by Maria K Todd, MHA PhD

CEO and Founder
Mercury Healthcare International, Inc.

Many medical tourism facilitators open their business without any medical knowledge or training.

To me, that's as crazy as deciding to open a piano tuning business because you can tell black keys from white keys and you know that people with pianos need piano tuners at least once every 6 months - but little else. 

One thing that makes me shake my head in disbelief is this notion of "Sun, Sand and Surgery" that's been repeated by the media, untrained and inexperienced medical tourism sellers and a number of pop-up industry trade associations in the medical tourism industry all looking to get in on a piece of the action. They set incorrect expectations and pair activities that are inappropriate for many patients seeking to combine a short respite vacation with a surgical procedure.  

Ignorance brings with it significant risks to patient safety, outcomes, comfort and the overall patient experience and can contribute to complications

A lack of knowledge of anatomy and physiology, pharmacology, and direct patient care is evident. These dangerous amateurs lack knowledge of what's appropriate to plan for a client considering recuperation at a nice resort in a sun-drenched location. While the risk they present is not intentional, their adequate lack of training and their decision not to acquire the training before entering medical tourism is inexcusable. 

Sun - sensitivities

So many medical tourism facilitators state on their websites that the patient can travel to a sun-drenched location and recuperate on a beach at a 5-star hotel in an exotic location.

Many pain medications - both narcotic and non-steroidal anti-inflammatory drugs (NSAIDs) cause a reaction in some individuals that is similar to a sunburn.

There are actually two types of reactions:

  • The phototoxic reactions may happen within hours of exposure to sun.
  • The photoallergic reactions may happen after several days of exposure to sun.

Photosensitivity (or sun sensitivity) is inflammation of the skin induced by the combination of sunlight and certain medications or substances. This causes redness (erythema) of the skin and may look similar to sunburn. Both the photosensitizing medication or chemical and light source have to be present in order for a photosensitivity reaction to occur.  Phototoxic drugs are much more common than photoallergic drugs.  Drug-induced photosensitivity or photosensitising medications can cause unexpected sunburn or a dry, bumpy or blistering rash on sun-exposed skin (face, neck, arms, backs of hands and often lower legs and feet). The rash may or may not be itchy.

They include, but are not limited to:

Common Photosensitizing Medications
Antibiotics
  • Tetracyclines
  • Fluoroquinolones e.g. ciprofloxacin
  • Sulfonamides
Nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Ibuprofen (Motrin)
  • Naproxen  (Aleve)
  • Ketoprofen
  • Celecoxib  (Celebrex)
Diuretics
  • Frusemide
  • Bumetanide
  • Hydrochlorothiazide
Retinoids
  • Isotretinoin
  • Acitretin
Hypoglycemics ( to control blood sugar)
  • Sulfonylureas (e.g. glipizide, glyburide)
Neuroleptics (anticonvulsants)
  • Phenothiazines (e.g. chlorpromazine, fluphenazine)
  • Thioxanthenes (e.g. chlorprothixene)
PDT Pro-photosensitisers
  • 5-aminolevulinic acid
  • Methyl-5-aminolevulinic acid
  • Photofrin
Other drugs
  • Amiodarone
  • Diltiazem
  • Quinine
  • Quinidine
  • Hydroxychloroquine
  • Enalapril
  • Dapsone

The clinical features differ between phototoxic and photoallergic reactions.

Reaction type Clinical features
Phototoxic

(Phototoxic reactions result from direct damage to tissue caused by light activation of the photosensitizing agent)

  • Skin reaction occurs minutes to hours after exposure to agent and light
  • Appears as an exaggerated sunburn reaction (reddening and swelling)
  • Vesicles, blisters and bulla may occur in severe reactions (pseudoporphyria)
  • May or may not be itchy
  • Less commonly, skin may change color, e.g. blue-green pigmentation is associated with amiodarone
  • Reaction is limited to sun-exposed skin
  • Photo-onycholysis (separation of the distal nail plate from the nail bed) may arise with many oral photosensitizing medications and may be the only sign of phototoxicity in dark-skinned individuals
Photoallergic

(Photoallergic reactions are a cell mediated immune response in which the antigen is the light-activated photosensitizing agent.)

  • Eczematous, itchy type reaction occurs 24-72 hours after exposure to agent and light
  • May spread to areas that have not be sun-exposed
  • Hyperpigmentation does not occur

Sand - Post operative mobility and potential infections and parasite risks

With sand, "shift happens".

Anyone having had a recent abdominal surgery has had an incision through about 6 layers of muscles. Even if only a "poke" hole for a liposuction to extract stem cells, a keyhole procedure, a hernia repair, or any other procedure on the torso will find that their ability to walk and balance is diminished for a few days post-operatively. Many people travel for joint replacement surgery of the knee, hip, shoulder or ankle.  That also impairs mobility. While flat surfaces may be tough enough, having to deal with shifting beach sand can cause subtle twisting motions that can disrupt stitches, cause falls, and make crutches useless.

When clients book and prepay for packages or situate themselves at a 5-star beach resort with the intention to lay in the sun on a lounge chair on the sand and read a book, and then can't, you'll have a disappointed angry client whole will be merciless in their ratings and social media feedback. And rightfully so!   Anyone who packages medical tourism experiences should know the procedures, know the recuperative process, and know the typical limitations and admonitions of every procedure they coordinate - or they simply should abstain from coordinating procedures they know nothing about.

Many facilitators "disclaim" liability for client choices. My attitude about this is as follows: "If you plan to disclaim the very things for which you are being paid to give advice on or be knowledgeable about - go do something else. You and your disclaimers aren't all that helpful or necessary and you will probably damage the provider's reputation and your own and endanger the clients who pay you."  While the client may have had shoulder or neck surgery, the risk of falling and reaching out to break the fall adds danger when walking on shifting sands.

Sand Flies

Then there's the sand itself. Sand flies. It gets into places where it shouldn't.  Why risk infections and complications caused by avoidable activities?

An infection could necessitate the use of antibiotics which cause phototoxicity and photosensitivity. Increased pain from a sand injury during the post operative period may require narcotics and NSAIDs and powerful debilitating nerve pain medications that also can cause phototoxicity and photosensitivity.

Sand Fleas

“Sand flea” bites come from small biting flies found in coastal areas. There are many creatures called “sand fleas” by people at the beach. However, true sand fleas are present in sandy areas such as beaches and marshes and are crustaceans, not insects and are not "usually" harmful.  Sand fleas are quite small they can cause severe skin problems. They typically bite the feet, ankles and legs because they are closest to the ground. Sand fleas can only jump around 20-40 cm, so there’s much less chance of getting bitten on the upper body unless your client lays down in or close to the sand. When one gets bitten, it’s most likely to happen during the evening, night or at dawn. This is when the sand fleas are most active, so advise clients to be on guard if they plan to go near the beach at this time.

There are two types of sand flea bites on humans.

The first one looks like a mosquito bite and happens when the fleas suck one's blood and then moves on to another host. They inject saliva to prevent blood clotting as they are feeding, and this saliva is what irritates the skin and may cause allergic reactions. Your client may be on anticoagulants after surgery to prepare for the flight back home and prevent blood clots. They don't really need an unknown variable in the mix.  The second one is a little worse and is caused by breeding female sand fleas. The fleas burrow themselves into the skin and stay there until their eggs hatch. Clients should look for swollen areas with black spots in the middle because these may be breeding sand fleas.  Imagine if this happens in the surgical site, and the larvae form and hatch inside their newly healing surgical wound. Eew!  And you encouraged it!

Both bite types will cause symptoms like itching, pain and unpleasantness. If your client is allergic to sand flea bites, then more severe reactions can be expected. When the breeding fleas burrow into the skin, they may also experience fever and infections in the area that can develop into a condition called tungiasis, which is an inflammatory skin disease that needs to be treated to prevent secondary infections.  That's all they need.... a superinfection and fever that is related to their recuperation that could be misidentified as malpractice or a complication of the surgery or attributed to acts of the surgeon or the health facility -- NOT FAIR.

Sand fleas that breed in your client's skin can suck their blood for WEEKS. While there are many home remedies for sand flea bites and their discomfort, they may be contraindicated for someone during the pre- or post-operative period, or conflict with the medications they have been prescribed.  Why risk it?