Archive for April 1st, 2015

Having “Urgent” but not “Emergency” Surgery in the Philippines, Part 1

by on Wednesday, April 1st, 2015

Open foyer between the towers at Medical City

Open foyer between the towers at Medical City

This year my friend Bob is making a one-year trip to Southeast Asia and cashing in the huge stockpile of Korean Air frequent flyer miles he built up over his decades as a merchant banker in Asia. The trip had to be interrupted for surgery. Based on my personal experience, I recommended The Medical City in Metro Manila, one of the leading hospitals in the Philippines. Although It is not the most expensive hospital in Manila, Medical City costs three times as much as the national hospitals. Excellent physicians also practice at public hospitals for humanitarian reasons, so the care is the same for the patients of equally qualified doctors, whether at private or national hospital. Of course any hospital is beyond the reach of many of the poor, who have no choice but to go back to the provinces and die.

For those of us with some knowledge of healthcare in Asia and health insurance in the US, the end of Bob’s story is highly predictable. I wonder what defensive tactics we’ll see from US insurance companies as they feel more and more threatened by medical tourism.

Bob and I spoke at my house in Quezon City. Thanks to Bob for some of the photos.

Bob’s story

Bob at lunch

Bob at lunch

In 2006 I developed a basal cell carcinoma on my face. It looked like a pimple, but it wouldn’t heal, and it got larger and larger. When I had my executive physical in Korea, I was referred to a dermatologist who did a biopsy and told me it was a basal cell carcinoma. It would never metastasize, never enter my lymph system or my blood stream, never travel to my lungs, my vital organs or my bones. It wasn’t dangerous, but it wouldn’t heal. He told me he could remove it on my Korean National Health Insurance. It was getting pretty ugly. The removal was just a two-hour procedure done under local anesthetic. All during the surgery the doctor and I had a pleasant conversation about living and working in the US and Korea. I did notice that the carcinoma was a less than dime-sized lesion, but the doctor had to tunnel under the skin on my cheek almost over to my ear and almost up to my eye and almost down to my chin. He kept taking biopsies and sending them out for results in order to determine that there were no cancer cells left in my face. I had a four-inch scar on my face which within two years wasn’t even noticeable.

Probably about 2012, I got a spot on my back to the left of my right shoulder blade. It felt similar to the earlier one. Remembering how slow-growing that was I just told myself I’d get around to having it removed eventually. Two years later when I was getting ready for my one-year travel adventure throughout Southeast Asia, I decided I should probably have it removed. My primary care physician referred me to a dermatologist and surgeon, Dr. Patel, an ethnic Indian physician in his seventies who’d been practicing in Massachusetts for forty years.

He said, “It looks like a basal cell carcinoma to me, but it’s so large that it’s going to need a skin transplant. When are you going to Asia?”

The scar from the first carcinoma

The scar from the first carcinoma

“September 17. I’ve already got tickets.”

“We don’t have time now because a skin graft is a delicate operation. You have to have the area immobilized for some time after to make sure that it takes. You’re grafting your own skin, but it has to establish a connection with the nerves and blood vessels. Really, you have no time. You should probably reschedule your trip.”

“Well, I had great experience with surgery in Korea. Maybe I’ll get it done there, maybe in Thailand or the Philippines.” I was still thinking it would be a simple procedure.

That led to a discussion about overseas surgery. He seemed very enthusiastic and proud of India’s growing reputation for medical tourism.

I said, “Since these things are slow-growing and never fatal, I might come back a year from now.”

“It’s going to be about 30% bigger, but you do have that option,” he said.

When I left on my trip the carcinoma had gotten larger and more ugly, but it never bothered me. If I took a hot shower or I rubbed it against the sheets, the scab on top would occasionally come off, and it would bleed a little.

Three months into my trip, it suddenly started getting much bigger, bursting and bleeding every couple of days. I was staying in different hotels every day. I bought two bath towels to place over the hotel sheets so that I wouldn’t bleed on the sheets. Some Asian countries can get very fussy about stains or a cigarette burn on their linen. I had an argument with the Hotel Stella in Cebu, Philippines, which wanted to fine me $17 because I hadn’t had time to wash blood from a towel before I left.

About four or five months into the trip I was in the Chulalongkorn Hospital, the finest teaching hospital in Bangkok. I got in line and went through a screening, and the doctor told me I had to get it done right away, I should come back and he’d schedule surgery. In the hotel I was filling out the hospital forms when I came to the section which said, “You must have 60 days remaining on your entry visa or we will not perform any surgery.” Thai immigration regulations are very cumbersome and very rigid, giving you a fixed number of days you can be in Thailand over various periods of time. I’d already used up a lot of time. So I went to Vietnam for a couple of weeks and tracked the number of days I’d been in Thailand during the last ninety days, and I saw that surgery in Thailand was out of the question. In the meantime the carcinoma had become a bloody mess, seeping and weeping and smelling.

I contacted my friend Carol Dussere about coming to visit earlier than we’d planned. She’d had fantastic experience with surgery in the Philippines—and eye surgery at that. I arrived in Manila on February 19. Carol had made an appointment at a beautiful medical facility, The Medical City in Ortigas. There are twin towers surrounded by a couple of other medical buildings and a really fully equipped, state-of-the-art hospital, very well staffed, covering every discipline available in medicine. It’s one of the leading hospitals in the country.

Dr. Lourdes Ramos

Dr. Lourdes Angliongto-Ramos

I saw Dr. Lourdes Angliongto-Ramos, the head of plastic surgery. Like Dr. Patel in the US, she was concerned that the carcinoma was so big she might have to do a skin graft, but she also thought there was a 30% chance she could just do a flap operation. During the flap procedure they remove the carcinoma in concentric circles leading out from the lesion, and do lots and lots of biopsies, stopping only where there is no cancer in the entire circle. The surgeon moves live skin and fat cells, tunneling under the skin and leaving a large area detached from the flesh, then filling up the hole made after the carcinoma was removed, in this case about a four-inch by seven-inch section. After that the skin and flesh are dragged forward and up and over from the different sides and attached where the carcinoma was. The advantages are that there’s usually not a problem with skin rejection or infection, and the hole is filled to a great extent with your own fat, whereas if you take tissue from your thigh and transplant it to your back, you’re got two very different kinds and colors of tissue and textures with no fat tissue for filler. Dr. Angliongto-Ramos said it would be very noticeable on my back, and I’d have a rectangular scar on my thigh where the skin came from. That was why she strongly favored the flap operation, but wouldn’t know until the surgery whether it was possible. Off the top of her head, Dr.  Angliongto-Ramos listed everything I would need from the surgery and recovery and hospital stay and said the bill would be between $4300 and $4700. This included seven days in one of the best hospitals in the country, food, nursing and everything. The following week I’d have surgery.

The pre-surgical preparation and testing was impressive. Dr. Angliongto-Ramos wrote what looked like prescriptions for blood work, pulmonary and cardiological work and chest x-rays. Then she sent me downstairs to an outpatient clinic in the next tower, where I took a number. Filipinos are both very kind and respectful to senior citizens, and there were senior priority queues throughout the hospital, so I didn’t have to wait very long for any procedure. I’d get in line, take a number and check my number on the video screen to see what to do next. I’d go to the cashier to pay, wait until I was called and have the test. I did probably three or five tests the first afternoon, went home, returned and found I had an appointment wiFth the cardiologist who was in charge of my pre-surgery screening. He sent me out for a couple of other tests. After a couple of day’s break, I learned that I’d just screwed up the system because the electrocardiograph would take so long. But the technicians moved heaven and earth and finally gave the cardiologist an unsigned, unofficial reading which he used for my clearance, knowing that the final report would be in before the surgery.

Then I met with an anesthesiologist. We reviewed my allergies, my history with anesthesia and my family history with anesthesia. He explained what would likely be used and gave me a couple of skin-prick tests. That was very good because my aunt had nearly died from anesthesia thirty years before during a very simple procedure at the hospital in Berverly, Massachusetts. Every time my mother had surgery her blood pressure dropped dangerously low, and that had happened with me too. Not only was the preparation incredibly thorough, these tests—it was pay as you go—were so inexpensive. A series of chest x-rays, including the scans and reports in English, cost me 500 pesos or $12.50. Other tests were five dollars here, four dollars there. If I’d been buying candy, I’d have bought a truckload. The most expensive test was the very involved electrocardiography done on a very expensive machine and with well-trained technicians reading these results, and that whole procedure was only $100.

I’m not used to going to doctors. I went for thirty years without going to a doctor. The only surgery I’d had prior to the first carcinoma was an appendectomy in 1967. I stay healthy, which is so much a state of mind in my opinion. The strongest thing I’d taken in the last forty years was aspirin, which is an amazing painkiller. I insisted to the anesthesiologist that I be given the absolute minimum of pain medication and that I be able to stop getting it at any time. He agreed. Later I got into discussions with nurses and floor doctors who just couldn’t believe I wanted to avoid pain medication. I got it stopped as soon as I got out of the operating room. I figure pain is your body’s way of telling you something. If you move and it’s painful, don’t move. I healed very quickly and wasn’t constipated from the narcotics. It was a great experience.

The day before the surgery I checked in. The room looked just like Beverly Hospital where I’d brought my mother many times, truly a state-of-the-art facility, but there were subtle differences that I hadn’t really thought about and wasn’t prepared for. As in other Asian countries, in the Philippines a hospital patient has a “companion” staying with them twenty-four hours a day—a domestic helper, a relative or even someone who’s been hired for the occasion—so the nurses are not tied up doing things that a layperson can do, like emptying a bedpan or getting a glass of water or picking up something. They staff accordingly. There aren’t as many floor nurses or aides as there are in the States. I think there was little bristling on the part of the desk staff because in their opinion it was not their job to dump my urine bottle or get me a knife and fork from across the room. It wasn’t their job to do many of the things I couldn’t do for myself the first few days. But several of the staff went out of their way to help me and make me comfortable and make me not feel guilty about it. It was obvious that I hadn’t planned that part.

The nurses' desk

The nurses’ desk

When I was brought out of surgery and returned to my room, the urinary catheter came halfway out. As soon as I came to I was in agony. I was using my nurse call button, but the call didn’t get a quick response because everybody assumed my companion would come to the desk for anything important. The other thing I didn’t know was that the communication systems are different. Everything goes through your surgeon, who has doctors who are assigned to cover her patients when she’s in surgery or at home. With the slightest movement came intense pain. I kept pressing the button. Responses were mixed. A nurse would come in, and of course in the Philippines for most people English is not their first language, although it’s a strong second language. Between an American English speaker and a Filipino English speaker there can be communication problems regardless of education level.

So there was confusion. The surgeon had ordered the catheter to stay in for three days. No one was authorized to remove it. Only a doctor could touch it, not even a nurse. On my fourth call the nurse came in, and I explained that I was looking up on the internet how to remove a frigging catheter myself. That’s how bad the pain was. I knew I needed a ten-milliliter syringe to put in the tube and remove the sterile water in the balloon in order to pull the catheter out, but of course I didn’t have access to the syringe. Finally they contacted the doctor who was assigned to fill in for my surgeon. However, her primary purpose in life was to avoid disturbing the surgeon at home. She was playing pain chart games with the nurse. “Well, find out is the pain a four or a six or ten.”

So the nurse was going back and forth. At this point she was convinced that there was something wrong. “Yes, he’s in great pain, and he really needs to see you.”

Bob after surgery

Bob after surgery

She refused to come and look at it. Finally, I went on a bit of a rampage. With the nurse’s full support, we upped my pain estimate to eight. According to hospital guidelines, at seven or over the doctor had to come and see me. She came, but she obviously still didn’t want to disturb Dr. Angliongto-Ramos. I’m the last one to bother the doctor at home, but it was agony. Finally she was persuaded to call, and Dr. Angliongto-Ramos authorized removal of the catheter provided that I promise not to try to get out of bed. They removed the catheter and gave me a urine bottle, which was a great relief.

The care was fantastic overall, and the sanitation was great. The food was amazing. I didn’t get a choice of food, but it didn’t matter. Later I found out the dietician had decided I was overweight so I should be on a low-carbohydrate diet, but I hadn’t noticed. There were lots of great soups, pork soups or chicken soups that you spoon over rice, and lots of vegetables. They fed you five times a day, three meals plus a mid-morning snack and a mid-afternoon snack. I couldn’t get over it. I don’t like fish so there were a couple of dishes I didn’t eat, but it was not a problem. After a couple of days I learned you could order room service twenty-four hours a day.

A readers writes:

Hi. I happened to awaken early this morning and so had time to read Bob’s story. Also, of interest due to my medical past and the issues with healthcare. Fascinating the differences between the cultures.What remains the same in both, however, is the godlike status of the surgeon who cannot be disturbed post surgery for anything less than an 8 on the pain chart. At least his pain didn’t cost him thousands upon thousands of dollars! I hope that Bob is recovering nicely.

Response:

In my experience, the attitude of the junior doctor in question is very, very much in the minority, actually if you discount punctuality the only one I’ve heard of among lots of helpful, caring, humble people, whereas in my experience in the States the godlike attitude seems to affect even medical students, including one of my former roommates. Bob is doing well.

A reader writes:
Forwarding to my husband and a few others who work at Medical City. Thanks, Carol. Hope your friend is well.
Response:
Bob’s doing well and following doctor’s orders to the letter.
A Medical City doctor writes:
First of all, congratulations on that detailed experience by your friend Bob. Nice to read a story which absolutely hides nothing. Experience wonderful or not is always valuable more so medical as this provides help to others as they too in the future may need it, and don’t we all in one time or another? I do agree that there is a chain of command in the medical hierarchy and this will continue to do so with good reason, but one thing is certain and that is cultures do differ. Having written that I can say that the care given here usually is more compassionate. Nice to know that Bob is doing great.

Response:

Thank you. I agree. Yesterday I had a reaction to the sugar shock test at Megaclinic. The staff immediately had me in a wheelchair and on a bed, took my blood pressure, gave me a electrocardiogram and sent in a doctor . In a short time I went back to the lab for the second blood extraction. When I thanked the technician for her kindness, she said, “We love you.” The doctor saw me again. Then I had my badly needed coffee and breakfast. That’s the kind of treatment I’ve had here. At home on the Internet, I found that passing out–which I came close to–is a common reaction to the sugar shock test, which would be why the staff wouldn’t let me leave the lab area.

A reader writes:

Good to know local medical facilities and health care specialists and teams are appreciated One should realize, though that the cost of less than US$5k, including taking lab tests for the cost candy, is still outside the reach of the regular working man in Manila. That amount is still over 200k Philippine Peso, more than half of our annual wages. How I wish we all could just afford ‘urgent care’. May I share this post with my friends who work in TMC?

Response:

I understand. That’s why I inserted that bit into the introduction about national hospitals and people who can’t afford them either. If I need any long-term care myself it will be in a national hospital where one of my Medical City doctors practices. Please share the post with as many people as you like. Perhaps they might do a pamphlet for foreign patients who don’t understand the Filipino companion system or the doctor system.