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Managing Anaphylaxis in Wilderness Environments expedition jungle

Managing Anaphylaxis in Wilderness Environments

 Following exposure to the inciting substance, allergen binding occurs to antigen specific immunoglobulin E (IgE) that are attached to previously sensitized mast cells and basophils. This causes immediate mediator release via degranulation. It is the mediators that are responsible for the secondary effects on smooth muscle tone, mucous membrane secretion and airway resistance that cause the classical symptoms. Individuals of all ages and races can be affected by anaphylaxis, although mortality is thought to increase with age due to co-morbidities (Krause 2009)
 
Respiratory: Involvement of the upper respiratory tract is common, with cough, hoarsness, rhinorrhoea, and stridor in severe cases when airway patency is compromised by tongue and pharyngeal swelling. Wheeze secondary to marked bronchospasm can cause significant hypoxaemia. Dyspnoea and tachypnoea are usually evident. Respiratory symptoms tend to be worse in patients with a history of asthma or reactive airways disease.
 
Cardiovascular: Minor reactions may have no cardiovascular implications. However, chemo-mediator related peripheral vasodilation can lead to capillary leakage, hypotension, tachycardia and fulimant shock. Shock may occur without other prominent features and collapse and cardiorespiratory arrest are the end-point of untreated anaphylaxis.
Gastrointestinal: Nausea, vomiting, abdominal cramps and diarrhoea are all common, particularly when the allergen is a food. Gastro-intestinal oedema may lead to temporary malabsorption.
Other: Anxiety and tremor are frequently seen and, prior to obtundation, hypoxia may render patients combative. Neurological impairment and unconsciousness is secondary to both cerebral hypoperfusion (as a result of low BP) and hypoxaemia.
 
The diagnosis of anaphylaxis is a clinical one and does not rely in specific tests. In a hospital setting mast cell Tryptase can be used if the diagnosis is uncertain. If there is a family history, C1-esterase levels may be useful to rule out hereditary angiooedema.
Pre-hospital care of anaphylaxis involves management of airway, breathing and circulation according to resuscitation protocols. Management should be tailored to the severity of the reaction and the proximity to advanced medical care. The resuscitation council UK provides an algorithm for the management of anaphylaxis (Resus UK 2008).
Rapid delivery of adrenalin is paramount to aborting severe attacks. Multiple doses may be needed and in resistant cases, adrenalin infusion (or other alpha-adrenergic drugs) may be required to maintain sufficient cardiac output. H1 Antihistamines (e.g. chlorphenamine), inhaled B-agonists (e.g. salbutamol) and oral/IV/IM steroids (e.g. prednisolone, dexamethasone) are all used in the acute phase and frequently for several days after discharge.
Following the primary reaction it is common to have a delayed secondary reaction that is usually evident by 6 hours after the original event (a biphasic reaction). This highlights the importance of observing casualties even after the initial reaction has subsided. Secondary reactions can also be life-threatening.
 
Overall, mortality is low with a case fatality rate of 1% (Brown 2001). Risk of death is increased in those with pre-existing poorly controlled asthma or those with asthma who delay use of adrenaline (Pumphrey 2007). The most common cause of death in anaphylaxis is complete airway obstruction. The annual risk of recurrence of anaphylaxis in an individual is 1% (Gupta 2004). In fatal cases, death is usually soon after exposure. In the case series (Pumphrey 2000) no deaths were reported after 6 hours.
 
 

 

Epipens are portable preloaded injection devices that can be carried on expeditions and by those who are known to suffer severe allergic reactions. They are easy and quick to use but even medical professionals would benefit with familiarisation. Expedition participants can go to: http://www.alk-lifeline.co.uk/home.htm and order a training pack and watch demonstration videos.

 The challenges of managing anaphylaxis in wilderness environments are numerous.

Airway & Breathing – continuous monitoring equipment for saturations, pulse and BP is not often available. Oxygen is rarely available unless on a high-altitude expedition. Life-saving airway interventions such as surgical airways and invasive ventilation are difficult to carry out even in the controlled environment of the hospital. In the wilderness, consideration has to be made of the sustainability of these measures, being that they are usually only briefly successful until more definitive care can be provided. Maintaining ventilation through a surgical airway, or even simply with a bag and mask, whilst undertaking a treacherous evacuation, would be near impossible. Positioning of tubes could not be maintained rendering ventilation futile.
Circulation – the provision of most medications is equally efficacious via the intra-muscular route. This allows for rapid delivery of life saving drugs such as adrenaline without the need for IV access. Ideally, if a large calibre line can be sited, IV fluid replacement can be instigated. However, away from the hospital, it is unlikely that large volumes of fluid would be available due to the impracticality of carrying such fluid on expeditions. IV lines are notoriously easily dislodged, making it difficult to calculate what doses of medication the patient has actually received (and what has gone s/c etc). In profound shock, there is even a delay in the onset of action of IM drugs as muscles become hypo-perfused. If cardiac output were to be lost on a patient remote from advanced medical care, resuscitation attempts would have to be carefully considered, again giving consideration to the sustainability of the effort, likelihood of survival and danger it might pose to the rescuers.
Evacuation considerations: All those who have suffered all but the mildest of allergic reactions should be evacuated to secondary care. Even if the original event has been successfully dealt with, the potential for rapid and catastrophic deterioration remains. Evacuation from remote environments may be by land, sea or air and so will require a certain level of casualty stability prior to evacuation.
The following case report describes true events that occurred in the Costa-Rican jungle in November 2009. Initials have been used to maintain anonymity.
The Case Report:
Date : 10th November 2009
Location : Expedition Medicine Costa Rica Jungle Course 2009, high jungle camp, 3 ½ hours from base camp, at approximately 600m elevation.
Base camp location 58682205
High Jungle Camp location 58952208
 
Team: 4 DS (Directing Staff), 1. EL (Expedition Leader) experienced jungle survival expert with UK forces, ex RM Commando Jungle Instructor, 2. EL and zoologist and biologist from Australia, 3. Doctor ex army (major), deployed in Belize, Bosnia, Iraq, GP and pre hospital physician, 4. Doctor GP and expedition medic, director expedition medicine, medical director private security company, ex HEMs.
The expedition participants were 22 medics with a wide variety of expertise ranging from consultant emergency physicians to junior doctors and military medics.
The Jungle Medicine Course in Costa Rica was reaching its climax, after 4 days in country of field training and lectures the group was planning on spending 3 days in the jungle practicing their skills. The first afternoons trek saw the group successfully through steep muddy jungle terrain, across rivers, and up to a camp site. After walking for 3 ½ hours the team arrived in camp and having arranged themselves into smaller units, begun to dig a latrine and arrange a suitable water supply.
17.00 Approximately 5 members of the team were stung whilst heading down to the water by bees/wasps. It is thought the bees may have been aggravated by the smoke from one of the camp-fires. They were particularly aggressive and most of the 5 people were stung a number of times. No one had a known bee/wasp allergy and some were self treated with topical antihistamines.
17.20 As dusk approached several of the same team went to a second water source. Team member S was found sitting by the side of the path, looking pale and vomiting. The other people present called for assistance and carried the casualty S back to the DS sleeping area. The first client on scene thought S may be having an anaphylaxis and requested an Epipen.
The two DS medics arrived at this stage with medical kits and with another client with an Epipen
Figure 8: The dense jungle environment (photo from participant)
17.20 S sitting up, retching and itchy, feeling lightheaded and nauseous, pale, palpable radial pulse but thready R90, RR 12
Diagnosis allergic reaction/anaphylaxis
Treatment: IM 0.5mg adrenaline (1) L deltoid, IV access by client, chlorpheniramine and 100mg hydrocortisone. The IV unfortunately did not gain access, the antihistamine went SC and the steroid ended up on the trousers of the person giving the medication.
S recovers slightly and is able to sit up and appears more alert, has a stronger radial pulse and is able to communicate. However very rapidly she deteriorates again. Within minutes she needs to lie down
17.30 S BP low (radial pulse assessment) P 100 R but thready, retching still, and scratching face, confused and disorientated, given 0.3mg adrenaline IM R buttock (2)
4 DS gather and decide needs rapid evac, time critical casualty, AC and SH to leave with 8 clients, guide and agent translator, making a 12 man evacuation team. Evac team also take a radio (VHF, but connected to a repeater system which gives it a range of several hundred miles), rope and lightweight med kit (size 7 NP, size 3 OP, surgical airway, 4 epipens, analgesia, leardal mask). MR and MM to stay with rest of group and return next day to base camp. MM left with sat phone and med kit and 4 doses of adrenaline in case another allergic reaction develops.
17.40 S improved to extent may walk, given 30mg prednisolone PO, 8mg piriton PO.
17.50 depart for evac, walk 10 yards until S collapses again, reduced conscious level, thready radial pulse, strong carotid pulse 100+
17.52 put into split rope piggy bag carry, AC carries over very difficult terrain for 10 minutes. S able to hold on.
18.02 YT carries until 18.09 over very hard terrain, S unable to hold on, becomes unconscious, too unstable to carry and keeps catching feet on jungle. The ground is incredibly difficult to carry someone over, very steep, contouring and crossing steep river cuttings. S needs a stretcher. Several members of the team move to flat ground to build stretcher using T shirts and trees as poles.
18.09 S pale, her airway is occluding and requires opening and placing in the recovery position on the stretcher, very thready radial pulse but good carotid pulse. Given 0.3mg adrenaline (3) R buttock
18.09 – 19.30 S on stretcher, very steep descent (35-45 degrees) over very hard terrain, narrow, uneven, long drops. During the confusion at the stretcher building area the med kit was left and had to be retrieved by two members of the team (15 minute run). Airway intermittently difficult, occasional retching requiring recovery position, airway opened using saline bag and rope to enable better position. Given 2 further IM adrenaline 0.3mg (4,5) into R buttock over this period. The carrying team rotate positions as the work is exhausting. The local guide clears the route and is very concerned about snakes. There are numerous yellow kneed tarantulas on the route when S is placed on the ground.
ML has comms on VHF repeater radio throughout and arranges through office and staff for 4x4 to pick us up on road out of base camp to then RV with ambulance with adrenaline and steroids and will then take us to clinic 1 hour away.
19.30 arrive at camp of another company, request adrenaline as BP low and airway difficult. Given last adrenaline we had (6). Now on easier terrain attempt NP, too big. OP too big and now not tolerated. Transfer onto spinal board from camp and then into back of quad vehicle. Short 1km transfer to zip wire. Guide goes ahead to ensure zip wire set up. S carried by AC onto zip line with YT, transfer to other side and stabilised.
19.40 S transferred back onto spinal board and begins carry up road. ML and SH get clothes, money and passports
19.52 RV with 4x4, transfer S into back of flat bed which has a mattress down for comfort. Evac team return to camp and plan to return to rest of group the next morning. SH continues with ML and PS. Patient head up and conscious level poor, but maintaining own airway. Patient not given final adrenaline as vehicle may get stuck on route.
20.20 RV ambulance, volunteer vehicle. Crew requiring ID before SH allowed to treat S, happy with GMC number. SH achieves IV access, N/S, 12mg dexamethasone IM, 1mg adrenaline IM
Transfer to local clinic arriving at 21.15
21.15 GCS 15, feeling better, though still itchy and covered in urticarial rash, given piriton IM, saturations 84% on air, possibly due to peripheral vasoconstriction and finger probe.
22.40 Transfer to Limon Hospital for overnight obs. ML followed in taxi.
00.30 Arrive Limon, recovered well, S stays overnight. CXR, bloods, ECG, IV fluids. SH and ML check into hotel
Next day S discharged with Prednisolone 50mg OD. Stay in hotel and rejoin group on 13th for raft out.
A note on Hymenoptera: Hymenoptera stings account for more deaths in the USA than any other envenomation (Vankawala 2009). The majority of stings cause minor reactions and even large local reactions do not necessarily predispose patients to generalized reactions. Hymenoptera are territorial and sting to protect the colony. They also respond to noisy machinery, perfumes and bright colours. In addition, they release pheromones to attract other nearby wasps to also attack, so victims are usually stung more than once. Toxic component of stings include phospholipase, histamine, bradykinin, acetylcholine, dopamine and serotonin (Vankawala 2009)
 
The debrief
Having successfully arrived at the last campsite by raft, participants met for a team debrief. It was an opportunity to express thoughts, feelings and experiences from the night of the casevac.
Summary of learning points collected from the meeting.
Learning points
1.    Everyone in group should bring Epipen and know how to use it.
2.    Medics to carry Epipen, 4 adrenaline, 12mg dexamethasone and piriton 10mg
3.    Need large numbers people to do evacuation
4.    Small portable stretchers are invaluable
5.    Perform casevac drill at the beginning of each expedition
6.    Snatch bag in waterproof bag containing, passport, money and med kit for clients
7.    Medics primary survey kit in bum bag so not left behind and easy to access without taking off
8.    Set up comms time or leave lines of comms open
9.    Take GMC certificate and number of credit cards
10.Team ID cards so easy to keep an eye on who is doing evac and who is left in camp
11.Individual responsible for kit
12.Casevac aide memoire
Perspectives
The Casualty: “The days trekking had been enjoyable and we settled into camp, excited to be erecting our hammocks for the night ahead. Three camp fires were planned, one centrally for meeting around, and two satellite fires for sub-group cooking. As the fires began to smoke, I headed off with LC to go down towards the water source. We had already seen a few others come up with stings, but no one was concerned. We headed down a steep single track path cleared by our local guide (M). Half way down we met IF who was on his way back up warning us that there were wasps all around the path. We stopped to apply insect repellent and, as we hesitated, the wasps all came up towards us and began to sting. I was stung 4 or 5 times on my right arm and once on my left thigh. The stings were surprisingly painful and I shouted out in surprise. We turned around and quickly made our way back up the path to the main camp. AA found us some topical antihistamine and already my arm had begun to swell.
 
We decided we would go back to another river we had crossed 5 mins before arriving in camp and collect water from there instead. Within a few minutes I noticed I was salivating excessively and started to feel sick, but continued down towards the water where I began to feel generally unwell and started retching. I told LC I wasn’t feeling well and was going to walk back to camp. I climbed about 20 metres towards camp and then started vomiting, feeling dizzy and had to sit down. AO and JM carried me back to the DS sleeping area and M had shouted for help and run to get SH. My face and body were extremely itchy and I remember an odd sensation of tingling in my mouth. I’m not sure whether other details I remember from then on are because several people have told me what happened or whether they are my own memories. I think I recall standing up and trying to walk. After that I remember being in the back of the ambulance and then arriving at Siqquires hospital.
 
Following transfer to Limon I had a sleepless night in an open ward. The staff were all very friendly although my lack of knowledge of Spanish made it quite difficult to understand what they were talking about. The doctor did mention that they had had quite a few attendances with people having serious allergic reactions from biting insects recently.
 
The following morning when I was collected, I felt exhausted and had a sore buttock (from all the IM!) but was otherwise OK. I was pleased to have a day to rest before rejoining the group. The re-union for the raft out was emotional for me. I found it difficult to put into words a thank-you that was more than just an ordinary thank-you. These people who I had met only a week before had put themselves in extreme danger to save my life and I was immensely grateful. Had it not been for their physical strength, quick thinking and courage things could have ended very differently. I found the debrief a surreal experience, hearing what had happened to me as if I hadn’t really been part of it. Reading the report on paper also seemed strange. I’m glad I didn’t know there were tarantulas around at the time!!
 
Following the end of the expedition I travelled in Costa Rica initially with other group members. This meant there was an opportunity to talk about things that had happened, without explanations. When I then travelled alone, I found the experience difficult to come to terms with. I had dreams of red and white lights, where I could hear people talking and but couldn’t understand them, and I was talking but no one could hear me. Following discussion, I have realised that this probably relates to the torch lights and situation during the rendezvous with the ambulance. On a visit to a National Park my guide told me of an English girl who was not known to be allergic to wasps and had been stung 11 times by a paper wasp the previous season. She had died due to lack of access to appropriate medical facilities.
 
Now I have arrived home, I have an Epi-pen. Fortunately my day-to-day life doesn’t put me in contact with wasps. I do think about the whole experience occasionally and it scares me. I remain forever grateful for what everyone did for me.
 
The Lead Medic: Over the last 13 years I’ve been involved in numerous evacuations from remote environments, however I never fail to learn something new every time.
Running a casualty evacuation is always a draining and difficult experience. This one in particular reinforced the difficulties of working and running an evacuation in a jungle environment. The terrain is very hard and claustrophobic and the fauna and flora are a true hazard (the week after we were in Costa Rica the same agent had 3 snake bites on one trip).
It is hard to imagine having run this evacuation without a number of elements.
 
1.     The most important is a strong and willing team.
2.     A good agent who is willing to work as hard as you and become fully immersed in the evacuation is invaluable. They provide the local knowledge and bridge the language barrier which may exist.
3.     Adequate medical kit. Anaphylaxis is one of the few truly time critical life threatening medical emergencies, and I will always now carry adequate adrenaline and ensure that the individual team members medical kit list includes an epipen
4.     I always used to carry a small medical grab bag, but will now carry a bum bag as it allows you to access your kit without even taking off the bag
5.     Never leave your patient until you are absolutely sure of the care and facilities. There were a number of occasions from when we exited the jungle that the medical infrastructure tried to take control and exclude us from the decision making process.
6.     Always carry enough money in cash and a number of cards. I spent $1500 and had one card refused by my bank as I wasn’t in the UK.
7.     A thorough and honest debrief is essential. Managing this requires some sensitivity and honest objectivity without any blame.
 
The first on scene (MI): After she got stung by the bees, there was a more profound local reaction on her skin, than ours. Both me and A had taken PO antihistamines. After 15 minutes after the sting, I heard that M called out that someone was throwing up, and I heard someone said allergic reaction. At that time I ran up to my backpack to get my Epipen, and down again finding her laying on the ground. I have to say, I was real worried when I looked at her, because I knew that she was critically ill. I was sure that she was having an anaphylactic shock. She was pale, the pulse was rapid and weak, and the symptoms she showed (itching and grabbing your throat and constantly throwing up.) I put the injection of the Epipen in her left deltoid area.  Then more people were coming with some PO medications. And I also put the IV access to her hand.
 
About then it was discussions about whether to take her to a hospital or not. We were also trying to warm her with the sleeping bag.  I lost track of time during the scenario, so I really don’t know how long it lasted before the evac team started to move out.
 
After the team left, we all gathered around the camp fire, and went through what happened. Not all people knew what was happening. The plan of the team was to get back in the camp later on in the night, after delivering the casualty to a hospital.
 
I know that we were worried that she would not survive, and there is one of L’s photos taken of us, and you can see that how we look in our faces on the photo. The worst thing when we waited, was that we did not know what was going on and we didn’t know if you survived or not, especially when the casavac team did not come back during the night. In the morning the team came back, and told us what happened. And I remember a comment from JH (military paramedic); " This has been the closest I came to loosing someone ", compared with his experiences in the war. My emotional reaction came on the last night when I got back to the hotel. I was just so happy that she made it through, and I have to say I had a few tears of happiness.
 
Non-medic member of the evacuation team: Initially I was alerted by calls for adrenaline as I was preparing firewood. I chose not to get involved at that stage as I guessed that enough doctors were present and I had no desire to get in the way. I knew they would call me if I was required.
Once the incident was dealt with, we found out what had happened. Several people had been stung by wasps or bees disturbed along a track that SH and I had recce’d earlier down to a stream. S that had been stung and had (while not immediately) gone in to anaphylactic shock. SH then approached the camp fire clearly with things on his mind. I asked him if we needed to do a casevac (casualty evacuation). He said ‘Yes’ explaining that while everything was alright now, he did not want to take the chance of S deteriorating in the night.
SH said that we would carry S out on our backs and to get eight other strong guys and meet him back down by his hammock. It was a good plan as S was light (approximately 120lbs) and the trail was only suitable for one in most places. I felt that there was no rush as it was only a precautionary casevac at this stage. We were going to have to walk in the dark, regardless of how quick we set off, as last light was approaching. The plan as I translated it, was to get SS down to the basecamp on the far side of the river and then for most of us to return straight away, eat, sleep and for the mini-expedition to carry on. 
I envisaged the first third of the route out to be the hardest as ascent was involved and then the rest was downhill albeit steep and slippery in places. As it turned out we did not return down the route we arrived by. The first phase was the same however and this involved ascent and decent, essentially traversing a wooded hillside over several small ridges and watercourses until we reached a larger ridge. We then headed more directly down to the main river following a slightly larger trail used by indigenous locals.
I approached the three strongest guys, who agreed to help and asked them to help me recruit others they knew to be capable. I asked them to assemble me at SH’s hammock. Two others I asked made the sensible call not to come as they did not feel fit enough after the day’s exertions. I then went back to my hammock and took my head-torch, some spare batteries and some food bars. 
SH then told me we needed to move right away. SH was now generating a much greater sense of urgency and while I was unsure what was happening as S seemed reasonably well if weak, obviously he had serious concerns. Not quite all the carrying party had arrived and I attempted to hurry them up by sending others back the few yards to shout. I saw that we had some water between us and SH then said “We need to move now!” 
Because of the difficulty of terrain, SH wisely decided to start with S walking but after watching her take only a few steps he quite rightly changed his mind and so using a rope coiled for a ‘split rope carry’ I put her on my back. SH’s plan was for each person to carry for ten minutes at a time. While S was limp she was conscious for the first 10 minutes. The rope carry was comfortable for me but only comfortable for her when my arms took the weight of her legs as in a ‘piggy-back’ carry. From experience we knew that it is best to time the stints accurately in order that carriers do not carry for too long in their enthusiasm. As it was 10 minutes was about right although at the time it felt long because the pace was quick. I followed SH who was helping where he could by giving me a hand to pull on. Out at the front was M (the local guide). SH drove us on, asking us to move as fast as possible, with a strong the sense of urgency.
Near the end of the most difficult phase, just short of the slightly larger track which we were to follow downhill to the river, the third carrier was exhausted.  After the initial ten minutes S had become harder to carry as she was by now completely unconscious. The watch said about 18 minutes had elapsed and we had to stop to change but on examination of S, SH decided a stretcher was needed.  Had S remained conscious the carry would have been relatively straightforward from then on but she now needed to have her airway maintained and this was not feasible while she was on someone’s back. SH dispatched those not immediately involved with S to make the stretcher. Two poles were presumably cut by Martine who had been leading the way and clearing the trail of snakes cut and on request we removed our shirts for use as the stretcher bed as this was the quickest method available. 
With four carrying the stretcher we moved off on a muddy, difficult and downhill track. Under SH’s leadership we were moving as fast as possible. He still obviously has serious concerns about S and it appeared to me that each dose of adrenaline administered had only had a short lived effect. I was not sure how many Epipens remained.
After about 40 minutes (a guess) we reached a permanent tourist hotel/lodge/camp on the river bank where helpful employees offered to raid their medical stores and returned with at least one Epipen, a spinal board, jugs of water and a vehicle. After attempting to transport S in the vehicle SH decided for the sake of S’s comfort it was easier to carry and we got to the wire cableway across to ML’s (local agent’s) camp and the correct side of the river. We moved S across the cableway with two of us as this was all the cage allowed and then the others followed in twos or threes. ML had run into his camp and returned with a spinal board. SH had grabbed money and other essentials and we headed up the track to rendezvous with a 4x4 that was heading down hill to meet us. We only needed to move a few hundred metres before we met the small truck/pickup vehicle. S was placed on the cargo bed at the back. SH took PS and ML with him. He gave me instructions to stay at the basecamp and return to the rest of the course the following morning when the guys were rested.
We could only hope that S survived and while I was more optimistic since the small resupply of adrenaline from the camp on the far bank, there had been a time during the descent when I had feared the worst.
A call in the morning assured us that S was much better and we returned to the main group to pack up and relay that news to the others. It seemed prudent to return the group to camp since our medical kit was now depleted of vital adrenaline and we had used up our allocation of good fortune.
Looking back, as things turned out we had moved off not fully prepared and the urgency of the developing situation had necessitated that we moved faster than was entirely safe. We had escaped further injury and snakebite [M had been particularly worried about the ‘Fer De Lance’ (venomous snake) threat as they naturally lie in ambush along tracks at night]. Had we had further injury or an envenomation incident during the evacuation things would have been even more interesting. Fortune had favoured us. In my opinion it was SH’s first class leadership, experience and medical expertise that had enabled a willing carrying party to get S to a vehicle on the track. The rest was out of our hands but his selection of the right companions to deal with events on the way to, and at the hospital, again proved correct and paved the way for a successful outcome.
Experience tells me that no casualty evacuation in that terrain is entirely without its anxious moments but by acting positively, boldly and under clear leadership, the group gave itself the best chance of success. 
Personally I would have liked to have foreseen the possibility of a stretcher being needed although SH himself had apparently briefly discussed the need for taking one with MR and discounted it. S’s speed of deterioration was completely unexpected. I would in future give more direction as to what the individuals should carry as, after explaining the situation, I left it to them to decide. In hind sight I would also have been more urgent in the assembling of a carrying party although at the time I had not realised how quickly we need to move and I had only sought to use a calm approach. I should also perhaps sought to help control some other hurried moments such as the stop resulting in us leaving behind a vital daysack that necessitated a big effort by ML and J to head back uphill and retrieve it. That said, I feel that part of the effort by me and others with previous relevant experience was to avoid too many voices and leave one leader.
While the phase from high camp to the river would have been a little more controlled had we been able to move at a slower pace, SH’s sense of urgency conveyed the message that every single second was vital. He was both the leader and the doctor in charge and he was without doubt correct. On first reflection after the incident I initially thought it may have been advantageous to split the medic and leader roles to allow SH more time to devote to monitoring S. Now I feel that while it may have taken some of the psychological pressure off SH, he was clearly up to the task at the time and it may also have only served to delay matters and overly complicate things; there were after all, three medics carrying the stretcher at any one time.
In the end it I feel that it was SH’s original decision to evacuate S as a precaution that was the difference between a good or disastrous outcome. It allowed certain preparation and team selection to take place and it saved what turned out to be vital time. Everyone played a vital role by maintaining positivity during a tricky descent with special mention to M the guide who was under pressure to find a quick way out which he did admirably well. Without ML’s (local agent) excellent communications system with its relay capacity to reach his office over a hundred kilometres away from a mountainous jungle location we would also have been less likely to succeed.
I was not party to the initial diagnosis and treatment at the high camp but I know that several others were involved in that phase. All in all, everyone played a part whether it was remaining calm at the high camp, the leadership of those remaining at the high camp or carrying S down the hill and the greatest part was played by SH in all phases and he deserves the greatest of credit for the successful outcome.”
 
References:
 
Brown AF, McKinnon D, Chu K. (2001) Emergency department anaphylaxis: A review of 142 patients in a single year. J Allergy Clin Immunol. 108(5):861-6.
 
Gupta R et al (2004) Burden of allergic disease in the UK: secondary analyses of national databases. Clin Exp Allergy. 34(4):520-6.
 
Krause RS (2009) Anaphylaxis. Emedicine [Online]. Available from www.emedicine.medscape.com/article/756150 [15 Dec 2009]
 
Liebermann P (2008) Epidemiology of anaphylaxis. Curr Opin Allergy Clin Immunol. 8(4):316-20.
Pumphrey RS. (2000) Lessons for management of anaphylaxis from a study of fatal
reactions. Clin Exp Allergy. 30(8):1144-50.
Pumphrey RS and Gowland MH.(2007) Further fatal allergic reactions to food in the
United Kingdom, 1999-2006. J Allergy Clin Immunol. 119(4):1018-9.
 
Resuscitation Council UK. (2008) Emergency treatment of anaphylactic reactions [Online]. Available from http://www.resus.org.uk/pages/reaction.pdf [19 Dec 2009]
 
Vankawala HH, Park R (2009). Hymenoptera Stings. Emedicine [Online]. Available from www.emedicine.medscape.com/article/768764 [16 Dec 2009)
 

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