Tuesday, December 24, 2013

Medical Planning for Extended Remote Expeditions

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).

 N°2) Anticipate Treatable 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.

 N°3) Stock appropriate Medications
   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!!!!

 N°9) Arrange for Knowledgeable and Timely Consultations
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..

 To sum up the following are the golden rules for medical planning of a Remote expedition:
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!!!!

Saturday, December 21, 2013

Hi Guys......
this time I had the honor  to be guest of one of the best #FOAM websites in Italy: www.medicinadurgenza.org
Thanks to Gemma Morabito (twitter ash.: @MedEmit...follow her) for hosting me...
My post is a review on a Great Conference I recently attended: Essentials of Emergency Medicine 2013 in San Francisco!!!!
Obviously the post is in Italian but the translation programme attached to the website is great!!! so can be read also in English without problems.....
Follow the link below and enjoy!!!......
From docvpb.... Merry Christmas on the Edge!!!!

Saturday, December 14, 2013

High altitude illnesses....My personal fast review

Hi Guys!!!!.....In this post I'd like to cover maybe the biggest issue in Expedition Medicine: High altitude related illnesses….and this is my personal fast review:

Hypobaric hypoxia found at high altitudes (especially over 2400m) is a strong stressor for the body especially in unacclimatized or not correctly acclimatized persons and may produce from a simple Headache, to Mountain sickness, to life-threatening conditions such as Acute polmonary Edema and Acute Cerebral Edema.

Prevention is of the utmost importance:

1.     Staged ascent:
-First camp no higher 2400m.
 Increase of no-more 300-600m per night.
 Two nights at same altitude for every increase of 600m.
-If expedition starts above 2700m: First two nights must be spent acclimatizing.
-Just a TIP: ”climb high,sleep slow”: proceed higher during the day, return to a lower elevation to sleep.
2.     Diet rich in carbohydrates may aid acclimatization and prevent High altitude illness.
3.     Is important to avoid excessive exercise until ucclimatized.
4.     High altitude increases fluid losses, Thus adeguate hydration ( maybe judged by Clear urine) is helpful.
5.     Drug Prophylaxis (Just for persons with previous history of AMS or forced rapid ascent):
250 mg twice/day orally, starting day before ascent.
-Dexamethasone (Just people intolerant to Acetazolamide or forced ascent to altitude over 4.200m - for instance in case of rescue operations):
4 mg every 8h orally.

High altitude Headache (HAH):

Usually is the First unpleasent symptom of High altitude exposure.

·       Occurs with an ascent greater than 2500m.
·       developes within 24h after ascent and resolves 8h after descent.
·       Can be defined HAH if has two of the Following characteristics:
-frontal or fronto-temporal.
-dull or pressing quality.
-aggravated by exertion, coughing, bending, movements, straining.

Ibuprofene, Aspirin or Paracetamole/Acetaminophene.

Acute Mountain Sickness:


At least One of:
                          -disturbed sleep


·       Stop ascent and wait for improvement.
·       O2 to reach and mantain SpO2>90%.
·       Acetazolamide: 250 mg twice/day orally (If intolerant: Dexamethasone 4 mg every 8h orally).
·       Treatment of Symptoms: -Haedache: Aspirine or Paracetamole/Acetaminophene.
                                                              -Nausea: Promethazine.

HAPE (High Altitude Pulmonary Edema)


Dyspnea on exertion, fatigue, dry cough, that can proceed to frothy sputum, crackles on lung auscultation.


·       immediate Descent of 600m-1200m.
·       If descent is impossible:a Portable hyperbaric bag is a temporary lifesaving device (50 min. in bag - 10 min. break every hour).

·       O2 to reach and mantain SpO2>90%.

·       Nifedipine 10mg oral.

HACE (High Altitude Cerebral Edema)


Change in the level of consciousness.


·       Immediate descent of 600m-1200m
      (Portable Hyperbaric chamber as temporizing measure if descent is impossible).

·       O2 to reach and mantain SpO2>90%.

·       Dexamethasone: 8-12 mg by the route fastly available, than 4 mg every 6 hours until simptoms subside.

....And This is it....!!!!!!!!
I tried to be as fast and schematic as possible.....
…..Hoping you Enjoy.....

Just have a good day on the Edge............................