 Speaker is Dr. Ken Isersen, Professor Emeritus of Emergency Medicine at the University of Arizona. Ken completed his fellowship at the McLean Center in 1991. Ken is Medical Director Emeritus of the Southern Arizona Rescue Association and a supervisory physician with Arizona's Disaster Medical Assistance Team. As you're about to hear, Ken has worked on medical missions on all seven continents. He recently returned from a six-month winter stint as lead physician of the U.S. Antarctic Program at McMurdo Station. Ken has published more than 10 books and hundreds of articles on emergency medicine, end of life care, clinical ethics, and on how to get into a medical residency. Is that the eighth or ninth edition? Ninth. Okay. Which is in the ninth edition. Today, what's your topic? Oh, I don't know. Okay, thanks, Mark. I'd like to start by thanking Mark for letting me into the fellowship low those many decades ago and allowing me to traverse the ethics community around the world. This topic was chosen by Mark. I want to let you know, I had a real bioethics topic, and he said, no, no, no, no, we want to hear about this. So this is bioethical issues in Antarctica, or actually what Mark wanted to hear is, what did I do in all of 2016? And I actually was in Antarctica as the lead physician twice, the first time for six months in 2009-10. That was the summer season. And then for nine months last year, and it started in the summer season, went to the next summer season. Yes, I was there during the entire Antarctic winter. Oh, all of my acid. Okay. This is basically a talk about the ethical issues involved in a resource poor environment. And it would have gone better probably in the global health talks, because that's really what it is. This is about resource poor environments. It's a complex and confusing topic, but it really comes down to two issues. What can we do with the resources at hand? And of all the things we can do, which ones should we do? And Antarctica is just one of those examples. But because I have talked to lots of people about Antarctica, there are so many misconceptions about what really goes on there. It is the seventh continent. Someone asked me today, are there really seven continents? Yes, yes, and Antarctica is the seventh. First half, more or less, I'm going to tell you about the environment, because that is what makes the ethical issues. And the second, a little bit about some of the specific ethical issues we faced. Antarctica overall is stunning, dangerous, resource poor, and it has a unique type of population there. It is a stunning environment. Those are emperor penguins. I did have an opportunity to get up close and personal, which most people actually don't get to do. And those are the southern lights. Those of you who've seen the northern lights, very few of you will ever have seen the southern lights. And they're just as beautiful. They're exactly the same. I'm colorblind, so I can't tell you if the colors are the same, but I assume they are. These are not permanent residents of Antarctica. The largest permanent resident, largest permanent resident in Antarctica is about a half an inch long and it's a worm, and it's in a few places around Antarctica. No penguins are not permanent residents. We have no polar bears there. That's the other end of the world. It's a dangerous environment. There I am in wearing what's called Big Red. Big Red is issued to everybody in the U.S. Antarctic Program. It is about this thick, and you wear it all the time if you want to live. That's our severe weather chart, and it's showing all red. That means you don't go outside unless there's an extreme emergency, and if there is, then you have to be with a rescue member, a special rescue team, and on a fixed rope, which we set up. That's a typical day. We're getting off the plane initially, and that's a typical day. Here are a couple of problems we saw. Some frostbite, and we did see frostbite. It's not frostbite, it's frostnip. I don't know how many times I saw it. Yeah, but your hand's turning black. The other one, and for the physicians, you'll be interested, it's high altitude pulmonary edema in one of our young people. We are resource poor. That's our medical facility, that's our hospital clinic, our pharmacy, trauma area. One month a year, we can bring in two ships, plus an icebreaker. It follows the icebreaker, and it's a supply ship and a fuel ship. Then we have fairly good communications, and that's some of the communication stuff that was sitting on my desk. The population, we have two, well three distinct populations. In the summer, and at McMurdo, McMurdo is the largest population center by far in Antarctica, and certainly the largest US station. We'll have more than a thousand people either working on the station or out of the station. Out of the station is very important because they're scientists who are also on the continent, and I'm responsible for their medical care. Even if they're working on the side of the volcano, I have done a rescue up on the volcano, or in the crevices or other places. In the winter, it drops down to about 100 people, 150 people, which includes personnel at the Kiwi base, the New Zealand base, about two kilometers away because we're their medical facility year-round. The three populations, one are the scientists, and all the scientists are under grants from the National Science Foundation. That's a requirement to be there as a scientist. The second population is the support personnel, and there's lots of support personnel year-round to keep the place going because people should not be in Antarctica. I mean, that's crazy. But we do science, almost every type of science imaginable is done there, and it's really important. It's not just global warming, it's everything. The third group are the Air National Guard, and the Air National Guard are the people who fly us in and out of the continent, in different places in the continent. No, they do not have weapons. That's one of the rules of the International Antarctic Treaty. I've worked at Scott Base in McMurdo and the South Pole. South Pole is about 600 miles away, and we have to go by air. You can only do that in the summer. Once you're at the South Pole in the winter, you're at the South Pole, except for something I'm going to show you shortly, kind of drama. We have to have a little drama in this conference. We did have most of the necessary equipment and medications. We had a lot of medications, a lot of equipment. What about during the winter? You can't get anything in? Well, you get at the beginning of the winter, you're stuck with, and that's it. Our personnel were generally screened medically before they came in. They had medical screening in labs and dental screening. People lie. Did you know that? That caused a lot of problems. In the summer, when people were still coming in and out, because we have about three flights in an on-continent and off-continent a week for various reasons, they gave leeway to key positions, which could be a problem. We had one guy. He probably should not have been out of the intensive care unit, but they led him come to Antarctica. That was for two days. That was because he was one of the three people in the world who could fix this one critical component on the station, and so they brought him in and out. Sometimes our VIPs, and I can't name who they were, but they were very important people, very important people, and they came in and they said, I don't need a medical screening. One guy got on the continent. He walked into the reception when it was being held for him, went to ground. For those who were not medical, that means he collapsed completely. He was in VTAC, and he knew that he went into VTAC frequently. He was on this special medicine that almost nobody could prescribe, and we didn't have it, so of course, we needed to get him out of there. This is in the summer. I should have been able to do that. I called up our chief of air operations. He said, you bet. We'll get him out of there with a medical team right away. Well, not right away. It'll be a week. We have the plane. We have the medical team, but the mother of all storms is coming in and you're stuck, so that's one of our problems. We tried to keep people with major disabilities off station. We had an application from a woman who was blind. I said, okay, you know, we have a few obstacles here, like everything is ice. You're walking around on ice all the time. We have stairs that are icy. We have all kind of, anyway, she didn't come. This is our medical building, and it was built around 1955 by the Navy who used to run McMurdo as a Navy station, but that's a whole, it's just a science station now. And that's inside our emergency department area. We have six beds for inpatients, and we, there's a picture of some of them, and we did use them. This is some of the medical equipment we have. So we did have medical equipment. We had a slant machine. We had oxygen, mostly oxygen concentrators because the big bottles were a little heavy to carry. Monitor at the defibrillators, ultrasound. Problem was we had different kinds of machines bought in different eras, and we had to know how to use all of them. It was kind of tough. A lot of ortho equipment, because a lot of ortho injuries, that was the number one problem we saw was orthopedic. We had a full dental clinic because two months a year there's a dentist there. The other time, I was a dentist. Yes, did I pull teeth? You bet. Was I using the dentist's power equipment to adjust bites? Yes, I did. Did I replace caps? Yes, I did. I was a dentist, and you want to know, did the patients know that I wasn't a real dentist? I lived with these people. I ate with these people. I played with these people. They knew what I was. But I was also the pharmacist, and any of you who are pharmacists, more power to you. That is the worst job in the world. So not only prescribed it, but I had to know where everything was and keep track and get rid of the old stuff. And what about the old stuff? If we had it, we used it. Radiology, yes, I was the X-ray tech, and I read the films, and I developed them. And we had a hyperbaric chamber, and it was a real hyperbaric chamber, a multi-placed chamber, because during the summer we do intensive scientific diving, dry-suit diving, obviously, but intensive diving. It has been used. I never had to have it used. We did do simulations, but that's one of my physician assistants inside the hyperbaric chamber, just for fun. She thought that would be cute. We had physical therapy, and no, I'm not a physical therapist, and that was the first consult that we had to have, was we had to call up and get physical therapy instructions, because that's tough. So now the ethical issues. Yesterday Paul Farmer talked about in a desert, clinical desert, what you're looking for is you're looking for stuff, staff, space, and systems. Okay, well, we had problems with systems, as I'll explain, and staff. We had the stuff, more or less, and we had the space. Okay, so of all the things, what could we do, and what should we do? Our interventions, these are some of the ones we were supposed to do, disease and injury prevention, and that was tough. Imagine I lived with all of you guys, you know, we all live together in dorms, we live in dorms or barracks, and I've got to convince you to have influenza shot. Okay, but I had one you say, well, this is new. This is the one, because we were in the southern hemisphere, so that comes early. So I have to convince you, and then I have to give it to you. And is it going to hurt? These are 300-pound mechanics, you know, I mean, they can lift a ton with their hand. Is it going to hurt? Okay, so it can be hard. And then we had two bars and a store that sold alcohol 18 hours a day. Disease prevention, let me think. Okay, all right. We did therapy, including rehab therapy. The first person in the winter that I had to treat was a shoulder dislocation, alcohol, ice, okay, and he was a little older, and I had, I don't want to move my arm. This is afterwards. As he was repaired, he was, okay, you know, I don't want to do that therapy. Said, if you don't do the therapy, I'm going to have you restricted the quarters for the rest of the winter. This was, he finally did it. But rehab is tough. And then patient support. Yeah, a lot of counseling. Here we have a psychotherapist. Boy, I could have used you. Really, really, not as much situational depression because of the dark. Everybody thinks it's because of the night. It's not. The alcohol takes care of that. But also the activities. They have scheduled activities and they're pretty good about that. So it's a community and we get over that. We had satellites. Okay. But this woman who is actually fairly experienced almost backed her truck over a cliff. I mean, it was halfway over the cliff when they got in there, got her out and attached the truck to a tow line. And I mean, she was you can imagine. I mean, she saw that she was going to die, which she was if she went over the cliff. So we had a lot of counseling. It's not really alternative therapy, but I do use hypnosis and I have for a long time in my practice, emergency medicine practice. And I used it with her and counseling and but a lot of other counseling, a guy got off the plane, got to the bottom of the steps. He looked around. No, I'm not staying here. All right. So we tried a little counseling, but we got him out. Okay. Okay. So I said one of our ethical issues related to staff and the staff was that we oftentimes didn't have the not the breadth of knowledge we needed to do all the things we really had to do dental boy. I was on the edge. I did have a consultant dentist that I could talk to at literally 24 seven. And I knew him and he's very good and very responsive. I took dental x-rays for those of you who haven't done it. That is please give me chest x-rays any day. Dental x-rays are terrible. So those ladies in the dental office who do that. That's tough. That really is anyway. So we did that dental was at the edge of what we were doing pharmacy managing the pharmacy. We knew how to prescribe radiology and imaging laboratory. We were also doing blood banking, blood banking. My wife in her first career was a medical technologist. She says that's hard. Tell me about it because we had stuff that from 15 years ago that we were having to use for blood banking and nursing procedures. Anybody who's a nurse in here more power to you. Boy, I wish we had had a nurse. We had to actually borrow a nurse during the winter. I had a PA and myself and we had to do this whole thing. But a friend of mine happened to be an RN, experienced RN. She was doing something else on station. She didn't want to do the RN stuff. But I said in a crisis will you come over and help. She said okay because it's you I'll come over and help. That's management in Antarctica. Please help me. Okay. So she came over occasionally and helped us especially with drips and things like that. Now what we could do is limited by the systems, the consultants. Occasionally we had consultants and they said we'll just bring them down to my office. Do you understand I am eight hours away by Air Force Jet from Christchurch, New Zealand, which is where we go in and out of. Do you have any clue who you're talking to or where we know? Okay, never mind. Sometimes they wouldn't come to the phone. Sometimes the quality was just terrible. So consultants is a problem in these kind of resource poor environments. I've worked in other resource poor environments. As Mark said, I've worked all over the world. Sometimes I relied on my own friends who in various specialties, the University of Arizona, and I could just call them up or email them and they said sure, this is what you do. That was fine. Sometimes we had to use other people. Supplies, medications, equipment, like I said, multiple different kinds. We had to know all of it instantaneously and sometimes it was outdated. Managerial decisions, we won't go into. Weather conditions, I told you about the case, but weather conditions all the time. And weather conditions also, we were part of the emergency response team I was as the lead physician, which meant middle of the night to get called up. Oh, this science team hasn't reported and you have to go to the command center and you have to figure out where they are and because the weather had just come up and they were going to get zapped. Okay, bureaucracy. Here's some of the patients it costs about for an emergency evacuation it can cost into the millions. And I'll show you why in just a second. And okay, this is about three minutes, but it's worth it. Tude of going to South Pole or anywhere in Antarctica in the middle of winter is fairly serious. We hadn't been involved with Antarctica in June before. So this is the unknowns and the first times were a lot of us. It's the worst time to be down there flying, that's for sure. The Antarctic poses bearing risk with extreme cold weather conditions high altitude during the winter season. The middle of winter is fairly serious. We hadn't been involved with Antarctica in June before. So this is the unknowns and the first times were a lot of us. It's the worst time to be down there flying, that's for sure. The Antarctic poses bearing risk with extreme cold weather conditions high altitude during the winter season. It's dark for the entire period. That makes this mission more challenging than what we routinely do. Prior to leaving I tried to visualize all the problems that we would have along the way to try and not be caught off guard by it. Things like an engine failure. If I had to land, where was it going to be? And you can plan for everything, you can plan for winds, you can plan for enroute weather, but you just can't plan for the breakdowns or the unknowns that come out. The limited resources and facilities on route compound the danger. You're just kind of out there on your own. Just watching our fuel it took up a lot of your mind for most of the trip. We don't have a lot of reserve, any kind of head winds and changes of two or three knots on that distance at our slow speed was going to make a difference and you know could we actually make it all the way. The weather extremes were quite large. The silt pole was minus 59.8 degrees exactly when we landed. Parting out a silt pole to tell you the truth we weren't entirely confident we had enough room of cleared the skiway. Just to get the airplane moving took pretty much all the power of the engines. They lit a fire and a couple of drums and that's what we had for lighting there. I believe we had maybe about 7000 feet down the skiway. Even at that point we weren't sure if that wasn't enough for us to get airborne. I got to recall just getting the nose off at around the five to six thousand foot marker and at a weight that is way over the maximum normal operating weight for that aircraft and we slowly got airborne. Okay that was the rescue first time ever during midwinter during actual midwinter from the south pole station. I was involved in the decision and also alternative preparations at our station in case they had to come back our way. You were seeing one of the pilots the guy who went to the south pole. He was asked are you the best pilot Ken Borek has. Ken Borek is the only company in the world that does that kind of flying. They fly in the Arctic and they fly in Antarctica and that's it and they have the only planes that'll land in that and can take off again in that weather because your oil freezes usually but that's a specially built plane. Anyway he was asked was he the best pilot because he was going to the south pole. No I'm the second best pilot. The best pilot is back in the British station on the peninsula the two planes because he's got to come get me if something happens. So what we should do is limited by costs. That was a more than a million dollar decision. They took out two patients. Okay and I can tell you one of them had an acute MI and potential danger always an incomplete knowledge. What we should do was limited by all the various constraints and I can tell you about one constraint which was public health is I instituted for the first time a quarantine system for people coming in who had any signs of upper respiratory disease and I quarantined them for three days. I got enormous pushback from the companies and then all of a sudden people realized hey we don't have diffuse coals throughout the station so it worked. Okay we had more medical resources on hand than most of the places in the world that I work resource poor same or better communications but we had less ability to get people to higher levels of care and usually none and I'll just end with a question that a number of people has asked what if I needed to do surgery on any of these people in midwinter. The setup we had was we were going to change our trauma area into an operating room. We had a telecommunications system there was going to be a camera over my shoulder. I was going to operate and surgeon was going to be talking to me because we did and we had plenty of anesthesia that was not a problem we had propofol but you just have to live on the edge and the people there knew it and that was kind of tough so while this is going on this is a I think we need the bottom one it's just going to play if you guys have any questions this is this is a combination of a actual drone going over and some fancy stuff they did but in any case thank you very much are there any questions any volunteers for next season okay okay