WEST
LANCASHIRE
COUNTY SCOUTS
Overseas Leaders’
Medical Pack
In the world of global communication we
believe all trip medics should have access to
an empathetic, experienced Doctor. Satellite
communication is difficult at times however
good communication and sound emergency
response plans are the core tenets of our
operations and training.
In a wilderness setting prevention is better
than cure. So the message is plan early and
phone a friend!
Please return to the ACC(Expeditions) after use.
These notes have been reproduced by kind
permission of
Wilderness Expertise Ltd, The
Octogon, Wellington College, Crowthorne,
Berkshire RG45 7PU (01344 744 430).
They are copyrighted and provided specifically
for use by Leaders of Overseas Ventures
operated by West Lancashire County Scouts and
no further reproduction is permitted. Wilderness
Expertise can accept no liability for the contents
or for any advice herein.
1
Overseas Leaders’ Medical Pack
These notes are designed to work alongside your first
aid training, and to extend that training and experience
in order to preserve life in a remote setting if
communication is not possible with your own 24hr
support doctor, local medical facilities, or insurance
company doctors.
The basic principle of first aid must always apply:
DO NO HARM
Section
1. Guidance on use of medications
2. Acute mountain sickness
3. Dehydration
4. Diarrhoea
5. Ear infections
6. Urinary tract infections
7. Allergic reactions – Anaphylaxis
8. Malaria
9. Heart conditions
10. Psychological considerations
11. Medical evacuations
12. Expedition mortality
13. Post traumatic stress
14. Notes on medications
15. Post expedition health brief
16. Patient treatment
17. Report cards
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Key points
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gain qualified medical advice as soon as
practical. Refer to your Critical Incident Plan
for all cases of medical treatment, a log of all
findings, activities and medication used must be
recorded
all medications must be secured from theft and
misuse. Keep medications cool, dry and out of
direct sunlight.
Updated by Peter Harvey & Dr Matt Ladbrook
Approved by Dr Caroline O’Keeffe, June 2007
2
1. Guidance on Use of Medications
Supportive care including rest, hydration and a good
diet will enable the patient’s immunity to fight infections.
This is the best road to health. Medications should be
used as a secondary measure and the benefits
weighed up against the side effects.
Non-prescription medications
On expedition, non-prescription medications should not
be given to minors (<18 yrs) without medical approval.
Participants may bring their own medications. However
it is important to get a full picture by asking for details.
Prescription medications
On expedition, prescription medications should only be
given under the direct or indirect control of a doctor.
The insurance contact number supplied is manned 24
hours a day by a doctor who can advise on emergency
treatment. For non-emergency treatment, contact the
on-call team who will obtain medical advice and contact
you with clarification on the appropriate treatment.
When medical advice is unobtainable, this MELP is
here to guide you until you are able get medical
assistance. In these situations the MELP must be
adhered to at all times and the Leader must not give
treatment he or she has not been trained to give.
The specific medical kit, which comes with these notes,
is tailored to your activities, group and destination.
Summary
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Keep it simple: rest, oral hydration, food;
Medications have side-effects, ensure benefits
outweigh risks;
Check correct indication for use of medication,
allergies, side effects, dosage, expiry date;
Stop if a rash or serious side effect develops;
Record all treatment and medication use.
3
2. Acute Mountain Sickness (AMS)
AMS is a spectrum of illness, ranging from mild
symptoms to life-threatening conditions.
AMS is
caused by going too high, too fast. Few people get
AMS below 2400 m. Mild AMS is common and usually
self-limiting. Symptoms classically appear 12-24 hours
after arrival at altitude. Mild symptoms will usually
subside after 72 hours at altitude.
Symptoms include:
 headaches;
 undue fatigue or shortness of breath;
 loss of appetite, nausea and/or vomiting;
 dizziness;
 difficulty sleeping.
Note: symptoms may be worse when sleeping. Mild
AMS may progress to more serious HAPE or HACE
(see below). However, some patients will develop
HAPE or HACE without having displayed symptoms of
mild AMS.
Prevention
 acclimatise: above 3000m ascend only 300m
a day and rest every third day;
 remember: ‘climb high, sleep low’;
 diet: extra fluids, light carbohydrate-rich diet.
Treatment
 DESCEND - DESCEND - DESCEND!
 avoid heavy exertion;
 light activity preferable to complete bed rest;
 absolutely no smoking or alcohol;
 consider giving Diamox.
Climbing is not about the peak - it is about enjoying the
journey. People will not enjoy the experience if they are
unwell and in pain. Go down - the mountain will be
there another time.
4
High Altitude Pulmonary Oedema (HAPE)
In this condition, fluid accumulates in the lungs,
commonly 2 - 4 days after arrival at altitude. The risk of
developing HAPE after a rapid ascent to 3600m is
approximately 1 in 200. An important first warning sign
is a party member who is more tired than the others.
Symptoms
 worsening shortness of breath, progressing
to shortness of breath at rest;
 dry cough, may produce frothy, pink phlegm;
 fatigue progressing to unconsciousness;
 bluish tinge to lips and extremities.
Note: symptoms may worsen rapidly at night
Treatment
 DISCUSS WITH ON CALL TEAM
 sit patient upright;
 give oxygen and use a hyperbaric chamber, if
available;
 consider giving Nifedipine;
 descend (unladen) patient without delay and
seek medical help. A descent of even 600 m
can offer prompt relief.
High Altitude Cerebral Oedema (HACE)
This condition affects some people as low as 3500m. It
is caused by fluid accumulating in the brain tissues.
Symptoms
 severe headache;
 vomiting and dizziness;
 visual disturbances, altered eye movements;
 poor co-ordination and confusion;
 drowsiness and coma.
Treatment
 DISCUSS WITH ON CALL TEAM
 descend without delay & seek medical help;
 give oxygen and use a hyperbaric chamber, if
available;
 consider giving Dexamethasone.
5
Lake Louise Self Assessment Scoring for AMS
This simple self-assessment scoring system can help
determine whether or not an individual may have AMS.
Because all scoring systems tend to over diagnose
AMS, scores should be interpreted in light of recent
altitude gain and should take allowance of any
background illness. Recent ascent AND headache
AND other symptom(s) AND a total score of 4 or more
suggests AMS.
People can become hypochondriacs. A key element is
getting honest feedback from the team. Do not rely on
this one tool alone. If in doubt call for a consultation.
Symptom
Headache
Gastrointestinal
Fatigue/
weakness
Dizziness/
lightheaded
Difficulty
Sleeping
Overall,
affect on
activities?
Severity
none at all
mild
moderate
severe/incapacitating
good appetite
poor appetite or nausea
moderate nausea or
vomiting severe nausea or
vomiting
not tired or weak
mild
moderate
severe
None
mild
moderate
severe/incapacitating
slept as well as usual
did not sleep as usual
woke many times
could not sleep at all
not at all
mild reduction
moderate reduction
severe reduction (bed rest
Score
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
0
1
2
3
Adapted from the Proceedings of the 7th International Hypoxia
Symposium, Lake Louise, Canada, 1991.
6
3. Dehydration
Dehydration is a common, avoidable condition. It is
potentially serious in its own right and also worsens
other conditions.
Preventable heat-related deaths
occur on expedition each year.
Under normal conditions, individuals require around 35
ml of water per kg weight per day – this equates to
approximately 2.5 L per day for a 70 kg man. Normally
around two thirds of our daily need is met by drinking,
the remainder comes from water contained in our food.
When an individual is drinking sufficient water, they
produce plenty (at least 1.5 L a day) of pale, straw
coloured urine. Indicators of dehydration are:
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thirst
small volumes of dark urine
headaches, dizziness, nausea
other signs: sunken eyes, dry mouth, loss of
skin elasticity
measure pulse and BP (low BP + high pulse
suggests dehydration)
High temperatures, physical activity, fever, diarrhoea
and vomiting all dramatically increase water needs.
Prevention
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educate and set a good example;
anticipate daily water requirements;
don’t wait until you’re thirsty;
monitor drinking using a ‘buddy-buddy’
system;
make water readily available;
drink from 1 L bottles to aid measurement;
individuals should monitor the colour of their
urine.
7
Treatment
Fluid lost by normal sweating can be replaced by
drinking water and ensuring some salt is eaten with
food. Excessive sweating, vomiting and diarrhoea
cause the body to lose significant amounts of water and
salts. In this case, rehydration can be achieved with
isotonic drinks such as Dioralyte (a solution made from
powder containing water, salts and glucose, see
Section 11). Isotonic solutions are absorbed more
quickly than water.
Rehydration should aim to replace fluid that has been
lost: 200 - 400 ml of Dioralyte for each vomit or loose
stool is reasonable. Fluid should be taken in frequent,
small volumes over 3 - 4 hours, after which the patient
should be reassessed. Following this, normal fluids are
used to meet the daily requirements and Dioralyte for
further losses from vomiting or diarrhoea.
Replacement needs are entirely dependent on the
amount of fluid and salt lost. In the field, the best rule
of thumb is that the patient drinks enough to produce
good volumes (1.5 L/day) of pale coloured urine.
Home-made isotonic drink can be made by mixing:
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1 L sterilised water
12 level teaspoons (40 g) of table sugar
1 level teaspoon (5 g) of table salt
Dispose of any unconsumed drink after 24 hours.
Fluid and salt can also be replaced by consuming soup,
broth and fruit juice – though specific rehydration liquids
are probably quicker.
Dehydration is hastened by diuretics such as alcohol,
tea, coffee and carbonated soft drinks with caffeine these cause the body to lose water.
8
4. Diarrhoea
Diarrhoea is the most common traveller’s illness,
affecting a third of visitors to developing countries.
Whereas mild diarrhoea is simply a nuisance, severe
diarrhoea can be life-threatening.
Loose Stools are defined as soft, unformed stools with
3 - 4 bowel movements a day. This is not true
diarrhoea. Common causes are a change in food or
water, medication side-effects (e.g. antibiotics), anxiety
or excitement. May last for days or weeks but usually
resolves without treatment. Loose stools, which persist
after returning home, should be investigated.
An individual passing multiple liquid stools should be
classed as having diarrhoea. Identifying whether the
diarrhoea is invasive or non-invasive (tricky in field),
allows appropriate treatment to be followed.
Non-invasive diarrhoea
These cases are caused by organisms that secrete
toxins into the contents of the gut.
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most common type of diarrhoea
usually less serious (except cholera)
commonly via faecal contamination of water
incubation is usually 12 - 48 hours
Infection lasts usually 2 - 5 days
Non-invasive diarrhoea is often associated with
intermittent abdominal cramps, nausea and vomiting.
There may be mild lower abdominal tenderness. Chills
and fever are usually mild or absent.
With the exception of cholera, non-invasive diarrhoea
should not be treated with antibiotics – they are usually
ineffective and can predispose sufferers to invasive
diarrhoea. Generally, anti-diarrhoea medications (e.g.
loperamide) are not recommended – but may be useful
to help control severe abdominal cramps or to facilitate
patient transport.
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Invasive diarrhoea (dysentery)
These cases are caused by organisms that invade the
lining of the gut and can spread throughout the body.
Cases are most common in tropical or semi-tropical
climates. Average incubation is 48 hours, but could be
anywhere from 12 hours to 5 days. Symptoms are the
same as non-invasive diarrhoea, with the addition of:
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chills and fever
pus, blood or mucus in the stools (commonly
4 - 5 hours after onset)
the patient appears ill
Note: symptoms may vary widely between individuals.
These cases should be evacuated to medical care and
treated with antibiotics. Choice of antibiotic depends on
the causative agent. Try to discuss this with the Doctor
on call if at all possible.
Patients should be barrier-nursed by one or two
nominated individuals who are scrupulous about their
hygiene. Faeces and vomit must be disposed of where
it poses no risks to water or to people. Infected
equipment should either be boiled or aired in bright
sunlight for two days. The use of anti-diarrhoea
medications only prolongs and aggravates this type of
diarrhoea.
Taking a history
Getting good details prior to calling for advice saves
time. This is a huge help in determining the type, cause
and progress of the infection. Knowing what an
individual’s ‘normal’ bowel habit is can be useful!
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When did the diarrhoea start?
Stool: number, colour, consistency, smell and
volume?
Any mucus, pus or blood present?
Associated symptoms: fever, nausea,
abdominal pains?
How many people affected?
Recent fluid and food intake?
10
Examination
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general impression (ill or not ill?)
check vital signs (pulse, BP and temperature)
assess for dehydration
General treatment for all diarrhoea
Essential treatment for vomiting and/or diarrhoea is
replacement of water and salt (see Section 3).
Nausea and vomiting may be treated with
prochlorperazine (see Section 11) if the tablets can be
kept down. Consider suppositories? Hot water bottles
can help with abdominal cramps. Paracetamol (see
Section 11) is good for fever and discomfort). Fasting
does not help – food should be taken if tolerated. Stick
to a bland diet of complex carbohydrates
(potatoes/pasta/rice). Avoid dairy products.
Prevention
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 strict hand-washing, including nail-scrubbing even more critical once a case of diarrhoea
exists in the group
 sterilise all drinking water – even for brushing
teeth
 sterilisation by bringing water to a rolling boil,
regardless of altitude, kills all organisms that
cause diarrhoea
 sterilisation with iodine/chlorine kills most
organisms except some parasitic agents
(cryptosporidia and cyclospora) which can be
removed by filtration
 bottled drinks with intact seals are safe
 other drinks and food should be boiled on first
cooking
 reheating previously undercooked food will
not make it safe to eat
 self-peel fruit and vegetables and use straight
away
 sterilisation of water used in food preparation
 sterilise cooking utensils
 avoid contact with all animals
 avoid seafood and unpasteurised milk
11
5. Ear Infections
Ear infections are common in childhood, but uncommon
in adulthood. 50% of cases of painful ears are due to
pain being referred from another problem – commonly
throat or tooth infections or neck muscle problems.
Ear infections affect the ear, hearing canal (outer ear)
or the inner hearing apparatus (middle ear).
Outer ear infection (‘Swimmer’s ear’)
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common, more so in adults
often due to damage by fingernails, irritants
or wet conditions
symptoms include: itching, pain and
inflammation of the skin, slight discharge,
tenderness when the ear is gently pulled
treat with gentle, dry, non-invasive cleaning
twice a day
pain killers and dry warmth help symptoms
antibiotics not useful unless there is
spreading skin infection or boil.
Middle ear infection
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often follows viral upper respiratory infection
symptoms: sudden onset pain, sometimes
fever, loss of appetite, vomiting and deafness
eardrum perforation may be followed by a
large discharge of pus and relief from pain
(discharge usually settles after 48 hours)
wash as above if there is discharge
pain killers and dry warmth help symptoms
most uncomplicated cases resolve on their
own. Consider amoxicillin (see Section 11) if
patient is unwell or no better after 72 hours
consider antihistamine (e.g. chlorphenamine,
see Section 11), if associated with hay fever
12
6. Urinary Tract Infections
Cystitis
Cystitis is caused by inflammation of the bladder. Main
symptoms are:
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burning sensation on urination
frequent and urgent urination
The urine may contain some blood. Fever and other
symptoms are rare.
Symptoms usually resolve in 2 - 3 days. Severe or
longer-lasting symptoms, or fever, require treatment
with antibiotics. In all cases, double normal fluid intake
helps recovery. Cystitis is common in females, but rare
in males. Male patients should see their GP on return.
Pyelonephritis
Infection involving one or both kidneys, characterised
by:
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sudden onset high fever with chills
pain over the kidney
the patient often looks and feels ill
symptoms of cystitis are common
slight to moderate bleeding may occur
tenderness when gentle pressure is applied
to the side of the backbone, just below the
lowest rib on the affected side
Treatment involves doubled fluid intake and antibiotics
(see Section 11), but this condition requires evacuation,
medical supervision and intravenous antibiotics.
13
7. Anaphylaxis
Anaphylaxis is a serious allergic reaction that can be
fatal. The use of an EpiPenand Antihistamine can
save the patients life. EpiPenis a device designed to
automatically inject adrenaline (or epinephrine) into the
muscle of the thigh to treat severe allergic reactions. It
is designed to be carried by people who are at risk of
anaphylactic reactions and should be carried by them at
all times.
EpiPencan cause problems in people with heart
disease, diabetes, thyroid problems and high blood
pressure however if an anaphylactic reaction is
confirmed then it is necessary to give it.
The oral Antihistamine tablets provides a delayed
(>30min) treatment to an anaphylaxis reaction.
Signs and Symptoms
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Minor
Itching
Rash
Flushing
Headache
Nausea
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Severe
Vomiting
Abdominal cramps
Light headed / dizzy
Swelling
lips,
throat,
tongue, hands & feet
Wheezing
Coughing / Shortness of
Breath
Unconsciousness
If a patient is developing symptoms of severe allergy:
1) Contact the on-call number immediately for
medical advice: The Co-ordinating Medic on duty will
assess the situation and provide treatment instruction.
If it is not possible to access Doctor’s advice, proceed
to step 2:
2) Give a standard dose of antihistamine in tablet form
orally to the patient
3) Observe the response and if severe allergy signs
and symptoms continue move to step 4.
14
4) Give EpiPeninjection (full directions in the
pack)
 Take EpiPenauto-injector out of the pack
 Pull off the grey safety cap
 Hold Auto-injector against the thigh with the
black tip against the skin
 Press Auto-injector hard against the thigh to
trigger Auto-injector mechanism
 Hold against thigh for 10 seconds after
triggered
 Remove Auto-injector
 Massage injection site for 10 seconds
 Discard Auto-injector safely
5) Proceed according to advice given by Doctor.
EpiPen Storage
Where possible, store the EpiPenaccording to the
directions on the box, i.e. below 25°C. This is obviously
not practical in many field situations however the
EpiPenhas been demonstrated to work effectively in
temperatures of around 40°C so it can safely be carried
in a field backpack. EpiPenshould not be stored in a
vehicle as this may lead to prolonged periods of
excessive temperatures which may reduce the
effectiveness of the EpiPen.
15
8. Malaria
Malaria is mainly a disease of the tropics and
subtropics, but is the world’s most common infection. It
causes approximately 1 million deaths a year, mostly in
children in sub-Saharan Africa
What is malaria?
Malaria is an infection caused by a protozoan parasite,
which is spread by the bite of infected mosquitoes.
There are 4 types of malaria: ovale, vivax, malariae and
the most serious, falciparum.
Prevention
The best way to avoid malaria is not to get bitten in the
first place! These physical measures include:
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use an insect repellent, preferably one
containing 50% DEET (diethyltoluamide)
keep covered up with long-sleeved shirts and
long trousers when mosquitoes are feeding at
dawn and dusk
sleep in a properly screened room or tent and
use a 'knockdown' spray to kill any
mosquitoes in the room
consider washing nets and clothes in the
chemical permethrin to deter mosquitoes
check nets for holes and tuck them in well
The second method is to take a chemical prophylactic:
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 before travelling, obtain medical advice on
which prophylactic medication to use
 take your anti-malarial tablets regularly as
directed and finish the course
Unfortunately, none of the precautions above will give
absolute protection.
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Symptoms
Symptoms of malaria are notoriously variable (the
disease is sometimes called ‘The Great Pretender’),
however, a classical time course is as follows:
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6 – 10 days post bite: muscular soreness and
low fever
after another 4 – 8 days a fever develops, but
the patient feels cold and shivers
1 hour later: patient feels very hot, is flushed,
may have headaches, may be delirious
2 hours later: drenching sweat develops and
the temperature falls. Severe head, back and
muscle aches may occur
The following symptoms suggest severe malaria:
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vomiting and/or diarrhoea
dark urine
shock
unconsciousness
KEY POINTS: Consider malaria in any patient with a
fever who has visited a malaria-affected region. The
repeated occurrence of fever is the classical hallmark of
malaria.
Treatment
You should start anti-malarial treatment if a team
member develops two of the symptoms listed above even if they think they have not been bitten. If at all
possible, you should try to get a medical opinion (e.g.
by telephone) before starting treatment. It is vital that
you get medical attention at the earliest opportunity,
even if the individual begins to feel completely well
again.
Suspected patients should be encouraged to rest and
take adequate oral fluids. Paracetamol is useful for
pains and fever.
17
If medical help is not available within 8 hours of the
onset of symptoms and you suspect malaria, stop any
tablets you are taking to prevent malaria and then
follow the following regime:
CoArtem (Artemether 20mg + Lumefantrine 120mg)
Take four tablets initially, followed by 5 further doses of
4 tablets, each given at 8, 24, 36, 48 and 60 hours
Total – 24 tablets over 60 hours
Ideally, CoArtem should be taken with milk or a fatcontaining food.
Because of the many possible
complications of treatment, it is vital that patients
receive proper medical attention.
Alternative Treatment for patients not taking malarone
as a prohylaxis:
Malarone (Atovaquone
hydrochloride 100mg)
250
mg
+
Proguanil
Take four tablets once a day for 3 days
Total – 12 tablets
On return
Because malaria can cause such varied symptoms, any
flu-like illness up to a year after travelling to a malaria
containing region should be investigated.
Always mention to your doctor that you have travelled
to a malaria affected region.
18
9. Angina and Heart Attack
The signs and symptoms of cardiac emergencies
include chest pain, shortness of breath, fast and slow
heart rates, fast breathing, ashen grey skin colour and
confusion.
Angina
If there is a history of angina the patient will probably
carry glyceryl trinitrate (GTN) spray or tablets and
he/she should be allowed to use them.
Where symptoms are mild and resolve rapidly with the
patient’s own medication, emergency evacuation is not
normally necessary, however the patient should see a
doctor as soon as possible.
For more severe attacks of chest pain, angina attacks
which seem to be worsening or coming more
frequently, or where there is a loss of consciousness,
emergency evacuation should be initiated straight
away.
Heart Attack
The pain of heart attack is similar to that of angina but
generally more severe and prolonged. There may only
be a partial response to the patient’s medication (GTN).
Patients experiencing chest pain with no previous
history of angina should be assumed to be having a
heart attack.
Signs and Symptoms of Heart Attack

 Progressive onset of severe, crushing pain in
the centre and across the front of chest. The
pain may radiate to the shoulders and down
the arms (more commonly the left), into the
neck and jaw or through to the back
 Skin becomes pale and clammy
 Nausea and vomiting are common
 Pulse may be weak
 Shortness of breath
19
Initial management of Heart Attack
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Call immediately for an ambulance (if
available) or initiate urgent evacuation.
Fetch an AED (defibrillator) if available.
Allow the patient to rest in the position that
feels most comfortable; in the presence of
breathlessness this is likely to be the sitting
position. Patients who faint or feel faint
should be laid flat; often an intermediate
position (dictated by the patient) will be most
appropriate.
Help the patient to take their GTN
spray/tablet (if available).
Reassure the patient as far as possible to
relieve further anxiety.
Give aspirin in a single dose of 300 mg orally,
crushed or chewed. Record the time and
dose, and pass this information on to
emergency medical personnel.
If the patient becomes unresponsive

 Open the airway.
 Check for breathing.
 In the absence of normal breathing start CPR
(ignore occasional ‘gasps’).
 Give compressions and ventilations at a ratio
of 30:2.
 If an AED is available, follow the machine’s
instructions.
 CPR should continue for up to 30 min, unless
the team is exhausted, in danger or relieved
by a more competent team, in which case
they should stop.
20
10. Psychological Considerations
An expedition is a stressful time for individuals and
providing emotional support is critical. This support
comes from many sources however as a medic you
need to ensure patients are supported. Contentiously –
happy people have fewer incidents. Therefore part of
caring for people is the emotional and physical support.
Breaking Bad News
During expeditions bad news may come to the
participants via telephone or email (e.g. exam results,
bereavements). Ideally, this information will come via
you to enable you to deliver the news appropriately.
Plan how you intend to structure the discussion. Be
straight – you can’t make bad news good news.
Formulate answers to likely questions.
Consider
possible consequences – can the student go home?
Rest the group and deliver the news in a place where
everyone can have some space.
During the discussion be prepared to listen. Allow
enough time to talk. Ask the person involved about
informing the group. The group should be told as close
friends will be the best support. Inform the person
involved first, do not allow the information to leak out.
Psychological Conditions
There are an increasing number of conditions from
eating disorders, depression to self-harm. Do not think
that the right words or intervention can resolve these
complex conditions during an expedition.
Expedition members should be observed for mood
swings and irrational behaviour however no single sign
or symptom can be used to diagnose conditions. On
expedition any psychological concerns should be raised
with the On-Call Doctor and patients should be
observed. Interventions should only be supportive care
and to protect the group and patient from harm.
21
11. Medical Evacuations
If you are questioning whether to evacuate on a trauma
site the answer is probably “yes“. If you are in doubt,
evacuate.
However, in some circumstances (difficult terrain, poor
helicopter access, poor weather, etc) it may be
necessary to bring emergency medical aid to the
patient. The group comes first and sometimes an
evacuation will need to be stopped for the safety of the
group.
When to evacuate:
The following medical signs and symptoms are sure
signs that you should initiate the evacuation:

 Sustained or progressive deterioration;
 Debilitating pain;
 Unable to sustain travel;
 Passage of blood via mouth or rectum.
 Signs & symptoms of serious high altitude
illness;
 Progressive infection even with correct
treatments;
 Chest pain, not linked musculoskeletal origin;
 Psychological illness effecting safety.
How to evacuate:
Full details of the evacuation will be found in the
Expedition Leader Pack and the Emergency Response
Plan.
For medical cases ensure the patient is well packaged
and is comfortable. Ensure frequent stops to reassess
vital signs.
Monitor the group – evacuations are emotionally and
physically draining. Watch out for the next injury /
incident.
22
12. Expedition Mortality
Sometimes things happen that are beyond our control.
In remote settings this can sometimes be fatal. With
the best will in the world, things do go wrong.
When dealing with a patient, one of the most difficult
decisions to make is when it is best to stop treatment or
halt the evacuation. The following guidelines will help
to clarify the situation:
Stop if


other members of the group are in danger
30 min CPR has been unsuccessful
Pronouncing death
This can only be done by a doctor. However, in the
wilderness, the following signs taken together suggest
that the patient has died:






patient is totally unresponsive
pupils are widely dilated and do not respond
to a direct, bright light for 15 seconds
no detectable breath sounds for 3 mins
no pulses or heart beat detectable for 1 min
purple marking on lower parts of body as
blood sinks
injuries incompatible with life
Note: Pulses, breathing and heart sounds may be very
difficult to detect in a patient with severe hypothermia. If
in doubt, re-warm.
“A patient isn’t dead until they are warm and dead”
Action






record all information
inform local Police
photograph location and patient’s body
do not move the body without police approval
inform Home Contact –support will fly out
(counsellor / doctor)
discuss the situation with the group
23
13. Post Traumatic Stress (PTS)
PTS is a normal reaction of normal people to an
abnormal situation.
Causes – some examples


team individual or young child dies
multiple casualties
Types



acute: within 1 - 2 days, remove group from
situation and observe
delayed: within 3 weeks, personality
changes, habits, sleeping problems
chronic: as delayed, but extended time period
Signs





sleep disturbance
appetite disturbance
nightmares
denial
Drug dependence (smoking and alcohol)
Associated issues





new friendships / relationships may develop
existing relationships might be strained,
leading to tension or conflict
you may feel that you can’t give as much as
expected
accidents more common after severe stress
alcohol and medication intake may increase
Common feeling associated with PTS
Crisis shows up human weaknesses as well as human
strengths. Common feelings and emotions are:
Numbness:




the event feels unreal, like it never happened
the misfortune may only be felt slowly
there may be denial of what has happened
Numbness may be misconstrued as ‘being
strong’ or ‘uncaring’.
24
Fear of:





damage to oneself and those we love
being left alone, of having to leave loved
ones
breaking down or ‘losing control’
a similar event happening again
helplessness
Sadness for deaths, injuries and losses of every kind
Longing for all that has gone.
Guilt:


for being better off than others, surviving, not
being injured, for still having material things
regrets of things not done
Anger:






at what has happened.
at whoever caused it or allowed it to happen.
at the injustice and senselessness of it all.
at the shame and indignities.
at the lack of proper understanding.
why me?
Memories of feelings, of loss or of love for other people
in your life who have been injured or died at other times
Disappointment for plans that can now not be fulfilled.
Hope for the future and better times.
Everyone may have these feelings. Experience has
shown that they may vary according to circumstances.
Nature heals by allowing these feelings to come out.
This will not lead to loss of control - but stopping these
feelings may lead to other problems.
25
Managing PTS
Activity:
Helping others may give you some relief.
Reality:
Facing the reality by attending funerals, inspecting
losses and returning to the scene will all help you to
come to terms with the event.
Support:
It can be a relief to receive other people’s physical and
emotional support. Sharing with others who have had
similar experiences can help.
Privacy:
In order to deal with feelings, you may find it necessary
to be alone, or just with family and close friends.
Do






talk with fellow group members. Express
emotions and let people share in the grief
take every opportunity to review the
experience. Do allow yourself to be part of a
group of people who care
take time to sleep, rest, think and be with
those important to you
express your needs clearly and honestly
try to keep your life as normal as possible
take the team to a safe location to enable the
group to rest, have time alone/together with
good comfort levels and support
Don’t




allow the group to bottle up feelings
avoid talking about what happened
expect the memories and emotions to go
away - the feelings will stay with you for a
long time to come
forget that people experience similar feelings
26
14. Notes on Medications
All medications have side effects and may interact with
other medications. Weighing up whether the intended
benefit of giving a medication is worth the potential side
effects is an important consideration.
Wherever possible, seek a trusted doctor’s opinion
before giving a prescription medication.
Always



ask if the patient has any allergies to
medications
what other medication they are taking
think whether the patient could be pregnant
Be aware that medications have internationally
recognised names and trade names. Trade names can
vary between countries. If possible, ask for advice from
a doctor before starting any medication.
Antibiotics
Supportive care, rest and wound care should be the
primary methods to prevent infections. Antibiotics have
side effects and should, when possible, be avoided.
Antibiotics may affect the action of the oral
contraceptive pill – patients should be warned
appropriately.
Amoxicillin (Amoxil)
This is a commonly used penicillin.
Indications: chest, urinary, ear and oral infections
Cautions: penicillin allergy (around 10%)
Side effects: nausea, diarrhoea, discontinue treatment if
rash develops
Dose:
Pneumonia: 500 mg (1 g if severe), 8 hourly
Middle ear infection: 500mg, 8 hourly for five days
27
Chloramphenicol
An antibiotic ointment used to treat eye infections.
Indications: conjunctivitis (sore, red, sticky eye)
Dose: apply ointment under the lower eyelid four times
daily for five days.
Ciprofloxacin (Ciproxin)
Indications: respiratory, skin, gastrointestinal, urinary
infections
Cautions: use with caution if history of epilepsy or
seizures, ensure good fluid intake, avoid excessive
sunlight exposure (discontinue if rash develops), do not
use in children (<16) or pregnant women (risk of
cartilage damage), do not prescribe with antiinflammatory medications, like brufen (Ibuprofen /
Nurofen) or aspirin, as fits may occur – even in nonepileptics, may impair performance of skilled tasks e.g.
driving
Side effects: nausea, vomiting, diarrhoea, headache,
dizziness and rashes.
Dose: All indications: 500 mg, 12 hourly for 5 days
Erythromycin
Erythromycin is used primarily as a substitute for
penicillin in individuals who are penicillin allergic.
Indications: chest, skin and wound infections
Cautions: do not prescribe with certain antihistamines
such as terfenadine (Triludan) and astemizole
(Hismanal) – cardiac arrhythmias.
Side effects: occasional diarrhoea, nausea, vomiting
(increased by high doses)
Dose: 250 – 500 mg, 6 hourly
Metronidazole (Flagyl)
Indications: oral, amoebic and giardia infections
Cautions: can cause severe vomiting when taken with
alcohol – no alcohol for 3 days after treatment,
Side effects: nausea, vomiting, unpleasant taste,
rashes
Dose: Giardia: 2 g once a day for 3 days.
Dental infections: 200 mg 8 hourly for 3 - 7 days.
Amoebic dysentery: 500 mg 8 hourly for 5 days.
28
Anti-Malarial Adult Medication
Malarone
Indications: prophylaxis & Treatment of malaria
Cautions: Avoid use during pregnancy and Kidney
diseases.
Side effects: Dizziness and loss of balance
Dose: Prevention: 1 tablet per day at the same time for
2 days pre, during travel in malarial area and 7 days
post. Treatment: 4 x tablets once a day for 3 days
Doxycycline
Indications: prophylaxis of malaria
Cautions: should not be given to children under 12
years (stains teeth). Do not give with milk, antacids or
iron supplements, increases risk of sunburn
Side effects: nausea, vomiting, oesophageal irritation
Dose: 200 mg daily (as a single or as divided doses) for
a minimum of 1 week
Mefloquine
Indications: prophylaxis of malaria
Cautions: avoid during pregnancy and 3 months after,
disturbed sense of balance may interfere with skilled
tasks (e.g. driving) and may persist for up to 3 weeks
Side effects: nausea, vomiting, diarrhoea, headache,
agitation, hallucinations
Dose: prophylaxis: start 2 – 3 weeks before travel;
continue for 4 weeks after return. If over 45 kg 250 mg
once a week
CoArtem
Indications: Treatment of malaria
Cautions: Pregnancy, Renal Impairment, Hepatic
Impairment
Side Effects: Abdominal Pain, Diarrhoea, Nausea
Dose: Take four tablets initially, followed by 5 further
doses of 4 tablets, each given at 8, 24, 36, 48 and 60
hours. Total – 24 tablets over 60 hours
29
High Altitude Medication
Acetazolamide (Diamox)
This medication promotes deeper, faster breathing and
may relieve some of the effects of AMS (particularly
sleeping problems) in poorly acclimatised individuals. It
also speeds up the process of acclimatisation.
While there is considerable medical opinion regarding
the effectiveness of this medication in treating AMS, the
picture is not entirely clear-cut. The medication is still
un-licensed in the UK for the treatment of AMS. No
medication is as good as effective acclimatisation.
The danger of preventative treatment of AMS is that it
encourages individuals to go further than they are
capable and masks early warning signs. AMS may
eventually be diagnosed too late. The most rational use
of acetazolamide is to assist the recovery of patients
with AMS to lower altitude.
Indications: emergency treatment of AMS
Cautions: keep well hydrated, should not be given to
those who are allergic to sulphonamide medications
(e.g. septrin), with kidney or liver disease, to pregnant
or breast-feeding mothers
Side effects: tingling in lips, hands and feet, altered
taste, blurred vision, weak diuretic effect
Dose: in the presence of symptoms of AMS, 250 mg 12
hourly until below 2500 m.
30
Dexamethasone
Dexamethasone is a strong steroid. At high altitude, it is
used to prevent the build up of fluid in the brain
(cerebral oedema) that occurs in HACE and contributes
to the symptoms of AMS (see Section 2). It is as
effective as acetazolamide in treating AMS, but does
not promote acclimatisation.
As for other AMS medications, dexamethasone is no
substitute in itself for evacuation to low altitude and
prompt medical attention.
Indications: emergency treatment of HACE and/or AMS
Cautions: evacuate as quickly as possible
Side effects: severe side effects would be rare for the
short period of use needed for evacuation to low
altitude
Dose: 4 mg, 6 hourly
Nifedipine (Coracten)
Nifedipine is usually used to treat high blood pressure
and heart blood vessel disease. It is useful in the
treatment of HAPE because it lowers blood pressure in
the arteries of the lungs, thereby reducing the amount
of fluid that accumulates in them. This can lower blood
pressure quite dramatically so please discuss with a
doctor before using.
Nifedipine has a place in treating casualties with HAPE
who are being evacuated to lower altitude. It is not a
treatment on its own and is no substitute for descent
and administering oxygen. Note that nifedipine is not
officially licensed in the UK for the treatment of HAPE.
Indications: emergency treatment of HAPE
Cautions: avoid in patients with heart or blood vessel
disease, in pregnancy, avoid grapefruit juice
Side effects: The commonest side effects seen are low
blood pressure, headache, flushing, dizziness and
ankle swelling.
Dose: 30 mg three times a day
31
Painkillers
Ibuprofen (Nurofen, Brufen)
Non-steroidal anti-inflammatory medication (NSAID)
Indications: treatment of muscle/joint pains, period
pains, fever and migraines
Cautions: should not be given to patients with aspirin
allergy or to those with peptic ulcers, only give to
asthmatic patients if they have had the same
medication before without worsening of asthma, do not
give with the antibiotic ciprofloxacin
Side effects: indigestion, heartburn, nausea, diarrhoea
Dose: initial dose 1.2 – 1.8 g daily in 3 – 4 divided
doses with or after food. Maintenance dose of 0.6 – 1.2
g daily may be adequate. Maximum daily dose is 2.4 g.
The analgesic action of ibuprofen reaches a maximum
after 3 days of regular therapy.
Paracetamol (Acetaminophen)
Non-opioid analgesic
Indications: mild to moderate pain, fever
Cautions: do not take with any other paracetamol
containing products (e.g. cold treatments). Immediate
medical advice should be sought in the event of an
overdose, even if the individual feels well, because of
the risk of delayed, serious liver damage.
Side effects: rare
Dose: 1 g 6 hourly
Paracetamol / Ibuprofen combined
These work well in combination and both can be taken
at maximum dose. If used in combination, always use
maximum Paracetamol before adding in Ibuprofen.
Dihydrocodeine - Opioid analgesic
Indications: moderate to severe pain
Cautions: enhances effect of alcohol, may affect
performance of skilled tasks (e.g. driving), avoid use
with head injuries, respiratory depression
Side
effects:
constipation,
nausea,
vomiting,
drowsiness
Dose: 30 mg every 4 - 6 hours
32
Other Medication
Antacid Tablets
Chew 1 - 2 tablets after meals as required for
indigestion and heartburn.
Chlorphenamine (Piriton)
Chlorphenamine is an antihistamine.
Indications: symptomatic relief of allergic reactions (e.g.
hay fever, insect bites, nettle stings) and emergency
treatment of anaphylactic reactions
Cautions: may affect performance of skilled tasks, like
driving
Side effects: drowsiness, the effects of alcohol are
increased, headaches, ringing in ears, dry mouth
Dose: 4 mg every 4 - 6 hourly, maximum 24 mg daily
Dioralyte
Dioralyte is a powder used to make oral rehydration
drink for the treatment of dehydration.
The aim is to replace at least as much fluid as has been
lost through vomiting and diarrhoea: 200 – 400 ml of
Dioralyte after each loose motion or vomit is sensible.
Add one sachet to 200 ml of purified water. Discard 1
hour after preparation unless refrigerated. Discard all
drink after 1 day.
Loperamide (Imodium)
Indications: may have a limited role in the treatment of
diarrhoea when abdominal cramps are severe or to
assist essential transport of the patient. Replacement of
lost body fluids and salts is the first priority of treatment.
Cautions: the reduced gut motility produced by this
medication probably prolongs diarrhoea illness
Side effects: abdominal cramps, bloating
Dose: 4 mg initially then 2 mg after each loose stool,
maximum 16 mg daily, 5 days maximum.
33
Lactulose
Lactulose is an osmotic laxative that increases the
amount of fluid in the bowel.
Indications: treatment of constipation
Cautions: avoid if patient is lactulose intolerant, may
take up to 48 hours to work
Side effects: flatulence, cramps, abdominal discomfort
Dose: 1 sachet (15 ml) at night, increased to twice daily
if required
Prochlorperazine (Stemetil)
Prochlorperazine is a member of the phenothiazine
family of medications. It is also an anti-psychotic
medication.
Indications: severe nausea, vomiting, vertigo
Cautions: avoid in pregnancy
Side effects: insomnia, dry mouth, drowsiness
Dose: nausea and vomiting (acute attack): 20 mg
initially, then 10 mg after 2 hours; for prevention use 5 10 mg 2-3 times a day.
vertigo: 5 mg 3 times a day, increasing to 30 mg daily if
required
Salbutamol (Ventolin) Inhaler
Salbutamol is a short-acting (3 - 5 hours) bronchodilator
Indications: treatment of asthma
Cautions: hyperthyroidism , cardiovascular disease
Side effects: tremor, headache, fast pulse
Dose: Usual dose is 2 puffs, taken separately every 4 6 hours. If no relief, give up to a further 4 puffs. Repeat
6 puffs 20 mins later.
If salbutamol fails to provide the usual relief that the
patient expects, this may herald worsening of the
asthma – urgent medical attention is required.
Throat lozenges
These are used for mouth and throat infections. They
are helpful at altitude in the cold, dry air.
34
Cream and Ointments
Anusol
A cream containing steroids, anaesthetic and soothing
agents.
Indications: Used to treat haemorrhoids.
Apply twice daily and after bowel movement. Max use 7
days.
Betadine
Iodine based skin disinfectant
Indications: skin disinfection
Cautions: flammable, avoid regular use in patients with
thyroid disorders, do not apply to large wounds or
severe burns, always ask about iodine sensitivity (rare)
Side effects: sensitivity reaction (rare)
Apply: undiluted to skin wounds twice daily
Canesten
Indications: Cream preparation used for fungal skin
infections, especially in the ano-genital region.
Apply 2 - 3 times daily. Patients should be investigated
for vaginal infection on return. Note: damages the latex
in condoms and diaphragms.
I
Hydrocortisone cream
Indications: hydrocortisone cream can be used for the
treatment of allergic contact or irritant dermatitis, insect
bite reactions and eczema
Cautions: do not apply to the face, ano-genital region or
infected skin (including cold sores, athlete's foot and
acne). It should not be used over large areas of skin
Side effects: worsening local infection, thinning of skin,
de-pigmentation
Apply: sparingly twice daily for a max of 1 week.
Gentisone HC drops
Indications: hydrocortisone containing drops for
treatment of outer ear/ear canal infection
Cautions: avoid prolonged use and use with untreated
local infection
Side effects: local sensitivity reaction
Dose: 3 drops into affected ear, 3 - 4 times daily
35
Dressings and Instruments
Flex-Splint
When padded can be moulded to support a fracture
during evacuation.
Isolaide
This protects the user when giving mouth-to-mouth
resuscitation.
Medi-swabs
Alcohol wipes for minor cuts and grazes. Flammable.
Melolin Dressing
Non-adhesive dressing - particularly suitable for
covering grazes and superficial burns. Apply shiny
surface to the wound.
Micropore Tape
Hypoallergenic tape for dressings.
Sterile Kit
The anti-infection kit contains sterile needles and drip
needles for use in areas where sterility of these items
cannot be guaranteed in hospitals. Syringe and needle
can be used for wound cleaning.
Steristrips
Once thoroughly cleaned, many superficial, gaping
wounds can be closed with Steristrips. Apply carefully
to hold the wound edges together - if this cannot be
done stitching may be required to prevent scarring.
Deep wounds or wounds which are not absolutely clean
should be left open to heal from the bottom.
Steristripsdo not work well over joints.
Vaseline Gauze
Suitable covering for open grazes and burns where
there is skin loss.
36
15. Post Expedition Health Brief
Many illnesses will not manifest themselves whilst on
expedition, but may cause symptoms on your return.
Therefore, it is critical to brief the team that they should
listen to their bodies and if they feel unwell they should
see their GP and mention that they have been away to
he specific country.
General points




anti-malarial medications and other courses
of treatment must be completed
see your GP if you feel unwell, especially with
fever for more than 24 hours or persistent
diarrhoea and tell him/her where you have
been (i.e. in a malaria area, if applicable)
keep hydrated and rested
watch out for ‘post expedition blues’, which
can be combated with:
contact with other team members
support from the experienced personnel
within West Lancashire Scout County
focusing on new challenge
Encourage to discuss issues and concerns with the
Leader team. Please do ensure people know they can
call.
If in doubt - get checked out!
37
16. Patient Treatment
Use the mnemonic ‘Dr ABCDE’:
D (danger)
r
(responsiveness)
A (airway, with control of cervical spine)
B (breathing)
C (circulation, with control of bleeding)
D (deformity and disability)
E (examination, etc.)
It’s never too soon to start thinking about evacuation!
D (danger)
Consider
 s there a risk to you or other bystanders?
 is the patient safe to approach?
 protect the patient from the environment
 number of casualties?
 consider the priority of treatment if more than
one patient
r (responsiveness)
What is the patient’s level of alertness?
 fully alert
 responds to your voice
 responds to a painful stimulus
 unconscious
A (airway, with control of cervical spine)
 is the airway clear?
 does the cervical spine need protecting?
B (breathing)
Look, listen and feel:
 is the patient breathing?
 what is the breathing rate?
 does it look and sound normal?
 consider head tilt and chin lift
C (circulation, with control of bleeding)
 what is the pulse rate?
 can it be felt at the neck and the wrist?
38



does it feel strong or weak?
what is the capillary refill time?
control serious bleeding using pressure and
elevation
D (deformity and disability)
 perform a rapid but head to toe check looking
for obvious injury
 can they move all four limbs normally?
E (examination etc.)
 expose and examine injuries
 evacuation plan
 emotional support
 evaluate and monitor treatment
History:
Use the mnemonic ‘SAMPLE’:
S symptoms
A allergies
M medication
P past medical history
L last oral intake
E events (including mechanism of injury)
Basic Life Support algorithm:
1.
2.
check responsiveness (shout assess AVPU)
open airway (head tilt, chin lift / jaw thrust (if
spinal)
3. check breathing for 10 seconds:
- if breathing continue as above
- if not breathing normal start CPR
CPR:
Chest compressions (1/3 chest) at rate of 100
per minute, 30 compressions then 2 breaths and repeat
cycle.
Note - if drowning / lightening / Under 12 yrs:
Before commencing CPR give 5 breaths
Recording
Recording findings on the patient cards.
39
17. Report Cards
Initial Incident Report
To save time and to improve reporting complete the
following report before calling in for support:
Background:

Venture Leader’s name and group name

contact information (i.e. telephone number
leader can be reached on)

exact location

summary of events and times
Patients:

patient numbers and injuries

treatment plan

rescuers:
o
on site
o
required
o
medical advice required?

equipment:
o
on site
o
required

evacuation plan/options
o
o
internal
o
external agencies required?
40
Medical Report
To save time and to improve reporting complete the
following report before calling in for medical advice:
Background:

Medic’s name and training

Summary of events and times
o
Weather / Terrain
o
Resources
o
Evacuation options
Patient:

Chief Complaint

History
o
o
o
Events
Mechanism of injury / illness
SAMPLE history

Physical Examination

Vital Signs over a period of time
o
see patient card for details

Field Diagnosis

Treatment so far
Advice:

Treatment Plan
o
Proposed

Evacuation
o
Options
o
Preference
o
Requests
o
Equipment
o
Resources
o
Medications

41
42