The Role of Primary Care Medicine in Travel

1
The Role of Primary Care Medicine in Travel

• Presented By
• Tod Sylvara, D.O.

2
The Role of Primary Care Medicinein Travel

• Primary care physicians are often questioned
  about pre-travel planning.
• Unfortunately post-travel problems that could
  have been easily avoided often must be addresses.
• Travel medicine is basically preventive medicine.

3
Prior Planning

• Prior planning is the absolute key to prevention,
  for safe travel and adventure!

4
Pre-Travel Planning

• The first part of pre-travel planning is an
  evaluation of individual health issues such as
  chronic conditions, medical history, and level of
  physical fitness.

• Travel destination is the next consideration,
  along with activities or adventures to be
  undertaken.

5
Pre-Travel Vaccinations

• Pre-travel vaccinations and prophylactic
  medication recommendations for specific travel
  destinations can be found on-line at
  www.cdc.gov/travel or the Global Infectious
  Disease and Epidemiology Network
  (www.gideononline.com)

• Pre-travel vaccinations and prophylactic
  medication recommendations for specific travel
  destinations can be found on-line at
  www.cdc.gov/travel or the Global Infectious
  Disease and Epidemiology Network
  (www.gideononline.com)

6
Pre-Travel Vaccinations Continued

• Travel clinics also offer services ranging from
  medical recommendations for specific travel
  destinations, travel warnings from the Department
  of State, treatment options, and often they have
  recommended oral, and injectable medications on
  hand.
• I personally have used the Travel Connections
  Clinic in Columbia, Missouri and have been
  pleased with the services provided.

7
Protective Gear and Clothing

• After evaluating your travel destination and
  adventures to be undertaken, you must carefully
  choose your clothing and footwear.

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Protective gear and Clothing

• Gortex outer-shell cuts wind and rain.
• Clothing that can be layered is a good idea.
• Wide brimmed hats and sturdy broken in footwear
  are also good ideas.
• Blisters on the first day of a once in a lifetime
  safari can be disastrous!
• Good quality wrap around sunglasses also serve as
  eye protection.

9
Protective gear and Clothing

• Long sleeves and pants along with keeping your
  head covered provide protection from the sun and
  insects.
• Leather gloves, sturdy kneepads, gators and snake
  boots are a good idea for some of my favorite
  adventures.

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Protective gear and Clothing

• I have found that using DEET containing spray and
  lotion, along with sunscreen spray and lotion
  work as a good combination.
• You want to use sunscreen that is a minimum of
  SPF 50-75, with frequent re-applications.
• Mosquito netting may also be a good idea!

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Protective gear and Clothing

• Make sure to bring along bags that seal closed,
  such as zipper bags, to pack your clothing and
  shoes in.
• These aid in keeping unwanted guests such as
  scorpions, reptiles, mosquitoes, and other
  potentially harmful bugs out of your belongings.
• You will also want to include a backpack, hand
  sanitizer, and last but not least toilet paper!

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Protective gear and Clothing

• You may consider safety straps and D rings if
  plans include hiking or mountain climbing.
• Diving equipment is another thing to consider
  packing.

13
Food Precautions

• Water purification with micro-filters are great
  for very remote areas.
• If boiled water is not available, water should be
  boiled, or chemically decontaminated.
• Any other drinks should be consumed directly from
  can or bottle without ice.

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Food Precautions

• Consume only foods that have been cooked or
  peeled.
• Eat only in establishments that are known to
  cater to foreigners or that are known by other
  foreigners to be safe.

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Food Precautions

• Do not eat from street vendors or market stalls
• Avoid buffets
• Eat well-cooked foods that are served steaming
  hot
• Avoid leafy, uncooked vegetables and salads

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Food Precautions

• Limit consumption of fruits, nuts and vegetables
  to those having thick skins, peels or shells that
  travelers can remove themselves before eating.
• Do not consume cold sauces, such as mayonnaise,
  salad dressing and salsas, which usually are raw
  and prepared by hand.

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Food Precautions

• Do not eat carnivorous fish, such as barracuda,
  red snapper, grouper, or eel, because they may
  contain concentrated toxins.
• Do not drink tap water or rinse a toothbrush in
  tap water.
• Do not assume water to be safe because it is
  chlorinated.
• Do not shower with an open mouth.
• Do not drink from cans or bottles because the
  water on them may be contaminated.
• Wipe cans and bottles dry before opening them.

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Food Precautions

• Do not use ice cubes
• Freezing does not kill microorganisms
• Use water that is sealed and bottled, chemically
  treated, filtered, or boiledfor brushing ones
  teeth, as well as drinking.
• Do not drink fruit juice unless it comes directly
  from a sealed container. It may have been diluted
  with tap water.

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Food Precautions

• Drink hot beverages made with boiled water, such
  as tea and manually brewed coffee.
• Water boiled one minute is safer to drink.
• Drink canned, boxed or commercially bottled
  carbonated water and drinks
• Internationally known brands are the safest.

20
Food Precautions

• Parasites associated with swimming are common
  throughout the world, in general fresh
  non-chlorine water should be avoided.
• Always wear protective footwear and avoid direct
  contact with the ground.
• Ground dwelling parasites exist in many places.

21
Travel Hazards

• Driving in a foreign country has inherent risks.
• Not only physically, but legally as well.

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Travel Hazards

• Unfamiliar rules of the road, poor road
  conditions, and who knows what and who you will
  be sharing the road with.
• Overall, I think it is safer to hire professional
  drivers than renting a car and driving yourself.

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Travel Hazards

• When traveling in remote areas, consider risks
  and benefits of driving versus flying.

• Potential Problems
• Aircraft maintenance
• remote dirt airstrips
• reliable fuel supplies
• properly trained pilots
• Weather
• Navigation
• road hazards
• poor roads
• Bridges
• Rockslides
• Roadblocks
• Shakedowns
• Poachers
• Bandits

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Travel Hazards

• What ever your mode of transportation you choose,
  use all safety equipment belts, helmets, PFDs,
  mark the exits, pay attention to your
  surroundings and location!

25
Personal Safety

• Proper mental preparation and attitude, plan and
  think ahead, anticipate potential problems and be
  forward thinking.
• Be aware of your surroundings and what is going
  on around you and pay close attention to detail.

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Personal Safety

• Pay attention to your gut feeling or vibes.
• Avoid potential human conflict, political
  rallies, demonstrations, some religious and
  sporting events is recommended.

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Personal Safety

• If something does not seem right, it very well
  may not be.
• Watch out for your travel partners, and choose
  travel partners carefully.
• Good judgment, stable, flexible, a good team
  player, with an optimistic can do attitude
  makes for a good world traveler.
• Whiners, weenies, wimps, wusses, complainers
  loose cannons, and the easily irritated need not
  apply.

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Personal Safety

• Another recommendation is to avoid wearing
  expensive or expensive looking jewelry.
• Another thing to avoid is any type of military
  style clothing.
• The idea behind this to try to blend as best you
  can, and not to draw any unwanted attention to
  yourself or your traveling companions.

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Medical Bag

• Try to evaluate the potential risks of activities
  and locations you are going to travel to.

• Use that to guide you in the stocking of your
  medical bag.

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Medical Bag

• I have a list of the contents of the bag that I
  usually carry.
• I also plainly state what the medicine is used
  for and how often to use it.
• I know what the medicine is for and how it is
  used, but I do that incase somebody else needs to
  use it, or I am incapacitated.

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Medical Bag

• Having a license to practice medicine in the
  United States does not infer the same as in other
  countries.
• I would be extremely cautious about treating
  other people in a foreign country.

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Medical Bag

• Sometimes while in remote areas, medical help is
  not available and it might be necessary to treat
  others around you, but I would use caution.
• I personally have found that military style
  cravats, and bandages have multiple functions.

33
Hi-Jack Situations

• These type of situations are rare, but
  unfortunately do occur. If you were to find
  yourself in this situation you need to decide
  immediately one of two courses
• Whether you are to comply with all the demands of
  the hostage takers OR
• Look for opportunities to escape or take evasive
  measures

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Hi-Jack Situations

• Most people that successfully escape these type
  of situations do so early on in the encounter.
• As a general rule, the longer it goes on the less
  your chance of escape.

35
Specific Pathogens

• Malaria- first and foremost avoid being bitten,
  mosquitoes transmit malaria along with other
  dangerous pathogens.
• Use protective gear long sleeves, hats, pants,
  mosquito netting, burn anti-bug coils as well as
  ultrasonic bug devices and repellant containing
  DEET.

• If possible avoid being outdoors at dawn, dusk,
  swamps and rainy seasons.

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Malaria Continued

• Malaria is an epidemic throughout much of Africa,
  Asia, and the Middle East as well as Central and
  South America.
• Transmitted by the Amopheles Mosquito, malaria is
  caused by four species of protozoa Plasmodium
  Falciparum, Plasmodium Malariae, Plasmodium
  Ovale, and Plasmodium Vivax.
• Chemoprophylatic resistance exists in some areas.
• Before choosing an agent, check the CDC website
  for resistance in your specific location.
• Mefloquine, Doxycycline, Arovaquonel, and
  Proguanil are better than the other agents, but
  they are more expensive.

37
Specific Pathogens

• Dengue Fever aka Break-Bone Fever is a viral
  infection spread by the female aedes mosquito in
  tropical and subtropical areas, often during the
  rainy season.

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Dengue Fever

• Dengue Fever is very serious and no vaccine is
  available.
• Again the best treatment is prevention!
• Use the above mentioned strategies to avoid being
  bitten.
• Symptoms of Dengue Fever include headaches,
  rashes on lower limbs and chest, a high and
  sometimes hemorrhagic fever, dehydration, and
  hypotension.
• Supportive and symptomatic treatment of fluids
  and acetaminophen.

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Specific Pathogens

• Schistosomiasis prevalent in sub-Saharan
  Africa, Asia and South America, a parasitic
  disease caused by schistosoma flatworm and
  transmitted by freshwater snails.

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Schistosomiasis

• Larvae penetrate unbroken skin, known as
  swimmers itch from fresh non-chlorinated water.
• Symptoms include muscle pain, weight loss,
  diarrhea, nausea, and coughing.
• Can lead to diseases of the bladder, kidneys,
  lungs, and intestinal tract.
• The anti-helmintic Praziquantel is the treatment
  and no vaccine is available

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Med Jet Assist

• Medical evacuation is crucial in a real
  emergency.

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Med Jet Assist

• I have bought the med jet service several times.
• Thankfully, I have never had to use this service
  for myself, although I have spoken to several who
  have.
• I think its very cheap insurance and a real
  bargain when you consider what it costs to
  transport a sick and injured person half way
  around the world.
• One also must keep in mind that commercial
  airlines will not transport sick and injured
  people for multiple reasons.

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Benefits of Med Jet Assist

• Benefits for med jet assist members
• Air medical transport from home hospital to
  specialty hospitals throughout the U.S.
• Transportation of mortal remains (domestic and
  international)
• World-wide medical and legal referrals
• Monitor medical condition and emergency message
  relay
• Translation assistance for foreign medical
  reports
• Pre-travel medical consultations

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Benefits of Med Jet Assist

• Additional Benefits for med jet assist members
• Travel intelligence and security briefs
• They will also evacuate you for injury or
  illness, as long as you are in a hospital and
  require hospitalization upon reaching your
  destination.
• They leave you in control to decide where you
  want to go for medical treatment
• They guarantee transports in the U.S. as well as
  internationally so long as you are more than 150
  miles from home and meet the criteria, you
  qualify for transport
• Med jet assist also has no limits on
  transportation costs
• For more information visit www.medjetassist.com

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Med Jet Assist

• I feel that med jet is worth it, if for nothing
  other than a piece of mind knowing that if youre
  far from home, sick and injured that you will be
  able to get home

• The cost can be absolutely astronomical.

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Med Jet Assist

• Two years ago a man was injured, while leopard
  hunting in Zimbabwe and did not have the med jet
  service. It cost him in excess of 140,000 to
  get him home.
• Often times, it is not even a case of how much it
  will cost, but that it would be impossible to
  make arrangements to get a sick or injured person
  from remote areas with little or no
  infrastructure or roads, with no commercial
  flights available.

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Med Jet Assist

• There are some other companies who are starting
  to do similar air evacuation services to med jut
  and I believe some may even have more in-depth
  medical treatment while enroot.

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Med Jet Assist

• If you are sick or injured and trying to get home
  on a commercial flight, do your best not to
  appear sick or injured. If the staff at the
  airport suspects that you are sick, they will
  question you and may not allow you to fly.
• So if you think that you can make it without
  assistance even though you are sick, I would try
  to keep a stiff upper lip and go on.

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Med Jet Assist

• If this is the case try to keep whatever
  medicines that you have available.
• You should keep the medicines being used on the
  person using them and not in your luggage.

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Field Transport and Stabilization

• You should come up with a tentative plan in case
  something bad does happen.
• In the field, where would you initially seek
  help? How would you get there and how would you
  communicate with the field evacuation team?

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Satellite Phone

• I always carry a satellite phone, which works
  anyplace in the world. I take it in the field
  with me.
• It is absolutely amazing equipment that is
  relatively inexpensive (1200-1500).
• The minutes are not that expensive and like I
  said it works anywhere in the world.

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Field Transport and Stabilization

• Heaven forbid something happens, but if it does
  we can notify air evac and other resources
  immediately and that is the key.
• I also carry a global positioning system GPS so
  we know exactly where we are so we can give our
  location at anyone who may be responding to help
  us.
• We must also consider the risk and benefits of
  receiving any treatment in remote areas.
• One must consider how safe it would be to receive
  certain types of care in third world countries.
• Also consider immediate treatment vs. evacuation

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Field Transport and Stabilization

• Pre-hospital care and transport to more
  definitive care should use basic ABCs and basic
  pre-hospital EMT techniques as far as C-spine
  immobilization stopping hemorrhage. The ABCs
  using what is available to bandage and stabilize
  in the field is important.

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Field Transport and Stabilization

• Keeping the patient out of immediate danger and
  preventing other threats is important.
• Good pre-hospital treatment should be done in
  concert with making arrangements or more
  definitive care, and this is where the SAT phone
  and air med jet are crucial.

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Field Transport and Stabilization

• If you are not familiar with basic pre-hospital
  care and army medic field manual, special forces
  medic manual, or basic EMT or paramedic manuals
  may be helpful to review before going to very
  remote areas where help is not available and you
  will be more or les on your own.

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Field Transport and Stabilization

• But throughout this process, keeping a calm head,
  identifying your objectives, and doing what needs
  to be done by any means to complete this is
  important.
• Hopefully, due to prior planning and the above
  mentioned strategies, a situation that requires a
  response can be avoided.

58
Field Transport and Stabilization

• This is not always the case and having
  contingency plans already in place is important.

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Closing

• I am sure you will find that your experiences
  abroad will charge your batteries as well as
  enrich your life.
• Having an outlet makes other parts of my life
  more enjoyable.
• It makes my daily line of work and other
  responsibilities a little easier to bear, knowing
  that around the corner I have plans made for
  another action adventure!