects the 10,000 visitors per year have on wildlife and ecology of the area.49 Although the bulk of tourists visit aboard cruise ships, there is an increasing number of overland participants who engage in camping, kayaking, diving, skydiving, mountaineering, Arctic or Antarctic traverses, polar challenges, and adventure tourism.50,77

Concerns about the dramatic increase in tourism and its effect on the ecosystem have led to a movement to limit the total number of tourist visits per year. The World Wildlife Fund and the United Nations have proposed guidelines to developing ecofriendly tourism in the Arctic. The guidelines cover its impact on the environment as well as on local populations. In April 2009 the consultative countries of the Antarctic Treaty endorsed a proposal to limit the size of cruise ships and the number of tourists who can go ashore at any one time and to eventually make it binding to all parties.122

This increasing number of visitors and expeditioners has created interest in polar medicine, in particular as it relates to land-based and extreme expeditions. Wilderness medicine courses specific to polar medicine are now offered. Tourist vessels generally carry a physician and sometimes a nurse. Although facilities vary in level of care, all have preparations for the most frequently encountered medical problems. Most illnesses are upper respiratory infections, gastrointestinal (GI) problems, motion sickness, and mild bruises or strains. As might be expected given the ages of many visitors, an occasional cardiac event or serious fracture occurs. The occasional expeditioner who needs rescue or assistance from a scientific station uses scarce resources.23,77 One peculiar phenomenon is that when patients and medical/rescue/evacuation resources are from different countries, a complex flurry of high-level diplomatic interchange must often occur before help can be rendered.

Perhaps the most notable tourist fatalities were associated with the ill-fated skydiving venture at the South Pole, which resulted in the death of three of the four participants,45 and the Air New Zealand flight that crashed into Mt Erebus with the death of all 257 people aboard.83

Hazards are inherent in any expedition and may well be the attraction for some participants. To be allowed to participate in risky activities, some tourists may fail to declare serious medical problems that later precipitate emergency medical evacuation. Thus one real concern is increased risk taking and the consequences thereof, or the dilemma between what is reasonable and what is foolhardy. From a medical perspective, making a risk assessment is multifactorial and differs for people, places, and goals. Hazards of an evacuation need to be assessed for both the patient and rescuers. Setting guidelines and anticipating needs in pre-event preparation are the keys to successful evacuation.46 Because of the occasional tourist in need of expeditious medical evacuation, IAATO and other governmental groups have suggested requiring insurance to defray the costs associated with these evacuations. There is also discussion of the ethical versus medicolegal implications of whether to render aid. The overriding issue should be care of the patient. Polar Challenges and expeditions are discussed later (see Medical Aspects of Arctic Racing).

Increases in Research Activities

Scientific research has been a part of polar exploration throughout this century. There are scientific and medical journals devoted to the polar regions, and thousands of articles are indexed each year in the Antarctic Bibliography (www.coldregions.org/antinfo.htm). The International Journal of Circumpolar Health (ijch.fi/Issues.htm) is a richer source for health issues in polar regions. Antarctic research continues to expand. All the continent’s permanent stations are primarily there to support research. The biggest study is the IceCube project at the South Pole station, which uses a series of downward-looking detectors spread over a square kilometer to look for traces of the notoriously elusive neutrinos, invisible particles churned out by nuclear reactions. The detectors seek particles that have already passed through the earth. The South Pole also hosts two large telescopes.

Another huge project involving multiple countries is ice core drilling, designed to catalog climate changes of tens of thousands of years. Other scientific endeavors include marine biology and ocean dynamics research; atmospheric and climatologic research, including air cleanliness monitoring and ice sheet movements; medical research (primarily at Japanese and Chinese stations)80; biologic research (ecosystems, penguins, seals, bacteria, lichen); seismic monitoring; aerial and sea floor mapping with unmanned vehicles in the harsh environment; paleontology; meteorite searches; and demonstrations of alternative power in extreme circumstances (e.g., wind generators at New Zealand’s Scott Base).

Some observers have discerned a north–south split, perceiving research in Antarctica as having more of a political motivation and that in the Arctic as being more practical. For both scientific and political reasons, an important part of scientific research in polar regions concerns environmental issues. The remoteness of these regions enhances their value as benchmarks for studies of pollution. Indeed, several worrisome facts have been revealed about the contamination of formerly pristine wilderness, such as widespread radioactive contamination, the prolonged effective half-life of radioactive fallout deposits,115,125 and increased chemical contamination, particularly in animals high on the food chain, with persistent organic compounds, heavy metals, and other contaminants affecting the environment and food supply.68,125 Widening of the ozone hole carries implications of increased ultraviolet (UV) radiation. As occupational and environmental health issues draw more attention, this aspect of polar medicine assumes greater importance.27,28

Brief History of Human Habitation in Polar Regions

A perspective on the contrasts between Arctic and Antarctic medicine may be sharpened by a brief summary of human habitation in polar areas. Humans are known to have inhabited Arctic regions for at least 4500 years. Anthropologists have uncovered evidence for several waves of population migration from Siberia through northern Canada to Greenland. Each of these migrations was probably linked to climatic conditions, and each resulted in a distinct set of cultures. The general pattern was of a nomadic life with population densities of approximately one person per 400 km2 (154.4 square miles).52,118 In more recent times, this long-established and remarkable adaptation to a hostile environment has been disturbed. The pace of cultural change increased dramatically during the second half of the 19th century, when the whaling industry moved into Hudson Bay, leading to sustained contact between Europeans and the Inuit. In the early part of the 20th century, religious missions, trading company posts, government stations, church missions, and eventually medical clinics and schools began to encourage permanent settlements, roughly quadrupling the population density.52 In some areas, such as Eurasia, large industrial and mining cities arose. This change in population distribution has at times led to conflict between indigenous and European cultures, and it has had significant environmental and medical consequences.126

The known history of human exploration of Antarctica, unlike that of the Arctic, is quite recent. Recorded sightings of the continent date only to around 1800, and “winter-over” sojourns did not occur for another century. Waves of settlement can also be observed to have occurred in Antarctica; there was sealing in the early 19th century and whaling in the early 20th, and there has been scientific exploration since the mid-20th century.118 The heroic era of Antarctic exploration occupied the early years of the 20th century, with exploits such as the highly publicized race for the South Pole between Roald Amundsen and Robert Scott in 1911, the extraordinary survival of the crew of the 1914 Endurance expedition, led by Ernest Shackleton,61 and the heroic survival of Douglas Mawson, an Australian geologist who wintered alone after his other expedition members perished.72 Perhaps because of these and other dramatic events, and perhaps because of the absence of an indigenous population and a scarcity of easily exploited resources, human activities in the Antarctic have retained a somewhat more expeditionary flavor than in the Arctic. This has helped shape the contrasts in medical practice between the northern and southern polar regions.

Arctic Medical Problems

Effects of Cultural and Demographic Transition

The Arctic is not a homogeneous region. Although the population is only approximately 4 million, it is very diverse, with few features in common except the latitude of residence and hours of daylight. Medical problems among indigenous populations in the Arctic, approximately 10% of the total population, are characteristic of displaced aboriginal people elsewhere in the world. There is a wide range of interrelated factors, including demographics; the social, economic, and physical environments; personal health practices; and availability of good-quality and culturally appropriate health care services.12,53 Although increased contact with industrialized cultures has brought benefits, it has also brought many problems. Some of the benefits include greatly improved life expectancy, largely due to a decrease in morbidity and mortality from infectious diseases and diseases of childhood (prevented by vaccines). Nevertheless, in indigenous Arctic peoples of the United States, Canada, and Greenland, infant mortality is higher and life expectancy is lower when compared with Arctic dwellers in Nordic countries.98 For many years, health care has lagged behind national norms in the Canadian Arctic, with infant mortality 2 to 3.5 times the national average.113 Age-adjusted death rates are also telling, with 8.4 per 1000 Northern Canadian people, compared with 5.8 per 1000 for the Canadian national average; 14.3 per 1000 in Greenland and up to 29.2 per 1000 in parts of Russia. Other striking statistics reveal a suicide rate in Nunavik six times that of the southern provinces of Canada,60,119 and an unintentional accidental death rate three to four times higher than the national average. Tuberculosis has decreased but is still unacceptably prevalent at 47 versus 7.1 per 100,000 persons. Diabetes mellitus has increased to 5% of the population of 30- to 39-year-olds, compared with 1% in the general Canadian population. In a population in which dental caries were previously almost unknown, the need for restorative dental work is up to 60%. Widely prevalent alcoholism and tobacco use greatly contribute to these problems.10,42,113 As the Arctic environment and indigenous Arctic populations make the cultural and demographic transitions to a Western industrialized way of life, the spectrum of medical problems has shifted. Changing social patterns have resulted in disturbing trends: increasing numbers of young adolescent mothers, rising prevalence of gonorrhea and syphilis among Greenlanders, and concerns about other transmissible diseases, such as viral hepatitis and acquired immunodeficiency syndrome (AIDS).76,130 Changes from the traditional diet and lifestyle have led to increased obesity, diabetes, cardiovascular disease, and mental health problems, including depression, binge drinking, alcoholism, and higher suicide rate.12,113,119

Environmental and Occupational Health Problems

Transboundary pollutants, primarily from Eurasia and the North American continent, have made deep and lasting changes.10 The Arctic, once viewed as pristine, is now considered a pollutant sink. Even so, promising new data reflect that strict environmental control (e.g., bans/restrictions on uses and emissions of persistent organic pollutants [POPs]) is working.123 The nuclear accident at Chernobyl in April 1986 led to cesium-134 and cesium-137 levels in reindeer meat 50 to 100 times those considered safe, forcing destruction of the Sami reindeer herds. During that same time, lake fishing and berry picking were curtailed because of contamination.37,126 Fortunately, research 20 years since this accident demonstrates thriving flora and fauna even in the most contaminated areas, demonstrating a rebounding environment. Nevertheless, the young people exposed to the nuclear accident have shown an impressive increase in thyroid cancers, and those exposed to the highest doses of radiation show an increase in leukemias, solid cancers, and circulatory system diseases.114 Industrial emissions from neighboring regions, including an estimated 100 million tons of sulfur dioxide, have led to the “Arctic haze” phenomenon, a gradual whitening of the historically deep-blue Arctic sky.37

Environmental impacts have had direct health consequences.10,42 During the last 500 years, industrial pollution has led to a sevenfold increase in lead levels in human tissues in the Arctic.37 Another survey found blood mercury levels above the normative limit in over 10% of Sami reindeer herders in northern Finland. In North Greenland, a study revealed that in 84% of human mothers, blood mercury levels were above the World Health Organization provisional limit.39 Oceans, rivers, and lakes reveal contamination and concentration of heavy metals in fish.126 Further contamination of the food chain with long-lasting POPs, including polychlorinated biphenyls (PCBs) and many organic pesticides, is increasingly identified.28,126 Long-term consequences of environmental pollutants on the health of the Arctic dwellers continue to be studied.27,28 Recent work suggests that the endocrine-disrupting effects of PCBs may have changed the normal ratio of male-to-female births from 1.05 to 1.02 in the past 30 years.12 It has been documented that the concentrations of PCBs in breast milk are seven times higher in the Arctic than in Quebec.113 As previously noted, fallout from radioactive testing has caused river pollution, and other environmental degradations have affected the food chain, such that it is estimated that an increase in certain cancers has been noted in both animals and humans.132 Fear of the effect of pollutants has caused many to abandon or significantly limit their consumption of traditional foods (e.g., marine mammals, fish, terrestrial mammals, and birds). Unfortunately, this can have negative nutritional effects, such as obesity, diabetes, and increased cardiovascular disease, and in some instances relative malnutrition.38 Tragically, POPs, even in low concentrations, have been shown to cause increased risk for diabetes, so both consumption of traditional foods and changes in diet to processed foods have contributed to the increased rate of diabetes in these regions.123 In some areas, consumption of traditional marine foods has led to blood levels of mercury exceeding current recommendations. Local health departments have to weigh overall nutritional benefits of traditional land and marine food sources against the potential long-term risks of neuropsychological and other potential health problems, particularly in newborns and infants.68 Fortunately, new trends show human exposure to pollutants in the Arctic is decreasing. For example, the number of Arctic childbearing-age women with excessive levels of PCBs, mercury, and lead is decreasing. This is believed to be due to dietary changes and increased awareness of the problem. However, new research is demonstrating many additional chemicals, some newly developed, that have the potential to collect in the Arctic food chain, so ongoing research, identification of these chemicals, and regulation of them are essential to continue improving the health of indigenous peoples.123

Nontoxicologic factors also make important contributions to Arctic morbidity and mortality. Accidents are more prevalent in the Arctic. In younger (up to age 35) Inuit groups, injuries account for approximately one-third of all deaths.15 It is striking that Alaska’s occupational death rate is three to four times that of the U.S. national average deaths per 100,000 workers, but this is markedly improved from five times the national average in the 1990s.85 With establishment of the Alaska surveillance system in 1991, there has been a 50% reduction in work-related deaths, including a significant reduction in commercial fishing deaths and very sharp decline in helicopter logging–related deaths.21 These data reflect in part the inherently hazardous working conditions and occupations and possible demographic biases of a young population. Other factors, however, may play a role. Because aircraft are a predominant mode of transportation in polar regions, it is not surprising that Alaska accounted for greater than one-third of all air crashes in the United States and 20% of the fatalities from 1990 to 2008.84 Nonscheduled or commuter plane (less than 30 seats) flights, commonly used in isolated areas, pose a risk for fatal crash six times that of scheduled airline flights, a figure not surprising given the often extremely challenging flying conditions (terrain, weather, and isolated landing sites with limited navigational aids and operator error). In recent years, the pilot occupational fatality rate has fallen from 298 to 148 per 100,000 (less than twice the rate for all U.S. pilots), felt to be due largely to increased awareness and proactive intervention in the industry.84 Overall, the mortality rate for Alaska natives is 939 per 100,000 per year as compared with the overall U.S. rate of 698.9 per 100,000 per year.123

Psychosocial Health Problems

With social disruption and increased environmental and occupational health risks, psychological problems in the Arctic have achieved greater visibility in recent years. For a variety of reasons, stress seems to be higher in winter. One survey of over 7000 adults living north of the Arctic Circle found a prevalence of midwinter mental distress of 14% in men and 19% in women.40 Most other studies suggest that this figure may be low. One study among Inuit found that 22%, or one in five, experience depression during the winter months, and 7% appeared to have seasonal affective disorder (SAD).36 Cultural stress, erosion of traditional lifestyles, and substance abuse are all contributory factors.12 Studies investigating scientific staff at Arctic research stations are relatively uncommon, but they show patterns of sleep disturbances, depression, and alcohol use reminiscent of those in Antarctic stations. The double apparent risk factors of high latitude and displaced indigenous populations have made alcohol abuse and concomitant violence a serious problem in the Arctic. In Greenland, one in three Inuit dies a violent death, and roughly 25,000 adults consume 28 million cans of beer a year, one of the highest per capita consumptions of alcohol in the world. Prevalence of “binge drinking” among Arctic peoples ranges from 12% to 39%, with male rates being greater than female rates. Fetal alcohol syndrome is 13% higher in Alaska than in the continental United States.12 One study compared alcohol consumption by the Greenland Inuit with nonindigenous local inhabitants and found that alcohol consumption was less among the Inuit. However, other studies found the reverse.60 Accidents are the leading cause of death in the Arctic, and one-third of these are estimated to be alcohol related. In the Canadian Arctic, alcohol consumption is one and a half times the national average, and Inuit and Indians between 15 and 24 years of age have a suicide rate up to 11 times the national average. In some communities, for boys and men ages 15 to 29, suicides are the most common form of injury leading to death.60,82

Current and Future Trends

In summary, indigenous populations of the Arctic show lower life expectancy, higher rates of infectious diseases, higher infant mortality, and higher rates of injuries and suicides when compared with norms in their respective countries.123 Fortunately, there are encouraging signs related to Arctic health care. The incidence of low birth weight, 5.5% in the central Canadian Arctic, has decreased, although it is still higher than that among non-Arctic dwellers.12 Tuberculosis, which incapacitated up to 20% of the Canadian Inuit by 1950, has largely been brought under control, although the rate of occurrence is still as much as 10 times the national average.15 Trends in environmental and occupational health problems show increased monitoring, intervention, and improvement. Unfortunately, the age-adjusted incidence of diabetes mellitus is dramatically rising among First Nations populations.25

An important development in recent years has been the institution of trauma registries to track and target significant causes of morbidity and mortality. Recent research emphasizes that injury prevention is not solely a function of safer design of equipment but is a complex interplay of environment, activity, and people, notably including personal risk-taking behavior. If current trends continue toward greater economic independence and education of Arctic peoples, such potentially modifiable adverse health behaviors may recede in importance in coming years.58,59

Antarctic Medical Practice

Medical practice, problems, and their study in the Antarctic are somewhat different from those in the Arctic. Extreme isolation makes Antarctic medicine unique. Because of the remoteness, it may not be possible to medically evacuate (medevac) a patient for weeks or even months. It might be easier to medevac from the international space station than from some of the more remote Antarctic stations.35 In general, the population is adult and is physically and mentally healthy, although at least the U.S. Antarctic Program grants health waivers to some individuals with certain chronic diseases so that they can visit or work for a limited time. Winter-over personnel, including those spending a year or more at a time in Antarctica, are required to pass medical screening that varies in intensity with the various national programs. Most stations only house adults. There are two exceptions: Chile and Argentina have families living at their principal bases and have even had children born on them. All stations have some form of medical care, usually a station physician. The more temporary camps have varied medical support, ranging from first-aid wilderness responders to paramedics or midlevel providers with limited medical supplies. In general, the permanent year-round bases have more sophisticated facilities, with radiograph, laboratory, surgical, and dental provisions and a reasonably well-stocked pharmacy for expected emergencies. There is at least one physician and sometimes nurses and ancillary medical personnel.

Medical Stations in Antarctica

Medical facilities in the Antarctic polar regions can be conveniently divided into permanent and expeditionary facilities. As a result of community expectations and long-term commitment to research in Antarctica, a notable shift from an expeditionary to an operational attitude has occurred in many of the Antarctic programs.

What type of physician is needed? To paraphrase Grant, the physician cannot be too specialized in approach; broad knowledge and a wide range of practical skills are necessary to provide good Antarctic medical care.35 Specialization in emergency medicine or the equivalent seems to be a suitable choice, especially to deal with emergencies. In nearly all bases, there is no room for the luxury of anesthetists and surgeons, dermatologists, and psychiatrists. These roles reside within the same person. However, modern communication, including video teleconferencing (VTC), help the polar physician be less isolated from advice, counsel, and guidance. For a significant proportion of the Antarctic population, it is still extremely difficult and costly to evacuate patients.35

The following is a description of the personnel and facilities in the U.S. Antarctic Program; other nations maintain similar facilities. McMurdo Station (MCM) has the largest population—around 200 in the winter and 1200 in the summer. Whereas the winter MCM and South Pole populations are isolated, their summer populations constantly have an influx of rotating personnel that bring new diseases. In the summer season, the medical component is staffed with two physicians, a physician’s assistant or nurse practitioner, an Air Force flight surgeon, a dentist, a radiograph technician, a laboratory technician, and a physical therapist. In the winter, the staff is composed of one physician, a physician’s assistant, and a physical therapist. All are cross trained on site. (Other large national stations provide necessary additional training in advance.) In addition, MCM has a full fire department with paramedics who respond to emergencies on station. The South Pole population peaks at 250-plus in summers and reaches a nadir of around 50 in the winter. There is one physician, a physician’s assistant or nurse practitioner, and a volunteer trauma team trained on station. Palmer Station is the smallest, with a population of 45 in the summer and a low of 10 to 20 persons in the winter. There is one physician, and volunteers are trained on site to provide assistance. How well these volunteers can function was demonstrated in 2009 when the station’s physician developed a peritonsillar abscess. She had one of the station emergency medical technicians needle drain and then incise it under topical and local anesthesia. She then used VTC and an intraoral camera to consult with an otolaryngologist based in the United States. She improved within a few days.26

The Australian stations have one physician. Before deployment, there is a 2-week training course for two of the crew in operating-theater nursing skills and for two persons in anesthesia assisting. The predeployment training has proved very valuable, as was clearly demonstrated in the case of a scientist who fell into a crevasse and suffered serious injuries, including internal bleeding, that required on-site surgery (Figure 9-1).102

All permanent U.S. medical facilities have digital radiograph and ultrasound capabilities, laboratory equipment for blood chemistries and cardiac enzymes, and the capability to perform immunologic testing for β-hemolytic Streptococcus, infectious mononucleosis, and influenza A, as well as common resuscitative equipment, including Life Pak 12 and Zoll monitor/defibrillators, portable ventilators, and crash carts similar to those in most emergency departments.

The pharmacies are well stocked and cover a broad range of potential medical problems. There is no blood storage, but in the event of significant bleeding, a “walking blood bank” (walk-in donor system) is activated. To facilitate this process, all winter-over and most summer personnel are blood typed and screened for hepatitis B, C, and human immunodeficiency virus (HIV). After a series of acute cholelithiasis cases, South Pole winter-over personnel are now screened with ultrasound for gallbladder disease. The Australian physician undergoes prophylactic appendectomy. Otherwise, the experience has been that early antibiotic therapy can abort an acute appendicitis attack, allowing the appendix to be removed electively at a later time.

The South Pole does not have 24-hour satellite coverage, but year-round stations have facilities for telemedicine, including live camera, still photos, fax, and digital radiography for transmission and consultation via satellite and the Internet. VTC, used for many years in Antarctica by multiple programs,35 came of age at the South Pole in 2002 with a midwinter repair of a patellar tendon rupture. The tendon was surgically reattached by the base physician under the direction of consultants at major medical centers via live video and voice connection. Various physicians at Antarctic stations are also able to consult with colleagues via VTC, such as with the South Pole medical staff’s successful management of a severely hypotensive tourist in 2009 with VTC input from MCM clinicians. In addition, telemedicine has been used for diagnosis and consultation in the treatment of a wide variety of ailments, including acute cholecystitis, ophthalmologic lesions, pancreatitis, pericarditis, fracture treatment, psychological consultations, radiologic reports, and many other situations. Telemedicine has improved the quality and availability of sophisticated care in these and other remote, hostile environments.

Medevacs are frequently dangerous and costly. Summer is the only season during which some stations can be reached for an evacuation. Winter evacuations are infrequent, very dangerous, and costly. Logistically it may be 2 or more weeks before a rescue can take place, and for some stations it may not even be possible. A historic medical evacuation from the South Pole was undertaken in the winter of 2001 with the first successful landing of a twin Otter aircraft in full darkness at a temperature of −68.9° C (−92° F) (Figure 9-2). This event, while fraught with danger, has opened new possibilities and has been repeated.16,19

To further increase the ability to provide medical assistance, even during the winter months, the U.S. Air Force recently proved their capability of landing C-17 aircraft at MCM using night-vision goggles and made successful air drops of critical equipment at the South Pole. Certainly, though, prevention through careful screening of candidates and increased use of telemedicine as a way to avoid medevacs still remains the ultimate goal.

To reduce the number of medical crises and need for urgent medical evacuations, all participants must pass a “physical qualification test.” Medical clearance criteria are used as a screening tool. To establish appropriate guidelines, evidence-based criteria from the medical literature, historical data of the Antarctic Program, and guidelines from other programs, such as the National Aeronautics and Space Administration (NASA), the Peace Corps, and the Navy, that have activities in remote areas were used. What appears to be lacking is screening for body mass index and alcoholism. However, up to 30% of all medical evacuations (both emergent and urgent) have been for trauma—that is, they were not related to the evaluation criteria. Of emergent and urgent evacuations, 10% were for GI and 8% for cardiovascular reasons (Figure 9-3). Considering only truly emergent medical evacuations, 28% were for cardiovascular and 28% were for GI reasons (Table 9-1). Figure 9-4, online is a chart showing the number of medevacs from MCM and the South Pole station.

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FIGURE 9-3 Evacuations for medical reasons, with percentages of 5-year totals (1998-2003).

(From Mahar H [Safety and Health Officer, OPP/NSF]: Medical clearance criteria: Revalidation study. Personal communication, 2003.)

Somatic Health Problems

Many of the primarily somatic health problems in Antarctica have to do with cold, altitude, and trauma and are thoroughly covered in the chapters on those topics. In a midwinter setting where a tossed mug of coffee freezes before the liquid hits the ground, the dangers of frostbite are clear. Anyone gasping for breath after climbing the six flights of stairs with 92 steps from the tunnel to the living area of the South Pole’s elevated station, or who has lost 5 kg (11 lb) in the first 2 weeks merely from resting tachycardia and tachypnea, can appreciate the physiologic stresses of rapid ascent to an equivalent of 3200 m (10,499 feet). Likewise, the dangers of UV exposure at altitude with an ozone hole and snow surface reflectance of 80% to 90% can become painfully evident to the unwary visitor.20,112

Cold-Related Problems

Cold is a dominant factor in polar medicine. It can be a source of humor, such as the infamous “300 Degree Club” at the South Pole. Membership requires sprinting, while somewhat less than completely clothed, from a 93.3° C (200° F) sauna to the Pole outside at an ambient temperature of −73.3° C (−100° F) or lower. Similarly, the quintessential polar first-aid story involves creative solutions to the problem of finding warm fluids,2 but it would be reckless to forget the ever-present danger of such a hostile environment. Windchill commonly drops the effective temperature far below −73° C (−100° F). It has been estimated that under the most severe winter conditions, an inactive person in full polar clothing could undergo a life-threatening drop in core temperature in only 20 minutes. Airplane refueling crews and others working with liquids at polar ambient temperatures are constantly reminded that even a small splash can mean instant frostbite.31

Rescue and treatment are complicated by the additional need for both victim and rescuer to avoid hypothermia and frostbite.52,54

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