Up the creek without a doctor: If it's Thursday, it must be naso-gastric intubation. Simon Calder takes a course in coping with medical emergencies in foreign parts - those of his classmates

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The Independent Travel
ON PAPER, Thursday looked the worst day. The timetable read: '9am: Gut problems; the acute abdomen. 11am: Diarrhoea; naso-gastric intubation. 1pm: Lunch.'

We were four days into a one-week course on advanced medicine for travellers in remote countries. A dozen of us had spent pounds 270 each to explore the effects of travel upon the human body. By Thursday we were so well-bloodied with jabs and intravenous drips that shoving a tube through the nose into the stomach seemed horribly normal.

The connection between naso-gastric intubation and exotic holidays seems as tenuous as a tendon, but this course is a consequence of ever-more adventurous travel. Conditions that can be easily treated in a well-equipped hospital can kill if help is not at hand.

The idea that non-specialists can be taught basic medical procedures for use in remote areas was hatched by a Cardiff GP, Jon Dallimore. He had undertaken expeditions to Kenya, Nepal and Ecuador sponsored by the engineering company GEC and accompanied by Barry Roberts, a management trainer.

Dr Dallimore was impressed by the amount of medical expertise his lay companion picked up, and believed that a little knowledge could be a valuable thing. Between them they devised a course for people travelling to places where medical help is not immediately available. 'People invest a lot of money in the expedition of a lifetime, and insure themselves to the hilt, but they do little to train themselves to deal with the likely emergencies,' Mr Roberts says.

A subtitle for the course could be 'Don't try this at home'. Dr Dallimore says the course is not intended to provide a grounding in medicine: 'We're talking about lifesaving procedures for life-threatening illnesses or injuries.'

Air travel, for example, presents the human body with challenges it may not be able to meet. A week in Thailand costs no more than a fortnight in Majorca, and charters fly from the relatively clean and pleasant environment of Gatwick to the uncertain sanitation of Gambia. In an hour you can travel from the Peruvian capital of Lima, now threatened by a cholera epidemic, to the Bolivian capital of La Paz, 13,000ft above sea- level, where the air is thin enough to induce high-altitude pulmonary oedema - blood in the lungs - in a significant number of travellers. The further the traveller's horizons, the wider the scope for catastrophe and the greater the need for sound travel medicine.

My 12 fellow students were as varied as their destinations. Melanie Solik, for instance, is a psychologist who runs an outdoor centre in South Wales for stressed executives: 'I'm climbing in Nepal in February, and later next year sailing a yacht via Iceland to Greenland. It makes me feel a lot more comfortable to have these skills.'

Some course members are responsible for taking young people to remote areas. Chris Davis and Ian Morley are teachers who guide sixth-formers on cross-country skiing expeditions in Norway. Mr Morley was not looking forward to every aspect of the course: 'I've heard of people going on nursing courses where they've injected oranges,' he said. 'It was a shock to find that we'd be puncturing each other. But you don't want to have to do it for the first time in life-threatening

circumstances.'

Philip Morris is one of three engineers planning a diving expedition to Belize to help conserve coral. He was keen to find out about antibiotics. 'Coral infections can be very dangerous, so it is essential to know how to react,' he says. Britain's former colony in Central America is a thinly populated jungle. 'Where we're going is totally isolated - we can't evacuate to a hospital, or even a doctor.'

Most of the other participants were sailors who preferred oceans to the local reservoir. Dawn Fletcher and Rob Kings are about to embark on a three-year circumnavigation on a yacht built with three friends. Mr Kings found a standard first-aid course worthwhile but 'every piece of information ended with the advice 'and wait until the doctor arrives'. In the middle of the Pacific, it could be a long wait.'

The course celebrity was the yachtsman Skip Novak, who has been sailing the globe for the past 20 years. He has competed in four Whitbread Round- the-World races and now organises yachting and climbing charters to Antarctica, about as far from medical help as it is possible to be. The law of averages brought him here: 'I've sailed for 20 years around the world and have been lucky enough not to have had any major injuries.'

Preparation for the rough living conditions is thoughtfully provided. The course takes place in a Toc H youth training centre on the outskirts of Bangor in north Wales. The centre itself is not altogether hazard-free; I concussed myself on a beam when walking into the lecture on head injuries. Eating and sleeping are communal. But if your sleep is disturbed by a snorer, you can take revenge next morning when giving an intra-muscular injection.

Six days are spent on a lightning tour covering topics ranging from snow blindness to syphilis and pregnancy to piles. En route, the differences between fractures, sprains and strains are discussed. You learn how to record a victim's medical history, discuss a spectrum of malaises from asthma to ingrowing toenails, and examine the global range of animal hazards including rattlesnakes and rabid dogs.

The Glasgow Coma Scale, which sounds like a device for measuring drunkenness, turns out to be invaluable for assessing head injuries. Attention is paid to maximising sterility and avoiding the exchange of bodily fluids - for your protection as much as the victim's, given the risk of contracting the Aids virus.

Participants are encouraged to contribute expertise from incidents on previous expeditions, but exotic remedies are frowned upon. 'Please keep suggestions for using natural yoghurt to yourselves,' requested Dr Dallimore at the start of the lecture on serious burns.

Easily the most significant threat in the big and often bad world is diarrhoea, which afflicts three in every 10 travellers who leave Britain. This unpleasant condition is not normally threatening, but participants are taught to recognise symptoms of more serious diseases. 'Basically, you can get a whole zoo up your bum,' warns Dr Richard Warner, the resident expert. The Trans-Asian Route was soon overtaken in conversation by the Faecal-Oral Route.

Malaria is a more serious concern. A dozen people die needlessly in Britain each year after contracting the disease from mosquito bites abroad. Malaria is almost always avoidable if tablets are taken during exposure to the mosquitoes which spread it, and for six weeks afterwards. You may find the unpleasant tablets easier to swallow if you think about the alternative: larvae incubating in your liver, then bursting forth to give you a screaming headache and a potentially fatal illness.

Our lectures were illustrated with slides and punctuated with practicals, which took place in the dining-room. We learnt to stitch wounds on slabs of pork belly. 'It must be fresh,' explained the instructor, 'to match the consistency of the human scalp.' The unsuspecting piece of meat was grievously wounded, then anaethetised and sutured. You can imagine the headlines: 'Pig Abuse Scandal in Bangor.'

The group of mature adults disintegrated into nervous giggles when confronted with the first hypodermic. Puncturing a pal's skin immediately after breakfast is a shock to both his and your systems. But injecting becomes trivial once you master the fact that you need to manipulate the syringe as if it were a dart.

The pub sports analogy continues with the insertion of an intravenous drip: this uses much the same skills as snooker. You restrict the flow of blood in the victim's arm and rub it to make a vein protrude, anaesthetise the area, then set about the limb with a large needle; after poking about a bit, you slide a tube into the vein. It is the same basic procedure used for taking blood, but watching it performed on the dining table of a North Wales hostel by a bunch of rank amateurs, it is hard to believe that the course has any connection with holidays.

Yet, as victim and practitioner, I found this potentially lifesaving procedure surprisingly painless - participants are obliged to try both. Not everyone was so lucky: Skip Novak is an excellent yachtsman, but having seen the pools of blood after his endeavours I was glad not to be his guinea-pig.

The intensive 12-hour day gave a glimpse of how stressful life must be for house doctors. Even afterwards in the pub it was impossible to avoid matters medical. Conversation revolved around health horror stories. I thought I held a fairly impressive hand: meningitis, acute food poisoning from a Venezuelan airline, and several near-fatal bicycle crashes. These turned out to be mere scratches compared with other traumatic tales. A urethra wrecked in a hang-gliding incident, and the subsequent insertion of a supra-pubic catheter, was acclaimed as the injury story of the week - even though it happened on the Isle of Wight rather than Tierra del Fuego.

Overload was reached with a grisly description of how, in an emergency, you can use a pocket knife and an empty Biro to bypass a blockage in a person's breathing tube. But when the last syringe was discarded and the last drop of blood mopped up, the verdict on the course was overwhelmingly favourable.

Mr Novak (by now nicknamed 'Slasher') said: 'It demystifies emergency care. It could be useful for anyone who plans to be away from the normal suburban atmosphere that most people live in.' I'm glad I don't live in his suburb. Dawn Fletcher had no illusions about her abilities, or the potential value of the course: 'Hopefully it will be a complete waste of time and money. But on the other hand, if it is ever useful, you just can't put a value on it.'

Dr Dallimore has already had reason to be grateful for his teaching skills. Earlier this year he suffered a deep wound to his arm while helping to build an orphanage in Kenya. Two graduates of a previous course stitched the wound properly, leaving only a modest scar - rather more cosmetically pleasing than the one I left on the pig.

The one-week course on advanced medicine for remote foreign travel is run by the GEC Management College (0788 810656). The next course will take place in spring 1993 and will cost about pounds 300, including meals and equipment.

Adequate preparation is essential for any journey to a remote area. Precise precautions depend on the area to be visited, the individual and the lifestyle adopted. The Department of Health publishes a useful introduction called the Traveller's Guide to Health, available free by dialling 0800 555 777.

Your doctor may be willing to research the health risks on your behalf, and to administer the necessary vaccinations. Alternatively, you could consult Medical Advisory Services for Travellers Abroad (071-631 4408). This organisation provides health profiles for specific countries and maintains a database on health risks.

Specialist travel clinics are also run by Thomas Cook (071-408 4157) and British Airways (071-831 5333, for information about the nearest clinic). The Malaria Reference Laboratory has pre-recorded advice on 071- 636 7921.

Recommended reading: to induce total hypochondria, read Dr Richard Dawood's fascinating Travellers' Health: How to Stay Healthy Abroad (Oxford Paperbacks, pounds 7.99), which describes the causes, symptoms and treatments of complaints ranging from roundworm, which affects one in five of the world's population, to bubonic plague.

Dr Dawood's catalogue of catastrophes is laced with worrying nuggets, such as the fact that a severed snake head can still deliver a venomous bite, and also provides useful information on how to remove a tumbu fly maggot from the skin - 'rather an unpleasant spectacle to watch'.

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