Newsletter
APRIL 2008
Hello to all our readers and welcome to the latest edition of the Expedition Medicine eNews.
We have lots of exciting news in this edition; Dr Kirstie Nicol tells us all about her time in Nepal working with the Himalayan Rescue Association (HRA); Dr Alison Cook writes about a case of splenic infarction at high altitude on expedition in Peru; Namibia Ultra Marathon results; plus all our course news! We still have places left on our Jungle, Diving and Desert courses and our UK course in September, so get your skates on before you miss the boat on these.
We hope you enjoy this edition of eNews and happy reading.
What's in this issue:
Course news -what’s going on and where
We have our usual favourite courses lined up, as well as our NEW Desert and Diving medicine courses. Our courses are getting very popular with the Polar and EML UK courses always being oversubscribed. We think our new courses will be just as popular.
Polar Course - Norway 15th - 21st February 2009.
LIMITED TO 24 PLACES
A winter extreme climate expedition medicine course for or anyone wanting to work in a polar, high altitude or arctic environment. For further details click here.
EML UK Course - Keswick, Cumbria 9th - 12th september 2008.
LIMITED TO 60 PLACES
Held in the stunning Barrow House, Keswick this course is for anyone aspiring to become an expedition medic. Read about the recent course in the BMJ for further details about the course click here.
NEW FOR 2008 Desert Course - Namibia 17th - 23rd August 2008
LAST 8 PLACES LEFT
Expedition Medicine is delighted at being able to offer a comprehensive course for all those medical professionals responsible for clients, patients or team members in a desert environment. The course aims to introduce participants to the skills required to be a valuable member of a desert expeditionary team, and to care for and treat injuries and illnesses likely to occur in this harsh environment. Set in the stunning Damaraland area in Namibia, for further details click here.
NEW FOR 2008 Diving Medicine- Oman 2008 18th - 24th Ocotber.
LIMITED TO 30 PLACES
We are very excited at being able to offer an inspirational Diving & Marine Medicine Course for all those medical professionals responsible for clients or expedition team members in a diving or marine environment. The course aims to introduce participants to the skills required to manage the common medical problems, which may emerge in a diving or marine environment. For application forms or further details visit our website.
Jungle Course - Costa Rica 9th - 15th November 2008.
LIMITED TO 30 PLACES
Our jungle course is going from strength to strength. We are now running our third course in Costa Rica. Ideal for those interested in tropical and jungle medicine. For further details click here.
Dr Kirstie Nicol in Nepal with the HRA
 In 2007 I left ‘normal’ working life as a GP in Haddington behind for a while to work for the Himalayan Rescue Association in a high altitude clinic in Nepal. The HRA is a Nepalese voluntary non-profit organisation formed in 1973 with an objective to reduce casualties in the Nepal Himalayas, especially in view of the increasing number of Nepalese and foreigners who trek up into the remote wilderness. Nepal alone now receives more than one hundred thousand trekkers from around the world every year. It can be easy to under-estimate the dangers of altitude illness; deaths from these conditions are all the more tragic because they are entirely preventable. Working at the clinic involves a mix of primary health care for local people including home visits, providing an emergency medical service for trekkers and the provision of daily lectures for trekkers emphasising the prevention, recognition and treatment of altitude illnesses. Because rescue is difficult in Nepal, prevention is a key part of the role.
Thus, the HRA increases the safety of the trekkers encouraging tourism, which boosts the Nepalese economy, and also uses the donations and charges to the foreigners attending the clinic to provide much-needed free healthcare to the local people. The Manang clinic where I worked is in a very remote part of northern Nepal situated at 3570m in a small mountain village surrounded by the 8000m peaks of the Annapurna mountain range. It is an incredibly beautiful and peaceful place. It takes seven days of trekking to reach it from the nearest road and the clinic is the only source of western medical care for the people there. The staff consisted of myself and another volunteer doctor and two Nepali staff who helped with day to day running of the clinic and translation. The clinic is open 24 hours a day, seven days a week during the two main trekking seasons. Manang is a mainly Buddhist area and Tibetan Buddhist philosophy is evident all around and added a very interesting aspect to our care of the local people.
 Life at the clinic is basic but rejuvenating. I slept in a tent for the best part of four months, there is no hot water and no heating and the food consists of daal bhaat every day- a Nepali staple of rice and lentils.
The clinic itself has a reasonable range of medications to cover most situations and an oxygen concentrator which is the life line.
This comes with its own problems though due to difficulty maintaining it and getting it adequately serviced. Also the only power supply is by solar panels which charge a battery and therefore if the weather is bad it is necessary to conserve power for the concentrator and conduct all business by torchlight and candles! It is difficult to get re- supplies in a hurry as they require to be sent from Kathmandu and take at least eight days to reach the clinic by mountain porters. Therefore an ability to do your best with what is available and be innovative is required. It can be refreshing to get back to the basics of medicine, relying on your clinical judgement with no back up from labs etc.
 The commonest presentations among the local population were respiratory tract infections, diarrhoea, joint pains and gastritis but we also dealt with emergencies such as acute abdomen, myocardial infarction, and stroke and one night I was called to my most feared situation of an obstetric emergency. Thankfully, eventually, a healthy baby was delivered, with a combination of assistance to the mum from the limited obstetric medical supplies we had available and the blessings from the lama. Nature is an incredible thing! As mentioned the locals did not pay for their healthcare at the clinic but the clinic did not provide evacuation costs for them if they required hospitalisation. It therefore very much depended on their position within the community what was possible for them. For instance one local man who was the owner of the roksi (local brew) shop and therefore  well known in the community, required emergency surgery and was an ‘in-patient’ with us for a few days whilst his family gathered a loan from prosperous teahouse owners and village elders, enabling him to be evacuated by helicopter to Kathmandu.
However life is much more difficult for others and I treated a young fifteen year old mule herder with life threatening pneumonia whose only means of evacuation was to be carried in a basket on the back of a porter; a journey which took five days for him to reach a basic hospital.
The commonest presentations in the trekkers were diarrhoea and acute mountain sickness. We treated several cases of life threatening high altitude pulmonary oedema and arranged helicopter evacuations where needed.
 The helicopter can only fly to this altitude during settled weather in daylight hours and even in an emergency often takes more than eight hours to come. Other means of evacuation are by horse or being carried by porters. Often these means are quicker and can be life saving at altitudes above Manang rather than waiting on a response from the helicopter. During our time we also ran a pilot study of a small clinic at Thorung Phedi 4500m, a teahouse stop where trekkers on the Annapurna circuit stay for the night before they attempt the Thorung La Pass 5416m. There is plenty exposure to high altitude medicine here!
It is amazing the range of people that come to trek in these mountainous areas, many with no or limited previous experience of mountain environments and of course others with a wealth of experience. Some of the life threatening cases we saw among the trekker population were related to people with pre- existing medical conditions that were compromised by being at altitude.
They either hadn’t been provided with adequate information about the risks of altitude or had failed to accept that the information they were given really did apply to them.
There is an important role in pre travel health consultations to educate travellers to high altitude areas about the risks, taking into account their past medical history. I carried out a questionnaire based study among the trekkers with the aim to establish whether advice about altitude illnesses was given at their pre-travel health consultation (i.e. when attending for vaccinations); what this advice consisted of; where they received it; whether they were advised to take or given a prescription for acetazolamide and if so at what dosage and when they were advised to start it; and whether they sought information about altitude illnesses from other sources e.g. internet, guidebooks. I am currently processing the results of this study but from the initial data survey it looks like we certainly could improve the information we give to travellers to high altitude areas to reduce their risks of these life threatening altitude illnesses. There will be more on that to follow once I have completed the data analysis.
My sincere thanks go to my partners for permitting me this period of unpaid leave and to the Alastair Short Memorial Award which provided me with financial support for this work and study project.
About the writer. Dr Kirstie Nicol is a G.P. with a keen interest in expeditions and the medical issues of remote locations. She has attended the Expedition and Wilderness Medicine course in Keswick and the Polar Medicine training course in Alta, Northern Norway and worked as an expedition medic for Across the Divide Expeditions in locations as diverse as Kilimanjaro and Peru.
Desert Medicine Course | Namibia
 Expedition Medicine are very excited at being able to offer a comprehensive course for all those medical professionals responsible for clients, patients or team members in a desert environment. The course aims to introduce participants to the skills required to be a valuable member of a desert expeditionary team, and to care for and treat injuries and illnesses likely to occur in this fascinating environment.
Our Desert Medicine Course is based in Damaraland, an area bounded to the south by the spectacular Namib Desert, to the east by the Kalahari, Ovamboland to the North and the world famous Skeleton Coast to the west. Overshadowed by Namibia’s highest and most impressive peak, Brandberg – which means ‘burnt mountain’ and whose Omukuruvaro name more aptly means 'mountain of the Gods' and whose massive bulk covers over 650 km² and with its peak Königstein at a height of 2573 m. Our training area is a natural reserve for specially adapted desert elephants and rhinos, which we hope to see during our week long stay. The top of the mountain is a large, flat area, that due to its height and inaccessibility, has been largely isolated from the surrounding countryside. This inaccessibility has created a unique ecological area, in which it is suspected, new species are yet to be found.
For further details on the Desert Medicine Course visit our desert course page.
Dr Alison Cook and a case of Splenic Infarction at high altitude in Sickle Cell Trait
, Inca Trail to Machu Picchu, Sacred Valley, near Cusco, Peru2.jpg) In March 2007 an ATD client with undiagnosed sickle cell trait (SCT) suffered a splenic infarction on a high altitude expedition. Although the phenomenon of splenic infarction in SCT at high altitude is well documented, it is a relatively rare event and therefore a worthwhile case to share amongst expedition medics.
I was the doctor for one of Across the Divide’s Peru treks when this unfortunate chain of events occurred. A couple of hours after landing in Cusco (3300M altitude), a client developed acute abdominal pain. He was a physically fit, 23 year old white man, with an unremarkable medical history. His initial symptom was mild-moderate epigastric pain and abdominal examination revealed a soft abdomen, tender in the epigastric region. Half an hour later he developed vomiting and over the course of the next couple of hours the upper abdominal pain became progressively worse. Thankfully we had only journeyed about an hour from Cusco so an easy transfer via taxi back to a hospital in Cusco was quickly organised.
On arrival in the clinic the patient was managed with oxygen, I.V. fluids and opioid analgesia. He was referred for a surgical opinion and the diagnosis of splenic infarction was subsequently made. Examination at this time revealed generalised tenderness, worst in the upper abdomen with marked pain on percussion over the spleen. An ultrasound scan revealed splenic enlargement and total splenectomy was performed within a few hours.
On return to the UK the client was referred to a haematologist and the diagnosis of SCT was made. The client had some Greek ancestry – his maternal grandfather being Greek. The large majority of people with SCT do not suffer health problems as a result of their condition, consequently many people are unaware of their diagnosis. Splenic infarction occurs at altitude in SCT because the red blood cells are subjected to low oxygen tensions which causes them to sickle and become lodged in the vasculature of the spleen.
There are 47 cases of splenic infarction at altitude recorded in the literature. Many of the cases have been successfully managed conservatively and others have undergone splenectomy. Conservative management with fluids, oxygen, analgesia and descent if possible, is considered appropriate first line therapy. Use of the hyperbaric chamber, although not documented, may also help. Surgical intervention may be necessary if conservative management fails or complications arise (eg. splenic rupture, abscess/pseudocyst formation or sepsis).
Since this case Across The Divide have made some changes to their pre-departure medical questionnaire - clients are now asked if they have a personal/family history of sickle cell or any other blood disorder or if they come from an area where sickle cell is common. If they answer positively to any of these questions they are advised to see their doctor to have a medical check – hopefully this way people with SCT can be diagnosed and counselled prior to departure. This does however rely on the GP having an awareness of this rare complication of altitude, so it’s something for expedition medics to look out for on pre-departure medical forms. We now have an ethnically very diverse population in the UK and people do not always know their sickle cell status – if there are doubts they can be offered a screening test prior to departure.
So… this case is one for the memory bank of expedition medics on trips to high altitude!
About the author - Dr Alison Cook is a G.P. with a keen interest in expeditions and the medical issues in remote locations. She has attended the Expedition and Wilderness Medicine course in Keswick and has worked as an expedition medic for Across the Divide Expeditions in locations diverse as Namibia and Peru. Alison has also worked with Medecins Sans Frontieres (MSF) in Niger.
New Media Page | www.expeditionmedicine.co.uk
 We have just launched our new media support page on the EML website. It gives you detailed information on what support we can give, recommended kit and the cost involved. You can find the page here.
At Expedition and Wilderness 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.
We can provide full medical cover for production teams and celebrities on your television or photographic project worldwide. We have an impressive portfolio of experienced medical professionals on our books, many of whom have media experience both on and off camera. Using Expedition and Wilderness Medicine to provide your medical cover resolves some of the most important logistical and safety considerations of foreign travel in remote environments. Through our ties with Across the Divide Expeditions we are also able to assist in the provision of outdoor specialists and logistical support in the worlds most remote locations.
Namibia Ultra Marathon | Results
 The Namibia ultra marathon was a great success. A fantastic route and we've had excellent feedback from the runners. Find out how they did on the results page.
"Across the Divide have captured the spirit of adventure racing in this event for me!" Andy McMenemy, Namibia ultra marathon participant 2008.
The next event is the Laugavegur Ultra Marathon in Iceland, see below. The extreme series was set up to offer a different experience for those wishing to take the challenge of running a marathon to the next level. All our marathons will be run in difficult environments to push runners just that little bit further.
Just Walk 2008
.JPG) Calling all medics in the South - come and join us on Just Walk. A fantastic fundraising event in the stunning South Downs. A great way to train for events and get those fitness levels up and raise funds for the charity of your choice.
For further details on this great event, visit the website
Situations Vacant
We are getting more and more exciting media positions on our website as well as the usual interesting expeditions. This month we have a position with Earthwatch, working on their expedition to Sabah, Malaysia and BSES Expeditions looking for a medic for their Norway training weekends. Please visit our situations vacant page – for an opportunity of a lifetime click here.
Join Across the Divide on a fundraising challenge
 Open charity challenges are designed so you can raise money for a charity of your choice - it could be your local hospice or a major cancer charity. Across the Divide have been delighted at the response to their new open events for 2008 and 2009 .
The dog sledding and Kilimanjaro challenges are selling out fast but they still have places left on the Peru, Ladakh, CHina and Everest challenge events - PLUS we have just listed a few NEW trips in 2009. An India bike ride, Trekking in Jordan and a project in Namibia- so book now to avoid disappointment later. Find out more about Across the Divide here.
For further information on our open events email Susan McDonagh.
Blog links
If you have your own blog and you think it is an interesting read for other expedition medics then please contact us and we'll see about linking to it.
Iceland Laugavegur Ultra Marathon July
The "Laugavegur" course is one of the most beautiful in Iceland, stretching from Landmannalaugar in the highlands to Thorsmork, a natural reservation area. The area is famous for the yellow, orange and purple hues of the surrounding mountains.
The race blazes a trail through moss fields, meadows of wool grass, steam springs, and bizarre lava formations, where various blossoms defy the raw climate.
The race ends at Thorsmork, described as Iceland’s brightest pearl, surrounded by rugged mountains and beautiful glaciers. To view further details about this race click here.
Sales Manager and Ultra marathon runner Steve Clark has recently returned from completing the marathon. Read about how he got on here.
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