Take a look at our latest newsletter to find out more about the amazingly adventurous Dr Andrew Peacock
We know that education opens doors and as the EWM crew are both interested and a bit nosey, we love to hear what our alumni get up to after attending our courses. Naturally then, we were delighted to hear from Ian P, who told us he and his wife loved the 2013 Wild Medicine course so much, they’re busy packing up in the UK and moving to Namibia…
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.
Expedition & Wilderness Medicine’s new Conservation Medicine course in Namibia has been accredited for 16.5 CME
Located at the stunning N/a’ankuse Lodge and Wildlife Sanctuary only 42kms east of Windhoek is Expedition & Wilderness Medicine’s new Conservation Medicine Course. This truly unique lodge is set amidst a natural savannah, with riverine vegetation, lush grass plains and magnificent mountain views, and offers a malaria free Wild Medicine course.
The main objective of the course is to educate attendees as to how we can integrate the diagnostic and problem solving skills of both human and animal health professionals with the knowledge of conservation professionals. Ultimately this should help all concerned to better manage the environment and biodiversity to the benefit of all the inhabitants of our beautiful planet.
The emerging interdisciplinary field of conservation medicine, which integrates human and veterinary medicine and environmental sciences, is largely concerned with zoonose. At the present time there is very little sharing knowledge in both an academic and practical session and this course serves to address this significant gap.
More information on our course here
Expedition Medicine’s UK Course Welcomes their University Liaison
With the sunshine out and the rasping sounds of the Search and Rescue Teams over the two-way radios out on the Cumbria hills – you would have been easily mistaken in thinking you were in the middle of a real emergency. In fact, it was the final Search and Rescue exercise (with CASEVAC) of a fantastic 4 day Expedition Medicine Course in Keswick in Cumbria.
As the University Liaison for Expedition Medicine, it was the first course that I attended as a new member of the ‘EM faculty’ – and what a fantastic experience it was. Not only did I get to absorb the electric atmosphere of the 60+ delegates there alongside the seasoned expedition medics leading the course but it gave me ample opportunity to see how such courses can align themselves with my role as University Liaison and to stimulate a few more ideas.
International Extreme Medicine EXPO- Expedition & Wilderness | Tactical | Disaster Medicine
‘Taking Medicine To The Extremes’
A major new International ‘World Extreme Medicine conference and EXPO’ series with the first inaugural event in London April 2012 followed by Salt Lake City in September 2012 with the very best speakers from around the world, leading figures from the world of expedition and wilderness travel, displays from focused industry leaders and also awards. All CME accredited on a modular basis to allow you select just a day or to attend the entire medical expo.
Over the last ten years the care of casualties in a remote environment has come a long way. This has been driven by conflict, the apparent exponential rise in natural disasters and our capacity to respond on an international scale and not least by the evolving interest in the field of expedition and wilderness medicine. The conference concept was generated out of a desire to amalgamate the associated specialties in this field and to share the skills and knowledge we have acquired. It will run over 4 days and involve some of the major specialists in their field of remote and austure medicine.
Developed specifically with medical professionals in mind the International ‘World Extreme Medicine EXPO’ will also be of interest to other medical specialists and students for which there will be a discounted rate.
The treatment of cholera in an active malaria zone is a difficult matter. This is especially true with lessons being learned in Haiti and their recent cholera outbreak. I am specifically referring to the combination of Chloroquine (antimalarial) and the antibiotic class Macrolides (used in treatment of cholera). A post that I made back in 2009 has new recent relevance and I wanted to repost that here:
Azithromycin, Chloroquine and Arrythmias:
Travel medicine frequently uses medicines that are taken under special circumstances and for short periods of time, like a trip. Many travelers carry an antidiarrheal antibiotic on their trip and a common choice is azithromycin. This can potentially be a problem when they are also traveling in a malaria area and using chloroquine for prevention. Two very commonly used medicines chloroquine (antimalarial) and azithromycin(macrolide antibiotic used for respiratory infections and diarrhea) both have wonderful safety profiles, individually. However when taken together, there is discussion of the chance of a heart arrhythmia, specifically prolonging the QT interval. In fact, my software I use for prescribing cites this as a combination to avoid.
There are several important articles that can be used to look at this problem and evaluate the risks. One very good paper looks at medications that prolong this QT interval:
- “What clinicians should know about the QT Interval” by Sana M. Al-Khatib, et al.
These authors list azithromycin as a “very improbable” medication, although other macrolides are listed as higher risk. Chloroquine is listed as an “Unknown” medication, with respect to prolongation of QT interval. This article was based on expert opinions.
- “Azithromycin/Chloroquine combination does not increase cardiac instability despite an increase in monophasic action potential duration in the anesthesized guinea pig” by Fossa, et al.
This study looked directly at this problem, in animal models. Their research showed no increase in arrhythmia risk.
- “Lack of a pharmacokinetic interaction between azithromycin and chloroquine” by Cook, et al.
A wonderful article that is actually helping to look at using this drug combination to treat resistant forms of malaria. More about this combination and treating malaria here. Their study did show an increase in the QT interval in both groups of those who received chloroquine alone and those who received the combination of chloroquine and azithromycin. This QT interval increase was maximum on day number three and returned to baseline by the end of the study.
Most of the information I am finding looks reassuring for safely using this combination, in healthy individuals. Those with a history of arrhythmia should use this combination with caution and discuss this problem with their doctor, before they take these two medicines within a close amount of time.
Contributer: Dr Erik McLaughlin | www.adventuredoc.net
Pre-hospital Expedition Medicine Series
Dr Amy Hughes, Medical Director of Expedition Medicine and Pre-Hospital Emergency Medicine Registrar and HEMS paramedic Dave Marshall, both part of the Kent Helicopter Emergency Medical Team, continue their series examining pre-hospital expedition trauma care and associated kit.
In the second article in the series, Dave Marshall gives an overview of managing pelvic fractures pre-hospitally and in an expedition environment, and introduces the use of the pelvic splint.
Edited by Dr Amy Hughes.
Pre hospital and Expedition management of pelvic trauma and use of the pelvic splint
Expeditions have become more and more adventurous over the past years, both in destination and the participants involved. As a result, the frequency and pattern of injury is changing and the demand on the medical team thus increased. Having a broad knowledge of fracture management, including mechanism of injury, clinical findings, reduction techniques and splinting is essential. Although one of the most enjoyable challenges of being a medic on an expedition team is improvisation regarding kit used to manage various ailments and injuries, practice and competence in the use of non-improvised kit such as the Pelvic Sam Splint is essential.
Mechanism of Injury
Pelvic fractures often result in extensive disruption of the bony structures and associated ligaments of the pelvis and are potentially life-threatening injuries. The fractures associated with the greatest morbidity and mortality involve significant forces such as motor vehicle crashes, motorcyclist crash, pedestrian versus car, falls from height and crush injuries. Early suspicion, identification and management of a pelvic fracture at the prehospital stage is essential to reduce the risk of death as a result of hypovolaemia, (1). It is especially important to be able to identify, treat and minimize risk of further damage when in a remote area miles from the nearest medical facility.
Understanding the mechanism of injury is vital in being able to predict the potential for significant injury to the pelvis and its underlying structures, even in the absence of clinical signs. It is, therefore, essential that time is taken to evaluate the mechanisms involved in any accident resulting from significant force or where there is pain or injury to the spine, abdomen, pelvis or femurs.
In motor vehicle accidents – a not uncommon event on expeditions – learning how to ‘read’ the wreckage to help identify possible pelvic injury, in conjunction with clinical suspicion, can significantly aid diagnoses.
The intrusion into the passenger and drivers door is likely to result in massive lateral injury to the pelvis.
The intrusion into fuel tank shows the imprint of the riders pelvis. This would often result in significant fracture to the pelvis – often multiple, often ‘’open book’’ pelvis.
Anatomical structure of the pelvis
The pelvic ring is often likened to a polo mint in that it is almost impossible to have a significant break in one place and not another. The most common area to be damaged in trauma is the pubic rami, acetabulum and the sacroiliac joint. There is extensive vasculature through and around the pelvic ring, most notably the iliac vessels. For imagery see > http://visualsunlimited.photoshelter.com/image/I0000kUOn3NJHcZU.
The greatest risk of a pelvic fracture is catastrophic haemorrhage and gentle handling of the patient in the initial and subsequent stages could literally be the difference between life and death. Whole blood clotting time is approximately 10 minutes, (depending on the environment). Expedition medics should be familiar with the ‘first clot best clot’ theory. In other words, a patient sustaining a traumatic injury resulting in haemorrhage will begin to form a clot using their own clotting factors. If this clot is disrupted they could easily bleed to death. A full fluid resuscitation will not be practical in the field as most expeditions carry a maximum of 2 litres of crystaloid. However it should be noted that overloading the patient with fluid can be equally harmful, and small boluses should be given to maintain a central pulse and cerebral perfusion. This is known as permissive hypotension and will be discussed in more detail in a future article. Disruption of this first clot in the prehospital setting could be fatal, and without access to blood and clotting agents the patient may die. Trauma will result in the patient becoming acidotic, hypothermic, and coagulopathic. (3)
This coagulopathy cannot be easily reversed pre-hospitally, each factor contributes to the decline in the others. (see above diagram). Any disruption to the first clot will have devastating consequences. Ultimately, the patient requires definitive haemorrhage control, (surgery, angiography and embolisation), and replacement of blood and clotting agents.
The glass pelvis: Think of the pelvis as being made of very fragile glass, and you can see the clot in the form of a cartoon jelly inside. The jelly is very delicate and unless movement is gentle and kept to a minimum, it will ‘wobble’ to the point of destruction very easily. The same applies to the blood clot! Early recognition of the potential for a pelvic injury, gentle handling and prompt stabilisation is vital to improve the outcome of a patient injured on an expedition.
Clinical Features of a pelvic injury:
- Management of pelvic fractures and clot preservation:
Asymmetry of the pelvis – do not spring the pelvis. Visual alignment and gentle palpation of the Anterior Superior Iliac Spine may help demonstrate pelvic injury, but often the pelvis visually appears normal, thus mechanism of injury is vital in determining injury
- Shortening/rotation of the leg/s
- Inguinal pain
- Localised swelling/contusion
- Hematuria/urinary incontinence
- Bleeding PR/PV – PR examination not recommended to determine pelvic injury.
- MECHANISM, MECHANISM, MECHANISM! (albeit not a clinical feature!) – there may be no obvious clinical abnormality despite significant injury. Thus clinical suspicion is essential.
As we have already discussed, a patient with a suspected pelvic fracture must be handled very carefully. Whether in a medical facility or the most extreme expedition environment, the same principles apply to prevent worsening the injury and preserving the clot.
Log rolling the patient should be avoided at all costs!
The medical kit available on expeditions will be minimal. Stretchers may have to be improvised and transportation limited. However, all medical kits should have some sort of pelvic binder which should be applied carefully and correctly at the earliest opportunity,
Application of the pelvic SAM splint.
The casualty will inevitably have to be placed in the supine position, to evacuate them on whichever device is available. This can be achieved by a coordinated team approach utilising other members of the expedition.
One person should be at the head end of the patient maintaining in manual inline immobilisation, (MILS), and they will give clear commands to the team when moving the casualty, (“ready, brace, roll”). A pelvic binder such as the one shown can be applied using a minimal 10-15% roll, (enough to get a bum cheek off the ground!)
Once in position the device can be tightened just enough to maintain anatomical alignment. Do not over tighten as this could cause significant further damage!
Log rolling patients.
Whilst sometimes useful in a controlled hospital environment following appropriate imaging, should be avoided in the pre hospital field. In simple risk versus benefit terms it could have catastrophic consequences. By using the hands available and correctly briefing the team about the amount of movement required (one cheek off!), it should be possible to optimise the care of the casualty prior to evacuating them to definitive care.
Improvised methods of pelvic splinting on expeditions
Much of the challenge of expedition medicine is improvisation. The medical kit you take out with you may not have SAM splints in them. Providing a support can be placed across the greater trochanter, then any sort of material could be used – for example clothing, a sheet, or a canvass of some kind.
The approach to fluid management in trauma has changed. Two litres of fluid is not necessarily required for management of pelvic injury. Titrate fluid according to the presence of pulses or cerebration (alertness). The presence of a radial pulse, and even in certain circumstances (without associated head injury) presence of a femoral pulse signifies the blood pressure is sufficient to perfuse the necessary organs and promote clot preservation. Further details of permissive hypotension will follow in another article.
Essential – this depends on what is available. Intravenous opiates or a fentanyl lolly is ideal for analgesia, after the use of paracetamol or a NSAID.
Pelvic injuries are often present in conjunction with other significant injuries – spinal, femur, urological or abdominal as examples. Whether or not other injuries have been excluded, spinal precautions are essential in conjunction with good management of the pelvis.
- Lee C, Porter K. The prehospital management of pelvic fractures, Emergency Medical Journal 2007;24:130-133
- Maya A, Matinowitz U, Kluger Y. Coagulopathy in the critically injured patient, Yearbook of Intensive Care and Emergency Medicine 2006, Part 5,232-243
- Crawford C, Pelvic Fracture in Emergency Medicine, available at: http://emedicine.medscape.com/article/825869-overview
Medical and Dental Defence Union of Scotland (MDDUS) took the opportunity in one of the quieter periods in Expedition and Wilderness Medicines Medical Director Amy Hughes hectic schedule to interview her about her career in expedition medicine.
MDDUS (Medical and Dental Defence Union of Scotland) is an independent mutual organisation offering expert medico-legal advice, dento-legal advice and professional indemnity for doctors, dentists and other healthcare professionals throughout the UK.
Feedback on our recent Polar Medicine training course in Norway has clearly affected some of the course delegates by creating a need for ‘biggles-speak’…
PapaFoxtrot calling Red Leaders AlphaHotel, AlphaCharlie, DeltaBravo, Bravo and Delta
Congrats on recent Operation Polar Bear
Bunks and chow excellent
Red Leaders all SPLENDID
Hope all returned to base safely
Please pass on to all members of Polar Bear as don’t have call signs
Do you read me ?
Dr Amy Hughes medical career has been far from ordinary and she talks about how she has ended up as medical lead at WEM.
Dr Hughes co-leads with Dr Luanne Freer our CME accredited Mountain Medicine course on the Everest Base Camp trail in Nepal.
Dr Amy Hughes, Medical Director of Expedition Medicine and Pre-Hospital Emergency Medicine Registrar with Kent Helicopter Emergency Medical Team gives a brief overview of managing femur fractures in an expedition environment, in the first article in a series examining pre-hospital expedition trauma care and associated kit..
Management of a mid-shaft fractured femur in the field and use of the Kendrick Traction Device
Expeditions have become more and more adventurous over the past years, both in destination and the participants involved. As a result, the frequency and pattern of injury is changing and the demand on the medical team thus increased. Having a broad knowledge of fracture management, including mechanism of injury, clinical findings, reduction techniques and splinting is essential. Although one of the most enjoyable challenges of being a medic on an expedition team is improvisation regarding kit used to manage various ailments and injuries, practice and competence in the use of non-improvised kit such as the Kendrick Traction Device is vital.
Mechanism of injury
Fractured femurs form only a small percentage of common injuries on expeditions but can be associated with significant morbidity and mortality. Early effective management is vital in view of the risk of significant blood loss, pain, long term complications and compartment syndrome. In assessing and managing femur injuries, it is also very important to exclude associated injuries such as chest, axial skeleton, pelvis and head. This article will focus only on mid shaft femur injuries, further discussion on management of multi-trauma will be examined in another article.
A high energy force is often needed to fracture the femur in a young, fit individual unless they have a pre- existing medical condition predisposing them to reduced bone density (osteoporosis, malignancy, malnutrition, muscle atrophy, previous fracture). Road Traffic Collision are the one of the most common risks to participants on an expedition and a common mechanism for high energy transfer resulting in fractures of the femur – especially dashboard injuries. Other mechanisms of injury include falls from height, pedestrian versus vehicle and direct trauma to the leg. As mentioned above, associated injury need to be considered and managed appropriately, especially pelvic injuries.
Mid shaft femur fractures
These fractures are almost always the result of high energy trauma, the mechanisms of which have been mentioned above. As the femur is very vascular, injury can result in significant blood lost and a requirement for haemorrhage control and clot preservation pre-hospitally until definitive care can be reached is paramount. The pattern of femur injury often results from the direction of force applied. For example, a perpendicular force results in a transverse fracture pattern, an axial force may damage the knee or hip and rotational forces may cause spiral or oblique fracture patterns (1) . Again, understanding the mechanism of the injury is fundamental in determining the resultant pathology. Further complications from mid-shaft femur fractures include deep vein thrombosis, fat emboli, nerve palsies and rarely compartment syndrome.
Pain is the initial most significant feature. The leg may be shortened and rotated and/or visually deformed with swelling and fullness to the thigh. If the injury is compound (or open) then there will be a wound over the fracture site communicating with the bone / bony fragments. The person will be unable to weight bear. A neurovascular assessment should always be done, with distal pulses felt (often worth marking the pulse with an ink cross) and distal perfusion monitored both after the initial injury, following any intervention and throughout the course of the casevac.
It is vitally important to ensure there are no other traumatic injuries, and an ATLS management approach to the patient should be made.
The ultimate aim of management of a femur fracture is to return the limb to its normal anatomical position. This not only helps reduce pain by bringing the bony fragments into alignment and reducing muscle spasm and soft tissue involvement, it also reduces bleeding, improves clot preservation and helps improve distal perfusion. In the pre-hospital expedition environment resources are limited but if there are no formal traction devices available, improvised devices can easily be used.
Steps to management of mid shaft femur fractures on an expedition
ANALGESIA – depending on what you have available:
- If the injury is a compound fracture (open) or has a wound associated with it, it must be irrigated. This does not have to be done with sterile water – water from drinking bottles or taps can be suitable for preventing wound infection (2, 3) . The wound must be irrigated thoroughly to reduce the risk of infection. It is likely that it will be some length of time before the injury is dealt with in definitive care and re-irrigated. This applies to any wounds sustained to the patient. A dressing can be applied to the area. Irrigation can be undertaken at the same time as traction is being applied.
- The leg needs to be put under traction. Whilst kit is being assembled, the leg can be held in traction by any member of the team. The foot and ankle can be held, and the leg pulled out to anatomical alignment and held in position. This is immensely painful for the patient, and thus adequate analgesia is essential. Once the leg is under traction, pain is often reduced.
- Kendrick Traction Device Use: The Kendrick Splint is an excellent lightweight piece of kit used widely in pre-hospital care and expedition medicine. It is easy to use, effective and relatively cheap. The pictures below demonstrate correct use of the splint:
Step 6: Boot hitch
Step 7: Boot Hitch
Step 8: Boot hitch
i. Sager traction splint – this is bulkier to carry as part of an expedition medical kit but is effective and allows traction of both femurs simultaneously.
ii. Improvised splints
Walking pole or sturdy wooden stick braced and secured to either side of fractured limb (the outside length up to the pelvis, the inside length up to groin) and extending a good 15cm below the ankle. A cross pole positioned across distal end of the poles below the ankle and tied into place. A figure of eight strapping around the ankle, extending down over the cross pole and tightened on itself thus pulling traction down the length of the leg. Alternatively, the figure of eight strapping can be tied to the cross bar and a small piece of wood or metal can be used on the length of strapping between the foot and the cross bar to twist the strapping and tighten the traction on the limb. Important to ensure traction is comfortable and foot remains perfused with a good distal pulse.
The injured leg splinted against the non-injured leg using a walking pole or sturdy stick and strapping (crepe bandage, clothing, rope). This doesn’t allow for traction but may be the only option available to provide some comfort to the patient prior to evacuation.
Providing the patient is cerebrating and has a good radial pulse, intravenous fluids are not required unless there are significant signs of haemorrhagic shock. Permissive hypotension is not discussed in this article and further reading is advised regarding the changes and advances in fluid management in trauma. Do not run 2 litres of fluid into the patient!!
IV Antibiotics for compound (open) fracture and Tetanus prophylaxis
Open fractures are tetanus prone wounds, and most participants on expeditions should be up to date with there tetanus vaccinations. However, it is vital to check with the participant when their last booster was and documenting it for handover when definitive care is reached. If a patient is not vaccinated, of if they are unsure, the vaccine should be administered. The current UK guidelines state that a patient is considered Tetanus immune if they have received five doses of vaccine in their lifetime (3).
Intravenous antibiotics should certainly be considered in the expedition environment. A Cochrane systematic review of the use of antibiotics in open fractures as an adjunct to irrigation and further care found that administering antibiotics did reduce the incidence of early wound infections (3, 4) . Depending on what you carry, a first generation cephalosporin can be used.
- F. Gaynor Evans; Herbert E Pedersen, H.R Lissner; The role of tensile strength in the mechanism of femoral fractures; Journal of Bone and Joint Surgery, 1951; 33; 485 – 501
- Fernandez R, Griffiths R 2008; Water for wound cleansing. Cochrane Database of Systemic Reviews, Issue 1, CD003861
- Barnard AR, Allison K; The Classification and principles of management of wounds in trauma. Trauma 2009; 11; 163-176
- Gosselin RA, Roberts I, Gillespie WJ; Antibiotics for preventing infection in open limb fractures; Cochrane Database of Systematic Reviews 2004, issue 1, Art No CD 003764
Nick Arding will be joining Expedition Medicines Mountain Medicine course on the Everest Base Camp Trail along with Dr’s Luanne Freer of Everest ER and Amy Hughes of Kent HEM’s service in October on what promises to be an amazing CME accredited course*.
Nick served as an officer in the Royal Marines for 22 years, travelling and climbing widely during that time. In ‘92 he took part in the British Annapurna 2 Expedition and in ‘93 led his own trip to climb the West Buttress of Mt McKinley in Alaska. He commanded the Commando Training Centre Royal Marines from 2003 to 2005.
In 2003 Nick led a Royal Navy expedition to climb Everest by its North Ridge; not only did they climb the mountain but his team were instrumental in rescuing two other climbers from above 8000m, the highest mountain rescue on record and for which he was awarded the Royal Humane Society Bronze Medal.
A keen rock climber and mountaineer since his teens, Nick holds the Mountaineering Instructor (MI) and International Mountain Leader (MIA) awards.He left the Royal Marines in 2005 to qualify as a teacher and now works as a leadership coach and management consultant. He has led civilian teams to Mongolia, Nepal and the Alps, and when not working can usually be found on a rock face or in a sea kayak! In 2009 Nick took a team of friends to the Rolwaling Valley in Nepal to attempt an unclimbed mountain called Cheki-go. He has close links with this region, having raised funds to sponsor local Sherpas, three of whom have been able to visit the UK to improve their climbing skills and English language.
*accredited by the Wilderness Medical Society
Dr Amy Hughes is currently a specialist registrar in pre-hospital care working for the Helicopter Emergency Medical Team (HEMS) in Kent. She has been involved in expedition medicine for the last 7 years, providing medical cover for all extremes of environments, including developing and leading the medical cover for a desert ultra marathon. She is involved extensively in teaching of expedition medicine and recently took over as medical director of Expedition Medicine. Amy completed the Diploma of Tropical Medicine in 2006, has a European Masters in Disaster Medicine and is en route to gaining a Post Graduate Certificate in Aeromedical Retreival.
To read more follow this link Dr Amy Hughes Expedition Medicine PDF
Next October sees the inaugural Expedition Medicine Mountain Medicine Course following the route of the Everest Base Camp Trail over period of 16 days based out of Kathmandu. The course will be CME certified for an estimated 20 points.
Expedition Medicine’s Mountain Medicine course in the Khumbu Valley in Nepal headed by Drs Luanne Freer MD FAWM and Dr Amy Hughes Medical Director of Expedition Medicine. Dr Freer many of you will know as the founder and director of Everest ER which is a seasonal tent-based medical clinic at the Everest base camp (17,600 ft/5350m) founded in 2003, a volunteer physician for the nonprofit Himalayan Rescue Association (HRA) in Nepal. Luanne, who is also a past president of the Wilderness Medical Society and medical director for the Yellowstone National Park aims to pass on through this mountain medicine course her years of experience of providing medical cover at this altitude as well as her passion for the Khumbu Valley and Nepal in general.
The Nepal Mountain Medicine course will also serve as a fundraiser for Everest ER