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Hello, I'm Doctor Lucy Obolensky. Welcome to your precourse learning for your wilderness first responder course. And for the next half an hour or so, we'll be discussing expedition medical planning. So if you have an expedition in mind or one that you're going on, please feel free to use that. Otherwise, if you'd be so kind as to consider this expedition, you're planning a 10 day kayak expedition down the Orange River in Namibia. You have six paddlers aged 32 to 58 and one local guide. You are self sufficient for 10 days with one access point to a road on day four on the exit point on day 10. What do you need to consider for your pre expedition medical plan? So if you just take a moment to write that down, just a spider diagram or just some thoughts on a paper, just jot down things that you think you'd want to consider all the aspects within this, within this medical plan to ensure that you and your team are safe during the expedition. We'll just pause for a moment while you do that. So hopefully, now you have a piece of paper with lots of thoughts jotted down all over it depending on your expedition or that one that we just discussed doing the kayak trip in Namibia before we go on to think about what you've put down or think about what we need for expedition, medical planning. I think, first of all, the most important thing to think about is risk and risk is always a balance, isn't it? It's not just in the medical plan or it's in the entire expedition itself. And we have to consider this in all aspects of what we do and in what and in the balance of what we are happy with, in terms of that balance of risk for that specific expedition. And that will depend on numerous factors who you're taking, where you're going, how far definitive medical care is. So I think it's important just to bear this in mind throughout the rest of this talk. I always like to consider this um concept of risk in terms of a graft. So if we have on this access, the um technical risk of the expedition and then on the X access, access the distance to appropriate medical care, if you think of us all just staying at home and watching TV, and popcorn, we are probably quite close to appropriate medical care and the technical risk of us doing that unless you're like me with ATV remote um is relatively low. If you then look at something like this like fast jet boating. The technical risk of the expedition is very high. Your probability of having severe or significant trauma should something untoward happen is high. Um However, your distance to appropriate medical care is likely to be relatively low. If you then consider something like hiking, uh, depending on where you're gonna be. Um, your distance to appropriate medical care may actually be quite a long way away. So far we're talking more than four hours, um possibly even days away. However, the technical risk, depending on the hike that you're doing could be relatively low. And then of course, you have this top corner where I've put in a red box where the technical risk of your expedition is also relatively high and the distance to appropriate medical care is far. And so then you need to have your own considerations of like we've said, who are you, who are you taking? What's the purpose of your expedition and why are you doing it? And what level of risk are you happy with? So I've put these smiley faces because, you know, you might be along here and think, oh, I don't feel very comfortable with that. You might not feel very comfortable with being up here or even here. So that's gonna change for all of us depending on our expedition in terms of, are you comfortable with this level of risk, this level of risk or this level of risk? And that is something that you will have to consider with your wider expedition team whilst you're making your expedition medical plan. So if we now come back to your scribbles on that piece of paper and the document of what do you actually need to consider in order to have an expedition medical planning list. Um We have written at Endeavor Medical, a checklist which I will take you through in more details now and this checklist is also available in your precourse materials um as a PDF if you'd like it. So I think the first question that you really need to answer regardless of whether you're a medic or an expedition leader acting as one of the medics. Um is probably this question is, do I have the knowledge, skills and competence required for this expedition? So that takes clearly that's quite subjective, but it takes some real honesty in looking at yourself saying what's actually being asked of me? And do I feel comfortable that I have the knowledge, skills and competence required and remembering as we'll go on to later with legal aspects, if you do sign up to something that you then don't have the competence for, um that could end up coming back to bite you at a later stage. So it's really being honest with yourself about your level of skills and competence. And once you've answered that question, I think the next question is looking at the company or the expedition itself and saying, do I want to work for this organization. Is this an expedition that I want to be part of? Um And we'll come back to that a little bit more later in this talk, but just really having a good look at those two questions before you then sign up and spend lots of your time looking at the planning phases in order to answer those two questions. Um There's two documents out there that I would highly recommend you have a look at which is the updated guidance for medical provision for wilderness medicine, that's in the Faculty of Prehospital Care and also the British Standards Guidance BS 8848, which some of you may know. Well, um otherwise this document, it is um you do have to buy this document, however, it's often freely available. Um If you belong to any mountain associations or expedition associations, you can get your hands on the BS 8848. So I would thoroughly suggest that you have a look at that um in conjunction with the expedition um outline that you've been sent to really help you answer both those two questions that we've just discussed. I also think at this point, it's worth us pausing just to consider the ethical and legal considerations of being the medic on expedition. And that's also gonna depend on a number of things in whether you are a medic, a doctor um or an allied health professional. And you've been employed on this expedition as a specific role as the medic that will also depend on whether the company is paying you or not and whether you're doing this as a voluntary position and if they are paying you, whether they're covering your expenses, your medical indemnity, that's a section that we're not gonna cover in this. Um We can talk about that on the course in person or on a separate to because it's so expedition specific. Um if you are an expedition leader, but you then don't have a doctor. So you take on the role of medic. Um that's also a slightly, they're slightly different, both ethical and legal. So just to remember that every situation, the intervention is expedition and situation specific. So clearly documenting it yourself in what the expedition is you're on. And if something do untoward does happen, the situation in which it happened, remember that the advanced skills that you're gonna use on this course are to be used when prehospital services are not readily at hand. So it would be inappropriate to use if you are a medic or a doctor, advanced hospital skills um out in the field when you might have ambulance or helicopters or prehospital service close to hand again, as a first aider, um using the skills that we're gonna teach you on this wilderness first responder course, if you could get access to a hospital relatively quickly, um would not be appropriate. Um in any sense, just being honest with the level of training and experience you have is absolutely crucial. Whether that be a first aid training or medical training, being totally honest with your casualties about um your level of training is absolutely key. If something did go to court, if a case did go to court, you would only be held to the same level as a fellow medic or a first aider who was done up to this level of training. Um and not beyond. So don't try and do anything that's above your competence or something that you feel comfortable in doing and in all cases ensure that you document absolutely everything the date, the time who is present um the medical info and the interventions you gave, you can do retrospective documentation. That's absolutely fine. And I would almost encourage that because often it's very stressful if you do have a worst case scenario or a significant event to try and document at the time. So once you've finished and the case is packaged up, have a, have a cup of tea, have a sit down and then go and find your notebook and document absolutely everything and times um that it happened at that stage. And just remember that in terms of documentation, if you record good notes, you would have good defense. If you document poor notes, you would have poor defense and no do notes is no defense. So again, just to encourage you to document absolutely everything. And if you need help remembering things. That's fine, you can get witness statements as well. Um But just to write something down, keep it in a securely locked box and you should keep your notes for at least up to 10 years. So I hope that helps, that helps to bring some clarity to the legal and ethical considerations of treating patients. Whilst on expedition. If we now come back to the expedition, medical preparation and plan, we'll come back to the checklist um that we talked about and we'll run through that in slightly more detail. So you've thought about the first question, which is, do I have the knowledge, skills and competence required for this expedition? We've talked about the legal and ethical um aspects surrounding that and we've talked about the documents that would help you consider the answer to that question. And also the question of, do I wish to work for this company? So presuming that you've ticked those two boxes on that checklist and you are now going on the expedition and you've decided this is a worthwhile expedition and a good company that you do want to work for. You now need to really think about that expedition medical plan. So moving on to the pre departure phase, things that you need to think about before you go are the environment in which you're going, the risk assessment, who's written it, who's done it? Do you have access to it? The team that you're going with who are they? And what kind of prescreening have they had the communications, you'll have the level of training um particularly of your other leaders and the medical kit that you'll take with you. So again, considering the environment that you're going to do, you really understand the environment, have you been there and had experience of it yourself? Do you understand the travel medicine needs the vaccinations or immunizations that you need to go there? This might also have implications on the risk assessment in terms of ascent profiles or acclimatizing to both heat and cold. Um You also then need to think about communications. We've become very reliant on mobile phones. Um And fantastic though, it is that we can get mobile phone signal um across most of the world. Now, we really shouldn't consider this um as our only means of communication. So you then need to think of what is your emergency backup. Are you gonna take an inreach a GPS device? Sat phones and then considering that some expeditions that you might go to or places that you will cover um that sat phones and mobile phone signal is banned uh by either the government or military law. So you may have to get permission to use something like a yellow brick in order for your emergency communications. Then thinking of the medical kits that you're gonna take, who's gonna put this together? Who's gonna be responsible for it? Are you gonna take prescription only medicines. Do you have training in these? Do you have governance process in order to use these? Do you have a checklist for which to give these drugs by? Are you taking medical equipment that you're familiar with using? And a toolkit that you're happy um with taking? You also need to think about uh how you're going to package this kit. Are your drugs going to be safe in the cold or in the heat? Are you going to a wet environment? If we think back to that kayak expedition in Namibia, um your medical kit needs to be robustly waterproof. Are you gonna carry a dental kit? Do you have experience in doing any dental work or do you, are you gonna suggest that all your participants get a dental health check before they go? These are all things that need to be considered prior to your departure in terms of the risk assessments, pre departure. I would strongly advocate that you as the medic. Um get to see these risk assessments and get some input into them. Again, this might be ascent profiles for altitude trips, level of work or tracking done during a heat um expedition or a jungle expedition or considering um preventative of cold injuries and non freezing cold injuries if you're going to a polar or cold environment. Um Again, what kind of uh tech or infrastructure are you gonna have on board? This was a picture from Antarctica where we had two subs on board many zodiacs and a helicopter. So lots of high tech um heavy equipment buzzing around all at the same time, which could have had high implications for a major trauma event. So again, just looking at the risk assessment of that um was really important, we've talked about level of training. Obviously, you are now doing this wilderness first responder course. So you're taking your medical training quite seriously. But what other training have the rest of the team? Have your other leaders? What training would you advise? And do you have if you don't have a medical doctor with you, do you need to consider taking one or do you have a reach back service or top cover service where you have access to um a doctor on telemedicine? Um And if so does that reach back service, do they have both the clinical and environmental competency to answer questions when you need it? Uh You then need to consider the team that's going on your expedition. Are you taking a highly trained team that has been to this place before? Are you taking a group of young adults? Um or young people away the implications that that carries? Um Are they just gonna be a bunch of muppets? You may not know that until you arrive on the team. Um Are you taking uh high net worth individuals or high profile individuals? Er although this shouldn't make a difference to your expedition, it does and in some cases, it makes a significant difference to the insurance that you need as well. So just something to bear that in mind, you also need to consider the predeparture medical screening, both for your leaders and the participants going when in discussion with leaders and clients coming on expedition, we actually like to call this form a supporting you form rather than predeparture medical screening, mainly because of the amount of non disclosure that goes along uh with medical screening. And we like to sell this as an opportunity to work with the clients um to get the most successful time they can have on the expedition and to work with them in the build up to ensure that they go away both medically and physically fit. So it's really using this form to then open up a relationship um with your clients with your leaders to look at. Are they safe to go on that expedition now? And if not, is this something that can be modified to ensure? Like I've said that they are both medically and physically fit? So again, this is a document, this is one version of a document that on endeavor, there are others. Um And you can have this in your pre course documents um as a PDF and you're very welcome to use this. But either way, what I would do is I would urge you to discuss with your companies, what kind of medical prescreening they do? Everyone should be doing some form of prescreening who it is, who looks at these forms and who actions it um I wouldn't have said it's necessarily fair to ask your average GP if a client is fit or well enough to summit Everest or go to Island Peak or do a diving expedition. If that GP doesn't have experience of altitude dive or heat environment, they're unlikely to be able to know whether that patient um is going in that kind of extreme environment. So in this case, it would be a question of you as the expedition medic working alongside either the GP or preferably the hospital specialist to discuss that in an open conversation with your client and say, how can we ensure that your condition, whether it's mental or physical um is optimized prior to your departure, moving on to the expedition phase um of expedition medical planning. If you now consider that you are on expedition, what kind of things do you think you need to think about whilst on expedition while on the checklist? These are the things that we've written down is the equitable healthcare, public health and hygiene, the culture that you're gonna instill on expedition documentation that we've talked about your evacuation procedures. Should you get a worst case scenario? And again thinking about that medical kit now it's out there with you on expedition. So equitable healthcare who provides the healthcare for your porters or in country team? And do they have the same access to healthcare. Should you get someone who have a fractured femur? Are they gonna have to walk down the mountain side on the donkey or are they gonna be jetted out of there? And is this equitable, is this ethical during your expedition? Public health is absolutely essential to keep everyone physically and mentally fit whilst on expedition. And it would be your job as the medic to instill public health procedures and education. Whilst you're away, think about those human factors in camp, make it very easy for hygiene to happen, particularly in and around camp around the kitchens and around the toilets don't make people have to walk to go and find their hand sanitizer or hand washing facilities. So think of those human factors you can put in place to make sure systems are easy to prevent infectious diseases occurring. Whilst you're on expedition, make sure that you get involved with looking at the kitchen hygiene, the food and water sanitation while you're while you're away. And if you're in a tropical place, thinking about bite prevention and again, the human factor is maybe everyone takes their malarial pills at breakfast time. So everyone does it together or you remind everyone to go and put er long trousers, long sleeves on in the evening. But that job will fall to you uh as the medic and then culture and mental health wellbeing is exceptionally important, particularly on long expeditions. Well on any expedition and it should fall to all members of the team, particularly the leadership team and particularly you as the medic to ensure that you are responsible for maintaining people's wellbeing in the best possible place they can be. And a good way to do that is to make sure that you have a good expedition culture right from the start. So thinking about how you're gonna do that, whether that's with regular check ins daily briefs, um small games or making sure that people have a buddy system, there's many different ways to do this but making sure that you can really have um great mental health and a good culture whilst you're away on trips will ensure that your expedition is successful. And again, as the medic on the expedition, just remember that your biggest threat is actually from ourselves is from humans. So remember the human factors and heuristics trap on any expedition that you're doing, um make sure that you create systems in place so that mistakes don't happen. Um And that you can have a smooth running trip once you've completed a successful expedition and you've come home, your expedition, medical planning should include an element of post expedition in the post expedition aspect. You should consider the debrief with your leaders and with your group, you should consider the follow up and resurgent disease. That might be possible. Who's gonna write the medical report and who's gonna look after the medical kit once it gets back ensure that it's returned to where it needs to be and any stock up is done. So again, thinking on return, the debrief and reporting is really important. Who are you reporting to? Is there a culture in the organization of being able to report and learn from near misses and who's gonna document these? Um Have you done your travel medicine? Well, be remembering on the preexpedition phase. Have you talked about travel health? And is your team aware of any possible resurgent disease and how or where to get help for this on return? And again, like I mentioned with the medical kit, does it get disposed of? Does it get reused? Who do you hand it on to? What protocols are there for disposing of out of date drugs? Um Does this company have protocols in place for doing this? How are you gonna restock and how are you gonna document what you've used? Um And remembering that your own documentation of anything that has taken place whilst on expedition needs to be held securely in a um secure file or folder or even a lockbox um for GDPR regulations, at least for up to 10 years I would suggest. So the final part of the checklist, we look a little bit more about ethics and sustainability and I think it seems like this, that every one of us watching this lecture would probably rather not see. And I think the question is how can we play our part. Um are these third world sites of beauty that we're going to visit in many places or are they first world playgrounds? So I would urge you to ask as a leader or as the medic to really think about what is the true purpose and necessity of your expedition? Are you doing an impact assessment? Is there reporting? What is, what are you bringing back from this trip? And how can you improve? And does the purpose of the expedition meet ethical and sustainable guidance, both on national and international levels or even on your personal and moral guidance? There may be no right answer to this, but I feel it's something that we all need to think about and certainly in working with companies questioning them, how can we be more sustainable? Is this really ethically correct to be doing this on expedition? But just having those questions in the back of your mind and feeling empowered to be able to ask them. So, thanks very much for listening to that talk. If you have any questions, then please do get in touch with me either on email or ask the course directors um during the WFR practical part of the course and just a few take home messages. Then from er this talk is just remember that your expedition, medical planning is absolutely essential. There's considerations during the pre during and post part of the expedition and these considerations will have legal, ethical and financial implications. Risk is very personal and it's expedition specific. And please remember the importance of good documentation and utmost on any expedition. Make sure that you instill a culture that you'd like to be part of. Thank you all very much for listening and enjoy the rest of the course.