Abstract
High-altitude expeditions expose teams to particular medical, environmental, and social challenges that can have unintended and severe consequences for crew members. In June 2017, the 9-d Equal Playing Field (EPF) expedition to Mount Kilimanjaro to set a world record for the highest-altitude soccer match ever played demonstrated the variety of challenges that may arise during these types of trips. This trip included a full-length soccer match at 5714 m (18,746 ft), leading to additional challenges for expedition members participating in the athletic event. The EPF medical team identified the challenges that occurred during the expedition and documented the methods used to resolve these challenges in real time. From the challenges faced during the expedition, we describe the lessons learned for future expeditions to Mount Kilimanjaro and other high-altitude environments. Challenges arose with medical tent visibility, medical disqualification, underreporting of medical events, and acute pain management, while anticipated challenges with interpersonal conflict did not occur. The rigorous preparation and anticipation by the EPF medical team prior to expedition departure may have helped mitigate this conflict as well as prevented unintended severe medical events from occurring.
Introduction
High-altitude expeditions bring about a particular set of medical, environmental, and social challenges that can have unintended and severe consequences when compared with their low-altitude counterparts. Expeditions that stretch >2500 m above sea level put crew members at risk of acute mountain sickness (AMS), ranging from mild symptoms, such as fatigue and sleep disturbance, to more severe manifestations, including high-altitude pulmonary edema and high-altitude cerebral edema (HACE). These environments also tend to impose freezing temperatures, challenging and frequently dangerous terrain, and limited access to high-quality medical resources and facilities. Demanding expeditions like this require significant planning, preparation, and teamwork to ensure the safe and successful completion of the expedition goals.
On June 25, 2017, 36 professional and semiprofessional women athletes and referees trekked to the summit of Mount Kilimanjaro (Uhuru Peak) to set a world record for the highest-altitude full-length soccer match. Crew members of this crowd-funded expedition faced not only medical and environmental challenges of Mount Kilimanjaro but also a physically challenging athletic event at altitude.1,2
These athletes were members of Equal Playing Field (EPF), an international nonprofit organization born out of the Kilimanjaro expedition with the mission to advocate for gender equity in sports through extraordinary sporting challenges, soccer camps, and conferences. The idea came from social impact entrepreneur Laura Youngson (United Kingdom), who saw that there were more stories about horses than women in sports pages and resolved to undertake a challenge that would gain media attention to the issues. Together with Erin Blankenship (United States) and Maggie Murphy (United Kingdom), EPF brought together an international group of players and referees to participate in this world-first expedition. Having previously seen a group of cricketers play a few overs at the top of Mount Kilimanjaro, the team planned to play a soccer match, for which all lines, corner flags, and goal posts would be transported up and down the mountain, leaving no trace in the National Park.
This record-breaking game was the first stop on a 2-part plan to set the world records for the highest- and lowest-altitude soccer matches ever played to raise awareness for the EPF mission. After completing the expedition, the funds raised were used to establish and support football clinics for young women around the world. The expedition was documented and filmed, with a full-length documentary released in 2021.
Members of the expedition included the 32 professional and semiprofessional athletes, 4 professional referees, and 20 media and support crew. The athletes included World Cup, Champions League, and Olympic professionals ranging from age 15 to 55 y. The overall age range on the expedition was 15 to 70 y. Expedition members represented 22 countries on 6 continents and 12 languages spoken. As many members also spoke English, this was the main language used for communication throughout the trip, although language barriers were still present given the sheer variety of backgrounds.
The EPF expedition was supported by the local guiding company Nature Discovery Ltd. There were 30 mountain guides and 400 porters on the expedition who helped carry equipment, care for expedition members, and set up the soccer match on the mountain.
The medical team consisted of 1 emergency medicine physician, who served as chief medical officer of the expedition, and 2 wilderness emergency medical technicians. The team was selected by EPF for their expertise in wilderness and high-altitude medicine. While the medical team did not know each other prior to departure, they were able to communicate speaking English. The chief medical officer was involved in the planning and execution of several past wilderness expeditions and had experience conducting research and practicing medicine at altitudes similar to those of Mount Kilimanjaro. During the game, 15 porters were designated as stretcher bearers and mobile oxygen stations; they carried oxygen tanks on their backs to run to players who needed additional oxygen support.
In preparation for the expedition, the medical team performed a brief literature review of wilderness expeditions and used the information to predict the types and quantities of medical events expected on the trip. All participants, excluding the support staff, filled out a questionnaire that included current medical conditions, medications, and allergies to account for these in the planning phase. The medical team then built a medical kit to manage the predicted medical events and any potential evacuations. 3 Given the high-altitude environment, all athletes were given the option to take prophylactic acetazolamide to prevent altitude-related illness.
The expedition included a 7-d ascent from an altitude of 3768 m (12,362 ft) to the main crater at an altitude of 5714 m (18,746 ft) via the Southern-Circuit Shira Route. During the ascent, the athletes played 1 practice match to acclimatize. The practice match occurred on day 3 at an elevation of 4205 m (13,800 ft).
On the high-altitude match day, the 1000-m ascent from camp to the playing field began before sunrise. Temperatures were well below freezing, and the expeditioners were functioning on little sleep. The camp was left assembled with the plan to return to it after the match. The support staff left first to arrange team tents, set up medical stations, and prepare the field. The players arrived later and rested until the field was ready. After the full-length soccer match, the expedition members ascended the final 181 m to the summit of Uhuru Peak before descending back to camp. The following day, the team descended the mountain.
There were 123 individual medical events documented during the EPF expedition. The individual medical events reported during the EPF expedition are documented in Table 1. More severe cases, defined as cases that posed a significant threat to life or long-term body function, included hand trauma, pneumonia, hypothermia, severe AMS, bronchospasm, and suspected HACE (Table 2). Two severe cases—both among porters—required evacuation before the match, 2 prevented players from participating in the match, and 1 was not reported at onset but required evacuation after the match.
Individual medical events reported during the Equal Playing Field expedition
Two cases with each of the following were reported: anxiety, asthma, chapped lips, constipation, hand trauma, insomnia, overuse injury, vertigo, and vision changes.
One case with each of the following was reported: acute mountain sickness (severe), dehydration, gastritis, gastroenteritis, high-altitude cerebral edema, herpetic lesions, hypothermia, interpersonal conflict, pneumonia, skin infection, and sunburn.
Cases of medical events leading to evacuation, actual medical disqualification, or near-medical disqualification during the Equal Playing Field expedition
HACE, high-altitude cerebral edema.
During and after the expedition, EPF medical coordinators identified the challenges, conflicts, and shortfalls that occurred during the 9-d trip. Major challenges arose with medical tent visibility, medical disqualification, evacuation, underreporting, and acute pain management. Although interpersonal conflict was anticipated, no observable conflict occurred.
Using these experiences, we outline the lessons learned for future expeditions to Mount Kilimanjaro and other high-altitude environments. Our goal was to use our experiences to help prepare expedition leaders and medical coordinators for unexpected challenges and provide some guidance on how to prevent or resolve these situations should they occur.
Lessons Learned
Medical Tent Visibility
There were >80 tents used on the EPF expedition, including 1 designated medical tent. The support staff and expeditioners used different tents, but within the groups, all tents were essentially identical, with no distinct markings. There was minimal organization of the tents at each campsite, and therefore, the medical tent was at a different location relative to the expedition members on most days.
There were several instances in which the expedition members needed medications or assistance at night but were unable to locate the medical tent. Because of this, care was delayed until the morning. While none of these events was life threatening, this may not be the case on future expeditions. The EPF medical team subsequently marked the medical tent with duct tape and a makeshift flag for easier identification.
Future expeditions should consider direct, bright, and visible markings to help distinguish the medical team’s location to avoid delays in care should a medical emergency occur. It would also be prudent for the medical team to preplan a brief orientation with the full expedition at each new campsite to direct everyone to the medical tent. This would allow participants to find the medical tent at each campsite prior to any emergencies to avoid crucial delays in care.
Medical Disqualification, Evacuation & Underreporting
Players were told at the beginning of the trip that certain symptoms may disqualify them from playing in the soccer match. The EPF medical team was concerned that this safety measure may lead to hesitancy in symptom reporting; so they attempted to mitigate the issue by familiarizing themselves with each expedition member and encouraging open, honest, and timely reporting of symptoms. The medical team wanted to avoid any deception regarding medical disqualification criteria under the assumption that this might lead to mistrust and further underreporting of symptoms.
There were 13 medical events that were considered severe medical cases during the expedition (Table 2). Three medical events involved porters, 2 of which led to evacuation. The other 10 events involved nonstaff participants, 2 of which led to medical disqualification. One participant was evacuated because of suspected HACE during the final ascent, although her symptoms began prior to the match. Her symptoms would have likely led to medical disqualification had the participant reported them at the time of onset. The participant’s reason for the delay in reporting was unclear, but fortunately, this case did not result in a more serious outcome.
The case described above was the only observed case of underreporting during the EPF expedition. Underreporting of symptoms, especially in the context of medical disqualification from an expedition or an athletic event, is a complicated issue, with challenges particular to each expedition. There are a host of studies that have demonstrated pervasive underreporting of and reasons for not reporting concussion symptoms in athletes, including a report that 17% of professional rugby players in Australia chose not to report likely concussive episodes to medical staff. 4 Possible reasons for such underreporting included not wanting to leave the game, not wanting to let the team down, or perceived interpersonal pressures, among others.4,5 Although fewer data are available for the reporting of general injuries in athletes, it is likely that injuries other than concussions also go underreported, and this may translate to illness reporting in athletes as well.
Underreporting of illness and injury is not unique to athletes.6,7 In extreme wilderness environments, such as that in the EPF expedition, expedition participants may have similar pressures as those imposed on athletes to avoid or delay reporting illness or injury. However, underreporting of illness or injury during wilderness expeditions has not yet been studied to our knowledge.
Because of the complicated nature of medical disqualification and underreporting, a single catch-all solution is not easy to discern. It is certainly prudent to inform crew members of the environmental dangers and warning signs, but we believe that future medical teams should carefully consider how to inform operational personnel about conditions that would prevent them from trekking further. Safety, treatment, and evacuation plans should be tailored to the expedition, and medical teams should clearly state to participants that all medical decisions will be made on a case-by-case basis after thorough evaluation. This approach may encourage more openness to symptom reporting when compared with a “one-size-fits-all” approach, which may cause participants to avoid reporting symptoms they know meet disqualification criteria. Medical teams should also seek to identify the expedition- and member-specific barriers to symptom reporting prior to departure, such as pride, prestige, and fear of medical disqualification, among others.
A specific strategy to mitigate underreporting is to create an expedition-specific medical screening form that can be distributed to members at predetermined intervals during an expedition. For example, the medical screening tool for high-altitude expeditions, such as the one described in this article, should include a tool to evaluate for AMS, such as the 2018 Lake Louise Acute Mountain Sickness Score. 8 Although this will inevitably require more preparatory work, routine screening forms may help medical teams establish baselines for each team member, better identify changes from baseline that might otherwise be missed or not reported, and provide members with the privacy of reporting on paper. However, this suggestion remains limited by the self-reporting of symptoms and may be prone to similar underreporting concerns documented in prior studies. 4 -7
Acute Pain Management
Nonstaff expeditioners reported multiple headaches attributed to AMS and 7 athletic musculoskeletal injuries during the EPF expedition: 2 overuse injuries and 5 muscle sprains and strains. Although pharmacological therapies, such as acetaminophen and ibuprofen, are mainstay treatments for acute pain in wilderness environments, 9 many of the participants chose not to take the offered nonopioid pain medications. To accommodate these players, several modalities, such as acupressure points for headaches and trigger point massage for muscle tension and overuse injuries, were employed.
The EPF expedition did not provide significant evidence for the reasons participants chose not to take nonopioid pain medications, but this observation suggests that there may be a role for alternative nonpharmacological therapies in remote environment operational medicine. However, the current Wilderness Medical Society guidelines for acute pain management in remote environments do not discuss nonpharmacological modalities beyond the standard Protection, Rest, Ice, Compression, Elevation (PRICE) therapy. 9
While there is limited evidence for the effectiveness of nonpharmacological therapies to treat acute pain in wilderness environments, evidence in other acute settings may be extrapolated to this setting. Alternative therapies, such as auricular acupuncture, battlefield auricular acupuncture (BFA), auricular acupressure, and myofascial trigger point (MTrP) compression, may be effective for acute pain management.
The practice of acupuncture posits that by stimulating specific points (acupoints) on the body—usually using fine needles—health can be regulated and restored. 10 This concept is similarly employed with acupressure, which uses the same acupoints but without the use of needles. Auricular acupuncture is the term for acupuncture of the external ear. Battlefield auricular acupuncture is a streamlined method of auricular acupuncture for more rapid pain relief, 11 while auricular acupressure is a less invasive form of BFA.
Auricular acupuncture, BFA, and auricular acupressure have all been associated with improved acute pain scores.10,12,13 Auricular acupuncture, in conjunction with standard-of-care pharmacological treatment, decreased acute pain scores in the emergency room by 23% when compared with standard-of-care treatment alone. 10 Under a similar protocol, BFA decreased pain scores for patients with acute low-back pain in the emergency room by 25%. 12 A meta-analysis of auricular acupressure for acute postoperative pain relief also reported decreased analgesic requirements and a significant reduction in pain scores. 13
Myofascial trigger point compression is a massage therapy that provides compression at stimulation sites analogous to acupoints to relieve pain. 14 In patients with acute low-back pain, patellofemoral pain syndrome, and chronic shoulder pain, MTrP compression has been shown to significantly decrease pain scores compared with untargeted compression therapy. 14 -16
The risks of unknown allergies, drug interactions, adverse reactions, weight and volume of pharmaceuticals and their containers, and patient preferences are all potential concerns while using pharmacological therapies for pain. While these therapies are a mainstay in the operational setting, the complementary use of nonpharmacological therapies, such as those described above, may further improve acute pain relief and reduce the amount of medication needed to effectively manage acute pain. Future studies may seek to address the feasibility and effectiveness of and best practices for use of these techniques in the remote operational environment.
Interpersonal Conflict
On an expedition that included participants from 22 countries, speaking 12 languages, and with participants used to competing against each other, interpersonal conflict was anticipated to be a major risk. It was not observed: there was only 1 documented case of a minor interpersonal conflict on the EPF expedition. We propose 2 possible reasons for this.
First, many of these athletes play at a professional level. As with many professional groups, the culture of their profession carries more similarities than the differences associated with the culture of their ethnicity. 17 This builds significant common ground and may limit conflict.
Second, the concept of the “jigsaw classroom” conflict resolution strategy may have come into play. This strategy recognizes that it is easy to generate conflict by emphasizing differences and separating populations.18,19 If people unite around a common goal, wherein everyone’s success is dependent on others in their group, conflict can be rapidly reduced or eliminated. 18 -20
The soccer players on the EPF expedition were divided into 2 teams that ultimately played the record-breaking match against each other. However, these teams did not ascend separately. Rather, players were divided into 5 smaller groups that ascended with a guide team and members from multiple countries. Members within each group depended on each other to get up the mountain. Members of each team knew that unless the other groups completed the ascent, their team would be short several players. This organization was intended to make the climbing logistics easier, but it also fits within the jigsaw classroom model and may have reduced interpersonal conflict on the expedition.
Another model that may be useful to mitigate interpersonal conflict during wilderness expeditions is the Goals, Roles, Processes, Interpersonal Relations (GRPI) model, which has been widely used for team building and conflict resolution in the business and medical fields. 21 Using this model as a guide, expedition leaders should ensure that members understand the team’s goals (Goals); members must know their individual role(s) (Roles) and plans for decision making and problem solving; conflict resolution should be in place prior to expedition departure (Processes); and leaders should emphasize trust, communication, and support (Interpersonal Relations).21,22
In operational settings in which high-performing teamwork and successful conflict resolution are critical to mission safety and success, tools such as the jigsaw classroom and GRPI model may provide a framework for expedition leaders to build team strength and mitigate interpersonal conflict.
Conclusions
The EPF expedition to Mount Kilimanjaro was demanding to participants given the high-altitude environment, physical demands of the mission, and competitive goals of the trip. Challenges arose with medical tent visibility, medical disqualification, evacuation, underreporting, and acute pain management. Some challenges were able to be remedied in real time, and anticipated concerns with interpersonal conflict were mitigated before they became a problem.
Perhaps the most valuable lesson from this expedition was the importance of anticipation and preparation prior to departure. The medical team identified the most likely medical events that would occur during the expedition, stratified them by risk and consequence to the individual and team, and planned the expedition medical kit accordingly. 3 The rigorous preparation and anticipation of problems and medical events that were likely to occur may have prevented dangerous situations and severe medical events from occurring.
Footnotes
Acknowledgments
We thank Equal Playing Field for their efforts in the planning and execution of this expedition and for allowing the research team to collect the necessary information for this report.
Author Contributions: study concept and design (TDW, DRL); drafting and critical revision of the manuscript (TDW, MEP, LRY, DRL); approval of the final manuscript (TDW, MEP, LRY, DRL).
Financial/Material Support: None.
Disclosures: None.