Top five things to look for in a travel doctor, and why you should have one

travel doctorsDespite writing about food and adventure travel for a living, I used to be somewhat blasé about the concept of travel medicine. Multiple incidents of Giardia/dysentery/traveler’s diarrhea/full-body outbreaks of mosquito and sand fly bites just taught me to carry a serious stash of antibiotics in my first-aid kit. At least I’ve always been conscientious about travel immunizations and educating myself about the primary diseases indigenous to my destination.

When you’re young and healthy, it seems silly to have a travel medicine specialist. Although this article is primarily directed at adventure travelers, odds are, the worst thing you’ll come home with is a backpack full of crappy souvenirs. But no one’s invincible, and should you require a specialist for something not responding to conventional treatment or with progressive symptoms, time is of the essence. Many “exotic” diseases progress rapidly, and can cause irreversible damage or death if not properly diagnosed and treated. Even with incurable diseases, the earlier you catch them, the easier it will be to manage symptoms and prevent them for worsening.

No, I’m not a doctor, although I come from a medical family. But I got seriously schooled after visiting Ecuador two years ago. After a fantastic month of adventure activities in remote parts of the Andes and Amazon Basin, I fell seriously ill the last day my trip. Two years of at-times crippling symptoms, 10 CT scans, five medical facilities, dozens of specialists, four surgical procedures, two surgeries, one cancer diagnosis, and near-medical bankruptcy later, I’ve become an expert at being my own advocate.

My infectious disease doctor believes that I contracted a form of bartonellosis called Oroya Fever after being bitten by sand flies. The good news: My health is currently stable, but we don’t know if the disease is in remission or not. But I have permanent cognitive damage, scarring or tumors on most of my internal organs, and intermittent arthritis. But believe me, I feel lucky.

I don’t want anyone to go through the health and medical nightmare I’ve endured, so I’ve compiled a list of essentials in a travel medicine doctor. Ergo, number one with a bullet:

1. Is he/she a travel or tropical medicine specialist?
Pre-bartonella, I used an internist as my GP/prescriber of antibiotics. If you can find an internist, gastroenterologist, or infectious disease doctor who is also a specialist in travel medicine, that’s a huge plus.travel doctors 2. Does he/she have personal experience traveling or practicing in developing nations?
There are a lot of practicioners who aren’t globally aware, so to speak. You can’t diagnose what you don’t understand, know about, or have first-hand experience with. Period.

3. Is he/she a good listener and empathetic?
It’s difficult to find these qualities in any doctor, especially in today’s medical climate. But it’s imperative to find someone you can communicate with, and who understands what you’re going through if you’re suffering from a mystery travel ailment. Don’t settle, even if you need to travel to another state or country to seek treatment (what stumps doctors here is often commonplace in the country of origin).

4. Does he/she have a good network of colleagues in multiple specialties (including travel/tropical medicine) to consult for additional opinions?
My current mantra is to seek a third opinion, from at least two different medical facilities. That, and to have a travel physician who actively consults colleagues and does additional research to assist with a diagnosis and/or treatment. My infectious disease doctor talked to specialists at a medical school in Peru on my behalf, and even tracked down a relevant medical paper from 1897 as he honed in on a diagnosis. And while I wouldn’t consider it a deal-breaker if the answer is no, see if your doctor is an active and participating member of the International Society of Travel Medicine.
travel doctors
5. Does he/she return your calls/provide you with email, pager, or office number so you can get in touch directly?
I’ve learned that a good doctor who is invested in your recovery will provide an open line of contact to address questions, concerns, and exchange pertinent information. Tip: Please don’t abuse this privilege. Physicians work insanely long hours, under constant stress. And don’t expect to hear back immediately if you leave a non-urgent message; be realistic. A couple of days, fine (many specialists aren’t in clinic every day). A week? Make a polite follow-up.

Whether or not you end up getting a travel doctor, the International Association for Medical Assistance to Travelers (IAMAT) provides loads of useful information, including a directory of global travel medicine clinics with English-speaking staff, and a destination-specific travel health planner. And depending upon what you plan to do on your trip, where you’re traveling, and your financial situation, you may want to invest in travel insurance.

[Photo credits: blood transfusion, Flickr user CarynNL;patient, Flickr user kk+; legs, Laurel Miller]

The Ultimate Travel First Aid Kit

Top five immunizations for adventure travelers

immunizationsSpending a lot of money to get poked with a needle may not be at the top of your pre-trip to-do list, but it should be. While some countries require proof of certain immunizations before they theoretically permit entry (details later in this post), there are a couple of vaccinations all travelers should get, barring any prohibitive allergies.

Getting vaccinated greatly reduces or virtually eliminates the odds of contracting certain serious illnesses or travel-related diseases, and helps prevent the spread of contagions. This is especially critical in developing countries, where there is generally little in the way of preventative or active health care, and lack of sanitation provides a fertile breeding ground for disease. As is true at home, infants, children, the elderly, and immuno-compromised are at greatest risk.

I consulted with Dr. John Szumowski, Clinical Fellow of the University of Washington Medical Center’s Division of Allergy and Infectious Disease, for expert advice before compiling the following list. As he pointed out, it’s tricky to generalize which immunizations are most important, since it depends upon where you’re going, and what you’re doing there.

That said, all of the immunizations on this list are a good idea if you travel frequently to developing nations, even if it’s for business or budget travel. They are especially important to have if you eat street food or visit rural areas.

The top five, after the jump.

[Photo credit: Flickr user johnnyalive]immunizations1. Flu
With flu epidemics making annual headlines, there’s no reason not to get a flu shot. This is especially true if you fly frequently or use other forms of public transit. Think of an airplane as a flying petri dish; why risk ruining your trip, or exposing others if you’re coming down with something? If you have an underlying health condition such as asthma, diabetes, or other lung or heart disease, it’s of particular importance to get immunized.

2. Tetanus
I grew up on a ranch, so tetanus shots have always been a part of my life. Many people don’t think about getting a tetanus vaccine, however, and as Dr. Szumowski points out, “It’s under-appreciated, and worth getting prior to travel given challenges of obtaining adequate, timely wound care.” Beats lockjaw, any day.

3. Hepatitis A
“Hepatitis A is common and can occasionally be quite serious,” cautions Dr. Szumowski. “For anyone with underlying liver disease (e.g. chronic hepatitis B or C) this is an especially important vaccination.”

4. Polio
Polio hasn’t been fully eradicated in parts of the developing world, so an inactivated poliovirus booster is important when traveling to areas where it’s still a problem, such as Nigeria and India.
immunizations
5. Typhoid
This vaccine can be taken either orally or by injection. Be aware that you must avoid mefloquine (an anti-malarial) or antibiotics within 24 hours of the vaccine doses.

Additional vaccines
Depending upon your destination, you may also require, by law, a Yellow Fever (tropical South America and sub-Saharan Africa), or Japanese Encephalitis/JE vaccination (parts of Asia and the Western Pacific). Dr. Szumowski recommends JE vaccine if you’re traveling for an extended (over one month) period in rural areas of affected countries.

Rabies vaccine isn’t usually recommended, but if you travel extensively in developing nations or have/expect frequent contact with animals, it’s a good idea. I’ve had a couple of canine-related experiences that have sold me on the idea. Dr. Szumowski notes that “excellent wound care and post-bite medical evaluation are still needed,” even if you’ve had a rabies pre-exposure vaccination.

Tips
It’s critical to allow ample time before your trip to allow the protective effects of the vaccines to establish themselves. Go to the Centers for Disease Control and Prevention’s vaccinations page for more information on what’s required and epidemic updates, if applicable. Often, your GP, internist, or local drugstore can provide some of these vaccinations; others require a specialist. For locations of a travel medicine clinic near you, click here.

Carry your immunization card with you as proof of vaccination, and email yourself a scanned copy, as well. The same goes for copies of your medical insurance cards.

Practice good hygiene and get enough rest, inasmuch as possible, while traveling, to maintain a healthy immune system. Airborne and Emergen-C are great immunoboosters to carry with you.

Consider travel insurance if you’ll be in a remote or sketchy area, or engaging in high-risk outdoor pursuits.

[Photo credits: swine flu, Flickr user ALTO CONTRASTE Edgar AVG. (away); polio, Flickr user Cambodia Trust;

Ask Gadling: You develop a serious illness while traveling

serious illness while travelingThe very thought of acquiring a serious illness or injury while traveling strikes fear into the hearts of even the most stalwart adventurers. Speaking from personal experience, it’s terrifying to find yourself alone (or not) in dodgy accomodations, in a remote area of a developing country, with a raging fever and/or an uncontrollable case of the runs or other unsavory symptoms. Which isn’t to say the same ailments suffered in the comfort of a five-star hotel in Paris are a picnic, either. Any way you slice it, getting sick in a foreign country sucks.

And sometimes, despite taking precautions, you fall ill anyway, as I can attest. It can be a matter of circumstance (That water my guide “boiled” in a bamboo culm on a Thai Hilltribe trek? Yeah, I pretty much saw the resulting case of dysentery coming), or just bad luck. I’ve been on my own during most of my unfortunate on-the-road maladies. Between my experiences and those of fellow travelers, I’ve accumulated some wisdom over the years for dealing with sudden-onset illness in less-than-ideal circumstances.

For the purposes of this article, I’m not going to include injuries, pre-existing conditions, or focus on food poisoning, which was well-covered in a previous Ask Gadling post by Melanie. I also want to stress that we’re not medical professionals here at Gadling, myself included. For the technical stuff, I turned to Dr. John Szumowski, Clinical Fellow of University of Washington Medical Center’s Division of Allergy and Infectious Disease.

After the jump, tips on prevention, what to do when illness strikes, and how to get yourself home in the event of a full-blown medical emergency.

[Photo credit: Flickr user MoHotta18]

serious illness while traveling

Before you leave home

Hit the internet
Do a bit of research on emergency medical options for a worst-case scenario. The U.S. Department of State produces a list of American doctors and hospitals in foreign countries.

If you have specific questions (about, say, where to find the best dentists in Europe), Lonely Planet’s Thorn Tree travel forum can be a useful place to get ideas (please do additional research before following any advice). Take the diagnostic-related questions directed to forum members with a heaping grain of salt, and save them for your doctor.

Get vaccinated
Check the CDC’s (Centers for Disease Control and Prevention) website to see what, if any, vaccinations you need before your trip. You can also get updates on things like outbreaks of cholera or bird flu. Be sure you allow ample time before your trip for the protective effects of vaccines to establish themselves. Dr. Szumowski also recommends the CDC’s “Survival Guide to Safe and Healthy Travel” webpage.

View more Ask Gadling: Travel Advice from an Expert or send your question to ask [at] gadling [dot] com.

Keep an immunization card on you (some countries require proof of certain vaccinations) as well as an online record, like Google Health.

All travelers should get flu and tetanus shots. If you’re a frequent world traveler, get vaccinated for hepatitis A, typhoid, and polio. Depending upon where you’re traveling, you may require a Yellow Fever or Japanese Encephalitis vaccine, or malaria prophylaxis.

I used to think a rabies vaccination was overkill until I saw a fellow traveler get seriously nipped by a puppy we were playing with in a remote village near the Myanmar border. The deathly silence that followed was sufficient motivation. Adds Dr. Szumowski, “It’s still important to remember that excellent wound-care and post-bite medical evaluation are necessary, even if a person has had prior rabies pre-exposure vaccination.” The International Society of Travel Medicine has a list of global travel medicine clinics.

I also carry an EpiPen, because you never know what could trigger anaphylaxis while you’re abroad. It also bears mentioning that you can develop a life-threatening allergy to something previously benign. A chef I know went into anaphylactic shock after tasting one of his dishes containing taro root, even though he’d been cooking with it for over 20 years.

If you get sick

Stay calm, and assess your symtoms
It’s easy to get carried away and assume the worst, but odds are your sudden fever isn’t malaria.
serious illness while traveling
Try to identify the source of infection or illness

Know when to seek professional medical assistance
In general, says Dr. Szumowski, some symptoms or exposures that should prompt “expeditious” medical evaluation include:

  • high fevers (over 101ºF, especially if sustained or accompanied by shaking or drenching sweats)
  • bloody diarrhea
  • inability to keep food or liquids down in situation of significant vomiting or diarrhea
  • confusion or severe headache
  • severe cough, especially if accompanied by shortness of breath
  • animal bite or other animal-related attack

Tips for self-care

Stay hydrated
If you’re vomiting or have diarrhea, stay hydrated with (purified/bottled water), and Gatorade or other electrolyte beverages. If you absolutely have to travel, take Imodium as an anti-diarrheal.

Eat bland foods
Remember the BRAT diet for gastrointestinal upset: rice, bananas, applesauce, and toast.
serious illness while traveling
Control your fever
To lower a high fever, take the recommended dosages of acetaminophen (Tylenol) or ibuprofen (Advil).

Wear ID
Wear a medical alert bracelet for serious conditions, allergies, etc., Write down your condition in your destination country’s language in both your phrasebook, and place a card in your passport.

Emergency Measures

Know when to self-diagnose
Sometimes, you find yourself in a position where you have no other option. That said, this is something you want to avoid for obvious reasons. Says Dr. Szumowski, “Self-diagnosis and treatment can be appropriate for less serious conditions such as traveler’s diarrhea, but it is important not to delay evaluation by a medical professional for more serious illness [see warning signs above]. If someone chooses to self-treat, it’s important to be aware of potential for counterfeit medications locally.”

What if the only available hospital/clinic/doctor’s office is seriously sketchy?
If you’re in a situation where the medical facility is primitive/lacking in sanitation, you’ve got a tough call on your hands.
serious illness while traveling
I posed this question to Dr. Szumowski. He says, “It depends on the acuity and seriousness of the condition. In general, evaluation and treatment in a facility with adequately-trained staff and more comprehensive resources is preferable whenever possible–this may mean seeking evaluation in the capital, at a private hospital, or even returning home. Aside from limited diagnostics and medications, smaller/less-resourced facilities may have inadequate sanitary practices (e.g. reuse of equipment) and screening of blood products, raising the risk of contracting pathogens such as hepatitis C or HIV. Therefore, having evacuation insurance is advisable, especially for extended travels in the developing world.”

In other words, you may be shit out of luck. But this is why you’re reading this article–so you can be prepared for all kinds of situations! Read on.

OTC antibiotics
In many countries, you can buy OTC antibiotics, and indeed, this may be your only option, but heed Dr. Szumowski’s warning, above. Caveat emptor.

If you need to be evacuated, the U.S. government offers financial assistance and/or repatriation loans. The American Citizens Service and Crisis Management (ACS) is linked to U.S. embassies and consulates all over the globe. It’s a good idea to enroll in the U.S. Department of State’s “Smart Traveler Enrollment Program (formerly known as “Traveler Registration)” if you’re traveling for a long period of time, to a high-risk region, or doing any extreme adventure activities.

Travel prepared

Get antibiotic prescriptions (and carry copies with you) from your primary care doctor or internist, or visit a travel medicine clinic, and pack them in you travel first-aid kit (You don’t have one? REI has some great options). Some people also carry sterile latex gloves and hypodermic needles with them. If you’re diabetic or have another condition that requires injections, this makes sense, provided you have a note from your medical provider. For everyone else, this is a personal choice that comes down to, “How comfortable are you with the knowledge that you’re carrying drug paraphernalia?” If you backpack, travel in places with notoriously corrupt law enforcement, or countries like, say, Malaysia, you may want to hedge your bets.
serious illness while traveling
Email yourself and family or a trusted friend copies of medical insurance, itinerary, and a list of medications, and doctors.

Consider traveler’s insurance.

If the worst happens

In the highly unlikely event you do come home with a mystery disease that isn’t responding to medical treatment, get to a specialist, asap. Depending upon where you’ve been, this may be an infectious disease or tropical medicine doctor, a dermatologist or rheumatologist who specializes in tropical medicine, etc.. You may need to travel–out of state–to find the right specialist. Find someone who has first-hand experience traveling/training or practicing in developing countries, and in diagnosing diseases not found in the U.S.. It may even be best to try and seek medical treatment in the country where you became ill (even if that means a return trip).

Unfortunately, I can speak with authority this subject, because I’m in my 22nd month of diagnostics following a trip to South America. If you do find yourself harboring a travel-related (or not) disease that defies diagnosis, you must be your own advocate. No one is more invested in your health than you are, and doctors are human. They may make mistakes, despite their best intentions. Seek not just a second, but a third opinion, from at least two different medical facilities.

And finally, don’t let anything in this article scare you and put you off travel. Odds are, you’ll come home with nothing more than great memories, and the eagerness to plan your next trip. I know I can’t wait.

[Photo credits: vaccination, Flickr user alvi2047; mosquito, Flickr user tonrulkens; toast, Flickr user snowriderguy; farmacia, Flickr user ibirque; drugs, Flickr user cavale]

Top five antibiotics to keep in your travel first aid kit

I’m not a doctor, nor do I play one on TV. But I do make my living off of eating while traveling which, if I have my way, usually entails sampling a lot of street food. That said, I do take precautions, but sometimes the inevitable happens anyway.

Back alley eateries aside, experienced adventurers know that it pays to visit a travel medicine clinic or their primary physician (an internist is best) before heading off the beaten path. I’ve learned through painful, sometimes embarrassing, experience to take a portable pharmacy with me when I travel, so I’m prepared when disaster strikes. Checking the Centers for Disease Control and Prevention site is a must when planning a trip to developing nations, so you can get the appropriate immunizations; plan far ahead, as some of these require months to take effect.

Please note that I’m not endorsing self-diagnosis, the purchase of dubious or over-the-counter pharmaceuticals, or the casual use of antibiotics. You can buy OTC meds in many countries, and I’ve had to do so more than once. But I wouldn’t recommend it unless it’s an emergency, you can’t get to a doctor, or the only medical assistance available is more high-risk than trying to diagnose and treat yourself.

Get legal prescriptions from your own doctor, one who hopefully understands tropical and/or travel medicine. Carry paper copies of your prescriptions with you, in case you find yourself subject to a random bag search (because life in a Thai prison isn’t fun, no matter what anyone tells you). For this reason, I don’t carry sterile syringes or hypodermic needles in my first-aid kit. If you’re diabetic or have a medical condition that requires injections, be sure to wear a medical alert bracelet and carry the appropriate paperwork on your person at all times.

I carry a small, nylon, wilderness first aid kit in my backpack. Besides the usual OTC stuff-hydrocortisone cream, antibiotic ointment, Airborne, ibuprofen, antihistamines, Imodium, and Pepto-Bismol tablets, my top five must-haves are listed below. Obviously, your list and doseages will vary based on your individual needs (I’m allergic to Penicillin), and you need to be extremely cautious about potential drug interactions, which is why you need a doctor to prescribe this stuff. All of these drugs are available in less-expensive generic forms.

1. Cipro: The big gun for serious bacterial infections
2. Doxycycline: a less expensive, less hardcore drug for bacterial infections, or for use in combination with other drugs for amoebic infections
3. Erythromycin: used for respiratory and streptococcal infections
4. Flagyl (metronidazole) for anaerobic bacterial, and certain parasitic infections
5. Gentomycin: an antibiotic eye ointment for stys, conjunctivitis, or other infections
6. Bonus round for women: Bactrim (for UTI’s, but also useful for GI infections), and Diflucan or Terazol (for yeast infections). If you’re traveling in the tropics or are withholding water consumption due to logistics (say, a 15-hour trip on a bus that has no toilet), you’ll be glad you have these on you. Trust me.

[Photo credit: Flickr user DawnVGilmorePhotography]

TSA workers at Logan Airport treated for scabies

I feel for those three TSA workers who were found to have scabies. I just read about them in this article at WBZ. Each of them worked during the same shift at the same check point at Logan Airport in Boston.

It is not clear how they got scabies. TSA officials have said that because the TSA workers wear gloves, the public has nothing to worry about. The workers are on medical leave until they have been told by a doctor that it’s okay for them to return to work.

To prevent the spread of scabies to the rest of the TSA workers at Logan, all of them were told to take all their clothes and uniforms home to wash them. The areas at the airport that could have been infected were also thoroughly cleaned.

Here’s a health refresher course. Scabies is caused by a microscopic scabies parasite that burrows under the skin, creating a blister that gets patchy, red and itches something fierce. It’s kind of gross really. I’ve had it. Like the TSA folks, I have no idea how I got it, but one day, there was a small patch of it above my upper lip when I was living in The Gambia. A friend of mine who was ONLY A FRIEND had a case much worse than I did under his beard. It must have been going around. In The Gambia, I seem to remember it being much more common during the dry season.

Scabies can be caught by: scratching, picking up mites under fingernails, touching another person’s skin, and touching anything that might be infected with mites because someone with scabies touched them. Think keyboards, toilets, clothes, towels, workout equipment etc. Luckily mites don’t live off of a body for longer than 72 hours. [Wikipedia]

Scabies is curable through the use of a prescription topical cream. It didn’t take me long to be as right as rain again.