UKH

I am interested in people's experiences and views of being on an expedition and happening to be a doctor.  I am not asking about situations where you are formally the expedition doctor; I'm asking about the practicalities of being a team member on an exped (as a doctor in rest of life).

It strikes me that being (a doctor) on an expedition does not mean you are obliged to go up and down the mountain to attend to all medical issues; people need to be able to take their own decisions without a doctor telling them what to do.  On the other hand, there could be the expectation that a doctor on a mountain should be willing to compromise their mountaineering exploits by attending to any medical situation.  I feel that a doctor on an exped (who is not the formal exped doctor) should be very willing (as anyone else) to help out at an emergency, but should not be pestered by the sort of medical issues that people should be able to take their own decisions about.  The argument that a doctor is qualified to provide help in a medical situation and should therefore do so at all times does not hold a lot of water.

Thoughts? 

Has anyone found that by virtue of being a doctor on a big mountain, there was the expectation that they would attend to all medical things regardless of severity and regardless of where they happen to be on the mountain? Or are people pretty sanguine about it, that there is a balance to be struck between individual responsibility and a doctor's responsibility.

I'm not a doctor but I can see in your position I'd be tempted to lie about my job!

Time off work is vital for wellbeing and it's not your responsibility to fix everyone.  

If someone needs genuine help then you should, but you don't want to be treating twisted socks and sun burn either. 

I'd speak to the exped organiser you won't be the first to ask. They should respect that this is your off duty time in all but life threatening injuries. 

If you don't want to go public with them, just create a new email address and be very non specific about which trip it is. 

if only it was that simple!

You don’t know who needs genuine help until you’re there; getting there should needs to be balanced with the risk of getting there; it’s all about where you draw the line. Someone vomits a few times at Camp 2 and wants a doctor (because they know a doctor is on the mouhtain?) - go or no go? ; someone feels horrendous with a headache and shortness of breath - go or no go? That could be life threatening, or could be the ups and downs of acclimatisation. Someone has a sore chest - go or no go? Acclimatisation or life threatening? 

I think the declaration of Geneva covers it. I'm surprised you think there's a grey area.

This bit? 

"I WILL ATTEND TO my own health, well-being, and abilities in order to provide care of the highest standard"

Nowhere in there does it say that there is a duty to other people's patients.  

Expeditions that need a doctor should provide a doctor.  Unless it's a very serious and unforseeable emergency no one should be relying on a doctor that happens to be around.   

Tricky one Nick.....is there GMC guidance on matters like this? One of my work colleagues (and good mate) is a psychiatrist and on a few occasions he's been involved in emergency help when we've been out in Scotland. He sees it as being decent at first aid and ABC emergency medicine but he did have a decent amount of time in A&E prior to his psychiatry training..

I’m surprised you think it is that simple. The declaration of Geneva does not mean a doctor is at the beck and call all the time of anyone who is unwell or who may, or may not, be unwell, who wants a doctor to help.

The extremes are easy; major accident and the doctor can safely get there - doctor goes; minor illness or injury - self-help and buddy-buddy system can sort this. But the grey area in between is huge, and that’s what I am asking about.

I agree with all your points.  If your not the expedition doctor you have no responsibility outside of an emergency situation whatsoever. 

I’d also question what as a doctor without any dignostic or theapeutic kit and or drugs  you could add compared to someone else with some relevant first aid training?  I don’t think the decision making is often very complex and advice via sat phone etc is more accessible than ever?

I think you’re spot on there; sure, a doctor can do stuff like CPR possibly a bit better than others but if someone’s having CPR up a big mountain, they’re gonna die. Even with drugs and diagnostics to hand the odds would be extremely low for survival. 

Where did I say that?

It expressly doesn't.  It lays out limits and priorities.  Marsbar is correct.  I thin you have misinterpreted which side I'm on!

Fair enough, apologies buddy!

The perils of interpreting forum posts!

There's something called the Hippocratic oath, without which having sworn you can't become a doctor. It includes this sentence (or one identical in meaning):

I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.

Sure, but how do you interpret that in the light of the question in my OP?

In an emergency it’s clear cut provided the doc feels it is safe to go to help.

But most situations aren’t emergencies; how do you interpret the Hippocratic oath in non-emergencies? Take a common scenario... doctor at or above camp 2, someone at camp 1 is vomiting and feels shite, personally I don’t think the doctor has an obligation to go to assist. 

"There's something called the Hippocratic oath, without which having sworn you can't become a doctor"

Quite a lot of people must slip through the net then!

If you're not the expedition doctor, then I wouldn't think there's any obligation to attend to all medical issues. Realistically, what would you be able to offer anyway, with no equipment, aside from advice?

If someone has AMS then it's going to be their decision about whether to go down. A doctor, who (I assume) has no relevant mountain medicine training doesn't need to be involved

The other issue would be indemnity - there's "good samaritan" cover if you're assisting in some kind of emergency medical event, but the non-urgent stuff probably wouldn't be covered, and in something like AMS could be argued to be outside of competence (if you don't have mountain medicine experience). A quick "could you look at this?" type consultation could end up with a very large legal bill!

I think you maybe need a fact check. Most doctors have not sworn an oath. Let alone the hypocratic oath.

Doctors, in the UK anyway, are governed by the guidance set out by the GMC. This sets out a duty of care to their patients. Like mentioned above all doctors are not at the neck and call of all of the general public all the time. 

The issue of what to do as a doctor on expedition when you’re not being paid to be there (or volunteering your services) is really difficult. I’m confident most doctors would happily give up their time or personal goals to help with any emergency without question.

As Alex says the ability to provide helpful advice or care without equipment or diagnostics is questionable and there is an issue of liability. It’s a difficult place to put yourself advising someone else to end their trip, especially if they haven’t sort out your advice.

I think the hardest part is trying to deal with the grey area of what constitutes an emergency. I think it’s unreasonable to expect someone to go out of their way or compromise their personal experience unless they are there as an expedition medic. Personally I’m sure I would find it hard to not offer help when requested if I felt I was able and qualified to. 

I think trying to keep your professional experience on the down low unless really necessary is the approach I would try and take. 

It does have quite an impact on going on an expedition or trip, commercial or otherwise. I know quite a few doctors that only do expeditions with friends that they know well for this reason, and this seems more common the more experience they have.

We have an ethical and legal imperative to help out in urgent and emergency situations of course. It’s worth noting the standards you will be judged against; the usual for Good Samaritan acts is against that of a doctor of similar training and experience in the situation you find yourself. HOWEVER, if you accept anything substantive from the company, eg a discount, no matter how small, you are now judged as having assumed a formal position as expedition Doctor, and that you should have the requisite skills. You then have a higher duty of care. Companies are aware of this and is often why they are so keen to offer a discount.

Ive always turned down any discount, it’s usually been at most 5%, and personally I don’t feel it’s worth it to change my position and the duty of care I would have. In most cases, I’ve told the trip leader not to tell anyone ahead of time I’m a doctor, I’ll tell people in my own time. On a longer trip, 4 months climbing, I had a formal talk and told people that while happy to help out with emergencies etc, I would not provide less urgent advice, even what they might have assumed simple cases like what is this rash. This may have sounded harsh, but I’m not a registered doctor in any other country but my home one, I cannot prescribe legally or arrange investigations. Even just giving advice assumes a duty of care accepting the risks of incorrect diagnosis, potential harm etc, I’ll either do this properly and formally or not at all. This is why people should have travel insurance and anything that can wait to see a local medical provider, should do.

In summary, be aware that being a doctor means you’re not just another client, it might mean you are the one that has to help evacuate someone, and miss the rest of the trip: perhaps don’t go if not prepared for this; have an up front chat about expectations; and I’d personally say refuse any discounts, either go as fully paid expedition doc, or as a fully paid client.

Thank you for taking time to give such a comprehensive reply. I certainly would be going as a filly paying bod not discounted or as the exped doc.

Clearly docs will help at emergencies but there is still a line to be drawn somewhere here; am emergency 8 hours lower down the mountain, I don’t think it is clear that a doc 8 hours higher up should turn round to help. 

Maybe I’m just unlucky here - I have twice on recent days on the Ben walked round the corner into an emergency and clearly helped out (with no fancy equipment) and needed to call out MRT so I’m wary here....

Living the medical dream....

I don’t think there’s a definite right answer here. Even among the faculty and students on the diploma of mountain medicine, there was a range of views. But I did think it striking that the more exped and general medical experience the docs on it seemed to have, the less likely they were to go on commercial expeds! (I’m aware there’s likely to be some confounding factors there.)

If it is an emergency and your 8 hours higher up, how much help are you realistically going to be anyway? 8 hours of an emergency without any sign on evac, in big mountains, they are pretty much dead surely.

Just a quick addition - you may also want to check the 'small print' for the country you intend to be in. France, for example, I believe has a 'good samaritan' law and you may fall foul of that more easily if you are a qualified doctor.

As a not a doctor this is not something I had ever thought about.

Would you have a leg to stand on suing the victims insurance provider after the event?

Surely it's simply an extreme case of a situation anyone on an expedition might face - the expedition is going well for you personally, but one of the team needs help. Do you push on, or return to help and jeopardise your goals. That could happen to anyone (albeit more likely for a medical expert). Anyone undertaking high altitude mountaineering must know and sign up to the personal risk they are taking, so in that sense the normal life imperative that medical assistance trumps everything else must be diminished. It comes down to the priorities and attitude to risk of you and the team.

Maybe bring it up for discussion with the whole team. If they expect you to risk your goals for their medical needs, then they should expect to risk their goals if you need support. If it is the type of commercial expedition where the company control the lines of communication, I would suggest that the personal goals weigh heavier. If you do find yourself with the choice of personal success or the safety of your fellow, that's your personal call and you have to live with the decision you make. I'd like to think that I would choose the latter, but until the chips are down none of us really know.

Just my thoughts...

Surely it’s no different from anyone else on the expedition - you all use your skill set to keep each other safe

That works in serious situations but not so easily in grey areas. 

For example, someone in another team is exhausted and poorly acclimatised and needs to be helped get to a lower altitude, a choice needs to be made as to who should go. Does a doctor add any value here that common sense doesn’t help with? Hydrate, eat, go steady, avpid overheating or getting too cols, all very simple stuff, but some would say a doctor should accompany this person down.... but to do what exactly? In case they collapse? What can a doctor (with no equipment/medicines) do that mountain conmon sense cannot achieve? 

Nick,

I am pleased you have raised this very complex issue and we are getting some very sensible comments on this forum. I suspect several are from doctors with an interest in mountain medicine who have faced this dilemma but sadly most people on this forum hide behind an alias.

This issue raises the problem of being employed on a commercial trip against a trip with mates. On the former you certainly should have a contract of employment (even if only 10% discount) and it is worth looking at the UIAA advice papers on a doctors contract and how to find a reputable commercial expedition company (UIAA website). If employed you certainly need professional insurance cover and any employing company should cover this expense. It may be expensive. Fortunately Gold membership of the new British Mountain Medicine Society (BMMS) can provide this as a benefit of membership. See thebmms.co.uk .

Of course a doctor, or any fellow mountaineer, has a moral obligation to help in a good Samaritan role and I would not want to be on a trip with a doctor who did not accept this. It is a requirement of GMC registration in the UK. Doctors in the UK answer to the GMC and have not taken a Hippocratic oath for many years and, indeed, historically there are several version of the oath.  The problem is how to define a good Samaritan? I think you would be unprofessional not to a least read up on altitude problems and take a basic medical kit with prescription only medication such as dexamethasone. It might be better to get some formal training. Of course once you do this you cease to be a simple good Samaritan so you are damned if you do and damned if you don't.

All my trips have been with mates and we all climbed as equals and we all threw in any skills we had. Some have been UIAGM guides on holiday but they have a similar professional obligation to offer help. Of course I offered medical skills if needed. Their ropework skills were far better than mine. I suspect I was not insured!

Another complicating problem is that one should only practice in a foreign country if registered with their equivalent of national GMC registration. Have you tried registering in some Himalayan countries? Have you any idea how hard it is for a doctor from a Himalayan country trying to register to work in the UK?  

We have not started on export and import of drugs and many other dilemmas. We have not touched on supervision of junior doctors (who may already have many years of post qualification experience). The GMC in the UK are fully aware of these difficult dilemmas and provide input into the UK diploma of mountain  medicine. It is hoped that the BMMS will continue to work with them. These questions will never be definitively answered. This will always be a grey area. My advice is to take any action you feel comfortable with and ensure you can live with your conscience. To date there is no case law on these issues but the BMMS does provide a large body of medical opinion that has a good grasp of the dilemmas and may be quite supportive, be that personally or (hopefully not) in court. Personally I would never pretend not to be a doctor. I am proud of my profession and with the ethical obligations it brings.     

I look forward to more comments in this fascinating field with no correct answers.

David Hillebrandt.

Dave,

Enjoyed your post which seemed to sum up a lot of the opinions (medical and non medical) expressed so far.

I sympathise with Nick. I've done several (military) expeditions as doctor/participant who is a doctor.

Away from the personal component of what you feel is right to do it is maybe more important as you say, to cover your back in terms of liability to practice in a foreign country/liaise with GMC & DiMM/BIMMS to get confidence that you have top cover before departing?

I agree with Nick that even if you go to help there may be precious little you can do over and above a competent "first aider" if you have no equipment.

(Very) Personally I think if the objective of the trip was one I was really keen to achieve then I would only go as small, "with friends" team. If I was a doctor in a bigger team and was concerned that I might be asked insidiously to cover medical eventualities it would be ideal (in an ideal world...) to get on the front foot and brief informally the exped participants on your experience and realities of what you can offer and NOT offer?

An interesting topic that could be relevant to more careers, not just doctors. My advice would be, if your on a commercial trip with a company that provides an expedition leader, whether it be in country or UK leader, than that would be your first port of call. I would speak privately with the leader on arrival in country and express your thoughts and give the realities of how much you can or are willing to help. Any client of a trip that encounters a problem should be contacting the exped leader in the first instance. That way at least you can make sure your singing from the same hymn sheet and may preempt some of these scenarios. Medical emergencies that happen in front of your eyes are of course another issue, one where I'm sure we all would help where we are able. 

Not a doctor, and in slightly different circumstances, but whenever my Mum goes on holiday, she never tells anyone in conversation that she's a nurse.

She found that saying that opened her up to basically hearing everyone's tales of medical woes (past and present), sometimes alongside some expectation of advice (!), and that's not what she wants to hear on holiday, where the whole purpose is to get away from it all.

Obviously, she'd step in if necessary, but, as said by others, there's only so much you can do beyond standard first aid when you're outside your normal practice with no access to medicines, dressings, patient history and so on - you're (no insult intended) a stop gap until the local cavalry can take over.

Interesting topic and some sage thoughts from folks far wiser than I.

for tuppence- as a doctor who lives amongst, ‘travels’ alongside and socialises with my patients, this is a perennial dilemma. I am frequently asked ‘work’ questions when I am off duty and tend to bat them away or redirect them to a more appropriate person/place/time. Equally on occasions events conspire where I feel bound to get involved to some degree and take pride and pleasure in doing what I can (it is why we do the job after all!). 

I echo Dr Hillebrand’s comment that you have to live with your choices. Almost any decision could be justified in a court, but only the right one will let you sleep at night!

Either way, a brief noted record of intervention or advice (beyond the truly banal) feels like a good plan as well as a chat with the expedition leader to establish boundaries.

I have a few doctor mates and they often lie about their profession when off duty and talking to strangers down the pub or crag. People seem to think it is completely fine to start talking about their various medical ailments or Aunt Ethel's bum grapes the moment they find out they are talking to a doctor. It gets very boring.

Equally, they have got hero status a few times when they have stepped in with the immortal line of 'let me through, I'm a doctor'

Which finally reminds me of a mate who made his way from the back of the stadium to the stage at a U2 concert using the above line, people just instantly moved to one side because he looked earnest and in a hurry despite being shitfaced.