Malcolm Roberts was thousands of miles from the nearest hospital when he suffered severe gastrointestinal bleeding. Could a team of doctors make it in time to save him?

In late April 2015, Tim Nutbeam was smuggled onto a plane carrying a big bag of blood to attempt a rescue mission in Antarctica. It was the beginning of winter when the continent is draped in almost total darkness and extreme cold, not to mention frequent high winds. Due to the dangerous conditions, there are normally no scheduled flights during the six months of winter.

But Nutbeam, a consultant in emergency medicine based in the UK, went ahead with the journey, joined by a pilot and engineer.

Their mission was to save the life of a critically ill worker on an Antarctic base. Malcolm Roberts, an engineer for British Antarctic Survey, had suffered a massive gastrointestinal bleed at the Halley Research Station days before. He was thousands of miles away from the nearest hospital.

Roberts had lost a lot of blood but had survived the first 24 hours. If they got to him in time, there was a chance that he would live – but there were many challenges that could prevent them from saving their patient.

The flight to Halley would take about 24 hours with one stop to refuel in Rothera, another base on the Antarctic peninsula, before making the same journey back, meaning they would be flying for about 48 hours straight. And on the way back, they would have to deal with a medical emergency at the same time, having had little sleep or rest.

Saving the patient’s life was challenge enough. But on top of that, how would Nutbeam be able to handle the mission psychologically?

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Initially, he wasn’t even meant to go on the trip. Nutbeam was supposed to be the back-up doctor on the mission. When the emergency occurred he had flown into Punta Arenas, a town near the southernmost tip of Chile. The plan was that he would be stationed there to help after the plane landed.

But when a volcano erupted north of where he was, everything changed. The lead doctor was waiting for a connecting flight in Santiago but all flights were cancelled. At the same time, there was a rare break in weather across the Drake Passage, the body of water between southern Chile and Antarctica, where visibility is often poor. “I suddenly realised that I would be going,” says Nutbeam. “It was too good an opportunity to wait.”

Nutbeam admits that everything happened so quickly that he didn’t think much about the potential dangers at the time. Instead, he remembers feeling excited about getting to go to Antarctica and do the rescue.

Extreme personalities

There have been few medical evacuations during the Antarctic winter. In 2016, an ill worker was airlifted from the South Pole mid-winter – when there are 24 hours of darkness – while another patient rescue took place from the main US research base in 2010.

According to Nathan Smith, a psychology researcher at the UK’s University of Manchester, people who take part in extreme expeditions often are motivated by the chance to do something that not many people do. “They are often highly trained so it’s an opportunity to test their skills out and do a task they haven’t done before,” he says.

Certain personality types are better able to deal with the stress of extreme expeditions. Research has shown that people who are less neurotic perform better. “What we see is that people in high-risk jobs are not easily anxious and when they are, they are able to control it quite well,” says Smith.

Conscientiousness also play a role. A study looking at the personality traits of people willing to take a parabolic flight, for example, found that conscientiousness allowed them to cope better with extreme demands. This goes against the common notion that people who take part in extreme activities are adrenaline junkies. “What we found is that people typically spend a lot of time de-risking,” says Smith. “They do a lot to avoid having an adrenaline rush because to them that signals a threat.”

Nutbeam and his team had to be diligent to deal with the challenges they faced during the long journey. Throughout the trip, for example, Nutbeam had to monitor the temperature of the bagged blood, ensuring that it remained within a narrow optimum range. The front of the plane, where the team was huddled, was kept warm, but it was about -10C at the back. “I had to try and find a sweet spot to put the blood and had to check on it every hour,” he says.

The team landed in Halley just as dawn broke and had about an hour and a half to retrieve Roberts before it would be too dark to take off again. It was -30C without the windchill factor. Nutbeam took a snowmobile to the station where he successfully performed what is thought to be the first Antarctic blood transfusion on Roberts and transferred him to the plane. Meanwhile, the engineer kept the plane’s engines functional, since if they got too cold they wouldn’t be able to start up again.

Nutbeam says that nothing was meticulously planned due to the unpredictable circumstances. His strategy was to “wing it in an informed way”.

Excessive planning was less important than having confidence in one’s skills

After interviewing expeditioners, Smith and his colleagues found that excessive planning was less important than having confidence in one’s skills. “Then it comes down to being flexible and adaptable and being able to adjust to the situation as it unfolds,” he says. “There are lots of things you can’t control so being able to accept that is really important.”

Sleep deprivation

Even a combination of expertise, conscientiousness and confidence could not make up for perhaps the biggest challenge: the extreme sleep deprivation of the 48-hour flights. Nutbeam says that he slept for about four hours over the course of the mission. “I just wasn’t functioning as a human,” he adds.

Microsleeps – quick bouts of shut-eye that can last between a fraction of a second and 30 seconds – can help the body recuperate. “The brain finds ways to catch up on sleep in short bouts if it can’t otherwise obtain the sleep it needs,” says Hans Van Dongen, the director of the Sleep and Performance Research Center at Washington State University in the US.

However, microsleeps cause lapses in attention that affect performance – if they occur while driving often resulting in car accidents for example.

Nutbeam was so tired that he had trouble recalling medical knowledge and making choices

During the long flight back to Chile, Nutbeam was so tired that he had trouble recalling medical knowledge and making choices. And that posed some serious dangers, given that Roberts’ condition required constant monitoring and there were important medical decisions to be made. Around Rothera, for example, they needed to be flying high to pass the tall mountains below. Roberts, however, had a low circulatory blood volume due to his bleed, which affects how long he could tolerate high altitude without the need for more blood.

“I needed to make a decision about Malcolm’s care and just could not decide,” says Nutbeam – an unfamiliar sensation for him. “I am normally pretty pragmatic in my approach and don’t struggle with decisions.”

Sleep also plays a role in regulating emotions and can affect mood: the emotional centers in the brain are less connected when a person hasn’t had enough rest so it’s harder to control one’s feelings. As a result, sleep-deprived people can be overly grumpy or giddy, says Von Dongen.

And this would be an additional challenge to Nutbeam’s decision making when, at a later point in the flight, Roberts suffered a stroke. Nutbeam had to give him more blood as well as fluid and medication to stabilise him. “I remember feeling quite emotionally overwhelmed,” says Nutbeam. “He must have been feeling terrible but was incredibly stoical.”

Understanding the effects of sleep loss can help people cope, says Smith. “People can prepare for it and think about how it might shape their decision-making,” he says. Nutbeam says that he knows that he is much less tolerant when he’s tired, which might have helped.

Teamwork

Nutbeam was also fortunate to have a dedicated team that helped to keep his sleep-deprived mind in check. In addition to the team aboard the plane, there was a remote support network keeping a close eye on their journey from afar. 

During stopovers, when they were able to communicate, colleagues abroad informed the team of weather conditions to help ease the logistical decision making.

Nutbeam also had regular debriefs with his boss in the UK about treatment and what to do in various circumstances.

When the plane landed in Rothera, for example, Roberts had another gastrointestinal bleed. There was a doctor there to help. But Nutbeam didn’t want to leave Roberts, even though he was exhausted.

A call from his boss in the UK put things in order. She told Nutbeam to let the local doctor take over so he could get some sleep: he was the only one that could look after Roberts during the remaining flight. “It was the best advice in the world,” says Nutbeam. “Otherwise I think I would have stayed with him and been even more tired and psychologically broken for the final leg of the journey.”

Tense situations can be easier to handle when there are others around. “Being in a dangerous environment surrounded by competent people who are supportive is a good way of mitigating stress,” says Smith.

It all depends on the team dynamics, though: if people aren’t able to work well together it can have a negative impact on the functioning of the group. Personality traits – in particular agreeableness - can often predict who will be a good team player. “People that have to work in small groups in risky settings tend to be good at getting on with people,” says Smith. “They are good at communicating effectively and maintaining group function.” 

Aftermath

After the final flight from Rothera, the plane landed in Punta Arenas, Chile. Roberts was transferred to a hospital where he was successfully treated. But Nutbeam didn’t feel like the mission was over yet. “I really didn’t want to let Malcolm go,” he says. “I wanted to go with him to the hospital even though I could hardly string a sentence together.”

Expedition groups often have similar reaction when they return. After having lived through an intense experience together, there is a sense of empathy among those who were there, says Smith. It can also be hard to communicate what it was like to people who weren’t present so there is a tendency to be drawn to those who shared the experience.

Nutbeam was able to visit Roberts regularly at the hospital and there was a daily meeting about his recovery which gradually helped him readjust.

According to Smith, people often reflect on what happened and what could have happened for about three weeks afterwards. After playing an important part in a mission, people may feel like they have no purpose when they return but finding something meaningful to do can ease the transition.

“Writing a report or putting your experience into a story is really helpful psychologically,” says Smith.

New types of training could help too. People working in extreme environments, such as astronauts or military workers, do a lot of simulations as preparation. But according to Smith, it’s rare to have training that focusses on the psychological aspects of a mission. “It seems a bit like missing a trick,” he says. “There is a lot that could be done to equip people with strategies to deal with these environments.”

In a sense, the rescue was just a more extreme version of what emergency room doctors encounter every day.

As a coping strategy, Nutbeam recommends mentally rehearsing events beforehand when well-rested. “This can prepare your mind for the insult of sleep deprivation,” he says.

Upon reflection, Nutbeam isn’t convinced that he would take part in such a mission again. He had mentally prepared himself to be the back-up doctor so hadn’t analysed the risks involved beforehand. Now he realises that there was a significant chance that they could have been stranded or suffered harm. “It’s nice to reflect on a successful rescue but there is a need to consider all the opportunities for it to go wrong and was the risk justified,” he says. “I’ve still not quite got my mind around that.”

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Tim Nutbeam talked about the expedition for the first time at the World Extreme Medicine conference in Edinburgh in November 2018. Sandrine Ceurstemont is a freelance science and technology writer.

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