Dr Sarah Hollis, many thanks for taking part in our series of Mountain Medic Interviews! You spoke last month at the Mountain Medicine Advanced Course about your work with British military personnel suffering from Non-Freezing Cold Injury (NFCI). Before we talk about that can I start by asking you how you got to where you are in medicine?
Mmm, not through planning that’s for sure. I did Arts A Levels intending to join the Police but then found I was too small so switched to medicine. Throughout medical school I was unsure whether I had made the right decision and this feeling endured into house jobs so I endeavoured to shore things up by moving to the Lakes, combining SHO jobs with Mountain Rescue work, and so my interest in wilderness medicine was born. Feeling my youth was slipping through my fingers I left medicine for a while and worked for Outward Bound as an instructor. Eventually I was drawn back to clinical practice with the opportunity of working in the mountains of Kurdistan with refugees fleeing Saddam Hussain, and several years of similar work ensued. Feeling a little ill equipped to deal with all I was encountering I returned to UK to do the Diploma in Tropical Medicine and for £600 got a qualification and a husband! As an Army wife, life changed direction, as did having 3 boys, but I funneled my interest into pre-hospital care of any kind including providing medical cover for charity challenges overseas, many at altitude. I fell into working for the Army because the NHS wouldn’t have me; it was an era when you had to buy into GP practices and no-one wanted a partner who would be posted in a couple of years. Luckily I have loved my job and still do.
What is your typical working week?
Two days of general practice interspersed with two days of occupational medicine, and a further day working from home on NFCI stuff and BMA work (I’m Deputy Chair of the Armed Forces Committee).
The general practice work is very cushy compared to the NHS: 15 min appointments, little multi-morbidity and poly-pharmacy, ready access to physio/rehab and mental health services but the IT is ABYSMAL with frequent outages and malfunctions; I live in total envy of a doctor who could stand it no more, wrenched the computer away from it’s tetherings and threw it out the window! I see a lot of sports medicine and environmental injury; stress fractures, heat illness and NFCI are our bread and butter.
Working in the Occupational Medicine Team is much more interesting than you might imagine, less of the toxicology and HSE regulatory stuff, and much more knowledge derived from first principles applied with pragmatism. For example my Diploma dissertation was on solutions for bomb disposal personnel working in Afghanistan at risk of heat illness.
Day to day I am looking at cases and determining how they may be employed or deployed in the military context dependent on their medical condition, and each week I hold an NFCI clinic.
Patients with NFCI are clearly an important part of your work. How do they typically present? How soon do you see them after their injury?
NFCI patients first present to their GP; they generally complain of persistent symptoms including numbness, pins and needles, tingling, burning, altered thermal sensation and cold sensitivity in hands and/or feet.
All soldiers in the North of England who are suspected of NFCI are referred from primary care into my NFCI clinic.
The NFCI clinic has been running for 4 years and initially swept up quite a lot of historical cases of NFCI with many presenting years after the initial injury, during this last year most cases have been relatively fresh; I aim to see cases within 6-8 weeks of injury, if not sooner.
What do you look for on examination?
On examination I first look at what they are wearing (it is not uncommon for people to complain of terrible cold sensitivity but present with bare feet in mesh trainers in winter!), then stance and gait as rough indicators of proprioception. After that it is onto the couch for assessment of skin appearance, skin temperature, pulses, cap refill, proprioception, pinprick (Neurotips), light touch (2g feet 1g hands) and vibration.
Importantly if their hands or feet are cold we warm them up in a foot spa or sink of water before examining, otherwise the cap refill and neurology are all over the place.
What further tests do you perform?
Before coming to NFCI clinic all patients have a set of blood test: FBC, U&Es, LFTs, TFTs, glucose, HbA1c, B12, folate and haemoglobinopathy screening (when indicated ethnically). These are essentially to screen out secondary causes of Raynaud’s Phenomenon.
Is there a criteria you use for diagnosing NFCI? Do most of your patients satisfy them?
We are slowly developing diagnostic criteria based on history and examination, but I’ll be honest it is still a bit ‘finger in the wind’. However very excitingly we are experimenting with AI which is looking promising, and we have a large research project looking at pathophysiology due to start this autumn, so I hope to have much better diagnostic criteria soon.
Using current criteria about 75% of patients coming to NFCI clinic are diagnosed with the condition.
What is the next step for patients who are diagnosed with NFCI in your clinic? Is there a role for occupational therapy within your service?
When patients are diagnosed with NFCI the next step depends on whether they have persistent sensory peripheral neuropathy, cold sensitivity or both. Those with neuropathy are referred to a specialist tertiary care clinic and undergo a battery of tests to assess the degree of nerve damage and thus inform prognosis. If neuropathic pain is an issue we do try medicines along the lines of the NICE neuropathic pain pathway, though anecdotally (data not yet analysed) these only appear to be useful in the acute phase of injury.
Thereafter our main role is to advise on self-help strategies to maintain normothermia (I have a leaflet with lots of top tips) and thus reduce symptoms, also to offer recommendations to the chain of command on how individuals may be employed and deployed taking into account the need to protect from cold to varying degrees.
I haven’t spotted a role for OT in our treatment pathway but we do use them to perform functional evaluations in those who are most severely affected, for example every soldier must be able to safely and reliably handle a weapon to remain in service.
Do you provide a “follow up”?
We do provide follow up. After the initial consult we see cases at 6 months and one year post-injury, and if they go to peripheral neuropathy clinic we see them to discuss results. They are discharged at the one-year point as it seems the vast majority of patients reach a steady state by this point, but we will always see them again if primary care report any dramatic changes.
Can you tell me about the “nuts and bolts” of your clinic? How many patients do you see? Are they mostly new referrals? Who do you work with? Do you often overrun?
I see about 50 patients a year from North of England. Other regions have yet to develop a service and consequently this year I have undertaken case reviews on another 40 patients.
I work in an occupational medicine team but I have developed the NFCI service on my own. James Kuht, a junior doctor has assisted in clinics over a period of about 6 months and has helped me immeasurably in data analysis which I am hopeless at, and has put together a paper on risk factors because I’m hopeless at writing papers too!
I don’t over run, but only because I decide how many patients I will see and when I will see them, but that does mean that I work unpaid hours to keep up with the throughput – see what being passionate about a subject does to you!
As clinicians we sometimes have memorable patients. Do you have any that have made a lasting impression upon you and your management of NFCI?
Funny, I’ve never thought of NFCI patients in those terms but as soon as I read your question two patients sprang to mind:
Patient A was on a Unit exercise on Salisbury Plain in the winter, immensely committed and proud of his work. He became very cold and lost feeling in his hands but he was the only ‘comms’ expert for his company as the other person able to take on that role had already ‘gone down’ with a back problem. Consequently his belief was that if he came off the exercise his company would fail, and if his company failed his unit would fail, and if his unit failed as well as being shameful then they would not be validated for deployment and so another unit would have to stay longer in theatre (a huge knock on effect). So he opted to stay in the field, his hands were so bad that he had to direct another soldier to connect wires and equipment as he had lost dexterity. He suffered severe NFCI and is likely to lose his job, but of course it is much more than that, he will lose his way of life that he loves, and his home. This kind of patient drives my work.
Patient B was one of my ‘exaggerators’ and proceeded to make a successful high value claim against the MOD. Another patient showed me a closed Facebook posting from Patient B which said: “If she sends you down to the clinic in London spend as much time as you can with your feet in the freezer to be sure you’ll have some damage when you’re seen.” This kind of patient also drives my work, but in a very different way.
You’ve done a lot of work on NFCI prevention. There’s a link to your excellent film at the end of the blog. Can you tell me how it came about?
A lot of the questions I ask in clinic are focused on how we can develop or improve our preventive strategies. I ask if they have had NFCI briefs and if so to tell me what they know about NFCI. Alarmingly most patients have been briefed but few seemed to have learned anything, so I looked through the educational material and was horrified to discover that the recommended video was 25 years old (David Jason is a young man in it!) and intensely boring. I tried and failed to get funding for a commercial venture (the MOD like every other government dept has no money) so instead I set the family to work on it; our eldest son came up trumps with a friend who had just finished film school, our middle son coerced his friend studying at drama school to be the actor, I learned a lot about script writing and selecting people for voice overs and lo and behold we had a film.
Finally, a rather flippant question! My wife’s an oncologist and assumes that every symptom she sees is evidence of cancer. How shall I put this? Do you have a low threshold for diagnosing NFCI in yourself and those around you?
Of course! Not only do I have NFCI I have Raynaud’s too!
Thanks Sarah for taking the time to speak to us!
Sarah’s excellent film “Pte Finn’s Story” can be found at…
And short clips at…