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

Knocked up abroad: pregnant travel in the first trimester

pregnant travelFor more on pregnant travel, see parts 1 and 2 of Knocked up abroad: pregnancy in a foreign country here and here.

There’s no question that having a baby changes you: your body, your lifestyle, even your shoe size. One thing I hoped not to change altogether was traveling, as long as it was reasonably safe and comfortable for me and the baby. From the beginning of my pregnancy in Istanbul, my doctor has okayed travel, as long as I get up to stretch frequently on flights and try not to overdo it. Most doctors (and mothers) agree that the second trimester is the most comfortable time for pregnant travel but the first trimester can be a good time as well (while you can still squeeze into pre-maternity clothes and walk without waddling) with a little extra precaution and a little more babying (of the mother, of course).


The first trimester of pregnancy is a tricky time for many women: the risk of miscarriage is highest up to 10 weeks, morning sickness is common, and hormones are running wild. It’s too early to tell anyone outside family or close friends and without a visible belly, it’s impossible for strangers to tell as well. At later points in your pregnancy, a baby bump acts as the international symbol for pregnancy and can make it much easier to express your condition when traveling abroad. If you travel in the early months before showing, you may want to learn the local language words for “I’m pregnant” to avoid a Bridget Jones-esque “mit kinder” scene if you need extra help while traveling.


Over this past December, my husband and I were looking for a good trip to take over the holidays, when I was around 10 weeks pregnant. Our location in Istanbul changes the list of short-haul destinations considerably from what we would have considered from New York, and we debated between a warm-weather beach destination (husband) or a snowy and “Christmassy” European city (me). We ruled out Egypt (not warm enough and not Christmassy), New Zealand (even less convenient to get to than from New York), and Sri Lanka (not enough time to plan properly and some risks of disease I couldn’t be vaccinated against). In the end, we chose…Russia.
Going to Russia in winter while pregnant may seem crazy to some, but for me it made sense: Moscow and St. Petersburg are a few hours from Istanbul by direct flight, my husband speaks fluent Russian in case of any problems, and there was no risk of malaria or eating any food that had spoiled in the sun. While it was cold and snowing during our trip and I couldn’t take advantage of some of Russia’s cold-weather remedies like vodka and saunas, a week in Moscow and St. Petersburg was a perfect mix of exotic and comfortable.

Nearly every cafe had a variety of non-alcoholic and caffeine-free beverages for me to choose from, I even had non-alcoholic sangria, mojitos, and mulled wine in addition to fresh juices and herbal teas. Both cities are beautiful to explore in the snow, with plenty of museums and cafes to warm up in, and the New Year holiday displays made it festive.

If you are planning a trip to a foreign country while pregnant, it makes sense to keep in mind the following guidelines. Always discuss plans with your doctor before booking and err on the side of caution when choosing a destination.

Check airline restrictions – Most airlines allow pregnant women to fly internationally up to 28 weeks, after which you must provide a doctor’s note issued within a week or so of departure. 35 weeks (earlier for women carrying multiples) is the cutoff for nearly all airlines to prevent women from giving birth on board. Most US domestic carriers will allow pregnant women to fly up to the final month; hilariously, Continental will not let women board if “physical signs of labor are present” though they don’t specify what.

Consider travel insurance – If your medical insurance doesn’t cover you overseas, you may want to look into supplementary medical travel insurance, but be sure it covers pregnancy as many policies do not. Additionally, if you are traveling to a country where English is not spoken, you may want to research the name of a clinic or doctor in case of emergency as well.

Be prepared for jet lag – Before pregnancy, I had little issues with jet lag, trying to get on local time as soon as possible. I discovered when flying back from the US to Turkey that it hits you much harder as a pregnant traveler, especially as you can’t use sleeping pills or alcohol to help you sleep. Factor this into your schedule and give yourself plenty of time to acclimate and adjust to time changes.

Realize your limits have changed – On a usual trip, I’d be up early to walk around a city all day, have a late lunch (or maybe just a big afternoon beer) followed by more museums and exploration, and still be up for checking out the local nightlife. Once pregnant, I required more sleep and three solid meals a day (plus maybe some snacks, I am eating for two!), tired after walking short distances, and was ready to call it a night long before last call. If you have an itinerary, pare it down to the must-sees and double the time to see everything; better to take it easy and enjoy your trip than feel exhausted and sick.

Look for destinations that don’t require vaccinations – One of the first tests your doctor will give you after confirming pregnancy will be for immunizations to hepatitis and rubella. If you haven’t had the vaccines, they will have to wait until after the baby is born as they are not safe for pregnant women. I have not had the hepatitis vaccine yet, and thus have a greater risk of contracting it, which rules out much of Africa and southeast Asia for travel, but also means I must avoid raw vegetables including salad in Istanbul. Most other medications and vaccines commonly given to travelers before going to an area prone to Malaria, Typhoid or Yellow Fever are not advised for pregnant women. But there’s still a big world out there, check the CDC for destination-specific information.

Be extra aware of food and water safety – Pregnant women are more susceptible to food poisoning the average person, as the immune system is suppressed so it doesn’t reject the fetus. This is the reason most pregnant women are told to avoid sushi and food that is not prepared in sanitized conditions. Even adventurous eaters should play it safe while pregnant and drink bottled water when in doubt. I recently had an opportunity to visit Mumbai, India but after consulting with a few friends who had lived there, I worried I’d spend the trip inside my hotel room eating pre-packaged food. Again,

check the CDC and use the same common sense you’d use anytime while traveling: stick with food that is freshly prepared in restaurants full of people.


Stay tuned for more on pregnancy travel, including Turkish superstitions and customs, travelling in the second trimester, where to do pre-baby shopping, and more on having a baby in a foreign country. Check here for further updates.

[Photo courtesy Mike Barish from the Istanbul tram]

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]

Ten reasons I thought I had malaria symptoms (but I didn’t)

Malaria SymptomsSometimes, fear of the worst gets the best of you. That’s what happened to me last week when, having recently traveled to Zambia, I thought I had malaria symptoms. Am I crazy? No. Am I usually a hypochondriac? Not at all — but that’s partially due to the fact that I almost never get sick. As a matter of fact, that’s the issue behind #3.

Ten reasons I thought I had malaria symptoms (but I didn’t)

1. I had been in Zambia.

Pre traveling to Zambia, I went to the doctor to get shots for Hepatitis A and Typhoid (that one hurts like a jerkstore), as well as prescriptions for Cipro and Malarone — a malaria prevention medication. Every travel document I received warned me and rewarned me that I was visiting a “malaria zone,” and I definitely came home with a fair few mosquito bites.

2. I missed a pill. Maybe more.

You have to start taking Malarone a couple days in advance of travel, then take one at the same time every day until seven days after you get back. The pill, like most pills, is not 100 percent effective even if you get it right, but I didn’t get it right. One night, I forgot to take my pill until after dinner (I’d been taking it at 6 and took it at 10), and after I got back, I completely forgot to take one on a Saturday. I read my instructions and they said to just skip it and take the next one at my normal time.

And what? And pray?

3. I got a cold.

Most people wouldn’t think twice about getting a cold, but I am one of those lucky folks who almost never (knock on wood) gets sick. When I developed a fuzzy head and a cough about ten days after getting back, I couldn’t help but think, just in the back of my mind: “Do I have malaria?”

4. I Googled.

As anyone with a computer would, I googled the symptoms for malaria. Our friends at WebMD (I know) informed me that the incubation period could be anywhere from nine days to ten months. Great. Symptoms:

  • Fever.
  • Chills.
  • Headache.
  • Sweats.
  • Fatigue.
  • Nausea and vomiting.
  • Dry (nonproductive) cough.
  • Muscle and/or back pain.
  • Enlarged spleen.

I wasn’t vomiting, didn’t know where my spleen was and hadn’t taken my temperature, but the rest was definitely going on. An even less heartening statement followed: “Symptoms may appear in cycles and may come and go at different intensities and for different lengths of time. But, especially at the beginning of the illness, the symptoms may not follow this typical pattern.”

Great.

5. I slept a ton.

I’m a good sleeper and all, but even after my cold symptoms started to diminish, I was suddenly sleeping like 10 hours per night, and feeling sleepy during the day. Does this happen to everyone now and then? Yes. But it was happening to me, Potential Malaria Victim Annie.

7. I felt “different.”

Perhaps it was psychosomatic, but I couldn’t help feeling that something was wrong. I was probably just still getting over the cold (and coping with the side effects of Nyquil), but I didn’t feel “normal.” I was sleepy, as I mentioned, and woozy and had no energy. This continued until a week after the cold hit. I wasn’t even getting as much work done as I should have been. At this point, I wasn’t sure I had malaria symptoms, but I was keeping an eye on it.

6. I had sudden, outrageous bathroom hell.

I’d been feeling nauseous all day. It had been my husband’s birthday the night before, so I attributed it to being out late, but suddenly, at 3:30 PM on a Tuesday afternoon, I was in the bathroom vomiting. It happened once, then again, and I still wasn’t feeling better. I sent an email cancelling my plans for the night, then was back in the bathroom. By an hour later, I had called my husband at work, sobbing and begging him to come home for fear I was going to pass out and choke on my own vomit. I was really sick. And, as the vomiting had finally come, I was pretty sure I had malaria.

8. I couldn’t move.

Unlike with the flu, during which you get a few minutes of glorious “I feel okay” time after you throw up, I was completely incapacitated. I spent twenty minutes just sitting on the bathroom floor with my cat looking at me pensively. When I finally made it into bed, the phone rang and I couldn’t look to see who it was, because even turning on my side made me dizzy and out of breath. I was obviously suffering from a violent strain of malaria, and probably near death. I lay paralyzed, worrying about my spleen.

9. I had a fever.

My husband came home terrified and immediately gauged that I had a fever (and kindly brought me Cheerios and a bucket). That was it. The final nail in my coffin. Even if I got better, I would have this strain of malaria for the rest of my life, however short that might be.

10. I’m an idiot.

My husband said “I’ve never seen you this sick!” … and that triggered me to think of the last time I’d been so sick. I couldn’t think of any instance, any precedent at all until … oh wait … that time I got food poisoning in London and threw up the second I got to Glasgow for about 18 hours straight. As I ate Cheerios one by one, about an hour later, my fever was gone. Shortly after that, I was eating Cheerios by handfuls.

At last, a far less dizzy me ventured into the restroom and had bathroom hell … the other way. I stepped out concerned that though I felt a little better, I was clearly still sick. My husband smiled and said “Honey, I think you’re in the final stages of food poisoning.”

Oh.

Whoops.

So, after a harrowing food poisoning experience and a completely harmless cold, about two days later, I felt completely fine — and I have felt fine ever since. I write this not just to overshare, but to confess, and to assure you that if you’ve ever convinced yourself you have a possibly fatal disease after traveling, you’re not crazy.

Or, you know, we’re both crazy.

[Photo by James Jordan via Flickr.]

Genetically-engineered mosquitoes may help end malaria

Tropical travelers rejoice: researchers are getting closer to finding a possible vaccine for malaria, using genetically-engineered mosquitoes.

The Anopheles stephensi species is one of the main spreaders of human malaria. By altering its salivary glands, the mosquito acts as a “flying vaccinator,” carrying the Leishmania vaccine within its saliva. About 60 species of the Anopheles are vectors of the malaria parasite, which are transmitted to humans when the female feeds on blood.

Tests showed that when an altered mosquito bit its host — in this case laboratory mice — it became a transmitter of the vaccine. The bites succeeded in raising antibodies in the mice, indicating successful immunization with the vaccine.

It’s hoped that continuous exposure to bites will maintain high levels of protective immunity, through natural boosting, for a lifetime.

Researchers hope the vaccinator mosquitoes could be used to formulate a new strategy in the global fight against malaria. Every year about 250 million people are infected with malaria, and nearly one million die, according to the World Health Organization. In Africa, one in every five childhood deaths is caused by malaria.

There are, however, barriers to using this form of vaccination in the wild, including issues of controlling dosage, “medical safety issues” and the “issues of public acceptance to [the] release of transgenic mosquitoes.” It may not be as romantic as sundowners of gin and tonic (quinine is an old school anti-malarial), but it sure beats the potential side effects of Lariam.