APEX 4 Bolivia 2014 is a high altitude medical research expedition to the Chacaltaya Mountain (5,300m) near La Paz, Bolivia in June 2014.
APEX 4 Bolivia 2014 is a high altitude medical research expedition to the Chacaltaya Mountain (5,300m) near La Paz, Bolivia in June 2014. The expedition is led by a motivated group of senior medical students at the University of Edinburgh.
The purpose of the expedition is to carry out scientific research to further our understanding of the severe and often unappreciated risks of high-altitude, and to translate this knowledge to the practice of critical care medicine at the bedside. The research has the potential to affect millions worldwide.
You can view the expedition brochure here.
Globally each year, 35 million individuals travel to high altitude for a variety of purposes (e.g. work, recreation, religious pilgrimages, and disaster relief). High altitude environments are extraordinarily stressful for lowland dwellers because they are low in oxygen. At high altitude, there is less oxygen available to tissues in the body, and rapid physiological adjustments are required to prevent harm.
This process of adjustment, known as acclimatisation, is highly variable. During an acute exposure to altitude, some individuals adjust sufficiently while others can develop altitude illnesses such as acute mountain sickness (AMS), high-altitude cerebral oedema (HACE; swelling of the brain tissue), and high-altitude pulmonary oedema (HAPE; fluid build-up in the lungs).
A greater knowledge of the mechanisms that lead to altitude illness is needed to improve the wellbeing of the millions of individuals who ascend to the high- altitude regions of the world each year. Importantly, knowledge gained from high-altitude research can also be applied to the practice of medicine at lower altitude, as many patients who are extremely unwell due to acute trauma or severe disease will also have low blood oxygen concentration.
A better understanding of how the body adjusts to cope with low oxygen levels could improve the management of many hundreds of thousands of people in intensive care units around the world and potentially save many lives.
APEX 4 will provide 28 Edinburgh University student volunteers with unique cultural and professional experiences, as well as the opportunity to gain first-hand experience of field-research in the stunning Bolivian Andes.
Our expedition will following in the footsteps of three previous highly successful APEX expeditions to Chacaltaya, Bolivia. The expedition is led by four senior medical students at Edinburgh University with the support of University clinicians and researchers.
Aims & Objectives
The main scientific aims of our expedition are to confirm previous findings that may develop our understanding of the mechanisms and consequences of the potentially fatal accumulation of fluid in the lungs at high altitude (HAPE).
While very few individuals ascending to altitude will develop HAPE, recent evidence suggests that the accumulation of small amounts of fluid in the lungs (commonly referred to as “subclinical pulmonary oedema”) is a nearly ubiquitous finding in lowlanders exposed to high-altitude. Despite being termed “subclinical,” this fluid accumulation is likely to further reduce the availability of oxygen to the tissues of the body, which would intensify the already harsh effects of altitude.
As there is variation in the amount of fluid that accumulates, the quantity of fluid could explain the variable responses to altitude: those with more fluid may acclimatise poorly to altitude. The mechanisms and consequences of this fluid accumulation as well as its role in high-altitude acclimatisation are poorly understood.
28 volunteers may take part in research studies involving minimally-invasive daily tests including:
Blood samples to look for changes that may account for differences in fluid accumulation
Non-invasive heart and lung ultrasound imaging to identify fluid accumulation
Acute Mountain Sickness symptom questionnaires
Effects of exercise on fluid accumulation in the lungs
Copies of the research protocols are available upon request.
The APEX 4 expedition will depart the UK for Bolivia on the 30th May 2014, with all volunteers arriving in La Paz on 31st May 2014. We will spend four days acclimatising in La Paz (3,700m) before ascending to Chacaltaya (5,300m) for a further eight days.
Throughout the expedition we will take regular physiological readings including ultrasound, echocardiography and blood tests.
APEX 4 is delighted to be endorsed by leading figures in both mountaineering and altitude medicine circles.
Sir Chris Bonington CVO, CBE
Sir Chris Bonington is one of Britain's most accompished mountaineers.
""Over the last few years APEX have carried out invaluable research into the medical effects of high altitude. Many young students have gained vital experience and knowledge which may well serve to improve our understanding of critical care medicine back in the UK. These young students deserve every encouragement and have my full support.""
Professor Sir John Savill BA, MBChB, PhD, FRCP, FRCPE, FRCSEd(Hon), FASN, F.MedSci, FRSE, FRS
Chief Executive of the Medical Research Council
"I have been impressed with the professionalism and planning of these expeditions, not least the care and attention given to the health and safety of expedition members. I commend your plans for a fourth expedition and offer enthusiastic support for this research visit."
Shona is a fourth-year medical student with boundless enthusiasm for the outdoors, sport and adventure. Whenever she can she’ll be off on adventures or hitchhiking around the world. Previous leadership and medical roles in expeditions in the Drakensberg Mountains, the Sri Lankan Jungle and the Bolivian Andes have influenced her research interests and wish to combine work and play in these environments. She’s thrilled to have such a fantastic team and can’t wait to get the promising and potentially highly influential research underway.
Research Coordinator and Publicity Officer
A fourth year medical student at Edinburgh, Calum is the Publicity Officer for the expedition and leading part of the research. He will be overseeing a study to examine the effect of a patent foramen ovale (a small opening in the heart) on altitude illness and hypoxia. He is passionate about expedition and pre-hospital medicine and loves being outdoors. He spends most of his spare time riding the stunning Scottish trails on his mountain bike or playing Shinty. If there's an opportunity for an adventure, he's there!
Research Coordinator and Fundraising Officer
Alistair is a fourth year medical student and will be coordinating research and fundraising for the APEX 4 Expedition. He will be leading the research arm investigating the effect of high altitude and hypoxia on coagulation; meaning he will spend a lot of time sticking needles in people! Outside of medicine Ally is a keen climber, and will often be found cycling about the place or drinking coffee. He is very much looking forward to this incredible opportunity to travel somewhere cool, research a fascinating area of medicine and get to know a superb bunch of enthusiastic people!
Safety and Logistics Coordinator
Yet another fourth year medical student, Sandy is the safety and logistics officer for the expedition. He was a volunteer on the APEX 3 expedition and is familiar with Chacaltaya and South America, having spend a number of years living in Chile. His academic interests lie in anaesthetics and critical care but outside of medicine Sandy is a keen member of the rugby club and can often be found out with his team enjoying a few quiet drinks. He is looking forward to getting back to South America with a fantastic group and doing some meaningful scientific research.
Georgie is a fourth year student of History and Chinese and is acting as Treasurer for APEX 4. Georgie’s involvement with the expedition is not due to any medical ability, but rather an insatiable quest for all things Latin American and a slightly mad enthusiasm for everything from trekking to ceilidhs. She fills her time between lectures playing hockey for EUWHC 3s, playing on boats and creating fancy dress costumes. She's very excited to be crashing a medical expedition and cannot wait to spend time with such great people in such an awesome place.
Senior Research Coordinator
Martin is a high-altitude researcher interested in the genetics and physiology of altitude acclimatization. He’s based in Vancouver, Canada, but his surname and formerly ginger hair are evidence of his Scottish heritage. Martin has led research expeditions in the Nepalese Himalaya, and he’s looking forward to feeling ill and doing science in a new and beautiful part of the world!
DR MATT WILKES
As a student, Matt took part in the APEX 2 Expedition ten years ago, kicking off an interest in wilderness medicine and altitude physiology. Since then, he has worked as an anaesthetist, critical care doctor and expedition medic in British Columbia, Tanzania, New Zealand and Nepal. Matt is Editor of the Adventure Medic magazine, and last year was the Lead Doctor on a record-breaking expedition to Mt. Kilimanjaro. He now teaches on wilderness medicine courses in the UK and is midway through an MSc. in Mountain Medicine.
DR ELLIE HEATH
Ellie is currently working in Emergency Medicine and will begin GP training in 2014. She has travelled extensively in the developing world including voluntary work in Tanzania, Ghana, Cameroon, Venezuela and Belize. Her interest in expedition and wilderness medicine grew from a love of travel and the great outdoors. Ellie has recently completed a diploma at Liverpool School of Tropical Medicine and holds a Certificate in Travel Medicine.
THE ORGANISING COMMITTEE
The APEX 4 expedition is led by a motivated group of senior students at the University of Edinburgh along with research advice and support from Martin MacInnis, a Canadian PhD student.
The APEX 4 team consists of 29 enthusiastic expedition members (the majority of whom are University of Edinburgh students), 2 expedition doctors and 2 researchers.
APEX 5 has been fortunate to be sponsored by the following organisations. We thank all of our sponsors for their continued support for our expedition.
RESEARCH AND FUNDING SUPPORT
We have kindly received research grants from the following bodies:
We would also like to thank the Wellcome Trust Clinical Research Facility at the Western General Hospital, Edinburgh for allowing us to use their incredible facilities free of charge.
Pathways to Professions Talk
Posted by Ally Rocke on Wednesday 29th October, 2014
Members of the APEX organising committee gave a lecture to local aspirant medical students, as part of the Pathways to Professions scheme. This is a University of Edinburgh initiative to provide support and guidance to pupils in local state schools applying to competitive professions, such as medicine, vet medicine, law and architecture.
In addition to talking about the expedition itself, Shona, Ally and Sandy also discussed the opportunities that studying medicine opens to the motivated student for research and adventure. Edinburgh University has offered us a very supportive environment in which to conduct ventures such as this one, as a leading centre of academic medicine.
The students were invited to ask any questions they had about their application to medical school, which we were delighted to answer. The session became much more interactive and we were able to speak with individual students at the end of the session. The APEX team would like to say a special thanks to Melanie Smith and the Pathways to Professions team for their help and kindness in arranging this talk.
Posted by Calum Stannett on Sunday 12th October, 2014
Thanks so much to everyone who has followed our blog and we apologise for having gone so quiet! As it turned out, a combination of altitude sickness, busy testing schedules and unreliable Bolivian internet connections (especially at the top of mountains) made it extremely difficult to keep the blog updated during the expedition.
The expedition is now well and truly over and was a huge success both in terms of the research we carried out and the trip itself. The expedition officially ended on the 11th of June, however most of the expedition members went on to travel around South America for the rest of the summer and have just returned to Edinburgh ready for the start of the next academic year.
The expedition went extremely well overall; however that is not to say that everything ran exactly as we had planned. We were forced to improvise on several occasions when faced with seemingly insurmountable obstacles. Some highlights would include fashioning makeshift stickers for the ECG machine from paperclips and duck tape, googling 'minus 80 freezers in La Paz' in a moment of desperation, and being forced to collect dry ice at 4am to avoid road blocks coming out of La Paz. With some grit, determination, a lot of luck and a huge amount of initiative, we managed to overcome every problem we were faced with.
We have added photos from the expedition to our Photostream which you can have a look at.
Since returning to Edinburgh, analysis of the blood samples and questionnaire data has started. Ally has also begun analysing the data he gathered from his ROTEM, Multiplate and plasma analyses. Processing of the samples and data analysis may take several months to complete. We have already begun to disseminate our initial findings and there are several publications and articles in the pipeline. Check back here soon for more updates on these!
We'd also like to say a huge thanks again to all of our incredible sponsors who made the expedition possible! Please head over to our Sponsors page to see a full list of all of the amazing organisations who supported us.
Day Seven in the big Chacaltaya House
Posted by Calum Stannett on Tuesday 10th June, 2014
First off, thank you so much to everyone who has been checking our blog and following our adventures at Chacaltaya! We've had an extremely busy but enjoyable 8 days up here at the lab. Please forgive us for the lack of blog updates; a mixture of sore heads, busy testing schedules and poor mobile internet connection has made it very difficult to keep the blog updated.
This is our penultimate day at the Club Andino and our final day of testing before we head back down to La Paz tomorrow afternoon. We had a minor panic last night when we had a sudden power-cut; after some negotiations with the nearby lab we were able to fix this in time for testing today. Wayne has now completed his scanning of the lungs and optic nerves, Guido is finishing off the last few echo scans of hearts and Ally and the coag team are making great progress with ROTEM, Multiplate and Plasma analyses.
Unfortunately, the full blood counter (FBC; a vital part of Ally's coagulation study) decided not to co-operate and has not worked at all at altitude. After some impressive attempts by the coag team over the past few day to nurse the faltering giant back to life, it was eventually pronounced dead at 20:24 on Sunday the 8th June. We were fortunately able to make arrangements with a local lab to have the samples analysed.
On Sunday Matt came to the rescue of 5 year old Diego, a wee boy who had come up to Chacaltaya with his mum. Diego's mum was a mountain guide, and although Diego had spent his whole life at 3650m in La Paz and had been up as far as 4000m before, upon reaching the towering heights of 5300m at Chacaltaya he became very unwell with acute mountain sickness. After a quick examination and some reassurance from Matt, Diego and his mum were soon safely on their way back down to La Paz.
Yesterday afternoon the APEX team assembled to head for the summit of the Chacaltaya Mountain en masse. After a slow, steady and slightly winding climb, we were able to get some incredible group pictures from the top. This afternoon we went outside to take some team photos. The jaw-dropping vista of the Huayni Potosi mountain provided a stunning backdrop for this, and we were able to take some truly breathtaking shots.
Cameron and Stewart have kindly written a little about their experience at the lab:
Cameron & Stewart:
Today is our penultimate at Chacaltaya. It has been a rollercoaster ride, with all the ups, downs and projectile vomiting that you would expect! While there have been technical difficulties in the lab, we have gelled as a team through the mediums of breathlessness and nausea and taken Apex to new heights.
The lab is a stunning place to spend a week, with the peak of Huayni Potosi and the Cordillera Real looming as a backdrop. As we put the finished touches on the official APEX 4 expedition music video (to be announced…) we look forward to ascending to even greater heights in the Bolivian charts!
Thanks to Cameron and Stewart for penning that for us; hopefully they will have given you some feel for how our week has been! Although a lot of us have been quite ill over the last few days, our doctors Matt and Ellie have done a tremendous job ensuring that everyone has been treated appropriately and well looked after. There have also been incredible displays of stoicism and perseverance and the whole team has really pulled together to look after one another, which has been great to see.
We descend from Chacaltaya back to La Paz tomorrow and we will put up a further update with photos from the faster internet connection there.
An update at last!
Posted by Sandy Jackson on Saturday 7th June, 2014
Finally we can update you all! I realise it has been a few days since our last update but things have been pretty busy and getting signal to connect to the internet at the lab is somewhat of a challenge!
The team have now all ascended to Chacaltaya, including our final arrival Guido, and all our kit has finally been released by customs!
The customs saga is a long one; suffice to say I have spent five full days shuttling between various bureaucrats getting forms stamped, signed and photocopied at every step. Finally after having used enough paper to fell a small forest our kit was released just in time for our research to start within it's optimal windows, a huge relief for me and the rest of the team.
The rest of the group meanwhile ascended early Wednesday morning to Chacaltaya. They were greeted by the truly fantastic views and blue skies, which I myself am now enjoying as I write this blog. We will try and get some photos up for you as soon as possible but the poor 3G signal may make this impossible. Within a few hours, however, the group began to feel the effects of the altitude. The first night was a fairly tough one with expedition doctors Matt and Ellie going from bed to bed doing their best Florence Nightingale impressions. A few cases of stomach upset were immediately dealt with, handwashing stations and rigorous infection control were established and ciprofloxacin administered at the first sign of trouble. With these measures in force everyone has improved and now seem to be on the mend.
As well as challenges the lab has brought some real treats for the team. The setting is truly remarkable. Clear blue skies greet us each morning with stunning views across the Condorirri Mountain Range and all the way down to the city of La Paz, with the urban sprawl of El Alto above it. It's a unique place and even those feeling under the weather are able to appreciate it. The food has also, apparently been a real treat, with not three, but four meals a day (the all improtant afternoon tea is included). This is my first day up here and I look forward to trying it all. Little morale boosters like this and the constant availability of a range of hot drinks have helped the team through the acclimatisation process.
The first 24 hours proved the most challenging and since then everyone has made gradual improvements with the group now starting to enjoy walks in the surrounding area. The research has been going ahead largely as planned and promises to give us valuable data and make the whole trip a real success.
We'd like to take this chance to thank everyone who has got us this far in the process. Ranging from Marco, our in-country logistics support, and his team of chefs and drivers to the La Paz medical school, who have generously provided us with the freezer space we need, and to all the sponsors of our expedition, please take a look at our sponsors page, we would highly recommend each and every one of them to you!
We'll try our best to keep you updated as best we can but as you can imagine at an altitude of 5300m in rural Bolivia this is easier said than done! Thank you everyone for you kind messages of support, we're all really excited to be here and hope the next few days will continue to bring us the experiences and scientific data that will really make this trip unique and worthwhile for everyone involved!
Another busy day in La Paz
Posted by Ally Rocke on Tuesday 3st June, 2014
Today has been another very busy day for everyone. We have sorted out many more of our outstanding issues but our kit is still retained by customs. Sandy has been working desperately hard and we are hoping it will be released tomorrow, in time for the first test day in Chacaltaya on Thursday. Calum worked his Spanish charm on an exceptionally helpful lab in the local Medical School, who are happy to store our samples in their -80 freezer. Everyone is now tucked up in bed getting some rest before the big ascent tomorrow. I (Ally) will be acclimatising further in La Paz for the next couple of days, and will keep everyone updated!
Monday's retrospective update
Posted by Sandy Jackson on Tuesday 3rd June, 2014
First off sorry this blog is coming a little late. Our relaxed Sunday meant we had a lot to get through on Monday. The committee were all up first thing and headed in different directions. Shona headed to the supermarket to pick up vital supplies for the lab, ably assisted by Charlotte, Tom and Dr Ellie. Calum and Matt went off to find Praxair, the company who we had arranged to buy oxygen and dry ice from.
Finally I went to do battle with Bolivian customs, accompanied by Cameron and Stewart, to secure the temporary importation of our research equipment.
Shona and her team had a successful visit to the supermarket. There was a slight hold up where Shona had to play charades with the shop assistants to describe firelighters, much to their amusement. Eventually, however, miming worked its magic and everything was all bought and paid for.
Calum and Matt had a real stroke of luck when their taxi driver to praxair turned out to work part-time as a scrub nurse. Jose-Luis was extremely helpful and friendly and agreed to help dispose of all our sharps and clinical waste free of charge! He also knew the location of praxair, which turned out to be a good thing as it was very well hidden. Calum and Matt made some initial arrangements for oxygen and dry ice but like everything in Bolivia it was going to take time and they arranged to head back the next day to finalise the details.
I on the other hand was somewhat less successful. What I had hoped would be a simple pick up of our bags, which had been retained over the weekend, turned into an all day struggle against the full weight of Bolivian bureaucracy. Our equipment was passed from customs, to a warehouse, with about 6 officials I had to liaise with in between. After 4 hours of sitting waiting for me I thanked Cameron and Stewart for their saintly patience and sent them back to the hostel as the end was not in sight! Another hour later it emerged I would have to visit the British Embassy for the next stage of the procedure. Thankfully Lizzett, who has been helping us for the past 6 months sprung into action and hoped to get the ball rolling. It's a ball I'm still pushing today but there is light at the end of the tunnel. When we finally get our kit I never will I have been so relieved to see a blood tube in my life!
The volunteers sound like they had a fantastic day, joining in with parades, getting great views of the city and taking some excellent photographs. I will try and get on of them to give you an update later today and we will be adding photos to our gallery soon. Sorry this blog is picture free but Bolivian customs offices aren't particularly picturesque, but look out for a more exciting one from the volunteers later and a full update on today's activities as we make final preparations for our ascent to Chacaltaya, it's getting close and we're all very excited!
Posted by Sandy Jackson on Sunday 1st June, 2014
Testing is now well and truly underway. Wayne is just over half way through his superhuman effort to scan the lungs, heart and optic nerve of all 28 participants. This herculean mission is likely to take him around 15 hours to complete and he is doing it all without a word of complaint; every time we ask him how he is his reply is simply "smashing!" Our massive thanks to him.
The rest of us meanwhile are taking things as easy as possible to ease our acclimatisation. The committee have had a few errands to run but, with it being a Sunday, most of the shops are closed. This provided an excellent excuse to shorten our to-do list for today. This allowed Calum and I to enjoy a leisurely 2-hour coffee and lunch break (sorry Shona we promise to work harder tomorrow!)
Rather than constantly hearing from the committee we thought it would be more interesting to hear from the volunteers, plus it allows us to write less! So here are some quick thoughts from Ellie D and Nandesh
Hi, I'm Ellie a member of the expedition team here in La Paz. I'm feeling pretty great right now and can't wait to get up to Chacaltaya on Wednesday! However, it wasn't quite the same landing at 4000m on Saturday morning. Straight away I noticed that I was breathing much faster than normal and I could feel my heart beating faster in my chest. I've got used to altitude more every hour and it isn't so noticeable now, so tomorrow a few of us will be venturing to the view point over the city - can't wait!
Hola, I'm Nandesh a member/volunteer of the expedition here in La Paz. It's been great so far in La Paz, very different to the UK. After all the hype I'm really excited/looking forward to going to Chacaltaya and experience how I will actually feel up at such high altitude. La Paz has been really fun so far, especially the 10 Boliviano (£1) and 7 Bolivianos (70p) lunch and dinner I had! In the next few days leading up to Chacaltaya I'm looking forward to further exploring, especially the Cholita wrestling this evening [Google it - Sandy]. Everyone is really keen to go and I'm official APEX Cholita organiser as apparently I've got a big passion for it!
Thanks to both Nandesh and Ellie for sharing their thoughts with us. I feel I should clarify I didn't pay them anything to be that positive. It's simply a testament to what an enthusiastic group we are lucky enough to have on the expedition. We will keep you posted with our preparations for ascent to Chacaltaya and hope to update you on our progress tomorrow.
Touchdown in La Paz...
Posted by Calum Stannett on Saturday 31st May, 2014
Hello from La Paz! Everyone has now arrived safe and sound and has settled into our hostel. We've spent today relaxing and recuperating from a busy couple of days travelling.
We met in the sunny hostel courtyard this morning for an expedition briefing. Doctors Matt and Ellie talked through what to expect from the altitude and how we can look after ourselves and each other during the expedition.
Wayne, our expedition ultrasonographer, has a mammoth day ahead of him tomorrow. He'll be scanning from 8am until 10pm to make sure he gets everyone in. Wayne has been here since Tuesday to give him time to acclimatise to the altitude.
The final countdown...
Posted by Calum Stannett on Thursday 29th May, 2014
All of the expedition kit is now packed into Ally's car and ready to go!
With just over 6 hours until we make our way to the airport, everything has now been packed away ready for our flight to La Paz, Bolivia at 6am tomorrow morning.
Tiso, Scotland's number one outdoor clothing and equipment specialist shop, kindly sponsored us by providing XL Northface duffel bags to transport our expedition kit. With well over 300kg of equipment, the bags are being put to good use!
Flying via Amsterdam and Lima, we will arrive in La Paz (3,650m) early on Saturday morning. We will then spend the next four days acclimatising before ascending to the Club Andino Lodge, Chacaltaya (5,300m) on Wednesday 4th June.
The whole expedition team has worked tirelessly over the last six months to reach this point and with just hours left until the expedition start, we can't wait to get going!
Baseline testing complete
Posted by Calum Stannett on Wednesday 28th May, 2014
Baseline testing for the coagulation arm of our study, which is being overseen by Ally, was completed today at the Royal Infirmary of Edinburgh.
Matt, Calum, Sandy and Ally gathered blood samples from the remaining half of the expedition members to measure blood clotting. With help from several members of the expedition who volunteered to help with our research, we carried out thromboelastometry (a measure of whole blood clotting), prepared plasma samples, measured full blood count and assessed platelet function.
That was the easy bit... Once baseline testing was complete, we packed up all of the gear required for the coagulation studies ready to fly with us to Bolivia on Friday. With over 300kg worth of equipment spread between 12 bags, this was no mean feat! Now we just have to get it there...
Medical kit from Medic 1 is packed!
Posted by Calum Stannett on Sunday 25th May, 2014
The medical kit for the expedition, very kindly provided by the Edinburgh Royal Infirmary Emergency Department, is packed and ready to go!
Expedition doctors Matt and Ellie now have everything they need to fly out on Friday.
Posted by Calum Stannett on Saturday 24th May, 2014
Welcome to the APEX 4 Bolivia 2014 Blog!
We will update this blog every day with news, photos and videos during our expedition, which runs from Friday 30th May until Wednesday 11th June 2014.
With less than a week to go until we depart for Bolivia there is real excitement in the air and we can't wait to get going. Most of our expedition members will fly out on the morning of Friday 30thMay. We will meet early on Saturday morning in La Paz, Bolivia. Wayne Pringle, our resident expedition ultrasonographer, will fly out this Monday the 26th to allow time to acclimatise to the altitude.
In the meantime, we have a final baseline testing day this coming Wednesday for the coagulation arm of our study. This exciting study will be the first to measure platelet function using multiplate at high altitude, and the second to use ROTEM. Once this is complete, we can pack up all of the analysers ready for transport to Bolivia on Friday!