The Rebel And The Insider

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11 January 2021

Faculty of Pre-Hospital Care

Earlier this year the Faculty of Pre Hospital Care (FPHC) at the Royal College of Surgeons (Edinburgh) updated its guidance on the standards expected from healthcare providers taking part in wilderness expeditions. This has now been linked to the legal framework set out by the Royal Geographical Society’s British Standard 8848. In this post, Dr David Hillebrandt takes us behind the scenes to tell us about his involvement in the drafting of the guidelines. Using these as a starting point, Dr Hannah Lock will then give us her thoughts on what these mean in practise.

Dr David Hillebrandt

Whilst in many ways these two documents provide a very relevant introduction to the hidden complexities of working as an expedition medic for the first time, for me they present a major conflict of interest. I attended many meetings in Birmingham between 2015 and 2019 when these documents were discussed. Although I appreciated the way the FPHC looked after us and covered our travel expenses, I frequently found two people sitting in my chair. Let me explain! One was the rebel mountaineer – somebody who started hillwalking in 1964, was rock climbing four years later and had joined his first Himalayan expedition in 1978, when he should have been doing his first house job. He had been told that the trip would be professional suicide! The other person was the insider – a semi-retired GP with the odd peer reviewed publication on his CV and a past that had included speaking at international academic meetings on mountain medicine. My interest in pre-hospital care also meant that I was a supportive member of the FPHC which had done so much to raise the standards of emergency care prior to arrival in hospital.

These two people were conflicted!

On several occasions I found myself nodding along to phrases such as “expedition medicine is becoming a sub speciality” and we are “formalising the practice”. Meanwhile the rebel mountaineer in me cringed and squirmed. If I had been limited by this formalisation I would not have joined my first major expedition. Luckily, every trip since has been with friends and I was present for my climbing skills as much as my medical knowledge. No commercial trips. I could foresee a situation where, by the time a young medic had sufficient medical skills to join an expedition, they would be too old and would not have spent sufficient time keeping their mountain skills up to date. On several occasions I was at the point of dropping out.

Richard Wain-Hobson discussing FPHC business on a new route near Padstow.

Why did I stay? The old rebel in me felt that I could only fight the system from the inside. I had to stand up for young expedition medics. Another side of me could see the need for guidance to protect some inexperienced medics joining commercial expeditions with no insight. But two things really kept me in the group. After raising several objections I was invited to write an introduction to the guidance notes. The unopposed acceptance of this convinced me of the underlying sincerity of the group. The second thing was my delight when the person in the next chair muttered quietly to me during an unrelated and rather boring discussion, “Do you fancy a climb sometime?”. A few weeks later we were putting up some easy but fun new routes on an unclimbed sea cliff crag in the South West. The true spirit of the whole project!

Sadly during the complex process of formulating the guidance the FPHC decided they could no longer support our Diploma in Mountain Medicine. As it joins the portfolio of the University of Central Lancaster (UCLan) I trust it will be acknowledged that whilst its roots are firmly based on a mountaineering ethos there is a need to maintain high quality medical care for our international mountain community.

At the end of the paper 26 people are listed as contributing under the impressive chairmanship of Dr John Hall. Doctors are normally strong willed people. Expedition medics are even more so. Imagine trying to chair such a diverse group who were never afraid to air their views. The mere fact the paper reached publication is a tribute to his skills!

Dr Hannah Lock

Here’s Dr Hannah Lock with her take on what these documents mean in practise

Earlier this year, the Faculty of Pre-Hospital Care at The Royal College of Surgeons of Edinburgh produced a document titled "Updated Guidance for Medicial Provision for Wilderness Medicine". This guidance is essential reading for any aspiring or established expedition medic (from first aider to senior doctor) as it provides a benchmark for the skills required. The document not only describes the clinical skills needed, but it also provides some guidance on the skills and experience needed for the other areas of an expedition medic’s role. It’s this last area that I wanted to explore and to do so, I wanted to hear from the people who work closely with the medic and ultimately lead the expedition.

After hearing Jo Bradshaw’s excellent talk at the recent World Extreme Medicine (virtual) Conference about, “Why being technically brilliant isn’t (good) enough!”, I wanted to delve further into this subject and see if I could find any patterns amongst expedition leaders in what they want from an expedition medic. This post, whilst celebrating the fantastic work that expeditions medics do, is designed to address where we can improve our service, from the perspective of those at the sharp end of that provision – our expedition leaders! So medical skills and knowledge aside, what other capabilities, qualities and experience does an expedition leader want the expedition medic to have?

I’ve spoken to some of the most incredible expedition leaders that I’ve had the pleasure of working with in the last few years, as well as reaching out to other experienced leaders who have worked alongside medics in all corners of the globe. From Everest guides, to leaders taking kids to the jungles of Borneo, UK mountain rescue team members and mountain leaders on Kilimanjaro. Over twenty outdoor professionals who have worked together with mountain medics have kindly given me their advice, opinions and top tips on what they want and need from their expedition medic. I am pleased to report that the general feeling was that having a medic provided a positive addition to an expedition team, especially at high altitude or in polar environments.

I have ordered the leader’s responses starting with the most common answers:

There is no substitute for expedition experience

Whether it is mountains, jungle, sea or desert, this was the most common theme I heard and the most important point for many. Whatever environment your expedition is in, if you have never been anywhere like it before and never looked after yourself in similar conditions, not only may you personally struggle with the challenge and require help yourself, but you are unlikely to be able to provide high quality health care for your team. Don’t become a hinderance rather than a help. This also goes for travel to developing countries – get some experience before you sign up as the responsible medic on an expedition to a developing area. Wherever you’re going, you must be within your comfort zone (or just slightly stretched) in order to perform well if something goes wrong. Having said this, you don’t need to be as slick as the guide or leader with the technical stuff such as rope work, climbing ability (if relevant) etc. but you do need to be comfortable with it and not be a first timer. A big bonus is if the medic has excellent skills for the expedition terrain and can work as a second leader on more technical terrain to help support the leader and the clients.

Keep on top of your documentation - wherever you are!

Personal admin

Being organised and having your expedition ‘personal admin’ down to a fine art is key. Again, the specifics of this depend on the details of the expedition you’re on, but practice and experience is vital. Don’t be the medic who everyone has to wait for because you’ve not packed your bag in time.

Be honest and be human

Honesty is required for all aspects of the expedition and between all members – be honest with the clients/pax, be honest with the leader and the rest of the team, and be honest with yourself about how you’re feeling. Be human and approachable to gain the team’s trust. Lots of clients on treks or climbs are anxious that if they have a medical issue the medic will stop them from continuing the expedition. Front load information in briefings to explain that you’re there to support them and will only turn people back in extreme situations, after trying hard not too. You need to make clients feel they can tell you about small issues so you can help ensure they don’t become serious problems.

Teamwork, trust and respect

Are absolutely essential. You’re together for extended time periods, often in remote areas with no backup so get to know each other and work together. Find out about and then respect the skills and experience of others, especially the leader who may have more first aid experience or terrain specific medical experience than you. Be willing to ask for and accept advice and acknowledge someone else’s expertise.

Look after yourself

Especially your mental health. Expeditions are hard and having a routine for some personal time each day is vital. In the same vein, don’t over work – encourage the clients to self manage small issues and don’t try to take on too many of the leader’s roles because although you may be trying to help, you’re just tiring yourself out unnecessarily.

Through experience, many of us quickly gravitate towards the back of any trekking group - that's where the problems can often be found!

Communicate clearly at all times

On expedition this is even more important than in a hospital setting as everything changes constantly. You may be working with new people, in new surroundings, with limited resources and in difficult environmental conditions. It is helpful to check in with every team member at least daily to see how they’re doing and if there are any issues they are struggling with. Similarly, check in with the expedition leader regularly to update them on anything relevant e.g. anyone you’re concerned about and vice versa. Be allies for each other. In an emergency situation ensure you clearly express how urgent or severe the situation is and make it clear what you need the leader to help with or organise e.g. do you think the casualty could be helped to walk or do you need to organise a rescue if possible?

No free riding

Do not come on an expedition with the attitude of being there for a ‘free ride’, e.g. appearing that you’re only there to complete the trek whilst considering your medical role as secondary. Obviously anyone that works on an expedition loves the opportunity to work in amazing places and do amazing things, but make sure you’ve got your priorities in the correct order because if you don’t, the leader and your clients will see straight through you. It can also be very hard work being an expedition doctor so be prepared that it won’t be a free ride at all. Luckily the role is extremely rewarding and an incredible way to experience expeditions from another angle.

Remember you’re not in charge

The expedition doctor is undoubtedly an important part of the expedition leadership team but you’re not in charge. You are there to contribute your medical expertise and although you may have group management skills too, this is not your role on the expedition and the expedition leader likely has far more experience and skill in this area in the context of the expedition. Support each other but don’t try to take charge.

The increasing availability of alcohol in mountainous regions can be an issue for medical staff!

Leader and medic should have two distinct roles

The leader and medic should help each other in busy times but if a client asks you about specifics of the itinerary or group management question direct them to the expedition leader. Sadly, there is still sexism in the expedition world and I have heard examples of some clients looking to a male team doctor rather than to their female expedition leader to answer questions regarding things like expedition logistics. A positive way to approach such issues is to direct questions to the correct person and explain that the leadership team have different roles relating to their expertise.

Meet or call the expedition leader in advance of the trip if possible

Find out about each other’s experience, what you’re both expecting from the expedition and from each other, and discuss your specific roles. Make a plan of how you can best work together. Plan who will cover which topics in any briefings to ensure nothing is missed. Discuss protocols for emergencies and evacuations.

Hydration often falls under the remit of the medical team!

Be proactive and get involved in all aspects of expedition life

You’ve got a job to do but that doesn’t mean you can’t have fun too! Be part of the team, get to know the clients and the locals.

No drama please

Don’t over medicalise everything. Use common sense and try simple solutions first. If an expedition has no medical issues and no major problems it’s a good thing!

Know your medical kit

Especially if you haven’t put it together! Know where to find things, check supply quantities, check things works etc. It looks unprofessional if you don’t know where things are or even what you’ve got with you in front of a client. Also know the limitations of your kit such as oxygen saturation probes not working in very cold conditions.

Documentation

After checking company guidelines first regarding confidential information sharing, give copies of incident notes to the expedition leader at the end of a trip to ensure they have proof everything was done correctly. Ask for copies of theirs too.

Make sure you're familiar with the contents of your medical kit and above al, know how to use it! The Diploma in Mountain Medicine is a very good place to start!

Don’t flap

Remain calm, and ask for help when needed.

I would like to think that none of the above points come as a huge surprise to most expedition medics, but there is still lots to be learnt and reflected upon and I’ve certainly taken something away from compiling this information, especially when hearing the same key points coming up time and again. I absolutely agree with the expedition leaders that being expedition competent is the number one requirement as the medic; it is fundamental and critical to working well and enjoying it. This is consistent with the Royal College of Surgeons guidelines which state that “as in all healthcare practice, it is the medic’s responsibility for ensuring they are adequately competent to deal with the associated situations”, and that, “You must be certain the demands of the trip fall within your competency and skill level, both clinical and the activities you will be undertaking on expedition". If there is one take home point for aspiring expedition medics, this must be it!

I am very grateful to all the expedition leaders who contributed and took the time to answer my questions and help me gather this information – a huge thanks for your input! To all aspiring expedition medics, good luck and enjoy it!"

To learn more about the British Mountain Medicine Society, click here.

The content above may contain the personal or professional views and opinions of the author(s) and does not necessarily reflect the official policy or position of the RCSEd or the FPHC. Further information can be found in the website Terms and Conditions.

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