ExpedMed CME Adventures: Polar Bears of Churchill

An up close visit with one of the polar bears of Churchill.When we began building ExpedMed, we tried to look for ways to expose medical professionals to Expedition Medicine and Wilderness Medicine experiences in authentic ways.  We recruited the best faculty and published an acclaimed textbook to help us present these important topics.

In 2009, we began offering CME trips to give our participants "hands on" experience in exotic environments.

Our goal was to partner with the best travel companies in the world. Our partners were expected to have not only exemplary records of safety and expertise in their travel programs, but also be committed to eco-friendly policies and sustainable growth practices that invest in local, indigenous poulations.

Downtown Churchill, CanadaOur first trip was with Tusker Trail, one of the preiminent safari and trekking companies in Africa.  Tusker leads our Kilimanjaro CME trips each year.

Our most recent trip was to Churchill, Canada to visit this remote outpost that sees more polar bears than anywhere on earth.  We selected travel company Frontiers North Adventures to partner with our ExpedMed team, and the result was a great experience in the "frozen tundra."  This is a quick report on our trip...

Our trip was in later October and began in Winnipeg, Canada.  

Winnipeg is a medium-sized city in which I was able to spend a few days.  During my time in Winnipeg I took a recommendation from Urbanspoon and visited Hermanos, a local restaurant.  The food at Hermanos was great.  I went there twice and got great service and ate the ribeye each time.  Fantastic.  I even splurged one night and tried their Black Gold dessert which was incredible.  Great place to eat.

The morning of the trip, our ExpedMed group boarded a shuttle and were transported with the rest of the Frontiers North crowd to a private jet for our flight to Churchill.  It was efficient and stress-free.  We had plenty of space to spread out and we landed in Churchill without any problems.

When we were on the tarmac, the wind was howling and the temperature was noticeably cooler than it was in Winnipeg.

I was ecstatic to finally be in Churchill, a town I had read about years before as an amazing intersection of polar bears and humans.

We spent that first day touring the small town and visiting the "polar bear jail," a place where polar bears are sent when they wander into town. 

Churchill has been dealing with polar bears for so long, they have developed a system for protecting the humans in this remote outpost and also being respectful and protective of the bears.  Any polar bear that wanders into Churchill is either tranquilized or, more often, caught in one of the large polar bear traps.  Once captured, the bear is sent to the "jail" for a period of time then flown outside the city and released.

Late in the afternoon our group boarded a famed "Tundra Buggy" and headed to our lodging for the next few days:  the Tundra Buggy Lodge.

Those touring Churchill can decide to stay in town or in the Tundra Buggy Lodge.  Our group booked rooms in the Lodge so we could get the feel for staying out on the Tundra, in the environment of the awesome creatures we hoped to see.

The next few days went by quickly.

We spent our days rolling around the tundra looking for bears and the evenings sharing excellent food and good company in the Lodge with our fellow travelers.  

While Churchill and the Tundra Buggy Lodge were interesting experiences, the bears were the stars, of course.

Polar bears are incredible animals, well-adapted to their frozen environment.  I had seen a few during my trip to the North Pole in 2008, but these bears were up close-- really, really close.  It was a privilege to see these magnificent beasts a few feet away from our Buggy, and a series of moments that I will never forget.

At some point in the future I hope to post some more about Churchill, our ExpedMed adventures, and polar bears, but for now I must round this up.  I'll finish with a few more photos and a video of one of the big bears as it approached out Buggy heading for a seal carcass.

Our plane arrives in Churchill

A Tundra BuggyPolar bear in front of the Tundra Buggy LodgeTwo polar bears An ExpedMed lecture inside a Tundra Buggy


Great White Shark Cage Diving CME Itinerary

Hey guys.

For those of you who want more information on our ExpedMed Great White Shark Cage Diving CME Adventure , we just posted the detailed itinerary.

For those who can't find the time to click over to the Great White Shark Adventure informational page, here's the itinerary below.

More information about our dive partners, Shark Diver, can be found on their website: 


Shark Diving Itinerary

Welcome to Shark Diver.Your dive expedition to the Pacific's most pristine and robust white shark dive site leaves from San Diego's famous H&M's Landing, 10 minutes from San Diego's airport and home to California's long range fishing fleets. Shark Divers vessel the MV Horizon boards divers from California to Isla Guadalupe. We are on site usually 20 hours later and beginning your first exciting white shark cage dives after a hearty breakfast. We take a maximum of 12 divers per trip - perfect for dive clubs, corporate groups, film crews, and photographers.

Day One

Boarding begins at 9:00pm -11.00pm on the evening prior to your expedition date. Prior to boarding most of our divers have booked with the Holiday Inn Bayside under our special Shark Diver Rate, we are happy to be working again this year with the Bayside, our 8th season with them. Divers generally come in a day early and take advantage of the Baysides free airport shuttle service and 7 minute location from the international airport. Our divers also like discover San Diego's Gas Lamp District, home to some of California's top restaurants and entertainment venues located minutes from the hotel. If you're coming to San Diego early plan on visiting the town. We generally depart from the docks at 11:00-12.00pm. Travel time to Guadalupe is approximately 20 hours. Once you arrive to the vessel you'll be greeted by Martin Graf, your dive operations manager. Martin holds the enviable distinction of spending the most time at Isla Guadalupe aside from the shark researchers at CICIMAR. His wealth of shark knowledge and dive operations prowess makes Martin our top choice again this year to run the white shark program on the MV Horizon. He also speaks German and Swiss fluently and works in tandem with the entire vessel crew who you'll soon get acquainted with. For now it's time to get settled and into bed, try and get some sleep because in a few hours from now the next time you set your head on your pillow just know there will probably be two or three white sharks swimming underneath it!

Day Two

We will arrive at Guadalupe approximately 9:00 am (breakfast time). The arrival to the island is, and remains, one of our favorite moments. For many of our shark divers who booked with us almost a year ago this is it, the Island of the Great White Sharks, you have arrived. If you're an early coffee drinker this moment will be etched in your mind for the rest of your life as you stand on the bow of the vessel taking in the scene. Guadalupe's craggy volcanic flanks rise 4000' to literally scrape the bottoms of cloud formations here, it's a big island. The large rock off to the tip of the island is Point Norte, or Shark Fin Rock, we'll pass this on to the small bay just ahead, white shark central. Upon arrival, we anchor, deploy our huge shark cages and begin operations. Breakfast is served in the galley, and Martin will be doing an in depth dive safety review prior to your cage time. Cage diving rotations are usually one hour at a time and the vessel is divided into four crews of three with six divers in the water at any given time. Your first cage dive is usually preceded by someone yelling "White Shaaaark!". A few years ago we had a young deck hand "Mikey from Main" who's tell tale white shark yell is a tradition we carry on to this day. Welcome to cage diving, keep your eyes open as you walk down a short ladder into the industries largest shark cages, chances are in a few minutes you'll ba face to face with the Great White shark. Lunch is served around noon and for most divers this is a welcome break from the morning and getting used to the world of cage diving. We pick up the afternoons cage diving rotations after lunch or power through depending on the shark action this day. Dinner is served approximately 6:00pm. After a hot shower and a change into your post shark encounter clothes, it's time for a sunset beer, or three on the bow with the other newly minted shark divers. Congratulations, it took you a long time to get here, but you did it, and now you're ready for the next two days of white sharks, and more. You are an official Shark Diver.

Day Three

If we decide to try a different site, we move early and begin operations at sunrise. Cage diving continues throughout the day and rotation times will be increased. Usually we stay in place as our crews and vessel captain know where to place the vessel and where the sharks are. Chances are you'll see another long range boat in the bay, but the sharks will transit from boat to boat, and with the density of animals on site everyone get's into sharks. We may get boarded by the MX Navy while were on site. They will board each vessel at least three or four time during the season. They are looking for valid commercial shark diving permits, passenger manifests, and some water or a soda. These young marines work very hard with little pay, so we always offer them lunch and water. Do not be surprised to see guns, this is a a typical Mexican boarding procedure and they have been doing this since 2008. The good news is their presence deters unlawful sport fishing boats who, in 2007, hooked a white shark right in front of us. Fortunately we sent a small boat over to them to film what they were doing and they soon cut the line and ran away. Having the MX Navy on site is a good thing. Day three ends as day two did, by now you have moved over to the expert class of Shark Diver and you know what the color of a white sharks eye really is. Only a real shark diver knows this so consider yourself one of the fortunate few. Like we said before, tonight when you go to sleep just know that a few feet below you lurk some of the white sharks you have come to know over the past few days. Shredder with his unique dorsal fin, Fat Tony, Mau, or even Bruce. They'll be here when you wake up.

Day Four

By now, everyone will be old pros and enjoy the relaxed feel of things. Your shark cage team will be some of your best friends even after this latest adventure with Shark Diver. Cage teams typically assign names for themselves, "The Wild Ones", "Team Dark Tide" when it's time to go cage diving you're team is ready and able, knowing where all the gear is located and how to suit up. Our photographers will be focused on getting the "best of the trip" shot and shark fans will now be able to accurately measure, sex, and identify each new shark. Shark Diver has a share and share alike policy towards shark images. Basically if you happen to nail the best trip shot, share it. Each night we provide memory sticks so divers can offload images and share them with each other. That way every divers goes home with the absolute best images they can, a group effort. The last cage rotation is always bitter sweet, time to say good by to animals that have captured our imaginations since, for many, childhood. It's amazing but sometimes if you really connect with an animal, there's a moment where the two of you just click. Shredder has been clicking with divers since our first season, and we hope you get to meet him this year, as he has proven to be quite a unique and wonderful animal.We depart around dinner time and head for home, make sure you take some last minute snap shots of Shark Fin Rock on the way out, usually the light is just right and it's a great way to say good by.

Day Five

We travel back to San Diego and arrive at the docks approximately 5:00 - 7:00 pm. 

New ExpedMed Adventure: Little Saint Simons Island

Just wanted to check in with you guys and let you know about a new CME trip we've developed here at ExpedMed for February 28 - March 3, 2013.

The trip is on Little Saint Simons Island, a private island that allows no more than 32 overnight guests, has seven miles of pristine beach, in overrun with birds, gators, dolphins, crabs, fish, deer, and other amazing wildlife, and has won numerous travel awards for its incredible food, history, service, and sustainable eco-friendly policies.

Little Saint Simons Island is an incredible place.  It's been in private hands for over 100 years and was converted from a hunting lodge into an eco-resort.  I toured it recently just to make sure it's what we would need for an event, and it was awesome.  

While on the island, I saw a bald eagle adult sitting on its nest with a chick peeking out over the nest edge, two adult gators (and two young gators), lots of birds, and wandered along a beach with no one but my friends as far as I could see in any direction.

The food was incredible and the cottages were really cool-- many were originals that had been updated with AC and electricity (but no tv, thankfully!).

Although we’ve reserved the entire island, I only have 11 rooms available. The cost per room is $1,950 which includes three nights on the island, all food, and all activities for two people.  

Activities include fishing (with all gear and bait), kayaking, guided tours of the island with naturalists, biking, exploring with motorized skiffs, beach wandering, bird and other wildlife watching, and hiking.

Rooms are double occupancy so if two people are in the room it's $325 per night each for three nights.

We are offering our 20 hour online course for CME plus 8 hours of live CME training.  CME fees are $799 (for a total of 28 hours of Category I CME).  

Please let me know ASAP if you are interested.  I’ve already sold three rooms and only have 8 more left.  

This is an incredible opportunity to visit one of my favorite places on earth.  By the way, kids are welcome and will love it-- when I toured the island last week I took my five year old and another dad with his 5 year old son.  Both the kids went crazy-- it was an awesome experience for all.

Travel Aps

I've been a loyal Mac guy for almost ten years now, and I've owned an iPhone since 2008.  I don't have a lot of cool aps for my iPhone, but there are a handful of aps that I take on the road with me when I travel.  I'm sure there are plenty of other good programs for all the road warriors out there, but these are some of my favorites.

1.  Tide GraphTide Graph

This is a handy ap that gives you the tides of any location in the United States.  You can track the tides and look ahead to see what they will be in the future.  The graphics are very intuitive, and well laid out.  Whenever I'm on Saint Simons Island, I use this ap quite often to let me know when it's paddleboard or fishing time.  ($1.99)

2. Kindle

If you're a Kindle person and you have an iPhone, you really need to get the Kindle ap.  Kindle is a great way to read all your ebooks, and what's especially cool is that it automatically synchs between your other devices.  For instance, if I read ahead on my iPad, when I open the same book on my iPhone it scrolls ahead to where I left off on the iPad-- very handy if you have more than one device. (Free)

3. White Noise

This ap is an awesome travel aid.  I've been using this ap for the past year and have turned it on to help me sleep during the day after night shift, and also to listen to through headphones when I'm trying to focus in a noisy location (like trying to read in a public area).  This ap generates a variety of background noises that are steady and soothing. My wife and I also use it to help the kids go to sleep when when in unfamiliar environments (like a new hotel room, etc...).  Below is a video demonstrating this ap ($1.99):


4. Urbanspoon

I like Urbanspoon, and while I don't use the website or ap often, when I'm in a new city I've found both to be very useful.  The ap is very easy to navigate and provides a lot of information very quickly.  One of the best features is that this ap can use your location to find nearby restaurants and estimate the distance to each.  Very useful for someone with limited time to grab a bite in an unfamiliar city. (Free)


These are the few aps I use routinely when I travel.  If you have others, feel free to make suggestions.

Great Restaurants in the Southeast U.S.

Hot and Hot Southern BouillabaisseOne of the things I love about travel is trying out new restaurants, and when I find a good one, I tend to stick with it.

Over the course of the past few years I've spent a lot of time in the southeast United States, so I thought it might be a good idea to highlight a few of my favorite places in a handful of cities I frequent.  Of course, there are other eateries that I enjoy-- BBQ joints deserve their own separate post-- but these are the ones that really come to mind when I think of great food.  

Here's my short list, in no particular order:

1. Hot and Hot Fish Club, Birmingham, Alabama

Of the restaurants mentioned in this post, Hot and Hot is the one I most recently found. I took my wife there on a date recently and it didn't disappoint.

Hot and Hot's gotten rave reviews from a variety of sources, and I first heard about this place when it was featured in a magazine I was reading (though I can't remember which magazine off the top of my head).  It specializes in fresh, southern food, and it's frequently changing menu is loaded with interesting dishes.  When my wife and I went, she got the Simple Grilled Tuna and I tried the Hot and Hot Southern Bouillabaisse.  Both were excellent.

Chris and Idie Hastings run the Hot and Hot and Chef Chris came out from the kitchen to greet some guests near our table.  Seemed like a nice guy.  The restaurant was cozy and busy, just like you'd imagine a hip, southern restaurant being.  My wife and I will be back sometime soon and consider the Hot and Hot a nice addition to our restaurant rotation.  The Hastings can be followed on Twitter at @HotnHotFishClub


2. McCrady's, Charleston, South Carolina

I must begin with a confession: I love Charleston.  It's a super-cool town with great food, amazing history, and lots of Southern charm.  Of all the excellent restaurants in Charleston, though, my absolute favorite is McCrady's.

McCrady's is named after Edward McCrady, the guy who in 1788 built the original structure that now houses the restaurant.  The building is listed on the National Register of Historic Places and Landmarks and is one of the draws of dining in this establishment.

The Executive Chef of McCrady's is Sean Brock, whose award-winning cuisine has been featured on numerous television shows and in many periodicals.  Chef Sean maintains a blog that you can check out here , and his personal website is here .  He can be followed on Twitter at @hseanbrock .

Whenever I am in Charleston, I try to hit this spot.  It has incredible food in a very cool location.  Be sure to check it out if you're ever in the area.


3. Halyards, Saint Simons Island, Georgia

 My family and I call Saint Simons Island home when we're not traveling hither and yon for work or pleasure.  It's a great community located just off the southern Georgia coast, and it's also home to some great places to eat.View of Jekyl Island from Neptune Park on Saint Simons Island

Whenever my wife and I want to join friends for a great meal, we head over to one of our favorite restaurant haunts: Halyards.  Everything I've had at this place has been excellent.  

Halyards is run by Chef Dave Snyder, who also owns and operates the popular restaurant Tramici .

Since I am a creature of habit, I get the same thing every time I visit Halyards-- the Grilled New York Strip with sweet potato fries, sauteed Shiitakes, and soy lime butter.  This is also a favorite meal of my buddy, PGA Tour pro Zach Johnson, who Zach Johnson's New York Stripwas so happy to be eating there one recent evening that he actually texted me a photo of his own New York strip.  I've posted Zach's steak photo for all you golf fans out there.


4. Kinkead's, Washington, DC

Okay, so this really isn't the southeast per se, but Washington, DC, is really its own little territory so I'm still going to count it.

Every year we have the Expedition Medicine National Conference in DC and my wife and I always try to swing over for one meal at Kinkead's.  

Described as an "American Brasserie," this restaurant has some of the best seafood I've ever eaten.  Plus, since this is DC, it is an interesting place to do some people watching and check out the other tables filled with foreign diplomats and recognizable politicians.

Kinkead's was founded and is run by Chef Bob Kinkead and, as would be expected, has won many prestigious awards for culinary excellence.


So there you have it-- four of my favorite restaurants in the southeast United States.  Stop by these fantastic locations sometime and tell them you read about them on the ExpedMed blog.

The Art of Flight

I mentioned the guys at Brain Farm in a prior post, so I thought I'd give a quick plug for their latest amazing project, The Art of Flight .
This video is incredible.  I downloaded it a few weeks ago and was amazed by the cinematography and incredible snowboarding skills of the pros on this film-- and I don't even snowboard.
If you get a chance, check out the video and if you want a quick peek, here's the trailer:

Kilimanjaro & Wilderness Medicine CME

Climb Kilimanjaro for your CME?

In the summer of 2009, I was working in my local Emergency Department when my cell phone informed me of an incoming text.

"At 14,500 feet. Preparing to summit tomorrow. All is well," read the text.

"Great," I thought, "and here I am dealing with sniffles and low back pain."

The text had come in from the face of Mount Kilimanjaro, the highest peak on the continent of Africa and one of the famed "Seven Summits."  The sender was my good friend Dr. David Townes who was helping lead a group of physicians to the summit of Kili for an ExpedMed CME event.

I was happy for Dave and excited for the CME participants, but also insanely jealous.  

Kilimanjaro is one of those romantic "must do" experiences for adventures around the world.  It stands just over 19,000 feet in northeastern Tanzania and rises independently from the plains of the surrounding region.  Mentioned by famed writers like Hemmingway (The Snows of Kilimanjaro), this magnificent peak towers over the African landscape and is the backdrop to many classic safari portraits.

I am pleased to say that Dave and the rest of the ExpedMed CME group made it to the top of the mountain in 2009.  The participants enjoyed it so much, we swore we'd lead another group back to Kili in the near future, but of course, as often happens, months turn into years and no new ExpedMed Kilimanjaro climbs were scheduled-- until now.

In the spring of 2012 we have scheduled another CME climb up Kilimanjaro.  The dates are March 24-April 6, 2012 .  Our outfitters are once again our esteemed friends at Tusker Trail.  Details of the CME trip can been seen at this Tusker link.

Find more information including pictures from the last Kili CME climb can be found on the ExpedMed Kilimanjaro CME Adventure page under the "Expedition & Wilderness Medicine Adventure" tab above. Here's a video about this majestic mountain:

The Adventures of Tintin

Yesterday I went with my family to see The Adventures of Tintin, an animation movie based on the international best-selling comic books.  The movie was made in both standard 2D and 3D.  We watched it in 2D since we didn't think our 3 year old would keep her 3D glasses on.
The movie is directed by Steven Spielberg and produced by Peter Jackson.  The animation is incredible and the storyline is a rolicking, international mystery adventure that takes the viewer all over the world.  My kids loved the action, but at 4 years old, 3 years old, and 4 months old, I thought they were a little young for all the violence.  It would be more appropriate for an older child.  If your kids liked Lord of the Rings or Harry Potter, this is about the same level.
I did really appreciate the fact that a show like this might encourage kids to become interested in fields like journalism, archeology, science, and/or exploration.  Enough of the video games!  Let's get kids off the couch and into the wild!

Motor Vehicle Travel: The Real "Death Zone" of International Travel

How do most physicians die in international medicine?

Here’s a pop quiz:  The most dangerous thing you and your companions will do while on your next expedition is:

(A) Trek to 14,000 feet while trying to avoid altitude sickness

(B) Push through that jungle trail hoping not to pick up a malaria parasite along the way

(C) Dive deep in the ocean while dodging Great Whites and the Bends

(D) Drive from the local airport to your hotel

If you answered “D” then give yourself a prize.

When most people think about international travel risks, they think about terrorists, wild animal attacks, exotic infectious diseases, or some other uniquely international threats such as lava flows or voodoo hexes.  However, many people are surprised to learn that statistically, the most dangerous thing they’ll do during their international trip is drive in an motorized vehicle.  Mountaineers talk about the “death zone” on a high-altitude peak, above which life is very sketchy.  For most international travelers, their “death zone” is a busy road in an unfamiliar international location.

According to an article published in the Public Health Reports , the most common way American civilians die abroad (excluding chronic "natural" causes such as heart disease or cancer that roughly correlate with typical US death rates for age and gender) is in traffic accidents.  The only recent exception to this rule is humanitarian workers in areas of conflict—in these cases intentional violence is the most common cause of death .

With so many people dying on the roads while traveling abroad, what are some basic travel-safety tips for medical officers to consider?  Below is an excerpt from the Travel Safety chapter of our Expedition & Wilderness Medicine textbook that was written by Dr. Michael VanRooyen, Director of the Harvard Humanitarian Initiative:

Consider a few practical tips for traveling via automobile when traveling abroad. This includes avoiding the temptation to drive yourself.  If you can hire a local driver, you might get a better sense of the region you are traveling, and if there is a traffic mishap, you are not held directly (and financially) accountable.  If you have to drive, take your time, know where you are going, and seek major routes.  It is also wise to avoid driving at night. Navigating the poorly lit roads in Nairobi in an unfamiliar vehicle, with many pedestrians walking along the road (as there are very few sidewalks) is a recipe for disaster, both for the person or persons you may hit, and for you. 

Helpful hints while driving abroad )

  • Become familiar with your vehicle in less crowded conditions
  • Don’t drive at night
  • Drive slowly and in control
  • Avoid large gatherings or busy markets
  • Wear a seat belt, always
  • Avoid driving when you are suffering from jet lag

If you need to rent a car, look for a common type vehicle from a reputable dealer, and make sure the car is in good working order, making note of any preexisting body damage.  Consider getting a car with air conditioning so you can have the windows rolled up and the car locked when you are in it.  If you encounter what appears to be an informal road block or rocks across the road creating a makeshift barrier, there is a good likelihood that these are ploys to get you to stop. Turn around and drive away. Carjackers and thieves work in very organized groups around service stations, parking lots, markets and along major highways.  Be suspicious of anyone who flags you down, or points to your car to indicate a flat or an oil leak, hails you or tries to get your attention when you are in or near your car.

Also, it is generally unwise to rent a motorcycle or motor scooter.  While locals may be whirring conveniently around, nimbly navigating through traffic, as an outsider you have a reasonable chance of becoming a hood ornament, and being forced to be content with the local health care system. Many organizations who deploy field staff, the US Peace Corps included, have long since discouraged the use of motorcycles or scooters for their staff. 

When my wife and I first moved to Doha, Qatar, a very busy urban area well-known for its aggressive drivers, we opted to drive a very solid Toyota Land Cruiser and practiced our driving during times when traffic was less.   Within a short while, my wife and I could easily negotiate the local roundabouts without difficulty and had no problem following the rules of the road.  However, had we not taken our time to get acclimated to the new driving scene, we most likely would have had some problems.

Motor vehicle accidents are a serious problem and a leading cause of death for international travelers.  However, by following some common-sense tips for motor vehicle safety when traveling, you’ll do much to ensure the safety of yourself and your traveling companions.  Be aware of the risks while traveling in your international “death zone” and you’ll up your chances for a safe and enjoyable time while overseas.

Evaluating Your International Contract & Employment Opportunity: Questions For Your Potential Employer

Evaluating contracts and employment positions overseas is much like evaluating these things in the States, with a few unique issues that should be discussed prior to signing. 

Here are a few of the questions you should ask any international employer prior to agreeing to a contract.

1. Transportation

If you take a position in another country, by definition you’ll be traveling to another place for your work.  A good question to ask your employer is who will be paying your relocation expenses. 

Some companies will employ you once you arrive at their facility overseas but require you to foot the bill for airplane flights and shipment of your personal items.  Other companies will cover your plane tickets and help cover the costs of shipping your personal items, but will require you to cover anyone in your family who is traveling with you.  The best arrangement for you, of course, is if the company agrees to cover the airfare for you and your family plus the shipment and/or storage of your personal belongings.  It’s important that you ask about this issue up front since you want to be sure to budget for any necessary expenses.

Once on the ground in your new “home,” be sure to ask how you’ll be traveling from home to work and around town.  Can you take public transportation?  Does the company provide a vehicle or do you need to provide your own?  If you are responsible for your own transportation, are there options to rent a vehicle or do most employees buy? 

If you will be driving yourself, be sure to ask about driving laws and restrictions.  Driving regulations can differ significantly from country to country and in some nations, driving may not be allowed.  For instance, in Bermuda, visitors are not allowed to rents cars (only scooters) while in Saudi Arabia, women are not allowed to drive.  Always remember that when you are in a foreign country, you are under the laws of that country.  As strange or unfair as some of the regulations might appear to you, the “that’s not how we do it back home” defense rarely flies when stopped by local authorities.

2.  Housing

An important aspect of your new employment will be discussing where you will live.  Good questions to ask your future employer are whether housing will be provided and if so, will you be given a certain house to use or a housing allowance? 

The house versus housing allowance issue is more than simply semantics.  A housing allowance gives you more flexibility, but a house protects you from rising house rental prices and other possible uncertainties.  For instance, if you are given a housing allowance you can shop around for accommodations that fit you better—a larger home for a family with children or maybe a flat in the city if you’re single.  However, if you are given a house, you are protected somewhat from the rising cost of rent or the uncertainty of where you will live once you arrive.  Regardless, this is a good conversation to have with your employer from the outset.

Another housing question to be considered is how far the housing is from your work site.  A home across the street from work is a big difference than one located out of town.  I have friends, for example, who actually live in the country of Bahrain and commute into the country of Saudi Arabia each day for work.  Yet another question is whether you have veto power over where you live.  If you arrive and the home you are given seems unsafe or unclean, can you move to another location or are you stuck with what’s been given?  Last, an often overlooked aspect of housing is who pays the utilities.  In a country with temperature extremes, this could make a significant difference with your monthly bills.  Find out in advance who is responsible for the utilities as well as who to call in case of maintenance issues (and who pays for any repair bills). 

3. Salary and Cost of Living Issues

Obviously, when you are negotiating a contract with any employer, salary needs to be discussed.  However, when working in a foreign country it is important to ask in what currency you will be paid.  It makes a big difference whether you are paid 80,000 US dollars or 80,000 pesos, for example.  Also, remember that since you are living in a foreign country, international exchange rates now affect your monthly income and purchasing power in obvious ways.  With the falling US dollar, many expatriates I know who are paid in USD’s have seen their relative income drop every year.  The flip side of this equation is that if you are paid in a foreign currency that is rising against the US dollar, you are in affect getting a raise each year relative to your income back in the States.

Be sure to accurately estimate your living expenses each month.  We’ve already discussed transportation and housing costs, but be sure to look into such monthly expenses as food and the cost of standard household items like toothpaste, soap, cleaning supplies, etc…  In some countries these things will be extremely cheap, but in others they could be very high.  Just make sure you know what you’re getting into.

4.  Other Issues to Consider

There are always lots of little loose ends to consider when making a move to work overseas.  There’s no way to cover everything, but a few more things to keep in mind and ask about prior to departure:

  • What about education for children?  Are there educational opportunities for your kids and if so, who pays.  I know certain Oil executives who have their children’s school tuitions written into their contract as part of their benefits package.  In some countries, the price of an English-speaking school is very high.  In other countries, it simply isn’t available.
  • Have a plan to deal with any chronic medical issues you or your family may have.  Try to pack a few months worth of any necessary meds and be sure to ask about healthcare in the region.  If you’re the only medical professional within 100 miles, you need to know this going in and plan accordingly.
  • Who actually is your employer?  This sounds like a silly question except sometimes it’s a difficult one to answer.  Depending on how your contract is structured, you might be an employee of the hospital, or a placement company, or some other entity.  If you sign a contract with an American company that then places you overseas, you in theory have more protections (due to American labor laws) than if you sign directly with a foreign company or government.  Foreign contracts are subject to foreign law, which may differ significantly from American law. For instance, in some countries, an employer can fire an employee for any reason without any notice whatsoever, without appeal.  If your contract is with an American employer, however, you should be given due process during any contract issues and at least have the security of knowing that you are protected under US state and federal labor laws.
  • Be sure to ask about health insurance and whether you have American health insurance, health insurance applicable to your employment country, or both (or neither).  I know many expats who have had difficulty with this issue.  In some cases, the expat gets sick in the foreign country only to find out their health insurance only applies to American healthcare.  In other cases, an expat back home on leave gets sick and finds out their health insurance does not cover American healthcare, only healthcare in their country of employment.  Be sure to look into this issue prior to signing your contract and plan accordingly.
  • The issue of pets is another one that can be very difficult.  Are pets allowed where you will be living?  Are your pets even allowed in the country in which you’ll be working?  In the Middle East, for instance, many breeds of dogs (specifically certain bulldog breeds) are not allowed into the country.  Exotic pets such as snakes and other unique animals are often difficult to bring into another country for any reason.  If you cannot bear the thought of leaving FiFi behind with friends or family while you’re away, make sure this issue is discussed before you sign a contract.

Working overseas can be a very rewarding experience.  Use these tips to avoid some common pitfalls and you’ll make your overseas experience a lot more enjoyable.

Staying Connected While Working Overseas

In the not so distant past, a job placement overseas meant extensive time away from family and very little real-time communication with those back home. 

I remember traveling the EurRail the summer after my first year of medical school and buying prepaid phone cards to use on the pay phones in the various European cities we visited.  That was 1996. My how things have changed.

Today if you decide to take a medical post in an international location, you can almost continue relationships with friends and family back home unabated.  There’s a trick to it, of course, and you have to adjust to the time-zone differences, but with the internet and all sorts of new communication tools, the world has never felt so small.

There’s so much material in the area of international communication technology that there’s really no good way to cover it all in a single post.  For those who want a more thorough discussion of some of the unique ways communication tools are being used in medical expeditions, I would recommend the chapter entitledCommunications Planning for the Expedition Medical Officer by Dr. Christian Macedonia that’s part of ourExpedition & Wilderness Medicine textbook.  For the others of you who are simply interested in hearing a quick overview of how technology has shrunk the world and taken a lot of the hassle out of working overseas, I give you the following anecdotes…

In 2003, as part of my International Emergency Medicine fellowship at Johns Hopkins, I was sent to the desert of Sudan to perform a nutritional study on a people group called the Beja.  The Beja live in the northeast corner of Sudan, a very desolate, arid region where the locals live basically as they have for thousands of years.  Due to the civil war in that country, the Beja had been cut off from their natural trading routes and many were starving.  USAID had provided a grant to help feed these people and I was sent by Johns Hopkins to ensure that the food was getting to the needy and they were responding to it appropriately.

The project itself was very challenging and after three weeks in the desert I was ready to come home, but it was a great experience and one I wouldn’t trade for anything.  One of the main memories I had of the trip was simply how isolated our group was.  After crossing the border from Eritrea into Sudan, it was simply desert sand—no roads, no electricity, nothing but khaki expanses, a few distant camel trains, and an occasional burned out armoured vehicle or unexploded ordinance left behind from the war and half-buried by sediment.

Amazingly, in spite of this isolation, I was still able to talk to my family back home in the States from time to time through the use of a satellite phone, and every night, powered by a battery that had been charged during the day with solar panels, our group listened to satellite radio as if we were all hanging out together on an extended camp out.  I’ll never forget how odd it seemed to be sitting out under the immense sky of that distant desert, listening to the camels while I talked to my girlfriend (now wife) on the phone and tapped my foot to the classic rock music coming in from the stereo.  Surreal.

In another example, a few years later I took a new job and my wife and I moved to the country of Qatar.  Initially, one of our main concerns was  keeping in touch with friends and family back home.  It shouldn’t have been.  Between email, online video chats using either the Apple iChat technology or video Skype, and ourVonage internet phone, staying in touch was a breeze.  Matter of fact, when we ordered our Vonage phone, we chose a local US phone number.  That way when our friends and family from the States called, it would be a local call for them and rang our house in Qatar just like any ordinary phone line.  It was crazy to talk to our loved ones on their cell phones while they were running errands, and so convenient to just walk over and call the States just like on any other household phone.  The cost for this convenience? A whopping $20 per month.  It was a steal.

The Vonage phone system worked so well and was so easy to use, I never felt like I skipped a beat when we moved outside the US.  My writing and other projects continued without difficulty.  Matter of fact, multiple conference calls relating to the planning of our Expediton & Wilderness Medicine textbook were held while I was overseas and our first Expedition Medicine National Conference was organized and planned using the internet, email, and our Vonage phone, entirely while I out of the country.  I flew back to the States the day before the event and went back overseas when it was over.

Another great device we purchased just prior to our expatriat experience was the Vonage V-Phone.   The V-Phone looks and feels like a flash drive and is designed to be stored on a keychain.  When my wife and I would travel to other countries, we could attach this device to our laptop, plug in a headset, and the V-Phone would enable us to make calls just like an ordinary phone.  It was amazing.  Currently these devices cost around $50 US, and they are well worth it.  However, it should be noted that the V-Phone is not compatible with Mac laptops and they are blocked in certain countries.  When we traveled to Dubai, for instance, we were disappointed to learn that not only our V-Phone but also Skype and the other internet phone services were blocked by the local government there. 

One last communication device worth noting…

During our travels, the coolest member in any expat community was the guy who had a device called aSlingbox hooked up to his tv.  Basically, a Slingbox is a device that enables you to control your home television over the internet.  Savvy expats would buy the device and install it on their home TVs back in the States (or give it as a gift to a family member or friend and install it on their TVs).  When overseas, the owner could go to the Slingbox webpage, login, and watch live television while having total control over the channels and DVR.  It was a great way to follow the home ball club (even though the games were usually played at 3am) or simply get a taste of your favorite TV show from time to time.  What’s great is that now the Slingbox has an iPad ap that allows Slingbox owners to watch live TV on their iPads.  I remember being at a lunch not long ago and noticing that golfing great Phil Mickelson, just one table away, was watching a live NFL game on his iPad via Slingbox.  Slingbox is a very cool technology for those who want to say in touch with certain sporting or cultural events while living in a foreign environment.

So there’s a quick anecdotal tour of how modern technology can keep the world small and enable you to stay in touch with colleagues back home, even though you’re miles away.  An international assignment does require some sacrifice at times, but modern communication technology greatly lessens the impact of such a move these days, and allows you to stay connected no matter where you live. 

Crossing International Borders

If you’ve never had the pleasure of crossing a border into a remote part of a developing country, you’re in for a real treat.  Some of the best travel stories-- both good and bad-- occur at border crossings.

While most crossings involve little more than a little eye contact and a perfunctory paperwork inspection, things can turn bad in a hurry for those who are unprepared.  Stories abound on the international travel circuit of travelers being detained—or worse—when attempting to cross a border in a less-than-appropriate fashion.  If you’re going to be traveling in remote, undeveloped regions, it’s best to have a plan for handling the crossing of national borders.

For many Westeners—especially the inexperienced physician traveler—the idea that someone in a country that they’re “trying to help” might not believe their good intentions seems preposterous.  Regardless of your intentions, however, you can run into problems.

You might be the nicest, most altruistic person in the world but look at it from the perspective of a border guard:  you’re foreign, you probably don’t speak the native language, you might appear rude due to your dress or mannerisms, and if you’re a medical officer you’re probably carrying lots of suspicious-looking pills, tablets, instruments, and other doo-dads. 

In the first chapter of our Expedition & Wilderness Medicine textbook, Dr. Howard Donner has some helpful tips for dealing with border crossings.  I’m quoting Howard here at length: 

Don’t carry white powder in zip lock bags.  As obvious as this may sound, it is amazing how tablets of all sorts tend to break down with humidity and then slowly disintegrate in zip lock bags. A poorly identified zip lock bag, with pulverized white medicine inside, presents a rather suspect impression to a customs official.  Try to be meticulous with your drugs.  Place your medicines in clearly labeled zip lock bags or medicine vials. If you choose to use zip locks, protect them from physical damage inside of a sturdy kit or case.   The more organized the kit looks, the less dubious the custom’s officials seem to look. 

Carry a copy of your medical license.  Showing a customs official a photocopy of your medical license carries a bit more credibility than stating, “but I’m a doctor, really." 

Present a letter of introduction.  Customs officials seem to love embossed stationery or letters embellished with gold seals. These blank forms can be easily purchased through most office supply stores.  Even if you’re not traveling with the National Geographic Society, you can print up your own letter on embossed stationary. Introduce yourself as the expedition doctor for the “2008 blank blank expedition”.  As long as your name is on the letter, along with a signature from the sponsoring foundation, (such as a friend of yours), custom officials seem to relax.

-Dr. Howard Donner, Chapter One: The Expedition Physician in Expedition  & Wilderness Medicine

In addition to medical kit issues, another big problem with border crossing revolves around trying to exit a country with interesting items of question.  Remember that really cool “antique” the local hustler sold you outside the tourist area?  Turns out it’s a stolen artifact from the local museum.  Be wary of buying local valuables that are sold in a surreptitious manner.  At a border it will be you, not the local “entrepreneur,” who will be charged with theft and attempts to export a national heirloom. 

Also, remember that many animal products such as furs or trophies (especially of endangered species) cannot be taken home as well as most alcohol, plants, food items, and some forms of tobacco.  If there’s any question, it’s best not to attempt to transport it.  Just leave it alone and tell stories about “the one that got away” to your friends when you’re home safe and sound.

Even with all the proper documentation and appropriate behavior, frustrating things can still happen when attempting to cross a border.  Some seasoned travelers recommend having a few small "give away" items such as cigarettes, t-shirts of your favorite ball club, small candies, or other light-hearted gift items in your luggage to help sooth escalating tempers.  It's amazing what a small gift accompanied by a smile and a calm demeanor can do to improve a difficult situation.  

If things still go from bad to worse, the best advice is always be respectful, keep your eyes open and your mouth shut, and do not attempt to bluff your way through with threats or angry gestures.  Remember, this is not your home turf, you are not in charge, and you are very much at the mercy of the nearest supervisor in the area.  All your impressive credentials and academic publications won't matter at all to your cellmate in the local jail, and in this situation, Miranda rights certainly do not apply.

Border crossings are a normal part of international travel.  By keeping a few principles in mind, these events can become routine and fun rather than frustrating and frightening.