Medical Handbook

Review by planetFear
Tuesday 1st June 1999
When I was a medical student in 1976 Peter Steele published Medical Care for Mountain Climbers. This was the first book of its kind in the UK and gave practical advice, beyond normal first aid, for the layman or inexperienced doctor feeling scared and lonely when caring for an injured companion in a remote area. The book became a close friend and invaluable second opinion living in the bottom of the medical kit on my first two Himalayan trips.

By the late 1980s the book was becoming out of date but Peter Steele updated it and republished it under the title Medical Handbook for Mountaineers. It was clear, concise, used plain English and was now in a convenient guidebook format. I carried it on further trips as an insurance policy in case I was the victim of an accident and recommended it to many mountaineers for use anywhere from a Cornish sea cliff to an expedition to the Greater Ranges.

In the last 10 years there has been an increasing interest in the pre-hospital care of injured mountaineers and I have felt that it was a great pity that Peter Steele’s classic text had become so dated. I was finding myself having to advise students to use the bulkier, more verbose American books. I was thrilled to find that this new edition of the book had recently arrived in the shops. This is even more impressive when one considers that Peter Steele must have been working on the update at the same time as writing the equally eloquent biography of Eric Shipton that recently won the Boardman/Tasker literature award.

The essential character of wellthought- out practical advice remains and it is obvious that it is written by a working clinician with experience of being on the sharp end in a remote location. Steele has worked in Bhutan and the Yukon and climbed in the Himalaya in the late ’60s publishing a book of his experiences on the International Everest expedition in 1971. This book oozes common sense and all climbers should read the section on the assessment and initial survey at the accident scene. Unless on a prolonged trip, it is designed to be read and left at home and the important clinical principles should lodge in the first aider’s mind. Hopefully realistic sections such as that on head injuries will keep things in perspective for the lonely carer.

Professionally, it is very easy to criticize the minutiae in a book of this sort since all doctors have their own favourite drugs, medical techniques and improvisation tricks. Ultimately, if I were sick or injured in a remote area and my companions followed the advice in this book I would be very pleased (and might even be alive).

I approached each chapter with a critical brief and at the end of each section I was impressed that not only had all the aspects been covered but the author had mentioned some aspects that I had not even considered. I particularly liked the introduction’s emphasis on minimal equipment backed by maximal knowledge. I also liked the sections on legal aspects and risk. The practical skills of injection and airway protection were covered well, although I feel it could have been mentioned that it is quite acceptable to reuse disposable syringes and needles on the same patient in a remote setting. Diabetics do this regularly with no increased infection rate.

Steele is realistic about the place for Cardio Pulmonary resuscitation in the hills but I am pleased that he kept it in the book since most of us know that the most dangerous part of a climbing trip is the drive to the crag. I have been preaching the use of sanitary towels for cheap wound dressings for years and I am pleased to see this recommended. Further personal experience confirms his comments regarding attacks of piles in blizzard conditions.

A recent study has shown that there is an increasing need for active mountaineers operating in remote areas to have some idea of appropriate drug use and Peter Steele has never shied away from this in any of his books. I was disappointed that he did not mention the newer, strong, non-controlled pain killing drugs such as Nalbuphine which has been widely accepted by the paramedic services in the UK. It is currently my drug of choice especially when crossing international boundaries.

Some authorities will find his use of the antibiotic cotrimoxazole confusing since it has gradually gone out of favour in Britain. I like his realistic section on neck injuries in the hills but those first aiders brought up on the dogmatic American- based Advanced Trauma Life Support teaching will find this mentally challenging. This is not a bad thing, even if it simply stimulates pub discussion, as it will serve to mentally prepare climbers for the sort of difficult decisions that have to be made after accidents in remote areas.

On the subject of fractures the new Kendrick lightweight traction splint for femoral fractures points the way for mountaineers to improvise traction splints from telescopic ski poles and this would be more efficient than those splints illustrated in the text. In the hills in the UK, heart attacks kill more people than any other single cause and I would like to have seen the administration of aspirin included in the treatment of severe non traumatic chest pain.

Overall I think the travel medicine sections are well laid out especially the water purification section and discussion on treatment for the shits. The malaria advice is very up-to-date with a mention of the new diagnostic tests. Immunization advice is becoming an increasingly complex field of risk/ benefit assessment based on the individual patient, their itinerary, and the increasingly complex protection that is available.

The general guidelines in this book are sound but I wish patients had been encouraged to get more specific personal advice well in advance of departure. There is more to a travel medicine consultation than planning an immunization programme.

In view of the high quality of most of this book it is with great reluctance that I have to admit that I read the chapter on high altitude problems three times to clarify the main messages. For a potentially fatal, and still misunderstood and underestimated, problem this chapter is too vague in its layout and recommendations. It should be readable and easily understood by a climber whose brain is beginning to be fuddled by anoxia. It does not pass this test; what a pity. I will still be recommending Pollard and Murdoch’s The High Altitude Handbook (Radcliff Medical Press, 1998) to complement Peter Steele’s book for people going above 3,000m.

With increasing specialization in the field of ‘Remote Area and Expedition Medicine’ most major mountaineering countries of the world have professional organizations dedicated to the education and certification of doctors with appropriate practical and theoretical skills. In the next edition of this book I hope that there will be details of these organizations to facilitate the dissemination of up-todate information to all mountaineers.

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