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Oxford Handbook of Tropical Medicine 5e (Oxford Medical Handbooks) 5th Edition Robert Davidson
THE INDISPENSABLE GUIDE to MEDICINE IN REMOTE PLACE}
OXFORD HANDBOOK OF EXPEDITION AND WILDERNESS MEDICINE
Jfin DalIimOre | Sarah ft. AndElion | Chris Imray
ChrisJohnson | James Moore I Shane Winser
All chapters revised and updated to reflet! the latest guidelines
Provides authoritative. practical advice for -use in remote environments, including latest treatment guidelines
Written and edited by experienced expedmoncrs. suitable (or doctors, paramedics, nurses, and travellers overseas
OXFORD MEDICAL PUBLICATIONS
Oxford
Handbook
of Expedition and Wilderness Medicine
Published and forthcoming Oxford Handbooks
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Oxford Handbook of Expedition and Wilderness Medicine 3e
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Expedition and Wilderness Medicine
Third Edition
Edited by
Dr Jon Dallimore
General Practitioner, Chepstow, Wales, UK; Director, International Diploma in Expedition and Wilderness Medicine, Royal College of Physicians and Surgeons of Glasgow, Medical Officer, Severn Area Rescue Association, UK
Dr Sarah R. Anderson
Consultant in Public Health, UK Health Security Agency, UK
Professor
Chris Imray
Professor of Vascular and Renal Transplant Surgery University Hospital, Coventry and Warwickshire NHS Trust; Director of NIHR Coventry Clinical Research Facility, UHCW NHS Trust, Coventry; Professor, Warwick Medical School; Professor, Coventry University; Professor, Exeter University, UK
Dr Chris Johnson
Retired Consultant Anaesthetist, UK
James Moore
Director, Travel Health Consultancy, Director, International Diploma in Expedition and Wilderness Medicine, Royal College of Physicians and Surgeons of Glasgow, UK
Shane Winser
Expeditions and Field Science Advisor, Royal Geographical Society (with IBG), London, UK
Great Clarendon Street, Oxford, OX2 6DP, United Kingdom
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First Edition published in 2008
Second Edition published in 205
Third Edition published in 2023
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This book is dedicated to the memory of our late very dear friend Bent Juel-Jensen who stimulated, encouraged, and supported us together with generations of other young explorers and expeditioners at the Royal Geographical Society and the University of Oxford. He was the archetypal and model expedition medical officer.
Born in Odense, Denmark, Bent qualified in medicine in Copenhagen in 949 but spent the rest of his life based in Oxford with his devoted wife Mary. At New College he studied physiology and Elizabethan literature and later became a loyal Fellow of St Cross College. His medical career began at the Radcliffe Infirmary with Dr Fred Hobson and Professor George Pickering, working on hypertension. In 960, he became hospital Medical Officer and, from 977 to 990, University Medical Officer. Bent took charge of infectious diseases in Oxford and pioneered the treatment of herpes zoster with antiviral drugs. Many of his protégés became consultants or professors of infectious diseases.
Bent’s greatest enthusiasm was exploration and expeditions. He was passionately committed to the Oxford University Exploration Club, eventually becoming its Honorary President. Bent greatly improved the medical preparedness and training of its largely undergraduate members and was the inspiration, advisor, and friend to many budding young explorers, including the editors of this handbook. Pharmaceutical companies were pressurized into donating essential drugs for their medical kits. As founding medical advisor to the Royal Geographical Society, he created a new awareness of the medical aspects of exploration. This contribution was recognized by his election to an Honorary Fellowship. The RGS-NMK Kora Research Project (Tana River, Kenya) in 983 had Bent as its energetic medical officer. He was friend and advisor to many famous explorers and travellers, the likes of Sir Wilfred Thesiger, Sir Vivian Fuchs, and Bruce Chatwin.
After England and Denmark, Bent’s favourite country was Ethiopia. Oxford expeditions to explore the rock-hewn churches of Tigre in 973 and 974 resulted in his forming a close friendship with the local ruler, Prince Ras Mangashia. Bent’s enthusiasm for Ethiopia stimulated him to learn Amharic and the priests’ language Ge’ez, to embrace its history, literature, culture, and food. He always carried his own supply of fiery berbera to ignite tame European dishes. His great physical courage, early displayed in his resistance to the Nazis in wartime Copenhagen, was again very much to the fore as he gave medical support across the Sudanese border to the Ethiopian Democratic Union’s army battling the evil despot Mengistu Haile Mariam.
Bent Juel-Jensen, what an incredible man and a marvellous friend for all seasons!
Foreword
An altered perspective
In the past, the main emphasis of publications on expedition and wilderness medicine was to encourage ambitious (even daring) travel and activities off the beaten track, while reducing the risk of associated diseases, injuries, and accidents. That emphasis has changed! Enthusiasm for adventurous exploration of remote locations, promoted by previous editions of the Oxford Handbook of Expedition and Wilderness Medicine (OHEWM), is now threatening to crowd-out, pollute, damage, and even destroy many of the most challenging destinations. In the face of climate change, expanding human population, and occupation of the planet leading to environmental degradation, as well as political uncertainties and pandemics, we should now recognize responsibility towards the environment as the overriding concern of expedition and wilderness medicine.
Responsible enjoyment of the environment
While encouraging participation in properly-planned travels and expeditions, the third edition of OHEWM emphasizes a more responsible, contributory, and sensitive approach to enjoying our natural environment. In Chapter 4, ‘Ethics and professional responsibilities’, under ‘Environmental impact’, those planning expeditions are urged to analyse and minimize the consequences of their activities. How best to travel to the site of the expedition? Reducing one’s carbon footprint should, perhaps, encourage rail or sea as an alternative to flying, even though they will be slower. Once arrived, conservation of local fauna and flora and respect for indigenous people should be the priority. Collection of voucher specimens for research studies or museums should be rigorously justified and controlled.
The fragility of nature is captured beautifully by Gerard Manley Hopkins’ poem ‘Binsey Poplars’, written in 879.
O if we but knew what we do
When we delve or hew—
Hack and rack the growing green!
Since country is so tender
To touch, her being so slender, .
Chapter 4 gives sound and detailed advice about mitigating environmental damage, but the hardest decision of all would be to opt for an alternative, perhaps less immediately appealing, destination, or for a less demanding scientific aim for the expedition, in the interests of preserving precious countryside and wildlife. Some of the most fragile and threatened locations will have to be closed to all visitors, to allow their return to a more serene primal state, before further incursion can be allowed.
Paul Auerbach (95–202)—‘the father of wilderness medicine’
Let us celebrate the many contributions and achievements of my American friend Paul Auerbach, who died of a cerebral glioblastoma on 23 June 202. He is widely regarded as being ‘the father of wilderness medicine’ having practically invented this subspeciality of emergency medicine. While a resident at UCLA in 978, he began working on a landmark publication, Management of Wilderness and Environmental Emergencies, which evolved into Auerbach’s Wilderness Medicine (7th edition, 207), the most comprehensive database available in this field. He co-founded the Wilderness Medical Society in 983. Paul strongly supported the development of expedition and wilderness medicine in the UK, notably by attending and enlivening the Oxford meeting of the Student Wilderness Medicine UK National Conference in November 2003. In choosing an appropriate and internationally recognizable title for the OHEWM, we were influenced by the transatlantic term ‘wilderness medicine’, promoted, if not coined, by Paul himself. His later espousal of the environmental imperative, as shown by his book Enviromedics: The Impact of Climate Change on Human Health, published in 207, supports the contentions I have expressed above.
OHEWM’s lineage of authorship
It is good to see contributions from a number of new authors and reviewers. However, in the OHEWM, authorship is built on previous contributions by a succession of writers and advisors, as is acknowledged on the title page of each chapter. All the chapters have been enhanced and updated over the three editions, that, in turn, were based on antecedent versions, before we were adopted by Oxford University Press in 2008.
Dr Bent Juel-Jensen remembered
The origins of this book were cyclostyled sheets, prepared by Oxford University Expedition Club’s medical advisor, Dr Bent Juel-Jensen, to equip undergraduate expeditioners for their adventures. The editors of this current edition, and many of its authors, were fortunate enough to have known Bent and to have been inspired by his example. However, most of its readers will not have had that privilege, so please read the Dedication. I warmly congratulate my successors as editors of the OHEWM for their achievement in publishing a magnificent new edition, and I wish the readers enjoyable, successful, but above all, environmentally responsible expeditions.
David A. Warrell Oxford October 202
Preface
Expedition medicine (also known as ‘wilderness medicine’) is concerned with maintaining physical and psychological well-being during travel to remote and challenging places. Adventurous travel is to be encouraged and wilderness medicine attempts to minimize the risk of injury and disease by proper planning, preventive measures such as vaccinations, sensible behaviour, and acquisition of relevant medical skills.
Exploration and wilderness travel has proved distinctly dangerous in the past because of poor understanding of the environment, limited medical knowledge, and inadequate equipment. Admiral Anson circumnavigated the globe in 74–742, losing five of his six ships and 626 of his 96 crew. All 24 members of Sir John Franklin’s ill-fated voyage to the northwest passage died. During Stanley’s trans-Africa expedition from Zanzibar to the Congo 874–877, 4 of his original 228 expedition members died from battle, murder, smallpox, dysentery, drowning, crocodile attack, fever, execution, getting lost, or falling victim to cannibalism post starvation. This level of expedition mortality was unacceptable even in those days. It led to Stanley being branded a ruthless and irresponsible leader, exhibiting highly disrespectful behaviours associated with colonialization, a system we now recognize as deeply wrong, and that must not be repeated.
The twentieth century saw safety improve and mortality fall but many expeditioners perished in the quest for mountain summits or during polar and remote area exploration. Until the 980s, % of Antarctic base members died of accident or disease, while for every ten climbers who summited Everest roughly one person died on the mountain.
The twenty-first century has seen a vast increase in the number of people visiting remote areas for research, education, and recreation. In 209, over 400,000 UK nationals booked an adventure holiday. In 208, 242,000 passengers visited remote destinations on expedition cruises. Visitors to Nepal increased from 460,000 in 2000 to .2 million in 209 and on 9 May 202, 234 climbers summited Everest. This desire to reach all parts of the earth means that there are now few unexplored land areas and so the aim of expeditions has shifted from discovery, sovereign possession, and scientific investigation in the nineteenth and twentieth centuries to adventure, personal development, and cultural exchange. Commercial expedition opportunities have resulted in the marketing of adventurous journeys by numerous companies, blurring the distinction between an expedition and a leisure activity, and exposing people to physical and psychological hazards for which they may be unprepared. Explicit standards such as British Standard (BS) 8848— a specification for the provision of visits, fieldwork, expeditions, and adventurous activities, outside the UK—set out good practice for organizing adventures and seek to optimize planning and risk management. The medical section of BS 8848 describes the need to consider pre-existing medical problems, disease prevention, first-aid kits, environmental illnesses, and levels of medical expertise. All of these areas are carefully considered in this book.
Many of the environmental hazards encountered by previous generations of explorers still challenge expeditions in the twenty-first century, but we are now in a much stronger position to minimize risk through careful planning based on a vast fund of medical knowledge and the development of drugs, vaccines, technology, and skills. In recent years, the advent of smartphones and tablets has altered the way we access knowledge while cellular and satellite networks link us to the internet from previously isolated locations. In the 980s, expeditions would seldom have communication with the outside world. Modern technology now means that it is possible to track the movements of an expedition remotely and to have real-time communication with expert help when required.
Clinicians, quite rightly, expect to receive appropriate training to equip themselves for new challenges. A number of organizations have produced competency-based syllabuses for expedition and wilderness medicine. This manual has proved a useful supplement for these courses.
This handbook, now in its third edition, started as a product of the Medical Cell at the Royal Geographical Society (with the Institute of British Geographers). The Medical Cell was set up to provide medical advice to expeditions and those seeking advice from the Society. The handbook is a distillation of the experience and skills accumulated by clinicians, explorers, expeditioners, local people, researchers, and remote area travellers from all around the world. The first edition, published in 2008, was designed to be a practical and portable guide to the prevention and treatment of common medical problems and injury conditions in extreme and remote environments. The handbook format proved very popular and has been used during the course of many expeditions by doctors, nurses, paramedics, and first-aiders, as well as by non-medical expedition members. The second edition of this handbook, published in 205, included more topics and treatment algorithms and had greater emphasis on risk management.
This edition has been fully revised and the editors are grateful for the valuable contributions from our new authors and reviewers. There are new colour plates, more treatment algorithms to guide care, and some chapters have been re-written. The work remains in its convenient rucksacksize handbook format but is also available electronically to save space and weight—both of which are at a premium on almost all expeditions. The information presented is based on the latest clinical guidelines or, where these do not exist, on best practice.
The world is a very different place since we edited the last edition. The COVID-9 pandemic delayed publication as many of our contributors have been involved with managing patients and health services during that time. We are hugely grateful to all of our contributors for devoting time to this work when so many healthcare providers have been busier than at any time in their working lives. While the pandemic caused great suffering, it also brought opportunities. Everyone has a greater awareness of the interconnected nature of human societies, animals, and the planet, the impact of global warming, and the opportunities presented through shared medical research for the common good of all humankind.
As international travel increases, we hope this handbook will encourage many people to experience and enjoy remote travel in a responsible way. Once the world begins to refocus after the pandemic, it is hoped that everyone will be more aware of the effects of burning fossil fuels and
climate change. We must all play our part in reducing the damage to our fragile planet. Our original aim when creating this handbook was to highlight the need to identify and minimize avoidable risks without allowing these concerns to detract from the essential excitement and sense of achievement while exploring the wilderness. Now, we need to add that our wish for adventure travel must not be to the detriment of our shared home. We want to encourage people to enjoy remote travel in a more responsible, contributive, and sensitive manner.
Jon Dallimore
Sarah R. Anderson
Chris Imray
Chris Johnson
James Moore
Shane Winser
September 202
Contributors
Edi Albert
Senior Lecturer in Remote and Polar Medicine, and Rural Generalist in Emergency Medicine, University of Tasmania, Hobart, Tasmania, Australia; Director, Wilderness Education Group
Sarah R. Anderson
Consultant in Health Protection, Public Health England, London, UK
Jules Blackham
Consultant Emergency Physician and HEMS Consultant, North Bristol NHS Trust and Great Western Air Ambulance, UK
Jim Bond
Specialist in Travel and Expedition Medicine, TrExMed Travel Clinic, Edinburgh, UK
Peter Bradley
Anaesthetist, Expedition, Medical and Prolonged Field Care Lead, Remote Area Risk International, UK
Spike Briggs
Consultant in Intensive Care and Anaesthesia, Poole Hospital NHS Foundation Trust; Director of Medical Support Offshore Ltd, UK
Rose Buckley
Consultant Anaesthetist, Sheffield Teaching Hospitals NHS Foundation Trust, UK
Tim Campbell-Smith
Consultant General and Colorectal Surgeon, Surrey and Sussex NHS Healthcare Trust, UK
Nicholas Chilvers
Specialty Trainee in Cardiothoracic Surgery, The James Cook University Hospital, Middlesbrough, UK; Medical Officer, Royal Army Medical Corps.
Anaesthetist and Expedition Doctor, Wild Medic Ltd, Brighton, UK
Paul Cooper
Consultant Neurologist, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust, UK
Rachael Craven
Consultant Anaesthetist, University Hospitals, Bristol, UK
Dr Jon Dallimore
General Practitioner, Chepstow, Wales, UK; Director, International Diploma in Expedition and Wilderness Medicine, Royal College of Physicians and Surgeons of Glasgow; Medical Officer, Severn Area Rescue Association, UK
Matthew Davies
Solicitor-Advocate. Remote Area Legal and Travel Risk Management. Duty of Care Subject Matter Expert at Remote Area Risk International. BS:8848 & ISO: 3030 committee member
Ian Davis
General Practitioner and Polar Explorer, UK
Richard Dawood
Medical Director, Fleet Street Clinic, London, UK
Matthew Dryden
Consultant in Infection, UKOT Program and RIPL, Porton Down, UK Overseas Territories, Global Operations, UK Health Security Agency
Matthew Ellis
Honorary Senior Lecturer in Global Child Health, University of Bristol, UK
Derek Evans
Independent Travel Medicine Specialist, Newport, Wales, UK
Adjunct Clinical Professor in Pharmacy Practice, Doctor of World Sciences, USA
Jonathan Ferguson
Consultant Cardiothoracic Surgeon, The James Cook University Hospital, Middlesbrough, UK
Simon Flower
General Practitioner, Bristol, UK; Medical Officer, Mendip Cave Rescue
Prof Karen Forbes
Professorial Teaching Fellow in Palliative Medicine, Programme Director, University of Bristol Medical School, UK
Prof Larry Goodyer
Professor of Pharmacy Practice, De Montfort University, Leicester, UK
Penelope B. Granger
General Dental Practitioner, BASMU, Derriford Hospital, Plymouth, UK; Norrbottens Låns Landsting, Sweden
Richard Griffiths
Consultant in Emergency Medicine, Ysbyty Gwynedd, Wales, UK; Chairman, Llanberis Mountain Rescue Team
Rebecca Harris
Freelance TV Producer, London, UK
Peter Harvey
Risk Management Specialist, Hampshire, UK
Debbie Hawker
Clinical Psychologist, InterHealth Worldwide, London, UK
Roderick Hay
Emeritus Professor of Cutaneous Infection, King’s College Hospital, London, UK
Craig Holdstock
Consultant Cardiothoracic Anaesthetist, University Hospitals Plymouth NHS Trust, UK; Medical Officer, Devon Cave Rescue Organisation
Amy Hughes
Flight Doctor, Essex and Herts Air Ambulance, Research Fellow, National Institute for Health and Care Research, Barts and The Royal London;
Senior Education Fellow, Institute of Pre-hospital Care, Queen Mary University, London, UK
Chris Johnson
Retired Consultant Anaesthetist, Frenchay, Bristol, UK
Clive Johnson
Retired Polar Specialist, Buxton, UK
Stephen Jones
Operations Manager, Antarctic Logistics & Expeditions LLC, UK
Burjor K. Langdana
Honorary Clinical Professor, University of Exeter, Founder of Wilderness Expedition Dentistry (WED), Leeds, UK
Nick Lewis
Environmental Scientist and Mountaineer; Antarctic Logistics and Expeditions LLC, Salt Lake City, USA
Tom Mallinson
Rural GP and Co-Director of Prehospital Care, BASICS Scotland, Brora, Scotland, UK
Carey M. McClellan
Advanced Physiotherapy Practitioner, Clinical Director, getUBetter, Bristol, UK
Iain McIntosh
Travel Health Consultant, St Ninian’s Travel Health Research Centre, Stirling, UK
Alastair Miller
Consultant Physician, Deputy Medical Director, Joint Royal Colleges of Physicians Training Board, London, UK
Ben Molyneaux
Dental Surgeon, London, UK
James Moore
Director and Nurse Specialist, Travel Health Consultancy, Exeter Director, International Diploma in Expedition and Wilderness Medicine, Royal College of Physicians and Surgeons of Glasgow, UK
Paddy Morgan
Consultant in Anaesthesia and Pre-Hospital Care, North Bristol NHS Trust, & Emergency Medical Retrieval and Transfer Service, Wales, UK
Daniel S. Morris
Consultant Ophtahlmologist, Cardiff Eye Unit, University of Wales, UK
Harvey Pynn
Consultant in Emergency Medicine and Pre-hospital Emergency Medicine, Bristol, UK
Defence Consultant Advisor in Prehospital Emergency Care
Paul Richards
General Practitioner, Mid and South Essex Integrated Care System; Member, Travel Medicine Subcommittee, Joint Committee on Vaccination and Immunisation
Barry Roberts Director, Wilderness Medical Training, Kendal, UK
Marc Shaw
Professor, College of Public Health, Medical and Veterinary Sciences, Division of Tropical Health and Medicine, James Cook University, Townsville, Australia; Medical Director, Worldwise Geographic Medicine, New Zealand
Julian Thompson
Consultant in Intensive Care Medicine, Southmead Hospital, Bristol, UK
Lesley F. Thomson
Consultant Anaesthetist University Hospitals Plymouth NHS Trust, Derriford Road, Plymouth, UK
Clare Warrell
Consultant in Tropical Medicine and Infectious Diseases, London, UK; Clinical Fellow, London School of Hygiene and Tropical Medicine
Prof Sir David A. Warrell
Emeritus Professor of Tropical Medicine, University of Oxford, UK
Andy Watt
Consultant Physician, Ayrshire and Arran NHS, UK
Jane Wilson-Howarth
General Practitioner and Global Health Specialist, Cambridge, UK
Jeremy Windsor
Consultant in Anaesthesia and Intensive Care, Chesterfield Royal Hospital, Derbyshire, UK; Senior Lecturer in Mountain Medicine, University of Central Lancashire, UK
Shane Winser
Expeditions and Field Science Advisor, Royal Geographical Society (with IBG), London, UK
Contributors to the second edition
Dr Edi Albert
Senior Lecturer in Remote and Polar Medicine, and Rural Generalist in Emergency Medicine, University of Tasmania, Hobart, Tasmania, Australia; Director, Wilderness Education Group
Dr Sarah R. Anderson
Consultant in Health Protection, Public Health England, London, UK
Dr Kristina Birch
Consultant in Anaesthetics and Intensive Care Medicine, North Bristol NHS Trust, UK
Dr Jules Blackham
Consultant Emergency Physician and HEMS Consultant, North Bristol
NHS Trust and Great Western Air Ambulance, UK
Dr Jim Bond
Specialist in Travel and Expedition Medicine, TrExMed Travel Clinic, Edinburgh, UK
Dr Spike Briggs
Consultant in Intensive Care and Anaesthesia, Poole Hospital NHS Foundation Trust; Director of Medical Support Offshore Ltd, UK
Mr Tim Campbell Smith
Consultant General and Colorectal Surgeon, Surrey and Sussex NHS Healthcare Trust, UK
Mr Alistair R. M. Cobb
Consultant Oral and Maxillofacial Surgeon, Southwest Regional Cleft Service, Bristol, UK
Dr Robert Conway
Anaesthetist and Expedition Doctor, Wild Medic Ltd, Brighton, UK
Dr Paul Cooper
Consultant Neurologist, Greater Manchester Neuroscience Centre, Salford Royal Foundation Trust, UK
Dr Rachael Craven
Consultant Anaesthetist, University Hospitals, Bristol, UK
Dr Jon Dallimore
General Practitioner and Specialty Doctor in Emergency Medicine, Bristol Royal Infirmary, UK
Dr Claire Davies
Travel Health Doctor/General Practitioner, InterHealth Worldwide, London, UK
Dr Ian Davis
General Practitioner and Polar Explorer, UK
Dr Richard Dawood
Medical Director, Fleet Street Clinic, London, UK
Dr Sundeep Dhillon
Honorary Research Fellow, Centre for Altitude, Space & Extreme Medicine (CASE), Institute of Sport, Exercise & Health, London, UK
Dr Rose Drew
Registrar in Anaesthesia and Intensive Care Medicine, Sheffield School of Anaesthesia, UK
Dr Matthew Dryden
Director of Infection, Rare and Imported Pathogens Department, Public Health England, Porton, Hampshire Hospitals NHS Foundation Trust and Southampton School of Medicine, UK
Dr Linda Dykes
Consultant in Emergency Medicine, Ysbyty Gwynedd, Bangor, UK
Mr Jonathan Ferguson
Consultant Cardiothoracic Surgeon, The James Cook University Hospital, Middlesbrough, UK
Prof Karen Forbes
Professorial Teaching Fellow and Consultant in Palliative Medicine, University of Bristol, UK
Prof Larry Goodyer
Head of the Leicester School of Pharmacy, De Montfort University, Leicester, UK
Paul F. Goodyer
CEO and Founder of Nomad Travel Stores and Travel Clinics, Enfield, UK
Penelope B. Granger
General Dental Practitioner, BASMU, Derriford Hospital, Plymouth, UK; Norrbottens Låns Landsting, Sweden
Rebecca Harris
Freelance TV Producer, London, UK
Peter Harvey
Risk Management Specialist, Hampshire, UK
Dr Debbie Hawker
Clinical Psychologist, InterHealth Worldwide, London, UK
Dr Amy Hughes
Clinical Lecturer in Emergency Response, Humanitarian and Conflict Response Institute, University of Manchester, UK
Prof Chris Imray
Consultant Vascular and Renal Transplant Surgeon, Warwick Medical School and University Hospital Coventry and Warwickshire NHS Trust, UK
Dr Chris Johnson
Consultant Anaesthetist, North Bristol NHS Trust, Westbury-onTrym, Bristol, UK
Clive Johnson
Polarsphere, Polar Logistics, Buxton, UK
Stephen Jones Operations Manager, Antarctic Logistics & Expeditions LLC, UK
Burjor K. Langdana
General and Expedition Dental Practitioner, Leeds, Dentist to British Antarctic Survey Medical Unit, UK
Dr Jonathan Leach
General Practitioner, Bromsgrove, UK
Dr Campbell MacKenzie
Specialist in Remote and Offshore Medicine, Bristol, UK
Dr Carey M. McLellan
Extended Scope Physiotherapist in Emergency Care, University Hospitals, Bristol, UK
Dr Iain McIntosh
Travel Health Consultant, St Ninians
Travel Health Research Centre, Stirling, UK
Dr Alastair Miller
Consultant Physician (Infectious Diseases), Royal Liverpool University Hospital and University of Liverpool, UK
James Moore
Director and Nurse Specialist, Travel Health Consultancy, Exeter, UK
Clare Morgan
Sexual Health Adviser, University Hospitals, Bristol, UK
Dr Paddy Morgan
Consultant Anaesthetist, North
Bristol NHS Trust, Westbury-onTrym, Bristol, UK
Mr Daniel S. Morris
Consultant Ophthalmologist, Cardiff Eye Unit, University of Wales, UK
Dr Annabel H. Nickol
Clinical Lecturer in Respiratory and General Medicine, Oxford Centre for Respiratory Medicine, UK
Dr Howard Oakley
Associate Specialist in Environmental Medicine, Institute of Naval Medicine, Alverstoke, UK
Prof Andrew J. Pollard
Professor of Paediatric Infection and Immunity, Department of Paediatrics, University of Oxford, UK
Lt Col Harvey Pynn
Consultant in Emergency Medicine and Pre-Hospital Care, University Hospitals, Bristol; Medical Director, Wilderness Medical Training, UK
Dr Paul Richards
General Practitioner and Travel Medicine Specialist; Honorary Lecturer, Centre for Altitude, Space & Extreme Medicine (CASE), UCL, London, UK
Barry Roberts
Director, Wilderness Medical Training, UK
George W. Rodway
Assistant Professor, Division of Health Sciences, University of Nevada, Reno, NV, USA
Prof Marc Shaw
Travel and Geographical Medicine
Consultant; Professor, School of Public Health, James Cook University, Townsville, Australia; Medical Director, Worldwise Travellers Health Centres, New Zealand
Dr Julian Thompson
Specialist Registrar in Anaesthesia and Intensive Care, Oxford University Hospitals, UK
Dr Lesley F. Thomson
Consultant Anaesthetist, Derriford Hospital, Plymouth, UK
Andrew Thurgood
Consultant Nurse—Prehospital Emergency Medicine, Mercia Accident Rescue Service and West Midlands CARE Team, UK
Prof David A. Warrell
International Director, Royal College of Physicians; Emeritus Professor of Tropical Medicine, University of Oxford, UK
Dr Andy Watt
Consultant Physician, Ayrshire and Arran NHS, UK
Dr Jane Wilson-Howarth
General Practitioner and Medical Director, Travel Clinic Ltd., Cambridge and Ipswich, UK
Dr Jeremy Windsor
Consultant in Anaesthesia and Intensive Care, Chesterfield Royal Hospital, Derbyshire, UK
Shane Winser
Geography Outdoors: the centre supporting field research, exploration and outdoor learning, Royal Geographical Society (with IBG), London, UK
Contributors to the first edition
Mr James Calder
Trauma and Orthopaedic Consultant, North Hampshire Hospital, and Clinical Senior Lecturer, Imperial College, London, UK
Dr Charles Clarke
Honorary Consultant Neurologist, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK and President of the British Mountaineering Council, UK
David Geddes
Dental Surgeon
Dr Mike Grocott
Senior Lecturer in Intensive Care Medicine, Centre for Altitude Space and Extreme Environment Medicine, UCL Institute of Human Health and Performance, London, UK
Dr Stephen Hearns
Consultant in Emergency Medicine, Lead Consultant Emergency Medical Retrieval Service, Royal Alexandra Hospital Paisley, UK
Dr Michael E. Jones
Consultant Physician, Regional Infectious Diseases Unit, Western General Hospital, Edinburgh, UK; HealthLink360 Edinburgh International Health Centre Carberry, Musselburgh, UK
Dr Akbar Lalani
Royal Army Medical Corps
Christina Lalani
Trainee in Anaesthesia, Frimley Park NHS Foundation Trust, UK
Nick Lewis
Environmental Consultant, Poles Apart, Cambridge, UK
Prof David Lockey
Professor of Trauma and PreHospital Emergency Medicine, North Bristol NHS Trust, UK
Prof Hugh Montgomery
Director, Institute for Human Health and Performance, University College London, UK
Dr Christopher Moxon
Research Associate, MalawiLiverpool-Wellcome Clinical Research Programme, Honorary Paediatric Registrar, College of Medicine, Malawi
Prof Ian Palmer
Professor of Military Psychiatry, Head of Medical Assessment Programme, MoDUK, St Thomas’ Hospital, London, UK
Dr Andy Pitkin
Department of Anesthesiology, University of Florida, Gainesville, FL, USA
Dr Tariq Qureshi
Department of Emergency Medicine, John Radcliffe Hospital, Oxford Radcliffe Hospitals, NHS Trust, UK
Dr Charlie Siderfin
General Practitioner, Heilendi
Family Medical Practice, Kirkwall, Orkney, UK
Dr Joe Silsby
Consultant in Anaesthesia and ICM Taunton and Somerset NHS Foundation Trust, UK
James Watson
Physiotherapy Officer, Medical Support Unit, Headquarters, Hereford Garrison, UK
Symbols and abbreviations
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M website
± with or without
ABC airway, breathing, circulation
ACE angiotensin-converting enzyme
ACL anterior cruciate ligament (knee)
ACVPU Scale to evaluate conscious level (awake/verbal/pain/ unresponsive)
UVR (UVA, UVB) ultraviolet radiation (types A and B)
VEGF vascular endothelial growth factor
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WHO World Health Organization
WMS Wilderness Medical Society
YF yellow fever
Expedition medicine
Chapter editor
Chris Johnson
Contributors
Sarah R. Anderson
Chris Johnson
Shane Winser
David A. Warrell (st and 2nd editions)
Linda Dykes (2nd edition)
Reviewer
Richard Griffiths
A global change 2
Wilderness travel 4
The scope of expedition medicine 6
Risk of death 0
Illness on expeditions 2
Medical evacuations 4
Meeting the challenge 6
A global change
The third edition of this handbook is being written amid huge global uncertainty and disruption. Coronavirus disease 209 (COVID-9), the first pandemic for a century, has disrupted life for most of the world’s 8 billion people. The pandemic struck a world that was becoming increasingly aware of the consequences of an exponential rise in human population, with its effects on global warming, resource depletion, and ecosystem destruction. Travel to exotic places, until half a century ago undertaken by a privileged few, has become a mass-market industry creating wealth and employment, but in popular locations has become unsustainable as excessive numbers of visitors cram into the most popular destinations.
Doomsday has been predicted many times, whether it be through plague, nuclear holocaust, global warming, or mass migration. ecologists now predict the possibility of a mass extinction event and it is far from certain whether there is the will to make the necessary social, economic, and environmental changes to avoid such a catastrophe. The internet means that debates on almost anything can rapidly become vitriolic and divorced from science. Writing in the midst of the pandemic we cannot be sure of the future for travel and expeditions but do so in the hope of again being able to visit the world’s remote and extreme environments.
Wilderness travel
This handbook is about the healthcare of travellers to remote areas. Remote areas are defined as places where access to sophisticated medical services is difficult or impossible, and the responsibility for dealing with medical problems falls on expedition members. In europe this branch of medicine is usually called ‘expedition medicine’, while in north America it is called ‘wilderness medicine’.
An expedition is an organized journey with a purpose. early expeditions sought new lands to claim, develop, and exploit. In the twentieth century, as blanks on maps shrank, geologists, naturalists, and ecologists added detail to the knowledge, while physiologists explored human responses to extreme environments. Today, new scientific knowledge generally requires a highly technological approach and considerable funding, and personal development, cultural exchange, and charity fundraising have become an increasingly important justification for travel.
Adventure travel organizations send tens of thousands of people overseas each year to areas that 30 years ago could only be reached by a wellequipped expedition. Given sufficient funding, journeys to both poles, the summit of everest, and even into space can be purchased. Age is no longer a bar to travel, with both healthy and less-fit elderly clients expecting to reach remote and often physically demanding destinations—an octogenarian has reached the top of everest, while expedition ships will take travellers with significant health problems to remote polar destinations. Attitudes to physical and mental disabilities have also changed enormously. A blind climber has summited everest and limbless military veterans walked to the South pole. The distinction between an expedition and a recreational journey is no longer obvious, but the challenges of caring for people far from a base hospital remain.
Technology has shrunk the world: superjeeps and helicopters enable ready access to previously isolated parts of the globe, while satellite navigation systems enable anyone with a smartphone or watch to locate their position precisely. Relatively inexpensive equipment enables global access to the internet and the progress of an expedition team can be monitored remotely and help summoned in the event of an accident. Increasingly, the wilderness is used as a playground for sporting endeavours that push the limits of human physiology.
Groups travelling to remote areas now include
• Well-organized and -funded expeditions.
• Film crews documenting ecosystems or adventurous pursuits.
• Small groups of independent travellers.
• Commercial trips to remote destinations.
• Charity fundraising treks to exotic destinations.
• participants in ‘adventure’ holidays.
• Competitors in extreme sporting events.
• Gap-year travellers.
Despite the improvements in communications and technology, the physical, environmental, and health risks of remote areas remain. This handbook is about helping travellers understand and prepare for those hazards. It is designed to assist doctors, nurses, and paramedics who support groups far from formal medical facilities.
Increasingly over the past two decades, military and disaster-relief organizations have developed the capability to provide portable but remarkably sophisticated healthcare in remote locations. This has been a response both to war in difficult environments such as the Middle east, and to better assist countries following major natural disasters such as tsunamis, earthquakes, or epidemic disease. These capabilities rely on skilled personnel and costly logistic support, and this handbook does not deal with this type of healthcare.
See instead, for example: partridge RA, proano L, Marcozzi D (eds). Oxford American Handbook of Disaster Medicine new York: Oxford University press; 202.
The scope of expedition medicine
expedition medicine is about:
• preparing for an expedition—to minimize ill health and maximize expedition achievements.
• Working during the expedition—in a professional capacity to diagnose, treat, and manage health problems.
• Managing expedition emergencies and potential evacuations.
• Finally, advising on health issues once the expedition has returned home.
Organizing the medical care of an expedition takes time and includes tasks such as:
• The assessment and reduction of risk and therefore injury.
• Team selection.
• First-aid training.
• preventive medicine, including dentistry, both before departure and in the field.
• Organization and transport of a suitable medical kit.
• Knowledge of particular health problems in the area of the visit.
• provision of medical skills in the field.
• Arrangements for medical back-up and evacuation.
• Organization of health insurance.
• Crisis management.
each of these aspects will be covered later in this handbook. expedition medicine is not just about the treatment of disease or coping with injuries—it should permeate all facets of the expedition. health criteria must be considered when the location of the base camp is selected and the activities of the trip planned. Food, sanitation, and psychology are part of the expedition medic’s work. The medic will fulfil many roles and will certainly be expected to be nurse as well as doctor. Sometimes the work will involve listening to and encouraging those who are finding the expedition emotionally challenging, either due to the remote environment or interpersonal conflicts. The obligation of the medic to care for the sick or accompany a casualty during evacuation may mean that certain personal goals are not attained. not all expeditions will include a trained doctor, nurse, or paramedic, but all expeditions must consider how they can prevent disease, and cope with illness or trauma. Correctly practised, expedition medicine should not constrain the enthusiasms and ambitions of an expedition but, by anticipating preventable medical problems, facilitate the achievements and enjoyment of all participants.
Surveys of medicine in remote areas
Several research studies have provided information about the nature and frequency of medical problems in remote environments. Their size, methodologies, and environments vary but some common themes emerge (Table .).
Expedition destinations
expedition medicine requires an understanding of how humans can physiologically acclimatize and technologically adapt to extreme environments.
Contemporary travel can within a few hours take someone from a relatively benign to a potentially life-threatening environment. newcomers may have no idea of the hazards they face and inadvertently place themselves in danger. Within an organized group, it is the role of the leader, local guides, and the medic to ensure that participants know how to behave to maintain safety, and that expedition plans match the physical and emotional capabilities of all the team members.
The Royal Geographical Society and Institute of british Geographers (RGS-IbG) surveyed a large number of expeditions in the late 990s2 and at that time mountainous terrain and tropical jungles were the most popular geographical areas for expeditions to visit (Fig. .). Other destinations have increased in popularity and accessibility. During the 970s, only a handful of tourists visited Antarctica. In the 980s, numbers increased to around 2000 a year, and this expansion has continued to the current level (209/2020) of 74,000 visitors. Iceland is a very popular adventure destination and saw a dramatic climb in visitor numbers from 250,000 per year in 2000 to 2.3 million a year in 208. nepal has seen a similar although less dramatic rise from 460,000 tourists in 2000 to .2 million a year in 209. however, even before the COVID-9 epidemic halted mass tourism, there were signs that visits to some areas were levelling off or dropping due both to environmental concerns and overcrowding at popular destinations.
numerous holidays are marketed as ‘adventure trips’ with >400,000 ‘adventure holiday’ packages sold in the UK in 209. These may range from expedition level trips to the great mountain ranges through to less extreme trekking or cycling tours in low- or middle-income countries.
In 208, 242,000 passengers visited remote destinations on ‘expedition cruises’ in small vessels capable of carrying 50–200 passengers. Such trips are relatively expensive and attract a high proportion of mature travellers, who may have associated health problems. While large cruise liners now have comprehensively equipped medical facilities, the smaller vessels usually carry a medic and basic equipment but very limited diagnostic and treatment facilities.
Adventurous outdoor education trips have been available for >60 years and share characteristics with more remote overseas travel. They offer youngsters the opportunity to participate in camping, trekking, cycling, canoeing, and other pastimes, often culminating in a supervised but independent expedition.
Given the number of opportunities now on offer for people of all ages to head into the wilderness, it is probable that a family practitioner will be consulted about the preparations required for travel to remote areas. While expedition participants 30 years ago were generally reasonably fit, experienced, and skilled, it is now very easy for a naïve traveller to visit an extreme environment. E Chapters 20–27 of this handbook provide information about human health and physiology in such extreme environments.
2 Anderson SR, Johnson CJh. expedition health and safety: a risk assessment. J R Soc Med. 2000:93:557–562. https://doi.org/0.77/04076800093002
