Gil and I are big travelers. The Paris-to-Normandy cruise on the Seine was our 10th major trip in the last five years. It was our first time, however, traveling with medical oxygen.
It can be tough planning a trip to an unknown or foreign destination. When you have a medical condition, it's a whole new ballgame. In our case, there are medical clearances to be had, airline and cruise line approvals and the rental of a portable oxygen concentrator. Go to a foreign country, and you have to make sure you bring the correct plugin adapters for your oxygen device. Take a shore excursion from your cruise ship, and you want to be certain you've got sufficient battery power to last the length of the outing. I remember joking once on a Caribbean cruise that the most stressful decision I had to make every day was which swimsuit to wear. Traveling with oxygen takes stress to a whole different level.
It is challenging, for sure. But it's also doable -- just as it is doable for people with other health conditions. As we started planning our trip to France, we began to think about travelers with other medical concerns. What hurdles do people with diabetes face as they plan and take trips? What about those with heart disease? As I searched for answers for us, I also wondered what solutions were out there for them.
One thing that applies across the board when you have a serious health condition: Consider travel insurance. Should you experience a heart attack or go into diabetic shock, as examples, insurance will cover medical expenses, your airfare home and some "trip interruption" expenses. "If you're in Egypt and you need to get out, there are boots on the ground that can help you ," says Nancy Cowen, an outside sales agent with Travel Leaders of High Point, NC. "It's very satisfying when I'm able to refund costs associated with a medical emergency or health-related trip cancellation." A caveat: Always disclose your pre-existing condition when you purchase insurance because, as Cowen bluntly frames it, "Insurance companies are always looking for a way out." For more on travel insurance, read our Travel Insurance Primer for Cruise Travelers.
When we first started researching the topic of traveling with oxygen, I wished for one central resource I could click on that would address all of our issues. I didn't find one. This is our attempt to break it down -- a one-stop shop for travelers with three common health conditions: oxygen dependency, diabetes and heart disease.
Traveling with Oxygen
Traveling with Diabetes
Traveling with Heart Disease
Traveling with Oxygen
The Prep: The first thing you need to do is get clearance from your doctor. Are you fit enough, even with medical oxygen, to take a trip? After our physician OK'd our plan, I got two important documents from him: a medical information form he filled out that was required by British Air, our carrier, and a "just in case something goes wrong while we're away" prescription that identifies Gil's diagnosis and the amount of oxygen he needs. It's also important to find out if your cruise line needs advance notice that you'll be traveling with oxygen. (Many cruise operators do; ours didn't.)
Next, I rented a portable oxygen concentrator, or POC, from one of the many companies I found online. A cautionary note: The POC didn't work, and we had to scramble last minute before our trip to find one locally. As it turned out, an independent pharmacy just an hour away was able to fix us up with a brand new unit -- and at half the price. The big lesson learned: Shop locally before you turn to online providers or rent a unit sight unseen. Also, give yourself a few days to get comfortable with the device, something we failed to do. In our case, we had to rent a POC because our in-home oxygen provider doesn't allow units to be taken overseas. It's worth asking your local vendor whether it supplies portable oxygen concentrators; if it does, insurance may cover the cost. Your physician could be a good resource for this, as well. Also, when traveling abroad, be sure to pack plugin adapters for your unit. In France, we had to use an adapter both on our ship and in our hotels.
If you require wheelchair assistance at the airport or during flight changes, be sure to alert your airline in advance. We also applied for -- and received -- approval from our airline's medical department for the use of in-flight oxygen. In other words, we used their oxygen, not ours. Our thinking was that our POC would run out of battery power on the long flight and that we needed backup. Airline policies regarding the use of in-flight oxygen and portable oxygen concentrators vary widely. It's key to check with your airline well in advance of departure about what documentation you will need from your doctor. (It's best to do it when you book your ticket.) A physician's statement, often on letterhead stationery, is usually required. It's also handy to have an official doctor's note when taking respiratory equipment through security checkpoints.
In Flight: The portable oxygen concentrator, first approved for use in airplanes by the Federal Aviation Administration in 2005, has revolutionized air travel for the oxygen-dependent. Until that time, traveling with oxygen was a major (and expensive) endeavor. Not only did passengers have to use the aircraft's in-flight oxygen, which often adds hundreds of dollars to the cost of a ticket, but in that pre-POC era they had to arrange for oxygen tanks and supplies at their destination (and, in the case of cruisers, at their various ports of call). Unlike compressed or liquid oxygen, banned on planes as hazardous, the POC is a small device that separates oxygen from nitrogen and other gases in the air -- providing oxygen to users at greater than 90 percent concentration. Best yet, the newest units weigh as little as five pounds.
To date, the Federal Aviation Administration has approved 11 POC's for use on U.S. carriers during all phases of a flight. For a listing of the policies of non-U.S. carriers, check out the European Lung Foundation's excellent Web site: www.european-lung-foundation.org. As of 2009, any airline from any country landing or taking off in the U.S. is now required to permit the use of battery-powered oxygen concentrators. Make sure your unit has an "FAA Approved" label on it. The 11 POC's that are currently authorized: Devilbiss Healthcare's iGo; International Biophysics Corp.'s LifeChoice; Inogen's Inogen OneG2 and Inogen 1; OxLife's Independence Oxygen Concentrator; Delphi Medical Systems' RS-00400; Invacare's XPO2; AirSep's Lifestyle and Freestyle; the SeQual Eclipse; and the EverGo from Respironics. One important caveat: If you will be using your POC continuously, bring enough batteries to power it for your entire flight, and then some. Some airlines require, for example, that you have enough batteries to power your unit for 150 percent of "flight time," which includes every minute spent onboard plus an allowance for gate holds and other delays. Because POC's and extra batteries are considered medical devices, they will not count against your carry-on baggage.
Although they are not required to do so, many U.S. and overseas carriers do provide in-flight oxygen. Be warned, though, that it may not be offered aboard all aircraft. Some, like British Air, provide the service for free. Most charge between $50 and $150 per leg. That means you are charged twice if you change planes.
Onboard: The best thing about cruising with a POC is that it's a lot like being at home. You plug in your device, or rev up the battery, and you're set. It really takes the worry out of the equation. To conserve battery power, it's not a bad idea to use an electrical outlet in the dining and recreational areas of the ship. You may want to talk to the maitre d' about securing a reserved table near one. As for shore excursions, make sure you have sufficient battery power for the duration of the tour. Also, get clarification from the tour desk about the degree of difficulty of each excursion you wish to book. By all means, ask about hills and steps and how long each walking tour will last. An excursion described in a brochure as "easily walkable" may not be for someone using oxygen. The message: Know before you go.
As with airlines, policies about medical oxygen use vary widely among cruise operators. To get an idea of what's out there, visit any cruise line's Web site, and search for "special needs" or "medical" or "disabilities," and you'll find a section on oxygen. Your travel agent can also help you compare cruise line policies. Some companies require an advance doctor's letter approving the travel plan and the itinerary along with the diagnosis, the dosage of oxygen the passenger uses and the passenger's present medical condition. Others are more relaxed about it. (Note: Passengers who prefer to use oxygen tanks instead of POC's must alert the cruise line in advance to make arrangements for the delivery of equipment to the ship from a local vendor.) One thing the cruise lines do agree upon: Passengers using oxygen are responsible for their own medical devices and their own supplies.
I realize that it's a lot of information to take in and a lot of effort pre-trip. But our thinking is that whatever it takes to travel, we'll do it. "Travel takes patience and planning and a little bit of courage. You need confidence in your equipment and confidence in your ability to communicate your needs along the way," says Dr. Jack Nissim, a pulmonary specialist associated with St. Joseph's Hospital in Towson, MD. "The people I know who travel have kind of adapted to what I think is the right way to think about oxygen: It enhances the quality of your life. It doesn't cause it to deteriorate."
One last factoid: Who knew oxygen-dependent cruisers were so cool? Sniffing a customer niche, several companies (Sea Puffer and Medical Travel, among them) now offer group sailings (in some cases with respiratory therapists) for oxygen-users.
Traveling with Diabetes
The Prep: While diabetes won't impede you from traveling, you have to accommodate it with some smart pre-planning. First, ask your doctor for a prescription for insulin and other medications you might need in the event of an emergency. Also, get a letter from your healthcare provider detailing any allergies and exactly what you need to do to keep your diabetes in check. No matter where you travel, plan to wear a medical ID bracelet that shows you have diabetes. If you leave the country, the American Diabetes Association (ADA) recommends learning how to say "I have diabetes" and "sugar or orange juice, please" in the languages of the countries you'll visit. If you have a flight that involves meals, you can request one in advance that is low in sugar, fat and cholesterol.
When you travel, the ADA and other advocates for people with diabetes recommend that you pack twice as much medication and blood-testing supplies as you think you will need. Be sure and pack these in a carry-on bag that you keep with you at all times. In addition, load it up with snack packs of crackers, cheese, peanut butter, fruit, nutrition bars and some form of sugar (hard candy, raisins or glucose tablets) to treat low blood glucose. It's a good idea to pack your meds in a see-through bag, and put your insulin in a bag that will keep it cool. Whenever possible, the FAA recommends that people also travel with their original pharmacy-labeled packaging.
Finally, plan for time zone changes. As the National Diabetes Education Program notes, "Make sure you'll always know when to take your diabetes medicine, no matter where you are. Remember, eastward travel means a shorter day. If you inject insulin, less may be needed. Westward travel means a longer day, so more insulin may be needed." To keep track of shots and meals through changing time zones, keep your watch on your home time zone until the morning after you arrive at your destination.
In Flight: One of the chief worries of people with diabetes about traveling by air involves airport security and screening. "People get very concerned that they may not be able to take their pumps, syringes and needles on planes," observes ADA president-elect Dr. Vivian Fonseca, chief of endocrinology at the Tulane University School of Medicine in New Orleans. He recommends carrying a physician's statement that says, "This is to certify that this patient has diabetes and requires insulin." It should be more than sufficient to address any questions that may arise at a security checkpoint.
Moreover, the Transportation Security Administration (TSA) clearly states in its own regulations that the following diabetes-related supplies and equipment are allowed through a checkpoint once they have been screened: insulin and insulin-loaded dispensing products, an unlimited number of unused syringes when accompanied by insulin or other injectable medication, lancets, blood glucose meters, blood glucose meter test strips, alcohol swabs, meter testing solutions, insulin pumps and insulin pump supplies, glucagon emergency kits, urine ketone test strips and an unlimited number of used syringes when transported in a sharps disposal container or a similar hard-surface container.
TSA regs also state that if you are concerned or uncomfortable about going through a walk-through metal detector with your insulin pump, notify a security officer that you are wearing one and would like a full-body pat-down and a visual inspection of your pump instead. Advise the officer that the pump cannot be removed because it is inserted with a catheter under the skin. For more information, consult the TSA Web site at www.tsa.org.
While in flight, take care to eat wisely. If you use insulin, the ADA recommends waiting until you see the food cart nearby before taking a shot. Otherwise, a delay in the meal could lead to low blood glucose. If you inject insulin while in flight, be careful not to inject air into the insulin bottle due to the pressurized cabin.
Onboard: Jetlag can make it difficult to tell whether you have very low or very high blood glucose, so check it as soon as possible after landing. If you don't have a sharps box, notify your stateroom steward upon boarding, and he or she will typically provide a proper disposal container. Cruise line policies differ when it comes to refrigeration of medications. Many will supply a stateroom mini-fridge. Others will provide insulin refrigeration with 24-hour access through room service or the front desk.
If you are more active than usual during your cruise, your blood glucose level could drop too low. Just in case, take along snacks when hiking or sightseeing. Dr. Fonseca cautions never to go barefoot and, as you do at home, to check your feet regularly for blisters, redness and swelling. On any shore excursion, take along your meds and a pair of extra socks to keep your feet dry. As he says, "You're on vacation, but you've got to remember that you've brought your diabetes with you." Use the opportunity while you are onboard to take a fitness class. Also, he says, carefully watch your diet. Ships today offer many savory food choices that are sugar-free or low in fat, sugar and cholesterol. "If it's a buffet, you can make choices. Focus on making the healthy choices," Dr. Fonseca adds, noting that you don't have to give up taste to eat healthy. Finally, he recommends checking your blood glucose more frequently than you would at home because changes in diet, activity level and time zones can impact your blood glucose level in unexpected ways.
Traveling with Heart Disease
The Prep: With heart disease, as with any serious medical condition, it's critical to plan ahead and know your limits. Cover the basics with your doctor before you take your trip: Are you fit enough to travel? How much activity is too much? If traveling to a mountainous area, will the altitude be a problem? If traveling to a remote area, should you be concerned about the absence of access to medical care? As cardiologist Dr. Nieca Goldberg, director of the Joan H. Tisch Center for Women's Health in New York City and national spokesperson for the American Heart Association, says, "It's important to ask those questions. And it's important for doctors to give a level of instruction about what is safe and what's not."
Generally, health practitioners say it's okay to travel two weeks after an uncomplicated heart attack or stent replacement. Some cruise lines require a letter from a physician on letterhead stationery stating that a patient with a heart condition is fit to travel. Other items you will need to tick off your checklist: Get a copy of your most recent EKG to take with you. If you have a pacemaker or an implanted cardiac defibrillator, get an ID card that says so along with a letter from your doctor. Make a contact information list that includes your doctor, family members and the manufacturers of any implanted devices. Pack an ample supply of meds in your carry-on bag. If traveling by air, arrange for a special low-fat, low-sodium, low-cholesterol meal.
In Flight: People with implanted medical devices are considered to have what the TSA calls "hidden disabilities," and special regulations are on the books that give guidance to both security personnel and travelers. In essence, the TSA recommends that people with pacemakers or implanted defibrillators carry documentation saying that they have them. Traveler should also show security officers exactly where the implants are located. Moreover, the TSA suggests that travelers ask for pat-down inspections rather than walk through metal detectors. A family member or traveling companion is permitted to be on site during the public or private screening.
One of the biggest risks facing air travelers who have heart disease is the formation of blood clots in the veins of the leg, pelvis or arms while in flight. Research shows that flights longer than eight hours pose the highest risk. During flight, consider wearing below-the-knee compression stockings, avoid alcohol, and drink plenty of water. Also, stretch your legs and walk around.
Onboard: Life onboard can be as active or relaxed as you want it to be -- within the parameters set by you and your physician. "Zip lines, bungee-jumping, scuba-diving, swimming -- if it looks like something you should have talked about with your doctor and didn't, don't do it," advises Dr. Goldberg.
Also, watch what you eat and drink. "There are lifestyle issues on vacation. This isn't a license to go out and eat everything in sight. Some of my patients really gain weight on cruises. So make good food choices. Avoid high levels of salt. Get your sauces on the side," she adds. "There's really no vacation from doing these healthy things for your heart."
Also, stay vigilant about symptoms to watch for: chest pain, shortness of breath, irregular pulse, lightheadedness or dizziness, unusual fatigue, swelling of the legs and/or feet, generalized feelings of illness, and/or sharp back pain in the mid to lower quadrant. If needed, seek help immediately from the ship's doctor. If there is no medical unit (typical of river ships, for example), contact the front desk.
"People should have a good time on their trip," Dr. Goldberg says. "Vacation is a very healthy way to get healthy and rejuvenate. You just need to pay attention to your heart."
--by Ellen Uzelac, Cruise Critic contributor