On The Road

Proper planning and research can spell the difference between success and disaster when your team travels to another country to compete.

By Maria Hutsick

Maria Hutsick, MS, ATC/L, CSCS, is Head Athletic Trainer at Boston University. She has spent the last year serving as Head Athletic Trainer for the USA Hockey Women's National Team. She can be reached at loon102@hotmail.com.

Training & Conditioning, 12.2, March 2002, http://www.momentummedia.com/articles/tc/tc1202/road.htm

Taking a team to a foreign country is an exciting and challenging endeavor. But in addition to the satisfaction of helping a team compete on an international scale, athletic trainers face many unique challenges before such a trip even begins.

This article describes the steps that athletic trainers should take and the issues they should consider before taking a sports team to another country. Proper pre-trip planning can ensure that athletes receive the best possible care during their travels, whether the destination is Canada or China. A lack of planning, however, can turn that trip into a disaster.

To illustrate the planning steps necessary for international travel, I will share some of my own team-travel experiences. These include taking football and lacrosse teams to England, an ice hockey team to Germany, and most recently, the USA Hockey Women's National Team to China, where it competed with Russia and China in the Friendship Cup this past summer.

DO YOUR HOMEWORK
Before taking your team on the road, your first step should be to research the country your team plans to visit. The first questions you'll need to answer are: What is the level of that country's healthcare? What is the quality of sports medical care in that nation? What are the health risks to your team and staff?

You can obtain answers to these questions by talking to your team physician, by calling the U.S. Department of State in Washington, D.C., or by logging on to travel-related Web sites. One Web site that I've found particularly valuable is that of the Mayo Travel and Geographic Medicine Clinic www.mayo.edu/ travel-clinic/. This Web site provides comprehensive travel-related information on the levels of healthcare available in many nations.

Another Web site that provides useful information for planning trips is the National Center for Infectious Diseases Traveler's Health site, which can be found at www.cdc.gov/travel/index.htm. This site provides health information for specific destination countries and regions. It also includes information on diseases, outbreaks, insect protection, and vaccinations.

I also suggest you seek the knowledge of those who have seen foreign healthcare systems firsthand. To start, speak with American athletic trainers who have recently been to the country you plan to visit. Also, speak with your hosts about the role of sports medicine in that host country.

For example, before traveling to Germany, we learned from our hosts that the standard of healthcare was excellent and there was an up-to-date focus on sports medicine. The rink we were playing at was adjacent to a small clinic, X-rays were easily obtainable, and hospitals were run very efficiently.

In England, healthcare was adequate, but standards for dealing with sports injuries were lower than what we are accustomed to in America. For example, we found that the emergency equipment was old and the ambulances were not well equipped. In addition, we discovered that X-rays are not routinely performed in England.

Our pre-travel research on China found medical care to be quite low in several regards. First, health and sanitary conditions were poor and the bacteria level in the water was high, which could pose health risks to our athletes. In addition, medical products and instruments were often recycled without proper sterilization, so the risk of hepatitis A and AIDS was also high. Needless to say, we knew in advance that standard Chinese healthcare for sports injuries would not be adequate for our athletes.

Once your research is completed, you can start preparing to deal with the host country's healthcare environment. In the next two sections, I'll detail how to prepare for sports injuries that occur while traveling and how to reduce the risk of other health problems.

EMERGENCY PLAN
Just as you would prepare emergency plans for athletic events on your home turf, you need an emergency plan for injuries incurred overseas. The extent of the plan, of course, will depend on what you've found out about your destination.

For example, when visiting England and Germany, our emergency action plans did not differ much from those we used for road contests in the States. We did, however, have our team physician write a letter of introduction to the hospitals in the areas we were competing. The letter described our team, where it would be playing, and the level of sports-medicine care it was accustomed to receiving.

We also asked the hospitals to explain their country's healthcare system procedures, plus any need for insurance. To cover all the bases, you might have your team physician speak to the hospital and then send a letter to confirm that conversation. We also brought along some portable medical supplies that might not be easily obtainable in Europe.

The emergency action plan (EAP) that we developed for the USA Hockey Team's visit to China was the most extensive I have done. Because of the lack of safe medical services, our aim was to be as self sufficient as possible. In other words, we attempted to treat our athletes completely outside the Chinese healthcare system.

To develop the plan, Team Physician Brad Stephens, MD, and I thought through every injury scenario and how we could treat it. We wanted to be able to handle injuries such as strains and broken bones, to perform surgery, and even to evacuate athletes whose injuries were beyond our capabilities.

Here is what we brought with us to accomplish this:

A well-packed athletic trainer's kit.

Orthopedic soft goods, including knee immobilizers.

A portable electrical stimulation and iontophorsor machine.

A spine board with neck collars, ladder splints, and a head immobilizer. To save space, we packed that equipment in the stick bag along with the extra hockey sticks and crutches.

A portable automatic defibrillator (AED), which was lent to us by the Lake Placid ice rink.

A Banyon Medical Kit, which includes a set of laryngoscopes, an IV, IV set-ups, hand-operated suction, an ambu bag, and a variety of emergency medications (available from Banyon, $896.95, at 800-351-4530). Note that a signed physician's authorization, which is often referred to as a "DEA certificate," must be obtained in order to purchase the Banyon Kit.

A supply of oxygen. Since oxygen cannot be taken aboard most commercial airliners, we used an oxygen kit that included an empty tank with chemicals that we could mix with water to "brew" our own oxygen if the need arose. Another option is to contact Advanced Aeromedical, a U.S.-based company that can arrange oxygen for you to pick up upon arrival in another country (800-346-3556).

We also made arrangements for a medi-vac plane to be available. The team's insurance provider, American International Group (AIG), handled the plane arrangements. In order for the medi-vac plane to be released for an emergency evacuation, the insurance company required discussions with the team physician and athletic trainer to determine if quick evacuation was necessary. If a situation had arisen in which the medi-vac was needed, we would have either flown the injured athlete to a large city in China or to a country where one of our armed forces' hospitals was located. Fortunately, we did not need to use this service.

While developing our EAP, we tested all procedures by rehearsing the treatment and evacuation of seriously injured athletes. These mock emergencies and evacuations not only sharpened our skills, but also helped us verify which medical supplies were essential to bring along.

Once overseas, we also rehearsed our EAP at each venue we practiced or competed at. While the team warmed up on the ice, we warmed up by going over all our procedures.

KEEPING HEALTHY
Although our trips to England and Germany required a few more healthcare preparations than we'd normally institute for domestic travel, our knowledge about the health and sanitary conditions in China prompted us to take additional steps to ensure our athletes would remain healthy on this trip.

First, we arranged vaccinations for hepatitis A, diphtheria, typhoid, and tetanus. These were given five days prior to our departure from the United States. If your school or college cannot afford the vaccinations, you may be able to charge the students' insurance for the cost. Or, if enough notice is provided, athletes may be able to obtain them well in advance at home from their family physicians.

We also brought along a sizable quantity of over-the-counter remedies for colds, some anti-inflammatory medications, and a large supply of gastrointestinal relief medications. Several antibiotics were also identified and supplied by our team physician.

Safe food and water was another concern. We knew that bottled water was necessary in China, and that many foods should be avoided there. Before leaving on the trip, we inquired with Chinese authorities to determine if good bottled water would be available once we arrived. We were happy to learn that clean, bottled water was available, so our team didn't have to haul water over there.

Since we would also have to be very picky about what we ate, we decided to pack energy bars and other foods that do not require refrigeration. These snacks held us over when safe food could not be arranged locally.

We also compiled this list of instructions:

Drink only bottled beverages that are sealed when served.

Do not put ice in your drinks, because the ice may be made from contaminated water.

Use bottled water for brushing teeth.

Make sure all water used for coffee and tea has been boiled.

Stay away from raw fruits, salads, and vegetables, because they may have been washed in contaminated water.

If food has been peeled, cooked, or boiled, then it is probably okay to eat.

Never eat raw or undercooked fish, eggs, or meat.

Avoid buying any food from street vendors.

Be sure your meal is hot and has not been sitting out for several hours.

TEAM MEETING
Once all health and safety plans are complete, it's important to have a team meeting to go over medical, health, and safety issues before departure. Before our take off for China, we met with the entire travel party to discuss all medical details, the EAP, plus food and water safety. During the meeting, we answered any questions that team members had, explained what was safe to eat and drink, and even suggested what clothes to pack. We also discussed the culture and customs of the country to avoid any difficult or embarrassing situations.

In addition, we distributed a handout that listed basic travel tips. We then explained each item in detail and answered any questions connected with that list. Here are those travel tips:

Avoid dehydration by drinking lots of water before and during the flight (8 oz. of water every hour).

Avoid deep vein thrombosis (DVT) by exercising and stretching often during the flight and by walking around the plane when permitted. In addition, avoid sitting with crossed legs, remember to wear socks, and take off your shoes. Those especially at risk for DVT are people on flights lasting more than 10 hours, people who recently have had leg surgery, and women on birth control pills.

Food safety will be an issue, so strictly follow the outlined rules.

The team will provide many non-perishable foods, but to make sure you are not hungry, pack some of your favorite snacks such as energy bars, oatmeal, dry cereal, peanut butter and jelly, crackers, or protein shakes.

Be forewarned that many bathrooms in China are squat toilets without a sink or paper. These toilets are simply troughs in the floor that you squat over. We have a large supply of antibacterial wipes and toilet paper for you to use.

We also have a large supply of insect repellent--and that's not for the outdoors. Expect to encounter fleas and bed mites.

Pack a sense of humor and a flexible attitude. If things don't go according to plan, then adapt and keep a positive outlook.

COPING OVERSEAS
That last bit of advice we provided the team was important for ourselves, too. For example, on our trip to China, we found out that ice machines were rare--making any type of cryotherapy impossible. But we found a solution by using ice from the Zamboni!

I remember arguing with an emergency room physician in England about an X-ray. He did not think that an athlete who had fractured her index finger warranted a picture. "You Americans think everything must be X-rayed!" he yelled at me. But, after some coaxing, he did take the X-ray and we were on our way.

Remember, travel to a foreign country can be an eye-opening experience. It can also help you to appreciate our standard of living in the United States.