Dr Robyn Johnston recently got in touch to tell us about her experience working as an expedition doctor in Kenya. Here's what she wrote...
"In February 2019 a group of climbers from the Alpine Club headed out on an exploratory trip to Kenya. Whilst the plan for a 3 week trip would include some climbing at Hell’s Gate and Sabache, the main focus would be a 9 day stint on Mt Kenya with the aim of climbing the peaks Nelion and Batian and also having a look at some interesting new route possibilities. The group were keen to have a doctor along. I had recently returned from a trip up Mt Kenya (September 2018) and having had my Batian hopes dashed by a 10cm snowfall, I jumped at the opportunity to go back and climb!
Mt Kenya from Mackinder's Camp. The narrow ice line that can be seen descending between the peaks of Nelion and Batian is the Diamond Couloir. A recent ascent of this legendary climb is described here.
I had just finished Core Training in Anaesthetics in Scotland, and had decided to take 12-18 months to pursue expedition and prehospital medicine full time before deciding upon my future training plans. My medical background could definitely be described as taking the scenic route – I qualified in Ireland in 2011 from the Royal College of Surgeons in Ireland (RCSI), completed internship in Cork and then moved to New Zealand where I worked from 2012-2015, initially in Paediatrics and then for about a year of surgical specialties (mainly Orthopaedics and Plastic Surgery) before finally ending up as a Registrar in the Emergency Department for my last year as well as another 6 months in Darwin, Australia. I then went “home” to Cape Town, South Africa where I was lucky enough to find some great mentors in the anaesthetic world who quickly improved my airway skills and pharmacology knowledge while swapping stories of mountains and rivers over coffee at work! In late 2016 I found myself in Scotland doing what I still describe as my dream job – 3 days a week as an Orthopaedic middle grade, 1 day of Anaesthetics, 1 day of ITU and then night shifts covering the Emergency Department. I can’t recommend the Borders General Hospital enough for those looking to develop skills and CV before applying to training posts. Anaesthetics Core Training was completed in Edinburgh with ITU rotations and primary FRCA followed!
Where it all began - Chogoria Gate (2950m)
My interest in expeditions and wilderness travel was established long before I ever trained in medicine. My parents (crazy or not) took me off on my first overnight mountain trip in South Africa when I was 8 weeks old. We then moved to rural Canada and my childhood included a lot of camping, hiking and canoeing. As soon as I finished my undergraduate degree (BSc) I promptly moved back to South Africa and studied Exercise Science before finding a job as a river guide on the Orange River that borders Namibia and South Africa. Spending a year sleeping under the stars on multi day whitewater trips remains the best job I’ve ever had, and I was lucky enough to be able to continue guiding occasional trips during medical school holidays. During medical school I went to a Wilderness Medicine Course in Sheffield and then to a WMT Wilderness Medicine Winter Course in Chamonix, both of which provided some really fun days out in good company learning skills like splinting, improvised stretcher carries, water rescue, hypothermia management and many others. In 2018 I joined the Wildmedix team on their Mt Kenya Mountain Medicine Expedition on Mt Kenya where we spent 2 weeks learning about wilderness and altitude medicine and practicing our technical skills and rescues. Since then I have been slowly working on my Fellowship in Wilderness Medicine through the Wilderness Medical Society while continuing to work as an expedition doctor as much as possible. As an expedition doctor I have subsequently visited Mt Kenya, Kilimanjaro, Great Wall of China, Madagascar, Serengeti, Vanuatu, and the Great Barrier Reef.
The first day on the Chogoria route takes you past the magnificent Nithi Falls
This was my second trip to Mt Kenya, but my first trip as expedition doctor. My previous trip was a 2 week long mountain medicine course with Wildmedix on which I was both a participant and a guest lecturer. During that trip, as a group of 9 medics and 2 non-medics, we hiked up the Timau route and down the Naro Moru. We spent 7 nights above 4000m while practicing technical and rescue skills as well as having evening lectures and discussions on altitude and wilderness medicine. We had an amazing trip, including a brief icy glacier climb up the back side of Lenana, definitely the highlight! Unfortunately, the night before our Batian climb it snowed and snowed and then hailed! This combined with beautiful sunshine in the morning meant extremely icy conditions and no safe way to climb. To be so close and yet so far! So you can see why I was keen to go back.
Lake Michaelson - one of the world's most beautiful campsites!
Although as doctors we usually think (at least a little bit!) about first aid and medical supplies when we head off ourselves into the hills, planning for a mountain trip with an official role as trip medic does change how you think, plan and pack. If studying for anaesthetic exams taught me anything it was “categorise, categorise, categorise!” and this approach works well for expedition planning as well. With that in mind I split the potential dangers of this trip into “team member specific” and “trip specific” and then “general expedition issues”.
Team member specific - Our team was an interesting mix, with the youngest member about 30 whilst the oldest 3 all being in their 70s (don’t be fooled, they outwalked and out-climbed me easily!). All were very fit and healthy with a lot of experience in overseas and mountain travel. Despite this there were some health conditions that made me think. One team member was on long term low dose steroids and another had type 1 diabetes (T1DM).
Trekking above Lake Michaelson
Trip specific – Altitude was my biggest trip specific concern on Mt Kenya. Although the mountain is not generally as high risk for high altitude illnesses as Kilimanjaro most ascent profiles offered commercially will put you into at a moderate risk of developing acute mountain sickness.if not a high risk category. We ascended the Chogoria Route and then established a base camp at American Camp (4500m). There were a few other things we did which I think helped our acclimatization. First, we spent 4-5 days before our Mt Kenya trip climbing in Hell’s Gate National Park. Apart from being a beautiful spot to see some animals and do some fun trad climbing, it also had the benefit of sitting at 1900m in the Rift Valley. We also managed to stretch our time on the mountain to 9 days, a huge luxury compared to most technical climbing trips on Mt Kenya. It’s not always possible to have this much time, but if you can, it is definitely worth it.
The other concern I had on this trip was trauma. Although a lot of the climbing on Mt Kenya is not of particularly extreme grades it is still exposed climbing at altitude with all the risks of loose rock, fatigue, and cold. There is a mountain rescue team and, weather dependent, the potential for a helicopter rescue off the mountain. However in the case of serious injury it’s reasonable to assume that you’ll be delayed 12-24 hours before getting someone off the mountain especially as the cloud cover tends to pull in by noon each day.
General Expedition Issues – While expedition and wilderness medicine always brings to mind images of femur fractures and snake bites, at the end of a year packed with expedition medicine trips I can hands down say that the most common thing I’ve dealt with is traveller's diarrhoea. I’ve learned a lot over the year and I will go into a bit more detail later as it’s not something we have to deal with in the acute hospital specialties.
Descending from Point Lenana
Luckily, other than gastroenteritis and some sunburn, we had an uneventful trip. On our first morning above 4000m there were a few people with very mild headaches and loss of appetite but everyone ate and walked normally. All vital signs remained reassuring! Because our route went up over Point Lenana and then down to a relatively low base camp at 4500m (often climbers choose to sleep at Austrian Hut 4790m before attempting the summit) the group generally felt well throughout the trip. However this doesn’t mean you don’t feel the altitude – it’s not possible to climb at 5000m without your lungs letting you know you’re alive! Some of the team slept in Howell Hut on top of Nelion (5188m) or Baillie’s Bivvy and they mentioned that they felt a bit rough the next morning but quickly improved as they descended.
The Howell Hut is situated just below the summit of Nelion - not the place to be taken short!
We had two notable cases of gastroenteritis and a few other people who had brief wobbles but quickly settled back to normal. The first case actually began before we reached the mountain. A 71 year old male with a past medical history of hypothyroidism and polymyalgia rheumatica (long term prednisolone 5mg). He presented with bloody diarrhoea early in the expedition. He denied vomiting or abdominal pain and his oral intake remained good throughout. I think by the time I heard about it, it was already day 2 and so we decided on antibiotics to try and settle things down before going higher on the mountain, especially given the blood and his chronic steroid requirements. He took intermittent loperamide, though as infrequently as possible, and ciprofloxacin 1g followed by 500mg BD until symptoms resolved. Luckily his symptoms settled within the first 48 hours on the mountain although unfortunately they recurred a week later during his stay at the Howell Hut, making for a very unpleasant night of dashing out into the cold at nearly 5200m! Whether that second bout was due to altitude or bugs remains a mystery.
Climbing high on the South East Face of Nelion
The second case was a male in his 50s who was fit and well – I mention this because on our ascent he was consistently first into camp while carrying the heaviest pack and was clearly enjoying pushing himself. I had been playing the nagging doctor (though perhaps not quite nagging enough!) during the first 3 days of the trip as he wasn’t drinking much water while walking and got a nasty sunburn on day 2 to top it off. On day 4, as we reached base camp, he was feeling a bit under the weather at dinner time – hot, tired, and feeling like he had a mild flu. His oxygen saturations were fine but he was tachycardic and flushed-looking. Unfortunately, he then admitted he’d stopped taking his malaria prophylaxis a few days earlier, so adding to my list of potential differential diagnoses! We filled up water bottles with oral rehydration solution (ORS) and left him to sleep. By morning he was feeling worse, now with frequent diarrhoea and nausea and occasional vomiting. He managed to keep down a reasonable amount of fluids, perhaps 2 litres per day, but remained flushed, tachycardic and completely exhausted - only leaving his tent to make dashes to the not very enticing long drop! We discussed antibiotics and loperamide and at this point, he wasn’t keen to take any antibiotics but did take an antiemetic and I left him with antibiotics in case he changed his mind during the day. By evening time, he looked no better and had decided to start ciprofloxacin, which I agreed with especially as he was now having bloody diarrhoea. He continued to have nausea and vomiting but this being day 1 of 4 potential climbing days he really didn’t want to descend in case he recovered enough to climb. By mid-afternoon the following day, with ongoing symptoms and a fluid intake that wasn’t great, we had a discussion with our local guides and agreed to move him down to Mackinders Hut (4200m) for the night where he could sleep a bit lower and in relative comfort. By the next morning (now day 3 of symptoms) he looked no better and in fact looked quite dehydrated, not helped by his sunburn having led to peeling skin all over his face. At this point I think he felt so rotten, and was probably so fed up with frequent trips to some of the least hygienic longdrops you can imagine, that he agreed to descend off the mountain. He walked himself off the mountain with a local guide (in a very quick time!), and was admitted to the Nanyuki Cottage Hospital for IV rehydration and antibiotics. He had an acute kidney injury on admission which quickly resolved. By the time we met him off the mountain 2 days later he was looking a decade younger and and proceeded to climb with the team in Samburu over the following days. On returning to the UK he saw his doctor as he still didn’t quite feel 100% and eventually tested positive for campylobacter. In the end he tells me it took nearly a month before he was back to full speed. We chatted afterwards about where he might have picked it up, as generally the team ate together throughout the trip and the rest of us remained well. We were also fairly good with hand hygiene at meal times in camp. The only things we could come up with were a chicken meal he had eaten at a roadside nyama choma (grilled meat) joint on our drive from Lake Naivasha to Chogoria (which was days earlier, so seems unlikely) or some untreated water he drank from a stream on the mountain on day 2 – maybe the more likely culprit. His comment was that despite always having disliked the taste of puri tabs in the future he will be treating all water before drinking it!
Abseiling off the route
On an unrelated note, having a very well educated and self-aware mountaineer with T1DM on the mountain was a huge learning experience for me. A note of caution to anyone going on cold weather or altitude trips with someone who uses subcutaneous glucose monitoring linked to their phones – we discovered that his was occasionally very inaccurate. On one occasion it reported a glucose of >22mmol/L while his finger prick monitor reported a glucose of 12mmol/L! Luckily he had double checked before treating the number.
This expedition was a great learning experience for me for a number of reasons...
First, I was the youngest member of the team and by far the least experienced climber/mountaineer and this, combined with this being one of my first official expedition medic posts, probably led me to be slightly less pushy about fluid intake in the first few days of the trip than I might have been. On the other hand, I was strict about a twice daily saturation, heart rate and health check for the whole team and I think the group actually enjoyed watching our vital signs change as we ascended, while also letting me pick up some mild symptoms amongst the group that I might have missed otherwise. On subsequent high altitude expeditions I’ve stuck to this twice daily check-up and find it an incredibly useful way to check in with the group while also encouraging some informal altitude sickness chat and education. I have become much more … annoying (some might say) about hand hygiene and adequate hydration on subsequent trips because of this experience. It made me realise that no matter what my level of experience/expertise in other aspects of the trip, as the expedition medic I am the medical lead for the trip and prevention is always better than treatment. I think this is easier with inexperienced groups, and sometimes harder to change behaviour in highly experienced mountaineers/travellers but with some good storytelling and frequent pestering I’ve luckily not had anyone quite as unwell on any of my trips since.
Just in case you were thinking about it...
Second, the guidelines for treating traveler’s diarrhoea have changed over the past year, with azithromycin replacing ciprofloxacin as the first line treatment. This is due to increasing resistance, particularly in India and the Himalayas, as well as the small but real risk of soft tissue side effects with ciprofloxacin. WMT has a really nice flowchart for the treatment of traveler’s diarrhoea which I’d recommend keeping on your phone as a reference when traveling or working as an expedition medic.
For anyone considering a trip to Mt Kenya, I can’t recommend it highly enough. It is a beautiful mountain with so much to offer in terms of both hiking and climbing, and remains relatively untouched by tourism compared to Kilimanjaro. It demands a good level of fitness but with a reasonable ascent profile (ideally at least 4 days up to Lenana) most reasonably fit hill-walkers can expect a good shot at the summit. I’ve been back up the mountain a number of times since this trip, and the Chogoria route remains my favourite with Lake Michaelson a not to be missed campsite!"
Further information on climbing Mt Kenya can be found here.