Expedition Medicine Blog
By Nathaniel Zona
Get ready to explore an alternative career as a physician in the field of expedition medicine. Sorry, pun intended. Today’s post discusses the practice of remote medicine and expedition medicine. Remote medicine is usually practiced in a stand-alone clinic at a remote outpost while expedition medicine is where the clinician may travel with a group of individuals to remote areas for the purposes of research, exploration, or volunteerism/charitable contributions. Remote medicine may also be practiced by telemedicine but this will be discussed in future episodes.
Wilderness medicine is basically taking the role of a regular physician and applying it in remote locations with limited resources, little to no available transportation, little if any diagnostic imaging/lab testing, and a lack of definitive care . In a lot of ways, it is like practicing medicine the way it was practiced a few hundred years ago BUT with the added knowledge from modern medicine. Just for clarification, this post may refer to a physician regularly but there are many other healthcare practitioners like physician assistants and nurses who practice wilderness medicine as well.
A lot of charitable and commercial organizations, scientific research groups, and even independent interest groups seek exploration and adventure travel for various reasons. All of these groups need somebody to prepare, prevent, and treat health-related matters. This is where the healthcare provider comes in. Because treatment typically occurs in remote areas, the physician must be comfortable with the concepts of urgent intervention, stabilization, and a general understanding of the spectrum of possible medical problems. Perhaps most important, they must have a strong reliance on clinical judgment . These qualities coincide with generalist specialties like emergency medicine, internal medicine, and family medicine. General or trauma surgeons can also be highly valuable for expeditions where heavy trauma might be expected, like military expeditions. General surgeons are also great for medical relief for charitable organizations that provide free surgeries in the developing world. Many of these surgeries are completed in situations with limited resources, solar-powered equipment, or dangerous surroundings. It is incredible what these practitioners are able to accomplish.
As mentioned, the physician certainly needs to be confident in their clinical judgment. When they are out on an expedition, there is no immediate access to advanced medical care or supplies, and, depending on the size of the expedition, there may not be another physician to consult. In hospital-based emergency medicine, physicians rely heavily on consultants, so this is already a big change. On top of that, in the case of an emergency medical evacuation, the patients are often a long way from the nearest hospitals, meaning stabilization of any medical condition is paramount for the prolonged evacuation time.
On an expedition, every adventurer's worst nightmare is to contract a serious disease, become critically injured, or get attacked by a dangerous animal. And although physicians will be prepared for these things, it is definitely the last thing they want to see as well. In reality, the most common cases dealt with on trail are rather mundane. Seventy percent of cases are GI, orthopedic, or other medical problems like respiratory infections and headaches. . Depending on the location of the expedition, environmental extremes can cause some medical issues for those that are unprepared . For example, altitude sickness is common on mountaineering trips. Heat exhaustion can be an issue in places with high temperatures, or on the other end of the spectrum, frostbite or cold injury can be a problem in frigid climates.
Preparation is extremely important for a successful trip. On mountaineering trips, the entire expedition can be jeopardized by one unprepared individual. As a physician on these trips, it is very important to recognize signs of illness, whether that be altitude sickness or other illness. Mountain climbers, in particular, are pretty tough, and pretty unwilling to give up a climb for any type of sickness, given the amount of preparation and money that is often involved in prepping for these expeditions. Sometimes, individuals on climbing expeditions are completely unaware, or unwilling to admit, how sick they are. They keep trying to climb, despite how they feel, which can put everyone on the expedition at risk. It is really important for a physician to step in at this juncture and help them understand their symptoms, why the symptoms are dangerous, and why they shouldn’t climb.
That was a bit of information about the kind of cases an expedition medical officer might deal with, but where do they practice? The short answer is, that depends. From the name, it is clear that a wilderness physician practices medicine in the wild, but where is “the wilderness?” That can be variable. The location of expeditions are really dependent on the goal of the group that is in need of the wilderness trained physician. There are locations that are much more common than others; in fact, over two thirds of expeditions take place in mountain ranges and tropical jungles. Other destinations include polar regions, like Antarctica, desert regions, and marine expeditions [2, 3].
Due to the wide range of practice locations, pre-expedition planning is a vital part of the job. Becoming familiar with the environment and the common problems in each austere location is the first step. On some expeditions, there is a need for medical input during the selection of team members . Unfortunately, depending on the expedition and the individual’s unique medical profile, it may be best for the applicant’s health, as well as for the other members of the team, for an applicant to not to participate in certain expeditions. Any medical emergency puts an entire crew or expedition at risk because the entire team’s resources have to be redirected to address that medical emergency. In some cases, it is impossible to treat a person’s injuries and the team is then faced with the decision to leave the person’s body in place in the wilderness or find a way to get the person’s body back to civilization. It is a harsh reality that must be considered when evaluating medical fitness and suitability for an expedition.
It is also important to determine what sorts of vaccinations should be given to expedition members. Vaccination requirements are highly variable and depend on what sort of diseases are expected in different areas of the world. The physician can be highly valuable when communicating vaccination needs and assisting members with obtaining those vaccinations or prophylactic medications, such as antimalarials. Additionally, in part of the practitioner’s evaluation of medical hazards, he or she must prepare proper medical kits . On long expeditions, this can be really difficult. Having a fully stocked medical kit may create too much weight to carry. This is why it is critically important to have a clinician who can evaluate what sorts of hazards can be expected, what is absolutely required, and what can be left at base camp or an outpost location. It is obvious that not bringing enough, or not bringing the correct medical supplies can also be troublesome. If a physician only brought one dose of antibiotics for a 20 person expedition where there is an outbreak of traveler’s diarrhea...everyone is in deep...well, you get the idea. Planning the medical kit is a critically important function of a medical provider on any expedition.
The point is, there is much more to expedition medicine than just treating patients while on the trip. Ideally, the physician will actually be doing as little medical care ON the trip as possible...which means fewer accidents. Rightfully so, fewer accidents come with deliberate prevention of these accidents by proper planning and training. Base camp health and hygiene is a large part of what a clinician should assist with planning for a mountaineering expedition. . Places like mountaineering camps can become major public health hazards. Everest Base Camp is known for being a rampant source of gastrointestinal illness due to densely populated areas without the best hygiene practices. Making sure kitchen hygiene, food storage, trash disposal, and water treatment are up to par is vital...and the word “kitchen” is used lightly. Most expeditions do not exist within the confines of a traditional building. The kitchen may just be a patch of ground away from sleeping tents and bathroom facilities. With gastroenteritis being one of the most common expedition complaints, attention to detail and cleanliness in densely populated, remote areas can save the clinician a headache -- and quite literally, a stomach ache.
Another crucial component of prevention is risk assessment . Although many experienced expeditioners will be familiar and capable of assessing risk, the medical officer should be willing and able to assist with risk assessment. Risk prevention includes safe route planning, making adjustments when needed, continued assessment of plants, animals, and climate safety, as well as ensuring simple safety measures such as proper helmets when climbing.
Dr. Warren Bowman wrote a great summary of the role of expedition physicians. He stated that physicians have to fill three roles when working in wilderness medicine. One role is the physician as a caregiver, dealing with medical issues that arise on an expedition. Another role is the physician as an advisor; this applies to all the risk prevention and pre-expedition planning that was discussed, from vaccination requirements to encouraged conditioning. And the third is the physician as a participant . It may be easy to forget, but just because the doctor is the one preventing and addressing all of the medical concerns on an expedition does not mean that they themselves are exempt from the stressors of the environmental extremes. The doc is just as likely to fall ill or face issues with exposure to extreme temperatures as the next guy. It’s necessary to do the research and know the little things about the environment that will be explored such as understanding proper clothing fabric and layering techniques and familiarity with the type of terrain.
Ultimately, it is important to note that while safety is of the utmost importance, the medical officer should be enhancing the enjoyment and achievement of the participants. Taking all the appropriate measures without limiting the enthusiasm of the trip creates the best experience. There is nothing better than that sense of accomplishment when safely finishing a big summit, dive, or hike.
Backer H. What is wilderness medicine? 1995;6(1):3-10. doi:10.1016/s1080-6032(13)80003-8
Johnson C, Anderson R. S, Dallimore J, Wisner S, Warrell A. D. Oxford Handbook of Expedition and Wilderness Medicine. Oxford University Press; 2008.
Warrell D, Anderson S. Expedition Medicine. Revised Edition. Routledge; 2013.
Bowman D. W. Perspectives on being a wilderness physician: is wilderness medicine more than a special body of knowledge? WEM. 2001;12(3):165-167. doi:https://doi.org/10.1580/1080-6032(2001)012[0165:POBAWP]2.0.CO;2