Tummy Troubles

 Tummy Ickies

This is going to get gross. So I figured we could at least make the title fun.

Many countries don’t have potable water. This and other hygiene issues means that you might experience some truly awful tummy problems.  These range from diarrhea to vomiting to cramping to gas.  

It could be as minor as the change of diet giving you gas or traveler’s diarrhea. It could be as major as dysentery and giardia.   But no matter what, it’s not fun.

Risk: 

In countries with potable water: 🦔/5

In countries without potable water 🦔🦔🦔/5 (and if you stay more than a few months, 🦔🦔🦔🦔🦔/5)

Severity: 🦔🦔🦔/5 (In general it can be treated easily and quickly but it can become very severe.)

Preparation and Prevention

The good news is there are lots of things you can do to reduce your likelihood of getting sick or prevent it altogether. And there are also lots of things you can do to make the situation less severe if it does happen.

Wash your hands! Sounds simple and it is.  If water isn’t readily available, have some good hand sanitizer in your purse.

Bottled, Boiled, or Filtered water only! And that includes ice! In general, cafes and stuff serving drinks with ice know this and only use bottled water for it. They lose their customer base if customers are getting sick. But it can’t hurt to ask. If you get bottled water, open it yourself. You want to feel the cap snap open.

Think carefully about where you eat! Some people might say “avoid the street side seller, eat at fancy looking restaurants” but you can actually see what the street side seller is doing! For example, the dhabas in India have big vats constantly boiling.  Nothing will survive in there.  In a fancy looking restaurant, they might put cilantro or something on top. A fancy hotel restaurant will probably be clean as they don’t want to lose customers, but a fancier place that caters to locals might not as locals probably are adapted to things we aren’t.

Don’t use wet utensils and wipe off wet plates and cups. This is one of the biggest traps. The food is clean, but if the plate is wet, you’ve undone all that effort to eat clean food.

Beware raw, unpeeled fruits and veggies! I say beware because it’s not a hard and fast rule and a lot of people choose to eat them. If you aren’t sure, though, you shouldn’t.

Have some stomach medication in your travel kit. Something to prevent nausea and gas, and something to prevent diarrhea and probably something for constipation.

Have rehydration salts in your travel kit. These can be Gatorade powder, Nuun tablets, or medical rehydration salts. It doesn’t matter too much. If you don’t do that, even bullion cubes will work if you like drinking broth. 

You’ve got a Tummy Icky. What now?

Well, it kind of depends on how severe it is. So let’s look at that first:

If you aren’t sure how severe it is, go to a clinic. Sometimes it’s easy to say “this is severe” or “this is nothing” but if you aren’t sure, a pharmacy or clinic can help. In many countries, pharmacies have an actual doctor or nurse on staff, even small roadside pharmacies. They can answer questions and give you a better idea.

A few good indicators are things like how much your stomach hurts. If you are having diarrhea, but your stomach doesn’t hurt much, it’s probably OK and best to let it run its course.  If you are having repeated diarrhea that is essentially shitting water, maybe be a bit more concerned. 

For vomiting, again if it still hurts after you vomit, probably see a doctor or nurse. A few other indications that it’s more than just travelers tummy are nausea, weird or sulfurous smelling burps, and cramps.

In short, if it feels worse than “Ugh, I really shouldn’t have had that for dinner last night” then maybe you should see a doctor!

Keep Hydrated! This is a tricky one, but vomiting and diarrhea will both cause you to lose water really quickly. That’s where the risk is.  Drink water slowly so you don’t trigger more nausea or vomiting. And mix in those rehydration salts if you can.  If you didn’t bring any, a pharmacy will have some. Bullion cubes can be mixed with hot water to make a sippable broth that has loads of electrolytes.

Know the signs of severe dehydration! We’ve all gotten a bit dehydrated. The first sign is your urine being way more yellow than usual. If you get to amber color, you should be concerned.  If you start getting muscle cramps, you are also really dehydrated. Finally, pinch the skin on the back of your hand.  If it doesn’t snap back into place when you let go but instead stays pinched up and eases down, you are really, really dehydrated. Go to the hospital.

Don’t be afraid of antibiotics! Obviously, only take them if the pharmacy/doctor tells you to. But if you have dysentery or giardia, you are going to need to take them. And take the full run. The last thing we need is multiple drug resistant dysentery. Ick.

It Happened to Me

Really? You want to read this? OK. Well, it’s happened a few times but I’ve spent months and months in Nepal. In general, it’s pretty minor.  I feel icky, I have the shits.  I take some loperamide if it doesn’t seem to be finishing up quickly and I take it easy.  Sometimes I need antibiotics.

But during one of my first trips to Nepal, I was feeling a bit icky, and then suddenly I felt awful.  I barely managed to make it back to my guesthouse, sprinting to my room and the bathroom before essentially shitting water.  This went on for a while. I would leave the bathroom for a few minutes and then rush back in. Meanwhile my stomach was cramping and I felt awful.   I became so dehydrated that my leg muscles were spontaneously cramping.

The next day I managed to make my way to a pharmacy. I described my symptoms and was given loperamide and antibiotics and some rehydration salts. I spent the day still in my room, eventually getting some toast  because I couldn’t imagine eating anything else.  It was miserable.

By the next day, with the antibiotics and the loperamide, I felt a little bit better, and within a couple of days I was back to normal.  But any time my stomach even gurgled for the rest of the trip, I was terrified!

Pick Pocketing

 (This risk has been calculated on the idea of someone who travels fairly frequently.  If you don't travel often or to many places, check out the risk in that particular country.

Getting Pick Pocketted

Risk: 🦔🦔🦔🦔🦔/5 (If you travel a lot, this WILL happen eventually)

Severity: 🦔🦔/5

Hello! 'Tis I, your favorite plague-riddled hedgehog, Murphy! This is going to be a hard one to write about because, as you can tell, we hedgehogs don't have pockets.  But I'll do my best.

One of the more common, and very nerve wracking events that happens to nearly all travelers eventually is arriving at a location to find that your wallet has been snatched. Never fear! Because this happens so often, there are lots of ways to prepare and lots of ways to deal with the situation.

Preparation and Prevention

Photography all Important Documents: Prior to traveling, take photos of your passport, drivers license, credit cards, etc.  Save these on a secure drive that you can access via the internet. That way if you lose something or get pick pocketed, it will be much easier to replace the missing items and prove your ID. Also save friends' phone numbers somewhere online so if your phone is stolen, you can still have their numbers and call them.

Travel pouches: I have been informed that humans, like hedgehogs, do not have pouches.  My echidna friends say that you can buy travel pouches from most travel stores.  These can go around your waist or under your shirt. Keep your most important stuff in there, as well as most of your money. 

Make yourself an inconvenient target: If you are going to keep things in your pockets, choose shirt breast pocket or front pants pockets rather than back pockets.  Turn your purse to face inwards instead of outwards.  Most criminals want an easy mark and a quick getaway. Something as simple as turning your purse around will dissuade most of them.

Walk Confidently: Yes, you may be in a new place and nervous, but walk confidently.  Even if you think you might be lost, chose a location (even the next street corner) and walk with confidence to it.  Criminals look for people that look lost or unsure.  Walking confident can be enough to dissuade them.

Take the minimum with you, leave the rest in your hotel: Especially if you have a hotel safe, take some cash, one card, passport photocopy or whatever (in some countries you need to take your passport with you, in which case, do). This way if something does happen, most of your IDs, cards, and cash are intact. 

Leave some "insurance money" with a trusted friend at home, and give them a password: This way if your money and cards are stolen, you can ask them to wire you money through one of the money transfer companies.  Why the password? "My wallet has been stolen and I need $2000 ASAP" is a really common scam.  So make sure there is a password that only you two know.  And slip it in subtly.  For example, make up a pet that doesn't exist.  That way when you email you can say "My wallet has been stolen, can you wire me $500 ASAP? Miss you so much. Give Twinkle extra kitty snuggles for me". Great safety measure!

Learn about local scams: Every location has its own tricks. Most have been well documented by other travelers and can be found online. That way you know the big tricks to look for.

Be friendly to local people: Yes, this seems weird, but if you are known as 'the person who always says hi' or 'the one who always smiles and treats us kindly', it's a heckuva lot more likely that a local person will intervene to stop a pick pocketing attempt and return your wallet.  

So you've been pick pocketed, What now?

Go to the Police.  If possible, go with a local friend.  Your hotel may even be willing to send an assistant manager or someone else with you to the police station.  Report the theft, give as much detail as possible, and get an official printed report. With an official report, you can send that to your insurance to get some money or value back.  And depending on the place, the police might have an easy time catching the thief! Make sure the police have a way to contact you, your hotel, and/or your embassy if they find anything.

Report your missing documents immediately: Look up those photos you saved earlier, call your credit card companies to cancel or freeze your cards before the thief decides they definitely want a new computer, and if something like a drivers license and/or passport went missing, call the nearest consulate or embassy of your country.  They should be able to issue you an emergency passport very quickly as well as keep any eye out for anyone using your documents illegally. This is one of the most common crises for travelers abroad, so your embassy will be ready to help.

It's okay to get emotional: Most people feel really embarrassed by this, but a lot of people cry after getting pick pocketed, even if they didn't lose much.  It's a very violating experience to realize that someone, completely without your knowledge, took your belongings just as you were holding them.  It's okay to be upset.  In fact, it's better to be upset for a day and then enjoy the rest of your travels than to hold it in and let it ruin your trip.

"It happened to me" Two pick pocketing experiences

With Help from the Police: I was running a bunch of errands while working in Mongolia. This included taking out my next quarter's rent from the bank.  Because of this I was carrying my major ID with me.  When I left the bank, I must have been scouted by some thieves.  Of course, I'd come straight from the bank so I was carrying a lot of money. As I was about to get into a taxi, I realized my wallet was gone, along with my credit cards, rent money, and ID.  

The first thing I did was call a local friend and ask if she could come to the police station with me (and front the taxi ride as I had no cash.) She was happy to accompany me to the police station.  We explained my situation in detail, and the police felt confident that with the traffic cameras, they could find the thieves.  I asked the police for a printed and signed report, which they happily gave to me.  This made it much easier to replace my lost IDs. Because of the language barrier, we gave the police my friend's phone number as well.  When I got home, I had a cup of tea and allowed myself to be frustrated for a bit. Then I called my credit card companies, explained the situation and asked them to put a freeze on my cards. I knew I could call to cancel my cards if they weren't returned, or unfreeze them if they were. But either way the thief wouldn't be able to use them.

A day later, the police called.  They caught the thief and nearly all of my money was returned to me (he had spent a little). Even my cards and ID were intact.  I was very relieved and took my friend out for a beer as a thank you.

With Help from the Community: When I was working in India, I was pick pocketed at the bus stop.  I knew India had a reputation for foreigners being pick pocketed, so fortunately my wallet had only the minimum money and ID that I needed for day-to-day interactions.  I kept the rest in a safe at home. But on that one particular day, I had been a bit laissez faire about safety, and hadn't been doing the little things like flipping my bag inwards.  I was tired.

When my stuff was stolen, I was frustrated, but not too concerned.  It wasn't a lot of money and there were no credit cards of major documents.  I assumed it was a loss.  Disappointing, but not awful.  

So you can imagine my surprise when I was at a local friend's home for dinner, his phone rang, and on the other line was someone saying "[NAME], aren't you friends with the foreigner who works at [location]? Some guys stole her wallet. We saw them looking through it and recognized her photo, so we wrestled it away from them." I had never met these people before, but they knew me around town as a friendly face, someone who was always polite, respectful, and a nice person, so even though they didn't know my name, they recognized me as someone who they would like to help. 

My friend explained that I was actually at his home right then.  Not 15 minutes later, two men showed up with my wallet, money, ID and all! The funny thing is that about two years later the same thing happened with an iPhone.  Again, some people recognized my picture and remembered me as "that nice foreigner who is always friendly", wrestled the phone away from the thief and gave it back to me.

Kindness is free and often pays interest!

Possible Rabies Exposure

Rabies Exposure

(Since rabies risk depends on location, please check out this page to look up individual countries and you can find a rabies risk world map here)

Risk of Exposure

In Rabies Endemic Countries: 🦔🦔🦔/5

In Rabies non-Endemic Countries: 🦔/5

Severity if Exposed: 🦔🦔🦔🦔/5 (While easily preventable within 72 hours, Developed Rabies has a 99.9% mortality rate)

When most people think of Rabies they think of raccoons or bats, but unfortunately in many parts of the world (take a look at the map above) cats and dogs could be that rabies carrier.  So that adorable puppy on the street that plays with you and nips your hand? The cute kitty that gives you a little scratch? Bad news: you might be exposed to rabies.

And rabies has no cure.  As of the time I’m writing this, I can count the number of people who have survived active rabies on one paw. And they had to be put into a medically induced coma. So basically: you get rabies, you die.

What counts as rabies exposure? Most of us assume the bite of a rabid (mammalian) animal. It’s actually a bit more complicated. The World Health Organization splits it into three categories: I, II, and III.

Category I is touching an animal or an animal licking you on fully intact skin. This isn’t rabies exposure. But wash your hands anyway.

Category II is a small bite, nip, or nibble on your uncovered skin, small scratches that don’t cause bleeding.  This is Rabies Exposure and you will need an immediate vaccine and local treatment.

Category III is a bite or scratch that breaks the skin, contact with a mucous membrane, or anything involving bats. This is severe Rabies Exposure and you will need an immediate vaccine, local treatment, and HRIG which is a whole new level of unpleasant.

Most people don’t think a scratch can carry rabies since it’s in saliva, but remember: animals groom and lick and chew their paws! Rabies is too dangerous of a risk.

Finally, some animals almost never carry rabies.  North american field mice and opossums, for example.  But if you don't know for sure, assume the animal might be dangerous.  The hospital can also advise you.

The good news is exposure isn’t rabies, and this is something you can get through with relatively minor pain!

How Can You Prevent Rabies Exposure?

There are lots of ways that you can help fully or partially prevent a rabies exposure.

Get the Rabies PrEP! Ask your doctor to get the Rabies PrEP vaccine. You might need to get it from a specialized travel doctor. PrEP stands for “Pre Exposure Prophylaxis”. Essentially, it’s a vaccine.  Unlike other vaccines though, this isn’t stand-alone.  We’ll get into that in the “What if it happens” section, so don’t stop reading! You aren’t in the clear yet. 

Wait, if it isn’t fully preventative, why get it? First of all, it reduces your risk of getting rabies if you are exposed. So if you get this and the post exposure boosters, you are safer than someone who just got the post exposure treatments. Secondly, if you do get exposed, you are in for a much easier follow up treatment than someone without the PEP. To read about that that nightmare, check out the “It happened to me” section.

It is especially important to get the PrEP if you will ever be somewhere that is more than 48 hours travel to the nearest hospital with rabies treatment. 

Avoid mammals! Ugh, I hate giving this advice because I don’t follow it myself (plus, I'm a hedgehog! we're mammals and I don't want you to avoid me, even if I do have bubonic plague). There are so many pitiful street dogs and adorable street cats everywhere. I would like to snuggle all of them! But unfortunately, they might have rabies.

Buy Travel Insurance! Okay, technically this can’t do anything to prevent your rabies exposure, but it will make what follows a lot easier. Especially on your pocket. Rabies treatment is expensive!

Have an emergency fund or someone willing to loan you money! Again, this won’t prevent rabies exposure, but treatment isn’t cheap. And it’s better to be down a few thousand dollars than to be dead. Having insurance obviously can prevent the “down a few thousand dollars” bit but depending on your insurance, you might still need to pay up front. This is a big enough emergency that if you can't build in an emergency fund, you will almost certainly qualify for assistance from your embassy.

What do you do if it happens to you?

Gosh darn it, you got scratched or bit by an animal or had direct, unintended contact with a wild bat. This is a Category II or Category III exposure.  Whether minor or severe, you need to take action NOW. Rabies doesn’t wait. Neither can you.

Clean the wound! Soap and water and a solid 15 minutes of washing. If you have something like Hydrogen peroxide or rubbing alcohol (yes, alcohol will hurt) use that too.  Then you can bandage it, if you feel it’s necessary.

Call a hospital! If it’s the middle of the night, feel free to wait until morning, but contact as soon as you can.  International travel hospitals are really familiar with this scenario, so try and contact one of them. If you can’t, any hospital will do. Arrange an appointment for as soon as possible.

Now go to the hospital and get your first treatment(s)! Tell the doctor if you’ve had the Rabies PrEP.  If you have, you’re in luck! All you will need is a series of follow up Rabies PEP (Post Exposure Prophylaxis). And don’t worry! It’s not like a few decades ago when it was a series of awful shots in the stomach. It’s going to be a few shots in the upper arm and hurts a bit more than a flu shot.  Usually it’s one on the day of exposure and one 3 day later, so it may effect your travel schedule but your life is far more important!  If your tetanus shot is out of date or soon in need of a booster (more than 7 years past the shot) you will also need a tetanus booster.

If you have not had the PrEP, you are in for a bad time. First you will get your first Rabies PEP injection. You will be given a non-negotiable schedule for the follow up PEP series, and its a longer series than the folks who go the PrEP: one on the day of exposure, one 3 days later, one 7 days later, and one 14 days later. This will almost certainly effect your travel plans, but again, better than death.  If your tetanus shot is overdue or almost overdue, you will need a booster there too.

Time to do the HRIG! The doctor will ask your weight, and no matter how shy you may be about this Do Not Lie! Your life depends on this information! The doctors will then measure out HRIG (Human Rabies Immunoglobulin) based on your weight. This will be injected directly into the open wound site or sites. This hurts badly. In fact, especially if the wound is on a sensitive area such as the hand, I highly recommend seeing if you can get a sedative prior to the injections.

Finally, Go Home, Calm Down, and Organize Your Medical Paperwork. Nightmare is over. You are almost 100% guaranteed to be safe from this rabies exposure. Photograph or scan your medical papers immediately and especially the bills for treatment. Insurance will need these later! And get yourself a treat. You’ve had a rough day. You deserve it.

"It Happened to Me: My Rabies Exposure"

CW: Pain. Lots of it.

(2018, Nepal)

I love cats. And usually they love me. But the one time that really wasn’t true was a total nightmare.

I had just started renting a new flat in Nepal and I hadn’t fully set it up yet.  I woke up in the night, around 1 am, to a strange sound and got up to investigate.  There, in my open, half unpacked suitcase, was a rummaging movement.  A closer look revealed a scrawny, adorable, wild kitten.

Maybe it was my previous luck with cats making me cocky. Maybe I was too sleepy to think logically. But I tried to shoo the cat out with my hand. Sharp kitty, as I now call her, did not take it kindly. She yowled and slashed and scratched to high heaven before eventually sprinting out the gap in the door.

A quick evaluation in the bathroom showed me that this was definitely a Cat III (pun intended) exposure.  I had 6 wounds: four on my left palm, one on the back of my left hand, and one on my right wrist. All were bleeding profusely.  I washed them out as best I could, but I knew that wouldn’t be enough. I hadn’t unpacked fully yet and I didn’t have wound disinfectant. 

But I did have an alcohol based hand sanitizer.

I poured that into my bleeding palm and held it.  It hurt like hell. I couldn’t make any noise because it was the middle of the night, but I held it in my palm for 30 seconds. Then I repeated on the back of the hand and the wrist before bandaging the wound as best I could.  I called the international hospital emergency line and told them the situation and how I had cleaned the wound. They advised that I could wait to come in until morning.

In the morning I called CIWEC travel hospital in Kathmandu and took a taxi over.  After a weigh-in they explained what they would be doing.  I was given my first Rabies PEP injection and a schedule for the next 3 shots.  Since my tetanus shot was 7 years prior, I wasn’t overdue but to be safe I was given another tetanus shot. 

Unfortunately, I didn’t have the PrEP so I needed the HRIG.  Let's talk about HRIG.  First of all, normal injections go into nice, squishy parts of your body, like your arm.  HRIG goes wherever the wound is.  That means that unless the wound is on a squishy part, it's going to be a lot of pressure. Secondly, for the average adult, the dose of HRIG is twice as large as a standard vaccine, so a heckuva lot is going in.  Finally, HRIG is a thick liquid, so not only does it require a large needle, you feel it going in.

If I had known what I was in for, I would have requested sedatives or even local anaesthesia.

I was brought into a room and asked to lie down on a stretcher.  Two nurses were called in, in addition to the doctor who would be administering the shots.  I’d never gotten a shot like this before.

The doctor warned me it would be uncomfortable, then the nurses helped me lie down, arms outstretched, and gently pinned me to the stretcher.  

And that was when the doctor started the first injection of HRIG directly into the first open wound on my palm.

At only one other time in my life have I have uncontrollably screamed from pain. And this was far worse. I had to be held down as I screamed and sobbed for each and every one of the injections. The one on the base of my finger was worst, but even the one on the back of my hand had me screaming so loudly that patients in the waiting room were horrified.  I don’t know what I can compare it to, but from my own experience I can tell you that I would rather have 5 cortisone shots than a single HRIG injection. It was worse than trying to stand on a shattered ankle. It was worse than steam burns.  It was worse than sliding down a gravel hill on my shins.  And I’ve done all those things.

I’m sure my experience was worse being on the palm, a major nerve center, but even on other parts of the body, HRIG is described as an unusually painful injection. The doctor told me he once had to do it on a child’s tongue, but I don’t like to think about that.

When it was all done, I was brought into a quiet room and given some water. I had to be helped into the bathroom because I could hardly walk, being near fainting, and I also nearly vomited from the pain.  My hand was so swollen that I couldn’t use it for n two days. Eventually I was able to walk to the counter and get my bill.  More than $2000, two times the average annual income in Nepal. I’ve heard its more expensive in other countries.

I took a taxi home and curled up on my bed and sobbed.

I would not wish the experience of the HRIG on my worst enemy. I now tell all my friends and anyone interested in travel: please get the PrEP! I don’t want anyone to experience what I had to experience. It is preventable 

But if I could go back in time to the moment I got slashed and I knew then what I know now about how much it would hurt and how much it would cost: would I do it again?  Yes. Not a question in my mind.  It hurt. It was horrible. Even thinking of it causes me pain and makes my heart race.

But I’m alive.  And that’s what matters. 

About the Murphy's Guide to World Travel

 We’ve all heard of Murphy’s Law: “Anything that can go wrong, will go wrong.”

This is also true while traveling.  And while that’s scary, it should never prevent you from going to interesting places.  Instead, you should learn about the risks, make educated decisions about what risks you are willing to take, and know what to do if something goes wrong.

With that in mind: I, Murphy the plague hedgehog, present to you 

The Murphy’s Guide to World Travel.

How it works:

Each risk will be assessed (yes, this is subjective. Sorry, I’m just one hedgehog) for it’s likelihood to occur and its severity if it does.  This will be on a scale of zero to five plague hedgehogs. 🦔

A zero for occurrence means it is near impossible or impossible.  A five means it’s a near certainty.

A zero for severity means that if it happens, it’s really nothing to worry about. A minor annoyance at worst.  A five means a decent likelihood of death.

Let’s give a couple of examples.

ENCOUNTERING A PLAGUE HEDGEHOGS!

Yep! We long-eared hedgehogs can carry plague.

Likelihood of Occurrence:

Outside Central Asia: 0/5 plague hedgehogs

In Central Asia:  🦔🦔🦔🦔🦔/5 (Meaning, you are almost certainly going to meet one of us)

Severity:

Outside of Central Asia: 0/5

In Central Asia: 🦔/5 (Unless you are picking up hedgehogs, you almost certainly won’t get the plague, and if you do it can be treated with antibiotics.  Is there a risk? Yes, is there even a risk of death? Yes. But it’s super unlikely.)

Oh? You want a non hedgehog example? Fine.  Boring.

Getting Pick Pocketed in Mongolia

Likelihood of Event: 🦔🦔🦔🦔/5 (Seriously. It happens to loads of people.)

Severity: 🦔🦔/5 (Losing your money, cards, and ID while traveling is a big problem! But fortunately, Mongolia’s many embassies are used to this crisis and ready to help.)

Make sense?

After the risk, we’ll tell you 

-How to prepare to prevent it and be ready if it happens

-What to do if it does happen

-An anecdote from someone who experienced it and can tell you if they made the right decisions.

Now remember, just like everything else in the world, your own experiences may vary.  But hopefully this will help you make good decisions when you travel.  

Welcome, to the Murphy's Travel Guide

 The Murphy's Travel Guide is here to help you when Everything that Can Go Wrong, Does Go Wrong...while travelling!

Join Murphy, the plague-hedgehog, as he guides you through your tourist nightmares helps you get out safely and with a good laugh.