BRITISH MEDICAL JOURNAL VOLUME 282 17 JANUARY 1981

Clinical Topics

Medical equipment for expeditions

ROBIN ILLINGWORTH

Each year more than 200 expeditions leave Britain to travel todestinations around the world, to climb mountains, explorejungles, to study plants or beetles, and to seek excitement andadventure. Expeditions may differ greatly in size, duration,objectives, and activities, but none can avoid the possibility ofaccident or illness. Most expeditions have no major medicalproblem. Nevertheless, any injury or disease that does occurmay be more serious and difficult to manage because of theremoteness that is an essential part of an expedition.

Expedition medicine entails far more than just taking a first-aid kit and hoping not to have to use it. It is most important toprevent illness and injury whenever possible by adequateimmunisations and antimalarial prophylaxis, careful attentionto the cleanliness of food and water, safety precautions duringpotentially dangerous activities, and general common sense.Dental and medical check-ups will be needed before departure,plans must be made for emergency evacuation if necessary, andfull medical insurance arranged. These and other aspects ofexpedition medicine have been discussed elsewhere.1-3Even with the best preventive medicine, however, a medical

kit is essential. This paper is the result of experience gained fromexpeditions and mountaineering in four continents and oforganising medical equipment for more than 60 expeditions.Most of these have been run by the Brathay Exploration Groupfor young men and women aged 16-22, with older leaders, toremote parts of Scotland, Norway, Iceland, Greenland, Canada,

FIG 2-Kiagtut Sermiaexpedition, 1969.)

glacier, South Greenland. (Brathay Greenland

FIG 3-Expedition equipment in dug-out canoes on Karamuak River,Borneo. (Brathay expedition to Sabah, 1977.)

FIG 1-Jokulsa lake and Vatnajokull icecap, South-east Iceland. Highestpoint of icecap is Hvannadalshnjukur, 2119 m, which was climbed by theBrathay Iceland expedition, 1979.

Accident and Emergency Department, General Infirmary, LeedsLS1 3EX

ROBIN ILLINGWORTH, BM, MRCP, senior registrar (also honorarymedical adviser to Brathay Centre for Exploration and Field Studies, OldBrathay, Ambleside, Cumbria LA22 OHN; present address: Accident &Emergency Department, St James's University Hospital, Leeds LS9 7TF)

Kenya, Borneo, and elsewhere (figs 1-3). This experiencemay be useful to others planning similar ventures.

Planning the kits

Organising the medical kits for an expedition takes a lot of time andtrouble if it is done properly. It is difficult to decide what to take, andwhat not to take, especially on a small expedition travelling in a remotearea and carrying all its equipment. A larger expedition can carry

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more medical equipment, but however much is taken one cannotpossibly deal with every conceivable accident or illness that mightoccur. If a medical kit is too large and heavy it is likely to be leftbehind and so will not be available when needed. With careful plan-ning, however, most common conditions may be treated withoutoutside help, and first aid for more serious problems may be given ifnecessary.The medical kits will probably be needed most often for blisters,

minor cuts and sprains, headaches, sunburn, insect bites, anddiarrhoea. Whether visiting the arctic or the tropics, the sea, desert, ormountains the same injuries may occur and the same basic medicalkits can be used. Nevertheless, extra drugs or equipment may beneeded to deal with particular hazards of the expedition's area oractivities. Advice from previous visitors to the area may be mostuseful.4 5

How much equipment to take will depend on many factors, such asthe remoteness from medical aid, the size and organisation of theexpedition (especially the number of camps and the travelling timebetween them), and the medical skills of the party. Accidents are mostlikely to happen in bad weather when travel is difficult. The timeneeded to get help is more important than the distance to a doctor orhospital, and in a remote area the nearest hospital may be small andpoorly equipped. There is no point in taking drugs and equipment ifno one knows how to use them, but sometimes advice may be obtainedby telephone or radio and evacuation of a patient may not be necessaryif the relevant medical supplies are available.

PERSONAL MEDICAL KIT

Each expedition member should take some personal medicalequipment, including Elastoplast or similar dressings, a crepe band-age, and also sun cream, lip salve, insect repellant, and foot powder asrequired. Anyone taking a drug regularly should carry the mainsupply and someone else look after a reserve stock.While travelling to the expedition area the main medical kits may be

packed and inaccessible. It is useful to have available a small kit con-taining a few dressings, tablets for headaches, diarrhoea, and travelsickness, and water-purifying tablets.

EXPEDITION MEDICAL KITS

Recommendations for communal medical equipment are based onkits used on Brathay expeditions. A typical expedition of 20 people(without a doctor) for three weeks in South-east Iceland might haveone "base-camp kit," one or two "mobile-camp kits," and four"field kits."

Field kit (table I)-Basic first-aid equipment for a small party awayfrom camp for a day contained in a plastic box 11 x 11 x 7 cm thatweighs 260 g. The total cost in 1980 is about £4. When items are usedthe kit may be replenished from the base-camp kit.

Mobile-camp kit (table II)-Intended for a small group away frombase camp for a few days and carrying all their equipment it is in aplastic box 23 x 13 x 8 cm and weighs 680 g. The total cost in 1980 isabout C9.

Base-camp kit (tablc III)-Designed as the main medical kit for anarea such as Iceland where medical help is available within one or twodays the kit is in a fibre-board box 40 x 25 x 13 cm and weighs 3-9 kg.The total cost in 1980 is about £50. Part of the base-camp kit is the"accident kit," which contains equipment that might be useful at anaccident away from camp. This should be kept intact at the top of thebox where it may be found quickly in an emergency.

TABLE I-Field kit contents

Item Amount

Plastic box and list of contents 1Large plain wound dressing, No 15 BPC 1Triangular bandage 1Melolin non-adherent dressing lOx 10 cm 1Elastoplast Airstrip dressings, assorted sizes 12Zinc oxide plaster, 1-25 cmx 5 m 1 rollInjection swabs (for cleaning small wounds) 6Blood lancets (for blisters or splinters) 2Safety pins 2Scissors 1 pairParacetamol tablets 10Mountain rescue message form 1Pencil 1

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TABLE Ii-Mobile-camp kit contents

Item Amount

Plastic box and list of contents 1Large plain wound dressing, No 15 BPC 1Medium plain wound dressing, No 14 BPC 1Triangular bandage 1Elastic adhesive bandage, 7-5 cm 1Melolin non-adherent dressing, lOx 10 cm 2Elastoplast Airstrip dressings 12Steristrip, 6-3 msx 10-2 cm 1 packet of 10Zinc oxide tape, 2-5 cmx 5 m 1 rollSavlon antiseptic concentrate, 10 ml sachets 2Plastic dressing forceps, sterile 1 pairGauze swabs, 7-5x 7-5 cm, packets of 5 3 packetsInjection swabs 10Safety pins 4Paper clip (for subungual haematoma) 1Blood lancets 2Scissors 1 pairThermometer 1Cotton-wool-tipped sticks 4Paracetamol tablets, 500 mg 20Co-trimoxazole tablets 20Chlorpheniramine tablets, 4 mg 20Codeine phosphate tablets, 30 mg 50Amethocaine eye drops, 1 °', single dose 2Fluorescein strip 1Chloramphenicol eye ointment 1 tubeBuprenorphine (Temgesic) 0-3 mg ampoules 4Syringe 2 ml 2Needles 38x 0-8mm 4Emergency message form, pencil, notebook 1Instructions on use of drugs and dressings

TABLE III-Base-camp kit contents

Item Amount

Accident kit (in a polythene bag with list of contents)

Large plain wound dressing, No 15 BPCMedium plain wound dressing, No 14 BPCSmall plain wound dressing, No 13 BPCTriangular bandageMelolin non-adherent dressing, 10x 10 cmCrepe bandage, 10 cmx 5 mElastic adhesive plaster, 2-5 cmx 4 5 mSafety pinsScissorsBuprenorphine (Temgesic) 0-3 mgSyringe 2 ml and needle 38x 0-8 mmInjection swabsInstructions for using buprenorphineLuggage labelEmergency message form and pencil

Books and instructions (in a polythene bag)

Medical Care for Mountain Climbers"'Mountain Hypothermia leaflet"7Instructions on use of drugs and dressingsList of contents of medical kitsNotebook and pencil

2224421 roll61 pair

10 ampoules1010

21

Dressings and bandages (in a polythene bag with list of contents)

Injection swabsSavlon antiseptic concentrate, 10 ml sachetsCotton-wool balls, sterile, packets of 5Gauze swabs, lOx 10 cm, packets of 5Melolin non-adherent dressing, lOx 10 cmMelolin non-adherent dressing, 5 x 5 cmBactigras dressing, lOx 10 cmElastoplast Airstrip dressings, assorted sizesElastoplast dressing strip, 6-3 cm x 1 m

Steristrip, 6-3 mmx 10-2 cmElastic adhesive bandage 7-5 cmx 4 5 mZinc oxide plaster, 2 5 cmx 5 mTubigrip, size CTubigrip, size DConforming bandage (Krinx or Kling) 7-5 cm

Eye bathCotton-wool-tipped sticks (for removing objects from eyes)Eye pad, sterile, No 16 BPC

121010 packets10 packets1010106013 packets1 roll1 roll1 metre1 metre31102

Drtugs and instruments (in a plastic box with list of contents)

ScissorsSplinter forcepsDressing forceps, plastic, sterileBlood lancetsDisposable scalpel, No 15 bladePaper clipSafety pinsThermometer, centigradeCalamine creamParacetamol tablets, 500 mgThroat lozengesAntacid tabletsCodeine phosphate tablets, 30 mgSenokot tabletsChlorpheniramine tablets, 4 mgCo-trimoxazole tabletsDihydrocodeine tablets, 30 mgOtrivine 0-1 %' nasal sprayAmethocaine 1 °' eye drops, single dose units

Homatropine 200 eye drops, single dose units

Fluorescein strips (Fluorets)Chloramphenicol eye ointment 1°,Vioform-hydrocortisone cream

Emergency dental filling (Provipast)

1 pair1 pair2 pairs611

612 tubes

502050

1002050505013221 tube1 tube1 tube

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EXTRA DRUGS AND EQUIPMENT

Many expeditions will need extra drugs and equipment in additionto those in the standard kits. For example, the Brathay expedition toBomeo in 1977, with 18 expedition members plus local guides andporters, took two base-camp kits, one mobile-camp kit, five field kits,and four extra boxes of drugs, intravenous fluids, plaster of Paris, andother items: the total weight of medical kits was 28 kg and their valueabout £300 (fig 4). On a larger expedition much more equipment maybe taken.6 Even if there is a doctor or nurse on the expedition theymay not be available immediately, so the best basic medical kit is onethat anyone can use if necessary with a separate kit for the doctor'suse only.

Suturing equipment and local anaesthetic may be necessary forclosing wounds, and could be used by non-medical people withsuitable training. Extra drugs may be needed if anyone is allergic to adrug in the standard kits, or has a pre-existing condition such asasthma. Injectable antibiotics and ampoules of hydrocortisone,glucose, diazepam, and an antiemetic may occasionally be useful.

Other items of equipment that might be taken if there is a doctor inthe party are an oropharyngeal airway, stethoscope, auroscope andophthalmoscope, urethral catheter, nasogastric tube, chest drainagecatheter and Heimlich valve for pneumothorax, and dental equip-ment.7 Intravenous fluids are heavy but indispensable in the event ofmajor trauma or severe illness: the most useful are probably saline,dextrose, and Haemaccel (Hoechst).

Splints are fortunately needed rarely, and on most expeditionsmaterials for making makeshift splints will be available. The mostuseful splint is a "long leg" splint for fractures of the tibia. Simple andcheap splints of padded cardboard made by Akla of Sweden areavailable from Marshall's Mountain Equipment, 306 George Street,Aberdeen AB1 IHL. Inflatable splints are effective for some fracturesbut may cause problems due to pressure on the skin; they are alsoliable to punctures and to changes in pressure due to temperature andaltitude. Plaster of Paris is useful to make "backslabs" for fracturedlimbs. The most convenient form is the Gypsona "emergency splintpack" (Smith& Nephew Ltd).Some expedition doctors take enough equipment for an emergency

appendicectomy, but in fact non-operative treatment of appendicitiswith fluids, analgesics, and antibiotics is safer than emergency surgeryoutside hospital.8 Fluids could be given by rectum if intravenousfluids are not available. If injections of antibiotics can be given thecombination of gentamicin and clindamycin is recommended, but ifonly oral drugs can be used co-trimoxazole with clindamycin ormetronidazole should be effective.

If anaesthesia is contemplated Boulton's articlel1 is essential read-ing. Local anaesthetic techniques could be useful for minor surgery.Ketamine is possibly the most suitable drug if general anaesthesia isunavoidable.

Special hazards ofparticular areasIn the tropics infectious diseases are common, especially malaria

and gut infections. Even if antimalarial prophylaxis is taken regularlydrugs for treating malaria must be available: in West Africa tabletsand ampoules of chloroquine, and in East Africa, Asia, or SouthAmerica quinine and pyrimethamine and sulphadoxine (Fansidar) aswell as chloroquine. Metronidazole is useful for amoebiasis orgiardiasis, chloramphenicol for typhoid, and piperazine for intestinalworms. Gastroenteritis is a major problem in hot countries: fluidmay be replaced by oral glucose and electrolyte solution made fromsodium chloride and dextrose compound powder, BPC, or by asolution of sugar and salt measured with a special plastic spoon.*

In hot areas, especially tropical rain forests,11 wound infections arecommon. Mercurochrome solution painted on minor abrasions shouldhelp to reduce infection, but many people may need treatment withoral antibiotics, such as flucloxacillin or erythromycin. Fungal skininfections may need Whitfield's ointment or clotrimazole cream, andclotrimazole vaginal tablets are useful for women suffering fromcandidiasis. Snake bite is rare if sensible precautions are observed:few expeditions need to carry antivenom, but expert advice about thisshould be obtained in high-risk areas.12

Mountaineering expeditions are likely to suffer from sun, cold, andhigh altitude.13 14 Many throat lozenges may be needed, and codeinephosphate helps the dry cough of altitude. Mountain sickness istreated by descent, but frusemide may help pulmonary oedema and

*Available from TALC, Institute of Child Health, 30 Guilford Street,London WClN 1EH.

FIG 4--Expedition me1977.)

dexamethasone cerebral oedema. Piles can be incapacitating at highaltitude, but ointment and suppositories provide some relief. Sleepingtablets may be needed: a short-acting drug such as triazolam (Halcion)is the most suitable.

Sailing parties may suffer from chapped hands, salt-water boils,and excessive sun.15 Lanolin hand cream may be needed in largequantities. Hyoscine or cinnarizine tablets often prevent sea-sicknessbut occasionally injections of an antiemetic are required. Salt andwater depletion is common in the tropics: "slow sodium" tablets(Ciba) are the most palatable form of salt. Fractures or scalds mayoccur while sailing in bad weather. Falling overboard is likely to befatal, so safety hamesses must be worn.

Diving expeditions share the same problems of exposure to sun andwater, and otitis externa is common, especially if swinmning near coral.Olive oil drops and antibiotic ear drops should be available.

Treating the local peopleIn a remote area the local people are likely to ask an expedition for

medical help, especially if there is a doctor in the party. The drugsmost often needed are analgesics, antibiotics, antimalarials, and insome areas vitamins. Many of the patients will be children, andsuitable doses of important drugs must be available. Small polythenebags are useful for dispensing tablets.

Packing the kits

All the medical kits must be carefully packed before departure sothat the contents are protected from trauma, dirt, and water but itemscan be found when needed. Tablets should be caken in plastic screw-topped containers labelled with the official and trade names of thedrug and with the labels covered by waterproof tape. Full instructionsmust be available for all drugs.During the expedition it is best if one person looks after the kits, but

everyone must know what is available ifan emergency occurs. In manyaccidents the first-aid kit is less important than shelter, food, andwater.

Conclusion

Expedition medicine entails far more than just taking amedical kit, but this is important and may take much planning.Fortunately most expeditions have no serious medical problem,and, unless the doctor or his companions are ill or injured,travelling as an expedition doctor may be a most enjoyableholiday.

I am grateful to many people for information and advice aboutexpedition medicine and for supplying items for medical kits.Suggestions for improvements in the medical kits will be welcome.

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References

Edholm OG, Bacharach AL, eds. Exploration medicine. Bristol: JohnWright, 1965.

2 Illingworth RN. Expedition medicine, a planning guide. 2nd ed, revisedreprint. Ambleside, Cumbria: Brathay Hall Trust, 1979.

3 Juel-Jensen BE, ed. A traveller's guide to health. 2nd ed. London: RoyalGeographical Society, in press.

4 Hull FM. Doctor in the mountains. Update 1978;16:1087-93.5 Barber SG. Drugs and doctorings for trans-Saharan travellers. Br MedJ

1978 ;ii :404-6.6 Hardie RH. Medical report. In: Fleming J, Faux R, eds. Soldiers on

Everest. London: HMSO, 1977: 187-98.7Watt DG. Emergency dentistry. Weybridge, Surrey: Clausen Publications,

1975.8 Bowers WF, Hughes CW, Bonilla KB. The treatment of acute appendicitis

under suboptimal conditions. United States Armed Forces MedicalJ7ournal 1958:9:1545-57.

9 Rice BH. Conservative, non-surgical management of appendicitis. MilitMed 1964:129;903-20.

10 Boulton TB. Anaesthesia and resuscitation in difficult environments. In:Hewer CL, ed. Recent advances in anaesthesia and analgesia. 11th ed.Edinburgh: Churchill Livingstone, 1972: 143-238.

Illingworth RN. Expedition to Borneo. Pulse 1979 :39;18-9.12 Caras RA. Dangerous to man. Harmondsworth, Middlesex: Penguin Books,

1978.13 Ward MP. Mountain medicine: a clinical study of cold and high altitude.

London: Crosby Lockwood Staples, 1975.14 Hackett P. Mountain sickness: prevention, recognition, and treatment. 2nd

ed. New York: American Alpine Club, 1980.15 Leach RD. The medicine of ocean yacht racing. Br MedJ7 1978:ii;1771-3.16 Steele PR. Medical care for mountain climbers. London: Heinemann, 1976.17 British Mountaineering Council. Mountain hypothermia. Manchester:

BMC, 1972.

(Accepted 31 October 1980)

MyStudent Elective

Chasing bugs in BrazilSIMON WESTON SMITH

Our little house in Brazil saw the first signs of life at the unfortu-nate hour of five in the morning. Three bodies stumbledout to eat a breakfast of coffee and cakes before the crashing ofgears and clouds of dust announced the arrival of Domingos in avehicle which had once passed as a jeep. Armed with torches,forceps, and little wooden boxes with clip-on lids, these three

bodies then clamberedinto this mechanicalmiracle and with moreroaring, crashing, anddust we would hurtledown the road out of

Salvadorthe village of Mambai

. into the surroundingcountryside. Five or six

aiBrcs a a hours later Mambai

*Brai awould once againtremble as Domingos

B RAZ L hurled the blue jeep upthe hill and around thecorner into "High

Rio de Janeiro Street," stopping to dis-; .̂3__ jgorge the three bodies

__0DX_ which had embarked___- ;Iearlier that morning,

_ - -- f_now covered from head_fDL f 000LX- __ to toe in dust and

RIO GRANDE __ bruises, but still carry-SOUTH ATLANTIC OCEAN - ing torches, forceps, and

__4~--Mile-X 0f0= ~~-~-- little wooden boxes with_X_ 100 oo- clip-on lids.--__7{ 200 400 __ 600800 This troubled village

_________________--=___=_=_______ ofMambai lies not far

from the centre of Brazil,about 400 km north-west of the city of Brasilia, and these threebodies, which plagued this village for two-and-a-half monthsduring the summer of 1979, belonged to two fellow students

St Thomas's Hospital Medical School, London SE1SIMON WESTON SMITH, medical student

and myself. We were driving around Mambai not with theintention of terrifying the local inhabitants, but rather withthe aim of studying the epidemiology of Chagas's disease,otherwise known less colourfully as South Americantrypanosomiasis.

No rain but plenty of water

Mambai is the central village of a municipality of about 1000houses and 5000 people spread over about 2000 km2. The area islargely uncultivated yet bears no similarity to the landscapemost people associate with wild Brazil. There are no Amazonianrain forests and no daily tropical rain storms; instead, Mambaiis an area of sparsely spread trees and shrubs without rainfallfor most of the year. Surprisingly, however, the land is crossedby ever-flowing palm-lined streams which receive their waterfrom vast underground lakes.These plentiful supplies of water throughout the year make

irrigation feasible; however, it is used to only a limited extent,and the landowners of Mambai are generally content with theirnon-intensive farming. Indeed, there is no market for the goodsthey might be able to grow, as transport to any centres of in-dustrialisation is exceedingly difficult. But things are changingand the German owner of a ranch covering some 400 km2 ofMambai looked forward to rearing large numbers of cattle on awell-irrigated stretch of land and driving the produce for sale inBrasilia.The people of Mambai are enormously varied in origin. The

majority are of Portuguese extraction, but there are negroeswho have moved west from the sugar plantations on which theirfathers worked as slaves. The picture is further complicated byNorthern European missionaries, whose enthusiastic proselytismseems to have produced some fair blue-eyed children among thedark-skinned Portuguese families. All the families, however,live a similar way of life in their mud-brick or wood-and-palmhouses. A few cattle are raised; rice, maize, coffee, and cotton aregrown; and sugar cane is crushed, fermented, and distilled tomake a potent brand ofrum known as pinga. In Britain house-to-house surveys might be met by offers of cups of tea, but inMambai we were given liberal quantities of this lethal spirit.

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