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A road less travelled: General practice and expedition medicine

Extreme, expedition and wilderness medicine are rapidly evolving specialities, that involve the planning and provision of pre-hospital medical care in outdoor, remote and austere settings, whilst allowing clinicians to capture the spirit of adventure and exploration (Imray, 2015 et al.). It sounds good right? But what does this have to do with general practice? Surely you need to be an anaesthetist or an emergency medicine doctor to work in this emerging field? Actually, GPs have been well represented in expedition medicine since its inception.

Let me address the elephant in the room: this may seem like a strange time to write about a speciality that is heavily reliant upon travel and, in some cases, mass-participation events. These have been two of the hardest hit industries with regards to COVID-19 and lost revenue, however these industries will eventually bounce back, and I believe that expedition and travel medicine will become more, rather than less, relevant as a result of the global pandemic.

Expedition medicine has become increasingly popular at an undergraduate level, with most medical schools having their own Wilderness Medicine Societies, that come together every year to host the Student Wilderness Medicine Conference, that I spoke at in 2019. Many junior doctors take time out post-foundation training to work on expeditions, and there are an increasing number of expedition medicine diplomas on offer as the speciality grows in academic status.

I qualified as a GP in 2017, having completed my VTS training in Tunbridge Wells in the South-East of England. Towards the end of my registrar year I used my study budget to attend an expedition and wilderness medicine course, run by World Extreme Medicine, at Plas Y Brenin in Snowdonia. This gave me an appetite for practising medicine outside of the comforts of the GP surgery, and I was hooked. Since then I have been working as a portfolio GP, combining sessional work with events and expeditions both within the UK and overseas.

Some highlights over the past few years have included working on the Delloite Ride Across Britain, a long-distance cycling event from Land’s End to John o' Groats, the Kenya Impact Marathon in the tea plantations of Kericho Kenya, and spending a month with a group of young people in the wilderness of the Canadian Yukon with British Exploring. Unfortunately, my planned expeditions for 2020 have understandably been put on hold, but there are early signs that, at least in the UK, some events may be starting up again which is great to see!

It can be a bit daunting at first, being permanently on-call in the middle of nowhere, but you quickly get used to it, and the views are usually pretty fantastic! The most common medical issues tend to be generalised aches and pains, stomach upset and headaches- indeed very similar to a morning in general practice!

It is obviously important to have relevant qualifications and experience in managing more serious problems. Having an annual BLS update is compulsory to work in general practice anyway, but most expedition companies also like you to have either Advanced Trauma Life Support (ATLS) or Pre-Hospital Trauma Life Support (PHTLS) as well. Out of these, PHTLS, the pre-hospital version, is arguably more relevant.

Much of the workload tends to be motivational and giving pastoral support, particularly when working with teenagers and young people, but also when working on some of the ultramarathon endurance events which are often in pretty wet and miserable conditions! Blisters are ubiquitous, especially in the long-distance events, and managing dehydrated, hypothermic collapsed patients is also a common occurrence.

With a growing incidence of mental health problems in the general population, there are also more participants on expedition who may have a history of depression, anxiety or similar. Likewise, potentially undiagnosed conditions can be unmasked by the stress of being on expedition.

The key to managing this is by providing good holistic medical care- similar to what you would do in the surgery- lots of listening, empathy and reassurance, combined with a sensible attitude to risk.

Ensuring that you have a stringent screening process and risk assessment for the trip is also essential and it is really important to consider the preparation part of any event or expedition that you may end up working on.

Indemnity is another thing that people often worry about. Usually the main medical indemnity companies cover event and expedition work, but there is often a supplementary cost which depends on whether you are being paid, the length of the expedition and whether you will have any senior support.

Pay is another factor to consider. Event and expedition work will not replace your GP job and pay the bills. Some UK jobs are paid whilst others, typically international expeditions are not, at least to start with. This is obviously an important factor to be aware of, however the flip side can include going to some unique locations, meeting new people and getting new opportunities.

This article has only scratched the surface on what I believe is a really exciting specialty that complements general practice really nicely. The skills that I learnt during my GP training, and since qualifying, have helped me when out in the field, and similarly the chance to work outside of the traditional GP surgery environment, has helped reduce the chances of burn-out when working in general practice, albeit in a slightly different COVID role at present.

Text first published: Grace D. A road less travelled: General practice and expedition medicine. InnovAiT. 2020 Dec 3;175573802097615.

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