Dr. Rose Recommends for Healthy & Safe Travel
Health Guide Chapter 16
Medical Care Abroad
Good trip preparation helps reduce the need for medical care abroad.
Short-term travelers are most concerned about emergency medical care; expatriates and long-stay travelers may have different health-care needs.
Travelers with an acute medical or surgical emergency should seek the nearest facility for immediate care. Most of the time this care will be adequate.
Most travelers should purchase a travel insurance policy that includes assistance benefits.
An assistance company can provide referrals to English-speaking physicians, monitor health care, and arrange emergency medical evacuation, if those become necessary.
Medical care abroad varies widely, and in many countries is of high quality. This high-quality care, however, may be available to only a small segment of the general population. Travelers should find out how to locate this care.
All travelers should carry at least a basic medical kit. They should have their own supply of pain medication, antibiotics, drugs for diarrhea, heartburn, etc. This can help avert a trip to a doctor or hospital.
Travelers should consider carrying a mobile phone that can make international calls. They should bring with them their personal physician's office telephone, mobile phone, and fax numbers and e-mail address so the traveler, or his family, and/or the physician overseas will be better able to assess the medical problem.
What do you do if you are suddenly taken ill or have a serious accident in a foreign country? How do you find an English-speaking physician? Or locate a reputable hospital? Where do you turn for help and advice? The first step in avoiding disaster is prevention. This means careful pre-trip planning as outlined in this Health Guide. But what if an unexpected illness or accident occurs? Statistics show that 25% of travelers develop some type of medical problem over a 2-week period. Most accidents and cases of medical illness are relatively minor. The problem may be self-evident. Most conditions resolve by themselves or can be treated with simple first-aid measures or with the medication you have on hand.
But what if you need a physician's treatment or hospitalization? When an emergency happens far from home, even a seasoned traveler may have trouble coping, especially if medical care is urgently needed. What starts out as a routine vacation or business trip could end up as a real nightmare.
How to Cope When Illness or Injury Suddenly Strikes
Stay Calm You may be able to solve the problem yourself. You may already have medicine with you to treat a minor infection, a rash, a cut, a bruise, or a sprain. If diarrhea should occur, follow the treatment guidelines for travelers' diarrhea in Chapter 6. Check to see what's in your medical kit. Home health-care guides and first-aid manuals are sources of useful advice, so you may wish to bring one of these with you.
Serious Accidents or Illness Demand Immediate Attention If you sustain a more serious injury, such as a deep laceration or a fracture, or have bleeding, unremitting chest or abdominal pain, or trouble breathing, don't waste your time trying to find a local physician. Go immediately to the nearest hospital. If you are in a large city, go to a hospital associated with a medical school if possible (these hospitals usually have English-speaking doctors as well as qualified specialists on staff). You can ask for directions or assistance from your hotel, your tour guide, a taxi driver, or the police. A taxi or private car may be faster than waiting for an ambulance. Remember, in an emergency, minutes count. Don't delay!
Note: If you think you are having a heart attack, early diagnosis and treatment are critical. Administration of a thrombolytic (clot dissolving) drug, or angioplasty, will greatly improve your chance of survival.
Less Urgent Illness This can usually be treated during a daytime visit to a doctor's office, but some doctors will make an after hours hotel “house call.” Your hotel can usually provide the names of one or more English-speaking physicians. Better yet, if you have friends, relatives, or business associates who are residents of the area, ask them for a referral to a doctor they know is qualified.
Colds, sore throats, ear aches, bronchitis, diarrhea, most urinary infections, and the flu are some of the conditions that usually don't require emergency attention, but do require monitoring and possible physician follow-up. You won't find overseas the widespread availability of over-the-counter drugs there is in the United States and Canada; so bring your own supply of antibiotics, pain medication, diarrhea pills, etc. The medication you bring may cure or sufficiently ameliorate the problem or make you feel better while waiting to see a physician. You can take levofloxacin (a standby antibiotic for travelers' diarrhea) for painful, frequent urination (urinary tract infection?) or a cough with fever (pneumonia?) pending further medical evaluation. Self treatment with an antimalarial drug is a good example of how self medicating can be potentially life saving. However, if you do have a fever that might be from malaria, be sure you are examined within 24 hours.
Request that all medications you receive from the doctor be identified or labeled with the generic as well as the trade name. This is important if you have drug allergies and must avoid certain medications or if you develop a drug-related reaction or have to see another doctor for ongoing care. That doctor will need to know what drugs you have been taking. Note: Familiar drugs will have different brand names in other countries, but generic names may also vary. For example, acetaminophen (Tylenol) has another generic name, paracetamol, in some countries; and meperidine (Demerol), is sometimes generically identified as pethedine.
Bring a Medical Kit and First-Aid Manual You can often save yourself a trip to the doctor if you are able treat cuts, abrasions, and other minor injuries yourself. Be sure your routine immunizations are up-to-date so you don't have to go to a hospital for a tetanus booster.
Carry a Phrase Book A phrase booklet or pamphlet that provides medical words and phrases in various foreign languages, or the KwikPoint medical visual language translator (www.kwikpoint.com), can be invaluable when a language barrier prevents the adequate communication of immediate medical needs. Find an interpreter as soon as possible.
Contact Your Doctor in the United States Bring a mobile telephone with you on your trip. If you are hospitalized, a consultation with your own physician back home can be invaluable. Hopefully your doctor, or an associate, will be available at the time you call. (Leave your number, or another call back number, if necessary.) Describe the history of your illness, your symptoms, what the diagnosis is, and what treatment you are receiving. Let your doctor know if you are in a country where there are tropical diseases. Have your own doctor discuss your case with the local doctor caring for you. Obviously, for certain conditions, treatment is standard and straightforward—surgery for appendicitis, casting for fractures, etc.—and your treatment may have already been rendered. However, for more serious or life-threatening problems, this consultation can be important. Your diagnosis may be in doubt, and the hospital and physician may not have the expertise to provide adequate care. Your physician can help assess the situation and reassure you that you are receiving proper care and that there's no need to worry, or your physician may feel that a second opinion is warranted or even that transfer to another facility is advisable.
Locating Physicians Abroad
In many cases, finding good medical care abroad is not a problem—maybe even less of a problem than back home where you may have to wait for hours in an ER! You have many options when it comes to finding a physician to care for you. The American and Canadian embassies and consulates maintain referral lists from which you can choose. The embassy or consulate, however, won't officially recommend individual doctors on the list. Other options to consider include the following:
Travel Insurance/Assistance Companies If you have purchased a travel health policy, call the 24-hour hotline number and you'll be connected with an assistance center that can give a physician referral. Companies such as International SOS Assistance and Shoreland, Inc. (publisher of Travax EnCompass), provide corporate and travel physicians, for a fee, with a list of worldwide medical facilities and contact information.
International Medical Clinics Because of globalization, there is a growing market for Western-style medicine* to serve the medical needs of the employees of multi-national corporations, visitors, expatriates, and insured travelers. These clinics, usually part of a chain, are found in large cities and may provide the best first contact for any medical problem. One such provider is the American Medical Centers that maintains clinics in Moscow, St. Petersburg, and Kiev. International SOS and MEDEX run clinics in Beijing and many other locations throughout the world.
IAMAT The International Association for Assistance to Travelers (IAMAT) is a Canadian foundation that publishes a booklet listing hospitals and English-speaking physicians who have agreed to adhere to a standard schedule of fees. Physicians are not listed by specialty. Contact IAMAT (www.iamat.org), 417 Center Street, Lewiston, NY 14092; 716-754-4883; in Canada, 40 Regal Road, Guelph, Ontario, N1K 1B5; 519-836-0102; no charge, but a donation is encouraged.
Cardholder Assistance Credit-card companies provide 24-hour emergency medical hotlines available to many of their cardholders, usually those in the “gold card” or “platinum card” category. Typically, the hotlines can refer you to English-speaking doctors and dentists and to hospitals with English-speaking staff members, arrange for replacement of prescription medicines, and help you charter an air ambulance. If you are an American Express cardholder, call the Global Assist hotline at 800-554-AMEX (301-214-8228 collect from overseas). If you are an American Express Platinum cardholder, call your special assistance number, 800-345-2639 (202-331-1688 collect from overseas). Visa Gold and Classic cardholders can call 800-332-2484 (410-581-9994 collect from overseas). MasterCard cardholders can call 303-278-8000 (collect from overseas).
Hotel and Resort Doctors Most large hotels will refer you to a local doctor or to a doctor who will come to your room to render treatment. Be warned, however, that the main qualification some of these doctors have is a payback arrangement with the hotel management. They may be helpful in providing referrals.
The Telephone Book You may find many doctors and clinics listed in the “yellow pages” of the local telephone book. These physicians often mention their qualifications and some may indicate that they have received specialty training in the United States, Canada, the United Kingdom, or other medically advanced country.
Personal Recommendation A time-tested method of locating a qualified physician (assuming time allows it) is to find a satisfied patient. Ask locals for personal recommendation. Contact employees of multi-national corporations or expatriates such as schoolteachers, relief workers, or missionaries who may have received medical care in-country. They are often familiar with high-quality private general hospitals or specialty clinics.
Because of cultural differences, the attitude of physicians toward their patients in foreign countries is often different than in the United States or Canada. Physicians abroad are often perceived as being more autocratic and authoritarian. This can make patient-doctor communication difficult. The doctor caring for you may not want you to question his or her care and may not be available to answer your questions (to be fair, this can sometimes be said of American physicians also). This does not mean that your care is substandard. In fact, the doctor caring for you may have more knowledge of local diseases than your own physician and be perfectly well qualified to diagnose and treat your illness. Nevertheless, you should seek a second opinion if you have doubts about the quality of your care.
Foreign hospitals can range from basic to the most advanced, but the quality of your medical care shouldn't necessarily be judged by your surroundings. If you're hospitalized in a less developed country, you might wonder if you should be moved to a “more modern” facility. This question faces hospitalized patients everywhere, not just travelers overseas. An analogy to being hospitalized in the United States might be appropriate. In the United States, the smaller community hospitals are adequate for almost all medical care. Occasionally, however, a patient requires transport to a specialty center for advanced, sometimes life-saving treatment. The same is true overseas. You may be in a small, seemingly inadequate facility that may, in fact, be perfectly adequate for your medical needs. Having someone available, in serious situations, to assess your diagnosis and treatment will help you or your family know when transfer or medical evacuation may be indicated.
Assessing Foreign Hospitals
If you need emergency care and minutes count, go to the closest facility. However, if the situation is not immediately critical—and there's more than one hospital nearby—use the following checklist to get a basic idea of what level of care is available to you. The checklist will also help you tell your doctor at home, if the occasion arises, what services are being provided.
Does the hospital have a coronary care unit, ICU, recovery room, and advanced resuscitation and diagnostic equipment?
What medical and surgical procedures can be performed? Are orthopedic surgeons, neurosurgeons, and other specialists on staff? If not, where is the closest referral facility?
Can they treat heart attacks with thrombolytics (clot-dissolving drugs), angioplasty, stenting, or cardiac bypass surgery (CABG)?
Can the hospital render qualified obstetric and postpartum care? Do they have a renal dialysis service?
Are computed tomography (CT), MRI, and ultrasound available?
Does the hospital or clinic stock disposable supplies, especially needles and syringes?
Does the blood bank screen for HIV, hepatitis B antigen, and hepatitis C antibody?
What vaccines are available (e.g., tetanus, rabies, rabies immune globulin, hepatitis B, hepatitis B immune globulin)?
Is the hospital air-conditioned? Are there private rooms? What types of meals are served?
Are private duty nurses available?
Does the hospital have 24-hour admitting capability?
Does the hospital have an emergency room, receive ambulances, and treat major trauma?
Do most of the doctors speak English?
What are the room rates and the charges for various medical and surgical procedures?
How will you pay the hospital? Do they accept major credit cards? Do they demand guarantee of payment from you or your travel insurance/assistance company “up-front?”
FACTORS DETERMINING EMERGENCY MEDICAL EVACUATION
Qualified medical consultation has determined that local medical care is not adequate.
Another facility, one that can provide a higher level of care, is available and accessible, and has accepted the patient in transfer.
The patient's condition has been sufficiently stabilized before transport.
- The patient can pay the cost of the transport.
*Western-style medicine has three main components: (1) evidence-based medicine; (2) quality assurance; and (3) patient- centered delivery of care. Evidence-based medicine means practicing medicine using diagnostic and treatment protocols that have been developed through research, not handed down from generation to generation.