Getting started in expedition medicine

Expedition medicine is varied and rewarding, but requires a number of considerations and thorough preparation

After a bruising few years in healthcare, many doctors are looking for a palate cleanser or reset button to make them fall in love with medicine again. If this sounds
familiar, have you considered expedition medicine?

Expedition medicine broadly involves supporting field activities outside of a clinical or controlled environment. This can involve adventure travel, sporting events or academic research.

There are many different types of expedition looking for medical cover across the world, both on a paid and voluntary basis. From extreme sporting events, such as the Arctic Ultra-Marathon, to conservation research expeditions with climate organisations, such as Operation Wallacea, there is no shortage of trips requiring medical input. Deciding what type of expedition is right for you depends on your interests and skill-set. Are you most comfortable working as part of a large team with access to diagnostics? Or do you feel confident working solo as a first responder?

It is crucial that you are comfortable working in the prehospital environment before signing up to provide expedition medical cover. It is also important that you have currency in all required skill-sets. If it’s been a long time since you dealt with minor injuries or in an emergency setting, it would be worth brushing up on these before you sign up to an expedition. The good news is that there are many ways to get these skills before you set off.

Besides emergency department work, there are opportunities to provide medical cover at events in Ireland or to get prehospital experience while shadowing paramedics. Local community first responder groups will often welcome medics and depending on where you live, there may be mountain rescue or Royal National Lifeboat volunteering opportunities. Prehospital practitioners have their own, distinct skill-set and doctors who are used to a clinical setting can pick up valuable tips here.

It’s very important to have frank conversations with the organisers of the expedition of what care you can provide and what care is not feasible. New organisations or non-medical staff may have very unrealistic expectations about what medical care it is possible for a single provider to give in an emergency. It’s very important to tease out exactly what is expected of you. Be very clear what is ‘in scope’ in terms of your own practice and what is not. If it is your first time working outside a clinic or hospital environment, it’s important to work as part of a team or with a more experienced colleague. Find out
who else on the expedition will have medical skills and what exactly they can do beforehand.

Most established organisations will have standard operating procedures for medical evacuation, safety briefs, etc. Ask to see these in advance, make sure all the information in them seems reasonable and is up-to-date. Get a sense of the organisation’s attitude to safety – the medic is also often the health and safety officer so make sure you’re comfortable with the proposed activities.

If physical activities are involved in the expedition – for example, mountaineering – make sure that you are physically fit enough to complete these activities without becoming a burden to the expedition as a whole. It is important to retain the mental space to assess risk and practice good medicine and this is only possible if you are not cognitively overwhelmed by the physical or mental demands of the expedition itself. You will also get more out of the experience.

Pre-expedition planning

The old maxim of ‘fail to prepare, prepare to fail’ is particularly apt for expedition medicine.

It is crucial to get the full medical history of all participants in advance of the trip. Any previous difficulties with the types of hazards that will be encountered on expedition, such as altitude sickness or diving-related illnesses, should be identified. Are they on medication? Do they have allergies? Making sure all participants have their own travel and health insurance can prevent problems later on.

Consider having a medical ‘check in’ on day one – if anyone is currently being treated for anything, has any medication with them, or is having any new symptoms of concern.

Have dedicated times throughout the day for ‘clinic’ or medical check-ins where participants can approach you in confidence. If you’re available, and are seen as generally approachable, people are more likely to come forward
with complaints.

I tend to emphasise a ‘nothing-is-too-small’ approach as it often means people will come before things escalate. On a hiking or mountaineering expedition, for example, foot care is crucial and if issues are not dealt with promptly then they can derail participation in activities for that individual for the rest of the trip.

Athletes can be particularly challenging, as they may not want to report problems that may get them taken out of competition. It is important to bear this in mind and be firm if participant safety is in question.

It is crucial that you are comfortable working
in the prehospital environment before
signing up to provide expedition medical cover

Checklists and briefs

There are a variety of good checklists available online both for the expedition medicine provider and for participants to make sure they are
prepared pretravel.

It is crucial to get essential health information across to participants early and often: Hand hygiene, foot care, clean water, local wildlife hazards, and heat illness prevention. If there is a morning brief or meeting, ask if a safety or medical section can be included in order to reduce risks.

Medication

Carrying medication across borders can be problematic. Always have ID that says you are a doctor. Make sure that you have all necessary permission letters required for each jurisdiction you will travel in before you agree to bring medication. Trafficking laws in many countries are very strict and you can quickly get into difficulty. There can be difficulties with counterfeit medications in many parts of the world so ensure that you can stand over the medication available. Only carry medication that you are confident to use and have experience with.

Know your kit and check your kit. It is likely that you have developed your own kit that you are comfortable with over time. It is even more important in a prehospital environment that your kit is reliable in an emergency. Bring spare batteries for pulse oximeters. Get defibrillators checked pre-travel. Have a contingency plan of how to get replacements if something fails and discuss it with the expedition organisers in advance.

Medical indemnity

Inform your medical indemnity provider before you go to ensure that you are fully covered. Is it a significant additional cost? Is the country you’re travelling to covered? Can it be covered by the company? Depending on your role, the activities being covered and the country in question, providing expedition cover may attract a significant premium. Check before you commit. If a medical evacuation requires a border crossing, are you covered to provide care in both countries? Don’t get caught out.

Each expedition medicine experience will be very different and require a degree of flexibility, good humour, and comfort in uncertainty. My most recent overseas deployment was as a solo doctor with the Irish Defence Forces’ 66th Infantry Group on their Syria mission. The role involved providing medical cover for 130 troops 24/7, as well as travelling to outposts with the engineers conducting UXO (unexploded ordnance) clearance operations.

The next trip could not be more different. I’m planning to be one of several doctors on a medical support team for the Austrian Space Forum’s space analogue research mission in Armenia. The demands of both trips are very different, but logistical challenges are central to both.

The three key priorities for the medical lead on expedition for when someone becomes unwell are: Where you are going to take them for definitive care? When do you need to get them there? Lastly, and most importantly, how are you going to get them there?

Helpful resources and opportunities

www.theadventuremedic.com/courses/.

www.gowme.org/home.

wilderness-medicine.com/.

www.opwall.com/.

www.bas.ac.uk/.

worldextrememedicine.com/.

CAPTAIN DR LISA MCNAMEE,
Space Medicine Lead; European Extreme Environments Medicine Committee; Medical Logistics Lead, Irish Paramedicine Education and Research Network; and Medical Officer, Irish Defence Forces