Thursday, September 23, 2010

1.13 Traveler Stay Well/Medical Problems Abroad/Medical Repatriation.

Physician's Notebooks 1 - - See Homepage

⑬Travel Health - Update 07 July 2020
   These are headings in descending order of appearance. Use search & find or scroll down to each.
     To Travel or Not 
A Vignette of Travel to Chaingmai Thailand
Further About Thailand  
Making Healthier Travel Choices 
Environmental Antigens Causing Illness  
Airport Body Scan X-ray
A surprisingly dangerous travel place
Health Information for International Travel (HIFIT)
New Dengue Fever Vaccine
Medical Advice & Insurance; Emergency Assistance Japan 
National Difference in Healthcare
Jet Flying Risks
Health Problems on Intercontinental Jets
No surgical procedures shortly before flying off on a trip
Specific Illnesses Experienced on Trips
Upper Respiratory, Gastro-Intestinal , Urology, Psychiatric, Allergy & Skin Rash, Head & Face, Heart & Blood Vessel, Joint & Bone, Back & Neck, Accident & Trauma, Rectal, Obsterics & Gynecology, Lung & Bronchial, Neurological, Pediatrics
Special Requests for Hotel Visits
Hi Altitudes
Medical Repatriation
"To Travel or Not to Travel?" question is especially for persons who suddenly come into much money (inheritance) or oldsters who have accumulated too much money in a long life. To answer it, the following formula should be attended to:

Too much money + limited life or poor education = unintelligent travel to bad-for-health places.

If health justifies travel, ask: "Why a trip?" Think of alternative: "Why not Spend summer to write a book or paint or study or to live in a nearby rural area observing natural life?" A trip has risks and the tripper may be an ill-informed monkey see, monkey do. Too many go to Thailand.

A Vignette of Travel to Chiangmai Thailand A young woman, with a 2-year-old child and at the start of 2015 living in New York City, came into a high dollar inheritance. Such an amount of money went to her head, causing her to decide to relocate her family in Chiangmai. Actually, she had little idea about Thailand and especially Chiangmai and was going by an adventurous feeling to "try out" an exotic place. In March she purchased an expensive car, and in June she relocated with family to Chiangmai where they rented a rather spacious house and cheaply got servants. She used the car to drive into the city where she took lessons in the Thai language. The major health problem, which she was not aware of, is that she had relocated to the most air-polluted place on Earth with particulate levels during the early part of each year 7 times above New York City, because of a combination of farm crop burning and fossil fuel burning. And the Chiangmai government has advised all inhabitants against bringing in fossil-fuel burning conveyances but here she and family are, foreigners, ignoring that advice and further polluting their area. For an adult, it will be bad enough but for a 2-year-old child, one can foresee asthma and chronic obstructive pulmonary disease. There are many other problems which include the child's language acquisition, the high crime, kidnapping and accident rate, and the exotic and very dangerous infectious diseases but the lesson to learn here is to always critically review your own or close family member's desire for travel from a good health point of view.  And especially be careful when a large amount of money falls into one's hands.

Further, About Thailand:  The sex tours to Bangkok are stimulated by the natives forced by poverty to sell themselves to tourist with the result of sexually transmitted disease led by HIV/AIDS. (Similarly Brazil, India, African countries, et al. with street crime too) And do not use the rotten reason, “Too late to change mind, I already saved up." Avoid doing a trip just because you have money. You'll do better watching an internet travel video in the inexpensive safety and comfort of home than by risking health on a dumb trip to a place you know nothing about and are not going to learn about on a few expensive tourist-trap days.
   Making Healthier Travel Choices What strikes me, in contemplating the preferences of trippers is how much great beauty, superb sources of Earth knowledge, and healthful bargains of vacation travel near home get missed. Americans, and others too, will enjoy more, stay healthier, get richer and become wiser, touring the cleaner, more interesting areas in the USA, while, in Japan, you can enjoy beautiful historic places without the usual risks of tourism. Don’t be fooled by prices. Visiting Bangkok may be dirt-cheap (Yeah, dirt!), but it costs more in bad health and shortened life.
   If you must do a foreign tour, prefer to go where a local acquaintance can be your guide. Red-marked ‘No Tourism’ should be areas that have malaria or yellow or dengue fever (Flash! Nov. 2015! Dengue fever cases in Hawaii!), spring-summer brain fever and insect-bite encephalitis, cholera, typhoid, typhus, and infectious meningitis.
   Environmental Antigens Causing Illness  Consider possibilities of environment antigen setting off an internal allergy. A 21-year-old developed a severe Rheumatoid Arthritis due to a several-month stay in India that put her in touch with RA-stimulating antigen, or a more delayed effect as in a middle-aged Japanese who developed a disease that destroyed his lungs because he spent time in Brazil where he contracted a parasite his body was not used to.

Airport Body Scan X-ray in the USA: two types.
One is called Back-Scatter Scanner that looks like 2 blue boxes you pass between and stop to get scanned. The scan gives a dose of x-ray that ups the risk for leukemia and other cancers and the risk increases each time you get a fresh scan. The risk is greatest for pregnant women, children, non-pregnant, fertile women, and frequent travelers. If you want to avoid it, just say to the TSA checker, "I want to opt out of the body scan," in a quiet, friendly voice and they will arrange for a body pat down with no harassment.
   The other type scan is called the Millimeter Wave Scanner. It looks like a round glass phone-booth with open ends at entry and exit and you are asked to stop and make a right face and raise your arms above head for the scan. It poses no risk for cancer or any other illness. But you may also opt out with no sweat.

A surprisingly dangerous travel place is Hawaii, especially the island of Maui because of swimming accident. 

The book Health Information for International Travel (HIFIT or the Yellow Book) is a gem (superb on immunization and infectious disease). Updated every two years (most recent 2018), may be obtained from Oxford University Press.

New Dengue Fever Vaccine (CYD-TDV) is a live dengue virus that is given in 3 shots at 0, 6 and 12 months with about 80% protections and is available in Indonesia, Mexico and Philippines at present. It is only useful for foreign guests or workers in a country that has endemic Dengue Fever mosquitoes. 

Medical Advice & Insurance; Emergency Assistance Japan Getting expert assistance is a trip & life saver. First, telephone in Tokyo  (03) 3811 8124 or email . In major hotels, ask the lobby manager for medical referral and prefer to visit medical university emergency room rather than have a doctor in the hotel.   
   And, last but not least - Me !  I now have the 24-hour Night & Day Medical Advisory; just telephone me on my mobile at 080 5034 989 (Also from USA, 1 702 234 1015), for advice or care, or text me by email  .
   A Tripper at risk should get travel insurance that will cover the cost of air ambulance back to home country, usually $500,000 (A one-week trip policy cost is trivial).

National Difference in Healthcare: The U.S., the U.K., and Commonwealth, northwestern Europe (France, Germany, Benelux, and Scandinavia), Japan and Israel give access to good medical care. In other places, the risk is high of acquiring HIV, hepatitis virus, mad cow disease by contaminated needle and surgical instrument or blood product infusion. (Because of the high rate of infected donors coupled with the low standard of training)
   If you plan a trip to a bad place, be sure you do not have badly low red blood cell anemia (reduce the need for transfusion), try to avoid injection, be afraid of surgery and be ready to fly out at once if it becomes a possibility. Some countries you want to get out of quickly if seriously ill are Philippines, most of Central and Latin America. all of central and Sahara Africa, India and Pakistan and SE Asia except Bangkok and Singapore.

Jet Flying Risks:  Intercontinental jets cruise at c.36,000 feet for 12 to 15 hours; the cabin is pressurized equivalent to 5000 to 8000 feet altitude, which causes a drop of oxygen in arterial blood that is tolerated if you are in good health.
    But if you have chronic lung disease or types of heart disease with lowered cardiac output or fixed slow heart rate, it is a risk.

Health Problems on Intercontinental Jets: Swollen feet and ankles are frequent. The final common pathway for ankle swelling during a jet trip is low air pressure. Typically both feet swell and near the end of flight after long sitting.  More in women and in older persons. It may be a sign of a weak heart or kidneys. Preventive is to take 15-minute aisle walks. For a person getting it for first time and worried about heart or kidney disease, a blood test, and an EKG and echocardiogram should be done, preferably just before travel, but if not done then, on return from the trip.
   Shortness of breath on assuming high altitude is a sign of heart or lung disease or anemia or sudden lowering of cabin pressure and an attendant should be called.
   Sudden ear pain on ascent or descent is from pressure change; a remedy is to yawn or chew gum.
   Acute arthritis attacks big toe or knee in travelers who do not get up and walk the aisle several times during a 12-or-more hour intercontinental flight.

No surgical procedures shortly before flying off on a trip: Do not have surgical procedures that could cause bleeding within at least 1 month before a trip.  I have seen several cases of hemorrhage either in flight or shortly after on a trip where the patients all had had surgical procedures within a week before the trip (prostate biopsy causing rectal hemorrhage, several cases of vaginal surgery causing vaginal hemorrhages). 

Specific Illnesses Experienced on Trips 
 The below comes from my statistics on a 10-year experience with tourist medical problems.
Acute Upper Respiratory: If you have flu, cold or grippe and younger than 65 without prior medical condition arriving at a hotel, try acetaminophen (Tylenol, Paracetamol) and go to bed, and you may feel better in an hour or two. Otherwise, seek medical advice.

Acute Gastrointestinal (GI): Diarrhea with nausea and vomiting caused by bad bacteria in food or by viruses makes traveler miserable but is usually better after several hrs. A diabetic should call his home doctor because GI upset is a risk for diabetic acidosis.
   Black tarry stool or vomit that looks like coffee grounds or is blood, a yellowing of the skin, or a severe abdominal pain needs emergency care at once.
   Inability to evacuate hard feces that seems stuck in the rectum may be due to eating foods like pizza (or taking calcium or opioids). The remedy is to use a moistened, lubricated index finger in the rectum to help deliver the stool into the toilet bowl. This type of constipation is not essentially harmful; it just slows the flow of stool.

Urology: Female cystitis causes painful frequent urination, with or without blood. It may be an infection or anything that irritates bladder outlet and urethra; most frequently heavy sex; otherwise, irritating soap in the bath (bubble bath cystitis), contraceptive irritation (jelly, diaphragm, IUD string), recent immunization, acute viral illness, and drug (chemotherapy cystitis). Cystitis can be a bloody bother for a tourist and she should look to possible cause in the previous 24 hours and be reassured as long as she stopped the activity. Take an acetaminophen pill and sit in a hot bath and urinate in the bath for relief.  If taking a prescribed antibiotic for cystitis, be sure to bring it along.
   Urethritis in Men: If one sees a white creamy discharge, it is gonorrhea from sex. Syphilis does not give discharge and cannot be diagnosed by test until chancre sore appears (usually on sexual organ or lips or in the mouth a week or more after initial contact).
   Renal tract stone pain (renal colic) is on one side from mid-back and sweeps around lowest rib down lower abdomen going into a testicle in men.  The pain pattern of spread is its most distinctive identifier. It comes in waves, builds to peak then recedes. The pain-free interval between attacks lasts a minute or two. At the start, the pain is slight discomfort located in the upper part of the back, loin, and flank. It can be confused with gallbladder attack if on right, or with early appendicitis. But within the hour the pains build up to typical, severe form. At worst, a sufferer can’t sit still and is doubled up. Untreated it lasts hours. Its cause is a small, stone passing from kidney to bladder. The problem is solved by getting strong pain-killer. Usually, it will take the edge off the pain and in several hours the stone will have passed into the bladder and will cause a brief episode of urethral pain when urinated. Watch the urine and, usually, you will see the stone.
   A stuck stone patient with diabetes or renal disease should see urologist quickly because of high risk for further damage to the kidney.

   A sudden swollen testicle noted on awakening, often painless, always disturbing is usually due to virus related to mumps. Go to the emergency.

Psychiatric IllnessHyperventilation panic is stimulated by chest pain, usually the night of arrival and typically involves a young man. Often it starts by doing too much ("A weekend warrior") like a recent case of a robust 20-year-old who did too many morning push-ups. The sufferer breathes overly deep, causing depletion of carbon dioxide in the blood and gets pins and needles feeling and twitches especially in the hands, a feeling of oppressed breathing and a panic.  Resting by lying flat on back, for an hour will cure.
   Psychosis: Stress of travel causes a psychotic break in one with incipient schizophrenia or past history of psychosis or borderline character disorder. Behavior is bizarre and heralded by undue suspicion, expression of weird ideas, and odd eating or sleeping behavior. Psychedelic medication may simulate psychosis. One (Travel companion) should stop the psychedelic, terminate the trip, and fly home for psychiatric care. One has to anticipate it based on observing early odd behavior. Once a tripper acts crazy he needs force.
   Factitious Symptom is distinctive. A tripper dramatically complains most often of back or belly pain or sudden inability to walk or speak. The symptom is not as important as the circumstance. With pain, there is lots of noise and it will be in a public place, like a lobby of a hotel or airport waiting room. A doctor is called and sometimes the sufferer ends up hospitalized. For a tour leader, the key is the secondary gain involved. (Termination of an unhappy tour, end of a love affair and need for instant separation, monetary gain or to escape payment of a bill or seeking a drug) The best thing a tour leader can do is to arrange emergency medical consultation to be certain nothing serious is going on, and then – alone with the tripper – find out what is being sought by the behavior. (Not by frank questions, but by indirection) Once you know the secondary gain sought, it can often be allowed without need for tripper to act out, e.g., a tripper who wants to end his tour should be assisted, an undesired flight reservation should have medical excuse so it can be canceled or changed without penalty, or for a drug addict, a doctor can supply the needed medicine.

Allergy & Skin Rash: Hives is an itchy rash of pale red flat spots and in a tripper is due to eating raw or poorly cooked shellfish or to chemical allergy. Hives without facial swelling is a minor complaint; gone in hours and the itch is easily self-treated by a cold shower.  
   Very itchy, red elevation of skin in irregular geographic like patches is contact dermatitis from soap or plants (poison ivy). A corticosteroid ointment rubbed into the warm moist skin after a bath or shower will stop the itch almost at once and the rash will fade after 24 hours.
   Herpes Zoster (HZ, Shingles): Chickenpox-like rash (red spots becoming pustular) on one side of body in localized zone (along left or right rib, strip of arm or leg, or on side of forehead; even a few isolated spots but always one-sided) preceded by day of weird subsurface pain/discomfort in area where rash will erupt; it is localized recrudescence of chickenpox virus in cranial or spinal nerve root. Not infrequent in travelers. And it may call for an end to the trip because unsightly and uncomfortable and infectious on close contact of a person who never had chickenpox. To diagnose it from its weird pain pattern on the day before rash will protect traveler against surgeon misdiagnosis of appendicitis that has been made with right-sided abdominal HZ. Early treatment with antiviral acyclovir (Zovirax) or valacyclovir may stop it.

Head &Face: Vertigo (dizziness) and nausea and vomiting after jet flight from air pressure change causing inflammation of the inner ear. Tripper arrives at his 1st destination and is suddenly hit by the vertigo and he vomits. The key that separates it from similar nausea/vomiting symptom of food poisoning or of cerebellum brain stroke is its extreme vertigo related to positions of the head and its lack of other sign or symptom. Nothing much helps but it improves day after day. Dizziness may remain for weeks and one learns to live with it. The anti-histamine treatment makes one drowsy and sluggish. No reason to stop trip but 1st night can be unpleasant.
   Face-aches or headaches are a problem when a tripper is not prepared with medication and far from usual medical care. Here, having acetaminophen or another NSAID like Ibuprofen is trip-saver for toothaches, earaches, weird facial tic pains, and headaches. Those who suffer from migraine and cluster headaches at home should come prepared with usual medication.
   Eye affliction of tripper is mostly a red eye, pinkeye or bloodshot eye due to a virus, air pollutant, or foreign body. Of course, remove foreign body and then corticosteroid with antibiotic eye drops help.
   Nosebleed: If it does not stop quickly on pressure over nostrils, go to emergency room.

Heart & Blood Vessel Illness: Chest pain should be immediately checked in the emergency room. Ask for an ambulance.
   If you have risk or history of heart failure, get heart check before deciding on an overseas trip. Avoid strenuous all-day walking tour especially at end of the trip, when the heart will be weakest.
   Swelling of ankles at end of the day or at end of a jet flight, shortness of breath especially worse lying flat, increasing fatigue, and rapid heart rate at rest suggests a weakened heart. Do not make a trip if you have any of these symptoms, and check at once if they develop.
   Cardiac Arrhythmia or Abnormality of Heart Rate that is new should be treated as an emergency. Most common is atrial fibrillation. With chronic, persistent fibrillation in the traveler who is stable, on medication and has been checked by a cardiologist, a foreign trip may be OK.
   Fainting should be treated as an emergency and do cardiology exam.

Joint & Bone Illness; Vignette: Morning after an all-day walk you awake with exquisite pain in left foot big toe. The skin over the toe is red, swollen and painful on pressure or touch – so much so, you don’t want to cover it with a sock, much less shoe. Diagnosis is gout, a common affliction of travelers due to high blood uric acid. Combination of a long flight, hiking, and over-eating & drinking make gout common on a trip and bring on an attack, often a day after arrival at 1st destination. Acetaminophen (Tylenol or an NSAID) as a single adult extra-strength dose dissolved under the tongue or chewed may work wonders. Also, drink lots of water to dilute the high uric acid in the blood.

Back & Neck: In the usual case, a tripper arrives, and in hotel bends down to open valise and – Wham – a terrible twinge of pain strikes mid to lower back on one or both sides. The degree of disability ranges from a victim who will barely move for fear of agony to one who gets around by walking gingerly on toes. Acetaminophen extra strength 500 mg pill or other NSAID will help, hot shower is good, but massage or manipulation may be terrible. Patience is called for because the pain may take weeks to resolve. X-ray is no help unless there is a history of trauma or previous back surgery. Of course, if these do not relieve immediately seek physician consult                                                                                
   A painful neck is one reason to include soft cervical collar in trip kit.

Accident & Trauma: Best preventive is to read my Accident chapters. Many accidents involve a tripper not watching where his feet are going. Band-aid is the remedy for a simple laceration. Seek emergency room care if in doubt.

Rectal Illness: All rectal illnesses I saw were painful swelling at or near the anus. A blood clot in hemorrhoid vein (acute hemorrhoid) and pus in swollen anal gland (rectal abscess) are conditions relieved and cured for the remainder of the trip by surgical scalpel incision in hospital emergency room. Occasionally they burst or are helped by a pleasantly hot salt bath. (Dump 2 cups of the salt in the bath; sit to 1 hour repeatedly). Stuck stool in rectum just above anal opening will be relieved at once by greased finger digital extraction.

Obstetrics & Gynecology:  Preferred time in pregnancy to travel if one must is 4th to 6th month. Better yet - do not travel if pregnant because of increased cosmic rays at high altitude and x-ray from body search machine. Hotel calls on pregnant cases were for bleeding. If you are a pregnant case, in the early stage, get to the nearest ER for an ultrasound check for tubal pregnancy or miscarriage.
   Other gynecologic complaints are a discharge from yeast overgrowth or trichomonas infection, and hemorrhage from sexual defloration. Granted that virgin bed-maiden is rare nowadays; still, hotel-room maidenhead hemorrhage can be dramatic. A remedy that works is to pack a hand towel firmly into the vagina and have the victim lie abed for 1 hour with thighs together. Then leave the towel in overnight and remove in the morning in a bath. Big bleeding should go to the hospital at once.

Lung & Bronchial Illness: Rare because most lung illnesses cause severe coughs or shortness of breath and even the dullest person knows better than to travel. Asthma in young and emphysema in the old made all the cases I saw. Bronchial asthma tripper should come supplied with medicine, inhalant, and adrenalin. Severe emphysema = no air travel.
   My recent data highlights pneumothorax mostly in young men who cough hard and gets a pain under rib, typically on a jet. A chest tube must be inserted quickly so it is always an emergency. Another may be a pulmonary embolus (PE) that typically afflict a traveler coming off an intercontinental jet flight after sitting cramped in the seat for hours (Economy seat syndrome). When not an acute collapse, the sign of PE is a tendency to shortness of breath, a cough and a stitch type of chest pain during or right after the flight. Get to the ER immediately.

Neurological Illness: Brain strokes are terminator of trip due to brain hemorrhage, from a cerebral aneurysm due to high blood pressure in the middle-age population, or cerebral artery thrombosis due to hi-cholesterol-caused cerebral and carotid artery atherosclerosis in the oldest or from emboli from heart to brain, mostly due to atrial fibrillation in the youngest group. This leads to advice that a potential traveler with any suggestion of heart or blood vessel disease should make sure that high BP is checked and under control just before trip, and that heart has had evaluation with EKG and ECHO to be sure no atrial fibrillation (Persistent AF with rate control med and on anticoagulant like coumadin with INR 2 to 3 may be OK'd if the trip is important), and that one’s carotid and cerebral arteries are checked by ECHO Doppler and MRI of brain and also that blood LDL cholesterol is under 100.

Pediatrics included fever, bellyache, diarrhea, infant fall, chickenpox, nosebleed, and overdose with acetaminophen.  Best not to take small children on overseas trips.

Special request for hotel visits that I noted over the years may tell a tripper what he should bring to avoid paying for what is suddenly needed. In my series, replacement of lost or forgotten medicines included anti-biotic, -hemorrhoid, -pain, -malarial, -intestinal-wormer, -viral, -gout, -coagulant, -asthmatic, and –hypertensive; as well as sleep, cardiac and diuretic medication. An injection was requested by a few and included anti-allergy (Traveler bringing own desensitization shot and needing a nurse to inject), antibiotic, narcotic, diabetic, fertility hormone, tetanus immunization, and Vitamin B12. Testing was requested rarely for urinalysis, glucose, cholesterol and uric acid blood and pregnancy; also for an introduction to non-M.D. health practitioner (acupuncture, physiotherapist, and dentist). Stitch removal, dressing change from recent surgery, and morning-after contraception also requested, and one traveler got her wedding ring stuck on a finger in flight and had to have the ring cut off.

Which Brings on the Following Advice:
*Carry an extra set of medication in a pocket separate from luggage.
*Take on the trip, a urine dipstik test, diabetic finger-stick blood test kit and pregnancy test, appropriate to the situation.
*If you will need stitch removal or dressing change you can’t manage alone, pre-arrange with the hotel to have nearby hospital ER take care of it.
*If appropriate, carry contraceptive and STD protector (condom for men and women – the woman should have it in case sex partner does not) or morning-after pill.
*If you wear rings on fingers, check for tight fits but best not to wear rings on the trip.
*If you have a potential surgical condition that could become emergency (a hernia, gallstone, bleeding) don’t make the trip until you get it attended to (at least surgeon opinion). If you must travel with such condition, be knowledgeable and have a game plan what to do if it becomes an emergency.
*Most hotel medical calls are on the day of arrival when tripper is worn out. Try to avoid medical visit then. A symptom that worried you the night before will often be going gone (disappearing) morning after.
*Tripper with special susceptibility (diabetic, heart, and lung, over 65, pregnant, immune deficient, chronic illness) should seek medical advice quickly if doubtful symptom or sign; also anyone complaining of chest pain, faintness or fever above 39 degrees C. But go to an ER recommended by your hotel manager. Get immunizations, esp. flu in season.

High Altitudes: Above  8,000 feet, high the partial pressure of oxygen is low enough to cause respiratory distress even to persons with normal heart and the lungs, if they even moderately exert themselves. Up to 12,000 feet (c.3,636 meters; The Rocky Mountains highest pass) is borderline tolerable as long as no exertion and normal heart and lungs. Above 12,000 feet, high-altitude sickness gives risk to life. I do not advise it without careful consultation and consideration. Headaches and shortness of breath are the first sign, immediate rest the treatment, and breathing pure oxygen the cure of serious symptom.

Medical Repatriation with Doctor and/or Nurse is provided by Emergency Assistance Japan worldwide (See above heading Medical Advice & Insurance; Emergency Assistance Japan for contacting EAJ).  I can do it too; just call me at 080 5034 9898. The guiding principle is: Will remaining under foreign medical care in particular country put a patient at greater risk of death or bad result than immediate return? Acute appendicitis in Russia is a reason for instant evacuation to a country with better surgical facilities; while same illness to the same tripper in France or Japan is most safely dealt with leaving the patient in place to be operated. The Philippines has poor medical care; you do not want to be stuck there, seriously ill.
   Repatriations differ in complexity. At simplest is medical escort where the patient sits with a physician or nurse. Medicated psychotic break or orthopedic case needing rapid non-emergency surgery is good there. For tripper who gets ill in Africa: get back to one's home place if the home is Western Europe, Japan or North America and, if it needs doctor repatriation not normally called for, request it. Excepting Johannesburg and Reunion in the Indian Ocean, Africa is a disaster zone for medical care and a place to fly from when illness hits or is anticipated.
   Next level is stretcher case: 8 to 10 seats taken out of the economy seat section (and must be paid for one-way) and stretcher substituted. Not so desperately ill that it needs ICU yet ill enough to need a bed with doctor and nurse. In this set is the recent stroke, orthopedic case that can’t sit, or case with pain, vomiting or diarrhea.
   The highest cost is air-ambulance, with its medical team for evacuation with myocardial infarction, coma, acute stroke with breathing and swallowing problem, or in shock. Air ambulance repatriation is often from a country with primitive medical care where even if the medical case is risky to repatriate, it is even more risk to leave for treatment. Also from an out-of-way place that has no easy commercial aircraft connections. The patient who will benefit is on verge of, or just needing ICU care or surgery and where home-country will improve chance.
   In traveler involved in sudden serious illness or accident, a window of opportunity may be recognized during which well-supervised repatriation can deliver the patient to hospital in home area in no worse condition than he was on leaving hospital in foreign country where he became ill; but, if quick decision is not made, the window shuts and the traveler is doomed with the choice of staying where he will get inferior care or being repatriated by air ambulance at terrific expense and risk of condition being worsened. Because it requires at least 2 to 3 days to get moving, those responsible for the patient have got to be thinking it and getting it moving from the earliest moment of illness or accident. If there is the slightest question of your health, get travel medical insurance that will cover costs of air ambulance before you travel. For a patient, friend or family, one may get in touch with the medical assistance company: Emergency Assistance Japan Co. Ltd, Operation, attention Dr Kawai. Or just call me at 080 5034 9898.
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