Jan Stevens recently visited the Extreme Medicine Conference held at the Royal Society of Medicine and wrote the following article in Dutch.
The next Extreme Medicine Conference is running from 28 October 2013 to 31 October 2013 at the Harvard Medical School Conference Centre in Boston – details to be released
extreme medicine
September 2012
For those of you who read Dutch – enjoy!
Expedition & Wilderness Medicine is the leading provider of expedition, wilderness and remote medicine training courses, conferences and EXPO’s for medical professionals. We combine decades of experience with passion, enthusiasm and hands-on practical knowledge.
Expedition & Wilderness Medicine is the leading provider of expedition, wilderness and remote medicine training courses, conferences and EXPO’s for medical professionals. We combine decades of experience with passion, enthusiasm and hands-on practical knowledge.
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Day one of the Plas y Brenin Expedition Medicine course
The first thing that hits you as you round the corner to Plas Y Brenin is the beauty of the location. The national mountain centre is nestled in a valley overlooking a lake and in the shadow of two mountains, the view is unbeatable. After a quick hello from the faculty we were led outside for ‘warm up’, a combination of getting to know our fellow course mates and a bit of exercise to get the blood pumping! Warm up complete, we were back in the lecture theatre for a series of lectures on the planning, logistics and legalities of being an Expedition Medic. A huge amount of information was covered in each lecture, and what really shone through was the experience and passion of the lecturers. We were also introduced to Martin Rhodes, a bit of a legend in the expedition medicine world. (If you want some inspiration, and to see where a medical degree and a lot of dedication to expedition medicine could take you, Google his name!)
After a hearty lunch we were split into groups and went round a series of hands on sessions covering RTAs, fracture management, wound management and emergency dentistry. These were great. We were introduced to specialised expedition equipment as well as getting moving and thinking about how we would deal with different scenarios. I even had a go at pulling out a tooth from a model used to teach dentists! The technique lives up to its name, and I hope for all parties involved I never have to do it in real life, but you never know and at least now I have a vague idea about the principles of managing dental conditions, a topic that in 5 years of medical school was not even brushed on (Sorry couldn’t resist)!
That evening we had a semi biographical lecture from Chris Van Tulleken, of ‘Medicine men gone wild’ fame. He, like the rest of the faculty, seemed to have fitted an impossible amount into his career, including quite a bit of NGO work, and gave a very thought provoking insight into charity work and our conception of it . After that we had just enough time for a couple of beers before getting off to bed for an early start the next day.
Day 2 started in a similar vein; several jam packed lectures from experts in the field covering all sorts of expedition medicine topics. One lecture that stood out was the lecture that every student dreads to see on their time table ‘public health’! It was given by Joe, a GP with a wide range of expedition experience. The fact that he managed to make it funny, interesting, and relevant, while also wearing every available bit of safety equipment, goes to demonstrate his enthusiasm for the subject!
In the afternoon we had another series of small group practicals, giving us the opportunity to go out on the hill and practise a range of skills, from navigation to carrying a casualty. The session of rope skills taught by instructors on the mountain leader course was particularly useful. I’m an avid climber myself and was a little dubious about being lowered down a rock face without the use of a harness or belay! However once we got to grips with the techniques it was a real eye opener and great insight into what is possible with just a rope.
Then it was back to the centre for a good solid meal and a few well deserved beers.
Day 3 was almost all small groups and practicals. Among other things we learnt about water purification methods and management of hypothermia, frost bite and altitude sickness. One of the highlights of the day was the wilderness resus scenario, with Cas Union actors playing the casualties. These guys were amazing, very convincing, and our fellow seemed so into his method acting that he preferred not to come in for a coffee break after the scenario, but remained at his fallen spot until the next group rotated round! Another highlight had to be the Comms Station. Here we were split into 5 groups and had to relay massages back to one another about a RTA using walkie talkies. It is amazing how difficult it actually is to have efficient and effective conversation over the radio. Although we got the hang of it eventually, the years of watching radio speak on TV resulted in the majority of us giving into the temptation to finish with ‘Over and out’ (apparently this doesn’t make any sense)!
That evening Amy Hughes gave a lecture on her career so far. Amy is one of the key organisers of the Expedition Medicine course and what she has managed to achieve in a relatively short career is quite amazing. There was expedition medicine, NGO work, Flying doctors in Australia, and a year with HEMS, the air ambulance service. It was really inspiring stuff and left quite a buzz among everyone in the bar later that night.
On the last day we were able to put into practice everything we had learnt so far in a real life scenario. Groups were given coordinates of where to find casualties, and had to find them, manage their injures, organise a helicopter retrieval, and transport the casualty to the RV point. I was a casualty in this scenario, something which I have never done before, but it was a really interesting experience. Firstly you get the casualty perspective, which really gave me a sense of the vulnerability and disorientation that people in that situation must feel, and secondly it was good in terms of the course because from my position I could sit back and analyse how the team functioned and preformed.
One of the best things about the course was the other delegates. There was a wide range of ages and grades, and specialities, but everyone had a buzz about them. Lots of them had done things a little differently and there were many good stories shared over the evening beers. There were two FY2 who had spent last year working in A&E in Australia; a GP who having finished his training had spent two years working in the Amazon, and another who had gone travelling in Oz, started working in Singapore to save up for the return journey, and ended up staying for 20 years; then there were two ex-army guys who had set up an endurance adventure travel company, which involved them rowing the Indian ocean and skiing across Greenland, to name but a few.
Overall the course was amazing, it provided a good grounding in all aspects of expedition medicine, as well as giving some insight into expedition media work, working for NGOs and working for the air ambulance 
service. Most importantly for me was the sense that, by the end of the course, everyone seemed to have a revived drive in them to pursue their own path. The experience of the faculty was awesome, and their approachability help make it a truly inspiring course.
Find out more – Expedition & Wilderness Medicine Courses
As I roll over in a tangle of sleeping bag, clothes and thermarest, cocooned by the sides of my hammock, I find that my mouth is dry with the bitter taste 
of permethrin. Apparently I spent some of the night sucking my mosquito net. This actually comes as a relief because at least I slept rather than lying awake in rigid fear of my hammock poles snapping. Again. I lie there in my post-sleep daze, slowly becoming aware of the increasing animal calls which surround me, waking me from that lovely slumber. I allow the sounds to wash over me for a while before opening my eyes to see the dense jungle emerging with the light of a new day. After following a complicated procedure to get dressed and exit my hammock, which resembles a badly choreographed gymnastics routine, I make my way over to the fire pit. Any of the team who have failed to be woken by the increasingly angry cicadas, are now summoned from their dreams by my efforts at splitting wood with a less-than-sharp machete. However, I eventually manage to light a carefully crafted wood pile and proudly watch as it roars into life. Whilst the water is heating above it for another morning of porridge and 2-in-1 coffee, I find myself staring into the dancing flames and considering my situation. I’m six days into a twelve day trek, deep in the jungle somewhere in Borneo. I am solely responsible for the health of my intrepid band of ten expeditioners using a limited medical kit and only my clinical cunning to make up for its shortfalls. To cap it all, my casevac plan states that the time to get a patient to anything vaguely resembling a hospital may be up to 24hours. A fairly normal question at this point may be, what am I doing here?
A few years ago, after doing some work as a remote care paramedic supporting extreme sports events, I decided it was time to take my interest in wilderness medicine further. So it was that I enrolled on the Expedition and Wilderness Medicine course. As anyone who has attended this course will know, I left with new skills, better knowledge of this speciality and a great deal of inspiration. An unexpected bonus of attending the course was the highly approachable and experienced faculty, of whom I took maximum advantage to glean all the information I could. A well-trodden path at the beginning of one’s expedition medicine career appeared to be working for Raleigh International. So, after an application form, a selection weekend and a pre-deployment training weekend I found myself on the plane to Borneo clutching my very shiny, very new copy of the Oxford Handbook of Expedition and Wilderness Medicine.
Working for Raleigh, purely from the medical perspective, was a varied and stimulating experience. Initially, in the pre-expedition phase, the focus was on preparation of equipment and staff. The medical team are responsible for evaluating the drugs and equipment, preparing the medical kits and training non-medical staff in first aid and health and hygiene. We also carried out site visits to review casualty evacuation plans and to assess the facilities of local hospitals and health clinics. Once the venturers arrived we ran training sessions with them emphasising preventative healthcare, such as hand washing and monitoring their fluid intake, but also empowered them to care for minor wounds and illness. The medics also carried out medical one-to-ones with each of the members of the expedition team to ensure vaccinations were current and a sufficient supply of personal medications had been packed as necessary.
Once the expedition began and we were deployed into the jungle, each smaller team of approximately ten people had one medic embedded in it. This role was very autonomous and how each medic ran their medical care was on an individual basis. Personally, I was very vocal on public health issues, the most contentious of which, particularly with some male members of the group, was ensuring regular bathing. I found this hands-on approach to be very effective when done tactfully and as a result I had to deal with very few preventable conditions. I also ran informal foot clinics each day, checking the teams’ feet during rest stops to check for maceration, blisters or leech bites. Another area that I was aggressive with was wound care, with even the smallest of scratches being immediately cleaned and treated with iodine.
However, it is not all plain sailing and with expedition medicine you have to be psychologically and clinically ready to deal with a serious condition in some very challenging environments. This was demonstrated one day when, five hours into a seven hour jungle trek, and several hours from the nearest road, I turned around to see one of my group plunge head first down a five foot drop and then tumble a further twenty feet down a landslide path. After assessment she was found to be miraculously relatively uninjured with conditions eminently treatable in the field. However, your clinical assessment and decision making skills are certainly tested during these times, particularly when the welfare of the rest of the team needs to be considered. If someone requires evacuation it may mean a stretcher carry for several hours, potentially risking injury to other members of the already tired team.
Other questions could be raised which, as the medic, people look to you to answer. Should we make camp now and evacuate in the morning? What kit should you take with you on the evacuation? Is there a water source on the evacuation route where we can purify drinking water? Would it be quicker to go to the road or the helicopter landing site? To feel more prepared to answer these questions and for a role as an expedition medic, the Expedition and Wilderness Medicine course is a sensible starting point. Whilst you cannot expect to leave as an expert on all the subjects, the benefit of having some knowledge and experience on the topics covered, prior to having to implement them in the field, cannot be underestimated. I found many of the lectures and skills stations to be pertinent to my role, from radio protocols to water purification, tropical medicine to group dynamics. The course content is very well thought out and is delivered by experts who have been there and done it. To take your interest in expedition medicine further, the combination of attending the course and obtaining a role on a large, well established expedition such as Raleigh, seems to offer an ideal combination.
Raleigh, and other organisations like them, provide an excellent starting point for expedition medics for several reasons. They employ doctors, nurses and paramedics and have expeditions leaving three times a year to three different locations, so there are plenty of opportunities to gain a position with them. The benefit of working for a large and well established organisation is that often the infrastructure of the trip is already in place. Rather than establishing everything from scratch, the medic can review and adapt current policies and procedures, which provides a fantastic opportunity to use new expedition knowledge but in a less stressful setting. A large expedition may also offer the support of a “Fieldbase Medic” who is located at the expedition’s headquarters and can offer advice over the radio or satellite phone. This provides reassurance for the medic in the remote site but also gives the HQ based medic an opportunity to develop their telemedicine skills. Raleigh is also non-discriminatory when it comes to allocation of roles. Whether a doctor, nurse or paramedic, each is a Medic and has the same capabilities as one another. As part of this ethos, the expedition medical team adapts a pre-existing prescribing protocol which covers all the medicines in the medical kits. All members of the team agree on and sign this protocol, allowing all grades of the medical team to prescribe the named medications within the scope of the procedures. This provides an excellent learning opportunity for nurses and paramedics who may not have been exposed to these drugs previously.
Away from the medicine, there are many other positives to working on an expedition. I had the chance to live and work in primary protected rainforest in which researchers wait years to gain a permit to enter. I had numerous wildlife encounters including orang-utans, monkeys, snakes and rare birdlife. I saw more stars than I knew existed and saw waterfalls that few have laid eyes on. During the community projects there was the chance to interact with welcoming locals from remote villages, teaching in their kindergartens, learning their culture, playing football with the young boys and one group even attended a wedding. Depending on whom you work for, the emphasis of the expedition may vary. Raleigh is a youth development charity and to see the young people changing throughout the expedition was massively rewarding.
On a personal level we left with a multitude of new skills both through formal training and experiential learning. This included practical tasks such as fire lighting, building a basha and numerous general skills required to live successfully in the jungle. Interpersonal skills like conflict resolution, facilitating discussions and providing structured feedback were learned through classroom time and implementation with the venturers. It’s not all serious though and you will leave an expedition with many amusing stories, such as the night I leapt out of my hammock, wearing only my pants, to chase a bearded pig into the jungle who was running off with a box of our food in his mouth!
Working on an expedition is a multi-dimensional experience with many benefits and to try and report everything here would not do it justice. I cannot recommend working on an expedition highly enough as the time I had was fascinating, scary, breath-taking, funny, beautiful and individual. However, don’t rock up on expedition with your chest puffed out and head held high because you’re the medic. The most important factor to remember is that you are part of the expedition team first and a medic second; so don’t be surprised to be digging long drops and burning used toilet paper or washing up that night or sleeping in the worst hammock spot because you allowed the rest of the team to choose their sites first. It’s all just part of the fun.
As Raleigh would say – “Get out there”
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EWM announced the winners of the EWM Remote Medicine Awards at their Extreme Medicine Conference at the Royal Society of Medicine on 17th April. The intention of the Remote Medicine Awards awards is to keep all everyone in the industry motivated, and they are dedicated to everyone involved in extreme medicine no matter how great or small their involvement, they recognize the achievements of some of the most inspiring personalities and companies that are associated, in one form or another, in the growth of the Remote Medicine industry.
EWM Remote Medicine Person of the Year 2012 was awarded to Denise Prior of Porter’s Progress UK
Denise is a founder member of Porters’ Progress and House Manager at the Royal Geographical Society. Since 2001 Denise has developed a an interest in climbing and mountains which led to her joining the Medex Expedition in 2003 where she was deeply impressed by the courage, endurance, dignity and hospitality of the mountain porters. Denise was also responsible for ensuring their welfare throughout the trek and became aware of the precarious and inherently dangerous nature of their lives
EWM Remote Medicine Company of the Year 2012 was awarded to Porter’s Progress UK
It was awarded for their work facilitating the safe treatment, education and empowerment of mountain porters and their communities through appropriate programmes, with priority given to creating change within the trekking industry.
“The awards are a great honour, they have not only raised the profile of Porter’s Progress but the publicity has bought us new assets” Denise Prior – Porter’s Progress UK.
