Never Off Duty?

Katie Hawkins / General Practitioner / Scotland

Another great article curtesy of Adventure Medics

So, you’re a doctor and you want to go on holiday somewhere exotic? Have you it through before you go? Dr Katie Hawkins, newly married and a recently qualified GP, tells us the tale of her honeymoon trek in remote Nepal. Her story beautifully illustrates some of the problems that can be encountered as an off-duty medic in a remote place. Katie also includes some excellent advice to help you deal with such problems yourself, while giving us the lowdown on the GMC and defence unions’ views on Good Samaritan Acts. Despite her honeymoon, Dr Hawkins remains happily married and is now working for the International Porter Protection Group in Nepal. (Photos: Sam Hawkins)

Big plans

Imagine this: it’s your honeymoon, and you’ve been dreaming of a big trip – to go away together, to be just the two of you. You love mountains, climbing, walking and adventures. Finally you manage to arrange time off work. You’ve not managed to get time like this since University days, trekking in Nepal. It’s a must, and you’ve earmarked a trek you’ve heard only a few people do. It will be bliss.

There are a few mutterings from friends:

Have you met the people you’re going with?

Don’t worry, we’ve been assured that they’re all super fit and anyway, if we get bored of each other at least we’ve got company.

The day before you leave a kind colleague thrusts some dexamethasone and nifedipine in to your hand and says ‘this might be useful’. Also by chance you ordered the book Pocket First Aid and Wilderness Medicine by Jim Duff and Peter Gormly. This arrives on the morning of your departure.

On arrival, there are the standard problems of missing luggage, retained passports and road blocks. However somehow, later that evening and despite the chaos, you find yourself eating veg thali and sipping on a cool beer. Well here we are.

However, it’s not just the two of you. You’re sitting at the table with your trekking group, all in their 60s. You think:

This can’t be right. Well if they’re not young then they must be fit

They are really lovely people and are filled with the same enthusiasm for the mountains that you have. For some of them though, it’s even more than this – this is their adventure of a lifetime! You decide not to be ageist. They seem lovely and you look on the bright side.

However, a few warning shots are fired. One man pipes up that this is his first trekking trip. It seems he hasn’t camped or trekked before. He is also recovering from a broken leg.

Then it emerges that your group also has a woman recently recovered from an episode of vestibular neuronitis, and a man who had a pneumothorax last year. The man with the broken leg is not able to take big steps does not trust it on uneven surfaces. Still you’re all a team now and you get along well. You’re still enthralled by the sights, sounds and smells around you, so you decide to appreciate being here and try not to let it all worry you.

Funnily enough it’s slowly dawning on you that although you’re on your romantic holiday, you’re still a doctor. Well are you? The inevitable conversation at the start of the trek begins, what do you do back home?’ Will you say it? What harm can it do? ‘Okay, I’m a doctor’. ‘Ah, she’s a doctor’, someone says to the trek leader… Help.

On the road

You come to the first village and due to their excessive loads, many of the porters have blisters. It seems that the trek leader’s kit has no tape in it, so you offer them some of your Compede. ‘She’s a doctor’ they all say and soon you have 5-10 people coming up to you for help. ‘You should get your local nurse to see to that’ you say to the man with a nasty sore. ‘There isn’t one for miles’. A quick check of the other people, and alarm bells are ringing. Only treat people in an emergency, you think to yourself. Is that right? What should I do? You soon escape the village, having handed over iodine solution and some plasters and realise you need a rethink. ‘I am a doctor, but I’m on holiday’, you tell the trek leader. Phew that should sort it.

Diarrhoea starts spreading around the porters, another comes to you with really painful athletes’ foot. Another porter bashes his head and is sent home (alone?) before you’ve even set eyes on him. Where does my responsibility lie?

Before you left you had a quick briefing. ‘If you get altitude sickness you must go down’. Back in your medical student days you’ve been to altitude with young, fit classmates. You vaguely remember one chap feeling a bit funny and heading down and not getting to the top, but otherwise everyone seemed okay. How would I recognise altitude illness? How fast should I really be ascending? You’ve always known it’s slow but not really thought about the specifics of how to avoid it and how to diagnose it?

You realise soon enough that the group are looking to you for advice:

Should we take Diamox?

How much water should I drink?

Should my hands be this puffy?

How should I manage my nasty cough at altitude?

One of these seems easier to answer than the rest, or does it? Where’s my stethoscope and sats probe? I didn’t think I’d need them on holiday.

Somehow you feel you’re in a role you were not prepared for. You tell the group that you’re interested in mountains but not the expedition doctor. They need to make their own decisions. You will try and help in an emergency but that’s it. However, you feel a sense of impending doom.

Altitude blues

You arrive at camp at 4800m. It’s been a fairly long day and you’ve now made it to well above the tree line. You can feel the altitude a bit here, but having trekked up and beyond the previous camps each night, you feel you’re acclimatising well. So you kick off a game of Frisbee with the porters. Beautiful light caressing the peaks, glowing with florescent colours. No wonder people used to think the mountains were Gods. You feel small and insignificant with these towering above you. And then the light is gone. A cold wind and chill sweeps through the valley. Although the mountains are tempting you up them, this is a stark reminder that ‘this is no place for men’.

Back at the tents you realise that one of the group has started to panic. This has been a recurring theme all the way up but you’ve got them to this stage so you feel you’ve done quite well. ‘He’s cold’ they say. Luckily you’ve been reminding yourself how to treat hypothermia by reading the pocket book. Hot drink, bottles in the sleeping bag and huddling in mess tent. He seems better pretty quickly. In the back of your mid you’re thinking is this AMS?

There’s the call of ‘Dinner is ready’. You see a woman emerge from their tent and stumble, trip, wobble. ‘This is how I always walk’, she says. This is true in part but how do you distinguish pre-existing vestibular neuronitis from cerebral oedema? You revert to your now trusty text. No advice there. You decide that it would be difficult. It’s dark and icy. You say:

It’s probably best that you go down

I’ll just have my dinner thanks and I’ll be fine

Can you argue with that? She’s certainly walking a bit better after dinner. You’re not sure what to advise, and should you be advising anyway? She refuses to descend so you make sure her tentmate will keep an eye on her.

In contrast, the man hardly eats anything at dinner. ‘I’ve had lots during the day.’ You advise him to go down as well but he refuses but agrees to share a tent with one of the other guys who will keep an eye on him. By now alarm bells are not just tinkling, they’re ringing loudly. You scribble down some notes before going to sleep; I probably ought to keep some sort of record. However, at the same time you plan a possible escape for the two of you.

At 0030, you have the dreaded feeling of needing a pee. This has been quite normal occurrence over the past few nights. You’re just having the same argument with yourself about leaving your warm sleeping bag, when you hear a kerfuffle outside.

Five porters are carrying the man in his sleeping bag to the shelter. Oh help. This is an emergency. I’ve no choice but to get involved now.

He looks a bit puffier, claims he can’t stand up, can’t see and his headache has returned. What headache? This time it’s 1am, you’re feeling the altitude yourself. Armed with your first aid kit and trusty book, you check his finger nose point test, he cannot walk and his respiratory rate is 40. This is an emergency. We’ve got to get him down. You give him a Diamox whilst the trek leader is ordering soup.

The rivers are bigger at this time of night due to the melt run-off in the day. It’s also icy (-20°) and the porters have flimsy plimsolls on their feet. The leader says they can’t take him down. You try to treat him. You look up the doses for nifedipine and dexamethasone. Soon after you’ve fumbled with boxes and books and plucked up the courage to give him the treatment, a decision is made to attempt descent.

You’re realising now that altitude sickness is unpredictable. Will descent make him better? You hope so, but now, being this involved you decide that you would not forgive yourself if anything was to happen. You’re going down too. The porters and leader prepare a basket with poles across the bottom and strap the man, in his sleeping back, into the basket with a belt. Three able porters then take it in turns to carry the basket, using straps across the fronts of their heads, and down you go.

The streams are bigger, throwing out the melting ice, rubble and dust from the mountains down to the camp below. The porters negotiate these, but also the landslides at top speed. By 5am, still dark, you can hear the familiar sound of the tinkling of Yak bells in the camp below. You’re all down safely. The man is feeling better and the porters are your new heroes.

What now?

Your only way out now is over a 4900m pass or 7 days of undulating trekking to back your starting point. The man assures you that now he’s fine and can continue the trek. You are at least certain of one thing: no chance. Fed up with the commotion and feeling sick with the lack of sleep you start strolling back to the previous day’s camp. On your way up you meet the chesty woman, still stumbling, coughing and looks as though she’s aged 20 years. Again??

So now, two casualties, both insisting they can carry on trekking, and you’re pretty sure that they can’t. Luckily the trek leader steps in and is very willing to organise a helicopter. Within two hours it arrives and they are both whisked away. Gone. All that’s left is the fluttering in the breeze of the makeshift ‘H’ made out of loo-roll. A small child is dancing delightedly holding a piece aloft.

Onwards

From here your trek goes up over a pass and into a still colder and higher valley. From this point, although missing the banter from the others, the pace picks up and there’s more time to spend together and stand in awe amongst the towers, pillars and giants above you.

Twenty-eight days finishes with smiles; a wonderful, memorable holiday to a magical place, the mountains of the gods. Yet there are still questions playing on your mind, most notably: did I do the right thing?

My honeymoon, as well as plenty of others’ tales, raises some of the issues to consider when going on holiday as a doctor. Although advice and guidance may differ depending on which country you travel to, I have attempted to offer some tips below.

It’s you!

Know when you might/need to help in an emergency

The GMC Good medical Practice Guide states that ‘In an emergency, wherever it arises, you must offer assistance, taking account of your own safety, your competence, and the availability of other options for care.’ Good Medical Practice applies to all doctors, whether they have a licence to practice or registration only.

In other words, you are in it, whether you like it or not.

Indemnity

Make sure you are aware of what your indemnity covers you for prior to departure.

The latest responses from the three leading UK defence unions from email and telephone advice (Feb 2013) are as follows:

MDU / The MDU is primarily a UK indemnifier. We are not set up to handle claims arising from overseas. For this reason we advise our members to seek indemnity in their destination country for work abroad. There are some circumstances where indemnity might be granted for overseas work but this is on a discretionary basis, We are unable to offer this for the USA, Canada, Australia, Zimbabwe, Hong Kong, Bermuda, Israel, Nigeria.

MPS / As a truly Global organisation, MPS provides indemnity and support to healthcare professionals in over 40 countries, We can offer access to indemnity for our UK-based members who undertake medical work abroad, including those who work as an expedition medic. The rate charged for this will vary largely on the location, nature of work to be undertaken, earnings of the doctor and the time period over which the indemnity is to be provided. Existing members will benefit from reduced subscription costs. MPS is unable to indemnify health professionals working in some countries, including the USA or Canada. If the act is a ‘good Samaritan act’, the MPS will aim to assist no matter where in the world the care is being provided or action is brought.

MDDUS / Doctors are only covered to go on expeditions provided that they are going on a voluntary basis with a UK registered charity. We require written notification from the charity confirming details of the expedition, and we only cover claims raised within the UK jurisdiction. If the doctor is being paid as the expedition medic and /or the doctor is not going with a UK registered charity, the doctor will not be covered. All members do have worldwide cover through MDDUS membership for Good Samaritan acts in emergency situations.

Kit

Think carefully about what you take in your first aid kit.

When you make up a first aid kit to go abroad, you must make decisions based on whether you are providing for yourself, for you and the group, or for everyone including porters and locals. If you are also providing for your group and locals, your treatment is no longer a ‘Good Samaritan act’. You would need to contact your defence union to make sure that you have the correct indemnity for this.

Jim Duff and Peter Gormly’s book provides a handy resource to help in emergencies. Ultimately, what you decide to take is your own personal decision but there are plenty of resources out there. For example, Adventure Medic’s own Resources Section.

If you prescribe for others on the trip think carefully about why you are doing this, especially at altitude. The GMC states:

Wherever possible you must avoid prescribing for yourself or anyone with whom you have a close personal relationship’. If you prescribe for yourself or someone close to you, you must make a clear record at the same time or as soon as possible afterwards. The record should include your relationship to the patient (where relevant) and the reason it was necessary for you to prescribe.

Tell your own or the patient’s general practitioner (and others treating you or the patient, where relevant) what medicines you have prescribed and any other information necessary for continuing care, unless (in the case of prescribing for somebody close to you) they object.

You must not prescribe or collude in the provision of medicines or treatment with the intention of improperly enhancing an individual’s performance in sport. This does not preclude the provision of any care or treatment where your intention is to protect or improve the patient’s health.

If you are prescribing a medicine for somebody overseas which is being dispensed overseas, you should check whether you need to be registered with the country in which you are prescribing.

Specialist?

If you do have mountain medicine experience, be wary of stating you are a ‘specialist’ as you will be judged against your peers.

Vetting

When going in a group, make sure you do your best to vet your companions carefully. You may be able to meet before-hand, speak over the phone or email. This will at least give you some idea of what you are letting yourself in for. I found this out the hard way, as problems within the group had been denied by the agency but only revealed themselves on our arrival. Some companies have medical vetting procedures and some don’t. It would be worth asking your company about this, even if you are only going on holiday somewhere remote.

10% off…

Be wary of companies that offer that you can act as Expedition Doctor and get a 10% reduction. This may be tempting but make the decision carefully. Check whether they would provide first aid kits/medications and what they would include. Check your indemnity. The extra cost may actually be considerably more than the 10% reduction.

Treating the locals?

Even if you are not medically qualified, if you employ local porters or guides, you are responsible for their health. They should be treated in the same way as any other member of the group. See the IPPG ‘Guidelines on Ethical Trekking’ for more on this subject.

The decision as to whether or not to treat local people en route is difficult. Unless the problem is an emergency it is usually best to refer the problem to local health care workers. Treatment may be appropriate if i) the problem is an emergency, ii) you can provide a full course of treatment, iii) you will be around in the area to give the patient adequate follow up.

In the case of chronic illness it may be appropriate to provide a letter for the patient to take to their nearest health care facility.

If a medical problem arises, keep detailed notes of what happened. This is important medico-legally, even if acting as a Good Samaritan. The GMC states ‘you must keep clear accurate and legible records, reporting relevant clinical findings, the decisions made, and any other drugs prescribed or other investigations or treatment’ and ‘make the records at the same time as the event you are recording or as soon as possible afterwards’.

Beware of buying medications abroad. It is common that medication ‘is not what it says on the tin’. Also be aware of internet sales as in >59% cases medicines from illegal sites have been found to be counterfeit.

Opiates

The home office website has some useful advice on where you can take opiates. Make sure you speak to them and also the country of origin prior to travelling, as well as taking all prescriptions with you. It is not advisable to take any opiate through United Arab Emirates countries or Saudi Arabia (5, 6).

Putting the ‘surgeon’ in Tree Surgeon

Consider the option of not telling anyone you’re a doctor. If you really are going on holiday, and fancy a break, there is always the option of not telling anyone you’re a doctor, but remember in the event of an emergency, GMC guidance says that you must step in. In such an event, it may then be hard to explain to your companions why a part-time musician/novelist/barmaid has suddenly morphed into a full-time, business-like clinician.

References

Duff, Jim; Gormly P. First Aid and Wilderness Medicine. Tenth ed. Cicerone Press; 2007. GMC. Good Medical Practice. Point number 11. P. 11. 13th Nov 2006. GMC. Good practice in prescribing and managing medicines and devices. GMC. 31 Jan 2013. World Health Organisation. Medicines: spurious/falsely-labelled/falsified/counterfeit (SFFC) medicines. WHO May 2012. Home Office: licensing for drugs.  Accessed 31/1/2013. Home Office: list of UK based Embassies. Accessed 31/1/13.

Of interest

• Expedition & Wilderness Medicine course
• Polar Medicine
• Jungle Medicine