Driving forces behind severe asthma cases
One of the joys of a medical degree is the entrée it provides to exotic jobs. Himalayan climbing expeditions gave me an opportunity to indulge my passions for climbing, travel, and medicine in developing countries.
In 1974, newly registered, I went to Nepal and worked for the Britain Nepal Medical Trust. For six months I ran three remote 'hospitals' with 20 local staff, and then Chris Bonington's expedition to Everest turned up!
Expeditions visit remote areas by air, land or sea, in temperate, tropical or polar regions. They may involve mountaineering, caving, rafting, kayaking, diving, high altitude, 4WD vehicles or sailing. Aims may range from serious exploration and scientific research, to pure adventure.
Treks and voyages, a fast-growing area within the travel industry, are mini-expeditions to remote areas, providing good exposure to wilderness medicine. While not strictly expeditions, positions might be found with the British Antarctic Survey or Himalayan rescue posts run by the International Porter Protection Group (IPPG) and Himalayan Rescue Asociation.
As the medical officer you are responsible for everyone's health and safety, from first-aid kit preparation in the beginning through to the expedition medical report. Though expert advice may be obtainable by sat-phone, you will have to manage all illness and accidents with just the equipment and skills you brought along.
Evacuation time to a hospital is measured in days or weeks. Your 'practice' demographic might range from teens (school groups) to octogenarians (travel industry) and in populated areas the locals will test your paediatrics and occasionally obstetrics.
Common problems are illustrated by the results of a survey of 4,000 trekkers to high altitude in the Himalayas (see box), but the list of possibilities is endless.
Perhaps the most difficult situation I had to deal with in the wild was a florid psychotic episode, but I have also sewn up a yak attacked by a snow leopard and resuscitated a hypothermic Himalayan vulture!
Expedition medicine is akin to war on the Western front: the 'boring' bit is filled with respiratory problems, GI infections and minor trauma, while the fear-filled action could be someone with a fractured C2 complicated by high altitude cerebral oedema (a case at the IPPG rescue post).
Expedition medicine is part of wilderness medicine, which has its own societies and a vast literature. The 'bible', Auerbach's Wilderness Medicine, weighs in at 4.2kg, while the Royal Geographical Society's Expedition Medicine is an excellent introduction to the doctor's role.
General practice and A&E are firm foundations, while anaesthetics or general surgery top the specialties. Supplementary skills might include a five-day wilderness first aid, BASICS, high altitude, dive or tropical medicine course.
Volunteering to staff rescue posts is a great way to gain lots of high altitude and wilderness medicine experience. Closer to home, sessions in A&E or working with your local ambos/paramedics or with a mountain/cave rescue team are possibilities. Finally, ask yourself: 'Do I have the necessary inventiveness, endurance, survival skills, self-sufficiency, diplomacy and sense of humour?'
To be paid for what you love to do is the Holy Grail of expedition medicine, and about as unobtainable. While you may not land a salary there may be spin-offs in the form of articles, books, photos, research papers or lectures. Consultancy work in the travel industry is also an option, or you may just strike it rich through the media. Eventually, when your joints wear out, you can always take up teaching wilderness medicine.
On a private adventure expedition, such as a round-the-world yacht race, you will probably have to pay most of your own way. Free trips are sometimes available, for instance charity treks or if sponsorship is available. Rescue posts will pay some of your in-country expenses.
A wage or lump sum only becomes a possibility when a government, company or the media are involved.
The nitty-gritty is time off from work and family. A GP will need an agreement with partners (and spouse) or work as a locum. Hospital doctors can arrange their contracts to fit.
Of course your career path may suffer, though for the determined 'butterfly', expedition medicine may just become the career!
Data on 4000 trekkers
going above 2500m
The 10 top presentations:
11 Acute mountain sickness 16.75%
12 Diarrhoea, treated as bacterial 7.25%, protozoal 1.75%, conservatively 3% 12.00%
13 Respiratory problems: sore throat, sinusitis, dry cough, asthma, chest infection 9.00%
14 Muskuloskeletal: trekker's knee, ankle sprain, back, shoulder and neck pain 2.18%
15 Abdominal pain, indigestion 1.13%
16 Food poisoning 1.05%
17 Vomiting, cause unknown 0.95%
18 Dehydration 0.90%
19 Lacerations 0.68%
10 HAPO and HACO 0.48%
(Unpublished data, Dr J Duff and Dr J Spinaze 2004)
British Antarctic Survey www.antarctica.ac.uk
Royal Geographical Society www.rgs.org
IPPG International Porter Protection Group www.ippg.net
HRA Himalayan Rescue Association www.himalayanrescue.com
Treksafe info on the PAC www.treksafe.com.au
Jim Duff was doctor on several major Himalayan expeditions and now leads high-altitude treks for doctors to Mount Everest and Mount Kilimanjaro
he is a GP in Cumbria