Medical Care for Traveling Teams: An Alternative View of Travel Medicine

Urgent message: International travel and high-impact competitive sports combine to equal a strong need for consistent, high-quality medical care that’s immediately accessible. Could your urgent care center provide it?

Travel medicine, sports medicine, and episodic injury care are all within the purview of urgent care practice.¹ Urgent care physicians and other healthcare providers are often tasked with provision and/or consultation for healthcare management of traveling groups and nonprofessional teams, including sports organizations, charity groups, mission trips, various educational and cultural exchanges, and, in this case, martial arts practitioners.

The medical literature provides ample information regarding travel care for sports teams. Here, however, we review aspects of nonprofessional international team travel such as team preparation, orientation, education, and international challenges. Specific detail regarding travel with groups involved in combative activities that may be at higher injury risk is provided here. Management includes a pretravel medical assessment, risk stratification, preventive advice/vaccinations, development of a medical aid bag, venue assessment, assessing local medical care available, and posttravel assessment (Table 1).^2,3

Our team consisted of 61 martial arts practitioners, most at the level of black belt proficiency with several years of individual martial arts experience. Ages ranged from 16 to 67, with participants from several U.S. states. The group attended the World Butoku-Sai, renowned international martial arts demonstration event, in Kyoto, Japan that included practitioners from Japan and 21 other nations—just under 800 participants, with the oldest active participant being a 94-year-old man who demonstrated knife attacks and jujitsu break falls (pretty amazing guy).

Pretravel Assessment
We disseminated a pretravel medical questionnaire with specific inquiries regarding previous medical history, medications, recent injuries (especially head injuries), and allergies. The medical team carried one copy of the form for every member while the participant carried a second. In the event of injury/illness, this duplication made information readily available. It also allowed the medical team to risk stratify and medically asses team members.^2,3

We specifically added questions about any recent significant head injuries, cardiac problems, and a history of current use of oral anticoagulants (ie, warfarin or Xa inhibitors; see Table 2). Due to the risk of anticoagulant use for those involved in combative activity, we provided those members specific risk information and suggested limited contact activity.⁴ Unfortunately, one team member taking an Xa inhibitor suffered a major injury 10 months prior to the trip. After practicing aikido falls, he struck his head and developed an occipital headache with visual changes. He subsequently underwent a craniotomy for drainage of a subdural hematoma. We, therefore, provided significant education to all team members and followed strict concussion guidelines, with removal from all contact activity along with limiting activity for those on warfarin or newer anticoagulants (see Table 2).^4-6 In addition, we also encouraged all members with any cardiac history to consult their primary care provider and consider stress testing prior to departure.

Though cardiac events are unusual, martial arts practice involves intermittent bursts of strenuous aerobic activity that can lead to angina or infarctions in those at risk. We have experienced three events outside of this trip:

• One person developed supraventricular tachycardia with a rate of 180 bpm accompanied by symptomatic weakness, but no chest pain or syncope. After multiple attempts at the Valsalva maneuver, carotid sinus massage, and ice packs to the face, conversion was unsuccessful and he was sent to the hospital.
• The second event involved a 58-year-old male developing chest pain and diaphoresis during training. He was given aspirin and transferred to the hospital. Upon arrival to the emergency department, he developed ventricular fibrillation (VF) requiring immediate electrical defibrillation and amiodarone. Symptom onset from chest pain to VF was approximately 30 minutes. He was found to have a left main and proximal left anterior descending lesion that was stented without complication.
• Finally, another trainee suffered cardiac arrest during a competition. CPR was rapidly initiated and an AED was applied, with multiple defibrillations. He was taken to the hospital, resuscitated, and stented with an excellent neurologic outcome.

These three cases illustrate that preparedness, rapid initiation of CPR, and the availability of an AED are critical in gatherings of large numbers of people involved in exertional activity. In addition, some physicians use an iPhone adapter that allows rhythm and rate analysis with a QRS complex that appears on the iPhone screen (cost is about $100 from AliveCor). This may have been of some diagnostic assistance in the first case described above.

The Travel Package/Medical Kit
The team maintained a well-stocked first aid kit with band aids, gauze, gloves, elastic bandages, and several other items. We recommend the use of local ice (this was the most utilized product). Commercial ice packs are helpful, but plastic bags with ice are far cheaper and more versatile for large joints, including the knee.
hen a physician accompanies the team, a medical bag is added, including a wrist blood pressure cuff, pulse oximeter, and iPhone adapter for ECG monitoring (optional, but useful). Some recommended medications would include aspirin, ondansetron, albuterol inhaler (with spacer), diphenhydramine, meclizine, and epinephrine injection pins in the event of anaphylaxis. Fully stocked resuscitation kits are available, but expensive and unnecessary when local emergency services resources are available.

Local Healthcare
Healthcare providers must research the healthcare available at the travel destination(s) in the event of acute illness or injury of a team member. Information regarding healthcare at the destination site, along with limitations for a physician and the international practice of medicine, can be easily retrieved through the internet. We suggest that you attempt to localize two facilities. One would include an urgent care clinic for minor ailments; the other would be a major health center for more serious events such as a myocardial infraction. In both cases, it is beneficial to find a medical facility with English-speaking translators. We actually had on-site translators from each country that could assist the site physician with interpretation into English. Sponsor hotels often maintain lists of both local healthcare providers and facilities. In addition, some hotels provide a physician on call that responds to the site. Most medical care is covered by routine travel health insurance, but preliminary research prior to the trip is helpful to avoid expensive out-of-pocket costs.

Tropical and subtropical destinations may necessitate malaria prophylaxis, along with recommendations for bed netting and mosquito repellents to prevent other mosquito-borne illness, including Zika virus. Health and safety advisories, along with travel information, are readily available through the many websites (see Table 3). All travelers should have basic immunizations updated, including tetanus.
Outside of the issues described above, the more common reasons for medical care include trauma from motor vehicle accidents, falls, and assaults. All team members should be advised of situational awareness, limiting alcohol consumption, and risk of local crime based on the area of travel. In addition, the U.S. State Department website provides information regarding the risk of terror and alerts in high risk areas (see Table 3).

Discussion
The critical part of traveling with a team involved in combative activity is anticipation of potential injuries. Though our team had limited exposure to substantial contact events, significant body blows occurred along with throws (involved in judo/jujitsu training) and falls (involved in aikido training). Debold-Hawley and Shufeldt described the typical martial arts injuries involved in mixed martial events in the October 2015 issue of JUCM.⁴ We have experienced similar injuries in past events, including fractures of the nose, fingers, feet, and toes. Martial arts training is very hard on major joints, including the hip, knee, and ankle. Most of my colleagues have had ligamentous repairs of knee injuries and I have had both hips replaced. One practitioner at this event had a medial meniscus injury of the knee requiring surgical repair one week after the trip.
Dislocations (fingers/toes) and fractures are quite common. We have reduced many dislocations on-site, followed by appropriate splinting. Follow-up care is essential, especially, for finger injuries that may have disruption of the extensor hood mechanism or collateral ligament injury of the thumb, both frequently requiring surgical repair. Toe reduction and straightening by trained provider followed by “buddy tape” splinting is a common occurrence.

During the event, we did have one participant taking an Xa inhibitor block a kick with his hand and subsequently develop a large dorsal hematoma. The injury resolved after several days with ice and practice limitation.
Most martial arts practitioners will not want to leave the training site, preferring to work through the pain even with significant bony injuries.⁴ They should be cautioned and advised about causing further injury. Removal from training should be at the discretion of the treating site physician.

Wound care with facial and foot lacerations are among the most common. Conservative treatment with appropriate cleansing and bandaging often is sufficient treatment, typically. The patient must be advised to have their tetanus immunization updated, if not already done, due to the potential for wound infection in contaminated environments. Lacerations may be repaired on site with butterfly bandages or tissue adhesive. The injured subject must understand and accept the potential complications of limited cosmesis and increased incidence of infection without proper wound cleansing. We strongly recommend that hand injuries from facial strikes that could include oral contamination from the opponent be referred to an emergency department for repair due to the incidence of infection and potential tendon injury.

Most medical practitioners provide care on a voluntary basis. These are not professional sports teams. We believe that with conservative care and an educated population that receives the care, malpractice exposure is limited and a “Good Samaritan” protection is sufficient. This may be different in various localities; therefore, each practitioner should consider advice from their current malpractice carrier.

General travel advice includes awareness of food and water contamination. The purchase of food from street vendors (though quite tempting) is discouraged, as is drinking local tap water.² These activities are dependent on the region of travel, but will reduce the incidence of food- and water-borne illness. The Centers for Disease Control and Prevention recommends hepatitis A vaccination before travel to regions that have a high incidence of hepatitis A. Ciprofloxacin and bismuth-containing products may be helpful with traveler’s diarrhea and could be of benefit to include in the medical bag.

We did have over 30 participants develop a respiratory illness with cough, fever, malaise, and myalgias. Two trainees were transported to the hospital. The pulse oximeter simplified triage, with those having an oxygen saturation of <90% transferred for medical evaluation. Two patients did well, while a third patient used an on-site inhaled beta agonist, with improvement of symptoms and avoidance of hospital transfer.

We had a very successful trip, with minimal events. The majority of our team developed pedal edema (2-3+ in some), likely from travel and dependent extremities. Compression stockings are a good alternative for long-distance travel, and assisted some of these individuals.

Two weeks post trip, we performed a follow-up assessment and questionnaire. Most members were well, and previous pedal edema problems had resolved. These assessments can benefit by uncovering occult injuries, development of deep vein thrombosis (DVT), the need for continued disease prophylaxis (eg, against malaria, etc.), the need for infectious disease testing, or the treatment of common ailments, including traveler’s diarrhea.

Conclusion
Though injury is more likely in events with combative activity, the principles of site assessment, pretravel assessment, participant education, preparation of a medical aid bag, and onsite treatment are broadly applicable to optimize outcomes. It should be reiterated that many common injuries sustained can be effectively treated onsite with a basic medical kit. Serious medical issues may arise emergently, requiring hospital transfer, and can be effectively managed if a nearby healthcare facility with sufficient resources has been selected beforehand. This proved quite helpful with our group. Finally, posttrip assessment benefits participants after they have arrived home in order to discover occult injury, DVT, or infectious disease exposure requiring testing or treatment. Further study in the field of travel medicine might include research into the incidence legal redress for physicians operating on a “Good Samaritan” basis internationally, and the subsequent outcome.

Michael F. Boyle, MD, MBA, FACEP, Regional Medical Director for ECI Healthcare, a Schumacher Healthcare Partner, and Brian Caldwell, EMT-B, BS.
References

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6. Giza C, Kutcher JS, Ashwal S, et al. Summaryof evidence-based guideline update: evaluation and management of concussion in sports.Neurology. 2013;80(24):2250-2257.