Travel Medicine: Brazilian style

Dr. Marco Foltran

Like so many of us in travel medicine, I became involved in our specialty more or less by accident. I trained in internal medicine and aero-medical transportation and became certified in emergency procedures such as Advanced Cardiac Life Support, Basic Trauma Life Support, and Pediatric Advanced Life Support.

In 1997, after I finished my medical training in Curitiba in the southern part of Brazil, I moved to Porto Seguro, a city in Bahia State in the Northeast. Porto Seguro is a beautiful place with about 80,000 residents, idyllic beaches, wonderful weather, and 1.5 million visitors per year. In the three years I was there I worked for an emergency health care system answering house calls, including many from hotels to see travelers. All together, I saw about 5,000 travelers. Most of them had minor ailments such as traveler's diarrhea, external ear infections, sore throats, allergies, and minor trauma. I also treated problems related to scuba diving, air travel, marine accidents, and exposures to new climatic conditions, sun and heat, for example. And, unfortunately, there were the occasional serious problems.

I came to realize that travelers are a unique group of people, and what an appealing field travel medicine is - without knowing that travel medicine existed. Not only did I help to restore their health, but I also helped them to accomplish their goal for which they were in Porto Seguro, to relax and to enjoy themselves. Wellness is the key. The obvious aim of the sick or injured traveler is to get back into the action as soon as possible. Sometimes they want miracles. It is our role to make it possible, with minimum limitations on their planned activities and in the fastest way. No one wants to ruin his or her trip with health problems; no one wants to miss the opportunity to see the sunset in Jericoacoara in Ceará State (a trip that I personally recommend) because of diarrhea. The aim of travel medicine is to keep people healthy during their trip, whether it is through pre-travel advice or visit to a physician during the trip.

Seeing so many travelers made me realize how demanding and difficult this field can be. You need to know so many different areas of medicine, be up to date on health-related conditions all over the world, and have fluency in other languages. The knowledge of the traveler's needs is challenging but especially gratifying.

I did travel medicine for five years before I became aware of the existence of the International Society of Travel Medicine and without any contact with colleagues in the field. Now I have read several travel medicine books, receive the Promed mail, and am involved with a couple of listservs. I am proud to be part of the GeoSentinel and the ISTM Host Country Committee. Moreover, I am working on some papers and I hope that in the next few months to send them to the Journal of Travel Medicine for publication.

Making so many hotel calls gave me the knowledge and skills to start giving pre-travel advice - with confidence. I know, from the other side, what really happens during international travel.

Since 2000, I live in Fortaleza in Ceará, also in the northeastern part of Brazil. It is a large city with 3 million inhabitants and 2 million visitors per year, a paradise for kite and windsurfers, those who love tropical climes all year round, and warm and friendly people.

Currently I have my own practice for pre-travel advice. I still work on emergency calls at hotels. I do consultations for colleagues and for hospitals, and I lecture on travelers' health-related subjects at universities that teach tourism. I am part of an organization that offers 24-hour emergency service all over the city with English-speaking doctors, an ICU ambulance service, laboratory, mobile ultrasound, and affiliations with major hospitals (with international accreditation). We accept all travel insurances and the fee for hotel calls is reasonable (about USD 100). The main way we publicize our services is by word-of-mouth among the tourism trade, publicity releases, and with some articles in non-medical journals and magazines.

To examine a patient, prescribe and treat in another language can be challenging, in part due to different cultural values. But in the past nine years of working with travelers, I have learned that respect for their cultures, showing them kindness, and understanding that their special needs are as important as prescribing the right medicine.

About five years ago I took an MBA degree in Health Systems Management. Last year I attended the travel medicine course at the Royal College of Physicians and Surgeons in Glasgow, where I had the opportunity to be with the HPS travel medicine team and exchange experiences with such people as Dr Eric Walker, Mrs. Lorna Boyne, Mrs. Fiona Genasi and many others. I speak English, French, Italian, Spanish and Portuguese and I can ask medical questions and prescribe in 11 different languages (Finnish, Hungarian, German, Polish, Czech, and Swedish). This is a big and pleasant surprise to my foreign patients. I am sure that when one is sick it is NOT a good time to try learning a foreign language.

I am married; my wife's name is Seline and I have two children, Barbara (12) and Massimo (3). I used to windsurf, but I am quite sedentary right now. My favorite sport is American football (not soccer - unbelievable, ha?). I enjoy reading and traveling, and especially to talk to foreigners which I do almost every day. This too is "traveling" to me, so I really have fun with my work.

One of the many things I like about travel medicine is that there are many humorous and memorable incidences. Here are some that come to mind:

• A honeymoon couple from Argentina was very ill with classical travelers' diarrhea. Both were very pale, without any strength to get up from the bed and even unable to open the door for me. After we started treatment with IV ringer lactate, antibiotics, etc. they began to feel better, and their mood improved. So they asked me to take a picture of them lying in bed, both hooked up to IV infusions. They said they would place the picture in their "honeymoon album", because the priest had said during their wedding ceremony that they were a couple "... for richer or poorer, in sickness and in health …" So the picture of them drinking coconut water on the sunny beach will be next to the one with the IV in bed.
• A young Dutch lady who called me late in the night with a "yellow color in her skin." I went to the hotel thinking about several possibilities, leptospirosis, hepatitis, and such. But when I got there the yellow spots were only on her hands. The history and clinical examination were totally normal. A very strange case. But then I noticed some old books on the side of her bed. I asked her to wash her hands. Bingo! The yellow color came from the old books. She was so ashamed, but she laughed and was very happy there was no illness to worry about.
• A Canadian young man, two days before the end of his vacation and after six days of traveler's diarrhea, called me at the hotel. After I treated him, I asked him what he thought about Brazil?" He said "Nice toilets!" It was a remarkable way to describe a vacation time.
• I was in a hotel room suturing a laceration in an 8-year-old boy from the USA. His father was watching. Suddenly I heard a big noise and the father just collapsed on the ground when he saw the blood. The result: four sutures for the boy and six for his father.
• This one is incredible. A Hungarian traveler was in the back seat of a taxi, after buying a magnificent dagger made of a serrated bony spine from a stingray. He was holding it in a plastic bag under his elbow. The taxi stopped very suddenly to avoid a crash with a bus. The bony spines pierced the man's elbow and caused a 4-centimeter laceration. He arrived in the lobby with the dagger hanging from his elbow, dripping blood. No one at the hotel could understand what or how this happened. The traveler spoke only Hungarian. The manager of the hotel asked if he was assaulted and if he should call the police. The only thing the traveler was saying was "bus accident!" We removed the dagger without any complications and the traveler was fine.
• In one of my very first medical calls to a traveler I saw a pregnant (5 weeks) young lady from Chile with travelers' diarrhea. I speak Portuguese; she spoke Spanish. Portuguese and Spanish are similar, but not identical, and at the time I didn't speak Spanish as well as I do today. She told me about her gastrointestinal complaints and that she was pregnant, all in Spanish. The word for pregnant in Spanish is "embarazada". This word in Portuguese (similarly to English) means "to feel uncomfortable because of shame" or "embarrassed". The dialog went something like this: "One more thing: I am embarrassed (embarazada), doctor," she told me. "There is no reason to be embarrassed, this is something simple and is quite common," I told her. "No, doctor, I am embarrassed," she insisted. "No problem, my dear, there is no reason to be ashamed or feel uneasy. Travelers' diarrhea is not a big deal, you will be fine in a couple of days," I replied. "No, no, no, doctor, I am REALLY embarrassed!" she laughed. I nodded and said, "OK, try to explain it to me…" Then she put a blouse under her T-shirt to indicate an extended abdomen, and pointed.

  Well, after that I was feeling "awfully uncomfortable" because of shame, and realized that I should learn more languages than Portuguese and English…