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Chapter 9 Travel for Work & Other Reasons

Adventure Travel

Christopher Van Tilburg

Adventure travel is unique because of the challenging terrain, extreme weather, remote locales, and long durations involved. Popular destinations include trekking to Everest Base Camp, climbing Mount Kilimanjaro, hiking the Inca Trail, sailing the South Pacific, touring the Galapagos, and exploring the North and South poles. Adventure travel often includes mountaineering, backpacking, cycling, skiing, diving, surfing, and river rafting. Travelers may be working, providing humanitarian relief, or completing scientific research; they may be part of expeditions climbing mountains or driving overland.

Risk of injury and illness associated with adventure travel is increased significantly compared to other types of travel for several reasons:

  • Destinations may be remote and lack access to care.
  • Communication is often limited.
  • Weather, climate, and terrain can be extreme.
  • Travelers exert themselves physically, increasing caloric, fluid, and sleep requirements.
  • Trips are often long, lasting: several weeks, months, or years.
  • Trips are often goal oriented, which can cause travelers to exceed safety limits and take increased risk.

Risk usually involves 2 components: probability and consequence. The probability of a mishap occurring is based on frequency, duration, and severity of exposure to hazards. Hazards are categorized as objective—omnipresent natural hazards like weather and terrain—and subjective—human-controlled hazards like lack of sleep, poor nutrition, and dehydration. All 3 components of probability (frequency, duration, and severity) are increased in adventure travel.

The second component of risk, consequence, is the outcome of an accident. Consequence of an accident or illness is nearly always greater in adventure travel with increased distance to help and austere conditions. Therefore, travelers should know that even if the probability of a mishap is low, the consequence is almost always increased. Even a minor injury or illness in the wrong setting can be disastrous.

In addition, major accidents are rarely due to a single event; usually multiple events occur in sequence preceding an accident. Travelers should have heightened awareness of the probability and consequence of risk and try to make good decisions before they get into trouble.

PRETRAVEL CONSIDERATIONS

In addition to routine travel medicine advice, providers should gather extra information and discuss precautions for wilderness and expedi­tion travel.

Trip Type

Obtain details about the type, length, and remoteness of the trip. Guided trips may eliminate some of the need for complex logistics planning on the part of the traveler. However, participants in guided trips should ask key questions of the trip organizers including:

  • Guide experience and medical training.
  • Type of medical kit and safety equipment carried by guides.
  • Contingency plan for emergencies.
  • Recommended medications and medical supplies to be carried by participants.
  • Type of insurance recommended.

In a few cases, such as polar cruises and Mount Everest expeditions, a formal medical officer with a comprehensive medical kit may be available. For self-planned trips, the travel medicine practitioner may need to augment a comprehensive medical kit with prescription medication and offer more support with logistics, evacuation planning, and insurance.

Confirm if the skill level of the participant matches the trip type. Beginners in an activity such as diving, mountaineering, skiing, or sailing should participate in instructional trips. Those with less experience or visiting a location for the first time should be encouraged to go on a guided trip. Since most people will consult a travel medicine professional only after they have selected and paid for their adventure, they may need assistance in changing the trip to be more in line with their skill and experience.

Personal Health Requirements

Adequate nutrition, hydration, and sleep may be in short supply, especially with increased demand because of weather, terrain, and exertion. Travelers should pay attention during the planning stages to how food and water will be obtained on the journey.

Screen travelers for conditions that can be exacerbated by high altitude, extreme heat, extreme cold, exertion, and other environmental hazards. These include diabetes, asthma, any cardiac disease, chronic pain treated with opiates, recent surgery, anaphylaxis-level allergy, oxygen-dependent emphysema, joint replacement, and sleep apnea. Caution travelers who have battery-operated devices, such as a continuous positive airway pressure machine or an insulin pump, about device failure, and discuss the need for a backup plan. A past history of environmental illness—altitude illness, hypothermia, frostbite, heat exhaustion, or anaphylaxis—likely puts one at increased risk for recurrence.

Travelers with chronic or major medical issues should carry a medication list, a copy of their most recent ECG and chest x-ray, and their medical history on their phone in PDF or JPG format.

Medical clearance for participation may be required for a guided trip. The traveler’s primary care provider should complete medical clearance for those with chronic disease. Travel health practitioners can complete pretravel medical clearance if it is a usual function of their practice and the patient has no chronic disease or medications. If possible, travelers should get medications for chronic illness from their primary care provider.

Money and Insurance

Rescue, evacuation, and repatriation may require upfront payment, especially with aeromedical transport from remote locations. Travelers should bring sufficient emergency cash and a credit card with high credit and cash advance limits.

Insurance is widely variable and comes in many forms, but insurance does not guarantee rescue (see Chapter 6, Travel Insurance, Travel Health Insurance & Medical Evacuation Insurance). Coverage may be contingent on preexisting conditions, deductibles, maximum expenditures, and medical control approval. Insurers may also not authorize aeromedical transport. Insurance companies may deny claims involving chronic illness, drugs, alcohol, pregnancy, mental health, and acts of war or civil unrest. Travelers should read policies carefully before purchasing and departing on their trip.

Types of insurance include:

  • Domestic health insurance, which may or may not be effective outside a home country. Often, travelers need to pay up front for medical care and get reimbursed from health insurance once they return home.
  • Travel insurance, which often includes medical, trip cancellation, evacuation, and repatriation benefits, but may exclude coverage for wilderness rescue and adventure sports like mountaineering, skiing, and diving. An adventure sports rider is available with some travel insurance policies.
  • Wilderness rescue insurance (usually separate from travel insurance), such as policies through North American mountaineering clubs, outdoor and professional associations, and scuba dive organizations. Short-term rescue insurance is available in some destination countries, for example, through local helicopter rescue companies, ski resorts, and mountaineering clubs.
  • Comprehensive expedition policies, which can include travel, medical, rescue, security, and repatriation services.

Training

If travelers have time, they should consider completing a first aid and basic life support course (CPR) before departure. This may be particularly helpful for regular adventure travelers. Such courses can be found through local community colleges and fire departments.

Emergency Resources

Before they go, travelers should know emergency escape routes, local rescue resources, embassy contacts, and local medical facilities.

If travel medicine practitioners are willing to accept phone calls, emails, and text messages from travelers abroad, make sure travelers understand this is not a substitute for local emergency care.

Travelers should keep their passport, money, credit card, and other documents on their person at all times, as they may need to seek medical care or evacuate urgently and without their luggage. Backup copies can be stored in PDF or JPG on a phone.

In a travel medicine encounter, physicians may only have a brief moment to educate travelers. Depending on the type, duration, and location of trip, a few key pearls may be worth discussing:

  • Travelers should understand basic wound care, seek help with signs of infection— redness, swelling, pus, and warmth—and be educated on self-treatment with antibiotics.
  • For hypothermia, cessation of shivering and mental status changes are dangerous signs.
  • Frostbite is treated with rapid rewarming, but people with frozen extremities should be careful not to refreeze a thawed extremity (see Chapter 3, Extremes of Temperature).
  • Heat stroke marked by a temperature of 40°C and mental status changes is a medical emergency.
  • Snakes, spiders, scorpions, ticks, and jellyfish can deliver toxic venom, inoculate microbes, and cause anaphylaxis. Region-specific antivenoms may be found around the world for certain venomous snakes, spiders, scorpions, and jellyfish.
  • Bites, stings, food, and other allergens can all cause anaphylaxis. Treatment with epinephrine and corticosteroids can be lifesaving if administered immediately.
  • Travel to high altitude may require acetazolamide, dexamethasone, and other medications to prevent or treat altitude illness. Mental status changes and ataxia are ominous signs of high-altitude cerebral edema. Breathlessness at rest is the sign of life-threatening high-altitude pulmonary edema.

WILDERNESS SUPPLIES

Travelers should pack and keep basic emergency supplies and equipment with them at all times.

Communication and Route Finding

Travelers should carry a cell phone enabled with global positioning system (GPS), such as a smart phone. Phones can be used to store documents, including plane tickets, embassy and hospital contact information, insurance, passport copies, and medical data in email, JPG, or PDF format. Importantly, not all North American cell phones and service plans are compatible with international networks. Travelers should check with their cell carrier before departing.

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

Where cell phone service is not available, travelers may consider an unlocked (no frequency restrictions) VHF/UHF radio or a satellite phone. Advise travelers that restrictions exist, and permits are required in many countries regarding use of handheld radios and satellite phones; they should check local restrictions prior to departing.

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

For extreme terrain and remote locations, adventurers should carry and know how to use a GPS unit (or have a GPS app installed on their phone), compass, altimeter, and local topographic map (the latter may need to be acquired in-country).

Clothing

Remind travelers that clothing helps prevent heat and cold illness as well as bites and stings from insects and arthropods.

Cold weather clothing should be 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), 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 and a bandana protect the head and neck. Sunglasses protect eyes. Clothing should be sprayed with permethrin to ward off insects and arthropods.

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

Emergency Kits

Adventure travelers often require a comprehensive, yet compact, personal emergency kit for survival, medical care, and equipment repair. In addition to a basic travel health kit (see Chapter 6, Travel Health Kits), travelers should consider packing additional items due to the remote nature of their travel. Standard kits may need to be augmented for specific activities like undersea, open ocean, jungle, polar, and high-elevation travel.

If travelers are on guided trips, they may only need a small personal medical kit. Before they depart, travelers should determine whether guides provide group emergency equipment such as an automatic external defibrillator, a portable stretcher, portable hyperbaric chamber, oxygen, and comprehensive medical kit.

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

Consider prescribing anaphylaxis, antibiotic, and analgesic medications in addition to routine travel medications. Instruct travelers on self-treatment of anaphylaxis, as this can be lifesaving, and provide guidance on self-treatment for gastroenteritis, febrile illness, wound infections, and respiratory illness. Consider opioid and prescription NSAID pain medication, bearing in mind that in some countries, travelers may be restricted from bringing in opioid drugs, even for their own use. In addition, consider prescribing ophthalmologic antibiotics and anesthetic, antiemetic/motion sickness medication, nonsedating antihistamines, and altitude illness medicines.

SAFETY SUPPLIES

Adventure travelers should consider packing additional safety equipment to supplement a travel health kit. These items can help in an emergency situation.

  • Spare phone power pack or solar/dynamo charger
  • Headlight with extra batteries
  • Map, compass, GPS (or GPS app on phone)
  • Perlon cord
  • Emergency sleeping sack or tarp
  • Earplugs and eyeshade
  • Sun hat, bandana, and sunglasses
  • Spare eyeglasses (if required)
  • Duct tape
  • Multi-tool
  • Safety pins
  • Polyurethane straps and plastic cable ties
  • Chemical heat packs
  • Whistle
  • Water purification tablets
  • Sunscreen and lip balm
  • Oral rehydration powder
  • Insect repellent
  • Rain poncho and umbrella
  • Hand sanitizer
  • Toilet paper
  • Antibacterial towelette
  • Sewing kit
  • Laundry detergent

BIBLIOGRAPHY

  1. Iserson KV. Medical planning for extended remote expeditions. Wilderness Environ Med. 2013 Dec;24(4):366–77.
  2. Lipman GS, Eifling KP, Ellis MA, Gaudio FG, Otten EM, Grissom CK. Wilderness Medical Society practice guidelines for the prevention and treatment of heat-related illness: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S55–65.
  3. Lipnick MS, Lewin M. Wilderness preparation, equipment, and medical supplies. In: Auerbach PS, editor. Auerbach’s Wilderness Medicine. 7th ed. Philadelphia: Elsevier; 2017. pp. 2272–305.
  4. McIntosh SE, Opacic M, Freer L, Grissom CK, Auerbach PS, Rodway GW, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of frostbite: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S43–54.
  5. Mellor A, Dodds N, Joshi R, Hall J, Dhillon S, Hollis S, et al. Faculty of Prehospital Care, Royal College of Surgeons Edinburgh guidance for medical provision for wilderness medicine. Extrem Physiol Med. 2015;4:22.
  6. Quinn RH, Wedmore I, Johnson EL, Islas AA, Anglim A, Zafren K, et al. Wilderness Medical Society practice guidelines for basic wound management in the austere environment: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S118–33.
  7. Zafren K, Giesbrecht GG, Danzl DF, Brugger H, Sagalyn EB, Walpoth B, et al. Wilderness Medical Society practice guidelines for the out-of-hospital evaluation and treatment of accidental hypothermia: 2014 update. Wilderness Environ Med. 2014 Dec;25(4 Suppl):S66–85.
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