Practical Tips for Working as an Expedition Doctor on High-Altitude Expeditions

Introduction

With the steady increase in adventure travel in recent decades, the practice of high-altitude expedition medicine has seen a surge in popularity. In the spring of 2016, more than 600 people reached the summit of Mount Everest, and many other teams attempted the other 8000-m peaks (Himalayan Database 2016). Working as an expedition doctor can be extremely rewarding, but lack of physical preparation and pertinent medical expertise can endanger the entire team. The goal of this article is to provide prospective candidates a guide to pursuing and preparing for medical work on a high-altitude expedition. Drawing on our own experiences practicing medicine on 8000-m peaks, as well as review of the existing literature, we discuss high-altitude expedition jobs available to physicians. We then provide insight into preparing for such work, including the working conditions, common medical problems encountered on expeditions, and ethical issues that may arise during the course of the expedition.

Considerations for Choosing a Commercial Guiding Company

If your goal is to work with a commercial guiding company, there are some basic, yet important questions to ask prospective operators. These basic questions relate to an operator's experience, team structure, and medical equipment, and are provided in Table 1. In addition to these basic questions, it is important to understand the company's approach to a high-altitude climb. For example, will the team follow the “Gold Standard” of not climbing too high too fast? Some companies are now offering so-called rapid ascent climbs in which climbers have slept in hypoxia tents before arrival (Dehnert et al., 2014). Although this approach may work for properly selected clients, it could increase the team's risk of developing altitude-related illness. It is important to understand what communications and logistical support are provided by the prospective operator. Will a dedicated base camp manager be responsible for coordinating these functions? Will all team members have a radio? You should also ensure that the company takes a fastidious interest in sanitary food and water preparation, as well as waste management, to minimize the chance of gastrointestinal illness. Inattention to hygiene can easily result in epidemics of travelers' diarrhea in a team. By choosing to work for a reputable and responsible company, you will make your job much safer and less stressful. Additional information on how to check the quality of a commercially organized expedition has been comprehensively covered by Hillebrandt et al. (2012).

Personal Preparation

An expedition doctor should be physically prepared to carry out clinical duties in an austere environment. Working on a high-altitude expedition involves being able to live in a tent for weeks in a cold environment. At a minimum, one needs to be physically fit and able to keep up with the team during the trek to the mountain's base camp. Depending on your current level of fitness, you may need to set aside several months of physical training to prepare yourself. In addition, it is expected that the doctor has experience with the rigors of backcountry travel and will not be a liability to the team.

In addition to physical stressors, an expedition doctor should prepare for mental challenges. For example, being equipped to fight boredom by having books, games, and other forms of entertainment is essential when the team is forced to remain in one location due to bad weather or other unexpected delays. At high altitude and in any other expedition environment, you will encounter setbacks and will need to maintain flexibility and patience.

It is advisable to go on an expedition with friends before you assume the role of expedition doctor. By doing this, you can hone your personal organization, improve your fitness, develop your mountain skills, and gain the experience you need to be confident that you can cope with the rigors of an expedition. In reality, these skills can be more important than medical skills on a high-altitude expedition.

Medical Preparation

Once you have established that your physical preparation and mountain skills are adequate for a high-altitude expedition, you need to ensure you have the proper medical training and experience to be able to recognize and treat diseases efficiently. For most doctors, this will mean having worked in general practice or emergency medicine for at least a year before going on an expedition. In addition to knowing the basics, you should ideally have some additional training or experience in both expedition and high-altitude medicine. There are various courses and postgraduate qualifications that can give you additional training in these fields, including an Advanced Wilderness Life Support course, Mountain Medicine course, Polar Medicine course, and Diploma in Mountain Medicine. (Wilkes, 2016). You may also need some additional knowledge specific to the medical histories of the participants on your trip. For example, it is important to review diabetes management if you will have a climber with diabetes on your trip.

Expedition doctors must be cognizant of any gaps in their own knowledge and seek appropriate advice from books and experienced colleagues when appropriate. Familiarity with communication devices while in the field is helpful, and it can be of added value to have a satellite phone so that you have the ability to consult with experts regarding specific problems. In most cases, the consultation will be of an informal nature with colleagues.

Preparation is key to a successful trip. No doctor will be expected to have treated every condition, and no doctor can prepare for every eventuality. However, you should be comfortable improvising and working independently, and have sufficient experience to rationally approach whatever arises (Kidd and Hillebrandt, 2013).

Finding a Job

Begin looking for employment only once you have become comfortable living in the great outdoors and are feeling equipped to assume the role of expedition doctor. With the growing popularity of expedition medicine, getting a job is not always easy, especially one on a high-altitude peak expedition. Familiarize yourself with the expeditions available and prepare your resume. Begin speaking with various operators and organizations to gather more detailed information and then start sending out your resume. Most expedition doctors are volunteers who provide medical care in exchange for an all-expense-paid trip, which should include airfare. There are a number of charity climbs that are in need of expedition doctors. In general, companies do not give positions on a trial basis, which is why it is ideal to have previous expedition experience. As stated earlier, always be critical of the organization you plan to expedition with, and carefully consider the outdoor activity being undertaken as well as the expedition team members. Be suspicious when you are offered a free trip and remember that you are medically responsible. The role of expedition doctor begins in these early stages as you ensure that the organization provides good hygiene, comfortable load carrying, safe shelters, and equipment for local staff.

Most companies will not offer any additional compensation beyond the cost of the trip; however, it is important to realize that this arrangement is still considered employment and you will need indemnity insurance to protect yourself. You should first ascertain from your own insurer whether they will provide coverage for volunteers as you will fit into this category if you are not being paid for your services. There are a limited number of insurers worldwide who will provide coverage for individuals working on an expedition, and you will likely discover that indemnity insurance can be very expensive. Good Samaritan laws vary between countries, but, in general, only apply when you are on an expedition as a paying member, participating without the intention of practicing medicine.

To be offered a paid expedition job you must show that you can cope with adversity and are adept in situations away from the sterile and controlled situations of a hospital. You can get this type of experience in a variety of ways, including working in a remote and austere medical clinic, working with search and rescue organizations, working at races or sporting events, or by volunteering on shorter expeditions (Kidd and Hillebrandt, 2013). These are usually unpaid positions, but provide opportunities to gain relevant experience, demonstrate flexibility and enthusiasm, and make contacts.

One of the benefits of being an expedition doctor is that in certain circumstances, you may get to attempt the climbing objective with the team. Whether the expedition doctor stays at base camp or climbs with the team will depend on a host of factors, including the size of the team, the nature of the expedition, and the doctor's previous climbing experience. If the doctor gets an opportunity to climb, it is understood that treatment of a sick or injured climber will always take precedence over climbing objectives.

Trip Preparation

Once you are committed to an expedition, you can start preparing to meet the medical needs of a specific group of climbers. Awareness is the first step in this preparation. All team members will be asked to fill out a medical form that will give you important information such as age, medical history, and known allergies. You should also ascertain whether participants have suffered with any psychological or drug problems in the past to help determine whether a person is psychologically fit enough to undertake the mental challenges of an expedition. A form that has not been completed truthfully can jeopardize the expedition and means that the team member in question might not be insured in the event of an emergency. Be aware that during the expedition, you are also responsible for medical care of the support staff, which usually consists of locals. Ideally the expedition company will require local staff to complete the same questionnaires and undergo a preexpedition physical but unfortunately many companies do not make this a requirement.

In addition to knowing who will be participating, it is important to know the expedition objectives so that you can undertake a proper risk assessment. Based on team members' medical histories and a risk assessment of the terrain you will travel over and the activity you will undertake, you should be able to determine what injuries and illnesses are most likely to occur. Will the expedition be on a popular peak with fixed ropes or will it involve climbing alpine style in a very remote area? You will also need to know the experience level of your team members and if it will be anyone's first time to high altitude. Another important thing to consider is making sure everyone (staff and clients) has insurance to cover an evacuation.

It is essential to have reviewed evacuation strategies before the start of the expedition. You should know what medical facilities are available nearby as well as what your transportation options to them are. It is also important to establish who will be in charge of logistics in the event of an evacuation. If you are working on Everest, you should familiarize yourself with the Everest ER, a nonprofit clinic that is open each spring. We recommend visiting the ER and introducing yourself to the physicians working there so that you have an understanding of each other's resources and will be prepared to work together in a mass casualty event. On other peaks, it is good to know whether the other climbing teams have doctors or extensive medical supplies since again you may need to work together during emergencies.

The doctor, in addition to the rest of the team, should be aware of possible risks to health. Educate your team regarding what to look out for and how they can prevent accidents and illness during the journey. Education is a continuous process throughout the expedition, and it includes educating expedition members on basic first aid in case the doctor becomes ill or injured. Education on altitude illness, hygiene, prevention of sunburn, and snow blindness can minimize delays and make a trip more enjoyable.

Medical Kits

What to include in the group medical kit depends on the terrain, the activity, the team members, the length of the trip, the endemic diseases, the distance from definitive medical care, and the doctor's skill and experience. Because every expedition is unique in its environment, duration, and number of people, there is no perfect medical kit (Auerbach, 2012).

Establish who will be responsible for creating and maintaining the group medical kit as this task can be both expensive and labor intensive. Restrictions on drugs will vary between countries, and potential legal issues with importing drugs can often be avoided by purchasing supplies in the country where the expedition will take place. If a group medical kit will be provided, it is important to check the kit personally before departure to ascertain if it is complete and in date. Ensure that you have enough medication, based on the number of people and the length of trip. Review allergies to make sure that you have medications to which your team members are not allergic.

At a minimum, your kit should include antibiotics for commonly seen infections, appropriate analgesics, treatment for gastrointestinal upset, blister and wound care, anaphylaxis treatment, and a trauma kit. We strongly advise to add equipment to monitor vital signs, respiratory treatments, cardiovascular medication, injectables plus needles, and a dental kit when going on a longer expedition. Overall, multipurpose supplies are recommended as bulky kits are often left behind. You should only bring medication and equipment that are familiar to you, bearing in mind that it is expected that you will apply dressings, monitor patients, and administer all medication yourself.

When working on a high-altitude expedition, your kit will need to include supplies for altitude-related illness and frostbite. If room allows, medicines for symptomatic relief of things such as the common cold and sore throat should be included since treating these conditions can significantly improve team morale.

All team members should be instructed to carry their own personal medical kit. This on-person medical kit should consist of commonly used items such as those needed for wound cleaning and dressing, oral and topical OTC preparations, and equipment such as a knife or multitool, and tape (Welch, 1997). If applicable, a medical alert bracelet and spare medication for preexisting problems should be included in the climbers' personal medical kit.

The Range of Problems an Expedition Doctor Should Expect to Encounter

While much of the attention in high-altitude medicine is focused on the risk and management of acute illness, there are wide ranges of conditions for which the expedition physician must be prepared. Notable conditions range from the simple, such as blisters, muscle strains, and upper respiratory infections, to the severe. Table 2 summarizes data from two reports on two major expeditions peaks, Denali and Mt Everest, and provides an overview of the categories of problems that were encountered (McIntosh et al., 2012; Nemethy et al., 2015). Within each of the categories, such as pulmonary or gastrointestinal, there can be a similarly wide spectrum of problems of both medical and traumatic origin.

Given the high incidence of altitude-related issues, it is important that the expedition doctor is familiar with the signs and symptoms of AMS, high-altitude pulmonary edema (HAPE), high-altitude cerebral edema (HACE), and their treatment. Both prevention strategies and treatment are well established and beyond the scope of this article, but have been reviewed by Hackett and Roach (2001), Bartsh et al. (2013), and Luks et al. (2014). It is always important to do a thorough history so that you can exclude issues such as dehydration and carbon monoxide poisoning, which can mimic HACE and HAPE.

One should be prepared to see cold-related injuries, including hypothermia, frost nip, and frostbite. The reviews by Zafren (2013) and McIntosh et al. (2014) cover the prevention and management of frostbite. In addition, a UK-based website is available for doctors and climbers to obtain international frostbite advice. The website is available at www.thebmc.co.uk/how-to-get-expert-frostbite-advice?s=4 (accessed March 1, 2017).

High-altitude cough is a frequent complaint among climbers and is often referred to as the “Khumbu Cough” in Nepal. High-altitude cough was the most common medical diagnoses made over a 10-year period at the Everest ER and was responsible for 14% of all medical diagnoses (Nemethy et al., 2015). Most cases of this cough have no obvious infectious etiology and are thought to be due to bronchial irritation from a combination of cold dry air and increased ventilatory drive. A detailed discussion of the pathophysiology of high-altitude cough is provided by Mason (2013). It is believed that wearing a thin face mask to warm and humidify the air you breathe and help block inhalation of dust during the trek in, can both help prevent and treat the cough. Anecdotal experience has shown that treatment with inhaled fluticasone/salmeterol may improve the symptoms. The cough almost universally disappears when climbers descend below base camp.

Retinal hemorrhages are a common occurrence in high-altitude climbers with reported frequencies as high as 79% (Barthelmes et al., 2011; Bosch et al., 2012). Depending on their size and location, hemorrhages range from being asymptomatic, to causing only mild scotomas, to severe visual impairment.

Unexpected problems often include skin and soft tissue infections such as boils and pilonidal cysts. It seems that the combination of decreased hygiene and friction from the pack work together to make people more susceptible to these conditions. In addition, people can frequently be embarrassed about this condition, so they may not seek immediate medical attention. Another embarrassing condition that seems to happen with some regularity is hemorrhoids. Knowing how to lance a thrombosed hemorrhoid is important since this is one instance where you can provide a team member with immediate relief.

If your team will include Sherpas, you should be prepared to treat some dental issues and gastrointestinal complaints. Many Sherpas do not have access to regular dental exams and it seems that the changes in pressure associated with frequent trips up and down the mountain can exacerbate chronic dental issues. Working as a dentist is most likely outside the expertise and comfort of most expedition doctors, but simply lancing an abscess and treating with antibiotics can frequently avoid progression to full-blown cellulitis and an emergency evacuation. If you have time, getting some training in expedition dentistry is helpful (Langdana and Edwards 2013).

Gastrointestinal complaints are common at high altitude, with the most frequent being acid reflux, gastritis, and gastroenteritis. Gastritis is particularly common in Sherpas, with one study finding the prevalence of Helicobacter pylori to be 70.5% in the Khumbu Valley (Sherpa et al., 2012). It is good to be prepared with plenty of H2 receptor blockers and proton pump inhibitors.

When evaluating a climber, it is important to ask yourself if anxiety or lack of confidence might be playing a role in their current complaint. It is common that a climber will come to you with a minor medical complaint, but when you spend time taking a careful history, you may discover that a crisis of confidence is the real underlying issue.

The avalanche in the Ice Fall on Everest in 2014 followed by the Nepal earthquake in 2015 illustrates that expedition doctors need to be ready for anything. In both situations, nature created an unexpected mass-casualty event. Although unexpected, the teams were able to improvise and work together to handle the situation efficiently (Stokes et al., 2015).

Medical Record Keeping

During an expedition, one has to keep notes on medical conversations, agreements made, and treatment given. It is useful to see people at least once a week when at high altitude to see how they are feeling and, if desirable, establish a baseline of their vitals. A SOAP note on waterproof paper is sufficient and provides a written record. In case of an evacuation, it can serve as a handover so that the next clinician has some background information about the person being transferred. A digital photograph of the notes can provide backup in case the note is lost or damaged. After the expedition, it is standard for the guiding company to keep the medical records, but it is a good idea to keep your own copy if the company and participants are amendable to this.

At the end of an expedition, it is not unusual to write a trip report. Medical incidents will be evaluated throughout and after the expedition. It is also important to talk to your team and debrief. Finally, it is good practice to ask your expedition leader for feedback at the end of the trip.

Ethical Issues

When working on a high-altitude expedition, there are some ethical dilemmas that you may encounter, and it is important to have reviewed them before you arrive on the mountain. One such issue is confidentiality. Not only is confidentiality difficult to maintain due to the close living quarters, but it can also pose an ethical challenge since you need to think not only of what is best for your client but also what is best for the entire team.

Another issue to consider is how you will address requests for medicine from local populations you will encounter as you trek to base camp. It is common for people with both acute and chronic conditions to approach expedition doctors. In these situations, consider not only whether there is enough medicine in your kit but also whether it is appropriate to treat someone when you have no ability to provide a proper follow-up. It is important to work together with any local healthcare systems that are already in place if you choose to offer foreign medicines or second opinions.

Another problem you may encounter is the need to turn a team member back due to a medical condition that makes continued climbing unsafe. For many climbers, this is a “once-in-a-lifetime” opportunity for which they have been saving money most of their lives. Contrary to popular belief, not all climbers are wealthy. In addition to spending a significant amount of money, many of these climbers have been training for years and have made numerous professional and personal sacrifices to be part of the expedition.

It is not only the expedition climbers who get sick but also potentially the Sherpas and other staff. Depending on the company you are working for, it may mean that when Sherpas are turned around, they will not get their full pay or summit bonus, money they are counting on to feed their families. This situation provides another example of why working for a reputable guiding company makes your job easier. A reputable company will support your medical decision-making by not allowing a climber to carry on if you do not think it is safe, and paying their Sherpas even if they become sick or injured.

A less-common, but important, scenario that can be encountered is a climber who demands evacuation even though you do not believe it is not clinically indicated. Sometimes the climber will demand evacuation to avoid the work of climbing down, but other times, the climber is just scared and afraid to climb down. Often this situation can be resolved with reassurance and education.

Medication use is another potentially complicated issue on expeditions. The article by Luks et al. (2016) reports that 43% of climbers on Mt. Everest used medications, with acetazolamide being the most commonly used. Most of us would agree that there is little harm in proper use of acetazolamide to help with acclimatization, but the situation becomes more complicated when you encounter climbers who want to use medicine such as dexamethasone, phosphodiesterase inhibitors, or stimulants other than caffeine, prophylactically. You want to create a non-judgmental environment in which climbers feel safe opening up to you about what drugs they plan to use. However, you must set firm boundaries and communicate clearly about drugs or drug combinations that you think may be dangerous to climbers. It is better to know what a climber is planning to take ahead of time rather than finding out when they are collapsed from exhaustion or polypharmacy, when it is potentially too late. If a climber does not follow your advice regarding medication use, it is important to document these details in their medical record. A review of medicines commonly used at high altitude is beyond the scope of this article, but has been comprehensively covered by Donegani et al. (2016).

Conclusion

Once you have spent some time in the mountains developing your personal mountaineering skills and have decided that you want to work as a high-altitude expedition doctor, the next step is to educate yourself and find a reputable company to join. You need to spend significant time before the trip doing a proper risk assessment of the participants, destination, and terrain, as well as ensuring that you have the right medical kit.

By doing these things, you will maximize your chances of having a successful trip where you can enjoy the beauty of the mountains, meeting new people, the rigors of expedition life, and most importantly, the chance to practice medicine in a truly unique environment.