Wednesday, January 29, 2014

Travel Medicine by a Traveling Medical Student

Working the pharmacy during my volunteer stay in Peru
Traveling can be very exciting and sometimes a bit scary, especially when you get sick. Sometimes
its just the common cold but it can make you scared enough to call home to mommy. I know this from experience. After a taste of Salmonella flavored Chinese food in Peru, a Giardia spiced water in Nepal, a Hep A seasoned Lassi in India and a nice leg of lamb that cured with E coli for over a week on the counter of my families home, I learned the hard way that mommy is not always there to feed you chicken soup and take your temperature.

I was scared, alone (but not really because there was always a handful of other travelers hearing my hourly bathroom visits) and very dehydrated.

Vaccines: 
Check so see what the countries you are traveling to require, you might need to get certain vaccines to enter some countries. 
  • Yellow Fever - Amazon and Sub-Saharan Africa
  • Typhoid Fever - India or Peru
  • Japanese Encephalitis - South East Asia
  • Hep A - 2 weeks before you go (you will have to get a booster after 6 months)
  • Hep B - if you are working in a medical setting (three shots)
  • Rabies - stay away from stray dogs (which is a huge problem everywhere)
  • MMR
  • Tetanus
  • Polio - this is a new requirement for India
  • Meningococcal - Sub-Saharan Africa


Malaria Treatment:
  • Prevention:
    • Once a week: Mefloquine
      • watch out for the side-effects, can cause bad dreams
      •  Start one week before you enter area with malaria and continue through your trip and 4 weeks after you leave the malaria area.
    • Everyday: Doxycycline and Malarone (atovaquone and proguanil)
      • Doxy: start the day before and continue 4 weeks after you leave malaria area
        • can cause you to get sunburned easier
        • don't take before bed
      • Malarone: much more expensive but less side effects
        • start one day before and continue until 7 days after trip into malarial area
    • Mosquito repellent -  at least 45% DEET
  • Symptoms: fever, stomach pains, headache, fatigue chills, sweats, vomiting and diarrhea.
    • Treatment - its recommended to take prophylaxis and avoid the disease, but just in case:
      • CoArtem - Artemether/lumefantrine 

Altitude:
Acute Mountain Sickness and High Altitude Pulmonary Edema (HAPE)
  • Treatment is to descent and use oxygen if available.
  • Prevention:
    • Climb high, sleep low (this does not mean sleep on the ground, this means that instead of sleeping on the pass, sleep at a lower village)
    • Avoid alcohol and sedatives
    • Eat a high carbohydrate diet - lots of pasta and potatoes 
    • If you are really worried, take Acetazolamide (Diamox) - start 1 day before you start your trek and each day until you descend. WARNING: this makes you have to pee all the time (for me, no joke, every 15mins) so stay hydrated.
At 18,340ft - highest motorable road in the world

Sun Exposure:
  • Cotton has an SPF of 7 so therefore you still need sunscreen.
  • Don't put sunscreen on top of bug repellent, Apply sunscreen first, then repellent just before exposure to insect.
Water Safety:
  • What do you do about a jellyfish sting? Everyone always says pee on it or use some vinegar, I prefer the vinegar and it works. 
  • Don't pee in the water in the Amazon - Candiru likes pee and will follow the stream of pee... well you got the idea. 
  • Keep hydrated while in the sun. 
  • If diving heed all the rules:
    • Don't dive if you have a cold (Can prevent you from clearing your ears and caus excessive pressure)
  • Wear water safety items. It does not matter if you know how to swim its important to follow any rules. If white water rafting, especially a class V or above please wear helmets and life jackets. 
    • If the company does not provide them then I would think about switching to a different company.
Snorkeling in Puerto Rico

Diarrhea/Nausea:

Travelers diarrhea is the most common traveler's illness.
  • Prevention: 
    • Only eat safe food (well this one is hard to do, but I guess if you really don't want diarrhea try to follow it...otherwise move ahead to treatment)
      • You can have: sealed food, piping hot food, fruit with a peal
      • Don't eat: ice, lettuce, tomatoes 
    • Brush your teeth with bottled water
  • Treatment:
    • Let it run its course - if your body is trying to get rid of something let it do it. 
    • While you are on the toilet make sure to stay hydrated. The easiest way are with re-hydration salts. These can be purchased at almost any pharmacy around the world. They often taste bad so mix them with some juice powder or get the flavored ones.
    • If that fails take Pepto-Bismol for nausea and diarrhea (don't take it every day) this may make your poop look black, don't worry.
    • If you have severe nausea and you can get your hands on some Zofran (Ondansetron), this will relive nausea in 15mins
    • If you have a fever, blood or mucus in stool, severe stomach cramps you might have a bacterial infection, this you will need to treat with antibiotics:
      • Levofloxacin 500mg for 1-3 days
      • Cipro 500 twice a day for 1-3 days
      • Azithromycin (Z-pack) 1g once or 500mg for 3 days
    • If you have diarrhea for over 2 weeks and is not resolved by antibiotics you probably have Giardia - to treat this you need Metronidazole (do not drink with this)
      • symptoms of Giardia include cramping and foul smelling stool, usually it occurs several weeks after exposure.


Sleeping 
On long bus rides or plane journeys can always be hard, here are some over the counter treatments you can use:
  • Benadryl, Tylenol PM, or melatonin
  • Try not to take hard-core sleeping pills, you don't want to be robbed  
Fever:
This can often accompany diarrhea or nausea, its a good idea to keep a small plastic thermometer in your first-aid kit. This will help you monitor your fever to determine if you should see a doctor or take medications. Acetaminophen (Tylenol), Ibuprofen (Advil), and Naproxen (Aleve) can help lower your fever. Fevers can also be the first sign of Malaria or other severe diseases, so always see a doctor if your fever is over 104 or if its accompanied by stiff neck, rash, or shortness of breath. As always stay hydrated.

 Volunteering at the clinic in Peru
General Staying Healthy
Sleeping, eating well, and taking it easy when you are sick are the best recommendations. Vitamins, in recent studies, have been found not to help much, unless you have an unbalanced diet or are in need of extra vitamins (pregnant, elderly, children). Probiotics especially during and after an antibiotic treatment is a good recommendation to replenish your normal flora (normal bacteria that help you combat infections, breakdown food, and metabolize vitamins). Anti-itch (hydrocortisone) cream for bed bug bites or poison ivy itching is a good addition to your first-aid kit.
Thanks for reading. Just note, I am not a doctor yet and this does not serve as a replacement to see your doctor, this is just a guide that could help you through some sticky situations. If symptoms last too long please go see a doctor. In most countries its actually fairly cheap and they often know better about local illnesses than doctors do in the western world.

I went to see a doctor in Nepal and in India, both visits were under $30. In Peru I was hospitalized for Salmonella for an entire day, I even had my own room. In the USA that would have cost thousands of dollars but in Peru it was about $200. 

Fellow Medical Student Volunteering in Peru

Monday, January 27, 2014

Puerto Rico on the Cheap

Who says you have to spend $$$$ to lay out on white sands and dive into clear waters. The most expensive part of visiting Puerto Rico is the flight. My friend Stephanie and I escaped for Spring Break 2013 to the wonderful and beautiful island of Puerto Rico.

Although public transportation exits in the greater San Juan area, its almost impossible to travel the rest of the island without a rental car. If you are under 25 (as I was last year) it cost $210 for a five day economy car rental. Split between two that's not too bad. If you are under 25 then your in luck, it will save you almost 1/2 that amount. We rented from Popular Auto in San Juan, they were very nice and they never tried to cheat us. I have heard many stories of companies charging extra for things that were not even in the agreement. They spoke no English at Popular Auto so knowing Spanish is a must if you want to use them. That said there are many other places to rent from, Popular Auto just seemed to be the lease expensive.



In San Juan we stayed at The Palace Hostel, its a bit out of the main part of the city, but it is still walkable. We drove from San Juan to El Yunque National Park, we explored this area for a couple hours before heading over to Fajardo to check into the Moonlight Bay Hostel. I recommend this place highly, they were very nice, they even went out of the way to make a veggie burger for me. The hostel is very close to the ferry terminal to head over to Isla Culebra. That evening we went on the Biobay kayak tour, if you are student you can get a discount, it only cost 35. It was an adventurous 3 hours of bumper kayaks. We maneuvered our way through small channels without any lights bumping into each other and trees until we finally reached the biobay. Although the biobays are a bit overused, and the plankton that create the color are dieing due to too much human traffic to the area we were still able to see the water light up. The best way to see the biobay is on kayak, it has less impact on the species than motor boat.



When you are waiting for the kayaks to depart to the biobay, don't forget to try the typical Puerto Rican arepa at one of the seafood shacks. An arepa is a flat corn bread stuffed with many different things, here its the bet to try the fresh seafood ones. 

After a good sleep (4hours) we woke up to get in line to buy tickets for the ferry. No matter how much you try to negotiate with the people at the ticket office, you still have to wait until the day of your trip to buy the tickets. We were able to get on the first ferry to Culebra. The ferry takes about 1 hour each way. Its a relaxing ride, it was so relaxing that I feel asleep.



In Culebra we reserved a camping site on Flaminco Beach. You can do this over the phone, you might have to call a bunch before you can actually get a hold of someone, again another reason to know Spanish. It was $25 for a camping site and you can split it by up to 6 people. It was just Stephanie and I, but it was still cheap. Make sure to bring your own tent, you can rent one, but its much more expensive. Also during spring break, most of the college students also go to camp at Flaminco, ask for the last camp ground, I think its letter E, this one is the quietest.

We rented a Golf Cart for the day, which was $45/day. It was a nice way to get around, originally Stephanie and I were going rent bikes, but Culebra is very hilly and quite hot. I think it would be doable, but you would be tired before you got to the beach.



We headed to Zoni Beach which is the most beautiful beach that I have ever been to. There were not too many people, unlike Flaminco, it was a very open long beach with white sand and clear blue water. Across from Zoni Beach is the Island of Culebrita. Whether you are snorkling, paddle boarding, kite surfing, or just laying out in the sun, Zoni Beach is the best place to do so.


After a wonderful small party on Flaminco Beach at night and a restful (wink) sleep in our tent we woke up the next day and walked to Tamarido Beach, it a long hot walk, and there is a part with a hill, but it is doable. We rented snorkeling equipment at Flaminco Beach camp ground, it was $10 per person for the day. It was here that we swam with the turtles. There is lots of awesome coral and neon color fish here that you can chase after. The sand is not as white as Zoni but there is much more shade. Remember to bring your sun screen.

After a long day of snorkeling and bathing in the sun we packed up our tent and headed back to the main island of PR. We were shocked at how safe it was to keep out items at the campground. We left most of our other belongings in our rental car in Fajardo. The ferry ticket is $4.50 both ways.

In all its not very expensive to travel around PR and have a good time.

Monday, January 20, 2014

Bucket List (9-10) On the Go

9. Iceland's Ring Road
It is said by many that Iceland is one the most beautiful places on earth. Pictures from there make me think that it might be close to true. Ring Road in Iceland circles the entire country, its also known as Route 1. Its 1,339 kilometres (832 mi) long and takes 10 days to drive all the way around and see all the sights including its thermal baths, huge waterfalls and hike-able glaciers. Iceland is pretty expensive, renting a car can cost $100 a day. Tour packages are also available, but they are pretty expensive too. Bus passes are offered for around $350.



10. Haute Route - Cross Country Ski the Alps
This 7 day trek on skis from France to Switzerland. With a combo of downhill skiing, cross country and climbing with skins this beautiful route take you across the Western Alps. Skiers stay in hotels along the way. The views of the snow covered peaks are breathtaking. You can either get a guide to take you or you can do the trip on your own with just a map. This is not a trip for the lazy or the poor. Skis must be bought or rented and lodges must be booked. Euro to the Dollar ratio does not help much. This will probably be one of those trips I do when I am older, I hope I have the energy to do this in 20 years.


Saturday, January 18, 2014

Bucket List (6-8) Interesting Places to Sleep

6. Göreme, Cappadocia, Turkey
Do you want to live under a rock, well you can visit Turkey and try it for a couple nights. For as little as $11 a night you can stay in a dimly lit cave with WiFi. Göreme National Park was added to the UNESCO World Heritage List in 1985. These human dwellings date back to the 4th century BC. These dwellings were known as a hide out for Christians. Cappadocia is known for its lunar-like landscape. With thousands of these rock houses and underground cities to explore you will never run out of things to do.


 
 7. Tree House Adventure, Costa Rica
For as little as $200 you can spend the night suspended at 90ft off the ground. Costa Rica is popular
destination for adventure seekers. If you can't get enough adventure while your awake just add adventure to your night. Finca Bellavista is a sustainable tree house community. Although $200 is not in my budget, maybe one day I will have the chance to stay in one of these fear-inducing tree houses.

8. Trans-Siberian Railway, Russia
Warm yourself with some spiked Russian tea or some Russian vodka and hop aboard a train that traverses the worlds longest railway. Recently one of my friends took the Trans-Siberian Railway, she loved it, her only complaint was her nose almost froze off. It was started in 1890, the main passage (Moscow to Vladivostok) is 5,753 miles and spans 7 time zones. It takes 8 days to complete the journey, but enjoy the stops along the way.

Thursday, January 9, 2014

First Publication

So in the science world your a big shot when you finally get published on a paper. I think that so many people are being published that its not such a big deal anymore, but for me January marked my first ever publication. Its not a fancy article with big science words or pretty charts and graphs, it does not intend to confuse people outside of my field, its not one that many people will read but I am happy that finally my name is somewhere I consider special.

The JAOA - Journal of American Osteopathic Association, its the largest Osteopathic journal in the USA and is fairly well known in the osteopathic community. I was published for my medical mission trip to Peru, which although it might not be a challenging scientific paper with big medical words, it talks about something that I really love to do. So for everyone's reading pleasure here is my article:

BIO1549

Benefits of Cultural Immersion in International Medical Relief—Sacred Valley, Peru
Adrienne F. Schlatter, OMS II

Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Background: In Peru many rural Andean families lack the access to preventative health care. This is due to socioeconomic issues including monetary, transportation, traditional and language barriers. In Peru most people speak Spanish, but in the rural Sacred Valley, many of the inhabitants speak Quechua, which has been carried down from Inca civilizations. The Andean (descendants of Inca culture) community practice traditions different from those that the Spanish brought when South America was colonized. This language and lifestyle discrepancy can be a barrier for many local physicians and international physicians to provide medical services. 

Methods: I volunteered with Maximo Nivel, a program that provides volunteers to the medically underserved areas of Cuzco and Sacred Valley. I volunteered with a group of local physicians, medical students, and nurses to provide health care. While I have the ability to speak Spanish, I had very small command of the Quechua language. Through history taking and working with a translator I was able to learn important words to help me communicate with my patients. I also lived in a rural area with an Andean family through an Immersion program sponsored through Maximo Nivel. This opportunity gave me insight into the daily lives of the rural Andean community, which allowed me to better relate and understand my patients. 

Results: A major part of osteopathic medicine is to provide holistic care to patients. With this principle in mind, it is important when providing outreach to a community that we learn about the social and traditional aspects of the people we seek to help. Through living in the community and volunteering at local clinics I learned about the local perception of Western medicine, misconceptions among the community about medical treatments, as well as local remedies. I was able to learn about the local diet, education, and lifestyles that have an impact on a person's health during my stay with the host family. With this knowledge I was better able to understand my patients' concerns while also educating them about preventive health measures. 

Conclusion: By living and experiencing the daily lives of our patients, we are able to better understand their needs and therefor better devise treatment plans. Learning from your patients allows you to better understand and treat their health problems. Patients that you treat abroad might have different health statuses due to different environmental factors. By educating yourself about their culture, language and traditions you will be able to better help the people you strive to serve. 

I hope you liked reading it. I am hoping to do another medical mission in a 2 years. I will keep everyone posted. 

Schlatter, Adrienne. "Benefits of Cultural Immersion in International Medical Relief—Sacred Valley, Peru" The Journal of the American Osteopathic Association vol. 114 no. 1 e48-e75, 

Wednesday, January 8, 2014

Californication

One side never ending coast line and the other snow covered peaks. California's evergreen trees and clear skies even in the middle of winter make it an amazing place to visit and the most wonderful place to live. After 5 months stuck in NJ I landed in SFO airport and was picked up by one of my good friends, Garima. I was excited to have the opportunity to see all my friends and family over the holidays.

The skies were clear and blue and the weather was warm enough for T-shirts and shorts. I headed to Roseville for my dad's art show and then hurried to meet my friend from Argentina whom had arrived the same night. On the way to meet up with her my friend who had gone to the airport to pick her up decided to pull a prank on me. My friend Tim said that they could not find her and had just left the airport to go back home without her. Of course I almost had a heart attack and scared the passengers in my car. Luckily it was a joke. 


Sole and I met in Machu Picchu two years ago, ever since we have been meeting every 6 months to travel together. It's always great to see her again. The distance makes me appreciate the friendship I have with Sole even more. Tim, Garima, Sole and I had a much anticipated reunion. We were all exhausted and headed to bed for a slumber party. 


We woke up to cook a typical Indian breakfast of aloo paratha and chai tea. After the filling breakfast we headed to SF for some exploring. First the Golden Gate Bridge walk, then the painted ladies, and Lombard street. We enjoyed clam chowder in a bread bowl for lunch at pier 39 (fishermans warf) and watched the sea lions fight with each other. We headed to the mission where we appreciated the street murals and the Latin culture. After the mission we headed to the Castro, which is the gay district of SF. We enjoyed window shopping and walking through the streets admiring the holiday decorations. 


That evening I took Sole to my favorite vegetarian restaurant, Saturn Cafe in Berkeley, to meet up with my friend Daniel. After a Space Cowboy veggie burger and a Turkish coffee milkshake we headed to the Claremont Hotel bar to enjoy the view of SF. Sitting on the lookout deck under warming lamps we enjoyed talking and fancy cocktails admiring the sparkling lights of SF across the bay.

The next morning we woke up and headed to see mi abuelita in Modesto. She recently had a second stroke, but is doing much better. She thinks I am her daughter (my mom) but that's ok because my mom is pretty cool. I am sure she wonders why I talk like a gringa (really badly), since my moms Spanish is perfect. After hanging out with mi abuelita and my cousin we headed back to Benicia to get ready for a night out in SF. I picked up my friend Hanna and we headed to SF for some drinks and a walk around Union Square. The weather was perfect. We enjoyed a couple different bars and a stroll down the main street, Market, where all the crazes come out at night. After some wonderful adventures in interestingly decorated bars we headed home. 


The next morning I dropped off my rental car and we picked up my friend Effie from Bart and went back to Benicia to prepare for Christmas dinner. We took a walk by the water and down the Main Street in Benicia. We feasted on turkey, mashed potatoes, cranberry sauce home cooked by my father, veggies, biscuits and stuffing. After dinner we enjoyed coco cake made my Sole and some pumpkin pie. My whole family got together, including my brother, and we sung holiday songs while Effie played the ukulele. After the singing we did some swing dancing followed by salsa and cumbia. We opened presents and went to bed hoping santa would leave us some more presents.


We woke up the next morning to have a breakfast of blueberry pancakes and scrambled eggs. Sole's friends from Buenos Aires came to visit from LA. We all drove to Berkeley to visit the beautiful UC Berkeley campus, and then to SF. We went to Ocean Beach and then out to eat in China Town. As a surprise Effie and I drove Sole to Coit Tower lookout. The view at night of the bay bridge and all the lit buildings is absolutely fabulous.

The following morning we woke up at 4am to drive up to Tahoe to go skiing. On the way up we picked up my friend Brooke. We skied and snowboarded all day through the evergreen pine trees, and despite the poor snow fall in California, we still managed to have a good time. It was Sole's firs time, but she did great on skis, she only fell when I was watching. We went to Tahoe to meet my friend Stephanie one of my classmates from medical school at a popular German restaurant in South Tahoe. 

After completely stuffing ourselves on spaetzle and German beers, we headed back to Brooke's parents home on the top of a mountain near Placerville. We went to bed in an oversized bed and woke up for brunch. Sole, Brooke, Brooke's mom and I went out to Cosmic Cafe (where Brooke and I use to chill back in the day, before I moved to the east coast). We had a very organic brunch and explored the caves that cosmic cafe uses as additional seating area. After brunch we said our goodbyes and Sole and I returned to the bay. 


We prepared for a night out dancing. We picked up Garima and headed to meet up with Sole's Argentinian friend. We went out dancing at The Cafe in the Castro. It was supposedly Sole's last night in Cali.

The next morning I drove Sole to the airport, we said our goodbyes and I started back home. Just Before I got back on the bridge I felt the urge to check my phone. Lucky I did because Sole's flight had been canceled and my whats-app was littered with distraught text messages. I turned back and picked her up from the airport. We sat at a Peets coffee and tea and tried to work out the situation. The people at the cafe were so nice, they saw that we were having a lot of trouble so they brought us free mochas and cookies. It felt so nice that someone cared. We left them a nice tip and a hand drawn thank you card. We were able to book a flight for the next day. 


We headed back to Benicia to meet with my dad. Sole and I had a relaxing walk by the water. We headed to my aunts house in Sacramento for a Christmas gathering. We played White Elephant game and Sole and I won a Kindle, which was perfect since that's exactly what Sole wanted for her trip. 

I realized that sometime things happen for a reason. Sole and I were able to spend an extra day together. She got exactly what she wanted for Xmas and so did I. 

Tuesday, January 7, 2014

Lucky Me

20 mins before my flight was about to depart from LAX to Cincinnati I found out my connecting flight to Philly had been cancelled. I boarded the plane to Cincinnati not knowing how long I would be stranded in below freezing weather. With the intent to take the next flight to Philly on standby, I had no hope that I would make it to my mandatory 1pm class.  When I arrived in Cincinnati I was greeted by an announcement that a flight to Newark, NJ was about to take off. I bolted from gate 1 to gate 18. Maybe the plane will still be there, maybe they have space for one more. 

I arrived at the gate huffing and puffing. The attendant at the desk gave me a seat right away and I was the last the board the flight. I took my seat, I was lucky to get a row to myself. I finished up my Bollywood movie and had a cup of coffee. Next hurtle is finding where my checked bag is. Probably still in Cincinnati. At least I will make it to class.