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:
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.
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.
Having participated in an Expedition and Wilderness Medicine training course can open up a whole network of contacts and opportunities, not only do expedition, media and travel organisations look more favourably on EWM trained medics who have participated in one of our courses we a have an incredible network of contacts who are constantly on adventures, working remotely and who need remote medical cover.
Recently expedition medics have been working with UNICEF and with a well known charity challenge compamy to provide medical cover on thier fundraising adventures – they are off to Namibia next and you can find out more about UNICEF’s fundraising expeditions here.
Across the Divide one of the markets leaders in the charity treks and challenges, the first company of its type to employ medics on its charity challenges has some rare vacancies within its medical support team and is looking for expedition doctors with previous Kilimanjaro or high altitude experience.
All expedition doctors at Across the Divide are salaried, reasonable expenses are covered and a full high altitude medical kit provided along with full risk assessments, casualty evacuation plans and satellite communications.
In order to make the most of this rare opportunity please contact Steve Clark – steve@acrossthedivide.com but experience is essential.
Expedition Medicines Mountain Medicine course in along the Everest Base Camp Trail in Nepal led by expedition doctor’s Luanne Freer and Amy Hughes and Everest Expedition Leader Nick Arding OBE has been formally accredited by the Wilderness Medical Society for 22.5 CME points.
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.
Previously Expedition Medicine had run it’s Diving and Marine Medicine course in the Bander Khayran area of the Oman coast but decided to change location to guarantee great diving to the Maldives. So, in October of this year an eclectic band of medics from literally all over the world joined Diving Medic Dr Lesley Thomson – who has treated divers at the Plymouth and Aberdeen Hyperbaric Units, Dr Robert Conway founder of award winning marine conservation charity Blue Ventures, Dr Mark Read a marine biologist and Head of the endangered species unit of the Great Barrier Reef National Park and Mark Hannaford veteran of over 25 years of adventure travel and expeditions to all of the worlds continents aboard the dive boat Ari Queen for a week amongst the coral atolls of the Maldives.
The diving standard was set by our first ‘proper’ dive after our initial check dive when we dived at a Manta Ray feeding station. I don’t think any of us were really prepared for the spectacle surrounding us. Diving down to about 25 metres we positioned ourselves below the reef edge and it wasn’t long before a mass of manta rays, both fully grown adults and juveniles, were looming out of the slightly murky water and gracefully glided over our heads. This really set the standard for the diving on the course, which reached a pinnacle on the last dive where a mass a over 10 Grey Sharks were spotted amongst huge flight of Eagle Rays, White tipped Reef Sharks, a giant Napoleon Wrasse and the most relaxed Hawksbill Turtle that any of us had ever dived with, calmly grazing next to us as we admired the gallery of marine life whilst a territorial Titan Trigger Fish took a fancy to our dive guide!
The teaching side of the course maintained equally high standards, with a range of specific diving medicine related topics covered, including decompression sickness and diving physiology. The team also drew upon Lesley’s experiences as a medical officer and diving medic for the British Antarctic Survey, Rob’s years of marine conservation work in Madagascar, Mark Read’s encyclopaedic knowledge of the underwater world and Mark Hannaford’s quarter century of experience of running expeditions and adventure travel.
If you are getting the impression that it was a pretty action-packed course you would be right - some days lecturing did not finish until 10pm! - but it was also hugely enjoyable! The enormous wealth of experience amongst the delegates meant that their input and knowledge added a great deal to the overall leaning. In terms of meeting like-minded people it was a great opportunity to establish some great networks and share contacts.
The Diving and Marine Medicine course in the Maldives is accredited by the Wildness Medical Society for CME points and also counts towards gaining a Fellowship of the Wilderness Medicine (FAWN). A full list of the topics covered can be found on the Diving Medicine course page of the Expedition Medicine website.
Dates for next year’s course are to be confirmed exactly but will be mid-October 2011 – send us an email here admin@expeditionmedicine.co.uk to preregister your interest.
Dr Leslie Thomson Course Director of the Diving and Marine Medicine course talks about her hyperbaric experience and diving in Antarctica
Dive Medicine expert and founder of award winning Blue Ventures marine conservation charity Dr Rob Conway explains why he likes the course so much.
Dr Mark Read of the Great Barrier National Park talks about what he gets out of the Diving Medicine course.
Dr Klassje Doorenbosch, a GP from Perth, Australia, a delegate on the Dive Medicine course gives her feedback.
A dispatch from our Polar Medicine instructor Per Thore Hansen after his epic sea kayak expedition in Svarlbard. ‘Back in Longyearbyen. All well 14 bears, had to scare away 4 of them that was walking into the camp. 550 kilometre paddling , 30 kilometre pulling 100 kilo kajak over the glacier. Surfing in 5 meter waves! Good fun…!’
In 2004 Hannah joined a British expedition to explore the isolated Wakan Corridor in the northeast of Afghanistan in search of the source of the River Oxus. The strip is walled by the Hindu Kush in Pakistan to the south, the Pamirs in Tajikistan to the north and the Karakorams in China to the east. The upper regions of this mountain valley can only be reached on foot by crossing several 15,000ft passes and has rarely been visited by westerners. Part of the research was to take DNA samples of the nomadic tribe people there to establish their genetic links to Alexander the Great and his army.
Lucy Dickinson has just returned from accompanying Helen Skelton and the BBC team as Helen kayaked 2,010 miles down the Amazon. Here are her thoughts upon her return.
” I’ve just had my first experience of TV expedition work escorting Helen Skelton from Blue Peter kayaking down the Amazon. I still can’t quite believe I got the opportunity to have such an amazing trip. So how did it compare to the other expedition work I’ve done? Well it’s still just you and your box of tricks in the middle of nowhere improvising and trying to manage the risks. It’s still having an adventure and seeing a beautiful part of the earth. It’s still meeting new people from different parts of the world and learning different ways of life that put some perspective on the way we live our lives here. It’s still being inspired by interesting people doing exceptional things.
For a change, this trip was no physical challenge for me, in fact it was a challenge to sit still for 6 weeks! It was new having people thriving on the little dramas “because they make good TV”. It was exciting watching the BBC team doing a live broadcast from a sand bank in the middle of the Amazon knowing that people in the UK were watching it back in the UK as it was happening. It is not my idea of fun being in front of a camera and I constantly thought back to that conversation I had in London with Eric, the producer, about how I agreed to be on film only in exceptional circumstances if absolutely necessary. The reality was far from this and I can only hope that when the Blue Peter specials and the Sport Relief programme come out this week that I won’t cringe at the appearance of my “character” as they refer to you. As with most expeditions I’ve done it was a great pleasure and a privilege to work with a team of very lovely, interesting and fun people and have an exciting diversion to day to day General Practice.
…..If they ever ask me to do another trip with them I’ll jump at the chance.”
One Step Forward was hosted and arranged by RSM. I was fortunate enough to be invited to speak on Expedition Medicine.
The other speakers were inspirational and it was delightful to hear a series of lectures by doctors who dont hold to the production line theory of doctor creation.
I tried to follow this theme and aimed to inspire the junior doctors and medical students to expand their horizons and experience other cultures and hopefully to become a more rounded physician in the process. I even got to lecture to Professor Kumar (Kumar and Clark)!
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