9789177410966

• • • • • • • • • • • • • •

Authors: Rickard Ånell, specialist physician (Above) and Jens Berglund, Security Director (Below) during an assignment i Afghanistan.

First aid Treatment guides for diseases and accidents Vaccinations and tropical diseases Dangerous animals Emergency assistance and insurance Surviving terror attacks and assaults Manage theft and robbery Travel security for women Safe accommodation and driving abroad Dealing with foreign cultures Information security and social media Survival in the wilderness Healthcare and security equipment Planning, preparations and risks

Facts, advice and treatments are based on international “best practice” for medicine and security during leisure, business or expeditionary travel. The handbook is designed to benefit professionals as well as the inexperienced traveller.

ISBN 978-91-7741-096-6

9

789177 410966

HANDBOOK TRAVEL MEDICINE & SECURITY

Handbook in Travel Medicine & Security is a safe and indispensable companion on all journeys and expeditions. It provides simple and smart tips that can be used irrespective of whether the destination is a holiday cottage, the South Pole, a major city or a conflict area. Here are some examples of the contents:

RICKARD ÅNELL & JENS BERGLUND

Contents Foreword

HANDBOOK

TRAVEL MEDICINE & SECURITY FACTS

|

ADVICE

|

TREATMENT

13

Part 1. Before travelling 1. Successful, secure travel 19 2. Planning and preparation 27 3. Flights, transport and accommodation 70 4. Security risk and medical risk 82 5. Dangerous animals 102 6. What to do in an emergency situation 109 Part 2. Treatment guide 7. About first aid 8. Trauma treatment 9. Injuries and accidents 10. Diseases and infections 11. Symptoms and conditions 12. More advanced medical care 13. Communication and reporting

141 145 163 177 201 231 235

Explanations References Notes

242 246 255

Page 121

• Stay at secure locations if an incident arises, avoid moving about.

• Carry paper copies of travel documents and contact details. Always have access to cash to buy transport out of the country.

• Carry a bag with 24 hour supply of water, food, clothes and hygiene articles.

• Bring a fully charged mobile, obtain information of alternative communications if the mobile network is down or limited.

• Try to have access to a car.

• Leave before the situation deteriorates to far for a secure evacuation.

After all emergencies:

Page 29

Follow the instructions from your insurance company’s assistance service and/or local police.

Inform next of kin (employer) and handle emotional reactions.

ICE

In Case of Emergency

Next-of-kin:

Card blocking:

Insurance company/assistance service:

Terror attack – within sight or hearing Page RUN: Flee and seek cover in the nearest secure place. Run in short stages. 118 HIDE: Hide in a secure place. Barricade the door. Set your mobile to silent mode.

FIGHT: Fight as a last resort. Try to overpower/disarm or play dead.

Terror attack – in the vicinity Page 1. Stop, avoid movement and exposure (risk of secondary attack).

120 2. Notify that you are unharmed, avoid overloading mobile-/internet network.

3. Gather information about direction of and distance of the threat.

4. Avoid gatherings of people and public transport.

Under fire Page 1. Seek cover.

115 2. Identify the direction of danger and where the nearest alternative cover is.

3. Move quickly, quietly and hidden to the next cover.

4. Continue in short stages at high speed, from cover to cover.

L A B C

Road block/Vehicle checkpoint Page • Drive in calmly, follow instructions. Only calm, predictable movements.

122 • If it is dark outside, turn on the interior lighting.

• If negotiations arise, appoint a spokesperson. Be patient, behave respectfully.

D

Robbery 1. Follow instructions from the perpetrator, keep calm, no sudden moves.

2. Go the the nearest secure place and carry out a self-check.

3. Block all cards and devices lost as quickly as possible.

E

Page 108

Assault – imminent Page 1. Place yourself tactically. Create distance and make sure there are 110 protective objects between you.

2. De-escalate with non-aggressive body language. Show your palms, speak calmly.

3. Check out the surroundings, so that no further person sneaks up from behind.

4. Identify a suitable flight path, flee or call for help.

Fire 1. Save yourself and those in danger.

2. Warn all threatened by the fire.

3. Activate the fire alarm or local emergency number.

4. Put out the fire if you think you can.

Page 117

Theft or loss of passport Page 106 1. Block all cards and devices lost as quickly as possible.

2. Block the passport via your embassy. They can issue a temporary passport.

Memory card

Life threatening • Manage life-threSituation and atening situation/ bleeding bleeding

• • • •

Fire, vehicle Attacker, weapon Risk of landslide/collapse Large-scale bleeding

Read more

Page 137

Airways

• Create free airways

• Clear the mouth • Stabilize the neck

Breathing

• Check the breathing function

• Remove tight clothes • Depth and frequency of breaths • Investigate chest movement

Page 142

Page 139

Circulation & chock

• Check pulse and stop bleeding

• Check pulse at wrist • Feel for a heartbeat • Apply pressure bandage

Page 146

Disability

• Check level of consciousness

A – Alert V – Voice P – Pain U – Unresponsive

Page 149

• Protect against weather and loss of heat • Check for further injuries

• Check that all injuries are found and dealt with • Isolate the patient from the ground • Document

Exposure

Keep updated Page Manage language and culture 26 Emergency assistance during travel Insurance cover Vaccinations Passport, visa, customs & local legislation Aids for finding the way (map, GPS)

❑ ❑ ❑

Security training Page Medical kit 39 Travel security equipment/ spare mobile Access to healthcare (“golden hour”) Medical and dental checkup Crisis and incident preparedness

Contact home (SITREP) Page Mental preparedness and support 50 In-depth personal information (ISOPREP) Protective equipment Advanced medical kit/travel pharmacy

❑ ❑ ❑

❑ ❑ ❑ ❑ ❑

Page 149

NEW EVALUATION EVERY 5 MINUTES Page 231

HAND OVER OF INJURED TO PROFESSIONAL CARE

❑ ❑ ❑ ❑ ❑ ❑ ❑

CONFLICT & DISASTER AREAS

• Follow developments, decide at what changes you will leave the area.

Read more

ELEVATED RISK

• Check the alternatives for travelling from the country: aircraft, ship, car or bus.

Memory card

Preparatory action and packing list

FIRST AID

ALL TRAVELLING

Evacuation

EMERGENCY MEASURES

Scale

1 cm

Map type

1:10 000

100 m

Orientation

1:25 000

250 m

Town

1:50 000

500 m

Terrain/field

1:100 000

1 km

Regional

M I S T

Mechanism of injury

Traffic, fall, drowning, knife, gun? (time?)

Injuries found

Location and severity? (time?)

Signs and symptoms

Pulse, blood pressure, changes?

1:250 000

2,5 km

Road atlas

Treatment given

Medicine, tourniqet, bandage, neck collar? (time?)

1:1 000 000

10 km

Nation

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

0

Page 121

• Stay at secure locations if an incident arises, avoid moving about.

• Carry paper copies of travel documents and contact details. Always have access to cash to buy transport out of the country.

• Carry a bag with 24 hour supply of water, food, clothes and hygiene articles.

• Bring a fully charged mobile, obtain information of alternative communications if the mobile network is down or limited.

• Try to have access to a car.

• Leave before the situation deteriorates to far for a secure evacuation.

After all emergencies:

Page 29

Follow the instructions from your insurance company’s assistance service and/or local police.

Inform next of kin (employer) and handle emotional reactions.

ICE

In Case of Emergency

Next-of-kin:

Card blocking:

Insurance company/assistance service:

Terror attack – within sight or hearing Page RUN: Flee and seek cover in the nearest secure place. Run in short stages. 118 HIDE: Hide in a secure place. Barricade the door. Set your mobile to silent mode.

FIGHT: Fight as a last resort. Try to overpower/disarm or play dead.

Terror attack – in the vicinity Page 1. Stop, avoid movement and exposure (risk of secondary attack).

120 2. Notify that you are unharmed, avoid overloading mobile-/internet network.

3. Gather information about direction of and distance of the threat.

4. Avoid gatherings of people and public transport.

Under fire Page 1. Seek cover.

115 2. Identify the direction of danger and where the nearest alternative cover is.

3. Move quickly, quietly and hidden to the next cover.

4. Continue in short stages at high speed, from cover to cover.

L A B C

Road block/Vehicle checkpoint Page • Drive in calmly, follow instructions. Only calm, predictable movements.

122 • If it is dark outside, turn on the interior lighting.

• If negotiations arise, appoint a spokesperson. Be patient, behave respectfully.

D

Robbery 1. Follow instructions from the perpetrator, keep calm, no sudden moves.

2. Go the the nearest secure place and carry out a self-check.

3. Block all cards and devices lost as quickly as possible.

E

Page 108

Assault – imminent Page 1. Place yourself tactically. Create distance and make sure there are 110 protective objects between you.

2. De-escalate with non-aggressive body language. Show your palms, speak calmly.

3. Check out the surroundings, so that no further person sneaks up from behind.

4. Identify a suitable flight path, flee or call for help.

Fire 1. Save yourself and those in danger.

2. Warn all threatened by the fire.

3. Activate the fire alarm or local emergency number.

4. Put out the fire if you think you can.

Page 117

Theft or loss of passport Page 106 1. Block all cards and devices lost as quickly as possible.

2. Block the passport via your embassy. They can issue a temporary passport.

Memory card

Life threatening • Manage life-threSituation and atening situation/ bleeding bleeding

• • • •

Fire, vehicle Attacker, weapon Risk of landslide/collapse Large-scale bleeding

Read more

Page 137

Airways

• Create free airways

• Clear the mouth • Stabilize the neck

Breathing

• Check the breathing function

• Remove tight clothes • Depth and frequency of breaths • Investigate chest movement

Page 142

Page 139

Circulation & chock

• Check pulse and stop bleeding

• Check pulse at wrist • Feel for a heartbeat • Apply pressure bandage

Page 146

Disability

• Check level of consciousness

A – Alert V – Voice P – Pain U – Unresponsive

Page 149

• Protect against weather and loss of heat • Check for further injuries

• Check that all injuries are found and dealt with • Isolate the patient from the ground • Document

Exposure

Keep updated Page Manage language and culture 26 Emergency assistance during travel Insurance cover Vaccinations Passport, visa, customs & local legislation Aids for finding the way (map, GPS)

❑ ❑ ❑

Security training Page Medical kit 39 Travel security equipment/ spare mobile Access to healthcare (“golden hour”) Medical and dental checkup Crisis and incident preparedness

Contact home (SITREP) Page Mental preparedness and support 50 In-depth personal information (ISOPREP) Protective equipment Advanced medical kit/travel pharmacy

❑ ❑ ❑

❑ ❑ ❑ ❑ ❑

Page 149

NEW EVALUATION EVERY 5 MINUTES Page 231

HAND OVER OF INJURED TO PROFESSIONAL CARE

❑ ❑ ❑ ❑ ❑ ❑ ❑

CONFLICT & DISASTER AREAS

• Follow developments, decide at what changes you will leave the area.

Read more

ELEVATED RISK

• Check the alternatives for travelling from the country: aircraft, ship, car or bus.

Memory card

Preparatory action and packing list

FIRST AID

ALL TRAVELLING

Evacuation

EMERGENCY MEASURES

Scale

1 cm

Map type

1:10 000

100 m

Orientation

1:25 000

250 m

Town

1:50 000

500 m

Terrain/field

1:100 000

1 km

Regional

M I S T

Mechanism of injury

Traffic, fall, drowning, knife, gun? (time?)

Injuries found

Location and severity? (time?)

Signs and symptoms

Pulse, blood pressure, changes?

1:250 000

2,5 km

Road atlas

Treatment given

Medicine, tourniqet, bandage, neck collar? (time?)

1:1 000 000

10 km

Nation

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

0

RICKARD Ã…NELL & JENS BERGLUND

HANDBOOK

TRAVEL MEDICINE & SECURITY FACTS

|

ADVICE

|

TREATMENT

© 2018 The authors and Gothia Fortbildning AB ISBN 978-91-7741-096-6 Prohibition against copying! Duplication of the contents of this book, in whole or in part, is prohibited under the Act (1960:729) on Copyright in Literary and Artistic Works without permission from the publisher Gothia Fortbildning AB, Stockholm. The prohibition applies to both text and illustrations and is valid for all forms of duplication.

Editor: Susanne Bardell Carlbring Cover, typesetting of insert: Richard Persson Graphic design, insert: Thomas Rudström Illustrations: Jeanette Engqvist Translation: Space 360 AB Second edition, first imprint Printing: Baltoprint, Litauen 2018 Gothia Fortbildning Box 22543, 104 22 Stockholm Customer service 08-462 26 70 info@gothiafortbildning.se www.gothiafortbildning.se Subject expert, travel security: Nikolina Ståhl, Combitech AB This edition is produced in collaboration with Saab AB.

Table of contents Foreword .........................................................11 Part 1. Before travelling..................................15 1. Successful, safe travel ..............................17 The correct information about your travel destination .................................................................17 Security risk and medical risk .....................................20 Where do risk areas exist? ..........................................22 2. Planning and preparation ..........................25 Preparations before of all travel .................................26 Preparations before travel with elevated risk .............40 Preparations before travel to conflict or disaster areas ..............................................................51 3. Flights, transport and accommodation ....68 Flights .........................................................................68 Traffic and land transport ..........................................71 Accommodation ........................................................77 4. Security and medical risk ..........................80 Behaviour ...................................................................80 Travel with others.......................................................82 Travelling as a woman ................................................82 Travelling as a senior or with children........................85 Food and drink ...........................................................85 Clothing in extreme climates .....................................87 Veneral disease (STD) ................................................88

Tattoos .......................................................................88 Weather and geography .............................................89 Dangerous sports .......................................................89 High altitude ..............................................................90 Blood clots .................................................................92 Social media ...............................................................92 Information security...................................................95 Surveillance and pursuit .............................................98 Landmines..................................................................98 5. Dangerous animals...................................100 6. What to do in an emergency situation....107 Traffic or transport disruption .................................108 Traffic accidents .......................................................109 Theft/loss of passport or payment card .................. 111 Robbery.................................................................... 112 Assault ...................................................................... 114 Imminent attack ....................................................... 115 Under fire .................................................................120 Fire ...........................................................................122 Terror attack within sight or hearing........................123 Terror attack in the vicinity ......................................125 Evacuation ................................................................126 Checkpoint/roadblock ............................................127 Kidnapping and hostage-taking................................129 Landmine or explosive device .................................. 131 Survival/lost in wilderness .......................................132

Part 2. Treatment guide................................137 7. About first aid ...........................................139 8. Trauma treatment .....................................143 Always raise an alarm if you can! .............................143 L: Life-threatening surroundings/bleeding ..............143 A: Airway and C-spine control .................................145 B: Breathing..............................................................148 C: Circulation. ..........................................................152 D: Disability .............................................................155 E: Exposure and environment ..................................155 Debriefing ................................................................159 9. Injuries and accidents ..............................161 Bite injuries............................................................... 161 Blue nails ..................................................................162 Burns ........................................................................162 Dental injuries ..........................................................165 Ear injuries ...............................................................165 Eye injuries ...............................................................165 Fracture ....................................................................166 Internal bleeding ......................................................169 Luxation, dislocation ...............................................170 Noise injury .............................................................. 171 Pneumothorax ......................................................... 171 Tension pneumothorax............................................172 Wound......................................................................172 10. Diseases and infections .........................175 Amoebic infection.................................................... 176

Athlete’s foot............................................................ 176 Blood poisoning (sepsis) .......................................... 176 Borrelia.....................................................................177 Chickenpox ..............................................................177 Cholera ....................................................................178 Cryptosporidium .....................................................178 Dengue fever/breakbone fever ................................178 Diabetes ...................................................................179 Diabetic coma, hyperglycaemia ...............................180 Diabetic with hypoglycaemia/coma ....................... 181 Ear infection in the auditory meatus/external otitis ......................................................................... 181 Ear inflammation/acute media otitis ....................... 181 Ebola ........................................................................182 EHEC/ETEC ...........................................................182 Epilepsy ....................................................................183 Giardia .....................................................................183 Haemophilus influenzae typ B (HIB) ......................184 Hepatitis A ..............................................................184 Hepatitis B ...............................................................185 Hepatitis C, D, E ......................................................185 HIV ..........................................................................186 Influenza...................................................................186 Japanese encephalitis ...............................................187 Leishmaniasis ...........................................................187 Malaria .....................................................................188 Measles, mumps, rubella ..........................................189 Meningococcal meningitis .......................................189

MERS-CoV ...............................................................190 Pneumococcal/streptococcal pneumonia ............... 191 Pneumonia ............................................................... 191 Polio .........................................................................192 Rabies .......................................................................192 Schistosomiasis/bilharzia.........................................193 Sepsis ........................................................................194 Sinusitis ....................................................................194 TBE (Tick borne encephalitis) .................................195 Tetanus and diphtheria ............................................195 Tuberculosis .............................................................196 Typhoid fever ...........................................................197 Urinary tract infection..............................................197 Whooping cough .....................................................197 Yellow fever ..............................................................198 Zika virus ..................................................................199 11. Symptoms and conditions .....................201 Abdominal pain........................................................202 Acute airway blockage, choking ...............................204 Allergic shock/anaphylactic shock ..........................206 Allergic reaction .......................................................207 Blister .......................................................................207 Blood clot/deep vein thrombosis, DVT ..................208 Cramps .....................................................................208 Cold .........................................................................208 Constipation ............................................................209 Cough.......................................................................209 Diarrhoea .................................................................209

Fainting .................................................................... 210 Fever ......................................................................... 210 Frostbite ................................................................... 211 Gynaecological pain ................................................. 212 Haemorrhoids ......................................................... 213 Head cold ................................................................ 213 Heart attack ............................................................. 213 Heat stroke/sun stroke (hyperthermia) ................... 213 Hyperventilation ...................................................... 214 Hypothermia ............................................................ 215 Infected wound ........................................................ 217 Ingrown toenail ........................................................ 217 Insect bite ................................................................. 218 Jellyfish sting............................................................. 218 Jet-lag ........................................................................ 219 Lumbago .................................................................. 219 Mountain sickness: HAI, AMS, HACE, HAPE........220 Muscular pain...........................................................222 Nausea......................................................................222 Nosebleed ................................................................222 Pain...........................................................................223 Parasites....................................................................223 Poisoning..................................................................224 Prostatitis .................................................................225 Reflux .......................................................................225 Scorpion sting ..........................................................225 Seasickness ...............................................................226 Slipped disc ..............................................................226 Snake bite .................................................................227

Snow blindness ........................................................228 Sore throat................................................................228 Stroke .......................................................................229 Sun stroke.................................................................229 Tick ..........................................................................229 Travel sickness..........................................................229 Unconsciousness......................................................230 12. More advanced medical care ................231 Inserting a needle intravenously or intraosseously...231 Suturing techniques ..................................................232 Linear anaesthesia ....................................................233 13. Communication and reporting ..............235 Injury journal ............................................................235 Report template .......................................................235 Prioritising injured persons ......................................239 Helicopter landing site.............................................240 Radio communication, spelling out .........................241 Examples of emergency calls....................................241 Explanations .................................................242 References ....................................................246

NOTE! As every individual and every situation is unique, more, fewer or completely different measures may be needed than those described in the handbook.

Foreword “Fortune favours the prepared mind.” . These words were coined by the French scientist Louis Pasteur, the founder of bacteriology and inventor of pasteurisation. But what does this have to do with travel medicine and security? Well, in all its simplicity and self-evidence, there is a lot in the quote that can benefit you while you travel. Unforeseen events are often related to as “luck” or “bad luck”, and causes are then assigned to randomness, someone else, or even to higher powers. Unfortunately, this attitude often leads to unnecessary misfortunes and frictions.

Those who are prepared, take responsibility for themselves and have good understanding usually experience fewer frictions.

When you read this book, we want you to have more “luck” when it comes to travel medicine and security.

In major cities, at charter destinations or in the remote countryside, there are security risks that can jeopardize your travel. Travelling in natural surroundings or beyond the familiar routes – whether to a cottage in the woodlands of northern Sweden, on an expedition in Namibia or on a ship in the Pacific Ocean – often means that you are far away from hospitals and medical care. What do you do when something happens, and there is no help available? This is what this book highlights.

11

The book deals with preparations, risks and actions in the event of various emergencies and conditions for travel to both secure and threatening environments. We strive to ensure you achieve the right security, that is to say somewhere between excessive and insufficient measures. Through stand-alone, simple and clear guides, you get practical guidance on security, first aid, injuries and accidents, but also on diseases, infections as well as symptoms and conditions. This book is intended to increase the rewards of travelling and to reduce the risks. Knowledge may be the difference between interrupted travel and being able to continue, irrespective of whether you are on an expedition, a business trip or an ordinary tourist.

You can make the difference – the right actions save lives!

Rickard Ånell & Jens Berglund Rickard Ånell is a doctor specializing in orthopedics, a company doctor and a flight and diving doctor. He works as Global Medical Adviser for Saab AB, and previously worked for the Swedish Armed Forces, the Swedish Polar Research Secretariat and the Centre for Teaching & Research in Disaster Medicine and Traumatology, and has for many years run Adapted Medical Solutions AB, which carries out training courses and gives advice to many Swedish security companies and international companies. Rickard Ånell also has a great interest in tropical medicine have trained in Sweden, Ethiopia, Tanzania and Zanzibar. He has worked as a surgeon and as an accident and emergency doctor.

12

Jens Berglund is the head of personnel security at Saab AB and has created the travel security system Deployment Ready for global assignments in all types of risk areas. He works with management, operational development and training within security. Jens Berglund has a background as an officer in the Swedish Armed Forces, and he is educated at the Institute for National Defence and Security Policy Studies at the Swedish Defence University. He has operated in Afghanistan, Brazil, India, Kenya, the Middle East and Thailand, including over 100 executive protection assignments in high-risk environments.

The medical content of the book has been scrutinized by Professor Tore Vikström, Centre for Teaching & Research in Disaster Medicine and Traumatology in Linköping, Per Loftås, Consultant at the Surgery Clinic, Norrköping, Dag Lemming, Docent, Aerospace Medical Centre, Linköping, Andreas Johansson, Surgery Clinic, Lidköping, Thomas Axelsson, Anaesthetics Clinic, Värnamo and Mats Wizén, Medical Officer on the state icebreaker ODEN, and Tomas Rohal, Registered Psychologist at Psykologpartners AB. The security content has been scrutinized by Niclas Lind of Ericsson AB, Mats Nyberg of Telia Company AB, Henrik Moll of Control Risks, Mikael Tärnlund, security adviser, Ronnie Purcell, International SOS and Gerry Mattheyse, Security and risk manager.

13

Since the defence and security company Saab was formed in 1937, we have endeavored to keep society and people safe. Feeling secure is a fundamental human need, and as we see it, a human right. Using systems and solutions to increase security, we can make it possible. Saab operates, and has employees in all continents, who travel across the world. Our global presence, innovative culture and ability to attract employees with unique competences mean that today we can share this knowledge with you.

Happy travelling!

14

Part 1.

Before travelling

15

16

1. Successful, secure travel Everything that is needed to ensure successful and secure travel can be summed up in a single sentence: Find the right facts, plan and take the correct preparatory measures by weighing the purpose and goal of the travel against the risks it might entail.

Important success factors for secure travel: • Good knowledge and the correct information about your travel destination.

• Good knowledge of the risks you might be exposed to.

• Situation-adapted preventive healthcare and security procedures.

• Access to necessary medical and security resources if anything goes wrong.

• Understanding of culture and adaptability of you and your operation.

Source: Saab AB

The correct information about your travel destination What do you need to know and consider in order to travel safetly? The answers depends on a number of factors. Here are some that you should consider: · Purpose of the travel. · Budget and ability to pay to solve problems.

17

· Self-knowledge and experience of the type of travel you are now planning to do. · Local knowledge about the travel destination in question. · Ability to handle the climate, your health and physique. · Ability to fit in and interact with the local culture. · Language skills. · Ability to improvise and handle stressful situations. · Ability to handle various risks. · Time margins. · Travel companions. · Access to well-qualified support.

If you are travelling on behalf of someone else – an organization, a company or another person – you will need to take that party’s needs and requirements into account. Find out what these are in order to avoid misunderstandings. This handbook is designed to ensure you find suitable guidance based on your particular prerequisites. The pitfalls can mainly be attributed to the following: · Being unprepared, with a naive attitude, often based on “nothing usually happens”. · Not taking responsibility for yourself and overestimating the ability of others to help and support in the event of a crisis.

18

· Having the wrong focus and priorities, as you let feelings rather than facts guide you. · Overestimating the value of theoretical knowledge gained from inadequate sources. · Overestimating the value of practical experience gained from irrelevant contexts. · Alcohol, drugs or psychological factors that limit the attention and logic of the individual. · Security that is too ambitious and complicated, which makes the work so difficult that advice are not adhered to.

How do you find the correct information about your travel destination? · Your country’s consular presence may provide an important part of the information you need, and is entirely crucial for how detailed the picture is. For example, you get a better picture of a country if your own country has a large embassy in it with many employees monitoring the situation rather than a small embassy with few employees. · The foreign ministries of other countries can provide important information to supplement yours, in particular if they have a larger consular presence than your own country.

Please note that the evaluations made by other countries are based on their own national values and views of risks.

19

¡ Information from travel agents, assistance services and non-governmental organisations can also provide a good supplement to information from public authorities. ¡ Several employers buy advanced information services from security companies to ensure their employees have access to updated information before and during business travel. Ahead of travelling on business, check what is available, and make sure you have a login and/or apps linked to the service. ¡ Irrespective of the supplier, descriptions of the security situation are often general, and may differ a lot from the local reality. Check whether the source has updated detailed knowledge about the area you are travelling to, by checking how detailed and up-to-date the information is.

Security risk and medical risk There are different types of risk categories, and the different categories require completely different solutions and preparations. When you travel, security risks and medical risks are usually central.

We will discuss these in slightly greater depth.

Medical risks are the weighted sum of the probability and consequences of becoming ill, infected or injured, and the possibility of local healthcare services being able to satisfy the need 20

for medical care. A higher level of medical risk imply that you need to bring additional resources, be able to handle trauma and medical incidents yourself, and locate the best medical care available locally. Conversely, a lower medical risk means that you can rely more on the local health services for support, and do not have to be as prepared yourself.

Security risks are the weighted sum of the probability and consequences of being subjected to crime, suffering accidents, dangers, involvement in disturbances or being affected by climate or the natural surroundings, as well as the ability of public authorities and security actors to warn, prevent and handle situations arising.

Analysis of medical risks and security risks can be obtained from public authorities, organizations and companies. These are both in-depth and description summary of general levels of exposure.

We recommend that you use a well-qualified and trustworthy information source when you are travelling in areas with identified high risk levels.

Please note that there are environments that are medically safe, but have high levels of security risks, such as terrorist incidents in countries with a high and developed level of infrastructure. In the same instance, there are environments that have a high medical risk with a low security risk, such as a stable country with a low level of criminality, but with a 21

climate, natural surroundings and infrastructure that offers considerable medical challenges. If the medical and the security risks are both high, you will need to consider local knowledge and ensure that procedures are in place to handle incidents locally.

Ensure you have access to an insurance company and assistance service with capacity at your travel destination!

Where do risk areas exist?

Risk areas ascends in places where the probability of encountering threats and danger is higher, or where it is difficult to handle the consequences of these. Just as in your home country, where you are probably more familiar with the geography, the risks do not arise everywhere or at anytime for everyone. Find out where the risks exist, and how they can impact on you. The following are “alarm bells” that you should take seriously: · Weak or outdated infrastructure, poor telecommunications · Few or outdated hospitals and/or rescue services · Accident-prone traffic · High level of criminality, in particular in areas where poverty and wealth meet · Political instability, demonstrations or ethnic tensions

22

路 Ongoing armed conflict, or high level of terrorist threat 路 Hostility against strangers (in particular where it is difficult to fit in) 路 Challenging climate, environment or natural surroundings 路 Presence of tropical diseases, ongoing major epidemics or environments where ill people congregate

FAVELA 2 km

115 m

FAVELA

Copacabana Beach

FAVELA 3 km

Ipanema Beach

Rio de Janeiro, Brazil. Favelas are poor shanty towns, which are also hang-outs for criminals who often need quick cash for drugs, etc. As the favelas in this case are located close to areas where business travellers and tourists with money stay, the risk of being exposed to pickpocketing and robbery is high. (The map is an illustrative example, and does not indicate exact positions.)

2. Planning and preparation In this chapter, you will find guidance on how you can prepare ahead of your journey. The guidance is divided up according to risk, where general preparations that are applicable in several contexts are listed first, and more specific preparations for high-risk travel are listed later on. You will find marks to indicate when you should consider carrying out the preparation in question. You can carry out a specific preparation as an extra security measure earlier than stated, but you can also disregard a measure if it is not applicable. The choice should be made after careful consideration with the other persons involved, or your operational managers, who will jointly determine how to approach the risk.

The preparations are described with Why they are to be carried out, and an explanation of How they are carried out in practice. There is also Further information where you can find more indepth knowledge in the book.

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Preparations ahead of all travel We deal initially with risk-reducing measures that are applicable and necessary for nearly all travelling, irrespective of risk.

Checklist Keep updated Manage language and culture Emergency assistance Insurance cover Vaccinations Passport, visa, customs and local legislation Aids for finding your way around

ALL TRAVELS

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Keep updated Make sure you get news and information from reliable sources about your travel destination.

Why: By having access to relevant and current information, you are able to make continuous risk assessments, to adapt your plans in time, and get the most out of your travelling.

During your travelling, you will need updated information giving guidance on the probability and consequences within relevant risk areas, such as traffic and infrastructure status, major events and crowds of people, local weather and health conditions and serious crime.

How: Use the Ministry for Foreign Affairs and the travel information services of other countries and security companies that have active situation reports and updates.

4. Security and medical risk Behaviour In general, it is a good idea not to display wealth, such as gold chains, watches or jewellery.

Wear clothing according to the local tradition, but without excess. Controversial clothing unfortunately brings with it an increased risk of being subjected to crime.

Consider your alcohol intake, and the risks of being alone outside at night. Get local knowledge about the areas associated with greater risk. For example, most journalists have a local “fixer”, who knows the surrounding environment.

In hotels or other housing, check emergency exits and sprinkler systems. Consider the risk of burglary if your room can be easily reached from the street or from external galleries. Do not take a room any higher up than you could jump, in the event of a fire or other threat. There are a number of good travel alarms that can be bought that may be a good investment.

Further issues to consider: Is there any local conflict in progress? If so, is there a “good” side, where I can seek support? Are muggings and assaults common? Is there any kidnapping? If you are planning to film, document or interview: Are journalists welcome? Could you be

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perceived as a journalist? Photographing and filming during riots and disturbances can be dangerous. There are journalists imprisoned all over the world.

Fundamental security principles that apply everywhere: · Be prepared: Make sure you know what to do in various emergency situations, and bring the equipment you need. · Be aware: Understand the nature and level of risk, notice any changes, and adapt your behaviour accordingly. · Low profile: Do not stand out more than necessary; a low profile and self-assured behaviour reduce the risk of becoming a target. · Unpredictable routines: Persons who vary their daily routines are less vulnerable and run less risk of becoming targets. · Keep in contact: Always have access to fully charged communications equipment, with numbers for relatives and assistance. Bring along a paper copy of important numbers. · Several layers of protection: No single measure can guarantee security, so several solutions that work independently of each other are necessary.

Source: Control Risks

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Travel with others This is more important than many imagine.

During an ordinary journey, as well as on a twoperson expedition, you may have to take care of your fellow traveller yourself, so an in-depth discussion about allergies, previous injuries and illnesses is important. How do I take care of my fellow traveller’s diabetes or heart disease? How should I act, and what medications can I give?

Talk about this before departure.

Travelling as a woman The risks of travel are in many circumstances greater for women, and in particular for a woman travelling alone. Women are statistically overrepresented as victims of sexual crime, kidnappings and pickpocketing, while men are more exposed to violent crime. These risks should be taken seriously, but with knowledge and small adaptations, journeys can be carried out without major limitations.

Clothing is a central issue in this context.

The beach, the market and the mosque usually have different dress codes. Bringing with you a shawl that can cover your head and shoulders as necessary, and always having the option of wearing a full-length skirt or trousers increases your flexibility and opportunity to interact socially. The following tips are from women who are used to travelling globally: 82

· Choosing discrete clothing that is locally adapted attracts less attention. Adapt how much skin is exposed according to local rules and traditions. · Avoid wearing earphones in both ears, talking on the telephone or staring down at a screen while moving about among people. You need to keep your attention on discovering and avoiding danger. · If you need to read a map or look at your mobile, do so in a safe place. · Do not accept any drinks that have been outside your span of attention. Note that there have been cases where personnel at a bar or restaurant in collusion with attackers have prepared drugs in bottles that have then been resealed. Choose places with a good reputation. · Ask trusted contacts or personnel to accompany you to the car, taxi or hotel if it is dark. · Be prepared to be confronted in public environments. Avoid eye contact with strangers, do not slow down; ignore and continue. In some cultures, eye contact with a man is considered to show that you are seeking his company. Sunglasses make things easier. · If you are stopped, or someone comes too close, set limits straight away, and attract attention, so that the situation is discovered. NOTE! In some environments this does not help; instead more attackers will approach and nobody in83

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·

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tervenes. If there is such a risk, do not go alone at all.

On public transport, there are many good opportunities for pickpockets and other attackers to find victims. Female pickpockets benefit from being perceived as less credible as perpetrators, and can stand close to another woman without breaking social taboos.

Hitching a lift with strangers or using an unlicensed taxi is very risky, as it is easier for an attacker to remain anonymous, he/she is alone with the victim and can drive to a place without witnesses that is safe for the attacker.

Put in place active monitoring, consisting of leaving times and places to someone who can check where you are and activate support if you do not get in contact as planned.

Try to find several independent references, and listen to their experiences. Your age, experience, and assignment, and where exactly you are going to, mean that entirely different factors can be crucial. Quite a lot of facts can be found on websites and in travel blogs, but it is even better to talk to experienced travellers and locally established women. Once on location, ask personnel at the hotel, in the local clothes shop or local colleagues at the office. Showing interest in another person’s culture is usually a respectful gesture.

6. What to do in an emergency situation To handle an emergency situation, it is important that the initial actions are as effective as possible.

This chapter gives advice on how to handle certain identified emergency situations. In several emergency situations, the actions are similar, in particular when handling the aftermath. We present all actions as stand-alone instructions, so that you can find all the necessary information quickly, in one place. The circumstances before a journey and the organization surrounding a traveller have an impact, and therefore the local conditions must always be considered.

First, some general advice: · Do not go to demonstrations, public order interventions or accident sites. · Avoid taking photographs. · Move to the safest place you can find, such as a major international hotel, an embassy/ consulate, a hospital or a well-known office. · Make immediate attempts at finding other members of your group. · Make immediate and repeated attempts to contact outsiders.

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ALL TRAVELS

Traffic or transport disruption Handling traffic disruptions, queues, delayed flights, etc.

Measures: 1. Estimate the scope of the disruption.

2. Consider alternative routes.

3. Rebook tickets and rebook disrupted meetings.

Explanation: Get an overview of the scope and the consequences as quickly as possible. If you are not at a time-critical stage, you could consider waiting for the disruption to end. Sometimes there is an alternative, less busy but longer route that is quicker, but this assumes very good knowledge of local traffic conditions, in addition to what can be seen on a GPS. For example, if you are in a major city, it is less probable that only your route is disrupted. An experienced local driver usually has the best picture. If you have good understanding of the traffic situation and want to make a detour, try to identify critical points for making new route choices, so that you do not cause a traffic hazard when you change routes. Other considerations are other means of transport, for example taking an overnight train instead of flying.

Base your decision on the highest quality information source you can find, such as the information desk at the airport, knowledgeable personnel at the hotel, or some other informed person at your destination. If the alternative routes do not solve the problem, you will have to handle the consequences of your delay.

Contact the travel agent or the people you are meeting, and explain the situation. It is better to be delayed or to cancel than to expose yourself to danger in traffic. Your travel agent will usually have good experience of handling changed travel plans, and can offer well-qualified help, but

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do note that flexibility in many cases is governed by the type of ticket you have. Rebooking locked tickets, or having to buy a new ticket, can entail considerable cost, which has to be weighed against other alternatives. If you do not manage to reach your destination in reasonable time, it is more respectful to those you are meeting to cancel or to notify your delay as soon as possible.

Measures: 1. Decide whether it is safe to stop at the accident site (otherwise continue with Item 3 from a safe place).

2. Save lives, give first aid L-ABCDE (see page 139).

3. Follow the instructions from your insurance company’s (rental car’s) assistance service and/or local police.

4. Inform next of kin, employer (on business trips) and handle emotional reactions.

ALL TRAVELS

Traffic accidents

Explanation: Are there secondary dangers, such as other traffic, limited sight or risk of fire? Other dangers that may arise at the accident sites is that in some countries, crowds may gather, and you may suffer violent crime or even lynching. This means that staying may be associated with danger to life. If the accident site is unsafe, you need to go to the nearest safe place, the nearest hospital or police station.

Contact and follow the directions of the assistance service provided by the insurance or rental car company and/or local police as quickly as possible. This is to avoid being perceived as having hit-and-run, and instead as a necessary safety measure.

If the accident site is safe, follow the local rules and

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regulations for marking out the accident site and handling accident reporting. Please note that as a driver in a foreign country, you are obliged to comply with local traffic rules and laws governing accidents and injuries. Check whether you or any of your travelling companions have been injured. Feel all over the body straight on the skin to check for traces of any sharp or blunt violence, such as blood or sore spots. Even serious injuries can be difficult to feel on yourself, due to high stress levels. Give first aid if necessary. For advice and support, contact and follow the directions of the assistance service provided by the insurance or rental car company and/or local police.

In some cases, the police is obliged to document the accident. Do not sign any papers or make any admission that you do not completely understand. This may lead to a long prison sentence or fine for something that you may not by guilty of. Not all countries have reliable public authorities, and in some cases foreigners are considered guilty, irrespective of who actually caused the accident.

Call for an interpreter if necessary. Phone and notify your immediate relatives and/or your manager, so that they know how to contact you to offer support if needed. During business travel, your employer needs to get information early in order to give the right support input and to report the incident according to the requirements. Your travel arranger may need to pay compensation to you. It is not unusual for a person who has witnessed or been involved in an accident to have some type of emotional reaction, often some time after the event, when the situation has calmed down.

Such a reaction is often natural and harmless, even if it might be perceived as unpleasant. In such situations, it is good to receive support and to talk to someone you can trust. If a person who has been involved does not want

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to talk, respect this and wait for the right time. Be vigilant to lasting symptoms two to three weeks afterwards, such as recurrent problems sleeping, difficulty getting over the event, lasting fear, anxiety or abnormal physical stress; these indicate that the person involved may need to seek help.

Measures: 1. Block and stop all cards and devices lost as quickly as possible. Block the passport via your embassy or consular emergency service; they can then issue a temporary passport.

2. Follow the instructions from your insurance company’s assistance service and/or local police.

3. Inform next of kin, employer (on business trips) and handle emotional reactions.

ALL TRAVELS

Theft/loss of passport or payment card

Explanation: Block all devices immediately to prevent any money being taken from your cards, or misuse of your mobile. If you mobile is stolen or not working, use the telephone of your hotel, a colleague or co-traveller. Blocking assumes you also have the numbers for the blocking service saved, preferably in several places. Contact your embassy or consular emergency service (outside office hours) for help in blocking the lost passport and getting a new one. Use the copy passport you have in your email or as a paper copy.

Your assistance company can help you if you have been the subject of crime. They will know for example which type of police to contact in countries where there are several different police forces. The police will be interested in details of the crime, such as description of perpetrator, time, place, etc. Your insurance company will often require you to have a correctly completed police report. Notify your next of kin

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Part 2.

Treatment guide

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7. About first aid In the event of trauma or acute illness, most people feel uncertain. The following two chapters are intended to give basic knowledge of lifesaving measures. It is always better to do something than not: the greatest interventions to save life can be made immediately at the scene of injury, in particular when it comes to life-threatening bleeding and blocked airways. Around 20 per cent of the fatalities that could have been prevented would have required immediate at the scene of injury. Pressing down on bleeding, applying a tourniquet (see page 144) and creating a free airway are direct lifesaving actions that play a greater role than any doctor the person might see later.

In Sweden, we often use an ABC mnemonic when giving treatment. ABC stands for Airways, Bleeding, Shock. Sometimes there is the addition L-ABC, where L stands for life-threatening surroundings. In order to adapt this advice to internationally used systems, the meaning has been altered a little and the mnemonic is L-ABCDE. The order of treatment is structured so that the areas where there is the greatest danger to life are dealt with first. By following the order presented here, we can save the greatest number of lives: ¡ L: Life-threatening bleeding or life-threatening

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surroundings. This should be treated immediately. · A: Airway, the creation of a free airway, with the addition of C-spine control–stabilising the neck/spine as necessary. · B: Breathing, which was what A previously stood for in Sweden. · C: Circulation, corresponds to both B and C (bleeding and shock) according to the old system. · D: Disability, degree of consciousness, neurology and paralysis. · E: Exposure/environment, whole body check and protection against climate.

The reason why the mnemonic is in English is because this makes communication easier during international travel. The English abbreviations are used in Sweden too, both within the health service and with other public authorities and companies.

A brief comparison between L-ABCDE and another system called MARCH, which is often used

by English-speaking military personnel, follows: · (L) M: Massive haemorrhage, i.e. lifethreatening bleeding. · (A) A: Airway, airway, stabilising the neck. · (B) R: Respiration, breathing. · (C) C: Circulation, circulation. · (D) H: Head/hypothermia, degree of consciousness and warmth.

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· (E) *: Exposure/environment, whole body check, protect from environment.

The MARCH mnemonic often has the addition MARCH ON, where ON represents: · O: Open wounds, any further open wounds to treat? · N: No pain, ameliorating pain prevents shock.

In this book we use the L-ABCDE system, as it is used by Swedish healthcare, police and rescue services. The system makes your communication with the units mentioned easier, and also with international medical care units that also use L-ABCDE. Swedish military personnel use C-ABCDE, where the first C stands for catastrophic bleeding.

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9. Injuries and accidents This section describes injuries and accidents that may occur, both on long-distance travel and at a holiday cottage or on a sailing trip. Many injuries and accidents require medical care and are marked “Seek medical care” or “Medical care may be needed”. Emergency conditions are marked “Emergency condition” and must be brought to a medical facility as soon as possible! The treatment advice also includes more advanced treatments and prescription medications (prescription medications are marked with a *) as a guide for those who have medical training and have brought such equipment along (see also Chapter 2). You should always raise an alarm and contact your 24/7 doctor before giving any prescription medication.

However, first aid and treatment according to L-ABCDE (see Chapter 8) must always be started immediately.

All bite injuries must be considered as infected wounds and are often treated with antibiotics for preventative purposes.

Cat bites (around 15 per cent of all bite injuries) often contain different bacteria (for example Pasteurella multicoda), which require broader spectrum treatment. For bite injuries from dogs (around 80 per cent of all bite injuries) and bats, consider the risk of rabies (see page 192). Bites from humans must also be considered as infected. Bite injuries are most common on knuckles, fingers and the head.

MEDICAL CARE MAY BE NEEDED

Bite injuries

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Symptoms: Infection, pain, redness, increased heat, pus formation, reduced mobility.

Cause: Bacterial infection.

Treatment: Wash the wound very carefully mechanically with soap, if you have any with you, and plenty of water. Remove any dead tissue. Always leave infected wounds open, with a covering dressing. Seek medical care. If you are far from medical facilities, treat with amoxicillin* + clavulanic acid* (SpectramoxÂŽ) 500 mg, 3 times daily for 10 days. For human bites, consider also the risk of hepatitis B and HIV infection. If the bite is located on the hand, extra careful checks must be made due to the great risk of infection close to the ligaments.

In the event of reduced mobility, redness, pain in fingers on the palm side, seek medical care as soon as possible, as an operative intervention is often necessary.

Blue nails Symptoms: Strong pain and discolouration of nails.

Cause: Crushing injury with bleeding under the nails.

Treatment: Heat one end of a paperclip in an open flame; once it is glowing, carefully push the tip through the nail where the blood layer is the thickest. Once the nail is perforated, the bleeding will empty and the pain reduce. If severe pain remains over the skeleton, suspect a fracture (see page 166); relieve pressure and seek medical care, in particular for pain from the joint.

Burns All burns apart from first degree burns (see next page) should be cooled as quickly as possible to halt the burning process.

Remove any warm, soaked or melted clothes that are not stuck to the wound, cut off remaining textiles, but leave those stuck in the wound. Rinse off any remaining chemicals. Check

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whether there is soot and redness around nose and throat, or if the injured person is hoarse or has difficulty breathing. If the injured person has inhaled heated gases, there is a risk the airway will swell shut, and the person should be taken to hospital as soon as possible.

Be prepared to give breathing assistance or create an open airway with the equipment you have, for example a “mushroom” or oropharyngeal airway, see Chapter 8 (page 146). If you do not have access to medical care on location, contact the doctor on call (24/7 service).

Persons with burns require a large amount of liquid due to leakage of body fluids from the damaged tissue as a result of the skin’s protective barrier being destroyed, and a pronounced evaporation takes place. Give conscious persons plenty of fluids. In order to calculate the fluid loss, you can use MUIR’s formula: (percent of a person’s surface that is burnt x weight in kilograms)/2 = fluid loss (ml). You can mix your own fluid replacement to give orally to conscious persons: 1 litre water, ½ tsp. salt, 1 tbsp. sugar, ½ tsp. baking powder.

Unconscious persons must be given fluid straight into the blood flow via various types of needles; intravenous or intraosseous, administered by a person with medical training.

Pain relief is always required for conscious patients, apart from isolated third degree burns, when the nerves are badly burnt and less pain is felt. Fentanyl* 400 mg lozenge (Actiq®) at the acute stage if the pain is very severe. For milder pain, use paracetamol 1 g x 4 (for example Panodil®) and Tramadol retard* 100 mg x 1–2 for severe pain (Tradolan retard®).

First-degree burns Symptoms: Red, painful skin. Damage to the outermost layer of skin.

Cause: Sunburn, for example.

Treatment: Cooling balm, avoid further exposure.

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10. Diseases and infections Before departure, you should investigate what particular diseases, parasites and other risks there are at your destination. Many diseases in this chapter require medical care and are marked “Seek medical care” or “Medical care may be needed”. Emergency conditions are marked “Emergency condition” and must be brought to a medical facility as soon as possible! If you do not have access to medical care, suggestions for more advanced treatment medication are also described, often with prescription medications (prescription medications are marked with a *) as a guide for those who have medical training and have brought such equipment along; see also Chapter 2). You should always raise the alarm and contact your 24/7 doctor before giving any prescription medication. However, first aid and treatment according to L-ABCDE (see Chapter 8) must always be started immediately.

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SEEK MEDICAL CARE

Amoebic infection A parasite that can cause dysentery or a liver abscess, i.e. infected hollows in the liver.

Symptoms: Local pain, cough, fever, bloody faeces.

Distribution vector: Polluted water.

Protection: Be careful to eat good quality food and consider basic hygiene.

Treatment: Metronidazole* 500 mg, 2 tablets 2 times daily.

Athlete’s foot Avoid by changing socks often, washing, airing, drying and dusting feet properly. Use bathing sandals in public showers and baths.

Symptoms: Dissolved skin, whitish coating, soreness, bad smell.

Cause: Fungal infection.

Treatment: Terbinafine single dose. Wash, file and dry the feet carefully, then apply the preparation over both feet up to the shin.

EMERGENCY CONDITION

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Blood poisoning (sepsis) Symptoms: Fever and severe shivering.

Cause: Widespread bacterial infection in the blood.

Treatment: If sepsis is suspected, antibiotic treatment in hospital should be started and blood cultures taken. If staying in an inaccessible environment, start antibiotics treatment. Discuss with 24/7 emergency services.

For example, ciproflocaxin* 500 mg, 3 times daily and metronidazole* 500 mg, 2 times daily. For sepsis, use the antibiotic with the broadest antibacterial spectrum available.

Symptoms: Sometimes called “the great imitator”, as practically any symptom may occur. Often starts as redness, an expanding ring around the tick bite (so-called erytema migrans), one to four weeks after infection. The redness sometimes fades after a while. Neuroborreliosis, i.e. affecting the brain and nervous system, is seen in the latter stages of untreated disease (stages 2–3). This produces diffuse symptoms, such as tiredness, antipathy to food, headache, and muscle ache. Swollen lymph nodes may occur.

Paralysis of the facial muscles. After a long time of untreated disease, more severe paralysis may also occur, with residual symptoms after treatment.

SEEK MEDICAL CARE

Borrelia

Distribution vector: Infection with borrelia from tick bite.

Protection: Covering clothing.

Treatment: Phenoximethylpenicillin* 3 g, 3 times daily for 10–14 days, or alternatively doxycycline 300 mg, 1 time daily for 14 days.

Very contagious viral disease. Contagious until the blisters have dried out entirely.

MEDICAL CARE MAY BE NEEDED

Chickenpox

Symptoms: Itchy rash, primary on the trunk and face. The blisters dry and produce itchy scabs. May return as shingles later in life with impaired immune defence. This can lead to chronic pain.

Distribution vector: Contact infection.

Protection: There is vaccine.

Treatment: Relatively mild disease in children; adults can be treated with antiviral substances, such as valacyclovir* 500 mg, 3 times daily for 7 days.

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SEEK MEDICAL CARE

Cholera Cholera is a bacterial disease that occurs epidemically when the drinking water is contaminated, for example in conjunction with flooding.

Symptoms: Severe watery diarrhoea, fever, tiredness.

Distribution vector: Polluted food or water.

Protection: Vaccine, for example Dukoral®, which provides good protection. Otherwise good hygiene procedures.

Treatment: Large amounts of liquid and liquid replacement solutions, often rice-based, to replace lost salts, etc.

SEEK MEDICAL CARE

Cryptosporidium This is a protozoan, i.e. a single cell organism with a cell nucleus. It is a zoonosis, an animal disease that can sometimes infect humans. Often, there are large-scale outbreaks via drinking water (as in Östersund in December 2010). Incubation period 2–12 days. Can cause long-term problems.

Symptoms: Diarrhoea, fever, stomach pain, nausea. Severe infections are seen with impaired immune defence, such as HIV infection.

Distribution vector: Polluted drinking water.

Protection: Avoid by boiling water and careful hand hygiene.

Treatment: Treated with fluid replacement for diarrhoea.

Good treatment is lacking. Metronidazole 1 g, 3 times daily is a suggestion. Chronic infections do occur.

SEEK MEDICAL CARE

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Dengue fever/breakbone fever A virus disease that is one of the bleeding fever diseases.

The most common disease spread by mosquitoes, around one hundred million cases per year. Has two types of

symptoms: DHF (dengue haemorrhagic fever) and DF (dengue fever). Small children can often have the infection without any clinical signs of disease.

Symptoms: DF typically presents as influenza, with high fever, swollen lymph glands, joint pain and reddened skin.

30 per cent of those infected have a positive tourniquet test (a blood pressure cuff applied for five minutes with a pressure between the body’s upper and lower pressure; if small bleedings like red spots on the skin appear, the test is positive). DHF: first there are minimal bruises on the skin, gradually after about a week, there is fever, severe swelling and reddened skin. In severe cases, there is spontaneous bleeding from intestines and mucous membranes. In the most severe cases, these lead to circulatory shock and death.

Distribution vector: Via mosquitoes.

Protection: There is no vaccine. Use covering clothing, insect repellent, insect spray, impregnated mosquito nets and so on.

Treatment: Good treatment is lacking. Serious cases require fluid replacement and blood transfusion at a medical facility.

Affects young persons in particular.

SEEK MEDICAL CARE

Diabetes Diabetes type 1 Symptoms: Weight loss, pronounced thirst, tiredness, large amounts of urine, visual disturbances, acetone smell (caused by the body’s inability to break down glucose, instead it creates ketones from fat as energy for the brain; these give rise to the acetone smell as a sign of relative starvation).

Cause: Insufficient insulin production.

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11. Symptoms and conditions This chapter describes a number of symptoms and conditions that in most cases may occur both at home and at distant destinations. The conditions that require medical care are marked “Seek medical care” or “Medical care may be needed”. Emergency conditions are marked “Emergency condition” and must be brought to a medical facility as soon as possible! If you do not have access to medical care, suggestions for more advanced treatment medication are also described, often with prescription medications (prescription medications are marked with a *) as guidance for those who have medical training and have brought such equipment along (see also Chapter 2). You should always raise an alarm and contact your 24/7 doctor before giving any prescription medication. However, first aid and treatment according to L-ABCDE (see Chapter 8) musty always be started immediately.

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MEDICAL CARE MAY BE NEEDED

Abdominal pain Common complaint with many causes. Irregular meals, unusual diet or lack of fibres often produce abdominal problems due to constipation or diarrhoea. Try to maintain a good diet and eat regularly. Finding the right cause of abdominal pain can be difficult. If generally affected, longterm inability to eat or drink or very severe pain, seek a medical facility as an emergency.

Diarrhoea and vomiting due to contaminated food or water are often associated with fever and severe griping pain.

Gallstone or kidney stone pain are a common cause of pain relief treatment at emergency medical facilities. Kidney stones can be prevented to some extent by a sufficiently high liquid intake. This can prevent stone formation and flush out smaller stone particles with the urine. Before contacting a 24/7 doctor, check pulse and blood pressure (see Chapter 8), temperature, urine and faecal function if possible.

Symptoms: Often general pain, often of a griping character during gut movement. Appendicitis pain classically starts diffusely in the centre of the abdomen, and then moves downwards towards the right groin. Gastritis often has a pain focus under the left rib cage, burning pain, sucking that is improved during food intake. Pain from diverticulitis is often localised along the left flank down towards the groin in the abdomen. Ileus often produces severe pain, bloated abdomen, a drum-like sound when knocking, vomiting, lack of gas and faecal passage.

Cause: Constipation, infection, menstruation problems, diarrhoea, gallstone, kidney stone, appendicitis, diverticulitis, gastritis, stomach ulcer, extra-uterine pregnancy, pancreatitis, ileus and so on.

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· · · · · · · · ·

12 o’clock: gastritis, stomach ulcer, heart attack, pancreatitis 1 o’clock: gastritis, pneumonia, splenitis 3 o’clock: kidney stone, diverticulitis, constipation 5 o’clock: diverticulitis, groin hernia, gynaecological pain 6 o’clock: urinary tract infection, prostatitis, constipation, gynaecological pain 7 o’clock: appendicitis, groin hernia, gynaecological pain 9 o’clock: kidney stone, appendicitis, colon inflammation 11 o’clock: gallstone, hepatitis, pneumonia, stomach ulcer Navel: ileus, gastritis, diarrhoea, heart disease.

Pain areas of the abdomen Figur 13

Treatment: Preventing abdominal problems is the most important measure. Abdominal pain, diarrhoea and consequent dehydration can reduce a person to helplessness. Be careful to eat good quality food regularly, only drink clean water, ensure a sufficient fibre intake and visit the toilet regularly.

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Explanations 24/7 – On duty day and night, 24 h per day, 7 days a week.

After-drop – Lowering of the central body temperature during warming due to inflow of cold blood from arms and legs in hypothermia sufferers.

Air-borne droplet infection – Infection spread by air-borne liquid particles.

Air-borne infection – Infection spread via the air.

AMS – Acute Mountain Sickness, see HAI. A.n. – As necessary.

Anaesthesia – Narcosis, pain relief.

Aspiration – Inhaling stomach contents into lungs.

Bacteria – Single cell micro-organisms that can multiply.

Bovine form – Disease usually found in animals/cattle.

BP – Blood pressure, measured in the unit millimetres mercury (mm Hg). The blood pressure referred to in this book is the upper pressure, i.e. the systolic blood pressure.

Breathing mask – Protection for the person carrying out lifesaving (HLL).

Celox – Blood-stopping substance placed on a gauze dressing, stops nearly all bleeding with correct application.

Chinlift – Creation of free airway by moving the lower jaw forwards.

CNS – Central nervous system, i.e. brain and spinal cord.

Combat Gauze – Blood-stopping substance placed on a gauze dressing, stops nearly all bleeding with correct application.

Compress – Press together.

Compression sock – Sock that reduces the amount of

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standing blood in the lower legs by squeezing the blood vessels (veins) together. Available from pharmacies.

Contact infection – Infection spread via physical contact.

CPB – Cardiopulmonary bypass, i.e. the blood is removed from the body via a heart/lung machine for warming and oxidation and then replaced in the body.

Dehydrated – Lacking fluid, suffers from a lack of fluid.

Distal status –Whether feeling, muscle function and pulse can be found below the injury, for example in the hand at a broken arm.

Droplet infection – Infection spread by saliva.

Elevated– Lifted.

Epidemic – Wide-spread infection.

Forceps – Narrow, plier-like surgical instrument.

Fracture – Broken bone.

HACE – High Altitude Cerebral Edema, brain oedema caused by staying at a high height.

HAI – High Altitude Illness, mountain sickness, AMS. HAPE – High Altitude Pulmonary Edema, lung oedema, water on the lungs due to stay at high height.

Heimlich manoeuvre – Technique for removing a foreign body when somebody is choking.

HLL – Heart and lung lifesaving.

Hyperthermia – The body is so warm that you can suffer exhaustion or heat stroke.

Hypothermia – The body temperature is below normal levels, which can cause death.

Infection – Bacterial colonisation.

Inflammation – Swelling, pain, redness.

Intraosseous (i.o.) – Into the bone, a way of administering medications.

Intravenous (i.v.) – Via a venous blood vessel, a way of administering medications straight into the circulation.

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Jaw thrust – Creation of free airway by moving the lower jaw forwards.

Leatherman – Type of multi-functional tool.

Luxation – Dislocation.

Mushroom – Rubber hose to push into the nose to facilitate free airway.

Nasopharyngeal – Via nose and throat.

Nasopharyngeal airway – See mushroom.

Neck brace – Hard support for the neck for suspected neck injuries.

Neck venostasis – Expanded blood vessels in the neck as a result of impaired return flow to the heart.

Neurological injury – Injury to the brain and nervous system.

Oedema – Swelling.

Oropharyngeal – Via mouth and throat.

Outward rotation – Turned outwards.

Pagoda – Stacking method where the wood is laid like a tower #.

Per oral (p.o.) – By mouth.

PNS – Peripheral nervous system, the nerves out in the body.

Pole – Thin tree.

Quick Clot ACS – Blood stopping substance packed into “teabags”, used for hard-to-staunch bleeding.

Quick Clot Gauze – See Combat Gauze.

Reposition – Resetting a fracture to the normal position.

Spineboard – Hard stretcher with fixings for locking in an injured person with neck or spine injury.

Stable sideways position – Position to facilitate free airway for unconscious persons.

Subcutaneous (s.c.) – Under the skin. Injection into the fat layer that is under the skin.

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Suture – Thread for sewing wounds.

Systolic blood pressure – The upper pressure, maximum pressure in the blood vessels when the left ventricle has contracted.

Tampon – Pack dressings hard into a wound hollow to stop bleeding.

Thorax – Chest.

Throat tube – Plasic aid for placing in the mouth to hold the tongue forwards, oropharyngeal airway.

Tourniquet – Constricting bandage (CAT II, SWATT).

Trauma – Wound or injury.

VAPS – Visual Analogue Pain Scale On an ungraded line, the person points to where he/she feels the pain is between no pain and the worst possible pain. The back of the scale is graded 1–10, and the point the patient points to is converted into a figure.

Virus – Micro-organism that cannot multiply, but has to infiltrate a host cell.

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References Aehlert, B. J. (2007) Rapid ACLS (2 ed.) Missouri: Mosby/JEMS. Armstrong, L. E. (2000) Performing in extreme environments.

Leeds: Human Kinetics.

Augner, M. (2004) Field course handbook. Stockholm: Swedish Polar Research Secretariat.

Boman, K. (1995) Livlinan. Första hjälpen vid olycksfall och akuta sjukdomar. Stockholm: Streiffert i samarbete med Röda Korset.

Bromley, M. (1996) Safety in Polar Bear Country. Yellowknife: Northwest Territories Renewable Resources.

Forgey, W. W. (1994) Wilderness Medicine. Merrillville, IN: ICS Books.

Gill, G. V. & Beeching, N. J. (eds.) (2004) Lecture Notes on Tropical Medicine (5 ed.). Malden, Mass: Blackwell Publ.

Hayenes, R. & Rosett, F. (2002) Personal Security Terrorism Awereness, Writers Club Press, (iUniverse).

Lauvik, K. (2011) Travel safe – travel smart. A comprehensive guide to travel security. Stockholm: Vesper.

Palmkvist, I. (2004) Sjukvård för sjöbefäl (2 uppl.). Lund: Studentlitteratur.

Special Operations Command (2008) Special Operations Forces Medical Handbook (2 ed.). Special Operations Command.

Militariy issue by US Departement of Defense.

Säkerhetspolisen (2008) Personlig Säkerhet, Alfa Print Sundbyberg.

Electronic sources: MedHand International AB: www.medhand.com: Dr Companion.

Berna products: www.bernaproducts.com: Traveler’s Companion.

ISOS – International SOS, www.isos.com Control Risks: www.controlrisks.com and www.travelsecurity.com SAAB AB: SaabNet (internal corporate network for employees)

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Index Abdominal pain 202 Acute airway blockage 204 Acute media otitis 181 Acute Mountain Sickness, AMS 91, 220 Allergic reaction 207 Allergic shock 206 Alligator 100 Amoebic infection 176 AMS 91, 220 Anaphylactic shock 206 Assault 114 Assistance company 30 Assistance service 29 Athlete’s foot 176 Bear 100 Bilharzia 193 Bite injuries 161 Blister 207 Blood clot 92, 208 Blood poisoning 176 Blood pressure 154 Blue nail 162 Body armour 57–59 Borrelia 177 Brain oedema 221 Breakbone fever 178 Breathing 148 Burn 162–165

CDI 212 Checkpoint 127 Chickenpox 177 Chilling 215 Choking 204 Cholera 178 Circulation 152 Cold 208 Compass 134 Coniotomy 147 Consciousness level 155 Constipation 209 Cough 209 Cramp 208 Crocodile 100 Cryptosporidium 178 Debriefing 159 Deep vein thrombosis 208 Defibrillator 150 Dengue fever 178 Dental injury 165 Diabetes 179–181 Diarrhoea 209 Diphtheria 195 Dislocation 170 Dog 101 Door wedge 46 DVT 208

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Ear infection in the auditory meatus 181 Ear inflammation 181 Ear injury 165 Ebola 182 EHEC 182 Elephant 102 Elk/moose 102 Emergency call 241 Emergency number 29 Epilepsy 183 ETEC 182 Evacuation 126 Exposure 155 External otitis 181 Eye injury 165 Fainting 210 Fever 210 Finger fixation 167 Fire 122 Fireman’s hold 158–159 Food and drink 85 Fracture 166 Frostbite 211 Giardia 183 Golden Hour 47 Gunfire fight 120 Gynaecological pain 212 HACE 92, 219 Haemophilus influenzae type B 184 Haemorrhoids 213 HAPE 92, 221

248

Head lice 104 Headlight 46 Heart attack 213 Heart compressions 149 Heart–Lung Rescue 149 Heat stroke 213 Heimlich manoeuvre 204–205 Helicopter landing site 240 Hepatitis A 184 Hepatitis B 185 Hepatitis C, D, E 185 HIB 184 High altitude 90 High Altitude Cerebral Edema, HACE 92, 221 High Altitude Pulmonary Edema, HAPE 92, 221 High altitude sickness 91 Hippopotamus 102 HIV 186 HLL 149 Hostage 129 Hyperglycaemia 180 Hyperthermia 213 Hyperventilation 214 Hypoglycaemia 181 Hypothermia 215 ICE 29 ICE number 30 Identity theft 95–97 Infected wound 217 Influenza 186 Information security 95

Ingrown toenail 217 Injury journal 236 Insect bite 218 Inserting a needle 231 Insufflation 149 Insurance cover 32 Internal bleeding 169 International SOS 29 ISOPREP 53 Japanese encephalitis 187 Jellyfish 102 Jellyfish sting 218 Jet-lag 219 Kidnapping 129 L-ABCDE 139 Landmine piking 131 Landmines 98 Leishmaniasis 187 Linear anaesthesia 233 Lion 103 Log roll 156–157 Loss of passport 111 Lost 132 Lumbago 217 Lung oedema 221 Luxation 169 Malaria 188 Measles 189 Medical kit 44, 60 Medical risk 20 Meningococcal meningitis 189 Mosquitoes 103 Mountain sickness 91, 220

Mumps 189 Muscular pain 222 Nausea 222 Neck brace 148 Neurological injuries 155 Noise injury 171 Nosebleed 222 Orientation 134 Pain 223 Parasites 223 Peer discussion 159 Pelvic girdle 166 Pneumococcus 190 Pneumonia 190 Pneumothorax 172 Poisoning 224 Polio 192 Pregnancy 85 Pressure bandage 153 Prone sideways position 150 Prostatitis 225 Pursuit 98 Rabies 192 Rabies vaccine 35 Radio communication 241 Reflux 225 Rental car 72 Report template 235 Repositioning 168 Reserve mobile 46 Risk areas 22 Risk sports 89 Roadblock 127

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Robbery 112 Rubella 189 Scabies 104 Schistosomiasis 193 Scorpion 105 Scorpion sting 225 Seasickness 226 Security risk 21 Security training 41 Security waist bag 46 Self defence 115–119 Sepsis 176, 194 Shooting 120 Sinusitis 194 SITREP 52 Slipped disc 226 Snake 105 Snake bite 227 Snow blindness 227 Social media 92 Sore throat 228 Stable sideways position 150 STD 88 Streptococcus 191 Stroke 229 Sun stroke 213 Surgical airway 147 Surveillance 98 Survival 132 Suturing techniques 232

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Tattoos 88 Taxi 75 TBE (Tick borne encephalitis) 195 Tension pneumothorax 172 Terror attack 123 Tetanus 195 Theft 111 Throat tube 146 Tick 105, 229 Tiger 103 Tourniquet 144 Traffic accidents 109 Travel pharmacy 45, 64 Travel sickness 229 Tuberculosis 196 Typhoid fever 197 Unconsciousness 230 Urinary tract infection 197 Vaccinations 34 Veneral disease 88 Weather and geography 89 Whooping cough 197 Windshield 133 Wolf 106 Wound 173 Wound infection 217 Yellow fever 198 Zika virus 199

Notes

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• • • • • • • • • • • • • •

Authors: Rickard Ånell, specialist physician (Above) and Jens Berglund, Security Director (Below) during an assignment i Afghanistan.

First aid Treatment guides for diseases and accidents Vaccinations and tropical diseases Dangerous animals Emergency assistance and insurance Surviving terror attacks and assaults Manage theft and robbery Travel security for women Safe accommodation and driving abroad Dealing with foreign cultures Information security and social media Survival in the wilderness Healthcare and security equipment Planning, preparations and risks

Facts, advice and treatments are based on international “best practice” for medicine and security during leisure, business or expeditionary travel. The handbook is designed to benefit professionals as well as the inexperienced traveller.

ISBN 978-91-7741-096-6

9

789177 410966

HANDBOOK TRAVEL MEDICINE & SECURITY

Handbook in Travel Medicine & Security is a safe and indispensable companion on all journeys and expeditions. It provides simple and smart tips that can be used irrespective of whether the destination is a holiday cottage, the South Pole, a major city or a conflict area. Here are some examples of the contents:

RICKARD ÅNELL & JENS BERGLUND

Contents Foreword

HANDBOOK

TRAVEL MEDICINE & SECURITY FACTS

|

ADVICE

|

TREATMENT

13

Part 1. Before travelling 1. Successful, secure travel 19 2. Planning and preparation 27 3. Flights, transport and accommodation 70 4. Security risk and medical risk 82 5. Dangerous animals 102 6. What to do in an emergency situation 109 Part 2. Treatment guide 7. About first aid 8. Trauma treatment 9. Injuries and accidents 10. Diseases and infections 11. Symptoms and conditions 12. More advanced medical care 13. Communication and reporting

141 145 163 177 201 231 235

Explanations References Notes

242 246 255