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Quadriplegics
and remote travel
Medical Aspects
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J. Francois Porret
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Translation
by Richard Jessup -
The
observations gathered in this chapter are the result of more than 15
years of Off Road Wheelchair (ORWC) riding in many countries, some of
which provide very rudimentary comforts and hygiene considerably below
Western standards. This resulted in a number of surprises, lessons,
difficulties and foul-ups that make up what we will modestly call
“experience”.
This is a quadriplegic’s experience,
enriched by other quadriplegic and paraplegic travel companions. The
adaptations, tricks and medical comments that were appropriate for some
cases are probably not directly suitable to other situations.
These comments are aimed at so-called
“adventure” travel, with nights spent in local hotels or bivouacking
directly on the ground. For those travelling in an air-conditioned BMW,
eating and sleeping at the Hilton, there is no need for this
information. Well, sometimes maybeJ… Furthermore, before starting out
on a big trip, it is important to have tested your capabilities and
limits in a few progressively more difficult expeditions. Individuals
differ considerably, some will adapt better to heat or cold (the time of
year, type of trip, choice of itinerary are all key factors).
Your comments and suggestions are
welcome, in order to broaden and enrich the shared experience on this
page.
Heat
A quadriplegic’s body temperature control is considerably diminished
(there is no perspiration or blood flow regulation through blood vessel
dilation below the injury level, except for a few insufficient reflex
mechanisms). The resulting sensitivity to outside temperature produces
(as is the case for cold-blooded animals, like lizards…) a rise in
core body temperature. The risk of overheating is critical, since it can
lead to death if the body temperature exceeds 41oC for an
extended period of time (e.g. the European heat wave of summer 2003).
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Passive prevention:
- shade (use a large umbrella like the ones used on baby
strollers, take breaks during the warmest hours of the day under
a shade tree, sit in the back of a car…)
- Clothing (loose, light coloured, long sleeves…).
- A hat (a wide brim cap covering your neck, a Bedouin’s
headscarf …).
- A space blanket (bright side to the outside) over your
legs and upper body.
- Take advantage of the wind if it is cool (choose
the best route).
Active prevention:
- Frequent spraying (head, neck), letting the water
evaporate for better effectiveness.
- Be careful in humid climates where there is little
evaporation (e.g. the Amazon).
- Lower the body temperature before sunrise (since a
quadriplegic’s body accumulates heat, somewhat like a stone,
he/she can make use of the cooler periods, for example by
sleeping unclothed, to start the day with a body temperature
that will rise slower).
- Drink a lot of cool water (don’t forget to insolate
your Camelbak®)
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Better to look silly than dead… |
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Cold
(Refer also to the scientific study on this subject published by GERTP
contact michel.guenin@wanadoo.fr
and http://perso.wanadoo.fr/plonge.medical/plongemedical/PlongTetraplegie.html)
A quadriplegic’s
body temperature control is considerably diminished (no blood flow
regulation through blood vessel constriction and especially no muscular
contractions or shivers below the injury level). The resulting
sensitivity to cold temperatures produces (as is the case for
cold-blooded animals, like lizards…) a drop in core body temperature
and therefore a deep feeling of cold. No case of serious or deadly
hypothermia has been reported in these conditions so far, but care must
be taken since serious hypothermia can lead to cardiac fibrillation or a
coma. On the other hand, the risk of frostbite in the paralysed area of
the body is lower than expected, precisely because of the lack of blood
vessel constriction. The only aggravating factor is the forced
immobility. If you really try, you can die of cold, but without
frostbite ;-) !
Wind or, more accurately, the wind-chill factor, is the quadriplegic’s
prime enemy (as much as it is an ally in the case of heat).
Excerpt
from the GERTP study:
Comparative trends of the internal temperature of two
quadriplegic and two able bodied subjects. All are wearing a 7
mm thick wet suit and are immersed in 18oC water
for thirty minutes. The temperature is recorded during the
phases of immersion, drying, dressing and rest (four hours
total).
The quadriplegic’s core body temperature vulnerability to
outside temperature conditions is clearly shown. |
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Passive
prevention:
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Retain body
heat (sleeping bag, parka, foam pads, multiple layers of
clothing)
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Stop radiation
heat loss (space blanket with the bright side inside, but
beware of condensation).
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Reduce
conductive heat loss (foam pad, self inflating mattress,
waterproof protection).
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Reduce
wind-chill with a good wind breaker.
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Protect your
head (> 60% of total heat loss occurs there).
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When
camping, use a small tent inside a large one. |
Active
prevention:
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A hot water
bottle. Extremely effective inside a sleeping bag and easy to
use. Chemical or battery powered heating devices can be
effective if worn during the day, but they are inconvenient
and heavy for long trips. Beware of burns on parts of your
body where there is no feeling.
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Place your
shoulders (they are the quadriplegic’s thermal source) in
the space being warmed, generally a sleeping bag (if not, your
legs will remain at a constant temperature, i.e. cold).
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Drink warm
beverages (but be careful about the ensuing self
catheterizations)
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Avoid humidity
(soaking clothes, rain).
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If
logistics permit, take a long bath or shower at 38oC. |
Altitude
(See
the 1993 study with a quadriplegic subject spending a month in the
Tibet’s high elevetions, by professors Geyssant
(“Physiologie et Physiopathologie de l'Exercice et Handicap”)
and Minaire from St Etienne Hospital).
For quadriplegics, the
risks are related to their lowered respiratory capacity and
impaired thoracic muscles. They will be more susceptible to
hypoxia induced problems, such as high altitude pulmonary oedema.
Irregular breathing at night also seems to increase while
acclimating, especially when sleeping on one’s back. There
doesn’t seem to be any increase in the incidence of headaches
versus the overall, non-acclimated population.
Acclimatisation leads to lower blood fluidity. This will require
more vigilance about sores, since the skin becomes more sensitive.
Prevention
will require, as for the able bodied, tests to determine your
adaptability to high altitude and
a careful acclimatisation. Once you start out, climbs should be
gradual (“climb high, sleep low”), with limited exertion.
Be careful of the effect on catheterizations of any prescription
drugs (avoid self prescribed medication) such as diuretics (Diamox®is
preventive, Lasix®is curative). Viagra®
seems to work as well as Diamox®, but the side effects
are different. Any volunteers to test it? J
Even
if this is unproven in medical literature, many mountaineers
believe that the body retains a memory of its previous forays into
high altitudes. A body accustomed
to hypoxia previously will react positively when exposed
again to rarefied oxygen. Or is it just accustomed to suffering?
There is a wide range of capacities among individuals that we
cannot really explain specifically: it may be from previous sports
activities, or maybe a quadriplegic is used to facing breathing
irregularity (overweight, sleeping on his back) and therefore
hypoxia.
We
can also ask ourselves if there is a correlation in a
quadriplegics’ better adaptation to hyperbaric (scuba diving) as
well as high altitude activities compared to their able-bodied
companions (refer to the GERTP tests and the study by Dr.
Wuyam from the “laboratoire d’explorations fonctionnelles
respiratoires” of the Grenoble hospital
Skin
Adventure travel punishes your skin with unusual sitting
conditions (up to 10 hours non stop per day in an ORWC, sometimes
for more than a week at a time, long trips in local buses with
hard seating, rattled for hours in a 4x4 vehicle with long dead
shocks, interminable airplane trips with your knees under your
chin, etc…)
Rain and humidity can leave you soaking in water, exacerbating the
risk of hypothermia and skin damage. The right protection is
required (cover, poncho, parka, hat, tent) and the areas at risk
need to be well ventilated. Be careful about bug bites that you
won’t be able to feel (scorpions in the desert, all kind of
nasty things in the Amazon…)
Situations where washing is difficult increase skin risks.
Disposable wipes and skin lotions will be appreciated.
The same prevention and protection is recommended for skin
abrasion (sand, especially during a storm where it seeps in
everywhere) and friction. Be careful with sunburn risks due to
excessive exposure to the sun (i.e. shorts or slacks that are too
short).
Watch for pressure points from foreign objects that might have
inadvertently slipped inside your sleeping bag.
Also,
beware of the effects of altitude on blood viscosity, making skin
more susceptible to sores.
Passive
protection
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Always use an
excellent seat cushion (e.g. Roho®). Beware about
the effects of the cold on gel cushions (they harden), and of
the sun (they burn). Altitude makes some foam cushions’ (e.g.
Jay®) closed cells burst, then collapse. Also be
careful about the effect of altitude variations on inflatable
cushions.
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Always keep a
small closed cell foam pad (40 x 40 x 3 cm) or a thin gel
cushion on hand to protect your back in buses, your ribs in 4x4
vehicles, your shins in charter flights and your backside on bad
mattresses.
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On the ground,
sleep on two or three 5cm thick foam mattresses or on a slightly
inflated air mattress (be careful about air leaks: you might
only find them out after a night spent on a hard spot on the
ground). Alternatively: a thick, self-inflating mattress: very
comfortable, and with a battery operated pump it’s ready in
one minute.
- Fragile
areas of your body can be protected with special
blister-preventing bandages. |
Active
protection:
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You will learn
to appreciate and even to seek (!) rough and bumpy
transportation (ORWC or 4x4 vehicles). It will massage your skin
(on an inflated cushion), even if your vertebrae will have to
bear it.
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Lift your weight
off of your seat as often as possible. Find the best positions
to alleviate critical pressure points.
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Whenever
possible, massage your skin in the evening and pay special
attention to areas exposed to pressure. Never let red spots
persist, they will lead to skin sores. Treat them immediately
(bandages, Conveen).
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Let your skin
breathe as much as possible.
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Sleep on your
side and roll over once or twice each night (in cold weather,
you can be lying down for up to 12 hours, waiting for the sun to
show up).
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You can use
padding on sensitive points (i.e. heels, knees, buttocks,
elbows), securing it with straps or Velcro. |
Digestive
tract
Digestive disorder risks increase in countries with rudimentary
hygiene. A bout of diarrhoea can create serious problems for a
quadriplegic if you can’t take the time to stop or if there is
no water available.
Prevention: wash your hands with antiseptic solutions before every
meal, avoid all salads, fresh vegetables and fruit and drink only
sealed, bottled water or purified water (MicroPure®,
Potable Aqua®…). Be paranoid, don’t worry about
ironic comments (the ones making them might be the ones running
for the bushes a few days later…).
Use an ultra light (2.5kg) portable toilet chair, inside a small
tent if you have that luxury. It is better to switch your daily
care to a 2 day frequency, with a preference for the evening as
you arrive at the bivouac, especially if mornings are very cold.
Use disposable wipes if there is no water.
Bladder
Use the same preventive measures as for the intestines, washing
your hands with an antiseptic solution before every meal and self
catheterization. Use disposable catheters (but don’t dispose of
them just anywhere, it pollutes, and in some countries locals
collect them and re-sterilize them!)
In public transportation (i.e. airplanes), you can use a blanket
or a cloth hanging on the seat in front of you to hide a bit while
self cath’ing. Your neighbour will usually understand if you
explain that you need a few minutes of privacy. However, with
today’s terrorism paranoia, it might be harder to explain…
For a night time catheterization, remember to use a back support.
For a quadriplegic without any balance, it is difficult to lean
against a tent wall or to sit with a back rest (use a beach chair
or stacked backpacks).
| Airplanes |
BewBeware
of oedema during long flights (use full-length, custom stockings
or elastic leg bandages). Drink a lot, even if means more self
caths.
Take aspirin regularly during the trip. Athletes do this
when travelling; it helps avoid blood clots and favours
recovery.
Do a catheterization before and after the flight, if possible
(the rest rooms in most airports are usually suited to this
purpose, otherwise behind a quiet counter or partition). In the
plane, explain the issue to your neighbour and hang a cloth
between your seat and the one in front of you for privacy.
Some
airports, and not necessarily third-world ones, transfer you
very carelessly (feet first and higher than your head when
seating you, bumping you on the armrests, no wheelchair
available on arrival…) |
| Bus |
Always
difficult to get in and out of, requiring a difficult lift.
Protect your buttocks with your hands to avoid trauma. Seats are
often small, be careful not to hit your legs in front. They can
be quite hard, use your handy little foam pad. |
| Automobiles |
All
terrain vehicles and their bouncing ride are, in fact, rather
beneficial, but use a cushion to absorb the bumps and avoid hard
spots. Use a foam pad in addition to the inflatable cushion
underneath your buttocks to protect you against lateral shocks.
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Countries
that inspired these comments:
The Amazon,
Cabo Verde, China,
Egypt, Ecuador, Ethiopia,
Hawaii, Jordan, Lebanon, Morocco,
Mauritania, Perou, Nepal,
Senegal, Tibet
Last update : 09/26/2005 12:25 |
