Expedition Dentistry for Wilderness Medics (Langdana, Edwards)
Burjor Langdana, WEM Faculty, former Dental Surgeon at the British Antarctic Survey Medical Unit and Matt Edwards, Expedition Doctor also WEM Faculty and Polar Medicine Course leader.
Dental problems are common on expeditions and anxiety provoking for the lone practitioner. This is generally because there is a lack of exposure to dental presentations and procedures in clinical practice. Patients, on the whole, go to dentists if they have a dental issue. Doctors employed for prolonged remote placements, e.g. the British Antarctic Survey, undergo formalised dental training prior to deployment. Luckily dental issues on expeditions can be made very simple for the non-dental practitioner and the purpose of this article is to help create a framework to help you decide what you can deal with, what you cannot, what kit to take and the relative urgency of any medevacs that may be required.
Consider this scenario: it is the end of day four of your expedition. Your team has just reached base camp. A team member complains of throbbing pain in his mouth. You are all exhausted and dental problems are a little out of your comfort zone. The questions you should be asking at this stage are:
Dental problems are common on expeditions. Diets change with increase in amount and, most importantly, frequency of sugar intake. Participants often have dry mouths with increased respiratory rate and inadequate fluid intake. Oral hygiene often becomes a secondary consideration when people are tired. There may be exposure to extreme cold (or heat) so teeth sensitivity becomes a major issue. Finally, teeth may be subject to trauma e.g. frozen chocolate is a common culprit.
Prevention is certainly possible for the vast majority of dental issues. Often pre-existing problems suddenly get worse due to the environmental stressors, and remember, this can happen to you as well.
Three months before the expedition: advise a proactive dental check up with chartings and necessary radiographs. Follow this up one month later and request dental chartings.
In your pre-expedition briefing, reinforce:
Finally, when you are on expedition, for those with any known sensitivity advise Anti-Sensitivity Toothpastes (Sensodyne,Colgate, OralB).
As in medicine, if you suspect a dental problem, first take a history including:
Previous dental history / Hopefully you will know this already
Location / Teeth or gums? Can he localise it at all?
Sensitivity / To what? Does it disappear immediately when stimulus removed or persists for a few minutes or longer?
Character / Is it constant or throbbing ache? Can biting down help localise the correct tooth?
Next, examine the patient.
Lighting / During the day, position the patient facing the sun and leaning against a good back rest. At night, use a head torch within a closed tent. Bugs rarely help dental examinations.
Positioning / Make life easy and comfortable. Get padding for patient and for your knees. Get a willing volunteer to help you, preferably two. If examining the lower teeth, then position the patient sitting up with lower teeth parallel to the floor, uppers at an angle of 45 degrees to floor. If you are looking at the upper teeth then lie the patient supine, with the neck fully extended.
Achieving dryness / Position multiple cotton rolls on the cheek side of upper first molars (i.e. next to the parotid duct), under the tongue for the submandibular ducts and to attempt to hold the tongue out the way and on the buccal side of the tooth needing treatment. Rotate head to the opposite of the working side, to reduce poolage. Suction is great if you have it, otherwise a rubber camera lens-blower can be helpful. Don’t forget to use your assistants and ask the patient politely to try to control their tongue.
Equipment / See the list at the end of the article.
Managing these problems will, for the vast majority, be a temporising measure, buying time before the patient can get to a dentist. But seeing as there are rarely ‘expedition dentists’ coming along with you, then you will likely need to do something.
In order of seriousness of the problem, the most common issues on expedition will be these:
Caries and Infection
Initial caries, not down to dentine, will leave the patient sensitive to cold (less than one minute) with a brown spot (demineralised patch) on the tooth. Manage with a high fluoride toothpaste (Duraphat) and/or anti-sensitivity toothpastes, alongside oral hygiene advice. Follow up with a dental hygienist. Dentine caries causes more severe sensitivity and pain, with a darker, deeper and softer lesion. Clean away the soft debris and fill the hole with filling material, then follow up with a dentist for a formal restoration.
Pulpitis / Apical Abscess
These cause pain over side of face, prolonged periods of sensitivity and the patient will be unable to eat on the effected side, though it may be difficult to locate the responsible tooth. There are no proprioceptive receptors in the pulp, only outside. Once it infiltrates local tissues or forms an apical abscess then it will become easier for the patient to localise. It is likely to have caries, or previous large restorations and may be tender to percussion. If you can, get ice and place it on each tooth. The diseased tooth should respond painfully.
You should seriously consider evacuating the patient. First line treatment is antibiotics, analgesia, no eating on that side and urgent dental review. Second line is Ledermix temporary filling (antimicrobial steroid dressing). Finally, third line would be tooth extraction, though this is a last resort and should be avoided. For follow up, standard UK treatment for this would be is either root canal treatment or extraction.
Severe pain and swelling on a gum. It is very difficult to differentiate between a tooth abscess (a decayed tooth and a dead pulp causing an apical abscess) and a gum abscess (food debris in the periodontal pocket, forming an abscess to point on the gum). Management is incision and drainage (see slide show above for technique), trimodal analgesia (NSAIDS, paracetamol, opiates) and antibiotics (see below). Follow up with an urgent dentist review for tooth abscesses. Gum abscesses should settle with simple management at home but prompt dental review is still important.
Bleeding on brushing, mild discomfort from the gums with inflamed friable gums on examination. Remember to always check behind back molars, as debris often collects there. Manage by encouraging more brushing, not less, flossing and mouthwashes. Follow up with a dental hygienist.
Severe pain, facial swelling, restricted mouth opening. Look for swelling around and posterior to back molars. There is little you can do in the field here with established infection – evacuate the patient. In the meantime, examine thoroughly behind molars and irrigate with mouthwash. Give regular trimodal analgesia and antibiotics. Once evacuated, follow up with a dentist or potentially maxillofacial surgeons.
Your preparations for dental issues on expedition will depend on multiple factors. A qualified dentist with good equipment can still perform complex treatments in the middle of nowhere and they regularly do. A non-dentally qualified practitioner working where evacuation might be impossible for prolonged periods might be expected to perform some reasonably complex dental procedures. That, however, assumes that they have had the appropriate pre-expedition training and can get some advice remotely. In the case of smaller trips or where evacuation is reasonably straightforward, advanced training and equipment cannot really be justified. Still, basic diagnosis and simple symptom management and will greatly help patients until evacuation or definitive care can be arranged. A way of thinking about the level of dental capabilities we would recommend are as follows:
|Short trip, evacuation reasonably quick and straightforward e.g. Kilimanjaro||No prior training required, expedition medicine course with a dental session advised||Advise dental checks||Basic dental kit: a few instruments, some temporary cement and oil of cloves|
|Long trip, evacuation likely to be a few days e.g. Greenland Crossing||Sit with a local dentist or attend an expedition medicine course with a dental session||Strongly request participants have dental checks||More extensive dental kit, plus: Duraphat, Ledermix, matrix bands, local anaesthestic. Preferably some remote access dental back up.|
|Remote clinic, difficult or impossible evacuation e.g. British Antarctic Survey||Formalised dental training course and visit a local maxillofacial surgeon or attend an expedition medicine course with a dental session and a maxillofacial trauma session||All participants must have regular dental checks before and during deployment||Advanced dental kit with basic dental extraction and interdental wiring kit. A reliable remote access dental back up. Radiology and telemedicine capabilities would be an added bonus|
Oral analgesia according to the standard pain ladder is normally sufficient. Need for strong opiates is rare. Use regular trimodal dosing i.e. NSAIDS, paracetamol and opiates.
Anti-sensitivity toothpastes can be used if increasingly uncomfortable twinges of pain are being generating by contact between hot, cold or sweet stimuli and an area of a tooth where temporary filling is not possible. Retaining the toothpaste in that area for as long as practical helps to reduce the sensitivity.
Clove oil on a cotton plug placed into a cavity is often temporarily soothing.
Duraphat, a high fluoride varnish applied to dry tooth surfaces reduces sensitivity.
Local anaesthesia, either as a nerve block or infiltration around the tooth can provide temporary respite.
Ledermix paste – contains the broad spectrum antibiotic demeclocycline and triamcinolone acetonide as an anti-inflammatory, can be used when there is an unremitting pulsating toothache, such as that associated with a large deep cavity, a lost filling, or a loose filling that can be easily be removed. The tooth is cleaned of all the soft debris, Ledermix paste is applied with a small cotton pledget to the depth of the cavity, and the cavity then sealed with a temporary dressing, such as Cavit.
Dental infections are typically caused by anaerobic bacteria and require treatment with a broad spectrum antibiotic. When in remote locations strongly consider higher doses than routinely prescribed. Antibiotics will generally reduce swelling and associated pain in 2–3 days. At this point the dose of anti-inflammatories can also be significantly reduced.
When there is an acute dento-alveolar infection, the treatment of choice is to drain the pus, by means of a gum incision into pointing abscesses or by extracting the affected tooth. If these local measures have proved ineffective or there is evidence of cellulitis, spreading infection or systemic involvement, one of the following first-line antibiotics can be prescribed. Local gum disease can be treated by debridement and irrigation together.
The antibiotics of choice if patient can take them are:
If the patient is penicillin allergic:
Dental pain may also arise from infections of the gum structure associated with poor oral hygiene around buried or partly erupted third molars. The gums will appear swollen reddish-purple in colour, may bleed spontaneously or on touch with an instrument, and may smell foul. Having diagnosed periodontal infection,. it is essential to minimize bacteria between the teeth and along the gum margins.
Mouthwashes are used as an adjunct to improved oral hygiene in the treatment of gum disease in particular. The patient should be encouraged to brush the painful area vigorously despite bleeding and discomfort. A case of being cruel to be kind.
Temporary filling materials are used to insulate the pulp from temperature, hypertonic solutions, chemicals or irritating foods. It will make the tooth feel much better. If a tooth is damaged during an expedition – whether through a lost or broken filling, decayed dentine, or cracked or broken enamel – but is not giving symptoms, then a temporary filling can still be useful as a preventive measure. Temporary filling materials suitable for placement when in a remote location fall into three categories:
Supplied in a sealed tube; squeeze out and apply. The premixed materials (e.g.‘Cavit’) are easier to use but have less structural strength. They requires a mechanically retentive cavity to stay put. i.e. a hole with walls. The material also erodes and may require replacing as often as every few days. The cavity can be a little damp but not wet.
Materials requiring mixing
Examples include IRM (Intermediate Restorative Material) or any glass ionomer filling material which is fussy, but also very sticky and retentive.
Consider the following before starting:
Improvisation can be attempted. Dip cotton pellet into oil of cloves or Eugenol. Swab the depth of the cavity. Then seal the cavity with candle wax, ski wax or sugarless chewing gum. Expect limited success, of a very short duration.
Flat-plastic spatula (for placing dental filling material onto tooth)
Pair of tweezers or forceps
Spoon excavator (medium) – for scraping out soft caries
Fine curved surgical scissors
Cement mixing spatula
Glazed mixing paper pad/or glass slab
Temporary filling materials: Glass Ionomer powder + liquid or Intermediate restorative material (IRM), Cavit
Chlorhexidine 0.2% mouthwash
Duraphat (high fluoride varnish)
Antibiotics: Co-amoxiclav 625 mg, Metronidazole 400mg
Painkillers: ibuprofen, paracetamol, codeine-phosphate
Dental local anaesthetic cartridges: 2% Lidocaine with 1:80,000 adrenaline
Toothpaste for sensitive teeth
Eugenol( oil of cloves) Topical Analgesic
Cotton wool rolls
Stainless steel wire for eyelet wiring (24G for eyelets, 26G for ligatures) or electrical cord for harvesting copper wire
Safety-plus disposable syringes: 27G long (can be used in upper and lower jaw)
5ml syringe with blunt needles (for irrigation and flushing out debris below operculum)
Gas aerosol suitable for camera cleaning – ideal for drying teeth and cavities
Optional equipment for the experienced
Upper single root extraction forceps
Upper molar extraction forceps left and right
Lower molar extraction forceps
Lower single root extraction forceps
Fine Luxator or Elevator-Coupland
Over the years, Andrew has joined expeditions that employ his abilities as both a doctor and photographer. “I’ve always loved to travel and explore the world and to experience different places and cultures. I try and involve myself with interesting expeditions or on journeys with a specific purpose to more remote areas where I can tell an interesting story photographically. It helps that I’m a medical doctor, which has given me great opportunities in recent years
to work on some awesome trips to places like Antarctica, Papua New Guinea, Pakistan, Nepal and India. A dramatic landscape and the people and/or wildlife moving within it is what really captures my attention the most.”
Andrews photos embody the look, feel, and subject matter that classic travel photography was founded upon. On his two trips to Antarctica, he captured images of surreal landscapes of ice and snow, desolate and never-ending vistas from their ship, and wildlife unaccustomed to human interaction. Because of Andrew’s passion for adventure and his admiration for the natural world, his images are full of life. They cultivate a sense of wonder and bring the viewer up close to the adventure at hand.
Read on to learn more about Andrew’s trips to Antarctica and the incredible aspects of his career as an expedition doctor and photographer. All of the remarkable and exciting photographs below were processed using VSCO Film 04.
Please tell us about your expertise in being a doctor. How did the opportunity to be a doctor on such expeditions come about? How has being a photographer enriched the expeditions you’ve been on?
It not only seems long ago now that I graduated as a doctor, it really is – 1991… I decided to volunteer and work as a doctor for the Tibetan Government in exile in Dharamsala, India. I contacted Fuji, and they kindly gave me fifty rolls of Velvia to take with me. I think any hope of a traditional medical ‘career’ was doomed from then on, as the life of a nomad climber and traveler appealed more, and I’ve never gone on to complete training in a speciality area.
Instead, I have built up an extensive amount of experience in general and emergency medicine, combining traditional hospital contract work with remote area and expedition work in Australia and overseas, aiming where I could to find ways of combining my climbing, paddling and photography skills with medical work, both paid and voluntary. As is often the case, networks built up over time generate the most opportunities in the area of expedition medicine. For instance,
I was asked to be the doctor for the recent Australasian Antarctic Expedition (AAE) by a climbing friend, Greg Mortimer, one of Australia’s most lauded mountaineers. We climbed Manaslu (8163m) together in 2002.
Being an Expedition Doctor can be a thankless task, because I’m only useful when things go wrong, and nobody wants that to happen. So it’s always good to add other skills to the mix, which is where photography comes in. So I ‘morph’ into the Expedition Photographer as well, giving instruction and talks on photography to the others. Interestingly, there was one expedition in the Arctic aboard a super yacht traveling through the Northwest Passage where my contractual engagement was as a photographer, yet I was expected to fulfill the responsibilities of a doctor if those skills were needed. I lead treks in India and Nepal occasionally and, also on those journeys, adopt the role of Expedition Photographer when I can. It’s satisfying helping and teaching others who are interested in the world of digital photography, and of course, there is no end to the learning experience for me.
Tell us more about your trips to Antarctica. What was the purpose for each trip? What are some of the things you enjoy most about traveling to such a desolate region?
The photos seen here are from the past two trips I’ve made to Antarctica. Both were ship based, which is the most common way that people get to experience the great white continent. By far, most of those trips are tourism based and go to the Peninsula, which was the basis for my first visit as a ship’s doctor. Compared with the rest of Antarctica, it is reached relatively easily in a few days sailing from the tip of South America. For the AAE, it took us 8 days to reach East Antarctica across the tempestuous Southern Ocean, after leaving from the bottom of New Zealand. The AAE was a science based expedition, utilizing private funding from paying passengers and university grants. The aim was to travel to the area of Commonwealth Bay and repeat and compare scientific observations with those made by an Australian scientist and adventurer Sir Douglas Mawson, who first landed there 100 years before with the original AAE. At the time, this was the Edwardian equivalent of today’s space travel. His team established a base hut in a spot which has now been proven to be one of the windiest places on earth, and there they made many oceanographic, geological and meteorological measurements over two winters. Clearly, we had more creature comforts than Mawson and his men, yet visiting the coast of East Antarctica is still a difficult proposition, and it felt very remote geographically speaking. The desolate landscape with multi-hued, blue ice features and the intense, 24-hour light at such a southern latitude makes for a wonderful, yet challenging environment in which to photograph. It’s a beautiful place, which changes remarkably in mood with the weather. Delightfully inquisitive penguins are a constant presence at the edge of the ice, and their charismatic personality means I never tire of photographing them.
Unfortunately, our ship for the AAE, the Akademik Shokalskiy, was caught by an unexpected breakout of old, multi-year pack ice far to the east of the area we were in. The expedition had completed its Antarctic shore based work, and we were making slow headway through the thick ice. We were only two miles from reaching open water when it became impossible to proceed. During the blizzard that followed, that distance became twenty miles; so we were effectively ‘stuck’. There was enough initial concern about large icebergs moving independently within the pack ice near the ship to require a request for help to be sent by the Russian Captain to maritime rescue authorities. Once that immediate danger had thankfully passed, for those onboard, it was a case of sit tight and celebrate Christmas Day and New Year in an usual fashion. Each day was a case of wondering what would transpire next as authorities canvased options, made plans, and then changed plans frequently. It was an unsettling experience for some of the passengers. So I and other expedition team members focused on doing what we could to keep spirits high and people informed and occupied. On January 2nd, a helicopter from the Chinese Icebreaker, “Xue Long”, that was unable to forge a path to extricate the Shokalskiy, was used to shuttle us across a vast expanse of glittering pack ice to the Australian ship Aurora Australis. It was a thoroughly professional operation conducted in good weather, and all of those evacuated are very thankful for the help that was offered. As a result of this event, I found myself at the centre of a somewhat overwrought media frenzy, and because of the technology we had available, I was able to take advantage of it to tell our story. For that slow news period between Christmas and New Year, it’s likely that I was the most published photographer in the world in both the press and web news sites. It was all a bit surreal given that I was stuck on a ship at the bottom of the world!
I really enjoy the challenges associated with photographing wildlife. I’m not a wildlife photographer per se, but I’d like to explore more subjects in that area. It definitely helps to know a bit about the ecology of the subject so you can be more in tune with the particular behavior of an animal species. I try to take up a position from which I can observe wildlife without altering its behavior, but sometimes, that’s difficult to do, as with inquisitive penguins who often approach the photographer for instance. Faced with numerous subjects all together, or a lot of movement, it can be overwhelming to know how and what to compose to produce a telling image. My approach will differ according to the situation. When the animal(s) are not going anywhere fast, then before taking any photos, I find it helps to observe for a while. Resist the urge to photograph straightaway; learn from what the animal is doing. Consider the overall scene, but also focus on specifics and tight compositions. See if there are any patterns emerging in the viewfinder, and look for unique characteristics that tell a story about the wildlife. I want to show something of its personality if possible. It may be just a turn of the head into a different position that can make all the difference between an average shot and one that stands out; so take the time to choose exactly when to fire the shutter. I am often looking for a specific moment when the movement is ‘just so’ to produce something interesting. That may involve changing lenses too in order to compose in a certain way. Of course, sometimes an interaction takes place quickly and with little time to think or contemplate.
While paddling a sea kayak off the Antarctic Peninsula last year, a Minke whale surfaced nearby and then began moving toward me. I had my Canon DSLR in a chest pouch, and there was just enough time to get the camera out, alter some settings, and take a few shots as it unexpectedly passed immediately underneath my kayak. I could have given up on the photo option and paddled out of its way, but I trusted this intelligent animal to know exactly where the hull of the kayak was and to avoid knocking me and my expensive, unprotected camera into the freezing water. The experience was amazing and all over in a flash. I was happy to get a couple of nice frames of such a beautiful mammal from a unique angle.
What are some important things you have you learned about yourself, mankind, and nature when going on expeditions to such far off and remote places?
Any expedition to remote areas teaches life lessons to those who participate. In many trips to mountainous and icy regions of the world, I’ve learned that such environments, while beautiful and spectacular, can also be dangerous and unpredictable. Anyone with a climbing background knows someone who has died pursuing their passion for high places. Personally, I’ve learned to make do with less and to always be thankful for the comforts and friendships of home, which are best appreciated on returning from exploring remote landscapes in pursuit of hiking, climbing, paddling or photographic goals. Yet, I am only a visitor to these places, and I am continually amazed at the fortitude of those who live
permanently in harsh environments. Expeditions are never about one or two individuals. Success is measured best by harmonious teamwork, sharing a common goal, and with a safe return home as friends. The resilience of mankind is a common thread running through such trips, whether historical or contemporaneous. Consider the awful circumstances of Sir Douglas Mawson arriving back at his hut barely alive after losing his two companions on a mapping expedition, only to find the ship that had waited to take him back to Australia was just disappearing over the horizon, condemning him to a second winter in the dark and cold of Antarctica. It’s apparent in the generous and unyielding nature of local people, living a life far removed from expeditioners they are often called upon to help- Sherpas in the Khumbu region of Nepal for instance or porters from the impoverished village of Skardu, the starting point for journeys up the Baltoro Glacier in Pakistan’s Karakorum mountains.
For those looking to get into the business of travel, adventure, or nature photography, what advice would you give them?
Clearly, it’s not easy to run a business focusing just on those areas of photography in this new digital era, because the market is saturated and budgets have evaporated for magazine work for instance. Hard work, networking, producing images with a unique style and access to amazing locations will be necessary. It’s a broad scope of practice; so be prepared to learn skills shooting across a wide range of subjects. It helps first of all to be a hardy traveler and/or an adventurer and a nature lover. Then, the photography will follow suit;
it doesn’t make sense to do it the other way around. Shoot what inspires you, and the images will stand out that much better because of your understanding of the subject. Enter photo competitions for fun and so that you have a real interest in learning from what images win (in case yours don’t!). Always shoot RAW files, edit critically, learn Lightroom, and get your photos out there— and by that I don’t just mean on Flickr. I mean in magazines, commercial websites, stock libraries, the walls of a gallery or a home etc. Value the time and effort you put in. Be proud of the images you produce by holding out for payment for your images, or at least learn to be an astute judge of when a contribution for free can lead to other things for you or when it’s OK to be generous for a cause.
What do you like about using VSCO Film? If you don’t mind sharing, what VSCO Film pack do you regularly use, and what are your favorite presets?
I really enjoyed taking photos with slide film back in the day and, in particular, using the Fuji emulsions. The ‘look’ of a print from transparency film is unmistakeable, and I think we have lost something special by transitioning almost entirely to digital files, which can sometimes look a little bland. Of course, there are many advantages to shooting digitally- more space in my backpack without the need to carry rolls of film into the backcountry being one of them. Naturally enough, I use the VSCO Film 04 Pack for Canon in my Lightroom RAW processing workflow. It contains some great Fuji and Kodak slide film presets, which when used on the right images help create a beautiful filmic look with good dynamic range. After starting with a good exposure and white balance setting, it’s a one click process to introduce the VSCO preset. And of course, it’s all non-destructive editing with a clear pathway for tweaking the settings to achieve more or less of the slide film effect. I like that flexibility in the creative process. My favorite presets are Agfa Scala for black and white processing, Kodak 100G for journalistic images, Fuji Astia for portraiture and Fuji Provia as a starting point for landscapes.
Where: Lecture Theatre 1 – New Hunt’s House, Guy’s Campus, King’s College London
Contact: [email protected]
(c) Guardian news
Deep in the heart of northern Norway lies the Kjølen mountain range, a series of jagged peaks that line the Swedish border. This bleak Arctic wilderness, more than 100 miles from any major hospital, may seem an unlikely setting for an event that changed medical history but, 14 years ago, the miraculous survival story of Anna Bågenholm for ever redefined our understanding of the boundary between life and death.
Bågenholm, a trainee doctor, was skiing off-piste with two of her colleagues when she lost control during a steep descent, falling on to a layer of ice covering a mountain stream. A hole opened in the ice sheet and she was dragged head-first into the freezing meltwater. Trapped hopelessly beneath eight inches of ice, she was slowly freezing to death.
Normally your core body temperature is 37C but with immersion in ice-cold water, this plummets rapidly. Below 35C, the body enters the state of hypothermia, characterised by shivering and pale skin. Below 30C, most victims will lose consciousness and, when body temperature drops to 25C, cardiac arrest will almost certainly occur.
Although Bågenholm’s friends immediately called for aid, it would take an hour and a half for a mountain rescue helicopter to reach their location. After 40 minutes of desperate struggling, Bågenholm’s body went limp. Shortly afterwards her heart stopped.
Following cardiac arrest, the body enters a state known as “downtime”. This is the twilight zone in which the process of dying begins. Normally within a few minutes of downtime, without immediate medical intervention, death will follow.
By the time Bågenholm was brought to the University Hospital of North Norway in Tromso, her heart had stopped for well over two hours. Her core temperature had plunged to 13.7C. She was in every sense clinically dead.
However, in Norway, there has been an old saying for the past three decades that you’re never dead until you’re warm and dead. Mads Gilbert is the head of emergency medicine at the hospital and, from experience, he knew that there was a slim chance the extreme cold had actually kept her alive.
“Over the last 28 years, there have been 34 victims of accidental hypothermia with cardiac arrest who were rewarmed on cardiopulmonary bypass and 30% survived,” he said. “The key question is, are you cooled before you have the cardiac arrest or are you first having a circulatory arrest and then getting cooled?”
While lowering the body temperature will stop the heart, it also reduces the oxygen demand of the body and, in particular, the brain cells. If the vital organs have been sufficiently cooled before the cardiac arrest occurs, then the inevitable cell death from the lack of circulation will be postponed, buying emergency services an extra time window to try and save the person’s life.
“Hypothermia is so fascinating because it’s a double-edged sword,” Gilbert said. “On the one side it can protect you but, on the other side, it will kill you. But it’s all a question of how controlled the hypothermia is. Anna was probably cooled quite slowly but efficiently so that, when her heart stopped, her brain was already so cold that the oxygen need in the brain cells was down to zero. Good CPR can provide up to 30-40% of the blood circulation to the brain and in these cases that is often sufficient to keep the person alive for sometimes seven hours while we try to restart the heart.”
Crucially the levels of potassium in Bågenholm’s blood were normal, a key indicator of the extent of cell damage in the body and the decision was taken to warm her up. If the potassium is beyond a certain threshold, the person has no chance of survival.
Four and a half hours after Bågenholm first fell through the ice, her heart was successfully restarted. She spent 35 days on a life support machine before being moved to intensive care and then a rehabilitation unit. From there, she began the slow process of training herself back to complete restoration.
Her extraordinary story has led to therapeutic hypothermia being introduced as a protective measure for victims of strokes, liver failure and epileptic seizures. Recent studies have also illustrated its effectiveness in newborn babies who have suffered a lack of oxygen at birth.
It is commonly used around the world in open heart operations where surgeons will cool the body down to as low as 10C, allowing them to cut off the arterial supply to the brain for up to 15 minutes without any notable brain damage.
Jasmin Arrich, of the Medical University of Vienna, researches the use of therapeutic hypothermia during or after resuscitation from cardiac arrest.
“In these cases, the patient’s body is cooled down to mild hypothermia (32-34C) for 12-24 hours,” she said. “We do this because when this patient can be resuscitated and the circulation starts again, various pathophysiologic mechanisms are initiated and substances are formed that continuously keep on damaging the brain cells and other cells of the body. Mild hypothermia exerts its beneficial effects on many of these mechanisms and substances.”
However, there has been some controversy over the introduction of therapeutic hypothermia as a mainstream procedure for certain conditions based on unsubstantial evidence. A group of Swedish scientists have released a new paper questioning the levels of hypothermia that are applied as a protective measure to the unconscious survivors of cardiac arrest.
“We have to be careful because hypothermia is also dangerous to the body,” Gilbert said. “It is upsetting the enzyme system, the cellular membrane balance and the integrity of the cells. And in trauma, we know there is a linear relationship between the degree of hypothermia in the trauma patient and the mortality rate. The clotting mechanisms are greatly influenced by hypothermia in a negative way. Anna was able to survive for so long because she didn’t have a trauma. She didn’t have any bleeding anywhere.”
Fourteen years on, Bågenholm now works as a senior radiology consultant in the very hospital where her life was once in the balance. Nobody before or since has been so cold and lived to tell the tale. These days, she once again partakes in extreme skiing in the mountains of north Norway, a living reminder of the human body’s capacity for endurance.
(c) Guardian news
London’s Air Ambulance features in BBC Two – An Hour To Save Your Life (#AHTSYL) – 3-part series starting 4th March, 9pm
This new series looks at innovations in emergency medicine and the improvements in patient outcomes as a result of doctor-led pre-hospital care and fast-tracking heart attack/cardiac arrest, stroke and trauma patients to specialist centres.
It was filmed over the summer of 2013, spending two months with London’s Air Ambulance including with our Physician Response Unit (PRU), a medical emergency fast response team who are tasked to out-of-hospital cardiac arrest patients, at The Royal London and London Chest Hospitals and with the London Ambulance Service. Filming also took place in Nottingham and Birmingham.
Across the three programmes, nine patient stories are featured, five of these are involving London’s Air Ambulance in the pre-hospital phase. The key clinicians involved in each patient case conducted in-depth retrospective interviews so the style of the programmes is very much clinicians taking the audience through what happens.
Watch the film here…
Not many things you can say that change your life! Attending the Wild Medicine course was one of those events. Amazing set of people and a fantastic opportunity to learn about conservation and desert medicine.
The kind of odd things we learnt…
– Take blood from a cheetah,
– Learn about (and touch – optional) many poisonous snakes,
– Sleep in a desert, walk 14km through a dry river canyon,
– What are the problem animals with Rabies? (A: Kudu),
– How can carnivores live outside conservation areas & not get killed by farmers &
– How to build a vineyard in a desert … what?!..
And the thing that changed our lives? Meet the Bushmen and see their need for healthcare! My wife and I are volunteering at Naankuse to run the Bushmen medical services. The real thing we learned? There are many people out there that can benefit from our skills …
Oh and by the way Namibia is amazing you get to see loads … but you can also get a 4×4 and do a week or so trip before the course.