Author(s): Christopher Van Tilburg

Adventure travel is unique because of challenging terrain, extreme weather, remote locales, and longer durations. Popular adventure travel destinations include trekking to Everest Base Camp, climbing Mount Kilimanjaro, hiking the Inca Trail, sailing the South Pacific, touring the Galápagos, and exploring the North and South Poles. Adventure travel can include activities like backpacking, cycling, diving, mountaineering, river rafting, skiing, and surfing. Adventure travelers could be conducting scientific research, providing humanitarian relief, or climbing mountains or driving overland as part of an expedition.

As compared to other types of travel, risk for illness and injury with adventure travel is much greater for several reasons (see Box 9-11). Risk for travel-associated illness and injury is a function of 2 variables: probability and consequence. The probability of a mishap occurring is based on the frequency (“how often”), duration (“how long”), and severity (“how bad”) of the hazards encountered; during adventure travel, each is increased. Objective hazards include difficult environmental conditions (e.g., terrain, weather). Dehydration, poor nutrition, and insufficient sleep are examples of subjective or human-controlled hazards.

Consequence, the second variable, is a measure of the outcome or result of an illness or injury. In adventure travel, where conditions are often austere and access to definitive care is remote, even if the probability of a mishap occurring is low, the consequences are nearly always magnified. Minor injuries or illnesses happening in the wrong setting can be disastrous.

Major accidents are rarely due to a single event. Multiple events usually occur in sequence preceding an accident. Travelers should be vigilant about the probability and consequence of risk, and try to make good decisions before they get into trouble.

Pretravel Considerations

During the pretravel consultation, in addition to providing routine travel medicine advice, gather extra information and discuss precautions for wilderness and expedition travel. Several excellent wilderness medicine resources exist, including conferences, journals and textbooks, and professional societies (e.g., the Wilderness Medical Society).

Trip Type

When talking with adventure travelers, obtain details about the type, length, and remoteness of the trip. Guided trips could eliminate some of the need for complex logistics planning on the part of the traveler. Even with guided trips, though, participants should still ask trip organizers about guide experience and medical training; types of medical kits and safety equipment carried by guides; contingency plans for emergencies; recommendations for medications and medical supplies to be carried by participants; and types of recommended insurance.

In a few cases (e.g., Mount Everest expeditions, polar cruises), a formal medical officer with a comprehensive medical kit might accompany the participants. By contrast, for self-planned trips, travel health providers might need to offer more support with logistics, insurance, evacuation planning, and to augment a comprehensive medical kit with prescription medications.

Confirm that the experience, fitness, and skill level of the participant matches the trip type. Novices at diving, mountaineering, sailing, or skiing should participate in instructional trips. Encourage people with less experience or who are visiting a location for the first time to go on a guided trip. Because many people will consult a travel medicine professional only after they have selected and paid for their adventure, some might need a medical waiver or letter to change the trip to be more in line with their skill, experience, and fitness.

Personal Health Requirements

Travelers might need medical clearance to participate in a guided trip. For travelers with chronic diseases, the primary care provider (PCP) should complete the medical clearance and provide prescriptions for regular medications, if possible (see Sec. 3, Ch. 3, Travelers with Chronic Illnesses). Travel health practitioners can complete pretravel medical clearance if it is a usual function of their practice, and the patient has no underlying chronic diseases or medications; even so, consider consulting with the traveler’s PCP to help determine medical clearance.

Screen travelers for conditions that can be exacerbated by exertion or environmental hazards (e.g., high elevation, temperature extremes). Ask travelers whether they have a history of anaphylaxis-level allergies, asthma, cardiac disease, cerebrovascular disease (e.g., stroke, transient ischemic attack), chronic pain treated with opiates, deep vein thrombosis, diabetes, oxygen-dependent emphysema, joint replacement, pulmonary embolism, recent surgery, or sleep apnea. Any of these conditions could indicate a traveler is at risk for adverse outcomes under physiological stressful conditions. Travelers with a previous history of environmental illness (e.g., altitude illness, anaphylaxis, frostbite, heat exhaustion, hypothermia) could be at risk for recurrence.

Travelers with chronic or major medical issues should carry a medication list, printed copies of their most recent electrocardiogram, chest x-ray, and their medical history; or download electronic copies to their phone in PDF or JPG format. Caution travelers who rely on battery- operated devices (e.g., continuous positive airway pressure [CPAP] machine, insulin pump) about the possibility of device failure, and discuss the need for a backup plan or the possibility that they should avoid adventure travel altogether. Some people with chronic illness, especially those who are medically dependent on electronic devices, who have difficulty ambulating, and who are medically frail, likely are not good candidates for adventure travel.

Adequate hydration, nutrition, and sleep could be in short supply, especially with increased demands due to exertion, weather, and terrain. During the planning stages, travelers should pay attention to how they will obtain water, food, and rest on their journey.

Travel Insurance

Insurance is widely variable and comes in many forms, and having insurance does not guarantee rescue (see Sec. 6, Ch. 1, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance). Travelers might need to pay in advance for rescue, evacuation, and repatriation, which can be expensive, especially for aeromedical transport from remote locations. Travelers should bring sufficient emergency cash and a credit card with high credit and cash advance limits.

Coverage can be contingent on preexisting conditions, deductibles, maximum expenditures, and medical control approval. Insurers also might not authorize aeromedical transport. Insurance companies might deny claims involving alcohol or drugs, chronic illness, mental health, pregnancy, and acts of war or civil unrest. Travelers should read policies carefully before purchasing and departing on their trip.

Domestic Health Insurance

Domestic health insurance might or might not be effective outside a home country. Often, travelers need to pay up front for medical care and get reimbursed from health insurance providers once they return home.

Travel Insurance

Travel insurance, which often includes medical, trip cancellation, evacuation, and repatriation benefits, might exclude coverage for wilderness rescue and adventure sports like diving, mountaineering, and skiing. An adventure sports rider is available with some travel insurance policies.

Wilderness Rescue Insurance

Usually purchased separately from travel insurance, wilderness rescue insurance policies are available through specialty clubs, outdoor and professional associations, and organizations (e.g., the American Alpine Club, Divers Alert Network).

Short-Term Rescue Insurance

Short-term rescue insurance is available in some destination countries through local helicopter rescue companies, mountaineering clubs, and ski resorts. In Switzerland, for example, travelers can become a member of Rega, the aeromedical rescue service.

Comprehensive Expedition Policies

Comprehensive expedition policies can include travel, medical, rescue, repatriation, and security services.

First Aid & Safety Training

If travelers have time, they should consider completing basic life support and first aid courses before departure. These can be particularly helpful for regular adventure travelers. Such courses can be found through local community colleges and fire departments, the American Heart Association, and the American Red Cross.

Emergency Resources

Travelers should always keep their credit cards, money, passport, and other documents on their person because they might need to seek medical care or evacuate urgently without their luggage. Travelers also can store backup copies as a PDF or JPG on a mobile phone.

Before leaving on their adventure, travelers should know embassy contacts, emergency escape routes, local medical facilities, and local rescue resources. Travel medicine practitioners willing to accept emails, phone calls, and text messages from travelers abroad should make sure that travelers understand this is not a substitute for local emergency care (see Sec. 2, Ch. 16, Telemedicine). In a pretravel medicine encounter, physicians might have only a few minutes to educate travelers. Depending on the type, duration, and location of trip, a few key adventure travel health and safety tips (see Box 9-12) might be worth discussing.

Wilderness Supplies

Adventure travelers should pack and carry the following clothing, supplies, and gear.

Clothing

Remind travelers that clothing helps prevent heat and cold illness as well as bites and stings from insects and other arthropods. Cold weather clothing should be made of polyester, nylon, Merino wool, or, in some circumstances, down. Layering typically consists of a base layer, insulating layers of heavy-pile polyester or nylon-encased polyester (down suffices if traveling to a location that is dry and cold, but does not function well when it gets wet), and a windproof, waterproof outer layer of tightly woven nylon with a durable water-repellent coating. Gloves, hat, neck warmer, warm socks, and goggles are vital to cover all exposed skin.

For hot weather, sun- and insect-protective clothing is important, including loose-fitting, lightweight clothing made from nylon, polyester, or a cotton blend. Long-sleeve shirts and long pants offer the most protection. A wide-brim sun hat, a sun shirt with a hood, and a bandana or buff protect the head and neck; sunglasses protect eyes. For more details on protection from sun exposure and extreme temperatures during travel, see the respective chapters in Section 4. Clothing should be sprayed with permethrin to ward off insects and arthropods (see Sec. 4, Ch. 6, Mosquitoes, Ticks & Other Arthropods).

Footwear should be activity-specific boots or shoes, equally important in a marine or mountain environment. Because even a minor foot injury can be debilitating, advise travelers to never go without footwear.

Communication & Route-Finding Equipment

Travelers should carry a mobile phone enabled with a global positioning system (GPS). Phones can be used to store electronic versions of documents (e.g., embassy and hospital contact information, insurance policies, medical data, passport copies, plane tickets) in email, JPG, or PDF format. Because not all North American mobile phones and service plans are compatible with international networks, travelers should check with their local (i.e., domestic) carrier before departing.

Alternatively, an unlocked (not restricted to any carrier) global-compatible mobile phone can be used with a local SIM card in the country of travel. Inexpensive phones and SIM cards are usually available at stores in airports and major cities. In some countries, registration to obtain a local SIM card requires fingerprinting and a passport.

An emergency satellite communication device is an excellent tool to carry. This device can synch with a mobile phone to send routine and emergency messages, usually via text. Where cellular phone service is not available, travelers might consider an unlocked (no frequency restrictions) VHF/UHF radio or a satellite phone. Several countries worldwide require users of handheld radios and satellite phones to have permits, however; advise travelers that restrictions might exist at their destination, and to learn what they are before departing.

Remind travelers that electronics are not foolproof; often they are limited by battery power, deep canyons, dense cloud cover, government restrictions, and physical damage caused by extreme temperatures, impact, or water exposure. A backup external battery and external power source (e.g., a solar or dynamo charger) are useful.

For extreme terrain and remote locations, adventurers should carry a GPS app installed on their mobile phone. Alternatively, they can carry a separate GPS device. Suggest that travelers upload maps to their phones or GPS devices prior to departure. They also might choose to learn how to use and to bring an altimeter, compass, and local topographic map (the latter might need to be acquired in-country).

Emergency Kits

Adventure travelers often require a comprehensive, yet compact, personal emergency kit for medical care and survival and equipment repair. Beyond a basic travel health kit (see Sec. 2, Ch. 10, Travel Health Kits), adventure travelers should consider packing additional items due to the remote nature of their travel. Standard kits might need to be augmented for specific types of travel (e.g., high elevation, jungle, open ocean, polar, undersea).

If travelers are on guided trips, they might only need a small personal medical kit. Before they depart, travelers should determine whether guides provide group emergency equipment (e.g., comprehensive medical kit, automatic external defibrillator, portable hyperbaric chamber and oxygen, portable stretcher). Be cautious if asked to prescribe medications for guides to stock in the expedition medical kit intended for clients. Third-party use of prescription medication is unlawful in most jurisdictions and best left for the guide company medical director. If prescribing to a guide as a patient, clarify that the medication is for the guide’s personal use.

Medications

Provide prescriptions and guidance for self-treatment for febrile illness, gastroenteritis (travelers’ diarrhea), respiratory illness, and wound infections. In addition to routine travel medications (e.g., analgesics, antiemetics, motion sickness medication), consider prescribing ophthalmologic antibiotics and anesthetic, nonsedating antihistamines, and altitude illness medicines. Instruct travelers on self-treatment of anaphylaxis, because this can be lifesaving; epinephrine auto injectors are common, but a less-expensive alternative is a vial of epinephrine and a syringe. Diabetics should carry glucagon and glucose gel for hypoglycemia.

Consider opioid and prescription nonsteroidal anti-inflammatory pain medication, bearing in mind that in some countries, travelers might be restricted from bringing in opioid drugs, even for their own use. A patient on chronic opioids might consider bringing naloxone for emergency reversal of opioid overdose.

Safety Supplies

In addition to items typically included in a general travel health kit, adventure travelers should consider packing safety equipment that can help in an emergency (see Box 9-13).