Aging Travel Edition

Stephen Anderson, MD, FACEP
Chair, Exploring Retirement Section

This installment of the Exploring Retirement Section’s newsletter, The Explorer, is based on a Zoom call meeting held on March 18th, 2024. As our section membership is aging, but travel remains a goal for multiple reasons, we decided to investigate some challenges and solutions gleaned by our members. Whether it’s because we now have more time to travel, narrowing window for our “bucket lists,” or simply to visit family and friends … the growth, enlightenment, discovery, rejuvenation, and other positive emotions drives us to continue to travel. But, alas, the inevitable processes of aging make planning a necessity. If you have any insight to add to this newsletter, please post on the engagED site.

So, here are just some of the insights gained from exploring this subject.

AIRPORT TRANSFERS/TSA

imply getting from the curb to the gate can offer a hurdle that prevents some from traveling. Some solutions are obvious, some are airline/airport specific. Obviously, traveling with another who can assist makes this easier, both mentally and physically. A warning however to keep personal items and travel documents WITH THE INDIVIDUAL (in case of separation). Most airlines offer wheelchair or golf cart assistance for transport, but these MUST be arranged prior to arrival at airport (and unless further arrangements done, do not include the physical pass-through TSA). One member laughed at the airline’s reference to the “miracle of flight” (the number of wheelchairs and early boarding often far outweighs the number of wheelchairs awaiting travelers at their destinations, presumably due to no TSA on arrival). Everyone acknowledged the increased ease of expeditious screening that comes with TSA Pre-check, CLEAR, and other services (for a price). As of today, a five-year TSA enrollment is $85, renewal $70. CLEAR costs $199 annually but can be lowered through promotions and can also expedite concerts, sporting events, etc. (but is only available in 90 airports). There is also Global Entry, which requires TSA and a separate application through the State Department (but can expedite international returns).
Of note, some services like CLEAR, are beginning a personal “curb to TSA/curb to gate” service for an additional $49 or $149 respectively, but only at limited airports.

The actual TSA screening offers its own unique challenges. One advantage, for those over 70, is that you get to leave your shoes on. But orthopedic joints steer you into the X-ray line, or wanding and pat down may be options. There was no clear answer to cardiac pacemakers, as individuals have been warned that some screening devices could act like a magnet and pause operation (largest concern was with wanding). The advice was simply to let the agent at the station know.

Medications and devices are to be discussed next.

TRAVEL WITH MEDICAL DEVICES

Let’s begin with the best news. If it’s a medical device, it doesn’t count as a carry on (CPAP, nebulizer, etc.) except in the case of oxygen. Oxygen must be prearranged with the airlines, possibly with a charge (this can include concentrators). Personal scooters are becoming more portable and are treated as gate check items at the bottom of the boarding walkway.
Interesting is the warning on implantable pumps (insulin, pain meds, etc.). It seems that on altitude gain during takeoff, some pumps are triggered to release bolus doses, and on landing air bubbles can interrupt delivery. Here’s some advice to any physician asked onboard to evaluate an unresponsive patient … ask about pumps, check a blood stick sugar, look for signs of overdose (pupils, etc.). I travel with Naloxone on my backpack and have only been congratulated by TSA agents that inquire about it (but one person had theirs confiscated into Mexico).

TRAVEL MEDICATIONS

First, if you need the medication, carry it with YOU on board. Lost luggage can be a worse nightmare if your needed medications are in it. Possibly for domestic travel, but absolutely for international travel, keep prescription medications in their own original bottle. If these are DEA restricted medications, it is recommended you have a letter from your physician documenting your need. The old idea of “I’ll take along a few leftover XXX tablets just in case” isn’t recommended across borders. On that note, it’s important to also be aware of what is considered prescription/ restricted in other countries. We heard of the extended detainment for “smuggling” diphenhydramine. If there is a question at a border, declare it up front! It’s better to be confiscated with a chastisement then to be detained.
Needles are their own situation (this includes auto injectors). In cases of preloaded syringes, have them labeled and packed together with documentation. It’s not a bad idea at TSA, and certainly at borders, to simply say “I have an EpiPen, or insulin syringes in my backpack” before they search your luggage when the machine diverts your bag. If you are carrying a medication “as a physician, just in case,” have proof of your medical license (medical mission trips should handle this for you).

As for “What should I pack if I’m going to XXX?,” obviously this depends on the region of travel, urban vs. rural, time of year, etc. We will get to vaccinations, but the advice for international travel is to consider a travel clinic appointment. We trust our investments to experts, and our unique health histories to specialists. Our “at risk travel” is best planned by an expert. Malarial prophylaxis offers several choices. Altitude may benefit from Diamox. traveler’s diarrhea can be treated symptomatically first with bulk fiber, Bismuth, Imodium, and other supplements (mostly avoiding dehydration). But specific antibiotics may vary from region based on local pathogens. The CDC states best first choices are trimeth/sulfa, doxy, azithromycin, or ciprofloxin (depending on region).

There was universal agreement that ondansetron is a vacation saver, and almost universally packed (in addition to OTC analgesic of choice). Other medications voted for included an EpiPen, aspirin, topical anti-bacterial, and others.

Finally, here’s a warning about food. Many countries have strict restrictions on “importing food,” specifically poultry, meat, agricultural products, etc. The story of being detained and having to throw out packaged hotdogs and buns was relayed. I suggested this might have been protested, as no one really knows what’s in a hotdog.

TRAVEL VACCINATIONS

Two discussions were held around vaccinations. The first was around regionally specific vaccinations and preventable travel diseases. Most are specific, based on regions (rural vs. urban, endemic vs. epidemic), time of year (rainy vs. dry season as mosquito bourn), lethality of contracting, etc. Some are cheap, and some are very expensive. For example, the vaccine for Japanese encephalitis is up to $950 a dose for two doses every two years, but very necessary as the illness itself is extremely lethal. The take home conclusion was again that a travel clinic should be able to advise on specific needs and supply the vaccine.

The most important thing regarding vaccinations is that “an ounce of prevention is worth a pound of cure.” Mosquitos remain the deadliest creature on earth for humans. Clothes should be treated and repellant reapplied frequently and mosquito netting effective.

Next, the discussion was on updates to vaccinations. Some are said to confer lifelong immunity, while others have CDC recommendations on revaccination. One can always have titers drawn to check on persistence of immunity. However, sometimes the cost of titers and the timeline for travel make the decision to “just revaccinate” an easier choice. There was specific discussion on measles. The CDC states if you were born before 1957, likely you are immune (thank your parent for rubbing you against the kid down the street at “measles parties”). Many of the vaccines administered from the 1960’s onward provide lifelong coverage, except if you may have received an inactivated vaccine from 1963 to 1967 (approximately 5% of those). A titer might be worth it, especially if traveling to west Texas!

TRAVEL INSURANCE

Quite a long time was spent discussing travel insurance and hearing exorbitant true stories. Several important points were made, beginning with whether your own health insurance covers you while traveling. Most Medicare and insurance plans will cover some costs for medical care received in emergencies during domestic travel, but “out of network” co-pays can be early and significant.

Whereas “universal coverage” in some countries keeps costs down, the “coverage” is for citizens. Overseas claims may be submitted upon return and possibly reimbursed, but you will likely need to pay with cash or with credit card up front. One story included >$80,000, requiring three maxed out credit cards for ICU care. The take home message was to travel with more than one card, with credit available on those cards. This doesn’t include evacuation cost/medical transport. Domestically, this can be in the five figures easily, internationally in the six figures, if no coverage.

“It will never happen to me,” but as we age, it does. The further off the beaten path you go, the more the decimal place on cost goes up.

So, what do you look for in travel insurance? Simply having a policy often contains cost, as the company you have purchased from has pre-negotiated fees with providers. Travel company policies (group tours, cruises, etc.) may be reasonably priced but study the coverage.

Insurance purchased separately SHOULD include BOTH medical care costs and evacuation costs. US News & World reports and other consumer agencies rate and recommend certain companies. Know that you can purchase single trip coverage, or if you travel a lot, there are annual policies to cover all your travel.

Finally, this is a discussion around vacation travel and has nothing to do with elective surgical/ medical travel. THAT is its own can of worms. Most of us have had the nightmare of trying to find an on-call surgeon during our shift that will care for a person with a complication arising from a surgery performed outside the US. Good luck, consider yourself warned.

CLOTHING

It’s best to wear clothing that is loose, in layers, and easily cleaned. Pockets (some zippered) are a plus. Best quote: “There is no such thing as bad weather when traveling, just bad clothes.”

Be sure to have coverage for sun protection, especially a hat. Some clothing comes with mosquito repellant. You can also buy Permethrin and treat your own clothes (lasting multiple washings). Shoes are for comfort, not for show.
If travel involves long distances of sitting, consider compression socks (15-20 mmHg minimum, 20-30 mmHg moderate). Get up/out and walk every few hours.

Remember your sunglasses and reading glasses.

COMMUNICATION

Your wireless network may have shoddy coverage in some areas of the United States but consider that it is a given when traveling internationally. Many plans include Canada and Mexico without a surcharge, but most other countries will require some form of upgrade (check before travel, plans vary widely).

Some up-charges are per call, some per day, and some for a specified time (weeks/months). Some kick on automatically, while some need to be turned on and off.

You can often buy a sim card on arrival in another country and replace yours (but upon landing, you won’t have that card in place until you make that purchase and change). Depending on how far off the beaten path you wander, you might even look into buying a satellite phone, which can cost $500-$1,500 plus service). As Starlink/SpaceX place more satellites in orbit, wi-fi coverage will expand in the years to come.

One strong suggestion if you have friends and family at home - consider a schedule of checking in. This can be by daily photos, or a planned call. A “wingman” back at home helps on several levels.

“OFF-THE-BEATEN-PATH”

In our youth, many of us were (still are) adrenaline junkies. Children, responsibilities, etc. can dampen this as we age. But on vacation, we frequently want to “get out there,” far from routine, and discover new and exotic things. The challenge is the realization of personal health and safety that comes with aging. Our athletic abilities diminish, and our awareness of vulnerability can become clouded. So, the discussion was very realistic in doing homework on climate, environment, and safety of destinations. Can I tolerate the altitude in Tibet or Machu Picchu? Am I as strong a swimmer with snorkeling? Is the walk from town back to the B&B safe after dark? An extra dose of common sense and personal realistic review has to temper our “bucket list.”

SPECIALIZED TRAVEL WITH MEDICAL ISSUES

Finally, there was some discussion around opportunities to travel with medical issues. Cruises seemed to offer the widest opportunities for support. Several cruise lines offer dialysis cruises in which dialysis machines and the support staff are brought onboard for one week to dialyze during sea days or evenings. To me, most interesting was travel agencies now offering “dementia travel.” For a price, partner care can be offered during the days on trips, so one member of a couple (the caregiver) can explore, while the “patient” is offered trained companionship in a safe environment.

The point here was … don’t give up because “we can’t do that anymore because my spouse has XXX.” There is still a wonderful world out there, with sunsets to be shared.

CLOSING “THANK YOU”

Before I close, I want to take a moment to thank Pam Bensen, MD, FACEP, for her leadership in founding this section and acting as its trailblazing first newsletter editor. Pam is stepping down as newsletter editor but not going away. For this, and EVERYTHING Pam has done for ACEP, we owe her a debt of gratitude that can only be repaid by personally committing to the section motto …

Remain Relevant