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Kilimanjaro & Wilderness Medicine CME

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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:

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Soul Surfer: Good Values for Adventurous Families

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As the dad of three daughters, I'm always looking for ways to encourage my girls to be active and to enjoy the outdoors.

When the movie Soul Surfer came out a few years ago, I hoped the movie would be a positive experience and demonstrate great examples of women athletes that I could use as role models for my girls.  I wasn't disappointed.

For those who might not know the story line, Bethany Hamilton is a pro surfer who lost her arm to a shark attack.  The movie Soul Surfer tells her story and how she battled back from near-death to become a top surf pro.

The story is full of positive themes-- a strong, supportive family, an encouraging community, and a character who perseveres and moves forward despite tremendous setback.

These strong themes plus the beautiful scenery of Kauai make this film a pleasure.

About the only scene that I didn't like was the one where the shark that supposedly attacked Bethany is killed and brought to the family home.  These sorts of culls don't work, and it's a shame that the movie decided to include a scene like this that will just further a misunderstanding of sharks and shark attacks.

I recommend Soul Surfer to families who are interested in promoting ocean activities to their youngsters.  For those who are interested, the movie trailer is below and a link to the real Bethany Hamilton's website is here.

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Our Great White Shark Dive Partners Film Commercial with Gillette

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In this video, you see a behind-the-scenes look at the filming of a recent Gillette commercial with our 2012 ExpedMed Great White Shark CME Adventure partners, Shark Diver .
I can't wait for this CME adventure. 
Here's the final commercial:
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Great White Shark Dive Information

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For those who want more information about our upcoming 2012 Great White Shark CME Adventure, check out this recent article in Sport Diver Magazine . This article discusses our partners, Shark Diver, and gives information about cage diving with Great Whites off Guadalupe Island.
Hope to see you guys on our trip.
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Great White Shark Dive CME

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For those of you who are interested in a very unique CME experience, check out our 2012 ExpedMed Great White Shark CME Adventure.

We've partnered with Shark Diver, a great organization headed by Patric Douglas, to give you an exceptional travel experience.  Shark Diver is one of the finest travel companies in the world and their exceptional experience with the Great Whites of Guadalupe Island is unparalleled.

For those who'd like a report from a recent Shark Diver trip, check out this article that appeared recently in the Vancouver Sun .

Our 2012 ExpedMed Great White Shark Adventure will be this August 27-31. Sign up today while there are still spots left!

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The Adventures of Tintin

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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!
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Wilderness Medicine Career: How to Get Into The Explorers Club

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Dr. Michael VanRooyen and Starting a Company

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Dr. Michael VanRooyen is the Director of the Harvard Humanitarian Initiative.  He's also the founder or co-founder of four start-up companies including Ibex, a patient tracking system for Emergency Departments that was eventually bought by Picis.

From 2002 to 2004, I worked as one of Mike's International Emergency Medicine fellows within the Johns Hopkins Department of Emergency Medicine.

This is a video clip of Mike's talk at our 2009 Medical Fusion Conference.  While Mike is most well-known for his humanitarian work, he's also a very astute businessman and entrepreneur.  If you're a Wilderness Medicine aficionado, you are probably familiar with Mike's work in international health, but in this video you get to see another side of him through his entrepreneurial experiences.

One of the purposes of this blog is to introduce you guys to the personalities behind the research and field work.  Mike is one of those dynamic individuals who is a leader in his field, and a great prototye for those interested in making Wilderness Medicine a career focus.

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Dr. Ken Kamler and the 1996 Everest Disaster

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One of the true privileges I have as the director of the ExpedMed and Medical Fusion conferences is the opportunity to meet and associate with so many amazing individuals.  Over the past few years I have been blessed to spend time with some incredibly talented and exceptional colleagues.  These associations have inspired and encouraged me, and I have grown tremendously because of these relationships.

One of these talented and inspiring individuals in Dr. Ken Kamler, Vice President of The Explorers Club.  I first met Ken a number of years ago at an Explorers Club event in New York City.  Since that first meeting, Ken has become a dear friend who has written a chapter in our Expedition & Wilderness Medicine textbook and also spoken numerous times at our conferences.  

The lecture above is a video of Ken giving a presentation at TED about the 1996 disaster on Mount Everest.  This event was chronicled in Jon Krakauer's book Into Thin Air.  Ken was the only physician on the mountain during this episode, and even though I have heard his talk numerous times, I still find it incredibly gripping.

Take a few minutes to watch Ken's presentation.  You won't be disappointed. 

Thanks once again to Ken for his participation in our events and his inspiring career, and thanks to all the other talented individuals who make our conferences so successful.

 

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Wilderness Medicine Career: What Medical Societies Should You Join?

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The ExpedMed Textbook

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For those of you who are interested in learning more about Expedition Medicine or Wilderness Medicine, I'd like to mention our textbook, Expedition & Wilderness Medicine, that was recently published by Cambridge University Press.

This textbook is used as the syllabus for our Expedition Medicine National Conference and also as a teaching tool for many other courses and organizations around the globe.

The textbook is a hardcover text over 700 pages in length, with full-color photos and diagrams.  We recruited more than sixty experts from around the world who contributed content for this project.  Contributors include many notable individuals such as 

Richard Carmona, MD, MPH, FACS: 17th Surgeon General of the United States

Luanne Freer, MD, FACEP, FAWM: past president of the Wilderness Medical Society and founder and director of Everest ER

Ken Kamler, MD: Vice President of The Explorers Club and author of Doctor on Everest

Richard Williams, MD, FACS: Chief Health and Medical Officer for NASA

Peter Hackett, MD: Director, Institute of Altitude Medicine

We have been pleased to read many favorable reviews of our book in multiple journals including the New England Journal of Medicine and JAMA. Here's an excerpt from the JAMA review:

Expedition&Wilderness Medicine, edited by Bledsoe, Manyak, and Townes, is a comprehensive guide to the multitude of issues facing the expedition physician. The book is organized into 3 sections covering expedition planning, specific and unique environments, and specific wilderness illnesses and injuries. The comprehensive and often humorous chapters have been edited in a style that allows for easy reading, and they include numerous excellent illustrations.

Several of the chapters are written by some of the world’s authorities on the topic. Not only have many of the authors published widely on their areas of expertise, they have spent considerable time in the field. The authors have diverse experience ranging from serving as the expedition physician on a climb of an 8000-m peak in the Himalayas to providing medical care to a patient injured thousands of feet underground in a Mexican cave. This experience—and the willingness of many of the authors to illustrate ways to avoid future problems by describing their own misadventures in the field—contribute to the strength of this text.

Expedition & Wilderness Medicine is a must-read before any expedition. It carefully details what an expedition medical kit should contain, along with details on what to consider taking along for toxicological and dental emergencies. Although this book is aimed at the expedition and wilderness medicine physician, many of the chapters are superb summaries of core emergency medicine knowledge that are better distilled and presented than chapters in some more traditional textbooks of emergency medicine. We recommend this text to all who practice acute care medicine and all physicians who hike, climb, or vacation outside the city or who might encounter anyone else who does.

Jones ID, and CM Slovis. JAMA. 2009;302(4):442-44

We'll be writing more about opportunities in Wilderness Medicine and Expedition Medicine here on the ExpedMed blog, but for those of you who need something to begin your journey, pick up a copy of our textbook online or attend our Expedition Medicine National Conference and receive the book for free.

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Passport Health: Your Travel Medicine Franchise

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For those interested in a career in Travel Medicine, one possibility is opening a travel medicine clinic through a franchise model with the company Passport Health.

Headquartered in Baltimore, Maryland, Passport Health allows owners to buy into their franchise model and "own" a specific geographic region for development.  They currently have over 160 locations and their website mentions opportunities for the entrepreneurially-minded:

If you are a health care professional or entrepreneur with appropriate connections, we can help you achieve your dreams. Passport Health is an excellent business opportunity for the right individual. Passport Health is a simple, low-overhead service company, which provides immunizations to those about to travel to a foreign country. Basically, we are in the immunization business; we offer on-site services such as Flu and Hepatitis clinics. However, we also specialize in safety and security travel information. We are already a household name in many areas across the country, but there are plenty of great territories remaining.

A follow-up email from the company provided more specific information about their franchise opportunity:

We generally sell large territories, including a city and the surrounding counties, with the owner expected to open multiple offices over time.  Our franchise fee is $35,000.00, and it includes training (5 business days), videos, materials and the use of our exclusive software, Passageware.  There is no build-out and very limited start-up expenses. Owners consist of doctors, nurses, and entrepreneurs, with one hospital (Sentara in Norfolk) and one university system (University of Rochester School of Nursing).  Due to the hard work of the individual owners and our marketing team, we are constantly adding corporate accounts and our business model is ever expanding to include all areas of vaccines.

Besides being an interesting field, Travel Medicine is open to healthcare providers from a variety of backgrounds.  While many Travel Medicine providers are trained in Infectious Disease, I know physicians with many different backgrounds involved in Travel Medicine.  

For those interested in Travel Medicine and desiring increased training in this area, our ExpedMed courses are an excellent way to be exposed to this niche.  A prior post here on the ExpedMed blog described other, multi-month programs in Tropical Medicine that are also available for those with increased desire and more time to invest.

Cool Gifts for Kid Explorers

As a dad of three young kids, I'm always on the lookout for fun, educational toys that encourage my kids to explore.  
This Christmas I did some searching and found a few cool potential gifts for the young explorers in your family.  Below is a link to the items with a quick blurb from me about each:

 

I'll let you know how the kids react to the gifts. Oh, and in case you're wondering, the photo above if for multiple kids and will be split between Christmas and birthdays.  

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Lifestyle Design for Physicians

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I wanted to say thanks to all the people who have come to our ExpedMed events over the past few years.  It's been a lot of fun and I've learned a lot from many of our participants.

At almost every event, I've heard from participants that they'd like to learn more about how to design a lifestyle that allows them significant time to participate in Wilderness Medicine activities.  This really shouldn't be a surprise.  Those who attend a Wilderness Medicine conference are likely to be interested in living a unique life (and vice versa).

In addition to running ExpedMed, I also write for FreelanceMD.com , a website for physicians looking to broaden their careers.  I thought it would be a good idea to link over to some of the prior articles I've written for Freelance MD regarding lifestyle design. I'm not 100% sure those in the Wilderness Medicine community will benefit from this, but I suppose it doesn't hurt.

Anyway, below are some of the articles I've written.  Hope this helps.

Physician, Build Your Own Ship

3 Thoughts on Physicians & Career Modification

First Things First: Handle Your Finances as a Physician

Physicians & Lifestyle Design

Plan Your Non-Clinical Career Escape as a Physician

Physician: What Are Your Assets?

Physicians & Evil Plans

Physician Career Diversity & Matt Dancing Around the World 

Emergent Field Medicine

In a prior post I mentioned the Health Emergencies in Large Populations (HELP) course for those who are interested in working in disaster areas providing humanitarian assistance.

Reviewing information about the HELP course reminded me of a great manual for those interested in humanitarian assistance.

The book Emergent Field Medicine was published a few years ago to help those who are providing care in under-developed regions and disaster areas.  My view of this textbook is biased– mainly because I am friends with a number of the editors and contributors of this text– but I still believe it is a great tool for anyone going to a remote area to provide care.

The text was written by a stellar group of experts and provides an overview of a variety of topics including public health, tropical infectious disease, refugee health, nutrition, and dental emergencies to name a few.  The format provides a reader with information that is easily accessible and of appropriate depth for a field manual.

For those who are considering working in a remote area, Emergent Field Medicine is a good way to prepare before you go, and a good resource to use while you’re away.

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Getting Started in International Medicine

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Alright, so you want a career in international medicine.  Where do you begin?

You’ve finished your specialty training and you’re looking for opportunities to work overseas.  Great.  You know how to run a code and diagnose a pneumonia.  Fantastic.

Now the work begins.

International medicine is such a broad field that whenever I am approached by a physician who wants to work overseas I always ask them to tell me a little about their overall goals.  Do you want to make international medicine a career pursuit?  Is your goal to work short-term in a variety of locations while holding a full-time position back home?   Where do you see yourself in 5-10 years?

It’s true that life has a way of rerouting even our best-laid plans, but it’s always better to have some sort of plan before embarking on a new career pursuit.  For those that don’t really know where to begin, I recommend the following:

1. Just get some experience

You can’t go wrong just getting a few short trips under your belt.  Whether you want to simply dabble in international health as a side career or begin to build a full-time career as an international medicine specialist with hopes of leading  a non-governmental organization (NGO) or academic research group, the place to start is with a few short volunteer trips.  No NGO or credible organization is going to actually pay you to do international health if you’ve never worked “in the field.” If you ask any seasoned person in international medicine, they always say time in the field is one of the biggest criteria they have for important hires.  You might be brilliant. You might have great “people skills.”  You might have incredible letters of recommendation, but if you’ve never packed your bags and lived in a remote place for a time providing medical care, then you’re basically an untested commodity.  No credible organization will take a chance on an untested person and place them in a position of responsibility if they can avoid it.  If you want to make international health a part of your life, you need to get some experience.

Where do you go to get experience?  Well, there are two easy places to begin.

First, visit your local faith centers or nonprofits and see if there are any positions available for volunteer physicians overseas.  In today’s world, you’d be surprised how many local religious organizations and nonprofits are sending people to obscure places and would absolutely love to have a physician come along (especially if the physician is paying their own way—and you need to be prepared to pay your own way in the beginning).  This is a great way to practice preparing for a trip, evaluating the medical gear you will and will not need, working with others (not a physician strong suit typically), and working in an unfamiliar environment.  Many individuals who go on to formal international medicine careers begin as volunteers in positions just like this. 

Second, there are multiple locum tenens companies who are placing more and more physicians in foreign environments.  Obviously, working in a fully staffed hospital in Australia is much different than working in a remote clinic like the Everest Base Camp ER, but you have to start somewhere and using a locums company like Global Medical Staffing to get your initial experience internationally can be a good place to start. 

2. Network

I’m not a fan of joining organizations simply for the sake of joining. However, there is a lot to be said for joining a couple of organizations in the beginning and attending a few medical conferences designed for international medicine, especially if you don’t have a lot of connections in these fields already.

In the United States, the three organizations that seem to most help individuals looking for opportunities in international medicine are (in no particular order) the Wilderness Medical Society (WMS), the International Society of Travel Medicine (ISTM), and The American Society of Tropical Medicine and Hygiene (ASTMH).  All of these organizations offer medical conferences where you can meet potential mentors and network with other event participants.  In addition to these organizations, there are a couple of private conferences that always garner great participant reviews.  The first is our ExpedMed events (yes, I direct these events and I am biased, but we do get great reviews and we draw top talent from the WMS, ISTM, and ASTMH, as well as many academic institutions, as speakers each year).  Information on ExpedMed can be found at www.ExpedMed.org  .  The other private group that always receives great reviews are the folks at  www.Wilderness-Medicine.com  .  Yes, I guess the reality is that these guys are really competitors of ExpedMed, but we use some of the same faculty and we consider them friends, so I don’t have a problem recommending them. 

I’m sure there are plenty of other great organizations and events that I could mention here, but these are the ones I hear about the most and the ones with which I have personal experience.  If you need a good place to start, I’d begin with one of these entities.

3.  Read

It goes without saying that if you’re interested in a career in international medicine you should be reading about the subject.  There are some great journals and textbooks out there, including our Expedition & Wilderness Medicine textbook, but don’t just stop there.  Read blogs about international medicine.  Get some adventure stories that are non-medical but involve international health in some fashion (Shackleton’s adventure for instance or Teddy Roosevelt’s River of Doubt journey).  Use these resources to not only stimulate your desire to travel but also to learn the history of the field you’re entering.  Oh, and when you read the academic work, don’t just read for clinical knowledge, read to see who the authors are and where they’re working. Look through the bibliography and see who is cited and where the research is taking place.  You never know where this sort of “sleuthing” might take you or what connections you might make.

4. Investigate formal training opportunities

I say "investigate" because depending on your career goals you may or may not need/want formal training. However, it's worth looking into since there are some great programs to teach things like tropical medicine or public health in disaster situations.

For Emergency Medicine specialists, formal fellowships in International Emergency Medicine are available around the country.  I completed one of these programs at Johns Hopkins in 2004, and really enjoyed the experience.  I wrote a prior post on the subject of International Emergency Medicine and for EM docs looking to move into the world of international medicine in a formal way, a fellowship is a great way to jump-start the process.

If tropical medicine is your thing, there are some excellent 3-4 month courses around the world that offer intensive tropical medicine education.  The two most famous are the Gorgas Course in Lima, Peru, and the course at the London School of Hygiene & Tropical Medicine.  I have friends who have graduated from and teach at these events and both are widely respected. You can check out a prior post here on Freelance MD that serves as an introduction to these courses.

The Health Emergencies in Large Populations (HELP) course is a great way to get exposure to handling public health issues after disasters (more information on this course can be found here ), and for those who really want to go deep, a Masters degree in Public Health from a university with an international focus like Hopkins or Harvard, will significantly broaden your view while deepening your understanding of international public health issues.

These tips should get you going and when you have some experience under your belt and some colleagues in the field to call, you’ll be surprised at the opportunities that begin presenting themselves.  

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

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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 ( http://danger.mongabay.com/ )

  • 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.

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

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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.

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Staying Connected While Working Overseas

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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. 

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Crossing International Borders

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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.

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