Christopher, Sarah

Sheffield Hallam University Research Archive

The medicine in remote areas (MIRA)/travel and tropical medicine course: an urban NHS paramedic’s experience.CHRISTOPHER, SarahAvailable from Sheffield Hallam University Research Archive (SHURA) at:http://shura.shu.ac.uk/13573/This document is the author deposited version.  You are advised to consult the publisher's version if you wish to cite from it.Published versionCHRISTOPHER, Sarah (2007). The medicine in remote areas (MIRA)/travel and tropical medicine course: an urban NHS paramedic’s experience. Today's Emergency, 13 (3), 72-75. Repository use policyCopyright © and Moral Rights for the papers on this site are retained by the individual authors and/or other copyright owners. Users may download and/or print one copy of any article(s) in SHURA to facilitate their private study or for non-commercial research. You may not engage in further distribution of the material or use it for any profit-making activities or any commercial gain.Sheffield Hallam University Research Archivehttp://shura.shu.ac.uk8.  Improvisation of first aid equip-ment and transportation devices.9.  Wound management.10.Realignment of displaced fractures and dislocations.11.Modifications of standard, urban CPR protocols.12.Modifications in standard proto-cols as appropriate for the wilderness environment.13.Use of advanced techniques, such as the insertion of thorac-ostomy and endotracheal tubes, cricothyroidotomy, intravenous fluids, bladder catheterisation etc.14.Expedition medicine education, including tropical and other exoticdiseases, vaccinations and sani-tation, including the provision of disinfected water and properly prepared food.15.Suggestions for contents of first aid kits.Background and CoursecontentEx+Med was formed by three ex-military directors who, betweenthem, have over 50 years of experi-ence in providing pre-hospital medi-cine to small and large deploymentsof personnel in hostile and remoteareas of the world [5].  The directorsall served in a medical capacity withUnited Kingdom (UK) SpecialForces units and, I learned, werecurrently providing the medicalcover for the Long Way Down proj-ect.  This project sees EwanMcGregor and his team with threemonths to cover the 15,000 milesfrom John O’Groats to Cape Townon motorcycles [6].The course itself fulfilled all therecommended curriculum standards[2-4].  The right balance was foundbetween both theoretical instructionand practical sessions, and thetraining facilities were outstanding.‘Live tissue’ workstations providedan excellent basis for physiologylectures, a practice being adoptedmore and more commonly in manymedical training institutions [7] andone with which I was already famil-iar after studying for a degree inpre-hospital care at the University ofWales, Swansea.  Throughout thecourse students were coachedthrough different moulages inEx+Med’s purpose built environmentrooms, which included both jungleand desert simulations.  These wereincredibly realistic even down todetails such as temperature andsound.  Next came a search andrescue moulage in a collapsedbuilding training area.  Dark, smokyand chaotic this environment wascertainly challenging, and workingwith only a head lamp for illumina-tion was a disorientating experience.All the students agreed that itprovided a realistic insight intocollapsed structure search andrescue.  A road traffic collision(RTC) simulation exercise followed.Whilst I have participated in suchexercises before, my role hasalways been that of a paramedicattending to the needs of the casu-alties involved.  This time was differ-ent, as I was placed in the role ofincident officer by the fire fighteroverseeing the moulage.  Beinggiven this alternative perspectivewas incredibly valuable, if somewhatstressful.  I was wrenched firmly outof my comfort zone and made toconcentrate on scene managementand rescue whilst leaving themedical needs of the casualty tothose in the role of primary medic.The highlight of the course for us allwas the 24 hour search and rescueexercise conducted in the ‘field’.Without a doubt it is one of the mostchallenging things I have done todate and its value inestimable.  Theexercise was conducted at night inprivate dense woodlands and acamp made ready for us to use as abase.  We reached camp mid after-noon and in the outdoor ‘class-rooms’ our education continued.  We learnt how to adapt to theremote environment in situationswhere state of the art equipmentmay simply not be available.  I never thought it would be possibleto fashion a traction splint out of treebranches and rope but rest assuredit is!At approximately 2300 hours ourteam were briefed as to our assign-ment.  We were told a young manhad gone missing 12 hours previ-ously wearing only light summerclothing and was presumed to besomewhere in the woodlands.Again, with only head lamps for illu-mination and in the pitch dark, wewere tasked to locate, treat andevacuate our casualty to definitivemedical care.  Our casualty waseventually found lying unconsciouson an extremely steep and slipperybank near a stream.  I have to sayhere that the casualty simulationteam did a phenomenal job for us.They were so utterly realistic andwent through no small amount ofdiscomfort so thanks guys!Our casualty presented with a flailchest, compound fractured femurand lowered levels of consciousnessthroughout.  As a team we dealt withthe injuries systematically whilst theinstructors took turns to pop up fromtheir hidden observation posts toapply even more pressure bysubjecting us individually to intensebouts of questioning.  With the casu-alty eventually ‘packaged’ and readyto move we began the long hardjourney carrying the casualty to therendezvous point where we weretold a helicopter was waiting.  Twiceduring the evacuation we were toldthe casualty had taken a turn for theworse, firstly requiring the insertionof a surgical airway and secondlyrequiring needle thoracocentesisfollowed by the insertion of a formalchest drain.  At these points wewere taken aside where pre-prepared live tissue skill stationswere waiting and had to perform theinterventions ‘for real’.  The pressurewas immense.The following morning after a nightin camp we were given a triageexercise where approximately 15casualties had to be located andassessed using formal triage scor-ing systems.  It is of interest to notethat on bespoke MIRA courses it isat this point a real helicopter arrives.Students are given the chance toIntroductionHaving worked for NHS ambulanceservices for over 11 years in urbanenvironments I had long felt readyfor a new challenge.  For some timeI had been considering looking intoremote medicine, especially since Ihad listened to the stories of friendswho worked in remote areas on aregular basis.  Consequently Ienrolled on the Medicine in RemoteAreas (MIRA)/Travel and TropicalMedicine course at Ex+Med inHereford.WHY MIRA?People are drawn to MIRA for a variety of reasons. They may wish totravel to remote areas which wouldotherwise be financially and logisti-cally impossible [1], may be attract-ed to the challenge of practicing in aremote environment with limitedequipment or assistance [1] or mayhave an interest in specific activitiessuch as mountaineering or diving[1].  For me it was a very challeng-ing way of hopefully gaining addi-tional skills and experience.  TheEx+Med MIRA/Travel and TropicalMedicine course had also beenpersonally recommended by severalcolleagues over a period of time andwas accredited by the Royal Collegeof Surgeons (RCS), something otherremote medicine courses did notoffer.Curriculum standardsWhatever the reasons for undertak-ing such a challenge, training andpreparedness are of paramountimportance.  Whilst there appears tobe no standard curriculum for pre-hospital MIRA [2] a review ofresearch conducted in the UnitedStates (US) gave me a very goodidea of what the course contentshould ideally include [2-4].  Theconsensus was that the followingshould be included [2-4]:1.  Orthodox emergency care and emergency medical techniques.2.  Extended care of the casualty, including stabilisation of body temperature, provision for food and water, elimination of body wastes, psychological support etc.3.  Wilderness rescue ‘packaging’ and transport.4.  Environmental illnesses and injuries, such as frostbite, hypo-thermia, high altitude illness, landand marine animal bites, insect stings etc.5. Wilderness survival techniques.6.  Assessment and treatment of medical illnesses.7.  Use of prescription and non-prescription drugs including anti-biotics, analgesics, gastro-intestinal drugs and drugs for high altitude illness.Author:Sarah ChristopherBSc (Hons), S.R (Para)Paramedic Work BasedAssessorEast MidlandsAmbulance ServiceThe Medicine In Remote Areas (MIRA) / Travel and TropicalMedicine Course: an urban NHS Paramedic’s experienceThe Medicine In Remote Areas (MIRA) / Travel and Tropical Medicine Course:an urban NHS Paramedic’s experienceStasch, T (2007) Welcome to the Jungle. Available from: http://www.careerfocus.bmj.com/cgi/reprint/334/7604/197This figure consisted of 609 inci-dents, 376 persons injured and 25fatalities [10].   Military search andrescue incidents can also be consid-ered.  In 2006 there were 1767 inci-dents resulting in 1948 callouts ofRoyal Navy and Royal Air Forcehelicopters [11].  Of this, 96% ofcallouts were in or around the UKand 95% to civilian incidents [11].It can be seen then that MIRAeducation and training is of value toeven NHS paramedics working inthe UK.  One does not have to beworking abroad to benefit.  AsStasch points out, survival skillsought to transfer to any situationwhere leadership, teamwork andrisk assessment are called for [12].Skills essential for medical practice,such as decision making, communi-cation skills and self reliance will bedeveloped [1].  For those wishing toexperience expedition medicine,participation is seen by manyemployers as a very good indicatorof personal development [1]. Whilst extremely challenging this isan experience I would not havemissed.  I’m certain I was lucky tobe with a really great bunch of fellowstudents from varying backgroundswho were all happy to support andcoach each other.  Additionally, theinstructors, whilst not averse toapplying pressure, were approach-able, supportive and left everyonewith a real sense of belonging. By sharing my experience of theMIRA/Travel and Tropical medicinecourse I hope others may beencouraged to give it a whirl. Go on,you might learn something!For further information onMIRA/Travel and Tropical Medicinecourses contact Mr. Steve BenbowSR Para, FRSH atsbenbow@exmed.co.uk.References1. Student BMJ.com (2007) Career Focus: Expedition Medicine. Available from: http://student.bmj.com/ back_issues/0800/education/ 278.html [Accessed on 12.07.07].2. Bowman, W. The Development andCurrent Status of Wilderness Prehospital Emergency Care in the United States. Journal of Wilderness Medicine. 1990; 1: 93-102.3. Goth, P. Update on Wilderness Medicine Programs. Response. Winter 1989, 24.4. Donelan, S. Wilderness First Aid Programs: directory. Wilderness First Aid. 1989.5. Ex+Med UK Ltd (2007) About Ex+Med UK Ltd. Available from: http://www.ex-med.co.uk/ pages.aspx?id=297[Accessed on 12.07.07].6. BBC.co.uk (2007) Two Men, Two Continents. Available from: http://www.bbc.co.uk/longwaydown/feature/ preparation.shtml [Accessed on 13.07.07].7. Howson, A. Back to Class (…Or a Busman’s Holiday in Layman’s Terms). Ambulance Today. 2007 Issue 15; 4: 17-19.8. Wilkerson, J. Ed (1985) Medicine for Mountaineering.3rd Edition. Seattle. The Mountaineers.9. Mountain Rescue.org (2007) The Mountain Rescue Regions. Available from: http://www.mountain.rescue.org.uk/regions/ [Accessed on 13.07.07].10. Mountain Rescue.org (2004) Mountain Rescue England and Wales. Incident Report 2004. Available from: http://www.mountain.rescue.org.uk/publications/statistics.php [Accessed on 13.07.07].11. Ministry of Defence (2006) MilitarySearch and Rescue Incidents: 2006. Available from: http://www.dasa.mod.uk/natstats/ sar/annual/intro.html [Accessed on12.07.07].12. Stasch, T (2007) Welcome to the Jungle. Available from http://www.careerfocus.bmj.com/ cgi/reprint/334/7604/197. Accessed on [24.07.07].experience the challenges involvedin treating and monitoring casualtieswhilst in helicopter transit, wherevital signs such as pulse and respi-ratory rate are extremely difficult toassess.Remote Medicine versusUrban PracticeMIRA is based upon the same prin-ciples of anatomy, physiology andpathophysiology as is orthodoxemergency care [2].  However,Wilkerson sums up the differencevery well by saying that the empha-sis is not on what to do until thedoctor comes, but rather on what todo for remote situations to which thedoctor is not coming [8].  It is ofvalue to consider at this point howremote medicine differs from medi-cine in an urban environment.  Theconsiderations discussed belowreally became apparent on theMIRA/Travel and Tropical Medicinecourse.  Bowman states that byinformal agreement among physi-cians experienced in remote medi-cine, specific ways that pre-hospitalremote medicine differs from urbanemergency care can be categorisedas follows [2]:1.  It is practised in the remote,outdoor environment, whereextreme conditions of heat, cold,altitude and storm are common anddifficulties in obtaining food, waterand shelter are significant.  Physicalhazards such as snow avalanches,rock falls, flash floods, wildfires andlightning may be present.  Hazardous micro-organisms,insects, marine animals, landanimals and plants may endangerthe health of remote travellers andpre-existing medical conditions mayrecur or flare at awkward times.2.  Definitive medical care may behours or days away because ofdistance, adverse environmentalconditions, lack of transportation ordifficulties in communication. Urbanprotocols that assume rapid trans-portation to a medical facility maybe irrelevant.3.  Illness rarely seen in the urbanenvironment, such as acute moun-tain sickness and deep frostbite,may be encountered.4.  The emergency medical servicerequirement that there be routinephysician control by telephone orradio may be unrealistic or impracti-cal.  More reliance on field protocolsis necessary.5.  It may be desirable to train intelli-gent and motivated non-profession-als to carry out advanced proce-dures for common injuries andillnesses, in which a treatment delayof more than a few hours may causeadverse effects which outweigh thepossible risks of the procedures.6.  There is a need for rescuers tolearn basic nursing and subsistencecare for an injured or ill person inorder to sustain the casualty fordays before medical assistance canbe reached (Emergency CarePractitioners would have a distinctadvantage here).7.  Certain standard urban treatmentprotocols, such as that for cardiacarrest, may be unrealistic or evenhazardous to rescuers.8.  The amount of medical equip-ment that can be carried by theaverage remote medic, or even thebest equipped remote search andrescue group with helicoptersupport, is limited.  Improvisation will be necessary.There are many other considera-tions to take into account. Coupledwith the challenges of a remoteenvironment, the area may also behostile with grave threats to safety.  Medical supplies and equipmentmay have to be sourced locally asreplenishment from the UK mayeither be impossible or too timeconsuming.  Different countries havedifferent legislation concerningspecific drugs, for examplemorphine, and alternatives mayhave to be found.  Additionally, adrug produced in the UK may havea very different presentation to thatof one produced abroad.Even for paramedics working in theUK, MIRA education is of value.Although this may not seem to bethe case, Bowman points out thereis an analogy to disaster emergencycare, where medical supplies, food,water and medical facilities may bedestroyed, the number of casualtiesoverwhelming and triage essential[2].  This has become very apparentrecently in light of the severe flood-ing to hit parts of England.   Additionally, there are currently ninemountain rescue regions in Englandand Wales [9].  Although inside theUK, mountain rescue medics prac-tice remote medicine on a day today basis.  In 2004, 804 casualtieswere assisted by mountain rescueteams in England and Wales [10].The Medicine In Remote Areas (MIRA) / Travel and Tropical Medicine Course:an urban NHS Paramedic’s experienceThe Medicine In Remote Areas (MIRA) / Travel and Tropical Medicine Course:an urban NHS Paramedic’s experienceVarley, J (2006) Bites, Blisters and Botflies: Nine weeks in the Belizean Rainforest.Available from http://www.careerfocus.bmj.com/cgi/reprint/332/7546/148.

The medicine in remote areas (MIRA)/travel and tropical medicine course: an urban NHS paramedic’s experience.

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