Avoiding Montezuma’s Revenge

accessible_bathroomQ. I’m in my second year as a T4 complete paraplegic. In July I will be flying to La Paz, Mexico, with a group of friends to go scuba diving in the Sea of Cortez — heading out on a dive boat each day and spending our evenings in town.

This is my first big trip since I became paralyzed. I’ve done my homework and checked the accessibility of the hotel and dive boat, including having them measure doorways and bathrooms and email me photos. I’m stoked about the trip, but my biggest worry is getting a case of Montezuma’s revenge — especially as a para. With no sensation, if I get the runs, I won’t know it until it’s too late.

Any suggestions on how to avoid it? And if I do get it, what to do about it?

— Frank

A. Frank — kudos to you for your advanced accessibility checking! As to your question, a more common name for the malady you fear is “Travelers’ Diarrhea” (TD), a common concern for people traveling outside the U.S. and, as you point out, a big concern for people with SCI, mainly because we can’t feel it coming, and we can’t feel the subsequent, urgent, four to five bouts of diarrhea per day that accompanies TD.

Although TD is sometimes caused by the stress of traveling or change in diet, according to the Centers for Disease Control and Prevention, TD is usually caused by bacteria that comes from consuming contaminated food or water — a reminder that we in the U.S. enjoy high standards for food handling, clean drinking water and sewage disposal.

Each year between 20 percent and 50 percent of international travelers will get TD. The CDC offers a good reference page on TD, including a list of destinations divided into three grades of risk for TD: low, intermediate, and high.

The good news is there are simple steps you can take to greatly reduce your risk of developing TD — steps that the CDC reports lower the risk of getting TD to around 14 percent.

The best way to decrease your chances of getting TD is to be careful of what you eat and drink. Liquids should either be boiled then cooled, or boiled and consumed hot (like hot tea or coffee) — or bottled, as in bottled water, soda, beer or wine. Since ice is usually made from tap water, avoid drinks with ice — unless the ice has been made from boiled and/or filtered water. In order to stay hydrated, purchase plenty of bottled water from a local market. Also use bottled water to brush your teeth.

Although cooking your own food is the best way to avoid TD, part of the fun of a vacation is eating out. An easy way to remember what to eat is, “if it’s not boiled, well-cooked or peeled” don’t eat it. Dry foods such as breads, or fruits that you can peel should be safe to eat. The CDC also recommends avoiding foods or beverages from street vendors. Other risky foods are unpasteurized milk and salads, since they are probably washed with local water.

Also, don’t forget to clean your hands before eating — carrying handi-wipes, or an alcohol-based hand cleaner makes this a breeze.

Another CDC tip is taking Pepto-Bismol — two tablets four times a day helps nasty bugs from grabbing on the lining of the stomach. Be aware that Pepto-Bismol turns the stool black (it’s harmless but would be scary if you didn’t know this) and can also turn your tongue black if you don’t rinse it off. It can also cause firm stool constipation — drinking extra water can help ease this.

Anecdotally, I’m a T10 complete para and my travels have repeatedly brought me to amazing places throughout Mexico and Central America, occasionally for weeks at a time. TD is a big concern so I stick to the recommendations. I do change the Pepto-Bismol routine a little and chew two tablets before each meal. Although these eating habits sometimes cause friends to tease me about being a tourist or “gringo,” in all my travels I’ve never had TD. Many of the same friends that tease me for my “tourist” habits and ignore these precautions have also missed vacation days sitting on the commode with TD!

Even if you take all precautions, TD can still occur. The CDC explains that most TD symptoms start abruptly and include abdominal cramping, bloating and four to five loose or water bowel movements (diarrhea) a day. Most cases begin to resolve in one to two days, but could take longer. Because of the diarrhea associated with TD, dehydration is a concern, so it is important drink enough water to stay hydrated. Electrolyte drinks like Gatorade may also help.

There are two schools of thought among paraplegics that have gone through bouts of TD. One school of thought is to get a good book and hole up in a hotel room, spending most of the time on the commode (with plenty of breaks for skin checks) and let the TD run its course. The other school of thought is to try and stop things up with Imodium. In either case, purchasing a bag of adult diapers like Depends, as well as getting some extra towels from the hotel for clean up will help. Additional information for dealing with inevitable accidents that come with TD can be found in this month’s feature article, “The Tao of Poo.

Once TD runs its course, the best way to stop things up and soothe a sour stomach is with the BRAT diet — a bland diet of Bananas, steamed Rice, Applesauce, and Toast.

Cat Davis, CRRN of the Craig Hospital SCI Nurse Advice Hotline explains that if other traveling partners or family members have the same symptoms and they don’t clear up within 24 hours, a trip to the doctor is warranted. If there is fever, and/or nausea and vomiting along with diarrhea, or if the stool is bloody, or frothy or fatty, or unusually foul smelling, these could be signs of serious infection and should be seen by a doctor, urgent care, or primary care physician that day.

Part of the excitement of travel is change of pace and navigating different challenges. I find that I’m still able to enjoy the local flavors of exotic travel — I’m just a bit more cautious. Things like boiling water and/or making sure I have enough bottled water on hand, navigating what to eat within my “TD risk-comfort zone” is part of the fun of travel. It makes me appreciate the adventure that much more and makes me re-appreciate the amazing infrastructure here in the U.S. — like being able to safely drink water right out of the tap!

Frank, I wish you a safe dive trip and hope you are lucky enough to see some of the many manta-rays that the Sea of Cortez is famous for.

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