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									Jagged Globe / Adventureworks Expedition Medical Protocols




 Expedition Medical Protocols Booklet




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                                    Contents


Introduction and Medical Advisors                          4
Altitude Fact Sheet                                        6
UIAA Field Management of AMS, HAPE
and HACE Fact Sheet                                        7
UIAA Portable Hyperbaric Chambers                         17
Analgesics Fact Sheet and Protocols                       22
Tramadol Protocol                                         24
Diarrhoea & Vomiting Protocol                             27
Asthma Advice                                             29
Asthma Treatment Protocol                                 31
Diabetes Protocol                                         33
Antibiotics Protocol                                      39
Diazepam Protocol                                         42
Antihistamines Protocol                                   44
Aspirin Protocol                                          45
Frostbite Protocol                                        46
Cuts & Wounds Protocol                                    49
General Bites Protocol                                    51
Rabies Prevention Protocol                                53
Snake Bites Protocol                                      55
Urinary Catheter Protocol                                 56
Rectal Fluids Protocol                                    58
Sex on Expeditions Advice                                 60
Deep Vein Thrombosis Advice                               64
The Doctors Dilemma                                       65
Calling For Medical Advice                                67
Medical Kit List – Jagged Globe                           70
Additional Drugs – 8000m Expeditions                      72
Additional Equip – 8000m Expeditions                      73
Medical Kit List – Adventureworks                         74
Casualty Assessment Card                                  76




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Introduction
Dr David Hillebrandt, our company doctor, has written these notes to help leaders
(& clients) understand more about the guidelines for administering drugs and
treating medical conditions that they may encounter on an expedition.

Many of the drugs mentioned in this booklet can be found in the Jagged
Globe/Adventureworks medical kits, together with an inventory of the amounts of
each drug supplied. Leaders MUST complete the inventory when any drug or
equipment is used from the stock. This is to ensure that stocks are replaced prior
to each trip. In addition a written first aid report must be submitted with the trip
report whenever drugs are administered.

This booklet is not designed to be comprehensive but when combined with Jim
Duff’s remote area first aid book which is also in the medical kit guidance for
most situations and drugs should be available. Drugs supplied in the medical kits
can be divided into two types. Those available to the public in the UK over the
counter (OTC) from a pharmacist and those that are only available in the UK on
prescription (POM). In the case of prescription only medication it is particularly
important that you follow these guidelines.

All clients will have filled in a medical screening form prior to departure and in the
event of any medical problems these should be used in conjunction with any
specific patient notes provided by the company doctor.

In an emergency it may be possible to obtain further advice from the company
doctors but this may take considerable time and communications may not be
reliable.

PRIOR READING

It is strongly recommended that you familiarise yourself with these notes and Jim
Duff’s book prior to departure. In addition the following websites have useful
medical sections:
UIAA: www.theuiaa.org
BMC: www.thebmc.co.uk
CIWEC Clinic Kathmandu: www.ciwec-clinic.com
Medex Down loadable booklet : www.medex.org.uk

Also Pollard and Murdock’s book ‘High Altitude Handbook’ gives excellent
background information for the layman.



Medical Advisor                 Medical Advisor                  Frostbite Specialist
Dr David Hillebrandt            Dr Paul Richards                 Dr Chris Imray
Derriton House                  The Surgery and Travel Clinic,   Consultant General & Vascular
Derriton,                       64 London Road,                  Surgeon,
Holsworthy,                     Wickford,                        Coventry & Warwickshire
Devon,                          Essex,                           County Vascular Unit,
EX22 6JX                        SS12 0AN                         Clifford Bridge Road,
                                                                 Coventry,
                                                                 CV2 2DX
Home: 01409 253 814             Work: 01268 568 240              Work: 02476 602 020 Ext 8944
Mobile: 07811 998 245           Mobile: 07715 104 796
Email:                          Email: paul@medex.org.uk         Email: chrisimray@aol.com
hillebrandt@freenetname.co.uk




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                 Altitude Illness




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Draft Three. 8/1/05 Reviewed 20/1/09Dr David Hillebrandt. Medical Advisor to Jagged Globe. dh@hillebrandt.org.uk .




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Taken from the UIAA Website – Original articles co-written by David Hillebrant.




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Portable Hyperbaric Chambers




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                               ANALGESICS


Introduction

I dislike pain, it hurts.

There are a variety of drugs available to cope with different types and degrees of
pain. These are Pharmacological treatments BUT

Don't forget to treat the cause e.g. rehydration for some headaches, foot care for
blisters, antibiotics for infections.

Don't forget very valuable additional treatments. Physical treatments such as ice
packs for muscle strains, splints for fractures, massage &/or an improvised hot
water bottle for backache, oral fluids for urinary infections. Psychological
treatment, most importantly the power of confident reassurance.

Medical Kit Contents

The Jagged Globe medical kit contains the following painkillers (analgesics) listed
in order of approximate increasing strength:

1) Paracetamol 500mg tabs (UK), Acetaminophen (international), Tylenol (US
trade name). OTC

2) Ibuprofen 400mg tabs OTC

3) Codeine Phosphate 15mg tabs POM

4) Tramadol 10mg ampoules for sublingual use or possibly injection. POM

With these drugs, used alone or in combination, most types of pain can be
controlled. There are many smart and expensive combination drugs which are
heavily advertised with exaggerated claims for strength and effect available from
chemists. These offer no advantages over your stock.

We encourage clients to carry their own preferred mild over the counter
analgesics to save troubling the leader for every minor ache and pain and for this
reason details are given here of similar drugs.



Paracetamol

Paracetamol is possibly the safest mild analgesic available. It is also useful for
reducing fever. It gets bad press due to overdose dangers (in excess of 15 tabs in
24 hours) which means that many people do not use adequate doses. An adult
needs 1 gram (2 x 500mg) tabs every 4-6 hours. Less is homeopathic.

At these doses side effects are rare. Allergy is rare. It is safe at all stages of
pregnancy. It does not upset the guts. It takes about 20mins to start working and
lasts for about six hours.




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Paracetamol mixes safely with most other medication and is very effective if
combined with Codeine or a Non Steroidal Anti Inflammatory Drug (NSAI) which
results in a stronger effect.

Ibuprofen (N.S.A.I.D)

Ibuprofen is the cheapest and safest Non Steroidal Anti Inflammatory Drug
(NSAID).

It is an analgesic but also has some effect on inflammation such as occurs after
muscle, joint, and bone injury, with gout or Gallbladder or Kidney Colic. For this
type of pain it can be used on its own at 400mg four times a day or at this dose
combined with full doses of Paracetamol &/or Codeine.

Its main side effect is that it can cause stomach irritation (indigestion) or even
gastric haemorrhage. In a few people susceptible to Asthma it can trigger an
attack. Do not use it in anybody with a history of Asthma (unless they already
use it regularly) or a history of indigestion.

For a very short period double doses could be used but must be stopped if
stomach pain occurs.

Other drugs in this NSAI group include Naproxen/Naprosyn, Diclofenac/Voltarol,
Indomethacin etc. They all share the same side effect profile to some extent and
should not be mixed. ASPIRIN is also a mild NSAI with the same side effects.

Codene Phosphate

Codeine Phosphate is the mildest opiate analgesic available.

In low doses it is ideal for those minor pains that do not quite respond to
Paracetamol. In medium doses, possibly combined with Ibuprofen, it is ideal for
severe bruising. In high doses combined with Ibuprofen it would take the edge off
the pain of a minor fracture or help with the pain of a more severe fracture after
it has been splinted and the patient made comfortable with initial Tramadol. It
has all the side effects of its more powerful relatives but in a milder form. It
causes drowsiness in large doses and frequently constipates (a potentially useful
side effect......see Travellers Diarrhoea Protocol). If used for more than a few
doses for pain consider giving a preventative regular laxative. Avoid using it for
undiagnosed abdominal pain which can itself be caused by constipation. In
overdose it can reduce breathing. It can be used in pregnancy.

You are issued with the lowest dose 15mg tablets to give you versatility
depending on the condition being treated. The dose for an adult is 15mg to 60mg
four hourly as needed. Start with the lower dose but do not be afraid to increase.

Codeine in any dose can be mixed with full doses of NSAI's or Paracetamol,
indeed it can be purchased in expensive combination tablets with Paracetamol but
these often have too low a dose of each ingredient.

Tramadol

Tramadol is a synthetic opiod. It is not a controlled drug. It is a very strong
analgesic for use in severe pain due to illness or trauma. It can be given
sublingually (best route for layperson) or by injection and renders the patient a




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stretcher case due to its sedative properties. Before using this drug be familiar
with the specific Jagged Globe protocol.

Nalbuphine (Nubain)

Nalbuphine injection is a synthetic form of Morphine opioid. It used to be
standard issue in JG medical kits but is no longer in production.

Dr David Hillebrandt,
Medical Adviser to Jagged Globe,
Derriton House,
Derriton,
Holsworthy,
Devon. EX22 6JX.
Tel:01409 253814
E Mail: dh@hillebrandt.org.uk

3/4/08 Revised 20/1/09




  INFORMATION FOR NON-MEDICALLY TRAINED PEOPLE TO
   ADMINISTER STRONG PAINKILLERS IN REMOTE AREAS

                                   TRAMADOL (POM)


Introduction

These notes come on two pages. This section gives theoretical background and is
designed to be read, remembered and left at home. The second page can be
reduced to A5 by photocopier, laminated and carried with your first aid kit.

Tramadol is a strong pain-killer which can be used following accidental injury or a
heart attack. It is an opioid and works at some of the same sites in the body as
morphine but is not legally controlled in the same way. Tramadol 100mg is
approximately equivalent to Morphine 10mg. It is a prescription only medicine
that has to be prescribed by a Doctor. These notes are intended to enable a fully
trained advanced First-Aider to give this drug confidently when in a remote area
away from medical help. A trained Medical Practitioner may chose to use the
drug in a different way and/or in a different dose from that indicated in these
notes.

The Drug

Tramadol is a synthetic painkiller which in many ways is similar to Morphine. It
has the same side effects but has less addictive potential and is therefore not a
controlled drug. Some Doctors may be prepared to write a private prescription
for this drug, so that it can be carried by trained advanced First-Aiders to be used
in conjunction with this protocol.

Tramadol is marketed in 100mg ampoules and as capsules and tablets but in this
protocol, only the 100mg ampoule will be used. This is to minimise any risk of
giving an accidental overdose when stressed. It is designed for use by injection
and can be safely given into a muscle (IM) or vein (IV) or in liquid form into the
mouth, preferably under the tongue, to be absorbed by the mucus membranes
lining the mouth and gums (sublingual route, S/L). This latter route works


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almost as well as many injections and may well be better than an IM injection in
a clinically shocked patient. It is much easier to use for a first aider than an
injection.



Route Of Administration

Although known for many years the sublingual route of administration is gaining
in acceptance for tramadol and some other drugs in the pre hospital care of
injured patients, especially when away from expert help. To give tramadol this
way simply draw up the ampoule of injection into a syringe, remove the needle
and drop the liquid slowly into the patients mouth, preferably under their tongue
whilst encouraging them not to swallow.

If a drug is given IM to a hypothermic shocked patient absorption can be very
delayed. It may not work until the patient is warmed on arrival in hospital so this
route is going out of favour.

If a drug is given into a vein, its effect will be seen within about 1-2 minutes, and
the dose can therefore be given very accurately. More skill and training is
required for an injection into a vein. If given this way it should be given at a rate
of 10 mg per minute and the total dose can be balanced against the level of pain.

Use

Tramadol is a strong painkiller. It usually causes sedation and renders the
patient unable to look after themselves, and therefore should only be used in
cases where stretcher evacuation is being considered. It can cause dizziness and
vomiting. In high doses it can reduce respiration (breathing).

In view of its sedative effect, it should be used with extreme caution in somebody
who is already sedated by other drugs such as alcohol, other painkillers,
sedatives or antidepressants.

The fact that it can cause sickness means that it is sometimes given combined
with an anti-sickness (anti-emetic) drug, possibly Buccastem which is sublingual
prochlorperazine (Stemetil) in tablet form.

Dose

A normal 70kg adult man or woman will usually get considerable pain-relief from
a 100mg dose of Tramadol. If given into a vein it works within minutes, if given
into a muscle it may take 20 minutes to work at room temperature and much
longer in a cold environment. If given sublingually it should work in about 15
minutes. One dose would normally work for between 4 and 6 hours. If there has
been an inadequate response to a 100mg sublingual dose in an adult (person
over 12 years) a second dose of 50mg can be given after 30 minutes.

Record Keeping

As with any drug, an accurate indelible record should be kept   of the type, time
and dosage of the drug given and the route of administration. This will be vital
for the patient's future care. It is often best to send the empty ampoules that
have been given with the patient to Hospital.




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Caution

Because Tramadol can make patients drowsy it should not be given to a patient
with a severe head injury that has caused deep unconsciousness. Fortunately
deeply unconscious patients cannot normally experience severe pain. If the
patient has a head injury, but is alert, orientated, not becoming unconscious and
in pain, it is still justifiable to give this drug. In the difficult case of a patient
whose consciousness is diminished but who is still experiencing pain and is
restless a carefully given intravenous dose, balanced against the pain level, can
be useful.

Training & Follow Up

It is strongly suggested that any first-aider giving prescription only drugs by
injection or the sublingual route should receive advanced training on a BASI or
REC course run at Plas y Brenin, Glenmore Lodge or some other reputable
organisation.

If you do use this protocol please inform me with comments to improve it for
future users.




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              JAGGED GLOBE MEDICAL ADVICE SHEET
              TRAVELLER'S DIARRHOEA & VOMITTING

Introduction

Travel medicine research shows that in any one year 7,900 “traveller years” are
spent with our asses suspended over third world latrines (1994 data). A lot of this
shit re-enters the local water supplies and therefore the guts of other travellers.

The causes of traveller's diarrhoea are frequently bacterial and totally different
from the causes of D&V at home. It is normally transmitted by what is politely
termed the "faecal oral route". In reality this means microscopic bits of shit
entering your mouth. Treatment is therefore slightly different and based on a
"best guess" of potential cause.

Prevention

Prevention is the ideal. Thoroughly wash, rewash and rewash your hands in soap
and water after every shit (better than "antibacterial" wipes). Purify all drinking
and tooth washing water. Avoid ice and ice cream and any uncooked or reheated
food. Peel all fruit.

Anybody in your group who claims to have travelled so much that they are
immune to gut problems is a fool. Possibly a lucky fool. Watch them when their
luck runs out! Even five star hotels frequently have zero star staff toilets and
therefore contaminated food.

Basic Treatment

Mild gut upsets due to a simple change in diet normally settle over a few days
and need no treatment.

More severe and frequent watery diarrhoea needs prompt treatment with fluid
replacement before the patient enters the spiral of lethargy and dehydration. The
patient should be encouraged to drink up to 4 or more of rehydration fluid per
day. For speed of initiating treatment preprepared sachets (Dioralyte or similar)
are useful for the first litre or two. It is then simple enough to make up your own
with:

1 Litre of boiled or iodine treated water with 8 level teaspoons of sugar or honey
or glucose or molasses (ghur in Hindi/Urdu) and one level teaspoon of salt.
Lemon/Lime can be added to make this more palatable.

If this is unavailable Coke or Fanta allowed to go flat, clear soup, oxo or Bovril
drinks, hot lemon, lemon tea or any clean drinkable fluid is better than none.

Most patients balk at the idea of this amount of fluid intake but this is the basis of
all treatment. Most will say "I only vomit it up immediately". Some fluid will be
absorbed despite their comments. Any other treatment is in addition to this, not
instead of fluid.




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Second Line Treatment

If there is no marked improvement with adequate fluid replacement it is worth
adding:

Ciprofloxacin (POM) 500mg twice a day for three days.

This antibiotic can sometimes help. Check that the patient is not allergic to it.
There is a theoretical risk of damage to the weight bearing joints in youngsters
below 17 from this drug. It would seem best to minimise the dose in these cases,
possibly giving 250mg twice a day, which you may be able to stop after two
doses depending on response.

If the diarrhoea is bloody contains a marked amount of mucus or is accompanied
with severe vomiting or pyrexia commence second line treatment earlier. Do the
same if the patient is “high risk” due to Diabetes or some other pre existing
illness.


Third Line Treatment

If the above has not worked after a day or two the following can be added to the
continued fluid replacement and second line treatment:

Metronidazole (POM) 200mg four times a day for 5 days.

Rest and Other Treatment

When ill rest normally helps. When travelling with a group or climbing this is not
always possible. If you have to travel using local buses or cramped flights you
may be forced to use drugs to slow the guts. They can delay full recovery. In this
situation continue to use the full fluid replacement (make up bottles before the
journey) and the antibiotics. Reduce the number of motions with:

Codeine Phosphate (POM) 15mg tabs. Use 1 to 4 tabs every 4 hours as a
maximum for as short a time as possible. At the higher doses the patient may
become drowsy. This drug is also a painkiller.

On Return

If any party member has suffered severe diarrhoea requiring more than basic
fluid replacement it may be worth visiting their GP at a routine appointment on
return to consider a laboratory analysis of stool samples. The GP will need details
of the drugs taken and countries visited. If nothing else it may liven up the day
for a laboratory technician used to British bugs.

Dr. David Hillebrandt.
Medical Adviser to Jagged Globe & Adventureworks.
Derriton House,
Derriton.
Holsworthy,
Devon. EX22 6JX.
Tel: 01409 253814
E Mail: dh@hillebrandt.org.uk 17th November 2000 Reviewed 8/1/2005. Reviewed 5/7/05 & 20/1/09.




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                ADVENTUREWORKS ASTHMA ADVICE

Introduction

Dr David Hillebrandt our company doctor has written this information sheet to
inform those participants on Adventureworks expeditions who have declared
Asthma as an existing medical condition.

We are fully aware that Asthma can vary from a minor inconvenience needing
occasional use of a Salbutamol (Ventolin) inhaler to a much more serious
condition needing admission to hospital. We are also aware that all patients have
different medical needs and anxieties.

If, after reading this information sheet, you or your child wish to have a chat with
our company’s medical advisor please do not hesitate to contact our office and
the staff will put you in touch.

What is Asthma?

Asthma is a breathing problem that is caused by a narrowing of the small air
passages in the lungs. This narrowing can be caused by a tightening of the
muscles of the air passages or by associated swelling of the lining of the air
passages. This makes it harder to move the air in and out of the lungs with the
associated wheeze and shortness of breath.

Causes of Asthma

Some people suffer from constant background asthma with occasional
exacerbations. Some can identify specific precipitating factors. These can include
colds, allergies, stress, exercise, cold air, smoke.

The good news is that the limited research that has been done on asthma at
altitude indicates that it is not normally a problem despite the relative lack of
oxygen at altitude. This is thought to be due to the thinner and less irritant
nature of the air with less allergens.

Asthma Treatment

Many asthmatics use blue Salbutamol (Ventolin) reliever inhalers that work within
a few minutes of being taken and go on working for about four hours. Some take
regular preventative inhalers that take hours to start working and last for over 12
hours. These are often steroid based and brown coloured such as
Beclomethasone (Becotide). Some asthmatics take newer preventative inhalers
such as Salmetrol (Green inhaler).

Treatment for severe exacerbations may involve use of a nebuliser (pressurised
inhaler) which, realistically, is too heavy and complicated to carry on an
expedition. A spacer with standard Salbutamol inhaler at high dose can be used
as a nebuliser substitute. Oral or injectable steroids such as prednisolone can be
used.

Asthma, allergies and hayfever are often associated.           Bring   you   normal
antihistamines or nose sprays if needed, with spares.

Our leaders do have instructions on how to treat an exacerbation of Asthma and
carry appropriate drugs.



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Interestingly peak flow meters are not reliable or consistent at altitude and
inhalers deliver an increased (but safe) dose. Those studying Physics can ponder
the theory of this.

Personal Care

It is important that any asthmatic client lets the trip leader know about their
condition. They must be sure that they are using their inhaler as efficiently as
possible and a GP or Practice or School nurse can check this before departure.
We like all asthmatics to carry enough inhalers for the duration of their trip plus a
100% extra reserve supply in case of loss or theft. If a spacer device is normally
used this should be brought on the trip.

If your asthma is triggered by cold air bring a scarf to put over your mouth and
nose to pre-warm the air on days when you will make predawn alpine starts. If it
is triggered by smoke be particularly careful to avoid smoky bars (!!!) or similar
places. Inevitably you will be exposed to exotic pollens not normally encountered
at home. It is rare that these trigger problems.

Summary

With all expedition medicine careful preparation is the key. Most people have no
problems but by being prepared with such things as spare supplies you will
minimise any problems if you do have difficulties. Read this, act on it and it is
unlikely that you will have any problems.


Dr David Hillebrandt.
Medical Advisor to Jagged Globe.

Revised 21-4-04 & 8/1/05 & 20/1/09



                      ACUTE ASTHMA ON EXPEDITIONS


Introduction

Asthma is a common breathing problem where the small tubes taking air deep
into the lungs constrict resulting in shortness of breath and the characteristic
wheeze. Different people have different factors that trigger an attack which may
include allergies (dust mites, pollens), physical irritants (smoke), psychological
stress, infection, exercise or cold air.

All the (limited) evidence indicates that Asthmatics do not normally get a
worsening of their condition at altitude so BEWARE the asthmatic client who gets
short of breath with ascent and swears that "its just my asthma and I can treat it
with my inhalers". They almost certainly have High Altitude Pulmonary Oedema
(HAPO). If in any doubt treat as HAPO. If they get no better with descent then
treat their asthma.


Preventative Treatment

Most patients know their trigger factors and avoid them. Many use inhalers of
various types. These can be divided into Treatment inhalers (Blue) and
Preventative   inhalers  (Brown     or   Green).  Treatment   inhalers  (e.g.



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Salbutamol/Ventolin or Terbutaline/Bricanyl POMs) work within 20 minutes.
Preventative inhalers (steroids such as Beclomethasone/Becotide POM) take
many hours or even days to work. Non steroid preventative inhalers (green)
contain Salmetrol (POM) which is best thought of as a slow onset longer acting
Salbutamol.

If an asthmatic client who normally takes a steroid preventative inhaler gets a
cold or chest infection they should immediately double or even treble their dose
for a few days and start taking their treatment inhaler every four hours.

Signs Of An Asthma Attack

Watch for the asthmatic client who feels short of breath, walks slower than
normal, finds it difficult to breath, cannot speak full sentences, is coughing or has
a wheeze or has visible indrawing between the ribs when breathing (intercostal
recession).
Personal Peak Flow meters for monitoring asthma are not consistent at different
altitudes.



                                   TREATMENT

Step One

Reassure patient and check that inhalers or any other medication is being taken
correctly in correct dose. Check that inhaler technique is correct and gets drug
deep into lungs. If no errors in treatment or no response to change in treatment
move on to step two and three.

Step Two

Treatment inhalers (e.g. Salbutamol) are very safe drugs. They work quickly and
it is safe to use up to ten times the normal dose every four hours for an attack of
asthma e.g. 20 inhalations at a time.

Spacer devices (eg volumatic) make inhalers much more effective by increasing
the dose that reaches the lungs. They can be improvised with plastic bottles or
similar.


Step Three (If No Better With Step One Or Severe Attack)

Initiate oral steroid treatment with prednisolone (POM). This takes up to six hours
to reach full effect so you buy time with steps one and two.

The dose for anybody over 12 years old is:
Prednisolone 40mg (most likely 8 x 5mg tabs) orally taken immediately and then
15mg every 12 hours for three days and then stop.

If the attack returns then restart the full treatment but after three days keep on
the lowest dose of prednisolone tablets that keeps the asthma under control
(expect 10mg daily) until you can get medical advice.




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Side Effects

Oral steroids have long-term (and short-term) side effects but asthma can kill.
The above advice balances these risks.

A short sharp course of steroids is virtually side effect free and can be life saving.
Do not be put off by the patient who gasps "I do not take steroids they make you
fat, give you greasy skin and spots, and weaken your bones". They are quoting
the side effects of very long term treatment and have read too many articles in
the neurotic lay press.

Very occasionally a patient on short-term high dose steroids may become
temporarily mentally excitable or even psychotic.........well better mad and alive
than dead!

Oral Steroids - Other Notes

Steroids suppress the body's allergic reaction. Oral steroids are therefore useful
for any severe allergic reaction but it is rare that any powerful drug such as this is
needed for anything less than severe allergy.

Dexamethasone (used for HACE) is also an oral steroid and could therefore be
used for asthma in the same doses as for HACE (see protocol) for three days if
prednisolone were not available. In an asthmatic with possible HACE &/or HAPE
you would fortunately have treated all three conditions with the same drug (and
descent).

Dr. David Hillebrandt,
Medical Adviser to Jagged Globe,
Derriton House,
Derriton,
Holsworthy,
Devon, EX22 6JX.
Tel:01409 253814
E Mail: dh@hillebrandt.org.uk

For Jagged Globe & Adventureworks

17th November 2000.Reviewed 27.12.01 Reviewed 30.3.02. Reviewed 6/3/04. Reviewed 8/1/05.
Reviewed 20/1/09




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                         REMOTE AREA DIABETES

INTRODUCTION (SECTION ONE)

Introduction

This set of guidelines is produced in three sections. The first gives an introduction
to this medical problem and is designed to be read and understood before dealing
with a diabetic client. The second is for use in an emergency in the UK, European
Alps or somewhere where rescue facilities are relatively easily available. The third
is for remote area and expedition work. It may be sensible to laminate sections
two and three to carry with you when on the hill.

Definition

Diabetes is an illness where the body looses its ability to control the level of sugar
in the blood (Blood Sugar/BS).

The BS is normally controlled by a hormone called Insulin produced by a gland
called the pancreas in the abdomen.

Sugar is vital as a fuel source for the body so too little sugar (Hypoglycaemia)
can result in a fairly rapid progression to unconsciousness. Too much sugar
(Hyperglycaemia) can act as a poison, mess up the chemical and fluid balance in
the body and lead to illness and later unconsciousness.

TYPES OF DIABETES

There are two main types of Diabetes: -

Type One Diabetes

Occurs when the body ceases to produce its own insulin. This normally occurs in
young and often fit people and can only be treated by the administration of
artificial Insulin by injection. Patients normally inject themselves under the skin
(subcutaneously, s/c) with long acting insulin twice a day although some may be
on up to four daily pre-meal injections of short acting Insulin or a continuous s/c
pump infusion (more common in the USA) of very short acting Insulin.

Soluble (fast acting) Insulin works quickly but only for a short period and is useful
for “fine tuning” BS levels in an emergency. It can be given subcutaneously (s/c)
or Intramuscularly (i/m), or intravenously under the guidance of a medical
practitioner.

Type Two Diabetes

Normally occurs in older obese patients (less likely to be our clients). In this case
the body cannot produce sufficient Insulin and treatment is by weight loss and
tablets that force the body to maximise its own insulin production.

Both types of Diabetes require careful balancing of sugar and food intake as a
major part of the treatment.

Under severe physiological stress (unaccustomed exercise levels, altitude, cold,
infection, D&V or injury) a Type Two Diabetic may need Insulin treatment. This
could be relevant in a very remote area where we have seen a case of
undiagnosed diabetes unmasked by expedition physiological stress (rare).


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           Jagged Globe / Adventureworks Expedition Medical Protocols



PREVENTION OF PROBLEMS

To prevent the immediate dangers of Diabetes (Hypo or Hyperglycaemia) patients
have to balance their diet, exercise and drug intake. Experienced patients are
often very skilful at this. It is particularly important that Diabetic clients gradually
build up their mountaineering experience and confidence since they not only have
to learn the mountain skills but at the same time skills to deal with their diabetic
control. They need a good idea of the days route plan and may need slightly
longer stops than other clients to enable them to monitor their condition. This
becomes especially true in adverse weather when a group shelter can be
invaluable.

Personal self care skills and confidence can be built by contact with other active
experienced mountaineering diabetics. I would suggest using the website:
http://www.mountain-mad.org .

Simple awareness of a client’s diabetic problem should be all that is needed and
we encourage all Diabetic Clients to share knowledge of their condition with their
leader and their group.

Experienced Diabetics should have had medical advice regarding meals and
insulin needs on long haul flights crossing time zones. They should always carry
spare food and insulin in their cabin baggage with a doctor’s letter for security
staff explaining this need.

Alcohol and Hypothermia both lower BS in anybody. This is obviously even more
relevant in Diabetic Clients.

Clients who have had diabetes for many years may have long-term damage to
the very small blood vessels (capillaries) throughout the body and nerves to the
feet (peripheral neuropathy). In the feet and hands this may make them more
prone to frostbite and to infection in the event of any tissue injury. In the eyes
diabetic retinopathy may be affected by altitude and puts the patient at much
higher risk of sudden loss of sight due to retinal haemorrhage so any diabetic
going above 4500m should have a retinal check prior to departure.

If a diabetic client becomes ill and stops eating his/her insulin MUST NOT BE
STOPPED. The body still needs Insulin but the amount may differ and constant
monitoring of BS may be needed with dose adjustment.


EQUIPMENT & DRUGS

All diabetics should have discussed their condition with their leader. They should
also carry clear identification giving details of their medical condition. It would be
sensible for them to demonstrate their equipment to their leader and indicate
where it will be carried when on the hill (and where spares will be kept).

Type One Equipment to Be Carried

Most of our clients will be Type One.

On a Course in the UK or Europe they should carry:-

      Supplies of their normal insulin(s) with spares




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           Jagged Globe / Adventureworks Expedition Medical Protocols


      Syringe and needles or an automatic injection device or infusion pump
       (with spare).
      A blood sugar measuring system (with spare batteries and test strips).
      A fast acting form of easily absorbed sugar (e.g. glucose tabs, sweets)
      Glucose gel (e.g. GlucoGel).
      Injectable Glucagon kit.
      Reagent urine strips to check for ketones
      Spare “complex carbohydrates” such as cake or butties or museli bars.

If on an expedition in a remote area in addition to the above Type One Diabetics
should carry: -

      Soluble Insulin or Insulin Lispro.
      Additional personal antibiotics.
      Possibly consider bringing 2-3 litres of IV fluid (0.9% normal saline) with
       needles and giving set.


Type Two Equipment to Be Carried

A Type Two Diabetic on a course in the UK or Europe should carry:-

      Normal tablet medication with spares.
      A fast acting form of easily absorbed sugar (e.g. glucose tabs or sweets).
      Spare food.
      Glucose Gel
      Possibly a blood sugar monitoring system.
      Urine testing strips for ketones or a blood ketone measuring system
       (optimim Xceed).

If on an expedition in a remote area in addition to the above Type Two Diabetics
should carry:-

      System to monitor BS levels.
      Some soluble insulin and syringes and needles in case of a worsening in
       their condition.


POINTS TO NOTE ABOUT EQUIPMENT AND DRUGS

Old-fashioned syringes and needles are versatile and known throughout the
world. Some modern western automatic injectors and cartridges are not
universally available or understood.

Battery operated BS monitoring systems are battery dependant. Batteries run out
and do not work when cold. Consider having a spare system that can be read
visually in event of a failure (eg Betachek http://www.betachek.com ).

There are many BS monitoring systems available. One that has been tested to
6500m is the Roche Active System. It has not been tested above 6500m but is
likely to still work, although any BS monitoring system should be kept warm.
Their operating temperature is often 10 – 40oC.

Insulin storage temperatures are not as critical as originally thought but protect
when possible by keeping it close to the body and avoid letting it freeze. Frio bags
aid storage (www.friouk.com).




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          Jagged Globe / Adventureworks Expedition Medical Protocols


If sugar is needed give it in the form that is easiest to administer. For example if
they are able to eat give sweets or soft drinks backed up by longer acting more
complex carbohydrates.

Even in a semi conscious person some sugar can be absorbed through the tissues
that line the mouth so glucogel, jam or honey smeared onto the gums may help.

Always assume that an ill, semiconscious or unconscious diabetic is
Hypoglycaemic and give sugar in some way if at all possible. This could save their
life and in the unlikely event of them being Hyperglycaemic it would be like a
“drop in the ocean” and do no harm.

Glucagon is a potentially life saving drug for an unconscious diabetic. It is given
by im injection but remember absorption of any im/sc injuection can be delayed
in a cold patient. It kicks the body into mobilising the last reserves of sugar from
the liver and may be enough to bring the person round enough so they can eat
and drink to complete their recovery. In an exhausted mountaineer it may not
work if the liver reserves are already exhausted which can also happen after a
hard day in a non-diabetic. If it is used remember that the person must then eat
lots of carbohydrate to restock the body reserves.

All used syringes, needles, finger prickers and blood-testing strips should be
regarded as medically contaminated and disposed of appropriately.

Due to complex metabolic effects acetazolamide may enhance Diabetic Keto
Acidosis and is not recommended for prevention of AMS in diabetics. Likewise
Dexamethasone may increase insulin resistance and is not recommended for
prevention of AMS. Both could be used to treat HAPE or HACE during descent but
careful diabetic monitoring would be essential.

Metformin (POM), a drug used alone or with insulin in some diabetics may cause
a chemical effect known as lactic acidosis in any situation of low oxygen
concentration (eg altitude). It should possibly be avoided in high mountains.




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           Jagged Globe / Adventureworks Expedition Medical Protocols


                            REMOTE AREA DIABETES
                               (SECTION TWO)

 TREATMENT OF DIABETIC EMERGENCIES IN REMOTE PARTS OF THE U.K
                         AND EUROPE


1) Prevention of problems is the key at all times.

2) Always listen to diabetic clients since they normally know their own condition
best. Having said that a person becoming hypoglycaemic can become irrational
and even aggressive (as if drunk, suffering from hypothermia or HACE).

3) Always assume that any unwell diabetic needs sugar and insist that they take
sweets glucose or sugary drinks if you are worried about them. They may make a
swift recovery and thank you.

4) If you ever have to give rapidly absorbed sugar to a diabetic always follow it
with other forms of longer acting carbohydrate to prevent a recurrence and cease
activity until a full recovery is made.

5) Progression to unconsciousness for a hypoglycaemic diabetic (especially if
cold) can be fairly rapid. It is like watching somebody become drunk. Initially
they may bit a bit vague, may have slurred speech and then loose balance and
coordination. They may act out of character and become irrational before
collapsing and unable to walk, eventually becoming totally unconscious when they
will be unable to swallow. They will loose specific, and later, non-specific pain
responses. They are now comatose and death will follow.

6) Treatment is to get oral sugar/glucose into the patient as soon as possible. If
they recover self rescue and retreat may then be a priority.

7) If they cannot swallow try using GlucoGel.

8) If they are unconscious you are unlikely to do any harm by giving one ampoule
of Glucagon (POM) by im injection. It is preferable to give this after checking a BS
measurement and confirming Hypoglycaemia (less than 4 mmol/l). In really
adverse weather this may not be possible and the injection should still be given.

9) Do not forget to treat any unconscious patient in line with basic first aid advice
such as nursing in the recovery/coma position, insulating from the cold etc.

10) If they recover after glucagon (it may take 20 mins) and then supplementary
sugar and carbohydrates an evacuation must be considered.

11) If they do not recover consciousness one is dealing with a full emergency. If
possible send details of any BS readings with the detailed message for help. It
may influence the equipment and expertise brought to the scene.

It is very unlikely that you will have to deal with an unconscious Hyperglycaemic
patient. This normally only occurs if there has been a mistake over a missed
insulin dose. The onset is normally much slower which should give you time to
monitor the BS level and discuss the management with the patient &/or get
expert advice or help.




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           Jagged Globe / Adventureworks Expedition Medical Protocols



                  REMOTE AREA DIABETES (SECTION THREE)

       TREATMENT OF DIABETIC EMERGENCIES ON A REMOTE AREA
             EXPEDITION AWAY FROM RESCUE FACILITIES


1) All the principles of care in the UK and Europe still apply for a hypoglycaemic
patient but the decision regarding continuation of the trip for the client becomes
more complex and requires discussion once they have fully recovered.

2) In a remote area the risk of incidental illness such as D&V or other infection is
much greater. Have a low threshold for commencing antibiotics for a possible
infection in a known diabetic. Malaria would be a major problem.

3) If in any doubt about an unwell diabetic try to get the patient to run a high
blood sugar e.g. 10-12m mol/l or 180mg/dl. This is safer than a low BS in a
remote area.

4) In the event of vomiting use standard oral rehydration sachets liberally. Have
a low threshold for commencing Ciprofloxacin (see D&V protocol).

5) An ill diabetic (e.g. infection or D&V) still needs insulin even if not eating but
they may also need to take extra easily absorbed sugary drinks. Monitor their BS
and alter their insulin dose as needed but do not stop it.

6) The drug of choice for a diabetic whose BS is rising is Soluble insulin or insulin
Lispro and they can normally administer this themselves with careful BS
monitoring. This is only likely to occur in the event of intercurrent illness, trauma
or if stuck in a tent in bad weather for a prolonged period with no exercise.

7) If a patient becomes unconscious due to Hyperglycaemia (high BS) they will
suffer from severe dehydration and this is often the factor that kills them. They
need Intravenous fluids. I would suggest one litre given over 2 hours then
another litre over 3 hours and then any more you have left at the same rate. It
could be given faster under medical supervision.

They may well also need soluble insulin or Insulin Lispro by injection. This should
only be given if you have 3 high BS readings (over 20m mol) taken over 20
minutes. I would recommend 6 units of soluble insulin half hourly and half hourly
BS readings. Four Units of insulin half hourly can be given if they start to recover
and the BS readings drop. This should be given at the same time as the IV fluid
is trickled into the vein. Remember that non-sterile fluid can be given at a rate of
about I litre over 12 hours by the rectal route if no sterile IV fluid is available.

If possible get medical help.

  PRAY….

Draft Ten of Diabetic Guidelines for Jagged Globe & Adventureworks 16/1/09
Dr David Hillebrandt & Dr Paul Richards, Derriton House, Holsworthy, Devon. EX22 6JX. UK.
Tel:01409 253814.
Email: dh@hillebrandt.org.uk




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           Jagged Globe / Adventureworks Expedition Medical Protocols


                                 ANTIBIOTICS

Introduction

Many infections are caused by bacteria.

Antibiotics are drugs which kill or control bacteria. They can be lifesavers. They
affect both good and bad (pathogenic) bacteria. They have no effect on viruses.

In an ideal world pathogenic bacteria would be quickly and accurately identified
and the most specific antibiotic used. On an expedition one has to rely on a "best
guess" diagnosis and what supplies are available. Frequently any antibiotic is
better than none.

Side Effects

Very rarely people have a potentially fatal allergy to an antibiotic (anaphylactic
shock). Quite frequently people have mild reversible adverse reactions such as
rashes or a feeling of nausea. In a remote area one may decide to accept these if
no alternative drug is available.

By killing off some beneficial bacteria in the gut and genital tract antibiotics may
trigger off attacks of the shits or vaginal thrush.

It is virtually impossible to overdose on most antibiotics taken over a short time.

Note that by changing the natural bugs in the gut any antibiotics can make the
oral contraceptive pill less effective potentially putting some female clients at risk
of pregnancy. If antibiotics have to be used explain this to the client and ensure
that they understand the necessity of using alternative methods of contraception
or abstaining from intercourse until instructed otherwise by a doctor on return
home.

Medical Kit

In view of the above Jagged Globe encourage clients to obtain one or two courses
of antibiotics from their General Practitioner (personal physician) prior to an
expedition. This ensures that personal drug sensitivities are taken into account.

The expedition medical kit also contains three basic antibiotics. Always ask about
known allergies before use.

These notes give details of the three antibiotics in the kit and a few others that
you may encounter. All these antibiotics mix safely with the analgesics in the
medical kit.

Magnapen Capsules (Pom)

Each capsule contains a mixture two Penicillin based drugs, Flucloxacillin and
Ampicillin.

For suspected Urine, Chest, Ear, Dental or skin infection use Magnapen, one
capsule four times a day for 5 days.

In the event of a potentially severe infection such as an internal abdominal injury,
suspected appendicitis or a compound (open) bone fracture (including skull) use
at least 2 caps four times a day with Metronidazole.


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           Jagged Globe / Adventureworks Expedition Medical Protocols



Ciprofloxacin (Ciproxin) (Pom)

Mainly included for use in Travellers Diarrhoea (see Protocol). Can also be used at
500mg twice a day for three days for urinary infections or in a five day course for
chest infection. Should be avoided in youngsters under 17 unless on medical
advice. Should not be given to people with history of epilepsy/seizures. Can
cause tendon problems in people of any age.


Metronidazole (Flagyl) (Pom)

A specific antibiotic for certain gut related problems (e.g. Giardia-see Travellers
Diarrhoea Protocol or anaerobe bugs) also useful to extend the range of cover by
mixing with Magnapen.

Can be used at 200mg four times a day for mild infection or 400mg four times a
day for more severe infection such as a compound fracture or abdominal or chest
trauma.

At high doses this can cause nausea. It will cause vomiting if taken with alcohol.

Erythromycin (Pom)

Kills almost the same bacteria as Penicillin but is chemically unrelated. Use it at a
dose of 250mg four times a day or 500mg four times a day for severe infection in
people who are allergic to Penicillin. It also mixes safely with Metronidazole.

Cotrimoxazole (Septrin) (Pom)

Is a mixture of Trimethoprim and sulphamethoxazole. It is currently out of vogue
in the UK but can be used at a dose of 2 tablets (960mg) twice a day for five
days for urine and chest infections. In the past it was used for traveller’s
diarrhoea.

Trimethoprim (Pom)

Use 200mg twice a day for three days for possible urine infections.


(Oxy)Tetracycline (POM)

Can be used in dose of 250mg four times a day for skin or chest infections. Avoid
in children and pregnant women.

Coamoxyclav (Augmentin) (Pom)

A Penicillin related drug. Use as for Magnapen but three times a day.        Safe at
high doses. Mixes with Metronidazole.

CHILDREN & YOUNGSTERS

All the above (unless specified) can be given in adult doses to children over 14
years old.




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             Jagged Globe / Adventureworks Expedition Medical Protocols


LIFE THREATENING INFECTION

If in doubt use high doses of all the antibiotics that you have available and pray.

SEXUALLY TRANSMITTED DISEASES

Prevention is better than cure! Do not "do a client a favour" by treating potential
STD's with blind courses of antibiotics. This fascinating family of diseases become
internationally more complex by the month. Accurate medical diagnosis is
essential before treatment even if this causes social difficulties on return home.

Dr David Hillebrandt,
Medical Adviser to Jagged Globe,
Derriton House,
Derriton,
Holsworthy,
Devon, EX22 6JX.
Tel:01409 253814
E Mail: dh@hillebrandt.org.uk

18th November 2000
Revised and updated 9.10.2001 & 8.1.05 & 20/1/09 for Jagged Globe and Adventureworks .




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           Jagged Globe / Adventureworks Expedition Medical Protocols


                  JAGGED GLOBE EXPEDITION MEDICAL KIT
                       DIAZEPAM (VALIUM) (POM)

Introduction

Diazepam (Valium) has received bad press over the years as an addictive
sedative drug over prescribed by doctors. Hopefully the medical profession has
now addressed these problems and, used correctly, it is an extremely useful drug
with a well-understood side effect profile and large safety margin in terms of
dosage.

In a small dose it is a very useful short-term muscle relaxant and in a higher dose
a mental sedative. It is included in your kit (as 5mg tablets) for both these uses.

Muscle Relaxant

In a dose of approximately 2mg (half a scored tablet) twice a day it is extremely
useful to relax injured muscles which have a natural tendency to go into spasm in
response to pain which in turn simply increases the pain. It is ideal used in this
way combined with either ibuprofen and/or paracetamol, or ibuprofen and
codeine for back muscle strain (see analgesic protocol). If this dose does not help
it would be acceptable to increase to half a tablet (approximately 2mg) four times
a day.

As the dose is increased one is likely to run into slight mental sedation. People’s
reaction is variable and anybody who takes regular similar medication (e.g.
Temazepam, Lorazepam etc) may require larger doses.

In the event of a joint dislocation (e.g. shoulder) attempted reduction could be
tried with a combination of an analgesic and 10mg of oral Diazepam. Under
medical supervision a larger dose may be appropriate. An oral dose starts
working within 10 minutes but should be given at least 30 mins to reach full
effect. Your medical handbook should be consulted for further advice regarding
dislocations.

MENTAL SEDATIVE

Panic

Anybody can become panicked in unfamiliar situations and part of the skill of
leadership is to minimise this risk and to have the ability to reassure and "talk
people down". Sometimes it is justified to use a dose of 5mg of Diazepam as a
sedative. This can be very effective and normally the client will simply feel slightly
embarrassed by the incident the next day.

Diazepam (5mg) can be used to help sleep but is not ideal for this since it stays
in the body for many hours resulting in a hangover effect and can be cumulative
if used over a period of time. Resist the idea of using sleep medication on an
expedition. Anybody using regular sleep medication should have declared it to the
company prior to departure and have had personal advice from the company
doctor.

Madness (Psychosis)

Occasionally a client with pre-existing mental illness will fail to declare it on the
registration medical form or somebody with a slight tendency to mental instability
can have a psychotic episode triggered by the stresses involved in travel, jet lag,



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            Jagged Globe / Adventureworks Expedition Medical Protocols


culture shock, group stresses and physical demands. If you sense warning signs
developing try to build even more rapport with the client. It may pay dividends if
the condition gets worse.

If panic as described above does not respond to reassurance and a small dose of
medication it may be the initial signs of psychosis.

In the event of a client becoming irrationally "mad" with no obvious cause such as
drug abuse, alcohol withdrawal or physical illness with toxicity, heavy sedation
may be necessary. Talk them into taking 20mg (4 tablets) of Diazepam. Hopefully
within half an hour they will become more cooperative. Ten mg doses can be
repeated at a maximum of six hourly intervals whilst they are moved to medical
help. This dose would make a well person sleep for many hours but in an agitated
or psychotic patient will often only slow them down to a manageable level. With
this oral dose reduction in breathing rate should not be a problem.

Fits

It is unlikely that you will have a client who fits unless they have a history of
previous epilepsy, which should have been declared and discussed with the
company doctor and trip leader. Such a client may well be carrying diazepam for
rectal administration and the leader will have been informed. If a client with no
previous history does fit 10mg of oral diazepam given as soon as they are able to
swallow and then 5mg four times a day should reduce the likelihood of further fits
until medical advice can be obtained.

Youngsters

Diazepam is best avoided in youngsters unless on medical advice

Dr. David Hillebrandt,
Medical Adviser to Jagged Globe & Adventureworks, Derriton House, Derriton, Holsworthy, Devon.
EX226JX.
Tel:01409 253814
E Mail: dh@hillebrandt.org.uk
Prepared 8.12.00 Revised 15/5/05 & 15/4/07 & 20/1/09




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                  JAGGED GLOBE ANTIHISTAMINE GUIDELINES
                               (LORATIDINE)


Antihistamines

Antihistamines are drugs used to minimise the effect of histamine on the body. As
such they are used to treat allergies such as hayfever, nettlerash reactions
(urticaria) and irritant itchy insect bites. They all cause some drowsiness and all
have a slightly different onset and duration of action.

Loratidine

We have chosen Loratidine as our standard medical kit antihistamine. It is one of
the new generation antihistamine and is much less likely to make a person
drowsy than the older chlorphenamine (Piriton). The dose is one 10mg tablet
every 24 hours for anybody over 6 years old. In the UK it is a non prescription
medication.

David Hillebrandt (copyright). Medical advisor to Jagged Globe & Adventureworks. Compiled 2/1/08
Reviewed 20/1/09
Derriton House, Derriton, Holsworthy. Devon. EX22 6JX. Tel : 01409 253814 E Mail :
dh@hillebrandt.org.uk




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            Jagged Globe / Adventureworks Expedition Medical Protocols



JAGGED GLOBE MEDICAL ADVICE FOR POSSIBLE HEART ATTACK/USE OF
                          ASPIRIN

Medical Kit Aspirin

The Jagged Globe medical kit contains a small quantity of 300mg Aspirin tablets.
Although aspirin is primarily thought of as a pain killer with mild anti-
inflammatory properties that also decreases an abnormally high body
temperature it is not included in the kit for this use and paracetamol is safer,
and ibuprofen a more effective anti-inflammatory drug. It is included solely for its
role in the management of a possible heart attack where a small dose taken early
on dramatically increases survival and decreases heart muscle damage.

Suspected Heart Attack

A Heart Attack (Myocardial Infarction, MI) is caused when the blood supply to the
heart’s own muscle is blocked for enough time for the muscle to be permanently
damaged. Angina is a similar phenomenon which is self limiting but can recur and
does not result in permanent muscle damage. An MI normally causes severe
chest pain and is commoner in older people and smokers and made worse by lack
of oxygen. Characteristically it presents as severe central chest pain that may
radiate to the left arm and into the jaw. The patient may become very short of
breath, sweaty and feel impending doom. Not all presentations are classic and it
may feel like severe indigestion and indeed be indistinguishable from indigestion
or indistinguishable from the pain of a clot on the lung (Pulmonary Embolus). It is
impossible to diagnose it in the field without a heart recording (ECG) and specific
blood tests. One has to rely on a working clinical diagnosis.

Treatment

If the patient has a history of indigestion and is normally fit it may be acceptable
to try a dose of an antacid medicine but if it does not respond and there is any
suspicion of a heart attack treat as an MI. Don’t worry that the one dose of
aspirin may make indigestion worse.

If the patient has a history of Angina and the pain responds to the use of their
normal spray or tablet of Glyceryl Trinitrate (GTN) under the tongue it is an
Angina attack. They should be given oxygen if available and descend slowly to
low altitude.

If the attack does not respond to a dose of GTN if available and the pain does not
settle they should be assumed to be having an MI. The pain will be severe and
merit the use of Tramadol or a stronger opiate if available. Oxygen should be
given if available. Give 300mg of Aspirin by mouth now and each day. Descent
should be by stretcher if possible since rest and increased oxygen is essential for
the ailing heart muscle. If impossible to descent the use of a Hyperbaric bag may
help marginally but take into account the claustrophobia, likelihood of vomiting
and fear.

Long Term Care

You are dealing with a medical emergency that has a high fatality rate even when
managed in a Cardiac Care Unit in hospital with specialised drugs and treatments.
Careful evacuation is essential. Good Luck.
David Hillebrandt copyright. For Jagged Globe. Derriton House. Holsworthy, Devon. EX22 6JX. Tel: 00
44 (0)1409 253814. dh@hillebrandt.org.uk 20/1/09




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           Jagged Globe / Adventureworks Expedition Medical Protocols


                                  FROSTBITE

Introduction

If the natural fluid in cells freezes it swells. Toxic chemicals are produced. These
two processes permanently damage the tissues. This is frostbite. It can vary in
the depth and extent of damage.

If only superficial skin is damaged and it is rewarmed soon after injury it may
recover completely. This is frostnip.

Frostbite commonly occurs on the extremities such as fingers, toes, ears, penis
and nose. It can occur elsewhere.

It obviously requires a cold, but not necessarily freezing, environment. Wind-chill
can add to the potential for damage. It is more likely at altitude (less oxygen for
the tissues) and in a hypothermic or injured person. It is more likely if circulation
is restricted by tight fitting clothes, boots or jewellery.

Climbers with pre-existing conditions which may predispose to poor circulation
(Diabetics, Raynauds sufferers etc) are more likely to suffer from frostbite.
Certain drugs that effect peripheral circulation may also predispose (b Blockers or
nicotine in cigarettes).

Prevention

Prevention is the key to “treatment”. Awareness and experience is the key to
prevention.

Diagnosis

Diagnosis is made from an awareness of the risk. Frostbite may initially be
painful, but may not be so. If a cold extremity becomes numb frostbite is the
likely cause. The skin may become white and blanched in appearance and tissues
feel “woody” to the patient. If a large area becomes frostbitten it may become
purple and blister due to blood sludging.

Field Treatment

Frostnip rapidly warmed should result in no long term damage. “Frostbitten” feet
where sensation fully returns after active rewarming are frostnipped and can be
walked on.

For Frostbite:

   1. Protect from further cold injury. Remove            jewellery,   put   on   dry
      gloves/mitts/socks if possible, adjust boots.

   2. Do not deliberately thaw part until it can be rapidly rewarmed in a water
      bath in a situation from which evacuation can be arranged without further
      pressure on damaged tissue (normally base camp).

   3. As soon as available give Ibuprofen (Brufen) 400mg twice a day to inhibit
      potentially damaging toxins.

   4. If above 4000m and oxygen is available give it.




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          Jagged Globe / Adventureworks Expedition Medical Protocols


   5. On arrival at a secure base the patient should first be treated for potential
      hypothermia by slow rewarming with insulation in a warm environment.

   6. The patient should be kept very well hydrated with warm fluid drinks.

   7. The frostbitten part should be rapidly rewarmed by immersion in warm
      water. This should be at 40-42oC (baby bath temperature). The “bath”
      should contain a large enough volume of water to minimise cooling by the
      cold body part and to facilitate easy top-ups with warm water to maintain
      the temperature. The damaged part should not be in contact with the side
      of the “bath”. Antiseptic can be added to the water if available. Full
      thawing may take an hour or more.


   8. Thawing may be very painful and strong painkillers may be needed by
      injection or sublingually.

   9. Once thawed the frostbitten part must not be used. A patient with
      frostbitten toes or feet will have to be carried. A patient with frostbitten
      fingers or hands will be unable to use a walking stick, ice axe or crutch
      and will need help with dressing, eating and going to the toilet.

   10. The damaged part should be loosely bandaged with dry protective non
       adherent dressings and well padded, especially between digits. Try to
       avoid bursting blisters but if inevitable do so with sterile needle or blade.

   11. Take daily digital photos and photos of all procedures for medical records.
       Particularly important are photos taken about an hour after rewarming
       showing line of damage. Digital photos can be used with E mail
       transmission if advice is needed.

   12. If there is any suspicion of infection start antibiotics.

   13. Check patient is up to date with tetanus cover.


Definitive treatment

World class centres for the treatment of frostbite are Chamonix and Anchorage.
Dr Emmanuel Cauchy and his team from Chamonix hospital have lectured to the
holders of the UK Diploma in Mountain Medicine and a liaison system has been
set up so that digital photos and digital bone scan images can be transmitted and
discussed.

Modern definitive treatment is based on the validated predictive data from Bone
Scans (Technitium 99 or MRI are best but even a duplex imaging is useful) taken
soon after injury. If doing a Technitium Scan put markers on the ends of the
digits.

Specialist intravenous vasodilators such as Iloprost daily for five days (UK c/o
Chris Imray) or Chlorohydrate of Buflomedil (in Chamonix) may be used in
hospital and may help.

Mr Chris Imray is a UK based vascular surgeon with access to all necessary
facilities. He is an active climber and holds the Diploma in Mountain Medicine.
He has volunteered to act as the UK liaison surgeon. We would suggest that any
cases are discussed with either him or with Dr David Hillebrandt or with Dr Paul



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            Jagged Globe / Adventureworks Expedition Medical Protocols


Richards, the Jagged Globe doctors, prior to decisions being made about any
surgery or repatriation.

Golden Rules for Frostbite

Do not:

        Rub, beat or cover with snow.

        Warm with external heat source such as stove or fire.

        Allow refreezing once thawed.

        Rewarm a frostbitten part unless hypothermia is being treated

        Submit to early amputation, grafting or sympathectomy unless advised by
         a true expert.

Do

        Rewarm rapidly in a safe environment. Preferably at hospital and within 48
         hours of injury. Base camp may be the best you can manage.

        Give analgesia

        Avoid infection

        Delay surgery

Contacts:

Mr Chris Imray, Consultant General and Vascular Surgeon,
Coventry and Warwickshire County Vascular Unit,
University Hospitals Coventry & Warwickshire,
Clifford Bridge Road, Coventry, CV2 2DX.
Tel: 02476 602020 Ext 8944
E Mail: chrisimray@aol.com or contact via: www.christopherimray.co.uk

David Hillebrandt, Medical Advisor to Jagged Globe & Adventureworks, Derriton
House, Derriton, Holsworthy, Devon. EX22 6JX
Tel: 01409 253814 home. 07811 998245 mobile.
E mail: dh@hillebrandt.org.uk

Dr Paul Richards, Medical Advisor to Jagged Globe & Adventureworks,
The Surgery & Travel Clinic, 64 London Road, Wickford, Essex. SS12 0AN. Tel:
01268 568240 home. 0771 510 4796 mobile.
E mail: Paul@medex,org.uk

Fourth Draft 28/12/05. Revised 2/1/08 & Reviewed 20/1/09.
David Hillebrandt




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           Jagged Globe / Adventureworks Expedition Medical Protocols


 JAGGED GLOBE MEDICAL NOTES ON CUTS, SKIN & WOUND
                   MANAGEMENT


Cuts

The cut human body normally heals well. Active treatment with stitching
(sutures) is the norm in the UK for any cut large enough to gape but like any
medical treatment has potential side effects, especially in inexperienced hands
and when a dirty and contaminated wound is present. It may serve to lock
potential infection into the deep tissues, with potentially serious later results.

In reality the only time sutures may be essential is to stop bleeding. They may
also be used to minimise scarring or to tidy up a gaping wound but if not inserted
by an experienced practitioner they may not achieve this aim. Correction can
always be undertaken later by an experienced plastic surgeon, if the owner does
not wish to keep their holiday souvenir which can normally be accompanied by a
series of good stories.

For dirty war wounds the International Red Cross now insists that all its doctors
practice the technique of Delayed Primary Suture whereby a wound is very
thoroughly cleaned, packed with sterile dressings and left open for several days
to ensure no infection is developing, prior to final suturing. Hopefully this
information will reassure any leader dealing one of their party has sustained a
potentially dirty cut when in a remote area.

Principles of Care

If any cut is bleeding catastrophically the control of the bleeding is the first
priority. This should be done with direct pressure, elevation if possible, and then
a pressure dressing. There may very occasionally be a place for the use of
modern haemorrhage arresting dressings or even a modern trauma tourniquet
but these are still being assessed in the field.

Thorough wound cleaning is essential for any cut. Active bleeding is itself
cleansing. The wound must then be flushed with very clean water or other
suitable fluid possibly using a syringe to direct a mild pressure jet. Local
anaesthetic or analgesia may be needed for this. Bleeding may restart and have
to be controlled with pressure again.

Once cleaned the wound should be dressed with any suitable clean material.
Redressing may be needed every few days to prevent and to check for infection.

Antibiotics are no substitute for initial wound care but if the wound is very dirty or
contaminated it will most likely do no harm to commence a course of suitable
antibiotics. Check that the patient has had a current tetanus immunisation.


Special Circumstances

Compound Fractures

If it is possible that an underlying bone has been broken the wound may indicate
a compound fracture where the bone has penetrated the skin and returned
approximately to its correct position. Splinting is needed but there is a very high
risk of developing a bone infection. This requires urgent evacuation and in



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            Jagged Globe / Adventureworks Expedition Medical Protocols


addition to the above wound care plan large doses of antibiotics should be started
as soon as possible.

High Altitude

All wounds take longer to heal in the low oxygen environment of altitude.
Sometimes simple descent for a few days facilitates healing.

Jungle

The Jungle is a hot humid environment, which bacterial and fungal infections
love. Add sweaty unwashed skin, possibly with a small wound and you have a
recipe for putrefaction. Ugh. Here prevention is even more essential. Regular
washing with soap and water and clean clothes are a council of perfection! In
reality do try to dry feet especially before sleeping, make liberal use of antifungal
powders for infection prevention and creams for any established fungal skin
infection such as athletes foot or athletes crutch. Even good jungle boots can
cause sweaty feet but open sandals give snakes a good target! You cannot win.

Regard any small cut as a potential entry point for infection and stop and clean it
thoroughly. Consider using tincture of iodine or similar and covering with a
plaster.

Diabetics

Anybody with diabetes has excess sugar in the blood which bugs love. They may
also have poor circulation, especially to the feet. There may be nerve damage to
the distant nerves to the feet. This combines to make personal skin care and
especially foot care essential in the UK and even more so in a remote area. Have
a low threshold for starting antibiotics for any skin problem.

“Polar Hands”

Polar hands can occur in any cold and dry environment. They are characterised
by painful chapping of the dry skin especially of the pulps of the fingers.
Superglue forms an excellent painless protective dressing if applied into the cut.
It may have to be reapplied every few days. Take great care not to touch
anything immediately after application! Natural healing will occur with descent.


Compiled by Dr David Hillebrandt (copyright) for use by Jagged Globe.
Derriton House, Derriton, Holsworthy, Devon, EX22 6JX. England. Tel: 01409 253814
E Mail : dh@hillebrandt.org.uk
Draft One 26.12.07 Revised 20/1/09




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          Jagged Globe / Adventureworks Expedition Medical Protocols


      JAGGED GLOBE MEDICAL ADVICE ON ANIMAL BITES

Animal Bites

Virtually any animal bite is a potential source of infection. Mammal bites carry a
specific risk of Rabies (see Rabies section) and snake, and some other animals,
carry the risk of envenomation (see snake bite section). Other biting bugs carry
other diseases. In Jungle areas the humid conditions mean any break in the skin
is a potential source of infection and for the development of a tropical ulcer. At
altitude any break in the skin tends to be slow to heal.

Management of Bites

Prevention

Prevention of any bite is the key to simple management.

Avoid dogs and monkeys. Do not attempt to pet animals.

To avoid insect bites cover up with long sleeved clothing especially at dawn and
dusk. Consider impregnating clothing with DEET especially socks. Tuck trousers
into socks. Use DEET based insect repellents and permethrin impregnated
mosquito nets.

To avoid snake, scorpion, centipede and spider bites walk noisily, cover up with
clothing, wear stout boots, if possible avoid walking in undergrowth, avoid deep
sand, avoid climbing overgrown logs and rocks (a favourite hiding place for
animals), do not swim in overgrown water, sleep off the ground (hammock) and
use a torch if going to the toilet at night.

Wound Management

If you are bitten clean the wound and keep it covered with a dry dressing.

If the bite is very itchy consider the use of an antihistamine (see Antihistamine
section).

If the bite appears to be infected when it will become red, hot and tender start
antibiotics (see antibiotic section). Many animal bites will become infected so
consider starting antibiotics before signs of infection are seen.

Always consider the risk of tetanus and, in the case of a mammal bite, rabies and
check on immunisation status.

Specific Potential Problems:

See www.fitfortravel.scot.nhs.uk for more specific country details

Mosquitoes

Some mosquitoes can transmit malaria but do not forget that they can transmit
other diseases such dengue fever, yellow fever and Japanese encephalitis which
cannot be controlled by the use of drugs so prevention of bites is even more
important.

Not normally a problem at high altitude but remember that you may have to pass
through a risk area en route to your objective. Malaria is not a problem in


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          Jagged Globe / Adventureworks Expedition Medical Protocols


Kathmandu or highland northern Nepal. It can be a problem in other areas of Asia
and in Africa kills well over a million people a year.

Ticks

Can transmit diseases such as flu like Lyme disease and even more serious tick
borne encephalitis (TBE) or exotically named Rocky Mountain Spotted Fever.
Again prevention is the key with clothing and DEET but these little blood sucking
bugs can be very persistent arriving on your body off undergrowth and then
embedding their mouthparts in personal body hollows and crevices to enjoy their
meal. When travelling in particular risk areas, which include wooded, moorland,
mountain areas in the UK and Europe, one should perform personal examination
each evening to check for these little friends. It can be best to work on a buddy
system for thorough examination!

If found they should be removed with tweezers to get the mouthparts out of the
skin and to avoid squashing the body and therefore increasing the risk of self
injection of a possible infection. The risk of infection is small but real (Czech
republic 600 TBE cases, Switzerland 200 TBE cases, Slovakia 75 TBE cases 2007
figures). The bite should be mentioned to a doctor if one feels ill up to a month
after visiting a risk area.

Leeches

Unpleasant blood suckers that live in vegetation and wait for a passing potential
blood meal to drop onto the victim, find a snug spot, inject their own anticlotting
chemicals and then painlessly take a meal from your circulation. Once full they
drop off to leave you to ooze blood from the bite site until their anticlotting
chemicals wear off. Best removed as soon as they are noticed by applying salt,
iodine or a lit cigarette to the leech’s body. A firm dry dressing may be needed to
stop the bleeding.

In some Himalayan areas leeches seem almost dependant on passing trekkers as
their main source of nutrition! May be a partly seasonal problem.


Scorpions

Avoid if possible, especially by shaking out boots before putting them on. They
love to sleep on the damp earth under groundsheets. If bitten it can be very
painful and may require Tramadol or equivalent painkiller or infiltration using
plain lignocaine local anaesthetic in experienced hands. Expect the patient to
experience an unpleasant “autonomic storm” which is an overwhelming feeling of
“fight, flight or fright response” effecting the guts, nervous system with sweat
salivation etc.

Tend to be a jungle and desert risk.

Caterpillars

Some caterpillars can deliver venom from their hairs. Remove hairs by applying
and removing adhesive tape. An antihistamine or even steroid tablets may be
needed for the reaction.




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           Jagged Globe / Adventureworks Expedition Medical Protocols


Spiders

Like snakes the effects are variable. Treatment is based on supportive first aid.
Analgesia and antibiotics may be needed. A snake bite dressing may help with
some serious bites.

Centipede

The good news is that there has never been a documented fatality as a result of a
centipede bite. Yet…..


Dr David Hillebrandt copyright for Jagged Globe. 2/1/08 reviewed 20/1/09
Derriton House, Derriton, Holsworthy, Devon. EX22 6JX. Tel : 01409         253814   E   Mail :
dh@hillebrandt.org.uk



      JAGGED GLOBE RABIES PREVENTION INFORMATION


Background Information

Rabies is a viral infection affecting the nervous system and once developed is
virtually 100% fatal. It is transmitted in the saliva of an infected animal (almost
any mammal but mainly dogs, monkeys, bats, skunks, rats, cattle etc) either by
a bite or a lick onto damaged skin. The incubation period varies from 9 days to
several years. It is found in most areas of the world and 40,000+ people a year
die of it in India alone.

Treatment

Other than sedation and palliative care there is no treatment for established
rabies so PREVENTION is essential!

Prevention

There are three keys to the prevention of Rabies:

   1. The avoidance of animal bites.
   2. Thorough wound cleaning if bitten.
   3. Immunisation both prior to exposure AND after any bite.

Avoidance

Be sensible. Doggies in the UK may be friendly, affectionate and enjoy being
petted but in many countries they are trained to guard property and animals or if
feral they hunt in packs. Keep well away and if worried keep some stones handy
to throw mercilessly before they get within biting range. Cute monkeys at holy
temples or elsewhere may appear to pose for pictures but in reality they are
intent on stealing your food and infecting you with a multitude of potentially
horrific diseases including rabies.

Wound Cleaning

If you are bitten by any potentially infected mammal, and remember any
mammal is potentially infected, immediate thorough cleaning of the wound is
essential. Initially this may involve flooding if with water and encouraging



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            Jagged Globe / Adventureworks Expedition Medical Protocols


bleeding. Later as more equipment becomes available use any liquid wound
disinfectant and consider irrigation under pressure using a syringe to direct the
jet to flush the wound. Keep doing this for at least quarter of an hour.

Never stitch a bite wound since this may lock potential infection into the wound.
Dressings will need regular changing.

Antibiotics will not prevent viral rabies but may minimise the risk of other
bacterial infections so a course of suitable skin infection antibiotics should be
started. Ensure that the patient’s tetanus immunisation is up to date.


Immunisation

Modern human diploid cell vaccine immunisation against rabies is very effective
and free of side effects, except expense. If you are ever bitten by a potentially
infected animal in a remote area in a country where the modern rabies
immunisation is not available (most areas JG & Adventureworks visit) you will
regard the cost of the three pre-exposure jabs very worthwhile. Even if you have
had all three pre-exposure jabs this slightly unusual jab only confers a
immunological “memory” into your body which will offer some protection but
which has to be “woken” by two booster doses started as soon as reasonably
possible after the bite.

If you “forgot” to have the recommended pre-exposure immunisation course and
have just been bitten you should now be feeling rather silly and more than a bit
worried. In effect your trip has just come to an end and you may have
inconvenienced your companions. You now need to have a full course of five post-
exposure immunisations with the human diploid vaccine with rabies
immunoglobulin AS SOON AS POSSIBLE. Most British consuls, embassies or
major hospitals in major capital cities will know where these are available. In
some countries this modern diploid vaccine is not available and the only option is
the administration of a course of local rabies vaccine and immunoglobulin these
post exposure vaccines may have more side effects. In India this is the only
vaccine available to most people.

Since rabies can develop years after the bite it is worth having the post exposure
vaccine even if there is some delay but for a totally unimmunised patient a
potentially infected bite is a medical emergency justifying medical evacuation,
which may not be covered by insurance, but worry about the cost later.


Dr David Hillebrandt.
Jagged Globe & Advenureworks medical advisor, Derriton House, Derriton, Holsworthy, Devon. EX22
6JX, England.
Tel: 00 44 (0)1409 253814. E Mail: dh@hillebrandt.org.uk
Draft One 24.12.07 reviewed 20/1/09




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            Jagged Globe / Adventureworks Expedition Medical Protocols


            JAGGED GLOBE SNAKE BITE MEDICAL ADVICE

Background

With only one shy venomous snake species in the UK we are unfamiliar with this
common worldwide risk. A least a quarter of a million people a year are crippled
by snake bites and 100,000 die worldwide. As with most animal bites prevention
is better than treatment but if bitten remember that most snakes are not
venomous and that even if bitten by a venomous species less than 50% of bites
result in toxic envenomation and even then few are fatal. Fear of the
consequences is often worse than the medical effects of the bite but even so any
bite must be taken seriously.

Bite Prevention

To minimise the risk of snake bites walk noisily, cover up with clothing especially
trousers, wear stout boots, if possible avoid walking in undergrowth, avoid deep
sand, avoid climbing overgrown logs and rocks (a favourite hiding place for
animals), do not swim in overgrown water, sleep off the ground (hammock) and
use a powerful torch if going to the toilet at night.

Treatment

99% of the advice on the treatment of snake bite is pure mythology and most
treatments are potentially harmful. Outdoor shops sell snakebite kits which
should be banned. They are made up of venom suckers, bite cutters, tourniquets,
magic stones and other mystical methods of torture. Some treatments are
specific to individual snake species or types and rely on the assumption that you
are experienced in the rapid identification of a retreating snake when scared. The
advice given here is designed for UK based travellers abroad and will do the
maximum good with a minimum risk of harm.

    1. Reassure the victim. This can be realistically based on the information
       above.
    2. Immobilise the patient by getting them to lie down. They will now have to
       be carried with all the logistic problems this entails.
    3. Immobilise the bitten part with a splint.
    4. Apply a Snake Bite Pressure Bandage to the bitten limb. This is done by
       spirally applying a series of broad strapping bandages up the limb from
       foot or hand to the top of the limb and back down again ideally with crepe
       bandages. This should be tight enough to give support and reduce
       lymphatic drainage but light enough to allow blood to circulate. Practice in
       advance. Regularly check the circulation to the hand or foot and ensure
       that two fingers can be inserted under the bandage to ensure that it is not
       too tight.
    5. The patient should be transported to medical care.
    6. The only specific field treatment is pain relief if needed and symptom
       treatment such as standard first aid airway control.
    7. Any anti-venom used must be species specific and itself frequently causes
       anaphylactic shock so should never be administered without facilities to
       treat this potential reaction.

David Hillebrandt copyright prepared for Jagged Globe & Adventureworks 27.12.07. Reviewed 20/1/09
Derrtion House, Derriton, Holsworthy, Devon, EX22 6JX, England. Tel : 00 44 (0)1409 253814. E
Mail : dh@hillebrandt.org.uk




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           Jagged Globe / Adventureworks Expedition Medical Protocols


                   URINARY CATHETER GUIDELINES

Introduction

The Jagged Globe medical kit now contains one plastic urinary catheter tube. The
primary use of a urinary catheter is to enable a patient to pass urine from the
bladder if the normal passage (urethra) is blocked by problems such as blood
clots, pressure from the prostate gland (in men), pressure from a full constipated
rectum or nerve problems due to spinal injury.

The catheter can also be used for other improvised procedures.

Equipment

The kit contains one male length Foley 12 g urinary catheter with 10ml retaining
balloon. It also contains a 5 or 10ml syringe and a tube of KY lubricating gel.

The male catheter can be used on a male or female. It consists of a central tube
to drain the urine and a second valved channel through the tube to just below the
tip of the catheter where there is a balloon. The balloon is filled after insertion
and is designed to hold the catheter tip in place within the bladder. This balloon
holds 10mls of clean water but practitioners often use slightly less than the
maximum fluid content.

The size 12g catheter is normally thick enough to do the job but thin enough not
to be too uncomfortable.

There are no collection bags but these can be improvised from gaffa tape & water
bottles for a short time once the priority of urine pressure relief has been
achieved.

Potential Risks

All medical procedures have associated risks. Catheters are notorious for causing
bladder infections. They can cause damage to the urethra (tube from the bladder
to the end of the penis in males or to the vulva in females). This damage can be a
false passage with or without bleeding. I would certainly not recommend use until
all other possibilities have been tried. If possible find a local trained doctor or
nurse to confirm the diagnosis and pass the catheter. If this is not possible you or
the patient themselves may have to pass the catheter.

If you cannot obtain local medical assistance consider using a satellite phone to
get medical advice from a Jagged Globe medical advisor.

Signs & Symptoms

Most patients in urinary retention will have increasingly severe lower abdominal
pain. They will not pass urine or only dribble urine. They may report that they
have had previous problems with slow passage of urine, especially older men with
a prostate gland that is gradually naturally increasing in size. They may report
that cold weather or a sudden fluid overload (night on the ale) have triggered
previous worrying symptoms. They may report constipation. They may be on
medication such as Finasteride to reduce known prostate size.

It is possible that their bladder may be palpable or even visible above the pubic
bone towards the tummy button.




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Alternatives

Always try simple methods to facilitate the passing of urine. Treat constipation,
try to relax the bladder muscles by sitting in a warm improvised bath &/or taking
10mg or oral diazepam which may help the patient even if you do have to
proceed to pass a catheter.

If Really Necessary

If really necessary a catheter may have to be passed. If possible wear gloves,
ensure the environment is as clinically clean as possible. Prepare everything
needed first. You will need lubricant gel of some sort (KY is adequate…from
personal experience) and clean, boiled and cooled water, a syringe and brave
confident hands.

Clean the penis in males or the vulva in women. Identify the external opening of
the urethra and smear the opening with gel and cover the catheter tip in gel.
Firmly grasp the penis in men and the catheter and simply pass it up the urethra
and into the bladder. In men you may experience some resistance as it passes
the prostate gland en route to the bladder. If it is passed to its full length in both
men and women it will reach the bladder and urine should flow (phew).

When, and only if, urine flows attach your syringe of water to the valved tube
located on the side of the catheter and insert about 8mls of water. You can then
gently tug the catheter and it will start to come out until the balloon reaches the
base of the bladder and acts as a urine-proof seal.

The patient will feel instant relief and be eternally thankful.

For double security do not rely on the balloon but also tape the catheter to the
patient’s leg.

The risk of infection is so high if this is done in a remote area the patient should
start on antibiotics (see protocol for urinary tract infection antibiotics) and
continue until they reach medical care. If conscious they should be encouraged to
drink masses of fluid to keep the whole system flushed through.

The catheter can be padded to absorb urine or attached to an improvised bag
that will need emptying.

Other Uses

Any medical tubing potentially has multiple uses in a remote area. In experienced
hands a urinary catheter has been used to administer rectal fluids to an
unconscious patient. It can be used as a chest drain. This is not for the layman
but experienced remote area physicians may improvise.


Draft Two 24/4/07 Reviewed 20/1/09
Dr David Hillebrandt, Derriton House, Derriton, Holsworthy, Devon. EX22 6JX. England
00 44 (0)1409 253814
E Mail: dh@hillebrandt.org.uk




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                Jagged Globe / Adventureworks Expedition Medical Protocols


          PROTOCOL FOR REHYDRATION VIA RECTAL CATHETER

Rationale

Unconscious patients suffering from heat and dehydration and others who are
unable to drink are suitable for rehydration by the rectal route. Fluid is well
absorbed from the rectum at a significant rate.
The technique is used in palliative care to good effect and has been used in the
wilderness environment to treat shock due to blood loss.
Suitable fluids include dioralyte and previously boiled water. Ordinary boiled water
if no electrolyte solution. A made up solution of water, tablespoon of sugar and
teaspoon of salt per litre.

Kit

         A 16 CH silastic catheter suitable for urinary retention and rectal insertion.

         A 60 ml luer lock syringe or other.




Technique

  Place patient in left lateral position. A pillow under hip may allow some elevation
                                    and downward tilt.

          Insert catheter 10 cm through anus after lubrication with Vaseline/ jelly.

                 Blow up balloon by insuring 10 ml air through orange lock.




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           Jagged Globe / Adventureworks Expedition Medical Protocols




             Attach syringe to lumen of catheter to use as reservoir.




                     Pour in fluid. Allow gravity to assist flow.




Many litres of fluid can be replaced in this way.

If no syringe; cut one fingertip off a rubber glove, tie with tape around lumen
tube (where syringe is above). Then pour fluid into glove, which acts as a
reservoir.

                           Dr Brian Tregaskis for Jagged Globe
                                   T: +44 7711694556




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          Jagged Globe / Adventureworks Expedition Medical Protocols


                          SEX ON EXPEDITIONS

Introduction

I find that more and more clients are asking about contraception at altitude. I suspect
that this reflects an increasing awareness of altitude and travel risks rather than a
major change in human behaviour.

These notes are intended for both men and women and cover the sexual aspects of
any expedition where the approach and return may be as medically risky as the time
spent at altitude. They are designed to applicable to those in stable relationships,
single clients, heterosexuals and homosexuals. If, after reading these notes you
require personal advice feel free to take this letter to your own medical advisor (GP,
Family Planning doctor or travel health specialist) or contact me via the Jagged Globe
office where, as with any medical question, you do not have to give details to the
staff.

Background

Many clients ask specifically about the use of hormone contraception at altitude but
sexual medicine generally is an important section of travel health. It is interesting to
postulate that travellers as a whole, and adventure travellers in particular, may have
different attitudes from the general population to new experiences and personal risk
exposure.

Culture

We travel to experience diverse cultures. Sexual attitudes vary from culture to culture.
Please remember this and, whatever your personal inclinations or beliefs, be sensitive
to local attitudes regarding dress code and body language. Some of the countries we
visit (and some areas within countries) have very different attitudes and laws to our
own regarding public displays of affection between couples of the opposite or same
sex and may even have strong feelings about personal conduct in private. On many
mountain trips there is little personal privacy.

In some countries prostitution may be very open and acceptable, especially for visiting
tourists. This can be very risky both medically and in terms of personal security.

SEXUALLY TRANSMITTED DISEASES (STDS)

In many parts of the world HIV infection and subsequent AIDS is decimating the adult
and child population. Governments are often keen to keep these statistics hidden from
tourists. The incidence of other more curable but nonetheless serious STDs
(Gonorrhoea, Chlamydia, Syphilis etc) has risen with the rise in HIV infection.

Clients who are tempted should keep the above in mind and remember that that the
only form of safe sex in some parts of the world is “on your own, under a mosquito
net, with a condom on” and some experts would add “wearing rubber gloves”!

Condoms on their own do not offer total protection.

If you are not travelling with your regular partner and do succumb to temptation be
aware of the false reassurance offered by “quick fix” STD clinics in some countries that
offer pre-return “reassurance and treatment” to returning tourists. For you ultimate
protection thorough diagnosis is essential in this field of medicine.




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CONTRACEPTION

Introduction

Some couples regard their Jagged Globe Expedition as a last fling before starting a
family. Whilst we welcome this potential expansion of our long-term client base a few
words of caution are merited. It may be worth considering delaying conception until
after return rather than aiming for a “7000m Baby”.

When on an expedition your diet may not be as varied as at home and Folic Acid
supplements are recommended for all women in the UK who are planning to conceive.
Foetal organ formation takes place in the first few weeks of pregnancy and we have no
sound data on the effect of low oxygen pressure on this. When travelling you may
have to take long term malaria prophylactic medication and also possibly drugs to buy
time for descent in the event of severe altitude problems, or other illness. Doctors will
not be available who can advise on the suitability of medication in pregnancy.
Inevitably some clients will pick up the Shits and may, on return, need treatment after
laboratory analysis of stool samples. Some of these treatments are best avoided
during pregnancy. A three-month delay in conception after returning and finishing any
malaria medication would seem sensible.


CONTRACEPTIVE METHODS

Rhythm Methods

Methods such as the Rhythm Method (Vatican Roulette) and the temperature method
become even more unreliable when travelling in hot climates with the possibility of
infections and menstrual irregularities.

Condoms

Every traveller should carry condoms even if they are just “to lend to a friend in case”.
The quality of home purchased condoms is normally high and the fit designed for the
national average! They give a degree of protection against STD transmission and can
be used with hormonal methods for extra safety (a bit like having a safety strap on
your step in crampons just in case). Those with a sense of humour who like female
condoms (Femidom) may find them totally unobtainable abroad.

Just as with sanitary towels and tampons thought must be given to how you propose
to dispose of used barrier contraception in a remote area in a developing country.
Locals will rummage through rubbish and animals are attracted by body smells.

Cervical Caps

If you are used to and happy with this method stick to it but remember that
unpackaged rubber is prone to weakening in some hot climates and tubes of
spermicidal cream can be messy if they break in a rucsac.

Intra Uterine Contraceptive Device (IUCD or “coil”)

If this is your normal method of contraception and it suits you stick with it but do not
change to it in the few months just before departure since the effects on periods is
unpredictable. Remember that there is a slightly increased risk of a potentially serious
ectopic pregnancy in IUCD users and the effects of STD may include pelvic infection.




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           Jagged Globe / Adventureworks Expedition Medical Protocols


Intra Uterine Contraceptive System (Mirena coil)

This “modern coil” gives much better contraceptive reliability and period control than
the traditional coil due to the slow release of the progesterone hormone from its stem.
If this is your normal contraceptive method stick with it and if you have plenty of
notice of your expedition you may wish to consider changing to this system. Do not
change in the few months prior to departure since you need to be confident that it
suits you over at least six months.

Hormone Methods

a) The Combined Oral Contraceptive Pill (COC).

This is the commonest contraceptive pill and contains a balance of two hormones,
Oestrogen and Progestogen. It is normally taken for 21 days followed by a seven-day
gap when a “period” usually occurs. If taken as directed, and not malabsorbed due to
vomiting, diarrhoea or concurrent use of antibiotics, it is a very reliable method of
contraception with good period control. The seven-day gap can be missed so that two
or three packets are taken in succession to avoid periods whilst away. This can
obviously be a major advantage in some third world countries but it is still worth
carrying some form of sanitary protection in case of slight break through bleeding.

It is known that the Oestrogen component of the COC increases the tendency for the
blood to clot. In a fit non-smoker at sea level this risk is minimal but at altitude the
blood further thickens due to its response to acclimatisation and also possible
dehydration. The risk of blood thickening and subsequent formation of a Deep Vein
Thrombosis (DVT) may be further increased by storm-imposed immobility in a tent.

A 1999 survey of 316 women on the Everest Base Camp Trek found that 30% were
taking the COC, many for period control, and none came to any harm, but the data is
limited. I would suggest that women should consider avoiding the COC if they are to
spend more than a week above 4500m. Below 4500m it is almost certainly safe in an
otherwise healthy active non-smoking lady with no personal or family history of
venous thrombosis.

b) The Progestogen Only Pill (POP, Mini Pill)

This pill contains only one hormone, Progestogen, and is taken every day without a
break between packets. Contraceptively it is slightly less effective than the COC and
gives less period control but it does not have the same clotting risks as the COC. For
maximum contraceptive efficiency it must be taken at the same time every day (or at
least within three hours) so make allowance for time zone changes.

Like the COC travellers diarrhoea or vomiting can reduce absorption and efficiency.

If this is your contraceptive of choice ensure that you are settled on it for several
months before departure. As with all medication make sure you carry a full set of
spare medication in case of loss or theft. Trips to local pharmacies to get replacements
are time consuming and it can be impossible to obtain your specific pill.

c) Injection Contraception (eg Depo-Provera)

These injections are given every three months and slowly release progestogen into the
body. In terms of blood clotting they are as safe as the POP. Efficiency is not affected
by stomach upsets or antibiotics and one only has to remember to have an injection
every three months. Time zone changes and potential loss pose no risk. With




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             Jagged Globe / Adventureworks Expedition Medical Protocols


injectable contraception periods may, initially, be unpredictable but this usually settles
with the second or third injection. Periods may eventually stop altogether.

Many clients find this the ideal expedition contraceptive but one should be well settled
on it before departure. If going for more than three months one could carry an extra
ampoule and learn how to self-administer. If a jab is due during the trip away it may
be possible to have it early (get personal advice).

d) Progesterone Implant (Implanon)

Very similar to the injection. A flexible rod of slow release progesterone is implanted
under the skin via a small surgical incision. Each implant works for three years. It is
again best to be well settled on this contraceptive method before departure and your
contraceptive decision should be discussed with your personal advisor.

e) Post Coital Emergency Contraception

For up to 72 hours after unprotected intercourse a high dose of progesterone
(Levonorgesterel 1.5mg, marketed as “Levonelle 1500” or Levonelle One Stop” in the
UK) can reduce the chance of unwanted pregnancy. The earlier this is taken after
unprotected intercourse the more efficient it will be. This is not suitable as routine
contraception due to the high dose of hormone needed but some doctors will prescribe
it to traveller “in case”. It comes with full instructions. It is not carried in the standard
Jagged Globe Medical Kit but can be purchased over the counter from a trained
pharmacist in the UK.

A less effective method of hormonal Post Coital Contraception with more side effects
uses two high doses of COCs.

For up to 120 hours (5 days) after unprotected intercourse an IUCD can be fitted by a
trained and experienced medical practitioner and should serve to prevent pregnancy.

BEWARE. Neither of the above gives any protection against STDs.

Any of the above may be a good reason for a rapid trip to a GP or Hospital casualty
Department direct from the airport.

Sterilisation

Male or Female. Virtually 100% effective as a contraceptive. No effect on blood
clotting or on periods. No protection against STDs. Nothing to remember. Permanent.
Not good for future expansion of the Jagged Globe client base.


Exhaustion

“I’m too tired tonight” and “I have a headache” both take on a new meaning on high
altitude expeditions but don’t rely on them as methods on the return journey. Cold
showers on trips are often the norm.


Updated 29/05/2004 & 8/1/2005 & 15/4/07 & 20/1/09.

Dr David Hillebrandt,
Medical Advisor to Jagged Globe Expeditions
dh@hillebrandt.org.uk




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            Jagged Globe / Adventureworks Expedition Medical Protocols


  JAGGED GLOBE MEDICAL ADVICE ON RISK OF LEG CLOTS
                   WHEN FLYING

Introduction

There has been a lot of media attention recently regarding the risk of developing
a Clot in the veins of the leg (DVT) whilst immobile in the dry low-oxygen
environment of a long haul flight. This is not a new problem and has been
recognised for some time in any immobile person. We know that the risk is much
higher in smokers, pregnant women and women on the combined oral
contraceptive pill.

Sensible Precautions

Airlines are now sensibly advising people to move around during flights (not
popular when meals are being served) and to minimise one’s alcohol intake, since
alcohol adds to the dehydration that is inevitable in the dry environment. It is
sensible to drink lots of fluid such as dilute orange or water but airlines currently
limit the fluids that you can take on board so do not be shy in repeatedly
requesting non alcoholic drinks especially water when seated. I would suggest 2-
3 litres for a flight to Nepal.

Some people are advised to take one adult Aspirin (300mg) before the flight to
reduce the stickiness of the blood’s platelets which are part of the body’s clotting
mechanism. This seems a sensible precaution unless you are allergic to Aspirin
or have a tendency to stomach ulcers or indigestion with Aspirin. Some other
authorities also recommend the use of compression stockings. I personally find
these tight, hot and uncomfortable but they might keep you safer.

High Altitude

One part of the body’s natural process of acclimatisation to High Altitude is to
produce more red cells to carry more oxygen from the thin air. This results in the
blood becoming thicker and therefore one is more prone to get DVT’s. This
process of acclimatisation remains for several weeks after return to lower altitude
and is a small part of the basis of altitude training for high standard athletes.

In theory this may put our clients, and any other returning high altitude tourists,
at greater than normal risk of developing a DVT during or soon after a long haul
return air flight. We stress that there is currently no hard evidence for this. The
matter is being further discussed by the British Travel Health Association and
International Society of Mountain Medicine.

Until we have more data we can only suggest that out clients take all possible
precautions as outlined above. Like any mountaineering risk we leave the
ultimate decision regarding precautions up to you, but remember that a post
expedition drinking session could leave you further dehydrated before your return
flight!

Advice Sheet by Dr David Hillebrandt, Medical Advisor to Jagged Globe& Adventureworks. 2.7.01
revised 8/1/05 & 20/1/09




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          Jagged Globe / Adventureworks Expedition Medical Protocols


                         THE DOCTORS DILEMMA

Background

Over the years Jagged Globe has built up a loyal client base which includes many
medically qualified doctors from different countries. Some come on our trips to
enjoy a complete break from the demands of patient care, others have a
particular interest in the complex and evolving speciality of altitude and
expedition medicine. We endeavour to respect and accommodate both attitudes.

Our trip leaders have specific remote area first aid training, access to our
company doctor and carry a suitable simple medical kit with advice sheets. In
addition they have many years of practical lay experience of mountain medicine.

As a company we constantly monitor changes in the international medico legal
situation regarding expedition medicine and also the training courses available for
doctors wanting to become involved in this speciality. Since 2001 we have
actively supported the development of the UK’s U.I.A.A Diploma of Mountain
Medicine.

Current Situation

We welcome doctors on our trips but are aware that if we offer a financial
discount to medical clients many professional insurance organisations would
deem this to be a contract of employment, with implications for insurance and
professional training expertise. As a general rule we do not expect medical clients
to use their medical skills on our trips.

We are aware that doctors have an ethical and moral obligation to use their skills
to the best of their ability in the event of a medical emergency as a Good
Samaritan. Historically there have been cases on commercial and non-commercial
expeditions when this has resulted in a climbing doctor having to give up any
chance of reaching a summit in order to care for a companion requiring
evacuation. Fortunately this is very rare but the ethical aspects of a doctor’s
obligations, plus the long tradition of mutual help amongst mountaineers, crosses
international boundaries. In the event of this happening the patients own health
insurance would most likely cover the doctor’s out of pocket expenses but would
not compensate for any lost mountaineering opportunity. All our clients and
locally employed staff have insurance cover.

Internationally all IFMGA Guides have a similar professional obligation to offer
mutual help in the mountains.

In summary, as a doctor you may occasionally be asked to advise and support an
expedition leader who will always maintain overall responsibility for the welfare of
team members. In exceptional circumstances you may be asked to help care for a
seriously ill or injured person in the mountains. This would be on the
understanding that you may have only limited skills relevant to this specialised
field of medicine.

Further Information/Training

Any doctor wishing to increase their expedition and mountain medical skills is
welcome to contact our staff and discuss this aspect of their expedition. We will
put you in touch our company doctor who is always happy to discuss medical
logistics on expeditions, medical equipment, treatment of altitude problems in the
field and suggest further reading and available courses in the UK and abroad.


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            Jagged Globe / Adventureworks Expedition Medical Protocols



More Formal Medical Role

Any doctor wishing to take on a more formal medical role on an expedition will
have to discuss this on an individual basis with a company director and our
company doctor at least two months prior to departure.


Simon Lowe & Dr David Hillebrandt.
Jagged Globe
5/3/04 Reviewed 20/1/09.




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          Jagged Globe / Adventureworks Expedition Medical Protocols


                    CALLING FOR MEDICAL ADVICE

Introduction

With the increasing use of satellite phones, E mail and digital photos leaders are
able to get faster medical advice than ever before. This advice sheet is designed
to help you plan for the information that a doctor may need to give you the most
efficient remote area help and advice possible. Doctors are used to
communicating about patients so they tend to use a fairly standard format that
has evolved over many years. You do not have to stick to it totally but it is a
useful guide and will increase the doctor’s faith in your knowledge.

You may have to communicate from a remote area or from a city when planning
a possible medical repatriation.

This advice sheet will not cover the normal mountaineering details required in any
message for help such as position, approach, injuries/illness, markers etc. If you
do not know this you should not be leading the trip!

Try to get these details in a relaxed private environment. Work methodically
through them and write them down for transmission. I assume that you have
dealt with life threatening injuries first!

Patient details

Name, age, sex, DOB, Ethnic origin.

Presenting complaint

This refers to the symptoms that are causing the problem. E.g. “ Short of
Breath”, or “Lower Abdominal Pain” or “Fall over steep rough ground of 100m
with leg injuries”

Do not give your diagnosis (yet)…..if you do you will bias the independent
opinion.

History

How long did the symptoms take to develop? How severe are they? It may be
necessary to relate the time to altitude and/or to distance over many days.
With pain: where is it? Is it getting better or worse? Is it constant? Does it come
and go? Is it stabbing or aching? Does anything make it better or worse? Has it
moved? Does it radiate from one place to another? Has any pain relief been tried?
Has the person had a similar problem/pain before and do they know what caused
it before? Pain can be assessed by asking the patient to score it from 0-10, 0 is
no pain and 10 is the worst imaginable.
Is the symptom related to food, diet, bowel function, peeing, activity, movement?
Have they lost consciousness? Was it witnessed? For how long?


Systemic enquiry

This covers all the things that might be relevant if not already volunteered by the
patient. Described by Jim Duff as the “Ins and Outs of the last 24 hours”
Any nausea? What is appetite like? Previous similar illness? Peeing OK? Crapping
OK? Any visible blood in pee or poo? Vomited? Colour of vomit? When was last
period (ladies)? Chance of pregnancy?


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            Jagged Globe / Adventureworks Expedition Medical Protocols



Past Medical History

In theory anybody with serious pre trip medical problems should have declared
them but…………(this is not the time to tell them lack of declaration may have
invalidated their medical insurance!)

Previous or coexisting: Asthma? Diabetes? Heart problems? Psychiatric or
Psychological problems?

Useful open questions are: “Have you ever been in hospital for anything?” “ Have
you ever had to take medication for anything for more than a month?” “ Have
you ever had to have a specialist’s outpatients appointment?” “Have you had to
see your normal doctor in the last year?”

Drugs

Are you on any medication at all at the moment?
Are you, or should you be, on any prescribed medication at the moment?
Are you using any complementary medications at the moment?
Have you missed any doses?
If yes to any of above: What drugs (trade and chemical names if possible)? What
doses? What frequency? Duration of treatment?

What about street drugs in last three months or alcohol (? Recently stopped).

Allergies

To any drugs, dressings or anything else?

Examination

A difficult skill. Always ask permission (if conscious) and explain what you are
doing. If in doubt compare two sides or compare with yourself.
Use all your senses…..Look, listen, feel, smell (you could even taste the urine for
sugar!)

Basic information is useful: Pulse rate, Breathing rate, temperature (hot/cold),
trunk and limbs. Colour of skin and lips.

“Unconscious” is a useless word. How unconscious??? Are they Alert and
orientated? Can they talk? Obey commands (e.g. squeeze my hand)? Coherent or
incoherent? Just noises if shouted at? Do they respond to pain? Is it a specific
response to move you away or just a vague movement? Do they not even
respond to induced pain (pinch, rub on breast bone)? (AVPU: Alert, Voice
response, Pain response, Unconscious no response to anything)

Check them from top of head to tip of toes front and back if necessary and in
warm protected environment.

Diagnosis

I will now let you make a guess at the most likely working diagnosis and other
diagnoses considered. Be prepared to modify this as you get more information
and time passes.




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            Jagged Globe / Adventureworks Expedition Medical Protocols


Treatment Given

Details of ALL treatment given so far, including drugs and times and doses. Fluid
orally or other routes, Pee output. Splinting etc.

Any investigations/tests done locally?

Your Preferred Action Plan

You are the person on the spot. We welcome you opinion and expertise.

Written Notes

Keep at least three sets of these notes. One to go with the patient, one for your
records, one for the company (one for the solicitor!). Remember this is
confidential medical information.


DIAGNOSIS OF DEATH

I hope you do not have to do this.

Keep calm. Do not accept somebody else’s opinion unless medically qualified.
Work on the same principle of History and Examination.

Get a full history of the incident including altitude, ascent, temperature from any
witnesses.

Examine patient. Beware the Hypothermic patient! Death can be confirmed with
injuries incompatible with life or decay. Otherwise ensure that the patient looks
dead, you can feel no pulse in wrist, neck and groin over one minute, you can feel
and see no breathing over five minutes and the pupils of the eyes are dilated
(big) and do not react if a light is shone into them.

Best if this is all done with a witness. If in Europe/USA etc leave body as
undisturbed as possible for full police investigation. In UK this is now officially a
“scene of crime” and under the control of the coroner of equivalent. In remote
area or area of risk you may have to leave the body. I recommend photographic
evidence keeping one film or digital card for local police and one for family in the
UK (Company doctor will look after the return of this). Explain to others that this
is being done for legal reasons to facilitate the inevitable paperwork and will help
the family sort out affairs in the home country.
If you have to dispose of the body do so with respect and to protect it from
animals. A member of the group may want to say some words. Again arrange for
photographs of the “ceremony” and the area, and a map for the family and for
officials. Ensure that you have taken responsibility for passport, identity cards
etc.

Remember that it is not only your group who require care but also yourself.


Dr David Hillebrandt.
Medical Advisor to Jagged Globe and Adventureworks
Derriton House, Derriton, Holsworthy, Devon. EX22 6JX . England
#00 44 (0)1409 253814
dh@hillebrandt.org.uk


Advice sheet 29/1/05 Revised 20/1/09



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         Jagged Globe / Adventureworks Expedition Medical Protocols



            Jagged Globe Medical Kit (Standard)
QUANTITY               ITEM                   NOTES          QTY R’TD.
                                ANALGESICS
   100          Paracetamol 500mg tabs
   50           Ibuprofen 400mg tabs
                Codeine Phosphate
   100
                15mg tabs
                Tramadol (100mg)
   10
                Ampoules
                Syringes (2ml) and
   10
                needles.
                Drug protocols &
    1           background information
                book
                               ANTIBIOTICS
   60           Magnapen caps
                Ciprofloxacin (Ciproxin)
   20
                500mg tabs
                Metronidazole (Flagyl)
   40
                400mg tabs
                Protocol for antibiotic
    1
                use.
                             ALTITUDE DRUGS
                Acetazolamide
   20
                (Diamox) 250mg tabs
                Nifedipine (Adalat)
   28
                20mg m/r tabs
                Dexamethasone
    4
                10mg/2ml amps
                Dexamethasone 2mg
   30
                tabs
                Protocol for altitude
    1
                illness.
                               OTHER DRUGS
                Aspirin Soluble 300mg
   30
                tabs
                Diazepam (Valium) 5
   28
                mg tabs with protocol.
                Prednisolone 5mg tabs
   50
                with protocol.
                Senna tabs (laxative)
   20
                Prochlorperazine 3mg
   20
                buccal tabs (Buccastem)
                Loratidine 10mg tabs
   30
                (antihistamine)
                Oral Rehydration
   12           Mixture Sachets
                (Dioralyte or similar)
    1           Otosporin Ear drops.
                Chloramphenicol eye
    1
                ointment 4g tube
    5           Amethocaine eye drops.


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              Jagged Globe / Adventureworks Expedition Medical Protocols


                      (local anaesthetic)
         1            Bonjela
        24            Strepsils
                      Clotrimazole and
                      Hydrocortisonne Cream
      1 tubes         (Canesten / HC)
                      (Vaginal thrush or
                      skin/groin rashes)
                                  GENERAL ITEMS
                      Medical Gloves (non
      4 pairs
                      sterile)
         1            Scissors.
                      Thermometer electric
         1
                      oral type
                      Catheter and protocol
         1
                      sheet
        1             10ml syringe
        1             Tube KY Jelly (small)
        1             Micropore tape
       Lots           Assorted Plasters.
        2             Strip of Elastoplast
                      Elastoplast elastic
         1            adhesive bandage. 7.5cm
                      x 4.5m
         1            Tincture of Iodine
        12            Sterile Wipes
                      Savalon/Germolene
         1
                      tube.
                      Melolin Dressing 10cm        .
         6
                      X 10cm
 Lots (10 approx)     Various size dressings
        10            Sanitary Towels.

HILL KIT- The trip leader may wish to divide the medical kit for use on the hill.
You may wish to carry a small stock of Altitude Drugs and Tramadol (with
protocols) plus a few improvised dressings. You may even wish to loan a similar
kit to a client if you feel they have sufficient experience to use these potentially
life saving emergency drugs.

EXPEDITION DOCTOR If your trip has an official JG doctor he/she may have
arranged for additional drugs or equipment to be added to the standard kit.

ADVICE For advice on drug use you must use JG guidelines and Jim Duff’s
excellent book “First Aid and Wilderness Medicine”

Dr David Hillebrandt, Updated 12/11/07 Reviewed 20/1/09




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              Jagged Globe / Adventureworks Expedition Medical Protocols


                       8000m Expedition – Extra Drugs List

                         Addition to Standard Medical Kit
              Item                    Quantity                  Returned
Tramadol 100mg                          10
Lignocaine 2% plain 20ml                 1
vial
Paracetamol 500mg tabs                   100
Ibuprofen 400mg tabs                     100
Diazepam 5mg tabs                        20
Dexamethasone 2mg tabs                   100
Dexamethasone 5mg/ml.                    10
2ml amps
Nifedipine (Adalat) 20mg                 56
retard tabs
Acetazolamide 250mg tabs                 112
Senna tabs                               50
Ranitidine (Zantac) 300mg                30
tabs
Coamoxiclav 625mg tabs                   42
Coamoxiclav 600mg inj                    5
amp
Erythromycin 250mg tabs                  40
Ciprofloxacin 500mg tabs                 60
Metronidazole 400mg tabs                 50
Metronidazole 500mg                      5
supp
Acyclovir (Zovirax) cream                 1
x 2g
Betnovate cream 30mls                     1
tube
Aqueous cream 50mls tube                  1
Amethocaine eye minims                    5
Chloramphnicol eye oint                   4
4g
Tropicamide 0.5% minims                   5
Betnesol eye/nose/ear                     1
drops 10mls
Water for injection 2ml                  10
amps
0.9% Normal Saline 500ml                  4
bags
Dioralyte sachets                        100
Non sterile gloves for                   10
personal protection

Reviewed 20/1/09




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           Jagged Globe / Adventureworks Expedition Medical Protocols


                  MEDICAL EQUIPMENT LIST 8000m

                       Additional to JG Standard Medical Kit

           Item                   Quantity           Returned
Gamow bag                               1
Nasal airways – 6/7mm                   2
Thermometer Electrical                  1
oral normal reading
IV giving sets                          2
Venflons green (18g)                    2
Venflons grey (16g)                     2
Venflons Pink (20g)                     2
Needles green (for                     20
syringe)
Needles blue (for                       5
syringe)
2ml syringes                           10
10ml syringes                           5
Durapore Tape 2.5 cm x                  2
5m
Elastoplast 7.5cm x                     3
4.5m adhesive dressing
#66004146
Sanitary towels                        30
individually packed
Melolin pads 10cm x                    20
10cm
Superglue                               1
Sam Splint                              2
Elastoplast adhesive                    4
strip with backing
Sutures 3/0 silk                        4
Scalpel blades                          5
Cavit (or other make)                   1
Dental Filling
Cling Film                              1
Scissors                                1




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          Jagged Globe / Adventureworks Expedition Medical Protocols



Adventureworks HA/ Rainforest Medical Kit
QUANTITY                 ITEM                      NOTES      QTY R’TD.
                                ANALGESICS
    100           Paracetamol 500mg tabs
     50           Ibuprofen 400mg tabs
                  Codeine Phosphate
    100
                  15mg tabs
    10            Tramadol (100mg)
    10            Syringes and needles.
                  Drug protocols &
     1            background information
                  booklet.
                               ANTIBIOTICS
    60            Magnapen caps
                  Ciprofloxacin (Ciproxin)
    20
                  500mg tabs
                  Metronidazole (Flagyl)
    40
                  400mg tabs
                  Protocol for antibiotic
     1
                  use.
                  Azithromycin /
     ?
                  Clarithromycin
                           ALTITUDE DRUGS
                  Acetazolamide
    20
                  (Diamox) 250mg tabs
                  Nifedipine (Adalat)
    28
                  20mg m/r tabs
                  Dexamethasone
     4
                  10mg/2ml amps
                  Dexamethasone 2mg
    30
                  tabs
                  Protocol for altitude
     1
                  illness.
OTHER DRUGS

                  Diazepam (Valium) 5
    30
                  mg tabs with protocol.
                  Prednisolone 5mg tabs
    50
                  with protocol.
     1            Salbutamol Inhaler
                  Senna tabs (laxative)
    50
                  Buccastem (for                Or Stugeron
    20
                  sickness)

                  Loratidine 10mg tabs
    30
                  (Antihistamine)
                  Oral Rehydration
    30            Mixture Sachets
                  (Dioralyte or similar)
     1            Otosporin Ear drops.


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               Jagged Globe / Adventureworks Expedition Medical Protocols


                       Chloramphenicol eye
         1
                       ointment 4g tube
                       Amethocaine eye drops.
         5
                       (local anaesthetic)
          1            Bonjela
         24            Strepsils

                       Clotrimazole and
                       Hydrocortisonne Cream
      2 tubes          (Canesten / HC)
                       (Vaginal thrush or
                       skin/groin rashes
                                   GENERAL ITEMS
                       Medical Gloves (non
      6 pairs
                       sterile)
         1             Scissors.
                       Thermometer electronic
         1
                       oral type
         1             Micropore tape
        Lots           Assorted Plasters.
         4             Strip of Elastoplast
                       Elastoplast elastic
         1             adhesive bandage 7.5cm
                       x 4.5m
          1            Tincture of Iodine
         12            Sterile Wipes
                       Savalon/Germolene
         1
                       tube.
   1 medium tub        Vaseline
                       Providone-Iodine dry
   150g aerosol        powder spray
                       (Betadine)
         6             Melolin Dressing               .
 Lots (10 approx)      Various size dressings
        10             Sanitary Towels.
                       Wide crepe Bandages
         3             (For Snake Bite
                       Dressing)
                       DEET based insect
                       repellant
         2


FIELD KIT- The trip leader may wish to divide the medical kit for use in the field. You may wish to
carry a small stock of Altitude Drugs and Tramadol (with protocols) plus a few improvised dressings.

EXPEDITION DOCTOR If your trip has an official Adventureworks doctor he/she may have arranged
for additional drugs or equipment to be added to this list.

ADVICE For advice on drug use you must use the Adventureworks guidelines and Jim Duff’s
excellent book “First Aid and Wilderness Medicine”

Dr David Hillebrandt, Updated 1/1/08 Reviewed 20/1/09




                                                 75
                 Jagged Globe / Adventureworks Expedition Medical Protocols


              Situation                                    Patient Details

Date                                   Name

Time                                   Age

Location (Grid Reference)              M     /        F

                                       Next of kin name, phone number and relationship
Others in party/ witnesses


       Level of consciousness                             Medical History

Alert                                  Symptons?
Voice
Pain
Unresponsive                           Allergies?
         Airway Open

Y   /     N                            Medication/ drugs?
              Breathing

Y /    N (CPR)                        Past medical history?
Noise?
          Circulation
                                       Last food/ drink?
Major bleeding?
Skin colour                            Events leading to incident?
Pulse
Caplillary refill > 2 seconds
             Deformity                       Monitor and Record every 5 minutes

Head to toe examination                Time
(Recovery position)

                                       AVPU


                                       Breathing


                                       Pulse


                                       Colour


                                       Temp.




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