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Many opportunities exist for CRNAs to use their skills to help others locally and abroad as part of a volunteer mission or in response to a natural disaster. The following frequently asked questions (FAQs) were developed by the AANA in collaboration with several CRNAs who regularly travel abroad on mission trips. These FAQs are meant to be a guide for issues anesthesia professionals should consider when preparing for a volunteer mission trip.
- How do I identify a volunteering opportunity?
- How do I fund a mission trip?
- What kinds of vaccinations do I need?
- What type of documentation do I need?
- Are there insurance considerations I should be aware of?
- Are there specific personal items I should take with me?
- How do I ensure my personal safety abroad?
- What concerns should I have about food and water while abroad?
- What do I need to know if volunteering in response to a disaster?
- How do I transport medications and controlled substances out of the U.S.?
- What type of anesthesia equipment will be available?
- What types of procedures can I perform?
- What should I be aware of when administering anesthesia in a new population?
- Can I participate as a student?
- Where can I find more information?
How do I identify a volunteering opportunity?
Many mission agencies exist, such as Health Volunteers Overseas, which provide opportunities for volunteering abroad. There is also a need for volunteers across the United States. Volunteering opportunities can be identified through mission agencies’ websites, networking with colleagues, local organizations such as local Veterans Affairs (VA) hospitals, or faith-based groups. When the AANA is made aware of an anesthesia-related mission opportunity, an announcement is posted at www.aana.com. CRNAs are encouraged to use these FAQs as a guide and to thoroughly research any organization they might chose to work with.
How do I fund a mission trip?
The payment for mission trip expenses varies by sponsoring agency, although mission trips are predominantly self-funded. The sponsoring agency may collect a specified dollar amount per volunteer to cover all in-country expenses (e.g., transportation, lodging, meals). It has also been noted that some agencies may have a tiered fee system, with variable rates depending on position. Airfare may or may not be included in this fee. You should work directly with the sponsoring agency to identify trip costs and determine what is and is not covered. Additionally, you should ensure that all expense-related issues or questions are addressed and understood before departing.
To alleviate some of the financial burden, the sponsoring agency or the individual volunteer may hold fundraisers or solicit donations to help defray the costs of the trip. It is the individual’s responsibility to determine whether there are any tax-related issues concerning a personal fundraiser or accepting donations. CRNAs should consult with the appropriate expert, such as a tax accountant, for this information.
Expenses incurred that are direct and documentable may be deductible from your income tax. Allowable expenses may include travel, lodging and medical supplies if not reimbursed. Lost income or the value of the services provided cannot be deducted from your income tax. Sightseeing or personal travel may affect deductibility. It is imperative that all specific expense- and tax-related questions be verified by an appropriate source, such as your tax accountant or the U.S. Internal Revenue Service, before departure.
What kinds of vaccinations do I need?
It is up to you to get the proper recommended vaccinations prior to travel. The CDC Travelers’ Health Vaccination webpage is a good resource for determining which vaccines are necessary based on destination. Volunteers may have to pay out-of-pocket if the recommended vaccinations are not covered under medical insurance. Ample time should be allotted when a series of vaccines (e.g., Hepatitis B) must be obtained to be effective. If you consult with a travel clinic or primary care provider before you go, ensure that it is understood that you will be working as a healthcare provider, not just traveling as a tourist. This information will help ensure that you receive the appropriate vaccinations.
Additionally, volunteers may fall ill and it is important to make sure there are enough medications for volunteers as well as patients. For example, volunteers should bring filled prescriptions of antibiotics, such as Ciprofloxacin. Other medications, such as HIV prophylaxis, should be brought to treat needle-stick injuries. Local facilities may not have these types of emergency medications readily available to volunteers.
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What type of documentation do I need?
A passport is required for entry into many countries and it is strongly recommended that volunteers have a passport for all countries. Volunteers may also want to determine whether a visa is necessary for entry to a foreign country. Volunteers should review the entry and exit requirements on the U.S. Department of State country specific information webpage to make sure that have the most up-to-date information regarding visa and password requirements. CRNA volunteers need a valid and current U.S. registered nursing license, the appropriate advanced practitioner credential if issued in the state of licensure, and evidence of certification or recertification as a CRNA. The destination country may or may not ask you for this information; however, it is prudent to have a copy of all your credentials should you be asked to present them by local authorities.
Volunteers should work closely with their agency to ensure that they have all required documentation in advance of their mission trip. The agency may, at a minimum, require copies of your nursing license and passport. Copies of all documents, including your passport, should be made and kept in a safe location separate from the original documents.
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Are there insurance considerations I should be aware of?
Volunteers should check their medical insurance coverage and determine whether their coverage applies when traveling abroad. Volunteers should check whether their insurance covers emergency situations such as medical evacuations, and determine whether their insurance will provide coverage for transport back to the United States or only to a comparable local hospital. Medical insurance benefits and coverage vary by provider. If volunteers do not feel they will be adequately insured while abroad, they may want to consider purchasing supplemental insurance. Additional information about travel insurance can be accessed through the U.S. Travel Insurance Association.
It may be prudent for CRNAs to verify their malpractice insurance benefits and coverage. Malpractice insurance benefits and coverage vary by provider. For example, insurance purchased through AANA Insurance Services automatically provides worldwide coverage; however, in order to activate the policy, the claim must be filed in the United States. Currently there are no insurance companies that are licensed and authorized to do business in every country. Additionally, insurance regulations among countries vary greatly. Volunteers are encouraged to work directly with their sponsoring agency to identify the need and options for malpractice insurance.
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Are there specific personal items I should take with me?
It is beneficial to pack in a portable manner, such as a duffle bag, backpack, or carry-on. Pack portable sizes of basic personal toiletries, insect repellant, sunscreen, and hand sanitizer as appropriate. Additionally, ensure that the personal apparel, work clothing, and footwear you pack are appropriate to the climate and culture where you will be traveling. Volunteers should work with their sponsoring agency to determine whether there will be opportunities to launder clothing. Otherwise, pack sufficient quantities of work and personal clothing to last the entire duration of your trip.
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How do I ensure my personal safety abroad?
Volunteers should also take into consideration the political stability of the country. It is important for volunteers to register with the U.S. Department of State before embarking on their trip. If a crisis, such as a natural disaster or government failure, were to occur while you are abroad, the State Department will take various actions to ensure your safety, but they first need to know you are there. The State Department’s website provides information regarding their response efforts during an emergency or crisis. Country specific information, travel warnings and travel alerts are regularly updated and accessible through the State Department’s website. The State Department offers valuable travel information and emergency contact phone numbers and procedures. Additionally, it is recommended that volunteers know where the local U.S. Embassy is located in the destination country.
While traveling, it is important to maintain contact with family and colleagues in the United States. If at least one individual in the traveling party has a cell phone with an international plan it will be much easier to stay in communication with key contacts back home. Volunteers should ensure that they have a means of contacting each other should some volunteers decide to take an excursion away from the primary facility or lodging location. Volunteers should determine whether their sponsoring agency has a curfew, travel restrictions for volunteers, or if any areas of the country are off-limits or unsafe for volunteers after dark.
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What concerns should I have about food and water while abroad?
Volunteers should also be aware of nutritional considerations when traveling. The CDC’s Safe Food and Water webpage is a good resource for information regarding the consumption of food and water while abroad. Food handling practices may also vary in different countries. Volunteers should remember to avoid ice cubes and raw vegetables when advised not to drink water in a country. Only fruits which can be peeled should be consumed in these situations. If food safety is in question, volunteers should consider bringing prepackaged snacks or meals ready to eat (MREs).
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What do I need to know if volunteering in response to a disaster?
As indicated previously, volunteers are strongly encouraged to register with the U.S. Department of State and be aware of travel warnings and advisories. In times of emergency or natural disasters, volunteers must realize that supplies, medical equipment, and medications may be limited.
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How do I transport medications and controlled substances out of the U.S.?
It is recommended to call the local airport Transportation Security Administration (TSA) at least one day before your departure and inform them of where you are going and exactly what you intend on bringing with you. Obtain from your sponsoring agency or from the chief of pharmacy at the facility where you received the medications for the trip a letter describing the mission purpose and what you are bringing. This letter should be provided to the TSA or any customs officials. Medications should be marked with a prescription or medication label and carried in their original containers. The TSA may inspect the medications you are bringing. Additionally, it is preferred to describe what you are bringing as "medications" rather than "drugs."
A greater concern exists once volunteers arrive in their destination country. Anesthesia professionals should be aware that medications you are traveling with may be lucrative on the black market and may be at risk for confiscation upon entry into the country.
Volunteers may be wary about shipping medications prior to their arrival. It is uncertain what type of transport and storage conditions packages may be exposed to. Black market concerns exist when shipping medications as well.
A possible source of medications may be a donation from a local U.S.-based hospital pharmacy. Typically, expired medications are not allowed to be transported and used. Medications may also be purchased in the destination country. It has been noted that some medications in short supply in the United States have been readily available abroad. It is recommended to work with the sponsoring agency to determine the amounts and types of medications required.
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What type of anesthesia equipment will be available?
Volunteers need to be aware that they may not encounter state of the art anesthesia equipment; regardless, every effort should be made to provide anesthesia at the same standard of care as practiced in the United States. The amount and types of equipment available may be limited. Volunteers should work with their sponsoring agency to understand the working conditions and determine what type of equipment will be available. Anesthesia equipment, which CRNAs are used to being readily available in the states, may not be as easily accessible at the mission facility. CRNAs should determine what types of equipment they need to be able to provide anesthesia services in remote locations. When considering what equipment is necessary, anesthesia professionals should keep in mind easily overlooked equipment and supplies such as tape, EKG pads, oxygen tank adapters, alcohol swabs, oral airways, and back-up light sources. As examples, and if not already provided by the agency, CRNAs should come prepared with anesthesia equipment such as portable pulse oximeters, various sizes of endotracheal tubes, and safety equipment (e.g., masks, gloves). Volunteers will very likely be using tank oxygen and need to be well equipped to readily make any necessary calculations to deliver safe anesthesia care. It would be beneficial for volunteers to bring a calculator and a reference sheet of formulas. It is important for volunteers to ensure that they know where various emergency equipment, drugs, and supplies (e.g., Dantrolene, crash set, airway equipment) are located at the mission facility prior to beginning any procedures.
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What types of procedures can I perform?
Mission work is not to be used as a training ground for procedures you are not familiar with. To safeguard patients, CRNAs, student registered nurse anesthetists, and other healthcare providers should not be doing procedures abroad that they are not qualified to do in the United States. Additionally, you should strive to deliver a similar standard of care as that found in the United States.
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What should I be aware of when administering anesthesia in a new population?
CRNAs must take into consideration the cultural differences that exist in the population they are serving. For instance, based on genetic variation and previous exposure (or lack of exposure) to certain medications, a patient in one country may metabolize an anesthetic medication differently than a patient in another country. Lifestyle differences should also be considered. For example, one experience described by a CRNA mission volunteer was that the country’s inhabitants lived in huts with a continuous fire used for cooking. In this situation, those living in such huts suffered from reactive airway disease, which the CRNA volunteer needed to adjust for in the administration of the anesthetic.
If traveling to a country where English is not the predominant language, a language barrier may prevent patients from understanding the potential risks of anesthesia. Often times, when a language barrier exists, identification of patients’ NPO status can be particularly challenging for volunteers. It is important for CRNAs to work with a translator or carry a translation dictionary, and if possible to learn key phrases in the native language prior to embarking on the trip. You should recognize that the services you are providing are highly needed and valued. It is important to remain respectful of the language, traditions, and culture of the population being served.
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Can I participate as a student?
Volunteering on a mission trip can be an invaluable experience for student registered nurse anesthetists. Students should be aware that their clinical time on the mission trip cannot count toward their graduation requirements because they will not be at a COA accredited site. Once at the destination country, students should work with their faculty member in attendance to identify which procedures are appropriate for them to perform.
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Where can I find more information?
It is imperative that volunteers do preliminary research about the country they are visiting, precautions that need to be taken, cultural differences of the population being served, and safety and security while abroad. The WHO country webpage contains information on various health-related statistics such as mortality, disease burden, immunizations, outbreaks, and nutrition as well as additional country specific data. The State Department website also provides country specific information such as embassy locations and notices, emergency contact information, security considerations, and additional information about the country’s infrastructure.
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