Mountain Medicine Online CPD - Taster!



Posted by Jeremy Windsor on Dec 11, 2020

Following on from the recent launch of the Mountain Medicine Winter Webinar Series, the BMMS together with University of Central Lancashire (UCLan) have launched a FREE online mountain medicine CPD resource. 

At the outset, it's worth saying that we're trying to do something a bit different. In the past, mountain medicine was all about recognising illnesses and injuries in healthy people and getting them off the hill as quickly as possible. However the population we're now treating is starting to change. Many with chronic medical problems are heading into the mountains. These conditions need to be optimised before departure and importantly, managed effectively when they deteriorate. To help us, we now have increasing access to a range of portable and highly sophisticated monitoring equipment that can be used alongside history taking and clinical examination to help us manage these problems. We want our mountain medicine CPD to reflect this!

The resource takes the form of 25 MCQ's based around 4 cases. Answers and detailed explanations are provided. CPD approval from the Royal College of Surgeons (Edinburgh) is being sought and a certificate will be issued to all those who complete the feedback.

Our thanks go to Dr Neil Long and the team at Life In The Fast Lane for their help in preparing the questions.

Thanks also to the Alpkit Foundation for providing invaluable support.

If you're ready to get started here's the linkOtherwise, try this first...



A 39 year old man is trekking to Mt Everest Base Camp. He has presented to your medical post at Pheriche (4300m) complaining of fatigue, lightheadedness and pain on urinating.

He has diabetes mellitus, hypertension, hypercholestrolaemia and obesity (BMI of 35).

In addition to using a combination of medium and long acting SC insulin, he also takes enalapril 20mg OD and simvastatin 20mg OD.

Acetazolamide 125mg BD was started for AMS prophylaxis 7 days ago.

He is allergic to penicillin.


The following observations are recorded:


Heart Rate: 100 beats per minute

Blood Pressure: 80/40

Respiratory Rate: 32 breaths per minute

Oxygen Saturation: 84% (normally > 90% in healthy visitors)

Temperature: 38 degrees C


The following investigations were undertaken:


Arterial blood gas (normal range in brackets):


pH 7.31 (7.35-7.45)

PO2 7.0 KPa (12-14 KPa)

PCO2 2.8 KPa (4.5-6 KPa)

Base Excess -7 (-3 to +3)

Sodium 135 mmol/l (135-145 mmol/l)

Potassium 9.3 mmol/l (3.5-5 mmol/l)

Bicarbonate 20 (22- 28 mmol/l)

Chloride 110 (96-106 mmol/l)

Haemoglobin 160 g/l (130-180 g/l)

Lactate 2.8 mmol/l (<2 mmol/l)

Glucose 10 mmol/l (4-7 mmol/l)

Ketones 0.0 mmol/l (<0.1 mmol/l)


Urinalysis:


Blood -

Glucose + 

Ketones -

Nitrites +++

Protein +


A 12 lead ECG is obtained:


(1) What does the ECG show?


(A) Atrial Fibrillation

(B) Sinus Arrhythmia

(C) Sinus Rhythm and changes consistent with hyperkalaemia

(D) Sinus Rhythm and changes consistent with an acute myocardial infarction

(E) Paroxysmal supraventricular tachycardia


(2) Which of the following factors may have contributed to this man’s hyperkalaemia?


(A) enalapril

(B) diabetic ketoacidosis

(C) acetazolamide

(D) simvastatin

(E) none of the above


Since his arrival at the medical post the weather has deteriorated and evacuation is no longer possible.


(3) How will you treat this man's hyperkalaemia?


(A) 1 litre of warmed 5% glucose over 8 hours

(B) 10 units of short acting insulin in 1 litre of warmed 5% glucose over 8 hours

(C) 10 units of short acting insulin in 100mls of warmed 20% glucose over 30 minutes

(D) 100 units of short acting insulin in 100mls of warmed 20% glucose over 30 minutes

(E) 100 units of short acting insulin in 1 litre of warmed 20% glucose over 8 hours



(4) You suspect this man has sepsis. Sepsis is defined as, "life threatening organic dysfunction caused by a dysregulated host response to infection". According to the Quick SOFA Score which of the following is NOT a criteria for "organ dysfunction"?


(A) Altered Mental Status

(B) Tachypnea (Respiratory Rate > 22/min)

(C) Hypotension (Systolic < 100mmHg)

(D) Tachycardia (Heart Rate > 100 beats/minute)


(5) You believe that a urinary tract infection is the source of this man's sepsis. Which of the following antibiotics should you administer?


(A) Coamoxiclav 1.2g IV TDS

(B) Tazocin 4.5g IV TDS

(C) Trimethoprim 200mg PO TDS

(D) Meropenem 1g IV TDS

(E) Nitrofurantoin 50mg PO QDS


Overnight your patient is given antibiotics, supplemental oxygen and 4 litres of warmed intravenous crystalloid. The next morning his observations have improved. He is transferred by helicopter to Kathmandu for further treatment.


Answers


1 (C) 

The ECG shows a prolonged PR interval, broad QRS complex and peaked T waves consistent with hyperkalaemia. For further ECG examples of hyperkalaemia and a comprehensive overview take a look at this.


2 (B) 

Enalapril acts by inhibiting the production of aldosterone. Since aldosterone is responsible for potassium excretion, ACE inhibitors can cause potassium retention. 

Acetazolamide is a reversible carbonic anhydrase inhibitor that reduces hydrogen ion secretion at the renal tubule and an increase in renal excretion of sodium, potassium, bicarbonate and water. 

Ketones are absent in the urine and blood making a diagnosis of diabetic ketoacidosis unlikely.

Simvastatin does not cause electrolyte disturbances.


3 (C) 

Urgent treatment is needed. A small dose of insulin matched with glucose is often effective at temporarily reducing the plasma potassium concentration until renal function is restored. 


4 (D) 

Tachycardia is not part of the qSOFA Score.


5 (D)

The patient is allergic to penicillin and therefore cannot receive coamoxiclav or tazocin. Trimethoprim and nitrofurantoin are used in the treatment of lower urinary tract infections. However this is a life threatening condition and oral absorption may be limited. More on treating urosepsis can be found here.


These questions were written by Marika Blackham, David Cambray Deakin and Jeremy Windsor.


Over the years we've organised quite a bit of CPD. Why not take look at these reports - Science Day and Surviving The Death Zone - look out for more in the future!

If you would like to find out more about mountain medicine why not join the British Mountain Medicine Society? See this link for details.


1 thought on “Mountain Medicine Online CPD - Taster!

David Hillebrandt commented 2 months ago
Dear Jeremy and team, Firstly a massive thank you for the work you have put into this BMMS/UCLAN CPD MCQ series. As somebody who has attempted and failed to write MCQs for mountain medicine in the past I am reluctant to sound too critical but when I read this sample it just did not feel right. I pondered this for a couple of days. In the hills I have never had the luxury of such detailed investigations or treatments and have always had to rely on old fashioned clinical acumen. The same is normally true when advising patients with co-existing conditions prior to departure to the mountains due to a lack of hard evidence. As pre trip medical advisors we have to be careful not to deter adventure in patients simply because they have a chronic medical condition. Many get “banned” from trips on the grounds of theoretical risk rather than well founded practical concerns. I wonder if this patient had any realistic pre departure advice from a clinician experienced in mountain and travel medicine. This MCQ is academically and educationally fascinating but it is not realistic in terms of mountain medicine which is normally a 50% blend of medical knowledge and mountain knowledge. In Nepal hospitals in Kathmandu can now offer private first world facilities and treatment. The reality once in the mountains is very different for the local population and also for trekkers, even on well trodden trophy routes. Most tourists have no insight into this and many advising doctors are also not aware of the realities of remote area medicine and assume rapid helicopter evacuation is available. The aid post run by the Himalayan rescue Association (HRA) in Pheriche is staffed during the trekking season by experienced mountain doctors and offers potentially life saving treatment and advice for simple conditions in trekkers and the local population. It is a charity run aid post not a hospital. It is resource poor. It does have an ECG machine which may be working. It may have simple urinalysis and blood sugar testing strips which may be in date. They certainly do not have facilities for a basic blood count, for electrolyte measurements or for blood gas measurement. They may have normal saline but doubt that there would be any other IV fluids and certainly no “exotic” antibiotics. The MCQ raises interesting theoretical learning points but what are the most important take home messages from this CPD? 1) If you have a pre-existing condition take early advice from an experienced mountain medicine doctor. 2) Prior to departure ensure that you and your advisor knows if there are any local medical facilities and understands their limitations. 3) Advise patients not to travel to remote locations unless they are prepared to initially be cared for with limited local facilities. 4) If you plan to act as an expedition medic ensure your mountain skills and knowledge match your medical skills. 5) If planning to work in a remote resource poor environment ensure you are mentally prepared to accept the limitations. I hope we have not given anybody the impression that advanced investigations are available in the Solo Khumbu. David Hillebrandt 2/1/21

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