Very occasionally, I take the opportunity to share someone else’s words on OstomyOutdoors.com when I think it will be of particular interest to you, my dear readers. Thank you for your ongoing support and please enjoy this article and photos from my guest author, Matilda.
–Heidi
International Travel with an Ostomy: Following the Druk Path
By Matilda
I’m really an iPhone photographer; my husband is the one who takes great photos and happened upon the brochure for a two-week photographic tour to Bhutan. We are both in our mid 50s, and though we had little outdoor adventure experience in our earlier years, have now discovered trekking holidays, so we added a six-day supported hike to follow on from the small group photographic tour.
Once I had found Bhutan on the map (between Tibet and India) I remembered Bhutan is recognized for its worthy goal of “Gross National Happiness,” which measures quality of life in more complete terms than just the material GDP.
Having chosen a total proctocolectomy and permanent ileostomy for Crohn’s colitis just over a year ago, I was both excited and apprehensive about the trip. We had taken a couple of independent supported walks since the surgery, including the Cape to Cape walk in Western Australia with its stunning coastal views, but the isolation of Bhutan is both a major appeal for travel there while at the same time posing additional risks.
The first two weeks of the trip would be fine–hotels with en suites, a couple of day hikes to Tango and Flying Tiger monasteries, and some early morning starts to arrive at scenic spots such as the Dochu La Pass for dawn low-light photography. These early starts were so much easier for me than they would have been pre-ileostomy.
When I chose surgery, I naively believed I could now make travel plans without worrying about a relapse or the timing of infusions interfering. I discovered that was overly optimistic thinking, as I needed a stoma revision six weeks before departure. When finally starting to train again for the trip, I sprained my ankle with associated aggravation of an old Achilles tendon injury. I iced and exercised it for two hours a day while my husband did some weekend training up and down nearby hills without me. Even when we left Australia for Bhutan, I wasn’t sure if I would be able to follow through with the trekking part of our plans and wondered if we would take a meditation retreat instead!
Any travel with an ostomy needs some planning. I had heard plastic bags were banned in Bhutan, which would make the practical aspect of disposing of soiled pouches potentially more complicated. This especially concerned me when a friend, who had only been transiting through Rwanda airport, had the plastic bags holding her toiletries confiscated. When trekking, I considered packing out my used pouches in a tube made of plumbing pipe as suggested in the book How to Shit in the Woods[1], and also ordered an odor-barrier zip lock bag[2]. Ultimately, I heard from our tour guide in Bhutan who advised that though plastic bags are banned, I could still use them (!) and they would be packed out with the other rubbish when we left camp. Biodegradable ostomy bags would be great, but so far are only available for those using a closed pouch.
Sadly, it turned out, plastic bags are far from being unavailable in Bhutan and though mostly a clean, welcoming and astonishingly picturesque country, plastic bags were to be found along the roadsides and in rivers. Though nights were bitterly cold for someone who lives in tropical Australia, the snow made our hike more aesthetically pleasing as it covered up the yak and mule excrement and rubbish some left behind at camp sites on this very popular route, the Druk Path, between Paro and Thimpu. Our team packed all our rubbish out with us, except food scraps, which were shared with the birds and stray dogs that followed us.
I experimented with some biodegradable baby wipes before departure, knowing I may not have ready access to clean water on trek, or on the minibus, especially if I needed to make unscheduled changes. It was important to know that my skin would not react to the wipes and adhesion of the flange be unaffected. I had also read a horror story about a trekker having difficulty with pouching at high altitude in cold conditions, so when weather conditions were cold, I carried a base plate underneath an inside layer of clothing day and night so that it would be flexible if I had to repouch. I discovered a couple of things, re-pouching sitting in the tent, rather than standing next the bathroom basin: the base plate fit my contours better when applied sitting down, and my skin was happier without soap.
I am always impressed when I hear of people who can wear their appliance for 3-4 days, or even a week at a time. I have never managed more than two days, and since my stoma revision just before the trip, felt lucky to make a day and a half without a leak and un-scheduled change needed. This meant carrying a lot of ostomy equipment with me–double what I expected to need–was the advice[3]. I divided my gear into four uneven piles, spreading them between my husband’s and my own carry-on bags and checked luggage. I still hoped that as the stoma settled down post op, I would be able to extend the wear time, but after several leaks leading to showering and washing out clothes in the middle of the night, luckily while staying in a hotel, I decided it would be best to plan on a daily change. From then on, I only had one leak, the first day on trek, when fortunately conditions were warm and sunny and I was able to wash out my clothes in the Sea to Summit “kitchen sink” I carried with me.
Our “private” trek, for just the two of us, included the company of a guide, cook, assistant cook, mule driver, and six mules! It is compulsory for most visitors to travel with a guide in Bhutan, and our guide and his staff thought of everything; they even supplied hot water bottles at night! I didn’t have to worry about carrying a heavy pack as the mules carried food, cooking equipment, tents, and even our personal gear.
I found the hip belt of my daypack obstructed the outflow of my stoma, so I took Heidi’s suggestion of padding out the belt to take pressure off the site. I found my “kitchen sink,” using its attached belt loop with the bulk of the sink on the inside (body side) of the belt rather than the usual outside, very effective without adding extra weight or equipment. When the temperature dropped and I had to wear more layers, the padding was no longer necessary.
Water was boiled for our drinking bottles, and I advised the company in advance that I needed to drink more fluids than most people due to my stoma, in case this required they carry extra fuel supplies. I gave up on my hydration bladder due to the hygiene risk of the open mouthpiece, and swapped to water bottles with a lid over the mouthpiece instead.
Here are some additional hints for traveling overseas with a stoma.
Travel Insurance:
Remember to declare pre-existing health conditions in your application. In the past, I was able to get Crohn’s disease coverage, by paying an excess fee.
Ironically, post op and off immunosuppressants, though I am much healthier, I now am unable to get cover for Crohn’s disease in the Americas, though I still can in Europe, Africa and Asia. Because I had a stoma revision operation planned, I didn’t seek insurance on this trip for Crohn’s disease (as I didn’t want the rejection on my record). Though there was a small chance of forfeiting the trip due to Crohn’s disease, the biggest risks were not related to my inflammatory bowel disease but to road trauma, altitude, accidents and infection, especially gastroenteritis.
Airports and security:
My stoma nurse suggested wearing a clear pouch (a post-op bag) for airport security. This seemed overly cautious but she told me of a woman asked to remove her pouch at a European airport to show what was underneath.
The only time I have been pulled aside was when the bag showed up on x-ray in the USA and I was simply asked to wipe my hands on my shirt, over the area. My hands were then tested for explosives, and I was waved through.
Remember, you can’t take sharps onboard, so make sure you pre-cut any flanges that you will carry on the plane (more than you think you will use, in case of problems on the plane or delays), and pack the scissors in your checked baggage.
Immunization:
See your medical practitioner in plenty of time, ideally three months before you go, to make sure you are fully immunized. This is important for everyone, but especially for those of us who are immunosuppressed due to medications (ideally we should have had the opportunity to update our immunization status before starting immunosuppressants, but there may be additional travel vaccines indicated). If you are immunosuppressed, you are unable to have live vaccines, such as Yellow Fever, and will need a certificate to enter some countries, explaining why you are not immunized. Though this documentation does not guarantee entry, there were no issues for me crossing from Argentina to Brazil a few years ago.
Medication:
Your doctor can also give hints on food and water safety and general travel health, and supply an emergency pack of antibiotics and rehydration solution if you do become ill. If you irrigate, remember it must be done with potable water. Ask the doctor to write a brief health summary and a list of your medications, stating they are for personal use. Keep the medications in their original packaging with labels attached. Like your stoma gear, you may want to divide medication between bags. Consider having your stoma nurse or doctor discuss how to handle obstruction before you go. I self-managed this issue a year ago (remember, I said I couldn’t get health insurance in the Americas!), using “Dr. Google” as a guide, but there is better internet access in Boston than on trek!
I use a “FRIO” bag for medications that need to be kept cool when there is no access to refrigeration. These work by evaporation and only need water to re-charge them.
Stoma gear:
Take twice as much as you would normally use and spread it out between your pieces of luggage. I also keep a little kit with everything I need for a pouch change within reach on the plane. I find I can’t drink carbonated drinks when flying as the extra gas plus the altitude blows up my bag. If I empty my pouch in the plane, I leave a little extra air in it, as descent seems to depressurize my bag. The exception is when landing at a higher altitude than you took off from, as I discovered landing at Paro airport, necessitating a quick trip to the loo[4] at the arrivals hall to empty my stoma bag of air!
Altitude:
The most important thing to avoid altitude sickness is to choose a trek that does not climb too high, too fast. A slow ascent (400 meters or 1,300 feet per day) and a rest day every three days is recommended to allow you to acclimatize.
Finally, don’t be put off by the idea of traveling with an ostomy. Though your trip may not be incident free regarding stoma issues, don’t miss the opportunity to discover other places and cultures; you will manage, and the change in routine may even help you learn something new about managing your stoma, your health and living life.
Think Gross National Happiness!
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[1] (1994) Meyer, Kathleen, How to Shit in the Woods: An Environmentally Sound Approach to a Lost Art, Random House
[2] LOKSAK OPSAK
[3] I was happily able to bring half of the appliances home again.
[4] Definition: bathroom, ladies’ or men’s toilet
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