Mike Grocott Expedition and Wilderness Medicine lecturer speaks to the BBC about the Caudwell Extreme Everest Expedition

Everest trip helps critically ill

Copyright  Michelle Roberts
BBC News health reporter

Dr Grocott and the Caudwell team plan another trek in 2009

The lessons learned by medics from a trip to Everest could help the treatment of critically ill patients.

The team that braved the Himalayan summit to study the body’s responses to extreme adversity has recorded the lowest ever human blood oxygen level.

The results could see treatment plans for some patients with similarly low blood oxygen levels re-evaluated.

The “Caudwell Xtreme Everest” work has been published in the New England Journal of Medicine.

The blood readings established what has long been suspected – that high-altitude climbers have incredibly low levels of oxygen in their blood, which at sea-level would only be seen in patients close to death.

The figures they have got are quite incredible. They are phenomenally low oxygen levels Anaesthetist Dr Andy Tomlinson

The average arterial oxygen level was 3.28 kilopascals or kPa – the lowest was 2.55 kPa.

The normal value in humans is 12-14 kPa and patients with a level below 8 kPa are considered critically ill.

Expedition leader Dr Mike Grocott said: “We rarely see below 6 kPa in our patients.

“Yet our readings were well below this and we were walking and talking and functioning normally.

“This gives us some perspective about what levels of oxygen deprivation people can tolerate.”

He said some critically ill patients may have adapted to the low oxygen levels and may not need the aggressive interventions, such as ventilation, that are currently given to get blood oxygen levels closer to normal ranges.

“All these interventions carry a risk of harm and you have to weigh up the benefits versus potential damage to organs like the lungs.

“Maybe we could be less aggressive in treating some of these patients.”

He said other intensive care researchers were planning to investigate it.

Tolerance limits

Acting as guinea pigs themselves, the London team of medics – five anaesthetists, two GPs and a vascular surgeon – took the first readings of human blood oxygen 8,400m above sea level.

The team climbed with oxygen tanks, then removed their masks 20 minutes prior to testing to give time for their lungs to get used to the low-oxygen atmosphere and to avoid any skewing of the readings.

The team were unable to make the measurement on the summit of Everest as conditions were too severe, with temperatures at -25C and winds above 20 knots.

Having descended a short distance from the summit, the doctors removed their gloves, unzipped their down suits and drew blood from the femoral artery in the groin.

The samples were then carried by Sherpas back down the mountain and analysed within two hours at a science lab set up at the team’s camp at 6,400m.

Based on calculations of the expected level of oxygen in the blood, the Caudwell Xtreme team speculate that accumulation of fluid in the lungs as a result of the high altitude might have contributed to the low oxygen levels.

They hope ongoing research will eventually lead to better treatments for patients with acute respiratory distress syndrome, cystic fibrosis, emphysema, septic shock, “blue baby” syndrome and other critical illnesses.

Dr Andy Tomlinson, an anaesthetist at the City General Hospital in Stoke-on-Trent and a keen climber, said: “The figures they have got are quite incredible. They are phenomenally low oxygen levels.

“There is obviously a difference between critically ill patients and fit and healthy climbers.

“Never the less, there are lessons to be learned for critical care.”

Dr Peter Nightingale of the Royal College of Anaesthetists said: “This may well make doctors re-evaluate their current provision of oxygen and the researchers may well be right that patients can run on lower oxygen levels.

“But we do not know and we need more research.”

Mike Grocott is a Expedition and Wilderness Medicine lecturer and presents on our UK training course – Expedition and Wilderness Medicine UK

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Expedition and Wilderness Medicine support for Commonwealth Championship for Mountain Running and Ultra Distance.

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Expedition & Wilderness Medicine  are to provide the medical cover for the Commonwealth Championship for Mountain Running and Ultra Distance. The events will run over four days in September 2009, and Keswick has been chosen as the venue.

Expedition & Wilderness Medicine Director, Dr Sean Hudson is acting as the Medical Director for the event and overseeing the medical care for the many international and local competitors who will be involved in a number high profile races. In conjunction with Across the Divide they will be managing the medical logistics and communication for the event.

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Expedition Medicine launches a new course on Dartmoor

Our highly rated Expedition and Wilderness Medicine Training Course is heading south.

We are really excited about our new course – following the same schedule as our Lakeland course and with many of the same inspirational faculty we have linked up with Dartmoor’s premier training faculty, the Heatree Centre located near Newton Abbot to provide an additional course in May.

We are hoping that will make the travelling time shorter for some of you and reduce to carbon footprint of the courses, we will of course be working with the Woodland Trust as well to identify one of their projects close by which the proceeds of the course will help support.

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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.

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.