Adventure Doc

I guess you could call this post a “review” of the books I think are great to study from. As I run into some new books, I’ll put them up, too! Like anybody reads this, anyway. The two people, including my mom who read this, please tell me any books I might not know about!

TRAVEL:

Travel and Tropical Medicine Manual
By: Jong and McMullen
0-7216-4214-4

Control of Communicable Diseases Manual
By: American Public Health Association, Edited by D. Heymann
0-87553-035-4

WILDERNESS:

Field Guide to Wilderness Medicine
By: Auerbach, Donner, Weiss
0-323-01894-7

This list is in no way complete, but a good place to start. In fact, these are the books I often refer to, the most. Anybody want to mention any others?

Traveler’s Diarrhea

This is, by far, the most common illness that affects people who travel. Traveler’s diarrhea can happen to anybody who leaves his or her city. This is because, when you travel, you encounter viruses and bacteria that are different to the ones that are in your hometown. Your body hasn’t built up immunity to this foreign stuff and it makes you a little sick. Sometimes it feels like it makes you a lot sick!

My main concern with diarrhea is whether there is blood or not. Most cases of diarrhea without blood do not need antibiotics or treatment other than a lot of fluids. When you have diarrhea, the water that your body stores is lost in the watery poop or vomit. It is essential that this be replaced! The normal amount of water your body needs per day (about 2-3 liters) must be replaced, in addition to what you are losing. Anybody that has had a bad case of diarrhea knows that this can be a lot of water. I advise replacing this lost water with water combined with a sports drink, such as Gatorade or Emergen-C. Make a glass of water only half-full and fill the rest with Gatorade. The Gatorade or other sports drink has potassium, salt and sugar (salt and potassium are important electrolytes). All these electrolytes are lost from your body, along with the water. Further, the sugar (glucose) in these sports drinks helps the water you drink get from your stomach and intestines into your blood stream quicker. This is where you need the water the most! If you are vomiting along with the diarrhea, still try to drink the mixture of water and sports drink. Even though it seems you are vomiting all of the drink back up, some is staying down and it is important to get even a little bit.

If you get into a tight spot and don’t have a sports drink/electrolyte drink to mix with your water, you can make your own. Two pinches of salt and two pinches of sugar added to a full glass of water will do the trick. Another piece of advice is to watch what you are eating for a few days. A bland diet of toast, soups, salads and fruit will help sooth an upset stomach and provide much needed water and electrolytes.

If you are seeing blood or running a fever, you should speak with your doctor. The presence of blood in the feces means that some bacteria is damaging the inside of the intestines and causing the lining of the intestinal wall to breakdown. This is a need for antibiotics. Of course if you have special circumstances such as being immunocompromised, pregnant or other chronic/long term illnesses and have any diarrhea, you should check with your doctor.

I am what you would call an “Adventurous Eater”. I eat at places I probably shouldn’t. I will try any new food. This is part of traveling to me. I also have frequent trouble with traveler’s diarrhea. This is a risk I know about and take. At the end of the day, the risk is up to the individual. Use your own common sense and judgment.

The majority of traveler’s diarrhea is caused by a bacterium called E. Coli. In fact, most cases of traveler’s diarrhea are from the E. Coli bacteria (up to 80%). There are a few types of E.Coli bacteria. There is an invasive form (EnteroInvasive E. Coli or EIEC), which can cause the bloody feces. There is a toxic form (EnteroToxic E. Coli or ETEC) that produces a toxin that does not usually cause bloody stools (poop). There are a few other types, but these are the main ones to know about.

Viruses are well known to cause diarrhea and some of the bad guys that do this are Rota Virus, Adeno Virus and Calici Virus (the famous Norwalk Virus is in this family). The problem with most viruses, in general, is that there is no real cure or treatment. The good thing is that, in most healthy people, viruses generally make you ill for a few days then go away on their own. Viruses that affect the GastroIntestinal (GI) System (stomach and intestines) do not usually cause bloody diarrhea. Rota Virus generally affects kids (6months to 3 years old) in developing countries. The Norwalk virus was made famous from several outbreaks that occurred on cruise ships. Viruses are very contagious and easily spread from person to person. The best way to stop the spread of GI viruses is to wash your hands, very often, with soap and water. Do this especially before you eat.

There are few other bad guys are capable of causing diarrhea in the traveler. One example is Giardia. This is a parasite that is most commonly seen in hikers and backpackers that drink from streams or lakes contaminated with the Protozoan (a type of microscopic organism). The way mountain lakes and streams get contaminated with Giardia is by people or animals defecating near the water. This is why you should always go at least 200 meters (2 football fields) away from the water source before “unpacking breakfast”. Giardia can be found worldwide, even in North America. To prevent this, hikers and backpackers should filter their water with a purifying system or use a bit of household bleach. I advise 2-4 drops of household bleach per liter of water (0.1 to 0.2 mL of bleach per liter). Boiling the water for at least 15 minutes works well, too. Iodine drops or tablets have been shown to be the worst method to use, as it is unreliable in killing the cystic form.

Cholera is a world famous bacterium. Cholera has caused several worldwide Pandemics as recently as 1994. Most of the problems were in developing nations. Cholera causes a severe form of watery diarrhea associated with vomiting. Cholera is common in developing nations, especially those in the tropics. Treatment for this nasty bacterial infection is aggressive re-hydration. Drink lots and lots of water! In healthy adults, Cholera generally lasts a few miserable days to a week and goes away on its own (if something goes away on its own, doctors call it “self-limiting”). In children, Cholera can be deadly due to the massive dehydration. Cholera kills many children in developing nations, just because they lose too much of their body’s water and can’t replace it! People get Cholera by eating or drinking water infected with the bacteria. This is why you should drink bottled water and eat at reputable restaurants with good hygiene, especially when traveling in tropical nations. Boling water is also effective, but often impractical in a hotel room. There are several vaccines available to prevent Cholera. They do not work very well and only provide protection against some types but not all. Further, they do not protect very well against the types they do cover either. I generally advise skipping a Cholera Vaccine and try to teach people what I have just said. Watch what you eat and drink. If you suspect that you have been exposed to Cholera, begin to replace the lost water from the vomiting and diarrhea with a water/electrolyte drink and contact your doctor.

Immodium? That seems to be a big question for travelers. Should I take it or not? There are some benefits and some negatives. Immodium is an anti-peristaltic drug that slows down the time it takes feces to move through your intestines. This means less diarrhea. Immodium (loperamide) decreases the number of loose stools by 80%. However, Immodium can trap invasive pathogens in the intestine, giving them more time to do damage to your body. The general rule is that if the diarrhea has blood in it, it is invasive. Invasive diarrhea means that the bacteria or pathogens are really damaging the intestinal wall. The last thing you want to do is trap them there, so the can do more damage. You want to pass them out of your body, as quickly as possible. However, if there is no blood in the stool and you are sure about this, immodium is great for slowing diarrhea down. This is especially important for business travelers and special circumstance trips, such as honeymoons. Please remember that early in an infection, the blood may be difficult to see, in the stool. A doctor can tell by performing a simple test. If there are any doubts, see a physician.

Another option for diarrheal control is bismuth subsalicylate (Pepto Bismol). Pepto-Bismol (bismuth subsalicylate) decreases the number of loose stools by 50%. Two tablets taken 4 times per day, Pepto is a good option for those looking for prophylaxis against traveler’s diarrhea. Pepto should be avoided by people with allergies to salicylates (aspirin) or those taking anticoagulants.

I am frequently asked about prophylactic antibiotics for travelers and I only advise their use in cases where travelers have a history of a prior medical condition such as HIV, inflammatory bowel disease or heart disease. Again, this is a decision that should be made between you and your personal travel doctor. Bactrim (TMP-SMX) or a flouroquinolone are generally the most common options.