Kafka in the Hospital

This is a long, rather bizarre post, but after editing it down to the essentials, I (Karen) decided to not condense it any further.  It’s one example where, in my opinion, details work far better than a summary.

Although we’re in New Zealand now, this story takes place in Tonga, an island Kingdom in the South Pacific.

It starts in Vava’u, and moves to the city of Nuku Alofa on the island of Tongatapu.

While I think that most doctors in poorer countries are overworked and under-supplied, and that there are some real heroes practicing medicine in remote places under difficult circumstances, there is no excuse for the deception I experienced in the hospital in Tonga.

It’s hard to think of a positive way to describe my Kafka-esque hospital stay for 2 ½ days in early October 2012, for examination and treatment of worrisome heart symptoms.  I promised to write about this in hopes that such frustration and fright are never repeated.  Because it was so stressful and strange, I wanted to remember the sequence of events as they happened, so I made a few surreptitious notes on my iPod (and took a couple of photos) when I felt well enough; that and a good memory helped to reconstruct the timeline.

I did not want to post anything on our blog about this while Jim and our other cruising friends were still in Tonga.  The chances of Tongan officials reading our blog are slim, but because my remarks are rather critical of the heath care I received, and because my doctor was also the King’s physician, and because his apparent refusal to take my case seriously was part of the problem, waiting seemed wiser.  Tonga, a constitutional monarchy, was named the sixth most corrupt country in the world in 2008 (Forbes magazine; more favorable rankings in in other surveys) and the 165th (out of 180) safest investment destination in the world in 2011 (Euromoney Country Risk Rankings.)

Let me make one qualification, though:  Individual Tongans, including most medical staff, were among the kindest and politest people we’ve met anywhere.

The short version:  Had this been a more serious condition, like a heart attack, I doubt that I would have survived.  Bottom line is, don’t get sick in Tonga, and if you do, get on a plane for New Zealand without delay.  Hire a medical flight escort if you have to, as this allows you to bring oxygen.  Do not use the Tongan hospital system.   I can’t speak for the health care quality of other countries except New Zealand, which is superb.

The long version:  It began last September while anchored in Vava’u’s Neiafu harbor, with heart palpitations that progressed despite resting for several days, to a forceful and irregular heartbeat which continued to grow worse.

Neiafu Harbor, Vava’u Group, Tonga.  Photo credit:  JSA_NZ

After consulting with our friend Pat Gans, a retired MD on another cruising boat called The Rose, we accepted her offer of help.  She called the Divers Alert Network (DAN,) a medical evacuation insurance organization originally formed for divers who experience barotrauma, but now also widely used by cruising sailors.  We’ve all heard that DAN does a good job on dive accidents, and since their literature indicates they’ll medevac you even on a non-dive issue if needed, they doubtless get a lot of non-diver business.

Jim and I had purchased DAN’s medical evacuation (medevac) insurance before leaving Mexico, assuming that DAN would live up to the claims on their web site that promise to get you out of a bad medical situation in a remote place. They didn't.

Ironically, Dr. Pat and her husband John were to have their own medical nightmare a few weeks later, when John stepped off a large boat onto a slippery concrete dock in the capital city of Nuku Alofa and spiral-fractured his ankle.  Surgery was needed, but Tonga’s main hospital, the same one I had gone to, was out of oxygen.  The entire medication given for his pain at the emergency room was one ibuprofen, and there were no crutches available.  DAN refused to medevac John, who eventually got on a commercial flight at his own expense.

No internet, no phones:  Because we had so little access to internet or phones in Vava’u, we had to taxi to the airport and hope there was room on the short commercial flight to Nuku Alofa, where I would be seen by a Tongan doctor that DAN assured us was a cardiologist.  DAN also told us they would pay both of our airfares.

This was to be my only view of the lovely Ha’apai Group of islands.  

The idea was to diagnose and if necessary, stabilize me so DAN could decide whether I needed an air ambulance or a medical escort for the flight to New Zealand.  It made sense.  DAN told me on the phone that they would pay for my flight to New Zealand but not Jim's.  They later reneged on all reimbursement.  DAN told us that they had called the hospital’s emergency room supervisor to alert the ER of our arrival.  While we were pleased with DAN at this point, things mostly went downhill from there.

First, a description of the hospital.  Compared to the 1950s-era hospital at Vava’u, initial impressions of Tonga’s brand-new Vaiola hospital in Nuku Alofa are good; it appears to be clean, bright, and well maintained.  Recent Japanese funding allowed the building and 2012 opening of this facility and an onsite nurse training school.  The staff are extremely friendly and as helpful as they are allowed to be.  But the disconnect comes when you realize the organization is so top-down that no decisions can be made in the absence of The Consultant, the man in charge who happens to be at the beck and call of the King and the entire, very large, very wealthy, Tongan Royal Family.  Because he was not available, we repeatedly met the argument, “I cannot exceed my authority,” even for simple, logical, reasonable requests.  Nurses were allowed to check vital signs and wheel you to the bathroom, but little else.

Tongatapu’s brand-new Vaiola Hospital

Day 1, 9:30 am, the emergency room:  The staff had no idea we were coming, and did not recognize the name of the person we mentioned as the supervisor DAN had talked to.  (36 hours later she stopped by my room and acknowledged getting DAN’s call, but offered no explanation as to why she had not alerted her staff.)  The only medical staff in the ER were 2 student nurses and a paramedic.  No doctors were in sight.  The paramedic asked, “Do you have angina?” which I couldn’t answer accurately because it amounts to asking a patient to self-diagnose.  I told her I was having some chest pain and headache.  She said, “This will help your angina,” and gave me an under-the-tongue spray of “something that works like Nitro,” then told me to chew an aspirin.  The ER’s only heart monitor was hooked up to an elderly man coughing noisily in the next bed, who seemed to have died after about an hour.  They then unhooked him, wheeled him out, and hooked me up.  The doctor will be here soon, they said.  There was no IV in evidence anywhere, and nothing to drink was ever offered, so by the next day I was dehydrated.

Noon:  Still waiting in the ER.  A woman doctor stopped by to say the hospital was admitting me, but she refused to examine me because she “was not authorized.”  She said that my doctor, whom she and everyone else reverently called “The Consultant,” was at lunch and would see me as soon as he was finished.  She also said that he was the King’s physician, and was very busy.

1:00 pm: admitted to the medical ward:  The Consultant must have taken a long lunch.  The nurses hooked me up to oxygen in my private room.

2:00 pm:  A nurse said the doctor would be there in late afternoon.  Jim went out to try and find a phone and an internet connection, because we knew DAN was trying to reach us.  He was befriended by a sympathetic group of taxi drivers, one of whom sold Jim his own cellphone for about $50.

2:30 pm:  The DAN team had been calling the hospital repeatedly, trying to talk to a doctor, any doctor, but the staff refused to talk to them.  A nurse came into my room and said, “Someone from Malaysia has been trying to reach the doctor about you, but he is far too busy to return the calls!”  She seemed quite amused by this.  “Malaysia?”  I asked.  “Yes, she said, “Do you know anyone in Malaysia?”   “No,” I said, “But I know my evacuation insurance team is trying to call him.”  She left chuckling.

3:00 pm:  The female doctor came in, saying the Consultant would see me before he went home at 4:30.  She still refused to examine or interview me, but admitted when asked, “I’ve looked at your medical chart.  There is no way you can fly without oxygen.  You will need a medical escort at the very least.”  Jim held up his new cellphone and said, “Please, could you just tell that to the DAN team?  I can call them right now, it won’t take a minute.”

She was not expecting this, and held up her hand to stop him. “No, I cannot exceed the Consultant’s authority.  He is the one who must talk to them, not me.”

“But he’s not around!” I said in exasperation.  The female doctor left.

3:30 pm: The nurse returned and said, “Someone from Malaysia wants to talk to you,” and disconnected the oxygen and wheeled me out to the nurse’s desk.  (There are no phones in any rooms.)  A concerned female voice identified herself as an employee of an agency that is part of the DAN medical team, and asked me what my treatment had been so far.  When I told her I’d had one aspirin, hadn’t been examined by a doctor yet, and was feeling worse than when I’d arrived, she was incredulous.  She said that DAN had been calling all day but no doctor would return their calls.  She asked, “What do you want to have happen in the next 24 hours?”  I whispered, “I can’t talk openly because it’s not private.  Please understand the emphasis implied when I beg you to get me out of here as soon as possible.”  She said, “Understood.”

4:00 pm:  A student nurse hooked me up to an in-room heart monitor, but couldn’t get it to work.  She seemed too embarrassed to ask for help, and backed out of the room saying, “Sorry, it doesn’t work,” leaving me hooked up anyway.  It never did work properly.

4:30 pm:  The Consultant has not come.

5:30 pm:  I asked a nurse when the doctor was coming.  She said he’d gone home for the day.  “He will see you in the morning, on his rounds,” she said.  Whenever I questioned why the doctor didn’t show, the answer was always explained thus: “He is the King’s physician.  When the King calls, he must go.  The King takes priority over everyone else.”  Despite the huge economic divide between wealth and poverty in Tonga, there was no irony on the face of anyone who repeated this mantra, not even the only other doctor there.  It is very unpopular in Tonga to criticize the monarchy, despite the Royal Family becoming larger and wealthier every year.

Unfortunately, I believed the nurses each time they said the doctor would be coming soon, because nurses are credible people, right?  Not in Tonga.  They’re nice as can be, but they will tell you what you want to hear.  It amounted to being lied to continually, and it added immensely to the stress.

Ironically, my room was labeled “High Dependency,” which a nurse proudly told me meant “intensive care.”  There’s a buzzer on the bed, but calls are answered in about half an hour.   My room was about 40 feet from the nurse’s station.  I wanted to ask “What am I doing in Intensive Care if I’m not sick enough for the doctor to examine me?”  To be honest, I was feeling worse by the hour; the heart felt as if it was galloping out of control and the ectopics (missed beats) were increasing to every two or three heartbeats.

Visiting hours 24/7:  In the evening, many visitors arrived and turned the lobby into a party room.  The nurse’s station gave Jim a narrow sleeping mat and a sheet.

Relatives are allowed to sleep in patients’ rooms, and they contribute greatly to patient care. This is common in many poorer countries.  So is the fact, unknown to us upon arrival, that patients must bring their own soap, towel, blanket, eating utensils, and a cup to drink from, or you’ll get nothing to drink and will have to eat with your hands.  This I refused to do, and my dinner got cold.  Finally I was able to eat my dinner with a tongue depressor that I’d asked a nurse to filch from a medicine cabinet.

A tongue depressor is slow but better than eating with dirty hands.

Luckily, I had a water bottle, and Jim filled it from the sink in my room.  But I wasn’t getting enough fluids.  The reason I refused to eat with my hands was that there was no soap to be found anywhere in the hospital, even in the bathrooms.  Who knew what germs were on my hands.  The bathrooms were disgusting; two for the entire floor, unisex, and you had to step over puddles of urine to reach the toilet.  The shower was gross and moldy, and the room reeked of old urine.  What I wouldn’t have given for a bottle of hand sanitizer.

The menu:
Breakfast:  2 or 3 white-bread butter sandwiches.  Lunch:  Cold fried eggs and a butter sandwich.  Dinner:  2 butter sandwiches and a hard-boiled egg.  Wow, wow, wow, I thought, is this some cardiac event-inducing diet, or what.

Breakfast: Butter sandwiches

On the second day a nurse felt sorry for me and asked if I wanted the Tongan diet instead of the one they gave to non-Tongans.  Yes, I said eagerly.  Things improved after that with lots of fried meat and taro, though breakfast was still 2 inedible butter sandwiches.  But they gave me silverware!

The Tongan diet was a big improvement, and taro is delicious.

Day 2, 4:00 am:  Still no doctor, and no nurse has made rounds since 8pm last night.  Jim saw the nurses playing computer games at their station.  I awoke at 4:00 feeling truly awful, and asked Jim to get a nurse, which he did.  Half an hour later she arrived.  Dehydrated and with a ragged weak pulse, I tearfully begged her to call the doctor.   “Please, please,” I said to her, “just call him.  I feel terrible.”  She took my pulse and said, “It’s weak.”  Then she took my blood pressure, and told me what it was.  “It’s never been that high,” I said.   She held my hand, looked at me and declared, “You are fine.”  I didn’t know what she meant by this, and could not stop crying.  I said, “I’m afraid.”  She said, “You have to wait ‘til morning.”  Jim pleaded with her to call the doctor.  Finally she reluctantly agreed to call him, but warned us that he was probably asleep and would not like it.  Another half hour later, she returned saying she’d called him.

5:00 am:  The Consultant had evidently told the nurse to take another EKG, because an attendant showed up after yet another half hour, with a machine that did not work.  He left; more time passed and the attendant came back with the EKG machine from the ER.   His eyes grew wide when he saw the printout of my heartbeat.  “This is very abnormal,” he said.  “Get the nurse, please.” I whispered.  He didn’t.

6:00 am:  Still feeling awful, I asked Jim to go get the nurse, who arrived half an hour later and told us that the doctor was not coming.   However, he would see me on his rounds in the morning at 9:00.  “What time will he be here?” asked Jim.  “He arrives at his office at eight,” she said.  “When will he see us?” pressed Jim.  “You have to make an appointment,” she replied.  “Can I make an appointment at the nurse’s station?” asked Jim.  “No,” she said, “You have to make an appointment with the Consultant.”  “If we don’t have an appointment, will he see us?” asked Jim.  “No,” she said, “You have to have an appointment.”

I could not believe it and was too weak to protest.  I said to Jim, “I don’t know what’s wrong, but I’ve never felt so bad.  I honestly don’t know if I’m going to make it out of here alive,” and went inward to prepare.  Jim got a message to DAN to call the hospital at eight, and told them to insist on speaking to the doctor.  Then he camped out in front of his office.

8:00 am:  I’m drifting in and out of sleep and feeling crummy.  We later learned that DAN called at exactly 8:00 am and spoke to the Consultant, who had still not seen me but updated them on my condition.  We don't know what he told DAN.

9:00 am:  Jim practically barged into the Consultant’s office.  He asked him to please come see me, but the Consultant said, “I don’t need to.”  This begs the question of why the nurses continually promised his visit to be imminent when in reality he never had any intention of seeing me.  Jim politely suggested that he look at the latest EKG, but the Consultant balked, saying he had all the information he needed to make a diagnosis, which amounted to the EKG taken several days prior at Vava'u, and an EKG from the emergency room.  No blood test, no stress test, no history, no examination, no echocardiogram.  He didn't have the X-ray they'd taken, either.

Besides, he said, the in-room heart monitor meant he didn’t need to see the latest EKG, because he could get everything off that if he wanted.  “But that monitor hasn’t worked all night!” said Jim, who again politely pleaded for the Consultant to look at the latest EKG, which he said was very different from the one of a couple days ago.  Reluctantly, the Consultant did look at it, and, surprised by the way it looked, told Jim he’d be by to see me.

10:00 am:  The Consultant showed up with a full retinue of about 8 reverentially silent people:  two interns, a couple of student nurses, and some others hovering at the doorway.  It’s showtime.  He has a portable echocardiogram machine.  He takes my vital signs and asks me how I feel.  Then it’s time for my shirt to go up again for the echocardiogram.  There is no curtain on my window, and two men painting a railing outside plus any passersby have had a full view of me since I arrived.  Two student nurses hold a sheet up across the window, not to block the view from outside but to shade the screen so The Consultant can see it.  They are texting on their cellphones and looking amused the entire time the bare-breasted procedure is being done.

The Consultant interprets the echocardiogram, examining my heart, and pronounces it strong and undamaged.  I hope with all my might that he is correct, because wild horses won’t stop me from getting out of Tonga.

Then someone hands him an X-ray taken previously, and he looks surprised.  So much for lots of testing and imagery—most of it was ignored by him.  He glances at it for less than two seconds and puts it down.  He turns to Jim and says, “She has no structural abnormalities.  She has Premature Ventricular Complexes at the rate of 18 ectopics per minute.”  He addresses no remarks to me, as if I’m stupid or not there at all, but tells Jim the results.  He says I can fly commercial, and that he will prescribe a beta blocker that will relieve my symptoms.  Although I asked about drug interactions for the medication, he would not give any information except that my feet may get cold because the beta-blocker squeezes peripheral blood vessels a bit.  He then invited us to “hitch a ride on a medical flight tomorrow.”  We asked him for more information about it, but he brushed us off, saying, “Ask the nurses.”  None of them knew anything about it.

11:30 am:  The nurse delivered my first dose of medication, half of a 50-mg pill, to be taken once a day.  My symptoms began to subside almost immediately.  It is now 26 hours since we arrived at this hospital.

12:00 noon:  One of the 2 interns came in to draw blood.  I asked her, “What’s the point?  The doctor has made his diagnosis already.”  She said, “We need a baseline and a ____” (I can’t remember) and held up two vials.  She said the baseline could be ready today but the other might take a couple of days.  I repeated, “But what’s the point?  Why do you want this now?  Aren’t the results going to come too late for the doctor’s report?”

She frowned and said angrily, “Do you just not want me to stick you?  Are you refusing this?”  I said, “It’s not that, though I don’t like needles.  I just don’t see the point.”  In a softer tone she said, “I can mark these ‘urgent’ and they’ll be ready soon.  Please just let me get a baseline, okay?”  Okay, I said, but she proceeded to fill both vials anyway.  Later the doctor’s report said that all blood levels were normal, but it turned out they weren’t.  A duplicate blood test in New Zealand showed cholesterol to be more than twice the normal level.  How did The Consultant miss that, unless he didn’t bother to have the blood sample tested, perhaps throwing it away and making up the results so he could pad the bill?

I asked the intern about the medical flight.  “Oh, that flight’s today,” she said.  I was shocked.  “But you were in the room when the doctor said it would be tomorrow!” I said.  “Well,” she replied,  “It might be today and it might be tomorrow, the time hasn’t been set yet.”  I asked her to find out for me; she said she would, but of course, she never did.

Around 2:00 pm:  To our surprise, The Consultant stopped by.  He said he wanted to keep me in hospital for one more night, to be released in the morning.  I asked if we could take all of my medical records with us, including the X-Ray, all 5 or 6 of the EKGs (which show the progression) and the blood test specifics.  I named each record I wanted.  He said, “Yes, everything will be in the record, and I will write up a report to be ready when you are discharged.”  He promised to discharge me first thing the next morning.

Day 3, 6:00 am:  I am awakened out of a sound sleep by the smiling orderly, who gives me a pill.  A whole one.  Too sleepy to realize what’s happening, I swallow it.  I have just taken twice the prescribed dose.  Jim goes to tell the nurses station, but they brush it off as unimportant.

8:00 am:  The nurse said The Consultant will see us on his morning rounds, and will give us the report then, too.  Meanwhile DAN called again, and spoke to the Consultant, who provided them with this diagnosis:  “She’s fine and needs no further treatment." DAN then called off all medevac help and all reimbursement, even what had previously been promised.  It added immeasurably to our stress.

10:00 am:  The Consultant has not shown up.  The two interns came in, accompanied by two nurses.  They tell us the doctor is out doing clinics with the poor, whom Jim had seen lined up in droves in the hallway near the ER.  The interns said The Consultant will not be able to see us until this afternoon, so do I have any questions?  Yes, I do.  I asked about drug interactions with my medication, a beta-blocker; specifically, is it unsafe to take aspirin, ibuprofen or acetominaphen in the event I get a big headache, and in the event I get chest pain on the airplane, is it safe to take a Nitro in case the plane crew offers them?

The male intern, who is rather imperious, said, “We can’t answer that question, you’ll have to ask the doctor.”  I said, “Why can’t you tell me that?  I don’t want to have problems, and the doctor’s not available.”  But he stolidly refused to tell me.  Any other questions, they asked.  Yes, I said, but they couldn't answer those either.  Talk to the Consultant, they said.

An exhausted Jim coping with the stress

11:00 am:  A nurse came in, said The Consultant will not be able to see me but I will get discharged this afternoon, and he would bring the report before I was to be discharged.

3:00 pm:  The Consultant has not come.  Jim walked to his office and waited to speak to him.  The Consultant told Jim he would not have the report ready, and that we must pick it up tomorrow morning.  Jim came back to tell me this, and I nearly burst into tears.  Coming back here was the last thing I wanted.  I got up out of bed and with Jim, walked to the nurses station.  This surprised the nurses  because I’m supposed to do nothing without permission and a wheelchair.

The female intern was filling out paperwork.  I told her I never got the answers to my questions, could she possibly help?  At first she said, “Nitro is okay to take with your medication,” (I later learn it is a dangerous combination) then she said, “Wait, let me call our pharmacy.”  She called again and again, but they didn’t answer.  “They are impossible to get on the phone!” she laughed, then added, “Well, perhaps you can Google it.”


3:15 pm:  Jim and I camped out in front of The Consultant’s office.  When the person who’s in there with him came out, Jim knocked once, heard a mumble, and walked in.  I followed.  The Consultant did not look pleased to see us, but he answered my questions.  His office is air conditioned, but the rest of the hospital is steamy-hot.   I said, “Doctor, we have a morning flight and we must come back here to pick up the records on the way to the airport.  I know you’re very busy, and I mean no offense by this, but it is causing me great stress to have to come back.  If you could please have the records ready for us on time, at 8:00, I would be grateful.”  He looked a bit pained, and promised to have them ready.

It took all of my will power to remain obsequious and not tell him how awful his so-called “care” has been.

4:00 PM:  Jim and I walked out the hospital’s door, just as a nurse ran up with the enclosure sheet from a box of medication.   We got in a taxi and checked into a hotel in Nuku Alofa.  This hospital stay has cost us 810 Tongan pa’anga, which is equivalent to about $500 US, and they insisted on cash, to be paid several hours before they would release me.  The stated reason is that some foreigners have left and not paid their bill, which provided us with the only amusing moment of the day.

Day 4, 8:00 am:  Our airport-bound taxi stopped at the hospital, and to our huge relief, the records were ready.  The Consultant was actually there to give them to us.  Unfortunately, the records were thin, and included only his report and one photocopy of the last EKG, but no X-Ray, no earlier 5 EKGs, no blood test specifics, no echocardiogram, nothing.  “We can’t release X-Rays,” he informed us, after having promised the day before to release everything.  I told him I still felt a little chest pain and was worried about the flight, and he said, “What you have isn’t angina, it’s something else.”  His demeanor implied that questions would not be welcome.  We thanked him and left.

Afternoon:  I managed the 3-hour flight to New Zealand just fine, but experienced shortness of breath and palpitations while trying to walk between the gate and Customs.  It frightened me.  Jim got a wheelchair.

My appointment at the Auckland Heart Center was scheduled quickly and went well; All the tests had to be repeated, and a Holter monitor 24-hour test was added.  I was reassured and felt much better after seeing the palpitations go down and then disappear during the stress test.  The cardiologist, a real one this time, corrected my medication to a longer-acting form.

The reassurance a competent doctor can provide is part and parcel of the medical treatment; in my opinion, it’s almost as important as medication.   Without it, unnecessary dread and anxiety, combined with neglected escalating symptoms, combined with a broken, command-and-control medical system that makes no bones about the relative worth of human lives, made conditions in Tonga far more than a little worse.

The provision on DAN’s attractive web page that interests most sailors is this:  “Emergency Evacuation (insurance):  Covers evacuation and transportation as directed by a physician to the nearest adequate medical facility (or home if medically required). Includes medical escort if advised by attending Physician.”

I wish it was that simple, but it’s not.  While we received valuable travel arrangements and some telephone assistance from DAN, and while we have not seen a penny in reimbursement despite promises to the contrary, my major beef  with them is being under the illusion that they would get me out of there.  It was their idea to go to this hospital, not ours.  We wasted valuable time.  Had we been on our own, we would have gone immediately to New Zealand with our own hired medical escort, and saved ourselves a traumatic and upsetting experience.  They didn’t know about the bizarre hospital treatment at the outset, but did after I wrote them a long letter explaining all of it.  In reply, they sent a form letter denying all reimbursement.  So much for truth in advertising.

In no way do I mean to be critical of the efforts Tonga has made to improve their health care system, except for the constant promises in response to requests that are not unreasonable, and the equally constant breaking of those promises.  That more than almost anything else increases stress and does not contribute to patient health.

After several months in New Zealand under the care of a cardiologist at the renowned Auckland Heart Center, I’m feeling better.  Exercise is part of the prescription, and that’s a joy.  We are staying in a rental flat, the same one I had before, and enjoying some land time.  What comes next on this excellent adventure will be decided later.  For now it’s enough to be here, together, and relaxing.