A Patient in a Strange Land

Meetings & Conventions A Patient in a Strange Land November 1999 Current Issue
November 1999

Be prepared for medical emergencies overseas

By Lisa Grimaldi

Before the accident, Margaret Domber was, in her own words, "very naive" about the possibility of medical emergencies arising during overseas incentive programs. "You think it will never happen to you," says the Cranford, N.J.-based senior vice president for Summit Bank. Three years ago, during a nonemployee program in France for people who provided the bank with business referrals, a participant slipped and broke his hip in the hotel's spa. Although it didn't take long to get him to a hospital via ambulance, the ordeal was a nightmare for all concerned.

"The hospital was a good facility, but there were problems. The most frustrating part was the language barrier most of the doctors and hospital personnel spoke only French. Luckily, someone with my destination management company spoke English well and could translate. Thank God she took the weekend off to help."

Complicating the matter was the fact that the patient had other conditions: a bad heart and allergies to a number of medications. In the event surgery was needed, "we were afraid to have it performed there," says Domber. Fortunately, surgery was not necessary, and after several days in the French facility, all parties involved decided the best course of action was to fly him home to be cared for by his personal physician.

Then the worst news arrived: His insurance did not cover all of his medical attention overseas, nor did it allow for repatriation, or evacuation back to the States. Without repatriation coverage, the cost for medical evacuation (medivac) flights from international destinations starts at about $50,000, and payment must be laid out up front.

Domber looked for alternatives. The airline that brought the group to France refused to take him back. Another commercial carrier agreed to do it, but only if Summit Bank arranged for a physician and nurse to accompany the patient and agreed to pay for the seats that had to be removed to create 10 feet of space to accommodate him. "On top of that," says Domber, "we had to get a release from the hospital, transport him by ambulance to the airport, and an ambulance had to pick him up at the airport when he arrived back in the United States."

The terms were accepted, and all went well, but the experience prompted Domber to enact a new policy: She now drafts a thorough medical emergency plan before each program. Additionally, she has beefed up the insurance for her programs, and she strongly recommends participants augment their personal health insurance for travel and medical evacuation coverage.

A critical plan
Planners too often are caught unprepared for international medical emergencies, according to Jonathan Spero, M.D.

"They take care of so many details for meetings, but they often avoid looking at medical issues because they're intimidating," says Spero, president of InHouse Physicians, a Naperville, Ill.-based firm that provides medical services for meetings, mostly international. "This should be the biggest thing for planners. People are like that about health care in general: Ignore it until something happens."

Among the critical issues to include in a basic medical-emergency plan are the following.

Names and numbers of at least two designated responders, people to be contacted if a problem arises

Name and number of an English-speaking local physician and pharmacy

Local emergency number (it is not 911 in every country)

Name and number of preferred hospital or medical facility

Beyond this foundation, other measures can further protect groups in the event of a medical emergency. Consider the following advice from experienced planners of overseas programs.

Do the research
Jalene Bowersmith, meeting planner for the Washington, D.C.-based International Policy Council on Agriculture, Food & Trade, an agricultural think tank, researches health conditions and services before planning her meetings in Europe, Africa, the Middle East and Asia. She checks the Web sites for the Centers for Disease Control and Prevention and the U.S. State Department (see "Preventive Medicine," page 58) for health warnings, such as disease outbreaks. Additionally, she contacts the U.S. embassy in the country under consideration. "Between the three, I'll get a good picture of the true health situation in that country."

The extent of the legwork depends on where the meeting is. "My next meeting is in Zimbabwe, at Victoria Falls," says Bowersmith. "We're not going to be near a city, so I'll have to research the hospitals, medical evacuation options, etc., more so than I would for, say, a meeting in Italy."

Lance Wieland, director of incentives and sales promotion for UnumProvident, an insurance firm based in Portland, Maine, also does his homework. As a result, his company rejects many international meeting sites because of insufficient local emergency procedures and facilities.

"As part of the site inspection, we look at the closest fire, police and medical emergency facilities," he says. "For a meeting we did in Mexico, one of the things that concerned me was that the fire department [which serves as the official emergency response team for the area] was not what you'd expect in the United States. We weren't convinced that people there would be able to give the right type of care in an emergency situation." In this instance, Wieland decided to use the site, with the understanding that he had to make contingency plans for medical emergencies.

Even an area with top-notch meeting facilities might be lacking in medical facilities, Jonathan Spero points out. "There are many places you expect to get the kind of care you get in the States but don't," he says. "Bali is a good example& You have five-star luxury hotels like the Ritz-Carlton and the Four Seasons, but the ambulance service on the island is basically an unsanitary truck."

In such situations, a planner might want to arrange an alternative plan for emergency transportation. If the nearest medical facilities are not up to snuff, planners can get recommendations on alternative facilities from the U.S. Consulate, the hotel or a DMC. Terri Ann DiJulio, meeting planner for SEI Investments, an asset management/technology firm in Oaks, Pa., also gets advice from the U.S.-based security firm she hires for international programs.

DON'T LEAVE HOME WITHOUT...

It is impossible to predict whether a medical emergency will occur during an event, but planners can take steps to mitigate risks and prepare for the worst. Jonathan Spero, M.D., president of Naperville, Ill.-based InHouse Physicians, suggests these measures.

Prescreening
1. Check with the Centers for Disease Control (www.cdc.gov) for any shots or pills required or suggested for visitors to the country or region.
2. Obtain a list of English-speaking physicians and pharmacies (available from the U.S. consulate or embassy).
3. Check the coverage offered by your organization's travel insurance. Is medical evacuation included? If attendees are not employees, find out what type of coverage their individual plans provide. If coverage is insufficient, planners can buy supplementary coverage through one of many insurance companies, such as New York International Group Inc. (212-268-8520; (www.nyig.com), that offer such programs. Also, for about $3 per day, per attendee, riders can be added to individuals' or groups' travel insurance to include medical evacuation coverage.
4. Pack a simple medical kit (aspirin, bandages, rubbing alcohol, Benadryl, etc.). "As long as they're over-the-counter drugs, they're OK to be administered by a planner," says Spero.
5. Review government travel warnings (travel.state.gov/travel_warnings.html).

Prepping attendees
1. Have attendees complete medical questionnaires listing allergies, chronic illnesses, medications, physician's name and number and emergency contact.
2. Send out information sheets, including health warnings.
3. Tell attendees to carry medicines in flight, in case checked bags are lost.

L.G.

FIRST AID

The local U.S. Embassy and/or consulate at your meeting's destination can provide names of recommended physicians, including English-speakers, as well as hospitals, pharmacies and medical evacuation services. In addition, planners can line up emergency assistance coverage before the trip from the following organizations.

International Association for Medical Assistance to Travellers
This nonprofit organization provides global health information and lists of doctors who speak English and/or French. Individual memberships are available in exchange for donations. 417 Center St.
Lewiston, N.Y. 14092
(716) 754-4883
www.sentex.net/~iamat

International SOS
SOS provides medical assistance via its 24 global alarm centers to both members and nonmembers; costs are substantially lower for members. 8 Neshaminy Interplex, Suite 207
Trevose, Pa. 19053
(215) 244 1500; fax: (215) 244 2227
www.internationalsos.com

Worldwide Assistance Services Inc.
This is the North American subsidiary of Europe Assistance Holding S.A., headquartered in Paris. It provides medical assistance around the globe. Corporate memberships or event- specific coverage are available.
1133 15th St. N.W., Suite 400
Washington, D.C. 20005
(800) 777-8710; fax: (202) 828-5892
www.worldwideassistance.com

InHouse Physicians This group offers on-site medical care for meetings and events. 25 W. 273 Concord Rd.
Naperville, Ill.
(800) 356-3627; fax: (630) 369-7657
www.inhousephysicians.com

L.G.

Bring a doctor
One way to avoid subjecting injured or ill attendees to the great unknown of foreign medical care is to hire medical professionals to travel with the group. That's where firms like Spero's come in. "We provide physicians, nurses, paramedics and equipment for mini emergency rooms for programs in hard-to-access areas," Spero says. For example, InHouse Physicians provided on-site emergency medical facilities last month for Dr Pepper/Seven-Up's incentive program to rural South Africa and Victoria Falls, Zimbabwe, where participants were scheduled to do some whitewater rafting.

Although their presence might put a planner's mind at ease, the cost of an on-site doc and a traveling emergency room is not cheap. InHouse Physicians charges $2,000 to $3,500 per day, depending on the location, size of group and other factors. "People hire us for liability; corporations have a duty to provide the level of care accessible to their people at home when they're outside the country" on company business, says Spero.

But along with the advantages of having a doctor on hand come limitations. Christine Woidi, the Toronto-based manager for meetings, incentives and convention services for Nesbitt Burns Inc., an investment services firm, says she'd rather work with recommended local physicians, because doctors licensed to practice in the United States or Canada (like those affiliated with InHouse Physicians) cannot prescribe medications or admit patients to hospitals in a foreign country. She briefly considered bringing a doctor along for a meeting she planned in China but ended up working with English-speaking local doctors instead.

Spero's firm also offers less costly alternatives to setting up a medical facility on site for a meeting. InHouse Physicians is affiliated with a network of 1,000 English-speaking doctors overseas who can be on call, rather than on site, for the duration of the program. The approximate cost, says Spero, is $1 per attendee, per day.

Some planners, like UnumProvident's Wieland, prefer having an emergency medical technician on site, rather than an M.D. "When we're in circumstances where things get 'squishy,' we bring an EMT. An EMT with a jump kit is better in the field than a doctor," he contends. Also, Wieland has a pretty good idea of the types of medical ailments his attendees, most of whom are in their 20s and 30s, will incur: cut feet, falls on buses, heat exhaustion and sports-related injuries. These injuries, he feels, are best handled by EMTs, who specialize in emergencies.

PREVENTIVE MEDICINE

The following Web sites provide valuable, free information on the health conditions of international destinations.

Centers for Disease Control and Prevention
www.cdc.gov/travel
The CDC site offers useful geographic health information, updates on global disease outbreaks and travel precautions, including recommended shots or pills for travelers.

U.S. State Department
www.state.gov
Consular information sheets online list health conditions for every country in the world. Additionally, travel warnings are issued when the State Department decides, based on all relevant information, to advise that Americans avoid travel to certain areas.

L.G.

DON'T BLAME ME

What are a planner's legal responsibilities when it comes to medical emergencies? There are no hard-and-fast rules, according to meetings industry attorney John Foster of Atlanta-based Foster, Jensen & Gulley LLC. "It really depends on the circumstances of the event or the site." Foster developed the following guidelines with Naperville, Ill.-based InHouse Physicians.

Planner's legal duties
1. Determine risks.
2. Warn attendees about risks.
3. Plan for the safety and well-being of every attendee (minimize risks).
4. Avoid unreasonable risk of harm.

First responder criteria
1. Two or more responders (designated on-site medical emergency contacts) must be available 24 hours a day.
2. Responders should be CPR- and first aid-certified.
3. First aid should be readily available, as should oxygen, in situations where attendees might need it (including high altitudes or during physical activities).
4. Standard response protocols should be established.

Medical/insurance coverage
Consider supplemental coverage if
1. The meeting is outside the United States.
2. Group size is more than 1,000.
3. Potentially dangerous activities are part of the agenda.
4. Remote locations are involved.
5. A high-risk attendee group (elderly, for example) is involved.

Waivers/agreements The following documents will further protect planners from liability.
1. Have attendees sign waivers for risky events.
2. Get hold harmless agreements from suppliers, so the planner and/or meeting sponsor is not held liable for negligence on the part of supplier.

L.G.

Call a specialist
Meeting planners who are concerned about the quality of local care might choose to hire a company that will step in and handle medical emergencies, should they occur. A number of firms, of which the best-known is International SOS, provide such services.

According to John Knapp, vice president of marketing for International SOS, which has headquarters in Singapore, London and Philadelphia, the organization has 24 alarm centers around the world, staffed by 250 physicians, that clients can call in an emergency situation. Staff at the centers will assess the urgency of the situation, speak with a local doctor and work out a care plan, which could include admission to a hospital, transfer to another facility, medical evacuation to the best and closest facility and/or repatriation back to the United States. The organization monitors and communicates with the patient and planner until the patient is discharged. Planners can purchase contracts with such an organization prior to a program. Costs, according to Knapp, vary according to group size but are based on a fee of $50 to $70 per month, per person; costs are adjusted to the duration of the program.

International SOS also will respond to emergency calls from planners who are not enrolled in its plan, but Knapp says the costs in those situations, particularly for medical evacuations, can be prohibitively high, generally starting at $50,000.

Medical evacuation services can be found on the Web or through the local U.S. Consulate.