One of the most enjoyable aspects of working in mountain medicine is being able to spend time with those working in the travel industry. It’s a fantastic opportunity to use the results of research to answer real life, practical problems. Last month I travelled to Farnborough to meet the product managers at Explore. On previous visits we'd focused upon reducing the risk of high altitude illness amongst clients and leaders heading to the mountains. Using the WMS guidelines, together with lots of collective local knowledge, we were able to come up with safe ascent profiles for more than 50 different trips. It wasn’t simply a matter of keeping the daily ascent rate to 500m and taking a rest day every 4th day. Rather, it was trying to look at things more broadly – taking into account factors such as levels of exercise, geographical features and opportunities to “climb high, sleep low”. It was good to hear that since these changes had been introduced the incidence of high altitude illness had fallen and feedback from clients had been very positive.
Speaking to the product management team at Explore
For this visit I was asked to give a presentation. After a bit of thought I decided to focus upon three new developments that I thought would be relevant to the travel industry. Here's what we covered…
Kilian Jornet acclimatising at home using a mask that delivers a low concentration of oxygen in order to simulate high altitude exposure
Pre-acclimatization - I kicked off by talking about Kilian Jornet and how he acclimatized for his record breaking ascent of Mt Everest in 2017. Rather than rely upon the traditional method of spending several weeks moving up and down an 8000m mountain, Jornet acclimatized at home and summited Cho Oyu within 10 days of arriving in Kathmandu! The key to Jornet’s success had been the use of equipment that simulated a high altitude environment and triggered the acclimatization process that was needed to ascend so rapidly. Given the enormous publicity surrounding Jornet’s achievements and the increasing availability of the equipment he used, it’s only a matter of time before those joining commercial treks and expeditions will want to try it.
According to NHS Digital, obesity in the UK has risen from 15% in 1993 to 26% in 2016.
Obesity – Next up, we concentrated upon obesity. Since the number of overweight and obese adults continues to rise in the UK it’s becoming increasingly important to identify the problems those with the condition face and do what we can to help. Between us, we were able to come up with a long list of issues and identified a number of potential solutions. It was impressive to see how far Explore's staff were prepared to go in order to help clients fulfill their ambitions. Nevertheless it was clear that if leaders felt that their client’s condition posed a significant health risk they had the full support of the office team to turn them around.
Drug Prophylaxis – For this section, we split the audience into two and gave each group the following scenario...
“A family of three – Mum, Dad and their 13-year-old daughter have joined your expedition to climb Kilimanjaro via the Lemosho Glades route. Five years ago the daughter was successfully treated for Acute Myeloid Leukaemia (AML) and their intention is to use the expedition to raise awareness and funds for a local children’s cancer charity. A journalist and film crew are accompanying them. The family has done a lot of preparation for this expedition, walking widely in the UK and on several holidays to the Alps and Pyrenees. Explore was chosen as it offered a long, slow ascent profile and had a very high summit success rate. There are four other paying clients on the expedition. At the end of the first day, Mum and daughter are suffering from mild symptoms of AMS. Over dinner, it is clear that other members are taking acetazolamide and are symptom free. Both Mum and daughter ask if you would provide acetazolamide from your medical kit so that both of them can continue. What do you do?”
Each group was then given 5 minutes to come up with an argument “for” or “against” the prescribing of acetazolamide. The debate threw up lots of issues and had us all thinking about what we’d do if presented with a similar situation!
Following the presentation, we spent the rest of the afternoon meeting with individual project managers and talking about their plans for future trips. One discussion really stood out. Tom Cheke is developing an ambitious overland tour through Tajikistan. It was impressive to hear about the enormous amount of work that had gone into developing it. Having sought out the experience of a number of visitors to Tajikistan, Tom was keen to minimise the risk of developing Traveller’s Diarrhoea (TD). Clearly, putting 8 clients in 2 4x4’s for a week and throwing in TD there’s going to be a problem! We talked through developing a prevention strategy and the use of antibiotics in symptom management. For this we followed the latest expert panel report published in the well respected Journal of Travel Medicine (JTM). Along with a plan to prevent TD, Tom wanted straightforward answers to two questions:
When should TD be treated?
According to the expert panel in the JTM report this is best done by distinguishing between “Mild” TD and “Moderate” or “Severe” TD. In the past, these definitions were complex and often relied upon sufferers counting stools, taking their temperature and recording their symptoms. Things have changed and all that matters now is the impact the condition has upon the victim. “Mild” is simply, “diarrhoea that is tolerable, is not distressing, and does not interfere with planned activities.” This, the panel felt, does not warrant treatment. “Moderate” TD is, “diarrhoea that is distressing or interferes with planned activities” and “Severe” TD is, “diarrhoea that is incapacitating or completely prevents planned activities”. These both warrant prompt treatment since, “timely and effective self-treatment will often enable the traveller to continue the journey as planned”.
Which drugs should be used to treat TD?
It’s worth saying at the outset that there’s ample evidence to show that antibiotics work for “Moderate” and “Severe” TD. They reduce the duration of symptoms to just 1 or 2 days. Azithromycin emerges as the drug most recommended by the panel. It has few side effects and importantly, has low levels of bacterial resistance. A single 1g dose is recommended. In the case of symptoms not resolving quickly, the drug (500mg twice a day) is then continued for 3 days. The report also supports the use of loperamide in the management of TD. For many years this drug has been avoided as it was thought to slow the expulsion of infective organisms and hence delay recovery. Recent studies have shown that this is not the case and loperamide can be used to further shorten the duration of illness. The initial dose is 4mg and a further 2mg is taken after each episode of diarrhoea. The maximum daily dose is 12mg.
Hopefully, these answers will help Tom brief prospective clients and provide them with the information they need to have an informed discussion with their GP's about how to manage this most unpleasant of conditions.
After that it was time to head across London and return to Hathersage - a thoroughly interesting day!
My thanks to Yvonne Ramsey and the team at Explore for making me feel so welcome.
For those curious about the cover photo - one of Explore's most popular guided tours is to abandoned sites in the Chernobyl Exclusion Zone. Details of this fascinating tour can be found here.