Welcome to a new section entitled "My Mountain Medicine..."!
This is our opportunity to get those who work in mountain medicine to tell us about what they do. Monica Piris has very kindly agreed to start us off. Over the last decade, Monica has worked as an Expedition Doctor on no fewer than twenty occasions. Sixteen of these expeditions have been to 8000m+ peaks. We caught up with Monica shortly after her return from Mt Everest.
Thanks Monica for agreeing to talk to "Surviving The Death Zone". You’ve spent a lot of time treating medical problems at high altitude. Just to give our readers some perspective - how many nights do you think you've spent above 5000m?
Way more than I would care to count, especially if we think they are not good for health!!!!
But to humour you and convince myself it is time to retire I am willing to do a rough calculation!
Let's take it that most 8000m peaks have a base camp at or above 5000m ... so that's 16 expeditions. The duration of 8000m peak expeditions has changed considerably over the years. My first expedition started on March 15th and finished on June 12th! This year, I left home on April 23rd and was home again on May 26th! So for this calculation let's say I did 8 x 8000m peak expeditions that lasted 60 days, and 8 that lasted 40. That should allow for a week or two either side over the ten years....so that's (8 x 60) + (8 x 40) = 800 days. Again, the number of nights spent below 5000m on an expedition has also significantly changed, ranging from 15 to 4 ... so let’s do the same (8 x 15) + (8 x 4) = 152 days. Therefore, that makes the total number of nights I have spent in a tent above 5000m as 648 – nearly two years of my life!
WAY MORE THAN I HAD EVER IMAGINED AND WAY TOO MANY!!
Before we talk about mountain medicine, can you tell us a little about your medical training?
My medical training was wholly unremarkable. I studied as an undergraduate at Edinburgh university and graduated in 1998, did house jobs in Edinburgh then went to New Zealand (NZ) for 2 years where I did SHO jobs in acute medical specialties and A&E in Wellington Hospital and latterly as a locum all over NZ. NZ is where I confirmed my absolute desire to spend significantly MORE of my life outside than in a hospital. On returning to the UK I did a few more SHO jobs in acute medicine in Edinburgh before landing a dream job on an SHO rotation in Truro, Cornwall (not many mountains but very outdoorsy)...however, I was unable to resist the desire to be climbing and when holidays become insufficient I resigned before completing the rotation. I had my MRCP part 1....nothing else!
At what point did you decide to focus upon mountain medicine?
After leaving Cornwall, I moved back to Spain (I am Spanish) and ran a small mountain hut in a beautiful granite, trad climbing area in central Spain with my then partner. I went back to the UK to do short locum jobs in A&E to earn some money, but mainly just ran the hut and rock climbed. After 5 years of that, I heard about the DMM and decided to try and see if there was a way to combine mountain and medicine. I did the Diploma in one year and through climbing and guide friends met an expedition company owner who was looking for a doctor for his commercial guiding trips to Everest. That was 2006 and in March 2007 I went on my first expedition as the team doctor.
Can you describe your "typical" year?
Nowadays a typical year for me is basically split into three parts. I spend winters (December to April) in Chamonix, then I go on expedition until early June, then from June to December I'm at my home in Spain. My partner is a professional alpinist and mountain guide so he also spends a few months a year on expedition. The remaining time we try to spend together in the Alps or in Spain.
Do your expeditions allow room for any other medical work or training?
Yes! By necessity both in terms of keeping skills and knowledge up to date and because of GMC requirements. I have a contract with Oxford University Hospitals Trust (OUHT) and I do locum work as a middle grade in the Emergency Department. I've had this contract for almost 8 years now (maybe more) and I'm delighted to be able to work in the same department every time I do some locum work. I usually do about 5 shifts a month when I'm not on expedition. I grab a cheap flight to the UK and I actually enjoy the work.....must be the novelty of it!
I revalidate in both EM and Mountain Medicine. I declare both in my "scope of work" and then have to ensure I meet requirements for CPD and QI etc in both of those fields. Because I have a contract with the OUHT, my Responsible Officer and appraisals are provided and done by the trust.
Can you describe a "typical" working day in the mountains? How far does it go beyond medical matters?
All of my mountain medicine work (bar just 2 or 3 trips) has been as the expedition doctor for a commercially guided expedition. The reason I'm there is to provide medical support to the team; but I am one more team member and on expeditions everyone must pull their weight in every area. On commercial expeditions the clients are exempt from this, and the staff must do much more. I'd say that every day I have at least one or two actual medical consultations from members of my own team or from other teams. In addition it is my responsibility to plan, order and prepare all the medical kits for the whole expedition. That makes for a lot of counting pills in order to make sure every camp is stocked with sufficient amounts of everything for a team of the size in question: plus personal kits for the mountain guides to carry, plus base camp and advanced base camp kits, plus a trauma grab bag for accidents, plus ...plus...
To directly answer the question, a typical day would include, meals with the whole team, a consultation or two if people had issues, base camp management (re-stocking, tidying, cleaning), a staff meeting to look at weather forecasts and discuss climbing schedules and plans, radio check in with the Sherpa higher on the mountain, meeting with the Sherpa team and Sirdar to discuss Sherpa movements and load carrying, a bit of socialising with other teams...perhaps an acclimatisation hike, lots of coffee...
What medical problems do you find most challenging to treat?
The most serious are always the most challenging! However, the most frustrating are the trivial things it's really hard to do anything about. The "blocked sinuses", the "common cold", the random "discomfort" … these are of course the most common complaints. I have learned over the years that people's ability and motivation to deal with discomfort varies on a scale of about 0 to about 100,000. Our clients, are closer to the 0, our Sherpa are close to 100,000. It's astonishing.
With experience are you now better at anticipating and preventing medical problems in the mountains?
Yes I think so, although I don't always succeed.
Are you involved in screening those who take part in your expeditions?
Yes. We have a very detailed medical form that I review before people are accepted onto trips to 8000m and if there is anything alarming I am allowed to say that I will not accept them onto the trip. I have done this, thankfully not often but on occasions.
Do you keep a day-to-day record of your time working in the mountains? If so, what does a typical day's record look like?
No, not really a daily journal. I keep detailed notes of all my medical consultations, and I keep an accurate radio log of all radio communications when people are above 7000m...but I don't keep a day to day log. It would be very boring.
With your experience do you feel you're able to predict those who go on to have success on 8000m peaks?
Yes! I FEEL able to.....but I get it wrong ALL the time!!!!
Do you share your assessment with anyone?
Yes, I share it with the guides all the time. We have daily meetings to discuss how we feel people are doing and whether there are any concerns, either from the guides' perspective or from mine.
How do you look after yourself at high altitude?
I don't really do anything in particular. If my sats are persistently below 60% I sleep on oxygen (sometimes this happens at advanced base camp which is 6400m), but other than that I don't do anything special.
You've been to some of the most beautiful mountains in the world. Is it difficult to put personal climbing ambitions to one side and concentrate on the medicine?
No. I have had ample opportunity to confirm that I am a poor acclimatiser and a poor sufferer. I have seen how difficult it is to climb 8000m peaks, even with Sherpa support, and mountain guides, and fixed lines and unlimited oxygen ... and I simply don't want to do it. So, I guess I don't have personal climbing ambitions for the mountains on which I work. I think it would be really hard to be a doctor based at BC or ABC and WANT to climb the mountain. I also think that it changes the dynamic between the doctor and the climbing team if they perceive you to be aiming to achieve the same goal as them. There is a huge amount of strange psychology involved in the climbing of these mountains ... for professionals, for the guides, for the Sherpa and for the clients. It's a mind game and I find that not being a part of the climbing team with my own agenda, makes me a better, more sympathetic and more supportive doctor.
From my own experience, I know it can take a long time to recover from high altitude exposure. Do you find it a challenge?
You're right, but I can't say I find it a challenge...however I think that's because I know that fitness and energy comes back eventually so I don't have unrealistic expectations.
Do you do anything to help your recovery?
After expeditions the things I want most are to be at home with my partner and nobody else for a good few weeks. Being on expeditions is socially exhausting as you are with people 24/7 ... I definitely need down time afterwards. Of course, eating lots of fresh fruit and vegetables and spending as much time outside in the summer warmth as possible are imperatives too. I'm lucky that I live by the sea, and because of the autonomy I have over deciding when to work or not it's easy for me to take a whole month off and spend time getting my fitness back. I can't imagine having to come back and get straight back into a full time hospital rota ... that would be unfathomably brutal to me.
Many of us remember certain patients that we've treated. Do you have patients that have made a strong impression on you?
I think my memory has been decimated by too much hypoxic damage!! I suppose if I put my mind to it I remember the most serious cases I've treated or big rescues I've been involved with. Sometimes I remember the idiots who did really stupid things and made poor decisions. But in general I think I've forgotten a lot!!!
Finally, can you give one piece of practical advice for anyone wishing to become an expedition doctor?
I can only really talk about my experience which has been with a particular type of expeditioning ... it's probably fair to say that it is much less exciting than it sounds and my main aim throughout the preparation and the expedition itself is always to avoid as much excitement as possible! There is a lot of down time, so for someone seeking an adrenaline filled job, this type of expedition medicine is not for them.
Mountains medicine permitting, we hope Monica will be joining us on future courses and events. Keep an eye on the blog for details!