Buy the Expedition and Wilderness Medicine Book online!

Expedition and Wilderness Medicine handbook

Visit the Expedition and Medicine website now and you will be able to purchased one most of the most comprehensively written handbooks compiled specifically with medical professionals in mind.

Available as a down-loadable PDF for £15 where no trees were harmed in its production or as hard copy for £18 including post and packaging– this A5 size booked by Drs, Sean Hudson and Caroline Knox, featuring the expedition photography of Mark Hannaford and written with the support of Across the Divide Expeditions is sure to be an instant best sellers … well at least in the circles we move in!

BUY IT NOW!!

About the authors

Dr Sean Hudson MSc MBBS is a Fellow of the Royal Geographical Society and on the expeditionary advisory board for Summit. Sean has been involved in a wide variety of expeditions over the last 20 years. During this time he has trekked across the Darien Gap and the Thar Desert; worked as a trekking guide and Chief Medic for Raleigh International in Namibia and Zimbabwe; a trauma medic in Columbia;

A Case of Splenic Infarction at High altitude in Sickle Cell Trait by Dr Alison Cook

 

 

A Case of  Splenic Infarction at High altitude in Sickle Cell Trait

About the author – Dr Alison Cook is a G.P. with a keen interest in expeditions and the medical issues in remote locations.  She has attended the Expedition and Wilderness Medicine course in Keswick and has worked as an expedition medic for Across the Divide Expeditions in locations diverse as Namibia and Peru.  Alison has also worked with Medecins Sans Frontieres (MSF)  in Niger.

In March 2007 an ATD client with undiagnosed sickle cell trait (SCT) suffered a splenic infarction on a high altitude expedition.  Although the phenomenon of splenic infarction in SCT at high altitude is well documented, it is a relatively rare event and therefore a worthwhile case to share amongst expedition medics.

Medicine in the Himalayas – Dr Kirstie Nicol

Working for the Himalayan Rescue Association in Nepal

About the writer.  Dr Kirstie Nichol is a G.P. with a keen interest in expeditions and the medical issues or remote locations.   She has attended the Expedition and Wilderness Medicine course in Keswick and the Polar Medicine training course in Alta, Northern Norway and worked as an expedition medic for Across the Divide Expeditions in locations as diverse as Kilimanjaro and Peru.

In 2007 I left ‘normal’ working life as a GP in Haddington behind for a while to work for the Himalayan Rescue Association in a high altitude clinic in Nepal.

The HRA is a Nepalese voluntary non-profit organisation formed in 1973 with an objective to reduce casualties in the Nepal Himalayas, especially in view of the increasing number of Nepalese and foreigners who trek up into the remote wilderness. Nepal alone now receives more than one hundred thousand trekkers from around the world every year. It can be easy to under-estimate the dangers of altitude illness; deaths from these conditions are all the more tragic because they are entirely preventable. Working at the clinic involves a mix of primary health care for local people including home visits, providing an emergency medical service for trekkers and the provision of daily lectures for trekkers emphasising the prevention, recognition and treatment of altitude illnesses. Because rescue is difficult in Nepal, prevention is a key part of the role.

Expedition and Wilderness Medicine Course Feedback

We’ve just received some excellent feedback from one of our previous UK course delegates,

“Since attending the Keswick course in 2006 I have accompanied four charity treks as medical officer with different companies.The course has proved invaluable and I can strongly recommend the training provided by Expedition Medicine to anyone wishing to act as a medical officer”

Have a look at the Expedition & Wilderness Medicine website for further information, www.expeditionmedicine.co.uk

What to put in your expedition medical Kit

  

Expedition Medical kits, everything but the Kitchen Sink by Dr Sean Hudson

Probably the most common question I’m asked as an expedition medic is ‘What shall I put in my medical kit?’  The question is very hard to answer and would receive a different answer from probably every doctor involved in remote medicine. It is dependent on skills, experience, environment, preferences, and purpose of expedition.

There are several items, which I always carry in my pocket if I’m working on an expedition in a wildnerness area:

· Roll of zinc oxide tape- covering blisters, taping injuries and dressings
· Ibuprofen- simple analgesia, especially useful for musculoskeletal injuries
· Imodium- To control the problem of gastroenteritis whilst participating in essential activities
· Tincture of iodine- used to purify water and antiseptic for wounds
· Gauze dressing- Simple dressings
· Compeed or similar dressing- adds padding to nasty blisters

The rest of the kit really depends on your experience and distance from help. I normally would break the kit down into:

· Analgesia
· Fracture Management
· Antibiotics
· Lotions and potions
· Dressings and Wound Closure
· Medical Emergencies
· IV Access and fluids
· Specialist Equipment (depends on environment)

· Analgesia is going to differ relative to your country of origin. As a doctor I would always take Morphine, IM Voltarol, Rectal Voltarol, Co-codamol, Paracetamol.

There are a variety of ways of immobilizing a fracture, the simplest being ingenuity, some zinc oxide tape or clingfilm. Otherwise Sam Splints are very versatile and a Kendrick Traction Device is lightweight and fantastic for lower limb fractures.

You want antibiotics to cover as wide a variety of infections as possible from dental abscess to travellers diarrhoea. I normally take Co-Amoxiclav, Ciprofloxacin, Metronidazole, and Flucloxacillin. Remember always be aware of sensitivities to antibiotics.

Irritating skin conditions are common on expedition especially in tropical regions, consider taking an antifungal, an antihistamine, a steroid and an antibiotic, Clotrimazole, Anthisan, 1% Hydrocortisone, and Fucidin and an Antiseptic spray or liquid.

Simple dressings possibly impregnated with betadine are useful, together with some dry dressings and crepe bandages. Wounds can be closed with steristrips, sutures, staples or even superglue. Some training is essential.

I always carry a Salbutamol Inhaler, and treatment for anaphylaxis, Adrenaline, Piriton and Hydrocortisone. IV Fluids, Giving Sets and Venflons and an assortment of Syringes and Needles.

Extra equipment is often needed for different environments.

· Altitude Expeditions are most likely to see AMS, HACE and HAPE, so the training and medication to look these conditions is imperative. Dexamethasone, Nifedipine, Acetazolamide, Oxygen and a Hyperbaric Chamber, Increasingly other medications are being trialled with some success.

· In polar environments portable devices for rewarming hypothermic patients are useful, The HEATPAC is light and easy to use.

Lightweight stretchers are useful, they can be improvised from rope but some ski stretchers are invaluable whilst backcountry skiing

As you can see there is no easy answer to this question. You may choose to take a 25kg rucksack full of equipment, or it may fit into a camera case. Look at the common conditions, endemic diseases, common injuries and logistical and medical support and adapt your medical kit to fit the occasion, and don’t ask too many doctors otherwise you’ll end up taking the kitchen sink.

Specialist equipement can be hired from Expedition and Wilderness Medicine, see their remote media support page.

About the author
Dr. Sean Hudson is a Fellow of the Royal Geographical Society and on the expeditionary advisory board for Summit. Sean has been involved in a wide array of expeditions over the last 18 years. During this time he has trekked across the Darien Gap, The Thar Desert, worked as a trekking guide and Chief Medic for Raleigh International in Namibia and Zimbabwe, a trauma medic in Columbia and ski field doctor in New Zealand. Since 1998 he has worked for Across the Divide Expeditions as medic and expedition medicine advisor, providing medical cover on expeditions in 21 different countries. Dogsledding to Desert trekking in Namibia. In 2002, he and his wife, expedition medic Dr. Caroline Knox, helped to established Expedition and Wilderness Medicine, which seeks to provide comprehensive training for medical professionals working as expedition medical officers in a variety extreme and remote environments.

Hiring Kit from Expedition and Wilderness Medicine

If you are about to head off as a medic on expedition or a tv company off to film on location and you need advice on your medical kit or need to hire some equipment, then why not let us know and we can help you with for all your medical needs.   See our support page here.

 

‘I found myself in the position of accepting an invite to be an expedition doctor without having had much prior experience. Whilst I’d done a number of treks, I’d never officially been the expedition doctor and was very much ‘wet behind the ears’. Although it was too late to book onto the Expedition Medicine course, I contacted Dr Sean Hudson for advice on a number of issues and his help and input was invaluable. He always responded quickly to my email/telephone requests and went out of his way to assist me, even offering to make himself available for advice when I was away. I also felt the Expedition Medicine handbook more than any other, gave me a solid foundation of the expectations and demands of being an expedition doctor. It gave me a framework of how to plan my kit, evacuation protocols and on how to structure my days on-trek.’

‘So I finally made it back – as did the other 60 trek members – thankfully in one piece with no major dramas. Although I was kept busy, the experience was unforgettable and has certainly whetted my appetite for more.

Many thanks again to the Expedition Medicine team, and to Sean for his generous support, for helping to give me the confidence to make this possible. ‘

Dr Mike Steven

How do I use a hyperbaric chamber? What are the alternatives?

Hyperbaric Chamber

The concept behind the 3 main portable hyperbaric chambers is they effect a physiological descent by inflating the air impermeable bags above ambient atmospheric pressure. The extent of the descent is dependent on the altitude at which the bag is used and the pressure to which they can be pumped. The patient is placed in the bag lying down (which can be claustrophobic), there is a window for the patient to look through, the fabric of the bag is thick but a conversation can be undertaken. If the patient has difficulty lying flat put the bag on a slope.

Oxygen can be placed inside the bag with the patient. It is worth ensuring the patient has something comfortable to lie on and has a sleeping bag if they get cold. Conversely if its day time the bag needs to be in the shade to avoid ‘boil in a bag’. The bag is zipped up and the bag inflated slowly using a foot pump until the pop-off valve hisses (at around 2 psi). The pressure then has to be maintained by continuing to pump but at a slower rate.

The patient is normally kept in the bag for about an hour, as long as they remain stable in the bag. As pressure increases, the patient needs to be warned to equalise if they are able. It may be worth giving the patient a bag to vomit in if required. Occasionally the zips burst, leading to rapid depressurization and the risk of barotrauma. When reducing the pressure to get the patient out do it slowly, the zip can normally be opened slowly when the side of the bag dimples on pressure.

What are the advantages and disadvantages of this piece of equipment? 

Advantages: Lightweight well tested, robust. All the equipment weighs aproximately 7kg. Fast to use, inexpensive in comparison to the others. 

Disadvantages: Still costs £1500 or so, the zip can breakdown and is the weak point. No carrying handles if you wanted to physiologically and geographically descend simultaneously. 

Who makes hyperbaric chambers?
The Gamow bag is the oldest design. The other bags are the PAC and the Certec. Both as good and lighter.  The Certec uses a different pumping system, which can be tiring. 

Gamow Bag.   The Gamow does not have handles but can be carried on a stretcher if absolutely necessary.   You can read more about Gammow Bags and their inventor, Igor Gamow, scientist, classicist, professor, adventurer, at web.mit.edu/invent. Gamow is the son of the famed physicist George Gamow, a co-author of the Big Bang Theory and the first to propose the genetic code. 

Where can I hire a Gamow Bag?
They can be hired from Expedition and Wilderness Medicine see our Media Support Page for more details.

More About CERTEC Bags.   The present CERTEC hyperbaric chamber is an improved version of a hyperbaric chamber that was originally designed in 1989 by a French and German team.

The color of the new CERTEC hyperbaric chamber is not orange but yellow and blue.

Its design is different from all other pressure bags (Gamow, PAC, etc.) since it is comprised of two bags in one:

An outside envelope made of very strong material (to withstand tension) and good friction (for stability on any surface) , an inside envelope made of polyurethane (for airtightness) 

Advantages of this double envelope design are: 
it is rugged and durable
good protection of the airtight inner envelope 

All air valve systems are doubled for security:
two inflation valves
two automatically opening preset valves (220 mB) 

A very large window allows contact with the person in the bag.

Two full length zippers (inside and outside bags) allow easy in- and egress.

The inflation pressure is 220 mB, corresponding to a virtual descent of about 2500 m (depending on the actual altitude).

Total weight of the CERTEC Hyperbaric Chamber is 4,8 kg (carry bag and pump included).

It comes with a very efficient double effect pump (i.e. that pumps during up and downstroke) has a volume displacement of 3,7 liters for each pump cycle.

Only 4 pump cycles per minute are necessary to keep the CO2 in the bag at acceptable levels.

The price of the CERTEC Hyperbaric Chamber is $2300. It can also be rented. 

Advantages: Higher pressures, though it isn’t known how clinically important/useful this is. The bag is lighter than the Gamow. The double-wall system should provide more durability.

Disadvantages: Similar to the Gamow bag, the Certec is expensive, around $2300. I have not seen the newer Certec bag, and my comments are based on the older orange model. I found the (old) pump to be quite difficult to use as it required bending over at the waist (see photo at top of page); it was very fatiguing. As in the Gamow® Bag, fresh air must be regularly pumped into the bag to prevent CO2 buildup.

More about The PAC® (Portable Altitude Chamber)
Dr. Jim Duff, an experienced climber and expedition physician, has developed a nice alternative to the Gamow® and Certec® bags. The PAC (a coated fabric bag) is about the same size and weight as the Gamow, but more of a mummy shape, so there is more room around the head and shoulders. It also develops a 2 psi pressure, equivalent to the Gamow bag. The PAC is much cheaper than the Gamow bag and is probably the most sturdiest of the three hyperbaric bags on the market.

The main design difference, however, is in the radial zipper at the head end. This opens the whole head end and makes access far easier than either the Gamow or Certec bags. This is especially important with large and/or comatose patients (ask anyone who has tried to stuff such a patient into the Gamow bag!). There is no pressure gauge, instead there is a clear pocket on the inside of the window, so you can insert an altimeter and watch it from outside. 

The external, dangling pressure gauge on the Gamow Bag is vulnerable to wear/damage and subsequent leakage, something avoided in the Certec by having the pressure gauge set flush into the bag. I should note that the presence or absence of a gauge does not affect treatment; the pressure gauge or altimeter is merely a reassurance that the equipment is functional, something that is easy to ascertain in straightforward ways, ie, the bag inflates and the pop-off pressure control valves hiss. 

Note that with the PAC the maximum pressure is limited by the pop-off valves to 2 psi, but you can adjust the valves to a lower pressure to accomodate patients who have trouble clearing their ears. Instructions for using the PAC are printed right on the side of the bag, as is a table showing the equivalent descent at various altitudes, a nice touch. This bag has recently been used in the HRA Pheriche clinic and seems to be durable.

Advantages: The shorter zipper and simplicity of design has resulted in a bag that is far cheaper than the other available alternatives: US$1,200 including delivery almost anywhere in the world. The end-opening design is a major advance in terms of ease of getting patients in and out

Disadvantages: No significant disadvantages.

Web Resources
High Altitude Medicine Guide
Gamov’s entry in Wikipedia
Climbing High
Interview with Igor Gamow
PAC Technology

About the author
Dr. Sean Hudson is a Fellow of the Royal Geographical Society and on the expeditionary advisory board for Summit. Sean has been involved in a wide array of expeditions over the last 18 years. During this time he has trekked across the Darien Gap, The Thar Desert, worked as a trekking guide and Chief Medic for Raleigh International in Namibia and Zimbabwe, a trauma medic in Columbia and ski field doctor in New Zealand. Since 1998 he has worked for Across the Divide Expeditions as medic and expedition medicine advisor, providing medical cover on expeditions in 21 different countries. Dogsledding to Desert trekking in Namibia. In 2002, he and his wife, expedition medic Dr. Caroline Knox, helped to established Expedition and Wilderness Medicine, which seeks to provide comprehensive training for medical professionals working as expedition medical officers in a variety extreme and remote environments.

Dr Amy Hughes writes about the EMDM

………PART 1 by Dr Amy Hughes

European Masters in Disaster Medicine – at first glance the NHS may spring to mind, especially for those who have been unfortunate enough to be entwined in the MMC debacle over the last year. However, not so, this is in-fact a superb, year long European Masters covering all aspects of disasters – epidemiology, preparation, management and prevention – whether they be human generated (terrorist attacks, chemical, biological, transport), natural (earthquakes, floods, tsunamis), mass casualty incidents or complex humanitarian emergencies; the aim being to enhance disaster education, train individuals in medical preparedness and management of disasters, improve research globally and ultimately merge together individuals internationally who share a common passion for the speciality.

Organised by the Universita’ del Piemonte Orientale, Italy and the Free University Brussels, Belgium, and supported internationally by the World Health Organization (WHO), International Committee of the Red Cross (ICRC), the European Academy of Disaster Medicine (EURADIM) and the European Society for Emergency Medicine (EuSEM), the EMDM is led by very distinguished and experienced professionals, many professors in Emergency Medicine, Anaesthetics or Intensive Care, all of whom have dedicated their time, both academically and practically, to increasing the awareness of and education in disaster medicine.

Having access to the internet is a must for successful completion of the Masters as it is structured as an online self-directed learning tool – modules are uploaded every two to three weeks depending on module length and the number of assessments requiring completion (MCQs and short answer). Topics include epidemiology of disasters, research methods, logistics, ethics, mass casualty management, public health, injury types and complex humanitarian operations. During completion of the modules there is constant liaison via email and a forum page to the professors, to your mentor (allocated in week one) and, most importantly, between the thirty other international students completing the Masters generating debates and discussions.

Towards the end of May, and following completion of eight modules, a residential course in Italy is organised where international students and tutors meet for an intensive, didactic interactive two week course encompassing mass casualty simulation exercises, discussion forums, scenarios, lectures and – for successful completion of the EMDM – planning and initiation of a thesis.

Five weeks in and three completed modules later – the latter finished in between Vin Chauds and snow plough turns in the French Alps and a week of ICU nights – I find it hard to fault the EMDM. The modules, although long and intensive, are varied, thought engaging, relevant and constructive. There is no lack of support and plenty of discussion and debate amongst all participants – whom combined have a wealth of experience. As a chance to be educated in a field of increasing prevalence and relevance by enthusiastic, inspiring and driven professionals, it would seem a shame not to embark on such an opportunity. As for any chance of a social life outside of work……that’s the one sacrifice…………

To be continued….

For further information: www.dismedmaster.com 

Mountain Medicine Course

Most of the UK Expedition and Wilderness Medicine Faculty has a background in Mountain Medicine, and like many British expedition medics most of us started climbing in the Alps before moving to the bigger mountains in Nepal. Following the same theme as our other extreme environment courses, the main thrust of the mountain medicine course is to introduce medics to the practical elements of working and providing medical cover in the mountains.

The instructors aim to familiarise the team with the fundamental skills which are essential to treat and evacuate casualties in the mountains as well as covering the common conditions encountered at altitude. Where else could we run this course but in Nepal. In order to experience winter conditions in the mountains the course will be run in the beautiful amphitheatre and ridges of Annapurna with the sacred mountain of Machapuchere as a backdrop. At this time of year the snow cover is low and the team will be able to train and experience the environment without undue exposure to high altitude.

Expedition and Wilderness Medicine is now a unique provider of medical courses in extreme environments and continues to attract fantastic staff and lecturers from around the world.  It’s advisable to put your name down now for this course as we envisage it to be a popular one!  Email Luci at admin@expeditionmedicine.co.uk

‘The faculty in Nepal will be very exciting and experienced. Can’t divulge any names yet but no one will be disappointed’. 

A participant’s write up – Polar Medicine Training Course February 2008

The setting for this year’s polar medicine training course was Alta, a small settlement, 72 degrees north and well within the arctic circle. A place with a deserted high street where you would be lucky to see one other passer by every 15 minutes, easily explained by a temperature at least ten degrees below freezing and a good foot of snow on the ground.

Base camp was a 40 km drive along icy roads to a picturesque mountain lodge by the name of Ongajoksetra. At the higher altitude the temperature was that much lower and if a wind was blowing, temperatures as low as minus fifty could be achieved. We were introduced to the Scandinavian team who would teach us methods of navigation across such tough terrain in harsh conditions and also to the Expedition Medicine team who would teach us polar medicine in a series of lectures and practical sessions both in the classroom and in the field. One more group I must not forget to mention is the team of fifty sled dogs who would provide another mode of transport across the snow.

My first day involved skidooing up a mountain demonstrating the importance of protective clothing, navigation aids and preparation for travel in severe blizzards with visibility of approximately two metres, sudden drops in temperature and rapid weather changes. I realised that without our trustworthy guide, Espen Ottem, we could become hopelessly lost in such conditions where you would be unable to survive more than a couple of hours at most. Our dog sledding guide, Pre-Thore was the perfect example of this as he told us of the time where inadequate preparation resulted in frostbite, blackening of his fingertips but fortunately no amputation. This story made me somewhat paranoid about the daily pain and numbness in my hands and feet when outside in the cold for prolonged periods. A “buddy system” was paramount to preventing frostnip. Simply by having that small exposed area of skin, pointed out to you to cover up

Dr Leslie Thomson, a consultant anaesthetist who had first – hand experience of polar medicine after spending several years in Antarctica taking part in the British Antarctic Survey gave an excellent lecture on hypothermia, bringing home how hypothermia is not just a condition seen near the poles but also in the Saturday night party goer who collapses under the stars, the homeless and the elderly. We were taught how to treat by various re-warming methods and when to commence C.P.R in the hypothermic patient sending home the message of not pronouncing death until warm and dead in certain individuals. This information was demonstrated by the story of Dr Anna Bagenholm , a 29 year old doctor who fell into icy water whilst skiing in Northern Sweden, immersed for approximately an hour, her body temperature was 13.7 degrees centigrade. C.P.R continued for three and a half hours alongside re-warming techniques such as bypass, bladder / stomach / peritoneal lavage and warm intravenous fluids. She survived to become the person with the lowest body temperature ever to survive.

Expedition and Wilderness Medicine obviously feel that first- hand experience is the best way of teaching and as a result each member of the group had to undergo cold water immersion. Prior to undertaking this challenge we were kindly taught about the cardiac arrhythmias that can be induced by the shock of entering the water, the short term cold water gasp reflex increasing the chance of aspiration and swimmers failure! One by one we stepped up to an ice hole in our thermal underwear and in the more daring members of the group a little less! to swim across icy water. I can confidently say that was the coldest I had ever been. As if several knives had been plunged into my body, breath taking and inducing chest pain, I swam across water of ridiculously low temperature to attempt getting out of the hole using my ski poles

Of our nights spent in the field we were taught how to construct snow holes. Five hours later our own little home with two double beds, stove, cupboards and shelves for our candles was constructed. It was as comfortable as it could be on a mountain side with winds blowing outside dropping the temperature to twenty below. I was amazed that the snow hole was so warm at five degrees compared to the outside however a slight air of nervousness was in the back of my mind as my avalanche detector slowly flashed in the corner and a rope attached to a spade inside connected our holes to other holes in case of us having to be dug out. The course perfectly demonstrated how to survive in such conditions

In summary the course prepared 25 everyday doctors to be able to traverse the polar landscape, recognise and competently treat local cold injury and hypothermia as well as to be safe expedition medics capable of caring for their groups and evacuating when required. To spend a week in such a location gave me the upmost respect for those who live in these regions and cross the landscape as part of everyday life, as well as a great respect for the land. In a day and age of global warming and melting of the polar ice caps it becomes paramount to look after our environment, to take only photographs and to leave only footprints.

Dr Claire Roche, Clinical Fellow in Emergency Medicine Countess of Chester Hospital.  See the BMJ article.

The next expedition medicine course will be in Desert Medicine Course which will be held in Namibia, August 17th -23rd 2008.

To see the full range of Expedition and Wilderness Medicine Training Courses see here.