Rat Race Mongol 100 | Part 2
Written by Dr. Harrison Banks
12/04/2024
Overall, the participants were very healthy and though Donna and I were busy, we managed to pre-empt any major issues before they arose. We had the expected footcare issues that are associated with completing a marathon distance every day for 4 days in what is, essentially, a polar environment. A few niggles, aches and pains. Shin splints. Melted clothing and one nasty burn from the stoves in the gers.
Frostnip was reasonably common, and the difficulty in distinguishing this from more serious ‘potential’ frostbite really came down to how quickly feeling was regained in the affected extremities. We did our best to follow WMS guidelines, which are helpful but not prescriptive, and relied mostly on our clinical judgement and sharing the decision making with participants. In general, it’s better to err on the side of caution; and participants are often happy to comply, especially when it comes to the potential loss of digits! For participants who experienced frostbite and who described Raynaud’s phenomena prior to the expedition, we started them on low dose nifedipine. Donna and I had spoken prior to the expedition about whether we should take a supply of nifedipine, as Donna suffers herself from Raynaud’s and was understandably very keen to keep her fingers and toes. A quick literature search revealed nothing about its use in preventing frostbite, save for an isolated study on the use of topical nifedipine which demonstrated no benefit and some added risk... so we decided to take some anyway, because… you never know.
Donna would be patient 1 in our non-controlled, non-blinded observational study, the results of which would revolutionise the field of expedition medicine!
All jokes aside, nifedipine startingly exhibited excellent patient reported benefits with the 3 participants that were started on it stating dramatic improvements in how cold their extremities felt, and crucially, no recurrence of frostnip. Following this, we agreed to trial it in 2 participants who had experienced frostnip on the expedition but without prior Raynaud’s phenomena. Again, very positive results. Now, of course more ‘actual’ work is needed than our unsolicited trial, but perhaps there is something in this?
One of the more interesting medical dilemmas on this trip came from another expedition group that had been steadily following behind us.
We were packing up camp on day 3 after our evening of vodka, reindeer and revelry when some down-clad figures approached the camp asking if we had a doctor. Hesitantly, I offered myself up. We quickly established that one of their members had a seizure. They didn’t have any medical personnel, a limited medical kit, and seemingly minimal knowledge of the in-country medical services available and no evacuation plan. Now the dilemma comes down to resource management. Our expedition was 50 strong including crew, and my primary duty is to the participants I am employed to look after, however, an untended woman who had a seizure without any medical input was clearly the ‘sickest’ person on the ice. A quick meeting with Donna, Abbi and I myself saw me taking one of our emergency grab bags and heading across the ice to their camp. Donna would rove up and down the pack with the bulk of our kit and Abbi would leave a vehicle with me. We would remain in contact with radios/phones as able and hopefully I wouldn’t be delayed too long.
On arriving into their camp, I found a young woman, apparently post-ictal lying in a tent with some vomit outside it.
Her first language is Czech and seems a bit confused but she is responding well enough through a translator. I don’t find any gross neurological signs and her observations including blood sugar are OK. On further prodding, she shares that she is an epileptic, but she didn’t state this on her forms due to fear of not being accepted onto the expedition. This is much more common that you would think. I was once 1 month into 3 month cycling expedition when a participant comes up to me saying his heart has been going 160-180 all through the night. Turns out she has paroxysmal AF and decided not to bring any meds as ‘they affect my cycling performance’… A thorough pre-departure medical declaration is an absolute must for any company that TrailMed works with and is required before we would allow participants on an expedition. However, these are not always filled out truthfully.
Reaching out to participants by email pre-expedition is a further exercise in encouraging transparency with their medical backgrounds. You can’t force people to be open and honest, but by providing the platform for them to share in a non-judgemental way and with safety as the aim, the hope is that they do. Often, they will. The only final course of action is to recognise that this happens and try to plan a reasonable medical kit that can count for any eventuality… This is very challenging and there is an acknowledgement that the care we can provide in the austere environment is very different to the care we would hope to provide back in the UK with all the NHS’s resources at our fingertips. Anyway, back to the patient.
We have a young woman, history of epilepsy who had a single self-terminating seizure lasting < 1 minute. She reports to have been taking her antiepileptics but did consume a reasonable amount of alcohol the night before. She reports she’s not had a seizure in a few years. She had normal observations and no gross neurological deficit, other than some mild confusion from her post-ictal state. So… what can I do about it? Clearly, it’s not safe for her to continue her expedition, so we arrange transport to the local medical services. It will take 3 hours for the car to arrive and then another 6 hours to medical services. What do we do in the meantime? This may be a simple case of alcohol and vomiting leading to poor absorption of her antiepileptics, but we can’t be sure this is all that’s going on. She could have severe electrolyte imbalances, there could be an underlying intracranial event... the possibilities are huge, and we have very minimal information. I start simple treatment, electrolytes in her fluids, sugary snacks.
We can always do the basics. I hesitantly ask around the new group if there is anyone medically trained, nervous about leaving our group for too long. I’m told someone here is a fireman. Great, they’ll be likely to keep their head in stressful situations, they’ll do! I go into my medical kit. We have one tube of rectal diazepam and a couple vials of IM midazolam. Carefully, I draw up the midazolam into a 1mg/ml solution and give instructions to the fireman how to administer IM injections, how much to give, when it would be indicated and how long to wait between doses if needed. At this point, I think to myself, there is little else that I would add by waiting here with them for transport, and I am keen not to leave the Rat Race participants short a medic for too long. If she was to have further seizures, I would give the midazolam as I instructed the fireman. If this didn’t work, there’s little more we could do for her, save some basic airway manoeuvres which I went through with the expedition team there.
Furthermore, I can’t go with this patient to wherever she is going, and I feel confident in the fireman and the team around them to administer the IM if needed. So I bid them farewell, advised the patient to keep taking electrolytes and sugary foods, give them my mobile number, reassure them that we have arranged transport to hospital for them and if they have any ongoing issues they can find us on the ice. Later, I run into the expedition leader back in Ulaanbaatar. The patient had 1 further 30 second self-terminating seizure, no IM was administered. She spent a night in hospital for observation and was discharged.
All good news!
Aside from the other issue with the other expedition team, day 3 passes by smoothly. It is dramatic and icy cold but exceptionally beautiful as the snow clears more to reveal more of the depths and clarity of the ice underneath. Medically we are into the swing of things and with slightly warmer temperatures the participants really starting to enjoy themselves. Any blisters that are likely to present have done so by now and been treated. Our frostnip patients are on nifedipine – to good effect. The latter stages of each event are marked by the excitement of a finish. Metaphorically and literally approaching the end of the goal they’ve been dreaming of. It’s easy to underappreciate the drive this brings to participants who have been beaten down by a harsh environment, but it is visceral, powerful and felt amongst all. The news of a short 18km final day, due to ice conditions on the lake, only sharpens this feeling and we go to sleep that night excited for the day to come.
The final day starts beautifully. Fresh, crisp clean air. If you’ve ever been to polar, or what I would call ‘very cold’ environments, you will know that there is a quality to the coldness that can’t be met anywhere closer to home. The air is completely devoid of smell, as if, the cold has frozen the particles so they can’t be transmitted. The cold stings your nose hairs, freezing them and causing nosebleeds. But the clarity that comes with such cold air means beautiful sunrises, sunsets and star shows. We are treated to another spectacular sunrise on that final day. Early on, I am called to review a participant we had medically retired earlier in the event with low energy and a vasovagal following an encounter with hypothermia and poor oral intake, who had been recuperating in basecamp. I expect to be gone a couple of hours and hand over reins to Donna who will rove in my absence. The retired participant is OK, still a little groggy from her encounter with hypothermia, troubled sleep and poor oral intake but she is improving slowly. She is able and elects to come back to the finish to cheer her friends over the line, so we head back out together.
Participants all battled hard against a really challenging environment and did immensely well.
There is a joyous energy surrounding us as participants are presented with medals and we share laughs and beers. They are all champions and I am happy for our part in helping them to achieve their dreams. However, the real unsung heroes are the 3 dogs who followed us across the ice from start to finish.
These 3 strays, nicknamed Vodka, Sammy and Bolt by the participants and crew, sat at markers to ensure participants didn’t miss a turning, waited at the finish line to ensure all participants made it through, and were very grateful for all the snacks and treats they received as payment for their services.
By luck, the finish day coincides with the Khovsgol Ice festival. Thousands of Mongolian’s attend and there are stunning ice sculptures, traditional wares for sale and food. We enjoy the atmosphere for a little while, and I toy with the idea of buying myself a fur hat before deciding that, ultimately, it would get little wear back in Manchester. Back at basecamp we are treated to an amazing group of local Mongolian singers who demonstrate throat singing as well as their own take on popular Western songs, ‘Country Road’ being a favourite in the camp.
The next day we travel back to Ulaanbaatar. Although just as long, 15 hours in the Delicia vans, the journey doesn’t feel as challenging this time. Perhaps we are all warmed by the experiences that we shared out on the ice.
The landscape now, instead of the feeling of hostility and fierceness on the drive in to Khovsgol, feels welcoming, almost homely. I see this environment now in different terms, not something to challenge and conquer as a barrier to my job of providing medical care, but to be respected, cherished and accepted. I have seen how harsh this environment can be and am thankful that it allowed us to pass through mostly unscathed.
Despite the huge logistical challenge of getting there, and the journey itself… I would go back in a heartbeat. It was an otherworldly experience to a part of the globe I had always dreamed of visiting and a brilliant testing ground for my ability to provide medical cover in a desperately harsh environment.
Thanks to TrailMed for the opportunity to work on such a brilliant expedition. Thanks for Rat Race for continuing to put on ground-breaking extreme events like this. And finally, thanks to Donna - we made a great team and I hope that we will work together again in the future!
