Expedition medicine

Sarah Whitehouse investigates the medicolegal challenges facing doctors in remote situations

In May 2003, American mountaineer Aron Lee Ralston was forced to make the grisly, but necessary, decision to amputate his lower right arm after becoming trapped by a boulder for five days when climbing alone in Utah.1 An expedition medicine doctor may not always be faced with such a daunting medical emergency, but they do have to be prepared for the unexpected.

Expedition medicine is as global in its many different forms as in its geographical range; covering, for example, tropical medicine, jungle medicine, polar medicine and desert medicine. What separates expedition, or wilderness, medicine from general medicine is its distinct autonomy – potential risks are exacerbated in sub-zero temperatures at 5,500m, when your medical opinion is the only opinion available.

Responsibility

Expedition doctors are responsible for the clinical care of the expedition team, risk assessment, medical kits and equipment, and prescribing medicine. Decision-making skills, communication skills and self-reliance are all important. Clinical situations should be assessed in relation to the limited equipment and resources available, the best interests of the patient, and a doctor’s own levels of competence and experience.

Common problems

Dr Marika Davies, a medicolegal adviser at MPS, spent two months as a medical officer to a team studying biodiversity in the rainforests on Negros, an island in the Philippines, in 2003.

“Medically, my time as an expedition doctor was relatively quiet – everyone on the expedition was young and fit, and, in essence, you are there in case something goes really wrong. I dealt mainly with day-to-day complaints, eg, insect bites, blisters, sickness and diarrhoea, as well as problems with dehydration, leeches and bat bites.”

In fact, research suggests that travelling with a well-organised expedition is no more dangerous than attending a scout camp or visiting a rock festival in the UK.2 Different environments do, however, present their own specific risks and associated illnesses, including acute mountain sickness, frostbite, deaths are from avalanches. Deaths by falling, hypoxia or the cold are comparatively rare.

On climbing expeditions, altitude starts to have an effect around 1,500 to 2,000m – air pressure gets lower and less oxygen is available. Altitude Mountain Sickness (AMS) symptoms include: headache, nausea, vomiting, fatigue, poor appetite and sleep disturbance.3 If a trekker has altitude sickness, it is important to decide quickly whether to treat them, or send them down the mountain for treatment. Help is not readily available on an expedition, and so you should assume the worst possible scenario when diagnosing.4

At high altitude (over 5,500m), nearly everyone develops a dry, persistent cough – known as the “Khumbu cough” in the Everest region – from exposure of the lung lining to excess cold air. Another common, often overlooked, problem on expeditions is mental illness, as trekkers may feel homesick, isolated, or detached from the group. Those with pre-existing psychological conditions will need to be appropriately assessed before taking part in any expedition.

Expedition medicine doctors need to be generalists. Experience in trauma, general practice, or emergency medicine is a good grounding for the common problems that are often encountered on expeditions.

Be prepared

Fifty-nine per cent of medical incidents on expeditions are preventable.5 Knowing your team is important in minimising risk – perhaps by sending out health questionnaires to find out about current and past medical conditions, drug histories and allergies, and detailing appropriate immunisations, antimalarials and personal medical kits. This can mitigate risk, as pre-existing conditions can be monitored adequately.

Dr Bill Smith, MPS medicolegal adviser, was an expedition doctor on a trek in the Himalayas: “I briefed each participant beforehand to make sure they were fit and had information to take to their GP to enable them to obtain their own emergency supplies. Many were prescribed antibiotics and sickness and diarrhoea tablets, even plasters and crepe bandages, as these are not always available.”

Expedition members are often given basic first aid training before setting out on an expedition, to ensure that everyone on the team is as prepared as possible in case of an emergency.

Good medical practice

Despite limited resources, the same good medical practice considerations apply however remote you are. It is the equipment you are dealing with or the cases presented to you that differ. Dr Davies stresses: “You should ensure that you have the consent of the patient, you are working within the limits of your own clinical competence, and that you are acting in the best interests of the patient, while also being aware that you have a responsibility for the safety of the team as a whole.”

Keeping a journal to record details of any consultation or drugs prescribed can be a useful stand-in for medical records if it is necessary to hand over a patient to a local medical facility – and can help if a problem, complaint, or claim should arise after the trip has ended. Limited communication infrastructure means that problems may have to be radioed back to base camp, often to someone who is not medically trained, who can then communicate via satellite phone with the nearest hospital or medical facility, which may be 24 hours away. Patient consent is needed before sharing any confidential information.

It is important to remember that despite working as part of a team, you need to maintain confidentiality and act within professional boundaries. Dr Sean Hudson, Medical Director at Expedition and Wilderness Medicine, says: “The most striking problem is balancing objectivity and confidentiality with functioning as a team in difficult conditions.”

Dr Davies explains: “Boundaries can become blurred if you are a doctor as well as a member of the team, and this can be different to your usual professional relationship.”

Appropriate indemnity

Before undertaking any expedition medicine, you should speak to MPS to ensure that you have adequate and appropriate indemnity. It may be that this is provided by the expedition company. Ensure that you are registered in the country you will be working in. Expedition doctors go beyond the scope of good Samaritan acts as, whether a fee-paying member of an expedition or not, doctors are expecting to provide medical attention, and so changes to your indemnity cover may be required.

In the UK and Ireland, there is an ethical, but not legal, obligation to assist those in need of medical treatment in an emergency. The GMC states: “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.”6 The Medical Council in Ireland states: “Doctors must provide care in emergency situations, unless they are satisfied that alternative arrangements have been made.”7 In other countries, the situation may be different. In France, for example, it is a legal obligation to assist in an emergency.

If legal proceedings are contemplated they are normally commenced in the country in which the alleged negligence has taken place, and so it is irrelevant what nationality a patient is. The only relevant issue to MPS is where the legal proceedings are brought. If proceedings are brought in the US or Canada, MPS will not offer indemnity, except for good Samaritan acts.

Problems

Dr Hudson says: “There are few cases against expedition medicine doctors, possibly due to their experience and the attitude of trekkers – by taking part in an expedition, participants have already accepted a degree of risk.” When treating patients, you should make it clear that you are giving assistance as a slightly more skilled first aider, as opposed to anything else. It is unrealistic to plan for surgery, even if there is a skilled surgeon in the party. In the UK, the standard of care expected is generally determined by the Bolam test – that is, what is expected from an ordinary, competent doctor.

Before you go, make sure you find out exactly what the medical facilities will be, what support, if any, you will have, and how you will contact people in an emergency. Ensure you are happy with the expedition company’s risk assessment – will your experience fit in with this?

Often, you can end up treating local people as well as those on your expedition. It is important to be sensitive to local customs and be aware that there is often not much you can do with the limited resources available. Guides or porters should receive the same medical treatment as other expedition members.

Training, pre-expedition planning and pre-expedition health assessments are essential in minimising the risk of you being called upon to deal with a serious medical emergency.

Dr Hudson states: “The main difference is you are everything: nurse, doctor, paramedic, possible interpreter and driver. We imagine expeditions are all about snake bites – in fact, they are about being a shoulder to cry on, buoying people along, dressing blisters and occasionally managing trauma.”

References

  1. http://aronralston.blogspot.com/ 
  2. Warrell D, Anderson S, Royal Geographical Society: Expedition Medicine, Profile Books p4 (2002) (Source: Journal of the Royal Society of Medicine 93:557-562 (2000)) 
  3. Medex, Travel at High Altitude, p13 (2008) 
  4. Warrell D, Anderson S, Royal Geographical Society: Expedition Medicine, Profile Books p88 (2002) 
  5. Ibid, (Source: Royal Geographical Society, Journal of the Royal Society of Medicine 93: 557-562 (2000)) 
  6. GMC, Good Medical Practice, p11 (2006) 
  7. Medical Council, Guide to Professional Conduct and Ethics, p16 (2009)