Intensive Care and Expedition Medicine - the perfect combination?

“Doc, doc, this is the captain. We need you back on the ship asap for a medical emergency” 

I’ve been working in expedition medicine for nine years and last year was the first time I was asked to deal with an emergency. I grabbed my bag packed with IV medications, defibrillator, scalpel, and various tubes, and jogged back to the beach to be shuttled to the ship with a certain amount of trepidation. My NHS work is as an ITU consultant in Birmingham, and like many emergency calls in the public areas of various hospitals over the years, this fortunately wasn’t one either. Someone had twisted an ankle. Put that laryngoscope down. Looks like I might get to a decade of this without an emergency after all. 

If any of you have the impression that expedition medicine is centred around a carrying a bag full of kit, prepared to perform an emergency cricothyroidotomy at advanced base camp on Kangchenjunga, then I’m afraid this blog might be a little disappointing. However, despite it paying well below minimum wage, I do find it both enjoyable and challenging enough to commit a reasonable proportion of my spare time. If you would like to find out why, read on! 

Worst days and best days 

To ground myself, I often say that my job in critical care is about supporting people through the worst days of their lives. While it’s another day at the office for me, my patient’s families will remember it forever. How you handle yourself is… well, critical. I therefore find it helpful to choose a side hustle where I am supporting people through the best days of their lives, for a balance between yin and yang, as it were. 

Expedition medicine is about helping people to undertake balanced and educated risks. If there is no risk, there is no need for a medic. If I cancel a traveller’s expedition with manageable risks, I have undermined the point of my role. Much of my role, therefore, is not performing finger thoracostomies, but assessment and mitigation of risk, careful planning of resources, medication and evacuation options, and understanding of team dynamics and human factors. 

I have never cancelled someone’s trip. Several people have decided to cancel their own expeditions when I’ve explained the risks to the best of my understanding, including those to their health, finances, and impact on the group. That’s not to say I wouldn’t ever “put my foot down” but so far I’ve never found the need to. 

Communication with clientele 

I find it a good personal challenge, but one that I feel comfortable undertaking. I have had to consider the risks of someone with COPD climbing to altitude, someone with Raynaud’s syndrome going to Antarctica, someone with deranged LFTs heading out to Cambodia, and someone with type 1 diabetes exerting themselves considerably more than usual while not enjoying the local Peruvian cuisine. All of these are situations I’ve managed, but even that isn’t the bulk of the work of an expedition doctor. 

Most of the work of an expedition doctor is to be available, approachable and flexible. Everyone wants something different from you. Some want you to be the pinnacle of professionalism, while others won’t stop trying to ply you with beers despite your constant reminder that they hardly want a drunk doctor in an emergency. Some want you to be able to ‘just fix it’, while others want you to give them an excuse to abandon the trip and go home while covered by insurance. Some hide significant injuries, while others won’t stop going on about their decade-long symptoms of arthritis. The bulk of the work, in my opinion, is communication. 

To evacuate or to not evacuate? 

Back to the ‘emergency’ – I returned to the ship, a 3400 ton merchant vessel, currently anchored near Parryøya, North of Svalbard and deep in the Arctic circle. Shortly afterwards, the patient was delivered by winch from their zodiac. The medical assessment in these situations tends to be the easy bit – she was non-weight bearing on a swollen ankle with medial malleolar tenderness. I could manage immobilisation, but a radiograph was indicated. With the nearest x-ray facility a few hours away by helicopter, risk assessment and communication skills become essential again.  

The risks of evacuation?  

• The end of her holiday, the disruption of 150 other people’s holidays, the consumption of limited local resources, the disturbance of endangered wildlife… not to mention the usual list of transfer risks we quote in our postgraduate medical examinations.  

The risks of remaining on board?  

• An unhappy immobile patient, improper fracture alignment, delay to possible surgery, potentially a higher risk of venous thromboembolism.  

The decision between these choices requires involvement of the patient, the company, the master of the ship, perhaps a second medical opinion over the radio if available, all while maintaining a degree of confidentiality. 

To this day, I don’t know if there was a fracture or not, but I don’t believe this is important. The challenge is to work with limited resources and limited information and do the best you can at the time. She remained on board with my perhaps sub-par below knee backslab, the Dutch maritime choice of low molecular weight heparin, meal service to her room, and a daily medical appointment, at least in part as a form of entertainment for the now bored patient. 

I touched on why Expedition Medicine is a worthy secondary specialty to support a career in Intensive Care Medicine. Similarly, I think Intensive Care Medicine is a perfect specialty to support Expedition Medicine. In no uncertain terms, the volume of practice in Expedition Medicine alone is insufficient to keep one’s emergency clinical skills up. While I wouldn’t consider resuscitative thoracotomy skills to be needed for any expedition, the ability to manage major medical and surgical cases is, and work in Intensive Care provides for this. And given that the majority of the rest of an Intensive Care Consultant’s job is communication and balancing of risks, we might just make the best expedition medics. 

Email: Jonathan.Messing@uhb.nhs.uk 

Instagram: @jonadventuremedic