MSF in action in the Congo, Early Bird tickets sales for Harvard Extreme Medicine and more…
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The Royal Australian College of General Practitioners features EWM
The Royal Australian College of General Practitioners magazine features our very own John Apps and the Polar Medicine course in New Zealand – see
pages 14-15
Medicine in the wilderness by Nick Johns-wickberg – see the full article here
Dr John Apps’ career in wilderness medicine has taken him on some extraordinary adventures. He now passes on his skills to other doctors.
There aren’t many people in the world who can run a marathon, let alone one at nearly 5000 metres elevation through the Himalayas. Rarer yet is a doctor who can keep up with the runners and tend to them in harsh conditions if anything goes wrong. John Apps is such a doctor. Overseeing the medical services for the Everest Marathon is all in a day’s work for the British-born adventure doctor and part-time GP.
‘I stationed a number of doctors on the descent route and my job was to jog behind the slowest person,’ Apps said. ‘There’s a lot of up and down, there’s a lot of rough ground, a lot of yaks to avoid.’
Apps’ work throws a wide range of challenges his way – yaks included. Overseeing the marathon isn’t easy, but Apps said the hardest part of that job is convincing the ultra-competitive runners to take it easy while acclimatising to the high altitude. He has also provided medical support for an extreme marathon in Antarctica, where the flatness of the course is offset by the fact that, as he puts it,
‘it’s just blooming cold’.
‘You’re hauling in all these huge lungfuls of air at minus 15°C and it does take it out of people,’.
The Royal Australian College of General Practitioners features EWM
The Royal Australian College of General Practitioners magazine features our very own John Apps and the Polar Medicine course in New Zealand – see
pages 14-15
Medicine in the wilderness by Nick Johns-wickberg – see the full article here
Dr John Apps’ career in wilderness medicine has taken him on some extraordinary adventures. He now passes on his skills to other doctors.
There aren’t many people in the world who can run a marathon, let alone one at nearly 5000 metres elevation through the Himalayas. Rarer yet is a doctor who can keep up with the runners and tend to them in harsh conditions if anything goes wrong. John Apps is such a doctor. Overseeing the medical services for the Everest Marathon is all in a day’s work for the British-born adventure doctor and part-time GP.
‘I stationed a number of doctors on the descent route and my job was to jog behind the slowest person,’ Apps said. ‘There’s a lot of up and down, there’s a lot of rough ground, a lot of yaks to avoid.’
Apps’ work throws a wide range of challenges his way – yaks included. Overseeing the marathon isn’t easy, but Apps said the hardest part of that job is convincing the ultra-competitive runners to take it easy while acclimatising to the high altitude. He has also provided medical support for an extreme marathon in Antarctica, where the flatness of the course is offset by the fact that, as he puts it,
‘it’s just blooming cold’.
‘You’re hauling in all these huge lungfuls of air at minus 15°C and it does take it out of people,’.
But there is much more to Apps’ work than the marathons. He recently returned to his New Zealand hometown of Westport after completing his ninth season in Antarctica, where he works for Antarctic Logistics and Expeditions, a private company that provides logistical and medical support to visitors, including emergency search and rescue. Clients range from ultra-fit adventurers setting off for the South Pole to elderly sightseers.
Each case presents its own set of challenges; older tourists need to be monitored for cardiac risk factors, joint problems and other issues associated with age, whereas those heading off on expeditions are at risk of trauma such as impact injuries and frostbite. Apps recalls an incident where a climber fractured his leg in a remote area that was unreachable by plane or vehicle. He and his colleagues had to call on all of their skills and experience to get the man back to safety.
‘The rescue probably took about 4 days to complete fully because of weather conditions and difficulty with access,’ he said. ‘We basically got our little ski plane as close as we could, and then it was a matter of putting the skis on, roping up the glacier and going off to collect this person, then dragging them back on a sledge.’
There have been some incredible moments at the other end of the globe, too. Before he moved down south, Apps did similar work in the Arctic, which he considers the toughest environment he has encountered.
‘Probably the harshest place I’ve ever worked has been up in the Arctic, where itis actually much colder than the Antarctic.’ ‘Although you’re at sea level, you’re actually on sea ice, so there’s an awful lot of moisture in the air. The combination of moisture plus cold really does suck it out of you.’
He tells the story of particularly memorable Arctic expedition, during which he was woken by a large piece of wood that had fallen onto his tent and just missed him.
‘One storm we lost one-third of our tents, and my tent was flattened by a piece of timber that got blown off a structure,’ he said. ‘I was quite lucky. ‘Quite literally you could not stand up in this storm. I remember crawling out of the wreckage of my tent and just being bowled over.’
Apps’ experience working in hostile conditions has taught him that wilderness medicine is as much about survival skills and teamwork as it is about medical knowledge.
This July, for the third consecutive year, he and several of his colleagues will conduct a Polar Medicine course in the mountains of New Zealand’s South Island to share their practical expertise with doctors from around the world. If someone on your ropefalls into a crevasse, you need to be able to know what to do instantly. The hands-on, 6-day course in the Pisa Range near Wanaka will show doctors how to apply their existing medical knowledge in completely different and adverse conditions.
‘The skills we impart are how to apply what they already know in a different environment where you haven’t got an ambulance, you haven’t got lots of nurses and a nice warmroom,’ Apps said.
Some of the practical training includes dogsledding, snowmobiling, cross-country skiing, travelling on glaciers and building shelters in the snow. Participants learn how to extract patients from dangerous situations and treat them in the cold, but equally important they learn how to keep themselves safe and ensure they are a competent and useful member of the rescue team.
‘We always teach that safety is the number one, and you need to not be aliability to the team,’ Apps said. ‘If someone on your rope falls into a crevasse, you needto be able to know what to do instantly, rather than say “Oi, what do I do?”
Apps’ fellow instructors include Dr Dick Price, an experienced search and rescue medic and Everest summiteer who Apps describes as a ‘legend’ in the field, Mike Roberts, who works as an Everest guide aswell as for the US Antarctic program, and Simon Murfin, a remote nurse and medic with Arctic experience. The course is accredited by the Wilderness Medical Society.
‘What I love to see is on about the third or fourth day, people have relaxed into their various groups and I think they’re suddenly realising the potential of what they can basically now get out and do,’ Apps said. It’s not feasible for all doctors to find a job where they can use these skills. Apps said the combination of ‘big bills and big mortgages and kids going through school’ – none of which he has to worry about – make the travelling life of an adventure doc impractical for many. But for those who do make the leap and choose this career path, the one guarantee is that ‘another day at the office’ is never just another day at the office.
Of interest
Médecins Sans Frontières (MSF) Surgeon David Lauter reports from the DRC
Médecins Sans Frontières in action…
Article © msf.org
It’s late in the evening and I’m on call overnight again. After a busy day in the operating room (OR) there hasn’t been much activity since 9pm. I ate a late dinner (late for me that is; the French and the Congolese here both like to take dinner at 8pm) with R, one of the Congolese nurse anesthetists here. She has worked for MSF for several years, spending a month at a time in Rutshuru between time at home in Goma with her husband and two daughters.
Among the cases toward the end of the afternoon were two men in their early 20’s with gunshot wounds, one in the arm, the other in the leg. They had been seen at another smaller hospital where their wounds were bandaged and splinted, then transferred to Rutshuru for definitive care. Ideally we would have x-rayed the injured extremities immediately but the x-ray machine was down for the day so they came to the OR for debridement [the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue] and wash-out of their wounds without x-rays.
It’s been awhile since I’ve treated someone with a gunshot wound though I saw my share during residency on the trauma service. There’s a significant difference between wounds from a handgun and a military rifle. The speed of a bullet as it leaves the barrel of a typical 9mm handgun is 300 meters/sec compared to 900 meters/sec for a military rifle. The force behind the bullet is in direct proportion to the speed of the bullet squared. This means that if a bullet from a Kalashnikov rifle is traveling 3 times faster than a bullet from a Glock 9mm handgun, it carries 9 times the impact. Compared to gunshot wounds at home, the ones in Rutshuru come with bigger holes and more tissue destruction. The protocol here for treating gunshot wounds is based on the recommendations of the International Committee of the Red Cross. It involves two operations, the first being debridement of all infected and dead material with leaving the skin edges of the wounds open, thus avoiding secondary infections that threaten life and limb.
The man with the leg wound had two holes in his upper leg. His smaller hole was the size of a US quarter, coming in the back of the leg at the mid hamstring and his larger hole was the size of my fist, coming out in the front just above his knee a bit to the outside. After induction of anesthesia, we removed his splint, pulled the compresses that had been packed into the wounds and surveyed the damage. There was a large cavity with torn muscle and bone fragments between the two holes. Almost all the bleeding had stopped. I could feel an abnormally rough texture to his femur bone but his leg felt structurally stable. I was comfortable that the main artery in his leg, the superficial femoral artery, was intact because it travels around the other side of the femur away from the damaged area, plus I had felt a good pulse in his foot before we started.
Using a scalpel I cut the bruised, dead skin from around both wounds so that I could better see into the cavity. I removed fragments of cloth and bone and cut away fat and torn, bruised muscle until I was satisfied that anything that would act as a source for bacteria to grow in had been removed. I rinsed out the cavity with saline and Betadine, put a loose dressing on both sides so that any infection could wick out and wrapped the wound. With the help of the nurses in the OR, we put his leg in a plaster splint to immobilize it until he can get an x-ray tomorrow.
The next patient clearly had an open fracture of the upper arm because even with the arm immobilized in a splint, it didn’t look quite anatomically correct. I felt a strong pulse at his wrist, indicating no major arterial damage. It was harder to be certain about the three major nerves (the median, ulnar and radial nerves) that travel through the upper arm. There is a quick examination to see if they are working but it can be difficult to rely on when your patient is in pain, has received narcotics and you don’t share a common language. After induction of anesthesia and the removal of his splint and dressing I could see he had a 2 inch diameter hole through his mid upper arm. By pulling on his arm I could see straight through to the other side. Needless to say, the exposure of his cavity was good. His humerus was broken with the two ends staring at each other 180 degrees apart and a visible gap. Without an x-ray it was impossible to tell how much of the bone, if any, was missing. I debrided skin and fat, cut away pieces of bruised and non-viable muscle with attached bone fragments and washed out the wound. There weren’t that many bone fragments so either he hadn’t lost much bone (good) or a big chunk had already been blown out (bad) or I had done an inadequate debridement and left dead bone fragments (worse). I looked in the cavity to see if I could identify the ends of a transected major nerve but didn’t see any. If I had seen one, I would tag it with a blue suture to help find it at the next operation when it would be repaired. Having completed the debridement, I washed out the wound with saline and Betadine, checked to be sure there wasn’t any more bleeding, placed a dressing followed by a plaster splint and we were finished.
Like all our patients with gunshot wounds, these two will come back to the OR in four or five days for re-evaluation. For smaller wounds without bone injuries or secondary infections, we close the skin at the time of the second operation (called delayed primary closure or DPC if you want to talk like a trauma surgeon). For larger wounds, we wait until they are ready for a skin graft. For patients with open fractures who need an external fixature (our second patient will definitely need one to salvage his arm), it is placed at the time of the second surgery. Some readers may be interested in looking at the ICRC publication “War Surgery” (just google search “war surgery ICRC” and you will find a downloadable pdf) which talks authoritatively about the treatment of high velocity gunshot wounds (some photos are not for the squeamish). As well, it provides a readable (at least I thought it was readable, but then I’m a surgeon) overview of the tremendous variety of injuries that occur during war and natural disaster and the complexities of treating these injuries.
When I left home to come to Rutshuru, there was a renewed and vigorous debate in the US about the restriction of military style rifles for personal ownership that began after the recent tragedy in Newtown, CT. The subject is a political hot potato involving powerful lobbies, heartbreaking tragedies and passionate arguments on both sides. Regardless of where one stands on those issues, there is one indisputable fact; bigger guns make bigger holes. If you ever get shot, hope it’s with a handgun and not an assault rifle.
Work for MSF – http://www.msf.org.uk/work-us
Of interest
Trauma Doctors by Channel 5
Channel 5 is featuring a major new documentary about the London HEM’s trauma doctors including Expedition & Wilderness Medicine’s Medical Director Amy Hughes and Extreme Medicine Conference speaker Anne Weaver
Trauma Doctors documents the on the spot medical decisions and procedures that can reverse the dying process in critically injured. The battle for a patient’s life starts within minutes of their injury when London’s Air Ambulance arrives at the scene of the incident, delivering advanced medical procedures to the roadside, and continues with their hospitalisation and subsequent treatment at The Royal London Hospital.
Heading up the team is Dr Gareth Davies, one of the UK’s leading trauma specialists, Medical Director of London’s Air Ambulance and Emergency Medicine Consultant at Barts Health NHS Trust. From helping patients in road traffic collisions to working on the aftermath of the 7/7 London Bombings, he and his team work at speed to bring the patient back to life.
Dr Gareth Davies said: “Trauma Doctors will give viewers an insight into the medical care provided by London’s Air Ambulance. We only attend the most serious trauma cases in London and are renowned throughout the world for our medical excellence. Most people do not realise that we deliver the emergency room to the patient so, by giving people a snapshot of what we do, we hope that one day everyone in the UK will receive similar levels of care.”
Barts Health Clinical Director for Emergency Medicine Dr Malik Ramadhan who also appears in the programme said: “The opening of the new Royal London Hospital last year has allowed us to combine one of the UK’s leading medical and nursing trauma structures with the facilities to provide world class care. In addition, the new trauma system in London means that severely injured patients are only taken to hospitals with the expertise to deal with a very complicated group of patients and The Royal London was one of the first hospitals in the UK to develop a formal trauma system. This programme gives an excellent insight into the thought processes of doctors looking after these patients.”
London’s Air Ambulance is on-call 24 hours a day to respond to life and death medical emergencies within the M25, treating almost 2,000 patients a year. The Royal London Hospital treats 2,800 trauma patients a year.
In the UK trauma accounts for around 18,000 deaths a year and covers a multitude of complex and life threatening injuries caused, for example, by vehicle collisions, industrial accidents and assaults, all of which are profiled in the series.
Of interest
Polar Medicine course in New Zealand and ski field medic jobs
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Urgent Ski Field Medic needed – New Zealand
Registered medical practitioner required to work at our accredited Urgent Care Clinics situated on the mountain at either Whakapapap or Turoa, Mt Rump for 2013 winter ski season.
A & E and Orthopaedic experience essential. Ideally you would have at least three years post-grad.
More information is available on our website www.mtruapehu.com under medical centres or alternately you can apply on line www.mtruapehu.com. For more information contact aguy@mtruapehu.com.
Off interest