Guest post: Travel in Bhutan

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.

Dochu La Pass, author’s photo
Dochu La Pass

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.

Campsite at Jimilang Tsho, sparkling clear morning after a snowy, blowy night; we would have been warmer in smaller tents!  Author’s photo
Campsite at Jimilang Tsho, sparkling clear morning after a snowy, blowy night; we would have been warmer in smaller tents!

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.

Pack mule, near Phajoding Monastery
Pack mule, near Phajoding Monastery

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!

_________________________________________________________________

[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 mens toilet

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Guest post by Bo Parrish: YOU’RE NOT DONE…

One of the things I love most about blogging is meeting others who have gone through ostomy surgery and are out there overcoming fears, living their dreams and making a difference in the lives of others. I recently had the pleasure of becoming acquainted with such an individual when Bo Parrish emailed me about doing a guest post on the blog.  Bo is a semi-professional, nationally sponsored triathlete who shares his story through his website www.conqueryourcomfortzone.com. He is also the recipient of the 2012 Great Comebacks® South Region Award. Bo’s message of embracing change resonates with me and his guest post is a perfect fit for Ostomy Outdoors. Enjoy!

You’re Not Done
By Bo Parrish
Can you imagine a life other than the one you are living right now? Is there something about you that you wish were not so? Does the thought of change excite or terrify you? Well, however you may feel about your current situation I can assure you that it will change! The road that you are currently traveling will indeed change in some way, form or fashion. Life has a funny way of working itself out with or without your liking. My life is a testimony to the incredible blessing that change can and will bring. I wish I could say that I chose it, but it chose me and I am extremely grateful!
SUB-TOTAL COLLECTOMY SURGERY CLEVELAND CLINIC, APRIL 2007
SUB-TOTAL COLECTOMY SURGERY
CLEVELAND CLINIC, APRIL 2007
I grew up a fairly normal kid in a small town. I never had to deal with adversity until my teenage years. You see, Crohn’s Disease chose me and my life would take a dramatic turn. I spent the better part of the next 14 years in a vicious cycle of stomach pain, fever, weight loss, anemia, bone loss, and social anxiety among others. I was the sick kid, the one who sat on the floor outside of the classroom so that I might make it to the bathroom multiple times throughout the day. I was the one who missed the prom and the parties for fear of not being able to find a bathroom. My entire freshman year of college was spent in the medical clinic while discovering that alcohol absolutely wreaked havoc on my comprised digestive system. Life was miserable and I knew of no other alternative. This continued into my early adult years as I transitioned into the workforce. I was sick more often that well and my employers quickly discovered my lack of productivity. All I could think about was making it through the day to return home to the comfort of my bed. My doctors recommended surgery to removed my diseased bowel, but the thought of a “bag” absolutely horrified me. I told myself that any amount of pain and suffering was better than a body-altering, image-wrecking surgery. As I mentioned before, life has a funny way of working itself out.
In the fall of 2006, I found myself in a rural emergency room in Canada in the hands of general surgeon. My large intestine had ruptured and my body was becoming septic. If I were to continue living, surgery was my ONLY option. I was on the verge of slipping into a coma before giving the doctor consent to operate. The next six weeks were pretty much a blur, but I was alive. My recovery was the farthest thing from comfortable that I can describe. I had a hole in the middle of my body and my midsection had been carved up like a Thanksgiving turkey. BUT….I WAS NOT DONE! Eventually, I started to recover my strength and shortly after my surgery I was introduced to the sport that I credit with my current athletic success. Triathlon gave me confidence; it gave me conviction that my life would be better. In the seven years since my life-saving surgery I have become an endurance athlete and have married my running coach. I have competed in Ironman events all over the world and raced in two world championships. I have learned how to eat and fuel my body for athletic performance. Most importantly I have gained a keen sense of gratitude. It is now my passion to encourage and support others who have recently faced or are anticipating ostomy surgery.
MUSIC CITY TRIATHLON, JULY 2012
MUSIC CITY TRIATHLON, JULY 2012
I know it sounds crazy, but life begins with your ostomy. If only I could have known how sweet life could be on the other side of surgery, I would have gladly volunteered. My biggest problem was my attitude. I was sure that my life would be forever ruined by an ostomy. I would never be able to take my shirt off in public. I would never find a woman who would be attracted to me much less get married. I would lose my ability to to be transparent. Oh, how ridiculous I was! Change is such a wonderful thing and in our particular application of an ostomy, it can be the difference in that other life you wish you could live. Life is too short to suffer without hope. Please, please, please don’t allow yourself to become an emergency surgery. Take it from me and my path these last seven years: change is the only thing that is keeping you from living the life of your dreams.