Tropical Medicine - James Moore
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Good morning or Good afternoon. My name's James More. I'm the director of the International Diploma in Expedition and Wilderness Medicine and also the Director of the Extra Travel Clinic. And I'm here to give you a talk on tropical medicine and a brief guide to how it works as an expedition medic when you work in the tropics, particularly in the jungles. So the session outline will be as follows. We're going to look but some vaccine preventable diseases. Uh This is just a quick overview of some of the more pertinent vaccine preventable diseases. And it's not an in depth look into vaccine preventable diseases, but just the ones that I think are important. When it relates to working in the tropics, we're going to look at some key non vaccine preventable diseases. And then finally working as a medic in the jungle, some a few hints and tips and I look at medical kits, etcetera. So to begin with vaccine preventable illnesses, I have a three stage approach when considering vaccine preventable disease, when assessing people for travel overseas. The first thing I do is I check people's childhood vaccinations. Are they up to date? Have they had all the vaccines that they are supposed to do as a child or young person. Secondly, I'd look at the essential vaccines and these are vaccines that I consider particularly important for the environment that they're going into. And then finally I'd look at optional vaccines and these are ones that may be useful depending on the individual, their activities, how long they're away for? So, childhood vaccinations uh in the UK, we have a very, very comprehensive childhood vaccination schedule, which now includes hepatitis B as you get to your teenage years, they include H B B and meningitis A C W Y. So it's important that any team member has gone up to date with all of their childhood vaccinations are pertinent for them, then we move on to essential vaccinations. So the first one, I'm going to talk about his hepatitis A. This is a disease that is spread by dirty food and water. And there's plenty of that around in the tropics. It has an incubation period of between two and six weeks and similar symptoms to flu uh plus some gastric symptoms. And of course, jaundice, the vaccination is incredibly effective. The first vaccination provides between one and five years' worth of cover. And if you have a second vaccination, that time it provides over 25 years cover, it's a very, very effective vaccination. Typhoid is also spread by dirty food and water has an incubator in period of between 7 to 7 days to two weeks. Uh The symptoms are abdominal pain, nausea, diarrhea, fever, it can be treated with antibiotics and the vaccine last for three years. It's important to note that the level of cover provided by the vaccine really does drop off in the last of those three years. So it may be for a high risk individual, they get their booster or they're re vaccination, mother slightly earlier and then finally on the essential vaccinations, I will pop in tetanus diphtheria polio. This is part of the childhood schedule and most people have had their five jabs don't require another one. But sometimes when you're traveling to certain countries, a tetanus booster is quite useful. If you've not had one for 10 years, we then move on to some of the recommended vaccinations. Hepatitis B is healthcare workers. You should all be vaccinated against hepatitis B. Some of the people on your expedition may not have been vaccinated against hepatitis B. Now, the most common way nowadays of getting Hepatitis B is through unsafe medical treatment. So that involves going into hospital perhaps in auroral clinic where they don't have the facilities or clean facilities and you end up having injections or medical treatment with equipment that has not been sterilized. And it's not uncommon around the world to have injections with needles that have been used on someone else. So we find that hard to believe in the UK, but certainly in places across the world where they do not have access to clean needles, needles get used on more than one person. And this is the biggest cause of viral Hepatitis B transmission. You can also get it from things like unsafe sex injecting where needles, tattoos and piercings. But all of those activities should be avoidable on an expedition. There are three main schedules for Hepatitis B. You can have a very rapid schedule if you're over the age of 16 on days, 07 and 21 plus an extra one. At 12 months, you can have a standard schedule which is delivered on months, +01 and two and an elongated schedule which is on months, not one and six. When it comes to boosters, the boosting times are about to change. But at risk, individuals would have a single booster in about five years and that's it. You don't need another one. Travelers really don't require a booster if they've had their primary course, unless they're at high risk. Next, on the list of recommended vaccines would be rabies. Rabies is an acute encephalitis caused by a rabies virus. There are furious and paralytic types of rabies and the incubation period varies between 20 and 60 days. However, there is quite a range here and some people have become symptomatic in five days and other people have taken several years to become symptomatic. The issue with rabies is that once you are symptomatic, you will die. So it has pretty much we can consider it to have 100% fatality rate, give or take. But the rules are that basically, if you become symptomatic, you're not going to survive and rabies is present across the globe. One person dies of Brady's about every 10 minutes somewhere in the world. And it's a particularly nasty disease to die from to rabies is present every, pretty much everywhere. Some places will have it in their furry animals. So dogs, bats, cats, monkeys, other places might be rangoon's and some places, it's just uh, animals such as bats. Now, the rabies vaccine is not quite like other vaccines and it doesn't give you 100% covered. You still need to have some following treatment where you to be bitten. So if you have your three vaccines before travel and you get bitten by an animal or scratched by an animal or licked in a wound, you need to go to hospital after washing the wound out and receive another two vaccinations. And you've got three days to get those vaccines in. If you travel unvaccinated and get bitten, scratched or licked by an animal on a wound, then you would need to have four vaccines over a couple of weeks plus something called rabies immunoglobulin. And you would need to have the rabies immunoglobulin on the first day and rabies immunoglobulin is very hard to find. It's in short supply. So you'll be hunting around for that and there's a very good chance in some parts of the world, you'd have to have to leave the country to get that rabies immunoglobulin. So, having the vaccines before you go traveling drastically improves your chances of success. Were you to be bitten by an animal? The schedule for rabies is given on the vaccines given on days nor seven and either 21 or 28 days or, nor three and seven days with the 12 month additional jab. If you really don't have any time, the World Health Organization have a really good schedule, which is two intradermal vaccines or two intramuscular injections given on days nought and day seven. And that's particularly effective at the moment. The boosters are for people who are at high risk. So those people working with animals would have a booster at one year and then 3 to 5 yearly depending on their antibody levels and high risk travelers perhaps would only need one booster at a year. And that's it. Is this a real problem on expedition? Well, rabies and travelers is actually incredibly rare. The chances of you getting rabies on expedition are very, very slim. However, the chances of being bitten aren't that slim. This is a picture taken on an expedition. I went out to Nepal with a school group and one evening came out of my room to some shouts and screams by the kids were on expedition with and learn behold this bat was flying up and down outside all of the rooms getting completely confused with the cacophony that was going on. Now, that bat may want have been perfectly healthy. We don't know whether it was carrying rabies or like the virus, however, had it landed and bitten or scratched. One of the individuals on that expedition, the fallout from that would have been considerably because we had to have evacuated them to give, to get them to hospital, to get them to have an appropriate rabies vaccination. So, whilst the chance of it requiring rabies is quite slim, the knock on effects of either having a disease would be significant or that even the knock on effects of the treatment that you need afterwards is quite significant. Also, then finally, on the list of recommended vaccines for the tropics, we would consider Japanese encephalitis. This is a flu virus. It's found in man, pigs and birds. It's spread by the culex mosquito. It has an incubation period between five and 15 days and the symptoms include fever, malaise, headache, nausea, aseptic meningitis and it can progress to a meningioma encapsulitis. There is no specific treatment. It's supportive treatment. Only interestingly, 98% of infections are in a symptomatic and most people who get Japanese and capitalize ear's don't even know they've had it. However, of the 2% who are symptomatic. The outcome is particularly bad with 40% of those likely to die. Japanese encephalitis is found across Southeast Asia right down into Australia and in fact, there's been some uh other cases in Australia uh further south than that is illustrated on this map. So other areas of Australia are now seeing cases of Japanese encephalitis. The predominant host for Japanese encephalitis is pigs which are kept in Germany inr oral locations, mosquitoes by the pigs. And they can also spread it within waterfowl wading birds and then they can also spread it to humans. So what is the risk for us as travelers? Well, actually, it's as rare as rocking horse to do less than one in a million travelers gets Japanese encapsulitis. There's only been about 40 cases reported over the last 30 years in travelers. So it's a very, very low incidence for us. So therefore, bite avoidance measures are key. However, if you've got a team who are going out to work inr oral locations in Southeast Asia, perhaps in farming locations and they're out there for more than a month or they're going to struggle to take good care of their bite prevention methods. Then this is a vaccine that should be considered the schedule where Children can have it from two months to three years. They'd have a half dose and then Children from three years and above up through to adult age would get half a half a mil to a full dose on days north from 28. You can do a rapid schedule if you're at high risk patient leaving in that short time. Finally, we talk about yellow fever. So yellow fever is a mosquito borne flooded virus and it's found in Africa. Most of it's found in Africa, but also in South America. The symptoms for yellow fever are fever, chills, loss of appetite, nausea, muscle pains, headache and jaundice. Now it's gone under recommended or essential for a good reason. Some countries you have to have this vaccine before you go in and you're required to display that you've had it virus certificate. Other countries are less worried and we'll come back to the certification in the second. So sometimes it's essential, sometimes it's recommended. Uh and this will depend on your clinical risk and also the legality within country, whether you need it or not for the certificate, yellow fever uh coverage varies in countries depending on the topography of the country. Here are some examples from South America. This is Peru, Argentina and Brazil. You can see the northern part of Argentina there, the northeastern part of Argentina around the grass who falls that borders the area in Brazil which is covered with yellow fever. And this has been expanding over the last few years. Some maps in Africa, these are just a few maps demonstrate where you'll find yellow fever in Kenya, you won't find it in Tanzania. Uh And there's a tiny bit in Zambia, but it's, it's relatively rare in Zambia. So recommended or essential countries will either require a certificate. So if you travel to some countries in Africa, they will not let you in unless you can demonstrate that you've had a yellow fever vaccination and you do this by the yellow fever certificate. Other countries like the UK do not require a certificate. So it doesn't matter whether you come here from a yellow fever endemic area or not. We're not that fussed about whether you have a certificate or not predominant because we don't have the mosquito here is uh in sufficient numbers to spread this disease. Some countries will cry a certificate if you're coming from a risk eric. So if you were traveling from Kenya into Tanzania, you would have to have a certificate. You would have to demonstrate that you have been vaccinated against yellow fever. However, if you're flying directly into Tanzania, you wouldn't from the UK, you wouldn't need to have a certificate. So there's a little bit of detective work that has to go on before you have this vaccination. It's a single injection and it can be given from nine months upwards. You can give it earlier than that. If you, if the patient is that really high risk, it's a single jab it last for life. However, there are groups of people that we do provide boosters for as described here on this slide. But for most people, if you have one injection of yellow fever, it will last for life and your certificate should be accepted across the world. Now, there are contra indications to give them the yellow fever vaccination. These include people who are less than six months old. Those who have anaphylaxis to any component of the vaccine. Those people who have a thymus disorder or who have had a thymectomy, anyone with primary immunodeficiency or immuno suppression and those people over the age of 60 where yet the World Health Organization considers yellow fever to be of no risk. Also, those patient's who have a family history of a yellow fever reaction, either a viscerotropic disease or neurological disease. We wouldn't give the vaccine to those individuals. We will probably supply them if they're going to travel with an exemption certificate along with some really stringent information about the pros and cons of traveling to the yellow fever area without the benefit of having the vaccination. There are some key vaccine resources out there and the two most important ones for you. If you've got questions about vaccinations are these? The first is the green book it used to be have a green cover. Now it has a white cover with green writing that has all the information you need to know about any vaccines that we give here in the UK. And then secondly, Travel Health Pro, which is the National Travel Health Network and Center website. And there is a huge amount of information, not only about vaccinations on that website, but about most other tropical diseases that are likely to affect the travelers overseas. Of course, the most important disease in the tropics is malaria and it is very important to consider this when traveling on expedition to the tropics. Uh the name comes from Mall area, which is Italian for bad air. And it was because they thought that malaria is transmitted in the bad air that you found in around the swampy regions. And when the individuals moved up to the higher regions where the air was clearer, they didn't seem to get malaria, which seemed to make sense at the time, it wasn't until 18 80. Well, Charles Lavera in the French physician looked at malaria down in microscope and worked out that actually this thing is probably coming from an insect from a mosquito. In particular, malaria gets imported into the UK each year from people who travel overseas. The majority of the cases are plasmodium falciparum. And these, the majority of these cases are obtained by people who are going back to visit their friends and relations in countries where they perhaps grew up to say, for instance, you grew up in Uganda, you never took malaria tablets. When you were a child, you then fly here to the UK to live because you're not getting better and you're not exposed to malaria, you lose any immunity that you had growing up and you lose that very, very quickly. And then when you go home to see your relatives, you never took malaria tablets when you were a kid. So you're not going to take them now and you get malaria because you're not immune to it anymore. There are five species of the genus of malaria. P falciparum P five at Po Valley P malaria and penal. See, and they're all found in different or combination of places around the world. The last one penal c has found predominantly, well, all in Southeast Asia and it's quite a rare form of malaria. Malaria is spread by the know fleas mosquitoes. The female anopheles mosquito that spreads this disease. You can tell it's an anopheles because um bums sticking up in the air there as, as it's feeding, there are 460 species of anopheles, mosquito and 20 or 30 to 40 of these transmit malaria. It's a fascinating disease are really, really fascinating disease. Mosquitoes. The female mosquito bites to have a feeder. She lands start sucking up some of your blood and in the mosquito saliva. Uh there are these parasites and they go straight into your blood and they get to your liver within 20 minutes. They sit in your labor for seven days whilst they develop mature into shy zones. And after seven days, these burst out of your liver cells and into the bloodstream in the form of Merah's avoids these then circulate infecting other red blood cells in the form of trophies, avoids. There are also gametocyte. It's in these red blood cells and they get sucked up by the next mosquito who comes along to have a feed that these committees, sites go into the mosquito intestine where they develop an assist on the outside of the intestine or a stomach of the mosquito. These then burst and the little trapezoids get back into the sliver gland of the mosquito and enter the next person when she's having a feed. So, a fascinating cycle. What are the signs and symptoms? You're probably all familiar with the signs and symptoms of malaria, fever, wriggle sweats, headache, my algebra Malays, vomiting, mild watery, diarrhea, anemia, splenomegaly and mild jaundice backache is quite common symptom for people who have malaria. Those last three are the latter stages of malaria and they also you could include in their coma. How do you diagnose it? Well, clinically, you should always suspect malaria and anyone who's been in the tropics more than seven days and has those symptoms. The gold standard is in microscopy. You can use the rapid tests and we always keep a couple of rapid malaria tests in our first aid kits. But microscopy is the most important way for diagnosing, most accurate way of diagnosing malaria. And you need to remember with as with a lot of these diseases, they may crop up when you get home. So you may be a symptomatic for your time in a malaria zone, you get home and then all of a sudden malaria crops up and it can happen up to a year later. So your team should be prepared when they come home to keep an eye out for signs and symptoms of some of these tropical diseases. And should they arrive then should make sure that they tell the clinical professional, they go to see that they have been in a tropical location. We have A B CS for lots of things in medicine and that includes the prevention of malarious that a stands for awareness. Make sure the team are aware of the illness and they're aware of the signs and symptoms. They need to make sure they're aware of the risk and how their behavior affects the chances of acquisition by prevention. This is the most important part of your, your kind of prevention of malaria. Because if you don't get bitten, you don't get malaria and you don't get dengue and you don't get yellow fever and you don't get all the other diseases that are spread by biting insects. So make sure people are sleeping under treated bed nets, treat them with permethrin, which is different than a repellent. Deet is a repellent and you don't need anything more than 50% deep. Make sure that people that have most suitable clothes for working in the jungle, which includes long sleeves, particularly before dusk. Uh and long trousers. Make sure they have coils and sprays available. If you're working out of bigger rooms, I wouldn't use these in small tents, but certainly use coils and sprays in dormitories. And most importantly, perhaps you need to make sure the team's behavior is onboard with this. So make sure they put up their nets before it gets dark and that they're looking out for each other. The malaria guidance in the UK advises against these things. Herbal remedies, homeopathy that won't work, which we know. Buzzers, vitamin B one and vitamin B 12. There's no evidence for that garlic, no evidence for that marmite, no evidence for that. And it tastes disgusting. Tea tree oil that doesn't work either in preventing uh insect bites or malaria. In fact, the British homeopathic society have made a very sensible decision and put something on their website that says, please don't use homeopathy to prevent or treat malaria. They also have a very similar statement in relation to vaccinations as well. See, chemo prophylaxis, take your tablets regularly. So if you're a malaria zone, you'll be taking malaria, chemo prophylaxis. These need to be taken regularly as directed on the packet. Do not give your medication away. We've got plenty of incidences where people give their medication away because somebody's lost theirs and then they get malaria, do not buy a medication overseas. There are huge amounts of counterfeit medication which are sub therapeutic. Uh These should not be used when looking to prevent malaria or treat it and make sure you finish the course. The three main drugs we use for preventing malaria. A doctor cycling eight of a coin and program now of Malarone and mefloquine or Larry. In the latter is still a very, very good drug. It's effective in many, many areas of the world. There is some resistance to it in Southeast Asia and it does have those well reported psychiatric effects in certain individuals. However, there is still a place for it and the guidance from malaria prevention still keep this as an option for certain people. And then finally, the diagnosis, the shortest incubate in here from malaria is one week. So if somebody has a fever within seven days of being in country provided, they've not been anywhere else in the previous year. The chances are it's not going to be malaria, fever, sweats, nausea, headache, backache, joint pain, sometimes diarrhea and a cough. Those are the main symptoms. Fever is the big one and it can be an intermittent fever in some people as well. So every two days or every three days, these are the guidance that we would follow in the UK which you can access freely online. You need to remember that malaria can be rapidly fatal, particularly in those who are new visitors to the tropics. So malaria is not often considered an emergency in adults in the population living in that country. Whereas for visitors, it can be an emergency travel, health risks without vaccines. So a bunch of diseases which are important to consider, I've picked a few but there are huge numbers of diseases. I don't think it's appropriate to go into all of them. So I picked some of the main ones that might be at risk cause a risk to you and your team. The first of these is schistosomiasis. This is a helminth infection. There's 200 million people affected worldwide. 85% of these are in Africa. The three main forms just Manson. I just so many hemato be. Um and schistosoma japonica um found in different areas of the world. It has a fascinating life cycle that involves the disease starting in humans or it can start anywhere on this cycle starts in humans. And the humans pass the eggs out during, into the urine and they or feces into the water. The the eggs then hatch and the hatchlings of this disease get into snails, freshwater snails. This is a freshwater disease. They then mature within the sales in the snails and then they get out of the snails and then they swim around in the water until they find their host and other human host at which point they penetrate the skin. So they drill their way through the skin, they migrate through the body into the liver or into the bladder and the whole thing starts again. So a really fascinating uh disease. What are the symptoms of sister smart as well? Swimmer's itch would be the first symptoms some people may get and this is where individuals swimming in the water. And as this little security berries through the skin, it leaves a tiny, tiny, tiny, perhaps red dot might not even be visible but a little itchy point on the skin over 2 to 3 week incubation period. Some people are a symptomatic during this time and then you have a symptomatic phase where people might have a fever, they might get tired, they might have a rash, they might have a raised eosinophilia, cough, diarrhea, weight loss, immature, your headaches, joint and muscle pain, hepatomegaly and splenomegaly. Not all of these symptoms appear, I had just, just the some ice and I managed to pick it up in Malawi, swimming in Cape mclear and they reckon if you swim in Cape mclear for about 20 minutes, monkey bay for about 20 minutes in Malawi, you've got a 50% chance of getting schistosomiasis. And I had a really annoying non productive particularly cough that just would not go. So it was diagnosed, you're using urine still microscopy and then treated with some praziquantel, which is basically a big worming tablet, horse sized worming tablet and it works very, very well. You can treat people too early. Those it's important to know people shouldn't be treated within two months of exposure because it may not be affected. Effective. Next on the list of nasties is leishmaniasis spread by the sand, fly, sand, flies live in the bricks of the muddy bricks of buildings and the ground they don't live in sand. Interestingly, there are two forms cutaneous or visceral leishmaniasis and it's the second largest parasitic killer after malaria. There are 1.5 to 2 million new cases each year. Over 90% of the cases of visceral leishmaniasis. The more serious form are found in India, Bangladesh, Nepal, Sudan and Brazil. And these are all areas where 1 may go on expedition. There are also cases in Northern Argentina reaching right up to southern Texas. It's found in Asia, the Middle East Africa and we're seeing increasing numbers around the borders of the Mediterranean as well. In a number of cases that have cropped up in northern from people who have visited northern uh southern Spain cutaneous leishmaniasis. Uh the mechanism of transfers via the sand flyers. I've already said they get into the skin, they get into the macrophages and replicate interest steadily. You then after a couple of weeks or months get a little lesion which then turns into this nasty little krater, this ulcer and the diagnosis by taking a little snip, a biopsy of the border of that krater. The treatment is species specific and for something like this, both cutaneous and visual leishmaniasis, you will need to see a specialist that discuss this with a specialist microbiologist, visceral leishmaniasis. It's the same mechanism get bitten by a sound fly. Um The, the Cinryze then invade human macrophages and replicates intracellular e these rupture and they target the liver and the spleen. Let me see this picture here. This kid with splenomegaly symptoms of fever and splenomegaly. And the treatment is amphotericin B or pentavalent Antam in ALS and there is a level of resistance to this. It's a very, very nasty disease uh that in some areas will be a greater risk to use. An expedition team. Dengue is present across the tropics. It's spread by the Aedes mosquito. The daytime biting mosquito is a flavor virus, same as yellow fever, the same family as yellow fever. There are five stereotypes has a 3 to 14 day incubation period. The symptoms are high fever, headache, vomiting, muscle and joint pain, skin rash, bleeding and shock. And that's the dengue hemorrhagic fever. There's no particular treatment for this. But if you do get dengue and you survive, you have long term immunity from that particular serotype. So you're not immune to all of them, you're just particular, you're immune to the one that you had. It also means however, that if you get one of the other four types as an increased risk of having a more serious reaction to the disease, there is a Dengue vaccine that's now available in several countries and we'll probably see that available here in the UK at some point. So how does this impact your role as a medic? Well, for our borough viruses, it's simple. If you don't get bitter, you can't get the disease. Therefore, this is a health promotion issue which means you as a medic need to make sure that not only are you looking after your own uh Asman as it were when it comes to bite prevention. But you need to make sure the whole team buy into this issue of bed nets, appropriate clothing, insect repellants and making sure that the whole group behavior is such that they're all looking out for each other and trying to prevent themselves and their colleagues from getting these diseases. We tend not to focus on individual of, of oral virus information in the clinic because our clients, our patient's, it would just go in one ear and out the other. If you start talking about all the different types of viruses, what's much more important and much more effective is that you focus on not getting bitter because if you don't get bitten, you can't get any of these other diseases. Of course, not everything is spread by bites of insects, mosquitoes or sand flies. So you need particular skills in order to prevent these in the tropics. And these include risk management skills. This is about you as a medic understanding the risks that things pose whilst in the tropics and some of these risks are specific to the tropics. Some of them are generic across lots of different expeditions. You also have to understand. Do you have your the right human behavior and knowledge to change the behavior of the individuals on your trip? Have you got the communication skills to make sure that people stick to the guidance that you're providing and they understand why they need to stick to it. And at the end of the day, have you got the experience, you need to make sure you've got experience of working in this environment because it is a very specialist environment that takes a lot of effort. So what's so special about the jungle environment? Well, it's nice and warm. It's rarely less than 27 degrees. It has high levels of humidity, 80 to 90%. This is important when we consider heat related disorders because we know that sweating ceases to be effective as a manner of cooling you down. When humidity is running at 80 to 90% it just doesn't work. So situations such as exercise, associated hyponatremia and other heat disorders are real problem. The average rainfall in the rainforest is about 2 m a year in Cardiff. Just to put this into context in Wales, the average is about a meter a year. So rains twice as much as it does in Cardiff and it rains for 300 days a year, which is more than Cardiff. And when it rains, it also reigns incredibly hard. It rained so hard that you can't sometimes have a conversation with a person next to you because of the level of water that's pouring out of the sky. The terrain is often very difficult to navigate in and it's very difficult to walk over. It has this micro topography which is quite extreme, so short and sharp ups and downs and it's also very can be quite cold at night, especially when you're slightly higher. So some of the jungles are in cloud forest and that makes them cooler in the evenings. This is where you find tropical forests across the globe and I've separated the jungle into three main types. You've got primary jungle which is undisturbed or unlocked. It has three canopy levels. So at 10, 20 and 50 m and maybe higher and there's less vegetation near the ground. Secondary jungle has been altered either by nature or by man. And this has allowed light to come in which makes the ground just spurt new bushes and you get rapid growth of pioneer species of creepers, vines and parts very, very poor visibility and very slow progress in secondary jungle. And then finally, you've got s Tareen jungle or tropical forests which are in blood flames, they might include mangrove swamps, they're hot, muddy, full of insects and best avoided. These are very, very difficult to live and move in. So this is primary jungle. You can see there's lots of space on the on the floor. You've got some creeping vines there on the floor and roots, but easy to navigate through secondary jungle. Very hard, very different story to get through that. It's incredibly difficult. And if anybody thinks that they are going to hack their way through a jungle in some Indiana Jones S manner, they are sorely mistaken. It would take a huge amounts of energy to go a very small distance. Indeed. This is a mangrove swamp estuary, tropical nasty place, which would be virtually impossible to get through any rate and certainly very impossible to live in something like this. You know, where to put your hammock up? Really? What are your other features of being in a jungle? Well, 12 hour cycles of day, daylight and nighttime and it gets dark very, very quickly. Rivers of water rays are really significant hazards and not just if it's raining near you, sometimes it can rain 10 or 20 miles away and it'll affect the river where you are. There is a huge diversity in the animal and plant life, which is what we'd expect and this constant and rapid change, it's never staying still. There's always something going on in the jungle. There also may be little light under the canopy. It makes it quite dark during the day. It makes it pitch black at night. You cannot navigate very easily at night. Even with a torch, it's very, very difficult to move around at night under the canopy. And this can have an effect on one's psychology when working in the jungle. However, without doubt, the jungle is a magical place to be. It's full of life. It is amazing place to work. But to work in the jungle, you do need specific skills. The first set of these skills involves your ability to just to live and function. So that involves camp craft, what we call camp craft. So how do you know where to put your hammer cup? How do you, can you construct a hammock and your bashers? Your basher is your shelter? Do you know how to put a basher up? What about your health and hygiene? How do you stay healthy yourself in the jungle? And how do you make sure you stay clean and tidy in the jungle? It takes a lot of effort to do that fire and cooking. Can you cook on an open fire? We tend to cook on open fires in the jungle because there's plenty of would it makes life a lot easier. But when was the last time you cooked on an open fire? And are you used to cooking on an open fire? Navigation? Navigation in the jungle is particularly difficult because of the micro topography because you cannot see where you're going. And the map quality is generally quite poor or at a large scale. Do you know how to use your equipment? Particularly a knife? It's incredibly important in the jungle to have a decent machete and a decent knife. If you don't know how to use it properly and those around, you don't know how to use a knife properly. You're going to end up spending time stitching people back together. What are the animal hazards in your particular jungle that you've chosen to go to? These vary greatly across the board. But uh you need to do your homework when it comes to disappearing into the jungle to find out exactly what the problem is going to be. And that might be knowing about the bigger animals or the reptiles or a combination of two. So, are the, what are the significant snakes or poisoning other poisonous animals in the jungle that you're going to go to? And how are you going to deal with those issues? Now, working as a medic in the jungle can only really start in any successful way once you've got all of those other skills honed and you're comfortable working in that jungle. If you can't look after yourself, you will not be able to care for others. If you're not comfortable in that environment. If you're not able to put up a hammock in the dark and be happy doing that, you'll struggle to look after other people in the jungle. When you need to in an emergency, it takes a huge amount of effort to uh to live comfortably in the jungle if you're not used to it. And if you spend 5% extra effort, you'll get 20% extra comfort. Just that little bit of extra effort makes a huge difference. And when you're providing care, you need to be kit confident. So no, your kit and know how to use it, know where it is, you know how to use it with your eyes closed in many situations. Remember, you're not going to have great light sometimes. So you need to know where everything is and you can put your hand out and grab what you need when you need it. I would also suggest as a medic, you have a larger than normal basher, so larger than normal shelter. This means that if you have to do something to a patient underneath, when it's raining, you've got space to move around, you can do dressings, you can apply bandages, you can do some observations uh or speak and consult with a patient in the comfort of a slightly larger basher. If you've got a tiny basher and it's raining your struggle to do anything of any use. I'd also say take an umbrella, you just need a small umbrella. But it makes a big difference when you're walking from Hammock to Hammock. When the rain is coming out of the sky jungle medical kits uh take a little bit of putting together, there's some practicalities and that they need to be really robust and waterproof. You need to make sure that uh they are put together well and that they're not going to fall apart that you can't have an off the shelf medical kit. Really. It has to be made specifically for the jungle and kept really well. You need to spend extra special care and attention to your medical kit to make sure it doesn't fall apart. All the labels will get damp and the labels will come unstuck and they fall apart in the packaging will just tear. So you need to look after it a lot, minimize access. If you're going I/O of the kit 10 times an hour, it's all going to fall apart. So make sure you only go into the medical kit when you need to and you might want to consider a smaller, more accessible kit for regular use. So the tops picture here is my main kit that I use when overseas. And then I've got a little tiny one that sits within my medical kit, which I've read together, which is in my bag. Rather my rucksack, which I get out more frequently, have a dedicated clinic time and most problems can be seen either first thing in the morning or last thing an evening. And this means that you're not getting a medical kit out of the time. Really mention about basher and net size and location. Make sure that you've got space to see who you need to see in your clinic and encourage self care if people are going to look after themselves at home. There's no reason why they can't look after themselves on expedition and just call on you when they're a little bit out of their depth and finally make sure you have got lots of light because it does get very dark underneath the canopy, particularly at night. This is not an exhaustive list, but at a few things that I would make sure that I had in my Jungle medical kit. So zinc oxide tape is fabulous, really tight and really sticky uh fabric plasters, stripped rather than lots of little individual plasters. I take some iodine or Betadine. Uh It takes some Friars Bolson. This is an old school technique. But if you put some Friars balsam on your skin, it goes really, really tacky. And then if you're using steri strips, the steri strips seem to stick a lot better. I have a suture kit. I also keep super glue in my first take it because that's fabulous thing for closing wounds. All rehydration sachets. I have lots of those particularly need to consider this in relation to exercise associated hyponatremia, extra torches extra deep from a medicine point of view. I have antipyretic six. I have analgesia. I have antifungal creams and powders. I have antibiotics, uh anti histamines and tiger balm have no, uh just come back to that. I have no evidence for Tiger Farm. Other than my own personal preference. It's the best thing for taking the itch away from a mosquito bite. It's fabulous stuff. It works far better as far as I'm concerned that anti histamines. So to conclude with working in the tropics can be hard, but it is incredibly rewarding. You really do need to be confident in your administration, your personal administration, keeping clean and tidy, you need to be confident in your kit knowing how to use it and you need to be confident in your individual ability to function within that environment. Please make sure that a little bit of extra effort makes a huge amount of extra comfort. And remember you're just part of the food chain. It's not personal. You will get bitten and scratch whilst you're in the jungle. It's just part and parcel of living in that environment. You will be wet and damp for most of the time, particularly really humid jungles. It's just a state of mind. Nobody's kind of come unstuck too badly by just being a little bit sweaty every now and then. It is an amazing place to work as an expedition, but it will really, really push you as an expedition medic. But without doubt, it's one of the most rewarding places to work. So, thank you for listening. I hope that's been useful. If you have any questions, please do direct them towards Lucy and she can bring them on to me and I'll be happy to answer them.