medex

Medex Newsletter, Number 9

March 2002

Welcome to the 9th Medex Newsletter. This Newsletter has been delayed until now pending a decision about the viability of the 2003 Expedition. I am delighted to say that a group of around 40 of us met in North Wales last weekend and carefully weighed the pros and cons of going to Nepal in 2003. As most people will be aware the political situation in Nepal has deteriorated over the last year which left us in serious doubt about the viability of our Expedition. All were included in the decision and I am very happy to report that we decided to go ahead as planned. If you are seriously considering coming on Medex 2003 I would seriously urge you to read the political section in this Newsletter and the eloquent report sent in by Don Patterson. Booking forms are on our website and we urge you to read the conditions very carefully.

Forthcoming dates

July 13th and 14th at Pinfold, Hyssington, Powys. This is a crucial Medex event if you are coming or thinking of coming on the Medex 2003 Expedition. As we get to know people during the weekend we can start to form the trekking groups, the essential part of a successful expedition. You can also meet some of the researchers and find out how you can get involved in the research projects. Hyssington is on the Welsh borders, just off the A488 between Shrewsbury and Bishops Castle. You can camp or make use of local B&B's. We will have the use of the village hall should the weather be wet. Please indicate if you are coming by sending an email to Simon@medex.org.uk. We will plan a barbeque for Saturday night and will co-ordinate the food once we know who is coming. Likewise if you need directions to find the Pinfold, please contact me.

1st - 3rd November, Old Dungeon Ghyll Hotel, Lake District Weekend. This is the annual Medex event and this year will be a key part of the run up to the 2003 expedition. On Sunday morning the researchers will be explaining the projects they will be carrying out on the expedition and how to do some of the simple en route data collection like mountain sickness scores ~ penalties will be awarded for the use of medical jargon and techno - mumbo - jumbo! This is a really good opportunity to come and ask questions about what volunteering for a study involves. We normally arrive on the Friday night, spend Saturday on the hill with dinner in the evening. B&B accommodation can be booked direct with the Hotel (tel: 015394 37272) and camping is available nearby. If you want to attend the dinner on the Saturday evening this must be booked direct with Medex as places are limited. A cheque for £25 will secure your place for dinner, made payable to Medex and sent to the Pinfold, Hyssington, Montgomery, Powys.

Weekends in Jan/ Feb 2003; Data Collecting Weekends. We will be carrying out studies on two consecutive weekends prior to the expedition. We very much hope everybody will be able to attend one of these weekends, so we have a base line for comparison with the observations we make at high altitude. Exact dates and locations to be advised but likely to be London based.

Membership continues to grow at a healthy rate with a further 30 joining in the last quarter. Total paid up now stands at: 210

Congratulations to Peter and Jane Barry who sent in this note: Due to the recent arrival of Oliver Henry (3.66kg, born 16.06 on 22/01/02, mother and baby doing fine, thanks) I will be even slower than normal answering my emails. Normal service will be resumed soon. Maybe....

George Smith. Those that were on the 1994 Expedition will be sad to learn of the death of George Smith.. He died in March 2000 of a heart attack whilst canvassing for the Liberal Democrats near his home in Edinburgh. With characteristic generosity he left £200,000 in his will to various Scottish mountaineering charities including one bequest to develop a new light weight mountain rescue stretcher.


Memorial for Will Reynish: Following the death of Medex member Will Reynish last year, a memorial concert is being held on Sunday 2nd June 2002. It's a charity concert to celebrate William's life, followed by a barbecue and ceilidh.

The programme will include Zadok the Priest; Handel, Hymn to St Cecilia: Britten, Aria s from The Marriage of Figaro and the Magic Flute: Mozart, and Spirituals from "A Child of our Time": Tippet. It will be held in The Great Hall Merchant Taylors' School, Northwood, North London at 2.30pm. Anyone wishing to sing in "Zadok the Priest" is invited to join in and bring their picnic and a copy for a rehearsal at 12.30pm just prior to the concert. Ticket prices are £10 (adults), £5 (concessions), children free for the concert. (In aid of PHAB and AGE Concern)

Roger McMorrow is organising an expedition to the Indian Himalaya this spring and this will be filmed by a documentary film crew and has the provisional backing of the National Geographical. He has had lots of publicity in Ireland and I include later in the Newsletter a snippet culled from the Irish Times. All this seems to have done no harm to his career as he has found himself an anaesthetic SPR rotation and won the anaesthetic prize after presenting his laryngoscope at a scientific meeting. Good luck in India!

Ulli Steiner writes, "Meanwhile I have started my internship in anesthesiology at the university in Munich.. Nanga Parbat was really unsuccessful due to bad ice conditions on the Rupal side and bad organisation. Such is life. Nevertheless I got the chance to visit Pakistan for 8 weeks "before the 11-th September". This year I am going to be the doctor of the German Alpine Club expedition to Changabang"

Scams by Paul Richards."I received this confirmation from Ingrid Slater who is Secretary to Prof. Bärtsch, General Secretary ISMM. Membership of ISMM does indeed include a subscription to the paper edition of HAMB. Since Regular ISMM Membership is $75 ($60 if a member of a national mountain medicine society/WMS) this represents incredibly good value as HAMB sub alone is usually $200! ($125 students)."

Expedition position sought. Sarah Trippick writes: "I have been given your contact through Annabel Nichol regarding the possibility of getting involved as an expedition doctor. I am currently an SHO in A&E at UCl and have a 6 month period from mid feb before a rotation. I have been on several commercial expeditions up to 6000m but wish to get involved as an expedition medic. I understand from Annabel that it may be possible to get more opportunities from your newsletter. Please let me know if you can help with this."

Plas y Brenin 2002 The recent Mountain Medicine and High Altitude Physiology Course at Plas y Brenin, North Wales was another resounding success. It was particularly satisfying to see a lot of new and youthful faces in the audience. As ever the speakers were drawn from an international who's who of mountain medicine. Peter Barry is, once again, to be congratulated on assembling yet another fine course.

The Mountain Medicine Diploma A small working group met during the recent Plas y Brenin Course and began work on developing the UK Mountain Medicine Diploma. We hope to have the UK syllabus ready in time to present to the UIAA for approval in Barcelona on 20th April. If all goes well we should be able to publish details in the next Medex Newsletter.

Political instability in Nepal: For many months now we have been monitoring the Maoist uprising in Nepal. Initially we had planned to take bookings for the 2003 trip last spring but decided to postpone in the hope that the political situation became clearer. The assassination of the Royal Family last summer unfortunately raised tensions to new heights. The Government then collapsed and the incoming administration sat down with the terrorist leaders to negotiate and for a while we were optimistic. In late November the talks broke down and the army was mobilised to put down the rebellion. Violence levels escalated at the end of November and we decided to use the Plas y Brenin meeting in March 2002 as the decision time. Accordingly a large group of Medex members sat down on 11/3/02 to discuss the viability of our Medex 2003 Expedition to Nepal. It was agreed that postponing the expedition was unlikely to make things clearer and that postponing the decision further would cause all sorts of problems booking airlines etc. We discussed alternative venues but agreed that none would be attractive or realistic within our time schedule. We discussed the risks to individuals and whether those present would be prepared to take those risks. We all agreed that the Expedition should go ahead as planned UNLESS we were advised, in the future, not to go by the Nepalese Government or the British Foreign Office. All present understood that there would be risks of cancellation that weren't covered by insurance, a risk of late re-location to another region within Nepal, risk of missing international flights due to strike action and, of course, a risk to personal safety. If you are planning to come on Medex 2003 please read - before you book - the 2 narratives sent in by Don Patterson both of which are printed below.

Comments on the current Politics in Nepal by Don Patterson
Good to hear that a decision has been reached about the trip. I am receiving slightly conflicting emails. One beautifully written one yesterday:-
.................... "The physical absurdity certainly stands. The metaphysical absurdity is a little different at this time. The world outside believes Nepal is in a mess, in a tragic mess with an economic pit before it and political horrors on-going of previously unknown and undreamed of violent strife between police, army, Maoists and peoples. But does Kathmandu believe this? Life has been going on in Kathmandu, not quite as it did 35 years ago, but with almost the same cultural threads dominating, or transcending, the new global features of party politics, human rights, multinationals, social justice, violence....................... And already there are more weird looking saddhus around preparing themselves for Shivaratri, which will, hopefully, present as ever its glorious magical night of the year.

Lots of other similar, but smaller gatherings take place to celebrate something. Shivapuri Baba's ashram was open for its usual offerings of peaceful meditation and food, for the needy as well as the followers.

For those who have been directly hit by the tragedies, there is no participation in all these activities, whether they are Kathmandu residents or refugees from the strife-torn areas outside. But for others the horror is more like a drama, to be discussed avidly, with disbelief perhaps, but not allowed to interfere noticeably. Even many of those desperately looking for some kind of income for survival are participating with open hearts. And, it seems, the participants are not only the 'establishment', the wealthy, the well set-up. They include also the shaky-positioned, the middle and lowish, though not the bottom, who, as ever, now or in the past, have no strength to raise their beings above the struggle for survival of the body.

How is this? Is it that a quality of the psyche in Kathmandu, and in Nepal in general, is to live in the present?"

In contrast, there is the following that I received last week:-

"Having just returned from Nepal.....I thought I should take this opportunity to update you .... on the current situation. I am unsure how much you are all aware of what has been happening recently. Importantly, it seems to me that we ...need to take stock. The two weeks while I was there saw both the Maoist attack on Achham district, and a two day bhand which ground the country to a complete halt and witnessed some horrific attacks on those who ignored it, and the extension to the Emergency by parliament. The attack on Achham (which I believe received news space in the UK as well) was undertaken by a large well organised Maoist force that ended with the deaths of the CDO, and all the stationed police and army in this district centre of the far west of the country. Over one hundred and forty people were reported killed - as well as all the bodies being mutilated, which caused the most horror amongst those I spoke with. The sense of vulnerability that many now feel in Kathmandu is acute. My sense was that it is hitting home that the Maoists are far more organised, with greater support and organisational capacity than was previously realised. As was pointed out to me the death toll DAILY reported in the papers is now usually in double figures. I have to seriously doubt whether extending the Emergency and its provisions, or the current strategy of the army will do much except entrench an increasingly violent guerrilla war (although I admit that in the current climate of the global war against terrorism my interpretation will not be universally accepted). What is certain though is that no one I spoke to seems able to anticipate what will happen. A special editorial of the Kathmandu Post after the Achham slaughter entitled "Please do something" just about sums up the desperation.............. there is considerable build up of Maoist forces around Diktel (well over a thousand reported). It is anticipated that a similar attack like that on Achham is planned in the near future. The army is currently over-stretched and the likelihood of getting forces there in any numbers is not great........ Similarly, in Khandbari there have been attacks on the district centre (with police killed) and staff have suspended all movements in the district. As well as this reports are emerging in the Nepali press (The Nepali version of Himal) of links between the Maoists and the Kiranti ethnic revivalists with attacks on higher castes in the hills of the east and resultant migration from the area of these groups. In short, it is possible that a form of ethnic cleansing may also be starting. I am not by nature an alarmist,.......It may be that I was there during a particularly bad two weeks of course, which has coloured my perception of things, but I was deeply distressed and shocked at the situation in Nepal, which in my opinion is nothing short of desperate."
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
My own view, for what it's worth, is that things are likely to get worse before they improve. Tourists are safe at present, although I would not recommend trekking through Khandbari (near Tumlingtar) at present. However, if western governments, in their fight against terrorism, see an opportunity to pursue this course in Nepal on the side of the govt., the Maoists may regard tourists from such countries as legitimate targets.
Fortunately, there is plenty of time for the situation to improve before March next year, but we have to accept the very real possibility that they could go the other way.
I heard from a friend in Kathmandu to-day, that she felt that there was a good chance of the King and the army taking over in the next twelve months. That could produce a genuine calm, or start a real civil war. I just do not know.
I can see why with the F.O. not being negative, you are planning to go ahead, but I know you will be flexible, and be prepared to keep really up-to-date with the situation.

Reply to Hugh Montgomery's letter in an earlier Medex newsletter by Richard Parris
Whilst never quite reaching the heights of some of the Medex expeditions, I have been fortunate to travel both independently and in commercial groups, in Peru, Africa and Nepal. My experiences reinforce Hugh's comments.
On an Exodus trip to Nepal I received a 10 % discount (£150) to act as a Doctor for a three week trip. This was to a group of 12 people of mixed ages (25 to 60) and varying fitness levels (none too good). Pre-trek health questionnaires were sent to all trekkers, none of who reported any medical problems. The MPS confirmed, in contrast to the MDU, that by accepting payment for my medical duties, I would not be acting outside my remit and knowledge. I was provided with a basic kit by Exodus but carried a kit of my own which included airway kit, vascular access, acetazolamide, steroids and antibiotics.

Virtually all the group experienced mild altitude sickness. Other problems that arose were of hydration, g.i.upset and minor injuries. What worried me most was the potential for more serious trauma, in particular limb trauma and head injuries. It was unclear as to how someone would be evacuated if serious trauma occurred and if I travelled commercially again, I would wish for this to be clarified.

The issue over payments for such duties is difficult. I would not offer to act again in an official capacity because, despite advice from the MPS, I feel that I would be exposing myself to potential litigation if injury or illness occurred. However, as shown on previous trips, I have inevitably acted in an unavoidable Good Samaritan role, at all hours of the day, predominantly dealing with primary care issues and minor injuries. If serious illness or injury occurred either in my group or in passing trekkers, I would be extremely reluctant not to help and travel with the injured party.

Regarding Hugh's second point, both in South America, Nepal and more so in Africa, I saw an increasing commercialisation of the Trekking or Overland industry reinforcing Hugh's experiences. This reached an incredible level on the path to Namche Bazaar where I counted at least 400 trekkers going past in the course of two hours. They were of a wide range of abilities, and ages with many of these individuals looking in a bad way.

I tried hard to find out from my guides as to the illness and death rate of trekkers but they could not help. Unconfirmed reports suggested an average of four trekkers a day being evacuated from higher altitude.

In Africa, two of my fellow travellers decided to climb Kilimanjaro, up and down in three days, £250 each for the privilege. They said, and I was unable to verify these figures, approximately 200 trekkers started the climb and people started to drop on day two, many vomiting by the path side. The overnight stays in the hut were miserable affairs, most climbers being cold, complaining of headaches, tired and generally unwell. Only approximately 25 made it to the top.

There are many difficult issues surrounding commercial expeditions to remote places. Whilst it would not be right to deny people the opportunity to travel and whilst most travellers are sensible and informed, I believe, like Hugh, that there is an increasingly significant minority who put themselves at risk of serious illness through unrealistic expectations, derived in part from the commercial companies. To quantify these problems is difficult. This applies not only to trekking at altitude but also to those problems encountered on overland expeditions. No mention has been made so far about the confounding problems of alcohol excess and drugs.

Is there an answer to these problems? It should firstly be remembered that responsibility lies with the individual to ensure they are informed and able to take on the trek they are undertaking. The companies themselves should take more responsibility in promoting realistic expectations of what a trip involves. An effort should be made to provide morbidity and mortality statistics if available. Collect them if not. With a single company like Exodus offering so many treks over a three month trekking period it would be difficult to provide a trained doctor for each group. Could the commercial companies employ a number of Doctors to be in a particular area, mobile and contactable by any particular group? If helicopter transport is unavailable why not have an evacuation team of trained locals, which would also be of benefit to the local population?

Certainly increased education of Doctors who wish to travel to these places is a step forward and Medex is ideally placed to supervise this. Perhaps it would be also possible for those practically inexperienced Doctors to accompany a more major expedition to be taught Mountain Medicine by experts in the field?

I have only been at modest altitude but surely this is where the major morbidity (not perhaps mortality) occurs. I hope that this letter extends the debate generated by Hugh.

From the Irish Times
Giving people headaches
By Roisin Ingle
A Belfast doctor believes that drug induced headaches can predict climbers' health
Every researcher hopes to have at least one eureka moment. The breakthrough that sparked important work by Roger McMorrow, a Belfast doctor, on altitude sickness came to him in bed, as he pondered an unusual headache. Earlier that day the doctor, who was then working as a junior in a cardiology unit, had decided, on a whim, to give himself a small, harmless dose of glyceryltrinitrate. One common side effect of the drug, which is administered to angina sufferers, is a headache caused as blood vessels widen throughout the body, including in the head.
"There was something about this headache, something that was different," says the 26-year-old, a keen mountaineer who will lead an expedition to scale a previously unclimbed and as yet unnamed Himalayan peak in northern India in May. "It was bugging me all night, and at around two in the morning I realised that it was identical to the headache that I usually get at altitude."
Headaches are a symptom of acute mountain sickness and the even more serious high-altitude cerebral oedema - or brain swelling - that can occur at high altitudes because of the lack of oxygen in the air. The conditions can affect anyone, regardless of fitness. Nobody really knows why some people are more susceptible to them than others. One current hypothesis - the "tight fit" theory - suggests that people with smaller skull-to-brain ratios are more likely to be affected.
While fairly rare, high-altitude cerebral oedema is responsible for most altitude-sickness-related deaths; at the moment there is no test to detect the swelling, which is the result of water forming on the brain. McMorrow began to consider whether glyceryltrinitrate-induced headaches, in which dilating blood vessels in the head cause swelling, might be able to predict who is at risk of developing acute mountain sickness or high-altitude cerebral oedema.
Last year, on an expedition to Kilimanjaro, he completed a pilot study that involved administering the drug to nine climbers at a range of altitudes. After McMorrow sprayed the drug under their tongues, to produce mild, five- to 15-minute headaches, his guinea pigs rated the aches on a scale of one to 10. According to McMorrow's theory, the strength of the headaches will give a reasonable prediction of how sick people will be as they climb higher.
If a climber at high altitude had a very severe headache after taking glyceryltrinitrate, for example, it could suggest that further brain swelling caused by altitude sickness could be dangerous. Another climber might experience only a mild headache after being given the drug, indicating less risk of developing severe altitude sickness.
"I am hoping to design a simple test to detect brain swelling before the individual shows signs of it, a test that a GP on a trek can do on the people in the group," he says. "If 10 people are saying they have headaches, the test will be able to determine if they are normal acute-mountain-sickness-type headaches or just starting to become cerebral oedema. In that way, it can act as a predictor for both acute mountain sickness and high-altitude cerebral oedema, and we should be able to judge from the strength or weakness of the headache that results from glyceryltrinitrate whether it is safe for the person to climb higher."
Altitude sickness can affect anyone at a height of more than 6,000 feet, from Olympic athletes on the peaks of Salt Lake City to the most confirmed coach potato. Any rapid ascent to high altitude would be uncomfortable for most people and can result in loss of appetite, dizziness and, in severe cases, hallucination.
An anaesthetist at Belfast City Hospital, McMorrow has already presented his findings at an international conference and hopes to pursue an academic career. But mountaineering remains a consuming passion. "It is an all-round sport," he says. "It is not just about the peak; it works on so many levels and takes you to places you would never otherwise see."
The other members of the May expedition to the virgin peak - which, in a reference to its height, is known only as Pk6044 - are Michael McCann, a chemical engineer from Northern Ireland; Gustau Catalan, a physicist from Spain; and Sara Spencer, who works in marketing, from Co Waterford. All they have is a photocopied photograph of the peak, which is four times as high as Carrauntoohil, and they have no idea of the level of difficulty or how long the climb will take.
A former president of Queen's University's mountaineering club, McMorrow will continue his research into high-altitude physiology on the trip. He is also looking for volunteers to join him on an expedition to Makalu, in Nepal, next year. They will be given glyceryl trinitrate and their headaches monitored. On that trip, McMorrow intends to use ultrasound to examine blood flow in the head, which will further bolster the young doctor's research.

Chris Smith sent in the following: 'Extreme Experiences' or 'Travels with a rifle!'
2001 was the best year yet for exploring the Earth's extremities - from the frozen wastes of Spitzbergen in May to the heat of the Botswanan bush in September.

Spitzbergen: At 78ºN, the trip to Spitzbergen was probably the nearest I'll ever get to the North Pole. Starting from Longyearbyen, the team (of 8) was taken high onto the ice cap by skidoo. From the drop off, our goal was to travel by Nordic ski to the highest peak Newtontoppen, then continue on a circuit to the second highest (technically more difficult) Perriertoppen.

....but then we had the weather - it was too warm (new plans with icebreakers had to be made because there were worries that there would be too little ice on the fjord for us to return by skidoo!) and storms (leaving us tent bound twice).

....and (in my opinion!) we had appalling leadership (resulting in three of us eventually breaking away).
We reached and spent a glorious day climbing (skiing up) Newtontoppen, but never made it to Perrientoppen.

Once the three of us had left the group behind in a white out, the adrenalin started to rise and the whole trip took on a new, exciting form. We were now a much smaller team, with clear aims and a determination to achieve as much as we could with the days remaining. We raised the maximum daily distance travelled from 14 km to 25km and worked well as a team - navigating accurately in white out conditions, sharing chores, the 'intimacy' of three in a two man tent and the relief at leaving so much 'baggage' behind! Suddenly we had freedom. The skiing got better and we had two excellent days climbing on Terrierfjellet, firstly up the steep rock / snow ridge and then via a snow route behind which lead to the summit.

The landscape was absolutely stunning. The glaciers are huge and the feeling of isolation is tremendous. The only sounds were that of the wind and, curiously, that of thousands of nesting sea birds every time we ventured near bare rock. I never ceased to marvel at the sheer scale of the landscape, the views for miles, the huge jumbled crevasses, the 'wicked' sastrugi and the polished blue ice.

Spitzbergen was amazing - definitely a place to return to - even if the isolation was broken when a lone French explorer wandered past or we crossed paths with other skidoo / ski tours (it was more of a playground for the Norwegians than I had expected!).

And the ancient Russian rifle went everywhere - just in case we met the paws that left the prints of a Polar Bear!

Botswana: My first trip into Africa. The plan, for those well read in Rudyard Kipling was to follow the 'Great Green Greasy' Limpopo River - on horseback!

We arrived on the Mashatu Reserve, by 'minuscule' aircraft, and spent the first evening in the most luxurious tented accommodation I've ever seen. (probably the most expensive night's sleep I've ever had too thinking about it!). The following day our group of five (two Fins, one Dane, Neil & I) met Steve - the boss (a South African), the support team (Botswanan, Australian and Finnish) and the seven trusty steeds ready for adventure.

Each day we set out as the sun rose and rode until the mid day sun became so hot (+40ºC) that only siesta's were possible. The riding was tremendous (the best 4 x 4 x far!) - sitting silently watching elephants, giraffe and crocodile from horseback, galloping at full speed through the bush amongst the wildebeest, impala and zebra and tracking the ostrich feathers of a leopard kill! And the setting - vast spaces of flat, dry grassland, huge dry river beds, those famous Baobab trees silhouetted on the horizon and bushes with the biggest thorns I've ever seen.

Each bush camp was different - under the Mashatu trees, on the riverbank, beside the watering hole - and each brought it's own game viewing opportunities - including the lion visiting at midnight! The food was excellent, prepared using local cooking methods on an open fire. Each evening we went for a walk - up a nearby hill, to an archaeological site, to a leopard kill (not entirely sure this one was a good idea!) or along the river bed - always learning more from Steven about the landscape and it's inhabitants and ending the day with a compulsory 'sun downer'. At night we fell asleep to the call of the hyenas and the drone of insects, knowing someone was keeping watch (over the horses!).

And the whole team - it felt just like being away with a group of friends thanks to great leadership (in my opinion!).

There was never a dull moment - as we watched and waited for what might be around the next corner or under the bush.

And the rifle went everywhere - just in case we met any peckish pussycats.

For anyone who fancies a wild ride - we booked through 'In the saddle' (www.inthesaddle.co), Steven Rufus runs 'Limpopo Valley Horse Safaris' (www.lvhsafaris.co.za) - both highly recommended.
Some of our photos are on the 'In the Saddle's web site.

There are also bike safaris at Mashatu (known locally as 'Meals on Wheels').