Team Meetings

Team meetings are essential to building a strong cohesive team. The meetings should include discussion of cultural traditions and behaviors; boundary setting; cultural differences and cultural sensitivity; and issues of dealing with extreme poverty, serious illnesses, abuse, and starvation. Illicit drug use and drunkenness are not acceptable behaviors on a medical brigade trip. Other issues to address are flights and lodging, itinerary, work schedules, local regional health issues, and practical tips for the trip. See Tables 6.8 to 6.13 for trip preparation materials.

The team should plan at least one or two tourist activities, such as sightseeing to the Taj Mahal and the Red Fort in the Delhi area. Shopping is also a fun experience for most team members, so selecting a hotel close to a shopping area is recommended.

Setting Up a Medical Camp

The host country/sponsor organization selects the sites for the camps and arranges the overall setup. For example, when working in the slums of New Delhi, the host rents tents that can be used in areas for slums that do not have school buildings. In some countries, established clinics, schools,

TABLE 6.6 Medical Brigade Pharmaceutical Resources

Medical Brigade Pharmaceutical Resources

Developed by Colleen Strand; modified by Lorna Schumann; reproduced with permission.

TABLE 6.7 Recommended Medications for International Medical Brigades

Analgesics, antipyretics, nonsteroidal

Antiinflammatory drugs

antiinflammatory drugs (NSAIDs)

Anesthetics

Antimalarial drugs

Antiallergics

Cardiovascular drugs

Antiamoebic drugs

Dermatologic preparations, disinfectants

Antiasthmatic drugs, antitussives

Diuretics

Antibacterials, antifungals, antiviral drugs

Gastrointestinal drugs

Antidiabetics

Laxatives

Antidiarrheal drugs

Ophthalmologic preparations

Antiepileptics

Psychotherapeutic agents

Antihelminthics, antifiliarial drugs

Vitamins and food supplements

TABLE 6.8 Short-Term Health Care Mission Team Leader Responsibilities

1. Begin planning the trip a year in advance. Decide on the type of project, dates, and location. Work with host country/sponsor team members to plan the medical brigade and determine the needs of the people.

2. Solicit application for team members and select a team. Interview and select team members about 6 months in advance so that they can request time off work.

3. Develop a budget that includes air flights, all transportation, housing, and food. Share the information with the team. Develop a plan for financing the trip.

4. Set up a schedule for team meetings and post trip debriefing. The first meeting should cover issues such as waivers, trip insurance, cultural sensitivity, appropriate behaviors for the trip, what to do in case of illness, how to obtain passports (if needed), how to obtain visas (if needed), needed immunizations, the approximate cost of the trip, and any issues the team members may have.

5. The team leader is responsible for coordinating medications and supplies to be taken on the trip. Each team member should pack the medications and supplies he or she is taking and make a list to give to the team leader. The number of bags allowed and the weight of the bags are determined by individual airlines. Some airlines allow only one checked bag free; others will allow up to three. Other luggage will need to be paid for, usually $25 to $75 per bag.

6. The team leader and host country/sponsor leader are responsible for the daily activities and debriefing activities. Should a team problem occur, the team leader and host country/sponsor leader should work together to resolve the issue.

7. Plan a posttrip debriefing meeting to discuss issues that occurred on the trip and since returning home. This meeting may need to take place on the last evening the team is together—some teams are composed of team members from other countries.

TABLE 6.9 Recommendations of What to Take for Medical Brigades to Developing Countries

Recommendations of What to Take for Medical Brigades to Developing Countries

TABLE 6.10 Pretravel Safety Precautions Review online travel recommendations:

• From the host country's embassy and other reliable resources

• Immunizations and medications (available at cdc.gov)

• Review State Department travel warnings (available at travel.state.gov/travel).

• Notify the State Department of trip purpose/travel itinerary (travel.state.gov or 888-407-4748).

• Collect team member licenses and colored copies of team member's signed passports/visas.

• Prepare a team emergency kit.

• Set up two or three team meetings. A conference call may be helpful using freeconferencecall.com.

TABLE 6.11 Travel Preparations

Documents

Passport

Application is available at travel.state.gov/passport Cost: $140 (adult first-time passport book and card) + $25 execution fee. Expedited services are an additional $60. Should not expire within 6 months after return to United States.

Visa(s)

May be required by individual country; check travel.state.gov/visa/ to determine visa requirements. Cost: Varies, but often around $150 to $200, when added to cost of FedEx, new photos, and the visa itself.

Immunization record

Some countries require verification of specific immunizations (especially yellow fever) to enter the country. Immunizations can be expensive for first-time trip members. The receiving country may require a photocopy of the yellow fever immunization when applying for a visa. Information is available at wwwnc.cdc.gov/travel/default.aspx.

Travel

Arrangements

Flights

Flights can be arranged online, but commonly used travel sites (e.g., Travelocity, Cheap Flights, Expedia) are often unable to book international travel to more remote settings. Help may be obtained from a travel agent or the airline. Consider choosing airlines that add frequent flyer miles based on connecting flights with partner airlines. An example is Delta/KLM/Kenya airlines to Nairobi. An excellent site for host country maps is WHO. int/maps.

Lodging

Hotels or other lodging facilities may not accept credit cards; other hotels may not accept all credit cards. If going to a malaria-endemic country, a bed net or net sleeping bag and mosquito repellant may be recommended. Recommendations of prophylactic medications can be reviewed at cdc.gov/travel. If air-conditioning is available, sleeping quarters need to be kept as cold as possible.

Food/water

Familiarity of types of food that will be available is helpful; if food security is a potential problem, bringing protein bars, trail mix, and water purification tablets may be necessary. A quality water filter is the Pre-Mac travel well "Trekker" (shop.eri-online.com).

Health Care

Medications

The Yellow Book 2014 from the CDC (wwwnc.

cdc.gov/travel/page/yellowbook-2014-home. htm) is a comprehensive resource for health risks and recommendations for every country including medications. The Yellow Book is also available for Android and iOS mobile devices. The iTunes store has a Yellow Book app for iPads and iPhones. In-country medications, if available, may not be correctly formulated or may be contaminated. They may also be expensive. One Zofran ODT is $5 in Ecuador.

When possible, enough medication (regularly taken medications and any prophylactic medications) to last the entire trip should be brought; some countries may require copies of prescribed medications, especially controlled substances; consider over-the-counter medications for pain, fever, nausea/ vomiting, diarrhea, constipation, cuts/scrapes, and insect bites. The team leader should obtain an emergency kit.

Bed nets

These provide protection in malaria-endemic countries.

Insurance coverage

Health insurance out-of-network coverage needs to be checked; evacuation insurance (e.g., medexassist. com) needs to be considered. Medicare/Medicaid does not provide coverage outside the United States.

Communication

Itinerary

All participants should carry a paper copy of the itinerary. An additional copy of the travel itinerary (flight, hotel, ground transportation) should be left with someone at home. Flight departures should be confirmed the day before traveling back to the United States.

In-country contacts

The names and numbers of in-country contacts should be left with someone at home; include country codes as part of the phone number.

Cell phones

Cell phone and data access can be expensive when used internationally; coverage and charges should be checked before departure to avoid huge bills upon return; purchase of an in-country cell phone is another option, with a SIM card to which more air time can be added as needed. Downloading WhatsApp to a smartphone for free text messaging when WiFi is available may be useful. Phone providers should be notified of travel outside the United States and may need details of the trip itinerary.

Money

ATM cards

Money exchange should be done before leaving the country. Banks can help with this process. ATM machines are becoming more available in developing countries, but it cannot be assumed one will be available in all locations; PIN number should be four numbers (many foreign ATM machines do not have letters, just numbers). Use of debit cards can be a problem; it is often safer to use credit cards. The card provider needs to be contacted before leaving; otherwise, the card may be terminated or useless. Special debit cards can be purchased for travel (e.g., Contour card). These can be thrown away when the balance is gone. Use outside the United States needs to be verified.

Traveler's cheques

Although fairly obsolete in many developed countries, traveler's cheques may still be used in some less developed settings.

Credit cards

In developing countries, many businesses (hotels, restaurants, shops) do not accept credit cards; if intending to use credit cards, the credit card company will need to be notified of travel plans.

Cash

All participants need to bring a certain amount of cash, exchanged as described earlier. In addition to personal expenses, there are always opportunities to help others (e.g., obtaining an oxygen tank for a young adult with tetralogy of Fallot). A working understanding of local currency is important to avoid overpaying or underpaying or being short-changed; there are smartphone apps that will help clarify currency exchanges. Cash should be carried in a money belt or belly pack. Some countries (e.g., Thailand) have a better exchange rate for larger bills.

TABLE 6.12 Packing Suggestions

Checked Luggage

Airline luggage limits need to be reviewed. Frequent flyer programs allow three free bags for Elite members.

Unnecessary personal items (e.g., expensive jewelry/equipment) need to be left at home. Personal medical equipment without batteries may be checked. Expensive personal or other medical equipment with batteries will need to be in carry-on bags.

Pack:

Water filter, if bottled water will not be available (eri-online. com/ ERI_Equipment.html)

Clothing appropriate for the weather and culture

DEET

Itemized list of medications and supplies Gifts for hosts and children Towel and washcloth

Carry-on Luggage

Lightly packed, there may be limits of 10 kg. Include:

Extra change of clothes (in case luggage gets lost or delayed)

Toiletries

Travel documents

Personal medications and medical equipment Belly pack Cell phone

TABLE 6.13 Airline, Hotel, and Transportation Safety

Airline Safety

If there are unusual items being transported, the airline needs to be checked with in advance.

Unruly passengers need to be avoided.

Passport needs to be carried on the body.

Hotel Safety

Rooms between the second and sixth floors are recommended.

Hotel business card should be carried in a wallet/belly pack, with the wallet in a front pocket.

The hotel escape plan should be reviewed.

Clothes, wallet, and shoes should be kept in the same place for emergency exiting.

Participants should be observant and avoid crowds. Room safes are not safe.

Transportation Safety

Gasoline shortages are not uncommon in resource-poor settings; it is important to verify that your transport has enough gasoline to complete journeys.

Some modes of transportation are relatively unsafe (e.g., minibuses). In some countries (e.g., Guatemala), public buses are not safe.

Some cities have very high rates of traffic accidents, particularly after dark.

or churches/temples can be used for the camp. Occasionally, setup may be under a tree.

Setup needs to include a patient check-in station (a triage nurse and interpreter) as the gatekeeper area for the flow of patients. Table 6.14 provides a list of common diseases seen in Central and South America. A similar analysis can be made for any region or country in order to prepare.

TABLE 6.14 Common Diseases/Disorders Exemplar—Central and South America

Burns/trauma/work injuries

Eye

Shoulder, neck, back, and leg pain

Conjunctivitis

Cataracts

Glaucoma

Blindness

Pterygium

Pinguecula

Cardiac

Fungal infections

Hypertension

Vaginal: vulvar candidiasis

Feet

Oral

Skin

Tinea versicolor

Ear, nose, throat (ENT)

Gastrointestinal conditions

Cerumen impaction

Parasites: pinworms, amoebas, Giardia

Otitis media

Gastritis

Otitis externa

Peptic ulcers

Diarrhea/ constipation

Endocrine

Genitourinary

Type 2 diabetes

Urinary tract infections

Hypothyroidism

Benign prostatic hyperplasia

Prostatitis

Bacterial vaginosis

Irregular menstrual cycles

Pregnancy

Chloasma

Musculoskeletal problems

Other infectious diseases/

Arthritis: osteoarthritis and rheumatoid

mosquito-borne diseases

Post trauma pain

Sexually transmitted infections

Back pain

Dengue fever

Myalgias

Malaria

Chikungunya (Africa/India/Caribbean)

Neuropsychologic conditions

Respiratory diseases

Depression

Colds

Headaches

Chronic cough

Seizures

Bronchitis

Peripheral neuropathy

Asthma

Pneumonia

Environmental allergies

Nutritional disorders

Skin

Malnutrition

Rashes

Dehydration

Scabies

Anemia

Infections

Hyperhidrosis resulting from lack of

B vitamins

Many organizations have developed forms for recording patient identification information, vital signs, allergies, current medications, significant medical history, and a list of problems the patient wants treated. Teams will need to consider limiting the number of problems they can deal with per patient because there are often many people waiting to be seen. Occasionally, providers are faced with unknown diagnoses.

Although individuals usually queue up on the basis of first come, first serve, or the sickest first, there is often crowding and claiming rank and status. On a medical mission in a Delhi slum, a Mercedes pulled up, and an elegantly dressed woman went to the front of the line. No one seemed to be bothered by this, except the team members.

Referrals/Transfer to the Hospital

Before opening the clinic, organizers need to check with hosts about referrals and transferring patients to the hospital. In some countries individuals refuse to go to the hospital because of bad care and high mortality rates. These individuals may also become angry that the team is unable to resolve their problems. The host country/sponsor administrator is the best person to deal with these issues.

Home Visits

Team members may be asked to do a home visit on an individual who cannot come to the clinic or who is dying. For safety, it is best that several members of the team accompany the interpreter. Culturally, this is often a very positive experience for the team members because they have the opportunity to experience what the individuals deal with on a daily basis. Wound care may require daily visits.

Team Member Injuries/Serious Illnesses

Typically, most team member illnesses can be treated by the team. However, if a team member is seriously injured, evacuation may be required. Evacuation may also be required for serious illnesses. Contact information for the in-country U.S. embassy can be obtained at travel.state.gov. The emergency number for the U.S. embassy is (888) 403-4747. Trip insurance is highly recommended because evacuation can cost more than $50,000 and in-country treatment can also be very expensive. Most U.S. medical insurances and Medicare/Medicaid do not provide coverage outside the United States. Trip health insurance can be obtained at travel.state.gov/travel/tips/brouchures/ brochures_1215.html.

The online brochure from the Smart Traveler Enrollment Program (STEP) contains excellent information on safety and preparedness. The link is travel.state.gov/tips_1232.html.

In-Country Debriefing

Ideally, debriefing should occur each evening in an informal setting. Discussion includes listing what activities went well and what activities should be improved. A list of needed medicines/supplies that are to be purchased while in the country should be compiled and then shared with the host in case the host is able to facilitate the purchase at a discount. A running list of recommendations for the next trip is another task for the team leader. Should team conflicts occur, the team leader and the host deal with the issues.

Post trip Debriefing

Team members need to be given the opportunity to process life-changing experiences, air feelings and reactions, and discuss what worked and what needs to be changed for the future medical brigades. The team leader may need to talk to individuals who had traumatic experiences in caring for patients. Team members may need to receive parasite medications. View Table 6.15 for recommendations on parasite treatments.

 
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