Hospital care in Kandy, Sri Lanka

You may, or may not, have noticed a pause in my rate of posting. Those of you who do not know me very well may have imagined that, perhaps, I was busy getting some useful work done. Those of you who know me better may have imagined that I had completely exhausted all the words I could ever have written in a lifetime, spewn out in the short time since we left Ohio. But the boring truth is that I have been as sick as a dog.

Tuesday, I did not feel well and went home early. Kris bought me a thermometer to confirm what my forehead was telling me: I had a bit of a fever. Wednesday, I had a class to teach, the first class of the semester, and did not feel too bad. So, instead of walking to work, I conserved my energy by arranging for a tuk-tuk to deliver me to campus shortly before class and to return me home not long after class. Class went OK, but soon after I got home, I began a sharp decline. My fever hit 39C (102F) and then my gut started producing only a distinctly Dickensian watery gruel apparently requiring for its production extensive, internal, painful laboring. My head hurt. My symptoms took turns keeping me awake that night: rush to the bathroom, back to bed, can’t get to sleep due to a throbbing headache, finally doze off, wake to feeling of knives in stomach, take some Tylenol, start to doze as pain dulls, rush to bathroom,… Lather, rinse, repeat.

By Thursday morning, I was exhausted, feverish, and with no desire to add to the feedstock for the gruel factory. So I told Kris that I was ready to go to the hospital. The Fulbright pre-departure orientation program had provided us with a list of hospitals in Sri Lanka that were the most up-to-date and with English-speaking doctors. In Kandy, the recommended hospital was Lakeside Adventist Hospital. We had passed it several times before. It is situated right on Kandy’s central lake, close to one of Kandy’s nicest, older hotels, the Hotel Suisse. We had been pleased about the recommendation for a kind of karmic connection in that Kris’ sister, Heidi, had been a nurse at a Seventh-Day Adventist Hospital in Paradise, CA for many years and, to this day, works for a pediatrician who was an Adventist missionary doctor.

Now this was clearly not an emergency, so while I suffered hellish torment, Kris called the hospital to make sure they could receive us. They could, but we were told to “come before noon.” Not a problem, in my book, attempting unsuccessfully to dodge yet another spear thrust from the little devils inside. But we could not leave right away as every tuk-tuk driver worth his salt in Sri Lanka was busy taking children to school and the ones not worth their salt could not have made headway on the clogged roads. So Kris made an appointment with our favorite tuk-tuk driver to come at 8:30AM, which allowed her time to have breakfast.

Off we go at the appointed hour. Let me tell you than when your stomach hurts, tuk-tuks are not the luxury traveler’s first choice. The little devils rested on their spears and let the many rough patches of roads do the torturing. Finally, we arrive at the hospital. The tuk-tuk driver stays with me, carrying my backpack with an overnight kit, while Kris approaches the desk. We are moved immediately from the entrance lobby to rather comfortable seating outside a pair of exam rooms. The doctor calls us in (not including the tuk-tuk driver, who waits outside) and listens to me describe my symptoms. It is all shaping up to be stomach flu. “We just want to do a couple of tests to be sure. We will need a blood sample and a stool sample.”

This was good timing as I was very ready at that very moment to provide a stool sample. We go to the lab for the appropriate accoutrement and the toilet is pointed out to us. There is a a bit of shuffling back and forth on the balls of my feet as the three of us (the tuk-tuk driver is back with us) wait for a bathroom to become free. And then it becomes free…

Now in comment number 3 of my “Arranged marriages” post, I promised to post more about the different toilet facilities and habits between East and West in some indefinite future. And I have been doing some theoretical research to prepare that posting. Good thing. Because here was the final exam. Squat toilet? Check! No toilet paper? Check! Student wearing western clothing? Check! Student operating under strict time limit? Check! Standing in that open doorway my life flashed before my eyes. My mind was completely distracted from my pain. The only thing that got me into that toilet and the door closed behind me was my quick evaluation that the worst outcome of attempting to use the toilet was essentially equivalent to the outcome of not using the toilet.

Fortunately, my Examiner was a fair one. Sturdy hand rail? Check! Previous occupant left room clean, even if wet? Check! Plastic bucket in room? Check! Plastic pitcher in room? Check! Working water faucet at test taker’s disposal? Check! But, wink, wink, we mounted the faucet at a 45 degree angle from straight down.

OK. Concentrate now. By the numbers. Put bucket under faucet. Turn on faucet. Water shoots off to left, missing bucket, adding to wetness on the floor. Turn off faucet. Estimate trajectory of water and adjust bucket accordingly. Turn faucet back on. Bucket begins to fill, but more slowly than expected. Examiner announces “You only have a limited time before you will proceed to the next phase of this test.” Right. How full does the bucket have to be? This is the problem with not doing the practicals. Well, I could add more later, if needed, right? What would be the harm?

OK, proceed to step two. Fill plastic pitcher from faucet. Place within easy reach. Open stool sample container and place within easy reach. Stand on the raised footprints on toilet, the ones that resemble those footprints used to teach dance steps and have the same purpose, to make sure the dancer has his feet in the right spot relative to his partner and is facing in the right direction. Basically roll trousers and pants down from waist keeping trouser legs from sagging onto wet floor. Squat slowly while doing so. Once the trousers have been neatly rolled together with the pants, grasp firmly in one hand as if both your feet had been cut off and you were applying a tourniquet to both ankles simultaneously.

Half way home. Collect sample of gruel. Set aside. Finish evacuation procedure. Splash water from pitcher to cleanse backsides. Pause a moment for air drying. Now begin process of returning to an upright position while unrolling trousers and pants. Fasten belt. Step off the footprints.

Almost there. Put cap on sample. Use pitcher and bucket to “flush” toilet and leave room clean for next visitor. Retrieve sample and exit room to face a crowd thundering with applause at your accomplishment. Well, maybe not that last part, but after surreptitiously checking that the backs of my trouser legs were not stained with telltale brown spots, I was pretty proud of myself. My euphoria lasted about six seconds.

Back to the lab. Lab takes blood sample. We are told that the results will take about an hour. Do we want to go home and come back then? No. The thought of two, twenty minute tuk-tuk rides for twenty minutes of the relative comfort of being home is not a difficult decision. It was the correct decision, too, as five minutes later we are called in to see the doctor again. At Lakeside, they do not wait until all the tests are complete if the lab spots something right away. My platelet count was  90 dodecahedrons per cubic femtometer (or whatever units they use) when normal is between 150 and 400 whatevers. As the doctor is telling Kris that they would like to admit me for observation, I second the motion by vomiting into the doctor’s washing up sink. The die is cast.

The three of us (the tuk-tuk driver is still with us) walk up one flight to my room. It is a nice room with a white-tiled floor, a single hospital bed, a couch for my visitors, a tray table for my meals, and a cabinet. Apparently I am supposed to know my role. I don’t, so the nurse looks at me, then at the bed, then at me, then at the bed. Finally I get it. I am supposed to lie down on the bed. Soemthing seems off, but I don’t pick up on it until later. The hospital is used to train nurses and a small flock arrive, all in white, egret-like in their identical starched uniforms, to measure my tempurature, blood pressure, pulse rate, and blood sugar levels. You can tell how long each of them has been in practical training to be a nurse by how assured they are as they approach me, a grown man and a foreigner at that. They all do fine.

One of them even shows some real “can do” spirit. To get a drop of blood to measure my blood sugar level, there is a specialized device that drives a needle a calibrated distance into my fingertip to release just the right amount of blood, minimizing the pain. (Every diabetic will know exactly what I am talking about.) Well, their device was acting up and after repeated efforts to get it to work, the nurse just grabbed the needle and stuck it into my finger tip up to its hilt. Some day I hope they teach her about the many nerve endings in our fingertips and that there might be better places for such a strategy, but it got the job done.

Then it was time to put in an IV. No student nurse for this operation, except as observers. In my later years, it has become harder and harder for nurses and phlebotomists to get me stuck right the first time. This is a terrible curse. I have had similar deviations from the norm, but this is one of the worst. For example, it was annoying when I was in my twenties and wanted to wear contact lenses so I would not look so dorky. I did not know then that dorkiness is not curable, it is a way of life. So, a few months into my first “real money” job in San Leandro, CA, I visited the optometrist to begin the process. Well, it was the usual hassle. The time overlapped with my courtship of Kris and she has her own tales of these events. I had a heck of a time sticking my finger in my eye every morning, but I gave it a good try. The problem was that at several times during the day, the contact lens would partially break contact with my eyeball leaving me with blurry vision at the most inconvenient times. The optometrist concluded that I had “tight eyelids” and gave me my money back. Tight eyelids?? Who has tight eyelids? I’ve never heard of anyone, even on a daytime TV soap, who was diagnosed with tight eyelids.  (“Marsha, I love you, but my family will never allow me to marry someone so disfigured.” “Your family is so narrow minded, John. What can it matter? Our love will sustain us. Let’s run away together!” “And give up two million bucks? Get real, Marsha.”) But the diagnosis was confirmed some ten years later in Los Alamos when I decided to give the contact lens experiment another try with the advent of the new breathable plastic lenses that could be worn for a week, hence reducing the number of times I would have to stick my finger into my eyeball, a wholly unnatural act. The results were indisputable the day I was seated on the edge of a twelve foot pit, both hands full, working on some very fine wiring on my low temperature physics apparatus and, with one blink, out popped one of my contacts, falling out-of sight into the bottom of the pit.

Tight eyelids I can live with. Now that I’m fifty-five and out of the business of contributing to the gene pool, it is poor consolation that thick, black-rimmed glasses are all the fashion rage. But hard-to-stick-veins are another story. An intermediate level nurse examined my left arm. Eyes already showing worry. She tapped, as if sending a coded signal for my vein to appear. No response. She rubbed an alcohol-soaked swab lengthwise along my wrist. Coaxing it out with the offer of a drink? No response. More tapping. Sonar? In goes the needle and the search begins. And continues. And continues. And then is abandoned. Back to the beginning, with a new quarry. Same result. Mutter, mutter, the flock takes flight. Minutes later, a new face appears. An experienced face. One who has seen all the places the shy veins hide in. She immediately switches to my right arm. Picks out her secret spot, along my ulna, close to the wrist. Needle goes in. A quick search and the deed is done. I have never had such a comfortable IV in my life.

They start a liter of saline to help me rehydrate. But the day is spent pretty miserably. I try to sleep but wake in cold sweats. I’m hot. I have to drag my IV with me to the bathroom. There is a western style toilet, but no toilet paper. No soap. No towels. Kris makes a shopping list.

Decisions are needed. First the nurses come to gather data. How many bowel movements have you had? Watery? Are you in any pain? Yes, but the saline IV seems to have improved things a bit. Then, lower ranked doctors. Two of them, each in succession. Same questions. Then, the Man, himself. My platelet count is still low. They will keep me overnight. Antibiotics intravenously, anti-cramping and anti-emetic drug orally, and a painkiller in the only orifice left over. I thought this latter was a bold move, to give someone with diarrhea a medication by suppository, but he was likely just showing off to the crowd his long experience at judging patients conditions to the smallest detail.

Blissful, blissful, sleep. Kris returned after having her dinner and restocked the room with necessary  supplies. She brings me a choice of my robe or my sarong. It was warm. I choose the sarong, which turns out to be a great hospital garment. But here is where I realize what was wrong when they put in my IV. They put it in while I was wearing my shirt. So to get my shirt off, we have to remove the IV bottle and thread it backward through my sleeve. We gained control of the air conditioning and it was all a smooth ride from there. I slept most of the evening and only awoke five times during the night. I awoke in much better shape the next morning, Friday. Throughout the day, my headaches slowly receded and my cramping lessened. The only symptom that remained obstinate was the gruel thing. Still is a problem actually.

Mostly on Friday, I continued to catch up with my sleep. I also eat very well, especially a lunch prepared especially for me. The only roadblock that appeared was when one of the visits of the flock yanked me almost violently from a deep sleep. At first I was disoriented, then annoyed. It was at that point that the head nurse appeared for, what the evening before had been, the pre-doctor visit to gather information. When she asked me how I was feeling I had to fight back the urge to say “Don’t you read charts? I’m the same as the last time a student nurse asked me that question maybe five minutes ago!” My Irish zen training kicked in, however, and my answer was that she had caught me at a bad time. My stool still resembled that of the geese on the lakeshore outside after a monsoon, my head still hurt, as did my stomach. I think that was when it became clear that I and my discharge, would be discharged that night.

All that was needed was the approval of the Man. Apparently, except for the goose turd- gruel thing, all my vital signs had returned to within normal bounds. We were led to believe that the Man would be by around 6:30 or 7PM. A lessor doctor appears about the same time as the night before. “Seems like you are ready to go home?” “Well, I am doing better, but would feel better staying one more night to see if we can get this diarrhea under control.” “Hmm. We will see what the Man says.”

One of my colleagues is kind enough to insist on on driving out to visit that evening and to drive either Kris or the both of us home depending on what the Man decides. Another blessing. My colleague arrives around 7:30PM. We are a little startled to realize that the doctor has not appeared as we had been assured. We chat together for an hour. During this chat, my colleague explains, in a kind way how, from a Sri Lankan point of view, I have gone about this all wrong and have just cost myself a lot of money. First, a Sri Lankan would never have let the bug get so far. Antibiotics are available over the counter. Sri Lankan homes are as prepared to deal with E. coli, salmonella, and all the stomach virii, as American homes are to deal with colds and flu. Not feeling well? Think back. Oh, yeah, chicken last Thursday night. Out come the antibiotics to kill off the salmonella bacteria.

So my first mistake was to treat a stomach virus as I treat a flu virus. I know intellectually that viral diseases cannot be cured, so treat the symptoms, suck it up, be a man, stiff upper lip, and  ride it out. Don’t contribute to the rise of super-resistant bacteria. But trying to ride out a stomach virus led me to the brink of dysentery.

A more minor (i.e., monetary) mistake was going to the hospital when all I really needed was a doctor’s opinion on what to do. Being associated with the University, I could have asked my colleague to take me to the University Health Clinic which is also staffed by top med school faculty. They would have evaluated me for free.

The evening grows late. My colleague goes out to discuss the doctor’s schedule with the nurses on duty. Ah! It’s Friday. The doctor is 150 km away and is not scheduled to get there until 10PM at the earliest. Hmm, 150 km, top speed 35 km per hour, I think 10PM is a tad optimistic.

At this point I should say a bit about doctors in Sri Lanka. Medicine is socialized here. Everyone gets free medical care. That is the good news. The bad news is that doctors are not paid much more (if any) than physicists in Sri Lanka, which is to say, not much. Sri Lanka seems to have modified its socialist past somewhat better than Cuba. In Cuba, recent reports indicate that the government was finally considering raising the pay of doctors, because the doctors were making considerably less in fact than the busboys in the new luxury resorts who get tips from Westerners. Here in Sri Lanka, doctors work their day jobs for their government salaries, but then are free to see private patients at rates the doctors set, before and or after work, earning the extra fees that keep them the highest paid among the professions. My colleague reports that in some cases, doctors see as many as 100 private patients each night between the hours of 4PM and 12M. Lakeside Adventist Hospital, being private, is staffed similarly, but with a twist. Lakeside is the premier hospital in the Kandy area. Its staff are drawn from the best of the teaching faculty at the University of Peradeniya’s Medical School, the top medical school inthe country. So, at Lakeside, the patient gets the care of the best available doctors, sometimes on kind of an odd schedule perhaps, and in much better facilities than the public hospitals. As importantly from the patient’s perspective, it is also the plum place to work for nurses, who are motivated to do their best work by simple consideration of the alternatives.

The evening was getting late and Kris is exhausted. My colleague has already done a lot. So an agreement is reached with those on duty. My colleague drives Kris home now, leaving his phone number with the staff. The hospital agrees that even if the Man decides to release me upon his arrival, they let me stay in my room until my colleague can drive me home at 7AM. Kris makes her goodbyes and off she goes to get some much needed sleep. I turn off the room light and roll over on my side to do the same. Oops. Maybe one more visit to the bathroom before I settle in. When I return to the room, the room light is blazing. Something is up.

In walks a doctor I have not yet seen. Maybe it was because I was back in bed when he walked in, but this guy is so tall that I think he would have gone far in pro basketball. He turns out to be the house doctor that night and the Man has telephoned in the orders for my release. “But my ride just left, I protest.” “No problem. He has already been contacted by phone and will return for you at 10PM.” And so it was. My colleague was kind enough to make another round trip, spend another hour and a half of his time away from his family to ferry me home.

And the discharge was the right decision. They sent me home with antibiotics to finish the course of treatment, an anti-emetic, and some Tylenol. I got a relatively good night’s sleep and continued to get better today. I plan to take it easy for the next few days.

Bottom line. My narrative may sound a bit critical, but that is primarily due to my unfamiliarity of the practice of medicine in Sri Lanka. The hospital staff made all the right calls and restored me to health as expeditiously as any American hospital would have. Oh. And the estimated bill for two full days of professional medical treatment and lab work and a one night stay with all meals? About $200.

And, I’m fine, Mom. Really. Sorry for worrying you.

Tim

(Note added 1/26 after paying the bill: The final bill, inclusive of hospital stay, food, all doctor’s bills, all laboratory work, and the medicines that I was sent home with, was $134. And this was the total bill, not after any insurance payments. I had no prior agreement or arrangement with the hospital. To them, I was a total stranger off of the street.)

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6 Comments

  1. SHANNON Jackson said,

    January 25, 2009 at 1:33 am

    Shit happens every day, right? or 10 times.
    I never have pain or illness with traveler’s disease so I always think it’s from drinking bottled water with minerals in it. Halfway through Western Turkey I finally found just plain bottled water-I think it was Dasani by Coke. By then I had suffered a truly embarrassing accident in my bed in a 4 or 5 star hotel in Antalya (southern Turkey). I decided it was time to start antibiotics and took one just before heading to the group breakfast. That caused vomiting of about 1 quart of concentrated stomach acid-bright yellow. OK forget the antibiotics! I started skipping meals and just eating bread, crackers and bottled water and felt better in a day or so-a little more woozy in the 105F heat but didn’t miss the highpoints of the tour. The person I was rooming with (not a close friend) has never asked to go on tour with me again! Who can blame her? I also heavily tipped the room maid. Poor woman!

  2. Kris said,

    January 25, 2009 at 4:10 pm

    I’ll just add a little to Tim’s narrative. He may have zoned out of the friendly nutritionist who provided written advice about diabetic foods, in English and Sinhala (for our household helper). He may not have been able to admire the two lake views from his two corner windows. He couldn’t watch the laundry department operating at ground level, washing, sun drying, and mending the hospital sheets and towels. He wasn’t aware of the most welcome help and suggestions from our Fulbright friends, bringing me important prescription information and inviting me to dinner or to spend the night (they live near the hospital). Nor could he see how grateful I feel for the excellent English, the caring patience, and the competence of the staff who cared for him, from the admission doctor to the house doctor. And the concern and willingness of our tuktuk driver and our maid to do whatever was needed, from driving me home long after normal hours, or making my dinner late at night. It was a trying time, but I felt that I was among kind and helpful people, which made all the difference. But I was very tired by the time we got home, translating for Tim and the staff. I can understand them well, and they can understand me, but it was hard for them to shout past Tim’s hearing issues, and his American accent made no sense to them. So I felt useful, and it was comforting for Tim to have me there, a familiar face among the unfamiliar faces and uniforms. He probably also missed the cleaning lady, who wore a sarong and blouse under a vest that said CAREKLEEN on the back in giant faded stenciled letters. She swept the room twice every day, cleaned the bathroom and shower, mopped with a disinfectant liquid, and smiled an infectious buck toothed grin when she was finished. A foreign patient must be a bit of a celebrity because we were also visited by the hospital administrator, whose two daughters are in nursing school in California, and we appreciated the air conditioner very much. Not only was it hot and noisy outside, so closing the windows kept the cool air in and blocked the heat and traffic noise, but closing the door meant people had to knock to come in instead of standing in the (wide) doorway and gawking. There was a man visiting the neighboring room who was one of the more unnerving gawkers; I was glad to close him out. Just stood there, watching. Us. We are getting used to being conspicuous, but watching a sleeping man is a little odd for entertainment. The village life must be quieter than we thought?

  3. Charles said,

    January 28, 2009 at 3:16 pm

    It is a good thing to study the faces of the people who serve you in restaurants in Sri Lanka, for they eat the same food themselves. Although our food hygiene is much better than that in India (remember “Delhi-belly”?), stomach upsets are common, and shit happens. The key to success is to develop your own immunity over time. This is why we can eat almost anything and still survive. Our cuisine is so full of chillies & pepper that they are our first defense against bacteria and viruses. It takes a lot to put a Sri Lankan down. But the problem of our toilets leaves much to be desired. When water is used instead of paper, the place becomes a foul mess. Many toilets lack toilet paper (& some even the toilet seat, and so people tend to stand on the rim and like a crane, slowly bend to bring their posterior down. It is a bit like docking a space ship).

    I remember once at the University of Ibadan (Nigeria) during an exam, a girl wanted to go to the toilet. I had to accompany her to the toilet and stand outside until she finished her job. On her emergence from the toilet, she had a painful look about her, and so to relieve the tension, I asked how the paper was (referring to the exam paper). She scowled at me and told me, “That was the problem, Sir. There wasn’t any”.

    In Sri Lanka, as in many other countries in Asia, water has replaced toilet paper. The left hand (sinister) is the one that does the cleaning. Ecclesiastes 9:10, “Whatever your hand finds to do, do it with all your might”.

  4. Kara said,

    February 1, 2009 at 1:54 am

    I failed you when I sent Kris a list of books that might be useful cross culturally if I did not include “Going Abroad: The Bathroom Survival Guide” — highly informative, useful, and quite amusing.

    Sorry to hear you were so sick, Tim. Hope the gruel thing clears up sooner rather than later. Bananas are good for that, as are apples (although I suspect bananas are easier to find than apples for you at the moment).

  5. February 7, 2009 at 2:48 pm

    […] I really should finish off the story of our Christmas trip, the story that was so rudely interrupted by my bout with a stomach virus. There is just one last day to report on, so this will be the final […]

  6. March 21, 2009 at 5:36 pm

    […] to people who know me best and have tried to get me to get back to them by email. I am not sick, the excuse I used for a previous episode of not posting. I am teaching more than I have been up until now. I just […]


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