Hi Guys!!!!....
Recently I read a great paper from the Wilderness &
Environmental Medicine Journal about Medical Planning for Extended Remote
Expeditions (follow the link below):
It gives not only 10
guidelines to help planners on the key, medically relevant elements of a
workable remote healthcare system, but it gives also,as explanation for
every point, a summary of a real clinical case.
This is my personal brief review:
“Remote travelers have long been concerned about their medical care.
Alexander the Great traveled with his personal physician, Philippus, as he
conquered the world. In the early twentieth century, Admiral Robert Peary took
Dr Frederick Cook on his 1891 Greenland expedition, where he set Peary’s
fractured leg. Ernest Shackleton brought Eric Marshall on Antarctic expeditions
as his chief surgeon/cartographer/surveyor. On his ill-fated 1912 expedition,
Robert Falcon Scott chose Edward Wilson as his doctor/marine
biologist/ornithologist.
Remote expedition medicine provides medical diagnosis and treatment to teams traveling to the developing world or to remote geographical regions “where
access to definitive medical care will involve prolonged evacuation over many
hours or days.”1 The practice of remote medicine involves many
challenges, including dealing with isolated environments, limited clinical
diagnostic support and specialist services, limited resources and equipment,
altered treatment protocols, and longer patient contact times. Medical
practitioners on these expeditions must have increased clinical acumen, public
health knowledge, and a cross-cultural understanding of their team members and
the region’s indigenous populations. They also must be able to provide and use
diagnostic and management advice via telecommunications, devise and implement
innovative practice methods, work beyond their normal scope of practice, make
independent decisions, and assume increased responsibility….”
N°1) Optimize workers fitness
Before every kind of Expedition is important to
perform workforce predeployment screening medical examinations in order to
identify ailments and abnormalities and therefore anticipate and be prepared to
cope with common and less common chronic illnesses, such as Allergies, Asthma,
Diabetes, Hypertension, Epilepsy, Cardiovascular deseases and so
forth….(General Dental screening could be also useful….Statistical
studies showed that 5% to 15% of all offshore oil workers evacuations were due
to Dental problems).
“Improvisation is the name of the game”
Planners should base their medication and equipment
stock on the most common presentation to EDs; a good resource could be : “ED
section of the annual National Hospital Ambulatory Medical Care survey based on
US hospitals”.
In general most commonly encountered problems
during expeditions are minor conditions: Gastrointestinal diseases, skin
deseases, minor trauma…furthermore dental and ophtalmological problems must not be forgot
and underestimated.
A) Stock
FIRST-LINE medications for the commonly anticipated illnesses; If possible
supply first-line medications with multiple uses such as Adrenaline and
diphenhydramine.
B)Stock
additional medications for specific environments: for instance otitis externa
medications and O2 for diving expeditions or Acetazolamide, Dexamethasone,
Salmeterole, Nifedipine and O2 for High Altitude ventures.
C)Quantity:
“(probable numer of pts. Needing the medication) x (the
number of doses needed to treat one pt.).
N°4) Provide appropriate Equipment
“The major criterion is to provide what clinicians
will need to diagnose and treat common problems, to convert patient evacuations
to restricted duty, or to convert emergency evacuations to scheduled departures.
This includes most equipment required for ophthalmologic, otolaryngologic,
dental, traumatic, orthopedic, and extraction/evacuation situations.”
Additional equipment such as advanced airways,
ventilation, laboratory testing and diagnostic imaging depends on remoteness of
location, expedition size, Medical provider experience and expertise.
It’s very important to test every piece of
equipment before departure in order to avoid bad surprises.....for example in the midth of
the Ocean…….
N°5) Provide adequate logistical support
“Given the situational constraints and the need for
frontline medical providers to have the tools they need, planners should ensure
that expedition logistics function as smoothly as possible using proven
healthcare supply systems.”
N°6) Provide Adequate medical communication
Large Extended expeditions require as a minimum Internet access with sufficient bandwidth;
Indeed the internet can be used not only to send
clinical images and Ultrasound movies but even for specialist referrals (VolP)
for particular clinical cases.
N°7) Know the Environmental Limitations on Patient
Access and Evacuation
When planning an expedition patient accessibility
in terms of weather, local environmental conditions and availability of
trasportation must always be considered;
Time requested for an eventual Medical Evaquation
must be took into account;
Moreover before an expedition the clinician must be
aware of local healthcare facilities and quality of Medicare available.
N°8) Use qualified Providers
Expedition doctor should have previous
experience in Emergency and prehospital
care, expedition medicine and the ability to operate effectively in remote
environments.
Familiarity with the specific conditions of the
expedition (for instance altitude related illnesses or Barotrauma) is
desiderable.
In my opinion ability to IMPROVISE is the most
important skill of an expedition doctor!!!!
Before departure is important to make Arrangements
to have a team of base specialists (possibly expert of remote medical
problems), ready for consultation even from remote locations.
N°10) Establish and Distribute Rational
Administrative Rules
Before the expedition medical personnel must be
aware of all administrative rules Sponsor’s specific and Country setting of expedition specific..
1. Optimize
workers’ fitness
2. Anticipate
treatable problems
3. Stock
appropriate medications
4. Provide
appropriate equipment
5. Provide
adequate logistical support
6. Provide
adequate medical communications
7. Know the
environmental limitations on patient
access and evacuation
8. Use
qualified providers
9. Arrange
for knowledgeable and timely consultations
10. Establish and distribute rational administrative
rule
Remember
that a good planning concurs for about 70% of success of a remote expedition
and this is true even for medical planning….
But
remember also that while practicing medicine in Extreme Environments Improvisation skills
could make the difference…..
Hoping
you will enjoy this publication and my review…….as always… have a good day on
the Edge!!!!
