Dr Amy Hughes writes about the EMDM

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Life Boat in rough seas………PART 1 by Dr Amy Hughes

European Masters in Disaster Medicine – at first glance the NHS may spring to mind, especially for those who have been unfortunate enough to be entwined in the MMC debacle over the last year. However, not so, this is in-fact a superb, year long European Masters covering all aspects of disasters – epidemiology, preparation, management and prevention – whether they be human generated (terrorist attacks, chemical, biological, transport), natural (earthquakes, floods, tsunamis), mass casualty incidents or complex humanitarian emergencies; the aim being to enhance disaster education, train individuals in medical preparedness and management of disasters, improve research globally and ultimately merge together individuals internationally who share a common passion for the speciality.

Organised by the Universita’ del Piemonte Orientale, Italy and the Free University Brussels, Belgium, and supported internationally by the World Health Organization (WHO), International Committee of the Red Cross (ICRC), the European Academy of Disaster Medicine (EURADIM) and the European Society for Emergency Medicine (EuSEM), the EMDM is led by very distinguished and experienced professionals, many professors in Emergency Medicine, Anaesthetics or Intensive Care, all of whom have dedicated their time, both academically and practically, to increasing the awareness of and education in disaster medicine.

Having access to the internet is a must for successful completion of the Masters as it is structured as an online self-directed learning tool – modules are uploaded every two to three weeks depending on module length and the number of assessments requiring completion (MCQs and short answer). Topics include epidemiology of disasters, research methods, logistics, ethics, mass casualty management, public health, injury types and complex humanitarian operations. During completion of the modules there is constant liaison via email and a forum page to the professors, to your mentor (allocated in week one) and, most importantly, between the thirty other international students completing the Masters generating debates and discussions.

Towards the end of May, and following completion of eight modules, a residential course in Italy is organised where international students and tutors meet for an intensive, didactic interactive two week course encompassing mass casualty simulation exercises, discussion forums, scenarios, lectures and – for successful completion of the EMDM – planning and initiation of a thesis.

Five weeks in and three completed modules later – the latter finished in between Vin Chauds and snow plough turns in the French Alps and a week of ICU nights – I find it hard to fault the EMDM. The modules, although long and intensive, are varied, thought engaging, relevant and constructive. There is no lack of support and plenty of discussion and debate amongst all participants – whom combined have a wealth of experience. As a chance to be educated in a field of increasing prevalence and relevance by enthusiastic, inspiring and driven professionals, it would seem a shame not to embark on such an opportunity. As for any chance of a social life outside of work……that’s the one sacrifice…………

To be continued….

For further information:

NEW | Expedition Medicine Media Support

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Remote media crew medical supportDue to the increasing number of enquiries, we have now set up a dedicated web page for any production/TV companies who need medical support whilst filming. The new web page gives you an idea what we can offer, support, and an idea of the costings for hiring equipment and a medic whilst on location.

Media Crew Expedition Medical Support – web page

here’s a taster

‘At Expedition Medicine we are aware that many TV projects are getting more adventurous and travelling to more remote environments. In these circumstances it is vitally important to have a qualified doctor or medical professional on site should the unexpected happen. Many locations do not have first world medical facilities and an Expedition Medicine medic equipped with the latest mobile medical kit and satellite communication can provide the peace of mind to allow you to focus on the production of your project’.

Mountain Medicine Course Nepal

Mountain Medicine Training CourseMost of the UK Expedition and Wilderness Medicine Faculty has a background in Mountain Medicine, and like many British expedition medics most of us started climbing in the Alps before moving to the bigger mountains in Nepal. Following the same theme as our other extreme environment courses, the main thrust of the Mountain Medicine Nepal course is to introduce medics to the practical elements of working and providing medical cover in the high mountains environments.

The instructors aim to familiarise the team with the fundamental skills which are essential to treat and evacuate casualties in the mountains as well as covering the common conditions encountered at altitude. Where else could we run this course but in Nepal. In order to experience winter conditions in the mountains the course will be run in the beautiful amphitheatre and ridges of Annapurna with the sacred mountain of Machapuchere as a backdrop. At this time of year the snow cover is low and the team will be able to train and experience the environment without undue exposure to high altitude.

Expedition and Wilderness Medicine is now a unique provider of medical courses in extreme environments and continues to attract fantastic staff and lecturers from around the world. It’s advisable to put your name down now for this course as we envisage it to be a popular one!

During the 17-day Mountain Medicine Nepal course you will follow the Everest Base Camp Trail from Lukla, 14 days will be trekking at an easy pace, staying in Nepalese teahouses along the route and enjoying the spectacular scenery along the route.

The price includes: accommodation, meals (unless otherwise stated), expedition medicine course manual, all course activities, support services on Everest Base Camp trail and return flights from Kathmandu to Lukla. For a kit list see below. The only additional costs are for your international flights, drinks and items of a personal nature.

Travel insurance is compulsory, must include the facility for helicopter evacuation in case of emergency and must cover high altitude trekking – a suitable policy can be obtained through Campbell Irivine Ltd.

What’s included?
All tutoring, accommodation and meals during the course
Safety equipment

What’s not included?
Travel costs
Travel and health insurance
Personal equipment
Additional drinks and food purchased from teahouses and shops

Do you need travel and health insurance?
We recommend all participant travelling outside of their home country, or where aero-medical evacuation may be required, have specific travel insurance in place for the expedition.

For your safety and security, we reserve the right to refuse access to an expedition until we have details of adequate insurance cover provided to us.  Find out more here…

A participant’s write up – Polar Medicine Training Course February 2008

Polar Medicine; A Cold Weather Medical Training Course

The setting for this year’s polar medicine training course was Alta, a small settlement, 72 degrees north and well within the arctic circle. A place with a deserted high street where you would be lucky to see one other passer by every 15 minutes, easily explained by a temperature at least ten degrees below freezing and a good foot of snow on the ground.

Base camp was a 40 km drive along icy roads to a picturesque mountain lodge by the name of Ongajoksetra. At the higher altitude the temperature was that much lower and if a wind was blowing, temperatures as low as minus fifty could be achieved. We were introduced to the Scandinavian team who would teach us methods of navigation across such tough terrain in harsh conditions and also to the Expedition Medicine team who would teach us polar medicine in a series of lectures and practical sessions both in the classroom and in the field. One more group I must not forget to mention is the team of fifty sled dogs who would provide another mode of transport across the snow.

My first day involved skidooing up a mountain demonstrating the importance of protective clothing, navigation aids and preparation for travel in severe blizzards with visibility of approximately two metres, sudden drops in temperature and rapid weather changes. I realised that without our trustworthy guide, Espen Ottem, we could become hopelessly lost in such conditions where you would be unable to survive more than a couple of hours at most. Our dog sledding guide, Pre-Thore was the perfect example of this as he told us of the time where inadequate preparation resulted in frostbite, blackening of his fingertips but fortunately no amputation. This story made me somewhat paranoid about the daily pain and numbness in my hands and feet when outside in the cold for prolonged periods. A “buddy system” was paramount to preventing frostnip. Simply by having that small exposed area of skin, pointed out to you to cover up

Dr Leslie Thomson, a consultant anaesthetist who had first – hand experience of polar medicine after spending several years in Antarctica taking part in the British Antarctic Survey gave an excellent lecture on hypothermia, bringing home how hypothermia is not just a condition seen near the poles but also in the Saturday night party goer who collapses under the stars, the homeless and the elderly. We were taught how to treat by various re-warming methods and when to commence C.P.R in the hypothermic patient sending home the message of not pronouncing death until warm and dead in certain individuals. This information was demonstrated by the story of Dr Anna Bagenholm , a 29 year old doctor who fell into icy water whilst skiing in Northern Sweden, immersed for approximately an hour, her body temperature was 13.7 degrees centigrade. C.P.R continued for three and a half hours alongside re-warming techniques such as bypass, bladder / stomach / peritoneal lavage and warm intravenous fluids. She survived to become the person with the lowest body temperature ever to survive.

Expedition and Wilderness Medicine obviously feel that first- hand experience is the best way of teaching and as a result each member of the group had to undergo cold water immersion. Prior to undertaking this challenge we were kindly taught about the cardiac arrhythmias that can be induced by the shock of entering the water, the short term cold water gasp reflex increasing the chance of aspiration and swimmers failure! One by one we stepped up to an ice hole in our thermal underwear and in the more daring members of the group a little less! to swim across icy water. I can confidently say that was the coldest I had ever been. As if several knives had been plunged into my body, breath taking and inducing chest pain, I swam across water of ridiculously low temperature to attempt getting out of the hole using my ski poles

Of our nights spent in the field we were taught how to construct snow holes. Five hours later our own little home with two double beds, stove, cupboards and shelves for our candles was constructed. It was as comfortable as it could be on a mountain side with winds blowing outside dropping the temperature to twenty below. I was amazed that the snow hole was so warm at five degrees compared to the outside however a slight air of nervousness was in the back of my mind as my avalanche detector slowly flashed in the corner and a rope attached to a spade inside connected our holes to other holes in case of us having to be dug out. The course perfectly demonstrated how to survive in such conditions

In summary the course prepared 25 everyday doctors to be able to traverse the polar landscape, recognise and competently treat local cold injury and hypothermia as well as to be safe expedition medics capable of caring for their groups and evacuating when required. To spend a week in such a location gave me the upmost respect for those who live in these regions and cross the landscape as part of everyday life, as well as a great respect for the land. In a day and age of global warming and melting of the polar ice caps it becomes paramount to look after our environment, to take only photographs and to leave only footprints.

Dr Claire Roche, Clinical Fellow in Emergency Medicine Countess of Chester Hospital. See the BMJ article.

The next expedition medicine course will be in Desert Medicine Course which will be held in Namibia, August 17th -23rd 2008.

To see the full range of Expedition and Wilderness Medicine Training Courses see here.

Kuiseb Canyon | Namibia | first decent

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Kobus Albert surveys the Kuiseb CanyonThere are not many places left in the world that have not been fully explored but the Kuiseb Canyon located deep within Namibia Namib-Naukluft is one such place. Its remoteness, inhospitality and lack of water have stopped easy travel though its hidden folds and preserved a landscape little influenced by outside influences.

However, recently an expedition to traverse its most inaccessible sections was mounted by former Namib Park Ranger Kobus Alberts from Namibia and veteran explorer and director of Expedition Medicine training company Expedition and Wilderness Medicine, Mark Hannaford. Starting at the Kuiseb Bridge and finishing at the Topnar settlement at Homeb its aim was to be the longest ever journey through the canyon and to record via video and photography the interior this remote area.

The main challenges to the expedition were expected to be very high temperatures within the canyon itself, expected to be in the region of 50 C, hyenas, a lack of water, the nigh time presence of marauding hyenas and the physical challenge of trekking 110 kilometres over difficult terrain. Preparation for the journey started the year before with special permission being kindly granted by the Namibia National Park Authority and the incumbent park manager Manie Le Roux and the preparation of the comprehensive route and safety plan. Given the lack of any sort of road in the area of the canyon – the impossibly of landing a helicopter within the narrow confines of the canyon itself the safety plan ended up being pretty simple – don’t get injured and if you do break a leg be prepared to wait four days before getting out.

The reality of the journey turned out to be somewhat different than expected, the 2008 wet season resulted in the much higher rainfall levels than normal with the plains surrounding the canyon erupting in a multi coloured carpet of otherwise dormant wild flowers and rather than a dry and water-scarce route the valley was flooded in some places wall-to-wall by a Kuiseb River in full flow. The flood water solved one problem of finding drinking water for the expedition but created a number of others. Quicksand and deep mud made movement in some areas virtually impossible without a massive effort or in some cases a long excursion up the side of the towering cliffs of canyon walls following meandering zebra trails. The manner in which these trails skirted obstacles and wended their way past seemingly impossible obstacles filled us with renewed admiration for the agility of the Mountain Zebras.

It was within ten paces of the start of the trek that we entered the river and seemingly we didn’t seem to exit it until four days later, we had expected the whole journey to take us about three and half days walking an average of about 30 kilometres a day – distances Kobus and I frequently walk together but this was based on a dry relatively flat canyon bottom with early morning starts resting during the hottest part of the day and then continuing on until the early evening before camping. The first evening saw us camping under a protective rock overhand a couple kilometres ahead of our schedule an in high spirits with our initial target reached and exceeded. The valley was still quite open and whilst the river was certainly flowing the banks on either side afforded us a good walking surface and the chance to spot the spoor of Gemsbok (Oryx), Hyena, Mountain Zebra and Springbok. Our main concern this evening was the presence of hyenas. The canyon has a well deserved reputation locally for large quite aggressive hyenas- campers recently at the tourist campsite near the dunes of Sesreim had been attacked during the night when camping without tents, so we were glad to have the rock wall at our backs and the rifle which Kobus had the pleasure of carrying for most of the expedition. Aside from the incessant drone of mosquitoes and a night time rain shower the night passed uneventfully.

The pattern of the next day set the template for the others – wake up just before first light at 05.30 and get the kit packed away whilst the stove boiled water for a single cup of coffee the kick start the day and to help wash down the three rusks – a type of hard baked biscuit which constituted breakfast, and then heading out as the sun rose and cast its welcome light in the gloomy corners of the canyon. This year wet season really was a bumper one and consequently the very high temperatures that we had been anticipating didn’t materialise and our days in the canyon followed a pattern of cloudy skies in the morning, burning off in the afternoon to give high temperatures for a couple of hours before giving way to an afternoon cloud build up and the first roll of thunder of surrounding storms in the late afternoon.

Camps where selected the criteria with the having our backs protected but also affording some sort of shelter from night-time storms. As we entered the canyon more deeply the walls close in on us and grew steadily higher and higher this had the effected of narrowing the river and we steadily lost the helpful banks being forced more and more often into the river itself – at one stage we did a two kilometre wade but we where soon presented with our biggest challenge of the expedition – quicksand. where the waters of the river where forced through narrower and narrower gaps the quicksand got deeper and deeper rising steadily up our legs, over our thighs until eventually we were stuck over our waists in a mixture of cloying sand and mud. It made movement extremely slow and tiring our hourly rate dropped to about 1.4 km an hour- at one stage seemingly completely stuck the only way to escape was to lie as flat as possible and crawl on hands and knees to the river back no mean task in a river with a heavy rucksack on our backs I can tell you!!

On the second day we only managed to cover 6 kilometres completely shattering any hopes of keeping up a 30 kilometre a day rate. kuiseb-trek.jpg Our original plan had been to scale the walls of the canyon to camp on its rim but the height of the walls – well over a kilometre tall in places just presented to much of a challenge at the end of hard days slogging through quicksand- the thought of filtering and then carrying five litres of water each on top of our already weighty packs up the steep cliffs also didn’t fill us with joy! That evening in camp Kobus and I discussed our options. The Google map (isn’t it great to able to get satellite imagery on the web) of the canyon showed the valley opening up further down its course- but we could not be sure how much would be flooded but hoped that there was a adequate river bank left to walk on- otherwise at midday on the next day we would be forced to climb out of the canyon – a challenge in itself, walk across the plains for 20 kilometres to road access at a park camping site at Zebra Pan. Whatever we decided our food would not last unless we started to ration it.The next day started with the usual narrow valley, steep cliffs and the now inevitable quicksand and Kobus and I had decided that 11 o’clock would our breakout point if we were not able to pick up hour speed but after an hour or so we got the break we needed as the valley opened up – the banks became visible and we were able to stretch our legs. The deadline passed with bearing a comment from the either of us as where now trundling our way rapidly down the valley – the canyon did narrow again and the quicksand did suck us back into its gritty folds but the joy of getting some distance under our belts has reassured us significantly and as the day went on the widening became more and more frequent. The day end total was 28 kilometres.

We left our overnight camp – if you can call two sleeping bags under a overhanging rock a camp, and continued down the canyon now painted by the red sands of the dune sea on its south bank and they grey of the rock desert on its north side – disturbing a large troop of baboons with some massive males feeding in the valley. As the valley broadened the wildlife, especially the birdlife increased significantly with large boisterous colonies of Cape Swifts’ enlivening the canyon with their raucous calls. Two snakes where spotted- both juveniles and both lying just of our track – a Western Banded Spitting Cobra which lifted itself and opened its hood in an irritable manner and more relaxed Horned Adder. The valley was now open and well vegetated along its banks with one of the issues now being able to find our way through the mass of fallen bands, flood debris and wild mustard stands but it allowed us to reach our end point at Homeb at 6 o’clock with tired backs, sore feet but with a massive sense of achievement.

Sometimes a plan works, sometimes it adapts, occasionally its perfection… We took out packs off and within 15 minutes Kobus’ co worker turned up with our transport, and a cooler full of cold beer… bliss!

To find out more about Expedition Medicines Desert Medicine training course in Namibia visit the Desert Medicine page here

Rains in the desert | Namibia

Diabetes on Expedition

As the medical management of diabetes improves, diabetics are increasingly becoming involved in adventurous pursuits in the wilderness and on expeditions. The aim of this article is to attempt to demystify the subject of insulin dependent diabetes. Diabetics on expeditions may increase their risk of a number of medical problems: hypo and hyperglycaemia, dehydration, frostbite, infections, poor wound healing. There can also be diagnostic dilemmas of differentiating diabetes related disease with a number of tropical diseases and altitude related conditions. None of these are insurmountable but require more vigilance and proactive monitoring by the individual and the expedition medic.

A letter from the client’s own GP outlining the condition, including the need to carry syringes, is necessary for air-travel and useful for border crossings. Young active diabetics may be well in tune with their disease and used to altering doses, but do not assume this. Often they are managed with background 24 hour insulin e.g. glargine with easily alterable short-acting e.g. lispro. (basal-bolus regime). Of course an insulin pump would be even better. For some people it may be useful to convert to this regime before the trip; if so, allow plenty of time to get used to it. Typically a basal-bolus regime is the recommended for the potentially unstable and unpredictable environment on an expedition.

Diabetics need to be thorough in their preparation prior to an expedition. Testing their devices, trialing new regimes with increased levels of activity. Basically ensuring maximal stability of their disease before going on an expedition. Physicians should ensure the diabetic patient has pre-expedition HbA1c, tests to establish any end organ damage and a thorough understanding of how to manage their diabetes on expedition.

Careful planned adjustment of doses is needed over time zones for any flights. Most diabetics find it useful to change to the destination time zone on the flight. As a rule of thumb, if flying west, the day will lengthen and insulin doses may need to increase, whilst eastern journeys result in shorter days and hence less insulin may be required. Importantly the diabetic patient needs to monitor their blood glucose closely.

Once on expedition, diabetics ideally need regular meals, but this may not be possible. Regular monitoring is vital and they should always carry snacks. The medic should consider an antiemetic early if vomiting occurs. Be aware that there may be alterations in insulin requirements:

UP – illness / exertion

DOWN – after regular prolonged exercise

Some monitoring devices do not function well at altitude or in the cold. Those which use reagent strips with glucose dehydrogenase are more stable, but still do not read accurately above 2500m (though the error is probably not significant). The monitors and insulin must be kept at a relatively stable temperature and not agitated too much. Insulin is surprisingly resistant to denaturing but always check that it is clear and colourless before use. There are a number of storage devices, the easiest to use and most efficient is currently the Frio Bag.

Interestingly there have been several cases of ketoacidosis in IDDM patients at altitude using acetazolamide, and until a clear connection is established its use in diabetics is not recommended. The alternative treatment is dexamethasone, however this should not be used as a prophylactic treatment as it can induce hyperglycaemia.

Source: Dr Sean Hudson, Expedition Medicine


Desert Medicine Training Course | Namibia

Dr Sean Hudson explains why we’ve chosen Namibia to run our new Desert Medicine Course.

There truly aren’t enough superlatives to describe how beautiful Namibia is. Hence when we came to choose a destination for our new desert medicine course, there was only one possible choice.

As a group, Expedition Medicine have been working, travelling, holidaying and honeymooning in Namibia for over 10 years. It has a quality which is becoming increasingly rare and difficult to find in Africa. It still remains exotic and predominantly unspoilt, tourism is increasing but slowly.

The diversity of the country is its strength, whether you yearn for endless deserts, exotic mountains, huge dunes, canyons, rivers, a myriad of game parks or the most remarkable coastline in the whole of Africa, it is all here. All set to the backdrop of German efficiency, which has created a medical infrastructure which can support any expedition.

Caroline and I first worked in the Namib as guides and medics in 1998 and fell in love with the country. We have returned many times and are very excited about the desert medicine course. It’s a beautiful location, with Brandberg as a backdrop, and the opportunity to encounter the remarkably adapted desert elephants which often can be found in the Uhab River.

The team are quite exceptional, and I can’t wait to learn from them and their vast experience, in this and other desert environments around the world. If you want to camp in one of the oldest deserts in the world, in the shadow of a mountain which has been a refuge for desert nomads in hard times for over 6000 years, track elephant, learn how to survive and treat medical conditions common in this environment, then there is no question you would enjoy our trip to Namibia.

Dr Sean Hudson

Find out more about the Expedition Medicine Desert Medicine training course in Namibia.

Dr Sean Hudson, Expedition Medicine director in Patriot Hills, Antarctica.

Dr Sean Hudson is a founding director of Expedition Medicine which

Expedition Medicine is the leading provider of expedition and wilderness medicine courses, both here in the UK and also in a number of carefully selected overseas locations.

A chance meeting at a MRT conference in 2007 led to the opportunity to help set up the most remote expedition clinic in the world. The medical clinic run by Antarctic Logistics and Expeditions (ALE) provides advice, support and rescue to all the expeditions on the Antarctic continent. It is a four flight to Punta Arenas, but this is only when the IL76 (jet) can land on the blue ice runway. The camp and clinic nestle under the Patriot Hills, which provide a beautiful backdrop to this most stunning of locations. Though temperatures can plummet, especially in the early part of the season, generally the weather is pretty kind, with average temperatures being around -15ºC and winds only occasionally picking up to 70 knots (120km/h).

During the season, which lasts from November to January, the camp plays host to over 300 individuals, who come to Patriot Hills to start their journey to the South Pole skiing, climbing Mount Vinsen, or just to fly out to the South Pole and experience being in one of the most incredible places on earth.

All of these people need to be assessed and seen by the clinic or by the medical team in the UK, which can be interesting as many of them speak little English and my grasp of Russian, Norwegian or Spanish extends little beyond “you have a big bum”! Most have a very good knowledge of the environment and its dangers but there is always the odd person who descends from the IL76 onto the ice runway in high heels and has a wardrobe full of miniskirts and tight tops (and newly acquired breasts).

The clinic is incredibly well thought out and has the capacity to manage most medical scenarios. The commonest complaint is of course frostbite. However most of my time was spent lecturing teams to ensure they new how to cope with the environment and avoid injury, or getting involved in the work of other departments. Putting up tents, helping with cooking, assisting the comms officers, and in the off time climbing, skiing and snowmobiling (hard life).

It was a hard but rewarding 6 weeks which Id recommend to anyone who has ever fancied a challenge.

Dr Sean Hudson

Find out more about Expedition Medicine Polar Medicine training course.