2012 Date Geography North America

A Hospital in Hawaii

If you read last week’s post, you will be aware that (i) I have just returned from a vacation in Kauai in Hawaii, where some friends and I enjoyed a week of hiking, biking and sea-kayaking; and (ii) in the course of this, I broke my ankle.

On the homeward stretch of our final day of hiking, around mid-afternoon, we found ourselves walking along a narrow section of the gruelling Kalalau trail. A chunk of the path gave way beneath me. I toppled over and slid down a steep embankment. I would have kept sliding, except that a large and helpful tree stepped in the way and grabbed me by the left ankle. For its part, my ankle responded with a loud and quite worrying “crunch” sound.

I stood and tried to step on my left foot, and a horrible searing pain shot up my leg. So I promptly toppled over again, and decided that it was time to suspend all hiking activities for the rest of the day. Which decision was a bit of a problem, because we were still some way from the end of the trail and there were no access points by which a rescue vehicle could reach us. All that separated me from the nearest paved road was four kilometres of steep ascents and rocky descents, along narrow cliff hugging paths.

We had no choice, really, and what followed was like a scene from a Vietnam War movie – you know the one, where the wounded GI, assisted by his noble buddies, heroically hobbles his way out of the jungle. All I can say is that although the movie version may be inspiring, it is absolutely no fun at all when the movie is real and the wounded GI is, in fact, you.

My friends foraged in a nearby grove of trees and found a couple of long, sturdy sticks. They became my crutches, and with one in each arm we began a slow, painful return to the end of the trail. Whenever we got to a steep uphill or downhill section (in other words, more or less the whole time) one of my mates would support me under an arm while another would grab my backpack from behind and lift me upwards, to take pressure off my injured foot.

Stumbling along in this way it took us almost two hours to walk the final four kilometres. Of course Hawaii chose that very moment to turn on the finest weather of our whole week there, so it was brilliantly sunny and blisteringly hot. When we finally got to the road and made our way to where we were staying, I was covered in dust and grime, soaked in sweat, and in serious agony to boot (no pun intended). I gingerly removed my shoe – my foot looked OK so I assumed it was a bad sprain, and I shoved it into an ice-bath, after which I taped it and went to bed.

The next morning, however, my left foot looked like an exhibit in a Ripley’s Believe It or Not freak show. The ankle joint had swollen up to the size of a small melon and my toes had gone a blue-black colour. This was clearly no ordinary sprain and it was thus time, like it or not, to brave the wilds of the US healthcare system.

I was less than thrilled with this proposition, given that from a distance medicine in the USA, despite being amongst the best in the world, does not generally have a great reputation. For those of us who do not live in the USA, their healthcare system appears scary: vast and complex to navigate, hellishly expensive, and not overly compassionate (unless you are rich or heavily insured). Plus, America is an extremely litigious society, and so a common perception is that their healthcare system operates on the basis of don’t get sued first, care for the patient second.

This perception had been reinforced for me the first night after my fall. After icing and taping my foot I had tried to sleep, but was not having much success. My foot was throbbing and as I lay in bed in my room at the Kauai Hyatt the pain became worse and worse. Eventually I couldn’t take it anymore, and shortly before midnight I called the hotel reception desk, and asked if some painkillers like Panadol / Tylenol (paracetamol) or Nurofen (ibuprofen) could be sent to my room, to tide me over until morning, when I would then visit the hospital.

Requesting these generally available over-the-counter pills is something that I have done many times before in hotels everywhere – from Australia to China to London – and it has never been an issue. But in Hawaii, the receptionist near snorted in horror at my request. “Sir, for legal reasons the hotel cannot dispense drugs”, she said.

I was a bit peeved with this, and, as I may have mentioned, I was in some degree of pain. So I asked the receptionist what she suggested I should do.

She replied: “Well Sir, there is an all-night gas station just up the road; perhaps you could go there? They might have something”.

I pointed out to the receptionist that a midnight stroll to a nearby gas station was perhaps not all that appropriate, given that my primary ailment was a suspected broken ankle. I also mentioned to her that I was asking for a low-grade painkiller like Tylenol, and not morphine or crack cocaine.

I understand Sir….” she said, and I heaved a sigh of relief, thinking that my evident misery must have finally got through to her. But before I had time to get even half-excited about the prospect of imminent pain relief, she finished her sentence: “…..but, as I said, for legal reasons I simply cannot send you any pills”. She added cheerfully: “Maybe I could send an ice-pack to your room?

Thanks for nothing, bitch-face. In the Land of the Free and the Home of the Brave, it would appear that frozen water is the most potent medication that can be dispensed without fear of being dragged through the court system for the rest of your natural life. What a sick state of affairs. (Again, no pun intended…..).

Another example: take the case of American television advertising for prescription drugs. For five nights in Kauai, even prior to my injury, my friends and I had watched each evening in fascination as ads for assorted pharmaceutical products had played repeatedly during commercial breaks. Pharmaceutical manufacturers are amongst the heaviest advertisers on US free-to-air TV, and so it is almost impossible to watch US television for more than a few minutes without encountering one of these advertisements.

It was not always so. Prior to 1997, advertising of prescription medication on American television was not allowed. In August 1997, the Federal Drug Authority (FDA) changed the rules, and since then the United States is one of only two places on the planet that allows drug companies to advertise their wares on television (the other is New Zealand; if you are familiar with New Zealand, this probably explains a lot).

There is a catch, however. FDA rules require that: “Advertisements promoting the medical use of prescription drugs must contain a ‘brief summary’ of all important information about the advertised drug, including its side effects, contra-indications and effectiveness … and must include a ‘major statement’ prominently disclosing all of the major risks associated with the drug.”

The result is drug ads which are typically at least sixty seconds long, where the first fifteen seconds describe the drug and its efficacy, and the remaining forty-five seconds detail everything bad the drug can do to you. And even though the ad is much longer than a normal thirty-second TV spot, to fit it all in the announcer runs through the long list of dangerous side effects and warnings so fast that you can barely hear them. It sounds a lot like someone calling a horse race, only the horses running in this race are named Fatal Consequence, Secondary Infection, Lymphoma, Cancer, and Acute Blood Disorder.

Here is the typical warning statement that accompanies the ads for popular prescription anti-depressants, in case you think I am making this up:

“[This drug] is not for everyone. Call your doctor if your depression worsens or if you have unusual changes in behaviour or thoughts of suicide. Increased suicidal thoughts or tendencies may occur, especially during the first few weeks of treatment. Extreme caution should be taken because [this drug] can cause seizures. Elderly dementia patients taking [this drug] have an increased risk of death or stroke. Call your doctor if you have high fever, stiff muscles, and confusion as this could indicate a possibly life threatening condition, or if you have uncontrollable muscle movements as these could become permanent. High blood sugar has been reported with [this drug] and medicines like it. In some cases, extreme blood sugar can lead to coma or death. Other risks include decreases in white blood cells, which can be serious, dizziness upon standing, trouble swallowing, and impaired judgment or motor skills.  Other more mild side effects include agitation, head-ache, dry-mouth, nausea, vomiting and tremor. Ask your doctor if [this drug] is right for you!

Bugger me. With drugs like this on offer, who needs poisons? Or, as one US blogger I came across so excellently put it, “every time I see US TV drug ads go on at length about serious and lethal side effects, I think: thank God my government bans pot”.

Anyway, after a painful and sleepless night, I made my way to the emergency room at the Wilcox Memorial Hospital first thing the next morning. The hospital, which has operated for almost 100 years, is the only hospital on Kauai Island, serving the resident population of 70,000. But, for a small community hospital, Wilcox Memorial is surprisingly large and well equipped, providing every health service you could ever need: surgery, ER, trauma, men’s health, women’s health, keikei health (otherwise known as children’s medicine / paediatrics), orthopaedics, podiatry, obstetrics, neurology, cardiology, every form of imaging under the sun (x-Ray, MRI), and so on.

The place was virtually empty, and I was one of only two people seeking treatment that morning. Donna, the receptionist who registered me, and Shirley, a nurse who took my blood pressure and vitals, were both super-friendly Hawaiians of mixed Asian / Polynesian extract. They were helpful and chirpy and almost sickeningly happy (hmm, would you believe, no pun intended, again). They fussed over me, offered me coffee and newspapers, and insisted on pushing me around in a wheelchair. The pair was so unexpectedly friendly that I even told them so: “you two are the nicest hospital staff I have ever met”, I said. Nurse Shirley laughed loudly in response: “Normally we are dragons – you’re just lucky that you got us on a good day!”

While I waited in the reception area, Nurse Shirley mentioned that Wilcox Memorial offers free WiFi throughout the hospital, so I pulled out my laptop to log on to the internet. A list of network options popped up on my screen.  I was greatly amused, if not a touch concerned, to see that just below the network choice labelled “Wilcox Guest” was another, entirely unexpected network option, labelled: “FBI Surveillance Van”.

Now, apart from the obvious question (what the fuck is an FBI surveillance team doing in the vicinity of Kauai’s one and only hospital?), it did occur to me that this was not exactly an example of first-class spy craft in action. I am no James Bond, of course, but might I suggest that if you are a secret service, and your objective is to secretly spy on someone, then labelling your WiFi network as the “FBI Surveillance Van” is not really the most sensible way to go.

About ten minutes later, I was wheeled around to the radiology department, where another super friendly and chirpy person – a young man in his mid-20s, clean-cut, neat beard, wearing the universal hospital orderly attire of blue overalls and croc sandals – shot some x-rays of my foot. We chatted, and I learned that Josh was originally from North Carolina but had been living in Kauai for some time. “I was stuck in a rut back home and I needed a change, so I came here six years ago, having never been to Hawaii before. It was the best thing I ever did and I have never regretted the move here for even a second – this is the greatest place in the world to live”, he said.

Once he was done Josh wheeled me back into a holding room, and after a short wait the doctor on my case – Dr Dee – came in to see me with the results of my x-ray. He too was wearing blue hospital overalls and crocs, but he had a scruffy, three-day stubble and longish, wispy gray hair that was tied back behind his head in a short ponytail. “I bet it hurts right there”, Dr Dee said as he pushed on  the protruding part of my ankle bone, at which point I obligingly squealed in pain and almost leapt clear off of the bed. This seemed to amuse Dr Dee enormously: “that’s where you have a fracture…..” he chuckled, although I must confess, I didn’t see the humour in quite the same way he did.

A brief chat later and I had learned that Dr Dee grew up in Laguna Beach, California, loved surfing, and he had been resident on Kauai for almost twenty years. Dr Dee was clearly still living in the late seventies, man. He scribbled me a prescription for a painkiller, Vicodin, which is the drug that TV doctor Greg House habitually pops like candy, and which I subsequently read online is “structurally related to codeine, and is approximately equal in strength to morphine in producing opiate-like effects”.

The key active ingredient in Vicodin is hydrocodone, which in its pure form is a controlled substance (that is, get caught dealing in hydrocodone and you could find yourself in jail). Vicodin is potentially addictive after as little as one week’s use in high doses and is susceptible to abuse, so much so that it is banned in the UK, Australia, Singapore and most other places. By contrast, in the USA, God bless ‘em, Vicodin is the most popular and widely prescribed prescription drug. And as Dr Dee, ever the hippy, explained to me: “it might get you a little high, so enjoy!

After being discharged, I wandered over to the hospital pharmacy, where another super-friendly fellow, Fred, filled my prescription. Fred, who I guess was mid-60s in age, struck me as being a typical mid-westerner: polite and measured in his speech, wearing a neat Aloha print shirt tucked into his crisply pressed chinos, thin-rimmed spectacles perched on the bridge of his nose. Fred was also one of those aging gentlemen who attempts to fight time by dramatically sweeping a few long strands of hair over his balding pate, fooling absolutely nobody except perhaps himself that he has more hair than he actually does. Fred told me he was from Ohio where he had owned a pharmacy for many years. He had retired to Kauai about ten years before, the global financial crisis had seen the value of his retirement savings fall by more than seventy percent, and so had taken on part-time pharmacy work in order to make ends meet.

All in all, my morning at Wilcox Memorial Hospital was a most unexpected surprise. Had it not been for the small matter of a broken ankle, I would go so far as to say it was a pleasure. I had prepared myself for a long wait, rude and harried staff, and a whopping big bill at the end. Turns out I was two-thirds wrong: I barely had to wait, and every person I dealt with at hospital was so exceedingly pleasant that when the whopping bill came (and whopping it was – almost $1,000 for a consultation and x-ray!), I left still smiling.

Later that afternoon I began the long flight from Hawaii back to Singapore. Sitting on the plane at 38,000 feet, pleasantly high on Vicodin (what is it with the puns today?) I thought of the various folks I had encountered earlier that day at Wilcox Memorial Hospital. There was Donna the receptionist and Nurse Shirley – happy, down-to-earth, native Hawaiian islanders, sporting big white smiles and even bigger, hearty laughs. There was John the radiologist – quite and serious, a Gen-X college graduate who had “found himself” in Hawaii.  There was Dr Dee, surfer-dude medico extraordinaire, who thanks to the laid-back tropical lifestyle available on Kauai had never quite managed to move beyond the hippy era. And then there was Fred the pharmacist, mid-western retiree to Hawaii, dealing with the personal fallout from bankers, more than 5,000 miles away in Wall Street, having screwed his retirement.

It occurred to me that in a funny sort of way, the collection of staff I met at Wilcox Memorial was almost a microcosm of modern-day Hawaii and the people who live there: native islanders of Polynesian and Asian heritage, joined in the sun by a motley assortment of “refugees” from across the United States – overgrown hippies, disaffected youth, and sun-seeking retirees. Each of these wonderful people helped me enormously, provided me with first class-health care, and gave me a new-found appreciation of the US healthcare system, and what is possible when it functions well. I thank you all.

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